Health Implications of A Vegetarian Diet: A Review

American Journal of Lifestyle Medicine
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Health Implications of a Vegetarian Diet : A Review

Kate Marsh, Carol Zeuschner and Angela Saunders
AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2012 6: 250 originally published online 4 November 2011
DOI: 10.1177/1559827611425762
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American Journal of Lifestyle Medicine May • Jun 2012
ANALYTIC Kate Marsh, BSc, MNutrDiet, PhD,

Carol Zeuschner, BSc, MSc, and
Angela Saunders, BS, MA
Health Implications of
a Vegetarian Diet: A Review
Abstract: There is now a significant Introduction that approximately 3% of US adults are
amount of research that demonstrates vegetarian (indicating that they never
the health benefits of vegetarian A vegetarian is someone who consumes eat meat, poultry, fish, or seafood), and
and plant-based diets, which have a diet consisting mostly of plant-based around 1% are vegan (they also never eat
been associated with a reduced risk foods, including fruits, vegetables, dairy, eggs, and honey).1
of obesity, diabetes, heart disease, legumes, nuts, seeds, and grains. Some
and some types of cancer as well as vegetarians also consume eggs and dairy
Health Benefits
increased longevity. Vegetarian diets products.
of a Vegetarian Diet
are typically lower in fat, particularly There are 4 main types of vegetarian
saturated fat, and higher in dietary diets: (1) a lacto-ovo-vegetarian Improved health is one of the many
fiber. They are also likely to include consumes dairy products and eggs but reasons people choose to adopt a
more whole grains, legumes, nuts, no meat, poultry, or seafood; (2) a lacto- vegetarian diet, and there is now a
and soy protein, and together with the vegetarian eats dairy products but not wealth of evidence to support the
absence of red meat, this type of eating eggs, meat, poultry, or seafood; (3) an health benefits of a vegetarian diet.
plan may provide many benefits for
the prevention and treatment of obesity
and chronic health problems, including
diabetes and cardiovascular disease. Improved health is one of the
Although a well-planned vegetarian or
vegan diet can meet all the nutritional
many reasons people choose
needs of an individual, it may be to adopt a vegetarian diet, and
necessary to pay particular attention to
some nutrients to ensure an adequate there is now a wealth of evidence
intake, particularly if the person is on
a vegan diet. This article will review to support the health beneﬁts
the evidence for the health benefits
of a vegetarian diet and also discuss of a vegetarian diet.
strategies for meeting the nutritional
needs of those following a vegetarian or ovo-vegetarian eats eggs but no dairy Research has found that vegetarians
plant-based eating pattern. products, meat, poultry, or seafood; and have lower rates of a number of health
(4) a vegan does not eat any animal problems, including overweight and
Keywords: vegetarian; vegan; obesity; products, including meat, fish, poultry, obesity, cardiovascular disease (CVD),
diabetes; cardiovascular disease; cancer; eggs, and dairy products; many vegans hypertension, type 2 diabetes, some
health; protein; iron; vitamin B12; will also avoid honey. cancers, gallstones, kidney stones,
calcium; zinc; vitamin D; essential fatty A 2009 nationwide poll conducted by constipation, and diverticular
acids the Vegetarian Resource Group estimated disease.2,3
DOI: 10.1177/1559827611425762. Manuscript received November 1, 2010; revised April 14, 2011; accepted April 18, 2011. From Northside Nutrition and Dietetics,
Chatswood, Australia. Address correspondence to Kate Marsh, BSc, MNutrDiet, PhD, Northside Nutrition and Dietetics, 74/47 Neridah Street, Chatswood NSW 2067,
Australia; e-mail: kate@nnd.com.au.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2012 The Author(s)
250

