Edition: 2022-03-24

This article is principally a target to link to when this question arises on the Dr. Davis Infinite Health Blog, and the former or Wheat Belly and Undoctored Blogs. This is not the official position of Dr. Davis. Page numbers refer to the print edition of Undoctored. Chapter numbers are provided for eBook editions. The Undoctored official position is found starting on page 134 (Chapter 7) of Undoctored, inset:  NO BOLOGNA: DEFICIENCIES OF VEGANISM AND VEGETARIANISM  (the later WB R&E and Super Gut books did not contain this focused summary).

The present article presumes that someone has already decided to adopt the Infinite Health (Undoctored, Wheat Belly) way of eating, and is just wondering if that can be done and remain vegetarian.

TL;DR; Yes,
it is possible to do Vegetarian or Vegan (and variations thereof), but there are challenges that are almost certainly going to result in {additional} supplements. Most of these challenges are not unique to how the program informs diet. They are inherent to or exacerbated by vegetarian diets:

Ad Hominems

Personally, I tried vegetarian the 1970s, promptly became anemic, and abandoned it. Dr. Davis has remarked several times (this from a 2012 WB Blog Comment):
“I don’t pick on the message of people like Dr. Esselstyn, Ornish, etc., as they are fighting the same battle as we are: Trying to best understand how to use diet effectively. If there are enemies, it is Big Food, Agribusiness, and Big Pharma, not these people.

However, there are a long list of reasons why the approach advocated by these people, I believe, is dead wrong, including the Ornish diet made me develop diabetes around 23 years ago. I am no longer diabetic having done the opposite of what Dr. Ornish advocated.’

We both understand that there are multiple reasons why people choose a vegetarian lifestyle (see bottom of article), and that some postures aren’t negotiable.

Introduction

The consequences, alas, aren’t negotiable either, if the nutrients below aren’t all attended to. Vegetarians basically have to address the deficiencies, change their minds, or accept the hazards.

It is difficult to find neutral information on this topic. Anyone providing cautions on being vegetarian (as I am doing here) has usually concluded that it’s not an ancestral human diet for most genotypes. Those advocating vegetarianism may be dismissive of the hazards, or unrealistic about easier work-arounds. Homework is required, multiple viewpoints being considered. Get tested.

Vegetarianism also seems to be a very emotional issue (for vegetarians). This cannot all be put down to zealotry. It may well be due to a number of substantial neurological hazards associated with the deficiencies listed below. I’ve underlined them for emphasis. They can actually interfere with making rational choices on all of this. Ex-vegetarians, some of whom have written books about the experience, may also be emotional, for other reasons. Meat eaters tend to be more sanguine about the whole issue.

Common Deficiencies

The following macro and micronutrients are commonly too low, or entirely absent in vegetarian diets (and the flip side of that is that by default, vegetarian diets tend to be either too high in net carbs, or too high in adverse fats, not topics here).

I have listed the potential deficiencies in alphabetical order. A priority order isn’t really possible, because they are all “essential” - humans need them, and can’t synthesize them in sufficient amounts (or in some cases, at all) from precursor foods. In some cases (e.g. Vitamin A) the synthesis problem is genetic. Any vegetarian who has not specifically supplemented for these, and has not been tested, needs to assume they are deficient.

Amino Acids

Four essential amino acids not provided by most plant foods are lysine, methionine, phenylalanine and tryptophan. Deficiency hazards are legion, including growth and energy (lysine), mood (methionine), brain function (phenylalanine) and mood/sleep (tryptophan).

There are any number of resources that describe which plants provide what, but the list of single plants that provide all, and meet Undoctored nutritional guidelines, may be empty.

So some combination of various food sources is required, and typical vegetarian sources lists are loaded with things to avoid for other reasons, such as quinoa (carb exposure), soy (multiple issues) and wheat germ (!).[Return to Nutrients List]

Calcium

Although osteoporosis is the commonly assumed hazard, hypocalcemia can result in neuromuscular problems (including adverse heart rhythms) and seizures.

Many vegetables provide calcium, but may also contain anti-nutrients that block absorption, so the issue is one of bioavailability. Nonetheless, eating a lot of spinach or kale may be safer than taking typical calcium supplements, which themselves are poorly absorbed, and often end up everywhere except bones.

If someone insists on supplementing, the hydroxyapatite form is worth a look. For bone health in particular, also attend to Vitamins D, K1 and K2 (Undoctored page 136, Chapter 7). The consensus RDA for Ca may be too high. [Return to Nutrients List]

Carnosine

A vegetarian (especially vegan) diet is deficient in adequate carnosine, compared to levels found in a standard diet. Deficiency is thought to accelerate aging and degenerative diseases, including neuromuscular and Alzheimer’s.

Vegan L-Carnosine (B-alanyl-L-histidine) supplements are available. [Return to Nutrients List]

Choline

The hazards of deficiency include fatty liver, liver disease, muscle damage, fetal neural tube defects and possible neurological problems. Choline is not considered "essential" unless methionine and folate are also absent.

