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The Adventist Health Studies: A contribution to preventive medicine. 1958-2010 IAD Health Summit, 2013 Tricia Penniecook, MD, MPH Dean, Loma Linda University School of Public Health Adventists – attractive to study Wide range of lifestyle • Exercise • Diet (from average US to vegans). ~ Some with: • High intake of soy, nuts, legumes • Very high fruit/vegetable intake • No meat/fish intake • No dairy intake • No confounding by smoking or alcohol • Fairly homogenous on “other” factors • church attendance, social support, etc. » Adventist Mortality Study, 1958 » Dr. Hardinge » Prospective study of 22,940 California Adventists » 5-year intensive follow-up and 25-year informal follow-up » For first five years, American Cancer Society had similar study with volunteers as well » The similarities between the groups were important because it has been found that individuals who volunteer for such studies tend to be healthier than the general population, and those in the upper socio-economic classes tend to have lower rates of disease overall. Thus, the Adventist Mortality Study and the American Cancer Society Study provide a reasonably fair comparison between Adventists and non-Adventists. Findings of AHS-1 vs. ACS study » Overall : 60% SDA men and 76% SDA women » Lung cancer: 21% » Colo-rectal cancer: 62% » Breast cancer: 85% » Prostate cancer: 92% » Lymphoma or leukemia: 86% for men and 100% for women » Coronary heart disease: 66% for men and 98% for women » Stroke: 72% for men and 82% for women » All deaths: 66% for men and 88% for women Comparison between SDA’s and nonsmokers All cancers: 85% for men and 78% for women Lung cancer: 67% for men and 42% for women Colo-rectal cancer: 67% for men and 42% for women Breast cancer: 81% Prostate cancer: 93% Lymphoma and leukemia: 93% for men and 89% for women Coronary heart disease: 76% for men, 101% for women Stroke: 75% for men and 79% for women All causes: 79% for men and 91% for women Adventist Health Studies in other parts of the world » Norway, 1960, the national census in Norway showed an existing population of 7,173 known Adventist. Studies compare them with other nationals with follow-up till 1986. » Adventist men were at 82 percent of the expected death rates for the general population, and Adventist women were at 95 percent. » Deaths due to cardiovascular disease in individuals less than 75 years of age: Adventist men 65 % and Adventist women at 90%. » Cancer deaths for Adventist men were at 78 percent and at 94 percent of expectation for Adventist women. More around the world… » Dutch Adventists, 1968 - 1977, 4000 members (Berkel and deWaard). » Compared to the total expected death rate, Dutch Adventists were at 45%. » Cancer deaths—50% » Breast cancer-- 50%; lung cancer --45%; colo-rectal cancer-- 43 %; and stomach cancer-- 59%. » Cardiovascular disease—41% » Ischemic heart disease—43%; for stroke—54%. Fundamental Weakness » Nonfatal events were not measured » What is it about the SDA lifestyle that enabled Adventists to live longer? » Would lifestyle differences among Adventists themselves produce different risks for contract specific diseases-both fatal and nonfatal? » The Adventist Mortality Study raised a number of interesting questions. What was it about the Adventist lifestyle that enabled Adventists to live longer? Would lifestyle differences among Adventists themselves produce different risks for contracting specific diseases-both fatal and nonfatal? Adventist Health Study-1, 1974 » Which components of lifestyle are protectors » Data reporting nonfatal events as well. » More detailed investigation of diet. » Started as primarily cancer investigation, cardiovascular component was added in 1981 » Two questionnaires, two years apart: 75% from White Non Hispanic subjects » Incredible response rates of 90-99.5% How the population was chosen » The initial mailing of 63,530 census questionnaires was sent to every Adventist household in California in an attempt to enroll every adult in these households over the age of 25 years. » Two years later, a second more extensive