Accepted Manuscript

Understanding the attitudes and perceptions of vegetarian and plant-based diets to

shape future health promotion programs

Tricia Corrin, Andrew Papadopoulos

PII: S0195-6663(16)30770-X
DOI: 10.1016/j.appet.2016.11.018
Reference: APPET 3225

To appear in: Appetite

Received Date: 8 June 2016

Revised Date: 12 November 2016
Accepted Date: 14 November 2016

Please cite this article as: Corrin T. & Papadopoulos A., Understanding the attitudes and perceptions
of vegetarian and plant-based diets to shape future health promotion programs, Appetite (2016), doi:
10.1016/j.appet.2016.11.018.

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3 Understanding the attitudes and perceptions of vegetarian

4 and plant-based diets to shape future health promotion

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5 programs
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7 Authors:
8 Tricia Corrin, HBSc, MPH Candidate
9 Andrew Papadopoulos, BASc, MBA, PhD, CIPHI(C)

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11 Department of Population Medicine

12 University of Guelph,

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13 50 Stone Road East
14 Guelph, Ontario
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15 N1G 2W1
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17 Corresponding author contact:
18 Tricia Corrin
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19 pcorrin@uoguelph.ca
20 647.673.8819
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34 Understanding the attitudes and perceptions of vegetarian

35 and plant-based diets to shape future health promotion
36 programs
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38 Abstract

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39 Vegetarian diets have become a prominent area of interest. However, little

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40 research has focused on the attitudes and perceptions on vegetarian diets. The purpose

41 of this scoping review was to methodologically search the literature and summarize

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42 public perceptions and attitudes towards a vegetarian diet. Using the information found

43 from this review, the Health Belief Model can be applied to shape future health

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promotion initiatives to move individuals towards a vegetarian or plant-based diet. The
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45 main findings indicate that vegetarian diets are generally perceived in a positive light.

There are many barriers to consuming this diet such as health concerns, an
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47 unwillingness to make dietary changes, and an enjoyment of eating meat.

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48
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49 Keywords: vegetarian, vegan, scoping review, health belief model, public health

50
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51 Introduction

52 While vegetarianism is not a new concept, the formal study of vegetarianism has
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53 recently become a significant area of interest (Ruby, 2012). These studies are relevant
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54 as vegetarianism has important implications in public health, food sustainability, and the

55 environment. A small percentage of the population identify as vegetarian (~2-10% of a

56 developed nations population depending on the country) (The Local, 2014; The

57 Vegetarian/Vegan Society of Queensland, 2010). Although the percentage is small, this

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58 accounts for millions of individuals across the globe. The definition of vegetarianism is

59 constantly evolving, which is a significant challenge when trying to study this topic with

60 consistency. Not only can one follow a vegetarian (also referred to as a lacto-ovo-

61 vegetarian) diet, one can also follow a vegan, semi-vegetarian, lacto-vegetarian, ovo-

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62 vegetarian, plant-based, pescatarian, or flexitarian diet. The most commonly known

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63 definition of a vegetarian is one that abstains from eating meat, fish, and fowl.

64 Pescatarians do not eat meat or fowl, but will eat fish. Vegans do not consume any

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65 animal products. A lacto-vegetarian is a type of vegetarian who does not eat any type of

66 meat or eggs, but still consumes dairy products. The reverse is an ovo-vegetarian, a

67
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vegetarian who eats eggs, but not dairy products. Semi-vegetarians, flexitarians, and
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68 plant-based diets are all used interchangeably. They are those who mainly eat a

vegetarian diet, but will sometimes consume meat. For the remainder of this review, the
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70 term “vegetarian” will be used to describe all of the types of vegetarian diets above with
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71 the exception of a vegan diet.

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72 The purpose of this scoping review was to synthesize existing research evidence

73 to explore the general perceptions and attitudes towards a vegetarian diet, and discuss
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74 how this information can be used to shape future health promotion initiatives to move

75 individuals towards a vegetarian or plant-based diet. A scoping review follows a

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76 structured protocol to address a broad, often policy-driven research question (Arksey &
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77 O’Malley, 2005; Colquhoun, et al., 2014; Pham, et al., 2014). The identification and

78 characterization of the literature was done in a reproducible and updateable manner to

79 summarize what is currently known and identify gaps in the literature to help direct

80 future research (Arksey & O’Malley, 2005; Colquhoun, et al., 2014; Pham, et al., 2014).
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81 This will build upon literature reviews completed by Matthew R Ruby (Ruby, 2012) and

82 Lenny R Vartanian (Vartanian, 2015).

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84 1.0 Methods

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85 The methodology proposed by Hilary Arksey and Lisa O’Malley (Arksey &

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86 O'Malley, 2005) was used for this scoping review. This five-stage process included

87 identifying the research question, identifying relevant studies, study selection, charting

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88 the data, and collating, summarizing, and reporting the results (Arksey & O'Malley,

89 2005).

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91 1.1 Research question

This review attempts to answer the research question: What are the perceptions
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93 and attitudes towards vegetarian and plant-based diets and how can this information be
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94 used to shape future health promotion initiatives?

