“I was Vegan for A While, But…”

March 12th, 2013 by Jack Norris RD

The recent controversy explained in my post To Quit or Not to Quit Veganism spurred me on to update the introduction to VeganHealth.org, “I was Vegan for A While, But…”.

Before getting to that, there is one more recent ex-vegan story, that of John Nicholson, as described in the article, From vegetarian to confirmed carnivore.

John Nicholson says that after having tried everything to cure his irritable bowel syndrome as a vegan, eating ox liver and rare steak cured it within 24 hours. Wow – maybe I was wrong and it is, indeed, the spirit of the dead animal that can perform such miracles.

I’d have more sympathy for these ex-vegans if their stories didn’t sound so strange, and if they didn’t swing from one extreme to the other. Nonetheless, there is no denying that Nicholson’s health improved when he went back to eating animal products.

Here is the article:

“I was vegan for a while, but…”

Let’s start with the good news: Vegans have a much lower risk of type-2 diabetes than do meat-eaters – in fact, it’s not even close. Research has also shown that vegans have a slightly lower risk of cancer by virtue of our diets.

Unfortunately, this isn’t the end of the story. While many people thrive on a vegan diet, others have a hard time. When someone is committed to reducing animal suffering, there are often solutions to these dilemmas, and finding answers has been a major focus of my nutrition writing. While bringing attention to these issues might not initially attract as many people as claiming that a vegan diet is a health panacea, getting people to stay vegan long-term is the more important task because every vegan who fails to thrive provides reasons for many people not to try veganism.

Macronutrients: The Bigger Picture

Something as simple as not eating enough calories might be a problem for an uninformed person who decides to eat vegan for a few days. They might only be aware of low-calorie vegan foods (e.g., salads, vegetables, fruits), and eating only these foods for a day might leave them feeling hungry and weak.

Of course, many advocacy groups are actively trying to educate people about the wide variety of satisfying vegan foods. In promoting the diet, each person could help prepare potential vegans for the real possibility that they won’t feel good if they don’t choose some calorie-dense foods.

In addition to calories, a lack of protein in the diet for a few days could lead to someone feeling less than optimal and wanting to eat animal products. While severe protein deficiency is certainly nothing to worry about on a vegan diet, if someone doesn’t know what high-protein vegan foods to choose, they could go from eating large amounts of protein (on an animal-based diet) to much smaller, less satisfying amounts on a vegan diet. Legumes (beans, peanuts, peas, lentils, soy), seitan, and quinoa are the best sources of protein for vegans. Include a few servings of these foods each day – maybe even each meal.

While a low-fat diet might improve someone’s health in the short-term, it might not be ideal over longer periods. If you are avoiding all added fats and you start to crave animal products, it might be time to add some fat back into your diet. People tend to think of animal products, and especially meat, as “protein,” but they are actually about 50% fat in many cases.

It’s theoretically possible that some vegans’ cholesterol levels might get too low on a low-fat, low-calorie, and/or low-saturated fat diet, leading to a low production of steroid hormones. In this case, adding plant saturated fat, such as coconut oil, to the diet, could improve their health. There is not much research into how low cholesterol levels must go, on average, to inhibit steroid hormone production and it may be very rare for this to happen. Two studies have shown vegans to have sex hormones on par with meat-eaters (1, 2), but one report showed vegan women to have lower levels of estrogen (3). A few anecdotal reports provide some evidence that low cholesterol problems might be an issue for some vegans (see Bonzai Aprodite’s story of regaining her health as a vegan, Facing Failing Health As A Vegan).

While the science is still in the early stages, it appears that some people genetically do not do well basing their diet on carbohydrates (see Dieting by DNA? Popular diets work best by genotype, research shows). For those people, the eco-Atkins type diet, high in plant proteins such as soy meats, legumes, and seitan, might be a better choice than a higher carbohydrate, low-fat diet.

