Dietary patterns and mortality in adventist health study 2

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In women, there were no signifi- sults. Overall HRs for vegetarians were then 0. The adjustment for body mass in- ity, and other mortality were moderately less than 1. Results dex did not consistently move results toward the null.

Mor- not included in table for stroke were, for both sexes com- tality results adjusted for body mass index affected statistical bined, HR, 1.

For all vegetarians com- and for women, 1. Pesco-vegetarians had signifi- ity in both sexes combined HR, 0. For cantly reduced risk in both sexes combined for all-cause specific vegetarian dietary patterns compared with nonveg- mortality HR, 0. Vegetarian diets have been associ- 0. Additional adjustment by dietary energy intake factors,17,,36,37 and nutrient profiles of the vegetarian di- resulted in negligible changes.

These apparent protective asso- ciations seem consistent with previously published findings showing an association of vegetarian diets with reduced risk Discussion of incident diabetes25 and of prevalent diabetes, hyperten- These results demonstrate an overall association of vegetar- sion, and metabolic syndrome. They also demonstrate some ity were detected.

The heterogeneous nature of cancer may ob- associations with lower mortality of the pesco-vegetarian, scure specific diet-cancer associations in analyses of com- jamainternalmedicine. J84, 29 deaths ; renal renal failure, ICD N, 40 deaths ; and endocrine c Also adjusted by sex male and female , menopause premenopausal diabetes mellitus, ICD E, 67 deaths. Early follow-up analysis may thus have bias toward the insufficient power to detect weaker associations at early follow- null, and true associations may remain undetected.

Ob- up. Early analyses of vegetarian dietary patterns and cancer served mortality benefits may be affected by factors related incidence in AHS-2 demonstrated significantly reduced risks to the conscious lifestyle choice of a vegetarian diet other than of female-specific and gastrointestinal cancers. Potential for uncontrolled confounding Effects were generally stronger and more significant in men remains. Dietary patterns may change over time, whereas the than women. Previous studies among Adventists have analysis relies on a single measurement of diet at baseline.

Cau- demonstrated effect modification by sex of the association of tion must be used in generalizing results to other populations vegetarian diets with reduced ischemic heart disease mortal- in which attitudes, motivations, and applications of vegetar- ity. It is possible that within dietary groups the diets of men ian dietary patterns may differ; dietary pattern definitions used and women differ in important ways; however, a recent may not reflect some common uses of these terms.

Alternatively, of specific foods and nutrients that characterize the different the biological effect of dietary factors on mortality may be dif- diet-pattern groups is a major future goal of the AHS-2 study.

Future analysis will evaluate pos- Later follow-up may yield more statistically robust results; al- sible effect modification by sex for particular foods or nutri- low direct comparisons between vegetarian groups and en- ents, which may suggest sex-specific mechanisms.

In both studies, the nutrient profiles of vegetar- unlikely; the shared religious affiliation of the cohort, which ians differ in important ways from those of nonvegetarians, may lead to greater homogeneity across several possible un- with vegetarians especially vegans consuming less satu- measured confounders, enhancing internal validity; and pre- rated fat and more fiber. For instance, the vegetarians in our study consume more fi- This analysis is limited by relatively early follow-up.

We believe that per- vegetarian dietary patterns were associated with lower mor- ceived healthfulness of vegetarian diets may be a major mo- tality. The evidence that vegetarian diets, or similar diets tivator of Adventist vegetarians. More important, other large with reduced meat consumption, may be associated with a cohort studies have linked increased red and processed meat lower risk of death should be considered carefully by indi- consumption to higher mortality,18,19,45 and our findings build viduals as they make dietary choices and by those offering on this work by demonstrating reduced mortality in those con- dietary guidance.

Dietary patterns and survival in older Dutch AHS Am J Clin Nutr. Published Online: June 3, Nut consumption, vegetarian diets, mortality. Eur J Epidemiol. Dietary evidence from epidemiologic studies.

