Vegetarian diets in the Adventist Health Study 2: a review of initial

published findings1–4
Michael J Orlich and Gary E Fraser

ABSTRACT DIETARY PATTERNS

The Adventist Health Study 2 is a large cohort that is well suited to In the AHS-2, dietary patterns were defined along a vegetarian
the study of the relation of vegetarian dietary patterns to health and continuum, which can be thought of as an index of animal food
disease risk. Here we review initial published findings with regard to avoidance. Cohort members were not asked to self-identify as
vegetarian diets and several health outcomes. Vegetarian dietary pat- vegetarians. Rather, they were categorized on the basis of their
terns were associated with lower body mass index, lower prevalence reported intakes of key food items of animal origin (see Table 1 for
and incidence of diabetes mellitus, lower prevalence of the metabolic dietary pattern definitions). Defined in this manner, 7.7% of cohort
syndrome and its component factors, lower prevalence of hyperten-
members are vegan, 29.2% are lactoovovegetarian, 9.9% are
sion, lower all-cause mortality, and in some instances, lower risk of
pescovegetarian, 5.4% are semivegetarian, and 47.7% are non-
cancer. Findings with regard to factors related to vegetarian diets and
vegetarian. For some analyses, these 5 dietary patterns were col-
bone health are also reviewed. These initial results show important
lapsed to yield fewer categories; for example, in some cases, the 4
links between vegetarian dietary patterns and improved health.
vegetarian categories (vegan, lactoovovegetarian, pescovege-
Am J Clin Nutr 2014;100(suppl):353S–8S.
tarian, and semivegetarian) were combined together as “vegetar-
ian” (see Table 2 for select demographic, lifestyle, and nutritional
characteristics for each dietary pattern category at baseline).
INTRODUCTION
Much of the current understanding of the health effects of
vegetarian diets has come from a few cohort studies, especially in HEALTH OUTCOMES
California Seventh-day Adventists and British vegetarians. The The main aims of the AHS-2 are to examine the possible effects
Adventist Health Study 2 (AHS-2) is a relatively new large cohort of dietary factors on the risk of specific cancers. These analyses for
with a high proportion of vegetarians, which promises to add to specific cancers will begin this year after the accrual of further
that understanding. Here, we review the characteristics of AHS-2 incident cases to provide sufficient power. Meanwhile, several
and the initial published findings related to vegetarian diets. early publicationsfrom AHS-2 haveexamined the relation of diet to
certain other health outcomes. Herewe review findings relating diet
to prevalent obesity, prevalent metabolic syndrome, prevalent
COHORT CHARACTERISTICS hypertension, prevalent diabetes mellitus, incident diabetes mel-
litus, bone density and fracture risk, mortality, and incident cancer
The AHS-2 is a large North American cohort. Approximately
(considered as all cancers combined and by organ system). A
96,000 cohort members were enrolled throughout the United
summary of selected results is provided in Table 3.
States and Canada between 2002 and 2007. Recruitment for the
study was done in Seventh-day Adventist churches, and the vast
majority of cohort members identify themselves as Adventists. OBESITY
There was a special effort to recruit black subjects (including As in earlier studies (10–12), vegetarians in the AHS-2 have
African Americans and Caribbean Americans) as an important lower BMI values. Among 60,903 participants, crude mean baseline
group that has been underrepresented in scientific studies of diet
and health. Approximately 27% of the cohort members are black 1
From the Division of Cardiology, Department of Internal Medicine
in AHS-2, with the vast majority of others identifying as white. (GEF) and Department of Preventive Medicine (MJO), School of Medicine,
Sixty-five percent of subjects are women. The mean age at en- and the Department of Epidemiology, Biostatistics, and Population Medicine
rollment was 57 y. A calibration sample of more than 1100 (GEF), School of Public Health, Loma Linda University, Loma Linda, CA.
2
participants was selected by using a 2-stage weighted random Presented at the symposium “Sixth International Congress on Vegetarian
process, with approximately equal numbers of blacks and whites, in Nutrition” held in Loma Linda, CA, 24–26 February 2013.
3
Project support was obtained from the National Cancer Institute
which food and physical activity recalls, biometric measurements,
(1U01CA152939; GEF).
and biological samples for laboratory analysis were obtained for 4
Address correspondence and requests for reprints to MJ Orlich, Adventist
the purpose of validation and calibration of the cohort question- Health Study 2, 24951 North Circle Drive, Nichol Hall 2031, Loma Linda,
naire data. Butler et al (1) provide a more detailed description of CA 92350. E-mail: [email protected].
the cohort’s characteristics and recruitment. First published online June 4, 2014; doi: 10.3945/ajcn.113.071233.