vol. 6 • no. 3 American Journal of Lifestyle Medicine
Although vegetarians generally have men, 23.52 kg/m2 in women), vegans body weight,28-30 and a lower incidence
a lower body mass index (BMI) and the lowest BMI (22.49 kg/m2 in men, of diabetes12,30,49 and hypertension,50-52
tend to be more health conscious than 21.98 kg/m2 in women), and fish eaters all of which contribute to CVD risk.
nonvegetarians,4 health outcomes remain and vegetarians a similar, intermediate Some research has also suggested
better even when these factors are taken mean BMI.29 Differences in macronutrient that a vegetarian diet may reduce the
into account. Furthermore, a number of intakes accounted for about half the susceptibility of LDL to oxidation.53
studies have shown increased longevity difference in mean BMI between vegans Specific aspects of a vegetarian diet,
among vegetarians.5,6 It is likely that and meat eaters, with high protein and including a lower intake of saturated
these benefits result from both a reduced low fiber intakes most strongly associated fat, higher intake of soluble fiber, and
consumption of potentially harmful with increasing BMI.29 Similarly, the increased consumption of whole grains,
dietary components, including saturated Adventist Health Study-2 found that mean legumes, nuts, and soy protein, are
fat, cholesterol, animal protein, red BMI was lowest in vegans (23.6 kg/m2) likely to contribute to its cardiovascular
meat, and heme iron, and an increased and incrementally higher in lacto- benefits.54 Several studies have
consumption of beneficial dietary ovo vegetarians (25.7 kg/m2), pesco- demonstrated an association between
components, including fruit, vegetables, vegetarians (those who also ate fish; whole grain intake and CVD risk, and
whole grains, legumes, and nuts, which 26.3 kg/m2), semivegetarians (those a recent meta-analysis estimated that
are rich in dietary fiber, antioxidants, and who ate meat, poultry, or fish less a greater intake of whole grains (2.5
phytochemicals.7 than once per week; 27.3 kg/m2), and servings per day vs 0.2 servings per day)
Vegetarian diets differ from nonvegetarians (28.8 kg/m2).30 was associated with a 21% lower risk of
nonvegetarian diets in many respects, There are a number of possible CVD events.55 The National Health and
but the most significant difference is explanations for this association, Nutrition Examination Survey (NHANES)
the absence of red meat intake in a including the lower fat intake, higher 1 Epidemiologic Follow-up Study found
vegetarian diet. Research has linked intake of dietary fiber, and lower energy that consuming legumes at least 4 times
higher intakes of red meat and processed density typical of a vegetarian diet. Foods per week, compared with less than
meat with an increased risk of obesity,8 such as whole grains and nuts are more once per week, was associated with a
type 2 diabetes,9-13 gestational diabetes,14 regularly consumed by vegetarians and 22% reduced risk of CHD and an 11%
CVD,15-17 and some types of cancer.18-25 have been independently associated with reduced risk of CVD.56 Similarly, the
These findings are summarized in a reduced risk of obesity and weight Japanese Collaborative Cohort Study
Table 1. A large study investigating the gain.31-33 A higher intake of red meat, on (JACC) found an inverse association
association of a wide range of meat the other hand, has been associated with between bean intake (which included
intakes with chronic disease mortality an increased risk of weight gain.34-36 soy) and CVD risk.57 The highest intake
found that both red and processed meat of legumes (4.5 servings per week) was
intakes were associated with modest Cardiovascular Disease associated with a 16% reduced risk of
increases in total mortality, cancer The most consistent evidence for total CVD and a 10% reduced risk of
mortality, and CVD mortality.26 Low meat the health benefits of a vegetarian diet total mortality. Regular nut consumption
intake, on the other hand, has been relates to a reduced risk of coronary has been found to protect against
associated with greater longevity.5 heart disease (CHD) and coronary CHD in both epidemiological and
disease mortality. Several studies have clinical trials. Nuts may protect against
Overweight and Obesity demonstrated a lower incidence of CHD through effects on lipids, lipid
Research has consistently shown that CHD,37-41 and a combined analysis of oxidation, inflammation, and vascular
vegetarians, and particularly vegans, 5 prospective studies reported a 24% reactivity.58 Soy protein has been shown
are leaner than their omnivorous lower risk of mortality from ischemic to reduce total and LDL cholesterol
counterparts.27-30 The European heart disease (IHD) in vegetarians levels, and a recent meta-analysis of
Prospective Investigation in Cancer and compared with meat eaters, with lacto- 30 studies demonstrated a small but
Nutrition (EPIC) Oxford study compared ovo vegetarians having a 34% reduced significant reduction in both total and
weight gain over 5 years in almost 22 000 risk and vegans a 26% reduced risk.42,43 LDL cholesterol with the consumption
meat-eating, fish-eating, vegetarian, and The benefit was apparent in those who of 25 g of soy protein per day.59 Since
vegan men and women.28 Weight gain had followed their diet for at least 5 years 1999, the US FDA has approved a health
was lowest in the vegan group and those and was greater in younger age groups. claim that foods high in soy protein may
who, during follow-up, had changed to These findings are perhaps not help lower heart disease risk.60 Although
a diet containing fewer animal foods. surprising considering that vegetarians individual components of a vegetarian
The same study reported a significant generally have a better cardiovascular diet may provide benefits for CVD risk,
difference in age-adjusted BMI between risk profile than nonvegetarians, with a combination of these foods is likely to
the 4 diet groups, with meat eaters lower total and low-density lipoprotein provide the greatest effect. For example,
having the highest BMI (24.41 kg/m2 in (LDL) cholesterol levels,38,44-48 a lower a vegetarian diet incorporating soluble
251

252
Table 1.
Studies Showing Association Between Red Meat Intake and Risk of Chronic Disease and Mortality
Dietary Measure of Meat Main Findings,

Study Follow-up Assessment Intake (Lowest vs RR or OR (95%
Reference Type Population Period Method Outcome Type of Meat Highest) CI) Adjustment
26
Sinha et al Cohort 322 263 Men 10 years FFQ All mortality Red meat 9.3 vs 68.1 g/1000 kcal 1.31 (1.27-1.35) Age, ethnicity, energy,
and 223 390 (men) education, marital
Processed meat 5.1 vs 19.4 g/1000 kcal 1.16 (1.12-1.20)
women aged 50 status, FH cancer,
to 71 years (NIH- All mortality Red meat 9.1 vs 65.9 g/1000 kcal 1.36 (1.30-1.43) smoking, alcohol, PA,
AARP Diet & (women) vitamin supplement
Health Study) use, fruit consumption,
Cancer mortality Red meat 9.3 vs 68.1 g/1000 kcal 1.22 (1.16-1.29) vegetable
(men) consumption, HRT use
in women
Cancer mortality Red meat 9.1 vs 65.9 g/1000 kcal 1.20 (1.12-1.30)
(women)
CVD mortality Red meat 9.3 vs 68.1g/1000 kcal 1.27 (1.20-1.35)
(men)
CVD mortality Red meat 9.1 vs 65.9 g/1000 kcal 1.50 (1.37-1.65)
(women)
Wang and Cross- 13 602 US N/A 24-hour recall Obesity Total meat 22 vs 516 g 1.27 (1.08 - 1.49) Age, sex, ethnicity,
Beydoun8 sectional adults (1999- SES, PA
Red meat 0 vs 151 g 1.20 (1.07 - 1.35)
2004 NHANES)

Central obesity Total meat 22 vs 516 g 1.33 (1.13 - 1.55)
Red meat 0 vs 151 g 1.09 (1.03 – 1.38)
Vang et al12 Cohort 8401 adults 17 years FFQ, five 24- Diabetes risk Total meats Never vs ≥1/wk 1.29 (1.08 - 1.55) PA, age, sex,
aged 45-88 (1960- hour recalls education, smoking,
Red meat Never vs ≥1/wk 1.27 (1.06-1.53)
years (Adventist 1976) on 147 cohort alcohol
Health Studies) members Processed meats Never vs weekly 1.38 (1.05 – 1.82)
Salted fish Never vs weekly 1.55 (1.00–2.39)
Frankfurters Never vs weekly 1.29 (0.94–1.76)
(continued)
May • Jun 2012
vol. 6 • no. 3
Table 1. (continued)

