DIET AND LIPID PROFILE OF VEGETARIANS AND NON- VEGETARIANS IN SOME SELECTED COMMUNITIES IN ACCRA BY CEDELL NAA OBLIKAI TETTEH (10362833) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTERS OF SCIENCE DIETETICS DEGREE. JULY, 2013 University of Ghana http://ugspace.ug.edu.gh i DECLARATION / SIGNATURE I, Cedell Naa Oblikai Tett eh , hereb y decla re that thi s diss ertati on is the result of m y own dil igent rese arc h work under the supervisi on of Dr. Geor ge As ar e (Maj. Rtd) and Dr. Matil da As ante of the School of Alli ed Healt h Scienc es , Uni versit y of Ghana. All refe ren ces cit ed in this work have been full y ackno wled ged. ………………………………………….. CEDELL NAA OBLIKAI TETTEH (STUDENT) ……………………………… …..………………………… DR. GEORGE ASARE (Maj. Rtd.) DR. MATILDA ASANTE (PRINCIPAL SUPERVISOR) (CO - SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh ii ABSTRACT Backgrou n d : Vegetaria nism is the practi ce of abstaini ng m ainl y fro m the consum pti on of meat, poult r y, sea food and flesh of an y anim al while dep ending mainl y on foods of pl ant ori gin. Ve getari an diets are t ypicall y low in fat, particularl y satur at ed fat and high in dietar y fibr e , ve getables, whol e grai ns and legumes. Plasma tot al cholesterols and low densit y lipoproteins (LD L) cholesterol lev els of veget arians are consi stentl y low er th an non - ve ge tarians. Although ve getarians do not eat meat there ma y be other sourc es of satur ated fat in the form of unhealt hy fat and oil s in their diet which ma y af fect the ir lipid profil e. Ther e is paucit y of data on dieta r y compo sit ion of veget arians in Ghana. Objectives : Th e main aim of the stud y was to compar e diet and s eru m lipid profil e of vegetarians an d non -ve geta rians in Accra. Methodology : A case – control stud y was carri ed out invol ving 54 vegetarians and 59 age and gen der match ed non-v e ge tarians. Blood pressur e and a nthropometric me asure ment (wei ght, hei ght , visceral fat and bod y fa t) was mea sured for all the part icipants. A structured questi onnaire was use d to obtain socio- demo graphi c data of the participants. Di etar y int ake was assess ed using a 24 -hour recall and food frequenc y questi onnair e. Overni ght fasti n g venous blood sampl es were coll ected for anal ysis of serum lipid profil e. Results: The me an age of vegeta rians and non - vegetarians was 54.24 ± 13.86 and 53.9 ± 11.2 ye ars , respe cti vel y. No si gni ficant diff eren ces wer e found regardin g nutrit ional status based on Bod y Mass Index (B M I ). Diastol ic blood pressure was signifi cantl y hi gh er in veget arians compared to non -ve getari ans ( p = 0.011). Wit h the ex cepti on of HDL- C, se rum tri gl yc erides, tot al choleste rol and University of Ghana http://ugspace.ug.edu.gh iii LD L cholesterol were not significantl y dif fer ent between ve get arians an d non - vegetarians ( p = 0.012). Most of the protein intakes of the vegeta rians (77.8%) were below the recomm e nded dail y int ak e. Majorit y of the vegetarians had lower int akes of vit ami n B 1 2 and B 6 (85.2% and 83.3% respe cti vel y) th an the recomm ended nutrient int ake. Also the me an int ake of fol ate was si gni ficantl y different b etween ve geta r ians th an the non-ve getar ians ( p= 0.002). Conclusion : There was no signific ant diffe ren ce in BM I between the two dietar y groups. The stud y was not able to clearl y est abli sh whether ve geta ri an diet improves the lipid status of an indi vidual . Wit h the ex cepti on of protein, there we re no signi ficant dif feren ces in the mac ro nutrients int ake betw e en the vegetarians and non - ve getarians ( p = 0.001). Keyword s : Ve geta rian , Non-ve geta rian, Lipi d pr ofil e and Diet University of Ghana http://ugspace.ug.edu.gh iv DEDICATION In lovi ng memor y of m y lat e gr andmot hers, Agn es Tett eh and Est he r Lar ye a who wished to se e me become a dietit ian. Unfortunatel y, the y passed awa y during the first ye ar of my pro gramm e and nev er witnessed the reali sati on of their dreams. University of Ghana http://ugspace.ug.edu.gh v ACKNOWLEDGEMENTS I thank God for the wisdom and stren gth that He gave m e to condu ct thi s resea rch proje ct and indeed throughout m y life. I thank God for making thi s dream a reali t y. It has been difficult but ex tremel y rewa rding. I would fu rther like to ex press m y sin cer e grati tude to m y principal sup ervisor Dr. Geo r ge Asar e (M aj.R td.) for his ten acit y, mo ti vati on and enthus iasm t oward s m y rese arch. M y deep est appreciation go es to m y second supervisor, Dr. Matil da Asante, fo r he r immen se knowled ge and insi ghtful co mm ents towar ds m y research and my entire masters’ degree programme. Special thanks go to th e senior res ear ch assi sta nts of the Chemi c al Pat holog y Labo rator y of School of Alli ed Healt h Sciences and Mr. David Nana Ad jei for their imm ense contribut ions towards thi s project. M y sinc erest gr ati tude goes to Mr. Wil li am Antwi for his insi ghtful comm en ts and immense contrib uti ons towards mine literature review. To the members of Mart yrs of Uganda Cathol ic Ch urch , Mamprobi, an d J amal Ru hani Satsang, Weij a who volunt ee red to participate in the resea rc h, I sa y thank you. Furthermo re, I would like to show appreciation to m y parents for their enduring love and suppo rt throu ghout m y lif e. To m y sibl ings: Edward, Thel ma and Sandra, I sa y a big tha nk you for yo u r love and support. Finall y, m y deepest gr ati tude goes to Mr. Antwi Opoku –Amoah, for his eno rmous contri buti ons towards the suc cess of th is project. University of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS PAGE Declar ati on i Abstract ii Dedicati on iv Acknowled gem ent s v Table of Contents vi List of Figu res xii List of Tabl es xiii List of Abbr eviations xiv CHAPTER ONE : INTRODUC T IO N 1 1.1 Back ground 1 1.2 Problem Statement 4 1.3 Significanc e of the Stud y 4 1.4 Hypothes es 5 1.5 Aims and Objecti ves 5 1.5.1 Aim 5 1.5.2 Specific Objecti ves 5 CHAPTER TWO: LIT ERATUR E REV IE W 7 2.0 Introdu cti on 7 2.2 Earl y Times of Vegetari a nism 7 2.3 Reasons for Adoptin g a Vegetari an Diet 8 2.3 .1 Support Personal Healt h and Heali n g 8 University of Ghana http://ugspace.ug.edu.gh vii 2.3 . 2 Protect the Environment 9 2.3 .3 Uphold Reli gious or Phil osophi cal Principl es 9 2.4 Types o f Vegetarian 10 2.4 .1 Types o f Vegetarian Diet s 10 2. 5 Nutriti onal Impl i cati ons of the Veget arian Di et 11 2.6.0 Comparison in Energ y and Nutrients Intake of Veget arians and Non-ve getarians 11 2.6 .1 Ener g y 11 2.6 .2 Protein 12 2.6 .3 Fats and Essenti al Fatt y Acids 12 2.6 .4 Carboh yd rates 14 2.6 .5 Vitamins 14 2.6 .5.1 Vitamin D 14 2.6 .5.2 Vitamin B 1 2 (Cobalamin) 15 2.6.6 Calcium 16 2.6.7 Ir on 17 2.6.8 Zinc 17 2.7 Overall Healt h and Lon gevit y of Vegeta rians 18 2.8.0 Bloo d Lipi ds and Lipop r oteins 18 2.8 .1 Lipi ds Metaboli sm 19 2.8 .2 Chl ylom ic rons 20 2.8 .3 Ver y Low -Densit y Lipop roteins (V LD L) 20 2.8 .4 Low -Densit y Lipop rotei ns Cholesterol (LD L- C ) 21 2.8 .5 High - Densit y Lipop rotei ns Cholesterol (HD L- C ) 22 2.8 .6 Total Blood Cholesterol (TC) 23 University of Ghana http://ugspace.ug.edu.gh viii 2.8 .7 Total Trigl yc erides (TG) 24 2.9 Dysli pidaemi a 25 2.10 Diet and Li fest yle In flue nces on Blood Lipi ds 26 2.10.1 Fats and Oil s 26 2.10.2 Trans - Fatt y Acids (t- FAs ) 26 2. 10 .3 Dietar y Cholesterol 26 2.10 .4 Omega-3 (n -3) Fatt y Aci ds 27 2.10 .5 Carboh yd rate 27 2.10 .6 Solubl e Fibre 28 2.10 .7 Alcohol 29 2.10 .8 Plant Sterols and Stanols 29 2.10 .9 Nuts 30 2. 10.10 So y Protein 30 2.11 Ph ysical Acti vit y 31 CHAPTER THREE : MATER IA LS AND ME THODS 32 3.1 Introdu ct ion 32 3.2 Stud y Desi gn 32 3.3 Stud y Sit e s 32 3. 4 Stud y Pa rticipants 32 3.5 In clusi on and Ex clusi on Crit eria 33 3.5 .1 In clusi on Crit eria 33 3 .5 .2 Ex clusi on Crit eria 33 3.6 Sampl e Siz e Determi nat ion 33 3 .7 Research M ethod 34 University of Ghana http://ugspace.ug.edu.gh ix 3.8 Sampl ing Technique 34 3.9 Pre-Testi n g of Qu esti onnaire 35 3.10 Data Collecti on 35 3.11 An thropometric Measu re ments 35 3.12 Bl ood Pressure M easur e ment 36 3. 13 .0 Dietar y Assessm ent 36 3.13 .1 24 -Hour Rec all 36 3.13 .2 Food Frequen c y Questi o nnaires 36 3.14 Blood Sampl e Col lecti on and Transport ati on 37 3.15 Biochemi c al Anal ys i s 37 3.16 Lipi d Profil e 37 3.16 .1 Ch olesterol -Test Principl e 37 3.16 .2 Trigl yc eride – Test Princ ipl e 38 3 .16 .3 HD L – Cholesterol 38 3 .16 .4 LD L – Choleste rol 39 3.16 .5 VLD L 39 3.16 .6 Assa y Pro ce dur e 39 3.1 7 Data Anal ysis 40 3.18 Ethi cal Issu es 40 CHAPTER FOUR: RESU LTS 41 4.0 Introdu cti on 41 4.1 Socio -demographic Cha r acterist ics of Particip ants 4 1 4.2 Vegetari anism 4 3 4.2.1 Len gth o f veget arian stat us 4 3 University of Ghana http://ugspace.ug.edu.gh x 4.2.2 Types and Reasons fo r Becomi ng a Vegetarian 4 3 4.3 Dietar y and M eal Patt ern 4 4 4.4 Healt h and Medic al Condit ion of Vegetarians and Non-Ve getarians 46 4.5 Lif e St yle Beh aviours 4 6 4.6 Comparison of Anthropo metric Vari ables amon g Vegetari ans and Non -v e getarian 4 7 4.7 Lipi d Profil e of Vegeta rians and Non-v e geta rians 49 4.8 Dail y Nut rient Intake of the Ve get arians and Non- Ve getari ans 50 4.9 Frequ en c y of Consum pti on of Food 55 4.9 .1 Animal Protein and Veget able Protein 55 4.9 .2 Fruits, Ve get ables, Fruit J uices and Drink s 56 4.9 .3 Cereals and Grains 56 4.9 .4 Deep Fried Food s, Fast Foods and Pastries 57 CHAPTER FIVE: DISCUSS ION 59 5.1 Socio -Demo graphic Cha racte risti cs of Parti cipant s 59 5.2 Vegetari an ism 60 5.3 Healt h and Lif est yle Beh aviours 61 5.4 Bod y Compos it ion and Blood Pressure 62 5.5 Lipi d Profil e 64 5.6 Dietar y Intak e of Particip ants 67 5.7 Dietar y Habit s 70 5.7 .1 Fruits, Ve get ables and Fr uit J uices 71 5 .7 .2 Cereals and Grains 72 University of Ghana http://ugspace.ug.edu.gh xi 5.7 .3 Deep Fried Food, Fast Food an d Pastries 72 5.8 Lim it ati on s of the Stud y 73 5.9 Conclusi on s 73 5.10 Recomm endati ons 74 REFERENCES 75 APP END IX I: INFORMED CONSENT FORM 95 APP END IX II: QUEST IONNA IR E 9 7 APP END IX III ETH IC A L C LEARANC E 101 APP END IX IV IN TRODUC TORY LET TERS 103 University of Ghana http://ugspace.ug.edu.gh xii LIST OF FIGURES PAGE Figu re 4.1: Dist ributi on for length of years of vegeta rianism 43 Figu re 4.2: Dist ributi ons for t ypes of vegetarian s 44 Figu re 4.3: Dist ributi ons of reasons for becomi n g a vegetari an 44 Figu re 4.4: Dist ributi on for histor y of medicati ons 4 6 Figu re 4.5: Comparisons of anim al protein and ve get able prot ein 55 Figu re 4.6: Comparisons of fresh fru it s and vegetables, fruit juice s and drink s betwe en ve get arians and non -ve geta ria ns 5 6 Figu re 4.7: Comparisons of cer eals & grains and tubers betw een vegetarians and non -ve ge tarians 57 Figu re 4.8 Comparisons of deep frie d foods, fast food s and pastries between ve getari ans and non -ve geta rians 58 University of Ghana http://ugspace.ug.edu.gh xiii LIST OF TABLES PAGE Table 4.1: Socio -demographic Cha r acterist ics of V egeta ri ans and non -v e g et arians 42 Table 4.2: Dietar y and M eal Patt ern s of Parti cipants 45 Table 4.3: Li fe St yl e Behaviou rs of Participan ts 47 Table 4.4: Comparison of Anthropo metric and Blood Pressur e Measurement between Vegetarians and Non-v e get arians 48 Tabl e 4.5 : Dist ributi on for the Classificati on of Risk of High Blood Pressure 48 Table 4.6: Comparison of Lipi d Pro file between Veget arians and Non-v e getarians 4 9 Table 4.7: Lev els of Lipi d Paramet e rs in Vegetari ans and Non-ve geta rian 50 Table 4.8: Co mparison of Macronut rients between Veget aria ns and Non-v e getarians 51 Table 4.9: Co mparison of Micronutrients between Veget aria ns and Non-v e getarians 52 Table 4.10: Comparison of Recomm ended Mac ronutrients intake in Vegetarians and Non- v egetarians 53 Table 4.11: Comparison of Recomm ended Micronutrients int ake in Vegetarians and Non- v egetarians 5 4 University of Ghana http://ugspace.ug.edu.gh xiv LIST OF ABBREVIATIONS ADA - American Di etetic s Asso ciation BM I - Bod y Mass Ind ex BP - Blood Pressure CVD - Cardiovascular Disease HD L- C - High - densit y lipoprotein s -C holesterol LD L- C - Low – densit y lipopr oteins -Cholesterol MUFA - Mono – unsaturated fatt y acids NV - Non- ve get arians PUFA - Pol y uns aturated fatt y aci ds RD I - Recomm ended dail y int a ke SFA - Saturated fatt y acids T-C - Total - cholesterol TG - Trigl yc erides V - Vegetari ans VLD L-C - Ver y low -d ensit y lipopro teins cholesterol University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.0 INTRODUCTION 1.1 Backgrou n d Ve getari an i s m dates back to a time bef ore recorded hist or y. Man y anthropologist s beli eve t hat earl y humans at e mai nl y plant foods, bein g m ore like gath er e r s than hunters (Spencer, 2000 ). Accordi ng to them, the natural diet of man consi sts of fruit s, nuts and gr ains, an d not meat (Spence r, 2000). This view is supported by the fact that the human digesti ve s ystem res embl es that of other plant eaters rath er than meat eaters (Schnit z er , 2005 ). Vegeta rianism invol ves the practi ce of followin g a diet that includes fruit s , ve getables, cer eals and gr ains, nuts and seeds with or without dair y products or eggs (Nivedita et al ., 2012). A vegetarian does not eat meat, including poult r y, fish , crustac eans and shell fish and ma y also abstain from products of anim al sources such as anim al -derived rennet and gelatin (Ma rs h et al ., 2011). Ve geta ria ns are cate goriz ed b y th e t ype of anim al foods restricted i n the i r diet. Th ere is a wide deb ate as to wheth er it is bett er to be a vegetari an or non - vegeta rian. M ost people are of the vie w that non -ve geta rian foods ar e the onl y sourc e for gett ing all the nutrients that can make them strong, he alt hy and acti ve. Ther e ar e a number of reasons wh y people go on a non - ve get arian diet. The reason for choosi ng a veget arian d i et go es be yond healt h and well -b eing and it includes amo ng othe rs reli gious, econ om ical, and social conc erns (Le it z mann , 2005). Imp rov ed he alt h is one of th e man y reasons people choos e t o adopt a vegeta rian die t and ther e is now a wealt h of evidence to support the healt h benefits of a veget a rian diet ( Marsh et al . , 2011). University of Ghana http://ugspace.ug.edu.gh 2 Ve getari ans usuall y con sume more frui ts and vegetables than non -v e ge tarian s and because of their restr icted consum pti on of animal sources of foods, they have lower int ake of saturate d fatt y aci ds and incr ea sed int ake of fibre and various kinds of anti ox idant s , compared to those of no n -ve geta rian ori gin (R au m a and M ykann 2000 ). This typ e of diet helps improve anti ox idant status lowers ox idative stress and reduces blood lipid levels (Garcia et al. , 2008 ). Veget arians gen erall y hav e a lower bod y mass index (BM I) and tend to be more healt h - conscious than non -ve ge ta rians (Bedfo rd and Ba rr , 2005 ), possi bl y beca use of their reduced tot al en er g y consum pti on , alt hough incr eased ex er cise ma y also pla y a role (Americ an Di etetic Association, 2007 ). Furthermo re, a number of studi es hav e show n increas ed lon gevit y among vegetarians (Si ngh et al. , 2003). It is li kel y th at these benefits result fro m both reduced consum pti on of potentiall y ha rmful dietar y compon ent s , in cludi ng saturated fat, cholesterol, anim al protein (red m eat ) and an inc reas ed consu mpt ion of benefi cial dietar y com ponents of fruit s, ve getab les, whole grains, le gum e s, and nuts which are rich in dietar y fibre , anti ox idant s and ph ytochemi c al s (Sebate , 2003). In fact , the nutrit ional and healt h consequ ences of vegetarians are neit her necessa ril y all good nor all bad. The ult im ate balance that ve get arians die t strike with respect to healt h depends on the ex tent to which the y are int e grate d with current knowl ed ge of nut rition al science in dieta r y planning (Dw yer, 1991 ). The major risk invol ved in veget arian diet s is ³deficienc y diseas es ´ or malnutrit ion, secondar y to the presence of some other associated cause that is negl ected or untr eated (Dw ye r, 1991). Th e risk s of deficien c y also rise during University of Ghana http://ugspace.ug.edu.gh 3 certain times of lif e incl uding pregnan c y and la c tation, infanc y, ea rl y chi ldhood and the rapid period of growt h in adoles ce nce wh en nutrient ne e ds are particularl y hi gh (Dw ye r, 1991) . Serum lipids are important dete rminants of cardiovascula r risks beh aviour associated with urbaniz at ion , and increas ed satu ra ted fat consum pti on, as well as decre ased ph ysical acti v it y hav e all been well cit ed and are associated with adverse chan ges in the lipid profil e (Marlow et al., 200 9 ). Elevat ed le vels of cholesterols, tri gl yc eride s and low densit y lipopr oteins ( LD L ) - cholester ol are documented as risk facto rs of arthe ro genesis (Ric hter et al., 2004). The vegeta rian diet ha s been found to be as sociated with some de gr ee of prot ecti on against h ype r tension and high er bloo d lipids (Richter et al. , 2004 ). Howeve r, most of these studi es have been co nducted in Caucasians and it remains uncle ar as to ho w much prot ecti on against hype rtension and oth er risk factors for cardiov ascul ar disease s is affo rded by vegetarian diet in African Americans (Niv edit a et al . , 2012). Studi es have not yet been condu cted to find whether Ghanai an ve getarian s gener all y hav e lower plasma low densit y lipoprotein choleste rol like other ve getarian s in certain parts of the world. There is also lack of information on diet quali t y of veget arians in Ghana and thi s is worth investi gati n g. University of Ghana http://ugspace.ug.edu.gh 4 1.2 Proble m State men t There are indi c ati ons that ve getari anism is increasin g in Gh ana and thi s is evidenced in the sprin gin g up veget arian res taurants . A veget arian diet is associated with man y he alt h benefits because of its high content of fibre, folic acid, vit ami ns C, vitamin E, magnesium , ph ytoch emi cals and a fat content that is more unsaturated (Dave y et al., 2003). Although veget arians do not eat meat there ma y be other sou rc es of saturated fat in the form of unh ealt h y fat s and oil s in their diet which ma y aff ect their lipid profil e. The Ame rican Dieteti c Association (ADA ) sta tes that appropri atel y planned ve getaria n di e t s are healt hful and nutriti onall y adequat e (ADA, 200 7 ). Ther e is paucit y of data on dietar y compos it ion of vegetarians in Gh ana. Thi s makes it di fficult fo r di eti ti ans to approve thi s diet for i ndivi duals who want to practi ce ve geta rian diet as part of a lipid lowering diet . 