Vegetarian Diet and Health

.

THE ROLE OF VEGETARIAN DIET

IN HEALTH AND DISEASE

By Dr. O. P. Kapoor

Foreword

Dr. M.P.Birla

It is a great honour and privilege to contribute a foreword to this excellent monography on "The Role of Vegetarian Diet in Health and disease", a publication of the Bombay Hospital Institute of Medical Sciences. It is one of the first such books written by Medical Professionals of great repute. The book is remarkably complete as it deals with the role of a vegetarian Diet in Health as well as in a very large number of disease conditions, with each chapter contributed by the medical experts in their fields. Further it is heartening to learn that the vegetarian diet by itself can be balanced and complete if scientifically observed. This fact has a great bearing in our country where the poor masses cannot afford expensive non-vegetarian food.

The preface should be read with care as it emphasises the evolution of the vegetarian diet in our hospitals. It further

stresses the fact that vegetarianism is gaining great popularity in the western countries where such trends are adopted after prolonged observation supported by extensive research. It is also gratifying to note that contributions are made by the members of the medical faculty of the Bombay Hospital and Medical Research Centre as well as outstanding scholars from other hospitals and abroad. I have no doubt that this volume will not only be beneficial to the public but would also be appreciated by the members of the medical profession. Since primarily the book is published for the general public, the simple language in which most of the chapters are written makes the contents easily assimilable and the book easy to read

To my knowledge, this book is the first of its kind to be compiled by medical experts and I have no doubt that it will serve to promote the cause of vegetarianism in our country and abroad.

Preface

O.P. Kapoor

. _{"You are what you eat" is an age old adage—and it is a fact that} it is food that maketh a man. The food we eat, its quality,

quantity, its timing and combinations is proven time and again to be of utmost importance in Health as well as in Disease.

At the Bombay Hospital we have been serving vegetarian food from the inception of this institution and now we feel that the time has come to offer scientific justification for this. Not only on religious or moral grounds is this justifiable, but also on scientific grounds vegetarian food seems the more suitable diet for human beings. More scientific work has been done on vegetarianism in the last two decades than in the entire previous history of the world. Therefore, we felt that we should take the lead and bring to the fore all that there is to know on vegetarianism from the scientific angle and thereby justity the use of vegetarianism in health and in disease.

There is a myth amongst people that consumption of meat would make them strong. It is also commonly believed that

nonvegetarian food has more nutritive value. It is significant and embarrassing to note, that while in U.S.A. nearly 10 million people have adopted vegetarianism and more and more people in U.K., U.S.S.R., West Germany, Japan, Switzerland, Israel and Mexico are gradually turning to vegetarian diet not only on humanitarian grounds but more so on medical grounds, in India many vegetarians have started eating meat and eggs only on "wrong" beliefs of the supposedly good qualities of

nonvegetarian diet.

There are many books written for lay public on vegetarianism based on cruelty to animals, spirituality, cultural and

philosophical values, economic, ecological, anthropological and humanitarian grounds. This book is being written by a team of specialists from various faculties of our institute and from other institutes in Bombay and abroad. Here they discuss and show that from the medical point of view the vegetarian diet is as good or is more suited to the human system than a nonvegetarian diet. Unlike other books written on vegetarianism which show that non-vegetarian food is bad for health, we have tried to prove, with medical evidence that vegetarian food is as nutritious or superior in some cases, to non-vegetarian food.

If only this publication can remove the bias from the minds of the public; if only they could be convinced that they could not only live longer with vegetarian diet, but also not suffer from many crippling diseases, we would feel that we have been amply

rewarded.

Since this book is a joint effort of many scientists it has been difficult to prevent the overlap of views. In fact, at times, repetitions have intentionally been retained to maintain the individual readability of the chapter. To give this scientific publication a well rounded look, chapters on growth, immunity and microbiology have been included. Immunology for the general physician is, at best, complicated and so it is for the lay person. Hence the chapter on Immunity and Vegetarian Diet may make heavy reading. Similarly the chapter on microbiology has been written only to emphasize the fact that the kind of food we eat decides the kind of bacteria that are present within us. Facts of their functions are pouring in every day and their real

importance will be evident to us very soon.

Religion or spiritualism are not the field of doctors. But the Indian public should be enlightened about the good qualities of

Vegetarian diet which are the high fibre content, low cholesterol content and low incidence of zoonotic disorders. Also, there is strong evidence that vegetarians are at a lesser risk for alcoholism.

In this monograph we have reproduced a few articles from 'The Bombay Hospital Journal' which is the regular scientific

publication of Bombay Hospital Institute of Medical Sciences. Vegetarianism can be divided into vegetarian, lacto-vegetarian and lacto-ovo-vegetarian diets. In this book lacto-vegetarian diet has been accepted as the Indian vegetarian diet. Similarly, many people, who eat fish, chicken and meat also eat vegetabies, fruits and cereals. Thus, really speaking scientifically they should be labelled as 'Omnivorous'. Instead for them, we have in this book used the colloquial term 'non-vegetarian'. The debate is wide open but it seems from the facts presented herein that the scales are tipped heavily in favour of vegetarianism.

We Acknowledge With Pleasure

Medical Sciences for being a constant source of inspiration to us.

• Surg. Rear Admiral J.K. Suchdeva, Medical Director of

the Bombay Hospital and Medical Research Centre for his invaluable guidance.

• Dr. D.C. Jain, Neurologist, New Delhi for initiating the

idea of this monograph.

• Shri C.G. Joshi, Executive Director of the Bombay

Hospital for all the co-operation extended during the accumulation and compilation of the data.

Hospital, who has been a constant source of guidance in the Editorial Committee. And all the contributors to this monograph who have helped to gather information on Vegetarianism under 'one roof'.

Further we would like to express our sincere gratitude to ....

• Shri P.R. Karve, Manager of the Bombay Hospital

Journal.

• Dr. Ramesh Mehta, for carefully reading the proofs of

the manuscript.

• Madhavrao Bhagwat of Mouj Printing Bureau.

• Shri Ashok Gokhale, cover artist.

• Jasra Graphics

• Shri Hemant Mistry, Photographer

• Dieticians: Miss Mariella Barreto, Miss Savita Dandekar for ferreting out references on Vegetarianism

and compiling the data.

• Secretaries: Mrs. Rewa Nair, Miss Emily Rodrigues, Miss Stella Bastian and Miss Pratima, for typing the

miles of manuscripts which went in the making of this monograph.

O.P. Kapoor

Editor

Anand Gokani

Assistant Editor

Food Values of A Vegetarian Diet

Mariella L. Barreto

. _{The health of an individual depends on his nutrition. It is this} well-known fact that has led man to be more aware of the food he consumes. A large number of diseases are known to be diet related. A certain diet may itself be the cause of disease or alter the course of a known disorder such as diabetes or kidney disease.

The food consumed by any individual or a community is determined by a number of factors viz. socio-economic status, religion, food availability and family traditions. Medical factors like food allergy, intolerance, diabetes and heart disease sometimes force a change in diet.

Diet patterns may be classified broadly as vegetarian or

on the food consumed, into fruitarians, vegans, lacto-vegetarians and lacto-ovo-vegetarians. The term vegetarian is generally used to refer to the lactovegetarian. The basic difference between the vegetarian and the non-vegetarian diet is the exclusion or inclusion of eggs, fish, meat and poultry.

The difference in the nutritive value of the diets is dependent on the nutritive value of these foods. In general, the foods

considered as non-vegetarian are high in protein and fat, low in fibre and are poor sources of carbohydrates, whereas vegetarian foods are rich in fibre, carbohydrate, vitamins, minerals and can be adequate in fat and protein as well. These differences in the nutritive value have given rise to the question - which diet is superior?

