Nutrition 31 (2015) 350358

Contents lists available at ScienceDirect

Nutrition
journal homepage: www.nutritionjrnl.com

Applied nutritional investigation

Comparative effectiveness of plant-based diets for weight loss:

A randomized controlled trial of ve different diets
Gabrielle M. Turner-McGrievy Ph.D., R.D. a, *, Charis R. Davidson M.P.H. a,
Ellen E. Wingard M.P.H., R.D. b, Sara Wilcox Ph.D. b, Edward A. Frongillo Ph.D. a
a
Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South
Carolina
b
Department of Exercise Science, Arnold School of Public Health, Public Health Research Center, University of South Carolina, Columbia,
South Carolina

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 2 July 2014
Accepted 5 September 2014

Objective: The aim of this study was to determine the effect of plant-based diets on weight loss.
Methods: Participants were enrolled in a 6-mo, ve-arm, randomized controlled trial in 2013 in
South Carolina. Participants attended weekly group meetings, with the exception of the omnivorous group, which served as the control and attended monthly meetings augmented with weekly
e-mail lessons. All groups attended monthly meetings for the last 4 mo of the study. Diets did not
emphasize caloric restriction.
Results: Overweight adults (body mass index 2549.9 kg/m2; age 1865 y, 19% non-white, and 27%
men) were randomized to a low-fat, low-glycemic index diet: vegan (n 12), vegetarian (n 13),
pesco-vegetarian (n 13), semi-vegetarian (n 13), or omnivorous (n 12). Fifty (79%) participants completed the study. In intention-to-treat analysis, the linear trend for weight loss across the
ve groups was signicant at both 2 (P < 0.01) and 6 mo (P < 0.01). At 6 mo, the weight loss in the
vegan group (7.5%  4.5%) was signicantly different from the omnivorous (3.1%  3.6%; P
0.03), semi-vegetarian (3.2%  3.8%; P 0.03), and pesco-vegetarian (3.2%  3.4%; P 0.03)
groups. Vegan participants decreased their fat and saturated fat more than the pesco-vegetarian,
semi-vegetarian, and omnivorous groups at both 2 and 6 mo (P < 0.05).
Conclusions: Vegan diets may result in greater weight loss than more modest recommendations.
2015 Elsevier Inc. All rights reserved.

Keywords:
Vegetarian
Vegan
Obesity
Weight loss
Diet

Introduction
Well-planned vegan and vegetarian diets can provide
adequate nutrition, and have demonstrated health benets in
disease prevention and treatment [1]. Vegan and vegetarian diets have been used effectively for weight loss and maintenance
[2,3]. Anchoring the two ends of the plant-based dietary spectrum are vegan diets (exclude all animal products) and omnivorous diets (omni: no foods excluded). Between these two diets
are other plant-based diets, such as semi-vegetarian (semi-veg:

GTM and SW designed the research study. GTM, EEW, and CRD conducted the
research. EAF performed statistical analysis. GTM, SW, and EAF wrote the paper.
GTM had primary responsibility for nal content. The authors have no conicts
of interest to declare.
* Corresponding author. Tel.: 1 803 777 3932; fax: 1 803 777 6290.
E-mail address: Brie@sc.edu (G. M. Turner-McGrievy).
http://dx.doi.org/10.1016/j.nut.2014.09.002
0899-9007/ 2015 Elsevier Inc. All rights reserved.

occasional meat intake), pesco-vegetarian (pesco-veg: excludes

meat except seafood), and vegetarian (veg: excludes all meat and
seafood, but contains eggs and dairy products). Several epidemiologic studies have examined differences in weight-related
outcomes among these diets, nding lower body weights [4]
and less weight gain over time among vegans compared with
other groups [5].
These prospective cohort studies [4,5] examining the ve
diets along the plant-based dietary spectrum have categorized
participants according to their preexisting dietary patterns,
making it difcult to account for the inherent differences that
may exist among individuals who self-select different patterns.
To date, there have been no randomized trials comparing the
effectiveness of these ve different diets on weight loss. Therefore, the goal of this study was to examine the differences in
weight loss among participants randomized to adopt an
omnivorous, semi-vegetarian, pesco-vegetarian, vegetarian, or