1.3 Signif icance of the Study The findi ngs of thi s stud y ma y provide useful information on diet quali t y of vegetarians in Ghana. The result s of the stud y ma y reveal wheth er the lower int ake of chol este rol, sat urated fat and inc reas e i n cer eals fruit s and ve getables will contribut e to lower blood lipid concentrati ons in vegetari ans. In addit ion, informat ion obtained from the stud y ma y pro vide an in - depth n utrition al knowledge on the risk s and benefits that are associated with veget arianis m. This information will be us eful for dietit ians, nutr it ion related pro fessi on als, the Vegetari an Association of Ghana and the gene r al publi c. The stud y wi ll also provide data on the lipid profil e of vege ta rians in Ghana. Serum lipids are one of the main determi nants of cardiovas cular diseas es (CVD). In conducti n g thi s University of Ghana http://ugspace.ug.edu.gh 5 stud y, spe cific const it uent of the vegetarian diet which af fords prot ecti on against CVD will be known . 1.4 Hypoth eses 1. There is no si gnificant differen ce in the di etar y int ake and lipid profil e of vegetarians and non - ve getarians. 2. There is no si gnificant di ffer ence betwe en the Bo d y Mass Ind ex (BM I), bl ood pressure (BP ), visce ral fat, and bod y fat am ong ve getarians and non - vegetarians. 1.5 Aims and Objectives 1.5. 1 Aim The main aim of the s tud y was to compare diet and se rum lipid pro file of vegetarians and non- ve getarians in sele cted com muni ti es in Accra. 1.5 .2 Specif ic Objectives The specific obj ecti ves o f the stud y wer e: 1. To ac cess so ciodemo gra hic and lif est yl e beh avio urs of vegeta rians and no n – vegetarians. 2. To ex ami ne the effect s of dietar y patt ern and nutrient int ake of vegeta r ians and non - ve get arians on l ipi d profile. 3. To compare BM I, BP , visceral fat and perc enta ge bod y fat of vegetarians and non vegetarians . University of Ghana http://ugspace.ug.edu.gh 6 4. To determi ne the associa ti on between nutrient int ake (S atu rated Fatt y Aci ds , Pol yuns aturated Fatt y Acids and Monounsaturated Fatt y Acids) and lipid profil e of vegetarians an d non -ve geta rians. 5. To measure biom ark ers of lipid profil e (total chole s terol, high -den sit y lipoproteins, low densit y- lipoproteins and trigl ycerides) of vegeta rians and non -ve geta rians . University of Ghana http://ugspace.ug.edu.gh 7 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introd u ctio n The term "ve getarian " was creat ed by the Britis h Veget arian Societ y in th e mid - 1800. The Lati n root of the word refe rs to the source of lif e (Spenc er, 2000) . Howeve r, ve geta rianism itself dates back to a time befor e reco rded hist or y. Man y anthropologist s beli eve t hat most earl y humans are prim aril y pl ant foods, being more like gather ers th a n hunters. This view is supported b y the fact t hat the human digesti ve s ystem resembl es that of other plant -eaters rather than that of meat -eat ers (Schnit z er , 2005). 2.2 Early Times of Vegetar ian ism V e g etari anism was not ver y popula r in the U.S. unti l 1971, when Fran ces Moore Lapp é 's bests ell er Diet for a Small Planet was publi shed. Lapp é devoted half of her book to the id ea o f "p rotein compl ementin g" – for ex ampl e how t o serve beans and ric e to geth er fo r the protein to Ee ³compOete .´ Man y "wo u l d -be" vegetarians wer e discour aged about ch an ging the ir diets because of th e careful planning the y thou ght was required in pre paring a well bal ance d diet ( www.edu.p e.c a/souris hing/pa ges/C mp6 -03/Beth/ homepa ge/hi stor yof vegetarianism htm ). Those legends wer e all destro ye d b y John Robbins ' 1987 book " Diet for a New America" . He demons trated how dan ge rous meat -bas ed diets are, an d ho w healt h y and saf e ve get arian di et is . 5oEins’ book resta rted the ve getarian University of Ghana http://ugspace.ug.edu.gh 8 movement in the U.S., as it instigated the ve gan m ovement, and helped int roduce the term "v e gan " int o the American vo cabula r y. In the earl y 90 's, the American Dietetic Associ ati o n publi shed a posi ti on pape r endorsing ve get arian die ts, and support for ve ge tarian diets started to be seen throughout the medic al comm unit y. Tod a y, reco gnit ion of vegeta rians b y medical authorit ies and the gen eral publi c is of si gnifi cant importanc e despit e some discrim ination the y some ti mes encounter in their l ives (Spencer, 2000). 2.3 Reason s for Adopting a Vegeta rian Diet The reason for choosi n g a veget arian diet often goes be yond healt h an d well - being. It includes among othe rs ec onomi cal, cosmeti c and so cial inf luence (Leit z man n , 2005). Meli na and Davies (2003) rep orted that the main four primar y reasons fo r people choosi ng a vegeta rian diet inclu de: 1. To support personal healt h and heali n g. 2. To promot e reve ren ce for life. 3. To protect the envi ron ment , and 4. To uphold reli gious an d phil osophi cal princ ipl es 2.3.1 Support Person al Healt h and Healin g Healt h is the most commonl y cit ed reason for be c omi ng veget ari an . Most people now reco gniz e that ve get arian diet s ar e not onl y a healt h y choice but ar e li kel y to protect against diseas es ( Leit zmann, 2005) . The potential heal th advant age of vegetarian diet includes a healt h y bod y wei ght an d reduc ed ch ronic dise as e s such as hyp ertension , ob esit y and ce rtain cance rs. T here is good evidenc e that a University of Ghana http://ugspace.ug.edu.gh 9 vegetarian diet and life-s t yles have posi ti ve eff e cts on weight, blood pressure and coronar y arte r y diseas e (Nivedit a et al., 2011). 2.3.2 Protect the Environ me n t Choosing a vegetari an diet can help protect th e environment, prevent global warming, rain for est de structi on and poll uti on , while saving wat er an d other precious resourc es (Ma rlow et al ., 2009). Ve geta r ians beli eve that ve geta rianism has a posi ti ve effect on the environment and ar gu e that the massive pr oducts for human consum pti on can lead to land de grad ati on, water and air pol lut ion and even ch an ge the cli mate (Baroni et al . , 2007). In 2000 , the World Heal th Organiz ati on (WHO) reported that one out of ever y three people su ffe red fro m malnut rition as a resul t of rapid popul ati on gro wth and dim ini shed land, water and ener g y resou rces. Therefo re in response to the increasin g publi c conce r ns about our impact on the earth an It ali an stud y that evaluated the environme ntal impact on non - ve getarians and ve getari ans /vegan s diet and concluded that meat -based diet s , str ain the environment most l y through water poll uti on compared to the plant - ba sed diet s (Baroni et al., 2 007). 2.3.3 Uphold Religiou s or Philosop h ical Princip les S ome indi viduals choos e a veget arian diet in keeping with their reli gion or the phil osoph y of a movem ent. Major wo rld reli gio n s that promot e ve getar ian or vegan diet as part of thei r basic tea chin gs include Buddhis m, J a inism , Hinduis m, Hare Krish n a and the Seventh Da y Adv enti st (Ch risti an reli gious gr oup ). In addit ion, man y reli gions that do not ex pli cit l y promote plant - based diet s have University of Ghana http://ugspace.ug.edu.gh 10 sub groups that promot e ve geta rian lif est yl e s . Good ex ampl es ar e the Christ ian Vegetari an Asso ciation and Musl im Vegan /Ve get arian So ci et y (M eli na and Davies, 2003). 2.4 Types of Vegetarian There ar e four main t yp es of vegetari ans: lacto -v egetarian, ovo -ve getarian , lacto - ovo -vegetarian, and ve gan (Marsh et al. , 2011). O ther t ypes of vegeta rian diet are p es cata rian, semi ve getarian and fruit arians (Robins on and Hack ett , 1995). 2.4 .1 Types of Vegetarian Diets Lacto-vege tarian : - C on sumes dair y products but not meat, eggs, poul tr y and sea food (Marsh et al. , 2011). Lacto-ovo -veg eta rian : - Consum es dair y prod ucts and eggs b ut not meat, poult r y or seafood (Mars h et al., 2011). Ovo-vegeta rian : - Cons umes eggs but avoid s dai r y products, me at, poult r y, fish, and other se afood. Vegans: - The y ex clude all anim al flesh and pr oducts, derived in gr edie nts and addit ives. The y avoid anim al products not onl y in their diet but also in ever y aspect of their life (Robins on and Hackett , 1995) . Man y ve gans ma y also avoid hone y (Marsh et al., 2011). Semi Vegeta rian : - Oc casionall y eats meat, poult r y and fish (Robins on and Hackett , 1995). Pescatarian : - Consum e s fish and possi bl y other seafood but ex cludes red meat and pou lt r y (Robins on and Hackett , 1995 ). University of Ghana http://ugspace.ug.edu.gh 11 Fruita rian : - This t ype of vegetari an mainl y eats raw fruit s, ve getable s, nuts, seeds, sprouted puls es an d gr ains (Robins on and Hackett , 1995). 2.5 Nutrition al Impli cation s of the Vegetarian Diet S ome nutrients can be m ore diffi cult to obtain fro m a veget a rian di et, but care ful planning and in some ca ses the use of fo rtified foods or suppl ements can ensure that indi vidual nutrit i onal needs are m et while m ax im iz ing the healt h ben efits of the vegetari an and ve gan diet. The Ameri can Di etetic Association report ed in t heir posi ti on statement that well planned ve getarian di ets, including ve gan diets ar e nutrit ionall y adequate and ar e appropriate fo r indi viduals during all stages of life (Craig and Mand el 2009). Vegetari ans who do not adequatel y plan th eir diet and do not replace vit al s ources of proteins, vit ami ns and minerals ma y be putt ing t hemselves and th eir fami li es at ri sk (Thomas and Bishop , 2007 ). In addit ion to iron and zinc, unplann ed ve gan diets are often low in kil ocalories , cal cium , vit ami n B 1 2 and vit ami n D unless suppl ementar y sou rces of these vit ami ns are provided, since plant foods contain no known sources of th es e vit am ins (Dw yer, 1991 ). 2.6.0 Comparison in Energy and Nutrient s Intak e of Vegetarian s and Non- Vegeta rian s 2.6.1 Energy Ve getari an s tend to have a sim il ar ener g y int ak e to non -ve geta rians (D rape r et al., 1993) but the energ y int ake of vegans tends to be lower (Dav e y et al ., 2003) in men. In ord er to prev ent the catabolis m of dietar y protein to provid e en er gy, it is University of Ghana http://ugspace.ug.edu.gh 12 im portant to ensure suff icient ener g y int ake for growth b y includin g m ore of ener g y dens e foods suc h as nuts, dried fruit s, so ya chees e , ve getabl e oil s and margarines. Ther e is evid enced th at a low er ener gy diet can modul at e bloo d lipids and reduc e athe roscle rosis and corona r y de aths (Kell y et al ., 2004 ). 2.6.2 Protein Although the adequ ac y of proteins in vegeta rian diet s is someti mes ques ti oned, vegetarian diets usuall y ex ceed protein requirem ents, alt hough th e y ma y provide less protein than a non - vegetarian diet (Cr ai g and Mandel, 2009). The main nutrit ional differenc es be tween plant and anim al pro tein source diets is the higher and more bioavail able micronutrient content of the latter. It was onc e thought that certain combi nati ons of plants foods had to be eaten at th e same meal to ensure sufficient essential ami no acids. Strict protein combi ning is not necessar y, but adequate ene r g y food i ntake eaten includin g a variet y of plant foods such as legumes, whole gr ains, nuts seeds, so y products and ve get ables ar e esse nti al in providi ng dietar y prot ein (Youn g and Pell et, 1994; America Dieteti cs Association, 2007 ). 2.6.3 Fats and Essential Fatty Acids The diet of semi - vegetarian and la cto - ovo vegetarians have be en found to contain sim il ar quanti ti es of tot al fat (Draper et al., 1993) and essential fatt y acids to the non-vegetarian di et (Davis and Kris -Ethe rton, 2003). T he EP IC Ox ford Stud y (Dav e y et al ., 2003) found that tot al fat int ake of vegetari ans co mpared with non -vegetarians was significantl y lower in vegans than the non -ve get arians . Vegans diets hav e been shown to be lower in saturated fat t y acids (SF A) and University of Ghana http://ugspace.ug.edu.gh 13 higher in pol yunsatur ate d fat t y acids (PU FA) t han ve getarian diets , an d both t ypes of diet s tend to be l ower in saturat ed fat tha n diet containing me at. There is ho wever the potential fo r ve gan or vegeta rian di ets to be hi gh in saturate d fat if oil s such as coconut and palm oil are used re gularl y (Thom as and Bishop , 2007 ). Omega-3 fatt y acid s pla y an important role in healt h and diseas e s , pa rticularl y with respe ct to cardi ovascular healt h and also inflamm ator y diseases (Yashodhor a et al ., 2009 ). Be cause fish and sea fo od are the main sour ces of long chain omega-3 fatt y acids, obtaining an adequat e int ake of omega -3 fatt y acids on a vegeta rian diet will be difficult (Marsh et al., 2011). Veget arians obtain o mega- 3 fatt y acids predomi nan tl y from the ome ga-3 Iatty acid Į-li nolenic acid (A LA) , but there is debate over the efficien c y of conversi on o f ALA to the longer -chain docosahex aenoic acid (DHA) and ei cosapenta e noic acid: EPA (Davis and Kris - Etherton, 2003). For the vegetarian, it has been su ggested that a rati o ran ge 2:1 to 4:1 of ome ga -6 to om ega-3 would max im iz e conversion (Davis an d Kris - Etherton, 2003) and red uce an y thrombot ic tend enc y that might inc reas e the ir gen erall y low risk of CVD (Bal l and Bartlett , 1999). Ome ga 3 fatt y aci ds lower trigl yce rides levels b y in hibi ti ng VLD L s ynthesis (Mahan et al., 2012). There is some eviden ce t o su ggest that the require ment for ome ga-3 fatt y acids in vegetarians is hi ghe r be cause of the inef ficient conversion of ALA to EPA a nd DHA and the la ck of direct sour ces of thes e fatt y acids (Ke y et al., 2006). To opti mi z e Omega-3 fatt y acid status in veget arians , it is best to avoid saturated and trans fat in favour of mo nounsaturated fats rather than Omega -6 fats. The richest sources of A LA include chia seeds , linseeds and flax seed oil . Walnut s and so y University of Ghana http://ugspace.ug.edu.gh 14 products also provid e a good sou rce of A LA, wi th small er amount s pr es ents in gr een le af y ve getables (Marsh et al ., 2011). 2.6.4 Carboh yd rates Ve getari an diet s can be high in carboh yd rate s and ve gans have the highe r carboh ydr ate int akes pr ovidi ng 50 -65% of tot a l ener g y int ake (Dave y et al. , 2003). Total sugar conte nt is sim ilar to that of a meat - containin g diet (Draper et al., 1993 ) alt hough the in take of su gars from fruit ma y be high in vegetaria ns and vegans. 2.6.5 Vitamin s Vitamins int ake of vegetarians are gener all y adequate , but ve gan s ma y have lower than recomm ende d int akes of vit ami n B 1 2 and vit ami n D (Draper et al ., 1993). 2.6.5.1 Vitamin D Vitamin D is best known for it s role in bone healt h. Ver y litt le calc ium is absorbed when vit ami n D levels are low. A rela ti vel y ne w era of resea rc h is its role in the pr eventi on of diseases such as canc er, hea rt diseas e, strokes, arthrit is, mul ti ple sclerosis and even depressi on (Holi ck et al., 2008). The main source of vit ami n D is ex po sure to the sun. The skin can produce what is need ed, however the amount produced de pends on man y factors, including the time of day, skin pigmentati on , use of sunscre en s , age and length of ex posure (Craig and Mandel , 2009). University of Ghana http://ugspace.ug.edu.gh 15 Vitamin D is found naturall y in onl y a few foods such as oil y fish (cod liv er oil ) , wild mush rooms and eggs. Be cause onl y a few products contain Vitamin D, it is often added to some dairy products and other forti fied foods. Although lact o - ovo vegetarians obtain some vit ami n D from eggs and dair y produ cts, most of their int akes come from forti fied foods. Vegans rel y onl y on forti fi ed foods to obtain adequate di etar y int ake (Marsh et al ., 2011). S tu dies have shown th at vegetarians and particula rl y ve gans have a low er intake of vit ami n D compared to non - vegetari ans (Outi la et al., 2000; Holick et al., 2008). The Adv enti st Healt h Stud y found no relat ionsh ip between se rum vit ami n D concentr ati on and ve getarian status, su ggesti n g that factors othe r than diet have a greater influen ce on vi tamin D levels (Chan et al., 2009). If sun ex posure an d int ake of foods fo rtifie d with vit ami n D is inadequate to meet the requir ements, vit ami n D supplement s are re comm ended (Cr ai g and Mandel, 2009). 2.6.5.2 Vitamin B 12 (Cobalamin) Vitamin B 1 2 is found only in anim al produ cts, so a deficienc y of thi s vit ami n is a potential concern for an yo ne followin g a vegan or vegetarian diet. Some studi es have found that serum l evels of vit ami n B 1 2 are gen erall y lower in vege tarians, especiall y ve gans, dec re asin g with incre asin g du rati on of followi ng th e vegetarian diet ( Allen, 2009; Gilsi ng and Crowe 2010). Vitamin B 1 2 is unique among the vit ami ns in t hat it is s ynthesiz ed b y bacteria, fun gi and certai n al gae and from microbial acti ons in anim als. University of Ghana http://ugspace.ug.edu.gh 16 Although plant foods , including mush rooms, tempah, miso and sea vegeta bles are often reported to provi de some source of vit a mi n B 1 2 , these are not reli able sources of thi s vit ami n. These foods contain an inacti ve form of B 1 2 , which int erfer es with the norm al absorp ti on and met ab oli sm of the acti ve form in the bod y and will not preve nt a deficien c y (Watanb e, 2007). A reli able sou rce of biol ogicall y acti ve vit ami n B 1 2 is recomm ended on a regula r basis , eit he r from fo rtified foods or suppl ements. It is recomm ended that all vegans shoul d suppl ement their diet with vit ami n B 1 2 and thi s is especiall y important for women who ar e pr e gnant or brea stfeedin g to pr event de ficienc y in thei r babies (Dror and Allen, 2008). 2.6.6 Calciu m An adequate c alcium int ake is needed as part of a balanced diet throu gho ut life to help reduce the risk of osteoporosis (W eaver et al ., 1999). Research has found that calcium int ake is generall y sim il ar betwe en lacto -ovo ve geta rians an d non - vegetarians, (Weav er et al ., 1999) alt hough vega ns t ypic all y hav e lower int ake (Dave y et al., 2003; Appl eb y, 2007). Ho weve r, the lower fat intake of vegetarians ma y aid calcium bioav ail abil it y, which has been shown to be inversel y rel ated to fatt y acid chain len gth and fatt y ph ytat e, and as a result foods such as spinach or cabba ge ma y not be a go od source of cal cium despit e their high calcium content (Dave y et al., 2003 ). Fo r lacto -ovo ve getari ans, dair y products provide ple nt y of calcium. Vegans can ob tain their calcium from forti fied so y milk and yoghurt, tofu or other pl ant food s rich in calcium. Plant foods that hav e hi gh calcium bioavail ab il it y includ e low ox alate green ve geta ble s such as broccoli and okra, University of Ghana http://ugspace.ug.edu.gh 17 which have more bioava il abil it y of 50- 60% compared with 32% from cow m il k (Weaver et al ., 1999). 2.6.7 Iron There are two t ypes of ir on found in food. Heme iron found onl y in anim a l foods such as meat, poult r y and fish and n on - heme iron present in anim al food including eggs and plant foods such as le gumes, whole grains, nuts, seeds as well as dark gre en lea f y ve getables. Non -h eme iron is not as well abso rbed by the bod y but its absorption is increased signifi cantl y in the pr esenc e of vit ami n C (Cook , 1990 ). Vegeta ria n diet s can contain as much or more iron (non - heme) than mix ed diet s , p rimari l y from whol e gr ain br ea d and cer eals in cludi ng forti fied cere als (Dav e y et al., 2003). Surprisi ngl y, iron deficienc y is not less com mon in vegetarians alt hou gh iron stores (as shown b y fer ritin levels) are often lo we r ( Ball and Ba r l et t , 1999; Messi na et al., 2004 ). 