January 1997: (Il)S6I S 6 8

Effects of Vegetarian Diets on Aging and Longevity

Paul Walter

Vegetarian diets are very heterogeneous, as are their ef- lacto- or lacto-ovovegetarians. The fat composition of the
fects on nutritional status, health, and longevity. They diet, in particular, may vary greatly depending on whether
encompass not only various animal food avoidance pat- the fat originates from dairy products or from plants.
terns but also differing health-related attitudes as well as There are a few good reviews in the l i t e r a t ~ r ecover-
~.~
widely philosophical and religious beliefs. Vegetarianism ing mainly the period from 1960 through 1990, when many-
is often considered to be a special lifestyle, because many studies were performed. Since 1990, many studies have
vegetariansare nonsmokers, drink little if any alcohol, and been in progress that concern more specific effects of veg-
engage in more than average physical exercise. When we etarian diets on human health. They deal with the risks on
evaluate results with vegetarians, we therefore not only the one hand and with the beneficial effects on the other.
have to take into account the uncertainty concerrfng the Both are important for longevity. We know that good nutri-
compliance with their diets but also many confounding tion during growth is an important basis for our health
factors due to the different life patterns. when we get older, and therefore nutritional risks should
A vegetarian is usually defined as someone who does be avoided, especially during the early period of our life.
not eat animal flesh (meat, poultry, fish). A strict vegetar- But after the growing period, nutrition remains a crucial
ian, or vegan, specifically excludes all animal products in- factor for maintenance of good health and prevention of
cluding dairy products and eggs, and the diet therefore disease in l&er years. Many recent studies give strong
consists mainly of plant foods such as fruits, vegetables, evidence-independent of meat consumption-for an in-
legumes, grains, seeds, and nuts. The lactovegetarian diet verse relationship between vegetablelfmit intake and vari-
includes dairy products, whereas the lacto-ovovegetarian ous types of cancer, for a relationship between type of
diet includes dairy products and eggs. Even within the dietary fat and coronary heart disease (for review, see
classification of these diets, considerable differences may WilletP), and for the effect of dietary fiber intake on mortal-
exist in the choice of plant foods. The “New Vegetarians’’ ity from coronary heart disease, cancer, and other sources.s
in The Netherlands and the United States, for example, are Because these nutritional aspects are directly related to
followers of the teachings of Ohsawa,’ preferring natural vegetarian diets, it seems reasonable to include them in the
unprocessed foods, which he called macrobiotics, con- discussion as well.
sisting of relatively large amounts of brown rice accompa-
nied by smaller amounts of fruits; followers of the vegan- Diet Adequacy and Risks ofvegetarian Diets
fruitarian diet restrict their diet to raw fi-uits, nuts, and ber-
In principle, protein from plant sources alone can provide
ries.
adequate amounts of the essential amino acids, provided
Many studies of vegan diets have been carried out
that the dietary protein sources are reasonably varied, e.g.,
with Seventh Day Adventist vegetarians. For idealistic rea-
maize with a protein low in lysine should be combined with
sons, this group shows good compliance with their diet
beans that are high in this amino acid. Soya protein has
and these results are therefore given considerable impor-
been shown to be nutritionally equivalent to proteins of
tance in the literature. However, the originally strict diet
animal origin and thus can serve as a main source of pro-
limitationsof this group have been changing and the Ameri-
tein intake. The vegetarians who accept dairy products
can Adventists of today are mainly lactovegetarians,
and eggs, of course, have no problem obtaining adequate
whereas in Germany they consume a mixed diet but one
protein supplies, whereas vegans have to be especially
that contains a lot of fruit and vegetables.
careful to combine various plant proteins in order to avoid
Concerning the nonvegan diets, it has been very diffi-
a deficiency of a single one of the essential amino acids.
cult to attribute the results to certain subgroups such as
Actually, as recently summarized by Margetts and Jack-
son,6 the adult requirement for protein in the diet is again
under debate. Young and Pellet7 claim that requirements
Professor Walter is in the Biochemistry Depart-
for essential amino acids cannot be satisfied by diets based
ment, University of Basel, Basel, Switzerland.

