Driven by growing interest in vegetarian and vegan diets in France, the health and safety agency Anses has undertaken expert appraisals to establish the facts. Plant-based food has become increasingly popular, with between 2 and 5 percent of French people now identifying as vegetarian or vegan. Environmental concerns are a key factor for many, particularly young people. These guidelines provide scientific bases for public health policies and recommendations on nutrition as part of the National Health and Nutrition Programme. Following on from this work, to take account of changes in eating habits, ANSES decided to undertake an expert appraisal specifically dedicated to adults on a vegetarian diet. The term ‘vegetarian’ refers to diets that exclude the consumption of any animal flesh (meat, fish, molluscs, crustaceans, etc.). The aim of the first expert appraisal was to identify epidemiological links between health and various types of vegetarian diets, by conducting a systematic review of the scientific literature.
Health Benefits of Vegetarian Diets
According to a study published by Anses, vegetarian and vegan diets are associated with several health advantages, provided nutritional balance is maintained.
Lower Risk of Type 2 Diabetes
The report highlights moderate evidence suggesting that vegetarians have a reduced risk of developing type 2 diabetes compared to non-vegetarians. This aligns with global research pointing to the benefits of plant-based diets in maintaining healthy blood sugar levels.
Potential Heart Health Benefits
There is weaker evidence indicating that plant-based diets may help lower the risk of heart disease by improving cholesterol levels, reducing inflammation, and supporting cardiovascular function.
Other Possible Health Improvements
Some studies also suggest that vegetarian diets may support reproductive health, reduce the risk of certain cancers (prostate, stomach, and blood), alleviate gastrointestinal issues, and protect against eye-related conditions. In addition, Anses also observed, albeit with a low level of evidence, that vegetarians are less likely than non-vegetarians to develop certain diseases, such as ischaemic heart disease, ovulation disorders, certain types of cancer (prostate, stomach, blood) and certain ophthalmological and gastro-intestinal diseases.
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While these benefits are promising, the experts caution that proper nutritional planning is essential to maximize these advantages.
Potential Health Risks of Plant-Based Diets
Anses also examined potential health risks linked to vegetarian and vegan diets. The findings indicate: possible nutrient deficiencies, long-term metabolic concerns, and specific risks for children, pregnant women, and elderly populations.
Bone Health Concerns
Some evidence points to a higher risk of bone fractures among individuals with poorly planned vegetarian or vegan diets due to deficiencies in calcium, vitamin D, and vitamin B12.
Nutritional Deficiencies
The review noted “less favourable” levels of iron, iodine, vitamin B12, vitamin D, and calcium-phosphate balance in vegetarians, with vegans particularly prone to low vitamin B2 and B12 levels. Lastly, the epidemiological studies undertaken showed that vegetarians have a less favourable nutritional status in iron, iodine and vitamins B12 and D, and a poorer calcium and phosphorus balance than non-vegetarians.
Other Possible Risks
Some preliminary research hints at potential congenital or developmental concerns, though experts agree that more studies are needed to establish any direct links.
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Anses Study on Vegetarian and Vegan Diets
The two reports from Anses represent the culmination of five years of systematic research, combining a literature review of 131 studies and the development of dietary recommendations.
Scientific Literature Review
Experts examined the impact of vegetarian and vegan diets on health outcomes across diverse populations, including metabolic, cardiovascular, and micronutrient aspects.
Dietary Recommendations
Using an optimization tool, the team formulated guidelines considering nutrition, potential food contamination, and typical eating patterns to help vegetarians and vegans maintain balanced diets. In its second expert appraisal, ANSES established dietary guidelines to enable vegetarians to better meet their nutritional needs without significantly altering their eating habits. More generally, the presence of contaminants in food is a major issue that affects the entire population, regardless of their diet.
Perrine Nadaud, deputy head of Anses’ nutritional risk assessment unit, emphasized that while some conclusions are based on weaker evidence, future research may refine or adjust these recommendations.
