Mediterr J Nutr Metab (2009) 2: DOI: 10.

1007/s12349-009-0059-y

MEDICAL HYPOTHESIS

VegPyramid: a proposal for a Vegetarian Food Guide for Italian people

Luciana Baroni

Received: 17 March 2009 / Accepted: 8 June 2009 / Published online: 21 October 2009 Springer-Verlag 2009

Abstract Vegetarian diets exclude any kind of meat. The vegan subtype also eliminates other animal products like eggs and dairy products. This classification, inspired by an exclusion principle, does not precisely describe the vegetarian dietetic pattern, better characterised by its positive content. Factors affecting the composition and the nutritional adequacy of a plant-based diet are, in fact, the variety and the degree of transformation of plant food, and the presence and the relative amount of indirect animal food. On the basis of these considerations, it can be very useful to classify the foods consumed in the context of a vegetarian diet into groups and transform the nutritional recommendations into a Food Guide, an easy tool to employ both for nutrition professionals and for vegetarian subjects. Our proposal for guidelines for Italian vegetarians, VegPyramid, allows the simplification of the planning of menus for vegetarian people, indicating the kind and the relative amounts of food to consume. Keywords Plant-food diet Vegetarian diet VegPyramid Food guide

Introduction Vegetarian diets exclude any kind of meat or processed animal food. The two main subtypes of vegetarian diets are lacto-ovo-vegetarianism, where animal products like eggs and dairy food are included, and veganism, where these types of food are excluded. Nevertheless, this negative principle cannot describe the vegetarian dietetic pattern well; it is better defined on the basis of a positive principle, inspired by the amount and variety of the food composing the diet, and on the degree of its transformation. A well balanced plant-based diet is not only nutritionally adequate namely safe regarding the risk of nutritional deficiency for all stages of the lifecycle (pregnancy, lactation, infancy, childhood, and adolescence), but offers some health benefits in the prevention and management of many important Western chronic diseases (cardiovascular disease linked to atherosclerosis and hypertension, overweight-obesity, diabetes, some types of cancer). Its nutritional composition is healthy thanks to lower levels of saturated fat, cholesterol, hemeiron and animal protein, and higher levels of carbohydrates, fibre, magnesium, potassium, folate and antioxidants such as vitamins C and E and phytochemicals [1]. Moreover, a plant-only diet has been shown to exert the lowest environmental impact [2]. A well balanced plant-based diet must adhere to some basic principles, first established about ten years ago at the Loma Linda University by an international team of researchers with expertise in vegetarian nutrition and later evolved thanks to new contributors: namely, the consumption of a variety of foods belonging to the five plant-food groups (cereals, legumes, vegetable, fruit and nuts/seeds); the optional consumption of milk and eggs;

L. Baroni ( ) Department of Neurorehabilitation Villa Salus Hospital via Terraglio 114 30174 Venice-Mestre, Italy e-mail: luciana_baroni@yahoo.it

Mediterr J Nutr Metab (2009)

respect of calorie requirements; the intake of natural, non-processed plant foods; attention towards the intake of the critical nutrients and discretionary calories [3, 4]. From a practical point of view, the planning of a vegetarian both lacto-ovo and vegan diet does not translate into the removal of animal foods from a meat-based diet, but, on the contrary, into the composition of a well balanced plant-food diet including, only if the client/patient agrees, small amounts of milk and egg. This action respects the principle of realising the nutritional adequacy of the diet by using healthy foods, that means non-processed plant foods. This principle should be respected for the planning of every type of diet, also for a meat-based diet, and the inclusion of any kind of animal (direct and indirect) food, in small amounts, should be the personal choice of the patient. Clearly, it is necessary for nutrition professionals to possess a deep knowledge of the large variety of plant foods available and of the criteria inspiring the realisation not only an adequate, but also a tasty menu. On the basis of these considerations, it can be very useful to classify the foods consumed in the context of a vegetarian diet into groups, containing foods similar in their nutritional composition. It can also be very useful to transform the nutritional recommendations into a Food Guide, an easy tool to employ for both nutrition professionals and vegetarian subjects. Moreover, adherence to the guidelines of a well balanced vegetarian diet allows the principle of nutritional adequacy to be surpassed, conferring to food a main role in the field of preventive medicine.

