• Vegetarian Pages: Best source on the web for information about vegetarianism. You can find information from recipes to restaurants in specific cities.
  
• Fat-Free Website: Incredible source of fat-free and low-fat vegetarian and vegan recipes
  
• Vegetarian Times: Mainstream vegetarian magazine
  
• Veggie Life Magazine: Veggie Life is the nation’s premiere vegetarian cooking magazine for today’s health conscious consumer—a seasonal commeration of “Good Food for Good Health.” Every issue features exciting tips, techniques, recipes and remedies from cooks, chefs, dietitians, and other health experts on great new ways to prepare creative plant based cuisine, implement diet programs, and use healing foods for an improved and vibrant lifestyle.
  
• VRG Vegetarian Journal: The practical magazine for those interested in Vegetarian Health, Ecology and Ethics
  

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Contents

• What is a vegetarian?
• Why do people choose a vegetarian eating style?
• Does a vegetarian eating pattern provide health benefits?
• Are vegetarian diets nutritionally adequate?
• More Information

What is a vegetarian?

A vegetarian is a person who eats no meat, poultry, and fish. People who eat a vegetarian diet base their food choices on plant sources. For example, a vegetarian would eat fruits, vegetables, grains, seeds, and nuts or foods made from these sources. Some vegetarians include eggs and/or dairy products in the diet. Generally, there are different types of vegetarians:

Why do people choose a vegetarian eating style?

There are many reasons why people choose a vegetarian lifestyle. Some include improving their health. Others become a vegetarian forenvironmental or ecological concerns, economic or world hunger issues, compassion for animals or belief in non-violence, food preferences, or spiritual reasons.

Does a vegetarian eating pattern provide health benefits?

Any diet has the potential to be beneficial or detrimental to health. It depends upon factors such as variety and availability of food. However, it may be easier for some individuals to meet the Dietary Guidelines for Americans with a vegetarian diet. Vegetarians have lower rates of heart disease, high blood pressure, some forms of cancer, adult-onset diabetes, and obesity. The health benefits of a vegetarian eating pattern may also reflect a healthful lifestyle.

Are vegetarian diets nutritionally adequate?

To eat a well-planned vegetarian diet, keep the following special needs in mind:

The key to planning a healthful vegetarian eating pattern is to choose a wide variety of foods with the following recommendations in mind:

• Keep the intake of low nutrient-dense foods, such as sweets and high-fat foods (salad dressings, spreads, cooking oils), to a minimum.
• Try some of the wide variety of readily available meat substitutes which are made from grain and vegetable proteins. These convenient items resemble the appearance and taste of the most popular processed meats but are completely free of meat, animal fat, and cholesterol. These can ease the transition to a vegetarian diet for all family members.
• Choose whole-grain products whenever possible.
• Use a variety of fruits and vegetables, including a good food source of vitamin C to enhance iron absorption.
• If dairy products are consumed, use low-fat varieties.
• Limit intake of eggs to 3 to 4 yolks per week.
• Vegetarian diets for pregnant and breastfeeding women, infants, and children require special planning to ensure adequate intakes of iron, calcium, vitamin D, vitamin B12, and calories.

For More Information

• The American Dietetic Association/National Center for Nutrition and Dietetics. For answers to your food and nutrition questions and for a referral to a registered dietitian in your area, call the Consumer Nutrition Hot Line at 800/366-1655.
• Simply Vegan: Quick Vegetarian Meals, by Debra Wasserman and Reed Mangels. Vegetarian Resource Group, 1991.
• Simple, Lowfat and Vegetarian, by Suzanne Havala. Vegetarian Resource Group, 1994.
• Laurel's Kitchen Recipes, by Laurel Robertson, Carol Flinders, and Brian Ruppental. Ten Speed Press, 1993.

