Wellplanned vegetarian di ets are appropriate for individuals during all stages of the life cycle in cluding pregnancy lactation infancy childhood and adolescence and for athletes A vegetarian diet is de64257ned as one that does not include meat in ID: 47093
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fromtheassociationPositionoftheAmericanDieteticAssociation:VegetarianDiets ItisthepositionoftheAmericanDi-eteticAssociationthatappropriatelyplannedvegetariandiets,includingtotalvegetarianorvegandiets,arehealthful,nutritionallyadequate,andmayprovidehealthbeneÞtsinthepreventionandtreatmentofcertaindiseases.Well-plannedvegetariandi-etsareappropriateforindividualsduringallstagesofthelifecycle,in-cludingpregnancy,lactation,infancy,childhood,andadolescence,andforathletes.AvegetariandietisdeÞnedasonethatdoesnotincludemeat(in-cludingfowl)orseafood,orproductscontainingthosefoods.Thisarticlereviewsthecurrentdatarelatedtokeynutrientsforvegetariansinclud-ingprotein,n-3fattyacids,iron,zinc,iodine,calcium,andvitaminsDandB-12.Avegetariandietcanmeetcur-rentrecommendationsforallofthesenutrients.Insomecases,supplementsorfortiÞedfoodscanprovideusefulamountsofimportantnutrients.Anev-idence-basedreviewshowedthatveg-etariandietscanbenutritionallyad-equateinpregnancyandresultinpositivematernalandinfanthealthoutcomes.Theresultsofanevidence-basedreviewshowedthatavegetar-iandietisassociatedwithalowerriskofdeathfromischemicheartdisease.Vegetariansalsoappeartohavelowerlow-densitylipoproteincholesterollev-els,lowerbloodpressure,andlowerratesofhypertensionandtype2diabe-testhannonvegetarians.Furthermore,vegetarianstendtohavealowerbodymassindexandloweroverallcancerrates.Featuresofavegetariandietthatmayreduceriskofchronicdiseaseincludelowerintakesofsaturatedfatandcholesterolandhigherintakesoffruits,vegetables,wholegrains,nuts,soyproducts,Þber,andphytochemi-cals.Thevariabilityofdietarypracticesamongvegetariansmakesindividualassessmentofdietaryadequacyessen-tial.Inadditiontoassessingdietaryad-equacy,foodandnutritionprofession-alscanalsoplaykeyrolesineducatingvegetariansaboutsourcesofspeciÞcnutrients,foodpurchaseandprepara-tion,anddietarymodiÞcationstomeettheirneeds.JAmDietAssoc.2009;109: POSITIONSTATEMENTItisthepositionoftheAmericanDi-eteticAssociationthatappropriatelyplannedvegetariandiets,includingtotalvegetarianorvegandiets,arehealthful,nutritionallyadequate,andmayprovidehealthbeneÞtsinthepre-ventionandtreatmentofcertaindis-Well-plannedvegetariandietsareappropriateforindividualsduringallstagesofthelifecycle,includingpregnancy,lactation,infancy,child-hood,andadolescence,andforathletes.VEGETARIANDIETSINPERSPECTIVEAvegetarianisapersonwhodoesnoteatmeat(includingfowl)orseafood,orproductscontainingthesefoods.Theeatingpatternsofvegetariansmayvaryconsiderably.Thelacto-ovo-vegetarianeatingpatternisbasedongrains,vegetables,fruits,legumes,seeds,nuts,dairyproducts,andeggs.Thelacto-vegetarianexcludeseggsaswellasmeat,Þsh,andfowl.Thevegan,ortotalvegetarian,eatingpat-ternexcludeseggs,dairy,andotheranimalproducts.Evenwithinthesepatterns,considerablevariationmayexistintheextenttowhichanimalproductsareexcluded.Evidence-basedanalysiswasusedtoevaluateexistingresearchontypesofvegetariandiets⠀).Onequestionforevidence-analysiswasidentiÞed:Whattypesofvegetariandietsareexaminedintheresearch?Thecom-pleteresultsofthisevidence-basedanalysiscanbefoundontheAmeri-canDieteticAssociationÕsEvidenceAnalysisLibrary(EAL)Website⤀andaresummarizedbelow.EALConclusionStatement:ThetwomostcommonwaysofdeÞningvege-tariandietsintheresearcharevegandiets:Dietsdevoidofallßeshfoods;ThisAmericanDieteticAssociation(ADA)positionpaperincludestheauthorsÕindependentreviewoftheliteratureinadditiontosystematicreviewconductedusingtheADAÕsEvidenceAnalysisProcessandinforma-tionfromtheEvidenceAnalysisLibrary.TopicsfromtheEvidenceAnalysisLibraryareclearlydelineated.Theuseofanevidence-basedapproachprovidesimportantaddedbeneÞtstoearlierreviewmethods.Themajoradvantageoftheapproachisthemorerigorousstandardizationofreviewcriteria,whichminimizesthelikelihoodofreviewerbiasandincreasestheeasewithwhichdisparatearticlesmaybecompared.Foradetaileddescrip-tionofthemethodsusedintheevidenceanalysisprocess,accessADAÕsEvidenceAnalysisProcessatConclusionStatementsareassignedagradebyanexpertworkgroupbasedonthesystematicanalysisandevaluationofthesupportingresearchevidence.GradeIGood;GradeIIFair;GradeIIILimited;GradeExpertOpinionOnly;andGradeVNotAssignable(becausethereisnoevidencetosupportorrefutetheconclusion).Evidence-basedinformationforthisandothertopicscanbefoundatandsubscriptionsfornonmembersareavailableforpurchaseat 0002-8223/09/10907-0019$36.00/0doi:10.1016/j.jada.2009.05.027 JournaloftheAMERICANDIETETICASSOCIATION2009bytheAmericanDieteticAssociation andvegetariandiets:Dietsdevoidofallßeshfoods,butalsoincludeegg(ovo)and/ordairy(lacto)products.However,theseverybroadcat-egoriesmaskimportantvariationswithinvegetariandietsanddietarypractices.Thesevariationswithinvegetariandietsmakeabsolutecat-egorizationofvegetariandietarypracticesdifÞcultandmaybeoneofthesourcesofunclearrelationshipsbetweenvegetariandietsandotherGradeIIInthisarticle,thetermwillbeusedtorefertopeoplechoosingalacto-ovo-,lacto-,orveganvegetariandietunlessotherwisespeciÞed.Whereaslacto-ovo-,lacto-,andvegan-vegetariandietsarethosemostcommonlystudied,practitionersmayencounterothertypesofvegetar-ianornear-vegetariandiets.Forex-ample,peoplechoosingmacrobioticdietstypicallydescribetheirdietasvegetarian.Themacrobioticdietisbasedlargelyongrains,legumes,andvegetables.Fruits,nuts,andseedsareusedtoalesserextent.Somepeo-plefollowingamacrobioticdietarenottrulyvegetarianbecausetheyeatlimitedamountsofÞsh.Thetradi-tionalAsian-Indiandietispredomi-nantlyplantbasedandisfrequentlylacto-vegetarianalthoughchangesof-tenoccurwithacculturation,includ-inggreaterconsumptionofcheeseandamovementawayfromavege-tariandiet.Arawfoodsdietmaybeavegandiet,consistingmainlyorex-clusivelyofuncookedandunproc-essedfoods.Foodsusedincludefruits,vegetables,nuts,seeds,andsproutedgrainsandbeans;inrareinstancesunpasteurizeddairyproductsandevenrawmeatand�栀maybeused.Fruitariandietsarevegandietsbasedonfruits,nuts,andseeds.Veg-etablesthatareclassiÞedbotanicallyasfruitslikeavocadoandtomatoesarecommonlyincludedinfruitariandiets;othervegetables,grains,beans,andanimalproductsareexcluded.Somepeoplewilldescribethem-selvesasvegetarianbutwilleatÞsh,chicken,orevenmeat.Theseself-de-scribedvegetariansmaybeidentiÞedinresearchstudiesassemivegetarians.Individualassessmentisrequiredtoaccuratelyevaluatethenutritionalqualityofthedietofavegetarianoraself-describedvegetarian.Commonreasonsforchoosingavegetariandietincludehealthconsid-erations,concernfortheenviron-ment,andanimalwelfarefactors.Vegetariansalsociteeconomicrea-sons,ethicalconsiderations,worldhungerissues,andreligiousbeliefsastheirreasonsforfollowingtheircho-seneatingpattern.ConsumerTrendsIn2006,basedonanationwidepoll,approximately2.3%oftheUSadultpopulation(4.9millionpeople)consis-tentlyfollowedavegetariandiet,statingthattheyneveratemeat,Þsh,orpoultry⠀).About1.4%oftheUSadultpopulationwasvegan⠀).In2005,accordingtoanationwidepoll,3%of8-to18-year-oldchildrenandadolescentswerevegetarian;closeto1%werevegan⠀Manyconsumersreportaninterestinvegetariandiets⠀⤀and22%reportregularconsumptionofmeatlesssub-stitutesformeatproducts⠀).Addi-tionalevidencefortheincreasingin-terestinvegetariandietsincludestheemergenceofcollegecoursesonvege-tariannutritionandonanimalrights;theproliferationofWebsites,period-icals,andcookbookswithavegetar-iantheme;andthepublicÕsattitudetowardorderingavegetarianmealwheneatingawayfromhome.Restaurantshaverespondedtothisinterestinvegetariandiets.Asurveyofchefsfoundthatvegetariandisheswereconsidered퉨潴팀or퉡perennialfavoriteÓby71%;vegandishesby63%).Fast-foodrestaurantsarebegin-ningtooffersalads,veggieburgers,andothermeatlessoptions.Mostuni-versityfoodservicesoffervegetarianNewProductAvailabilityTheUSmarketforprocessedvegetar-ianfoods(foodslikemeatanalogs,nondairymilks,andvegetarianen-treesthatdirectlyreplacemeatorotheranimalproducts)wasestimatedtobe$1.17billionin2006⠀).Thismarketisforecasttogrowto$1.6bil-lionby2011⠀Theavailabilityofnewproducts,in-cludingfortiÞedfoodsandconveniencefoods,wouldbeexpectedtohaveanimpactonthenutrientintakeofvege-tarianswhochoosetoeatthesefoods.FortiÞedfoodssuchassoymilks,meatanalogs,juices,andbreakfastcerealsarecontinuallybeingaddedtothemar-ketplacewithnewlevelsoffortiÞca-tion.Theseproductsanddietarysup-plements,whicharewidelyavailableinsupermarketsandnaturalfoodsstores,canaddsubstantiallytovegetariansÕintakesofkeynutrientssuchascal-cium,iron,zinc,vitaminB-12,vitaminD,riboßavin,andlong-chainn-3fattyacids.WithsomanyfortiÞedproductsavailabletoday,thenutritionalstatusofthetypicalvegetariantodaywouldbeexpectedtobegreatlyimprovedfromthatofavegetarian1to2decadesago.Thisimprovementwouldbeenhancedbythegreaterawarenessamongthevegetarianpopulationofwhatconstitutesabalancedvegetariandiet.Consequentlyolderresearchdatamaynotrepresentthenutritionalsta-tusofpresent-dayvegetarians.HealthImplicationsofVegetarianDietsVegetariandietsareoftenassociatedwithanumberofhealthadvantages,includinglowerbloodcholesterollevels,lowerriskofheartdisease,lowerbloodpressurelevels,andlowerriskofhy-pertensionandtype2diabetes.Vege-tarianstendtohavealowerbodymassindex(BMI)andloweroverallcancerrates.Vegetariandietstendtobelowerinsaturatedfatandcholesterol,andhavehigherlevelsofdietaryÞber,mag-nesiumandpotassium,vitaminsCandE,folate,carotenoids,ßavonoids,andotherphytochemicals.Thesenutri-tionaldifferencesmayexplainsomeofthehealthadvantagesofthosefollow-ingavaried,balancedvegetariandiet.However,vegansandsomeothervege-tariansmayhavelowerintakesofvita-minB-12,calcium,vitaminD,zinc,andlong-chainn-3fattyacids.Recently,outbreaksoffood-borneill-nessassociatedwiththeconsumptionofdomesticallygrownandimportedfreshfruits,sprouts,andvegetablesthathavebeencontaminatedbyEscherichiacoli,andothermicro-organismshavebeenseen.Healthadvocacygroupsarecallingforstricterinspectionandreportingproce-duresandbetterfood-handlingprac-NUTRITIONCONSIDERATIONSFORPlantproteincanmeetproteinre-quirementswhenavarietyofplantfoodsisconsumedandenergyneeds July2009JournaloftheAMERICANDIETETICASSOCIATION aremet.Researchindicatesthatanassortmentofplantfoodseatenoverthecourseofadaycanprovideallessentialaminoacidsandensuread-equatenitrogenretentionanduseinhealthyadults;thus,complementaryproteinsdonotneedtobeconsumedatthesamemeal⠀Ameta-analysisofnitrogenbal-ancestudiesfoundnosigniÞcantdif-ferenceinproteinneedsduetothesourceofdietaryprotein⠀).Basedontheproteindigestibility-correctedaminoacidscore,whichisthestan-dardmethodfordeterminingproteinquality,otherstudieshavefoundthatalthoughisolatedsoyproteincanmeetproteinneedsaseffectivelyasanimalprotein,wheatproteineatenalone,forexample,mayresultinareducedefÞciencyofnitrogenutiliza-tion⠀).Thus,estimatesofproteinrequirementsofvegansmayvary,de-pendingtosomedegreeondietarychoices.Foodandnutritionprofes-sionalsshouldbeawarethatproteinneedsmightbesomewhathigherthantheRecommendedDietaryAl-lowanceinthosevegetarianswhosedietaryproteinsourcesaremainlythosethatarelesswelldigested,suchassomecerealsandlegumes⠀Cerealstendtobelowinlysine,anessentialaminoacid⠀).Thismayberelevantwhenevaluatingdietsofin-dividualswhodonotconsumeanimalproteinsourcesandwhendietsarerelativelylowinprotein.Dietaryad-justmentssuchastheuseofmorebeansandsoyproductsinplaceofotherproteinsourcesthatarelowerinlysineoranincreaseindietarypro-teinfromallsourcescanensureanadequateintakeoflysine.Althoughsomeveganwomenhaveproteinintakesthataremarginal,typicalproteinintakesoflacto-ovo-vegetariansandofvegansappeartomeetandexceedrequirements⠀Athletescanalsomeettheirproteinneedsonplant-baseddiets⠀n-3FattyAcidsWhereasvegetariandietsaregener-allyrichinn-6fattyacids,theymaybemarginalinn-3fattyacids.DietsthatdonotincludeÞsh,eggs,orgen-erousamountsofalgaegenerallyarelowineicosapentaenoicacid(EPA)anddocosahexaenoicacid(DHA),fattyacidsimportantforcardiovascu-larhealthaswellaseyeandbraindevelopment.Thebioconversionof-linolenicacid(ALA),aplant-basedn-3fattyacid,toEPAisgenerallylessthan10%inhumans;conversionofALAtoDHAissubstantiallyless⠀Vegetarians,andparticularlyvegans,tendtohavelowerbloodlevelsofEPAandDHAthannonvegetarians⠀DHAsupplementsderivedfrommi-croalgaearewellabsorbedandposi-tivelyinßuencebloodlevelsofDHA,andalsoEPAthroughretroconver-sion⠀).Soymilkandbreakfastbars,fortiÞedwithDHA,arenowavailableinthemarketplace.TheDietaryReferenceIntakesrec-ommendintakesof1.6and1.1gALAperday,formenandwomen,respec-tively⠀).TheserecommendationsmaynotbeoptimalforvegetarianswhoconsumelittleifanyDHAandEPA⠀⤀andthusmayneedaddi-tionalALAforconversiontoDHAandEPA.ConversionratesforALAtendtoimprovewhendietaryn-6levelsarenothighorexcessive⠀).Vege-tariansshouldincludegoodsourcesofALAintheirdiet,suchasßaxseed,walnuts,canolaoil,andsoy.Thosewithincreasedrequirementsofn-3fattyacids,suchaspregnantandlac-tatingwomen,maybeneÞtfromDHA-richmicroalgae⠀Theironinplantfoodsisnonhemeiron,whichissensitivetobothinhibi-torsandenhancersofironabsorption.Inhibitorsofironabsorptionincludephytates,calcium,andthepolypheno-licsintea,coffee,herbteas,andcocoa.Fiberonlyslightlyinhibitsironabsorp-tion⠀).Somefoodpreparationtech-niquessuchassoakingandsproutingbeans,grains,andseeds,andtheleav-eningofbread,candiminishphytatelevels⠀⤀andtherebyenhanceironabsorption⠀).Otherfermentationprocesses,suchasthoseusedtomakemisoandtempeh,mayalsoimproveironbioavailability⠀VitaminCandotherorganicacidsfoundinfruitsandvegetablescansubstantiallyenhanceironabsorp-tionandreducetheinhibitoryeffectsofphytateandtherebyimproveironstatus⠀).Becauseoflowerbio-availabilityofironfromavegetariandiet,therecommendedironintakesforvegetariansare1.8timesthoseofnonvegetarians⠀Whereasmanystudiesofironab-sorptionhavebeenshortterm,thereisevidencethatadaptationtolowin-takestakesplaceoverthelongterm,andinvolvesbothincreasedabsorp-tionanddecreasedlosses⠀).In-cidenceofiron-deÞciencyanemiaamongvegetariansissimilartothatofnonvegetarians⠀).Althoughvegetarianadultshavelowerironstoresthannonvegetarians,theirse-rumferritinlevelsareusuallywithinthenormalrange⠀Thebioavailabilityofzincfromvege-tariandietsislowerthanfromnonveg-etariandiets,mainlyduetothehigherphyticacidcontentofvegetariandiets).Thus,zincrequirementsforsomevegetarianswhosedietsconsistmainlyofphytate-richunreÞnedgrainsandle-gumesmayexceedtheRecommendedDietaryAllowance⠀).Zincintakesofvegetariansvarywithsomeresearchshowingzincintakesnearrecommen-dations⠀⤀andotherresearchÞndingzincintakesofvegetarianssigniÞ-cantlybelowrecommendations⠀OvertzincdeÞciencyisnotevidentinWesternvegetarians.DuetothedifÞ-cultyinevaluatingmarginalzincsta-tus,itisnotpossibletodeterminethepossibleeffectoflowerzincabsorptionfromvegetariandiets⠀).Zincsourcesincludesoyproducts,legumes,grains,cheese,andnuts.Foodpreparationtechniques,suchassoakingandsproutingbeans,grains,andseedsaswellasleaveningbread,canreducebindingofzincbyphyticacidandin-creasezincbioavailability⠀).Organicacids,suchascitricacid,canalsoen-hancezincabsorptiontosomeextentSomestudiessuggestthatveganswhodonotconsumekeysourcesofiodine,suchasiodizedsaltorseaveg-etables,maybeatriskforiodinede-Þciency,becauseplant-baseddietsaretypicallylowiniodine⠀).Seasaltandkoshersaltaregenerallynotiodizednoraresaltyseasoningssuchastamari.Iodineintakefromseaveg-etablesshouldbemonitoredbecausetheiodinecontentofseavegetablesvarieswidelyandsomecontainsub-stantialamountsofiodine⠀Foodssuchassoybeans,cruciferousvegetables,andsweetpotatoescon- July2009Volume109Number7 