Although the USDA Dietary Guidelines for Americans, published in 2005, promote a healthy diet and include a section on vegetarian diets [5], the Italian Dietary Guidelines [6] do not take into account the needs of Italian vegetarians (actually about 6 million people [7]), for whom no information, advice or recommendation is available from government agencies.

Vegetarian Food Guide for Italian people: VegPyramid Our proposal of a Food Guide for Italian vegetarians, VegPyramid (Fig. 1 [8]), takes into account these considerations and the recommendations of the previous Dietary Guidelines for Vegetarians, General Population and Healthy Eating proposed in the USA [3, 4, 5, 9] and fits them into the framework of a Mediterranean diet. It indicates the amount of different foods to consume daily to obtain a well planned vegetarian (both lacto-ovo-vegetarian and vegan) Italian diet (Tables 1 and 2). VegPyramid classifies the foods consumed in the context of a vegetarian diet into 6 groups: (1) cereals or grains; (2) protein-rich foods (like legumes, nuts, soy derivates and seitan, milk and eggs); (3) vegetables; (4) fruits; and (5) fats. The 6th group is a cross-sectional group, encompassing foods belonging to the previous 5 groups that are particularly calcium-rich. The nutritional recommendations proposed in VegPyramid also take into account the discretionary calories and the intake of critical nutrients (omega-3 fatty acids, calcium and vitamin D, vitamin B12).

Fig. 1 VegPyramid: proposal of a Vegetarian Food Guide for Italian people [8]

Table 1 Number of servings and diet composition according to the calorie content of the diet [8, 17, 18]

Total calories

Cereals

Protein-rich foodsa,b

Vegetablesc

Fruit

Fat foodsb

Omega-3-rich foodsb

Calcium-rich foodsd

Essential kcal (ideal)

Essential kcal (real amount) Discretionary kcal (ideal) Protein (g) % Proteine Fat (g) % Fatf

Carbohydrate (g)

% Carbohydrateg Fibre (g)

Water (g)

Calcium (mg)

Phosphate (mg) Iron (mg)

Zinc (mg)

Sodium (mg)

Potassium (mg)

Magnesium (mg) RE (mg)

Vitamin C (mg)

Vitamin B1 (mg)

Vitamin B2 (mg)

Vitamin B3 (mEq) Tocopherol (mg)

Cholesterol (mg)

Saturated fats (g)

Monounsaturated fats (g) Polyunsaturated fats (g)

0 0 0 0 0 0 0 0 3.34 3.34 4.07 4.07 4.79 4.79 5.51 6.24 15.36 15.36 19.00 19.00 22.65 22.65 26.30 29.95 14.18 14.18 14.55 14.55 14.93 14.93 15.31 15.68

Mediterr J Nutr Metab (2009) 2:

1600 1800 2000 2200 2400 2600 2800 3000

7 8 9 10 11 12 13 14

5 5 5 5 5 6 6 6

4 4 4 4 4 4 4 4

2 3 3 4 4 4 4 4

2 2 3 3 4 4 5 6

2 2 2 2 2 2 2 2

6 6 6 6 6 6 6 6

1468 1605 1733 1910 2038 2190 2374 2488

1472 1633 1769 1929 2065 2196 2332 2468

132 195 267 290 362 410 426 512

64 68 70 74 76 82 85 87

16.7 15.9 15.2 14.6 14.1 14.3 13.9 13.5

44 45 50 51 57 60 65 71

25.6 23.5 24.5 22.8 23.6 23.4 24.1 24.7

222 259 279 316 336 357 378 398

57.7 60.6 60.4 62.6 62.2 62.3 62.0 61.7

34 38 39 42 43 44 44 45

829 962 969 1102 1108 1227 1233 1239

1171 1216 1224 1269 1277 1435 1442 1450

1345 1444 1511 1610 1676 1801 1867 1934

18 19 19 20 21 21 22 22

11 11 11 11 11 11 11 12

548 600 649 701 750 839 888 937

3909 4282 4329 4702 4750 4947 4995 5042

389 408 412 431 436 440 445 449

1017 1050 1052 1084 1086 1086 1088 1090

248 291 291 334 334 334 334 334

1.51 1.66 1.74 1.88 1.96 2.11 2.19 2.27

1.44 1.51 1.52 1.60 1.61 1.95 1.96 1.98

13.18 14.58 15.44 16.83 17.69 18.67 19.52 20.38

9.27 9.48 10.81 11.02 12.35 12.56 13.89 15.22

Recommended intakesh

536215

<30%16

>55%16

>2516

800100015 (>80016) 800100015

101815 (1516)

