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NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #171 ISSUES IN GASTROENTEROLOGY, SERIES #171

Carol Rees Parrish, M.S., R.D., Series Editor

Moo-ove Over, Cow’s : The Rise of -Based Alternatives

Meagan Bridges

Consumer demand for alternatives to dairy is on the rise, and with it, an ever-expanding array of plant-based products from which to choose. This is especially evident when considering milk substitutes. Each type of non-dairy milk offers a unique nutritional profile, with a wide range of values for , and , along with and minerals. Learn more about which non- dairy beverages are gaining in popularity and how these options compare nutritionally to cow’s milk.

The Rise of Plant-Based hen choosing milk, it is no longer simply and thermal treatments are used to improve the a matter of whole, low-fat, or skim. Now suspension and stability of the product. They are Wmore than ever, consumers can choose made to visually resemble cow’s milk and often from a plethora of plant-based “milks” derived include the word ‘‘milk’’ in the beverage name. from a variety of sources, including nuts, , Specific nutritional properties depend on the plant , and . source, processing, and fortification. The most Worldwide sales of non-dairy milk alternatives widely available plant-based milks in the U.S. are more than doubled between 2009 and 2015, identified in Table 1. reaching $21 billion – a reflection of both consumer The increasing popularity of non-dairy milks demand and the burgeoning array of products to can be attributed to many factors. More and more meet that demand. Meanwhile, consumption of people are consuming non-dairy alternatives, cow’s milk has dropped 13 percent in the U.S. over whether due to an , intolerance or the last five years.1 adherence to a vegan/plant-based . Still others Plant-based milk substitutes are essentially are concerned over levels, hormone suspensions of dissolved and disintegrated plant content, and antibiotic use in dairy . But material and extracts in . Homogenization with an ever expanding array of options, the dairy

Meagan Bridges, RD Nutrition Support Specialist, University of Virginia Health System, Charlottesville, VA

20 PRACTICAL GASTROENTEROLOGY • JANUARY 2018 Moo-ove Over, Cow’s Milk: The Rise of Plant-Based Dairy Alternatives NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #171 NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #171

aisle can end up being a place of utter confusion, Table 1. Plant-Based / Non-Dairy Milk Alternatives especially when weighing not only taste, texture, Milk Alternative Plant Type and other sensory attributes of non-dairy milks, but also the nutritional qualities of these beverages and Cereal-Based • milk how they compare to cow’s milk. • milk -Based • How Do Plant-Based Milks • milk Compare to Cow’s Milk? Dairy are often good sources of important -Based • milk , including protein, D, , -Based • milk and . As some plant-based milks are • milk very low in these nutrients, consumer awareness is important when dairy-free alternatives are used -Based • milk as a direct replacement for cow’s milk in the diet. • milk For example, of all the non-dairy alternatives, • milk only soy milk naturally contains protein in an amount comparable to cow’s milk (8 g per 8 oz. cup). By contrast, – one of the most By the same token, while the quantity of most popular non-dairy options among consumers – only has been established for cow’s milk, contains 1 g of protein per 8 oz. cup. similar information is not available for most non- Moreover, every gram of protein is not created dairy beverages. In fact, only figures for calcium equally, and it is important to evaluate the quality and are consistently reported for non- of protein when comparing plant-based milks to dairy milks on the USDA’s Composition cow’s milk. is based on amino Databases; figures on phosphorus, , thiamin, composition, digestibility, bioavailability, niacin, vitamin B6, , , , and specific protein-derived components. Protein and other micronutrients are often missing.4 Table from animal sources is generally of higher quality 2, which compares the nutritional profile of popular than plant-based protein due to its more “complete” plant-based milks to 2% cow’s milk, omits these array of amino .2 Cow’s milk contains both particular vitamins and minerals, as most of this and , which have high information is not yet readily available. biological value given their “usability” by the In addition to protein and vitamin/ body. While is also recognized for content, added is another variable that can its high biological value among plant sources, its vary widely among plant-based milks and depart usability when derived from soy milk has not been drastically from cow’s milk. While unsweetened extensively studied.3 Most other proteins found in versions have as few as 25 per cup, most plant-based milks are not complete and do not offer non-dairy milks are sweetened with added the full array of essential amino acids. (such as rice , , or cane sugar) to While non-dairy alternatives do not offer exact make them more palatable. Many sweetened and/ nutritional equivalency to cow’s milk, they can or flavored non-dairy milks contain up to 20 g of be fortified with certain nutrients – especially sugar, compared to 12.5 g of naturally occurring calcium, vitamin D, and – to make lactose in 2% cow’s milk. them more comparable. In fact, many fortified Finally, consumers should be aware of any plant-based milks are marketed as having equal additives used to emulsify and stabilize plant- or greater amounts of calcium and vitamin D than based milks. Some leading nut milks, for example, cow’s milk. However, it is important to recognize contain , a thickener and emulsifier that the bioavailability of such nutrients varies derived from seaweed that has recently been significantly among products and in many cases implicated in some preliminary (though far from is not precisely known.3 conclusive) studies on ulcers, inflammation, and

