By Reed Mangels, PhD, RD

A recently published study about fracture risk in non-meat eaters has received a lot of media attention. Here’s what you need to know.

What is the study?

The study is from the United Kingdom and was conducted by researchers at Oxford University and the University of Bristol. Study subjects were recruited between 1993 and 2001 and were studied until 2016. About 55,000 men and women were included in the study. At the start of the study, subjects were classified into 1 of 4 dietary groups based on their responses to a questionnaire which asked questions like “Do you eat any meat?” The groups were meat eaters, fish eaters (did not eat meat but ate fish), vegetarians (did not eat meat or fish, but ate one or both of dairy or eggs), and vegans (participants who did not eat meat, fish, dairy, and eggs). At the start of the study there were 29,380 meat eaters, 8,037 fish eaters, 15,499 vegetarians, and 1,982 vegans. 

     Some subjects completed a similar follow-up questionnaire in 2010. The majority of subjects had followed the same diet for years before the start of the study. For example, 88% of fish eaters, vegetarians, and vegans had not eaten meat for at least 5 years before recruitment, 85% of vegetarians and vegans had not eaten fish for at least 5 years before recruitment, and 82% of vegans had not eaten eggs or dairy for at least 3 years before recruitment.

     During the follow-up period, the occurrence of fractures was determined through use of the National Health Service’s records. The study’s goal was to determine if there were differences in fracture risks between vegetarians, vegans, and non-vegetarians.

What did it find?

Over the follow-up period which averaged 17.6 years, there were 3,491 fractures – 566 arm fractures, 889 wrist fractures, 945 hip fractures, 366 leg fractures, 520 ankle fractures, and 467 other fractures. The researchers were not able to determine how many fractures were due to trauma like auto accidents and how many were due to osteoporosis (weak bones).

     Compared with meat eaters, vegetarians and vegans had a higher risk of total fractures and hip fractures and vegans had a higher risk of leg fractures and of vertebral fractures. Vegetarians had a 25% higher risk of hip fractures than did meat eaters while vegans had more than twice the risk. No significant differences were seen between the groups in the risk of wrist or ankle fractures or the risk of arm fractures after controlling for body mass index (BMI).

     Differences in BMI between the groups account for some of the differences in fracture risk. Vegans tend to have a lower BMI on average. A lower BMI has been associated with less dense bones because bones are strengthened by weight-bearing exercise. If a person weighs more, their bones do more weight-bearing. Additionally, some studies have found increased risk of hip fractures with lower BMIs, possibly because of less fat to cushion the hip when a fall occurs.

     The vegans had lower average intakes of calcium and protein from food. The average calcium intake of vegans was 591 milligrams per day, considerably below the approximately 1,000 milligrams per day which was the average for the other diet groups. However, even when only those study participants who had calcium intakes above the U.K. recommendations were examined, the vegans still had a higher risk of bone fractures. The differences in dietary protein and calcium intake do not account for all the differences in fracture risk between the groups and the researchers were unable to explain why differences in fracture risk persisted even after their data were adjusted for differences in BMI and calcium and protein intake.

     Additionally, there was a higher risk of total fractures among vegans who were not very physically active and who had a low BMI but vegetarians (not vegans) with a higher BMI had a higher risk of hip fracture. There were a limited number of subjects who were in these subgroups which makes it difficult to be confident that these results would hold in a larger group.

What are the study’s limitations?

While the investigators examined dietary calcium intake, they did not determine if there were differences in intake of calcium supplements, nor did they investigate vitamin D intake or status. Adequate vitamin D is needed to promote calcium absorption. They also did not investigate vitamin B12 status or intake. Inadequate vitamin B12 is associated with an increased fracture risk.

     Because of the observational nature of this study, it is not possible to say if changes in vegans’ dietary or supplement practices (such as increased calcium, vitamin D, vitamin B12, or protein intake) could have affected their risk of fracture.

Are there practical implications?

This study alerts vegans that they may be at increased risk for several types of fractures including hip and vertebral fractures. Vegans should follow general recommendations to promote healthy bones including:

• Meeting calcium recommendations,
• Getting adequate vitamin D,
• Getting enough protein,
• Using fortified foods and/or supplements to meet recommendations for vitamin B12,
• Getting weight-bearing exercise.

Tong TYN, Appleby PN, Armstrong MEG, et al. Vegetarian and vegan diets and risks of total and site-specific fractures: results from the prospective EPIC-Oxford study. BMC Med. 2020;18(1):353.

The 2020 Dietary Guidelines Advisory Committee has completed their review of the evidence on nutrition and health. The final report reflects the Advisory Committee’s full examination of the evidence using three rigorous approaches: data analysis, systematic reviews, and food pattern modeling. The Scientific Report also includes advice to the United States Departments of Agriculture and Health and Human Services to consider in the development of the next edition of the Dietary Guidelines for Americans. The Advisory Committee’s Scientific Report is not a “draft” of the next edition of the Dietary Guidelines for Americans. USDA and HHS will consider the Advisory Committee’s Scientific Report, along with public and agency comments, as the Departments develop the 2020-2025 Dietary Guidelines for Americans.  

The Vegetarian Resource Group submitted the following comment on the Advisory Committee report

To the U.S. Department of Agriculture and U.S. Department of Health and Human Services.

August 7, 2020

Thank you for the opportunity to submit comments on the Scientific Report of the 2020 Dietary Guidelines Advisory Committee.

We commend the Committee for their diligence, especially during this challenging time. We appreciate the inclusion of additional life stages in this report and support the overall overarching guidelines (pages 43-45/835).

Since the Committee has made dietary patterns a centerpiece of their report (according to page 14/835), we have chosen to focus our comments on the Healthy Vegetarian Pattern.