Position of the American Dietic Association
Vegetarian Diets: Technical Support Paper

Contents

• Introduction
• Vegetarianism in Perspective
• Implications for Health Promotion
• Nutrition Considerations
• Groups with Special Needs
• Meal Planning
• References
• The Authors and Reviewers

Introduction

The attention focused today on personalhealth habits is unprecedented, as more and more Americans adopthealth-promoting life-styles that include alterations in diet andexercise patterns. Simultaneously, there has been a marked risein interest in vegetarian diets. A considerable body ofscientific data suggests positive relationships betweenvegetarian life-styles and risk reduction for several chronicdegenerative diseases and conditions, such as obesity, coronaryartery disease, hypertension, diabetes mellitus, colon cancer,and others. The high incidence of such diseases in industrializednations, as compared with other cultures, warrants specialattention to diet and other factors in life-styles that may varybetween vegetarians and nonvegetarians.

It is the position of The American Dietetic Association that vegetarian diets are healthful and nutritionally adequate when appropriately planned.

Both vegetarian and nonvegetarian dietshave the potential to be either beneficial or detrimental tohealth. Sound nutrition planning may result in risk reduction andcontrol of some diseases and conditions by dietary measures,whereas poorly planned or haphazard diets increase the likelihoodof diet-related disorders of deficiency or excess. However, inaddition to the possible health benefits of some vegetariandiets, consideration may also be given to ecological, economical,and philosophical or ethical reasons for adopting such a diet. Itmay be easier, as well as more acceptable, for some individualsto meet the Dietary Guidelines for Americans by following avegetarian diet rather than a nonvegetarian diet (1).

Vegetarianism inPerspective

There is no single vegetarian eatingpattern. From the standpoint of nutritional health, vegetariandiets are distinguished from one another by (a) the extent towhich the foods included vary, (b) the degree to which the dietsare planned to correspond to the findings of nutritionalsciences, and (c) the health attitudes and practices that areassociated with the diets.

Vegetarian diets differ in the extent towhich they avoid animal products. Veganism, or totalvegetarianism, completely excludes meat, fish, fowl, eggs, anddairy products. Lacto-vegetarianism is the avoidance of meat,fish, fowl and eggs, whereas ovo-lacto-vegetarianism involvesavoidance of only meat, fish, or fowl. Semi-vegetarian patternsallow limited amounts of most animal foods.

In addition to proscriptions on animalfoods, some vegetarian diets also incorporate restrictions onother foods and beverages, such as honey, alcohol, caffeinatedbeverages, highly processed foods, and foods that are grown orprocessed nonorganically or with certain additives andpreservatives. Finally, some patterns include the addition ofspecial foods or practices that are thought to have unique healthpromotive or curative properties. Included are vitamin-mineralsupplements, dietary fiber and essential fatty acid supplements,health foods, herbal teas, and practices such as periodicfasting.

Since vegetarianism is a term thatencompasses such a wide variety of eating patterns, nutritionassessment of such diets is difficult without information aboutspecific food avoidances and health-related attitudes andpractices. The differences may have a significant impact onnutritional status (2).

Studies of vegetarians indicate that thispopulation generally has lower mortality rates from severalchronic degenerative diseases than do non- vegetarians. It islikely that the effects are due not to diet alone but also to ahealthy life-style, including desirable weight, regular physicalactivity, and abstinence from smoking, alcohol, and illicitdrugs, with adequate health monitoring (3,4,5,6).

Even though the health benefits of avegetarian diet make it attractive from a nutrition standpoint,this does not preclude the possibility of obtaining similarhealth benefits from a prudent nonvegetarian diet if it can beplanned in accordance with the Dietary Guidelines for Americans.However, in addition to health aspects, considerations that maylead to the adoption of a vegetarian diet include: ecologicalimplications of eating low on the food chain with regard topreservation of the environ- ment or for the perceived solutionto world hunger problems by decreasing the demand on the world'sfood resources; economic reasons, since diets low in animalproteins are typically less expensive than meat-based diets; andphilosophical or ethical reasons, which include animal rightsissues and attitudes toward violence. Still other individuals aremotivated by religious beliefs.

