A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Bonnie Farmer, M.S., RD: PlantWise Nutrition Consulting, LLC Brian T Larson, PhD: JG Consulting Services, LLC, Victor L Fulgoni, PhD: Nutrition Impact, LLC Alice Jo Rainville, PhD, RD: Eastern Michigan University (EMU) George U Liepa, PhD: EMU JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

Background Study overview Population-based studies have shown that: A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Study overview Background Population-based studies have shown that: Vegetarians have lower body mass index than non-vegetarians, suggesting that vegetarian diets may be an approach for weight management. Vegetarian dietary patterns are lower in calories than non-vegetarian, suggesting a version of low calorie dieting. A perception exists that vegetarian diets are deficient in certain nutrients. The purpose of this study was to compare dietary quality of vegetarians, non- vegetarians and dieters, and to test the hypothesis that a vegetarian diet would not compromise nutrient intake when used as a method for weight management. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

Study Design Baseline data A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Baseline data Study Design Cross-sectional analysis of NHANES (1999-2004) dietary and anthropometric data. Adults ages 19 years and older, excluding pregnant and lactating women (N=13,292). Lacto-ovo vegetarian diets were portrayed by intakes of participants who did not eat meat, poultry, or fish on the day of the survey (n=851). Weight loss diets were portrayed by intakes of participants who consumed 500 kcal less than their estimated energy requirements (n=4,635). Mean nutrient intakes and BMIs were adjusted for energy, gender, and ethnicity. Using analysis of variance, all vegetarians were compared to all non- vegetarians, dieting vegetarians to dieting non-vegetarians, and non-dieting vegetarians to non-dieting non-vegetarians. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Adjusted mean nutrient intakes for vegetarians and non-vegetarians, ages 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day food intake. b Energy intake adjusted for gender and ethnicity; all other nutrients adjusted for energy, gender, and ethnicity. c Retinol activity equivalents. d α-tocopherol. e Dietary folate equivalents. ** p < 0.01 within vegetarian and non-vegetarian comparisons. Farmer B, et al. J Am Diet Assoc. 2011; 111 (June). JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Adjusted mean nutrient intakes for vegetarians and non-vegetarians, ages 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day food intake. b Energy intake adjusted for gender and ethnicity; all other nutrients adjusted for energy, gender, and ethnicity. c Retinol activity equivalents. d α-tocopherol. e Dietary folate equivalents. ** p < 0.01 within vegetarian and non-vegetarian comparisons. Farmer B, et al. J Am Diet Assoc. 2011; 111 (June). JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Adjusted mean nutrient intakes for vegetarians and non-vegetarians, ages 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day food intake. b Energy intake adjusted for gender and ethnicity; all other nutrients adjusted for energy, gender, and ethnicity. c Retinol activity equivalents. d α-tocopherol. e Dietary folate equivalents. ** p < 0.01 within vegetarian and non-vegetarian comparisons. Farmer B, et al. J Am Diet Assoc. 2011; 111 (June). JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Correlation matrix Comparison of mean vitamin A intakes for vegetarians, non-vegetarians, and dieters, ages 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day nutrient intake adjusted for energy, gender, and ethnicity DV= dieting vegetarian NDV= non-dieting vegetarian DNV= dieting non-vegetarian NDNV= non-dieting non-vegetarian JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Comparison of mean vitamin C intakes for vegetarians, non-vegetarians, and dieters, ages 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day nutrient intake adjusted for energy, gender, and ethnicity DV= dieting vegetarian NDV= non-dieting vegetarian DNV= dieting non-vegetarian NDNV= non-dieting non-vegetarian JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Figure Comparison of mean vitamin E intakes for vegetarians, non-vegetarians, and dieters, ages 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day nutrient intake adjusted for energy, gender, and ethnicity DV= dieting vegetarian NDV= non-dieting vegetarian DNV= dieting non-vegetarian NDNV= non-dieting non-vegetarian JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Comparison of mean fiber intakes for vegetarians, non-vegetarians, and dieters ages, 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day nutrient intake adjusted for energy, gender, and ethnicity DV= dieting vegetarian NDV= non-dieting vegetarian DNV= dieting non-vegetarian NDNV= non-dieting non-vegetarian JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Figure Comparison of mean iron intakes for vegetarians, non-vegetarians, and dieters ages, 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day nutrient intake adjusted for energy, gender, and ethnicity DV= dieting vegetarian NDV= non-dieting vegetarian DNV= dieting non-vegetarian NDNV= non-dieting non-vegetarian JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Figure Comparison of mean zinc intakes for vegetarians, non-vegetarians, and dieters ages, 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day nutrient intake adjusted for energy, gender, and ethnicity DV= dieting vegetarian NDV= non-dieting vegetarian DNV= dieting non-vegetarian NDNV= non-dieting non-vegetarian JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination (NHANES) 1999-2004 Figure Healthy Eating Index scores for vegetarians, non-vegetarians, and dieters, ages 19 years and older (NHANESa 1999-2004) a National Health and Nutrition Examination Survey, one day food intake. b Solid Fat, Alcohol, and Added Sugar. ** p < 0.01 within vegetarian and non-vegetarian comparisons. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination (NHANES) 1999-2004 Figure Healthy Eating Index scores for vegetarians, non-vegetarians, and dieters, ages 19 years and older (NHANESa 1999-2004). a National Health and Nutrition Examination Survey, one day food intake. b Solid Fat, Alcohol, and Added Sugar. ** p < 0.01 within vegetarian and non-vegetarian comparisons. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).

Conclusion Study overview A Vegetarian Dietary Pattern as a Nutrient Dense Approach for Weight Management: An Analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2004 Study overview Conclusion Adjusted mean intakes for all vegetarians in the present study suggest that they did not have an increased risk for lower nutrient intakes when compared to all non-vegetarians. Although vegetarians in this study had higher intakes of vitamins E and A, calcium, magnesium, and fiber than non-vegetarians, improvements are necessary for both groups. It may be necessary for vegetarians to be more aware of zinc intake, and dietitians should assist vegetarians, particularly those who are new to this eating pattern, in planning menus that incorporate good sources of zinc, such as legumes, seeds, and fortified foods. There may be a critical point at which decreasing the caloric level of a vegetarian diet would result in poor diet quality and nutrient intakes below recommendations; however, this eating pattern may be a way to maintain a nutrient dense diet while decreasing energy intake enough to maintain a healthy weight. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION Farmer B, et al. J Am Diet Assoc. 2011; 111 (June).