Abstract
Background
Differences in nutrient profiles between vegetarian and non vegetarian dietary patterns reflect nutritional differences that may contribute to the development of disease.
Objective
To compare nutrient intakes between dietary patterns characterized by consumption or exclusion of meat and dairy products.
Design
Cross-sectional study of 71751 subjects (mean age 59 years) from the Adventist-Health-Study-2. Data was collected between 2002 and 2007. Participants completed a 204-item validated semi-quantitative food frequency questionnaire. Dietary patterns compared were: non vegetarian, semi vegetarian, pesco vegetarian, lacto-ovo vegetarian and strict vegetarian. ANCOVA was used to analyze differences in nutrient intakes by dietary patterns and were adjusted for age, and sex and race. BMI and other relevant demographic data were reported and compared by dietary pattern using chi-square tests and ANOVA.
Results
Many nutrient intakes varied significantly between dietary patterns. Non vegetarians had the lowest intakes of plant proteins, fiber, β-Carotene, and Mg than those following vegetarian dietary patterns and the highest intakes of saturated, trans, arachidonic, and docosahexaenoic fatty acids. The lower tails of some nutrient distributions in strict vegetarians suggested inadequate intakes by a portion of the subjects. Energy intake was similar among dietary patterns at close to 2000 kcal/d with the exception of semi vegetarians that had an intake of 1713 kcal/d. Mean BMI was highest in non-vegetarians (mean; standard deviation [SD]) (28.7; [6.4]) and lowest in strict vegetarians (24.0; [4.8]).
Conclusions
Nutrient profiles varied markedly between dietary patterns that were defined by meat and dairy intakes. These differences can be of interest in the etiology of obesity and chronic diseases.
Keywords: Dietary Pattern, Nutrient Profile, Vitamins, Minerals, Vegetarian
INTRODUCTION
Awareness of possible differences in nutrient profiles is of importance when comparing dietary patterns and their associations with disease. Previous studies have shown that dietary patterns characterized by lower meat intake1 are associated with lower risk of disorders such as the metabolic syndrome2;3, diabetes3;4, cardiovascular disease5–7 and certain types of cancers8;9. Variations in nutrient content may account for these observed differences in health outcomes.
The Adventist Health Study 2 (AHS-2) provides a rich data resource to address these questions. With 45% of the 96,335 study subjects being vegetarian, and approximately 8% strict vegetarians, it is presently one of the very few large cohort studies that include a high proportion of vegetarians. Thus associations between vegetarian dietary patterns and health outcomes can be addressed with adequate power.
This report describes the intakes of major nutrients, vitamins and minerals in dietary patterns that are characterized by varying animal and plant food consumption. Relevant demographic and socioeconomic data such as age, education, marital status and income as well as other lifestyle factors such as physical activity, alcohol consumption and smoking were included in this study as they may be of relevance when comparing dietary patterns. To show possible associations that differing dietary patterns may have with health relevant outcomes, BMI was similarly reported and briefly discussed.
SUBJECTS AND METHODS
The analyses are based on cross-sectional data obtained between 2002–2007 from a 50-page self-administered questionnaire10. The number of subjects in the present analysis included 71751 U.S. and Canadian participants from the AHS-2 cohort whose dietary data had been released for analysis10. The study was reviewed and approved by the institutional review board of Loma Linda University, Loma Linda, California, and informed consent was obtained from all participants.
Race and ethnicity were stratified into black (African American, West Indian/Caribbean, African, or other black) and white (white non-Hispanic, Hispanic, Middle Eastern, Asian, Native Hawaiian/other Pacific Islander, or American Indian) subjects. Education was stratified into three categories: completed high school diploma or less; some college; bachelors, masters or higher university degrees.
Participants reported anthropometric data on height (without shoes in feet and inches and weight wearing light clothes) in pounds, that had previously been demonstrated to have good validity.11 BMI was calculated as weight/length2. Alcohol intake and tobacco use were defined as never, past or current consumption.
Assessment of Intake of Nutrients, Vitamins, and Minerals
The FFQ includes more than 204 hard-coded foods and space for approximately 50 writeins, all relating to the diet during the previous one year. It consists of two major sections. The first section includes fruits, vegetables, legumes, grains, nuts, oils, dairy, fish, eggs, meats, and beverages, and the second consists of approximately 70 commercially-prepared products, such as dietary supplements, dry cereals, and vegetarian protein products. Pictures of common foods or beverages typically served together were included with the questionnaire to assist participants in estimating portion sizes. The questionnaire was mailed to each subject, completed at home, and then returned to AHS-2. The FFQ has been validated against 24 hour recall data.12;13 In this report intakes from supplements are combined with dietary intakes, to form total intakes.
FFQ data were entered using the Nutrition Data System for Research version 4.06 (NDS-R, Nutrition Coordinating Center, Minneapolis, MN, USA). Nutrient composition of foods was based on the NDS-R 2008 database, which contains over 20000 foods that are annually updated while maintaining nutrient profiles true to the version used for data collection14.
Dietary Patterns
Dietary patterns were defined by level of animal food intake stratified in five categories 15. Non vegetarians were defined as those consuming some meat (red meat, poultry, at least once per month), and the total of meat and fish >1 time/week. Semi vegetarians may consume dairy products and/or eggs, eat some meat (red meat and poultry) ≥1 time/month, and the total of fish and meat ≥1 time/month but <1 time/week. Pesco vegetarians were subjects consuming fish ≥1 time/month but who consumed red meat and poultry <1 time/month. There were no restrictions on dairy or egg intake. Lacto-ovo vegetarians were those who reported consuming the total of meat, poultry or fish <1/month, also with no restrictions on eggs and or dairy products. Strict vegetarians were subjects who reported consuming each of the following not at all, or less than one time per month: meat (red meat, poultry), fish, eggs, milk, and dairy products.
Nutrient intakes were standardized to 2000 kcal by multiplying observed nutrient by the ratio 2000/measured kcal. Total caloric intake was calculated by summing information from all dietary sources captured in the FFQ. Percentages of energy intake for major nutrients were reported.
Statistical Analysis
On average 6–7% of dietary data were missing for any particular food item and were filled by guided multiple imputation16. Dietary patterns were then compared according to selected demographic variables. Chi-square tests (categorical variables) and ANOVA (continuous variables) were used for these comparisons. Percentiles (5th, 50th and 95th) for nutrient intakes stratified by dietary pattern were reported.
ANCOVA with Sidak’s adjustments for multiple comparisons was used to test nutrient and BMI differences between dietary patterns. Nutrient intakes were logarithmically transformed for statistical testing. Mean values are reported stratified by dietary pattern and adjusted for age, sex or race. Mean intake values that differed by ≥20% between dietary patterns were marked.
Analyses were carried out using the statistical software packages IBM SPSS Statistics 20.0 (SPSS Inc., Chicago, IL, USA) and R 2.13.1: A Language and Environment for Statistical Computing (R Foundation for Statistical Computing, Vienna, Austria). Type I error rate was set at 0.05.
RESULTS
Basic demographic information is reported in Table 1. Significant differences by dietary pattern were seen for all variables. Across all dietary patterns 30 to 55 year olds comprised the largest group (P<0.001). The proportions of men among semi or strict vegetarian were 3 percentage points higher than in non vegetarians. Non-vegetarians and pesco vegetarians had relatively high proportions of blacks (respectively 29.4% and 31.6%), compared to 24.3% overall.
TABLE 1.
Basic socio economic and lifestyle characteristics of the AHS-2a cohort expressed as percentages or mean [SDd] by dietary pattern.
| Non Vegetarian (n=33634) |
Semi Vegetarian (n=4042) |
Pesco Vegetarian (n=6583) |
Lacto Ovo Vegetarian (n=21799) |
Strict Vegetarian (n=5694) |
Pb | |
|---|---|---|---|---|---|---|
| Age Group (years) | <0.001 | |||||
| 30 – 54.9 | 47.1 | 39.2 | 40.4 | 39.3 | 40.1 | |
| 55 – 69.9 | 33.0 | 33.4 | 33.1 | 31.3 | 32.9 | |
| ≥70 | 20.0 | 27.4 | 26.5 | 29.1 | 26.9 | |
| Sex | <0.001 | |||||
| Female | 64.5 | 67.3 | 66.7 | 63.5 | 63.2 | |
| Male | 33.5 | 32.7 | 33.3 | 36.6 | 36.8 | |
| Race | <0.001 | |||||
| Black | 29.4 | 14.4 | 31.6 | 20.7 | 16.9 | |
| White | 70.6 | 85.6 | 68.4 | 89.3 | 83.1 | |
| Education | <0.001 | |||||
| High School or less | 24.6 | 23.0 | 19.6 | 15.2 | 18.5 | |
| Some College | 30.7 | 28.1 | 26.8 | 24.7 | 27.7 | |
| College Degree | 44.6 | 48.9 | 53.6 | 60.1 | 53.9 | |
| Vigorous Physical Activity (min/day) | <0.001 | |||||
| ≥45 | 32.5 | 29.4 | 31.9 | 27.9 | 29.2 | |
| Alcohol consumption | <0.001 | |||||
| Never | 46.6 | 61.1 | 62.4 | 74.1 | 66.8 | |
| Past | 41.7 | 34.3 | 33.2 | 24.0 | 32.8 | |
| Current | 11.8 | 4.4 | 4.4 | 1.9 | 0.4 | |
| Smoking | <0.001 | |||||
| Never | 71.8 | 78.8 | 81.4 | 86.9 | 82.7 | |
| Past | 26.2 | 20.8 | 18.2 | 13.0 | 17.2 | |
| Current | 2.0 | 0.4 | 0.4 | 0.1 | 0.1 | |
| BMIc (kg/m2) | <0.001 | |||||
| <25 | 29.4 | 38.8 | 46.6 | 50.3 | 66.9 | |
| 25–29.9 | 37.3 | 37.0 | 35.5 | 33.0 | 23.7 | |
| ≥30 | 33.3 | 24.2 | 17.9 | 16.7 | 9.4 | |
| Mean[SDd] | 28.7[6.4] | 27.3[5.6] | 26.2[5.2] | 25.9[5.2] | 24.0[4.8] |
AHS-2=Adventist Health Study 2.
