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WILLIAM W. POWERS STATE RECREATION AREA is an Illinois state park administered by the Illinois Department of Natural Resources on in the Hegewisch community area of the City of Chicago in Cook County, Illinois, United States.[1] The area includes of water in Wolf Lake that provides about of shoreline to fishermen.[2] The park hosts about half a million visitors annually.[3] The park contains numerous species, and is one of the most important biological sites in the Chicago region.

History

Wolf Lake in Illinois has a storied history that somehow has lost track of the origins of the name that goes back over 150 years. Part of this history includes visits by Abraham Lincoln in which Mary Todd Lincoln nearly drowned.[4] In 1947, the state acquired a parcel known as the Wolf Lake State Recreation Area. Later acquisitions were added to the property and have increased the area which was known as Wolf Lake Conservation Area. In 1965, the Illinois General Assembly named the area after William W. Powers.[5] Powers had been a Chicago alderman on the Chicago City Council and Illinois General Assembly legislator in the 1920s, and used the site for picnics to feed the needy during the Great Depression.[6]

The park also has a military history. There is a defunct Nike Ajax missile honoring the missile site that occupied the area during the Cold War years. Memorial Day, Independence Day, and Veterans Day ceremonies attract veterans who place flags at markers near a former re-dedication ceremony site that featured the Moving Vietnam Wall.[7]

Unlike the Lake Michigan shoreline which has been reshaped by sand and clay, Wolf Lake has been filled in large part with slag from steel mills.[8]

Wildlife

[Monk parakeets can be found in the park] Wolf Lake contains largemouth bass, northern pike, bluegill, redear sunfish, crappie, bullhead, carp, walleye, hybrid muskie, and yellow perch.[9] There is also an occasional salmon and rainbow trout caught in the lake.[10] Salmon can access the lake via the Calumet River and its Indian Creek tributary.

Native trumpeter (_Cygnus buccinator_) and tundra swans (_Cygnus columbianus_) and non-native mute swans (_Cygnus olor_) may all be found on the lake in winter.[11] Tundra swans are absent in summer as they migrate to the arctic and subarctic to nest, however, the non-native, Eurasian mute swans compete for habitat with the non-migrating trumpeter swan population and is an impediment to restoration of the native trumpeters around the Great Lakes.[12][13][14] Additional native birds hosted by the lake include cardinals, blue jays, finches, orioles, woodpeckers, teal, mallards, resident and migratory Canada geese, and an occasional bald eagle.[15]

Birdwatchers enjoy the non-native monk parakeet, which is a South American parrot, that nests in the park.[16] Hunters enjoy the seasonal waterfowl.[17] The South American monk parakeets arrived at the site in 1999 and have since established two nests with seven or eight birds each. They are presumed to have migrated from the Hyde Park community area.[18]

The park contains many willow and cottonwood trees.[19]

The park also attracts city dwelling mammals such as squirrels, rabbits, raccoons, muskrats, opossums, and the occasional coyote and white-tailed deer.[20] Beaver sign indicates that there are beaver on the lake currently.[21]

On August 23, 2002, Wolf Lake was one of three neighboring regions that hosted the Calumet BioBlitz. This bioblitz convened over 150 expert scientists to identify and record as many living organisms as possible within 24 hours. The purpose was to demonstrate the resilience of the extraordinary range of organisms in nature's battle against the South Side of Chicago's collage of factories, warehouses, forest preserves, residences, and highways as well as its battle of survival against killer pest species. Unofficially, the BioBlitz counted 1,815 species.[22] The BioBlitz included teams of scientists from Eastern Illinois University, Field Museum, Forest Preserve District of Cook County, Illinois Natural History Survey, Indiana Department of Natural Resources, University of Illinois - Champaign, U.S. Environmental Protection Agency, and U.S. Fish & Wildlife.[23]

Lake sturgeon, endangered in both Indiana and Illinois, as well as banded killifish, threatened in Illinois, are both part of the Wolf Lake ecology.[24] The lake supports the nesting habitat for four species of endangered birds: little blue heron, yellow-crowned night heron, black-crowned night heron, and yellow-headed blackbird.[25]

Conservation

The U.S. Army Corps of Engineers and the Illinois Water Survey are studying ways to halt degradation of the lake and the USDA Forest Service is helping with a study of public interests in recreation at Wolf Lake.[26] The Wolf Lake water level determines the drainage to Lake Michigan because the connecting Calumet River flows southward during elevated levels and northward during lowered levels.[27] The water in Wolf Lake was about 18 inches higher until 1998 when the Illinois Department of Natural Resources removed several beavers and their dams that had been built across Indian Creek. The subsequent drop in water depth encouraged weed growth and changed fishing conditions.[28]

The Illinois Department of Natural Resources and the City of Hammond, IN initiated the Reconnaissance Report in December 1998. It was approved in September 2000. An environmental assessment was held in 2002. The Project Cooperation Agreement commenced in 2005.[29] The Wolf Lake ecosystem degradation problem is multifaceted. It includes exotic plant species proliferation, low diversity of plant and fish species, water depth inadequacy, poor aquatic habitat, contaminant impact, and shoreline erosion. Proposed project features include new aquatic and wetland habitat plantings; shoreline restoration; creating deep holes to locally diversify the lake bottom; herbicidal and biological controls; channels clearing, and dikes and causeways construction to restore natural water levels.[30]

Use

The park offers stoves and has shelters available by reservation for picnicking. Two of the shelters each have capacity for 50 people, and two others each have capacity for 100 people. Fishing and hunting is permitted in accordance with regulations, but camping is not allowed.[31] Ice fishing is permitted in the winter and motorboats are permitted during the summer.[32] The lake has several dikes that temper the wave height.[33] There are 25 hunting blinds to hunt waterfowl. These sites are awarded in yearly lotteries held in late July. During the season, daily drawings are held to allocate blinds of absentee blind holders.[34]

The use of the park is protected by several types of volunteers. For example, at the 14th Annual Earth Day Wolf Lake Cleanup on April 21, 2001, more than 350 volunteers, including Hammond, IN Mayor Duane Dedelow, Jr., helped clean up and remove an estimated of waste.[35] A week later, Friends of Wolf Lake and associates collected more than 3,000 discarded tires from the lake and its shoreline.[36] Semi-annual cleanups are organized by the Southeast Sportsmen's Club and the Wolf Lake Rod and Gun Club who work with the scouts, community organizations and the Hegewisch Chamber of Commerce.[37]

Geography

Wolf Lake extends across the Illinois and Indiana State line between 120th and 134th streets.[38] It is an lake that has within the city of Chicago and the remainder in the city of Hammond.[39] Its maximum depth is .[40] Wetlands adjacent to the lake include the Eggers Woods Forest Preserve, Powderhorn Lake Prairie, and Hyde Lake Wetland.[41] William W. Powers State Recreation Area is on Chicago's far southeast side, off highways 94, 90, and 41. The main park entrance is at 12949 South Avenue O.[42]

At one time, the Wolf lake was connected to Lake Michigan by a creek running through Hammond on the Indiana side, but the creek has long since been blocked by development. On the Illinois side, Wolf Lake empties into Indian Creek, which feeds into the Calumet River. The Illinois and Indiana are separated by State Line Road, which is a road elsewhere along the border, but it is only represented by a rock-and-gravel dike that passes through the lake. State Line Road ends in foot bridges where water enters from the Indiana side.[43]

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title: William W. Powers State Recreation Area

question: What are the plans to curb the Wolf Lake ecosystem degradation issues?

answer: The Wolf Lake ecosystem degradation problem is complex. It includes exotic plant species proliferation, low diversity of plant and fish species, water depth inadequacy, poor aquatic habitat, contaminant impact, and shoreline erosion. The intended project to curb these issues includes new aquatic and wetland habitat plantings, shoreline restoration, creating deep holes to diversify the lake bottom locally, herbicidal and biological controls, clearing channels, and construction of dikes and causeways to restore natural water levels.

question: What are the significant occurrences that took place at Wolf Lake?

answer: Firstly, Abraham Lincoln and his wife Mary Todd Lincoln visited Wolf Lake. However, during this visit, Mary almost drowned in the lake. Secondly, it has a military history. A defunct Nike Ajax missile honoring the missile site occupied the area during the Cold War years. Events like the Memorial Day, Independence Day, and Veterans Day ceremonies attract veterans who place flags at markers near a former re-dedication ceremony site that featured the Moving Vietnam Wall.

question: What uses does the park offer to visitors?

answer: The park offers stoves and shelters available by reservation for picnicking. Two of the shelters each have the capacity for 50 people, and two others each have the capacity for 100 people. Fishing and hunting are permitted following regulations, but camping is not allowed. Also, ice fishing is permitted in the winter, and motorboats are permitted during the summer. The lake has several dikes that temper the wave height. For hunters, the park offers 25 hunting blinds to hunt waterfowl. These sites are awarded in yearly lotteries held in late July.


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DO NOT USE THIS PLACE if you have a child that is a runner do NOT take them here these people tell you they can help you that they work with troubled teens all the time if your child runs they can’t get far they do NOT tell you they are not a lock down facility they lead you to believe your child will be safe and someone will watch them that is NOT the case two teens ran from this place within two weeks of their stay and this place will not refund any of the $6,000 I did some research on teen challenge.

