I have updated the article Disease Rates of Vegetarians and Vegans with the results from a report on vegetarian mortality rates that was released this week from the Adventist Health Study-2. I have reproduced the highlights below.
In 2013, death rates for the first 5.8 years of Adventist Health Study-2 (AHS2) were released (1). When combining vegans, lacto-ovo-vegetarians, pesco-vegetarians, and semi-vegetarians into one group, vegetarians had a 12% lower risk of mortality. Vegans had a 15% lower risk of death, but it was not quite statistically significant.
The difference in mortality rates can mostly be explained by a lower incidence of cardiovascular disease among vegetarian men. Vegetarian women had about the same rates as non-vegetarian women. This is similar to the findings from the first Adventist Health Study. There was also a benefit for all vegetarians for death from renal and endocrine (mostly diabetes) disease.
The researchers said that having only 5.8 years of follow-up would bias the results towards not finding differences.
In comparing their findings to British vegetarians, they said:
“The lack of similar findings in British vegetarians remains interesting, and this difference deserves careful study. In both cohorts, the non-vegetarians are a relatively healthy reference group. In both studies, the nutrient profiles of vegetarians differ in important ways from those of non-vegetarians, with vegetarians (especially vegans) consuming less saturated fat and more fiber. It appears that British vegetarians and US Adventist vegetarians eat somewhat differently. For instance, the vegetarians in our study consume more fiber and vitamin C than those of the EPIC-Oxford cohort: mean dietary fiber in EPIC-Oxford vegans was 27.7 g/d in men and 26.4 g/d in women compared with 45.6 g/d in men and 47.3 g/d in women in AHS-2 vegans; mean vitamin C in EPIC-Oxford vegans was 125 mg/d in men and 143 mg/d in women compared with 224 mg/d in men and 250 mg/d in women in AHS-2 vegans. Individuals electing vegetarian diets for ethical or environmental reasons may eat differently from those who choose vegetarian diets primarily for reasons of perceived superiority for health promotion. We believe that perceived healthfulness of vegetarian diets may be a major motivator of Adventist vegetarians.”
Make sure you eat your fiber!
1. Orlich MJ, Singh P, Sabaté J, et al. Vegetarian Dietary Patterns and Mortality in Adventist Health Study 2. JAMA Intern Med. 2013;():1-8. doi:10.1001/jamainternmed.2013.6473. | link
This past week, a study was released from Poland in which the diet and iron status of vegetarian children were investigated (1). To the researchers knowledge, it was the first study to examine the diet and iron status of Caucasian children, and I know of only one other study on any vegetarian children, a study from India that I mention below.
Some quick background: Meat contains about 40% of its iron as heme-iron, which is more easily absorbed than non-heme iron. Non-heme iron is the only iron found in plants. Because iron deficiency anemia is the most common nutrient deficiency in Western countries, especially among menstruating women who lose blood (and, therefore, iron) every month, there is a concern about vegetarians getting enough iron.
The study from Poland compared 22 vegetarian children (5 ate fish, none were vegan) to 18 omnivores, aged 2 to 18 years old. Of the vegetarian girls of menstruating age, 2 of the 5 had iron deficiency anemia, whereas none of the 4 omnivore menstruating girls had iron deficiency anemia. The researchers noted that their anemia was not due to menstrual period disorders, and that they had been trying to lose weight for “quite a long time.” Of the vegetarians, 36% (8) had iron deficiency compared to only 11% (2) of the omnivores.
Median iron intake in vegetarians was only 65% of the RDA, but the omnivores was even lower at 60%. 82% of vegetarian children did not meet the iron RDA while none of the omnivore children met it. As for vitamin C, which increases plant iron absorption, the vegetarians had higher intakes (171% vs. 95% of the RDA). The average vitamin C intake for the vegetarians was 69 mg per day.