Chi-square tests were used to test differences between dietary pattern and P values are reported.
BMI=Body mass index.
SD=Standard Deviation.
Across dietary patterns lacto-ovo vegetarians had the highest proportion of college graduates (60.1%). Lacto-ovo vegetarians had the lowest proportion of low household incomes and strict vegetarians had the highest (28.2% vs. 38.0%). Lacto-ovo and strict vegetarians had the highest proportions of married subjects (78.1% and 76.2%). The proportion of those engaging 45 minutes or more in vigorous physical activity was generally similar across dietary patterns with the highest proportion in non vegetarians (32.5%) and the lowest in lacto-ovo vegetarians (27.9%).
Non vegetarians had the highest proportion of subjects who had used alcohol or tobacco at some point in life (41.7% and 26.2% respectively) and the highest proportions of current users (11.8% and 2% respectively).
Non vegetarians had the highest mean BMI values (28.7, SD 6.4) and the highest proportion of obese subjects (33.3%) when compared to any other dietary pattern. Strict vegetarians had the lowest BMI (24.0, SD 4.8) and the lowest proportion of obese subjects (9.4%). ANCOVA showed that after adjustments for age, sex, race and physical activity dietary pattern was significantly associated with BMI (P<0.001) with non vegetarians having much higher mean BMI values than the vegetarian groups. Mean BMI values including confidence intervals (CI) were: non vegetarians (28.6; CI 28.6–28.7), semi vegetarians (27.4; CI 27.3–27.6), pesco vegetarians (26.1; CI 26.0–26.2), lacto-ovo vegetarians (26.1; CI 26.0–26.2) and strict vegetarians (24.1; CI 24.0–24.2).
Table 2 reports 5th, 50th and 95th percentiles for each nutrient. In many cases nutrient intakes were skewed. For nutrients, values at the 95th percentiles were generally 2–3 times higher than those at the 5th percentiles. For a few nutrients, and for most vitamins and minerals, this ratio was much higher. More than 50% of both lacto-ovo-vegetarians and strict vegetarians reported zero intakes of DHA, and the 5th percentiles of vitamin B12 intake (0.4µg/day) and vitamin D intake (0.1 µg/day) in strict vegetarians were low.
TABLE 2.
The 5th, 50th and 95th percentiles of dietary and total nutrient intakes standardized to 2000 kcal/day by dietary pattern in the AHS-2a cohort.
| Non Vegetarian |
Semi Vegetarian |
Pesco Vegetarian |
Lacto Ovo Vegetarian |
Strict Vegetarian |
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5th | Percentiles Median |
95th | 5th | Percentiles Median |
95th | 5th | Percentiles Median |
95th | 5th | Percentiles Median |
95th | 5th | Percentiles Median |
95th | |
| Food Intake (g/d) | 1324 | 2776 | 4822 | 1277 | 2625 | 4379 | 1406 | 2874 | 4877 | 1458 | 2799 | 4534 | 1501 | 2974 | 4767 |