There was a big thing about it when Bush was the governor in Texas and then it went nationwide when he became president. Basically, the state was getting ready to close it down because it wasn’t following state mandate and yet it was still claiming to be a treatment center (to claim to be a treatment or medical center licensed clinical staff must be employed there and all activity is regulated by the state). Bush stepped in and said that since it is a religious organization the state could not regulate it. So basically, since they claim to be religious based they definitely are not regulated at all. And from what I read, they used to be primarily substance abuse camps so most of the kids were probably in withdrawals and couldn’t run if they tried. The only treatment they offer is bible reading and prayer.This is an article that was written about programs that aren’t regulated by the state. Teen challenge is mentioned. It seems to go along with what you were saying. It also stares that the parents do sign papers that prevent them from lawsuits. It also states that there are no refunds if the program is not completed, even if they are expelled from the program. Keep in constant contact with your lawyer about this. Criminal charges are usually still possible as they are not usually protected by papers that protect from civil lawsuits. It would be nearly impossible to prove anything

A friend of mine decided she would voluntarily call them and act like she had a troubled teen kind of like My teen and how could they handle her this is what she sent me “This is what i got from Alexis there:i asked if it was a locked down place she said no. but they are in a very rural area and there is no place to go. and if she does run away they put them in bright orange shirts and kaki pants. and give them shoes that are too big for them. there is a one time fee of 1300 due at time of intake. then it’s 2300 hundred a month. asked if she was on k2 and pot real bad could they help and she said yes.”

Miss Shannon would NOT speak to me for the three days our teen has been gone she’s having her minions call our teen is STILL on the run and is endangered they called today and told me to come get her stuff no money will be refunded the are headed to Africa in the morning for a “missions” trip this is the message I got Exact words “we have been in a staff meeting all day and we all agree **** needs a lock down facility we are leaving for Africa tomorrow but there will be someone here for you to come get her stuff we wish you the best good luck and may God be with you” EXCUSE ME but if miss Shannon is so Godly why is she leaving and not staying back and willing to find our kid?

Sources:

-   The original testimony found on Topix
-   THE TRUTH ABOUT STRAIGHT, INC, TEEN CHALLENGE (Heal-online)

My son went to Teen Challenge in NM for about 11/2 to 2 years of his life at age 17. He came out in worse shape than he went in. Horrible place with no skills but slave labor, stress and bible babble. And I mean babble. The only thing he achieved there was a setback in his natural maturity, no life skills to move forward, and a mistrust of his Faith.

I am thanking God that his family was there for him after being put on a plane to OK with no money and a ‘ discharge’ after completing his studies. He only received a GED (the state court ordered him back to complete his diploma) and was set back in his studies for many years. He was discharged for standing up for his family and not wanting to become a ‘jailer’ to the other boys there. I am blessed and thankful he was able to turn his life around with the help of his ‘sinful, uncaring’ family. It took him close to 5 years to do so. So, again, I am proud for you; but the Majority of young people coming out of this particular state program have not fared so well. The boys t.c. Was shut down for making the boys clean up raw sewage. But.. They were allowed to take a 5 minute rinse in the sewer shower water after working in it for hours in the heat. Then they were allowed to eat out of date, nasty molded food they cooked for themselves. Great place for a lost child to recover in!! No communication with family except to recite bible verses for the allotted time with the ‘lead’ on the phone at all times. Yes, I am a Christian and I pray the God I know will take care of this group of control freaks in His own way! I Trust only in Him; not some lunatic ex-cop and his wife with power in there thoughts and actions. It is a disgrace to our children. As a last resort, my sons father brought up to the lead ‘lady’ the question of his diploma being court ordered… She told him if he would keep all info to himself, she would send him an ‘accredited diploma’. The paper he received was just that… basically, just another piece of paper!

Sources:

-   The original testimony found on Topix
-   THE TRUTH ABOUT STRAIGHT, INC & TEEN CHALLENGE (Heal-online)

I just got out of Teen Challenge of New Mexico. I spent a very long time there. The place is crazy. If you have any talents whatsoever they will abuse it and tell you that everything that you are doing is in the name of Jesus Christ. They do their best to brain wash their students in to become little christian robots that obey and do everything that they are told to do.

They claim that they love their students but they are cruel with their words and often time tell the students that the parents don’t want them home or tell them they don’t want to speak to them after the student requested to talk to their parents so that they could leave and Teen Challenge Staff never called them in the first place. The center is full of liars and wacked out people. Do not send your children there no matter how desperate you become keep searching for something better.

Sources:

-   The original testimony found on Topix
-   THE TRUTH ABOUT STRAIGHT, INC & TEEN CHALLENGE (Heal-online)

My son was in Teen Challenge for almost 2 years. Yes, he was having troubles in his life. If I had more control, he would have gone to a boot camp and been better off. There is no such thing as a true diploma with them. For the most part of his time there, when we were ‘allowed’ to talk to him on the phone, he sounded like a robot quoting bible. He earned his release and they bad mouthed his family (who they knew nothing about) which angered him. He was put on his first plane ride home with no money or food, called us and told us what his flight was. The director ‘Brother’ Lynn called me and spoke to me like I have never been spoken to in my life.

This particular center is not good. My son came out with no life skills. He was emotionally worse off then when he went in. Instead of coming out with deserved pride in himself, ‘Sister’ Kathy and Lynn made him feel like he was nothing. It has taken us over a year to get him back on the right track to help him get over this emotional and spiritual draining of his self worth. I know there are good centers out there, but this one should definitely be shut down. It is my mission to continue to blog against the New Mexico Teen Challenge for boys. I am very concerned for the ‘inmates’ who are still there. It is like a Nazi camp. Kathy and Lynn run this with no credentials, only their egos and their opinion of God who is against anything they don’t personally believe in.

Feel free to contact me for more information. I am deeply considering a court action against this ‘Hell Hole’. I thank the God I know for getting my son through that and on his way to truly believing in a God who is all about Love, Honor, and what is Right. Shame on Kathy and Lynn.

Sources:

-   The original testimony found on Topix
-   THE TRUTH ABOUT STRAIGHT, INC & TEEN CHALLENGE (Heal-online)

I COMPLETELY agree with these posts on the abuses of Teen Challenge of New Mexico.

I never finished because apparently I couldn’t be saved, God just gave up on me, and so I was made to leave. My schooling for the entire year was for nothing – my high school transcript is blank my junior year, and I had to work twice as hard as the other seniors just to graduate on time because of it. I was like a zombie when I left there. I was brainwashed, even my faithful Christian parents thought I was a little “cult-like”. When I was there, I was constantly “in trouble” for ridiculous things, and was one of the girls in the dumpster-cleaning group. Of course, back then, I felt really guilty about my “sins”. I could never measure up.

If you were in trouble, you couldn’t receive the Christmas gifts you’d been given because of your behavior, so, needless to say, I never saw mine!(not that it matters now 🙂 I made a close friend there, and we were made to separate houses and couldn’t even be in the same room together (not to mention ever talk!). This was because some attention-hungry other girl wrongfully accused us of kissing! The thing I’ve been sad for most of the whole experience was losing that friend – I’ve been looking for her ever since. She was from Seattle, or maybe it was Tacoma. Anyhow…..Teen Challenge of New Mexico drastically altered my life. When I was far away from there, several months down the road, and I started thinking like a normal person again, I became so angry. I still am, but I have to tell myself that maybe all of us girls, or the ones that realized what happened to us – maybe we’re better people now for experiencing it.

If everyone is saying NOT to let one experience with one Teen Challenge affect how we look at all of them – well maybe this one shouldn’t be carrying the “Teen Challenge” name then…

Sources:

-   The original testimony found on Topix
-   THE TRUTH ABOUT STRAIGHT, INC & TEEN CHALLENGE (Heal-online)

I also went to Teen Challenge of New Mexico. I completely agree with Kleyva. I not only attended the school but I was brain washed into working as a staff member for over 2 years after I graduated. I learned how to clean out freezers and dumpsters, but I didn’t learn a thing about the real world. The overall character of the staff is totally based on money. The directors live in a beautiful 2 story house while the girls live in an old house with run down cars and have to take 3 minute showers even after cleaning out a mouse infested dumpster. They don’t even allow you to look out of the windows or watch anything other than FOX News. They also influence you to ONLY vote republican.

After spending almost 5 years of my life there I later found out that my “High School Diploma” is not a real diploma. Teen Challenge is not a credited school. Of the 5 years I was there, only 3 girls were tested at a high school level for A.C.E. The rest of the girls (over 200) were tested at a 2nd grade level and made to “graduate” with a FAKE vocational diploma. Teen Challenge of New Mexico is the biggest manipulating and brain washing cult I have ever known.

Sources:

-   The original testimony found on Topix
-   THE TRUTH ABOUT STRAIGHT, INC & TEEN CHALLENGE (Heal-online)

I went to the adolescent teen challenge center in New Mexico 7 years ago. They don’t have student who get food stamps or anything like that letter. They only collect money from the parents based on what they can afford. They accepted several students who had literally nothing- they brought their clothing in cardboard boxes. Their parents couldn’t afford to pay anything-and one of those people was there for 2 years. I know they truly changed my life, and never mentioned money or giving to them to me ever!

Sources:

-   The original testimony found on Topix
-   THE TRUTH ABOUT STRAIGHT, INC & TEEN CHALLENGE (Heal-online)

I too went to Teen Challenge of New Mexico. It is abusive and brain washing. Although I am a contribute to society the experience has scared me. Cleaning dumpsters with a toothbrush, both trailers are mice infested, gifts are not accepted from family unless they contribute. It is a mess over there. I am in contact with not one but SEVEN girls some graduates some not that all share horrible experiences. Final thought, if your work is not satisfactory to the director it you will stay for at least three years. That time leaves a younge girl or boy unprepared for real life and afraid to speak a mind of there own.