Implications forHealth Promotion

Mortality from coronary artery disease islower in vegetarians than in nonvegetarians (7,8). Total serumcholesterol and LDL cholesterol levels are usually lower, whileHDL cholesterol and triglyceride levels vary depending on thetype of vegetarian diet that is followed (9,10,11,12).Vegetarian diets that are typically very low in fat andcholesterol may decrease levels of apoproteins A, B, and E (12).Platelet composition and possible platelet functions may very,and plasma viscosity may be decreased (13). Such effects maybe attributed to the vegetarian's lower intake of total fat,saturated fat, and cholesterol, along with lower weight,increased physical activity, and abstinence from smoking (10, 14,15).Vegetarians generally have lower blood pressures and lower ratesof Type II diabetes than do nonvegetarians, which may decreasethe risk of coronary artery disease in the vegetarian population.

Vegetarians of the Seventh-Day Adventistfaith have lower rates of mortality from colon cancer than doesthe general population (4). That may be due to dietary differences whichinclude increased fiber intake, decreased intake of total fat,cholesterol, and caffeine, increased intakes of fruits andvegetables, and, in lacto-vegetarians, increased intake ofcalcium (16). Although it is still speculative, the dietarydifferences, especially in vegans, may produce physiologicalchanges that may inhibit the causal chain for colon cancer (16,17).Lung cancer rates are lower in many types of vegetarians becausethey typically do not smoke or, possibly, because of theirincreased intake of beta carotene or other constituents of fruitsand vegetables that may also lower lung cancer risk (18).Preliminary evidence suggests that vegetarians may be at lowerrisk for breast cancer, but further study is indicated (19).

Obesity is a complicating conditionexacerbating many diseases. Vegetarians, especially vegans, haveweights that are closer to desirable weights than dononvegetarians (20). Several factors may be involved, includingmoderation in energy intakes, increased physical activity, andbetter regulation of food intake. The high-carbohydrate, low-fatvegetarian diet, in combination with exercise, may decrease therisk of obesity (21).

Vegetarians are at lower risk for noninsulin-dependent diabetes, partly because they are leanerthan nonvegetarians (22,23). The vegetarians' high intake of complexcarbohydrates, with its relatively high fiber content, improvescarbohydrate metabolism, lowering basal glucose levels (24,25).

Finally, vegetarians have lower rates ofosteoporosis, kidney stones, gallstones, and diverticular disease(29, 30, 31). Studies documenting these benefits, however, areinconclusive at this time, and reasons may be related to aspectsof life-style other than diet.

Vegetarians have lower rates ofhypertension than do nonvegetarians, which may be due tovegetarians' relative leanness (26,27).Other aspects of life-style may also be involved (28),such as dietary habits, increased physical activity, andabstinence from smoking.

NutritionConsiderations

The body's need for essential amino acidscan be met by consumption of animal or plant sources of proteinsince, after absorption, amino acids from exogenous andendogenous sources combine in the body's protein pool (32).Plant foods contain less of the essential amino acids than doequivalent quantities of animal food, but a plant-based dietprovides adequate amounts of amino acids when a varied diet isconsumed on a daily basis. A mixture of proteins from unrefinedgrains, legumes, seeds, nuts, and vegetables will complement oneanother in their amino acid profiles so that deficits in one aremade up by another.

Intakes of different types of protein thatcomplement one another should be eaten over the course of theday. However, since endogenous sources of amino acids are alsoavailable, it is not necessary that complementation of amino acidprofiles be precise and at exactly the same meal, as the recentlypopular "combined protein theory" suggested. Thistheory urged conscious combining of proteins at every meal withthe caveat that malnutrition would ensue if this was not donewithin a strict time interval (33).

Although vegetarian diets usually meet orexceed requirements for protein, they typically provide lessprotein than nonvegetarian diets. This lower protein intake maybe beneficial, however, and may be associated with a lower riskof osteoporosis in vegetarians and improved kidney function inindividuals with prior kidney damage (34,35).Further, a lower protein intake generally translates into a lowerfat diet with its inherent advantages, since foods high inprotein are frequently also high in fat.

Plant carbohydrates are accompanied byliberal amounts of dietary fiber, which has been shown to beimportant in the prevention and treatment of disease. Foodsderived from animal sources contain no fiber. Complexcarbohydrates from plants also improve glucose tolerance, aspreviously noted.

