Dr. Aseem Malhotra

We are deeply saddened to hear about the premature death of Dr. Anish Malhotra and our sincere condolences go out to Dr. Aseem Malhotra and his family. However, the factually inaccurate, confused article by Dr. Malhotra about his mother cannot go unanswered by the plant-based medical community. In it, he blames a vegetarian diet for his mother's premature death. The media outlets that have used such an inflammatory headline are also culpable for inaccurate reporting.

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Let's examine the points made in the article and then decide whether vegetarianism was really the cause. It should first be clarified that describing someone as vegetarian or vegan does not tell you anything about what they are eating, only what they are not eating. Veganism is a social justice movement for animal liberation and not a diet.

1. 'I believe that what was finally written on her death certificate – severe sepsis and discitis with concomitant myocardial infarction (heart attack) – was entirely avoidable'

We agree with this statement. Myocardial infarction or heart disease is the commonest cause of death in men and women around the World and is caused by a combination of lifestyle factors, including an unhealthy diet.

The 'Western-style' diet pattern, high in ultra-processed and animal-derived foods, is an important risk factor. Various healthy diet patterns, including the Mediterranean, DASH (Dietary Approaches to Stop Hypertension) and vegetarian diets, are characterized by high amounts of whole plant foods and have been associated with reduced risk of heart disease and its risk factors (1).

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In a meta-analysis of multiple health outcomes, vegetarian/vegan diets were associated with a 25 percent reduction in the risk of heart disease (2). In fact, a study conducted in India using a low-fat vegetarian diet composed of whole plant foods in people with coronary artery stenosis (narrowing) showed reversal of the disease in those adherent to the diet (3).

2. 'I witnessed her regular consumption of starchy carbohydrates and ultra-processed snack foods of biscuits, crisps and chocolate'

This statement describes a diet of ultra-processed foods that we can all agree is unhealthy and contributes to chronic disease. We agree that >50 percent of foods purchased in the UK are ultra-processed, but this is not an issue of vegetarianism, as the overwhelming majority of UK residents are omnivores.

It is an issue with the predominant 'Western-style' diet pattern, which is being adopted around the world, including India, and is detrimental to health. It does not describe the traditional Indian vegetarian diet, which has become more 'Westernised' over the last few decades (4). Studies have shown that an unhealthy plant-based diet is just as bad for health as an unhealthy omnivorous diet, and increases the risk of heart disease (5).

Starchy carbohydrates have been the cornerstone of a number of healthy, traditional diet patterns, including those consumed in the 'Blue Zones' - countries where there are more centenarians than anywhere else in the world. Consumption of whole grains, beans, vegetables and fruits, all full of healthy carbohydrates have been associated with longevity and good health when compared to low carbohydrate diets. In contrast, low carbohydrate diets, advocated for by Dr. Malhotra, especially when high in animal-derived foods are associated with an increased risk of heart disease and death. In particular, high intake of red and processed meat has been associated with increased risk of several causes of death and all-cause mortality.

3. 'I still have a vivid memory of her only meal on a weekly fast day consisting of a large chapatti and what can only be described as a mountain of table sugar'

We are not sure what type of chapattis these were but traditionally they are made from wholemeal flour, water, salt and butter (optional). We agree that excess white, refined sugar has a number of detrimental health effects, including an increased risk of heart disease (6). However, again, this is not an issue of vegetarianism but a 'Western-style' diet pattern

4. Her weight contributed to developing high blood pressure in her 40s and as a result, she suffered a brain haemorrhage in 2003'

Overweight and high blood pressure (BP) are major risk factors for heart disease and other chronic diseases. However, a meta-analysis of studies has demonstrated that vegetarian diet patterns are associated with a lower incidence of high BP, and a vegetarian diet pattern is one that is recommended for preventing heart disease by the American College of Cardiologists (7).

In addition, studies with large numbers of vegetarians and vegans, such as the EPIC-Oxford and the Adventist Health Studies, have shown that vegetarians and vegans have a lower body mass index than non-vegetarians and a reduced risk for high BP (8). Studies in Indians have also shown benefits for high BP and weight in those following a vegetarian diet pattern (9).

5. 'Her vegetarian diet required her to take Vitamin B12 and iron supplementation'

B12 is made by microorganisms, not by animals or plants. Therefore the lack of B12 in a vegetarian diet (although there is some in dairy and eggs) is not unique. In fact B12 supplementation may be prudent for all adults older than 50 years of age regardless of diet pattern due to reduced absorption with aging. Animal feed is increasingly supplemented with B12.

A vegetarian diet is no more likely to cause iron deficiency than a omnivorous one. Iron stores may be lower, but this is not thought to have negative consequences on health and may even be beneficial (10).

