credits available for this article — see page 88.
Special Report
Nutritional Update for Physicians: Plant-Based Diets
Philip J tuso, MD; Mohamed h ismail, MD; Benjamin P ha, MD; carole Bartolotto, Ma, RD
daily; and atorvastatin, 20 mg daily. He Abstract
The objective of this article is to present to physicians an update on plant-based diets. daily; glipizide, 5 mg daily; and 10 units Concerns about the rising cost of health care are being voiced nationwide, even as un- healthy lifestyles are contributing to the spread of obesity, diabetes, and cardiovascular disease. For these reasons, physicians looking for cost-effective interventions to improve health outcomes are becoming more involved in helping their patients adopt healthier lifestyles. Healthy eating may be best achieved with a plant-based diet, which we define sugars and limited bread, rice, potatoes, as a regimen that encourages whole, plant-based foods and discourages meats, dairy and tortillas to a single daily serving. He products, and eggs as well as all refined and processed foods. We present a case study as an example of the potential health benefits of such a diet. Research shows that plant- based diets are cost-effective, low-risk interventions that may lower body mass index, in addition to up to 2 ounces of nuts and blood pressure, HbA , and cholesterol levels. They may also reduce the number of medications needed to treat chronic diseases and lower ischemic heart disease mortality rates. Physicians should consider recommending a plant-based diet to all their patients, especially those with high blood pressure, diabetes, cardiovascular disease, or obesity.
primary care clinic. Over a 16-week pe-riod, significant improvement in biometric Introduction
In the HBO documentary The Weight National dietary guidelines for active completely weaned off of amlodipine, of the Nation, it was noted that if you living and healthful eating are available hydrochlorothiazide, glipizide, and neutral “go with the flow” in the US, you will at A typical protamine Hagedorn insulin. Follow-up healthful plate of food is 1/2 plant foods blood pressure remained below 125/60 ters reported that in some areas of the (nonstarchy vegetables and fruits), 1/4 mmHg, HbA improved to 6.3%, and country, the rate of obesity is 39% and is whole grains or unprocessed starchy food, total cholesterol improved to 138 mg/dL. increasing at a rate of 5% per year.2 Risks and 1/4 lean protein.
Lisinopril was gradually decreased to 5 mg The goal of this article is to review the daily and his diabetes is controlled with cardiovascular disease, along with their evidence supporting plant-based diets and metformin alone, 1000 mg twice daily.
ensuing complications (eg, behavioral to provide a guideline for presenting them
health and quality-of-life problems) often to patients. We start with a case study and Definitions of
go hand-in-hand and are strongly linked conclude with a review of the literature.
Plant-Based Diets
to lifestyle, especially dietary choices.3 Of all the diets recommended over the Case Study
ample of the effect a plant-based diet can last few decades to turn the tide of these A 63-year-old man with a history of have on biometric outcomes like blood chronic illnesses, the best but perhaps hypertension presented to his primary pressure, diabetes, and lipid profile. The least common may be those that are care physician with complaints of fa- tigue, nausea, and muscle cramps. The in 3 months is much better than would Despite the strong body of evidence result of a random blood glucose test be expected with monotherapy with met- favoring plant-based diets, including stud- was 524 mg/dL, and HbA was 11.1%. formin6 or daily exercise.7 The improve- ies showing a willingness of the general Type 2 diabetes was diagnosed. His ment in blood pressure observed over a public to embrace them,4 many physicians total cholesterol was 283 mg/dL, blood 4-month period with few medications is are not stressing the importance of plant- pressure was 132/66 mmHg, and body also rarely encountered in clinical practice based diets as a first-line treatment for mass index (BMI) was 25 kg/m2. He was and is likely related to a low-sodium diet chronic illnesses. This could be because taking lisinopril, 40 mg daily; hydrochlo- of a lack of awareness of these diets or a rothiazide, 50 mg daily; amlodipine, 5 mg the patient was not obese and did not Philip J tuso, MD, is the Regional Co-Lead for the Complete Care Program of the Southern California Permanente
Medical Group and the National Physician Lead for the Care Management Institute’s Total Health Program. E-mail: [email protected] Mohamed h ismail, MD, is a Physician at the Riverside Medical Center in CA. E-mail:
[email protected] Benjamin P ha, MD, is the Associate Area Medical Director for Family Medicine at the
Bakersfield Medical Center in CA. E-mail: [email protected] carole Bartolotto, Ma, RD, is a Senior Consultant for
Regional Health Education for the Southern California Permanente Medical Group. E-mail: [email protected]
The Permanente Journal/ Spring 2013/ Volume 17 No. 2 Nutritional Update for Physicians: Plant-Based Diets have significant weight loss with the diet, Lacto-ovo vegetarian: Excludes meat, the dramatic improvements appear to be seafood, and poultry and includes eggs the nationally representative data col-related to the quality of his new diet.
