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Health effects of vegetarian and vegan diets
Proceedings of the Nutrition Society (2006), 65, 35–41
Health effects of vegetarian and vegan diets
Timothy J. Key*, Paul N. Appleby and Magdalena S. Rosell
Cancer Research UK Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive,
Vegetarian diets do not contain meat, poultry or fish; vegan diets further exclude dairy productsand eggs. Vegetarian and vegan diets can vary widely, but the empirical evidence largelyrelates to the nutritional content and health effects of the average diet of well-educated vege-tarians living in Western countries, together with some information on vegetarians in non-Western countries. In general, vegetarian diets provide relatively large amounts of cereals,pulses, nuts, fruits and vegetables. In terms of nutrients, vegetarian diets are usually rich incarbohydrates, n-6 fatty acids, dietary fibre, carotenoids, folic acid, vitamin C, vitamin E andMg, and relatively low in protein, saturated fat, long-chain n-3 fatty acids, retinol, vitamin B12and Zn; vegans may have particularly low intakes of vitamin B12 and low intakes of Ca. Cross-sectional studies of vegetarians and vegans have shown that on average they have a relativelylow BMI and a low plasma cholesterol concentration; recent studies have also shown higherplasma homocysteine concentrations than in non-vegetarians. Cohort studies of vegetarianshave shown a moderate reduction in mortality from IHD but little difference in other majorcauses of death or all-cause mortality in comparison with health-conscious non-vegetariansfrom the same population. Studies of cancer have not shown clear differences in cancer ratesbetween vegetarians and non-vegetarians. More data are needed, particularly on the healthof vegans and on the possible impacts on health of low intakes of long-chain n-3 fatty acidsand vitamin B12. Overall, the data suggest that the health of Western vegetarians is good andsimilar to that of comparable non-vegetarians.
A large number of individuals around the world follow
with a very large increase in East Asia from only 8.7 in
vegetarian diets, but in most countries vegetarians com-
1964–6 to 58.5 in 2030 (World Health Organization,
prise only a small proportion of the population. India is
2003). Steinfeld (2004) has estimated that world total meat
a notable exception because a substantial proportion of
production ( · 106 tonnes/year) increased from about 92
the population, perhaps approximately 35 %, follows a
in 1967–9 to 218 in 1997–9 and will increase further to
traditional vegetarian diet and has done so for many
376 in 2030, a fourfold increase in 60 years.
generations (International Vegetarian Union, 2005; Refsum
Understanding of the health effects of vegetarian and
et al. 2001). The numbers of vegetarians in Western
vegan diets is quite good but many uncertainties remain
countries are unknown, with estimates based on rather
(Fraser, 1999; Key et al. 1999a; Sanders, 1999a; Willett,
small samples; for example, in a survey of 2251 indivi-
2003). The purpose of the present brief overview is to
duals throughout the UK (Henderson et al. 2002) 5 %
summarize current knowledge on the health effects of
reported being vegetarian or vegan. While the number of
vegetarian and vegan diets with an emphasis on recent
vegetarians may be increasing in some of the most affluent
findings and results from large studies, including the work
countries, there is an opposite picture for other countries
of the authors’ group on the European Prospective Investi-
around the world, in that meat consumption is increasing
gation of Cancer and Nutrition (EPIC)-Oxford cohort
greatly in many countries that until recently had a low
(Davey et al. 2003). Most of the discussion is related
intake of meat. Per capita meat consumption (kg/year) is
to vegetarians in affluent Western countries; the health of
predicted to increase from 24.2 in 1964–6 to 45.3 in 2030,
vegetarians and individuals with a very low meat intake in
Abbreviation: EPIC, European Prospective Investigation of Cancer and Nutrition.
*Corresponding author: Professor Tim Key, fax + 44 1865 289 610, email firstname.lastname@example.org
poorer countries is a very important topic and there is some
close to or above the recommended intakes, where appli-
information available, but proper consideration of this
cable (Davey et al. 2003), and these nutrients are not dis-
topic is outside the scope of the present brief overview.
cussed further in the present review. For n-3 fatty acids andvitamin B12, however, there is substantial recent researchrelevant to the status of vegetarians in relation to these
Dietary characteristics of vegetarian diets
nutrients and this aspect will be discussed further, togetherwith Fe status.
