VegetarianDietAdequate MJA2012

Editorial
5 MJA Open 1 Suppl 2 4 June 2012

MJA Open ISSN: 0025-729X 4 June 2012 1 2 5-5
MJA Open 2012 www.mja.com.au
MJA Open 2012
he current world food system is inequitable and
unsustainable, and is creating huge and costly
health problems.
1
Of the seven billion people in
the world, 1.5 billion are overweight or obese
2
while
almost a billion go to bed hungry each night.
3
The poor
are overrepresented in both groups.
Climate change will add pressure to food production,
especially if the surging populations in developing
countries aspire to a Western-style diet with its high
animal content. The modern Western diet also plays a
major role in the increasing incidence of non-
communicable diseases, which are currently responsible
for 63% of deaths throughout the world.
4
Dietary choices influence not only health, but also
greenhouse gas (GHG) emissions, with meals of similar
energy content differing in their emissions by a factor of
between two and nine.
5
Regional differences need to be
considered, but, in general, plant foods are associated
with lower GHG emissions than is meat, especially from
ruminant animals.
5
This has led climate change experts to
recommend a reduction in meat consumption, especially
from methane-producing cattle and sheep.
6
The
recommendation to reduce meat consumption in the
human diet dovetails with dietary guidelines for
increased consumption of vegetables, legumes, fruits,
nuts and wholegrain products, and with our knowledge
about Mediterranean dietary patterns, whose health
benefits are well documented.
7
A Meatless Mondays movement began in 2003, and
this is now promoted by many groups in Europe, Japan,
the United States, Britain, Canada, Israel and Australia.
In 2009, the Belgian city of Ghent was the first to officially
adopt weekly vegetarian days. San Francisco followed
with meat-free Mondays (dubbed Vegetarian Day) and a
major food service provider in the US now offers meatless
meals to its 10 million customers each Monday.
8
Johns
Hopkins Bloomberg School of Public Health embraced
the concept to improve personal health and reduce the
ecological footprint of food choices. They now provide
information and recipes to encourage people to begin
each week with healthy, environmentally friendly, meat-
free alternatives.
9
The English language has even responded with new
terms for those who wish to reduce their meat
consumption without going all the way to vegetarianism.
These include flexitarians, who occasionally add fish or
meat to their vegetarian choices, and vegivores who
describe their meals in terms of the plant foods, adding
animal protein almost as a condiment.
From a sustainability viewpoint, there is widespread
support for a reduction in meat consumption.
7,10
A
minority of people follow a vegetarian diet, and even
fewer espouse the principles of a totally vegan diet.
However, discussion of the adequacy and potential
problems of diets with no meat may also be relevant to
the increasing numbers of people who are aiming to eat
less meat. As issues of future food security and
sustainability force their way to prominence, these will
also need attention.
How healthy are diets that are partially or totally
vegetarian? Can they meet nutritional needs? Which
aspects need special attention? The articles in this
supplement investigate these questions and provide
evidence-based answers on the healthfulness and
adequacy of vegetarian and vegan diets. Most usefully,
they also highlight areas requiring special attention.
Addressing perceptions of likely problems with meat-
free diets is particularly useful. Fears that a diet without
meat may mean a lack of protein can be put to rest.
Concern about adequate intakes of iron and zinc are
A plant-based diet
good for us and for the planet
Feeding and greening the world requires a fresh look at plant foods
T
Rosemary A Stanton
OAM, PhD(Hon),
BSc, APD,
Nutritionist, Visiting
Fel low
1
1 School of Medical
Sciences, University of
New South Wales,
Sydney, NSW.
rosemary.stanton@
westnet.com.au
doi: 10.5694/mjao11.11508
Editorial
important, but need to be balanced with the risks of a
high meat intake, and specifically with too much haem
iron. The World Cancer Research Fund now considers
the evidence convincing that a high intake of red meat
causes colorectal cancer.
11
One mechanism that has
been proposed, and confirmed in ileostomy studies,
12
is
that haem iron facilitates the formation of carcinogenic
N-nitroso compounds.
The bodys ability to alter its absorption of iron, zinc
and other minerals in the context of various diets has
not been well addressed in the past. Previous
recommendations have also distorted the situation by
using absorption studies related only to a single meal.
13
Valid concerns and solutions are important for vitamin
B
12
and, possibly, also for long-chain omega-3 fatty acids.
Their inclusion in this supplement may stimulate new
ideas for innovation within the food industry for food
production.
Nutrition is a complex science and much remains to be
elucidated. Dietary patterns may be more important than
specific foods,
13
and plant foods contain hundreds of
protective factors. The positive aspects of a diet featuring
more plant foods may be more important than any
adverse effects of meat. It is worth noting, however, that
healthy Mediterranean and Asian dietary patterns feature
a wide variety of plant foods, and less meat and highly
processed foods and drinks than Western diets.
14
They
also offer pleasure for the palate, and it is pleasing that
each article in this supplement includes suggestions for
foods and eating patterns that not only provide the
nutrient in question, but also emphasise the diversity of
plant-food options.
Not everyone needs to or wants to become vegetarian,
but reducing our dependence on meat is a good recipe for
our own health and also that of our planet. Diets
dominated by plant foods are almost certainly the way of
the future.
Competing interests: No relevant disclosures.
Provenance: Commissioned by supplement editors; externally peer
reviewed.
1 McMichael A, Powles J, Butler C, Uauy R. Food, livestock production,
energy, climate change and health. Lancet 2007; 370: 1253-1263.
2 World Health Organization. Obesity and overweight. Fact sheet 311;
March 2011 http://www.who.int/mediacentre/factsheets/fs311/en/
(accessed Nov 2011).
3 Food and Agriculture Organization of the United Nations. Economic
and Social Development Department; September 2010. Global hunger
declining but still unacceptably high. http://www.fao.org/docrep/012/
al390e/al390e00.pdf (accessed Nov 2011).
4 United Nations General Assembly. Prevention and control of non-
communicable diseases. September 2011. http://www.un.org/en/ga/
ncdmeeting2011 (accessed Nov 2011).
5 Carlsson-Kanyama A, Gonzlez AD. Potential contributions of food
consumption patterns to climate change. Am J Clin Nutr 2009; 89
(Suppl): 1704S-1709S.
6 Garnaut R. The Garnaut climate change review. 2008 Garnaut review.
Canberra: Australian National University, 2008: 680. http://
www.garnautreview.org.au/2008-review.html (accessed Nov 2011).
7 Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits
of adherence to the Mediterranean diet on health: an updated
systematic review and meta-analysis. Am J Clin Nutr 2010; 92:
1189-1196.
8 Cappelaere A. Survey results from Sodexos Meatless Monday
initiative. Center for a liveable future website: 9 Apr 2012. http://
www.livablefutureblog.com/2012/04/survey-results-sodexo-
meatless-monday (accessed Apr 2012).
9 Johns Hopkins Bloomberg School of Public Health. The Johns Hopkins
Healthy Monday Project. Eating for the future. Meatess Monday. http://
www.jhsph.edu/clf/programs/eating/proj_meatless.html (accessed
Nov 2011).
10 Williams JE, Price RJ. Impacts of red meat production on biodiversity in
Australia: a review and comparison with alternative protein production
industries. Animal Prod Sci 2010; 50: 723-747.
11 World Cancer Research Fund and American Institute for Cancer
Research. Food, nutrition, physical activity, and the prevention of
cancer: a global perspective. Washington, DC: WCRF, 2007.
12 Kuhnle GG, Story GW, Reda T, et al. Diet-induced endogenous
formation of nitroso compounds in the GI tract. Free Radic Biol Med
2007; 43: 1040-1047.
13 Saunders AV, Craig WJ, Baines SK, Posen JS. Iron and vegetarian diets.
MJA Open 2012; 1 Suppl 2: 11-16.
14 Brunner EJ, Mosdl A, Witte DR, et al. Dietary patterns and 15-y risks of
major coronary events, diabetes, and mortality. Am J Clin Nutr 2008; 87:
1414-1421. J
Clinical focus
MJA Open2012 www.mja.com.au
MJA Open 2012
t is a common myth among both consumers and health
professionals that protein needs are difficult to meet on
a vegetarian diet. Our objectives in this article are to (i)
provide evidence from Australian research to show that
vegetarians, while consuming less protein than
omnivorous individuals, are meeting recommended
i ntakes of protei n; (i i ) summari se our current
understanding from the literature of the issues of protein
quality and protein combining in a vegetarian diet; (iii)
show that many plant foods contribute significant amounts
of protein to the diet and illustrate how protein needs can
easily be met on a vegetarian diet by including a variety of
these foods over the course of a day; and (iv) discuss the
role of protein in weight management and disease risk,
explaining why the lower protein intakes of vegetarians
may be beneficial with respect to some health outcomes.
Role of protein
Proteins are the major structural component of muscle and
other body tissues, and are used to produce hormones,
enzymes and haemoglobin. An adequate dietary intake of
protein is essential for growth and repair of body cells, the
normal functioning of muscles, transmission of nerve
impulses and immunity. Protein can also be used as
energy, but is not the bodys preferred energy source, so
this occurs only when the amounts of carbohydrate and
fats consumed are insufficient, and can be at the expense
of tissue maintenance, growth and repair, and immune
function.
1
Amino acids the building blocks of protein
Amino acids are classified as being either essential (or
indispensable), meaning the body cannot adequately
synthesise them and must obtain them from the diet, or
non-essential (or dispensable), indicating that the body
can make them (Box 1). However, a number of the latter
are conditionally indispensable under certain physiological
conditions and in certain disease states. In particular,
biosynthesis and/or intake of amino acids such as
glutamine, arginine and cysteine may be inadequate in
meeting physiological requirements during times of stress
such as illness, surgery or injury.
2
Infants and growing children have relatively higher
requirements compared to adults for indispensable amino
acids and some conditionally indispensable amino acids.
1,3
Protein quality
Protein foods that have large amounts of all essential
amino acids are often referred to as high-quality proteins.
These include foods of animal origin as well as a few plant
foods including soy and the grains quinoa and amaranth.
Other plant protein sources usually have all of the essential
amino acids, but the amounts of one or two of these amino
Protein and vegetarian diets
I
Summary
A vegetarian diet can easily meet human dietary
protein requirements as long as energy needs are
met and a variety of foods are eaten.
Vegetarians should obtain protein from a variety of
plant sources, including legumes, soy products, grains,
nuts and seeds.
Eggs and dairy products also provide protein for those
following a lacto-ovo-vegetarian diet.
There is no need to consciously combine different
plant proteins at each meal as long as a variety of
foods are eaten from day to day, because the human
body maintains a pool of amino acids which can be
used to complement dietary protein.
The consumption of plant proteins rather than animal
proteins by vegetarians may contribute to their
reduced risk of chronic diseases such as diabetes
and heart disease.
Kate A Marsh
AdvAPD,
MNutrDiet, PhD,
Director and
Senior Dietitian
1
Elizabeth A Munn
BSc, DipNutr&Diet,
Consul tant Dietitian
2
Surinder K Baines
BSc(Hons), APD, PhD,
Senior Lecturer,
Nutrition and Dietetics
3
1 Northside Nutrition
and Dietetics,
Sydney, NSW.
2 Sanitarium Health
and Wellbeing,
Berkeley Vale, NSW.
3 School of Health
Sciences, University
of Newcastle,
Newcastle, NSW.
kate@nnd.com.au
MJA Open 2012;
1 Suppl 2: 710
doi: 10.5694/mjao11.11492
1 Classification of amino acids
Essential (indispensable) Non-essential (dispensable)
Phenylalanine Aspartic acid
Valine Asparagine
Threonine Glutamic acid
Tryptophan Alanine
Isoleucine Serine
Methionine Cysteine*
Leucine Tyrosine*
Lysine Taurine*
Histidine Glycine*
Arginine*
Glutamine*
Proline*
* Conditionally indispensable. N
Clinical focus
acids may be low. For example, cereals, and especially
wheat, are particularly limited in their lysine content, and
legumes are low in methionine. In comparison to animal
proteins, plant proteins have lower levels of leucine,
methionine, lysine and tryptophan.
4
The protein quality of a given food can be determined by
the Protein Digestibility-Corrected Amino Acid Score
(PDCAAS), which evaluates protein quality based on both
the amino acid requirements of humans and their ability to
digest the food. Most animal proteins (including meat,
eggs and milk) have a PDCAAS score close to or equal to
1.0 (the maximum score), as does soy protein, but the
scores for other plant proteins are generally lower.
5
However, a combination of vegetable proteins with
adequate energy intake provides enough amino acids of
good quality to meet physiological needs.
6
The protein combining myth
As most plant foods contain limited amounts of one or
more essential amino acids, it was once thought that certain
combinations of plant foods had to be eaten at the same
meal to ensure a sufficient intake of essential amino acids.
While nutritional adequacy can be maintained by including
a variety of plant foods which complement each other in
terms of their amino acid profiles (eg, consuming a mixture
of grains and legumes or nuts), it is now known that strict
protein combining is not necessary, provided energy
intake is adequate and a variety of plant foods are eaten
each day.
6,7
The body maintains a pool of indispensable
amino acids which can be used to complement dietary
proteins; this is one reason why strict protein combining is
no longer considered to be necessary.
8,9
Recommended dietary intakes
Nutrient reference values (NRVs) for Australia and New
Zealand include a recommendation for an acceptable
macronutrient distribution range (AMDR) for protein of
15%25% of energy intake.
10
The AMDR is an estimate of
the range of intake for each macronutrient for individuals
(expressed as a percentage of total energy intake) that
would allow for an adequate intake of all the other
nutrients. The NRV document notes that while, on
average, only 10% of energy need be consumed as protein
to meet the physiological need for protein, this level is
insufficient to allow for estimated average requirements
(EARs) for micronutrients when consuming foods
commonly eaten in Australia and New Zealand.
10
In other
words, while consuming lower amounts of protein-rich
foods could meet the bodys protein needs, it would not
provide sufficient amounts of other nutrients found in
these foods including iron, zinc, calcium and vitamin B
12
.
Recommended dietary intakes (RDIs) for protein for
different sex and age groups are shown in Box 2.
The 1995 National Nutrition Survey (NNS) for
Australians found the mean daily protein intake for those
aged 19 years and over was 91 g or 17% of energy.
11
Mean
intakes for those aged 19 years and over were 109 g for
men and 74 g for women amounts well above the RDI.
Intakes were at least 60% greater than the RDI for most
groups, except those aged 65 years and over, whose mean
intakes were 84 g for men and 64 g for women; although
relatively lower, these amounts were still adequate in
terms of RDI. Children and adolescents were eating close
to or more than double their RDIs and, while pregnant
women were not surveyed separately, the average intake
for women would be adequate to meet the RDI during
pregnancy or lactation.
In general, studies of Australian vegetarians have found
that their protein intakes are significantly lower than those
of omnivores. A study of Australian men aged 2050 years
found that those on a lacto-ovo-vegetarian (LOV) diet
consumed 80g of protein per day (16% of energy) and
vegans consumed 81g of protein per day (12% of energy)
compared with 108g (17% of energy) for omnivores.
12
2 Recommended dietary intake (RDI)* of protein per day
10
Sex and age group RDI
Men
1970 years 64g
>70 years 81g
Women
1970 years 46g
Pregnant 5860g
Breastfeeding 6367g
>70 years 57g
Children
06 months 10g
712 months 10g
13 years 14g
48 years 20g
Boys 913 years 40g
Boys 1418 years 65g
Girls 913 years 35g
Girls 1418 years 45g
*The RDI is the average daily dietary intake level that is sufficient to meet the
nutrient requirements of nearly all healthy individuals (97%98%) of a
particular sex and life stage. N
3 Protein content of a range of plant foods and animal foods*
Plant foods
Protein
per 100g Animal foods
Protein
per 100g
Peanuts, raw 24.7g Lamb chop, grilled 32.6 g
Pumpkin seeds, raw 24.4g Beef, fillet, lean, grilled 31.9 g
Almonds, raw 20.0g Beef, round steak, grilled 31.6 g
Soybeans, cooked 13.5g Kangaroo, loin fillet, grilled 30.7 g
Tofu 11.9g Beef, sirloin steak, grilled 30.3 g
Lentils, cooked 6.8g Turkey breast, baked 29.4 g
Chickpeas, cooked 6.3g Chicken breast, baked 29.0 g
Baked beans 4.9g Pork fillets, trimmed, roasted 28.5 g
Quinoa, cooked
4.4g Cheese, cheddar 24.6 g

