Professional Documents
Culture Documents
Dr Kate Marsh
BSc, MNutrDiet, PhD, Grad Cert Diab Edn & Mgt
Advanced Accredited Practising Dietitian
Credentialled Diabetes Educator
Introduction
A vegetarian is someone who consumes a diet consisting mostly of plant-based foods
including fruit, vegetables, legumes, nuts, seeds and grains. Some vegetarians also consume
eggs and dairy products. While not true vegetarians, others follow a semi-vegetarian diet
where they restrict only certain animal foods or a pesco-vegetarian diet where they eat fish
but no other animal flesh.
While we dont have any good data on the number of vegetarians and vegans in Australia, A
2010 national Newspoll survey of 1200 adults indicated seven out of 10 Australians are
eating some plant based meals in the belief that eating less meat and more plant foods
improves overall health. The popularity of the Meat-Free Mondays movement, which began
in 2003 and has been adopted in many countries including the US, UK, Canada, Israel and
Australia, also reflects the increasing awareness of the health and environmental benefits of
eating less meat and adopting more plant-based meals.
If you are not already aware of the Meat-Free Mondays movement, take a look at the
website now to find out more. Why not join up and receive regular emails and tasty meatfree recipe to try every Monday? http://foodwise.com.au/meat-free-mondays/homepage/
Dr Kate Marsh
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The reasons for choosing a vegetarian diet are varied but include:
Health there is now a significant body of evidence to demonstrate the health benefits
of vegetarian and plant-based diets and this is a common reason someone might choose
to become vegetarian
Environment there is increasing awareness of the environmental benefits of eating
more plant foods and less meat for the environment, and this is becoming an
increasingly common reason for people choosing a vegetarian diet or eating more plantbased meals.
Animal rights many people choose to follow a vegetarian diet as they believe that
killing animals for food is inhumane, and there is an increased awareness of the
questionable treatment of farm animals in factory farming. Watch this video to
understand more about animal welfare.
Religion many religions advocate a vegetarian diet including Seventh-day Adventists,
Hindus, Jains and Buddhists. Others avoid certain meats or only allow the consumption
of meats which have been slaughtered in a particular way.
Food safety - outbreaks of food-borne disease (eg food poisoning, mad-cow disease)
from meat products, as well as increased concern over the additives in meat such as
hormones and antibiotics have led some people to be concerned over the safety of
eating meat.
Ethics this ties in with animal rights, with many vegetarians and vegans believing that it
is not ethical to unnecessarily kill another living creature for food. There is also the issue
of environmental ethics and food sustainability due to the fact that the production of
animal foods is far less efficient than the harvesting of plant-foods.
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.
Rosemary Stanton
(Source: Stanton. A plant-based diet good for us and good for the planet (editorial). MJA
Open 2012; 1 Suppl 2: 5-6. Read the full paper here
Dr Kate Marsh
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Red meat
Nuts
Processed meats
Legumes
Animal protein
Haem iron
Wholegrains
Refined grains
Soy products
High GI carbs
Low GI carbs
As you can see above, vegetarian diets differ from non-vegetarian diets in many respects,
but the most significant difference is the absence of red meat intake in a vegetarian diet.
Research has linked higher intakes of red meat and processed meat with an increased risk of
obesity, type 2 diabetes, gestational diabetes, cardiovascular disease and some types of
cancer.
A large study investigating the association of a wide range of meat intakes with chronic
disease mortality found that both red and processed meat intakes were associated with
modest increases in total mortality, cancer mortality and cardiovascular disease mortality.
Low meat intake, on the other hand, has been associated with greater longevity.
Dr Kate Marsh
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28.2
28
26.8
27
25.9
25.6
26
25
24
23.8
23
22
21
Vegan
LOV
Pesco-vegetarian Semi-vegetarian
Non-vegetarian
There are a number of possible explanations for this association including the lower fat
intake, higher intake of dietary fibre, and lower energy density typical of a vegetarian diet.
Foods such as wholegrains and nuts are more regularly consumed by vegetarians and have
been independently associated with a reduced risk of obesity and weight gain. A higher
intake of red meat, on the other hand, has been associated with an increased risk of weight
gain.