Am J Clin patterns and survival of older Europeans: the accuracy of the data analysis. Risk factors for Investigation into Cancer and Nutrition. Am J Epidemiol. Rochtchina E, Mitchell P. Consumption of all-cause and cause-specific mortality: two cohort Drafting of the manuscript: Orlich, Singh, and polyunsaturated fatty acids, fish, and nuts and risk studies. Ann Intern Med. Mortality Critical revision of the manuscript for important ;93 5 Ten years of life: is it a findings from a collaborative analysis of 5 Beeson, and Fraser.

Arch Intern Med. Statistical analysis: Orlich, Singh, Fan, Beeson, and Obtained funding: Fraser. Fraser GE. Differences in overall mortality in cancer, ischemic heart disease, and all-cause Knutsen and Beeson. Seventh-day Adventists.

A ;70 3 suppl SS. Conflict of Interest Disclosures: Dr Orlich reports receiving a small honorarium from the Northern prospective study of dietary patterns and mortality Meat intake and mortality: a partially defray travel expenses for a speaking Arch engagement at which he gave an overview and 7. Intern Med. Red meat small honorarium from the Southern California mortality: twenty-one—year follow-up on 27, consumption and mortality: results from 2 Conference of Seventh-day Adventists for a adult Seventh-day Adventists.

Adherence to a Mediterranean diet should we eat? N Engl J Med. Japanese-American men. Greek EPIC prospective cohort study. K, Fraser GE. Vegetarian diets and blood pressure Disclaimer: The views expressed in this article are ;b Public Health Nutr. Hypertension authors, and endorsement by the NCI, NIFA, or relation to year mortality in elderly European and blood pressure among meat eaters, fish eaters, their contractors or subcontractors is not intended subjects: the HALE project.

Eur J Clin Nutr. Public nor should it be inferred. Health Nutr. Previous Presentation: These findings were Accruing Am J Clin Health Study 2.

Diabetes Care. Research Associate, Adventist Health Studies, jamainternalmedicine. Vegetarian diets and the incidence of type 2 diabetes. Fraser GE, Yan R. Guided multiple imputation of cancer in a low-risk population [published online Cancer Epidemiol Biomarkers Vegetarian diets and incidence of ;18 2 Nutr Diet as primordial prevention in Metab Cardiovasc Dis.

Beeson WL, Chan J. Missing data in a long food Seventh-day Adventists. Prev Med. Diet and the risk of coronary heart frequency questionnaire: are imputed zeroes 2 :SS In: Fraser GE, ed. Diet, Life Expectancy, and correct? A Chronic Disease. Team RDC. R: a language and environment for possible protective effect of nut consumption on Press; Chronic disease among Seventh-day Hmisc: Harrell Meat Adventists, a low-risk group: rationale, Miscellaneous.

Prev methodology, and description of the population. Accessed April 29, Health benefits Proc Nutr Soc. Mortality in British Vegetarian diets: what do we know SS. Cohort Clin Nutr. Int J Differences and similarities in dietary pattern and Diet, other risk factors, and aging.

In: Epidemiol. Fraser GE, ed. Diet, Life Expectancy, and Chronic nutrient profiles between the sexes and blacks and Accessed December 1, Robert B. Baron, MD, MS As a graduate student studying nutrition in the early s, I a well-done, prospective cohort study of more 70 Seventh- became a vegetarian a lacto-ovo vegetarian, to be exact.

Vegetarian diets also were associ- health outcomes on meat-free diets. Similarly, early reports ated with reductions in cardiovascular mortality and several suggested that meat production was wasteful and had other categories of cause-specific mortality. The mainstream nutrition The study, however, illustrates several challenges in try- community, though, strongly resisted the growing vegetar- ing to answer the core question of whether vegetarian diets ian movement, often raising concerns about nutritional improve health outcomes.

Like all observational studies, deficiencies with the most extreme types of vegetarian this one provides associations, not cause-and-effect evi- diets. By the time I was a third-year medical student, I had dence. Although the authors use state-of-the-art returned to eating meat, given the lack of vegetarian options approaches to adjustment for potential confounders, one in hospital cafeterias.

As my clinical training and experience can never be sure that there are not other factors influenc- increased, though, I became convinced that patients in any ing the association between vegetarian diets and mortality. Vegetarian options are increasingly avail- Another weakness of the study is that it relies on a single able in US hospitals, restaurants, and social events.