tainnaturalgoitrogens.ThesefoodshavenotbeenassociatedwiththyroidinsufÞciencyinhealthypeoplepro-vidediodineintakeisadequate⠀Calciumintakesoflacto-ovo-vegetar-iansaresimilarto,orhigherthan,thoseofnonvegetarians⠀),whereasintakesofveganstendtobelowerthanbothgroupsandmayfallbelowrecommendedintakes⠀).IntheOx-fordcomponentoftheEuropeanPro-spectiveInvestigationintoCancerandNutrition(EPIC-Oxford)study,theriskofbonefracturewassimilarforlacto-ovo-vegetariansandmeateaters,whereasveganshada30%higherriskoffracturepossiblyduetotheirconsiderablylowermeancal-ciumintake⠀).Dietsrichinmeat,Þsh,dairyproducts,nuts,andgrainsproduceahighrenalacidload,mainlyduetosulfateandphosphateresidues.Calciumresorptionfrombonehelpstobufferthisacidload,resultinginincreasedurinarylossesofcalcium.Ahighsodiumintakecanalsopromoteurinarycalciumlosses.Ontheotherhand,fruitsandvegeta-blesrichinpotassiumandmagne-siumproduceahighrenalalkalineloadwhichslowsbonecalciumresorp-tion,anddecreasescalciumlossesintheurine.Inaddition,somestudiesshowthattheratioofdietarycalciumtoproteinisabetterpredictorofbonehealththancalciumintakealone.Typically,thisratioishighinlacto-ovo-vegetariandietsandfavorsbonehealth,whereasveganshavearatioofcalciumtoproteinthatissimilartoorlowerthanthatofnonvegetarians).Manyvegansmay�搀itiseas-iertomeettheircalciumneedsifcal-cium-fortiÞedfoodsordietarysupple-mentsareutilized⠀Low-oxalategreens(eg,bokchoy,broccoli,Chinesecabbage,collards,andkale)andfruitjuicesfortiÞedwithcalciumcitratemalatearegoodsourcesofhighlybioavailablecalcium(50%to60%and40%to50%,respec-tively),whilecalcium-settofu,andcowÕsmilkhavegoodbioavailabilityofcalcium(about30%to35%),andsesameseeds,almonds,anddriedbeanshavealowerbioavailability(21%to27%)⠀).ThebioavailabilityofcalciumfromsoymilkfortiÞedwithcalciumcarbonateisequivalenttocowÕsmilkalthoughlimitedresearchhasshownthatcalciumavailabilityissubstantiallylesswhentricalciumphosphateisusedtofortifythesoybeverage⠀).FortiÞedfoodssuchasfruitjuices,soymilk,andricemilk,andbreakfastcerealscancontributesigniÞcantamountsofdietarycal-ciumforthevegan⠀).Oxalatesinsomefoods,suchasspinachandSwisschard,greatlyreducecalciumabsorption,makingthesevegetablesapoorsourceofusablecalcium.Foodsrichinphytatemayalsoinhibitcal-ciumabsorptionVitaminDVitaminDhaslongbeenknowntoplayaroleinbonehealth.VitaminDstatusdependsonsunlightexposureandintakeofvitaminDÐfortiÞedfoodsorsupplements.TheextentofcutaneousvitaminDproductionfol-lowingsunlightexposureishighlyvariableandisdependentonanum-beroffactors,includingthetimeofday,season,latitude,skinpigmenta-tion,sunscreenuse,andage.Lowvi-taminDintakes⠀),lowserum25-hydroxyvitaminDlevels⠀),andreducedbonemass⠀⤀havebeenre-portedinsomeveganandmacrobioticgroupswhodidnotusevitaminDsupplementsorfortiÞedfoods.FoodsthatarefortiÞedwithvita-minDincludecowÕsmilk,somebrandsofsoymilk,ricemilk,andor-angejuice,andsomebreakfastcere-alsandmargarines.BothvitaminD-2andvitaminD-3areusedinsupple-mentsandtofortifyfoods.VitaminD-3(cholecalciferol)isofanimalori-ginandisobtainedthroughtheultra-violetirradiationof7-dehydrocholes-terolfromlanolin.VitaminD-2(ergocalciferol)isproducedfromtheultravioletirradiationofergosterolfromyeastandisacceptabletoveg-ans.Althoughsomeresearchsug-geststhatvitaminD-2islesseffectivethanvitaminD-3inmaintainingse-rum25-hydroxyvitaminDlevels⠀otherstudies�搀thatvitaminD-2andvitaminD-3areequallyeffective).IfsunexposureandintakeoffortiÞedfoodsareinsufÞcienttomeetneeds,vitaminDsupplementsareVitaminB-12ThevitaminB-12statusofsomeveg-etariansislessthanadequateduetonotregularlyconsumingreliablesourcesofvitaminB-12⠀Lacto-ovo-vegetarianscanobtainad-equatevitaminB-12fromdairyfoods,eggs,orotherreliablevitaminB-12sources(fortiÞedfoodsandsupple-ments),ifregularlyconsumed.Forvegans,vitaminB-12mustbeob-tainedfromregularuseofvitaminB-12-fortiÞedfoods,suchasfortiÞedsoyandricebeverages,somebreak-fastcerealsandmeatanalogs,orRedStarVegetarianSupportFormulanu-tritionalyeast;otherwiseadailyvita-minB-12supplementisneeded.NounfortiÞedplantfoodcontainsanysigniÞcantamountofactivevitaminB-12.Fermentedsoyproductscannotbeconsideredareliablesourceofac-tiveB-12⠀Vegetariandietsaretypicallyrichinfolacin,whichmaymaskthehema-tologicalsymptomsofvitaminB-12deÞciency,sothatvitaminB-12deÞ-ciencymaygoundetecteduntilafterneurologicalsignsandsymptomsmaybemanifest⠀).VitaminB-12statusisbestdeterminedbymeasur-ingserumlevelsofhomocysteine,methylmalonicacid,orholotransco-balaminII⠀VEGETARIANDIETSTHROUGHOUTTHELIFECYCLEWell-plannedvegan,lacto-vegetarian,andlacto-ovo-vegetariandietsareap-propriateforallstagesofthelifecycle,includingpregnancyandlactation.Ap-propriatelyplannedvegan,lacto-vege-tarian,andlacto-ovo-vegetariandietssatisfynutrientneedsofinfants,chil-dren,andadolescentsandpromotenor-malgrowth⠀Figure1speciÞcsuggestionsformealplanningforvegetariandiets.Lifelongvegetari-anshaveadultheight,weight,andBMIsthataresimilartothosewhobe-camevegetarianlaterinlife,suggest-ingthatwell-plannedvegetariandietsininfancyandchildhooddonotaffectÞnaladultheightorweight⠀).Vege-tariandietsinchildhoodandadoles-cencecanaidintheestablishmentoflifelonghealthfuleatingpatternsandcanoffersomeimportantnutritionaladvantages.Vegetarianchildrenandadolescentshavelowerintakesofcho-lesterol,saturatedfat,andtotalfatandhigherintakesoffruits,vegetables,andÞberthannonvegetarians⠀).Veg-etarianchildrenhavealsobeenre- July2009JournaloftheAMERICANDIETETICASSOCIATION portedtobeleanerandtohavelowerserumcholesterollevels⠀PregnantandLactatingWomenThenutrientandenergyneedsofpregnantandlactatingvegetarianwomendonotdifferfromthoseofnonvegetarianwomenwiththeexcep-tionofhigherironrecommendationsforvegetarians.Vegetariandietscanbeplannedtomeetthenutrientneedsofpregnantandlactatingwomen.Ev-idence-basedanalysisoftheresearchliteraturewasusedtoevaluateexist-ingresearchonvegetarianpregnancy).Sevenquestionsforevidence-analysiswereidentiÞed:Howdomacronutrientandenergyintakeinpregnantvegetariansdif-ferfromintakesinpregnantomni-Arebirthoutcomesdifferentformotherswhomaintainavegetarianvsanomnivorousdietduringpreg-Howdomacronutrientandenergyintakeinpregnantvegansdifferfromintakesinpregnantomnivores?Arebirthoutcomesdifferentformotherswhomaintainaveganvsanomnivorousdietduringpreg-Whatarepatternsofmicronutrientintakeamongpregnantvegetarians?Whatisthebioavailabilityofdiffer-entmicronutrientsinpregnantveg-Whatarebirthoutcomesassociatedwiththemicronutrientintakeofmaternalvegetariandiets?Thecompleteresultsofthisevidence-basedanalysiscanbefoundontheEALWebsite⠀andaresummarizedbelow.MacronutrientandEnergyIntake.primaryresearchstudieswereidenti-�搀thatexaminedmaternalmacro-nutrientintakeduringlacto-ovo-orlacto-vegetarianpregnancy⠀Nonefocusedonpregnantvegans.EALConclusionStatement:Limitedre-searchonnon-USpopulationsindi-catesthatthemacronutrientintakeofpregnantvegetariansissimilartothatofnonvegetarianswiththefol-lowingexceptions(aspercentagesofenergyintake):pregnantvegetariansreceivestatis-ticallylowerlevelsofproteinthanpregnantnonvegetarians;andpregnantvegetariansreceivestatis-ticallyhigherlevelsofcarbohydratesthanpregnantnonvegetarians.Itisimportanttonote,however,thatnoneofthestudiesreportaclin-icallysigniÞcantdifferenceinmacro-nutrientintake.Inotherwords,noneofthestudiesreportaproteindeÞ-ciencyinpregnantvegetarians.GradeIIIEALConclusionStatement:NoresearchwasidentiÞedthatfocusedonmacro-nutrientintakesamongpregnantveg-GradeVNotAssignable.BirthOutcomes.FourcohortstudieswereidentiÞedthatexaminedtherela-tionshipbetweenmaternalmacronu-trientintakeduringpregnancyandbirthoutcomessuchasbirthweightandlength⠀).Noneofthestudiesfocusedonpregnantvegans.EALConclusionStatement:Limitedre-searchonnon-USpopulationsindi-catesthattherearenosigniÞcanthealthdifferencesinbabiesborntononveganvegetarianmothersvsnon-GradeIIIEALConclusionStatement:NoresearchwasidentiÞedthatfocusedonthebirthoutcomesofveganvsomnivorousGradeVNotAssignable.MicronutrientIntake.Basedon10stud-ies⠀),twoofwhichwereconductedintheUnitedStates⠀onlythefollowingmicronutrientshadlowerintakeamongvegetariansthanvitaminB-12;vitaminC;calcium;andVegetariansdidnotmeetdietarystandard(inatleastonecountry)for:vitaminB-12(intheUnitedKing-iron(intheUnitedStates,forbothvegetariansandomnivores);folate(inGermany,thoughlowerrateofdeÞciencythanamongomni-vores);andzinc(intheUnitedKingdom).EALConclusionStatement:GradeIIIMicronutrientBioavailability.Sixstudies⣞癥non-US,onewithcombinedUSandnon-USsamples;allbutoneofpos-itivequality)wereidentiÞedthatex-aminedthebioavailabilityofdifferentmicronutrientsinvegetarianvsnon-vegetarianpregnantwomen⠀).Ofthemicronutrientsexam-inedintheresearch,onlyserumB-12levelsweresigniÞcantlylowerinnon-vegan-vegetariansthannonvegetar-ians.Inaddition,onestudyreportedthatlowerB-12levelsaremorelikelytobeassociatedwithhighserumtotalhomocysteineinlacto-ovo-vegetariansthanlowmeateatersoromnivores.WhereaszinclevelswerenotsigniÞ-cantlydifferentbetweennonvegan-vegetariansandnonvegetarians,vege-tarianswhohaveahighintakeofcalciummaybeatriskforzincdeÞ-ciency(becauseoftheinteractionbe-tweenphytate,calcium,andzinc).Basedonlimitedevidence,plasmafo-latelevelsmayactuallybehigheramongsomevegetariangroupsthanEALConclusionStatement:GradeIIIMicronutrientsandBirthOutcomeEALCon-clusionStatement:Limitedevidencefromsevenstudies(alloutsidethe Avarietyofmenuplanningapproachescanprovideadequatenutritionforvegetarians.TheDietaryReferenceIntakesareavaluableresourceforfoodandnutritionprofessionals.Variousfoodguides(41,52)canbeusedwhenworkingwithvegetarianclients.Inaddition,thefollowingguidelinescanhelpvegetariansplanhealthfuldiets:Chooseavarietyoffoods,includingwholegrains,vegetables,fruits,legumes,nuts,seeds,and,ifdesired,dairyproducts,andeggs.Minimizeintakeoffoodsthatarehighlysweetened,highinsodium,andhighinfat,especiallysaturatedfatand-fattyacids.Chooseavarietyoffruitsandvegetables.Ifanimalfoodssuchasdairyproductsandeggsareused,chooselower-fatdairyproductsandusebotheggsanddairyproductsinmoderation.UsearegularsourceofvitaminB-12and,ifsunlightexposureislimited,ofvitaminD. Figure1.Suggestionsforplanningvegetarianmeals. July2009Volume109Number7 UnitedStates)indicatedthatthemi-cronutrientcontentofabalancedma-ternalvegetariandietdoesnothavedetrimentaloutcomesforthehealthofthechildatbirth⠀).Theremaybe,however,ariskforafalsepositivediagnosisofDownsyndromeinthefetuswhenmaternalserumfreebeta-humanchorionicgonadotro-pinandalphafetoproteinlevelsareusedasmarkersinvegetarianmoth-GradeIIINutritionConsiderations.Resultsofevi-dence-basedanalysissuggestthatvegetariandietscanbenutritionallyadequateinpregnancyandcanleadtoapositivebirthoutcome⠀KeynutrientsinpregnancyincludevitaminB-12,vitaminD,iron,andfolatewhereaskeynutrientsinlacta-tionincludevitaminB-12,vitaminD,calcium,andzinc.Dietsofpregnantandlactatingvegetariansshouldcon-tainreliablesourcesofvitaminB-12daily.Basedonrecommendationsforpregnancyandlactation,ifthereisconcernaboutvitaminDsynthesisbecauseoflimitedsunlightexposure,skintone,season,orsunscreenuse,pregnantandlactatingwomenshouldusevitaminDsupplementsorvita-minDÐfortiÞedfoods.Nostudiesincludedintheevidence-analysisex-aminedvitaminDstatusduringveg-etarianpregnancy.Ironsupplementsmaybeneededtopreventortreatiron-deÞciencyanemia,whichiscom-moninpregnancy.Womencapableofbecomingpregnantaswellaswomeninthepericonceptionalperiodaread-visedtoconsume400gfolatedailyfromsupplements,fortiÞedfoods,orboth.ZincandcalciumneedscanbemetthroughfoodorsupplementsourcesasidentiÞedinearliersec-tionsonthesenutrients.DHAalsoplaysaroleinpregnancyandlactation.InfantsofvegetarianmothersappeartohavelowercordandplasmaDHAthandoinfantsofnonvegetarians⠀).BreastmilkDHAislowerinvegansandlacto-ovo-vegetariansthaninnonvegetarians).BecauseofDHAÕsbeneÞcialef-fectsongestationallength,infantvi-sualfunction,andneurodevelopment,pregnantandlactatingvegetariansandvegansshouldchoosefoodsourcesofDHA(fortiÞedfoodsoreggsfromhensfedDHA-richmicroalgae)oruseamicroalgae-derivedDHAsup-plement⠀).SupplementationwithALA,aDHAprecursor,inpreg-nancyandlactationhasnotbeenshowntobeeffectiveinincreasingin-fantDHAlevelsorbreastmilkDHAconcentration⠀Growthofyoungvegetarianinfantsreceivingadequateamountsofbreastmilkorcommercialinfantformulaisnormal.Whensolidfoodsareintro-duced,provisionofgoodsourcesofen-ergyandnutrientscanensurenormalgrowth.Thesafetyofextremelyre-strictivedietssuchasfruitarianandrawfoodsdietshasnotbeenstudiedinchildren.Thesedietscanbeverylowinenergy,protein,somevita-mins,andsomemineralsandcannotberecommendedforinfantsandchil-Breastfeedingiscommoninvege-tarianwomen,andthispracticeshouldbesupported.Thebreastmilkofvegetarianwomenissimilarincompositiontothatofnonvegetariansandisnutritionallyadequate.Com-mercialinfantformulasshouldbeusedifinfantsarenotbreastfedorareweanedbefore1yearofage.Soyformulaistheonlyoptionfornon-breastfedveganinfants.Otherprep-arationsincludingsoymik,ricemilk,andhomemadeformulasshouldnotbeusedtoreplacebreastmilkorcom-mercialinfantformula.Solidfoodsshouldbeintroducedinthesameprogressionasfornonveg-etarianinfants,replacingstrainedmeatwithmashedorpureedtofu,le-gumes(pureedandstrainedifneces-sary),soyordairyyogurt,cookedeggyolk,andcottagecheese.Later,around7to10months,foodssuchascubedtofu,cheese,orsoycheeseandbite-sizepiecesofveggieburgerscanbestarted.Commercial,full-fat,forti-�搀soymilkorpasteurizedcowÕsmilkcanbeusedasaprimarybever-agestartingatage1yearorolderforachildwhoisgrowingnormallyandeatingavarietyoffoods⠀).Foodsthatarerichinenergyandnutrientssuchaslegumespreads,tofu,andmashedavocadoshouldbeusedwhentheinfantisbeingweaned.Dietaryfatshouldnotberestrictedinchil-drenyoungerthan2years.Guidelinesfordietarysupplementsgenerallyfollowthosefornonvegetar-ianinfants.Breastfedinfantswhosemothersdonothaveanadequatein-takeofvitaminB-12shouldreceiveavitaminB-12supplement⠀).Zincintakeshouldbeassessedandzincsupplementsorzinc-fortiÞedfoodsusedwhencomplementaryfoodsareintroducedifthedietislowinzincormainlyconsistsoffoodswithlowzincbioavailability⠀Growthoflacto-ovo-vegetarianchil-drenissimilartothatoftheirnonveg-etarianpeers⠀).Littleinformationaboutthegrowthofnonmacrobioticveganchildrenhasbeenpublished.Somestudiessuggestthatveganchil-drentendtobeslightlysmallerbutwithinthenormalrangesofthestan-dardsforweightandheight⠀).Poorgrowthinchildrenhasprimarilybeenseeninthoseonveryrestricteddiets⠀FrequentmealsandsnacksandtheuseofsomereÞnedfoods(suchasfor-tiÞedbreakfastcereals,breads,andpasta)andfoodshigherinunsatur-atedfatscanhelpvegetarianchildrenmeetenergyandnutrientneeds.Av-erageproteinintakesofvegetarianchildren(lacto-ovo,vegan,andmacro-biotic)generallymeetorexceedrec-ommendations⠀).Veganchildrenmayhaveslightlyhigherproteinneedsbecauseofdifferencesinpro-teindigestibilityandaminoacidcom-position⠀⤀buttheseproteinneedsaregenerallymetwhendietscontainadequateenergyandavari-etyofplantfoods.Foodguidesforvegetarianchildrenhavebeenpublishedelsewhere⠀Growthoflacto-ovo-vegetarianandnonvegetarianadolescentsissimilar).Earlierstudiessuggestthatveg-etariangirlsreachmenarcheslightlylaterthannonvegetarians⠀);morerecentstudies�搀nodifferenceinageatmenarche⠀Vegetariandietsappeartooffersomenutritionaladvantagesforado-lescents.VegetarianadolescentsarereportedtoconsumemoreÞber,iron,folate,vitaminA,andvitaminCthannonvegetarians⠀).Vegetarianadolescentsalsoconsumemorefruitsandvegetables,andfewersweets,fastfoods,andsaltysnackscomparedtononvegetarianadolescents⠀Keynutrientsofconcernforadoles- July2009JournaloftheAMERICANDIETETICASSOCIATION centvegetariansincludecalcium,vi-taminD,iron,zinc,andvitaminB-12.Beingvegetariandoesnotcausedisorderedeatingassomehavesug-gestedalthoughavegetariandietmaybeselectedtocamoußageanex-istingeatingdisorder⠀).Becauseofthis,vegetariandietsaresomewhatmorecommonamongadolescentswitheatingdisordersthaninthegen-eraladolescentpopulation⠀).Foodandnutritionprofessionalsshouldbeawareofyoungclientswhogreatlylimitfoodchoicesandwhoexhibitsymptomsofeatingdisorders.Withguidanceinmealplanning,vegetariandietscanbeappropriateandhealthfulchoicesforadolescents.OlderAdultsWithaging,energyneedsdecreasebutrecommendationsforseveralnu-trients,includingcalcium,vitaminD,andvitaminB-6arehigher.Intakesofmicronutrients,especiallycalcium,zinc,iron,andvitaminB-12,declineinolderadults⠀).Studiesindicatethatoldervegetarianshavedietaryintakesthataresimilartononveg-etarians⠀OlderadultsmayhavedifÞcultywithvitaminB-12absorptionfromfood,frequentlyduetoatrophicgas-tritis,sovitaminB-12-fortiÞedfoodsorsupplementsshouldbeusedbe-causethevitaminB-12infortiÞedfoodsandsupplementsisusuallywell-absorbed⠀).Cutaneousvita-minDproductiondecreaseswithag-ingsothatdietaryorsupplementalsourcesofvitaminDareespeciallyimportant⠀).Althoughcurrentrec-ommendationsforproteinforhealthyolderadultsarethesameasthoseforyoungeradultsonabodyweightbasis),thisisacontroversialarea⠀Certainlyolderadultswhohavelowenergyrequirementswillneedtocon-sumeconcentratedsourcesofprotein.Olderadultscanmeetproteinneedsonavegetariandietifavarietyofprotein-richplantfoods,includingle-gumesandsoyproducts,areeatenVegetariandietscanalsomeettheneedsofcompetitiveathletes.Nutri-tionrecommendationsforvegetarianathletesshouldbeformulatedwithcon-siderationoftheeffectsofbothvegetar-iandietsandexercise.ThepositionofAmericanDieteticAssociationandDi-etitiansofCanadaonnutritionandathleticperformanceprovidesaddi-tionalinformationspeciÞctovegetar-ianathletes⠀).Researchisneededontherelationbetweenvegetariandietandperformance.Vegetariandietsthatmeetenergyneedsandcontainavari-etyofplant-basedproteinfoods,suchassoyproducts,otherlegumes,grains,nuts,andseeds,canprovideadequateproteinwithouttheuseofspecialfoodsorsupplements⠀).Vegetarianath-letesmayhavelowermusclecreatineconcentrationduetolowdietarycreat-inelevels⠀).Vegetarianathletesparticipatinginshort-term,high-inten-sityexerciseandresistancetrainingmaybeneÞtfromcreatinesupplemen-tation⠀).Some,butnotallresearchsuggeststhatamenorrheamaybemorecommonamongvegetarianthannon-vegetarianathletes⠀).FemalevegetarianathletesmaybeneÞtfromdietsthatincludeadequateenergy,higherlevelsoffat,andgenerousamountsofcalciumandiron.VEGETARIANDIETSANDCHRONICCardiovascularDisease(CVD)Evidence-basedanalysisofthere-searchliteratureisbeingusedtoevaluateexistingresearchonthere-lationshipbetweenvegetariandi-etarypatternsandCVDriskfactors).Twoevidenceanalysisquestionshavebeencompleted:WhatistherelationshipbetweenavegetariandietandischemicheartHowismicronutrientintakeinavegetariandietassociatedwithCVDriskfactors?IschemicHeartDisease.Twolargeco-hortstudies⠀⤀andonemeta-analysis⠀⤀foundthatvegetarianswereatlowerriskofdeathfromisch-emicheartdiseasethannonvegetar-ians.Thelowerriskofdeathwasseeninbothlacto-ovo-vegetariansandveg-ans⠀).Thedifferenceinriskper-sistedafteradjustmentforBMI,smokinghabits,andsocialclass⠀ThisisespeciallysigniÞcantbecausethelowerBMIcommonlyseeninveg-etarians⠀⤀isonefactorthatmayhelptoexplainthelowerriskofheartdiseaseinvegetarians.Ifthisdiffer-enceinriskpersistsevenafteradjust-mentforBMI,otheraspectsofaveg-etariandietmayberesponsiblefortheriskreduction,aboveandbeyondthatwhichwouldbeexpectedduetolowerBMI.EALConclusionStatement:Avegetar-iandietisassociatedwithalowerriskofdeathfromischemicheartdisease.GradeIBloodLipidLevels.Thelowerriskofdeathfromischemicheartdiseaseseeninvegetarianscouldbeex-plainedinpartbydifferencesinbloodlipidlevels.Basedonbloodlipidlev-elsinonelargecohortstudy,thein-cidenceofischemicheartdiseasewasestimatedtobe24%lowerinlifelongvegetariansand57%lowerinlifelongveganscomparedtomeateaters⠀Typically,studies�搀lowertotalcho-lesterolandlow-densitylipoprotein(LDL)cholesterollevelsinvegetari-ans⠀,forexample).Interventionstudieshavedemonstratedareduc-tionintotalandLDL-cholesterollev-elswhensubjectsswitchedfromtheirusualdiettoavegetariandiet⠀forexample).Althoughevidenceislimitedthatavegetariandietisasso-ciatedwithhigherhigh-densityli-poproteincholesterollevelsorwithhigherorlowertriglyceridelevels,avegetariandietisconsistentlyassoci-atedwithlowerLDLcholesterollev-els.OtherfactorssuchasvariationsinBMIandfoodseatenoravoidedwithinthecontextofavegetariandietorlifestyledifferencescouldpartiallyexplaintheinconsistentresultswithregardtobloodlipidlevels.FactorsinavegetariandietthatcouldhaveabeneÞcialeffectonbloodlipidlevelsincludethehigheramountsofÞber,nuts,soy,andplantsterolsandlowerlevelsofsaturatedfat.Vegetari-ansconsumebetween50%and100%moreÞberthannonvegetariansandveganshavehigherintakesthanlacto-ovo-vegetarians⠀).SolubleÞberhasbeenrepeatedlyshowntolowertotalandLDLcholesterollevelsandtore-duceriskofcoronaryheartdisease⠀AdiethighinnutssigniÞcantlylowerstotalandLDLcholesterollevels⠀Soyisoßavonesmayplayaroleinre-ducingLDLcholesterollevelsandinreducingthesusceptibilityofLDLtooxidation⠀).Plantsterols,foundinlegumes,nutsandseeds,wholegrains,vegetableoils,andotherplant-based July2009Volume109Number7 foodsreducecholesterolabsorptionandlowerLDLcholesterollevels⠀FactorsAssociatedwithVegetarianDietsthatMayAffectRiskofCVD.Otherfac-torsinvegetariandietsmayimpactCVDriskindependentofeffectsoncholesterollevels.FoodsthatfeatureprominentlyinavegetariandietthatmayofferprotectionfromCVDin-cludesoyprotein⠀),fruitsandvegetables,wholegrains,andnuts).Vegetariansappeartocon-sumemorephytochemicalsthandononvegetariansbecauseagreaterpercentageoftheirenergyintakecomesfromplantfoods.Flavonoidsandotherphytochemicalsappeartohaveprotectiveeffectsasantioxi-dants,inreducingplateletaggrega-tionandbloodclotting,asanti-in-ßammatoryagents,andinimprovingendothelialfunction⠀).Lacto-ovo-vegetarianshavebeenshowntohavesigniÞcantlybettervasodilationresponses,suggestingabeneÞcialef-fectofvegetariandietonvascularen-dothelialfunction⠀EvidenceanalysiswasconductedtoexaminehowthemicronutrientmakeupofvegetariandietsmightberelatedtoCVDriskfactors.EALConclusionStatement:Nore-searchmeetinginclusioncriteriawereidentiÞedthatexaminedthemi-cronutrientintakeofavegetariandietandCVDriskfactors.NotAssignable.Notallaspectsofvegetariandietsareassociatedwithreducedriskforheartdisease.Thehigherserumho-mocysteinelevelsthathavebeenre-portedinsomevegetarians,appar-entlyduetoinadequatevitaminB-12intake,mayincreaseriskofCVD⤀althoughnotallstudiessupportthis⠀Vegetariandietshavebeensuc-cessfullyusedintreatmentofCVD.Aregimenthatusedaverylow-fat10%ofenergy)nearvegan(limitednonfatdairyandeggwhitesallowed)dietalongwithexercise,smokingces-sation,andstressmanagement,wasshowntoreducebloodlipidlevels,bloodpressure,andweight,andim-proveexercisecapacity⠀).Anear-vegandiethighinphytosterols,vis-cousÞber,nuts,andsoyproteinhasbeenshowntobeaseffectiveasalow-saturatedfatdietandastatinforloweringserumLDL-cholesterollev-els⠀Across-sectionalstudyandacohortstudyfoundthattherewasalowerrateofhypertensionamongvegetari-ansthannonvegetarians⠀SimilarÞndingswerereportedinSeventh-dayAdventists(Adventists)inBarbados⠀⤀andinpreliminaryresultsfromtheAdventistHealthStudy-2cohort⠀).Vegansappeartohavealowerrateofhypertensionthandoothervegetarians⠀Severalstudieshavereportedlowerbloodpressureinvegetarianscomparedtononvegetarians⠀althoughotherstudiesreportedlittledifferenceinbloodpressurebetweenvegetariansandnonvegetarians).Atleastoneofthestudiesreportinglowerbloodpres-sureinvegetariansfoundthatBMIratherthandietaccountedformuchoftheage-adjustedvariationinbloodpressure⠀).VegetarianstendtohavealowerBMIthannonvegetar-ians⠀);thus,vegetariandietsÕin-ßuenceonBMImaypartiallyaccountforreporteddifferencesinbloodpres-surebetweenvegetariansandnon-vegetarians.Variationsindietaryin-takeandlifestylewithingroupsofvegetariansmaylimitthestrengthofconclusionswithregardtotherela-tionshipbetweenvegetariandietsandbloodpressure.Possiblefactorsinvegetariandietsthatcouldresultinlowerbloodpres-sureincludethecollectiveeffectofvariousbeneÞcialcompoundsfoundinplantfoodssuchaspotassium,magnesium,antioxidants,dietaryfat,andÞber⠀).ResultsfromtheDietaryApproachestoStopHyper-tensionstudy,inwhichsubjectscon-sumedalow-fatdietrichinfruits,vegetablesanddairy,suggestthatsubstantialdietarylevelsofpotas-sium,magnesium,andcalciumplayanimportantroleinreducingbloodpressurelevels⠀).Fruitandvege-tableintakewasresponsibleforaboutone-halfofthebloodpressurereduc-tionoftheDietaryApproachestoStopHypertensiondiet⠀).Inad-dition,ninestudiesreportthatcon-sumptionof�攀to10servingsoffruitandvegetablessigniÞcantlylowersbloodpressure⠀AdventistvegetariansarereportedtohavelowerratesofdiabetesthanAd-ventistnonvegetarians⠀).IntheAdventistHealthStudy,age-adjustedriskfordevelopingdiabeteswastwo-foldgreaterinnonvegetarians,com-paredwiththeirvegetariancounter-parts⠀).Althoughobesityincreasestheriskoftype2diabetes,meatandprocessedmeatintakewasfoundtobeanimportantriskfactorfordiabe-tesevenafteradjustmentforBMI).IntheWomenÕsHealthStudy,theauthorsalsoobservedpositiveas-sociationsbetweenintakesofredmeatandprocessedmeatandriskofdiabetesafteradjustingforBMI,totalenergyintake,andexercise⠀).AsigniÞcantlyincreasedriskofdiabe-teswasmostpronouncedforfrequentconsumptionofprocessedmeatssuchasbaconandhotdogs.Resultsre-mainedsigniÞcantevenafterfurtheradjustmentfordietaryÞber,magne-sium,fat,andglycemicload⠀).Inalargecohortstudy,therelativeriskfortype2diabetesinwomenforeveryone-servingincreaseinintakewas1.26forredmeatand1.38to1.73forprocessedmeats⠀Inaddition,higherintakesofvege-tables,whole-grainfoods,legumes,andnutshaveallbeenassociatedwithasubstantiallylowerriskofin-sulinresistanceandtype2diabetes,andimprovedglycemiccontrolinei-thernormalorinsulin-resistantindi-viduals⠀).Observationalstudieshavefoundthatdietsrichinwhole-grainfoodsareassociatedwithimprovedinsulinsensitivity.Thisef-fectmaybepartlymediatedbysignif-icantlevelsofmagnesiumandcerealÞberinthewhole-grainfoods⠀Personswithelevatedbloodglucosemayexperienceanimprovementininsulinresistanceandlowerfastingbloodglucoselevelsaftertheyhaveconsumedwholegrains⠀).Peopleconsumingaboutthreeservingsperdayofwhole-grainfoodsare20%to30%lesslikelytodeveloptype2dia-betesthanlowconsumers⠀3serv-ingsperweek)⠀IntheNursesÕHealthStudy,nutconsumptionwasinverselyassoci-atedwithriskoftype2diabetesafteradjustmentforBMI,physicalactiv-ity,andmanyotherfactors.Theriskofdiabetesforthoseconsumingnuts�攀ormoretimesaweekwas27%lowerthanthosealmostnevereatingnuts,whereastheriskofdiabetesforthoseconsumingpeanutbutteratleast�攀timesaweek(equivalentto July2009JournaloftheAMERICANDIETETICASSOCIATION 5ozpeanuts/week)was21%lowerthanthosewhoalmostneveratepea-nutbutter⠀Becauselegumescontainslowlydi-gestedcarbohydrateandhaveahighÞbercontent,theyareexpectedtoim-proveglycemiccontrolandreducein-cidentdiabetes.Inalargeprospectivestudy,aninverseassociationwasseenbetweentheintakeoftotalle-gumes,peanuts,soybeans,andotherlegumesbyChinesewomen,andtheincidenceoftype2diabetesmellitus,afteradjustmentforBMIandotherfactors.Theriskoftype2diabeteswas38%and47%lower,forthoseconsumingahighintakeoftotalle-gumesandsoybeans,respectively,comparedtoalowintake⠀Inaprospectivestudy,theriskoftype2diabeteswas28%lowerforwomenintheupperquintileofvege-table,butnotfruitintake,comparedtothelowerquintileofvegetablein-take.IndividualvegetablegroupswereallinverselyandsigniÞcantlyassociatedwiththeriskoftype2di-abetes⠀).Inanotherstudy,con-sumptionofgreenleafyvegetablesandfruit,butnotfruitjuice,wasas-sociatedwithalowerriskofdiabetesFiber-richvegandietsarecharac-terizedbyalowglycemicindexandalowtomoderateglycemicload⠀Ina5-monthrandomizedclinicaltrial,alow-fatvegandietwasshowntoconsiderablyimproveglycemiccon-trolinpersonswithtype2diabetes,with43%ofsubjectsreducingdiabe-tesmedication⠀).Resultsweresuperiortothoseobtainedfromfol-lowingadietbasedonAmericanDia-betesAssociationguidelines(individ-ualizedbasedonbodyweightandlipidconcentrations;15%-20%pro-7%saturatedfat;60%to70%carbohydrateandmonounsaturated200mgcholesterol).AmongAdventists,about30%ofwhomfollowameatlessdiet,vegetar-ianeatingpatternshavebeenassoci-atedwithlowerBMI,andBMIin-creasedasthefrequencyofmeatconsumptionincreasedinbothmenandwomen⠀).IntheOxfordVege-tarianStudy,BMIvalueswerehigherinnonvegetarianscomparedwithvegetariansinallagegroupsforbothmenandwomen⠀).Inacross-sec-tionalstudyof37,875adults,meat-eatershadthehighestage-adjustedmeanBMIandvegansthelowest,withothervegetarianshavinginter-mediatevalues⠀).IntheEPIC-OxfordStudy,weightgainovera5-yearperiod,amongahealth-con-sciouscohort,waslowestamongthosewhomovedtoadietcontainingfeweranimalfoods⠀).Inalargecross-sectionalBritishstudy,itwasobservedthatthosepeoplewhobe-camevegetarianasadultsdidnotdif-ferinBMIorbodyweightcomparedtothosewhowerelife-longvegetari-ans⠀).However,thosewhohavebeenfollowingavegetariandietforatleast5yearstypicallyhavealowerBMI.AmongAdventistsinBarbados,thenumberofobesevegetarians,whohadfollowedthedietformorethan5years,was70%lessthanthenumberofobeseomnivoreswhereasrecentvegetarians(followingthedietyears)hadbodyweightssimilartoomnivores⠀).Alow-fatvegetariandiethasbeenshowntobemoreeffec-tiveinlong-termweightlossforpost-menopausalwomenthanamoreconventionalNationalCholesterolEducationProgramdiet⠀).Vege-tariansmayhavealowerBMIduetotheirhigherconsumptionofÞber-rich,low-energyfoods,suchasfruitandvegetables.Vegetarianstendtohaveanoverallcancerratelowerthanthatofthegeneralpopulation,andthisisnotconÞnedtosmoking-relatedcancers.DatafromtheAdventistHealthStudyrevealedthatnonvegetarianshadasubstantiallyincreasedriskforbothcolorectalandprostatecancercomparedwithvegetarians,buttherewerenosigniÞcantdifferencesinriskoflung,breast,uterine,orstomachcancerbetweenthegroupsaftercon-trollingforage,sex,andsmoking).ObesityisasigniÞcantfactorin-creasingtheriskofcanceratanum-berofsites⠀).BecausetheBMIofvegetarianstendstobelowerthanthatofnonvegetarians,thelighterbodyweightofthevegetariansmaybeanimportantfactor.Avegetariandietprovidesavarietyofcancer-protectivedietaryfactors).Epidemiologicstudieshaveconsistentlyshownthataregularconsumptionoffruitandvegetablesisstronglyassociatedwithareducedriskofsomecancers⠀).Incontrast,amongsurvivorsofearlystagebreastcancerintheWomenÕsHealthyEatingandLivingtrial,theadoptionofadietenhancedbyaddi-tionaldailyfruitandvegetableserv-ingsdidnotreduceadditionalbreastcancereventsormortalityovera7-yearperiod⠀Fruitandvegetablescontainacom-plexmixtureofphytochemicals,pos-sessingpotentantioxidant,antiprolif-erative,andcancer-protectiveactivity.Thephytochemicalscandisplayaddi-tiveandsynergisticeffects,andarebestconsumedinwholefoods).Thesephytochemicalsinter-ferewithseveralcellularprocessesin-volvedintheprogressionofcancer.Thesemechanismsincludetheinhibi-tionofcellproliferation,inhibitionofDNAadductformation,inhibitionofphase1enzymes,inhibitionofsignaltransductionpathwaysandoncogeneexpression,inductionofcellcyclearrestandapoptosis,inductionofphase2en-zymes,blockingtheactivationofnu-clearfactor-kappaB,andinhibitingan-giogenesis⠀AccordingtotherecentWorldCan-cerResearchFundreport⠀),fruitandvegetablesareprotectiveagainstcancerofthelung,mouth,esophagus,andstomach,andtoalesserdegreesomeothersites.Theregularuseoflegumesalsoprovidesameasureofprotectionagainststomachandpros-tatecancer⠀).Fiber,vitaminC,carotenoids,ßavonoids,andotherphy-tochemicalsinthedietarereportedtoexhibitprotectionagainstvariouscan-cers.Alliumvegetablesmayprotectagainststomachcancerandgarlicpro-tectsagainstcolorectalcancer.Fruitsrichintheredpigmentlycopenearereportedtoprotectagainstprostatecancer⠀).Recently,cohortstudieshavesuggestedthatahighintakeofwholegrainsprovidedsubstantialpro-tectionagainstvariouscancers⠀Regularphysicalactivityprovidessig-niÞcantprotectionagainstmostofthemajorcancers⠀Althoughthereissuchavarietyofpotentphytochemicalsinfruitandvegetables,humanpopulationstudieshavenotshownlargedifferencesincancerincidenceormortalityratesbetweenvegetariansandnonvegetar-ians⠀).Perhapsmoredetailedfoodconsumptiondataareneededbe-causethebioavailabilityandpotency July2009Volume109Number7 ofphytochemicalsdependsonfoodpreparation,suchaswhethertheveg-etablesarecookedorraw.Inthecaseofprostatecancer,ahighdairyintakemaylessenthechemoprotectiveeffectofavegetariandiet.Useofdairyandothercalcium-richfoodshavebeenassociatedwithanincreasedriskofprostatecancer⠀),al-thoughnotallstudiessupportthisÞnding⠀Redmeatandprocessedmeatcon-sumptionisconsistentlyassociatedwithanincreaseintheriskofcolorec-talcancer⠀).Ontheotherhand,theintakeoflegumeswasnegativelyassociatedwithriskofcoloncancerinnonvegetarians⠀).Inapooledanal-ysisof14cohortstudies,theadjustedriskofcoloncancerwassubstantiallyreducedbyahighintakeoffruitandvegetablevsalowintake.Fruitandvegetableintakeswereassociatedwithalowerriskofdistalcoloncan-cer,butnotwithproximalcoloncan-cer⠀).Vegetarianshaveasub-stantiallygreaterintakeofÞberthannonvegetarians.AhighÞberintakeisthoughttoprotectagainstcoloncan-cer,althoughnotallresearchsup-portsthis.TheEPICstudyinvolving10Europeancountriesreporteda25%reductioninriskofcolorectalcancerinthehighestquartileofdi-etaryÞberintakecomparedtothelowest.BasedupontheseÞndings,Binghamandcolleagues⠀⤀con-cludedthatinpopulationswithalowÞberintake,doublingtheÞberintakecouldreducethecolorectalcancerby40%.Ontheotherhand,apooledanalysisof13prospectivecohortstudiesreportedahighdietaryÞberintakewasnotassociatedwithade-creasedriskofcolorectalcancerafteraccountingformultipleriskfactorsSoyisoßavonesandsoyfoodshavebeenshowntopossessanti-cancerproperties.Meta-analysisofeightstudies(onecohort,andsevencasecontrol)conductedinhigh-soy-con-sumingAsiansshowedasigniÞcanttrendofdecreasingriskofbreastcan-cerwithincreasingsoyfoodintake.Incontrast,soyintakewasunrelatedtobreastcancerriskinstudiescon-ductedin11low-soy-consumingWesternpopulations⠀).However,controversyremainsregardingthevalueofsoyasacancer-protectiveagent,becausenotallresearchsup-portstheprotectivevalueofsoyto-wardsbreastcancer⠀).Ontheotherhand,meatconsumptionhasbeenlinkedinsome,butnotall,stud-ieswithanincreasedriskofbreastcancer⠀).Inonestudy,breastcan-cerriskincreasedby50%to60%foreachadditional100g/dayofmeatcon-sumed⠀Dairyproducts,greenleafyvegeta-bles,andcalcium-fortiÞedplantfoods(includingsomebrandsofready-to-eatcereals,soyandricebeverages,andjuices)canprovideamplecalciumforvegetarians.Cross-sectionalandlongitudinalpopulation-basedstudiespublishedduringthepast2decadessuggestnodifferencesinbonemin-eraldensity(BMD),forbothtrabecu-larandcorticalbone,betweenomni-voresandlacto-ovo-vegetarians⠀Althoughverylittledataexistonthebonehealthofvegans,somestud-iessuggestthatbonedensityisloweramongveganscomparedwithnon-vegetarians⠀).TheAsianveganwomeninthesestudieshadverylowintakesofproteinandcal-cium.Aninadequateproteinandlowcalciumintakehasbeenshowntobeassociatedwithbonelossandfrac-turesatthehipandspineinelderlyadults⠀).Inaddition,vitaminDstatusiscompromisedinsomeveg-ans⠀ResultsfromtheEPIC-Oxfordstudyprovideevidencethattheriskofbonefracturesforvegetariansissimilartothatofomnivores⠀).Thehigherriskofbonefractureinvegansappearedtobeaconsequenceofalowercalciumintake.However,thefractureratesoftheveganswhoconsumedover525mgcalcium/daywerenotdifferentfromthefractureratesinomnivores⠀).Otherfactorsassociatedwithavegetariandiet,suchasfruitandvegetablecon-sumption,soyintake,andintakeofvi-taminK-richleafygreensmustbecon-sideredwhenexaminingbonehealth.Bonehasaprotectiveroleinmain-tainingsystemicpH.Acidosisisseentosuppressosteoblasticactivity,withthegeneexpressionofspeciÞcmatrixproteinsandalkalinephosphataseac-tivitydiminished.Prostaglandinpro-ductionbytheosteoblastsincreasessynthesisoftheosteoblasticreceptoractivatorofnuclearfactorkappaBli-gand.TheacidinductionofreceptoractivatorofnuclearfactorkappaBli-gandstimulatesosteoclasticactivityandrecruitmentofnewosteoclaststopromoteboneresorptionandbuffer-ingoftheprotonload⠀Anincreasedfruitandvegetableconsumptionhasapositiveeffectonthecalciumeconomyandmarkersofbonemetabolism⠀).Thehighpo-tassiumandmagnesiumcontentoffruits,berries,andvegetables,withtheiralkalineash,makesthesefoodsusefuldietaryagentsforinhibitingboneresorption⠀).FemoralneckandlumbarspineBMDofpremeno-pausalwomenwasabout15%to20%higherforwomeninthehighestquar-tileofpotassiumintakecomparedwiththoseinthelowestquartileDietarypotassium,anindicatorofnetendogenousacidproductionandfruitandvegetableintake,wasshowntoexertamodestinßuenceonmark-ersofbonehealth,whichoveralife-timemaycontributetoadecreasedriskofosteoporosis⠀Highproteinintake,especiallyan-imalprotein,canproduceincreasedcalciuria⠀).Postmenopausalwomenwithdietshighinanimalpro-teinandlowinplantproteinrevealedahighrateofbonelossandagreatlyincreasedriskofhipfracture⠀Althoughexcessiveproteinintakemaycompromisebonehealth,evi-denceexiststhatlowproteinintakesmayincreasetheriskoflowbonein-tegrity⠀Bloodlevelsofundercarboxylatedosteocalcin,asensitivemarkerofvi-taminKstatus,areusedtoindicateriskofhipfracture⠀),andpredictBMD⠀).Resultsfromtwolarge,prospectivecohortstudiessuggestaninverserelationshipbetweenvitaminK(andgreen,leafyvegetable)intakeandriskofhipfracture⠀Short-termclinicalstudiessuggestthatsoyproteinrichinisoßavonesde-creasesspinalbonelossinpostmeno-pausalwomen⠀).Inameta-analy-sisof10randomizedcontrolledtrials,soyisoßavonesdemonstratedasigniÞ-cantbeneÞtonspineBMD⠀).Inarandomizedcontrolledtrial,postmeno-pausalwomenreceivinggenisteinex-periencedsigniÞcantdecreasesinuri-naryexcretionofdeoxypyridinoline(amarkerofboneresorption),andin-creasedlevelsofserumbone-speciÞcal-kalinephosphatase(amarkerofboneformation)⠀).Inanothermeta-anal-ysisofninerandomizedcontrolledtri- July2009JournaloftheAMERICANDIETETICASSOCIATION