the moment for plant-based eating is nowthe moment for plant‐based eating is now march 24, 2017...

The moment for plant‐based eating is Now March 24, 2017

Alpro Foundation 20 years symposium 1

The Moment for Plant-basedEating is Now

Plant-based eating and health outcomes: The Adventist Health Study (U.S.)

Gary E. Fraser

Loma Linda University

California



It was not a randomized study. Is the p value really small?

The Belgian Dairy Board & New Zealand Meat Board will cut my research funds

Pernicious anemia! Protein mal-nutrition! My bones will melt. Yikes!

7 of 8 studies show protection – the 9th

may not! What about dietary measure-ment error?

May cause cancer of the heel bone –who knows.

Adventists are biologically different! It’s Ok for Americans – not Europeans

BARRIERS

Adventist Health Study-2—in brief

Adventists in the U.S. are a natural experiment

About half are vegetarian, half are not—mainly low meat

No smoking, very little alcohol

Otherwise very much like other Americans



Cohort Profile: Adventist Health Study‐2

A prospective, study (n = 96,001) that enrolled a cohort from 2002 through 2007 to investigate the role of diet and other lifestyle exposures (i.e. physical activity, anthro-pometrics) on outcomes such as cancer and mortality.

Subjects represent a largely bi-racial sample of adult church members from across the US and Canada.

Butler TL et al. Cohort Profile: The Adventist Health Study-2 (AHS-2). Int J Epidemiol 2008; 37:260-65.

Cohort Profile: Study Population

• 96,001 subjects

• 25,000 Black subjects, of whom 25% are West Indian living in the North America.

• Only 3% Hispanic, 3% Asian

• 65% female

• Mean age at enrollment:

-60 years, White subjects

-56 years, Black subjects



Classification of Dietary Status

Number %

Vegan 9,062 8.5%

Lacto-OvoVegetarian 30,103 31%

Pesco-Vegetarian 9,793 10%

Semi-Vegetarian 4,801 5.5%

Non-Vegetarian 42,410 45%

Vegan, also other vegetarian diets, arevery different from omnivorous diets

Tofu Quinoa Hummus Chia Chick peas Flax seed



0,00 0,50 1,00 1,50 2,00 2,50 3,00

drinking water

beverages

snack foods

sweets

added fats

eggs

dairy products

meat

nuts & seeds

soy foods & meat analogues

legumes

grains

potatoes

avocados

vegetables

fruit

Relative mean quantity eaten compared to non vegetarians(adjusted for age, sex & race and standardized to 2000kcal)

Vegan vs. Nonveg

Lacto vs. Nonveg

Pesco vs. Nonveg

Semi vs. Nonveg

Orlich MJ et al. Patterns of food consumption among vegetarians and non-vegetarians.Br J Nutr. 2014 Nov 28;112(10):1644-53.

Average Duration of Present Dietary Pattern in AHS-2

Slide on average duration in present dietary pattern

48

39

2421 19

0

10

20

30

40

50

60

Dur

atio

n

Type of Vegetarian

Average Duration (in years) in Present Dietary Pattern

Non-Vege Lacto-Ovo Semi-Vege Vegan Pesco



All these are “Vegetarian” (there are vegan versions) healthy plant foods

Less healthy vegetarian foods (incl dairy)

foods in an Indian vegetarian diet

Healthy Plant Foods Less Healthy Vegetarian Foods Indian Vegetarian Food

Different kinds of vegetarians

Need to be careful when reading the literature to identify what the diet under investigation ACTUALLY is

Adventist and other U.S. vegetarians

U.K vegetarians

Indian vegetarians

Vegans, lacto-ovo-, fruitarians etc

?? Vegetarian = Mediterranean diet—Plus ??



The Health Benefits enjoyed by Vegetarians

Risk factors

Mortality, Life Expectancy

Disease Events

Selected Risk Factors in Vegetarians vs Nonvegetarians

from AHS-2.