Vegetarian diets that are low in animalfoods are typically lower than nonvegetarian diets in total fat,saturated fat, and cholesterol, an important factor in riskreduction for heart disease and some forms of cancer. The ratioof polyunsaturated and monounsaturated fats to saturated fats isalso more favorable in a largely plant-based diet.

Vegetarians and nonvegetarians alike mayhave difficulty meeting recommendations for iron. Absorption ofdietary iron is enhanced by concurrent consumption of ascorbicacid or animal foods; it is inhibited by the intake of tea,fiber, and phytates (36). Western vegetarians generally have better ironstatus than those in developing countries. The former have arelatively high intake of iron from plant foods, such as darkgreen leafy vegetables, iron-fortified cereals, and whole grains.They may take supplements of ascorbic acid or iron and have agreater intake of ascorbic acid from plant foods. In contrast,vegetarians in developing countries consume less ascorbic acidand animal protein, rely on low-iron food staples, and consumemore fiber and tea than do Westerners (37).

The requirement for vitamin B-12 is minute,but there is no vitamin B-12 in anything that grows from thesoil. It is, however, contained in all animal foods; hence, adiet that includes animal foods, such as dairy products, isunlikely to be deficient in vitamin B-12. Bacteria producevitamin B-12 in the human gut, but it appears to be producedbeyond the ileum, the site of absorption in the intestine.Ninety-five percent of what is produced is actually inactivevitamin B-12 analogs. The need for vitamin B-12 is very small,and lack of intrinsic factor is a more common cause of vitaminB-12 deficiency than lack of vitamin B-12 in the diet.

Nevertheless, adequate vitamin B-12 intakeis a legitimate concern for Western vegans. In countries wheresanitary conditions are poor, contamination of foods withmicrobes and organisms that produce the vitamin may contributeall that is needed. In Western countries, however, where sanitarypractices are better, the risk of vitamin B-12 deficiency isgreater. Vegans must include a reliable source of vitamin B-12 intheir diets or be at risk of eventually developing a deficiency.

However, food labeling of vitamin B-12 canbe misleading. The vitamin B-12 content of most foods in theUnited States has been determined by use of a microbiologicalassay which measures not only physiologically active forms ofvitamin B-12 for human subjects but also inactive vitamin B-12analogs. By microbiological assay, as much as 80% to 94% of theso- called vitamin B-12 in fermented plant foods, such as tempeh,and in other plant foods may be inactive vitamin B-12 analogs.

Some of the of vitamin B-12 analogs alsocompete with active forms of vitamin B-12 for absorption. Thus,vegans should supplement their diets with a source of vitaminB-12 such as a cobalamin supplement or select appropriatelyfortified foods that meet the Recommended Dietary Allowances toensure an adequate intake of the active form of the nutrient.Further research on vitamin B-12 is needed, as there is a greatdeal that is not clearly understood regarding available sourcesof vitamin B-12 for vegans.

Calcium absorption appears to be inhibitedby such plant consti- tuents as phytic acid, oxalic acid, andfiber, but this effect may not be significant. Calcium deficiencyin vegetarians is rare, and there is little evidence to show thatlow intakes of calcium give rise to major health problems amongthe vegetarian population. One recent study has shown thatvegetarians absorb and retain more calcium from foods than dononvegetarians (38). Other studies cite lower rates of osteoporosis invegetarians than in nonvegetarians (29).

Reliance on sunshine alone, particularly innorthern climates or in cultures where most of the body isconcealed in clothing, may not provide all the vitamin D neededto protect children against rickets (39). For those who donot use vitamin D-fortified milk products, a vitamin D supplementmay be necessary, especially for dark-skinned individuals and forinfants whose only source of vitamin D is breast milk after 4 to6 months of age.

Groups with SpecialNeeds

Those whose nutrient needs are especiallyhigh because of growth, lactation, or recovery from illness willfind it especially helpful to consult a registered dietitian orother qualified nutrition professional for expert help in dietplanning. Infants and children who consume well-plannedvegetarian diets including milk products or eggs can generallymeet all of their nutritional requirements for growth. Those whofollow vegan or vegan-like diets which include no animal productscan be healthy, but more care must be taken to ensure adequacy.Vitamin D and iron supplements, in addition to vitamin B-12 atlevels sufficient to meet the Recommended Dietary Allowances, mayneed to be provided (40).