This one might be the easiest to address. Cauliflower, broccoli, brewer’s yeast, spinach and tofu are satisfactory vegetarian sources of choline.

Denise Minger identifies some genetic issues that can exacerbate the risks of choline deficiencies. [Return to Nutrients List]

Co-Enzyme Q10

This quinone is essential for mitochondrial and cardiovascular health. We can synthesize it, but often in insufficient amounts (esp. if a statin is being used). A vegetarian grain-free diet raises the deficiency risk.

Deficiency risks include: generalized weakness/fatigue, difficulty concentrating, mood/depression, memory lapses. The complete list is a bit too long for this summary.

Vegetable sources of CoQ10, that are considered “unlimited” on Undoctored include spinach, broccoli, and cauliflower. Legumes are also a source, but are considered “limited”. CoQ10 supplementation is straightforward and needs to be considered.[Return to Nutrients List]

Creatine

This is also not considered strictly "essential", but total creatine is usually significantly lower in vegetarians. The hazards of deficiency include impaired muscle mass/performance and impaired thinking.

Vegetarian creatine supplements are available, but there is debate on whether this is entirely risk-free. [Return to Nutrients List]

Iodine

Iodine deficiency is a significant cause of hypothyroidism, and results in a long and varied list of problems. This deficiency is a problem for pretty much all modern humans, unless they are on a diet heavy in seafood. Vegetarians are at elevated risk, and need to pay more attention to symptoms and effective lab tests (which the standard TSH is not, nor, usually, is any diagnosis of "normal" based on it).

Supplementation is usually simple (kelp), and exceeding RDA needs to be considered. But any supplementation requires first ruling out contraindicating conditions, such as Hashimoto’s Thyroiditis, in which iodine supplementation can be a hazard. [Return to Nutrients List]

Iron

Hazards include anemia, with symptom indications including but not limited to fatigue, dizziness, hair loss, twitches, irritability, RLS. Iron deficiency is by no means limited to vegetarians, either; they are just at higher risk.

Plants often contain ample iron, but bioavailability from plant sources is the concern, compared to heme iron (from meat). Absorption from plant sources may be further inhibited by other foods. Effective supplements are easy to find, but take Iron well away from any other supplements.[Return to Nutrients List]

Omega 3 DHA & EPA

Deficiencies have not been fully tallied yet, but likely include cardiovascular disease and heart rhythm disturbances, various neurological problems (depression, ASD), autoimmune inflammatory conditions (RA, lupus), cancers and asthma.

This is another problem for everyone, but more acute for vegetarians. Unless one is surf zoner chowing down on fish, or an inland hunter-gatherer consuming game snout to tail, one is not getting enough of these fatty acids. The Undoctored recommendation is 3000—3600 mg per day. This is substantially above RDA. Vegetarians are unlikely to achieve an RBC Omega 3 Index of even 5% without supplements, and 10% may be optimal.

Omega 3 ALA, widely available from plant sources, is an inadequate substitute (and without specific attention, may itself be deficient in a vegetarian diet). Yes, we can convert a few percent of it to DHA and EPA, but not enough, without getting an overload of ALA. Also, when considering any pro-vegetarian discussion on this, pay attention to the daily intake or synthesis of DHA suggested. If you are going to rely on ALA (to DHA) conversion to any degree, be sure to get ample curcumin.

Omega 6 and 9 are no substitutes at all, and high intake of Omega 6 further degrades ALA conversion. High intake of Omega 6 LA (Linoleic Acid) is a flat out hazard. This PUFA is pervasive in modern food-like substances, thanks to the rise in industrial grain and seed oils, mistakenly promoted as healthy. They are obesogenic, inflammatory, and probably both trigger cancer and feed it.

The only non-animal source for DHA & EPA is marine algae (and maybe yeast, but check the DHA/EPA balance, and last I looked, that product was off the market). Vegetarian DHA or EPA is quite likely from these sources. Aside - low-fat high-carb (LFHC) vegetarian is almost certainly going to be seriously deficient in DHA and EPA, and may quite literally be an insane thing to do. Getting down near a 1:1 ratio of ω6:ω3, with ample DHA & EPA in the ω3, is tough for any modern. It’s harder for vegetarians. [Return to Nutrients List]

Taurine

Deficiency hazards include vision loss, muscle atrophy, reduced endurance, anxiety, depression, ASD, gout, hypothyroid and more. It’s pretty critical stuff, but easily obtained in adequate amounts from meat, fish and eggs.

Vegetarian sources include brewer’s yeast. Taurine can be synthesized industrially, but is then at high risk of being sourced from China. Some trendy sports drinks include mass quantities of taurine, but getting it that way is at risk of needless sugar or artificial sweetener exposure (in addition to the question of where the taurine came from). [Return to Nutrients List]

Vitamin A

Deficiency hazards include night blindness, complete blindness, and compromised immune function.

What’s needed is a supplement, in the retinol form. RDA suffices. The plant form is beta-carotene, which is inefficiently converted (it would be a lot of carrots or kale). Denise Minger reports that about 45% of the population has BCMO1 polymorphisms that result in even lower response to beta carotene. [Return to Nutrients List]

Vitamin B12

Undoctored page 297 (Chapter 12): Hazards include anemias, neurologies, psychiatric disorders (including mania and psychosis), learning impairment, cognition impairment, weakness, fatigue.