Dr Kate Marsh
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Cardiovascular Disease
The most consistent evidence for the health benefits of a vegetarian diet is for a reduced risk
of coronary heart disease (CHD) and coronary disease mortality. A combined analysis of 5
prospective studies reported a 24% lower risk of mortality from ischaemic heart disease
(IHD) in vegetarians compared to meat-eaters. Lacto-ovo vegetarians had a 34% reduced risk
and vegans a 26% reduced risk. The benefit was apparent in those who had followed their
diet for at least 5 years and was greater in younger age groups.
These findings are not surprising considering that vegetarians generally have a better
cardiovascular risk profile than non-vegetarians with lower total and low density lipoprotein
(LDL) cholesterol levels, a lower body weight, and a lower incidence of diabetes and
hypertension all of which contribute to CVD risk.
Specific aspects of a vegetarian diet likely to contribute to its cardiovascular benefits include:
A lower intake of saturated fat and greater proportion of unsaturated fats
A higher intake of wholegrains. Several studies have demonstrated an association
between wholegrain intake and cardiovascular disease risk and a recent meta-analysis
estimated that a greater intake of wholegrains was associated with a 21% lower risk of
CVD events.
A higher intake of legumes. The National Health and Nutrition Examination Survey
(NHANES) 1 Epidemiologic Follow-up Study found that consuming legumes at least 4
times per week, compared to less than once per week, was associated with a 22%
reduced risk of CHD and an 11% reduced risk of CVD.
A higher intake of nuts. Regular nut consumption has been found to protect against
CHD in both epidemiological and clinical trials. Nuts may protect against CHD through
effects on lipids, lipid oxidation, inflammation and vascular reactivity.
A higher intake of soy foods. Soy protein has been shown to reduce total and LDL
cholesterol levels and a meta-analysis of thirty studies demonstrated a small but
significant reduction in both total and LDL cholesterol with the consumption of 25g of
soy protein per day.
While individual components of a vegetarian diet may provide benefits for CVD risk, the
combination of these foods is likely to provide the greatest effect. For example a vegetarian
diet incorporating soluble fibre, soy protein, almonds and plant sterols (the Portfolio diet)
has been shown to reduce LDL cholesterol to a similar extent to a low dose of statins (the
most commonly prescribed cholesterol-lowering medication) over 4 weeks.
While some studies have linked red meat intake with coronary heart disease risk a recent
meta-analysis found that processed meat intake, but not red meat intake, was associated
with a higher risk of coronary heart disease. Several studies have demonstrated the benefits
of a Mediterranean diet, a mostly plant-based diet with low meat intake, with a reduced risk
of coronary heart disease.
Dr Kate Marsh
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Hypertension
Evidence suggests that a vegetarian diet may help in both the prevention and management
of hypertension.
The EPIC-Oxford study found that non-meat eaters had a lower prevalence of hypertension
and lower systolic and diastolic blood pressures than meat eaters but this was largely due to
differences in body mass index. The age-adjusted prevalence of self-reported hypertension
was significantly different between the four diet groups, ranging from 15.0% in male meat
eaters to 5.8% in male vegans, and from 12.1% in female meat eaters to 7.7% in female
vegans. Fish eaters and vegetarians had a similar, intermediate prevalence of hypertension.
In the Adventist Health Study-2, a significant, graded association with blood pressure was
also observed. Compared with non-vegetarians, the odds ratio for hypertension (defined as
a systolic BP > 139 mmHg or diastolic BP > 89 mmHg or use of antihypertensive medications)
0.37 for vegans, 0.57 for lacto-ovo vegetarians and 0.92 for partial vegetarians. The
relationship remained but was attenuated after adjustment for BMI (see figure 2).
Figure 2: Risk of hypertension according to vegetarian diet status
1.4
1.22
1.2
1
0.86
0.92
0.8
0.53
0.6
0.4
0.57
0.37
0.2
0
Vegan
LOV
Partial vegetarian
Non-vegetarian
A number of randomised clinical trials have shown that a vegetarian diet can lower blood
pressure in both normotensive and hypertensive individuals. While it is well accepted that
both weight loss and reducing sodium intake can lower blood pressure , the effect of a
vegetarian diet on blood pressure appears to be independent of these, suggesting that other
components of the diet are responsible. These findings are consistent with the results of the
DASH (Dietary Approaches to Stopping Hypertension) trial which found that a diet high in
fruit, vegetables, wholegrains, and low fat dairy products significantly reduced blood
pressure in those with normal blood pressure or mild hypertension.
