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COMMENTARY

Plant-Based Diets: A Physician’s Guide


Julieanna Hever, MS, RD, CPT 3HUP-6XPPHU  
(SXE KWWSG[GRLRUJ733

ABSTRACT growth factor-1, more is generated


Because of the ever-increasing body of evidence in support of the health advantages endogenously.21 Fostering growth as a
of plant-based nutrition, there is a need for guidance on implementing its practice. This full-grown adult can promote cancer
article provides physicians and other health care practitioners an overview of the myriad proliferation.
ILULÄ[ZVMHWSHU[IHZLKKPL[HZ^LSSHZKL[HPSZVUOV^ILZ[[VHJOPL]LH^LSSIHSHUJLK • Heme iron: Although heme iron, found
U\[YPLU[KLUZLTLHSWSHU0[HSZVKLÄULZUV[HISLU\[YPLU[ZV\YJLZKLZJYPILZOV^[VNL[ in animal products, is absorbed at a
started, and offers suggestions on how health care practitioners can encourage their higher rate than nonheme iron, found
patients to achieve goals, adhere to the plan, and experience success. in plant-based and fortified foods,
absorption of nonheme iron can be
SUMMARY OF HEALTH BENEFITS recommendations15 for a heart-healthy increased by pairing plant-based pro-
Plant-based nutrition has exploded in diet to include no more than 5% to tein sources with foods high in vitamin
popularity, and many advantages have 6% of total calories from saturated fat, C.22 Additionally, research suggests that
been well documented over the past sev- which is just the amount found natu- excess iron is pro-oxidative23 and may
eral decades.1 Not only is there a broad rally in a vegan diet (one consisting of increase colorectal cancer risk 24 and
expansion of the research database sup- no animal products). promote atherosclerosis25 and reduced
porting the myriad benefits of plant-based • Dietary cholesterol: Human bodies insulin sensitivity.26
diets, but also health care practitioners produce enough cholesterol for ad- • Chemical contaminants formed from
are seeing awe-inspiring results with equate functioning. Although evidence high temperature cooking of cooked
their patients across multiple unique suggests that dietary cholesterol may animal products: When flesh is cooked,
subspecialties. Plant-based diets have only be a minor player in elevated serum compounds called polycyclic aromatic
been associated with lowering overall cholesterol levels, high intakes are linked hydrocarbons,27 heterocyclic amines,28
and ischemic heart disease mortality2; to increased susceptibility to low-density and advanced glycation end products29
supporting sustainable weight manage- lipoprotein oxidation, both of which are formed. These compounds are
ment3; reducing medication needs4-6; low- are associated with the promotion of carcinogenic, pro-inflammatory, pro-
ering the risk for most chronic diseases7,8; CVD.16-18 Dietary cholesterol is found oxidative, and contributive to chronic
decreasing the incidence and severity of almost exclusively in animal products. disease.
high-risk conditions, including obesity,9 • Antibiotics: The vast majority (70% to • Carnitine: Carnitine, found primar-
hypertension,10 hyperlipidemia,11 and hy- 80%) of antibiotics used19,20 in the US ily in meat, may be converted in the
perglycemia;11 and even possibly reversing are given to healthy livestock animals body by the gut bacteria to produce
advanced coronary artery disease12,13 and to avoid infections inherent in the trimethylamine N-oxide (TMAO).
type 2 diabetes.6 types of environments in which they High levels of trimethylamine n-oxide
The reason for these outcomes is two- are kept. This is, therefore, the num- are associated with inflammation, ath-
fold. First, there are inherent benefits to ber one contributor to the increasingly erosclerosis, heart attack, stroke, and
eating a wide variety of health-promoting virulent antibiotic-resistant infections death.30
plants. Second, there is additional benefit of the type that sickened 2 million and • N-Glycolylneuraminic acid (Neu5Gc):
from crowding out—and thereby avoid- killed 23,000 Americans in 2013.20 This compound is found in meat and
ing—the injurious constituents found in • Insulin-like growth factor-1: Insulin- promotes chronic inflammation.31,32
animal products, including the following: like growth factor-1 is a hormone On the other hand, there are infinite
• Saturated fats: Saturated fats are a naturally found in animals, includ- advantages to the vast array of nutrients
group of fatty acids found primarily in ing humans. This hormone promotes found in plant foods. Phytochemicals
animal products (but also in the plant growth. When insulin-like growth and fibers are the two categories of nu-
kingdom—mostly in tropical oils, such factor-1 is consumed, not only is the trients that are possibly the most health
as coconut and palm) that are well es- added exogenous dose itself taken in, promoting and disease fighting. Plants are
tablished in the literature as promoting but because the amino acid profile the only source of these nutrients; they
cardiovascular disease (CVD).14,15 The typical of animal protein stimulates are completely absent in animals. Plants
American Heart Association lowered its the body’s production of insulin-like contain thousands of phytochemicals,

1\SPLHUUH/L]LY4:9+*7;is a Dietitian and Author in Los Angeles, CA.


E-mail: julieannaheverMSRD@yahoo.com.