G. M. Turner-McGrievy et al. / Nutrition 31 (2015) 350358

vegan diet. Transitioning to plant-based diets may lead to greater

increases in ber [68], with high-ber diets being associated
with lower body weights in epidemiologic studies [9], and
greater decreases in dietary fat [68], with studies showing that
low-fat diets are associated with weight loss [10]. Because of
these potential changes in nutrients among groups, we hypothesized that differences in weight loss would follow similar patterns seen in epidemiologic studies with weight loss being
incrementally greater along the plant-based dietary spectrum
from omni to semi-veg to pesco-veg to veg to vegan diets.
Furthermore, we hypothesized that the vegan group would have
signicantly greater weight loss compared with the pesco-veg,
semi-veg, and omni groups.
Materials and methods
The New DIETs (New Dietary Interventions to Enhance the Treatments) for
weight loss study was a 2-mo weight loss intervention with a 4-mo follow-up
period. Recruitment and exclusion criteria are described elsewhere [11]. Briey,
overweight or obese (body mass index [BMI] 2549.9 kg/m2) adults, who were
interested in losing weight, were between the ages of 18 and 65 y with a stable
medical status (e.g., no uncontrolled thyroid conditions or diabetes), and were
willing to accept random assignment of diet, were recruited through worksite
listserv messages and newspaper ads. Participants attended an orientation session to learn about questionnaires and complete a consent form. Participants
were informed that the purpose of the study was to assess changes in body
weight after randomization to one of ve different diets. Questionnaires assessed
demographic characteristics, dietary intake from 2 d of unannounced 24-h dietary recalls (one weekday and one weekend day) collected and analyzed using
the automated self-administered 24-h dietary recall [12], and physical activity
(Paffenbarger Physical Activity Questionnaire) [13].
Once all participants completed baseline questionnaires, they were randomized to one of the ve diets using a computerized random-number
generator and stratied by BMI and sex (both self-reported on screening
questionnaires). Before revealing randomization assignment, weight was
measured in light street clothes without shoes using a calibrated digital scale
(SECA 869, Hamburg, Germany) accurate to 0.1 kg. Height was measured using a
stadiometer (SECA 213) after participants had removed hats and shoes. All
measures (with the exception of height and demographic characteristics) were
assessed at baseline, 2 mo, and 6 mo. A university Institutional Review Board
approved the study, and all the participants gave written informed consent.
Participants received a $20 incentive payment for completion of all 2-mo
assessment activities, but did not receive any incentives for completion of 6mo assessments.
Intervention diets
After all baseline measurements were assessed, participants met with their
randomized group. All participants received a handout that provided details on
their assigned diet, including food groups that can be included and ones that
should be avoided, and details on low-fat cooking instructions and the glycemic
index [14]. Two registered dietitians with graduate degrees and expertise in all
the study diets led the classes. These research dietitians provided participants
with the orientation presentation that detailed menu planning and reviewed
recipes given to each group. All groups were provided with several foods to
sample during the rst class. Self-monitoring dietary or energy intake was not
required by any of the groups and was not discussed at group meetings. Participants were free to eat whenever they wanted and at a frequency of their own
choosing as long as it adhered to their diet assignment. All participants were
encouraged to limit fast foods and processed foods in favor of more minimally
processed foods to meet low-fat and low-glycemic index dietary recommendations. Participants could dine out and were instructed on how to make healthy
choices at restaurants.
Table 1 provides an overview of the ve intervention diets used in the New
DIETs study as well as sample dinner menus. Because both low-glycemic index
[15] and low-fat diets [10] are associated with weight loss, all participants were
instructed to follow diets that favored low-glycemic index and low-fat foods.
Participants were told they could include limited amounts of nuts and nut
butters, avocados, seeds, and olives in their diets but were encouraged to focus
on lower fat food options. There was no recommended restriction on energy
intake for any of the ve groups. All groups attended weekly 1-h meetings for 8
wk, with the exception of the omni group. The omni group allowed for the
examination of consuming a usual diet (as all participants were following an
omnivorous diet at baseline), while at the same time controlling for the selection made by all participants to participate in a weight loss study. The omni

351

group attended meetings at baseline, 1 mo, and 2 mo, and received their dietary
information by e-mail, which included a weekly lesson plan covering the same
topics addressed in the group sessions as well as an e-mail message providing
an overview of the lesson information. Previous research studies have used this
method of providing weekly e-mail lessons for a weight loss intervention [16,
17]. In summary, the omni group allowed for the examination of what would
occur via minimal intervention with no recommendation to limit food groups
(i.e., usual diet).
Although only vegan diets require supplementary vitamin B12 [1], to control
for supplement intake across groups, all participants were required to purchase
and take a multivitamin or other form of vitamin B12 daily. After the 2-mo main
intervention was completed, all participants (including the omni group) were
offered monthly meetings to assist with dietary maintenance. Participants were
also provided with a private Facebook group for their diet group after the 2-mo
mark to provide social support in between monthly meetings (joining was
optional). After the 2-mo intensive intervention phase, participants were
encouraged to continue following their assigned diet and meet with their diet
group each month. Participants were told they could make alterations to the diet
if they needed to but were encouraged to maintain their dietary changes. Participants received handouts and recipes related to the session topic for every
meeting during the 6-mo study. Topic sessions for all the group meetings were
informed by the Diabetes Prevention Program [18] and were grounded in social
cognitive theory [19]. Each class included food samples or a cooking demonstration. All group sessions covered identical topics among the ve groups with
the only difference being the type of diet discussed. The rst eight topic sessions
for all groups were as follow:
1.
2.
3.
4.
5.
6.
7.
8.

