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Vegetarian Diets Dietetic Association 2009

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Position of the American Dietetic Association: Vegetarian Diets - Journal of the American Dietetic Association (2009)
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    ABIteteplatothemapredisetsducluchathascluconrevkeingiodB-rennuoramideetaeqpooubaianofVelowelsrattesvegmass index and lower overall cancerrates. Features of a vegetarian dietthat may reduce risk of chronic diseaseincanfrusoy

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    VEGETARIAN DIETS IN PERSPECTIVEA vegetarian is a person who does not

    examined in the research? The com-plete results of this evidence-based

    are summarized below.EAL Conclusion Statement: The two

    most common ways of defining vege-tarian diets in the research are vegan

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    126eat meat (including fowl) or seafood, diets: Diets devoid of all flesh foodsoi: 10.1016/j.jada.2009.05.027

    6 Journal of the AMERICAN DIETETIC ASSOCIATION 2009 by the American Dietetic Associationlude lower intakes of saturated fatd cholesterol and higher intakes ofits, vegetables, whole grains, nuts,products, fiber, and phytochemi-

    eases. Well-planned vegetarian dietsare appropriate for individuals duringall stages of the lifecycle, includingpregnancy, lactation, infancy, child-hood, and adolescence, and for athletes.

    analysis can be found on the Ameri-can Dietetic Associations EvidenceAnalysis Library (EAL) Web site(www.adaevidencelibrary.com) andfrom thPosition o

    STRACTis the position of the American Di-tic Association that appropriatelynned vegetarian diets, includingal vegetarian or vegan diets, arealthful, nutritionally adequate, andy provide health benefits in thevention and treatment of certaineases. Well-planned vegetarian di-are appropriate for individuals

    ring all stages of the life cycle, in-ding pregnancy, lactation, infancy,ildhood, and adolescence, and forletes. A vegetarian diet is definedone that does not include meat (in-ding fowl) or seafood, or productstaining those foods. This articleiews the current data related toy nutrients for vegetarians includ-protein, n-3 fatty acids, iron, zinc,ine, calcium, and vitamins D and12. A vegetarian diet can meet cur-t recommendations for all of thesetrients. In some cases, supplementsfortified foods can provide usefulounts of important nutrients. An ev-nce-based review showed that veg-rian diets can be nutritionally ad-uate in pregnancy and result insitive maternal and infant healthtcomes. The results of an evidence-sed review showed that a vegetar-diet is associated with a lower risk

    death from ischemic heart disease.getarians also appear to have lower-density lipoprotein cholesterol lev-, lower blood pressure, and loweres of hypertension and type 2 diabe-than nonvegetarians. Furthermore,etarians tend to have a lower bodye assocthe American Die

    s. The variability of dietary practicesong vegetarians makes individualessment of dietary adequacy essen-l. In addition to assessing dietary ad-acy, food and nutrition profession-can also play key roles in educatingetarians about sources of specifictrients, food purchase and prepara-n, and dietary modifications to meetir needs.m Diet Assoc. 2009;109:

    66-1282.

    SITION STATEMENTis the position of the American Di-tic Association that appropriatelynned vegetarian diets, includingal vegetarian or vegan diets, arealthful, nutritionally adequate, and

    This American Dietetic Associationuthors independent review of the leview conducted using the ADAs Evidion from the Evidence Analysis Libraribrary are clearly delineated. Therovides important added benefits todvantage of the approach is the moreriteria, which minimizes the likelihooase with which disparate articles mayion of the methods used in the evidevidence Analysis Process at http://adConclusion Statements are assignased on the systematic analysis and evidence. Grade IGood; Grade IIVExpert Opinion Only; and Gradeo evidence to support or refute the coEvidence-based information for thisttps://www.adaevidencelibrary.com anvailable for purchase at https://www.iationetic Association:egetarian Diets

    products containing these foods.e eating patterns of vegetariansy vary considerably. The lacto-ovo-etarian eating pattern is based onins, vegetables, fruits, legumes,ds, nuts, dairy products, and eggs.e lacto-vegetarian excludes eggswell as meat, fish, and fowl. Thean, or total vegetarian, eating pat-n excludes eggs, dairy, and otherimal products. Even within thesetterns, considerable variation mayst in the extent to which animalducts are excluded.vidence-based analysis was used

    evaluate existing research on typesvegetarian diets (1). One questionevidence-analysis was identified:at types of vegetarian diets are

    DA) position paper includes therature in addition to systematicce Analysis Process and informa-opics from the Evidence Analysisof an evidence-based approach

    rlier review methods. The majorgorous standardization of reviewf reviewer bias and increases thecompared. For a detailed descrip-e analysis process, access ADAsl.com/eaprocess/.a grade by an expert work groupuation of the supporting researchair; Grade IIILimited; GradeNot Assignable (because there islusion).nd other topics can be found atsubscriptions for nonmembers areevidencelibrary.com/store.cfm.orThmaveggraseeThasvegteranpaexiproE

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    NUVEGProPlaqud vegetarian diets: Diets devoid offlesh foods, but also include eggo) and/or dairy (lacto) products.owever, these very broad cat-

    ories mask important variationsthin vegetarian diets and dietaryactices. These variations withingetarian diets make absolute cat-orization of vegetarian dietaryactices difficult and may be one ofe sources of unclear relationshipstween vegetarian diets and othertors. Grade IIFair.n this article, the term vegetarianll be used to refer to people choosingacto-ovo-, lacto-, or vegan vegetariant unless otherwise specified.hereas lacto-ovo-, lacto-, andan-vegetarian diets are thosest commonly studied, practitionersy encounter other types of vegetar-or near-vegetarian diets. For ex-ple, people choosing macrobioticts typically describe their diet asetarian. The macrobiotic diet issed largely on grains, legumes, andetables. Fruits, nuts, and seedsused to a lesser extent. Some peo-following a macrobiotic diet are

    t truly vegetarian because they eatited amounts of fish. The tradi-nal Asian-Indian diet is predomi-ntly plant based and is frequentlyto-vegetarian although changes of-occur with acculturation, includ-greater consumption of cheese

    d a movement away from a vege-ian diet. A raw foods diet may be aan diet, consisting mainly or ex-sively of uncooked and unproc-ed foods. Foods used include fruits,etables, nuts, seeds, and sproutedins and beans; in rare instancespasteurized dairy products andn raw meat and fish may be used.uitarian diets are vegan dietssed on fruits, nuts, and seeds. Veg-bles that are classified botanicallyfruits like avocado and tomatoescommonly included in fruitarian

    ts; other vegetables, grains, beans,d animal products are excluded.ome people will describe them-ves as vegetarian but will eat fish,cken, or even meat. These self-de-ibed vegetarians may be identifiedresearch studies as semivegetarians.ividual assessment is required tourately evaluate the nutritionalality of the diet of a vegetarian or af-described vegetarian.ommon reasons for choosing a

    etarian diet include health consid- aretions, concern for the environ-nt, and animal welfare factors.getarians also cite economic rea-s, ethical considerations, worldnger issues, and religious beliefs asir reasons for following their cho-eating pattern.

    sumer Trends2006, based on a nationwide poll,proximately 2.3% of the US adultpulation (4.9 million people) consis-tly followed a vegetarian diet,ting that they never ate meat, fish,poultry (2). About 1.4% of the USult population was vegan (2). In05, according to a nationwide poll,of 8- to 18-year-old children and

    olescents were vegetarian; close towere vegan (3).any consumers report an interest

    vegetarian diets (4) and 22% reportular consumption of meatless sub-tutes for meat products (5). Addi-nal evidence for the increasing in-est in vegetarian diets includes theergence of college courses on vege-ian nutrition and on animal rights;proliferation of Web sites, period-ls, and cookbooks with a vegetar-theme; and the publics attitudeard ordering a vegetarian mealen eating away from home.estaurants have responded to thiserest in vegetarian diets. A surveychefs found that vegetarian dishesre considered hot or a perennialorite by 71%; vegan dishes by 63%. Fast-food restaurants are begin-g to offer salads, veggie burgers,d other meatless options. Most uni-sity foodservices offer vegetariantions.

