The Failure to Thrive–Speculations on the Nutritional Adequacy of 100% Plant-Based Diets, by John Allen Mollenhauer and Michael Klaper, M.D

Years ago, I made the Switch to a More Plant-Based, Nutrient-Rich healthy-eating style. I did so after almost two decades of eating the SAD, Standard American Diet, and another five years as a bodybuilder, where I was essentially a professional dieter eating a predominantly animal product-based diet by calorie. This is not far from how many people eat today who attempt low-carbohydrate, high-animal protein diets to manage their weight. At first, I did not make the “nutrition transition” correctly and experienced a variety of symptoms, like fatigue, which were heightened, for what was in-retrospect, a relatively short period of time–even though it didn’t feel short when I was going through it.

For anyone making the Switch to a plant-based diet, a vegan diet, or what we refer to here as a 90% or More Plant-Based Nutrient Rich® healthy-eating style–the “nutrition-transition” is different. At first, the change can be challenging. Over time, it gets easier, and eventually it will get so pleasurable, for so many reasons, that you will never even think of going back to eating the Standard American Diet, or to the typical weight loss-only or muscle-building diets.

I made the Switch when people and professionals were really just learning how to make such a change, the field of nutrition was just on the verge of an explosion, but was still operating on outdated models of thinking, and the “high-nutrient density” or “nutrient-rich” healthy eating styles were not understood, and weren’t even terms people were using. The idea of eating a plant-based diet was just coming into vogue, on the heels of the vegetarian movement–and all of this was considered “alternative.”

That was 1990. Over the past two decades, early adopters of a plant-based, nutrient-rich eating style have learned so much about what it means to eat healthy that it will probably be decades before the masses even catch up. There is a lot to know (80% of which, is about what you no longer want to do, not what you need to do) and so many people in the nutritional field are clinging to outmoded ways of eating. In fact, many professionals and the people they serve may find themselves locked in either the vicious cycle of eating nutrient poor for many more years to come, or eating “healthier” for decades, but falling short of their true potentials.

That said, this post is not about the history or emergence of dietary changes or the healthy success results one can experience when they learn how to make the Switch to nutrient-rich healthy eating style. Rather, this article is about why some people thrive when making these changes, and others don’t. I can completely understand why many people get tripped up during a nutrition transition, and go back to eating the way they once did. Note: Not everyone has the same experience and please read our disclaimer.

Everyone who makes a nutrition transition, for the purposes of detoxification, wanting healthy and natural weight loss, as opposed to dieting, improved health, disease-reversal, and/or for slower aging and longevity purposes, will experience the symptoms of change. It’s just what inevitably happens when you no longer consume significant quantities of foods that are super-stimulating, rapid growth-promoting and toxic to the body.

Just like any significant change in life–change can be hard at first. Metaphorically speaking, it’s like moving from PC to MAC. Significant changes force you to get familiar with a new operating system, so to speak, and some new routines and experiences that can really test your patience, are sometimes uncomfortable at first, and/or emotional. The same is true when you change eating styles. In the case of making a nutrition transition to a healthier diet, which inevitably means eating more plant-based nutrient rich foods, your body has to adjust to fiber-rich, phytochemical-rich foods. And this, healthy “new normal” requires your body–particularly your digestive track, to adapt its functions.

It has taken years to understand the nutrition-transition period, and how to guide people through it. I for one did not do it correctly–because understanding how to make the Switch to a plant-based “nutrient-rich” healthy eating style was not understood when I did it. Most people, when making a dietary change, make the Switch to a “plant-based diet,” by going vegetarian or vegan, and giving up animal products. Doing it this way may translate into a very unhealthy eating style, even though you may not be eating animals. Eating “nutrient rich,” which may or may not be vegan or vegetarian, is a healthy eating style, and it is about far more than not eating meat alone.

But for one reason or another, going vegan–all the way to a 100% plant-based diet– has become quite popular. I think it’s because of the animal welfare issues, and the fact that it is a simple-minded, single-variable approach to dietary change, it’s one that is very emotionally charged, and it is a real door-opener to people who want to eat healthier. The problem is–not everyone thrives when eating a vegan diet, for two reasons:

  1. They don’t know how to make a nutrition transition, and
  2. They are mainly focused on eliminating animal products, without understand the nutrient-rich healthy eating style, which causes them to inevitably end up eating a “healthier” diet that is still nutrient poor.