All foods of animal origin are said to contain proteins of high biological value, viz. proteins that may be better utilized by the body. Proteins consist of amino acids, some of which can be synthetized by the body while some cannot. Amino acids that are not synthesized by the body are referred to as essential amino acids. Non-vegetarian foods contain all the essential amino acids unlike any single vegetarian protein source(except milk).

However, all the essential amino acids can easily be obtained in a vegetarian meal by the judicious combinations of various foods. That a vegetarian diet is deficient in vitamin B12 is another bone of contention. Though most sources of vegetarian food are low in their vitamin B12 content, there are never any manifest

deficiencies of this vitamin even in strict vegans. It is therefore likely that vitamin B12 is required in very minute quantities. Hence B12 cannot be the justification for resorting to foods of animal origin.

It is widely believed that a vegetarian diet cannot provide adequate calories, but it is untrue. Balanced vegetarian diet can give adequate calories quite easily.

Food may be divided into groups on the basis of the nutrient supplied:

1. Carbohydrates (energy) e.g. rice, sugar, honey etc.

2. Protein (building blocks) e.g. eggs, meat, fish, pulses, milk, nuts etc.

3. Vitamins and minerals e.g. fruits and vegetables.

4. Fat (energy and insulation) e.g. oils, nuts, red meats etci The main difference in the vegetarian and the non-vegetarian foods is the quantity and quality of proteins available in both. The non-vegetarian food is said to be rich in proteins but as

mentioned earlier, vegetarian sources can supply the same if judiciously combined. Hence when a vegetarian seeks protein he

has to focus his attention on pulses, nuts and milk.

PULSES

Pulses, the seeds of the leguminosae family are the main source of protein in a vegetarian diet. The major portion of the pulse cultivated is consumed after being dehusked and decorticated. This process not only shortens cooking time but also makes them more easily digestible. Whole pulses are best consumed after being soaked and sprouted. These sprouts have a high dietary fibre. Being live foods, they have the capacity and potential to create and generate new life.

Seeds, grains, beans and even nuts can be sprouted. Sprouted food is easily accepted, digested and assimilated. Sprouting also gives a tremendous boost to the vitamin and enzyme content. In fact, in growing children, where extra proteins and vitamins are needed, lightly steamed sprouts are the best choice of food. A biogenic diet includes fruits, fresh vegetables, whole grains, nuts, beans and seeds which contain life-generating and cell renewal capacities for youth and life.

Sprouts (see fig. alongside) are living plant life, easily digested and

invigorating in their effects.

Energy

This group supplies 350 cats/ 100 gms and has a protein content of 20 % with the exception of soyabean (40%). To ensure the best utilization of this protein the first criterion is to meet the energy requirement. If the diet is deficient in calories the protein is used to make up this deficiency.

Protein

Proteins are made up of units called amino acids. The quality of a protein is dependent on the amount of essential amino acids available from it. A protein that has all the essential amino acids in the desirable amount is said to be of the best quality. Non-vegetarian sources of protein are complete in their amino acid contents whereas vegetarian sources of protein are not as complete. However, the combination of two food substances more than makes up for individual deficiencies e.g. pulses are deficient in sulphur containing aminoacids whereas cereals are

rich in sulphur containing amino acids. This makes a cerealpulse combination a complete source of protein. Hence it is a mistaken belief that non-vegetarian food is essential to provide adequate proteins for growth and development.

Looking into any of the traditional vegetarian meals of India we see that this is a practice that has been followed since ages. Not only is every meal a cereal-pulse combination, but in most cases, is accompanied by a complete protein source (milk or any of its products). The traditional idli-sambar, varan-bhat, thepla-dahi are some of the many examples of cereal-pulse, cereal-milk

combinations.

Carbohydrate

Pulses have a carbohydrate content of 60%, most of which is in a complex form. Certain oligosaccharides present in pulses escape digestion and are responsible for flatulence in a few susceptible individuals. Common home processing methods like sprouting and germinating decrease the amount of flatulence producing oligosaccharides. Garlic is a bacteriostatic agent and aids in decreasing flatulence.

Fat

The fat present in pulses has a higher polyunsaturated fatty acid content (1.5%). This makes pulses not only qualitatively but also quantitatively better than meat.

Minerals

The minerals present in pulses are calcium, phosphorus, magnesium, sodium, potassium and iron. Of the phosphorus present, 80% is bound to phytate and is biologically unavailable. Soaking of pulses in water before preparation decreases some of the bound phytate, thus increasing the amount of available minerals.

Vitamins

The thiamine and carotene content of pulses is similar to that of cereals. Pulses are rich in niacin but devoid of vitamin C and poor in riboflavin. Once sprouted, pulses are excellent source of vitamin A, B complex, C, D and K.

Sprouting dramatically increases the vitamin C content of the food. The vitamin E content of sprouted wheat increases 300% in four days. So much so, that because of the excess of vitamin E content, sprouted food administrated to patients of submucosal fibrosis of the mouth over two to three years, halts the progress of the disease and in some cases can cause actual regression.

The vitamin C content also increases 600%. There is more carotene in sprouted wheat than in a carrot.

The edible pulses contain two thermolabile factors that have been implicated in toxic effects. They are the trypsin inhibitors and haemagglutinins. The trypsin inhibitors suppress the release of amino acids making it unavailable and may also stimulate extra production of trypsin which leads to a loss of pancreatic activity. Sprouting of legumes causes a loss of this inhibitor and, if still present, it is then more susceptible to destruction by heat. Haemagglutinin present in pulses may combine with haem and result in destruction of haemoglobin. This constituent of pulse is generally not absorbed and is destroyed by cooking.

Fermentation and sprouting help to speed up this destruction. Maximum utilization of pulses is thus obtained if the diet is adequate in calories and the whole pulses are soaked and sprouted prior to cooking. Soda, often added to pulses while cooking, decreases cooking time but also decreases the nutrients and is therefore best avoided.

MILK

Milk is considered as a perfect food because it constitutes the entire diet for the young of all

mammals. Milk has a protein of excellent quality (second to that of an egg). The efficiency with which it is converted to body

protein is second best to that of an egg

The quantitative

composition of milk varies with breed, season, stage of lactation etc. Fat is the most variable constituent, with protein following. The composition of the milk of a mammal is best for the young of that mammal. The milk having the closest similarity to that of human milk, with regards to composition, is that of goats, followed by that of cows (refer fig alongside)

Protein

The main protein of milk is casein (80%), the rest is lactalbumin and lactaglobulin which are the whey proteins. Most of the casein is bound to calcium. Casein is easily coagulated by acid or by enzyme renin while the other proteins are not. The milk protein contains all the essential amino acids and has a high digestibility co-efficient (97 - 98%).

Fat

Milk fat is also called butter fat and is characterised by the presence of short chain saturated fatty acids. The fat content of milk is variable (3 - 5%) and is present as an emulsion making it easily digestible.

Carbohydrate

Lactose is the carbohydrate in milk which is broken down by the enzyme lactase. An absence or insufficiency of lactase causes micro-organisms to act on lactose leading to the formation of gases and thus the cramping discomfort and diarrhoea in 'lactose intolerence'. The lactose content of the milk can be decreased by fermenting milk to form yogurt (curd) where the amount of lactic acid is higher. The lactose content of milk is 5%.

Minerals

The minerals present in milk are sodium, phosphorus, sulphur, magnesium, manganese, calcium and iron. Calcium is bound to phosphate which, with casein, forms a phosphoprotein. It is also present with fat. The quantity of iron is low in milk, but is of an excellent quality resulting in its ready absorption.

