Plantekost er hovedkilden til jern i et vanlig norsk/nordisk/vestlig kosthold. Kjøtt bidrar kun med 10 % av det totale inntaket av jern. Nyere undersøkelser i Norge og Europa viser at til og med veganere får i seg nok jern. Se alle våre innspill her.

1. Vegetarian diet and iron

General comment

You write several places that vegetarians and vegans are at risk of iron deficiency (ID) and ID anemia. I do not see that you have the evidence for this.

We have evidence for following: that iron STORES are lower than in omnivores. Theoretically, you could think that lower stores gives higher risk for ID and IDA. But what do we know from the studies? This is following:

Per 2023, studies show that vegans and vegetarians in developed countries have a good iron status, and get enough iron with their food. Iron stores are somewhat lower in vegans, compared to omnivores,

but
1) The iron stores are between references range,
2) Vegans do not have iron deficiency or iron deficiency anemia more often than omnivores.

Here I will refer to and quote several recent sources for vegans and vegetarians in Europe

Henjum, Norway, 2019-2021, study in Norwegian vegans and vegetarians

Quoted:
«To our knowledge, this present study is among the first to include multiple measures to evaluate iron status among Norwegian vegans, vegetarians and pescatarians. Although the participants were eating restricted plant-based diets, the majority had sufficient iron status evident by blood markers within the reference range in multiple measures (S-Fe, S-Iron, S-TIBC, S-TSAT). No difference was found in iron status between the dietary groups.»

Only a few vegans took supplements in this study. The percentage of those who had iron stores lower than reference values was 9% – roughly the same as the rest of the population. The study concludes that menstruating women should pay attention to their iron status, because some lose too much iron during menstrual bleeding:

«5. Conclusions The majority of the vegans, vegetarians and pescatarians in the Oslo area in Norway had sufficient iron status. Female vegans and vegetarians of reproductive age might be at risk of low iron status as women of fertile age have increased needs for iron because of losses due to menstrual bleeding. Young women with restrictive diets should have their iron status monitored.»

Source:
Henjum S, Groufh-Jacobsen S, Stea TH, Tonheim LE, Almendingen K. Iron Status of Vegans, Vegetarians and Pescatarians in Norway. Biomolecules. 2021 Mar 18;11(3):454. doi: 10.3390/biom11030454. PMID: 33803700; PMCID: PMC8003004. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8003004/

Sobiecki, 2015; European Prospective Investigation into Cancer and Nutrition-Oxford study, writes that the intake of iron in vegans was higher than in omnivores:

“Vegans had the highest intakes of polyunsaturated fatty acids, dietary fiber, vitamins C and E, folate, magnesium, iron, and copper.”

Source: Sobiecki JG, Appleby PN, Bradbury KE, Key TJ. High compliance with dietary recommdations in a cohort of meat eaters, fish eaters, vegetarians, and vegans: results from the European Prospective Investigation into Cancer and Nutrition-Oxford study. Nutr Res. 2016 May;36(5):464-77. doi: 10.1016/j.nutres.2015.12.016. Epub 2016 Jan 6. PMID: 27101764; PMCID: PMC4844163.

The study you refer to, Haider 2018, concludes that vegetarians had lower iron stores, which is not the same as iron deficiency and anemia or deficiency. Quoted:

“….adult vegetarians have significantly lower serum ferritin levels than their non-vegetarian controls (…..)

The Academy of Nutrition and Dietetics, which is the world’s largest association for nutrition professionals, concluded the following based on summary of relevant studies:

“The absorption process appears to adapt effectively in the case of Western vegetarians because their hemoglobin values and most other measures of iron status are similar to those values seen in nonvegetarians.7”

Source: Melina V, Craig W, Levin S. Position of the Academy of Nutrition and Dietetics: vegetarian diets. J Acad Nutr Diet. 2016;116:1970-1980

Specific comment:

On page 1, in Abstract, you write:

“Several large population groups in the Nordic and Baltic countries are at risk of iron deficiency, including infants, young children, menstruating females, pregnant women as well as vegetarians.”