Vegetarians are defined as individuals who do not eatany meat, poultry or fish. Vegetarians are sub-classified aslacto-ovo vegetarians who eat dairy products and/or eggs
and vegans who do not eat any animal products. Since
Plant foods can provide a-linolenic acid but are devoid
vegetarian diets are defined by what they do not contain,
of the long-chain n-3 fatty acids EPA and DHA (marine
the actual composition of vegetarian diets can vary widely.
algae can provide EPA and DHA and are acceptable to
For the purpose of the present review the discussion is
vegetarians but are not considered here as a plant food);
largely based on the observed average diet of vegetarians
eggs and to a lesser extent dairy products contain low
as described in published reports, and mostly for indi-
levels of EPA and DHA that vary according to the feeding
viduals living in affluent Western countries.
of the animal. Studies of plasma levels of n-3 fatty acidshave consistently shown that vegetarians have lower levelsof EPA and DHA than meat-eaters, with lower levels in
vegans than in lacto-ovo-vegetarians (Sanders et al. 1978a;Sanders, 1999b). Recently, it has been shown that plasma
levels of EPA and DHA in vegans are not related to the
Reviews by expert groups such as the American Dietetic
duration of adherence to the diet over periods of £20
Association and Dietitians of Canada (2003) have con-
years, suggesting that the endogenous production of these
cluded that a well-planned vegetarian diet is adequate for
fatty acids in vegetarians and vegans may result in low
all stages of the life cycle including infancy, childhood and
but stable plasma concentrations (Rosell et al. 2005c).
adolescence. Comparisons of the food intakes of vege-
Studies using labelled a-linolenic acid have shown that
tarians and non-vegetarians show that vegetarian diets
conversion of this fatty acid to EPA and DHA can occur in
generally provide relatively large amounts of cereals,
human subjects but that the rate of conversion is low in
pulses, nuts, fruits and vegetables. Together with the differ-
females and very low in males (Williams & Burdge, 2006).
ences in intakes of animal foods, these differences in food
Vegetarian diets are usually rich in linoleic acid, which
intake result in several characteristic differences in nutrient
may reduce the conversion of a-linolenic acid to EPA
intake. Vegetarian diets are usually rich in carbohydrates,
and DHA (Davis & Kris-Etherton, 2003), but there is no
n-6 fatty acids, dietary fibre, carotenoids, folic acid, vita-
direct evidence that plasma levels of EPA and DHA in
min C, vitamin E and Mg, and relatively low in protein,
vegetarians can be substantially increased by following a
saturated fat, long-chain n-3 fatty acids, retinol, vitamin
diet low in linoleic acid and high in a-linolenic acid.
B12 and Zn; vegans can have particularly low intakes of
It is unknown whether the low levels of EPA and DHA
vitamin B12 and low intakes of Ca (e.g. data from EPIC-
in the plasma of vegetarians have effects on health. In a
small uncontrolled trial in which supplements of EPA and
These differences in nutrient intake might have favour-
DHA were given to ten vegetarians Mezzano et al. (2000)
able or unfavourable effects on the nutritional status and
observed an increase in the plasma levels of these fatty
health of vegetarians. Current knowledge of nutrition sug-
acids and a reduction in platelet aggregation, a possible
gests that the relatively high intakes of dietary fibre, folic
risk factor for CVD, but more research is needed to explore
acid, vitamin C, vitamin E and Mg and low intake of
saturated fat might all have benefits. In particular, vege-tarians are more likely than non-vegetarians to reach the
UK Department of Health (1991) targets for fruit and
vegetables and the dietary reference values for saturated
Food plants do not contain vitamin B12; therefore, the only
fatty acids of 10 % total energy and NSP of 18 g/d. For
reliable sources of vitamin B12 for vegetarians are dairy
example, mean saturated fat intakes expressed as percen-
products and eggs, fortified foods and dietary supplements
tage energy are estimated as 10.7 and 10.4 in male and
(Herbert, 1988; Dagnelie et al. 1991). It has been claimed
female meat-eaters, 9.4 and 9.3 in male and female vege-
that some plant foods such as seaweed and tempeh might
tarians and 5.0 and 5.1 in male and female vegans (Davey
provide true vitamin B12, but this claim has not been
et al. 2003). For NSP, mean intakes (g/d) are 18.7 and 18.9
established and much or all the material in these foods
in male and female meat-eaters, 22.7 and 21.8 in male and
that is detected by assays for vitamin B12 may be vitamin
female vegetarians, and 27.7 and 26.4 in male and female
B12 analogues that are either inactive or may antagonize
true vitamin B12 (Dagnelie et al. 1991; Dagnelie, 1997).