Now imagine these two factors compounded by the long-standing physiological effects of a previous usual diet that was disease-promoting, and a certain percentage of people will experience “the failure the thrive,” even when switching to a healthy eating style. The Failure to Thrive means they will experience symptoms that persist beyond a reasonable period of time, and will be forced to go back to the unhealthy ways of eating that their body was used to, so they can feel better. It’s the old story of the coffee addict who feels uncomfortable when he/she stops drinking coffee, and then needs another cup to feel better. That statement is packed!

It’s one thing to say that people experiencing the Failure to Thrive are simply dealing with withdrawal symptoms from nutrient-poor and nutrient-barren foods, but in reality it’s more than that and this calls into question the nutritional adequacy of 100% plant-based diets for many. This is not a post against going vegan, as we are very much in support of those who do it. Rather, this post is about the speculations on why some people thrive eating a vegan diet and others don’t. It’s also the reason we promote a “90% or More Plant-Based Nutrient Rich healthy eating style, with the option of going vegan if you choose to do so. We want everyone to thrive.

When making a nutrition-transition, the body has to go through a rebuilding process, and it has to adapt to what is now an overall nutrient-rich (phytochemical-rich, fiber-rich) diet, which will have a noticeable impact on how the body functions. For one, the body will detoxify faster and more intensely when it has thousands of cell-protective, immune system-boosting phytonutrients coursing through it, in addition to fiber-regulating food transit, and nutrient absorption among many other functions working well.

I had speculated, with a high degree of confidence, that these two adjustments alone can prompt an uncomfortable set of symptoms for a least a period of time, but I really wanted to delve deeper into why some people just feel a little better when including small amounts of animal products. So to get an in depth answer, I worked with long-time, pioneering vegan doctor, and health luminary, Michael Klaper, MD. With decades of experience, I knew he would have some great insight to add to this conversation.

Here’s what he had to say about the nutritional adequacy of 100% plant-based or “vegan” diets:

“I have been a practicing physician for almost forty years, with post-graduate training in internal medicine, surgery, anesthesiology, and obstetrics, and a strong, career-long interest in applied nutrition. Over the years, I have seen the beneficial effects of a plant-based diet, specifically, a 100% whole-foods, (vegan) diet as a specific therapy for so many of the chronic, degenerative diseases that plague modern Western society: high blood pressure, obesity, Type II (“adult-onset”) diabetes, prostate cancer, and many inflammatory and auto-immune diseases, such as rheumatoid arthritis and asthma .

“With its abundant phyto-nutrients (phytochemicals) and fiber, and minimal amounts of saturated fats and inflammation-inciting proteins, such as casein and lactabumin, a vegan diet is a powerful therapeutic tool for arresting and even reversing many of these feared disease states. With its smaller ecological footprint and lack of cruelty to sentient animals, it is no wonder that many people around the world are adopting a purely plant-based dietary style. Indeed, many ecologists are now advocating a plant-based dietary style as a key component in arresting global warming and feeding Earth’s burgeoning human population, sustainably, in the decades to come.

I have had the opportunity to observe many people who have adopted and maintained a vegan diet for 20 years, or more. Many of these people are thriving on diets comprised of 100% unrefined plant foods; a wide variety of whole green and colored vegetables, legumes, fruits, nuts and seeds and whole grains The science seems to validate this, since, upon nutritional analysis, all the nutrients – amino acids, vitamins, minerals, and essential fats can be found within a broad-based, unprocessed, vegan diet.

With a source of supplemental vitamin B-12 (produced by microorganisms) to compensate for the losses of intake from previous natural sources, like water from open streams and wells and unwashed vegetables, these people demonstrate that a vegan diet is the best dietary style for them, and I have no reason to dispute their claim. To me, their apparent vitality and lack of disease states are powerful validations of a whole-foods, plant-based diet as a nutrient-rich “fuel mixture” to nourish the human body.

However, despite the theoretical nutritional adequacy of a completely vegan diet, not everyone who attempts to nourish themselves without consuming animal products seems to do so successfully. After months or years on a vegan diet, but without knowledge of some basic nutritional principles, people can find themselves lacking in vitality and muscular strength–sometimes with physical signs, such as dry skin, cracking fingernails, and lack of muscle mass.

