Healthcare professionals who work in wound management know the routine: When faced with a patient with compromised skin integrity, they pump up the protein — typically, by recommending increased amounts of meat, poultry, fish/seafood, eggs, dairy products, and sometimes protein supplements. But well-meaning health practitioners who offer these suggestions to their vegetarian patients will likely encounter strong resistance. Vegetarianism is not simply a diet plan that a person goes on (and off); it encompasses an entire lifestyle. In fact, not only do some vegetarians abstain from eating anything derived from animals, but they also may abstain from using animal products such as silk, leather, wool, and similar items.1
People follow vegetarian diets for a variety of reasons, including animal rights and welfare, health, environment, ecology, religious beliefs, taste (eg, dislike of meat), economics, ethics, world hunger issues, and belief in nonviolence.2,3 According to a 2006 national poll,3 approximately 2.3% of the US adult population reported they were vegetarians who never eat meat, poultry, or fish/seafood. However, consumer interest in vegetarian diets is on the rise,2 so the probability of encountering patients who practice some form of vegetarianism may increase. Plus, vegetarian diets have been in the news lately; celebrities extolling their virtues include Bill Clinton, Ellen DeGeneres, and Gwyneth Paltrow.
Several types of vegetarianism have been described; each depends on the extent to which animal products are excluded from the diet (see Table 1). Vegetarian diets most often studied by researchers include those that omit all flesh foods but include egg (ovo) and/or dairy (lacto) products, as well as vegan-vegetarian diets. Vegan diets are considered one of the most animal-restrictive diets because they omit all flesh- and animal-derived foods, often even honey. On the other end of the spectrum are the folks who consume a plant-based diet most but not all of the time; they label themselves as flexitarian or semi-vegetarian. Other types of vegetarian or near-vegetarian diets include macrobiotic diets or raw foods diets.2 Vegetarian diets may be broadly interpreted by followers. Thus, diet assessment tools such as food frequencies, 24-hour or usual-diet recalls, or food records can help determine specifically what foods the patient typically avoids and consumes.
The biggest question on most omnivores’ minds when they encounter a vegetarian patient is, “How will they get enough protein?” If a vegetarian has poor skin integrity or a chronic wound, there may be concern about other nutrients as well, such as zinc and vitamin C. First, it should be noted that the term vegetarian is not synonymous with healthy. Some self-proclaimed “vegetarians” barely eat any vegetables at all; instead, they seem to exist on snack chips, crackers, breads, pastries, ice cream substitutes, and the like. However, research unequivocally indicates that, in general, vegetarians eat a nutrient-dense diet. For example, a recent population study4 found that mean intakes of fiber, thiamin, riboflavin, folate, calcium, magnesium, potassium, iron, and vitamins A, C, and E were higher for vegetarians than nonvegetarians. Vegetarians also consumed significantly more whole grains, fruit, soy, dark-green vegetables, and legumes than nonvegetarians. Diets rich in these foods contain more carotenoids, flavonoids, and other phytochemicals that are beneficial to health.2 In concurrence with current dietary advice,5 vegetarians consumed less total fat, saturated fat, cholesterol, and sodium than non-vegetarians,4 making a vegetarian diet an ideal choice for heart health. Vegetarian diets also may be beneficial for the prevention and/or treatment of diabetes, obesity, certain cancers, osteoporosis, diverticulitis, constipation, gallstones, and rheumatoid arthritis. Although vegetarian protein and zinc intakes were lower than nonvegetarians in the population study,4 the findings corroborated those of other studies2,6 in which intakes met or exceeded recommended amounts. Table 2 lists typical nutrients of concern for vegetarian diets and food sources of each.
Fatty acids. Sometimes certain supplements might be recommended, even in the absence of additional needs for wound healing. Vegetarian diets that exclude fish or eggs are typically low in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are important for cardiovascular health as well as eye and brain development in utero. The plant-based omega-3 fatty acid, alpha-linolenic acid (ALA), can be converted to EPA and DHA, but this conversion rate is <10% and inhibited by excessive intake of omega-6 fatty acids, which are prevalent in the typical American diet. Therefore, vegetarians should be encouraged to consume good sources of ALA to promote bioconversion (see Table 2), and also should consider taking supplements derived from microalgae to enhance blood levels of EPA and DHA.2
Vitamin B12. Vitamin B12, important for peripheral nerve function, is found naturally in animal sources only. Unfortified plant foods and fermented soy products are not reliable sources of B12. Therefore, vegetarians who do not regularly consume animal sources of this vitamin, such as dairy products or eggs, may have inadequate intakes. This nutrient is of particular concern for older adults who may have difficulty absorbing B12 from food due to atrophic gastritis. However, absorption from fortified foods is generally good; reliable sources include fortified soy and rice milk beverages, fortified breakfast cereals and meat analogs, and Red Star® Vegetarian Support Formula nutritional yeast (Lessafre Yeast Corporation & Red Star Yeast Company, Milwaukee, WI). If inadequate intake is suspected, a vitamin B12 supplement, which is also well absorbed, should be considered.2
Vitamin D. Vitamin D is necessary to properly utilize calcium and for general bone health. A person’s vitamin D status is related to dietary intake of vitamin D, as well as exposure to sunlight, which, in turn, facilitates cutaneous vitamin D production that varies according to geographic location (latitude), season, skin pigmentation, sunscreen use, time of day, and age. Dairy products are the primary dietary sources of vitamin D in most American diets. Therefore, vegans should be encouraged to consume products fortified with vitamin D, including some soy and rice milk beverages, orange juices, breakfast cereals, and margarine. A supplement is recommended if sun exposure and intake of fortified foods are insufficient to meet needs.2 Vitamin D is linked to many vital health issues and is proving to be an important medical issue. The definitive way to assess a patient’s status is with laboratory values, which can be added to routine blood work. Once identified, any deficiencies are easily addressed with supplements and monitoring.