As the vegetarian children got older, their iron intake decreased (as a percentage of the RDA). The researchers suggested that as the kids got into their teens, parents had less input on their food choices and the quality of their diets suffered.
There was no association found between vitamin C intake and iron status. A significant amount of other research has shown that vitamin C can greatly increase iron absorption from plants when eaten at the same meal. It’s possible that you need more vitamin C at meals than these children were getting. The research showing that vitamin C increases iron absorption uses doses from 50 mg up 500 mg per meal. In the study from India mentioned above, vegetarian children with iron deficiency anemia (and low vitamin C intakes) were given 100 mg of vitamin C at both lunch and dinner for 60 days. They saw a drastic improvement in their anemia, with most making a full recovery (2).
It might be a good idea for vegetarian kids, and especially teenage girls, to make sure they eat a food that has a large amount of vitamin C with at least two meals each day, especially meals with legumes. Some foods that are high in vitamin C per typical serving are orange juice and grapefruit juice (80 mg per cup), oranges (50 mg per small orange), broccoli (50 mg per 1/2 cup cooked, chopped), strawberries (85 mg per 1 cup of whole berries), grapefruit (40-50 mg per 1/2 fruit), yellow peppers (70 mg per 1/4 cup chopped), and red peppers (50 mg per 1/4 cup chopped).
As an aside, the note I had in my post about supporting JackNorrisRD.com by purchasing music through Amazon links might have seemed strange given that if you get my blog as an email via Feedburner, it did not include the links. So, I have reproduced them below. Thank you!
1. Gorczyca D, Prescha A, Szeremeta K, Jankowski A. Iron Status and Dietary Iron Intake of Vegetarian Children from Poland. Ann Nutr Metab. 2013 May 25;62(4):291-297. [Epub ahead of print] | link
2. Seshadri S, Shah A, Bhade S. Haematologic response of anaemic preschool children to ascorbic acid supplementation. Hum Nutr Appl Nutr. 1985 Apr;39(2):151-4. (Abstract only) | link
Dr. Michael Greger has an interesting video on mushrooms, allergies, cancer, and inflammation over at NutritionFacts.org.
A 2012 study suggests that eating mushrooms can increase the body’s secretion of IgA, which can scavenge unwanted invaders on the surface of our digestive tract. It doesn’t appear that the study measured any outcomes other than IgA production, but it would be interesting to know if eating mushrooms regularly would decrease allergies and colds.
I have a lot of articles in the queue that I’m anxious to write about and questions to be answered. You, dear readers, sure know how to ask complicated questions that make me question my assumptions!
It’s been 6 weeks since I asked for support, and support has been dwindling, so I’m asking again. And this time, I have a new way to support JackNorrisRD.com.
But first, I got rid of the Google Ads from the website. I had hoped that at some point Google’s ad algorithm would pick up that my site was for vegans and start advertising vegan-related products. Not so much. And while they generated some revenue, it was not enough to keep cheesy (the site is vegan, after all!) ads in the margins.
But I came up with a new idea that might be fun and hopefully not too annoying – provide links to the songs I’m currently listening to. If you follow the links and buy a song or album (or anything else) at Amazon, I will get a percentage. So, I have listed below 8 songs and 1 album that have been on my playlist lately. I realize they will only appeal to a select group, but if you find that your music tastes jive with mine, it might be a good way to find some music.
Below the song links are the typical ways to support JackNorrisRD.com. Making a donation (by far my biggest source of support), and buying things at Pangea through the link provided. You can also set up a recurring donation in the upper right corner of the website.
After I published my last post, DHA Recommendations Updated (A Bit), I received comments from a reader saying that there is no evidence that vegans need to supplement with DHA. So, I went digging for the evidence.
The first bit comes from the experience of Joel Fuhrman, MD, which I blogged about in November of 2010 in the post DHA Supplements: A Good Idea, Especially for Older Vegan Men, in which Dr. Fuhrman said that he has been seeing numerous elderly vegans with severe DHA deficiency, and he believes it may have exacerbated Parkinson’s disease and tremors in some of his patients.