Dr Kate Marsh
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Diabetes
Observational studies have demonstrated a significantly lower risk of type 2 diabetes in
individuals following a vegetarian diet compared to non-vegetarians. The original Adventist
Health Study found that vegetarians had approximately half the risk of developing diabetes
while in the more recent Adventist Health Study-2, involving more than 60 000 men and
women, those following a vegan diet were found to have a diabetes prevalence
approximately one-third that of non-vegetarians, while the lacto-ovo vegetarians, pescovegetarians and semi-vegetarians had an intermediate diabetes prevalence. After adjusting
for confounding factors, those following a vegan diet had almost a 50% reduction in the risk
of developing type 2 diabetes compared to non-vegetarians and the risk reduction became
incrementally smaller as more animal products were consumed as shown in Figure 3.
1
0.8
0.7
0.6
0.76
0.56
0.54
0.51
0.69
0.43
0.4
0.32
0.2
0
Vegan
LOV
Pesco-vegetarian Semi-vegetarian
Non-vegetarian
Whether the reduction in risk of diabetes in vegetarians can be attributed to the absence of
meat or the higher intake of plant foods such as wholegrains, legumes and nuts is unclear.
However several studies have shown a positive association between dietary heme iron
intake and heme iron intake from red meat and the risk of type 2 diabetes. A positive
association between the intake of red meat, processed meats and animal protein and the
incidence of type 2 diabetes has also been shown. A recent systematic review and metaanalysis of cohort studies of meat consumption and type 2 diabetes risk estimated the
relative risk comparing high versus low intake was 1.17 for total meat, 1.21 for red meat and
1.41 for processed meat. The authors predict that a 120g per day increase in red meat
consumption increases the risk of diabetes by 20% and a 50g per day increase in processed
meat consumption increases the risk by 57%.
Dr Kate Marsh
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There are only a few intervention studies assessing the effects of a vegetarian diet in people
with diabetes, and weight loss has generally been greater on the vegetarian diets, making it
difficult to determine the independent effect of the diets. However, greater weight loss may
be one of the advantages of a vegetarian diet as even small amounts of weight loss can help
in both the prevention and management of type 2 diabetes. One study comparing a low fat
vegan diet with a diet based on the American Diabetes Association (ADA) guidelines found
that the vegan diet reduced HbA1c levels significantly more than the ADA diet (1.23 versus
0.38 percentage points in those who didnt change medication). Furthermore, 43% of
subjects were able to reduce their medication compared to only 26% in the ADA group.
Earlier studies of low fat vegan diets in patients with type 2 diabetes have also
demonstrated significant improvements in blood glucose control and blood fats, as well as
considerable reductions in medication use although the larger of these studies was not
controlled.
Dr Kate Marsh
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Cancer
Overall, cancer rates in vegetarians appear to be moderately lower than non-vegetarians,
and life expectancy appears to be greater. However, results for specific cancers are less
convincing and require more study. Most of the research conducted on vegetarian diets and
cancer has involved lacto-ovo-vegetarians. Of the studies looking at vegan groups, most
only cover a short period of time or a small group.
The health benefits of protective compounds in a plant-based diet have been linked to the
prevention of cancer initiation and a reduction in cancer cell growth. Foods that are central
to vegetarian diets such as wholegrains, legumes, fruits, and vegetables are rich in fibre, folic
acid, phytochemicals and antioxidants which may protect against cancer. On the other hand,
eating red meat may contribute to cancer formation. The consumption of red meat cooked
at high temperatures, diets rich in animal fat and cholesterol or diets high in animal protein
have been associated with an increased risk of developing cancer.
The World Cancer Research Fund released their second expert report in 2007 Food,
Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective, which is a is a
comprehensive analysis of the literature on food, nutrition, physical activity and cancer. One
of the 10 recommendations they make for reducing cancer risk relates to animal foods and is
to limit intake of red meat and avoid processed meats. They recommend that individuals
who eat red meat should to consume less than 500g per week, with very little, if any, being
processed. They refer to 'red meat' as beef, pork, lamb, and goat from domesticated
animals including that contained in processed foods, and 'processed meat' as meat
preserved by smoking, curing or salting, or the addition of chemical preservatives, including
that contained in processed foods.