Amaranth, cooked
3.8g Salmon, Atlantic, grilled 24.3 g

Soy yoghurt 3.6g Bream, fillet, baked 22.0 g
Soy milk 3.14.2 g Egg, whole, boiled 12.4 g
Brown rice, cooked 3.0g Yoghurt, low-fat, containing fruit 5.2 g
*From Food Standards Australia New Zealand. NUTTAB 2010 online searchable database.
18
From United
States Department of Agriculture Nutrient Reference Database for Standard Reference.
19
N
Clinical focus
Among women aged 1845 years, those following a
vegetarian diet (LOV and vegan) had a mean protein intake
of 54g per day (14% of energy) compared with 67g per day
(18% of energy) for omnivores.
13
While the reported protein
intakes of vegetarians are significantly lower, it is clear from
these studies that most vegetarians and vegans still meet
the RDI for protein, and intakes are within the AMDR.
Do protein requirements differ for vegetarians?
Protein requirements for healthy adults have not been found
to differ according to whether dietary protein is
predominantly from animal, vegetable or mixed protein
sources provided soy protein or a variety of other vegetable
proteins is consumed.
14
However, studies comparing single
sources of protein have found significant differences between
plant and animal sources, particularly with cereal proteins
such as wheat and rice,
4,15-17
as their low lysine content may
be a limiting factor. Consequently, if protein intake was to be
restricted to a single plant source, such wheat, rice or legumes
(other than soy), then the amount of protein required to meet
essential amino acid needs may be increased.
7
Protein in a vegetarian diet
As discussed above, while vegetarian diets may provide
less protein than a non-vegetarian diet, they are still able
to meet protein requirements. If a vegetarian diet is
planned to meet the requirements for essential
micronutrients, including iron, zinc, calcium and vitamin
B
12
, it is likely that protein needs will be exceeded. Most
plant foods contain some protein, with the best sources
being legumes, soy foods (including soy milk, soy yoghurt,
tofu and tempeh), Quorn (mycoprotein), nuts and seeds.
Grains and vegetables also contain protein, but in smaller
amounts. Box 3 shows the protein content of common
plant foods and a comparison with animal protein sources.
Health professionals should encourage vegetarians to
include a variety of protein-rich foods each day, not only to
ensure an adequate intake of protein, but also to provide
sufficient iron, zinc, calcium and vitamin B
12
. This range of
foods should include:
legumes such as soybeans, chickpeas, lentils, kidney
beans, split peas and baked beans;
wholegrains such as brown rice, buckwheat, polenta,
quinoa and amaranth;
soy products such as soy beverages, soy yoghurt, and tofu;
nuts and seeds; and
dairy foods and eggs (for those following an LOV diet).
Box 4 shows a sample meal plan designed to meet daily
protein requirements as well as the requirements for all
micronutrients within an acceptable energy intake for a
woman aged 3150 years.
The benefits of plant protein
While the lower protein intake and quality of protein in a
vegetarian diet is often believed to be a concern, there is
increasing evidence that consuming protein from plant
rather than animal sources may, in fact, be one of the
reasons why vegetarians generally have a lower risk of
overweight, obesity and chronic disease. In comparison to
4 A sample vegetarian meal plan designed to meet the
protein and micronutrient requirements of a 3150-
year-old woman, showing protein content of the
foods*
Meal Protein content
Breakfast
Bowl of cereal with fruit, and poached egg on toast
2 wholegrain wheat biscuits 3.6 g
4 strawberries 0.8 g
10g chia seeds 2.0 g
1/2 cup low-fat soy milk 4.6 g
1 slice multigrain toast 3.4 g
1 poached egg (omega-rich egg) 6.0 g
Snack
Nuts and dried fruit
30g cashews 5.1 g
6 dried apricot halves 0.9 g
Lunch
Chickpea falafel wrap
1 wholemeal pita flatbread 6.2 g
1 chickpea falafel 9.1 g
30g hummus 2.8 g
1/2 cup tabouli 2.7 g
Salad 0.8 g
Snack
Banana and wheatgerm smoothie
2 teaspoons wheatgerm 0.7 g
1 banana 1.4 g
Dinner
Stir-fry greens with tofu and rice
100 g tofu 11.9 g
2 spears asparagus, 1/3 cup bok choy and
25g snow peas
2.4 g
12g cashews 2.0 g
1 cup cooked brown rice 6.6 g
Snack
Fortified malted chocolate beverage
1 cup low-fat soy milk 9.1 g
10g fortified malted chocolate powder 1.3 g
Total protein 90.2g
* Source: FoodWorks 2009 (incorporating Food Standards Australia New
Zealands AUSNUT [Australian Food and Nutrient Database] 1999),
Xyris Software, Brisbane, Qld. N
Clinical focus
protein foods of animal origin, most plant protein sources
are lower in saturated fat, free of cholesterol and haem
iron, higher in fibre, and are good sources of antioxidants
and phytochemicals, all of which may contribute to a
reduced disease risk.
A number of studies have shown that a higher intake of
protein, particularly animal protein, in infants and early
childhood may increase the risk of overweight and obesity in
later life.
20-22
In adults, the European Prospective
Investigation in Cancer and Nutrition (EPIC)-Oxford study
compared weight gain over 5 years among almost 22000
meat-eating, fish-eating, vegetarian, and vegan men and
women; it found that weight gain was lowest in the vegan
group and in those who, during follow-up, had changed to a
diet containing fewer animal foods.
23
The study also found
that meat-eaters had the highest body mass index (BMI) and
vegans the lowest BMI, while fish-eaters and vegetarians had
similar, intermediate mean BMIs.
24
Differences in
macronutrient intakes accounted for about half the difference
in mean BMI between vegans and meat-eaters, with high
protein and low fibre intakes most strongly associated with
increasing BMI.
24
More recently, a study of several cohorts
from the EPIC study participating in the diet, genes and
obesity (Diogenes) project reported that in contrast to plant
protein intake, total protein and protein from animal sources
was positively associated with subsequent weight gain
although there was no overall association between dietary
protein and change in waist circumference.
25
While the safety of high-protein, low-carbohydrate diets
is debated, the type of protein in such diets may be
important. A report of two cohort studies found that a low-
carbohydrate diet based on animal sources was associated
with higher all-cause mortality, while a vegetable-based
low-carbohydrate diet was associated with lower all-cause
and cardiovascular disease mortality rates.
26
Other studies
have shown benefits of plant protein compared with
animal protein for lowering blood pressure
27,28
and the risk
of type 2 diabetes
29,30
and of ischaemic heart disease in
healthy men.
31
Furthermore, consumption of soy protein
may slow the progression of kidney disease compared with
consumption of animal protein, particularly red meat.
32
Conclusion
Vegetarians who eat a range of plant foods can easily meet
their protein requirements, even though the protein
content of vegetarian diets is usually lower than that of
omnivorous diets. Most Australians eat significantly more
protein than is required. The consumption of plant protein
rather than animal protein may play a role in weight
management and reducing chronic disease risk.
Competing interests: Kate Marsh previously consulted for Nuts for Life
(Horticulture Australia). Elizabeth Munn consults for Nuts for Life and
Sanitarium Health and Wellbeing, and has previously consulted for Go
Grains Health and Nutrition, Avocados Australia, Healthy Food Guide
magazine, and the Almond Board of Australia. Go Grains Health and
Nutrition and Nuts for Life are providing a contribution towards the cost
of publishing this supplement.
reviewed.
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22 Koletzko B, von Kries R, Closa R, et al; European Childhood Obesity Trial
Study Group. Lower protein in infant formula is associated with lower
weight up to age 2 y: a randomized clinical trial. Am J Clin Nutr 2009; 89:
1836-1845.
23 Rosell M, Appleby P, Spencer E, Key T. Weight gain over 5 years in 21,966
meat-eating, fish-eating, vegetarian, and vegan men and women in EPIC-
Oxford. Int J Obes (Lond) 2006; 30: 1389-1396.
24 Spencer EA, Appleby PN, Davey GK, Key TJ. Diet and body mass index in
38000 EPIC-Oxford meat-eaters, fish-eaters, vegetarians and vegans.
Int J Obes Relat Metab Disord 2003; 27: 728-734.
25 Halkjr J, Olsen A, Overvad K, et al. Intake of total, animal and plant
protein and subsequent changes in weight or waist circumference in
European men and women: the Diogenes project. Int J Obes (Lond) 2011;
35: 1104-1113.
26 Fung TT, van Dam RM, Hankinson SE, et al. Low-carbohydrate diets
and all-cause and cause-specific mortality. Ann Intern Med 2010; 153:
289-298.
27 Elliott P, Stamler J, Dyer AR, et al. Association between protein intake and
blood pressure: the INTERMAP Study. Arch Intern Med 2006; 166: 79-87.
28 Altorf-van der Kuil W, Engberink MF, Vedder MM, et al. Sources of dietary
protein in relation to blood pressure in a general Dutch population. PLoS
One 2012; 7: e30582.
29 Pounis GD, Tyrovolas S, Antonopoulou M, et al. Long-term animal-protein
consumption is associated with an increased prevalence of diabetes
among the elderly: the Mediterranean Islands (MEDIS) study. Diabetes
Metab 2010; 36: 484-490.
30 Sluijs I, Beulens JW, van der A DL, et al. Dietary intake of total, animal, and
vegetable protein and risk of type 2 diabetes in the European
Prospective Investigation into Cancer and Nutrition (EPIC)-NL study.
Diabetes Care 2010; 33: 43-48.
31 Preis SR, Stampfer MJ, Spiegelman D, et al. Dietary protein and risk of
ischemic heart disease in middle-aged men. Am J Clin Nutr 2010; 92:
1265-1272.
32 Anderson JW. Beneficial effects of soy protein consumption for renal
function. Asia Pac J Clin Nutr 2008; 17 Suppl 1: 324-328. J
Clinical focus
Clinical Focus
ron is an essential nutrient for haemoglobin and
myoglobin formation and is vital for health and peak
performance. Much of our iron requirement is met
through recycling of the iron in red blood cells.
1
The amount
of iron stored is carefully regulated by intestinal absorption,
as we have a limited ability to excrete excess iron.
2
Groups considered at risk of iron deficiency
There are three levels of iron deficiency, in increasing order
of severity: depleted iron stores, early functional iron
deficiency and iron deficiency anaemia (Box 1). Iron
deficiency limits oxygen delivery to cells, resulting in
weakness, fatigue, reduced immunity, shortness of breath,
sensitivity to cold, and heart palpitations. Iron deficiency
anaemia in pregnant women can result in premature
delivery, low birthweight in infants and higher infant
mortality. Other symptoms include delayed psychomotor
development in infants and impaired cognitive function.
3
Iron deficiency is the most common nutritional
deficiency in the world, affecting about 25% of the global
population, particularly young women and children.
4
At
most risk are people who follow restricted diets. In
developing countries this is usually due to a limited food
supply, but in Western countries like Australia it is most
commonly seen in young obese women who follow
restricted energy diets to lose weight.
5
Iron deficiency is not always caused by inadequate
dietary intake, but may result from various medical
conditions. Dialysis treatment in people with chronic renal
failure can lead to loss of iron; gastrointestinal
inflammation (eg, in Crohns disease or coeliac disease)
may impair iron absorption; and gastrointestinal blood loss
(eg, associated with colorectal cancer, aspirin use or
genitourinary diseases) may cause iron deficiency,
particularly in older people. Excessive intake of zinc (due to
zinc supplementation) may also impair iron absorption.
3
It is commonly thought that vegetarians (people who
exclude meat, poultry and seafood from their diet, but
include dairy foods and/or eggs) and vegans (those who
exclude all animal products) may be more prone to iron
deficiency. Additional concerns about vegetarian diets
include lower bioavailability of iron from plant sources
(relative to animal sources) due to dietary inhibitors such
as phytate in plants. In this article we consider (i) whether
plant-based vegetarian diets can provide enough iron from
non-meat sources to prevent iron deficiency; (ii) factors
that affect how much iron we absorb; and (iii) whether the
higher recommended dietary intake (RDI) of iron for
vegetarians in the 2006 revised Nutrient reference values for
Australia and New Zealand including recommended dietary
intake
6
is warranted.
Types and best sources of iron
There are two types of iron in food: haem and non-haem
iron. In animal products, 40% of the total iron content is
haem iron and 60% non-haem iron.
7
Haem iron provides
10%15% of total iron in meat-eating populations, but
because of its higher and more uniform absorption
(estimated at 15%35%), haem iron could contribute at
least 40% of all iron absorbed.
8
Plant foods contain only
non-haem iron, which is found naturally in wholegrain
cereals and breads; dried beans and legumes; dark green
leafy vegetables; dried fruits; and nuts and seeds. Many
breakfast cereals and some breads are also fortified with
iron.
Even for non-vegetarians, most iron in the Australian
diet comes from plant foods rather than meat. Less than
20% of iron intake comes from meat and meat products
and about 40% comes from cereals and cereal products.
9
The same is true in the United Kingdom, where 45% of
dietary iron comes from cereals and cereal products and
less than 20% comes from meat and meat products.
10
Iron-
fortified cereals make an important contribution to iron
intake in both vegetarian and non-vegetarian meal plans,
particularly in energy-restricted diets.
5
RDIs for iron have
been set based on the assumption that a substantial
Iron and vegetarian diets
I
Summary
Vegetarians who eat a varied and well balanced diet
are not at any greater risk of iron deficiency anaemia
than non-vegetarians.
A diet rich in wholegrains, legumes, nuts, seeds, dried
fruits, iron-fortified cereals and green leafy vegetables
provides an adequate iron intake.
Vitamin C and other organic acids enhance non-haem
iron absorption, a process that is carefully regulated by
the gut.
People with low iron stores or higher physiological
need for iron will tend to absorb more iron and excrete
less.
Research to date on iron absorption has not been
designed to accurately measure absorption rates in
typical Western vegetarians with low ferritin levels.
Angela V Saunders
BS(Dietetics),
MA(Ldshp&MgmtHS),
APD,
Senior Dietitian,
Science and Advocacy
1
Winston J Craig
PhD, RD,
Professor of Nutrition
2
Surinder K Baines
Senior Lecturer,
3
Jennifer S Posen
MB BS, FRACP, FRCPA,
Clinical Haematologist
and Pathol ogy
Haematologist
4
1 Corporate Nutrition,
Sanitarium Health
and Wellbeing,
Berkeley Vale, NSW.
2 Nutrition and
Wellness Department,
Andrews University,
Berrien Springs,
Mich, USA
3 School of Health
of Newcastle,
Newcastle, NSW.
4 Sydney Adventist
Hospital, Sydney, NSW.
angela.saunders@
sanitarium.com.au
MJA Open 2012;
1 Suppl 2: 1116
doi: 10.5694/mjao11.11494
Clinical focus
amount of iron will come from non-meat sources. The iron
content per 100 g of commonly available plant and animal
foods is shown in Box 2. The iron content of plant sources
of iron per common serve size is shown in Box 3.
Iron stores: regulation, adaptation and impact on
absorption
The amount of non-haem iron absorbed is primarily
determined by the bodys need for iron people with the
lowest iron stores will absorb more and excrete less.
8,13
Humans can adapt successfully to a wide range of iron
requirements and intakes.
14
If iron intake is low,
vegetarians adapt by excreting less faecal ferritin. In
pregnant women, who need the most iron, absorption can
increase by 60% relative to normal.
15,16
Non-haem iron is
nearly as well absorbed as haem iron by people with very
low iron stores.
13
There is apparently no advantage in
storing more than a minimal amount of iron.
17
RDIs for
iron are set with the goal of maintaining serum ferritin
levels at 15 g/L or functional adequacy.
3
Haem iron and non-haem iron are both absorbed in the
small intestine, but via different mechanisms. Haem iron
is absorbed through the gut wall intact, regardless of how
much we need.
18
Non-haem iron absorption is more
carefully controlled, as it is more readily absorbed when
the body has need for iron a protective measure for iron
overload.
13
This sensitivity is vital, as the body has limited
mechanisms for excreting excess iron: shedding skin,
sloughing off of mucosal cells in the intestinal and urinary
tracts, loss of hair, and menstruation.
Bioavailability of iron: inhibitors and enhancers
Non-haem iron bioavailability is influenced by various
dietary components that either enhance or inhibit its
absorption. The efficiency of non-haem iron absorption in
people with low iron stores depends on these enhancing
and inhibiting food constituents being consumed
concurrently.
13
Although inhibitors and enhancers may
cancel each other out, particularly in a diet that includes a
wide variety of foods,
19
it is wise to be aware of their
possible effects until more is known about their full impact.
The main inhibitor of non-haem iron absorption is
phytate, or phytic acid, which is usually found in legumes,
nuts, wholegrain cereals and unprocessed bran. Processing
the wholegrain removes much of the phytate content, but
also removes other beneficial nutrients such as iron and
zinc. Soaking and sprouting legumes, grains and seeds
reduces phytate levels, as does leavening of bread.
20
Phytic
acid may actually provide health benefits as a potent
antioxidant, reducing the risk of several chronic diseases,
including various forms of cancer.
20-22
Other inhibitors of
non-haem iron absorption include polyphenol-containing
beverages such as tea (including herbal teas), coffee, cocoa
and red wines.
23
1 Three levels of iron deficiency*
There are three levels of iron deficiency commonly used to
evaluate iron status:
Depleted iron stores
Depleted iron stores are indicated by a serum ferritin level
of <1215g/L,
but no apparent limitation in iron supply. An

increased total iron binding capacity (TIBC) indicates depletion
of iron stores, but is a less precise measure than ferritin level.
Serum ferritin concentration <12g/L
TIBC >400g/dL
Early functional iron deficiency
In early functional iron deficiency, iron supply to the bone marrow
and other tissues is suboptimal, but there is no decrease in
haemoglobin level and therefore no anaemia.
Transferrin saturation < 16%
Iron deficiency anaemia
In iron deficiency anaemia, there is a measurable deficit in
erythrocytes, the most accessible functional compartment.
Haemoglobin concentration <135g/L (male); < 115g/L (female)
Mean cell volume < 80 fL
* Adapted from United States Institute of Medicine Panel on Micronutrients.
3

<12g/L in US; < 15 g/L in Australia. N
2 Iron content of commonly available plant and animal
foods*
Foods Iron per 100g
Plant foods
Iron-fortified breakfast cereals 4.016.0mg
Pumpkin seeds/pepitas 10.0mg
Iron-fortified bread 7.1mg
Sundried tomatoes 5.6mg
Sesame seeds/tahini paste 5.2mg
Cashew nuts 5.0mg
Mixed-grain bread roll 4.7mg
English spinach, raw 3.5mg
Dried apricots 3.1mg
Tofu, firm 2.9mg
Fortified malted chocolate beverage,
with whole milk
2.7mg
Dried dates 2.6mg
Lentils/soybeans/kidney beans 1.82.2mg
Amaranth, cooked 2.1mg
Tofu, silken/soft 1.8mg
Quinoa, cooked 1.5mg
Figs, dried 1.4mg
Baked beans 1.0mg
Animal foods
Liver, chicken/beef/veal 6.011.0mg
Kangaroo, fillet, grilled 4.1mg
Beef, round steak, grilled 3.3mg
Lamb chop, grilled 2.9mg
Beef, sirloin steak, grilled 2.2mg
Beef, fillet, lean, grilled 2.2mg
Egg, whole, boiled 1.6mg
Salmon, Atlantic, grilled 1.3mg
Pork fillets, trimmed 1.0mg
Turkey breast, baked 0.6mg
Chicken breast, baked 0.5mg
Bream/flathead, grilled 0.4mg
Cheese, cheddar 0.2mg
Milk, whole 0.04mg
*From Food Standards Australia New Zealand. NUTTAB 2010 online
searchable database.
11
N
Clinical focus
While some studies have found that oxalic acid (present
in spinach, silverbeet and beetroot leaves) may inhibit iron
absorption, recent studies suggest that its effects are
relatively insignificant.
24
Calcium has also been considered
an inhibitor of both haem and non-haem iron absorption,
but recent research suggests that, over a long period of
time, calcium has a limited effect on iron absorption
(possibly due to an adaptive physiological response).
25
Nevertheless, it may be best to avoid consuming high-
calcium supplements with meals.
26
The most significant enhancer of iron absorption is
vitamin C (both synthetic and dietary), which can enhance
absorption up to sixfold in those who have low iron
stores,
27
overcoming the effects of phytic acid,
polyphenols, calcium and milk proteins.
3,8,28,29
Absorption
is increased as much as three- to sixfold with the addition
of 50 mg of vitamin C per meal.
30
Vitamin C facilitates the
conversion of Fe
3+
(ferric) to Fe
2+
(ferrous) iron, the form in
which iron is best absorbed. Vegetarians typically have
high intakes of vitamin C from a wide variety of fruit and
vegetables. Meals rich in vitamin C may have no effect on
serum ferritin levels if iron stores are already elevated.
31
Other organic acids (citric, malic and lactic acids),
32
as
well as vitamin A and -carotene, enhance non-haem iron
absorption.
33
An ascorbic acid derivative, erythorbic acid
(E315), used widely as an antioxidant in processed foods,
appears to be almost twice as effective as ascorbic acid in
enhancing non-haem iron absorption.
34
Meat also enhances non-haem iron absorption, but
animal proteins (milk protein, egg proteins and albumin)
inhibit iron absorption.
7
It was previously thought that soy
protein also had an inhibitory effect on iron absorption,
35
but new research shows that iron in soy is in the form of
ferritin and is highly available. It has no negative effect on
iron status,
36,37
and is as well absorbed as iron from ferrous
sulfate.
38
Estimating how much iron we absorb
The amount of total iron available from a mixed diet
(including meat) is estimated at 18%, whereas the amount
of total (non-haem) iron available from a vegetarian diet is
considered to be about 10%.
3
Estimates of iron absorption
rates are based on short-term and single-meal studies
(meals high in inhibitors) that are usually carried out in
people with adequate iron stores. In such people, iron
absorption will have been down-regulated and is unlikely to
accurately reflect absorption over the long term. Single-
meal studies do not allow for intestinal adaptation involving
increased absorption and decreased losses.
39
For a more
accurate estimate of iron absorption in vegetarian diets,
studies need to be done on vegetarians (with the usual low
ferritin levels) who eat more typical vegetarian diets.
Some researchers state that concerns over non-haem iron
bioavailability and the effect of enhancers and inhibitors are
less important than previously thought,
19,28,39,40
and that
iron absorption is underestimated.
41
In fact, researchers
report that iron status is more important than bioavailability
in determining the amount of non-haem iron absorbed
8,13,42
and that, in women, menstrual blood loss (rather than
dietary composition) is the major determinant of iron
stores.
42
3 Plant sources of iron per common serve*
Source
Iron
per serve
Amaranth grain, cooked, 1 cup 5.2mg
Iron-fortified bread, 2 slices 4.2mg
Lentils, dried peas or beans, cooked, 1 cup 3.8mg
Iron-fortified breakfast cereals, average serve 1.23.0mg
Tofu, firm, 1/2 cup (100 g) 2.9mg
Quinoa, cooked, 1 cup 2.8mg
Cashews, 25 nuts (50g) 2.6mg
Tempeh (fermented soybean), cooked, 100g
2.2mg
Fortified yeast spread, 5 g 1.8mg
Baked beans, 1/2 cup (140g) 1.8mg
Soybeans, 1/2 cup (90 g) 1.8mg
Dried apricots, 10 halves (50 g) 1.6mg
Rolled oats, cooked, 1 cup 1.3mg
Fortified malted chocolate beverage, 1 tsp (5g) 1.3mg
Almonds, dry roasted, 2025 nuts (30 g) 1.1mg
Brown rice, 1 cup 1.0mg
Wheatgerm, 1 tbsp (10 g) 1.0mg
Broccoli, cooked, 1/2 cup (100 g) 1.0mg
tbsp = tablespoon. tsp = teaspoon. *From Food Standards Australia New
Zealand. AUSNUT 2007 online searchable database.
12
Source: product
information. N
4 Estimated average requirement (EAR)* and recommended dietary intake (RDI)
of iron per day, by sex and age group