While we strongly support the inclusion of a Healthy Vegetarian Pattern as a healthy eating pattern for Americans, we have concerns with the composition of the dietary pattern. The food choices in the Healthy Vegetarian Pattern were informed by a survey (page 752/835) that is more than 10 years old and that was based on a single day’s dietary recall of self-described “vegetarians.” A large portion of the self-identified “vegetarians” consumed meat, fish, or poultry¹ which prevents their diet intake records from being informative about the composition of a vegetarian diet which does not include meat, fish, seafood, or poultry.

The aforementioned study reported that 2.1% of the U.S. population identified themselves as “vegetarian” and that 3% of the vegetarians did not use any animal products on the day of the survey.¹  In contrast, our most recent polls indicate that between 3.3% and 6% of the adult and child/adolescent U.S. population “never eats meat, fish, seafood, or poultry” and thus would be classified as vegetarian.^2-5 Approximately half of these adult vegetarians and a quarter of the child/adolescent vegetarians “never eat meat, fish, seafood, poultry, dairy products, or eggs” and thus would be classified as vegan.^2-5  Table 1 provides details about the percentages of vegetarians and vegans in our most recent surveys.

We recommend that additional research be conducted on the food choices of vegetarians (those who do not eat meat, fish, and poultry) including vegans (no meat, fish, poultry, dairy products, eggs) in the United States and that these results be used to inform the food choices in the Healthy Vegetarian Pattern. Additional support for the inclusion of food patterns for those using a vegan diet is found in Table 2 which presents the results of surveys of U.S. adults’ behavior when eating out. Many adults eat vegetarian, including vegan meals when they eat out. In our most recent survey, 46% of U.S. adults who ate vegetarian meals when eating out chose to eat vegan meals.² In view of the consistent results of our polls demonstrating that as many as half of vegetarians do not eat dairy products or eggs and that those Americans sometimes choosing to eat vegetarian meals frequently choose to eat vegan meals, we urge the Committee to increase the flexibility of the Healthy Vegetarian Pattern to include vegan diets. An additional consideration is the potential health benefits of vegan diets.

Vegan diets are associated with health benefits, in some cases superior to those of lacto-ovo vegetarian diets and in some cases similar to those of lacto-ovo vegetarian diets. Specifically,

• A 15% lower incidence of cancer in vegans and an 8% lower incidence of cancer in vegetarians overall compared to nonvegetarians.⁶
• Vegetarians have a lower mean BMI than nonvegetarians (Vegetarians: -1.48 kg/m²; vegans: -1.72 kg/m²).⁶
• Vegetarians had a 27% lower risk of developing diabetes than did nonvegetarians. This reduced risk was seen in vegans and in lacto-ovo, lacto, and ovo vegetarians.⁷
• Vegetarians have lower total cholesterol (Vegetarian: -28.16 mg/dL; vegans: -31.02 mg/dL) and LDL cholesterol (Vegetarians: -21.27 mg/dL; Vegans: -22.87 mg/dL) than nonvegetarians.⁶
• Vegetarian diets, especially vegan diets, effectively promote weight reduction.⁸ 
• Changing from a nonvegetarian to a vegetarian or vegan diet is associated with a mean decrease in blood cholesterol concentration of 14 mg/dL and a mean decrease in LDL concentration of 13 mg/dL. Reductions of this scale correspond to an estimated 9 to 10.6% decrease in risk of heart disease.⁹

The current Healthy Vegetarian Pattern does not include options for those who do not eat eggs. There are many reasons that consumers choose not to eat eggs including taste preference, allergies, religious or cultural practices, and other considerations. In order to provide realistic guidance, options should be provided so that eggs do not appear as an essential component of the Healthy Vegetarian Pattern. This inclusion of the egg subgroup seems contrary to the Committee’s statement that “… a strength of the Food Patterns is that it has a tremendous amount of flexibility that allows it to be tailored to an individual’s cultural and taste preferences. This flexibility occurs because the resulting Patterns are only prescriptive for the larger food groups and subgroups amounts but not the specific types of foods to be consumed, permitting choices and options for the consumer.” (page 732/835). Eggs are a specific type of food and alternatives are not presented which would allow the flexibility of other subgroups. We strongly recommend that eggs not be in a subgroup unless non-animal-based alternatives are included in this subgroup.

Similarly, guidance is needed about alternative sources of the nutrients provided by the dairy group for those who do not use dairy products. While fortified soy milk is included in the dairy group, many consumers will not use 3 cups of fortified soy milk daily. We encourage the Committee to offer other options including increased use of leafy green vegetables and calcium-fortified foods in addition to soy milk, such as other plant milks and orange juice, as sources of bioavailable calcium.

We note that a study of Seventh-day Adventists found that lacto-ovo vegetarians, pescatarians, and semi-vegetarians all consumed smaller amounts of dairy products and eggs than did nonvegetarians¹⁰ suggesting that alternatives to dairy products and eggs are needed in the Healthy Vegetarian Pattern for those consistently choosing a vegetarian diet and for those who sometimes choose vegetarian or vegan meals. We recommend greater flexibility in the Healthy Vegetarian Pattern.

The Healthy Vegetarian Pattern has limited use of legumes, a food group with numerous health benefits including cholesterol-lowering, blood glucose control, and anti-inflammatory effects.^11,12 Currently, on a 2000 calorie meal plan, only 1.5 cups (6 oz eq) of legumes/week are included as a protein food with an additional 1.5 c eq as vegetables (page 750/835). This is less than a half cup of beans daily. An older survey of self-defined U.S. vegetarians who did not eat meat on the day of the survey found that their average consumption of dried beans was about ½ cup daily.¹³ The inclusion of more legumes in the Protein Foods Group could allow greater flexibility, especially if the subgroups were eliminated and the foods in the Protein Foods Group (soy/nuts/seeds/legumes/eggs) could be chosen at will. 

We note that in Table D14.3 (pages 750-751/835), that legumes in the Vegetable Group are measured in cup eq/wk whereas legumes in the Protein Foods Group are measured in oz eq/wk. We are concerned that the use of different units of measure (c eq and oz eq) depending on whether legumes are being counted as a protein or a vegetable will be confusing to consumers.

