Update on vegetarian and vegan athletes: a review

Abstract

Interest in vegetarian and vegan diets continues to grow, not only in the general population, but in the high-performing athlete. Vegetarian diets may lower risk of chronic diseases and have proposed ergogenic benefits to the athlete regarding exercise performance and enhanced recovery. However, controversy and confusion exist in the literature regarding vegetarianism. Traditionally, a vegetarian or vegan diet was considered low in certain micronutrients (iron, zinc, calcium, iodine, vitamin A, B2, B12, D), as well as protein, omega-3 fatty acids, and total energy needs. However, a vegetarian diet typically contains higher complex carbohydrates, dietary fiber, magnesium, nitrates, folic acid, vitamin C and E, carotenoids and other phytochemicals which may offer certain performance benefits to the athlete. This review summarizes the current literature on the benefits of a vegetarian diet specific to the athlete, clarifies nutritional requirements, and provides insight on the potential performance benefits. With proper meal planning, an athlete can meet all their nutritional needs with foods derived from plants without any loss in physical performance.

Full text

J Phys Fitness Sports Med, 10 (1): 1-11 (2021)
DOI: 10.7600/jpfsm.10.1
JPFSM: Review Article
Update on vegetarian and vegan athletes: a review
Kenneth Vitale1* and Shawn Hueglin2
Received: April 20, 2020 / Accepted: July 14, 2020
Abstract Interest in vegetarian and vegan diets continues to grow, not only in the general
population, but in the high-performing athlete. Vegetarian diets may lower risk of chronic
diseases and have proposed ergogenic benefits to the athlete regarding exercise performance
and enhanced recovery. However, controversy and confusion exist in the literature regarding
vegetarianism. Traditionally, a vegetarian or vegan diet was considered low in certain micro-
nutrients (iron, zinc, calcium, iodine, vitamin A, B2, B12, D), as well as protein, omega-3 fatty
acids, and total energy needs. However, a vegetarian diet typically contains higher complex
carbohydrates, dietary fiber, magnesium, nitrates, folic acid, vitamin C and E, carotenoids and
other phytochemicals which may offer certain performance benefits to the athlete. This review
summarizes the current literature on the benefits of a vegetarian diet specific to the athlete,
clarifies nutritional requirements, and provides insight on the potential performance benefits.
With proper meal planning, an athlete can meet all their nutritional needs with foods derived
from plants without any loss in physical performance.
Keywords : vegetarian, vegan, diet, athlete, nutritional requirements
Introduction
In recent years, there has been growing interest in veg-
etarian and vegan diets, not only in the general public, but
the athlete population as well. About 3.3% of Americans
report being vegetarian, and 46% of these individuals are
vegan1,2); however, the overall prevalence of vegetarian
athletes is largely unknown3). In a survey of athletes in the
2010 Commonwealth Games, 8% of the athletes followed
vegetarian diets, and 1% of them reported being vegan4).
Furthermore, vegetarianism is also growing in the young
adult population, as 5% of high school students (grades
9-12) and 6% of young adults (18-34 years) report being
vegetarian or vegan. In addition, there is a growing shift
in recommendations for people to switch to more plant-
based, whole food diets5), increased awareness regarding
animal welfare6) and concern for environmental repercus-
sions7,8) if high animal protein consumption countries
such as America do not change their farming practices.
Last year, the documentary film “Game Changers”9)
received wide media attention on the potential benefits
of “plant-based” (vegetarian) diets for athletes, but also
received criticism for possible sensationalism and pseu-
doscience7,10). Unfortunately, because of the variability in
vegetarian diets (e.g., vegetarian, vegan, lacto-ovo, whole
foods diets, raw foods diet) there are no high-quality stud-
ies on the effects of the vegetarian diet overall in athletes.
Most studies in athletes examine specific plant foods or
single-dose plant food supplementation, not the effects of
a vegetarian diet as a whole. With the recent popularity
and increased media visibility of vegetarian and vegan di-
ets, however, clinicians treating athletes need to be aware
of the latest science and recommendations. This review
summarizes current available literature on vegetarian and
vegan diets specific to the athlete. A background on these
“plant-based” (vegetarian) diets is presented, along with a
summary of key macro- and micronutrients important to
athletes considering a change to a vegetarian or vegan diet.
Methods
A literature search utilizing PubMed/Medline was per-
formed in April 2020 including the past 10 years prior.
No data restrictions were employed for language, date,
subject age, or article type. Keywords included vegan,
vegetarian, plant-based, athlete, exercise, nutritional re-
quirements, and performance.