6

Male Female Pregnant women Lactating women
Age
(years) EAR RDI
180%
of RDI EAR RDI
180%
of RDI EAR RDI
180%
of RDI EAR RDI
180%
of RDI
13 4mg 9mg 16.2mg 4mg 9mg 16.2mg
48 4mg 10mg 18mg 4mg 10mg 18mg
913 6mg 8mg 14.4mg 6mg 8mg 14.4mg
1418 8mg 11mg 19.8mg 8mg 15mg 27mg 23mg 27mg 48.6mg 7mg 10mg 18mg
1930 6mg 8mg 14.4mg 8mg 18mg 32.4mg 22mg 27mg 48.6mg 6.5mg 9mg 16mg
3150 6mg 8mg 14.4mg 8mg 18mg 32.4mg 22mg 27mg 48.6mg 6.5mg 9mg 16mg
5170 6mg 8mg 14.4mg 5mg 8mg 14.4mg
>70 6mg 8mg 14.4mg 5mg 8mg 14.4mg
* The EAR is a daily nutrient level estimated to meet the requirements of half the healthy individuals of a particular sex and life stage. The RDI is the average daily
dietary intake level that is sufficient to meet the nutrient requirements of nearly all healthy individuals (97%98%) of a particular sex and life stage. N
Clinical focus
Are vegetarians at risk of iron deficiency?
Vegetarian and vegan diets generally contain just as much
or more iron than mixed diets containing meat.
43-45
The
2003 UK National Diet and Nutrition Survey
46
showed
that a vegetarian diet was not associated with lower-than-
average total iron intake
47,48
and that there was little
association between indicators of iron status and dietary
iron intake.
42
Compared with meat-eaters, vegetarians
may often have lower serum ferritin levels (although still
within the normal range), even when their iron intakes are
adequate,
44,49-51
but the physiological impact of reduced
ferritin levels in vegetarians is unknown at this time.
Vegetarians may reduce their risk of low iron levels by
eating foods rich in enhancers, such as vitamin C and
organic acids.
47
In Western countries like Australia, where we enjoy a
varied food supply, vegetarians are no more likely to suffer
from iron deficiency anaemia than non-vegetarians.
13
Low
iron stores, without iron deficiency anaemia, have not
been shown to adversely affect function.
13
Iron deficiency
clearly impairs function only when haemoglobin
concentrations are measurably decreased, but this has not
been shown across all studies.
13,15
In the large European
Prospective Investigation into Cancer and Nutrition
(EPIC)-Oxford study of 43 000 women, vegetarians and
non-vegetarians had similar iron intakes and haemoglobin
concentrations.
44
Many studies in Western societies
suggest there is little difference, if any, in iron status
(measured by haemoglobin levels, haematocrit, total iron-
binding capacity, transferrin saturation and serum iron
levels) between vegetarians and non-vegetarians,
15,52
but a
number of studies suggest that vegetarians are at greater
risk of having low iron stores (as reflected by serum
ferritin).
15
Higher iron requirement for vegetarians is it
justified?
The current Australian RDI for iron is based on research by
the United States/Canadian Institute of Medicine (IOM),
which recommends for the first time that the iron
requirement for vegetarians be 1.8 times that of the regular
RDI.
6
Interestingly, the UK Food Standards Agency has
not set a higher iron requirement for vegetarians.
53
Although the research is far from conclusive, the IOMs
dietary reference intake committee appears to have used a
single 1991 study
19
to justify the 80% greater iron
requirement for vegetarians.
3
This is of questionable
validity, as the study was not looking at a typical Western
vegetarian diet, but rather at a diet that was specifically
designed to reduce the absorption of non-haem iron and
was only marginally vegetarian, as it contained limited
amounts of fruits and vegetables. One study group was
given meals that were designed to maximally enhance
non-haem iron absorption (meals included meat and
vitamin C-rich fruits and vegetables). Another group was
given meals designed to maximally inhibit non-haem iron
absorption (meals excluded meat and vitamin C-rich fruits
and vegetables but included foods and beverages high in
inhibitors). The IOM committee based its recommended
iron requirement for vegetarians on the latter group. This
5 A sample meal plan designed to meet the iron
requirements of a 1950-year-old vegetarian woman,
showing non-haem iron content of the foods*
Meal Iron content
Breakfast
Bowl of cereal with fruit, and poached egg on toast
2 fortified wholegrain wheat biscuits 3.0 mg
4 strawberries 0.3 mg
10 g chia seeds 0.7 mg
1/2 cup low-fat fortified soy milk 0.7 mg
1 slice multigrain toast and 1 teaspoon olive oil spread 0.8 mg
1 poached egg 1.0 mg
Snack
30 g cashews 1.5 mg
6 dried apricot halves 0.7 mg
Lunch
1 wholemeal pita flatbread 2.0 mg
1 chickpea falafel 2.9 mg
30 g hummus 0.8 mg
1/2 cup tabouli 1.6mg
Salad 0.3 mg
Snack
3/4cup low-fat fortified soy milk 1.0 mg
1teaspoon wheatgerm 0.3 mg
1 banana 0.4 mg
Dinner
100g tofu 7.9 mg
25 g snow peas
1.3mg
12 g cashews 0.6 mg
1 cup cooked brown rice 1.0 mg
Snack
1 cup low-fat fortified soy milk 1.3 mg
10 g fortified malted chocolate powder 2.5mg
Total iron 32.6mg
Zealand's AUSNUT [Australian Food and Nutrient Database] 1999), Xyris
Software, Brisbane, Qld. N
Clinical focus
same study concluded that iron bioavailability issues
(enhancers and inhibitors) are less important than has
been traditionally thought over the long term.
19
Current (2006) RDIs for iron
6
are shown in Box 4. The
current RDI for non-vegetarian women aged 1950 years
(18 mg/day) is slightly higher than the previous (1991) RDI
(16 mg/day).
54
The current estimated average requirement
(EAR) for iron for these women (ie, the daily nutrient level
estimated to meet the requirements of half the healthy
women in this group) of 8 mg/day, as compared with the
RDI, reflects the very high variability in iron requirements
among women because of significant differences in
menstrual loss.
6
For premenopausal women, blood loss
through menstruation is the most significant factor
affecting iron status, while dietary composition appears
largely unrelated to iron status.
55
A number of studies have
reported an association between the length of menstrual
periods and serum ferritin concentrations.
56
The higher RDIs for pregnant women (Box 4) ensure an
adequate supply of iron to the fetus and developing infant.
During pregnancy, iron absorption increases from 7% at 12
weeks to 36% at 24 weeks and 59% at 36 weeks.
16
The UK
Food Standards Agency has not set higher iron
requirements for pregnant women, assuming that existing
body iron stores (if adequate at conception) will provide
what is required, given that menstruation has ceased and
intestinal absorption has increased.
53
As iron absorption is substantially greater when the
body has a need, as in the case of pregnancy, it seems
reasonable to assume that the bioavailability of iron from
vitamin C-enhanced vegetarian meals will be considerably
greater when the long-term vegetarian has an increased
need for iron (as shown by a low ferritin level). Thus it is
pertinent to ask whether it is really necessary to
recommend a higher iron requirement for vegetarians
when adaptive processes respond to lower iron stores.
Future research with long-term vegetarians eating more
typical vegetarian meals over a period of time (rather than
examining responses relating to a single meal) would be
valuable in addressing this issue.
There is a higher prevalence of iron deficiency in obese
people, possibly due to inadequate iron intake or a higher
blood volume. Chronic inflammation in obese people is
associated with higher levels of hepcidin, which down-
regulates intestinal iron absorption. Serum ferritin is not
considered a good indicator of iron status in obese people,
as serum ferritin levels are elevated by inflammation.
5,57
A sample meal plan appropriate for 1950-year-old
lacto-ovo-vegetarian women, who have the highest iron
requirements of any group other than pregnant vegetarian
women, is shown in Box 5. The sample meal plan also
meets the requirements for other key nutrients (except
vitamin D and long-chain omega-3 fatty acids). For more
details on meeting nutrient reference values on a
vegetarian diet, as well as other sample meal plans, see the
article by Reid and colleagues (page 33).
58
Conclusion
Well planned vegetarian diets provide adequate amounts
of non-haem iron if a wide variety of plant foods are
regularly consumed. Research studies indicate that
vegetarians are no more likely to have iron deficiency
anaemia than non-vegetarians. Vegetarian diets are
typically rich in vitamin C and other factors that facilitate
non-haem iron absorption. The limited iron absorption
studies conducted to date have not yet clarified how much
iron Western vegetarians require daily. Research studies,
which have been used to set official RDIs, have not taken
into account long-term adaptive mechanisms, such as
increased absorption and reduced excretion when iron
stores are low, or during times of increased physiological
need.
Competing interests: Angela Saunders is employed by Sanitarium Health
and Wellbeing, sponsor of this supplement.
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pdfs/ndnsv3.pdf (accessed May 2012).
11 Food Standards Australia New Zealand. NUTTAB 2010 online
searchable database. http://www.foodstandards.gov.au/
consumerinforma tion/nuttab2010/nuttab2010onlinesearchable
database/online version.cfm (accessed Jun 2011).
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consumer information/ausnut2007/ausnut2007microsofte4060.cfm
(accessed Jun 2011).
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301-308.
15 Hunt JR, Roughead ZK. Nonheme-iron absorption, fecal ferritin
excretion, and blood indexes of iron status in women consuming
controlled lactoovovegetarian diets for 8 wk. Am J Clin Nutr 1999; 69:
944-952.
16 Whittaker PG, Barrett JF, Lind T. The erythrocyte incorporation of
absorbed non-haem iron in pregnant women. Br J Nutr 2001; 86:
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18 Geissler C, Powers H. Human nutrition. 11th ed. Edinburgh; New York:
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19 Cook JD, Dassenko SA, Lynch SR. Assessment of the role of nonheme-
iron availability in iron balance. Am J Clin Nutr 1991; 54: 717-722.
20 Harland BF, Morris ER. Phytate: a good or bad food component?
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21 Slavin JL. Mechanisms for the impact of whole grain foods on cancer
risk. J Am Coll Nutr 2000; 19 (3 Suppl): 300S-307S.
22 Fox CH, Eberl M. Phytic acid (IP6), novel broad spectrum anti-neoplastic
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in man by polyphenolic-containing beverages. Br J Nutr 1999; 81:
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24 genannt Bonsmann SS, Walczyk T, Renggli S, Hurrell RF. Oxalic acid
does not influence nonhaem iron absorption in humans: a comparison
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25 Mlgaard C, Kaestel P, Michaelsen KF. Long-term calcium
supplementation does not affect the iron status of 1214-y-old girls.
Am J Clin Nutr 2005; 82: 98-102.
26 Mangels R, Messina V, Messina M. The dietitians guide to vegetarian
diets: issues and applications. 3rd ed. Sudbury, MA: Jones and Bartlett
Learning, 2011.
27 Hallberg L. Bioavailability of dietary iron in man. Annu Rev Nutr 1981; 1:
123-147.
28 Hallberg L, Hulthn L. Prediction of dietary iron absorption: an
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29 Davidsson L. Approaches to improve iron bioavailability from
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30 Allen LH, Ahluwalia N. Improving iron status through diet. The
application of knowledge concerning dietary iron bioavailability in
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31 Hunt JR. High-, but not low-bioavailability diets enable substantial
control of womens iron absorption in relation to body iron stores, with
minimal adaptation within several weeks. Am J Clin Nutr 2003; 78:
1168-1177.
32 Gillooly M, Bothwell TH, Torrance JD, et al. The effects of organic acids,
phytates and polyphenols on the absorption of iron from vegetables.
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33 Garca-Casal MN, Layrisse M, Solano L, et al. Vitamin A and beta-
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reference values on a vegetarian diet. MJA Open 2012; 1 Suppl 2:
33-40. J
Clinical focus
Clinical Focus
lthough vegetarians have an overall lower risk of
common chronic diseases than non-vegetarians,
there are some nutrients, including zinc, that need
special attention in those who follow a vegetarian diet.
Since plant sources of zinc contain phytate and other
inhibitors of zinc absorption, vegetarians and vegans may
potentially be at risk of zinc deficiency. We present a review
of the evidence about zinc in relation to vegetarians,
including the bioavailability of zinc from plant sources. We
also consider the bodys adaptive homeostatic mechanisms
and what these mean in terms of vegetarians zinc status
and dietary requirements.
Zincs important role
Zinc is a trace mineral abundantly distributed throughout
all body tissues and fluids, and second only to iron among
trace elements in the body. It is essential for multiple
aspects of metabolism, including catalytic, structural and
regulatory functions, and also plays an important role in
the immune system.
1,2
Zinc is a catalyst for a large number
of metabolic enzymes (> 50).
2
It helps maintain structural
integrity of some proteins and can play a role in the
regulation of gene expression.
3
Sixty per cent of total body
zinc content is in skeletal muscle and 30% is in bone mass,
with plasma zinc representing less than 1%. High
concentrations are found in the choroid of the eye and in
prostatic fluids.
1
In blood plasma, zinc is bound to and
transported by albumin and transferrin.
4
Dietary sources of zinc
Dietary zinc is available from plant and animal sources
(Box 1). The recommended dietary intake (RDI) for
vegetarians is 12 mg/day for women and 21 mg/day for
men (Box 2). This is 150% of the RDI for the general
Australian population, based on the lower bioavailablity of
zinc from a vegetarian diet (see below). Lean red meat,
wholegrain cereals and legumes provide the highest
concentrations of zinc, generally in the range of 2.5
5.0 mg/100 g raw weight.
1
As zinc is contained within the
outer layer of grains, unrefined whole grains provide
higher concentrations of zinc than refined grains (up to
5.0 mg/100 g, compared with 1.0 mg/100 g).
7
Wholegrain
breads and cereals, rolled oats, brown rice, nuts, seeds,
legumes, tofu, soy products and fortified breakfast cereals
are important dietary sources of zinc for everyone, not just
vegetarians. Fruit and green leafy vegetables have much
lower concentrations of zinc due to their high water
content.
8
Bioavailability of zinc inhibitors and enhancers
The main inhibitor of dietary zinc absorption is phytic acid
found in legumes, unrefined cereals, seeds and nuts.
9
Phytate forms an insoluble complex by chelating with zinc,
inhibiting absorption.
10
The molar ratio of phytate to zinc
in the diet has been used to predict zinc bioavailability, and
ratios greater than 15 have been associated with
suboptimal zinc status.
11
The inhibitory effect can be overcome by food-
processing techniques that use enzymes or thermal
processing to hydrolyse phytic acid.
11
Wheat grain contains
the enzyme phytase that breaks down phytate during yeast
fermentation, and the heat during baking destroys over
50% of the phytate in yeast-leavened wholemeal breads or
sourdough breads.
10
Soaking and sprouting beans, grains
and seeds also reduces phytate.
12
Modern processing
methods such as leavening and fermentation often achieve
Zinc and vegetarian diets
A
Summary
Well planned vegetarian diets can provide adequate
amounts of zinc from plant sources.
Vegetarians appear to adapt to lower zinc intakes by
increased absorption and retention of zinc.
Good sources of zinc for vegetarians include whole
grains, tofu, tempeh, legumes, nuts and seeds, fortified
breakfast cereals and dairy products.
The inhibitory effects of phytate on absorption of zinc
can be minimised by modern food-processing methods
such as soaking, heating, sprouting, fermenting and
leavening.
Absorption of zinc can be improved by using yeast-
based breads and sourdough breads, sprouts, and
presoaked legumes.
Studies show vegetarians have similar serum zinc
concentrations to, and no greater risk of zinc
deficiency than, non-vegetarians (despite differences
in zinc intake).
Angela V Saunders
BS(Dietetics),
MA(Ldshp&MgmtHS),
APD,
Senior Dietitian,
1
Winston J Craig
PhD, RD,
Professor of Nutrition
2
Surinder K Baines
Senior Lecturer,
3
Sanitarium Health
and Wellbeing,
Berkeley Vale, NSW.
2 Nutrition and
Wellness Department,
Andrews University,
Berrien Springs,
Mich, USA.
3 School of Health
of Newcastle,
Newcastle, NSW.
angela.saunders@
sanitarium.com.au
MJA Open 2012;
1 Suppl 2: 1722
doi: 10.5694/mjao11.11493
Clinical focus
a molar ratio of phytate to zinc of below 12, so
bioavailability is less of an issue.
13
Zinc absorption from
some legume-based diets (eg, white beans and lupin
protein) is comparable with animal-protein-based diets
despite a higher phytate content in the legumes.
1
Due to
modern processing methods and the wide variety of plant-
derived foods rich in zinc, zinc deficiency is less likely to be
a problem in Western vegetarian diets compared with
plant-based diets in developing countries.
Taking iron supplements may also inhibit zinc
absorption, although the presence of iron in a meal that
also contains zinc does not reduce zinc absorption.
14
In the
past, calcium and dietary fibre were also thought to inhibit
zinc absorption; however, several studies have shown no
significant differences in zinc absorption when calcium
was added to infant cows milk formula compared with the
regular level of calcium.
12
Similarly, although foods high in
phytic acid also contain high amounts of dietary fibre, fibre
itself does not interfere with zinc absorption.
15
Some
studies have shown that the total amount of zinc in a meal
may have a greater effect on zinc absorption than the
presence of phytate. For example, in a comparison of white
and wholemeal bread, the much higher zinc content of
wholemeal bread resulted in more zinc being absorbed
overall, even though bioavailability was half that of the
white bread.
16
Sulphur-containing amino acids (cysteine and
methionine, found in a range of seeds, nuts, grains and
vegetables) and hydroxy acids (citric acid found in citrus
fruits, lactic acid in sour milk, malic acid in apples, tartaric
acid in grapes) bind to zinc and enhance its absorption.
12
Organic acids that are present in foods or produced
during fermentation can also enhance zinc absorption
but probably do so to a lesser extent than for iron
absorption.
17
Higher levels of dietary protein enhance
zinc absorption, as zinc binds to proteins. Different types
of protein influence zinc absorption in different ways.
Casein in milk has an inhibitory effect on zinc absorption,
whereas soy protein does not.
12
The greater availability of
zinc from human milk compared with cows milk, which
has a much higher casein content than human milk, is an
example of how protein digestibility influences zinc
absorption.
18
Zinc regulation, absorption and adaptation
The body has homeostatic mechanisms that tightly
regulate plasma zinc concentration in spite of diverse
dietary zinc intakes and differences in bioavailability.
18
These mechanisms maintain zinc sufficiency by reducing
endogenous zinc losses and increasing the efficiency of
zinc absorption.
2,19
Metallothionein and zinc transporters
sense zinc status and coordinate exogenous and
endogenous absorption, secretion and distribution.
7,20,21
If zinc balance is not maintained, zinc is mobilised from a
small, vulnerable and rapidly exchangeable pool.
2
Plasma
zinc concentrations and zinc bound to metallothionein
are part of the zinc pool. Considerable amounts of zinc
come from endogenous sources such as pancreatic
secretions.
19
Gut and pancreatic metallothionein
concentrations respond rapidly to changes in dietary zinc
intake, helping to maintain zinc homeostasis.
2
The
efficiency of zinc absorption also increases during periods
1 Examples of plant and animal sources of dietary zinc*
Plant-derived foods Zinc per 100g
Animal-derived
foods Zinc per 100g
Sun-dried tomatoes 13.6 mg Oysters, raw 47.9 mg
Zinc-fortified breakfast cereals 1.97.8 mg Oysters, smoked or
canned
14.7 mg
Pumpkin seeds 7.5 mg Beef, fillet, lean,
grilled
7.8 mg
Sunflower seeds 5.8 mg Lamb chop, grilled 5.4 mg
Sesame seeds/tahini 5.5 mg Cheddar cheese 3.6 mg
Pine nuts/cashews 5.35.5 mg Kangaroo fillet,
grilled
3.1 mg
Sausage, vegetarian, zinc
fortified
4.4 mg Pork fillet 2.4 mg
Flaxseed
4.3 mg Crabmeat, canned 2.2 mg

Almonds/pecans/brazil nuts 3.74.1 mg Fetta cheese 1.8 mg
Lentils/soy beans/kidney
beans, dried
3.04.0 mg King prawns 1.6 mg
Whole wheat biscuit breakfast
cereal
2.02.7 mg Egg, whole 1.2 mg
Bread roll, mixed grain, toasted 2.0 mg Milk, whole 0.4 mg
*From Food Standards Australia New Zealand. NUTTAB 2010 online searchable database.
5

From Food Standards Australia New Zealand. AUSNUT 2007 online searchable database.
6
N
2 Estimated average requirement (EAR)* and recommended dietary intake (RDI)
of zinc per day, by sex and age group

