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Comparison of gut microbiota profile in celiac disease, non-celiac gluten sensitivity and irritable bowel syndrome: A systematic review.
Transeth, EL, Dale, HF, Lied, GA
The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology. 2020;31(11):735-745
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Dysbiosis refers to a disturbance in the quantity and composition of the gut microbiota, and this shift in the microbiota profile is associated with a variety of GI disorders including celiac disease (CD), irritable bowel syndrome (IBS) and non-celiac gluten sensitivity (NCGS). There is no current clinical distinction between IBS and NCGS although it is hypothesised the characteristics of gut microbiota of these clinical presentations may overlap. The aim of this review is to analyse the gut microbiota profile in these three diagnoses. Thirteen trials were included in this review and show the bacterial composition of the gut microbiota of patients with CD and IBS shared many similarities when compared to healthy controls, including an overall reduction in microbial abundance. There were fewer similarities between IBS and NCGS, in part due to the lack of existing literature. Based on these findings, the authors suggest the bacterial profiles of patients CD and IBS share certain disease-specific trends. While the current data is limited, the authors hope these suggested trends influence further research to examine the overlap between NCGS and IBS and distinguish differential diagnostic and treatment plans.
Abstract
Gut microbiota is vital for human health. Shifts in the microbial diversity can affect bacterial function, and dysbiosis is associated with a variety of gastrointestinal disorders, including celiac disease (CD) and irritable bowel syndrome (IBS). The distinction between IBS and non-celiac gluten sensitivity (NCGS) is unclear, and it is conceivable that the gut microbiota profile of these patients may overlap. To our knowledge, no existing literature has evaluated the microbial characteristics in CD, IBS, and NCGS. Hence, this systematic review aims to compare the gut microbiota profile in these three diagnoses. A literature search was conducted in PubMed (Medline) until April 2019. Studies investigating bacterial diversity in the gut of patients with CD, IBS, and NCGS were eligible. Inclusion criteria were observational studies and randomized controlled trials reporting bacterial profile at baseline. Ninety-one articles were identified, of which 13 trials were eligible for inclusion. Overall, the bacterial composition of the gut microbiota of patients with CD and those with IBS shared the many similarities. The microbial richness was correspondingly reduced in these patient-groups compared with healthy controls, but this was not reported for NCGS. Our findings suggest that the bacterial profiles of patients with IBS and CD share certain disease-specific trends. Fewer similarities were observed between the bacterial profiles of patients with IBS and NCGS. Notably, the data are limited; thus, no solid conclusions can be made on the basis of these findings alone. The suggested trends can be a valuable basis for further research.
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Comparing eating behaviours, and symptoms of depression and anxiety between Spain and Greece during the COVID-19 outbreak: Cross-sectional analysis of two different confinement strategies.
Papandreou, C, Arija, V, Aretouli, E, Tsilidis, KK, Bulló, M
European eating disorders review : the journal of the Eating Disorders Association. 2020;28(6):836-846
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Stress and mental health problems which may be induced by restrictions imposed during the Covid-19 pandemic can lead to unhealthy eating habits. Restrictions have varied amongst countries and this cross-sectional analysis aimed to compare eating behaviours and symptoms of stress experienced by 1841 individuals in countries with differing lockdown measures. The results showed that individuals in the country with higher lockdown measures showed lower restraint in eating, they were more likely to overeat if they saw or smelt food and reported increased anxiety. However, they did not display depression or overeating when experiencing negative feelings. It was concluded that both countries had a high frequency of depression and anxiety. Higher restrictions were associated with greater anxiety, lower restraint and overeating when confronted with food. This paper could be used by healthcare professionals to recognise the need to include dietary advice when dealing with patients who are reporting anxiety during the current Covid-19 pandemic.