Sources:

-   The original testimony found on Topix
-   THE TRUTH ABOUT STRAIGHT, INC & TEEN CHALLENGE (Heal-online)

question: What does the text say about Bush's influence on Teen Challenge?

answer: The state of Texas was going to close Teen Challenge down but Bush intervened because Teen Challenge is a religious organization and thus can't be regulated by the state. As a result, the organization is unregulated and its program seems to offer symbolic not accredited diplomas for its graduates.

question: Summarize the purpose of Teen Challenge.

answer: Teen Challenge is a religious organization that has a paid program that takes troubled teens sent by parents/guardians to help them get their lives together. The curriculum is apparently Bible-based and includes hard manual labor to occupy and train teens. Graduates of the program receive a diploma.

question: What does the text say about diplomas?

answer: The participants in the Teen Challenge program are given non-accredited high school diplomas. Apparently, the fact that the diplomas are not accredited is not transparent upon beginning the program. It seems that one way Teen Challenge gets away with this is by calling the offered diploma a "vocational diploma."

question: What does the text say about miss Shannon's family?


text:
IN JUNE 2006, ultra-Orthodox Rabbi Leib Tropper nullified a conversion over a year after supervising it himself. He decided that the convert, whom we will call “Sarah,” had become a Jew under “false Pretext [sic].” Rabbi Tropper informed Sarah’s husband, … Read More

By / May 14, 2008

[] IN JUNE 2006, ultra-Orthodox Rabbi Leib Tropper nullified a conversion over a year after supervising it himself. He decided that the convert, whom we will call “Sarah,” had become a Jew under “false Pretext [sic].” Rabbi Tropper informed Sarah’s husband, “Avraham,” that his wife’s conversion had been registered as nullified with the Chief Rabbinate of Israel, and that the child produced by their marriage would not be regarded as Jewish, either. Finally, Rabbi Tropper declared that it was “forbidden” for Avraham to be married to Sarah. “Even if she decides to become observant,” Rabbi Tropper wrote via email, “she will need a new conversion,” and the couple would require a “new halachic marriage.” What happens if despite a rabbi’s best due diligence, a convert to Orthodox Judaism doesn't keep Jewish law for the long haul? If that convert begins eating cheeseburgers and driving on Shabbat? Does the conversion remain valid? Is a convert 100% Jewish no matter what? Historically, a lapsed convert was still considered a Jew unless those lapses were immediate to the conversion, public, and intentional. The convert had to know what he was about to do was wrong, and then had to do it anyway. (Before the 19th century and the advent of ultra-Orthodoxy, according to Zvi Zohar, an Israeli scholar who studies this issue, there is no evidence a rabbi ever revoked a conversion for any reason.)

Times have changed. That’s because haredi (ultra-Orthodox) Jews like Leib Tropper, founder and director of Eternal Jewish Family—an organization dedicated to converting non-Jewish spouses of intermarried Jews—represent the most rapidly growing demographic in Judaism. Tropper also founded and runs a yeshiva in Monsey, New York, and travels regularly to Israel, where he frequents the halls of haredi power and hobnobs with its leaders. People like him are the Jewish future. They’re at the center of a seemingly irrevocable schism between Orthodoxy and every other denomination of Judaism. They're determined to restrict and to monitor all Orthodox conversions as part of their spiritual war against non-haredi Judaism, and they want nothing less than ultimately to define who is a Jew. Tropper did not revoke Sarah’s conversion because she bowed down to idols, accepted Jesus as her Lord and Savior, or identified with the atheist philosophies of Christopher Hitchens. She didn’t renounce any universally accepted tenet of Judaism. Sarah’s conversion was ruled invalid because she did what many Modern Orthodox women do every day: get dressed and go out of the house. Sarah’s conversion was reversed because Tropper heard that she had worn pants, and occasionally—only when shopping outside the Jewish neighborhood—she had left her hair uncovered. Sarah and Avraham live hundreds of miles from Tropper, who is based in the ultra-Orthodox enclave of Monsey, New York. How did Tropper find out about Sarah’s clothing? Easy: Her husband told him.

A “_baal teshuva_,” Avraham was as new to ultra-Orthodoxy as Sarah was to Judaism. Like many people who become Orthodox as adults, he had questions. Orthodox Jewish law mandates how to put on and tie one’s shoes; when, how, and even if to have sex; what and when to eat, and hundreds of other daily minutiae. Was it a major transgression for Sarah occasionally not to cover her hair? What about wearing pants?

Avraham didn’t know, so he asked Tropper, who said that her behavior showed a flagrant disregard for Judaism, and that she was taking Jewish law lightly. He questioned Sarah’s original intent in converting, and contacted her for an explanation. Shocked that her husband had gone behind her back, Sarah refused to talk, and Tropper revoked her conversion. In an email to Avraham, Tropper wrote, “We must keep our word. [Sarah] ACCEPTED on herself to OBSERVE ALL of the torah & rabbinical commanments [sic]. She never did. You know that & you told me that.”
[] IN LEXINGTON, KENTUCKY, Tropper wreaked havoc on another family of seekers. Leah Bourne's maternal grandmother was Jewish, so according to Jewish law she was as well, but she hadn’t been raised that way. Her husband Peter wasn’t Jewish at all. After marrying and having children, the Bournes became involved with a Reform synagogue, but they wanted more. Along with their 16-year-old son Jonathan, they attended an EJF information seminar in their town. Raised in the Bible Belt, the Bournes were attracted to Tropper’s Jewish fundamentalism. They invested in the expensive process of koshering their home, kept the Sabbath, and studied Torah. They were a model family—so much so that EJF featured them in its promotional video. Tropper even convinced Jonathan, then a junior in high school, to forsake his senior year and enroll at Kol Yaakov, Topper’s Monsey-based yeshiva for Baal Teshuva students. Though at first his parents didn't agree with their son missing his senior year of high school, Tropper assured them that Jonathan would be able to learn Torah and get his GED at the same time. As they delved deeper into ultra-Orthodoxy, the Bournes were intrigued by the idea of their son becoming a learned Jew, and perhaps even a rabbi. Jonathan moved to Monsey, where he spent his days studying. Peter, meanwhile, worked toward converting by learning Torah over the phone with a Monsey rabbi. Peter’s teacher happened to work at Tropper’s yeshiva, and kept the proud father informed about Jonathan’s progress. The reports were very good: Jonathan was a diligent, budding scholar. Tropper promised the Bourne family that he’d send a rabbi to open a synagogue and build a mikvah in Lexington. Having an Orthodox synagogue and mikvah in their town was essential because EJF will not authorize conversions for people who live in areas without an acceptable Orthodox infrastructure. Unable to relocate, the Bournes depended on Tropper’s guarantees. Eventually, Leah and Peter traveled to Monsey for an EJF seminar. Leah, who has an architecture degree, was shocked by what she found. In her words, Kol Yaakov was “unfit for human habitation.” It was dirty, unkempt, and unsafe. She saw students living in overcrowded basement rooms without egress windows or other safe exits. According to Leah, “What pathetic stuff they had down in that basement to serve as a kitchen and dining room were disgustingly filthy, neglected, and inadequate for the number of boys living there.…They were not provided with breakfast (except maybe some day-old or stale pastries from a local bakery) or lunch, and for dinner they were divided up and sent around to other people’s homes every night—not just for Shabbat.” Leah was amazed that in light of all this, Tropper had helped find Jonathan a black hat and suit. “Clearly, the clothes were far more important to Tropper than making sure they had food.”
[] Just as Sarah’s clothes were more important to Tropper than the radical life change she’d made in embracing Orthodox Judaism, and just as her uncovered hair was more important to Tropper than her relationship with her husband, Jonathan Bourne’s black hat was prioritized over his health, his personal safety—and his education. There was no GED program available at Kol Yaakov, and when Jonathan began to ask questions, Tropper’s response was to chastise him for not finding an outside program to enroll in. As Peter was completing the requirements for his conversion, Tropper presented the family with a major setback: There would be no synagogue or mikvah in Lexington. Peter was instructed to abandon his job and future pension, and move his family to Monsey. When Tropper’s nebulous offers to help Peter find a job there weren’t enough to quell the Bournes’ anger and disappointment, Tropper—who refused to comment for this story—expelled Jonathan from Kol Yaakov without notice, dumping him on the street. IN ISRAEL, THE ONLY government recognized conversions are Orthodox. Last year, Israeli Rabbi Avraham Atia—a government-empowered haredi rabbinic judge based in Ashdod—retroactively annulled a woman’s conversion to Judaism that had been performed by Conversion Authority head Rabbi Haim Druckman fifteen years before. The nine-page legal decision by Atia could be understood to invalidate thousands of conversions performed by Druckman, a Religious Zionist rabbi, and the rabbis with whom he’s worked over the years. This reading of Rabbi Atia’s ruling was adopted by the Chief Rabbinate’s High Rabbinic Court, which heard the Atia case on appeal. In a fifty-five page ruling released in early May of this year, the lead rabbinic judge—another haredi rabbi, Avraham Sherman—ruled every conversion performed by Rabbi Druckman from 1999 onward invalid. Thousands of converts and their children are now deemed “goyyim,” their marriages void, their relationships with their spouses now “illicit.” While Israel’s Modern Orthodox and National Religious rabbis invested their energy, time, and money into settling the West Bank and creating an ever-greater Israel, haredim used their resources to become the dominant Orthodox political force in the country—even as they remain ambivalent about the validity of a Jewish state. They took control of the country’s Chief Rabbinate and its entire bureaucracy, whose authority they now wield as a weapon to attack and delegitimize more moderate Orthodox rabbis in Israel and abroad.