A healthy, plant-based diet aims to maxi- mize consumption of nutrient-dense plant foods, plant-based diet but allows small aim of their study was to analyze the foods while minimizing processed foods, amounts of chicken, dairy products, eggs, associations between meat consumption oils, and animal foods (including dairy and red meat once or twice per month. and obesity. Using linear and logistic re-products and eggs). It encourages lots of Fish and olive oil are encouraged. Fat is gression analyses, they showed that there vegetables (cooked or raw), fruits, beans, not restricted.
peas, lentils, soybeans, seeds, and nuts Whole-foods, plant-based, low-fat: consumption and obesity.15 (in smaller amounts) and is generally low Encourages plant foods in their whole fat.8,9 Leading proponents in the field have form, especially vegetables, fruits, an Prospective Investigation into Cancer varying opinions as to what comprises legumes, and seeds and nuts (in smaller and Nutrition assessed changes in weight the optimal plant-based diet. Ornish et amounts). For maximal health benefits and BMI over a five-year period in meat-al recommends allowing animal products this diet limits animal products. Total fat eating, fish-eating, vegetarian, and vegan such as egg whites and skim milk in small is generally restricted.
During the five years of the study, mean Benefits of Plant-Based Diets
cular prevention and reversal program at the Cleveland Clinic Wellness Institute, prove our health. In this section, we will containing fewer animal foods. The study recommends completely avoiding all an- review the literature for key articles that also reported a significant difference in imal-based products as well as soybeans demonstrate the benefits of plant-based age-adjusted BMI, with the meat eaters and nuts, particularly if severe coronary diets. Our review consists of existing having the highest BMI and vegans the artery disease is present.12 studies that include vegan, vegetarian, lowest.16 Similar results were reported by Despite these smaller differences, there and Mediterranean diets. is evidence that a broadly defined plant- based diet has significant health benefits. Obesity
demiologic studies indicate that vegetarian It should be noted that the term plant- In 2006, after reviewing data from 87 diets are associated with a lower BMI and based is sometimes used interchangeably published studies, authors Berkow and a lower prevalence of obesity in adults with vegetarian or vegan. Vegetarian or Barnard13 reported in Nutrition Reviews and children. A meta-analysis of adult veg-vegan diets adopted for ethical or reli- that a vegan or vegetarian diet is highly etarian diet studies estimated a reduced gious reasons may or may not be healthy. effective for weight loss. They also found weight difference of 7.6 kg for men and It is thus important to know the specific that vegetarian populations have lower 3.3 kg for women, which resulted in a definitions of related diets and to ascertain rates of heart disease, high blood pres- the details of a patient’s diet rather than sure, diabetes, and obesity. In addition, with nonvegetarians, vegetarian children making assumptions about how healthy their review suggests that weight loss in are leaner, and their BMI difference be-it is. The following is a brief summary of vegetarians is not dependent on exercise comes greater during adolescence. Studies typical diets that restrict animal products. and occurs at a rate of approximately 1 exploring the risk of overweight and food A key distinction is that although most pound per week. The authors further groups and dietary patterns indicate that of these diets are defined by what they stated that a vegan diet caused more a plant-based diet seems to be a sensible exclude, the plant-based diet is defined calories to be burned after meals, in con- trast to nonvegan diets which may cause in children. Plant-based diets are low Vegan (or total vegetarian): Excludes fewer calories to be burned because food in energy density and high in complex all animal products, especially meat, sea- food, poultry, eggs, and dairy products. Farmer et al14 suggest that vegetarian may increase satiety and resting energy Does not require consumption of whole diets may be better for weight manage- expenditure.”18 The authors conclude that foods or restrict fat or refined sugar.
ment and may be more nutritious than plant-based dietary patterns should be Raw food, vegan: Same exclusions as diets that include meat. In their study, encouraged for optimal health.
veganism as well as the exclusion of all they showed that vegetarians were slim-
foods cooked at temperatures greater mer than their meat-eating counterparts. Diabetes
than 118°F.