Vitamins

Vitamin A - carotene present gives the milk yellowish tinge and

is obtained from plant feed. The amount varies with the breed, the amount present in the feed and the fat content of milk.

Vitamin D, E & K - These nutrients are present in small

amounts. As they are fat soluble, they are associated with the fat content of the milk. The skimmed milk has an even smaller amount of these vitamins.

Thiamine - This nutrient is also dependent on the amount

present in the feed but it is also synthetized by the lumen of the gut of the cow and is therefore present in fair amounts in cow's milk.

nutrient. It is present in very small amount (0.05 -0.1%) and is dependent on the amount present in the feed.

Niacin - Milk is a good source of tryptophane which is a precursor

of niacin.

Vitamin C - This vitamin is easily destroyed by application of

heat and exposure to air. The small amount present in the milk is destroyed during pasteurisation.

Milk is a food that is highly perishable. Thus processing it will

help to store it. Spray drying of the milk to powder or condensing it are some examples. Processing, in most cases, involves high temperatures and this destroys some of the nutritive value. This loss can be overcome by fortification.

There are a number of dairy products and these may be classified into 'fermented' & 'unfermented'. The most common in India is dahi (curd). This has a better nutritive value, not due to an

increase in nutrients but an increase in digestibility. Fermentation increases the vitamin content and lactose is converted to lactic acid. The calcium and phosphorus of curd are more easily assimilated.

NUTS AND OILSEEDS

Nuts, which are the seeds of fruits, contain nutrients to aid in the growth of a new plant. This is why all nuts are not only a good source of nutrients quantitatively but also qualitatively. Nuts are classified, depending on their nutrient content (protein, fats and

carbohydrates). The nuts with a high fat content, in most cases, are also high in protein, and this group includes most of the nuts. Those high in

carbohydrate are few e.g. chestnut. On an average, nuts are found to contain 50% of fat and 25% of protein. Nuts are a rich source of essential fatty acids. This group of food thus supplies not only calories but also, weight

for weight, twice as much protein as any other food crop (fig.2). Nuts are a good source of vitamin B complex in particular. Groundnuts are rich in thiamine and nicotinic acid. They have a mineral content of 2%, a large fraction of it being phosphorus and potassium.

The most common complaint regarding nuts is indigestion. This, in a majority of the cases, is due to over-indulgence and poor mastication, both of which we can easily rectify. In order to get the maximum utilization, nuts must be consumed in limited amount. Nuts may also be soaked overnight. Humidity and unhygienic storage conditions cause food to get easily contaminated with fungi. Groundnuts are prone to such

infestation which produces aflatoxin. This toxin causes damage to the liver and can be avoided by proper storage.

Nuts are consumed in various forms. They may be had fresh, dried, dehydrated or roasted. Nuts are used for oil extraction. The meal left after the extraction of oil from nuts is rich in protein. Nuts are most often considered to be expensive and out of the common man's reach. Comparing the cost of almonds and cashewnuts per kg with that of eggs and meat, the cost of 10 gms of protein is similar, if not less, in the case of nuts.

COCONUT

Coconuts are botanically stone fruits and not nuts as they are termed. This stone fruit is largely used for oil extraction and it is thus classified as an oilseed.

This fruit is consumed at different stages of maturity and its nutritive value varies accordingly.

Tender Coconut: The most tender coconut contains only a liquid

in it and no kernel meal. The tender coconut water is a common food in the sick room and this drink has the advantage of being sterile. This drink is a good source of electrolytes. As this- fruit matures the amount of water decreases and the amount of meal increases. The thin initial layer of meal has a high percentage of water and so is not a dense source of nutrients, this is one of the reasons that makes it an easily digestible food.

Ripe Coconut: The thick layer of kernel is much lower in

moisture and high in calories. The coconut kernel is high in oil content and is used for oil extraction. The coconut oil has a high

percentage of medium chain triglycerides (M.C.T.). This M.C.T. is of great therapeutic value when other forms of fat are not tolerated. Another byproduct is the coconut milk which is obtained from the endosperm. This is grated, ground and squeezed to expel milk. The endosperm on grating can be air dried to reduce its moisture content to less than 2% to obtain the dessicated coconut. This is commonly used for the preparation of sweets and biscuits.

Nutritive Value of The Coconut at Different Stages of Maturity per 100 Grns

Coconut

Water

Tender

Coconut

Coconut

Milk

Fresh Dry

Moisture (%)

93.8

90.8

42.8

36.3

4.3

C alories

24

41

430

444

662

Protein (gms)

1.4

0.9

3.4

4.5

6.8

Fat (gms)

0.1

1.4

41

41.6

62.3

Carbohydrate (gms)

4.4

6.3

11.9

13

18.4

Dry Coconut: This is the coconut at its maximum degree of

maturity and thus with the lowest percentage of moisture. At this stage the coconut has only 4.3% of moisture as compared to the tender coconut that has 90.8%. This is also the most

concentrated form of nutrients. It supplies 6.8 gms of proteins and 62.3 gms of fat per 100 gms.

The above discussion on the nutritive value of pulses, nuts, milk and coconut makes it clear that the nutrients supplied by a non-vegetarian diet can be obtained from a non-vegetarian meal. All this calls for is an intelligent combination of the foods permitted. The vegetarian sources of protein are low in saturated fat and thus have an advantage over protein obtained from meats.

Thus a vegetarian meal that is well balanced can be as nutritious, if not more, than a non-vegetarian meal.

Coronary Heart Disease and Vegetarian Diet

B.k. Goyal

. _{'Heart attacks', which have become so common, occur due to} involvement of coronary arteries, which carry the blood supply to the heart. An 'attack' results when one of the coronary arteries suddenly gets blocked and causes death of the muscle tissue of the heart supplied by that artery. This is clinically known as an 'attack' of myocardial infarction.

Why do coronary arteries get blocked ? There are two reasons which have been detected on post-mortem examination:

I. Blockage due to gradual narrowing of these arteries as a result of a degenerative disease known as atherosclerosis. Even as early as fifty to sixty years ago this atheroma was seen only in old people and was synonymous with the aging process. As the civilization has progressed, the time has come when the

postmortems done on young children and young adults who have died due to accidents or other causes, have been showing

atherosclerosis of the coronary arteries. Smoking, presence of long standing diabetes and high blood pressure, overweight and sedentary life are some of the known causes. However, the most important single biochemical abnormality which can be spotted and correlated with atheroma is the level of blood cholesterol. In the last few years the whole family of blood lipids has come to light. This consists of triglycerides, HDL and LDL cholesterol and a variety of apolipoproteins. It has been found that if the diet is rich in saturated fatty acids as in the case of non-vegetarian diets, the blood fat levels become highly abnormal and the process of atherosclerosis starts right from childhood. So striking was this association, that ten years back in the Western

countries, the public was warned through the television and radio media, that their children should not be given more than two eggs per week. In fact such sensational discoveries have led many people in the West to take to vegetarianism.

Vegetarians have low intakes of total fat, saturated fatty acids and cholesterol. Their intake of polyunsaturates is equal or slightly higher and dietary fibre intake is usually much higher than w that of nonvegetarians. Some evidence exists that protein or dietary fibre in vegetarians may be involved in reducing

coronary heart disease. The type and amount of dietary fat and cholesterol are most strongly associated with changes in serum lipids, apolipoproteins and blood rheology, all of which are the causes of coronary heart disease and heart attacks and are discussed below:

Blood Lipids (Fat)

Cholesterol circulates in the blood in two forms. The high density lipoprotein (HDL) cholesterol is protective for the heart and reduces the risk of coronary artery disease. As against this the low density lipoprotein (LDL) cholesterol increases the risk of coronary artery disease. The blood cholesterol levels are affected by the type of dietary fat and the amount of cholesterol present in it, alcohol, smoking and physical activity. The consumption of high saturated fatty acids (as in ghee and coconut oil) and cholesterol increases the LDL cholesterol levels. On the other hand the consumption of polyunsaturated fatty acids lower the levels of LDL cholesterol and not only that, they also increase HDL cholesterol levels thereby protecting the patients from coronary artery disease.