The Permanente Journal/Perm J 2016 Summer;20(3):15-082 93


COMMENTARY
Plant-Based Diets: A Physician’s Guide

such as carotenoids, glucosinolates, and Table 1. Food group recommended servings per day
flavonoids, which perform a multitude of
Food group Recommended servings per day
beneficial functions, including:
Vegetables, all types, including starchy Ad libitum, with a variety of colors represented
• Antioxidation, neutralizing free radicals33
Fruits, all types VHUYLQJV VHUYLQJ PHGLXPSLHFHRUFXS
• Anti-inflammation34
• Cancer activity reduction via several Whole grains (eg, quinoa, brown rice, oats) VHUYLQJV VHUYLQJ FXSFRRNHGRUVOLFH
whole grain bread)
mechanisms, including inhibiting tu-
/HJXPHV EHDQVSHDVOHQWLOVVR\IRRGV VHUYLQJV VHUYLQJ FXSFRRNHG
mor growth, detoxifying carcinogens,
retarding cell growth, and preventing /HDI\JUHHQYHJHWDEOHV HJNDOHOHWWXFH $WOHDVWVHUYLQJV VHUYLQJ FXSUDZRU
broccoli) FXSFRRNHG
cancer formation35
Nuts (eg, walnuts, almonds, pistachios) 1-2 ounces
• Immunity enhancement36
6HHGV HJFKLDKHPSDQGÀD[VHHGV WDEOHVSRRQV
• Protection against certain diseases, such
as osteoporosis, some cancers, CVD, )RUWL¿HGSODQWPLONV HJVR\DOPRQGFDVKHZ 2SWLRQDOFXSV
macular degeneration, and cataracts37-39 Fresh herbs and spices Optional, ad libitum
• Optimization of serum cholesterol.40,41
Fibers found in whole plant foods
powerfully support the gastrointestinal, “well-planned vegetarian diets are appro- Seeds, too, are special in that their es-
cardiovascular, and immune systems priate for individuals during all stages of sential fat ratios are well-balanced, and
through multiple mechanisms. Yet more the life cycle, including pregnancy, lacta- they contain multiple trace minerals and
than 90% of adults and children in the US tion, infancy, childhood, and adolescence, phytochemicals. One or 2 tablespoons per
do not get the minimum recommended and for athletes.” Because any type of meal day will boost overall nutrition. Opting for
dietary fiber.42 plan should be approached with careful whole food sources of fats, as opposed to
Thus, it can be advantageous for physi- thought, it is helpful to note that plant- extracted fats as found in oils, is optimal
cians to recommend and support plant- based diets, including calorie-restricted, to decrease caloric density and increase
based eating to achieve optimal health weight-loss diets, have been found to be nutrient and fiber consumption. Herbs
outcomes and possibly minimize the need more nutritionally sound than typical and spices also contain phytochemicals
for procedures, medications, and other dietary patterns.45 and help make food delicious, varied, and
treatments. Aiming for lifestyle changes A well-balanced, plant-based diet is exciting, and should be used according
as primary prevention has been estimated composed of vegetables, fruits, whole to preference. Food group recommended
to save upwards of 70% to 80% of health grains, legumes, herbs, spices, and a small servings per day are shown in Table 1.
care costs because 75% of health care amount of nuts and seeds. Half of the plate
spending in the US goes to treat people should consist of vegetables and fruits in PLANT-BASED MACRONUTRITION
with chronic conditions.43 Offering this accordance with the US Department of All calories (kcals) come from some
option and guiding patients through the Agriculture, American Cancer Society, combination of carbohydrates (4 kcals/g),
logistics and their concerns about plant- and American Heart Association, because proteins (4 kcals/g), and fats (9 kcals/g).
based eating is a viable first line of therapy they are filled with fiber, potassium, mag- Alcohol also provides calories (7 kcals/g)
in the clinical setting. This article will nesium, iron, folate, and vitamins C and but is not considered an essential nutri-
delineate how best to achieve a well-bal- A—almost all of the nutrients that tend ent. The ideal ratio of intake of these 3
anced, nutrient-dense meal plan, define to run low in the American population, macronutrients is highly controversial
notable nutrient sources, describe how according to the Scientific Report of the and debatable. There is plenty of evidence
to get started, and offer suggestions on 2015 Dietary Guidelines Advisory Com- supporting health and weight management
how physicians can encourage and work mittee.46 Legumes are excellent sources of benefits of low-fat/high-carbohydrate di-
with their patients who are interested to lysine (an amino acid that may fall short ets, as seen in the traditional Okinawan
maintain adherence and enjoy success. in a plant-based diet), fiber, calcium, iron, diet51 and in Dean Ornish, MD’s12 and
zinc, and selenium. It is ideal to consume Caldwell Esselstyn, MD’s13 reversal of ad-
NOTABLE NUTRIENTS one to one-and-a-half cups of legumes vanced coronary artery disease and Neal
Although nutrient deficiency is a per day. Substantiating meals with whole Barnard, MD’s6 reduction of glycemia in
primary concern for many people when grains aids with satiety, energy, and versa- type 2 diabetes using a plant-based diet
considering plant-based eating, the Acad- tility in cuisine. Nuts are nutritional nug- with 10% of calories from fat. Similarly,
emy of Nutrition and Dietetics states44 gets, brimming with essential fats, protein, the Mediterranean52 and many raw food53
that “vegetarian diets, including total fiber, vitamin E, and plant sterols, and have diets consisting of upwards of 36% or
vegetarian or vegan diets, are healthful, been shown to promote cardiovascular more of calories from fat show consistently
nutritionally adequate, and may provide health47 and protect against type 2 diabetes positive health advantages. Thus, it appears
health benefits in the prevention and treat- and obesity,48 macular degeneration,49 and that it is likely the quality of the diet that
ment of certain diseases.” The Academy’s cholelithiasis.50 One oz to 2 oz (or 30 g to is responsible for health outcomes rather
position paper goes on to conclude that 60 g) of nuts per day is recommended. than the ratio of macronutrients.