Vegetarians are at lower risk for noninsulin-dependent diabetes and have lower rates of hypertension, osteoporosis, kidney stones, gallstones, and diverticular disease than nonvegetarians

Vegan diets tend to be high in bulk, whichmakes it more challenging to meet energy needs, especially forinfants, children and adolescents (41). Further, caremust be taken to obtain enough vitamins D and B-12. A properlyfortified soy product may be helpful. Both vegetarians andnonvegetarians whose infants are premature or are breast fedexclusively beyond 4 to 6 months of age should providesupplements of vitamin D and iron from birth or at least by 4 to6 months, as medical guidance suggests. The guidelines of theAmerican Academy of Pediatrics for supplementation of infants arehelpful (42).

Well-planned vegetarian diets are adequatefor pregnant and lactating women. With both vegetarian andnonvegetarian diets, iron and folate supplements are usuallynecessary during pregnancy, although vegetarians frequently havegreater intakes of those nutrients than do nonvegetarians.

Meal Planning

In planning vegetarian diets of any type,one should choose a wide variety of foods, which may includefruits, vegetables, whole grain food products, nuts, seeds,legumes, low-fat dairy products or fortified soy substitutes, anda limited number of eggs. Additionally, the followingrecommendations are made (43,44):

• Keep the intake of low nutrient-dense foods, such as sweets and fatty foods, to a minimum
• Choose whole or unrefined grain products whenever possible, instead of refined products.
• Use a variety of fruits and vegetables, including a good food source of vitamin C to enhance iron absorption.
• If milk products are consumed, use low-fat varieties.
• Limit intake of eggs to two to three yolks per week to ensure that cholesterol intakes are not excessive.
• For vegans, use a properly fortified food source of vitamin B-12, such as fortified soy milks or breakfast cereals, or take a cobalamin supplement.
• For infants and children, ensure adequate intakes of iron, vitamin D, and energy. Consult a registered dietitian or other qualified nutrition professional.

The Dietary Guidelines for Americansrecommend a reduction in fat intake and an increased consumptionof fruits and vegetables, and whole grains. Well-plannedvegetarian diets effectively meet these guidelines and theRecommended Dietary Allowances and can be confidently embraced asa healthy dietary alternative. However, vegetarians, particularlytotal vegetarians, living in a nonvegetarian society such as theUnited States, must be aware that foods most readily available inthis culture may not be those which are most appropriate fortheir eating patterns; thus, vegetarians must pay specialattention to ensuring nutrient adequacy. Additionally, bothvegetarians and nonvegetarians must obtain adequate healthmonitoring throughout the life cycle.

References

(1) Calson, E., Kipps, M., Lockie, a., and Thomson,J.: A comparative eval- uation of vegan, vegetarian and omnivorediets. J Plant Foods 6:89, 1985.

(2) Dwyer, J. T.: 1983 Nutrition status andalternative lifestyle diets with special reference tovegetarianism in the USA. In Reichaig, M., ed.: CRC Handbook ofNutritional Supplements. Vol. 1. Human Use. Boca Raton, FL: CRCPress, 1983, pp. 343-410.

(3) Kahn, R. H., Phillips, R. L., Snowdon, D. A., and Choi, W.: Association between reported diet and all causemortality: Twenty-one year follow up on 27,530 adult Seventh DayAdventists. Am J Epidemiol 119:775, 1984.

(4) Phillips, R.L., Garfinkel, L., Kuzma, J.W.,Beeson, W.L., Lotz, T., and Brian,B.: Mortality among CaliforniaSeventh Day Adventists for selected cancer sites. J Nat CancerInst 65:1097, 1980.

(5) The diet and all causes death rate in the SevenCountries study. Lancet 2:58, 1981.

(6) Kromhout, D., Bosschieter, E.B., and de Lezenne Coulander, C.: Dietary fiber and 10 year mortality from coronaryheart disease, cancer, and all causes. Lancet 2:518, 1982.

(7) Burr, M.L., and Sweetnam, P.M.: Vegetarianism,dietary fiber, and mortality. Am J Clin Nutr 36:873, 1982.

