Mortality in British vegetarians: results from the European Prospective Investigation into Cancer and Nutrition (EPIC-Oxford)

Cause-specific and all-cause mortalities in vegetarian compared with those in nonvegetarian participants from the Adventist Health Study-2 cohort

BACKGROUND

There have been mixed results reported internationally when associating vegetarian dietary patterns with all-cause and cause-specific mortalities.

OBJECTIVES

This study aimed to extend our previous results by evaluating, with a larger number of deaths (N = 12,515), cause-specific mortalities comparing different vegetarian types with nonvegetarians.

METHODS

This prospective study used data from the Adventist Health Study-2 cohort. Mortality was ascertained between study baseline, 2002-2007, and follow-up through 2015. Dietary data were collected at baseline using a validated quantitative food frequency questionnaire and then categorized into 5 dietary patterns: nonvegetarian, semivegetarian, pescovegetarian, lacto-ovovegetarian, and vegan. Main outcomes and measures include all-cause and cause-specific mortalities using Cox proportional hazards regression models and competing risk methods.

RESULTS

The analytic sample included 88,400 participants who provided 971,424 person-years of follow-up. We report results pairwise as estimated at ages 65 and 85 y owing to age dependence of many hazard ratios (HRs). Compared with nonvegetarians, vegetarians had lower risks of mortality, overall (HR: 0.89; 95% confidence interval [CI]: 0.83, 0.95; HR: 0.98; 95% CI: 0.91, 1.04), from renal failure (HR: 0.52; 95% CI: 0.38, 0.70; HR: 0.65; 95% CI: 0.55, 0.76), infectious disease (HR: 0.57; 95% CI: 0.40, 0.82; HR: 0.90; 95% CI: 0.70, 1.17), diabetes (HR: 0.51; 95% CI: 0.33, 0.78; HR: 0.69; 95% CI: 0.53, 0.88), select cardiac (HR: 0.75; 95% CI: 0.65, 0.87; HR: 0.89; 95% CI: 0.83, 0.95), and ischemic heart disease causes (HR: 0.73; 95% CI: 0.59, 0.90; HR: 0.84; 95% CI: 0.75,0.94). Vegans, lacto-ovovegetarians, and pescovegetarians were also observed to have lower risks of total mortality and several similar cause-specific mortalities. However, higher cause-specified neurologic mortalities were observed among older vegetarians (estimated at age 85 y), specifically stroke (HR: 1.17; 95% CI: 1.02, 1.33), dementia (HR: 1.13; 95% CI: 1.00, 1.27), and Parkinson's disease (HR: 1.37; 95% CI: 0.98, 1.91). Results in Black subjects for vegetarian/nonvegetarian comparisons largely followed the same trends, but HRs were less precise owing to smaller numbers.

CONCLUSIONS

Vegetarian diets are associated with lower risk for all-cause and many cause-specific mortalities, especially among males and in younger subjects. However, higher risks are observed among older vegetarians for stroke and dementia. These results need further support and investigation.

Gene-vegetarianism interactions in calcium, estimated glomerular filtration rate, and testosterone identified in genome-wide analysis across 30 biomarkers

We examined the associations of vegetarianism with metabolic biomarkers using traditional and genetic epidemiology. First, we addressed inconsistencies in self-reported vegetarianism among UK Biobank participants by utilizing data from two dietary surveys to find a cohort of strict European vegetarians (N = 2,312). Vegetarians were matched 1:4 with nonvegetarians for non-genetic association analyses, revealing significant effects of vegetarianism in 15 of 30 biomarkers. Cholesterol measures plus vitamin D were significantly lower in vegetarians, while triglycerides were higher. A genome-wide association study revealed no genome-wide significant (GWS; 5×10-8) associations with vegetarian behavior. We performed genome-wide gene-vegetarianism interaction analyses for the biomarkers, and detected a GWS interaction impacting calcium at rs72952628 (P = 4.47×10-8). rs72952628 is in MMAA, a B12 metabolic pathway gene; B12 has major deficiency potential in vegetarians. Gene-based interaction tests revealed two significant genes, RNF168 in testosterone (P = 1.45×10-6) and DOCK4 in estimated glomerular filtration rate (eGFR) (P = 6.76×10-7), which have previously been associated with testicular and renal traits, respectively. These nutrigenetic findings indicate genotype can modify the associations between vegetarianism and health outcomes.

A burden of proof study on alcohol consumption and ischemic heart disease

Cohort and case-control data have suggested an association between low to moderate alcohol consumption and decreased risk of ischemic heart disease (IHD), yet results from Mendelian randomization (MR) studies designed to reduce bias have shown either no or a harmful association. Here we conducted an updated systematic review and re-evaluated existing cohort, case-control, and MR data using the burden of proof meta-analytical framework. Cohort and case-control data show low to moderate alcohol consumption is associated with decreased IHD risk - specifically, intake is inversely related to IHD and myocardial infarction morbidity in both sexes and IHD mortality in males - while pooled MR data show no association, confirming that self-reported versus genetically predicted alcohol use data yield conflicting findings about the alcohol-IHD relationship. Our results highlight the need to advance MR methodologies and emulate randomized trials using large observational databases to obtain more definitive answers to this critical public health question.

Vegetarianism and mental health: Evidence from the 1970 British Cohort Study

BACKGROUND

Reducing animal product consumption has benefits for population health and the environment. The relationship between vegetarianism and mental health, however, remains poorly understood. This study explores this relationship in a nationally representative cohort in Great Britain.

METHODS

We use data from the 1970 British Cohort Study, which collected information on vegetarianism at age 30 in 2000 (n = 11,204) and psychological distress (PD) at ages 26, 30, 34, 42, and 46-48 in 2016/18. We first developed a statistical adjustment strategy by regressing PD at age 30 on vegetarianism and 14 confounders measured at ages 10 and 26. We then ran multilevel growth curve models, testing whether within-person changes in PD between ages 30 and 46-48 differed by vegetarianism, before and after statistical adjustment.

RESULTS

At age 30, 4.5 % of participants reported being vegetarian. In the cross-sectional models at age 30, vegetarians reported more distress compared with non-vegetarians in bivariate analysis (b = 0.30, 95%CI 0.09, 0.52), but this difference disappeared in the fully-adjusted model (b = 0.02, 95%CI -0.17, 0.21). In the longitudinal models between ages 30 and 46/48, there were no differences in within-person changes in psychological distress between vegetarians and non-vegetarians (p = .723). Sensitivity analyses using red meat consumption yielded similar findings.

CONCLUSION

In this British cohort, vegetarianism at age 30 was not associated with changes in psychological distress during mid-adulthood. Since psychological distress in early adulthood predicted vegetarianism at age 30, more studies are needed to disentangle the progression of this relationship over the life-course.

Emerging factors affecting peri-implant bone metabolism

Implant dentistry has evolved to the point that standard implant osseointegration is predictable. This is attributed in part to the advancements in material sciences that have led toward improvements in implant surface technology and characteristics. Nonetheless, there remain several cases where implant therapy fails (specifically at early time points), most commonly attributed to factors affecting bone metabolism. Among these patients, smokers are known to have impaired bone metabolism and thus be subject to higher risks of early implant failure and/or late complications related to the stability of the peri-implant bone and mucosal tissues. Notably, however, emerging data have unveiled other critical factors affecting osseointegration, namely, those related to the metabolism of bone tissues. The aim of this review is to shed light on the effects of implant-related factors, like implant surface or titanium particle release; surgical-related factors, like osseodensification or implanted biomaterials; various drugs, like selective serotonin reuptake inhibitors, proton pump inhibitors, anti-hypertensives, nonsteroidal anti-inflammatory medication, and statins, and host-related factors, like smoking, diet, and metabolic syndrome on bone metabolism, and aseptic peri-implant bone loss. Despite the infectious nature of peri-implant biological complications, these factors must be surveyed for the effective prevention and management of peri-implantitis.

Association between vegetarian diet and gouty arthritis: A retrospective cohort study

BACKGROUND AND AIMS

A vegetarian diet is rich in vegetables, fruits, and soy products. Although vegetarian diet is beneficial for improving the health outcomes such as body mass index, metabolic syndrome, cardiovascular disease, and mortality rate, the association between a vegetarian diet and gout incidence is not well known.

METHODS AND RESULTS

We linked the MJ Health Survey Data and MJ Biodata 2000 with the National Health Insurance Research Database (NHIRD) and the National Registration of Death (2000-2018). Information on the diet was collected from the MJ Health Survey Data, and the incidence of gouty arthritis was confirmed using the NHIRD. The Kaplan-Meier survival curve and log-rank test were used to compare the differences between vegetarian and non-vegetarian participants. Cox regression models were used to estimate the risk of the incidence of gouty arthritis. Among 76,972 participants, 37,297 (48.46%) were men, 2488 (3.23%) were vegetarians and the mean age was 41.65 ± 14.13 years. The mean baseline uric acid level was 6.14 ± 1.65 mg/dL. A total of 16,897 participants developed gouty arthritis, including 16,447 (22.08%) non-vegetarians and 450 (18.9%) vegetarians over a mean follow-up of 19 years. Significant differences were observed in the Kaplan-Meier survival curves between vegetarians and non-vegetarians (log-rank p < 0.001). Vegetarians had a significantly decreased incidence of gouty arthritis compared with non-vegetarians (hazard ratio = 0.87, 95% confidence interval = 0.78-0.98, p = 0.02) after adjusting for potential confounders.