94 The Permanente Journal/Perm J 2016 Summer;20(3):15-082


COMMENTARY
Plant-Based Diets: A Physician’s Guide

Carbohydrates metals, such as mercury, lead, and cad- production of hormones, vitamin D,
The Institute of Medicine’s adequate mium, as well as industrial pollutants.55 and bile acids, the liver produces enough
intake of carbohydrates54 is 130 g/d for Also, plant sources are more sustainable cholesterol on its own. Excessive intake
everyone (except during pregnancy and than fish sources.56 of dietary cholesterol is associated with
lactation) beginning at age 1 year. Optimal Monounsaturated fats are not essential increased risk of CVD.
sources of carbohydrates, such as whole- but have been found to impart either a Phytosterols, which are similar to cho-
some vegetables, fruits, whole grains, and neutral or slightly beneficial effect on lesterol, are plant-based sterols found in
legumes, are high in fiber and nutrients. serum cholesterol levels, depending on all plant foods (especially wheat germ,
Refined carbohydrates from sugars, flours, which nutrient they are replacing. When nuts, seeds, whole grains, legumes, and
and other processed foods can lead to mal- swapped for saturated fats, trans fats, or unrefined plant oils). Phytosterols reduce
nourishment and promote illness. refined carbohydrates, monounsaturated cholesterol absorption in the gut, thereby
fats may lower low-density lipoprotein optimizing lipid profiles. Together with
Protein and raise high-density lipoprotein cho- viscous fibers, soy proteins, and almonds,
Adequate intake54 of protein is based lesterol. These fatty acids are found in phytosterols have been found to be as ef-
on weight and is estimated at 1.5 g/kg/d olives, avocados, macadamia nuts, hazel- fective as statins in some studies in lower-
for infants, 1.1 g/kg/d for 1 to 3 year olds, nuts, pecans, peanuts, and their respec- ing low-density lipoprotein cholesterol.5,58
0.95 g/kg/d for 4 to 13 year olds, 0.85 g/kg/d tive oils, as well as in canola, sunflower, It is crucial to note that all whole foods
for 14 to 18 year olds, 0.8 g/kg/d for adults, and safflower oils. contain all three macronutrients. It is a
and 1.1 g/kg/d for pregnant (using prepreg- Saturated fats, as mentioned above, pervasive misunderstanding to identify
nancy weight) and lactating women. Protein are not essential in the diet and can a food as a “carb,” “protein,” or “fat.”
is readily available throughout the plant promote CVD. They are found primar- Instead, these are all nutrients within a
kingdom, but those foods that are particu- ily in animal products but are available complex of other myriad constituents
larly rich in protein include legumes, nuts in some plant foods, mostly in tropical that are beyond the oversimplification
and nut butters, seeds and seed butters, soy fats and oils, such as palm and coconut, perpetuated by the media and trendy
foods, and intact whole grains. and also in other high-fat foods, includ- diet fads.
ing avocados, olives, nuts, and seeds. If a Ideally, a healthful diet is loaded with
Fats vegan diet contains an average of 5% to wholesome carbohydrates, moderate
Fats—or fatty acids—are more com- 6% of kcals from saturated fat, which is in fat, and temperate in protein. The
plicated because there are several differ- what the American Heart Organization emphasis must be on the quality of the
ent chemical varieties based on level and recommends for a heart-healthy diet, any totality of foods coming from whole
type of saturation. Each category of fatty added serving of animal products will plant sources as opposed to calculations
acid performs different functions and significantly increase the total intake. and perfect ratios.
acts uniquely in the body.14 Trans fatty acids are laboratory-made
The essential fatty acids are polyun- via hydrogenation and are found in pro- PLANT-BASED MICRONUTRITION
saturated and include both omega-3 and cessed, fried, and fast foods. Although All nutrients, with the exception of vi-
omega-6 fatty acids. Omega-3 fats are they were originally developed to be a tamin B12 and possibly vitamin D, which
found in their shorter chain form as al- healthy alternative to butter and lard, is ideally sourced from the skin’s exposure
pha linolenic acid and are used as energy. trans fatty acids were found to signifi- to the sun’s ultraviolet rays, can be found
They are also converted by the body to cantly increase CVD risk. In November in plants. They are also packaged together
the longer-chain eicosapentaenoic acid 2013, the US Food and Drug Admin- with thousands of powerful disease-fight-
(EPA) and then docosahexaenoic acid istration issued a notice that trans fatty ing nutrients that work synergistically to
(DHA). Because this conversion pro- acids were no longer considered safe57 support optimal health.59
cess can be inefficient, some people may and is now trying to eliminate artifi-
require a direct source of these longer- cially produced trans fatty acids (there Vitamin B12
chain EPA and DHA in the form of a are small amounts found naturally in Cobalamin, commonly referred to
microalgae supplement. Alpha linolenic meat and dairy products) from the food as vitamin B12, is the only nutrient not
acid can be found in flaxseeds, hemp- supply. Be aware that a nutritional label directly available from plants. This is
seeds, chia seeds, leafy green vegetables can state a food product contains “0 g because vitamin B12 is synthesized by mi-
(both terrestrial and marine), soybeans trans fats” even if it contains up to 0.5 g croorganisms, bacteria, fungi, and algae,
and soy products, walnuts, and wheat per serving. Thus, advise your patients but not by plants or animals. Animals
germ, as well as in their respective oils. to focus on the ingredient list on food consume these microorganisms along
A direct plant source of EPA and DHA products and to avoid anything with the with their food, which is why this vitamin
is microalgae, through which fish acquire words “partially hydrogenated.” can be found in their meat, organs, and
them. Plant sources may be superior be- Dietary cholesterol is a sterol that is byproducts (eggs and dairy). Vitamin B12
cause they do not contain the contami- found primarily in animal products. deficiency can lead to irreversible neuro-
nants that fish contain, including heavy Although cholesterol is required for the logic disorders, gastrointestinal problems,

