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FROM THE ACADEMY

Position Paper

Position of the Academy of Nutrition and


Dietetics: Vegetarian Diets

ABSTRACT POSITION STATEMENT


It is the position of the Academy of Nutrition and Dietetics that vegetarian diets can It is the position of the Academy of Nutrition
provide health benefits in the prevention and treatment of certain health conditions, and Dietetics that vegetarian diets may pro-
vide health benefits in the prevention and
including atherosclerosis, type 2 diabetes, hypertension, and obesity. Well-designed treatment of certain health conditions,
vegetarian diets that may include fortified foods or supplements meet current including atherosclerosis, type 2 diabetes,
nutrient recommendations and are appropriate for all stages of the life cycle, including hypertension, and obesity. Well-designed
pregnancy, lactation, infancy, childhood, and adolescence. Vegetarians must use special vegetarian diets that may include fortified
foods or supplements meet current nutrient
care to ensure adequate intake of vitamin B-12. Vegetarian diets are primarily plant- recommendations and are appropriate for all
based, comprised of grains, legumes, nuts, seeds, vegetables, and fruit; do not include stages of the life cycle, including pregnancy,
flesh foods (beef, pork, poultry and fowl, wild game, and fish); and may or may not lactation, infancy, childhood, and adoles-
include some animal products, such as dairy (milk and milk products), eggs, and pro- cence. Vegetarians must use special care to
ensure an adequate intake of vitamin B-12.
cessed foods that contain casein or whey. Although vegetarians may have a higher
deficiency risk for some nutrients (eg, vitamin B-12) compared to nonvegetarians,
nutritional deficiencies are not the main causes of mortality or morbidity in Western
societies. Vegetarian diets are associated with a lower risk of ischemic heart disease,
hypertension, type 2 diabetes, obesity, and some types of cancer; low-fat vegetarian diets,
in combination with other healthy lifestyle factors, have been shown to be effective in the
treatment of these diseases. Vegetarians have lower low-density lipoprotein, better serum
glucose control, and lower oxidative stress. Low intake of foods containing saturated fat
and cholesterol, and high intake of vegetables, fruits, whole grains, legumes, nuts and
seeds, and soy products that are rich in fiber and phytochemicals are components of a
vegetarian diet that contribute to reduction of chronic disease.
J Acad Nutr Diet. 2015;115:801-810.

V
EGETARIANISM, A GENERAL plant-based eating pattern can be limited or eliminated. Interest in and
term given to plant-based appropriate for these purposes and commitment to a vegetarian diet may
diets, is inherently complex in more as they deliver adequate nutrition fluctuate throughout the life cycle,
eating style, food choice, and to satisfy current recommendations. Yet, based on the previously mentioned
the motivation that leads one to choose simply avoiding meat, dairy, or eggs factors as well as economics, moral
a vegetarian lifestyle. Vegetarianism does not guarantee adequate nutrition, concern for the environment, and
in the United States during the 16th and individuals who describe them- ethical support for animal rights. Mo-
through 18th centuries may have been selves as vegetarian may not be eating tivations for choosing a vegetarian diet
born from social, political, and religious healthfully. are not static. In fact, vegetarian adults
concerns—complete with spiritual roots, Vegetarian dietary patterns are quite exhibit constant fluidity, as some have
biblical prohibitions regarding eating diverse and variant due to food avail- dropped their initial motivation, added
meat, and heated philosophical, psycho- ability, region, age, gustatory reasons, new ones, and modified their beliefs
logical, and medical debate.1 Today, and religious and cultural beliefs. They over time. Of interest, vegetarian di-
choosing to adopt a vegetarian diet encompass a wide array of plant foods etary patterns based on health may be
may stem from a compassionate moral and food practices based on these fac- more flexible than those based on
order to protect animals and our envi- tors and always begin with a plant- religious or moral reasons.2 Motiva-
ronment, enhance quality of life, prevent based foundation. Vegetarian diets are tions influence dietary practices,
health complications, or promote self- almost always comprised of plant which may impact nutrient intake.
management strategies to therapeuti- foods, such as grains, legumes, nuts, Although there is some risk for
cally treat disease. A well-designed, seeds, vegetables, and fruit; animal nutrient deficiencies in a vegetarian
products, such as flesh foods (beef, diet compared to nonvegetarian diets,
pork, poultry and fowl, wild game, and there are tremendous advantages
2212-2672/Copyright ª 2015 by the
Academy of Nutrition and Dietetics.
fish), dairy (milk and milk products) toward prevention of chronic health
http://dx.doi.org/10.1016/j.jand.2015.02.033 and eggs, along with processed conditions by adhering to a vegetarian
foods that contain casein or whey, are eating pattern.