CONCLUSION

People with a vegetarian diet had a significantly decreased risk of developing gouty arthritis compared with non-vegetarians in Taiwan.

Vegetarian and vegan diets: benefits and drawbacks

Plant-based diets have become increasingly popular thanks to their purported health benefits and more recently for their positive environmental impact. Prospective studies suggest that consuming vegetarian diets is associated with a reduced risk of developing cardiovascular disease (CVD), diabetes, hypertension, dementia, and cancer. Data from randomized clinical trials have confirmed a protective effect of vegetarian diets for the prevention of diabetes and reductions in weight, blood pressure, glycosylated haemoglobin and low-density lipoprotein cholesterol, but to date, no data are available for cardiovascular event rates and cognitive impairment, and there are very limited data for cancer. Moreover, not all plant-based foods are equally healthy. Unhealthy vegetarian diets poor in specific nutrients (vitamin B12, iron, zinc, and calcium) and/or rich in highly processed and refined foods increase morbidity and mortality. Further mechanistic studies are desirable to understand whether the advantages of healthy, minimally processed vegetarian diets represent an all-or-nothing phenomenon and whether consuming primarily plant-based diets containing small quantities of animal products (e.g. pesco-vegetarian or Mediterranean diets) has beneficial, detrimental, or neutral effects on cardiometabolic health outcomes. Further, mechanistic studies are warranted to enhance our understanding about healthy plant-based food patterns and the biological mechanisms linking dietary factors, CVD, and other metabolic diseases.

Vegetarians: Past, Present, and Future Regarding Their Diet Quality and Nutritional Status

The term "vegetarian" usually refers to individuals who exclude meat, fish, poultry and/or their derived products from their diet [...].

Do all vegetarians have a lower cardiovascular risk? A prospective study

BACKGROUND

Vegetarian diets are heterogeneous and their health benefits may vary. This study aimed to compare the cardiovascular risk among vegetarian diets that meet existing health guidelines, those that do not, and diets that include red meat.

METHODS

391,124 participants (55.5% women) from the UK Biobank prospective population-based study were included. Using data from a food frequency questionnaire, participants were categorised into lacto-vegetarian or meat-eaters. Then, both groups were dichotomised into a healthier and less healthy group using an unweighted score based on current UK guidelines. Ischaemic heart disease (IHD) and myocardial infarction (MI) incidence - both separately and as a composite of major adverse cardiovascular events (MACE) - were the outcomes included. Associations between types of diets and health outcomes were investigated using Cox proportional hazard models adjusted for confounder factors.

RESULTS

After a median follow-up of 10.4 years, there were 40,048 MACE. When the analyses were adjusted for prevalent morbidity and lifestyle factors, people who followed healthier vegetarian and meat-eater diets had 18% (95% CI: 0.73 to 0.92) and 5% (95% CI: 0.93 to 0.97) lower risk of MACE than less healthy meat-eaters. Similar patterns were identified for the individual outcomes, with the strongest association observed for MI. The cardiovaculasr risk among less healthy vegetarians and less healthy meat-eaters were not significnatly different.

CONCLUSIONS

Vegetarian diets are heterogeneous and the cardiovascular risk varied accordingly. Future studies should consider the overall dietary patterns of vegetarians rather than just based on meat consumption. Guidelines advocating a plant-based diet need to stress the importance of overall diet quality in addition to the reduction of meat.

Association of Healthful Plant-based Diet Adherence With Risk of Mortality and Major Chronic Diseases Among Adults in the UK

Importance

Plant-based diets have gained popularity for both environmental and health reasons, but a comprehensive assessment of their quality in relation to risk of mortality and major chronic diseases is lacking.

Objective

To examine whether healthful vs unhealthful plant-based dietary patterns are associated with mortality and major chronic diseases among UK adults.

Design, Setting, and Participants

This prospective cohort study used data from adults in the UK Biobank, a large-scale population-based study. Participants were recruited between 2006 and 2010 and followed up using record linkage data until 2021; follow-up for different outcomes ranged between 10.6 and 12.2 years. Data analysis was conducted from November 2021 to October 2022.

Exposures

Adherence to a healthful vs unhealthful plant-based diet index (hPDI vs uPDI) derived from 24-hour dietary assessments.

Main Outcomes and Measures

The main outcomes were hazard ratios (HRs) and 95% CIs of mortality (overall and cause specific), cardiovascular disease (CVD [total, myocardial infarction, ischemic stroke, and hemorrhagic stroke]), cancer (total, breast, prostate, and colorectal), and fracture (total, vertebrae, and hip) across quartiles of hPDI and uPDI adherence.

Results

This study included 126 394 UK Biobank participants. They had a mean (SD) age of 56.1 (7.8) years; 70 618 (55.9%) were women. The majority of participants (115 371 [91.3%]) were White. Greater adherence to the hPDI was associated with lower risks of total mortality, cancer, and CVD, with HRs (95% CIs) of 0.84 (0.78-0.91), 0.93 (0.88-0.99), and 0.92 (0.86-0.99), respectively, for participants in the highest hPDI quartile compared with the lowest. The hPDI was also associated with lower risks of myocardial infarction and ischemic stroke, with HRs (95% CIs) of 0.86 (0.78-0.95) and 0.84 (0.71-0.99), respectively. By contrast, higher uPDI scores were associated with higher risks of mortality, CVD, and cancer. The associations observed did not show heterogeneity across strata of sex, smoking status, body mass index, or socioeconomic status or with polygenic risk scores (specifically with regard to CVD end points).

Conclusions and Relevance

The findings of this cohort study of middle-aged UK adults suggest that a diet characterized by high-quality plant-based foods and lower intakes of animal products may be beneficial for health, irrespective of established chronic disease risk factors and genetic predisposition.

Plant Based Diet and Its Effect on Cardiovascular Disease

Cardiovascular disease remains the leading cause of death globally and here in the United States. Diet has a major impact on the pathogenesis of atherosclerosis and subsequent cardiovascular morbidity and mortality. An unhealthy diet is the most significant potential behavioral and modifiable risk factor for ischemic heart disease. Despite these established facts, dietary interventions are far less frequent than pharmaceutical and procedural interventions in the management of cardiovascular disease. The beneficial effects of a plant-based diet on cardiovascular morbidity and mortality have been demonstrated in a number of recent clinical studies. The significant findings of each study are discussed in this review article, highlighting the role of a healthy plant-based diet in improving cardiovascular outcomes. From a clinician's standpoint, the knowledge and understanding of the facts and data points from these recent clinical studies would ensure more effective patient counseling on the substantial benefits of dietary interventions.

Animal- and Plant-Based Protein Sources: A Scoping Review of Human Health Outcomes and Environmental Impact

Dietary proteins are indispensable to human nutrition. In addition to their tissue-building function, they affect body composition and regulate various metabolic pathways, as well as satiety and immune system activity. Protein use can be examined from a quantitative or qualitative viewpoint. In this scoping review, we compare animal- and plant-based protein sources in terms of their effects on human health and the environment. We conclude that the consumption of vegetable protein sources is associated with better health outcomes overall (namely, on the cardiovascular system) than animal-based product use. The healthier outcomes of vegetable protein sources dovetail with their lower environmental impact, which must be considered when designing an optimal diet. Indeed, the health of the planet cannot be disjointed from the health of the human being. Future research will clarify the mechanisms of action underlying the health effects of plant-based protein sources when compared with animal sources, fostering better agronomic practices and influencing public health in a direction that will benefit both the planet and its inhabitants.

Exploring the role of mindful eating and self-compassion on eating behaviours and orthorexia in people following a vegan diet

Orthorexia nervosa (ON) is a new concept that is more prevalent in vegan populations. ON is characterised by obsessive focus on healthy eating, following restrictive dietary practices and dietary restrictions escalating over time. The aim of this study was to explore problematic eating behaviours in a vegan population, and to explore whether mindful eating and self-compassion have an impact on ON. Two hundred and eighty-seven females and twenty-eight males who followed a vegan diet completed scales in Orthorexia, Self-Compassion, Mindful, Emotional, External and Restraint Eating. The results indicated that individuals with high levels of ON display low levels of self-compassion, and high levels of restrained eating. Moreover, the findings indicated that self-compassion, but not mindful eating, partially mediated the relationship between restrained eating and orthorexia nervosa. The present results contribute to a better understanding of orthorexic eating behaviours in a vegan population, and identifies the mediating capacity of self-compassion. Further implications and future directions are discussed.Level of evidence: Level V, cross-sectional descriptive study.

Systematic review of the impact of a plant-based diet on prostate cancer incidence and outcomes

BACKGROUND

Plant-based diets are increasingly popular and have many well-established benefits for health and environmental sustainability. Our objective was to perform a systematic review of plant-based diets and prostate cancer.

METHODS

We performed a systematic database and citation search in February 2022. Studies were included if they reported primary data on plant-based dietary patterns (i.e., vegan, vegetarian, plant-based) and incidence among at-risk men for prostate cancer, or oncologic, general health/nutrition, or quality of life outcomes among patients with prostate cancer or caregivers.

RESULTS

A total of 32 publications were eligible for the qualitative synthesis, representing 5 interventional and 11 observational studies. Interventional studies primarily focused on lifestyle modification including plant-based diets for men on active surveillance for localized prostate cancer or with biochemical recurrence after treatment, showing improvements in short-term oncologic outcomes alongside improvements in general health and nutrition. Observational studies primarily focused on prostate cancer risk, showing either protective or null associations for plant-based dietary patterns. Studies of the vegan diet consistently showed favorable associations with risk and/or outcomes. Gaps in the current literature include impact for long-term disease-specific outcomes.