More details can be found here:
http://www.dietandcancerreport.org/expert_report/recommendations/recommendation_a
nimal_foods.php
Other diseases
Limited research has suggested that a vegetarian diet may also reduce the risk of other
health conditions including diverticular disease, gallstones, rheumatoid arthritis, gout and
kidney disease. While these findings are positive and add to the evidence of the health
benefits of a vegetarian diet, the small number of studies mean that further research is
required to confirm these benefits.
Dr Kate Marsh
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Dr Kate Marsh
Protein
Iron
Zinc
Calcium
Vitamin B12
Milk, yoghurt, cheese, eggs, B12 fortified soy or rice milk, B12
fortified meat analogues (e.g. sausages and burgers). Note
mushrooms are not a reliable source as they provide only very
small amounts.
Omega-3 fats
Vitamin D
Page | 11
Protein
Protein is an essential nutrient that is required for many vital roles in the body. Proteins are
made up of amino acids some of these can be made by the body while others (known as
essential amino acids) must be supplied by the diet. A vegetarian can obtain of all the
essential amino acids they need by eating a variety of different types of protein-rich plant
foods each day. It was once thought that certain combinations of plant foods had to be
eaten at the same meal but it is now known that strict protein combining is not necessary as
long as a variety of protein-rich foods are eaten from day to day.
Food sources of protein on a vegetarian diet:
legumes including chickpeas, lentils and dried or canned beans
soy foods including tofu, tempeh, textured vegetable protein (TVP)
mycoprotien (Quorn)
seitan (gluten)
grains (particularly quinoa, amaranth)
nuts and seeds
soy milks and yoghurt
eggs and dairy products (for lacto-ovo vegetarians)
64g
81g
46g
57g
Pregnancy
Breastfeeding
58-60g
63-67g
Dr Kate Marsh
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Iron
Iron is an essential mineral which plays a vital role in forming haemoglobin, which transports
oxygen around the body, and assisting in energy-producing chemical reactions and
maintaining a healthy immune system. Low iron levels lead to anaemia.
There are two types of iron in food - haem iron is found in animal foods while non-haem iron
is found in eggs and plant foods such as legumes, cereal grains, nuts, seeds and dark green
leafy vegetables. Non-haem iron is not as well absorbed by the body but including foods high
in vitamin C at the same meal can improve absorption. Phytates (in wheat bran) and
polyphenols (in tea, coffee, cocoa and red wine) can inhibit the absorption of iron.
Food sources of iron on a vegetarian diet:
legumes
wholegrains (especially amaranth and quinoa)
iron fortified cereals
tofu, tempeh
dried fruit
nuts & seeds
dark green leafy vegetables
Pregnancy
Breastfeeding
48mg
16-18mg
* set at 180% higher than RDI for non-vegetarians due to lower absorption of non-haem iron although
there is some question around the evidence for this recommendation read more about iron and
vegetarian diets here.
Dr Kate Marsh
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Zinc
Zinc is needed for reproduction, growth, wound healing, sexual maturation and for
maintaining a healthy immune system. While it is found widely in plant foods, its absorption
is reduced by phytates found in wheat bran, wholegrains and legumes. Processing a food by
soaking, fermenting or sprouting can reduce the phytate level and make zinc more readily
available for example, the leavening and fermenting of grains in bread-making and the
soaking & sprouting of legumes and grains.
Food sources of zinc on a vegetarian diet:
legumes
wholegrains
tofu, tempeh
nuts & seeds
eggs
dairy foods (eg. milk and yoghurt)
Pregnancy
Breastfeeding
15-16.5mg
16.5-18mg
* set at 150% higher than RDI for non-vegetarians due to lower absorption of non-haem iron although
there is some question around the evidence for this recommendation read more about zinc and
vegetarian diets here.
Dr Kate Marsh
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Calcium
Calcium is important for healthy bones and teeth and also plays a role in muscle contraction
and relaxation, blood clotting, nerve function and regulation of blood pressure. While dairy
products can provide plenty of calcium for lacto-ovo vegetarians, there are also many plant
sources of calcium. Vegans can obtain their calcium from fortified non-dairy milks (eg soy,
rice, oat or almond milks) or other plant foods rich in calcium. Calcium absorption is
improved in the presence of vitamin D but is reduced by sodium, caffeine, carbonated drinks
and phytates.