| Caloric Intake (kcal/d) | 836 | 1773 | 3408 | 753 | 1609 | 3037 | 863 | 1815 | 3387 | 918 | 1803 | 3210 | 910 | 1791 | 3269 |
| Energy density (kcal/kg) | 384 | 652 | 1069 | 363 | 623 | 1057 | 399 | 645 | 1057 | 400 | 653 | 1071 | 377 | 610 | 1048 |
| Carbohydrate (% Energy) | 37.8 | 53.4 | 68.1 | 42.5 | 56.2 | 70.3 | 43.0 | 56.9 | 71.0 | 43.9 | 57.0 | 69.8 | 47.7 | 61.7 | 75.2 |
| Protein (% Energy) | 10.7 | 14.9 | 20.5 | 10.2 | 14.2 | 19.4 | 10.6 | 14.5 | 20.0 | 10.6 | 14.1 | 19.0 | 10.4 | 14.1 | 19.5 |
| Plant Protein (% Energy) | 4.8 | 8.5 | 13.7 | 6.5 | 10.6 | 15.6 | 7.4 | 11.4 | 16.9 | 7.8 | 11.7 | 16.6 | 10.0 | 13.5 | 18.6 |
| Animal Protein (% Energy) | 2.2 | 5.9 | 12.2 | 1.0 | 3.1 | 7.7 | 0.8 | 2.6 | 7.0 | 0.5 | 1.9 | 6.3 | 0.1 | 0.5 | 1.4 |
| Fat (% Energy) | 21.9 | 34.5 | 49.3 | 20.5 | 33.3 | 47.3 | 20.2 | 32.5 | 46.9 | 21.6 | 33.0 | 46.3 | 17.7 | 29.4 | 43.9 |
| PUFAb (% Energy) | 5.4 | 8.8 | 13.3 | 5.5 | 9.4 | 13.9 | 5.8 | 9.4 | 14.2 | 6.2 | 9.8 | 14.3 | 5.7 | 9.5 | 14.4 |
| MUFAc (% Energy) | 8.1 | 14.0 | 22.7 | 7.4 | 13.4 | 21.9 | 7.2 | 13.3 | 22.5 | 7.8 | 13.4 | 21.5 | 6.1 | 12.0 | 21.6 |
| SFAd (% Energy) | 4.9 | 8.6 | 13.9 | 4.3 | 7.7 | 12.6 | 3.8 | 6.7 | 11.1 | 4.1 | 7.0 | 11.4 | 3.0 | 5.0 | 8.2 |
| Total Carbohydrate (g) | 189 | 267 | 341 | 212 | 281 | 352 | 215 | 285 | 355 | 219 | 285 | 349 | 238 | 309 | 376 |
| Total Sugar (g) | 61 | 106 | 178 | 66 | 108 | 176 | 66 | 108 | 174 | 67 | 106 | 164 | 68 | 107 | 176 |
| Total Fiber (g) | 16.2 | 29.8 | 46.1 | 21.0 | 34.6 | 50.7 | 23.3 | 37.4 | 53.7 | 23.6 | 37.3 | 52.2 | 33.7 | 46.4 | 61.2 |
| Total Protein (g) | 53.5 | 74.7 | 103 | 50.8 | 70.8 | 97.0 | 52.8 | 72.7 | 100 | 53.1 | 70.6 | 95.1 | 52.2 | 70.7 | 97.3 |
| Plant Protein (g) | 24.0 | 42.7 | 68.3 | 32.7 | 52.8 | 78.2 | 37.0 | 56.9 | 84.3 | 39.2 | 58.6 | 83.0 | 49.9 | 67.7 | 92.8 |
| Animal Protein (g) | 10.8 | 29.4 | 61.2 | 4.8 | 15.3 | 38.6 | 3.9 | 13.2 | 35.0 | 2.5 | 9.6 | 31.3 | 0.7 | 2.5 | 7.1 |
| Dairy Protein (g) | 1.4 | 9.3 | 29.4 | 0.7 | 7.7 | 30.0 | 0.4 | 4.5 | 23.7 | 0.5 | 4.8 | 25.7 | 0.2 | 0.6 | 2.4 |
| Soy Protein (g) | 0.0 | 2.8 | 17.7 | 0.0 | 5.9 | 22.6 | 0.8 | 8.5 | 27.5 | 1.3 | 8.0 | 25.1 | 1.3 | 10.9 | 31.3 |
| Total Fat (g) | 48.7 | 76.7 | 110 | 45.5 | 74.0 | 105 | 44.9 | 72.1 | 104 | 48.1 | 73.4 | 103 | 39.3 | 65.4 | 97.6 |
| PUFAb (g) | 11.9 | 19.6 | 29.6 | 12.3 | 20.8 | 31.0 | 12.9 | 21.0 | 31.5 | 13.9 | 21.8 | 31.9 | 12.8 | 21.1 | 32.1 |
| MUFAc (g) | 17.9 | 31.0 | 50.4 | 16.4 | 29.7 | 48.6 | 16.0 | 29.5 | 50.0 | 17.3 | 29.7 | 47.7 | 13.6 | 26.7 | 48.1 |
| SFAd (g) | 10.9 | 19.1 | 30.8 | 9.5 | 17.0 | 27.9 | 8.5 | 14.9 | 24.7 | 9.2 | 15.6 | 25.3 | 6.7 | 11.2 | 18.2 |
| TFAe (g) | 1.3 | 3.9 | 9.1 | 1.0 | 3.5 | 8.7 | 0.6 | 2.7 | 7.2 | 0.9 | 3.2 | 7.9 | 0.3 | 1.7 | 5.1 |
