Vegetarianism in Food-Based Dietary Guidelines

Plant foods are staples of many cultures in the world. Conversely, the appearance of vegetarianism in Western countries is a relatively recent phenomenon, showing an upward trend: people following vegetarian diets (both lacto-ovo-vegetarian-LOV and vegan-VEG), account today for about 10% of the Western population. According to the principle of non-discrimination, the most recent national dietary guidelines for the general population (DGLs) of some Western countries have adapted their contents to comprise vegetarian eating patterns. Moreover, since 1997, specific vegetarian food guidelines (VFGs) were developed. The aim of this review was to summarize and compare the information and recommendations of the foodbased dietary guidelines (FBDGs) contained in the DGLs usable by vegetarians, and in the main VFGs; to extract a list of basic criteria for the planning of a well-balanced vegetarian diet, and to identify the most valid FBDG for vegetarians. An Internet search was conducted in the English language, in order to identify national DGLs applicable to vegetarian dietary patterns, and international VFGs. Four Western DGLs and six VFGs were selected. Compared to the majority of DGLs, VFGs are not an "adaptation" of omnivorous (OMN) eating patterns to vegetarian ones, but rather devoted guides: they include only foods consumed by vegetarians, and take into account their specific nutritional needs. VFGs offer qualified advice to meet the most updated standards of adequacy and safety of the diet: the varied consumption of all plant foods, mainly unprocessed; the respect of individual’s calorie requirements; the optional addition of small amounts of foods of animal origin (dairy/ eggs); the attention towards some potentially critical nutrients. According to this criteria, the VFG for North American Vegetarians can represent the most accurate and practical model: not only is it consistent with research on the adequacy of vegetarian diets, but it is applicable both to LOV and VEG eating patterns and to all lifecycle stages beyond 4 years of age. DOI : 10.14302/issn.2379-7835.ijn-14-588 Corresponding Author: Dr. Luciana Baroni, e-mail: luciana_baroni@yahoo.it; lbaroni@ulss.tv.it Running title: Vegetarianism in food-based dietary guidelines

Lacto-ovo-vegetarianism (LOV) (including every kind of plant foods, dairy foods and eggs, but excluding meat, fowl, and salt-and fresh-water animal foods), which can be further divided into lacto-vegetarianism (including dairy products, but excluding eggs) and ovovegetarianism (including eggs, but excluding dairy foods).
Veganism (VEG) (including every kind of plant foods, but excluding meat, fowl, salt-and fresh-water animal foods, dairy products, eggs and honey).
In this paper, the term "vegetarianism" will not be used as synonymous of LOV.
Other types of vegetarian eating patterns also exist, such as the raw, fruitarian, hygienist and macrobiotic patterns. They are less common and more restrictive than the above two main patterns described above, as they may limit or exclude one or more plant food groups; moreover, some do not always exclude flesh. Therefore, they can not represent a good model for a well-balanced vegetarian diet.
Similarly, the results of clinical intervention trials support the effectiveness of vegetarian diets in the management of metabolic diseases and in the control of cardiovascular risk factors [17][18][19][20][21][22] .
According to the American Dietetic Association (ADA), compared to non-vegetarian diets, vegetarian diets are associated with lower intakes of saturated fat and cholesterol and higher intakes of fiber, magnesium and potassium, vitamins C and E, folate, carotenoids, flavonoids, and other phytochemicals, which can be responsible for some of the health advantages of vegetarian diets. However, vitamin B12, calcium, vitamin D, zinc, and long-chain omega-3 fatty acid intakes could be lower in some vegetarian subjects 23 . All vegetarians can be at risk of an inadequate vitamin B12 nutritional status 24,25 , and VEGs calcium intakes can range from 500 to 940 mg/daily 26,27 . Alpha linolenic acid (ALA) intakes and blood levels vary among the different studies on vegetarians, but all studies report low intakes and low blood levels of omega-3 long-chain polyunsaturated fatty acid [28][29][30][31][32] . Vitamin D deficiency represents instead a worldwide problem 33 : it is not associated with vegetarian

Selection Criteria
The selection of the FBDGs, which will be discussed in this review, was performed as follows:

Data evaluation
The structure and content of each FBDG were carefully examined. For both categories, we summarized the main characteristics (food groups, resources for vegetarians in the DGLs, applicability to lifecycle stages) in Table 1 (for DGLs) and Table 2 (for VFGs), and compared the respective recommendations regarding some nutrients to focus on, in Table 3.

International Panorama
The    to reflect healthy patterns of dietary intake that are not only adequate but promote optimal health" 47 .
Translated into a pyramid-shaped diagram, these recommendations can be adopted both by LOVs and VEGs, as they propose five groups of plant foods at the bottom of the pyramid, representing the core of any healthy vegetarian diet, and four groups at the top of the pyramid, considered optional, unnecessary for the nutritional adequacy of the diet (Figure 2 and Table 2). This VFG recommends also the attention toward potentially critical nutrients, as listed in Table 3  Formulated in the shape of a pyramid (USA, Figure 4) and a rainbow (Canada), it distributes food in 5 major groups (  48,49 . No recommendation on critical nutrients is included (Table 3).  IJN CC-license DOI : 10.14302/issn.2379-7835.ijn-14-588 Vol-1 Issue 2 Pg. no. 62 be applicable also as therapeutic regimen. It includes only 4 groups of plant foods, recommends the consumption of a small amount of nuts and seeds (about 30g/d) ( Table 2), and of a reliable source of vitamin B12 (Table 3).
Unlike other VFGs, Power Plate does not include information on the amount of foods to consume for each of the four groups, thus representing an extremely simple food guide. It states that any scientific basis for emphasizing one or more groups is lacking, and that the key message is to consume a variety of plant foods rather than focusing on specific food groups 87 .
The nutritional composition of this VFG, promoting ad libitum consumption of plant foods without any added fats, was checked in clinical trials: it can meet or exceed the Dietary Reference Intakes, and provide a beneficial ratio of health protective-detrimental nutrients [88][89][90][91] . Its acceptability was also assessed and resulted similar to that of other therapeutic regimens [92][93][94] .

Lessons for Vegetarianism
Attention toward vegetarian citizens has been shown in modern times by some Western governments, with the inclusion of specific sections and recommendations for vegetarians in their DGLs. However, since 1997, some VFGs are available. Their advantage is not to simply represent an "adaptation" of recommendations for

Confilct of Interest
Author has no conflict of interest.

Acknowledgement:
The Author wishes to thank the anonymous reviewers who made many useful suggestions to improve the manuscript, dr. Paul Griffith for his valuable suggestions and the revision of the manuscript, and researchers which provided images and gave permission to reproduce their Vegetarian Food Guides. References: