Vegetarian Diet benefit and deficiencies
Vitamin requirements and shortcomings
Eating a Healthy Diet
January 4 2019 by Ray Sahelian, M.D.

An estimated 3 percent of adult Americans choose not to eat meat, poultry or fish, and a subset of those are vegans, who avoid all animal products including dairy and eggs. According to Vegetarian Times magazine, the In the West, there are now appreciable numbers of individuals who are classified as "vegetarian" (those who exclude meat, fish, and poultry) or "vegan" (those who exclude all foods of animal origin). A 2014 survey suggests that 3% of US adults adhere to a vegetarian-based diet and 0.5% of US adults consume no animal products at all. Similar figures have also been published for the United Kingdom 3% are completely vegetarian. Advantages include lower heart disease risk and lower blood pressure, Feb. 24, 2014, JAMA Internal Medicine article.

Vegetarian-based dietary patterns lead to lowered serum C-reactive protein and fibrinogen levels.

Supplements and vitamins that benefit those on a Vegan or Vegetarian diet
You are probably getting lots of important carotenoids, flavonoids, fiber, vitamins, minerals, and other beneficial nutrients, unless you are eating lots of simple carbohydrates. However, as a vegetarian or vegan, even if you have a good diet, you may still be missing some key nutrients if you don't consume animal or dairy products. Veg Power Rx could help you provide these missing nutrients to make you feel more energetic and vital. Vitamins and nutrients that are found in very small amounts in a plant based diet and could possibly be beneficial as supplements to a vegetarian or a vegan, include:

B12 vitamin, also known as methylcobalamin -- B12 is crucial for healthy red blood cells and the neural system, low levels lead to anemia. It is also involved in keeping homocysteine levels low.
Carnitine is a nutrient that helps with energy production in mitochondria and helps form acetylcarnitine.
   Eur J Nutr. 2016. Effect of L-carnitine supplementation on the body carnitine pool, skeletal muscle energy metabolism and physical performance in male vegetarians. More than 95% of the body carnitine is located in skeletal muscle, where it is essential for energy metabolism. Vegetarians ingest less carnitine and carnitine precursors and have lower plasma carnitine concentrations than omnivores. Sixteen vegetarians and eight omnivores participated in this interventional study with oral supplementation of 2 g L-carnitine for 12 weeks. Before carnitine supplementation, vegetarians had a 10% lower plasma carnitine concentration, but maintained skeletal muscle carnitine stores compared to omnivores. Skeletal muscle phosphocreatine, ATP, glycogen and lactate contents were also not different from omnivores. Oral L-carnitine supplementation normalizes the plasma carnitine stores and slightly increases the skeletal muscle carnitine content in vegetarians, but without affecting muscle function and energy metabolism.
CoQ10 is another nutrient crucial for energy metabolism within mitochondria.
Creatine is a nutrient that helps form stronger muscles and adds strength. Vegetarian body building enthusiasts could benefit from creatine. This supplement could also cognitive enhancement benefits.
Fish oils provide important omega3 fatty acids such as DHA and EPA. Alternatively, flax seed oil could be a partial substitute. Flax seed oil provides omega3 fatty acids that may be converted into EPA and DHA, but there is no guarantee that such conversion will occur in adequate amounts. If you wish to take DHA in fish oils from a vegetarian source, consider DHA from algae.
Iron - Iron deficiency can cause fatigue. Iron deficiency, even to a moderate degree, can hinder memory and learning -- but iron supplements can turn those problems around. Get iron by eating spinach, nuts, seeds, eggs and legumes.

By adding these supplements, a person on a vegetarian diet may notice having more energy and pep, and perhaps a feeling of uplifted mood. Even if no such effect is noticed, a vegan and vegetarian will do their body good by providing these missing nutrients as part of a life long health maintenance.

Vegans should eat nuts, seeds, legumes and whole-grain breads and cereals to get enough protein. Vegetarians who eat sufficient eggs and dairy products needn't be worried about protein deficiency.

