# data[].attributes.headline
Don't go to multiple sites to purchase groceries.

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Don't go to multiple sites to purchase groceries.

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Theme: User needs to be accepted for their plant based food choices.
Insights:
1. Users want a way to not make a fuss in social settings due to their food choices.
2. Users greatly prefer foods that can easily be substituted into their social group's or family's meals.
3. Users do not want to be singled out for choosing plant based foods.

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Top 3: Carlos
*Don't know how to cook vegan foods. (QR Code linking to recipes video)
*Cheaper?
*Resistance of partner/family not supportive (awkward social situations)

# data[].attributes.body
Theme: | User doesn't know how to cook plant based meals
Insights:
1. | Users want an easy way to make meals
2. | Users greatly prefer simple recipes that substitute meats and dairy easily.
3. | Users do not want to be confused and to work really hard to eat plant based meals.

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The Hartman Group found that plant-based purchasers tend to be younger, more ethnically diverse, with higher incomes, urban/suburban, and more trend-forward with an average age of 40. They also found flexitarians to be more food- and flavor-focused, so health today is less about low-fat, low-carb and more about full flavor, and on some occasions, full (good) fats.

# data[].attributes.body
The Hartman Group found that plant-based purchasers tend to be younger, more ethnically diverse, with higher incomes, urban/suburban, and more trend-forward with an average age of 40. They also found flexitarians to be more food- and flavor-focused, so health today is less about low-fat, low-carb and more about full flavor, and on some occasions, full (good) fats.

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Health concerns are the primary motivation behind flexitarian eating, while environmentalism is a secondary driver. Also, as concerns about animal welfare have become more mainstream, more consumers - especially younger ones - have begun to question whether any animal products are ethical to eat.

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Overall, I was surprised by my wife’s apprehension towards a meat alternative.  Her discussion surrounding the health benefits of meat made me question if the meat alternative market was here to stay or a fad that would be easily subdued over time.  I also noted her buying habits and wondered how many Canadian Flexitarians lived in downtown locations versus suburbs.  Based on the live client feedback, they’re current model of distribution through an online store or specialty grocery stores would most likely eliminate the more suburban consumer.  Lastly, I wondered if expanding the network of restaurants carrying Neophyto food options would be beneficial in increasing the consumer’s acceptance as it given them a chance to try it in the best and most perfectly cooked way, reducing the apprehension or worry of not cooking their meat alternative properly.  

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Lots of "social" barriers and logistic barriers to eating plants instead of meat.

# data[].attributes.subject
Lots of "social" barriers and logistic barriers to eating plants instead of meat.

# data[].attributes.body
Interviewed people don’t know how to cook vegan alternatives.

Alternatives are expensive.

Resistance from family members and friends

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Very Good Butchers Amazing Video that hits all the barriers that flexitarians, vegans and vegetarians face on a daily basis.

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The plant-forward trend to eat more plant-based food is not being driven by vegetarians or vegans, but rather by meat-eaters looking to reduce the amount of animal protein they eat. Melanie Bartelme, an analyst at Mintel puts it this way, "For the majority of consumers, it's not abandonment [of animal products], it's a 'sometimes swap.'" CH

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The Very Good Butchers | Whole-food, Vegan Meats Handcrafted in BC

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We butcher beans, not animals. Plant-based meats handcrafted in Victoria, BC with 100% real, whole-food ingredients.

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Flexitarian-ism will become bigger than veganism.  Mostly due to environmentalism.

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Flexitarian-ism will become bigger than veganism.  Mostly due to environmentalism.

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https://www.cbc.ca/news/canada/british-columbia/the-future-is-vegan-ish-1.5300501

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AWESOME Marketing approach should not try to promote anti-meat consumption

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AWESOME Marketing approach should not try to promote anti-meat consumption

# data[].attributes.body
Don't look at it like enforcing a moral issue - that alienates customers.

# data[].attributes.body
Christie's Customer Journey Mapping

# data[].attributes.headline
Women are more likely to identify as flexitarian

# data[].attributes.subject
Women are more likely to identify as flexitarian

# data[].attributes.body
Eating meat is seen as socially masculine - to avoid identity threats, some men avoid labeling themselves as vegan.

