FROM THE ACADEMY Position Paper

Position of the Academy of and Dietetics: Vegetarian Diets

ABSTRACT POSITION STATEMENT It is the position of the Academy of Nutrition and Dietetics that vegetarian diets can It is the position of the Academy of Nutrition provide health benefits in the prevention and treatment of certain health conditions, and Dietetics that vegetarian diets may pro- vide health benefits in the prevention and including atherosclerosis, , , and . Well-designed treatment of certain health conditions, vegetarian diets that may include fortified or supplements meet current including atherosclerosis, type 2 diabetes, nutrient recommendations and are appropriate for all stages of the life cycle, including hypertension, and obesity. Well-designed fi pregnancy, lactation, infancy, childhood, and adolescence. Vegetarians must use special vegetarian diets that may include forti ed foods or supplements meet current nutrient care to ensure adequate intake of vitamin B-12. Vegetarian diets are primarily - recommendations and are appropriate for all based, comprised of , , nuts, , , and ; do not include stages of the life cycle, including pregnancy, flesh foods (beef, pork, poultry and fowl, wild game, and fish); and may or may not lactation, infancy, childhood, and adoles- include some animal products, such as (milk and milk products), eggs, and pro- cence. Vegetarians must use special care to ensure an adequate intake of vitamin B-12. cessed foods that contain casein or whey. Although vegetarians may have a higher deficiency risk for some nutrients (eg, vitamin B-12) compared to nonvegetarians, nutritional deficiencies are not the main causes of mortality or morbidity in Western societies. Vegetarian diets are associated with a lower risk of ischemic heart disease, hypertension, type 2 diabetes, obesity, and some types of cancer; low-fat vegetarian diets, in combination with other healthy lifestyle factors, have been shown to be effective in the treatment of these diseases. Vegetarians have lower low-density lipoprotein, better serum glucose control, and lower oxidative stress. Low intake of foods containing and , and high intake of vegetables, , whole grains, legumes, nuts and seeds, and soy products that are rich in fiber and phytochemicals are components of a vegetarian that contribute to reduction of chronic disease. J Acad Nutr Diet. 2015;115:801-810.

EGETARIANISM, A GENERAL plant-based eating pattern can be limited or eliminated. Interest in and term given to plant-based appropriate for these purposes and commitment to a vegetarian diet may diets, is inherently complex in more as they deliver adequate nutrition fluctuate throughout the life cycle, V eating style, choice, and to satisfy current recommendations. Yet, based on the previously mentioned the motivation that leads one to choose simply avoiding meat, dairy, or eggs factors as well as economics, moral a vegetarian lifestyle. does not guarantee adequate nutrition, concern for the environment, and in the United States during the 16th and individuals who describe them- ethical support for . Mo- through 18th centuries may have been selves as vegetarian may not be eating tivations for choosing a vegetarian diet born from social, political, and religious healthfully. are not static. In fact, vegetarian adults concerns—complete with spiritual roots, Vegetarian dietary patterns are quite exhibit constant fluidity, as some have biblical prohibitions regarding eating diverse and variant due to food avail- dropped their initial motivation, added meat, and heated philosophical, psycho- ability, region, age, gustatory reasons, new ones, and modified their beliefs logical, and medical debate.1 Today, and religious and cultural beliefs. They over time. Of interest, vegetarian di- choosing to adopt a vegetarian diet encompass a wide array of plant foods etary patterns based on health may be may stem from a compassionate moral and food practices based on these fac- more flexible than those based on order to protect animals and our envi- tors and always begin with a plant- religious or moral reasons.2 Motiva- ronment, enhance quality of life, prevent based foundation. Vegetarian diets are tions influence dietary practices, health complications, or promote self- almost always comprised of plant which may impact nutrient intake. management strategies to therapeuti- foods, such as grains, legumes, nuts, Although there is some risk for cally treat disease. A well-designed, seeds, vegetables, and fruit; animal nutrient deficiencies in a vegetarian products, such as flesh foods (beef, diet compared to nonvegetarian diets, pork, poultry and fowl, wild game, and there are tremendous advantages 2212-2672/Copyright ª 2015 by the fish), dairy (milk and milk products) toward prevention of chronic health Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2015.02.033 and eggs, along with processed conditions by adhering to a vegetarian foods that contain casein or whey, are eating pattern.