2.6.8 Zinc Ve getari ans and ve gans of all ages gene rall y hav e a diet ar y int ake of zinc sim il ar to or higher than that of non -ve geta rians (Dr aper et al., 1993). Most veget arians have ad equate blood lev els alt hough chil dren an d infants ma y be at risk due to th eir high er requir ements (Gibson et al . , 2006 ). Zi nc is sim il ar to iron in th at the richest sour ces are foun d in anim al foods. Abs orpti on of zinc is reduc ed b y ph ytate found in whe at bran, whol e gr ains an d legumes. How ever, proc essi ng food b y leav enin g ( ye ast in breads ), soakin g, fer menting or sprouting can reduc e ph ytate lev el s and make zinc more readil y av ail ab le ( Gibson et al., 2006). Again, like iron, comm onl y eaten plant foods such as nuts, seeds and whole gr a ins are University of Ghana http://ugspace.ug.edu.gh 18 high in zinc and ma y be the reason fo r the apparent s ati sfactor y st atus in vegetarians (Marsh et al., 2011). 2.7 Overall Health and Longevity of Vegetarian s Although ve geta rians ge nerall y have a lowe r BM I and tend to be more healt h con scious than non -ve ge tarians (Bedfo rd and Ba rr, 2005) , a numbe r of studi es have shown incr eas ed longevit y amon g ve getari a ns (Fr aser, 2009 ; Singh et al., 2003). It is likel y that t hese benefits result fro m both redu ced consum pti on of potentiall y harmful dieta r y components including saturated fat, cholestero l, red meat and inc reas ed cons umpt ion o f benefici al die tar y components includin g fruit , vegetables, whole gr ains, legum es and nuts which are rich in di etar y anti ox idant s and ph ytoch emi cals (Se bate, 2003). Resear ch has linked higher int ake of red meat and proc essed me at with an increas ed risk of obesit y, t ype II diabetes (Dam et al., 2004) and some t ype of can cers (Baz z ano e t al., 2001 ). Low meat in take on the other hand has been associated with greater l ongevit y (Tonstand et al ., 2009). Vegetari ans are gener all y mor e healt h y people , as the y tend to pra cti ce healt h y, acti ve, lifest yles and refr ain from smok ing (Singh et al. 2003). A vegetari an diet coupled with regula r ex ercise and absti nenc e fr om smok ing; seem to be che ap, ph ysiol o gical and saf e approach for th e pr eventi on and possi bl y mana ge ment of modern lifest yl e diseases (Mahan et al., 2012). 2.8.0 Blood Lipid s and Lipoprotein s Bec ause lipid is not water solub le, blood lipids (cholesterol, tri g yc erid es and phosphol ipi ds) are trans ported in the blood bound to proteins (Mahan et al. , 2012). These comp lex particles call ed lip ipoprot eins var y in compos it ion, siz e University of Ghana http://ugspace.ug.edu.gh 19 and densit y. Lipop rotein s measured in cli nical practi ce (ch ylom icrons, ve r y low densit y lipoproteins [V LD Ls] LD Ls and HD Ls ) consi st of var yin g amou nts of trigl yce ride, cholesterol, phosphol ipi d and prote in. Each class of lipoproteins actuall y repr esents a co nti nuum of particles (Mahan et al . , 2012). The protein portion of the lipoprote in is call ed apolipoprotein (Nelm s et a l. , 2011 ). The ph ysiol o gic role of lipoproteins includes transporting lipids to cell s for ener g y, storage, or us e as a subst rate for s ynthesis of other compounds s uch as prostagl andins and l euk otrienes (M ahan et al . , 2012). In epidemiol ogic studi es high -f at diets of people in Mediterrane an countrie s have been associ ated wit h low blood cholesterol level s and CHD incidence (T richopoulou et al ., 2003). Among the Mediterran eans, the main fat source is oli ve oil , which is high in monouns aturated fatt y acids (MUFAs ). This obs ervati on led to man y stu dies on the benefits of hi gh - MU FA diets. Mediterr ane an - t ype step I diet was sh own to reduce rec urre nt CVD by 50 - 70 % (De Lo geri l, 1999). This diet emphasises fruit s, root vegetabl es, green lea f y ve getables, cereals, fish, and foods high in alpha linolenic acid, ve get able oil products and other products mad e wit h non hydro genated oil s, nuts and seed. (Kris - Ethe rton et al., 2001). Althou gh higher – fat (low in SFAs with MUFAs as the predo mi nant fat) can low er blood cholesterol, the y shoul d be used with cauti on because of the calori c den sit y of high -f at diets. The resu lt s of a clinical trial have shown new atheros c leroti c lesions in men who consum e highe r fat diet (M ah an et al ., 2012). 2.8.1 Lipids Metabol ism Lipi ds such as cholest ero l and tri gl yc erid es are ess enti al subs trate s fo r man y bod y processes. Cholesterol is a stru ctural component of cell membr anes and nerv e University of Ghana http://ugspace.ug.edu.gh 20 sheaths and is required for the s ynthesis of steroi d and adrenoc orti cal hor mon es and bil e salt s. Trigl yc eri de is required as an ene rg y sourc e, its const it uent fatt y acids and gl yc erol eit he r being immediatel y m e taboliz ed or reconst it uted into trigl yce rides and stor ed to meet future ener g y nee ds (Thomas and Bishop , 2007). Lipi d metaboli sm is the process b y which the i nit iall y lar ge lipid - fille d, low- densit y compl ex es trans porting eit he r diet -de rived or endo genousl y s ynt hesiz ed lipids undergo gr adual conversion to small er, more dense particles ri ch in protein and phosphol i pids prior t o their uti li z ati on or ex c reti on. The bod y s ynthes iz es at least as much cholesterol as is obtained from the di et ever y da y (Thomas and Bishop , 2007). 2.8.2 Chlylomicron s C hl ylom ic rons are the la rgest particle that transp orts dietar y fat and cholesterol from the small int esti ne to the li ver and per ipher y (Mahan et al ., 2012). Chl ylom ic rons transport dietar y lipids af ter int e sti nal absorption (Nelm s et al ., 2011 ). The live r metab oli z es these ch ylom icro n remnants, but some deli ver cholesterol to the arteri al wall and thus are consi dered athero ge nic. Consum pti on of high - fat meals produ c es more ch ylom icrons an d remnants. 2.8.3 Very Low- Density Lipoprotein s (VLDL) They are s ynthesiz ed by th e liver from ch ylo mi cron remnants and comprise mainl y of tri gl yc erid es (Thomas and Bishop , 20 07). The lar ge buo yant VLD L particle is beli eved to be non -athero genic (M aha n et al. , 2012). Vegetari an diet and low fat diet increase the formation of large VLD L pa rticles. VLD L maintains University of Ghana http://ugspace.ug.edu.gh 21 a suppl y of tri gl yce rides for en er g y produ cti on to bod y t iss ues in the fasti n g state (Thomas and Bishop , 2007 ). 2.8.4 Low - Density Lipoprotein s Cholesterol (LDL- C) LD L-C is the prim ar y ch olesterol car ried in the blood, formed by th e brea kdown of VLD L (M ahan et al . , 2012). As the trigl yce ri des are removed b y bod y cell s, the remaining cholest er ol is concentrated withi n LD L for transf er to the peripher al tissues. About 60% of the tot al circulating cholesterol is con tained withi n the LD L - C (T homas and Bishop , 200 7). L o w - densit y lipoproteins cholesterol has be en linked to atheroscle rosis, cardiovascul ar he art disease (CHD), and stroke (M a han et al . , 2012 ). A decrea s e of 1 mg/d L in LD L - C result s in about a 1- 2% decre ase in the relative risk of CHD. According to the American Heart Asso cia ti on (2012), for persons who are without disease, LD L- C levels ar e classified as opti mal, (  100 mg/d L) nea r opti mal, (  129 m g/d L), borderline risk, (130 to 159 mg/d L), hi gh risk (16 0 to 189 mg/d L) and ver y hi gh risk (  190 mg/d L) . Fact ors that increas e LD L- C include agin g geneti c s diet, obesit y, neph ritic s ynd ro me and some steroid an d anti h ype rtensive dru gs (Mahan et al ., 2012 ). Dietar y fibres esp eciall y solub le fibres such as guar, gum, pe cti n, and oat gum have be en shown to low er choleste rol levels, pri maril y b y low er in g LD L -C and trigl yce ride lev els withou t consi stent eff ect on HDL-C (T aku et al ., 2007 ). Bec ause ve geta rians esp eciall y ve gans ma y have fibre int ak e two to thre e times more than those of non -vegetarians (Sack, 2006 ) fibre int ake m a y contrib ute to vegetarians favourabl e lipid profil e. In a stud y of the metaboli c effect of dietar y University of Ghana http://ugspace.ug.edu.gh 22 li pids invol ved in feedin g a lacto -ovo -ve get arian diet and non- ve geta ria n diet , the findings o f the stud y indi cated that lacto - ovo vegetarian diet result ed in lower tot al and LD L-cholest ero l levels but no chan ge in tot al HD L l evels than th e non - vegetarian diet (Cooper et al., 19 82). Another stud y compar ed plasma lipids of dedicated ve gans with those of lacto ve geta rians; the findings rev ealed a gr eate r than 20% hi gher tot al an d LD L-chol esterol lev el and 7% hi ghe r HD L- cho lesterol ex ist ed in lacto -vegetari ans (Sack , 2006). The stu d y concluded that fatt y dair y product s aff ect LD L- C more than HD L- C. So y protein has been s hown to reduc e LD L- C levels. A meta- anal ysi s of 30 studi es demons trate d a small but significant red ucti on in both tot al and LD L - cholesterol , with the co nsum pti on of 25 g of so y protein dail y (Harla nd and Haffn er, 2008). 2.8.5 High -Density Lipoprotein s Cholesterol (HDL- C) High - densit y lipoprotei ns particles contain mor e proteins than an y of the other lipoproteins (Mahan et al., 2012 ). The main apoli poprotein in HDL- C is the anti inflamm ator y, anti ox idant protein that also helps to remov e chol esterol from the arterial wall to the liver (Barter and R ye, 200 6). HD L - C is associat ed with cholesterol removal. Hi gh concentrati ons ar e ben eficial and inversel y rela ted to Cardiovascular Heart Di sease (CHD). Man y pop ulation studi es have shown that HD L- C is a strong, negati ve independent pr e dictor of CHD incidence and mortali t y in men and women (Riz z o et al., 2010 ). Becaus e of th e inverse relations hip between HD L- C and CHD risk, a high HD L cholest erol leve l (  60 mg/d L) is now consi der ed a negati ve risk factor and low HD L cholest er ol level University of Ghana http://ugspace.ug.edu.gh 23 (  40 mg/d L) is consi de red to be a posi ti ve risk factor fo r CHD and stroke (NCEP, 2002). Major factor s th at incr e ase HD L- C levels ar e ex ogenous estro gen, in tensive ex ercise, and loss of ex cess bod y fat and moderate consum pti on of alcoho l (Mahan et al ., 2012 ). Th e ve geta rian diet , when i t comes to its relations hip with HD L- C, lev el is more th an just eli mi nati ng me at and meat produ cts. Elim inating saturated fats and tr ans fat such as those found in butt ers and ma r garine wil l help raise the HD L-C level. In cludi ng monouns aturat ed and pol yuns aturated fat in yo ur diet on the other hand, will rais e your HD L- C levels (Lee et al., 2000). These good fats are foun d in le gumes, nuts and oi ls such as canola and oli ve oil s. The combi nati on of raw and li ghtl y cooked fruit and ve getables, whole gr ains, fibres and good fat wi ll work to raise HD L - C levels without negat i vel y affecti n g LD L- C (J enkins et al ., 2002 ). It is fo r thi s reaso n that the la y publi c ofte n ref ers HD L-C as ³good´ choOesteroO. +oZeYer the choOesteroO is neither good nor Ead it is the lipoprotein com plex rather than th e chol esterol bein g tr ansported that is associated wit h CHD and stroke. 2.8.6 Total Blood Cholesterol (TC) A tot al cholest erol me as urement captures cholest erol cont ained in a ll lipoprotein fracti ons. 60 - 70% is car ried on LD L, 20 - 30 % on HDL, and 10- 15 % on VLD L (Mahan et al ., 2012 ). Cli nical studi es have consi s tentl y shown that a hi gh serum cholesterol level and spe cificall y hi gh LD L - C is one of the key caus es of CHD, stroke and mortali t y. Pop ulations that consum ed diet high in s aturated fatt y acids (SFAs) had incre ased blood cholesterol levels (Mahan et al ., 2012). Total University of Ghana http://ugspace.ug.edu.gh 24 cholesterol howev er flu ctuates over the course of da ys or weeks; ther efore a diagnosi s of h yper choles terolemia shoul d not be based on a sin gle measu r ement. It is recomm ended that several separ ate lipid measure ment s be made before diagnosi s is confirmed and drug therap y start ed (J BS 2, 2005). Numerous factors affe ct serum cholesterol levels, includin g age, diet high in fat, and geneti cs (M ahan et al . , 2012). Fasti ng tot al cholesterols are classified as norm al (  2 00 mg/d L), bord erline hi gh (200 to 239 mg/d L), and high (  240 m g/d L) (Gr und y et al., 2004). 2.8.7 Total Triglycerid es (TG) The tri gl yc erid e - ri ch lipoproteins include ch ylom icrons, VLD Ls and an y remnants or int ermedia r y products formed in m etabolis m (Mahan et al., 2012 ). Accordin g to th e Nati onal Cholesterol Educ ati on Programm e (2002) , fasti n g trigl yce rides lev els ar e classified as no rmal (  150 mg/d L); bo rderline high (150 - 199 mg/d L); high (200 - 499 mg/d L) and ver y high (  500 m g/d L). There is evidence of a si gnificant and ind ependent associati on betw een serum trigl yce rides conc entrati ons and the incidence of major coronar y ev ents (Assm an et al., 1996; Mahan et al ., 2012). A meta-analys is for controll ing HD L – C suggested th at for ev er y 1 mmol /L rise in serum trigl yce ride con centr ati on, the relative risk of CHD increased b y 14% in men and 37% in women (Hokanson and Austi n, 1996). S tudi es have con cluded that indi viduals on vegeta ri an diet have lowe r lipid blood le vels espe ci all y LD L- C and trigl yc erides as comp ared to indi viduals who consum e meat (Man cil a – Carva ho and Cr ew, 1990; Ke y , 1999). High consum pti on of rapidl y absorbed refined ca rboh ydrates can ex a cerbat e University of Ghana http://ugspace.ug.edu.gh 25 h ype rtri glceida emi a , an d all pati ents with raised trigl yc erides shoul d be encoura ged to choose lo w gl yc aemi c index foods (Kumar et al . , 2012 ). 2.9 Dyslip id aemia This previous l y was kn own as hyp erlipi deami a and ref ers to the prese nce of abnormal blood conc entr ati on of lipid chol esterol and tri gl yc erides (Thom as and Bishop , 2007). T ypicall y, d ysli pidemia is a condit ion in which LD L - C lev els ar e elevated and HD L - C levels ar e lo w (Nelm s et al. , 2011). D ysli pida emi a is usuall y s ympt oml ess an d henc e often rem ains undiagno s ed. Specifi c si gns and s ympt oms usuall y onl y occur if the elev ati on of the lipid lev el is parti cularl y severe. Seve ral forms of hype rlipi daemi a hav e strong geneti c comp onents (Ott estad , 2006 ). Studi es have identified some defects in gen es that pr oduce hepati c lipase, the liver enz yme invol ved in the trigl yce rides removal fro m the bloods tream (Ci eveira, 2004). Lipi d profil e is a blood test done to assess the status of fat metaboli sm in the bod y and is important in the heart diseases (Nivedita et al ., 2012). Alterati ons in the lipid profil e have also been associat ed wit h age (Richte r et al . , 2004). Estrogen is the major pr otecti ve hormone in wo men and that pr otecti on i s alt ered by m enopause. Estro gen favour abl y affe cts the l ipi d profil e . T he incide nce of abnormal lipid levels is higher in men, but aft er menopause thi s becomes more prevalent in women. Dietar y and life-st yle factors ma y in fluenc e the age dependen c y of lipi d profi le (Dholpuria et al ., 2007 ). University of Ghana http://ugspace.ug.edu.gh 26 2.10 Diet and Lifestyle Influ en ces o n Blood Lipid s 2.10.1 Fats and Oils Lev els of cholesterol in blood can be redu ced by subst it uti ng SFA with eit her MUFA or PUFA (Gardn er and Kra emer, 1995; Poppit t et al., 2002). Substi tut ing saturated fat with unsat u rated alt ern ati ves ma y also make lipid lower ing diet more palatabl e and impr ove compl iance. Tropic a l oil s such as palm kern el and coconut oil are relatively hi gh in saturated fats and shoul d be used sparingl y (Dreh er, 1996 ). In vie w of thi s, US dietar y recom mendati ons, suggested th at SFA shoul d be reduced to 7-8%, MUFA shoul d be increas ed to 13 -15% and PUFA raised to 7-10% of dail y ener g y with the tot al fat contribut ing to no t more than 30% of all cal ori es consu med (Kris Etherton , 1999 ; Grund y and Cleaman 1999). 2.10.2 Trans-Fatty Acids (t-FAs) Trans -f att y acids are pro duced b y h yd ro gen ati on of vegetable and ma rine oil s to produce harden ed fats s uch as mar garines, cook ing fats and shortenin gs . The y have sim il ar eff ects as sa turated fats. Thes e fatt y acids shoul d be limi ted, because the y raise LD L choles terol (D ave y et al., 2003 ). Metaboli c studi e s have demons trated that t-F As rend er the plasma lipid profil e even more ather ogeni c than saturated fatt y acid s, by no t onl y elevati n g LD L – C to sim il ar lev els but also decr easin g HD L – C levels (J udd et al ., 1994). 2.10.3 Dietary Cholest erol Cholesterol in the bloo d and tissues is derive d from two sou rces , diet and endogenous s ynthesis (Redd y and Katan, 200 4). The influenc e of dietar y cholesterol on blood cho lesterol is relativel y sma l l because the liver s ynt hesiz es University of Ghana http://ugspace.ug.edu.gh 27 cholesterol , and inc rea sed dietar y int ake ten ds to be offset b y decreas ed endogenous producti on (Hopkins , 1992). Onl y ex treme levels of int ake , for ex ampl e, a typic all y hi gh consum pti on of eggs, shell fish , liver, dair y fat and meat are likel y to hav e a significant elevati n g ef f e ct (Thomas and Bishop , 2007 ). The United States Nati onal Cholesterol Educati on Program m e (2002) cu rrentl y recomm ends an int ak e of less than 200 mg/da y. 2.10.4 Omega-3 (n-3) Fatty Acids Fish oil s rich in n-3 fat t y acids have been sho wn to redu ce both fasti ng and post prandial bl ood trigl ycerides levels (Roche an d Gibne y, 2000; Castro et al., 2005). Effe cti ve amoun ts range betw een the ra peuti c doses of 3 -5 g/ da y in suppl emental form and cardio prote ct ive int ake of 1 g/da y (Kris -Eth erton et al., 2003). The effe ct of fish oil s on blood cholesterol is more equivocal. Some studi es have found that suppl emental doses elev ate LD L cholest erol and reduce HD L chol esterol (Britis h Nutriti on Found ati on , 1999). Som e functi ona l foods enriched with n-3 fatt y acids have been found to increase tot al, LD L an d HD L cholesterol (C astro et al., 2005), wh ere as othe rs appear to have no eff ect (B ritis h Nutriti on Foundati on , 1999). 2.10.5 Carboh yd rate Although carboh yd rate has no dir ect eff ect on blood choleste rol lev e ls, an increas e in the proportion of energ y deriv ed from carboh ydrate is usuall y encoura ged as a me ans of keeping the proportion of satur ated fat lo w (Niv edit a et al ., 2011 ). A high carb oh ydr ate diet app ears t o reduc e HD L – C lev els and increas e the fra cti on of small dense LD L - C, both of which ma y impact ad versel y University of Ghana http://ugspace.ug.edu.gh 28 on vascular disease (Re dd y and Kat an, 2004). Carboh yd rate diets with high - gl yc aemi c index might adversel y impact on gl ucose control, with ass ociated chan ges in plasma lipids (W il let et al ., 2000; J enkins et al ., 2002). High consum pti on of rapidl y absorb ed refin ed carboh ydrat e s can ex ac erbate hype rtri gl yc erid aema . All pati ents with raised tri gl yc erides shoul d be enco ura ged to choose low gl yc aemi c index foo ds (Thomas and Bishop , 200 7 ). 