| Omega 3 (g) | 1.2 | 2.1 | 3.9 | 1.1 | 2.0 | 3.7 | 1.3 | 2.2 | 4.1 | 1.1 | 2.0 | 3.5 | 1.0 | 1.8 | 3.5 |
| Linoleic Acid (g) | 10.1 | 17.1 | 26.4 | 10.8 | 18.6 | 27.9 | 11.0 | 18.5 | 28.0 | 12.4 | 19.7 | 28.8 | 11.5 | 19.1 | 29.1 |
| Arachidonic Acid (mg) | 18.4 | 71.5 | 198 | 4.1 | 19.2 | 66.7 | 2.7 | 32.6 | 130 | 0.0 | 6.0 | 40.2 | 0.0 | 0.0 | 6.3 |
| DHAh (mg) | 3.2 | 102 | 706 | 0.0 | 3.1 | 411 | 0.0 | 98.4 | 762 | 0.0 | 0.0 | 253 | 0.0 | 0.0 | 1.8 |
| Vitamin B6 (mg) | 1.5 | 3.1 | 72.4 | 1.7 | 3.4 | 85.1 | 1.8 | 3.5 | 86.8 | 1.8 | 3.3 | 75.9 | 1.9 | 3.2 | 81.2 |
| Vitamin B12 (µg) | 2 | 7.1 | 64.5 | 1.6 | 8.3 | 75.4 | 1.6 | 8.5 | 88.6 | 1.5 | 8 | 80.7 | 0.4 | 6.3 | 89.1 |
| Vitamin C (mg) | 70 | 250 | 1660 | 84.3 | 273 | 1939 | 101 | 308 | 1862 | 95.8 | 271 | 1701 | 109 | 293 | 1810 |
| Folate (µg) | 356 | 672 | 1822 | 403 | 731 | 1959 | 427 | 766 | 1934 | 427 | 729 | 1870 | 457 | 723 | 1845 |
| β-Carotene (µg) | 1485 | 5525 | 21983 | 1685 | 5861 | 21820 | 2284 | 7417 | 31853 | 1969 | 6303 | 25823 | 2554 | 8474 | 39071 |
| Vitamin D (µg) | 1.4 | 6.1 | 30.3 | 0.7 | 5.5 | 32 | 0.9 | 5.8 | 30.3 | 0.5 | 4.6 | 28 | 0.1 | 2.4 | 24.5 |
| Vitamin E (mg) | 6.8 | 20 | 504 | 7.9 | 26.1 | 561 | 8.4 | 26.9 | 511 | 8.5 | 24.7 | 510 | 8.9 | 18.5 | 481 |
| Ca (mg) | 535 | 1072 | 2790 | 575 | 1195 | 3107 | 574 | 1125 | 2770 | 577 | 1145 | 2854 | 520 | 933 | 2556 |
| Fe (mg) | 12.1 | 20 | 71.4 | 13.6 | 21.7 | 61.8 | 14.4 | 22.4 | 75.6 | 14.7 | 22.1 | 61 | 16.2 | 22.2 | 53.1 |
| K (mg) | 2197 | 3487 | 5091 | 2390 | 3627 | 5258 | 2589 | 3853 | 5521 | 2547 | 3667 | 5161 | 2934 | 4120 | 5922 |
| Mg (mg) | 271 | 448 | 966 | 320 | 492 | 1087 | 340 | 519 | 1061 | 341 | 514 | 1063 | 433 | 591 | 1162 |
| Na (mg) | 1852 | 3272 | 7301 | 1848 | 3346 | 7448 | 1595 | 3101 | 6734 | 1931 | 3432 | 7304 | 1475 | 3066 | 7043 |
| P (mg) | 984 | 1359 | 1872 | 994 | 1360 | 1865 | 1018 | 1366 | 1823 | 1028 | 1348 | 1805 | 1044 | 1370 | 1710 |
| Zn (mg) | 7.4 | 11.9 | 44.9 | 7.3 | 11.6 | 47.4 | 7.2 | 11.5 | 43.9 | 7.5 | 11.5 | 44.9 | 7.9 | 11.3 | 41.5 |
AHS-2=Adventist Health Study 2.
PUFA=Poly Unsaturated Fatty Acid.
MUFA= Mono Unsaturated Fatty Acid.
SFA= Saturated Fatty Acid.
TFA=Trans Fatty Acid.
DHA= Docosahexaenoic Acid.
Table 3 summarizes mean nutrient intakes including standard errors. Intakes of animal derived proteins and fats were highest in non vegetarians. Figure 1 illustrates these contrasts for different protein fractions. The mean percentage of energy derived from animal protein was 2.5 times higher in non vegetarians than in lacto-ovo vegetarians. Intakes of plant protein, glucose, and fiber were lowest in non vegetarians. Vitamins associated with fruits and vegetables were lower in non vegetarians than in other groups, whereas intakes of vitamins B12 and D were highest in non-vegetarians.
TABLE 3.
