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Copyright (c) 2022 Slovenian Medical Journal. This work is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License.
Alternative nutrition: literature review
Alternativna prehrana: pregled literature
Lučka Šetinc
Abstract
The recent years have seen an increase in alternative nutrition practices in which certain nutrients are excluded from a 
person’s diet; most commonly observed are variations of vegetarianism and veganism which limit to varying extents the 
inclusion of meat, eggs, and dairy products in the diet. Such diets without the addition of necessary food supplements 
can lead to growth retardation, developmental delay, and irreversible physical damage; health professionals in Slovenia, 
therefore, advise against such diets especially in pregnant women, newborns, and infants. Certain published and regularly 
cited research works, e.g. the statement on vegetarianism by the American Dietetic Association published in 2009, support 
to a certain extent the use of alternative nutrition practices even in earlier stages of the life cycle and could have contrib-
uted to the increase of such practices in Slovenia. This article aims to identify the effects of alternative nutrition practices 
on health and development in all stages of life cycle and to provide advice for preventing nutrient deficiencies when such 
practices are used. We included the most cited and clinically relevant articles published on the topic of vegetarianism and 
veganism and listed the dietary guidelines supported by the Slovenian Paediatric Society and the Slovenian Ministry of 
Health. Alternative nutrition practices can lead to nutrient deficiencies, especially deficiency of vitamin B12, iron, and cal-
cium. Other nutrients that require medical attention in people following such practices are proteins, ω-3 fatty acids, zinc, 
and vitamin D. Vegetarian and vegan diets can lead to nutrient deficiencies especially in pregnant and lactating women, 
newborns, infants, and children. In line with the proven effects of vegetarian and vegan diets on health and development, 
the Slovenian Paediatric Society advises against the use of such diets in pregnant and lactating women, newborns, infants, 
children, and adolescents. Alternative nutrition practices in these stages of the life cycle require supervision and monitor-
ing by a clinical dietitian, a paediatrician, or a family physician.
Izvleček
V zadnjih letih narašča prevalenca načinov prehranjevanja, pri katerih oseba iz svoje prehrane izključuje določena hranila; 
najpogosteje gre za oblike vegetarijanstva in veganstva, ki v različni meri omejujejo uživanje mesa, jajc in mlečnih izdelkov. 
Izključujoči načini prehranjevanja ob neupoštevanju navodil o potrebnih prehranskih dopolnilih lahko privedejo do zaos-
tajanja v rasti in razvoju in do nepopravljivih telesnih okvar, zato zdravstvena stroka v Sloveniji takšne načine prehranjeva-
nja odsvetuje zlasti pri nosečnicah, novorojenčkih in dojenčkih. Nekatere pogosto citirane raziskave in smernice navajajo, 
University Medical Centre Ljubljana, Ljubljana, Slovenia
Correspondence / Korespondenca: Lučka Šetinc, e: lucka.setinc@gmail.com
Key words: diet; vegetarian; vegan; malnutrition; growth and development
Ključne besede: prehrana; vegetarijanstvo; veganstvo; podhranjenost; rast in razvoj
Received / Prispelo: 8. 10. 2019 | Accepted / Sprejeto: 24. 7. 2021
Cite as / Citirajte kot: Šetinc L. Alternative nutrition: literature review. Zdrav Vestn. 2022;91(5–6):242–54. DOI: https://doi.org/10.6016/
ZdravVestn.2994
eng slo element
en article-lang
10.6016/ZdravVestn.2994 doi
8.10.2019 date-received
24.6.2021 date-accepted
Nutrition Prehrana discipline
Professional article Strokovni članek article-type
Alternative nutrition: literature review Alternativna prehrana: pregled literature article-title
Alternative nutrition Alternativna prehrana alt-title
diet, vegetarian, vegan, malnutrition, growth 
and development
prehrana, vegetarijanstvo, veganstvo, podhran-
jenost, rast in razvoj kwd-group
The authors declare that there are no conflicts 
of interest present.
Avtorji so izjavili, da ne obstajajo nobeni 
konkurenčni interesi. conflict
year volume first month last month first page last page
2022 91 5 6 242 254
name surname aff email
Lučka Šetinc 1 lucka.setinc@gmail.com
name surname aff
eng slo aff-id
University Medical Centre 
Ljubljana, Ljubljana, Slovenia
Univerzitetni klinični center 
Ljubljana, Ljubljana, Slovenija 1
Slovenian Medical Journallovenian Medical Journal
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Alternative nutrition: literature review
1 Introduction
1.1 Types and prevalence of vegetarianism
Vegetarianism refers to diets in which a person ex-
cludes foods of animal origin from their diet to varying 
degrees (1-6). Less restrictive vegetarian diets include 
pescatarianism, which allows the consumption of milk, 
dairy products, eggs, fish and seafood (but no red meat 
or poultry), and lacto-ovo vegetarianism, which allows 
the consumption of milk, dairy products and eggs (but 
not meat of any kind) (2). Vegans do not consume any 
products of animal origin (1-6). According to various 
data, the estimate of the prevalence of vegetarianism is 
1-10%. It has been growing in Europe and the US for the 
last three decades (1-6). The growing prevalence of vege-
tarianism is likely to be due to a growing body of research 
and reports that label vegetarian and vegan diets safe and 
appropriate, regardless of age (3,4,7-11).
1.2 The impact of vegetarian diet on health
In 2005, Campbell et al. published the now well-
known “China Study” in which they concluded that a 
plant-based diet reduces the incidence of cardiovascular 
disease, diabetes, and certain cancers (9). Some of the 
listed effects of plant-based diets were later confirmed 
in many studies (12-20); however, a similar impact on 
health can be achieved by increasing the intake of plant 
foods and by reducing the intake of foods of animal or-
igin, but not necessarily by completely excluding meat 
and animal products (8,21-23). In addition, vegetari-
an diets are associated with a healthier lifestyle in gen-
eral. It is possible that the positive health effects are an 
da so alternativni načini prehranjevanja ustrezni v vseh obdobjih življenjskega cikla, kar je verjetno prispevalo k popu-
larizaciji tovrstnih načinov prehranjevanja tudi pri nas. Presečne raziskave pri vegetarijancih ugotavljajo nižjo incidenco 
ishemične bolezni srca in rakavih bolezni ter ugodnejšo sestavo črevesnega mikrobioma, vendar so našteti učinki lahko 
posledica zdravega življenjskega sloga in nižje telesne mase pri vegetarijancih in veganih, ne pa neposredno izključevanja 
mesa iz prehrane. Po drugi strani lahko vsi omejevalni načini prehranjevanja privedejo do pomanjkanja hranil, zlasti vita-
mina B12, železa, kalcija, pa tudi beljakovin, maščobnih kislin ω-3, cinka in vitamina D. Pomanjkanje makro- in mikrohranil 
je nevarno predvsem v zgodnjih obdobjih življenjskega cikla, saj lahko povzroči hud zaostanek v rasti in razvoju, v najhujših 
primerih pa celo smrt. Zdravstveni zapleti pri odraslih vključujejo osteopenijo in osteoporozo, anemijo, kognitivni upad 
in »paradoksno« povečanje tveganja za srčno-žilne bolezni. Tveganje za neustrezno prehranjenost ob vegetarijanski ali 
veganski prehrani je večje pri športnikih, starostnikih in kroničnih bolnikih. Pravilno vodena vegetarijanska in veganska 
prehrana je ob strokovno načtovani in nadzorovani prehranski strategiji lahko ustrezna za zdrave odrasle ljudi. V skladu z 
znanimi podatki o hranilih, potrebnih za normalno rast in razvoj, in zaradi hudih posledic ob morebitnem pomanjkanju teh 
hranil slovenska pediatrična stroka odsvetuje izključujoče načine prehranjevanja pri nosečnicah, doječih materah, novo-
rojenčkih, dojenčkih, otrocih in mladostnikih. Ob vegetarijanskem ali veganskem načinu prehranjevanja v teh obdobjih je 
priporočljivo spremljanje kliničnega dietetika, izbranega pediatra ali osebnega zdravnika.
indirect result of lower body weight and lower fast food 
and alcohol intake in vegetarians and vegans, but not a 
direct consequence of the exclusion of meat and animal 
products from the diet (7,8,23-25,39). As vegetarians and 
vegans are at higher risk of nutrient deficiencies and re-
lated conditions, the topic remains problematic and will 
require more prospective research in the future (26,27).
1.2.1 Cardiovascular diseases
People who maintain a vegetarian or vegan diet have 
significantly lower cardiovascular disease morbidity and 
mortality (12-14).
A meatless diet helps lower blood pressure (29,30). In 
a 2014 meta-analysis, Yokoyama et al. found that both 
systolic and diastolic blood pressure were lower in veg-
etarians (14). Pettersen et al. report a lower likelihood 
of developing hypertension in vegans, vegetarians and 
partial vegetarians, although only part of this effect is at-
tributed to the diet itself; the difference between the cal-
culated odds ratio for the development of hypertension in 
vegetarians and non-vegetarians decreased significantly 
when the model was corrected for body mass index (30). 
The causes of lower blood pressure in vegetarians are not 
fully understood and are likely to be numerous: they in-
clude a higher intake of potassium and plant proteins and 
a lower intake of saturated fatty acids (14). According to 
some data in the literature, sodium intake in vegetarians 
is significantly lower (31,32), while in others it is similar 
to that of omnivores (33); differences in sodium intake 
are not a satisfactory explanation for the lower preva-
lence of arterial hypertension in vegetarians (4,14).
