NTRODUCTION

A nationwide poll conducted in April 2006 by Harris Interactive reported that 1.4% of the
American population is vegan, in that they eat no meat, fish, dairy, or eggs (1). Vegan diets are
growing in popularity today among teenagers and youth, especially females. For many vegans,
nutritional choices center around taking better care of the earth’s resources and the environment,
ethical issues about animal care, the use of antibiotics and growth stimulants for the production
of animals, the threat of animal-borne diseases, and the health advantages of a plant-based diet
(2–6). In addition, the potential of allergies from dairy products and lactose intolerance have
fueled the popularity of soy-based dairy substitutes.

What then is the nutritional and health status of those who follow a vegan diet? Compared with
other vegetarians (eg, lactoovovegetarians), are there any advantages or disadvantages to
following a vegan diet? Does the elimination of dairy and eggs offer any additional benefits or
create potential concerns? The purpose of this brief review is to summarize current knowledge
on the health effects of vegan diets, to discuss the nutritional concerns or shortfalls of a vegan
diet and to provide some practical dietary recommendations for following a healthy vegan diet.
Key et al (7) have provided a pertinent overview of the health effects of vegetarian diets,
focusing on their European Prospective Investigation into Cancer and Nutrition–Oxford (EPIC-
Oxford) study and other large population studies.

HEALTH EFFECTS OF VEGAN DIETS

Vegan diets are usually higher in dietary fiber, magnesium, folic acid, vitamins C and E, iron,
and phytochemicals, and they tend to be lower in calories, saturated fat and cholesterol, long-
chain n-3 (omega-3) fatty acids, vitamin D, calcium, zinc, and vitamin B-12 (8). In general,
vegetarians typically enjoy a lower risk of cardiovascular disease (CVD), obesity, type 2
diabetes, and some cancers (3). A vegan diet appears to be useful for increasing the intake of
protective nutrients and phytochemicals and for minimizing the intake of dietary factors
implicated in several chronic diseases (9). In a recent report (10), different plant food groups
were rated with respect to their metabolic-epidemiologic evidence for influencing chronic
disease reduction. According to the evidence criteria of the World Health Organization and Food
and Agriculture Organization (WHO/FAO), cancer risk reduction associated with a high intake
of fruit and vegetables was assessed as probable or possible, risk of CVD reduction as
convincing, whereas lower risk of osteoporosis was assessed as probable (10). The evidence for a
risk-reducing effect of consuming whole grains was assessed as possible for colorectal cancer
and probable for type 2 diabetes and CVD. The evidence for a risk-reducing effect of consuming
nuts was assessed as probable for CVD (10).

Cardiovascular disease

In summarizing the published research, Fraser (11) noted that, compared with other vegetarians,
vegans are thinner, have lower total and LDL cholesterol, and modestly lower blood pressure.
This is true not only for whites; work by Toohey et al (12) showed that blood lipids and body
mass index (BMI; in kg/m2) were significantly lower in African American vegans than in
lactoovovegetarians. Similarly, among Latin Americans, vegetarians had lower plasma lipids
than did their omnivore counterparts, with the lowest reported among vegans (13). In that study,
plasma total and LDL cholesterol were 32% and 44% lower among vegans than among
omnivores. Because obesity is a significant risk factor for CVD, the substantially lower mean
BMI observed in vegans may be an important protective factor for lowering blood lipids and
reducing the risk of heart disease (8).

Vegans, compared with omnivores, consume substantially greater quantities of fruit and
vegetables (14–16). A higher consumption of fruit and vegetables, which are rich in fiber, folic
acid, antioxidants, and phytochemicals, is associated with lower blood cholesterol concentrations
(17), a lower incidence of stroke, and a lower risk of mortality from stroke and ischemic heart
disease (18, 19). Vegans also have a higher consumption of whole grains, soy, and nuts
(14, 15, 20), all of which provide significant cardioprotective effects (21, 22).

Cancer

Data from the Adventist Health Study showed that nonvegetarians had a substantially increased
risk of both colorectal and prostate cancer than did vegetarians (23). A vegetarian diet provides a
variety of cancer-protective dietary factors (24). In addition, obesity is a significant factor,
increasing the risk of cancer at a number of sites (25). Because the mean BMI of vegans is
considerably lower than that of nonvegetarians (8), it may be an important protective factor for
lowering cancer risk.