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96 1.2 Data sources and search strategy

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97 Five electronic sources were selected based on their relevance to the research

98 question. These were accessed through the University of Guelph Library and include
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99 PUBMED (1950 – present), ProQuest Databases, Web of Science (section(s): AHCI,

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100 1975 - present; SCI & SSCI, 1955 - present), EBSCOHost Databases, and PsycINFO

101 (1872 – present). The initial search using these five databases was conducted on June

102 10, 2015 using a consistent search query: (attitude* OR barrier* OR perception*) AND

103 (“vegetarian diet*” OR “vegetarian lifestyle” OR “vegetarianism”). In addition, filters were

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104 applied in each database to limit the sources to journal articles

105 (trade/academic/scholarly) published between the years 2000-2015 which are in the

106 English language.

107 Google Scholar was also searched using the initial search query. After screening

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108 the first 200 hits and acquiring no new research evidence, a decision was made to abort

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109 this search. A secondary search was conducted on June 13, 2015. Web of Science and

110 Google Scholar were searched to identify relevant articles that cite the journal articles

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111 that were located in the initial search. Finally, the reference lists of each article were

112 manually searched to identify any further research that had not already been captured.

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114 1.3 Citation management

The web-based reference manager EndNote Web was used to import all
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116 citations. Duplicate citations were removed at this stage. The citations were then
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117 imported into the web-based systematic review software DistillerSR (Evidence Partners,
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118 Ottawa, Ontario) for further screening. Another round of duplicates was also removed.

119
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120 1.4 Eligibility criteria

121 The screening process was completed by one reviewer and was comprised of
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122 three stages. This included a title and abstract screening, followed by a full-paper
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123 screening. To be included in the first round of screening, the title had to appear relevant

124 to the research question. The abstract and full-article screening stages were used to

125 locate articles that discussed perceptions, barriers, and attitudes towards a vegetarian

126 diet.
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127 A second reviewer was used to verify the screening process. There were no

128 disagreements between the reviewers and no changes were made.

129

130 1.5 Data characterization

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131 A table was created in Microsoft Excel 2010 to extract pertinent data from the

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132 studies such as date of publication, publication type, authors, country of origin, and

133 study methods. No further exclusions were made based on this information.

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134

135 1.6 Limitations

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Limitations of this scoping review include limited studies on the subject, the
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137 selection of databases used, and the exclusion of books and studies not published in

English. The inclusion criteria was developed and applied by an individual and verified
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139 by one reviewer. In addition, the definition of vegetarianism was not consistent
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140 throughout the literature as the term is constantly evolving. This presented a challenge
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141 in creating search terms to capture all of the variations of the definition across the global

142 literature. Due to these limitations, the review may have missed some relevant studies.
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144 2.0 Results

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146 2.1 Search and selection of articles

147 The initial search yielded 1833 potentially relevant citations. Duplicates were

148 removed at 2 different stages; upon import into EndNote Web and again upon import

149 into DistillerSR (Evidence Partners, Ottawa, Ontario). After duplicates were removed,
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150 240 citations remained. Three-stages of screening on these citations produced 11

151 articles available for synthesis. This included a title, abstract, and full article screen. The

152 secondary search involved looking for relevant articles that were cited or referenced by

153 the original 11 articles. This yielded an additional 13 articles. Due to the limited number

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154 of articles available, all articles were included. In total, 24 articles were included in this

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155 scoping review. The flow of information through the scoping review process is depicted

156 in Figure 1.0 (Moher, Liberati, Tetzlaff, & Altman, 2009).

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157

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158
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159 Figure 1.0 PRISMA flow diagram of scoping review selection process

160

161 2.2 General characteristics of included articles

162 All of the articles were published between January 2000 and June 2015, with

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163 62.5% (15/24) being published after 2009. The majority (66.7%, 16/24) of the included

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164 articles used questionnaires as the main method of data collection. Other methods

165 include interviews (16.7%, 4/24), literature reviews (8.3%, 2/24), a cross-sectional

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166 observational study (4.2%, 1/24), and a newspaper screen (4.2%, 1/24).

167 Australia (29.2%, 7/24) and the US (29.2%, 7/24) together accounted for the

168
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majority of the articles (58.3%, 14/24). Canada (12.5%, 3/24) and the UK (12.5%, 3/24)
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169 had the next largest number of articles included. The other reviews came from Belgium

(4.2%, 1/24), Slovenia (4.2%, 1/24), Finland (4.2%, 1/24), and Portugal (4.2%, 1/24).
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171 Other general characteristics such as study design and sample size are depicted in
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172 Table 1.
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173 Table 1: General characteristics of 24 included publications

Author (Year) Country of Study Sample Publication Dietary Terminology Dietary Preference of
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Origin Design size Status Used the Participants

Position of the United States Literature N/A Published Vegetarian, vegan N/A
American Dietetic and
Association: systematic
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Vegetarian Diets, review

2009
Browarnik, 2012 United States Cross- 102 Un-published Vegetarian 16.5% vegetarian;
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sectional 83.5% omnivore

Burgess, United States Cross- 49 Un-published Vegetarian, vegan 4% vegetarian; 2%
Carpenter, & sectional vegan; 94% omnivore
Henshaw, 2014
Chin, Fisak Jr, & United States Cross- 226 Published Vegetarian Did not specify
Sims, 2015 sectional
Cole & Morgan, United Review N/A Published Vegan N/A
2011 Kingdom
Crnic, 2013 Slovenia Cross- 800 Published Vegetarian 0.4% vegans, 0.8%
sectional lacto-ovo vegetarians
and 1.6%
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pescatarians; 97.2%
omnivore
Ensaff, et al., 2015 United Qualitative 30 Published Plant-based Did not specify
Kingdom
Graça, Oliveira, & Portugal Qualitative 410 Published Plant-based 13.7%
Calheiros, 2015 vegetarian/vegan;
86.3% omnivore
Guerin, 2014 United States Qualitative 19 Un-published Vegan 47.4% vegan; 52.6%