CONCLUSIONS

Interventional studies showed generally favorable results of lifestyle modifications incorporating a plant-based diet with prostate cancer outcomes as well as improvements in nutrition and general health. Observational studies demonstrated either a lower risk of prostate cancer or no significant difference. These results are encouraging in light of the many benefits of plant-based diets for overall health, as well as environmental sustainability and animal welfare.

Association of meat, vegetarian, pescatarian and fish-poultry diets with risk of 19 cancer sites and all cancer: findings from the UK Biobank prospective cohort study and meta-analysis

BACKGROUND

The associations of cancer with types of diets, including vegetarian, fish, and poultry-containing diets, remain unclear. The aim of this study was, therefore, to investigate the association of type of diet with all cancers and 19 site-specific incident cancers in a prospective cohort study and then in a meta-analysis of published prospective cohort studies.

METHODS

A total of 409,110 participants from the UK Biobank study, recruited between 2006 and 2010, were included. The outcomes were incidence of all cancers combined and 19 cancer sites. Associations between the types of diets and cancer were investigated using Cox proportional hazards models. Previously published prospective cohort studies were identified from four databases, and a meta-analysis was conducted using random-effects models.

RESULTS

The mean follow-up period was 10.6 years (IQR 10.0; 11.3). Compared with meat-eaters, vegetarians (hazard ratio (HR) 0.87 [95% CI: 0.79 to 0.96]) and pescatarians (HR 0.93 [95% CI: 0.87 to 1.00]) had lower overall cancer risk. Vegetarians also had a lower risk of colorectal and prostate cancers compared with meat-eaters. In the meta-analysis, vegetarians (Risk Ratio (RR): 0.90 [0.86 to 0.94]) and pescatarians (RR 0.91 [0.86; 0.96]) had lower risk of overall and colorectal cancer. No associations between the types of diets and prostate, breast, or lung cancers were found.

CONCLUSIONS

Compared with meat-eaters, vegetarians and pescatarians had a lower risk of overall, colorectal, and prostate cancer. When results were pooled in a meta-analysis, the associations with overall and colorectal cancer persisted, but the results relating to other specific cancer sites were inconclusive.

The role of plant-based alternative foods in sustainable and healthy food systems: Consumption trends in the UK

A global transformation towards sustainable food systems is crucial for delivering on climate change mitigation targets worldwide. In high- and middle-income settings, plant-based meat and dairy alternatives present potential substitutes for animal sourced foods, and a pathway to transition to more sustainable diets. We examined plant-based alternative foods (PBAF) consumption trends in the UK by analysing repeated cross-sectional food consumption data from the National Diet and Nutrition Survey 2008-2019. Dietary data for 15,655 individuals aged 1.5 years and over were analysed to assess aggregate change in intake of PBAF and six other food groups that play a role in transformative dietary change. Characteristics associated with consumption of PBAF were explored using logistic regression, and consumption patterns in high and low meat consumers were explored by examining intake of potential animal product substitute food groups. The proportion of individuals reporting consumption of any PBAFs increased from 6.7% in 2008-2011, to 13.1% in 2017-2019 (p < 0.01). Compared to 2008-2011 PBAF consumption rose by 115% in 2017-2019 (p < 0.01). Females were 46% more likely than males to report consumption of PBAF (p < 0.01). Millennials (age 24-39 years) were the most likely generation to report PBAF consumption (p < 0.01 compared to generation Z (age 11-23 years) and traditionalists (age 75+ years)), as were individuals of the highest income tertile (p < 0.01). Among "low meat consumers", PBAF consumption was on average higher than "high meat consumers" (18.6 g versus 4.8 g PBAF per day, p < 0.01). Our results support the hypothesis of a pivotal role of PBAF in the transition towards sustainable food systems in the UK, by demonstrating they are becoming increasingly popular among UK consumers. This highlights the urgent need to assess in detail the environmental and health impacts of large scale and population-wide consumption of PBAF in comparison to their animal-based equivalents.

Plant-based diets and incident cardiovascular disease and all-cause mortality in African Americans: A cohort study

BACKGROUND

Prior studies have documented lower cardiovascular disease (CVD) risk among people with a higher adherence to a plant-based dietary pattern. Non-Hispanic black Americans are an understudied group with high burden of CVD, yet studies of plant-based diets have been limited in this population.

METHODS AND FINDINGS

We conducted an analysis of prospectively collected data from a community-based cohort of African American adults (n = 3,635) in the Jackson Heart Study (JHS) aged 21-95 years, living in the Jackson, Mississippi, metropolitan area, US, who were followed from 2000 to 2018. Using self-reported dietary data, we assigned scores to participants' adherence to 3 plant-based dietary patterns: an overall plant-based diet index (PDI), a healthy PDI (hPDI), and an unhealthy PDI (uPDI). Cox proportional hazards models were used to estimate associations between plant-based diet scores and CVD incidence and all-cause mortality. Over a median follow-up of 13 and 15 years, there were 293 incident CVD cases and 597 deaths, respectively. After adjusting for sociodemographic characteristics (age, sex, and education) and health behaviors (smoking, alcohol intake, margarine intake, physical activity, and total energy intake), no significant association was observed between plant-based diets and incident CVD for overall PDI (hazard ratio [HR] 1.06, 95% CI 0.78-1.42, p-trend = 0.72), hPDI (HR 1.07, 95% CI 0.80-1.42, p-trend = 0.67), and uPDI (HR 0.95, 95% CI 0.71-1.28, p-trend = 0.76). Corresponding HRs (95% CIs) for all-cause mortality risk with overall PDI, hPDI, and uPDI were 0.96 (0.78-1.18), 0.94 (0.76-1.16), and 1.06 (0.86-1.30), respectively. Corresponding HRs (95% CIs) for incident coronary heart disease with overall PDI, hPDI, and uPDI were 1.09 (0.74-1.61), 1.11 (0.76-1.61), and 0.79 (0.52-1.18), respectively. For incident total stroke, HRs (95% CIs) for overall PDI, hPDI, and uPDI were 1.00 (0.66-1.52), 0.91 (0.61-1.36), and 1.26 (0.84-1.89) (p-trend for all tests > 0.05). Limitations of the study include use of self-reported dietary intake, residual confounding, potential for reverse causation, and that the study did not capture those who exclusively consume plant-derived foods.

CONCLUSIONS

In this study of black Americans, we observed that, unlike in prior studies, greater adherence to a plant-based diet was not associated with CVD or all-cause mortality.

Evidence Update on the Relationship between Diet and the Most Common Cancers from the European Prospective Investigation into Cancer and Nutrition (EPIC) Study: A Systematic Review

The European Prospective Investigation into Cancer and Nutrition (EPIC) is a multicentre prospective study conducted in 23 centres in 10 European countries. Here we review the findings from EPIC on the relationship between diet-related exposures and incidence or mortality from the four most frequent cancers in the European population: colorectal, breast, lung, and prostate cancer. We conducted a systematic review following PRISMA guidelines and identified 110 high-quality studies based on the EPIC cohort. Fruit and vegetable consumption had a protective effect against colorectal, breast, and lung cancer, whereas only fruit had a protective effect against prostate cancer. A higher consumption of fish and lower consumption of red and processed meat were related with a lower risk of colorectal cancer; and higher consumption of fatty fish with lower risk of breast cancer. Calcium and yogurt intake were found to protect against colorectal and prostate cancer. Alcohol consumption increased the risk for colorectal and breast cancer. Finally, adherence to the Mediterranean diet emerged as a protective factor for colorectal and breast cancer. The EPIC study results are in agreement with the latest evidence from leading authorities on cancer prevention and help to inform public prevention policies and strategies.

Meta-analysis of effect of vegetarian diet on ischemic heart disease and all-cause mortality

Objective

To summarize the association between vegetarian versus non-vegetarian diet on mortality due to ischemic heart disease, cerebrovascular disease, or all-cause mortality.

Methods

We searched PubMed, Cochrane databases, and ClinicalTrials.Gov from the inception of the databases to October 2019 with no language restriction. Randomized controlled trials or prospective observational studies comparing the association between vegetarian versus non-vegetarian diets among adults and reporting major adverse cardiovascular outcomes were selected. We used Paule-Mandel estimator for tau2 with Hartung-Knapp adjustment for random effects model to estimate risk ratio [RR] with 95% confidence interval [CI].The primary outcome of interest was all-cause mortality. The secondary outcome was ischemic heart disease mortality.

Results

Eight observational studies (n = 131,869) were included in the analysis. Over a weighted mean follow-up of 10.68 years, very low certainty of evidence concluded that a vegetarian diet compared with a non-vegetarian diet was associated with similar risk of all-cause (RR: 0.84, 95% CI: 0.65-1.07, I² : 97%) or cerebrovascular mortality (RR: 0.84, 95% CI: 0.63-1.14, I² : 90%), but was associated with a reduced risk of ischemic heart disease mortality (RR: 0.70, 95% CI: 0.55-0.89, I² : 82%).

Conclusion

A vegetarian diet, compared with a non-vegetarian diet, was associated with a reduced risk of ischemic heart disease mortality, whereas it had no effect on all-cause and cerebrovascular mortality. However, the results are to be considered with caution considering the low certainty of evidence. Despite recent studies supporting no restriction on animal protein intake gaining wide media attention and public traction, consideration for vegetarianism amongst those with risk factors for coronary artery disease should be contemplated.