America’s largest rabbinic group, the Rabbinical Council of America (RCA) which represents “Centrist” and Modern Orthodox rabbis, was negotiating with Israel’s Chief Rabbinate over the conversion issue when we spoke with its executive vice president, Rabbi Basil Herring, in January. The Chief Rabbinate wanted the RCA to set up formal “conversion courts” with American judges approved by the Chief Rabbinate, who would first travel to Israel to be “trained” by the Chief Rabbinate to “properly” supervise conversions. Herring described the RCA’s relationship with Israel’s Chief Rabbinate as “very warm and positive.” “And that includes [the subject of] conversion,” Rabbi Herring emphasized. He was unwilling to comment on specific cases that might disturb that idyll—such as Rabbi Atia’s conversion revocation—because, he claimed, he was not privy to the specific details of the case. But privy he would soon be. This spring, the RCA reached an agreement (labeled “capitulation” by critics, including at least one former RCA president) with Israel’s Chief Rabbinate ensuring that American conversions will be much stricter from now on, and will be done only through formal, pre-approved “conversion courts." On May 6, the RCA reacted with outrage to the High Rabbinic Court’s revocation of thousands of Modern Orthodox conversions:

  “T]he RCA finds it necessary to state for the record that in our view the ruling itself, as well as the language and tone thereof, are entirely beyond the pale of acceptable halachic practice, violate numerous Torah laws regarding converts and their families, create a massive desecration of God's name, insult outstanding rabbinic leaders and halachic scholars in Israel, and are a reprehensible cause of widespread conflict and animosity within the Jewish people in Israel and beyond. The RCA is appalled that such a ruling has been issued…

The RCA also claimed it had been “assured” by Sephardic Chief Rabbi Shlomo Amar, the haredi president of the rabbinic court system, that the High Rabbinic Court ruling “directly countermanded his instructions and policies” and had “no legal standing at this time.” Reports in the Israeli media noted that Rabbi Amar was “trying” to annul the ruling.
[] On May 11, the _Jerusalem Post_ reported that many of Israel’s marriage registrars—all Orthodox—are refusing to register marriages of converts until Amar clarifies the status of Sherman’s ruling. In a country without civil marriage and with no other recognized Jewish options, this leaves converts in a limbo that could continue indefinitely. Amar says he wants to have the Chief Rabbinate's governing council discuss the issue, but the council is not seated. Therefore, Amar plans to wait for elections to the council to be held. His spokesman claims to be unsure how long this might take. HAREDIM SEE ULTRA-ORTHODOXY as the only true Judaism. They don’t view non-Orthodox Judaism as a theological threat, because in their minds Reform, Conservative, and post-denominational Jews are only a few years from irrelevance. In the US, for every 1.36 children a Reform Jewish couple have, haredim have 6.72, and Modern Orthodox have 3.39.

Although they still have Modern Orthodoxy to contend with, the reality is that haredim now control Israel’s Chief Rabbinate and rabbinic courts. They provide teachers for Modern Orthodox day schools, dominate Jewish outreach, and serve as rabbis in Modern Orthodox synagogues. Through control of the conversion process, haredim can determine who is a Jew, who is an Orthodox rabbi, and therefore what traditional Judaism is. The pawns in this haredi power play are the thousands of Orthodox Jewish converts who, just like Sarah, woke up one day to find they are no longer Jewish, their marriages are null and void, and their children are forbidden to marry Jews.

question: What does the article say about things that are forbidden?

answer: Rabbi Tropper declared it forbidden for Avraham to be married to Sarah. It is against Jewish law to eat cheesburgers and drive on Shabbat. It is implied that it's also bad to bow down to idols, accept Jesus, or identify with Christopher Hitchens's athiest philosophies. Sarah's conversion was revoked because she left her hair uncovered and wore pants. Sarah's children are also forbidden to marry Jews.

question: What does the article say about the rules of Christianity?

question: What does the article say about clothing?

answer: Sarah's conversion was reversed because she wore pants and left her hair uncovered. Orthodox Jewish law mandates how to put on and tie one's shoes. Tropper helped Jonathan find a black hat and suit.


text:
_Henry Selick's new 3D stop-motion animation film Coraline is adapted from a story by Neil Gaiman, who's perhaps best known for his groundbreaking graphic novel series The Sandman. Gaiman began writing the story in the early '90s at the request of his daughter Holly, who desired a narrative about a little girl whose mother gets kidnapped by evil witches resembling her mother. Happy to oblige, Gaiman created an inquisitive girl named Coraline who finds trouble behind a forgotten doorway in her drafty old house that leads into a seemingly better version of her current, dreary home._

_Though the plot device owes a debt to the Narnia books (as well as Hansel and Gretel), the resemblance quickly fades once Coraline is greeted by her ostensibly kinder "Other Mother," and "Other Father." Something delightfully sinister lurks behind their button eyes, and the lavish film adaptation, shot in stereoscopic 3D, loses none of Gaiman's signature creepiness. Director Henry Selick's insistence on hand-made detail is refreshing in this era of CGI, and the result is an avalanche of extraordinary eye candy that takes Selick's previous work on Nightmare Before Christmas and James and the Giant Peach to another level of wonder. The movie opens February 6th (until then, the website is quite impressive)._

HOW LONG DID YOU SPEND WORKING ON THIS, FROM THE BEGINNING UP TO NOW? You can’t really put it into those terms because it was a very long time since I met Neil and read the pages and wrote the first couple of drafts. I couldn’t get the film going then, so I went off and did other things. It’s really been the last four years that I’ve been most dedicated, with nearly two years of that spent shooting the film.

HOW DO YOU STAY BALANCED DURING SUCH A LONG, DETAILED PROCESS? Well some would say that I don’t stay balanced! [Laughs] But I do yoga; actually we have people come in and lead a lunch time yoga session two times a week. And I sort of make it a point to develop my abilities, to zoom in to minutia and zoom back out. I think that’s where people can get lost making a film like this. Minutia can be overwhelming and you think you’re making a movie but really all you’re doing is paying attention to detail. I was pretty strict about trying to step back, showing things to trusted friends pretty regularly to get feedback. You know, find some balance there.

SO IS _CORALINE_ THE FIRST 3D STOP-MOTION FILM? It’s the first one shot that way. They actually did a post-production process about two years ago on _The Nightmare Before Christmas_ which was pretty effective. That wasn’t shot in 3D but they did this treatment that's not as immersive as what we did. _Coraline_'s the first stop-motion shot in 3D.

WHY HAS THERE BEEN SO LITTLE DEVELOPMENT IN MAKING A 3D STOP-MOTION, WHEN THEY’VE MADE ALL THESE OTHER ADVANCES WITH DIGITAL TECHNOLOGY. Basically CG [computer generated animation] came along and derailed 2D and stop-motion pretty much for feature films until more recently. You know, _Toy Story_ came along and was astonishing; the technology and the story was shiny and new. Stop-motion, like hand-drawn animation, is old tech; it’s not sexy. But after this many years of CG it seems the audience likes a variety of things on their menu.

WHEN YOU WERE TRYING TO GET THIS PROJECT OFF THE GROUND, DID YOU HAVE TO OVERCOME ANY PRESSURE TO DO IT JUST AS A CG FILM? We went through many iterations. In fact, when the deal was first set up it wasn’t allowed to be animation, it was planned as a live action. But all along I was sort of writing it as an animated film. It’s had a long life to get to where it is but it got to the best possible place: stop-motion shot in 3D.

I ALSO FEEL REALLY STRONGLY ABOUT PUPPETRY AND STOP MOTION ANIMATION AND EVEN HAND-DRAWN ANIMATION OVER CG. _STAR WARS_ WASN’T STOP-MOTION, BUT I PREFER THE PUPPETRY IN THE ORIGINAL FILMS OVER THE PREQUELS, WHICH GEORGE LUCAS MADE WITH CGI. I like the old Yoda better than the one that can flip and do moves in the air when he’s fighting. I don’t know; I like animated things, I like the sense of an artist’s hand actually on screen in the painting. For me it’s a much more pleasurable way to make a film. I’ve done one CG short and I worked with very talented people, but with stop motion you’ve got stages, lights; you’re performing through puppets. And that world of cutting things out of wood and molding things in plastic and machining things in metal... I’m just very attracted to that.

And when you see it on the screen, it’s imperfect, it’s always going to be less than perfect. I don’t think perfection and smoothness is very important. It certainly seems that once we get to that point in CG, then everything will be fine. It’s like when they invented the morph. I forget which film it was, but I think it was ILM wanting something to transform to something else in live action. In one year they were using it to update car models and ads and it was commonplace.

I think there’s a timeless quality and an inherent charm [to stop-motion]. You know these things are real, you don’t know how big they are or how they are being moved. But they are real things. And you have to work a little; you have to participate in making the magic happen. Not very much; we’re not trying to make it very difficult but you’re not just sitting back and having it poured over your head like warm honey. You have to use your imagination just a little bit more when it’s hand-drawn and puppet animation or practical effects.

WHAT ADVANCES DOES _CORALINE_ MAKE, EVEN IN TERMS OF ADVANCES FROM YOUR PREVIOUS STOP-MOTION FILMS? Some of it was simply paying even more attention to detail. I wanted to go in for close-ups where you’d still believe in the character, so that required very meticulous work in the hair and the finish on the faces and on the costumes. We have miniature sweaters and clothes.

I UNDERSTAND THIS WAS THE FIRST STOP-MOTION FILM THAT USES SOMETHING LIKE ACTUAL HAIR, INSTEAD OF SOMETHING THAT WAS PAINTED ON OR ATTACHED. Yeah, I mean we’ve used things in the past that were more like hair but this was a more refined technique, with a wig maker that works in miniature. And of course the hair has to animate, so you have to hide little bits of wire in it, or a little flat foil underneath strands. We also shot digitally and in 3D and were able to take shots that you could watch them right away. They could be sent to the edit room almost immediately. There was more of a give and take and back and forth in the making of the film, whereas not too long ago you’d shoot the shot and it would go to the lab, and you’d have to wait for everybody's dailies.

Now, we did use CG to help plan the mice circus, to help create some of the in-between forms, and to help create some of the in-between face forms for Coraline. We used the stuff where we could, but in the end you’re still moving the puppets under real light on real set.

WHAT WERE THE BIGGEST CHALLENGES YOU FACED DURING PRODUCTION? [SPOILER ALERT] Everything is challenging, but what we love to do is solve problems. The final battle with the Other Mother was very challenging; when Coraline faces the Other Mother in her final form, where she’s like a spider lady and the floorboards of the living room fly up and this huge spiral web is revealed that drops down to a void. That was very challenging; that web fully extended was 20 feet long, we had to do five different versions of it. We had to find a way to suspend it, lay it, have it move so it had a sense of weight and springiness to it and then have the animators be able to move the chargers on it as Coraline tries to escape the Other Mother. That was very, very challenging.

The fantastic garden, the garden is grown into a portrait of Coraline, that was a challenge to not make it look trite; we used CG in a couple of blue flowers to help them grow, they are composites. But most of those flowers and plants are _actually transforming_. One of our rigors, Olly, did experiments to find ways to get that using toys, like a dog toy.