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omnivore
Lea & Worsley, Australia Cross- 707 Published Vegetarian, semi- 16.3%
2001 sectional vegetarian vegetarian/semi-
vegetarian; 83.7%

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omnivore
Lea & Worsley, Australia Cross- 707 Published Vegetarian, semi- 16.3%
2002 sectional vegetarian vegetarian/semi-
vegetarian; 83.7%

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omnivore
Lea & Worsley, Australia Cross- 601 Published Vegetarian, semi- 1.5% vegetarian; 7.2%
2003a sectional vegetarian semi-vegetarian;
91.3% omnivore

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Lea & Worsley, Australia Cross- 707 Published Vegetarian, semi- 16.3%
2003b sectional vegetarian vegetarian/semi-
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vegetarian; 83.7%
omnivore
Lea, Crawford, & Australia Cross- 415 Published Plant-based 0.7% vegetarian; 11%
Worsley, 2006a sectional semi-vegetarian;
88.3% omnivore
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Lea, Crawford, & Australia Cross- 415 Published Plant-based 0.7% vegetarian;
Worsley, 2006b sectional ~20% semi-vegetarian;
~79.3% omnivore
Merriman, 2010 United States Qualitative 23 Published Vegetarian 100% vegetarian
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Pohjolainen, Finland Cross- 1890 Published Plant-based 1.9% vegetarian;

Vinnari, & Jokinen, sectional 98.1% omnivore
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2015
Povey, Wellens, & United Cross- 111 Published Vegetarian, vegan, 23.4% vegan; 30.6%
Conner, 2001 Kingdom sectional meat avoider vegetarian; 23.5%
meat-avoider; 22.5%
omnivore
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Pribis, Pencak, & United States Cross- 609 Published Vegetarian, vegan, 4% vegan; 25% lacto-
Grajales, 2010 sectional lacto-ovo vegetarian, ovo-vegetarian; 4%
pesco-vegetarian pesco-vegetarian; 67%
omnivore
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Rothgerber, 2014 United States Cross- 90, 77, Published Vegetarian 100% omnivore
sectional 77, 68,
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78 (5
surveys)
Ruby & Heine, Canada Cross- 273, 88 Published Vegetarian Study 1 – 83.8%
2011 sectional (2 omnivore; 8.8%
surveys) vegetarian; 7.6% other
Study 2 – 100%
omnivore
Ruby, 2012 Canada Literature N/A Published Vegetarian N/A
review
Vanhonacker, Van Belgium Cross- 221 Published Vegetarian, plant- Did not specify
Loo, Gellynck, & sectional based
Verbeke, 2013
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Vartanian, 2015 Australia Literature N/A Published Vegetarian N/A

Review
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175 2.3 General perceptions and attitudes

176 To date, there have not been many studies conducted on the attitudes and

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177 perceptions of a vegetarian or vegan diet. In 3 studies, vegetarian diets were perceived

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178 in a more positive light than a vegan diet (Chin, Fisak Jr, & Sims, 2015; Cole & Morgan,

179 2011; Crnic, 2013). Two studies indicated that a vegetarian diet was perceived

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180 positively (Chin, Fisak Jr, & Sims, 2015; Crnic, 2013) and as healthy amongst the

181 general population (Lea & Worsley, 2001; Povey, Wellens, & Conner, 2001). Some

182
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positive attributes associated with vegetarians include healthy (Lea & Worsley, 2001;
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183 Povey, Wellens, & Conner, 2001), virtuous (Ruby & Heine, 2011), hipster (Burgess,

184 Carpenter, & Henshaw, 2014), thoughtful (Burgess, Carpenter, & Henshaw, 2014), and
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185 animal lovers (Burgess, Carpenter, & Henshaw, 2014). However, those who consume a
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186 vegetarian diet can still be subject to ridicule and negative stereotyping (Burgess,
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187 Carpenter, & Henshaw, 2014; Crnic, 2013). Negative characteristics associated with

188 vegetarians include unhealthy, weak, insane, and freak (Burgess, Carpenter, &
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189 Henshaw, 2014). One study showed that 69% of vegans considered a vegetarian diet

190 “hypocritical” (Povey, Wellens, & Conner, 2001).

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191 Interest in vegetarianism has been on the rise, with many vegetarian options
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192 being offered at restaurants and food services (Position of the American Dietetic

193 Association: Vegetarian Diets, 2009). In two studies out of Australia, a large majority of

194 the populations expressed interest in learning more about vegetarian diets (Lea,

195 Crawford, & Worsley, 2006; Lea & Worsley, 2003). One study indicated that 83.7% of

196 the participants knew a vegetarian (Chin, Fisak Jr, & Sims, 2015).
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197 In Slovenia, the general public had a very negative attitude to vegetarianism as a

198 choice for children (Crnic, 2013), but vegetarian diets for children were supported by the

199 American Dietetic Association (Position of the American Dietetic Association:

200 Vegetarian Diets, 2009).

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201 Attitudes towards a vegetarian lifestyle have been shown to be significantly

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202 correlated with nutritional knowledge (Pribis, Pencak, & Grajales, 2010). Knowledge, in

203 the form of scientific information and facts was what drove positive attitudes towards

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204 vegetarian lifestyles (Pribis, Pencak, & Grajales, 2010). This was also shown in the

205 reverse, adhering to a vegetarian diet may promote an increase in nutritional knowledge

206 (Pribis, Pencak, & Grajales, 2010).