The impact on health of the relatively high intakes
Early studies of vitamin B12 status in vegetarians have
of carbohydrates and n-6 fatty acids and relatively low
shown that, as would be expected, dietary intake and
intakes of protein, retinol and Zn in vegetarians is unclear;
plasma concentrations are lower than those in meat-eaters
mean intakes of these nutrients in vegetarians are probably
(Armstrong et al. 1974; Sanders et al. 1978b). Clinical
evidence of vitamin B12 deficiency has been reported in
some vegans but is apparently uncommon (Antony, 2003).
Studies of Western vegetarians have consistently reported
Recent research using more sensitive indicators of vitamin
that vegetarians have a lower BMI than comparable
B12 status (plasma methylmalonic acid, homocysteine and
holotranscobalamin II) has shown that substantial propor-
about 1 kg/m2 (Key et al. 1999b); the proportion of
tions of vegans and even of vegetarians have suboptimal
vegetarians who are obese is correspondingly lower than
vitamin B12 status according to these criteria, both among
that among non-vegetarians (Key & Davey, 1996). The
affluent Western vegetarians and in other countries
reasons for this difference are not well understood, but
including India, China and Taiwan (Mann et al. 1999;
may include differences in the composition of the diet such
Refsum et al. 2001; Hung et al. 2002; Kwok et al. 2002;
as a higher fibre intake and a lower protein intake (Spencer
Herrmann et al. 2003; Koebnick et al. 2004). Dietary
et al. 2003). Follow-up of body weight among 21 966
vitamin B12 deficiency is also now recognized to be a
individuals in EPIC-Oxford shows a mean body-weight
serious problem in non-vegetarian populations with a low
increase of approximately 400 g/year overall, with signifi-
intake of meat because of poverty (Stabler & Allen, 2004).
cantly lower weight gain in vegans, but not in vegetarians,
Recent work shows that vegetarians must be careful to
than in meat-eaters (Rosell et al. 2005b).
ensure that they do consume adequate amounts of vitamin
B12 (Herrmann & Geisel, 2002; Antony, 2003; Stabler &
BMI between vegetarians and non-vegetarians, obesity is
Allen, 2004). The current UK dietary reference values for
common among some populations that follow largely
vitamin B12 (1.5 mg/d in adults; Department of Health,
vegetarian diets, such as Indians living in the UK (Jebb
1991) were derived partly from studies of vegetarians and
et al. 2004) and in India (Shetty, 2002).
vegans that have suggested that intakes of vitamin B12 ofapproximately 0.3 mg/d are sufficient to prevent anaemiaand macrocytosis. However, intakes of 0.3 mg/d may be
probably associated with moderate elevation in homo-
cysteine that might be detrimental to health.
Studies have consistently reported that total plasmacholesterol is lower in vegetarians than in non-vegetarians,
e.g. by 0.61 mmol/l in the Health Food ShoppersStudy, 0.43 mmol/l in the Oxford Vegetarian Study and
The Fe content of vegetarian diets is typically quite similar
0.39 mmol/l and 0.35 mmol/l in men and women respec-
to that of non-vegetarian diets, but the bioavailability of
tively in EPIC-Oxford (Key et al. 1999b). The effect of a
the Fe is lower because of the absence of haem-Fe. Vegan
vegetarian diet on plasma cholesterol is dependent on the
diets are usually higher in Fe than lacto-vegetarian diets
exact composition of the diet, particularly in relation to
because dairy products are low in Fe. For example, in
saturated and unsaturated fatty acids, and Jenkins et al.
EPIC-Oxford estimated Fe intakes among 43 582 women
(2003) have shown that a vegetarian diet including a
are 12.6, 12.8, 12.6 and 14.1 mg/d for meat-eaters, fish-
portfolio of cholesterol-lowering foods such as soyabean
eaters, lacto-vegetarians and vegans respectively (Davey
and nuts reduces serum LDL-cholesterol substantially
et al. 2003). Studies of Fe status (for example, see
more than a control vegetarian diet.