lifestyle questionnaire was sent to those who had responded to the census questionnaire. This second questionnaire included previous medical history, drug therapy, more than 60 dietary questions, a variety of psychosocial questions, and questions about physical activity. The response rate from White non-Hispanic subjects was the highest of any ethnic group at 75 percent, and numbered 34,198 individuals. » When the gathering of follow-up data was officially concluded for the Adventist Health Study, 32,000 hospitalizations were reported, representing 28,000 hospital charts on 18,053 different individuals. In California, 698 different hospitals were involved, and 960 hospitals out-of-state. » Researchers from many studies of this type are pleased when they receive a response rate of 50 percent. The rate of returns from the annual follow-up questionnaires which asked about hospitalization, critical to the entire research process, received response rates in excess of 90 percent, usually above 95 percent. The final and most critical mailing received an incredible 99.5 percent response. Descriptive data » Average age: 51 years for men and 53 for women. » Hypertension levels close to expected » Virtually no smokers » Two thirds women, well-educated » Half ate meat less than once a week AHS-1: Dietary findings 21% consume beef more than twice/week 10% ate fish once/week 35% drink coffee 77% consume primarily whole wheat bread 66% eat nuts at least once/week 24% eat nuts more than four times/week 81% eat fruit at least once a day, 49% eat fruit at least three times/day Life Expectancy AHS-1 1976-88 .Cal 81.2 Years of life SDA Veg. SDA 83.9 83.3 79.5 73.9 Males © 2004 Adventist Health Study-2 Females 85.7 Fatal Heart Disease Californians & Adventists 1976-88 Californians SDA Males SDA Females 45-54 55-59 60-64 Years © 2004 Adventist Health Study-2 65-69 70-74 Diet & Weight AHS-1 1976-88 ,Veg .Semi Veg 183 169 176 Weight in pounds Male © 2004 Adventist Health Study-2 .Non Veg 152 145 139 Female Weight Differences Between Vegetarians and Non-Vegetarians Vegan Pounds Lacto-ovo Pesco-veg Semi-veg Non-veg 200 180 160 161 171 188 180 164 177 193 181 161 140 146 120 100 0 Female 5’ 6” tall Male 5’ 10” tall Relative Period Incidence of Hypertension requiring Medication 196076 by Meat intake (AMS and AHS-1) RR 2.5 2.24 2 1.82 1.5 1 1 0.5 0 Never < 1/week 1+/week Prevalent Treated High Blood Pressure and Diet % Reporting Hypertension Vegan 25% 20% 15% 10% 5% 0% Lacto-ovo Pesco-veg Semi-veg Non-veg AHS-1 Cancer findings Fruit is protective-those who consume it more than once a day, 25% lung cancer of those less than 3 times a week Many-fold protection against stomach cancer Legumes: 1/30th risk of pancreatic cancer Dates, raisins and dried fruit: 1/5th risk of pancreatic cancer Beans: 42% lower risk of colon cancer Beef: more than two-fold risk of bladder cancer Dried fruit: decrease prostate cancer by 40% Meat intake and risk of different incident cancers. AHS-1. RR 2.5 P (t): 0.01 ns <.01 0.02 2 1.5 Never week/1 < 1 week/+1 0.5 0 Colon Colon Prostate Postmenopausal Ovary Ovary Ovary Fruit & Lung Cancer AHS-1 1976-88 wk/3< Relative Risk © 2004 Adventist Health Study-2 day/1< day/1> Meats & Colon Cancer AHS-1 1976-88 Never Relative Risk © 2004 Adventist Health Study-2 wk/1< wk/+1 Red Meat & Colon Cancer AHS-1 1976-88 Never Relative Risk © 2004 Adventist Health Study-2 wk/1< wk/+1 White Meat & Colon Ca AHS-1 1976-88 Never Relative Risk © 2004 Adventist Health Study-2 wk/1< wk/+1 Legumes & Colon Cancer AHS-1 1976-88 wk/1< Relative Risk © 2004 Adventist Health Study-2 wk/1-2 wk/2> Tomatoes & Prostate Ca AHS-1 1976-88 wk/1< Relative Risk © 2004 Adventist Health Study-2 wk/1-4 wk/4> Legumes & Prostate Ca AHS-1 1976-88 wk/1< Relative Risk © 2004 Adventist Health Study-2 wk/1-2 wk/2> Soy Milk & Prostate Ca AHS-1 1976-88 Never Relative Risk © 2004 Adventist Health Study-2 day/1< day/1 day/1> Diabetes—Cases in the US Associations between Vegetarian Status and the Prevalence of Diabetes in Adventists MEN Vegetarian Status WOMEN Adjusted 95% Adjusted for Age Confidence for Age and BMI Interval and BMI 95% Confidence Interval Vegetarian 1.00 Semivegetarian 1.29 0.97-1.71 0.98 0.80-1.20 Nonvegetarian 1.72** 1.36-2.19 1.60*** 1.36-1.88 ***p<.0001 1.00 Prevalence of diabetes according to dietary profile. 