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207 A Canadian study indicated that vegetarian men were perceived as less

masculine than their omnivore counterparts (Ruby & Heine, 2011). Some men have
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209 also encountered homophobic epithets from strangers and acquaintances with regards
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210 to their dietary choices (Merriman, 2010). One study contradicted these findings
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211 indicating that male vegetarians were not looked at more negatively than female

212 vegetarians or their omnivore counterparts (Browarnik, 2012). It is believed that the
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213 discrepancy was due to a small sample size and homogeneity of the participants

214 (Browarnik, 2012). However, in a family environment, a man’s choice to be a vegetarian

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215 was looked upon in a neutral or favorable manner by friends and family in a small
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216 qualitative study (Merriman, 2010). In contrast, this same study reported that some

217 women vegetarians have expressed that they have received significant hostility and

218 disapproval regarding their diet from their male omnivore family members (Merriman,

219 2010).
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220 While vegetarianism was still the topic of ridicule and jokes (Crnic, 2013);

221 veganism was perceived with more negativity. Approximately 74% of newspaper articles

222 in the UK that contained the word “vegan” were classified as negative (Cole & Morgan,

223 2011). In these articles, veganism was described as difficult or impossible to maintain

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224 and was often discredited through ridicule (Cole & Morgan, 2011). Common negative

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225 terms associated with veganism include restrictive (Burgess, Carpenter, & Henshaw,

226 2014; Povey, Wellens, & Conner, 2001), hippie (Burgess, Carpenter, & Henshaw,

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227 2014), faddists (Cole & Morgan, 2011), sentimentalists (Cole & Morgan, 2011),

228 unhealthy (Burgess, Carpenter, & Henshaw, 2014), and weak (Burgess, Carpenter, &

229
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Henshaw, 2014). In addition, a qualitative study reported that there was a strong
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230 stereotype amongst omnivores that vegans were hostile and/or confrontational (Guerin,

2014).
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232 There has also been some conflict shown between different dietary groups. A US
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233 qualitative study looked at the “vegan-omnivore conflict”. While most of the omnivores in
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234 this study reported overall positive interactions with vegans, some felt judged by vegans

235 and 100% (n=23) of the participants reported conflict with vegans (Guerin, 2014). The
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236 conflicts were also reported to be instigated by vegans (Guerin, 2014). This study in

237 conjunction with another US study showed that vegetarians and vegans, or talk about
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238 these dietary choices produced a host of negative reactions in omnivores (Guerin, 2014;
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239 Rothgerber, 2014). This included omnivores using ridicule or derogatory measures to

240 minimize dissonance (Rothgerber, 2014).

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242 2.4 Perceived benefits

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243 The American Dietetic Association fully supported the consumption of a

244 vegetarian or vegan diet (Position of the American Dietetic Association: Vegetarian

245 Diets, 2009). Specifically, their position statement was “appropriately planned

246 vegetarian diets, including vegan diets, are healthful, nutritionally adequate, and may

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247 provide health benefits in the prevention and treatment of certain diseases” (Position of

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248 the American Dietetic Association: Vegetarian Diets, 2009). Supported by scientific

249 research, the American Dietetic Association stated that as long as a vegetarian or

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250 vegan diet is well-planned, they are appropriate for all stages of the lifecycle (Position of

251 the American Dietetic Association: Vegetarian Diets, 2009). This includes during

252
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pregnancy, lactation, infancy, childhood, adolescence, and adulthood (Position of the
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253 American Dietetic Association: Vegetarian Diets, 2009). In addition, a balanced diet with

an emphasis on plant-based foods was recommended by the American Cancer Society,

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255 American Heart Association, Health Canada and the Heart and Stroke Foundation
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256 (Position of the American Dietetic Association: Vegetarian Diets, 2009).

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257 It was widely acknowledged that vegetarian diets are healthy and provide many

258 health benefits (Lea & Worsley, 2001; Lea & Worsley, 2003a; Lea & Worsley, 2003b;
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259 Position of the American Dietetic Association: Vegetarian Diets, 2009; Povey, Wellens,

260 & Conner, 2001). A study out of Australia showed that the belief that meat is unhealthy
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261 was a strong predictor of an individuals perceived benefits of vegetarianism, specifically

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262 the non-health benefits such as environmental, peace and contentment, and animal

263 welfare (Lea & Worsley, 2002; Lea & Worsley, 2003b). The belief that meat is

264 unhealthy included beliefs that meat causes disease and or other health problems (Lea

265 & Worsley, 2003b). Believing that meat is not necessary and frequent information
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266 gathering on healthy eating were additional positive predictors for the belief that

267 vegetarian diets provide health benefits (Lea & Worsley, 2003b).