The Healthy Vegetarian Pattern for age 12-24 months only includes guidance for those toddlers not receiving human milk or infant formula. Although the Committee states that “most infants in the United States (66 percent) are no longer receiving human milk after age 12 months” (page 429/835), a third of the infants in the United States are receiving human milk after age 12 months and require guidance. Guidance is needed for toddlers who are receiving some human milk or infant formula and who are being fed according to the Healthy Vegetarian Pattern. 

The Healthy Vegetarian Pattern for age 12-24 months does not include legumes in the Protein Foods Group and only a small amount of legumes are included in the Vegetable Group. Legumes can supply significant amounts of protein, iron, and zinc for toddlers.¹⁴ Inclusion of legumes in the Protein Foods Group adds additional flexibility and increases the likelihood that toddlers will become familiar with foods such as lentils and garbanzo beans that will eventually play a significant role in their diet.

The report states (page 467/835), “Without supplements and/or fortified products, it is not possible to meet all nutrient goals with a vegan diet at this age [12-24 months]. We agree that supplements and fortified foods are needed to ensure the adequacy of nutrients such as vitamin B12 and vitamin D. We question, however, why fortified foods were not used to develop a vegan food pattern for this age group. The Committee endorses the use of fortified dairy products to supply vitamin D and fortified infant cereals to supply iron and zinc, suggesting that fortified foods are acceptable. Given this acceptance of the used of fortified foods, it seems reasonable to provide guidance for the use of fortified foods and supplements by parents/caregivers who want to use a vegan diet for 12-24-month-olds.

In addition to the preceding comments that specifically address the Healthy Vegetarian Pattern, we have comments on other parts of the Report.

We encourage the Committee to more broadly consider alternatives in all Patterns. For example, the Committee notes that 88% of people do not meet recommendations for dairy foods (page 136/836). The Report also notes, “The dietary patterns commonly consumed by racial-ethnic and cultural groups often have unique characteristics (such as the lack of dairy intake by some groups) that differ from the Healthy U.S.-Style Pattern. These differences may cause the patterns from these groups to appear inadequate because some of the unique foods consumed in these populations that provide the missing nutrients are not represented in the food item clusters used in food pattern modeling. It is now, and will become even more, imperative that dietary guidance reflect dietary patterns of growing demographic groups, particularly LatinX and Asian populations “(page 800/835). Use of alternatives, such as leafy green vegetables, tofu, fortified plant milks in addition to soy milks, could allow the nutrition recommendations to be more acceptable to a greater spectrum of the American population.

Another example of an area where more consideration of options should be included is the egg subgroup. All of the three Patterns include eggs as a subgroup. As discussed previously, this inclusion seems contradictory to the Committee’s statement that Patterns are not prescriptive for specific types of foods consumed. We notice that the Food Pattern Modeling Report¹⁵ includes an examination of the effect of increasing the number of eggs included in the Patterns but does not examine the effect of decreasing or eliminating eggs and replacing them with plant-based protein sources in all Patterns. Greater flexibility in food groups and subgroups seems needed in all Patterns to meet the needs of those with different cultural, religious, and other influences.

Although the Healthy Vegetarian Pattern includes legumes as a subgroup in the Protein Foods Group, the other Healthy Patterns fail to emphasize legumes as a protein source. Legumes have numerous health benefits.^{11, 12} Some of these benefits are illustrated in Table D8.1 (page 513/835). Legumes should be included in all food patterns as a protein source.

We note that Table D1.4 (page 185/835) should include some additional foods in the last column. Fortified plant milks and fortified orange juice supply vitamin D and are more readily available than mushrooms exposed to UV light. Fortified plant milks and dark green leafy vegetables supply bioavailable calcium. Seaweed is not typically recommended as an iodine source because their content is variable, and some sea vegetables provide large amounts of iodine.¹⁶

The Report repeatedly recommends seafood consumption in pregnancy due to the high DHA content of some seafood. Since DHA consumption is what underlies the potential benefits of seafood consumption, research that included DHA supplementation can be used to examine whether increased DHA consumption offers benefits. Benefits of DHA supplementation in pregnancy are primarily associated with gestational duration and birth weight. A meta-analysis of 70 randomized controlled trials (RCTs) found that omega-3 interventions in pregnancy consisting of either supplements (mainly DHA) or food were associated with a reduced risk of preterm birth (<37 weeks) and early preterm birth (<34 weeks), a slightly longer gestational length, and a reduced risk of having a low birthweight infant.¹⁷ Omega-3 supplementation in pregnancy was not associated with significantly improved cognition, IQ, vision, or other developmental or growth outcomes.¹⁶ Approximately 20% of people in the United States reported no fish or seafood consumption over a 30-day period.¹⁸ Guidance is needed throughout the Report for those who avoid fish due to allergies, cultural influences, preference, or because they are vegetarian or vegan. This is especially the case for pregnancy and lactation where this Report seemed to emphasize the consumption of fish.

The Report includes many excellent ideas for further research including expansion of diversity among populations studied and the expansion of USDA databases to incorporate additional foods and beverages from diverse populations” (pages 766-767/835). We encourage increased sampling of those choosing vegetarian, including vegan, dietary patterns and the expansion of the USDA databases to incorporate additional foods commonly eaten by vegetarians, including vegans, especially fortified foods and replacements for animal-derived products. Additional research should be conducted, which could be used to inform future vegetarian food patterns, on the food choices of vegetarians who do not consume meat, fish, seafood, or poultry and those vegetarians who also do not consume dairy products and eggs.

We noted the statement in the Committee’s letter to the Secretaries, “In addition, comments identified the importance of evaluating sustainability of recommended dietary patterns, addressing the social and economic aspects of access to foods that are components of healthy dietary patterns, and considering systemic changes to encourage behavior change consistent with the guidelines. These comments point to areas that are important for USDA and HHS to address through appropriate mechanisms, and their consideration may provide useful approaches for implementing the recommendations in the Dietary Guidelines for Americans” (page 3/835). We support these comments and strongly encourage USDA and HHS to address the issues of social and economic access to foods that are components of healthy dietary patterns and of including sustainability as an important consideration when recommending dietary patterns.