PRACTICAL GASTROENTEROLOGY • JANUARY 2018 21 Moo-ove Over, Cow’s Milk: The Rise of Plant-Based Dairy Alternatives NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #171 other GI complications. Other non-dairy milks can health concerns. It is perhaps best known for being be thickened with sunflower or a variety of low in calories, typically between 30 and 50 per gums. Learn more about the specific properties of 8 oz. cup (unsweetened), or about one-third the the most popular plant-based milks below. calories of 2% cow’s milk. Sweetened varieties, however, can contain up to 90 calories per cup Soy Milk and 16 g of sugar. Likely the most recognizable among dairy-free Nut milks in general tend to be highly diluted alternatives, soy milk is the “original” replacement with water. While this allows them to be relatively for cow’s milk, first appearing on shelves in the lower in calories, this also means that they supply U.S. in the 1950s. Made by soaking, crushing, minimal amounts of the nutrients typically found cooking, and straining , it is the only in nuts, including protein, , , milk alternative that naturally contains the same and copper. A major drawback of almond milk amount of protein as a cup of cow’s milk - 8 grams is that the protein content from the is - along with omega-3 fatty acids and fiber. Most strained out of the milk along with the pulp; hence, manufacturers also fortify soy milk with vitamins it contains very little protein – usually only 1 g per A, D, B12, and calcium. In addition, soy milk can 8 oz. cup, compared to 8 g in cow’s milk. be a good source of manganese and magnesium. Through fortification, almond milk can offer Interestingly, when considering the a comparable amount of vitamins and minerals as process, soy milk is likely the “least cow’s milk – and in some cases, can offer more. processed” out of all plant-based milks. At the However, it is still devoid of most , same time, soy is one of the top three genetically essential fatty acids, and many trace elements such modified organisms (GMOs) in the U.S., with 94% as zinc and copper. One unique aspect of almond of all soybeans in the country being genetically milk is its high vitamin E (alpha ) engineered.5 Most mainstream brands, however, content, with one cup offering up to 10 mg, or use certified non-GMO ingredients. 50% of the daily value for adults. In recent decades, soy foods have garnered increasing attention for the amount of isoflavones they contain. These are being There are not many advantages to rice milk over extensively studied for their potential health other plant-based milks, but it is likely the most effects ranging from heart disease and breast cancer hypoallergenic of all non-dairy alternatives. prevention to bone mineral density reduction in Though usually derived from boiled post-menopausal women. Current evidence, and brown rice , it has no fiber and a thin however, is far from conclusive, and much remains consistency. It has considerably less protein than to be learned about these compounds.6 cow’s milk (only 1 g per 8 oz. cup) and a very small Of additional note, soybeans do contain high amount of natural calcium, though most brands levels of , a compound sometimes are calcium-fortified and enriched with vitamins referred to as an “anti-nutrient,” which is not A, D, and B12. It is also low in fat; however, some destroyed or reduced during the conventional manufacturers do add as an emulsifier manufacturing process for soy milk.7 Phytic acid and stabilizer. has a high affinity for binding minerals such as Rice milk generally tastes sweeter than cow’s calcium, , magnesium, and zinc and can render milk, owing to the addition of sweeteners (usually these nutrients unavailable for absorption. This ) and . It is also significantly effect, however, only occurs when such minerals higher in carbohydrates. are ingested simultaneously with phytic acid. Almond Milk Oat milk is made from oat groats ( that have Almond milk is made from ground almonds and been cleaned, toasted, and hulled), water, and water. It is quickly gaining in popularity, especially potentially other grains and , such as , among those avoiding soy due to or other (continued on page 24) 22 PRACTICAL GASTROENTEROLOGY • JANUARY 2018 Moo-ove Over, Cow’s Milk: The Rise of Plant-Based Dairy Alternatives NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #171