Nutrition Reviews, Vol. 55, No. 1 S6 1

upon cereals only unless at least 30% of total protein is One of the main problems of vegetarian diets is the
derived from animal sources or at least 40% of the total danger of iron deficiency and consequent anemia. Iron
protein is derived from animal sources plus a meat substi- bioavailability from foods of plant origin is low compared
tute such as soya. with that from meat. Consequently, vegetarians have a
With regard to a possible deficiency in micronutri- higher risk of iron deficiency than meat eaters. Among
ents, special attention should be given to vitamins B,, and vegetarians, who often have a limited intake of heme iron,
D, as well as to iron and zinc. Vitamin B,, is present in the effect of vitamin C-containing foods on improving the
substantial amounts only in animal foods. Its deficiency is absorption of nonheme iron is of particular importance."
therefore a matter of concern in diets that are partially or On the other hand, nonheme iron binds to phytates, tannins,
totally devoid of animal sources. Especially for vegans and phosphates, all commonly present in plant food diets.
there clearly exists a risk of vitamin B,, deficiency, as has Phytates are commonly found in whole grain, bran, and
been reported in the literature.s-10 soya products and have strong inhibitory effects on iron
It should also be remembered that depletion of vita- absorption.18Furthermore, oxalic acid, present in spinach,
min B,, stores in vegans is slow and depends on the initial rhubarb, etc., also forms insoluble complexes with iron,
body vitamin B,, pool, and therefore symptoms of vitamin thereby inhibiting its absorption. Vegetarians are therefore
B,, deficiency appear slowly but are nevertheless very advised to consume plant foods that are rich in nonheme
dangerous. A special problem, therefore, arises in children iron and low in substances that decrease the absdlption of
ofvegan women with low vitamin B,, stores where special this trace element. Special problems arise in children born
precautions must be taken.".l2 to vegetarian mothers with lower stores of iron. If these
A good deal of confusion exists about how much and children are breast-fed for a long period they more likely
what kind of vitamin B,, can be supplied by plants and by will develop anemia. It also has been reported that low iron
microbiologic sources. Fermented soya products such as status in the first trimester of pregnancy may increase the
tempeh contain many corrinoids (i.e., ring structures simi- risk of premature birth.19*20 Therefore, additional intake of
lar to vitamin B,,), which have little if any vitamin B,, activ- iron before conception and during pregnancy is necessary
ity in humans.I3Similarly, spirulina, another plant product, for vegetarians.
also contains corrinoids with virtually no vitamin B,, activ- Zinc deficiency also may be of concern, because in
ity. A recent articleI4 reported that vegans who consumed the United States over two-thirds of the zinc supply comes
nori or chlorella seaweed had vitamin B,, concentrations in from'animal products such as red meat, eggs, oysters, and
the serum twice as high as those who did not eat the sea- other seafood. Several studies have reported lower con-
weed. However, these values were still significantly lower centrations of plasma zinc for vegetarians and vegans com-
than normal. It can therefore be concluded that in the long pared with n ~ n v e g e t a r i a n s . ~ Whether
,-~~ these slightly
run all these products cannot sufficiently replace vitamin lower concentrations of plasma zinc are of clinical signifi-
B,, from animal sources. Vegans as well as other vegetar- cance, however, remains to be investigated.
ians therefore are advised to consider supplementing their Concerning the n-3 fatty acids there is some concern,
diet with vitamin B,,, e.g., by including processed food especially for infants who are born to vegan mothers and
that is fortified with this vitamin. then breast-fed. It is known that the n-3 fatty acids are
It should be noted that the standard microbiologic important for development of the central nervous system
assay for vitamin B,, in foodstuffs cannot differentiate and the retina. Because vegans and other vegetarians do
between inactive plant vitamin B,, derivatives and vitamin not eat seafood, their uptake of eicosapentanoic acid and
B,, from animal sources. Therefore, results in the literature docosahexanoic acid is very small. However, the biologic
on vitamin B,, content in plants must be examined care- precursor of these two compounds, a-linolenic acid, oc-
fillly. curs in some plant oils, and it is possible that endogenous
Many risk groups today have a low folic acid intake. synthesis of the longer chain derivatives may be suffi-
However, on the whole, vegetarians do not seem to have a cient. It appears that more research in this area is required
greater folic acid deficiency problem than nonvegetarians before exact conclusions can be drawn.3,24.25
unless they boil their green leafy vegetables at high tem- If we look at the influence of vegetarian diet on growth
perature~.~~.~~ and development, the results are equivocal and of course
Vitamin D, deficiency and lack of calcium do not usu- depend on the kind of vegetarian diet c o n ~ u m e d . ~The J~
ally occur in lacto-ovovegetarians because of their intake classic experiment by Widdowson and McCanceZ6clearly
of milk and dairy products. In the United States, although demonstrated that children will grow and develop quite
70% of calcium uptake is from dairy products, adequate normally on a diet consisting of plenty of bread and veg-
calcium can be supplied for vegans if sufficient amounts of etables with minimum amounts of milk and meat. However,
vegetables and fruits high in calcium are consumed. Vita- several studies report that vegan children often fail to grow
min D,, however, may turn out to be critical for strict as well as their omnivorous cohorts (for review, see
vegans .4 Acosta,'). Lower rates of growth, particularly in the first 5