ª 2015 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 801
FROM THE ACADEMY

Being well informed of these issues nationwide poll, which is up by 2% societies formed from the offshoot of
will enhance the counsel of registered from a similar poll taken in 2006.3 The the 1975 World Vegetarian Congress
dietitian nutritionists (RDNs) and nu- same poll revealed 47% of Americans share the principles of and accessibility
trition and dietetics technicians, regis- eat at least one vegetarian meal per to vegetarianism with conventional
tered (NDTRs) regardless of clients’ week. More than half to nearly three- audiences.
reasons, convictions, motivation, and fourths of vegetarians and vegans pol- Also, the outreach of vegetarian food
nutrition knowledge. RDNs and NDTRs led seek healthier whole-food options festivals is growing and aims to extend
should be aware of these considerable and would purchase a vegan deli compassion into the community. For
health advantages of a vegetarian diet sandwich in a chain restaurant. Forty- instance, for more than 15 years, the
to more effectively counsel and educate four percent of younger consumers free-admission Boston Vegetarian Food
clients on the utility of plant-based di- choose meatless meals once weekly.4 Festival has grown from 1 to 2 days to
ets for disease prevention and man- One in four US adults claim to be sample foods; attend presentations;
agement. RDNs and NDTRs, along with meat reducers, those who continue to and learn about eco-friendly, sustain-
assessing knowledge, beliefs, reasons, eat meat but for health reasons limit able vegetarian diets. This growth re-
and motivations for choosing a vege- their intake. This is another growing sulted in selling tickets for prefestival
tarian dietary pattern, should educate field moving toward plant-based diets hours to shop without crowds. New
on the importance of including a variety of which to take note. York and San Francisco’s veggie food
of colorful fresh or frozen foods that are There is a growing demand for fests have also added days and moved
unrefined and minimally processed. products that are “meat-free,” have a to larger venues. This speaks well to
This will promote self-management “meat-like texture,” are “suitable for substantiate the growing percentage of
strategies that meet nutrition needs vegetarians,” and are for “meat and Americans experimenting with meat-
and address specific nutrient consider- veggie lovers alike.”5 Sales of alterna- free eating.
ations to assure optimal nutrition. tive meat products, driven largely by A plant-based diet, which is the foun-
What follows are some of the types health reasons and resemblance to dation of a vegetarian diet, is becoming
of plant-based diets one may choose: meat, reached $553 million in 2012, an mainstream, as further evidenced by
8% increase in 2 years; 31% and 36% of many nonprofit and governmental in-
 Vegetarian diet: A vegetarian
survey responders sought organic and stitutions highlighting this dietary
diet is devoid of all flesh foods,
vegan meat alternatives, respectively, choice. The American Institute for Can-
but may include egg or dairy
especially in the 18- to 44-year age cer Research encourages a plant-based
products.
group.5,6 This age group is more likely diet defined as two-thirds of our di-
 Ovo-vegetarian diet: A vegetarian
to follow a strict diet, be interested in etary intake being comprised of vege-
diet free from flesh foods and
current dietary fads like gluten- and tables, fruits, whole grains, and beans.7
dairy foods but includes eggs.
lactose-free diets, and tend toward so- In addition, the US Department of
 Lacto-ovo-vegetarian diet: A vege-
cial media in a way the older popu- Agriculture modified meal plans for
tarian diet free from flesh foods but
lation does not. Thus, the high lacto-ovo-vegetarian and vegan dietary
includes eggs and dairy products.
availability of ready-to-eat, refined, patterns are listed as Appendices 8 and
 Vegan diet: A vegan dietary
gluten-free, and faux-meat foods may 9 of the 2010 Dietary Guidelines for
pattern is free from all flesh
be enticing to this group who adopt Americans.8 And, the National School
foods, eggs and dairy products,
a vegetarian lifestyle. However, a diet Lunch Program, while not requiring
and sometimes honey.
heavy in nonanimal, meat-like prod- vegetarian options per se, requires
 Raw vegan diet: A strictly fresh
ucts and refined and highly processed schools to increase availability of
and uncooked food intake based
vegetarian foods, while allowing the fruits, vegetables, and whole grains in
on fruit, nuts, seeds, and
client to remain committed to a moral, current meal patterns in the school
vegetables.
ethical, or health obligation to eat menu. These government-driven and
 Macrobiotic diet: A strict whole-
vegetarian, may diminish or limit health institutional changes reflect a
foods, plant-based diet that in-
overall nutrition. Many of these “con- considerable shift in the attitude of
cludes fish but no other flesh
venience” foods have little nutritional Americans.
foods and includes mostly brown
value and added sugars and high- Lastly, those adhering to a vegetarian
rice and whole grains supple-
fructose corn syrup, salt, and chemical lifestyle now have technological sup-
mented with local vegetables
additives. Noting avoidance of certain port. To date, while no online nutrition
and seaweed, beans, nuts, seeds,
foods, like gluten or lactose, and the food tracker exists strictly for vegetar-
certain fruits, and miso soup.
client’s reason will enable a more ians, some allow clients adopting this
 Semi-vegetarian diet: A plant-
thoughtful recommendation by the lifestyle to select vegetarian and vegan
based dietary pattern with occa-
RDN. plans. Various applications for mobile
sional beef, pork, poultry, or fish
Leading scientists and vegetarian devices allow vegetarians to grasp
perhaps once or twice weekly.
experts from all over the world join nutritional needs, track intake, and
together every 5 years at Loma Linda locate restaurants and markets where
TRENDS, DIVERSITY, AND University for the International Con- vegan foods are available. The online
MOTIVATIONS THAT INFLUENCE gress on Vegetarian Nutrition. Here, tracking tool at www.SuperTracker.
ADULT VEGETARIANS presentations on the most up-to-date usda.gov is a part of the US Depart-
In 2012, approximately 5% of US vegetarian health research and up- ment of Agriculture Choose MyPlate
adults were vegetarian, according to a dates are heard. Local vegetarian program.9