Lacto-vegetarian: Excludes eggs, meat, more magnesium, potassium, iron, thia- tage over those that are not plant based seafood, and poultry and includes milk min, riboflavin, folate, and vitamins and with respect to prevention and manage-products.
less total fat. The authors conclude that ment of diabetes. The Adventist Health Ovo-vegetarian: Excludes meat, sea- vegetarian diets are nutrient dense and Studies found that vegetarians have ap- food, poultry, and dairy products and can be recommended for weight manage- ment without compromising diet quality.14 The Permanente Journal/ Spring 2013/ Volume 17 No. 2 Nutritional Update for Physicians: Plant-Based Diets Vang et al20 reported that nonvegetarians 70% decrease in all-cause mortality. The an increased risk of cardiovascular mortal-were 74% more likely to develop diabetes intervention group’s Mediterranean-style ity.29 Low meat intake has been associated over a 17-year period than vegetarians. diet included more plant foods, veg- In 2009, a study involving more than etables, fruits, and fish than meat. Butter 60,000 men and women found that the and cream were replaced with canola oil meta-analysis to investigate cardiovascular prevalence of diabetes in individuals on margarine. Canola oil and olive oil were disease mortality among vegetarians and a vegan diet was 2.9%, compared with the only fats recommended.22 7.6% in the nonvegetarians.17 A low-fat, In 1998, a collaborative analysis using ies that reported relative risks and corre- plant-based diet with no or little meat original data from 5 prospective studies sponding 95% confidence intervals. Seven may help prevent and treat diabetes, pos- studies with a combined total of 124,706 sibly by improving insulin sensitivity and nal Public Health Nutrition. It compared participants were analyzed. Vegetarians decreasing insulin resistance.
ischemic heart disease-specific death rate had 29% lower ischemic heart disease Barnard et al21 reported in 2006 the ratios of vegetarians and nonvegetarians. mortality than nonvegetarians.31 results of a randomized clinical trial The vegetarians had a 24% reduction
comparing a low-fat vegan diet with a in ischemic heart disease death rates Health Concerns About
diet based on the American Diabetes As-
compared with nonvegetarians.23 The Plant-Based Diets
sociation guidelines. People on the low-fat lower risk of ischemic heart disease may Protein
vegan diet reduced their HbA levels by be related to lower cholesterol levels in
1.23 points, compared with 0.38 points for individuals who consume less meat.24 diet are not at risk for protein deficiency. sociation diet. In addition, 43% of people ated with lower risk of several chronic some of which, called essential amino on the low-fat vegan diet were able to diseases, different types of vegetarians acids, cannot be synthesized by the body reduce their medication, compared with may not experience the same effects on and must be obtained from food. Es-26% of those on the American Diabetes health. The key is to focus on eating a sential amino acids are found in meat, Association diet.18 dairy products, and eggs, as well as many Heart Disease
sential amino acids can also be obtained In the Lifestyle Heart Trial, Ornish10 High Blood Pressure
found that 82% of patients with diagnosed heart disease who followed his program sory Committee performed a literature rice with beans, and hummus with whole had some level of regression of athero- review to identify articles examining wheat pita. Therefore, a well-balanced, sclerosis. Comprehensive lifestyle changes the effect of dietary patterns on blood plant-based diet will provide adequate appear to be the catalyst that brought pressure in adults. Vegetarian diets were amounts of essential amino acids and about this regression of even severe coro- associated with lower systolic blood pres- nary atherosclerosis after only 1 year. In sure and lower diastolic blood pressure.26 his plant-based regimen, 10% of calories One randomized crossover trial found beans are good sources of protein and came from fat, 15% to 20% from protein, that a Japanese diet (low sodium and may help lower levels of low-density and 70% to 75% from carbohydrate, and plant based) significantly reduced systolic lipoprotein in the blood34 cholesterol was restricted to 5 mg per day. blood pressure.27 vegetarian