Evaluation of Dietary Patterns and All-Cause Mortality: A Systematic Review

Importance

The 2020 Dietary Guidelines Advisory Committee conducted a systematic review of existing research on diet and health to inform the current Dietary Guidelines for Americans. The committee answered this public health question: what is the association between dietary patterns consumed and all-cause mortality (ACM)?

Objective

To ascertain the association between dietary patterns consumed and ACM.

Evidence Review

Guided by an analytical framework and predefined inclusion and exclusion criteria developed by the committee, the US Department of Agriculture's Nutrition Evidence Systematic Review (NESR) team searched PubMed, the Cochrane Central Register of Controlled Trials, and Embase and dual-screened the results to identify articles that were published between January 1, 2000, and October 4, 2019. These studies evaluated dietary patterns and ACM in participants aged 2 years and older. The NESR team extracted data from and assessed risk of bias in included studies. Committee members synthesized the evidence, developed conclusion statements, and graded the strength of the evidence supporting the conclusion statements.

Findings

A total of 1 randomized clinical trial and 152 observational studies were included in the review. Studies enrolled adults and older adults (aged 17-84 years at baseline) from 28 countries with high or very high Human Development Index; 53 studies originated from the US. Most studies were well designed, used rigorous methods, and had low or moderate risks of bias. Precision, directness, and generalizability were demonstrated across the body of evidence. Results across studies were highly consistent. Evidence suggested that dietary patterns in adults and older adults that involved higher consumption of vegetables, fruits, legumes, nuts, whole grains, unsaturated vegetable oils, fish, and lean meat or poultry (when meat was included) were associated with a decreased risk of ACM. These healthy patterns were also relatively low in red and processed meat, high-fat dairy, and refined carbohydrates or sweets. Some of these dietary patterns also included intake of alcoholic beverages in moderation. Results based on additional analyses with confounding factors generally confirmed the robustness of main findings.

Conclusions and Relevance

In this systematic review, consuming a nutrient-dense dietary pattern was associated with reduced risk of death from all causes.

Knowledge of Vegetarian and Nonvegetarian Peruvian Dietitians about Vegetarianism at Different Stages of Life

Background:

The vegetarian diet continues to gain recognition and popularity among people; however, few studies have considered the level of knowledge of professional dietitians about this dietary pattern.

Objective:

This study aimed to compare the level of knowledge of vegetarian and nonvegetarian Peruvian dietitians regarding vegetarianism at different life stages.

Methods:

A cross-sectional study was carried out. An online questionnaire based on the recommendations of the current dietary guidelines was administered to more than 400 registered dietitians. Of which, a total of 179 decided to participate in the study: 72 vegetarians and 107 nonvegetarians. The data were analyzed using the chi-square test, considering a significance level of 5%.

Results:

Women represented the largest proportion of the sample. The participants demonstrated a complete and exhaustive knowledge of the definition of vegetarian diets. Regarding the risks and benefits associated with vegetarianism, the largest proportion of those who got the correct answers were vegetarians. The percentage of correct answers selected for both groups regarding the critical nutrients were less than 50%. Only 17.6% identified the correct answer regarding the risk of eating disorders of vegetarianism.

Conclusions:

Dietitians did not demonstrate complete and comprehensive knowledge of the critical nutrients of vegetarianism and lack information on the risks of eating disorders from the vegetarian diet.

Plant-based diets and risk of disease mortality: a systematic review and meta-analysis of cohort studies

We aimed to examine the association between adherence to plant-based diets (PBDs) and the risk of mortality among the general population. Relevant investigations were identified through PubMed, Scopus, Embase, and ISI Web of Knowledge. Data were pooled using a random-effects or a fixed-effects model. Twelve prospective cohort studies with 42,697 deaths among 508,861 participants were included. The hazard ratios (HRs) for the highest compared to the lowest category of adherence to the PBDs were 0.90 (95% confidence interval [CI]: 0.82, 0.99; I² = 91%, n = 12) for all-cause and 0.77 (95% CI: 0.70, 0.86; I² = 36%, n = 8) for coronary heart disease (CHD) mortality. Among PBDs subtypes, there was an inverse association between healthy plant-based 0.92 (95% CI: 0.88, 0.96; I² = 0%, n = 2), Pesco-vegetarian 0.81 (95% CI: 0.70, 0.92; I² = 0%, n = 2), and Pro-vegetarian 0.74 (95% CI: 0.55, 0.88; I² = 61.2%, n = 2) diets and the risk of all-cause mortality. A vegetarian diet was also associated with lower risk of mortality due to cardiovascular 0.92 (95% CI: 0.85, 0.99; I² = 0%, n = 5) and CHD 0.76 (95% CI: 0.68, 0.85; I² = 35%, n = 7). Our findings show the potential protective role of PBDs against chronic disease mortality. As there were certain limitations in some of the studies included in this systematic review and meta-analysis, further research is necessary to confirm our findings.

Vegetarians, fish, poultry, and meat-eaters: who has higher risk of cardiovascular disease incidence and mortality? A prospective study from UK Biobank

AIMS

To compare the incidence and mortality risk for cardiovascular diseases (CVD) [CVD and also ischaemic heart disease (IHD), myocardial infarction (MI), stroke, and heart failure (HF)] among people with different types of diets-including vegetarians, fish eaters, fish and poultry eaters, and meat-eaters-using data from UK Biobank.

METHODS AND RESULTS

A total of 422 791 participants (55.4% women) were included in this prospective analysis. Using data from a food frequency questionnaire, four types of diets were derived. Associations between types of diets and health outcomes were investigated using Cox proportional hazard models. Meat-eaters comprised 94.7% of the cohort and were more likely to be obese than other diet groups. After a median follow-up of 8.5 years, fish eaters, compared with meat-eaters, had lower risks of incident CVD {hazard ratios (HR): 0.93 [95% confidence intervals (CI): 0.88-0.97]}, IHD [HR: 0.79 (95% CI: 0.70-0.88)], MI [HR: 0.70 (95% CI: 0.56-0.88)], stroke [HR: 0.79 (95% CI: 0.63-0.98)] and HF [HR: 0.78 (95% CI: 0.63-0.97)], after adjusting for confounders. Vegetarians had lower risk of CVD incidence [HR: 0.91 (95% CI: 0.86-0.96)] relative to meat-eaters. In contrast, the risk of adverse outcomes was not different in fish and poultry eaters compared with meat-eaters. No associations were identified between types of diets and CVD mortality.

CONCLUSION

Eating fish rather than meat or poultry was associated with a lower risk of a range of adverse cardiovascular outcomes. Vegetarianism was only associated with a lower risk of CVD incidence.

Health and sustainability outcomes of vegetarian dietary patterns: a revisit of the EPIC-Oxford and the Adventist Health Study-2 cohorts

Knowledge in the role of plant-based diets on health had been shaped in part by cohort studies on vegetarians. We revisited publications from two ongoing longitudinal studies comprising large proportions of vegetarians-the Adventist Health Study-2 (AHS-2) and the European Prospective Investigation into Cancer and Nutrition-Oxford (EPIC-Oxford)-to describe the food and nutrient intake, health effects, and environmental sustainability outcomes of the dietary patterns identified in these studies. The vegetarian diet groups in both cohorts have essentially no meat intake, lower intake of fish and coffee, and higher intakes of vegetables and fruits compared to their non-vegetarian counterparts. In the AHS-2 cohort, vegetarians have higher intake of whole grains, legumes, nuts, and seeds. Vegans in AHS-2 have 16% reduced risk while vegans, vegetarians, and fish-eaters in EPIC-Oxford have 11-19% lower risk for all cancers compared to non-vegetarians. Pesco-vegetarians in the AHS-2 cohort had significantly lower mortality risk from all causes and ischemic heart disease while EPIC-Oxford fish-eaters had significantly lower all-cancers mortality risk than their non-vegetarians counterparts. Morbidity risks and prevalence rates for other chronic diseases were differentially reported in the two cohorts but vegetarians have lower risk than non-vegetarians. Greenhouse gas emissions of equicaloric diets are 29% less in vegetarian diet in AHS-2 and 47-60% less for vegetarian/vegan diets in EPIC-Oxford than non-vegetarian/meat-eating diets. The beneficial health outcomes and reduced carbon footprints make the case for adoption of vegetarian diets to address global food supply and environmental sustainability.

Plant- and animal-based diet quality and mortality among US adults: a cohort study

Not all plant-based and animal foods exert the same health effects due to their various nutrient compositions. We aimed to assess the quality of plant-based v. animal foods in relation to mortality in a prospective cohort study. Using data collected from a nationally representative sample of 36 825 adults in the National Health and Nutrition Examination Survey 1999-2014, we developed a de novo Comprehensive Diet Quality Index (cDQI) that assesses the quality of seventeen foods based on the healthfulness and separately scored the quality of eleven plant-based foods in a plant-based Diet Quality Index (pDQI) and six animal foods in an animal-based Diet Quality Index (aDQI). Mortality from all causes, heart disease and cancer were obtained from linkage to the National Death Index up to 31 December 2015. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95 % CI after multivariable adjustments. During a median follow-up of 8·3 years, 4669 all-cause deaths occurred, including 798 deaths due to heart disease and 1021 due to cancer. Compared with individuals in the lowest quartile, those in the highest quartile of cDQI had a lower risk of all-cause mortality (HR 0·75, 95 % CI 0·65, 0·86; Ptrend < 0·001), which largely reflected the inverse relationship between quality of plant-based foods (pDQI) and all-cause mortality (HR 0·66, 95 % CI 0·58, 0·74; Ptrend < 0·001). No independent association was found for the quality of animal foods (aDQI) and mortality. Our results suggest that consuming healthy plant-based foods is associated with lower all-cause mortality among US adults.