Mean nutrient intake values with standard errors (SE) standardized to 2000 kcal/d stratified by dietary pattern with adjustments made for sex, race and age in the AHS-2a
| Non Vegetarian |
Semi Vegetarian |
Pesco Vegetarian |
Lacto Ovo Vegetarian |
Strict Vegetarian |
||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Mean | SE | Mean | SE | Mean | SE | Mean | SE | Mean | SE | |
| Caloric Intake (kcal/d) | 1890 | 4 | 1713 | 12 | 1937 | 9 | 1899 | 5 | 1894 | 10 |
| Carbohydrate (% Energy) | 53.1 | <0.1 | 56.6 | 0.1 | 56.8 | 0.1 | 57.2 | 0.1 | 61.7 | 0.1 |
| Protein (% Energy) | 15.2 | <0.1 | 14.4 | <0.1 | 14.9 | <0.1 | 14.4 | <0.1 | 14.5 | <0.1 |
| Plant Protein (% Energy) | 8.8 | <0.1 | *10.8 | <0.1 | *11.6 | <0.1 | *11.9 | <0.1 | *13.8 | <0.1 |
| Animal Protein (% Energy) | 6.4 | <0.1 | *3.5 | <0.1 | *3.2 | <0.1 | *2.4 | <0.1 | *0.6 | <0.1 |
| Fat (% Energy) | 35.1 | <0.1 | 33.4 | 0.1 | 33 | 0.1 | 33.1 | 0.1 | 29.8 | 0.1 |
| Total Carbohydrate (g) | 266 | 0.2 | 283 | 0.7 | 284 | 0.5 | 286 | 0.3 | 309 | 0.6 |
| Total Sugar (g) | 110 | 0.2 | 113 | 0.5 | 111 | 0.4 | 110 | 0.2 | 112 | 0.5 |
| Total Fiber (g) | 30.4 | <0.1 | *34.9 | 0.1 | *37.7 | 0.1 | *37.5 | 0.1 | *46.7 | 0.1 |
| Total Protein (g) | 75.8 | 0.1 | 71.8 | 0.2 | 74.3 | 0.2 | 72.0 | 0.1 | 72.3 | 0.2 |
| Plant Protein (g) | 43.9 | 0.1 | *54.1 | 0.2 | *58.2 | 0.2 | *59.7 | 0.1 | *69.2 | 0.2 |
| Animal Protein (g) | 31.8 | 0.1 | *17.6 | 0.2 | *16.0 | 0.2 | *12.2 | 0.1 | *3.1 | 0.2 |
| Dairy Protein (g) | 11.8 | <0.1 | 10.2 | 0.1 | *7.7 | 0.1 | *7.5 | 0.1 | *0.7 | 0.1 |
| Soy Protein (g) | 4.9 | <0.1 | *8.0 | 0.1 | *10.5 | 0.1 | *10.2 | 0.1 | *13.1 | 0.1 |
| Total Fat (g) | 78.1 | 0.1 | 74.2 | 0.3 | 73.4 | 0.2 | 73.6 | 0.1 | 66.1 | 0.2 |
| bPUFA (g) | 20.2 | <0.1 | 21.1 | 0.1 | 21.5 | 0.1 | 22.1 | <0.1 | 21.6 | 0.1 |
| cMUFA (g) | 32.4 | 0.1 | 30.5 | 0.2 | 30.9 | 0.1 | 30.3 | 0.1 | 28 | 0.1 |
| dSFA (g) | 19.9 | <0.1 | 17.4 | 0.1 | *15.8 | 0.1 | 16 | <0.1 | *11.6 | 0.1 |
| eTFA (g) | 4.4 | <0.1 | 4 | <0.1 | *3.1 | <0.1 | 3.6 | <0.1 | *2.1 | <0.1 |
| Omega 3 (g) | 2.3 | <0.1 | 2.1 | <0.1 | 2.4 | <0.1 | 2.1 | <0.1 | 2 | <0.1 |
| Linoleic Acid (g) | 17.6 | <0.1 | 18.8 | 0.1 | 19 | 0.1 | 19.9 | <0.1 | 19.5 | 0.1 |
| Arachidonic Acid (mg) | 84.1 | 0.3 | *27.2 | 0.7 | *43.6 | 0.6 | *13.4 | 0.3 | *2.6 | 0.6 |
| fDHA (mg) | 182 | 1.2 | *69.8 | 3.6 | 187 | 2.8 | *33.8 | 1.5 | *18.2 | 3 |
| Vitamin B6 (mg) | 13.5 | 0.2 | 14.9 | 0.5 | 15.7 | 0.4 | 13.6 | 0.2 | 14.4 | 0.4 |
| Vitamin B12 (µg) | 22.1 | 0.4 | 24.3 | 1.2 | 26.5 | 1 | 24.2 | 0.5 | 23.3 | 1 |
| Vitamin C (mg) | 488 | 3.5 | 530 | 10 | 568 | 7.8 | 497 | 4.3 | 531 | 8.4 |
| Folate (µg) | 848 | 2.9 | 912 | 8.2 | 926 | 6.5 | 889 | 3.6 | 888 | 6.9 |
| β-Carotene (µg) | 8830 | 84.6 | 8987 | 242 | *11275 | 190 | 10002 | 106 | *13300 | 204 |
| Vitamin D (µg) | 10.6 | 0.1 | 9.9 | 0.2 | 9.8 | 0.2 | 8.6 | 0.1 | *6.3 | 0.2 |
| Vitamin E (mg) | 122 | 1 | 131 | 2.9 | 132 | 2.3 | 116 | 1.3 | 101 | 2.4 |
| Ca (mg) | 1333 | 4 | 1410 | 11.4 | 1352 | 9 | 1332 | 5 | 1156 | 9.6 |
| Fe (mg) | 32.9 | 0.3 | 34.1 | 0.9 | 34.6 | 0.7 | 34.1 | 0.4 | 31.6 | 0.8 |
| K (mg) | 3550 | 4.8 | 3694 | 13.6 | 3910 | 10.7 | 3745 | 5.9 | 4234 | 11.5 |
| Mg (mg) | 509 | 1.3 | 554 | 3.7 | 581 | 2.9 | 567 | 1.6 | *652 | 3.1 |
| Na (mg) | 3788 | 10.5 | 3808 | 30 | 3537 | 23.6 | 3851 | 13.1 | 3531 | 25.3 |
| P (mg) | 1391 | 1.4 | 1381 | 4.1 | 1394 | 3.2 | 1363 | 1.8 | 1371 | 3.5 |