2.10.6 Soluble Fibre Solubl e fibre reduces tot al cholesterol and LD L - C (Brown et al., 1999; Castro et al. , 2005) whereas insol uble fibre does not (Dave y et al ., 2003). Solubl e fibre in particularl y is thought to bind bil e acids in the int esti nes and preve nt re - absorption int o the bod y, consequentl y decr easin g circulatin g cholesterol in the blood (Baz z ono et al., 200 1 ; Fardet , 2010 ). Although an inc reas ed int ake of solub le fibre can be ex pected to have onl y limi ted impact on cholesterol levels, the cardio protecti ve pro perties of foods rich in solub le fibre , pa rticularl y fruits and ve getables , are s ufficient justi ficati on to advocate their inc rease d consum pti on by d ysli pidaemi c pati ents (Bonnie e t al., 2010 ). Oats , a good source of solub le fib re m a y als o be benefi cial in respe c t of blood lipids (Dav e y et al., 2003 ). The inclusi on of oats as part of a diet lo w i n saturated fat and a healt h y lifest yle can hel p reduc e blood cholesterol (J HC I, 2004). Non-so y le gumes are als o a particularl y good so urce of dieta r y fibr e. No n- so y legumes in clude a variet y of beans such as pint o , nav y, kidne y, lima , an d black eye be ans. Studi es hav e shown that non -so y l egum es co nsum pti on ha s been associated wit h a decre as e in tot al cholesterol and LD L- C in cli nical tri als (Kushi University of Ghana http://ugspace.ug.edu.gh 29 et al., 1999; Baz z ano et al., 2001; Anderson et al ., 2002). For in stance, pht ytost erols , a compone nt of plant cell membranes have been sh own to reduce blood cholesterol levels and are present in small to moderate amount s in man y t ypes of non - so y le gume s such as chick peas (Roc hfert and Panoz z o, 2007). 2.10.7 Alcohol Alcohol raises both tot al trigl yce ride and HD L- C levels. The eff ect of alco hol on trigl yce ride levels are cl ose dependent and are great in persons with trigl yc e ride levels ex ceeding 150 m g /d L (Mah an et al., 2012 ). Wine contains reservatr ol, an anti fungal compound in gr ape skins that has been associ ated with 11- 16% increas e in HDL cholest erol (Hans en , 2005). Th e Fr ench ma y ex perienc e lower rates of CVD despit e a high fat diet, mainl y beca use of thei r consum pti on of red Zine ³the )rench parado[´ 6Xn et al . , 2002). There is evid en ce that alcohol consum pti on modul ates incre ase in HD L fracti ons , and sti mul ates revers e transportati on of lipids (Baer et al., 2002; Vander et al., 2001 ). Alcohol consum pti on in ex cess of three drinks per da y is associated with a rise in blood pressure and plasma tri gl yc e ride lev els (Redd y an d Katan, 2004). 2.10.8 Plant Sterols an d Stanols P lants do not contain cholesterol but the y do have sim il ar sterols comp onents. There are ov er 60 diff e rent t yp es of plant ster ols but the most common is a sit osterol. Humans do not synthesis these sterols as the y do for chol ester ol, nor are the y well absorbed (Nelm s et al., 2011). A number of studi es have demonst rated that when these plant sterols ar e es terified to comm on fatt y acids (Stanol ester or sterol ester) , the y can assi st in lowerin g serum cholester ol and University of Ghana http://ugspace.ug.edu.gh 30 LD L- C levels (Pinedo e t al., 2007; Van -Dam et al., 200 8). Consuming 2 g/da y of plant sterols or st ano ls has been shown to reduce LD L – C b y abou t 10% withi n 2 – 3 weeks (Katan and Grund y, 2003 ), alt hough there ar e consi d erable variati ons betwe en indi viduals. A number of products such as fat spreads, yo ghurt and milk have be en forti fied with plant ste rols and stanols. 2.10.9 Nuts C onsum pti on of 50 -500 g of nuts fiv e or more ti mes per week as part of a healt h y heart diet ma y signifi ca ntl y decr ease tot al chole sterol and LD L choleste rol s in dysli pidemic indi viduals (Mukuddem – Peter son et al., 2005). Walnut s, macadami a, alm onds and cashe w nuts have choles terol – lowerin g prope rties, and a beneficial ef fe ct on the lipoproteins profil e (Abbe y et al ., 1994). In a con trolled randomi s ed crossove r stud y b y Ande rson et al . (2002 ) in 18 normo - cholesterola emi c men, result s of the stud y indi cated that diets rich in walnut s decre ased tot al cholest erols (0.58 mmol/ L;12 .4%), LD L cholester ol (0.47 mmol/ L; 16.3 % ) and tr igl yce rides (0.11mm ol/ L; 8.3%). Whether nuts lower blood lipi ds independent of other fa ctors is yet to be dete rmined. Althou gh HD L - C was lowered by 4.9%, the LD L - C to HDL -C rati o was lowered si gnif icantl y by 12.0%. 2.10.10 Soy Protein Vegetable proteins ar e u seful for the treatm ent of hype rlipi deami a . A so y- bean protein diet lowered the serum choleste rol to a greater de gree than a low - cholesterol, low - satur ate d fat diet containin g an equivalent amount of prot eins of anim al origin (Goldber g et al. , 1994 ). Subst anti al decr eases wer e obser ved in University of Ghana http://ugspace.ug.edu.gh 31 both serum cholesterol (21% afte r 3 weeks) and trigl yc erides , in pati ent s with t ype IIa and IIb h yperlipoproteinaemi a, including some with fami li al hype rcholeste rolemi a (Sacks et al ., 2006). Onl y ver y la r ge int ake of so y protein at Oeast haOI oI a person’s daiOy protein inta ke) ma y de cre ase LD L – C by few percent when it replac es anim al protein (Ta ku et al., 2007). The mechanism s of the hypocholeste romic effect of so y prot ein are unknown. It has been su ggested that the beneficial eff ec t of so y protein ma y be as a result of the ami no -acid patt ern and pepti de stru ct ure of the so y prot ein (M cVei gh et al., 2006). 2.11 Physical Activity Regula r ph ysical acti vit y app ears to have ben eficial effe cts on lipoproteins metaboli sm which are not due solel y to an y asso ciated wei ght lo ss (Tho mas and Bishop , 2007 ). Aerobic acti vit y of at least 8 minutes a week has been sh own to result in an inc reas e in HDL – C and decr eas e in fasti n g tri gl yc eride levels (Hardman, 1999 ; Altens et al. , 2006). In vegeta r ians, ph ysi cal ex er cise reduced LD L- cholesterol apo B levels, and incre ased significantl y H D L - ch olesterol levels (Delgado et al ., 2000). To modi f y lipid protein metaboli sm , regul ar and frequent ex ercis e is reco mm ended which can be of moderate int ensit y in ener g y ex pendit ures (Harland, 2008 ). University of Ghana http://ugspace.ug.edu.gh 32 CHAPTER THREE 3.0 MATERIALS AND METHODS 3.1 Introd u ction This chapter gives an account of the resea rch design, the stud y sit es, target population, sampl es and sampl ing technique tha t wer e empl o yed in thi s stud y. Procedures for data coll ecti on, anal yses of th e data and ethi c al iss ues are also described in this chapte r. 3.2 Study Design A case – control design was used for the stud y. A case control was adopted in the stud y becaus e the natur e of th e resea rch topi c requires comparison of subjects who have a particular condit ion (cases) with subj ects who do not have that condit ion, but otherwise sim il ar to the cases (cont rols). 3.3 Study Sites The stud y was ca rried out at the premi ses of Jamal Ruhani Satsang (a vegetarian reli gious bod y) at Weij a, a suburb of Accr a. Controls were recruited fro m the Mart yr s of Uganda Cath oli c Church , Mamprobi. 3.4 Study Particip an ts The stud y popul ati on co mprised ve geta rians (vegans and lacto ve geta ria ns and non - ve get arians. The vegetarians ( c ases) were all members of Jamal Ruhani Satsang. Th e non - ve getarians (controls) wer e parishners of the Mar t yrs of University of Ghana http://ugspace.ug.edu.gh 33 Uganda Cathol ic Church and indi viduals living around the church premi se s. The subj ects were m ade up of males and fem ales betw een the ages of 25 - 75 years. 3.5 Inclu sion and Exclusion Criteria 3.5 .1 Inclu sion Criteria : Subjects who have be en v e ga ns and l acto - vegetarians for mor e than two yea rs wer e incl uded in the stud y. Th e control group was mad e up of apparentl y healt h y non - vegetarians. The cont rol grou p was matched b y age and gend er to the cases. 3.5 .2 Exclu sion Criteria : In divi duals who have been ve gans and lacto - vegetarians fo r less than two ye ars were ex cluded from the stud y. Subjec ts who were on cholesterol low ering me dicati on were also ex cluded , to minim iz e the int roducti on of erro rs in the stud y. Thes e dru gs reduce cholesterol bio s ynthesis in the liver b y inhi bit ing the enz ym e HmG Co - A redu ctase. Also , all su bjects outsi de the age ran ge of 25 -75 ye ars wer e ex cluded from the stud y. 3.6 Sample Size Deter min ation A sampl e siz e of 50 was determi ned based on th e population of the Vege tarian s Association of Gh ana, Accra (about 300 member s). An absol ute pre cisi on of 5% and a confiden ce int erv al of 95%, in accord anc e wit h the strategic fun cti on of Epi In fo Statist ical Sof tware were used. Allowan ce was given fo r a non -partic ipation rate of 10% and non - resp onse rate of 20%. University of Ghana http://ugspace.ug.edu.gh 34 N= ( z ) 2 (P) (1-p) E 2 = 1.96 2 (0.05 x 0.95) 0.06 = 50 Where N is esti mated sa mpl e siz e E is desired mar gin of err or Z is the critical Z score on the desired lev el of confiden ce (95 %) P is the prevalence of veget arians in Ghan a. A sa mpl e of 50 for cases and 50 for controls (100) was obtained. 3.7 Resear ch Method The res ear ch methods th at wer e empl o yed in thi s stud y included int erview s using structured questi onnair es, anthropometric m easurem ents and biochemi cal measurements. 3.8 Sampli n g Techniqu e The sampl ing met hods empl o yed for thi s stud y were purposiv e sampl ing and convenienc e sampl ing. Purposi ve sampl ing was used to select the ve ge tarians. Convenience s ampl ing was used to select the non ve getarians. Pur posi ve sampl ing is a non proba bil it y sampl in g method by which the resea rch er selects the sampl es for the stud y based on his or her own judgment. Purposi ve sampl ing is normall y used fo r cas e control studi es when the sampl e being investi gated is quit e small , especiall y when compar ed with the probabil it y sampl in g tech niques such as simpl e and rando m sampl ings . University of Ghana http://ugspace.ug.edu.gh 35 3.9 Pre Testin g of Questionn aire In order to fami li aris e wit h the resear ch environ ment and ensur e accu rac y in the acquisi ti on of data, the questi onnaires were pr e -te sted on one of the m eeti ng da ys of the Jamal Ruhani Satsang to eli mi nate issues of ambi guit ies. 3.10 Data Collection S ubjects who gav e conse nt and met the incl usion criteria were rec ruited int o the stud y. Data was coll ect e d between Mar ch , 2013 and April , 2013. Anthrop ometric measurements and blood sampl es were coll ected on a single visi t at the various centres. Pa rticipants wer e int erview ed in a priva te area b y the rese ar che r using structured questi onnair e to assess demographic factors, medic al hist ory an d dietar y patt e rns of the participants. Inte rviews were admi nist ered in the Engli sh langu a ge and a n y lo cal Ghanaian l an gua ge whic h was spoken and und ers tood by the participants. 3.11 Anthrop ome tric Measu re men ts Bod y wei ght and heigh t were measured to the nearest 0.1 kg and 0. 5 cm , respecti vel y, with the su bjects standing in upri gh t posi ti on s and without an y foot wear. Hei ght was me as ured with a Sec a Stadio meter ( Model, SEC -213) . Bod y weight, visce ral fat and percent a ge bod y fat of the participants wer e measured with an Omron Bioi mpe dance anal yz er (Omron Healt hca re, Incorpo rated , model HBF-514C ) the pa rticipa nts being in light clot hin g and without shoes . The bod y mass index (BM I) was comput ed as the rati o of weight (k g) divi ded by height in meters squar ed (m 2 ) and thi s was used to classif y ob esit y based on the World Healt h 2rgani]ation’s W HO, 1998) criteria. University of Ghana http://ugspace.ug.edu.gh 36 3.12 Blood Pressu re Measur e men t Blood pressur e (BP ) was measur ed with an Omron Blood Pressur e Moni tor (model BP 785 ) followin g a 5 – minute se ated res t. In a relax ed posi ti on, t he cuf f of the blo od pressur e mo nit or was pla ced around the upper arm 1 - 2 cm abo ve the elbow. Two resti ng BP measur ements were tak en (spac ed 3 minutes apart) for each subj ect and the av e ra ge of the two BP readings were recorded and used in the statist ical anal ys es. 3.13.0 Dietary Assess men t 3.13.1 24 -Hour Recall A two da y 24 - hour recall which includ ed one week end was used to assess nutrient int ake of the participants. Participants were int ervi ewed to des cr ibe all food and beve ra ges cons umed over a 24 -hour pe rio d. 3.13.2 Food Frequen cy Question n aires A modi fied food frequ e nc y questi onnaire (Asa r e, J .2011 ) was admi nist ered to assess habit ual diet int ake of the stud y parti cipants. The food fre q uenc y questi onnaire included food items or specific fo od groups that were con sumed over a refe renc e perio d. The participants foo d consum pti on patt ern s were assessed b y mul ti ple res ponse s in which respondents were ask ed to esti mate how often a particula r food or bever a ge was consum ed. Catego ries ran gin g from µneYer’ µZeeNOy’ µmonthOy’ Zere incOXded in the TXestionnaire and the participants chos e one of the se opt ions . The die tar y information was co ll ected and anal yz ed using ESHA FPRO nutrient anal ysi s software. . University of Ghana http://ugspace.ug.edu.gh 37 3.14 Blood Sample Collectio n and Transp ortation After an overni ght fast (8 – 12hrs), 3 ml of ven ous blood sampl es were drawn int o serum separator tubes (from the antecubit al space of the forea rm ) by a quali fied phlebotomi st. Fasti n g blood sampl es of at least 12 hou rs were used fo r a full lipids profil e (J BS 2 , 2005). Blood sampl es wer e coll ected betwe en the hours of 6 am and 9 am. The tubes containing th e blood sampl es were p l aced on dr y ice and quickl y trans ported to the labor ator y where the y wer e centrifu ged at 3000 rpm for 5 minutes. The remaining se rum was separat ed in eppendor f tubes and stored at - 20 ° C unti l read y for an al yses. Fo r HD L anal yses, a pre cipi tant was used to separate the HD L in sampl e int o a super natant. The supern atan t was then ali quoted and stored unti l use. 3.15 Biochemical Anal yses All blood sampl es were anal ysed at the Chemi cal Pathol og y Unit of th e School of Alli ed Healt h Scienc es, Korle - Bu, Accra. 3.16 Lipid Profil e 3.16.1 Cholesterol -Test prin cip le C holesterol was deter mi ned after enz ym ati c ox idation in the presence of cholesterol ox idase int o cholestenone and h ydr ogen perox ide. The h ydrogen perox ide produced react ed unde r the cat al yti c acti on of perox idi se (POD) with phenol and 4-ami nophe naz one to form a pink colour ed produ ct quinoneimi ne which was measu red at 5 00 nm. The int ensit y of th e colour produc ed was directl y proportional to the chole sterol concentr ati on. University of Ghana http://ugspace.ug.edu.gh 38 Chol. esterase Cholesterol ester + H 2 O Cholesterol + fatt y acid (Eq . 1) Chol. Ox idase Cholesterol + ½ O 2 + H 2 O Cholestenone + H 2 O 2 (Eq. 2) POD 2H 2 O 2 + 4 -ami nophenaz one + Phenol Quinoneimi ne + 4H 2 O (Eq.3) 3.16.2 Triglycerid e -Test prin c ip le Trigl yc eride + H 2 O Lipase Gl yce rol + fatt y acid (Eq. 1) Gl yc erol + ATP Gl yc erol Kinase Gl yc erol -3 - P + ADP (Eq. 2) Gl yc erol -3 -P +O 2 G-3 - Ox idase Dih ydrox ya cet one –P + H 2 O 2 (Eq. 3) 2 H 2 O 2 + 4 -Aminoantip yrine + 4- chorophenol Per ox idase Quinoneim ine + 4 H 2 O 3.16.3 HDL- Cholesterol Ver y low densit y lipopro teins (VLD L) and low densit y lipoproteins (LD L) in the sampl e were pr ecipi tat ed with phosphot ungstate and ma gnesiu m ions. The supernatant cont ained hi gh densit y lipoprotei ns (HD L). Th e HD L Chol esterol was then sp ectrophome tricall y m easur ed b y means of a coupl ed reacti on described below at 500 n m. University of Ghana http://ugspace.ug.edu.gh 39 Chol. esterase Cholesterol ester + H 2 O Cholesterol + fatt y acid (Eq . 1) Cholesterol + ½ O 2 + H 2 O Chol. Ox idase Cholestenone + H 2 O 2 (Eq. 2) POD 2H 2 O 2 + 4 -ami nophenaz one + Phenol Quinoneimi ne + 4H 2 O (Eq. 1) 3.16.4 LDL-Cholester ol LD L- Cholesterol was es ti mated based on the Frie dewald equ ati on: LD L= Total Cholesterol - [(Trigl yce rides / 2.2 ) - HD L Choleste rol) ] (Fried ewald et al . , 1972 ) 3.16.5 VLDL V LD L was calculated as the concentr ati on of Tri gl yc erides/2.2 (Fried ewald et al . , 1972 ) 3.16.6 Assay Proced u r e All sampl es were all owe d to thaw at room tempe rature. Sampl es were run on an A25 Bios ystems autoan a l yz er; (Spain, Madrid). Quali t y control sampl es obtained from Bios ystems wer e ru n to ensure accu ra c y of result s. Test sampl es were run in dupli cates. University of Ghana http://ugspace.ug.edu.gh 40 3.17 Data Analyses Data was enter ed int o Stati sti cal Packa ge fo r Social Sciences (SP P S version 20.0) for all an al ys e s . Two- wa y anal ysis of varianc e (ANOVA) was used to test for the differen ces in conti nuous variables amon g th e two groups. Chi square t est was used to determi ne th e associati on betwe en cate goric al vari ab les. Lo gist ic regressi on was used to determi ne the stren gt h of the relations hip between dependent va riables and independent va riables. Ind epend ent t -test was used to compare m ean lev els of lipids amo ng ve get arians and non -ve getarians . Al l tests were comput ed as tw o -tail and p -valu es les s than 0.05 wer e con sidered significant . Qu anti tative data was summ ariz ed as proportions, perc enta ges, means and standa rd devi ati on. The term qu anti tat ive data is used to des cribe a set of information that can be counted or ex pressed numericall y. Summ ar y of result s were displ a ye d in graphs , tables and nar rati ve fo r ms. 3.18 Ethical Issues The stud y was given ap proval by the Ethi cs and Protocol Review Commit tee of the School of Alli ed He alt h Sciences ( SAHS-ET./10362833/AA/8A/2012-2013 Append ix 1 ). Introdu ct or y lette rs were s ent to the Mart yrs of Ugand a Cathol ic Church, Mamprobi and J amal Ruhani Satsang, W eij a , to seek permiss ion prior to the comm encem e nt of data col lecti on. Participa nts recruited int o the stu d y were provided with information about the stud y and s igned the consent form. Blood sampl es were coll ected by a quali fi ed phlebotomi st . All data coll ected was kept confidenti al and anon ymi t y wa s ensur ed. Inf ormation gat her ed fro m the participants was kept in a file in a locked cabi net and later trans fer red int o a password prote cted comp uter. University of Ghana http://ugspace.ug.edu.gh 41 CHAPTER FOUR RESULTS 4.0 Introd u ction This stud y sou ght to compare diet and serum lipids in vegeta rians and non - vegetarians. The result s of the stud y ar e pr esente d below in accord ance wit h the objecti ves of the stud y in the form of tables and ch arts. 4.1 Socio-demog rap h ic Characte ristics of Particip an ts The stud y s ampl ed 113 participants , out of which 59 (52.2%) wer e non - veget arians and 54 (47.8 %) were ve get arian s. Th e mean age of the partic ipants was 54.06 ±1 2.5 ye ars. The mean age of veget arians was 54.24 ± 13.86 ye ars and non -ve geta rians wer e 53.9 ± 11.2 ye ars, (Ta ble 4.1). The stud y parti cipants were made up of more males (69.5% ) than fem ale s (30.5%) in the non -ve getarian group. In the vegetarian group, majorit y of th e participants (68.5% ) were males , while the rest (31.5%) were females. In both ve ge tarians and non -ve getaria ns the rati o of males to females was 2:1. There was no significant diff eren ce in the proportion of males an d femal es in both grou ps ȡ 0.006). M ajorit y of the vegetarians and non -ve getarians were mar ried (4 7.5% and 53. 