Plant-based Dietary Patterns
Recent trending plant-based diets, which include Vegan, Vegetarian, Flexitarian, Plant-forward and Whole-food diets align with Healthy Vegetarian eating guidelines. The Vegetarian diet pyramid can be seen in Figure 1.53
Figure 1: Healthy Vegetarian and Vegan Eating Patterns
There are several reasons why patients may be choosing a plant-based diet, including weight loss, heart health, high fiber or sustainable eating. The science confirms that these trending plant-based dietary patterns truly are beneficial for weight control and disease prevention. Taking this further, fruits and vegetables are low in calories and fat, and provide healthy dietary nutrients and components necessary for a healthy oral cavity, including fiber, vitamins and minerals and phytochemicals. The good news is that this style of eating, which is often referred to as “plant-forward” is currently a significant culinary mega-trend according to the Culinary Institute of America. It is defined as “eating that emphasizes and celebrates, but is not limited to plant-based foods-including fruits and vegetables (produce); whole grains; beans, other legumes (pulses) and soy foods; nuts and seeds; plant oils; and herbs and spices-and that reflects evidence-based principles of health and sustainability.”54
The newly released 2020-2025 Dietary Guidelines for Americans (DGA) recommend that our patients follow one of three dietary patterns - Healthy U.S.-Style, Healthy Vegetarian or Healthy Mediterranean-Style, as part of a healthy lifestyle, in order to maintain a healthy weight, promote overall health and reduce risk of chronic disease. The DGA define a healthy dietary pattern as “meeting food group and nutrient needs with nutrient-dense foods and beverages, and limiting intake of foods and beverages that are not nutrient-dense.”1 All of these dietary patterns include limiting foods high in sodium, saturated fat and sugar, while emphasizing fruits, vegetables, whole grains, nuts, seeds, legumes, herbs, spices, healthy fats, dairy or alternative and lean proteins. The DGA recommends that we eat 2 cups of fruits and 2.5 cups of vegetables per day and that ½ of the grains we eat should come from whole grains. Multiple studies have concluded that fruit, vegetable and whole grain consumption is associated with weight loss and also linked to reduced risk of weight gain, overweight and obesity. A 2020 comprehensive narrative review points out how increasing intake of fruits and vegetables to the levels recommended in the DGA contributes to successful weight loss in women. Fruits and vegetables along with legumes, nuts, seeds and whole grains are fiber-rich. They are digested slowly and keep us feeling full longer. Eating foods that are high in fiber and low in calories help complement weight loss.55 A systematic review of 14 studies evaluated the relationship between vegetable intake and change in weight-related outcomes among adults using prospective cohort studies. The studies that explored change in vegetable consumption over time discovered a beneficial relationship between increasing vegetable intake and weight control. Higher vegetable intakes were associated with the lowest risks of weight gain. The largest risk reduction was observed in a study of Spanish adults, whereby those consuming ≥ 4 vegetable servings per day over a 10-year period had an 82% reduced risk of gaining more than 3.4 kg. This evidence suggests that diets that more closely adhere to the recommended daily vegetable intake may reduce the risk of weight gain in the long term.56
A large meta-analysis of 12 RCTs compared weight loss among vegan and lacto-ovo-vegetarians versus low-fat and low-carbohydrate diets. Results indicated that the vegetarians and vegans had significant weight reduction compared to non-vegetarians. The individuals who were following vegan diets had the greatest weight loss.57 Even though a vegan diet may be beneficial for weight control, there is a risk for potential nutritional deficiencies, including vitamin B12, protein, omega-3 fatty acids and iron. There are limited food options for vegans trying to meet their B12 needs, and they include: nutritional yeast, fortified plant-milks, plant-based meats, fortified cereals, tempeh, and nori seaweed. Strict vegans often benefit from the guidance of a registered dietitian.58 It is also important to note that Vitamin B12 deficiency can show up as oral manifestations, including glossitis, glossodynia, recurrent oral ulcers, angular cheilitis, dysgeusia, lingual paresthesia, burning sensations, and pruritus. The presence of any of these oral symptoms, together with a vegan dietary history, may offer the dentist an opportunity to aid in diagnosing a vitamin B12 deficiency.59
A recent large-scale cross-sectional study utilizing data from the National Health and Nutritional Examination Survey (NHANES) that was published in JADA, shed light on the relationship between a healthful eating pattern and oral health benefits in adults. The researchers examined decayed, missing, filled teeth and compared this data to Healthy Eating Index (HEI) scores. This is a score that is based on how closely overall diet quality aligns with the DGA.60 This study highlighted that higher HEI scores were associated with less untreated caries and specifically, when these individuals ate more plant-based whole foods, including whole fruits and total fruits, greens and beans this resulted in a decrease in caries risk.61 Additionally, a small German study linked specific nutrients that are plentiful in an “anti-inflammatory” plant-based dietary pattern to potential oral health benefits and reduced gingivitis. This RCT looked at adults who following an “anti-inflammatory” whole food diet for 4 weeks, defined by researchers as a diet low in processed food and high in plants. At the end of the study, the “anti-inflammatory” diet group, eating more foods rich in omega-3 fatty acids, vitamins C and D, antioxidants and fiber, had significant reduction in gingival bleeding, compared to the adults eating their regular diet. “Dental teams should address dietary habits and give adequate recommendations in the treatment of gingivitis, since it might be a side effect of a pre-inflammatory Western diet,” is the advice written in the article.62 Furthermore, a separate large-scale systematic review of 4 intervention studies, 3 cohort studies and 8 cross-sectional studies included 10,604 people ages 15-90. The results suggest eating at least 5 servings of fruits and vegetables a day in order to potentially prevent the progression of periodontal disease and tooth loss.63 This guidance is in line with the DGA and the advice that healthcare professionals have been preaching for decades, “Eat your 5-a-day.” Registered dietitians believe in food first and encourage patients to follow a whole food plant-based dietary pattern, per the DGA guidance. However, recent data indicates that Americans are grossly underconsuming fruits, vegetables and whole grains. 80% of the population are not meeting the fruit recommendation, 90% are not meeting the vegetable recommendation and 98% are not eating enough whole grains.1
By encouraging your patients to select a nutrient-dense, plant-based dietary pattern, your patients can maintain a healthy weight, healthy dentition, healthy periodontium and prevent oral and systemic disease. The need for a balanced approach to weight loss and maintenance is of paramount importance for reaching the goal of sustaining a healthy weight and oral cavity throughout the lifecycle.
The bottom line: As oral healthcare provider you can recommend that patients increase their fruit and vegetable intake, as part of a wholesome, nutrient-dense plant-based dietary pattern. There are many benefits to following a plant-based diet. Not only does eating fruits and vegetables as part of a healthful plant-based dietary pattern foster a healthy weight, it also promotes a healthy oral cavity and periodontium as well.