Food sources of calcium on a vegetarian diet:
calcium-fortified soy, rice or oat milk
hard tofu (particularly calcium-set)
unhulled tahini
kale, Asian green vegetables
almonds
milk
yoghurt
cheese
1000mg
1300mg
1000mg
1300mg
Pregnancy
Breastfeeding
1000mg
1000mg
Dr Kate Marsh
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2.4mcg
2.4mcg
Pregnancy
Breastfeeding
2.6mcg
2.8mcg
Dr Kate Marsh
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Omega-3 Fats
Omega-3 fatty acids are essential fats which are important in maintaining cell membranes,
and which help to regulate metabolism, reduce inflammation, lower blood pressure and
cholesterol, and may protect against heart disease. Omega-3 fatty acids are particularly
important during pregnancy and breastfeeding as they play a role in brain and eye
development. As the main source of these fats in the diet is fatty fish, vegetarians generally
have low intakes, however the implications of this is unclear particularly when vegetarians
generally have lower risk of chronic disease.
A number of plant foods contain omega-3 fats but in the short-chain form (known as alphalinoleic acid, or ALA) which must be converted to the longer chain fats that our body uses
(DHA and EPA). This conversion process may be inefficient in
some people but can be optimized by choosing the right balance
of fats in the diet.
Food sources of omega-3 fats on a vegetarian diet:
Chia seed (ALA)
Flaxseed (ALA)
Canola oil (ALA)
Walnut (ALA)
Hempseed (ALA)
Soybean (ALA)
Wheatgerm (ALA)
Green leafy vegetables (ALA)
Eggs (DHA)
Sea vegetables (DHA)
Microalgae (DHA)
Dr Kate Marsh
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For more details about the adequacy of vegetarian diets read this
supplement to the Medical Journal of Australia: Is a vegetarian diet
adequate? Concepts and controversies in plant-based nutrition.
Written by Australian Accredited Practising Dietitians and leading
researchers the supplement includes papers on protein, iron, zinc,
vitamin B12, omega-3 fats and meeting the Australian Nutrient
Reference Values (NRVs) on a vegetarian diet, as well as a paper on
the practical aspects of a vegetarian diet.
Activity:
Look up the content of key nutrients in some of the vegetarian foods mentioned above and
compare this to the current Recommended Dietary Intakes (RDIs) to get an idea of the
amount of these key foods needed to meet nutritional requirements for different ages and
genders.
The following websites are good for looking up nutrient details:
NUTTAB 2010 the official Australian nutrient database (all nutrients apart from
vitamin B12) http://www.foodstandards.gov.au/consumerinformation/nuttab2010/
Calorie King Australia search function for Australian foods including brand-name
items (protein and calcium) http://www.calorieking.com.au/
The papers in the supplement above also contain tables showing the amounts of key
nutrients in commonly-eaten vegetarian foods (protein, iron, zinc, vitamin B12,
omega-3) https://www.mja.com.au/open/2012/1/2
Dr Kate Marsh
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Vegetarian athletes
While some may question the adequacy of a vegetarian diet for athletes, there are plenty of
well-known vegetarian and vegan athletes whose success would suggest otherwise. This
includes Olympian Carl Lewis, ultra-marathon runner Scott Jurek, tennis legend Martina
Navratilova, boxer Mike Tyson and football star Ricky Williams.
The American Dietetic Association, in their position paper on vegetarian diets, say that a
well-planned vegetarian diets, including total vegetarian or vegan diets, are appropriate for
individuals during all stages of the life cycle, and for athletes.
Read this interview from the New York Times with three experts (a professor of health and
exercise science, an associate professor of human nutrition and author of Vegetarian Sports
Nutrition, and a dietitian and the author of Nancy Clarks Food Guide for Marathoners) about
vegetarian diets for athletes.
If you work with vegetarian athletes, the following resources might also be helpful.
Australian Institute of Sport fact sheet on Vegetarian Eating
The Vegetarian Resource Group Athlete & Vegetarian/Vegan Diet resources
Vegetarian diets : nutritional considerations for athletes (Venderley & Campbell).