The Permanente Journal/Perm J 2016 Summer;20(3):15-082 95


COMMENTARY
Plant-Based Diets: A Physician’s Guide

and megaloblastic anemia. Among other appears to be a worldwide epidemic respect to bone mineral optimization dur-
populations, vegans who do not supple- of deficiency. Vitamin D is not widely ing the lifespan. However, because bone
ment with a reliable source of vitamin B12 available from the food supply. Sources metabolism is multifactorial and complex,
or breastfeeding infants of vegan mothers of preformed vitamin D include fish it is important to emphasize consumption
who are not consuming a regular reli- liver oil, oily fish, liver, and in smaller of ample sources of calcium as well as vi-
able source of vitamin B12 are at risk for doses, meat and egg yolk—foods that also tamins K and B12, fluoride, magnesium,
deficiency. contain high concentrations of saturated phosphorus, and potassium; to maintain
The body can store vitamin B12 for ap- fat, cholesterol, and other less-than-ideal serum vitamin D levels; and to ensure con-
proximately three to five years, but after components. Vitamin D from sunshine sistent exercise. Throughout the lifespan,
that, with no repletion or with inability to and animal sources is in the form of dietary recommendations for adequate
absorb, deficiency symptoms may present; cholecalciferol, or vitamin D3. A second intake of calcium fluctuate.62
deficiency may also be asymptomatic. Be- form called ergocalciferol, or vitamin Excellent plant sources of calcium in-
cause of this lag time and because serum D2, is found in plant sources, mostly clude leafy green vegetables—especially
tests for B12 levels can be skewed by other in ultraviolet B-irradiated mushrooms. bok choy, broccoli, napa cabbage, collard
variables, irreversible damage may occur However, a plant-derived version of D3 greens, dandelion greens, kale, turnip
before a deficiency is caught. made by lichen was recently discovered.60 greens, and watercress—as well as forti-
In a vegan diet, vitamin B12 can be Dietary supplements may contain either fied plant milks, calcium-set tofu, dried
found in fortified plant milks, cereals, D2 or D3, both of which can be effective figs, sesame seeds and tahini, tempeh, al-
or nutritional yeast. However, these are at optimizing blood levels. monds and almond butter, oranges, sweet
not dependable means of achieving B12 More and more physicians are testing potatoes, and beans.
requirements. Although there are claims for serum levels of vitamin D using the No matter how much calcium is con-
that fermented foods, spirulina, chlorella, 25-hydroxyvitamin D test. The Institute sumed, the amount that is actually absorbed
certain mushrooms, and sea vegetables, of Medicine concluded that adequate is more significant. Many variables affect
among other foods, can provide B12, the serum 25-hydroxyvitamin D levels are ≥ calcium levels via absorption or excretion,
vitamin is not usually biologically active. 50 nmol/L (≥ 20 ng/mL).61 including:
These inactive forms act as B12 analogues, If patients have suboptimal levels, em- • Overall consumption determines how
attaching to B 12 receptors, preventing phasizing food sources (especially fortified much is absorbed. Only about 500 mg
absorption of the functional version, and plant milks) as well as supplements may can be absorbed at a time, and absorption
thereby promoting deficiency. The most be helpful. Dosing may be tricky because decreases as calcium intake increases
reliable method of avoiding deficiency for of variable responses in individuals and • Age. Calcium absorption peaks in in-
vegans or anyone else at risk is to take a differences in types of vitamin D formu- fants and children, as they are rapidly
B12 supplement. las. Of note, although both of the 2 forms growing bone, and then progressively
Because the body can absorb only ap- of vitamin D—cholecalciferol (D3) and decreases with age
proximately 1.5 µg to 2.0 µg at a time, it ergocalciferol (D2)—are effective at rais- • Phytates, compounds found in whole
is ideal to supplement with a dose greater ing serum D levels in small doses (4000 grains, beans, seeds, nuts, and wheat
than the Recommended Dietary Allow- IU or less), cholecalciferol (D3) is supe- bran, can bind with calcium as well as
ance (RDA) to ensure adequate intake. rior when using large boluses. Because with other minerals and inhibit absorp-
Plant-based nutrition experts recommend the supplement industry is not regulated tion. Soaking, sprouting, leavening, and
a total weekly dose of 2000 µg to 2500 µg. by the Food and Drug Administration, fermenting improve absorption
This can be split into daily doses or into it is “buyer beware” in the supplement • Oxalates are constituents found in some
2 to 3 doses of 1000 µg each per week to market. Thus, aim to find well-reputed leafy green vegetables, such as spinach,
help enhance absorption. Because vitamin companies. A few organizations, such as Swiss chard, collard greens, parsley,
B12 is water soluble, toxicity is rare. Consumer Lab, NSF International, and leeks, and beet greens; berries; almonds;
US Pharmacopeia, act as independent cashews; peanuts; soybeans; okra; qui-
Vitamin D third parties and offer seals of approval noa; cocoa; tea; and chocolate. They
Vitamin D, or calciferol, is also known after testing products for potency and may also somewhat inhibit absorption
as the “sunshine vitamin” because it is contaminants. They do not, however, test of calcium and other minerals, but some
the only nutrient that is acquired from for safety or efficacy. may still be absorbed. Emphasizing vari-
the sun. Although vitamin D is classified ety in the foods eaten on a regular basis
as and treated like a fat-soluble vitamin, Calcium encourages adequate absorption
it is actually a prohormone produced in Calcium, a macromineral, is the most • Serum vitamin D levels must be within
the skin upon exposure to ultraviolet B abundant mineral in the human body. A optimum range in order for the body to
sun radiation and then activated by the mere 1% of the body’s calcium circulates absorb calcium.
liver and kidneys. in the blood and tissues; 99% is stored in • Excessive intake of sodium, protein,
Although human bodies evolved to the bones and teeth. Calcium is a nutrient caffeine, and phosphorus (as from dark
produce vitamin D via the sun, there of concern for the general population with sodas) may enhance calcium excretion.62