I suggest to remone “as well as vegetarians”. The available studies on iron status among vegetarians and vegans in the Nordic countries show the opposite. Including the study you refer to, Haider 2018.
They tend to have lower stores (Haider 2018 and AND 2016), but good intake of iron (Sabiecky 2015, Henjum 2021).

On page 9 you write: “A low dietary iron intake is a risk factor for iron deficiency in all age groups. Individuals on a vegetarian or vegan diet are a special risk group, see below.”

I suggest to delete this: “Individuals on a vegetarian or vegan diet are a special risk group, see below.”

On page 3 you write: “In vegetarian diets, legumes and processed products, wholegrain cereals and dark green
vegetables are important iron sources.” Do any studies show this? I do not think so. I do not believe that vegans eat less cereals, fruits, berries and veggies than omnivores.

The main source of iron in the Norway, for example, is bread and other cereal products, which contribute 40-50% of the total iron intake. Meat contributes 20%. Vegetables, fruit, berries and juice – with 20%. Fish, eggs and dairy products together contribute approximately 10%. (The sources are:
–table 25b on page 44, Norkost 3. A nationwide dietary survey among men and women in Norway aged 18-70, 2010-11. The University of Oslo, the Norwegian Food Safety Authority and the Directorate of Health.
— table 51 on page 59 in The nationwide dietary survey among pupils in 4th and 8th year in Norway, Ungkost 2016, The Norwegian Institute of Public Health https://www.fhi.no/globalassets/dokumenterfiler/rapporter/2016/ungkost-rapport-24.06.16.pdf
–table 28 page 45 in Småbarnskost – Astrup H, Myhre JB, Andersen LF, Kristiansen AL. “Småbarnskost 3. Landsomfattende undersøkelse av kostholdet blant 2-åringer i Norge”. [Småbarnskost 3. Nationwide dietary survey among 2-year-olds in Norway] Rapport 2020. Oslo: Folkehelseinstituttet og Universitetet i Oslo, 2020.

on page 19 you write:

“Vegetarian adolescents and adults Vegetarians have significantly lower iron stores than non-vegetarians (126).”

I suggest that you either delete this sentence, or supply it with following:

“But the stores are still within the reference range. And the prevalence of iron deficiency anemia is not higher than among omnivores.”

and than that you delete this sentence: “This is probably due to a combination of difficulty of reaching the RI and a lower iron bioavailability.”

In this sentence “A well-composed vegetarian diet including wholegrains, legumes, seeds and green vegetables and together with enhancers has the potential to secure iron supply.”

I suggest that you change this sentence on page 19 : 1)delete “green” – because potatos, beetroot, onions and tomatoes have the same amount of iron as pac-choi, and broccoli, some salads and many other green vegetables.
2) supply with four food groups: “A well-composed vegetarian diet including wholegrains, legumes, nuts and seeds, vegetables, fruits and berries, and together with enhancers has the potential to secure iron supply.”

and that you specify word “the enhancers” that you specify this by adding this sentence:

“What are “the enhancers”? Iron bioavailability increasis in meals with presence of vitamin C and friut acids, which both naturally occurs in many vegetables (kale, bell pepper, brussels sprouts, broccoli, turnip, red and head cabbage, cauliflower, tomato, broccoli and many others – see matvaretabellen.no or https://frida.fooddata.dk ), and the most of friuts and berries.
Which means that meals containing vegetables, fruits and berries will enhance the bioavalability of iron.”

2. Sources of Iron

General comments

Sources of iron

On page 3, in section Dietary sources and bioavailability, you write:

“Meat, poultry and fish as well as cereals are the main iron sources in a mixed diet.”

This is not entirely true, at least not in Norway.

Dietary surveys show that the main source of iron, in both adults and children, is bread and cereal products, together they account for at least 40% of the total intake,

and potatos, vegetables, fruits and berries – for 20 % .
Meat and meat products contribute only 20-22 % of iron in the Norwegian diet.