Is there any evidence for a connection here? I’m not an expert on the literature regarding DHA and the brain, but here is an excerpt from a 2005 study that indicates it’s plausible:
“Docosahexaenoic acid (DHA), a dietary essential omega-3 fatty acid concentrated in membrane phospholipids at synapses and in retinal photoreceptors is decreased in [the Alzheimer disease] brain. This deficiency may be due to enhanced free radical–mediated lipid peroxidation, decreased dietary intake, and/or impaired liver DHA shuttling to the brain. Decreased DHA serum content correlates with cognitive impairment. Moreover, epidemiologic studies suggest neuroprotective consequences of diets enriched in omega-3 fatty acids (1).”
Note the part, “impaired liver DHA shuttling to the brain.” I would assume, then, that an important way that DHA gets to the brain is by being produced by the liver (or eaten) and shuttled via the blood. So if vegans have low blood levels of DHA (as they do, without supplementation), that could mean they are not getting enough to the brain.
The second bit is less strong, but comes from the paper, Mortality in British Vegetarians, a 2002 report showing that vegetarians in the Oxford Vegetarian Study had twice the risk of dying from a mental or neurological disease as did non-vegetarians (see Disease Rates of Vegetarians and Vegans). A different report, from the Adventist Health Study, found the opposite: vegans and lacto-ovo vegetarians had half the risk of dementia (2).
I tend to think the culprit in these disparate findings is vitamin B12 (not DHA), as Seventh-day Adventists have traditionally known to supplement with vitamin B12 whereas other populations of vegans have neglected it. But I would not completely rule out DHA at this time.
My sense is that kids who are raised vegan are rarely supplemented with DHA and to our knowledge most of them develop normally. This would indicate that dietary DHA is not necessary for optimal health. But none of these children have made it to old age (that I am aware of) to know if the situation changes as they get older. It could be that people born without a source of DHA past infancy become highly efficient at converting ALA to DHA, an ability that might not be developed in people who become vegetarian as adults.
While I would love nothing more than to dispense with the entire DHA/omega-3 issue, I just don’t believe we can do that unless future research proves there is nothing to be concerned about.
References
1. Lukiw WJ, Cui JG, Marcheselli VL, Bodker M, Botkjaer A, Gotlinger K, Serhan CN, Bazan NG. A role for docosahexaenoic acid-derived neuroprotectin D1 in neural cell survival and Alzheimer disease. J Clin Invest. 2005 Oct;115(10):2774-83. | link
2. Giem P, Beeson WL, Fraser GE. The incidence of dementia and intake of animal products: preliminary findings from the Adventist Health Study. Neuroepidemiology. 1993;12(1):28-36. | link
A reader was questioning whether the amount of DHA I recommend is adequate. He sent me a list of studies on DHA supplementation in vegetarians, all of which I had previously read and were cited in my article, Omega-3 Fatty Acid Recommendations for Vegetarians. However, I had never actually taken the data from those studies to try to mathematically come up with an amount of DHA supplementation that would provide the same level of DHA in vegetarians as in omnivores. Instead, I had been taking more of an educated guess as to what might be a good supplementation level.
After doing the math, which you can see under the new section, DHA Supplementation in Vegetarians, it appears that supplementing with 300 mg per day will provide enough DHA to give your average vegetarian the same DHA levels as the average omnivore. A lot of vegans were included in that average, so I consider it a good approximation for both vegans and lacto-ovo vegetarians.
In the past I have recommended 200-300 mg every 2-3 days for vegetarians under 60, and 200-300 mg every day for vegetarians 60 and over. Due to the fact that we don’t really know if vegetarians need higher DHA levels, and given the expense of DHA supplements, I still consider this amount to be a viable option as a bit of insurance.