Diet Patterns and Body Weight,Non‐Blacks

137

166

150

178

150

179

158

186

165

194

100

120

140

160

180

200

Females 5'4'' tall Males 5'10'' tall

Vegan Lacto-ovo Pesco-veg Semi-veg Non-vegP

ou

nd

s

Self reported, currently treated, doctor-diagnosed Hypertension – Non-Black Participants

*significant relationship

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Vegan* Lacto* Pesco Non-Veg



* Hypertension is BP ≥ 140/90 or on hypertension medication

Pettersen BJ et al. Vegetarian diets and blood pressure among white subjects:Results from the Adventist Health Study-2 (AHS-2). Public Health Nutrition, 2012. 15(10):1909-1916

MEASURED Blood Pressure in White Subjects

Prevalent Treated Diabetes and Diet% Reporting Type 2 Diabetes

0%

2%

4%

6%

8%

Vegan Lacto-ovo Pesco-veg Semi-veg Non-veg



Odds ratios of Incident DIABETES by Diet Group -AHS-2 adjusted for age, BMI, ethnicity, gender, educational level, income, TV watching, sleep, alcohol, physical activity and cigarette smoking.

Very similar patterns in Black and non-Black subjectsTonstad W et al. VegetarianDiets and incidence of diabetesin Adventist Health Study 2.

Nutr Metab Cardiovasc Dis. 2012

0

0,2

0,4

0,6

0,8

1

1,2

Vegans Lacto-Ovo Pesco Semi Non-Veg

Prevalent Treated High Blood Cholesterol and Diet

% Reporting High Cholesterol

0%

5%

10%

15%

Vegan Lacto-ovo Pesco-veg Semi-veg Non-veg



Mortality, Life Expectancy, Common ChronicDiseases

Note that in AHS-2 the vegetarians are compared to a “low meat” non-vegetarian reference group. On average the non-vegetarians consume only about 49 g/d of meat (13g/day red meat, 18 g/day poultry, 18 g/day fish)

12% reduction in mortality from all causes for vegetarians even when compared to AHS-2 non-vegetarians : Orlich MJ et al. Vegetarian Dietary Patterns and Mortality in Adventist Health Study 2. JAMA Internal Medicine 2013



Coronary Heart Disease: AHS-1/Stanford 5-Cities Study Comparison

Note: Rate Ratio for non-Adventist=1.0

Standardized Rate Ratios (95% confidence intervals)Men Women

First event definite fatal CHD

All Adventists 0.51 (.37- .69) 0.48(.31 - .74)Vegetarians 0.38(.20 - .71) 0.18(.06 - .55)

First definite myocardial infarction

All Adventists 0.53(.42 - .68) 0.42(.30 - .59)Vegetarians 0.26(.14 - .47) 0.53(.30 - .93)

Adapted from Fraser GE. Diet, Life Expectancy and Chronic Disease. Oxford University Press, 2003



Coronary Heart disease

We could talk about:

the adverse associations of red meats, and perhaps saturated fats and animal proteins

Beneficial associations with nuts

Beneficial associations with whole grains

Incidence of Three Common Cancers in Vegetarians

AHS-2 results to date But I’m a vegetarian!



of Colorectal Cancer

Figure 1. A comparison of the probability of surviving to a given age without having received a diagnosis of colorectal cancer (i.e. colorectal-cancer-free survival) for all vegetarians compared to non-vegetarians. Generated by PROC PHREG, SAS 9.4; race and sex held constant.



Colorectal Cancer: All Vegetarians

Model Diet N Cases HR (95% CI) pvalue

1: BasicVeg 40367 252 0.80 (0.67‐0.96) 0.019

Non-veg 37292 238 1 (reference) ref

2: FullVeg 40367 252 0.78 (0.64‐0.95) 0.013


3: + BMI

Veg 40367 252 0.81 (0.67‐0.99) 0.042


Summary Colorectal Cancer

Preliminary data:

So processed red meat is confirmed here as an important reason for the vegetarian advantage

In addition vegans may do a little less well as dairy and calcium may be protective—though perhaps in different ways.

Note: We find INDEPENDENT associations of dairy with rectal cancer, and calcium with colon cancer, both in the protective direction.



Risk of Prostate CancerAge Family

History Race Diet Hormones

Results

All prostate cancer (N= 1133)

Aggressive/Advanced prostate cancer (N=244)

Black subjects (N=306)



Age-adjusted and multivariate adjusted HR of the association between vegetarian dietary patterns and prostate cancer incidence

Prostate Cancer

Variables Vegan Lacto-vegetarian

Pesco-vegetarian

Semi-vegetarian Non-Vegetarian

Overall Number of events

59 333 121 63 503

HR3 (95%CI) 0.66 (0.50, 0.87) 0.96 (0.83, 1.12) 1.07 (0.88, 1.31) 1.18 (0.91, 1.54) 1.00

Advanced Number of events

15 70 28 13 111

HR3 (95%CI) 0.78 (0.45, 1.35) 0.91 (0.66, 1.24) 1.10 (0.72, 1.68) 1.09 (0.61, 1.95) 1.00

3 multivariate model 2, includes model 1 plus BMI

Potential mechanisms of lycopene

Has been stated that lycopene usually has highest serum levels of the carotenoids. In our data beta carotene a little higher.

