Plant-based Diets, Entomophagy, and Evidence

I have chosen to do my first blog post on the concept of plant-based diets. What is a plant based diet? What are the claims being made about plant-based diets? Are the claims supported by scientific evidence? I will also share my own journey over the past year converting from a lifetime of heavy animal product consumption to one that is mostly plant-based in a separate post.

Finally, the scriptures actually have a lot to say about diet and nutrition. I will explore a few of the passages as they pertain to practical nutritional advice. I am not a nutritionist nor pretend to be one. Rather, I am a master’s prepared nurse trained in analyzing research, I happen to be fascinated by the topic of nutrition, and simply desire to share my own experience and findings.

What is a Plant-Based Diet?

In an article found in the the Journal of Geriatric Cardiology, the following definition is provided: “A plant-based diet consists of all minimally processed fruits, vegetables, whole grains, legumes, nuts and seeds, herbs, and spices and excludes all animal products, including red meat, poultry, fish, eggs, and dairy products” (Ostfeld, 2017, para 1). In other words, a vegan diet in this definition, consisting of exclusively non-processed plant-based foods.

Bluezones.com describes a “plant slant” in its food guidelines that is somewhat less restrictive. In these guidelines, the authors advocate for 95%-100% plant-based diet choices, allowing very small quantities of animal products such as dairy (yogurt, feta cheese), eggs, fish and meat in very small quantities spread over the week (constituting an estimated 5% of the diet in terms of nutrients and calories).

What is a “vegetarian?”: In the literature you will see below, the studies frequently involve a variety of plant-based diets grouped together. For example, much of the research is conducted using vegetarians who may still eat dairy products and eggs (lacto-ovo vegetarians), vegans, and pesco-vegetarians (vegetarians who also eat fish but no other meat). Some studies separate the various plant-based dieters, while others group them together and simply call them all “vegetarians.”

Claims Made About Plant-Based Diets

Longer, Healthier Life: The claims are pretty significant regarding plant-based diets. For example, in the linked article at bluezones.com, it is claimed that there is a general consensus among scientists and experts in the field of nutrition concerning the superior nature of a plant-based diet. (“Blue Zones” are a reference to five places in the world with the longest living, healthiest populations–see bluezones.com for more info).

However, the guidelines referenced above acknowledge that in all five zones cited as “Blue Zones” where populations live the longest and healthiest, animal products were consumed in small amounts. “Small amounts” means limiting animal products to amounts such as zero to three eggs PER WEEK, 1 to 3 oz fish at one to three times PER WEEK, small amounts of cheese or yogurt a few times per week, perhaps small bits of meat as an minor additive to soups–certainly smaller amounts than most Americans are accustomed to eating!!!

Disease Reversal, Restoration of Health, and More “Natural” for Our Bodies: Documentaries such as What the Health (Anderson & Kuhn, 2018) and Forks Over Knives (Fulkerson, Corry, & Wendel, 2011) suggest that humans are not really designed (or evolved per their perspective) to eat or digest animal products. Both films show compelling cases of disease reversal after persons switched over to plant-based diets.

Cancer, Cardiac Disease, Chronic Disease Risk Reduction and even Reversal: In the book, The China Study (Campbell & Campbell, 2004), strong arguments (along with a robust reference list of supporting scientific publications) are made suggesting that cancer development and progression, cardiac disease development and progression, and numerous other chronic diseases (such as diabetes, autoimmune disease, arthritis and others) can be stopped in their tracks by limiting animal protein to less than 10% of all protein consumed paired with an all or nearly all whole-foods (non-processed) plant-based diet. A copy of the book is available here.

In the book How Not to Die (Greger, 2015), Dr. Greger discusses evidence supporting utilization of a whole foods (non-processed) vegan diet in reducing risks of infections, heart, Parkinson’s, lung, kidney, prostate and liver diseases along with vegan diets helping to reduce blood pressure, diabetes risks and various cancers. His book can be ordered here.