562 Nutrition Reviews, Vol. 55, No. 1

years of life, have been reported for children reared on and for gastrointestinal cancer in females. Deaths from dis-
veganz8and on macrobiotic diets.29A critical issue seems eases of the respiratory and digestive systems were also
to be intake of dietary fiber, which may have a greater nega- reduced by about 50%. However, a slight increase of deaths
tive effect on nutrient and energy balances in infants and occurred as a result of anemia. When the strict and moder-
children than in adults.27According to Jakobs and Dwyer,)O ate vegetarians were analyzed separately, the strongest
nutritional deficiencies that are rare in the general popula- difference was found for ischemic heart disease, which
tion have occurred in children reared on vegetarian and was more than 50% less frequent among strict vegetarians
vegan diets, and therefore the growing stage seems to be a for both sexes than for the control group, confirming ear-
critical period. The same is true for pregnancy where-as lier observation^.^^ Again, confounding factors such as
mentioned earlier-vitamin B,,, vitamin D,, iron, and n-3 socioeconomic status and smoking are mentioned.
fatty acids may be critical factors for the development of It should especially be emphasized that vegetarians
babies of vegan mothers. are seldom overweight, as observed in many studies.3740
This is very likely due to the fact that vegetarian diets
Benefits ofvegetarian Diets containing fiber and complex carbohydrates have a lower
energy density4’and cause satiety at a lower calorie intake
In 1988,Dwye? reviewed the effects of vegetarian diets on
level. The fact that overweight and obesity are less fre-
nutritional status, health, and longevity. Her summary
quent in vegetarians may in itself be a reason for greate;
points out that mortality rates are similar or lower for veg-
longevity, because many studies have shown these two
etarians than for nonvegetarians and that the risks of di-
parameters to be important determinants for m0rtality.4~~~
etary-deficiency disease are increased for vegan but not
for all vegetarian diets. She mentions that both vegetarian
Final Conclusions
dietary and lifestyle practices are involved and that the
evidence for decreased risks for certain chronic degenera- 1) From what we know, vegetarian diets result in a lower
tive diseases varies: data are strong that vegetarians are at risk for many diseases such as obesity, cardiovascular dis-
lower risk for obesity, constipation, and lung cancer; evi- ease, some types of cancer, constipation, hypertension,
dence is good that risks for hypertension, coronary heart and type I1 diabetes. If we take the observed lower mortal-
disease, type I1 diabetes, and gallstones are lower; data are ity rates as a parameter, longevity is higher.
only fair to poor that risks of breast cancer, diverticular 2) People on a vegan diet have an increased risk of
disease of the colon, colonic cancer, calcium kidney stones, iron, vitamin B,,, vitamin D,, and calcium deficiency; even-
and osteoporosis are lower. tually also zinc, n-3 fatty acids, and protein intake may not
Ifwe look at mortality rates as an index for longevity in fulfill the basic requirements. Except for vitamin B,,, it ap-
more detail: there is a very large study in which 27,530 pears that a vegan diet can fulfill the requirements, but it
vegetarian and nonvegetarian Seventh Day Adventists takes quite a bit of knowledge and even expertise to choose
living in California were After 21 years of fol- the fruits and vegetables that contain all the necessary
low-up, those whose food habits were mostly vegetarian nutrients.
were found to have lower age-specific mortality rates than 3) Based on our present knowledge that high con-
those with more omnivorous eating practices. In this and tents of vegetables, fruits, and complex carbohydrates and
several other studies with groups of Seventh Day Adventist low amounts of saturated fatty acids are correlated with a
vegetarians, coronary heart disease mortality rates were reduced risk for the same diseases mentioned under point
lower and cancer rates were no higher than in the general 1, it is obvious that total abstinence from eating meat is not
population.2In other studies, lower death rates for cancer a major factor for the beneficial effects of vegetarian diets.
and heart disease have been observed in some groups of 4) The vegetarian-type diet with lots of vegetables
Seventh Day Adventist vegetarian^.^^,^^ However, con- and fruits and complex carbohydrates can be considered a
founding factors, such as abstinence from smoking, alco- prudent diet in the sense of today’s guidelines (see, e.g.,
hol, tea, and coffee, may have played a role. Actually, Fraser Dietary Guidelines for Americans 1990).48
et al.34showed that the lower rate of lung cancer in Sev- 5) History has shown that vegetarians were right when
enth Day Adventists could be attributed to abstinence they claimed more than 100 years ago that the vegetarian
from tobacco. In a recent study, a cohort of 1905 vegetar- diet including fruits, vegetables, fibers, and complex car-
ians and persons living a “healthy country lifestyle” occa- bohydrates is a healthy one.
sionally consuming meat products were followed for 11 6 ) The inclusion of some low-fat meat and fish does
years in the Federal Republic of germ an^.^' So far, 225 not seem to be harmful; it could actually be beneficial in
deaths have been observed and mortality from all causes lowering the risk of deficiencies in some extreme cases of
was reduced by 50% compared with the general popula- vegetarianism.
tion. Cancer mortality was reduced by 50% in men but by 7) Finally, we should realize that about 40% of today’s
only 25% in women. The deficit in cancer deaths was ob- world grain production is used for meat-producing live-
served mainly for lung and gastrointestinal cancer in males This conversion of cereal grains and other food