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NUTRITION CONSIDERATIONS with these essential oils, their dose is source of iron in cooked foods, may
FOR VEGETARIANS relatively small, as is their contribution prove to be the most important factor
to overall intake when compared to in iron deficiency prevention.
Protein the recommendations.14 RDNs should
A concern that vegetarians, especially assess dietary intake of essential fatty
vegans and vegan athletes, may not
Zinc
acids for all stages of the life cycle and Individuals in most regions of the
consume an adequate amount and recommend consideration of available
quality of protein is unsubstantiated. world who habitually adhere to vege-
vegetarian-friendly supplements to en- tarian diets, especially vegans, have
Vegetarian diets that include a variety sure adequate intake and stores.
of plant products provide the same low zinc intakes and status.23 Vegans
protein quality as diets that include and vegetarian women from devel-
Iron oping countries have the highest risk of
meat.10 Protein consumed from a vari- Generally, because iron intake among
ety of plant foods supplies an adequate low zinc intake and status. Due to the
vegetarian men and postmenopausal presence of zinc absorption inhibitors
quantity of essential amino acids when women is higher than the Institute of
caloric intake is met. Pregnant and in plant foods, the recommendation
Medicine’s recommendation, iron de- for vegetarians, compared to non-
lactating vegetarian women, including ficiency and depletion of iron stores
vegan women, need to follow the vegetarians, is 50% greater.15 This
are almost never noted among these highlights the need for a higher intake
recommendation for protein intake for vegetarians.15,16 However, children,
their life stage and should include an of zinc among vegetarians. This may be
pregnant women, and premenopausal especially important for pregnant and
additional 25 g protein each day.10 women may consume less iron
RDNs should assess quality of protein lactating women. Overt symptoms of
than the Recommended Daily Allow- zinc deficiency are not common in
intake and recommend that children, ance.17-19 Although some studies
adolescents, adults, pregnant adoles- Western societies and it is unclear
showed adequate iron stores and low what impact the low intake and status
cents and adults, and athletes include to no deficiency rates among vege-
an adequate variety of protein foods of zinc among vegetarians may have.
tarian children, other findings docu-
daily. Combining two or more incom- mented relatively high rates of iron
plete protein foods (those low in one or deficiency, ranging from about one-fifth
Calcium
more essential amino acids, such as to more than one-third of sampled Although it is not always the case,
rice and beans, peanut butter and vegetarian children.17,19,20 Similarly, as lacto-ovo-vegetarians show a relatively
whole grain bread, tortillas with beans, high as 26% of vegetarian pregnant high intake of calcium, often exceeding
and cooked beans with cornbread) is women were diagnosed with iron defi- the Institute of Medicine’s recommen-
not required in every meal as long as ciency in one study.21 Preventing iron dations.24 In contrast, vegans consis-
variety is present. deficiency among vegetarian children is tently show lower-than-recommended
imperative and may be strictly a matter calcium intake.25 Findings from one
n-3 Fatty Acids of appropriate dietary planning. large prospective study showed that
Vegetarians can meet the Adequate Two types of inadequate iron status vegans with calcium intake <525 mg/
Intake of a-linolenic acid from foods exist: iron deficiency and iron- day had a 25% higher risk of bone
such as flaxseeds, chia seeds, walnuts, deficiency anemia, the former being fractures.26 RDNs should assess cal-
canola and soybean oil, and a few other the less severe form. Vegetarians have cium intake in both vegans and
plant sources.11 Use of these products is a comparable rate of iron-deficiency adolescent vegetarians who may need
effective in increasing serum/plasma anemia to nonvegetarians. However, to increase their intake of dietary cal-
a-linolenic acid concentration. While vegetarians have a higher rate of iron cium. Calcium can be found in dairy
studies have shown that increasing the deficiency.22 Adverse symptoms are products, legumes (including soy-
dietary a-linolenic acidetoelinoleic already seen when iron deficiency is beans), spinach, kale, turnips, collards,
acid ratio can result in a substantial present. In addition to low intake, this broccoli, calcium-fortified soy milk,
increase in the plasma or red blood cell is most likely a result of low iron ab- and other calcium-fortified nondairy
concentration of the a-linolenic acid, sorption due to the traditional iron- milk alternatives and orange juice, and
studies with vegetarians consistently absorption inhibitors, such as fiber or calcium-set tofu. If dietary intake of
showed low plasma eicosapentaenoic phytic acid. RDNs and NDTRs can guide calcium is low, a well-absorbed calcium
acid (EPA) among vegetarians, especially and counsel vegetarians in dietary supplement can be recommended in
vegans compared to nonvegetarians.12 planning regarding the best strategies divided doses.
Similarly, plasma decosahexaenoic to meet iron recommendations from
acid (DHA) concentration among vege- plants in order to obtain adequate iron Vitamin D
tarians has been shown to be very low, stores. The recommendation to focus Low serum vitamin D concentrations
as consumption of plant foods rich in on good sources of nonheme iron, have recently been reported among
a-linolenic acid has virtually no impact such as iron-fortified breads and ce- both vegetarian children and adults.27-30
on serum/plasma DHA concentration.11 reals, beans and lentils, raisins, and There are considerable variations in
Consuming adequate amounts of EPA blackstrap molasses, along with good vitamin D concentrations subject to the
and DHA seems to be especially critical sources of vitamin C, like tomatoes different seasons of the year, with
in pregnancy, infancy, and in elderly and citrus fruits for optimal iron ab- the lowest concentrations reported in
people.13 Although foods such as some sorption, and cooking in cast iron pans, winter months.27,28 Depending on the
brands of soymilk have been fortified which also provides an additional place of residence, vegetarians may