Certainly such claims are exciting, and in fact, many of the sources I cited above have their own extensive lists of supporting research citations. But what about all the contradicting studies that barrage us seemingly daily? Are the above authors and websites merely biased–was the evidence “cherry picked” or exaggerated?

Potatoes, beans, fruits, grains–what about all those “carbs”? Are there risks? What about protein and muscle and nutrient deficiencies–don’t we need meat?

What Does the Current Evidence Say?

Overall Mortality (rates of death versus the general population of similar age, sex, social status, etc.): McEwen and Bingham (2019) cite multiple studies that show vegans enjoy lower mortality rates and lower chronic illness rates from a variety of causes. As you will see below, there is strong evidence of improved cardiac health when following a diet heavily based on plants and free of meat (excepting fish). Le and Sabate (2014) noted lower rates of death by as much as 68% from cardiovascular and cerebral vascular causes for vegetarians among comparison cohort groups, and lower overall mortality rates by 10-20% from all causes.

Cancer: In an article published in the peer-reviewed journal Nutrition Bulletin, Harland and Gartland (2016) cite the position of the World Cancer Research Fund as supporting a 2/3rds plant-based, 1/3rd animal-based diet for cancer risk reduction. This pattern is similar (while less restrictive) to the Blue Zones stance noted above where animal products (meat, fish, dairy, eggs, etc.) are to serve more as garnishes as opposed to main courses.

Research by Dinu, Abbate, Gensini, Casini, and Sofi (2017) involved a meta-analysis of 86 cross sectional studies (studies examining a group of people at a specific moment in time) and 10 prospective cohort studies (studies that follow groups with similar conditions over time) has found a reduction in total cancer mortality of 8% for vegetarians versus meat eaters and 15 % reduction for adherents of vegan diets.

In a study comparing outcomes for 96,000 participants broken into cohorts based on dietary patterns, vegetarians experienced colon cancer at half the rate of meat eaters, as well as experienced overall gastrointestinal cancer at levels 23% lower than meat eaters (Le & Sabate, 2014). Also, breast cancer mortality rates were 48% lower for vegetarians versus meat eaters. Prostate cancer risk was reduced by 35% for vegetarians. Interestingly however, urinary tract cancer rates were substantially higher, increased by 78% for vegans.

Heart Disease and Deaths from Heart Disease: Want a healthier heart? Plant-based diets (plus fish) are the evidence-based way to go! Vegetarian diets were found to significantly reduce heart disease incidence and mortality (death) rates by 25% versus meat eaters according to a meta-analysis of 7 prospective cohort studies (Dinu et al, 2016, as cited in Harland & Gartland, 2016).

In a separate meta-analysis of five prospective cohort studies conducted over a 10 year period and containing over 76,000 participants, deaths from cardiac disease were 25% lower for those following vegetarian diets versus meat eaters (Key et al., 1999, as cited in Harland & Gartland, 2016). Effects improved the longer a person followed a vegetarian diet (showing a “dose effect”–an indicator that the diet and not some other factor is responsible for the outcomes). However, the greatest heart disease risk reduction was found in those that avoided meat but still ate fish.

Persons who ate no meat but DID eat fish along with vegetarians that still ate eggs and dairy saw a 34% reduction in mortality rates from heart disease (vegans enjoyed a 26% reduced mortality rate, Key et al., 1999, as cited in Harland & Gartland, 2016).

Cholesterol: Plant-based diets reduce cholesterol, with vegans achieving better results than vegetarians. An analysis of 14 randomized-controlled trials (RCT’s– the “gold standard” for testing the effects of an intervention in research) along with 13 observational studies showed implementing vegetarian diets lowered total cholesterol and LDL cholesterol levels by 10-15% for general vegetarians, with vegans achieving 15-25% reductions (Ferdowsian & Barnard, 2009 as cited in Harland & Gartland, 2016).

Similar findings of significant cholesterol reduction occurred in a randomized controlled trial comparing whole-foods plant-based diet versus standard care (Wright, Wilson, Smith, Duncan, & McHugh, 2017).

