1. A presentation for Harvard
Medical Students Lunch and
Learn 01/25/2011
Stephan Esser MD
www.esserhealth.com

2. Plant Based Nutrition
Exploring the Myths
Engaging the Science
Stephan Esser USPTA, MD
www.esserhealth.com

3. Disclosures

4. Goals
• What are we meant for?
• Why it’s Important?
• Review Basic Definitions
• Explore some Myths
• Engage the Science
• Recommendations for self/family/friends

11. What are we meant for?
• Evolution or Creation
• Anatomy
• Physiology

12. Anatomy
• Grinding/Reciprocating Molar Teeth
• Absence of Claws
• Opposable Thumbs
• Vision: color vs B&W
• Colonic Shape:
– Convoluted vs Smooth
• Long Intestines
– 12 times the length of our torsos (about 30 feet).
– 3 times the length of its torso.

13. Physiology
• Absence of Uricase
– Present in vertebrates
• Weak Stomach Acid
– 3-4
– 1-2
• Vitamin Requirements
– Vit. C

14. Why it Matters
• Eating
– Universal
– Uniquely Modifiable
• Opportunity for Influence
– Modifiable risk factor
• 20-30% Cancer Risk WHO
• Obesity, CAD, HTN, HLD, Stroke, T2D Etc.

15. Definitions
• Carnivore:
– flesh-eating mammals that include dogs, foxes,
bears, raccoons, and cats
• Omnivore:
– One consuming both plant and animal matter

16. Definitions
• Vegetarian:
– No flesh-foods
– Pescatarians: fish
– Ovo-Lactotarians: dairy and eggs
• Vegan
– No “animal” products
– Nothing with a “face or a mother”

17. The Quandry

18. Food Basics……
• Is it safe?
– Death, Morbidity
– Deficiency
• Does it Alter Mortality/Morbidity?
• Is it Therapeutic?

19. Safety
• Sufficiency of:
– Calories
– Vitamins/Minerals
• Vit. B12, D, Omega 3,Calcium, Zinc, Selenium
• Risk of:
– Protein Deficiency
– Anemia
– Neurologic Deficits
– Osteoporosis

20. Nutrition Concerns and Health Effects of
Vegetarian Diets
Volume 109, Issue 7, Pages 1266-1282 (July 2009
Nutr Clin Pract December 7, 2010 vol. 25 no. 6 613-620
It is the position of the American Dietetic Association that appropriately
planned vegetarian diets, including total vegetarian or vegan diets,
are healthful, nutritionally adequate, and may provide health
benefits in the prevention and treatment of certain diseases. Well-
planned vegetarian diets are appropriate for individuals during all
stages of the life cycle, including pregnancy, lactation, infancy,
childhood, and adolescence, and for athletes. A vegetarian diet is defined as one that
does not include meat (including fowl) or seafood, or products containing those foods. This article reviews the current data
related to key nutrients for vegetarians including protein, n-3 fatty acids, iron, zinc, iodine, calcium, and vitamins D and
B-12. A vegetarian diet can meet current recommendations for all of these nutrients. In some cases, supplements or
fortified foods can provide useful amounts of important nutrients. An evidence-based review showed that vegetarian diets
can be nutritionally adequate in pregnancy and result in positive maternal and infant health outcomes. The results of an
evidence-based review showed that a vegetarian diet is associated with a lower risk of death from ischemic heart disease.
Vegetarians also appear to have lower low-density lipoprotein cholesterol levels, lower blood pressure, and lower rates of
hypertension and type 2 diabetes than nonvegetarians. Furthermore, vegetarians tend to have a lower body mass index
and lower overall cancer rates. Features of a vegetarian diet that may reduce risk of chronic disease include lower intakes
of saturated fat and cholesterol and higher intakes of fruits, vegetables, whole grains, nuts, soy products, fiber, and
phytochemicals. The variability of dietary practices among vegetarians makes individual assessment of dietary adequacy
essential. In addition to assessing dietary adequacy, food and nutrition professionals can also play key roles in educating
vegetarians about sources of specific nutrients, food purchase and preparation, and dietary modifications to meet their
needs.

21. Content and bioavailability of trace
elements in vegetarian diets
Am J Clin Nutr May 1994 vol. 59 no. 5 1223S-1232S
Despite the apparent lower bioavailability of
zinc, copper, manganese, and selenium in
vegetarian diets because of the high contents
of phytic acid and/or dietary fiber and the low
content of flesh foods in the diet, the trace
element status of most adult vegetarians
appears to be adequate.