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Being well informed of these issues nationwide poll, which is up by 2% societies formed from the offshoot of will enhance the counsel of registered from a similar poll taken in 2006.3 The the 1975 World Vegetarian Congress dietitian nutritionists (RDNs) and nu- same poll revealed 47% of Americans share the principles of and accessibility trition and dietetics technicians, regis- eat at least one vegetarian meal per to vegetarianism with conventional tered (NDTRs) regardless of clients’ week. More than half to nearly three- audiences. reasons, convictions, motivation, and fourths of vegetarians and vegans pol- Also, the outreach of vegetarian food nutrition knowledge. RDNs and NDTRs led seek healthier whole-food options festivals is growing and aims to extend should be aware of these considerable and would purchase a vegan deli compassion into the community. For health advantages of a vegetarian diet sandwich in a chain restaurant. Forty- instance, for more than 15 years, the to more effectively counsel and educate four percent of younger consumers free-admission Boston Vegetarian Food clients on the utility of plant-based di- choose meatless meals once weekly.4 Festival has grown from 1 to 2 days to ets for disease prevention and man- One in four US adults claim to be sample foods; attend presentations; agement. RDNs and NDTRs, along with meat reducers, those who continue to and learn about eco-friendly, sustain- assessing knowledge, beliefs, reasons, eat meat but for health reasons limit able vegetarian diets. This growth re- and motivations for choosing a vege- their intake. This is another growing sulted in selling tickets for prefestival tarian dietary pattern, should educate field moving toward plant-based diets hours to shop without crowds. New on the importance of including a variety of which to take note. York and San Francisco’s veggie food of colorful fresh or frozen foods that are There is a growing demand for fests have also added days and moved unrefined and minimally processed. products that are “meat-free,” have a to larger venues. This speaks well to This will promote self-management “meat-like texture,” are “suitable for substantiate the growing percentage of strategies that meet nutrition needs vegetarians,” and are for “meat and Americans experimenting with meat- and address specificnutrientconsider- veggie lovers alike.”5 Sales of alterna- free eating. ations to assure optimal nutrition. tive meat products, driven largely by A plant-based diet, which is the foun- What follows are some of the types health reasons and resemblance to dation of a vegetarian diet, is becoming of plant-based diets one may choose: meat, reached $553 million in 2012, an mainstream, as further evidenced by 8% increase in 2 years; 31% and 36% of many nonprofit and governmental in- Vegetarian diet: A vegetarian survey responders sought organic and stitutions highlighting this dietary diet is devoid of all flesh foods, vegan meat alternatives, respectively, choice. The American Institute for Can- but may include egg or dairy especially in the 18- to 44-year age cer Research encourages a plant-based products. group.5,6 This age group is more likely diet defined as two-thirds of our di- Ovo-vegetarian diet: A vegetarian to follow a strict diet, be interested in etary intake being comprised of vege- diet free from flesh foods and current dietary fads like gluten- and tables, fruits, whole grains, and .7 dairy foods but includes eggs. lactose-free diets, and tend toward so- In addition, the US Department of Lacto-ovo-vegetarian diet: A vege- cial media in a way the older popu- modified meal plans for tarian diet free from flesh foods but lation does not. Thus, the high lacto-ovo-vegetarian and vegan dietary includes eggs and dairy products. availability of ready-to-eat, refined, patterns are listed as Appendices 8 and Vegan diet: A vegan dietary gluten-free, and faux-meat foods may 9 of the 2010 Dietary Guidelines for pattern is free from all flesh be enticing to this group who adopt Americans.8 And, the National School foods, eggs and dairy products, a vegetarian lifestyle. However, a diet Lunch Program, while not requiring and sometimes honey. heavy in nonanimal, meat-like prod- vegetarian options per se, requires Raw vegan diet: A strictly fresh ucts and refined and highly processed schools to increase availability of and uncooked food intake based vegetarian foods, while allowing the fruits, vegetables, and whole grains in on fruit, nuts, seeds, and client to remain committed to a moral, current meal patterns in the school vegetables. ethical, or health obligation to eat menu. These government-driven and Macrobiotic diet: A strict whole- vegetarian, may diminish or limit health institutional changes reflect a foods, plant-based diet that in- overall nutrition. Many of these “con- considerable shift in the attitude of cludes fish but no other flesh venience” foods have little nutritional Americans. foods and includes mostly brown value and added sugars and high- Lastly, those adhering to a vegetarian rice and whole grains supple- fructose corn syrup, salt, and chemical lifestyle now have technological sup- mented with local vegetables additives. Noting avoidance of certain port. To date, while no online nutrition and seaweed, beans, nuts, seeds, foods, like gluten or lactose, and the food tracker exists strictly for vegetar- certain fruits, and soup. client’s reason will enable a more ians, some allow clients adopting this Semi-vegetarian diet: A plant- thoughtful recommendation by the lifestyle to select vegetarian and vegan based dietary pattern with occa- RDN. plans. Various applications for mobile sional beef, pork, poultry, or fish Leading scientists and vegetarian devices allow vegetarians to grasp perhaps once or twice weekly. experts from all over the world join nutritional needs, track intake, and together every 5 years at Loma Linda locate restaurants and markets where TRENDS, DIVERSITY, AND University for the International Con- vegan foods are available. The online MOTIVATIONS THAT INFLUENCE gress on Vegetarian Nutrition. Here, tracking tool at www.SuperTracker. ADULT VEGETARIANS presentations on the most up-to-date usda.gov is a part of the US Depart- In 2012, approximately 5% of US vegetarian health research and up- ment of Agriculture Choose MyPlate adults were vegetarian, according to a dates are heard. Local vegetarian program.9

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NUTRITION CONSIDERATIONS with these essential oils, their dose is source of in cooked foods, may FOR VEGETARIANS relatively small, as is their contribution prove to be the most important factor fi to overall intake when compared to in iron de ciency prevention. the recommendations.14 RDNs should A concern that vegetarians, especially assess dietary intake of essential fatty vegans and vegan athletes, may not acids for all stages of the life cycle and consume an adequate amount and Individuals in most regions of the recommend consideration of available world who habitually adhere to vege- quality of protein is unsubstantiated. vegetarian-friendly supplements to en- Vegetarian diets that include a variety tarian diets, especially vegans, have sure adequate intake and stores. 23 of plant products provide the same low zinc intakes and status. Vegans protein quality as diets that include Iron and vegetarian women from devel- meat.10 Protein consumed from a vari- oping countries have the highest risk of Generally, because iron intake among low zinc intake and status. Due to the ety of plant foods supplies an adequate vegetarian men and postmenopausal quantity of essential amino acids when presence of zinc absorption inhibitors women is higher than the Institute of in plant foods, the recommendation caloric intake is met. Pregnant and Medicine’s recommendation, iron de- lactating vegetarian women, including for vegetarians, compared to non- ficiency and depletion of iron stores 15 vegan women, need to follow the vegetarians, is 50% greater. This are almost never noted among these highlights the need for a higher intake recommendation for protein intake for 15,16 vegetarians. However, children, of zinc among vegetarians. This may be their life stage and should include an pregnant women, and premenopausal 10 especially important for pregnant and additional 25 g protein each day. women may consume less iron RDNs should assess quality of protein lactating women. Overt symptoms of than the Recommended Daily Allow- zinc deficiency are not common in intake and recommend that children, ance.17-19 Although some studies adolescents, adults, pregnant adoles- Western societies and it is unclear showed adequate iron stores and low what impact the low intake and status cents and adults, and athletes include fi to no de ciency rates among vege- of zinc among vegetarians may have. an adequate variety of protein foods tarian children, other findings docu- daily. Combining two or more incom- mented relatively high rates of iron plete protein foods (those low in one or deficiency, ranging from about one-fifth more essential amino acids, such as to more than one-third of sampled Although it is not always the case, rice and beans, peanut and vegetarian children.17,19,20 Similarly, as lacto-ovo-vegetarians show a relatively whole bread, tortillas with beans, high as 26% of vegetarian pregnant high intake of calcium, often exceeding and cooked beans with cornbread) is fi the Institute of Medicine’s recommen- women were diagnosed with iron de - 24 not required in every meal as long as ciency in one study.21 Preventing iron dations. In contrast, vegans consis- variety is present. fi tently show lower-than-recommended de ciency among vegetarian children is 25 imperative and may be strictly a matter calcium intake. Findings from one n-3 Fatty Acids of appropriate dietary planning. large prospective study showed that < Vegetarians can meet the Adequate Two types of inadequate iron status vegans with calcium intake 525 mg/ a fi day had a 25% higher risk of bone Intake of -linolenic acid from foods exist: iron de ciency and iron- 26 such as flaxseeds, chia seeds, , deficiency , the former being fractures. RDNs should assess cal- canola and oil, and a few other the less severe form. Vegetarians have cium intake in both vegans and plant sources.11 Use of these products is a comparable rate of iron-deficiency adolescent vegetarians who may need effective in increasing serum/plasma anemia to nonvegetarians. However, to increase their intake of dietary cal- a-linolenic acid concentration. While vegetarians have a higher rate of iron cium. Calcium can be found in dairy studies have shown that increasing the deficiency.22 Adverse symptoms are products, legumes (including soy- dietary a-linolenic acidetoelinoleic already seen when iron deficiency is beans), spinach, kale, turnips, collards, fi acid ratio can result in a substantial present. In addition to low intake, this broccoli, calcium-forti ed , fi increase in the plasma or is most likely a result of low iron ab- and other calcium-forti ed nondairy concentration of the a-linolenic acid, sorption due to the traditional iron- milk alternatives and orange juice, and studies with vegetarians consistently absorption inhibitors, such as fiber or calcium-set . If dietary intake of showed low plasma eicosapentaenoic . RDNs and NDTRs can guide calcium is low, a well-absorbed calcium acid (EPA) among vegetarians, especially and counsel vegetarians in dietary supplement can be recommended in vegans compared to nonvegetarians.12 planning regarding the best strategies divided doses. Similarly, plasma decosahexaenoic to meet iron recommendations from acid (DHA) concentration among vege- in order to obtain adequate iron Vitamin D tarians has been shown to be very low, stores. The recommendation to focus Low serum vitamin D concentrations as consumption of plant foods rich in on good sources of non iron, have recently been reported among a-linolenic acid has virtually no impact such as iron-fortified breads and ce- both vegetarian children and adults.27-30 on serum/plasma DHA concentration.11 reals, beans and , raisins, and There are considerable variations in Consuming adequate amounts of EPA blackstrap molasses, along with good vitamin D concentrations subject to the and DHA seems to be especially critical sources of , like tomatoes different seasons of the year, with in pregnancy, infancy, and in elderly and citrus fruits for optimal iron ab- the lowest concentrations reported in people.13 Although foods such as some sorption, and cooking in cast iron pans, winter months.27,28 Depending on the brands of soymilk have been fortified which also provides an additional place of residence, vegetarians may