Diabetes: Diabetics tend to worry about the “carbs” in plant-based diets. However, a review of the evidence concerning plant-based diets for diabetic sufferers is fascinating. Plant-based diets have been shown to reduce A1C measures, a blood test measure that is elevated in persons with type 2 diabetes (Dinu et al., 2016 as cited in Harland & Gartland, 2016; Wright et al., 2017). Several diabetics actually had their A1C measures drop to normal levels by following the whole foods plant based diet. In a study of over 8,000 Seventh Day Adventists, those that ate meat just once a week raised their risk of diabetes by 29% over a 17 year follow up period versus those that abstained from meat entirely (Vang, Singh, Lee, Haddad, & Brinegar, 2008 as cited in Olfert, & Wattick, 2018).

For lifelong adherence to a vegetarian diet, diabetes rates were 74% lower than for Adventists who ate meat (Vang et al., 2008 as cited in Olfert & Wattick, 2018). However, you can apparently dramatically lower your risk switching over to a vegetarian diet even if you ate meat most of your life. In a study of nearly 3,000 Buddhists, those that switched to a vegetarian diet lowered their risk of developing diabetes by 53% versus those that consumed meat during a five-year period, even after controlling for family history, age, and physical activity levels (Chiu, Pan, Lin, & Lin, 2018 as cited in Olfert & Wattick, 2018) .

Similar to heart disease, the more plant-based the diet and the less animal products consumed, the more diabetes risk was reduced, again demonstrating a “dose effect” (Zhangling et al., 2018 as cited in Olfert & Wattick, 2018).

For those already suffering with diabetes, research cited by Olfert and Wattick (2018) notes whole-food vegan diets were superior in reducing A1C levels versus the American Diabetic Association’s own diet, with results sustained one year later at follow up. Diabetic persons who adopted a vegan diet saw significant reductions in neuropathic pain when supplementing with vitamin B12 versus minimal improvement for meat eaters supplementing with vitamin B12. Kidney function also improved significantly in terms of improved creatinine clearance and reduced urine protein levels for diabetics adopting a vegan diet. Finally, in multiple studies, diabetic patients were able to drastically reduce or even eliminate medications and insulin after adopting vegetarian or vegan diets (Olfert & Wattick, 2018).

Lose Weight, Stay Lean: Research cited by Pilis, Stec, Zych, and Pilis (2014) determined that adults who adopt a vegetarian diet on average have lower body weights and body mass indexes than their meat eating counterparts. Vegetarian males weighed on average nearly 17 lbs less than meat eating males, while vegetarian females weighed an average of 7 lbs lighter than their meat eating counterparts. Another study of over 20,000 men and 38,000 women found that vegans had the lowest body mass index (BMI) averaging a BMI of 23, with BMI increasing upon introduction of dairy, eggs, then increasing again when fish was added in, climbing again with occasional meat consumption, and with the highest BMI (28) for regular meat eaters (Tonstad, Butler, Ru, Fraser, 2009 as cited in Pilis et al., 2014).

Digestive Health: Vegetarians have lower risks of diverticular disease and diverticulitis according to research by Appleby and Key (2016, as cited in McEwen & Bingham, 2019). Diverticulitis is a painful and potentially deadly condition of the bowel in which small, balloon like pouches develop in the bowel wall. These can become inflamed, infected, and rupture causing serious and even life threatening abdominal infections.

The high fiber content in plant-based diets can help to promote regular bowel movements and prevent constipation (McEwen & Bingham, 2019). Further, the soluble fiber can bind up excess water and reduce watery bowel movements. Finally, the fiber serves as a prebiotic, promoting growth of health promoting microbes within the bowel. These microbes are believed to counter disease-causing microbes and reduce inflammation (McEwen & Bingham, 2019).

What about nutrient deficiencies–don’t we need meat? What are the risks of a plant-based diet?

Below are examples of common concerns versus literature findings.

