by Jack Norris, RD
- Blood Lipids
- Cholesterol in EPIC-Oxford
- Cholesterol in Western Vegans
- Cholesterol in USA Vegans
- Blood Pressure
- Body Mass Index
- 2013 Report From Adventist Health Study-2
- 2003 Report From EPIC-Oxford
- Body Mass Index Over Time as a Vegan
- Body Fat
Numerous studies have measured cholesterol levels, blood pressure, obesity, and other markers of disease in vegans. Most of these studies included information on lacto-ovo vegetarians (lacto-ovo), fish-eaters (pesco), and non-vegetarians (non-veg). This article surveys those published since 1980. Not much was published on vegans before that time.
Lipids are fat-soluble substances, including cholesterol and fatty acids. Blood lipid measurements generally include total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides.
Total cholesterol is a measure of all the various types of cholesterol in the blood. Cholesterol can be separated according to the lipoprotein that carries it in the blood. Cholesterol carried by low-density lipoproteins (LDL) is considered “bad” because it tends to be deposited on the artery walls, causing heart disease. Cholesterol carried by high-density lipoproteins (HDL) is considered “good” because it tends to be taken to the liver where it is then broken down or excreted into the digestive tract in the form of bile. Dietary fiber (especially soluble) can then bind to some and it will be excreted in the stool.
There are also other lipoproteins, such as very low density lipoproteins (VLDL). They will not be examined here as they have not been measured in many vegans.
Cholesterol in EPIC-Oxford (2013)
The most recent report of cholesterol in vegans is from the EPIC-Oxford study in which vegetarians were compared to meat-eaters with healthy lifestyles (Bradbury, 2013). The results are in Table 1 and show vegans to have a 34 mg/dl and 23 mg/dl lower cholesterol level than meat-eaters for men and women respectively. Most of this difference was in the non-HDL cholesterol. Adjusting the results for body mass index reduced the difference by 13% for men and 17% for women.
Vegans also had a significantly lower amount of apolipoprotein B which is thought to promote fat deposits in the arteries.
The authors of the study suggest that vegans have lower cholesterol levels due to a lower body mass index, replacement of saturated fats with polyunsaturated fats, and higher fiber intakes.
|Table 1. Cholesterol Levels in EPIC-Oxford (2013) in mg/dl|
|Total Cholesterol||170||188||196||204||< .001|
|Apolipoprotein B||82||89||93||100||< .001|
|Total Cholesterol||172||184||188||195||< .001|
|Apolipoprotein B||76||81||82||87||< .001|
Source: Bradbury, 2013
Results adjusted for age, alcohol, and physical activity.
Cholesterol in Western Vegans (1980 – 2002)
Between 1980 and 2002, cholesterol levels of vegans living in Western countries was measured in 17 studies. The average cholesterol level of vegans was 160 compared to 202 mg/dl for non-vegetarians. Table 2 shows the results.
|Table 2. Cholesterol in Western Vegans (1980-2002)|
|Cholesterol : HDL||3.1||3.3||3.2||3.7|
aNumber of people measured
Sources: Allen, 2000; Bissoli, 2002; Fisher, 1986; Fokkema, 2000; Haddad, 1999; Krajcovicová-Kudlácková, 2000; Kritchevsky, 1984; Li, 1999; Lock, 1982; Roshanai, 1984; Sanders, 1978; Sanders, 1987; Sanders, 1992; Thomas, 1996; Thorogood, 1987; Thorogood, 1990; Toohey, 1998;
Cholesterol in USA Vegans
Of the 17 studies in Table 2, five were of vegans living in the USA. Of those studies, the lowest average finding for total cholesterol for vegans was 135 mg/dl. The data from all 5 studies is compiled in Table 3. The total cholesterol of the 135 vegans averaged out to 146 mg/dl.
|Table 3. Cholesterol in USA Vegans|
|Cholesterol : HDL||3.2||3.5||3.7|
|aNumber of people measured
Sources: Fisher, 1986; Haddad, 1999; Kritchevsky, 1984; Lock, 1982; Toohey, 1998
Elevated triglycerides are generally thought to increase the risk for heart disease. However, there is a debate as to whether moderately high triglycerides are merely associated with other risk factors for heart disease, while not being a cause in themselves. Normal triglycerides for adults is 40-160 mg/dl for men and 35-135 mg/dl for women (Fischbach, 2000). Triglyceride levels above 250 mg/dl are more of a concern (Fischbach, 2000).