3
Male Female Pregnant women Lactating women
Age
(years) EAR
RDI,
general
RDI,
vegetarian EAR
RDI,
general
RDI,
vegetarian EAR
RDI,
general
RDI,
vegetarian EAR
RDI,
general
RDI,
vegetarian
13 2.5 mg 3 mg 4.5 mg 2.5 mg 3 mg 4.5 mg
48 3 mg 4 mg 6 mg 3 mg 4 mg 6 mg
913 5 mg 6 mg 9 mg 5 mg 6 mg 9 mg
1418 11 mg 13 mg 19.5 mg 6 mg 7 mg 10.5 mg 8.5 mg 10 mg 15 mg 9 mg 11 mg 16.5 mg
1930 12 mg 14 mg 21 mg 6.5 mg 8 mg 12 mg 9.0 mg 11 mg 16.5 mg 10 mg 12 mg 18 mg
3150 12 mg 14 mg 21 mg 6.5 mg 8 mg 12 mg 9.0 mg 11 mg 16.5 mg 10 mg 12 mg 18 mg
5170 12 mg 14 mg 21 mg 6.5 mg 8 mg 12 mg
> 70 12 mg 14 mg 21 mg 6.5 mg 8 mg 12 mg
* The EAR is the daily nutrient level estimated to meet the requirements of half the healthy individuals of a particular sex and life stage. The RDI is the average daily dietary intake level that is
sufficient to meet the nutrient requirements of nearly all healthy individuals (97%98%) of a particular sex and life stage. RDIs for vegetarians, according to Australian National Health and Medical
Research Council nutrient reference values, are 150% of corresponding RDIs for the general population. N
Clinical focus
of high physiological demand (infancy, pregnancy and
lactation).
22
Plasma zinc concentrations are also
influenced by infection, stress and fasting.
2
Adaptation appears to occur in vegetarians, with zinc
status likely to remain stable after an initial adjustment
period.
23,13
Reduced plasma and urinary zinc levels have
been seen in the first 3 months of changing to a
vegetarian diet, with no further reductions during 9
months of follow-up.
24
This may be due to reduced
endogenous zinc losses and increased efficiency of zinc
absorption.
2,3
Hence, vegetarians may have a lower zinc
intake than non-vegetarians, but their zinc status
appears to be protected after an initial adjustment
period.
Risk of zinc deficiency
The prevalence of zinc deficiency is low in developed
countries, whereas people in developing countries are at
greater risk due to marginal zinc intake and dependence
on unrefined grains, which are high in phytate. Diets in
developing countries are also low in fruits and vegetables,
foods that enhance zinc absorption and counteract the
effect of phytate. Zinc deficiency can cause higher
morbidity and mortality rates in children, and contributes
to impaired growth and development.
25
While zinc is involved in a wide variety of metabolic
processes, mild clinical deficiency of zinc is difficult to
detect or establish conclusively. The effects of mild or
marginal zinc deficiency are reduced growth rate, reduced
immunity, increased susceptibility to infection, impaired
taste acuity and poor wound healing.
1,26
The reasons for
primary zinc deficiency include poor dietary bioavailability
or high physiological demand during infancy, childhood,
pregnancy and lactation.
20
The effects of zinc deficiency
can be particularly apparent during periods of rapid
growth and development, such as i nfancy and
adolescence.
27
In a national random survey of Australian adults, daily
intakes of zinc were marginal, with 67% of men and
85% of women below the RDA (United States
recommended dietary allowance) for zinc.
28
Plasma or
serum zinc levels are the most commonly used indices
for evaluating zinc deficiency; however, plasma zinc
concentrations are not considered a sensitive enough
indicator to measure zinc status.
11
Consequently, with
the lack of sensitive clinical criteria, it is difficult to
evaluate the long-term effects of marginal or low zinc
intake in vegetarians.
23
Vegetarian zinc intake and status
Zinc intake is a challenge for vegetarians and non-
vegetarians alike. With good planning, vegetarians can
consume enough zinc from legumes, wholegrain
products and a frequent intake of nuts and seeds as well
as fruits and vegetables that enhance absorption. Overall,
zinc intakes from vegetarian diets are either similar to or
lower than non-vegetarian diets.
19
Because phytate or
other dietary inhibitors in vegetarian diets typically
decrease zi nc absorpti on, there i s normal l y a
compensatory improved efficiency of absorption and
excretion of zinc.
2,18,19
A US study showed that the average daily zinc intake of
long-term vegetarian women was 9.2 mg.
29
In contrast, a
more recent Australian study showed that the mean
dietary zinc intake of lacto-ovo-vegetarian women was
3 Zinc recommendations for men
Level of bioavailability: type of diet
Phytate: zinc
molar ratio
Assumed
bioavailability
WHO recommendation,
1965+ years
1
Australian RDI,* 1970+ years
for non-vegetarians
3
Low: entirely unrefined plant-based or vegan >15 15% 14 mg/day
Moderate: omnivore, vegetarian (lacto-ovo) and
vegan (includes some refined cereals)
515 30%35% 7 mg/day 14 mg/day
High: includes highly refined, low cereal fibre, large
amounts of meat
<5 50%55% 4.2 mg/day 14 mg/day
RDI = recommended dietary intake. WHO = World Health Organization. *The RDI is the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all healthy
individuals (97%98%) of a particular sex and life stage. N
4 Sources of zinc for lacto-ovo-vegetarians, per serve*
Food, serving size
Zinc
per serve
Brown rice, cooked, 1 cup 1.9mg
Tofu, firm, 100g 1.7mg
Cashews, 30g
1.7mg
Cheese, 2 slices (42g) 1.62.0mg
Lentils, 3/4 cup 1.6mg
Pine nuts, 30 g
1.6mg
Sundried tomatoes, 1 tablespoon (11.2 g) 1.5mg
Green peas, frozen, 1/2 cup 1.5mg
Soybeans, cooked/canned (1/2 cup) 1.3mg
Zinc-fortified breakfast cereals, 1/2 cup 1.2mg
Pumpkin seeds, 1 tablespoon (15 g)
1.2mg
Pecans, 30g
1.2mg
Brazil nuts, 30g
1.2mg
Egg, whole 1.2mg
Almonds, 30 g
1.1mg
Tempeh, 100g 1.1mg
Cows milk, 1 cup (250mL) 0.9mg
Sunflower seeds, 1 tablespoon (15 g)
0.9mg
Mixed-grain bread, 2 slices 0.7mg
Wholemeal bread, 2 slices 0.6mg
Cocoa powder, 1 tablespoon (7 g) 0.6mg
Peanut butter, 3 teaspoons (15 g) 0.5mg
Tofu, silken, 100 g 0.5mg
*From Food Standards Australia New Zealand. AUSNUT 2007 online
6
Foods likely to be high in phytate. N
Clinical focus
6.8 mg/day (only 57% of the RDI for vegetarian women
[Box 2]) compared with 8.4 mg/day in omnivorous
women.
30
Vegetarian men had a similar mean dietary zinc
intake to omnivorous men; the intake of 11.1 mg/day for
male lacto-ovo-vegetarians represented only 53% of the
RDI of zinc for vegetarian men (Box 2).
30
Despite lower
zinc intakes among vegetarians, mean serum zinc levels
were similar for female omnivores and vegetarians, and
higher in vegetarian men than omnivore men, and
vegetarians did not have a significantly greater risk of low
zinc status than omnivores.
30
Other studies have shown
that mean serum zinc concentrations for vegetarian
subjects were within the normal range.
29
Zinc balance can be maintained in vegetarians with the
inclusion of whole grains and legumes. An 8-week
controlled lacto-ovo-vegetarian and non-vegetarian
crossover design study showed that although vegetarian
diets supplied 14% less zinc and vegetarian women
absorbed 21% less zinc than the non-vegetarian group,
zinc balance was maintained in vegetarian women because
less zinc was excreted.
31
Further, when vegetarians had a
similar intake of zinc to omnivores and they consumed the
same amount of phytic acid, the absorption of zinc was
ultimately dependent on the concentration of zinc in the
food.
32
Modest supplementation of zinc or zinc-fortified
plant-derived food products may represent an efficient
way of providing further zinc through non-animal-based
sources.
Cross-sectional plasma zinc measurements have not
usually differed between vegetarians and non-
vegetarians.
23
Because of the bodys capacity to respond to
fluctuations in dietary zinc intake, plasma and serum zinc
levels only significantly drop (or dip) with severe dietary
restriction.
33
Sensitive indices for assessing zinc status are
unknown at present and require further research.
1
Research on metallothionein and zinc transporters is
proving promising.
2
Higher dietary requirements for vegetarians
The amounts of zinc required for vegetarians and the
general population are based on the amount of absorbed
zinc necessary to match total daily excretion of
endogenous zinc.
3
Yet the requirement for vegetarians has
been set at 1.5 times the zinc requirement of the general
population, apparently because of the higher content of
phytate in a vegetarian diet, and especially to allow for
diets with a phytate : zinc molar ratio >15.
3,8,23,14
This does
not appear to take into account the adaptative response of
reducing losses and increasing absorption efficiencies
mentioned earlier.
Of note, the World Health Organization recommends
only 14 mg/day of zinc for vegan men (considered to be on
a low bioavailability diet), and 7 mg/day for vegetarians
and omnivores,
1,23
which is significantly lower than the
Australian recommendation for vegetarian men, of 21 mg/
day, to meet 150% of RDI. (Box 3). The current Australian
RDI for men aged 1970 years who are not vegetarian or
vegan is 14 mg/day.
Box 4 shows sources of zinc from plant-derived foods,
dairy and eggs in common serve sizes. Food items that
are likely to be high in phytate, and not subjected to
zinc requirements of a 70+-year-old lacto-ovo-
vegetarian man, showing zinc content of the foods*
Meal Zinc content
Breakfast
Rolled oats (1/2 cup dry oats) with 1.0 mg
1/2 cup low-fat fortified soy milk 0.3 mg
2 tablespoons wheatgerm 0.9 mg
10 g chopped walnuts 0.3 mg
30 g pumpkin seeds 2.0 mg
1 banana 0.2 mg
Snack
1 apple 0.1 mg
Hot chocolate
2 teaspoons cocoa powder 0.3 mg
1 teaspoon sugar 0.0 mg
Lunch
Mixed-grain-bread sandwich
2 slices mixed-grain bread 0.7 mg
40 g cheese 2.0 mg
1/2 cup salad 0.1 mg
4 pieces sun-dried tomatoes 1.6 mg
Margarine 0.0 mg
125mL glass orange juice 0.3 mg
Snack
3 rye crispbread with 0.6 mg
1 tablespoon tahini 1.0 mg
3 teaspoons honey 0.3 mg
Dinner
Lentil curry with vegetables and rice
3/4 cup lentils 1.6 mg
1/2 cup pumpkin, 1/2 cup peas, 1/4 cup beans,
1/4 cup canned tomatoes
2.4 mg
40 g cashews 2.2 mg
2 teaspoons sesame seeds 0.3 mg
1 cup brown rice 1.6 mg
Snack
10 g walnuts 0.3 mg
Hot chocolate
2 teaspoons cocoa powder 0.3 mg
1 teaspoon sugar 0.0 mg
Total zinc
21.4mg
Zealands AUSNUT [Australian Food and Nutrient Database] 1999), Xyris
Clinical focus
processes that would reduce phytate (heating, leavening,
etc), are noted.
A sample meal plan appropriate for lacto-ovo-
vegetarian men, who have the highest zinc requirements
of either sex, is shown in Box 5. The sample meal plan also
meets the requirements for other key nutrients (except
vitamin D and long-chain omega-3 fatty acids).
3
Another
article in this supplement provides more details on
meeting nutrient reference values on a vegetarian diet, as
well as other sample meal plans (see page 33).
Conclusion
Well planned vegetarian diets can provide adequate zinc
for all age groups, and vegetarians appear to be at no
greater risk of zinc deficiency than non-vegetarians.
Important sources of zinc for vegetarians include
wholegrains, legumes and soy products, nuts, seeds, as
well as fortified cereals and dairy. Vegetarians in Western
societies have access to a wide variety of zinc-rich plant-
derived foods, and methods of food preparation can aid
zinc absorption. Concerns regarding the inhibitory effects
of phytate on zinc absorption are minimised by modern
food processing and cooking methods. RDIs for zinc are
formulated on the basis of the results from single meal
studies, which do not take into consideration the bodys
long-term compensatory mechanisms. This homeostatic
mechanism adapts to a lower zinc intake by absorbing
more zinc and excreting less. Further research is needed to
better understand zinc metabolism and requirements in
vegetarians.
Acknowledgements: We acknowledge the work of Simon Barden, who is
employed by Sanitarium Health and Wellbeing, and Nicole Brown (student
dietitian at the time of her contribution), who assisted with a scientific
literature review.
reviewed.
1 World Health Organization and Food and Agriculture Organization of
the United Nations. Vitamin and mineral requirements in human
nutrition: report of a joint FAO/WHO expert consultation, Bangkok,
Thailand, 2130 September 1998. 2nd ed. Geneva: FAO/WHO, 2004:
230-245.
2 King JC. Zinc: an essential but elusive nutrient. Am J Clin Nutr 2011; 94:
679S-684S.
4 Mahan LK, Escott-Stump S. Krauses food, nutrition, and diet therapy.
11th ed. Philadelphia, PA: Saunders Elsevier, 2004.
searchable database. http://www.foodstandards.gov.au/consumer
information/nuttab2010/nuttab2010onlinesearchabledatabase/
onlineversion.cfm (accessed Jun 2011).
6 Food Standards Australia New Zealand. AUSNUT (Australian Food and
Nutrient Database) 2007. AUSNUT 2007 Microsoft Excel files. Nutrient
file. http://www.foodstandards.gov.au/consumerinformation/
ausnut2007/ausnut2007microsofte4060.cfm (accessed Jun 2011).
7 Geissler C, Powers H. Human nutrition. 11th ed. Edinburgh; New York:
Elsevier/Churchill Livingstone, 2005.
8 Gibson RS. Zinc nutrition in developing countries. Nutr Res Rev 1994;
7: 151-173.
9 Adams CL, Hambidge M, Raboy V, et al. Zinc absorption from a low-
phytic acid maize. Am J Clin Nutr 2002; 76: 556-559.
10 Trk M, Carlsson NG, Sandberg AS. Reduction in the levels of phytate
during wholemeal bread making; effect of yeast and wheat phytases.
J Cereal Sci 1996; 23: 257-264. doi: 10.1006/jcrs.1996.0026.
11 Samman S. Zinc. Nutrition & Dietetics 2007; 64 Suppl s4: S131-S134.
doi: 10.1111/j.1747-0080.2007.00200.x.
12 Lnnerdal B. Dietary factors influencing zinc absorption. J Nutr 2000;
130 (5 Suppl): 1378S-1383S.
13 Hunt JR, Beiseigel JM, Johnson LK. Adaptation in human zinc
absorption as influenced by dietary zinc and bioavailability. Am J Clin
Nutr 2008; 87: 1336-1345.
14 Chiplonkar SA, Agte VV. Predicting bioavailable zinc from lower phytate
forms, folic acid and their interactions with zinc in vegetarian meals.
J Am Coll Nutr 2006; 25: 26-33.
15 Sandstrm B, Almgren A, Kivist B, Cederblad A. Zinc absorption in
humans from meals based on rye, barley, oatmeal, triticale and whole
wheat. J Nutr 1987; 117: 1898-1902.
16 Sandstrm B, Arvidsson B, Cederblad A, Bjrn-Rasmussen E. Zinc
absorption from composite meals. I. The significance of wheat
extraction rate, zinc, calcium, and protein content in meals based on
bread. Am J Clin Nutr 1980; 33: 739-745.
diets: issues and applications. 3rd ed. Sudbury, Mass: Jones & Bartlett
Learning, 2011.
zinc. Washington, DC: National Academy Press, 2001. http://
www.nap.edu/openbook.php?record_id=10026&page=R1 (accessed
Apr 2012).
19 National Research Council. Dietary reference intakes: the essential
guide to nutrient requirements. Washington, DC: National Academies
Press, 2006. http://www.nap.edu/catalog.php?record_id=11537
(accessed May 2012).
20 Krebs NF. Overview of zinc absorption and excretion in the human
gastrointestinal tract. J Nutr 2000; 130 (5 Suppl): 1374S-1377S.
21 Maret W, Sandstead HH. Zinc requirements and the risks and benefits
of zinc supplementation. J Trace Elem Med Biol 2006; 20: 3-18.
22 Krebs NF, Hambidge KM. Zinc requirements and zinc intakes of breast-
fed infants. Am J Clin Nutr 1986; 43: 288-292.
24 Srikumar TS, Johansson GK, Ockerman PA, et al. Trace element status
in healthy subjects switching from a mixed to a lactovegetarian diet
for 12 mo. Am J Clin Nutr 1992; 55: 885-890.
25 Brown KH, Rivera JA, Bhutta Z, et al. International Zinc Nutrition
Consultative Group (IZiNCG) technical document #1. Assessment of
the risk of zinc deficiency in populations and options for its control.
Food Nutr Bull 2004; 25 (1 Suppl 2): S99-S203.
26 Shankar AH, Prasad AS. Zinc and immune function: the biological basis
of altered resistance to infection. Am J Clin Nutr 1998; 68 (2 Suppl):
447S-463S.
27 Black MM. Zinc deficiency and child development. Am J Clin Nutr 1998;
68 (2 Suppl): 464S-469S.
28 Baghurst KI, Dreosti IE, Syrette JA, et al. Zinc and magnesium status of
Australian adults. Nutr Res 1991; 11: 23-32. doi: 10.1016/S0271-
5317(05)80147-2.
29 Anderson BM, Gibson RS, Sabry JH. The iron and zinc status of long-
term vegetarian women. Am J Clin Nutr 1981; 34: 1042-1048.
30 Ball MJ, Ackland ML. Zinc intake and status in Australian vegetarians.
Br J Nutr 2000; 83: 27-33.
31 Hunt JR, Matthys LA, Johnson LK. Zinc absorption, mineral balance, and
blood lipids in women consuming controlled lactoovovegetarian and
omnivorous diets for 8 wk. Am J Clin Nutr 1998; 67: 421-430.
32 Kristensen MB, Hels O, Morberg CM, et al. 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; 95: 963-967.
33 King JC, Shames DM, Woodhouse LR. Zinc homeostasis in humans.
J Nutr 2000; 130 (5 Suppl): 1360S-1366S. J
Clinical focus
Clinical Focus
egetarians have a lower overall risk of common
chronic diseases, possibly due to a lower saturated
fat and cholesterol intake than non-vegetarians.
1
However, vegetarians (and those who eat minimal
amounts of oily fish) may be at a disadvantage where
intake of essential fatty acids (EFAs) is concerned, and this
could potentially counteract some health benefits of the
vegetarian diet. In this article, we review EFA intake and
status of vegetarians and consider whether current intakes
in this population are sufficient to achieve and maintain
optimal health. We also explore the potential benefits of
adding supplemental sources of docosahexaenoic acid
(DHA) and eicosapentaenoic acid (EPA) derived from
microalgae, and make practical suggestions for optimising
EFA status in vegetarians.
Functional and biological aspects of EFAs
Fats i n foods and the body contain saturated,
monounsaturated and polyunsaturated fatty acids
(PUFAs), the latter comprising omega-6 (n-6) and omega-
3 (n-3) families. There are two EFAs: linoleic acid (LA), the
parent of the n-6 fatty acid family; and -linolenic acid
(ALA), the parent of the n-3 fatty acid family. EFAs cannot
be synthesised by the body and therefore must be supplied
by the diet. LA and ALA can be converted by enzymes into
long-chain PUFAs
2
LA is a precursor of arachidonic acid
(AA), and ALA is a precursor of EPA, DHA and
docosapentaenoic acid (DPA), with stearidonic acid (SDA)
an intermediate in the pathway. The long-chain PUFAs are
not technically essential because they can be produced
endogenously, but they can become essential if insufficient
precursor is available for their production.
AA and EPA act as substrates for eicosanoids
(prostaglandins, thromboxanes, leukotrienes and
prostacyclins) that regulate inflammation, platelet
aggregation and blood clotting, blood vessel contraction
and dilation, muscle contraction and relaxation, immune
responses and regulation of hormone secretion.
Eicosanoids from n-3 PUFA (3-series) have opposing
effects to those from n-6 PUFA (2-series). Eicosanoids
from AA are very potent and overproduction is associated
with increased risk of disease (heart disease,
cancer, diabetes, osteoporosis, and immune and
inflammatory disorders).
2-4
Eicosanoids from
EPA are less potent and have anti-inflammatory
properties that assist in preventing coronary
heart disease, hypertension, autoimmune
diseases, arthritis and several cancers.
2-4
Extremely powerful mediators called protectins
(derived from DHA) and resolvins (derived
from DHA and EPA) help protect against and
resolve inflammation.
5
Long-chain n-3 PUFAs
al so favourably affect cel l membranes,
enhancing intracellular signalling processes and
gene expression. DHA is particularly abundant in the
cerebral cortex, retina, testes and semen.
2,6,7
LA and ALA share the same pathway and enzymes for
conversion to long-chain PUFAs. An excess of LA,
common in Western diets, can suppress conversion of ALA
to EPA and DHA and increase production of AA. This in
Omega-3 polyunsaturated fatty acids and
vegetarian diets
V
Summary
While intakes of the omega-3 fatty acid -linolenic acid
(ALA) are similar in vegetarians and non-vegetarians,
intakes of eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA) are low in vegetarians
and virtually absent in vegans.
Plasma, blood and tissue levels of EPA and DHA are
lower in vegetarians than in non-vegetarians, although
the clinical significance of this is unknown. Vegetarians
do not exhibit clinical signs of DHA deficiency, but
further research is required to ascertain whether levels
observed in vegetarians are sufficient to support
optimal health.
ALA is endogenously converted to EPA and DHA, but
the process is slow and inefficient and is affected by
genetics, sex, age and dietary composition.
Vegetarians can take practical steps to optimise
conversion of ALA to EPA and DHA, including reducing
intake of linoleic acid.
There are no official separate recommendations for
intake of fatty acids by vegetarians. However, we
suggest that vegetarians double the current adequate
intake of ALA if no direct sources of EPA and DHA are
consumed.
Vegetarians with increased needs or reduced
conversion ability may receive some advantage from
DHA and EPA supplements derived from microalgae.
A supplement of 200300 mg/day of DHA and EPA is
suggested for those with increased needs, such as
pregnant and lactating women, and those with
reduced conversion ability, such as older people or
those who have chronic disease (eg, diabetes).
Angela V Saunders
BS(Dietetics),
MA(Ldshp&MgmtHS),
APD,
Senior Dietitian,
1
Brenda C Davis
HBASc(Human
Nutrition), RD,
Consul ting Dietitian,
2
and Lead Dietitian
3
Manohar L Garg
PhD, MND, MSc,
Professor and Director,
Nutraceuticals
Research Group
4
Sanitarium Health
and Wellbeing,
Berkeley Vale, NSW.
2 Kelowna,
British Columbia, Canada.
3 Diabetes Wellness
Center, Majuro,
Marshall Islands.
4 School of Biomedical
Sciences and Pharmacy,
University of Newcastle,
Newcastle, NSW.
angela.saunders@
sanitarium.com.au
MJA Open 2012;
1 Suppl 2: 2226
doi: 10.5694/mjao11.11507
Abbreviations
AA arachidonic acid
AI adequate intake
ALA -linolenic acid
DHA docosahexaenoic acid
DPA docosapentaenoic acid
EFA essential fatty acid
EPA eicosapentaenoic acid
LA linoleic acid
n-3 omega-3
n-6 omega-6
PUFA polyunsaturated fatty acid
SDA stearidonic acid
Clinical focus
turn can have significant adverse consequences for
health.
2,8,9
The balance of LA and ALA can be even more
precarious in vegetarian diets, as vegetarians largely rely
on conversion for the production of long-chain n-3 PUFAs
and their metabolites.
10,11
Other dietary factors associated
with reduced conversion are trans fatty acids and excesses
of alcohol and caffeine. Nutritional inadequacies such as
protein deficiency or lack of vitamin and mineral cofactors,
especially zinc, magnesium, niacin, pyridoxine and vitamin
C, can diminish the activity of conversion enzymes.
12
Non-
dietary factors that negatively affect conversion are
genetics, sex (young males convert less efficiently than
young females), advancing age, chronic disease (eg,
diabetes, metabolic syndrome, hypertension and
hyperlipidaemia) and smoking.
12,13
Dietary sources of PUFAs
The n-3 PUFAs ALA and SDA originate from land plants,
whereas EPA, DHA and DPA that occur in fish or other
seafood originate from marine plants (eg, microalgae). The
n-6 fatty acid LA originates from land plants, and AA
originates from animal-based foods. Box 1 shows
important dietary sources of PUFAs.
EFA intake and status of vegetarians
While ALA intakes are similar among vegetarians, vegans
and non-vegetarians, LA intakes tend to be somewhat higher
among vegetarians and vegans.
14-18
In one study, vegetarians
and vegans averaged 19.4g/day of LA and 1.34g/day of ALA
compared with 13.1g/day of LA and 1.43g/day of ALA for
meat eaters.
17
These findings are consistent with other
research studies.
19
By excluding fish and other seafood,
intakes of EPA and DHA are low in vegetarian diets and
virtually absent in the vegan diet.
Plasma, blood and tissue concentrations of EPA and
DHA are about 30% lower in vegetarians and 40%50%
lower in vegans than in non-vegetarians.
6,14,17,20
A large
prospective study in the United Kingdom (196 meat-
eaters, 231 vegetarians and 232 vegans) reported no
change in long-chain n-3 PUFA status in vegetarians and
vegans over time (< 1 year to >20 years), suggesting that
endogenous synthesis of EPA and DHA from ALA was
sufficient to keep levels stable over many years.
6
It is unknown whether the lower DHA levels reported in
vegetarian and vegan populations have adverse
consequences for health,
19
although increased platelet
aggregation has been reported and is thought to be linked
to poor n-3 status and high n-6 intake.
21
However,
vegetarians tend to have more favourable results for other
clotting factors, including factor VII and fibrinogen, and for
fibrinolysis.
22-24
Regardless, low plasma levels of DHA are
a potential concern, due to the importance of DHA for the
development and maintenance of retinal and neural tissue,
and its role as an indirect substrate for eicosanoids,
resolvins and protectins.
14
EFA requirements and adequate intakes
The minimum intake of EFAs to prevent deficiency is
estimated to be 2.5% of daily energy intake as LA, plus
0.5% as ALA.
25
The World Health Organization
recommends that 5%8% of calories consumed be from
n-6 PUFA and 1%2% from n-3 PUFA.
26
Health
authorities worldwide recommend daily intakes ranging
from 250 to 550 mg/day for EPA and DHA.
27-29
In
Australia, adequate intakes (AIs) for ALA have been set at
1.3 g/day for men and 0.8 g/day for women, and AIs for
long-chain n-3 PUFAs are 160 mg/day for men and 90 mg/
day for women (115 mg/day during pregnancy, and
145 mg/day during lactation) (Box 2).
30
Suggested dietary targets for long-chain n-3 PUFAs,
aimed at reducing chronic disease risk, are 610 mg/day for
men and 430 mg/day for women.
30
Consumption values as
high as 3000 mg/day reduce other cardiovascular risk
factors and have not had adverse effects in short- and
intermediate-term randomised trials.
25
The upper level of
intake of combined EPA, DHA and DPA is 3000 mg/day.
4,30
Adapting recommendations for vegetarian
populations
There are no official separate recommendations for n-3
PUFA intake in vegetarians or vegans. Current intakes of
ALA and LA in vegetarian populations are not consistent
1 Dietary sources of omega-3 and omega-6
polyunsaturated fatty acids
Omega-3 polyunsaturated fatty acids
-linolenic acid (ALA)
Chia seed, chia oil
Flaxseed, flaxseed oil
Canola oil
Walnut, walnut oil
Hempseed, hempseed oil*
Soybean, soybean oil
Wheatgerm, wheatgerm oil
Green leafy vegetables
Stearidonic acid (SDA)
Echium oil
Blackcurrant oil
Genetically modified soybean oil
Genetically modified canola oil
Eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and

docosapentaenoic acid (DPA)
Microalgae (plant DHA and EPA), not blue-green algae
Fish and other seafood, particularly oily fish
Meat (from grass-fed animals)
Eggs
Breast milk
Sea vegetables
Linoleic acid (LA)
Safflower seed, safflower oil
Sunflower seed, sunflower oil
Sesame seed, sesame seed oil
Walnut, walnut oil
Corn kernel, corn oil

