I am thrilled to have this guest post about vegan nutrition!
Many of my eating disorder clients have adopted a vegan diet, for better or worse, and are not meeting their nutritional needs. Vegan and vegetarian diets are very healthy when done correctly, but if the whole purpose is to cut more things out in the name of restriction, then malnutrition is almost certain.
If you are vegan, or contemplating starting a vegan or vegetarian diet, read-on to learn about plant-based sources of certain nutrients that are often hard to get when animals are off the table.
The Vegan Diet - A Guide to Nutritional Needs
By: Emily Baird
Emily is a 1st year nutrition student at Cal Poly who plans to become a registered dietitian. She has been vegan for 2 years, and plans to incorporate that into her career.
Every year more and more people are making the transition to a vegan diet, and for good reason! The vegan diet can have so many health benefits for our bodies including disease prevention, weight management, and protection against cancers. But with being vegan, also comes the common questions about: “How do vegans get enough protein?” “How are they getting any B12 in their diet?” “How to vegans get calcium if they don’t drink cow’s milk?”. And although these are valid questions, a well-balanced diet full of fruits, vegetables, beans, legumes, and carbohydrates is all a vegan needs to fulfill their nutritional requirements.
Iron is an important component of the red blood cells that carry oxygen from the lungs to the rest of the body, as hemoglobin. Think of it like the engine to a car; the engine provides the car with the power it needs to make it move. Similarly iron allows hemoglobin to have the needed strength to get oxygen where it needs to go. Without it, the body cannot make hemoglobin, which means organs and tissues won’t get the oxygen they need.
There are two types of iron - heme and non-heme. “Non-heme” iron is found only in plants foods and is harder for the body to absorb than “heme” iron which is only found in meat products, so we need to eat more plant-based iron to truly get the same amount as if we were eating meat.
Many plant foods are naturally high in iron, but there are also many packaged foods that are now being fortified with iron. The recommended daily allowance (RDA) is between 8 - 18 mg (depending on age and gender, up to 27 mg during pregnancy). Be sure to include a source of vitamin C with your iron for better absorption.
VEGAN SOURCES OF IRON
1 cup soybeans: 8.8 mg
2 tbsp flax seeds: 4.1 mg
½ cup cooked lentils: 3.3 mg
½ cup fortified total whole grain cereals: 8 mg
(For a complete list click here)
Calcium is responsible for building and maintaining strong bones and teeth. When the body isn’t supplied with sufficient amounts, it increases the risk of developing disorders like - osteoporosis, hypercalcemia, kidney disease, and even alzheimer's. Calcium can be included either by nutrient dense foods or by incorporating calcium fortified foods. Most breakfast cereals, milks, breads, and juices contain added calcium, but be sure to read the nutrition label to be sure. The RDA is around 1000 - 1300 mg. Vitamin D intake is essential to adequate calcium absorption.
VEGAN SOURCES OF CALCIUM
100 g calcium set tofu: 350 mg
¾ cup calcium fortified plant milk: 240 mg
⅓ cup cooked kale: 110 mg
¼ cup dried figs: 95 mg
(For a complete list click here)
Zinc is essential for the body’s immune system to function properly. It also works in cell division, cell growth, the breakdown of carbohydrates, and wound healing. Although it is so important for our bodies, not much is actually needed; the RDA for zinc is 11 mg for men and 8 mg for women. Even though plant sources of zinc are not absorbed as easily as animal sources, vegans were shown to only have a slightly lower amount of zinc.
VEGAN SOURCES OF ZINC
Tofurky italian sausage: 9 mg
½ cup hummus: 2.3 mg
1 tbsp nutritional yeast: 2 mg
¼ cup roasted pumpkin seeds: 2.3 mg
(Click here for a complete list)
Your body must have vitamin D in order to properly absorb calcium in the body. Vitamin D is not typically a problem for vegans during the summer months, but those living in colder climate may be at risk of developing a vitamin D deficiency. The RDA is 600 - 800 IU. Just about 10 to 20 minutes (depending on skin tone) in the sun per day will provide the body with sufficient levels. But those living closer to the northern hemisphere, may need to include more vitamin D rich foods in their diet.