Finally, if you find yourself craving animal products, it could be because you have a strong preference for the taste of glutamate, also known as umami. You can read more about foods high in umami in Ginny Messina, MPH, RD’s article, Is Umami a Secret Ingredient of Vegan Activism?

Micronutrient Deficiencies

Vitamin B12 in plant-based diets has long been a source of controversy and myths, so much so that a large portion of this site is dedicated to discussing B12. Although it rarely happens quickly, these myths have led to many vegans getting B12 deficiency. If you do not get a reliable source of vitamin B12, the chances are high that you will, at some point, find your health failing.

The need for calcium on vegan diets has also been surrounded by misleading ideas. Many vegan advocates have suggested that animal protein, including milk, is the main cause of osteoporosis in Western countries. Following this line of logic, it would make sense that vegans do not need to worry about osteoporosis since they are not eating animal protein. The research actually shows that vegans, like non-vegans, should try to meet the calcium recommendations for the greater population. Vegans are at a disadvantage in this area because our diets tend to contain much less calcium than your typical animal-based diet, so we must make an effort to ensure good sources of calcium on a daily basis.

More often than not, vegans who come to me with severe fatigue are suffering from vitamin D deficiency. This is not just a vegan problem, many people develop vitamin D deficiency in this era of sun avoidance. But vegans are at a slight disadvantage, on average, because we get less vitamin D in our diets. Make sure that you have a reliable source of vitamin D.

Although it appears to be a small percentage, some women develop iron-deficiency anemia after becoming vegetarian. If you think you are at risk, see the article on Iron for tips on increasing iron absorption from plants.

Iodine is a nutrient that most vegans rarely think about but a 2011 study showed that vegans do not get enough. Especially if you eat soy, you should make sure you are getting some iodine.

DHA is an omega-3 fatty acid that is important for cognition. A short time on a vegan diet is not likely to cause any sort of deficiency, but long-term vegans should take a supplement.

Finally, some vegans might not get enough vitamin A and zinc, depending on their dietary choices. Vitamin A is easy to get through orange vegetables, though eating them daily is critical to this strategy. Zinc is trickier and some vegans just opt for a modest supplement of 50-100% of the RDA.

For more information on all of these nutrients, please see the Daily Recommendations for people on plant-based diets.

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References

1. Thomas HV, Davey GK, Key TJ. Oestradiol and sex hormone-binding globulin in premenopausal and post-menopausal meat-eaters, vegetarians and vegans. Br J Cancer. 1999 Jul;80(9):1470-5. | link

2. Key TJ, Roe L, Thorogood M, Moore JW, Clark GM, Wang DY. Testosterone, sex hormone-binding globulin, calculated free testosterone, and oestradiol in male vegans and omnivores. Br J Nutr. 1990 Jul;64(1):111-9. | link

3. Goldin BR, Gorbach SL. Effect of diet on the plasma levels, metabolism, and excretion of estrogens. Am J Clin Nutr. 1988 Sep;48(3 Suppl):787-90. Review. | link

VeganHealth.org: Vitamin D2 in Mushrooms

March 11th, 2013 by Jack Norris RD

I added some research on vitamin D2 in mushrooms to the Bones, Vitamin D, and Calcium page at VeganHealth.org:

Vitamin D2 in UV Treated Mushrooms

Food manufacturers are now creating large amounts of vitamin D2 in mushrooms by exposing them to commercial ultraviolet light or direct sunlight (55, 56). The vitamin D is well-retained in the mushrooms over the course of the typical storage life of fresh mushrooms, up to two weeks (55, 57). This vitamin D is effective in improving vitamin D status and no different from a vitamin D2 supplement (2).