An initial search including vegan/vegetarian and athlete/
exercise produced 78 potential articles. Studies that did
not include relevance to exercise or athletes, and studies
that involved patients or medical diseases were excluded.
Abstracts of conference proceedings, as well as in-vitro
and animal studies were also excluded. Additionally,
manual searching of references of the above retrieved ar-
*Correspondence: kvitale@health.ucsd.edu
1Department of Orthopedic Surgery, Division of Sports Medicine, University of California San Diego, 9300 Campus Point Drive,
#7894, La Jolla, CA 92037, USA
2Senior Sports Dietitian, United States Olympic Committee, 2800 Olympic Parkway, Chula Vista, CA 91915, USA

2JPFSM : Vitale K and Hueglin S
ticles and additional expanded search of NCBI databases,
including NLM Catalog, PubMed Central (PMC), and
Google Scholar yielded 25 additional articles; duplicates
were removed. Fig. 1 represents the PRISMA search
strategy.
A total of 50 studies met eligibility criteria. Due to sig-
nificant methodological heterogeneity, pooling of data
and a systematic review was impossible; therefore, a nar-
rative review was performed.
Vegetarian and vegan diets for athletes
A vegetarian diet is defined as a diet that does not in-
clude any animal meats, including red meat, poultry and
seafood11). Variations include lacto-, ovo-, lacto-ovo, or
pesco-vegetarian which are diets that include dairy, eggs,
both dairy and eggs, or fish, respectively. Vegan diets ex-
clude all animal-derived products and byproducts includ-
ing meat, fish, seafood, dairy, eggs, and honey11 ). While
there are minor differences in lacto-, ovo-, and lacto-ovo
vegetarian diets, vegetarians in general tend to consume
slightly more calcium, phosphorous, vitamin D and vi-
tamin B12 than vegans due to the consumption of dairy
products3,5,11). Vegans are traditionally considered to be
at risk for low protein, creatine and carnitine3,11) and risk
low EPA and DHA omega-3 fatty acid intake6) due to lack
of eggs and seafood. All vegetarian diets (vegan and the
above vegetarian variations)3,5,11) need to ensure adequate
intakes in protein, iron, zinc, calcium, vitamin A, vita-
min B12, omega-3 fatty acids EPA and DHA intake and
iodine, as well as vitamin D and overall caloric intake6).
Table 1 outlines key differences in these diet variations in
terms of potential nutrient deficiencies.
Vegetarian diets may lower risk of chronic diseases such
as cardiovascular disease, diabetes, obesity, hypertension,
and even cancer mortality11,12). Although chronic disease
prevention may not be the primary concern of an elite ath-
lete, it is proposed that these same diets may enhance an
athlete’s performance and/or speed recovery from intense
or strenuous exercise bouts3,13,14).
This is due to several potential reasons. Some authors
feel the higher intake of complex carbohydrates, dietary
Fig. 1 PRISMA flow diagragm search strategy

3JPFSM : Update on Vegetarian Athletes
fiber, magnesium, folic acid, vitamin C and E, carotenoids
and other phytochemicals consumed by vegetarians15,16)
may improve performance3). The increased carbohydrate
intake may promote better glycogen storage14,17). The
overall increased antioxidant and other phytochemical in-
take from foods derived from plant sources may enhance
the antioxidant system to offset the increased exercise-
induced oxidative stress in elite athletes and potential en-
vironmental oxidative stresses, including altitude and pro-
longed sun exposure18,19). Another advantage of vegetarian
diets is that the antioxidants derived from whole foods are
generally favored over antioxidant supplements in terms
of effectiveness20).
It is also suggested that plant-based diets reduce inflam-
mation and blood viscosity, improve arterial flexibility
and endothelial function14). This may improve vascular
flow, tissue oxygenation, and cardioprotection14,17) for the
endurance athlete that may be at higher-than-average risk
for atherosclerosis and myocardial damage21-24). There are
even studies suggesting that, due to the slight alkalinizing
effect on serum during exercise25), foods derived from
plants may induce an ergogenic effect by improved buff-
ering of acid production from intense exercise26).
Another ergogenic benefit includes the high nitrate
content in plants. Since a landmark study in 2007 show-
ing decreased oxygen cost during submaximal exercise27),
several studies have demonstrated how nitrate-rich plant
foods (such as beets and nitrate-rich greens [e.g. spinach
and arugula]) can improve performance27,29-31). Dietary
nitrate gets converted in the body to nitric oxide, which
exerts pleotropic effects pertinent to athletes, including
improved vasodilation, blood flow and oxygen regulation
in muscle, mitochondrial function, and overall muscle
contraction/relaxation28-30). Cumulatively, these effects
can improve muscle economy during exercise, improve
efficiency and mitigate fatigue, decrease cardiorespiratory
effort at submaximal workloads, and improve exercise
(e.g. cycling time trial) performance29-33).