VEGAN SOURCES OF VITAMIN D
1 cup portabella mushrooms: 634 IU
1 serving instant oatmeal: 180 IU
1 cup fortified soymilk: 120 IU
1 cup fortified orange juice: 100 IU
(Click here for a complete list)
SHOULD I BE INCLUDING SUPPLEMENTS?
Eating a healthy variety of plants and grains will ensure that the body gets sufficient levels of nutrients. The exception to that is vitamin B12. Vitamin B12 is not as easily accessible through plant based foods, so it can be important to include a supplement in your diet. If you are overwhelmed by what kind of B12 supplement to choose, check out this article. Nutritional yeast is an example of a vegan food that does naturally contain B12. It is usually used as a cheese replacement or topping, and can supply 2.4 mcg per 3 tbsp (which is the RDA).
A well-balanced, plant based diet will supply the body with all the nutrients that it needs to thrive. There are many people who question the vegan diet and believe that vegans are lacking essential nutrients, but with the right knowledge of nutritional needs, a vegan diet can be very beneficial.
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(originally posted 7/21/2016. libbysfitnutrition.com)
People intrinsically want to believe and have hope in something. When “big-pharma” and doctors are not making patients feel significant and understood, people will go searching for healing elsewhere, this is where dietary supplements (DS) come in. Most DS work under the realm of “placebo effects,” unless they are being used to treat a nutritional deficiency.
The definition of “placebo effect” is, “improvement in the condition of a patient that occurs in response to treatment but cannot be considered due to the specific treatment used(1).” This phenomenon has been identified in several studies. One of which was a study of patients with irritable bowel syndrome (IBS) which “treated” patients with either “open-label placebo (non-deceptive and non-concealed administration)” or no treatment. Even knowing that the pill they were given was a placebo made of an inert substance, the sufferers found significant relief over those receiving no treatment. The conclusion was that “Placebos administered without deception may be an effective treatment for IBS (2).”
Doctors have long-known the benefits of placebo effects in patients and will utilize this in treatment. While the “placebo” thinking may help people heal, “no-cebo” thinking can render even an active drug useless. This phenomenon is summed up well in Henry Ford’s famous quote: “whether you think you can or cannot, you are correct.” It may be that doctors owe it to their patients to boost healing by any means possible, including treatment by placebos for more effectiveness (3). Nonetheless, the American Medical Association stated in 2006, that it is unethical for doctors to give patients undisclosed placebo treatment/medications (4). If doctors are ethically not allowed to give undisclosed placebos, then suggesting a DS labeled, “This product is not intended to diagnose, treat, cure, or prevent any disease” might be their way around this ethical dilemma.
Psychological effects of placebos
The placebo effect often is used, consciously or not, in the context of classical conditioning. Discovered by Ivan Pavlov, classical conditioning takes a neutral stimulus (which should cause no response - the “placebo”) and, through learned response, makes it a conditioned stimulus to elicit a conditioned response (5). An example of this in the medical setting would be giving a patient a pain medication that actually works to reduce pain every day for five days, then giving a sugar pill that looks the same on the sixth day and eliciting the same pain-reducing response.
The conscious expectations by a patient of a treatment to work may cause an inert substance to have a desired effect on the patient. These expectations can be elevated by how the health care professional (HCP) interacts with the patient. The study of medicine “generally does not pay adequate attention to psychological and social variables (6),” which are determined by the relationship of the HCP and patient. This may interfere with drug study controls. If the person in the placebo group of the study is getting attention and believes the treatment will work, then they may exhibit signs of the placebo working that may make the active treatment not have a significant desirable outcome over the placebo.