B12 supplementation may be prudent for all adults older than 50 years of age regardless of diet (Photo: Adobe. Do not use without permission)

6. 'Protein deficiency led to sarcopenia (a decline in muscle mass) which limited her mobility even further. In the last six months of her life, she had two hospital admissions with agonising spontaneous sequential bilateral osteoporotic fractures of her pelvis'

There is no increased risk of osteoporotic fracture in vegetarians compared to omnivores if adequate nutrients are obtained from the diet, including calcium, magnesium, potassium and vitamins K and D - all abundant in plant-foods or from sunshine exposure. In fact, high intake of animal protein and diets low in fruits and vegetables may be more likely to result in osteoporosis (11),(12). Physical exercise is equally important.

It is also well established that protein requirements can be adequately met on a plant-based/vegan diets at all stages of life10. In fact, high protein diets, when protein is from animal sources is associated with increased risk of death from cardiovascular disease, but this association is not seen with plant-derived protein(13).

7. 'Being 'overfat' (defined as excess body fat that can impair health and contribute to chronic disease) is now estimated to affect 70 to 80 percent of Indian adults and 41 percent of children. A large percentage of overfat individuals will have a normal Body Mass Index, with up to 50 per cent having excess body fat linked to risk factors for disease'

We completely agree that despite being a normal weight, people can be at high risk of chronic disease due to abnormal distribution of fat, including in the muscle and liver cells, resulting in metabolic syndrome and insulin resistance. Again, this is associated with a ‘Western-style’ diet pattern, not a healthy vegetarian one. This is a particular issue for South Asians and this article nicely explains the reasons and the associations with diet. The diet pattern associated with a reduced risk of metabolic syndrome and ‘overfat’ is one composed of predominantly whole plant foods (14).

8. 'It is instructive to note that India, with more vegetarians and vegans than the rest of the world combined, is the 'diabetes capital of the world''

This is exactly right. Most vegetarian and vegans avoid animal products for ethical reasons and may not be following a healthy diet. It is therefore not an issue related to vegetarianism per se but the ‘Western-style’ diet pattern high in sugar, salt and fat, which has been exported all round the world. Healthy plant-based diets are associated with some of the lowest rates of chronic disease, including diabetes but also heart disease and some cancers (2), (8).

9. 'A large observational study conducted in Australia in 2016…Similarly, a large Austrian study published...'

Citing single, poor quality studies on vegetarian/vegan health, whilst ignoring the entirety of evidence is not an accurate representation of the data and does not befit a Professor of evidence-based medicine. The Australian study has a relatively short follow-up and a crude dietary assessment method, which was only performed at one point in time.

An analysis from the EPIC-Oxford also found no association between a vegetarian diet and mortality when using only the baseline dietary assessment to analyse the association. However, when excluding people who changed their diet during follow-up there was a 10 percent reduction in all-cause mortality and 19 percent reduction in overall cancer mortality among vegetarians compared to regular meat eaters, suggesting that dietary changes during follow-up in some cases might obscure associations between vegetarian diets and mortality. This is remarkably similar to the 12 percent reduction in all-cause mortality reported among vegetarians versus non-vegetarians in the Adventist Health Study 2.

The Austrian Study had a cross-sectional design, and cannot establish the temporal relation between diet and disease because both the exposure and the outcome is assessed at the same time. Therefore it is impossible to say whether people become vegetarian because they were already sick or did they become sick because of their vegetarian diet. Large prospective studies, where initially healthy people are followed up over time for occurrence of new disease, have shown that vegetarians and vegans have an eight-18 percent lower overall cancer incidence. Systematic reviews and meta-analyses of the data have confirmed many health benefits for healthy vegetarian/vegan diets2.

10. 'The point about saturated fat is: the evidence is now looking pretty good, but the guidance hasn't shifted'

We think it is too early to draw a final conclusion with regard to the health effects of saturated fat intake because there are many large cohort studies that have not yet published results on the association between saturated fat and heart disease and other outcomes. However, consensus from leading world organisations is that saturated fat (from animal foods) should be replaced by unsaturated/polyunsaturated fats from plant sources because this leads to better of health. A small amount of butter on bread is neither here nor there, but most dietary fat should be from plant sources (15),(16),(17). Dr. Malhotra is out-with consensus on these statements about saturated fat.

11. 'There's been much media hype recently suggesting that adopting a meat or animal product free diet is best for human and planetary health, but this is not evidence-based. An independent report from the US Department of Agriculture predicts complete removal of animals from the food supply would only reduce total US greenhouse gases by 2.6 percent but simultaneously increase dietary energy consumption from a plant only system and worsen nutritional deficiencies'

The paper cited is by two authors who represent the animal agriculture industry, and has been criticized. In contrast, one of the most comprehensive analyses of the global farming system, assessing all aspects of the food chain from 'farm to fork', concluded that shifting to a plant-based diet would have the most impact on planetary health than any other driver of climate change. Even the production of meat and dairy with the lowest environmental footprint is less sustainable than the worst performing plant food source.