Zhang Cohort 13 110 Women 7 years FFQ GDM risk Red meat 0.14 vs 1.07 servings/d 1.74 (1.35 – 2.26) Age, parity, BMI,
et al14 (Nurses Health (1991- smoking, ethnicity, FH-
Total processed meat 0 vs 0.57 servings/d 1.68 (1.30 – 2.16)
Study II) 1998) DM, PA, energy
Bacon 0 vs ≥0.14 servings/d 1.29 (1.02-1.63)
Hot Dogs 0 vs ≥0.14 servings/d 1.25 (1.00-1.56)
Other processed meats 0 vs ≥0.14 servings/d 1.60 (1.31-1.95)
9
Fung et al Cohort 69 554 women 14 years FFQ Type 2 diabetes Red meat 0.21 vs 0.96 servings/d 1.36 (1.18-1.56) Age, FH-T2DM, HC
aged 38 to 63 (1984- risk smoking, menopausal
Total processed meat 0.04 vs 0.55 servings/d 1.60 (1.39-1.83)
years (Nurses 1998) status, energy, HT, PA,
Health Study) Bacon 0 vs 0.19 servings/d 1.42 (1.26-1.59) alcohol, BMI, missing
FFQ.
Hot dogs, 0 vs 0.14 servings/d 1.33 (1.17-1.51)
Processed meats 0 vs 0.28 servings/d 1.40 (1.23-1.59)
Total processed and red 0.32 vs 1.41 servings/d 1.55 (1.34-1.80)
meats
Song et al11 Cohort 37 309 women 8.8 years FFQ Type 2 diabetes Red meat 0.03 vs 1.42 servings/d 1.24 (1.00-1.54) Age, BMI, energy, PA,
aged 45 years or risk alcohol, smoking,
Total processed meat 0 vs 0.56 servings/d 1.19 (1.00-1.42)
more (Womens FH-DM. Additional
Health Study) Bacon <1/wk vs ≥2/wk 1.17 (1.02-1/35) adjustment for dietary

fibre, GL, Mg, total fat
Hot dogs <1/wk vs ≥2/wk 1.24 (1.05-1.45)
Schulze Cohort 91 246 US 8 years FFQ Type 2 diabetes Total processed meat <1/wk vs ≥5/week 1.72 (1.26-2.36) Age, BMI, energy,
et al10 women aged risk alcohol, PA, FH-DM,
26 to 46 years smoking, HC. HT,
(Nurses Health HRT use, OCP use.
Study II) Additional adjustment
for Mg, GI, cereal fiber,
caffeine, fatty acids
(continued)
253
254

van Dam Cohort 42 504 Men 12 years FFQ, 2 × Type 2 diabetes Total processed meat <1 serving/month vs 1.46 (1.14 - 1.86) Age; energy; time
et al13 aged 40-75 (1986- 1-week risk ≥5 servings/wk period, PA, smoking,
years (Health 1998) diet records alcohol, HC, HT, FH-
Bacon 1.33 (1.11-1.58)
<1 serving/month vs ≥2
Professionals for 127 T2DM, intake of cereal
servings /wk
Follow-Up study) participants fiber and Mg, BMI
Hot dogs <1 serving/month vs ≥2 1.26 (1.00–1.60)
servings /wk
Other processed meats <1 serving/month vs ≥2 1.18 (0.99-1.41)
servings /wk
Hamburgers <1 serving/month vs ≥2 1.27 (0.99-1.62)
servings /wk
Bernstein Cohort 84 136 Women 26 years FFQ CHD risk Total meat 0.79 vs 2.48 servings/d 1.22 (1.06-1.40) Age, smoking, alcohol,
et al17 aged 30 to 55 energy, cereal fiber,
Red meat 0.49 vs 2.11 servings/d 1.29 (1.12-1.49)
years in the trans fats, BMI,
Nurses’ Health Red meat excluding 0.28 vs 1.17 servings/d 1.13 (0.99-1.30) menopausal status,
Study processed meat parental history of early
MI, multivitamin use,
vitamin E supplement
use, aspirin use, PA
Kontogianni Case 848 Cases (of n/a FFQ ACS risk Total meat <4 vs >8 portions / 4.79 (3.32-6.92) BMI, smoking, PA,
et al15 Control first event of an month education, FH-CHD,
ACS) and 1078 HT, HL, DM, medication

population-based use
controls, age and
sex matched
Qi et al16 Cohort 6 161 Women 20 years FFQ Total CHD Red meat 0.55 vs 2.39 servings/d 1.36 (0.97-1.91) Smoking, alcohol,
with type 2 HT, HC, FH-CHD,
Fatal CHD Red meat 0.55 vs 2.39 servings/d 2.05 (1.08-3.90)
diabetes (Nurses PA, aspirin use,
Health Study) Coronary Red meat 0.55 vs 2.39 servings/d 1.91 (0.96-3.83) duration of diabetes,
revascularization menopausal status and
postmenopausal HRT
use, dietary factors
(cereal fiber, trans fat,
P:S ratio, GL, vitamin C
May • Jun 2012
(continued)

vol. 6 • no. 3

Cross et al22 Cohort 300 948 US 7 years FFQ Colorectal Red meat 451 vs 668 g/1000 kJ 1.24 (1.09-1.42) Sex, education, BMI,
men and women cancer smoking, energy,
Processed meat 440 vs 633 g/1000 kJ 1.16 (1.01-1.32)
(NIH-AARP Diet fiber, dietary calcium.
and Health Colon cancer Red meat 451 vs 668 g/1000 kJ 1.21 (1.03-1.41) Red meat and white
Study) meat were mutually
adjusted for each
Rectal cancer Red meat 451 vs 668 g/1000 kJ 1.35 (1.03-1.76) other. Processed meat
was adjusted for
nonprocessed meat
Kolahdooz Case 683 Cases and N/A Semiquantitative Ovarian cancer Meat and fat 0 vs 4 or more serves/d 2.49 (1.75-3.55) Age, age squared,
et al25 control 777 control FFQ and oral contraceptive
Processed meat 0 vs 4 or more serves/d 2.49 (1.69-3.69)
women aged 18- interviews use, parity, education,
79 years Red meat 0 vs 4 or more serves/d 2.72 (1.89-3.93) energy intake
Lagiou Case 2304 Patients N/a FFQ UADT cancer Red meat Not specified (based 1.14 (1.05-1.25) Age, sex, BMI, height,
et al23 control with UADT on increasing tertiles of education, alcohol,
(upper consumption) smoking
aerodigestive
Pork 1.13 (1.02-1.25)
tract) cancer
(1861 men and Cold cuts 1.12 (1.02-1.22)
443 women) and
2227 control
Navarro Case Population- N/A Interview, Esophageal Total meat Not specified (based on 1.43 (1.11-1.83) Sex, study location,
Silvera control based 687 questionnaire adenocarcinoma increasing intake of 1 age, ethnicity, income,

et al24 controls, 1095 and FFQ serving per day) education, BMI,
Gastric cardia Total meat 1.37 (1.08-1.73)
cases aged 30- smoking, alcohol,
adenocarcinoma
79 years energy
Esophageal Red meat 2.10 (0.99-4.45)
squamous cell
carcinoma
Nongastric High nitrite meats 1.88 (1.24-2.84)
cardia
adenocarcinoma
(continued)
255
256