Abstract
OBJECTIVE We compared eating behaviours, and depressive and anxiety symptoms in two countries with different confinement strictness strategies and different levels of COVID-19 pandemic. METHOD A web-based cross-sectional survey was administered during and shortly after the COVID-19 related lockdown in Spain and Greece. Multivariable linear regression analyses were performed to identify country differences associated with eating behaviour, and symptoms of depression and anxiety. RESULTS This study included 1,002 responders in Spain and 839 in Greece. The mean ± SD of restraint, emotional and external eating was 2.5 ± 0.79, 2.1 ± 0.81 and 2.6 ± 0.65 in Spain, whereas 2.7 ± 0.85, 2.3 ± 0.99 and 2.9 ± 0.74 in Greece. Spanish participants had lower average scores of restraint and external eating compared to Greek participants (p < .001), but no difference was seen for emotional eating. In Spain, 13.6%, and 12.3% of the survey respondents reported moderate to severe depressive and anxiety symptoms, respectively, whereas in Greece the respective values were 18.8 and 13.2%. After adjusting for several risk factors, a higher prevalence of anxiety symptoms was observed in Spain compared to Greece (p = .001), but no difference was seen for depressive symptoms. CONCLUSIONS This study demonstrated high scores of inappropriate eating behaviours and a high frequency of depressive and anxiety symptoms in two Mediterranean countries during the COVID-19 outbreak. Our findings revealed that compared to Greek participants, Spanish participants, that faced more severe COVID-19 pandemic and stricter lockdown measures, were associated with lower restraint and external eating and increased anxiety symptoms, but not with depressive symptoms or emotional eating.
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Systematic review and meta-analysis of the associations of vegan and vegetarian diets with inflammatory biomarkers.
Menzel, J, Jabakhanji, A, Biemann, R, Mai, K, Abraham, K, Weikert, C
Scientific reports. 2020;10(1):21736
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A growing trend towards vegetarianism and veganism has emerged in the past few years. Evidence has led to the assumption that these diets may protect against chronic disease, and one potential mechanism is through the modulation of inflammatory biomarkers. The aim of this review was to investigate the associations of veganism and vegetarianism with inflammatory markers. From the 21 cross-sectional studies included in this study, both vegan and vegetarian diets were associated with lower levels of CRP compared to omnivores. There was no association with all other inflammatory markers. Based on these findings, the authors conclude there is evidence for both vegan and vegetarian diets reducing CRP, a major marker of low-grade inflammation. More research is needed as most inflammatory markers have only been investigated in single studies thus far.
Abstract
Plant-based diets like vegetarian or vegan diets might influence circulating levels of inflammatory biomarkers, thereby reducing the risk of chronic diseases. This systematic review and meta-analysis aimed to investigate the associations of veganism and vegetarianism with circulating inflammatory biomarkers in comparison to omnivores. Literature search was conducted in Pubmed and EMBASE until April 2020 and mean differences of biomarkers were assessed for: C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-18 (IL-18), interleukin-1 receptor antagonist (IL-1 RA), tumor necrosis factor-alpha (TNF-ɑ), E-selectin, intercellular adhesion molecule-1 (ICAM-1), monocyte chemoattractant protein-1 (MCP-1), adiponectin, omentin-1 and resistin. Of initially identified 1073 publications, 21 cross-sectional studies met the inclusion criteria and were included in the systematic review and meta-analysis. Vegan diet was associated with lower levels of CRP compared to omnivores [mean difference - 0.54 mg/l, 95%-CI: - 0.79 to - 0.28, p < 0.0001]. This association was less pronounced in vegetarians [mean difference - 0.25 mg/l, 95%-CI: - 0.49 to 0.00, p = 0.05]. In patients with impaired kidney function, the association between vegetarian nutrition and CRP was much stronger with - 3.91 mg/l (95%-CI: - 5.23 to - 2.60; p < 0.0001). No substantial effects were observed for all other inflammatory biomarkers. Despite strong associations between CRP and a vegan or vegetarian diet were seen, further research is needed, as most inflammatory biomarkers were investigated only in single studies so far.
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Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies.
Toews, I, Lohner, S, Küllenberg de Gaudry, D, Sommer, H, Meerpohl, JJ
BMJ (Clinical research ed.). 2019;364:k4718
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Consumption of non-sugar sweeteners (NSS) has recently increased due to an emphasis on a low sugar diet. However, the exact health effects of this switch are uncertain. The aim of this systematic review and meta-analysis of 56 randomised and non-randomised trials aimed to determine the health effects of NSS’s in adults and children. The results showed that amongst adults body weight, blood sugar, daily energy intake, and blood pressure were all lower when exposed to NSS’s. Other health measures such as cancer and neurological disorders remained unaffected. Amongst children blood sugar was significantly higher and a small increase in body mass index was also observed when exposed to NSS’s. It was concluded that most health outcomes were unaffected by NSS’s, and there appears to be no health benefits on a broad range of outcomes when switching from sugar. Potential harm from regular NSS consumption could not be ruled out from this study. Healthcare professionals could use this study to understand that recommending diets which switch from sugar to NSS’s may have limited health benefits.
