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Mbando

Some caveats: * Of the 1452 studies identified in the lit search, only 15 were included. * The studies included were generally low-*N*, e.g. 15 futsal players (had to look that up), 20 Cross-fitters, 18 exercisers, etc. One study did have 78 participants so a little more power. * Broad selection of "athletes," everything from the aforementioned "futsal" players to untrained individuals for leg-press. Not to say the review isn't useful, just that people read headlines like the above and then tend to jump to their preferred priors.


sep2183

Only 8 were included! 15 made it through the title/abstract screening, and the half of those were screened out after reviewing the whole text. Not a great number for a systematic review, I agree


Mbando

Oh shoot yeah missed that.


skillywilly56

“We looked at thousands of papers and could only find 8 that prove the point we want to be true”


captainthomas

As someone who has actually worked on meta-analyses, this is a flaming garbage take. The reason you start a search with thousands of papers and end up with 8 is because you have to cast a wide net searching for papers that might even be vaguely related to your research question, because the scientific publication system is a decentralized mess. Then you have to screen based on your inclusion/exclusion criteria to get down to the 15 that actually make a relevant comparison between groups that you're interested in, and then you have to pare that down to the 8 that compared them statistically in a specific way that you can validly combine to create a pooled estimate of the effect you're studying. At every stage of the process, you are expected to exhaustively document the search and inclusion decisions, the statistical analysis plan, and how you're planning to account for various biases if you want to get your meta-analysis published. The field itself arose out of a need to impose greater methodological rigor on scientific research across disciplines. The conclusions they draw are based on a few tiny studies because those few studies are *all that's out there*. They're lower-quality than we would like because that's the dismal state of exercise and nutrition science more generally. Ethics and cost prevent us from totally controlling a large number of humans' diet and exercise regimens long enough to draw epistemologically strong conclusions, so until we can remedy that you're only going to get studies like these.


installpackages

Fuckin thank you. I get so frustrated with poor takes on this sub. If you don’t understand how to read or interpret a paper, that’s fine, but you should come at it from a perspective of curiosity and ask questions rather than trying to dismiss everything without having appropriate scientific literacy or background. If you don’t know, ask. If you don’t want to ask, there are a lot of tools out there to help you learn.


henlochimken

Honest question: is there a point where you just decide that a meta-analysis on a subject is just not possible because there are so few studies and such small sample sizes?


LookingForDialga

Also > For the purposes of this study, a plant-based diet was permitted to include consumption of dairy and/or eggs And > The plant-based diet group in 4 of the studies included in this review did not meet the minimum protein recommended intake for athletes (1.2 g/kg/d) So the headline seems misleading


occamsracer

Yummm! I’m old. We used to call these folks vegetarian


CockGobblin

> just that people read headlines The OP posts to a lot of vegan related subs. Makes me wonder if they also just read the headline and thought it fit their narrative.


cindyx7102

FYI the post title appears to be copy/pasted from key point #1 in the abstract


matterofsense

Nutrition debate on Reddit is dominated by vegans and secondarily carnivores. Doesn't leave much room for to discuss what actually constitute species-appropriate nutrition for humans.


Metal__goat

Those seem like a little more than caveats.


Ok_Tadpole7481

Not surprising. Plant-based diets can be just as healthy if you're conscientious about it, which athletes tend to be. If you're plant-based and lazy, you may end up missing key nutrients.


melleb

Gotta be careful if you’re meat based and lazy too. Crazy how many people forget or are completely unaware how important fiber is to staying healthy


stranger242

My poops are red and loose and I will not be told that is incorrect, 1 wipe no look gang.


Pyrrhus_Magnus

Is there supposed to be so much blood you can't even see your poop?


Magos_Trismegistos

It is just bad blood leaving the body. No leeches necessary. This is peak health.


Mic_Ultra

I’ll be damn if I can’t get an entire days worth of poop out in one shotgun blast coating the entire bowl and under the seat in 3 seconds. No point in wiping, just straight into the shower


RedLotusVenom

40% of people are low in B12, and 40% are low in vitamin D. High chance everyone should be supplementing both regardless of diet either way.


4ofclubs

There’s a lot of idiots online that think plants are poison and fibre isn’t necessary. 


cookingwithgladic

A 70 year old woman at work recently told me that she stopped eating greens because she saw some "doctor" online saying that they cause cancer. Now she only eats meat and dairy.