Follow-up Assessment Intake (Lowest vs RR or OR (95%
Reference Study Type Population Period Method Outcome Type of Meat Highest) CI) Adjustment
Cross et al18 Cohort NIH- 494 036 Up to 8.2 FFQ Colorectal Red meat 9.8 vs 62.7 g/1000 kcal 1.24 (1.12-1.36) Age, sex, education,
AARP Diet (294 724 men years cancer marital status, FH-
and Health and 199 312 cancer, ethnicity,
Study women) aged Liver cancer Red meat 9.8 vs 62.7 g/1000 kcal 1.61 (1.12-2.31) BMI, smoking, PA,
50-71 years. energy, alcohol,
Mean follow- fruit and vegetable
up 6.8 years Lung cancer Red meat 9.8 vs 62.7 g/1000 kcal 1.20 (1.10-1.31) consumption.

Pancreatic Red meat 9.8 vs 62.7 g/1000 kcal 1.43 (1.11-1.83),
cancer men
Processed meat 1.6 vs 22.6 g/1000 kcal 1.31 (1.01-1.68),
men
Myeloma Processed meat 1.6 vs 22.6 g/1000 kcal 1.3 (0.98-1.71)
Cervical cancer Processed meat 1.6 vs 22.6 g/1000 kcal 1.72 (0.96-3.09)
Cross et al19 Randomized 29 361 Men 3-5 years FFQ Prostate cancer Very well done meat 0 vs >10 g/d 1.42 (1.05-1.92) Age, ethnicity,
control trial aged 55-74 study center, FH
PLCO Cancer years prostate cancer,

Screening BMI, smoking, PA,
Trial energy, vitamin E
supplement use,
lycopene intake,
history of DM,
aspirin use,
number of screening
exams during
follow-up
(continued)
May • Jun 2012
vol. 6 • no. 3

Follow-up Assessment Intake (Lowest vs RR or OR (95%
Reference Study Type Population Period Method Outcome Type of Meat Highest) CI) Adjustment
20
Norat et al Cohort (EPIC) 478 040 Men 6 years Country-specific Colorectal Red and processed <10 vs ≥160 g/d 1.35 (0.96-1.88) Age, sex, energy
and women (mean 4.8 validated cancer meat from fat and nonfat
aged between years) FFQ +/− food sources, height,
35 and records weight, occupational
70 years PA smoking, dietary
fiber, alcohol,
Processed meat <10 vs ≥80 g/d 1.42 (1.09-1.86) geographical center
Bosetti Case control Cases, 1031 7.5 years FFQ Ovarian cancer Red meat <2.2 vs 7 servings/wk 1.53 (1.13-2.05) Age, study center,
et al21 women (age education, year at
range 18- interview, parity, OCP
79 years); use, energy
controls, 2411
women (age
range 17-79
years)