Nutrition Reviews, Vol. 55,No. 1 S63

concentrates to animal products involves large losses in mia vs iron deficiency: increased risk of preterm de-
energy; 1 kg of American beef requires 5 kg of grain. There- livery in a prospective study. Am J Clin Nutr
fore, if meat consumption could be lowered, more cereal 1992;55:985-8
21. Anderson BM, Gibson RS, Sabry JH. The iron and
grains and other valuable food components could be used zinc status of long term vegetarian women. Am J Clin
to improve the world's nutrition. Nutr 1981;34:1042-9
22. King JC, Stein T, Doyle M. Effect of vegetarianism on
1. Ohsawa G. Macrobiotics: an invitation to health and zinc status of pregnant women. Am J Clin Nutr
happiness. San Francisco: George Ohsawa 1981;34:104%55
Macrobiotic Foundation, 1991 23. Freeland-Graves J. Mineral adequacy of vegetarian
2. Dwyer JT. Health aspects of vegetarian diets. Am J diets. Am J Clin Nutr 1988;48:859-62
Clin Nutr 1988;48:712-38 24. Sanders TAB, Reddy S. Nutritional implications of a
3. Dwyer JT. Nutritional consequences of vegetarian- meatless diet. Proc Nutr SOC1994;53:297-307
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4. Willett WC. Diet and health: what should we eat? Sci- maternal vegetarian diet on essential fatty acid status
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C. Dietary fibre and 10-year mortality from coronary tive value of bread and the effect of flour on the growth
heart disease, cancer, and all causes. The Zutphen of undernourished children. London: MRC-Special
Study. Lancet 1982;ii:518-22 Report Series, 1954;no. 287
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amino acids in adults and their implications for inter- 28. Sanders TAB, Manning J. The growth and develop-
national planning. Food Nutr Bull 19~0;12:289-300 ment of vegan children. J Human Nutr Dietetics
8. Misra HN, Fallowfield JN. Sub-acute combined de- 1992;5:11-21
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Med J 1971;47:624-6 Burema J. Do children on macrobiotic diets show
9. Campbell M, Lofters WS, Gibbs WN. Rastafarianism catch-up growth? Eur J Clin Nutr 1988;42:1007-16
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Increased risk of vitamin 812 and iron deficiency in 31. Kahn RH, Phillips RL, Snowdon DA, et al. Associa-
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11. Sanders TAB. Growth and development of British ve- Day Adventists. Am J Epidemiol 1984;119:775-87
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12. Lamberg-Allardt C, Karkkainen M, Seppanen R, et al. tality because of all causes combined, coronary heart
Low serum 25-hydroxyvitamin D concentrations and disease, stroke, diabetes, and cancer in Seventh Day
secondary hyperparathyroidism in middle-agedwhite Adventists. Am J Clin Nutr 1988;48:739-48
strict vegetarians. Am J Clin Nutr 1993;58:684-9 33. Fonnebo V. Mortality in Norwegian Seventh Day
13. Herbert V, Drivas G, Manusselis C, et al. Are colon Adventists 1962-1 986. J Clin Epidemiol
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Invited Comment
Jorge L. Rosado