Reduced risk for cancer by Ray Sahelian, M.D.
Analysis of data from 52,700 men and women shows that those who did not eat meat had significantly fewer cancers overall than those who did. But surprisingly, the researchers also found a higher rate of colorectal cancer - a disease linked with eating red meat - among the vegetarians. In this study, researchers looked at men and women aged 20 to 89 recruited in the UK in the 1990s. They divided participants into meat-eaters, fish-eaters, vegetarians and vegans. There was a significantly lower incidence of all cancers among the fish-eaters and vegetarians compared with the meat eaters. For colorectal cancer, however that trend was reversed with vegetarians having a significantly higher incidence of the condition than the other groups. American Journal of Clinical Nutrition, March 2009. There does not seem to be a good explanation why this particular study found a higher rate of colon cancer in vegetarians.

Dig Dis Sci. Dec 10 2013. Vegetarianism as a Protective Factor for Colorectal Adenoma and Advanced Adenoma in Asians. The purpose of this study was to examine the protective effect of a vegetarian diet against colorectal adenoma and advanced adenoma. This cross-sectional study compared the prevalence of colorectal adenoma among Buddhist priests, who are obligatory vegetarians, with that among age and sex-matched controls. All the subjects underwent health checkups in a health-promotion center in Korea. Colorectal adenoma and advanced adenoma were both more prevalent in the general population group than in the Buddhist priest group (25.2 vs. 17.9 %, 6.7 vs. 2.0 %). However, the prevalence of metabolic syndrome, high body mass index, and waist circumference were higher in the Buddhist priest group. According to univariate analysis, non-vegetarian diet (general population) significantly increased the prevalence of colorectal adenoma and advanced adenoma compared with a vegetarian diet (Buddhist priests). In a conditional regression analysis model, non-vegetarian diet was also a significant risk factor for colorectal adenoma and advanced adenoma. Vegetarianism may be effective in preventing both colorectal adenoma and advanced adenoma in Asians.

A vegetarian diet reduced the risk of colorectal cancer.

Homocysteine and Vitamin B12
Those on a vegetarian diet have considerably higher levels of total plasma homocysteine, greater prevalence of hyperhomocysteinemia and lower levels of serum vitamin B12 than do non-vegetarians. Clinicians from several Veronese Research Units designed a comparative study of fasting total plasma homocysteine levels in vegans, lacto-ovovegetarians and control subjects. In addition, they evaluated the relationship between these levels and nutritional variables in vegetarians. Participants included 45 vegetarians with an average age of 46 years, composed of 31 vegans, (19 males, 12 females) and 14 lacto-ovovegetarians (six males, eight females). They were compared with 29 control subjects composed of 19 males and 10 females. High performance liquid chromatography was used to evaluate the total plasma homocysteine. Considerably higher homocysteine levels were noted in vegetarians by comparison with controls. Its prevalence was also higher in vegetarians compared with controls. However, vegetarians had a lower serum vitamin B₁₂ by comparison with control subjects.

Carnitine food sources
L-carnitine, is a naturally occurring substance found in most cells of the body, particularly the brain and neural tissues, muscles, and heart. Carnitine, whose structure is similar to choline, is widely available in animal foods (meat, poultry, fish and dairy products), whereas plants have very small amounts. A vegetarian diet may not provide sufficient carnitine for optimal metabolism.

CoQ10 for energy
CoQ10 is a naturally occurring nutrient found in each cell of the body. CoQ10 was first identified by University of Wisconsin researchers in 1957. CoQ10 -- or spelled also CoQ 10 -- is found in foods, particularly in fish and meats. In addition to playing a significant role in the energy system of each of our cells, CoQ10 is also believed to have antioxidant properties. Many who take CoQ10 notice that this nutrient enhances physical energy. A vegetarian diet may not provide sufficient Coenzyme Q10 for optimal metabolism.

Creatine for muscle growth and strength
Vegetarians, particularly those who are on a strict lacto-ovo-vegetarian diet do not ingest much creatine since creatine is mostly found in meats, fish, and chicken. Creatine helps muscle stay bulky and strong. In a study published in the Journal of Sports Nutrition and Exercise Metabolism, thirty-two healthy men, who regularly consumed an omnivorous diet, were split into two groups. One group consumed a lacto-ovo-vegetarian diet while the other group had an omnivorous diet (they ate everything). The study lasted 26 days. In addition to their diet, on day 22 of the study, subjects were assigned in a double-blind manner to receive either creatine monohydrate 0.3 g per kilogram of body weight per day or an equivalent dose of placebo for 5 days. The results demonstrated that consuming a lacto-ovo-vegetarian diet for 21 days decreased muscle creatine concentration in individuals who normally consume meat and fish. However, the creatine content of muscle in the lacto-ovo-vegetarian diet group returned back to normal after a period of only 5 days. Dr. Sahelian says: A person on a vegetarian diet may consider supplementing with creatine monohydrate.