25 20 RR 15 Veg Semi- Nonveg veg Veg Semi- Nonveg veg 10 5 0 Males Females Prevalent Treated Diabetes and Diet % Reporting Type 2 Diabetes Vegan 8% 6% 4% 2% 0% Lacto-ovo Pesco-veg Semi-veg Non-veg AHS-1: Interesting dietary findings » Nuts and whole wheat bread significantly reduce the risk of coronary heart disease » Beef significantly increases the risk of fatal coronary heart disease AHS-1: Findings for coronary heart disease » Lower cholesterol overall » Exercise has not been studied well, however when asked, SDA’s said 2.38X/week vs. 1.5X/week for their neighbors » Double the risk of heart attacks for diabetics, three times the risk for hypertensives, elevation of risk for current and past smokers and more than double the risk for obese. Beef & Fatal CHD Risk AHS-1 1976-88 Never wk/3< wk/+3 Relative Risk Male © 2004 Adventist Health Study-2 Female Fish & CHD Risk AHS-1 1976-88 Never Relative Risk © 2004 Adventist Health Study-2 wk/1< wk/+1 Bread & CHD Risk AHS-1 1976-88 White Relative Risk © 2004 Adventist Health Study-2 Mixed Whole Nuts & CHD Risk AHS-1 1976-88 wk/1< wk/1-4 wk/4> Relative Risk Male © 2004 Adventist Health Study-2 Female Nuts & CHD Risk AHS-1 1976-88 wk/1< wk/1-4 wk/4> Relative Risk Vegetarian © 2004 Adventist Health Study-2 Non-Vegetarian AHS-1: Findings for nuts, 1992 » 1-4/week: 74% risk of nonfatal MI and 73% risk of fatal MI » 5+/week: 52% risk of nonfatal MI and 62% risk of fatal MI » Obese nut eaters had 46% risk of coronary heart disease Exercise & All Deaths AHS-1 1976-88 Low Relative Risk © 2004 Adventist Health Study-2 Medium High An Extra 10 Years of Life Adventist Health Study-1 demonstrated that 5 simple habits Adventists have promoted for over 100 years extend their life by as much as 10 years in both men and women Regular exercise Eating plant-based diet Eating small amounts of nuts regularly Maintaining normal body weight Not smoking © 2004 Adventist Health Study-2 Effects of Individual Risk Factors To Increase Life Expectancy Variable Men Women Vegetarian diet 2.38 yrs 1.65 yrs Vigorous Exercise 2.14 yrs 2.19 yrs Frequent Nut Consumption 2.87 yrs 1.18 yrs Avoid High BMI 1.51 yrs 1.90 yrs Never Smoked 1.33 yrs 1.49 yrs © 2004 Adventist Health Study-2 » The study's strengths lie in the large size of the cohort group, the extensive data gathered on each subject, the inclusion of both men and women from a wide range of ages, and, perhaps most important, the wide range of nut consumption among Adventists. » In February of 1992, grant money was received to further examine the existing data and address questions that have been raised about the longevity of Adventists. » Mortality follow-up of the 34,198 individuals from the original study through 1988, a time span of 12 years. » Questions such as: ~ "Do diet or exercise patterns influence longevity?” ~ "Which dietary components are important?” ~ "If Adventists with particular habits live longer, is it due to the fact that they tend to live closer to a certain maximum life span and die rapidly, or is there an increase in the maximum life span and the entire distribution of ages at death?” » Certain factors are known to increase the risk of heart disease and cancer. Of all Adventist deaths, 56.7 percent were from cardiovascular diseases and 20.9 percent from cancer. These figures are quite similar to those of the non-Adventist population. Then, what is the difference? The difference lies in the fact that Adventists develop these same problems at a later age Adventist Health Study-2 2002-Present Demographics About 96,000 subjects More than 25,000 Black study members Mean age at enrollment 58.7 years Age range 30-110 years 35% male, 65% female » AHS-2 is of the largest, and most exciting health studies of its kind ever designed and will have national importance and international significance. As one of the largest health studies of Black/African Americans, it aims to help answer why Black/African