Nutritional Challenges for Vegetarians and Vegans
Maintaining adequate nutrient intake is critical for plant-based diets:
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Key Nutrients Often Low in Vegetarians
Iron, iodine, vitamins B12 and D, and calcium-phosphate balance.
Additional Vegan Considerations
Vitamin B2, B12, zinc, and certain Omega-3 fatty acids can be difficult to obtain without fortified foods or supplements.
The UK’s National Health Service (NHS) also echoes this, noting that with careful planning, a vegan or vegetarian diet can meet all nutritional requirements, but failure to do so may lead to deficiencies and health risks.
Vegetarianism and Veganism in France
Vegetarianism in France remains relatively niche, but interest is growing:
A 2021 IFOP survey found that only 2.2% of French adults identify as vegetarian, while around 8% attempt to limit meat consumption.
Motivations include animal welfare concerns, environmental impact, and health benefits. Supporting this, a 2023 study in Nature highlighted that reducing meat consumption lowers environmental impact, including greenhouse gas emissions, land use, water use, and biodiversity loss.
Recommended Foods for Plant-Based Diets
Anses provides clear guidance for vegetarians and vegans to maintain nutritional balance:
Daily Essentials
Fruits, vegetables, legumes (lentils, beans), starchy foods or bread, nuts and seeds, brewer’s yeast, dairy products, or fortified vegan alternatives.
Focus on Key Nutrients
Include sources of vitamin B12, vitamin D, Omega-3 fatty acids, iron, calcium, zinc, and iodine, particularly for vegans.
Supplementation if Necessary
Fortified foods or dietary supplements can help meet nutritional needs, especially for nutrients harder to obtain from plant-based sources. Vegan patients, as well as many OLV patients, require vitamin B12 supplementation. Several case reports have been published about vegetarian children with growth disorders due to severe vitamin B12 deficiency, often associated with defective medical follow-up in the context of distrust toward pediatricians by the affected families.
Primary Care Physicians' Perspectives on Vegetarian Diets
A cross-sectional survey was conducted among general practitioners and pediatricians through a questionnaire including socio-demographic characteristics, specific care to vegetarians, and the risks and benefits of vegetarian diets according to physicians.
Physician Demographics and Practices
Out of the 177 participating physicians, 104 (59%) have seen at least one vegetarian patient in consultation in the last three months. The median ages of the responding GPs and pediatricians were 49 and 56 years old, respectively. Women accounted for 93% of the pediatricians (n = 26) and 41% of the GPs (n = 61). Practice location was urban for 59 GPs (40%) and 24 pediatricians (86%). Concerning nutrition, four GPs and one pediatrician had a nutrition degree (3% of the 177 physicians).
Physician Attitudes Toward Vegetarian Diets
Half of the physicians declared that they would dissuade their patients from switching to a vegan diet (n = 88, 51%) and 14% (n = 24) from switching to an ovo-lacto-vegetarian (OLV) diet. Most physicians (n = 141, 88%) did not feel informed enough about these diets. Physicians thought that the most frequent deficiencies for OLV and vegan diets were iron (76% and 84%, respectively) and protein (45% and 79%, respectively).
Perceived Risks and Benefits
Among adults, most of the physicians considered that the adoption of an OLV diet led to a protective effect on the overall cardiovascular risk, myocardial infarction, high blood pressure, obesity, and global risk of cancer, with a median of 7 on the scores ranging from 0 (harmful effect) to 10 (protective effect). Regarding the deficiencies, 132 (76%) physicians felt that an OLV diet was at risk of iron deficiency, 84 (49%) mentioned vitamin B12 deficiency and 78 (45%) mentioned protein deficiency.
Suitability for Different Populations
The OLV diet was considered unsuitable for children under six months by 94 physicians (54%), for children over six months by 116 physicians (67%), for teenagers by 93 physicians (53%), for pregnant and breastfeeding women by 87 physicians (51%), and for elderly persons by 88 physicians (51%).