Overview of assigned diet

Grocery shopping tips
Meal planning and dining out
Recipe modication
Grocery store tour
Problem solving: handling holidays and family pressures
Dealing with weight plateaus and the slippery slope
Ways to stay motivated.

Participants met with only their assigned diet group, which corresponded to
a day of the week. Dietary adherence was measured as the absence of any proscribed foods from the dietary recalls (e.g., absence of meat, dairy, and eggs from
vegan participants food records). Participants in the omni group were considered adherent if their percent energy from fat was 40%. This method of
assessing dietary adherence has been used in previous studies [3,20].

Statistical analyses
The study was powered to detect a signicant difference in weight loss at
2 mo among the ve groups with a signicant trend in weight loss demonstrating
a decrease in percent body weight incrementally going from the omni, semi-veg,
pesco-veg, veg, through the vegan group. Assuming a mean incremental difference in change in body weight of 1% successively between each of the ve groups
(corresponding to an effect size of 0.57), a pooled SD of 2.5%, and signicance at a
0.05, a sample size of 60 participants (12 per group) was estimated to provide
94% power for the linear trend among the ve groups [21]. The sample size of 12
per group provided 80% power for differences of 2.85% for linear contrasts
between two groups. Attrition was dened as a participant not completing the
main outcome of body weight at either 2 mo (for 2-mo outcomes) or 6 mo (for
6-mo outcomes).
For differences in baseline demographic characteristics, analysis of variance (ANOVA) was used with the Tukeys test for post hoc analyses of
continuous variables and c2 test of independence was used for categorical
variables. Change in percent weight loss among the ve groups was analyzed
at both 2 mo (after the intensive intervention) and at 6 mo (to assess weight
loss maintenance) using one-way ANOVA. To test that weight loss would be
incremental among the ve groups (going from the vegan group losing the
most to omnivores losing the least), an a priori linear contrast for trend was
used at each time point. Additionally, three a priori linear contrasts among the
specic groups were examined at each time point: vegan versus omni, vegan
versus semi-veg, and vegan versus pesco-veg. Because weight loss differences
between veg and vegan participants were expected to be smaller than the
other groups, this study was not powered to detect weight loss differences
between veg and vegan. Missing data for body weight was handled in two
ways: 1) baseline observation carried forward for missing values at each time
point (assuming no change) and 2) weight gain imputed at a rate of 0.3 kg/mo.
This rate of weight gain has been shown to commonly occur during behavioral
weight loss interventions [22,23] and has been used as the weight gain
amount for other large, dietary weight loss trials [24,25]. Weight gain was
extrapolated from time of attrition up through the 2- and 6-mo assessment

352

G. M. Turner-McGrievy et al. / Nutrition 31 (2015) 350358

Table 1
Description of the ve intervention diets and example meals
Dietary group

Denitions of diet patterns

Example day of meals

Vegan

Does not contain any animal products (meat, sh, poultry, eggs,
or dairy) but emphasizes plant-based foods,
such as fruits, vegetables, whole grains, and legumes/beans.

Breakfast
 Oatmeal with cinnamon and soymilk topped
with sliced strawberries
Lunch
 Hummus sandwich with lettuce, tomato, and
mustard on pumpernickel bread
 Baked tortilla chips
 Baby carrots

Vegetarian

Does not contain meat, sh, or poultry but does contain eggs
and dairy, in addition to plant-based foods,
such as fruits, vegetables, whole grains, and legumes/beans.

Dinner
 Soft tacos made with whole wheat tortillas, black
beans, roasted peppers, and salsa
 Fruit salad
Breakfast
 Oatmeal with cinnamon and 1% milk topped
with sliced strawberries
Lunch
 Hummus sandwich with lettuce, tomato, reduced-fat
feta, and mustard on pumpernickel bread
 Baked tortilla chips
 Baby carrots

Pesco-vegetarian

Does not contain meat or poultry but does contain sh and shellsh,
eggs, and dairy, in addition to plant-based
foods, such as fruits, vegetables, whole grains, and legumes/beans.