Protein: Pilis et al. (2014) reference several studies that found protein deficiencies in improperly executed vegetarian diets, while also citing another study that found no protein deficit. In other words, those adopting vegetarian diets need to do so with proper planning, true of any optimal eating plan. There are plenty of plant sources of protein. Also, the high carbohydrate content of plant-based diets significantly reduces the amount of protein consumed by the body (thereby sparing protein for other uses) during high intensity exercise (Borrione, Loredana, Quaranta, & Parisi, 2009 as cited in Pilis et al., 2014).

A vegan diet consisting of puffed rice and potato chips won’t cut it. Beans, legumes, seeds, whole grains and nuts are great protein sources. For those still concerned, vegetarian diets adopting dairy and eggs (Pilis et al., 2014) or pesco-vegetarianism (where fish is consumed with an otherwise vegetarian diet) can help boost protein numbers. Another interesting source of protein (and B12, see below) are edible insects!! But, that’s another blog post for another day. I cover the amounts of protein needed based on activity levels and goals here.

Vitamin B12: A vitamin B12 deficiency is no joke, and it is a potential complication of vegetarian diets (Skerrett, 2013). A vitamin B12 deficiency is dangerous, but can easily be avoided through use of readily available supplements over the counter or injections ordered through a physician/medical provider (for those with absorbance issues). Complications of deficiencies can include anemia, nerve damage, problems walking among others. Again, this is easily avoided through use of proper supplementation using a vitamin B12 supplement (consult with your doctor, a blood test can be ordered, and many persons who eat meat become deficient nonetheless as their ability to absorb the vitamin declines with age). Vitamin B12 supplements are cheap and easy to find, such as here.

Herrmann, Schorr, Purschwitz, Rassoul, and Richter (2001, as cited in Pilis et al., 2014) discuss the risk of B12 deficiencies for vegetarians. B12 deficiency is associated with a rise in homocysteine protein, a risk factor for cardiac disease. B12 is present in dairy, eggs, fish, meat and other products but essentially absent from plant-based foods unless it is added as a fortified vitamin. A study by Wegmüller, Schüpbach, Herter-Aeberli, Berguerand, and Bui (2017) tested approximately 100 total vegans and vegetarians and noted adequate B12 levels thanks to high awareness of supplementation needs and ease of access to B12 supplementation.

Irregular Menses: Women with inadequate fat and caloric intake who are highly active may experience irregularities with their menstrual cycle, including potentially even cessation of menses (Pilis et al., 2014). This is not directly from the plant-based diet per say, but more strict vegetarian diets and vegan diets in particular tend to have lower caloric and fat levels which can lead to disruptions in estrogen production. A properly balanced vegetarian diet however can actually lead to less disruptive menses through a more moderate lowering of estrogen levels, reducing estrogen spikes.

Iron Deficiency: Wegmüller at al. (2017) studied approximately 100 meat eaters and 100 vegetarian / vegan persons and noted iron deficiencies to occur at low and similar rates among all groups. Iron levels may be a concern nonetheless. Vegan diets have the least amount of iron, according to the American Dietetic Association and Dietitians of Canada (as cited in Pilis et al., 2014), with iron intake rising as eggs, dairy, then fish and meat are added into the diet. Vegetarians can improve their iron intake through eating iron rich plant-foods with vitamin C rich foods simultaneously to boost absorption.

Omega 3 Intake: Omega 3 fatty acids play essential roles in formation of cell membranes and cell receptor function, relaxing artery walls, reducing inflammation and serving various other biologic functions critical to health (Harvard.edu, 2019). McEwen and Bingham (2019) discuss the low omega 3 blood levels in vegans due to inefficiencies in converting plant-based omega 3 fatty acids (ALA) into forms utilized by animals and humans, namely DHA and EPA. The authors suggest supplementation. There are plant-based options for DHA and EPA which include seaweed or algae. A plant-based supplement can be found here.