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269 Well-Being and Peace/Contentment Benefits

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270 In two studies, most of the perceived benefits of a vegetarian diet fell into the

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271 categories of improving well-being and peace/contentment (Lea, Crawford, & Worsley,

272 2006b; Lea & Worsley, 2002). Surveys generated high scores on benefits such as

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273 “being more content with myself”, “have a better quality of life”, “stay healthy and fit”,

274 "help the feminist cause", "be less aggressive", and "help create a more peaceful world"

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(Lea, Crawford, & Worsley, 2006b; Lea & Worsley, 2002).
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Health Benefits
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278 Health benefits ranked second to well-being and peace/contentment benefits in

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279 two different studies (Lea, Crawford, & Worsley, 2006b; Lea & Worsley, 2002). Four
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280 studies also indicated health benefits were one of the most important benefits of a

281 vegetarian diet (Graça, Oliveira, & Calheiros, 2015; Lea, Crawford, & Worsley, 2006a)
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282 (Lea & Worsley, 2003a; Lea & Worsley, 2003b). Health benefits associated with

283 vegetarian diets included decreased saturated fat intake, increased fruit and vegetable
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284 intake, weight control, increased fiber intake, and disease prevention (Graça, Oliveira, &
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285 Calheiros , 2015; Lea, Crawford, & Worsley, 2006a; Lea & Worsley, 2002; Lea &

286 Worsley, 2003a). Decreased fat intake was the most agreed upon health benefit to

287 consuming a vegetarian diet (Lea, Crawford, & Worsley, 2006a; Lea & Worsley, 2003a).

288 It should be noted that non-vegetarians have also been shown to possess uncertainty
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289 about the association between some of the health benefits and a vegetarian diet (Lea &

290 Worsley, 2003b).

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292 Ethical and Environmental Benefits

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293 Animal welfare and environmental sustainability ranked the lowest and were the

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294 least agreed upon non-related health benefits (Lea, Crawford, & Worsley, 2006a; Lea,

295 Crawford, & Worsley, 2006b; Lea & Worsley, 2002). These benefits included decreasing

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296 third world hunger, animal welfare rights, and increasing efficiency of food production.

297 A Belgian study indicated that participants were only vaguely aware of the

298
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environmental stress caused by the meat production industry (Vanhonacker, Van Loo,
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299 Gellynck, & Verbeke, 2013). The main perception was that meat production was not as

detrimental to the environment as other human activities (Vanhonacker, Van Loo,

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301 Gellynck, & Verbeke, 2013).

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302
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303 2.5 Perceived barriers

304 The strongest perceived barrier of adopting a vegetarian diet was the enjoyment
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305 of eating meat (Graça, Oliveira, & Calheiros, 2015; Lea, Crawford, & Worsley, 2006b;

306 Lea & Worsley, 2001; Lea & Worsley, 2003a). A study in Australia showed that 78% of
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307 the participants perceived that the main barrier of adopting a vegetarian diet was the
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308 enjoyment of meat (Lea & Worsley, 2003a).

309 Health and convenience barriers ranked second overall as perceived barriers to

310 adopting a vegetarian diet. Many studies showed that other significant barriers were an

311 unwillingness to alter their eating habits (Graça, Oliveira, & Calheiros, 2015; Lea,
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312 Crawford, & Worsley, 2006a; Lea, Crawford, & Worsley, 2006b; Lea & Worsley, 2001;

313 Lea & Worsley, 2003; Pohjolainen, Vinnari, & Jokinen, 2015), and that humans were

314 “meant to eat meat” (Lea, Crawford, & Worsley, 2006b; Lea & Worsley, 2001; Lea &

315 Worsley, 2003a; Pohjolainen, Vinnari, & Jokinen, 2015). Other noted barriers included a

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316 perceived lack of protein and/or iron (Lea, Crawford, & Worsley, 2006b; Lea & Worsley,

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317 2001), a perception that vegetarian diets were nutritionally unbalanced (Povey, Wellens,

318 & Conner, 2001), and a general worry about overall health (Lea, Crawford, & Worsley,

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319 2006b; Lea & Worsley, 2001; Pohjolainen, Vinnari, & Jokinen, 2015). Some of the

320 convenience barriers found were that it was difficult and time consuming to prepare

321
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vegetarian foods (Lea, Crawford, & Worsley, 2006b; Pohjolainen, Vinnari, & Jokinen,
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322 2015), their family/partner would not consume a vegetarian diet (Lea, Crawford, &

Worsley, 2006b), and lack of options when eating out (Lea, Crawford, & Worsley,
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324 2006a; Lea, Crawford, & Worsley, 2006b; Lea & Worsley, 2001; Vanhonacker, Van Loo,
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325 Gellynck, & Verbeke, 2013). Vegetarian diets were also perceived as boring and bland
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326 (Lea & Worsley, 2001; Povey, Wellens, & Conner, 2001).

327 Information barriers came up frequently in the literature, but their level of
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328 importance varied across studies. Two different studies showed that approximately 42%

329 of participants perceived the main barrier to the adoption of a vegetarian diet was a lack
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330 of information about the diets (Lea, Crawford, & Worsley, 2006a; Lea & Worsley,
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331 2003a). Some information barriers included not knowing how to prepare vegetarian

332 meals, and not knowing what to eat besides meat (Lea, Crawford, & Worsley, 2006b;

333 Lea & Worsley, 2001).

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334 Social and financial barriers were also found in the literature, but also varied in

335 their degree of importance across the studies. Some social barriers included not

336 wanting to be stereotyped negatively (Lea, Crawford, & Worsley, 2006b; Lea & Worsley,

337 2001), and concerns that all of their friends/family eat meat (Lea & Worsley, 2001). The

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338 main financial barrier found was that adopting a vegetarian diet was perceived as

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339 expensive (Lea, Crawford, & Worsley, 2006b; Povey, Wellens, & Conner, 2001).

340 Vegetarians were most concerned with health issues, whereas knowledge and

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341 convenience issues were most important to non-vegetarians (Lea & Worsley, 2003b).