Abbreviations: RR, relative risk; OR, odds ratio; CI, confidence interval; BMI, body mass index; PA, physical activity; MS, marital status; SES, socioeconomic status; OC, oral contraceptive use; HRT, hormone replacement
therapy; FH, family history; DM, diabetes; T2DM, type 2 diabetes; HC, hypercholesterolemia; HT, hypertension; HL, hyperlipidemia; ACS, acute coronary syndrome; CHD, coronary heart disease; MI, myocardial infarct; Mg,
magnesium; GI, glycemic index; GL, glycemic load; energy, total dietary energy intake; FFQ, food frequency questionnaire; P:S, polyunsaturated to saturated fat ratio.
257
fiber, soy protein, almonds, and plant a diet high in fruit, vegetables, whole colon cancer risk.79 The bulking effect
sterols has been shown to reduce LDL grains, and low-fat dairy products of fiber may increase the transit rate
cholesterol by a similar amount as 20 g of significantly reduced blood pressure in of carcinogens through the bowel and
lovastatin does, over 4 weeks.61 those with normal blood pressure or mild reduce the surface contact exposure of
Although some studies have linked red hypertension.72 carcinogenic compounds with the bowel
meat intake with CHD risk,62 a recent wall.80,81 Those who eat vegetarian diets
meta-analysis found that processed meat Cancer have colonic environments that are
intake, but not red meat intake, was Overall, cancer rates in vegetarians different from those who eat meat-rich
associated with a higher risk of CHD.63 appear to be moderately lower than diets. They tend to have lower colonic
Several studies have demonstrated the others living in the same communities, cell proliferation, different profiles of
benefits of a Mediterranean diet—a and life expectancy appears to be intestinal bacteria, lower levels of fecal
mostly plant-based diet with low meat greater.40,51,73 However, results for specific enzymes, and lower levels of mutagens
intake—for a reduced risk of CHD.64-66 cancers are less convincing and require in feces—all of which may play a role in
more study.74 Most of the research reducing bowel cancer risk.82-84 However,
Hypertension conducted on vegetarian diets and cancer the protective effects of fiber on
Evidence suggests that a vegetarian diet has involved lacto-ovo-vegetarians. Of colorectal cancer remains controversial,
may help in both the prevention and the studies looking at vegan groups, with a large pooled analysis suggesting
management of hypertension.67 The EPIC- most only cover a short period of time that dietary fiber intake did not affect
Oxford study found that non–meat eaters or a small group. Furthermore, many colorectal cancer incidence.85
had a lower prevalence of hypertension Western vegetarians choose a meat-free Research also suggests that lifelong
and lower systolic and diastolic blood diet for its health benefits in addition to vegetarianism may be associated with
pressures than meat eaters, but this was other health or lifestyle practices, such as a reduction in the risk of breast cancer
largely a result of differences in BMI.50 abstaining from smoking and avoidance through its association with a higher
The age-adjusted prevalence of self- or moderate consumption of alcohol,5,39,75 intake of vegetables, fruit, soy, and
reported hypertension was significantly which are also linked with cancer risk. pulses and the avoidance of red meat.86-
different between the 4 diet groups, The World Cancer Research Fund 90
Potential reasons for a lower incidence
ranging from 15.0% in male meat eaters reported in 2007 that there is convincing of breast cancer include the fact that
to 5.8% in male vegans, and from 12.1% evidence that consumption of red vegetarians have lower levels of blood
in female meat eaters to 7.7% in female meat and processed meat increase the estrogens, longer menstrual cycles, and
vegans.50 Fish eaters and vegetarians risk of colorectal cancer. One would a later onset of menstruation, resulting
had a similar, intermediate prevalence therefore expect vegetarians to have in a reduction in exposure to estrogen.89
of hypertension. In the Adventist Health a lower incidence of colorectal cancer However, more recent studies have not
Study-2, a significant, graded association than those who eat meat; however, the supported these findings, and further
with blood pressure was also observed.51 evidence to support this is not consistent. research to clarify the benefits of a plant-
Compared with nonvegetarians, vegans Whereas US Adventist studies found that based diet for breast cancer prevention is
were 75% less likely to be treated for vegetarians had a lower risk of colon needed.
hypertension, lacto-ovo vegetarians cancer, a study of British vegetarians The health benefits of protective
65% less likely, pesco-vegetarians found that they had a similar rate of compounds in a plant-based diet have
38% less likely, and semivegetarians colon cancer to nonvegetarians.40,51,76-78 been linked to the prevention of cancer
23% less likely. It may be that the classification of initiation and the retardation of cancer
A number of randomized clinical vegetarian and nonvegetarian is too cell growth. Foods that are central to
trials have shown that a vegetarian simple, and vegetarian diets may differ vegetarian diets such as whole grains,
diet can lower blood pressure in widely in nutrient composition, even legumes, fruits, and vegetables are rich
both normotensive and hypertensive in the absence of red meat. This may in fiber, folic acid, phytochemicals, and
individuals.68,69 Although it is well particularly be the case when comparing antioxidants.91 Carotenoids, ascorbate,
accepted that both weight loss and vegetarians in different countries.51,78 The tocopherols, selenium, dithiolthiones,
reducing sodium intake can lower blood definition of vegetarian may also differ isothiocyanates, indoles, phenols,
pressure,70 the effect of a vegetarian between studies, with some classifying protease inhibitors, allium compounds,
diet on blood pressure appears to themselves as vegetarian while still plant sterols, limonene, and other
be independent of these, suggesting regularly consuming seafood or white biologically active compounds are often
that other components of the diet meat. It has been suggested that more collectively referred to as phytochemicals
are responsible,68,69,71 These findings descriptive vegetarian subtypes need to that, among many other properties, have
are consistent with the results of the be used for epidemiological research.51 anticancer activity.92-95
DASH (Dietary Approaches to Stopping The higher fiber intakes of vegetarians In addition to the cancer-protective
Hypertension) trial, which found that may play a major role in reducing effect of a plant-based diet, eating red
258

meat may contribute to cancer formation. risk, pesco-vegetarians a 30% reduction intake of saturated fat and a higher
The consumption of red meat cooked at in risk, and semivegetarians a 24% intake of dietary fiber, whole grains,
high temperatures, diets rich in animal reduction in risk.30 legumes, and nuts. These dietary factors
fat and cholesterol, or diets high in Whether the reduction in risk of have also been shown to reduce CVD
animal protein may increase the risk diabetes in vegetarians can be attributed risk, one of the main complications of
of developing cancer.18,26,96-98 Red meat, to the absence of meat or the higher diabetes. Furthermore, substituting soy
particularly high-fat processed meats, intake of plant foods such as whole or vegetable protein for animal protein
may give rise to cancerous compounds grains, legumes, and nuts is unclear. in the diet has been shown to reduce the
when cooked at a high temperature, However, several studies have shown risk and progression of renal disease in
the metabolism of which are risk a positive association between dietary both type 1 and type 2 diabetes.105-110
factors for the development of cancer.99 heme iron intake and heme iron intake There are only a few intervention
Excessive iron is also thought to promote from red meat and the risk of type 2 studies assessing the effects of a
the formation of reactive species of diabetes.11,100-103 A positive association vegetarian diet in people with diabetes,
free radicals that can damage cells.99 between the intake of red meat, and weight loss has generally been
However, although some researchers processed meats, and animal protein greater on the vegetarian diets, making
have found significant results showing and the incidence of type 2 diabetes has it difficult to determine the independent
a direct link between red meat, heme also been demonstrated,9-12 and a high effect of the diets.111 However, greater
iron, and high temperature cooking and intake of red meat prior to becoming weight loss may be one of the
cancer formation (see Table 1), the issue pregnant significantly increased the risk advantages of a vegetarian diet because
remains contentious and requires further of developing gestational diabetes.14 even small amounts of weight loss
research. In the Adventist Mortality Study and can help in both the prevention and
Adventist Health Study, those who management of type 2 diabetes. One
Diabetes were weekly consumers of all meats study comparing a low-fat vegan diet
Vegetarian and vegan diets offer (including red meat, poultry, and fish) with a diet based on the American
significant benefits for the prevention and were 29% more likely to develop Diabetes Association (ADA) guidelines
management of diabetes. Observational diabetes compared with those who ate found that the vegan diet reduced HbA1c
studies have demonstrated a significantly no meat, whereas those who consumed levels significantly more than the ADA
lower risk of type 2 diabetes in any processed meats (including salted diet (by 1.23 vs 0.38 percentage points in
individuals following a vegetarian diet fish and frankfurters) were 38% more those who did not change medication).112
when compared with nonvegetarians.30,49 likely to develop diabetes.12 Furthermore, Furthermore, 43% of people were able
The original Adventist Health Study long-term adherence (over a 17-year to reduce their medication compared
found that vegetarians had approximately interval) to a diet that included at least with only 26% in the ADA group.
half the risk of developing diabetes, weekly meat intake was associated with Earlier studies of low-fat vegan diets in
with a significant association observed a 74% increase in the risk of diabetes patients with type 2 diabetes have also
between red meat intake and diabetes compared with long-term adherence to demonstrated significant improvements
risk, independent of body weight, other a vegetarian diet (no meat intake). Even in blood glucose control and blood fats
dietary factors, and physical activity.49 after controlling for weight and weight as well as considerable reductions in
In the more recent Adventist Health change, weekly meat intake increased medication use,113,114 although the larger
Study-2 involving more than 60 000 men the risk of diabetes by 38%. A recent of these studies was not controlled.
and women, those following a vegan systematic review and meta-analysis
diet were found to have a diabetes of cohort studies of meat consumption Other Diseases
prevalence that was approximately one and type 2 diabetes risk estimated the
Limited research has suggested that
third that of nonvegetarians (2.9% vs relative risk comparing high versus low
a vegetarian diet may also reduce
7.6%), whereas the lacto-ovo vegetarians, intake, and this was 1.17 for total meat,
the risk of other health conditions,
pesco-vegetarians, and semivegetarians 1.21 for red meat, and 1.41 for processed
including diverticular disease, gallstones,
had an intermediate diabetes prevalence meat.104 The authors predict that a 120
rheumatoid arthritis, gout, and kidney
of 3.2%, 4.8%, and 6.1%, respectively.30 g/d increase in red meat consumption
disease. Although these findings are
After adjusting for confounding factors, increases the risk of diabetes by 20%
positive and add to the evidence of
those following a vegan diet had an and a 50 g/d increase in processed meat
the health benefits of a vegetarian diet,
almost 50% reduction in the risk of consumption increases the risk by 57%.
the small number of studies mean that
developing type 2 diabetes compared In addition to the absence of red meat,
further research is required to confirm
with nonvegetarians. The risk reduction there are a number of other aspects
these benefits.
became incrementally smaller as more of a vegetarian diet that may protect
animal products were consumed: lacto- against and assist in the management Diverticular disease. Vegetarians tend to
ovo vegetarians had a 46% reduction in of type 2 diabetes, including a lower have a lower incidence of diverticular
259