had progression of atherosclerosis. After 5 Mortality
diets were
years, stenosis in the experimental group associated
decreased from 37.8% to 34.7% (a 7.9% mittee also performed a 2010 literature Association36 reported that with lower
relative improvement). The control group review to determine the effect of plant- systolic and
experienced a progression of stenosis based diets on stroke, cardiovascular who regularly consumed soy diastolic blood
from 46.1% to 57.9% (a 27.7% relative disease, and total mortality in adults. products had a 32% lower pressure …
worsening). Low-density lipoprotein They found that plant-based diets were risk of breast cancer recur-had decreased 40% at 1 year and was associated with a reduced risk of cardio- vascular disease and mortality compared risk of death, compared with women who ter 5 years. These reductions are similar with non-plant-based diets.26 consumed little or no soy.36 An analysis The benefit of plant-based diets on of 14 studies, published in the American mortality may be primarily caused by Journal of Clinical Nutrition, showed that decreased consumption of red meat.28 increased intake of soy resulted in a 26% tion trial, de Lorgeril found that the inter- vention group (at 27 months) experienced of red meat, which is associated with an genic nature of soy products, women a 73% decrease in coronary events and a increased risk of all-cause mortality and with a history of breast cancer should The Permanente Journal/ Spring 2013/ Volume 17 No. 2 Nutritional Update for Physicians: Plant-Based Diets discuss soy foods with their oncologists. mended for those who are at risk for low animal products consumed. Strict forms of Also, overly processed, soy-based meat bone mineral density and for those found plant-based diets with little or no animal substitutes are often high in isolated soy to be deficient in vitamin D. with inoperable or severe coronary artery not be as healthy as less processed soy Fatty Acids
products (ie, tofu, tempeh, and soy milk).
Essential fatty acids are fatty acids may be prescribed for individuals with that humans must ingest for good health high blood pressure or a family history because our bodies do not synthesize of coronary artery disease or stroke. A Plant-based diets contain iron, but the them. Only two such essential fatty acids patient with obesity and diabetes will iron in plants has a lower bioavailability are known: linoleic acid (an omega-6 benefit from a plant-based diet that in-than the iron in meat. Plant-based foods fatty acid) and alpha-linolenic acid (an cludes a moderate amount of fruits and that are rich in iron include kidney beans, omega-3 fatty acid). Three other fatty vegetables and minimal low-fat animal black beans, soybeans, spinach, raisins, acids are only conditionally essential: products. Severe obesity may require cashews, oatmeal, cabbage, and tomato palmitoleic acid (a monounsaturated fatty counseling and initial management with juice.38 Iron stores may be lower in in- acid), lauric acid (a saturated fatty acid), a low-calorie diet or very-low-calorie diet dividuals who follow a plant-based diet and gamma-linolenic acid (an omega-6 and the supervision of a physician’s team. and consume little or no animal products. fatty acid). Deficiency in essential fatty Patients with kidney disease may need a However, the American Dietetic Associa- acids may manifest as skin, hair, and nail plant-based diet with special restrictions, tion states that iron-deficiency anemia is abnormalities.45 The fatty acids that vegans are most are high in potassium and phosphorus. likely to be deficient in are the omega-3 Finally, patients with thyroid disease will fats (n-3 fats). Consumptions of the plant need to be careful when consuming plants Vitamin B
version of omega-3 fats, alpha-linolenic that are mild goitrogens, like soy, raw cru- acid, are also low in vegans. Adequate ciferous vegetables, sweet potatoes, and intake of n-3 fats is associated with a corn. These patients should be informed ciency is a very serious problem and can reduced incidence of heart disease and that cooking these vegetables inactivates lead to macrocytic anemia and irreversible stroke. Foods that are good sources of n-3 the goitrogens.