7%, respe cti vel y). A high er proportion of the vegetarians (27.8% ) compa red to non -ve ge tarians (8.5%) had terti ar y edu cati on. Almos t all the vegetarians (93.2% ) an d non - vegetarians (90.7 %) wer e Christ ians. More than half of both the vegetari ans and non - ve geta rians were empl o yed (57.4 % and 69 .5% and resp ecti vel y). About a University of Ghana http://ugspace.ug.edu.gh 42 quarter (27.8% ) of the vegetarians were reti red personnel, while 15.3% of the non -ve geta rians were un empl o yed (Table 4.1 ). Table 4.1 Socio-demog rap h ic Characteristi cs of Vegetarian s an d Non-vegeta rian s V (n= 54) NV(n= 59) Gender Frequen cy % freq u en cy % Male 37 68.5 41 69 .5 Female 17 31.5 18 30 .5 Marital statu s S ingle 14 25.9 17 28.8 Married 29 53.7 28 47.5 Divorced 6 11.1 5 8.5 Widowed 5 9.3 6 10.2 Separated 0 0 3 5.1 Education al level No formal edu cati on 4 7 .4 7 11.9 Basic educati on 17 31.5 29 49.2 SHS 18 33.3 18 30.5 Tertiar y 15 27.8 5 8.5 Religion C hrist ian 49 90.7 55 93.2 Musl im 2 3.7 4 6.8 Buddhis t 2 3.7 0 0 Hindu 1 1.9 0 0 Employ men t sta tus Empl o yed 31 57.4 41 69.5 Unempl o ye d 4 7.4 9 15.3 Reti red 15 27.8 7 11.9 Student 4 7.4 2 3.4 Vegeta rian s (V) Non- vegeta rian s (NV) University of Ghana http://ugspace.ug.edu.gh 43 4.2 Vegeta rian ism 4.2.1 Length of vegetarian Status Approx im atel y tw ent y s even per cent of the part icipants (27.8%) report e d that the y had be en ve getari ans betwe en 11 -20 yea rs. Twent y two per cent of the participants had be en ve get arians betw een 21 -30 ye a rs and 18.5% betw ee n 31 -40 ye a rs. Fi fteen pe rcent als o reported that the y had been ve get arian s for mor e than 40 years (Fi gure 4.1 ) Figure 4.1 Length of years of vegetarian is m. The high est numb er of years was fou nd to be 11-20 years and the low est was less than 40 years. 4.2.2 Types and Reason s for Beco min g a Vegetarian Eight y-two per cent (82% ) were lacto -v e geta rians while 18% were ve gans (Figu re 4.2). More than half (53.7%) of the vegetari ans repo rted that th e y became vegetarians fo r reli gious purposes; 27.8% reporte d that the y did so to protect the environment, while 18.5% stated that their reaso n for becomi n g ve geta ria n was to promot e healt h (Fi gur e 4.3). 0 5 1 0 1 5 2 0 2 5 3 0 2 -1 0 1 1- 2 0 2 1- 3 0 3 1- 4 0 > 40 P ercentage Years University of Ghana http://ugspace.ug.edu.gh 44 Figure 4.2 Types of veg etarian. Figure 4.3 Reason s for beco min g a vegeta rian. 4.3 Dietary and Meal Pattern More than half (50.8 %) of the non -v e geta rians st ated that the y ate thr ee meals a day while 51.9% of the vegetarians repo rted eati ng twic e dail y. Majorit y of the non -ve geta rians (61%) and vegetarians (75.9% ) reported that the y ate br eakfast dail y. More th an half of the non -ve geta rian s (54.2%) and 48.1% of the 0 1 0 2 0 3 0 4 0 5 0 6 0 T o su pp o rt p ers o nal hea lth R elig iou s T o pro tect the en vi ro n men t 1 8 . 5 53 .7 27 .8 P ercentage Reaso ns Vegans 18 % Lac to - vegetar ians 82 % University of Ghana http://ugspace.ug.edu.gh 45 vegetarians reported tha t the y ate sna cks. Soft drinks were the main snack consum ed b y non -ve ge tarians (25.4% ) while m ost of the vegeta rians (33.3%) snacked on fruits and ve getables (Tabl e 4.2) Table 4.2 Dietary and Meal Pattern s of Particip an ts Pattern s V n =54 NV n=59 Numbe r of main meals Frequen cy % Frequen cy % One 1 1 .9 1 1.7 Two 28 51.9 28 47.5 Three 25 46.3 30 50.8 Skip break f ast Yes 13 24.1 23 39.0 No 41 75.9 36 61.0 Snacks in betw een meal s Yes 26 48.1 32 54.2 No 28 51.9 27 45.8 Types of snack s Fruits and vegetables 18 33.3 10 16.9 Soft Drinks 4 7.4 15 25.4 Pastries 5 9.3 7 11.9 Frequen cy of fru its in tak e Dail y 41 75.9 27 45.8 Weekl y 6 11.1 14 23.7 Mont hl y 2 3 .7 3 5.1 Occasionall y 4 7.4 9 15.3 Never 1 1.9 6 10.2 Vegeta rian s (V) Non- vegeta rian s (NV) University of Ghana http://ugspace.ug.edu.gh 46 4.4 Health and Medical Condition of Vegetarian s and Non- Vegetarian s About 44% of the non -vegetarians and 29.6% of the vegetarians repo r ted that the y were h yp ertensive (Fi gure 4.4.) Twent y - four per cent of the vegetarians reported that th e y wer e on herb al medicati o ns , while 20.4% of th e non - vegetarians reported so. Some of the reported herbal medicati ons included Moring a oli efera , µagEeYe’ herEs and µ.ingdom herEs’. )igXre . Figure 4.4 History of med ication use 4.5 Life Style Behaviou rs The findings of the stud y showed that smok ing was uncomm on in both groups. Onl y 1.7% and 1.9 % of non - ve geta rians and ve getarians reported th at the y were current smok e rs and th e frequenc y of smok in g was once a week. A few (1. 9%) of the vegetari ans consum e d alcohol while 66.1% of non -ve get arians reporte d the y consum ed alcohol. Th e most frequentl y con sumed alcohol for the non - vegetarians was beer (4 7.5%) out of which 28.8% consum ed it occasionall y. Most of the non -ve getari ans (37.3%) co nsum e a bott le of beer or a tot of whisk y weekl y (T able 4.3) 0 1 0 2 0 3 0 4 0 5 0 B p Med icatio n Her b al Medi ca tio n 4 4 . 1 20 .4 29 .6 24 .1 P ercentage Histo ry of Medica t io n No n veg etar ians Veg etar ian University of Ghana http://ugspace.ug.edu.gh 47 Table 4.3 Life Style Behaviou rs of Particip an ts V(N= 54) N=54 NV ( N=59) N=59 Frequen cy % Frequen cy % Curren t smok e rs 1 1 .9 1 1. 7 Alcohol drin k ers 1 1.9 39 66.1 Type of alcohol W ine onl y 0 0.0 4 6.8 Bee r onl y 1 1.9 28 47.5 Hard liquor 0 0.0 5 7.5 wine, beer 0 0.0 1 1.7 Frequen cy in take Dail y 0 0.0 7 11.9 Weekl y 1 1.9 7 1 1.9 Mont hl y 0 0.0 5 8.5 Occasionall y 0 0.0 17 28.8 Quantity of intake half medium glass 1 1. 9 9 15.3 1 mini Guinness or beer 0 0.0 22 37.3 1 tot of hard liquor or whisk y 0 0.0 5 8.5 Others 0 0.0 2 3.4 Vegeta rian s (V) Non- vegeta rian s (NV) 4.6 Comparison of Anthropome tric Variab les of Vegeta rian s and Non- Vegeta rian s There wer e no signifi ca nt differ ences in weight, BM I, viscer al fat and s ys tol ic blood pressure between ve getari ans and non - vegetarians (p>0.05 ). However, there was a si gnific ant differ ence in bod y fat ( p=0.040) and diastol ic blood pressure ( p=0.011) betwe en the two groups (T able s 4.4 and 4.5). University of Ghana http://ugspace.ug.edu.gh 48 Table 4.4 Comparison of Anthropome tric and Blood Pressu re Measure men t betw een Vegeta rian s (V) and Non-Vegeta rian s (NV) Anthrop ome tric variab les Groups N Mean SD P-valu e 95% C.I. Weight V 54 70.38 12.85 NV 59 74.29 16.18 0.160 - 1.57 9.39 BMI V 54 25.54 4.56 NV 58 27.46 5.70 0.1 52 - 0.02 3.87 Visceral fat V 54 8.70 4.42 NV 59 8.95 3.41 0.740 - 1.21 1.71 Body fat V 54 25.63 11.60 NV 59 29.90 10.19 0.040* 0.20 8.32 Systolic BP V 54 140.00 24.52 NV 59 132.02 26.52 0.100 - 17.531 1.57 Diastolic BP V 54 85.94 13.57 NV 59 79.27 13.97 0.011* - 11.816 - 1.53 *Signif icant at 5% Table 4.5 Classi f ication of Risk of High Blood Pressu r e of vegeta rian s and Non- vegetarian s V NV N (%) N (%) Z -valu e P-valu e Systolic BP mmHg Optim al <120 32 (54.2) 21 (35.6) - 1.327 0.184 Normal <130 11 (18.6) 12 (20.3) 0.102 0.918 High No rmal <130 - 139 4 (6.8) 6 (10.2) 0.185 0.852 High Grade 1 140 - 159 8 (13.6) 7 (11.9) - 0.098 0.947 High Grade 2 160 - 179 0 (0.0) 5 (8.5) 4.234 0.001* High Grade 3 >180 4 (6.8) 8 (13.6) 0.350 0.726 Diastolic mmHg Optim al Bp <80 15 (27.8) 33 (55.9) 1.795 0.073 Normal Bp <85 34 (63.0) 20 (33.9) - 2.067 0.038 High No rmal 85 - 89 5 (9.3) 6 (10.2) 0.063 0.950 High Grade 1 90 - 99 14 (25.9) 16 (27.1) 0.074 0.948 High Grade2 100 - 109 14 (25.9) 18 (30.5) 0.868 0.775 High Grade 3 >110 13 (24.1) 11 (18.6) - 0.326 0.744 *Signif icant at 5% Referen ce : C lassificati on of blood pressure lev els, Britis h Hyp ertension Societ y Guideli nes, Wil li am et al ., 2004. University of Ghana http://ugspace.ug.edu.gh 49 4.7 Lipid Profil e of Vegetarian s and Non-v egetaria n s There were no si gnific a nt differen ces in the me an levels of tri gl yc erid e s, tot al cholesterol, and LD L and VLD L conc entrati ons between the two groups. Howeve r, ther e was a signi ficant dif fer enc e betw een the mean HD L concentr ati ons of vegeta rians and non - veget aria ns , ( p = 0.012 ) (Tables 4.6 and 4.7). Table 4.6 Comparison of Lipid Profil e betw een Veget arian s (V) and Non-Vegeta rian s (NV) Lipid paramete rs Groups N Mean S.D. P-valu e 95% C.I. TG V 54 1.29 0.52 NV 59 1.13 0.52 0.119 - 0.35 0.04 TC V 54 5.54 1.17 NV 59 5.70 1.20 0.479 - 0.28 0.60 LDL V 54 3.45 1.15 NV 59 3.31 1.24 0.524 - 0.59 0.65 HDL V 54 1.55 0.48 NV 59 1.92 0.96 0.012* 0.09 0.67 VLD L V 54 0.59 0.24 NV 59 0.51 0.24 0.116 - 0.16 0.01 *Signif icant at 5% University of Ghana http://ugspace.ug.edu.gh 50 Table 4.7 Classif ication of Lipid Para me ters of Vegetarian s (V) and Non-v egeta rian s (NV) V NV (N=54) (N=59) P-valu e Total Cholesterol (mmo l/L) Optim al Lev el <5.2 19 (35.2) 22 (37.3) 0.889 Borde rline 5.2 - 6.2 20 (37.0) 20 (33.9) 0.834 High Risk >6.2 15 (27.8) 17 (28.8) 0.950 HDL (mmol/L) Optim al Lev el >/=1.6 15 (27.8) 33 (55.9) 0.071 Borde rline 1.03 - 1.5 34 (63.0) 20 (33.9) 0.039* High Risk<1.03 5 (9.3) 6 (10.2) 0.960 LDL mmol/L Optim al Lev el l<2.6 14 (25.9) 16 (27.1) 0.941 Near optim um 2.6 - 3.3 14 (25.9) 18 (30.5) 0.775 Borde rline 3.4 - 4.1 13 (24.1) 11 (18.6) 0.744 High Risk 4.1 - 4.9 9 (16.7) 6 (10.2) 0.735 Ver y Hi gh Risk >/5.0 4 (7.4) 8 (13.6) 0.346 Triglycerid es (mmol/L) Optim al Lev el <1.7 43 (79.6) 53 (89.8) 0.751 Borde rline 1.7 - 2.2 10 (18.5) 3 (5.1) 0.161 High Risk 2.3 - 5.6 1 (1.9) 3 (5.1) 0.891 Ver y Hi gh Risk 0 (0.0) 0 (0.0) NA NA = Not Applicab le *Signif icant at 5% Referen ce : Europe an societ y guidelines for the mana gement of dysli pid aemi a, Reiner et al., 2011 4.8 Daily Nutrient Intake of Vegetarian s and Non-Vegeta rian s No signifi cant diff ere nces were found between me an lev els of ener g y , carboh ydr ate, tot al fat, cholesterol, satur ated fat, mon o unsaturated fat and dietar y fibre betw een ve geta rian s and non -ve getarians . However, si gnific ant diff e rences were found in mean lev els of protein ( p =0.001) and pol yuns aturated fat int ake ( p =0.001) (t able 4.8). Wit h rega rds to micron utrients there were no si gnific ant differen ce betw een the mean levels of vit ami n C, vit ami n E , iron, and calcium. Mean levels of folate ( p =0.002) and pot assi um ( p=0.001) betw een the tw o were significantl y diff erent as indi c ated in Table 4.9. University of Ghana http://ugspace.ug.edu.gh 51 Table 4.8 Co mparison of Macro n u trients betw een Vegetarian s (V) and Non-Vegeta rian s (NV) Groups N Mean S.D. P-valu e 95% C.I. Energy (Kcal) V 54 1414 568 NV 59 1619 760 0.111 - 47.587 456.85 Total Protein V 54 37.2 12.5 (g) NV 59 59.4 31.3 0.001* 13.091 31.16 Total carb oh yd rate V 54 214.8 92.9 (g) NV 59 259.0 336.8 0.353 - 49.69 138.21 Total fat (g) V 54 53.4 33.7 NV 59 69.0 141.3 0.428 - 23.41 54.78 Cholesterol V 54 4.7 156 (mg) NV 59 85 164 0.496 - 39.24 80.48 Saturated fat V 54 7.5 15.4 (g) NV 59 4.7 5.9 0.190 - 7.14 1.43 MUFA (g) V 54 8.2 9.8 NV 59 6.1 11.2 0.300 - 6.03 1.88 PUFA (g) V 54 9.7 8.7 NV 59 2.8 4.1 0.001* - 9.40 - 4.38 Dietary fib re V 54 17.1 12.12 (g) NV 59 21.0 28.3 0.350 - 4.34 12.16 *Signif icant at 5% University of Ghana http://ugspace.ug.edu.gh 52 Table 4.9 Co mparison of Micron u trients betw een Veget arian s (V) and Non-Vegeta rian s (NV) Groups N Mean S.D. P-valu e 95% C.I. Folat e (µg) V 54 88 64 NV 5 9 51 58 0.002* - 60.76 - 14.65 Vitamin C V 54 77.29 88.14 (mg) NV 59 79.79 89.72 0.882 - 30.70 35.697 Vitamin E V 54 3.87 4.79 (mg) NV 59 2.56 6.80 0.243 - 3.52 0.90 Iron (mg) V 54 20.8 49.8 NV 59 26.9 62.5 0.570 - 15.09 27.27 Calciu m V 54 468 250 (mg) NV 59 748 1858 0.274 - 225.22 785.68 Potassi u m V 54 835 785 (mg) NV 59 686 670 0.001* 185.22 374.68 Sodium V 54 516 434 (mg) NV 59 665 646 0.159 - 58.99 355.75 *Signif icant at 5% 4.8 Recommen d ed Nutrien ts Intak e in Vegetarian s and Non- Vegetarian s Protein int ake of ma jorit y of the vegeta rians (77.8% ) was bel ow the recomm ended levels wh il e 22.2% of non - ve ge tarians had int ak es abo ve the recomm ended dail y int a ke. Majorit y of the vegetarians had lower int a kes of vit ami n B 1 2 (85.2% ) a n d B 6 (83.3%) than the recomm ended nutri ent int ake. (Tables 4.10 and 4.11 ) University of Ghana http://ugspace.ug.edu.gh 53 Table 4.10 Comparison of Reco mmen d ed Macro Nutrients Intake in Vegetarian s (V) and Non- vegeta rian s (NV) V NV (n=54) (n=59) P-valu e % % Energy < RDI 37 (68.5) 38 (64.4) 0.707 > RD I 17 (31.5) 21 (35.6) 0.790 Protein < RDI 42 (77.8) 23 (39.0) 0.002* > RD I 12 (22.2) 36 (61.0) 0.019* Carbohyd rates < RDI 36 (66.7) 38 (64.4) 0.835 > RD I 18 (33.3) 21 (35.6) 0.881 Total Fat < RDI 16 (29.6) 23 (39.0) 0.545 > RD I 38 (70.4) 36 (71.0) 0.955 Cholesterol RD I 20 (37.0) 13 (32.0) 0.768 Saturated Fat < RDI 47 (87.0) 56 (94.9) 0.157 > RD I 7 (13.0) 3 (5.11) 0.710 Mono saturated Fat < RDI 37 (68.5) 35 (59.3) 0.416 > RD I 17 (31.5) 24 (40.7) 0.547 Poly saturat ed Fat < RDI 14 (25.9) 27 (45.8) 0.215 > RD I 40 (74.1) 32 (54.2) 0.078 Dietary Fibre < RDI 48 (88.9) 45 (76.3) 0.107 > RD I 6 (11.1) 14 (23.4) 0.526 *Signif icant at 5% University of Ghana http://ugspace.ug.edu.gh 54 Table 4.11 Comparison s of Recommen d ed Micron u trie n ts Intake in Vegeta rian s and Non-vegetarian s V NV (n=54) (n=59) P-valu e % % Vit B 6 RD I 8 (14.8) 58 (98.3) *** Vit B 12 RD I 9 (16.7) 50 (84.7) 0.935 Folat e RD I 1 (1.9) 7 (11.9) 0.762 Vit C RD I 22 (40.7) 25 (42.4) 0.906 Vit E RD I 21 (38.9) 39 (66.1) 0.042* Iron RD I 35 (64.8) 47 (79.7) 0.131 Mono unsaturated Fat RD I 17 (31.5) 24 (40.7) 0.547 Calciu m RD I 1 (1.9) 51 (86.4) 0.737 Potassi u m RD I 1 (1.9) 4 (6.8) 0.835 Sodium RD I 0 (0.0) 6 (10.2) *** ***n o t app li cab le, < less than, > greater than University of Ghana http://ugspace.ug.edu.gh 55 4.9 Frequen cy of Consump tion of Food 4.9.1 Animal Protein and Vegetabl e Protein Non-ve geta rians freq uen tl y consum ed red meat (54 .2%) and sea food including fish and shrimps (61 %) dail y. None of the vege tarians consum ed these anim al proteins. Milk (full crea m , ski mm ed and s emi skim med milk) was con sumed more frequentl y b y the non -ve geta rians compared to the vegeta rians. (35.6 % v s. 24.1%) as shown in figur e 4.5 . Again majori t y of the vegetarians (83.3%) consum e ve getable prote in such as groundnuts, s o ybe ans, ³agXshie´ in the Iorm of stews and soups than t he non - ve get arian s (25.4 %) (Figu re 4.5 ). V= Vegetarians NV= Non-ve getarians Figure 4.5 show s the in take of co mp arison s of animal prot ein and veg etabl e protein of vegetarian s and non-vegetarian s. N V V N V V N V V N V V N V V N V V An im al Pro tein Seaf o od E g gs Milk Fat ty Meat Veg etab le p ro tein P ercentage Dail y W ee kl y 2 -3 wk s Mo nt hly Occ as ion ally Nev er University of Ghana http://ugspace.ug.edu.gh 56 4.9.2 Fruits, Vegetabl es, Fruit Juice s and Drink s A high er perc enta ge of t he veget arians (92.6%) consum e d more ve getable s dail y than the non- vegetarians (72.9%). Fruits were co nsum ed more frequ entl y by the vegetarians (79.6 %) tha n non -vegetarians (74.6 %). Fr equenc y of fruit jui ce int ake was highe r amo ng the ve get arians (57. 6%) than the non -ve ge tarians (28.8%). In both groups fruit drinks were freq u entl y less consum ed (Fi gu re 4.6 ) NV= Non-ve getarians V= Ve geta rians Figure 4.6 Intake of fresh fru its and vegetabl es, fruit juice s and drin k s betw een vegetarian s and non-vegetarian s. 4.9.3 Cereals an d Grains C ereals and grains su ch as maiz e, ric e and whe at wer e con sumed week l y b y a higher propo rtion of non- ve getarians (27.1% ) compa red to the vegetarians (11.1%) Again a gr eat er proportion of non - vegetarians had a high er weekl y N V V N V V N V V N V V Veg etab les Fru its Fru it Ju ice Fru it Dr in k P ercentage Dail y W ee kl y 2 -3 wk s Mo nt hly Occ as ion ally Nev er University of Ghana http://ugspace.ug.edu.gh 57 int ake of plantain, and tuber such as, yam and cassav a (30.5 %) as comp ared to vegetarians (24.1%) (Fi gure 4.7) NV= Non-ve getarians N= Ve geta rians Figure 4.7 The intake of cereals and grain s and tub ers betw een vegetarian s and non-vegetarian s. 4.9.4 Deep Fried Foods, Fast Foods and Past ries The proportion of participants who never consum ed deep fried foods (eg. frie d ya m and plant ain) was higher amon g ve geta rian s (29.6 %) than non -v e ge tarians (3.4%). Also, ve geta ria ns who never consum e fast foods were si gnif icantl y higher (90.7% ) than the non -ve getarians (30. 3%). A few of the participants from both the vegetari a ns and non –veget arian group consum ed pastries such as vegetable pi e and mush room pies dail y (7% vs. 3.4% resp ecti vel y). Ho wever, vegetari ans who nev er consum ed pastries of an y kind were higher (20.4 %) than non -ve geta rian s (5.1% ) as showed in Fi gure 4.8 . N V V N V V C erea l s & G rai ns T u ber s P ercentage W ee kl y 2 -3 wk s Mo nt hly Occ as ion ally Nev er University of Ghana http://ugspace.ug.edu.gh 58 NV = Non-v e geta rians V = Vegetarians Figure 4.8 Intake of deep fried f ood s, fast food s and pastries betw een vegetarian s and non-vegetarian s. N V V N V V N V V 4 Dee p Frie d Food 4 Fast Foo d 4 Past ri es P eercentage Dail y W ee kl y 2 -3 wk s Mo nt hly Occ as ion ally Nev er University of Ghana http://ugspace.ug.edu.gh 59 CHAPTER FIVE DISCUSSION 5. 1 Socio ± Demograp h ic Characteristi cs of Partici p an ts As ex pected , there wer e no significant dif fer ences in the mean age of vegetaria ns and non- ve geta rians du e to the fact that pa rticipants wer e match ed b y age and gend er. The me an age of vegetari ans (54.2 ± 13.9) and non-ve get arians (53.9 ± 11.2 ye ars ) in thi s curr en t stud y was sim il ar to the ages of participants in a stud y that investi gated the eff e cts of long term ve geta rianism on lipid levels in Korea (K yun g et al ., 2012). The mean ages of vegeta r ians and non -ve get arians in the Korean stud y was 56.4 and 55.9, respe cti vel y. Howeve r, ther e is evide nce that vegetarians t end to be ol der than non -v e getari ans (Dave y et al ., 2003). The stud y s ampl ed mor e males than females in both the ve geta r ians an d non - vegetarians. Th e 2.1 rati o of males to females in thi s stud y is contrar y to findi ngs in other studi es that have found that vegetarian and ve gan diets wer e fre quentl y chosen b y females than males in other countries (Dave y et al ., 2003). Th is was att ributed to the fact tha t females ar e more con c erned about their bod y shape and wei ght than males, and as a result is more interested in tr yin g diff er en t diets to achieve thi s (Dave y et al ., 2003). Vegetari ans hav e been shown to be more edu c ated than the non -ve getarians (Dave y et al ., 2003). Twent y- ei ght perc ent of the vegetari ans in thi s stud y had att ained educ ati on to the terti ar y level compared t o the non -ve get arians (8. 