Released last week:

Heart disease rates of all vegetarians compared to all non-vegetarians were calculated for EPIC-Oxford from 1993 until 2009 (1). These participants were all thought to be free of heart disease at the beginning of the study. The results showed that vegetarians had a statistically significant, ~30% reduced risk of heart disease (.68, .58-.81). That is a fairly impressive finding for a nutrition study.

All results were adjusted for age, smoking, alcohol, physical activity, education, socioeconomic status, oral contraceptives, and hormone replacement therapy. The findings held after adjusting for body mass index (BMI) and removing the first two years of follow-up. (See the table in EPIC-Oxford: Heart Disease (2013) of VeganHealth.org for the relative risks.)

The researchers believed the difference in heart disease rates to be due mainly to the lower non-HDL cholesterol and systolic blood pressure of the vegetarians. The non-vegetarians had an average total cholesterol level of 222 mg/dl vs. 203 mg/dl for the vegetarians, while HDL was 52 vs. 50 mg/dl respectively. Systolic blood pressure was 134 for non-vegetarians and 131 mm Hg for vegetarians.

Given that vegetarians had cholesterol levels an average of 203 mg/dl – a full 33% higher than the 150 mg/dl, upper-end-of-healthy that many of the very low-fat doctors recommend – it might come as a surprise to learn that, in the authors’ words, “On the basis of the absolute rates of hospitalization or death from IHD [ischemic heart disease], the cumulative probability of IHD between ages 50 and 70 y was 6.8% for nonvegetarians compared with 4.6% for vegetarians.”

In other words, with cholesterol levels that high in both groups, you might think they would have a very high rate of heart disease, but, from what I can tell (see reference #2), their rates are relatively comparable to the general population of the United States (2).

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Reference

1. Crowe FL, Appleby PN, Travis RC, Key TJ. Risk of hospitalization or death from ischemic heart disease among British vegetarians and nonvegetarians: results from the EPIC-Oxford cohort study. Am J Clin Nutr. 2013 Jan 30. [Epub ahead of print] | link

2. Prevalence of Coronary Heart Disease — United States, 2006–2010
Morbidity and Mortality Weekly Report (MMWR) for October 14, 2011. Accessed February 3, 2013. | link (PDF)

Question:

Regarding your cholesterol article, I was wondering which plants contain cholesterol and how much. I saw some biscuits that contained .4 mg of cholesterol per 100 g of the product. The company claimed all ingredients were plant based, but there was quite a stir in a vegan forum regarding that cholesterol amount. Is there an article you can refer me to.

Answer:

Unbeknownst to most people, the labels on packaged food normally do not represent a laboratory analysis where the various nutrients have been directly measured. Rather, the company takes a list of ingredients and plugs them into a software package which then produces the label based on a combination of all the ingredients and serving size. If one of the ingredients they plug in typically contains cholesterol, then it will contain cholesterol in the result.

As a rule, the USDA nutrient database, which most of these nutrition label generating software applications are based on, just assumes a cholesterol amount of zero for plant foods. Take a look at raw baby carrots at PeaCounter. It lists cholesterol as zero, but it also lists the “data points” as zero. In other words, they didn’t measure it, they just assumed it to be zero.

I don’t know all the ins and outs of the process of producing labels for all foods, and it would seem to me that normally, for biscuits, the company would be plugging in basic nutrients and if they were of plant origin, they would not register any cholesterol on a nutrition label. But in this case, I would guess that the .4 mg of cholesterol shown on this supposedly vegan food was simply a result of inaccurate ingredients plugged into the software. It definitely wasn’t that they included enough plant foods with cholesterol that the cholesterol actually registered in a laboratory analysis.

Here is an article that lists the cholesterol amounts in some plant foods:

Behrman EJ, Gopalan V. Cholesterol and plants. The Journal of Chemical Education. 2005. 82(12):1791. | link to pre-publication PDF

And here are a few of the listings for comparison:

Olive oil, .5-2 mg/kg
Soybean oil, 29 mg/kg
Coconut oil, 14 mg/kg
Egg yolk, 15 g/kg
Butter, 2.5 g/kg

Note that when you move from the plant oils to the animal foods, the units change from mg/kg to g/kg (and a g is 1,000 times more than a mg).