<600016

310015

60070015

6015

0.81.215

1.31.615

aThe

bThe

total number of servings includes 1 serving of nuts or seeds number of servings of the omega-3-rich foods must be included in the total number of servings of protein-rich foods or fat foods cThis number of servings must be considered the minimum one and can be increased ad libitum dThis total number of servings must be consumed as calcium-rich foods from the other food groups e,f,gCalories respectively from protein, fat and carbohydrates expressed as percent of total calories hRecommended intakes of nutrients for Italian adults [15, 16] are always below the intakes provided from the menu planning of VegPyramid, according to the Italian Database

71015

141815

Mediterr J Nutr Metab (2009)

Cereals or grains It is important, for the planning of vegetarian menus, to consider the inclusion of every type of grain or cereal (not only wheat, rice and corn but also the minor cereals like oat, barley, kamut, millet, rye, spelt) and of buckwheat, quinoa and amaranth. In fact, the protein quality is higher for minor cereals but it is the highest for buckwheat, quinoa and amaranth which belong to other botanic families. This choice is in accordance with the principle that the consumption of a large variety of food belonging to the same food group is important to assure the nutritional adequacy of the diet. All cereals can be consumed in their natural form of kernels (raw or cooked) or via their products (bread, pasta). According to the international recommendation on cereals, they should be consumed mainly as whole cereals [5].

like calcium and group B vitamins. Legumes, particularly, are a key component of the traditional Mediterranean diet, and their nutritional value is very high [10]. Dairy foods are included in the protein-rich food group of VegPyramid, while in the Dietary Guidelines for meateaters they constitute a food group apart and are considered the main source of calcium in the diet. VegPyramid, according to USA dietary recommendations for vegetarian diets, emphasises the intake of calcium from a large variety of plant foods, belonging to all the food groups of the Pyramid. Nuts and seeds, also present in the fat food group, should be consumed on a regular basis in every type of diet, including a meat-based diet, due to their favourable effect on cardiovascular risk [11]. Last but not least, they contribute to enhance the taste of preparations and, especially walnuts and flaxseeds, are fundamental foods, in the context of a vegetarian diet, to assure the adequate intake of omega-3 fatty acids [4].

Protein-rich food group Protein-rich foods in vegetarian diets are legumes, nuts, seeds, soy products, seitan and, for lacto-ovo-vegetarians, small amounts of dairy foods and eggs. They provide also good intakes of iron and the other main nutrients, Vegetables The intake of all the varieties of vegetables available on the market should be emphasised in every type of diet,

Table 2 Serving size specific for each food group of VegPyramid (edible part) Cereals Bread: 30 g Crackers (whole flour): 5 crackers Cereal kernels (rice, barley, corn, wheat, spelt, kamut, oat, rye, millet, quinoa): cooked, 80 g; raw, 30 g Pasta: cooked, 80 g; raw, 30 g Bulgur, cous cous: cooked, 80 g; raw, 30 g Popcorn: 30 g Ready-to-eat cereals: 30 g (enriched with calciuma) Vegetable rice-beverage: 125 ml (enriched with calciuma) Protein-rich foods Legumes (soybeansa): cooked, 80 g; raw, 30 g Tofua or tempeha, other soy products: 70 g Cow or soy milk or yogurt: 125 ml (enriched with calciuma) Meat analoguesa (with soy or gluten): 30 g Nut butter (almonda): 30 g Seed butter (sesame tahina): 30 g Nut (almonda) or seed (sesamea): 30 g Egg: 1 (no more than 12/week) Cheese: 20 g Vegetable Cooked or raw vegetable (rocketa, cabbagea, broccolia, artichokea, lettucea, endivea): 100 g Vegetable juice: 125 ml Fruit Raw fruit: 1, medium (150 g) Cooked or sliced fruit: 150 g Dry fruit: 2030 g Fruit juice (enriched with calciuma): 125 ml Fats Oil, mayonnaise (and soft margarine): 5 g Nut butter: 10 g Seed butter: 10 g Nuts and seeds: 10 g
a

Calcium-rich foods [8]

Mediterr J Nutr Metab (2009) 2:

Table 3 Nutritional composition of vegetables [17] P (g/100) Asparagus Beet Artichoke Green cabbage Cultivated mushrooms Porcini muschrooms Lettuce Eggplant Potato Pepper Tomato Spinach Zucchini Total 4.6 1.3 2.7 2.1 2.2 3.9 1.8 1.1 2.1 0.9 1 3.4 1.3 2.18 F (g/100) 0.20 0.10 0.20 0.1 0.30 0.70 0.40 0.40 1.00 0.30 0.20 0.70 0.10 0.36 C (g/100) 4.00 2.80 2.50 2.5 4.50 1.00 2.20 2.60 17.90 4.20 3.50 2.90 1.40 4.00 kcal/100 g 36.20 17.30 22.60 19.30 29.50 25.90 19.60 18.40 89.00 23.10 19.80 31.50 11.70 27.99 g/100 kcal 276.24 578.03 442.48 518.13 338.98 386.10 510.20 543.48 112.36 432.90 505.05 317.46 854.70 447.39 %kcal P 50.8% 30.1% 47.8% 43.5% 29.8% 60.2% 36.7% 23.9% 9.4% 15.6% 20.2% 43.2% 44.4% 35.1% %kcal F 5.0% 5.2% 8.0% 4.7% 9.2% 24.3% 18.4% 19.6% 10.1% 11.7% 9.1% 20.0% 7.7% 11.8% %kcalC 44.2% 64.7% 44.2% 51.8% 61.0% 15.4% 44.9% 56.5% 80.4% 72.7% 70.7% 36.8% 47.9% 53.2% AAlim leu lys lys lys sulf lys lys sulf leu tryp leu lys threo IC 69 80 52 54 95 68 66 76 88 71 45 100 77 72

P protein, F fat, C carbohydrate, kcal/100 g amount of calories in 100 g of food (edible part), g/100 kcal grams of food providing 100 kcal, %kcal P percent of total calories provided from protei, %kcal F percent of total calories provided from fat, %kcal C percent of total calories provided from carbohydrate, AAlim the limiting amino acid of the food, IC chemical index of the protein calculated from the limiting amino acid of the food and the same amino acid of the pattern proposed from FAO/WHO/UNU (1991) [17]

owing to their protective effect against many chronic degenerative diseases. In vegetarian diets, the consumption of large amounts of vegetables represents a rich source of micronutrients (vitamin C, beta-carotene, vitamin K, vitamin E, folic acid, phytochemicals, iron and calcium) but also of protein. In fact, the mean composition of vegetables, if expressed as calorie percentage, shows that over 30% of the total calorie amount can be referred to its protein content: an amount comparable with the protein content of legumes, traditionally considered the best source of vegetable protein (Table 3).

(ALA)). Two daily servings of omega-3-rich fat foods (flaxseeds, flaxseed oil, walnuts) provide about 46 g of ALA, the amount recommended for subjects who do not receive a preformed source of EPA and DHA [12].

Calcium-rich food group Dietary sources of calcium, in a vegetarian diet, should be obtained mainly or exclusively from plant food. All food groups in VegPyramid include some calcium-rich foods, mainly legumes, nuts, soy products and some vegetables (cruciferous, green leafy vegetables). The calcium-rich food group is a cross-sectional group, encompassing all the calcium-rich foods belonging to the previous 5 groups. Moreover, the market offers some plantderived beverages similar to milk (rice, soy, oat, almond) and supplemented with the same amount of calcium as provided by cow milk. Water, in addition, can represent a good source of calcium, both tap and mineral, especially if characterised by a high calcium content. One must consider that in a vegetarian diet the presence of factors negatively affecting the calcium balance is limited and that bone health can be enhanced by some particular factors like a high potassium, vitamin K and phytoestrogen content. One serving of a calcium-rich food can provide a mean intake of 100150 mg of calcium (Table 4) [8]. The vitamin D status can be satisfactory, at Italys latitude, thanks to regular exposure of the skin to sunlight. It has been estimated that 515 minutes of sun exposure to the face, hands and forearms can provide the endogenous synthesis of vitamin D, a vitamin that can be deficient in any type of diet [13].