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need to rely on sun exposure, food EATING DISORDERS AND A vegetarian diet for wellness is fortified with vitamin D, and/or vegan VEGETARIAN DIETS guided toward individuals in generally supplements to maintain adequate se- It has previously been hypothesized good health who are not in need of fi rum levels. However, obtaining ad- that a vegetarian diet may be moti- speci c recommendations or alter- fi equate vitamin D from forti ed foods is vated by weight control and restrained ations for health problems or disease. A the most challenging for vegans eating.35 Some findings support that therapeutic approach differs in that fi because few plant foods are forti ed adult vegetarians have a higher rate of clients following or transitioning to a with this vitamin. In such cases, vegan disordered eating than nonvegetarians, vegetarian or vegan diet do so because vitamin D supplements seem to be the while others suggest higher rates in of a clinical need for treatment or most prudent way to ensure adequate nonvegetarians or no difference.36 management of a health problem or vitamin D status. RDNs should assess There is also an association between chronic disease. Disease state, length of the biochemical data for vitamin D for vegetarianism and disturbed eating intervention, restrictiveness, and client fl clients whose dietary assessment re- among adolescents.36,37 Adolescent support are factors that may in uence veals inadequate intake. and young adult vegetarians were adherence to a diet. For adult clients, RDNs should monitor and evaluate Vitamin B-12 more likely to engage in binge eating with loss of control, and former vege- adherence to a therapeutic vegetarian Vegetarian diets are associated with tarians were more likely than those diet, as these diets appear to perform fi vitamin B-12 depletion and/or de - who never were vegetarian and cur- as well or better than omnivorous diets fi ciency. A high prevalence of de ciency, rent vegetarians to engage in extreme in terms of attrition rate, provided ad- assessed by methylmalonic acid and/or unhealthful weight-control behav- equate nutrition education and appro- holotranscobalamin II concentrations, iors.37 However, it is still a matter of priate dietary support are received. is found among vegetarians, regardless Employing a variety of counseling 31 debate whether adopting a vegetarian of the type of diet they follow. There diet is the cause of disordered eating or approaches and strategies, including is a high prevalence of low serum whether it is one of the manifestations motivational interviewing, frequent en- vitamin B-12 and elevated homocyste- counters, cooking demonstrations, and 32 of disordered eating (casual vs symp- ine among vegetarians. Vitamin B-12 tomatic relationship). The majority of incentives, can improve nutrition- status is usually the most compromised related outcomes when using a vege- 31 women reduce meat intake after the among followers of vegan diets. onset of an eating disorder, so it is tarian diet therapeutically. Prevalence of B-12 deficiency ranged unlikely vegetarianism is a risk factor Obesity from 30% to 86% among healthy, for developing an eating disorder.36,37 nonpregnant adult vegetarians, 46.9% Vegetarianism then may not lead to Healthier eating and food choice are to 68% in adults older than 55 years, a growing trend largely driven by 31 disordered eating. However, semi- and 43% to 88% in vegans. vegetarians, who restrict meat intake more than two-thirds of overweight Although severe overt symptoms of for weight control and convert to and obese Americans (69.2%) trying fi 41 vitamin B-12 de ciency may most vegetarianism after the eating disorder to effectively manage their weight. likely be manifested only in a stage IV onset, could see vegetarianism playing Health promotion and improving car- fi de ciency, mild and subtler symptoms a role in the maintenance of the eating diovascular function and insulin sensi- fl like fatigue and weakness may be disorder.38 tivity by reducing the in ammatory fi more common. Vitamin B-12 de - Vegetarian children and adolescents response that underlies most disease ciency during pregnancy and lactation are more likely than nonvegetarian processes are a myriad of reasons cli- may lead to severe developmental children to have a diet consistent with ents seek weight loss. problems in the developing fetus and the Healthy People 2010 dietary Research indicates the therapeutic 33 fi infants. Adult vitamin B-12 de ciency guidelines, and this is especially true of use of a vegetarian diet is effective is associated with a range of health meeting recommendations for specific for treating overweight and obesity in < problems from mild to severe, in- foods and nutrients including fruits, both the short term ( 1 year) and > cluding increased risk for and vegetables, and total and saturated longer term ( 1 year), and may per- ’ Alzheimer s disease, multiple sclerosis, fat.39,40 However, a subset of vegetarian form better than alternative omnivo- psychosis, mood swings, neuropathy, adolescents and young adults shows rous diets for the same purpose. A myelopathy, memory impairment, de- higher patterns of unhealthful dieting vegan diet with structured group sup- pression, brain atrophy, hearing loss, port and behavioral therapy compared 34 practices than omnivores or more and occlusive vascular disease. En- health conscious vegetarians of the to the National Cholesterol Education suring adequate vitamin B-12 status same age.38 RDNs should assess for Program diet was associated with sig- seems to be most important among nificantly greater weight loss at years problem behaviors such as dieting in 42 pregnant and lactating vegetarian adolescent and young adult (19 to 30 1 and 2. If consistent with client women and in older vegetarians. RDNs years) vegetarians. preference, RDNs may recommend should assess B-12 status in children, and educate on the therapeutic use of adolescents, and adults, including a nutrient-dense vegetarian diet for pregnant adolescents and adults, and THERAPEUTIC VEGETARIAN adults seeking treatment for over- recommend that vegetarians, regard- DIETS AND CHRONIC DISEASE weight or obesity. As research shows lessofthetypeofvegetariandietthey The terms wellness and therapeutic lower compliance rates for weight-loss adhere to, take vitamin B-12 supplements have been applied to clarify the treat- clients vs clients treated for other dis- based on their physician’sguidance. ment purpose of a vegetarian diet.41 ease states, RDNs should monitor and

