Fracture Rates in China and Sweden

My two biggest concerns about vegan nutrition are vitamin B12 and calcium. The message about vitamin B12 has gotten through to anyone who has been paying attention and isn’t in nutrition la la land (unfortunately, this are still a lot of vegans on both accounts). But even today, calcium and bones is a particularly tough sell among people who are interested in mainstream science and have been paying some attention.

Normally when I harp on the need for calcium, explaining that animal protein does not cause osteoporosis and so vegans are not protected by virtue of not eating any, someone will point out that countries that have higher intakes of dairy (northern Europe and the USA) have higher rates of osteoporosis than do Asian and African countries where much less milk in consumed. Here is a study that helps explain this paradox for Asians.

The first prospective study measuring clinically diagnosed vertebral fractures in an Asian population, the Hong Kong Osteoporosis Study, was released in March of 2012 (1). It measured the vertebral and hip fractures in a Chinese population and compared the rates to Sweden. Data from Japan was also included, but the measurements of vertebral fracture were estimated for Japan.

Rather than typing out the numbers for the various age groups, which are tedious to read, the results can be seen in the diagram below (or you can click here for an easier version to see).

The Swedish have higher rates of hip fracture while the Chinese have higher rates of vertebral fractures (much higher after age 80).

The authors state:

“The observed ethnic differences in fracture incidences may be due to the fact that hip fracture risk was affected by fall risk, whereas the risk of vertebral fracture mostly depends on bone strength. Despite the low hip fracture rate in our population, Hong Kong women had a higher prevalence of osteoporosis (bone mineral density T- score à “2.5 at any one site in reference to ethnic-specific peak young mean according to the ISCD recommendation) than US Caucasian women (35.8% vs. 20%, respectively) and a similar prevalence of about 6% in Hong Kong and US Caucasian men.”

In other words, the Chinese don’t have lower rates of osteoporosis.


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1. Bow CH, Cheung E, Cheung CL, Xiao SM, Loong C, Soong C, Tan KC, Luckey MM, Cauley JA, Fujiwara S, Kung AW. Ethnic difference of clinical vertebral fracture risk. Osteoporos Int. 2012 Mar;23(3):879-85. | link

11 Responses to “Fracture Rates in China and Sweden”

  1. Will Says:

    Hi Jack,

    Here when you said, “…someone will point out that countries that have the higher intakes of dairy (northern Europe and the USA) have lower rates of osteoporosis than do Asian and African countries where much less milk in consumed.”

    I think you meant to say *higher* rates of osteoporosis than do Asians? 🙂

  2. Jack Norris RD Says:

    Thanks, Will!

  3. Wes Novack Says:

    Thanks for the post Jack. So what vegan foods do you recommend as a dietary staple in order to maintain adequate levels of calcium intake? I have to 17 month old boys and we give them calcium fortified almond milk as well as a lot of quinoa, but I’m always interested in additional vegan foods containing calcium.

  4. Jack Norris RD Says:


    Quinoa is not particularly high in calcium (only 35 mg per cup), but it is high in protein:

    Here are my calcium recommendations:

    If you click on the “high calcium greens” link, it will take you lower on the page to a chart of the best vegan foods for calcium.

  5. Michael Says:

    Thanks for sharing this. I admit I’d boughten into (and spread) the idea that animal protein contributes to osteoperosis. Thankfully, I was also quick to add that vegans needed to ensure they get an adequate supply of calcium and vitamin D. But it’s good to know that things aren’t quite as straight forward as Forks Over Knives makes them appear!

  6. Mathieu Says:

    I’m French, but I have been living in Hong Kong for the past 2.5 years (and I became a vegetarian almost 2 years ago).

    And honestly, my impression is that Hong Kong people eat **much** more meat and seafood than the French, at every meal, usually at the same time.

    That doesn’t change your conclusion that vegans shouldn’t pay attention to their calcium intake of course, it’s just that the idea that Chinese have a lower intake of animal protein seems entirely unjustified (at least in Hong Kong)

  7. Jack Norris RD Says:


    You raise a good point. This study shouldn’t be taken as proof of anything regarding diet and osteoporosis, but rather it serves as evidence that hip fracture rates don’t tell the whole story when comparing the bone health of populations.

  8. Becci Says:

    Fantastic information, Jack. Thank you.

  9. Marco Pagliarulo Says:

    Hi Jack,

    Your website is so interesting and informative!

    Anyway, I agree that simply being vegan does not protect one from osteoporosis, but I think it may help a little bit. There are several studies showing a relationship between diet and measures of osteoporosis.

    Intake of animal protein has been associated with increased forearm fracture (Feskanich et al., 1996, Am J Epid 143:472-9 – even with data controlled for vigorous activity ), higher rates of bone loss (Sellmeyer et al. 2001, Am J Clin Nutr 73:118-22; Ho-Pham et al., 2012, Eur J Clin Nutr 66:75-82), and increased risk of hip fracture (Sellmeyer et al., 2001). The relationships are not generally very strong, so either the effect is weak or the story isn’t so simple.

    Perhaps it’s not that animal products are doing damage per se, but rather there may be something beneficial in the diet that is more common among those eating less animal products. Tucker et al., 2002 (Am J Clin Nutr 76:245-52) found that elderly men with high fruit and veg intake had higher bone mineral density than other dietary patterns. Maybe it’s soy isoflavones or other dietary phytoestrogens. A review paper (Setchell and Lydeking-Olsen, 2003, Am J Clin Nutr 78:593S-609S) concluded that the collective data suggest that diets rich in phytoestrogens have bone-sparing effects in the long-term. This is not surprising given the propensity for osteoporosis among women.

    In all, I agree that it’s important for vegans to know that calcium intake and weight-bearing exercise are what keep bones strong in the long run, not simply being vegan. However, there may be some other – relatively minor – beneficial effect from a healthy vegan diet.

  10. Jack Norris RD Says:


    I agree with you conclusion. I would add that older vegans need to make sure they’re getting enough protein. That is in part due to possibly increased needs, as I discuss in my protein article here:, but also because older people sometimes eat less calories making the % of protein needs higher.

  11. Marco Pagliarulo Says:

    Interesting! I’ll read your protein article.

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