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Total cholesterol and low-density lipoprotein (LDL) 
levels are significantly lower in vegetarians and vegans, 
contributing to a lower prevalence of ischemic heart dis-
ease in these groups (28,34). Reasons for a better lipid 
profile in vegetarians include increased intake of fibre, 
plant protein, and antioxidants (34). Non-vegetarians 
can achieve a similar effect if they limit their meat intake 
and increase their intake of whole grains, legumes, nuts, 
fruit and vegetables (8).
However, despite these effects, a vegetarian diet can 
in some cases even increase the risk of ischemic heart 
disease and stroke: lower body stores of vitamin B12 can 
lead to decreased levels of high-density serum lipopro-
teins (HDL) and elevated homocysteine levels, leading 
to thrombosis (34-36). The risk of developing cardiovas-
cular disease in vegetarians may also increase with insuf-
ficient intake of ω-3 fatty acids (37).
To prevent cardiovascular disease, a balanced diet 
with less meat and more fruit and vegetables is recom-
mended (8,21).
1.2.2 Body mass index and obesity
Body mass index is lower in vegetarians than in om-
nivores and lowest in vegans (38-41). Vegetarian diets 
are usually lower in energy and contain more fibre and 
less animal fat, so the prevalence of obesity in vegetari-
ans and vegans is lower (38,40,41). Several studies have 
shown that a plant-based diet is effective in both pre-
venting and treating obesity (19,38,40). Nevertheless, it 
should be noted that the body mass index of vegetarians 
and vegans may be lower also due to lower muscle mass 
as a result of lower total protein intake and lower intake 
of individual amino acids (39).
1.2.3 Diabetes
Vegetarians and vegans have a lower risk of devel-
oping type 2 diabetes than omnivores (15-18). This is 
due to a higher intake of fibre, fruit and vegetables and a 
lower intake of saturated fatty acids, and indirectly to a 
lower energy content in the diet (15). In omnivores, the 
consumption of red meat is an independent risk factor 
for the development of type 2 diabetes (16) and the in-
cidence is also increased by the intake of other types of 
products, especially meat products (25,42).
Vegetarian diet is also beneficial in already developed 
diabetes, as it can help reduce insulin resistance and ox-
idative stress and provide better glycaemic control, as 
well as reduce the likelihood of cardiovascular and neu-
rological complications of diabetes (15-18).
1.2.4 Cancer
Some research has shown that a vegetarian diet re-
duces the risk of developing cancer (43,44), but other 
authors report a comparable incidence of malignancies 
in vegetarians and omnivores (12). Some studies de-
scribe a lower incidence of prostate, breast, stomach, 
bladder, ovarian and bone marrow cancers in vegetari-
ans (43,45,46), but the results are unreliable due to lim-
ited research and conflicting data (44). Nevertheless, it 
is likely that a vegetarian diet reduces the risk of cancer, 
as such a diet avoids the intake of red meat and meat 
products, which in large quantities have been shown to 
increase cancer mortality (47), and increases the intake 
of fibre, antioxidants, isoflavones and other chemicals 
of plant origin that act protectively against the develop-
ment of malignant diseases (48,49).
1.2.5 Osteoporosis
Vegetarian diet can affect bone mineral density, as, 
on the one hand, it contains less calcium, vitamin D, vi-
tamin B12, ω-3 fatty acids and proteins that are import-
ant for maintaining bone health, and, on the other hand, 
more magnesium, potassium and antioxidants, which 
have a protective effect on bone (50). Research shows 
that bone mineral density in vegetarians, especially veg-
ans, is reduced (50-52). Bone fracture risk reports in 
vegetarians and vegans are inconsistent; research reports 
both unchanged and higher risk of breakage compared 
to omnivores (50-54).
1.2.6 Dementia
The pathogenesis of dementia is influenced by sever-
al factors, so the type of diet is only one of the possible 
causes for its development (55). Antioxidants, ω-3 fatty 
acids and B vitamins are mentioned in the literature as 
neuroprotective nutrients that inhibit the development 
of dementia (55-57). According to the data so far, the 
type of diet that has the most beneficial effect on brain 
function is the Mediterranean diet which is rich in fruit, 
vegetables, whole grains, legumes, and nuts, and a low to 
moderate intake of dairy products, fish, and poultry (55). 
Research has reported various effects of a vegetarian diet 
on the development of dementia, focusing in particular 
on Alzheimer’s disease and vascular dementia (55-59). 
Some authors report a lower risk of developing dementia 
in vegetarians (58,59), but according to other data the 
risk does not change (56) and a higher risk is reported 
in vegetarians who have elevated serum homocysteine 
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levels as a result of a vitamin B12 deficiency (60).
1.2.7 Gut microbiome
Increasingly, research is linking changes in the com-
mensal bacteria of the gut flora with the development 
of cardiovascular, autoimmune and neurological dis-
eases (61,62). A diet with a higher intake of fibre and 
a lower intake of fat increases the number of beneficial 
commensals in the gut and the synthesis of protective 
short-chain fatty acids, which has a beneficial effect on 
glycaemic control and regulates the immune response 
(61-68); according to some data, it could also prevent 
the development of some psychiatric illnesses, especial-
ly chronic depression (69-71). These findings are based 
on studies of the effects of a predominantly plant-based 
diet, where the diet is not necessarily meatless (61,64).
2 Macro- and micronutrients in vegetarians 
and vegans
In all types of vegetarian diets, especially vegan di-
ets, there can be a significant deficiency of macro- and 
micronutrients: iron, zinc, calcium, vitamins B12, B2, A 
and D, ω-3 fatty acids and protein (1-8,26,73). The risk 
of malnutrition is higher in more exclusive diets and in 
younger children. As a result of prolonged nutrient de-
ficiencies, growth and developmental disorders may de-
velop and immune resistance may be impaired (1,2,26). 
Exclusive diets are problematic, especially in the case 
of inadequate implementation and non-compliance 
with the recommendations on the addition of dietary 
supplements (75,76).
Table 1 shows possible nutrient deficiencies in vege-
tarian and vegan diets.
2.1 Protein
Protein intake in vegetarians may be insufficient for 
three reasons: (a) there is less protein in plant foods, (b) 
plant proteins are less digestible than animal proteins, 
and (c) in plant proteins, one or more essential amino 
acids may be present in smaller amounts (e.g. lysine in 
maize, rye and wheat and methionine and cysteine in le-
gumes) (77-79). Lack of protein can lead to loss of mus-
cle mass, decreased immunity, weakening of the heart 
and respiratory system, as well as stunted growth in 
children, protein malnutrition despite sufficient calorie 
intake and, in extreme cases, even death (26,27).
The recommended daily protein intake in an adult 
omnivore is 0.8 g/kg of body weight (79). In several 
clinical trials, the average protein intake was highest in 
omnivores, slightly lower in pescatarians, even lower in 
lacto-ovo vegetarians, and lowest in vegans. However, in 
all groups it was above the recommended daily intake 
(79,80). In all groups studied, there were several people 
who did not achieve the recommended protein intake: 
1–3% of them were omnivores, 6–10% were vegetarians 
and 8–16.5% were vegans (79,80). Research finds the 
lowest protein intake in vegan women (79-81).
Protein deficiency in vegetarians and vegans is also 
possible with a seemingly sufficient intake, as the absorp-
tion of protein from plant-based foods is less efficient 
(8,79). While protein intake in lacto-ovo vegetarians 
Type of diet
Type of nutrient lacto-ovo-vegetarian lacto-vegetarian ovo-vegetarian vegan
Iron X X X X
Zinc X X X X
Calcium X X
Vitamin B12 X X
Vitamin B2 X
Vitamin D X X X X
Vitamin A X
ω-3 fatty acids 
(DHA) X X X X
Protein X X X X
Table 1: Possible nutrient deficiencies in vegetarian and vegan diets. Taken from Fewtrell M. et al., 2017 (73).
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may be sufficient at all life stages (22,82), vegan pregnant 
women, breastfeeding mothers and toddlers are recom-
mended to consume protein-rich foods or dietary sup-
plements (73). The European Society for Paediatric Gas-
troenterology, Hepatology and Nutrition (ESPGHAN) 
warns of possible protein deficiencies in children with 
all forms of vegetarian diet (73).
Adult vegetarians and vegans are recommended to 
have up to 1.3 times higher protein intake than omni-
vores; a sufficient protein intake can be achieved by eat-
ing a veried diet of plant origin and no other measures 
are needed (8). Amino acid digestibility values can be 
helpful to vegetarians and vegans when choosing quality 
protein-rich foods (8).
2.2 Fats and fatty acids
Vegetarian diets are typically rich in ω-6 fatty acids 
(linoleic and α-linolenic acids) and less ω-3 fatty acids 
(eicosapentaenoic, docosapentaenoic and docosahex-
aenoic acids); the latter are especially lacking in people 
who do not include fish and eggs in their diet (78). Ω-3 
fatty acids are important for the health of the cardiovas-
cular system, and in children also for normal psychomo-
tor development and vision development (4).
Eicosapentaenoic acid (EPA) and docosahexaenoic 
acid (DHA) levels are significantly lower in vegetarian 
and especially vegan diets (83). Vegetable oils contain 
α-linolenic acid (ALA), which is converted to EPA and 
DHA, but only in a small proportion (4). Dietary intake 
of ALA as a precursor to DHA is much less effective in 
accumulating DHA in the brain than consuming DHA 
(4). An additional source of DHA in vegetarians may be 
microalgae and DHA-enriched soy milk or bars (3).
2.3 Iron
Iron is found in plant foods in non-haem iron form, 
which has a lower bioavailability (approx. 10%) com-
pared to iron in haem-iron form (approx. 18%) (77). 