Am J Clin Nutr 2014;100(suppl):353S–8S. Printed in USA. Ó 2014 American Society for Nutrition 353S
354S ORLICH AND FRASER
TABLE 1
Definitions and prevalence of dietary patterns in the Adventist Health Study 2
Dietary pattern

Vegan Lactoovovegetarian Pescovegetarian Semivegetarian Nonvegetarian

Prevalence (%) 7.7 29.2 9.9 5.4 47.7

All meats, including fish (servings) ,1/mo ,1/mo $1/mo $1/mo but #1/wk .1/wk
Nonfish meat (servings) ,1/mo ,1/mo ,1/mo $1/mo but #1/wk $1/mo
Fish (servings) ,1/mo ,1/mo $1/mo #1/wk Any amount
Eggs and dairy products (servings) ,1/mo $1/mo Any amount Any amount Any amount

BMIs (in kg/m2) were 23.6 for vegans, 25.7 for lactoovovegetarians, METABOLIC SYNDROME
26.3 for pescovegetarians, 27.3 for semivegetarians, and 28.8 for Rizzo et al (7) examined the relation of dietary patterns to
nonvegetarians (4). After adjustment for age, sex, and race, mean metabolic syndrome and its component risk factors in the cali-
BMIs were 24.1 for vegans, 26.1 for lactoovovegetarians, 26.0 for bration sample of the AHS-2 (n = 773). Diets were considered
pescovegetarians, 27.3 for semivegetarians, and 28.3 for non- in 3 categories: vegetarian (vegan plus lactoovovegetarian),
vegetarians among 73,308 participants (2). semivegetarian (pescovegetarian plus semivegetarian), and

TABLE 2
Select baseline characteristics by dietary pattern category
Dietary pattern