Freshwater fishing and grass fed beef were also found to have a greater environmental effect than any plant food source (18). In fact, one of the authors became vegan himself after conducting the study. To then criticize the EAT-Lancet report is, again, out-with consensus. The commission has brought together over 30 world experts in health, nutrition, environment and nutrition policy, from 16 countries, and have based their recommendations on the best available scientific data, not the opinion of a few (19).

13. 'Sadly, her devout religious faith to avoid consuming animal products, combined with a high starch, high sugar diet, was ultimately to the detriment of her health'

The avoidance of animal products in our opinion was not the cause of Dr. Anish Malhotra's death, but rather a diet of ultra-processed foods. To link the two is irresponsible and non-scientific. Those who avoid animals foods for ethical reasons can, without doubt, eat a healthy diet composed of whole plant foods (fruits, vegetables, nuts, seeds, legumes and whole grains). The evidence suggests that this diet pattern is one of the healthiest, associated with reduced risk of most common diseases and increased longevity.

Acknowledgements: Dr. Dagfinn Aune for editing and checking accuracy.

References:

1. Van Horn L, Carson JAS, Appel LJ, et al. Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement from the American Heart Association. Circulation. 2016. doi:10.1161/CIR.0000000000000462

2. Dinu M, Abbate R, Gensini GF, Casini A, Sofi F. Vegetarian, vegan diets and multiple health outcomes: A systematic review with meta-analysis of observational studies. Crit Rev Food Sci Nutr. 2017. doi:10.1080/10408398.2016.1138447

3. Gupta SK, Sawhney RC, Rai L, Chavan VD, Dani S, Arora RC. Regression of Coronary Atherosclerosis through Healthy Lifestyle in Coronary Artery Disease Patients - Mount Abu Open Heart Trial. Indian Heart J. 2011;63:461-469.

4. Bhattacharya M. A historical exploration of Indian diets and a possible link to insulin resistance syndrome. Appetite. 2015. doi:10.1016/j.appet.2015.07.002

5. Satija A, Bhupathiraju SN, Spiegelman D, et al. Healthful and Unhealthful Plant-Based Diets and the Risk of Coronary Heart Disease in U.S. Adults. J Am Coll Cardiol. 2017. doi:10.1016/j.jacc.2017.05.047

6. De Koning L, Malik VS, Kellogg MD, Rimm EB, Willett WC, Hu FB. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation. 2012. doi:10.1161/CIRCULATIONAHA.111.067017

7. Yokoyama Y, Nishimura K, Barnard ND, et al. Vegetarian diets and blood pressure a meta-analysis. JAMA Intern Med. 2014. doi:10.1001/jamainternmed.2013.14547

8. Tonstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care. 2009. doi:10.2337/dc08-1886

9. Shridhar K, Dhillon PK, Bowen L, et al. The association between a vegetarian diet and cardiovascular disease (cvd) risk factors in india: The indian migration study.PLoS One. 2014. doi:10.1371/journal.pone.0110586

10. Melina V, Craig W, Levin S. Position of the Academy of Nutrition and Dietetics: Vegetarian Diets. J Acad Nutr Diet. 2016. doi:10.1016/j.jand.2016.09.025

11. Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Protein consumption and bone fractures in women. Am J Epidemiol. 1996. doi:10.1093/oxfordjournals.aje.a008767

12. Sellmeyer DE, Stone KL, Sebastian A, Cummings SR. A high ratio of dietary animal to vegetable protein increases the rate of bone loss and the risk of fracture in postmenopausal women. Am J Clin Nutr. 2001.

13. Song M, Fung TT, Hu FB, et al. Association of animal and plant protein intake with all-cause and cause-specific mortality. JAMA Intern Med. 2016. doi:10.1001/jamainternmed.2016.4182

14. Gadgil MD, Anderson CA, Kandula NR, Kanaya AM. Dietary Patterns Are Associated with Metabolic Risk Factors in South Asians Living in the United States. J Nutr. 2015. doi:10.3945/jn.114.207753

15. Li Y, Hruby A, Bernstein AM, et al. Saturated Fats Compared with Unsaturated Fats and Sources of Carbohydrates in Relation to Risk of Coronary Heart Disease A Prospective Cohort Study. J Am Coll Cardiol. 2015. doi:10.1016/j.jacc.2015.07.055

16. Ludwig DS, Willett WC, Volek JS, Neuhouser ML. Dietary fat: From foe to friend? Science (80- ). 2018. doi:10.1126/science.aau2096

17. Sacks FM, Lichtenstein AH, Wu JHY, et al. Dietary fats and cardiovascular disease: A presidential advisory from the American Heart Association. Circulation. 2017. doi:10.1161/CIR.0000000000000510

18. Poore J, Nemecek T. Reducing food’s environmental impacts through producers and consumers. Science (80- ). 2018. doi:10.1126/science.aaq0216

19. Willett W, Rockström J, Loken B, et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019;6736:3–49. doi:10.1016/S0140-6736(18)31788-4

Written on behalf of plant-based health professionals UK (pbhp.uk)

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