Dinner
 Soft tacos made with whole wheat tortillas, black
beans, roasted peppers, reduced-fat cheddar cheese,
and salsa
 Fruit salad
Breakfast
 Oatmeal with cinnamon and 1% milk topped with
sliced strawberries
Lunch
 Hummus sandwich with lettuce, tomato, reduced-fat feta,
and mustard on pumpernickel bread
 Baked tortilla chips
 Baby carrots

Semi-vegetarian

Omnivorous

Contains all foods, including meat, poultry, sh and shellsh, eggs,

and dairy, in addition to plant-based foods,
such as fruits, vegetables, whole grains, and legumes/beans. However,
red meat is limited to once per week
and poultry is limited to 5 times per week.

Contains all food groups.

Dinner
 Soft tacos made with whole wheat tortillas, sh (mahi mahi),
roasted peppers, reduced-fat cheddar cheese, and salsa
 Fruit salad
Breakfast
 Oatmeal with cinnamon and 1% milk topped with
sliced strawberries
Lunch
 Hummus sandwich with lettuce, tomato, reduced-fat
feta, and mustard on pumpernickel bread
 Baked tortilla chips
 Baby carrots
Dinner
 Soft tacos made with whole wheat tortillas, chicken,
roasted peppers, reduced-fat cheddar cheese, and salsa
 Fruit salad
Breakfast
 Oatmeal with cinnamon and 1% milk topped with
sliced strawberries
Lunch
 Chicken breast sandwich with lettuce, tomato, reduced-fat
feta, and mustard on pumpernickel bread
 Baked tortilla chips
 Baby carrots
Dinner
 Soft tacos made with whole wheat tortillas, ank steak,
roasted peppers, reduced-fat cheddar cheese, and salsa
 Fruit salad

G. M. Turner-McGrievy et al. / Nutrition 31 (2015) 350358

periods. Both methods of imputation for missing data yielded similar results;
therefore only analyses that used a weight gain of 0.3 kg/mo imputed for
missing data are presented. Missing dietary and physical activity data were
analyzed by carrying forward baseline observations, assuming no change in
dietary intake or physical activity. All analyses were conducted using SPSS 21.0
for Windows software (SPSS Inc., Chicago, IL, USA) with a P 0.05 to indicate
statistically signicant differences.

353

Results
Participants were screened in February 2013 and the trial was
completed by August 2013. Of 219 participants who were
screened, 63 (29%) were randomly assigned to a diet. At the 2-mo
assessment time point, 57 (90%) of those assigned to a diet

Fig. 1. CONSORT diagram showing the ow of participants through each stage of the New DIETs 6-mo weight loss trial. BMI, body mass index; New DIET, New Dietary
Interventions to Enhance the Treatments.

354

G. M. Turner-McGrievy et al. / Nutrition 31 (2015) 350358

Table 2
Baseline demographic characteristics, body mass index, and dietary intake of study participants in New DIET weight loss studies

n
Mean age, y (SD)
Sex
Female (%)
Male
Race (%)
Black
White
Other
Education (%)
High school or some college
College graduate
Advanced degree
Marital status (%)
Married
Other
Mean BMI, kg/m2 (SD)
Energy, kcal/d (SD)
Protein, % energy (SD)
Fat, % energy (SD)
Saturated fat, % energy (SD)
Carbohydrate, % energy (SD)
Fiber, g (SD)
Cholesterol, mg (SD)

Vegan

Vegetarian

Pesco-vegetarian

Semi-vegetarian

Omnivorous

12
48.2  7.4

13
53.0  3.8

13
48.8  8.0

13
42.7  9.8*

12
51.0  8.6

8 (67)
4

10 (77)
3

9 (69)
4

10 (77)
3

9 (75)
3

3 (25)
9 (75)
d

3 (23)
9 (69)
1 (8)

3 (23)
10 (77)
d

2 (15)
11 (85)
d

1 (8)
11 (92)
d

d
8 (67)
4 (33)

d
6 (46)
7 (54)

1 (8)
6 (46)
6 (46)

d
8 (62)
5 (38)

3 (25)
5 (42)
4 (33)

9 (75)
3 (25)
32.5 
2460 
16.1 
40.2 
13.9 
41.9 
18.5 
290.5 

7 (54)
6 (46)
35.1  5.0
2070  230
17.0  1.0
40.0  1.7y
12.4  0.7
43.8  2.5
18.1  1.9
361.3  42.1

