dietS &

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SCIENCE OF MEDICINE MiniSerieS

a look at Plant-Based diets

by Julia Clem, MD & Brandon Barthel, MD

introduction which can promote weight loss

A high sugar, high fat, and ameliorate many so-called
processed food-laden diet has lifestyle diseases. Physicians need to
a well-planned diet of contributed significantly to the understand the benefits and possible
plant-based whole foods burden of obesity and chronic risks of alternative diets in order to
incorporating a variety disease in America. Not only effectively counsel patients on their
of vegetables, whole do Americans consume fewer adoption.
grains, nuts, and legumes than the recommended daily
can be one tool to help servings of fruit and vegetables, Plant-Based diets through
physicians and patients but the average American eats the ages
address the chronic approximately 200 pounds of red Throughout human history,
lifestyle diseases with meat and poultry each year.1 This different groups have adhered
which many struggle. volume is higher than needed to plant-based diets. In ancient
to meet the average daily calorie Greece, the philosopher Pythagoras
and protein requirements of a extolled the health benefits of a
healthy diet. According to recent vegetarian diet and taught that
data published by the Centers for animal slaughter was immoral. This
Disease Control (CDC), just over tenet was based on his belief that
42% of Americans are obese.2 the immortal soul was reincarnated
Rates of obesity-related diseases after death of the body. He and his
such as cardiovascular disease, disciples ate a simple diet of bread,
hypertension, and type 2 diabetes honey, and vegetables. Thus, until
mellitus are at an all-time high. the 1800s, a plant-based diet was
These common chronic diseases are known widely as the Pythagorean
known to be heavily impacted by Diet. Many religions feature a long
diet and lifestyle. As a result, many tradition of adhering to a vegetarian
people are looking to modify their diet, including both Buddhism and
diets for weight loss and improve Jainism. Much like Pythagoras’s
their overall health. followers, these religions approach
Many Americans will go to the plant-based diet through the
extreme lengths to lose weight, as lens of nonviolence. In contrast, in
is evident from the proliferation the mid-1800s, the newly formed
of fad diets like the South Beach Seventh-Day Adventist Church
diet and the cabbage soup diet. advocated a vegetarian diet for its
Many physicians recommend plans adherents, although its aim was
Julia Clem, MD, is a graduate of
University of Missouri–Kansas City School such as the Mediterranean diet to promote personal health and
of Medicine (UMKC SOM) and is now to help patients manage chronic longevity rather than adhere to an
a Family Medicine Resident at the
Indiana University School of Medicine,
comorbidities and pursue their ethical framework.
Indianapolis, Indiana. Brandon Barthel, health goals. Though perhaps less Today, plant-based eating
MD, (above), is Assistant Professor of often recommended by physicians, continues to be popular. The
Medicine in Internal Medicine and
Endocrinology, Truman Medical Center a whole food, plant-based diet is number of Americans who follow
at UMKC SOM. another evidence-based option a vegan diet increased 600% from