Americans have a disproportionate amount of cancers and heart disease. It is estimated that 40 percent of cancers could be prevented by a proper diet. AHS-2 seeks to increase understanding of the benefits of healthy eating. » Every study member filled out a 50-page diet and lifestyle questionnaire at the start of the study. Every two years after that, participants fill out hospital history forms and list any hospitalizations and diagnoses of cancers, stroke, heart attack and diabetes during the previous two years. Adventist Health Study-2 Emphasis will be on effects of: Soy Meats Dairy products Linolenic acid Particular families of vegetables BMI/Body shape ON Common cancers and other chronic diseases ALSO Diet and disease in African-Americans (N=25,000) Religiosity/psychosocial factors/Mortality/Quality of life The Oldest-Old in AHS-2 » 90-99 years of age --- 1043 subjects » 100+ --- 46 subjects They all completed a 50 page questionnaire!! » Our study is made up of 96,000 Adventists ages 30 to 112 from all 50 U.S. states, as well as Canada. Enrollment occurred between 2001 and 2007. About 64% were members of the Adventist church by the age of 15 years. The study members are 65.1% female, with a mean age of 60.2 at enrollment. Additionally, 65.3% of our study members are White (nonHispanic) and 26.9% of our study members are Black/African American. Our study includes small numbers of other ethnic minorities. Only 1.1% of our study members report being current smokers and 6.6% report current alcohol use. Questions AHS 2 is asking » What specific foods enhance quality of life? » Do soy products really help prevent breast and prostate cancer? » What foods help prevent cancer, diabetes, heart disease, Alzheimer's, and arthritis? » Heredity or lifestyle – which is more important? » Does faith contribute to a healthier life? AHS 2 subjects » 8% are vegan (No red meat, fish, poultry, dairy or eggs) - 28% are lactoovo vegetarian (Consume milk and/or eggs, but no red meat, fish or poultry) - 10% are pesco-vegetarian (Eat fish, milk and eggs but no red meat or poultry) - 6% are semi-vegetarian (Eat red meat, poultry and fish less than once per week) - 48% are non-vegetarian (Eat red meat, poultry, fish, milk and eggs more than once a week) Education No High School Diploma 8.98% High School Diploma Only 53.07% Bachelor's Degree 20.63% 17.33% Graduate Degree 0 10 20 30 40 50 60 Diet: Mean Servings Per Week 25 20.44 20 15 10 5 4.2 4.6 6.1 0.84 0 Cruciferous Vegetables Fish Fruits Legumes Tomatoes » Our data show a progressive weight increase from a total vegetarian diet toward a non-vegetarian diet. For instance, 55-year-old male and female vegans weigh about 30 pounds less than non-vegetarians of similar height. Additionally, levels of cholesterol, diabetes, high blood pressure, and the metabolic syndrome all had the same trend – the closer you are to being a vegetarian, the lower the health risk in these areas. In the case of type 2 diabetes, prevalence in vegans and lacto-ovo vegetarians was half that of non-vegetarians, even after controlling for socioeconomic and lifestyle factors. » Compared to non-vegetarians, vegans/vegetarians: » - Watched less television - Slept more hours per night - Consumed more fruits and vegetables - Consumed less saturated fat - Typically ate foods with a low glycemic index, such as beans, legumes and nuts Associations between Vegetarian Status and the Prevalence of Hypertension in Adventists. AHS-2 Men Women Diet Adj. for Age and BMI 95% Adj. for 95% Confidence Age and Confidence Interval BMI Interval Vegetarian 1.00 1.00 Semivegetarian 1.66 1.34-2.07 1.50 1.30-1.73 Nonvegetarian 2.26 1.87-2.73 2.31 2.04-2.61 Weight Differences Between Vegetarians and Non-Vegetarians Vegan Lacto-ovo Pesco-veg Semi-veg Non-veg 200 Pounds 180 160 188 180 171 161 164 177 193 181 161 140 146 120 100 0 Female 5’ 6” tall Male 5’ 10” tall Prevalent Treated High Blood Pressure and Diet % Reporting Hypertension Vegan 25% 20% 15% 10% 5% 0% Lacto-ovo Pesco-veg Semi-veg Non-veg Prevalent Treated High Cholesterol and Diet % Reporting High Cholesterol Vegan Lacto-ovo Pesco-veg Semi-veg