5%) in University of Ghana http://ugspace.ug.edu.gh 60 t his stud y. This finding ma y thus suggest that generall y indi viduals with higher levels of educ ati on tend to take gre ater responsi bil it y fo r their he alt h and nu triti on whils t those who are less educated ar e also less knowledgeable abo ut the importance of good nutri ti on and healt h. 5.2 Vegeta rian ism S tudi es have shown that persons who follow a vegetarian diet ar e more content with their dietar y regim en and are likel y to foll ow it for a longer perio d than those who undertake die tar y pla ns for wei ght reducti on purposes (Whit e et al., 1999; Smi th et al., 2000). The pres ent stud y indi cates that maj orit y of the vegetarians (85.2%) hav e been practi cin g ve getar ianism for more than a year and 14.8% for ove r 40 yea rs. In another stud y that in vesti gated se rum fatt y ac ids and lipid profil e of Hong Kong Chinese non -v e ge tarians and ve get arians, it was sugges ted that to stud y the healt h and nu triti onal status of vegetarian s, the y shoul d have been on the diet for at le ast a period of one year ( Lee et al. , 2000). This observati on ma y be accounted fo r b y the fact that vegetarianism is not just dietar y persu asio ns , but also refle cts a life st yl e (Dave y et al ., 2003). In a Korean stud y on cholesterol lev els of vegetarians, the au thors concluded that the main reason for choosi n g a vegetarian diet was to m aint ain good he alt h and prevent diseases (Nivedit a et al ., 2012; K yun g et al ., 2012). In thi s stud y how ev er, the main reason for choos ing a vegeta rian diet was to uphold reli giou s and philosop hical principles. Less than a thi rd of parti cipant s from thi s stud y (18.5 % ) stated that the y followed vegetarianism fo r person al healt h purposes. University of Ghana http://ugspace.ug.edu.gh 61 Additi onall y, majorit y of veget arians (82% ) were lacto - vegetarians while s 18% were ve gans. Th e reas on for hi gh lacto -ve getarians in thi s stud y ma y be att ributed to the fact that lacto - ve getarian s beli eve their dail y prot ein requir ement can be met through the consum pti on of dair y pr oduct s such as milk , butter and cheese, comp ared to the vegans who do not co nsum e foods of anim al origin. Howeve r, in anothe r rel ated stud y conduct ed in African -Ameri cans, maj orit y of the veget arians wer e la cto - ovo vegeta rians (8 5%), while 15% were vegans (Toohe y et al., 1998).This impli es that it is more pref err ed to be a lacto - vegetarian or lacto - ovo - vegetarian th an a vegan. 5.3 Health and Lifestyle Behaviou rs About 44% of non -v e get arians and 29 % of veget arians were h yp ertensive . This is consi stent with findings of othe r studi es in vegetarian popul ati on s . Recent studi es have reported l ower rat es of hyp erten sion in vegetarians tha n non- vegetarians (Tonst add et al., 2009; Rizz o et al., 2008 ). It must be emp hasiz ed that, alt hough the ve ge tarian diet appea rs hea lt h y and ma y prev ent non - comm unicable diseas es, gen eti c va riati on and increas e in age could also be contribut ing factors to the incidence of hyp erte nsion among the partici pants of thi s stud y. The terato genic effe ct of smok ing is well documented. Ghanaians are be comi ng more healt h conscious and thi s could be the reason wh y onl y 1.7 % of the vegetarians and 1.9 % of the non -v e getari ans sa mpl ed for thi s stud y do smok e. Vegetari ans normall y have regular ph ysical acti vit y and usuall y abstain from smok ing and alcohol consum pti on than non -veget arians (Dave y et al. , 2003 ; University of Ghana http://ugspace.ug.edu.gh 62 Hansen, 2005 ). Th e resu lt s of thi s stud y also ind icate a healt h y lif est yl e of the vegetarians. Alcohol con sump ti on was low in the vegetarian population (1.9%) while 66.1% of non - vegetarians stated that the y consum ed alcohol. 5.4 Body Composition and Blood Pressu re Epidemi ological studi es often report that ve ge tarians ar e thi nner than non - vegetarians (Dav e y et al . , 2003; Fras er, 2009). Ho wever, thi s was not obser ved in the curr ent stud y. No si gnificant diffe renc es were observed in BM I of vege tarians and non-ve getarians. Th is finding is in agr eemen t with the result s of a st ud y in rural Ban gladesh, which investi gated nutrit ion and lipid profil e in the gen eral popu lation and vegetari a ns , but did not find any si gnific ant differ ence s in the BM I betw een the two gr oups (Kumar et al., 2012 ). There was how ever, significant diff eren ce i n the mean bod y fat of the vegetarians and non -ve get arians ( p=0. 040). The mean bod y fat for non - vegetarians was si gnifica ntl y high er (29.9 ± 10.19 % ) than fo r ve get arians (25.63 ± 11.60%). Another stud y conducted b y Del gad o et al. (2000) whi ch ev aluated the ef fect of dair y produ ct int ake on the plasma lipid profil e in vegetari a ns and non -ve geta rians also fou nd that BM I was sim il a r in both groups but per c enta ge bod y fats mass was lo wer and l ean bod y mas s was high er in the veget arian group. Low er per centa ge of bod y fat of vegetari ans ma y prob abl y be du e to an increas ed consum pti on of more fibre and less saturated fatt y foods. High fibre diets have lower ener g y densit y, result ing in less fat accumul ati on. University of Ghana http://ugspace.ug.edu.gh 63 C oncernin g blood pressu re par ameters, th e onl y st ati sti call y si g nificant diff erenc e between the two groups was in the diastol ic arterial pre ssur e ( p = 0.011). The vegetarians ha d a high er mean diastol ic pressure 85.94 ± 13.57 mmHg than the non - ve get arians (79.27 ± 3.97 mmHg). How ever , both groups had mean s ys tol ic and diastol ic values withi n the high normal blood pressure ran ge accor ding to :iOOiams’ cOassiIication :iOOiams et al. , 2004). Diastol ic blood pressure was significantl y high er in veget arians compa red to non -ve geta rians. Compar ison in blood pressu re m easurem ents of vegeta ria ns and non - ve get arians have sh own var yin g result s. A st ud y conducted in Braz il , which investi gated th e se rum lip id levels of la cto –vegetarians, repo rted t hat the vegetarians had lower s ystol ic arterial pressur e va lues than non -ve geta rian s even while ex hibi ti ng sim il ar BM I (Fernand e et al ., 2011). On the con tr ar y, another stud y condu cted in Chi na which inv esti gat ed t he nutrit ional status of elderl y Chinese ve geta rians and non -ve get a rians did not find an y diff eren ces in blood pressure between th e two groups (Woo et al ., 1998). Howeve r, in the current stud y, the prevalen ce of hype rtension was signifi cantl y higher amon g the non - vegetarians (44.1%) compared to the vegetarians (2 9.6%). It is assum ed that the disproporti onatel y hi ghe r percenta ge of non -ve ge tarians using pharm acolo gical t herapies to lowe r BP would clearl y att enu ate the true blood pressure dif fer enc es betwe en the two grou ps. The higher di astol ic pressure among the ve get arians is inex pli cable. It indi c ates that the adhe renc e of a vegetarian di et is not nec essaril y associated with gr eate r protecti ve eff ect against blood pressure el evati on. University of Ghana http://ugspace.ug.edu.gh 64 5.5 Lipid Profil e Most epidemiol ogical studi es on the lipi d profil e of vegetarians an d non - vegetarians concluded th at vegetaria ns had a f av ourable lipid profil e tha n non - vegetarians (Woo et al ., 1998; Kumar et al. , 201 2). This stud y h ypothesi z ed that there will be no signific ant differ ence between l ipi d profil e of vegetari a ns and non -ve geta rians. Result s from the pres ent stud y s upport the h ypothesis. Wit h the ex cepti on of HDL, se ru m trigl yc erid es (TG), tot al cholesterol and LD L- C were not significantl y diff eren t between vegetari ans and non - vegeta rians ( p > 0.05). Neverthel ess, bot h me an values of TG and LD L-C of both groups were at o pti mal levels acco rding to the European Socie t y Guid eli nes for the classific ati on of dysli pidaemi a (Reine r et al ., 2011). However, th e mean TG of the veget arians (1.29 ± 0.52 mmol/ L) was sl ightl y high er than non - ve geta rians (1.13 ± 0.52 mmol/ L). In reali t y, ve get arians ma y consum e more carboh ydr ates in various forms such as fructose which might refl ect high er serum tri gl yc erid e lev els than the non-ve geta rians. A rich carboh yd rate diet makes great er av ail ab il it y of carboh ydr ates for s ynthe sis of trigl yc e rides (J hala et al., 2009). Vegeta ria ns also consum e a lot of fruit s which contain fructose. Dietar y fructos e also contribut es to TG elevati on (Rein er et al ., 2011). La ck of si gnificant diffe renc es in th e serum TG betwe en the two gro ups is consi stent with literatur e which shows that plasma TG are not af fect ed by alt erati on in saturated fat, MUFA and PU FA (Cari appa et al ., 2005). The mean value of the tot al cholesterol (TC) was sli ghtl y hi gher amon g the non - veg etarians (5.70 ± 1.20 mmol/ L) than the vegetarians (5.54 ± 1.17 mmol /L) aOthoXgh Eoth mean YaOXes Zere on the ³EorderOine normaO´. ,n a stXdy University of Ghana http://ugspace.ug.edu.gh 65 conducted in Br az il , which compared lev els of TG, TC and LD L - C, i t was concluded that the ve get arian diet was as sociat e d with lower levels of TG, TC, and LD L- C than th e non - ve get arian di et (Car iappa et al ., 2005). In another stud y condu cted in Kore a which also comp ared the lipid profil e of veg e tarians and non- ve getarians, si gnific antl y low er lipid levels wer e obs erv ed am ong the vegetarians (K yun g et al., 2012). How ever, the present stud y is in cons onance with a stud y condu cted i n India whi ch compa red the lipid profil e of vege tarians and fish eaters. Th e aut hors rev ealed th at there was no si gnific ant diff erenc e between the lipid profil e s of vegetarians and no n - ve get arians (Cariapp a et al., 2005). Furthermor e, the mean LD L – C levels of both groups was not significant l y dif fer ent i n thi s stud y. Although not signifi cant , an une x pected finding was the low er mean level s of LD L – C (3.31 ± 1.24 mmol/ L) in non- vegetarians compar ed to that in vegetarians (3. 4 5 ± 1.15 mmol/ L). The mean LD L- C of non -ve getari ans and ve geta rians can be int erpreted as nea r opti mal and borderline normal re specti vel y acco rding to t he European Societ y Gui deli nes for the classific ati on of dys li pidaemi a (Rein er et a l. , 2011). The hi gher LD L – C mean values ma y be att ributed to the fact that majo rit y of the veget arians sampl ed were more of lacto - ve ge tarians (82%) than ve gan s (8%). The lacto – ve geta rians consum e dair y product s such as milk, cheese and µZaagashi’ cXred OocaO miON . 0iON Iat contains some oI the most commonOy consum ed saturat ed fatt y acids such as lauri c and m yristi c acids that hav e a more pronounced infl u ence on plasma choleste rol (Nivedita et al ., 2012). Another possi ble ex planati on of the relativel y hi ghe r LD L – C of the vegetari ans ma y be due to higher tr ans - fatt y acids (TFA ) in their diet. Partiall y h ydro gen ated fatt y University of Ghana http://ugspace.ug.edu.gh 66 acids repr esent the maj or sourc e of trans -f att y acids found in vegeta ria n pies which incre ases TG and LD L cholesterols (Le e et al ., 2000). In a stud y ca rried out in Braz il to investi gate the relation between diet ar y and circulatin g lipids in lacto – vegeta rians and ve getarians , it was conclud ed that there was no si gnifica nt differen ce in HD L - C between the two groups (Fe rnandes et al., 2011 ). Howev er, in thi s pre sent stud y, th e HD L- C was statis ti call y signi ficant between th e two grou ps (p = 0.0 12) whic h is in disagr eement with the st u d y b y Fern andes et al ., conducted in 2011. Th e non - vegetarians had a hi ghe r mean value of HDL -C (1.92 ± 0.96 mmol/ L) th an the vegetarians (1.55 ± 0.4 8 mmol/ L). Neve rtheles s, both groups wer e wit hin the opti mal levels of the HDL- C ref eren ce ran ge ac c ordin g to the Eu rope an Societ y Guideli nes for the man a gement of d ysli pidaemi a (Reiner et al ., 2011). The discrep ancies betwe en HD L- C con centr ati ons ma y be due to sev eral factors. The fact that majorit y of the non -vegetarians (66.1%) consum e d alco hol as agains t 1.9% of the vege tarians ma y hav e contribut ed to the significantl y highe r HD L-C Ther e is evidenc e that alcohol consum pti on increase s HD L - C fra cti ons and sti mul ates revers e t ransportati on of lipids (Vander et al., 2001). Alcohol consum pti on of more than t hre e drinks per da y is associated with raised blood pressure and plasm a tri gl yc erides (Redd y and Katan, 2004). Th e t ype of alcohol consum ed ma y also be ta ken int o consi de rati on when one ne eds to inc reas e his or her HDL- C in the bod y. Wine contains rese rva t rol, an anti fun gal compo und in gr apes skins that has been asso ciated with 11 % to 16% incr ease in HDL - C (Hansen A. S 2005 ) . Another ex planati on for the discrepan cies ma y be att r ibut ed University of Ghana http://ugspace.ug.edu.gh 67 to increased carboh ydr at e consum pti on as isocaloric subst it uti on for fat. This is associated with signifi c ant dec re ase in HDL – C (0.1mmol / L fo r ever y 10 % ener g y subst it uti on). However, in carboh ydr ate -rich foods with hi gh fibre content, the redu cti on of HDL- C is eit her not observed or is ver y sm all (Mensink et al ., 2003; Frost et al ., 2004). Usu all y, a high er fructose or su crose in take is associated with a more pronounced dec re ase in HDL - C (Frost et al ., 2004). The lower HD L- C in vegetarians ma y hav e led to the increase in LD L concentr ati ons ob served in thi s population , as HDL – C is beli eved to be a carri er of ex cess cholesterol (Br ewer,2004 ) 5.6 Dietary Intake of Partic ip an ts W it h the ex cepti on of protein, there wer e no sign ificant differ ences in the macro nutrients ( p=0.001). The ve getari an s had a si gnif icantl y low er int ak es of protein (37.2 ± 12.5 g) than non –vegetarians (59.4 ± 31. 3 g). Studi es hav e repo rted that vegetarians gener all y ha ve lower int ake of protei ns compared to indi viduals who eat meat . Despit e thi s , their int akes wer e sti ll wit hin an adequate int ake range (Appleb y et al ., 1998; Dave y et al., 2003). Fin dings of thi s stud y sho wed that vegetarians had low er i ntakes of protein which was below the recom mended dail y int ake. This partiall y agr ees with Appleb y et al . (1998) and Dave y et al.  . 9egetaEOe protein can sXppOy an indiYidXaO’s protein needs Zhen a variet y of foods of veget able ori gin are consum e d and the ener g y needs are met (Kumar et al ., 2012). Rega rdin g dieta r y fat and monouns aturated fat, there was no sign if icant differen ce betwe en the two groups. Surprisi n gl y, the m ean values for the University of Ghana http://ugspace.ug.edu.gh 68 saturated fat was hi gh er in the vegetari ans (7.55 ± 15.43g) than t he non vegetarians (4.70 ± 5.90 g). This ma y be due to the fact that those vege tarians who participated in the stud y consum ed a lot of fried foods or palm nut soups wh ich ar e hi gh in saturated fat. Diet ar y int ak e of pol yu nsatu rated fat was significant in the two gr oups ( p = 0.001). The vegetarians had a high e r mean value of pol yunsatur ated fat (9.7 ± 8.7 g) than the non -ve geta rians (2.8 ± 4. 1 g). A possi ble ex planati on fo r thi s is that pol yuns atur ated fat is most l y derive d from plant sources su ch as so ya beans, sunflowe r and seed weeds. Vegetaria ns are more likel y to consu me these foods in large quanti ti es. In cre as e in pol yunsatur ated fat int ake tends to lower bloo d cholesterol levels especiall y LD L- C . (St -On ge et al. , 2007 ). High diet ar y po l yunsatur ated fat int ake among vegetarians has been rep orted in sim il ar studi es done b y Bonnie et al . (20 10) and Kareli s et al. (2010 ). Vegetari ans are sti ll at a low er risk of cardio vascular diseases probabl y be cau se of other favour able dietar y features such as lower int ake of trans - fatt y acid s and high er int akes of pol yunsatur ated fat (Lee et al., 2000). Again, there was a sign if icant differen ce in dietar y folate betw een the ve getarians and the non – vegetarian s ( p = 0.0 02). Th e ve getarians had a hi gh er me a n folate int ake (88 ± 64.56 m g) than the non -ve getarian s (51 ± 58 mg). Othe r studi es corrobor ate thi s finding (Appleb y et al ., 1998; Kyu n g et al ., 2012). A pl ausibl e ex planati on is that ve get arians consum e more gr een le af y ve getables and fruit s which are rich in foli c ac ids. University of Ghana http://ugspace.ug.edu.gh 69 This stud y showed no signific ant differ ences in dietar y anti ox idant s (vitami n C and E) betw een both gr o Xps. 1eYertheOess   oI the Yegetarians’ Yitamin ( int ake was less than the recomm ended dail y i ntake. Vitamin E is a powerful antio[idant in the Eody’s Oipid phase. ,t can preYent /'/ - C lipid pero x idation caused b y fre e radical re acti on (Stephen et al. , 1996). The low er dail y i ntake of vit ami n E of the vegetari ans showed a negati ve correlation with their seru m LD L – C, which is supported by studi es done by Castr o et al . (2005), Lee et al. (2000) and Kyun g et al . (2012). Significant diffe renc es in dieta r y calcium int ake of the vegetarians and non – vegetarian were not obser ved in thi s stud y. Nev er theless 98% of the calcium int ake of th e veget arians was less than the recom mended dail y int ak e comp ared to the non -v e geta rian s (13.6%). Other studi es have establi shed that vegetaria ns have a lower int ake of calcium than non - ve get arians (Woo et al ., 1998 and Kyu n g et al., 2012). A sim il ar result to the afor em e nti oned studi es was observ ed in thi s stud y. As a cons e quence th ere is the nee d for dietar y edu cati on on how to max im ise the absorption of calcium among vegetarians. The lowe r calcium uti li sati on in vegetarians is probabl y due to the higher int ak e of a so ya bean - bas ed diet. So ya beans ma y advers el y affe ct calcium absorption due t o the high ox ali c acid co ntent that ma y int erf er e with calcium absorpti on in the bod y (Dave y et al ., 2003). The Yegetarians’ intaNe oI Yitamin % 6 (85%) and vit ami n B 1 2 (83%) fell below the recomm ended dail y int ake. The int ake of vit a mi n B 1 2 is lower in veget arians and defi ciencies in vit ami n B 1 2 have be en reporte d in adult ve get arians es peciall y among ve gans (Her rman n and Geisel, 2002, Her mann et al., 2003). Th e result s of thi s stud y confi rmed the reports of Her r mann and Geisel (2002) and He rrm ann et University of Ghana http://ugspace.ug.edu.gh 70 al., (2003). Fu rthermor e , thi s highli ghts the nee d for ve getarians to regularl y include a reli abl e sour ce of vit ami n B 1 2 such as fo rtified foods or suppl em ents in their diet. Vitamin B 1 2 d eficienc y is usuall y the result of reduced absorptio n and / or lack of vit ami n B 1 2 in the i r diet. Although vit ami n B 1 2 deficienc y is co mm on to both vegetari ans and vegans , the y often hav e good int akes of folic aci d that ma y m ask the defi cienc y which can onl y be di agnos ed wh en suf fer ers present with neurologic al s ympt o ms (Thomas and Bishop , 2007). 