The Impact of Plant-Based Dietary Patterns on Cancer-Related Outcomes: A Rapid Review and Meta-Analysis

Long-term cancer survivors represent a sizeable portion of the population. Plant-based foods may enhance the prevention of cancer-related outcomes in these patients. We aimed to synthesize the current evidence regarding the impact of plant-based dietary patterns (PBDPs) on cancer-related outcomes in the general population and in cancer survivors. Considered outcomes included overall cancer mortality, cancer-specific mortality, and cancer recurrence. A rapid review was conducted, whereby 2234 original articles related to the topic were identified via Pubmed/Medline. We selected 26 articles, which were classified into studies on PBDPs and cancer outcomes at pre-diagnosis: vegan/vegetarian diet (N = 5), provegetarian diet (N = 2), Mediterranean diet (N = 13), and studies considering the same at post-diagnosis (N = 6). Pooled estimates of the associations between the aforementioned PBDPs and the different cancer outcomes were obtained by applying random effects meta-analysis. The few studies available on the vegetarian diet failed to support its prevention potential against overall cancer mortality when compared with a non-vegetarian diet (e.g., pooled hazard ratio (HR) = 0.97; 95% confidence interval (CI): 0.88-1.06). The insufficient number of studies evaluating provegetarian index scores in relation to cancer mortality did not permit a comprehensive assessment of this association. The association between adherence to the Mediterranean diet and cancer mortality reached statistical significance (e.g., pooled HR = 0.84; 95% CI: 0.79-0.89). However, no study considered the influence of prognostic factors on the associations. In contrast, post-diagnostic studies accounted for prognostic factors when assessing the chemoprevention potential of PBDPs, but also were inconclusive due to the limited number of studies on well-defined plant-based diets. Thus, whether plant-based diets before or after a cancer diagnosis prevent negative cancer-related outcomes needs to be researched further, in order to define dietary guidelines for cancer survivors.

Less Animal-Based Food, Better Weight Status: Associations of the Restriction of Animal-Based Product Intake with Body-Mass-Index, Depressive Symptoms and Personality in the General Population

Restricting animal-based products from diet may exert beneficial effects on weight status; however, less is known about such a diet and emotional health. Moreover, personality traits, for example high neuroticism, may contribute to restrictive eating habits and potentially confound diet-health associations. We aim to systematically assess if restrictive dietary intake of animal-based products relates to lower weight and higher depressive symptoms, and if differences in personality traits play a significant role. Cross-sectional data from the baseline LIFE-Adult study were collected from 2011–2014 in Leipzig, Germany (n = 8943). Main outcomes of interest were dietary frequency of animal-derived products in the last year measured using a Food Frequency Questionnaire (FFQ), body-mass-index (BMI) (kg/m²), and the Center of Epidemiological Studies Depression Scale (CES-D). Personality traits were assessed in a subsample of n = 7906 using the Five Factor Inventory (NEO-FFI). Higher restriction of animal-based product intake was associated with a lower BMI, but not with depression scores. Personality, i.e., lower extraversion, was related to higher frequency of animal product intake. Moreover, personality traits were significantly associated with depressive symptoms, i.e., higher neuroticism, lower extraversion, lower agreeableness, lower conscientiousness, and with higher BMI. These findings encourage future longitudinal studies to test the efficacy of restricting animal-based products as a preventive and therapeutic strategy for overweight and obesity.

Background Diet Influences TMAO Concentrations Associated with Red Meat Intake without Influencing Apparent Hepatic TMAO-Related Activity in a Porcine Model

Red meat has been associated with an increased cardiovascular disease (CVD) risk, possibly through gut microbial-derived trimethylamine-N-oxide (TMAO). However, previous reports are conflicting, and influences from the background diet may modulate the impact of meat consumption. This study investigated the effect of red and white meat intake combined with two different background diets on urinary TMAO concentration and its association with the colon microbiome in addition to apparent hepatic TMAO-related activity. For 4 weeks, 32 pigs were fed chicken or red and processed meat combined with a prudent or western background diet. ¹H NMR-based metabolomics analysis was conducted on urine samples and hepatic Mrna expression of TMAO-related genes determined. Lower urinary TMAO concentrations were observed after intake of red and processed meat when consumed with a prudent compared to a western background diet. In addition, correlation analyses between urinary TMAO concentrations and relative abundance of colon bacterial groups suggested an association between TMAO and specific bacterial taxa. Diet did not affect the hepatic Mrna expression of genes related to TMAO formation. The results suggest that meat-induced TMAO formation is regulated by mechanisms other than alterations at the hepatic gene expression level, possibly involving modulations of the gut microbiota.

Vegetarian Epidemiology: Review and Discussion of Findings from Geographically Diverse Cohorts

Epidemiologic cohort studies enrolling a large percentage of vegetarians have been highly informative regarding the nutritional adequacy and possible health effects of vegetarian diets. The 2 largest such cohorts are the European Prospective Investigation into Cancer and Nutrition-Oxford (EPIC-Oxford) and the Adventist Health Study-2 (AHS-2). These cohorts are described and their findings discussed, including a discussion of where findings appear to diverge. Although such studies from North America and the United Kingdom have been important, the large majority of the world's vegetarians live in other regions, particularly in Asia. Findings from recent cohort studies of vegetarians in East and South Asia are reviewed, particularly the Tzu Chi Health Study and Indian Migration Study. Important considerations for the study of the health of vegetarians in Asia are discussed. Vegetarian diets vary substantially, as may associated health outcomes. Cohort studies remain an important tool to better characterize the health of vegetarian populations around the globe.

The effects of plant-based diets on the body and the brain: a systematic review

Western societies notice an increasing interest in plant-based eating patterns such as vegetarian and vegan, yet potential effects on the body and brain are a matter of debate. Therefore, we systematically reviewed existing human interventional studies on putative effects of a plant-based diet on the metabolism and cognition, and what is known about the underlying mechanisms. Using the search terms "plant-based OR vegan OR vegetarian AND diet AND intervention" in PubMed filtered for clinical trials in humans retrieved 205 studies out of which 27, plus an additional search extending the selection to another five studies, were eligible for inclusion based on three independent ratings. We found robust evidence for short- to moderate-term beneficial effects of plant-based diets versus conventional diets (duration ≤ 24 months) on weight status, energy metabolism and systemic inflammation in healthy participants, obese and type-2 diabetes patients. Initial experimental studies proposed novel microbiome-related pathways, by which plant-based diets modulate the gut microbiome towards a favorable diversity of bacteria species, yet a functional "bottom up" signaling of plant-based diet-induced microbial changes remains highly speculative. In addition, little is known, based on interventional studies about cognitive effects linked to plant-based diets. Thus, a causal impact of plant-based diets on cognitive functions, mental and neurological health and respective underlying mechanisms has yet to be demonstrated. In sum, the increasing interest for plant-based diets raises the opportunity for developing novel preventive and therapeutic strategies against obesity, eating disorders and related comorbidities. Still, putative effects of plant-based diets on brain health and cognitive functions as well as the underlying mechanisms remain largely unexplored and new studies need to address these questions.

Relation of Vegetarian Dietary Patterns With Major Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

Background: Vegetarian dietary patterns are recommended for cardiovascular disease (CVD) prevention and management due to their favorable effects on cardiometabolic risk factors, however, the role of vegetarian dietary patterns in CVD incidence and mortality remains unclear.

Objective: To update the European Association for the Study of Diabetes (EASD) clinical practice guidelines for nutrition therapy, we undertook a systematic review and meta-analysis of the association of vegetarian dietary patterns with major cardiovascular outcomes in prospective cohort studies that included individuals with and without diabetes using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

Methods: MEDLINE, EMBASE, and Cochrane databases were searched through September 6th, 2018. We included prospective cohort studies ≥1 year of follow-up including individuals with or without diabetes reporting the relation of vegetarian and non-vegetarian dietary patterns with at least one cardiovascular outcome. Two independent reviewers extracted data and assessed study quality (Newcastle-Ottawa Scale). The pre-specified outcomes included CVD incidence and mortality (total CVD, coronary heart disease (CHD) and stroke). Risk ratios for associations were pooled using inverse variance random effects model and expressed as risk ratios (RRs) with 95% confidence intervals (CIs). Heterogeneity was assessed (Cochran Q-statistic) and quantified (I²-statistic). The overall certainty of the evidence was assessed using GRADE.

Results: Seven prospective cohort studies (197,737 participants, 8,430 events) were included. A vegetarian dietary pattern was associated with reduced CHD mortality [RR, 0.78 (CI, 0.69, 0.88)] and incidence [0.72 (0.61, 0.85)] but were not associated with CVD mortality [0.92 (0.84, 1.02)] and stroke mortality [0.92 (0.77, 1.10)]. The overall certainty of the evidence was graded as “very low” for all outcomes, owing to downgrades for indirectness and imprecision.

Conclusions: Very low-quality evidence indicates that vegetarian dietary patterns are associated with reductions in CHD mortality and incidence but not with CVD and stroke mortality in individuals with and without diabetes. More research, particularly in different populations, is needed to improve the certainty in our estimates.

Clinical Trial Registration:Clinicaltrials.gov, identifier: NCT03610828.