Vegan Lactoovovegetarian Pescovegetarian Semivegetarian Nonvegetarian

1,2
Age, (y) 57.9 6 13.6 57.5 6 13.9 58.8 6 13.7 57.8 6 14.1 55.9 6 13.1
Female sex1 (%) 63.8 64.9 68.0 69.7 65.3
Race, black1 (%) 21.0 13.6 39.1 17.8 34.0
Marital status, married1 (%) 75.6 76.3 73.1 71.5 70.3
Educational level1 (%)
High school or less 16.7 13.9 18.4 21.3 24.4
Trade, associate, some college 39.4 35.7 38.1 39.2 42.2
Bachelor’s degree 24.4 25.3 23.0 21.3 19.2
Graduate degree 19.5 25.1 20.5 18.3 14.1
Alcohol consumption1 (%)
None 98.8 96.8 92.5 92.4 83.4
Rare 0.6 1.8 4.0 4.2 7.5
Monthly 0.2 0.5 1.1 1.1 3.1
Weekly 0.3 0.7 1.9 2.0 4.7
Daily 0.1 0.2 0.5 0.3 1.3
Smoking1 (%)
Never 85.0 88.2 84.1 81.4 75.7
Former 14.9 11.7 15.5 18.3 22.3
Current 0.1 0.1 0.4 0.3 2.0
Exercise1,3 (%)
None 15.1 17.3 18.0 20.6 23.4
1–20 min/wk 16.2 18.6 16.8 20.5 20.0
21–60 min/wk 16.1 16.5 16.2 16.1 15.8
61–150 min/wk 27.8 26.8 27.5 24.5 23.6
$151 min/wk 24.8 20.8 21.6 18.3 17.2
Energy intake1,2 (kcal/d) 1897 6 729 1912 6 735 1939 6 772 1720 6 713 1884 6 773
Macronutrients4,5 (% of energy)
Carbohydrate 58.1 6 0.1 54.3 6 0.1 54.5 6 0.1 53.9 6 0.1 51.4 6 ,0.1
Fat 28.2 6 0.1 31.9 6 0.1 31.3 6 0.1 32.2 6 0.1 33.8 6 ,0.1
Protein 13.6 6 ,0.1 13.7 6 ,0.1 14.2 6 ,0.1 13.7 6 ,0.1 14.7 6 ,0.1
Select nutrients4,5 (g/d)
Total fiber 46.7 6 0.1 37.5 6 0.1 37.7 6 0.1 34.9 6 0.1 30.4 6 ,0.1
SFAs 11.6 6 0.1 16.0 6 0.1 15.8 6 0.1 17.4 6 0.1 19.9 6 ,0.1
Animal protein 3.1 6 0.2 12.2 6 0.1 16.0 6 0.2 17.6 6 0.2 31.8 6 0.1
1
Results from reference 2 (n = 73,308). Adjusted for age, sex, and race (as appropriate) by direct standardization.
2
Values are means 6 SDs.
3
Exercise defined as “vigorous activities, such as brisk walking, jogging, bicycling, etc, long enough or with enough intensity to work up a sweat, get
your heart thumping, or get out of breath.”
4
Results from reference 3 (n = 71,751). Mean nutrient intake values standardized to 2000 kcal/d, adjusted for age, sex, and race.
5
Values are means 6 SEs.
 REVIEW OF VEGETARIAN DIETS IN AHS-2 355S
TABLE 3
Summary of the association of vegetarian dietary patterns with selected health outcomes in the Adventist Health Study 2
Dietary pattern

Health Outcome1 Vegan Lactoovovegetarian Pescovegetarian Semivegetarian Nonvegetarian

Cross-sectional findings
BMI2 (4) (kg/m2) 23.6 6 4.4 25.7 6 5.1 26.3 6 5.2 27.3 6 5.7 28.8 6 6.3
Diabetes3 (4) [OR (95% CI)] 0.51 (0.40, 0.66) 0.54 (0.49, 0.60) 0.70 (0.61, 0.80) 0.76 (0.61, 0.80) Referent
Prevalence (%) 2.9 3.2 4.8 6.1 7.6
Hypertension [OR (95% CI)]
Nonblacks4 (5) 0.37 (0.19, 0.74) 0.57 (0.36, 0.92) 0.92 (0.70, 1.50) Referent
Blacks5 (6) 0.56 (0.36, 0.87) 0.94 (0.54, 1.63) Not reported Referent
Metabolic syndrome6,7 (7) [OR (95% CI)] 0.44 (0.30, 0.64) Not reported Referent
Prevalence6 (%) 25.2 37.6 39.7
Prospective findings
Diabetes8 (8) [OR (95% CI)] 0.38 (0.24, 0.62) 0.62 (0.50, 0.76) 0.79 (0.58, 1.09) 0.49 (0.31, 0.76) Referent
n 3545 14,099 3644 2404 17,695
Incident cases (%) 0.54 1.08 1.29 0.92 2.12
All cancers9 (9) [HR (95% CI)] 0.84 (0.72, 0.99) 0.93 (0.85, 1.02) 0.88 (0.77, 1.01) 0.98 (0.82, 1.17) Referent
n 4922 19,735 6846 3881 33,736
No. of events 190 878 276 182 1413
All-cause mortality10 (2) [HR (95% CI)] 0.85 (0.73, 1.01) 0.91 (0.82, 1.00) 0.81 (0.69, 0.94) 0.92 (0.75, 1.13) Referent
n 5548 21,777 7194 4031 35,359
No. of events 197 815 251 160 1147
1
Numbers in parentheses are reference numbers.
2
Values are means 6 SDs.
3
Logistic regression model, adjusted for age, sex, race, BMI, physical activity, education, income, sleep, television watching, and alcohol consumption.
4
Pescovegetarians and semivegetarians were considered together as partial vegetarians because of the small numbers in both categories (logistic
regression model, adjusted for age, sex, and exercise).
5
Vegans and lactoovovegetarians were considered together as vegetarians because of the small number of vegans (logistic regression model, adjusted for
age, sex, education, and physical activity).
6
Vegans and lactoovovegetarians were considered together as vegetarians because of the small number of vegans; pescovegetarians and semivegetarians
were considered together as semivegetarians because of the small numbers in both categories.
7
Logistic regression model, adjusted for age, sex, ethnicity, physical activity, smoking, alcohol consumption, and dietary energy.
8
Logistic regression model, adjusted for age, sex, race, BMI, physical activity, education, income, sleep, television watching, smoking, and alcohol
consumption (2-y follow-up).
9
Cox proportional hazards regression model, adjusted for age, race, family history of cancer, education, smoking, alcohol consumption, age at menarche,
pregnancies, breastfeeding, oral contraceptive use, hormone replacement therapy, and menopausal status (4.14-y average follow-up).
10
Cox proportional hazards regression model, adjusted for age, sex, race, smoking, exercise, personal income, educational level, marital status, alcohol,
geographic region, menopause (in women), and hormone therapy (in postmenopausal women) (5.79-y average follow-up).