8 (61)
5 (39)
35.8 
2028 
16.8 
33.2 
10.8 
45.2 
17.8 
318.2 

5 (39)
8 (61)
35.1 
2321 
16.2 
36.8 
12.4 
42.8 
15.6 
289.1 

10 (83)
2 (17)
36.3 
2125 
16.8 
38.1 
12.3 
46.1 
22.9 
297.0 

P-value for difference among groups

0.02
0.97

0.69

0.20

0.16

5.2
239
1.0
1.7y
0.8
2.6
2.0
44.2

5.2
230
1.0
1.7
0.7
2.5
1.9
42.2

5.3
230
1.0
1.7
0.7
2.5
1.9
42.1

5.5
239
1.0
1.7y
0.8
2.6
2.0
43.8

0.49
0.65
0.96
0.045
0.09
0.80
0.15
0.73

BMI, body mass index; New DIET, New Dietary Interventions to Enhance the Treatments
* Signicantly different from the vegetarian group (P 0.01).
y
Signicantly different from the pesco-vegetarian group (P < 0.01).

completed the body weight assessment and questionnaires, and

56 (89%) completed 2 d of dietary recalls. At the 6-mo time point,
50 (79%) completed the study (i.e., provided a body weight
measurement at 6 mo), 46 completed the questionnaires (73%),
and 49 (78%) completed 2 d of dietary recalls (Fig. 1 presents a
CONSORT diagram).
There were no differences in baseline demographic characteristics or BMI among the ve groups with the exception of age
and percent energy from dietary fat (Table 2). Attrition did not
signicantly differ by diet group. One participant in the vegan
group was diagnosed with insulin-resistant polycystic ovary
syndrome and hypothyroidism during the rst month of the
study and began treatment with levothyroxine and metformin.
Because both of these conditions and/or medications were

reasons for exclusion from the study (as a result of their potential
effect on body weight), this participant was excluded from
weight loss analyses, but was included in physical activity and
dietary outcomes.
Weight loss
Figure 2 shows the weight loss among each group over the
course of the 6-mo study. The trend for weight loss among the
ve groups was signicant at both 2 mo (P < 0.01) and 6 mo (P <
0.01) with the greatest weight loss occurring in the vegan group
(7.5%  4.5%), followed by the veg (6.3%  6.6%), pesco-veg
(3.2%  3.4%), semi-veg (3.2%  3.8%), and omni (3.1% 
3.6%) groups. Specically, percent weight loss comparing the
vegan group with the omni, semi-veg, and pesco-veg groups was
examined. At 2 mo, weight loss in the vegan group (4.8% 
2.1%) was not signicantly different from pesco-veg (4.3% 
1.8%; P 0.60) or semi-veg (3.7%  2.4%; P 0.24) but was
different from the omni group (2.2%  2%; P < 0.01). At 6 mo,
the weight loss in the vegan group (7.5%  4.5%) was signicantly different from the omni (3.1%  3.6%; P 0.03), semi-veg
(3.2%  3.8%; P 0.03), and pesco-veg (3.2%  3.4%; P 0.03)
groups. Self-reported intentional physical activity (kcals/d) was
not signicantly different among the ve groups (means  SE),
adjusting for baseline levels, at either 2 mo (vegan 99.3  33.3,
veg 136.0  31.9, pesco-veg 107.7  33.4, semi-veg 169.0  38.9,
and omni 178.8  36.6; F 1.08, P 0.38) or 6 mo (vegan 227.9 
45, veg 205.4  46.3, pesco-veg 158.8  53.4, semi-veg 83.0 
49.1, and omni 194.3  55.6; F 0.89, P 0.48); therefore, there
was no need to adjust analyses of weight loss for physical
activity.
Dietary intake

Fig. 2. Percent weight loss (SE) during 6-mo New DIETs trial by diet group. New
DIET, New Dietary Interventions to Enhance the Treatments. *P trend < 0.01.

Table 3 shows changes in dietary intake at each time point.

The trend for changes in energy intake was not signicant at

G. M. Turner-McGrievy et al. / Nutrition 31 (2015) 350358

355

Table 3
Changes in macronutrients, ber, and cholesterol intake and dietary adherence among ve diet groups at 2 and 6 mo*
Outcome variable and group

Energy intake (kcals/d)

Vegan
Vegetarian
Pesco-vegetarian
Semi-vegetarian
Omnivorous
% Energy from protein
Vegan
Vegetarian
Pesco-vegetarian
Semi-vegetarian
Omnivorous
% Energy from fat
Vegan
Vegetarian
Pesco-vegetarian
Semi-vegetarian
Omnivorous
% Energy from saturated fat
Vegan
Vegetarian
Pesco-vegetarian
Semi-vegetarian
Omnivorous
% Energy from carbohydrate
Vegan
Vegetarian
Pesco-vegetarian
Semi-vegetarian
Omnivorous
Fiber (g)
Vegan
Vegetarian
Pesco-vegetarian
Semi-vegetarian
Omnivorous
Cholesterol (mg)
Vegan
Vegetarian
Pesco-vegetarian
Semi-vegetarian
Omnivorous
Number of participants meeting
dietary adherence criteria (%)
Vegan
Vegetarian
Pesco-vegetarian
Semi-vegetarian
Omnivorous
*