disease than nonvegetarians.115 This is protein intake. There was a protective or CVD, a dietary pattern rich in whole
believed to be a result of the higher effect from vegetable and dairy proteins, grains, fruit, and low-fat dairy food
dietary fiber intake of vegetarians from an with the consumption of low-fat dairy was associated with a lower risk for
increased consumption of whole grains, products significantly reducing the risk microalbuminuria and high mean albumin-
fruits, vegetables, nuts, and legumes.3 of gout. A second study looking at the to-creatinine ratio (ACR), whereas intake
More recent research suggests that diets effect of a vegetarian diet and different of nondairy animal foods was positively
high in fat and red meat, independent of omnivorous diets on the risk of uric acid associated with high ACR.132
fiber intake, may be linked to an increase crystallization found that the risk of uric
in diverticulitis.116 acid crystallization was highest with high Meeting Nutritional
levels of meat intake and Western diets, Needs
Gallstones. Vegetarians may be only
declined significantly on a balanced
half as likely to develop gallstones as The American Dietetic Association
omnivorous diet, and was lowest on a
nonvegetarians.117 In a cross-sectional support the fact that, in addition to
vegetarian diet.125
study, the prevalence of gallbladder their health benefits, well-planned
disease was significantly lower in female Rheumatoid arthritis. Several studies vegetarian diets, including vegan
vegetarians than female omnivores have shown that individuals with diets, are nutritionally adequate and
(12% vs 25%).117 In addition, a 20-year rheumatoid arthritis may benefit from are appropriate for individuals during
prospective study of 80 898 women a period of fasting followed by a all stages of life.133 Some nutrients
found that increased consumption low-fat vegetarian or vegan diet.126- can be more difficult to obtain on a
of vegetable protein was associated 129
A systematic review of 4 controlled vegetarian diet, but careful planning
with a reduced risk of having a studies lasting at least 3 months found a and, in some cases, the use of fortified
cholecystectomy.118 A separate evaluation clinically and statistically significant effect foods or supplements can ensure that
of the same cohort of women found of such diets.130 The exact mechanism an individual’s nutrition needs are met
that increasing the consumption of fruits for these improvements is unclear, but while maximizing the health benefits of a
and vegetables was associated with a they may be a result of a reduction in vegetarian or vegan diet.
decreased incidence of gallstones.119 inflammation.126 Weight loss may also
In hamsters fed a lithogenic diet, the play a part; however, a pooled analysis Protein
incidence of gallstones was decreased of 3 studies found that weight reduction Although the adequacy of protein in
in a dose-dependent manner by did not significantly contribute to the vegetarian diets is sometimes questioned,
progressively replacing casein with improvement in rheumatoid arthritis vegetarian diets usually exceed protein
soy protein in the diet.120,121 It has when individuals were on lacto- requirements, although they may provide
been proposed that the lower BMI of vegetarian, vegan, or Mediterranean less protein than a nonvegetarian diet.133
vegetarians; higher fiber, legume, and diets.131 Because most plant foods contain limited
lecithin intakes; and possibly greater amounts of one or more essential amino
Kidney disease. High intakes of animal
soy protein intake may be contributing acids, it was once thought that certain
protein may have adverse effects for
factors.122 A recent study in women found combinations of plant foods had to
those with underlying kidney problems.
that frequent nut consumption (often be eaten at the same meal to ensure
A study of individuals with type 2
higher in vegetarian diets) reduced the sufficient essential amino acids. It is now
diabetes and macroalbuminuria found
risk of cholecystectomy.123 known that strict protein combining is
that eliminating red meat from the diet,
Gout. Limited research suggests that gout either by replacing it with chicken or not necessary, provided energy intake is
may also be less common in vegetarians. by following a lacto-vegetarian, low- adequate and a variety of plant foods are
A study of nearly 50 000 male individuals protein diet improved renal function and eaten each day, including legumes, whole
older than 12 years, comparing those blood fat levels.108 In patients with type grains, nuts and seeds, soy products, and
who suffered from gout with those who 1 diabetes, improved kidney function vegetables.134 Furthermore, soy protein
did not, found that the consumption of has been demonstrated following dietary has a PDCAAS (protein digestibility–
meat, particularly red meat, and all types intervention in which animal protein corrected amino acid score) that is almost
of seafood significantly increased the risk was replaced with vegetable protein109 identical to meat.135 Plant sources of
of gout.124 Eating more than 2 servings of and soy protein.110 A recent study protein include legumes, nuts, and soy
red meat per week increased the risk by in patients with type 2 diabetes and products, including soy milk, soy yoghurt,
50%, whereas eating more than 1 serving nephropathy found that replacing 35% tofu, and tempeh. Grains and vegetables
of canned tuna per week increased the of animal protein intake with soy protein also contain protein but in small amounts.
risk by 28%. In contrast, no increased significantly reduced proteinuria and
risk was seen with the consumption of urinary creatinine.106 Vitamin B12 (Cobalamin)
purine-rich vegetables, and there was The Multiethnic Study of Atherosclerosis Vitamin B12 is found only in animal
no association with the overall vegetable found that in those without diabetes products, so a deficiency of this vitamin
260

