Osteoporosis International

, Volume 24, Issue 11, pp 2827–2836 | Cite as

Greater intake of fruit and vegetables is associated with a lower risk of osteoporotic hip fractures in elderly Chinese: a 1:1 matched case–control study

Original Article



In this case–control study, we examined the relationship between the consumption of fruit and vegetables and risk of hip fractures in 646 pairs of incident cases and controls in elderly Chinese. We found that greater consumption of both fruit and vegetables in men and vegetables in women was associated with a lower risk of osteoporotic hip fractures in elderly Chinese.


The association between fruit and vegetable consumption and the risk of osteoporotic fractures remains controversial due to limited published evidence. The purpose of this study was to determine whether consuming fruits and vegetables has a protective effect against hip fractures.


Between January 2008 and December 2012, 646 (162 males, 484 females) incident cases (70.9 ± 6.8 years) of hip fractures were enrolled from five hospitals, with 646 sex- and age-matched (±3 years) controls (70.7 ± 6.8 years) from hospitals or the community. Face-to-face interviews were conducted to assess habitual dietary intakes using a 79-item food frequency questionnaire and various covariates by structured questionnaires.


Multivariate conditional logistic regression analyses showed dose-dependent inverse correlations between the intake of total fruit (p-trend = 0.014), total vegetables (p-trend <0.001), fruits and vegetables combined (p-trend < 0.001) and the risk of hip fractures after adjustment for sociodemographic characteristics, dietary factors and other potential confounders. The adjusted odds ratios (95 % confidence interval) for hip fractures in the top quartiles (vs. the lowest quartiles) for the intake of fruits, vegetables and the combination of fruits and vegetables were 0.53 (0.32–0.87), 0.37 (0.23–0.60) and 0.25 (0.15–0.41), respectively. Stratified analyses showed that the benefits remained significant in males (p = 0.001) but not in females (p = 0.210) (p-interaction 0.045). Among the subcategories of fruits and vegetables, similar associations were observed for all subgroups except light-coloured fruits.


Our findings suggest that greater consumption of both fruits and vegetables in men and vegetables in women may decrease the risk of osteoporotic hip fractures in elderly Chinese.