But the ques- measurement of dietary intake at baseline and, as the au- tion remains: Can vegetarian diets improve health outcomes? The study also is limited by the great evidence that vegetarian diets are associated with improved variety of diets consumed by those identified as vegetarians.

International Journal of Food Sciences and Nutrition Adherence to a Mediterranean diet by vegetarians and vegans as compared to omnivores View supplementary material. American Journal of Clinical Nutrition Vitamin B and homocysteine status among vegetarians: a global perspective.

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By using the site you are agreeing to this as outlined in our privacy notice and cookie policy. Abstract Available from publisher site using DOI. A subscription may be required. Segovia-Siapco G 1 ,. Affiliations 2 authors 1. This article has been corrected. See Eur J Clin Nutr. Share this article Share with email Share with twitter Share with linkedin Share with facebook.

Abstract Knowledge in the role of plant-based diets on health had been shaped in part by cohort studies on vegetarians. We revisited publications from two ongoing longitudinal studies comprising large proportions of vegetarians-the Adventist Health Study-2 AHS-2 and the European Prospective Investigation into Cancer and Nutrition-Oxford EPIC-Oxford -to describe the food and nutrient intake, health effects, and environmental sustainability outcomes of the dietary patterns identified in these studies.

The vegetarian diet groups in both cohorts have essentially no meat intake, lower intake of fish and coffee, and higher intakes of vegetables and fruits compared to their non-vegetarian counterparts.

In the AHS-2 cohort, vegetarians have higher intake of whole grains, legumes, nuts, and seeds. Pesco-vegetarians in the AHS-2 cohort had significantly lower mortality risk from all causes and ischemic heart disease while EPIC-Oxford fish-eaters had significantly lower all-cancers mortality risk than their non-vegetarians counterparts. Morbidity risks and prevalence rates for other chronic diseases were differentially reported in the two cohorts but vegetarians have lower risk than non-vegetarians.

The beneficial health outcomes and reduced carbon footprints make the case for adoption of vegetarian diets to address global food supply and environmental sustainability. Full text links Read article at publisher's site DOI : References Articles referenced by this article 1 The environmental cost of protein food choices. Smart citations by scite.

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Comparison of polyphenol intakes according to distinct dietary patterns and food sources in the Adventist Health Study-2 cohort. Association between vegetarian diets and cardiovascular risk factors in non-Hispanic white participants of the Adventist Health Study The long-term health of vegetarians and vegans. Joining Europe PMC. Tools Tools overview. ORCID article claiming. Journal list.

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Journal of Nutritional Science. View 5 excerpts, cites results and background. Patterns of plant and animal protein intake are strongly associated with cardiovascular mortality: the Adventist Health Study-2 cohort. Tharrey , F.

Mariotti , Andrew Mashchak , P. Barbillon , M. Delattre , G. International journal of epidemiology. View 1 excerpt, cites background. Frontiers in Nutrition. View 2 excerpts, cites background and results. Dietary patterns related to total mortality and cancer mortality in the United States Marcela R. Entwistle , Donald W.

Schweizer , Ricardo Cisneros Medicine. Vegetarian diet, Seventh Day Adventists and risk of cardiovascular mortality: a systematic review and meta-analysis. Kwok , Saadia Umar , P. Myint , M. Mamas , Y. Loke Medicine. International journal of cardiology.

View 4 excerpts, cites background. The aim of this review is to assess the effects of … Expand. View 2 excerpts, cites background. Estruch Medicine. Clinical nutrition. Cai , X. Zheng Medicine. Vegetarian diets and incidence of diabetes in the Adventist Health Study Tonstad , K. Stewart , K. Oda , M. Batech , R. Herring , G. Nutrition, metabolism, and cardiovascular diseases : NMCD. Rizzo , J. Jaceldo-Siegl , G. Diabetes Care. Dietary patterns and survival in older Dutch women. Waijers , M.

The American journal of clinical nutrition. Jaceldo-Siegl , Jing Fan , G. Public Health Nutrition. The Adventist Health Study 2 N. Rizzo , K. Vegetarian groups tended to be older, more highly educated, and more likely to be married, to drink less alcohol, to smoke less, to exercise more, and to be thinner.