Effect of a defined lacto-ovo-vegetarian diet and oral creatine monohydrate supplementation on plasma creatine concentration.
J Strength Cond Res. 2005. School of Family, Consumer and Nutrition Sciences, Northern Illinois University DeKalb, Illinois
This study examined the effects that preceding creatine supplementation with a lacto-ovo-vegetarian diet would have on plasma creatine concentration. Twenty-six healthy moderately fit omnivorous men were assigned to either a 26-day lacto-ovo-vegetarian or omnivorous (Omni) diet. On day 22, subjects were also assigned in a double-blind manner either creatine monohydrate (CM; 0.3 g.kg.day + 20 g Polycose) or an equivalent dose of placebo for 5 days. Consuming a lacto ovo vegetarian diet for 21 days was effective in reducing plasma creatine concentration. Regardless of diet, the creatine monohydrate group showed an increase in plasma creatine concentrations, whereas the placebo group's levels remained the same.

Weight lifters and athletes don't have to eat meat to build muscle. Eggs and dairy products are complete proteins, which contain nine essential amino acids. Eat small amounts of protein throughout the day, so your body always has what it needs.

Zinc and Vegetarian Diet
Total zinc absorption in young women, but not fractional zinc absorption, differs between vegetarian and meat-based diets with equal phytic acid content.
Br J Nutr. 2006. Department of Human Nutrition, Center for Advanced Food Studies (LMC), The Royal Veterinary and Agricultural University, Rolighedsvej Frederiksberg C, Denmark.
Zinc bioavailability is often lower in a vegetarian diet mainly due to low Zinc and high phytic acid contents. The objective of the present study was to determine the fractional and total absorption of Zinc from a vegetarian diet in comparison with meat diets with equal concentrations of phytic acid. In conclusion, the vegetarian diet compared with the meat-based diets resulted in lower amounts of absorbed Zinc due to a higher content of Zinc in the meat diets.

DHA Supplement for a Vegetarian Diet
Docosahexaenoic acid supplementation in vegetarians effectively increases omega-3 index: a randomized trial.
Lipids. 2005. Division of Metabolic Diseases and Nutrition, Dr. von Hauner Children's Hospital, Ludwig Maximilians University of Munich, Munich, Germany.
Low red blood cell (RBC) membrane content of EPA + DHA (hereafter called omega-3 index) has recently been described as an indicator for increased risk of death from coronary heart disease. Healthy vegetarians consumed daily a microalgae oil from Ulkenia sp. (0.94 g DHA  per day) or olive oil (placebo) for 8 wk. DHA supplementation significantly increased DHA in RBC total lipids and in plasma phospholipids whereas EPA levels rose to a much lesser extent. Microalgae oil supplementation increased the omega-3 index from 4.8 to 8.4 wt%. After intervention, 69% of DHA-supplemented subjects (but no subject of the placebo group) reached an omega-3 index above the desirable value of 8 wt%. We conclude that an 8-wk supplementation with 0.94 g DHA/d from microalgae oil achieves a beneficial omega-3 index of > or =8% in most vegetarian diet subjects with low basal EPA + DHA status.

Healthy Vegetarian Diet
Vegetarian diets do not contain meat, poultry or fish; vegan diets further exclude dairy products and eggs. Vegetarian and vegan diets can vary widely, In general, vegetarian diets provide relatively large amounts of cereals, nuts, fruits and vegetables, but some vegetarians have the problem with excessive sugar consumption. In terms of nutrients, vegetarian diets are usually rich in carbohydrates, n-6 fatty acids, dietary fiber, carotenoids, folic acid, vitamin C, vitamin E and Magnesium, and relatively low in protein, saturated fat, long-chain n-3 fatty acids such as EPA and DHA, retinol, vitamin B(12) and Zinc. Vegetarians and vegans have a relatively low BMI and a low plasma cholesterol concentration; but higher plasma homocysteine concentrations than in non-vegetarians. Vegetarians have a lower rate of mortality from heart disease but little difference in other major causes of death or all-cause mortality in comparison with health-conscious non-vegetarians from the same population. Studies of cancer have not shown clear differences in cancer rates between vegetarians and non-vegetarians. Perhaps the low intakes of EOA, DHA, and some of the other nutrients found in Veg Rx could lead to a vegetarian being healthier.

Osteoporosis and bone strength
Vegetarian diets, particularly vegan diets, are associated with lower bone mineral density, but the magnitude of the association is clinically insignificant. American Journal of Clinical Nutrition, 2009.

Weight Loss
Switching to a meat-free diet is one way to keep your weight down. Researchers who studied the eating habits of 22,000 people over five years, including meat eaters and vegetarians, found they all put on a few kilos but meat eaters who changed to a vegetarian or vegan diet gained the least. The research compared weight gain among meat eaters, fish eaters, vegetarians and vegans - who eat no animal products. It showed that on average people gained 2 kilos (4.4 lb) over five years. None of the volunteers was overweight. The weight gain was less in the vegans than in the meat-eaters and somewhere in between in the other groups. The lowest weight gain was in people who changed their diet to eat fewer animal products. Exercise was another important factor in controlling weight. The data also showed that people who became more physically active during the five-year period gained less weight than people who did very little exercise.  The findings are from the British arm of EPIC (European Prospective Investigation into Cancer and Nutrition), which is comparing the diets of 500,000 people in 10 countries to discover how diet is linked to cancer. The EPIC study has already revealed that diabetics have three times the normal risk of developing colorectal cancer, which kills more than 490,000 people worldwide each year. It also showed that diet is second only to smoking as a leading cause of cancer, and, along with alcohol, is responsible for nearly a third of cancer cases in developed countries.

People on strict raw food vegetarian diets are thin but healthy. Although nutritionists and the food industry have warned that a diet without dairy foods can lead to the bone-thinning disease osteoporosis, a team at Washington University School of Medicine in St. Louis found the vegans they studied had many of the signs of strong bones. Raw food vegetarians believe in eating only plant-derived foods that have not been cooked, processed, or otherwise altered from their natural state. Researchers expected the vegans to have low vitamin D levels because they avoid dairy products, which are fortified with the vitamin. But in fact their vitamin D levels were "markedly higher" than average. Vitamin D is made by the skin when the body is exposed to sunlight and is key to keeping strong bones. And the vegans had low levels of C-reactive protein, an inflammatory molecule that is linked with the risk of heart disease, diabetes and other chronic disease. Furthermore, they had lower levels of IGF-1, a growth factor linked to risk of breast and prostate cancer.

Vegetarian Diet and Menopause
Effects of long-term vegetarian diet on cardiovascular autonomic functions in healthy postmenopausal women.
Am J Cardiol. 2006. Department of Neurology, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan.
We hypothesized that long-term vegetarian diets might modulate cardiovascular autonomic functions measured by frequency-domain techniques in healthy postmenopausal women. A total of 35 healthy vegetarians  who had been vegetarians for greater or =2 years and 35 omnivores participated in this study. These subjects were all postmenopausal without hormone replacement therapy. Fluctuations in arterial blood pressure and heart rate variability were diffracted into low-frequency (0.04 to 0.15 Hz) and high-frequency (0.15 to 0.4 Hz) segments. Cardiovascular autonomic functions and baroreflex sensitivity were evaluated by specific frequency-domain measures. The vegetarians had statistically lower systolic and diastolic blood pressure, and lower serum total cholesterol, low-density lipoprotein cholesterol, triglycerides, fasting blood sugar, and hemoglobin levels compared with the nonvegetarians. They also exhibited a significantly higher high-frequency power of heart rate variability and increased baroreflex sensitivity than did omnivores. No statistical differences were found in the low-frequency/high-frequency ratio or percentage of low frequency of heart rate variability between the 2 groups. In conclusion, in addition to the lower blood pressure and lipid concentrations in vegetarians, long-term vegetarian diets may facilitate vagal regulation of the heart and increase baroreflex sensitivity in healthy postmenopausal women, without increasing the sympathetic modulations of the cardiovascular system.

