Editorials
Long-Term Benefits of a resulted in an overall cohort (including
Vegetarian Diet
ERIK J. LINDBLOOM, MD, MSPH
University of Missouri School of Medicine
Columbia, Missouri
See related article on page 571.
▲
In this issue of American Family Physician,
Walker and Reamy review many of today’s
most popular diets.1 In addition to inqui-
ries about these specific diets, physicians
may be asked about vegetarian diets in gen-
eral. Patients may have many reasons for
their interest in a vegetarian diet, including
health issues, spiritual beliefs, environmental
effects, or animal welfare concerns. Dr. Dean
Ornish’s Life Choice Diet is one example of
a well-studied vegetarian program that has
had encouraging results. However, its strict
fat limitation and inclusion of one to two
hours of daily meditation and exercise may
limit adherence. There is evidence that sim-
ply reducing the amount of meat in the diet,
or eliminating it entirely, may be enough to
achieve significant patient-oriented health
benefits. I offer a brief summary of two
simultaneously published studies that exam-
ined the association between vegetarian diets
and mortality rates in several large cohorts.
The Oxford Vegetarian Study recruited
6,000 vegetarians and 5,000 nonvegetarians
in the United Kingdom and followed them
for an average of 12 years.2 Outcomes favor-
ing the vegetarians included lower overall
mortality during the study period (rate ratio,
0.80; 95% confidence interval [CI], 0.65 to
0.99) and lower mortality from malignant
neoplasms (rate ratio, 0.61; 95% CI, 0.44 to
0.84). There was also a non-statistically sig-
nificant trend toward lower death rate ratios
from ischemic heart disease among vegetar-
ians (rate ratio, 0.72; 95% CI, 0.47 to 1.10).
Adjustments were made for smoking habits,
body mass index, and socioeconomic fac-
tors. The researchers also tried to compen-
sate for other possible lifestyle differences by
recruiting nonvegetarians through referrals
from vegetarian participants. This strategy
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the nonvegetarians) that appeared much
healthier than the general population, with
an all-cause mortality rate that was one half
that of England and Wales. However, even
within this healthy cohort, a significantly
lower mortality rate was noted among the
vegetarians.
Another large mortality study included
the Oxford study in addition to four other
large prospective cohorts.3 This resulted in
a pooled analysis of data from more than
76,000 men and women, with an average fol-
low-up period of 10.6 years. After adjusting
for age, sex, and smoking status, mortality
from ischemic heart disease was 24 per-
cent lower in vegetarians (rate ratio, 0.76;
95% CI, 0.62 to 0.94). More specific sub-
group analysis was possible from four of the
five cohorts, based on the amount and type
of meat consumed. Compared with regular
meat eaters, which included participants
with at least weekly meat consumption,
mortality from ischemic heart disease was
20 percent lower in occasional meat eaters,
and 26 percent lower in vegans (i.e., those
who consumed no animal products whatso-
ever, including meat, eggs, and dairy prod-
ucts). The largest reduction (34 percent) was
noted in lacto-ovo vegetarians (i.e., those
who ate eggs and dairy products) and in
those who ate fish but no other meat. The
lower mortality rates from ischemic heart
disease among vegetarians were greater in
younger participants and in those who had
followed their current diet for more than
five years. Mortality from all other causes
did not differ among groups.
These large cohort studies suggest that
vegetarian diets confer significant health
benefits without necessarily requiring a rig-
idly structured diet program. Although ran-
domized trials would provide the best level
of evidence, they would be prohibitively large
and expensive to study a long-term outcome
such as mortality. Smaller vegetarian diet
trials have measured intermediate outcomes
(e.g., glycemic control)4 and benefits specific

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Editorials

to certain conditions (e.g., nephrolithia-
sis, rheumatoid arthritis, dysmenorrhea).5-7
Taken as a whole, the evidence base favor-
ing a vegetarian diet is encouraging, and
informed patients who choose to reduce or
eliminate meat consumption are likely to
improve their overall health.
Address correspondence to Erik J. Lindbloom, MD,
MPH, at lindbloome@health.missouri.edu. Reprints are
not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. Walker C, Reamy BV. Diets for cardiovascular disease pre-
vention: what is the evidence? Am Fam Physician. 2009;
79(7):571-578.
2. Appleby PN, Thorogood M, Mann JI, Key TJ. The Oxford
Vegetarian Study: an overview. Am J Clin Nutr. 1999;
70(3 suppl):525S-531S.
3. Key TJ, Fraser GE, Thorogood M, et al. Mortality in
vegetarians and nonvegetarians: detailed findings from
a collaborative analysis of 5 prospective studies. Am
J Clin Nutr. 1999;70(3 suppl):516S-524S.
4. Barnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan
diet improves glycemic control and cardiovascular risk
factors in a randomized clinical trial in individuals with
type 2 diabetes. Diabetes Care. 2006;29(8):1777-1783.
5. Siener R, Hesse A. The effect of a vegetarian and differ-
ent omnivorous diets on urinary risk factors for uric acid
stone formation. Eur J Nutr. 2003;42(6):332-337.
6. Müller H, de Toledo FW, Resch KL. Fasting followed
by vegetarian diet in patients with rheumatoid arthri-
tis: a systematic review. Scand J Rheumatol. 2001;
30(1):1-10.
7. Barnard ND, Scialli AR, Hurlock D, Bertron P. Diet and
sex-hormone binding globulin, dysmenorrhea, and
premenstrual symptoms. Obstet Gynecol. 2000;95(2):
245-250. ■

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