The proportion of blacks was highest among pesco-vegetarians and lowest in lacto-ovo—vegetarians. Of postmenopausal women, far fewer vegans were receiving hormone therapy. Mean reported duration of adherence to current dietary pattern not included in Table 2 was 21 years for vegans, 39 years for lacto-ovo—vegetarians, 19 years for pesco-vegetarians, 24 years for semi-vegetarians, and 48 years for nonvegetarians.

The mean SD follow-up time was 5. Table 3 gives the age-sex-race standardized mortality rates by dietary pattern. Vegans, lacto-ovo—vegetarians, and pesco-vegetarians had significantly lower mortality rates compared with nonvegetarians. Table 1 reports the comparison of multivariate-adjusted risk of death for all vegetarians combined with that for nonvegetarians.

Vegetarians had 0. In men, the hazard ratio HR was 0. For men, CVD mortality 0. In women, there were no significant reductions in these causal categories of mortality, although the effect estimates for IHD mortality, cancer mortality, and other mortality were moderately less than 1.

Table 4 reports the comparison of the multivariate-adjusted risk of death for 4 categories of vegetarians compared with nonvegetarians. In men and women combined, vegetarians had a significantly reduced risk of renal mortality HR, 0.

Forty of 67 renal deaths were associated with renal failure for both sexes combined, HR, 0. Sixty-seven of endocrine deaths were associated with diabetes mellitus for both sexes combined, HR, 0. A sensitivity analysis in which body mass index was added to the model generally had only a modest effect on the results. Overall HRs for vegetarians were then 0.

The adjustment for body mass index did not consistently move results toward the null. Mortality results adjusted for body mass index affected statistical significance in the following instances.

Additional adjustment by dietary energy intake resulted in negligible changes. These results demonstrate an overall association of vegetarian dietary patterns with lower mortality compared with the nonvegetarian dietary pattern.

They also demonstrate some associations with lower mortality of the pesco-vegetarian, vegan, and lacto-ovo—vegetarian diets specifically compared with the nonvegetarian diet. Some associations of vegetarian diets with lower cardiovascular mortality and lower noncardiovascular, noncancer mortality were observed. Vegetarian diets have been associated with more favorable levels of cardiovascular risk factors, 17 , 22 - 25 , 36 , 37 and nutrient profiles of the vegetarian dietary patterns suggest possible reasons for reduced cardiovascular risk, such as lower saturated fat and higher fiber consumption.

These apparent protective associations seem consistent with previously published findings showing an association of vegetarian diets with reduced risk of incident diabetes 25 and of prevalent diabetes, hypertension, and metabolic syndrome. No significant associations with reduced cancer mortality were detected. The heterogeneous nature of cancer may obscure specific diet-cancer associations in analyses of combined cancer mortality, and lack of significance may reflect insufficient power to detect weaker associations at early follow-up.

Early analyses of vegetarian dietary patterns and cancer incidence in AHS-2 demonstrated significantly reduced risks of female-specific and gastrointestinal cancers. Effects were generally stronger and more significant in men than women. Previous studies 40 - 42 among Adventists have demonstrated effect modification by sex of the association of vegetarian diets with reduced ischemic heart disease mortality.

It is possible that within dietary groups the diets of men and women differ in important ways; however, a recent evaluation 38 of the nutrient profile of the dietary patterns in this cohort did not reveal striking differences. Alternatively, the biological effect of dietary factors on mortality may be different in men and women. Future analysis will evaluate possible effect modification by sex for particular foods or nutrients, which may suggest sex-specific mechanisms.

Strengths of this study include the large number of participants consuming various vegetarian diets; the diverse nature of this cohort in terms of sex, race, geography, and socioeconomic status, enhancing generalizability; the low use of tobacco and alcohol, making residual confounding from these unlikely; the shared religious affiliation of the cohort, which may lead to greater homogeneity across several possible unmeasured confounders, enhancing internal validity; and precise dietary pattern definitions based on measured food intake rather than self-identification of dietary patterns.

This analysis is limited by relatively early follow-up. If dietary patterns affect mortality, they may do so with moderate effect sizes, via complex pathways, and with long latency periods. Early follow-up analysis may thus have bias toward the null, and true associations may remain undetected.

