A review of the week’s plant-based nutrition news 13th June 2021

This week I cover the impact of nutrition on COVID19 severity, vegan diets for children and a shocking report on vegetables consumption in the UK.

DIET AND COVID19 SEVERITY; Early on in the pandemic many clinicians and researchers, including ourselves, were advocating for the promotion of healthy diets as part of the pandemic response. This was based on empirical evidence from other respiratory infections where the consumption bioactive compounds predominantly found in fruits, vegetables, herbs and spices were associated with better outcomes. In addition, the key to a robust immune system is a healthy gut microbiome, which requires plenty of fibre from whole plant foods.

Eighteen months on we have the first study supporting a dietary approach to reducing COVID19 severity. The paper highlighted reports the results of a case-control study of healthcare workers, mostly physicians, with significant exposure to COVID19 patients from 6 countries. Participants completed a web-based survey from 17 July to 25 September 2020. Information was collected on basic demographic characteristics, past medical history, medications, lifestyle, and COVID19 symptoms, and a 47-item food frequency questionnaire. The questions captured the dietary patterns of participants over the prior 1 year and included 11 choices; whole foods, plant-based diet; keto diet; vegetarian diet; Mediterranean diet; pescatarian diet; Palaeolithic diet; low fat diet; low carbohydrate diet; high protein diet; other; none of the above. For the analysis ‘whole foods, plant-based’ diets and ‘vegetarian’ diets were placed into one category called ‘plant-based diets’, n=254. For the pescatarian diet, data were combined from those following a whole foods plant-based, vegetarian and pescatarian diets, the latter only being 40 participants (n=294). The study included 568 COVID19 cases and 2316 controls. Those participants who had had COVID19 were asked to rate the severity based on 5 options from very mild to critical, requiring intensive care.

The results showed that those following a plant-based diet pattern had a 73% reduction in the risk of moderate or severe COVID19 and those following a pescetarian diet had a 59% reduction in risk. This was independent of BMI and underlying chronic health conditions. In contrast, participants following a high protein, low carbohydrate diet had a 3-fold higher odds of moderate or severe COVID-19 when compared to the plant-based group.

We do have to accept the major limitations of this study when extrapolating these results to a healthy plant-based or vegan diet. This was not a study of people following a vegan or 100% plant-based diet, despite the media headlines suggesting the contrary. In fact, those classified as plant-based were not that healthy, consuming a median of 3.7 portions of legumes and 9.8 portions of fruits per week and still consuming some animal foods, including similar amounts of dairy and eggs to the non-plant-based group, and similar amounts of refined grains. However, their consumption of legumes, nuts and vegetables was significantly higher and consumption of red/processed meat, sugar-sweetened beverages and alcohol significantly lower than those participants who did not follow a plant-based diet.

Furthermore, this is not a robust study design being a case-control study, with self-reported dietary data and no set definition of low-carb or plant-based. The impact of residual confounding can not be excluded and people with more severe COVID19 may not have been able to participate. In addition, the participants were mainly male, Caucasian physicians.

Accepting these limitations, we have more than enough data to support healthy diets as part of the pandemic response given the association with reduced risk and prevalence of chronic diseases, better immune health and more recently the studies highlighting the association between a healthy gut microbiome and better COVID19 outcomes. Nothing to lose in my view!

NUTRITION IS THE KEY TO PANDEMIC RESILIENCE: This is a bold editorial highlighting the potential positive impact of healthy nutrition for pandemic resilience. It did not take long for those on the front line of the pandemic response to observe that people with underlying chronic health conditions had a greater risk of developing severe COVID19, requiring hospitalisation, intensive care treatment and ultimately dying. These underlying health conditions were noted to be associated with a number of modifiable risk factors including overweight and obesity, cardiovascular disease and type 2 diabetes. In the UK, more than 90% of those that died in the first wave of the pandemic had at least one underlying chronic condition. In the US, 60% of the attributable risk of hospitalisation from COVID19 was down to 4 underlying conditions: hypertension, heart failure, type 2 diabetes and obesity. These risk factors are intimately related to four modifiable lifestyle factors: tobacco smoking, excessive alcohol consumption, lack of physical activity and unhealthy diets. Back in 2019, a large analysis from the Global Burden of Disease study group reported that unhealthy diets were responsible for 20% of deaths globally, mainly from cardiovascular disease, cancer and type 2 diabetes, and thus responsible for more deaths than any other risk factor in the world.