Sources of iron of plant origin are whole grains, legumes, 
leafy green vegetables, nuts, dried fruits and fortified ce-
reals (4). Absorption of iron in non-haem iron form is 
more susceptible to the effects of inhibitors and absorp-
tion enhancers than iron in haem-iron form (4); absorp-
tion is impaired by phytates, calcium, polyphenols in tea 
and coffee, and fibre, and improved by vitamin C and 
other organic acids in fruit and vegetables (3,78). Taking 
vitamin C together with a source of iron may reduce the 
inhibitory effects of phytates (4). Iron absorption can al-
so be improved by soaking or sprouting beans, cereals, 
and seeds, as this leads to the hydrolysis of phytates (4). 
The body can adapt to a longer period of reduced iron 
intake with improved absorption and reduced loss of 
iron (84,85).
Due to the poorer bioavailability of iron in foods of 
plant origin, 1.8 times higher iron intake is recommend-
ed for vegetarians than for people who eat a mixed diet 
(4,78). However, too much iron in food, especially in 
the form of dietary supplements, is harmful because it 
hinders the absorption of other minerals and increases 
cellular oxidative stress (86).
Iron deficiency can be present in all vegetarian diets, 
especially vegan diets (4). Children with long-term iron 
deficiency experience impaired growth and develop-
ment; the consequences can be permanent and include 
low growth and reduced motor and cognitive skills (1). 
Iron deficiency is otherwise first and foremost manifest-
ed by microcytic hypochromic anaemia (77,78). Some 
research has shown that the prevalence of hypochromic 
anaemia in vegetarians and vegans is similar to that of 
omnivores (32,87,88), but in the most recent meta-anal-
ysis of this issue from 2018 R. Pawlak et al. note that the 
incidence of iron deficiency anaemia in vegetarians is 
significantly higher (89).
2.4 Zinc
Sources of zinc in the diet are beef, pork, poultry, 
eggs, milk and cheese, and plant foods include soy, le-
gumes, cereals and nuts (3). The bioavailability of zinc 
in vegetarian diets is lower mainly due to the higher 
content of phytates, calcium and fibre in the diet, but it 
can be increased by soaking seeds and cereals and by in-
creasing the intake of certain organic acids (e.g. citrates) 
(3,78). Zinc is not stored in large quantities in the body, 
so its constant intake is required (1). According to some 
studies, zinc intake in vegetarians is sufficient (80,92), 
but other studies report it is too low (93,94).
2.5 Calcium
The source of calcium in the vegan diet is green 
vegetables with low oxalate content, e.g. broccoli, kale, 
cabbage and certain types of cauliflower (4). Possible ad-
ditional sources include mineral waters, juices, and cal-
cium-fortified foods. The bioavailability of calcium from 
these sources is lower (4). Calcium from nuts, dried le-
gumes and vegetables high in oxalates (e.g. spinach) has 
low bioavailability (1). Calcium absorption improves 
with adequate intake of vitamin D and protein (4).
According to the American Dietetic Association, 
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calcium intake of lacto-ovo vegetarians is on average 
higher than calcium intake in people with mixed diets, 
while calcium intake in vegans is lower than in the other 
two groups, so it may be too low according to recom-
mendations (4). Decreased plasma calcium concentra-
tions lead to increased calcium resorption from bone, 
which manifests as decreased bone mineralization and 
osteopenia or rickets in children (1).
2.6 Vitamin B12
The only reliable source of vitamin B12 or cobalamin 
is food of animal origin; plant foods do not contain sig-
nificant amounts of vitamin B12 (1). Vitamin B12 defi-
ciency is possible in all people who eat meat or fish less 
than once a week (8). Lacto-ovo vegetarians can achieve 
a sufficient intake of vitamin B12 by regular consumption 
of milk and eggs, and vegans need to replace vitamin B12 
with dietary supplements and foods enriched with vita-
min B12 (3). Dairy products contain less vitamin B12 than 
eggs, meat and fish (8), but the bioavailability of vitamin 
B12 from milk is higher than from eggs or meat (97,98). 
The bioavailability of vitamin B12 from dietary supple-
ments is significantly lower than from foods of animal 
origin (1).
Several studies have shown reduced levels of vitamin 
B12 in children on a strict vegan diet (10,77,78,99,100) 
and in infants breastfed by vegan mothers, even in cas-
es where the mother’s vitamin B12 stores were sufficient 
(8,100). Vitamin B12 deficiency in infants can cause slow-
er growth and slower cognitive development, hypoten-
sion, microcephaly, and megaloblastic anaemia (100). 
Prolonged neurological damage due to vitamin B12 defi-
ciency cannot be completely rerversed even with proper 
treatment (77). In adults, symptoms of vitamin B12 defi-
ciency may be absent for a long time, as the vegetarian 
diet contains large amounts of folic acid, which obscures 
the haematologic symptoms of vitamin B12 deficiency 
(101,102).
2.7 Vitamin B2
Sources of vitamin B2 or riboflavin include milk and 
dairy products, meat, fish and eggs, and in plant-based 
foods the sources include beans, broccoli, asparagus, 
kale, lentils, bananas, figs, sweet potatoes and tofu. Vi-
tamin B2 deficiency is rare in vegetarians and vegans 
(4,78). Deficiency can occur with a strict vegan diet, es-
pecially if plasma homocysteine levels are elevated (1). 
Consequences of riboflavin deficiency include dermati-
tis, inflammation of the oral mucosa and tongue, ulcers 
of the corners of the mouth and, in severe cases, normo-
cytic anaemia, as well as growth disorders in children (1).
2.8 Vitamin A
Vitamin A is crucial for the growth and proper func-
tioning of the immune system, and vitamin A aldehyde 
is important for vision (1). The only source of vitamin A 
is food of animal origin. Dark green and yellow-orange 
vegetables and fruit contain a precursor of vitamin A 
(β-carotene) (4). The process of absorption of β-carotene 
from food of plant origin is relatively inefficient, so the 
intake may be too low for both vegetarians and vegans 
(105,106). For adequate intake of vitamin A in vegetari-
ans, it is recommended to eat leafy green and yellow-or-
ange vegetables and fruit three times a day (78). The ab-
sorption of β-carotene is improved by cooking with the 
addition of small amounts of fat (107,108), and possibly 
also by chopping and grinding (108,109).
Vitamin A deficiency in vegetarians and vegans is ra-
re in developed countries (4); it is most common in chil-
dren fed a strictly vegan diet (110). Additional vitamin A 
in the form of dietary supplements is not recommended 
to vegetarians and vegans due to its lipid solubility and 
possible hypervitaminosis (4).
2.9 Vitamin D
Vitamin D is synthesized during exposure to sun-
light. Dietary sources of vitamin D are meat, sea fish, fish 
oil, egg yolk, and to a lesser extent milk and plant-based 
beverages (3,78). Vitamin D deficiency can occur in all 
forms of vegetarian diets (3). Deficiency is more likely to 
be greater in infants, children, and the elderly, as their 
vitamin D synthesis is less efficient (111,112). In infants 
and children, deficiency manifests itself with the onset 
of rickets, decreased muscle strength, and increased sus-
ceptibility to infections (1). In adults, severe vitamin D 
deficiency causes osteomalacia (3).
All forms of vegetarian diets require the addition of 
vitamin D in forms of vitamin D-fortified beverages or 
dietary supplements (78). Vitamin D-3 is of animal ori-
gin, so vegans only take vitamin D-2. According to some 
studies, vitamin D-2 is less effective than vitamin D-3 in 
maintaining sufficient serum concentrations of 25-hy-
droxy vitamin D (113), but other studies have shown 
comparable efficacy (114).
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3 Implementation of alternative diets in 
life stages
3.1 Pregnant and breastfeeding mothers
Several studies have found lower protein intake, high-
er carbohydrate intake, and lower intake of vitamin B12, 
vitamin C, calcium, and zinc in pregnant and breast-
feeding vegetarian mothers (73). In some cases, the in-
take of vitamin B12, iron and zinc was too low according 
to recommendations (115). Adequate intake of vitamin 
B12, vitamin D, iron, and folate is particularly important 
during pregnancy, while vitamin B12, vitamin D, calcium 
and zinc are important in breastfeeding mothers (73). 
Serum DHA levels are significantly lower in newborns 
and infants of vegetarian mothers (3). According to some 
studies, newborns of vegetarian mothers are more likely 
to have low birth weight, although other studies contra-
dict this finding (115,116).
Regardless of the diet, all pregnant women are rec-
ommended to consume 400 μg of folate per day (4). It 
is recommended that pregnant women and breastfeed-
ing mothers on a vegetarian diet receive at least 200 mg 
of DHA per day as a dietary supplement (78,117). Con-
sumption of trans-fatty acids, which inhibit the forma-
tion of DHA, is not recommend (78).
During pregnancy, zinc is recommended for vegetar-
ians and vegans in the form of dietary supplements (1). 
During breastfeeding, vegetarians can achieve adequate 
zinc and calcium intake through proper diet or nutri-
tional supplements (3). A vegan mother’s milk does not 
contain enough zinc for a baby after 7 months of age, so 
zinc should be added to the baby’s diet (78).
It is also recommended to add vitamin B12 and vi-
tamin D in the form of dietary supplements (78). Iron 
supplements are necessary in the event of sideropenic 
anaemia (3).
A vegetarian diet during pregnancy with the recom-
mended nutritional supplements can provide all the nec-
essary nutrients for the baby (4). However, there is not 
enough research in this area to be able to determine with 
certainty the impact of a pregnant woman’s vegetarian di-
et on the health of the newborn or the baby in later life 
(115,116). A mixed diet is recommended for pregnant 
and breastfeeding mothers, while choosing one of the 
vegetarian diets requires taking care of the appropriate 
level of critical nutrients obtained from a varied diet and 
nutritional supplements, and regular monitoring of the 
course of pregnancy (1,8).
