Vegans and pescetarians (people who eat fish and shellfish but not meat) could be at risk of bone fractures, according to a study published in the journal BMC Medicine.

When compared with meat-eating people, vegans who have lower calcium and protein intakes, were found to have a 43% higher risk of fractures anywhere in the body, including fractures of the hips, legs, and vertebrae.

The study also found that pescetarians had a higher risk of hip fractures than people who ate meat.

Lead author Dr. Tammy Tong of the University of Oxford said, “This is the first comprehensive study on the risks of both total and site-specific fractures in people of different diet groups.”

“We found that vegans had a higher risk of total fractures which resulted in close to 20 more cases per 1000 people over a 10-year period compared to people who ate meat.”

Dr. Tong, who is a Nutritional Epidemiologist, added. “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 1000 people over 10 years.”

The study researchers analyzed data from nearly 55,000 people in the EPIC-Oxford study. Out of those participants, over 29,000 ate meat, nearly 8,000 ate fish but not meat, almost 15,500 were vegetarians, and 1,982 were vegans.

The team followed all the participants for 18 years on average, until 2016 for the occurrence of fractures. They found that a total of 3,941 fractures occurred in the study period, “including 566 arm, 889 wrist, 945 hip, 366 leg, 520 ankle and 467 fractures at other main sites, defined as the clavicle, ribs and vertebrae,” according to Science Daily.

There was no significant difference in risks between diet groups for arm, wrist or ankle fractures once BMI was taken into account.

They found that the difference in risk of total body and site-specific fractures was partly reduced after taking BMI, dietary calcium, and dietary protein intake into consideration.

Dr. Tong explained, “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,” she added.

“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,” Dr. Tong continued. “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.”

However, the investigators cautioned that they were unable to differentiate between fractures caused by poorer bone health and those caused by accidents because data on the causes of the fractures were not available.

Also, no information was available on differences in calcium supplement use between the different groups. They said more research is needed from different populations to explore possible differences in risk. The article originally appeared on Science Daily.