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FROM THE ACADEMY

need to rely on sun exposure, food EATING DISORDERS AND A vegetarian diet for wellness is
fortified with vitamin D, and/or vegan VEGETARIAN DIETS guided toward individuals in generally
supplements to maintain adequate se- It has previously been hypothesized good health who are not in need of
rum levels. However, obtaining ad- that a vegetarian diet may be moti- specific recommendations or alter-
equate vitamin D from fortified foods is vated by weight control and restrained ations for health problems or disease. A
the most challenging for vegans eating.35 Some findings support that therapeutic approach differs in that
because few plant foods are fortified adult vegetarians have a higher rate of clients following or transitioning to a
with this vitamin. In such cases, vegan disordered eating than nonvegetarians, vegetarian or vegan diet do so because
vitamin D supplements seem to be the while others suggest higher rates in of a clinical need for treatment or
most prudent way to ensure adequate nonvegetarians or no difference.36 management of a health problem or
vitamin D status. RDNs should assess There is also an association between chronic disease. Disease state, length of
the biochemical data for vitamin D for vegetarianism and disturbed eating intervention, restrictiveness, and client
clients whose dietary assessment re- among adolescents.36,37 Adolescent support are factors that may influence
veals inadequate intake. and young adult vegetarians were adherence to a diet. For adult clients,
more likely to engage in binge eating RDNs should monitor and evaluate
Vitamin B-12 with loss of control, and former vege- adherence to a therapeutic vegetarian
Vegetarian diets are associated with tarians were more likely than those diet, as these diets appear to perform
vitamin B-12 depletion and/or defi- who never were vegetarian and cur- as well or better than omnivorous diets
ciency. A high prevalence of deficiency, rent vegetarians to engage in extreme in terms of attrition rate, provided ad-
assessed by methylmalonic acid and/or unhealthful weight-control behav- equate nutrition education and appro-
holotranscobalamin II concentrations, iors.37 However, it is still a matter of priate dietary support are received.
is found among vegetarians, regardless debate whether adopting a vegetarian Employing a variety of counseling
of the type of diet they follow.31 There diet is the cause of disordered eating or approaches and strategies, including
is a high prevalence of low serum whether it is one of the manifestations motivational interviewing, frequent en-
vitamin B-12 and elevated homocyste- of disordered eating (casual vs symp- counters, cooking demonstrations, and
ine among vegetarians.32 Vitamin B-12 tomatic relationship). The majority of incentives, can improve nutrition-
status is usually the most compromised women reduce meat intake after the related outcomes when using a vege-
among followers of vegan diets.31 onset of an eating disorder, so it is tarian diet therapeutically.
Prevalence of B-12 deficiency ranged unlikely vegetarianism is a risk factor
from 30% to 86% among healthy, for developing an eating disorder.36,37
Obesity
nonpregnant adult vegetarians, 46.9% Vegetarianism then may not lead to Healthier eating and food choice are
to 68% in adults older than 55 years, disordered eating. However, semi- a growing trend largely driven by
and 43% to 88% in vegans.31 vegetarians, who restrict meat intake more than two-thirds of overweight
Although severe overt symptoms of for weight control and convert to and obese Americans (69.2%) trying
vitamin B-12 deficiency may most vegetarianism after the eating disorder to effectively manage their weight.41
likely be manifested only in a stage IV onset, could see vegetarianism playing Health promotion and improving car-
deficiency, mild and subtler symptoms a role in the maintenance of the eating diovascular function and insulin sensi-
like fatigue and weakness may be disorder.38 tivity by reducing the inflammatory
more common. Vitamin B-12 defi- Vegetarian children and adolescents response that underlies most disease
ciency during pregnancy and lactation are more likely than nonvegetarian processes are a myriad of reasons cli-
may lead to severe developmental children to have a diet consistent with ents seek weight loss.
problems in the developing fetus and the Healthy People 2010 dietary Research indicates the therapeutic
infants.33 Adult vitamin B-12 deficiency guidelines, and this is especially true of use of a vegetarian diet is effective
is associated with a range of health meeting recommendations for specific for treating overweight and obesity in
problems from mild to severe, in- foods and nutrients including fruits, both the short term (<1 year) and
cluding increased risk for dementia and vegetables, and total and saturated longer term (>1 year), and may per-
Alzheimer’s disease, multiple sclerosis, fat.39,40 However, a subset of vegetarian form better than alternative omnivo-
psychosis, mood swings, neuropathy, adolescents and young adults shows rous diets for the same purpose. A
myelopathy, memory impairment, de- higher patterns of unhealthful dieting vegan diet with structured group sup-
pression, brain atrophy, hearing loss, practices than omnivores or more port and behavioral therapy compared
and occlusive vascular disease.34 En- health conscious vegetarians of the to the National Cholesterol Education
suring adequate vitamin B-12 status same age.38 RDNs should assess for Program diet was associated with sig-
seems to be most important among problem behaviors such as dieting in nificantly greater weight loss at years
pregnant and lactating vegetarian adolescent and young adult (19 to 30 1 and 2.42 If consistent with client
women and in older vegetarians. RDNs years) vegetarians. preference, RDNs may recommend
should assess B-12 status in children, and educate on the therapeutic use of
adolescents, and adults, including a nutrient-dense vegetarian diet for
pregnant adolescents and adults, and THERAPEUTIC VEGETARIAN adults seeking treatment for over-
recommend that vegetarians, regard- DIETS AND CHRONIC DISEASE weight or obesity. As research shows
less of the type of vegetarian diet they The terms wellness and therapeutic lower compliance rates for weight-loss
adhere to, take vitamin B-12 supplements have been applied to clarify the treat- clients vs clients treated for other dis-
based on their physician’s guidance. ment purpose of a vegetarian diet.41 ease states, RDNs should monitor and