(continued from page 22) In addition, contains fiber and iron, barley, brown rice, and soybeans. It has a mild two notable departures from cow’s milk. flavor and is slightly sweet. Its consistency is similar to that of 1% or skim milk. Oat milk is low in overall calories, , Though unlikely to ever gain the same kind of and saturated fat. It is higher in fiber than other milk popularity as soy or almond milk, hemp milk is alternatives, with 2 g per cup or sometimes more, considered ideal for people who cannot consume depending on whether oat has been added. , nuts, and/or soy. It can also be a viable It also contains iron, vitamin E, and folic acid. In option for those who are on a starch-limited diet addition, it offers 4 g of protein per cup, which and/or must avoid . is relatively higher than most other non-dairy Hemp milk is made from the hulled seeds of alternatives. At the same time, naturally occurring the industrial hemp plant, which includes varieties sugars give this beverage a higher of sativa that are low in the psychotropic content. substance (THC) and are Depending on the manufacturer, oat milk could grown for food and uses. It has an earthier be another viable option for people with nut and flavor that may be off-putting to some consumers seed allergies. It is important, however, to read the and/or lead them to buy the sweetened versions. label for added ingredients that could be allergens. Hemp milk naturally contains more protein than other non-dairy alternatives, but at 2-3 g per Coconut Milk 8 oz. cup, it is still not a particularly good source. Made from grated and squeezed coconut , this It does offer a three-to-one ratio of omega-6 to high-, high-fat beverage is not for drinking omega-3 essential fatty acids, including around straight-up but is usually reserved for cooking, 1,000 mg of alpha-linolenic acid. Other nutrients especially in southeast Asian . It is often include magnesium and phytosterols, as well as found canned and in the ethnic foods section of some calcium, fiber, iron, and . the . It has a natural, creamy thickness with a mild nutty flavor. A 1-cup serving of canned raw coconut milk Pea milk is one of the newer dairy-free milk contains 445 calories and 48 g of fat, of which 43 alternatives, with only one major manufacturer g are saturated. Recently, however, manufacturers currently in the U.S. but a second one gearing up are now offering “coconut milk beverage,” which to introduce its own line soon. Made from yellow is essentially coconut milk that has been diluted field , this beverage is poised to gain more with water, to appeal to consumers who seek to popularity, owing largely to its naturally high it more regularly. While this type of diluted protein content (at least 7 g per 8 oz. cup). During coconut milk has far fewer calories and much less manufacturing, yellow peas are milled into , fat, it also has very little protein – less than 1 g per which is then processed to separate the protein 8 oz. cup. This version of coconut milk is usually content from the fiber and starch, and the protein found in (not cans) in the dairy aisle. is then further purified and blended together with Whether concentrated or diluted, coconut milk water and other ingredients. This is a departure offers medium-chain triglycerides and a relatively from most nut-based milks, in which the protein high amount of potassium. If fortified, it can content is removed and never reintroduced. serve as a good source of vitamin D and can also Like most other non-dairy alternatives, pea supply up to 50% more calcium than dairy milk. milk is fortified to contain 150% more calcium than cow’s milk. Moreover, its taste and consistency is actually very close to cow’s milk. An added benefit: PRACTICAL GASTROENTEROLOGY yellow peas are easy and inexpensive to grow, so pea milk carries a much lower water footprint than practicalgastro.com almond milk and a much smaller carbon footprint than cow’s milk.8