YEAH, I SAW THAT ON THE WEB SITE. HOW MANY FLOWERS WOULD YOU SAY THERE ARE IN THAT SHOT? There are probably fifteen different types that are transforming, changing shape. And then a total of 350 special ones that are shape changers, and 500 just background.

I KEEP THINKING ABOUT THAT SCENE WHEN SHE GOES UP IN THAT WEIRD PRAYING MANTIS HELICOPTER; THAT OVERHEARD SHOT REALLY STUCK WITH ME. AMAZING. WHEN YOU WATCH THAT ARE YOU SATISFIED OR DO YOU HAVE THE KIND OF PERSONALITY WHERE YOU NOTICE DETAILS THAT YOU WISH YOU COULD CHANGE? With that particular scene, I’m very satisfied. It was very difficult; it was one of those things we kept putting off. We didn’t know how to do it but eventually it worked out. In watching the film now there are plenty of moments where I’m not exactly satisfied. It’ll probably take about five years before all that fades away.

YOU HAD A GREAT CAST WITH IAN MCSHANE, JOHN HODGMAN AND A BUNCH OF TALENTED PEOPLE. DID YOU PERSONALLY WORK MUCH WITH THE ACTORS? I directed all the voice recordings, that’s the normal task of a director in an animated film.

SO WHAT WAS THAT PROCESS LIKE? It’s fun but it’s challenging. It’s a fluid thing, you can’t ever figure out all your lines in the beginning, you record some version of everything and then you go back. The film changes and you have to go back, in Dakota’s case, seven times, in Terry Hatcher’s case, five times over the course of a couple years. You have to help them refocus, get back into character. You show them some new footage and it’s one of those very draining experiences because you’re helping them believe; they don’t have costumes, they don’t have other actors to work off of, they’re not on a set. It’s very challenging work for them. A lot of them who have never done it before are kind of astonished; they can’t phone it in. But it’s fun, you’d be surprised which actors can actually improvise.

WAS IT FUN WORKING WITH JOHN HODGMAN? He was great. He’s a very good writer himself and he came up with a few variations. I mean I’d get stuff I couldn’t use in the film because he went on too long but he was very, very funny.

I’M A HUGE THEY MIGHT BE GIANTS FAN AND I WAS SURPRISED AND DELIGHTED TO HEAR THEM IN THE MOVIE. HOW DID THEY BECOME INVOLVED IN THE PROJECT? Just happenstance. Someone I worked with, Courtney Booker, who did a little of the early color work on _Coraline_, did a rock video for them, for the song "Bastard Wants to Hit Me." And so I told her I was a big fan and we managed to get together. They actually did some other demo songs that are brilliant, they are beautiful, but the film just kind of changed; it wasn’t going to become a musical. I was very happy to work with them and I'd love to work with them on another show where they have like ten songs in it. I’m wondering whether to convince them to write all new songs for their, like, _Yellow Submarine_, or to just work with them and pick the ten best songs and see if I can find a way to string them together for a story.

THAT WOULD BE AWESOME. WHAT ABOUT YOUR CHILDREN? I’M WONDERING IF THEY’VE SEEN THE FILM. Yeah my oldest song has grown up fast; he’s 17 and the younger one is ten. They’ve been involved; I’ve shown them stuff for years as it's developed and the younger one actually does the voice of the ghost child. And the older one does the voice of one of the friends in the photos who speak to Coraline.

SO THEY’VE SEEN THE FINISHED PRODUCT? Yeah, they’ve seen it and I’d regularly bring stuff home and show them character designs and voices. They carry more weight than I would ever let them know.

IS THERE ONE PARTICULAR WAY THAT THEY’VE INFLUENCED YOU THAT YOU CAN RECALL? I think pushing me to be bolder actually, pushing me to be scarier, even when George was, in the beginning, six years old. The main way they pushed is that I wanted to make sure there was stuff for boys in the movie. It’s called _Coraline_ and there’s that tradition wherein Hollywood thinks boys won’t go to a girls film. But after _Twilight_ and _Juno_ I think things have changed.

WHAT’S THE GENERAL REACTION YOU’VE GOTTEN FROM KIDS SO FAR? I’M TECHNICALLY A GROWN-UP AND I CAN’T WAIT TO SEE IT AGAIN, SO IT OBVIOUSLY WORKS ON MANY LEVELS. BUT I’M WONDERING HOW KIDS REACT. We think it’s for brave children of all ages. Under eight, you have to know your kid; it could be intense for someone who’s so little. But so far, so good. I’m especially pleased that the boys have liked it as much as the girls.

AND WHAT WAS NEIL GAIMAN’S REACTION WHEN HE FINALLY SAW THE FINISHED PRODUCT? I personally flew out there two weeks ago to present it to him and his friends and family—some people very protective of _Coraline_—and everyone was very happy. As far as I could tell, Neil was pleased with the finished product.

NYC NEWS NEVER SLEEPS. GET THE GOTHAMIST DAILY NEWSLETTER AND DON'T MISS A MOMENT.

question: Summarize some of the challenges to making Coraline.

answer: Henry Selick, the director of the movie, confessed to going through different iterations of Coraline before settling for animation as a medium. There was also lots of planning and thinking about how the animation should be until he settled for puppetry and stop animation. The crew had difficulty animating the final battle between Coraline and the Other Mother. Also, the garden that was grown into a portrait of Coraline was a challenge as it combines CG and puppetry with some of the flowers numbering up to 500. Because of changes in the script over the years, Selick had to invite some of the actors back to redo some of the voiceovers for the movie.

question: What made Henry Selick choose Coraline as a movie he wants to make?


text:
1.  Research
2.  Risks of ischaemic...
3.  Risks of ischaemic heart disease and stroke in meat eaters, fish eaters, and vegetarians over 18 years of follow-up: results from the prospective EPIC-Oxford study

Research BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4897 (Published 04 September 2019) Cite this as: BMJ 2019;366:l4897

Linked editorial

Vegetarian diets and health

1.

    Tammy Y N Tong, nutritional epidemiologist1,
2.

    Paul N Appleby, senior statistician1,
3.

    Kathryn E Bradbury, nutritional epidemiologist1,
4.

    Aurora Perez-Cornago, nutritional epidemiologist1,
5.

    Ruth C Travis, associate professor1,
6.

    Robert Clarke, professor of epidemiology and public health medicine2,
7.

    Timothy J Key, deputy director1

1.
    ¹Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Oxford OX3 7LF, UK
2.
    ²Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK

1.

    Correspondence to: T Y N Tong tammy.tong{at}ndph.ox.ac.uk (or @tammy_tong on Twitter)

-   Accepted 10 July 2019

Abstract

OBJECTIVE To examine the associations of vegetarianism with risks of ischaemic heart disease and stroke.

DESIGN Prospective cohort study.

SETTING The EPIC-Oxford study, a cohort in the United Kingdom with a large proportion of non-meat eaters, recruited across the country between 1993 and 2001.

PARTICIPANTS 48 188 participants with no history of ischaemic heart disease, stroke, or angina (or cardiovascular disease) were classified into three distinct diet groups: meat eaters (participants who consumed meat, regardless of whether they consumed fish, dairy, or eggs; n=24 428), fish eaters (consumed fish but no meat; n=7506), and vegetarians including vegans (n=16 254), based on dietary information collected at baseline, and subsequently around 2010 (n=28 364).

MAIN OUTCOME MEASURES Incident cases of ischaemic heart disease and stroke (including ischaemic and haemorrhagic types) identified through record linkage until 2016.

RESULTS Over 18.1 years of follow-up, 2820 cases of ischaemic heart disease and 1072 cases of total stroke (519 ischaemic stroke and 300 haemorrhagic stroke) were recorded. After adjusting for sociodemographic and lifestyle confounders, fish eaters and vegetarians had 13% (hazard ratio 0.87, 95% confidence interval 0.77 to 0.99) and 22% (0.78, 0.70 to 0.87) lower rates of ischaemic heart disease than meat eaters, respectively (P<0.001 for heterogeneity). This difference was equivalent to 10 fewer cases of ischaemic heart disease (95% confidence interval 6.7 to 13.1 fewer) in vegetarians than in meat eaters per 1000 population over 10 years. The associations for ischaemic heart disease were partly attenuated after adjustment for self reported high blood cholesterol, high blood pressure, diabetes, and body mass index (hazard ratio 0.90, 95% confidence interval 0.81 to 1.00 in vegetarians with all adjustments). By contrast, vegetarians had 20% higher rates of total stroke (hazard ratio 1.20, 95% confidence interval 1.02 to 1.40) than meat eaters, equivalent to three more cases of total stroke (95% confidence interval 0.8 to 5.4 more) per 1000 population over 10 years, mostly due to a higher rate of haemorrhagic stroke. The associations for stroke did not attenuate after further adjustment of disease risk factors.

CONCLUSIONS In this prospective cohort in the UK, fish eaters and vegetarians had lower rates of ischaemic heart disease than meat eaters, although vegetarians had higher rates of haemorrhagic and total stroke.

Introduction

Vegetarian and vegan diets have become increasingly popular in recent years, partly due to perceived health benefits, as well as concerns about the environment and animal welfare.1 In the United Kingdom, both the representative National Diet and Nutrition Survey 2008-12 and a 2016 Ipsos MORI survey estimated about 1.7 million vegetarians and vegans living in the country.23 Evidence suggests that vegetarians might have different disease risks compared with non-vegetarians,4 but data from large scale prospective studies are limited, because few studies have recruited sufficient numbers of vegetarian participants.

For ischaemic heart disease, some but not all previous studies reported significantly lower risks of mortality from ischaemic heart disease in vegetarians than in non-vegetarians.567 In terms of incidence, the only previous study (the European Prospective Investigation into Cancer (EPIC)-Oxford) reported that vegetarians had a lower risk of ischaemic heart disease than non-vegetarians,8 but at the time of publication the study had an insufficient duration of follow-up to separately examine the risks in other diet groups (fish eaters and vegans).