References

1. Juan W, Yamini S, Britten P. Food intake patterns of self-identified vegetarians among the U.S. population, 2007-2010. Procedia Food Sci. 2015;4:86-93. doi:10.1016/j.profoo.2015.06.013.
2. How Many Adults in the U.S. are Vegan? Vegetarian Resource Group. https://www.vrg.org/blog/2020/08/07/how-many-adults-in-the-u-s-are-vegan-how-many-adults-eat-vegetarian-when-eating-out-asks-the-vegetarian-resource-group-in-a-national-poll/ Published August 7, 2020.
3. Stahler C. How Many People are Vegan? How Many Eat Vegan When Eating Out? Vegetarian Resource Group. https://www.vrg.org/nutshell/Polls/2019_adults_veg.htm Published 2019.
4. How Many Adults in the U.S. are Vegetarian and Vegan? Vegetarian Resource Group. https://www.vrg.org/nutshell/Polls/2016_adults_veg.htm Published 2016.
5. How Many Teens or Other Youth are Vegetarian or Vegan? Vegetarian Resource Group. https://www.vrg.org/blog/2014/05/30/how-many-teens-and-other-youth-are-vegetarian-and-vegan-the-vegetarian-resource-group-asks-in-a-2014-national-poll/ Published May 30, 2014.
6. Dinu M, Abbate R, Gensini GF, Casini A, Sofi F. Vegetarian, vegan diets and multiple health outcomes: a systematic review with meta-analysis of observational studies. Crit Rev Food Sci Nutr. 2017;57:3640-3649.
7. Lee Y, Park K. Adherence to a vegetarian diet and diabetes risk: a systematic review and meta-analysis of observational studies. Nutrients. 2017 Jun 14;9(6). pii: E603.
8. Huang RY, Huang CC, Hu FB, Chavarro JE. Vegetarian diets and weight reduction: a meta-analysis of randomized controlled trials. J Gen Intern Med. 2016;31(1):109‐116.
9. Wang F, Zheng J, Yang B, Jiang J, Fu Y, Li D. Effects of vegetarian diets on blood lipids: A systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2015;4(10):e002408.
10. Orlich MJ, Jaceldo-Siegl K, Sabaté J, Fan J, Singh PN, Fraser GE. Patterns of food consumption among vegetarians and non-vegetarians. Br J Nutr. 2014;112(10):1644-1653.
11. Messina V. Nutritional and health benefits of dried beans. Am J Clin Nutr. 2014;100 Suppl 1:437S-42S.
12. Pribis P. The role of legumes in maintaining health. In Craig W, ed. Vegetarian Nutrition and Wellness. Boca Raton, FL: CRC Press; 2018:1-9.
13. Haddad EH, Tanzman JS. What do vegetarians in the United States eat? Am J Clin Nutr. 2003;78(3 Suppl):626S-632S. doi:10.1093/ajcn/78.3.626S
14. Mangels R, Driggers J. The youngest vegetarians: Vegetarian infants and toddlers. ICAN: Infant, Child & Adolescent Nutrition. 2012; 4:8-20.
15. 2020 Dietary Guidelines Advisory Committee and Food Pattern Modeling Team. Food Pattern Modeling: Ages 2 Years and Older. 2020 Dietary Guidelines Advisory Committee Project. Washington, D.C: U.S. Department of Agriculture. Published 2020.
16. Teas J, Pino S, Critchley A, Braverman LE. Variability of iodine content in common commercially available edible seaweeds. Thyroid. 2004;14(10):836–841.
17. Middleton P, Gomersall JC, Gould JF, Shepherd E, Olsen SF, Makrides M. Omega-3 fatty acid addition during pregnancy. Cochrane Database Syst Rev. 2018;11(11):CD003402. doi: 10.1002/14651858.CD003402.pub3
18. Jahns L, Raatz SK, Johnson LK, Kranz S, Silverstein JT, Picklo MJ. Intake of seafood in the US varies by age, income, and education level but not by race-ethnicity. Nutrients. 2014;6(12):6060-6075. doi:10.3390/nu6126060

By Reed Mangels, PhD, RD

Shortly after our post about updated Daily Values on food labels, we got a question from a reader who asked, “The FDA webpage you linked to highlights that the DV for total fat has been updated from 65 g to 78 g and the DV for sodium has been updated from 2,400 mg to 2,300 mg. Do you have any comments on those changes?”

As you may recall from an earlier post, the Nutrition Facts portion of a food label includes Daily Values which are established by the FDA to be used for the labels of foods and supplements. Daily Values are amounts of nutrients that people are recommended to consume or not to exceed each day. 

In the most recent update, the Daily Value for total fat went from 65 grams to 78 grams of fat per day. Of course, this doesn’t mean that you need to eat more fat. Remember, in this case, this indicates an upper limit – don’t eat more than 78 grams of fat a day if you’re eating 2,000 calories a day. 2,000 calories is the amount the FDA decided to use as a guide for general nutrition advice.

We wondered why there was an increase in the upper limit for total fat. Some quick calculations showed us that if your diet has 65 grams of fat and 2,000 calories, your diet gets 30% of its calories from fat. If your diet has 78 grams of fat and 2,000 calories, your diet gets 35% of calories from fat.

The RDAs include recommendations for the acceptable macronutrient distribution range (AMDR) – the percentage of calories that should come from protein, fat and carbohydrate. The AMDR for total fat is 20-35% of calories (1). Since 35% appears to be the upper limit, that is likely why 78 grams of fat (35% of 2,000 calories) was used as the DV. 

The change in the sodium DV is due to a new recommendation for sodium. In 2019, the National Academies of Sciences, Engineering, and Medicine, (the non-profit organization that makes nutrition recommendations for the United States) developed a new method for evaluating dietary intake called the Chronic Disease Risk Reduction Intake (CDRR). The CDRR is defined as the lowest level of intake for which there was strong enough evidence to say that above this intake, there is a greater risk of chronic disease (2).