alsonmenopausalwomen,soyisoßa-vonessigniÞcantlyinhibitedboneresorptionandstimulatedboneforma-tioncomparedtoplacebo⠀Topromotebonehealth,vegetari-ansshouldbeencouragedtoconsumefoodsthatprovideadequateintakesofcalcium,vitaminD,vitaminK,po-tassium,andmagnesium;adequate,butnotexcessiveprotein;andtoin-cludegenerousamountsoffruitsandvegetablesandsoyproducts,withminimalamountsofsodium.RenalDiseaseLong-termhighintakesofdietaryprotein(above0.6g/kg/dayforaper-sonwithkidneydiseasenotundergo-ingdialysisorabovetheDietaryRef-erenceIntakeforproteinof0.8g/kg/dayforpeoplewithnormalkidneyfunction)fromeitheranimalorvege-tablessources,mayworsenexistingchronickidneydiseaseorcauserenalinjuryinthosewithnormalrenalfunction⠀).ThismaybeduetothehigherglomerularÞltrationrateas-sociatedwithahigherproteinintake.Soy-basedvegandietsappeartobenutritionallyadequateforpeoplewithchronickidneydiseaseandmayslowprogressionofkidneydiseaseOnestudysuggeststhatvegetariansareatlowerriskofdevelopingdemen-tiathannonvegetarians⠀).Thisreducedriskmaybeduetothelowerbloodpressureseeninvegetariansortothehigherantioxidantintakeofvegetarians⠀).Otherpossiblefac-torsreducingriskcouldincludealowerincidenceofcerebrovasculardiseaseandpossiblereduceduseofpostmenopausalhormones.Vegetari-anscan,however,haveriskfactorsfordementia.Forexample,poorvita-minB-12statushasbeenlinkedtoanincreasedriskofdementiaapparentlyduetothehyperhomocysteinemiathatisseenwithvitaminB-12deÞ-ciency⠀OtherHealthEffectsofVegetarianDietsInacohortstudy,middle-agedvege-tarianswerefoundtobe50%lesslikelytohavediverticulitiscomparedwithnonvegetarians⠀).Fiberwasconsideredtobethemostimportantprotectivefactor,whereasmeatin-takemayincreasetheriskofdivertic-ulitis⠀).Inacohortstudyof800womenaged40to69years,nonveg-etariansweremorethantwiceaslikelyasvegetarianstosufferfromgallstones⠀),evenaftercontrol-lingforobesity,sex,andaging.Sev-eralstudiesfromaresearchgroupinFinlandsuggestthatfasting,followedbyavegandiet,maybeusefulinthetreatmentofrheumatoidarthritisPROGRAMSANDAUDIENCESAFFECTEDSpecialSupplementalNutritionProgramforWomen,Infants,andChildrenTheSpecialSupplementalNutritionProgramforWomen,Infants,andChildrenisafederalgrantprogramthatservespregnant,postpartum,andbreastfeedingwomen;infants;andchildrenuptoage5yearswhoaredocumentedasbeingatnutri-tionalriskwithfamilyincomebelowfederalstandards.Thisprogrampro-videsvoucherstopurchasesomefoodssuitableforvegetariansinclud-inginfantformula,iron-fortiÞedin-fantcereal,vitaminCÐrichfruitorvegetablejuice,carrots,cowÕsmilk,cheese,eggs,iron-fortiÞedready-to-eatcereal,driedbeansorpeas,andpeanutbutter.Recentchangestothisprogrampromotethepurchaseofwhole-grainbreadsandcereals,allowthesubstitutionofcannedbeansfordriedbeans,andprovidevouchersforpurchasingfruitsandvegetables).Soy-basedbeveragesandcal-cium-settofuthatmeetspeciÞcationscanbesubstitutedforcowÕsmilkforwomenandforchildrenwithmedicaldocumentation⠀ChildNutritionProgramsTheNationalSchoolLunchProgramallowsnonmeatproteinproductsin-cludingcertainsoyproducts,cheese,eggs,cookeddriedbeansorpeas,yo-gurt,peanutbutter,othernutorseedbutters,peanuts,treenuts,andseedstobeused⠀).Mealsservedmustmeetthe2005DietaryGuidelinesforAmericansandprovideatleastonethirdoftheRecommendedDietaryAllowanceforprotein,vitaminsAandC,iron,calcium,andenergy.SchoolsarenotrequiredtomakemodiÞca-tionstomealsbasedonfoodchoicesofafamilyorachildalthoughtheyarepermittedtoprovidesubstitutefoodsforchildrenwhoaremedicallycerti-�搀ashavingaspecialdietaryneed).Somepublicschoolsregularlyfeaturevegetarianchoices,includingvegan,menuitemsandthisseemstobemorecommonthaninthepastal-thoughmanyschoolfoodprogramsstillhavelimitedoptionsforvegetar-ians⠀).PublicschoolsareallowedtooffersoymilktochildrenwhobringawrittenstatementfromaparentorguardianidentifyingthestudentÕsspecialdietaryneed.SoymilksmustmeetspeciÞedstandardstobeap-provedassubstitutesandschoolsmustpayforexpensesthatexceedfederalreimbursements⠀FeedingProgramsforElderlyAdultsThefederalElderlyNutritionPro-gramdistributesfundstostates,ter-ritories,andtribalorganizationsforanationalnetworkofprogramsthatprovidecongregateandhome-deliv-eredmeals(oftenknownasMealsonWheels)forolderAmericans.MealsareoftenprovidedbylocalMealsonWheelsagencies.A4-weeksetofveg-etarianmenushasbeendevelopedforusebytheNationalMealsonWheelsFoundation⠀).Similarmenushavebeenadaptedbyindividualpro-gramsincludingNewYorkCityÕsDe-partmentfortheAgingwhichhaspreapproveda4-weeksetofvegetar-ianmenus⠀CorrectionsFacilitiesCourtrulingsintheUnitedStateshavegrantedprisoninmatestherighttohavevegetarianmealsforcertainreligiousandmedicalreasons⠀Inthefederalprisonsystem,vegetar-iandietsareonlyprovidedforin-mateswhodocumentthattheirdietisapartofanestablishedreligiouspractice⠀).Followingreviewandapprovalbythechaplaincyteam,theinmatecanparticipateintheAlterna-tiveDietProgrameitherthroughself-selectionfromthemainlinethatin-cludesanonßeshoptionandaccesstothesalad/hotbarorthroughprovisionofnationallyrecognized,religiouslycertiÞedprocessedfoods⠀).Ifmealsareservedinpreparedtrays,localproceduresaredevelopedfortheprovisionofnonßeshfoods⠀).Inotherprisons,theprocessforobtain-ingvegetarianmealsandthetypeof July2009Volume109Number7 mealavailablevariesdependingonwheretheprisonislocatedandthetypeofprison⠀).Althoughsomeprisonsystemsprovidemeatlessal-ternatives,otherssimplyleavemeatofftheinmateÕstray.Military/ArmedForcesTheUSArmyÕsCombatFeedingPro-gram,whichoverseesallfoodregula-tions,providesachoiceofvegetarianmenusincludingvegetarianMeals,Ready-to-Eat⠀OtherInstitutionsandQuantityFoodServiceOrganizationsOtherinstitutions,includingcolleges,universities,hospitals,restaurants,andpubliclyfundedmuseumsandparks,offervaryingamountsandtypesofvegetarianselections.Re-sourcesareavailableforvegetarianquantityfoodpreparation.ROLESANDRESPONSIBILITIESOFFOODANDNUTRITIONPROFESSIONALSNutritioncounselingcanbehighlybeneÞcialforvegetarianclientswhomanifestspeciÞchealthproblemsre-latedtopoordietarychoicesandforvegetarianswithexistingclinicalcon-ditionsthatrequireadditionaldi-etarymodiÞcations(eg,diabetes,hy-perlipidemia,andkidneydisease).DependingontheclientÕsknowledgelevel,nutritioncounselingmaybeusefulfornewvegetariansandforin-dividualsatvariousstagesofthelifecycleincludingpregnancy,infancy,childhood,adolescence,andfortheel-derly.Foodandnutritionprofession-alshaveanimportantroleinprovid-ingassistanceintheplanningofhealthfulvegetariandietsforthosewhoexpressaninterestinadoptingvegetariandietsorwhoalreadyeatavegetariandiet,andtheyshouldbeabletogivecurrentaccurateinforma-tionaboutvegetariannutrition.In-formationshouldbeindividualizeddependingontypeofvegetariandiet,ageoftheclient,foodpreparationskills,andactivitylevel.Itisimpor-tanttolistentotheclientÕsownde-scriptionofhisorherdiettoascertainwhichfoodscanplayaroleinmealFigure1providesmealplanningsuggestions.Figure2videsalistofWebresourcesonvege-tariandiets.QualiÞedfoodandnutritionprofes-sionalscanhelpvegetarianclientsinthefollowingways:ProvideinformationaboutmeetingrequirementsforvitaminB-12,cal-cium,vitaminD,zinc,iron,andn-3fattyacidsbecausepoorlyplannedvegetariandietsmaysometimesfallshortofthesenutrients.GivespeciÞcguidelinesforplan-ningbalancedlacto-ovo-vegetarianorveganmealsforallstagesofthelifecycle.Supplyinformationaboutgeneralmeasuresforhealthpromotionanddiseaseprevention.Adaptguidelinesforplanningbal-ancedlacto-ovo-vegetarianorveganmealsforclientswithspecialdietaryneedsduetoallergiesorchronicdis-easeorotherrestrictions.Befamiliarwithvegetarianoptionsatlocalrestaurants.Provideideasforplanningoptimalvegetarianmealswhiletraveling.Instructclientsabouttheprepara-tionanduseoffoodsthatfrequentlyarepartofvegetariandiets.Thegrowingselectionofproductsaimedatvegetariansmaymakeitimpos-sibletobeknowledgeableaboutallsuchproducts.However,practitio-nersworkingwithvegetariancli-entsshouldhaveabasicknowledgeofpreparation,use,andnutrientcontentofavarietyofgrains,beans,soyproducts,meatanalogs,andfortiÞedfoods.Befamiliarwithlocalsourcesforpurchaseofvegetarianfoods.Insomecommunities,mailordersourcesmaybenecessary.Workwithfamilymembers,partic-ularlytheparentsofvegetarianchildren,tohelpprovidethebestpossibleenvironmentformeetingnutrientneedsonavegetariandiet.Ifapractitionerisunfamiliarwithvegetariannutrition,he/sheshouldassisttheindividualinÞndingsomeonewhoisqualiÞedtoadvisetheclientorshoulddirecttheclienttoreliableresources.QualiÞedfoodandnutritionprofes-sionalscanalsoplaykeyrolesinensur-ingthattheneedsofvegetariansaremetinfoodserviceoperations,includ-ingchildnutritionprograms,feedingprogramsfortheelderly,correctionsfa-cilities,themilitary,colleges,universi-ties,andhospitals.Thiscanbeaccom-plishedthroughdevelopmentofguidelinesspeciÞcallyaddressingtheneedsofvegetarians,creationandim-plementationofmenusacceptabletovegetarians,andtheevaluationofwhetherornotaprogrammeetstheneedsofitsvegetarianparticipants. Appropriatelyplannedvegetariandietshavebeenshowntobehealthful,nutri-tionallyadequate,andmaybebeneÞ-cialinthepreventionandtreatmentofcertaindiseases.Vegetariandietsareappropriateforallstagesofthelifecy-cle.Therearemanyreasonsfortheris-inginterestinvegetariandiets.ThenumberofvegetariansintheUnitedStatesisexpectedtoincreaseduringthenextdecade.Foodandnutritionprofessionalscanassistvegetariancli-entsbyprovidingcurrent,accuratein-formationaboutvegetariannutrition,foods,andresources. VegetarianNutritionDieteticPracticeAndrewsUniversityNutritionDepartmentCenterforNutritionPolicyandPromotionFoodandNutritionInformationCenterMayoClinicMedlinePlus,VegetarianDietSeventh-dayAdventistDieteticTheVeganSociety(vitaminB-12)TheVegetarianResourceGroupTheVegetarianSocietyoftheUnited Figure2.UsefulWebsitesconcerningvege-tariandiets. July2009JournaloftheAMERICANDIETETICASSOCIATION 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BonaiutoM,DÕAnnaR,CannataML,Cor-radoF,AdamoEB,WilsonS,SquadritoF.Effectsofthephytoestrogengenisteinonbonemetabolisminosteopenicpostmeno-pausalwomen:Arandomizedtrial.InternMed.2007;146:839-847.184.MaDF,QinLQ,WangPY,KatohR.Soyisoßavoneintakeinhibitsboneresorptionandstimulatesboneformationinpausalwomen:Meta-analysisofrandomizedcontrolledtrials.EurJClinNutr.2008;62:185.BernsteinAM,TreyzonL,LiZ.Arehigh-protein,vegetable-baseddietssafeforkid-neyfunction?Areviewoftheliterature.JAmDietAssoc.2007;107:644-650.186.GiemP,BeesonWL,FraserGE.Theinci-denceofdementiaandintakeofanimalproducts:PreliminaryÞndingsfromtheAdventistHealthStudy..1993;12:28-36.187.LuchsingerJA,MayeuxR.DietaryfactorsandAlzheimerÕsdisease.LancetNeurol188.HaanMN,MillerJW,AielloAE,WhitmerRA,JagustWJ,MungasDM,AllenLH,GreenR.Homocysteine,Bvitamins,andtheincidenceofdementiaandcognitiveim-pairment:ResultsfromtheSacramentoAreaLatinoStudyonAging.AmJClin.2007;85:511-517.189.GearJS,WareA,FursdonP,MannJI,NolanDJ,BroadribbAJ,VesseyMP.Symptomlessdiverticulardiseaseandin-takeofdietaryÞbre..1979;1:511-190.AldooriWH,GiovannucciEL,RimmEB,WingAL,TrichopoulosDV,WillettWC,Aprospectivestudyofdietandtheriskofsymptomaticdiverticulardiseaseinmen.AmJClinNutr.1994;60:757-764.191.PixleyF,WilsonD,McPhersonK,MannJ.Effectofvegetarianismondevelopmentofgallstonesinwomen.BrMedJ(ClinRes.1985:291:11-12.192.MullerH,deToledoFW,ReschKL.Fastingfollowedbyvegetariandietinpatientswithrheumatoidarthritis:Asystematicreview.ScandJRheumatol.2001;30:1-10.193.SpecialSupplementalNutritionProgramforWomen,Infants,andChildren(WIC):RevisionsintheWICFoodPackages;In-terimRule.FederalRegister.7CFR,Part246,Dec.6,2007;72:68966-69032.194.ModiÞcationoftheÒVegetableProteinProductsÓrequirementsfortheNationalSchoolLunchProgram,SchoolBreakfastProgram,SummerFoodServiceProgramandChildAndAdultCareFoodProgram.(7CFR210,215,220,225,226)FederalReg-.March9,2000;65:12429-12442.195.AccommodatingchildrenwithspecialneedsintheSchoolNutritionPrograms.USDepartmentofAgriculture,FoodandNutritionServiceWebsite.PostedFall2001.AccessedJulyHealthyschoollunches.2007schoollunchreportcard.PhysiciansCommitteeforRe-sponsibleMedicineWebsite.PostedAugust2007.AccessedJuly10,2008.197.FluidmilksubstitutionsintheSchoolNu-tritionPrograms.