    Product Availabilitye US market for processed vegetar-foods (foods like meat analogs,

    ndairy milks, and vegetarian en-es that directly replace meat orer animal products) was estimatedbe $1.17 billion in 2006 (7). Thisrket is forecast to grow to $1.6 bil-n by 2011 (7).he availability of new products, in-ding fortified foods and convenienceds, would be expected to have anpact on the nutrient intake of vege-ians who choose to eat these foods.rtified foods such as soy milks, meatalogs, juices, and breakfast cereals

    continually being added to themar- foo

    July 2009 Journal oftplace with new levels of fortifica-n. These products and dietary sup-ments, which are widely available inermarkets and natural foods stores,add substantially to vegetarians

    akes of key nutrients such as cal-m, iron, zinc, vitamin B-12, vitaminriboflavin, and long-chain n-3 fattyds. With so many fortified productsailable today, the nutritional statusthe typical vegetarian today wouldexpected to be greatly improvedm that of a vegetarian 1 to 2 decadeso. This improvement would behanced by the greater awarenessong the vegetarian population ofat constitutes a balanced vegetariant. Consequently older research datay not represent the nutritional sta-of present-day vegetarians.

    lth Implications of Vegetarian Dietsgetarian diets are often associatedth a number of health advantages,luding lower blood cholesterol levels,er risk of heart disease, lower bloodssure levels, and lower risk of hy-tension and type 2 diabetes. Vege-ians tend to have a lower body massex (BMI) and lower overall canceres. Vegetarian diets tend to be lowersaturated fat and cholesterol, andve higher levels of dietary fiber, mag-sium and potassium, vitamins C andfolate, carotenoids, flavonoids, ander phytochemicals. These nutri-nal differences may explain some ofhealth advantages of those follow-a varied, balanced vegetarian diet.wever, vegans and some other vege-ians may have lower intakes of vita-n B-12, calcium, vitaminD, zinc, andg-chain n-3 fatty acids.ecently, outbreaks of food-borne ill-

    ss associated with the consumptiondomestically grown and importedsh fruits, sprouts, and vegetablest have been contaminated by Sal-nella, Escherichia coli, and othercro-organisms have been seen.alth advocacy groups are calling foricter inspection and reporting proce-res and better food-handling prac-es.

    TRITION CONSIDERATIONS FORETARIANSteinnt protein can meet protein re-irements when a variety of plant

    ds is consumed and energy needs

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    126met. Research indicates that anortment of plant foods eaten overcourse of a day can provide all

    ential amino acids and ensure ad-uate nitrogen retention and use inalthy adults; thus, complementaryteins do not need to be consumedthe same meal (8).

    meta-analysis of nitrogen bal-ce studies found no significant dif-ence in protein needs due to therce of dietary protein (9). Based on

    protein digestibility-correctedino acid score, which is the stan-rd method for determining proteinality, other studies have found thathough isolated soy protein canet protein needs as effectively asimal protein, wheat protein eatenne, for example, may result in auced efficiency of nitrogen utiliza-n (10). Thus, estimates of proteinuirements of vegans may vary, de-nding to some degree on dietaryoices. Food and nutrition profes-nals should be aware that proteineds might be somewhat highern the Recommended Dietary Al-ance in those vegetarians whosetary protein sources are mainlyse that are less well digested, suchsome cereals and legumes (11).ereals tend to be low in lysine, anential amino acid (8). This may beevant when evaluating diets of in-iduals who do not consume animaltein sources and when diets areatively low in protein. Dietary ad-tments such as the use of moreans and soy products in place ofer protein sources that are lowerlysine or an increase in dietary pro-n from all sources can ensure anequate intake of lysine.lthough some vegan women havetein intakes that are marginal,ical protein intakes of lacto-ovo-etarians and of vegans appear toet and exceed requirements (12).hletes can also meet their proteineds on plant-based diets (13).

    Fatty Acidsereas vegetarian diets are gener-y rich in n-6 fatty acids, they maymarginal in n-3 fatty acids. Dietst do not include fish, eggs, or gen-us amounts of algae generally arein eicosapentaenoic acid (EPA)

    d docosahexaenoic acid (DHA),ty acids important for cardiovascu-

    health as well as eye and brain W

    8 July 2009 Volume 109 Number 7velopment. The bioconversion ofinolenic acid (ALA), a plant-basedfatty acid, to EPA is generally lessn 10% in humans; conversion ofA to DHA is substantially less (14).getarians, and particularly vegans,d to have lower blood levels of EPAd DHA than nonvegetarians (15).A supplements derived from mi-algae are well absorbed and posi-ely influence blood levels of DHA,d also EPA through retroconver-n (16). Soy milk and breakfastrs, fortified with DHA, are nowailable in the marketplace.he Dietary Reference Intakes rec-mend intakes of 1.6 and 1.1 g ALAr day, for men and women, respec-ely (17). These recommendationsy not be optimal for vegetarianso consume little if any DHA andA (17) and thus may need addi-nal ALA for conversion to DHA andA. Conversion rates for ALA tendimprove when dietary n-6 levelsnot high or excessive (14). Vege-ians should include good sources ofA in their diet, such as flaxseed,lnuts, canola oil, and soy. Thoseth increased requirements of n-3ty acids, such as pregnant and lac-ing women, may benefit fromA-rich microalgae (18).

    ne iron in plant foods is nonhemen, which is sensitive to both inhibi-s and enhancers of iron absorption.ibitors of iron absorption includeytates, calcium, and the polypheno-in tea, coffee, herb teas, and cocoa.er only slightly inhibits iron absorp-n (19). Some food preparation tech-ues such as soaking and sproutingns, grains, and seeds, and the leav-ing of bread, can diminish phytateels (20) and thereby enhance ironsorption (21,22). Other fermentationcesses, such as those used to makeso and tempeh, may also improven bioavailability (23).itamin C and other organic acidsnd in fruits and vegetables canbstantially enhance iron absorp-n and reduce the inhibitory effectsphytate and thereby improve irontus (24,25). Because of lower bio-ailability of iron from a vegetariant, the recommended iron intakesvegetarians are 1.8 times those ofnvegetarians (26).

    hereas many studies of iron ab- vegption have been short term, thereevidence that adaptation to low in-es takes place over the long term,d involves both increased absorp-n and decreased losses (27,28). In-ence of iron-deficiency anemiaong vegetarians is similar to thatnonvegetarians (12,29). Althoughetarian adults have lower ironres than nonvegetarians, their se-m ferritin levels are usually withinnormal range (29,30).

    ce bioavailability of zinc from vege-ian diets is lower than from nonveg-rian diets, mainly due to the higherytic acid content of vegetarian diets). Thus, zinc requirements for someetarians whose diets consist mainlyhytate-rich unrefined grains and le-mes may exceed the Recommendedetary Allowance (26). Zinc intakes ofetarians vary with some researchwing zinc intakes near recommen-tions (32) and other research findingc intakes of vegetarians signifi-tly below recommendations (29,33).ert zinc deficiency is not evident instern vegetarians. Due to the diffi-ty in evaluating marginal zinc sta-, it is not possible to determine thesible effect of lower zinc absorptionm vegetarian diets (31). Zinc sourceslude soy products, legumes, grains,ese, and nuts. Food preparationhniques, such as soaking andouting beans, grains, and seeds asll as leavening bread, can reduceding of zinc by phytic acid and in-ase zinc bioavailability (34). Organicds, such as citric acid, can also en-nce zinc absorption to some extent).