804 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2015 Volume 115 Number 5
FROM THE ACADEMY

evaluate adherence and motivation and hypertension. Results of the EPIC (Eu- in the EPIC-Oxford study was equal to
provide continued nutrition education ropean Prospective Investigation into the risk among nonvegetarians, vegans
and behavioral change support. Cancer and Nutrition)-Oxford study who consumed <525 mg calcium/day
showed that vegans have the lowest had a 30% higher risk.26 Also, among
rate of hypertension of all diet groups participants of the Adventist Health
Cardiovascular Disease Including (vegans, vegetarians, fish eaters, and Study 2, vegans had an 86% higher risk
Hyperlipidemia, Ischemic Heart meat eaters), including the lowest and vegetarians a 24% higher risk of
Disease, and Hypertension systolic and diastolic blood pressure.56 fractures.61 RDNs should counsel veg-
Vegetarian diets improve several diet- Vegan members of the Seventh-day etarians, especially vegans, on fracture
related modifiable heart disease risk Adventist Church had a 63% lower prevention, including making appro-
factors, including abdominal obesity, odds ratio of developing hypertension priate food and/or supplement selec-
blood pressure, serum lipid profile, and compared to nonvegetarians, while tion to improve their calcium, vitamin
blood glucose, and can lower total vegetarians had a 43% lower risk.44 B-12, and other relevant nutrients
cholesterol from 7.2% to 26.6% and low- intake.
density lipoprotein cholesterol from Diabetes
8.7% to 35%.43-46 They also decrease Obesity increases the risk of type 2 VEGETARIAN DIETS
markers of inflammation such as C-
reactive protein and reduce oxidative
diabetes. The difference in BMI be- THROUGHOUT THE LIFECYCLE
tween vegans and nonvegetarians in-
stress, and protect from atheriotic dicates a substantial potential for
Pregnant and Lactating Women
plaque formation.47 Consequently, vegetarianism to counteract environ- Neonates born to vegetarian, especially
vegetarians have a reduced risk of mental forces leading to obesity and vegan, mothers from developed coun-
developing and dying from ischemic increased risk of type 2 diabetes.46 tries, have higher birth weight and
heart disease.48-50 It was estimated Vegan and lacto-ovo-vegetarian diets lower prevalence of low-birth-weight
that the probability of vegetarians are associated with a nearly one-half compared to nonvegetarian mothers.21
developing cardiovascular disease at reduction in risk of type 2 diabetes Vegetarian pregnant women have a
age 55 years was 6.1% compared to compared with nonvegetarian diets.46 high risk of vitamin B-12 deficiency.
17.9% among age-matched omnivo- In addition, a vegetarian diet can This is especially true of long-term
rous.47 Vegan diets seem to be most decrease or maintain blood glucose vegetarians, especially vegans.33 Vi-
beneficial in improving heart disease levels, and a vegan diet can decrease tamin B-12 deficiency in pregnancy can
risk factors.44,45 hemoglobin A1c.45 If consistent with result in spontaneous abortion.62 Vege-
Vegetarians can also decrease their client preference, RDNs can recom- tarian, especially vegan, pregnant
risk of developing circulatory health mend and educate on the benefits of women need to supplement their diet
problems by ensuring a reliable source the therapeutic use of a vegetarian diet with vitamin B-12.31 While deficiency
of, and adequate dose of, vitamin B-12, for adults seeking treatment for type 2 symptoms might not always be seen
which is associated with improved diabetes. among pregnant women, within a few
arterial epithelial function and better months postpartum, infants of mothers
blood flow.51 Also, vitamin B-12 is es- who are vitamin B-12deficient can
sential in reducing homocysteine,
Cancer experience severe anthropometric and
which is an independent risk factor for Several epidemiological studies, developmental complications.33 Neu-
heart disease.52 While vegetarians tend including large prospective studies rologic symptoms that develop in in-
to have a lower body mass index (BMI; with Seventh-day Adventist church fants and children who are vitamin
calculated as kg/m2), an additional members and with British vegetarians, B-12deficient can have long-term
reduction in risk can be made by documented modestly lower overall complications.
keeping weight within the range for cancer risk among vegetarians com- Pregnant vegetarian women are at a
healthy BMI and by regularly con- pared to nonvegetarians.57,58 A recent high risk for iron deficiency, evidenced
suming a variety of vegetables, fruit, meta-analysis based on seven pro- by more than one in four pregnant
whole grains, and nuts, like almonds spective studies showed a nonsignifi- vegetarian women who develop an
and walnuts. cant 9% lower risk of overall cancer iron deficiency.21 Iron deficiency dur-
Low-fat vegan and vegetarian diets, mortality and an overall 29% statisti- ing pregnancy can result in inadequate
combined with other lifestyle factors, cally significant reduction in cancer fetal weight gain; premature delivery;
including not smoking and weight re- incidents.48 and a higher risk of maternal, fetal, and
duction, have been shown to reverse infant death. They are also at risk for
atherosclerosis.53-55 Plaque thickness Osteoporosis inadequate EPA and DHA intake and
was reduced within just a few months Vegetarian compared to nonvegetarian status.11 These essential fatty acids are
of dietary and lifestyle modification, children 2 to 10 years of age have a important in brain and eye develop-
even without the use of cholesterol- 20%, 10%, and 15% reduced serum level ment of the fetus and breastfed infant.
lowering drugs.55 As such, these diets of osteocalcin, bone alkaline phospha- Adequate intake is associated with
are strongly recommended to all cli- tase, and osteoclast activity, respec- increased pregnancy duration. It is
ents with heart disease who are willing tively.59 Vegetarians, especially vegans, also associated with decreased risk of
to adopt them. have lower bone mineral density as asthma and better attention span in
Vegetarians compared to non- compared to nonvegetarians.27,30,60 children. In addition, pregnant vegan
vegetarians have a lower prevalence of While fracture risk among vegetarians women should ensure they consume