Sports Med 2006; 36 (4): 293-305.
Vegetarian Sports Nutrition by Enette Larson-Meyer
Thrive Fitness by Brendan Brazier
The No Meat Athlete Matt Frazier
Dr Kate Marsh
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Vegies and/or salads should include a variety of colours and fill half of plate.
Wholegrains are preferred over refined grain foods (e.g. brown rice instead of
white rice) and occupy about one quarter of your plate.
Plant proteins legumes, nuts, seeds, soy products or vegetarian convenience
products should satisfy about one quarter of your plate.
Dairy or fortified soy these can be included as snack (eg a tub of yoghurt or fruit
smoothie) or incorporated into meals (eg yoghurt or milk with cereal, grated cheese
on pasta).
Fruit is best eaten mostly whole, rather than juiced, and enjoyed as a dessert or
snack.
While its important to try to include all these components in each meal, certain cooking
styles and cuisines may determine how you plate up your food and whether its eaten at
once or spread over the day.
Activity:
Using the information above on the key nutrients, and healthy eating plate guide above,
design yourself a 1-day vegetarian eating plan to meet your nutritional needs. Click here to
download some sample vegetarian meal plans for different age groups and genders.
Dr Kate Marsh
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Tempeh is made from soybeans which are cooked and fermented and
then formed into a patty or cake. It has a firm texture and can be can be
grilled, baked or pan-fried, or diced and added into stir-fries. It can also
be sliced and used in place of meat in a wrap.
Gluten also known as seitan, it has a meaty texture and can be used
in stir fries, casseroles or crumbed and cooked as schnitzel. Buy it
canned or fresh from Asian stores or make your own from gluten flour.
Dr Kate Marsh
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Convenience vegetarian products including burgers, patties, sausages and schnitzels. These
are generally made from soy, nuts, gluten and/or grains and are available in canned, chilled,
frozen or shelf stable options. Most are ready to heat and serve or can be used as
ingredients in various meals. Some are fortified with nutrients including iron, zinc and
vitamin B12 (mainly the Sanitarium range) which can be a useful way to boost intake of
these nutrients. However many are also high in sodium so not ideal for everyday use.
http://www.sanitarium.com.au/products/vegetarian
Frys
http://www.frysvegetarian.co.za/product-category/our-food/
http://www.beansupreme.co.nz/
Syndian
http://syndian.com.au/products/
Have a look at the products available from the companies above to get an idea of the
range of vegetarian options now on offer. Consider trying some of these yourself to see
what they taste like!
Dr Kate Marsh
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Supplements
Vegetarians dont need to take supplements routinely. Depending on their individual
dietary restrictions, health, and stage of life however, certain supplements may be
beneficial.
Vitamin B12 - those who dont consume at least 2 serves of a food rich in vitamin
B12 each day should take a vitamin B12 supplement and have a blood test annually
to check vitamin B12 levels.
Omega 3 A microalgae DHA supplement may benefit pregnant women, children or
people with arthritis.
Vitamin D Those following a vegan diet and those who have little sun exposure
may need a supplement.
Iron an iron supplement should only be taken on the advice of a doctor or dietitian
if the individual has confirmed iron deficiency, as excess iron can cause harm.
For those who do need a supplement, not all supplements are suitable for
vegetarians as they can contain animal-derived ingredients including gelatine
and lactose this is most relevant for vegans. To determine whether they are
suitable, individuals can check labels carefully, check with the supplement
manufacturer or choosing brands specifically formulated for vegans (eg Deva
Vegan, Available online at www.devanutrition.com).
Dr Kate Marsh
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Dr Kate Marsh
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Conclusion
Well-planned vegetarian diets are not only nutritionally adequate, but also provide many
health benefits, particularly in the prevention and treatment of many chronic diseases. In
fact in Western countries, a vegetarian diet may present a significant advantage over meatbased diets and a number of studies have shown increased longevity in vegetarians. While
potentially lower in some nutrients, careful planning can help to ensure that both a
vegetarian or vegan diet meets all of the current recommended intakes for essential
nutrients as well as maximising the intake of protective components present widely in plant
foods. In fact, a vegetarian diet may well be one of the best ways to meet population
dietary guidelines.
Dr Kate Marsh
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Dr Kate Marsh
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