Vegans consume considerably more legumes, total fruit and vegetables, tomatoes, allium
vegetables, fiber, and vitamin C than do omnivores (14–16, 20, 23). All those foods and nutrients
are protective against cancer (25). Fruit and vegetables are described as protective against cancer
of the lung, mouth, esophagus, and stomach and to a lesser degree some other sites, whereas the
regular use of legumes provides a measure of protection against stomach and prostate cancer. In
addition, fiber, vitamin C, carotenoids, flavonoids, and other phytochemicals in the diet are
shown to exhibit protection against various cancers, whereas allium vegetables provide
protection against stomach cancer, and garlic against colorectal cancer. Foods rich in lycopene,
such as tomatoes, are known to protect against prostate cancer (25).

Fruit and vegetables are known to contain a complex mixture of phytochemicals that possess
potent antioxidant and antiproliferative activity and show additive and synergistic effects
(24, 26). The phytochemicals interfere with several cellular processes involved in the progression
of cancer. These mechanisms include inhibiting cell proliferation, inhibition of DNA adduct
formation, inhibiting phase 1 enzymes, inhibiting signal transduction pathways and oncogene
expression, inducing cell-cycle arrest and apoptosis, inducing phase 2 enzymes, blocking the
activation of nuclear factor-κB, and inhibiting angiogenesis (24).

With this wide array of useful phytochemicals in the vegetarian diet, it is surprising that
population studies have not shown more pronounced differences in cancer incidence or mortality
rates between vegetarians and nonvegetarians (7, 27). The bioavailability of the phytochemicals,
which depends among other things on food preparation methods, may be an important
determining factor. However, new evidence suggests that a low vitamin D status, a problem
often reported in vegan populations (8, 28), is associated with an increased risk of cancers
(29, 30).

The sources of protein avoided or consumed by vegans also have definite health consequences.
Red meat and processed meat consumption are consistently associated with an increase risk of
colorectal cancer (25). Those in the highest quintile of red meat intake had elevated risks,
ranging from 20% to 60%, of esophageal, liver, colorectal, and lung cancers than did those in the
lowest quintile of red meat intake (31). In addition, the use of eggs was recently shown to be
associated with a higher risk of pancreatic cancer (32). Although vegans avoid consuming red
meat and eggs altogether, they consume greater amounts of legumes than do omnivores
(14, 16, 20). This protein source was seen in the Adventist Health Study to be negatively
associated with risk of colon cancer (23). New data suggest that legume intake is also associated
with a moderate reduction in the risk of prostate cancer (33). In Western society, vegans also
consume substantially more tofu and other soy products than do omnivores (14, 16).
Consumption of isoflavone-containing soy products during childhood and adolescence protects
women against the risk of breast cancer later in life (34), whereas a high childhood dairy intake
has been associated with an elevated risk of colorectal cancer in adulthood (35). Cancer risk in
vegans may be altered because vegans consume soy beverages rather than dairy beverages. Data
from the Adventist Health Study showed that consumption of soy milk by vegetarians protected
them against prostate cancer (36), whereas in other studies the use of dairy was associated with
an increased risk of prostate cancer (25, 37–39).

Further research is needed to explore the relation between consuming plant-based diets and risk
of cancer because there are many unanswered questions about how diet and cancer are
connected. To date, epidemiologic studies have not provided convincing evidence that a vegan
diet provides significant protection against cancer. Although plant foods contain many
chemopreventive factors, most of the research data comes from cellular biochemical studies.