Observed mortality benefits may be affected by factors related to the conscious lifestyle choice of a vegetarian diet other than dietary components. Potential for uncontrolled confounding remains. Dietary patterns may change over time, whereas the analysis relies on a single measurement of diet at baseline. Caution must be used in generalizing results to other populations in which attitudes, motivations, and applications of vegetarian dietary patterns may differ; dietary pattern definitions used may not reflect some common uses of these terms.

Further study of the possible association with mortality of specific foods and nutrients that characterize the different diet-pattern groups is a major future goal of the AHS-2 study. The lack of similar findings in British vegetarians 28 remains interesting, and this difference deserves careful study. In both cohorts, the nonvegetarians are a relatively healthy reference group. In both studies, the nutrient profiles of vegetarians differ in important ways from those of nonvegetarians, with vegetarians especially vegans consuming less saturated fat and more fiber.

We believe that perceived healthfulness of vegetarian diets may be a major motivator of Adventist vegetarians. More important, other large cohort studies have linked increased red and processed meat consumption to higher mortality, 18 , 19 , 45 and our findings build on this work by demonstrating reduced mortality in those consuming low-meat dietary patterns. Notably, the findings of the present study are similar to those of prior North American Adventist cohorts, demonstrating a consistent association over several decades and replicating prior results in a population with greater geographic and ethnic diversity.

In conclusion, in a large American cohort, we found that vegetarian dietary patterns were associated with lower mortality. The evidence that vegetarian diets, or similar diets with reduced meat consumption, may be associated with a lower risk of death should be considered carefully by individuals as they make dietary choices and by those offering dietary guidance.

Corresponding Author: Michael J. Published Online: June 3, Author Contributions: Drs Orlich and Fraser had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conflict of Interest Disclosures: Dr Orlich reports receiving a small honorarium from the Northern California Conference of Seventh-day Adventists to partially defray travel expenses for a speaking engagement at which he gave an overview and update of Adventist Health Studies research and a small honorarium from the Southern California Conference of Seventh-day Adventists for a speaking engagement at which he lectured on lifestyle approaches for chronic disease prevention.

The ideas and opinions expressed herein are those of the authors, and endorsement by the NCI, NIFA, or their contractors or subcontractors is not intended nor should it be inferred. Previous Presentation: These findings were presented in a brief oral presentation at the Society for Epidemiologic Research annual meeting; June 28, ; Minneapolis, Minnesota.

Table 1. View Large Download. Table 2. Table 3. Table 4. Table 5. Nut consumption, vegetarian diets, ischemic heart disease risk, and all-cause mortality: evidence from epidemiologic studies. Am J Clin Nutr. PubMed Google Scholar. Am J Epidemiol. PubMed Google Scholar Crossref.

Consumption of polyunsaturated fatty acids, fish, and nuts and risk of inflammatory disease mortality. Ten years of life: is it a matter of choice? Arch Intern Med. Differences in overall mortality in the elderly may be explained by diet. A prospective study of dietary patterns and mortality in Chinese women.

Association between reported diet and all-cause mortality: twenty-one—year follow-up on 27, adult Seventh-day Adventists. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. Comparison of three different dietary scores in relation to year mortality in elderly European subjects: the HALE project. Eur J Clin Nutr. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis.

Dietary patterns and survival in older Dutch women. Healthy food and nutrient index and all cause mortality. Eur J Epidemiol. Public Health Nutr. Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies.

Ann Intern Med. Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies. Fraser GE. Associations between diet and cancer, ischemic heart disease, and all-cause mortality in non-Hispanic white California Seventh-day Adventists. Meat intake and mortality: a prospective study of over half a million people.

Red meat consumption and mortality: results from 2 prospective cohort studies. How much should we eat? Hypertension and blood pressure among meat eaters, fish eaters, vegetarians and vegans in EPIC-Oxford. Vegetarian dietary patterns are associated with a lower risk of metabolic syndrome: the Adventist Health Study 2.

Diabetes Care. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Vegetarian diets and incidence of diabetes in the Adventist Health Study Nutr Metab Cardiovasc Dis.

Diet and the risk of coronary heart disease.