342 A study conducted in Finland showed that many of the perceived barriers were

343
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strongly correlated (Pohjolainen, Vinnari, & Jokinen, 2015). In addition, the strongest
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344 predictor of barriers in the study was meat-consumption frequency (Pohjolainen,

Vinnari, & Jokinen, 2015).

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345

346
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347 2.6 Readiness to consume a vegetarian or plant-based diet

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348 It has been reported from a study in the UK that most people had positive

349 attitudes and beliefs about their own diets, and negative attitudes and beliefs about
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350 other diets (Povey, Wellens, & Conner, 2001). Therefore, people only had positive

351 intentions to follow their own diet, and not others (Povey, Wellens, & Conner, 2001).
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352 Individuals were more likely to consider changing to a vegetarian diet if they had a
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353 strong identity as a healthy-eater (Povey, Wellens, & Conner, 2001).

354 A study conducted in Australia looked at the stages of change in considering a

355 vegetarian diet (Lea, Crawford, & Worsley, 2006b). The majority of the participants

356 (58%) were in the pre-contemplation stages of consuming a vegetarian diet (Lea,
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357 Crawford, & Worsley, 2006b). The rest of the participants were in the

358 contemplation/preparation (14%) or action/maintenance stages (28%) (Lea, Crawford, &

359 Worsley, 2006b). Most of the perceived benefits to consuming a vegetarian diet were

360 consistent across the various stages, with the main difference between those in the pre-

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361 contemplation stage and those in the action/maintenance stage (Lea, Crawford, &

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362 Worsley, 2006b). Benefits such as health, weight, ethical, convenience, and well-being

363 were all recognized by those in the action/maintenance stage, but not by those in the

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364 pre-contemplation stage (Lea, Crawford, & Worsley, 2006b). Barriers to consuming a

365 vegetarian diet were relatively consistent across all of the stages of change (Lea,

366 Crawford, & Worsley, 2006b).

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367 A qualitative study out of Portugal revealed that although 60% of the participants

intended to change their diet, only 12.4% intended to change it to eliminate meat
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368

369 (Graça, Oliveira, & Calheiros, 2015). However, 48.8% stated that they were willing to
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370 reduce the amount of meat in their diet (Graça, Oliveira, & Calheiros, 2015). Individuals
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371 who viewed meat in a negative or neutral light were more willing to reduce their

372 consumption of meat and shift to a vegetarian diet (Graça, Oliveira, & Calheiros, 2015).
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373 In contrast, those who had a more positive view and dependency on meat were less

374 willing to reduce their meat consumption patterns (Graça, Oliveira, & Calheiros, 2015).
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375 Individuals were most likely to reduce their meat consumption as opposed to
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376 eliminating it completely (Lea, Crawford, & Worsley, 2006a; Vanhonacker, Van Loo,

377 Gellynck, & Verbeke, 2013). In addition, individuals expressed a clear willingness to eat

378 more organic and consume more environmentally friendly meat choices such as

379 sustainable farmed fish (Vanhonacker, Van Loo, Gellynck, & Verbeke, 2013). There
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380 were neutral to slightly positive responses to consuming plant-based meat substitutes

381 and hybrid meat products (Vanhonacker, Van Loo, Gellynck, & Verbeke, 2013).

382 However, consumers were less willing to pay for these alternatives as they were to

383 consume them (Vanhonacker, Van Loo, Gellynck, & Verbeke, 2013).

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384

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385 2.7 Socioeconomic and demographic factors

386 When considering the stages of change in a study out of Australia, those who

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387 were contemplating or preparing to change to a vegetarian diet were younger (mean

388 age of 47 +/- 13 years) than those who were in the pre-contemplation and maintenance

389
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stages (mean age of 53 +/- 15 years) (Lea, Crawford, & Worsley, 2006b). A study in
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390 Slovenia showed that 25% (n=800) of the participants favorable to consuming a

vegetarian or vegan diet were under the age of 30, and 75% were between the ages of
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391

392 30-60 (Crnic, 2013). Four studies found that the youngest groups of participants were
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393 the least willing to change to a vegetarian or vegan diet (Crnic, 2013; Ensaff, et al.,
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394 2015; Lea, Crawford, & Worsley, 2006b; Vanhonacker, Van Loo, Gellynck, & Verbeke,

395 2013).
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396 Those with higher levels of education (Crnic, 2013; Lea, Crawford, & Worsley,

397 2006a), women (Graça, Oliveira, & Calheiros, 2015), and those who have more
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398 vegetarian friends (Lea & Worsley, 2001), were the most likely to consume a vegetarian
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399 or vegan diet. In addition, the groups that most supported vegetarianism were liberals,

400 women, those in higher professions (senior/leadership roles), and adults and children

401 considered upper and middle class (Crnic, 2013).