3.2 Babies
A vegetarian diet is not recommended for infants, 
although it can provide adequate growth and develop-
ment with appropriate food supplements (8,10,24,73). 
A vegan diet with proper implementation and medical 
monitoring can provide all the important nutrients for a 
baby, but the consequences of inadequate or incomplete 
feeding can be extremely severe and include irreversible 
neurological damage due to vitamin B12 deficiency and 
even death (8,26,27,73). Special attention is required re-
garding the content of vitamin B12, vitamin D, iron, zinc, 
folate, ω-3 fatty acids (especially DHA), calcium, and 
protein in infants, and it is necessary to ensure adequate 
energy intake (26,73).
Infants that are not breastfed should be formula-fed 
for the first 6 months (73). The introduction of a mixed 
diet is recommended between 17 and 26 weeks of age 
(applies to all infants) (1). From the age of 6 months, the 
baby can enjoy tofu, soy products or legumes enriched 
with iron and vitamin B12 (73). Sufficient energy intake 
can be ensured by adding vegetable oils (1).
The European Society of Paediatric Gastroenterology, 
Hepatology and Nutrition (ESPHGAN) advises against 
feeding infants a vegetarian diet, especially a vegan di-
et, due to the risk of nutrient deficiencies (73). A similar 
position is shared by the German Nutrition Association 
(DGE) (26), the French-speaking Paediatric Hepatology, 
Gastroenterology and Nutrition Group (GFHGNP) (27) 
and the Slovenian Paediatric Society (1). However, some 
guidelines advocate the appropriateness of a vegetarian 
and vegan diet during infancy (4,10,11).
3.3 Children and adolescents
The growth of lacto-ovo-vegetarian children is compa-
rable to the growth of their peers (120-122). The growth 
of children with markedly restrictive diets is slowed (123); 
due to the inadequacy of such diets in children, data on 
this are based on individual reports (3,120). In vegetari-
ans, the age of girls at the onset of their first menstrual pe-
riod is similar to that of omnivores (121). Vegetarian ad-
olescents consume more fibre, iron, folate, vitamin A, and 
vitamin C, and less fast food and salty snacks (122,124). 
According to some data, vegetarian children have a low-
er body mass index than their peers, and the difference 
increases during adolescence (24,125). Several authors 
report an increased prevalence of eating disorders in ad-
olescents who eat a vegetarian or vegan diet (126-129).
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Adequate intake of vitamin B12, vitamin D, iron, calci-
um, zinc, ω-3 fatty acids, and protein should be ensured 
in children and adolescents who eat a vegetarian and es-
pecially a vegan diet (122). The risk of iron deficiency is 
reduced by an iron-fortified diet (122). In children and 
adolescents who do not consume milk, the addition of 
calcium in the form of calcium-fortified plant drinks is 
necessary, and in vegans also the addition of vitamin B12 
in the form of dietary supplements or consumption of 
Chlorella algae (10,122).
The growth and development of children who eat 
exclusive diets must be monitored, paying attention to 
signs of possible nutrient deficiencies (8).
Properly planned vegetarian and vegan diets in 
children and adolescents can provide all the necessary 
nutrients (4,8,122). Some professional associations be-
lieve that a lacto-ovo-vegetarian diet in childhood and 
adolescence may still be appropriate, but advise against 
a vegan diet, because, despite the possibility of provid-
ing missing nutrients with supplements, the risk of nu-
trient deficiencies is too great, and the consequences 
of possible deficiency are too severe (21-27,73,122). In 
Slovenia, members of the Slovenian Professional Board 
of Paediatrics recommend a balanced diet that includes 
foods from all groups during childhood and adolescence 
(21,22).
3.4 Adults
In adulthood, a vegetarian or vegan diet is safe and ap-
propriate if implemented properly; this means consum-
ing a variety of plant-based nutrients and responding to 
possible signs of critical macro- and micronutrient defi-
ciencies (3-8). Consumption of nutritional supplements 
in adults with a quality lacto-ovo-vegetarian diet is not 
necessary; the exceptions are pregnant women, breast-
feeding mothers, athletes and the elderly (26,27). Adult 
vegans should add vitamin B12 to their diet and, if nec-
essary, iron, zinc, vitamin D, calcium and ω-3 fatty acids 
(4,8). A diet based on plant-based foods can contribute 
to lower cardiovascular morbidity, obesity and diabetes 
(12-20,38-41).
Vegetarian and vegan diets can also meet the nutri-
tional needs of athletes, but greater caution is needed in 
these cases (131-137). The diet should contain nutrients 
rich in vitamin B12, iron, zinc, vitamin D, calcium and 
vitamin B2; if necessary, the listed nutrients can be added 
in the form of food supplements (133,138). Some authors 
also recommend the addition of protein in the form of 
dietary supplements to vegan athletes (133). In athletes, 
higher amounts of fibre should be excluded from the 
diet, as they cause early satiety and reduce energy intake 
and absorption of carbohydrates (133). Complications of 
low nutrient intake in athletes include lower bone mass, 
bone fractures, weakened immune system, endothelial 
dysfunction, mood disorders, and menstrual disorders 
in women (138-141). The performance of vegetarian and 
omnivorous athletes is comparable (136).
A vegetarian diet in old age can increase the risk of 
nutrient deficiencies (145,146). Adequate protein intake 
is especially important for vegetarian elderly people, as 
it is, in any case, often too low in old age to meet their 
needs (146). 6–15% of older adults are deficient in vita-
min B12 (149), and the prevalence of deficiency may be 
even higher in vegetarians; Vitamin B12 supplementation 
is recommended for all elderly people who eat a vege-
tarian diet (146). Regular addition of vitamin D is also 
important, as ultraviolet light-stimulated vitamin D pro-
duction in the skin decreases with age (4). Calcium and 
zinc supplementation are also required in some elderly 
people (145,146).
4 Conclusion
A professionally guided and supervised vegetarian or 
vegan diet can adequately support an individual’s meta-
bolic needs and thus contribute to the prevention of obe-
sity and the development of chronic diseases such as car-
diovascular disease, diabetes, and cancer (12-18,44,49). 
Negative consequences are manifested in particular in 
the lack of critical nutrients: protein, ω-3 fatty acids, 
iron, zinc, calcium, vitamin B12, vitamin B2, vitamin D, 
and vitamin A (4,8). Deficiency health complications 
include osteopenia and osteoporosis, anaemia (mega-
loblastic or microcytic hypochromic), cognitive decline, 
and, paradoxically, increased risk of cardiovascular dis-
ease (50–52,59,78). The consequences are more severe 
with more restrictive diets; during pregnancy and when 
a child is still a baby or an infant, nutrient deficiencies 
can lead to serious growth and developmental delays 
and, in the worst cases, even death (1,8,26-28).
Vegetarian diets, when properly implemented and 
controlled, can ensure adequate intake of macro- and mi-
cronutrients and do not have harmful effects on health; 
nutrition education is crucial (4,8,35,78). Due to severe 
and often irreversible health consequences of nutrient 
deficiencies, several professional associations advise 
against vegetarian and vegan diets in pregnant wom-
en, breastfeeding mothers, new-borns, infants, children 
and adolescents (1,26,27,73), while a number of studies, 
review articles and guidelines support vegetarian and 
vegan diets at all stages of life (4,8,9-11). When deciding 
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References
1. Orel R, Sedmak M, Fidler Mis N. Vegetarijanska prehrana pri otrocih – 
praktična navodila. Zdrav Vestn. 2014;83(2):169-81. 
2. Allès B, Baudry J, Méjean C, Touvier M, Péneau S, Hercberg S, et al. 
Comparison of sociodemographic and nutritional characteristics 
between self-reported vegetarians, vegans, and meat-eaters from the 
Nutrinet-Santé study. Nutrients. 2017;9(9):1023. DOI: 10.3390/nu9091023 
PMID: 28926931 
3. Mangels A, Messina V, Melina V; American Dietetic Association; Dietitians 
of Canada. Position of the American Dietetic Association and Dietitians 
of Canada: vegetarian diets. J Am Diet Assoc. 2003;103(6):748-65. DOI: 
10.1053/jada.2003.50142 PMID: 12778049 
4. Melina V, Craig W, Levin S. Position of the Academy of Nutrition and 
Dietetics: vegetarian Diets. J Acad Nutr Diet. 2016;116(12):1970-80. DOI: 
10.1016/j.jand.2016.09.025 PMID: 27886704 
5. Appleby PN, Key TJ. The long-term health of vegetarians and vegans. 
Proc Nutr Soc. 2016;75(3):287-93. DOI: 10.1017/S0029665115004334 
PMID: 26707634 
6. White R, Frank E. Health effects and prevalence of vegetarianism. West J 
Med. 1994;160(5):465-70. PMID: 8048240 
7. Fox N, Ward K. Health, ethics and environment: a qualitative study of 
vegetarian motivations. Appetite. 2008;50(2-3):422-9. DOI: 10.1016/j.
appet.2007.09.007 PMID: 17980457 
8. Van Winckel M, Vande Velde S, De Bruyne R, Van Biervliet S. Clinical 
practice: vegetarian infant and child nutrition. Eur J Pediatr. 
2011;170(12):1489-94. DOI: 10.1007/s00431-011-1547-x PMID: 21912895 
9. Campbell TC, Campbell TM. The China Study. Dallas: BenBeella Books; 
2004. 