I have modified my recommendations to provide both of these options so that people will know what it might take to have DHA levels the same as your average omnivore, but also what might provide some insurance without necessarily having levels as high as omnivores. Here is a link to the recommendations which have 3 steps (DHA supplements being only one of them): link.
It’s not often that I get time to read anything of significant length other than nutrition papers, but a few days ago I indulged myself.
Adam Merberg, author of the Say What, Michael Pollan? blog, sent out his final post from that blog which led me to his new blog, Inexact Change. I ended up reading two articles:
Half-baked – a review of Michael Pollan’s new book Cooked
In February, my post To Quit or Not to Quit Veganism briefly mentioned ex-vegan blogger and holistic health counselor Alex Jamieson. Jamieson had just written an article about how she was no longer vegan.
Then a couple of weeks ago, I was contacted by the producer of The Current, a radio show in Toronto. They were doing a story on Jamieson’s choice to no longer be vegan and the backlash it entailed, and wanted to interview me.
The Current’s story aired on May 15 (link). None of my comments were included, which is probably just as well because I wasn’t very eloquent.
After listening to the show, I have further thoughts on Jamieson’s experience with veganism and since she continues to publicly talk about it, I feel okay about doing so, too. In fact, in her interview, she says that she might some day return to a vegan diet so this is in the spirit of helping her or people like her.
I definitely have sympathy for Jamieson – it must have been very stressful to feel like you could no longer eat a diet that you have been promoting. If I started to believe that I could no longer be vegan because my health was failing it would be quite disconcerting.
Here is Jamieson’s story from what I can piece together:
She ate a lot of junk food most of her life, and she also had iron deficiency issues. She went vegan and felt great for about 10 years after which she started having cravings for animal products. At a certain point, she started menstruating too frequently. She tried adding “mineral rich” foods and iron supplements and it didn’t help. She tried eating foods higher in protein (as I pointed out in my previous post, none of the foods she mentions eating for protein are terribly high in protein). She started eating eggs which made her feel a lot better, and then added back meat. She now eats 75%+ plant foods and her menstrual cycles have normalized and she feels good. When speaking about it in the interview, she attributes her improvements to “animal protein.”
Let’s go through the usual suspects:
Vitamin B12 – Jamieson doesn’t mention B12 anywhere. But her symptoms are not indicative of B12 deficiency.
Choline – Jamieson starts out craving, eating, and feeling better from eggs. Eggs are high in choline. But once again, her symptoms don’t seem to be typical of choline deficiency. I did some searching and found an article, which I do not consider reliable, suggesting that choline deficiency can cause liver problems, “resulting in excessive estrogen produced during menstrual cycle leading to hormone imbalance and endometrial cramps (link).” Severe choline deficiency can cause liver problems, but I don’t know where they got the part in quotes and if there is any direct evidence for it. Still, choline deficiency is a potential culprit.
Iron – Except for the fact that she never says she got her iron levels tested, there’s little question that she likely had iron deficiency given her history of it and the fact that she was having frequent menstruation. The question is whether she could have improved her iron deficiency by way of adding vitamin C to her meals and doing the other typical things that are recommended such as avoiding tea and coffee at meals.
Cholesterol – In watching some of her videos Jamieson appears to be on the thin side and her diet sounds very low in fat. A low-fat diet with low body weight could theoretically lead to low steroid hormones (made from cholesterol) leading to menstrual disruption (though admittedly less frequent menstruation, not more, in most cases). And eggs are probably the easiest way to get cholesterol, so a craving for eggs could make some sense.
Cravings
Can you crave foods because they have cholesterol, choline, or iron and you are deficient? Can you crave fat? It’s hard to know – there is very little research on craving nutrients during deficiency. And if a low fat intake (leading to low cholesterol) was a problem, why didn’t she just crave higher fat, higher saturated fat, or higher choline plant foods?