Change in outcome measures

Comparisons among groups

Change from
baseline to 2 mo

P-value for linear

contrasts

786
134
401
481
455







1043
729
618
767
517

2.4
3.6
1.8
1.4
2.6







11.3
3.7
2.8
3.4
1.4

Change from
baseline to 6 mo
903
223
327
397
194







1238
530
921
650
377

2.1
3.8
5.6
4.1
4.7

1.3
2.8
0.5
1.1
1.7







2.7
4.6
5.8
4.1
4.3







8.6
10.6
7.3
8.3
9.8

9.4
6.6
0.7
0.2
0.6







10.1
6.1
4.5
9.4
3.9

8.2
1.5
1.9
0.4
0.5







3.5
4.1
3.3
6.1
2.9

5.3
2.4
1.4
1.3
0.7







5.7
2.4
2.9
2.0
1.9

14.0
5.2
3.1
2.9
3.5







8.4
12.7
9.0
9.8
11.8

11.7
6.7
4.0
0.3
1.1







13.7
11.4
9.9
6.1
5.6

12.1
9.3
3.9
0.6
4.3







18.4
5.2
7.3
9.0
10.1

2.3
3.2
2.4
1.1
1.0







15.5
8.4
10.8
6.8
8.6

311.3
146.1
62.8
62.0
33.2







202.2
276.7
242.6
162.3
186.2

240.5
172.8
60.8
11.1
38.5







221.9
198.1
225.9
131
117.7

2 mo

6 mo

6 (50)
10 (77)
7 (54)
8 (62)
4 (33)

4
5
5
6
5

2 mo,
P-values

6 mo,
P-values

Trend across 5 groups

0.65

0.09

Vegan vs. pesco-veg

Vegan vs. semi-veg
Vegan vs. omni
Trend across 5 groups

0.29
0.32
0.21
<0.001

0.08
0.12
0.03
0.02

Vegan vs. pesco-veg

Vegan vs. semi-veg
Vegan vs. omni
Trend across 5 groups

0.02
0.03
<0.01
<0.01

Vegan vs. pesco-veg

Vegan vs. semi-veg
Vegan vs. omni
Trend across 5 groups

0.02
0.03
<0.01
<0.001

0.01
0.03
0.02
0.01

Vegan vs. pesco-veg

Vegan vs. semi-veg
Vegan vs. omni
Trend across 5 groups

<0.001
<0.001
<0.001
<0.001

0.05
0.04
<0.01
<0.01

Vegan vs. pesco-veg

Vegan vs. semi-veg
Vegan vs. omni
Trend across 5 groups

<0.01
<0.01
<0.001
<0.01

0.13
0.02
<0.01
0.32

Vegan vs. pesco-veg

Vegan vs. semi-veg
Vegan vs. omni
Trend across 5 groups

0.17
0.07
<0.01
<0.01

Vegan vs. pesco-veg

Vegan vs. semi-veg
Vegan vs. omni

<0.01
<0.01
<0.01

0.02
<0.01
0.01

c2 difference between groups:

2 mo

6 mo

c2 5.2, P 0.27

c2 0.47, P 0.98

(33)
(39)
(39)
(46)
(42)

0.65
0.19
0.11
<0.01

0.99
0.50
0.52
0.001

Results are means  SD except for adherence criteria results.

either 2 or 6 mo. The only difference among the groups was

between the omni and vegan groups at 6 mo with vegan participants decreasing their energy intake more than omni participants (P 0.02). Vegan participants decreased their percent
energy from protein more than did the pesco-veg, semi-veg, and
omni groups at 2 mo but the between-group contrasts were not
signicant at 6 mo. Vegan participants also decreased their fat
and saturated fat more than did the pesco-veg, semi-veg, and
omni groups at both 2 and 6 mo. Opposite of the direction of fat
intake, carbohydrate intake increased incrementally examining
the groups from omni up through vegan at both 2 and 6 mo.
Vegan participants had greater increases in carbohydrate intake
compared with pesco-veg at 2 mo and compared with semi-veg
and omni at both 2 and 6 mo. Vegan participants increased their
ber intake more than omni participants at 2 mo. Vegans had a

greater decrease in cholesterol intake compared with pesco-veg,

semi-veg, and omni participants at both time points. Adherence
to the dietary recommendations did not differ by diet group at
either 2 or 6 mo (Table 3).
Discussion
This randomized trial examined the effect of differing levels
of plant-based diets on body weight and intake of macronutrients, ber, and cholesterol. This is the rst study to go beyond
observational trials to intervention research by randomizing
participants to adopt these ve different plant-based eating
styles. This randomized design allowed for a more rigorous
control of factors that may affect body weight, such as exercise
and education level, than can be used in observational designs.