These 3 surveys are relevant (for Norway) Norkost 3, Ungkost and Småbarnskost:

Adults, Norkost 3, 2011:
In table 25b on page 44, we can see that the sources of iron in Norway (adults) are following:

-Bread 30% cereals 7% cakes 3%
-potatoes 4%
-vegetables 8%
-fruit and berries 5%
-juice 2%
-Meat and meat products 20%
-fish and fish products 2%
-egg 5%
-wine 4%.

Source: Norkost 3. A nationwide dietary survey among men and women in Norway aged 18-70, 2010-11. The University of Oslo, the Norwegian Food Safety Authority and the Directorate of Health.

The same applies to children of school age (Ungkost 2016 – survey)
The nationwide dietary survey among pupils in 4th and 8th year in Norway, Ungkost 2016, conducted by the Norwegian Institute of Public Health shows (see table 51 on page 59) that

bread, cereals and cakes contributed to a total of 49% of the intake of iron,
while meat and meat products contributed 22%,
and fruits and veggies – with 14 %.

In total, plant foods contribute with about 63%, while animal products – with approx. 30%.

Table 51. Sources of nutrients. All participants in 4th year (n=636). Percentage of total intake per person per day (%).
Sources of iron were in this table 51 on page 59 the following,
-bread 33%
-cereals 11%
-cookies 5%
-potatoes 3%
-vegetables 6%
-fruit berries 1%
-juice 4%
-meat meat products 22%
-fish 1%
-egg 3%

Source: The nationwide dietary survey among pupils in 4th and 8th year in Norway, Ungkost 2016, The Norwegian Institute of Public Health https://www.fhi.no/globalassets/dokumenterfiler/rapporter/2016/ungkost-rapport-24.06.16.pdf

2-year-old children
Also nationwide dietary survey among 2-year-olds in Norway, conducted by Norwegian Institute for public health, 2020, Småbarnskost 2020, shows on table 28 page 45 following

–Bread 31 (whole bread 25%)
–Porridge 12% (Industrially produced porridge 7% and homemade porridge 5%)
–Meat and meat products 12% – including liver paste 8%
–Multivitamin Tablets 9%
–Fruit and berries 6%
–Vegetables 6%
–Cheese 3%
–Eggs 3%
–Cereal and semolina with milk 3%
–Flour, rice, pasta 3%

Source; Astrup H, Myhre JB, Andersen LF, Kristiansen AL. “Småbarnskost 3. Landsomfattende undersøkelse av kostholdet blant 2-åringer i Norge”. [Småbarnskost 3. Nationwide dietary survey among 2-year-olds in Norway] Rapport 2020. Oslo: Folkehelseinstituttet og Universitetet i Oslo, 2020.

These 3 surveys are from different years, but the Norwegian Directorate of Health also publishes annual dietary survey, named The development of the Norwegian diet in Norway https://www.helsedirektoratet.no/rapporter/utviklingen-i-norsk-kosthold

Spesific comments

Could you check similar surveys for other Nordic and Baltic countries, possibly? When the intake of food groups is roughly the same in these countries, one can hardly expect that the intake of iron is significantly different.

On page 3, I suggest therefore that you remove this sentence
“Meat, poultry and fish as well as cereals are the main iron sources in a mixed diet.”

and replaced this with the following:

“The main source of iron in the Nordic and Baltic countries is bread and other cereal products, which contribute 40-50% of the total iron intake. Meat contributes 20%. Vegetables, fruit, berries and juice – with 20%. Fish, eggs and dairy products together contribute approximately 10%.”

Les også: Innspill protein utkast NNR 2022

3. Meat and cancer

General

The evidence about that read and processed meats cause colorectum-cancer is strong. Both WHO and WCRF have made this conclusion.

Therefor many expert panels recommend to avoid processed meats and limit red meats.