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FROM THE ACADEMY

BREAKFAST BREAKFAST
1
/2 cup dry oats, cooked 2 scrambled eggs or scrambled tofu
1 cup 1% milk or soymilk 2 corn tortillas
1
/2 cup blueberries 3 tablespoons salsa
1 1
/2 medium banana, sliced /2 cup avocado, cubed
2 tablespoons slivered almonds 1 part-skim string cheese
1 tablespoon maple syrup 510 calories
529 calories
LUNCH LUNCH
6-inch whole-wheat tortilla Pinto bean salad:
1 1
/2 cup hummus /2 cup canned pinto beans, drained
1
Tomato, lettuce, and cucumbers /4 cup red bell pepper, diced
Basil leaves, rolled and sliced thinly 1
/4 cup purple onion, finely diced
1
Drizzle with dressing: /4 cup cucumber, diced
1
1/4 cup lemon juice /4 cup frozen corn, thawed
3 tablespoons extra-virgin olive oil 2 tablespoons fresh cilantro, chopped
2 teaspoons minced garlic 2 tablespoons vinaigrette
339 calories 2 cups mixed greens
1 tablespoon vinaigrette
1 naval orange
463 calories
DINNER DINNER
1 cup oven-roasted butternut squash cubes 6 ounces pan-seared barbecued seitan (wheat gluten)
1 cup steamed Haricot verts (thin green beans) 1 cup steamed cauliflower/broccoli with 1 teaspoon
with 1 teaspoon vegan margarine vegan margarine
1 1
/2 cup corn kernels /2 cup brown rice
3 ounces oven-baked tofu marinated in teriyaki sauce Whole-wheat dinner roll with 1 teaspoon vegan margarine
1
/2 cup cranberry almond quinoa salad 414 calories
490 calories
SNACK SNACK
1 cup grapes Apple crisp
1 cup non-fat plain Greek or soy yogurt 1 sliced apple
1 1
/2 cup low-fat granola /4 cup dry oats
444 calories 1 teaspoon lemon juice
2 teaspoons brown sugar, packed
1
Total calories: 1,815 /2 cup vanilla soy ice cream
Carbohydrate: 261 g (54%) 376 calories
Protein: 86 g (18%)
Fat: 56 g (26%) Total calories: 1,763
Fiber: 43 g Carbohydrate: 245 g (52%)
Protein: 77 g (16%)
Fat: 61 g (29%)
Fiber: 43 g
Figure 1. Two sample 1,800-calorie vegetarian meal plans for optimal nutrition.

an adequate amount of dietary or than optimal concentration, based on RDNs should design a dietary plan
supplemental calcium. clinical judgment, RDNs should counsel and offer comprehensive nutrition
For the pregnant adolescent or adult the patient or client to increase intake education and skill development on
vegetarian, if assessment of iron, cal- of foods rich in these nutrients, adding planning a diet for pregnant adult
cium, EPA, and DHA intake or status foods that were fortified with them and adolescent vegetarians that pro-
reveals a potential deficiency or lower and/or taking supplements. vides adequate protein from a variety