(7CFRParts210andFederalRegister.September12,2008;198.Four-weekvegetarianmenusetforMealsonWheelsSites.TheVegetarianResourceGroupWebsite.PostedMay18,1998.AccessedJuly10,2008.199.Vegetarianmenus.NewYorkCityDepart-mentfortheAgingWebsite.AccessedJanuary19,2009.OgdenA,RebeinP.Doprisoninmateshavearighttovegetarianmeals?VegetarianJour-Mar/Apr2001.TheVegetarianResourceGroupWebsite.PostedJan-uary16,2001.AccessedJuly10,2008.Prisonregulationsbyjurisdiction.PrisonVegetarianProjectWebsite.AccessedJuly10,2008.FederalBureauofPrisons.Programstate-ment.Religiousbeliefsandpractices.USDeptofJusticeWebsite.PostedDecem-ber31,2004.AccessedJuly10,2008.SpecialbrieÞngonObjectiveForceWarriorandDoDCombatFeedingProgram.May23,2002.USDepartmentofDefenseWebcessedJuly10,2008.Combatfeedingdirectorateimprovesmeals.USDeptofDefenseWebsite.AccessedJuly10,AmericanDieteticAssociation(ADA)positionadoptedbytheHouseofDelegatesLeadershipTeamonOctober18,1987,andreafÞrmedonSeptember12,1992;September6,1996;June22,2000;andJune11,2006.ThispositionisineffectuntilDecember31,2013.ADAauthorizesrepublicationoftheposition,initsentirety,providedfullandpropercreditisgiven.Readersmaycopyanddistributethispaper,providingsuchdistributionisnotusedtoindicateanendorsementofproductorservice.CommercialdistributionisnotpermittedwithoutthepermissionofADA.RequeststouseportionsofthepositionmustbedirectedtoADAheadquartersat800/877-1600,ext.4835,orWinstonJ.Craig,PhD,MPH,RD(AndrewsUniversity,BerrienSprings,MI);AnnReedMangels,PhD,RD,LDN,FADA(TheVegetarianResourceGroup,Baltimore,MD).PediatricNutritionandSports,Cardiovascular,andWellnessNutritiondieteticpracticegroups(CatherineConway,MS,RD,YAI/NationalInstituteforPeoplewithDisabilities,NewYork,NY);SharonDenny,MS,RD(ADAKnowledgeCenter,Chicago,IL);MaryH.Hager,PhD,RD,FADA(ADAGovernmentRelations,Washington,DC);VegetarianNutritiondieteticpracticegroup(VirginiaMessina,MPH,RD,NutritionMatters,Inc.,PortTownsend,WA);EstherMyers,PhD,RD,FADA(ADAScientiÞcAffairs,Chicago,IL);TamaraSchryver,PhD,MS,RD(GeneralMills,Bloomington,MN);ElizabethTilak,MS,RD(WhiteWaveFoods,Inc,BroomÞeld,CO);JenniferA.Weber,MPH,RD(ADAGovernmentRelations,Washington,DC).AssociationPositionsCommitteeWorkgroup:DianneK.Polly,JD,RD,LDN(chair);KatrinaHolt,MPH,MS,RD;JohannaDwyer,DSc,RD(contentadvisor).Theauthorsthankthereviewersfortheirmanyconstructivecommentsandsuggestions.Thereviewerswerenotaskedtoendorsethispositionorthesupportingpaper. July2009Volume109Number7 andvegetariandiets:Dietsdevoidofallßeshfoods,butalsoincludeegg(ovo)and/ordairy(lacto)products.However,theseverybroadcat-egoriesmaskimportantvariationswithinvegetariandietsanddietarypractices.Thesevariationswithinvegetariandietsmakeabsolutecat-egorizationofvegetariandietarypracticesdifÞcultandmaybeoneofthesourcesofunclearrelationshipsbetweenvegetariandietsandotherGradeIIInthisarticle,thetermwillbeusedtorefertopeoplechoosingalacto-ovo-,lacto-,orveganvegetariandietunlessotherwisespeciÞed.Whereaslacto-ovo-,lacto-,andvegan-vegetariandietsarethosemostcommonlystudied,practitionersmayencounterothertypesofvegetar-ianornear-vegetariandiets.Forex-ample,peoplechoosingmacrobioticdietstypicallydescribetheirdietasvegetarian.Themacrobioticdietisbasedlargelyongrains,legumes,andvegetables.Fruits,nuts,andseedsareusedtoalesserextent.Somepeo-plefollowingamacrobioticdietarenottrulyvegetarianbecausetheyeatlimitedamountsofÞsh.Thetradi-tionalAsian-Indiandietispredomi-nantlyplantbasedandisfrequentlylacto-vegetarianalthoughchangesof-tenoccurwithacculturation,includ-inggreaterconsumptionofcheeseandamovementawayfromavege-tariandiet.Arawfoodsdietmaybeavegandiet,consistingmainlyorex-clusivelyofuncookedandunproc-essedfoods.Foodsusedincludefruits,vegetables,nuts,seeds,andsproutedgrainsandbeans;inrareinstancesunpasteurizeddairyproductsandevenrawmeatand�栀maybeused.Fruitariandietsarevegandietsbasedonfruits,nuts,andseeds.Veg-etablesthatareclassiÞedbotanicallyasfruitslikeavocadoandtomatoesarecommonlyincludedinfruitariandiets;othervegetables,grains,beans,andanimalproductsareexcluded.Somepeoplewilldescribethem-selvesasvegetarianbutwilleatÞsh,chicken,orevenmeat.Theseself-de-scribedvegetariansmaybeidentiÞedinresearchstudiesassemivegetarians.Individualassessmentisrequiredtoaccuratelyevaluatethenutritionalqualityofthedietofavegetarianoraself-describedvegetarian.Commonreasonsforchoosingavegetariandietincludehealthconsid-erations,concernfortheenviron-ment,andanimalwelfarefactors.Vegetariansalsociteeconomicrea-sons,ethicalconsiderations,worldhungerissues,andreligiousbeliefsastheirreasonsforfollowingtheircho-seneatingpattern.ConsumerTrendsIn2006,basedonanationwidepoll,approximately2.3%oftheUSadultpopulation(4.9millionpeople)consis-tentlyfollowedavegetariandiet,statingthattheyneveratemeat,Þsh,orpoultry⠀).About1.4%oftheUSadultpopulationwasvegan⠀).In2005,accordingtoanationwidepoll,3%of8-to18-year-oldchildrenandadolescentswerevegetarian;closeto1%werevegan⠀Manyconsumersreportaninterestinvegetariandiets⠀⤀and22%reportregularconsumptionofmeatlesssub-stitutesformeatproducts⠀).Addi-tionalevidencefortheincreasingin-terestinvegetariandietsincludestheemergenceofcollegecoursesonvege-tariannutritionandonanimalrights;theproliferationofWebsites,period-icals,andcookbookswithavegetar-iantheme;andthepublicÕsattitudetowardorderingavegetarianmealwheneatingawayfromhome.Restaurantshaverespondedtothisinterestinvegetariandiets.Asurveyofchefsfoundthatvegetariandisheswereconsidered퉨潴팀or퉡perennialfavoriteÓby71%;vegandishesby63%).Fast-foodrestaurantsarebegin-ningtooffersalads,veggieburgers,andothermeatlessoptions.Mostuni-versityfoodservicesoffervegetarianNewProductAvailabilityTheUSmarketforprocessedvegetar-ianfoods(foodslikemeatanalogs,nondairymilks,andvegetarianen-treesthatdirectlyreplacemeatorotheranimalproducts)wasestimatedtobe$1.17billionin2006⠀).Thismarketisforecasttogrowto$1.6bil-lionby2011⠀Theavailabilityofnewproducts,in-cludingfortiÞedfoodsandconveniencefoods,wouldbeexpectedtohaveanimpactonthenutrientintakeofvege-tarianswhochoosetoeatthesefoods.FortiÞedfoodssuchassoymilks,meatanalogs,juices,andbreakfastcerealsarecontinuallybeingaddedtothemar-ketplacewithnewlevelsoffortiÞca-tion.Theseproductsanddietarysup-plements,whicharewidelyavailableinsupermarketsandnaturalfoodsstores,canaddsubstantiallytovegetariansÕintakesofkeynutrientssuchascal-cium,iron,zinc,vitaminB-12,vitaminD,riboßavin,andlong-chainn-3fattyacids.WithsomanyfortiÞedproductsavailabletoday,thenutritionalstatusofthetypicalvegetariantodaywouldbeexpectedtobegreatlyimprovedfromthatofavegetarian1to2decadesago.Thisimprovementwouldbeenhancedbythegreaterawarenessamongthevegetarianpopulationofwhatconstitutesabalancedvegetariandiet.Consequentlyolderresearchdatamaynotrepresentthenutritionalsta-tusofpresent-dayvegetarians.HealthImplicationsofVegetarianDietsVegetariandietsareoftenassociatedwithanumberofhealthadvantages,includinglowerbloodcholesterollevels,lowerriskofheartdisease,lowerbloodpressurelevels,andlowerriskofhy-pertensionandtype2diabetes.Vege-tarianstendtohavealowerbodymassindex(BMI)andloweroverallcancerrates.Vegetariandietstendtobelowerinsaturatedfatandcholesterol,andhavehigherlevelsofdietaryÞber,mag-nesiumandpotassium,vitaminsCandE,folate,carotenoids,ßavonoids,andotherphytochemicals.Thesenutri-tionaldifferencesmayexplainsomeofthehealthadvantagesofthosefollow-ingavaried,balancedvegetariandiet.However,vegansandsomeothervege-tariansmayhavelowerintakesofvita-minB-12,calcium,vitaminD,zinc,andlong-chainn-3fattyacids.Recently,outbreaksoffood-borneill-nessassociatedwiththeconsumptionofdomesticallygrownandimportedfreshfruits,sprouts,andvegetablesthathavebeencontaminatedbyEscherichiacoli,andothermicro-organismshavebeenseen.Healthadvocacygroupsarecallingforstricterinspectionandreportingproce-duresandbetterfood-handlingprac-NUTRITIONCONSIDERATIONSFORPlantproteincanmeetproteinre-quirementswhenavarietyofplantfoodsisconsumedandenergyneeds July2009JournaloftheAMERICANDIETETICASSOCIATION aremet.Researchindicatesthatanassortmentofplantfoodseatenoverthecourseofadaycanprovideallessentialaminoacidsandensuread-equatenitrogenretentionanduseinhealthyadults;thus,complementaryproteinsdonotneedtobeconsumedatthesamemeal⠀Ameta-analysisofnitrogenbal-ancestudiesfoundnosigniÞcantdif-ferenceinproteinneedsduetothesourceofdietaryprotein⠀).Basedontheproteindigestibility-correctedaminoacidscore,whichisthestan-dardmethodfordeterminingproteinquality,otherstudieshavefoundthatalthoughisolatedsoyproteincanmeetproteinneedsaseffectivelyasanimalprotein,wheatproteineatenalone,forexample,mayresultinareducedefÞciencyofnitrogenutiliza-tion⠀).Thus,estimatesofproteinrequirementsofvegansmayvary,de-pendingtosomedegreeondietarychoices.Foodandnutritionprofes-sionalsshouldbeawarethatproteinneedsmightbesomewhathigherthantheRecommendedDietaryAl-lowanceinthosevegetarianswhosedietaryproteinsourcesaremainlythosethatarelesswelldigested,suchassomecerealsandlegumes⠀Cerealstendtobelowinlysine,anessentialaminoacid⠀).Thismayberelevantwhenevaluatingdietsofin-dividualswhodonotconsumeanimalproteinsourcesandwhendietsarerelativelylowinprotein.Dietaryad-justmentssuchastheuseofmorebeansandsoyproductsinplaceofotherproteinsourcesthatarelowerinlysineoranincreaseindietarypro-teinfromallsourcescanensureanadequateintakeoflysine.Althoughsomeveganwomenhaveproteinintakesthataremarginal,typicalproteinintakesoflacto-ovo-vegetariansandofvegansappeartomeetandexceedrequirements⠀Athletescanalsomeettheirproteinneedsonplant-baseddiets⠀n-3FattyAcidsWhereasvegetariandietsaregener-allyrichinn-6fattyacids,theymaybemarginalinn-3fattyacids.DietsthatdonotincludeÞsh,eggs,orgen-erousamountsofalgaegenerallyarelowineicosapentaenoicacid(EPA)anddocosahexaenoicacid(DHA),fattyacidsimportantforcardiovascu-larhealthaswellaseyeandbraindevelopment.Thebioconversionof-linolenicacid(ALA),aplant-basedn-3fattyacid,toEPAisgenerallylessthan10%inhumans;conversionofALAtoDHAissubstantiallyless⠀Vegetarians,andparticularlyvegans,tendtohavelowerbloodlevelsofEPAandDHAthannonvegetarians⠀DHAsupplementsderivedfrommi-croalgaearewellabsorbedandposi-tivelyinßuencebloodlevelsofDHA,andalsoEPAthroughretroconver-sion⠀).Soymilkandbreakfastbars,fortiÞedwithDHA,arenowavailableinthemarketplace.TheDietaryReferenceIntakesrec-ommendintakesof1.6and1.1gALAperday,formenandwomen,respec-tively⠀).TheserecommendationsmaynotbeoptimalforvegetarianswhoconsumelittleifanyDHAandEPA⠀⤀andthusmayneedaddi-tionalALAforconversiontoDHAandEPA.ConversionratesforALAtendtoimprovewhendietaryn-6levelsarenothighorexcessive⠀).Vege-tariansshouldincludegoodsourcesofALAintheirdiet,suchasßaxseed,walnuts,canolaoil,andsoy.Thosewithincreasedrequirementsofn-3fattyacids,suchaspregnantandlac-tatingwomen,maybeneÞtfromDHA-richmicroalgae⠀Theironinplantfoodsisnonhemeiron,whichissensitivetobothinhibi-torsandenhancersofironabsorption.Inhibitorsofironabsorptionincludephytates,calcium,andthepolypheno-licsintea,coffee,herbteas,andcocoa.Fiberonlyslightlyinhibitsironabsorp-tion⠀).Somefoodpreparationtech-niquessuchassoakingandsproutingbeans,grains,andseeds,andtheleav-eningofbread,candiminishphytatelevels⠀⤀andtherebyenhanceironabsorption⠀).Otherfermentationprocesses,suchasthoseusedtomakemisoandtempeh,mayalsoimproveironbioavailability⠀VitaminCandotherorganicacidsfoundinfruitsandvegetablescansubstantiallyenhanceironabsorp-tionandreducetheinhibitoryeffectsofphytateandtherebyimproveironstatus⠀).Becauseoflowerbio-availabilityofironfromavegetariandiet,therecommendedironintakesforvegetariansare1.8timesthoseofnonvegetarians⠀Whereasmanystudiesofironab-sorptionhavebeenshortterm,thereisevidencethatadaptationtolowin-takestakesplaceoverthelongterm,andinvolvesbothincreasedabsorp-tionanddecreasedlosses⠀).In-cidenceofiron-deÞciencyanemiaamongvegetariansissimilartothatofnonvegetarians⠀).Althoughvegetarianadultshavelowerironstoresthannonvegetarians,theirse-rumferritinlevelsareusuallywithinthenormalrange⠀Thebioavailabilityofzincfromvege-tariandietsislowerthanfromnonveg-etariandiets,mainlyduetothehigherphyticacidcontentofvegetariandiets).Thus,zincrequirementsforsomevegetarianswhosedietsconsistmainlyofphytate-richunreÞnedgrainsandle-gumesmayexceedtheRecommendedDietaryAllowance⠀).Zincintakesofvegetariansvarywithsomeresearchshowingzincintakesnearrecommen-dations⠀⤀andotherresearchÞndingzincintakesofvegetarianssigniÞ-cantlybelowrecommendations⠀OvertzincdeÞciencyisnotevidentinWesternvegetarians.DuetothedifÞ-cultyinevaluatingmarginalzincsta-tus,itisnotpossibletodeterminethepossibleeffectoflowerzincabsorptionfromvegetariandiets⠀).Zincsourcesincludesoyproducts,legumes,grains,cheese,andnuts.Foodpreparationtechniques,suchassoakingandsproutingbeans,grains,andseedsaswellasleaveningbread,canreducebindingofzincbyphyticacidandin-creasezincbioavailability⠀).Organicacids,suchascitricacid,canalsoen-hancezincabsorptiontosomeextentSomestudiessuggestthatveganswhodonotconsumekeysourcesofiodine,suchasiodizedsaltorseaveg-etables,maybeatriskforiodinede-Þciency,becauseplant-baseddietsaretypicallylowiniodine⠀).Seasaltandkoshersaltaregenerallynotiodizednoraresaltyseasoningssuchastamari.Iodineintakefromseaveg-etablesshouldbemonitoredbecausetheiodinecontentofseavegetablesvarieswidelyandsomecontainsub-stantialamountsofiodine⠀Foodssuchassoybeans,cruciferousvegetables,andsweetpotatoescon- July2009Volume109Number7 tainnaturalgoitrogens.ThesefoodshavenotbeenassociatedwiththyroidinsufÞciencyinhealthypeoplepro-vidediodineintakeisadequate⠀Calciumintakesoflacto-ovo-vegetar-iansaresimilarto,orhigherthan,thoseofnonvegetarians⠀),whereasintakesofveganstendtobelowerthanbothgroupsandmayfallbelowrecommendedintakes⠀).IntheOx-fordcomponentoftheEuropeanPro-spectiveInvestigationintoCancerandNutrition(EPIC-Oxford)study,theriskofbonefracturewassimilarforlacto-ovo-vegetariansandmeateaters,whereasveganshada30%higherriskoffracturepossiblyduetotheirconsiderablylowermeancal-ciumintake⠀).Dietsrichinmeat,Þsh,dairyproducts,nuts,andgrainsproduceahighrenalacidload,mainlyduetosulfateandphosphateresidues.Calciumresorptionfrombonehelpstobufferthisacidload,resultinginincreasedurinarylossesofcalcium.Ahighsodiumintakecanalsopromoteurinarycalciumlosses.Ontheotherhand,fruitsandvegeta-blesrichinpotassiumandmagne-siumproduceahighrenalalkalineloadwhichslowsbonecalciumresorp-tion,anddecreasescalciumlossesintheurine.Inaddition,somestudiesshowthattheratioofdietarycalciumtoproteinisabetterpredictorofbonehealththancalciumintakealone.Typically,thisratioishighinlacto-ovo-vegetariandietsandfavorsbonehealth,whereasveganshavearatioofcalciumtoproteinthatissimilartoorlowerthanthatofnonvegetarians).Manyvegansmay�搀itiseas-iertomeettheircalciumneedsifcal-cium-fortiÞedfoodsordietarysupple-mentsareutilized⠀Low-oxalategreens(eg,bokchoy,broccoli,Chinesecabbage,collards,andkale)andfruitjuicesfortiÞedwithcalciumcitratemalatearegoodsourcesofhighlybioavailablecalcium(50%to60%and40%to50%,respec-tively),whilecalcium-settofu,andcowÕsmilkhavegoodbioavailabilityofcalcium(about30%to35%),andsesameseeds,almonds,anddriedbeanshavealowerbioavailability(21%to27%)⠀).ThebioavailabilityofcalciumfromsoymilkfortiÞedwithcalciumcarbonateisequivalenttocowÕsmilkalthoughlimitedresearchhasshownthatcalciumavailabilityissubstantiallylesswhentricalciumphosphateisusedtofortifythesoybeverage⠀).FortiÞedfoodssuchasfruitjuices,soymilk,andricemilk,andbreakfastcerealscancontributesigniÞcantamountsofdietarycal-ciumforthevegan⠀).Oxalatesinsomefoods,suchasspinachandSwisschard,greatlyreducecalciumabsorption,makingthesevegetablesapoorsourceofusablecalcium.Foodsrichinphytatemayalsoinhibitcal-ciumabsorptionVitaminDVitaminDhaslongbeenknowntoplayaroleinbonehealth.VitaminDstatusdependsonsunlightexposureandintakeofvitaminDÐfortiÞedfoodsorsupplements.TheextentofcutaneousvitaminDproductionfol-lowingsunlightexposureishighlyvariableandisdependentonanum-beroffactors,includingthetimeofday,season,latitude,skinpigmenta-tion,sunscreenuse,andage.Lowvi-taminDintakes⠀),lowserum25-hydroxyvitaminDlevels⠀),andreducedbonemass⠀⤀havebeenre-portedinsomeveganandmacrobioticgroupswhodidnotusevitaminDsupplementsorfortiÞedfoods.FoodsthatarefortiÞedwithvita-minDincludecowÕsmilk,somebrandsofsoymilk,ricemilk,andor-angejuice,andsomebreakfastcere-alsandmargarines.BothvitaminD-2andvitaminD-3areusedinsupple-mentsandtofortifyfoods.VitaminD-3(cholecalciferol)isofanimalori-ginandisobtainedthroughtheultra-violetirradiationof7-dehydrocholes-terolfromlanolin.VitaminD-2(ergocalciferol)isproducedfromtheultravioletirradiationofergosterolfromyeastandisacceptabletoveg-ans.Althoughsomeresearchsug-geststhatvitaminD-2islesseffectivethanvitaminD-3inmaintainingse-rum25-hydroxyvitaminDlevels⠀otherstudies�搀thatvitaminD-2andvitaminD-3areequallyeffective).IfsunexposureandintakeoffortiÞedfoodsareinsufÞcienttomeetneeds,vitaminDsupplementsareVitaminB-12ThevitaminB-12statusofsomeveg-etariansislessthanadequateduetonotregularlyconsumingreliablesourcesofvitaminB-12⠀Lacto-ovo-vegetarianscanobtainad-equatevitaminB-12fromdairyfoods,eggs,orotherreliablevitaminB-12sources(fortiÞedfoodsandsupple-ments),ifregularlyconsumed.Forvegans,vitaminB-12mustbeob-tainedfromregularuseofvitaminB-12-fortiÞedfoods,suchasfortiÞedsoyandricebeverages,somebreak-fastcerealsandmeatanalogs,orRedStarVegetarianSupportFormulanu-tritionalyeast;otherwiseadailyvita-minB-12supplementisneeded.NounfortiÞedplantfoodcontainsanysigniÞcantamountofactivevitaminB-12.Fermentedsoyproductscannotbeconsideredareliablesourceofac-tiveB-12⠀Vegetariandietsaretypicallyrichinfolacin,whichmaymaskthehema-tologicalsymptomsofvitaminB-12deÞciency,sothatvitaminB-12deÞ-ciencymaygoundetecteduntilafterneurologicalsignsandsymptomsmaybemanifest⠀).VitaminB-12statusisbestdeterminedbymeasur-ingserumlevelsofhomocysteine,methylmalonicacid,orholotransco-balaminII⠀VEGETARIANDIETSTHROUGHOUTTHELIFECYCLEWell-plannedvegan,lacto-vegetarian,andlacto-ovo-vegetariandietsareap-propriateforallstagesofthelifecycle,includingpregnancyandlactation.Ap-propriatelyplannedvegan,lacto-vege-tarian,andlacto-ovo-vegetariandietssatisfynutrientneedsofinfants,chil-dren,andadolescentsandpromotenor-malgrowth⠀Figure1speciÞcsuggestionsformealplanningforvegetariandiets.Lifelongvegetari-anshaveadultheight,weight,andBMIsthataresimilartothosewhobe-camevegetarianlaterinlife,suggest-ingthatwell-plannedvegetariandietsininfancyandchildhooddonotaffectÞnaladultheightorweight⠀).Vege-tariandietsinchildhoodandadoles-cencecanaidintheestablishmentoflifelonghealthfuleatingpatternsandcanoffersomeimportantnutritionaladvantages.Vegetarianchildrenandadolescentshavelowerintakesofcho-lesterol,saturatedfat,andtotalfatandhigherintakesoffruits,vegetables,andÞberthannonvegetarians⠀).Veg-etarianchildrenhavealsobeenre- July2009JournaloftheAMERICANDIETETICASSOCIATION