Phytosterols and Triterpenoids for Prevention and Treatment of Metabolic-related Liver Diseases and Hepatocellular Carcinoma

Background:

Liver ailments are among the leading causes of death; they originate from viral infections, chronic alcoholism, and autoimmune illnesses, which may chronically be precursors of cirrhosis; furthermore, metabolic syndrome may worsen those hepatopathies or cause Non-alcoholic Fatty Liver Disease (NAFLD) that may advance to non-alcoholic steatohepatitis (NASH). Cirrhosis is the late-stage liver disease and can proceed to hepatocellular carcinoma (HCC). Pharmacological treatment options for liver diseases, cirrhosis, and HCC, are limited, expensive, and not wholly effective. The use of medicinal herbs and functional foods is growing around the world as natural resources of bioactive compounds that would set the basis for the development of new drugs.

Review and Conclusion:

Plant and food-derived sterols and triterpenoids (TTP) possess antioxidant, metabolic-regulating, immunomodulatory, and anti-inflammatory activities, as well as they are recognized as anticancer agents, suggesting their application strongly as an alternative therapy in some chronic diseases. Thus, it is interesting to review current reports about them as hepatoprotective agents, but also because they structurally resemble cholesterol, sexual hormones, corticosteroids and bile acids due to the presence of the steroid nucleus, so they all can share pharmacological properties through activating nuclear and membrane receptors. Therefore, sterols and TTP appear as a feasible option for the prevention and treatment of chronic metabolic-related liver diseases, cirrhosis, and HCC.

Comparison of Major Protein-Source Foods and Other Food Groups in Meat-Eaters and Non-Meat-Eaters in the EPIC-Oxford Cohort

Differences in health outcomes between meat-eaters and non-meat-eaters might relate to differences in dietary intakes between these diet groups. We assessed intakes of major protein-source foods and other food groups in six groups of meat-eaters and non-meat-eaters participating in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Oxford study. The data were from 30,239 participants who answered questions regarding their consumption of meat, fish, dairy or eggs and completed a food frequency questionnaire (FFQ) in 2010. Participants were categorized as regular meat-eaters, low meat-eaters, poultry-eaters, fish-eaters, vegetarians and vegans. FFQ foods were categorized into 45 food groups and analysis of variance was used to test for differences between age-adjusted mean intakes of each food group by diet group. Regular meat-eaters, vegetarians and vegans, respectively, consumed about a third, quarter and a fifth of their total energy intake from high protein-source foods. Compared with regular meat-eaters, low and non-meat-eaters consumed higher amounts of high-protein meat alternatives (soy, legumes, pulses, nuts, seeds) and other plant-based foods (whole grains, vegetables, fruits) and lower amounts of refined grains, fried foods, alcohol and sugar-sweetened beverages. These findings provide insight into potential nutritional explanations for differences in health outcomes between diet groups.

Is Grassfed Meat and Dairy Better for Human and Environmental Health?

The health of livestock, humans, and environments is tied to plant diversity-and associated phytochemical richness-across landscapes. Health is enhanced when livestock forage on phytochemically rich landscapes, is reduced when livestock forage on simple mixture or monoculture pastures or consume high-grain rations in feedlots, and is greatly reduced for people who eat highly processed diets. Circumstantial evidence supports the hypothesis that phytochemical richness of herbivore diets enhances biochemical richness of meat and dairy, which is linked with human and environmental health. Among many roles they play in health, phytochemicals in herbivore diets protect meat and dairy from protein oxidation and lipid peroxidation that cause low-grade systemic inflammation implicated in heart disease and cancer in humans. Yet, epidemiological and ecological studies critical of red meat consumption do not discriminate among meats from livestock fed high-grain rations as opposed to livestock foraging on landscapes of increasing phytochemical richness. The global shift away from phytochemically and biochemically rich wholesome foods to highly processed diets enabled 2.1 billion people to become overweight or obese and increased the incidence of type II diabetes, heart disease, and cancer. Unimpeded, these trends will add to a projected substantial increase in greenhouse gas emissions (GHGE) from producing food and clearing land by 2050. While agriculture contributes one quarter of GHGE, livestock can play a sizable role in climate mitigation. Of 80 ways to alleviate climate change, regenerative agriculture-managed grazing, silvopasture, tree intercropping, conservation agriculture, and farmland restoration-jointly rank number one as ways to sequester GHG. Mitigating the impacts of people in the Anthropocene can be enabled through diet to improve human and environmental health, but that will require profound changes in society. People will have to learn we are members of nature's communities. What we do to them, we do to ourselves. Only by nurturing them can we nurture ourselves.

Vegetarian diets and risk of hospitalisation or death with diabetes in British adults: results from the EPIC-Oxford study

BACKGROUND

The global prevalence of diabetes is high and rapidly increasing. Some previous studies have found that vegetarians might have a lower risk of diabetes than non-vegetarians.

OBJECTIVE

We examined the association between vegetarianism and risk of hospitalisation or death with diabetes in a large, prospective cohort study of British adults.

METHODS

The analysed cohort included participants from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Oxford study who were diabetes free at recruitment (1993-2001), with available dietary intake data at baseline, and linked hospital admissions and death data for diabetes over follow-up (n = 45,314). Participants were categorised as regular meat eaters (≥50 g per day: n = 15,181); low meat eaters (<50 g of meat per day: n = 7615); fish eaters (ate no meat but consumed fish: n = 7092); and vegetarians (ate no meat or fish, including vegans: n = 15,426). We used multivariable Cox proportional hazards models to assess associations between diet group and risk of diabetes.

RESULTS

Over a mean of 17.6 years of follow-up, 1224 incident cases of diabetes were recorded. Compared with regular meat eaters, the low meat eaters, fish eaters, and vegetarians were less likely to develop diabetes (hazard ratio (HR) = 0.63, 95% confidence interval (CI) 0.54-0.75; HR = 0.47, 95% CI 0.38-0.59; and HR = 0.63, 95% CI 0.54-0.74, respectively). These associations were substantially attenuated after adjusting for body mass index (BMI) (low meat eaters: HR = 0.78, 95% CI 0.66-0.92; fish eaters: HR = 0.64, 95% CI 0.51-0.80; and vegetarians: HR = 0.89, 95% CI 0.76-1.05).

CONCLUSIONS

Low meat and non-meat eaters had a lower risk of diabetes, in part because of a lower BMI.

Association between vegetarian diets and cardiovascular risk factors in non-Hispanic white participants of the Adventist Health Study-2

The association between dietary patterns and CVD risk factors among non-Hispanic whites has not been fully studied. Data from 650 non-Hispanic white adults who participated in one of two clinical sub-studies (about 2 years after the baseline) of the Adventist Health Study-2 (AHS-2) were analysed. Four dietary patters were identified using a validated 204-item semi-quantitative FFQ completed at enrolment into AHS-2: vegans (8·3 %), lacto-ovo-vegetarians (44·3 %), pesco-vegetarians (10·6 %) and non-vegetarians (NV) (37·3 %). Dietary pattern-specific prevalence ratios (PR) of CVD risk factors were assessed adjusting for confounders with or without BMI as an additional covariable. The adjusted PR for hypertension, high total cholesterol and high LDL-cholesterol were lower in all three vegetarian groups. Among the lacto-ovo-vegetarians the PR were 0·57 (95 % CI 0·45, 0·73), 0·72 (95 % CI 0·59, 0·88) and 0·72 (95 % CI 0·58, 0·89), respectively, which remained significant after additionally adjusting for BMI. The vegans and the pesco-vegetarians had similar PR for hypertension at 0·46 (95 % CI 0·25, 0·83) and 0·62 (95 % CI 0·42, 0·91), respectively, but estimates were attenuated and marginally significant after adjustment for BMI. Compared with NV, the PR of obesity and abdominal adiposity, as well as other CVD risk factors, were significantly lower among the vegetarian groups. Similar results were found when limiting analyses to participants not being treated for CVD risk factors, with the vegans having the lowest mean BMI and waist circumference. Thus, compared with the diet of NV, vegetarian diets were associated with significantly lower levels of CVD risk factors among the non-Hispanic whites.

Age, sex, and the association of chronic kidney disease with all-cause mortality in Buddhist priests: An analysis of the standardized mortality ratio from the Korean Buddhist priests cohort

Buddhist priests lead a unique lifestyle, practicing asceticism, with a vegetarian diet. Such behavior may have an impact on clinical outcomes. Hence, we explored the mortality among Korean Buddhist priests as compared with the general population.This study is a single-center, retrospective study. Among the 3867 Buddhist priests who visited Dongguk University Gyeongju Hospital between January 2000 and February 2016, 3639 subjects were available for mortality data from Statistics Korea. Standardized mortality ratio (SMR) was computed for all causes of death and compared with the general population using national statistics in Korea. Information regarding end-stage renal disease (ESRD) was investigated from the Korean Society of Nephrology registry. Among the 3639 patients, the baseline laboratory results were obtained in 724 patients. Chronic kidney disease (CKD) was defined as dipstick proteinuria ≥1 or an estimated glomerular filtration rate <60 mL/min/1.73 m.The mean age was 50.0 ± 12.5 years, and 51.0% were men. During the follow-up period for 31.1 ± 35.6 months, 55 (7.6%) patients died. During the follow-up period, 3 (0.4%) and 23 (3.2%) patients developed ESRD and urinary stone, respectively. The SMR for all causes of death was 0.76 (95% confidence interval [CI] 0.57-0.99; men 0.91, 95% CI 0.65-1.23; women 0.52, 95% CI 0.28-0.87). Among 724 patients, 74 (10.2%) patients had CKD. The SMR for non-CKD patients (0.61, 95% CI 0.43-0.85) was significantly lower than the general population. Female and patients older than 50 years (0.74, 95% CI 0.55-0.98) had a significantly lower SMR. In the Cox proportional hazards model with adjustment, older age (adjusted HR 1.04, 95% CI 1.10-1.07) and presence of CKD (adjusted HR 2.55, 95% CI 1.07-6.06) were independently associated with increased all-cause mortality.Buddhist priests and especially Buddhist priests without CKD showed a significantly lower mortality compared with the general population.