Apo-lipoprotein Levels

Apo-lipoprotein levels may be better than serum lipid levels for predicting the risk of coronary heart disease. Table 1 shows that in most but not in all studies, lipid-modified vegetarian diets were found to change levels of apolipoprotein as well as lipoprotein composition and levels.

II. The second reason for sudden blocking of the coronary arteries is the occurrence of a blood clot in an otherwise clean blood vessel. This type of blockage is specially seen in young people dying of heart attacks. Although there are a number of constituents in the blood responsible for this clotting, the role of platelets in blood seems to be outstanding.

Table I

Studies of Vegetarians and Coronar y Artery Disease

Outcome Vanable Study or Observations Mortality from

coronary artery disease

Negative association between

vegetarianism and ischemic heart disease mortality, even after removing confounding effects of smoking, especially in males. 35-64-y-old Seventh-day Adventist vegetarian men had lower mortality than did nonvegetarians although in men over 65 and women differences were significant, even after taking smoking into account. Serum cholesterol

levels:

comparisons of vegetarians and nonvegetarians

Total serum cholesterol, low-density-lipoprotein cholesterol, and to a lesser extent high-density-lipoprotein cholesterols are lower in vegetarians and especially vegans compared with lactovegetarians or omnivores.

Vegetarian diets usually produce a selective lowering of LDL levels, with lowered total cholesterol: LDL or LDL:HDL ratios. Serum cholesterol

levels Groups such as Macrobiotics and Hare Krishnas with members eating vegan or very restrictive vegetarian diets low in fat, high in polyunsaturated: saturated fatty acid ratios, high in dietaty fiber, and low in cholesterol show decreased total

cholesterol and LDL cholesterol than do omnivores.

Vegetarians' LDL cholesterol levels are usually decreased but HDL cholesterol levels vary, some being higher than those of nonvegetarians, some lower.

Serum cholesterol levels: feeding vegetarians animal foods

Feeding vegetarians beef, which is high in total fat and saturated fatty acids and cholesterol, causes 19% increases in total plasma cholesterol because of increase in LDL cholesterol whereas HDL cholesterol levels stay constant over a 2-wk period Feeding lactovegetarians eggs for 3 wks, which increases dietary cholesterol, increases total and plasma cholesterol. Serum cholesterol

levels: feeding vegetarians animal foods

Decreasing the amount and altering type of fat in Seventh-day Adventist vegetarians' diets further decreases serum lipid levels. Serum cholesterol

levels: feeding nonvegetarians vegetarian diets

Nonvegetarians have decreased total cholesterol and LDL and HDL cholesterols when they are fed vegetarian diets low in total fat, saturated fatty acids, cholesterol protein, and high polyunsaturated fatty acids, P: S ratios carbohydrate, and dietary fiber for several months, Decreases are only one-third of those observed in lifelong vegetarlans.

Normolipidemic nonvegetarians fed a low-fat, semivegetarian diet for 3 mo have decreased total cholesterol, LDL cholesterol, and LDL: HDL ratios whereas HDL levels, weights, and plasma triglycerides stay constant.

Apoprotein levels Nonvegetarians fed vegetarian diets exhibit declines in apoprotein Al levels when diet is low in total fat, saturated fatty acids, and cholesterol and moderate in

polyunsaturates .

Vegetarians on low fat, total fat, and saturated fatty acid diets show decreased apoprotein AI and B levels and elevated HDL cholesterol apoprotein Al and HDL: LDL cholesterol ratios increased.

Addition of eggs high in cholesterol to the diet of lactovegetarians increases

apolipoprotein B levels in 3 wk.

Lactovegetarian diets fed to nonvegetarians for 6 wk led to no changes in apoprotein B levels although apoprotein B: total

cholesterol and apoprotein B:LDL cholesterol ratios increased.

Platelet levels Lactovegetarians have altered platelet linoleic and arachidonic acid concentrations in comparison with nonvegetarians. Vegans and vegetarians do not differ in serum thromboxane or prostacyclin levels or platelet aggregation .

Nonvegetarians show changes in platelet function when saturated fatty acids are decreased and P: S ratios are increased platelet aggregation to thromboxane and clot ting activity of platelets is decreased and response to adenosine diphosphate aggregation is enhanced.

Saturated fatty acids increase thrombin aggregation and platelet function can be decreased by altering diets.

Platelets are important in clotting and in the development of the arterial thrombi that underlie most 'heart attacks' due to acute myocardial infarctions. They may also modulate coronary artery disease independently of factors such as smoking, blood

pressure and genetics. Platelet composition and functional changes can be induced by dietary fat modifications. Saturated fatty acids are most highly associated with the changes in platelet aggregation to thrombin and platelet clotting activity. One of the theories is that, by decreasing saturated fatty acids as in the vegetarian diet, platelet aggregation and blood clotting changes predisposing to thrombosis will decrease.

Also clotting of a blood vessel depends on the blood fluidity known as "Blood Rheology". Possibly vegetarians have a better than average blood fluidity and this puts them at a lower risk of suffering coronary artery disease.

Finally in vegetarians, factors other than the diet may also be involved in lowering the risk of heart disease. These include i) the nonsmoking and the non-alcoholic status of vegetarians, which may affect HDL-cholesterol levels, ii) their physically active lives, which may favourably alter apo-lipoproteins as well as HDL cholesterol, iii) their relatively low weights, which may decrease risks of hypertension and non-insulin dependent diabetes. It is also worth noting that the reduction in risks of coronary heart disease seem to be associated with the type of vegetarian diet that is followed rather than some genetic protective effect of vegetarianism per se.

The fact that mortality and morbidity from coronary artery disease is lower in vegetarians than in non-vegetarians has also been confirmed at the Bombay Hospital.

Although this hospital caters to all the communities the patients are strictly provided with vegetarian diet only. The studies are in progress at the Bombay Hospital Institute of Medical Sciences to go into the dietary causes of coronary artery disease and our initial data from these studies shows that out of the last hundred coronary heart disease patients, only thirty six patients were vegetarians.

Are there any special substances in the vegetarian diet which give protection against coronary heart disease? In India a lot of work has already been done on the role of garlic and onion in lowering blood cholesterol. Maize bran has also been shown to have a protective effect on the cardiovascular status. Many other vegetarian foods, protective to the heart, have been discussed in another chapter.

Hence it seems evident, that vegetarianism offers definite protection from coronary heart disease.

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7. Ellis F.R. amd Sanders T.A.B., "Angina and vegan diet", The American Heart Journal June 1977, 93(6):803. 8. Lock DR, et al ApoA-I/ApoA-II ratios in plasma of

vegetarians. Metabolism 1983 Dec; 32(2): 1142-5. 9. Masarei JR et al. Vegetarian diets, lipids and

cardiovascular risk. Aust NZ J Med 1984 Aug; 14(4); 439-43.

10. Ernst E et al. Blood rheology in vegetarians. Brit J Nutr 1986 Nov 56(3) 555-60.

11. Gupta O.P. et al, Role of Maize Bran on Cardiovascular status, lipid profile and glycaemic control in Diabetes Mellitus J. Ass. Phy. India 1987:35:353.