5. 7 Dietary Habits S ix t y per cent (60 %) of t he non -ve getari ans cons umed more fish dail y th an red meat (54.2% ) in thi s stu d y. Th e frequ ent consu mpt ion of fish was enco ura ging since some fish oils ar e known to be rich in n-3 fatt y acids and hav e bee n shown to reduce both fasti ng and post prandial blood trigl yc eride lev els (Roche and Gibne y, 2003 ; Cast ro et al ., 2005). Surpris ingl y, onl y 8.5% of the non - vegetarians consum ed egg dail y. High consum p ti on of eggs is lik el y to have a significant elev ati ng effe ct on blood cholesterols especiall y LD L- C (Tho mas and Bishop , 2007). The high er int ake of fish and lower int ake of eggs of the non - vegetarians indi cates tha t thi s group had he alt h y food choices . Consum pti on of vegetable prot ein such as beans and so y be ans was high er (83.3 %) am ong the vegetarians th an the non- vegetarians (25.4%). Accordin g to the Join t Healt h Claims Init iative (J HC L, 2004) the inclusi on of at least 25 g of so ya prote in per da y as part of a diet low in saturates, ca n help reduce blood cholesterol levels. Howev er, practi ca l impl icati on s of a regula r lar ge consum pti o n of so ya pro tein produ cts need to be consi dered with lifest yle iss ue. University of Ghana http://ugspace.ug.edu.gh 71 The saf et y of hi gh int a kes of so ya ph ytoesto ge ns ma y be of con cern to some indi viduals. Dietar y prot eins var y in their nutrit ional quanti t y; t he di gesti b il it y of some plant proteins is lo wer than most anim al sources of proteins (Thomas and Bishop , 2007). The biol ogic al value (BV) can also be lower in plant pr oteins especiall y with di ets based on un -suppl eme nted ce reals or sta rch y root s . Howeve r, withi n a mix ed diet, plant protein sources can meet the dem a nds f or indi spensable ami no acids as well as anim al source proteins (Mahan et al ., 2012) Neverthel ess, so ya protei n has a sim il ar protein qu ali t y as anim al protein (Young, 1994). The main nutrit i onal differ enc e betw een a plant sour ce and an anim al source prot ei n diet is in the highe r and mor e bio avail able, micronutri ent content of the latter (Mill ward, 2004). This reflects wh y 78% of the vegetarians did not meet the recomm end ed dail y int ak e of protei n , and highli ghts the need for nutrit i onal educati on on how to max imi z e vege table protein to meet the dail y needs for ve geta rians in Accr a. 5.7. 1 Fruits, Vegetabl es and Fruit Juices 9egetaEOes sXch as tomatoes garden eggs µnNontomire’ Zere consXmed daiOy Ey 92% of th e vegetari ans , compar ed to 72 % of t he non – veget arians. This was ex pected, since ve get able s form the basi s of the veget arian diet. Dail y fruit int ake was sim il ar between the veget arians (79% ) and the non – vegetarians (74%). Fruits and ve getables ar e good sou rces of folate and solub le fibre. Solub le fibre reduces tot al LD L choles terol (Castro et al ., 2005 ). Although a n incre ased int ake of solub le fibr e can be ex pected to hav e onl y a limi ted impact on chol esterol levels, the ca rdio protect ive properties of foods ri ch in solub le fibre (p arti cularl y fruit s and veget ables) are sufficient just ificati on to advocate their inc reased University of Ghana http://ugspace.ug.edu.gh 72 consum pti on by d ysli pid aemi c pati ents (Dav e y et al., 2003). On the other hand, dail y fruit jui ce consum pti on was higher amon g the vegetarians (58 %) t han the non – vegeta rians (29 %). Fruit jui ce contains fructose. High fructos e int ake contribut es to TG elev ati on (Stanhope et al ., 2009 ). Result s from thi s stud y seem to suggest that fruit jui ce (ev en without added suga r) shoul d be consu med in moderati on to prevent hi gh TG le vels. 5.7 .2 Cereals an d Grains The stud y result s show e d that more than half of t he veget arians (76%) fre quentl y consum ed more ce reals and grains than the non -v egetarians (58 %. ). Ex ampl es of cere als and gr ains consu med by the participants were maiz e , ri ce, mill et, and oats. Ad dit ionall y, these fo ods provide ener g y and wer e major sou r ces of carboh ydr ates for th e participants. Eviden ce co nsis tentl y demons trat es a TC – and LD L – C lowering ef fect of water – solub le fibre from oat s, wheat and maiz e. A dail y dose of solub le fibre of 5 – 15 g/da y is recomm ended for LD L – C lowering eff ect (Rideout et al ., 2008). 5.7 .3 Deep Fried Food s, Fast Foods and Past ries Deep fried foods such as fried ya m and pl antains and fried foods gener all y, wer e not comm onl y consum e d by both groups. Th e result s of thi s stud y ex plain the healt h consciousness of the vegeta rians. Fast foo ds are high in trans -fatt y acids. High t rans -f att y acids int ake have been shown to elevate LD L – C and decreas e HD L – C (Richte r et al ., 2004). Also 49% of the non -ve geta rians and 37% of the vegetarians reported a mont hl y int ak e of pastries. Comm on pastries mention ed by the participants included veget able pies and me at pies. Hardened fats such as University of Ghana http://ugspace.ug.edu.gh 73 margarines (produ ced by h yd ro genati on of vegetable oil s) wer e used in the prepar ati on of pastries. Hard ened fat s have si mi lar eff ects as satur ated fats. In cre ased intake of satu rated fat incre ases LD L – C in the blood. 5.8 Limitation s of the Study i . Fail ure to include a ho mogenous ve geta rian di et group const it uted a limi tation to a more uniform data. In thi s stud y, ve gans and lacto - vegetarians were both i ncluded , but an al ysis was not done s epar atel y because of the small numbers. ii. Findi ngs of the sampl e s ma y be gen erali z able to a sim il ar group in Accra bu t ma y not be repr esent ati ve of the tot al ve get ari an population in Ghana. iii. The lipid profil e of an i ndivi dual also depends on ex ercise and ph ysical acti vit ies. These facto rs were not taken int o ac co unt in the present stud y. This ma y be th e reason for the lac k of si gnific ant differ ences in the lipid profil e of vegetarians an d non -ve geta rians. iv. The dieta r y ass essm ent methods used in thi s stu d y m a y hav e a level of under reportin g or over reporting. It is also likel y that eati ng habit s were modi fied to impress the rese arch er and thes e might have af fe ct ed the result s. 5 .9 Conclu sion s The stud y was not able to clearl y establi sh whet her a vegetarian di et improved the serum lipid status of an indi vidual. Ther e was also no signifi cant diff er ence in BM I betw een ve getari a ns and non - ve getarian s. The prev alenc e of alcohol consum pti on for ve get a rians (1.9%) was lower th a n non-ve geta rians (66.1 %). University of Ghana http://ugspace.ug.edu.gh 74 Ve getari ans had a high er mean diastol ic blood pr essure than the non-ve ge tarians in thi s stud y. With the ex cepti on of protein ther e wer e no si gnificant diffe rences in the macro- nutrients intake between the two dietar y groups ( p= 0.001) . Onl y 22% of the vegeta rians met the recomm ended dail y int ake of protein. Rega rdin g micro-nutrients there was significant diffe renc e between the mean folat e int ake between the two grou ps ( p = 0.002). Onl y 16% of vegetarians m et the recomm ended dail y int a ke of vit ami n B 1 2 , with onl y 14% meeti n g the RD I of vit ami n B 6 in this stud y. 5.10 Recommen d ation s A lar ge r stud y of the vegeta rian population in Ghana will give a bett er understandin g on the impact of vegetarianism on t he lipid profil e of Ghan aians Vegetari ans shoul d regul arl y includ e a reli able so urce of vit ami n B 1 2 in their diet such as forti fied foods or suppl ements. A vari et y of plant foods consum e d dail y can provide all essential ami no acids and ensur e adequate nitro gen balanc e . In couns eli ng sessi ons , dietit ians shoul d not be judgmental of vegetarian diets. As dietit ians there is th e nee d to give app ropriate info rmati on on the pros and cons of vegetarian di et s . This wil l enable the cli ent to mak e an informed decisi on. A healt h y di et does not stem mer el y from eli mi nati ng meat and fat, it is of essential importance to stress the bene fits of a di versified diet rich in frui ts and vegetables, fibre and an ti oxidants for a desi r abl e lipid profil e and saf e blood pressure. University of Ghana http://ugspace.ug.edu.gh 75 REFERENCES Abbe y, M., Noakes, M., Bell ing, B. and Nestel , J . (1994). Partial repla ce ment of saturated fatt y acids wit h alm onds and walnut s lowers tot al plasma chol esterol and low densit y lipoprot ein cholesterol . Journal of Cli nical Nutri ti on, 234:129 - 133. Allen, L.H. (2009). How comm on is vit ami n B 12 deficienc y? American Journal of Cli nical Nutrit ion, 89: 6935 - 6965. Altens, T.S., Michaelso n, J .L, Ball , S.D., Guil ford, B. L. and Thom as , T.R. (2006). Lipop rotein subf racti on chan ges afte r con ti nuous or int ermitt ent ex ercise traini ng. M edical Scien ce Sports Exercise, 38 : 36 7 – 327. American Dietetic Ass ociation (2007). Posit ion of the Ame rican Dietetic Association and Dieti ti ans of Can ada: Diet ar y fatt y Acids: Journal of American Diet Associat ion , 107: 1599 – 1611. American Heart Associa ti on (AHA), (2012). He alt h y lifest yle diet av ail able at: htt p:/ /www.heart.or g/pre senter.jnt ml , [Assessed 30 t h November, 2012] . Anderson, J .W. and Major, A.W . (2002). Pulses and Lipad emi a, short and long – term eff ect in the pre venti on of cardiovascul ar diseas e. Brit ish Jou rnal of nutri ti on , 88: 263 – 271. University of Ghana http://ugspace.ug.edu.gh 76 Appleb y, P.N., Tho ro go od , M., Mann, J . I., Key, J . T. (1998). Low bo d y mass index in non – meat eaters . The possi ble roles of anim al fat, dietar y fibre and alcohol. Internat ional Jo urnal of obesit y , 1998; 22: 454 – 460. Asare, J . (2011). Obesit y and its determinant s among juni or high school chil dren in the Accra Metropolis : Mphil Thesis , Universit y of Ghana, Le gon. Assman, G., Schult e, H. and Von - Ech ardstein, A. (1996). H ypatri gl yc erid aemi a and elev ated lipoprotein s are risk factors for m ajor co ronar y events in middle aged men. Am erican Jou rnal of Cardi ology, 56: 1179 – 1184. Bae r, D. J., Judd, J . T., Clevidence, B. A., Mu es ing, R. A., Campbell, W. S. and Brown E. D. (2002). Moderate alcohol consu mpt ion lowers risk factors for cardiovas cular dis ease in post -menopausal women a controll ed di et. A merican Journal of Cli nical Nutriti on, 75: 593 – 599. Ball , M. J. and Bartlett, M. A. (1999). Dietar y int ake and iron status of Au strali an vegetarian women. Am erican Journal of Cli nical Nutri ti on, 70: 353 – 358. Baroni, I. L., Cen cil , L. and Tett amt i, S. (2007). Evaluating the envi ron mental impact of various di eta r y patt erns combi ned with different food pro ducti on s ystems . European Journal of Cli nical N utri ti on, 15:56 -59. Bart er, P. J. and R ye, K. A. (2006). The rati onal for using opo A - I as a clinical marker of cardiovascula r risk. Journal Internal Medicine, 259 : 447. University of Ghana http://ugspace.ug.edu.gh 77 Baz z ano, L. A., Ogd en L. G., Myers. and Loria, C . (200 1). Le gume consu mpt ion and risk of coron ar y Heart dise ase in US men and wom en. N.H. A.N.E.S. Epidemi ologic foll ow up stud y. Arch int ernal Medicine , 161:2573 -2578. Baz z ano, L. A., Thompson, A. M., Tees, M. Winham. M. (2011). Non – so y legume consum pti on low ers choleste rol levels. A Meta – anal ysis of rando mi z ed controll ed trials. Nutrition : Metabol ism Cardi ovascular Disease. 34:22 -35. Bedfo rd, J .L. and Barr, B. L. (2005). Diet and Se lected lifest yl e pra cti ces of self - defined adult ve geta rians from a populatio n - base d sampl e suggest the y ar e more healt h conscious. Interna ti onal Behaviour Nutri ti on. Phys Act , 24: 23-35. Bonnie, L., Beez hold, C., J ohnston, S. and Deanna R. (2010). Vegeta ria n diets are associated with he alt h y mood states. Across secti onal stud y i n Sev en th Day Adventi st adult s. N utri ti on Journal , 9:26. Brewer, H. B. (2004) In creasin g HD L chol ester ols levels. T he New England Journal of Medicine ,350 :1491 -1495 . Britis h Nutriti on Found a ti on [BNF] (1999). n -3 Fatt y acids and healt h. Briefin g paper. London: BN F. Brown, L., Rosne r, B., Wil let, W.W . and Sacks, F. M. (1999) Cholesterol - lowering af fe ct of diet ar y fib er. A Meta an al ysis . American Journal of C li nical Nutri ti on, 69: 30 – 42. University of Ghana http://ugspace.ug.edu.gh 78 C ariappa, M., Poorima, K., Nandin, M. and Kadil a ya, H. (2005). Ox idant status and Lipi d profil e in ve get arians and fish eater s . Indian Journal of C li nical biochemist ry , 20:103 – 108. Castro, I. A., Barroso, L. P. and Sinnecke r, P. (2005). Fun cti onal foo ds for Coronar y Hea rt disease risk reducti on : A meta- anal ysis usin g mul ti variate approach . American Jour nal of Cli nical N utri ti on , 82: 32 – 40. Chan, J ., J aceldo -S igel, K. and Frase r, G. F. (200 9). Serum 25 h ydrox yvit ami n D status of vegetarians, partial ve getarians and non -ve geta rians. Th e Ad venti st Healt h Stud y-2. A mer ica n Journal of Cli nical Nutrit ion, 89:24 -43. Cieveira, F. (2004). Guideli nes for the diagnosi s and mana gem ent of heteroz ygous fami li al h ypercholeste rolemi a. Arth erosclerosi s , 173: 55. Cook, J . D. (1990). Adapti on in iron metaboli sm. American Journal of C li nical Nutri ti on 1990, 59: 1233-1237. Cook, J .D. (1990). Adap tation in iron metaboli sm. American . Journal of C li nical Nutri ti on. 51:301 -308. Craig, W. J. and Man del, A.R. (2009). Posit ion of the Am erican Dietetic Association Vegetari an diet. American Journal of Cli nical Nutri ti on, 109: 1266 – 1282. University of Ghana http://ugspace.ug.edu.gh 79 Dave y, G. K., Spen ce r, E.A., Appleb y, P.N., Allen , N.E. and Knox , K.H., (2003). Ke y EP IC -Ox ford: lifes t yle cha ract eristi cs and nutrient int akes in a cohort of 33,883 meat eaters and 31546 non meat eaters in the UK. Publi c Healt h Nutri ti on, 6: 259 – 269. Davis, B.C. and Kris -Et herton, P.M. (2003). Achieving opti mal essentia l fatt y acid status in vegetari a ns: Knowledge and pr acti cal impli cati ons. American Journal of Cli nical Nutriti on, 79 (3): 6405 – 6465. De Lor geril, M. (1999). Mediterran ean di et, tradit ional risk factors and the rate of cardiovas cular, compl ic a ti ons after myo ca rdial inf arcti on. C irculat ion, 99: 179. Delgado, M., Gonz alez , B. and Casti ll o, M. J. (2000). Ph ysical Ex ercise Revers e diet induced incre ase in LD L – cholesterol and APO B levels in healt h y Ovo – lacto ve geta rian Subjects . N utri ti on Research, 45:1707 – 1714. Dholpuria, R., Rajas, S. and Gupta, B.K. (2007 ). Atheroscle rotic risk fac tors in adolescents. Indian Jour nal of Pediat rics , 74 (9): 823-826. Drape r, A., Malhotra, W. and Wheeler, E. (1 993). The en er g y and nutrients int akes of different t yp es of vegeta rian: A case of suppl ements. Brit ish Journal of Nutri ti on , 69: 3 - 9. Drehe r, M. L., Mah er, C. V. and Kearn e y, P. (199 6). The tr adit ional and emergin g roles of nuts in healt hful diets . Nut rit ion Review, 67:23 -37. University of Ghana http://ugspace.ug.edu.gh 80 Dror, D.K. and Allan, L. H. (2008). Effect of vi tamin B 1 2 deficienc y on neuro - developm ent in infants: Current knowled ge and possi ble me chanism . N utt rit ion Review, 66 :250 – 255. Dwye r J T. (1991 ). N utrit ional consequences of vegetari anism . Depa rtment of Medicine – Tufts Univ er sit y Medical School and Fran ces Stern Nutriti on Centre, New En gland Medi cal Centre Hospit al: Massachu sett s. Esteve, E. (2005). D ysli pidemia and inflamm ati on: An evolut ionar y co nserved mechanism . C li nical Nutrit ion, 24 :16 -21. Fard et, A. (2010 ). A new hypoth esis for the he alt h protecti ve me chanis ms of whole- grain ce re als. What is beyond fibr e? N utriti on Research Review , 23 , 65 – 134. Fern andes, K. Dou rado , F., Auruda, M. I.and Sakuga ra S. (2011). Relation between dieta r y and circulating lipids in lacto – ovo vegetari an. N utri ti on hospital , 26:959 – 964. Fras er, G.E. (2009). Vegetarian diets. What do we know of their effect on comm on chronic diseas e ? American Journal of Cli nical Nutrit ion, 89: 16075 – 16125. University of Ghana http://ugspace.ug.edu.gh 81 Friede wald, W. T., Lev y, R.J . and Frederickson, D. S. (1972). Esti mation of the concentr ati on of low den sit y lipoprot ein cholester ol in plasma, without use of the prepar ati ve ult ra centrifu ge. C li nical , Chemical, 1 8: 499 – 502. Frost K. S., G Whit aker, V and Summ berbell C. (2004). Low gl yc a emi c index diets for coron ar y he art d isease . Codrone Databas e System Review , CDC . Garcia, A. L., Koebnick, C., Dagnell ie, P.C., Leit z mann, C. and Hof fm ann, I., (2008). Lon g term strict raw food diet is associat ed with favourabl e plas ma beta - caroten e and low plasma l ycopen e concent rati ons in Germans. Brit ish Journal of Nutri ti on , 99:1293 -1300. Gardne r, C.D. and Kraemer, H.C. (1995). Mono unsaturated vers us pol y unsaturated dietar y fat and serum lipids. A meta -anal ysis . Arteriosclerosi s Thrombosis and Vascular Biology, 15:1917 – 1927. Ghana Statist ical Service (2012). Result s of the 2010 Ghana Populat ion and Housing Census. Gibson, R.S ., Perlas, L. and Hotz , C. (2006). Improving the bioav ail ab il it y of nutrients in plant foods at the household level. Proceeding of the Nutri ti on Society , 65:160 – 168. Gilsi ng, A. M. and Cro we,F. L. (2010). Serum co ncentr ati on of vit ami n B 12 and folate in Britis h male omni vore,ve geta rian an d ve gans result from a cross - University of Ghana http://ugspace.ug.edu.gh 82 secti onal anal ysis of th e EP IC - Ox ford cohort stud y. European Journal of Cli nical Nutrit ion. 43,455 -465. Goldber g, A.P., Lim D., Kolar. J .B. and Grundh aus er, J . J. (1994). So ya be an protein independentl y lowers plasma cholesterol levels in prim ar y hype rcholeste rolemi a. At herosclerosi s 43: 355 – 367. Grund y, S. M. and Clee man, J . I. (2004 ). Impl ica ti ons of rec ent cli nical tri als for the nati onal cholestero l educati on pro gr am adult treatm ent panel III. Guide li ness - C irculat ion. Adul t Treatment Panel II I. 34:14 -27. Grund y, S. M., (1997). What is the desirable rat io of saturated pol y unsa turated and mono unsatur ated fatt y acids in the diet? American Journal of Cli nical Nutri ti on, 66: 9885 -9905. Hans – D ehmet, (2002 ). What is the optimal diet of the anthr opoid primate home sapiana. Department of ph ysics, Unive rsit y of Washington. Hansen, A. S. (2005). Effect of red wine and red grap e ex tract on blood lipids, haemost ati c factors, and other risk factors for ca rdiovascular disease. Eu ropean Journal of Cli nical Nutriti on , 