portedtobeleanerandtohavelowerserumcholesterollevels⠀PregnantandLactatingWomenThenutrientandenergyneedsofpregnantandlactatingvegetarianwomendonotdifferfromthoseofnonvegetarianwomenwiththeexcep-tionofhigherironrecommendationsforvegetarians.Vegetariandietscanbeplannedtomeetthenutrientneedsofpregnantandlactatingwomen.Ev-idence-basedanalysisoftheresearchliteraturewasusedtoevaluateexist-ingresearchonvegetarianpregnancy).Sevenquestionsforevidence-analysiswereidentiÞed:Howdomacronutrientandenergyintakeinpregnantvegetariansdif-ferfromintakesinpregnantomni-Arebirthoutcomesdifferentformotherswhomaintainavegetarianvsanomnivorousdietduringpreg-Howdomacronutrientandenergyintakeinpregnantvegansdifferfromintakesinpregnantomnivores?Arebirthoutcomesdifferentformotherswhomaintainaveganvsanomnivorousdietduringpreg-Whatarepatternsofmicronutrientintakeamongpregnantvegetarians?Whatisthebioavailabilityofdiffer-entmicronutrientsinpregnantveg-Whatarebirthoutcomesassociatedwiththemicronutrientintakeofmaternalvegetariandiets?Thecompleteresultsofthisevidence-basedanalysiscanbefoundontheEALWebsite⠀andaresummarizedbelow.MacronutrientandEnergyIntake.primaryresearchstudieswereidenti-�搀thatexaminedmaternalmacro-nutrientintakeduringlacto-ovo-orlacto-vegetarianpregnancy⠀Nonefocusedonpregnantvegans.EALConclusionStatement:Limitedre-searchonnon-USpopulationsindi-catesthatthemacronutrientintakeofpregnantvegetariansissimilartothatofnonvegetarianswiththefol-lowingexceptions(aspercentagesofenergyintake):pregnantvegetariansreceivestatis-ticallylowerlevelsofproteinthanpregnantnonvegetarians;andpregnantvegetariansreceivestatis-ticallyhigherlevelsofcarbohydratesthanpregnantnonvegetarians.Itisimportanttonote,however,thatnoneofthestudiesreportaclin-icallysigniÞcantdifferenceinmacro-nutrientintake.Inotherwords,noneofthestudiesreportaproteindeÞ-ciencyinpregnantvegetarians.GradeIIIEALConclusionStatement:NoresearchwasidentiÞedthatfocusedonmacro-nutrientintakesamongpregnantveg-GradeVNotAssignable.BirthOutcomes.FourcohortstudieswereidentiÞedthatexaminedtherela-tionshipbetweenmaternalmacronu-trientintakeduringpregnancyandbirthoutcomessuchasbirthweightandlength⠀).Noneofthestudiesfocusedonpregnantvegans.EALConclusionStatement:Limitedre-searchonnon-USpopulationsindi-catesthattherearenosigniÞcanthealthdifferencesinbabiesborntononveganvegetarianmothersvsnon-GradeIIIEALConclusionStatement:NoresearchwasidentiÞedthatfocusedonthebirthoutcomesofveganvsomnivorousGradeVNotAssignable.MicronutrientIntake.Basedon10stud-ies⠀),twoofwhichwereconductedintheUnitedStates⠀onlythefollowingmicronutrientshadlowerintakeamongvegetariansthanvitaminB-12;vitaminC;calcium;andVegetariansdidnotmeetdietarystandard(inatleastonecountry)for:vitaminB-12(intheUnitedKing-iron(intheUnitedStates,forbothvegetariansandomnivores);folate(inGermany,thoughlowerrateofdeÞciencythanamongomni-vores);andzinc(intheUnitedKingdom).EALConclusionStatement:GradeIIIMicronutrientBioavailability.Sixstudies⣞癥non-US,onewithcombinedUSandnon-USsamples;allbutoneofpos-itivequality)wereidentiÞedthatex-aminedthebioavailabilityofdifferentmicronutrientsinvegetarianvsnon-vegetarianpregnantwomen⠀).Ofthemicronutrientsexam-inedintheresearch,onlyserumB-12levelsweresigniÞcantlylowerinnon-vegan-vegetariansthannonvegetar-ians.Inaddition,onestudyreportedthatlowerB-12levelsaremorelikelytobeassociatedwithhighserumtotalhomocysteineinlacto-ovo-vegetariansthanlowmeateatersoromnivores.WhereaszinclevelswerenotsigniÞ-cantlydifferentbetweennonvegan-vegetariansandnonvegetarians,vege-tarianswhohaveahighintakeofcalciummaybeatriskforzincdeÞ-ciency(becauseoftheinteractionbe-tweenphytate,calcium,andzinc).Basedonlimitedevidence,plasmafo-latelevelsmayactuallybehigheramongsomevegetariangroupsthanEALConclusionStatement:GradeIIIMicronutrientsandBirthOutcomeEALCon-clusionStatement:Limitedevidencefromsevenstudies(alloutsidethe Avarietyofmenuplanningapproachescanprovideadequatenutritionforvegetarians.TheDietaryReferenceIntakesareavaluableresourceforfoodandnutritionprofessionals.Variousfoodguides(41,52)canbeusedwhenworkingwithvegetarianclients.Inaddition,thefollowingguidelinescanhelpvegetariansplanhealthfuldiets:Chooseavarietyoffoods,includingwholegrains,vegetables,fruits,legumes,nuts,seeds,and,ifdesired,dairyproducts,andeggs.Minimizeintakeoffoodsthatarehighlysweetened,highinsodium,andhighinfat,especiallysaturatedfatand-fattyacids.Chooseavarietyoffruitsandvegetables.Ifanimalfoodssuchasdairyproductsandeggsareused,chooselower-fatdairyproductsandusebotheggsanddairyproductsinmoderation.UsearegularsourceofvitaminB-12and,ifsunlightexposureislimited,ofvitaminD. Figure1.Suggestionsforplanningvegetarianmeals. July2009Volume109Number7 UnitedStates)indicatedthatthemi-cronutrientcontentofabalancedma-ternalvegetariandietdoesnothavedetrimentaloutcomesforthehealthofthechildatbirth⠀).Theremaybe,however,ariskforafalsepositivediagnosisofDownsyndromeinthefetuswhenmaternalserumfreebeta-humanchorionicgonadotro-pinandalphafetoproteinlevelsareusedasmarkersinvegetarianmoth-GradeIIINutritionConsiderations.Resultsofevi-dence-basedanalysissuggestthatvegetariandietscanbenutritionallyadequateinpregnancyandcanleadtoapositivebirthoutcome⠀KeynutrientsinpregnancyincludevitaminB-12,vitaminD,iron,andfolatewhereaskeynutrientsinlacta-tionincludevitaminB-12,vitaminD,calcium,andzinc.Dietsofpregnantandlactatingvegetariansshouldcon-tainreliablesourcesofvitaminB-12daily.Basedonrecommendationsforpregnancyandlactation,ifthereisconcernaboutvitaminDsynthesisbecauseoflimitedsunlightexposure,skintone,season,orsunscreenuse,pregnantandlactatingwomenshouldusevitaminDsupplementsorvita-minDÐfortiÞedfoods.Nostudiesincludedintheevidence-analysisex-aminedvitaminDstatusduringveg-etarianpregnancy.Ironsupplementsmaybeneededtopreventortreatiron-deÞciencyanemia,whichiscom-moninpregnancy.Womencapableofbecomingpregnantaswellaswomeninthepericonceptionalperiodaread-visedtoconsume400gfolatedailyfromsupplements,fortiÞedfoods,orboth.ZincandcalciumneedscanbemetthroughfoodorsupplementsourcesasidentiÞedinearliersec-tionsonthesenutrients.DHAalsoplaysaroleinpregnancyandlactation.InfantsofvegetarianmothersappeartohavelowercordandplasmaDHAthandoinfantsofnonvegetarians⠀).BreastmilkDHAislowerinvegansandlacto-ovo-vegetariansthaninnonvegetarians).BecauseofDHAÕsbeneÞcialef-fectsongestationallength,infantvi-sualfunction,andneurodevelopment,pregnantandlactatingvegetariansandvegansshouldchoosefoodsourcesofDHA(fortiÞedfoodsoreggsfromhensfedDHA-richmicroalgae)oruseamicroalgae-derivedDHAsup-plement⠀).SupplementationwithALA,aDHAprecursor,inpreg-nancyandlactationhasnotbeenshowntobeeffectiveinincreasingin-fantDHAlevelsorbreastmilkDHAconcentration⠀Growthofyoungvegetarianinfantsreceivingadequateamountsofbreastmilkorcommercialinfantformulaisnormal.Whensolidfoodsareintro-duced,provisionofgoodsourcesofen-ergyandnutrientscanensurenormalgrowth.Thesafetyofextremelyre-strictivedietssuchasfruitarianandrawfoodsdietshasnotbeenstudiedinchildren.Thesedietscanbeverylowinenergy,protein,somevita-mins,andsomemineralsandcannotberecommendedforinfantsandchil-Breastfeedingiscommoninvege-tarianwomen,andthispracticeshouldbesupported.Thebreastmilkofvegetarianwomenissimilarincompositiontothatofnonvegetariansandisnutritionallyadequate.Com-mercialinfantformulasshouldbeusedifinfantsarenotbreastfedorareweanedbefore1yearofage.Soyformulaistheonlyoptionfornon-breastfedveganinfants.Otherprep-arationsincludingsoymik,ricemilk,andhomemadeformulasshouldnotbeusedtoreplacebreastmilkorcom-mercialinfantformula.Solidfoodsshouldbeintroducedinthesameprogressionasfornonveg-etarianinfants,replacingstrainedmeatwithmashedorpureedtofu,le-gumes(pureedandstrainedifneces-sary),soyordairyyogurt,cookedeggyolk,andcottagecheese.Later,around7to10months,foodssuchascubedtofu,cheese,orsoycheeseandbite-sizepiecesofveggieburgerscanbestarted.Commercial,full-fat,forti-�搀soymilkorpasteurizedcowÕsmilkcanbeusedasaprimarybever-agestartingatage1yearorolderforachildwhoisgrowingnormallyandeatingavarietyoffoods⠀).Foodsthatarerichinenergyandnutrientssuchaslegumespreads,tofu,andmashedavocadoshouldbeusedwhentheinfantisbeingweaned.Dietaryfatshouldnotberestrictedinchil-drenyoungerthan2years.Guidelinesfordietarysupplementsgenerallyfollowthosefornonvegetar-ianinfants.Breastfedinfantswhosemothersdonothaveanadequatein-takeofvitaminB-12shouldreceiveavitaminB-12supplement⠀).Zincintakeshouldbeassessedandzincsupplementsorzinc-fortiÞedfoodsusedwhencomplementaryfoodsareintroducedifthedietislowinzincormainlyconsistsoffoodswithlowzincbioavailability⠀Growthoflacto-ovo-vegetarianchil-drenissimilartothatoftheirnonveg-etarianpeers⠀).Littleinformationaboutthegrowthofnonmacrobioticveganchildrenhasbeenpublished.Somestudiessuggestthatveganchil-drentendtobeslightlysmallerbutwithinthenormalrangesofthestan-dardsforweightandheight⠀).Poorgrowthinchildrenhasprimarilybeenseeninthoseonveryrestricteddiets⠀FrequentmealsandsnacksandtheuseofsomereÞnedfoods(suchasfor-tiÞedbreakfastcereals,breads,andpasta)andfoodshigherinunsatur-atedfatscanhelpvegetarianchildrenmeetenergyandnutrientneeds.Av-erageproteinintakesofvegetarianchildren(lacto-ovo,vegan,andmacro-biotic)generallymeetorexceedrec-ommendations⠀).Veganchildrenmayhaveslightlyhigherproteinneedsbecauseofdifferencesinpro-teindigestibilityandaminoacidcom-position⠀⤀buttheseproteinneedsaregenerallymetwhendietscontainadequateenergyandavari-etyofplantfoods.Foodguidesforvegetarianchildrenhavebeenpublishedelsewhere⠀Growthoflacto-ovo-vegetarianandnonvegetarianadolescentsissimilar).Earlierstudiessuggestthatveg-etariangirlsreachmenarcheslightlylaterthannonvegetarians⠀);morerecentstudies�搀nodifferenceinageatmenarche⠀Vegetariandietsappeartooffersomenutritionaladvantagesforado-lescents.VegetarianadolescentsarereportedtoconsumemoreÞber,iron,folate,vitaminA,andvitaminCthannonvegetarians⠀).Vegetarianadolescentsalsoconsumemorefruitsandvegetables,andfewersweets,fastfoods,andsaltysnackscomparedtononvegetarianadolescents⠀Keynutrientsofconcernforadoles- July2009JournaloftheAMERICANDIETETICASSOCIATION centvegetariansincludecalcium,vi-taminD,iron,zinc,andvitaminB-12.Beingvegetariandoesnotcausedisorderedeatingassomehavesug-gestedalthoughavegetariandietmaybeselectedtocamoußageanex-istingeatingdisorder⠀).Becauseofthis,vegetariandietsaresomewhatmorecommonamongadolescentswitheatingdisordersthaninthegen-eraladolescentpopulation⠀).Foodandnutritionprofessionalsshouldbeawareofyoungclientswhogreatlylimitfoodchoicesandwhoexhibitsymptomsofeatingdisorders.Withguidanceinmealplanning,vegetariandietscanbeappropriateandhealthfulchoicesforadolescents.OlderAdultsWithaging,energyneedsdecreasebutrecommendationsforseveralnu-trients,includingcalcium,vitaminD,andvitaminB-6arehigher.Intakesofmicronutrients,especiallycalcium,zinc,iron,andvitaminB-12,declineinolderadults⠀).Studiesindicatethatoldervegetarianshavedietaryintakesthataresimilartononveg-etarians⠀OlderadultsmayhavedifÞcultywithvitaminB-12absorptionfromfood,frequentlyduetoatrophicgas-tritis,sovitaminB-12-fortiÞedfoodsorsupplementsshouldbeusedbe-causethevitaminB-12infortiÞedfoodsandsupplementsisusuallywell-absorbed⠀).Cutaneousvita-minDproductiondecreaseswithag-ingsothatdietaryorsupplementalsourcesofvitaminDareespeciallyimportant⠀).Althoughcurrentrec-ommendationsforproteinforhealthyolderadultsarethesameasthoseforyoungeradultsonabodyweightbasis),thisisacontroversialarea⠀Certainlyolderadultswhohavelowenergyrequirementswillneedtocon-sumeconcentratedsourcesofprotein.Olderadultscanmeetproteinneedsonavegetariandietifavarietyofprotein-richplantfoods,includingle-gumesandsoyproducts,areeatenVegetariandietscanalsomeettheneedsofcompetitiveathletes.Nutri-tionrecommendationsforvegetarianathletesshouldbeformulatedwithcon-siderationoftheeffectsofbothvegetar-iandietsandexercise.ThepositionofAmericanDieteticAssociationandDi-etitiansofCanadaonnutritionandathleticperformanceprovidesaddi-tionalinformationspeciÞctovegetar-ianathletes⠀).Researchisneededontherelationbetweenvegetariandietandperformance.Vegetariandietsthatmeetenergyneedsandcontainavari-etyofplant-basedproteinfoods,suchassoyproducts,otherlegumes,grains,nuts,andseeds,canprovideadequateproteinwithouttheuseofspecialfoodsorsupplements⠀).Vegetarianath-letesmayhavelowermusclecreatineconcentrationduetolowdietarycreat-inelevels⠀).Vegetarianathletesparticipatinginshort-term,high-inten-sityexerciseandresistancetrainingmaybeneÞtfromcreatinesupplemen-tation⠀).Some,butnotallresearchsuggeststhatamenorrheamaybemorecommonamongvegetarianthannon-vegetarianathletes⠀).FemalevegetarianathletesmaybeneÞtfromdietsthatincludeadequateenergy,higherlevelsoffat,andgenerousamountsofcalciumandiron.VEGETARIANDIETSANDCHRONICCardiovascularDisease(CVD)Evidence-basedanalysisofthere-searchliteratureisbeingusedtoevaluateexistingresearchonthere-lationshipbetweenvegetariandi-etarypatternsandCVDriskfactors).Twoevidenceanalysisquestionshavebeencompleted:WhatistherelationshipbetweenavegetariandietandischemicheartHowismicronutrientintakeinavegetariandietassociatedwithCVDriskfactors?IschemicHeartDisease.Twolargeco-hortstudies⠀⤀andonemeta-analysis⠀⤀foundthatvegetarianswereatlowerriskofdeathfromisch-emicheartdiseasethannonvegetar-ians.Thelowerriskofdeathwasseeninbothlacto-ovo-vegetariansandveg-ans⠀).Thedifferenceinriskper-sistedafteradjustmentforBMI,smokinghabits,andsocialclass⠀ThisisespeciallysigniÞcantbecausethelowerBMIcommonlyseeninveg-etarians⠀⤀isonefactorthatmayhelptoexplainthelowerriskofheartdiseaseinvegetarians.Ifthisdiffer-enceinriskpersistsevenafteradjust-mentforBMI,otheraspectsofaveg-etariandietmayberesponsiblefortheriskreduction,aboveandbeyondthatwhichwouldbeexpectedduetolowerBMI.EALConclusionStatement:Avegetar-iandietisassociatedwithalowerriskofdeathfromischemicheartdisease.GradeIBloodLipidLevels.Thelowerriskofdeathfromischemicheartdiseaseseeninvegetarianscouldbeex-plainedinpartbydifferencesinbloodlipidlevels.Basedonbloodlipidlev-elsinonelargecohortstudy,thein-cidenceofischemicheartdiseasewasestimatedtobe24%lowerinlifelongvegetariansand57%lowerinlifelongveganscomparedtomeateaters⠀Typically,studies�搀lowertotalcho-lesterolandlow-densitylipoprotein(LDL)cholesterollevelsinvegetari-ans⠀,forexample).Interventionstudieshavedemonstratedareduc-tionintotalandLDL-cholesterollev-elswhensubjectsswitchedfromtheirusualdiettoavegetariandiet⠀forexample).Althoughevidenceislimitedthatavegetariandietisasso-ciatedwithhigherhigh-densityli-poproteincholesterollevelsorwithhigherorlowertriglyceridelevels,avegetariandietisconsistentlyassoci-atedwithlowerLDLcholesterollev-els.OtherfactorssuchasvariationsinBMIandfoodseatenoravoidedwithinthecontextofavegetariandietorlifestyledifferencescouldpartiallyexplaintheinconsistentresultswithregardtobloodlipidlevels.FactorsinavegetariandietthatcouldhaveabeneÞcialeffectonbloodlipidlevelsincludethehigheramountsofÞber,nuts,soy,andplantsterolsandlowerlevelsofsaturatedfat.Vegetari-ansconsumebetween50%and100%moreÞberthannonvegetariansandveganshavehigherintakesthanlacto-ovo-vegetarians⠀).SolubleÞberhasbeenrepeatedlyshowntolowertotalandLDLcholesterollevelsandtore-duceriskofcoronaryheartdisease⠀AdiethighinnutssigniÞcantlylowerstotalandLDLcholesterollevels⠀Soyisoßavonesmayplayaroleinre-ducingLDLcholesterollevelsandinreducingthesusceptibilityofLDLtooxidation⠀).Plantsterols,foundinlegumes,nutsandseeds,wholegrains,vegetableoils,andotherplant-based July2009Volume109Number7 