Yet, how can an inert substance elicit a similar response to an active treatment? A large part of this stems from the psychological variants at play. Much of the patient’s outcome may be determined by the HCP’s confidence in a treatment's ability to work, empathy, active listening, and care setting. “[it is] suggested that the success of the many forms of psychotherapy [are] due to a placebo effect rather than the distinctive features claimed by the different therapists (6).” Hope that it will work, and follow-through on actually seeking treatment, are other reasons that patients have better outcomes with either the active treatment or the placebo (7). DS are often prescribed either by licensed HCPs (like doctors) or “alternative healers” (like acupuncturists). The diplomas on the wall, or the attention given by the healer can contribute to the patient “feeling” the DS responding to treatment. Additionally, since chronic conditions often ebb and flow with severity, the patient is likely to look for treatment when symptoms are about to naturally decrease, leading to the belief that the DS “healed” them (8).
Physiological effects of placebos
Placebo effects are not “all in the head” as once thought. They can make actual physical changes in the body, under the right circumstances. A test group for an antidepressant medication versus a placebo showed interesting brain activity in the results. By viewing brain activity with fMRI studies, placebo responses increased activity in the prefrontal cortex of the brain, while the medication suppressed this activity. Both groups exhibited less perceived depression, though on different timelines (the drug working weeks faster than the placebo). To this finding, researchers said, “administration of an inert pill appears to be an active treatment rather than a no-treatment comparison as previously thought. [however, the] placebo response is not equivalent to an active drug response, since the two groups' brain physiology was altered differently (7).”
Even people with Parkinson’s disease can potentially have real physiological benefit from placebo “treatment.” The effect of the placebo increasing dopamine in the brain, modifying the neuron that is promoting the abnormal activity that causes the tremors (9). People in this study physically had reduced shaking while taking the placebo, showing that there is true physical effects in some placebo “treatments”.
Studies should have tighter placebo controls
The Food and Drug Administration requires new drugs to significantly outperform the placebo control before going to market (3). Placebo controlled, double blind trials have been the gold standard of research (8). However, most research studies for medical treatment (whether drug, DS, surgery, or other) could be better controlled for placebo response. This could be met with a few tweaks to methods of “treatment.”
Dr. John Farrar, a neurologist and epidemiologist, provides some insight into what can strengthen study design to control for placebo effects (3):
(originally posted 7/16/2016. libbysfitnutrition.com)
A paper I wrote for my Master's program class on dietary supplements. Bottom line- multi vitamin supplements may do more harm than good. If you cannot get all of your needed nutrients from food (which is totally do-able), then specific single nutrient supplements are a better choice than a multi. (HERE is a free handout on basic macronutrient composition we need to be eating.)
Here is the research:
Use of Multi Vitamin and Mineral Supplements for “Health Insurance” and Disease Prevention
Do “multi vitamin and mineral dietary supplements” have a place in health prevention and treatment? As will be discussed below, the answer appears to be a resounding no.
Background of Multi Vitamin and Mineral Supplements
Multi-Vitamin and Mineral Supplements (MVM) have been available to Americans since the 1940’s (1), and have only increased in use since that time. The general consensus is that a MVM contains three or more vitamins or minerals without other herbs or drugs (3); However, there is no one-definition for what a MVM is or contains (ingredient, number of ingredients, or level of potency). In fact, there are many dietary supplements (DS) on the market that are not labeled as MVMs that are essentially the same as other products labeled MVM (1). The 2011-12 NHANES data shows approximately 40% of Americans took at least one DS in the last 30 days (2). Many of the people surveyed listed to [maintain health, or prevent health problem(s)] as their reason for taking a DS (2). But what is the actual role of MVMs?
Usefulness, role, and dangers of MVMs
In the 1920s, the United States started fortifying major food sources starting with adding iodine to salt to counter widespread deficiency and prevent goiter. In the following years Vitamin D was added to commercially sold milk, and some B vitamins and iron were added to flour (3) minimizing deficiencies in the majority of Americans. Nowadays, many more foods for purchase are fortified with additional vitamins and minerals. With fortification meeting the needs of the general population, benefits of MVMs seem to be limited.