For stroke, two previous reports,56 including one that included EPIC-Oxford data,6 found no significant differences in risk of total stroke deaths between vegetarians and non-vegetarians. However, no previous studies have examined the incidence of stroke in relation to vegetarian diets, or have examined the main stroke types.

We report here the risks of both incident ischaemic heart disease and stroke in people with distinct dietary habits—that is, meat eaters, fish eaters and vegetarians (including vegans)—with a separate evaluation of ischaemic and haemorrhagic strokes, over 18 years of follow-up in the EPIC-Oxford study.

Methods

Study population and design

EPIC-Oxford is a prospective cohort study of about 65 000 men and women who were recruited across the UK between 1993 and 2001. Details of the recruitment process have been described previously.9 Individuals were recruited from either general practices or by postal questionnaire. The general practice recruitment method recruited 7421 men and women aged 35 to 59 who were registered with participating general practices, all of whom completed a full questionnaire on their diet, lifestyle, health characteristics, and medical history. The postal recruitment preferentially targeted vegetarians, vegans, and other people interested in diet and health, and recruited 57 990 participants aged 20 or older. A full questionnaire was mailed to all members of the Vegetarian Society and all surviving participants of the Oxford Vegetarian Study,10 and respondents were invited to provide names and addresses of relatives and friends who were also interested in receiving a questionnaire. A short questionnaire was also distributed to all members of the Vegan Society, enclosed in vegetarian and health food magazines, and displayed in health food shops; and a full questionnaire was subsequently mailed to all those who returned the short questionnaire.

Despite the targeted recruitment of the postal method, about 80% of meat eaters in the cohort were recruited by post. Subsequently, a follow-up questionnaire was sent to participants in 2010, which asked similar questions on their diet and lifestyle, and participants returned the questionnaires between 2010 and 2013. A participant flowchart of the recruitment process and inclusion into this study is shown as supplementary figure 1. The study protocol was approved by a multicentre research ethics committee (Scotland A Research Ethics Committee) and all participants provided written informed consent.

Assessment of diet group and diet

The full baseline questionnaire collected responses to four questions about consumption of meat, fish, dairy products, and eggs, in the form of “Do you eat any meat (including bacon, ham, poultry, game, meat pies, sausages)?” or similar for the other three food groups. These four questions were used to classify participants into meat eaters (participants who reported eating meat, regardless of whether they ate fish, dairy, or eggs), fish eaters (participants who did not eat meat but did eat fish), vegetarians (participants who did not eat meat or fish, but did eat one or both of dairy products and eggs), and vegans (participants who did not eat meat, fish, dairy products, or eggs). The follow-up questionnaire sent in 2010 included identical questions on consumption of meat, fish, dairy products, and eggs (yes/no). Therefore, at both baseline and follow-up, participants were classified into one of four diet groups: meat eaters, fish eaters, vegetarians, and vegans. Owing to the small number of vegans, vegetarians and vegans were combined as one diet group in the main analyses, but the two groups were examined separately for each outcome in secondary analyses.

The baseline questionnaire also included a semiquantitative food frequency section containing 130 items, which asked about dietary intake over the past year, and which was previously validated using 16 days (in four sets of four days) of weighed dietary records and selected recovery and concentration biomarkers.111213 For calculation of food and nutrient intakes, the frequency of consumption of each food or beverage was multiplied by a standard portion size (mostly based on data from the UK Ministry of Agriculture, Fisheries, and Food)14 and nutrient content of each food or beverage (based on McCance and Widdowson’s food composition tables).15 Because our prespecified analysis plan was to examine disease risks associated with distinct dietary groups, the associations of individual foods and nutrients with risks were not assessed in this study, but information on intakes of foods and nutrients were used in descriptive and secondary analyses.

Assessment of other characteristics

In addition to diet, the baseline questionnaire also asked questions on sociodemographic characteristics, lifestyle, and medical history, including questions on education level, smoking, physical activity, use of dietary supplements, and use of oral contraceptives or hormone replacement therapy in women. Socioeconomic status was categorised by use of the Townsend deprivation index,16 based on the participants’ postcodes. For physical activity, based on their responses to questions asked about their occupation and their time spent participating in activities including walking, cycling, and other physical exercises, participants were categorised by a validated physical activity index with four levels.17 Alcohol consumption was determined from responses to five items on the food frequency questionnaire. Questions relating to smoking and alcohol consumption were also asked on the follow-up questionnaire in 2010.

For biological measurements, body mass index was calculated from participants’ self reported height and weight at recruitment, which was previously found to be accurate compared with measured height and weight in a validation study of about 4800 participants.18 All participants were also asked at recruitment whether they were willing to have their blood pressure measured at their general practice and to provide a blood sample. Details of the procedures for blood pressure measurement and blood sample collection, which were conducted in subsets of the cohort, have been previously reported.81920

Outcome ascertainment

Participants were followed up via record linkage to records from the UK’s health service up to 31 March 2016. Outcomes of interest were ischaemic heart disease (codes 410-414 from ICD-9 (international classification of diseases, 9th revision) or codes I20-I25 from ICD-10), including acute myocardial infarction (ICD-9 410 or ICD-10 I21); and total stroke (ICD-9 430-431, 433-434, 436; or ICD-10 I60-I61, I63-I64), including ischaemic stroke (ICD-9 433-434 or ICD-10 I63) and haemorrhagic stroke (ICD-9 430-431 or ICD-10 I60-I61). Details of events, using the relevant ICD-9 or ICD-10 codes, were obtained from hospital records or death certificates.

Exclusion criteria

Participants who were not resident in England, Wales, or Scotland (n=945) were excluded, as were those with no Hospital Episode Statistics data or NHS number (n=20). We also excluded participants who completed the short questionnaire only (n=7619); were younger than 20 (n=1) or older than 90 at recruitment (n=58); had no follow-up (were censored at or before the date of recruitment (eg, if they were living abroad), n=364); could not be traced by the NHS (n=14); had an unknown diet group (if they did not answer the relevant questions to be classified, n=132); had unreliable nutrient data (≥20% of food frequencies missing, or daily energy intakes <500 kcal or >3500 kcal for women or <800 kcal or >4000 kcal for men (1 kcal=4.18 kJ=0.00418 MJ), n=1219); had a self reported history of acute myocardial infarction, stroke, or angina at recruitment (n=6837); or had a date of diagnosis that preceded or equalled the date of recruitment (n=14).

Statistical analyses

Baseline characteristics and food and nutrient intakes of the EPIC-Oxford participants were summarised by diet group. For self reported body mass index, and measures of blood pressure (systolic and diastolic blood pressure) and blood lipids (total cholesterol, high density lipoprotein cholesterol (HDL-C), non-HDL-C), the means and 95% confidence intervals are presented, after adjustment for sex and age at entry (in 5-year age groups), alcohol consumption (<1, 1-7, 8-15, ≥16 g/day), and physical activity (inactive, low activity, moderately active, very active, unknown).17

Cox proportional hazards regression models were used to estimate the hazard ratios and 95% confidence intervals for the associations between diet group (meat eaters, fish eaters, vegetarians including vegans) and each outcome of interest, with meat eaters as the reference group. For participants who completed both the baseline and follow-up questionnaire, diet group and relevant time varying covariates (smoking and alcohol consumption) were updated at follow-up. The underlying time variable was the age at recruitment to the age at diagnosis, death, or administrative censoring, whichever occurred first. For acute myocardial infarction or ischaemic heart disease, events were censored on the respective outcomes of interest. For total stroke, ischaemic stroke, and haemorrhagic stroke, events were censored on any stroke. All analyses were stratified by sex, method of recruitment (general practice or postal), and region (seven regions across the UK), and adjusted for year of recruitment (per year from 1994 to 1999), education (no qualifications, basic secondary (eg, O level), higher secondary (eg, A level), degree, unknown), Townsend deprivation index (quarters, unknown),16 smoking (never, former, light, heavy, unknown), alcohol consumption (<1, 1-7, 8-15, ≥16 g/day), physical activity (inactive, low activity, moderately active, very active, unknown), dietary supplement use (no, yes, unknown), and oral contraceptive use (no, yes ever, unknown) and hormone replacement therapy use (no, yes ever, unknown) in women.

We used Wald tests to test for heterogeneity of risk between diet groups. The proportional hazards assumption was assessed on the basis of Schoenfeld residuals, and was not violated for the variables of interest in the adjusted model for either ischaemic heart disease or stroke (P>0.05 for all categories). Self reported history of high blood pressure (no, yes, unknown), high blood cholesterol (no, yes, unknown), diabetes (no, yes, unknown), and body mass index (<20, 20-22.5, 22.5-25, 25-27.5, ≥27.5, unknown) were assessed as potential physiological mediators, since these factors were known to be associated with vegetarian diets,1920212223 as well as being established cardiovascular risk factors.24 Total fruit and vegetable intake, total dietary fibre, and total energy intake (each continuous) were assessed as possible relevant dietary factors. We assessed the effects of potential physiological mediators and possible relevant dietary factors by adding each variable one at a time to the previous model. An additional model was also fitted including all potential physiological mediators.

To estimate the population impact of vegetarian diets on cardiovascular health, we assessed the absolute risk difference for each outcome between meat eaters, fish eaters, and vegetarians. Predicted incidence and absolute risk differences were presented as per 1000 population over 10 years, and were estimated by use of hazard ratios and 95% confidence intervals expressed as floating absolute risks,2526 which do not alter the value of the hazard ratios but assign an appropriate 95% confidence interval to all groups, including the reference group (thereby allowing an estimation of the uncertainty in the effect size in the reference group). In meat eaters, predicted incidence over this time period of each outcome was calculated as (1−Sr)×1000, where Sr=(1−observed incidence in meat eaters)¹⁰, and represents the predicted 10 year survival (that is, non-incidence) in meat eaters. By subtracting this estimate of survival from 1, and multiplying by 1000, the resulting estimate represents incidence per 1000 population over 10 years. For all other diet groups, predicted incidence was calculated as (1−SrHR)×1000, where HR represents the hazard ratio or confidence intervals for each outcome in that diet group. By applying HR or confidence interval estimates in each diet group as an exponential to survival in the reference group, SrHR represents the predicted 10 year survival rate in the each of the other diet groups. Absolute risk differences were then calculated as the crude differences between the predicted incidence per 1000 population over 10 years between each diet group and the meat eaters.