Fruits Fruits are classified in the fourth food group of VegPyramid, distinct from the vegetable group. In fact, although fruits and vegetables share many similar proprieties, fundamentally they are not equivalent foods, and in any healthy diet it is important to consume food belonging to both the groups, enhancing the intake of vegetables over fruit.

Fats A well-planned vegetarian diet includes small amounts of fats (the intake of fats in VegPyramid is about 25% of the total calorie intake). Fats in vegetarian diets are vegetable oils, margarine and, again, nuts and seeds. Very important is the consumption of flaxseeds and flaxseed oil, which represent the richest sources of omega-3 fatty acids available on the market (in the form of alpha-linolenic acid

Mediterr J Nutr Metab (2009)

Intake of other critical nutrients The dietary intake of iron is commonly considered a critical issue in a vegetarian diet, although iron deficiency anaemia rates are similar in vegetarians and non-vegetarians [14]. Nevertheless, iron deficiency anaemia is the most common nutrition disease in women of fertile age and a well planned vegetarian diet must provide an adequate iron intake. Although the iron content in many common plant foods is high, they contain only non-heme iron, which is more sensitive than heme iron to both inhibitors and enhancers of iron absorption. The main inhibitor of iron absorption in vegetarian diets is phytate, while fibre appears to have a minor effect on iron absorption. As iron intake increases with increasing intake of phytate, effects on iron status are somewhat

less than might be expected. Anyway, vitamin C and other organic acids found in fruits and vegetables can enhance iron absorption and can help to reduce the effects of phytate [1]. The consumption of 6 servings of calcium-rich foods recommended in VegPyramid (with the exclusion of dairy foods), provides a notable intake of iron (Table 4), which can be increased with the consumption of other common iron-rich foods listed in Table 5, allowing adequate iron content in the diet, as shown in Tables 1,6-9. Small amounts of foods that can be considered exotic, like seaweeds, a rich source of iodine, containing also small amounts of DHA and taurine, can help to enhance the nutritional quality of a plant-based diet. A convenient alternative is to use 1 teaspoon of iodised salt, providing the daily LARN of 150 g [15].

Table 4 Calcium and iron content in 1 serving of calcium-rich foods of VegPyramid (and in water for calcium) [17, 18] Serving size Grains Ricemilk, plus calcium* Legumes, nuts and other protein-rich foods Legumes Soymilk, plus calciuma Tofu Soybeans, dried Tempeh Average content per serving Nuts Tahina Almond buttera Almonds, dried Average content per serving Other protein-rich foods Yogurt Cow milk Cheese (average) Average content per serving Vegetables Raw Rocket Green radicchio Endive Cabbage Cooked Turnip greens Chicory Thistle Artichoke Broccoli Cabbage Bruxelles cabbage Average content per serving Fruits Dried figs Water Calcium-rich watera (300 mg/l) Tap water (average)a (100 mg/l)
aNutritional label nd missing value

Calcium content (mg/serving) 150

Iron content (mg/serving) nd

125 ml

125 ml 70 g 30 g (80 g cooked) 70 g

150 111 77 70 102 245 83 72 133 156 150 111 139

0.50 1.86 2.07 1.89 2 2.64 nd 0.9 1.8 0.13 0.25 0.05 0.14

30 g 30 g 30 g

125 ml 125 ml 20 g

100 g 100 g 100 g 100 g 100 g 100 g 100 g 100 g 100 g 100 g 100 g

309 115 93 60 222 188 160 116 102 61 57 135 149 450 150

5.2 7.8 1.7 1.1 3.2 1.9 0.3 1.4 1.6 1.1 1.2 2 2.4 nd nd

5 figs 1500 ml 1500 ml

Mediterr J Nutr Metab (2009) 2:

Supplementation with vitamin B12, recommended in some situations regardless of the presence of animal food in the diet allows the completion of nutrient intake needed for a well balanced diet [4].
Table 5 Iron content in plant food and in some kinds of meat [17] Food (100 g of edible part) Bitter cocoa Bran Wheat germ Borlotti, canellini and black eye beans, lentils Green chicory, pistachios Soybeans, garbanzo beans, dried peaches, cashews Muesli, italian lupini, dried apricots, rocket, broad beans, dark chocolate Peas, oatflour, buckwheat Horse meat Prune, wheat Olives, peanuts, millet, hazelnuts, raisins Cooked lamb Whole wheat flour, almonds, dried figs, parboiled rice, spinaches Deer, guinea-fowl Dates, walnuts, whole wheat bread, corn Veal meat Pig, turkey and hen meat

Table 6-9 shows a 2000 kcal weekly vegan sample menu, and its nutritional content, according to Italian RDAs [15] and the European Nutritional objectives [16].

Iron (mg) 14.3 12.9 10.0 9.08.0 7.87.3 6.96.0 5.65.0 4.54.0 3.9 3.93.6 3.53.3 3.2 3.02.9 2.8 2.72.4 2.3 1.91.6

Table 6 Weekly vegan sample menu and its nutritional content (2000 kcal) [8, 17, 18]. Section 1: number of total daily servings Food Cereals Protein-rich foods Vegetables Fruit Fat foods Omega-3-rich foods Calcium-rich foods Total calories: 2000; Essential kcal (ideal): 1733; Discretionary kcal (ideal): 267 Table 7 Weekly vegan sample menu and its nutritional content (2000 kcal) [8, 17, 18]. Section 2: composition of daily breakfast, snacks and dinner Amount (g/ml) Breakfast Soymilk, fortified with calcium Cornflakes Whole grain toasted bread Pear or other fruit Morning snack Apple or other fruit Afternoon snack Banana Almonds or other nuts Beverages Calcium-rich water Tap water P protein-rich foods, C cereals or grains, F fruits 125 30 30 150 150 150 30 1000 1000 Servings (n) 1 (P) 1 (C) 1 (C) 1 (F) 1 (F) 1 (F) 1 (P) Servings (n) 9 5 4 3 3 2 6

Mediterr J Nutr Metab (2009)

Table 8 Weekly vegan sample menu and its nutritional content (2000 kcal) [8, 17, 18]. Section 3: daily composition of lunch and dinner Lunch Whole grain bread Olive oil Flaxseed oil, 1 tsp Day 1 Whole grain pasta with fresh tomato Tofu with rocket salad Day 2 Whole grain pasta with broccoli Seitan with lettuce salad Day 3 Whole grain pasta with Bruxelles cabbages Tofu with green salad Day 4 Whole grain pasta with cabbage Seitan with endive salad Day 5 Whole grain pasta with frozen peas Tempeh with roasted onions Day 6 Whole grain pasta with red peppers Seitan with green salad Day 7 Whole grain pasta with garlic, oil and chili pepper and onions Tofu with boiled french beans Amount (g/ml) 30 0 5 90 50 70 150 90 150 70 100 90 100 70 100 90 100 70 100 90 100 70 50 90 100 70 100 90 50 70 100 Servings (n) 1 (C) 0 1 (Fat/3) 3 (C) 0.5 (V) 1 (P) 1.5 (V) 3 (C) 1.5 (V) 1 (P) 1 (V) 3 (C) 1 (V) 1 (P) 1 (V) 3 (C) 1 (V) 1 (P) 1 (V) 3 (C) 1 (V) 1 (P) 0.5 (V) 3 (C) 1 (V) 1 (P) 1 (V) 3 (C) 0.5 (V) 1 (P) 1 (V) Dinner Whole grain bread Olive oil, 1 tsp Flaxseed oil, 1 tsp Garbanzo beans soup with spelt Roasted carrots and onions with spices Boiled lentils with whole rice Onions with cooked chicory boiled canellini beans with barley Boiled green cabbage with raw leeks Whole rice cooked with spinach Boiled soybeans with raw celery Boiled Borlotti beans with Corn and spices Roasted eggplants with rocket Boiled garbanzo beans with turnip green, Leeks with Boiled spelt and spices Roasted lentils with broccoli and boiled barley Lettuce salad Amount (g/ml) 60 5 5 60 30 150 50 60 30 50 100 60 30 150 50 30 150 60 50 60 30 150 100 60 150 50 30 60 150 30 100 Servings (n) 2 (C) 1 (Fat) 1 (Fat/3) 2 (P) 1 (C) 1.5 (V) 0.5 (V) 2 (P) 1 (C) 0.5 (V) 1 (V) 2 (P) 1 (C) 1.5 (V) 0.5 (V) 1 (C) 1.5 (V) 2 (P) 0.5 (V) 2 (P) 1 (C) 1.5 (V) 1 (V) 2 (P) 1.5 (V) 0.5 (V) 1 (C) 2 (P) 1.5 (V) 1 (C) 1 (V)