What is the reality of MVM use? MVMs may be beneficial if the blends of ingredients are tailored to the needs to the individual. According to the National Institute of Health (NIH), “several studies have found that MVM users tend to have higher micronutrient intakes from their diet than nonusers. Ironically, the populations at highest risk of nutritional inadequacy who might benefit the most from MVMs are the least likely to take them (1).”
Several large studies show this irony: In a large study of adult participants from Los Angeles and Hawaii, food frequency analysis showed that the majority of people (~75%) had adequate intakes from food alone (1). With MVM adequacy improved, especially for vitamins E, A, and zinc; but there was an increased risk of excessive intake, especially in vitamin A, iron, zinc, and niacin (1). A study of U.S. children under four, concluded that, “usual nutrient intakes were adequate for the majority of US infants, toddlers, and preschoolers, except for a small but important number of infants at risk for inadequate iron and zinc intakes (4).” They also noted that many children were at additional risk of excessive intake for folate, vitamin A, zinc, and sodium even without supplementation (4). Many children with autism are given MVMs, which are unnecessary, and contribute to excessive intake in many. Even with MVMs, there may be additional need for calcium and vitamin D in children, according to the Academy of Nutrition and dietetics (5).
There is an increased risk of nutrient toxicity when taking DS. The NIH states, “MVMs did not reduce the risk of any chronic disease (1).” and “There is potential for adverse effects in individuals consuming dietary supplements that are above the upper level. This can occur...in individuals who consume a healthy diet rich in fortified foods in combination with MVM supplements (3).” Typically MVMs have nutrient levels that are lower than the RDA for a particular nutrient, and without adequate food sources MVM users may need additional supplementation of nutrients (such as magnesium or calcium) not contained in high enough doses from the MVM; however, as discussed above, toxicity from supplementation is all too common (1), sometimes with irreversible health consequences.
Just a few examples of health issues caused by excess vitamin or mineral intake include: excess vitamin A or beta-carotene correlated to increased risk of lung cancer in smokers or former smokers (1); excess vitamin A (as preformed retinol) increasing risk of birth defects in fetuses of pregnant women taking supplements (1); and iron supplements have been noted as a “leading cause of poisoning in children until age 6 years (1),” due to children getting into supplement containers. Additionally, people taking blood thinning medications need to keep vitamin K levels steady, so any supplements should be checked and confirmed with their doctor before taking or changing doses (1).
Though many large-scale studies have been done separately with either male or female participants, there is not a significant difference in health risks between the genders. The Physician’s Health Study II was a large-scale, double-blind, placebo-controlled RCT of over 14,000 male doctors in the United States, the study showed that, “daily multivitamin supplementation modestly but significantly reduced the risk of total cancer (6).” In conflict, another study of the “295,344 men enrolled in the National Institutes of Health (NIH)-AARP Diet and Health Study (7) found that low-dose MVM use had no discernable increase in risk of prostate cancer, but those who took higher doses (more than 7 times/week) of MVMs had an “increased risk of advanced and fatal prostate cancers is of concern and merits further evaluation (7), than non MVM users (1). Another large study (n= 83,639) of male physicians found no association between cardiovascular disease and MVM use(1).
Women were no different in terms of conflicting research. A study of Swedish women (n= 35,329) found an increased risk of developing breast cancer with MVM use (1); while another study of U.S. women (n=37,920) “found no such association but did find indications that MVM use might reduce the risk of estrogen- and progesterone- receptor– negative breast cancer and breast cancer overall in women who consume alcohol (1).” Swedish women in a cohort study had a lower risk “of myocardial infarction when taking MVMs, especially when taken for at least 5 years (8).” A cohort study of Iowa women found a slight increased risk of mortality from long term MVM use compared with non-MVM-users (1). And finally, long-term MVM use appeared to have benefit for men but not women in total cancer and mortality risk in a NIH study, but no benefit to either group for CVD (3). Overall, the data is inconclusive of significant benefit to either gender taking MVMs long-term.