96 The Permanente Journal/Perm J 2016 Summer;20(3):15-082


COMMENTARY
Plant-Based Diets: A Physician’s Guide

Iron soy products, dark chocolate, blackstrap of consuming a source of iodine to avoid
Ironically, iron is one of the most molasses, sesame seeds, tahini, pumpkin thyroid issues. Sources of iodine include
abundant metals on Earth and yet iron seeds, sunflower seeds, raisins, prunes, iodized salt and sea vegetables. However,
deficiency is one of the most common and cashews. it is important to note that iodine is not
and widespread nutritional deficiencies. Iron absorption may be diminished found in sea salts, gourmet salts, or other
It is the most common deficiency in the in the presence of phytates, tannic acids salty foods. One half-teaspoon of iodized
world and is a public health problem in from tea, calcium in dairy, fiber, poly- salt provides the daily recommended
both industrialized and nonindustrialized phenols in coffee and cocoa, and certain 150-µg dose. Also, iodine levels in sea
countries.63 It is particularly prevalent spices (eg, turmeric, coriander, chilies, vegetables fluctuate dramatically, with
in women of childbearing age, pregnant and tamarind). To minimize this, separate some (especially dulse and nori) contain-
women, infants, children, teenage girls, iron-rich foods from these nutrients as ing safe amounts and others (such as kelp)
and anyone experiencing bleeding, such much as possible. An example is to drink harboring toxic doses. Hijiki, also spelled
as people with ulcers, inflamed intestines coffee or tea separately from meals or to hiziki, should be avoided owing to its ex-
caused by malabsorptive disorders, or mix up meal combinations. One of the cessive arsenic levels. A preexisting iodine
heavy menstruation. Iron-deficiency ane- best tips for optimizing iron absorption deficiency, a selenium deficiency, or high
mia is no more common in vegetarians is to eat iron-rich foods in combination intake of goitrogens (antinutrients found
than in nonvegetarians. with foods high in vitamin C and organic in cruciferous vegetables, soy products,
Because plant-sourced iron is nonheme acids. This improves solubility, thereby flaxseeds, millet, peanuts, peaches, pears,
iron, which is susceptible to compounds facilitating absorption. Examples of such pine nuts, spinach, sweet potatoes, and
that inhibit and enhance its absorption, optimizing food combinations are a green strawberries) can interfere with iodine
the recommendation for vegans and veg- smoothie with leafy greens (iron) and fruit absorption. There is no need to avoid
etarians is to aim for slightly more iron (vitamin C) or salad greens (iron) with goitrogenic foods as long as iodine intake
than nonvegetarians. Fortunately, this is tomatoes (vitamin C). is sufficient. If a patient does not enjoy sea
easy to do with the wide array of iron-rich vegetables or is minimizing intake of salt,
food choices in the plant kingdom. Leafy Iodine an iodine supplement may be warranted.
greens and legumes are excellent sources Dietary sources of the trace mineral
of iron and a multitude of other nutrients, iodine are unreliable and fluctuate geo- Selenium
so it is advantageous to include these graphically because of varying soil quali- Selenium is a potent antioxidant that
foods often. Other good choices include ties. It is crucial for vegans to be mindful protects against cellular damage and also
plays a role in thyroid hormone regula-
tion, reproduction, and dialpha nucleic
Table 2. Sources of notable nutrients acid (DNA) synthesis. Brazil nuts are
Nutrient Food sources an especially rich source of selenium in
Protein legumes (beans, lentils, peas, peanuts), nuts, seeds, soy foods (tempeh, tofu) the plant kingdom. Although selenium
2PHJDIDWV VHHGV FKLDKHPSÀD[ OHDI\JUHHQYHJHWDEOHVPLFURDOJDHVR\EHDQVDQGVR\IRRGV
content varies depending on the source,
walnuts, wheat germ an average ounce (approximately 6 to 8
Fiber vegetables, fruits (berries, pears, papaya, dried fruits), avocado, legumes (beans, nuts) can provide 777% of the RDA.
lentils, peas), nuts, seeds, whole grains When accessible, one Brazil nut a day is
Calcium low-oxalate leafy greens (broccoli, bok choy, cabbage, collard, dandelion, kale, an ideal way of meeting selenium recom-
ZDWHUFUHVV FDOFLXPVHWWRIXDOPRQGVDOPRQGEXWWHUIRUWL¿HGSODQWPLONVVHVDPH mendations. Other plant sources include
VHHGVWDKLQL¿JVEODFNVWUDSPRODVVHV whole grains, legumes, vegetables, seeds,
Iodine sea vegetables (arame, dulse, nori, wakame), iodized salt and other nuts.
Iron legumes (beans, lentils, peas, peanuts), leafy greens, soybeans and soy foods,
quinoa, potatoes, dried fruit, dark chocolate, tahini, seeds (pumpkin, sesame, Zinc
VXQÀRZHU VHDYHJHWDEOHV GXOVHQRUL Zinc supports immune function and
=LQF legumes (beans, lentils, peas, peanuts), soy foods, nuts, seeds, oats wound healing; synthesis of protein and
Choline legumes (beans, lentils, peas, peanuts), bananas, broccoli, oats, oranges, quinoa, soy DNA; and growth and development
foods throughout pregnancy, childhood, and
Folate leafy green vegetables, almonds, asparagus, avocado, beets, enriched grains (breads, adolescence. Because of the presence of
pasta, rice), oranges, quinoa, nutritional yeast phytates, bioavailability of zinc from
9LWDPLQ%12 IRUWL¿HGIRRGV QXWULWLRQDO\HDVWSODQWPLONV VXSSOHPHQW μg per week) plants is lower than from animal prod-
Vitamin C fruits (especially berries, citrus, cantaloupe, kiwifruit, mango, papaya, pineapple), leafy ucts. Zinc deficiency may be difficult
green vegetables, potatoes, peas, bell peppers, chili peppers, tomatoes to detect in blood tests but can show
Vitamin D VXQIRUWL¿HGSODQWPLONVVXSSOHPHQWLIGH¿FLHQW up clinically as delayed wound healing,
Vitamin K OHDI\JUHHQYHJHWDEOHVVHDYHJHWDEOHVDVSDUDJXVDYRFDGREURFFROL%UXVVHOV growth retardation, hair loss, diminished
VSURXWVFDXOLÀRZHUOHQWLOVSHDVQDWWǀ DWUDGLWLRQDO-DSDQHVHIRRGPDGHIURP immunity, suppressed appetite, taste
soybeans fermented with Bacillus subtilis var QDWWǀ)