12. Burr ML, Sweetman PM. Vegetarianism, dietary fibre and mortality. Am J Clin Nutr 1982, 36:873-7.

13. Masarei JRL, Rouse IL, Lynch WJ, Robertson K, Vandongen R. Beiling LJ, Vegetarian diets, lipids and cardiovascular risk. Aust NZ J Med 1984; 14:400-4.

14. Sainani G.S., Desai P.B., Gorha N.H.. Natu S.M., Pise D V. and Sainani P.G. Effect of dietary garlic and onion on serum lipid profile Ind J. Med. Res. May 1979.

15. Effect of Dietary garlic and onion on some coagulation parameters in Jain Community Jr. Asso. Phys. of India, June, 1979.

16. Jain, R.C., Effect of dietary garlic and onion on serum lipid profile: Lancet, 1975, 1:1240.

Vegetarian Food and The Gastro-Intestinal Tract

O.P. Kapoor

. _{That man is a vegetarian animal is amply exemplified by his basic} anatomy. Unlike carnivorous animals, man has teeth suited for biting and grinding and not for tearing. The intestines of man are longer as compared to their carnivorous counterparts. These are but the most basic of differences that exist between vegetarian and non-vegetarian 'animals'.

The digestive tract of man starts in the mouth. The lips, the teeth and the tongue play an important role in the mastication and the softening of the food. Digestion commences in the mouth with the help of the saliva. The food, after due mastication is swallowed whence it enters the oesophagus (or food pipe). The food pipe empties into the stomach. The food in the stomach is acted upon by gastric acid and enzymes which help in digesting the food to its more basic constituents. The continuous churning of the stomach further helps in breaking down the food. From the stomach the food enters the intestines which are the longest part of the gastro-intestinal tract. Here various enzymes complete the digestive processes and absorption of the various elements of the food begins. What is undigested and unabsorbed enters the colon (large intestine). Here the faeces are formed which are gradually taken upto the rectum and anal canal and egested at periodic intervals (Refer figs. I and 2 below for anatomical topography) .

Fig. 1 Fig. 2

Let us now consider the advantages of a vegetarian diet in relation to each of the parts of the gastro-intestinal tract.

1. Vegetarian food being high in its fibre content increases the flow of saliva which enhances digestion and protects the teeth from caries.

2. Cancer of the oesophagus is less common in vegetarians. This is because vegetarian foods like fresh fruit, vegetables, especially amla and citrus fruits contain large doses of vitamin C which has a protective action against malignant disease (cancer).

3. Hiatus hernia which occurs at the junction of the oesophagus and the stomach is less common in vegetarians. Though the cause of this phenomenon is unknown, it is postulated that, vegetarian food, particularly in the natural form, contains very little fat. The fat when present in the diet in excess delays emptying time of the stomach. This leads to pressure on the diaphragm which causes the hiatus hernia.

4. By virtue of the high vitamin C and fibre content the vegetarian food offers protection from stomach malignancy.

5.

The intestines are the home of many parasites. The longest of them—taenia

saginata and taenia solium (Fig alongside) are found almost exclusively in non-vegetarians, especially in those who eat beef and pork. These worms are almost never found in vegetarians.

6. There are clinical observations that suggest that appendicitis (attack of inflammation of the appendix) is less common in vegetarians.

7. The large intestine (the colon) is most susceptible to the kind of food eaten by us.

The advantages of a vegetarian diet have been observed in following diseases of the colon:

Constipation

The larger undigestible matter present in fruits and vegetables provides bulk which enhances the forward passage of undigested waste matter from the caecum to the rectum and anal canal. It also reduces the transit time from caecum to rectum. This prevents stasis of poisonous end-products of digestion and resulting diseases of the colon. Thus, while non-vegetarians pass small stools (on an average 100 gm), the vegetarians pass large bulky stools (on an average 300 gm). Also vegetarians pass less foul smelling stools. A few years ago, in my book on 'Common Chronic Disease Patterns in the Arabian Gulf, Saudi Arabia and Yemen', I mentioned that constipation is extremely common in the Arab popula tion. It has been noticed time and again that when these patients are given more vegetables and fruits (in addition to plenty of water to drink), their bowels move freely and they are relieved of their constipation.

In elderly subjects the incidence of constipation increases markedly due to the development of the above condition. Fig. alongside shows the small pouches looking like pseudopodia which appear on different sides of the colon. Not only do these pouches make the colon very sluggish, but they can get inflamed like the appendix or can bleed like an ulcer. The modern refined and non-vegetarian diet is responsible for this disease. The reduced faecal bulk causes narrowing of the colonic lumen and an increase in intraluminal pressure. This results in protrusion of these pouches known as diverticula. Diverticula may also develop due to the attempts of the proximal colon to overcome obstruction caused by the segmented and narrowed distal colon. Owing to the high fibre content of the vegetarian food, this disease is infrequent in a vegetarian population.

Irritable Bowel Syndrome

This illness is the most common cause of bowel irregularities and colonic gripes. Incidentally it is less frequent in vegetarians owing to the high fibre content of such a diet.

Chronic Ulcerative Colitis

Unlike amoebiasis and giardiasis which are easily treated with drugs, ulcerative colitis is a 'lifelong bloody dysentery'. The incidence of this disease is much less in vegetarians because of the high fibre content.

Cancer of the Colon

It has been proved all over the world that the incidence of the cancer of the colon is very low in vegetarians. It is postulated that the high fibre content of pulses, cereals, vegetables and fruits increases the amount of faeces and reduces the transit time through the colon. As mentioned earlier, the latter reduces the exposure to carcinogens responsible for the development of the cancer of the colon. These substances include tryptophane, tyrosine, methionine, basic amino acids, cholesterol and bile acids. The bile acids are the most important carcinogens. A number of epiderniological studies have shown and several authors have found a significant relationship between the faecal bile acid concentration and colonic cancer.

8. Rectum and anal canal—The diseases of the terminal end of the gastrointestinal tract e.g. fissure and piles are abundant in the normal population. In fact, the incidence of these diseases is highest in the Arab population as described by me in my book on

Arab diseases. The fact is that both are related to underlying severe constipation. The straining done to expel the hard stools from the rectum and anal canal, "keeps up" the piles and the fissures.

In the medical world, it is a very common observation that these diseases are much less common in vegetarians. This seems to be related to the low incidence of constipation amongst vegetarians.

9.

The liver and the gallbladder are also affected by the vegetarian diet. Fig. alongside shows the presence of stones in the gall-bladder which can occur in as much as 10% of the population above the age of 70 years. It is interesting to note that the incidence of gall-stones in vegetarians is significantly less. The high fibre content of the vegetarian diet causes reduced deoxycholate absorption which in turn increases the synthesis of chenodeoxycholate. The latter affects the cholesterol saturation of the bile resulting in less stone formation. In fact patients having gall-stones are

prescribed high fibre vegetarian diets in order to reduce further gall-stone formation.

10.

Liver is discussed in a separate chapter.

11. Pancreas—Pancreatic malignancies are known to be less common in vegetarians.

All-in-all it appears that vegetarian food is beneficial in prevention as well as in the management of most of the gastro-intestinal diseases.

REFERENCES

1. Bennion LJ, Grundy SM. Risk factors for the development of cholelithiasis in man. N Engl J Med 1978; 299:1221-7.

2. Pixley F. Wilson D, McPherson K, Mann 1. Effect of vegetarianism on developmenl of gallstones in women. Br Med J 1985; 291:11-2. 3. Gear JSS. Warc A, Fursdon P. et al. Symptomless divenicular

disease and intake of dietary fiber. Lancet 1979, 1:511-4. 4. Ornstein MH, Littlewood ER, Baird IM, Fowler J. Nonh WRS, Cox

AG. Are fibre supplements really necessary in divenicular disease of the colon ? A controlled clinical trial. Br Med J 1981; 2S2:1353-6.