Many of these people have consulted me over the years, seeking guidance in optimizing their vegan diets. In many cases, the cause is obvious: their diet revolves around devitalized, overly-processed foods, such as veggie-burgers, soy milk, and non-dairy cheeses, yogurts and “ice creams.” Such synthetic foods are nutrient poor, excessively high in sugar and sodium, while lacking fiber and the phyto-nutrients that whole, unprocessed nutrient-rich fruits, vegetables and legumes, whole grains, nuts and seeds provide.

Many of these people soon find themselves thriving when they eliminate the lifeless “junk foods” and transition to a truly health-supporting vegan diet, such as described in, Becoming Vegan, by Vesanto Melina, R.D., Preventing and Reversing Heart Disease, by Caldwell Esselstyn, M.D and Eat to Live, by Joel Fuhrman, M.D.

For others, detecting and correcting deficiencies in trace minerals or omega-3 fatty acids can provide the “missing link” that allows them to achieve the good health and vitality that they seek. The balance of omega-3 to omega-6 fats can be determined with a drop of blood on a card. If a deficiency of omega-3 fats are found, increasing intake of walnuts, flax, and green vegetables is indicated, and if necessary, supplementation with 300 mg of algae-derived DHA, daily.

Other supplements to consider if a non-thriving vegan person wishes to keep their diet completely plant based:

•    Multivitamin/mineral supplements to assure adequacy of minerals like selenium, manganese, iodine and zinc.

•    Supplemental taurine and carnitine and/or creatine (amino acid-based supplements available at natural food stores).

•    Supplemental DHEA, after one has their salivary, cortisol and DHEA levels measured. (Amounts will be considered later.)

Yet, despite these counseling successes, I am aware that there is a significant population of long-term vegans, who despite their best efforts, and mine, to optimize their vegan diets, still remain pale, underweight, and unable to achieve the robust health they seek. When, out of frustration, with years of trying to overcome their nutritional challenges by using various supplements and vegan food regimens, a number of them reluctantly, but finally, reverted to adding some meat or eggs back into their diets, they often achieve significant benefits–sometimes with dramatic results. Increased energy levels and muscle mass became evident in a many of them.

These people are nutritional enigmas to me and have made me theorize about what factors may be at work to prevent achieving their nutritional goals on a vegan diet. I present my speculations in the sections that follow:

However, before I present my ideas about possible mechanisms that may explain the “vegan failure-to-thrive syndrome,” I must assert that the problem ultimately lies with my lack of nutritional understanding, rather than an inherent lack of nutritional adequacy in a well-planned, whole-foods vegan diet. I am a general practitioner in private practice, not a nutritional biochemist. I feel strongly that with proper scientific study and clinical application, a 100% plant-based diet can be made to meet virtually every person’s nutritional needs–if we just knew enough about human physiology and nutrition.

It is a source of great dismay to me that in the United States, the highly-esteemed, federally-funded, National Institutes of Health consists of 27 separate institutes, like the National Cancer Institute, the National Eye Institute, and the National Heart, Lung and Blood Institute–yet, not ONE of the Institutes has the word “Nutrition” in its name. If the United States was really serious about improving the state of health of its citizens, there would certainly be a National Institute of Nutrition as part of the N.I.H–and within it would be the “Division of Vegan Studies,” where plant-based diets and their effects upon human health and disease would indeed be studied with the technological resources and scientific rigor that they deserve.

Volunteers would be brought into the Institute and fed controlled plant-based diets for prolonged periods of time and have many parameters measured, including blood tests and metabolic balance studies. Much can be learned by examining tissue obtained through “skinny-needle” biopsies of muscle and fat to see what actually happens during long-term adherence to a vegan diet among people of various ages, races and body types. I am sure that with this kind of proper scientific study, the riddle of the “vegan failure-to-thrive syndrome” would be solved. With computer analysis of a drop of blood, a nourishing, health-enhancing, completely plant-based diet could be optimized for each individual.