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Question:

Smith-Lemli-Opitz Syndrome (SMOS) is a genetic mutation that impairs the body’s ability to produce its own cholesterol. This very small group of people (1 in 20,000) would need cholesterol in their diet. Any suggestions on how to answer this? Are there any vegan cholesterol sources?

Answer:

The listing for Smith-Lemli-Opitz Syndrome Treatment & Management at Medscape says, “Currently, no treatment has proven effective for patients with Smith-Lemli-Opitz syndrome (SLOS). Potentially, cholesterol supplementation is a logical treatment because it may be expected to raise plasma and tissue cholesterol levels…. Therapeutic trials are underway.”

Someone with SMOS should be under the care of a physician who is probably instructing them (or their parents) as to whether they need cholesterol supplementation and how much they need in their diet.

I am not aware of any vegan sources of cholesterol with which someone could supplement. My understanding is that some plants contain cholesterol, but only in miniscule amounts. For committed vegans, obtaining eggs from someone with companion chickens would be a way to get cholesterol in the diet while causing minimal or no harm to animals. Oysters, clams, or mussels might be another option.

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I have a question in my inbox from someone asking if there “is anything to the ‘no oil’ diets,” such that Dr. Caldwell Esselstyn promotes. My answer is – certainly there is something to it. Dr. Esselstyn (1) and Dr. Dean Ornish (2) have used a very low-fat, plant-based diet (10% of the calories as fat) as part of a cholesterol-lowering program that has decreased the amount of plaque in patients’ arteries and led to much better outcomes than typical treatment for heart disease. Dr. Neal Barnard and the Physician’s Committee for Responsible Medicine have used a very low-fat, vegan diet to treat type-2 diabetes with impressive outcomes (link).

But is it the only healthy diet that all vegans should eat? Let’s look at some other evidence.

A 2000 cross-sectional report (3) on cholesterol levels in men from EPIC-Oxford found the following:

So the vegan men were eating a diet of 30% of their calories as fat while still maintaining cholesterol levels of 158 mg/dl. Some people would consider this level of cholesterol too high, and while trials of people with heart disease who lower their cholesterol levels to below 150 mg/dl have shown a great benefit in doing so, it is not clear (to me, anyway) that people without a history of high cholesterol and heart disease need to go as low as 150 mg/dl. Low calories (or body weight) and saturated fat may be the most important aspect of lowering cholesterol levels.

A cross-sectional study on cholesterol levels is not the highest form of evidence compared to the clinical trials I mentioned earlier. What about trials of higher fat diets?

The Eco-Atkins diet, a high-protein, higher fat version of a vegan diet found better changes in blood lipids and higher levels of satiety when compared to a lower fat, near-vegan diet (4). But this trial only lasted 4 weeks, not nearly long enough to measure heart disease outcomes. Cholesterol levels of the people on Eco-Atkins went from 257 to 205 mg/dl – nowhere near as low as the very low-fat diets generally achieve, but, again, it was only four weeks long.

Most of the very low-fat diets do not allow for many nuts. While nuts have consistently been associated with positive health outcomes (lower body weight, better cholesterol levels, etc.), one vegan doctor, who uses low-fat diets to treat heart disease, told me that many of his patients binge on nuts when they are part of their diets and so he suggests they avoid them. I’ve heard from others that if they eat nuts they gain weight. It doesn’t completely surprise me that someone on a very low-fat diet might binge on nuts – they might be craving the fat or protein. But if you are someone who can eat nuts in moderation, then having some is most likely beneficial for preventing heart disease and long-term weight maintenance.

Though it may be rare, or even extremely rare, some people who follow a very low-fat diet find that they lose their libido and regain it upon eating more fat.