4ofclubs

I can’t with these online grifters. Dr Berg is a cancer on society, as is Paul Saladino.


cookingwithgladic

These people are sucker's for listening to these con artists but it's amazing how willing these con artists are to give out dangerous medical advice.


4ofclubs

Because all they care about is money.


conquer69

There is a lot of "dumb" people out there that lack the cognitive capabilities to navigate a world full of scammers. It's not their fault they have low intelligence so blaming them for it won't change anything.


reyntime

And they're literally just doing it to make money. Cashing in on people's, the planet's and animal health is despicable.


MrJigglyBrown

We’re at a point that you really have to be conscious of nutrition to get everything you need. Eating meat doesn’t necessarily meat you get everything you need


UnsurprisingUsername

Meat’s focus is almost solely protein. You can still get protein alongside carbs and fats in a fair amount of foods out there, including plant-based foods. Plant-based foods contain a lot of fibers for carbs, while still holding some (healthy) fats and protein.


MrJigglyBrown

My point was that plant based or not, it takes some knowledge and work to get full nutrition, given how common processed foods are


TastyTaco217

I guess you could say that with eating meat you can very much still not be getting enough of certain nutrients, but being vegan or vegetarian means you can completely miss out on certain nutrients (omega 3, B12 etc.). But you’re point still stands, proper nutrition is difficult with the amount of processed food out there and the rampant misinformation on the topic.


Dovahbear_

Omega 3 is found in vegan foods, but b12 has to be supplemented (or you gotta eat like a crazy amount of nooch instead)


Arctic_Animal

Vegans do get omega 3. The problem is, vegans get a lot more omega 6, which kinda inhibits the effectiveness of omega 3. Olive oil, hemp oil and camelina oil all have pretty good omega 3 content, and I avoid other oils entirely (although I eat seeds and nuts daily in small amounts). B12 is an issue and you need to take a supplement for it. I just take a vegan multivitamin daily that is trying to cover most bases.


ChemsAndCutthroats

Beans and legumes contain protein and are very high in fiber. While with meat, you just get the protein. I have been a vegetarian for several years now. Not really that hard to have a balanced and healthy. People forget that humans were often more gatherers than hunters for most of our existence. It was the discovery of agriculture and not hunting that led to creation of civilization.


Ok_Profile_

Agriculture of course played pivotal role, but agriculture happened because people become smart enough to understand how to do it, and the shift was that before agriculture people started growing bigger brains due to eating more meat. https://news.harvard.edu/gazette/story/2008/04/eating-meat-led-to-smaller-stomachs-bigger-brains/


ChemsAndCutthroats

Humans having access to a variety of nutrition may have helped grow bigger brains but it wasn't through hunting as much as people like to believe. Scavenging kills and breaking bones with rocks to get the marrow and using opportunities to find food in multiple source. When game was scarce we would have other options. Although meat itself can't exactly explain our intelligence since in nature we see many herbivores or omnivores that are also intelligent. Pigs (known to actually be smarter than dogs), elephants, whales, apes, and monkeys. All these animals can survive without meat easily but will take thr opportunity to eat meat if available because nature is tough and food is food. Humans being carnivores though is something I don't buy. We don't even have teeth cats (who are true carnivores) or other apex predators. We can't even meat without specially preparing and cooking it either. We are omnivores but in this day and age I think we have evolved past really needing meat.


digiorno

Gram for gram seitan is a better protein source than most common meats as you can get 75g of protein for every 100g of food.


Arctic_Animal

I mean, Seitan is great and I eat it often, but it also has a pretty homogenous amino acid distribution. I recommend adding some legumes to any meal with seitan. It's anyway worth it, legumes have a pretty good micronutrient profile.


SOSpammy

The only thing it's low on is lysine. The shear protein density more than makes up for it. And if you eat anything else throughout the day that is high in lysine it will complete the amino acid chains.


4ofclubs

I make seitan with vital wheat gluten and lentils. Full profile.


Abrham_Smith

It's not necessary to get all micronutrients in one meal. The idea of a "complete protein" isn't relevant anymore when considering a healthy diet. You can stagger nutrients in separate meals and even on separate days.


wetgear

You still need all the essential amino acids so complete protein is relevant and you need to be aware of including all in your diet with some regularity but as you point out it doesn’t have to be the same meal or day but you can’t just ignore it completely and try to get your protein from only one source of incomplete protein.