10. Messina V, Mangels AR. Considerations in planning vegan diets: children. 
J Am Diet Assoc. 2001;101(6):661-9. DOI: 10.1016/S0002-8223(01)00167-5 
PMID: 11424545 
11. Baroni L, Goggi S, Battaglino R, Berveglieri M, Fasan I, Filippin D, et al. 
Vegan nutrition for mothers and children: practical tools for healthcare 
providers. Nutrients. 2018;11(1):5. DOI: 10.3390/nu11010005 PMID: 
30577451 
12. Key TJ, Fraser GE, Thorogood M, Appleby PN, Beral V, Reeves G, et 
al. Mortality in vegetarians and nonvegetarians: detailed findings 
from a collaborative analysis of 5 prospective studies. Am J Clin Nutr. 
1999;70(3):516S-24S. DOI: 10.1093/ajcn/70.3.516s PMID: 10479225 
13. Kahleova H, Levin S, Barnard ND. Vegetarian dietary patterns and 
cardiovascular disease. Prog Cardiovasc Dis. 2018;61(1):54-61. DOI: 
10.1016/j.pcad.2018.05.002 PMID: 29800598 
14. Yokoyama Y, Nishimura K, Barnard ND, Takegami M, Watanabe M, 
Sekikawa A, et al. Vegetarian diets and blood pressure: a meta-
analysis. JAMA Intern Med. 2014;174(4):577-87. DOI: 10.1001/
jamainternmed.2013.14547 PMID: 24566947 
15. Olfert MD, Wattick RA. Vegetarian Diets and the Risk of Diabetes. Curr Diab 
Rep. 2018;18(11):101. DOI: 10.1007/s11892-018-1070-9 PMID: 30229314 
16. Kahleova H, Matoulek M, Malinska H, Oliyarnik O, Kazdova L, Neskudla 
T, et al. Vegetarian diet improves insulin resistance and oxidative stress 
markers more than conventional diet in subjects with Type 2 diabetes. 
Diabet Med. 2011;28(5):549-59. DOI: 10.1111/j.1464-5491.2010.03209.x 
PMID: 21480966 
17. Yokoyama Y, Barnard ND, Levin SM, Watanabe M. Vegetarian diets and 
glycemic control in diabetes: a systematic review and meta-analysis. 
Cardiovasc Diagn Ther. 2014;4(5):373-82. PMID: 25414824 
18. Bunner AE, Wells CL, Gonzales J, Agarwal U, Bayat E, Barnard ND. A 
dietary intervention for chronic diabetic neuropathy pain: a randomized 
controlled pilot study. Nutr Diabetes. 2015;5(5):e158. DOI: 10.1038/
nutd.2015.8 PMID: 26011582 
19. Tonstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body weight, 
and prevalence of type 2 diabetes. Diabetes Care. 2009;32(5):791-6. DOI: 
10.2337/dc08-1886 PMID: 19351712 
20. Ginter E. Vegetarian diets, chronic diseases and longevity. Bratisl Lek 
Listy. 2008;109(10):463-6. PMID: 19166134 
21. Gabrijelčič Blenkuš M, Pograjc L, Gregorčič M, Adamič M, Čampa A. 
Smernice zdravega prehranjevanja v vzgojno-izobraževalnih ustanovah 
(od prvega leta starosti naprej). Ljubljana: Ministrstvo za zdravje; 2005. 
22. Hlastan Ribič C, Blaznik U, Gregorič M, Jarm K. Strokovno mnenje glede 
vegetarijanstva in Kitajske študije. Ljubljana: Nacionalni inštitut za javno 
zdravje; 2011 [cited 2021 May 24]. Available from: https://www.nijz.si/sl/
strokovno-mnenje-glede-vegetarijanstva-in-kitajske-studije.
23. Thorburn AN, Macia L, Mackay CR. Diet, metabolites, and “western-
lifestyle” inflammatory diseases. Immunity. 2014;40(6):833-42. DOI: 
10.1016/j.immuni.2014.05.014 PMID: 24950203 
24. Robinson-O’Brien R, Perry CL, Wall MM, Story M, Neumark-Sztainer D. 
Adolescent and young adult vegetarianism: better dietary intake and 
weight outcomes but increased risk of disordered eating behaviors. J Am 
Diet Assoc. 2009;109(4):648-55. DOI: 10.1016/j.jada.2008.12.014 PMID: 
19328260 
25. Bedford JL, Barr SI. Diets and selected lifestyle practices of self-defined 
adult vegetarians from a population-based sample suggest they are 
more ‘health conscious’. Int J Behav Nutr Phys Act. 2005;2(1):4. DOI: 
10.1186/1479-5868-2-4 PMID: 15829014 
26. Richter M, Boeing H, Grünewald-Funk D, Heseker H, Kroke A, Leschik-
Bonnet E, et al. Vegane Ernährung: Position der Deutschen für Ernährung 
e.V. (DGE). Ernaehrungs Umschau international. 2016;4(16):92-102. 
27. Lemale J, Mas E, Jung C, Bellaiche M, Tounian P; French-speaking 
Pediatric Hepatology, Gastroenterology and Nutrition Group (GFHGNP). 
Vegan diet in children and adolescents. Recommendations from the 
French-speaking Pediatric Hepatology, Gastroenterology and Nutrition 
Group (GFHGNP). Arch Pediatr. 2019;26(7):442-50. DOI: 10.1016/j.
arcped.2019.09.001 PMID: 31615715 
on a vegetarian or vegan diet, it is important to create a 
diet plan in accordance with the recommendations, and 
for children and pregnant women, to be monitored by a 
paediatrician or clinical dietitian (1,8,73).
Due to the growing importance of the issue of veg-
etarianism and veganism, further research in this field, 
training of experts, and the development of the most 
uniform possible guidelines for the proper implementa-
tion of alternative diets are needed (4,61,73).
Conflict of interest
None declared.
251
PROFESSIONAL ARTICLE
Alternative nutrition: literature review
28. McEvoy CT, Temple N, Woodside JV. Vegetarian diets, low-meat diets and 
health: a review. Public Health Nutr. 2012;15(12):2287-94. DOI: 10.1017/
S1368980012000936 PMID: 22717188 
29. Liu HW, Liu JS, Kuo KL. Vegetarian diet and blood pressure in a hospital-
base study. Tzu-Chi Med J. 2018;30(3):176-80. DOI: 10.4103/tcmj.
tcmj_91_17 PMID: 30069127 
30. 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;15(10):1909-
16. DOI: 10.1017/S1368980011003454 PMID: 22230619 
31. Clarys P, Deliens T, Huybrechts I, Deriemaeker P, Vanaelst B, De Keyzer 
W, et al. Comparison of nutritional quality of the vegan, vegetarian, 
semi-vegetarian, pesco-vegetarian and omnivorous diet. Nutrients. 
2014;6(3):1318-32. DOI: 10.3390/nu6031318 PMID: 24667136 
32. Larsson CL, Johansson GK. Dietary intake and nutritional status of young 
vegans and omnivores in Sweden. Am J Clin Nutr. 2002;76(1):100-6. DOI: 
10.1093/ajcn/76.1.100 PMID: 12081822 
33. Rizzo NS, Jaceldo-Siegl K, Sabate J, Fraser GE. Nutrient profiles of 
vegetarian and nonvegetarian dietary patterns. J Acad Nutr Diet. 
2013;113(12):1610-9. DOI: 10.1016/j.jand.2013.06.349 PMID: 23988511 
34. Wang F, Zheng J, Yang B, Jiang J, Fu Y, Li D. Effects of vegetarian diets 
on blood lipids: a systematic review and meta-analysis of randomized 
controlled trials. J Am Heart Assoc. 2015;4(10):e002408. DOI: 10.1161/
JAHA.115.002408 PMID: 26508743 
35. Sedmak M. Vegetarijanska prehrana pri otrocih in mladostnikih – da ali 
ne? Ljubljana: Medis; 2020 [cited 2021 May 24]. Available from: https://
www.nasa-lekarna.si/clanki/clanek/vegetarijanska-prehrana-pri-
otrocih-in-mladostnikih-da-ali-ne/.
36. Založnik U. Odnos ljudi do veganstva in presnega veganstva. [Magistrsko 
delo]. Izola: Univerza na Primorskem, Fakulteta za vede o zdravju; 2018. 
37. Mezzano D, Kosiel K, Martínez C, Cuevas A, Panes O, Aranda E, et 
al. Cardiovascular risk factors in vegetarians. Normalization of 
hyperhomocysteinemia with vitamin B(12) and reduction of platelet 
aggregation with n-3 fatty acids. Thromb Res. 2000;100(3):153-60. DOI: 
10.1016/S0049-3848(00)00313-3 PMID: 11108902 
38. Turner-McGrievy G, Mandes T, Crimarco A. A plant-based diet for 
overweight and obesity prevention and treatment. J Geriatr Cardiol. 
2017;14(5):369-74. PMID: 28630616 
39. Soeters PB. Editorial: Vegan diets: what is the benefit? Curr Opin Clin Nutr 
Metab Care. 2020;23(2):151-3. DOI: 10.1097/MCO.0000000000000623 
PMID: 32028321 
40. Barnard ND, Levin SM, Yokoyama Y. A systematic review and meta-
analysis of changes in body weight in clinical trials of vegetarian diets. 
J Acad Nutr Diet. 2015;115(6):954-69. DOI: 10.1016/j.jand.2014.11.016 
PMID: 25620754 
41. Huang RY, Huang CC, Hu FB, Chavarro JE. Vegetarian diets and weight 
reduction: a meta-analysis of randomized controlled trials. J Gen Intern 
Med. 2016;31(1):109-16. DOI: 10.1007/s11606-015-3390-7 PMID: 26138004 
42. Vang A, Singh PN, Lee JW, Haddad EH, Brinegar CH. Meats, processed 
meats, obesity, weight gain and occurrence of diabetes among adults: 
findings from Adventist Health Studies. Ann Nutr Metab. 2008;52(2):96-
104. DOI: 10.1159/000121365 PMID: 18349528 
43. Key TJ, Appleby PN, Spencer EA, Travis RC, Allen NE, Thorogood M, et al. 
Cancer incidence in British vegetarians. Br J Cancer. 2009;101(1):192-7. 