Wheatgerm, wheatgerm oil
Soybean, soybean oil
Arachidonic acid
Poultry and red meats
Eggs
Milk
*Not currently available in Australia as a food. Regular soybean and canola
oils are not sources of SDA. Walnuts, wheatgerm and soybeans are sources
of both ALA and LA. N
Clinical focus
with optimal conversion to EPA and DHA,
6,14,20
and the
predictable result is reduced EFA status. While the health
consequences of this are not known, there is a clear inverse
association between EPA and DHA intake and risk of
cardiovascular disease, as well as limited evidence for
cognitive decline, depression and age-related macular
degeneration.
29,31-33
There is also some evidence for
improvements in visual acuity, growth, development and
cognition with higher maternal DHA intake during
pregnancy and lactation, and during the first 2 years of
life.
34
Thus, while vegetarians do enjoy certain health
advantages, improving their EFA status might afford
further protection
There are two possible means of achieving improved EFA
status by adjusting intakes of LA and ALA to improve
conversion, and by adding DHA and EPA supplements
derived from microalgae. Although increasing ALA intake
can boost its conversion to EPA and DHA, capacity for
conversion is limited and genetic variations in metabolism
can compromise conversion in some people.
35,36
If
microalgae-derived DHA and EPA are used, no adjustment
in ALA intake is suggested. If the diet does not provide
sufficient DHA and EPA, we suggest that the current AI for
ALA be doubled to help shift the balance of LA: ALA
towards more efficient conversion.
20
This would mean a
minimum ALA intake of 2.6g/day for vegetarian men and
1.6g/day for vegetarian women (Box 2). Studies consistently
show improved conversion with higher intakes of ALA and
lower intakes of LA. Some evidence suggests optimal
conversion may be achieved at an n-6: n-3 ratio of 4: 1 or
less.
12,37,38
Practical suggestions for optimising conversion
are provided in Box 3.
Supplementation for vegetarians
While evidence suggests that dietary n-3 PUFA needs can be
met with ALA alone,
14
there may be advantages to adding
DHA and possibly EPA supplements derived from
microalgae, particularly for people with increased needs (eg,
pregnant and lactating women) or reduced conversion ability
(eg, people with diabetes, metabolic syndrome or
hypertension, and older people). Although women have a
greater capacity to convert ALA,
39
demand for DHA may
exceed production during pregnancy and lactation, even with
relatively efficient conversion rates.
18,20
For those with
increased needs or reduced conversion ability, an intake of
200300mg/day of DHA and EPA microalgae-derived
supplements is recommended. For other vegetarians and
vegans, meeting the AI for long-chain n-3 PUFA (Box 2) from
foods (including fortified foods) or supplements is suggested,
although including supplementation of 100300mg/day (or
23 times per week) would be a reasonable choice.
Another option is direct consumption of SDA, which
bypasses the first step in ALA conversion (desaturation by
6
desaturase) to EPA and DHA. In humans, SDA is a better
substrate than ALA for formation of EPA and, compared
with ALA, SDA supplementation results in greater
accumulation of EPA in the erythrocyte membranes.
40
Although SDA is not found in commonly eaten foods, rich
sources of preformed SDA include echium oils, genetically
modified soybean oil, and blackcurrant oil. Regular soybean
oil is not a source of SDA.
Box 4 shows a sample vegetarian meal plan for a 1950-
year-old woman, which easily meets the suggested ALA
intake of 1.6g as well as requirements for other key
nutrients (except vitamin D and long-chain n-3 PUFA).
25
For more details, and other sample meal plans, see page 33.
Conclusion
Although vegetarians consume minimal EPA and DHA,
studies show plasma levels of n-3 PUFA are typically low
3 Dietary strategies for maximising ALA conversion to
EPA, DHA and DPA
12,20
Regularly include good sources of ALA in the diet: ground
flaxseed,* flaxseed oil, chia seeds, canola oil, hempseeds,

hempseed oil
and walnuts. Smaller amounts come from

soybeans, green leafy vegetables and sea vegetables.
Suggested ALA intakes for vegetarians are at least 2.6 g/day
for men and 1.6g/day for women.
Limit intake of omega-6 (n-6) oils and margarines (sunflower,
safflower, corn, sesame, grapeseed oil). Consume whole food
sources of n-6 (sunflower seeds, pumpkin seeds, sesame seeds,
walnuts, wheatgerm, soybeans), as they contribute smaller
amounts of n-6 and supply other valuable nutrients.
Use monounsaturated fats (olive oil, canola oil, avocado, olives
and nuts) in place of n-6 oils and margarines.
Limit alcohol and caffeine intake and avoid smoking.
Ensure a nutritionally adequate diet with due attention to
nutrients that are important in the conversion process: vitamins
B
3
(niacin), B
6
(pyridoxine) and C, and the minerals zinc and
magnesium.
ALA= -linolenic acid. EPA=eicosapentaenoic acid.
DHA= docosahexaenoic acid. DPA=docosapentaenoic acid.
* It is important to grind flaxseeds before use, as whole flaxseeds are not well
digested. Hempseeds and hempseed oil are not currently available in
Australia as a food, although they are in countries such as Canada. Food
Standards Australia New Zealand is currently reviewing this. N
2 Recommended adequate intake (AI)* of omega-3
polyunsaturated fatty acids (n-3 PUFAs) per day
30
AI
Sex and
age group
Combined
EPA + DHA
+ DPA ALA
Suggested
ALA for
vegetarians
20
Men 160 mg 1.3 g 2.6g
Women 90 mg 0.8 g 1.6g
Pregnant 115 mg 1.0 g 2.0g
Lactating 145 mg 1.2 g 2.4g
Children
13 years 40 mg 0.5 g 1.0g
48 years 55 mg 0.8 g 1.6g
Boys 913 years 70 mg 1.0 g 2.0g
Boys 1418 years 125 mg 1.2 g 2.4g
Girls 913 years 70 mg 0.8 g 1.6g
Girls 1418 years 85 mg 0.8 g 1.6g
Infants n-3 PUFA
06 months 0.5g
712 months 0.5g
EPA=eicosapentaenoic acid. DHA= docosahexaenoic acid.
DPA= docosapentaenoic acid. ALA=-linolenic acid. *The AI is the average
daily nutrient intake level based on observed or experimentally determined
approximations or estimates of nutrient intake by a group (or groups) of
apparently healthy people that is assumed to be adequate. N
Clinical focus
but apparently stable. An adequate amount of ALA can be
consumed from plant sources, and vegetarians can take
steps to optimise conversion of ALA to EPA and DHA. The
diet must be well supplied with dietary sources of ALA,
and there is some evidence that a direct source of
microalgae-derived DHA and EPA may be beneficial,
particularly for those with increased needs or difficulty
converting ALA. There is no convincing evidence that
vegetarians or vegans experience adverse effects as a result
of a low dietary intake of EPA and DHA. Finally, further
research is required to understand if ALA and SDA can be
substituted for marine EPA and DHA, or if direct sources
of EPA and DHA are essential for optimal health.
Acknowledgements: We acknowledge the work of Emily Francis who
assisted with a literature review as part of her dietetic student placement
program.
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Learning, 2010.
20 Davis BC, Kris-Etherton PM. Achieving optimal essential fatty acid
status in vegetarians: current knowledge and practical implications.
Am J Clin Nutr 2003; 78 (3 Suppl): 640S-646S.
21 Li D. Chemistry behind vegetarianism. J Agric Food Chem 2011; 59:
777-784.
suggested intake of -linolenic acid (ALA) for a 1950-
year-old woman, showing ALA content of the foods*
Meal ALA content
Breakfast
Bowl of cereal with fruit, and poached egg on
toast
10 g chia seeds 1.9 g
1 poached egg (omega-rich egg) 0.1 g
Snack
30 g cashews 0.0 g
Lunch
30 g hummus 0.0 g
Salad 0.0 g
Snack
2teaspoons wheatgerm 0.04 g
1 banana 0.0 g
Dinner
100 g tofu 0.5 g
25 g snow peas
0.0 g
12 g cashews 0.0 g
Snack
1 cup low-fat soy milk 0.05 g
10 g fortified malted chocolate powder 0.0 g
Total ALA 2.8g
* Source: FoodWorks 2009 (incorporating Food Standards Australia
New Zealands AUSNUT [Australian Food and Nutrient Database] 1999), Xyris
Clinical focus
22 Famodu AA, Osilesi O, Makinde YO, et al. The influence of a vegetarian
diet on haemostatic risk factors for cardiovascular disease in Africans.
Thromb Res 1999; 95: 31-36.
23 Mezzano D, Muoz X, Martinez C, et al. Vegetarians and cardiovascular
risk factors: hemostasis, inflammatory markers and plasma
homocysteine. Thromb Haemost 1999; 81: 913-917.
24 Li D, Sinclair A, Mann N, et al. The association of diet and thrombotic
risk factors in healthy male vegetarians and meat-eaters. Eur J Clin
Nutr 1999; 53: 612-619.
25 Fats and fatty acids in human nutrition. Proceedings of the Joint FAO/
WHO Expert Consultation. November 10-14, 2008. Geneva,
Switzerland. Ann Nutr Metab 2009; 55: 5-300.
26 Nishida C, Uauy R, Kumanyika S, Shetty P. The joint WHO/FAO expert
consultation on diet, nutrition and the prevention of chronic diseases:
process, product and policy implications. Public Health Nutr 2004; 7:
245-250.
27 Calder PC, Dangour AD, Diekman C, et al. Essential fats for future
health. Proceedings of the 9th Unilever Nutrition Symposium, 26-27
May 2010. Eur J Clin Nutr 2010; 64 Suppl 4: S1-S13.
28 Kris-Etherton PM, Grieger JA, Etherton TD. Dietary reference intakes
for DHA and EPA. Prostaglandins Leukot Essent Fatty Acids 2009; 81:
99-104.
29 Harris WS, Mozaffarian D, Lefevre M, et al. Towards establishing
dietary reference intakes for eicosapentaenoic and docosahexaenoic
acids. J Nutr 2009; 139: 804S-819S.
30 National Health and Medical Research Council, New Zealand Ministry
of Health. Nutrient reference values for Australia and New Zealand
including recommended dietary intakes. Canberra: NHMRC, 2006.
http://www.nhmrc.gov.au/guidelines/publications/n35-n36-n37
31 Anderson BM, Ma DW. Are all n-3 polyunsaturated fatty acids created
equal? Lipids Health Dis 2009; 8: 33.
32 Christen WG, Schaumberg DA, Glynn RJ, Buring JE. Dietary -3 fatty acid
and fish intake and incident age-related macular degeneration in
women. Arch Ophthalmol 2011; 129: 921-929.
33 Sublette ME, Ellis SP, Geant AL, Mann JJ. Meta-analysis of the effects
of eicosapentaenoic acid (EPA) in clinical trials in depression. J Clin
Psychiatry 2011; 72: 1577-1584.
34 Hoffman DR, Boettcher JA, Diersen-Schade DA. Toward optimizing
vision and cognition in term infants by dietary docosahexaenoic and
arachidonic acid supplementation: a review of randomized controlled
trials. Prostaglandins Leukot Essent Fatty Acids 2009; 81: 151-158.
35 Simopoulos AP. Genetic variants in the metabolism of omega-6 and
omega-3 fatty acids: their role in the determination of nutritional
requirements and chronic disease risk. Exp Biol Med (Maywood) 2010;
235: 785-795.
36 Baylin A, Ruiz-Narvaez E, Kraft P, Campos H. alpha-Linolenic acid,
Delta6-desaturase gene polymorphism, and the risk of nonfatal
myocardial infarction. Am J Clin Nutr 2007; 85: 554-560.
37 Liou YA, King DJ, Zibrik D, Innis SM. Decreasing linoleic acid with
constant alpha-linolenic acid in dietary fats increases (n-3)
eicosapentaenoic acid in plasma phospholipids in healthy men. J Nutr
2007; 137: 945-952.
38 Harnack K, Andersen G, Somoza V. Quantitation of alpha-linolenic acid
elongation to eicosapentaenoic and docosahexaenoic acid as
affected by the ratio of n6/n3 fatty acids. Nutr Metab (Lond) 2009; 6: 8.
39 Burdge GC, Wootton SA. Conversion of alpha-linolenic acid to
eicosapentaenoic, docosapentaenoic and docosahexaenoic acids in
young women. Br J Nutr 2002; 88: 411-420.
40 Whelan J. Dietary stearidonic acid is a long chain (n-3) polyunsaturated
fatty acid with potential health benefits. J Nutr 2009; 139: 5-10. J
Clinical focus
MJA Open ISSN: 0025-729X 4 June 2012 1 2
27-32
Clinical focus
itamin B
12
(cobalamin) is an essential vitamin,
required for DNA synthesis (and ultimately cell
division) and for maintaining nerve myelin
integrity.
1
It is found almost exclusively in animal-based
products including red meats, poultry, seafood, milk,
cheese and eggs. As vitamin B
12
is produced by bacteria in
the large intestines of animals, plant-based foods are
generally not a source of vitamin B
12
. It is therefore a
nutrient of concern for vegetarians and particularly for
vegans who choose an entirely plant-based diet. A cross-
sectional analysis study involving 689 men found that
more than half of vegans and 7% of vegetarians were
deficient in vitamin B
12
.
2
Vitamin B
12
deficiency
Vitamin B
12
deficiency is a serious health problem that can
result in megaloblastic anaemia, inhibition of cell division,
and neurological disorders.
3
Folate deficiency can also
cause megaloblastic anaemia and, although a high folate
intake may correct anaemia from a vitamin B
12
deficiency,
subtle neurological symptoms driven by the vitamin B
12
deficiency may arise. Loss of intrinsic factor, gastric acid or
other protein-digesting enzymes contributes to 95% of
known cases of vitamin B
12
deficiency.
4
Other factors that
may contribute to vitamin B
12
deficiency are listed in Box
1.
13
However, in vegetarian and vegan populations, dietary
insufficiency is the major cause.
4
Furthermore, high levels
of folate can mask vitamin B
12
deficiency a concern for
vegetarians and vegans whose folate intake is generally
high while vitamin B
12
intake is low. The addition of
vitamin B
12
to any foods fortified with folate has been
advocated to prevent masking of haematological and
neurological manifestations of vitamin B
12
deficiency.
14
Subtle neurological damage (even in the absence of
anaemia) may be more likely in vegans because of their
increased folate levels preventing early detection of
vitamin B
12
deficiency.
4
Vitamin B
12
deficiency can also lead to demyelinisation
of peripheral nerves, the spinal cord, cranial nerves and the
brain, resulting in nerve damage and neuropsychiatric
abnormalities. Neurological symptoms of vitamin B
12
deficiency include numbness and tingling of the hands and
feet, decreased sensation, difficulties walking, loss of
bowel and bladder control, memory loss, dementia,
depression, general weakness and psychosis.
3,4
Unless
detected and treated early, these symptoms can be
irreversible.
Digestion and absorption of vitamin B
12
The digestion of vitamin B
12
begins in the stomach, where
gastric secretions and proteases split vitamin B
12
from
peptides. Vitamin B
12
is then free to bind to R-factor found
in saliva. Pancreatic secretions partially degrade the R-
factor, and vitamin B
12
is then bound to intrinsic factor.
Intrinsic factor binds to the ileal brush border and
facilitates the absorption of vitamin B
12
.
15
Box 2 illustrates
the process of vitamin B
12
digestion and absorption.
Vitamin B
12
and vegetarian diets
V
Summary
Vitamin B
12
is found almost exclusively in animal-
based foods and is therefore a nutrient of potential
concern for those following a vegetarian or vegan diet.
Vegans, and anyone who significantly limits intake of
animal-based foods, require vitamin B
12
-fortified foods
or supplements.
Vitamin B
12
deficiency has several stages and may be
present even if a person does not have anaemia.
Anyone following a vegan or vegetarian diet should
have their vitamin B
12
status regularly assessed to
identify a potential problem.
A useful process for assessing vitamin B
12
status in
clinical practice is the combination of taking a diet
history, testing serum vitamin B
12
level and testing
homocysteine, holotranscobalamin II or methylmalonic
acid serum levels.
Pregnant and lactating vegan or vegetarian women
should ensure an adequate intake of vitamin B
12
to
provide for their developing baby.
In people who can absorb vitamin B
12
, small amounts
(in line with the recommended dietary intake) and
frequent (daily) doses appear to be more effective
than infrequent large doses, including intramuscular
injections.
Fortification of a wider range of foods products with
vitamin B
12
, particularly foods commonly consumed by
vegetarians, is likely to be beneficial, and the feasibility
of this should be explored by relevant food authorities.
Carol L Zeuschner
BSc, MSc, APD,
Manager of Nutrition
and Dietetics
1
Bevan D Hokin
BSc, MAppSc, PhD,
Director of Pathol ogy
1
Kate A Marsh
AdvAPD,
MNutrDiet, PhD,
Director and
Senior Dietitian
2
Angela V Saunders
BS(Dietetics),
MA(Ldshp&MgmtHS),
APD,
Senior Dietitian,
3
Michelle A Reid
BND, APD, AN,
Senior Dietitian,
Nutrition Marketing
3
Melinda R Ramsay
BMedSci, MNutrDiet,
APD,
Project Coordinator
4
1 Sydney Adventist
2 Northside Nutrition and
Dietetics, Sydney, NSW.
Sanitarium Health
and Wellbeing,
Berkeley Vale, NSW.
4 Sanitarium Health and
Wellbeing Services,
Sanitarium Health and
Wellbeing, Sydney, NSW.
carol.zeuschner@
sah.org.au
MJA Open 2012;
1 Suppl 2: 2732
doi: 10.5694/mjao11.11509
Clinical focus
Vitamin B
12
absorption may decrease if intrinsic factor
production decreases. There are many well documented
factors causing protein-bound vitamin B
12
malabsorption,
including gastric resection, atrophic gastritis, and the use
of medications that suppress acid secretion (see Box 1).
Up to 89% of vitamin B
12
consumed in the diet is
absorbed, although as little as 9% is absorbed from some
foods (including eggs).
17,18
This relatively high rate of
absorption, combined with low daily requirements and the
bodys extremely efficient enterohepatic circulation of
vitamin B
12
, contributes to the long period, often years, for
a deficiency to become evident. Studies have been
inconsistent in linking the duration of following an
unsupplemented vegan diet with low serum levels of
vitamin B
12
.
2,19
Intestinal absorption is estimated to be
saturated at about 1.52.0 g per meal, and bioavailability
significantly decreases as intake increases.
18
Ageing causes a decreased level of proteases, as well as a
reduced level of acid in the stomach. As a result, vitamin
B
12
is less effectively removed from the food proteins to
which it is attached, and food-bound vitamin B
12
absorption is diminished.
4
The Framingham Offspring
Study found that the vitamin B
12
from supplements and
fortified foods may be more efficiently absorbed than that
from meat, fish and poultry.
20
While low vitamin B
12
status in vegetarians and vegans
is predominantly due to inadequate intake, some cases of
pernicious anaemia are attributable to inadequate
production of intrinsic factor. Under the law of mass
action, about 1% of vitamin B
12
from large oral doses can
be absorbed across the intestinal wall, even in the absence
of adequate intrinsic factor.
21
Assessing vitamin B
12
status
Taking a simple diet history can be a useful indicator of
vitamin B
12
intake and adequacy. However, laboratory
analyses provide a much more accurate assessment.
Measurement of serum vitamin B
12
levels is a common and
low-cost method of assessing vitamin B
12
status. The
earlier method of measuring vitamin B
12
using biological
assays was unreliable, as both the active and inactive
analogues of vitamin B
12
were detected, so levels were
often overestimated.
17
Modern radio isotope and
immunoassay methods reliably measure biologically
available analogues of vitamin B
12
. The early measured
ranges of acceptable levels of serum vitamin B
12
were
determined using individuals who were apparently healthy
but had potentially marginal levels of vitamin B
12
. This has
resulted in reference intervals probably being set too low to
provide a reliable clinical decision. To improve the ability to
predict marginal vitamin B
12
status, a higher reference
interval (>360 pmol/L) has been proposed.
4,22
Objective
measures of neurological damage have been found in
patients with vitamin B
12
levels below 258 pmol/L.
23
However, the usual reference interval for vitamin B
12
deficiency is < 220 pmol/L. Achieving national and
international agreement on the definition of serum
vitamin B
12
deficiency would provide some clarity for
comparison of studies and reduce variability in defining
2 Diagram illustrating vitamin B
12
digestion and absorption
15,16
Mouth
Vitamin B
12
consumed from
dietary sources
bile
Stomach
Intrinsic factor produced by parietal
cells (production parallels
hydrochloric acid production)
Gastric acid and proteases split
vitamin B
12
from food peptides
Vitamin B
12
then binds to R-factor
(haptocorrin)
Upper small intestine
Pancreatic secretions partially
degrade the R-factor
Vitamin B
12
then binds to intrinsic
factor, becoming the
cobalaminintrinsic factor complex
Terminal ileum
Intrinsic factor binds to the ileal brush
border via a receptor assisting
absorption into the bloodstream
Blood
Transcobalamin II transports
vitamin B
12
to body cells (for
immediate use) and the liver
(for storage)
Liver
Vitamin B
12
is stored on
transcobalamin III and released
into the small intestine via bile
(enterohepatic circulation)
Excretion
Small amount of vitamin B
12