Abstract
OBJECTIVE To assess the association between intake of non-sugar sweeteners (NSS) and important health outcomes in generally healthy or overweight/obese adults and children. DESIGN Systematic review following standard Cochrane review methodology. DATA SOURCES Medline (Ovid), Embase, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and reference lists of relevant publications. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies including generally healthy adults or children with or without overweight or obesity were eligible. Included study designs allowed for a direct comparison of no intake or lower intake of NSS with higher NSS intake. NSSs had to be clearly named, the dose had to be within the acceptable daily intake, and the intervention duration had to be at least seven days. MAIN OUTCOME MEASURES Body weight or body mass index, glycaemic control, oral health, eating behaviour, preference for sweet taste, cancer, cardiovascular disease, kidney disease, mood, behaviour, neurocognition, and adverse effects. RESULTS The search resulted in 13 941 unique records. Of 56 individual studies that provided data for this review, 35 were observational studies. In adults, evidence of very low and low certainty from a limited number of small studies indicated a small beneficial effect of NSSs on body mass index (mean difference -0.6, 95% confidence interval -1.19 to -0.01; two studies, n=174) and fasting blood glucose (-0.16 mmol/L, -0.26 to -0.06; two, n=52). Lower doses of NSSs were associated with lower weight gain (-0.09 kg, -0.13 to -0.05; one, n=17 934) compared with higher doses of NSSs (very low certainty of evidence). For all other outcomes, no differences were detected between the use and non-use of NSSs, or between different doses of NSSs. No evidence of any effect of NSSs was seen on overweight or obese adults or children actively trying to lose weight (very low to moderate certainty). In children, a smaller increase in body mass index z score was observed with NSS intake compared with sugar intake (-0.15, -0.17 to -0.12; two, n=528, moderate certainty of evidence), but no significant differences were observed in body weight (-0.60 kg, -1.33 to 0.14; two, n=467, low certainty of evidence), or between different doses of NSSs (very low to moderate certainty). CONCLUSIONS Most health outcomes did not seem to have differences between the NSS exposed and unexposed groups. Of the few studies identified for each outcome, most had few participants, were of short duration, and their methodological and reporting quality was limited; therefore, confidence in the reported results is limited. Future studies should assess the effects of NSSs with an appropriate intervention duration. Detailed descriptions of interventions, comparators, and outcomes should be included in all reports. SYSTEMATIC REVIEW REGISTRATION Prospero CRD42017047668.
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Micronutrient Gaps in Three Commercial Weight-Loss Diet Plans.
G Engel, M, J Kern, H, Brenna, JT, H Mitmesser, S
Nutrients. 2018;10(1)
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Globally, around 39% of adults are overweight and 13% obese, and more than one third of American adults are obese. Being overweight or obese is associated with many chronic conditions, such as heart disease, high blood pressure and type 2 diabetes. Weight loss, even at moderate level, can reduce the risk of these obesity-related chronic conditions. Commercial weight-loss diet plans can vary greatly, not only in energy content but also in macronutrient and micronutrient composition. Most plans restrict calories or certain macronutrients, particularly carbohydrate or fat, and in doing so, often overlook micronutrient, i.e. vitamin and mineral, content. Previous studies have shown that many weight-loss plans do not provide adequate amounts of all micronutrients, and in order to reach the reference daily intakes for various vitamins and minerals, dieters would need to increase their calorie intake significantly and often unrealistically. The authors of this paper analysed seven single-day menus of three select commercial diet plans to determine their micronutrient sufficiency. The diet plans included were Eat to Live-Vegan, Aggressive Weight Loss (ETL-VAWL), Fast Metabolism Diet (FMD), and Eat, Drink and Be Healthy (EDH). ETL-VAWL diet provided less than 90% of recommended amounts for B12, B3, D, E, calcium, selenium and zinc. The FMD diet was low in B1, D, E, calcium, magnesium and potassium, while EDH diet didn’t meet the recommended amounts for vitamin D, calcium and potassium. Even after adjusting all the plans to an intake of 2000 kcal/day, several micronutrients were found to remain inadequate (vitamin B12 in ETL-VAWL, calcium in FMD and EDH and vitamin D in all diets). The authors conclude that, in order to reduce the risk of micronutrient deficiencies, more attention needs to be paid to micronutrient rich foods when designing commercial diet plans. Alternatively, these nutrient gaps should be filled in other ways, e.g. using appropriate dietary supplements.