DOI: 10.1038/sj.bjc.6605098 PMID: 19536095 
44. Lanou AJ, Svenson B. Reduced cancer risk in vegetarians: an analysis of 
recent reports. Cancer Manag Res. 2010;3:1-8. DOI: 10.2147/CMAR.S6910 
PMID: 21407994 
45. Sanjoaquin MA, Appleby PN, Thorogood M, Mann JI, Key TJ. Nutrition, 
lifestyle and colorectal cancer incidence: a prospective investigation 
of 10998 vegetarians and non-vegetarians in the United Kingdom. Br J 
Cancer. 2004;90(1):118-21. DOI: 10.1038/sj.bjc.6601441 PMID: 14710217 
46. Taylor VH, Misra M, Mukherjee SD. Is red meat intake a risk factor for 
breast cancer among premenopausal women? Breast Cancer Res Treat. 
2009;117(1):1-8. DOI: 10.1007/s10549-009-0441-y PMID: 19543971 
47. Sinha R, Cross AJ, Graubard BI, Leitzmann MF, Schatzkin A. Meat intake 
and mortality: a prospective study of over half a million people. Arch 
Intern Med. 2009;169(6):562-71. DOI: 10.1001/archinternmed.2009.6 
PMID: 19307518 
48. Divisi D, Di Tommaso S, Salvemini S, Garramone M, Crisci R. Diet and 
cancer. Acta Biomed. 2006;77(2):118-23. PMID: 17172193 
49. Craig WJ. Health effects of vegan diets. Am J Clin Nutr. 
2009;89(5):1627S-33S. DOI: 10.3945/ajcn.2009.26736N PMID: 19279075 
50. Tucker KL. Vegetarian diets and bone status. Am J Clin Nutr. 
2014;100(1):329S-35S. DOI: 10.3945/ajcn.113.071621 PMID: 24898237 
51. Iguacel I, Miguel-Berges ML, Gómez-Bruton A, Moreno LA, Julián C. 
Veganism, vegetarianism, bone mineral density, and fracture risk: a 
systematic review and meta-analysis. Nutr Rev. 2019;77(1):1-18. DOI: 
10.1093/nutrit/nuy045 PMID: 30376075 
52. Ho-Pham LT, Nguyen ND, Nguyen TV. Effect of vegetarian diets on bone 
mineral density: a Bayesian meta-analysis. Am J Clin Nutr. 2009;90(4):943-
50. DOI: 10.3945/ajcn.2009.27521 PMID: 19571226 
53. Appleby P, Roddam A, Allen N, Key T. Comparative fracture risk in 
vegetarians and nonvegetarians in EPIC-Oxford. Eur J Clin Nutr. 
2007;61(12):1400-6. DOI: 10.1038/sj.ejcn.1602659 PMID: 17299475 
54. Ho-Pham LT, Vu BQ, Lai TQ, Nguyen ND, Nguyen TV. Vegetarianism, bone 
loss, fracture and vitamin D: a longitudinal study in Asian vegans and 
non-vegans. Eur J Clin Nutr. 2012;66(1):75-82. DOI: 10.1038/ejcn.2011.131 
PMID: 21811293 
55. Swaminathan A, Jicha GA. Nutrition and prevention of Alzheimer’s 
dementia. Front Aging Neurosci. 2014;6:282. DOI: 10.3389/
fnagi.2014.00282 PMID: 25368575 
56. Khalsa DS, Perry G. The four pillars of Alzheimer’s prevention. Cerebrum. 
2017;2017:cer-03-17. PMID: 28698774 
57. Dominguez LJ, Barbagallo M. Nutritional prevention of cognitive decline 
and dementia. Acta Biomed. 2018;89(2):276-90. PMID: 29957766 
58. Ling M, Chiu T, Chang C. The impact of a plant-based dietary pattern on 
dementia risk: a prospective cohort study. Innov Aging. 2019;3:S734. DOI: 
10.1093/geroni/igz038.2691 
59. Giem P, Beeson WL, Fraser GE. The incidence of dementia and intake of 
animal products: preliminary findings from the Adventist Health Study. 
Neuroepidemiology. 1993;12(1):28-36. DOI: 10.1159/000110296 PMID: 
8327020 
60. Moore E, Mander A, Ames D, Carne R, Sanders K, Watters D. Cognitive 
impairment and vitamin B12: a review. Int Psychogeriatr. 2012;24(4):541-
56. DOI: 10.1017/S1041610211002511 PMID: 22221769 
61. Medawar E, Huhn S, Villringer A, Veronica Witte A. The effects of plant-
based diets on the body and the brain: a systematic review. Transl 
Psychiatry. 2019;9(1):226. DOI: 10.1038/s41398-019-0552-0 PMID: 
31515473 
62. David LA, Maurice CF, Carmody RN, Gootenberg DB, Button JE, Wolfe BE, 
et al. Diet rapidly and reproducibly alters the human gut microbiome. 
Nature. 2014;505(7484):559-63. DOI: 10.1038/nature12820 PMID: 
24336217 
63. Wu GD, Chen J, Hoffmann C, Bittinger K, Chen YY, Keilbaugh SA, et al. 
Linking long-term dietary patterns with gut microbial enterotypes. 
Science. 2011;334(6052):105-8. DOI: 10.1126/science.1208344 PMID: 
21885731 
64. Kim MS, Hwang SS, Park EJ, Bae JW. Strict vegetarian diet improves 
the risk factors associated with metabolic diseases by modulating gut 
microbiota and reducing intestinal inflammation. Environ Microbiol Rep. 
2013;5(5):765-75. DOI: 10.1111/1758-2229.12079 PMID: 24115628 
65. Kumar M, Babaei P, Ji B, Nielsen J. Human gut microbiota and healthy 
aging: recent developments and future prospective. Nutr Healthy Aging. 
2016;4(1):3-16. DOI: 10.3233/NHA-150002 PMID: 28035338 
66. Wu GD, Compher C, Chen EZ, Smith SA, Shah RD, Bittinger K, et al. 
Comparative metabolomics in vegans and omnivores reveal constraints 
on diet-dependent gut microbiota metabolite production. Gut. 
2016;65(1):63-72. DOI: 10.1136/gutjnl-2014-308209 PMID: 25431456 
252
NUTRITION
Zdrav Vestn | May – June 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.2994
67. Wanders AJ, van den Borne JJ, de Graaf C, Hulshof T, Jonathan MC, 
Kristensen M, et al. Effects of dietary fibre on subjective appetite, 
energy intake and body weight: a systematic review of randomized 
controlled trials. Obes Rev. 2011;12(9):724-39. DOI: 10.1111/j.1467-
789X.2011.00895.x PMID: 21676152 
68. Brunkwall L, Orho-Melander M. The gut microbiome as a target for 
prevention and treatment of hyperglycaemia in type 2 diabetes: 
from current human evidence to future possibilities. Diabetologia. 
2017;60(6):943-51. DOI: 10.1007/s00125-017-4278-3 PMID: 28434033 
69. Lach G, Schellekens H, Dinan TG, Cryan JF. Anxiety, depression and the 
microbiome: a role for gut peptides. Neurotherapeutics. 2018;15(1):36-
59. DOI: 10.1007/s13311-017-0585-0 PMID: 29134359 
70. Saulnier DM, Ringel Y, Heyman MB, Foster JA, Bercik P, Shulman 
RJ, et al. The intestinal microbiome, probiotics and prebiotics in 
neurogastroenterology. Gut Microbes. 2013;4(1):17-27. DOI: 10.4161/
gmic.22973 PMID: 23202796 
71. Maes M, Kubera M, Leunis JC, Berk M. Increased IgA and IgM responses 
against gut commensals in chronic depression: further evidence 
for increased bacterial translocation or leaky gut. J Affect Disord. 
2012;141(1):55-62. DOI: 10.1016/j.jad.2012.02.023 PMID: 22410503 
72. Craig WJ. Nutrition concerns and health effects of vegetarian diets. Nutr 
Clin Pract. 2010;25(6):613-20. DOI: 10.1177/0884533610385707 PMID: 
21139125 
73. Fewtrell M, Bronsky J, Campoy C, Domellöf M, Embleton N, Fidler Mis N, 
et al. Complementary Feeding: A Position Paper by the European Society 
for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 
Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2017;64(1):119-32. 
DOI: 10.1097/MPG.0000000000001454 PMID: 28027215 
74. Bratanič B, Fidler Mis N, Hlastan Ribič C, Poličnik R, Širca Čampa A, 
Kosem R, Fajdiga Turk V.. Smernice zdravega prehranjevanja za dojenčke. 
Ljubljana: Ministrstvo za zdravje Republike Slovenije; 
75. Slovenija. Zakoni. Pravilnik o prehranskih dopolnilih. Uradni list RS. 
2013(66)2010 [cited 2020 May 24]. Available from: http://www.pisrs.si/
Pis.web/pregledPredpisa?id=PRAV11675#.
76. Dwyer JT, Coates PM, Smith MJ. Dietary supplements: regulatory 
challenges and research resources. Nutrients. 2018;10(1):41. DOI: 
10.3390/nu10010041 PMID: 29300341 
77. Di Genova T, Guyda H. Infants and children consuming atypical diets: 
vegetarianism and macrobiotics. Paediatr Child Health. 2007;12(3):185-8. 