Vegetarian athlete
Q Are there any cautions that vegetarian athletes should be aware of when choosing vitamin supplements - and what are they?
   A. There are no specific cautions regarding vegetarian athletes compared to non-vegetarian athletes in terms of supplement use. A general caution is that higher amounts of supplements are not necessarily better. Too many supplements can sometimes cause irritability, increased body temperature, increased heart rate and insomnia. All these could reduce performance.

Q. Are there any specific ingredients to "watch out for" when reading a supplement label in terms of a vegetarian athlete?
   A. Much depends on the dosage rather than the individual ingredients. Many formulas may include a dozen or two ingredients, some in very small dosages. Therefore, this would not negate the use of the formula.

Research points to iron, calcium, zinc, copper and magnesium as being possible deficiencies in vegetarian athletes. What do you recommend for active women in regards to knowing whether or not they're deficient? And are there certain nutrients (like carnitine or creatine) that should be used as a supplement?
    Certain nutrients are deficient in a vegetarian diet. A product called Veg Rx has most of the nutrients that a vegan or vegetarian is likely to have a deficiency in. The ingredients in Veg Rx include Vitamin D, Vitamin B2, Vitamin-B12, Iron, Iodine, Zinc, Calcium, CoQ10, Creatine and Carnitine.

Vegetarian restaurants
For a guide to vegetarian and vegan restaurants around the world, see HappyCow dot net

Returning to meat consumption
Vegetarians often go back to eating meat, according to research conducted by the Humane Research Council. The study, which involved more than 11,000 U.S. adults, showed eighty-four percent of vegetarians go back to eating meat or other animal products. Forty-three percent said the diet was just too difficult to maintain, and 63 percent said they didn’t like that their diet made them stand out in a crowd. Of those who are currently vegetarians or vegans, almost 75% are women. Vegetarians / vegans are also slightly more likely to be politically liberal and less likely to practice any religion.

Research
Diet, vegetarian food and prostate carcinoma among men in Taiwan.
Br J Cancer. 2005.
Chia Nan University of Pharmacy and Science, 60 Erh-Jen Road, Jen Te, Tainan, Taiwan 717, Taiwan.
In a case-control study in a veterans hospital in Taiwan, we compared 237 histology-confirmed prostate carcinoma cases with 481 controls, frequency matched by age, for their consumption of vegetarian food, namely soybean products, rice, wheat protein and other vegetables. This study suggests that the intake of the low fat local vegetarian food has a protective effect against prostate carcinoma for thin men in this study population.

The vegetarian lifestyle and DNA methylation.
Clin Chem Lab Med. 2005.
Vegetarians have a lower intake of vitamin B12 than omnivores do. Vitamin B12 deficiency (holotranscobalamin II <35 pmol/L or methylmalonic acid >271 nmol/L) was found in 58% of 71 vegetarians studied. Higher homocysteine levels found in 45% indicate disturbed remethylation of homocysteine to methionine. The methylation of DNA is strongly linked to homocysteine metabolism. Since DNA methylation is an important epigenetic factor in the regulation of gene expression, alteration of the methylation pattern has been associated with aging, cancer, atherosclerosis and other diseases. Three observations indicate that DNA methylation could be diminished by a vegetarian lifestyle. The vegetarian diet has a low content of methionine, remethylation of homocysteine is reduced by vitamin B12 deficiency and elevated homocysteine levels can induce the generation of S-adenosylhomocysteine (SAH), a potent inhibitor of methyltransferases. In conclusion, an inhibitory effect of SAH on whole-genome methylation was found, but from our data no interaction between vegetarian lifestyle and DNA methylation could be determined.

Email questions
Q. Just finished reading your extremely informative book Mind Boosters. Two questions regarding your recommendations for vegetarians (i.e. Carnitine, CoQ10, Omega-3 oils, Creatine, B Vitamins): Should one begin taking all of these together or would it be better to slowly add one item at a time over a period of weeks?
   A. Most of the time we prefer adding supplements individually. This helps with a better understanding of how each affects the body. Once this is done over several weeks, then the combination pills would be okay. Once you learn how each one of these supplements is influencing you and your health, then you can combine them. Or, you can just take them all together as a combination in a great formula such as Veg Rx.