nonvegetarian. In ANCOVA analysis, with adjustment for age, having hypertension were 0.37 (95% CI: 0.19, 0.74) and 0.57
sex, ethnicity, smoking, alcohol intake, physical activity, and (95% CI: 0.36, 0.92) for vegans and lactoovovegetarians, re-
dietary energy intake, significant differences between the dietary spectively, compared with nonvegetarians (5). Additional adjust-
groups were found for all of the metabolic syndrome compo- ment for BMI (a possible causal intermediate) attenuated the
nents except for HDL (triglycerides, diastolic blood pressure, results to 0.53 (95% CI: 0.25, 1.11) and 0.86 (95% CI: 0.51, 1.45),
systolic blood pressure, waist circumference, BMI, and glucose), respectively. A subsequent analysis (6) showed similar findings in
with vegetarians having more favorable levels in each case. black subjects (n = 592). In a logistic regression analysis that
Considering metabolic syndrome as a whole, the prevalence was adjusted for age, sex, education, and physical activity, the OR for
25.2%, 37.6%, and 39.7% for vegetarians, semivegetarians, and prevalent hypertension among vegetarians (vegans and lactoo-
nonvegetarians, respectively; and in logistic regression analysis vovegetarians combined) was 0.56 (95% CI: 0.36, 0.87) compared
with adjustment for the same potential confounders, vegetarians with nonvegetarians.
had 0.44 (95% CI: 0.30, 0.64) times the odds of having meta-
bolic syndrome as did nonvegetarians (7).
DIABETES MELLITUS
The relation of vegetarian diets to both prevalent and incident
HYPERTENSION diabetes mellitus has been examined in AHS-2. Prevalence of
Pettersen et al (5) examined the relation of dietary patterns to type 2 diabetes was 2.9% among vegans, 3.2% among lac-
prevalent hypertension among whites in the calibration sample toovovegetarians, 4.8% among pescovegetarians, 6.1% among
(n = 500). Diets were considered in 4 categories: vegans, lactoo- semivegetarians, and 7.6% among nonvegetarians (4). In logistic
vovegetarians, partial vegetarians (pescovegetarians plus semi- regression analysis, compared with nonvegetarians, the multi-
vegetarians), and nonvegetarians. In a logistic regression analysis variate adjusted (for age, sex, ethnicity, education, income,
that controlled for age, sex, and exercise, the adjusted ORs of physical activity, television watching, sleep habits, alcohol use,
356S ORLICH AND FRASER