Case–control study Chinese Elderly Fruit Hip fractures Vegetables 


  1. 1.
    Johnell O, Kanis J (2005) Epidemiology of osteoporotic fractures. Osteoporosis International: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 16 Suppl 2:S3-7. doi:10.1007/s00198-004-1702-6Google Scholar
  2. 2.
    Dennison E, Mohamed MA, Cooper C (2006) Epidemiology of osteoporosis. Rheum Dis Clin North Am 32:617–629. doi:10.1016/j.rdc.2006.08.003 PubMedCrossRefGoogle Scholar
  3. 3.
    Cooper C, Atkinson EJ, Jacobsen SJ, O'Fallon WM, Melton LJ 3rd (1993) Population-based study of survival after osteoporotic fractures. Am J Epidemiol 137:1001–1005PubMedGoogle Scholar
  4. 4.
    D'Amelio P, Tamone C, Pluviano F, Di Stefano M, Isaia G (2005) Effects of lifestyle and risk factors on bone mineral density in a cohort of Italian women: suggestion for a new decision rule. Calcif Tissue Int 77:72–78. doi:10.1007/s00223-004-0253-3 PubMedCrossRefGoogle Scholar
  5. 5.
    Prentice A (2004) Diet, nutrition and the prevention of osteoporosis. Public Health Nutr 7:227–243. doi:10.1079/PHN2003590 PubMedCrossRefGoogle Scholar
  6. 6.
    Cashman KD (2007) Diet, nutrition, and bone health. J Nutr 137:2507S–2512SPubMedGoogle Scholar
  7. 7.
    Masse PG, Dosy J, Tranchant CC, Dallaire R (2004) Dietary macro- and micronutrient intakes of nonsupplemented pre- and postmenopausal women with a perspective on menopause-associated diseases. J Hum Nutr Diet 17:121–132. doi:10.1111/j.1365-277X.2004. 00508.x PubMedCrossRefGoogle Scholar
  8. 8.
    Yaegashi Y, Onoda T, Tanno K, Kuribayashi T, Sakata K, Orimo H (2008) Association of hip fracture incidence and intake of calcium, magnesium, vitamin D, and vitamin K. Eur J Epidemiol 23:219–225. doi:10.1007/s10654-008-9225-7 PubMedCrossRefGoogle Scholar
  9. 9.
    Bischoff-Ferrari HA, Dawson-Hughes B, Baron JA, Kanis JA, Orav EJ, Staehelin HB, Kiel DP, Burckhardt P, Henschkowski J, Spiegelman D, Li R, Wong JB, Feskanich D, Willett WC (2011) Milk intake and risk of hip fracture in men and women: a meta-analysis of prospective cohort studies. J Bone Miner Res 26:833–839. doi:10.1002/jbmr.279 PubMedCrossRefGoogle Scholar
  10. 10.
    Kanis JA, Johansson H, Oden A, De Laet C, Johnell O, Eisman JA, Mc Closkey E, Mellstrom D, Pols H, Reeve J, Silman A, Tenenhouse A (2005) A meta-analysis of milk intake and fracture risk: low utility for case finding. Osteoporos Int 16:799–804. doi:10.1007/ s00198-004-1755-6 PubMedCrossRefGoogle Scholar
  11. 11.
    Monma Y, Niu K, Iwasaki K, Tomita N, Nakaya N, Hozawa A, Kuriyama S, Takayama S, Seki T, Takeda T, Yaegashi N, Ebihara S, Arai H, Nagatomi R, Tsuji I (2010) Dietary patterns associated with fall-related fracture in elderly Japanese: a population based prospective study. BMC Geriatr 10:31. doi:10.1186/1471-2318-10-31 PubMedCrossRefGoogle Scholar
  12. 12.
    Benetou V, Orfanos P, Zylis D, Sieri S, Contiero P, Tumino R, Giurdanella MC, Peeters PH, Linseisen J, Nieters A, Boeing H, Weikert C, Pettersson U, Johansson I, Bueno-de-Mesquita HB, Dorronsoro M, Boffetta P, Trichopoulou A (2011) Diet and hip fractures among elderly Europeans in the EPIC cohort. Eur J Clin Nutr 65:132–139. doi:10.1038/ejcn.2010.226 PubMedCrossRefGoogle Scholar
  13. 13.
    Kaptoge S, Welch A, McTaggart A, Mulligan A, Dalzell N, Day NE, Bingham S, Khaw KT, Reeve J (2003) Effects of dietary nutrients and food groups on bone loss from the proximal femur in men and women in the 7th and 8th decades of age. Osteoporos Int 14:418–428. doi:10.1007/s00198-003-1391-6 PubMedCrossRefGoogle Scholar
  14. 14.
    Thorpe DL, Knutsen SF, Beeson WL, Rajaram S, Fraser GE (2008) Effects of meat consumption and vegetarian diet on risk of wrist fracture over 25 years in a cohort of peri- and postmenopausal women. Public Health Nutr 11:564–572. doi:10.1017/S1368980007000 808 PubMedCrossRefGoogle Scholar
  15. 15.
    Lin PH, Ginty F, Appel LJ, Aickin M, Bohannon A, Garnero P, Barclay D, Svetkey LP (2003) The DASH diet and sodium reduction improve markers of bone turnover and calcium metabolism in adults. J Nutr 133:3130–3136PubMedGoogle Scholar