There is strong evidence that reducing sodium intake reduces blood pressure (2,3). The CDRR for adults for sodium is 2,300 mg/d; above this level of intake, a reduction in sodium intake is recommended. This new recommendation appears to be the reason that the DV for sodium was changed to 2,300 milligrams.

As was the case for fat, this does not mean that you must take in the DV for sodium daily to be healthy. It means that you should reduce your sodium intake so that it is below 2,300 milligrams.

 References

1. Institute of Medicine Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academy Press; 2002.
2. National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes for Sodium and Potassium. Washington, DC: The National Academies Press. 2019.
3. Newberry SJ, Chung M, Anderson CAM, et al. Sodium and Potassium Intake: Effects on Chronic Disease Outcomes and Risks. Comparative Effectiveness Review No. 206. (Prepared by the RAND Southern California Evidence-based Practice Center under Contract No. 290-2015-00010-I.) AHRQ Publication No. 18-EHC009-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2018.

The latest Nutrition Hotline column in Vegetarian Journal by Reed Mangels, PhD, RD focuses on Vitamin A Toxicity and Plant Foods. A reader had asked, “If I eat a lot of carrots and sweet potatoes, do I have to worry about vitamin A toxicity?”

     Dr. Mangels’ response begins with, “The short answer is, “No, you won’t develop a vitamin A toxicity from eating a lot of carrots and sweet potatoes. There are two forms of vitamin A in food. The first, called preformed vitamin A retinol, or retinyl ester, is found in foods from animal sources including dairy products, fish, and meat. This form of vitamin A would only be found in a vegan diet in supplements and fortified foods. Preformed vitamin A can be chemically synthesized.

     The second form of vitamin A comes from provitamin A carotenoids. These substances, which our body uses to make vitamin A, are found in plants, especially dark orange or yellow vegetables and fruits, leafy green vegetables, and tomatoes. The most important provitamin A carotenoid is beta-carotene.

The two other provitamin A carotenoids are alpha-carotene and beta-cryptoxanthin. Even large amounts of the provitamin A carotenoids over a long period of time aren’t associated with vitamin A toxicity.”

The entire column can be read here: https://www.vrg.org/journal/vj2020issue2/2020_issue2_nutrition_hotline.php

To subscribe to Vegetarian Journal in the USA, see: https://www.vrg.org/member/2013sv.php

You can also subscribe to the Kindle version of Vegetarian Journal in the USA and United Kingdom. In the USA, visit: https://www.amazon.com/dp/B07LBY2Y7K/ref=sr_1_1?ie=UTF8&qid=1544727482&sr=8-1&keywords=B07LBY2Y7K  In the United Kingdom, visit: https://www.amazon.co.uk/dp/B07LBY2Y7K/ref=sr_1_1?s=digital-text&ie=UTF8&qid=1544731957&sr=8-1&keywords=B07LBY2Y7K

By Reed Mangels, PhD, RD

The Nutrition Facts label on packaged foods is being updated. New labels are being phased in. As of January 1, 2020, large manufacturers – those with $10 million or more in annual sales  –  were required to switch to the new label by January 1, 2020. Smaller manufacturers have until January 1, 2021 to comply. This means that for the time being, you may see a mix of new and old versions of the labels at stores. A sign that you are looking at the new version of the label is that it includes added sugars, vitamin D, and potassium. These were not required to be included in the older version of labels.

Daily Values are established by the FDA. The Daily Value for a nutrient is a single value, often similar to the Recommended Dietary Allowance (RDA), that is selected to be used for the labels of foods and supplements.  Daily values are amounts of nutrients that people are recommended to consume or not to exceed each day. The Daily Value may be somewhat different from the amount of a nutrient you need. For example, the RDA for calcium for adults ranges from 1,000 milligrams for younger adults to 1,300 milligrams for pregnant and lactating women. The new Daily Value for calcium is set at 1,300 milligrams.  If you are a young adult, you would not have to get 1,300 milligrams, but the label could still help you to see whether a food is high in calcium. The label actually provides the %Daily Value so that consumers can see how much (what percentage) a serving of the product contributes to reaching the Daily Value. The new labels give both the %Daily Value and the actual amount of the nutrient in a product. For example, the Nutrition Facts label for 1 cup serving of one brand of fortified soy milk says that it has 450 mg of calcium, 30% DV (note that this %DV is rounded since 390 mg is actually 34% of 1300 mg).

Calcium is one example of a nutrient whose Daily Value has increased. Others include potassium, vitamin C, and vitamin D. Nutrients whose Daily Value has decreased include zinc and vitamin B12. These changes don’t mean that an individual’s need for the nutrient has changed; rather, the change is with the amount on the label. You can see all of the changes here.

By Camryn Bell, Dietetic Intern

Going to the hospital seems like an inevitable event for most people, whether it’s for pregnancy, elective or minor surgery, or maybe for a more serious ailment. Just because a trip to the hospital may seem stressful does not mean you can’t help alleviate that stress by having a plan in place for when you do go. Being vegan and put into a new situation or place, like the hospital, can come with its obstacles, but I am here to help guide you around those challenges. Let’s all be honest, being vegan is tough for some individuals at times and voicing an opinion can be hard, but being vegan is rewarding and empowering so that is why we do it. When it comes to the hospital setting, it is no different; the most important tool we have is our voice. Communication is crucial to getting what you want and understanding your options, but it is important to remember to treat the staff with respect and empathy, and to also understand the limitations the hospital staff may be working under.

What to Know Before You Go

Stating as early as possible that you are vegan, either by writing down on your admission paperwork or by simply telling the staff, can give you and the staff more time to smooth out the wrinkles and make sure everyone is on the same page. They may even be able to add into your medical record that you would like to avoid the food items you tell them, like dairy, meat, and eggs. If you have a pre-op appointment before coming into the hospital, you could discuss with the staff then about being vegan and how they can best serve you during your hospital stay.