Assessment of dietary nitrate intake in humans: a systematic review

Background

The nitrate content of foods and water is highly variable, which has implications for the compilation of food-composition databases and assessment of dietary nitrate intake.

Objective

A systematic review was conducted to ascertain the dietary assessment methods used and to provide estimates of daily nitrate intake in humans.

Design

Relevant articles were identified by a systematic search of 3 electronic databases (PubMed, Web of Science, and Embase) from inception until February 2018. Observational studies conducted in adult populations and reporting information on dietary assessment methods and daily nitrate intake were included. Ecological analyses were conducted to explore the association of nitrate intake with indexes of economic development [Gross Domestic Product (GDP) and KOF Index of Globalization].

Results

A total of 55 articles were included. Forty-two studies investigated associations between nitrate intake and disease risk; 36 (87%) of these studies examined the association between nitrate intake and cancer risk, whereas only 6 studies explored the association of nitrate intake with the risk of diabetes, glaucoma, kidney failure, hypertension, and atherosclerotic vascular disease. The majority of studies used food-frequency questionnaires to assess nitrate intake (n = 43). The median daily nitrate intakes in healthy and patient populations were 108 and 110 mg/d, respectively. We found a significant inverse correlation of nitrate intake with GDP (r = -0.46, P < 0.001) and KOF index (r = -0.31, P = 0.002).

Conclusions

The median estimated daily nitrate intakes by healthy and patient populations were similar, and these values were below the safe upper intake of daily intake (3.7 mg nitrate ion/kg body weight). However, there is considerable heterogeneity in the application of food-composition tables, which may have implications for the accuracy of estimated daily nitrate intake. The association between nitrate intake and risk of cardiometabolic diseases needs further investigation. The protocol for this systematic review has been registered in the PROSPERO database (https://www.crd.york.ac.uk/prospero; CRD number: 42017060354).

Association of fish and long-chain omega-3 fatty acids intakes with total and cause-specific mortality: prospective analysis of 421 309 individuals

BACKGROUND

Prevailing dietary guidelines recommend regular fish consumption. However, the associations of fish and long-chain omega-3 polyunsaturated fatty acids (LCn-3 PUFAs) intakes with mortality remain unclear.

OBJECTIVES

To examine the associations of fish and LCn-3 PUFAs intakes with total and cause-specific mortality.

METHODS

A total of 240 729 men and 180 580 women from NIH-AARP Diet and Health Study were prospectively followed-up for 16 years. Dietary intakes were assessed using a validated NIH Diet History Questionnaire.

RESULTS

A total of 54 230 men and 30 882 women died during 6.07 million person-years of follow-up. Higher fish and LCn-3 PUFAs intakes were significantly associated with lower total mortality (P < 0.0001). Comparing the highest with lowest quintiles of fish intake, men had 9% (95% confidence interval, 6-11%) lower total mortality, 10% (6-15%) lower cardiovascular disease (CVD) mortality, 6% (1-10%) lower cancer mortality, 20% (11-28%) lower respiratory disease mortality and 37% (17-53%) lower chronic liver disease mortality, while women had 8% (5-12%) lower total mortality, 10% (3-17%) lower CVD mortality and 38% (20-52%) lower Alzheimer's disease mortality. Fried fish consumption was not related to mortality in men whereas positively associated with mortality from all causes (P = 0.011), CVD and respiratory disease in women. LCn-3 PUFAs intake was associated with 15% and 18% lower CVD mortality in men and women across extreme quintiles, respectively.

CONCLUSION

Consumption of fish and LCn-3 PUFAs was robustly associated with lower mortality from major causes. Our findings support current guidelines for fish consumption while advice on non-frying preparation methods is needed.

The Design, Development and Evaluation of the Vegetarian Lifestyle Index on Dietary Patterns among Vegetarians and Non-Vegetarians

Traditionally, healthful diets and lifestyles have been examined only in relation to single nutrients, foods, or food groups in terms of dietary exposure. An alternative approach is to conceptualize an index based on vegetarian food pyramid guidelines as a measure of overall diet and lifestyle quality. Our objectives were to: (1) develop the Vegetarian Lifestyle Index (VLI); and (2) evaluate adherence to the Vegetarian Food Guide Pyramid (VFGP) among a low-risk population of Adventists. The index was based on the operationalization of 14 dietary and lifestyle components. All components were equally weighted. Higher score reflected greater adherence to the VFGP. The analytic sample (n = 90,057) comprised 47.7% non-vegetarians, 5.6% semi-, 10.1% pesco-, and 29.0% lacto-ovo-vegetarians, and 7.7% vegans, of which 1.1% were current smokers and 9.9% were alcohol consumers. Population mean VLI score was 7.43 (SD = 1.75) ranging from 1 to 12.5. Non-vegetarians (6.14; 95% confidence interval (CI), 6.06⁻6.21) had a significantly lower mean compared to semi- (7.31; 95% CI, 7.22⁻7.40), pesco- (7.41; 95% CI, 7.32⁻7.49), and lacto-ovo-vegetarians (8.16; 95% CI, 8.08⁻8.24), as well as vegans (8.88; 95% CI, 8.78⁻8.96). Vegetarians scored on average 1.18 to 2.73 more points than their non-vegetarian counterparts. Results demonstrate that the index has strong discriminant ability across distinct dietary patterns. Additionally, the VLI provides a useful measure of diet and lifestyle adherence to further refine vegetarian food pyramid guidelines.

Healthy Plant-Based Diets Are Associated with Lower Risk of All-Cause Mortality in US Adults

Background

Plant-based diets, often referred to as vegetarian diets, are associated with health benefits. However, the association with mortality is less clear.

Objective

We investigated associations between plant-based diet indexes and all-cause and cardiovascular disease mortality in a nationally representative sample of US adults.

Methods

Analyses were based on 11,879 participants (20-80 y of age) from NHANES III (1988-1994) linked to data on all-cause and cardiovascular disease mortality through 2011. We constructed an overall plant-based diet index (PDI), which assigns positive scores for plant foods and negative scores for animal foods, on the basis of a food-frequency questionnaire administered at baseline. We also constructed a healthful PDI (hPDI), in which only healthy plant foods received positive scores, and a less-healthful (unhealthy) PDI (uPDI), in which only less-healthful plant foods received positive scores. Cox proportional hazards models were used to estimate the association between plant-based diet consumption in 1988-1994 and subsequent mortality. We tested for effect modification by sex.

Results

In the overall sample, PDI and uPDI were not associated with all-cause or cardiovascular disease mortality after controlling for demographic characteristics, socioeconomic factors, and health behaviors. However, among those with an hPDI score above the median, a 10-unit increase in hPDI was associated with a 5% lower risk in all-cause mortality in the overall study population (HR: 0.95; 95% CI: 0.91, 0.98) and among women (HR: 0.94; 95% CI: 0.88, 0.99), but not among men (HR: 0.95; 95% CI: 0.90, 1.01). There was no effect modification by sex (P-interaction > 0.10).

Conclusions

A nonlinear association between hPDI and all-cause mortality was observed. Healthy plant-based diet scores above the median were associated with a lower risk of all-cause mortality in US adults. Future research exploring the impact of quality of plant-based diets on long-term health outcomes is necessary.

Current Level of Fish Consumption is Associated with Mortality in Chinese but not US Adults: New Findings From Two Nationwide Cohort Studies With 14 and 9.8 Years of Follow-Up

SCOPE

Whether dietary fish consumption is linked to mortality remains unclear. We aim to investigate the association of fish consumption with mortality in Chinese and US nationwide populations.

METHODS AND RESULTS

We utilize data from China Health and Nutrition Survey (CHNS, n = 14 117) and National Health and Nutrition Examination Survey (NHANES, n = 33 221) including NHANES III conducted in 1988-1994 and continuous NHANES 1999-2010. Cox proportional hazards regression is used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). During a median follow-up of 14 and 9.8 years for CHNS and NHANES, 1007 and 5209 deaths are documented, respectively. Among Chinese adults, increased fish intake is significantly associated with decreased total mortality. The multivariable-adjusted HRs (95% CIs) across increasing categories of fish intake are 0.45 (0.36-0.56), 0.72 (0.60-0.86), and 0.70 (0.59-0.85) (p trend < 0.0001). However, fish intake is not associated with total mortality among US adults (p trend = 0.21). We only detected a borderline inverse association between fish intake and stroke mortality (p trend = 0.05), whereas a positive association with diabetes mortality in the third category of fish intake in NHANES.

CONCLUSION

In these two nationwide cohort studies, fish consumption is associated with a reduced risk of total mortality for Chinese but not US populations.

Association between empirically derived dietary patterns with blood lipids, fasting blood glucose and blood pressure in adults - the India migration study

BACKGROUND

Dietary patterns (DPs) in India are heterogenous. To date, data on association of indigenous DPs in India with risk factors of nutrition-related noncommunicable diseases (cardiovascular disease and diabetes), leading causes of premature death and disability, are limited. We aimed to evaluate the associations of empirically-derived DPs with blood lipids, fasting glucose and blood pressure levels in an adult Indian population recruited across four geographical regions of India.