foodsreducecholesterolabsorptionandlowerLDLcholesterollevels⠀FactorsAssociatedwithVegetarianDietsthatMayAffectRiskofCVD.Otherfac-torsinvegetariandietsmayimpactCVDriskindependentofeffectsoncholesterollevels.FoodsthatfeatureprominentlyinavegetariandietthatmayofferprotectionfromCVDin-cludesoyprotein⠀),fruitsandvegetables,wholegrains,andnuts).Vegetariansappeartocon-sumemorephytochemicalsthandononvegetariansbecauseagreaterpercentageoftheirenergyintakecomesfromplantfoods.Flavonoidsandotherphytochemicalsappeartohaveprotectiveeffectsasantioxi-dants,inreducingplateletaggrega-tionandbloodclotting,asanti-in-ßammatoryagents,andinimprovingendothelialfunction⠀).Lacto-ovo-vegetarianshavebeenshowntohavesigniÞcantlybettervasodilationresponses,suggestingabeneÞcialef-fectofvegetariandietonvascularen-dothelialfunction⠀EvidenceanalysiswasconductedtoexaminehowthemicronutrientmakeupofvegetariandietsmightberelatedtoCVDriskfactors.EALConclusionStatement:Nore-searchmeetinginclusioncriteriawereidentiÞedthatexaminedthemi-cronutrientintakeofavegetariandietandCVDriskfactors.NotAssignable.Notallaspectsofvegetariandietsareassociatedwithreducedriskforheartdisease.Thehigherserumho-mocysteinelevelsthathavebeenre-portedinsomevegetarians,appar-entlyduetoinadequatevitaminB-12intake,mayincreaseriskofCVD⤀althoughnotallstudiessupportthis⠀Vegetariandietshavebeensuc-cessfullyusedintreatmentofCVD.Aregimenthatusedaverylow-fat10%ofenergy)nearvegan(limitednonfatdairyandeggwhitesallowed)dietalongwithexercise,smokingces-sation,andstressmanagement,wasshowntoreducebloodlipidlevels,bloodpressure,andweight,andim-proveexercisecapacity⠀).Anear-vegandiethighinphytosterols,vis-cousÞber,nuts,andsoyproteinhasbeenshowntobeaseffectiveasalow-saturatedfatdietandastatinforloweringserumLDL-cholesterollev-els⠀Across-sectionalstudyandacohortstudyfoundthattherewasalowerrateofhypertensionamongvegetari-ansthannonvegetarians⠀SimilarÞndingswerereportedinSeventh-dayAdventists(Adventists)inBarbados⠀⤀andinpreliminaryresultsfromtheAdventistHealthStudy-2cohort⠀).Vegansappeartohavealowerrateofhypertensionthandoothervegetarians⠀Severalstudieshavereportedlowerbloodpressureinvegetarianscomparedtononvegetarians⠀althoughotherstudiesreportedlittledifferenceinbloodpressurebetweenvegetariansandnonvegetarians).Atleastoneofthestudiesreportinglowerbloodpres-sureinvegetariansfoundthatBMIratherthandietaccountedformuchoftheage-adjustedvariationinbloodpressure⠀).VegetarianstendtohavealowerBMIthannonvegetar-ians⠀);thus,vegetariandietsÕin-ßuenceonBMImaypartiallyaccountforreporteddifferencesinbloodpres-surebetweenvegetariansandnon-vegetarians.Variationsindietaryin-takeandlifestylewithingroupsofvegetariansmaylimitthestrengthofconclusionswithregardtotherela-tionshipbetweenvegetariandietsandbloodpressure.Possiblefactorsinvegetariandietsthatcouldresultinlowerbloodpres-sureincludethecollectiveeffectofvariousbeneÞcialcompoundsfoundinplantfoodssuchaspotassium,magnesium,antioxidants,dietaryfat,andÞber⠀).ResultsfromtheDietaryApproachestoStopHyper-tensionstudy,inwhichsubjectscon-sumedalow-fatdietrichinfruits,vegetablesanddairy,suggestthatsubstantialdietarylevelsofpotas-sium,magnesium,andcalciumplayanimportantroleinreducingbloodpressurelevels⠀).Fruitandvege-tableintakewasresponsibleforaboutone-halfofthebloodpressurereduc-tionoftheDietaryApproachestoStopHypertensiondiet⠀).Inad-dition,ninestudiesreportthatcon-sumptionof�攀to10servingsoffruitandvegetablessigniÞcantlylowersbloodpressure⠀AdventistvegetariansarereportedtohavelowerratesofdiabetesthanAd-ventistnonvegetarians⠀).IntheAdventistHealthStudy,age-adjustedriskfordevelopingdiabeteswastwo-foldgreaterinnonvegetarians,com-paredwiththeirvegetariancounter-parts⠀).Althoughobesityincreasestheriskoftype2diabetes,meatandprocessedmeatintakewasfoundtobeanimportantriskfactorfordiabe-tesevenafteradjustmentforBMI).IntheWomenÕsHealthStudy,theauthorsalsoobservedpositiveas-sociationsbetweenintakesofredmeatandprocessedmeatandriskofdiabetesafteradjustingforBMI,totalenergyintake,andexercise⠀).AsigniÞcantlyincreasedriskofdiabe-teswasmostpronouncedforfrequentconsumptionofprocessedmeatssuchasbaconandhotdogs.Resultsre-mainedsigniÞcantevenafterfurtheradjustmentfordietaryÞber,magne-sium,fat,andglycemicload⠀).Inalargecohortstudy,therelativeriskfortype2diabetesinwomenforeveryone-servingincreaseinintakewas1.26forredmeatand1.38to1.73forprocessedmeats⠀Inaddition,higherintakesofvege-tables,whole-grainfoods,legumes,andnutshaveallbeenassociatedwithasubstantiallylowerriskofin-sulinresistanceandtype2diabetes,andimprovedglycemiccontrolinei-thernormalorinsulin-resistantindi-viduals⠀).Observationalstudieshavefoundthatdietsrichinwhole-grainfoodsareassociatedwithimprovedinsulinsensitivity.Thisef-fectmaybepartlymediatedbysignif-icantlevelsofmagnesiumandcerealÞberinthewhole-grainfoods⠀Personswithelevatedbloodglucosemayexperienceanimprovementininsulinresistanceandlowerfastingbloodglucoselevelsaftertheyhaveconsumedwholegrains⠀).Peopleconsumingaboutthreeservingsperdayofwhole-grainfoodsare20%to30%lesslikelytodeveloptype2dia-betesthanlowconsumers⠀3serv-ingsperweek)⠀IntheNursesÕHealthStudy,nutconsumptionwasinverselyassoci-atedwithriskoftype2diabetesafteradjustmentforBMI,physicalactiv-ity,andmanyotherfactors.Theriskofdiabetesforthoseconsumingnuts�攀ormoretimesaweekwas27%lowerthanthosealmostnevereatingnuts,whereastheriskofdiabetesforthoseconsumingpeanutbutteratleast�攀timesaweek(equivalentto July2009JournaloftheAMERICANDIETETICASSOCIATION 5ozpeanuts/week)was21%lowerthanthosewhoalmostneveratepea-nutbutter⠀Becauselegumescontainslowlydi-gestedcarbohydrateandhaveahighÞbercontent,theyareexpectedtoim-proveglycemiccontrolandreducein-cidentdiabetes.Inalargeprospectivestudy,aninverseassociationwasseenbetweentheintakeoftotalle-gumes,peanuts,soybeans,andotherlegumesbyChinesewomen,andtheincidenceoftype2diabetesmellitus,afteradjustmentforBMIandotherfactors.Theriskoftype2diabeteswas38%and47%lower,forthoseconsumingahighintakeoftotalle-gumesandsoybeans,respectively,comparedtoalowintake⠀Inaprospectivestudy,theriskoftype2diabeteswas28%lowerforwomenintheupperquintileofvege-table,butnotfruitintake,comparedtothelowerquintileofvegetablein-take.IndividualvegetablegroupswereallinverselyandsigniÞcantlyassociatedwiththeriskoftype2di-abetes⠀).Inanotherstudy,con-sumptionofgreenleafyvegetablesandfruit,butnotfruitjuice,wasas-sociatedwithalowerriskofdiabetesFiber-richvegandietsarecharac-terizedbyalowglycemicindexandalowtomoderateglycemicload⠀Ina5-monthrandomizedclinicaltrial,alow-fatvegandietwasshowntoconsiderablyimproveglycemiccon-trolinpersonswithtype2diabetes,with43%ofsubjectsreducingdiabe-tesmedication⠀).Resultsweresuperiortothoseobtainedfromfol-lowingadietbasedonAmericanDia-betesAssociationguidelines(individ-ualizedbasedonbodyweightandlipidconcentrations;15%-20%pro-7%saturatedfat;60%to70%carbohydrateandmonounsaturated200mgcholesterol).AmongAdventists,about30%ofwhomfollowameatlessdiet,vegetar-ianeatingpatternshavebeenassoci-atedwithlowerBMI,andBMIin-creasedasthefrequencyofmeatconsumptionincreasedinbothmenandwomen⠀).IntheOxfordVege-tarianStudy,BMIvalueswerehigherinnonvegetarianscomparedwithvegetariansinallagegroupsforbothmenandwomen⠀).Inacross-sec-tionalstudyof37,875adults,meat-eatershadthehighestage-adjustedmeanBMIandvegansthelowest,withothervegetarianshavinginter-mediatevalues⠀).IntheEPIC-OxfordStudy,weightgainovera5-yearperiod,amongahealth-con-sciouscohort,waslowestamongthosewhomovedtoadietcontainingfeweranimalfoods⠀).Inalargecross-sectionalBritishstudy,itwasobservedthatthosepeoplewhobe-camevegetarianasadultsdidnotdif-ferinBMIorbodyweightcomparedtothosewhowerelife-longvegetari-ans⠀).However,thosewhohavebeenfollowingavegetariandietforatleast5yearstypicallyhavealowerBMI.AmongAdventistsinBarbados,thenumberofobesevegetarians,whohadfollowedthedietformorethan5years,was70%lessthanthenumberofobeseomnivoreswhereasrecentvegetarians(followingthedietyears)hadbodyweightssimilartoomnivores⠀).Alow-fatvegetariandiethasbeenshowntobemoreeffec-tiveinlong-termweightlossforpost-menopausalwomenthanamoreconventionalNationalCholesterolEducationProgramdiet⠀).Vege-tariansmayhavealowerBMIduetotheirhigherconsumptionofÞber-rich,low-energyfoods,suchasfruitandvegetables.Vegetarianstendtohaveanoverallcancerratelowerthanthatofthegeneralpopulation,andthisisnotconÞnedtosmoking-relatedcancers.DatafromtheAdventistHealthStudyrevealedthatnonvegetarianshadasubstantiallyincreasedriskforbothcolorectalandprostatecancercomparedwithvegetarians,buttherewerenosigniÞcantdifferencesinriskoflung,breast,uterine,orstomachcancerbetweenthegroupsaftercon-trollingforage,sex,andsmoking).ObesityisasigniÞcantfactorin-creasingtheriskofcanceratanum-berofsites⠀).BecausetheBMIofvegetarianstendstobelowerthanthatofnonvegetarians,thelighterbodyweightofthevegetariansmaybeanimportantfactor.Avegetariandietprovidesavarietyofcancer-protectivedietaryfactors).Epidemiologicstudieshaveconsistentlyshownthataregularconsumptionoffruitandvegetablesisstronglyassociatedwithareducedriskofsomecancers⠀).Incontrast,amongsurvivorsofearlystagebreastcancerintheWomenÕsHealthyEatingandLivingtrial,theadoptionofadietenhancedbyaddi-tionaldailyfruitandvegetableserv-ingsdidnotreduceadditionalbreastcancereventsormortalityovera7-yearperiod⠀Fruitandvegetablescontainacom-plexmixtureofphytochemicals,pos-sessingpotentantioxidant,antiprolif-erative,andcancer-protectiveactivity.Thephytochemicalscandisplayaddi-tiveandsynergisticeffects,andarebestconsumedinwholefoods).Thesephytochemicalsinter-ferewithseveralcellularprocessesin-volvedintheprogressionofcancer.Thesemechanismsincludetheinhibi-tionofcellproliferation,inhibitionofDNAadductformation,inhibitionofphase1enzymes,inhibitionofsignaltransductionpathwaysandoncogeneexpression,inductionofcellcyclearrestandapoptosis,inductionofphase2en-zymes,blockingtheactivationofnu-clearfactor-kappaB,andinhibitingan-giogenesis⠀AccordingtotherecentWorldCan-cerResearchFundreport⠀),fruitandvegetablesareprotectiveagainstcancerofthelung,mouth,esophagus,andstomach,andtoalesserdegreesomeothersites.Theregularuseoflegumesalsoprovidesameasureofprotectionagainststomachandpros-tatecancer⠀).Fiber,vitaminC,carotenoids,ßavonoids,andotherphy-tochemicalsinthedietarereportedtoexhibitprotectionagainstvariouscan-cers.Alliumvegetablesmayprotectagainststomachcancerandgarlicpro-tectsagainstcolorectalcancer.Fruitsrichintheredpigmentlycopenearereportedtoprotectagainstprostatecancer⠀).Recently,cohortstudieshavesuggestedthatahighintakeofwholegrainsprovidedsubstantialpro-tectionagainstvariouscancers⠀Regularphysicalactivityprovidessig-niÞcantprotectionagainstmostofthemajorcancers⠀Althoughthereissuchavarietyofpotentphytochemicalsinfruitandvegetables,humanpopulationstudieshavenotshownlargedifferencesincancerincidenceormortalityratesbetweenvegetariansandnonvegetar-ians⠀).Perhapsmoredetailedfoodconsumptiondataareneededbe-causethebioavailabilityandpotency July2009Volume109Number7 ofphytochemicalsdependsonfoodpreparation,suchaswhethertheveg-etablesarecookedorraw.Inthecaseofprostatecancer,ahighdairyintakemaylessenthechemoprotectiveeffectofavegetariandiet.Useofdairyandothercalcium-richfoodshavebeenassociatedwithanincreasedriskofprostatecancer⠀),al-thoughnotallstudiessupportthisÞnding⠀Redmeatandprocessedmeatcon-sumptionisconsistentlyassociatedwithanincreaseintheriskofcolorec-talcancer⠀).Ontheotherhand,theintakeoflegumeswasnegativelyassociatedwithriskofcoloncancerinnonvegetarians⠀).Inapooledanal-ysisof14cohortstudies,theadjustedriskofcoloncancerwassubstantiallyreducedbyahighintakeoffruitandvegetablevsalowintake.Fruitandvegetableintakeswereassociatedwithalowerriskofdistalcoloncan-cer,butnotwithproximalcoloncan-cer⠀).Vegetarianshaveasub-stantiallygreaterintakeofÞberthannonvegetarians.AhighÞberintakeisthoughttoprotectagainstcoloncan-cer,althoughnotallresearchsup-portsthis.TheEPICstudyinvolving10Europeancountriesreporteda25%reductioninriskofcolorectalcancerinthehighestquartileofdi-etaryÞberintakecomparedtothelowest.BasedupontheseÞndings,Binghamandcolleagues⠀⤀con-cludedthatinpopulationswithalowÞberintake,doublingtheÞberintakecouldreducethecolorectalcancerby40%.Ontheotherhand,apooledanalysisof13prospectivecohortstudiesreportedahighdietaryÞberintakewasnotassociatedwithade-creasedriskofcolorectalcancerafteraccountingformultipleriskfactorsSoyisoßavonesandsoyfoodshavebeenshowntopossessanti-cancerproperties.Meta-analysisofeightstudies(onecohort,andsevencasecontrol)conductedinhigh-soy-con-sumingAsiansshowedasigniÞcanttrendofdecreasingriskofbreastcan-cerwithincreasingsoyfoodintake.Incontrast,soyintakewasunrelatedtobreastcancerriskinstudiescon-ductedin11low-soy-consumingWesternpopulations⠀).However,controversyremainsregardingthevalueofsoyasacancer-protectiveagent,becausenotallresearchsup-portstheprotectivevalueofsoyto-wardsbreastcancer⠀).Ontheotherhand,meatconsumptionhasbeenlinkedinsome,butnotall,stud-ieswithanincreasedriskofbreastcancer⠀).Inonestudy,breastcan-cerriskincreasedby50%to60%foreachadditional100g/dayofmeatcon-sumed⠀Dairyproducts,greenleafyvegeta-bles,andcalcium-fortiÞedplantfoods(includingsomebrandsofready-to-eatcereals,soyandricebeverages,andjuices)canprovideamplecalciumforvegetarians.Cross-sectionalandlongitudinalpopulation-basedstudiespublishedduringthepast2decadessuggestnodifferencesinbonemin-eraldensity(BMD),forbothtrabecu-larandcorticalbone,betweenomni-voresandlacto-ovo-vegetarians⠀Althoughverylittledataexistonthebonehealthofvegans,somestud-iessuggestthatbonedensityisloweramongveganscomparedwithnon-vegetarians⠀).TheAsianveganwomeninthesestudieshadverylowintakesofproteinandcal-cium.Aninadequateproteinandlowcalciumintakehasbeenshowntobeassociatedwithbonelossandfrac-turesatthehipandspineinelderlyadults⠀).Inaddition,vitaminDstatusiscompromisedinsomeveg-ans⠀ResultsfromtheEPIC-Oxfordstudyprovideevidencethattheriskofbonefracturesforvegetariansissimilartothatofomnivores⠀).Thehigherriskofbonefractureinvegansappearedtobeaconsequenceofalowercalciumintake.However,thefractureratesoftheveganswhoconsumedover525mgcalcium/daywerenotdifferentfromthefractureratesinomnivores⠀).Otherfactorsassociatedwithavegetariandiet,suchasfruitandvegetablecon-sumption,soyintake,andintakeofvi-taminK-richleafygreensmustbecon-sideredwhenexaminingbonehealth.Bonehasaprotectiveroleinmain-tainingsystemicpH.Acidosisisseentosuppressosteoblasticactivity,withthegeneexpressionofspeciÞcmatrixproteinsandalkalinephosphataseac-tivitydiminished.Prostaglandinpro-ductionbytheosteoblastsincreasessynthesisoftheosteoblasticreceptoractivatorofnuclearfactorkappaBli-gand.TheacidinductionofreceptoractivatorofnuclearfactorkappaBli-gandstimulatesosteoclasticactivityandrecruitmentofnewosteoclaststopromoteboneresorptionandbuffer-ingoftheprotonload⠀Anincreasedfruitandvegetableconsumptionhasapositiveeffectonthecalciumeconomyandmarkersofbonemetabolism⠀).Thehighpo-tassiumandmagnesiumcontentoffruits,berries,andvegetables,withtheiralkalineash,makesthesefoodsusefuldietaryagentsforinhibitingboneresorption⠀).FemoralneckandlumbarspineBMDofpremeno-pausalwomenwasabout15%to20%higherforwomeninthehighestquar-tileofpotassiumintakecomparedwiththoseinthelowestquartileDietarypotassium,anindicatorofnetendogenousacidproductionandfruitandvegetableintake,wasshowntoexertamodestinßuenceonmark-ersofbonehealth,whichoveralife-timemaycontributetoadecreasedriskofosteoporosis⠀Highproteinintake,especiallyan-imalprotein,canproduceincreasedcalciuria⠀).Postmenopausalwomenwithdietshighinanimalpro-teinandlowinplantproteinrevealedahighrateofbonelossandagreatlyincreasedriskofhipfracture⠀Althoughexcessiveproteinintakemaycompromisebonehealth,evi-denceexiststhatlowproteinintakesmayincreasetheriskoflowbonein-tegrity⠀Bloodlevelsofundercarboxylatedosteocalcin,asensitivemarkerofvi-taminKstatus,areusedtoindicateriskofhipfracture⠀),andpredictBMD⠀).Resultsfromtwolarge,prospectivecohortstudiessuggestaninverserelationshipbetweenvitaminK(andgreen,leafyvegetable)intakeandriskofhipfracture⠀Short-termclinicalstudiessuggestthatsoyproteinrichinisoßavonesde-creasesspinalbonelossinpostmeno-pausalwomen⠀).Inameta-analy-sisof10randomizedcontrolledtrials,soyisoßavonesdemonstratedasigniÞ-cantbeneÞtonspineBMD⠀).Inarandomizedcontrolledtrial,postmeno-pausalwomenreceivinggenisteinex-periencedsigniÞcantdecreasesinuri-naryexcretionofdeoxypyridinoline(amarkerofboneresorption),andin-creasedlevelsofserumbone-speciÞcal-kalinephosphatase(amarkerofboneformation)⠀).Inanothermeta-anal-ysisofninerandomizedcontrolledtri- July2009JournaloftheAMERICANDIETETICASSOCIATION