and BMI) ORs for prevalent type 2 diabetes were 0.51 (95% servings soy milk/d compared with those not consuming soy
CI: 0.40, 0.66) for vegans, 0.54 (95% CI: 0.49, 0.60) for lac- milk was 0.44 (95% CI: 0.20, 0.98) (20). Thus, soy milk ap-
toovovegetarians, 0.70 (95% CI: 0.61, 0.80) for pescovegetarians, peared to be associated with improved bone health to a similar
and 0.76 (95% CI: 0.65, 0.90) for semivegetarians (4). degree as dairy products, suggesting that it may provide a useful
Among 41,387 participants who did not report having diabetes alternative to dairy in certain vegetarian diets. This finding may
mellitus at baseline, diabetes incidence was calculated from be related to the protein content of soy milk and, in the case of
a response to a follow-up questionnaire at 2 y. The percentage many fortified soy milks, the calcium content. The protein
who reported developing diabetes was 0.54% in vegans, 1.08% in content of unfortified soy milk is 3.27 g/100 g, compared with
lactoovovegetarians, 1.29% in pescovegetarians, 0.92% in 3.15 g/100 g for whole milk; the calcium contents of unfortified
semivegetarians, and 2.12% in nonvegetarians (8). In multivariate and fortified soy milks are 25 mg/100 g and 123 mg/100 g,
adjusted (for age, sex, education, income, television watching, respectively, compared with a calcium content of 113 mg/100 g
physical activity, sleep, alcohol use, smoking, and BMI) logistic for whole milk (21).
regression analysis, ORs for developing diabetes compared with
nonvegetarians were 0.38 (95% CI: 0.24, 0.62) for vegans, 0.62
(95% CI: 0.50, 0.76) for lactoovovegetarians, 0.79 (95% CI: 0.58, CANCER
1.09) for pescovegetarians, and 0.49 (95% CI: 0.31, 0.76) for Tantamango-Bartley et al (9) recently published an initial
semivegetarians (8). Similar analyses stratified by race found analysis of the association of dietary patterns with cancer in-
reductions in odds among blacks for the vegan (0.30; 95% CI: cidence in AHS-2. Because this was early follow-up, there was
0.11, 0.84) and lactoovovegetarian (0.47; 95% CI: 0.27, 0.83) not yet sufficient power to analyze the effect on specific cancers.
dietary patterns and among nonblacks for the vegan (0.43; 95% However, interesting results were shown in analyses of all in-
CI: 0.25, 0.74), lactoovovegetarian (0.68; 95% CI: 0.54, 0.86), cident cancers and of cancers categorized by organ system.
and semivegetarian (0.50; 95% CI: 0.30, 0.83) dietary patterns Among 69,120 participants included in the analysis, there were
(8). 2939 incident cancers. In multivariate adjusted (for age, race,
family history of cancer, education, smoking, alcohol, age at
menarche, pregnancies, breastfeeding, oral contraceptives, hor-
OSTEOPOROSIS mone replacement therapy, and menopause status) Cox pro-
The relation of diet to osteoporosis risk is complex, and the portional hazards regression analyses comparing all vegetarians
scientific understanding of it is incomplete. In particular, there is combined (vegans, lactoovovegetarians, pescovegetarians, and
conflicting evidence with regard to the relation of protein intake semivegetarians) with nonvegetarians, significant reductions in
(particularly animal protein) with bone density and fracture risk risk were found for all cancers (HR: 0.92; 95% CI: 0.85, 0.99) and
(13–18). Thorpe et al (19) examined the relation of protein-rich gastrointestinal system cancers (HR: 0.76; 95% CI: 0.63,0.90)
foods of both animal and plant origin to the incidence of wrist (9). When the 4 vegetarian groups were compared separately with
fracture over 25 y among 1865 women who were participants in the nonvegetarian referent group, reduced risk was found in
both the AHS-1 and AHS-2. Higher consumption of protein-rich vegans for all cancer (HR: 0.84; 95% CI: 0.72, 0.99) and for
foods of both animal and plant origin was found to be protective. female-specific cancers (HR: 0.66; 95% CI: 0.47, 0.92) and in
In Cox proportional hazards regression analysis, among those lactoovovegetarians for gastrointestinal system cancers (HR:
with the lowest consumption of animal protein (vegetarians), 0.75; 95% CI: 0.60, 0.92) (9).