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evaluate adherence and motivation and hypertension. Results of the EPIC (Eu- in the EPIC-Oxford study was equal to provide continued nutrition education ropean Prospective Investigation into the risk among nonvegetarians, vegans and behavioral change support. Cancer and Nutrition)-Oxford study who consumed <525 mg calcium/day showed that vegans have the lowest had a 30% higher risk.26 Also, among rate of hypertension of all diet groups participants of the Adventist Health Including (vegans, vegetarians, fish eaters, and Study 2, vegans had an 86% higher risk Hyperlipidemia, Ischemic Heart meat eaters), including the lowest and vegetarians a 24% higher risk of Disease, and Hypertension systolic and diastolic blood pressure.56 fractures.61 RDNs should counsel veg- Vegetarian diets improve several diet- Vegan members of the Seventh-day etarians, especially vegans, on fracture related modifiable heart disease risk Adventist Church had a 63% lower prevention, including making appro- factors, including abdominal obesity, odds ratio of developing hypertension priate food and/or supplement selec- blood pressure, serum lipid profile, and compared to nonvegetarians, while tion to improve their calcium, vitamin blood glucose, and can lower total vegetarians had a 43% lower risk.44 B-12, and other relevant nutrients cholesterol from 7.2% to 26.6% and low- intake. density lipoprotein cholesterol from Diabetes 43-46 8.7% to 35%. They also decrease Obesity increases the risk of type 2 fl VEGETARIAN DIETS markers of in ammation such as C- diabetes. The difference in BMI be- THROUGHOUT THE LIFECYCLE reactive protein and reduce oxidative tween vegans and nonvegetarians in- stress, and protect from atheriotic Pregnant and Lactating Women 47 dicates a substantial potential for plaque formation. Consequently, vegetarianism to counteract environ- Neonates born to vegetarian, especially vegetarians have a reduced risk of mental forces leading to obesity and vegan, mothers from developed coun- developing and dying from ischemic increased risk of type 2 diabetes.46 tries, have higher birth weight and heart disease.48-50 It was estimated lower prevalence of low-birth-weight Vegan and lacto-ovo-vegetarian diets 21 that the probability of vegetarians are associated with a nearly one-half compared to nonvegetarian mothers. developing cardiovascular disease at reduction in risk of type 2 diabetes Vegetarian pregnant women have a fi age 55 years was 6.1% compared to compared with nonvegetarian diets.46 high risk of vitamin B-12 de ciency. 17.9% among age-matched omnivo- This is especially true of long-term 47 In addition, a vegetarian diet can 33 rous. Vegan diets seem to be most decrease or maintain blood glucose vegetarians, especially vegans. Vi- beneficial in improving heart disease tamin B-12 deficiency in pregnancy can 44,45 levels, and a vegan diet can decrease 62 risk factors. hemoglobin A1c.45 If consistent with result in spontaneous abortion. Vege- Vegetarians can also decrease their client preference, RDNs can recom- tarian, especially vegan, pregnant risk of developing circulatory health mend and educate on the benefits of women need to supplement their diet 31 fi problems by ensuring a reliable source the therapeutic use of a vegetarian diet with vitamin B-12. While de ciency of, and adequate dose of, vitamin B-12, for adults seeking treatment for type 2 symptoms might not always be seen which is associated with improved diabetes. among pregnant women, within a few arterial epithelial function and better months postpartum, infants of mothers fl 51 fi blood ow. Also, vitamin B-12 is es- Cancer who are vitamin B-12 de cient can sential in reducing homocysteine, experience severe anthropometric and which is an independent risk factor for Several epidemiological studies, developmental complications.33 Neu- heart disease.52 While vegetarians tend including large prospective studies rologic symptoms that develop in in- to have a lower (BMI; with Seventh-day Adventist church fants and children who are vitamin calculated as kg/m2), an additional members and with British vegetarians, B-12deficient can have long-term reduction in risk can be made by documented modestly lower overall complications. cancer risk among vegetarians com- keeping weight within the range for 57,58 Pregnant vegetarian women are at a healthy BMI and by regularly con- pared to nonvegetarians. A recent high risk for iron deficiency, evidenced suming a variety of vegetables, fruit, meta-analysis based on seven pro- by more than one in four pregnant fi whole grains, and nuts, like almonds spective studies showed a nonsigni - vegetarian women who develop an and walnuts. cant 9% lower risk of overall cancer iron deficiency.21 Iron deficiency dur- Low-fat vegan and vegetarian diets, mortality and an overall 29% statisti- ing pregnancy can result in inadequate cally significant reduction in cancer combined with other lifestyle factors, 48 fetal weight gain; premature delivery; including not smoking and weight re- incidents. and a higher risk of maternal, fetal, and duction, have been shown to reverse infant death. They are also at risk for atherosclerosis.53-55 Plaque thickness inadequate EPA and DHA intake and was reduced within just a few months Vegetarian compared to nonvegetarian status.11 These essential fatty acids are of dietary and lifestyle modification, children 2 to 10 years of age have a important in brain and eye develop- even without the use of cholesterol- 20%, 10%, and 15% reduced serum level ment of the fetus and breastfed infant. lowering drugs.55 As such, these diets of osteocalcin, bone alkaline phospha- Adequate intake is associated with are strongly recommended to all cli- tase, and osteoclast activity, respec- increased pregnancy duration. It is ents with heart disease who are willing tively.59 Vegetarians, especially vegans, also associated with decreased risk of to adopt them. have lower bone mineral density as asthma and better attention span in Vegetarians compared to non- compared to nonvegetarians.27,30,60 children. In addition, pregnant vegan vegetarians have a lower prevalence of While fracture risk among vegetarians women should ensure they consume