Some people are concerned that, although a vegan diet can lower cholesterol levels, it may increase triglyceride levels. As can be seen from Table 4, in the 11 studies that measured triglycerides, vegans were shown to have lower levels than lacto-ovo and non-veg.
|Table 4. Triglycerides in Western Vegans|
|aNumber of people measured
Sources: Bissoli, 2002; Fisher, 1986; Fokkema, 2000; Haddad, 1999; Krajcovicová-Kudlácková, 2000; Kritchevsky, 1984; Lock, 1982; Roshanai, 1984; Sanders, 1992; Thomas, 1996; Toohey, 1998
The total cholesterol of Western vegans averages out to 160 mg/dl. This is 40 points lower than the non-vegetarians in these studies and well below the “desirable” level of less than 200 mg/dl according to the National Heart Lung and Blood Institute. It is possible to eat a vegan diet that is high in fat and hydrogentaed oils and is highly processed with little fiber. This sort of diet might not provide the benefits seen in the studies compiled above. Additionally, some people have a strong genetic predisposition to high cholesterol. The American Heart Association recommends that people over the age of 20 have their cholesterol levels checked every 4 to 6 years (American Heart Association, 2018).
In 2009, preliminary cross-sectional data from Adventist Health Study-2 was reported based on a population of about 89,000 people in which 43.7% were regular meat-eaters, 8.3% were semi-vegetarian, 9.7% were pesco-vegetarian, 34.0% were lacto-ovo vegetarian, and 4.3% were vegan. The prevalence of self-reported high blood pressure is shown in the table below. Vegans had a considerably lower prevalence of high blood pressure. Results were not adjusted for smoking.
|Prevalence of High Blood Pressure in AHS-2 (2009)|
|Prevalence||1.00||.77 (.72-.82)||.62 (.59-.66)||.45 (.44-.47)||.25 (.22-.28)|
Source: Fraser, 2009
Adjusted for age, gender, and race.
In 2012, a more thorough, cross-sectional report was published from Adventist Health Study-2. It included only white people, and results didn’t appear to be adjusted for anything. Rates for having high blood pressure are shown in Table 12; vegans had had a considerably lower rate of high blood pressure.
|Table 12. Relative Rates of High Blood Pressure in AHS-2 (2012)|
|RateA||1.00||.92 (.50-1.70)||.57 (.36-.92)||.37 (.19-.74)|
|Rate adjusted for BMI||1.00||1.22 (.64-2.33)||.86 (.51-1.45)||.53 (.25-1.11)|
Source: Pettersen, 2012
A. Not adjusted.
In 2002, EPIC-Oxford reported the rates of high blood pressure in different diet groups. Vegans had significantly lower rates of high blood pressure than meat-eaters (P <.0005). Adjusting for BMI removed the statistical significance for women.
|Blood Pressure in EPIC-Oxford (2002)|
|Number of Women||3,741||1,431||3,014||467|
|High Blood Pressure||12%||10%||9%||8%|
|Number of Men||996||297||786||272|
|High Blood Pressure||15%||10%||10%||6%|
Source: Appleby, 2002
Self-reported, adjusted for age.
Vegetarians and Blood Pressure Meta-Analysis
In 2014, researchers from Japan published a meta-analysis of clinical trials and cross-sectional observational studies of a vegetarian diet and blood pressure (Yokoyama, 2014). Many of these vegetarians were actually semi-vegetarians. Among seven clinical trials, a vegetarian diet was found to reduce systolic and diastolic blood pressure by an average of 4.8 and 2.2 mm Hg, respectively. Among the 32 cross-sectional studies, vegetarians were found to have a lower systolic and diastolic blood pressure of 6.9 and 4.7 mm Hg respectively. These findings were statistically significant. The authors said, “According to Whelton et al, a reduction in systolic BP of 5 mm Hg would be expected to result in a 7%, 9%, and 14% overall reduction in mortality due to all causes, coronary heart disease, and stroke, respectively.”