See my specific comment and sources

Could you also explain what is red meats and processed meats?

Cancer Research UK, WCRF https://www.wcrf-uk.org/preventing-cancer/what-can-increase-your-risk-of-cancer/red-and-processed-meat-and-cancer-risk/
Quoted:
«What is processed meat?
Processed meat has been smoked, cured or had salt or chemical preservatives added rather than having just been cooked or reformed (like most sausages and burgers). This includes bacon, salami, chorizo, corned beef, pepperoni, pastrami, hot dogs and all types of ham.”

WHO. Cancer: Carcinogenicity of the consumption of red meat and processed meat https://www.who.int/news-room/questions-and-answers/item/cancer-carcinogenicity-of-the-consumption-of-red-meat-and-processed-meat

Healthy Eating Plate. Harvard School of Public Health, her http://www.health.harvard.edu/healthy-eating-plate

Spesific

On page 11 you write following:
“The World Cancer Research Fund in 2018 concludes that there is limited evidence that consumption of red meat and processed meat increases the risk of colorectal cancer (85) and most authorities, including the NNR, recommend a limitation of the consumption of red meat and processed meat.”

I suggest that you replace LIMITED in”.. that there is limited evidence that consumption..” with STRONG.

If you look at the table page 38 in your source 85 (WCRF AICR https://www.wcrf.org/wp-content/uploads/2021/02/Summary-of-Third-Expert-Report-2018.pdf ), here we can see that there is convincing ecidence about proscessed meat and probable about read meat, reg. colorectum.

It is red colour on processed meat and orange colour on red meat,

Red colour mean convincing increased risk, and orange – propably increased risk.
Both mean strong evidence.

This is correct that “most authorities, including the NNR, recommend a limitation of the consumption of red meat and processed meat.” ANd after this sentence I suggest writing following:

“And some authorities – WHO, recommend to avoid processed meats.

Sources:

WHO and IARC. The European Code Against Cancer. The International Agency for Research on Cancer (IARC) is the specialized cancer agency of the World Health Organization. https://cancer-code-europe.iarc.fr/index.php/en/
Quoted:

“Avoid processed meat; limit red meat and foods high in salt.”

Cancer Research UK, WCRF https://www.wcrf-uk.org/preventing-cancer/what-can-increase-your-risk-of-cancer/red-and-processed-meat-and-cancer-risk/
Quoted:

“Our Recommendation is to limit red meat and avoid processed meat – find out how”

Norwegian Cancer Association (Kreftforeningen) oreningen.no/forebygging/kosthold-og-kreft/

“Limit the amount of red meat and avoid processed meat products such as bacon, minced meat and sausages as far as possible. If you do eat meat, it is best to choose white meat, clean meat and lean meat products with little salt.”

“We recommend avoiding processed meat because there is strong evidence that it is a cause of bowel and stomach cancer. It also tends to contain added salt, and be higher in fat and provide fewer nutrients than unprocessed red meat, making unprocessed red meat the better choice if you do eat red meat.»

Then, could you consider to explain what processed meats are?

WHO. Cancer: Carcinogenicity of the consumption of red meat and processed meat https://www.who.int/news-room/questions-and-answers/item/cancer-carcinogenicity-of-the-consumption-of-red-meat-and-processed-meat
Quoted:
“What do you consider as processed meat?
Processed meat refers to meat that has been transformed through salting, curing, fermentation, smoking, or other processes to enhance flavour or improve preservation. Most processed meats contain pork or beef, but processed meats may also contain other red meats, poultry, offal, or meat by-products such as blood.”

“Examples of processed meat include hot dogs (frankfurters), ham, sausages, corned beef, and biltong or beef jerky as well as canned meat and meat-based preparations and sauces.”

WHO about red meat, quoted:
“What do you consider as red meat?
Red meat refers to all mammalian muscle meat, including, beef, veal, pork, lamb, mutton, horse, and goat.”