METHODS

We used cross-sectional data from the Indian Migration Study (2005-2007). Study participants included urban migrants, their rural siblings and urban residents and their urban siblings from Lucknow, Nagpur, Hyderabad and Bangalore (n = 7067, mean age 40.8 yrs). Information on diet (validated interviewer-administered, 184-item semi-quantitative food frequency questionnaire), tobacco consumption, alcohol intake, physical activity, medical history, as well as anthropometric measurements were collected. Fasting-blood samples were collected for estimation of blood lipids and glucose. Principal component analysis (PCA) was used to identify major DPs based on eigenvalue> 1 and component interpretability. Robust standard error multivariable linear regression models were used to investigate the association of DPs (tertiles) with total cholesterol (TC), low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), triglycerides, fasting-blood glucose (FBG), systolic and diastolic blood pressure (SBP and DBP) levels.

RESULTS

Three major DPs were identified: 'cereal-savoury' (cooked grains, rice/rice-based dishes, snacks, condiments, soups, nuts), 'fruit-vegetable-sweets-snacks' (Western cereals, vegetables, fruit, fruit juices, cooked milk products, snacks, sugars, sweets) and 'animal food' (red meat, poultry, fish/seafood, eggs) patterns. High intake of the 'animal food' pattern was positively associated with levels of TC (β = 0.10 mmol/L; 95% CI: 0.02, 0.17 mmol/L; p-trend = 0.013); LDL-C (β = 0.07 mmol/L; 95% CI: 0.004, 0.14 mmol/L; p-trend = 0.041); HDL-C (β = 0.02 mmol/L; 95% CI: 0.004, 0.04 mmol/L; p-trend = 0.016), FBG: (β = 0.09 mmol/L; 95% CI: 0.01, 0.16 mmol/L; p-trend = 0.021) SBP (β = 1.2 mm/Hg; 95% CI: 0.1, 2.3 mm/Hg; p-trend = 0.032); DBP: (β = 0.9 mm/Hg; 95% CI: 0.2, 1.5 mm/Hg; p-trend = 0.013). The 'cereal-savoury' and 'fruit-vegetable-sweets-snacks' patterns showed no association with any parameter except for a positive association with diastolic blood pressure for high intake of 'fruits-vegetables-sweets-snacks' pattern.

CONCLUSION

Our results indicate positive associations of the 'animal food' pattern with cardio-metabolic risk factors in India. Further longitudinal assessments of dietary patterns in India are required to validate the findings.

Vegetarian, vegan diets and multiple health outcomes: A systematic review with meta-analysis of observational studies

BACKGROUND

Beneficial effects of vegetarian and vegan diets on health outcomes have been supposed in previous studies.

OBJECTIVES

Aim of this study was to clarify the association between vegetarian, vegan diets, risk factors for chronic diseases, risk of all-cause mortality, incidence, and mortality from cardio-cerebrovascular diseases, total cancer and specific type of cancer (colorectal, breast, prostate and lung), through meta-analysis.

METHODS

A comprehensive search of Medline, EMBASE, Scopus, The Cochrane Library, and Google Scholar was conducted.

RESULTS

Eighty-six cross-sectional and 10 cohort prospective studies were included. The overall analysis among cross-sectional studies reported significant reduced levels of body mass index, total cholesterol, LDL-cholesterol, and glucose levels in vegetarians and vegans versus omnivores. With regard to prospective cohort studies, the analysis showed a significant reduced risk of incidence and/or mortality from ischemic heart disease (RR 0.75; 95% CI, 0.68 to 0.82) and incidence of total cancer (RR 0.92; 95% CI 0.87 to 0.98) but not of total cardiovascular and cerebrovascular diseases, all-cause mortality and mortality from cancer. No significant association was evidenced when specific types of cancer were analyzed. The analysis conducted among vegans reported significant association with the risk of incidence from total cancer (RR 0.85; 95% CI, 0.75 to 0.95), despite obtained only in a limited number of studies.

CONCLUSIONS

This comprehensive meta-analysis reports a significant protective effect of a vegetarian diet versus the incidence and/or mortality from ischemic heart disease (-25%) and incidence from total cancer (-8%). Vegan diet conferred a significant reduced risk (-15%) of incidence from total cancer.

Dietary Intake of High-Protein Foods and Other Major Foods in Meat-Eaters, Poultry-Eaters, Fish-Eaters, Vegetarians, and Vegans in UK Biobank

Vegetarian diets are defined by the absence of meat and fish, but differences in the intake of other foods between meat-eaters and low or non-meat eaters are also important to document. We examined intakes of high-protein foods (meat, poultry, fish, legumes, nuts, vegetarian protein alternatives, dairy products, and eggs) and other major food groups (fruit, vegetables, bread, pasta, rice, snack foods, and beverages) in regular meat-eaters, low meat-eaters, poultry-eaters, fish-eaters, vegetarians, and vegans of white ethnicity participating in UK Biobank who had completed at least one web-based 24-h dietary assessment (n = 199,944). In regular meat-eaters, around 25% of total energy came from meat, fish, dairy and plant milk, cheese, yogurt, and eggs. In vegetarians, around 20% of energy came from dairy and plant milk, cheese, yoghurt, eggs, legumes, nuts, and vegetarian protein alternatives, and in vegans around 15% came from plant milk, legumes, vegetarian alternatives, and nuts. Low and non-meat eaters had higher intakes of fruit and vegetables and lower intakes of roast or fried potatoes compared to regular meat-eaters. The differences in the intakes of meat, plant-based high-protein foods, and other foods between meat-eaters and low and non-meat eaters in UK Biobank may contribute to differences in health outcomes.

Dietary poultry intake and the risk of stroke: A dose-response meta-analysis of prospective cohort studies

BACKGROUND & AIMS

We performed a meta-analysis to illuminate and quantify the potential relationship between poultry intake and risk of stroke through summarizing available evidence using a dose-response meta-analysis of prospective cohort studies.

METHODS

Pertinent prospective cohort studies attained using electronic searches through PubMed, and Scopus up to September 25th, 2017. Relative risks (RR) s with corresponding 95% confidence intervals (CIs) of the highest versus the lowest for cohort studies were evaluated using DerSimonian and Laird random-effects models to find combined RRs. We also assessed the dose-response effect of this relationship.

RESULTS

A total of 7 studies involving 354 718 participants were met inclusion criteria. The pooled RR of total stroke risk was [RR = 0.92 95% CI, 0.82, 1.03, I² = 19.8%, P_{heterogeneity} = 0.28] for the highest versus lowest categories of poultry intake. Subgroup analysis showed an inverse associations for the US people [RR = 0.86 95% CI, 0.77, 0.95, I² = 0.0%, P_{heterogeneity} = 0.38] and women [RR = 0.83, 95% CI, 0.72, 0.93, I² = 0.0%, P_{heterogeneity} = 0.63]. We did not obtain any significant association in the subtypes of strokes with highest versus lowest poultry intake [Ischemic stroke (RR = 0.91; 95% CI: 0.79, 1.02, I² = 0.0%, p = 0.93), Hemorrhagic (RR = 0.82; 95% CI: 0.59, 1.04, I² = 20.5%, P_{heterogeneity} = 0.28)]. One serving per week increment in poultry intake was not associated with the risk of stroke (RR: 1.00, 95% CI: 0.96, 1.03, I² = 69.0%, P_{heterogeneity} = 0.004). Nonlinear dose-response meta-analysis showed lower risk of stroke at consumption ∼1 serving/week.

CONCLUSION

Our meta-analysis revealed that poultry intake is not associated with total stroke risk; furthermore, an inverse relationship in US population and females must be interpreted with caution.

Vegetarianism and colorectal cancer risk in a low-selenium environment: effect modification by selenium status? A possible factor contributing to the null results in British vegetarians

BACKGROUND

Despite the consistent findings of lower total cancer incidence in vegetarians than in meat-eaters in the UK, the results of studies of colorectal cancer (CRC) risk in British vegetarians have largely been null. This was in contrast to the hypothesis of a decreased risk of CRC in this population due to null intake of red and processed meats and increased intake of fibre. Although the data are inconsistent, it has been suggested that selenium (Se) status may influence CRC risk.

METHODS

A literature review was performed of studies on CRC risk in vegetarians, Se intakes and status in vegetarians, and changes of Se intakes and status in the UK throughout the follow-up periods of studies on CRC risk in British vegetarians.

RESULTS

Vegetarians in the UK and other low-Se areas were found to have low Se intakes and status compared to non-vegetarians. There was some evidence of a reverse J-shaped curve of Se intakes and status in the UK throughout the last three decades. These presumed patterns were followed by the changes in CRC mortality or incidence in British vegetarians during this period.

CONCLUSIONS

Available data on Se intake and status in British vegetarians, as well as the relationship between their secular changes in the UK and changes in CRC risk in this dietary group, are compatible with the hypothesis that low Se status may contribute to the largely null results of studies of CRC risk in vegetarians in the UK.

In response to the December 2016 article entitled "Vegetarian diet and all-cause mortality: Evidence from a large population-based Australian cohort - the 45 and Up Study"

In response to the December 2016 article entitled "Vegetarian diet and all-cause mortality: Evidence from a large population-based Australian cohort - the 45 and Up Study". A brief analysis of the article with suggestions for interpretation and considerations for future research.