  16. 16.
    Macdonald HM, Black AJ, Aucott L, Duthie G, Duthie S, Sandison R, Hardcastle AC, Lanham New SA, Fraser WD, Reid DM (2008) Effect of potassium citrate supplementation or increased fruit and vegetable intake on bone metabolism in healthy postmenopausal women: a randomized controlled trial. Am J Clin Nutr 88:465–474PubMedGoogle Scholar
  17. 17.
    Tucker KL, Hannan MT, Chen H, Cupples LA, Wilson PW, Kiel DP (1999) Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women. Am J Clin Nutr 69:727–736PubMedGoogle Scholar
  18. 18.
    Prynne CJ, Mishra GD, O'Connell MA, Muniz G, Laskey MA, Yan L, Prentice A, Ginty F (2006) Fruit and vegetable intakes and bone mineral status: a cross sectional study in 5 age and sex cohorts. Am J Clin Nutr 83:1420–1428PubMedGoogle Scholar
  19. 19.
    Chen YM, Ho SC, Woo JL (2006) Greater fruit and vegetable intake is associated with increased bone mass among postmenopausal Chinese women. Br J Nutr 96:745–751PubMedCrossRefGoogle Scholar
  20. 20.
    Zalloua PA, Hsu YH, Terwedow H, Zang T, Wu D, Tang G, Li Z, Hong X, Azar ST, Wang B, Bouxsein ML, Brain J, Cummings SR, Rosen CJ, Xu X (2007) Impact of seafood and fruit consumption on bone mineral density. Maturitas 56:1–11. doi:10.1016/j.maturitas.2006.05. 001 PubMedCrossRefGoogle Scholar
  21. 21.
    Li JJ, Huang ZW, Wang RQ, Ma XM, Zhang ZQ, Liu Z, Chen YM, Su YX (2012) Fruit and vegetable intake and bone mass in Chinese adolescents, young and postmenopausal women. Public Health Nutr 17:1–9. doi:10.1017/S1368980012001127 Google Scholar
  22. 22.
    Langsetmo L, Hanley DA, Prior JC, Barr SI, Anastassiades T, Towheed T, Goltzman D, Morin S, Poliquin S, Kreiger N (2011) Dietary patterns and incident low-trauma fractures in postmenopausal women and men aged ≥ 50 y: a population-based cohort study. Am J Clin Nutr 93:192–199. doi:10.3945/ajcn.110.002956 PubMedCrossRefGoogle Scholar
  23. 23.
    Xu L, Dibley M, D'Este C, Phillips M, Porteous J, Attia J (2009) Food groups and risk of forearm fractures in postmenopausal women in Chengdu, China. Climacteric 12:222–229. doi:10.1080/13697130802626958 PubMedCrossRefGoogle Scholar
  24. 24.
    McTiernan A, Wactawski-Wende J, Wu L, Rodabough RJ, Watts NB, Tylavsky F, Freeman R, Hendrix S, Jackson R (2009) Low-fat, increased fruit, vegetable, and grain dietary pattern, fractures, and bone mineral density: the Women's Health Initiative Dietary Modification Trial. Am J Clin Nutr 89:1864–1876. doi:10.3945/ajcn.2008.26956 PubMedCrossRefGoogle Scholar
  25. 25.
    Szathmari M (2011) Evaluation of fracture risk in osteoporosis. Orv Hetil 152:1304–1311. doi:10.1556/OH.2011.29191 PubMedCrossRefGoogle Scholar
  26. 26.
    Zhang CX, Ho SC (2009) Validity and reproducibility of a food frequency questionnaire among Chinese women in Guangdong province. Asia Pac J Clin Nutr 18:240–250PubMedGoogle Scholar
  27. 27.
    Liu YT, Dai JJ, Xu CH, Lu YK, Fan YY, Zhang XL, Zhang CX, Chen YM (2012) Greater intake of fruit and vegetables is associated with lower risk of nasopharyngeal carcinoma in Chinese adults: a case–control study. Cancer Causes Control 23:589–599. doi:10.1007/s10552 -012-9923-z PubMedCrossRefGoogle Scholar
  28. 28.
    Yang YX, Wang GY, Pan XC (2002) China food composition. Peking University Medical Press, BeijingGoogle Scholar
  29. 29.
    Willett WC, Howe GR, Kushi LH (1997) Adjustment for total energy intake in epidemiologic studies. Am J Clin Nutr 65:1220S–1228SPubMedGoogle Scholar
  30. 30.
    Hamidi M, Boucher BA, Cheung AM, Beyene J, Shah PS (2011) Fruit and vegetable intake and bone health in women aged 45 years and over: a systematic review. Osteoporos Int 22:1681–1693. doi:10.1007/s00198-010-1510-0 PubMedCrossRefGoogle Scholar
  31. 31.
    Ebrahimof S, Hoshyarrad A, Hossein-Nezhad A, Zandi N, Larijani B, Kimiagar M (2006) Fruit and vegetable intake in postmenopausal women with osteopenia. Arya J 1:183–187Google Scholar
  32. 32.
    Ebrahimof S, Hoshiarrad A, Hossein-Nezhad A, Larijani B, Kimiagar SM (2009) Effects of increasing fruit and vegetable intake on bone turnover in postmenopausal osteopenic women. Daru 17:30–37Google Scholar