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G. M. Turner-McGrievy et al. / Nutrition 31 (2015) 350358

Additionally, this study provides evidence that participants can

learn to adopt each of these dietary patterns using a minimal
amount of contact time.
The weight loss achieved in this study occurred without the
need for dietary self-monitoring. Dietary self-monitoring is
considered the cornerstone of behavioral treatment for weight
loss [23]; however, dietary self-monitoring requires daily
recording of all foods and drinks consumed, which can be
burdensome [26], time-consuming, and tedious [27]. Adherence
to self-monitoring can be low and may decrease over time [28],
highlighting the need to study dietary strategies that do not
require dietary self-monitoring for effective weight loss. The
mean 6-mo weight loss among the vegan participants (mean of
7.5% decrease in body weight) was greater than what has been
observed in previous behavioral weight loss interventions, which
typically lead to an average of 5% weight loss using a diet-only
approach (with no exercise) [29]. It is possible that greater
initial weight loss was motivational for the vegan group as other
studies have demonstrated that early initial weight loss is predictive of long-term weight loss success [30]. This initial weight
loss success also could have provided a stronger motivation to
maintain dietary changes in the vegan and vegetarian groups
leading to continued weight loss between 2 and 6 mo that was
not seen in the pesco-veg and semi-veg groups.
Prevention of weight regain and promotion of weight loss
maintenance has been challenging, with studies showing only
20% of individuals who lose weight are able to maintain it [31].
Future research examining these plant-based eating styles
should examine long-term maintenance of weight loss beyond
the 6-mo time frame. Additionally, the omni group saw
continued weight loss from 2 to 6 mo. Future research should
examine if this low-fat, low-glycemic index diet approach that
includes all foods is effective for long-term weight loss.
As hypothesized, there was a trend in weight loss among the
ve groups at both 2 and 6 mo with greater weight loss seen in
the vegan group at 6 mo compared with the other three dietary
patterns that included meat (pesco-veg, semi-veg, and omni).
The more plant-based diets also led to more favorable changes in
macronutrients, ber, and cholesterol, particularly among the
vegan diet group. The ndings point to a potential use of plantbased eating styles in the prevention and treatment of obesity
and related chronic diseases. The weight loss results of the
present study going from greatest weight loss among the vegan
group to the least in the omni group mirror the direction of
other health-related outcomes observed in several large nonrandomized prospective cohort studies, including metabolic
syndrome [32], cancer incidence [33], type 2 diabetes [4], and
all-cause mortality [34].
Differences in health and weight outcomes among these ve
diets seen in other studies and in the present study may be the
result of the differing intake in nutrients. The nutrition ndings
of the present study mirror the ndings of several epidemiologic
studies, which have consistently shown higher dietary ber
[3538] and lower saturated fat intakes [35,36,38,39] among
vegans and/or vegetarians compared with omnivores. Randomized trials comparing adoption of a vegan diet to a standard
therapeutic or usual diet also have found greater increases in
ber and decreases in saturated fat among vegan diet participants [68]. These differences in dietary intake may be one of the
reasons why vegan and vegetarian diets have higher dietary
quality compared with omnivorous diets [7,40]. Additionally,
there were greater decreases in percent energy from protein in
the vegan group compared with the groups consuming sh,
poultry, or meat at 2 mo, but not at 6 mo. It is possible that this

decrease in protein may have resulted in a loss of lean mass.