Why Do Vegans Have Lower Blood Pressure?
EPIC-Oxford (Appleby, 2002) and Adventist Health Study-2 (Pettersen, 2012) found lower body mass index explained most of the differences in blood pressure among the diet groups. Other contributory factors could be higher consumption of potassium, lower consumption of sodium, modulation of baroreceptor sensitivity, direct vasodilatory effects, changes in catecholamine and renin–angiotensin–aldosterone metabolism, improvement of glucose tolerance with lower insulin levels, and lower blood viscosity in vegetarians (Pettersen, 2012).
Body Mass Index
Body mass index (BMI) is measured by taking one’s weight in kilograms and dividing it by their height in meters squared (i.e., kg/m2). It is a way of measuring weight while taking into consideration differences in height. A healthy BMI is considered to be between 20 and 25. Generally, a BMI of 30 or higher is considered obese (Mahan, 2000).
Recent research has shown that a BMI of 22.5 to 25.0 is associated with the lowest mortality rate. It has been known for some time that a lower BMI has been associated with an increased risk of death, but that was thought to be due mostly to smoking-related diseases. A 2009 meta-analysis of 900,000 people found that even in those who never smoked, there is a slight increase in mortality below a BMI of 22.5 (Whitlock, 2009). The excess mortality below 22.5 has not been explained. One theory is that the excess mortality might be due to lower fat-free mass, which would most likely be lower muscle mass (though could also technically be bones, or even some organs) (Whitlock, 2009, Wändell, 2009). Studies on BMI and mortality to date have not differentiated between fat and fat-free body mass.
2013 Report from Adventist Health Study-2
In 2013, cross-sectional data on BMI were released from the Adventist health Study-2 (Orlich, 2013).
|Table 7. Body Mass Index in Adventist Health Study-2 (2013)|
Source: Orlich, 2013
BMI—Body Mass Index • Semi-Veg—eat red meat and poultry ≥ 1 time per month and < 1 time per week • aNumber of people measured • Adjusted for age, sex, race
In AHS-2, vegans had a lower BMI than all other diet groups. The study wasn’t focused on BMI, and the report didn’t mention testing for statistical significance.
2003 Report From EPIC-Oxford
A report on BMI from EPIC-Oxford was published in 2003. Results are in Table 8.
|Table 8. Body Mass Index in EPIC-Oxford (2003)|
Source: Spencer, 2003
Body Mass Index = kg/m2 • Adjusted for age, smoking, education level, physical activity, marital status, ethnicity, parity. • Differences between the vegans and other groups were statistically significant. • aNumber of people measured
The differences between the vegans and meat-eaters was accounted for mostly by differences in protein, polyunsaturated fat, and fiber intake. The authors note that protein intake’s influence on weight has not been reported often in the literature, but there is some mention of it altering hormones in a way that increases abdominal fat. They also note that low fiber intakes have been previously associated with higher body weight and this is thought to be via making people feel full on less calories, insulin control, and reducing fat absorption.
Body Mass Index Over Time as a Vegan
A 1996 letter to the editor of the British Medical Journal from the authors of the EPIC-Oxford study (Key, 1996) reported BMI according to the time on current diet (less than or greater than 5 years). The number in each group were:
- 1,652 Vegan
- 8,827 Lacto-Ovo
- 3,776 Pesco
- 6,850 Non-Veg
The actual BMIs were not given, but a graph was provided (which can be viewed at bmj.com/cgi/content/full/313 /7060/816/F1). The graph shows that those on a vegan diet for more than 5 years had the lowest BMI, followed by those on a vegan diet for less than 5 years, for both men and women. This is impressive, as most weight loss is not sustained for more than one year. Of course, weight loss can sometimes be difficult even for vegans, and some people actually gain weight after becoming vegan. But, on average, the evidence supports the notion that becoming vegan is conducive to permanent weight loss.
In 2006, a report from EPIC-Oxford (Rosell, 2006) showed that over a 5 year period, vegans had the lowest weight-gain compared to meat-eaters, fish-eaters, and lacto-ovo vegetarians. The group who had switched to a diet of eating less animal products had the lowest weight gain of all. The group of people who reverted to a diet of more animal products had the most weight-gain, but this was not statistically significant. All groups had some weight gain over the 5 year period.