  33. 33.
    New SA, Bolton-Smith C, Grubb DA, Reid DM (1997) Nutritional influences on bone mineral density: a cross-sectional study in premenopausal women. Am J Clin Nutr 65:1831–1839PubMedGoogle Scholar
  34. 34.
    New SA, Robins SP, Campbell MK, Martin JC, Garton MJ, Bolton-Smith C, Grubb DA, Lee SJ, Reid DM (2000) Dietary influences on bone mass and bone metabolism: further evidence of a positive link between fruit and vegetable consumption and bone health? Am J Clin Nutr 71:142–151PubMedGoogle Scholar
  35. 35.
    Lampe JW (1999) Health effects of vegetables and fruit: assessing mechanisms of action in human experimental studies. Am J Clin Nutr 70:475S–490SPubMedGoogle Scholar
  36. 36.
    Carpenter TO, DeLucia MC, Zhang JH, Bejnerowicz G, Tartamella L, Dziura J, Petersen KF, Befroy D, Cohen D (2006) A randomized controlled study of effects of dietary magnesium oxide supplementation on bone mineral content in healthy girls. J Clin Endocrinol Metab 91:4866–4872. doi:10.1210/jc.2006-1391 PubMedCrossRefGoogle Scholar
  37. 37.
    Jehle S, Hulter HN, Krapf R (2013) Effect of potassium citrate on bone density, microarchitecture, and fracture risk in healthy older adults without osteoporosis: a randomized controlled trial. J Clin Endocrinol Metab 98:207–217. doi:10.1210/jc.2012-3099 PubMedCrossRefGoogle Scholar
  38. 38.
    Cockayne S, Adamson J, Lanham-New S, Shearer MJ, Gilbody S, Torgerson DJ (2006) Vitamin K and the prevention of fractures: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 166:1256–1261. doi:10.1001/archinte.166.12.1256 PubMedCrossRefGoogle Scholar
  39. 39.
    Palacios C (2006) The role of nutrients in bone health, from A to Z. Crit Rev Food Sci Nutr 46:621–628. doi:10.1080/10408390500466174 PubMedCrossRefGoogle Scholar
  40. 40.
    Aruoma OI, Grootveld M, Bahorun T (2006) Free radicals in biology and medicine: from inflammation to biotechnology. Biofactors 27:1–3PubMedCrossRefGoogle Scholar
  41. 41.
    Benzie IF (2003) Evolution of dietary antioxidants. Comp Biochem Physiol A Mol Integr Physiol 136:113–126PubMedCrossRefGoogle Scholar
  42. 42.
    Bu SY, Hunt TS, Smith BJ (2009) Dried plum polyphenols attenuate the detrimental effects of TNF-alpha on osteoblast function coincident with up-regulation of Runx2, Osterix and IGF-I. J Nutr Biochem 20:35–44. doi:10.1016/j.jnutbio.2007.11.012 PubMedCrossRefGoogle Scholar
  43. 43.
    Bu SY, Lerner M, Stoecker BJ, Boldrin E, Brackett DJ, Lucas EA, Smith BJ (2008) Dried plum polyphenols inhibit osteoclastogenesis by downregulating NFATc1 and inflammatory mediators. Calcif Tissue Int 82:475–488. doi:10.1007/s00223-008-9139-0 PubMedCrossRefGoogle Scholar
  44. 44.
    Macdonald HM, New SA, Reid DM (2005) Longitudinal changes in dietary intake in Scottish women around the menopause: changes in dietary pattern result in minor changes in nutrient intake. Public Health Nutr 8:409–416. doi:10.1079/PHN2005705 PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2013

Authors and Affiliations

  • H.-L. Xie
    • 1
  • B.-H. Wu
    • 1
    • 2
  • W.-Q. Xue
    • 1
  • M.-G. He
    • 3
  • F. Fan
    • 1
  • W.-F. Ouyang
    • 1
    • 4
  • S.-l. Tu
    • 1
    • 5
  • H.-L. Zhu
    • 1
    • 7
  • Y.-M. Chen
    • 1
    • 6
  1. 1.Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public HealthSun Yat-sen UniversityGuangzhouPeople’s Republic of China
  2. 2.Guangzhou Orthopaedics Trauma HospitalGuangzhouPeople’s Republic of China
  3. 3.Zhongshan Ophthalmic CenterSun Yat-sen UniversityGuangzhouPeople’s Republic of China
  4. 4.Guangdong General HospitalGuangzhouPeople’s Republic of China
  5. 5.Orthopaedics Hospital of Baishi DistrictJiangmenPeople’s Republic of China
  6. 6.Department of Medical Statistics and Epidemiology, School of Public HealthSun Yat-sen UniversityGuangzhouPeople’s Republic of China
  7. 7.Department of Nutrition, School of Public HealthSun Yat-sen UniversityGuangzhouPeople’s Republic of China

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