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402 The barrier perception was strengthened by socioeconomic factors such as being

403 male, living in a rural area, low education, absence of a vegetarian friend or family

404 member, valuation of traditions and wealth, and the presence of children in the family

405 (Pohjolainen, Vinnari, & Jokinen, 2015). The most prominently connected variable to the

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406 barrier perception was being male (Pohjolainen, Vinnari, & Jokinen, 2015). There were

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407 distinct differences in perceived barriers between the sexes. More men than women

408 agreed that humans were “meant to eat meat” (Lea, Crawford, & Worsley, 2006a; Lea &

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409 Worsley, 2003a), plant based diets would not be tasty enough (Lea, Crawford, &

410 Worsley, 2006a), and that someone else decides on the food they consume (Lea,

411
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Crawford, & Worsley, 2006a). Women tended to have more health and convenience
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412 concerns than men (Lea & Worsley, 2001). The perceived barriers that were more

prominent in women included believing that vegetarian diets lack sufficient iron and
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413

414 protein (Lea & Worsley, 2001), lack of knowledge about vegetarian diets (Lea &
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415 Worsley, 2001), the inconvenience of preparing and consuming a vegetarian diet (Lea &
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416 Worsley, 2001), and the unwillingness of their family and/or spouse to consume a

417 vegetarian diet (Lea & Worsley, 2003a). Common barriers of a vegetarian diet to the
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418 younger participants were insufficient information (Ensaff, et al., 2015; Lea, Crawford, &

419 Worsley, 2006a) and a perceived lack of protein and iron (Lea & Worsley, 2001). The
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420 older cohorts agreed more on health concerns and the unwillingness of themselves and
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421 their families and partners to consume a vegetarian diet as significant barriers (Lea,

422 Crawford, & Worsley, 2006a; Lea & Worsley, 2003a).

423 Benefits of a vegetarian diet were found with the younger participants, and

424 included improving the environment (Lea & Worsley, 2003a) and animal welfare
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425 (Ensaff, et al., 2015; Lea & Worsley, 2003a), disease prevention (Lea & Worsley,

426 2003a), decreased saturated fat intake (Lea, Crawford, & Worsley, 2006a), and

427 improved overall health (Ensaff, et al., 2015). The older participants had the most

428 agreement on benefits such as increased fiber consumption, decreased saturated fat

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429 intake, and a greater variety of interesting food (Lea, Crawford, & Worsley, 2006a). In

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430 terms of gender differences, more women than men agreed eating a vegetarian diet

431 could be tasty (Lea, Crawford, & Worsley, 2006a), help improve animal welfare (Lea,

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432 Crawford, & Worsley, 2006a; Lea & Worsley, 2003a), and help people remain healthy

433 (Lea, Crawford, & Worsley, 2006a). Whereas more men than women agreed that

434
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vegetarian diets helped to decrease saturated fat intake (Lea & Worsley, 2003a).
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435

3.0 Discussion
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436

437 The results of this scoping review indicate that individuals were more likely to
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438 reduce their meat consumption as opposed to eliminating it completely (Graça, Oliveira,
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439 & Calheiros, 2015; Lea, Crawford, & Worsley, 2006a; Vanhonacker, Van Loo, Gellynck,

440 & Verbeke, 2013). In addition, most people had positive attitudes and beliefs about their
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441 own diets, and negative attitudes and beliefs about other diets (Povey, Wellens, &

442 Conner, 2001). People were more likely to change to a diet that is similar to their own
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443 (Povey, Wellens, & Conner, 2001). This information points towards creating health
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444 promotion plans that focus on encouraging individuals to reduce meat consumption

445 instead of eliminating it completely.

446 As the population continues to grow, we need to address the issue of feeding

447 large numbers of people in a way that is both healthy and sustainable (Dagevos &
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448 Voordouw, 2013; Lang & Barling, 2013). If the population and per capita income

449 continues to grow at this rate, it is estimated that by 2050, the demand for livestock

450 products will increase by 70% (Gerber, et al., 2013). This has the capacity to be

451 detrimental to the health of the population, food availability, and our environment

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452 (Dagevos & Voordouw, 2013; Lang & Barling, 2013).

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453 The Health Belief Model (HBM) can be used as a framework to design health

454 promotion initiatives with the intention to move individuals towards a vegetarian diet.

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455 The Health Belief Model is comprised of six factors that are believed to motivate and

456 influence changes in health behavior (Edberg, 2007). These factors include perceived

457
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susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action,
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458 and self-efficacy (Edberg, 2007).
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459

460 Perceived Susceptibility & Severity

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461 The HBM postulates that a person must believe that they are susceptible to
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462 developing health issues by not changing their behavior (Edberg, 2007). In addition,

463 they must believe that the consequences of developing these health issues will be
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464 severe (Edberg, 2007). This could explain why younger participants were the least

465 willing to change to a plant based or vegetarian diet (Crnic, 2013; Ensaff, et al., 2015;
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466 Lea, Crawford, & Worsley, 2006b; Vanhonacker, Van Loo, Gellynck, & Verbeke, 2013).
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467 Generally, people become more concerned with their health as they age. Research also

468 suggests a general lack of information on health outcomes such as a decreased risk of

469 mortality from ischemic heart disease through the consumption of a vegetarian diet (Lea

470 & Worsley, 2003b).

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471 Non-vegetarians were found to be less concerned with health issues in

472 comparison to their vegetarian counter-parts (Pribis, Pencak, & Grajales, 2010). People

473 need to know that their dietary choices have a strong link to health outcomes. This

474 information provides an opportunity for health promoters to design programs to create a

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475 strong link between diet and health outcomes, especially for non-vegetarians. If people

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476 feel that their dietary choices could have severe health consequences, they may be

477 more inclined to make positive dietary changes. Specifically, campaigns tailored

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478 towards younger generations should work to establish this link, and middle-generations

479 to strengthen this link.