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BREAKFAST BREAKFAST 1 /2 cup dry oats, cooked 2 scrambled eggs or scrambled tofu 1 cup 1% milk or soymilk 2 corn tortillas 1 /2 cup blueberries 3 tablespoons salsa 1 1 /2 medium banana, sliced /2 cup , cubed 2 tablespoons slivered almonds 1 part-skim string cheese 1 tablespoon maple syrup 510 calories 529 calories LUNCH LUNCH 6-inch whole-wheat tortilla Pinto salad: 1 1 /2 cup hummus /2 cup canned pinto beans, drained 1 Tomato, lettuce, and cucumbers /4 cup red bell pepper, diced 1 Basil leaves, rolled and sliced thinly /4 cup purple onion, finely diced 1 Drizzle with dressing: /4 cup cucumber, diced 1 1/4 cup lemon juice /4 cup frozen corn, thawed 3 tablespoons extra-virgin 2 tablespoons fresh cilantro, chopped 2 teaspoons minced garlic 2 tablespoons vinaigrette 339 calories 2 cups mixed greens 1 tablespoon vinaigrette 1 naval orange 463 calories DINNER DINNER 1 cup oven-roasted butternut squash cubes 6 ounces pan-seared barbecued seitan () 1 cup steamed Haricot verts (thin green beans) 1 cup steamed cauliflower/broccoli with 1 teaspoon with 1 teaspoon vegan vegan margarine 1 1 /2 cup corn kernels /2 cup brown rice 3 ounces oven-baked tofu marinated in teriyaki sauce Whole-wheat dinner roll with 1 teaspoon vegan margarine 1 /2 cup cranberry almond salad 414 calories 490 calories SNACK SNACK 1 cup grapes Apple crisp 1 cup non-fat plain Greek or 1 sliced apple 1 1 /2 cup low-fat granola /4 cup dry oats 444 calories 1 teaspoon lemon juice 2 teaspoons brown sugar, packed 1 Total calories: 1,815 /2 cup vanilla soy ice cream : 261 g (54%) 376 calories Protein: 86 g (18%) Fat: 56 g (26%) Total calories: 1,763 Fiber: 43 g Carbohydrate: 245 g (52%) Protein: 77 g (16%) Fat: 61 g (29%) Fiber: 43 g Figure 1. Two sample 1,800-calorie vegetarian meal plans for optimal nutrition.

an adequate amount of dietary or than optimal concentration, based on RDNs should design a dietary plan supplemental calcium. clinical judgment, RDNs should counsel and offer comprehensive nutrition For the pregnant adolescent or adult the patient or client to increase intake education and skill development on vegetarian, if assessment of iron, cal- of foods rich in these nutrients, adding planning a diet for pregnant adult cium, EPA, and DHA intake or status foods that were fortified with them and adolescent vegetarians that pro- reveals a potential deficiency or lower and/or taking supplements. vides adequate protein from a variety

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of complementary mixtures of plant Vegetarian/Vegan Myths consumed throughout the day. RDNs should ensure adequate Di- Safety of Soyfoods etary Reference Intakes of protein and B-12 in Vegetarian Diets all micronutrients, particularly B-12, Isoflavones in Vegetarian Diets iron, , and zinc, and recommend Health Effects of Soy supplementation as appropriate to Zinc in Vegetarian Diets ensure adequate intake. Iron in Vegetarian Diets Meeting Calcium Recommendations on a Vegan Diet Infants, Children, and Choline in Vegetarian Diets Adolescents Vegetarian Diets in Pregnancy (Spanish translation available) Regardless of assessment methods Vegetarian Diets During Lactation (Spanish translation available) ’ used, age, sex, or participant s ethnic Vegetarian Infants background, vegan and vegetarian Vegetarian Diets for Toddlers and Preschoolers (Spanish translation available) children attain adequate growth that is comparable with nonvegetarian chil- Vegetarian Nutrition for School-Aged Children (Spanish translation available) dren.63,64 Although vegetarianism dur- Vegetarian Teens ing the first 2 decades of life might be Vegetarian Diets in Diabetes associated with a higher risk of defi- Vegetarian Diets in Chronic Kidney Disease ciency of some nutrients, such as vita- Eat More Plant-Based Meals mins C and B-12, iron, zinc, and Combining Vegetarian, Vegan, and Gluten-Free Diets calcium, vegetarian children and teens Sports Nutrition for Vegetarians are at lower risk of some health prob- lems, such as obesity.18,30,59,65 This Protein in Vegetarian Diets might be, in part, a result of vegetarian Therapeutic Use of Vegetarian Diets in Chronic Disease children being more likely than Climate Change and Sustainability of Vegetarian Foods nonvegetarian children to have a diet Lactose Intolerance and Dairy Substitutions consistent with the Healthy People 2010 dietary guidelines, including Figure 2. Vegetarian Nutrition dietetic practice group (www.vndpg.org) resources for meeting recommendations for specific registered dietitian nutritionists and consumers. These resources respond to questions or concerns regarding specific vegetarian or vegan dietary nutrients and protocols. foods and nutrients including fruits, Typically two to four pages in length, they are authored by registered dietitian nu- vegetables, and total and saturated 39,40 tritionists who are experts on the topic and members of the Vegetarian Nutrition fat. RDNs should assess micro- dietetic practice group. These resources provide a wealth of evidence-based infor- nutrient intake, particularly vitamins mation and guide one to implement and maintain an appropriate nutrient-adequate C and B-12, iron, zinc, and calcium, vegetarian diet for all stages of the life cycle. and macronutrient intake, especially protein and essential fatty acids, in children and adolescents ascribing to a number of environmental problems anthropogenic methane; and 65% vegetarian dietary pattern. from water, soil, and air pollution to anthropogenic nitrous oxide.68 Another global warming.68 The livestock sector area of concern related to modern meat Older Adults and the Elderly has been described by the Food and production is the use of antibiotics “ Vegetarian diets might be beneficial for Agriculture Organization as one of the in animal feed. A recent Centers for fi older adults and the elderly in pre- top two or three most signi cant con- Disease Control and Prevention report vention of chronic health conditions, tributors to the most serious environ- listed this practice as one of the factors such as heart disease and obesity, but mental problems at every scale from associated with antibiotic resistance. ”69 not osteoporosis.66,67 These individuals local to global. According to the US Antibiotic resistance is estimated to Environmental Protection Agency, cause >2 million infections, resulting can also have a lower risk of iron 70 deficiency compared to younger vege- about 70% of all water pollution in in at least 23,000 deaths. rivers and lakes in the United States is a tarians, but may have a higher risk 69 fi result of pollution from animal farms. for a de ciency of vitamin B-12 ROLES AND RESPONSIBILITIES due to a reduction in intrinsic factor. Animal agriculture is associated with land degradation, water shortage, and OF THE RDN AND NDTR This is especially true of long-term 68 vegetarians.31 loss of biodiversity. In order to effectively counsel the Among the examples of the envi- therapeutic or wellness adoption and ronmental impact of meat production implementation of, and adherence to, a Ethical Choices for Vegetarian Diets that the Food and Agriculture Organi- vegetarian lifestyle, RDNs and NDTRs In comparison to omnivorous diets, zation report are 70% deforestation of must have adequate knowledge and vegetarian diets are environmentally the Amazon region, resulted from access to educational materials to friendlier. The increasing demand creating pastures and feedlots in areas facilitate lifestyle choices of health- for meat and modern methods of previously covered by Amazon forest; promoting vegetarian diets. To that meat production are associated with a 9% anthropogenic CO2 emissions; 37% end, Figure 1 identifies two generalized