excreted in urine, and remainder
in faeces (in bile salts)
Intestinal cell
Vitamin B
12
attaches to
transcobalamin II (a protein that
transports vitamin B
12
in the blood)
1 Causes of vitamin B
12
deficiency, with contributing
factors
Inadequate dietary intake
Restrictive diet or dieting; vegetarian or vegan diets without
supplementation or use of fortified foods
Inadequate absorption or impaired utilisation
Loss of intrinsic factor, loss of gastric acid and/or other
protein-digesting enzymes (contributes to 95% of known
cases)
4
Use of medications that suppress acid secretion, including
somatostatin, cholecystokinin, atrial natriuretic peptide, and
nitric oxide
5
Pancreatic disease
Gastric resection, sleeve or banding surgery
6
Ileal disease or ileal resection (secondary to Crohns disease)
7
Use of metformin (oral hypoglycaemic agent)
8
Use of angiotensin-converting enzyme inhibitor
9
Use of levodopa and catechol-O-methyltransferase
inhibitors
10
Autoimmunity to intrinsic factor
Gastric infection with Helicobacter pylori
11
Ileocystoplasty
12
Atrophic gastritis
Increased requirements
During pregnancy and lactation
Increased excretion
Alcoholism N
Clinical focus
those at risk of deficiency. Internationally, the cut-off for
vitamin B
12
varies markedly between < 130 pmol/L and
< 258 pmol/L.
Serum vitamin B
12
levels alone do not provide a measure
of a persons reserves of the vitamin. It is recommended
that a metabolic marker of vitamin B
12
reserves, such as
serum homocysteine, also be determined. Elevated
homocysteine levels can be a useful indicator for vitamin
B
12
deficiency, because serum homocysteine levels increase
as vitamin B
12
stores fall. While serum homocysteine levels
greater than 9 mol/L suggest the beginning of depleted
vitamin B
12
reserves,
24
standard laboratory reference
intervals suggest levels greater than 15 mol/L as a marker
for depleted vitamin B
12
reserves. Although homocysteine
levels may also increase with folate or vitamin B
6
deficiency, these deficiencies are likely to be rare in
vegetarians and vegans.
Other markers for vitamin B
12
deficiency include serum
holotranscobalamin II (TC2) and urinary or serum
methylmalonic acid (MMA). TC2 is the protein that
transports vitamin B
12
in blood, and its levels fall in vitamin
B
12
deficiency. Testing for this carrier protein can identify
low vitamin B
12
status before total serum vitamin B
12
levels
drop.
25
Vitamin B
12
is the only coenzyme required in the
conversion of methylmalonyl-CoA to succinyl-CoA, so
methylmalonyl-CoA levels increase with vitamin B
12
deficiency. As it is toxic, methylmalonyl-CoA is converted
to MMA, which accumulates in the blood and is excreted
in the urine, enabling either urinary or serum MMA to be a
useful measure of vitamin B
12
reserves. Because TC2 is one
of the earliest markers of vitamin B
12
deficiency, it may be
one of the better means of assessing vitamin B
12
status.
22
Requirements
Box 3 shows the vitamin B
12
nutrient reference values for
Australia and New Zealand.
26
As no recommended dietary
intakes (RDIs) are available for infants under 12 months of
age, an adequate intake is recommended instead. Vegans
at all stages of the life cycle need to ensure an adequate
and reliable source of vitamin B
12
from fortified foods, or
they will require supplementation equivalent to the RDI.
Vegetarians and vitamin B
12
status
While reported cases of frank vitamin B
12
deficiency in
vegetarians or vegans are rare, several studies have found
lower vitamin B
12
levels in vegans and vegetarians
compared with the general population.
27,28
The European
Prospective Investigation into Cancer and Nutrition
(EPIC)-Oxford cohort study found that 121 of 232 vegans
(52%), 16 of 231 vegetarians (7%) and one of 226
omnivores (0.4%) were classed as vitamin B
12
-deficient.
2
There was no significant association between age or
duration of subjects adherence to a vegetarian or vegan
diet and the serum levels of vitamin B
12
.
2
Intuitively, it is
assumed that prevalence of deficiency increases with a
longer duration of vegetarian diet. Although it can take
years for deficiency to occur, it is likely that all vegans and
anyone who does not regularly consume animal-based
foods, and whose diets are unsupplemented or unfortified,
will eventually develop vitamin B
12
deficiency. Vegetarians
and vegans should have their vitamin B
12
status regularly
assessed to enable early intervention if levels fall too low.
Vegetarian infants and vitamin B
12
status
The risk of a breastfed infant becoming deficient in vitamin
B
12
depends on three factors: the vitamin B
12
status of the
mother during pregnancy; the vitamin B
12
stores of the
infant at birth; and the vitamin B
12
status of the
breastfeeding mother. The fetus obtains its initial store of
vitamin B
12
via the placenta, with newly absorbed vitamin
3 Recommended dietary intake (RDI)* and estimated
average requirement (EAR)
of vitamin B
12
per day
26
Sex and age group RDI EAR
Men 19 years 2.4g 2.0 g
Women 19 years 2.4g 2.0 g
Pregnant women 2.6g 2.2 g
Lactating women 2.8g 2.4 g
Children
06 months 0.4g
712 months 0.5g
13 years 0.9g 0.7 g
48 years 1.2g 1.0 g
913 years 1.8g 1.5 g
1418 years 2.4g 2.0 g
* The RDI is the average daily dietary intake level that is sufficient to meet
the nutrient requirements of nearly all healthy individuals (97%98%) of a
particular sex and life stage. The EAR is a daily nutrient level estimated to
meet the requirements of half the healthy individuals of a particular sex and
life stage. These values are adequate intakes, which are the average daily
nutrient intake levels based on observed or experimentally determined
approximations or estimates of nutrient intake by a group (or groups) of
apparently healthy people that are assumed to be adequate. N
Clinical focus
B
12
(rather than maternal stores) being readily transported
across the placenta.
29
Under normal conditions, full-term
infants will have enough stored vitamin B
12
at birth to last
for about 3 months when the maternal diet does not contain
vitamin B
12
.
30
An infant born to a vegetarian or vegan
mother is at high risk of deficiency if the mothers vitamin
B
12
intake is inadequate and her stores are low. Vegetarian
women who have repeated pregnancies place infants at
greater risk, because their vitamin B
12
stores are likely to
have been depleted by earlier pregnancies.
31
Vegetarian or
vegan women must have a balanced diet, including
adequate intake of vitamin B
12
, to provide for their babies
during both pregnancy and lactation. Recent studies
suggest that maternal stores of vitamin B
12
are also reflected
in breastmilk. When maternal serum vitamin B
12
levels are
low, vitamin B
12
levels in breastmilk will also be low, and the
infant will not receive an adequate vitamin B
12
intake.
32
There have been reports of deficiency in the breastfed
infants of vegan (or strict vegetarian) mothers who did
not supplement their diets with vitamin B
12
, because of the
smaller stores of vitamin B
12
gained by the infant during
pregnancy and the low vitamin B
12
content of breastmilk
(reflective of the mothers serum levels).
33,34
Infants have
presented with a range of symptoms, often initially
signalled by developmental delay.
35
Lack of vitamin B
12
in
the maternal diet during pregnancy has been shown to
cause severe retardation of myelination in the nervous
system of the infant.
36
Visible signs of vitamin B
12
deficiency in infants may include involuntary motor
movements, dystrophy, weakness, muscular atrophy, loss
of tendon reflexes, psychomotor regression, cerebral
atrophy, hypotonia and haematological abnormalities.
37,38
While supplementation with vitamin B
12
results in rapid
improvements in laboratory measures of vitamin B
12
status, there is continuing research about the long-term
effects of deficiency in infants.
37
Vitamin B
12
in the vegetarian diet
Lacto-ovo-vegetarians will have a reliable source of
vitamin B
12
in their diet, provided they consume adequate
amounts of dairy products and eggs, although their intake
is likely to be lower than in meat eaters. However, those
who follow a vegan diet will not have a reliable intake
unless they consume foods fortified with vitamin B
12
or
take a supplement.
It was once thought that some plant foods, such as
spirulina, and fermented soy products, including tempeh
and miso, were dietary sources of vitamin B
12
, but this has
been proven incorrect.
39
Recent research has found traces
of vitamin B
12
in white button mushrooms
40
and Korean
purple laver (nori),
41
but the quantity in a typical serving
means that they are not a significant dietary source of this
vitamin. An average serving of mushrooms contains about
5% of the RDI, making the quantity required to supply
adequate amounts of vitamin B
12
to vegetarians
impractical. Further, use of Korean laver is unlikely to be
widespread in the Australian diet. With the unique
exception of these two plant foods,
40,41
any vitamin B
12
detected in other plant foods is likely to be the inactive
4 A sample vegetarian meal plan designed to meet
requirements for vitamin B
12
and other key nutrients
for a 1950-year-old woman, showing vitamin B
12

content of the foods*
Meal
Vitamin B
12
content
Breakfast
Bowl of cereal with fruit, and poached egg on
toast
10g chia seeds 0.0 g
1/2 cup low-fat fortified soy milk (or dairy milk) 0.5 g (0.8g)

1 poached egg 0.9g
Snack
30g cashews 0.0 g
Lunch
30g hummus 0.0 g
Salad 0.0 g
Snack
3/4 cup low-fat fortified soy milk (or dairy milk) 0.8 g (1.1g)
2 teaspoons wheatgerm 0.0 g

1 banana 0.0 g
Dinner
100 g tofu 0.0 g
25g snow peas
0.0 g
Snack
1 cup low-fat fortified soy milk (or dairy milk) 1.0 g (1.5g)
10g malted chocolate powder 0.0 g

Total vitamin B
12
3.2g (4.3g)

Zealands AUSNUT [Australian Food and Nutrient Database] 1999), Xyris
Software, Brisbane, Qld. Figures are for soy milk (dairy milk). N
Clinical focus
analogue, which is of no use to the body and can actually
interfere with the absorption of the active form.
42
Box 4 shows a sample vegetarian meal plan for a 1950-
year-old woman, which includes food sources typical in a
Western-style diet and meets the RDI of vitamin B
12
and
requirements for other key nutrients (except vitamin D and
long-chain omega-3 fatty acids). Excluding or limiting
dairy foods or fortified soy milk from the vegetarian diet
would necessitate the need for vitamin B
12
supplements.
Fortified foods
In contrast to the United States, where foods are
extensively fortified with vitamin B
12
, Food Standards
Australia New Zealand permits only a limited number of
foods to be fortified with vitamin B
12
. This includes
selected soy milks, yeast spread, and vegetarian meat
analogues such as soy-based burgers and sausages.
Examples of the vitamin B
12
content of foods suitable for
vegetarians are shown in Box 5.
Vitamin B
12
added to foods is highly bioavailable,
especially in people with vitamin B
12
deficiency caused by
inadequate dietary intake. An unpublished Australian
study (Hokin BD. Vitamin B
12
deficiency issues in selected
at-risk populations [PhD thesis]. Newcastle: University of
Newcastle, 2003) compared the effectiveness of fortified
soy milk (two servings of 250 mL/day), soy-based meat
analogues (one serving/day), vitamin B
12
supplements
(one low-dose tablet/day or one high-dose tablet/week)
and vitamin B
12
intramuscular injections (one injection/
month) in raising serum vitamin B
12
levels in subjects with
deficiency. The study found that fortified foods were
superior to the traditional methods of supplementation
(intramuscular injections and tablets). Further research
would be beneficial to confirm these findings. With
inadequate dietary intake being a risk for vegetarians and
vegans, further fortification of foods commonly consumed
by this population with vitamin B
12
would be beneficial
and should be considered by the relevant authorities.
Supplements
In a vegan diet, using a supplement or consuming fortified
foods is the only way to obtain vitamin B
12
. As the body
can only absorb a limited amount of vitamin B
12
at any one
time, it is better to take small doses more often, instead of
large doses less often. One study found that small doses of
vitamin B
12
in the range of 0.10.5g resulted in
absorption ranging between 52% and 97%; doses of 1g
and 5g resulted in mean absorption of 56% and 28%,
respectively, while higher doses had even lower
absorption, with 10g and 50g doses resulting in 16%
and 3%, respectively, being absorbed.
17
While sublingual
supplements are often promoted as being more efficiently
absorbed, there is no evidence to show that this form of
supplement is superior to regular oral vitamin B
12
.
44
Vitamin B
12
supplements are not made from animal-based
products and are suitable for inclusion in a vegan diet.
Conclusion
Vitamin B
12
deficiency is a potential concern for anyone
with insufficient dietary intake of vitamin B
12
, including
those adhering to a vegan or vegetarian diet or
significantly restricting animal-based foods. Studies have
found that vegetarians, particularly vegans, have lower
serum vitamin B
12
levels, and it is likely that anyone
avoiding animal-based foods will eventually become
deficient if their diet is not supplemented. All vegans, and
lacto-ovo-vegetarians who dont consume adequate
amounts of dairy products or eggs to provide sufficient
vitamin B
12
, should therefore supplement their diet with
vitamin B
12
from fortified foods or supplements. It is
particularly important that pregnant or breastfeeding
vegan and vegetarian women consume a reliable source of
vitamin B
12
to reduce the risk of their baby developing a
vitamin B
12
deficiency.
Acknowledgements: We acknowledge the assistance of dietitians Sue
Radd and Rebecca Prior in the early development stages of this article.
Competing interests: Kate Marsh previously consulted for Nuts for Life
(Horticulture Australia), who are providing a contribution towards the cost
of publishing this supplement. Angela Saunders, Michelle Reid and Melinda
Ramsay are employed by Sanitarium Health and Wellbeing, sponsor of this
supplement.
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5 Vitamin B
12
content of lacto-ovo-vegetarian food
sources*
Vegetarian sources
Vitamin B
12

per 100g
Sausage, vegetarian style, fortified 2.0 g
Cheese, cheddar, reduced fat (16%) 1.8 g
Egg (chicken), whole, poached 1.7 g
Milk, cow, fluid, regular or reduced fat 0.6 g
Soy beverage, unflavoured, regular fat,
fortified
0.9 g
Soy beverage, unflavoured, reduced fat
(1.5%), fortified
0.9 g
Soy beverage, unflavoured, low fat, (0.5%),
fortified
0.3 g
Yoghurt dessert, regular fat, flavoured 0.2 g
*From Food Standards Australia New Zealand. NUTTAB 2010 online
43
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Clinical focus
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deficiency and determination of holotranscobalamin in populations at
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http://www.nhmrc.gov.au/guidelines/publications/n35-n36-n37
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day Adventist ministers in Australia. Am J Clin Nutr 1999; 70 (3 Suppl):
576S-578S.
28 Miller DR, Specker BL, Ho ML, Norman EJ. Vitamin B-12 status in a
macrobiotic community. Am J Clin Nutr 1991; 53: 524-529.
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32 Specker BL, Black A, Allen L, Morrow F. Vitamin B-12: low milk
concentrations are related to low serum concentrations in vegetarian
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1990; 52: 1073-1076.
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36 Lvblad K, Ramelli G, Remonda L, et al. Retardation of myelination due
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Clinical focus
Clinical Focus
lthough only 5%6% of females and 1%3% of
males claim to be vegetarian,
1,2
a 2010 Newspoll
Survey (commissioned by Sanitarium Health and
Wellbeing) found that seven out of 10 Australians are
eating more plant-based meals than previously, in the
belief that eating less meat and more plant foods improves
overall health. As with any dietary practice, vegetarian
diets need to be well planned to ensure that meals are
healthy, delicious and nutritionally adequate.
3
Research has shown that a well planned vegetarian diet
can meet nutritional needs for good health
4
and may
reduce the risk of cancer,
4-8
cardiovascular disease,
5,8,9
metabolic syndrome, insulin resistance, type 2 diabetes,
10-14
hypertension
7,15,16
and obesity.
11,17-19
Choosing plant-
based meals is also environmentally beneficial.
20-22
Vegetarian diets are generally lower in saturated fat and
cholesterol and higher in dietary fibre, antioxidants and
phytochemicals than non-vegetarian diets.
4
It is likely that
the combination of these factors provide vegetarians with a
significant health advantage.
7,23,24
Our article showcases well designed lacto-ovo-
vegetarian meal plans for all age groups and both sexes
that meet the nutrient reference value (NRV) requirements
(Box 1), as well as the higher requirements set for iron and
zinc for vegetarians.
The challenge for vegetarians
Since the release, in 2006, of the revised Nutrient reference
values for Australia and New Zealand including recommended
dietary intakes,
25
which supersede the 1991 recommended
dietary intakes (RDIs),
26
there has been some concern
expressed about the ability to meet these recommend-
ations. Compared with the 1991 RDIs, the 2006 NRVs
recommend a small increase in iron for men, women and
pregnant women and an increase in zinc for men (Box 2).
For vegetarians, the further recommended increases in
Meeting the nutrient reference values on a
vegetarian diet
A
Summary
Surveys over the past 10 years have shown that
Australians are increasingly consuming more plant-
based vegetarian meals.
Many studies demonstrate the health benefits of
vegetarian diets. As with any type of eating plan,
vegetarian diets must be well planned to ensure
nutritional needs are being met.
This clinical focus project shows that well planned
vegetarian diets can meet almost all the nutritional
needs of children and adults of all ages.
Sample single-day lacto-ovo-vegetarian meal plans
were developed to comply with the nutrient reference
values including the increased requirements for iron
and zinc at 180% and 150%, respectively, for
vegetarians for both sexes and all age groups set by
Australias National Health and Medical Research
Council and the New Zealand Ministry of Health.
With the exception of vitamin D, long-chain omega-3
fatty acids and extended iron requirements in
pregnancy for vegetarians, the meal plans meet key
requirements with respect to energy; protein;
carbohydrate; total fat; saturated, poly- and
monounsaturated fats; -linolenic acid; fibre; iron; zinc;
calcium; folate; and vitamins A, C, E and B
12
.
Michelle A Reid
BND, APD, AN,
Senior Dietitian,
Nutrition Marketing
1
Kate A Marsh
AdvAPD,
MNutrDiet, PhD,
Director and
Senior Dietitian
2
Carol L Zeuschner
BSc, MSc, APD,
Manager of Nutrition
and Dietetics
3
Angela V Saunders
BS(Dietetics),
MA(Ldshp&MgmtHS),
APD,
Senior Dietitian,
1
Surinder K Baines
Senior Lecturer,
4
Sanitarium Health
and Wellbeing,
Berkeley Vale, NSW.
3 Sydney Adventist
4 School of Health
Sciences, University of
Newcastle,
Newcastle, NSW.
michelle.reid@
sanitarium.com.au
MJA Open 2012;
1 Suppl 2: 3340
doi: 10.5694/mjao11.11510
Abbreviations
AI adequate intake
ALA -linolenic acid
AMDR acceptable macronutrient distribution
range
DHA docosahexaenoic acid
EER estimated energy requirement
EPA eicosapentaenoic acid
n-3 PUFA omega-3 polyunsaturated fatty acid
NRV nutrient reference value
PAL physical activity level
RDI recommended dietary intake
UL upper level of intake
Clinical focus
iron requirement (80% higher than current RDIs for non-
vegetarians) and zinc requirement (50% higher than
current RDIs for non-vegetarians) present additional
challenges. The higher iron requirement is based on the
assumption that only 10% of iron is absorbed from a
vegetarian diet, compared with 18% from a mixed diet that
includes meat.
25,27
The higher zinc requirement is based on
the fact that vegetarian diets have a higher phytate
content
25,28-30
and evidence that the phytate-to-zinc ratio
can affect zinc absorption.
25,27
Iron and zinc requirements
are discussed in detail elsewhere in this supplement.
31,32
Developing meal plans
The aim of our project was to develop single-day lacto-
ovo-vegetarian meal plans that could be used as
educational tools for vegetarian clients. Sample meal plans
were developed for each sex and age category (Box 3),
taking into account the appropriate physical activity level
(PAL). The meal plans show the types and quantities of
foods required to comply with the NRVs.
Foods were selected from a wide range of commonly
available Australian foods. Each meal plan was devised to
meet the recommended increased iron (180% of RDI) and
zinc (150% of RDI) requirements within reasonable energy
intakes while keeping macronutrient intakes within the
acceptable macronutrient distribution range (AMDR).
25
Other nutrients, such as -linolenic acid (ALA), fibre,
vitamin B
12
, vitamin C and calcium were included in
amounts designed to meet the prescribed NRV value while
not exceeding the upper level of intake (UL) for sodium or
certain antioxidants such as vitamins A and E.
25
When the
NRVs differed between sexes within an age group, the
meals were planned to meet the higher requirements
within an energy range applicable to both males and
females. In many cases, meal plans were sex specific.
Infants less than 1 year old were not considered because of
1 Definitions of nutrient reference values
25
Nutrient reference value Definition
Estimated average requirement
(EAR)
A daily nutrient level estimated to meet the requirements of half the healthy individuals of a particular
sex and life stage.
Recommended dietary intake
(RDI)
The average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all
healthy individuals (97%98%) of a particular sex and life stage.
Adequate intake (AI)* The average daily nutrient intake level based on observed or experimentally determined approximations
or estimates of nutrient intake by a group (or groups) of apparently healthy people that is assumed to be
adequate.
Upper level of intake (UL) The highest average daily nutrient intake level likely to pose no adverse health effects to almost all
individuals in the general population. As intake increases above the UL, the potential risk of adverse
effects increases.
* Used when an RDI cannot be determined. N
2 Comparison of 1991
26
and 2006
25
nutrient reference values (NRVs) for iron and zinc recommended by the National
Health and Medical Research Council, including NRVs for vegetarians
Men Women Pregnant women Lactating women
RDI
1970+
years Vegetarian*
1970+
years Vegetarian*
1450
years Vegetarian*
1450
years Vegetarian*
Iron
1991 7 mg 16 mg
/7 mg
22 mg
/36mg
16 mg
/7 mg
2006 8 mg 14mg 18 mg
/8 mg
32 mg
/14mg
27 mg 49 mg 10 mg
/9 mg
18 mg
/16mg
Zinc
1991 12 mg 12mg 16 mg 18 mg
2006 14 mg 21mg 8 mg 12 mg 10 mg
/11mg
15 mg
/16mg
11mg
/12 mg
17 mg
/18mg
RDI = recommended dietary intake. *180% of non-vegetarian RDIs for iron and 150% of non-vegetarian RDIs for zinc. 1950 years. 5170+ years.
1418 years. N
Clinical focus
variable intake and reliance on breastmilk or infant
formula as their main source of nutrition.
Energy requirements for each meal plan were
determi ned accordi ng to the estimated energy
requirements (EERs) outlined in the NRVs.
25
Within each
NRV age group under 18 years, the youngest child in the
group was chosen, on the grounds that if nutritional
requirements are met at a lower energy level, requirements
will also be met for older or more active children.
Additional energy may be added as required. For adults,
average height (165cm for women and 175 cm for men),
along with PAL, determined the estimated energy
requirements. Although the 1995 National Nutrition
Survey states that the mean height for adults over 19 years
is 161.4 cm for women and 174.9cm for men,
33
we adopted
the average heights of 165cm for women and 175 cm for
men as used by the National Health and Medical Research
Council in the recent revision of the Australian guide to
healthy eating.
34
A PAL of 1.8 (moderate activity) was chosen for
teenagers and adults. A PAL equal to or above 1.75 is
considered compatible with a healthy lifestyle for adults.
25
A light PAL (1.6) was chosen for young children, older
adults, pregnant women and lactating women. In line with
NRV recommendations, an additional 1.4 MJ/day and
2.0 MJ/day were applied for pregnant and lactating
women, respectively.
25
As no vegetarian consumption data are currently
available, food selection for meal plans was based on foods
that are commonly available in Australia and are
considered good sources of the nutrients in focus. Meal
plans were initially created and analysed using FoodWorks
Professional, version 5, 2007 software (Xyris Software,
Brisbane, Australia) using the AUSNUT 1999 (Australian
food and nutrient database, 1999 version) food
composition database.
35
As information on vitamins D, E
and B
12
content in foods was not available when meal
plans were initially entered into FoodWorks, other sources
were used to determine the content of these nutrients in
our meal plans. The amounts of these nutrients in each
meal plan were hand-calculated using the NUTTAB 2006
(nutrient tables for use in Australia, 2006 version)
database.
36
The RMIT Lipid Research Groups fatty acid
composition database
37
was used to calculate ALA
content.
36
Food product nutrition information panels and
nutrient information from company websites were used
when needed.
3 Nutrient reference value (NRV) categories by age and sex, showing appropriate physical activity level (PAL) as a
rationale for developing sample meal plans
NRV age group Physical activity level Sample meal plan created
Children 13
years
1.6 (light activity)* 1-year-old, 2-year-old and 3-year-old child. Boys and girls have the same NRV
requirements. Different ages within the 13-year-old category had different energy
needs, which were reflected in the three sample meal plans for this age group. An
energy range applicable to male and female was met.
Children 48
years
1.6 (light activity) 4-year-old.
Boys and girls have the same NRV requirements. An energy range
applicable to male and female was met.
Children 913
years
1.8 (moderate activity) 9-year-old.
Boys have higher NRV requirements. An energy range applicable to male

and female was met.
Children 1418
years
1.8 (moderate activity) 14-year-old male and female.
Differing NRV and energy requirements.