22. B12
• Water soluble
• Stored in liver: enterohepatic re-circulation
• Function: -DNA synthesis
– Red cell production
– Myelin synthesis
– Immune function
– Psychiatric health
• Blood Levels
– MMA

23. B12
• VITAMIN B12 DEFICIENCY AS A WORLDWIDE PROBLEM
Nutrition: Annual Review of Nutrition Vol. 24: 299-326
• Vitamin B12 (cobalamin) deficiency in elderly patients
CMAJ • August 3, 2004; 171 (3). doi:10.1503/cmaj.1031155. (20%)
• Vitamin B12 Deficiency Due to a Strictly Vegetarian Diet in
Adolescence
CLIN PEDIATR December 1987 vol. 26 no. 12 662-663
• Reversible Subacute Combined Degeneration of the Spinal
Cord in a 14-Year-Old Due to a Strict Vegan Diet
CLIN PEDIATR July 1, 2001 40: 413-415

24. B12 Deficiency
• Strict Vegan:
– 3-10 yrs to exhaust body stores
• Other Causes:
• Bacterial overgrowth in part of the small intestine
• Malabsorption
• Inflammatory bowel disease
• Fish tapeworm infection
• Post-Surgical short gut syndrome
• Drugs such as antacids and metformin
• Lack of intrinsic factor
• Decreased stomach acidity
• Consider repletion at
– 1000-2000mcg/ day

25. Vitamin D
• ADEK
• Vitamin or Neuro-hormone?
• Functions:
– Osseous balance
– Mood
– Cardiovascular Health
– Pain
– Anti-oxidation
– Immune function
–?

27. Mushrooms
½ cup = 2 IU

28. Omega 3
• ALA/ EPA / DHA
• Function
– Inflammation
– Cardiovascular Health
– Mood
– Neuro-development

30. Protein
• Adequate
• Clinically relevant deficiency is extremely rare
• WHO 5%, 10-15% of total calories
• May benefit from 
– Elderly/Adolescent
– Pregnancy/Lactating
– Athletes

31. General Health
Is there any evidence that
Plant-based nutrition
alters morbidity or mortality?

34. Dietary habits and mortality in 11 000 vegetarians
and health conscious people: results of a 17 year
follow up
BMJ 1996; 313 : 775 (Published 28 September 1996)
Results: 2064 (19%) subjects smoked, 4627 (43%) were
vegetarian, 6699 (62%) ate wholemeal bread daily, 2948
(27%) ate bran cereals daily, 4091 (38%) ate nuts or dried fruit
daily, 8304 (77%) ate fresh fruit daily, and 4105 (38%) ate raw
salad daily. After a mean of 16.8 years follow up there were
1343 deaths before age 80. Overall the cohort had a
mortality about half that of the general population.
Within the cohort, daily consumption of fresh fruit was
associated with significantly reduced mortality from
ischaemic heart disease (rate ratio adjusted for smoking 0.76
(95% confidence interval 0.60 to 0.97)), cerebrovascular
disease (0.68 (0.47 to 0.98)), and for all causes combined
(0.79 (0.70 to 0.90)).

35. Vegetarian diets: what do we know of their
effects on common chronic diseases?
Am J Clin Nutr May 2009 vol. 89 no. 5 1607S-1612S
There is convincing evidence that vegetarians
have lower rates of coronary heart disease,
largely explained by low LDL cholesterol,
probable lower rates of hypertension and
diabetes mellitus, and lower prevalence of
obesity. Overall, their cancer rates appear to
be moderately lower than others living in the
same communities, and life expectancy
appears to be greater.

36. Hypertension

37. 90
77.3
80 70.8
65.4 64.6
Percent of Population
70
60 53.2 54.1
50 38.8 38.4
40
30 24.4
16.2
20 12.2
6.6
10
0
20-34 35-44 45-54 55-64 65-74 75+
Men Women
Prevalence of high blood pressure in Adults age 20 and older, by age and sex
(NHANES: 2003-2006). Source: NCHS and NHLBI.

38. BLOOD-PRESSURE-LOWERING EFFECT OF A
VEGETARIAN DIET: CONTROLLED TRIAL IN
NORMOTENSIVE SUBJECTS
The Lancet, Volume 321, Issue 8314, Pages 5-10I.Rouse
59 healthy, omnivorous subjects aged 25-63 years were randomly allocated to a
control group, which ate an omnivorous diet for 14 weeks, or to one of two
experimental groups, whose members ate an omnivorous diet for the first 2
weeks and a lacto-ovo-vegetarian diet for one of two 6-week experimental
periods. Mean systolic and diastolic blood pressures did not change in the
control group but fell significantly in both experimental groups
during the vegetarian diet and rose significantly in the
experimental group which reverted to the omnivorous diet.
Adjustment of the blood-pressure changes for age, obesity, heart rate, weight
change, and blood pressure before dietary change indicated a diet-related fall
of some 5-6 mm Hg systolic and 2-3 mm Hg diastolic. Although the
nutrient(s) causing these blood-pressure changes are unknown, the effects
were apparently not mediated by changes in sodium or potassium intake