C cereals or grains, P protein-rich foods, V vegetables, F fruits, Fat fat foods, 3 omega-3-rich foods

Discretionary calories The consumption of food with a high density of nutrients, like natural plant food, can allow the intake of a small amount of discretionary calories in the diet. These calories can be provided as empty calories, but it is safer to consume healthy food, like vegetables and fruits, or use this amount of calories to implement the intake of oil and fats suggested in VegPyramid [5, 8].

Conclusions An abundant consumption of vegetables, fruits, cereals, nuts and legumes has been related to a lower risk for several chronic western diseases. Although vegetarian diets, as any other diet pattern, may have potential health risks (related to marginal intake of a few essential nutrients), from a public health viewpoint, the health benefits of a vegetarian diet far outweigh its potential risks [3]. This

Table 9 Weekly vegan sample menu and its nutritional content (2000 kcal) [8, 17, 18]. Section 4: total daily and weekly average nutritional content

Day

Essential kcal (real amount)

Protein (g)

% Protein Fat (g) % Fat

Carbohydrate (g) % Carbohydrate Fibre (g)

Water (g)

Calcium (mg)a

Phosphate (mg)a Iron (mg)a

Zinc (mg)a

Sodium (mg)a

Potassium (mg)a

Magnesium (mg)a RE (mg)a

Vitamin C (mg)a

Vitamin B1 (mg)a

Vitamin B2 (mg)a

Vitamin B3 (mEq)a Tocopherol (mg)a

Cholesterolo (mg) Saturated fats (g)a

Monounsaturated fats (g)a Polyunsaturated fats (g)a

0 0 0 0 0 0 0 0 4.27 19.48 3.09 17.18 3.87 18.47 3.01 17.08 4.61 19.44 3.49 18.13 3.95 18.57 3.76 18.34 33.84 165.06 15.45 10.21 13.61 9.93 13.09 12.01 13.89 12.60 113.4 0.2 6.2a

Mediterr J Nutr Metab (2009) 2:

1798.49 70.87 1714.49 71.49 1749.49 74.61 1801.59 81.76 1838.69 74.11 1732.72 70.46 1748.69 73.39 1769.17 73.81 1828 295.25 267 2036 24 60

51.62 42.82 48.77 54.33 51.24 46.20 48.21 49.03 441.23

278.92 274.62 268.65 259.08 287.33 272.16 271.41 273.17 1092.67

51.21 48.17 57.68 48.18 48.68 48.96 54.45 51.05

2952.30 2906.24 2941.61 2899.17 2935.52 2918.32 2950.68 2929.12

1829.04 1064.64 1549.84 1138.64 1211.24 1077.52 1422.34 1327.61

1139.21 961.11 1116.41 1120.11 1223.11 1019.10 1106.51 1097.94

21.68 16.10 24.82 18.24 22.38 21.18 17.09 20.21

8.32 6.18 4.18 4.38 4.09 4.01 7.28 5.49b

223.12 84.10 109.52 298.70 246.92 81.60 86.82 161.54

3353.06 2421.76 3168.06 4052.76 3504.86 2444.16 2659.46 3086.30

230.26 188.46 237.76 221.16 285.66 230.16 229.06 231.79

2945.14 769.64 872.14 1175.64 911.74 1163.14 543.64 1197.30

221.14 169.00 239.14 228.00 196.00 276.93 167.14 213.91

0.74 0.95 5.99 1.00 1.45 9.14 0.94 1.63 7.72 1.38 2.10 7.89 1.28 1.33 9.26 0.74 1.73 7.96 1.03 1.60 9.42 1.02b 1.54b 8.20b

8.92 9.13 8.92 9.13 8.92 8.92 8.92 8.98

1 2 3 4 5 6 7 Weekly average Calculated calories Discretionary calories Total calories % total kcala