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2014 to 2018.3 Interest in plant-based diets is driven studies that researched how a plant-based diet affects
by a number of factors. Many choose a plant-based cardiovascular outcomes.
diet in the pursuit of health, out of concern for animal The Lifestyle Heart Trial examined the relationship
welfare, or as a way to reduce their environmental between atherosclerosis and diet. In this study, patients
footprint. Some have also been driven in part by with cardiac disease were switched from their standard
celebrity endorsement, media attention, and popular omnivorous diets to either a plant-based diet or the
documentaries. Regardless of the reasons for their American Heart Association Diet, which is the current
change, more Americans than ever are seeking to standard of care dietary intervention. The study found
incorporate more plant-based foods into their diet. that 34% more patients on the plant-based diet had
As interest in plant-based diets has grown, so too reduction of atherosclerosis than those on the diet
has the market. Many restaurants are incorporating recommended by the American Heart Association.8
meat alternatives into their options, with some crafting A meta-analysis featuring seven prospective
and marketing dedicated plant-based menus. Items cohort studies reviewed heart health in vegetarians vs.
like the Beyond Burger® are popular among vegans and omnivores. The analysis concluded that those who do
meat-eaters alike. In grocery stores, plant-based egg, not consume meat have significantly lower rates of both
cheese, and milk alternatives have driven sales. The ischemic heart disease and all-cause mortality.9
interest in plant-based alternatives is evident; the plant- In a combined evaluation of five prospective
based foods market has increased 29% in the U.S. analyses comparing omnivore vs. vegetarian rates of
between 2017 and 2019.4 death from ischemic coronary disease, vegetarians were
found to have 24% lower rates of death from ischemic
obesity heart disease than those who ate meat after controlling
There are many benefits to consuming a diet high for factors such as smoking status, age, and gender.10
in fresh fruits and vegetables, one being better weight A recent experimental study swapped amateur
control. Multiple studies have linked plant-based diets athletes’ omnivorous diets to a vegan diet and studied
to a lower BMI, and experimental data has shown that the athletes’ cardiac structure via echocardiogram prior
switching to a plant-based diet can help with weight to and following the diet. This study suggested that
loss. One example is a 16-week randomized control actual structural remodeling of the heart can occur
clinical analysis published in 2018.5 This study assessed when switching from an omnivorous diet to a plant-
whether a diet void of animal protein and rich in plants based diet.11 This structural remodeling of the heart,
would affect one’s body fat percentage, body mass index albeit noted in healthy athletes, may play a role in the
(BMI), and degree of insulin resistance. Participants documented improvement of health in those with
were counseled not to change their physical activity cardiovascular disease who adapt a plant-based diet.
level, and those in the control group continued their
previous omnivorous diets. The findings demonstrated type ii diabetes Mellitus
an association between eating plant-based protein and Evidence suggests that a plant-based diet can help
decreased BMI, lower visceral fat, and improved insulin patients with type II diabetes achieve weight loss and
resistance.5 A systematic review published in January improve glycemic control. The American Diabetes
2020 analyzing 40 diet- and weight-related case studies Association (ADA) Standards of Medical Care in
or cohort studies reported that those following a vegan Diabetes recognizes a plant-based diet as a viable
diet were less likely than those following any other diet option for patients with type II diabetes.12 Multiple
to be overweight and had lower BMIs.6 studies have shown an inverse relationship between a
vegan diet and type II diabetes.13 Research published
cardiac Health in the Journal of Nutritional Medicine in 1994 studied
In addition to helping improve insulin sensitivity 21 patients with type II diabetes who simultaneously
and decrease BMI, a vegan diet may reduce risk of changed to a diet free of animal products and began an
cardiovascular disease and improve cardiac function. exercise regimen.14 Notable improvements included a
This is of particular importance given that the CDC decrease in triglycerides, total cholesterol, fasting blood
ranked heart disease as the leading cause of death in glucose, and insulin resistance. Within two weeks,
the United States in 2020.7 There have been many participants’ fasting blood glucose dropped an average

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The Many Variations of a Plant-Based Diet

Vegetarian: Also known as ovo-lactovegetarian, this diet
includes all plant-based foods, as well as allowing eggs
and dairy.

Vegan: This is a diet that consists of plant-based foods

only and excludes meat, dairy, eggs, and often honey.
Many who follow this lifestyle do so for ethical or
environmental reasons, and other lifestyle modifications
are typically included in addition to the dietary changes.

Pescatarian: This is a largely vegetarian diet that also

includes seafood.

Whole-foods, plant-based (WfPB): Extremely similar to a

vegan diet, this diet eschews the ethical baggage and
focuses on the health aspect. High in fruit, vegetables
and whole grains while typically low in fat.

flexetarian: This is a broad term used by those who

primarily follow a vegetarian or plant-based diet, but
allow for some meat, dairy, and seafood on occasion.

of 35%, and five participants improved so much that Hypertension

they no longer required glucose-lowering medications. A meta-analysis and systematic review of 24
During long-term follow-up for four years, 17 out of studies published between the years 1984 and 2019
the 21 patients had remained on the vegan diet and was conducted to analyze the effect that dietary
continued with an exercise program. These patients changes had on blood pressure in patients with type II
continued to have improved glycemic control. diabetes.16 The vegan diet was reviewed alongside other
Whereas meat consumption has been linked to popular diets including the Dietary Approaches to Stop
an increased risk of developing diabetes, higher intake Hypertension (DASH) diet and the Mediterranean
of fruits and vegetables has been shown to reduce the diet. All dietary changes were analyzed against a
risk by as much as 50%. A prospective 10-year-long control, defined as patients making no dietary changes.
case-cohort study of over 300,000 individuals found an The vegan diet, along with several others, was found
inverse relationship between the amount of fruits and to significantly lower both systolic and diastolic blood
vegetable servings eaten per day and risk of developing pressure.
type II diabetes mellitus.15 This research, published A similar systematic review published in 2020
in BMJ in July 2020, found that increased produce found that a vegan diet is associated with a significant
intake was linked to higher levels of plasma vitamin decrease in blood pressure in those with hypertension
C and carotenoids, markers of vegetable and fruit (WMD = −3.118, 95% CI = −4.540, −1.696).17 Those
consumption, which was associated with decreased that followed either a vegetarian diet or a vegan diet
development of diabetes. Participants who developed reported decreases in blood pressure, although the
diabetes over the course of the study had markedly decrease was more significant in those that followed
lower biomarkers of fruit and vegetable intake than a fully vegan diet. High blood pressure contributes to
those who did not develop diabetes. Following a whole many other health complications and can compound
food plant-based diet, or simply increasing daily fruit the risks that those with diabetes already have.
and vegetable consumption, is one step individuals can Hypertension is an independent risk factor for both
take to reduce their risk of type II diabetes. heart disease and stroke; however, those with both