It is important to note however, that low blood levels of Omega 3 fatty acids are not unique to those eating strict plant-based diets. Givens and Gibbs (2006) note that consumption of oily fish for example tends to be low among the general population. For meat eaters and plant-based diets, unless there is either supplementation or a diet high in fatty fish (or sea vegetables), low levels are common regardless.

As noted above, the risk of cardiac illness is lower for those with plant-based diets. The clinical significance of low omega 3 fatty acid intake for those consuming plant-based diets is uncertain. For those who are concerned, either plant-based omega 3 supplementation, fish oil supplementation, or consuming fatty fish while otherwise sticking to a plant-based diet are options.

Iodine Deficiency and Thyroid Function: Those following a strict plant-based diet, especially if such is free of seafood have been found to have lower iodine intake (McEwen & Bingham, 2019). Since the thyroid uses iodine to create its primary hormone, a low intake of iodine can result in goiter and hypothyroidism (American Thyroid Association, 2019). Iodized salt has drastically lowered the incidence of hypothyroidism.

Common sources of iodine include dairy products, sea food, and as mentioned, iodized salt. Surprisingly perhaps, despite vegans generally avoiding these foods, a longitudinal study (following a group of people over a long period of time) involving 97,000 persons found that thyroid dysfunction rates were low in vegans (Tonstad, Nathan, Oda, & Fraser, 2013 as cited in McEwen & Bingham, 2019). An easy way to boost iodine intake (while being careful to avoid toxic levels) involves seaweed.

Yes, seaweed. Similar to a salt or pepper shaker, seaweed flakes actually taste pretty good on a variety of foods (such as soups and pastas) and just a small amount contains 100% of your daily iodine needs. A product I use and can vouch for flavor-wise is available here.

Another option to get your iodine is to simply add a small amount of seaweed to your smoothie. The amount needed to get your iodine is truly quite small, about 1/7th of a serving size (in the following product). A product great for smoothies can be found here.

The risk for iodine deficiency for those opting for a plant-based diet therefore is low, and can be prevented entirely through use of whole-foods products such as those listed above, or by consuming the foods mentioned above that are high in iodine.

Other Micronutrient Deficiencies: It is true that those eating a mainly plant-based diet may become deficient in certain nutrients, the same is true of those eating meat…the groups simply differ in their deficiencies. Wegmüller at al. (2017) found that those that ate meat had higher rates of folic acid deficiencies (58% of the 100 omnivores in the study were deficient). Vegetarians were deficient in B6 (58% of the 53 participants) and niacin (34%), while vegans were deficient in zinc (47% of the 53 participants).

Meat eaters had the lowest intake of the following: magnesium, vitamin C, vitamin E, niacin and folic acid, while vegans had low intake of calcium, vitamin D and and vitamin B12. As noted above however, B12 deficiencies were rare thanks to supplementation. Vegetarians had superior intake of the following: thiamin, folate, vitamin C, carotene, potassium and vitamin E versus the general population (Harland & Gartland, 2016).

Creatine levels are also lower in those following vegetarian diets (Arnarson, 2019). While creatine is naturally produced by the liver, it is also obtained from meat. Increased creatine levels have been associated with improved brain function, muscular strength, and endurance. Vegan-friendly creatine supplement options are made through laboratory synthesis of 3 amino acids and one example I use is available here.

Summary of the Evidence

A review of the evidence above, including numerous high quality studies, clearly supports a plant-based diet in terms of cardiac health, reduced cancer risk, reduced diabetes risk and improved overall general health. Perhaps surprising to me (and let the haters hate), the evidence as I see it supports a diet that is heavily based on plants while allowing for fish and small amounts of dairy and eggs over a strictly vegan diet when striving for optimum health. Interestingly, this is consistent with the dietary guidelines referenced above at (and available here) bluezones.com.

I read numerous books supporting veganism and myself experimented with veganism. However, even in books such as The China Study (Campbell & Campbell, 2004), its acknowledged that populations with the healthiest outcomes in China and other areas still ate animal products. Generally no more than 10% of their protein came from animal sources.