16

Recommended intakesb

536215

<30%16

>55%16

>2516

800100015 (>80016)

800100015

101815 (1516)

<600016

310015

60070015

<10%16

aMissing

bRecommended

value for more listed foods intakes of nutrients for Italian adults [15, 16] are always below the intakes provided from the menu, according to the Italian Database, except for some of the nutrients missing in some foods of Italian Database [17]

71015

48%16

10

Mediterr J Nutr Metab (2009)

6. INRAN (Italian National Institute for the Research on Foods and Nutrition) (updated 2003) Dietary Guidelines for a Healthy Diet. Available at www.inran.it/servizi_cittadino/stare_bene/guida_ corretta_alimentazione/Linee%20Guida.pdf. (Accessed 3 March 2009) 7. Eurispes (2006) Rapporto Italia 2006 8. Baroni L (2009) VegPyramid, la dieta vegetariana degli italiani, 2nd Edn. Sonda, Casale Monferrato (AL) 9. Harvard School of Public Health (2007) The Nutrition Source. Healthy Eating Pyramid. Available at www.hsph.harvard.edu/nutritionsource/pyramids.html. (Accessed 3 March 2009) 10. Dilis V, Trichopoulou A (2009) Nutritional and health properties of pulses. Mediterr J Nutr Metab 1:149157 11. Hu FB, Stampfer MJ (1999) Nut consumption and risk of coronary heart disease: a review of epidemiologic evidence. Curr Atheroscler Rep 1:204209 12. WHO/FAO (2003) Diet, nutrition, and the prevention of chronic disease. Report of the Joint WHO/FAO expert consultation. WHO, Geneva. Available at http://whqlibdoc.who.int/trs/who_TRS_916.pdf. (Accessed 3 March 2009) 13. Holick MF (1996) Vitamin D and bone health. J Nutr 126:1159S1164S 14. Craig WJ (1994) Iron status of vegetarians. Am J Clin Nutr 59[Suppl]:1233S1237S 15. SINU (Italian Society of Human Nutrition) (updated 1996) LARN (Daily Recommended Levels of Intake of Nutrients for Italian Population). Available at www.sinu.it/larn/tab_rias.asp. (Accessed 3 March 2009) 16. Eurodiet Core Report (2001) Nutrition and Diet for Healthy Lifestyles in Europe. Science and Policy Implications. Public Health Nutr 4.2:19 17. INRAN (Italian National Institute for the Research on Foods and Nutrition) (2000, updated) Tables of Composition of Foods. Italian Database. INRAN 2000, EDRA. www.inran.it/servizi_cittadino/per_saperne_di_piu/tabelle_composizione_alimenti 18. USDA Nutrient Database. Available at http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl. (Accessed 3 March 2009)

is the reason why not only should vegetarian subjects receive information on how to achieve a well balanced vegetarian diet, but also a diet very rich in vegetables, vegetarian or quasi-vegetarian, should be promoted to the general population. This dietetic choice can help sustain the health of the environment as well. Our Mediterranean tradition can make it easier for the Italian population to adhere to a well balanced, plantbased dietary pattern. This proposal of Guidelines for Italian vegetarians, VegPyramid, allows simplification of the planning of menus for vegetarian people, and offers information on the kind and the relative amounts (servings) of food to consume.
Conflict of interest The author has no conflict of interest.

References
1. ADA & DoC (2003) ADA Report. Position of the American Dietetic Association and Dietitians of Canada: vegetarian diets. J Am Diet Assoc 103:748765 2. Baroni L, Cenci L, Tettamanti M, Berati M (2007) Evaluating the environmental impact of various dietary patterns combined with different food production systems. Eur J Clin Nutr 61:279286 3. Sabat J (2001) Vegetarian nutrition. CRC Series in Modern Nutrition, New York 4. Messina V, Mangels R, Messina M (2004) The dietitians guide to vegetarian diets. Issues and applications, 2nd Edn. Johnes and Bartlett Publishers, Sudbury, MA 5. USDA (2005) Dietary guidelines for Americans 2005. Available at www.healthierus.gov/dietaryguidelines; www.mypyramid.gov/tips_resources/vegetarian_diets_print.html. (Accessed 3 March)