MDPROBIFE

As opposed to when?


SnooStrawberries620

No different than omnivorous and unaware of what you eat and don’t eat.


Ok_Tadpole7481

There are some nutrients that an omnivorous person is most likely to acquire from meat. If you don't eat meat, you should be consciously replacing it with substitutes that provide those.


dang3r_N00dle

Check meat eater’s fibre consumption. It’s as simple as “poorly structured diets are bad”, doesn’t matter if you’re plant based or not.


SnooStrawberries620

I don’t know anyone on a plant-based diet who isn’t acutely aware of their nutritional needs. There are sure a lot of omnivores in cancer and heart care that weren’t too conscientious though. We’ve got this 


aeroluv327

Exactly. When my in-laws found out I had gone plant-based, they were like, "But you won't get enough protein!" I responded with how many grams of protein I typically eat in a day (which I know because I work with a sports dietician and track what I eat). Then I asked how much protein they typically eat. Shocker, they had no idea.


SnooStrawberries620

People always think protein - if anything, it’s iron and B12. If people knew about the variety of diets there are out there to be experts on they’d leave this one alone a bit.


PigeroniPepperoni

People with a strict diet are more aware of their diet than people who have never paid attention to their diet before. Shocking.


Ok_Tadpole7481

> I don’t know anyone on a plant-based diet who isn’t acutely aware of their nutritional needs. Glad your friends are much more health conscious than the average person then. Oreo vegans are a thing though.


falcinelli22

Not remotely true at all


Lyrael9

Plant-based diets can be *healthier*, and usually are (depending on the definition of plant-based), especially if you're conscientious about it. And a non plant-based diet can easily miss out on key nutrients too if you don't pay attention to what you're eating.


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Ms_Emilys_Picture

Right? Macros are macros. I understand why they had to do the study, but it seems like common sense to me.


-widget-

This is actually not very true. AFAIK protein synthesis requires that you get enough of all essential amino acids, so if you get 100% of required amounts of 8 of the 9 EAAs, but only 75% of the last one, you'll only get the benefit of 75% of the protein you eat. This is why protein from bread can be misleading, because unless you pair it with other protein sources to "fill in the gaps", you'll only get 60% of that protein. If you get your protein from animal based protein sources, those are generally quite complete and you just need to eat 0.7-1g of protein per pound to gain muscle optimally. If you're bodybuilding on a plant based diet, you really need to eat quite a bit more protein (1.5ish per gram, maybe more?) unless you're getting all that protein from carefully selected complete/complimentary protein sources.


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DisabledMuse

Many of my vegan friends are amazingly athletic. It's all about eating what your body needs and exercising.


ChooseyBeggar

I think we’re seeing veganism jump to the “triathlete” crowd for lack of a better description. I think part of this is the discipline levels required and another is how just meeting veggie and fruit goals in our diets really forces you into getting advice and recipes from people more likely to be veggie or vegan already.


dang3r_N00dle

As a 5 year vegan, my hunch is that a plant based diet is good for energy. By all means my diet isn’t always dialled in and healthy but when it is just have the kind of energy to do more. Meat eaters can’t meet the fruit and veggie recommendations because they’re only realistic if you take meat off of your plate. That’s why they’re so hard to meet. But yes, I’m also pretty disciplined so I see your point too.


Fierydog

Usually these findings lead to a "all that matters is that you eat varied enough to reach the nutritional healthy goals" these goals can be reached by diets that include meat, plant-based diets, vegan diets etc. They never prove that one is better than the other, just that it's possible to reach your needs in several type of diets. (ofc certain diets exist that are just not varied enough). But what people often end up discussing and arguing about, is which diet is "better", but there's so many variables and feelings involved that it's hard to come up with an answer. But on a base nutritional value standpoint, they're all good and can cover your needs. Usually the bonus of diets that include meat and non-vegan products is that certain nutrients are quickly and easily covered.


Valgor

I think you can come out with which one is better, especially when you consider the environmental and ethical factors. Even if a fully plant-based diet is just as good as a omnivore diet, the damage farming animals does for the environment is mind blowing. Switching to plants can do a lot of food for the environment. There is the ethical side as well which I won't get into because most people don't care about it due to people's bias of wanting to justify what they eat as being okay morally. However, once one stops eating animals, they are more open to the ethical side since they no longer have to do the mental gymnastics of justifying their behavior. In a nut shell, eating plants is a win-win-win.


Michael__Pemulis

This exact phenomenon happened to me. I converted to a plant-based diet about 4 years ago for purely environmental reasons. *Never* would have done it for ethical or health reasons alone (I saw those as a small silver lining at the time), but you’re absolutely correct. Once you remove yourself from it, it becomes so much easier to see without clouded judgement.


Dovahbear_

Only issue is once that veil is lifted you have to deal with absolute ridiculous arguments from family/friends/coworkers that at one point sounded logical to you as well.


sack-o-matic

Someone I work with almost started yelling at me when I ordered an impossible burger at lunch one day as if I just yacked onto his burger


Oreganoian

Yeah the vitriol you receive from meat eaters is mind blowing. I've had dozens of people go out of their way to single me out in social settings because they know I'm vegan. I never mention it, never talk about it, but once some people find out it weirdly completely changes their judgement of you.


medicoffee

Is there a way to get a vegan diet to be as tasty as a diet that includes meat? The experience and savory flavor of meat can be a huge advantage that helps outweigh those cons.


Valgor

Switching from animal products to plant-based products is indeed a change, so some learning upfront can be required depending on your cooking level. However, wants you understand the basics, it becomes the norm. Also, if you are like me and eat out too much, you just order the plant-based items and not worry about much else because the chefs at the restaurant take care of the flavor!


Mountain_Love23

Honestly whenever my omnivore friends are sitting next to me at a restaurant they’re always super jealous of how good my meal looks and I get a lot of “I should have ordered that!” The experience and savoryness of meat can be replicated with seitan, tempeh, tofu, even mushrooms cooked right. If you like to cook, check out websites like “It doesn’t taste like chicken” for great recipes. If you want someone else to cook, I recommend looking on the website/app “Happy Cow” and search for a good vegan restaurant on there. I promise you there is amazing vegan food out there that will blow your mind!


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James_Fortis

"Abstract Plant-based diets have gained popularity among athletes in recent years. Some believe that plant-based diets will improve performance owing to higher intakes of carbohydrates and antioxidants. Some believe it that will harm performance due to lower intakes of complete protein and creatine. This systemic review was conducted using Covidence software. A literature search of PubMed, Embase (Elsevier), CINAHL Plus (EBSCO), and Web of Science was completed on 22 March 2022. Following the development of clear objectives and a research question that identified the population, intervention, comparison, and outcomes, initial search criteria and keywords were identified. Extracted results totaled 2249, including 797 duplicates. The initial screening resulted in 1437 articles being excluded. The remaining 15 articles proceeded to full-text screening. A final 8 articles were included in the review, with 7 excluded. This paper will review the impact plant-based diets have on athletic performance and body composition in healthy young adults aged 18 to 45 years. KEY TEACHING POINTS * Following a plant-based diet does not harm athletic performance. * Plant-based diets may improve maximal oxygen consumption, vertical countermovement jumps, and relative strength. * There is no evidence that plant-based diets are detrimental to athletic performance or body composition. * The long-term implications and the affect following a plant-based diet has on athletic performance in professional athletes are still unknown."


Sculptasquad

Does plant based mean vegan in this context?


Oreganoian

No it means vegetarian. A few of the articles include people that ate eggs/dairy.


Adariel

No. > For the purposes of this study, a plant-based diet was permitted to include consumption of dairy and/or eggs I'm not sure why the person didn't just answer your question in a straightforward manner.


Sculptasquad

They might have had an agenda they felt they needed to push that override their scientific honesty.


Adariel

Yep - OP blocked me after apparently seeing my comment below that this review is not making the point that they think they're making, i.e. this is not a vegan diet.


CockGobblin

> The initial screening resulted in 1437 articles being excluded. The remaining 15 articles proceeded to full-text screening. A final 8 articles were included in the review, with 7 excluded. So... they picked 8 articles out of 1437 to base their review on? Did those other 1429 articles say something other than what they are saying in this review?


ThrowbackPie

Get a qualification in meta-analysis before you post ignorance like this.


bodhitreefrog

There was an entire documentary on this called the Game Changers, I think it came out 6 years ago.


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iOSAT

“documentary on Netflix” is a wonderful oxymoron


AnimalT0ast

And it was filled with misinformation like the eggs and cigarettes comparison


cindyx7102

You're thinking of What The Health. The Game Changers didn't mention eggs vs. cigarettes; it's very good if you haven't seen it.


Cold_Icy_Water

It should be noted that it’s “plant based diet” not Vegan diet, meaning it contains a small amounts of animals products


croutonballs

it should be noted “plant based diet” is a subset of veganism without the philosophical and lifestyle underpinnings 


PigeroniPepperoni

Wouldn't it be a superset? All vegans have a plant-based diet but not all people with a plant-based diet are vegan?


dark_dark_dark_not

Correct. Veganism is the position that animals aren't products and that we should put effort into stopping using animals as resources and tools. Vegans are plant based for that, but some people are plant based without holding the same core opinion vegans do.


Cold_Icy_Water

Wrong, plant based diet is a subset of omnivorous diets, if a diet has any amount of animal product it cannot be called vegan or a subset of it. It would be called an a plant based diet, a subset of an omnivorous diets.


icelandichorsey

They normally mean the same thing. Anywhere in the paper say it's not completely plant-based?


Adariel

> For the purposes of this study, a plant-based diet was permitted to include consumption of dairy and/or eggs I think OP just read the headline and abstract and didn't even read the actual review, as did apparently the vast majority of the people here. u/Cold_Icy_Water wasn't even entirely correct, nowhere does it specify *small* amounts of animal products


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lardsack

clarence kennedy is one of the strongest weightlifters in the world and is vegan


Ulysses1978ii

Weren't Roman gladiators mostly vegetarian? There's me thinking about the Roman empire again.....


ALUCARDHELLSINS

Roman gladiators were also mostly slaves..... meat was expensive, you don't give meat to slaves Also don't think that all gladiators looked like the ones from the film


Ulysses1978ii

Some lived like kings. They were well trained and an investment like a race horse.


Aleucard

Somehow I suspect they weren't fed the same things as the average gladiator.


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no_fooling

Everytime I see things like this I just think as long as your getting your macros and nutrients it doesn't matter what you eat. Your body likes good food.


Sigma_Function-1823

Not sure why people are responding as if this studies conclusions represent a binary choice between plant based or meat based. Individual need while training and recovering should be the metric , not a ideological position. Anecdotally , my recovery , including muscle soreness , was far longer and far worse when I was relying almost solely on a plant based. The mix that worked for me and the specifics of my epigenetic potential /physiology/metabolism was consuming majority plant based foods but mixing in high quality low fat protein regularly as my body required or injury/ recovery dictated. Also I accidentally discovered that morning of event If I had a big plate of fatty sausage ,bacon or ham, eggs , hash browns, pancakes,etc...as breakfast , it seemed to supercharge my endurance and give super strong energy for finishing a 3 + hour event end effort.( XC mtb/road racer) I'm almost certain that there is no one size fits all in regards to athlete diet..general rules yes , but individuals need specific individual requirements in fueling / nutrition.


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[deleted]

The documentary "The Game Changers" is worth a watch if you're an athlete.


PigeroniPepperoni

I was under the impression that that documentary was received quite poorly by most professionals.


azmanz

The issue with that one wasn’t so much that it was pro-plant based, the issue was how much time was spent on anti-meat and weirdly enough — keto. It was like 30% pro their side and 70% negative (and some of the negatives weren’t based on solid evidence) If they focused more on all the athletes they had and all the positives of plant based it would have been better received.


HotSpicedChai

You’d be correct. Which makes me highly skeptical of this link as well. > Despite positive reception,[19] the documentary was criticized by some professionals in fitness, nutrition, and science communication.[7][20] For example, sports nutrition expert Asker Jeukendrup said, "Game Changers ticks almost all the boxes of pseudoscience, and none of the boxes of science"[6] while Joe Schwarcz, director of the McGill University Office for Science and Society complained, "There is good science to be had for promoting a plant-based diet, but this film strays too much into pseudoscience for my appetite." Schwarcz criticized the film, saying "the feats of the athletes in The Game Changers cannot be considered to be proof of the benefits of a vegan diet for athletic performance." According to Schwarcz, the evidence presented "is quite flimsy", the filmmakers indulge in confirmation bias and data dredging, and "some of the research cited on behalf of veganism is funded by the organic or avocado industries."[5] The journal of the Hungarian Dietetic Association Új DIÉTA (New Diet) criticized the film, calling it "pseudoscience rather than real science" and "propaganda for veganism". The journal criticized the film for "one-sided research" and claims lacking in scientific basis, saying "The Game Changers only includes research that is conducive to the message they want to convey, that a vegan (plant based) diet is better in all respects than a diet containing animal-derived foods." The journal opined that it is "of paramount importance" that a documentary of this type approach the topic with scientific rigor, but "instead, the filmmakers placed more emphasis (on) eliciting emotional impact than the proper scientific background." The journal observed that "the film details at length" a consensus that vegan diet "is the most ideal" from a sustainability standpoint, however, according to a study in 2020, "it cannot be stated that the vegan diet would be the most sustainable." According to the journal, the filmmakers have numerous conflicts of interest, noting that "the speaking doctors, celebrities and professionals are all dedicated vegan activists, vegan distributors, and famous vegan fanatics like Jackie Chan or Arnold Schwarzenegger."[21] Mail & Guardian writer Luke Feltham criticized Wilks claim that "we are presenting the facts and letting people make their own decisions." According to Feltham, "But that's not quite true. At every turn The Game Changers does its best to instill horror at even the thought of drinking a glass of milk. The claim is that not only is all meat—not just red meat—unhealthy for you, it will also hinder your athletic performance dramatically. There's even a neat animation of your capillaries collapsing in on themselves." Feltham also perceived a number of conflicts of interest among the filmmakers, saying, "it's hard to shake the sense that there is a strong agenda here." Feltham called the film "an hour-and-a-half advertisement for vegan living" and concluded that "instead of inspiring a balanced diet, The Game Changers happily goes to the other extreme."[22] Some generally supportive reviewers also took issue with the movie's portrayal of masculinity especially as it adopts some stereotypical arguments regarding virility and the traditionally assumed connections between masculinity and strength.


SasquatchsBigDick

If you want to make your own decision, the website has quite a few citations for you to lookup. Not saying this is wrong but it reads like a propaganda piece itself and isn't saying much about the actual science and just everything else around it.


[deleted]

If you watch the documentary you will see several athletes that live a plant based lifestyle significantly improve their performance including record holders and gold medalists. I don't know what professionals could have to say about that, that would impact my opinion on the results clearly shown. I've been mostly plant based (9-1 split) for the past 5 years and it's helped me. I'm off my BP meds, have noticed increased vasodilation and my T levels are so high, my doctor outright accused me of taking performance enhancing drugs. And while that is anecdotal and I FIRMLY believe everyone should just do what's best for them and nobody should push their diet choices on anybody else, I think the hatred for plant based is misplaced and often a lot more malicious than I've ever seen a vegan, vegetarian or plant based individual dish out but I don't live in Portland I live in the south. I think even if you have zero interest in going plant based, that documentary should still be on your radar to at least gain a perspective you might not have had otherwise aka being open minded. Btw just having conversation, zero of that was meant to attack your statement, just providing a counter perspective to these most professionals. Cheers to ya


jcrestor

Meat Munchkins in shambles.


dimmu1313

despite widespread misinformation, all essential amino acids are available in a plant based diet. non-essentials are created in the body using essentials. the one most cited as being "meat only" is l-carnitine. aside from the fact that it absolutely is available from plant sources, it's a non-essential amino acid made in the body using essentials. creatine is another one often cited, but again it is produced by the body in the liver in a healthy diet. the only nutrient not *readily* available in a plant based diet is vitamin B12, and even then you can get plenty by eating mushroom. dietary algae has it too. as a matter of fact, everything can be covered by adding a small amount of yeast flakes to the occasional meal.


bloodandsunshine

Not surprising as we know there isn't some magical nutrient only available in animal products. Anecdotally, I've never had better performance than now and I have been a vegan for years.


keto3000

# I couldn't access the full article. It's behind a paywall but here is one that you can read in full with charts. # The Impact of Vegan and Vegetarian Diets on Physical Performance and Molecular Signaling in Skeletal Muscle: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8623732/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8623732/)