DOI: 10.1093/pch/12.3.185 PMID: 19030357 
78. Amit M. Vegetarian diets in children and adolescents. Paediatr Child 
Health. 2010;15(5):303-14. PMID: 21532796 
79. Mariotti F, Gardner CD. Dietary protein and amino acids in vegetarian 
diets – a review. Nutrients. 2019;11(11):2661. DOI: 10.3390/nu11112661 
PMID: 31690027 
80. Davey GK, Spencer EA, Appleby PN, Allen NE, Knox KH, Key TJ. EPIC-
Oxford: lifestyle characteristics and nutrient intakes in a cohort of 33 883 
meat-eaters and 31 546 non meat-eaters in the UK. Public Health Nutr. 
2003;6(3):259-69. DOI: 10.1079/PHN2002430 PMID: 12740075 
81. Orlich MJ, Fraser GE. Vegetarian diets in the Adventist Health Study 2: a 
review of initial published findings. Am J Clin Nutr. 2014;100(1):353S-8S. 
DOI: 10.3945/ajcn.113.071233 PMID: 24898223 
82. Mangels R, Messina V, Messina M. The Dietitian’s Guide to Vegetarian 
Diets. 3rd ed. Sudbury (MA): Jones and Bartlett; 2011. 
83. Rosell MS, Lloyd-Wright Z, Appleby PN, Sanders TA, Allen NE, Key TJ. 
Long-chain n-3 polyunsaturated fatty acids in plasma in British meat-
eating, vegetarian, and vegan men. Am J Clin Nutr. 2005;82(2):327-34. 
DOI: 10.1093/ajcn/82.2.327 PMID: 16087975 
84. Hunt JR, Roughead ZK. Nonheme-iron absorption, fecal ferritin excretion, 
and blood indexes of iron status in women consuming controlled 
lactoovovegetarian diets for 8 wk. Am J Clin Nutr. 1999;69(5):944-52. 
PMID: 10232635 
85. Hunt JR, Roughead ZK. Adaptation of iron absorption in men consuming 
diets with high or low iron bioavailability. Am J Clin Nutr. 2000;71(1):94-
102. DOI: 10.1093/ajcn/71.1.94 PMID: 10617952 
86. Jiang R, Manson JE, Meigs JB, Ma J, Rifai N, Hu FB. Body iron stores in 
relation to risk of type 2 diabetes in apparently healthy women. JAMA. 
2004;291(6):711-7. DOI: 10.1001/jama.291.6.711 PMID: 14871914 
87. Ball MJ, Bartlett MA. Dietary intake and iron status of Australian vegetarian 
women. Am J Clin Nutr. 1999;70(3):353-8. DOI: 10.1093/ajcn/70.3.353 
PMID: 10479197 
88. Saunders AV, Craig WJ, Baines SK, Posen JS. Iron and vegetarian diets. 
Med J Aust. 2013;199:S11-6. PMID: 25369923 
89. Pawlak R, Berger J, Hines I. Iron status of vegetarian adults: a 
review of literature. Am J Lifestyle Med. 2016;12(6):486-98. DOI: 
10.1177/1559827616682933 PMID: 30783404 
90. Śliwińska A, Luty J, Aleksandrowicz-Wrona E, Małgorzewicz S. Iron status 
and dietary iron intake in vegetarians. Adv Clin Exp Med. 2018;27(10):1383-
9. DOI: 10.17219/acem/70527 PMID: 30062867 
91. Hunt JR. Bioavailability of iron, zinc, and other trace minerals from 
vegetarian diets. Am J Clin Nutr. 2003;78(3):633S-9S. DOI: 10.1093/
ajcn/78.3.633S PMID: 12936958 
92. Saunders AV, Craig WJ, Baines SK. Zinc and vegetarian diets. Med J Aust. 
2013;199:S17-21. PMID: 25369924 
93. Foster M, Chu A, Petocz P, Samman S. Effect of vegetarian diets on zinc 
status: a systematic review and meta-analysis of studies in humans. J Sci 
Food Agric. 2013;93(10):2362-71. DOI: 10.1002/jsfa.6179 PMID: 23595983 
94. Foster M, Herulah UN, Prasad A, Petocz P, Samman S. Zinc status of 
vegetarians during pregnancy: a systematic review of observational 
studies and meta-analysis of zinc intake. Nutrients. 2015;7(6):4512-25. 
DOI: 10.3390/nu7064512 PMID: 26056918 
95. Weaver CM, Proulx WR, Heaney R. Choices for achieving adequate dietary 
calcium with a vegetarian diet. Am J Clin Nutr. 1999;70(3):543S-8S. DOI: 
10.1093/ajcn/70.3.543s PMID: 10479229 
96. Weaver CM, Peacock M. Calcium. Adv Nutr. 2011;2(3):290-2. DOI: 10.3945/
an.111.000463 PMID: 22332061 
97. World Health Organization and Food and Agriculture Organization of the 
United NationsVitamin and mineral requirements in human nutrition. 
Hong Kong: Sun Fung; 2004. 
98. Watanabe F. Vitamin B12 sources and bioavailability. Exp Biol Med 
(Maywood). 2007;232(10):1266-74. DOI: 10.3181/0703-MR-67 PMID: 
17959839 
99. Dagnelle PC, Van Stavaren WA. Macrobiotic nutrition and child health: 
results od a population-based, mixed-longitudinal cohort study in 
The Netherlands. Am J Clin Nutr. 1994;59(5):1187-96. DOI: 10.1093/
ajcn/59.5.1187S 
100. Honzik T, Adamovicova M, Smolka V, Magner M, Hruba E, Zeman J. 
Clinical presentation and metabolic consequences in 40 breastfed 
infants with nutritional vitamin B12 deficiency—what have we learned? 
Eur J Paediatr Neurol. 2010;14(6):488-95. DOI: 10.1016/j.ejpn.2009.12.003 
PMID: 20089427 
101. Hermann W, Schorr H, Purschwitz K, Rassoul F, Richter V.. Total 
homocysteine, vitamin B(12), and total antioxidant status in vegetarians. 
Clin Chem. 2001;47(6):1094-101. PMID: 11375297
102. Carmel R. Current concepts in cobalamin deficiency. Annu Rev Med. 
2000;51(1):357-75. DOI: 10.1146/annurev.med.51.1.357 PMID: 10774470 
103. Herrmann W, Geisel J. Vegetarian lifestyle and monitoring of vitamin 
B-12 status. Clin Chim Acta. 2002;326(1-2):47-59. DOI: 10.1016/S0009-
8981(02)00307-8 PMID: 12417096 
104. Herrmann W, Obeid R, Schorr H, Geisel J. Functional vitamin B12 
deficiency and determination of holotranscobalamin in populations 
at risk. Clin Chem Lab Med. 2003;41(11):1478-88. DOI: 10.1515/
CCLM.2003.227 PMID: 14656029 
105. Institute of Medicine (US) Panel on MicronutrientsDietary Reference 
Intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, 
iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and 
zinc. Washington (DC). Washington: National Academies Press; 2001. 
253
PROFESSIONAL ARTICLE
Alternative nutrition: literature review
106. van het Hof KH, Brouwer IA, West CE, Haddeman E, Steegers-Theunissen 
RP, van Dusseldorp M, et al. Bioavailability of lutein from vegetables is 5 
times higher than that of beta-carotene. Am J Clin Nutr. 1999;70(2):261-8. 
DOI: 10.1093/ajcn.70.2.261 PMID: 10426704 
107. Hedrén E, Diaz V, Svanberg U. Estimation of carotenoid accessibility 
from carrots determined by an in vitro digestion method. Eur J Clin Nutr. 
2002;56(5):425-30. DOI: 10.1038/sj.ejcn.1601329 PMID: 12001013 
108. Ribaya-Mercado JD. Influence of dietary fat on beta-carotene absorption 
and bioconversion into vitamin A. Nutr Rev. 2002;60(4):104-10. DOI: 
10.1301/00296640260085831 PMID: 12002680 
109. Castenmiller JJ, West CE, Linssen JP, van het Hof KH, Voragen AG. The food 
matrix of spinach is a limiting factor in determining the bioavailability 
of beta-carotene and to a lesser extent of lutein in humans. J Nutr. 
1999;129(2):349-55. DOI: 10.1093/jn/129.2.349 PMID: 10024612 
110. Colev M, Engel H, Mayers M, Markowitz M, Cahill L. Vegan diet and 
vitamin A deficiency. Clin Pediatr (Phila). 2004;43(1):107-9. DOI: 
10.1177/000992280404300116 PMID: 14968902 
111. Holick MF. Vitamin D and bone health. J Nutr. 1996;126(4):1159S-64S. 
DOI: 10.1093/jn/126.suppl_4.1159S PMID: 8642450 
112. Lee LT, Drake WM, Kendler DL. Intake of calcium and vitamin D in 3 
Canadian long-term care facilities. J Am Diet Assoc. 2002;102(2):244-7. 
DOI: 10.1016/S0002-8223(02)90057-X PMID: 11846119 
113. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than 
vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89(11):5387-91. 
DOI: 10.1210/jc.2004-0360 PMID: 15531486 
114. Holick M, Biancuzzo R, Chen T, Klein E, Young A, Bibuld D, Reitz R.. Vitamin 
D2 is as effective as vitamin D3 in maintaining circulating concentrations 
of 25-hydroxyvitamin D. J Clin Endocrinol Metab. 2008;93(3):677-81. DOI: 
10.1210/jc.2007-2308 PMID: 18089691
115. Piccoli GB, Clari R, Vigotti FN, Leone F, Attini R, Cabiddu G, et al. Vegan-
vegetarian diets in pregnancy: danger or panacea? A systematic narrative 
review. BJOG. 2015;122(5):623-33. DOI: 10.1111/1471-0528.13280 PMID: 
25600902 
116. Tan C, Zhao Y, Wang S. Is a vegetarian diet safe to follow during pregnancy? 
A systematic review and meta-analysis of observational studies. Crit Rev 
Food Sci Nutr. 2019;59(16):2586-96. DOI: 10.1080/10408398.2018.1461062 
PMID: 29621406 
117. Jensen CL, Voigt RG, Prager TC, Zou YL, Fraley JK, Rozelle JC, et al. 
Effects of maternal docosahexaenoic acid intake on visual function 
and neurodevelopment in breastfed term infants. Am J Clin Nutr. 