alsonmenopausalwomen,soyisoßa-vonessigniÞcantlyinhibitedboneresorptionandstimulatedboneforma-tioncomparedtoplacebo⠀Topromotebonehealth,vegetari-ansshouldbeencouragedtoconsumefoodsthatprovideadequateintakesofcalcium,vitaminD,vitaminK,po-tassium,andmagnesium;adequate,butnotexcessiveprotein;andtoin-cludegenerousamountsoffruitsandvegetablesandsoyproducts,withminimalamountsofsodium.RenalDiseaseLong-termhighintakesofdietaryprotein(above0.6g/kg/dayforaper-sonwithkidneydiseasenotundergo-ingdialysisorabovetheDietaryRef-erenceIntakeforproteinof0.8g/kg/dayforpeoplewithnormalkidneyfunction)fromeitheranimalorvege-tablessources,mayworsenexistingchronickidneydiseaseorcauserenalinjuryinthosewithnormalrenalfunction⠀).ThismaybeduetothehigherglomerularÞltrationrateas-sociatedwithahigherproteinintake.Soy-basedvegandietsappeartobenutritionallyadequateforpeoplewithchronickidneydiseaseandmayslowprogressionofkidneydiseaseOnestudysuggeststhatvegetariansareatlowerriskofdevelopingdemen-tiathannonvegetarians⠀).Thisreducedriskmaybeduetothelowerbloodpressureseeninvegetariansortothehigherantioxidantintakeofvegetarians⠀).Otherpossiblefac-torsreducingriskcouldincludealowerincidenceofcerebrovasculardiseaseandpossiblereduceduseofpostmenopausalhormones.Vegetari-anscan,however,haveriskfactorsfordementia.Forexample,poorvita-minB-12statushasbeenlinkedtoanincreasedriskofdementiaapparentlyduetothehyperhomocysteinemiathatisseenwithvitaminB-12deÞ-ciency⠀OtherHealthEffectsofVegetarianDietsInacohortstudy,middle-agedvege-tarianswerefoundtobe50%lesslikelytohavediverticulitiscomparedwithnonvegetarians⠀).Fiberwasconsideredtobethemostimportantprotectivefactor,whereasmeatin-takemayincreasetheriskofdivertic-ulitis⠀).Inacohortstudyof800womenaged40to69years,nonveg-etariansweremorethantwiceaslikelyasvegetarianstosufferfromgallstones⠀),evenaftercontrol-lingforobesity,sex,andaging.Sev-eralstudiesfromaresearchgroupinFinlandsuggestthatfasting,followedbyavegandiet,maybeusefulinthetreatmentofrheumatoidarthritisPROGRAMSANDAUDIENCESAFFECTEDSpecialSupplementalNutritionProgramforWomen,Infants,andChildrenTheSpecialSupplementalNutritionProgramforWomen,Infants,andChildrenisafederalgrantprogramthatservespregnant,postpartum,andbreastfeedingwomen;infants;andchildrenuptoage5yearswhoaredocumentedasbeingatnutri-tionalriskwithfamilyincomebelowfederalstandards.Thisprogrampro-videsvoucherstopurchasesomefoodssuitableforvegetariansinclud-inginfantformula,iron-fortiÞedin-fantcereal,vitaminCÐrichfruitorvegetablejuice,carrots,cowÕsmilk,cheese,eggs,iron-fortiÞedready-to-eatcereal,driedbeansorpeas,andpeanutbutter.Recentchangestothisprogrampromotethepurchaseofwhole-grainbreadsandcereals,allowthesubstitutionofcannedbeansfordriedbeans,andprovidevouchersforpurchasingfruitsandvegetables).Soy-basedbeveragesandcal-cium-settofuthatmeetspeciÞcationscanbesubstitutedforcowÕsmilkforwomenandforchildrenwithmedicaldocumentation⠀ChildNutritionProgramsTheNationalSchoolLunchProgramallowsnonmeatproteinproductsin-cludingcertainsoyproducts,cheese,eggs,cookeddriedbeansorpeas,yo-gurt,peanutbutter,othernutorseedbutters,peanuts,treenuts,andseedstobeused⠀).Mealsservedmustmeetthe2005DietaryGuidelinesforAmericansandprovideatleastonethirdoftheRecommendedDietaryAllowanceforprotein,vitaminsAandC,iron,calcium,andenergy.SchoolsarenotrequiredtomakemodiÞca-tionstomealsbasedonfoodchoicesofafamilyorachildalthoughtheyarepermittedtoprovidesubstitutefoodsforchildrenwhoaremedicallycerti-�搀ashavingaspecialdietaryneed).Somepublicschoolsregularlyfeaturevegetarianchoices,includingvegan,menuitemsandthisseemstobemorecommonthaninthepastal-thoughmanyschoolfoodprogramsstillhavelimitedoptionsforvegetar-ians⠀).PublicschoolsareallowedtooffersoymilktochildrenwhobringawrittenstatementfromaparentorguardianidentifyingthestudentÕsspecialdietaryneed.SoymilksmustmeetspeciÞedstandardstobeap-provedassubstitutesandschoolsmustpayforexpensesthatexceedfederalreimbursements⠀FeedingProgramsforElderlyAdultsThefederalElderlyNutritionPro-gramdistributesfundstostates,ter-ritories,andtribalorganizationsforanationalnetworkofprogramsthatprovidecongregateandhome-deliv-eredmeals(oftenknownasMealsonWheels)forolderAmericans.MealsareoftenprovidedbylocalMealsonWheelsagencies.A4-weeksetofveg-etarianmenushasbeendevelopedforusebytheNationalMealsonWheelsFoundation⠀).Similarmenushavebeenadaptedbyindividualpro-gramsincludingNewYorkCityÕsDe-partmentfortheAgingwhichhaspreapproveda4-weeksetofvegetar-ianmenus⠀CorrectionsFacilitiesCourtrulingsintheUnitedStateshavegrantedprisoninmatestherighttohavevegetarianmealsforcertainreligiousandmedicalreasons⠀Inthefederalprisonsystem,vegetar-iandietsareonlyprovidedforin-mateswhodocumentthattheirdietisapartofanestablishedreligiouspractice⠀).Followingreviewandapprovalbythechaplaincyteam,theinmatecanparticipateintheAlterna-tiveDietProgrameitherthroughself-selectionfromthemainlinethatin-cludesanonßeshoptionandaccesstothesalad/hotbarorthroughprovisionofnationallyrecognized,religiouslycertiÞedprocessedfoods⠀).Ifmealsareservedinpreparedtrays,localproceduresaredevelopedfortheprovisionofnonßeshfoods⠀).Inotherprisons,theprocessforobtain-ingvegetarianmealsandthetypeof July2009Volume109Number7 mealavailablevariesdependingonwheretheprisonislocatedandthetypeofprison⠀).Althoughsomeprisonsystemsprovidemeatlessal-ternatives,otherssimplyleavemeatofftheinmateÕstray.Military/ArmedForcesTheUSArmyÕsCombatFeedingPro-gram,whichoverseesallfoodregula-tions,providesachoiceofvegetarianmenusincludingvegetarianMeals,Ready-to-Eat⠀OtherInstitutionsandQuantityFoodServiceOrganizationsOtherinstitutions,includingcolleges,universities,hospitals,restaurants,andpubliclyfundedmuseumsandparks,offervaryingamountsandtypesofvegetarianselections.Re-sourcesareavailableforvegetarianquantityfoodpreparation.ROLESANDRESPONSIBILITIESOFFOODANDNUTRITIONPROFESSIONALSNutritioncounselingcanbehighlybeneÞcialforvegetarianclientswhomanifestspeciÞchealthproblemsre-latedtopoordietarychoicesandforvegetarianswithexistingclinicalcon-ditionsthatrequireadditionaldi-etarymodiÞcations(eg,diabetes,hy-perlipidemia,andkidneydisease).DependingontheclientÕsknowledgelevel,nutritioncounselingmaybeusefulfornewvegetariansandforin-dividualsatvariousstagesofthelifecycleincludingpregnancy,infancy,childhood,adolescence,andfortheel-derly.Foodandnutritionprofession-alshaveanimportantroleinprovid-ingassistanceintheplanningofhealthfulvegetariandietsforthosewhoexpressaninterestinadoptingvegetariandietsorwhoalreadyeatavegetariandiet,andtheyshouldbeabletogivecurrentaccurateinforma-tionaboutvegetariannutrition.In-formationshouldbeindividualizeddependingontypeofvegetariandiet,ageoftheclient,foodpreparationskills,andactivitylevel.Itisimpor-tanttolistentotheclientÕsownde-scriptionofhisorherdiettoascertainwhichfoodscanplayaroleinmealFigure1providesmealplanningsuggestions.Figure2videsalistofWebresourcesonvege-tariandiets.QualiÞedfoodandnutritionprofes-sionalscanhelpvegetarianclientsinthefollowingways:ProvideinformationaboutmeetingrequirementsforvitaminB-12,cal-cium,vitaminD,zinc,iron,andn-3fattyacidsbecausepoorlyplannedvegetariandietsmaysometimesfallshortofthesenutrients.GivespeciÞcguidelinesforplan-ningbalancedlacto-ovo-vegetarianorveganmealsforallstagesofthelifecycle.Supplyinformationaboutgeneralmeasuresforhealthpromotionanddiseaseprevention.Adaptguidelinesforplanningbal-ancedlacto-ovo-vegetarianorveganmealsforclientswithspecialdietaryneedsduetoallergiesorchronicdis-easeorotherrestrictions.Befamiliarwithvegetarianoptionsatlocalrestaurants.Provideideasforplanningoptimalvegetarianmealswhiletraveling.Instructclientsabouttheprepara-tionanduseoffoodsthatfrequentlyarepartofvegetariandiets.Thegrowingselectionofproductsaimedatvegetariansmaymakeitimpos-sibletobeknowledgeableaboutallsuchproducts.However,practitio-nersworkingwithvegetariancli-entsshouldhaveabasicknowledgeofpreparation,use,andnutrientcontentofavarietyofgrains,beans,soyproducts,meatanalogs,andfortiÞedfoods.Befamiliarwithlocalsourcesforpurchaseofvegetarianfoods.Insomecommunities,mailordersourcesmaybenecessary.Workwithfamilymembers,partic-ularlytheparentsofvegetarianchildren,tohelpprovidethebestpossibleenvironmentformeetingnutrientneedsonavegetariandiet.Ifapractitionerisunfamiliarwithvegetariannutrition,he/sheshouldassisttheindividualinÞndingsomeonewhoisqualiÞedtoadvisetheclientorshoulddirecttheclienttoreliableresources.QualiÞedfoodandnutritionprofes-sionalscanalsoplaykeyrolesinensur-ingthattheneedsofvegetariansaremetinfoodserviceoperations,includ-ingchildnutritionprograms,feedingprogramsfortheelderly,correctionsfa-cilities,themilitary,colleges,universi-ties,andhospitals.Thiscanbeaccom-plishedthroughdevelopmentofguidelinesspeciÞcallyaddressingtheneedsofvegetarians,creationandim-plementationofmenusacceptabletovegetarians,andtheevaluationofwhetherornotaprogrammeetstheneedsofitsvegetarianparticipants. Appropriatelyplannedvegetariandietshavebeenshowntobehealthful,nutri-tionallyadequate,andmaybebeneÞ-cialinthepreventionandtreatmentofcertaindiseases.Vegetariandietsareappropriateforallstagesofthelifecy-cle.Therearemanyreasonsfortheris-inginterestinvegetariandiets.ThenumberofvegetariansintheUnitedStatesisexpectedtoincreaseduringthenextdecade.Foodandnutritionprofessionalscanassistvegetariancli-entsbyprovidingcurrent,accuratein-formationaboutvegetariannutrition,foods,andresources. VegetarianNutritionDieteticPracticeAndrewsUniversityNutritionDepartmentCenterforNutritionPolicyandPromotionFoodandNutritionInformationCenterMayoClinicMedlinePlus,VegetarianDietSeventh-dayAdventistDieteticTheVeganSociety(vitaminB-12)TheVegetarianResourceGroupTheVegetarianSocietyoftheUnited Figure2.UsefulWebsitesconcerningvege-tariandiets. July2009JournaloftheAMERICANDIETETICASSOCIATION 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July2009JournaloftheAMERICANDIETETICASSOCIATION BonaiutoM,DÕAnnaR,CannataML,Cor-radoF,AdamoEB,WilsonS,SquadritoF.Effectsofthephytoestrogengenisteinonbonemetabolisminosteopenicpostmeno-pausalwomen:Arandomizedtrial.InternMed.2007;146:839-847.184.MaDF,QinLQ,WangPY,KatohR.Soyisoßavoneintakeinhibitsboneresorptionandstimulatesboneformationinpausalwomen:Meta-analysisofrandomizedcontrolledtrials.EurJClinNutr.2008;62:185.BernsteinAM,TreyzonL,LiZ.Arehigh-protein,vegetable-baseddietssafeforkid-neyfunction?Areviewoftheliterature.JAmDietAssoc.2007;107:644-650.186.GiemP,BeesonWL,FraserGE.Theinci-denceofdementiaandintakeofanimalproducts:PreliminaryÞndingsfromtheAdventistHealthStudy..1993;12:28-36.187.LuchsingerJA,MayeuxR.DietaryfactorsandAlzheimerÕsdisease.LancetNeurol188.HaanMN,MillerJW,AielloAE,WhitmerRA,JagustWJ,MungasDM,AllenLH,GreenR.Homocysteine,Bvitamins,andtheincidenceofdementiaandcognitiveim-pairment:ResultsfromtheSacramentoAreaLatinoStudyonAging.AmJClin.2007;85:511-517.189.GearJS,WareA,FursdonP,MannJI,NolanDJ,BroadribbAJ,VesseyMP.Symptomlessdiverticulardiseaseandin-takeofdietaryÞbre..1979;1:511-190.AldooriWH,GiovannucciEL,RimmEB,WingAL,TrichopoulosDV,WillettWC,Aprospectivestudyofdietandtheriskofsymptomaticdiverticulardiseaseinmen.AmJClinNutr.1994;60:757-764.191.PixleyF,WilsonD,McPhersonK,MannJ.Effectofvegetarianismondevelopmentofgallstonesinwomen.BrMedJ(ClinRes.1985:291:11-12.192.MullerH,deToledoFW,ReschKL.Fastingfollowedbyvegetariandietinpatientswithrheumatoidarthritis:Asystematicreview.ScandJRheumatol.2001;30:1-10.193.SpecialSupplementalNutritionProgramforWomen,Infants,andChildren(WIC):RevisionsintheWICFoodPackages;In-terimRule.FederalRegister.7CFR,Part246,Dec.6,2007;72:68966-69032.194.ModiÞcationoftheÒVegetableProteinProductsÓrequirementsfortheNationalSchoolLunchProgram,SchoolBreakfastProgram,SummerFoodServiceProgramandChildAndAdultCareFoodProgram.(7CFR210,215,220,225,226)FederalReg-.March9,2000;65:12429-12442.195.AccommodatingchildrenwithspecialneedsintheSchoolNutritionPrograms.USDepartmentofAgriculture,FoodandNutritionServiceWebsite.PostedFall2001.AccessedJulyHealthyschoollunches.2007schoollunchreportcard.PhysiciansCommitteeforRe-sponsibleMedicineWebsite.PostedAugust2007.AccessedJuly10,2008.197.FluidmilksubstitutionsintheSchoolNu-tritionPrograms.(7CFRParts210andFederalRegister.September12,2008;198.Four-weekvegetarianmenusetforMealsonWheelsSites.TheVegetarianResourceGroupWebsite.PostedMay18,1998.AccessedJuly10,2008.199.Vegetarianmenus.NewYorkCityDepart-mentfortheAgingWebsite.AccessedJanuary19,2009.OgdenA,RebeinP.Doprisoninmateshavearighttovegetarianmeals?VegetarianJour-Mar/Apr2001.TheVegetarianResourceGroupWebsite.PostedJan-uary16,2001.AccessedJuly10,2008.Prisonregulationsbyjurisdiction.PrisonVegetarianProjectWebsite.AccessedJuly10,2008.FederalBureauofPrisons.Programstate-ment.Religiousbeliefsandpractices.USDeptofJusticeWebsite.PostedDecem-ber31,2004.AccessedJuly10,2008.SpecialbrieÞngonObjectiveForceWarriorandDoDCombatFeedingProgram.May23,2002.USDepartmentofDefenseWebcessedJuly10,2008.Combatfeedingdirectorateimprovesmeals.USDeptofDefenseWebsite.AccessedJuly10,AmericanDieteticAssociation(ADA)positionadoptedbytheHouseofDelegatesLeadershipTeamonOctober18,1987,andreafÞrmedonSeptember12,1992;September6,1996;June22,2000;andJune11,2006.ThispositionisineffectuntilDecember31,2013.ADAauthorizesrepublicationoftheposition,initsentirety,providedfullandpropercreditisgiven.Readersmaycopyanddistributethispaper,providingsuchdistributionisnotusedtoindicateanendorsementofproductorservice.CommercialdistributionisnotpermittedwithoutthepermissionofADA.RequeststouseportionsofthepositionmustbedirectedtoADAheadquartersat800/877-1600,ext.4835,orWinstonJ.Craig,PhD,MPH,RD(AndrewsUniversity,BerrienSprings,MI);AnnReedMangels,PhD,RD,LDN,FADA(TheVegetarianResourceGroup,Baltimore,MD).PediatricNutritionandSports,Cardiovascular,andWellnessNutritiondieteticpracticegroups(CatherineConway,MS,RD,YAI/NationalInstituteforPeoplewithDisabilities,NewYork,NY);SharonDenny,MS,RD(ADAKnowledgeCenter,Chicago,IL);MaryH.Hager,PhD,RD,FADA(ADAGovernmentRelations,Washington,DC);VegetarianNutritiondieteticpracticegroup(VirginiaMessina,MPH,RD,NutritionMatters,Inc.,PortTownsend,WA);EstherMyers,PhD,RD,FADA(ADAScientiÞcAffairs,Chicago,IL);TamaraSchryver,PhD,MS,RD(GeneralMills,Bloomington,MN);ElizabethTilak,MS,RD(WhiteWaveFoods,Inc,BroomÞeld,CO);JenniferA.Weber,MPH,RD(ADAGovernmentRelations,Washington,DC).AssociationPositionsCommitteeWorkgroup:DianneK.Polly,JD,RD,LDN(chair);KatrinaHolt,MPH,MS,RD;JohannaDwyer,DSc,RD(contentadvisor).Theauthorsthankthereviewersfortheirmanyconstructivecommentsandsuggestions.Thereviewerswerenotaskedtoendorsethispositionorthesupportingpaper. July2009Volume109Number7 fromtheassociationPositionoftheAmericanDieteticAssociation:VegetarianDiets ItisthepositionoftheAmericanDi-eteticAssociationthatappropriatelyplannedvegetariandiets,includingtotalvegetarianorvegandiets,arehealthful,nutritionallyadequate,andmayprovidehealthbeneÞtsinthepreventionandtreatmentofcertaindiseases.Well-plannedvegetariandi-etsareappropriateforindividualsduringallstagesofthelifecycle,in-cludingpregnancy,lactation,infancy,childhood,andadolescence,andforathletes.AvegetariandietisdeÞnedasonethatdoesnotincludemeat(in-cludingfowl)orseafood,orproductscontainingthosefoods.Thisarticlereviewsthecurrentdatarelatedtokeynutrientsforvegetariansinclud-ingprotein,n-3fattyacids,iron,zinc,iodine,calcium,andvitaminsDandB-12.Avegetariandietcanmeetcur-rentrecommendationsforallofthesenutrients.Insomecases,supplementsorfortiÞedfoodscanprovideusefulamountsofimportantnutrients.Anev-idence-basedreviewshowedthatveg-etariandietscanbenutritionallyad-equateinpregnancyandresultinpositivematernalandinfanthealthoutcomes.Theresultsofanevidence-basedreviewshowedthatavegetar-iandietisassociatedwithalowerriskofdeathfromischemicheartdisease.Vegetariansalsoappeartohavelowerlow-densitylipoproteincholesterollev-els,lowerbloodpressure,andlowerratesofhypertensionandtype2diabe-testhannonvegetarians.Furthermore,vegetarianstendtohavealowerbodymassindexandloweroverallcancerrates.Featuresofavegetariandietthatmayreduceriskofchronicdiseaseincludelowerintakesofsaturatedfatandcholesterolandhigherintakesoffruits,vegetables,wholegrains,nuts,soyproducts,Þber,andphytochemi-cals.Thevariabilityofdietarypracticesamongvegetariansmakesindividualassessmentofdietaryadequacyessen-tial.Inadditiontoassessingdietaryad-equacy,foodandnutritionprofession-alscanalsoplaykeyrolesineducatingvegetariansaboutsourcesofspeciÞcnutrients,foodpurchaseandprepara-tion,anddietarymodiÞcationstomeettheirneeds.JAmDietAssoc.2009;109: POSITIONSTATEMENTItisthepositionoftheAmericanDi-eteticAssociationthatappropriatelyplannedvegetariandiets,includingtotalvegetarianorvegandiets,arehealthful,nutritionallyadequate,andmayprovidehealthbeneÞtsinthepre-ventionandtreatmentofcertaindis-Well-plannedvegetariandietsareappropriateforindividualsduringallstagesofthelifecycle,includingpregnancy,lactation,infancy,child-hood,andadolescence,andforathletes.VEGETARIANDIETSINPERSPECTIVEAvegetarianisapersonwhodoesnoteatmeat(includingfowl)orseafood,orproductscontainingthesefoods.Theeatingpatternsofvegetariansmayvaryconsiderably.Thelacto-ovo-vegetarianeatingpatternisbasedongrains,vegetables,fruits,legumes,seeds,nuts,dairyproducts,andeggs.Thelacto-vegetarianexcludeseggsaswellasmeat,Þsh,andfowl.Thevegan,ortotalvegetarian,eatingpat-ternexcludeseggs,dairy,andotheranimalproducts.Evenwithinthesepatterns,considerablevariationmayexistintheextenttowhichanimalproductsareexcluded.Evidence-basedanalysiswasusedtoevaluateexistingresearchontypesofvegetariandiets⠀).Onequestionforevidence-analysiswasidentiÞed:Whattypesofvegetariandietsareexaminedintheresearch?Thecom-pleteresultsofthisevidence-basedanalysiscanbefoundontheAmeri-canDieteticAssociationÕsEvidenceAnalysisLibrary(EAL)Website⤀andaresummarizedbelow.EALConclusionStatement:ThetwomostcommonwaysofdeÞningvege-tariandietsintheresearcharevegandiets:Dietsdevoidofallßeshfoods;ThisAmericanDieteticAssociation(ADA)positionpaperincludestheauthorsÕindependentreviewoftheliteratureinadditiontosystematicreviewconductedusingtheADAÕsEvidenceAnalysisProcessandinforma-tionfromtheEvidenceAnalysisLibrary.TopicsfromtheEvidenceAnalysisLibraryareclearlydelineated.Theuseofanevidence-basedapproachprovidesimportantaddedbeneÞtstoearlierreviewmethods.Themajoradvantageoftheapproachisthemorerigorousstandardizationofreviewcriteria,whichminimizesthelikelihoodofreviewerbiasandincreasestheeasewithwhichdisparatearticlesmaybecompared.Foradetaileddescrip-tionofthemethodsusedintheevidenceanalysisprocess,accessADAÕsEvidenceAnalysisProcessatConclusionStatementsareassignedagradebyanexpertworkgroupbasedonthesystematicanalysisandevaluationofthesupportingresearchevidence.GradeIGood;GradeIIFair;GradeIIILimited;GradeExpertOpinionOnly;andGradeVNotAssignable(becausethereisnoevidencetosupportorrefutetheconclusion).Evidence-basedinformationforthisandothertopicscanbefoundatandsubscriptionsfornonmembersareavailableforpurchaseat 0002-8223/09/10907-0019$36.00/0doi:10.1016/j.jada.2009.05.027 JournaloftheAMERICANDIETETICASSOCIATION2009bytheAmericanDieteticAssociation