Waldmann et al. 2004) have consistently shown that serumferritin is lower in vegetarians than in non-vegetarians and
that Hb levels are similar or slightly lower in vegetariansthan in non-vegetarians. Low Fe status is not common in
The main diet-related determinants of hypertension are
men, but is moderately common among premenopausal
high salt intake, obesity and excess alcohol consumption
women throughout the world, and young female vegetar-
(Scientific Advisory Committee on Nutrition, 2003). Some
ians need to ensure that their diet includes good sources of
early studies have suggested that vegetarians have a lower
Fe with vitamin C to help absorption and that they take
blood pressure than similar non-vegetarians, with differ-
ences of 2–10 mmHg in systolic or diastolic pressure(Beilin et al. 1988). However, analyses of blood pressureamong 11 004 men and women in EPIC-Oxford indicatevery little difference in blood pressure between vegetarians
and meat-eaters (£1 mmHg); blood pressure was observedto be 2–3 mmHg lower in vegans than in meat-eaters,
A well-planned vegetarian diet is considered to be ade-
largely associated with the lower BMI of the vegans
quate for all stages of the life cycle including infancy,
(Appleby et al. 2002). In this study the very small differ-
childhood and adolescence (American Dietetic Association
ences in blood pressure between the dietary groups would
and Dietitians of Canada, 2003), but epidemiological data
not be expected to cause a detectable difference in rates
on growth and development in vegetarians are still sparse.
Recent data on 390 lifelong vegetarians in EPIC-Oxford(Rosell et al. 2005a) show no significant differences in
height in men or women, or in age at menarche in women,between lifelong vegetarians and those who became
Collaborative re-analysis of five prospective studies, each
including a large proportion of vegetarians, has shown the
mortality from IHD to be 24 (95 % CI 6, 38) % lower
in vegetarians than in non-vegetarians (Key et al. 1999b).
Most of the epidemiology of breast cancer can be
Results published subsequently are similar; a death rate
explained by hormonal factors, and the only definite
ratio of 0.75 (95 % CI 0.4, 1.37) in the first analysis of
dietary effects on risk are obesity in post-menopausal
EPIC-Oxford (Key et al. 2003) and 0.70 (95 % CI 0.41,
women and alcohol. Endogenous oestrogen levels are
1.18) in the extended follow-up of the cohort in Germany
clearly associated with breast cancer risk in post-
(Chang-Claude et al. 2005). In a case–control study among
menopausal women (Key et al. 2002), and there is some
Indians in Bangalore the risk for myocardial infarction
evidence that high levels of insulin-like growth factor-I
in vegetarians compared with non-vegetarians has been
may also increase risk (Renehan et al. 2004). Although
reported to be 0.81 (95 % CI 0.46, 1.43; Pais et al. 1996).
studies of hormone levels in vegetarians have shown that
Law et al. (1994) have estimated that a reduction in total
plasma oestrogen levels are not different from those of
serum cholesterol of 0.6 mmol/l would reduce mortality
non-vegetarians (Thomas et al. 1999), they have shown
from IHD by 27 %; therefore, the observed differences
that vegans have lower plasma levels of insulin-like growth
in cholesterol between vegetarians and non-vegetarians of
factor-I than either meat-eaters or lacto-vegetarians (Allen
approximately 0.4 mmol/l would be expected to reduce
et al. 2002). Vegetarians, and especially vegans, often
mortality from IHD by approximately 20 %. The observed
consume substantial amounts of soyabeans or foods made
difference in mortality of about 24 % is therefore of the
from soyabeans; soya foods are rich in phyto-oestrogens,
magnitude that might be predicted from the difference in
which have been hypothesized to reduce breast cancer risk
serum cholesterol. The lower BMI of vegetarians would
but research on this topic has so far been inconclusive
also be expected to cause a small reduction in mortality
Studies of breast cancer incidence or mortality have
not demonstrated any difference between lacto-vegetariansand non-vegetarians (Mills et al. 1989a; Rao et al. 1994;
Key et al. 1999b; Dos Santos Silva et al. 2002).