Earlier this month, Jeff Nelson of Vegsource.com wrote an article, How the ethical argument fails veganism. In it, he disagrees with my co-founder of Vegan Outreach, Matt Ball, and my co-author of Vegan For Life, Ginny Messina, as to whether the health argument is the way to go when spreading veganism. He also disparages “AR dietitians” in general, of which I can’t help but notice that I am one.

Aside from the fact that Matt nor I care about veganism as anything more than a tool for protecting animals and the environment, the central thesis of Nelson’s article is that people who become vegan for health reasons are more likely to stick with the diet than people who go vegan for ethical reasons. He says that people who go vegan for ethical reasons are usually not as educated about health and nutrition due to being persuaded by organizations that do not give them adequate information; so they eat processed foods and end up concluding that a vegan diet is not healthier. The people who go vegan for health reasons, on the other hand, understand the importance of avoiding processed foods and oils, and their health improves.

While many people do well on a whole-foods only, very low-fat vegan diet, my experience has been that such diets can sometimes result in failure to thrive, while many people do thrive on a vegan diet that includes more fat and processed foods.

The vegans I know are mostly animal advocates, and, therefore, are dedicated to being vegan. Very few of them had been diagnosed with heart disease or type-2 diabetes before becoming vegan, so they are not necessarily in the same boat as people who become vegan to treat their disease. The vast majority of the vegan, animal advocates I have know have stayed vegan, and most eat processed foods. From soy foods to french fries to desserts made with white flour and sugar, the vegans I know eat ‘em. Of course, most of them also eat more fruit, vegetables, whole grains, legumes and nuts than the average American.

My cholesterol tends to be around 150 mg/dl. If I were eating a very low-fat diet, it might be even lower, possibly decreasing my risk for heart disease. But I crave protein and feel better when eating a good amount, possibly due to my fairly intensive weight lifting. I do much better eating soyfoods and other processed foods such as pasta, than when eating only whole plant foods.

There are health issues that might prevent people from eating only whole foods, such as digestive problems, and those have to be dealt with on a case by case basis.

I generally tell people who have metabolic syndrome that they should tend towards a whole-foods diet, greatly limiting added oils but including nuts, while those who are not as much at risk can afford to eat more processed foods, especially those high in protein and/or pastas (which generally do not raise blood sugar as high as other processed grains). Monitoring your weight, cholesterol, and blood sugar levels is a good idea to see if the diet you are eating is working for you.

At some point there might be clinical trials examining cardiac outcomes in people on vegan diets that are not so low in fat or in vegans who have not been diagnosed with heart disease. We do have some data on heart disease in vegans from the 1999 meta-analysis, but it isn’t much.

References

1. Esselstyn CB Jr. Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology). Am J Cardiol. 1999 Aug 1;84(3):339-41, A8. | link

2. Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998 Dec 16;280(23):2001-7. Erratum in: JAMA 1999 Apr 21;281(15):1380. | link

3. Allen NE, Appleby PN, Davey GK, Key TJ. Hormones and diet: low insulin-like growth factor-I but normal bioavailable androgens in vegan men. Br J Cancer. 2000 Jul;83(1):95-7. | Link

4. Jenkins DJ, Wong JM, Kendall CW, Esfahani A, Ng VW, Leong TC, Faulkner DA, Vidgen E, Greaves KA, Paul G, Singer W. The effect of a plant-based low-carbohydrate (“Eco-Atkins”) diet on body weight and blood lipid concentrations in hyperlipidemic subjects. Arch Intern Med. 2009 Jun 8;169(11):1046-54. Erratum in: Arch Intern Med. 2009 Sep 14;169(16):1490. | link

Here’s something I’ve been mentioning in my talks lately. A 2000 study measured the percentage of calories as fat in the diet as well as cholesterol levels in a subset of EPIC-Oxford vegan and non-vegan men. Here is what they found:

Vegans ate 30% of their calories as fat compared to 34% for meat-eaters. Not a huge difference and many people would be horrified at such a high fat intake on behalf of the vegans. Yet, their cholesterol levels were well below what is commonly considered the danger zone.