    ineme studies suggest that veganso do not consume key sources ofine, such as iodized salt or sea veg-bles, may be at risk for iodine de-iency, because plant-based dietstypically low in iodine (12,35). Seat and kosher salt are generally notized nor are salty seasonings suchtamari. Iodine intake from sea veg-bles should be monitored becauseiodine content of sea vegetables

    ries widely and some contain sub-ntial amounts of iodine (36).oods such as soybeans, cruciferous

    etables, and sweet potatoes con-

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    ciumlcium intakes of lacto-ovo-vegetar-s are similar to, or higher than,se of nonvegetarians (12), whereasakes of vegans tend to be lowern both groups and may fall belowommended intakes (12). In the Ox-d component of the European Pro-ctive Investigation into Cancerd Nutrition (EPIC-Oxford) study,risk of bone fracture was similarlacto-ovo-vegetarians and meat

    ters, whereas vegans had a 30%her risk of fracture possibly due toir considerably lower mean cal-m intake (38). Diets rich in meat,h, dairy products, nuts, and grainsduce a high renal acid load,inly due to sulfate and phosphateidues. Calcium resorption fromne helps to buffer this acid load,ulting in increased urinary lossescalcium. A high sodium intake cano promote urinary calcium losses.the other hand, fruits and vegeta-s rich in potassium and magne-m produce a high renal alkalined which slows bone calcium resorp-n, and decreases calcium losses inurine. In addition, some studies

    ow that the ratio of dietary calciumprotein is a better predictor of bonealth than calcium intake alone.pically, this ratio is high in lacto--vegetarian diets and favors bonealth, whereas vegans have a ratiocalcium to protein that is similar tolower than that of nonvegetarians). Many vegans may find it is eas-to meet their calcium needs if cal-m-fortified foods or dietary supple-nts are utilized (39).ow-oxalate greens (eg, bok choy,ccoli, Chinese cabbage, collards,d kale) and fruit juices fortifiedth calcium citrate malate are goodrces of highly bioavailable calcium% to 60% and 40% to 50%, respec-ely), while calcium-set tofu, ands milk have good bioavailabilitycalcium (about 30% to 35%), andame seeds, almonds, and driedans have a lower bioavailability% to 27%) (39). The bioavailabilitycalcium from soy milk fortified withcium carbonate is equivalent to

    s milk although limited research etas shown that calcium availability isbstantially less when tricalciumosphate is used to fortify the soyverage (40). Fortified foods such asit juices, soy milk, and rice milk,d breakfast cereals can contributenificant amounts of dietary cal-m for the vegan (41). Oxalates ine foods, such as spinach andiss chard, greatly reduce calciumsorption, making these vegetablesoor source of usable calcium. Foodsh in phytate may also inhibit cal-m absorption

    amin Damin D has long been known toy a role in bone health. Vitamin Dtus depends on sunlight exposured intake of vitamin Dfortifiedds or supplements. The extent oftaneous vitamin D production fol-ing sunlight exposure is highlyriable and is dependent on a num-r of factors, including the time ofy, season, latitude, skin pigmenta-n, sunscreen use, and age. Low vi-in D intakes (42), low serum 25-

    droxyvitamin D levels (12), anduced bone mass (43) have been re-rted in some vegan and macrobioticups who did not use vitamin Dpplements or fortified foods.oods that are fortified with vita-n D include cows milk, somends of soy milk, rice milk, and or-ge juice, and some breakfast cere-and margarines. Both vitamin D-2d vitamin D-3 are used in supple-nts and to fortify foods. Vitamin3 (cholecalciferol) is of animal ori-and is obtained through the ultra-let irradiation of 7-dehydrocholes-ol from lanolin. Vitamin D-2gocalciferol) is produced from theraviolet irradiation of ergosterolm yeast and is acceptable to veg-s. Although some research sug-ts that vitamin D-2 is less effectiven vitamin D-3 in maintaining se-m 25-hydroxyvitamin D levels (44)er studies find that vitamin D-2d vitamin D-3 are equally effective). If sun exposure and intake oftified foods are insufficient to meeteds, vitamin D supplements areommended.

    amin B-12e vitamin B-12 status of some veg-

    rians is less than adequate due to eta

    July 2009 Journal oft regularly consuming reliablerces of vitamin B-12 (12,46,47).cto-ovo-vegetarians can obtain ad-uate vitamin B-12 from dairy foods,s, or other reliable vitamin B-12rces (fortified foods and supple-nts), if regularly consumed. Forans, vitamin B-12 must be ob-ned from regular use of vitamin12-fortified foods, such as fortifiedand rice beverages, some break-

    t cereals and meat analogs, or Redr Vegetarian Support Formula nu-tional yeast; otherwise a daily vita-n B-12 supplement is needed. Nofortified plant food contains anynificant amount of active vitamin12. Fermented soy products cannotconsidered a reliable source of ac-e B-12 (12,46).egetarian diets are typically rich

    folacin, which may mask the hema-ogical symptoms of vitamin B-12ficiency, so that vitamin B-12 defi-ncy may go undetected until afterurological signs and symptomsy be manifest (47). Vitamin B-12tus is best determined by measur-serum levels of homocysteine,

    thylmalonic acid, or holotransco-lamin II (48).

    ETARIAN DIETS THROUGHOUT THEE CYCLEll-planned vegan, lacto-vegetarian,d lacto-ovo-vegetarian diets are ap-priate for all stages of the life cycle,luding pregnancy and lactation. Ap-priately planned vegan, lacto-vege-ian, and lacto-ovo-vegetarian dietsisfy nutrient needs of infants, chil-n, and adolescents and promote nor-l growth (49-51). Figure 1 providescific suggestions for meal planningvegetarian diets. Lifelong vegetari-s have adult height, weight, andIs that are similar to those who be-e vegetarian later in life, suggest-that well-planned vegetarian dietsinfancy and childhood do not affectal adult height or weight (53). Vege-ian diets in childhood and adoles-ce can aid in the establishment oflong healthful eating patterns andoffer some important nutritional

    vantages. Vegetarian children andolescents have lower intakes of cho-terol, saturated fat, and total fat andher intakes of fruits, vegetables, ander than nonvegetarians (54,55). Veg-

    rian children have also been re-

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    127ted to be leaner and to have lowerum cholesterol levels (50,56).

    gnant and Lactating Womene nutrient and energy needs ofgnant and lactating vegetarianmen do not differ from those ofnvegetarian women with the excep-n of higher iron recommendationsvegetarians. Vegetarian diets canplanned to meet the nutrient needspregnant and lactating women. Ev-nce-based analysis of the researchrature was used to evaluate exist-research on vegetarian pregnancy). Seven questions for evidence-alysis were identified:

    ow do macronutrient and energyntake in pregnant vegetarians dif-er from intakes in pregnant omni-ores?re birth outcomes different forothers who maintain a vegetarians an omnivorous diet during preg-ancy?ow do macronutrient and energyntake in pregnant vegans differrom intakes in pregnant omnivores?re birth outcomes different forothers who maintain a vegan vsn omnivorous diet during preg-ancy?hat are patterns of micronutrient

    ntake among pregnant vegetarians?hat is the bioavailability of differ-nt micronutrients in pregnant veg-tarians?hat are birth outcomes associatedith the micronutrient intake ofaternal vegetarian diets?

    he complete results of this evidence-ed analysis can be found on the EALb site (www.adaevidencelibrary.com)

    variety of menu planning approaches canhe Dietary Reference Intakes are a valuable resoarious food guides (41,52) can be used when wllowing guidelines can help vegetarians plan he Choose a variety of foods, including whole g

    and, if desired, dairy products, and eggs. Minimize intake of foods that are highly sw

    especially saturated fat and trans-fatty acids Choose a variety of fruits and vegetables. If animal foods such as dairy products and

    and use both eggs and dairy products in m Use a regular source of vitamin B-12 and, i

    ure 1. Suggestions for planning vegetarian md are summarized below. veg

    0 July 2009 Volume 109 Number 7cronutrient and Energy Intake. Fourmary research studies were identi-d that examined maternal macro-trient intake during lacto-ovo- orto- vegetarian pregnancy (58-61).ne focused on pregnant vegans.AL Conclusion Statement: Limited re-rch on non-US populations indi-es that the macronutrient intakepregnant vegetarians is similar tot of nonvegetarians with the fol-ing exceptions (as percentages ofergy intake):

    regnant vegetarians receive statis-ically lower levels of protein thanregnant nonvegetarians; andregnant vegetarians receive statis-ically higher levels of carbohydrateshan pregnant nonvegetarians.

    t is important to note, however,t none of the studies report a clin-lly significant difference in macro-trient intake. In other words, nonethe studies report a protein defi-ncy in pregnant vegetarians.ade IIILimited.AL Conclusion Statement: No researchs identified that focused on macro-trient intakes among pregnant veg-s. Grade VNot Assignable.