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Again, women are more likely to reduce meat intake

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Again, women are more likely to reduce meat intake

# data[].attributes.body
Also older folks are more likely to reduce meat intake.

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Abstract

A flexitarian or semi-vegetarian diet (SVD) is one that is primarily vegetarian with the occasional inclusion of meat or fish. Of late, there appears to be an increasing movement toward this practice. There has not been a recent update on these diets from a health perspective. Using the National Centre for Biotechnology Information PubMed database, a search was made for all studies published between 2000 and 2016 that met defined inclusion criteria. A total of 25 studies were located with 12 focusing on body weight and diet quality. There was emerging evidence suggestive of benefits for body weight, improved markers of metabolic health, blood pressure, and reduced risk of type 2 diabetes. SVD may also have a role to play in the treatment of inflammatory bowel diseases, such as Crohn's disease. Given that there is a higher tendency for females to be flexitarian yet males are more likely to overconsume meat, there is a clear need to communicate the potential health benefits of these diets to males.

Keywords: flexitarian, semi-vegetarian diet, public health, gender differences, dietary trends

Introduction

"Flextarianism" is a neoteric term that has been emerging in the scientific and public sectors recently. Added to the Oxford English Dictionary in 2014, flexitarian is a portmanteau of "flexible" and "vegetarian," referring to an individual who follows a primarily but not strictly vegetarian diet, occasionally eating meat or fish ( 1). Despite the global demands for meat, it appears that there are now a growing number of flexitarian consumers who abstain from eating meat regularly ( 2).

Most consumers can be grouped into meat consumers, meat avoiders, or meat reducers ( 3). The trend toward flexitarian diets (FDs) appears to reflect consumers who are "meat-reducers," eating meat within meals on some but not every day of the week ( 3), as with typical "meat-eaters". This definition is most closely in line with that of semi- or demi-vegetarianism. Subsequently, the terms are often used inter-changeably in the literature. For example, in one publication semi-vegetarian diets (SVDs) are defined as those significantly reducing meat intake on at least 3 days of the week ( 4).

The FD seems to recognize the fact that meat is an important source of protein, fat, and micronutrients ( 5, 6), yet also considers the ethical sides, such as the need to avoid intensification and improve animal welfare ( 7). It also considers evidence that long-term consumption of increasing amounts of red meat and particularly processed meat may increase the risk of mortality, cardiovascular disease, type 2 diabetes, and certain forms of cancer such as colon cancer ( 6). Recently, the International Agency for Research on Cancer classified red meat as probably carcinogenic and processed meat carcinogenic to humans ( 8).

Research from NatCen's British Social Attitudes survey found that 29% of people in Britain have reduced the amount of meat that they ate in the past 12 months ( 9). The definition of meat reducers included reductions in all meats except fish. In particular, women (34%) were most likely to reduce their meat intake. Similarly, 39% of 65- to 79-year olds had reduced their red meat intake compared with 19% of 18- to 24-year olds. The report also showed that men (23%) were shifting and reducing their meat intake. Over half (58%) cited health reasons along with saving money, concerns over animal welfare, and food safety ( 9).

The aim of the present paper was to review the evidence looking at the FD/SVDs and health, using defined inclusion criteria. While some discussion papers have been published about vegetarianism ( 10) and low-meat diets and health ( 11), no publications have focused on the current trend of flexitarianism or SVDs. The present paper set out to evaluate the evidence-based looking as FD/SVDs from a public health perspective.

Methods

The National Centre for Biotechnology Information (NCBI) search engine (PubMed) was used to extract relevant English-language papers published between January 2000 and June 2016. Data files were extracted from the NCBI collection depository and imported into Covidence software used to create systematic reviews.

As flexitarian is a relatively new term, the search terms "flexitarian," "semi-vegetarian," and "demi-vegetarian" were combined with "blood pressure," "body weight," "cancer," "diabetes," "diet quality," "health," "heart disease," "metabolic health," and "nutrient intake/status" to filter publications. Data extracted from each article included (1) country of research, (2) subjects (number of participants, gender, age), (3) design and methods, (4) definitions used, and (5) study outcomes/findings.