Additional sensitivity analyses included analyses using baseline diet group only, excluding participants with less than five years of follow-up, including participants recruited via the postal method only, censoring at age 70 or setting entry time at age 70 to evaluate possible differences by age at event, and performing multiple imputation (with 10 imputations) for missing covariates. The percentages of missing values in the covariates were 12.7% for the Townsend deprivation index, 10.9% for physical activity, 6.3% for education level, and less than 2% for each of the other covariates. We assessed heterogeneity in the associations between diet group and risk of ischaemic heart disease or stroke by sex, age at recruitment (<60 or ≥60 years), smoking status (never, former, or current), body mass index (<25 or ≥25), presence of risk factors (one or more of self reported history of high blood pressure, high blood cholesterol, or diabetes), and any long term treatment for any illness or condition (no, yes) by adding appropriate interaction terms to the Cox models and testing for statistical significance of interaction across strata using likelihood ratio tests. All analyses were performed with Stata version 14.1 or 15.1 (Stata Corp, TX, United States) and P values less than 0.05 were considered significant.

Patient and public involvement

No members of the community or patients were involved in setting the research question or the outcome measures, nor were they involved in developing plans for recruitment, design, or implementation of the study. They were not asked to advise on interpretation or writing up of results. We are appreciative of our participants who, although not partners, were engaged in the progress of EPIC-Oxford through follow-up questionnaires. The results are disseminated to study participants through newsletters and the study website (www.epic-oxford.org/).

Results

Cohort characteristics

The analyses included 48 188 participants, of whom 28 364 had reported on diet both at baseline and at follow-up on average 14 years later. Of these participants with repeated measures of diet, 13 972 (96%) of 14 540 meat eaters at baseline remained meat eaters at follow-up. Of fish eaters and vegetarians at baseline, 2608 (57%) of 4555 and 6746 (73%) of 9269 were in the same diet group at follow-up, respectively.

Cohort characteristics of the study participants for each of the three diet groups (meat eaters, fish eaters, vegetarians including vegans) at baseline are presented in table 1 (and separately for vegetarians and vegans in supplementary table 1). Overall, non-meat eaters were younger and had a lower area level socioeconomic status than meat eaters, but were more highly educated, less likely to smoke, reported slightly lower alcohol consumption, were more physically active, and were more likely to report dietary supplement use. They were also less likely to report previous high blood pressure, high blood cholesterol, or diabetes; or receive long term treatment for illnesses. In women, non-meat eaters were more likely to report oral contraceptive use but less likely to report use of hormone replacement therapy. Non-meat eaters reported having lower body mass index and had lower measured blood pressure than meat eaters. For blood lipids, vegetarians had about 0.5 mmol/L lower plasma concentrations of total cholesterol and non-HDL-C than meat eaters. Fish eaters had slightly higher plasma concentrations of HDL-C than meat eaters, while vegetarians had slightly lower concentrations.

Table 1

Baseline characteristics of participants in different diet groups in the EPIC-Oxford study(n=48 188)

Food and nutrient intakes in the different diet groups are presented in table 2 and supplementary table 2 (separately for vegetarians and vegans). Intakes of most foods and nutrients differed between the dietary groups: for example, vegetarians had higher intakes of fruit and vegetables, legumes and soya foods, nuts, and dietary fibre, and had a lower intake of saturated fat (10% _v_ 12% energy) and sodium than meat eaters.

Table 2

Food and nutrient intakes of participants in different diet groups in the EPIC-Oxford study (n=48 188)

Association of diet groups with cardiovascular diseases

Over 18.1 years of follow-up in 48 188 participants, 2820 cases of ischaemic heart disease (including 788 cases of acute myocardial infarction) and 1072 cases of total stroke (including 519 cases of ischaemic stroke and 300 cases of haemorrhagic stroke) were reported. Fish eaters (hazard ratio 0.87, 95% confidence interval 0.77 to 0.99) and vegetarians (0.78, 0.70 to 0.87) had lower rates of ischaemic heart disease than meat eaters (Pheterogeneity<0.001 between all diet groups; fig 1). Conversely, vegetarians, but not fish eaters, had significantly higher rates of haemorrhagic stroke than meat eaters (1.43, 1.08 to 1.90; Pheterogeneity=0.04) and higher rates of total stroke (1.20, 1.02 to 1.40; Pheterogeneity=0.06). We saw no significant differences between diet groups for the risk of acute myocardial infarction or ischaemic stroke. When we assessed vegetarians and vegans separately, the point estimates for vegans were lower for ischaemic heart disease (0.82, 0.64 to 1.05) and higher for total stroke (1.35, 0.95 to 1.92) than meat eaters, but neither estimate was statistically significant, possibly because of the small number of cases in vegans, as indicated by the wide confidence intervals (supplementary table 3).

[Fig 1]

Fig 1

Rates of ischaemic heart disease and stroke in fish eaters and vegetarians (including vegans) compared with meat eaters in the EPIC-Oxford study (n=48 188). Meat eaters were participants who reported eating meat, regardless of whether they ate fish, dairy, or eggs; fish eaters were participants who did not eat meat but did eat fish; and vegetarians included vegans. Meat eaters were used as the reference group throughout. All analyses included age as the underlying time variable; were stratified by sex, method of recruitment (general practice or postal), and region (seven categories); and were adjusted for year of recruitment (per year), education (no qualifications, basic secondary (eg, O level), higher secondary (eg, A level), degree, unknown), Townsend deprivation index (quarters, unknown), smoking (never, former, light, heavy, unknown), alcohol consumption (<1, 1-7, 8-15, ≥16 g/day), physical activity (inactive, low activity, moderately active, very active, unknown), dietary supplement use (no, yes, unknown), and oral contraceptive and hormone replacement therapy use in women. P heterogeneity=significance of heterogeneity in risk between diet groups based on Wald tests. Box sizes are proportional to the number of cases in each group

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When the roles of potential mediators of the associations were assessed, the associations between diet group and ischaemic heart disease were marginally attenuated when adjusted for self reported history of high blood pressure, high blood cholesterol, and diabetes, and for self reported body mass index. The lower rate of ischaemic heart disease in vegetarians was of borderline significance when adjusted for all potential mediators simultaneously (0.90, 0.81 to 1.00; supplementary table 4). For stroke, adjustments for potential mediators caused small changes in the hazard ratios; the association became slightly stronger for vegetarians after adjustment for self reported history of high blood pressure, and to a lesser extent when adjusted for history of diabetes or for body mass index. Additional adjustment for fruit and vegetable intake, total fibre, or total energy had little effect on the results.

Absolute risk difference for vascular disease outcomes by diet group

Table 3 shows the absolute risks of ischaemic heart disease and total stroke in the three diet groups. By comparing the absolute risk difference of each outcome by diet group, for an individual of the cohort’s average age (44.7 years) and other characteristics (supplementary table 1), and not accounting for competing risk from other diseases or influences from other external factors, vegetarian diets were associated with 10 fewer (95% confidence interval 6.7 to 13.1 fewer) cases of ischaemic heart disease per 1000 population over 10 years than meat eaters. Conversely, vegetarian diets were associated with three more (95% confidence interval 0.8 to 5.4) cases of total stroke.

Table 3

Absolute risk difference (per 1000 population over 10 years) of ischaemic heart disease and stroke in different diet groups in the EPIC-Oxford study

Sensitivity and subgroup analyses

In sensitivity analyses using baseline diet group only, excluding participants with less than five years of follow-up, including participants recruited via the postal method only, and performing multiple imputations for missing covariates, the results were similar (supplementary table 5). When the analyses were censored at age 70 or limited to those above age 70 (setting entry time at age 70) respectively, a significantly higher rate of haemorrhagic stroke was observed in vegetarians who had an event above the age of 70, but not in those who had an event before age 70 or were censored at that age. In subgroup analyses, significantly lower rates of ischaemic heart disease were observed among fish eaters only in those aged less than 60 years at recruitment, but lower rates were observed in vegetarians in both age groups (supplementary table 6). No other significant interactions by subgroups were observed for the association between diet group and ischaemic heart disease or stroke (supplementary tables 6-7).

Discussion

The present study examines the risks of both ischaemic heart disease and stroke, including subtypes, in meat eaters, fish eaters, vegetarians, and vegans in a cohort with a large proportion of non-meat eaters. We observed lower rates of ischaemic heart disease in fish eaters and vegetarians than in meat eaters, which appears to be at least partly due to lower body mass index and lower rates of high blood pressure, high blood cholesterol, diabetes associated with these diets. Conversely, vegetarians had higher risks of haemorrhagic and total stroke.

Comparison with other studies

In a collaborative meta-analysis of five previous prospective studies (Adventist Mortality Study, Health Food Shoppers Study, Adventist Health Study, Heidelberg Study, Oxford Vegetarian Study) with median recruitment between 1960 and 1980, vegetarians had a 24% lower rate ratio of death from ischaemic heart disease (0.76, 95% confidence interval 0.62 to 0.94) than non-vegetarians.5 In other analyses of death from ischaemic heart disease, the death rate ratios comparing vegetarians with non-vegetarians were 0.99 (0.79 to 1.23) in a combined analysis of EPIC-Oxford and the Oxford Vegetarian Study,6 0.70 (0.41 to 1.18) in the German Vegetarian Study,27 and 0.81 (0.64 to 1.02) in the Adventist Health Study 2.7 In a recent meta-analysis that pooled the estimates from these previous prospective studies, including a previous report from the EPIC-Oxford study that only compared vegetarians with non-vegetarians (meat and fish eaters combined),8 the risk ratio for ischaemic heart disease comparing vegetarians with non-vegetarians was 0.75 (0.68 to 0.82).28

For stroke, previous analyses, including one study that included EPIC-Oxford data but with fewer cases than the present study,6 reported no significant differences in stroke mortality by diet group,56 and pooled analyses showed a similar result.28 However, previous studies only reported on stroke mortality,56 which might be strongly influenced by treatment as well as the underlying disease risk,28 and no studies were found which reported on the two subtypes of stroke.