24 PRACTICAL GASTROENTEROLOGY • JANUARY 2018 Moo-ove Over, Cow’s Milk: The Rise of Plant-Based Dairy Alternatives Moo-ove Over, Cow’s Milk: The Rise of Plant-Based Dairy Alternatives NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #171 Soy Original 100 8.0 4.01 0.501 7.99 1.0 6.00 299 1.07 39 299 119 0.510 2.99 501 119 Rice Pacific Original 130 1.01 1.99 0 27.00 0 13.99 300 1.08 N/A N/A 60 N/A N/A 499 101 Potato Dari- Free 70 0 0 0 20 0 2 300 0.72 N/A 50 120 0.13 0.96 300 90 Pea Ripple Original 101 7.99 4.51 0.5 6.00 0 6.00 451 2.69 0 451 130 N/A N/A 499 120 Oat Pacific Original 130 4.01 2.50 0 24.00 1.9 19.01 350 1.80 N/A 120 115 0.509 N/A 499 101 Hemp Living Original 101 1.99 7.01 0.504 7.99 0 6.00 300 1.08 41 N/A 110 0.425 1.49 499 101 Flax Good Karma Plain 24 0 2.50 0 1.01 0 0 300 0.36 N/A 0 79 N/A 1.49 499 101 N/A = not available 3 Thai Kitchen Coconut Milk (canned) 424 3.03 42.42 30.303 9.09 0 3.03 0 6.55 N/A 491 46 N/A N/A 0 N/A Coconut So Delicious Original (diluted beverage/ ) 70 0 4.51 4.512 7.99 1.0 7.01 101 0 41 41 0 N/A 3.00 499 101 Cashew Silk Original 60 1.01 2.50 0 9.00 0.0 7.01 451 0.36 17 29 170 0.509 3.00 499 101 Califia Original 59 1.00 4.01 0 6.00 0.9 5.00 450 0.71 N/A N/A 161 0.424 3.01 500 100 Almond Blue Diamond Almond Breeze 41 1.01 2.50 0 4.01 1.0 3.00 451 0.72 N/A 180 149 0.034 N/A 499 89 Cow’s Milk 2% with & D 122 8.05 4.83 3.067 11.71 0 12.35 293 0.05 27 342 115 0.451 1.29 464 120

Nutrition Content Product Energy (kcal) Protein (g) Fat (total g) Saturated (g) Carbohydrate (g) Fiber (g) Sugars (g) Calcium (mg) Iron (mg) Magnesium (mg) Potassium (mg) Sodium (mg) (mg) Vitamin B12 (mcg) Vitamin A (IU) Vitamin D (IU) Information obtained from the USDA Food Composition Databases. Table 2. Nutritional Composition of Cow’s Milk and Non-Dairy Beverages per 8 oz. Cup (240 mL) PRACTICAL GASTROENTEROLOGY • JANUARY 2018 25 Moo-ove Over, Cow’s Milk: The Rise of Plant-Based Dairy Alternatives NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #171

Table 3. Pros and Cons of Cow’s Milk and Non-Dairy Beverages Beverage Pros Cons Cow’s Milk, 2% High in protein, calcium Not suitable for those with allergies or lactose and vitamin D intolerance; higher in saturated fat; may be derived from cattle treated with antibiotics and/or hormones Soy Milk Highest protein and least Higher fat than other plant-based milks; processed among plant-based sweetened varieties can contain up to 19 g sugar milks Almond Milk Low-calorie; high in vitamin E Very low-protein Rice Milk Best option for those with Least amount of protein; often manufactured with multiple allergies added sugars Oat Milk Contains fiber, iron, and a Ingredient list could contain potential allergens moderate amount of protein Coconut Milk Good source of potassium Higher fat content than other plant-based milks; (490-600 mg per 8 oz. cup low in protein of canned milk); contains iron and fiber Hemp Milk High in essential fatty acids Higher fat content than cow’s milk; earthy flavor Cashew Milk Creamy taste and texture Low-protein Flax Milk Low-calorie; high in essential Very low-protein fatty acids Pea Milk High in protein; creamy taste Not widely available and texture Potato Milk Fat-free; soy-, nut-, gluten- Very low-protein; not widely available; may and casein-free contain allergenic additives