Bone health

Cross-sectional and longitudinal population-based studies published within the past 2 decades
suggest no differences in bone mineral density (BMD), for both trabecular and cortical bone,
between omnivores and lactoovovegetarians (40). More recent studies with postmenopausal
Asian women showed spine or hip BMD was significantly lower in long-term vegans (41, 42).
Those Asian women, who were vegetarian for religious reasons, had low intakes of protein and
calcium. An inadequate protein and low calcium intake has been shown to be associated with
bone loss and fractures at the hip and spine in the elderly (43, 44). Adequate calcium intake may
be a problem for vegans. Although lactoovovegetarians generally consume adequate amounts of
calcium, vegans typically fall short of the recommended daily intake for calcium (8, 45, 46).
Results from the EPIC-Oxford study provide good evidence that the risk of bone fractures for
vegetarians was similar to that of omnivores (46). The higher risk of bone fracture seen in vegans
appears to be a consequence of a lower mean calcium intake. No difference was observed
between the fracture rates of the vegans who consumed >525 mg calcium/d and the omnivore
fracture rates (46).

Bone health depends on more than just protein and calcium intakes. Research has shown that
bone health is also influenced by nutrients such as vitamin D, vitamin K, potassium, and
magnesium and by foods such as soy and fruit and vegetables (47–50). Vegan diets do well in
providing a number of those important substances. The maintenance of acid-base balance is
critical for bone health. A drop in extracellular pH stimulates bone resorption (51), because bone
calcium is used to buffer the pH drop. An acid-forming diet, therefore, increases urinary calcium
excretion (52). However, a diet rich in fruit and vegetables that is typical of a vegan diet has a
positive effect on the calcium economy and markers of bone metabolism in men and women
(49). The high potassium and magnesium content of fruit and vegetables provides an alkaline
ash, which inhibits bone resorption (53). Higher intakes of potassium are associated with greater
BMD of the femoral neck and lumbar spine of premenopausal women (54).

Blood concentrations of undercarboxylated osteocalcin, a sensitive marker of vitamin K status, is

considered an indicator of hip fracture (55) and a predictor of BMD (56). Results from 2 large,
prospective cohort studies support an association between vitamin K intake and relative risk of
hip fracture. In the Nurses’ Health Study, middle-aged women consuming the most vitamin K
had the lowest risk of hip fracture. Risk of hip fracture was decreased 45% for ≥1 servings/d of
green leafy vegetables (the main vitamin K source) compared with ≤1 serving/wk (57). In the
Framingham Heart Study, elderly men and women in the highest quartile of vitamin K intake had
a 65% decreased risk of hip fracture than did those in the lowest quartile (58).

In addition to a high intake of fruit and vegetables, vegans also tend to have a high intake of tofu
and other soy products (14, 16). Soy isoflavones are suggested to have a beneficial effect on
bone health in postmenopausal women (50). In a meta-analysis of 10 randomized controlled
trials, soy isoflavones showed a significant benefit to spine BMD of menopausal women (59). In
another meta-analysis, soy isoflavones significantly inhibited bone resorption and stimulated
bone formation compared with placebo (60). In a randomized clinical trial lasting 24 mo
involving osteopenic postmenopausal women, increases in BMD of both lumbar spine and
femoral neck were substantially greater with the soy isoflavone, genistein, than with placebo
(61).

As long as the calcium and vitamin D intake of vegans is adequate, their bone health is probably
not an issue because their diet contains an ample supply of other protective factors for bone
health. However, more studies are needed to provide more definitive data on the bone health of
vegans.

POTENTIAL NUTRITIONAL SHORTFALLS

To obtain a nutritionally adequate diet, the consumer must first have an appropriate knowledge
of what constitutes a nutritionally adequate diet. Second, accessibility is important, ie, the
availability of certain foodstuffs and foods fortified with key nutrients that are otherwise lacking
in the diet. This accessibility will vary greatly, depending on the geographic region of the world,
because different countries have different fortification laws. The following section deals with
nutrients of concern in the vegan diet. The problem of insufficient calcium has already been
discussed in the section on bone health.

