Research Article: Fruit and vegetable intake and bones: A systematic review and meta-analysis

Date Published: May 31, 2019

Publisher: Public Library of Science

Author(s): Juliana E. Brondani, Fabio V. Comim, Liziane M. Flores, Lígia Araújo Martini, Melissa O. Premaor, Margaret Allman-Farinelli.


Although intake of fruits and vegetables seemed to have a protective effect on bone metabolism, its effect on fractures remains uncertain.

A systematic review of randomized controlled trials (RCTs) and cohort studies (PROSPERO: CRD42016041462) was performed. RCTs and cohort studies that evaluated the combined intake of fruits and vegetables in men and women aged over 50 years were included. We considered fractures as a primary outcome measure. Changes in bone markers were considered as secondary outcomes. The search strategy included the following descriptors: fruit, vegetables, vegetable products, bone and bones, bone fractures, postmenopausal osteoporosis, and osteoporosis. PubMed, Embase, and Cochrane Library were the databases used. The appraisal of the studies was performed by two independent reviewers, and discussed and agreed upon by both examiners. The data extracted from the RCTs and cohort studies were summarized separately. The risks of fractures were combined across studies using random models. Bone resorption marker (CTx) was summarized with standardized mean differences. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate the strength of recommendations.

Of the 1,192 studies screened, 13 articles were included in the systematic review and 10 were included in the pooled analysis (6 cohort studies and 4 RCTs). The six cohort studies included in the meta-analysis included a population of 225,062. The pooled hazard ratio (HR) (95% confidence interval (CI)) of the hip in five studies was 0.92 (0.87, 0.98). Its heterogeneity was moderate (I2 = 55.7%, p = 0.060), GRADE (⊕⊕⊕O). Two cohort studies evaluated the risk of any fracture; the HR was 0.90 (95% CI: 0.86–0.96), with aheterogeneity of 24.9% (p = 0.249, GRADE (⊕⊕⊕O)). There was no association between the bone resorption marker CTx and 3 months of fruit and vegetable intake evaluated by four RCTs, GRADE (⊕⊕O O).

There was an association between the increase of at least one serving of fruits and vegetables per day and decreases in the risk of fractures. The level of evidence for this association is moderate.

Partial Text

Osteoporosis is considered a multifactorial and chronic systemic disease of the skeleton, closely related to aging. It is characterized by a reduced bone strength, which may lead to fractures [1, 2]. More than 200 million individuals worldwide are currently affected with osteoporosis [3, 4]. The World Health Organization estimated that the annual number of hip fractures would increase from 1.7 million in 1990 to 6.3 million in 2050 [3, 4]. According to Caroli et al. (2011), it is possible that the incidence of osteoporotic fractures will increase further [5]. This increase in incidence is due to the increased life expectancy and other important risk factors such as industrialization and reduced physical activity.

A systematic review of randomized clinical trials (RCTs) and cohort studies with meta-analysis was performed. The study protocol was registered in the International Prospective Register of Systematic Reviews on 2016 (CRD42016041462; available at This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

We performed a systematic review (13 studies) and meta-analysis (10 studies) of studies that evaluated the regular consumption of fruits and vegetables, either in the form of servings per day or grams per day. The meta-analysis, based on data from available cohort studies, showed that the increase of at least one serving of fruits and vegetables per day is associated with a lower risk of fractures.




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