Abstract
Weight-loss diets restrict intakes of energy and macronutrients but overlook micronutrient profiles. Commercial diet plans may provide insufficient micronutrients. We analyzed nutrient profiles of three plans and compared their micronutrient sufficiency to Dietary Reference Intakes (DRIs) for male U.S. adults. Hypocaloric vegan (Eat to Live-Vegan, Aggressive Weight Loss; ETL-VAWL), high-animal-protein low-carbohydrate (Fast Metabolism Diet; FMD) and weight maintenance (Eat, Drink and Be Healthy; EDH) diets were evaluated. Seven single-day menus were sampled per diet (n = 21 menus, 7 menus/diet) and analyzed for 20 micronutrients with the online nutrient tracker CRON-O-Meter. Without adjustment for energy intake, the ETL-VAWL diet failed to provide 90% of recommended amounts for B12, B₃, D, E, calcium, selenium and zinc. The FMD diet was low (<90% DRI) in B₁, D, E, calcium, magnesium and potassium. The EDH diet met >90% DRIs for all but vitamin D, calcium and potassium. Several micronutrients remained inadequate after adjustment to 2000 kcal/day: vitamin B12 in ETL-VAWL, calcium in FMD and EDH and vitamin D in all diets. Consistent with previous work, micronutrient deficits are prevalent in weight-loss diet plans. Special attention to micronutrient rich foods is required to reduce risk of micronutrient deficiency in design of commercial diets.
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Integrated Evaluation of the Potential Health Benefits of Einkorn-Based Breads.
Antognoni, F, Mandrioli, R, Bordoni, A, Di Nunzio, M, Viadel, B, Gallego, E, Villalba, MP, Tomás-Cobos, L, Taneyo Saa, DL, Gianotti, A
Nutrients. 2017;9(11)
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While health benefits of whole grains has been long established, recent findings suggest ancient grains may provide additional cardiovascular and anti-inflammatory benefits. Einkorn is an ancient crop that has a favourable biochemical makeup however very little research exists on its properties. The aim of this study was to evaluate the nutritional characteristics and health benefits of eikorn-based bread compared to wheat-based breads. Both types of grains were subject to either conventional fermentation with baker’s yeast or sourdough fermentation with lactic acid. Breads were digested in-vitro using the Dynamic Gastrointestinal Digestor, a controlled system that simulates the in vivo digestion process. Bread content was characterised before and after digestion, and the product of their digestion was used to evaluate anti-inflammatory effects. The primary finding of this study was a significantly higher carotenoid level in einkorn compared to modern wheat. Additionally, the use of sourdough fermentation aided to preserve these carotenoids, thus improving the availability and accessibility of nutrient absorption in the final product. Based on this study, the authors conclude einkorn is a good candidate to produce bakery products with enhanced nutritional properties.
Abstract
Nowadays the high nutritional value of whole grains is recognized, and there is an increasing interest in the ancient varieties for producing wholegrain food products with enhanced nutritional characteristics. Among ancient crops, einkorn could represent a valid alternative. In this work, einkorn flours were analyzed for their content in carotenoids and in free and bound phenolic acids, and compared to wheat flours. The most promising flours were used to produce conventional and sourdough fermented breads. Breads were in vitro digested, and characterized before and after digestion. The four breads having the best characteristics were selected, and the product of their digestion was used to evaluate their anti-inflammatory effect using Caco-2 cells. Our results confirm the higher carotenoid levels in einkorn than in modern wheats, and the effectiveness of sourdough fermentation in maintaining these levels, despite the longer exposure to atmospheric oxygen. Moreover, in cultured cells einkorn bread evidenced an anti-inflammatory effect, although masked by the effect of digestive fluid. This study represents the first integrated evaluation of the potential health benefit of einkorn-based bakery products compared to wheat-based ones, and contributes to our knowledge of ancient grains.
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An internet-based self-administered intervention for promoting healthy habits and weight loss in hypertensive people who are overweight or obese: a randomized controlled trial.