| Zn (mg) | 18.7 | 0.1 | 18.6 | 0.2 | 18.4 | 0.2 | 17.9 | 0.1 | 16.3 | 0.2 |
ANCOVA was used in testing differences between dietary patterns. Values were logarithmically transformed for statistical testing. Values for effects of dietary pattern was P<0.001 for all reported nutrients and are therefore not indicated in an individual column.
Significant contrast (P<0.05) and a mean difference ≥20% when compared to non vegetarian dietary pattern as the group of reference.
AHS-2=Adventist Health Study 2.
PUFA=Poly Unsaturated Fatty Acid.
MUFA= Mono Unsaturated Fatty Acid.
SFA= Saturated Fatty Acid.
TFA=Trans Fatty Acid.
DHA= Docosahexaenoic Acid.
Figure 1.
Dietary mean protein intakes by dietary pattern in the AHS-2. Adjustments were made for age, sex and race.
Total calorie intake was lowest in semi vegetarians. There was little difference between semi vegetarians and other non-strict vegetarians for dietary calcium. Intakes of dairy protein were higher in non- and semi-vegetarians than lacto-ovo vegetarians.
Pesco vegetarians had intake values for most variables that were close to those of lacto-ovo vegetarians. However, animal protein intake was comparatively higher, as was intake of arachidonic acid. Intakes of Omega 3 fatty acids, vitamin E and D were highest in pesco vegetarians.
Lacto-ovo vegetarians had significantly lower intakes of dairy fat and protein than non vegetarians. Strict vegetarians had the lowest intakes of saturated, trans-fat, and arachidonic acid and the highest intakes of fiber, soy protein and vitamins C, folate, β-carotene and E. Calcium and iron intakes were also lowest in strict vegetarians.
DISCUSSION
The present study found that mean nutrient intakes often differed greatly across dietary groups. Contrasts were usually greatest between strict vegetarians and non vegetarians. Previous studies have shown that plant-based dietary patterns or diets restricted in animal products are associated with both lower cardio-metabolic risk and lower coronary heart disease event rates 4;17–19. These findings may be related to the sizeable differences in nutrient composition between the dietary patterns.
Energy-dense nutrients such as total fat, saturated fat, and trans-fat which have often been associated with higher rates of vascular disease20 were highest in non vegetarians and lowest in strict vegetarians. In addition, vegetarians had higher intakes of fiber in the form of fiber-rich foods, such as fruits, vegetables, and nuts21 which has been associated with lower rates of several chronic diseases20;22;23. The higher intake of long chain omega-3 fatty acids in pesco vegetarians may be protective, as these fatty acids have been associated with lower rates of sudden cardiac death and possibly prostate cancer24.
The results showed that there were small amounts of animal protein consumed by strict vegetarians. This may be due to the rare consumption of some animal-derived foods (less than one time per month) or alternatively may be artifacts of the food database used to evaluate certain recipes.
Strict vegetarians had the highest intakes of vitamins that are commonly associated with fruits. However, differences were less pronounced after taking into account the intake of supplements, as strict vegetarians used less supplements than subjects with other dietary patterns (data not shown).