nerve damage. Vitamin B is produced fats should be emphasized. They include by bacteria, not plants or animals. Indi- ground flax seeds, flax oil, walnuts, and time to get away from terms like vegan viduals who follow a plant-based diet canola oil.46 and vegetarian and start talking about eating healthy, whole, plant-based foods vulnerable to B deficiency40 and need to Conclusion
A healthy, plant-based diet requires minimizing consumption of meat, eggs, planning, reading labels, and discipline. and dairy products. Physicians should be The recommendations for patients who informed about these concepts so they Calcium and Vitamin D
want to follow a plant-based diet may can teach them to staff and patients. Calcium intake can be adequate in a include eating a variety of fruits and veg- etables that may include beans, legumes, of the health care team that designs a based diet. People who do not eat plants seeds, nuts, and whole grains and avoid- plant-based diet for patients with chronic that contain high amounts of calcium may ing or limiting animal products, added disease, especially if multiple medications be at risk for impaired bone mineraliza- fats, oils, and refined, processed carbo- tion and fractures. However, studies have hydrates. The major benefits for patients lying conditions, patients with chronic shown that fracture risk was similar for who decide to start a plant-based diet are disease who take multiple medications vegetarians and nonvegetarians. The key the possibility of reducing the number of need close monitoring of low blood to bone health is adequate calcium intake, medications they take to treat a variety of sugar levels, low blood pressure, or rapid which appears to be irrespective of dietary chronic conditions, lower body weight, weight loss. If these occur, the physician preferences.42 Some significant sources of decreased risk of cancer, and a reduc- calcium include tofu, mustard and turnip tion in their risk of death from ischemic cases, such as the one presented here, greens, bok choy, and kale. Spinach and heart disease.
eliminated altogether. Although the risk although abundant, is bound to oxalate nothing program, but a way of life that of deficiencies may be low, health care and therefore is poorly absorbed.43 is tailored to each individual. It may be teams need to be aware that a motivated Vitamin D deficiency is common in the especially beneficial for those with obe- patient on a strict plant-based diet may general population. Plant-based products sity, Type 2 diabetes, high blood pressure, need monitoring for deficiencies of certain such as soy milk and cereal grains may lipid disorders, or cardiovascular disease. nutrients, as outlined above.
be fortified to provide an adequate source The benefits realized will be relative to the level of adherence and the amount of physicians understand the potential ben- The Permanente Journal/ Spring 2013/ Volume 17 No. 2 Nutritional Update for Physicians: Plant-Based Diets efits of a plant-based diet, to the end of through healthy eating and active living. If McDougall cookbook: 300 delicious ultra-low- working together to create a societal shift we are to slow down the obesity epidemic fat recipes. New York, NY: Plume; 1997 Jan 1.
10. Ornish D, Brown SE, Scherwitz LW, et al. toward plant-based nutrition. There is at and reduce the complications of chronic Can lifestyle changes reverse coronary heart least moderate-quality evidence from the disease, we must consider changing our disease? The Lifestyle Heart Trial. Lancet 1990 literature that plant-based diets are as- culture’s mind-set from “live to eat” to Jul 21;336(8708):129-33. DOI: http://dx.doi.
sociated with significant weight loss and “eat to live.” The future of health care will 11. Ornish D, Scherwitz LW, Billings JH, et al. a reduced risk of cardiovascular disease involve an evolution toward a paradigm Intensive lifestyle changes for reversal of and mortality compared with diets that are where the prevention and treatment of 16;280(23):2001-7. DOI: http://dx.doi.
not plant based. These data suggest that disease is centered, not on a pill or surgi- plant-based diets may be a practical solu- cal procedure, but on another serving of 12. Esselstyn CB Jr. Prevent and reverse heart tion to prevent and treat chronic diseases.
disease: q & a with Caldwell B Esselstyn, Jr, MD [monograph on the Internet]. Lyndhurst, OH: Prevent and Reverse Heart Disease; [cited 2012 ways to make plant-based diets the new Disclosure statement
Oct 6]. Available from: www.heartattackproof.
The author(s) have no conflicts of interest We cannot cure chronic diseases, but we to disclose. Apr;64(4):175-88. DOI: http://dx.doi.
14. Farmer B, Larson BT, Fulgoni VL 3rd, Rainville Kathleen Louden, ELS, of Louden Health Communications provided editorial AJ, Liepa GU. A vegetarian dietary pattern as a nutrient-dense approach to weight manage- ment: an analysis of the national health and nutrition examination survey 1999-2004. J may be reluctant to support the efforts of References
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Let food be thy medicine and medicine be thy food.
— Hippocrates, c 460-370 BCE, ancient Greek physician in the Age of Pericles known as the father of modern medicine The Permanente Journal/ Spring 2013/ Volume 17 No. 2


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