(8) Phillips, R.L., Kuzma, J.W., Beeson, W.L., and Lotz, T.: Influence of selection versus lifestyle on risk offatal cancer and cardiovascular disease among Seventh DayAdventists. Am j Epidemiol 112:296, 1980.

(9) Sacks, F.M., Ornish, D., Rosner, B., McLanahan,S., Castelli, W.P., and Kass, E.H.: Plasma lipoproteins invegetarians: The effect of intake of dietary fat. JAMA 254:1337,1985.

(10) Knuiman, J.T., and West, C.E.: The concentrationof cholesterol in serum and in various serum lipoproteins inmacrobiotic, vegetarian, and nonvegetarian men and boys.Atherosclerosis 43:71, 1982.

(11) Masarei, J.R.L., Rouse, I.L., Lynch, W.J.,Robertson, K., Vandongen, R., and Beilin, L.J.: Effects of alactoovovegetarian diet on serum concentrations of cholesterol, triglyceride,HDL-C, HDL-2-C, HDL-3-C, apoprotein B, and Lp(a).Am J Clin Nutr 40:468, 1984.

(12) Cooper, R.S., Goldberge, R.B., Trevisan, M., Tsong, Y., Liu, K.,Stamler, J., Rubenstein, A., and Scanu, A.M.:The selective lipid lowering effect of vegetarianism on lowdensity lipoproteins in a crossover experiment. Atherosclerosis44:293, 1982.

(13) Fisher, M., Levine, P.H., Weiner, B., Ockens, I.S., Johnson, B., Johnson,M.H., Natale, A.M., Vaudreuil, C.H.,and Hoogasian, J.: The effect of vegetarian diets on plasma lipidand platelet levels. Arch Intern Med 146:1193, 1986.

(14) Sacks, F.M., Miller, L., Sutherland, M., Albers, J.J., Salazar, J., Foster,J.M., Samonds, K.W., and Kass, E.H.:Ingestion of egg raises plasma low density lipoproteins in freeliving subjects. Lancet 1:647, 1984.

(15) Renoud, S., Godsey, F., Dumont, E., Thevonen, C.,Ortchanian, E., and Martin, J.L.: Influence on longterm dietmodification on platelet function and composition on Mosellefarmers. Am J Clin Nutr 43:136, 1986.

(16) Turjiman, N., Goodman, G.T., Jaeger, B., and Nair,P.P.: Diet, nutrition intake and metabolism in populations athigh and low risk for colon cancer: Metabolism of bile acids. AmJ Clin Nutr 4:937, 1984.

(17) Adlercreutz, H.: Does fiber rich food containinganimal lignan precursors protect against both colon and breastcancer? An extension of the fiber hypothesis. Gastroenterology86:761, 1984.

(18) Golditz, G.Z., Stampfer, M.J., and Willett, W.C.:Diet and lung cancer: A review of the epidemiological evidence inhumans. Arch Intern Med 147:157, 1987.

(19) Goldin, B.R.: The metabolism of the intestinalmicroflora and its relationship to dietary fat, colon and breastcancer. In Ip, C., Birt, D., Rogers, A., and Mettlin, C., eds.:Dietary Fat and Cancer. New York: Alan R. Liss, 1986.

(20) Bergan, J.G., and Brown, P.T.: Nutritional statusof "new" vegetarians. J Am Diet Assoc 76:151, 1980.

(21) Bray, G.A.: Obesity: A disease of nutrient orenergy balance? Nutr Rev 45:33, 1987.

(22) West, K.M., and Kalbfleisch, J.M.: Glucosetolerance, nutrition, and diabetes in Uruguay, Venezuela, Malaya,and East Pakistan. Diabetes 15:9, 1966.

(23) West, K.M., and Kalbfleisch, J.M.: Influence ofnutritional factors on prevalence of diabetes. Diabetes 20:99,1971.

(24) Stevens, J., Burgess, M.B., Kaiser, D.L., and Sheppa,C.M.: Outpatient management of diabetes mellitus withpatient education to increase dietary carbohydrate and fiber.Diabetes Care 8:359, 1985.