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www.VNDPG.org (Vegetarian Nutrition [VN] dietetic practice group): Member benefits include professional information on vegetarian nutrition, registered dietitan nutritionist (RDN) resources, and quarterly newsletters. www.vegetariannutrition.net (VN’s consumer website): Provides a blog with evidence-based vegetarian nutrition plus RDN resources for consumers. www.vrg.org: The Vegetarian Resource Group provides nutrition information, recipes, meal plans, and recommended readings for vegetarian nutrition. www.PCRM.org: The Physician’s Committee for Respsonsible Medicine promotes preventive medicine through inno- vative programs and offers free patient educational materials. www.PETA.org: People for the Ethical Treatment of Animals, an animal rights organization, also offers free vegetarian literature and menu plans. www.veganhealth.org: This website offers evidence-based recommendations covering the myriad ways one can stay healthy eating plant-based diets. www.vegweb.com: Offers vegetarian recipes and community. www.vegetarian-nutrition.info: Offers articles, resources, and news on vegetarian nutrition. Figure 3. Professional and consumer websites for vegetarian nutrition that provide information on vegetarian and vegan dietary nutrients and protocols as well as animal ethics and social and environmental issues. Many of these sites provide high-quality educational material that the registered dietitian nutritionist can rely on for patient or client education on individual nutrients of concern, meal plans, plant-based substitutions for meat-based dishes, and vegetarian nutrition concerns throughout the life cycle.

vegetarian meal plans that ensure vegetarian and vegan intakes provide 3. Stahler C. How often do Americans eat adequate intake of macro- and micro- adequate nutrition for all cycles of life, vegetarian meals? And how many adults in the US are vegetarian? The Vegetarian nutrients sufficient to support healthy including both wellness and thera- Resource Group website. http://www.vrg. intake. Additional food recommenda- peutic uses for disease prevention and org/journal/vj2011issue4/vj2011issue4poll. tions can be found in the 2010 Dietary treatment. While vegetarians may php. Accessed October 10, 2013. Guidelines for Americans. Figure 2 lists have a higher risk of some nutrient 4. Nachay K. Targeting the new vegetarian fi foods consumer. Inst Food Technol. 2001; all evidence-based RDN consumer de ciency (eg, vitamin B-12) 65(11). http://www.ift.org/food-technology/ and professional resources available compared to nonvegetarians, nutrient past-issues/2011/november/features/target through the Vegetarian Nutrition di- deficiencies are not the main cause of ing-the-new-vegetarian-foods-consumer. aspx?page¼viewall. Accessed September etetic practice group; while the RDN mortality and/or morbidity in Western 10, 2013. can refer clients to the consumer re- societies. Vegetarians have a lower 5. Mintel International Group Limited. Meat sources, only members of the Vege- risk of most main causes of mortality, Alternatives. Executive Summary. Chicago, tarian Nutrition dietetic practice group including heart disease and some IL: Mintel International Group Limited; have access to the professional re- cancers. Choosing a meat-free diet is June 2013. sources. Figure 3 contains useful web- deemed environmentally protective, a 6. Hoek AC, Luning PA, Weijzen P, Engels W, Kok FJ, de Graaf C. Replacement of meat sites that promote and encourage strong impetus for some in moving by meat substitutes. A survey on person- appropriate evidence-based recom- toward vegetarianism. Greater re- and product-related factors in consumer mendations and food choices for both sources are now available, such as acceptance. Appetite. 2011;56(3):662-673. the RDN and clientele. Additional rec- online tools and educational sites, as 7. American Institute for Cancer Research. ommendations can be found at the well as RDNs and NDTRs who are Recommendations for cancer prevention. http://www.aicr.org/reduce-your-cancer-risk/ Academy’s Evidence Analysis Library more up-to-date on vegetarian diets recommendations-for-cancer-prevention/ (www.andeal.org), a free benefit to all and who can assist the general public recommendations_04_plant_based.html? Academy of Nutrition and Dietetics in making better-informed decisions gclid¼CJ6__O7dpboCFcid4AodhkMAIA. Accessed October 10, 2013. members. about their health and intake through vegetarian nutrition, foods, and re- 8. US Department of Agriculture, US Depart- ment of Health and Human Services. sources. RDNs and NDTR are the most Dietary Guidelines for Americans, 2010.7th CONCLUSIONS optimal resources to vegetarian and ed. Washington, DC: US Government fi vegan clients. Printing Of ce;2010 http://www.health. Awareness in plant-based diets con- gov/dietaryguidelines/dga2010/Dietary tinues to grow in the United States Guidelines2010.pdf. Accessed October with encouragement from govern- 10, 2013. References mental entities and the wide outreach 9. US Department of Agriculture. Super- 1. Shapin S. love: The history of Tracker. https://www.supertracker.usda. of vegetarian organizations. Diverse vegetarianism. The New Yorker; January gov/default.aspx. Accessed November 13, interest and curiosity in vegetarian 22, 2007. 2013. and vegan diets increases rapidly, 2. Hoffman SR, Stallings SF, Bessinger RC, 10. Institute of Medicine. Dietary reference especially given the abundant con- Brooks GT. Differences between health intakes for energy, carbohydrate, fiber, sumer choices that create greater ease and ethical vegetarians. Strength of fat, fatty acids, cholesterol, protein, and conviction, nutrition knowledge, dietary amino acids. http://www.iom.edu/Reports/ in adherence to this dietary practice. restriction, and duration of adherence. 2002/Dietary-Reference-Intakes-for-Energy- When well designed and thought out, Appetite. 2013;65:139-144. Carbohydrate-Fiber-Fat-Fatty-Acids-Cholester