Is there still a use for MVM?
The NIH, Office of Dietary Supplements (ODS) states, “supplements cannot take the place of the variety of foods that are important to a healthy diet (1).” Eating a well-balanced nutritious diet is the goal for everyone, and can be done. That being said, there are populations that do benefit from taking specially-formulated MVMs or DS.
The American Academy of Pediatrics and the (formerly) American Dietetic Association, list potential populations that will benefit from use of MVMs: “[people with] nutritional risk....those who have anorexia or an inadequate appetite, follow fad diets, have chronic disease, come from deprived families or suffer parental neglect or abuse, participate in dietary programs for managing obesity, consume a vegetarian diet without adequate dairy products,..have failure to thrive...people with medical conditions and diseases that impair digestion, absorption, or use of nutrients [bariatric surgery]… some supplements might help people who do not eat a nutritious variety of foods to obtain adequate amounts of essential nutrients (1).”
However, not every MVM on the market is appropriate of any of these populations. In these scenarios, it would be far better to use specific formulations of needed vitamins and minerals to make up for lacking nutrients. The 2010 Dietary Guidelines for Americans, and the NIH–sponsored State-of-the-Science Conference, claims there is no supporting evidence for the general population to take a MVM to prevent chronic diseases (1, 7).
How should MVM be regulated?
Currently the Food and Drug Administration (FDA), or any government body, does not have the ability to test DS, legally (due to the Dietary Supplement Health Education Act, or “DSHEA”), or in resources (staff or funds) to do so. “Both the [FDA] and the Federal Trade Commission (“FTC”) regulate claims made by food and dietary supplement manufacturers (9).” The FDA regulates labeling, which prohibits false or misleading information on the supplement labels “under the Food, Drug and Cosmetic Act” (9). The FDA issues warning letters to manufacturers against law violations in labeling, but rarely uses other methods of enforcement (9) mainly due to inability to keep up with the booming DS industry. This means the regulating agencies are bound to fail when the staff is disproportionately small, and the enforcement of laws is poorly executed (9). If a DS was listed as a food additive, or drug, it would require pre-market approval (3), and there would not be the insurmountable task of keeping up with the production of DS.
While the FDA focuses on the direct product label, the FTC regulates the advertising of DS. This may include “evaluat[ing] dietary supplement labels if they are being used by an advertiser to promote the product...under the FTC Act, claims in advertising made about foods and dietary supplements may not be “unfair” or “deceptive” (9).” As presented in the American Journal of Law & Medicine, a “limited private right of action [private sector lawsuits] under the FTC act” would more easily bring “enforcement actions in federal court” to protect consumers regarding DS (9), and would greatly increase the amount of products being enforced.
The NIH has excellent recommendations regarding change in regulatory laws and action, for instance, “The FDA should have the authority to better inform consumers and health professionals regarding the existence of upper levels as well as the possible risks of exceeding those levels; [the FDA should] develop a formal, mandatory adverse event reporting system for dietary supplements; and mandate provision of a MedWatch toll-free telephone number or Web site on product labels to facilitate reporting of adverse events. Furthermore, we recommend that healthcare professionals, consumers, and manufacturers use the FDA MedWatch adverse event reporting system to report adverse events associated with the use of dietary supplements. Finally, we recommend that Congress revise and update the law to reflect current knowledge...design and conduct rigorous randomized control trials of the impact of individual supplements (or paired supplements, when biologically plausible) to test their efficacy and safety in prevention of chronic disease, using well-validated measures.(3).” Ultimately, DS should be regulated as drugs, due to the fact that they interact and “medicate” like drugs in the body.
Should this information change consumer behavior?
If approached properly, there may be a way to help consumers better understand the dangers and lack of regulation of DS. Two studies on consumer education about DS, showed that consumers taught about DSHEA and the regulation of DS “rated DS as less safe and less effective” than the control group (10). This gives us a starting place on what message needs to be making its way to consumers. “Consumers may be especially susceptible to health claims, because they usually lack the knowledge to assess claims referring to physiology or metabolic processes and may be especially impressed by purported scientific evidence bolstering the claims (9).”