    th Outcomes. Four cohort studiesre identified that examined the rela-nship between maternal macronu-ent intake during pregnancy andth outcomes such as birth weightd length (59-62). None of the studiesused on pregnant vegans.AL Conclusion Statement: Limited re-rch on non-US populations indi-es that there are no significantalth differences in babies born tonvegan vegetarian mothers vs non-

    vide adequate nutrition for vegetarians.e for food and nutrition professionals.ing with vegetarian clients. In addition, theful diets:s, vegetables, fruits, legumes, nuts, seeds,

    ned, high in sodium, and high in fat,

    s are used, choose lower-fat dairy productsration.nlight exposure is limited, of vitamin D.

    s.etarians. Grade IIILimited. froAL Conclusion Statement: No researchs identified that focused on the birthtcomes of vegan vs omnivorousthers. Grade VNot Assignable.

    ronutrient Intake. Based on 10 stud-(58-60,63-69), two of which wereducted in the United States (64,65),ly the following micronutrients hader intake among vegetarians thannvegetarians:

    itamin B-12;itamin C;alcium; andinc.

    egetarians did not meet dietaryndard (in at least one country) for:

    itamin B-12 (in the United King-om);ron (in the United States, for bothegetarians and omnivores);olate (in Germany, though lowerate of deficiency than among omni-ores); andinc (in the United Kingdom).

    AL Conclusion Statement: Grade IIImited.

    ronutrient Bioavailability. Six studiese non-US, one with combined USd non-US samples; all but one of pos-e quality) were identified that ex-ined the bioavailability of differentcronutrients in vegetarian vs non-etarian pregnant women (58,63,64,,67,69). Of the micronutrients exam-d in the research, only serum B-12els were significantly lower in non-an-vegetarians than nonvegetar-s. In addition, one study reportedt lower B-12 levels are more likelybe associated with high serum totalmocysteine in lacto-ovo-vegetariansn low meat eaters or omnivores.ereas zinc levels were not signifi-tly different between nonvegan-etarians and nonvegetarians, vege-ians who have a high intake ofcium may be at risk for zinc defi-ncy (because of the interaction be-een phytate, calcium, and zinc).sed on limited evidence, plasma fo-e levels may actually be higherong some vegetarian groups thannvegetarians.AL Conclusion Statement: Grade IIImited.

    ronutrients and Birth Outcome EAL Con-sion Statement: Limited evidencean

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    somlesrepfolnoadanfastoited States) indicated that the mi-nutrient content of a balanced ma-nal vegetarian diet does not havetrimental outcomes for the healththe child at birth (58-63,69). Therey be, however, a risk for a falsesitive diagnosis of Down syndromethe fetus when maternal serume beta-human chorionic gonadotro-and alpha fetoprotein levels are

    ed as markers in vegetarian moth-. Grade IIILimited.trition Considerations. Results of evi-nce-based analysis suggest thatetarian diets can be nutritionallyequate in pregnancy and can leada positive birth outcome (57).ey nutrients in pregnancy include

    amin B-12, vitamin D, iron, andate whereas key nutrients in lacta-n include vitamin B-12, vitamin D,cium, and zinc. Diets of pregnantd lactating vegetarians should con-n reliable sources of vitamin B-12ily. Based on recommendations forgnancy and lactation, if there iscern about vitamin D synthesiscause of limited sunlight exposure,in tone, season, or sunscreen use,gnant and lactating women shoulde vitamin D supplements or vita-n Dfortified foods. No studiesluded in the evidence-analysis ex-ined vitamin D status during veg-rian pregnancy. Iron supplementsy be needed to prevent or treatn-deficiency anemia, which is com-n in pregnancy. Women capable ofcoming pregnant as well as womenthe periconceptional period are ad-ed to consume 400 g folate dailym supplements, fortified foods, orth. Zinc and calcium needs can bet through food or supplementrces as identified in earlier sec-ns on these nutrients.HA also plays a role in pregnancy

    d lactation. Infants of vegetarianthers appear to have lower cordd plasma DHA than do infants ofnvegetarians (70). Breast milkA is lower in vegans and lacto-ovo-etarians than in nonvegetarians). Because of DHAs beneficial ef-ts on gestational length, infant vi-al function, and neurodevelopment,gnant and lactating vegetariansd vegans should choose foodrces of DHA (fortified foods or eggsm hens fed DHA-rich microalgae)use a microalgae-derived DHA sup-

    ment (72,73). Supplementation moth ALA, a DHA precursor, in preg-ncy and lactation has not beenown to be effective in increasing in-t DHA levels or breast milk DHAcentration (74,75).

    antsowth of young vegetarian infantseiving adequate amounts of breastlk or commercial infant formula isrmal. When solid foods are intro-ced, provision of good sources of en-y and nutrients can ensure normalwth. The safety of extremely re-ictive diets such as fruitarian andfoods diets has not been studied

    children. These diets can be veryin energy, protein, some vita-

    ns, and some minerals and cannotrecommended for infants and chil-n.reastfeeding is common in vege-ian women, and this practiceould be supported. The breast milkvegetarian women is similar inposition to that of nonvegetarians

    d is nutritionally adequate. Com-rcial infant formulas should beed if infants are not breastfed orweaned before 1 year of age. Soy

    mula is the only option for non-astfed vegan infants. Other prep-tions including soymik, rice milk,d homemade formulas should notused to replace breast milk or com-rcial infant formula.olid foods should be introduced insame progression as for nonveg-rian infants, replacing strainedat with mashed or pureed tofu, le-mes (pureed and strained if neces-y), soy or dairy yogurt, cooked eggk, and cottage cheese. Later,und 7 to 10 months, foods such asbed tofu, cheese, or soy cheese ande-size pieces of veggie burgers canstarted. Commercial, full-fat, forti-d soy milk or pasteurized cowslk can be used as a primary bever-e starting at age 1 year or older forhild who is growing normally andting a variety of foods (51). Foodst are rich in energy and nutrientsch as legume spreads, tofu, andshed avocado should be used wheninfant is being weaned. Dietaryshould not be restricted in chil-n younger than 2 years.uidelines for dietary supplementserally follow those for nonvegetar-infants. Breastfed infants whose

    thers do not have an adequate in- Ke

    July 2009 Journal ofe of vitamin B-12 should receive aamin B-12 supplement (51). Zincake should be assessed and zincpplements or zinc-fortified foodsed when complementary foods areroduced if the diet is low in zinc orinly consists of foods with low zincavailability (76).

    ldrenowth of lacto-ovo-vegetarian chil-n is similar to that of their nonveg-rian peers (50). Little informationout the growth of nonmacrobiotican children has been published.me studies suggest that vegan chil-n tend to be slightly smaller butthin the normal ranges of the stan-rds for weight and height (58). Poorwth in children has primarily beenn in those on very restrictedts (77).requent meals and snacks and the

    e of some refined foods (such as for-ed breakfast cereals, breads, andsta) and foods higher in unsatur-d fats can help vegetarian childrenet energy and nutrient needs. Av-ge protein intakes of vegetarianildren (lacto-ovo, vegan, and macro-tic) generally meet or exceed rec-mendations (12). Vegan childreny have slightly higher proteineds because of differences in pro-n digestibility and amino acid com-sition (49,78) but these proteineds are generally met when dietstain adequate energy and a vari-of plant foods.ood guides for vegetarian childrenve been published elsewhere (12).

    olescentsowth of lacto-ovo-vegetarian andnvegetarian adolescents is similar). Earlier studies suggest that veg-rian girls reach menarche slightlyer than nonvegetarians (79); moreent studies find no difference ine at menarche (53,80).egetarian diets appear to offere nutritional advantages for ado-

    cents. Vegetarian adolescents areorted to consume more fiber, iron,ate, vitamin A, and vitamin C thannvegetarians (54,81). Vegetarianolescents also consume more fruitsd vegetables, and fewer sweets,t foods, and salty snacks comparednonvegetarian adolescents (54,55).