For inclusion, studies needed to clearly define the terms flexitarian, semi-vegetarian, or demi-vegetarian used in their study. Data results and findings also needed to be reported and analyzed separately from other forms of dietary patterns. Randomized controlled trials (RCTs) and observational studies were included. Articles were excluded if they were published before 2000, a pilot study, or focused solely on vegan diets or vegetarianism.

Results

The NCBI search identified 46 papers and after an adjustment for replica papers, 39 articles remained for assessment. Of these, 14 papers were discarded after reviewing the abstracts and article content as they did not meet the inclusion criteria. This left 25 articles for general review. This included 21 epidemiological studies and 4 randomized controlled or clinical trials. The algorithm of qualifying publications is shown in Figure . Of these, 12 studies were conducted in the US or Canada, 6 in Europe, 5 in Asia, and 2 in Australasia.

Definitions

Definitions of flexi-semi-vegetarianism were extracted from the identified papers (Table ). Definitions tended to vary between studies. For example, some authors specified that participants on an SVD restricted their intake of red meat ( 12, 13), while others restricted fish ( 14). In studies using data from the Adventist Health Study-2, SVDs were defined as those consuming dairy products and/or eggs and meat (red meat and poultry ≥1 time/month and <1 time/week) ( 15- 20).

In a more general sense, other authors defined SVDs as those containing moderate levels of animal products ( 21, 22), though it was not specified what "moderate" was. One paper defined these as eating red meat, poultry, or fish no more than once a week ( 23), while other studies reported participants as being semi-vegetarian (SV) if they excluded red meat from their diet but ate other meats ( 13).

Health

Body Weight

As shown in Table , six studies focused on SVDs and body weight. Two RCTs looked at the effects of different plant-based diets in relation to weight loss. In one study, authors undertook a 6-month RCT, where overweight adults were allocated to five different plant-based diets. Vegan diets were associated with significantly higher levels of weight loss by the end of the study ( 22). A Korean study reported that postmenopausal women maintaining an SVD over 20 years had a significantly lower body weight, body mass index (BMI), and percentage of body fat compared with non-vegetarians (NVs) ( 12).

Table 2

Reference; country

Subjects

Study design and methods

Findings

Kim and Bae ( 12); Korea

Postmenopausal SV F ( n  = 54). Mean age 61.4 years

Cross-sectional. Anthropometric and blood biomarkers compared between the two groups

SV had sig. lower body weight ( P < 0.01), BMI ( P < 0.001), and percentage of body fat ( P  < 0.001) than the NV

Moore et al. ( 21); US

n  = 15 SV/PVs

6-month RCT. New DIETs study-randomization to one of four plant-based diets (vegan, vegetarian, PV, SV) or an omnivore diet

At 6 months, non-adherent vegan and vegetarian participants had a sig. decrease in cholesterol intake than non-adherent PV/SV ( P = 0.02) or omnivore participants ( P  = 0.04)

Turner-McGrievy et al. ( 22); US

n  = 13 SV (18-65 years)

6-month RCT. Overweight and obese adults randomized to different diets for 6 months

At 6 months, the weight loss in the vegan group (−7.5%) was higher than the omnivorous (−3.1%; P = 0.03), SV (−3.2%; P = 0.03), and PV (−3.2%; P  = 0.03) groups

Tonstad et al. ( 15); US

n  = 3,386 SV. Mean age 57.7 years. 65.7% F

Cross-sectional. Analysis of different types of vegetarian diet from the Adventist Health Study-2. Anthropometric data collected from a self-administered questionnaire

Mean BMI was lowest in vegans (23.6 kg/m ²) and incrementally higher in LOV (25.7 kg/m ²), PV (26.3 kg/m ²), SV (27.3 kg/m ²), and NV (28.8 kg/m ²)

Baines et al. ( 13); Australia

n  = 827 SV F (22-27 years)

Cross-sectional. Data analyzed from the Australian Longitudinal Study on Women's Health