Adults 1930 years;
adults 3150 years
1.8 (moderate activity) Males and females aged 1930 years and 3150 years have very similar NRV
requirements within the same sex, although male and female requirements differ.
Average adult heights were used to determine energy level.
Adults 5170 years;
adults 71+ years
1.6 (light activity) Male and female. Meeting the older age group requirements (71+ years)
automatically means the younger age group requirements (5170 years) are met.
Male and female requirements differ.
Pregnant women 1.6 (light activity) Female with additional energy requirements (1.4 MJ/day).
Lactating women 1.6 (light activity) Female with additional energy requirements (2.0 MJ/day).
*PAL is not assigned until the age of 3 years. For children under the age of 3 years, estimated energy requirements are prescribed values. Youngest age chosen to
meet nutritional requirements in minimal kilojoules applicable to the NRV age range. N
Clinical focus
Nutritional anal yses were compared with the
appropriate NRVs RDI or adequate intake (AI).
25
The
use of RDI when planning diets for individuals ensures
that the needs of most people are covered by these
recommendations.
25
When an RDI cannot be determined,
an AI is used. The sodium content of each meal plan was
compared with the daily recommended UL for sodium,
25
and the saturated fat target was chosen to be less than 10%
of total energy.
25
For macronutrients, the goal was to
achieve the AMDR. The AMDR is an estimate of the range
of intake for each macronutrient for individuals (expressed
as percentage contribution to energy) that would allow for
an adequate intake of all other nutrients while maximising
general health outcome.
25
Key nutrients
In planning vegetarian diets to ensure adequate nutritional
intake, it is wise to be aware of some key nutrients.
4
Iron,
zinc, vitamin D and long-chain omega-3 polyunsaturated
fatty acids (n-3 PUFAs) are considered nutrients of
concern in vegetarian diets. It is important to note that
vitamin D and long-chain n-3 PUFAs are also a concern
for non-vegetarians who have limited sun exposure and
consume minimal amounts of oily fish. Following, we
highlight points of interest regarding these nutrients.
Iron
Cereal products are the main source of dietary iron for all
Australians (a bigger contributor than meat, according to
consumption data).
33
Consequently, cereal products
were also a significant source of iron in these meal plans.
Cereals, legumes, nuts, seeds and fortified foods were
selected mostly in combination with vitamin C-rich
foods, as vitamin C enhances iron absorption.
38
However, absorption concerns are less of an issue than
previously thought.
39
Even though iron requirements
have been set higher for vegetarians, those with lower
stores of iron or higher physiological need will absorb
more iron and excrete less iron an important adaptive
mechanism.
28,31,32
Zinc
While red meat and seafood are good sources of zinc for
non-vegetarians, other foods such as nuts, seeds, legumes
and dairy foods are important sources of zinc for
vegetarians and were included in the meal plans. Concerns
4 Four sample vegetarian meal plans*
NRV age group:
children 48 y
4-year-old child, PAL 1.6
Reference weight 16.2 kg (boys),
15.8 kg (girls); reference height 102 cm
(boys), 101 cm (girls)
NRV age group:
women 1930 y and 3150 y
35-year-old woman, PAL 1.8
Reference weight 60.0 kg; reference
height 165 cm (average height)
NRV age group:
adults 5070+ y
71-year-old man, PAL 1.6
Reference weight 67.5 kg; reference
NRV age group:
pregnant women
25-year-old pregnant woman, PAL 1.6
Reference height 165 cm (average height)
Energy requirements: additional
1.4 MJ/day for pregnancy
Breakfast:
2 fortified wholegrain wheat biscuits,
1/2 cup low-fat fortified soy milk,
sprinkle (5 g) of chia seeds;
1 slice iron-fortified wholemeal toast
with chopped banana
Breakfast:
2 fortified wholegrain wheat biscuits,
4 strawberries, 10 g chia seeds,
1/2 cup low-fat fortified soy milk;
1 slice multigrain toast with
1 poached egg
Breakfast:
Rolled oats made with 1/2 cup dry oats,
1/2 cup low-fat fortified soy milk,
2 tbsp wheatgerm and
10 g chopped walnuts,
30 g pumpkin seeds and 1 banana
Breakfast:
2 fortified wholegrain wheat biscuits with
1/2 cup low-fat fortified soy milk with
1 banana and sprinkle (< 10 g) of chia seeds;
1 slice iron-fortified toast with Marmite and
margarine; 1/2 cup freshly squeezed orange juice
Snack:
3/4 cup low-fat fortified soy milk
and 2 strawberries
Snack:
30 g cashews and 6 dried apricot
halves
Snack:
1 apple; hot chocolate made with
1 cup low-fat fortified soy milk,
2 tsp cocoa powder and 1 tsp sugar
Snack:
25 g cashews and
5 dried apricot halves
Lunch:
Salad sandwich with tahini, tabouli
and 2 slices wholemeal iron-fortified
bread
Lunch:
1 wholemeal pita flatbread
with chickpea falafel, hummus,
1/2 cup tabouli and salad
Lunch:
Mixed-grain-bread sandwich with
40 g cheese, salad, 4 pieces sundried
tomato and margarine; 1/2 cup orange
juice
Lunch:
2 slices wholemeal iron-fortified toast with
baked beans and 20 g low-fat melted cheese;
hot chocolate made with 1 cup low-fat fortified
soy milk and 2 tsp fortified malted chocolate
powder
Snack:
2 rye and sesame crispbread biscuits,
1 spread with tahini and 1 with
Marmite
Snack:
made with 3/4 cup low-fat fortified
soy milk, 2 tsp wheatgerm and
1 banana
Snack:
3 rye biscuits with tahini
and honey
Snack:
35 g almonds and 1 kiwifruit
Dinner:
Honey and soy brown fried rice,
made with 40 g tofu, just under
1 cup cooked brown rice and
vegetables
Dinner:
Stir-fried greens with tofu, served with
1 cup cooked brown rice (100 g tofu,
asparagus, bok choy and snow peas)
Dinner:
Lentil curry with vegetables (pumpkin,
peas, beans, canned tomatoes,
1/2 cup lentils) and cashews, served
with 1 cup cooked brown rice and
sprinkled with sesame seeds
Dinner:
Tofu (100 g), chickpea (1/2 cup) and vegetable
(spinach, broccoli and carrot) curry with
1 cup cooked brown rice
Snack:
100 g low-fat plain yoghurt
Snack:
Hot chocolate, made with
1 cup low-fat fortified soy milk and
10 g fortified malted chocolate powder
Snack:
Hot chocolate, made with
1 cup low-fat fortified soy milk,
2 tsp cocoa powder and
1 tsp sugar; 10 g walnuts
Snack:
200 g low-fat fruit yoghurt and
25 g pumpkin seeds
NRV = nutrient reference value. PAL = physical activity level. tbsp = tablespoon. tsp = teaspoon. y = years. * Add water as desired. N
Clinical focus
about phytate as an inhibitor of zinc absorption are
minimised by modern food processing methods.
40
When
considering zinc requirements, it is important to remember
that the body can adapt to different levels of zinc intake by
adjusting the amount of zinc absorbed relative to the
amount of endogenous zinc lost.
41,42
Given that vegetarian diets exclude fish as a source of n-3
PUFAs, it is important to include adequate amounts of
short-chain n-3 PUFAs such as ALA (found predom-
inantly in chia seeds, flaxseeds and walnuts). Small
amounts of these seeds were included in the meal plans
and provided significant amounts of ALA. ALA is
endogenously converted to long-chain omega-3 fatty
acids, but conversion depends on age, sex and dietary
composition.
43
The meal plans used minimal amounts of
omega-6 fatty acids (oils and margarines) to optimise
conversion.
43
Vitamin D
Vitamin D deficiency is not just a concern for vegetarians.
44
The average dietary intake of vitamin D for Australians is
23 g/day, which is substantially below the AI of 5 g/day
(for children and younger adults).
25
Important dietary
sources of vitamin D are margarine, eggs, vitamin D-
fortified soy milk, and oily fish.
45
Minimal amounts of
margarine and eggs were included in the meal plans, due
5 Nutrient analyses for the four sample vegetarian meal plans presented in Box 4
NRV age group:
children 48 y
4-year-old child, PAL 1.6
Reference weight 16.2 kg (boys),
15.8 kg (girls); reference height
102 cm (boys), 101 cm (girls)
NRV age group:
women 1930 y
and 3150 y
35-year-old woman, PAL 1.8
Reference weight 60 kg; reference
NRV age group:
adults 5070+ y
71-year-old man, PAL 1.6
Reference weight 67.5 kg;
reference height 175 cm (average
height)
NRV age group:
pregnant women
25-year-old pregnant woman, PAL 1.6
Reference height 165 cm
(average height)
Energy requirements: additional
1.4 MJ/day for pregnancy
Nutrient
Meal plan
provides NRV/goal*
Meal plan
provides NRV/goal*
Meal plan
provides NRV/goal*
Meal plan
provides NRV/goal*
Energy (kJ) 5800 55005900
8600
10 05010 350
9700 920010 100
10 600 10 30010 600
Protein (g) 55 20 90 46 101 81 120 60

% total energy 16% 15%25%
18% 15%25%
18% 15%25%
19% 15%25%
CHO (g) 186 262 277 284

52% 45%65%
48% 45%65%
46% 45%65%
Fat (g) 38 64 80 91
27% 20%35%
30% 20%35%
32% 20%35%
SFA (g) 8 12 14 17
% total energy 5% < 10%
5% < 10%
5% < 10%
6% < 10%
% total fat 21% 19% 18% 19%

PUFA (g) 17 22 34 26
% total fat 45% 34% 43% 29%
MUFA (g) 13 30 32 48
% total fat 34% 47% 40% 53%
ALA (g) 1.4 0.8 2.8 0.8 1.3 1.3 2.1 1.0
LC n-3 PUFA (mg) 55 90 160 115
Fibre (g) 31 18 46 25 48 30 53 28
Iron (mg) 18 18 (180% RDI) 32.6 32.4 (180% RDI) 24.8 14.4 (180% RDI) 36.6** 48.6 (180% RDI)
Zinc (mg) 7 6 (150% RDI) 13 12 (150% RDI) 21.4 21 (150% RDI) 16.5 16.5 (150% RDI)
Vitamin B
12
(g) 1.5 1.2 3.2 2.4 2.9 2.4 3.2 2.6
Calcium (mg) 824 700 1386 1000 1489 1300 2083 1000
Folate (g) 463 200 (UL 400) 517 400 (UL 1000) 494 400 (UL 1000) 716 600 (UL 1000)
Vitamin A
equivalents (g)
429 400 (UL 900) 748 700 (UL 3000) 928 900 (UL 3000) 992 800 (UL 28003000)
Vitamin E (mg) 40 6 (UL 100) 10 7 (UL 300) 65 10 (UL 300) 25 7 (UL 300)
Vitamin D (g) < 1 5 < 1 5 < 2 15 < 2 5
Vitamin C (mg) 80 35 (no UL) 115 45 (no UL) 106 45 (no UL) 175 60 (no UL)
Sodium (mg) 1298 300600 (UL 1400) 1738 460920 (UL 2300) 1786 460920 (UL 2300) 1908 460920 (UL 2300)
ALA = -linolenic acid. CHO = carbohydrate. LC n-3 PUFA = long-chain omega-3 polyunsaturated fatty acids. MUFA = monounsaturated fatty acids. NRV = nutrient reference value.
PUFA = polyunsaturated fatty acids. RDI = recommended dietary intake. SFA = saturated fatty acids. UL = upper level of intake. y = years. * NRVs for Australia and New Zealand (RDI and adequate
intake).
25
Energy value range is applicable to both male and female for the youngest in this NRV age group (males being the higher and females being the lower value). If additional energy is
required in an individual diet for an older child, add discretional kJ from foods including avocado, dried fruit, fresh juice, peanut butter and olive oil spread. Nutritional requirements are still met.
The energy in this meal plan meets the requirements for a lower PAL of 1.6 (light activity), associated with an estimated energy requirement of 89009200 kJ. If additional energy is required in an
individual diet, add discretionary kJ. Nutritional requirements are still met. Energy range is provided to be applicable to the large age range in this NRV group. If additional energy is required, add
discretionary kJ. Nutritional requirements are still met. Acceptable macronutrient distribution range.
25
** This sample meal plan did not meet the extended RDI for iron (providing 180% of RDI for
iron during pregnancy results in a level that is above the UL). N
Clinical focus
to a focus on whole plant-food sources of fat, such as nuts,
seeds and avocado. Vitamin D-fortified soy milk was not
included in the meal plans, as its availability is currently
limited in Australia. The AI for vitamin D assumes most
Australians receive some vitamin D from the sun to
adequately meet requirements.
25,45
Those with limited sun
exposure, older adults (with higher requirements) or those
with dark skin should supplement their diet with vitamin
D.
4,45
Analysis of sample lacto-ovo-vegetarian
meal plans
The 13 sample meal plans are available online at http://
www.sanitarium.com.au/~/media/sanitarium/sns-pdfs/
meal-plan-summary-tables.ashx. The full nutritional
analyses for all sample meal plans are available at http://
www.sanitarium.com.au/~/media/sanitarium/sns-pdfs/meal-
plans-and-analyses.ashx. Almost all meal plans met key
NRVs (for energy; protein; carbohydrate; total fat;
saturated, poly- and mono-unsaturated fats; ALA; fibre;
iron; zinc; calcium; folate; and vitamins A, C, E and B
12
),
including the increased requirements for iron and zinc. An
exception was for pregnant women, for whom increased
iron requirements were not met. AI levels for vitamin D
and long-chain n-3 PUFAs were not met across all meal
plans. Below is a brief explanation of the analysis. Four
examples of single-day vegetarian meal plans are
presented in Box 4, and a nutrient analysis of each plan is
provided in Box 5.
Energy
The NRV goals for energy were met based on the youngest
child in each NRV category and on average heights for
adults, with a PAL of 1.8 for adults and 1.6 for younger
children, older adults, pregnant women and lactating
women.
Macronutrients
Protein, carbohydrate and fat intakes were within the
AMDR. The proportion of total energy contributed by
saturated fat was consistently below the 10% target.
Polyunsaturated and monounsaturated fats were the
predominant sources of fat in each of the sample meal
plans.
-linolenic acid
As the ALA content of each meal plan was hand-
calculated, the values are approximate. The AI for ALA was
achieved in all meal plans, with the richest sources being
chia seeds, walnuts and tofu.
Fibre
The AI was exceeded in all meal plans. There is no UL set
for fibre, as a high intake of dietary fibre does not result in
adverse effects when consumed as part of a healthy diet.
25
Iron
The increased iron requirement for vegetarians (180% of
RDI) was achieved for all meal plans with the exception of
the meal plan for pregnant women. The best vegetarian
sources of iron in our meal plans were firm tofu, iron-
fortified breads and breakfast cereals, cashews, chickpeas,
pumpkin seeds, sesame seeds, brown rice, fortified malted
chocolate powder and tabouli.
Zinc
The increased zinc requirement for vegetarians (150% of
RDI) was achieved for all meal plans, including adult males
with the highest zinc requirements, without exceeding
energy and fat needs. The best vegetarian sources of zinc
in our meal plans included muesli, pumpkin seeds,
sunflower seeds, wheatgerm, tofu, brown rice and
sundried tomatoes.
Vitamin B
12
As the vitamin B
12
content of each meal plan was hand-
calculated, the values are approximate. All meal plans,
including those for lactating women, meet the RDI for
vitamin B
12
. In our meal plans, the best sources of vitamin
B
12
were milk, fortified soy milk, yoghurt, cheese, egg and
fortified yeast spread.
Calcium
Calcium requirements were easily met for all meal plans,
including those for adolescents and older adults, who have
the highest requirements. Care was taken not to exceed
the UL for calcium (2500 mg) in high-energy meal plans.
The best vegetarian sources of calcium in our meal plans
were low-fat milk and cheese, tofu (calcium set), fortified
soy milk, yoghurt, sesame seeds and sesame paste (tahini).
Vitamin E
As the vitamin E content of each meal plan was hand-
calculated, the values are approximate. All meal plans met
vitamin E requirements. The best sources of vitamin E in
our meal plans were tahini, sesame seeds, wheatgerm,
almonds, peanut butter, olive oil, margarine and eggs.
Vitamin D
As the vitamin D content of each meal plan was hand-
calculated, the values are approximate. The meal plans did
not meet the AI for vitamin D. The small amount of
vitamin D accounted for in the analyses was attributed to
margarine and cheese. Some brands of soy milk are
fortified with vitamin D and provide a good source for
vegetarians. Our analysis did not take into account vitamin
D derived from safe sun exposure.
Long-chain omega-3 polyunsaturated fatty acids
Vegetarian diets cannot meet the requirements for n-3
PUFAs unless vegetarian docosahexaenoic acid (DHA)
and eicosapentaenoic acid (EPA) supplements (derived
from microalgae) or fortified foods are consumed. As
DHA/EPA-fortified foods are not widely available in
Australia, long-chain n-3 PUFAs were not analysed in our
meal plans. Although there is no separate official
recommendation for n-3 PUFAs for vegetarians, it is
suggested that they double the current AI of ALA if they
do not consume a direct source of DHA and EPA, as ALA
is converted to DHA and EPA.
43
People with increased
need for n-3 PUFAs (eg, pregnant women, older people
and people with diabetes) may benefit from adding a
microalgae-derived DHA and EPA supplement.
46
Clinical focus
Other nutrients
Requirements for folate, vitamin C and vitamin A were
met for all meal plans. Salt was not added to the meal
plans, but the sodium content of the meal plans would be
lower if the food composition database contained more
food options without added sodium. Sodium levels did not
exceed the UL.
Discussion
Our meal plans were designed to be nutrient-dense in
order to meet nutritional requirements without supplying
excess energy. For people who have higher energy needs,
additional discretionary kilojoules may be added. A
vegetarian dietary pattern that focuses on nutrient density
rather than energy deficit will naturally assist with weight
loss and maintain healthy weight status in the long
term.
47-49
The higher i ron requi rement (180% of RDI)
recommended for pregnant vegetarian women translates
to 49 mg per day. Of interest, the UL during pregnancy is
45 mg.
25
Our meal plan was only able to provide 36.6 mg
within a reasonable energy intake. However, it is well
recognised that the increased iron requirements during
pregnancy can be difficult to meet, even for non-
vegetarian women, and iron supplements are commonly
recommended.
4
The iron content of most multivitamin
supplements formulated for pregnant women would easily
compensate for this shortfall.
In our dietary analysis, fibre intakes were well above the
RDIs and suggested dietary targets. There is currently no
UL set for dietary fibre and there are no significant adverse
effects of a high fibre intake eaten as part of a healthy
diet.
25
Limitations
While we attempted to use mostly whole plant foods, in
order to meet the NRVs (incl udi ng the higher
requirements for iron and zinc), some commonly available
fortified foods were included (eg, soy beverages fortified
with calcium and vitamin B
12
; iron-fortified cereals and
bread; fortified malted milk powder; and fortified yeast
spread). The analyses were also limited to values available
in the AUSNUT database used by FoodWorks in our
analyses. There are also limitations in using the NRVs for
estimating dietary adequacy. RDIs overestimate needs (as
they are designed to meet the needs of the majority of the
population) and dont take into account adaptive
responses, as with iron
31
and zinc
32
or the protective
phytonutrients from plant foods. These issues are
particularly relevant to vegetarians.
Conclusion
Requirements for most key nutrients (except vitamin D,
long-chain n-3 PUFAs and iron during pregnancy) can be
met across the life cycle by well planned plant-based lacto-
ovo-vegetarian diets. Furthermore, nutrient-dense
vegetarian diets are more likely to provide additional
health benefits, particularly with respect to prevention and
treatment of many chronic diseases.
Acknowledgements: We would like to thank dietitians Anne Scott, Malindi
Greenwood, Julia Haydon, Nicole Brown, Dawn Tan, Erin Fisher, Kylie Young,
Alison Robinson and Alison Walsh for their assistance with this project.
Competing interests: Michelle Reid and Angela Saunders are employed by
Sanitarium Health and Wellbeing, sponsor of this supplement. Kate Marsh
has previously consulted for Nuts for Life (Horticulture Australia).
reviewed.
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Educational resource
MJA Open ISSN: 0025-729X 4 June 2012 1 2 41-
45
MJA Open
t is not only what a diet excludes, but what it includes,
that shapes health outcomes. This article is a practical
guide for doctors to help them advise patients on
nutrient-rich foods, which should form the basis of all
types of plant-based diets. Of the recognised types of
plant-based diets (Box 1), the most widely studied is the
lacto-ovo-vegetarian diet.
Key points about plant-based diets
Plant-based diets focus on fruits, vegetables, legumes,
nuts, seeds and grains. Some vegetarian diets also
include eggs and dairy, and a few traditional (eg,
Mediterranean and Asian) plant-based diets include
limited amounts of meat and/or seafood.
A varied and balanced plant-based diet can provide all
of the nutrients needed for good health (Box 2 ).
2
Plant-based diets may provide health benefits compared
with meat-centred diets, including reduced risks of
developing chronic diseases such as obesity, heart
disease, colorectal cancer and type 2 diabetes.
1
Plant-based diets more closely match recommended
dietary guidelines to eat plenty of fruits, vegetables,
legumes and wholegrains, and to limit intakes of
saturated fats and sugars.
3
A 2010 national Newspoll survey of 1200 adults
indicated that 70% of Australians consume some plant-
based meals in the belief that eating less meat and more
plant foods improves overall health (Newspoll
Research, Leaders in Nutrition, May 2010, com-
missioned by Sanitarium Health and Wellbeing).
A vegetarian diet does not mean just cutting out meat.
Careful planning, along with knowledge of practical
ideas for using a variety of plant foods, is needed to
ensure nutritional requirements are met, particularly for
new vegetarians or those with special needs.
Nutrients that may need more attention in a vegetarian
diet include iron, zinc, calcium, vitamin B
12
, vitamin D
and omega-3 fats. It may be beneficial to refer people to
an Accredited Practising Dietitian experienced in
vegetarian nutrition.
Any dietary change can increase preparation time to
begin with, but cooking plant-based meals need not be
more time consuming after some training and regular
practice.
A minimally processed plant-based diet, with limited (if
any) amounts of animal foods derived from animals
lower down the food chain, provides environmental
advantages over a Western-style meat-rich diet.
4-6
Common myths about vegetarian diets
Myth: it is difficult to get enough protein on a
vegetarian diet
Studies of Australian vegetarians have found that
although their protein intakes are significantly lower
than those of omnivores,
7,8
their intakes still easily meet
recommended dietary intakes (RDIs) because most
omnivores eat much more protein than is required. Most
plant foods contain some protein, with the best sources
Practical tips for preparing healthy and delicious
plant-based meals
I
Sue Radd
BSc(Nutr), GradDipDiet,
APD,
Founding Director and
Lead Dietitian
1
Kate A Marsh
AdvAPD,
MNutrDiet, PhD,
Director and
Senior Dietitian
2
1 Nutrition and Wellbeing
Clinic, Sydney, NSW.
sradd@
ozemail.com.au
doi: 10.5694/mjao11.11511
1 Types of plant-based diets
1
Semi-vegetarian: includes red meat, poultry and fish less than once a week.
Pesco-vegetarian: includes fish and seafood but no red meat or chicken.
Lacto-ovo-vegetarian: includes dairy foods, eggs, or both, but no red meat, poultry or
seafood. This is the most common type of vegetarian diet.
Vegan: excludes all animal products including meat, poultry, seafood, eggs and dairy foods.
Most vegans also wont use honey or other animal products. N
2 Sources of key nutrients in a vegetarian or vegan diet*
Nutrient Food source
Protein Legumes, tofu, soy milk, tempeh, gluten, wholegrains (particularly
amaranth and quinoa), nuts, seeds, eggs, milk, yoghurt
Iron
Legumes/soybeans, wholegrains (particularly amaranth and quinoa),