A large proportion of the population in Mexico consume tion of some vitamins, especially vitamin A, riboflavin, and
diets consisting primarily of plant foods. It has been re- ascorbic acid, is reported to be low in several groups of
ported that 80% of Mexicans, representing a sighicant Mexicans and is generally associated with the rural Mexi-
part of the urban population and most of the less devel- can diet.2 In general, intake of minerals is not deficient
oped rural areas, consume diets based on corn tortillas, even though iron deficiency anemia is the most common
beans, vegetables, and fruits. Tortillas and beans provide nutritional deficiency in the ~ o u n t r yand
, ~ plant-based di-
most of the dietary energy and protein. Inclusion of animal ets may contain more iron than other diets. Thus, habitual
products is occasional and highly variable in both popula- ingestion of a plant-based diet may lead to a low ingestion
4

tion groups and regions. Because a majority of Mexicans of some nutrients, especially some vitamins, and, in the
include high amounts of plant foods in their diets, the po- poorest regions, a low ingestion of energy as well.
tential adverse effects as well as the potential benefits of Plant-based diets like the diet typical of rural areas in
such diets are relevant for the population. This comment Mexico are high in substances that may interfere with the
has the objective of reviewing some of the potential risks absorption of several nutrients. Of relevance to this poten-
and benefits of vegetarian diets in the Mexican popula- tial effect is a studf in which we evaluated the effect of an
tion. average rural diet on the absorption of nutrients. The aver-
*
age rural diet contained 1.1 0.1 g of phytic acid per day
Adverse Nutritional Effects of the Plant-Based and 40.2 i-2.6 g of dietary fiber per day. The absorption of
Rural Mexican Diet nutrients with this diet was evaluated by balance studies
Nutrient deficiencies are due to poor ingestion of a nutri- using polyethylene glycol as a quantitative marker and it
ent, a decrease in the nutrient bioavailability, and/or an was compared with the absorption of the same nutrients
increase in the requirements for the nutrient. All these with an average urban diet, which contained more animal
foods. On average, the urban diet contained only 0.07 g of
mechanisms are relevant to understanding the association
between nutrition deficiencies and intake of plant-based *
phytic acid per day and 12.1 0.9 g of dietary fiber per day.
diets. A summary of the results of this study is presented in
Plant-based diets are less energy dense and also may Table 1. The apparent absorption of all nutrients studied
contain less protein. The information of the most recent was significantly reduced with the rural diet. In particular,
National Nutrition Survey' carried out in rural areas in there was a very large decrease in absorption of iron, zinc,
Mexico shows that deficient energy and protein intake and calcium with the rural diet. This study and the large
occurs only in the most marginal regions of the country, body of information about the negative effect of plant food
among the poorest groups of the population. The inges- constituents on the absorption of minerals suggest that
the low bioavailability of nutrients might be an important
mechanism responsible for the high incidence of nutrient
deficiencies in the population who habitually consume
~~

Dr. Rosado is at the Departamento de Fisiologia plant-based diets.

de la Nutricion, lnstituto Nacional de la Nutricion
Salvador Zubiran, Vasco de Quiroga No. 15, Deleg.
Many of the regions of Mexico where plant-based
Tlalpan, 14000, Mexico, D.F. diets are habitually consumed are also regions where para-

Nutrition Reviews, Vol. 55, No. 1 S65