2005;82(1):125-32. DOI: 10.1093/ajcn/82.1.125 PMID: 16002810 
118. Mangels AR, Messina V. Considerations in planning vegan diets: infants. J 
Am Diet Assoc. 2001;101(6):670-7. DOI: 10.1016/S0002-8223(01)00169-9 
PMID: 11424546 
119. Bührer C, Genyel-Borovicyenz O, Jochum F, Kauth T, Kersting M, Koletyko 
B, et al. Ernährung gesunder Säuglinge. Monatsschr Kinderheilkd. 
2014;162:527-38. 
120. Keller M, Müller S. Vegetarische und vegane Ernährung bei Kindern - 
Stand der Forschung und Forschungsbedarf. Forsch Komplement Med. 
2016;23(2):81-8. PMID: 27160086 
121. Rosell M, Appleby P, Key T. Height, age at menarche, body weight 
and body mass index in life-long vegetarians. Public Health Nutr. 
2005;8(7):870-5. DOI: 10.1079/PHN2005730 PMID: 16277803 
122. Rudloff S, Bührer C, Jochum F, Kauth T, Kersting M, Körner A, et al. 
Vegetarian diets in childhood and adolescence : Position paper of the 
nutrition committee, German Society for Paediatric and Adolescent 
Medicine (DGKJ). Mol Cell Pediatr. 2019;6(1):4. DOI: 10.1186/s40348-019-
0091-z PMID: 31722049 
123. Van Dusseldorp M, Arts IC, Bergsma JS, De Jong N, Dagnelie PC, Van 
Staveren WA. Catch-up growth in children fed a macrobiotic diet in early 
childhood. J Nutr. 1996;126(12):2977-83. DOI: 10.1093/jn/126.12.2977 
PMID: 9001364 
124. Perry CL, McGuire MT, Neumark-Sztainer D, Story M. Adolescent 
vegetarians: how well do their dietary patterns meet the healthy people 
2010 objectives? Arch Pediatr Adolesc Med. 2002;156(5):431-7. DOI: 
10.1001/archpedi.156.5.431 PMID: 11980547 
125. Sabaté J, Wien M. Vegetarian diets and childhood obesity prevention. Am 
J Clin Nutr. 2010;91(5):1525S-9S. DOI: 10.3945/ajcn.2010.28701F PMID: 
20237136 
126. Bardone-Cone AM, Fitzsimmons-Craft EE, Harney MB, Maldonado CR, 
Lawson MA, Smith R, et al. The inter-relationships between vegetarianism 
and eating disorders among females. J Acad Nutr Diet. 2012;112(8):1247-
52. DOI: 10.1016/j.jand.2012.05.007 PMID: 22818732 
127. Aloufy A, Latzer Y. [Diet or health—the linkage between vegetarianism 
and anorexia nervosa]. Harefuah. 2006;145(7):526-31. PMID: 16900745 
128. Brytek-Matera A, Czepczor-Bernat K, Jurzak H, Kornacka M, Kołodziejczyk 
N. Strict health-oriented eating patterns (orthorexic eating behaviours) 
and their connection with a vegetarian and vegan diet. Eat Weight Disord. 
2019;24(3):441-52. DOI: 10.1007/s40519-018-0563-5 PMID: 30155858 
129. Barnett MJ, Dripps WR, Blomquist KK. Organivore or organorexic? 
Examining the relationship between alternative food network 
engagement, disordered eating, and special diets. Appetite. 
2016;105:713-20. DOI: 10.1016/j.appet.2016.07.008 PMID: 27397727 
130. Millward DJ. The nutritional value of plant-based diets in relation 
to human amino acid and protein requirements. Proc Nutr Soc. 
1999;58(2):249-60. DOI: 10.1017/S0029665199000348 PMID: 10466163 
131. Rodriguez NR, DiMarco NM, Langley S; American Dietetic Association; 
Dietitians of Canada; American College of Sports Medicine: Nutrition 
and Athletic Performance. Position of the American Dietetic Association, 
Dietitians of Canada, and the American College of Sports Medicine: 
nutrition and athletic performance. J Am Diet Assoc. 2009;109(3):509-27. 
DOI: 10.1016/j.jada.2009.01.005 PMID: 19278045 
132. Barnard ND, Goldman DM, Loomis JF, Kahleova H, Levin SM, Neabore 
S, et al. Plant-based diets for cardiovascular safety and performance in 
endurance sports. Nutrients. 2019;11(1):130. DOI: 10.3390/nu11010130 
PMID: 30634559 
133. Venderley AM, Campbell WW. Vegetarian diets : nutritional considerations 
for athletes. Sports Med. 2006;36(4):293-305. DOI: 10.2165/00007256-
200636040-00002 PMID: 16573356 
134. Rogerson D. Vegan diets: practical advice for athletes and exercisers. J 
Int Soc Sports Nutr. 2017;14(1):36. DOI: 10.1186/s12970-017-0192-9 PMID: 
28924423 
135. Nebl J, Haufe S, Eigendorf J, Wasserfurth P, Tegtbur U, Hahn A. Exercise 
capacity of vegan, lacto-ovo-vegetarian and omnivorous recreational 
runners. J Int Soc Sports Nutr. 2019;16(1):23. DOI: 10.1186/s12970-019-
0289-4 PMID: 31109329 
136. Wirnitzer K, Seyfart T, Leitzmann C, Keller M, Wirnitzer G, Lechleitner C, et 
al. Prevalence in running events and running performance of endurance 
runners following a vegetarian or vegan diet compared to non-vegetarian 
endurance runners: the NURMI Study. Springerplus. 2016;5(1):458. DOI: 
10.1186/s40064-016-2126-4 PMID: 27119062 
137. Larson-Meyer DE. Vegetarian and vegan diets for athletic training and 
performance. Sports Escience exchange. 2016;29(1):7. 
138. Cialdella-Kam L, Kulpins D, Manore MM. Vegetarian, gluten-free, and 
energy restricted diets in female athletes. Sports (Basel). 2016;4(4):50. 
DOI: 10.3390/sports4040050 PMID: 29910298 
139. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun 
C, et al. The IOC consensus statement: beyond the Female Athlete 
Triad – relative energy deficiency in sport (RED-S). Br J Sports Med. 
2014;48(7):491-7. DOI: 10.1136/bjsports-2014-093502 PMID: 24620037 
140. Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren 
MP; American College of Sports Medicine. American College of Sports 
Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 
2007;39(10):1867-82. PMID: 17909417 
141. Warren MP, Perlroth NE. The effects of intense exercise on the female 
reproductive system. J Endocrinol. 2001;170(1):3-11. DOI: 10.1677/
joe.0.1700003 PMID: 11431132 
142. 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 (> 65yrs). Nutr 
Metab (Lond). 2011;8(1):37. DOI: 10.1186/1743-7075-8-37 PMID: 21672249 
254
NUTRITION
Zdrav Vestn | May – June 2022 | Volume 91 | https://doi.org/10.6016/ZdravVestn.2994
143. Krajčovičová-Kudláčková M, Valachovičová M, Pauková V, Dušinská M. 
Effects of diet and age on oxidative damage products in healthy subjects. 
Physiol Res. 2008;57(4):647-51. DOI: 10.33549/physiolres.931244 PMID: 
17705666 
144. Krajcovicova-Kudlackova M, Babinska K, Blazicek P, Valachovicova 
M, Spustova V, Mislanova C, et al. Selected biomarkers of age-related 
diseases in older subjects with different nutrition. Bratisl Lek Listy. 
2011;112(11):610-3. PMID: 22180985 
145. Weddle DO, Fanelli-Kuczmarski M. Position of the American Dietetic 
Association: nutrition, aging, and the continuum of care. J Am Diet 
Assoc. 2000;100(5):580-95. DOI: 10.1016/S0002-8223(00)00177-2 PMID: 
10812387 
146. Bernstein M, Munoz N; Academy of Nutrition and Dietetics. Position of the 
Academy of Nutrition and Dietetics: food and nutrition for older adults: 
promoting health and wellness. J Acad Nutr Diet. 2012;112(8):1255-77. 
DOI: 10.1016/j.jand.2012.06.015 PMID: 22818734 
147. Campbell WW, Johnson CA, McCabe GP, Carnell NS. Dietary 
protein requirements of younger and older adults. Am J Clin Nutr. 
2008;88(5):1322-9. PMID: 18996869 
148. Houston DK, Nicklas BJ, Ding J, Harris TB, Tylavsky FA, Newman AB, et 
al.; Health ABC Study. Dietary protein intake is associated with lean mass 
change in older, community-dwelling adults: the Health, Aging, and 
Body Composition (Health ABC) Study. Am J Clin Nutr. 2008;87(1):150-5. 
DOI: 10.1093/ajcn/87.1.150 PMID: 18175749 
149. Allen LH. How common is vitamin B-12 deficiency? Am J Clin Nutr. 
2009;89(2):693S-6S. DOI: 10.3945/ajcn.2008.26947A PMID: 19116323 
150. Green R. Is it time for vitamin B-12 fortification? What are the questions? 
Am J Clin Nutr. 2009;89(2):712S-6S. DOI: 10.3945/ajcn.2008.26947E PMID: 
19141694