What does it matter if vegans weigh less if they simply have less muscle mass? Above (Table 9) we saw that vegans have an average BMI of about 22.2 to 22.5, which is right in the middle of the healthy range of 20 to 25. So, vegans are not too thin. But what if a lower percentage of their body weight is muscle (which would mean that a higher percentage of their body weight is fat)?
Table 10 lists the studies that measured percentage of body fat or skinfold thickness (an indicator of body fat) in vegans. Determining the percentage of body fat can vary greatly from method to method, so averaging the results would not be appropriate. Instead, we should look at the general trend. In the 5 comparisons made, the vegans had lower body fat in all five. In three of those comparisons, the differences were statistically significant.
|Table 10. Percentage of Body Fat in Vegans|
21 M & 17 F
6 M & 5 F
20 M & 19 F
|None. Vegans had more men.||Not SSa|
|Vegans slightly older.||P < .05a|
|Vegans were older.||P < .05a|
|Tricep Skinfold Thickness|
11 M13.5 mm
11 M17.3 mm
|Matched for age, body build. Energy intake did not differ.||NR|
|Sum of skinfold measurements|
12 M & 10 F
12M & 10 F
|Matched for age, height, ethnic, socio economic status.||P < .01a|
|F—female • M—male • NR—not reported • SS—statistical significance • P—the % chance that the finding was due to random chance • aStatistically significant between vegans and non-veg
A. Thomas, 1996
B. Janelle, 1995
C. Ross, 1990
D. Sanders, 1987
E. Sanders, 1978
So, we now know that vegans have lower BMIs and they also tend to have lower body fat percentage (though the numbers measured are small).
There is one marker of cardiovascular disease for which some vegans are at a disadvantage—homocysteine. Elevated homocysteine is associated with chronic disease, and numerous studies have measured homocysteine in vegans and found elevated levels in those who don’t have a regular source of vitamin B12. For more information, please see Homocysteine and Mild B12 Deficiency in Vegans.
In summary, the evidence shows:
- Vegans have lower total cholesterol, LDL cholesterol, and triglycerides, while having about the same HDL cholesterol as
lacto-ovo and non-veg.
- Vegans have lower rates of high blood pressure than lacto-ovo and non-veg.
- Vegans have a lower BMI and body fat percentage than lacto-ovo and non-veg. People who have been vegan for more than
5 years have the lowest BMI of all diet groups studied here.
Last updated September 2018
Allen, 2000. Allen NE, Appleby PN, Davey GK, Key TJ. Hormones and diet: low insulin-like growth factor-I but normal bioavailable androgens in vegan men. Br J Cancer. 2000 Jul;83(1):95-7.
American Heart Association, 2018. American Heart Association. What Your Cholesterol Levels Mean. Updated May 3, 2018. Accessed June 17, 2018.
Appleby PN, Thorogood M, Mann JI, Key TJ. The Oxford Vegetarian Study: an overview. Am J Clin Nutr. 1999 Sep;70(3 Suppl):525S-531S. Not cited.
Appleby, 2002. Appleby PN, Davey GK, Key TJ. Hypertension and blood pressure among meat eaters, fish eaters, vegetarians and vegans in EPIC-Oxford. Public Health Nutr. 2002 Oct;5(5):645-54.
Bissoli, 2002. Bissoli L, Di Francesco V, Ballarin A, Mandragona R, Trespidi R, Brocco G, Caruso B, Bosello O, Zamboni M. Effect of vegetarian diet on homocysteine levels. Ann Nutr Metab. 2002;46(2):73-9.
Bradbury, 2013. Bradbury KE, Crowe FL, Appleby PN, Schmidt JA, Travis RC, Key TJ. Serum concentrations of cholesterol, apolipoprotein A-I and apolipoprotein B in a total of 1694 meat-eaters, fish-eaters, vegetarians and vegans. Eur J Clin Nutr. 2014 Feb;68(2):178-83. Epub 2013 Dec 18.
Fischbach, 2000. Fischbach F. A Manual of Laboratory & Diagnostic Tests, 6th Ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.