     Hospitals have different menus and ordering systems. In some, you can order through a written form; in others, you must call the diet office to order your meals. If you have the option to call the diet staff, this would be a good time to ask the questions you have regarding ingredients and vegan options. If you are using the written form, you may be able to write on it the food items you wish to avoid. In this case you would still have to call the food staff or dietitians if you have any questions. Some hospitals have a system where you are given a menu and you can pick the items you want from the menu; this is a good situation to be in. When in doubt, stick to simple items like rice, fruit, salads, or beans that are less likely to have any hidden ingredients.

     These are just some starting examples; you will obviously need to try to get a well-balanced meal. If you have any questions or want to know the ingredients in the menu items, for example, if you are unsure if there are hidden animal products in items, calling the food service staff or the dietitians can help provide you with information and guidance. The food service staff’s number may be on the menu so look there, or ask your nurse to speak with them or the dietitian. Stating that you would like to speak to the diet staff or dietitians may help you not only get their contact information, but you may also get to speak with them in person, and that would be beneficial to really work through your options.

Who’s Who

Registered dietitians (RDs) are health professionals who have specialized in foods, diets, and nutrition. They are a great resource for support and help throughout your hospital stay. They have a lot of knowledge they would like to share with patients, and they want to help their patients enjoy their food while eating something that will help them get better. The dietitians’ specialty is more about the knowledge and implementation of food, whereas the diet staff is more about the hands-on application of food.

     The food service staff can have multiple jobs including preparation of food, serving meals, stocking, and cleaning. When it comes to the food staff, I would not assume that every member knows what veganism means, so it would be a good idea to specifically tell them the foods you avoid. You may even be able to write down these foods, and have it sent to the food staff if they are unable to put it in your chart.

     There are also DTRs (dietetic technician, registered) or dietitian assistants who could be working in the hospital. They have similar roles as the RDs but usually work under them because they have not completed the same qualifications. It can sometimes be difficult to distinguish between these different staff members. Looking at their name tags can give you insight into their job titles. The food staff will most likely be those delivering the food and taking meal orders. The dietitians are those who come in asking or giving nutrition information. They should also tell you what their job title is, but if not, just ask. 

Hospital Vegetarian Menu

Some hospitals may have a vegetarian menu, so starting with that and making adjustments to make it vegan may be easier than starting with a regular (non-vegetarian) menu. The vegetarian menu may not be attached to the regular menu, so ask the nutrition or nursing staff if there is one available.

Talking with Your Doctor

Some hospitals will only provide a standard meal to every patient unless they have a special order from the physician. In this case, speaking with your doctor would be helpful in getting a change to your diet order to meet your preference. If a meeting with your doctor to discuss your diet is not possible, ask your nurse or dietitian to be your advocate. You can also have an opportunity to bring up the topic up with the doctor the next time they come to your room to speak with you.

     Before you are able to meet with the dietitian or your doctor, see if the food service staff can add additional items onto your standard tray that you can eat. Some of these items could include additional servings of fresh, cooked, or canned fruits and vegetables, grains like rice or bread, different types of beans, non-dairy milk, or any meat alternatives they have on hand.

Bringing in Your Own Food

If the staff cannot accommodate your preferences, you may be able to bring in your own food if it is cleared by the hospital. If your diet includes other restrictions like low carbohydrate, low sodium, or texture modified, then the hospital staff would be more likely to object and not allow outside food to be brought in because it would likely not follow the stricter diet they set for you. If this is the case, try to eat what vegan food is available to you. As discussed above, the tips to help you with doing this is communicating with the food staff or dietitians about questions and support and pick simple food items from the menus provided.

     If you are cleared to bring in your own food, you can bring snacks with you when you are admitted. Healthy filling snack ideas don’t have to be complicated. Bringing staple items that can be incorporated into different snacks will give you variety without having to bring your whole pantry. Some good snack ideas could include apples and peanut butter, trail mix, vegan cheese and crackers, veggies and hummus, granola/protein bars.

     Some hospital rooms have their own mini fridges in them where you can store your food, but if this is not an option it is appropriate to ask the staff to store your refrigerated items in a fridge somewhere. There are usually refrigerators on each floor either in the staff eating areas or in the nutrition rooms.

     The food staff may also be able to store your food somewhere where it would be unlikely to contaminate other foods. You may also ask to have your food heated up if needed. The staff is there to serve you so asking for these accommodations is not far-fetched.

     You may also have friends or family pick you up meals and brings these in. Preparing a list of nearby restaurants with menu items you can eat may be helpful for those bringing you food.

Special Situations

Calling ahead to hospitals to see how they can accommodate and what they can offer you is a good idea, but sometimes admission is unexpected. In this instance having a note in your wallet listing your preferences could be helpful, and even in the Emergency Medical ID section of your phone you could indicate that you are vegan. 

     When you are in the hospital, you may require nutrition supplement drinks/food or tube feeding formula. Most of these formulas are vegetarian because they are made with milk protein excluding the fact that they contain vitamin D3. Vitamin D is often sourced from sheep lanolin (the waxy substance secreted by the glands in sheep skin), so it is not vegan. If you are requiring these products, I would ask the staff if they are able to order a vegan option or if they would be willing to make blenderized meals for you. This link lists different vegan meal replacements, supplements, and feeding tube formulas, https://www.vrg.org/seniors/#meal. It is always best to consult your dietitian and doctor to confirm that these options are appropriate for your situation and medical status. If you have any questions regarding the ingredients in your supplements or tube feeds, you can look at the ingredients on the back of the container, look up the ingredients online, or call the company (their number is usually on their website). This may be a case where you have to do the best that you can, keeping in mind that it is not a vegan world. You may also ask a friend or family member to do the research if you do not feel well enough to take this task on yourself.

     After a surgery or procedure, there is usually a natural progression in your diet orders to ensure that you are tolerating food well and that your GI tract is working as it should. This progression may begin with a clear liquid diet, move to a full liquid diet, then a soft diet, and then back to a regular diet. These diets are already limiting so let me give you some ideas of what you may be able to eat from them. A clear diet is a diet that consists of (you guessed it) clear liquids. It usually includes broth, sugar-free gelatin, clear fruit juices, popsicles, tea, sports drinks without color, clear sodas, or water. Although you should stay clear of meat based broths and gelatin, all the other options should be appropriate. Consider asking for vegetable broth instead.

     A full liquid diet will include more liquid options and even some soft foods. Appropriate vegan options on a full liquid diet could include all the items from the clear liquid diet in addition to oatmeal/grits made without milk, milk alternatives, creamy peanut butter, the vegan supplement nutrition drink mentioned above, puréed fruits, or mashed potatoes. The hospital may be able to make you smoothies if you ask. If you are able to bring in food beforehand, vegan protein powder may be a great option. Protein powder can help you get protein, vitamins, and minerals if the hospital is unable to provide sufficient options. Speak with your doctor beforehand though to confirm this is an appropriate option for you. A soft diet would include all mentioned above, but it could also include refried beans, cooked vegetables, softer fruits like bananas or cooked pears, soft noodles, or soft tofu.

     Once you are back on the regular diet, you can use all the tips above for planning your vegan meals. And again, if you have questions about what ingredients are in your food, calling the dietitian or food staff is the way to go to get the information you need. Here are links for texture alterations for vegan diets: https://www.vrg.org/fsupdate/fsu981/fsu981design.htm and https://www.vrg.org/journal/vj2009issue2/texture.htm.

Corona-Upending-Everything-Virus

As I said, going to the hospital can be scary, but going during a pandemic is a completely different story. This is a new territory for the whole world. Although having your preferences during this time might seem trivial, standing strong on your beliefs does not have to feel like a nuisance to the staff. I believe that all the tips mentioned above are still appropriate but it may be harder to accommodate you during this trying time. It may be more difficult to have your own food brought in due to avoiding outside contamination; discuss that with the hospital staff.

     Some hospitals may even switch over to house or standard trays, but they still have to accommodate those with allergies, and although being vegan for most people is because of values not medical necessity, they still may be willing to alter your meals for you. When it comes to supplements and tube feeding, this may not be something they are able to change. Most nutrition departments are stocking up on commonly used formulas, and vegan formulas most likely will not make the cut, so it may not be possible for them to order a special formula for you in time, if at all. If none of these attempts work for you and you have no other choices left, just know that it is likely short-term. It may be hard to go against your beliefs, but having the mindset that you tried your hardest and once you are healthy again you can go home and resume your normal lifestyle, may help ease the weight.

     The hospital system does have room for improvement when it comes to veganism, but much like society, they have come a long way with accommodating and offering vegan options. It is a lot easier to get information on ingredients and being able to have vegan food in the hospital than it was even a few years ago. So, although it may seem frustrating while being in the hospital and having a lack of options, it’s noteworthy that progress has been happening and will continue. I would also just keep in mind that as you expect understanding and respect with your decisions and expectations, you extend the same courtesy to those staff members who are trying to help you. Although it is the healthcare staff’s job to help you, showing kindness is always an effective way to really get them on your side. Good luck with any future hospital stays.

Camryn Bell is a dietetic intern with Lenoir-Rhyne University in South Carolina. She is originally from Arkansas; go Hogs! She looks forward to becoming a dietitian and spreading accurate and positive information to help people with their nutrition needs and goals.

The contents of this article, website, and our other publications, including Vegetarian Journal, are not intended to provide personal medical advice. Medical advice should be obtained from a qualified health professional. We often depend on product and ingredient information from company statements. It is impossible to be 100% sure about a statement, info can change, people have different views, and mistakes can be made. Please use your best judgment about whether a product is suitable for you. To be sure, do further research or confirmation on your own.

The Vegetarian Resource Group 2020, www.vrg.org

A VRG member has osteoporosis and asked about the bioavailability of different vegan calcium sources such as fortified soymilk, vegan supplements, etc.

VRG Nutrition Advisor Reed Mangels, PhD, RD responds:

There’s not a lot of difference in terms of the percentage of calcium absorbed from different forms of calcium.

Here’s some information from FDA’s Office of Dietary Supplements: The two main forms of calcium dietary supplements are carbonate and citrate. Calcium carbonate is inexpensive, but is absorbed best when taken with food. Some over-the-counter antacid products, such as Tums® and Rolaids®, contain calcium carbonate. Each pill or chew provides 200-400 mg of calcium. Calcium citrate, a more expensive form of the supplement, is absorbed well on an empty or a full stomach. In addition, people with low levels of stomach acid (a condition more common in people older than 50) absorb calcium citrate more easily than calcium carbonate.

These two forms of calcium (calcium citrate and calcium carbonate) are well absorbed as is calcium phosphate.

Calcium absorption is best when a person consumes no more than 500 mg at one time. So a person who takes 1,000 mg/day of calcium from supplements, for example, should split the dose rather than take it all at once.

Calcium carbonate is the fortificant used in most soymilk sold in the U.S. As noted above, it is well absorbed. A variety of calcium salts are used to fortify orange juice. There has been little research on their relative bioavailability. One study found that calcium citrate malate was quite bioavailable.

By Reed Mangels, PhD, RD

Freeda Vitamins recently contacted The Vegetarian Resource Group to let us know that they had changed the formulation of their Prenatal One Daily supplement so that it supplies 150 micrograms of iodine. This change in formulation was due to a letter from VRG encouraging them to add iodine to their prenatal products because of the important role that iodine plays in pregnancy. Even a mild iodine deficiency can result in neurologic and psychological deficits in infants and young children. The American Thyroid Association recommends that pregnant women (whether or not they are vegan or vegetarian), should supplement their diet with a daily oral supplement that contains 150 micrograms of iodine in the form of potassium iodide.