Lycopene is a strong anti-oxidant

Active in cell signaling

Greater bioavailability of lycopene in cooked tomatoes (and products)

Other glycoalkaloids in tomatoes



Alpha-Linolenic Acid & Prostate Cancer–preliminary findings

Total Calcium & Prostate CancerAll cases, All races

Comparing extreme quintiles of intake

Model beta SE Chi2 p HR 95% CI

Full Model -0.07661 0.09522 0.6473 0.4211 0.90 0.69 1.17



Summary Prostate Cancer

Vegans do better than non-vegetarians and probably other vegetarians

ALA associated with decreased risk

Cooked tomatoes associated with decreased risk

Dairy associated with increased risk

These all probably fit with the decreased risk in vegans.

Vegetarian Diets and Risk of Breast Cancer



Probability of Survival without BC by Dietary Pattern.

Dietary Patterns and Risk of Breast Cancer: Hazard Ratios comparing to Non-vegetarians

Pattern Participants Cases HR No BMI

95%CI no BMI (p-value)

HR with BMI

95% CI with BMI (p-value)

Vegan 3,725 51 0.78 0.58-1.05 (0.09) 0.84Lacto-Ovo 14,312 286 1.05 0.89-1.23 (0.57) 1.08 0.92-1.27 (0.34)Pesco 5,077 81 0.91 0.71-1.17 (0.48) 0.94 0.73-1.21 (0.65)Semi 2,953 54 0.91 0.67-1.23 (0.91) 0.91 0.68-1.24 (0.56)Vegetarian 26,066 472 0.97 0.84-1.11 (0.64) 1.00 0.87-1.16 (0.97)Non Vegetarian

24,223 420 Ref Ref 1.00 Ref



Conclusions

Health benefits of plant-based diets are real. There is a consistency between risk factor benefits and disease and mortality experience in AHS-2. Some benefits appear to be of fairly large magnitude.

Risk Factors Disease/Mortality Events

Lower Body Weight Less cancer by ~10% (All U.S. Adventists 30% less cancer)

Lower BP Less colorectal cancer by 20% (Processed meats (+), Calcium(-), Dairy(-))

Less diabetes Vegans less prostate cancer by 35% (Cooked tomatoes(-), ALA(-), Dairy(+),?Soy)

Better blood lipids Vegans possibly less breast cancer (?Soy in place of Dairy)

Lower fasting insulin/glucose Other cancers (??—yet to be analyzed)

Lower CRP levels Less heart attack and fatal heart disease by 50% (Red meat(+),Nuts(-),Grains(-))

?Vegans lower IGF-1 Lower mortality/Greater longevity by 3+ years

Conclusions (cont’d)

We see benefits in vegetarians and are starting to understand which foods may be responsible.

Notice that health benefits are due not only to reductions in animal products but also increased plant foods.

May be complex (e.g. dairy associated with reduced colorectal cancer risk, but increased risk of prostate cancer)

Possible importance of duration of dietary habits



William C. Roberts, Editor, Am J CardiolAm J Cardiol 83:817,1999

“If the money we use to purchase and eat the muscles of cows, pigs, chickens, turkeys and fish were put into vegetables, fruits and lipid lowering drugs, our health would skyrocket…. [To paraphrase. ‘Ask the animals about the slaughter’]--- the cows (100,000 killed/day), or pigs (250,000/day) or chickens (15,000,000/day).

The healthier are our nonhuman animals, the healthier are the human

ones. We kill them, and then, they kill us!”

No-one said there are no risks of BeingVegetarian—but they are small!



If you are vegetarian already, CONGRATULATIONS

If you are not—well at least you are interested enough to be here!

In conclusion, Vegetarianism provides obvious benefits for the planet and to our animal friends

Add this to what we now know about health advantages, and

IT JUST MAKES GOOD SENSE!

the moment for plant-based eating is nowthe moment for plant‐based eating is now march 24, 2017...

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