So, if you eat about 150 grams of protein per day, only 15 grams of that protein would come from animals. Small bits of meat in a soup, a single Greek yogurt, a very small portion of fish…it does not take much to hit 10%. This matches research cited by Harland and Gartland (2016) as well…more plants and less animal products (while not totally eliminating them) boosted numerous health outcomes. Animal products should be a garnish at best.

The evidence also was clear: meat (excepting fish) is out! Even weekly portions of meat as noted above raises disease risk. While nutrient deficiencies are possible on any diet, including diets that include meat, careful dietary planning (again necessary for anyone pursuing health regardless of meat consumption) and some supplementation drastically reduces or eliminates such deficiencies.

What Does the Bible Have to Say (If Anything) Concerning Plant-Based Diets?

An entire commentary on biblical dietary practices is beyond the scope of this blog! However, regarding plant-based diets, an interesting passage in the book of Daniel chapter 1 references a situation in which Daniel, a captive from Israel during the Babylonian exile is granted an opportunity to eat from the Babylonian king’s table:

“And the king appointed for them a daily provision of the king’s delicacies and of the wine which he drank, and three years of training for them, so that at the end of that time they might serve before the king” (Daniel 1: 5-6; The New King James Version).”

Daniel refuses this offering, much to the fear of the eunuch in charge of his well-being.

“I fear my lord the king, who has appointed your food and drink. For why should he see your faces looking worse than the young men who are your age? Then you would endanger my head before the king.” (Daniel 1:10; NKJV)

Instead, Daniel states the following:

“So Daniel said to the steward whom the chief of the eunuchs had set over Daniel, Hananiah, Mishael, and Azariah, 12“Please test your servants for ten days, and let them give us vegetables to eat and water to drink. 13Then let our appearance be examined before you, and the appearance of the young men who eat the portion of the king’s delicacies; and as you see fit, so deal with your servants.” 14 So he consented with them in this matter, and tested them ten days.” (Daniel 1: 11-14; NKJV).

After eating the above described plant-based diet over a brief period, the youth are described as follows:

“And at the end of ten days their features appeared better and fatter in flesh than all the young men who ate the portion of the king’s delicacies. 16Thus the steward took away their portion of delicacies and the wine that they were to drink, and gave them vegetables.” (Daniel 1:15-16; NKJV).

The scriptures note that Daniel and his peers looked healthy and strong eating essentially a vegan diet, and the other youth were subsequently put on the same diet. They were then kept in the care of the eunuchs for three years, and from the above description, it is apparent that they and the youth continued on the plant-based diet during that time.

There are plenty of places in the scriptures where eating meat is clearly part of the diet of ancient Jews and Christians. However, the above is an interesting reference in the ancient text to a vegan diet and the strong health (and healthy appearance) associated with this kind of diet. Also interesting are the fears of the eunuch, which sounds pretty similar to people who are plant-based diet skeptics today!!

I hope you enjoyed my first post and feel free to leave a comment!!

Related posts

Plant-based Diets: Fears & Answers: In this post I tackle common myths, misconceptions, and biases concerning plant-based diets

Evidence at a Glance: Plant-Based Diet Benefits: A quick snapshot/ overview of the numerous, research-backed benefits of plant-based diets

Plant-based Diets: What do the Scriptures Say?: An interesting look at both the passages of Daniel and also, the origins and benefits of the now famous Ezekiel Bread

References:

American Thyroid Association. (2019). Iodine deficiency. Retrieved from https://www.thyroid.org/iodine-deficiency/

Anderson, K., & Kuhn, K. (Producers & Directors). (2017). What the health [Motion Picture]. United States: A.U.M. Films & Media

Arnarson, A. (2019). 7 Nutrients that you can’t get from plants. Retrieved from https://www.healthline.com/nutrition/7-nutrients-you-cant-get-from-plants#1