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FROM THE ACADEMY

of complementary mixtures of plant


Vegetarian/Vegan Myths
proteins consumed throughout the
day. RDNs should ensure adequate Di- Safety of Soyfoods
etary Reference Intakes of protein and B-12 in Vegetarian Diets
all micronutrients, particularly B-12, Isoflavones in Vegetarian Diets
iron, folate, and zinc, and recommend Health Effects of Soy
supplementation as appropriate to Zinc in Vegetarian Diets
ensure adequate intake. Iron in Vegetarian Diets
Meeting Calcium Recommendations on a Vegan Diet
Infants, Children, and Choline in Vegetarian Diets
Adolescents Vegetarian Diets in Pregnancy (Spanish translation available)
Regardless of assessment methods Vegetarian Diets During Lactation (Spanish translation available)
used, age, sex, or participant’s ethnic Vegetarian Infants
background, vegan and vegetarian
Vegetarian Diets for Toddlers and Preschoolers (Spanish translation available)
children attain adequate growth that is
comparable with nonvegetarian chil- Vegetarian Nutrition for School-Aged Children (Spanish translation available)
dren.63,64 Although vegetarianism dur- Vegetarian Teens
ing the first 2 decades of life might be Vegetarian Diets in Diabetes
associated with a higher risk of defi- Vegetarian Diets in Chronic Kidney Disease
ciency of some nutrients, such as vita- Eat More Plant-Based Meals
mins C and B-12, iron, zinc, and Combining Vegetarian, Vegan, and Gluten-Free Diets
calcium, vegetarian children and teens
Sports Nutrition for Vegetarians
are at lower risk of some health prob-
lems, such as obesity.18,30,59,65 This Protein in Vegetarian Diets
might be, in part, a result of vegetarian Therapeutic Use of Vegetarian Diets in Chronic Disease
children being more likely than Climate Change and Sustainability of Vegetarian Foods
nonvegetarian children to have a diet Lactose Intolerance and Dairy Substitutions
consistent with the Healthy People
2010 dietary guidelines, including Figure 2. Vegetarian Nutrition dietetic practice group (www.vndpg.org) resources for
meeting recommendations for specific registered dietitian nutritionists and consumers. These resources respond to questions
foods and nutrients including fruits,
or concerns regarding specific vegetarian or vegan dietary nutrients and protocols.
Typically two to four pages in length, they are authored by registered dietitian nu-
vegetables, and total and saturated
tritionists who are experts on the topic and members of the Vegetarian Nutrition
fat.39,40 RDNs should assess micro-
dietetic practice group. These resources provide a wealth of evidence-based infor-
nutrient intake, particularly vitamins mation and guide one to implement and maintain an appropriate nutrient-adequate
C and B-12, iron, zinc, and calcium, vegetarian diet for all stages of the life cycle.
and macronutrient intake, especially
protein and essential fatty acids, in
children and adolescents ascribing to a number of environmental problems anthropogenic methane; and 65%
vegetarian dietary pattern. from water, soil, and air pollution to anthropogenic nitrous oxide.68 Another
global warming.68 The livestock sector area of concern related to modern meat
Older Adults and the Elderly has been described by the Food and production is the use of antibiotics
Vegetarian diets might be beneficial for Agriculture Organization as “one of the in animal feed. A recent Centers for
older adults and the elderly in pre- top two or three most significant con- Disease Control and Prevention report
vention of chronic health conditions, tributors to the most serious environ- listed this practice as one of the factors
such as heart disease and obesity, but mental problems at every scale from associated with antibiotic resistance.
not osteoporosis.66,67 These individuals local to global.”69 According to the US Antibiotic resistance is estimated to
can also have a lower risk of iron Environmental Protection Agency, cause >2 million infections, resulting
deficiency compared to younger vege- about 70% of all water pollution in in at least 23,000 deaths.70
tarians, but may have a higher risk rivers and lakes in the United States is a
for a deficiency of vitamin B-12 result of pollution from animal farms.69
Animal agriculture is associated with ROLES AND RESPONSIBILITIES
due to a reduction in intrinsic factor.
This is especially true of long-term land degradation, water shortage, and OF THE RDN AND NDTR
vegetarians.31 loss of biodiversity.68 In order to effectively counsel the
Among the examples of the envi- therapeutic or wellness adoption and
ronmental impact of meat production implementation of, and adherence to, a
Ethical Choices for Vegetarian Diets that the Food and Agriculture Organi- vegetarian lifestyle, RDNs and NDTRs
In comparison to omnivorous diets, zation report are 70% deforestation of must have adequate knowledge and
vegetarian diets are environmentally the Amazon region, resulted from access to educational materials to
friendlier. The increasing demand creating pastures and feedlots in areas facilitate lifestyle choices of health-
for meat and modern methods of previously covered by Amazon forest; promoting vegetarian diets. To that
meat production are associated with a 9% anthropogenic CO2 emissions; 37% end, Figure 1 identifies two generalized

May 2015 Volume 115 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 807
FROM THE ACADEMY

 www.VNDPG.org (Vegetarian Nutrition [VN] dietetic practice group): Member benefits include professional information
on vegetarian nutrition, registered dietitan nutritionist (RDN) resources, and quarterly newsletters.
 www.vegetariannutrition.net (VN’s consumer website): Provides a blog with evidence-based vegetarian nutrition plus
RDN resources for consumers.
 www.vrg.org: The Vegetarian Resource Group provides nutrition information, recipes, meal plans, and recommended
readings for vegetarian nutrition.
 www.PCRM.org: The Physician’s Committee for Respsonsible Medicine promotes preventive medicine through inno-
vative programs and offers free patient educational materials.
 www.PETA.org: People for the Ethical Treatment of Animals, an animal rights organization, also offers free vegetarian
literature and menu plans.
 www.veganhealth.org: This website offers evidence-based recommendations covering the myriad ways one can stay
healthy eating plant-based diets.
 www.vegweb.com: Offers vegetarian recipes and community.
 www.vegetarian-nutrition.info: Offers articles, resources, and news on vegetarian nutrition.
Figure 3. Professional and consumer websites for vegetarian nutrition that provide information on vegetarian and vegan dietary
nutrients and protocols as well as animal ethics and social and environmental issues. Many of these sites provide high-quality
educational material that the registered dietitian nutritionist can rely on for patient or client education on individual nutrients
of concern, meal plans, plant-based substitutions for meat-based dishes, and vegetarian nutrition concerns throughout the
life cycle.