Lastly, single dose supplementation with plant-based
products may also improve performance15,34,35). In a recent
novel study, a single dose of fermented soy during a 20-
km time trial cycling race improved cyclists’ times to race
completion, lowered average heart rates, and had sig-
nificantly improved power outputs34). It is believed these
performance benefits were due to the isoflavones found
in soy, improving vascular endothelial relaxation, increas-
ing limb blood flow, and decreasing cardiac demand.
These isoflavone-induced effects would not be seen in
animal-based protein sources. Another study has shown
soy supplementation also improves time to exhaustion
in prolonged endurance exercise35), due, it is believed, to
soy’s high antioxidant capacity. This study was the first
of its kind to show improved race performance times and
reduced heart rates.
Conversely, there have been conflicts in research and
an overall misunderstanding in the literature concerning
vegetarianism15), especially regarding nutritional deficien-
cies. Traditionally, vegetarians were considered to have
inadequate intakes in protein, iron, zinc, calcium, vitamin
A, vitamin B12, omega-3 fatty acids EPA and DHA, and
iodine15), as well as vitamin D and overall caloric intake6).
However, several studies demonstrate these deficiencies
are typically due to poor meal planning15) rather than in-
adequate nutrient content in a vegetarian diet. In the fol-
lowing sections, select macronutrients and micronutrients
(including a special section on protein) are reviewed with
recommendations specific to the plant-based athlete. Also,
performance considerations are provided for the elite or
professional athlete interested in following a vegetarian
or vegan diet.
Macronutrients
Carbohydrate. Carbohydrates can be an important com-
ponent to an endurance athlete’s diet as they are necessary
for glycogen repletion if the athlete undergoes exhaustive
exercise. Due to the inherent nature of carbohydrate-rich
foods in a vegetarian diet, a vegetarian athlete is likely
able to meet typical carbohydrate needs36). Although some
sports such as power or skill-based sports require less car-
bohydrate intake (3-5 g/kg/day) and not a concern, even
endurance and ultra-endurance athletes following a veg-
etarian diet can easily meet carbohydrate loading (“carbo
loading”) and overall high carbohydrate needs (up to 8-12
g/kg/day) with a plant-based diet36).
One precaution if an athlete switches to a vegetarian
Table 1. Vegetarian vs. Vegan Diet Considerations
Pesco-ovo vegetarian Lacto-ovo vegetarian Vegan All vegetarian diets
Adequate omega-3
fay acids EPA and
DHA from fish
May have adequate B12
intake compared to vegans;
Beer omega-3 fay acid EPA
and DHA intake from eggs
compared to vegans; Higher
calcium, phosphorous,
vitamin D and B12 from dairy
products than vegans
At risk for low protein,
creane and carnine;
risk low omega-3 fay
acids EPA and DHA
intake due to lack of
eggs or seafood; Lower
B12 and may need
supplementaon
All vegetarian diets
(including vegan) at risk
for low protein, iron, zinc,
calcium, iodine, vitamin A,
vitamin B2, B12, D,
omega-3 fay acids EPA
and DHA intake, and
overall caloric intake

4JPFSM : Vitale K and Hueglin S
diet is the potential risk of consuming too much carbohy-
drate compared to their previous intake– this can have a
negative impact on body composition, and therefore per-
formance, in some sports. For example, when athletes ex-
change an animal source of protein for a plant source (e.g.
chicken for black beans) there is an associated change in
nutrient profile resulting in higher carbohydrate per gram
of beans compared to chicken. Weight class athletes and
athletes in which excess body fat negatively impacts per-
formance and competition results (e.g. running, jumping,
diving, gymnastics, aesthetic sports) need to be aware that
plant-based protein sources tend to increase carbohydrate
and fat to their total intake. Appropriate planning and edu-
cation on the differences in plant vs. animal-based protein
sources is recommended to ensure an optimal range of
carbohydrate intake.
Fat. Dietary fat can provide energy during prolonged
exercise, if glycogen stores are depleted, and aids in fat-
soluble vitamin absorption. Athletes should follow current
public health guidelines to ensure adequate fat intake36,37),
since athletes who restrict fat intake to <20% of total en-
ergy can be low in fat-soluble vitamins and essential fatty
acids36). Lacto-ovo vegetarians and pesco-vegetarians (fish
consumption with vegetarian diet, also called pescetari-
anism) typically consume adequate essential fatty acids;
however strict vegans may be low in the omega-3 fatty
acid eicosapentaenoic acid (EPA). Even though conver-
sion of alpha-linolenic acid (ALA) to EPA and docohexae-
noic acid (DHA) in humans is inefficient, current research
suggests vegan athletes can meet EPA/DHA requirements
by adequate intake of ALA12). Vegetarian athletes may
also opt for DHA-rich microalgae supplements38).
Overall, adequate energy intake is important for any
athlete, regardless of whether they eat foods derived from
animal and/or plants. Athletes not meeting total energy
requirements may suffer impaired performance, recovery,
and may experience health consequences such as weight
loss, sarcopenia, low bone mass, chronic fatigue and ill-
ness3,36). Plant-based athletes may risk inadequate caloric
intake due to the high-fiber and low caloric density foods
contained in a plant-based diet. However, frequent meals,
selecting energy-dense foods, and limiting excessive
high-fiber foods should help meet energy needs in a veg-
etarian and vegan athlete.
Protein. Protein intake is often the most controversial
aspect of vegetarian and vegan diets for athletes. In addi-
tion, protein supplements are a multi-billion-dollar market
with widespread use in sports39), and many athletes fol-
low a high-protein diet39). Traditional recommendations
indicate high-performance athletes require 1.2-2.0 g/kg/
day of protein according to sport category36), however
newer recommendations suggest 1.6 g/kg and up to 2.2g/
kg depending on type of sport and goals40). Additionally,
protein timing may favorably impact athletes. Intake of
a 0.25-0.3 g/kg dose within the 0-2 hour post-exercise
window can stimulate muscle protein synthesis (MPS)36,41).
Alternatively, 0.4 g/kg 4 times a day40) may be a simpler
way to achieve protein needs. This latter approach may
be more practical to high-level athletes who usually train
multiple times a day - the window after exercise may be
less important compared to steady intake throughout the
day to cover the times after each training session. Regard-
less of protein source, this dose should have a high con-
centration of not only branched-chain amino acids, such
as leucine to stimulate MPS, but approximately 10g of the
essential amino acids (EAA) to maximize MPS36,41,42).
There is little evidence that protein requirements in
vegetarian athletes are any different than omnivorous
athletes3). However, athletes who consume plant-based
protein sources need adequate EAA and leucine intake to
ensure appropriate MPS. Leucine (at least 2.5g doses) has
been shown in multiple studies to be a powerful activa-
tor of mTORC and other signaling proteins involved in
MPS36,41,42). While animal-based whey protein is high in
leucine and classically considered a preferential source
for omnivorous athletes, soy, pea, brown rice, potato, and
corn all can provide leucine requirements43). However,
individual plant leucine amounts vary. Due to the greater
leucine content of corn, 20 g of corn protein would need
to be ingested to provide 2.7 g leucine. The dose of other
individual plant-based proteins would need to be in-
creased [e.g. 33 g (potato), 37 g (brown rice), 38 g (pea),
40 g (soy)] to achieve a similar leucine content as corn43).
Therefore, athletes should incorporate varied plant-based
sources of protein to obtain appropriate leucine and
EAAs.
Individual plant-based protein sources may lack ade-
quate amounts of certain amino acids such as leucine, me-
thionine, and lysine. The relative shortage of these amino
acids may contribute to potential lower anabolic capacity
of plant-based proteins compared to animal sources43).
Other possible reasons for lower anabolism may be due to
the lower digestibility and absorption (about 10-15% low-
er) of plant-based proteins, greater splanchnic extraction
and subsequent urea synthesis44) and shuttling of plant
protein towards oxidation rather than MPS45), which may
be related to lower concentration of certain EAA in plant-
based proteins44). However common food combinations
e.g. rice and beans, beans and nuts/seeds [hummus], nut
butter sandwiches typically are complementary and can
provide a complete profile of all EAA (e.g. grains are low
in lysine but high in methionine, legumes are low in me-
thionine but high in lysine, and corn and potatoes are high
in leucine)43). This is further supported by a recent review
pointing out that protein-rich plant foods are sufficient for
human requirements, and the question of amino acid de-
ficiency in plant foods has been substantially overstated5).
Furthermore, the once-popular recommendation that one
needs to combine protein sources in the same meal to
achieve a complete EAA profile at each feeding no lon-

5JPFSM : Update on Vegetarian Athletes
ger appears necessary, as long as the daily total intake
is adequate8,12,43,46). This allows more flexibility in meal-
planning for an athlete that consumes only plant protein
sources.
There are numerous studies and reviews suggesting
cardiovascular disease risk and metabolic syndrome risk
may be reduced by incorporating more plant-based pro-
tein sources47,48), as well as all-cause and cardiovascular
mortality49). However, to date there are limited high-
quality studies specifically examining animal vs. plant-
based protein regarding athletic performance. A recent
study investigated 25g of either pea or whey protein
supplementation twice a day in a double-blind random-
ized placebo-controlled trial and showed no difference in
muscle strength or thickness50). Another study compared
24g of whey vs. pea protein supplementation taken before
and after exercise on training days and in-between meals
on non-training days during an 8-week high-intensity
functional training program51). There were no differences
in body composition, muscle thickness, strength (thigh
muscle peak force or rate of force development), or per-
formance (benchmark workouts of the day)51). However,
these preliminary studies have limitations, since they
were not conducted on elite, professional, or Olympic/
Paralympic athletes; and in some cases, the sample size is
quite small. While preliminary, they do suggest there are
no significant differences for athletes in terms of muscle
size, muscle strength, or performance when consuming
whey vs. pea protein supplements, although more studies
are needed.
Micronutrients
Vegetarian athletes should emphasize the adequate in-
take of certain micronutrients, as several of these have
been shown to be either less abundant or less efficiently
absorbed compared to animal sources3). These include
iron, zinc, calcium, vitamin A (according to one study15)),
vitamin B2, vitamin B12, iodine and vitamin D6,15). In
contrast, vegetarian diets typically have higher concen-
trations of folic acid (vitamin B9), vitamin A, C, E, and
K, and carotenoids12,16), as well as potassium and mag-
nesium12,15,16). The following sections explain important
vitamin and mineral issues faced by vegetarian athletes;
Table 2 provides a summary of the important differences
in vegetarian diets compared to omnivorous diets.
Vitamins. An advantage of a vegetarian diet is the re-
ported higher intake of folic acid (vitamin B9), vitamin
C and E, and carotenoids16); this higher intake has been
proposed to improve performance3). Plant-based diets also
typically have plentiful sources of the vitamins A and K
as well12). A vegetarian athlete typically contains adequate
amounts of these micronutrients and supplementation
therefore is generally not needed52).
Furthermore, as mentioned above, the overall increased
antioxidant effect from the higher intake of these vitamins
may offset the increased exercise-induced oxidative stress
in elite athletes, and potential environmental oxidative
stresses such as altitude and prolonged sun exposure ex-
perienced by athletes18,19). Another advantage is that the
antioxidant vitamins derived from whole foods are gener-
ally favored over antioxidant supplements in terms of ef-
fectiveness20).
However, there are a few concerns regarding micronu-
trient vitamin intake. Traditionally, vegetarians are con-
sidered to have potential inadequate intakes of vitamin A
(according to one study15)), B2 and B12, as well as vita-
min D6,15). Vitamin D supplementation may be required
if an athlete lives in an area (or follows a lifestyle) with
limited natural sunlight exposure (e.g., athletes who use
sunscreen regularly when training outdoors, practice in-
doors, have darker skin color). Strict vegan athletes may
not consume adequate vitamin B12, found in animal-
derived foods12). Fortified foods or B12 supplementation
is recommended for vegans12), whereas lacto-ovo vegetar-
ians generally obtain sufficient amounts.
However, studies demonstrate these deficiencies are
usually due to poor meal planning15) rather than inad-
equate nutrient content in a vegetarian diet. Careful
meal planning can avoid these pitfalls in the plant-based
athlete’s meal plan. Obtaining these micronutrients via
natural or fortified foods is recommended; however,
plant-based athletes may opt for supplementation due to
convenience12,36).
Minerals. In contrast to vegetarians often showing a
higher intake of multiple vitamins, the only minerals
reported to be higher in vegetarians is potassium and
magnesium12,15,16). A vegetarian athletic diet typically
contains adequate amounts of these micronutrients and
supplementation is generally not needed52). Furthermore,
these are critical minerals to athletes and higher intakes
are purported to improve performance3).
Traditionally, vegetarians are considered to have in-
adequate intakes of iron, zinc, calcium, and iodine15).
However, as with vitamins, studies show these mineral
deficiencies are often due to poor meal planning15) rather
than inadequate nutrient content in a vegetarian diet.
Although, a few considerations are worth mentioning.
Non-heme iron and zinc are better absorbed with vita-
min C and should be taken together, and single high-
dose mineral supplementation should be avoided, as high
doses of one mineral may compete for absorption with
another12). Certain food preparation techniques such as
soaking, sprouting, and fermenting/leavening also reduce
the phytate content, which binds minerals and can prevent
absorption12). High oxalate content in certain greens (e.g.
spinach, chard) may also bind and limit availability of
calcium52). Lastly, iodine may be adequate according to
geographic region, but supplementation is recommended
if an athlete lives in a region with iodine-poor soil, or

6JPFSM : Vitale K and Hueglin S
consumed by vegetarians15,16) may improve performance3).
The overall increased phytochemical intake from plant
sources may enhance the antioxidant system and offset
the increased exercise-induced oxidative stress experi-
enced by elite athletes18,19).
Another ergogenic benefit mentioned above is derived
from the high nitrate content in plants. Several stud-
ies have demonstrated how nitrate-rich plant foods can
improve performance in athletes27,29-31). Nitric oxide can
improve blood flow and oxygen regulation in muscle and
improve mitochondrial function28-30); cumulatively, these
uses only iodine-free salts12,52). These nutrients can eas-
ily be obtained with a simple well-balanced diet, and as
mentioned above, these deficiencies typically occur more
commonly due to poor meal planning6) rather than poor
food sources.
Other micronutrients such as nitrates, antioxidants,
polyphenols, isoflavones, and other phytochemicals.
Plant-based diets typically have plentiful sources of
nitrates, antioxidants, polyphenols, isoflavones, and other
phytochemicals12). The increased levels of phytochemicals
Table 2. Macronutrient and micronutrient differences of vegetarian diets
Potenally low in vegetarian diets Considered high in vegetarian diets
Macronutrients
Carbohydrate Higher; may promote glycogen storage
Fat Lower, especially omega-3 fay acids
EPA and DHA if vegan
Protein Lower; especially leucine and other EAA
Micronutrients: Vitamins
Vitamin A
carotenoids
Lower in one study Higher in several studies
Vitamin B2 Lower
Vitamin B9 (folate) Higher
Vitamin B12 Lower; vegans may need
supplementaon
Lacto-ovo vegetarians may have adequate
intake
Vitamin C Higher
Vitamin D Lower; supplementaon may be
needed if low sunlight exposure,
training indoors, darker skin color
Vitamin E Higher
Vitamin K Higher
Micronutrients: Minerals
Magnesium Higher; may improve performance
Potassium Higher; may improve performance
Iron Lower; Non-heme iron beer absorbed
with vitamin C
Zinc Lower; beer absorbed with vitamin C
Calcium Lower; High oxalate content in certain
greens may limit calcium absorpon
Iodine Lower; supplementaon may be
needed if iodine-poor soil, or athletes
uses iodine-free salts
Other:
Fiber Higher
Anoxidants Higher; may offset increased oxidave
stress
Phytochemicals Higher; may offset inflammaon
Nitrates Higher; may improve performance
Isoflavones (in soy) Higher; may improve performance
Creane Lower; may affect high-intensity
exercise, supplementaon considered
β-alanine Lower; supplementaon may be
consider if power sport
Carnosine Lower; supplementaon may be
consider if power sport
Total Calories Lower; due to the high-fiber and low
caloric density foods contained in a
plant-based diet

7JPFSM : Update on Vegetarian Athletes
mentation. Further studies are needed.
The overall exercise capacity of vegan, lacto-ovo-veg-
etarian and omnivorous recreational runners was exam-
ined in a recent study58). Vegan and lacto-ovo-vegetarian
runners were compared to omnivorous runners and per-
formed a maximal exercise stress test to exhaustion. All
three groups had comparable training frequency, training
time, and running distance. There were no differences in
terms of maximal power output or lactate levels, and the
authors concluded that any of the vegetarian diets might
be suitable alternatives for recreational athletes compared
to omnivorous diets.
However, this previous study presumes that the athletes
all had similar energy availability. As mentioned in the
carbohydrate section, vegetarian athletes usually can meet
carbohydrate needs due to the inherent carbohydrate-rich
nature of plant-based foods. Some may assume there-
fore they are able to meet overall energy needs as well.
However, on the contrary, some athletes who primarily
eat plant-based foods may struggle to maintain an appro-
priate energy balance due to more restrictive eating pat-
terns. Although energy balance is considered important
(comparing energy intake to energy expenditure), energy
availability is most important to athletes. Energy avail-
ability is the amount of dietary energy remaining after
exercise, available for other physiological functions such
as growth, muscle recovery, and homeostasis59). Athletes
who eat primarily plant-derived foods may be at risk of
low energy availability if their total daily intake is insuf-
ficient. For example, one of the key concerns of vegetar-
ian diets is the high fiber content, which may lead to early
satiety and appetite blunting60) resulting in potentially
too few calories consumed to support energy expendi-
ture from training. Also, besides consuming more high-
fiber foods, vegetarian athletes may choose less energy-
dense foods resulting in undereating61). Another challenge
when transitioning to plant-based foods is an athlete may
exclude certain foods (i.e. animal-based foods) without
replacing the nutrients from another source. These factors
can lead to a decrease in total daily calories, low energy
availability, energy imbalance, and poor performance in
the vegetarian athlete59).
Furthermore, low energy availability underlies the fe-
male athlete triad, male athlete triad, and relative energy
deficiency in sport (RED-S) syndromes59). The health
concerns associated with these low energy availability
syndromes (e.g. menstrual and cardiovascular dysfunc-
tion, compromised bone health) can also contribute to
impaired sports performance59). Therefore, it is paramount
for athletes to achieve proper energy balance and energy
availability. A detailed meal plan designed to support the
athlete’s training volume, intensity, and duration is key to
avoiding an unwanted energy imbalance.
Lastly, in regard to performance considerations, Table 3
summarizes key recommendations for athletes including
macronutrient breakdown32). While specific macronutrient
effects can improve muscle economy and efficiency, re-
duce fatigue and cardiorespiratory effort at submaximal
workloads, and improve performance29-33).
Finally, the isoflavones found specifically in soy can
improve vascular endothelial relaxation, increase limb
blood flow, and decrease cardiac demand15,34,35). While
this would be specific to the athlete who eats soy as part
of their diet, studies have shown these isoflavone-induced
effects can improve power outputs and cyclists’ times to
race completion, as well as lower average heart rates34).
Performance Considerations
Specific to the athlete, there has been skepticism regard-
ing vegetarian diets and performance compared to tradi-
tional omnivorous diets. However, vegetarian-based diets
compared to omnivorous mixed diets (when matched for
total energy, micro- and macronutrient intake appropriate
to support the needs of the athlete) have shown no distin-
guishable differences in physical performance in several
randomized trials and reviews53-55) in terms of strength/
power, aerobic exercise and anaerobic exercise perfor-
mance. In addition, specifically animal vs. plant protein
supplementation has shown no strength, muscle size, or
performance differences50,51).
However, there are a few legitimate concerns. Female
and male athletes following vegetarian and vegan diets
may be at increased risk of (non-anemic) iron deficiency
that may limit endurance performance17,56), and needs to
be carefully accounted for in an athlete’s dietary choices
and monitored with bloodwork as clinically indicated.
Male and female athletes who rely primarily on plant-
based proteins may also have lower mean muscle creatine
concentrations compared to their omnivore counter-
parts, which may affect supramaximal (repeated high-
intensity bouts, high intensity interval training) exercise
performance56). Some research suggests that creatine and
β-alanine supplementation may be beneficial to vegan
athletes who engage in power sports, since they may
have lower creatine and muscle carnosine levels6). One
study has suggested vegetarians were likely to experience
greater performance increments, after creatine loading, in
short high-intensity sports that mainly rely on the adenos-
ine triphosphate/phosphocreatine (ATP/CP) system for
energy56). It is important to note that the majority of elite
athletes perform some type of strength training which
relies on this energy system; even endurance athletes
regularly utilize the ATP/CP system and may benefit from
elevated levels of muscle creatine. And, in a very recent
study in soccer players, creatine supplementation seems
to have shown some improvement in cognitive perfor-
mance57), warranting further investigation into the brain
phosphocreatine’s effects on mental fatigue. While there
have been no studies specifically in vegetarian or vegan
athletes regarding brain creatine levels, this finding is of
importance to athletes who may consider creatine supple-

8JPFSM : Vitale K and Hueglin S
zinc, calcium, vitamin A, vitamin B2 and B12, iodine,
vitamin D, and overall energy intake. Protein require-
ments are no different in a vegetarian athlete compared
to an omnivorous athlete, as long as a plant-based athlete
can meet EAA (including leucine) requirements and total
protein intake throughout the day. While more studies are
needed, plant-based diets may even provide certain health
and performance benefits compared to omnivorous diets.
With the right meal planning an athlete can not only meet
all nutritional requirements with plant-based foods, but
also enjoy similar strength/power, aerobic and anaerobic
exercise performance.
amount and timing recommendations based on duration
of exercise are outside the scope of this manuscript, this
table concisely summarizes carbohydrate, protein and fat
requirements, and additionally provides key information
regarding other nutrients relevant to athletes such as so-
dium, water, nitrates, caffeine, and whether or not a veg-
etarian athlete chooses probiotic supplementation.
Conclusion
With proper planning, athletes can achieve all their nu-
tritional needs via a vegetarian or vegan diet. There are
certain considerations in terms of macro- and micronu-
trient intake specific to a plant-based diet, such as iron,
Table 3. Key recommendations for macronutrients, hydration, and supplements for athletes (exercise duration is
listed in italics within parentheses). Adapted from: “Nutrition and supplement update for the endurance athlete:
review and recommendations” by Vitale, K. and Getzin, A., 2019, Nutrients, 11(6), p.1289. Copyright 2019 by
Kenneth Vitale. Reprinted with permission by author.
Nutrient Daily Requirements Pre-Exercise During Exercise Post-Exercise
Carbohydrate
5–7 g/kg/day (1
h/day)
6–10 g/kg/day (1–3
h/day)
8–12 g/kg/day
(4≥h/day)
6 g/kg/day (<90 min)
10–12 g/kg/day (> 90
min)
+
1–4 g/kg (1–4 h prior
to event)
30–60 g/h (<2.5 h)
60–70 g/h (>2.5 h)
90 g/h (>2.5 h, if
tolerable)
8–10 g/kg/day (first 24
h) 1.0–1.2 g/kg/h (first
3–5 h) or
0.8 g/kg/h + protein (0.3
mg/kg/h) or caffeine (3
mg/kg)
Protein 1.4 g/kg/day
0.3 g/kg every 3–5 h
0.3 g/kg immediately
prior (or post–
exercise)
0.25 g/kg/h (if high
intensity/eccentric
exercise)
0.3 g/kg within 0–2 h
(or pre-exercise)
Fat
Do not restrict to <20% total caloric energy
Unclear role of CLA, omega-3, MCT supplements
Consider limiting fat intake only during carbohydrate loading, or pre-race if GI comfort concerns
Water
Try initial hydration plan at ~400–800 mL/h;
Adjust according to individual athlete variations (sweat rates, sweat
sodium content, exercise intensity, body temperature, ambient
temperature, bodyweight, kidney function)
Follow thirst mechanism, monitor parameters (bodyweight, urine
color)
Replace fluid with 150%
of fluid lost
Sodium
Try initial sodium plan at 300–600 mg/h if high sweat rate (>1.2 L/h),
subjective “salty sweater,” or prolonged exercise >2 h
Adjust intake according to individual athlete variations (sweat rates,
sweat sodium content, exercise intensity, body temperature, ambient
temperature, bodyweight, kidney function)
Improved water
repletion observed with
>60 mmol/L sodium
content (~1380 mg/L)
Nitrates
300–600 mg of nitrate (up to 10 mg/kg or 0.1 mmol/kg) or 500 mL beetroot juice or 3–6 whole beets
within 90 min of exercise onset
Consider multi-day dosing e.g., 6 days of a high-nitrate diet prior to event
Antioxidants
Avoid prior to exercise to maximize training adaptation
Take prior to exercise only if recovery needed within 24 h
Many options: whole foods, dark berries, dark greens, green tea
e.g., 8–12oz tart cherry juice twice a day (1oz if concentrate) 4–5 days prior and 2–3 days after event
e.g., green tea extract (270–1200 mg/d)
Caffeine
3–6 mg/kg taken 30–90 min prior to exercise
Consider “topping-up” every 1–2 h as needed
≥9 mg/kg does not further enhance performance, may have undesirable
side effects, + drug test
≤3 mg/kg can also be ergogenic without side effects
3 mg/kg with
carbohydrate enhances
glycogen repletion
Probiotics
Lactobacillus and Bifidobacteria may help with upper respiratory and/or GI symptoms

9JPFSM : Update on Vegetarian Athletes
Conflict of Interests
The authors declare that there is no conflict of interests regard-
ing the publication of this article.
Author Contributions
KV conceptualized, designed, developed the theory of the
manuscript, performed literature review and background data
collection, and wrote the manuscript. SH revised the manuscript,
provided critical feedback, direction and planning of the manu-
script, and made critical contributions. Both authors read and
approved the final manuscript.
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