Bluezones.com. (2019). Author of “Truth About Food” Reveals 3 Truths to End All Confusion About a Healthy Diet. Retrieved from https://www.bluezones.com/2018/11/author-of-truth-about-food-reveals-3-truths-to-end-all-confusion-about-a-healthy-diet/

Bluezones.com. (2019). Food guidelines. Retrieved from https://www.bluezones.com/recipes/food-guidelines/

Campbell, T. C., & Campbell, T. M. (2004). The China Study. Dallas, TX: BenBella Books

Dinu, M., Abbate, R., Gensini, G. F., Casini, A., & Sofi, F. (2017). Vegetarian, vegan diets and multiple health outcomes: A systematic review with meta-analysis of observational studies. Critical reviews in food science and nutrition, 57(17), 3640-3649. doi: 10.1080/10408398.2016.1138447

Fulkerson, L. (Director), Corry, J., & Wendel, B. (Producers). (2011). Forks Over Knives [Motion Picture]. United States: Monica Beach Media .

Givens DI, & Gibbs RA. (2006). Very long chain n-3 polyunsaturated fatty acids in the food chain in the UK and the potential of animal-derived foods to increase intake. Nutrition Bulletin, 31(2), 104–110. Retrieved from http://search.ebscohost.com.lopesalum.idm.oclc.org/login.aspx?direct=true&db=cin20&AN=106217997&site=ehost-live

Greger, M. (2015). How Not to Die. New York, NY: Flatiron Books

Harland, J., & Garton, L. (2016). An update of the evidence relating to plantbased diets and cardiovascular disease, type 2 diabetes and overweight. Nutrition Bulletin, 41(4), 323–338. https://doi-org.lopesalum.idm.oclc.org/10.1111/nbu.12235

Harvard.edu. (2019). Omega-3 fatty acids: An essential contribution. Retrieved from https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-and-cholesterol/types-of-fat/omega-3-fats/

Le, L. T., & Sabaté, J. (2014). Beyond meatless, the health effects of vegan diets: findings from the Adventist cohorts. Nutrients, 6(6), 2131–2147. doi:10.3390/nu6062131

McEwen, B., & Bingham, M. (2019). Vegan diet and chronic disease: A brief report. Journal of the Australian Traditional-Medicine Society, 25(2), 77–79. Retrieved from http://search.ebscohost.com.lopesalum.idm.oclc.org/login.aspx?direct=true&db=a2h&AN=137322002&site=ehost-live

Olfert, M. D., & Wattick, R. A. (2018). Vegetarian Diets and the Risk of Diabetes. Current diabetes reports, 18(11), 101. doi:10.1007/s11892-018-1070-9

Ostfeld R. J. (2017). Definition of a plant-based diet and overview of this special issue. Journal of geriatric cardiology : JGC, 14(5), 315. doi:10.11909/j.issn.1671-5411.2017.05.008

Pilis, W., Stec, K., Zych, M., & Pilis, A. (2014). Health benefits and risk associated with adopting a vegetarian diet. Roczniki Panstwowego Zakladu Hygieni, 65(1), 9-14. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24964573

Skerrett, P. J. (2013). Vitamin B12 deficiency can be sneaky, harmful. Retrieved from https://www.health.harvard.edu/blog/vitamin-b12-deficiency-can-be-sneaky-harmful-201301105780

Wegmüller, R., Schüpbach, R., Herter-Aeberli, I., Berguerand, C., & Bui, M. (2017). Micronutrient status and intake in omnivores, vegetarians and vegans in Switzerland. European Journal of Nutrition, 56(1), 283–293. https://doi-org.lopesalum.idm.oclc.org/10.1007/s00394-015-1079-7

Wright, N., Wilson, L., Smith, M., Duncan, B., & McHugh, P. (2017). The BROAD study: A randomised controlled trial using a whole food plant-based diet in the community for obesity, ischaemic heart disease or diabetes. Nutrition & diabetes, 7(3), e256. doi:10.1038/nutd.2017.3