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!

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A reader (thanks, Syd!) pointed out an article in The Huffington Post that was critical of the Cleveland Clinic study suggesting carnitine causes cardiovascular disease (see Carnitine, Red Meat, TMAO & CVD).

While the Huffington Post article was one of many criticizing the Cleveland Clinic study, it was the only one I saw that made any good points. The article is Does Carnitine Really Cause Heart Disease? by Alan Gaby, MD, who is the past president of the American Holistic Medical Association. Towards the very end of the article, Dr. Gaby says, “It is noteworthy that the observed association between heart disease and carnitine levels disappeared completely when the researchers corrected for differences in kidney function.”

This is true – when the researchers corrected for a number of conditions, including kidney function and TMAO levels, the association of carnitine with major adverse cardiac events (MACE) disappeared. The researchers used that model to say that it proved that TMAO was the problem, not carnitine, and it didn’t occur to me in my first analysis that perhaps TMAO levels were high simply because the kidneys couldn’t clear the TMAO. After reading Dr. Gaby’s article I downloaded the online supplementary material and found that kidney function did progressively get worse as carnitine levels increased among the subjects, and this trend was statistically significant. So it seems plausible that perhaps the higher TMAO levels were simply a result of poor kidney function. But this is such an obvious possibility that I couldn’t believe the researchers didn’t consider it and perhaps run an unreported model to test for it. I then wrote the corresponding author of the study, Dr. Stanley Hazen, who is out of the office until the end of the month.

But there’s more. On Thursday, I awoke to news that the Cleveland Clinic group of researchers had published yet another study on TMAO! This time, it was on eggs and lecithin (1). In 2011, they had reported that choline can increase TMAO levels and TMAO was associated with the existence of cardiovascular disease in a cross-sectional study (more info). This time, they were testing phosphatidylcholine (lecithin) from eggs to see if it increased TMAO levels. It did.

Then they performed a prospective study much like the one in the carnitine study (maybe even an arm of the same one?) to see if TMAO was associated with more MACE. Once again, people with higher TMAO levels also had poorer kidney function. But even after adjusting for kidney function, TMAO was still significantly associated with MACE (1.43, 1.05–1.94).

That fully adjusted model included age, sex, smoking status, systolic blood pressure, LDL, HDL, diabetes, C-reactive protein, myeloperoxidase, glomerular filtration rate (kidney function), total white-cell count, body-mass index, medications (aspirin, statins, ACE inhibitor, ARB, or beta-blocker), and the extent of disease as seen on angiography. That’s a lot of adjustments some of which might even be too much, dampening the true effect of TMAO.

As things stand, it appears that kidney function is not the cause of high TMAO and that TMAO might, after all, be a significant cause of MACE. Stay tuned – this story is not over.

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Reference

1. Tang WHW, Wang Z, Levison BS, Koeth RA, Britt EB, Fu X, Wu Y, Hazen SL. Intestinal Microbial Metabolism of Phosphatidylcholine and Cardiovascular Risk. N Engl J Med 2013(April 25, 2013);368:1575-1584. | link

I have finally finished my article on choline! It is posted at VeganHealth.org.

After all was said and done, it was much ado about not much. Still, it is important that the issue of choline in vegan diets has now been researched.

Here is the summary from the article:

Choline is found in a wide range of plant foods in small amounts. Eating a well-balanced vegan diet with plenty of whole foods should ensure you are getting enough choline. Soymilk, tofu, quinoa, and broccoli are particularly rich sources.

The Dietary Reference Intake (DRI) for choline is 550 mg/day for men and 425 mg/day for women. It is based on only one study comparing those amounts to 50 mg/day, with no intermediary amounts examined. Eating less than 50 mg/day can result in liver damage, but it is very unlikely that a vegan would have such a low intake.

Some people have genetic mutations that increase the need for choline; it is not clear how much choline such people need but the DRI is probably adequate for almost everyone. If you suspect any sort of liver dysfunction, it might be worth talking to your physician about boosting your choline intake or supplementing with it in moderate amounts.

The data on choline and chronic disease (cardiovascular disease, dementia, and cancer) is somewhat mixed. Ideal amounts appear to be about 300 mg per day. Most vegans probably get about that much from the foods they eat.

Vegan women who are considering getting pregnant should make sure they are meeting the DRI for choline to reduce the risk of neural tube defects, and might need a modest supplement.

End summary.

As part of writing this article, I recorded everything I ate from one day and then calculated the amount of choline. When I recorded the food I ate, I didn’t know how much choline was in any of it as I had never done more than casually browse the USDA’s list of the choline content of foods. I actually expected it to be quite low, so it came as a nice surprise to find I met the recommendations I had already formulated before conducting the diet analysis. You can see my diet record in Table 2 of the article.

My choline intake came to 343 mg. However, there was no amount listed for hummus (or garbanzo beans) in the USDA database. Based on other legumes, I would assume at least 20 mg for 1/2 cup of hummus which would boost my intake to 363 mg. I was pretty surprised that after I plugged everything into the database, the only foods without values were hummus, canola oil, and grapeseed oil.

I list eating .5 cup of tofu. That was actually my estimate for the amount of tofu in Tofurky (4 slices for lunch and a 1/2 sausage for dinner). Tofurky is made from pressed tofu.

Not too long before I started writing this article, I purchased a bottle of choline supplements and started taking 300 mg twice a day (600 mg total). As I got further along in the choline research, I decided it might not be such a good idea to take so much. And since doing my diet analysis, I haven’t seen much need to to take any at all. It had been an experiment to see if taking choline would make me feel any different and I didn’t notice any change after a few weeks.

In conclusion, most vegans are probably getting enough choline in their diets.

I’d like to give special thanks to Jean Bettanny for doing another fantastic job in proofing the choline article!