those who consumed protein-rich plant foods more than once
per day had an HR of 0.32 (95% CI: 0.13, 0.79) for wrist
fracture compared with those consuming plant protein foods MORTALITY
,3 times/wk (19). Similarly, among those with the lowest A longevity advantage for those who consume vegetarian diets
consumption of plant protein foods, those who consumed meat was previously shown in the AHS-1 cohort (12, 22). On the other
.4 times/wk had an HR for wrist fracture of 0.20 (95% CI: 0.06, hand, a reduction in all-cause mortality has not been associated
0.66) compared with those not consuming meat (19). with vegetarian dietary patterns in the European Prospective
Dairy products are generally thought to be good sources of Investigation into Cancer and Nutrition–Oxford cohort (23).
dietary protein and calcium, raising the concern that reduced Orlich et al (2) examined the possible association of vegetarian
dairy product consumption among vegetarians, particularly dietary patterns with all-cause mortality and broad categories of
vegans, may increase the risk of osteoporosis. Many vegetarians cause-specific mortality in AHS-2. After a mean follow-up of
(and many nonvegetarians) use soy milk or other types of milk 5.79 y (n = 73,308), Cox proportional hazards regression anal-
substitutes to replace dairy consumption. Matthews et al (20) ysis (adjusting for age, race, sex, smoking, exercise, education,
examined whether soy milk consumption might confer similar marital status, alcohol, geographic region, menopause, and
benefits on bone health as dairy product consumption. Among hormone therapy) showed reduced all-cause mortality for all
337 postmenopausal white women from AHS-2 evaluated for vegetarians compared with nonvegetarians (HR: 0.88; 95% CI:
osteoporosis by broadband ultrasound attenuation of the calca- 0.80, 0.97). For specific dietary patterns, the HRs were 0.85
neus, the multivariate adjusted OR for osteoporosis for those (95% CI: 0.73, 1.01) for vegans, 0.91 (95% CI: 0.82, 1.00) for
consuming $1 servings dairy products/d compared with those lactoovovegetarians, 0.81 (95% CI: 0.69, 0.94) for pescovege-
consuming dairy less than twice per week was 0.38 (95% CI: tarians, and 0.92 (95% CI: 0.75, 1.13) for semivegetarians. Ef-
0.17, 0.86) (20). These analyses come from a logistic regression fects were stronger in men and less often significant in women.
model in which both soy milk consumption and dairy product Apparent beneficial associations were seen in some cases for
consumption were included. The OR for those consuming $1 mortality from cardiovascular, renal, and endocrine diseases (2).
 REVIEW OF VEGETARIAN DIETS IN AHS-2 357S
DISCUSSION is beyond the scope of this brief review; however, we offer a few
Because of its relatively large number of vegetarians, the AHS- comments.
2 is a valuable cohort for the study of the possible effects of Adiposity is a core feature of the metabolic syndrome and an
vegetarian dietary patterns on various health outcomes. The important risk factor for diabetes mellitus, cardiovascular dis-
initial published results, reviewed previously, show a number of ease, and certain cancers. Thus, the stepwise increase in BMI
apparent health benefits of vegetarian diets. Vegetarian diets in values from vegan (lowest) to nonvegetarian (highest) presented
AHS-2 are associated with lower BMI values, lower prevalence here is noteworthy and may serve as an important intermediate in
of hypertension, lower prevalence of the metabolic syndrome, pathways of causation leading from dietary pattern to disease.
lower prevalence and incidence of diabetes mellitus, and lower The reason for this BMI gradient is not well understood. Caloric
all-cause mortality. Initial analyses also showed possible mod- intakes are similar among the 5 dietary pattern groups (3).
erate reductions in the rates of certain cancer outcomes for some Significant differences in BMI persist after control for both di-
vegetarians. The bone health research presented here links in- etary energy intake and physical activity (7). Vegetarian diets