Banos, RM, Mensorio, MS, Cebolla, A, Rodilla, E, Palomar, G, Lisón, J, Botella, C
BMC cardiovascular disorders. 2015;15:83
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Overweight and obesity are chronic conditions that have been linked with an increased risk of developing hypertension. Healthy lifestyle habits around eating behaviour and physical activity are known to help counteract these conditions. The aim of this study will be to evaluate whether an self-administered internet-based programme targeting eating behaviour and physical activity levels can help improve disease markers in hypertensive obese patients. The internet-based programme consisted of nine modules designed to promote healthy eating and increased physical activity. A randomised trial will be conducted with 100 hypertensive patients and participants will be randomised to either receive the online programme or usual medical care for three months. Patients will be assessed at baseline, three months, six months and one year for blood pressure and body mass index, as well as quality of life measures. The authors conclude the current literature highlights the need for more studies on the benefits of using internet-based lifestyle interventions, and suggests this protocol will provide a starting point for developing cost-effective healthy lifestyle interventions.
Abstract
BACKGROUND The prevalence of overweight and obesity is on the rise worldwide with severe physical and psychosocial consequences. One of the most dangerous is hypertension. Lifestyle changes related to eating behaviour and physical activity are the critical components in the prevention and treatment of hypertension and obesity. Data indicates that the usual procedures to promote these healthy habits in health services are either insufficient or not efficient enough. Internet has been shown to be an effective tool for the implementation of lifestyle interventions based on this type of problem. This study aims to assess the efficacy of a totally self-administered online intervention programme versus the usual medical care for obese and overweight participants with hypertension (from the Spanish public health care system) to promote healthy lifestyles (eating behaviour and physical activity). METHOD A randomized controlled trial will be conducted with 100 patients recruited from the hypertension unit of a public hospital. Participants will be randomly assigned to one of two conditions: a) SII: a self-administered Internet-based intervention protocol; and b) MUC-medical usual care. The online intervention is an Internet-delivered, multimedia, interactive, self-administered programme, composed of nine modules designed to promote healthy eating habits and increase physical activity. The first five modules will be activated at a rate of one per week, and access for modules 5 to 9 will open every two weeks. Patients will be assessed at four points: before the intervention, after the intervention (3 months), and at 6 and 12 months (follow-up). The outcome variables will include blood pressure, and Body Mass Index, as primary outcome measures, and quality of life and other lifestyle and anthropometrical variables as secondary outcome measures. DISCUSSION The literature highlights the need for more studies on the benefits of using the Internet to promote lifestyle interventions. This study aims to investigate the efficiency of a totally self-administered Internet - +based programme for promoting healthy habits and improving the medical indicators of a hypertensive and overweight population. TRIAL REGISTRATION NCT02445833.
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Fructose, high-fructose corn syrup, sucrose, and nonalcoholic fatty liver disease or indexes of liver health: a systematic review and meta-analysis.
Chung, M, Ma, J, Patel, K, Berger, S, Lau, J, Lichtenstein, AH
The American journal of clinical nutrition. 2014;100(3):833-49
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There have been increasing concerns on the relationship between non-alcoholic fatty liver disease (NAFLD) and fructose or high-fructose corn syrup (HFCS). The objective of this systematic review was to assess the effect of dietary fructose in different forms on NAFLD and various biomarkers of liver health. This review included 21 published intervention studies and found a diet supplemented with fructose or glucose increases liver fat and aspartate aminotransferase (AST) concentrations when compared with a maintenance diet in healthy adults. Based on the available research, the authors point out the relationship between liver health markers and fructose, but also recognise this association may be confounded by excess energy intake. Due to the lack of robust findings, they conclude there is insufficient evidence on HFCS and NAFLD.