Non-veg 15% 10% 5% 0% Also supported by studies of non-Adventist vegetarians Prevalent Treated Diabetes and Diet % Reporting Type 2 Diabetes Vegan 8% 6% 4% 2% 0% Lacto-ovo Pesco-veg Semi-veg Non-veg »Total Mortality »Risk of Dying – Dividing to Different Ages Red Meat and Total Mortality* Risk Factor RR 95% Confidence Intervals No red meat 1.00 1 oz/day 1.27 1.19– 1.35 2 oz/day 1.61 1.42 – 1.83 3 oz/day 2.05 1.70 – 2.47 *Adjusted for Age, gender, and Ethnicity. »Coronary Heart Disease (CHD) Mortality »Risk of Dying from CHD – Dividing to Different Ages »Dietary Pattern & Prostate Screening Utilization US Adventist vegetarians who increased their meat intake to weekly consumption of meat over a 17-year interval experienced a 3.6 year decrease in life expectancy Increased meat intake Maintained Zero Meat Intake Singh PN, Sabate J, Fraser GE. Does low meat consumption increase life expectancy in humans? Am J Clin Nutr 2003, 78(3): 526-532 From the 1st (1960) to the 2nd study (1976), some Adventists changed from vegetarian diet to some meat. Disease next 6 years (‘76-’82). RR (Singh et al.) Also noteworthy is a pathway linking increased meat intake in US Adventists to obesity, weight gain, and the occurrence of diabetes*. Increased Meat Intake 74% increase in risk of Diabetes Half of the Risk Produced is mediated by a pathway involving obesity (>30 kg/m2) And weight gain of 10 kg or more Vang A, Singh PN, Lee JW, Haddad E, Brinegar C. Meats, Processed Meats, Obesity, Weight Gain, and the Occurrence of Diabetes among Adults: Findings from the Adventist Health Studies. Ann Nutr Metab 2008. Among Adventist vegetarians, cessation of a faith-based vegetarian diet pattern produced a decrease in life expectancy that was primarily attributable to higher rates of stroke, coronary heart disease, and diabetes. Important questions for future research » » What are the advantages and risks of soy consumption (if any)? Do all meats increase risk of CHD, colon cancer, and possibly other chronic diseases equally? Do processed meats have greater effects? » The decreased risk of several chronic diseases in vegetarians is probably not only due to reduced or absent meat consumption. The possible effects of particular families of vegetables, fruit, nuts, and grains should be evaluated to gain greater specificity. » Report descriptive details of vegetarian diets in different countries. Are these diets comparable, and how are pooled analyses best conducted? AHS-2--wrist fractures » Thorpe et al examined diet practices and wrist fracture numbers over a 25year period of 1,865 women who participated in AHS-1 and AHS-2. Women who reported fractures were more likely: To be older To have a history of fractures To report low or no vigorous physical activity To have experienced menopause more than 15 years earlier To have never used hormones AHS-2 African-American Cohort » Almost 26,000 Black participants » Help answer why Blacks have different risks of certain diseases. » Examine how best to overcome historical barriers in working with the Black community in a research setting. Descriptive information African-American Cohort AHS-2 » Compared to the rest of the AHS-2 study members, the Black cohort included more females and younger individuals. Fewer were currently married and more were never married, divorced or separated. » - The average age of baptism was 24.3 years. » - Compared to non-Adventist Blacks, rates of smoking, drinking and meat consumption were lower, and rates of vegetarianism and water consumption were higher for Black study members. » - The education level was higher for Black study members (35% hold a bachelor’s degree or higher) than for Blacks nationally (15% hold a bachelor’s degree or higher). Descriptive information African-American Cohort AHS-2 » Compared to other Adventists, Black Adventists have more cases of type 2 diabetes, stroke and high blood pressure, but fewer cases of emphysema, myocardial infarction, heart attacks, fibromyalgia and high cholesterol. » - Black females had significantly less cancer than did non-Black females. » - Black males had 47% higher prevalence of