This editorial is a call to action. It highlights that most citizens are not following country-based dietary guidelines. In the UK and US, ultra-processed foods make up well over 50% of calories consumed, with fruit and vegetables consumption at an all time low. We have a global pandemic of malnutrition with the double burden of undernutrition and overweight/obesity estimated to affect at least 44% of the global population, often present in the same country. The editorial highlights that adequate, healthy nutrition is a human right and that the pandemic has highlighted the fragile nature of global food security with policy makers not paying enough attention to the importance of food quality and its impact on health outcomes. The toxic food environment is partly to blame with unhealthy foods often cheaper and more heavily advertised than healthier options. Quoting the author ‘it is strange to see so many countries sacrifice the health of their nations on the altar of raw capitalism’.

This is not an issue of individual failure, but a failure of governments and policy makers who have allowed this to happen. The conclusion of this editorial is spot on; ‘What is needed the most is moral courage and leadership and for everyone to perceive what they have to give, to do the hard things while spreading meaning and purpose. It seems clear from the data available that nutrition is one of the keys to global pandemic resilience, both for the current and future pandemics and could reduce burdens on healthcare systems. Optimal nutritional status is a defence against both communicable and non-communicable diseases. It is also something that can be attended to right now and is not months away. We are ecological creatures at a crossroad — let this pandemic be your wakeup call’.

VEGAN DIETS FOR CHILDREN: This paper generated some sensationalised and rather misleading headlines. The cross-sectional study examined the health of Polish children aged 5–10 years and compared the health of 52 vegan children to 63 vegetarians and 72 omnivores. The reason for the negative headlines was that vegan children were around 3cm shorter than omnivores and had lower bone density. However, when you looks at the data you find that the vegan children were still of NORMAL height and well within the expected reference range for age. Additionally parents height had not been calculated, despite this being a major predictor of a child’s final height. We know that cow’s milk consumption increases growth but this is not necessarily a good thing. A taller height for example is associated with a higher risk of cancer in later life. In addition, we know that breastfed babies grow more slowly than those raised on milk formula and the vegan children were more likely to be be breastfed and for longer in this study. We have no idea whether this difference will last into adulthood and is unlikely to be of any clinical relevance.

With regards bone health, we do need to take the findings seriously. Vegan children had a 5% lower bone mineral content and given that optimal bone mineral density is reached in our 20’s, this is an important finding. BUT, only a third of vegan children were supplementing appropriately with vitamin D and a third were not supplementing with vit B12. Median calcium intake was only 376mg per day. In the UK, for this age group 550mg of calcium is recommended.

Lower protein intake is cited in vegans, the median being 42.4g per day. But once again this is more than adequate and exceeds recommended intakes, which in the UK for this age group is 28.3g per day. In fact the high intake of protein in the omnivore group, 57.3g per day, is more of a concern especially if coming mainly from animal sources as this is associated with increased risk of chronic illness and early death in adulthood.

An alternate headline based on the data could have been ‘Vegan children have better cardiometabolic health than veggie and omnivore kids’. The study showed vegan children had lower fat mass, blood cholesterol and fasting glucose levels. Vegan children had higher intakes of some beneficial nutrients including fibre, vitamin C, folate, carotenoids, unsaturated fats, magnesium, all a reflection of the consumption of healthy plant foods. In contrast, those following an omnivorous diet were consuming higher than recommended amounts of saturated fat, free sugar and insufficient fibre. Given that atherosclerosis starts in childhood, this is a potential big advantage of a vegan diet. Interestingly the vegetarian group had a less favourable cardiovascular risk profile compared to both omnivores and vegans, which was suggested to be due to higher consumption of processed foods.

A study that did not generate sensationalised headlines was a report from the German VeChi youth study in which the health of a larger number of vegan children aged 6–18 yrs (n=115) was assessed. Vegans were appropriately supplementing with B12 and Vitamin D with much better calcium intakes and the study concluded that ‘a vegan diet can meet the nutrient requirements in childhood and adolescence’. In addition, a previous report from the same cohort reported normal growth in vegan children.

How do we interpret these two studies and the differing results? Essentially, that when appropriately planned, vegans diets can support good health in children and may have an advantage for cardiovascular and metabolic health. The key is ‘appropriately planned’ but this is no different for vegetarian and omnivorous diets. With a vegan diet, certain nutrients need attention, including, Vitamin B12, iron, zinc, calcium, vitamin D, iodine and omega-3 fatty acids. Omnivorous diets require attention too with nutrients such as potassium, fibre, folate, carotenoids and unsaturated fats being important to consider.