What accounts for this? The vegans’ much lower intake of saturated fat probably explains a lot. But the vegans’ 20% fewer calories also probably accounts for much of their lower cholesterol levels. Addendum 1/27/12: Additionally, higher fiber intake and zero or near-zero cholesterol intake all likely contribute to the vegans’ lower cholesterol levels. Clarification 1/30/12: People who exercise a lot can eat more calories without cholesterol levels increasing as long as they are not eating so much that they gain body fat (thanks, Ginny).

Some people might point out that ideal cholesterol levels are actually less than 150 mg/dl, so 158 mg/dl is too high. While many clinical trials in people with heart disease (and normally on cholesterol-lowering medication) show a benefit to getting levels below 150 mg/dl, I have not seen evidence that this is ideal, or even desirable in people without diagnosed heart disease or normally high cholesterol. Instead, the observational studies I’ve seen measuring cholesterol levels and mortality have not shown a benefit from cholesterol levels less than 160 mg/dl.

I would not completely rule out the idea that studies have not shown reduced mortality in people with cholesterol levels less than 160 mg/dl because they have not included enough people with cholesterol levels that low and who do not have such low levels due to undiagnosed disease. But “not completely ruling out something” is a far cry from saying there is good evidence that it is true.

The reason I think this is particularly important is anecdotal evidence that people on long-term, low-fat diets can find them hard to stick with. I know there are some exceptions – people who find them easy to stick with, but I sense that there are more who find it difficult. When people crave meat, they tend to think they are craving the protein. But meat is also about 50% fat on average and it would not surprise me if such people are often craving fat as much or more than protein. Eating a diet closer to 30% fat might prevent such cravings.

Yes, lots of qualifiers above that I’m not 100% certain of everything I’m saying. But I think there is enough evidence that I should share it with readers rather than just keeping it to myself until “further studies” are done.

Reference

Allen NE, Appleby PN, Davey GK, Key TJ. Hormones and diet: low insulin-like growth factor-I but normal bioavailable androgens in vegan men. Br J Cancer. 2000 Jul;83(1):95-7. Link

The Behavioral Medicine Report reports that after 6 months of eating 75 g of dried apples per day, women 45 to 65 years old had a 23% decrease in LDL (bad) and a 4% increase in HDL (good) cholesterol. The people eating the apples also lost about 3 lbs on average and had lower levels of inflammatory markers.

The apple regimen was compared to dried prunes which apparently didn’t fare so well. The prune lobby must be livid.

Link to abstract. (Thanks, Michael!)

People occasionally write me asking how to increase their HDL. It looks like dried apples might be the way to go! Exercise and nuts are also likely to help.

In other strange HDL news, I randomly heard from two, unconnected people today whose HDL cholesterol levels were higher than their LDL levels. I had never heard of that before and then I got two in one day.

Thanks to Anne for sending me the apple story link!

QuasiVegan, written by Christina Arasmo, is a new blog discussing failure to thrive in vegans. Christina is not a health professional, but I have been very impressed with what she has written.

In particular, I am intrigued by what she has been saying about low cholesterol possibly being the cause of many of the health problems ex-vegans have experienced. I have considered this in the past, but given that cholesterol levels of around 100 mg/dl are supposedly commonplace in Asian countries, I have figured it probably was not such a problem for most people to have a low cholesterol level.

Early studies on blood cholesterol and mortality showed a U shaped-curve, indicating that very low blood cholesterol was associated with increased mortality. But this was thought to be due to undiagnosed disease causing low cholesterol levels and not that low cholesterol levels were causing the disease.

Meta-analyses such as this indicate that the lower the blood cholesterol, the better.

That said, I have often wondered that perhaps a cholesterol of 150 to 170 mg/dl might be ideal (for people without heart disease) and have told otherwise healthy people who have written me worried because their cholesterol was not under 150 mg/dl that they should not worry about getting it that low.

I would love to find out if the problems are caused by low cholesterol because in most cases there is a very easy and fun solution to that problem – eat more fat.

Looks like another topic to add to the queue of research reviews I need to do.

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