is a potential concern for anyone tannins, found in tea and coffee,142 and and increasing absorption.152,160 As with
following a vegan or vegetarian diet or phytates in whole grains and legumes iron, zinc deficiency is no greater in
anyone who significantly restricts animal can inhibit the absorption of iron, vegetarians than in nonvegetarians,152
products. Serum levels of vitamin B12 are with vitamin C aiding absorption most and zinc intakes of vegetarians are close
generally lower in vegetarians, especially effectively in meals containing high to recommended levels.148 Absorption
vegans, decreasing with increasing levels of phytates and polyphenols.143-145 of zinc is reduced by phytates found in
duration of following the diet.136,137 The net effect of various enhancers or wheat bran, whole grains, and legumes.
Although it can take several years inhibitors may be less important in a However, processing a food by leavening
for deficiency symptoms to develop, highly varied diet, where no one factor (yeast in breads), soaking, fermenting, or
anyone excluding animal products will is present in sufficient amounts to be of sprouting can reduce the phytate level
eventually become deficient if their diet significance.146,147 and make zinc more readily available.161
is not adequately supplemented. Recent Vegetarian diets can contain as much Again, like iron, commonly eaten plant
findings from the EPIC-Oxford study or more iron (nonheme) than mixed foods, such as nuts, seeds, and whole
showed that in a cohort of 689 men diets, primarily from whole grain grains, are high in zinc and may be the
(226 omnivores, 231 vegetarians, and breads and cereals, including fortified reason for the apparent satisfactory status
232 vegans) 52% of vegans, 7% of cereals.148,149 Surprisingly, iron deficiency in vegetarians.
vegetarians, and 1 omnivore were is not more common in vegetarians,
classified as vitamin B12 deficient.136 although iron stores (as shown by ferritin Calcium
Although plant foods, including levels) are often lower.150-153 It is thought Research has found that calcium intakes
mushrooms, tempeh, miso, and sea that lower iron stores may reduce the are generally similar between lacto-
vegetables, are often reported to risk of chronic diseases as previously ovo vegetarians and nonvegetarians,163
provide some vitamin B12, they are discussed. Iron requirements are set although vegans typically have lower
not a reliable source of this vitamin. 80% higher for vegetarians than for intakes.148,164 A recent review of the
These foods contain an inactive form of nonvegetarians because of bioavailability literature concluded that there are no
B12, which interferes with the normal issues with nonheme iron144; yet it has significant differences in bone health
absorption and metabolism of the active been suggested that these bioavailability indices between lacto-ovo vegetarians
form in the body and will not prevent a concerns may have been exaggerated and those who eat meat, and although
deficiency.138 Recent research has found by studying absorption from single vegans do have lower bone mineral
some bioavailable vitamin B12 (in the meals under lab conditions because the densities (BMDs), the differences are
same form present in animal products) influence of enhancers and inhibitors not clinically significant.165,166 The EPIC
on the surface and in the flesh of was much less pronounced over several Oxford study found that the fracture
mushrooms.139 These amounts, however, weeks in comparison with single-meal risk was similar in vegetarians and in
are small and inadequate to meet dietary studies.147,154 meat and fish eaters, but there was an
needs. A reliable source of biologically Despite concerns regarding dietary increased risk for vegans.164 However,
active vitamin B12 is recommended bioavailability and iron absorption, no increased risk was observed in those
on a regular basis, either from fortified iron status is thought to be the consuming at least 525 mg/d of calcium,
foods or supplements. In particular, all determining factor regulating nonheme suggesting that the lower calcium intake
vegans should supplement their diet iron absorption.155 Humans can adapt of some vegans was responsible for the
with vitamin B12, and this is especially successfully to a wide range of iron increased fracture risk. In contrast, a
important for women who are pregnant requirements and intakes.156 Absorption is recent study in postmenopausal Buddhist
or breastfeeding, to prevent deficiency in regulated by physiological requirements nuns following a lifelong vegan diet
their baby.140 and iron status more than the type of found that despite a much lower intake of
food eaten or its bioavailability—lower calcium (330 vs 680 mg/d in omnivorous
Iron body stores result in intestinal adaptation, women), bone mineral densities were
There are 2 types of iron in food: with increased absorption and reduced similar to nonvegetarians.167 There was no
heme iron found only in animal foods, excretion.133,152,154,157 During pregnancy, significant correlation between calcium
such as meat, poultry, and fish, and women will absorb 60% more iron when intake and BMD.
nonheme iron found in animal foods, requirements are highest.157-159 For lacto-ovo vegetarians, dairy
including eggs and plant foods such products provide plenty of calcium.
as legumes, whole grains, nuts, seeds, Zinc Vegans can obtain their calcium from
dark green leafy vegetables, and dried Although zinc is found widely in fortified soy milk and yoghurt, tofu (set
fruit. Nonheme iron is not as well plant foods, like iron, its absorption with calcium salts), or other plant foods
absorbed by the body but its absorption is dependent on body stores and rich in calcium. Plant foods that have
is increased significantly in the presence requirements—the body appears to high calcium bioavailability include
of vitamin C.141 Polyphenols such as adapt to lower intakes by reducing losses low oxalate greens, which have a
261