Abstract
BACKGROUND Concerns have been raised about the concurrent temporal trend between simple sugar intakes, especially of fructose or high-fructose corn syrup (HFCS), and rates of nonalcoholic fatty liver disease (NAFLD) in the United States. OBJECTIVE We examined the effect of different amounts and forms of dietary fructose on the incidence or prevalence of NAFLD and indexes of liver health in humans. DESIGN We conducted a systematic review of English-language, human studies of any design in children and adults with low to no alcohol intake and that reported at least one predetermined measure of liver health. The strength of the evidence was evaluated by considering risk of bias, consistency, directness, and precision. RESULTS Six observational studies and 21 intervention studies met the inclusion criteria. The overall strength of evidence for observational studies was rated insufficient because of high risk of biases and inconsistent study findings. Of 21 intervention studies, 19 studies were in adults without NAFLD (predominantly healthy, young men) and 1 study each in adults or children with NAFLD. We found a low level of evidence that a hypercaloric fructose diet (supplemented by pure fructose) increases liver fat and aspartate aminotransferase (AST) concentrations in healthy men compared with the consumption of a weight-maintenance diet. In addition, there was a low level of evidence that hypercaloric fructose and glucose diets have similar effects on liver fat and liver enzymes in healthy adults. There was insufficient evidence to draw a conclusion for effects of HFCS or sucrose on NAFLD. CONCLUSIONS On the basis of indirect comparisons across study findings, the apparent association between indexes of liver health (ie, liver fat, hepatic de novo lipogenesis, alanine aminotransferase, AST, and γ-glutamyl transpeptase) and fructose or sucrose intake appear to be confounded by excessive energy intake. Overall, the available evidence is not sufficiently robust to draw conclusions regarding effects of fructose, HFCS, or sucrose consumption on NAFLD.
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Vegetarian dietary patterns and mortality in Adventist Health Study 2.
Orlich, MJ, Singh, PN, Sabaté, J, Jaceldo-Siegl, K, Fan, J, Knutsen, S, Beeson, WL, Fraser, GE
JAMA internal medicine. 2013;173(13):1230-8
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Vegetarian diets have been associated with reduced risk of several chronic cardiometabolic diseases. The aim of this cohort study was to evaluate the effect of vegetarian diets on mortality. The study followed 73,308 male and female Seventh-day Adventists for a mean of 5.79 years. At baseline, just under half were non-vegetarians. Vegetarians had a lower mortality than non-vegetarians: death rates (deaths per 1000 person-years) were 5.4 for vegans, 5.61 for ovo-lacto vegetarians and 5.33 for pesco-vegetarians, which were significantly lower than that of non-vegetarians (6.61). After adjustment for a variety of factors, the lowered hazard ratio seen with vegetarian diets only remained statistically significant in pesco-vegetarians (compared to non-vegetarians). The non-vegetarians had on average higher rates of other risk factors, such as smoking, they consumed more alcohol, exercised less and had lower educational level. The authors concluded that vegetarian dietary patterns were associated with lower mortality.
Abstract
IMPORTANCE Some evidence suggests vegetarian dietary patterns may be associated with reduced mortality, but the relationship is not well established. OBJECTIVE To evaluate the association between vegetarian dietary patterns and mortality. DESIGN Prospective cohort study; mortality analysis by Cox proportional hazards regression, controlling for important demographic and lifestyle confounders. SETTING Adventist Health Study 2 (AHS-2), a large North American cohort. PARTICIPANTS A total of 96,469 Seventh-day Adventist men and women recruited between 2002 and 2007, from which an analytic sample of 73,308 participants remained after exclusions. EXPOSURES Diet was assessed at baseline by a quantitative food frequency questionnaire and categorized into 5 dietary patterns: nonvegetarian, semi-vegetarian, pesco-vegetarian, lacto-ovo-vegetarian, and vegan. MAIN OUTCOME AND MEASURE The relationship between vegetarian dietary patterns and all-cause and cause-specific mortality; deaths through 2009 were identified from the National Death Index. RESULTS There were 2570 deaths among 73,308 participants during a mean follow-up time of 5.79 years. The mortality rate was 6.05 (95% CI, 5.82-6.29) deaths per 1000 person-years. The adjusted hazard ratio (HR) for all-cause mortality in all vegetarians combined vs nonvegetarians was 0.88 (95% CI, 0.80-0.97). The adjusted HR for all-cause mortality in vegans was 0.85 (95% CI, 0.73-1.01); in lacto-ovo-vegetarians, 0.91 (95% CI, 0.82-1.00); in pesco-vegetarians, 0.81 (95% CI, 0.69-0.94); and in semi-vegetarians, 0.92 (95% CI, 0.75-1.13) compared with nonvegetarians. Significant associations with vegetarian diets were detected for cardiovascular mortality, noncardiovascular noncancer mortality, renal mortality, and endocrine mortality. Associations in men were larger and more often significant than were those in women. CONCLUSIONS AND RELEVANCE Vegetarian diets are associated with lower all-cause mortality and with some reductions in cause-specific mortality. Results appeared to be more robust in males. These favorable associations should be considered carefully by those offering dietary guidance.