MVMs, particularly due to the lack of content consistency, are not useful in human health and disease prevention or treatment. The Medical Letter, an unbiased publication for pharmacists, declares that long-term use of MVMs, or any substance, is not without risk; and taking vitamins A, C, E, or beta-carotene in high doses or long-term may be more harmful than helpful (12). They furthermore suggest the only beneficial supplements (in healthy people consuming a normal diet) are folic acid, vitamin D and B12, in specific populations (12). If supplemental nutrients are necessary for populations listed previously who cannot obtain enough from diet alone, they should be carefully chosen as individual (well-researched) DS, and not in MVMs which may (with or without accurate labeling) contain excessive levels of substances (vitamin/minerals, or drugs/herbs) that may be harmful. I strongly recommend against the use of MVMs given the research available to us today.
(originally posted 3/28/2013. libbysfitnutrition.com)
Considering supplements to boost your health? What do you take? Do you even need them? More is better, right? Let's dig in a bit and see....
Dietary supplement, as defined by the Food and Drug Administration (FDA) is, "A product taken by mouth that contains a dietary ingredient intended to supplement the diet." Categorized as "foods," supplements are not as regulated as drugs, nor does their safety need to be approved by the FDA before selling. Furthermore, herbal/botanical supplements can interfere just like drugs with other medications you may be taking and/or medical conditions (ex: renal failure, diabetes, pregnancy, etc.).
The serving size, or % daily value, is not regulated in supplements, but labels are required to follow certain guidelines including: identity, quantity, directions, supplement facts panel, other ingredients, and manufacturer's address for more information.
Do I need to take supplements?
Know that supplements are not intended to replace good nutrition,
they are a "supplement" not an "instead-of."
Vegans and strict vegetarians may need certain supplements. Speak to your Dietitian or Doctor about this.
Different stages of the lifecycle and different disease states may benefit from certain supplements.
Analyze your total diet first- are you lacking in certain nutrients? Try to find food sources first.
Taking some supplements can be harmful, and taking any in excess can be fatal. Many water-soluble vitamins and minerals are not easily absorbed; therefore, you are just paying for expensive urine.
Looking for a weight-loss pill? While many might not "hurt" you, know that if there was a magic pill there would not be an obesity epidemic. (And many supplements can definitely do damage!)
Are you pregnant or planning to become pregnant? A multi-vitmain with iron and Folic Acid can be necessary if diet is lacking, to prevent infant abnormalities like spina-bifida.
Inadequate calcium intake? Calcium + Vit D taken seperatly from calcium containing foods can be beneficial in preventing bone loss. (btw- there are vegan foods that contain calcium! Try dark green leafy veggies, like bok choy).
When researching and selecting supplements, ask yourself:
What is the purpose of the source (website, advertisement, article) you are getting the information from? Do they have a vested-interest in selling? Or is this purely educational?
Is your doctor/whoever getting kick-back from the company to sell it?
Claims that are supported by scientific evidence are important! How big was the study (s)? Same demographic of people as yourself? Were the results significant?
"USP" or "U S Pharmacopoeia" should be on the package, to indicate that standards of processing were followed for safety. (Note- this does not mean that the dose/ingredients are "safe" to consume, just manufactured in a safe environment.
"Natural" does not equal "safe." Many toxic substances are "natural," like Mercury.
I hope this helped you understand supplements better so that you can be safe, informed consumers.
If you have further questions about specific supplements please ask your doctor or registered dietitian.
Source: Nutrition: An Applied Approach, 3rd Ed. Thompson, J., Manore, M. Pearson Education, Inc. 2012. Pg 360-367.
Libby is a Registered Dietitian focusing on eating disorder treatment and prevention. She is working on the central coast to create wellness in individuals and the community.
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