    y nutrients of concern for adoles-

    the AMERICAN DIETETIC ASSOCIATION 1271

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    127t vegetarians include calcium, vi-in D, iron, zinc, and vitamin B-12.eing vegetarian does not causeordered eating as some have sug-ted although a vegetarian diety be selected to camouflage an ex-ing eating disorder (82). Because ofs, vegetarian diets are somewhatre common among adolescentsth eating disorders than in the gen-l adolescent population (83). Foodd nutrition professionals should beare of young clients who greatlyit food choices and who exhibitptoms of eating disorders.ith guidance in meal planning,etarian diets can be appropriated healthful choices for adolescents.

    er Adultsth aging, energy needs decreaset recommendations for several nu-ents, including calcium, vitamin D,d vitamin B-6 are higher. Intakesmicronutrients, especially calcium,c, iron, and vitamin B-12, declineolder adults (84). Studies indicatet older vegetarians have dietaryakes that are similar to nonveg-rians (85,86).lder adults may have difficulty

    th vitamin B-12 absorption fromd, frequently due to atrophic gas-tis, so vitamin B-12-fortified foodssupplements should be used be-se the vitamin B-12 in fortifiedds and supplements is usuallyll-absorbed (87). Cutaneous vita-n D production decreases with ag-so that dietary or supplementalrces of vitamin D are especiallyportant (88). Although current rec-mendations for protein for healthyer adults are the same as those fornger adults on a body weight basis), this is a controversial area (89).rtainly older adults who have lowergy requirements will need to con-me concentrated sources of protein.der adults can meet protein needsa vegetarian diet if a variety oftein-rich plant foods, including le-mes and soy products, are eatenily.

    letesgetarian diets can also meet theeds of competitive athletes. Nutri-n recommendations for vegetarianletes should be formulatedwith con-

    eration of the effects of both vegetar- dis

    2 July 2009 Volume 109 Number 7diets and exercise. The position oferican Dietetic Association and Di-tians of Canada on nutrition andletic performance provides addi-nal information specific to vegetar-athletes (90). Research is needed onrelation between vegetarian diet

    d performance. Vegetarian diets thatet energy needs and contain a vari-of plant-based protein foods, such

    soy products, other legumes, grains,ts, and seeds, can provide adequatetein without the use of special foodssupplements (91). Vegetarian ath-es may have lower muscle creatinecentration due to low dietary creat-levels (92,93). Vegetarian athletes

    rticipating in short-term, high-inten-y exercise and resistance trainingy benefit from creatine supplemen-ion (91). Some, but not all researchgests that amenorrheamay bemoremon among vegetarian than non-etarian athletes (94,95). Femaleetarian athletes may benefit fromts that include adequate energy,her levels of fat, and generousounts of calcium and iron.

    ETARIAN DIETS AND CHRONICEASEdiovascular Disease (CVD)idence-based analysis of the re-rch literature is being used toluate existing research on the re-ionship between vegetarian di-ry patterns and CVD risk factors). Two evidence analysis questionsve been completed:

    hat is the relationship between aegetarian diet and ischemic heartisease?ow is micronutrient intake in aegetarian diet associated withVD risk factors?

    hemic Heart Disease. Two large co-rt studies (97,98) and one meta-alysis (99) found that vegetariansre at lower risk of death from isch-ic heart disease than nonvegetar-s. The lower risk of death was seenboth lacto-ovo-vegetarians and veg-s (99). The difference in risk per-ted after adjustment for BMI,oking habits, and social class (97).is is especially significant becauselower BMI commonly seen in veg-rians (99) is one factor that maylp to explain the lower risk of heart

    ease in vegetarians. If this differ- vegce in risk persists even after adjust-nt for BMI, other aspects of a veg-rian diet may be responsible forrisk reduction, above and beyondt which would be expected due toer BMI.AL Conclusion Statement: A vegetar-diet is associated with a lower risk

    death from ischemic heart disease.ade IGood.

    od Lipid Levels. The lower risk ofath from ischemic heart diseasen in vegetarians could be ex-ined in part by differences in bloodid levels. Based on blood lipid lev-in one large cohort study, the in-ence of ischemic heart disease wasimated to be 24% lower in lifelongetarians and 57% lower in lifelongans compared to meat eaters (97).pically, studies find lower total cho-terol and low-density lipoproteinL) cholesterol levels in vegetari-

    s (100, for example). Interventiondies have demonstrated a reduc-n in total and LDL-cholesterol lev-when subjects switched from theirual diet to a vegetarian diet (101,example). Although evidence isited that a vegetarian diet is asso-ted with higher high-density li-protein cholesterol levels or withher or lower triglyceride levels, aetarian diet is consistently associ-d with lower LDL cholesterol lev-. Other factors such as variationsBMI and foods eaten or avoidedthin the context of a vegetarian dietlifestyle differences could partiallylain the inconsistent results withard to blood lipid levels.actors in a vegetarian diet thatld have a beneficial effect on bloodid levels include the higher amountsber, nuts, soy, and plant sterols ander levels of saturated fat. Vegetari-s consume between 50% and 100%re fiber than nonvegetarians andans have higher intakes than lacto--vegetarians (12). Soluble fiber hasn repeatedly shown to lower totald LDL cholesterol levels and to re-ce risk of coronary heart disease (17).iet high in nuts significantly lowersal and LDL cholesterol levels (102).y isoflavones may play a role in re-cing LDL cholesterol levels and inucing the susceptibility of LDL todation (103). Plant sterols, found inumes, nuts and seeds, whole grains,

    etable oils, and other plant-based

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    conateadityoffivlownuthods reduce cholesterol absorption ander LDL cholesterol levels (104).

    tors Associated with Vegetarian Dietst May Affect Risk of CVD. Other fac-s in vegetarian diets may impactD risk independent of effects onolesterol levels. Foods that featureminently in a vegetarian diet thaty offer protection from CVD in-de soy protein (105), fruits andetables, whole grains, and nuts6,107). Vegetarians appear to con-me more phytochemicals than donvegetarians because a greaterrcentage of their energy intakees from plant foods. Flavonoids

    d other phytochemicals appear tove protective effects as antioxi-nts, in reducing platelet aggrega-n and blood clotting, as anti-in-mmatory agents, and in improvingdothelial function (108,109). Lacto--vegetarians have been shown tove significantly better vasodilationponses, suggesting a beneficial ef-t of vegetarian diet on vascular en-thelial function (110).vidence analysis was conductedexamine how the micronutrientkeup of vegetarian diets might beated to CVD risk factors.AL Conclusion Statement: No re-rch meeting inclusion criteriare identified that examined the mi-nutrient intake of a vegetariant and CVD risk factors. GradeNot Assignable.ot all aspects of vegetarian dietsassociated with reduced risk for

    art disease. The higher serum ho-cysteine levels that have been re-rted in some vegetarians, appar-tly due to inadequate vitamin B-12ake, may increase risk of CVD1,112) although not all studiespport this (113).egetarian diets have been suc-sfully used in treatment of CVD. Aimen that used a very low-fat10% of energy) near vegan (limitednfat dairy and egg whites allowed)t along with exercise, smoking ces-ion, and stress management, wasown to reduce blood lipid levels,od pressure, and weight, and im-ve exercise capacity (114). A near-an diet high in phytosterols, vis-s fiber, nuts, and soy protein hasen shown to be as effective as a-saturated fat diet and a statin forering serum LDL-cholesterol lev-

    (115). haertensioncross-sectional study and a cohortdy found that there was a lowere of hypertension among vegetari-s than nonvegetarians (97,98).ilar findings were reported in

    venth-day Adventists (Adventists)Barbados (116) and in preliminaryults from the Adventist Healthdy-2 cohort (117). Vegans appearhave a lower rate of hypertensionn do other vegetarians (97,117).everal studies have reporteder blood pressure in vegetarianspared to nonvegetarians (97,118)

    hough other studies reported littleference in blood pressure betweenetarians and nonvegetarians0,119,120). At least one of thedies reporting lower blood pres-re in vegetarians found that BMIher than diet accounted for muchthe age-adjusted variation in bloodssure (97). Vegetarians tend tove a lower BMI than nonvegetar-s (99); thus, vegetarian diets in-ence on BMI may partially accountreported differences in blood pres-re between vegetarians and non-etarians. Variations in dietary in-e and lifestyle within groups ofetarians may limit the strength ofclusions with regard to the rela-nship between vegetarian dietsd blood pressure.ossible factors in vegetarian dietst could result in lower blood pres-re include the collective effect ofrious beneficial compounds foundplant foods such as potassium,gnesium, antioxidants, dietary fat,d fiber (118,121). Results from theetary Approaches to Stop Hyper-sion study, in which subjects con-med a low-fat diet rich in fruits,etables and dairy, suggest thatbstantial dietary levels of potas-m, magnesium, and calcium playimportant role in reducing bloodssure levels (122). Fruit and vege-le intake was responsible for aboute-half of the blood pressure reduc-n of the Dietary Approaches top Hypertension diet (123). In ad-ion, nine studies report that con-mption of five to 10 servings of fruitd vegetables significantly lowersod pressure (124).