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References

2. Urbain P, Singler F, Ihorst G, Biesalski HK, Bertz H. Bioavailability of
vitamin D₂ from UV-B-irradiated button mushrooms in healthy adults deficient in
serum 25-hydroxyvitamin D: a randomized controlled trial. Eur J Clin Nutr. 2011
Aug;65(8):965-71. doi: 10.1038/ejcn.2011.53. Epub 2011 May 4. | link

55. Kalaras MD, Beelman RB, Elias RJ. Effects of postharvest pulsed UV light treatment of white button mushrooms (Agaricus bisporus) on vitamin D2 content and quality attributes. J Agric Food Chem. 2012 Jan 11;60(1):220-5. | link

56. Simon RR, Phillips KM, Horst RL, Munro IC. Vitamin D mushrooms: comparison of the composition of button mushrooms (Agaricus bisporus) treated postharvest with UVB light or sunlight. J Agric Food Chem. 2011 Aug 24;59(16):8724-32. | link

57. Roberts JS, Teichert A, McHugh TH. Vitamin D2 formation from post-harvest UV-B treatment of mushrooms (Agaricus bisporus) and retention during storage. J Agric Food Chem. 2008 Jun 25;56(12):4541-4. | link

VeganHealth.org Update: Vitamin D2 vs. D3

March 10th, 2013 by Jack Norris RD

In continuing to bone up on the bones research, I have summarized some recent findings on vitamin D2 vs. D3 and updated the Bones, Vitamin D, and Calcium page at VeganHealth.org.

So that I do not have to continue updating this page to reflect the VeganHealth.org page, I have cut the article from this post and readers should just refer to the link above. Thank you.

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Fracture Rates in China and Sweden

March 7th, 2013 by Jack Norris RD

My two biggest concerns about vegan nutrition are vitamin B12 and calcium. The message about vitamin B12 has gotten through to anyone who has been paying attention and isn’t in nutrition la la land (unfortunately, this are still a lot of vegans on both accounts). But even today, calcium and bones is a particularly tough sell among people who are interested in mainstream science and have been paying some attention.

Normally when I harp on the need for calcium, explaining that animal protein does not cause osteoporosis and so vegans are not protected by virtue of not eating any, someone will point out that countries that have higher intakes of dairy (northern Europe and the USA) have higher rates of osteoporosis than do Asian and African countries where much less milk in consumed. Here is a study that helps explain this paradox for Asians.

The first prospective study measuring clinically diagnosed vertebral fractures in an Asian population, the Hong Kong Osteoporosis Study, was released in March of 2012 (1). It measured the vertebral and hip fractures in a Chinese population and compared the rates to Sweden. Data from Japan was also included, but the measurements of vertebral fracture were estimated for Japan.

Rather than typing out the numbers for the various age groups, which are tedious to read, the results can be seen in the diagram below (or you can click here for an easier version to see).

The Swedish have higher rates of hip fracture while the Chinese have higher rates of vertebral fractures (much higher after age 80).

The authors state:

“The observed ethnic differences in fracture incidences may be due to the fact that hip fracture risk was affected by fall risk, whereas the risk of vertebral fracture mostly depends on bone strength. Despite the low hip fracture rate in our population, Hong Kong women had a higher prevalence of osteoporosis (bone mineral density T- score à “2.5 at any one site in reference to ethnic-specific peak young mean according to the ISCD recommendation) than US Caucasian women (35.8% vs. 20%, respectively) and a similar prevalence of about 6% in Hong Kong and US Caucasian men.”

In other words, the Chinese don’t have lower rates of osteoporosis.

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Reference

1. Bow CH, Cheung E, Cheung CL, Xiao SM, Loong C, Soong C, Tan KC, Luckey MM, Cauley JA, Fujiwara S, Kung AW. Ethnic difference of clinical vertebral fracture risk. Osteoporos Int. 2012 Mar;23(3):879-85. | link

Soy vs. Cow’s Milk and Bone Mineral Density Take Two

March 6th, 2013 by Jack Norris RD

Yesterday, I wrote about a clinical trial comparing soy vs. cow’s milk’s impact on bone mineral density (BMD) in Chinese women (link). To sum it up, the cow’s milk fared better than soy, which fared better than nothing.