The main known risk factor for stroke is high bloodpressure. The only data on stroke mortality in vegetarianscomes from the five prospective studies, pooled analysis of
which shows a death rate ratio for stroke in vegetarians
Hormones are thought to be important determinants of
compared with non-vegetarians of 0.93 (95 % CI 0.74,
prostate cancer risk, but understanding of these relation-
ships is still poor. There is some evidence that high levelsof active androgens and of insulin-like growth factor-I mayincrease prostate cancer risk (Eaton et al. 1999; Renehan
et al. 2004). No differences in androgens have been foundbetween vegetarians and non-vegetarians but, as in women,
There are few data on cancer rates in vegetarians but
vegan men have lower plasma levels of insulin-like growth
some information is available, particularly for colo-rectal,
factor-I than either meat-eaters or lacto-vegetarians (Allen
Studies of prostate cancer incidence or mortality have
not demonstrated any difference between lacto-vegetarians
and non-vegetarians (Mills et al. 1989b; Key et al. 1999b).
The causes of colo-rectal cancer are not well understoodbut researchers agree that diet is important, and there issubstantial, although not conclusive, evidence that diets
high in red and processed meat are associated with amoderate increase in colo-rectal cancer risk (Key et al.
The bone health of vegetarians has been a topic of interest
2004; Norat et al. 2005). As well as the absence of meat
for many years but few data are available. Ca intake in
from their diet, some putative risk factors for colo-rectal
lacto-vegetarians is similar to that in non-vegetarians,
cancer are more favourable in vegetarians than in non-
whereas vegans usually have a substantially lower Ca
vegetarians; for example, vegetarians have a lower
intake unless they consume a lot of Ca-rich plant foods
proportion of secondary bile acids in their faeces (Reddy
such as dark-green vegetables. It has been suggested that
et al. 1998) and are less likely to have infrequent bowel
the absence of meat might be beneficial for bone health
movements (Sanjoaquin et al. 2004a). Studies of colo-
because of a reduced ‘acid load’, but whether this factor
rectal cancer in vegetarians have suggested that the inci-
is important is controversial and overall it is not clear
dence may be lower than in non-vegetarians (Fraser, 1999;
whether the bone health of vegetarians is better or worse
Sanjoaquin et al. 2004b), but the pooled analysis of
than that of comparable non-vegetarians (New, 2004).
mortality among vegetarians and non-vegetarians in five
Early results from EPIC-Oxford show no difference in
cohorts shows no difference between the dietary groups
fracture rates between vegetarians and non-vegetarians, but
(Key et al. 1999b; some of the cases in this analysis
do show the importance of adequate Ca intake in reducing
of mortality are the same individuals as in the studies of
fracture risk (TJ Key, PN Appleby, EA Spencer, AW
incidence of Fraser (1999) and Sanjoaquin et al. (2004b).
Roddam and NE Allen, unpublished results).
prostate, but there are no data on the risk for these cancersin vegans; the only data on cancer risk are for vegetarians,
The question of whether vegetarianism is associated with
mostly lacto-vegetarians, who do not have reduced levels
beneficial or detrimental effects on athletic performance
of insulin-like growth factor-I. Vegetarians have low levels
has been investigated in some observational studies and
of long-chain n-3 fatty acids and often have low levels of
a few small trials (Nieman, 1999; Barr & Rideout, 2004).
In general, there is little evidence that athletic performance
research on the health effects of these differences is
differs much between vegetarians and non-vegetarians,
needed. Overall, the health of vegetarians appears to be
as long as the diet is nutritionally adequate, but more data
good, but as with all dietary patterns care is needed to
are needed. Particular care needs to be taken to ensure
ensure that the diet is as nutritious and well-balanced as
adequate Fe status, and there is some evidence that the
possible according to current understanding.
lower muscle creatine concentration in vegetarians mayreduce supramaximal exercise performance (Barr &Rideout, 2004).
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Learn to Swim 1C Mrs. Macquaries Road The Domain, Sydney, 2000 Enrolment Agreement If participant is under 18 Years of Age then Enrolment Agreement MUST be completed by Parent /Guardian FAMILY NAME: _______________________________________________ Father’s Name: __________________________ Mothers Name: ___________________________ Mobile: _______________________________
USING NIACIN AND AVOIDING SIDE EFFECTS The vitamin Niacin (B-3) given in pharmacologic amounts is a very effective medication to combat atherosclerosis and reduce the risk of heart attack and stroke. It has been used for decades but eclipsed in recent years by statin drugs (Lipitor, Zocor, etc.) which are more potent in lowering the LDL so called "bad" cholesterol. However, it i