iron-fortified cereals, tofu, tempeh, dried fruit, nuts, seeds, green leafy
vegetables
Zinc Wholegrains, legumes, tofu, nuts, seeds, tempeh, eggs, milk, yoghurt
Calcium Milk, yoghurt, cheese, calcium-fortified soy, rice or oat milk, calcium-set
tofu, unhulled tahini, kale, Asian green vegetables, almonds
Vitamin B
12
Milk, yoghurt, cheese, eggs, vitamin B

12
-fortified soy or rice milk, vitamin
B
12
-fortified meat analogues (eg, some vegetarian sausages and burgers)
Omega-3 fats Flaxseed oil,
linseeds/flaxseeds,
chia seeds,
walnuts,
soy foods,

omega-3 eggs and DHA-fortified foods (eg, breads, yoghurts, orange
juice)
Vitamin D Milk, eggs, vitamin D-fortified soy milk, vitamin D mushrooms
DHA=docosahexaenoic acid.
* Amounts of each food required each day will vary for individuals depending on age and sex and,
for women, whether they are pregnant or breastfeeding. Various health conditions or the use
of certain medications may also affect requirements for particular nutrients. Non-haem iron,
the absorption of which is improved in the presence of vitamin C and inhibited by phytates and tannins.
Mushrooms are not a reliable source as they provide only trace amounts. -linolenic acid (ALA) is
converted to the long-chain omega-3 fatty acids in the body; this conversion is improved with a diet low in
omega-6 polyunsaturated fats and trans fats. N
being legumes, soy foods (including soy milk, tofu and
tempeh), nuts and seeds. Grains and vegetables also
provide protein. A glossary of protein-rich plant-based
foods is provided in Box 3.
Myth: vegetarians need to combine proteins at meals
As most plant foods contain limited amounts of one or
more essential amino acids it was once thought certain
combinations had to be eaten at the same meal to
ensure sufficient essential amino acids. Research has
found that strict protein combining at each meal is
unnecessary, provided energy intake is adequate and a
variety of plant foods are eaten over the course of a day,
including legumes, wholegrains, nuts and seeds, soy
products and vegetables.
9
Soy protein is a complete
protein as it has a Protein Digestibility-Corrected
Amino Acid Score (PDCAAS) equivalent to that of
eggwhite or dairy protein (casein).
10
Myth: vegetarians need to take an iron supplement
Vegetarian diets can contain as much or more total
(non-haem) iron as mixed diets; this iron comes
primarily from wholegrain breads and cereals.
11,12
Iron
deficiency anaemia is not more common among
vegetarians, although their iron stores (serum ferritin
levels) are often lower.
7,12,13
Some studies have found
that lower iron stores are associated with reduced risk of
chronic diseases (such as cardiovascular disease and
type 2 diabetes), which may partly explain the lower risk
of these diseases in vegetarians.
14,15
Myth: dairy foods are the only good source of calcium.
Dairy products are not the only sources of calcium in the
diet. Fortified soy, rice and oat milks, unhulled tahini,
Asian greens, almonds and calcium-set tofu are good
sources of bioavailable calcium in non-dairy diets.
16,17
Calcium needs can be met using plant foods as long as
adequate amounts of these foods are consumed each day.
Myth: vegetarian diets are not suitable during
pregnancy
Vegetarian diets can be planned to supply the required
levels of nutrients during pregnancy. Research shows
there are no significant health differences in babies born
to vegetarian mothers.
18
The higher fibre content and
lower energy density of many vegetarian diets may offer
significant advantages, including a reduced risk of
excess weight gain.
19
Further, some studies suggest that
a lower intake of meat and dairy products reduces the
pesticide content of breast milk.
20,21
Myth: vegetarian diets are not suitable for children
Vegetarian diets are appropriate for children of all ages.
2
The growth of vegetarian and vegan children is similar
to that of non-vegetarian children if meals are planned
well, according to the American Academy of Pediatrics
22
and American Dietetic Association.
2
Meal planning
As for all healthy diets, meal planning for plant-based diets
should focus on incorporating a wide variety of minimally
processed foods from each of the main food groups to
ensure a plentiful supply of nutrients and phytonutrients.
The Healthy Eating Plate device (Box 4) has been created
as a visual guide for planning plant-based meals at home.
Vegetables and/or salads: these should include
vegetables of a variety of colours, and should fill half of a
main meal plate.
3 Glossary of protein-rich plant food
There are many protein-rich plant foods available, including whole foods such as legumes, traditional products like tofu, and faux meats, which can make transition to
a plant-based diet easier and more convenient.
Food Description and additional information
Legumes Dry beans, peas or lentils available in hundreds of varieties (eg, chickpeas, borlotti beans, black beans, puy lentils, lima beans). Many
canned varieties are available from supermarkets.
Textured vegetable
protein (TVP)
A good substitute for mince when making bolognaise sauce, shepherds pie or taco filling. Made from soy flour, TVP is dehydrated and
resembles mince crumbles or chunks. It can be stored in the pantry for many months.
Tofu This is available in different textures (silken, soft and firm) and can be cut to desired size. It is excellent for curries, stir fries, burgers, creamy
dressings or dessert. Also known as bean curd, tofu is made by curdling soy milk.
Tempeh This is a savoury fermented soybean cake that can be sliced or diced then grilled, baked or pan fried.
Gluten Also known as seitan, gluten has a meaty texture and can be used in stir fries and casseroles or crumbed and cooked as schnitzel. It is
available canned or fresh from Asian stores or can be made at home from gluten flour.
Convenience vegetable
protein products
These are made from soy, nuts, gluten and grains. They are available canned, chilled, frozen or shelf-stable. Most are ready to heat and
serve or can be used as ingredients in other dishes. Many have high levels of sodium, and so are not ideal for everyday use. N
Wholegrains: these are preferred over refined grain foods
(eg, brown rice instead of white rice), and can occupy
about a quarter of a main meal plate. When choosing grain
foods, choose those with a low glycaemic index (GI). Low
GI carbohydrates help to regulate blood glucose and
insulin levels, lower the levels of low-density lipoproteins
and triglycerides and raise the high-density lipoprotein
level, and can assist with weight management.
23-25
Plant proteins: from sources such as legumes, nuts, seeds,
soy products or vegetarian convenience products should
occupy about a quarter of a main meal plate. Semi-vegetarians
may sometimes substitute fish, poultry or red meat.
Dairy or calcium-fortified soy, rice or oat products:
these may be liquids or solids, and consumed as a side dish
or integrated into the contents of a main meal plate. Lower
fat varieties are preferable. The lower protein content of
rice and oat beverages may not be suitable for infants and
young children.
Fruit: this is best eaten whole with the skin (rather than
juiced), and consumed as a dessert or snack.
While it is desirable to plan to include all of these
components in each meal, different cooking styles and
cuisines may determine the composition of a meal and
whether the recommended balance of nutrients is eaten at
each meal or spread over the meals for the day.
Easy meal ideas for main plates and snacks are provided
in Box 5, and Healthy Eating Plate images for main courses
are shown in Box 6.
Shopping tips
When choosing alternatives to dairy foods (eg, soy or
rice milk), look for products enriched with calcium and
vitamin B
12
.
Tofu, tempeh, Quorn (meat-free, soy-free products
based on high-quality mycoprotein), textured vegetable
protein, canned and frozen or chilled convenience
products (eg, Sanitarium Vegie Delights, Frys
Vegetarian foods and Syndian Natural Food Products)
are available in most supermarkets.
Many varieties of legumes and wholegrains are available
in Asian, Indian and health food shops.
Vegetarian cheese, dairy-free margarine/chocolate or
frozen convenience meals may sound healthy, but many
can hide excess kilojoules, fat, sugar or salt.
Seven cooking tips
1. Enrol in a cooking class to improve your culinary skills
and increase dietary variety.
2. Plan meals that you know you can easily prepare for
several days of each week to help you avoid buying
takeaway meals.
3. Stock your pantry with a flexible range of ingredients, with
an emphasis on whole foods to make it easy to prepare a
5 Some delicious plant-based meal and snack ideas
Breakfast ideas
Bircher muesli with yoghurt and berries
Soy and linseed bread with almond spread
Fruit salad with low-fat yoghurt and a sprinkle of natural muesli
Toasted rye sourdough with ricotta, fresh tomato and oregano
Smooth polenta porridge with soy milk
Baked beans on wholegrain English muffins
Homemade carrot, rosemary and zucchini muffins with chia
seeds
Millet with macadamia nuts, currants and low-fat milk
Lunch ideas
Vietnamese rice paper rolls filled with vegetables, tofu and
fresh herbs
Vegetable frittata with mixed green leaves
Falafel roll with hummus, tabouli, tomato and lettuce
Mixed bean and pasta salad with lemon
Homemade mini pizzas with Mediterranean vegetables
Wholegrain egg and lettuce sandwich
Lentil burger with baby spinach, tomato, beetroot and
caramelised onion
Jacket potato with spicy bean mix, coleslaw and fresh avocado
topping
Dinner ideas
Vegetable stir fry with tempeh, hokkien noodles and satay
sauce
Spaghetti with red wine and cinnamon bolognaise sauce (made
with textured vegetable protein)
Three-bean dhal with steamed brown rice and minted cucumber
raita
Spinach and ricotta cannelloni with fresh cabbage, carrot and
shallot salad
Lentil shepherds pie with tossed salad
BBQ tofu and vegetable kebabs with wild rice salad and wasabi
dressing
Moroccan chickpea and vegetable tajine with quinoa
Crumbed gluten (seitan) schnitzel with cauliflower mash,
pumpkin and broccolini with almonds
Snack ideas
Fresh fruit in season
Low-fat dairy or calcium-fortified soy yoghurt
Handful of almonds or cashews
Few dried figs or prunes
Milo made with low fat milk
Fresh cob of corn or popcorn
Roasted soy nuts or chic nuts (roasted chickpeas)
Wholemeal pita pocket with hummus and cherry tomatoes
Berry and banana soy smoothie with ground linseeds/flaxseeds
Sweet potato in its jacket N
4 The Healthy Eating Plate device
Healthy Eating Plate
Fruit
mostly whole mostly whole
Dairy
Soy
or fortified
Whole
grains
Whole
grains
Plant
Proteins
Plant
Proteins
Veges or
Salads
Veges or
Salads
Fruit
meal (eg, wholegrain spaghetti, canned brown lentils and
a tomato-based pasta sauce for spaghetti bolognaise).
4. Invest in a pressure cooker to cook legumes and
wholegrains quickly, or a slow cooker to cook them
overnight on low heat.
5. Freeze portion-sized quantities of homemade leftover
soups, stews and curries for easy lunches.
6. Shell your own walnuts (these are rich in -linolenic
acid, making them highly prone to oxidation on
exposure to oxygen) and store nuts and seeds in the
fridge or freezer to extend shelf life.
7. Choose cooking oils that have high levels of omega-9
(eg, extra virgin olive oil, macadamia oil) or omega-3
(eg, canola oil) fatty acids. Do not heat flaxseed oil or
chia oil (because they have a very high omega-3 fatty
acid content making them highly prone to oxidation),
and store in the fridge.
Supplements
It is not necessary for people to take supplements routinely
just because they follow a plant-based diet. However,
6 Healthy Eating Plate images for main courses
depending on dietary restrictions, health, and stage of life,
certain supplements may be beneficial. For example, those
eating a vegan or low-dairy diet should ensure a sufficient
intake of foods fortified with vitamin B
12
or take a
supplement that provides at least the RDI of vitamin B
12
.
Patients beginning a plant-based diet should see their
doctor or an Accredited Practising Dietitian for further
advice on their individual supplement needs. In some
cases, high doses of supplements may be harmful.
Conclusion
There are many health benefits from eating a plant-based
diet, but, as with any eating plan, it is important that it is
well planned to ensure that nutritional needs are met. In
this article, we provide a basic guide to preparing healthy
plant-based meals that incorporate key nutrients. It is
intended as a starting point, as individual needs will vary.
An Accredited Practising Dietitian can help develop an
eating plan specific to individual needs.
This practical paper is intended for use in patient
education and may be reproduced for this purpose.
Additional resources are shown in Box 7. For further details
on the scientific evidence behind these recommendations
please see the other articles in this supplement.
Acknowledgements: We thank Anna Minko for assistance with graphic
design and Greg Teschner for food photography.
Competing interests: Sue Radd previously consulted for Sanitarium
Health and Wellbeing, sponsor of this supplement. Kate Marsh previously
consulted for Nuts for Life (Horticulture Australia), who are providing a
contribution towards the cost of publishing this supplement.
reviewed.
1 Fraser GE. Vegetarian diets: what do we know of their effects on
common chronic diseases? Am J Clin Nutr 2009; 89: 1607S-1612S.
3 Farmer B, Larson BT, Fulgoni VL 3rd, et al. A vegetarian dietary pattern
as a nutrient-dense approach to weight management: an analysis of the
national health and nutrition examination survey 19992004. J Am Diet
Assoc 2011; 111: 819-827.
4 Carlsson-Kanyama A, Gonzalez AD. Potential contributions of food
consumption patterns to climate change. Am J Clin Nutr 2009; 89:
1704S-1709S. Epub 2009 Apr 1.
5 Marlow HJ, Hayes WK, Soret S, et al. Diet and the environment: does what
you eat matter? Am J Clin Nutr 2009; 89: 1699S-1703S. Epub 2009 Apr 1.
6 McMichael AJ, Powles JW, Butler CD, Uauy R. Food, livestock production,
energy, climate change, and health. Lancet 2007; 370: 1253-1263.
7 Ball MJ, Bartlett MA. Dietary intake and iron status of Australian vegetarian
women. Am J Clin Nutr 1999; 70: 353-358.
9 Young VR, Pellett PL. Plant proteins in relation to human protein and amino
acid nutrition. Am J Clin Nutr 1994; 59 (5 Suppl): 1203S-1212S.
10 Sarwar G, McDonough FE. Evaluation of protein digestibility corrected
amino acid score method for assessing protein quality of foods. J Assoc
Off Anal Chem 1990; 73: 347-356.
11 Davey GK, Spencer EA, Appleby PN, et al. EPIC-Oxford: lifestyle
characteristics and nutrient intakes in a cohort of 33883 meat-eaters and
31546 non meat-eaters in the UK. Public Health Nutr 2003; 6: 259-269.
13 Alexander D, Ball MJ, Mann J. Nutrient intake and haematological status
of vegetarians and agesex matched omnivores. Eur J Clin Nutr 1994; 48:
538-546.
14 Rajpathak SN, Crandall JP, Wylie-Rosett J, et al. The role of iron in type 2
diabetes in humans. Biochim Biophys Acta 2009; 1790: 671-681. Epub 2008
May 2003.
15 Sun L, Franco OH, Hu FB, et al. Ferritin concentrations, metabolic
syndrome, and type 2 diabetes in middle-aged and elderly chinese.
J Clin Endocrinol Metab 2008; 93: 4690-4696. Epub 2008 Sep 16.
16 Weaver CM, Proulx WR, Heaney R. Choices for achieving adequate dietary
calcium with a vegetarian diet. Am J Clin Nutr 1999; 70: 543S-548S.
17 Weaver C, Plawecki K. Dietary calcium: adequacy of a vegetarian diet.
Am J Clin Nutr 1994; 59: 1238S-1241S.
18 Mangels R, Messina V, Messina M. The dietitians guide to vegetarian diets:
issues and applications. 3rd ed. Sudbury, Mass: Jones & Bartlett Learning,
2011.
19 Stuebe AM, Oken E, Gillman MW. Associations of diet and physical activity
during pregnancy with risk for excessive gestational weight gain.
Am J Obstet Gynecol 2009; 201: 58.e1-8. Epub 2009 May 21.
20 Dagnelie PC, van Staveren WA, Roos AH, et al. Nutrients and contaminants
in human milk from mothers on macrobiotic and omnivorous diets. Eur J
Clin Nutr 1992; 46: 355-366.
21 Patandin S, Dagnelie PC, Mulder PG, et al. Dietary exposure to
polychlorinated biphenyls and dioxins from infancy until adulthood: a
comparison between breast-feeding, toddler, and long-term exposure.
Environ Health Perspect 1999; 107: 45-51.
22 Committee on Nutrition AAoP. Pediatric nutrition handbook. 6th ed. Elk
Grove Village, IL: American Academy of Pediatrics, 2009.
23 Livesey G, Taylor R, Hulshof T, Howlett J. Glycemic response and health a
systematic review and meta-analysis: relations between dietary glycemic
properties and health outcomes. Am J Clin Nutr 2008; 87: 258S-268S.
24 Opperman AM, Venter CS, Oosthuizen W, et al. Meta-analysis of the health
effects of using the glycaemic index in meal-planning. Br J Nutr 2004; 92:
367-381.
25 Thomas DE, Elliott EJ, Baur L. Low glycaemic index or low glycaemic load
diets for overweight and obesity. Cochrane Database Syst Rev 2007; (3):
CD005105. J
7 Resources
Free images of the Healthy Eating Plate device and sample plant-based food plates
developed by the first author can be downloaded in full colour and high-resolution for
educational purposes (www.sueradd.com/resources/healthyeatingplate.html).
For one-on-one dietary advice, find an Accredited Practising Dietitian with expertise in
vegetarian nutrition (www.daa.asn.au).
Nutrition information, recipes, cooking classes and forums can be found at the Australian
Vegetarian Society (www.veg-soc.org).
Sanitarium Health & Wellbeing Australia website (www.sanitarium.com.au) provides an
abundance of free vegetarian recipes and other practical information. N
Educational resource Notes
Notes
Educational resource Notes

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Editorial

5 MJA Open 1 Suppl 2 4 June 2012

4.4g Cheese, cheddar 24.6 g

3.8g Salmon, Atlantic, grilled 24.3 g

but no apparent limitation in iron supply. An

of iron per day, by sex and age group

4.3 mg Crabmeat, canned 2.2 mg

of zinc per day, by sex and age group

Genetically modified canola oil

Eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and

Corn kernel, corn oil

Soybean, soybean oil

and walnuts. Smaller amounts come from

1 slice multigrain toast 0.0 g

2 teaspoons wheatgerm 0.0 g

10g malted chocolate powder 0.0 g

* Source: FoodWorks 2009 (incorporating Food Standards Australia New

Boys have higher NRV requirements. An energy range applicable to male

Differing NRV and energy requirements.

9700 920010 100

10 600 10 30010 600

Protein (g) 55 20 90 46 101 81 120 60

CHO (g) 186 262 277 284

% total fat 21% 19% 18% 19%

Legumes/soybeans, wholegrains (particularly amaranth and quinoa),

Milk, yoghurt, cheese, eggs, vitamin B

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