    betesventist vegetarians are reported to

    ve lower rates of diabetes than Ad- lea

    July 2009 Journal oftist nonvegetarians (125). In theventist Health Study, age-adjustedk for developing diabetes was two-d greater in nonvegetarians, com-red with their vegetarian counter-rts (98). Although obesity increasesrisk of type 2 diabetes, meat andcessed meat intake was found toan important risk factor for diabe-even after adjustment for BMI6). In the Womens Health Study,authors also observed positive as-iations between intakes of redat and processed meat and risk ofbetes after adjusting for BMI, totalergy intake, and exercise (127). Anificantly increased risk of diabe-was most pronounced for frequentsumption of processed meats suchbacon and hot dogs. Results re-ined significant even after furtherjustment for dietary fiber, magne-m, fat, and glycemic load (128). Inarge cohort study, the relative risktype 2 diabetes in women for everye-serving increase in intake was6 for red meat and 1.38 to 1.73 forcessed meats (128).n addition, higher intakes of vege-les, whole-grain foods, legumes,d nuts have all been associatedth a substantially lower risk of in-lin resistance and type 2 diabetes,d improved glycemic control in ei-r normal or insulin-resistant indi-uals (129-132). Observationaldies have found that diets rich inole-grain foods are associated withproved insulin sensitivity. This ef-t may be partly mediated by signif-nt levels of magnesium and cerealer in the whole-grain foods (133).rsons with elevated blood glucosey experience an improvement inulin resistance and lower fastingod glucose levels after they havesumed whole grains (134). Peoplesuming about three servings pery of whole-grain foods are 20% to% less likely to develop type 2 dia-tes than low consumers (3 serv-s per week) (135).n the Nurses Health Study, nutsumption was inversely associ-d with risk of type 2 diabetes afterjustment for BMI, physical activ-, and many other factors. The riskdiabetes for those consuming nutse or more times a week was 27%er than those almost never eatingts, whereas the risk of diabetes forse consuming peanut butter at

    st five times a week (equivalent to

    the AMERICAN DIETETIC ASSOCIATION 1273

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    127oz peanuts/week) was 21% lowern those who almost never ate pea-t butter (129).ecause legumes contain slowly di-ted carbohydrate and have a higher content, they are expected to im-ve glycemic control and reduce in-ent diabetes. In a large prospectivedy, an inverse association wasn between the intake of total le-mes, peanuts, soybeans, and otherumes by Chinese women, and theidence of type 2 diabetes mellitus,er adjustment for BMI and othertors. The risk of type 2 diabetess 38% and 47% lower, for thosesuming a high intake of total le-mes and soybeans, respectively,pared to a low intake (132).n a prospective study, the risk ofe 2 diabetes was 28% lower formen in the upper quintile of vege-le, but not fruit intake, comparedthe lower quintile of vegetable in-e. Individual vegetable groupsre all inversely and significantlyociated with the risk of type 2 di-etes (131). In another study, con-mption of green leafy vegetablesd fruit, but not fruit juice, was as-iated with a lower risk of diabetes6).iber-rich vegan diets are charac-ized by a low glycemic index and ato moderate glycemic load (137).a 5-month randomized clinical

    al, a low-fat vegan diet was shownconsiderably improve glycemic con-l in persons with type 2 diabetes,th 43% of subjects reducing diabe-medication (138). Results were

    perior to those obtained from fol-ing a diet based on American Dia-

    tes Association guidelines (individ-lized based on body weight andid concentrations; 15%-20% pro-n; 7% saturated fat; 60% to 70%bohydrate and monounsaturated; 200 mg cholesterol).

    esityong Adventists, about 30% ofom follow a meatless diet, vegetar-eating patterns have been associ-d with lower BMI, and BMI in-ased as the frequency of meatsumption increased in both mend women (98). In the Oxford Vege-ian Study, BMI values were highernonvegetarians compared withetarians in all age groups for both

    n and women (139). In a cross-sec- con

    4 July 2009 Volume 109 Number 7nal study of 37,875 adults, meat-ters had the highest age-adjustedan BMI and vegans the lowest,th other vegetarians having inter-diate values (140). In the EPIC-ford Study, weight gain over aear period, among a health-con-ous cohort, was lowest amongse who moved to a diet containinger animal foods (141). In a largess-sectional British study, it wasserved that those people who be-e vegetarian as adults did not dif-in BMI or body weight comparedthose who were life-long vegetari-s (53). However, those who haveen following a vegetarian diet for atst 5 years typically have a lowerI. Among Adventists in Barbados,number of obese vegetarians, who

    d followed the diet for more than 5rs, was 70% less than the numberobese omnivores whereas recentetarians (following the diet 5rs) had body weights similar tonivores (116). A low-fat vegetariant has been shown to be more effec-e in long-term weight loss for post-nopausal women than a moreventional National Cholesterolucation Program diet (142). Vege-ians may have a lower BMI due toir higher consumption of fiber-h, low-energy foods, such as fruitd vegetables.

    cergetarians tend to have an overallcer rate lower than that of theeral population, and this is notfined to smoking-related cancers.ta from the Adventist Healthdy revealed that nonvegetariansd a substantially increased risk forth colorectal and prostate cancerpared with vegetarians, but there

    re no significant differences in risklung, breast, uterine, or stomachcer between the groups after con-lling for age, sex, and smoking). Obesity is a significant factor in-asing the risk of cancer at a num-r of sites (143). Because the BMI ofetarians tends to be lower thant of nonvegetarians, the lighterdy weight of the vegetarians mayan important factor.vegetarian diet provides a varietycancer-protective dietary factors4). Epidemiologic studies havesistently shown that a regular

    sumption of fruit and vegetables is cauongly associated with a reducedk of some cancers (108,145,146). Intrast, among survivors of earlyge breast cancer in the Womensalthy Eating and Living trial, theoption of a diet enhanced by addi-nal daily fruit and vegetable serv-s did not reduce additional breastcer events or mortality over aear period (147).ruit and vegetables contain a com-x mixture of phytochemicals, pos-sing potent antioxidant, antiprolif-tive, and cancer-protective activity.e phytochemicals can display addi-e and synergistic effects, and aret consumed in whole foods8-150). These phytochemicals inter-e with several cellular processes in-ved in the progression of cancer.ese mechanisms include the inhibi-n of cell proliferation, inhibition ofA adduct formation, inhibition ofase 1 enzymes, inhibition of signalnsduction pathways and oncogeneression, induction of cell cycle arrestd apoptosis, induction of phase 2 en-es, blocking the activation of nu-

    ar factor-kappaB, and inhibiting an-genesis (149).ccording to the recent World Can-Research Fund report (143), fruit

    d vegetables are protective againstcer of the lung, mouth, esophagus,d stomach, and to a lesser degreee other sites. The regular use ofumes also provides a measure oftection against stomach and pros-e cancer (143). Fiber, vitamin C,otenoids, flavonoids, and other phy-hemicals in the diet are reported toibit protection against various can-s. Allium vegetables may protectainst stomach cancer and garlic pro-ts against colorectal cancer. Fruitsh in the red pigment lycopene areorted to protect against prostatecer (143). Recently, cohort studiesve suggested that a high intake ofole grains provided substantial pro-tion against various cancers (151).gular physical activity provides sig-cant protection against most of thejor cancers (143).lthough there is such a variety of