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diabetes and hypertension have the highest risk of fatal These studies suggest that plant-based diets may
stroke. With more emphasis on dietary change, patients decrease modifiable risk factors for certain cancers.
could see a substantial decrease in blood pressure
while decreasing polypharmacy and the side effects nutrient content of a Plant-Based diet
that anti-hypertensive medications can provoke. A plant-based diet is not always healthful. As the
interest in plant-based eating has risen, so have the
dyslipidemia options for plant-based “junk food” such as donuts
Consumption of dietary cholesterol found in and cinnamon rolls. Imitation meat, milk, egg, and
meat and dairy products contributes to atherosclerosis cheese products are typically lower in fat and calories
and heart disease. Since humans are capable of than their animal product counterparts, but they are
synthesizing all needed cholesterol, further dietary not necessarily nutritious. Attention must be paid to
intake is not required for optimal function. A study both the macro- and micro-nutrient content of any
published in May 2020 analyzed the correlation diet. A person could eat a diet that is plant-based yet
between meat consumption and low-density high in sugar, saturated fats, and highly processed food
lipoprotein (LDL) levels in patients diagnosed with products, thus negating some of the health benefits
coronary artery disease.18 The mean LDL level in of a plant-based diet. A healthful plant-based diet is
the omnivorous group was found to be 34.75 points one composed of high-quality whole foods like grains,
higher than the mean of the vegetarian group. fruits, vegetables, legumes, nuts, and seeds.
Similarly, a large review of vegetarian diets and health
outcomes, published in 2020, found there to be a fiber
clinically significant decrease in both total and LDL A startling 95% of Americans are deficient in
cholesterol levels in those who do not consume meat fiber, which is likely related to ingesting high amount
or fish products.13 High levels of LDL are known of processed foods, yet little fruit, vegetables, legumes
to increase both the risk and severity of coronary or whole grains.22 A plant-based diet is by nature
artery disease including heart disease, angina, and high in fiber, whereas animal products are devoid of
myocardial infarction. Therefore, reducing dietary fiber. All dietary sources high in fiber, such as beans,
cholesterol by eliminating meat and dairy from broccoli, berries, avocados, and apples, are plant-
one’s diet may represent one option to reduce risk of derived. Sufficient fiber intake is protective against
coronary disease. insulin resistance, hypertension, cancer, gastrointestinal
disease, obesity, heart failure and digestion-related
cancer disorders.23 The small proportion of Americans who
Although many studies have been inconclusive have adequate fiber intake are nearly all vegetarian or
as to whether or not vegetarian diets reduce risk of vegan, and incorporation of more plant foods into
various specific cancers, some studies have suggested the standard American diet could help provide some
that eating processed meats such as ham, bacon, mitigation against common chronic diseases.
and salami pose an increased risk of developing
cancer. In fact, the World Health Organization Protein
(WHO) classified processed meats as a Group 1 While a plant-based diet is rich in many
carcinogen and red meats as a Group 2 carcinogen.19 micronutrients that are missing from the standard
Examination has also identified heme iron, the iron American’s diet, care should be taken with any diet
obtained by eating animal tissue, to be a risk factor to ensure adequate intake of all vital nutrients. When
for colorectal cancer.20 Further recent research has considering a plant-based diet, the first component
suggested a dose-related effect between the amount many people think about is protein. While most people
of heme iron consumed and overall colorectal cancer equate protein with meat, dairy, and eggs, many plant
risk due to heme-mediated DNA damage. A cohort foods contain high amounts of protein as well. Brown
study in 2006 of French women concluded that rice, quinoa, beans, and legumes can be added as part
women whose diets were rich in meats had a greater of a plant-based diet to ensure adequate intake of all
likelihood of developing colorectal cancer than those essential amino acids. Americans tend to prioritize
who did not consume large amounts of red meat.21 protein, but according to the Institute of Medicine,