Research has demonstrated that vegan and vegetarian diets can
meet adequate protein needs [1], but other dietary factors, such
as calcium, may be lower in those following a vegan diet and may
in turn impact body composition [41]. Future studies should
examine changes in body composition during transition to
different plant-based diets.
Use of plant-based dietary approaches for weight loss has
public health appeal. There was no restriction on energy intake
recommended to any of the groups in the study. Participants
were free to eat until they were satised. Because traditional
weight loss dietary approaches require dietary self-monitoring,
which often is viewed as burdensome [26], time consuming,
and tedious by participants [27], dietary approaches that do not
require self-monitoring may be appealing for individuals who
are resistant to dietary self-tracking. Additionally, rates of dietary
adherence did not differ by group, demonstrating that no single
diet emerged as easier for participants to follow.
In studies using traditional reduced-energy weight loss diets,
adherence to and frequency of self-monitoring are highly correlated with weight loss [28]. Whereas adherence is important with
traditional dietary approaches, the present study examines the
effect of recommending different plant-based diets to free-living
individuals and suggests that adherence to plant-based diets,
such as vegan and vegetarian diets may not need to be complete. In
a randomized trial examining 2-y weight loss comparing a vegan
diet to the National Cholesterol Education Program Step 2 diet
(a standard low-fat diet), dietary adherence at 2 y was marginal
(60% adherent vegan, 55% adherent in Step 2) and not signicantly
different between the two diet groups, but the vegan group had a
signicantly greater weight loss than the Step 2 diet group [3].
Although adherence rates were low in all groups, the vegan group
had more dietary adherence criteria to meet to count as adherent
than the other groups. The 2 d of dietary recalls at each time point
had to be free of eggs or foods containing eggs, dairy products or
foods containing dairy products, meat, poultry, and sh to be
considered adherent. For example, a participant in the vegan group
could have had egg whites in a recipe, which wouldnt impact
overall macronutrient intake to any large degree, but would still be
considered nonadherent to the diet. Participants in the pesco-veg
group, for example, could have had eggs or foods containing
eggs, dairy products or foods containing dairy products, and sh on
their dietary recalls and still be considered adherent.
There are several strengths to the present study. The study
was delivered with modest contact with study participants in the
four plant-based groups, who received eight weekly classes,
followed by four additional classes and online support via
Facebook groups over 4 mo (total of 12 one-hour class sessions in
6 mo). In behavioral weight loss treatment research, weight
regain is common when contact time in a study is decreased [42,
43]. In the present study, weight loss continued to occur in the
vegan and veg groups despite transitioning to monthly meetings.
In addition to the modest contact, other aspects of the study also
make the ndings applicable outside the research setting,
including participants preparing all their own foods or nding
meals to eat at restaurants. The study also had a low attrition rate
of 21%, particularly considering that no incentive was provided at
6 mo. Most behavioral weight loss studies have attrition rates
greater than 30% [44,45]. Greater weight loss occurred in the
vegan group despite equal diet adherence among the groups. The
present study was also conducted in the southern United States
where traditional southern food preferences might result in high
obesity rates greater challenges to adoption of more plant-based
eating styles than other regions [46].

G. M. Turner-McGrievy et al. / Nutrition 31 (2015) 350358

There are also some limitations. Although weight change was

an objectively measured outcome, diet and physical activity were
both self-reported, and changes in body composition, including
changes in lean mass, were not assessed. The dietary data were
collected by two unannounced, 24-h recalls, which is considered
to be an accurate way to measure overall dietary intake [4749].
For energy expenditure, the Paffenbarger Physical Activity
Questionnaire was used and has been shown to be both valid and
reliable [50,51]. Other limitations include the short duration and
a sample that was mostly white and educated. The sample had a
higher percentage of men, however, than is typical for behavioral
weight loss programs [5255]. Additionally, neither participants
nor study personnel were blinded to diet assignment. The study
was not powered to detect differences in weight loss and dietary
intake between the vegan and vegetarian groups. Future
research with a larger sample size will be needed to examine
differences between vegan and vegetarian. Finally, the present
study had reduced contact time for the omni group, which met
monthly during the initial 8 wk of the study, receiving their dietary information mainly by e-mail during that time. All groups
received the same intensity of the intervention for the majority
of the study (months 36), however, and even without the omni
group included, weight loss among vegan participants was
signicantly greater than pesco-veg or semi-veg participants.
This indicates that, even without inclusion of the omni group,
there is evidence toward greater weight loss with the vegan diet
compared with plant-based diets, which include some sh or
meat.
Conclusions
This study provides evidence for greater short-term weight
loss and improved macronutrient, ber, and cholesterol intake
among individuals randomly assigned to follow plant-based diets that do not include meat (vegan) compared with other plantbased approaches with limited meat (pesco-veg and semi-veg)
or unrestricted meat intake (omni). Studies examining the effect of plant-based diets on long-term weight loss maintenance
are needed. Diets excluding food groups have not been the norm
in nutrition recommendations, with the predominant message
from nutrition and health organizations being that modest dietary changes are more acceptable to participants and that all
foods t [56,57]. Stricter dietary recommendations, however,
may yield greater dietary changes than more modest recommendations [58]. Additionally, dietary approaches that include
all foods require strict adherence to dietary self-monitoring if
weight loss is to occur [59]. Because complete adherence may
not be necessary with plant-based dietary approaches, and
vegan and vegetarian diets appear to be effective strategies for
both weight loss and improving nutrition proles, those creating
dietary guidelines for disease prevention and treatment should
consider these plant-based eating styles as a potential strategy
for healthy eating recommendations.
Acknowledgments
The authors acknowledge the University of South Carolinas
Ofce of Public Health Practice for assistance with survey design.
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