When I haven’t eaten in a while, I crave the versions of foods that contain more of those nutrients and with less fiber, presumably so that my body can get the nutrients faster. While an apple will provide carbohydrates, when real hungry I prefer cookies or juice. It doesn’t mean that’s the best or only way to get those nutrients on an ongoing basis.
If someone has gone for years on an exceptionally low-fat diet and has depleted their fat stores to the point that they are having low-cholesterol and hormone irregularities, combined with iron deficiency, it seems plausible that they might crave the food that is most quickly going to replenish those nutrients such as eggs (cholesterol) and meat (iron).
In searching around, I have found that there are other low-fat vegans who have egg cravings (link), so apparently it’s not unusual.
Probably the most obvious thing about eggs, when it comes to what separates them from other foods sensually, is the sulfur smell, which I find rather disgusting and it’s hard for me to imagine craving them unless you really have a serious deficiency! The sulfur smell is probably due to a high level of sulfur-containing amino acids (cysteine and methionine). Could it be those amino acids that people are craving in eggs? It seems possible, but unlikely since those amino acids are also in tofu in decent amounts, yet these people don’t crave tofu. Not a lot is known about sulfur and nutrition, but it’s something to consider.
Animal Protein
Jamieson repeatedly refers to what she needed as “animal protein.”
What we know about physiology and nutrition would indicate that there is nothing important about animal protein that separates it from plant protein except in cases of extremely low intakes. On the other hand, we shouldn’t rule out that she had extremely low intakes.
In her video on food cravings (link) Jamieson tells people that if they are craving protein, to add hemp seeds to their diet. I cannot find reliable info on how much protein hemp seeds have, but it looks like the highest amount being tossed around is 5 grams per tablespoon. Unless you are blending a whole lot of hemp seeds, you aren’t going to get large amounts of protein from that ratio. How about a Tofurky Italian sausage instead, with a whopping 29 grams of protein?!
Jamieson mentions that she was flirting with orthorexia, and people with orthorexia are unlikely to even consider processed foods like Tofurky.
I don’t think protein was likely her problem (or her main problem), but if you think you’re low on protein, eat something with some serious protein. Most of the vegans I know who are not failing to thrive do eat processed foods, and I’d venture that a good 1/3 of my food intake is processed. It is disappointing to hear about people who quit veganism to take up eating higher-fat, higher-protein animal foods when they could have tried the higher-protein, higher-fat plant foods but didn’t because they are processed.
Edited: 2013-05-26T17:36:46 Don’t Forget the Shellfish!
Oysters and clams are high in cholesterol and they are not capable of suffering. If processed vegan foods don’t help, then ex-vegans might consider trying oysters and clams to see if that would solve their problems before eating products from conscious animals.
Don’t Forget Bivalves: Clams, Oysters, Scallops, and Mussels
Oysters, clams, scallops, and mussels have significant amounts of cholesterol and they are not capable of suffering. If processed vegan foods don’t help, then ex-vegans might consider eating these animals to see if that would solve their problems before eating products from conscious animals.
Privilege
At minute 19:00 of Jamieson’s interview on The Current, the interviewer talks about how having the luxury to debate our food choices comes from a “very privileged place” and suggests that this whole conversation is “navel gazing”.
I object. Calling veganism “privileged” is a common dart thrown at it, usually by people who are, themselves, living relatively privileged lives. We should keep in mind that the farmed animals are the least privileged of anyone in discussions about whether to be vegan or not. Eating gourmet cheeses and steak, or being any sort of “foodie” is a privilege. Buying fair trade bananas and chocolate is privileged. The forty-hour work week and child labor laws only can happen in privileged societies.
So, while I agree that many people in the world do not have the option to eat a vegan diet (for one thing, some people don’t have access to vitamin B12 supplements or fortified foods), just because everyone cannot do something doesn’t mean it’s not the right thing for the rest of us to do. It’s not a good excuse for middle-class (or wealthier) Americans and Canadians to embrace farmed animal exploitation just because some other people are too poor to buy vegan packaged products at Whole Foods.