The Permanente Journal/Perm J 2016 Summer;20(3):15-082 97


COMMENTARY
Plant-Based Diets: A Physician’s Guide

abnormalities, or skin or eye lesions. • How many times per week do you eat
Suggested Internet Nutrition Resources
Consider advising patients to aim for fried foods/red meat/processed meat/
50% or greater than the RDA of zinc refined sugars? www
www.nlm.nih.gov
daily by including legumes, cashews and • How often do you choose whole grains https://ndb.nal.usda.gov
other nuts, seeds, soy products, and whole over refined grains? http://vegetariannutrition.net
grains. Preparation methods such as soak- • Do you eat at least a cup to a cup-and- http://nutritionfacts.org
ing, sprouting, leavening, and fermenting a-half of legumes (beans, lentils, peas) www.pcrm.org
will improve absorption. Table 2 provides per day? www.brendadavisrd.com
a convenient chart highlighting excellent • Do you include leafy green vegetables www.veganhealth.org
sources of notable nutrients. in your daily diet? http://plantbaseddietitian.com
2. When discussing a patient’s treatment www.theveganrd.com
HELPING PATIENTS GET STARTED plan, include diet as a viable option with www.vrg.org/nutrition/
To support patients to delve into positive effects (eg, improved gastrointes- https://fnic.nal.usda.gov/lifecycle-
this therapeutic nutrition plan to help tinal function, decreased risk for chronic nutrition/vegetarian-nutrition
them prevent or manage chronic disease diseases, and better outcomes for existing www.vegansociety.com
and improve or maintain their state of conditions).
health, it is crucial to provide optimis- 3. Advocate simple suggestions to start
tic, simple, and strategic guidance. See off. Instead of overwhelming a patient with
Label-Reading Protocol
Sidebar: Six-Step Guide for Initiating drastic renovations to their current way of
and Maintaining a Nutrition Dialogue eating, begin with a few changes that can • Ignore misleading marketing ter-
with Patients. be made within reason. Some examples minology on labels (eg, “excellent
include the following: source of,” “free of,” “natural”)
GUIDE FOR INITIATING AND • Incorporate leafy green vegetables with • Focus solely on ingredient list and
MAINTAINING A NUTRITION at least two meals or snacks each day ignore rest of packaging
DIALOGUE WITH PATIENTS (enjoy a salad, add broccoli to pasta, • Strive to purchase foods with:
1. During the first part of an office visit try a green smoothie for breakfast or a - Only recognizable ingredients
when interviewing patients regarding well- snack). - Few total ingredients listed
ness behaviors (typically covering exercise • Start reducing intake of red and pro-  (IZLUJLVMHY[PÄJPHSJVSVYZ
and smoking), include questions about cessed meat to once per week or less. ÅH]VYPUNZZ^LL[LULYZ
diet, such as the following: • Opt for whole grains over refined (eg, YLÄULKZ\NHYZWYLZLY]H[P]LZ
• Do you eat at least 7 to 9 servings of brown rice instead of white rice, whole stabilizers, thickeners, or any
vegetables and fruits every day?64 grain pasta instead of white pasta, 100% unrecognizable names
whole grain or sprouted bread).