However, until that golden age of nutritional research and understanding dawns, solo practitioners like me, who slog away “at the coalface” of applied nutrition must rely on only the biochemistry learned in medical school, post-graduate training, and the clinical experience gained through many years of empirical practice to help our non-thriving vegan patients. It is from this island of nutritional observation and speculation that I offer some possible mechanisms that may underlie this problem, as well as possible strategies to overcome them–while trying to do the least harm to people, animals and the planet.

So, why may a seemingly-adequate plant-based diet comprised of 100% unrefined plant foods appear to be less than optimal in a given individual? Rather than an inherent deficiency of nutrients necessary to fuel a Homo sapien’s body, the origins may lie in the early years of development of our individual digestive systems.

Like all other organs in our body, our gastrointestinal system is undoubtedly influenced by how we treat those tissues in our earliest years. When considering the gastrointestinal system, of course, it is the food we eat that exerts the greatest influence upon the developing tissues that digest and absorb our nutrients. Specifically, the food we present to the surface of the intestinal membranes, which then absorbs those nutrients and sends them to the liver, may be a deciding factor in the developing structure and function of those organs.

Specifically, if a person grows up eating the “Standard American Diet” based on meat and dairy products, the food stream that is repeatedly slathered over the 26 feet of intestinal membranes has some specific characteristics–it is high in fat, high in protein, high in cholesterol, low in fiber and complex carbohydrates, and is rich in easily-absorbed minerals like zinc and magnesium. It also contains substantial quantities of pre-formed, animal-derived nutrients, like carnitine and creatine, needed for energy metabolism and muscle function.

If this is the food stream that is continually applied to the intestinal surface membranes, day after day, month after month, throughout childhood, the membranes will adapt appropriately:

•    The mucus that the intestinal membrane secretes on its surface, and through which all nutrients must pass to be absorbed, will be optimized for absorbing fats cholesterol, and minerals from the fiber-less, fast-food slurry that is presented to it.

•    The enzymes in the intestinal cells, responsible for the absorption of amino acids, minerals, vitamins and other essential substances into the bloodstream, become the most efficient for absorbing those nutrients from a high-fat, low-fiber food stream.

•    The enzymes in the liver cells are induced to create the optimal balance needed to best metabolize that “animal-rich” nutrient mixture in the bloodstream.

It is not difficult to visualize that if a person eats this “Standard American Diet” (SAD) throughout their childhood, adolescence and young adulthood–usually for decades–their digestive system may “set” in the mode which is most efficient in digesting and absorbing the above-named nutrients from the highly-processed, high-fat, low-fiber food stream. With a daily diet that is over-the-top in calories, fats, protein, and an absorption system that has adapted to become highly efficient at absorbing those dense energy sources, the SAD-diet eaters often become overweight, and then ill with a host of blood vessel and obesity-related diseases.

If, in their twenties, thirties, or later, the person reads a book, attends a lecture, sees a program, or meets a person who extols the virtues of a vegan or vegetarian diet, the individual may decide that he or she also wants to nourish themselves on completely plant-based foods. In adopting a “healthy” vegan regimen, based upon unprocessed grains, legumes, fruits, vegetables, nuts and seeds, they are effectively doing a near 180-degree reversal on many of the major qualities of their previously-eaten food stream, which was in many cases up to 90% or more nutrient-poor foods:

•    Instead of being high in fat, it is now low in fat.
•    Instead of being high of protein, it is lower in protein.
•    Instead of being low in complex carbohydrates, it is now high in complex carbohydrates.
•    Instead of easily absorbed minerals, the zinc and magnesium are firmly bound to plant fiber.
•    Very importantly, animal-associated molecules like omega-3 fats, carnitine and creatine, which are needed for energy metabolism and muscle function, respectively, that used to come into the body preformed, with meat products, are now suddenly absent. Consequently, the liver, muscles and other tissues must now “gear up” enzymes and metabolic co-factors to synthesize all of these substances on their own.

In doing so, it MAY be that after 30+ years of not having to synthesize these molecules, the liver, muscles and other organs may be unable to adequately create these substances, in the quantities required, for that individual to experience optimal function of all organs. As a result, the body’s vital tissues may find themselves functioning with sub-optimal amounts of particular nutrients. This could, theoretically, result in lower muscle mass and/or suboptimal function.