GENERAL COMMENT

On page 11, Iron and risk of cancer, you write “Other meta-analyses have shown only very weak associations between red and processed meat consumption and cancer outcomes (83).” Later you refer also to 84.

Your sources 83 and 84 (some of the authors are members in NutriRecs consortioum) have been commented by many researchers and expert panels. Several researchers,
for example, Harvard T.H. Chan School of Public Health
https://www.hsph.harvard.edu/nutritionsource/2019/09/30/flawed-guidelines-red-processed-meat/

where surprised about Zeraatkar et al. studies and are concerned about following:
1–the use of methodology and
2–abstract conclusion vs findings.

Quoted Harvard T.H. Chan School of Public Health:
“The new guidelines are not justified as they contradict the evidence generated from their own meta-analyses. Among the five published systematic reviews, three meta-analyses basically confirmed previous findings on red meat and negative health effects.”

“This is a prime example where one must look beyond the headlines and abstract conclusions. It is important for journalists, health professionals, and researchers to look beyond the sensational headlines and even the abstracts of the papers to verify the evidence behind the claims. It’s also crucial to understand that nutrition research is a long and evolving process, and therefore critical to look at the totality of the evidence.

These studies should not change current recommendations on healthy and balanced eating patterns for the prevention of chronic diseases. Existing recommendations are based on solid evidence from randomized controlled studies with cardiovascular risk factors as the outcomes, as well as long-term epidemiologic studies with cardiovascular disease, cancer, type 2 diabetes, and mortality as outcomes. “

Norwegian researches (Fadnes LT, Arnesen EK, Aune D. Should we reduce consumption of red meat? Tidsskr Nor Laegeforen. 2020;140(10):10.4045/tidsskr.19.0786. Published 2020 Jun 24. doi:10.4045/tidsskr.19.0786 https://pubmed.ncbi.nlm.nih.gov/32602328/ )

ask about these (Iron-chapter sources 83 and 84): “To what degree do these add new knowledge and the direction for how we regard the health effect of red meat?”

Quoted, and the source nr 1 here is Iron-chapter-source number 84:
“The new systematic reviews on red and processed meat show that a reduction in consumption of processed meat of 21 g per day is associated with a relative risk reduction of 8 % for premature deaths (1). However, mean consumption in Norway is three times as high (approx. 70 g/day) (2), and a reduction that corresponds to the mean consumption is associated with a relative risk reduction of around 35 % for premature deaths (1, 3). For each 50 g per day reduction in unprocessed red meat intake, a 7 % risk reduction in premature mortality was found.”

the source nr 1 is Iron-chapter-source number 84.

Could you please consider asking your NNR 2022-metodology-collegues about the use of methodology in the sources 83 and 84? And more: if the conclusions in 83 and 84 are in line with the main findings in 83 and 84?

Specific

I suggest that you remove this sentence page 11:
“There is a lack of evidence from intervention trials that show any effect of lower red meat intake on cancer outcomes (84).”

It is very difficult/in practice not possible to conduct intervention trials on diet and cancer.
Intervention trials are not basically/initially suitable for assessing health outcomes that develop over a long period of time, such as cancer and CVD/atherosclerosis.

I refer to The NNR 2022 principles and methodologies:

“Lifestyle habits such as diet and physical activity are difficult to control over a long period of time in free-living people, but their impact on health develops over a long period of time.

In addition, adequate controls for foods and lifestyle habits are difficult to achieve and poor compliance with the intervention complicates the interpretation of the results.

Such studies therefore normally only cover a small part of the development of the disease, and often lack post-trial follow-up on the long-term effects of the intervention.

A notable exception are studies focusing on type 2-diabetes.”

Christensen JJ, Arnesen EK, Andersen R, et al. The Nordic Nutrition Recommendations 2022 – principles and methodologies. Food Nutr Res. 2020;64:10.29219/fnr.v64.4402. Published 2020 Jun 18. doi:10.29219/fnr.v64.4402

Could you please confer with this NNR-methodology-group?