(25) Munoz, J.M.: Fiber and diabetes. Diabetes Care7:297, 1984.

(26) Page, L.B.: Hypertension and atherosclerosis inprimitive and acculturating societies. In Hunt, J.C., ed.:Hypertension Update. Bloomfield, NH: Health Learning Systems,1980.

(27) Reisin, E., Abel, R., Modan, M., Silverber, D., Eliahou, H., andModan, B.: Effect of weight loss without saltrestriction on the reduction of blood pressure in overweighthypertensive patients. N Engl J Med 298:1, 1978.

(28) Rouse, I.L., Beilin, L.J., Armstrong, B.K., andVandongen, R.: Vegetarian diet, blood pressure, andcardiovascular risk. Aust NZ J Med 14:439, 1984.

(29) Marsh, A.G., Sanchez, T.V., Mickelsen, O., Keiser,J., and Mayor, G.: Cortical bone density of adultlactoovovegetarians and omnivorous women. J Am Diet Assoc 76:148,1980.

(30) Pixley, F., Wilson, D., McPherson, K., and Mann,J.: Effect of veget- arianism on development of gallstones inwomen. Br Med J 291:11, 1985.

(31) Gear, J.S., Ware, A., Fursdon, P., Mann, J.I.,Nolan, D.J., Brodribb, A.J., and Vessey, M.P.: Symptomlessdiverticular disease and intake of dietary fiber. Lancet 1:511,1979.

(32) Scrimshaw, N.S.: Nature of protein requirements. JAm Diet Assoc 54:94, 1969.

(33) Hardinge, M.G., Crooks, H., and Stare, F.J.:Nutritional studies of vegetarians: 5. Proteins and essentialamino acids. J Am Diet Assoc 48:25, 1966.

(34) Osteoporosis Consensus Conference. NationalInstitutes of Health, Bethesda, MD, 1984.

(35) El Nahas, A.M., and Coles, G.A.: Dietary treatmentof chronic renal failure: Ten unanswered questions. Lancet 1:597,1986.

(36) International Nutritional Anemia ConsultativeGroup. The Effects of Cereals and Legumes on Iron Availability.Washington, DC: Nutrition Foundation, 1982.

(37) Sanders, T.A.B.: Vegetarianism: Dietetic andmedical aspects. J Plant Foods 5:3, 1983.

(38) Nnakwe, N., and Kies, C.: Calcium and phosphorusutilization by omnivores and lactoovovegetarians fed laboratorycontrolled lactovegetarian diets. Nutr Rep Int 31:1009, 1985.

(39) Curtis, J.A., Kooh, S.W., Fraser, D., andGreenberg, M.L.: Nutritional rickets in vegetarian children. CanMed Assoc J 128:150, 1983.

(40) Vyhmeister, I.B., Register, U.D., and Sonnenberg, L.M.: Safe vegetarian diets for children. Pediatr Clin North Am24:203, 1977.

(41) Truesdell, D.D., and Acosta, P.B.: Feeding thevegan infant and child. J Am Diet Assoc 85:837, 1985.

(42) Committee on Nutrition, American Academy ofPediatrics: Vitamin and mineral supplement needs in normalchildren in the United States. Pediatrics 66:1015, 1980.

(43) American Dietetic Association: Position paper onthe vegetarian approach to eating. J Am Diet Assoc 77:61, 1980.

(44) Register, U.D., and Crooks, H.: Nutritionallyadequate vegetarian diets. In Reichaig, M., ed.: CRC Handbook ofNutritional Supplements, Vol 1. Human Use. Boca Raton, FL: CRCPress, 1980.

The Authors andReviewers

Authors: Suzanne Havala, R.D. andJohanna Dwyer, D.SC., R.D.
Reviewers: Phyllis Acosta, Dr. P.H., R.D.; George Eisman,R.D.;
Alice Marsh, R.D.; Connie Metcalf, R.D.; Patricia Mutch, Ph.D.,R.D.;
U. D. Register, Ph.D., R.D; Kathleen Zolber, Ph.D., R.D.
From: Journal of the American Dietetic Association,March, 1988, Volume 88, Number 3, pp. 352-355.