Grain eaters may additionally be deficient due to absorption impairment from grain proteins, which interference subsides when the grains are gone. Vegetarians usually need to supplement, and not rely on pseudovitamin B12 sources (which not only fail to provide B12, they actively interfere with absorption of any real B12 consumed). Undoctored page 298 (Chapter 12) has dosing details, which are well above RDA for everyone, not just vegetarians. The methylcobalamin form is preferred, unless you have had your methylation status assessed, and know that the more common cyanocobalamin form is safe and effective for you. [Return to Nutrients List]

Vitamin D

Deficiency hazards include but are not limited to inflammation, a variety of bone pathologies, higher blood sugar and insulin resistance, elevated cancer risk, elevated risk of heart attack, cognition, depression, SAD, and autoimmune conditions.

Undoctored starting page 272 (Chapter 12): This is a major deficiency for everyone, and Undoctored recommends a target serum 25-hydroxyvitamin D level of 60 to 70 ng/dl. This implies an intake well above RDA, as a supplement (D3, cholecalciferol) for people who aren’t young and aren’t exposed to substantial lower latitude sun and aren’t getting it from animal sources. Response to serum level is a U-shaped curve. Both deficiency and overdose need to be avoided.

Vitamin D3 supplements are available for vegetarians, sourced from lichen (example). Claims that plant-sourced D2 (found in certain mushrooms) is a suitable substitute require some homework by the reader. [Return to Nutrients List]

Vitamin K2

Deficiency hazards include fragile bones and arterial plaques. Even meat eaters may need to supplement MK-4 or MK-7. See Undoctored page 344 (Appendix A). How could a vegetarian marathoner die of a sudden heart attack? This is how (plus the usually high net carb aspect of the diet).

For vegetarians, natto is a great source of K2. So hold your nose, or supplement. Yes, K1 is plentiful in plants, and your microbiome might convert some of it to K2, but very likely not enough.[Return to Nutrients List]

Zinc

Deficiency hazards include but are not limited to skin and hair ailments, oral ailments, sensory disturbances, intestinal distress, poor wound healing and infection resistance, anorexia, cognitive and psychological disorders.

Zn absorption from plant sources is the main challenge, due to anti-nutrients. Supplementing is relatively simple (Undoctored page 296, Chapter 12), but attend to copper at higher doses. [Return to Nutrients List]

Reconsiderations

As I see it, there are six broad reasons, with one or more applying to any individual, of why people adopt one of the vegetarian dietary approaches:

1. Allergics
   These people have an actual biologic adverse response to dairy (common) or meat (uncommon, but get some alpha-gal from a lone star tick bite, and it could happen to anyone). In addition to needing information on missing micronutrients, those biologically allergic only to dairy need to know that the allergy might vanish by switching to beta casein A2 bovine dairy, or caprine (goat) or ovine (sheep) dairy, or simply after many months off gut antagonists in the diet, like wheat. Even the meat allergy might eventually vanish, once the gut has healed from grain protein and lectin insults, and the antibody titer has receded.
    
2. Epicureans
   These people simply cannot abide the taste of meat and/or fish. They may otherwise be open to consuming the missing micros as supplements, even if animal-sourced.
    
3. Environmentals
   These folks think that the big problem with meat eating is that it’s environmentally unsustainable, and that’s true, but only if one falls for a false dichotomy, and assumes that CAFO, supported by industrial scale grain growing, is the only answer. The alternative, phased pastured, as done by Joel Salatin and others, actually solves multiple problems and is sustainable:
   • eliminates CAFO and its problems
   • turns grainland into grassland
   • reverses desertification
   • reverses micronutrient depletion
   • supports consumable critters
    
4. Theoreticals
   These folks think vegetarian is an ideal or ancestral human diet. It isn’t, and it wasn’t, except possibly for some obscure isolated tribes [genotypes]). The odds of any reader here being such a genotype: about 0. Even when it might have been an ancestral diet, that doesn’t necessarily mean it was ideal (as in living much beyond twice reproductive age). They may have adapted to it because they had no choice. Theoreticals are often open to information that counters what they think they know. The work of Denise Minger is a place to start.
    
5. Ethicals
   These people may be horrified by CAFO, resent being descended from predators, or have other reasons why they don’t wish to be involved in harvesting animals. On CAFO, they have a point (several actually: conditions, antibiotics, hormones, adverse industrial feed, reduced nutritional value, diseases, concentrated waste, etc.). Ethicals may only need to be plugged into regional sources of humane pasture-raised organic meats, but in any event they need to be aware of the health trade-off they are making, and how to counter it.
    
6. Philosophicals
   For these people, the big V is either a secular religion or a tenet of an actual religion. The actual health consequences are immaterial. Only the dogma matters, although out of respect for dogs, they may prefer it be called orthodoxy.

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Bob Niland [disclosures] [topics] [abbreviations]