People who don’t eat meat, in particular vegans, may be at an increased risk of bone fractures.

Researchers at Oxford University in England report that vegans have a 43 percent higher risk of having fractures anywhere in the body, as well as higher risks of fractures in certain areas like the hip.

“We found that vegans had a higher risk of total fractures, which resulted in close to 20 more cases per 1,000 people over a 10-year period compared to people who ate meat. The biggest differences were for hip fractures, where the risk in vegans was 2.3 times higher than in people who ate meat, equivalent to 15 more cases per 1,000 people over 10 years,” Tammy Tong, PhD, BSc, the lead author of the study and a nutritional epidemiologist at the Nuffield Department of Population Health at the University of Oxford, said in a press release.

The study, published in the journal BMC Medicine, analyzed data from more than 54,000 people involved in the EPIC-Oxford study, a large cohort of men and women in the United Kingdom who were recruited for the study between 1993 and 2001.

Of the participants, nearly 30,000 were meat eaters, about 8,000 didn’t eat meat but did eat fish, about 15,000 were vegetarian, and nearly 2,000 were vegans at the beginning of the study.

Participants were tracked for an average of 18 years until 2016. During that time, 3,941 fractures occurred. The highest number of fractures were in the hip, followed by the wrist, arm, ankle, and leg.

The researchers said that vegetarians and people who ate fish but not meat had a higher risk of hip fractures than their counterparts who ate meat. This risk was partially reduced when body mass index (BMI), calcium, and protein intake were taken into account.

“Previous studies have shown that low BMI is associated with a higher risk of hip fractures, and low intakes of calcium and protein have both been linked to poorer bone health. This study showed that vegans, who on average had lower BMI as well as lower intakes of calcium and protein than meat eaters, had higher risks of fractures at several sites,” Tong said.

“Well-balanced and predominantly plant-based diets can result in improved nutrient levels and have been linked to lower risks of diseases, including heart disease and diabetes,” she added. “Individuals should take into account the benefits and risks of their diet, and ensure that they have adequate levels of calcium and protein and also maintain a healthy BMI, that is, neither under nor overweight.”

Lauri Y. Wright, PhD, an assistant professor of nutrition and dietetics at the University of North Florida, said the findings of the research aren’t surprising.

“The study results are consistent with previous studies, so not a surprise. The findings of increased fractures in non-meat eaters was partially explained by protein and calcium intake as well as BMI. However, there continued to be higher risk of fractures in vegans when those factors were controlled. This may be related to bioavailability of those key nutrients in bone health,” Wright told Healthline.

“For example, the vegans may have consumed adequate amounts of calcium, but many plant-based sources of calcium like spinach are not as bioavailable as dairy,” she added. “Protein quality is another example. Vegans may have consumed an adequate amount of plant proteins, but the amino acid ratio does not support resorption and remodeling as well as the amino acid ratio in animal proteins.”

All the experts who spoke with Healthline said it’s possible to be vegan and still have healthy bones.

“I have many patients that are vegan and when done correctly, studies do not show drawbacks,” Kristin Kirkpatrick, MS, a registered dietitian and manager of wellness nutrition services at the Cleveland Clinic Wellness Institute in Ohio, told Healthline.

“The key is doing it right,” she explained. “For example, an individual can easily consume plenty of vegan processed junk food, which would have adverse impact on health. However, when the focus is whole foods and plants, there is little drawback. Protein can be derived from whole soy, beans, and legumes, as well as nuts and seeds. Supplementation of B12 and vitamin D are also recommended for health.”