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only 10% to 35% of daily of calorie intake needs to mineral density (BMD) than those who eat meat,
be from protein.24 Most people have no issue meeting evidence published in late 2020 suggests that fracture
this goal. If protein is a concern, a plant-based diet can risk may be higher as well.27 Some, but not all of this
be augmented with increased content of high-protein increased risk was accounted for by differences in
plant foods. For those with high protein goals such as BMI, as obesity may be protective against fracture at
athletes, plant-based protein supplements are widely certain sites. However other recent research, including
available. a recent meta-analysis, failed to show an association
between increased dairy intake and prevention of
Micronutrients fractures.28 Therefore, it is unclear whether a plant-
One micronutrient that often raises concern in based diet – devoid of dairy – would increase fracture
a plant-based diet is vitamin B12. Some studies have risk. Regardless, it is prudent for those on a plant-based
shown that those on a plant-based diet are found to diet to ensure sufficient intake of calcium- and vitamin
have lower plasma vitamin B12 levels and higher levels D-containing foods. Careful attention to intake of
of vitamin B12 deficiency than those who consume fortified foods, such as plant-based milks, may be
animal products.6 Vitamin B12 is an important helpful.
cofactor in DNA synthesis, and deficiency can lead According to another recent study published in
to anemia and severe neurological dysfunction. It is the British Medical Journal, hemorrhagic stroke was
especially critical that pregnant persons ensure adequate cited as a risk for vegetarians and vegans.29 This study
Vitamin B12 levels, as a deficiency can lead not only compared the rates of stroke between meat eaters,
to neural tube defects, but long-term consequences in pescatarians, and vegetarians, and found a statistically
weight management and brain development affecting significant increase in hemorrhagic stroke in vegetarians
the unborn child past delivery into its adulthood.25 compared to meat eaters. Their research found that
Vitamin B12 is created by bacteria in the soil. vegetarians had “three more cases of total stroke
Due to current food processing procedures removing (95% confidence interval 0.8 to 5.4 more) per 1,000
this bacteria, vitamin B12 is primarily obtained population over 10 years.” However, it was found that
by consuming meat products. Fortunately, many risk of mortality from stroke was not significantly
modern foods, like breakfast cereals and nondairy higher or lower in vegetarians compared to meat eaters.
milks, are fortified with vitamin B12. In addition, This study also did not differentiate results between
vitamin B12 supplements are widely available and those eating dairy and eggs and those following purely
commonly found at health food stores and pharmacies. plant-based diets due to the small number of vegans
Some evidence suggests that vegans are also at risk enrolled. It is postulated that a low level of LDL, which
for deficiencies of other micronutrients, including is found primarily in animal products, may lead to
selenium, zinc, niacin, vitamin B2, vitamin B6, and increased risk of hemorrhagic stroke.30 Although the
calcium.6 Supplementation of vitamin B12 and other study was informative, these results of increased stroke
micronutrients is one way to ensure adequate intake risk have not been corroborated by further studies. This
and reduce the risk for developing deficiency while on same study found that vegetarians, including vegans,
a plant-based diet. However, a German study published had lower rates of myocardial infarction, ischemic heart
in 2020 compared serum levels of micronutrients of disease, obesity, high cholesterol, hypertension, and
36 omnivores and 36 vegans and found that there was diabetes.
no significant difference in vitamin B12 levels between
the two groups. This suggests that eating a variety of conclusion
fortified foods and taking a supplement is sufficient for As millions of Americans continue to struggle with
obtaining normal vitamin B12 levels.26 obesity, diabetes, and cardiovascular disease, many
continue to seek healthier alternatives to the typical
unresolved issues American diet. According to an expansive review
Recently published research has identified other published in 2020, plant-based diets “were associated
potential risks of a plant-based diet which deserve with a significantly reduced risk of negative health
further study. Whereas older studies have shown that outcomes with a pooled ES of 0.886 (95% CI: 0.848
persons following a plant-based diet have lower bone to 0.926; P < 0.001) without significant heterogeneity

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disclosure
studies. Am J Clin Nutr. 1999;70(3):516s-524s. doi:10.1093/ajcn/70.3.516s None reported. MM

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