Six-Step Guid
Guide for Initiating and Maintaining a Nutrition Dialogue with Patients
+\YPUN
+\YPUN[OLÄYZ[WHY[ 3. Advocate simple suggestions to 5. Offer patients educational support (see Sidebar:
VMHUVMÄJL]PZP[^OLU start off. Instead of overwhelming Suggested Educational Support). Information in
interviewing patients a patient with drastic renovations the form of pamphlets, onsite nutrition counsel-
regarding wellness behav- to their current way of eating, ing, in-house cooking classes, and articles on
iors (typically covering begin with a few changes that can the Internet (see Sidebar: Suggested Internet
exercise and smoking), be made within reason. Nutrition Resources) is ideal because there are
include questions about 4. Educate patients on both the risks multiple points of reference and communication
diet. associated with inadequate intake for patients.
2. When discussing a pa- of produce and regular con- 6. Maintain a plan for follow-up and continued
tient’s treatment plan, in- Z\TW[PVUVMYLÄULKZ\NHYZHUK encouragement. It is common for people to lose
clude diet as a viable op- animal products as well as the motivation, and to become frustrated over time,
tion with positive effects advantages of emphasizing whole particularly if there is not a strong support system
(eg, improved gastrointes- plant foods. Enlist all health care in place (see Sidebar: Tips for Patient Motivation).
tinal function, decreased practitioners on the patient’s team Engage patients by ensuring they are enrolled
risk for chronic diseases, [VILH^HYLVMKPL[TVKPÄJH[PVU in classes, have family or friends participat-
and better outcomes for goals. One way to simplify this is ing alongside them, are connected to others in
existing conditions). by charting progress and goals. similar phases of transition, and have access to
continued information, as designated above.55

98 The Permanente Journal/Perm J 2016 Summer;20(3):15-082


COMMENTARY
Plant-Based Diets: A Physician’s Guide

• Enjoy 2 to 4 servings of fruit per day. 4. Educate patients on both the risks Internet Nutrition Resources) is ideal
• Include colorful vegetables with each associated with inadequate intake of because there are multiple points of ref-
meal. produce and regular consumption of erence and communication for patients.
• Try making a plant-based meal and then refined sugars and animal products as It is also important to educate pa-
an entire plant-based day by prioritizing well as the advantages of emphasizing tients on the importance of reading
previously loved plant-based dishes (eg, whole plant foods. Enlist all health labels (see Sidebar: Label-Reading
pasta primavera, bean and rice burrito, care practitioners on the patient’s team Protocol).
bean chili). to be aware of diet modification goals. 6. Maintain a plan for follow-up and
• Aim to eat a rainbow every day (foods One way to simplify this is by charting continued encouragement. It is common
naturally red, orange, yellow, green, and progress and goals. for people to lose motivation, and to be-
blue/purple). 5. Offer patients educational support come frustrated over time, particularly if
For those patients eager to make more (see Sidebar: Suggested Educational there is not a strong support system in
dramatic changes, encourage switching Support). Information in the form of place (see Sidebar: Tips for Patient Mo-
to eating a combination of vegetables, pamphlets, onsite nutrition counseling, tivation). Engage patients by ensuring
fruits, legumes, and whole grains, ac- in-house cooking classes, and articles they are enrolled in classes, have family
cording to the recommendations above. on the Internet (see Sidebar: Suggested or friends participating alongside them,
are connected to others in similar phases
of transition, and have access to contin-
Suggested Educational Support ued information.65
• Informational sheets, such as pamphlets and handouts, of meal options,
YLJPWLZU\[YPLU[ZV\YJLZHZPU;HISLZHTWSLTLHSWSHUZILULÄ[ZVMLH[PUN CONCLUSION
healthfully, additional resources, and advice based on the information in this Ultimately, it is a win-win situation—
guide will support the patient in pursuing plant-based eating at home. for patients, and for health care practi-
• Individual nutrition counseling as prescribed by a physician provides encour- tioners—to have plant-based eating as a
agement, reinforces positive outcomes, and helps address needs and concerns. powerful tool in the toolbox. Pharmaceu-
• Cooking classes, available in many communities, led by plant-based chefs or ticals are an important tool in a physician’s
registered dietitians are excellent tools for successful adaptation of healthy armamentarium, particularly in treating
cooking patterns in the home. Demonstrations and interactive methods where- acute illness, but lifestyle changes, eg diet,
by participants are able to prepare food or at least taste samples and receive can be an important and powerful tool in
recipes to take home will inspire adherence. treating chronic illness. To facilitate lower
• Art
Articles on the Internet (see Sidebar: Internet Nutrition Resources) and other health care costs and likely better health
VUSPULYLZV\YJLZVYL]LUU\[YP[PVUZWLJPÄJ>LIZP[LZHYLVWWVY[\UP[PLZ[V outcomes, let food be medicine and the
provide patients with ready-to-go information and perhaps a 24-hour interac- route of the future. Y
tive resource.
Disclosure Statement
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disclose.