480
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481 Perceived Benefits and Barriers

There are many perceived benefits and barriers to consuming a vegetarian diet.
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482

483 Although many people acknowledged the health benefits of a vegetarian diet (Lea &
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484 Worsley, 2001; Lea & Worsley, 2003a; Lea & Worsley, 2003b; Position of the American
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485 Dietetic Association: Vegetarian Diets, 2009; Povey, Wellens, & Conner, 2001), there

486 were also a lot of people who had concerns about the healthiness of a vegetarian diet
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487 (Lea, Crawford, & Worsley, 2006b; Lea & Worsley, 2001; Pohjolainen, Vinnari, &

488 Jokinen, 2015), and if the proposed health benefits are directly attributable to a
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489 vegetarian diet (Lea & Worsley, 2003b). It is possible that the health benefits are not
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490 enough to encourage dietary change (Lea, Crawford, & Worsley, 2006a).

491 The results indicate that it might be more beneficial to focus on eliminating or

492 decreasing the barriers of consuming a vegetarian diet as opposed to highlighting the

493 benefits. Many of the perceived barriers were correlated (Pohjolainen, Vinnari, &
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494 Jokinen, 2015), so health promotion campaigns designed to reduce specific barriers

495 could have a cascading effect in decreasing other barriers. There are opportunities for

496 health promotion campaigns to focus on removing the stigma that vegetarian diets do

497 not contain enough protein and iron. Information barriers should also be tackled by

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498 improving knowledge on what to eat besides meat and how to prepare vegetarian

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499 meals. In addition, socioeconomic factors should also be considered when designing

500 health promotion initiatives. For example, a campaign geared toward women should

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501 focus on eliminating health and convenience barriers such as addressing the perceived

502 lack of protein and iron in a vegetarian diet and providing information on quick and easy

503
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vegetarian meals for families (Lea & Worsley, 2001).
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504 Although vegetarian options are starting to be offered more frequently at

restaurants and by food service organizations, there is still a lot of work that can be
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505

506 done. Making the choice to eat more vegetarian food needs to be convenient. In
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507 addition, vegetarian meal options need to be perceived as tasty and both quick and
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508 easy to prepare.

509
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510 Cues to Action

511 People are also motivated to make behavioral changes when they receive a “cue
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512 to action” (Edberg, 2007). This is generally an event that occurs which causes the
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513 person to make a change. Interest in vegetarianism is on the rise, with a large majority

514 of the population interested in learning more about plant-based and vegetarian diets

515 (Lea, Crawford, & Worsley, 2006a; Lea & Worsley, 2003a; Position of the American
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516 Dietetic Association: Vegetarian Diets, 2009). There is now a window of opportunity for

517 health promoters to design campaigns to try to shift eating behaviors.

518

519 Self-Efficacy

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520 A person must believe that they are capable of making a change before they can

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521 successfully do so (Edberg, 2007). The results indicate that there is a severe lack of

522 information on how to prepare vegetarian meals, and not knowing what to eat besides

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523 meat (Lea, Crawford, & Worsley, 2006b; Lea & Worsley, 2001). Providing people with

524 the information and tools to prepare and eat vegetarian meals is key to improving a

525
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person’s belief that they can make a positive change to their diet.
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526 In combination with providing the tools for preparing and cooking vegetarian

meals, these meal types also need to be convenient and accessible outside of the
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527

528 home. Arming people with the ability to make these choices both at home and in social
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529 settings will drastically improve the degree in which they believe they are capable of
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530 making positive dietary changes.

531
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532 4.0 Conclusion

533 From the limited number of journal articles found during this scoping review, it is
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534 recommended that research efforts be increased in order to learn more about the
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535 perceptions and attitudes towards a vegetarian diet. While research continues, it is

536 important that these findings be used constructively.

537 With interest in vegetarianism on the rise, there is a window of opportunity for

538 health promoters that intend to move individuals towards a vegetarian diet to use the
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539 information from this scoping review in conjunction with the Health Belief Model to

540 create and tailor their initiatives.

541 When considering a vegetarian diet, the majority of the studied population is in

542 the pre-contemplative stage and will likely only change if the diet is similar to their own.

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543 To improve an individual’s self-efficacy and belief that they can make a positive change

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544 to their current diet, health promotion initiatives geared towards providing people with

545 the information and tools needed to prepare and eat a vegetarian diet, and focusing on

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546 reducing overall meat consumption instead of eliminating it completely could be

547 successful.

548
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Vegetarian diets were perceived positively and as healthy amongst the general
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549 population. The perceived barriers to a vegetarian diet such as enjoyment of meat,

convenience, and lack of information may outweigh the perceived health, well-being,
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550

551 environmental, and ethical benefits. Therefore, it would be more beneficial to focus on
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552 eliminating or decreasing the barriers of consuming a vegetarian diet as opposed to

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553 highlighting the benefits. The socioeconomic and demographic factors such as age,

554 gender and level of education accounting for these perceptions can be used to eliminate
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555 the perceived barriers of moving to a vegetarian diet. They can also be used to increase

556 perceived susceptibility and severity of dietary choices by creating a stronger link
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557 between diet and health outcomes. These factors are important for health promoters to
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558 consider when attempting to alter an individual’s behavior.

559

560 Acknowledgements
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561 A special thank you to Courtney Primeau for reviewing and confirming the

562 methods in this scoping review.

563

564 *The authors declare that no competing interests exist.

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565 *This research did not receive any specific grant from funding agencies in the public,

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566 commercial, or not-for-profit sectors.

567

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568 References

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570 Journal of Social Research Methodology, 8(1), 19-32. doi:10.1080/1364557032000119616
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652