Today I found a prospective study from the Adventist Health Study-2 (2011) comparing soy vs. cow’s milk (1). They followed 337 post-menopausal, Caucasian women, who had not been previously diagnosed with osteoporosis, for two years. 61% were considered vegetarians because they ate meat less than once a month.

The authors sum up the results:

“Those drinking soy milk at least once a day or more (highest category) were 57% less likely to have osteoporosis than those who never used soy milk [.43 (.21–.89)]. Likewise, those eating dairy products at least once a day or more were 62% less likely to have osteoporosis than those consuming dairy less than twice a week [.38 (.17–.86)].”

There was not a separate soymilk group and cow’s milk group, both findings were comparing the entire group of women to each other, though the results for each milk were adjusted for intake of the other milk.

The researchers did not measure total calcium intake, but they seemed to assume that most of this soymilk was calcium-fortified. They also found no correlation between calcium or vitamin D supplement usage (amounts not measured) and better bone health.

Interestingly, cheese was the only dairy product that, when separated out, was correlated with better bone health (the other categories were “milk,” and “yogurt/ice-cream”). The authors speculated that it was due to the higher calcium and protein content of cheese.

In conclusion, it appears to be about equally beneficial for bone health for Caucasian, postmenopausal women to be drinking either soymilk or cow’s milk.

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Reference

1. Matthews VL, Knutsen SF, Beeson WL, Fraser GE. Soy milk and dairy consumption is independently associated with ultrasound attenuation of the heel bone among postmenopausal women: the Adventist Health Study-2. Nutr Res. 2011 Oct;31(10):766-75. | link

VeganFitness.net

March 5th, 2013 by Jack Norris RD

A great resource for vegans into fitness:

VeganFitness.net

Soy vs. Cow’s Milk and Bone Mineral Density

March 5th, 2013 by Jack Norris RD

I’m going through my backlog of research on bones in order to write a reader-friendly version of the tome that is Bones, Vitamin D, and Calcium on VeganHealth.org.

In January 2012, a report from China was released of a randomized clinical trial comparing the effects of cow’s milk and soymilk on bone mineral density (BMD) in postmenopausal women (1).

The women were divided into three groups: soy, cow’s, and control. The women knew which treatment they were receiving, while the control group got nothing. The milk and soymilk had 250 mg of calcium and they drank one serving per day.

BMD was measured in the spine, hip, and femur at 6, 12, and 18 months.

In the cow’s milk group, BMD increased in the hip and femur. In the soymilk group, BMD did not change significantly, but showed a downward trend in all three locations. In the control group, there was a downward trend in all three locations that only reached significance in the femur at 18 months.

It should be strongly noted that the participants were asked to avoid calcium from other milks and supplements during the trial which means their total calcium intake was probably quite low and I’m somewhat amazed that their BMD didn’t decrease more or in all three groups. Total calcium intake during the study period was not reported.

Compliance was 93.1% in the cow’s milk group and 82.5% in the soymilk group. This might explain a small amount of the differences between those groups. Other possibilities are that calcium in fortified soymilk is known to quickly settle to the bottom of the milk where it might not be ingested but left in the container, and that milk contains phosphorus and growth factors that might increase BMD.

This is just one small study and more work needs to be done before any conclusions should be drawn.

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Reference

1. Gui JC, Brašić JR, Liu XD, Gong GY, Zhang GM, Liu CJ, Gao GQ. Bone mineral density in postmenopausal Chinese women treated with calcium fortification in soymilk and cow’s milk. Osteoporos Int. 2012 May;23(5):1563-70. Epub 2012 Jan 27. | link

Calcium Supplements and Cardiovascular Disease in the News

March 4th, 2013 by Jack Norris RD

In 2010, I wrote about a meta-analysis on calcium supplements and cardiovascular disease, Calcium Supplements: Are They Safe? The association with heart disease was limited to people who started out with a dietary calcium intake of 700 mg/day or more (not including the supplements). Then in 2011, I noted a study on supplement use in older women that found a link between calcium supplements and a lower risk of mortality (Supplement Safety).