Other Milks be an excellent source of vitamin D. In addition, one 8 oz. cup contains 50% of the recommended Cashew Milk daily value for vitamin E. With only 60 calories per cup and no saturated fat or cholesterol, unsweetened cashew milk is often Flax Milk considered a good option for those looking for a With a similar nutrition profile to that of almonds, creamier alternative to almond milk without the fat flax milk is low in calories (around 25 kcal in 1 cup and calories of canned coconut milk. It is made by of unsweetened) and very little protein. Flax milk blending water-soaked with water. is made commercially by combining cold-pressed Like almond milk, after the pulp is strained flax oil with water, thickeners, and emulsifiers. away, most of the protein content and naturally Flax milk has the additional benefit of 1,200 mg occurring vitamins and minerals in cashews ends of omega-3 fatty acids (alpha-linolenic acid) per up being lost. Through fortification, however, 8 oz. cup. It is also fortified with calcium, vitamin cashew milk can offer close to 50% more calcium D, and vitamin B12, though not to the same degree than cow’s milk. Fortified cashew milk can also as some other non-dairy alternatives.

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Flax does contain a very high amount of fortification. These factors are especially important phytoestrogens - over three times that of soy - but when considering the protein, vitamins, minerals, it is unclear how much remains in the oil after and sugar in each serving. Most non-dairy milk the seeds are pressed. And again, the potential alternatives are fortified to provide a reasonable health effects (both positive and negative) of these amount of calcium and vitamin D, although amounts compounds are still being extensively researched. of other micronutrients are often unknown. Besides taste and texture, protein and added sugars are Potato Milk perhaps the most widely variable attributes among Potato milk is another newcomer to the non-dairy plant-based milks. Consumer awareness, therefore, milk scene. It is not widely available at grocery is important when plant-based substitutes are used stores, but it can be ordered online. Commercially, to fully replace cow’s milk in the diet. it is usually found in powdered form. Like rice milk, potato milk is high in carbohydrates but References low in protein, though it is usually fortified with 1. Whip L, Daneshkhu, S. Big identifies appetite for calcium and vitamins. It is also a good option for plant-based milk. Financial Times. July 15, 2016. http:// www.ft.com. Accessed September 14, 2017. those who may have a soy or nut allergy, as well as 2. Hoffman J, Falvo M. Protein – Which is Best? Journal of those following a gluten- and/or casein-free diet, Sports Science & Medicine. 2004;3(3):118-130. although consumers should read the label to check 3. Singhal S, Baker R, Baker S. A Comparison of the Nutritional Value of Cow’s Milk and Non-dairy Beverages. for potentially allergenic additives. J Pediatr Gastroenterol Nutr. 2017 May;64(5):799-805. In addition to providing as much calcium as 4. USDA Food Composition Databases. Agricultural Research cow’s milk, potato milk provides more iron than Service website. https://ndb.nal.usda.gov/ndb/search/list. Accessed August 2017. many other non-dairy alternatives. 5. USDA. Recent Trends in GE Adoption. Economic Research Service website. https://www.ers.usda.gov/data-products/ CONCLUSION adoption-of-genetically-engineered-crops-in-the-us/recent- A growing number of consumers are opting for trends-in-ge-adoption.aspx. Updated July 2017. Accessed September 16, 2017. plant-based milk substitutes, either for medical 6. Messina M. Soy and Health Update: Evaluation of reasons or as a lifestyle choice, and as a result, the the Clinical and Epidemiologic Literature. Nutrients. current generation of plant-based milks continues 2016;8(12):754. 7. Jiang S, Cai W, Xu B. Improvement of Soy to expand. Table 3 outlines the pros and cons of Milk Made from Short-Time Germinated Soybeans. Foods. the various types of non-dairy milk alternatives. 2013;2(2):198-212. The nutritional profile of each type of “milk” 8. Krader, Kate. For One Silicon Valley Startup, This Vegetable Is the Future of Milk. Bloomberg. September depends not only on the plant source, but also 12, 2017. http://www.bloomberg.com. Accessed October the manufacturing process and the degree of 12, 2017.

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