Similarly, the mineral atoms, like zinc, copper, magnesium, which are essential for enzyme function etc., that were so easily absorbed from meats and eggs, must now be wrestled away from the plant fibers to which they are firmly attached. Remember, the old adage, “you are what you eat” is NOT true. In actuality, you are what you ABSORB–and it is easier to absorb zinc and magnesium from a piece of steak than it is from a piece of kale.

This places upon the plant-eater the responsibility to do all they can to assure more efficient mineral absorption – namely, to chew each mouthful of kale or broccoli to a puree before swallowing, in order to rupture the cellulose membranes that surround each cell and thus liberate the contained nutrients for absorption.

In this high-pressure, modern world, where, it seems, we all have a plane to catch or a meeting to attend, we throw down our meals with a couple of desultory chews, and much of the minerals we eat in the plant foods may pass through our digestive tract without ever making it into our bloodstream.

Another factor that conspires to further reduce mineral absorption: the high-fiber quality of a plant-based diet. While excellent for bowel health and weight loss, plant fiber, like phytates, not only holds the minerals in tight bondage, but hurries the food mass through the intestinal tract. This is great for regularity, but not so great for mineral absorption–especially for zinc and magnesium .

As the food mass hurries its way through the intestines, there is less physical time for mineral absorption to occur. The net effect works against good mineral balance, and it may be that the people who eat mostly raw plant foods–especially, if they do not chew their food sufficiently–may draw down upon the minerals in their cells. As the years go by, they may be faced with sub-optimal levels of the tissue minerals required to make essential enzyme reactions function optimally–possibly leading to fatigue and sub-optimal physical performance.

To sum up, the mechanisms that MAY be contributing factors as to why some people fail to thrive on a purely vegan diet:

•    POSSIBLE sub-optimal mineral absorption and utilization due to phytate binding and rapid intestinal transit time, resulting in sub-optimal tissue enzyme function.

•    POSSIBLE insufficient synthesis of long-chain omega-3 fatty acids, carnitine, creatine and other nutrients that previously were consumed preformed in animal products. Studies show that vegetarians have lower levels of carnitine and omega-3 fats in their blood and tissues.

These functional deficiencies would also explain why, when these people re-introduce even small amounts of flesh foods–with their readily absorbable minerals, and preformed carnitine, etc. into their diet–they rapidly feel improvement in their strength and well-being.

This places a physician like me in a difficult position. I am a practicing clinician who wants to see all of my patients thrive with abundant energy, good health and freedom from disease. I am also a long-time vegan, mostly out of a desire to reduce the violence and death in the world, for which I am responsible–including the death of animals consumed for food. It transgresses deeply-held beliefs for me to condone or recommend consumption of flesh foods, knowing that I am possibly sanctioning the death of innocent animals.

So, what is a reasonable path through this physiologic and ethical thicket?

First, I would strongly urge that anyone who wants to maintain a 100% plant-based (vegan diet) do all they can to optimize consumption and absorption of the nutrients they require:

1) Eat a WIDE variety of plant foods, especially green and yellow vegetables, fresh fruits, cooked legumes and raw nuts and seeds. Eat large green salads frequently, sprinkled with pumpkin seeds, for their zinc, and with walnuts for the omega-3 fats.

2.) Whatever food is eaten, place a forkful into your mouth, then put the fork down and CHEW THE FOOD TO A PUREE before you swallow it.

This allows you to savor the food (which is, after all, the reason you are eating it in the first place) and, very importantly, to break up the plant-fiber to increase mineral absorption.

3. Include vegetable soups, stews, and blended salads in your diet on a regular basis to increase mineral absorption.

4. AVOID refined foods–especially, refined carbohydrates like pastries, candies, (vegan) ice creams, bottled fruit juices, breads and pastas made with highly-refined flours (I almost never eat breads or pastas any more–only the occasional slice of sprouted grain breads).

5. Breakfasts should generally be a bowl of fresh fruit, with or without (non-“instant”) oatmeal, with some raisins or dates added to the oatmeal, while cooking for sweetness.

Lunches and dinners should be based upon large, fresh salads, hearty vegetables soups and stews (with beans and other legumes served over quinoa, millet, or other low-gluten grains,) and generous helpings of steamed green vegetables (kale, broccoli, chard, etc.). Bean burritos, lentil stews, whole-grain pastas and casseroles provide satisfying meals, and a wide range of nutrients. A plethora of vegan cookbooks available online provide delicious easy-to-make recipes.