Since I recommend that vegans get their calcium levels up to at least 700 mg and preferably the DRI (1,000 mg for adults under 50; 1,200 mg for adults over 50) by whatever means necessary (greens, fortified foods, or supplements), I try to keep track of this research as closely as I can. In February, results from two different studies looking at calcium supplements and cardiovascular disease were reported.

One study was from the USA and followed people aged 50 to 71 at baseline for 12 years (1). No association between cardiovascular disease deaths and calcium intake was found for women. For men, calcium supplements of 400 to 1,000 mg/day was associated with an increased risk of cardiovascular death, but was just barely statistically significant. But supplements of more than 1,000 mg/day were associated with a highly significant increase in cardiovascular mortality:

(mg/day)  
None 1.00
< 400 .99 (.94-1.04)
400–1,000 1.09 (1.01-1.18)
> 1,000 1.20 (1.05-1.36)

When the numbers were stratified for smoking, there was a strong trend towards the risk being mainly in current smokers. The average user of supplements for men had a dietary calcium intake (not including supplements) of 815 mg. So once you figure in another 400 to 1,000+ mg of supplemental calcium, their intakes were anywhere from the DRI to about 50% higher than the DRI.

The second study was from Sweden, on older women (2). All-cause mortality for dietary calcium (not including supplements) was a U-shaped curve, with both low calcium and high calcium associated with an increase in mortality:

(mg/day)  
< 600 1.38 (1.27, 1.51)
600-999 1.00
1000-1399 1.00 (.96-1.04)
≥ 1,400 1.40 (1.17-1.67)

The findings were similar, but even stronger for cardiovascular disease, and were also very similar for dietary plus supplemental calcium.

One thing to consider for this Swedish study is that 1,400 mg of non-supplemental calcium would indicate a pretty high dairy intake. If you assume 300 mg per serving of dairy, that’s at least 3 servings of dairy per day (on top of the calcium they might be getting from other foods). The results did not adjust for dairy product intake so it’s possible that dairy of 3 servings (or more) per day could have caused the increase in cardiovascular deaths.

While it’s not yet clear what is going on here, my conclusion remains that vegans should aim for at least 700 to 1,000 mg/d (or 700 to 1,200 mg/d if over 50) from foods or supplements, but that you should not go much above that.

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References

1. Xiao Q, Murphy RA, Houston DK, Harris TB, Chow W, Park Y. Dietary and Supplemental Calcium Intake and Cardiovascular Disease Mortality: The National Institutes of Health–AARP Diet and Health Study. JAMA Intern Med. 2013;():1-8. | link

2. Michaëlsson K, Melhus H, Warensjö Lemming E, Wolk A, Byberg L. Long term
calcium intake and rates of all cause and cardiovascular mortality: community
based prospective longitudinal cohort study. BMJ. 2013 Feb 12;346:f228. | link

To Quit or Not to Quit Veganism

February 28th, 2013 by Jack Norris RD

Sayward Rebhal, of Bonzai Aphrodite, has an excellent post about her struggles to stay healthy as a vegan. When I got done reading it, I thought “This is EXACTLY what I’ve been saying!” It sounds like she had not been aware that there is a group of vegan health professionals who do not promote very low-fat diets or dismiss any concerns about protein.

Her post is here: Facing Failing Health As A Vegan

In contrast, another (now ex-) vegan blogger, Alex Jamieson, posted yesterday that, “I’m not vegan anymore.”

Jamieson became vegan for health reasons, but it appears that she later came to be a vegan for more than just health, in which case it is disappointing that she didn’t try to do more to figure out why the diet might not have been working for her. Taking a vitamin B12 supplement or getting tested for iron are two things that are easy to do and that could be the culprits in many of these cases of ex-vegans.

