New Proof That Being a Vegetarian is Healthier?

According to this blog post from ABC News, the recently published (behind paywall) results of a large prospective cohort study performed in the UK offers "further proof that eating meat can be hazardous to health." That strikes me as sort of an odd way of framing it, and I hope after reading this you'll understand why I think so. The proper conclusion really should be that we have more evidence that being a vegetarian is associated with a reduced risk of heart disease, but it's still difficult to tell how much other lifestyle choices play into this. In other words, as long as you live a healthy lifestyle in general and eat meat a few times a week or less, it's still difficult to assume you'd see a significant benefit by cutting that meat out of your diet.

The study began in 1993 and followed 44,561 men and women in England and Scotland, 34% of whom were vegetarians when the study began. After an average follow-up time of nearly 12 years, the incidence of developing ischemic heart disease (IHD) was compared between the vegetarian group and the meat-eating group. A subset of the study population was also used to measure risk factors related to heart disease such as body-mass index (BMI), non-HDL-cholesterol levels, and systolic blood pressure, and again the vegetarian group came out ahead. The investigators controlled for some obvious potential confounding variables such as age (the vegetarian group was 10 years younger on average), sex, and exercise habits. Overall, I agree with the quoted physician from the ABC post that it's a very good study, and does a pretty good job of trying to estimate the singular effect of whether a person eats meat or not.

This is essentially the type of design I was talking about being needed in the lead/crime post, and while it represents a pretty high level of evidence, there's still some very important limitations to be aware of. That's not to justify being skeptical of the entire claim that being a vegetarian is healthier for the heart than not, but it's not as simple as just saying "meat is hazardous to your health." The two groups being compared are not randomized, so it could very well be that the vegetarians had an overall healthier lifestyle, of course including exercise, but also dietary factors beyond just not eating meat. How would the results compare if you took a vegetarian that ate a lot of whole grains and vegetables vs. an omnivore that ate meat maybe once or twice a week but also ate a lot of whole grains and vegetables? My guess would be that the risks of IHD for the latter individual wouldn't be much higher, if at all. The central issue here is called selection bias, and it refers to the possibility that the two populations are different enough that drawing a firm cause and effect relationship to one specific difference between the groups is suspect.

The perils of reading too much into a cohort study are illustrated by the story of hormone-replacement therapy (HRT) for post-menopausal women. In 1991, a large cohort study based on a population of nurses came to the conclusion that HRT protected women from cardiovascular diseases. This was one out of a series of cohort studies for HRT that found a variety of purported benefits. Immediately, concerns about selection bias were raised, but were largely dismissed. HRT became very common throughout the rest of the decade based on these very well-designed cohort studies that seemed to provide really good evidence. Finally, in 2002, the first double-blinded randomized control trial for HRT vs. placebo was performed. Both the estrogen plus progestin and estrogen only arms of the study were halted early because the risks for heart disease, stroke, and pulmonary embolism were higher than in the placebo groups. The exact opposite of the results of the cohort study were found when the comparison groups were randomized. Again, this isn't to say I dispute that completely eliminating meat is a healthy choice, or that if an RCT were performed, the meat-eaters would turn out to be healthier. I'm just illustrating why you should be always be aware of the possibility of selection bias in non-randomized studies.

Another issue to look out for is how reduced risks are presented in studies. There are essentially two ways to do it: by subtracting the difference in risk in one group vs. the other, or by presenting a risk ratio. Looking at the numbers, only 2.7% of the entire study developed IHD, about 1.6% for meat-eaters vs. 1.1% for vegetarians. Another way of putting this is, "a vegetarian diet is associated with 0.5% less risk of developing IHD." That doesn't sound quite as impressive, but it's completely accurate. It's a lot more eye-opening to divide the 1.1% by the 1.6% and get your 32% reduced risk. I'm not saying anybody did anything inappropriate, but the raw numbers have a way of putting things like this into the proper perspective. 

Ultimately, what does all this amount to? If I were at risk for IHD, I'd adopt a healthy lifestyle of a well-rounded diet with moderate to no meat, as well as to exercise regularly and stay active throughout the day. Hardly an earth shattering piece of advice, but that's what we've got. To put it bluntly, just eat like a person is supposed to eat, goddamnit. You know what I mean.