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ol-Protein-and-Amino-Acids.aspx. Accessed anaemia_iron_deficiency/WHO_NHD_01 versus non-vegetarians. Appetite. 2012; October 10, 2013. .3/en/. Accessed September 12, 2013. 58(3):982-990. 11. Francois CA, Connor SL, Bolewicz LC, 23. Foster M, Chu A, Petocz P, Samman S. Ef- 37. Fisak B, Peterson RD, Tantleff-Dunn S, Connor WE. Supplementing lactating fect of vegetarian diets on zinc status: A Molnar JM. Challenging previous concep- women with flaxseed oil does not in- systematic review and meta-analysis of tions of vegetarianism and eating disorders. crease in their milk. studies in humans. J Sci Food Agric Eat Weight Disord. 2006;11(4):195-200. Am J Clin Nutr. 2003;77(1):226-233. 2013;(15). 93:2362-2371. 38. Bardone-Cone AM, Fitzsimmons-Craft EE, 12. Welch A, Shakya-Shrestha S, Lentjes M, 24. Institute of Medicine. Dietary Reference Harney MB, et al. The inter-relationships Wareham N, Khaw K. 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Health, United States, September 30, 2013. D and intact parathyroid hormone 2012. http://www.cdc.gov/nchs/data/hus/ 15. Institute of Medicine. Dietary Reference within normal ranges during the winter hus12.pdf#063. Accessed November 15, Intakes for vitamin A, vitamin K, arsenic, in Finland. J Am Diet Assoc. 2000;100(4): 2013. 434-441. boron, chromium, copper, iodine, iron, 42. Turner-McGrievy GM, Barnard ND, manganese, molybdenum, nickel, silicon, 28. Crowe FL, Steur M, Allen NE, Appleby PN, Scialli AR. A two-year randomized weight vanadium, and zinc - http://www.iom.edu/ Travis RC, Key TJ. Plasma concentrations loss trial comparing a vegan diet to a Reports/2001/Dietary-Reference-Intakes- of 25-hydroxyvitamin D in meat eaters, more moderate low-fat diet. Obesity. for-Vitamin-A-Vitamin-K-Arsenic-Boron- fish eaters, vegetarians and vegans: Re- 2007;15(9):2276-2281. Chromium-Copper-Iodine-Iron-Manga sults from the EPIC-Oxford study. Public 43. Ferdowsian HR, Barnard ND. 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Nutr Metab. plementation on serum 25-hydroxyvitamin 2011;14. 8(1):37. 45. Barnard ND, Katcher HI, Jenkins DJ, D and bone turnover markers concentra- Cohen J, Turner-McGrievy G. Vegetarian 17. Deriemaeker P, Alewaeters K, tions in vegetarian children. Med Wieku and vegan diets in type 2 diabetes man- Hebbelinck M, Lefevre J, Philippaerts R, Rozwoj. 2009;13(1):34-39. agement. Nutr Rev. 2009;67(5):255-263. Clarys P. Nutritional status of Flemish vegetarians compared with non- 31. Pawlak R, Parrott SJ, Raj S, Cullum- 46. Tonstad S, Butler T, Yan R, Fraser GE. Type vegetarians: A matched samples study. Dugan D, Lucus D. How prevalent is of vegetarian diet, body weight, and fi Nutrients. 2010;2(7):770-780. vitamin B12 de ciency among vegetar- prevalence of type 2 diabetes. Diab Care. ians? Nutr Rev. 2013;71(2):110-117. 2009;32(5):791-796. 18. Gorczyca D, Prescha A, Szeremeta K, Jankowski A. Iron status and dietary iron 32. Obersby D, Chappell DC, Dunnett A, 47. Yang SY, Li XJ, Zhang W, et al. Chinese intake of vegetarian children from Poland. Tsiami AA. Plasma total homocysteine lacto-vegetarian diet exerts favorable Ann Nutr Metab. 2013;62(4):291-297. status of vegetarians compared with om- effects on metabolic parameters, intima- nivores: A systematic review and meta- media thickness, and cardiovascular 19. Chelkowska M, Klemarczyk W, analysis. Br J Nutr. 2013;109(5):785-794. risks in healthy men. Nutr Clin Pract. Ambroszkiewicz J, Gajewska J, Laskowska- 2012;27(3):392-398. Klita T. Iron status in children on 33. Dror DK, Allen LH. Effect of vitamin vegetarian diet. Pediatr Pol. 2007;82(6): B12 deficiency on neurodevelopment in 48. Huang T, Yang B, Zheng J, Li G, 425-429. infants: current knowledge and possible Wahlqvist ML, Li D. Cardiovascular dis- mechanisms. Nutr Rev. 2008;66(5): ease mortality and cancer incidence in 20. Wongprachum K, Sanchaisuriya K, 250-255. vegetarians: A meta-analysis and sys- Sanchaisuriya P, Siridamrongvattana S, 34. Rusher DR, Pawlak R. A review of 89 tematic review. Ann Nutr Metab. 2012; Manpeun S, Schlep FP. Proxy indicators 60(4):233-240. for identifying iron deficiency among published case study of vitamin B12 anemic vegetarians in an area prevalent deficiency. J Hum Nutr Food Sci. 2013; 49. Orlich MJ, Singh PN, Sabaté J, et al. Vege- for thalassemia and hemoglobinopathies. 1(2):1008. http://www.jscimedcentral. tarian dietary patterns and mortality Acta Haematol. 2012;127(4):250-255. com/Nutrition/Articles/nutrition-1-1008. in Adventist Health Study 2. JAMA Intern pdf. Accessed October 12, 2013. Med. 2013;173(13):1230-1238. 21. Drake R, Reddy S, Davies J. Nutrient intake during pregnancy and pregnancy outcome 35. Forestell CA, Spaeth AM, Kane SA. To eat 50. Crowe FL, Appleby PN, Travis RC, Key TJ. of lacto-ovo-vegetarians, fish-eaters and or not to eat red meat. A closer look at the Risk of hospitalization or death from non-vegetarians. Veg Nutr. 1998;2:45-52. relationship between restrained eating ischemic heart disease among British and vegetarianism in college females. vegetarians and nonvegetarians: Results 22. United Nations Children’s Fund, United Appetite. 2012;58(1):319-325. from the EPIC-Oxford cohort study. Am J Nations University, World Health Orga- Clin Nutr. 2013;97(3):597-603. nization. Iron deficiency anaemia assess- 36. Timko CA, Hormes JM, Chubski J. Will the ment, prevention, and control. A guide for real vegetarian please stand up? An 51. Kwok T, Chook P, Qiao M, et al. Vitamin B- programme managers. http://www.who. investigation of dietary restraint and 12 supplementation improves arterial int/nutrition/publications/micronutrients/ eating disorder symptoms in vegetarians function in vegetarians with subnormal