prostate cancer than did nonBlack males. » - Obesity was more prevalent among Blacks than non-Blacks (35% vs. 22%). For Body Mass Index (BMI), 42% of non-Blacks had normal weight, and 28% of Blacks had normal weight. Descriptive information African-American Cohort AHS-2 » 53% of Blacks reported sleeping six or fewer hours per night. » -Overall, Black Adventist study participants reported better physical and mental quality of life than the U.S. norm. » Cases of hypertension and diabetes were lower for Black Adventists than comparable national rates for both Blacks and non-Blacks, a noteworthy finding. This may be explained by the fact that Black Adventists reported better health habits than Black non-Adventists. Why there is underrepresentation of Blacks in scientific studies » Blacks have been under-represented in scientific studies for several reasons. From the Black community’s fear of exploitation based on mistreatment in the past, to researchers’ failure to recruit Blacks through targeted strategies, much work is needed to improve the representation of Blacks in medical/scientific research. AHS-2 has documented the methods involved in recruiting 26,000 Black Adventists in order for future researchers to achieve better representation also. What we have learned about research with Blacks from AHS-2 » The local Adventist churches were the main area for recruitment to AHS-2, as this is the center for community life and activity. » - Focus groups in three churches revealed several areas of concern, including: » Confidentiality » Use of Social Security numbers » Respectful and culturally appropriate treatment » Meaningful and motivating incentives » On-going sharing of results Adventist Health and Smog Study: 1976-Present AHSMOG is made up of 7,000 participants from the first Adventist Health Study. Through funding by the Environmental Protection Agency, Dr. David Abbey of the Center for Health Research and fellow investigators are in the midst of studying the effects of various air pollutants--both indoor and outdoor--on lung function. The EPA has been especially interested in the Adventist population because nearly all abstain from smoking. Testing of the 1,500 participants at more than 30 locations throughout California has been completed. The data is now being analyzed by the researchers. Religion and Health Studies » What specific aspects of religion account for better or worse health? » What are the biopsychosocial pathways to health? Religion and Health Study, 2006Present » In 2006 and 2007, 10,988 Adventists from Adventist Health Study-2 filled out a questionnaire about religious beliefs and practices, stressful life experiences, psychological characteristics and social life. A smaller group who live in Southern California gave blood and urine samples at a clinic and underwent physical performance testing (e.g., grip strength) and memory testing, and also allowed us to measure blood pressure, weight, body fat, and waist and hip circumference. In 2009, we sent out a second questionnaire to 7,000 participants to see how responses had changed. In 2010-2011 many of the original clinic members returned to a second clinic. ARHS Findings Overall, Adventists report better physical and mental health than comparable non-Adventists. »The advantage Adventists have over non-Adventists for mental health is bigger in older age groups than in younger age groups. »Individuals who experienced childhood poverty are more religious. However, childhood poverty also relates to more abusive and conflicted families in childhood, particularly in White participants. Those who experienced an abusive home as a child are less likely to be religious. ARHS Findings » Religious individuals have less negative emotions and those who experienced an abusive home have more negative emotions. These negative emotions predict worse physical health. » Some blood markers for inflammation were higher among Blacks than Whites, older than younger and non-vegetarians compared to vegetarians. » Individuals who engaged in secular activities on Sabbath had poorer reported physical health. Those who said Sabbath relieved