5. Burkitt DP. Epidemiology of cancer of the colon and rectum. Cancer 1971; 28:3-13.

6. Bingham SA, Williams DRR, Cole TJ, James WPT. Dietary fibre consumption and regional large bowel cancer monality in Britain. Br J Cancer 1979; 40:456-63.

cancer of the colon and rectum. JNCI 1978; 61:790-814.

8.

9. Rider A, Anhus RS, Calkins BM, Nair PP, Diet, nutrition intake and metabolism in populations at high and low risk for colon cancer; selected biochemical parametcrs in blood and urinc. Am J Clin Nutr 1984; 40:917-20.

10.

11. Preston DM, Lennard-Jones JE. Severe chronic constipation of young women. Idiopathic slow transit constipation. Gut 1986; 27:41-8.

12. J.F. Fraumeni, "Cancers of the Pancreas and Biliary Tract:

Epidemiological Considerations", Cancer Research 1975: 35:343. 13. Pixley F. et al. Effect of vegetarianism on developmcnt of gall

stones in women. Br. Med. J (Clin. Res) 1985 Jul 6, 291 (6487):11-2.

14. Kapoor O.P., Common chronic disease patterns in Arabian Gulf, Saudi Arabia and Yemen. S.S. Publishers Bombay 1983, Page 23.

Of Diabetes and Vegetarianism

. _{In order to evaluate the role of vegetarianism in diabetes we shall} review the current dietary recommendations in diabetes. We shall further examine the suitability of vegetarian foods in composing such diets.

Evolution of Principles of Diet in Diabetes

Diets prescribed for diabetics have gone through remarkable changes in the insulin era, post-insulin era, and most importantly in the last two decades. Diets in the pre-insulin era consisted of a very low carbohydrate content. In insulin-dependent diabetics, the

carbohydrate content was reduced to 10-20 gm/day. Thus, in order to provide the requisite amount of calories the fat content of the diet had to be proportionately increased. Such diets were highly

unpalatable. Diabetic diets in the post-insulin era derived 40%, 20% and 40% of their calories from carbohydrates, proteins and fats respectively. This has further changed in the past two decades. The present day diabetic diets derive 50 - 60% of their calories from carbohydrates and proportionately reduced amount of calories from fats (Table 1). Diets in India, where vegetarianism is practised

extensively, have always been high in carbohydrates and low in fats.

Table 1

Distribution of Major Nutrients in Normal & Diabetic Diets

Nutrients Diet Starch & Other polysacharid es Sugar & Dextrin s Total Carbohydrat es Fat Protei n Alcohol Normal Western diets in the Past 25-35 20-30 45-50 36-45 p/s* ratio abou t 0.3 12-19 0-10 Tradition al Diabetic Diets 25-30 10-15 35-40 40-₄₅ 16-21 0 Newer diabetic diets in Western countries 30-40 5-15 45-55 25-₃₅ 12-24 0-6 Diabetic Diets in India 50-55 5-15 60-65 20-25 p/s 15 0-5

ratio abou t 1 or mor e

* p/s: is the total intake of polyunsaturated fat divided by the intake of saturated fat.

Currently prescribed diabetic diets are high carbohydrate, high fibre, low fat diets. The amount of saturated fats is usually half of the total fat intake. We shall examine how an optimal diabetic diet can be derived from vegetarian sources.

High Carbohydrate Diet

Traditionally, diabetes mellitus has been treated with a low

carbohydrate diet because of the misconception that carbohydrates will cause an increase in the blood glucose levels. As early as 1935, it was reported that carbohydrate tolerance in healthy adults was improved by an increase in the proportion of carbohydrate in the diet. By 1960, it was appreciated that rural Africans eating a traditional high carbohydrate diet had low fasting blood glucose levels and reduced plasma insulin responses to glucose loads as compared with a matched group of whites. Although all dietary carbohydrates provide the same amount of energy (as measured by kilocalories), they are not all handled with equal efficiency by the body.

Initially, it was assumed that the blood glucose responses (glycaemic responses) after ingestion of various carbohydrate foods are directly correlated with their carbohydrate content. However, it was clearly disproved by Dr. David Jenkins and co-workers at the University of Toronto who introduced the concept of the glycaemic index:

Glycaemic Index= 100 * (Blood glucose rises after ingestion of food under study) / (Blood glucose rise after ingestion of equivalent amount of standard carbohydrate glucose.)

The blood glucose response to various foods of similar carbohydrate content varies widely (Table 2). These variations are attributed to the variable quantity and quality of fibre contained in these foods. Soluble fibre tends to lower the glycaemic index more effectively than

insoluble fibre.

Table 2

Glycaemic Indices of Selected Foods

Glucose 100_%

80-90% Bread (whole meal), millet, rice (white), broad beans (fresh),

potato (new) 70-79%

Bread (white), rice (brown), shredded wheat, beetroot,

bananas, raisins. 60-69%

Spaghetti (white), sweet com, peas (frozen), yam, cane sugar(sucrose), potato chips.

50-59% Spaghetti (whole meal), porridge (oats), potato (sweet),

beans(canned, navy), peas (dried), oranges, orange juice

40-49% Black eyed peas, chick peas, apples, milk (skim), milk (whole), yogurt, tomato soup.

30-39% Kidney beans, lentils, fruit sugar (fructose) 20-_29% Soyabeans, soyabeans (canned), Peanuts. 10-_19%

The glycaemic indices are further influenced by the processing and cooking methods. For example, ground rice has a higher glycaemic index than whole rice. Mixed meals produce variable glycaemic responses because of the interaction between starches and other nutrients.

It is important to appreciate that 55-60 per cent of the energy requirements can be derived from the complex carbohydrates

contained in cereals and pulses. This does not present any difficulty in achieving control of diabetes, both in insulin-independent and non-insulin dependent diabetics. This was well documented by many Indian investigators much before the resurgence of interest in high carbohydrate diets in the western countries.

It is further advantageous to combine cereals and pulses, as is traditionally done in a vegetarian diet. our own data con firms that this produces a lower glycaemic index, partly due to the high dietary fibre content and partly due to an increases insulin secretion following

ingestion of a pulse-based diet. The mixing of cereals and pulses also removes the imbalance of essential arnino-acids. Cereals are limiting in Iysine and pulses it methionine, thus, when both are taken together, their amino acid

compositions complement each other, producing a protein mixture of fairly high biological value. Not just cereals ant pulses, but proteins from all

vegetable food sources also cornplement each other (Fig. 1).

High Fibre Diet

The edible, but indigestible, component of plants contain two types of fibres: soluble and insoluble. Chemically, the fibre in plants is either cellulose and lignin which are insoluble or noncellulose

polysaccharides like hemicellulose, gum and pectin, which are

soluble. Although many diet plans take the crude fibre into account, it is important to study the total fibre content and its soluble and

insoluble components(Table 3).