SV had a lower BMI (mean 23 kg/m ² than NVs (23.7 kg/m ²) and tended to exercise more

Diabetes and metabolic health

Kim and Bae ( 12); Korea

Postmenopausal SV F ( n  = 54). Mean age 61.4 years

Cross-sectional. Blood biomarkers compared between the two groups

SV had sig. lower body weight ( P < 0.01), BMI ( P < 0.001), % of body fat ( P < 0.001), and serum levels of leptin ( P < 0.05), glucose ( P < 0.001), and insulin ( P  < 0.01), than the NV

Agrawal et al. ( 14); India

n = 8,140 SV, n  = 4,675 F (20-49 years)

Cross-sectional. Data from India's third National Family Health Survey (2005-2006)

Consumption of a lacto- (OR: 0.67, P < 0.01), LOV (OR: P = 0.03), and SV (OR: P  = 0.03) diet was associated with a lower likelihood of diabetes than an NV diet in the adjusted analyses

Rodenas et al. ( 27); Spain

Cross-sectional. Blood pressure of postmenopausal F measured

Omnivores had sig. higher systolic ( P < 0.01) and diastolic ( P  < 0.05) pressures than SVs

Turner-McGrievy et al. ( 22); US

6-month RCT. Overweight and obese adults randomized to five different plant-based diets.

Vegan, vegetarian, and PV subjects had sig. improvements in the dietary inflammation index score compared with SV participants at 2 months ( P  < 0.05) with no differences at 6 months

Kornsteiner et al. ( 28); Austria

Observational study. Amount and composition of ingested fat were calculated from 24-h recalls

The unbalanced n-6/ n-3 ratio and the limited dietary sources of EPA and DHA in vegans and vegetarians led to reductions in C20:5n-3, C22:5n-3, C22:6n-3, and total n-3 fatty acids compared with omnivores and semi-omnivores

Baines et al. ( 13); Australia

9,113 F (22-27 years)

Cross-sectional. Data analyzed from the Australian Longitudinal Study on Women's Health

The BMI and levels of physical activity of SV women suggest they were healthier than NV. There were greater reports of menstrual problems and the poorer mental health which could be of clinical significance

Cross-sectional data from 71,751 participants taking part in the Adventist Health Study-2 (2002-2007) showed that BMI was highest in NVs (mean 28.7 kg/m ²), slightly lower in SVs (mean 27.4 kg/m ²), and lowest in strict vegetarians (mean 24.0 kg/m ²) ( 18). These findings are similar to earlier trends (2002-2006 analysis) showing that mean BMI was lowest in vegans (23.6 kg/m ²) and incrementally higher in lacto-ovo vegetarians (LOVs) (25.7 kg/m ²), pesco-vegetarians (PVs) (26.3 kg/m ²), SVs (27.3 kg/m ²), and NVs (28.8 kg/m ²) ( 15). Cross-sectional research on 9,113 young Australian women (22-27 years) identified that SVs had a lower BMI and tended to exercise more than NVs ( 13).

Cancer

Four studies were found to fulfill the inclusion criteria. One study examined vegetarian patterns in relation to breast cancer (BC) risk using data from 96,001 adults taking part in the prospective Adventist Health Study-2 (2002-2007). Findings showed that vegans had a significantly lower risk of BC compared with vegetarian and NVs ( 24).

With regard to prostate cancer risk, data from 26,346 males taking part in the Adventist Health Study-2 found that only vegan diets were associated with reduced prostate cancer risk ( 25). Equally, an earlier analysis of this study showed that vegan diets had statistically significant protection for overall cancer incidence (hazard ratio = 0.84; 95% confidence interval: 0.72, 0.99) ( 26). Other work using data from the same North American study discovered that PVs had the lowest risk of colorectal cancer, followed by LOVs, vegans, and SVs when compared with NVs ( 20).

Diabetes and Metabolic Syndrome

Six studies were found looking at SVDs in relation to markers of metabolic health or risk of diabetes. In one study, authors observed that postmenopausal women following an SVD for more than 20 years had significantly lower glucose, insulin levels, and homeostatic model assessment of insulin resistance compared with NV controls ( 12).