Fisher, 1986. Fisher M, Levine PH, Weiner B, Ockene IS, Johnson B, Johnson MH, Natale AM, Vaudreuil CH, Hoogasian J. The effect of vegetarian diets on plasma lipid and platelet levels. Arch Intern Med. 1986 Jun;146(6):1193-7.
Fokkema, 2000. Fokkema MR, Brouwer DA, Hasperhoven MB, Martini IA, Muskiet FA. Short-term supplementation of low-dose gamma-linolenic acid (GLA), alpha-linolenic acid (ALA), or GLA plus ALA does not augment LCP omega 3 status of Dutch vegans to an appreciable extent. Prostaglandins Leukot Essent Fatty Acids. 2000 Nov;63(5):287-92.
Fraser, 2009. Fraser GE. Vegetarian diets: what do we know of their effects on common chronic diseases? Am J Clin Nutr. 2009 May;89(5):1607S-1612S. Epub 2009 Mar 25. Review. Erratum in: Am J Clin Nutr. 2009 Jul;90(1):248.
Haddad, 1999. Haddad EH, Berk LS, Kettering JD, Hubbard RW, Peters WR. Dietary intake and biochemical, hematologic, and immune status of vegans compared with nonvegetarians. Am J Clin Nutr. 1999 Sep;70(3 Suppl):586S-593S.
Herrmann W, Schorr H, Purschwitz K, Rassoul F, Richter V. Total homocysteine, vitamin B(12), and total antioxidant status in vegetarians. Clin Chem. 2001 Jun;47(6):1094-101. Not cited.
Janelle, 1995. Janelle KC, Barr SI. Nutrient intakes and eating behavior scores of vegetarian and nonvegetarian women. J Am Diet Assoc. 1995 Feb;95(2):180-6, 189, quiz 187-8.
Key, 1996. Key T, Davey G. Prevalence of obesity is low in people who do not eat meat. BMJ. 1996 Sep 28;313(7060):816–817.
Krajcovicová-Kudlácková, 2000. Krajcovicová-Kudlácková M, Blazícek P, Babinská K, Kopcová J, Klvanová J, Béderová A, Magálová T. Traditional and alternative nutrition–levels of homocysteine and lipid parameters in adults. Scand J Clin Lab Invest. 2000 Dec;60(8):657-64.
Kritchevsky, 1984. Kritchevsky D, Tepper SA, Goodman G. Diet, nutrition intake, and metabolism in populations at high and low risk for colon cancer. Relationship of diet to serum lipids. Am J Clin Nutr. 1984 Oct;40(4 Suppl):921-6.
Li, 1999. Li D, Sinclair A, Mann N, Turner A, Ball M, Kelly F, Abedin L, Wilson A. The association of diet and thrombotic risk factors in healthy male vegetarians and meat-eaters. Eur J Clin Nutr. 1999 Aug;53(8):612-9.
Lock, 1982. Lock DR, Varhol A, Grimes S, Patsch W, Schonfeld G. Apolipoprotein E levels in vegetarians. Metabolism. 1982 Sep;31(9):917-21.
Mahan, 2000. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, & Diet Therapy, 10th Ed. Philadelphia, PA: W.B. Saunders, Co. 2000.
Orlich, 2013. Orlich MJ, Singh P, Sabaté J, et al. Vegetarian Dietary Patterns and Mortality in Adventist Health Study 2. JAMA Intern Med. 2013;():1-8.
Pettersen, 2012. Pettersen BJ, Anousheh R, Fan J, Jaceldo-Siegl K, Fraser GE. Vegetarian diets and blood pressure among white subjects: results from the Adventist Health Study-2 (AHS-2). Public Health Nutr. 2012 Oct;15(10):1909-16. Epub 2012 Jan 10.
Rosell, 2006. Rosell M, Appleby P, Spencer E, Key T. Weight gain over 5 years in 21,966 meat-eating, fish-eating, vegetarian, and vegan men and women in EPIC-Oxford. Int J Obes (Lond). 2006 Sep;30(9):1389-96. Epub 2006 Mar 14.
Roshanai, 1984. Roshanai F, Sanders TA. Assessment of fatty acid intakes in vegans and omnivores. Hum Nutr Appl Nutr. 1984 Oct;38(5):345-54.