39. • BLOOD PRESSURE IN VEGETARIANS
– Am. J. Epidemiol. (1974) 100 (5): 390-398.
• Vegetarian diet in mild hypertension: a
randomised controlled trial.
– 58 subjects aged 30-64 with mild untreated hypertension were allocated either to a
control group eating a typical omnivorous diet or to one of two groups eating an
ovolactovegetarian diet for one of two six week periods.
A fall in systolic blood
pressure of the order of 5 mm Hg occurred during the vegetarian
diet periods, with a corresponding rise on resuming a meat diet.

40. Cholesterol
• The Effect of Vegetarian Diets on Plasma
Lipid and Platelet Levels Arch Intern Med. 1986;146(6):1193-1197

41. Rapid reduction of serum cholesterol and
blood pressure by a twelve-day, very low fat,
strictly vegetarian diet.
J Am Coll Nutr. 1995 Oct;14(5):491-6.
During this short time period, cardiac risk factors
improved: there was an average reduction of total
serum cholesterol of 11% (p < 0.001), of blood
pressure of 6% (p < 0.001) and a weight loss of 2.5 kg
for men and 1 kg for women.

43. Food Portion Cholesterol/mg
Vegetables Unlimited 0
Fruits “ “ 0
Nuts “ “ 0
Seed “ “ 0
Grains “ “ 0
Milk (non-fat) 100g 2
Milk (whole) 100g 10
Butter 1 Tbs 31
Beef 100g 61
Salmon 100g 55
Chicken 100g 65
Shrimp 100g 126
Lobster 100g 127
Egg 100g 372
http://www.nal.usda.gov/fnic/foodcomp/search/

44. Diabetes

45. “Without preventive action, 1 in 3 children born in
2000 will develop diabetes in their lifetime.” (HHS)

47. Diabetes
• Does a vegetarian diet reduce the occurrence of
diabetes? American Journal of Public Health, Vol. 75, Issue 5 507-512
– 25,698 adult White Seventh-day Adventists identified in 1960 followed for 21 years
– vegetarians had a substantially lower risk than non-vegetarians of diabetes as an
underlying or contributing cause of death
• Fruit and Vegetable Consumption and Diabetes
Mellitus Incidence among U.S. Adults Preventive Medicine Vol 32 Iss
1 January 2001. Pages 33-39
– Appr. 10, 000 participants, highest fruit and vegetable consumption = lowest risk of
T2D
• Dietary Patterns and the Incidence of Type 2
Diabetes Am. J. Epidemiol. (2005) 161 (3): 219-227.
– 4,000 Finnish en and women, followed 23 years
– Highest consumption of fruits/vegetables in prudent diet resulted in decreased risk

48. A Low-Fat Vegan Diet Improves Glycemic Control
and Cardiovascular Risk Factors in a Randomized
Clinical Trial in Individuals With Type 2 Diabetes
Diabetes Care August 2006 vol. 29 no. 8 1777-1783
– 100 people randomized vegan vs ADA diet 22 weeks
– 43% VG 26% ADA reduced diabetes medications.
– HbA1c (A1C)  0.96 points VG 0.56 points in the ADA group
– Excluding those who changed medications, A1C fell 1.23
points in the vegan group compared with 0.38 points in the
ADA group
– Body weight  6.5 kg VG and 3.1 kg ADA
– LDL cholesterol  21.2% in the vegan group and 10.7% in the
ADA group (P = 0.02).
– urinary albumin reductions 15.9 mg/24h VG than in the ADA
group 10.9 mg/24 h

49. A low-fat vegan diet and a conventional diabetes
diet in the treatment of type 2 diabetes: a
randomized, controlled, 74-wk clinical trial
Clin Nutr May 2009 vol. 89 no. 5 1588S-1596S
Weight loss was significant within each diet group but not significantly different between groups
(−4.4 kg in the vegan group and −3.0 kg in the conventional diet group, P = 0.25) and related
significantly to Hb A1c changes (r = 0.50, P = 0.001). Hb A1c changes from baseline to 74 wk
or last available values were −0.34 and −0.14 for vegan and conventional diets, respectively
(P = 0.43). Hb A1c changes from baseline to last available value or last value before any
medication adjustment were −0.40 and 0.01 for vegan and conventional diets,
respectively (P = 0.03). In analyses before alterations in lipid-lowering medications, total
cholesterol decreased by 20.4 and 6.8 mg/dL in the vegan and conventional diet
groups, respectively (P = 0.01); LDL cholesterol decreased by 13.5 and 3.4
mg/dL in the vegan and conventional groups, respectively (P = 0.03).Conclusions: Both diets
were associated with sustained reductions in weight and plasma lipid concentrations. In an
analysis controlling for medication changes, a low-fat vegan diet appeared to improve
glycemia and plasma lipids more than did conventional diabetes diet recommendations.
Whether the observed differences provide clinical benefit for the macro- or microvascular
complications of diabetes remains to be established.

50. Toward Improved Management of NIDDM: A
Randomized, Controlled, Pilot Intervention
Using a Low-fat, Vegetarian Diet
Preventive Medicine, Volume 29, Number 2, August 1999 , pp. 87-91(5)
28% mean reduction in fasting serum glucose of the
experimental group, from 10.7 to 7.75 mmol/L (195
to 141 mg/dl), was significantly greater than the 12%
decrease, from 9.86 to 8.64 mmol/L (179 to 157 mg/
dl), for the control group (P < 0.05). The mean weight
loss was 7.2 kg in the experimental group, compared
to 3.8 kg for the control group (P < 0.005).

52. The calorically restricted low-fat nutrient-dense diet in Biosphere
2 significantly lowers blood glucose, total leukocyte count,
cholesterol, and blood pressure in humans
PNAS December 1, 1992 vol. 89 no. 23 11533-11537
• Biosphere 2 is a 3.15-acre space containing an ecosystem that is energetically open (sunlight,
electric power, and heat) but materially closed, with air, water, and organic material being
recycled. Since September 1991, eight subjects (four women and four men) have been sealed
inside, living on food crops grown within. Their diet, low in calories (average, 1780 kcal/day; 1
kcal = 4.184 kJ), low in fat (10% of calories), and nutrient-dense, conforms to that
which in numerous animal experiments has promoted health, retarded aging, and extended
maximum life span. We report here medical data on the eight subjects, comparing preclosure data
with data through 6 months of closure. Significant changes included: (i) weight, 74 to 62 kg
(men) and 61 to 54 kg (women); (ii) mean systolic/diastolic blood pressure
(eight subjects), 109/74 to 89/58 mmHg (1 mmHg = 133 Pa); (iii) total serum
cholesterol, from 191 +/- 11 to 123 +/- 9 mg/dl (mean +/- SD; 36% mean
reduction), and high density lipoprotein, from 62 +/- 8 to 38 +/- 5 (risk ratio
unchanged); (iv) triglyceride, 139 to 96 mg/dl (men) and 78 to 114 mg/dl (women); (v)
fasting glucose, 92 to 74 mg/dl; (vi) leukocyte count, 6.7 to 4.7 x 10(9) cells per
liter. We conclude that drastic reductions in cholesterol and blood pressure may be
instituted in normal individuals in Western countries by application of a carefully
chosen diet and that a low-calorie nutrient-dense regime shows physiologic features in
humans similar to those in other animal species.

54. Vegetarian diet: panacea for modern
lifestyle diseases?
QJM (1999) 92 (9): 531-544.doi: 10.1093/qjmed/92.9.531
There are few adverse effects, mainly
increased intestinal gas production
and a small risk of vitamin B12
deficiency.

55. Other Reasons
• Food and Agriculture Organization of the United Nations
– Livestock use 30% of the Earth’s Land Surface
– Produce 18% of greenhouse gases
• 70+ % of antibiotics used in US are for livestock
• 80+% of all wheat, corn, rye and oats for livestock
• Cruelty/Abuse etc
• Loss of Ocean Species/Pollution of waterways
– http://www.fao.org/newsroom/en/news/2006/1000448/index.html
– http://www.nytimes.com/2009/07/14/health/policy/14fda.html

56. Take Homes
• Plant Based Diets:
– Are Safe when adequately planned
– Minimal, readily addressed ‘risk’
– Have Therapeutic Benefit
• Obesity
• Heart Disease
78% Health Care Expenditures are consumed by
• High Blood Pressure of chronic disease
the management
• High Cholesterol Holman, H. JAMA 2004 Sep 1; 292:1057-1059
• Type 2 Diabetes

57. Points to Consider
• Repletion in “at Risk” Populations
– B12
– Vitamin D
• Supplementation
– Consider Omega 3’s

58. Knowledge = Responsibility
• Do it!
• Have fun with it!
• Celebrate Colors, Flavors!
• Achieve your best health!
• Share it and Inspire Others!

59. Thank You!

60. www.abeforfitness.com

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