    tent phytochemicals in fruit andetables, human population studiesve not shown large differences incer incidence or mortality rates

    tween vegetarians and nonvegetar-s (99,152). Perhaps more detailedd consumption data are needed be-

    se the bioavailability and potency

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    thacrepasissoycanranpapernamacrekaforphytochemicals depends on foodparation, such as whether the veg-bles are cooked or raw. In the caseprostate cancer, a high dairy intakey lessen the chemoprotective effecta vegetarian diet. Use of dairy ander calcium-rich foods have beenociated with an increased risk ofstate cancer (143,153,154), al-ugh not all studies support thisding (155).ed meat and processed meat con-

    mption is consistently associatedth an increase in the risk of colorec-cancer (143). On the other hand,intake of legumes was negativelyociated with risk of colon cancer innvegetarians (98). In a pooled anal-s of 14 cohort studies, the adjustedk of colon cancer was substantiallyuced by a high intake of fruit andetable vs a low intake. Fruit andetable intakes were associatedth a lower risk of distal colon can-, but not with proximal colon can-(156). Vegetarians have a sub-

    ntially greater intake of fiber thannvegetarians. A high fiber intake isught to protect against colon can-, although not all research sup-rts this. The EPIC study involvingEuropean countries reported a

    % reduction in risk of colorectalcer in the highest quartile of di-ry fiber intake compared to theest. Based upon these findings,gham and colleagues (157) con-ded that in populations with a lower intake, doubling the fiber intakeld reduce the colorectal cancer by%. On the other hand, a pooledalysis of 13 prospective cohortdies reported a high dietary fiberake was not associated with a de-ased risk of colorectal cancer afterounting for multiple risk factors8).oy isoflavones and soy foods have

    en shown to possess anti-cancerperties. Meta-analysis of eightdies (one cohort, and seven casetrol) conducted in high-soy-con-ming Asians showed a significantnd of decreasing risk of breast can-with increasing soy food intake. Intrast, soy intake was unrelated toast cancer risk in studies con-cted in 11 low-soy-consumingstern populations (159). However,troversy remains regarding thelue of soy as a cancer-protectiveent, because not all research sup-

    rts the protective value of soy to- actrds breast cancer (160). On theer hand, meat consumption hasen linked in some, but not all, stud-with an increased risk of breastcer (161). In one study, breast can-risk increased by 50% to 60% for

    ch additional 100 g/day of meat con-med (162).

    eoporosisiry products, green leafy vegeta-s, and calcium-fortified plant foodscluding some brands of ready-to-t cereals, soy and rice beverages,d juices) can provide ample calciumvegetarians. Cross-sectional andgitudinal population-based studiesblished during the past 2 decadesggest no differences in bone min-l density (BMD), for both trabecu-and cortical bone, between omni-es and lacto-ovo-vegetarians (163).lthough very little data exist onbone health of vegans, some stud-suggest that bone density is lowerong vegans compared with non-etarians (164,165). The Asianan women in these studies hady low intakes of protein and cal-m. An inadequate protein and lowcium intake has been shown to beociated with bone loss and frac-es at the hip and spine in elderlyults (166,167). In addition, vitaminstatus is compromised in some veg-s (168).esults from the EPIC-Oxford studyvide evidence that the risk of bonectures for vegetarians is similar tot of omnivores (38). The higher riskbone fracture in vegans appeared toa consequence of a lower calciumake. However, the fracture rates ofvegans who consumed over 525 mgcium/daywere not different from thecture rates in omnivores (38). Othertors associated with a vegetariant, such as fruit and vegetable con-ption, soy intake, and intake of vi-in K-rich leafy greens must be con-ered when examining bone health.one has a protective role in main-ning systemic pH. Acidosis is seensuppress osteoblastic activity, withgene expression of specific matrixteins and alkaline phosphatase ac-ity diminished. Prostaglandin pro-ction by the osteoblasts increasesthesis of the osteoblastic receptorivator of nuclear factor kappaB li-nd. The acid induction of receptor

    ivator of nuclear factor kappaB li- ysi

    July 2009 Journal ofnd stimulates osteoclastic activityd recruitment of new osteoclasts tomote bone resorption and buffer-of the proton load (169).n increased fruit and vegetablesumption has a positive effect oncalcium economy and markers of

    ne metabolism (170). The high po-sium and magnesium content ofits, berries, and vegetables, withir alkaline ash, makes these foodseful dietary agents for inhibitingne resorption (171). Femoral neckd lumbar spine BMD of premeno-usal women was about 15% to 20%her for women in the highest quar-of potassium intake compared

    th those in the lowest quartile2).ietary potassium, an indicator of

    t endogenous acid production andit and vegetable intake, was shownexert a modest influence on mark-of bone health, which over a life-e may contribute to a decreasedk of osteoporosis (173).igh protein intake, especially an-

    al protein, can produce increasedciuria (167,174). Postmenopausalmen with diets high in animal pro-n and low in plant protein revealedigh rate of bone loss and a greatlyreased risk of hip fracture (175).hough excessive protein intakey compromise bone health, evi-nce exists that low protein intakesy increase the risk of low bone in-rity (176).lood levels of undercarboxylatedeocalcin, a sensitive marker of vi-in K status, are used to indicate

    k of hip fracture (177), and predictD (178). Results from two large,spective cohort studies suggest anerse relationship between vitamin(and green, leafy vegetable) intaked risk of hip fracture (179,180).hort-term clinical studies suggestt soy protein rich in isoflavones de-ases spinal bone loss in postmeno-usal women (181). In a meta-analy-of 10 randomized controlled trials,isoflavones demonstrated a signifi-t benefit on spine BMD (182). In adomized controlled trial, postmeno-usal women receiving genistein ex-ienced significant decreases in uri-ry excretion of deoxypyridinoline (arker of bone resorption), and in-ased levels of serum bone-specific al-line phosphatase (a marker of bonemation) (183). In anothermeta-anal-

    s of nine randomized controlled tri-

    the AMERICAN DIETETIC ASSOCIATION 1275

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    127on menopausal women, soy isofla-es significantly inhibited boneorption and stimulated bone forma-n compared to placebo (184).o promote bone health, vegetari-s should be encouraged to consumeds that provide adequate intakescalcium, vitamin D, vitamin K, po-sium, and magnesium; adequate,t not excessive protein; and to in-de generous amounts of fruits andetables and soy products, withnimal amounts of sodium.

    al Diseaseng-term high intakes of dietarytein (above 0.6 g/kg/day for a per-with kidney disease not undergo-dialysis or above the Dietary Ref-nce Intake for protein of 0.8 g/kg/y for people with normal kidneyction) from either animal or vege-les sources, may worsen existingronic kidney disease or cause renalury in those with normal renalction (185). This may be due to theher glomerular filtration rate as-iated with a higher protein intake.y-based vegan diets appear to betritionally adequate for peopleth chronic kidney disease and mayw progression of kidney disease5).

    entiae study suggests that vegetariansat lower risk of developing demen-than nonvegetarians (186). Thisuced risk may be due to the lowerod pressure seen in vegetarians orthe higher antioxidant intake ofetarians (187). Other possible fac-s reducing risk could include aer incidence of cerebrovascularease and possible reduced use ofstmenopausal hormones. Vegetari-s can, however, have risk factorsdementia. For example, poor vita-n B-12 status has been linked to anreased risk of dementia apparentlye to the hyperhomocysteinemiat is seen with vitamin B-12 defi-ncy (188).

    er Health Effects of Vegetarian Dietsa cohort study, middle-aged vege-ians were found to be 50% lessely to have diverticulitis comparedth nonvegetarians (189). Fiber was

    sidered to be the most important a f

    6 July 2009 Volume 109 Number 7tective factor, whereas meat in-e may increase the risk of divertic-tis (190). In a cohort study of 800men aged 40 to 69 years, nonveg-rians were more than twice asely as vegetarians to suffer fromllstones (191), even after control-g for obesity, sex, and aging. Sev-l studies from a research group inland suggest that fasting, followeda vegan diet, may be useful in theatment of rheumatoid arthritis2).