Ross, 1990. Ross JK, Pusateri DJ, Shultz TD. Dietary and hormonal evaluation of men at different risks for prostate cancer: fiber intake, excretion, and composition, with in vitro evidence for an association between steroid hormones and specific fiber components. Am J Clin Nutr. 1990 Mar;51(3):365-70.
Sacks FM, Wood PG, Kass EH. Stability of blood pressure in vegetarians receiving dietary protein supplements. Hypertension. 1984 Mar-Apr;6(2 Pt 1):199-201. Not cited.
Sanders, 1978. Sanders TA, Ellis FR, Dickerson JW. Studies of vegans: the fatty acid composition of plasma choline phosphoglycerides, erythrocytes, adipose tissue, and breast milk, and some indicators of susceptibility to ischemic heart disease in vegans and omnivore controls. Am J Clin Nutr. 1978 May;31(5):805-13.
Sanders, 1987. Sanders TA, Key TJ. Blood pressure, plasma renin activity and aldosterone concentrations in vegans and omnivore controls. Hum Nutr Appl Nutr. 1987 Jun;41(3):204-11.
Sanders, 1992. Sanders TA, Roshanai F. Platelet phospholipid fatty acid composition and function in vegans compared with age- and sex-matched omnivore controls. Eur J Clin Nutr. 1992 Nov;46(11):823-31.
Spencer, 2003. Spencer EA, Appleby PN, Davey GK, Key TJ. Diet and body mass index in 38000 EPIC-Oxford meat-eaters, fish-eaters, vegetarians and vegans. Int J Obes Relat Metab Disord. 2003 Jun;27(6):728-34.
Thomas, 1996. Thomas EL, Frost G, Barnard ML, Bryant DJ, Taylor-Robinson SD, Simbrunner J, Coutts GA, Burl M, Bloom SR, Sales KD, Bell JD. An in vivo 13C magnetic resonance spectroscopic study of the relationship between diet and adipose tissue composition. Lipids. 1996 Feb;31(2):145-51.
Thorogood, 1987. Thorogood M, Carter R, Benfield L, McPherson K, Mann JI. Plasma lipids and lipoprotein cholesterol concentrations in people with different diets in Britain. Br Med J (Clin Res Ed). 1987 Aug 8;295(6594):351-3.
Thorogood, 1990. Thorogood M, Roe L, McPherson K, Mann J. Dietary intake and plasma lipid levels: lessons from a study of the diet of health conscious groups. BMJ. 1990 May 19;300(6735):1297-301.
Tonstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care. 2009 May;32(5):791-6. Epub 2009 Apr 7. Not cited.
Toohey, 1998. Toohey ML, Harris MA, DeWitt W, Foster G, Schmidt WD, Melby CL. Cardiovascular disease risk factors are lower in African-American vegans compared to lacto-ovo-vegetarians. J Am Coll Nutr. 1998 Oct;17(5):425-34.
Wändell, 2009. Wändell PE, Carlsson AC, Theobald H. The association between BMI value and long-term mortality. Int J Obes (Lond). 2009 May;33(5):577-82.
Whitlock, 2009. Prospective Studies Collaboration, Whitlock G, Lewington S, Sherliker P, Clarke R, Emberson J, Halsey J, Qizilbash N, Collins R, Peto R. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009 Mar 28;373(9669):1083-96.
Yokoyama, 2014. Yokoyama Y, Nishimura K, Barnard ND, Takegami M, Watanabe M, Sekikawa A, Okamura T, Miyamoto Y. Vegetarian Diets and Blood Pressure: A Meta-analysis. JAMA Intern Med. 2014 Feb 24.
2 thoughts on “Cardiovascular Disease Markers of Vegans”
Do you know a good database that lists the amount of sugar and kinds of sugars in plants? Due to a genetic disorder I can’t digest 5 kinds of sugars including fructose and have been looking for a good database that contains information about the amount and type of sugars in Whole food plants since I eat a WFPB diet and know all plants contain sugar
Hi Bill, the USDA’s FoodData Central is a free nutrition database. It provides sugar breakdowns for some foods but not all – that is a good place to start.