tensions and promoted feelings of calm and peace reported better mental health. ARHS Findings » Not surprisingly, divorced individuals had more depressive symptoms than non-divorced individuals, but divorced individuals who used positive religious coping had fewer depressive symptoms than those who did not use positive religious coping. The three types of positive religious coping that were inversely associated with depressive symptoms were: » Collaborative religious coping: Defined as forming a problem-solving relationship with God. This kind of coping is not a solitary process, but is aided by a caring and powerful God who is active in each person's life. » Benevolent religious reappraisals: Problems are reinterpreted as part of a divine plan or as an opportunity for growth. » Seeking spiritual comfort from God: Defined as engaging God through prayer or other devotional practices. This type of coping had the strongest inverse association with depressive symptoms. Perceived Physical Health - Females U.S. Norm Black SDA White SDA Percentile 60 55 50 45 40 35 35-44 45-54 55-64 Age 65-74 >74 Perceived Physical Health - Males U.S. Norm Black SDA White SDA 60 Percentile 55 50 45 40 35 35-44 45-54 55-64 Age 65-74 >74 Perceived Mental Health - Females U.S. Norm Black SDA White SDA Percentile 60 55 50 45 40 35 35-44 45-54 55-64 Age 65-74 >74 Perceived Mental Health - Males U.S. Norm Black SDA White SDA Percentile 60 55 50 45 40 35 35-44 45-54 55-64 Age 65-74 >74 Vegetariansim and Vitamin D » Vitamin D is an important hormone in the prevention of osteoporosis and rickets but beyond that has major functions in the prevention of heart disease, cancers, diabetes and in the regulation of the immune system. Foods naturally rich in vitamin D are all from animal sources: cod liver oil, finfish, and shellfish. The only naturally occurring plant sources of vitamin D are certain mushrooms, in which it is present in only small amounts. There has been concern that vegetarians would have lower blood levels of vitamin D than non-vegetarians. » AHS-2 looked at the vitamin D status of vegetarians, partial vegetarians and non-vegetarians. The results demonstrated that a vegetarian diet was not associated with lower levels of vitamin D. Other factors, such as vitamin D supplementation, degree of skin pigmentation, and amount and intensity of sun exposure had a greater influence on vitamin D levels in blood than diet. A Healthy Dairy-free Vegetarian Diet »Quality depends on the overall character of the diet, not just the absence of animal products. »To obtain calories vegans usually eat more fruit, vegetables, legumes, seeds, nuts, and berries—packed with healthy phyto-chemicals. »What about vegan diets where this is NOT so? Exposed to “downsides” but not the “upsides” of the animal-free diet. If no dairy a) Ensure ample grains, vegetables, legumes, fruits, nuts, seeds and berries; b) Avoid replacing animal foods by refined, sweet, fatty commercial products, even if from plant sources; c) Obtain adequate sunlight and emphasize high calcium vegetables, or supplement calcium; d) Consider algal supplements high in omega-3 fatty acids; e) Supplement with vitamin B12. The Optimum Vegetarian Diet! We don’t know! So far vegans are looking very good, but not yet convincingly superior to lacto-ovo vegetarians. We will keep looking as the data grows more robust. Overall Conclusions The health advantage experienced by the more conforming Adventists over many years is remarkable. However, strong conclusions require strong evidence. AHS-2 will provide this. We have data from 96,000 Adventists across the U.S and Canada, a large number. This improves precision and helps rule out chance as an explanation. Practical Conclusion The evidence is right now sufficient to support a diet that: i) may still include some lacto-ovo foods; ii) is otherwise plant-based, or trends that direction. strongly in If you wait to modify your lifestyle till all the details are known, for sure you will be dead! Final Thoughts Heal me, Lord, and I will be healed; save me and I will be saved, for you are the one I praise. Jeremiah 17:14