While I do not dismiss all cravings for meat as being simply in people’s heads, and I think Jamiesons’s cravings for meat might really have indicated a nutritional deficiency, it is very frustrating to see people talk about getting in tune with their bodies as though it’s some legitimate stand-in for nutrition science.

Jamieson says, “At first, I thought: ‘I must be mineral deficient. Or maybe I need more concentrated protein. I’ll eat more sea vegetables. I’ll just add more nuts and hemp seeds and drink more green juice. Then the cravings will stop.'”

Those are not terribly concentrated sources of protein. It sounds like she was on a very low-fat diet, too, something that might have caused cravings.

In any case, it is not the leftover remnants of the spirit of the animal that is making her feel better. Her body might require some molecules, or mixtures of molecules, that she was only able to find in animal flesh. But if that same mixture of molecules could be reproduced outside of an animal, it would satisfy her body’s needs.

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Strontium for Increasing Bone Mineral Density

February 27th, 2013 by Jack Norris RD

IMPORTANT UPDATE: On October 1, 2014 the European Medicines Agency’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended that strontium ranelate (Protelos/Osseor, Servier) no longer be used to treat osteoporosis because of data demonstrating serious negative side effects.

—–

Three of the six people who answered my request for information about successfully increasing bone mineral density (BMD) used strontium. A week ago, I had never even heard of strontium as a supplement for bone health, but I have come to find that it’s all the rage!

Strontium is a mineral that has some properties similar to calcium. It appears to cause both an increase in bone formation and a decrease in bone breakdown. Strontium ranelate has been approved for use as a drug in Europe. The FDA has not approved strontium ranelate, but strontium citrate is available in the U.S. The ranelate is separated from the strontium in the digestive tract and has no pharmacological value, so strontium citrate and other versions are thought to be similarly effective.

The Cochrane Database group published a systematic review of the evidence for treating low BMD or osteoporosis with strontium ranelate in 2006, and later updated it in 2008 (1). They concluded:

“There is silver level evidence to support the efficacy of strontium ranelate for the reduction of fractures (vertebral and to a lesser extent, non-vertebral) in postmenopausal osteoporotic women and an increase in BMD in postmenopausal women with/without osteoporosis. Diarrhea may occur, however, adverse events leading to study withdrawal were not significantly increased. Potential vascular and neurological side-effects need to be further explored.”

2 grams per day is the amount typically given and found to be especially effective.

Since 2008, a bit more evidence has come to light:

A 5-year study comparing strontium ranelate to a placebo group was extended to 10 years, but without a placebo group (2). The participants were also put on calcium (< 1000 mg/day) and vitamin D (400 to 800 IU/day). It was an open label trial, meaning the participants knew they were taking strontium ranelate. The extra five years of strontium showed it to be as effective as the first five years, which had been effective at preventing fractures and a loss of BMD.

In March of 2012, the European Medicines Agency issued a press release cautioning people with a history of venous thromboembolism or who are immobilized or bed ridden not to use strontium ranelate (3). They also recommended that people over 80 not use strontium ranelate. Finally, people should be aware of potential skin rashes with its use and discontinue if a skin rash or other allergic reaction occurs.

Please talk to your doctor before taking strontium!

References

1. O’Donnell S, Cranney A, Wells GA, Adachi J, Reginster JY. Strontium ranelate for preventing and treating postmenopausal osteoporosis. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005326. DOI: 10.1002/14651858.CD005326.pub3. | link. PubMed: link

2. Reginster JY, Kaufman JM, Goemaere S, Devogelaer JP, Benhamou CL, Felsenberg D, Diaz-Curiel M, Brandi ML, Badurski J, Wark J, Balogh A, Bruyère O, Roux C. Maintenance of antifracture efficacy over 10 years with strontium ranelate in postmenopausal osteoporosis. Osteoporos Int. 2012 Mar;23(3):1115-22. | link

3. European Medicines Agency confirms positive benefit-risk balance of Protelos/Osseor, but recommends new contraindications and revised warnings. March 16, 2012. Accessed February 27, 2013. | link