vegetarian meal plans that ensure vegetarian and vegan intakes provide 3. Stahler C. How often do Americans eat
vegetarian meals? And how many adults
adequate intake of macro- and micro- adequate nutrition for all cycles of life,
in the US are vegetarian? The Vegetarian
nutrients sufficient to support healthy including both wellness and thera- Resource Group website. http://www.vrg.
intake. Additional food recommenda- peutic uses for disease prevention and org/journal/vj2011issue4/vj2011issue4poll.
tions can be found in the 2010 Dietary treatment. While vegetarians may php. Accessed October 10, 2013.
Guidelines for Americans. Figure 2 lists have a higher risk of some nutrient 4. Nachay K. Targeting the new vegetarian
foods consumer. Inst Food Technol. 2001;
all evidence-based RDN consumer deficiency (eg, vitamin B-12) 65(11). http://www.ift.org/food-technology/
and professional resources available compared to nonvegetarians, nutrient past-issues/2011/november/features/target
through the Vegetarian Nutrition di- deficiencies are not the main cause of ing-the-new-vegetarian-foods-consumer.
aspx?page¼viewall. Accessed September
etetic practice group; while the RDN mortality and/or morbidity in Western 10, 2013.
can refer clients to the consumer re- societies. Vegetarians have a lower 5. Mintel International Group Limited. Meat
sources, only members of the Vege- risk of most main causes of mortality, Alternatives. Executive Summary. Chicago,
tarian Nutrition dietetic practice group including heart disease and some IL: Mintel International Group Limited;
June 2013.
have access to the professional re- cancers. Choosing a meat-free diet is
sources. Figure 3 contains useful web- deemed environmentally protective, a 6. Hoek AC, Luning PA, Weijzen P, Engels W,
Kok FJ, de Graaf C. Replacement of meat
sites that promote and encourage strong impetus for some in moving by meat substitutes. A survey on person-
appropriate evidence-based recom- toward vegetarianism. Greater re- and product-related factors in consumer
mendations and food choices for both sources are now available, such as acceptance. Appetite. 2011;56(3):662-673.
the RDN and clientele. Additional rec- online tools and educational sites, as 7. American Institute for Cancer Research.
Recommendations for cancer prevention.
ommendations can be found at the well as RDNs and NDTRs who are
http://www.aicr.org/reduce-your-cancer-risk/
Academy’s Evidence Analysis Library more up-to-date on vegetarian diets recommendations-for-cancer-prevention/
(www.andeal.org), a free benefit to all and who can assist the general public recommendations_04_plant_based.html?
Academy of Nutrition and Dietetics in making better-informed decisions gclid¼CJ6__O7dpboCFcid4AodhkMAIA.
Accessed October 10, 2013.
members. about their health and intake through
8. US Department of Agriculture, US Depart-
vegetarian nutrition, foods, and re- ment of Health and Human Services.
sources. RDNs and NDTR are the most Dietary Guidelines for Americans, 2010. 7th
CONCLUSIONS optimal resources to vegetarian and ed. Washington, DC: US Government
Printing Office;2010 http://www.health.
Awareness in plant-based diets con- vegan clients.
gov/dietaryguidelines/dga2010/Dietary
tinues to grow in the United States Guidelines2010.pdf. Accessed October
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ol-Protein-and-Amino-Acids.aspx. Accessed anaemia_iron_deficiency/WHO_NHD_01 versus non-vegetarians. Appetite. 2012;


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This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on October 18, 1987, and reaffirmed
on September 12, 1992; September 6, 1996; June 22, 2000; June 11, 2006; and March 19, 2012. This position is in effect until December 31, 2019.
Requests to use portions of the position or republish in its entirety must be directed to the Academy at journal@eatright.org.
Authors: Diana Cullum-Dugan, RDN, LDN (Namaste Nutrition, Watertown, MA); Roman Pawlak, PhD, RD (East Carolina University, Greenville, NC).
Reviewers: Weight Management dietetic practice group (DPG) (Laura Andromalos, RD, LDN, Brigham and Women’s Hospital, Boston, MA); Sharon
Denny, MS, RD (Academy Knowledge Center, Chicago, IL); Julie Driggers, RD, LDN, CNSC (The Children’s Hospital of Philadelphia, Philadelphia,
PA); School Nutrition Services DPG (Beverly L. Girard, PhD, MBA, RD, Sarasota County Schools, Sarasota, FL); Jessica Larson, MS, RDN (Academy
Policy Initiatives & Advocacy, Washington, DC); Vegetarian Nutrition DPG (Susan Levin, MS, RD, CSSD, Physicians Committee for Responsible
Medicine, Washington, DC); Kelly McGrath, MS, RD, CSG, LDN (FutureCare Health and Management Corporation, Baltimore, MD); Meena
Somanchi, PhD, CNS, LDN (University of Maryland, College Park, MD); Alison Steiber, PhD, RD (Academy Research & Strategic Business Devel-
opment, Chicago, IL); Hunger and Environmental Nutrition DPG (Teri Underwood, RD, MS, CD, Sustainable Diets, Park City, UT).
Academy Positions Committee Workgroup: Alana D. Cline, PhD, RD (chair) (University of Northern Colorado, Fort Collins, CO); Penny E. McConnell,
MS, RDN, SNS (Fairfax County Public Schools, Springfield, VA); Ella Haddad, DrPH, MS, RD (content advisor) (Loma Linda University, Loma
Linda, CA).
We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position or the
supporting paper.

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