We have some amazing factsheets on our website to help you appropriately plan your vegan pregnancy and raise vegan children.

RAISING VEGAN CHILDREN: This paper highlights why parents may be finding it difficult to get support when choosing to raise vegan children. The study sought the opinions of 176 parents (mostly mothers) raising vegan children in Italy and asked about their relationship with their primary care paediatrician. The study aimed to uncover the barriers faced by vegan parents in this healthcare relationship, how involved the paediatrician is with providing support and advice about a vegan diet and issues faced by parents with implementing a vegan diet in everyday life. This was a cross-sectional study using an online survey distributed by social media.

The results showed that parents did not inform their paediatricians about their child’s vegan diet in 36.2% of the cases. The reason for this was mostly cited as not thought to be relevant but over a quarter believed they would be adversely judged and a further quarter knew their paediatrician was opposed to a vegan diet. 70.8% of parents perceived that their paediatrician was sceptical or against a vegan diet. About 71.2% of the parents relied on medical dietitians, and 28.2% on nutritionists/dietitians for dietary counselling. 46.2% also used scientific websites and 23.4% used friends and social networks for information. Parents reported that schools were the least likely place to be able to find vegan options and they had received criticism from friends and family for raising their child on a vegan diet. Parents administered an individual B12 supplement in 87.2% of the cases and regular vitamin B12 supplementation was associated with asking for nutrition counselling.

This survey highlights some important points for all clinicians. Understanding your patients’ diet pattern is important and relevant to all specialities and with all aspects of medical care we should approach this in an open and non-judgmental manner, respecting the views of our patients and their family members. Given that major dietetic organisations have endorsed a 100% plant-based diets as being nutritionally adequate for all stages of life, clinicians should not be critical with this choice. The study highlights the need for better nutrition education for paediatric doctors (and probably all clinical staff), especially since more and more parents are likely to choose to raise their children vegan. Whether you choose to follow a vegan diet, clinicians need to have sufficient knowledge and be aware of relevant resources by which to guide their patients. If parents are not comfortable discussing their diet choices with their child’s doctor then there is the potential that adequate nutrition support will not be provided and nutritional deficiencies more likely. A follow up study to this would be a survey of paediatricians’ attitudes and beliefs about raising vegan children.

SHOCKING UK REPORT ON VEGETABLE CONSUMPTION: 2021 is the United Nation’s International Year of Fruit and Vegetables. So how are we doing? In short, UK citizens are not eating enough vegetables. Nowhere near enough. I found this both shocking and sad. It is a long report but well worth reading.

Here are some of the headline facts: 18000 premature deaths in the UK are caused by not eating enough veg and legumes; about one third of children aged 5–10 years don’t even eat one portion of veg a day; 23% of children aged 11–16 eat less than a portion of veg a day; baked beans and pizza make up 16% of a child’s veg consumption; 77% of adults are eating less than the recommended 3–5 portions of veg a day; only 1.9% of food and drink advertising budget is spent on promoting veg consumption; household income impacts veg consumption with the poorest households eating the least; 15–20% of veg is consumed in the form of ultra-processed foods; there are some ethnic differences with White, Asian and Asian British groups eating a greater amount of veg on average than Black, Black British and Mixed ethnicity groups; The UK currently has 4.6 million metric tonnes of veg available, of which it produces 53%, that is, 2.4 million tonnes. For the UK population to meet 5-a-day (assuming half comes from veg) there would need to be 5.4 million tonnes available or 7.6 million tonnes for 7-a-day.

The study also makes another relevant point, in that even though veganism is a growing movement this does not equate to a healthy plant-based diet. Although the numbers of people signing up to take part in Veganuary have increased 25-fold between 2016 and 2021, retail sales of vegetables in January increased by just 3.7% during the same period, suggesting a shift to consuming processed rather than whole plant foods during Veganuary. The report also summarises the benefits to human and planetary health of consuming more veg in place of meat and processed foods, which I don’t need to summarise.

So what needs to change? We need to match our production of food with healthy eating recommendations and the food we produce needs to be sustainable for the producer, society and the planet. The food environment, including advertising, needs to reflect healthy, nutritious foods rather than industry-created processed foods and sugary drinks. Access to healthy food should be considered a human right and therefore veg needs to be accessible and affordable to all. This means that these foods needs to be promoted, supported and probably subsidised by Governments. So much work to be done, yet it will be rewarding and worthwhile for individuals and society to support the implementation of healthier diets for children and adults.

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