Other research using data from India's third National Family Health Survey 2005-2006 ( n = 156,317) from adults aged 20-49 years found that the consumption of lacto-, lacto-ovo-, and SVDs were associated with a reduced likelihood of diabetes compared with NV diets, after data adjustments ( 14). Equally, research from the Adventist Health Study-2 found that cases of diabetes developed were lowest in vegans (0.54%), followed by SVs (0.92%), LOVs (1.1%), and PVs (1.3%) compared with 2.1% in NVs ( 16).

Furthermore, cross-sectional data from the Adventist Health Study-2 ( n = 773) showed that the prevalence of metabolic syndrome was highest in NVs (39.7%), intermediate in SVs (37.6%), and lowest in vegetarians (25.2%). Data for vegans were not reported ( 17). Findings from the same study also highlighted that diabetes prevalence was 2.9% in vegans, 4.8% in SVs, and 7.6% in NVs ( 15). With regard to blood pressure, research involving 26 postmenopausal women from convents found that omnivores had significantly higher systolic and diastolic pressures than the SVs ( 27).

Diet Quality

Six studies focused on dietary quality, nutritional intakes, and/or status. In a randomized trial, overweight and obese adults were allocated to different plant-based diets. Participants allocated to the vegan and vegetarian diets had significantly improved macronutrient profiles and Diet Inflammatory Index (DII) scores (a tool for assessing the inflammatory potential of a diet). Vegan, vegetarian, and PV groups all had significant improvement in the DII score at 2 months but not at 6 months ( 22).

Remaining studies were mainly observational in nature. For example, an internet-based survey using data collection tools from the Belgian Food Consumption Survey and a convenience sample of subjects showed that vegan diets had the lowest total energy and highest fiber intake compared with omnivores ( 23). Alongside this, results from 96,335 adults in the Adventist Health Study-2 showed found that those eating SVDs had the lowest caloric intakes (1,713 kcal/day) but other than this there were few dietary differences ( 18).

Cross-sectional research from the Australian Longitudinal Study on Women's Health ( n = 9,113) showed that rates of low iron, iron-deficiency, or anemia were highest in vegetarians (42.6%), followed by SVs (38.6%) and then NVs (25.5%) ( 13). Other research focusing on the omega-3 profile of diets showed that vegan and vegetarian diets led to reductions in eicosapentaenoic acid and docosahexaenoic acid levels compared with semi-omnivores ( 28).

Additional Health Outcomes

Three studies focused on other health outcomes. One study observed that SVDs helped to prevent relapse of symptoms in patients with inflammatory bowel disease (IBD) ( 29). Additional research by the same team concluded that up to 32.4 g dietary fiber, delivered via an SVD could be given to patients with IBD, indicating that these could be used as a supportive treatment for Crohn's disease patients ( 30).

Other work involving 73,308 adults from the Seventh-day Adventist study-2 demonstrated that vegetarian diets, including SVDs were associated with lower all-cause mortality, with results appearing to be more robust in males ( 19).

Discussion

Flexitarian diets have been gaining popularity-a transition that seems to have been fueled by a combination of health, environmental, and animal welfare concerns. The present paper has identified that flexitarian/SVDs could have potential health benefits with strongest evidence appearing to be in relation to weight loss and metabolic health benefits, including reduced diabetes risk and blood pressure (Table ).

There is also emerging evidence that SVDs could be an option for patients with IBD, such as Crohn's disease ( 30). While the mechanisms behind this are yet to be confirmed, it has been speculated that a plant-based diet may be effective for gut inflammation, namely, through the actions of dietary fiber ( 31).

Physicians focused on non-invasive and cost-effective interventions could help their patients improve health outcomes by encouraging a shift toward diets higher in vegetables, whole grains, legumes and fruits, and fewer animal products ( 32) with an FD being a useful tool in this transition. Furthermore, it has been estimated that making a transition toward plant-based diets that are aligned with standard dietary guidelines could help to reduce global mortality by 6-10% ( 33).