Q. Your website is great and I love the work you are doing. You are helping a lot of people. Next, let me state one criticism, which you may or may not agree with - but either way, I hope you at least consider altering your views on the topic of vegetarianism. You wrote in response to a reader:  "In my practice I do find that it is very difficult for patients to have a good, satisfying diet being vegetarian. Some are able to do it, while many end up satisfying their urges by overconsuming carbohydrates and not getting enough protein. In addition to perhaps not getting enough protein, many vegetarians may not be getting enough omega-3 oils found in fish, carnitine, CoQ10, and creatine." I take omega 3 oils everyday which do not contain fish oils (it is flax) and this isn't a problem at all. Also, most of my friends who are vegetarians, are in much better health than my non-vegetarian friends! Your statements clearly indicate that you are not a vegetarian and that you are at least somewhat biased in your views. You would be much more convincing if you at least showed some awareness of the benefits of vegetarianism (of which there are many).
   A. Ethically and morally, I support vegetarianism. We do not have the inherent right to kill and eat animals, although one could argue that, unfortunately, that’s the way things work on this planet: i.e, animals kill and eat other animals, big fish devour smaller fish, etc. I also support vegetarianism for its environmental benefits. Our resources are being depleted, there are fewer fish in our oceans, and who knows how long we can supply all this abundant food to so many mouths. On a side note: I think Americans are hypocritical when it comes to killing animals. It is alright to kill chickens, cattle, pigs, and fish for food, yet it is not all right (and sometimes a crime) to kill dogs and horses for food. Why the distinction? Is a horse inherently superior to a cow? In some Asian countries, eating dogs is acceptable. Regarding vegetarianism purely on medical grounds, and although theoretically quite possible, I find some people are not able to maintain a healthy diet by being vegan or vegetarian. I have seen too many patients who end up feeling fatigued, or get depressed, when they try to be strict vegetarians. Due to a reduced number of food choices, many end up overconsuming simple carbohydrates, or over consuming the same foods all the time (I have a theory that sometimes we may develop allergies to certain foods if too much of the same ones are eaten repeatedly). Furthermore, there are an excessive number of tempting simple sugar and bad fat-laden goodies easily within reach in grocery and health food stores which may substitute for healthier food sources. In the past, (and currently in many underdeveloped countries), vegetarians did not have these unhealthy temptations. Those, perhaps like you, who are able to be vegetarian by choosing and combining the right foods, are likely to be quite healthy (and most likely healthier than the average white-bun, burger- and fries-devouring chubby American), particularly if they are knowledgeable enough to supplement with the right amounts of B12, coq10, creatine, and carnitine. By the way, although flax contains omega-3 oils such as alpha-linolenic acid (ALA), it does not contain EPA and DHA, longer chained omega-3s. The body is able to convert ALA to EPA and DHA but perhaps not everyone has the enzymatic ability to do so efficiently.

Some vegetarians have metabolic signs indicating a vitamin B-12 deficiency leading to a substantial increase in total homocysteine concentrations. High blood homocysteine levels can damage arteries and make blood clot more easily.

Q. My teenager wants to go on a vegetarian diet, is that okay?
   A. As long as your teenager studies the topic quite well and makes sure he or she consumes the right macro and micro nutrients, I don't have a problem with the vegetarian choice as long as a healthy vegetarian diet is incorporated with good a vegetarian protein source with little sugar and white flour.

Q. Are you familiar with a vegetarian glucosamine source?
   A. At this time I am not aware of a vegetarian glucosamine source.

Q. Are there vegetarian gelatin capsules available for supplements?
   A. Gelatin is usually from pork or beef. Vegetarian made capsules are available and your supplement bottle should mention it if it is suitable for vegetarians.

Q. I am vegan and there are many Physician Formulas products that I cannot take due to the fact that they are made with gelatin capsules. I am particularly interested in the Mind Power Rx. Is there a reason why some of Physician Formulas products are not made with veggie caps?
   A. Thank you for your email. Unfortunately Mind Power Rx is in a gelatin capsule, but many people open the capsules and just use the contents. The capsules can be easily opened by pulling on each side and dropping the contents in water or juice. Only a very small percentage of users are vegan, and vegetarian capsules usually add a large cost to the bottles which makes the majority of people less willing to pay for the higher cost. And since the capsule can be easily opened, that give an option to vegans and vegetarians.

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