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vitamin B-12 status. J Nutr Health Aging. 59. Ambroszkiewicz J, Klemarczyk W, 66. Löwik MR, Schrijver J, Odink J, van den 2012;16(6):569-573. Gajewska J, Chełchowska M, Laskowska- Berg H, Wedel M. Long-term effects of Klita T. Serum concentration of biochem- a vegetarian diet on the nutritional 52. Elmadfa I, Singer I. Vitamin B-12 and homocysteine status among vegetarians: ical bone turnover markers in vegetarian status of elderly people (Dutch Nutrition children. Adv Med Sci. 2007;52:279-282. Surveillance System). J Am Coll Nutr. A global perspective. Am J Clin Nutr. 2009; 1990;9(6):600-609. 89(5):1693S-1698S. 60. Ho-Pham LT, Nguyen ND, Nguyen TV. Ef- 53. Ornish D. Avoiding revascularization with fect of vegetarian diets on bone mineral 67. Brants HA, Löwik MR, Westenbrink S, lifestyle changes: The Multicenter Life- density: A Bayesian meta-analysis. Am J Hulshof KF, Kistemaker C. Adequacy of style Demonstration Project. Am J Cardiol. Clin Nutr. 2009;90(4):943-950. a vegetarian diet at old age (Dutch Nutrition Surveillance System). J Am Coll 1998;82(10B):72T-76T. 61. Lousuebsakul-Matthews V, Thorpe DL, Nutr. 1990;9(4):292-302. 54. Ornish D, Brown S, Scherwitz L, et al. Knutsen R, Beeson WL, Fraser GE, Can lifestyle changes reverse coronary heart Knutsen SF. Legumes and meat analogues 68. United Nations Food and Agriculture disease? Lancet. 1990;336(8708):129-133. consumption are associated with hip Organization. Livestock’s long shadow. fracture risk independently of meat intake Environmental issues and options. ftp:// 55. Esselstyn C. Updating a 12-year experi- among Caucasian men and women: The ftp.fao.org/docrep/fao/010/a0701e/a0701e. ence with arrest and reversal therapy for Adventist Health Study-2. Public Health pdf. Accessed October 22, 2013. coronary heart disease (an overdue Nutr. 2013;17(10):2333-2343. requiem for palliative cardiology). Am J 69. US Environmental Protection Agency, 62. Bennett M. Vitamin B12 deficiency, Cardiol. 1999;84(3):339-341. Office of Water. Environmental assess- infertility and recurrent fetal loss. J Reprod ment of proposed revisions to the national 56. Appleby PN, Davey GK, Key TJ. Hyper- Med. 2001;46(3):209-212. tension and blood pressure among meat pollutant discharge elimination system eaters, fish eaters, vegetarians and vegans 63. Nathan I, Hackett AF, Kirby S. The dietary regulation and the effluent guidelines in EPIC-Oxford. Public Health Nutr. 2002; intake of a group of vegetarian children for concentrated animal farming opera- 5(5):645-654. aged 7-11 years compared with matched tions. http://water.epa.gov/scitech/ omnivores. Br J Nutr. 1996;75(4):533-544. wastetech/guide/cafo/proposedrule-docs. 57. Tantamango-Bartley Y, Jaceldo-Siegl K, cfm. Accessed October 30, 2013. Fan J, Fraser G. Vegetarian diets and the 64. Sabaté J, Lindsted KD, Harris RD, incidence of cancer in a low-risk popula- Sanchez A. Attained height of lactoovo- 70. Centers for Disease Control and Preven- tion. Cancer Epidemiol Biomarkers Prev. vegetarian children and adolescents. Eur J tion. Antibiotic resistance treats in the 2013;22(2):286-294. Clin Nutr. 1991;45(1):51-58. United States, 2013. http://www.cdc.gov/ 58. Key T, Appleby P, Spencer E, et al. Cancer 65. Sabaté J, Wien M. Vegetarian diets and drugresistance/threat-report-2013/pdf/ar- incidence in British vegetarians. Br J Can- childhood obesity prevention. Am J Clin threats-2013-508.pdf. Accessed November cer. 2009;101(1):192-197. Nutr. 2010;91(5):1525S-1529S. 12, 2013.

This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on October 18, 1987, and reaffirmed on September 12, 1992; September 6, 1996; June 22, 2000; June 11, 2006; and March 19, 2012. This position is in effect until December 31, 2019. Requests to use portions of the position or republish in its entirety must be directed to the Academy at [email protected]. Authors: Diana Cullum-Dugan, RDN, LDN (Namaste Nutrition, Watertown, MA); Roman Pawlak, PhD, RD (East Carolina University, Greenville, NC). Reviewers: dietetic practice group (DPG) (Laura Andromalos, RD, LDN, Brigham and Women’s Hospital, Boston, MA); Sharon Denny, MS, RD (Academy Knowledge Center, Chicago, IL); Julie Driggers, RD, LDN, CNSC (The Children’s Hospital of Philadelphia, Philadelphia, PA); School Nutrition Services DPG (Beverly L. Girard, PhD, MBA, RD, Sarasota County Schools, Sarasota, FL); Jessica Larson, MS, RDN (Academy Policy Initiatives & Advocacy, Washington, DC); Vegetarian Nutrition DPG (Susan Levin, MS, RD, CSSD, Physicians Committee for Responsible Medicine, Washington, DC); Kelly McGrath, MS, RD, CSG, LDN (FutureCare Health and Management Corporation, Baltimore, MD); Meena Somanchi, PhD, CNS, LDN (University of Maryland, College Park, MD); Alison Steiber, PhD, RD (Academy Research & Strategic Business Devel- opment, Chicago, IL); Hunger and Environmental Nutrition DPG (Teri Underwood, RD, MS, CD, Sustainable Diets, Park City, UT). Academy Positions Committee Workgroup: Alana D. Cline, PhD, RD (chair) (University of Northern Colorado, Fort Collins, CO); Penny E. McConnell, MS, RDN, SNS (Fairfax County Public Schools, Springfield, VA); Ella Haddad, DrPH, MS, RD (content advisor) (Loma Linda University, Loma Linda, CA). We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position or the supporting paper.

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