    OGRAMS AND AUDIENCES AFFECTEDcial Supplemental Nutrition ProgramWomen, Infants, and Childrene Special Supplemental Nutritionogram for Women, Infants, andildren is a federal grant programt serves pregnant, postpartum,d breastfeeding women; infants;d children up to age 5 years whodocumented as being at nutri-

    nal risk with family income beloweral standards. This program pro-es vouchers to purchase someds suitable for vegetarians includ-infant formula, iron-fortified in-t cereal, vitamin Crich fruit oretable juice, carrots, cows milk,eese, eggs, iron-fortified ready-to-t cereal, dried beans or peas, andanut butter. Recent changes to thisgram promote the purchase ofole-grain breads and cereals, allowsubstitution of canned beans for

    ed beans, and provide vouchers forrchasing fruits and vegetables3). Soy-based beverages and cal-m-set tofu that meet specificationsbe substituted for cows milk for

    men and for children with medicalcumentation (193).

    ld Nutrition Programse National School Lunch Programows nonmeat protein products in-ding certain soy products, cheese,s, cooked dried beans or peas, yo-rt, peanut butter, other nut or seedtters, peanuts, tree nuts, and seedsbe used (194). Meals served mustet the 2005 Dietary Guidelines forericans and provide at least onerd of the Recommended Dietaryowance for protein, vitamins A andiron, calcium, and energy. Schoolsnot required to make modifica-

    ns to meals based on food choices of

    amily or a child although they are ingrmitted to provide substitute foodschildren who are medically certi-

    d as having a special dietary need5). Some public schools regularlyture vegetarian choices, includingan, menu items and this seems tomore common than in the past al-ugh many school food programsll have limited options for vegetar-s (196). Public schools are allowedoffer soy milk to children who bringritten statement from a parent orardian identifying the studentscial dietary need. Soy milks mustet specified standards to be ap-ved as substitutes and schoolsst pay for expenses that exceederal reimbursements (197).

    ding Programs for Elderly Adultse federal Elderly Nutrition Pro-m distributes funds to states, ter-ories, and tribal organizations for ational network of programs thatvide congregate and home-deliv-d meals (often known as Meals oneels) for older Americans. Mealsoften provided by local Meals oneels agencies. A 4-week set of veg-rian menus has been developed fore by the National Meals on Wheelsundation (198). Similar menusve been adapted by individual pro-ms including New York Citys De-rtment for the Aging which hasapproved a 4-week set of vegetar-menus (199).

    rections Facilitiesurt rulings in the United Statesve granted prison inmates the righthave vegetarian meals for certainigious and medical reasons (200).the federal prison system, vegetar-diets are only provided for in-

    tes who document that their diet ispart of an established religiousctice (201). Following review andproval by the chaplaincy team, theate can participate in the Alterna-

    e Diet Program either through self-ection from the main line that in-des a nonflesh option and access tosalad/hot bar or through provisionnationally recognized, religiouslytified processed foods (202). Ifals are served in prepared trays,al procedures are developed for thevision of nonflesh foods (201). Iner prisons, the process for obtain-

    vegetarian meals and the type of

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    Figtarial available varies depending onere the prison is located and thee of prison (201). Although someson systems provide meatless al-natives, others simply leave meatthe inmates tray.

    itary/Armed Forcese US Armys Combat Feeding Pro-m, which oversees all food regula-ns, provides a choice of vegetariannus including vegetarian Meals,ady-to-Eat (203,204).

    er Institutions and Quantity Foodvice Organizationsher institutions, including colleges,iversities, hospitals, restaurants,d publicly funded museums andrks, offer varying amounts andes of vegetarian selections. Re-rces are available for vegetarianantity food preparation.

    LES AND RESPONSIBILITIES OF FOODD NUTRITION PROFESSIONALStrition counseling can be highlyneficial for vegetarian clients whonifest specific health problems re-ed to poor dietary choices and foretarians with existing clinical con-ions that require additional di-ry modifications (eg, diabetes, hy-rlipidemia, and kidney disease).pending on the clients knowledgeel, nutrition counseling may beeful for new vegetarians and for in-iduals at various stages of the lifele including pregnancy, infancy,ildhood, adolescence, and for the el-rly. Food and nutrition profession-have an important role in provid-assistance in the planning of

    althful vegetarian diets for thoseo express an interest in adoptingetarian diets or who already eat aetarian diet, and they should bele to give current accurate informa-n about vegetarian nutrition. In-mation should be individualizedpending on type of vegetarian diet,e of the client, food preparationills, and activity level. It is impor-t to listen to the clients own de-iption of his or her diet to ascertainich foods can play a role in mealnning. Figure 1 provides mealnning suggestions. Figure 2 pro-es a list of Web resources on vege-

    ian diets. vualified food and nutrition profes-nals can help vegetarian clients infollowing ways:

    rovide information about meetingequirements for vitamin B-12, cal-ium, vitamin D, zinc, iron, and n-3atty acids because poorly plannedegetarian diets may sometimesall short of these nutrients.ive specific guidelines for plan-ing balanced lacto-ovo-vegetarianr vegan meals for all stages of theife cycle.upply information about generaleasures for health promotion andisease prevention.dapt guidelines for planning bal-nced lacto-ovo-vegetarian or veganeals for clients with special dietaryeeds due to allergies or chronic dis-ase or other restrictions.e familiar with vegetarian optionst local restaurants.rovide ideas for planning optimal

    egetarian Nutrition Dietetic Practiceroupttp://vegetariannutrition.net

    ndrews University Nutrition Departmentttp://www.vegetarian-nutrition.info

    enter for Nutrition Policy and Promotionttp://www.mypyramid.gov/tips_resources/egetarian_diets.html

    ood and Nutrition Information Centerttp://www.nal.usda.gov/fnic/pubs/bibs/gen/egetarian.pdf

    ayo Clinicttp://www.mayoclinic.com/health/egetarian-diet/HQ01596

    edline Plus, Vegetarian Dietttp://www.nlm.nih.gov/medlineplus/egetariandiet.html

    eventh-day Adventist Dieteticssociationttp://www.sdada.org/plant.htm

    he Vegan Society (vitamin B-12)ttp://www.vegansociety.com/food/nutrition/12/

    he Vegetarian Resource Groupttp://www.vrg.org

    he Vegetarian Society of the Unitedingdomttp://www.vegsoc.org/health

    ure 2. Useful Web sites concerning vege-an diets.egetarian meals while traveling. foo

    July 2009 Journal ofnstruct clients about the prepara-ion and use of foods that frequentlyre part of vegetarian diets. Therowing selection of products aimedt vegetarians may make it impos-ible to be knowledgeable about alluch products. However, practitio-ers working with vegetarian cli-nts should have a basic knowledgef preparation, use, and nutrientontent of a variety of grains,eans, soy products, meat analogs,nd fortified foods.e familiar with local sources forurchase of vegetarian foods. Inome communities, mail orderources may be necessary.ork with family members, partic-larly the parents of vegetarianhildren, to help provide the bestossible environment for meetingutrient needs on a vegetarian diet.f a practitioner is unfamiliar withegetarian nutrition, he/she shouldssist the individual in findingomeone who is qualified to advisehe client or should direct the cliento reliable resources.

    ualified food and nutrition profes-nals can also play key roles in ensur-that the needs of vegetarians aret in foodservice operations, includ-child nutrition programs, feedinggrams for the elderly, corrections fa-ties, the military, colleges, universi-s, and hospitals. This can be accom-shed through development ofidelines specifically addressing theeds of vegetarians, creation and im-mentation of menus acceptable toetarians, and the evaluation ofether or not a program meets theeds of its vegetarian participants.

    NCLUSIONSpropriately planned vegetarian dietsve been shown to be healthful, nutri-nally adequate, and may be benefi-l in the prevention and treatment oftain diseases. Vegetarian diets arepropriate for all stages of the life cy-. There are many reasons for the ris-interest in vegetarian diets. The

    mber of vegetarians in the Unitedtes is expected to increase duringnext decade. Food and nutrition

    fessionals can assist vegetarian cli-ts by providing current, accurate in-mation about vegetarian nutrition,

    ds, and resources.

    the AMERICAN DIETETIC ASSOCIATION 1277

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