bioavailability of 50% to 60% compared these fatty acids.174 However, a recent is its role in diseases such as cancer,
with cow’s milk at around 32%, whereas study showed smaller differences in heart disease, strokes, arthritis, multiple
the bioavailability from fortified soy plasma n-3 polyunsaturated fatty acid sclerosis, and even depression.183
milk, sesame seeds, and almonds is status between fish eaters and non– Recent evidence suggests that vitamin
estimated to be around 21% to 24%.163 fish eaters than would be expected D deficiency is a public health problem
Thus, many plant foods can provide from dietary intakes, which could be not just for vegetarians and is more
a significant amount of bioavailable explained by a greater conversion of widespread than once thought.184 Vitamin
calcium despite generally being lower ALA to EPA and DHA in the non–fish D is unusual in that it is more like a
in calcium content than dairy foods. eaters.176 Some believe that a vegetarian’s hormone than a vitamin, and given the
Absorption of calcium is improved in need for omega-3 fatty acids can be right amount of careful sun exposure
the presence of vitamin D, whereas met by dietary ALA.177 DHA is absent (the main source of vitamin D), our skin
excretion of calcium is increased by from unsupplemented vegan diets and can produce what we need. However,
sodium, caffeine, and, according to some present in limited amounts in vegetarian the amount we produce depends on
studies, by excess animal protein.163,168-171 diets. Hence, the proportions of DHA many factors, including the time of day,
Low protein intakes, however, may in plasma, blood cells, breast milk, season, latitude, skin pigmentation, use
also reduce calcium absorption.170 and tissues are substantially lower in of sunscreen, amount of skin exposed,
The 1999-2002 National Health and vegans and vegetarians compared with length of time of exposure, and age.133
Nutrition Examination Survey (NHANES) omnivores; however, the significance Vitamin D is found naturally in only a
found an increased risk of fractures of this difference on health outcomes few foods such as oily fish (cod liver oil),
in postmenopausal women with low remains unclear.174,177,178 Omega-3 wild mushrooms, and eggs. Because only
protein intakes (<46 g/d) despite calcium requirements appear to increase as a few products contain vitamin D, it is
intakes of at least 1200 mg/d.170 These omega-6 intake increases, and reducing also added to some dairy products and
findings may be particularly relevant to omega-6 intake to <2% of energy greatly other fortified foods. Although lacto-ovo
those following a vegan diet who may reduces omega-3 requirements.179 To vegetarians obtain some vitamin D from
have a lower intake of both calcium and optimize omega-3 fatty acid status in eggs and dairy products, most of their
protein. vegetarians, it is best to avoid saturated intake comes from fortified foods, Vegans
and trans fats, and favor monounsaturated rely only on fortified foods to obtain
Essential Fatty Acids fats rather than omega-6 fats. The richest adequate dietary intake. Recent research
Omega-3 fatty acids play an important sources of ALA include chia seeds and found that button mushrooms exposed to
role in health and disease, particularly linseeds (or flaxseed oil). Walnuts and ultraviolet irradiation produced vitamin D,
with respect to cardiovascular health soy products also provide a good source which could potentially provide a
but also in inflammatory diseases and of ALA, with smaller amounts present in food source for vegans.185 There are
neurological and eye development.173 green leafy vegetables. 2 main forms of vitamin D used for
Because fish and seafood are the main Both ALA and marine-derived omega-3 supplements and fortification: D2
sources of long-chain omega-3 fatty fatty acids are associated with a reduced (ergocalciferol), which is sourced from
acids, obtaining an adequate intake on risk of CVD.174 Adding DHA-fortified plants (yeast), and D3 (cholecalciferol),
a vegetarian diet is difficult. Vegetarians foods to an already healthy vegetarian which is sourced from animals (sheep’s
obtain omega-3 fats predominantly diet may have little additional health wool). It has been suggested that D2
from the omega-3 fatty acid α-linolenic benefits in terms of CVD.180 However, has only about 60% of the bioavailability
acid (ALA), but there is debate over those with higher requirements, such of animal-derived D3,186 but other
the efficiency of conversion of ALA as pregnant and breastfeeding women, studies suggest that they are equally
to the longer-chain docosahexaenoic and those at greater risk for poor absorbed.133,183
acid (DHA) and eicosapentaenoic acid conversion, such as people with diabetes, Whereas some studies have shown
(EPA).174 For vegetarians, it has been older people, and premature infants, that vegetarians, and particularly
suggested that a ratio range of 2:1 to 4:1 may benefit from microalgae-rich DHA vegans, have lower intakes of vitamin
of omega-6 to omega-3 would maximize supplements.174,181,182 Omega-3-rich eggs D compared with nonvegetarians,187-189
conversion174 and reduce any thrombotic or foods fortified with algal DHA are the recent Adventist Health Study-2
tendency that might increase their direct sources of DHA. found no relationship between serum
generally low risk for CVD.175 vitamin D concentrations and vegetarian
There is some evidence to suggest that Vitamin D status, suggesting that factors other
the requirement for omega-3 fatty acids Vitamin D is best known for its role than diet have a greater influence on
in vegetarians is higher because of the in bone health—we absorb very little vitamin D levels.190 If sun exposure
inefficient conversion of ALA to EPA and calcium when vitamin D levels are and intake of foods fortified with
DHA and the lack of direct sources of low. A relatively new area of research vitamin D is inadequate to meet the
262

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ANALYTIC Kate Marsh, BSc, MNutrDiet, PhD,

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Dietary Measure of Meat Main Findings,

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Dietary Measure of Meat Main Findings,

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Dietary Measure of Meat Main Findings,

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Study Follow-up Assessment Intake (Lowest vs RR or OR (95%

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Dietary Measure of Meat Main Findings,

Processed meat 1.6 vs 22.6 g/1000 kcal 1.16 (1.06-1.26)

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Dietary Measure of Meat Main Findings,

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Downloaded from ajl.sagepub.com at Faculty of Political Science on July 29, 2012

Downloaded from ajl.sagepub.com at Faculty of Political Science on July 29, 2012

Downloaded from ajl.sagepub.com at Faculty of Political Science on July 29, 2012

Downloaded from ajl.sagepub.com at Faculty of Political Science on July 29, 2012

Downloaded from ajl.sagepub.com at Faculty of Political Science on July 29, 2012

Downloaded from ajl.sagepub.com at Faculty of Political Science on July 29, 2012

Downloaded from ajl.sagepub.com at Faculty of Political Science on July 29, 2012

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