Flexitarian diets/semi-vegetarian diets could also be useful in helping those with high meat intakes to fall in line with recommended guidelines. For example, data from the UK National Diet and Nutrition Survey showed that red and processed meat intakes were 84 g/day for men and 47 g/day for women ( 34). Scientific Advisory Committee on Nutrition guidelines are set at 70 g/day for adults for red and processed meat ( 35). Subsequently, there is a greater tendency for males to exceed red and processed meat guidelines. Interestingly, looking at the studies reviewed, around 70% of conscious flexitarians were educated females ( 15, 18, 20, 26). Considering this, there is clear scope to educate males about the health benefits of FDs.

In order to align with meat intake guidelines other approaches can also be taken. These include a greater use of simulated meat-like products with a similar flavor, texture, and color to meat ( 36). As it is the International Year of the Pulse, there has been much interest in these from a health perspective. Pulses include beans, peas, and lentils, which have been eaten for at least 10,000 years, providing protein, fiber, and essential micronutrients, including iron, folate zinc, magnesium, as well as phytochemicals, such as saponins and tannins ( 37). It has been estimated that eating just half a cup of beans or peas daily can significantly enhance diet quality and nutrient density, helping consumers to meet dietary recommendations ( 37).

Limitations

On the whole, FDs appear to have emerging health benefits. However, it should be considered that before any formal recommendations about FDs can be made, official definitions of these diets are needed. For example, the inclusion criteria used in the present article did not always bring up publications using the same definition of SVDs. In Germany, legal definitions of vegetarian and vegan have been compiled by the German Federation of Food Law and Food Science and the Vegetarierbund Deutschland to facilitate the categorizing and labeling of foods, though these definitions are yet to be formalized by the European Commission ( 38). Similarly, a formal classification of FDs is needed that can be put into appropriate use in future research.

Presently, large cohort investigations also appear to overlook FD/SVDs. For example, the recent European Prospective Investigation into Cancer and Nutrition did not include SVDs when comparing the metabolic profile of meat eaters, vegetarians, and vegans ( 39). It is also worth pointing out that large dietary surveys, such as the UK National Diet and Nutrition Survey, could look to include a definition and analysis of flexitarian or SVDs.

Equally, impending RCTs looking to investigate the health benefits of FD/SVDs need to align methodologies with the Consolidated Standards of Reporting Trials guidelines for RCTs ( 40). In the case of observational studies, these should follow the Strengthening the Reporting of Observational studies in Epidemiology guidelines ( 41). It was a limitation in the present review that the most research came from the US and Canadian Adventist Health Study. The SV dietary approaches taken by these Adventists may be different that of other flexitarians or SVs. More research in the UK and Europe is needed to examine this.

One a final note, in the present review, the focus was on "flexitarianism" as this terminology has been increasingly used by the public press. Nevertheless, it should be considered that terms such as "meat reduction" or "Mediterranean diets" which may also constitute an FD were not included in this review. These could form the basis of future publications, along with an anticipated future growth in studies looking at FD and markers of health.

Conclusion

The trend of flexitarianism does not appear to be subsiding. This review provides a first line of evidence that FDs may have emerging health benefits in relation to weight loss, metabolic health, and diabetes prevention. While most flexitarians presently seem to be female, there is a clear need to communicate the potential health benefits of these diets to males. As not everyone and in particular men might not want to exclude meat altogether, FDs offer a path that includes their dietary preferences yet could improve public health outcomes.

Author Contributions

This review has been researched and written by an Independent Nutrition Consultant.

Conflict of Interest Statement

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer AT and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.

Funding

This review was supported by Marlow Foods (Quorn Foods) Limited, Stokesley, England. The views expressed are those of the author alone and Marlow Foods had no role in writing the review.

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# data[].attributes.attachment_link.title
Flexitarian Diets and Health: A Review of the Evidence-Based Literature

# data[].attributes.attachment_link.description
A flexitarian or semi-vegetarian diet (SVD) is one that is primarily vegetarian with the occasional inclusion of meat or fish. Of late, there appears to be an increasing movement toward this practice. There has not been a recent update on these diets ...