Vegetarian diets are becoming increasingly popular, for both health and ideological reasons, and ethical concerns.

Vegetarian diets are the same as most other diets, but exclude meat and fish. Some vegetarians will also exclude dairy products and eggs, while others include them in their diet. Some of the dietary benefits of vegetarianism include:

• A high fiber content
• A high folic acid content
• An increased amount of vitamins C and E
• An increased amount of potassium, magnesium, and many phytochemicals
• A low fat content, consisting of mostly unsaturated fats.

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These benefits are increased further in the case of vegan diets, when all animal products are removed from the diet, which also includes honey. As a result of these dietary differences, vegetarians have a lower risk of cardiovascular disease, obesity, and type 2 diabetes.

There are several studies and reviews that investigate the claims that vegetarian diets reduce the risk of developing certain cancers.

Convincing evidence has been found to suggest that red meat and processed meat increases rates of colorectal cancer, esophageal, lung, pancreative, endometrial, lung, stomach and prostate cancer. However, more research is needed to solidify the links between meat eating and elevated cancer risks, and there are not clear results when linking vegetarianism and protection against specific cancers.

On an evidence basis, it thought to be possible that colorectal cancer incidence is reduced, probable that type 2 diabetes and osteoporosis is reduced, and convincing proof exists that cardiovascular disease risk is reduced.

Calcium Deficiency

Postmenopausal women in Asian vegetarian populations were found to have significantly lower bone mineral density (BMD) at the spine and hip, apparently due to the low protein and calcium intake and low vitamin D, which has been generally linked to increased bone loss and fractures in the elderly. However, results from cross-sectional and longitudinal population studies show no differences in BMD between ovo-lacto vegetarians and omnivores.

Moreover, bone fracture risk was found to be similar in vegetarians and omnivores. Calcium intake is likely to be inadequate only with a vegan diet.

Thus, the risk of fractures is higher in vegans, but this could be reverted to that of omnivores by the addition of 525 mg of calcium a day. This is explained by the positive impact of a diet plentiful in fruit and vegetables, which provides large amounts of potassium and magnesium.

This creates an alkaline milieu that inhibits bone resorption, increases the BMD and inhibits bone fractures. Vitamin K, which also benefits bone health is found abundantly in a vegetarian diet.

Vitamin D Deficiency

Chronic deficiency of vitamin D leads to low concentrations of its 25-hydroxy metabolite and excessively high parathyroid hormone, especially at high altitudes and in cold climates, which in turn causes decreases in BMD. One study shows that these abnormal results persist throughout the year in vegans compared to omnivores.

Fatty Acids

In the absence of fish, eggs, and seaweed, long chain fatty acids of the omega-3 family are generally deficient in the diet, in particular, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These carry important health benefits for cardiovascular and visual health, as well as for brain functioning.

The major source of these omega-3 acids is omega-3 fatty acid alpha-linolenic acid (ALA) which is a plant-based fatty acid. Because of the low percentage of conversion of this to EPA and DHA, their concentrations in serum are lower in vegetarians. The Reference Dietary Intakes are 1.6 and 1.1 g ALA/d for men and women, respectively.

Thus fortification of vegetable foods and especially consumption of microalgae in the form of supplements is advised to ensure adequate concentrations of these fatty acids, as this will provide DHA which can be converted to EPA within the body.

Iron

Another element of concern is iron, since heme iron from animal foods is significantly higher in bioavailability than the non-heme form found in plant foods. However, this does not usually translate clinically into anemia due to iron deficiency because of the synergistic action of vitamin C, which is rich in vegetarian diets.

Vitamin B12

Vitamin B12 concentration is lower in vegans than in lacto-ovovegetarians. This is associated with a higher incidence of B12 deficiency, which can precipitate neuropsychiatric manifestations and macrocytic anemia, as well as, in children, growth failure. Plasma homocysteine levels are also raised which can be a risk factor for cardiovascular disease as well as bone fractures due to osteoporosis.

An important point is that a vegetarian diet by itself doesn’t necessarily bring down the risk of heart disease compared to an omnivorous diet. This is because refined flour and sugar, as well as potatoes, are associated with a positive energy balance and obesity as well as dyslipidemia, which increase the risk of cardiovascular disease.

Thus, a healthy vegetarian diet should include high levels of whole grains, fruits and vegetables, as well as healthy oils and fats, including nuts and seeds in moderation.

Conclusion

The following guidelines are recommended to avoid potential nutrient shortfalls in vegetarian diets:

B12-fortified foods such as fortified beverages from soy and rice, breakfast cereals, nutritional yeast, or supplements. It is not enough to increase the consumption of fermented soy and green leafy vegetables, or seaweed, by themselves.

Calcium fortification is also an essential step in ensuring adequate BMD and can include the above foods as well as whole fruit juices (orange or apple) which contain calcium citrate malate, a highly bioavailable form of calcium. Fortified soy milk contains tricalcium phosphate instead with a somewhat inferior bioavailability compared to cow milk.

Vitamin D fortification is necessary to prevent deficiency particularly in the winter. If not available, daily supplements are advised, especially in older vegans.

Vegan sources of ALA include walnuts, soy, hemp-based beverages and flaxseed, which should be part of the daily diet. Fortified foods are also recommended. DHA supplements are recommended for pregnant and lactating women who need higher intakes.

Zinc deficiency is rarely seen clinically in vegans, but it is recommended that whole grains and legumes or fortified foods be ingested to avoid the possibility of a shortfall.

Further Reading

• All Vegetarian Content

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.