n-3 Polyunsaturated fat

Diets that do not include fish, eggs, or sea vegetables (seaweeds) generally lack the long-chain n-
3 fatty acids, eicosapentaenoic acid (EPA; 20:5n-3) and docosahexaenoic acid (DHA; 22:6n-3),
which are important for cardiovascular health as well as eye and brain functions. The plant-based
n-3 fatty acid α-linolenic acid (ALA; 18:3n-3) can be converted into EPA and DHA, albeit with a
fairly low efficiency (62, 63). Compared with nonvegetarians, vegetarians, and especially
vegans, tend to have lower blood concentrations of EPA and DHA (64). However, vegans can
obtain DHA from microalgae supplements containing DHA, as well as from foods fortified with
DHA. However, EPA can be obtained from the retroconversion of DHA in the body. The oil
from brown algae (kelp) has also been identified as a good source of EPA.
The new Dietary Reference Intakes recommend intakes of 1.6 and 1.1 g ALA/d for men and
women, respectively, which accounts for <1% of the daily calories. Presently, the intake of EPA
plus DHA in the United States is only 0.1–0.2 g/d, with the DHA intake being ≈2–3 times the
intake of EPA (65). Vegans should be able to easily reach the n-3 fatty acid requirements by
including regular supplies of ALA-rich foods in their diet and also DHA-fortified foods and
supplements. However, DHA supplements should be taken with caution. Although they can
lower plasma triacylglycerol, they can raise total and LDL cholesterol (66, 67), cause excessively
prolonged bleeding times, and impair immune responses (65).

Vitamin D

In the EPIC-Oxford study, vegans had the lowest mean intake of vitamin D (0.88 μg/d), a value
one-fourth the mean intake of omnivores (8). For a vegan, vitamin D status depends on both sun
exposure and the intake of vitamin D-fortified foods. Those living in areas of the world without
fortified foods would need to consume a vitamin D supplement. Living at high latitudes can also
affect one’s vitamin D status, because sun exposure in that region is inadequate for several
months of the year (68). Those who are dark skinned, elderly, who extensively cover their body
with clothing for cultural reasons, and who commonly use sunscreen are at an increased risk of
vitamin D deficiency (45). Another matter of concern for vegans is that vitamin D2, the form of
vitamin D acceptable to vegans, is substantially less bioavailable than the animal-derived vitamin
D3 (69).

In Finland, the dietary intake of vitamin D in vegans was insufficient to maintain serum 25-
hydroxyvitamin D and parathyroid hormone concentrations within normal ranges in the winter,
which appeared to have a negative effect on long-term BMD (28). Throughout the year serum
25-hydroxyvitamin D concentrations were lower and parathyroid hormone higher in vegan
women than in omnivores and other vegetarians. BMD in the lumbar region of the spine was
12% lower in vegans than in omnivores.

Iron

Heme iron absorption is substantially higher than non-heme iron from plant foods. However,
hemoglobin concentrations and the risk of iron deficiency anemia are similar for vegans
compared with omnivores and other vegetarians (70). Vegans often consume large amounts of
vitamin C–rich foods that markedly improve the absorption of the nonheme iron. Serum ferritin
concentrations are lower in some vegans, whereas the mean values tend to be similar to the mean
values of other vegetarians but lower than the mean value for omnivores (71). The physiologic
significance of low serum ferritin concentrations is uncertain at this time.

Vitamin B-12

Compared with lactoovovegetarians and omnivores, vegans typically have lower plasma vitamin
B-12 concentrations, higher prevalence of vitamin B-12 deficiency, and higher concentrations of
plasma homocysteine (72). Elevated homocysteine has been considered a risk factor for CVD
(73) and osteoporotic bone fractures (74). Vitamin B-12 deficiency can produce abnormal
neurologic and psychiatric symptoms that include ataxia, psychoses, paresthesia, disorientation,
dementia, mood and motor disturbances, and difficulty with concentration (75). In addition,
children may experience apathy and failure to thrive, and macrocytic anemia is a common
feature at all ages.

Zinc

Vegetarians are often considered to be at risk for zinc deficiency. Phytates, a common
component of grains, seeds, and legumes, binds zinc and thereby decreases its bioavailability.
However, a sensitive marker to measure zinc status in humans has not been well established, and
the effects of marginal zinc intakes are poorly understood (76). Although vegans have lower zinc
intake than omnivores, they do not differ from the nonvegetarians in functional
immunocompetence as assessed by natural killer cell cytotoxic activity (14). It appears that there
may be facilitators of zinc absorption and compensatory mechanisms to help vegetarians adapt to
a lower intake of zinc (77).