59:449. Hardman, H. E. (1999). Inte ra cti on of Ph ysic al acti vit y and Diet. Impl icat ion for Lipoprotein met aboli sm. Publi c Healt h Nut rit ion , 92: 369 – 376. University of Ghana http://ugspace.ug.edu.gh 83 Harland, J . I. and Haffne r, T. A. (2008). S ystemat ic review. A Meta anal ys is and regressi on of randomi se d controll ed trials report ing on associati on betw een an int ake of Circ a 25 g so ya protein pe r da y and blo od cholesterol. Athoros cl orosi s, 200 :13 – 27. Hermann, W., and Gie sel, J . (2002). Vegetari an lifest yle and moni to ring of vit ami n B 1 2 status. C li nica Chemica Acta , 326:57 - 59. Herrmann, W., Schorr, H., Obeid, R. and Geisel, J . (2003). Vitamin B 12 status, particularl y holot rans cob alamin II and meth ylm a loni c acid con centr ati ons, and hype rhomoc ysteinemi a i n vegeta rians. Am erican Journal of Cli nical Nutri ti on 78(1): 131-136. Hokanson , J .E. and Austi n, M.A., 1996. Plasma tri gl yc erides lev el is a risk factor for cardiovascul ar dise a se independent of hi gh densit y lipoprotein cholesterol level. A Meta anal ysis of population based perspecti ve studi es. Jour nal of Cardi ovascular Risk, 3: 213 – 219. Holick, M.F., Bian cuz z o, R. M. and Chen, T.C. (2 008). Vitamin D 2 is as ef fective as vit ami n D 3 in maintaining ci rculatin g con centr a ti ons of 25 -h ydrox y vit a mi n D. Journal of Cli nini cal Endocrinal Metabol ism , 93: 677 – 681. Hopkins, P.N. (1992). Ef fect of diet ar y choleste ro l on serum cholesterol. A meta - anal ysis and revie w. Ame rican Journal of Cli nical Nutri ti on, 55: 1060 – 1070. University of Ghana http://ugspace.ug.edu.gh 84 J enkins , D.J ., Kendall , C.W . and Faulkn er, D. (2002). A diet ar y po r tofoli o approach to cholesterol reducti on: Combi ned eff ect of plant ste rols, ve getable proteins, and viscous fibers in hyp er - cholestero lemia. Metabol ism, 51:1596 – 1604. Jhala, C. I.,P C J oshi , P.C., Shah, T.K. and B, Naik, B. (2009). Establis h ment of Normal lipid ref eren ce values in healt h y ve geta rians popu lation of Rural Western and Northe rn Guj arat an d comparison with avail a ble sim il ar data of othe r parts of India . Gujarat Medical Journal , 64:25 -30. Joint Britain Societies [JBS 2] (2005). Guideli nes on preventi on of cardi o v ascular disease in clini cal pract ice. J oint Healt h Claim Init iative [J HCL] (2004) . Generic healt h clai m for oats on blood cholesterol. J udd, J .T. and Clavidence, B. A. (1994 ). Dieta r y tr ans fatt y acids ef fe cts of plasma lipids and lipoprotein on healt h y m en an d women. American Jou rnal o f Cli nical Nutrit ion , 59:861 - 868. Kareli s, A. D., Tex , A. and Herman, D. (2010). Comparison of Sex hor monal and metaboli c profil e between omni vores and vegetarians in pr e and post – menopausal women. Brit ish Journal of Nutri tion , 56: 24-34. University of Ghana http://ugspace.ug.edu.gh 85 Katan, M. B. and Grund y, S.M. (2003 ). Workshop participants. Ef fica c y and safet y of pl ant stands an d sterols in the mana ge ment of blood cholestero l levels. Mayo Clini c Proceedings , 78: 965 – 978. Ke y, T. J. (1999). Mortali t y in vegetari ans and no n - vegetari ans detailed fi ndings from a coll abor ati ve an al ysis of 5 prospecti ve studi es. American Jou rnal of Cli nical Nutrit ion, 70: 88-93. Ke y, T. J., Appleb y, P.N. and Rosell, M.S ., 2006. Healt h eff ects of veget arian and ve gans diets. Proc ee ding of Nutri tion Society, 65: 35 – 41. Kris -Etherton, P. M., NU, F.B., Rose, E. and Sebate, J . (2001). The role of tree nuts and peanuts in the preventi on of coron ar y heart diseas e mul ti ple potential mechanism s. Journal of Nutri ti on, 138:17463 – 17515. Kris -Etherton, P.M. (1999). Mono-saturated fatt y acids and risk of cardiovascular disease. C irculat ion, 100 , . 1253 – 1258. Kris -Etherton, P.M. Seb ate, J . and Harns, W.S . (2003). Fish consum pti on, fish oil s, omega-3 fatt y acids and cardiovas cular disea se. Arteriosclerosi s Thrombosis and Vascular Biology , 23: 45-56. Kumar ,S., S yed, A., Mo hamm ed, J ., Shanawaz , C. and Mamum, A.D. (2012). Nutriti on in lipid profil e in gene ral population and vegetarian indi vidual s living in Rural Ban glad esh. Jou rnal Obesit y and Weight loss Therapy , 55: 123 -138. University of Ghana http://ugspace.ug.edu.gh 86 Kumar, M., Nagp al, R., Verm a, V. and Singh B. (2 012). Choleste rol -lowerin g probiot ics as a potential biot herapeuti cs for met a boli c disease. Diabetes , 22:32 - 43. Kush, I. L. H., Me ye r, K. A. and Jacobs, D. R . (1999). Cere als, Le gu mes and chronic disease redu cti on. Evidence from epidemiol ogical studi es. American Journal of Cli nical Nutriti on , 70: 45: 48. Kyun g, K., Woon, S.C. and Kyoun g, P.Y., 2012. Lon g –term vegetarian s have low ox idative stress, bod y fat, and choleste r ol levels. N utri ti on Rese arch Practi ce , 62 155:161. Lee, J ., Woo, Z. Y., Cha n, S.F., Leun g P. and Peng X. (2000) . Serum fat ty acids, lipid profil e an d dieta r y int ake of Hon g Kong Chines e omni vore s and vegetarians . European jo urnal of Cli nical Nutri ti on. 55; 768 – 773. Leit z mann, C. (2005). V egetari an Diets: What are the Advantages ? Insti tut e of Nutriti onal Sciences, Uni versit y of Giessen, Germ an y. MacVei gh, B. L., Dill ingham, B. L., Lampe, J . W. and Duncan, A. M. (2000). Effects of so ya prot ein var yin g isoflavons cont e nt on se rum lipids in healt h y yo un g men . American Jo urnal of Cli nical nutrit ion, 25:244 – 251. Mahan, L.K, Escott -S tum p, S. and Ra ymond, J . (2012). K rause Fo od and Nutri ti on Therapy Care Process. 13 t h ed. Phil adelphi a: S aunder Elsevier. University of Ghana http://ugspace.ug.edu.gh 87 Mancil a-C arv aho , J .J . and Crews, D.E. (1990). Lipi ds profil e of Yan omano Indians of Braz il . Journal of Preventi on Medicin e, 67:13 -27. Marlow, H. J., Hayes, W . K., Soret, S., Charter, R. L., Schweb, E. R., and Sabate. A. (2009). Diet and the environment: Does what you eat matter? Journal American Clini cal Nutri tion , 59:16995 – 17035. Marsh, K., Zeuschne r, C., and Saunders, A. (2 011). Healt h impli cati on s of a Vegetari an Diet. Am eric an Journal Lif estyle Med ication , 1 (10): 1177. Melina, V. and Davies, B. (2 003). T he ess enti al guide to a healt hy vegetari an Diet . USA: Healt h y living Publi cati on. Mensink, R. P., Zo ck, P. L., Keste r, A. M. and Kantan, M. B. (2003). Ef fects of dietar y fatt y acids and carboh ydrat es on the rati o of serum tot al to HDL cholesterol and on se ru m lipids and apoli poproteins: A meta – anal ysi s of 60 controll ed trials. America n jour nal Cli nical Nutri tion, 77: 1146 –1155. Messina, V., Man gels, A.R. and Messia, M. (2004) . The dietitian’s guide to vegetari an diets, iss ues and applications (2 nd ed. ), Jones and Barlett : Sudbur y. Mill ward, D. J. (2004). Protein and ami noacid requirements of athl etes . Journal of Sports Science , 22: 14 3 – 145. University of Ghana http://ugspace.ug.edu.gh 88 Mukuddem-P etersen,J ., Oothuiz ia, W. and Jerling J . C.(2005). A syst ematic review of nuts on blood lipid profi le in humans. . American Sco ciet ies for N utri ti onal Sciences ,133,2082 -2089. Nati onal Cholesterol Educati on Pro gram [NC EP] (2002). Ex pert panel on detention, evaluation an d treatm ent of hi gh blo od cholesterol in adult s (Adult Treatm ent Panell III) . Fi nal Report Circulat ion, 106: 3143. Nelm s, M., Sucher, K. P., Lac e y, K. and Roth, S. L. (2011). N utri ti on Therapy and Pathophisiol ogy (2 n d Ed .) USA: Wadsworth Cenga ga Le arnin g In c. Nivedit a, S., Singh, S. P. and Raiz ada, A., (2 012 ). A compa rati ve st ud y on param ete rs of lipid meta boli sm and fasti ng blood suga r in normal ve geta ria ns and non – vegetarians. Journ al of Advanced Resear ch in Biol ogical Sciences , Vol. 4 (4) 306 – 311. Pinedo, S., Vissers, M. N., Von - Ber gmann, K. and Elharch aoui, F. (2007). Plasma lev els of plant sterols and the risk of coronar y arter y disea se: The perspecti ve EP IC – Norf olk Population Stud y. Jo urnal of lipid Research., 48: 139 – 144. Poppit t, S.D. Hayes, D. and Keo gh, G. F. (200 2). Lipi d lowe rin g ef fec ts of a modi fied butt er fat: A controll ed int erventi on trial in healt h y men. Eu ropean Journal of Cli nical Nutriti on, 56:64 – 71. University of Ghana http://ugspace.ug.edu.gh 89 R auma, A. L. and M ykan an, H., 2000. Antiox idant status in vegeta rians an d non - vegetarians. Journal of Amer ican Nutrit ion, 16:109 -119. Redd y, K.S. and Kata n, M.B. (2004). Diet, nutriti on and the prev enti on of hype rtension and ca rdiovascular diseas es. Publi c Healt h Nutri ti on, 7 (1A):167 - 186. Reiner, Z., Catap ano, A. L., Grah am, I. and Taskinen, R. K. (2011) . European Societ y of Cardiolog y. Guideli nes for the mana gement of d ysli pidaemi as . European Heart Journal , 32:1769 -1819. Richter, V., Rassoul , F., Hentschel, B., Kothe, K. and Krobora, M. (2004). Age – dependen ce on li pid paramete rs in the gener al population and ve ge tarians . Geront ol Geriat r. 37: 207 – 213. Rideout, T. C., Haerdin g S. V., Jones D. J. and Fan M. Z. (2008). Gua r gu m and sim il ar solub le fibre in the regulation of ch olesterol metaboli sm: Current understandin gs and futur e resea rch priori ti es vasc ular Healt h Risk Management. European Journal of Cli nical Nutri ti on , 44: 1023 – 1033. Rizz o, N.S., Sebate, J ., Jacelot o, K. and Fr aser , G. (2008). Vegetarian diet s are associated wit h lower risk of metaboli c s yndrome. T he Adventi st Healt h Study 2. University of Ghana http://ugspace.ug.edu.gh 90 5oEinson ). and +acNett $.  . 9egetarianism. :hat’s in the name" Ve getari anism and Healt h: A Discussi on of curr ent ideas. Liv erpool: Li verpool J ohn Moores Universit y. Roche, H. M., Gibne y, M. J. (2003). Effe ct of long chain n – 3 pol yuns aturate d fatt y acids on fasti ng and post prandial triagl yce rol metaboli sm. American Journal of Cli nical Nutrit ion , 71:98 -101. Rochfert, S. and Panoz z o, J . (2007) . P h yto che mi cals for Healt h, the role of pulses . Journal of Agri cult ural and food chemist ry, 34:21 -27. Sacks, F. M. (2006). S o y protein, isoflavon es and cardiov ascular he alt h. A summ ar y of a statem ent for prof essi onal from t he Americ an he art Asso ciation Nutriti on Comm it tee. Artheriosclerosi s Thrombosis Vascular Biol ogy, 26:1670 - 1689. Schnit z er, S.A . (2005). A mechanist ic ex planati on for the global patt erns of liana abundanc e and distribut ion. T he American Nat ural ist , 166 : 262-276. Sebate, J . (2003). The Contribut ion of vegetari an diet to healt h and disease: paradi gm shi ft. American Journal of Cli nical Nutriti on , 783, pp. 5025 – 5075. Sebate, J., Fraser, G. E., Burke, K., Knust sen, S., Bennet, H., and Linst ed, K. D. (1993). Eff ects of w alnut s on serum lipid levels and bloodpressure in normmal men. Nutriti on Engli sh Journal of Medicine. 328: 603 –607 . University of Ghana http://ugspace.ug.edu.gh 91 S ingh, P.N, Sabote, J . and Fras er, G.E. (2003) . Does low meat consum pti on increas e life ex pectanc y in humans? American Journal of Cli nical Nutri tion, 78 (3): 5265 – 5325. Smith, C., Burk, L.E. and Wing, R. (2000). Vegetarians and weight l oss diet among youn g adult s. Obesit y Research , 8:123 -12 9. Spencer C. (2000) . The Hereti cs feast: Hist ory of vegetari anism, England: Universit y Pr ess of New England. St – Onge, M. P., Aban, I. B., Osar ge, A., Gowe r, B, Hecker, K. C. and Alli son , D. B. (2007). Snack chips fried corn oil all eviat e ca rdiovascula r dise ase in risk factors wh en subst it uted for low fat or hi gh fat snacks. American Jour nal of Cli nical Nutrit ion , 45:78-56. Stampfer, M. J. and Kra use, R. M. (1996). A pr ospecti ve stud y of tri gl yceride level, low densit y lipo protein particles diame ten, and risk of m yo cardial infarcti on. Journal of the American Me dical Associat ion, 276 : 882 – 888. Stanhope, K. L., Schw a rz , J .M., Keim , N. L., Griffen, S.C ., Br emer, A.A. , Graham, J . L. and Hat cher, B. (2009). Cons umi ng fru ctose -sw eeten ed, not glucose -swe etened, bev era ges incre ases visc er al adipos it y and lipids and decre ases insul in sensit ivi t y in over wei ght/ obes e humans. Journal of Cli nical Investment , 20119 (5):13 22 -1334. University of Ghana http://ugspace.ug.edu.gh 92 S tephens, D. Hean y, R. and Ni gel, G. (1996). Randomi z ed controll ed trial of vit ami n E in pati ents with corona r y diseas e . Cam bridge Heart anti ox idant stud y. T he lancet volume 347. 6Xn $. <.  . ³7he )rench 3arado[´ and Eeyond. 1eXroprotectiYe eff ects of pol yphenols 2) . Fr ee Rad ical Biol ogy Medicine , 32: 314 -321. Taku, K., Ume gaki, K., Sato, Y., Taki, Y. an d Wantanabes. F. (200 7). So y isoflavons lower se rum tot al and LD L cholesterol in humans : A meta anal ys is of II randomi z ed contrail trial. American Journal of Cli nical Nutri ti on, 66: 1148 – 1156 . Thomas, B. and Bishop , J . (2007). Manual of Di e tetics Practi ce . 4 t h ed. Ox ford: Blackw ell Publi shing Ltd . Tonstad, S., Butl er, T.Y. and Franser, G.E. (2009 ). Typ e of vegetarian die t, bod y weight and prev alenc e of t ype 2 diab etes. Diabete s Care , 32: 791 – 795. Toohe y, M. L., Harris, M., Foster, G. and Me lb y, L. (1998). Cardiov ascular disease risk factors are lower in Afri can - Ameri can ve gans compar ed to lacto - ovo -ve geta rians. Journal of the American C oll ege of Nutri ti on , 5:425 -434. Trichopoulou, A, Costacou, T, Bami a C. and Trichopoulou, D. (2003). Adheren ce to a Medite rrane an diet and surviv al in Greek population. N ew England Journal of Cli nical Medicine , 348:35 -43. University of Ghana http://ugspace.ug.edu.gh 93 Van - Dam, R. M., Wil let, W. C., Ri mm , E. B. , Stampfer, M. (2008). Meat, processed m eats, obesit y, wei ght gain and occur r ence of diabet es amon g adult s. Findi ngs from Adventi st healt h studi es. American Nutriti on Metabol ism, 52, 33: 96 – 104. Van Dam, R. M., Wil let, W. C., Rim m, E. B., Stampfer, M. J. and Hu, F. B. (2002). Dieta r y fat and meat int ake in relation t o risk of t ype 2 diabetes in men . Diabetes Care , 25: 417 – 424. Vander, M., Caa g, M. S. and Van -Tol, A. (2001). Al cohol cons umpt ion sti mul ates earl y steps in revers e cholester ol trans port . Lipids Research, 42: 2077 – 2083. Watanbe, F. (2007). Vitamin B 1 2 sources and bioavail abil it y. Experience Biol ogical Medicine , 23 7 :1266 – 1274. Weaver, C. M., Proulx , W. R. and Heane y, R. (1999). Choices for ac hieving adequate diet ar y calciu m with a veget arian die t. American Journal of Cli nical Nutri ti on , 70 : 5435 – 5485. Webster – Gand y M adde n, A. and Holdsworth, M. (2006). O xford hand book of Nutri ti on and Dietetics ; New York: Ox ford Univ ersit y Press. Whit e, R. F., Se ymour, J ., Fra nk, E. (1999). Veget arianism amon g us women ph ysicians. Journal of American Diet Associat ion . 99: 595 – 598. University of Ghana http://ugspace.ug.edu.gh 94 W il li am, B., Poult er ,N.R., Brown, M. I. and Davies, M. (2004). Britis h Hyp ertensive Societ y. Guidelines for mana geme nt of hyp ertension . Jour nal of Human Hypert ension 18:138 -185. Woo, J ., Kwok , T ., Suz anna C. and Appril le S. (1998). Nutriti onal status of elderl y Chinese ve getaria ns . Age and Aging 29: 455 – 461. World Healt h Organiz ati on (2000). T urni ng the tide of malnutr it ion. Responding to the chall enge of the 21 st century. World Healt h Organiz ati on. Geneva. www.edu.pe. ca/souris hin g/pa ges/C mp6 -03/Beth/ h omepa ge/hi stor yof vegetarianism .htm . (Asse ssed on Januar y 11, 2013 ) www.edu.pe ca./souris hin gpa ges/C mp6 -03Beth/ ho mepa ge/hi stor yof vegetarianism htm . (Asse ssed 11/01/2013). www.ehow/how_do es_ra isi ng_hdl_ve geta rian_die t.ht ml . (Assessed 16/12/ 2012) Yashodhar a, B. M., Uma kanth , S., Pappacham, J .M, Bhat, S.K., Kamath, R. and Choo, B.H. (2009). Ome ga -3 fatt y acids: A comp rehensive review of their role in healt h and diseas e. Postgr aduate Medical Journal .34:256 -264. Young, V.R. and Pell et, P. L. (1994). Plant prot e in in relation to human protein and ami no acid nut rition . American Journal of Cli nical Nutri ti on, 71:120 – 135 . University of Ghana http://ugspace.ug.edu.gh 95 Appendix I UNIVERSITY OF GHANA SCHOOL OF ALLIED HEALTH SCIENCES INFORMED CONSENT FORM I am Cedell Naa Oblik ai Tett eh, condu cti ng a resea rch er on lipids pr ofil e of vegetarians and non -ve ge tarians. I am a final ye a r student offerin g MSc. Dietetics with the school of Alli ed Healt h Scien ces, Coll e ge of Healt h Scien ces, Un iversit y of Ghan a, Korl e Bu. Th e main fo cus of thi s pro posed stud y is to dete rmine the relations hip betwe en dietar y cholest erol int ak e and plasm a lipids among vegetarians and the gene ral population. About 10ml (2 teaspoons, the amo unt of blood usuall y requir ed to test the blood) will be dr awn from you to measure lipids in the blood. Your height, weight, and waist circu mferen ces will be measured and be requir ed to answe r fe w questi ons about you rse lf. The information provide d will no t be harmful to yo u in an y wa y. You are assured that the information pro vided will be avail able onl y to the scientis t con ducti ng the stud y and will be kept confidenti al and secure. If the information is publi shed in the scientific journ al, you will not be identif ied by name. This study ma y contribut e to the ex ist ing knowled ge of vegetari an diet and cholest erol levels. There is no risk invol ved in the stud y, ex cept a litt le discomfort and bruisi ng yo u will ex perience at the sit e of blood drawn. Partici pati ng in thi s stud y is vol untar y, without an y cost and you are free to withdraw at an y point in time without losi ng an y m edical treatm ent. The resea rche r will be avail able and will in g to answe r an y fu rther qu esti ons about the rese arch, no w or during th e cours e of th e project. University of Ghana http://ugspace.ug.edu.gh 96 C ONS ENT I agre e that the resea rch project named above has been ex plained to m y sati sfacti on and I agre e to take part in this stud y. I understand that I am agr eein g by m y si gnature/t humbpr int on form to take part i n thi s resear ch project an d I understand I will re ceive a signed cop y of this con sent form for m y records. NAME OF RESEAR C H ER: Cedell Naa Oblikai Tetteh '$7( ……………………………… 6,*1$785( ………………………… TELEPHO NE NUM BE R : 0243851887 1$0( 2) 3$57,&,3$17 ……………………………………… SIGN ATUR E/THUM BP R INT  …………………… '$7( ……………… 02%,/( 180%(5 ………………………………… University of Ghana http://ugspace.ug.edu.gh 97 Append ix II QUESTIONNAIRE (Section A) 3articipant’s ,' ……………………….. 'ate…………………………… Socio ±Demograp h ic Status 1. Age of participant ( ye ars ) 20-29 [ ] 30-39 [ ] 40-49[ ] 50 -59 [ ] 60 and above [ ] 2. Gender i. Male [ ] ii. Female [ ] 3. Marit al Status i. single [ ] ii. Married [ ] iii. Divorced [ ] iv. Widowed [ ] v. separat ed [ ] 4. R eli gion i. Christ ian [ ] ii. Musl im [ ] iii Buddhis ts [ ] iY. +indX > @ Y. 2thers pOease speciIy ………………………… 5. Educati onal Back ground i. No formal educ ati on [ ] ii. Basic edu cati on (middl e/J HS) [ ] iii. SHS/ O –Lev el [ ] iv. HND/Dipl oma Certi ficate [ ] v. Bach elor De gre e [ ] vi. Post Degre e [ ] 6. Empl o ym ent Status: i Emplo yed [ ] ii Unempl oye d [ ] iii Reti red [ ] IV. Student [ ] 7. Are you a vegeta rian? YES [ ] NO [ ] E. ,I