Conclusion
I do not want to blame the victim – Jamieson had failing health as a vegan and there might not have been any way to help her that we know of. And I think it’s commendable that instead of going from vegan to all-out paleo, she went from vegan to 75% vegan.
In her interview on The Current she says, “I may go back to a completely 100% plant-based diet. If and when that’s appropriate for me. I’m not ruling that out. The only problem is that I’m no longer welcomed back into that vegan community. I’ve been shut out of that conversation to help people be healthier in that way, to even promote plant-based living because I’m somehow a heretic.”
I would welcome her back.
Alex, you could be the first high-profile ex-ex-vegan – think about it!
The Linus Pauling Institute says, “Vitamin A and retinoic acid play a central role in the development and differentiation of white blood cells, such as lymphocytes, which play critical roles in the immune response (1).”
Unlike omnivores, vegans do not have a direct, dietary source of vitamin A, but rather get it indirectly via carotenoids (mainly beta-carotene). Beta-carotene is fat-soluble. It seems theoretically, possible then, that a low intake of carotenoids or fat could contribute to lower vitamin A status and white blood cell count (WBC).
This is purely hypothetical; to my knowledge vitamin A levels have not been measured in vegans and other signs of low vitamin A status have not been a noted problem. Anecdotally, I had been eating plenty of beta-carotene and fat at the last measurement of my WBC which showed them to be below normal.
Paul Appleby, of EPIC, passed on a study to me of a clinical trial using a “Daniel Fast” from the University of Memphis (2). In this trial, mostly healthy and some vegetarian subjects (13 men, 30 women; 20-62 years old) went on a Daniel Fast for 21 days, eating no processed or packaged food and only plant foods (as much as they wanted). Their WBC went from an average of 5.7 to 5.0 (2). 5.0 is within the normal range, but on the lower end (normal being about 3.5 to 12.5 billion per liter).
The authors of the Daniel Fast study say, “It has been suggested that ingestion of food additives and preservatives can increase white blood cell count by triggering an immune response due to a sensing of invading pathogens from the food stuff; however, we are unaware of any scientific reports that confirm this hypothesis.” I should point out that lots of things have been suggested, but it doesn’t seem impossible that vegans generally eat less food additives and preservatives and this could be contributing to low WBC.
I have added this information to VeganHealth’s article on White Blood Cells.
There were some other interesting things about this study. Here are the before and after (or during in the case of the nutrient intakes):
The authors did an analysis which showed that the improvements in these parameters did not occur in only the unhealthier subjects, but rather across the board. They say, “It is interesting to note that even those subjects who were vegetarian prior to starting the fast experienced dramatic reductions in total and LDL-[cholesterol], in addition to improvements in other markers. Clearly, the exclusion of meat from the diet (as is the case for vegetarians) is not the only dietary factor involved in raising circulating cholesterol and other risk factors for cardiovascular and metabolic disease.”
It should be noted that this trial had no control group and was not randomized in any way.
I found this interesting because even though the subjects didn’t lose much weight (the weight change wasn’t even statistically significant), their blood pressure and cholesterol levels went down substantially in only 3 weeks. That’s impressive. But does it mean that it is the diet that everyone should be on all the time, indefinitely?
Stay tuned.
Reference
1. Linus Pauling Institute. Micronutrient Information Center. Vitamin A. Accessed 5/20/13 | link
2. Bloomer RJ, Kabir MM, Canale RE, Trepanowski JF, Marshall KE, Farney TM, Hammond KG. Effect of a 21 day Daniel Fast on metabolic and cardiovascular disease risk factors in men and women. Lipids Health Dis. 2010 Sep 3;9:94. | link
Howard Jacobson, administrator of The China Study Facebook Page, saw my article on the NHANES meat and mortality study and asked to do an interview with me. The interview is about 30 minutes. Click here for the FB page or click here for the direct mp3 download.