Table 3

Comparison of Crude Fibre and Total Dietary Fibre Content of Vanous Foods Crud e fibrea Total Dietary fibre Noncellulose polysaccharid es (soluble fibre) Cellulose Lignin( insoluble fibre)

Food (g/100 g edible portion)

Cereals Flour, white 0.3 3.2 2.5 0.6 0.03 Flour. whole 2.3 9.5 6.3 2.5 0.8 Wheat Bread, white 0.2 2.7 2.0 0.7 Tr Bread, whole wheat 1.6 8.5 6.0 1.3 1.2 Fruits Apples 0.6 1.4c _0.9c _0.5c _0.1c Oranges (peeled) 0.5 0.29 0.22 0.04 0.03 Pears 1.8 11.0c _5.04c _2.9c _3.0c Banana 0.5 1.8 1.1 0.4 0.3

Peaches 0.6 2.3 1.5 0.2 0.6 Legumes and Nuts Kidney beans 1.8 7.3 5.7 1.4 0.2 White beans 1.7 7.3 5.7 1.4 0.2 Peanuts (roasted) 2.0 9.3 6.4 1.7 1.2 Peas 2.0 7.1 4.5 2.4 0.2 Vegetables Beans, green 1.0 3.4 1.9 1.3 0.2 Carrots 1.0 3.7 2.2 1.5 Tr Cabbage, white 0.8 2.8 1.8 .07 Tr Cauliflower 1.0 1.8 0.7 1.1 Tr Lettuce, romaine 0.6 1.5 0.5 1.0 Tr Pepper, green 1.4 0.9 0.6 0.3 Tr Potatoes svith skin 0.05 3.5 2.5 1.0 Tr Corn, cooked 0.8 4.7 4.3 0.3 0.1 Tomatoes. fresh 0.5 1.4 0.7 0.4 0.3 Turnips, raw 0.9 2.2 1.5 0.7 Tr Tr = Traces

a= Crude fibre,g/100 edible portion, method of Weende. in

Composition of Foods (Agncultural Hand-book No.456'. Washington. D.C.: U.S. Department of Agriculture, 1975.

b = Total dietary fibre. Southgate method. D.A.T. Southgate et al. J.Human Nutr. 30: 303 - 313, 1976.

c = Flesh only.

The soluble fibre forms a gel in the gut and retards the absorption of most nutrients. It effectively lowers the glycaemic indices of foods. Its prolonged use lowers the blood lipids. The insoluble fibre is fermented by the gut bacteria. It maintains normal gut flora and also contributes to the increased faecal bile excretion along with pectin and other soluble fibres.

gm/dav. In African countries the fibre content is as high as 75-150 gm/day. In Asian countries, usually 25-50 gm of fibre is ingested per day. Probably, an intake of 30 gm/day is adequate, which is easily achieved in vegetarian diets. This effectively lowers the blood glucose and lipids, and assists in weight loss.

A high fibre diet also has important effects on metabolism in the liver, as it reduces the urea synthesis by the liver.

The high fibre vegetarian foods also contain phytates and lectins. These substances reduce the rate of digestion of starch and thereby diminish post-meal hyperglycaemia. Tannins contained in these foods may have a similar effect.

The vegetarian diet is generally a high carbohydrate-high fibre diet. It usually contains the recommended amount of fibre intake of 10 gm crude fibre or 50 - 60 gm of total fibre per day. It is unwarranted to supplement it with any other fibre. For research purposes, guar gum has been used extensively as a fibre supplement in diabetics. The results have mostly been gratifying in both insulin-dependent and non-insulin dependent diabetics, with an occasional study reporting the failure of guar gum in reducing post-prandial hyperglycaemia. It is always more pleasant to ingest a high fibre diet in the form of high fibre foods instead of a fibre supplement.

Ingestion of fibre in excessive amounts can result in flatulence, abdominal distension and diarrhoea. It may also result in

malabsorption of many micronutrients like calcium, iron, copper, magnesium, phosphorus and zinc.

Low Fat Diet

The currently prescribed diabetic diets are low fat diets; only about 25-30 per cent of the calories being derived from fat. The fat intake in our diet occurs from two sources; visible fat and invisible fat. It is easy to control the quantity of visible fat ingested. Most vegetarian foods contain intrinsically a very low quantity of fat except the nuts, seeds, whole milk and its products. It is easy to separate out the milk fat and hence control the overall amount of fat eaten in a vegetarian diet. The nonvegetarian foods carry various amounts of invisible fat with them; which progressively increases from lean meat (fish and chicken) to medium fat meat (ham, egg and beef) to high fat meat (corned beef, pork, cold cuts). One ounce (30 gm) of lean meat, medium fat meat and high fat meat contains 3, 5 and 8 gm of animal fat respectively. For a vegetarian, the only source of animal fat is milk products. By using skimmed milk and its products such as curds, cottage cheese or paneer made from skimmed milk, the vegetarian can minimise the amount of animal fat ingested.

Vegetable fats are used for cooking by both the vegetarians and non-vegetarians. It is advisable to derive half of the fat intake from saturated fats and the other half from polyunsaturated fats.

Alternatively, one-third of the fat intake can be derived from each group of fats, i.e. saturated, monounsaturated and polyunsaturated fats (Table 4). A vegetarian can easily accomplish this goal by using small amounts of butter or cream with bread or chapati and by using polyunsaturated oil for cooking. Such dietary approaches involving a low &t diet containing polyunsaturated fats have resulted in a hopeful trend towards lowering of the incidence of coronary artery disease in U.S.A.Such dietary trends are easy to achieve in vegetarian

communities.

Types of Fats

1. Fats rich in Saturated fatty acids:

Animal fat (contained in meat products), dairy products (ghee, butter, cream), coconut oil.

2. Fats rich in Monounsaturated fatty acids: Olive oil, palm oil, groundnut oil

3. Fats rich in Polyunsaturated fatty acids: (per cent

polyunsaturated fatty acid content is given in parenthesis) Safflower oil (74), soyabean oil (60), sunflower oil (58) corn oil (55), cotton seed oil (51),

fish oil (50), sesame seed oil (43), groundnut oil (31)

Other Advantages of a Vegetarian Diet in Diabetes

Foods of vegetable origin also contain certain metabolically active compounds which act on specific tissues. One of such compounds is myoinositol, which is deficient in a diabetic with peripheral

neuropathy. Hence, ingestion of vegetarian foods containing myoinositol can improve peripheral nerve function. The vascular complications of diabetes are ascribed to an increased generation or deficient removal of free oxygen radicals, which have the potential of damaging various tissues. Our own research shows that in

uncontrolled diabetics, certain enzymes required for the removal of free oxygen radicals are functioning poorly.

This situation improves with good control of diabetes. Treatment with known antioxidants, like vitamin E, which also has the potential of removing the free oxygen radicals has thus far produced

disappointing results. Vegetarian foods like fruits, vegetables and spices contain large amount of bioflavonoids, which have the capacity to mop up the free oxygen radicals.

Quantitative & Qualitative Aspects of Protein Intake

The commonest misconcept regarding vegetarian diet is that it may be deficient in protein. It is important to appreciate that the quantity of protein intake will be sufficient if a diet of adequate caloric content is prescribed. On the other hand, a hypocaloric diet, irrespective of its high protein content will produce a negative nitrogen balance and loss of body proteins. Qualitatively, vegetable proteins from a single source possess a low biological value. A vegetarian diet obviates this

difficulty by incorporating about 10 gm of milk protein in diet. Alternatively, a cereal pulse mixture provides protein of a fairly high biological value, which approximates that of animal protein.

To summarise, a vegetarian diet is eminently suitable for all non-insulin dependent and non-insulin-dependent diabetics. It is easy to provide a high carbohydrate, normal protein, low-fat diet through vegetarian foods. Such a diet is always high in fibre content and allows a highly selective and well regulated fat intake. This type of diet permits good metabolic control to be achieved. The

hyperglycaemia, as well as hypercholesterolaemia, can be normalised or reduced significantly by such a dietary approach, thus minimising long-term complications of diabetes.

REFERENCES

1. Chandalia H.B. and Sheth P.S. Conquest of Diabetes, Research Society,Grant Medical College, 1987

2. Krall Leo P. and Beasar Richard S. Joslin Diabetes Manual 12th ed. Lea & Febiger, 1989.

The Vegetarian's Kidneys

Ashok L. Kirpalani

. _{The normal diet consists of fat, carbohydrate and proteins. In} structure, both fat and carbohydrate are very similar, in that they contain only carbon, hydrogen and oxygen; whereas the proteins differ by the extra content of nitrogen. When digested fats and carbohydrates are metabolised they breakdown into carbon dioxide and water, both of which are volatile and can be excreted by the lungs. Water is also excreted by the kidneys in urine and by the skin as sweat. The protein, however, metabolises to form non-volatile material called the 'nitrogenous waste', a mixture of many compounds of which urea and creatinine are most

important and well known. One of the main functions of the kidney is to remove these poisons, urea and creatinine, from the body through the urine. It naturally follows that the greater the protein intake of a human being, the larger will be the

nitrogenous waste load produced and greater the work demand on the kidneys to excrete it in the urine. Non-vegetarian diets have much larger protein content than the vegetarian diets. Eating a non-vegetarian diet produces a larger work demand on both kidneys. This has been clearly demonstrated by scientific methods.

Until recently it was thought that in health, the kidneys are able to meet this extra demand quite well and perform satisfactorily, but recent animal experiments have revealed quite clearly that when healthy kidneys are constantly exposed to very large

protein loads, they seem to age much faster and may be tne cause of the development of high blood pressure in animals. With the appearance of this scientific data the whole world is now sitting up to realise that too much protein is deleterious to healthy kidneys. In fact the average adult western

non-vegetarian diet consists of I - 1.5 gms/kg body weight of protein whereas the minimum requirement for good health is only 0.75 gms/kg body weight which is the requirement quite adequately met by the average Indian adult vegetarian diet.

In Renal Failure, where the kidney's efficiency slowly and subtly reduces from 100% to 30% without even giving a slight warning to the patient, it is quite obvious that a greater work demand on the kidneys put by a non-vegetarian diet would further produce a great strain on the already diseased kidney. This has been very exhaustively proved in patients of renal disease such as

glomerulonephritis, chronic renal failure, renal disease due to diabetes (diabetic nephropathy) and renal disease due to high blood pressure (hypertensive nephrosclerosis). In these diseases, the patient suffers an initial mild and prolonged phase of

"azotaemia" wherein life is possible without dialysis before reaching the stage of "uraemia" at which stage life can only be maintained by doing dialysis. The phase of "azotaemia" is best treated by a very strict dietary protein restriction and this is best achieved by a vegetarian diet containing 30 gms proteins of which 20 gms are supplied by milk and milk products while the remaining 10 gms comes from vegetable, cereals etc.

'Azotaemia" is best tolerated this way and the "uraemia" phasc may be postponed by years by this dietary principle in

conjunction with other dietary restrictions of salt, water, potassium and the usage of certain drugs.

Gout is a disease affecting joints and causing kidney stones. It is due to deposition, in joints and kidneys, of uric acid which is both generated in the body and also derived from food products like all meats. Those suffering from gout and uric acid kidney stones benefit most by omitting meat from their diet and converting to a vegetarian diet. With proper adjuvant therapy the incidence of kidney stones reduces and the patient suffers less joint pains. In Conclusion The Nephrologist, like the diabetologist uses diet as a major part of his therapeutic armamentarium most

effectively and must prescribe the total diet of his patient taking into consideration the calories, fluid intake vis-a-vis urine output, protein, carbohydrate and fat intake, potassium and salt intake. Each patient will be given a different diet prescription but the one universal advice that will apply to all will be "It is better for you to become a vegetarian ". Nephrologists have come to believe that this advice is applicable even to those who have no renal disease so as to prevent normal kidneys from overworking and aging rapidly. In fact, many nephrologists in western

SUGGESTED FURTHER READING

1. Barry M. Brenner and Jay H. Stein. "The Progresslve

Nature of Renal Disease" Churchill Livingstone Ed. Williarn E. Mitch, 1986

2. Brenner B.M., Meyer T.W. and Host setter T.H. Dietary Proteins Intake and the Progressive Nature of Kidney Disease. New Eng Journal Medicine 1982, 307, 652.

Vegetarianism and The Liver

N.H.Banka

. _{The liver has been described as a chemical workshop of the} human body. All the nutrients and other substances absorbed from the intestines pass through the liver before entering into the systemic circulation. Thus the liver is vulnerable to the damage caused by a host of infections and toxic agents. Several types of viruses and alcohol are by far the commonest of these agents. The impairment of the liver function usually manifests as jaundice. Persistent infection and continuing impairment of function may be followed by death unless these changes can be controlled.

The morphological changes in liver damage can manifest as fatty liver, hepatitis, cirrhosis of the liver and cancer of the liver. A well planned dietary regimen is of utmost importance in the prevention and treatment of most hepatic disorders. It has been proved beyond doubt that some of the proteins derived from animals are responsible for producing persistent symptoms related to liver disease. Thus vegetarian diet, as mentioned below, has gained momentum in the treatment of hepatic disorders.

Viral Hepatitis

Since there are no antiviral agents against hepatitis,rest, abstinence from alcohol and dietary modifications form the mainstay of the treatment. Most patients have nausea and lack of appetite. They should be served with attractive and well cooked foods. Small meals served separately will be better tolerated than three large meals. A diet containing

approximately 2000 kcal which can be provided by 20-25 gms fat, 80-90 gms pro teins and 400 gms carbohydrate is suitable. This requirement can be fulfilled by glucose, sugar, fruits, fruit juices, bread, cereals, vegetables, salads, jelly, jam, rice, boiled potatoes and puddings made with cereals and sugar. Though diets high in their fat content do not ultimately influence the course of the disease they are poorly tolerated by jaundiced

patients. Fried food, milk and butter cause dyspepsia and should be avoided. Thus a vegetarian diet is better tolerated by the patients suffering from viral hepatitis.

Cirrhosis of Liver

Most of the patients of cirrhosis of liver are severely

malnourished and require a high calorie and high protein diet. A high protein diet, particularly if derived from animal proteins, carries a high risk of precipitating hepatic encephalopathy. The best source of vegetarian proteins is milk, its products and Casilan. Choline present in foods like wheat germ, soyabean, peanuts and skimmed milk may prevent the formation of a fatty liver. It is also believed that cerebral disturbances due to liver damage are caused by the type of protein in the diet. Cirrhotic diet prescribed in a standard Indian books on diet and nutrition does not contain proteins derived from animal sources. A diet high in carbohydrate and proteins low in fat and fortified with vitamins would be most suitable. Thus a vegetarian diet is more suited to patients having cirrhosis of liver.

Ascites

In terminal stages of cirrhosis fluid accumulates in the abdominal cavity due to failure of the liver to synthetize plasma albumin. For such patients, a high protein diet which is low in sodium would be most suitable. But since these patients have no appetite, milk is the only practical diet which can supply the above requirements.

Finally when the liver fails - the condition is known as hepatic encephalopathy. There is a strong incidence of animal protein intake increasing the incidence of hepatic encephalopathy. The clinical features of this syndrome are sleep disturbances, restlessness, drowsiness, impaired intellectual function,

confusion and stupor progressing to coma. Significant number of these patients develop chronic encephalopathy and can be managed successfully at home. They should be given 20 gms of protein in the diet. This should mainly be derived from skimmed milk.

Thus, it is very obvious that a vegetarian diet is more useful in the treatment of all liver disorders including the last stage of liver failure.

REFERENCES

1. Antia F.P. Clinical dietetics and nutrition—Oxford publication, 1975, page 416.

2. Anonymous, Diet and Hepatic Encephalopathy (editorial) Lancet 1983, 1:625-6.