Desserts and snacks should be melon chunks, organic grapes or other fresh fruit, which can be frozen and blended into sorbets and “ice creams.”

6. Assure omega-3 fatty acid sufficiency by eating a small handful of walnuts every day, along with 1-2 tablespoons of freshly ground flaxseeds on your oatmeal. If there is any question of fatty acid deficiency, which is indicated by dry skin and/or depression, take 300 mg of algae-derived DHA (the content of one “vegi-cap” available at the natural food store), daily.

7. Assure vitamin B-12 adequacy by taking 1000 mcg of B-12 twice weekly, preferably in a liquid or sub-lingual form.

If the above measures do not produce the level of function and well-being desired, try adding supplements to supply the nutrients most likely in short supply:

A multivitamin/mineral tablet that has the RDI for zinc, and other minerals… (READ LABELS – avoid products that have preformed Vitamin A, which may increase osteoporosis and cancer risk, and folic acid, which may increase risk of prostate cancer  You get plenty of natural, safe, folate in green vegetables–you don’t need, or want, folic acid from other sources).

•    Carnitine supplement –  500 mg – 1000 mg in the mornings
•    Taurine supplement – 1000 mg., daily
•    DHEA after having levels measured in saliva

As a scientist, I have to recognize that there may be other–possibly many–nutrients found in flesh foods that are unrecognized at this time. In some people, for the reasons described above, some of those nutrients may be extremely beneficial, perhaps essential.

Consequently, in my nutritional counseling, I have (reluctantly) come to the point of saying that, if all the above measures have been tried for at least 12 months and NO improvement is noted, I do not condemn my patients if they add in a small amount of animal-based food, such as the eggs from the neighbor’s backyard chicken. If a person feels they must eat flesh-based foods to feel optimally nourished, I urge that they consume the smallest amount possible, and to choose that which causes the lease suffering to animals and damage to the planet. I make it clear that this intake of flesh should be viewed as medicinal only, and should be taken for nourishment, not for taste or gluttony, as sparingly as possible. Most of these people find that consuming such products, only once or twice, weekly produces the desired effects–and that often decreases over to once or twice monthly, or ceases altogether.

That means eating at least 90% or more, plant-based, nutrient-rich foods and keeping in mind that this may mean you eat some refined foods, while eating 100% based, and it may also mean you are eating some animal foods and not refined foods. Either way,  though my vegan purist-friends might complain that I am sacrificing my principles, I would rather have people eat a small amount of animal products and maintain a 90+ percent, whole-foods, plant-based diet than continue to eat the standard, Western, animal-based diet, which is killing our people, and our planet with ever greater momentum.

If all Americans made whole plant foods 90+ percent of their diets, the health of the people and the planet would benefit tremendously. If you can’t go 100% plant-based right away–and you may never–don’t be deterred. 90%” is a wonderful starting point from which to work toward an ever-healthier diet, body and future. You can make the choice for yourself three times per day. Choose wisely–and enjoy the learning, and the eating!

The future holds promise of two advances that may make any food derived through animal suffering unnecessary:

1. Development of “in vitro” meat–meat grown artificially in a bio-reactor–is proceeding with support of various national governments and private industry. Cultured muscle cells are then compressed and converted into a ground beef-like product. This could provide the “nutrient X” of animal tissue without the environmental damage and animal suffering inherent in conventional flesh-derived products. The production cost must come down and further technological refinements must be made, but the product is on the horizon. For those who do not find the product inherently unappetizing, it may provide the solutions to a number of nutritional and ecological challenges.

2. Advances in genetic typing are bringing us close to the day when a person–vegan or not–can have a drop of blood analyzed and thus learn how to tailor their diet to exactly meet their genetic needs. This technology would make designing a health-supporting, plant-based food program customized for each individual far more feasible.

So, until the above happy days arrive, for omnivores and nutritionally-challenged vegans, I would urge you to adopt and optimize your plant-based, nutrient-rich diet as best you can as suggested above–and when it comes to consuming flesh-based foods, “less is more.”

90% or More Plant Based, Nutrient-Rich, is the way to go and grow!

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