In strict vegetarians low dietary intakes of vitamin B12 and D, calcium, and omega-3 fatty acids, in addition to iron and zinc, have often been of concern25. In the present study, mean intakes of these nutrients were above minimum requirements26 in strict vegetarians. The fortification of many foods may provide relatively high mean intakes of these nutrients that are sometimes marginal among strict vegetarian living in other geographic and cultural contexts. However, relatively low intakes of vitamin B12 and D, (Table 2) are of concern for a small proportion of Adventist strict vegetarians in the U.S., as can be seen in the very low intakes at the 5th percentile.
Marked differences in BMI were seen between the dietary groups (see Table 1). Strict vegetarians were the only group with a mean BMI value (24.0 kg/m2) below the cut-off point (25.0 kg/m2) defining overweight status. There was a clear association between higher proportions of obesity, higher mean levels of BMI, and dietary patterns characterized by progressively higher intakes of meat and dairy products. The contrast was stark when comparing non vegetarians who had 33.3% prevalence of obesity and an adjusted mean BMI of 28.6 with strict vegetarians who had 9.4% obesity rate and an adjusted mean BMI of 24.1.
These marked differences in BMI are of particular interest given that total energy intakes were similar between the dietary patterns whereas mean macronutrient composition and micronutrient intakes were markedly different between the dietary patterns. Some studies have suggested that the source and composition of dietary energy intake may affect body weight independent of total energy consumption27 and our findings are consistent with these observations.
Smaller studies of vegetarian subjects have also shown lower BMI levels for vegetarians when compared to non vegetarians28;29. A large study, the Epic-Oxford study30, which to our knowledge has the highest numbers of vegetarian subjects beside the AHS-2, also reported similar results. However, BMI levels were markedly higher in our American study across all dietary pattern groups when compared to the U.K subjects30.
The observed differences in obesity between dietary patterns that were seen in our study and in previous investigations may be of particular interest in view of the rising prevalence of obesity in both industrialized and economically developing countries31.
Comparing AHS-2 Americans with British lacto-ovo vegetarians, reported total energy intake in the U.S. was 5% lower in men and 1.8% higher in women, than in the U.K. Energy-adjusted consumption of U.S. lacto-ovo vegetarians (men; women) was (12.5%; 7.8%) higher for carbohydrates, (5.1%; 9.5%) higher for total fat, (23.2%; 22.8%) lower for SFA, and (74.6%; 89.0%) higher for PUFA, than in the U.K.
Dietary fiber intakes, measured in g/day, were (62.1%; 60.1%) higher in American vegetarians than the corresponding non-starch polysaccharide figures in the U.K. Dietary intakes of vitamins were often much higher in the U.S. lacto-ovo vegetarians, this being true for vitamins B12, C, folate, and vitamin D, although intakes of vitamin E were similar. Iron, magnesium, and zinc were higher in the U.S., often markedly so, while dietary calcium and potassium intakes were lower in the U.S.
Some of the observed differences between U.S. and U.K. vegetarians may be due to fortification of foods, or the relative high intake of nuts in U.S. Adventists32. Thus there appear to be dissimilarities of vegetarian dietary habits between countries, although reported differences may be partly attributable to differing dietary assessment methods or differences in the dietary tables used.
CONCLUSIONS
The present study provides new data on dietary intakes in a large population. Dietary patterns defined by intakes of animal-derived foods are associated with large differences in nutrient, vitamin, and mineral intakes in this large study population. Thus, these dietary patterns identify strongly contrasting groups of subjects. Associations between diet patterns and health outcomes, perhaps partially mediated by the markedly different dietary intakes and BMI values, are of interest and invite continued investigation.
Acknowledgements
Funding Disclosure
This work was supported by the National Institutes of Health Grant 1R01-CA-94594. Nico S. Rizzo was supported by the National Institute of Food and Agriculture Grant 2010-38938-20924.
Footnotes
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Contributor Information
Nico S. Rizzo, med. Dr., PhD, Asst. Professor, Department of Nutrition, School of Public Health, Loma Linda University, Loma Linda, CA, USA. 24951 North Circle Drive, Loma Linda, CA 92350, USA. Tel: +1 909 558 4300 ext. 47167, Fax: +1 909 558 4095, nrizzo@llu.edu
Karen Jaceldo-Siegl, DrPH, Asst. Professor, Department of Nutrition, School of Public Health, Loma Linda University, Loma Linda, CA, USA. Tel: +1 909 558 4300 ext. 87580, Fax: +1 909 558 4095, kjaceldo@llu.edu.
Joan Sabate, MD, DrPH, Professor, Department of Nutrition, School of Public Health, Loma Linda University, Loma Linda, CA, USA. Tel: +1 909 558 4300, Fax: +1 909 558 4095, kjaceldo@llu.edu.
Gary E. Fraser, PhD, Professor, Department of Epidemiology, School of Public Health, Loma Linda University, Loma Linda, CA, USA. Tel: +1 909 558 4300, Fax: +1 909 558 4095, efraser@llu.edu
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