adequate protein amounts to an increased risk of osteoporosis and may result in differences in energy absorption and utilization that
fractures; however, it appears to show that plant sources of lead to differences in BMI. The results for diabetes mellitus
protein, like animal sources, decrease this risk. reviewed here are interesting in that significant reductions in risk
As with all observational research, caution must be exercised for vegetarians remained after BMI was controlled for. Some of
in inferring causation from the results reviewed here. Although this remaining effect may still be mediated by differences in
appropriate attempts at adjustment for possible confounders were adiposity not fully captured by BMI (central adiposity, visceral
made in each case, it remains possible that some uncontrolled adiposity); however, mechanisms entirely independent of adi-
confounding may explain all or part of these findings. Mea- posity may also be in effect.
surement error is another challenge and potential source of bias in Differences in the intake of specific nutrients may mediate
nutritional studies (24), but this would seem less likely to affect some of the effects of vegetarian dietary patterns. For example,
analyses by broad dietary pattern than analyses according to the vegetarians have higher intakes of potassium (3), which is
intake of specific foods or nutrients. considered an important micronutrient for the prevention of
Although large, high-quality clinical trials examining the ef- hypertension. Tantamango-Bartley et al (9) provided a discussion
fects of vegetarian dietary patterns on major health outcomes of many possible mechanisms linking vegetarian dietary patterns
have not been conducted as they have for the Mediterranean to reduced cancer risk; in particular, they discussed the possibility
dietary pattern (25, 26), small interventional studies provide that increased soy consumption among vegetarians could be
indirect support for some findings presented here, particularly in relevant to their finding of a reduction in risk of female-specific
regard to reduced weight (27–32), improvements in serum lipid cancers among vegans (9).
concentrations (33–37), and improvements in control of diabetes
mellitus (27, 38, 39) with vegetarian diets. ONGOING AHS-2 RESEARCH
The dietary patterns described here are defined according to
The primary aim of the AHS-2 is to investigate potential
the avoidance of certain foods of animal origin. However, the
connections between dietary factors and the risk of specific
shown associations may not always be related to reduced animal
cancers. To this end, we are attempting record linkages with the
product consumption. They may also result from an increase in
cancer registries of all 50 states and all Canadian provinces,
nutritional components related to plant foods, such as the in-
something that, to our knowledge, has not previously been done.
creased fiber intake (Table 2). There may also be considerable
This process is well advanced, and we anticipate important
heterogeneity of food and nutrient consumption within each
publications on the relation of diet to specific major cancers
vegetarian-spectrum dietary pattern, as we have previously
starting in 2014. We are hopeful that these ongoing and future
discussed (40), so additional analyses by food, nutrient, or dietary
analyses will add to our understanding of the relation of vege-
indexes will be of value. As with all diets, vegetarian diets should
tarian dietary patterns to health and longevity.
be carefully planned for nutritional adequacy. Nutrients of
possible concern for vegetarian diets include vitamin B-12 The authors’ responsibilities were as follows—GEF and MJO: designed
(particularly for vegans), iron, calcium, zinc, vitamin D, and the research; MJO: wrote the manuscript; and GEF: had primary responsi-
protein (41). Rizzo et al (3) analyzed the nutrient profiles of the bility for the final content. Neither of the authors declared a possible conflict
5 dietary patterns described here in detail and reported consid- of interest.
erable variation by diet pattern. In no cases were mean values of
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