Readers should be aware that Freeda’s Mini-Prenatals do not contain iodine. Pregnant women choosing this product will need to use a separate supplement that provides 150 micrograms of iodine daily.

Freeda’s products are marketed to vegetarians and vegans. The addition of iodine makes Freeda’s Prenatal One Daily a better choice for pregnant women than similar supplements without iodine. According to the company, all Freeda products are Gluten Free and Kosher, and with the exception of their vitamin D3 tablets, all other Freeda products are 100% vegan. 

The contents of this article, our website and our other publications, including Vegetarian Journal, are not intended to provide personal medical advice. Medical advice should be obtained from a qualified health professional. We often depend on product and ingredient information from company statements. It is impossible to be 100% sure about a statement, info can change, people have different views, and mistakes can be made. Please use your best judgment about whether a product is suitable for you. To be sure, do further research or confirmation on your own.

References about iodine and pregnancy:

1. Alexander EK, Pearce EN, Brent GA, et al.  2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid. 2017;27(3):315-389.

2. Leung AM, Pearce EN, Braverman LE. Iodine nutrition in pregnancy and lactation. Endocrinol Metab Clin North Am. 2011; 40:765–777.

3. Leung AM, Lamar A, He X, Braverman LE, Pearce EN. Iodine status and thyroid function of Boston-area vegetarians and vegans. J Clin Endocrinol Metab. 2011 Aug;96(8):E1303-1307.
4. Lee SY, Stagnaro-Green A, MacKay D, Wong AW, Pearce EN. Iodine contents in prenatal vitamins in the United States.Thyroid. 2017 Aug;27(8):1101-1102.

Freeda’s contact info for their products is www.freedahealth.com, or call (973) 882-0002.

The most recent Vegetarian Journal takes a look at recent scientific literature on veggie diets. One topic covered is taking Vitamin B12 daily or weekly. Here’s our write-up on this study:

Vitamin B12 recommendations from many vegan groups, including The Vegetarian Resource Group, are based on calculating how much vitamin B12 is likely to be absorbed from supplements containing different amounts of vitamin B12. For example, in 2015 we said, “About 5% of the vitamin B12 in a supplement containing 25 mcg of vitamin B12 is absorbed. A lesser amount, 1% or less of the vitamin B12 in a supplement containing more than 100 micrograms of vitamin B12, is absorbed.”¹ A recent study examines whether these theoretical absorption rates actually apply in vegans and non-vegan vegetarians.

In this study,² 36 vegetarian (including vegan) adults who were marginally deficient in vitamin B12 based on their blood vitamin B12 levels, were randomly divided into two groups. During the 12 week study period, one group took 50 micrograms of vitamin B12 daily and the other group took 2,000 micrograms of vitamin B12 once a week. Blood vitamin B12 was rechecked throughout the 12 weeks. Both groups’ blood vitamin B12 levels improved as did other indicators of vitamin B12 status so that, at the end of the study, they were no longer considered to be deficient. These results support recommendations to take vitamin B12 supplements either daily if you are using a lower dose (25-100 micrograms) or weekly for a higher dose of 2000 micrograms. One advantage of using a lower dose daily could be that you’re less likely to forget to take your supplement if it is part of your daily routine. On the other hand, taking a larger dose one day each week, perhaps first thing Monday morning, may be easier for some people to remember to do. In any case, it’s important to have a regular source of vitamin B12, whether fortified food or supplement.

¹ Mangels R. 2015. Nutrition Hotline. Vegetarian Journal. Issue 4. https://www.vrg.org/journal/vj2015issue4/2015_issue4_nutrition_hotline.php

² Del Bo C, Riso P, Gardana C, et al. 2018. Effect of two different sublingual dosages of vitamin B12 on cobalamin nutritional status in vegans and vegetarians with a marginal deficiency: A randomized controlled trial. Clin Nutr. pii: S0261-5614(18)30071-2. [Epub ahead of print].

You can read the entire column here: https://www.vrg.org/journal/vj2019issue2/2019_issue2_scientific_update.php

Subscribe to Vegetarian Journal in the USA only by visiting https://www.vrg.org/member/2013sv.php

You can also subscribe to the Kindle version of Vegetarian Journal in the USA and United Kingdom.

In the USA, visit: https://www.amazon.com/dp/B07LBY2Y7K/ref=sr_1_1?ie=UTF8&qid=1544727482&sr=8-1&keywords=B07LBY2Y7K

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Vegetarian Journal features a column called Nutrition Hotline, where we answer readers’ questions related to vegan diets. The latest issue offers dietary advice related to sports-related concussions.

Vegetarian Resource Group Nutrition Advisor Reed Mangels, PhD, RD, starts off by stating that “General recommendations to eat well and to drink fluids for hydration apply when recovering from a concussion. Limiting or avoiding caffeinated drinks like soft drinks, coffee, and tea can make it easier to get needed rest.” Reed then goes on to say, “Other suggestions are based on limited research and are only speculative. Creatine (also known as creatine monohydrate) is an amino acid made by our body and found in meat and fish. The International Olympic Committee’s (IOC) consensus statement about supplement use mentions that creatine supplements are associated with decreased damage and improved recovery post-concussion … Vegan creatine supplements are available from Vegan Essentials and other online retailers.”

You can read about the entire column here: https://www.vrg.org/journal/vj2019issue2/2019_issue2_nutrition_hotline.php

Subscribe to Vegetarian Journal in the USA only by visiting https://www.vrg.org/member/2013sv.php

You can also subscribe to the Kindle version of Vegetarian Journal in the USA and United Kingdom.

In the USA, visit: https://www.amazon.com/dp/B07LBY2Y7K/ref=sr_1_1?ie=UTF8&qid=1544727482&sr=8-1&keywords=B07LBY2Y7K

In the United Kingdom, visit: https://www.amazon.co.uk/dp/B07LBY2Y7K/ref=sr_1_1?s=digital-text&ie=UTF8&qid=1544731957&sr=8-1&keywords=B07LBY2Y7K