Interpretation of results and implications

The results of the present study showed that fish eaters and vegetarians had lower risks of ischaemic heart disease than meat eaters. The associations were attenuated after adjustment for self reported high blood pressure, high blood cholesterol, diabetes, and body mass index, which suggests that part of the associations might be attributed to these factors. However, the lower risk in vegetarians and vegans remained marginally significant after adjustment for all of these factors. The reason for such differences is not certain, but could be partly attributed to lower concentrations of low density lipoprotein cholesterol (LDL-C; or non-HDL-C concentrations as a surrogate) associated with meat-free diets,293031 differences that were not fully accounted for by adjusting for self reported high blood cholesterol. Previous meta-analyses of prospective studies showed that lower concentrations of non-HDL-C or LDL-C were associated with lower risks of ischaemic heart disease.2632 Furthermore, both randomised trials of statin treatments33 and mendelian randomisation studies30 have confirmed a causal association of LDL-C with ischaemic heart disease. Hence, fish eaters and vegetarians, who have lower non-HDL-C (table 1) or LDL-C than meat eaters,1934 could have lower risks of ischaemic heart disease. However, the possible beneficial roles of generally healthier diets that included high intakes of fruit and vegetables,35 legumes,36 or fibre37 cannot be excluded, despite little change in the hazard ratios after adjustment for these individual components.

For stroke outcomes, the combined results from two randomised statin trials reported 21% higher risks of haemorrhagic stroke per 1 mmol/L reduction in LDL-C,2938 which are consistent with results of observational studies of cholesterol concentrations and haemorrhagic stroke.394041 A recent study that included observational and genetic evidence from China alongside the trial evidence from western countries has suggested this inverse association between LDL-C and haemorrhagic stroke might be causal.42 These previous studies corroborate the findings of the present study, indicating that vegetarians, who have relatively low LDL-C, had higher risks of haemorrhagic stroke. For ischaemic stroke, previous prospective studies and randomised trials have consistently shown weak positive associations of non-HDL-C or LDL-C levels with risk,26323338 which is supported by recent mendelian randomisation studies.3142 This apparent discordance between previous evidence and those of the present study for LDL-C levels and ischaemic stroke suggests that other dietary factors associated with the lack of animal food consumption could contribute to the observed associations.

Results of several studies in Japan, showing that individuals with a very low intake of animal products had an increased incidence and mortality from haemorrhagic and total stroke, and also a possibly higher risk of ischaemic stroke mortality,43444546 suggest that some factors associated with animal food consumption might be protective for stroke. Vegetarians and vegans in the EPIC-Oxford cohort have lower circulating levels of several nutrients (eg, vitamin B₁₂,47 vitamin D,48 essential amino acids,49 and long chain n-3 polyunsaturated fatty acids50), and differences in some of these nutritional factors could contribute to the observed associations.4551525354 Serum concentrations of these nutritional factors and non-HDL-C have only been measured in a subset of the EPIC-Oxford cohort, and therefore their role in the observed associations of vegetarian diets with ischaemic heart disease or stroke cannot be accurately determined in the current context, but should be further investigated.

High blood pressure is an established major risk factor for both ischaemic heart disease and stroke,2455 and recent evidence confirmed this is true for all age groups, especially for haemorrhagic stroke.56 However, given that the vegetarians in the EPIC-Oxford study had lower blood pressure than the meat eaters, and the fact that the association between diet group and stroke risk became slightly stronger after adjustment for history of high blood pressure, this factor is unlikely to account for the higher risks of haemorrhagic and total stroke observed among vegetarians in the present study. Furthermore, although differential treatment of cardiovascular risk factors including hypertension in the different diet groups could influence their subsequent disease risk, this does not appear to be the case in the EPIC-Oxford study; previous analyses in this cohort have shown that although vegetarians had lower use of drug treatment overall than non-vegetarians, no significant differences were seen in the use of specific treatments for high blood pressure, high blood cholesterol, or diabetes by diet group, among those individuals who reported a diagnosis of these conditions.57

Misclassification of stroke cases, such as the misclassification of haemorrhagic stroke as ischaemic stroke, cannot be excluded as a possible explanation for the possibly discrepant results for ischaemic stroke, although previous adjudication studies of stroke types confirmed the reliability of hospital admission records and death certificates in the UK for diagnosis of stroke types in the UK population over this calendar period.5859 Although age is also an important risk factor for both ischaemic heart disease and stroke, and meat eaters in the present study were on average 10 years older than the vegetarians, age is known accurately in our cohort, and therefore any potential confounding or cohort effect is accounted for by the analyses that use age as the underlying time variable and further adjust for calendar year of entry.

The current study focused on the examination of risks associated with predefined dietary groups, and therefore the relative contributions of individual foods have not been assessed. Future research could benefit from dose-response analyses of foods that distinguish the diet groups, including meat, fish, dairy, and eggs, to identify possible optimal levels of consumption for balancing risks from different outcomes. Such analyses might be better performed in other large scale cohorts with greater numbers of people who consume these foods, or pooled analyses from multiple cohorts with varying levels of consumption. Methods such as diet optimisation modelling or linear modelling6061 could also be explored to identify optimal diets for disease prevention while respecting individual dietary choices.

Strengths and limitations

The strengths of this study include a large sample size, a long follow-up, and outcome ascertainment by linkage to medical records that minimised the loss to follow-up. Because the exposure of interest was distinct diet groups, defined by the exclusion of animal foods, the chance of misclassification of exposure was relatively low. Long term adherence to diet groups in the cohort was also generally high, and where possible we updated the exposure and important confounders at 14 year follow-up to allow for any changes. The analyses also included adjustment for multiple confounders, assessment of several possible mediators, and sensitivity analyses to confirm the robustness of the results.

Among the limitations of the present study, diet group was self reported, and reasons for choosing each diet were not recorded. Changes in diet group or other behaviours not captured by the follow-up were also possible, and the composition of vegetarian diets could have changed during follow-up owing to increasing availability of vegetarian foods, but differences in nutrient intakes between the diet groups were similar at baseline and at follow-up.962 Reverse causality is possible but not likely, because the results were similar after we excluded the first five years of follow-up, and most participants had followed their current diet (eg, vegetarian) for more than five years at the time of recruitment. Information on drug treatment use (including statins) at recruitment was not available. As with all observational studies, residual confounding from either dietary or non-dietary factors is possible, which might be particularly relevant if results were of borderline significance. Generalisability could be limited, because the present study was based predominantly on white European individuals.

Conclusions

Overall, the present study has shown that UK adults who were fish eaters or vegetarians had lower risks of ischaemic heart disease than meat eaters, but that vegetarians had higher risks of stroke. Future work should include further measurements of circulating levels of cholesterol subfractions, vitamin B₁₂, amino acids, and fatty acids in the cohort to identify which factors might mediate the observed associations. Additional studies in other large scale cohorts with a high proportion of non-meat eaters are needed to confirm the generalisability of these results and assess their relevance for clinical practice and public health.

What is already known on this topic

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    Vegetarian and vegan diets have become increasingly popular in recent years, but the potential benefits and hazards of these diets are not fully understood

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    Previous studies of two diet groups have reported that vegetarians have lower risks of ischaemic heart disease than non-vegetarians

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    However, no evidence has been reported of a difference in the risk of mortality from stroke, possibly because of limited available data and lack of available evidence on stroke subtypes

What this study adds

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    This study showed that fish eaters and vegetarians (including vegans) had lower risks of ischaemic heart disease than meat eaters

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    Vegetarians (including vegans) had higher risks of haemorrhagic and total stroke than meat eaters

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    Further research is needed to replicate these results in other populations and to identify mediators that might contribute to the observed associations

Acknowledgments

We thank all participants in the EPIC-Oxford cohort for their invaluable contribution.

Footnotes

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    Contributors: TYNT and TJK conceived and designed the research question. TYNT analysed the data and wrote the first draft of the manuscript; PNA created the figure and prepared the data for analysis; and PNA, KEB, AP-C, RCT, RC, and TJK provided input on data analysis and interpretation of results. All authors revised the manuscript critically for important intellectual content, and read and approved the final manuscript. TYNT is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

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    Funding: The work is supported by the UK Medical Research Council MR/M012190/1 and Wellcome Trust Our Planet Our Health (Livestock, Environment, and People, LEAP 205212/Z/16/Z). KEB is supported by the Girdlers’ New Zealand Health Research Council Fellowship.

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    Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the UK Medical Research Council and Wellcome Trust for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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    Ethical approval: The study protocol was approved by a multicentre research ethics committee (Scotland A research ethics committee), and all participants provided written informed consent.

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    Data sharing: The data access policy for the EPIC-Oxford study is available via the study website (www.epic-oxford.org/data-access-sharing-and-collaboration/).

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    The lead author (the manuscript’s guarantor) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

View Abstract

question: What is being studied?

answer: Risks of ischaemic heart disease and stroke in meat eaters, fish eaters, and vegetarians

question: Who is conducting the study?

answer: EPIC-Oxford

question: What is the objective of the study?

answer: To examine the associations of vegetarianism with risks of ischaemic heart disease and stroke.

question: What is found amongst vegetarians?

answer: higher rates of haemorrhagic and total stroke.

question: Write a ~2 sentence summary.

answer:
A study reveals the risks of ischaemic heart disease and stroke in meat eaters, fish eaters and vegetarians.
However, the present study has shown that UK adults who were fish eaters or vegetarians had lower risks of ischaemic heart disease than meat eaters, but that vegetarians had higher risks of stroke.