A well-planned vegetarian diet that provides adequate calories can meet the nutrient needs for individuals across all stages of the life cycle, and protein needs can be met if a variety of protein-rich plant foods are consumed daily.2 A vegetarian patient with a chronic wound should be counseled about the importance of adequate protein intake and asked questions to determine if the patient needs further education and/or a referral to a registered dietitian (RD). As with any medically compromised patient, the diet should be assessed by a trained nutrition professional for overall nutritional adequacy and supplemented as necessary, while honoring and respecting the patient’s lifestyle choice to abstain from certain animal products.
The following sample lacto-vegetarian meal plan, analyzed by Food Processor (version 10.9.0; ESHA Research, Salem, OR), provides approximately 1,800 calories, 80 g protein, 46 g dietary fiber, 20% of calories from total fat, 4% of calories from saturated fat, 37 mg cholesterol, and 1,654 mg sodium. Based on current Dietary Reference Intakes,8 this 1-day menu plan meets or exceeds recommended amounts for adults over age 50 years for the following micronutrients: vitamin A, most B vitamins (including vitamin B12 and folate), vitamin C, vitamin K, calcium, copper, iron, magnesium, manganese, potassium, selenium, and zinc.
Breakfast: 6 fl oz vitamin D- and calcium-fortified orange juice; 1 cup fortified raisin bran; 4 fl oz 1% milk; 8 oz coffee or black tea
Snack: 1 slice whole grain toast; 1 Tbsp natural peanut butter; 1/2 medium banana, sliced
Lunch: 1 cup black bean soup; 1 Tbsp nutritional yeast, stirred into soup; 1/2 oz shredded cheddar cheese, sprinkled on soup; 4 whole wheat crackers
Snack: 1/2 cup low fat plain yogurt; 1 tsp ground flax seed, stirred into yogurt; 1/2 cup blueberries, fresh or thawed from frozen
Dinner: Sautéed vegetables: onion (1 oz), mushrooms (1/2 cup), kale (1 cup), garlic (1 clove), olive oil (2 tsp), and water, if necessary; 1 cup cooked whole wheat pasta; 1/2 cup tomato, basil, and garlic spaghetti sauce; 3 oz veggie meatballs or “meat” crumbles in sauce; 1/2 cup chilled apricot halves, canned in extra light syrup
Snack: 2 graham crackers; 4 fl oz 1% milk; 1 medium orange
1. Most Frequently Asked Questions. The Vegetarian Resource Group. Available at: www.vrg.org/nutshell/faq.htm . Accessed January 7, 2012.
2. Craig WJ, Mangels AR, American Dietetic Association. Position of the American Dietetic Association: Vegetarian diets. J Am Diet Assoc. 2009;109(7):1266–1282.
3. Stahler C. How many adults are vegetarian? The Vegetarian Resource Group Web site. Available at: www.vrg.org/journal/vj2006issue4/vj2006issue4poll.htm . Accessed January 7, 2012.
4. Farmer B, Larson BT, Fulgoni V, Rainvlile AJ, Liepa GU. A vegetarian dietary pattern as a nutrient-dense approach to weight management: an analysis of the National Health and Nutrition Examination Survey 1999–2004. J Am Diet Assoc. 2011;111:819–827.
5. USDA Center for Nutrition and Policy Promotion, Dietary Guidelines for Americans 2010 Available at: www.cnpp.usda.gov/dgas2010-policydocument.htm . Accessed January 13, 2012.
6. Deriemaeker P, Aerenhouts D, De Ridder D, Hebbelinck M, Clarys P. Health aspects, nutrition and physical characteristics in matched samples of institutionalized vegetarian and non-vegetarian elderly (>65 years). Nutr Metab. 2011;8:37–44.
7. USDA Agricultural Research Service, Products and Services. Reports by Single Nutrients. Available at: www.ars.usda.gov/Services/docs.htm?docid=22114 . Accessed January 8, 2012.
8. USDA National Agricultural Library, Dietary Guidance. DRI Tables. Available at: http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=3... . Accessed January 13, 2012.
• “Eating Vegetarian” links and resources available at the USDA: http://riley.nal.usda.gov/nal_display/index.php?info_center=11&tax_level... 
• Vegetarian guides, articles and handouts at the Vegetarian Resource Group (VRG): www.vrg.org/nutshell/ 
• 4-Week vegetarian menu set for Meals on Wheels sites at the VRG: www.vrg.org/fsupdate/fsu974/fsu974menu.htm 
Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Dr. Cristen Harris is an Assistant Professor in the Department of Nutrition and Exercise Science, Bastyr University, Kenmore, Washington. She is a practicing vegetarian. This article was not subject to the Ostomy Wound Management peer-review process.