Reasons for Choosing Vegetarian Diets
Regarding the reasons why patients chose to follow a vegetarian diet, 86% of the physicians thought that it could be for health reasons (n = 150), 80% for animal welfare (n = 139), 74% for environmental care (n = 130), 52% for fashion (n = 89), 32% linked with eating disorder (n = 55), and 18% for religious beliefs (n = 31).
Physician Advice and Knowledge Gaps
Most physicians had seen at least one recognized vegetarian (OLV or vegan diet) patient in the last three months (n = 104, 59%). Whereas 24 (14%) physicians declared that they would advise their patients against switching to an OLV diet, 88 (51%) would advise patients against switching to a vegan diet. According to 46% of the physicians (n = 81).
These results highlight the fact that French primary care physicians feel concerned by this subject and need more information on these diets.
The Need for Accurate Information and Training for Healthcare Providers
As vegetarian diets are becoming increasingly common in France, the accuracy of information delivered by healthcare providers is crucial. In this survey, while half of the GPs and pediatricians have seen at least one recognized vegetarian patient during the previous three months, most (81%) did not feel sufficiently informed about these diets.
Most of the physicians involved in this survey declared that, in their opinion, OLV and vegan diets were associated with iron deficiency (76% and 84%, respectively) and protein deficiency (45% and 79%, respectively). There is now evidence that balanced vegetarian diets are not at risk of protein deficiency in developed countries, and although vegetarians usually have lower iron stores, there is no evidence of adverse health effects (moderately lower iron stores may even be associated with a lower risk of chronic diseases).
In our survey, the risk of vitamin B12 deficiency came fourth after iron, calcium, and protein deficiencies, according to the physicians’ beliefs; whereas it represents the greatest risk of deficiency in vegetarian or vegan diets. Vitamin B12 is present only in animal products.
Factors Influencing Physician Advice
In univariate analyses, advice against switching to a vegan diet was associated with the age of the GP being older and with the physician believing that vegan diets put patients at risk of folate deficiency. As folate is present in large quantities in plants, OLV and vegan patients are unlikely to have any deficiency. The association with age suggests that younger physicians may be more open or informed to vegetarian and vegan diets.
Agreement on the risk of folate deficiency in a vegan diet may therefore be interpreted as a marker of limited knowledge in these diets, and such physicians might be more likely to discourage patients from switching to a vegetarian diet. These initial results suggest a lack of awareness and some apprehension of GPs and pediatricians regarding the care of vegetarian patients.
Recommendations and Guidelines
Pediatric academic societies have taken different positions worldwide. In France, the Pediatric Hepatology, Gastroenterology and Nutrition Group, advises against a vegan diet in children. Regular dietary monitoring is essential in vegan children, where vitamin D (also noted for other diets) and vitamin B12 supplementation is necessary. Concerning adults, they are exposed to vitamin B12 deficiency as well and must be supplemented.
Motivations for Adopting Vegetarian Diets
According to the physicians in our survey, patients mainly adopt a vegetarian diet for health reasons (n = 150, 86%). In an American survey, the authors found that the reason depended on age, and younger people (11 to 20 years old) were more likely to choose a vegetarian diet for moral or environmental reasons.
The Role of Primary Care Physicians
Primary care physicians presented a knowledge gap in nutrition; yet, the prevalence of vegetarian diets are increasing. More and more patients choose to follow a vegetarian diet. Physicians perceived that their training was insufficient to deliver good advice to their patient. Specific training in this topic is needed.
As stated by the World Health Organization: “Health professionals play a central and critical role in improving access and quality health care for the population. They provide essential services that promote health, prevent diseases and deliver health care services to individuals, families and communities based on the primary health care approach”.
Limitations
Our study was limited by a small sample size, and it can be assumed that participating physicians felt more concerned by this subject, which induced recruitment bias. Our population may not be fully representative of French physicians, but we relied on a physician network that is used to conduct epidemiological studies in primary care. As with any survey-based study, our results could have been affected by reporting bias among respondents.