Tips for Patient Motivation Acknowledgment


• Focus on optimism. Encourage every positive choice because food is deeply Mary Corrado, ELS, provided editorial assistance.
WLYZVUHSHUKTHRPUNZPNUPÄJHU[JOHUNLZPZJOHSSLUNPUNMVYTVZ[WLVWSL,]LY`IP[L
matters. How to Cite this Article
Hever J. Plant-based diets: A physician’s guide.
• Encourage the conversation with patients who are interested. The single person
3HUP-6XPPHU  
most people trust for advice and recommendations on health, diet, and well- '2,KWWSG[GRLRUJ733
ness is their physician. It is an honor and special occasion to be able to open
up the dialogue from a place of caring and support and without judgment. Of-
fer advice and an ear to help propel patients onto the path of long-term health. References
1. Graffeo C. Is there evidence to support a vegetarian
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a few new ingredients are discovered, which is like learning some new words. <RUN1<&OLQLFDO&RUUHODWLRQV-XQ>FLWHG
0DU@>DERXWS@$YDLODEOHIURPZZZ
Then enjoyable recipes and meals become part of the repertoire, which is simi- FOLQLFDOFRUUHODWLRQVRUJ"S 
lar to learning some phrases in the new language. Finally, the knowledge base 2. Orlich MJ, Singh PN, Sabaté J, et al. Vegetarian
expands so greatly that it becomes second nature to choose and prepare plant- dietary patterns and mortality in Adventist Health
6WXG\-$0$,QWHUQ0HG-XO  
IHZLKTLHSZHRPU[VZWLHRPUN[OLSHUN\HNLÅ\LU[S`/LHS[OJHYLWYHJ[P[PVULYZ '2,KWWSG[GRLRUJ
HYLPKLHSS`ZP[\H[LK[VLHZPS`N\PKLWH[PLU[Z[V^HYKÅ\LUJ`HUKZ\JJLZZPU[OPZ MDPDLQWHUQPHG
new language.  5RVHOO0$SSOHE\36SHQFHU(.H\7:HLJKWJDLQ
RYHU\HDUVLQPHDWHDWLQJ¿VKHDWLQJ
vegetarian, and vegan men and women in EPIC-

The Permanente Journal/Perm J 2016 Summer;20(3):15-082 99


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Plant-Based Diets: A Physician’s Guide

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4. Ornish D. Statins and the soul of medicine. Am J WKUHDWUHSRUW   3K\WRFKHPLFDOVWKHFDQFHU¿JKWHUVLQWKHIRRGVZH
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SDUWLFLSDQWV$P-&OLQ1XWU)HE   1RY   phytochemicals in modulating human immune
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fat vegan diet and a conventional diabetes diet in %HWKHVGD0'1DWLRQDO,QVWLWXWHVRI+HDOWK2I¿FH editors. Nutrition and immunology: principles and
the treatment of type 2 diabetes: a randomized, RI'LHWDU\6XSSOHPHQWV)HE>FLWHG SUDFWLFH7RWRZD1-+XPDQD3UHVV,QF
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/L'&DUGLRYDVFXODUGLVHDVHPRUWDOLW\DQGFDQFHU 0D\  '2,KWWSG[GRL 'HF  '2,KWWSG[GRLRUJM
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  7RQVWDG6%XWOHU7<DQ5)UDVHU*(7\SHRI status is associated with carotid atherosclerotic Nutritional and potential disease prevention
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vegetarians and vegans in EPIC-Oxford. Public 6HS 6XSSO 66 /'/FKROHVWHUROLQKXPDQVDPHWDDQDO\VLVRI
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  )HUGRZVLDQ+5%DUQDUG1'(IIHFWVRISODQW occurrence in foods, dietary exposure and health   +RZDUG%9.ULWFKHYVN\'3K\WRFKHPLFDOVDQG
based diets on plasma lipids. Am J Cardiol HIIHFWV>,QWHUQHW@%UXVVHOV%HOJLXP(XURSHDQ cardiovascular disease. A statement for healthcare
2FW  '2,KWWSG[GRL Commission Health and Consumer Protection professionals from the American Heart Association.
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GLVHDVH-$0$'HF  '2, 28. Chemicals in meat cooked at high temperatures $PHULFD¶V¿EHULQWDNHJDSVXPPDU\RIDURXQGWDEOH
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Eat food.
Not too much.
Mostly plants.

— Food Rules, Michael Pollan, b 1955, American author,


journalist, activist, and professor of journalism

The Permanente Journal/Perm J 2016 Summer;20(3):15-082 101