The Global Influence of the Seventh-Day Adventist Church on Diet.

The emphasis on health ministry within the Seventh-day Adventist (SDA) movement led to the development of sanitariums in mid-nineteenth century America. These facilities, the most notable being in Battle Creek, Michigan, initiated the development of vegetarian foods, such as breakfast cereals and analogue meats. The SDA Church still operates a handful of food production facilities around the world. The first Battle Creek Sanitarium dietitian was co-founder of the American Dietetics Association which ultimately advocated a vegetarian diet. The SDA Church established hundreds of hospitals, colleges, and secondary schools and tens of thousands of churches around the world, all promoting a vegetarian diet. As part of the 'health message,' diet continues to be an important aspect of the church's evangelistic efforts. In addition to promoting a vegetarian diet and abstinence from alcohol, the SDA church has also invested resources in demonstrating the health benefits of these practices through research. Much of that research has been conducted at Loma Linda University in southern California, where there have been three prospective cohort studies conducted over 50 years. The present study, Adventist Health Study-2, enrolled 96,194 Adventists throughout North America in 2003-2004 with funding from the National Institutes of Health. Adventist Health Studies have demonstrated that a vegetarian diet is associated with longer life and better health.


Introduction
For millennia, numerous faith traditions have encouraged adherents to limit eating meat, even if temporarily. The Seventh-day Adventist Church, which began in mid-nineteenthcentury America explicitly linked theology and food to encourage a vegetarian lifestyle among present and potential believers. The Church also influenced the diet of non-members around the world through its ambitious organizational structure dedicated to education, health care, and the development and mass production of plant-based foods, such as meat analogues, breakfast cereals, and soy milk. Lastly, results of research conducted among vegetarian Adventists and at universities affiliated with the church have greatly contributed to the scientific understanding of the health effects of vegetarian diets and to dietary changes of the society at large.
Historians have noted that the religious and social upheaval of the Second Great Awakening of early to mid-nineteenth Century America produced movements such as Mormonism, Shakerism, and Millerism (Butler 1986). When the Millerite prediction that the world would end in the early 1840's did not come to pass, a handful from that movement went into a period of reflection and reassessment, resulting in a core group of 'Adventists.' This group increased from about 200 in 1850 to 3500 when the Seventh-day Adventist church was officially organized in 1863, having wide-ranging interests such as temperance, education, and religious liberty (Butler 1986).
Historically, the SDA church began as a sect, marked by a high "state of tension" with the surrounding sociocultural environment due to factors such as prohibitions on diet and entertainment, observance of Saturday as the Sabbath, refusal to bear arms, and belief in the imminent end of the world (Lawson 1998). Over time, the Adventist church reduced those tensions, in part as a result of the educational and healthcare institutions it developed and also through legal and political accommodations (Lawson 1998).
In this review we will show the important role of diet within the theology and practice of Adventism, how the organizational and institutional structure of the church advances the Adventist perspective on diet-particularly in the marketplace, and how Adventists have used research and professional activities to advance vegetarianism in the broader society. Although this article focuses on efforts within the United States, there are examples of efforts across the world-wide church. We will be using the term 'vegetarian' as opposed to 'plant-based' to refer to the Adventist diet. However, there are also sub-groupings with this group such as vegan (no animal products), lacto-ovo-vegetarian (can include eggs and/or milk), pesco-vegetarian (can also include fish), and semi-vegetarian (eat red meat, poultry, and fish less than once per week and more than once per month) (Le and Sabate 2014).

Theology and Health Message
The SDA church has long been noted as a Bible-based church. In contrast to many Christian denominations, the church views many of the Old Testament's teachings and practices as still applicable. This is demonstrated in the church's name referencing the seventh-day Sabbath established at creation as presented in Genesis 2:1-3 and reiterated in the Mosaic covenant at Mount Sinai as written in Exodus 20:8-11. Another aspect of the creation account appreciated by Adventists is that the initial human diet was proclaimed by God as drawing on "every seed-bearing plant on the face of the whole earth and every tree that has fruit with seed in it" (Genesis 1:29 New International Version).
The church does not have a formal creed, but has published a list of fundamental beliefs (28 Fundamental Beliefs 2015). Fundamental Belief #22 is titled "Christian Behavior." It includes the idea that the human body is the temple of the Holy Spirit and, thus, requires attentive care. Specifically regarding diet: "Along with adequate exercise and rest, we are to adopt the most healthful diet possible and abstain from the unclean foods identified in the Scriptures" (28 Fundamental Beliefs 2015). Leviticus 11:1-23 identifies 'unclean' animals such as pigs, shellfish, vultures, and bats. Ceremonially clean animals include fish with scales and fins, chickens, duck, geese, and four-legged animals which chew the cud and have split hooves, such as cattle, sheep, and goats. The concept of body as a temple was advanced early in the denomination's history. An extreme example was SMI Henry, who wrote in 1900 that the Holy Spirit could even eliminate disease and restore health, based on her experience of supernatural healing as a patient in the Battle Creek Sanitarium in 1896 (Land 2001).
One of the Church's founding leaders, and certainly its most prolific writer, was Ellen G. White, who lived from 1827 until 1915. She wrote about many topics, including diet, and may be one of the most translated woman authors in history (Sanchez et al. 2016). One of her books, Ministry of Healing, includes a chapter titled "Diet and Health." In that chapter she provides a number of recommendations. Some notable assertions include: • "Grains, fruits, nuts, and vegetables constitute the diet chosen for us by our Creator" (p. 296).
• "There is more religion in a good loaf of bread than many people think" (p. 302).
• "When it comes to diet, one person cannot lay down an exact rule for another" (p. 310).
A survey of Adventist religious faculty found that many considered wholism to be the church's most important contribution to theology-more so than interpretations regarding the second advent and the seventh-day Sabbath (Bull 1990). This understanding that "a healthy mind and body directly affects one's morals and one's ability to discern truth" is distinct from the anthropological dualism of many Christian (Sanchez et al. 2016) as well as non-Christian faith traditions. Adventist faculty in Chile examined the social meaning of vegetarian diet, based primarily on two books: Prophetess of Health: A Study of Ellen G. White, written by historian and former Adventist, Ronald L. Numbers (1st edition 1976, 3rd edition 2008, and the SDA response, Messenger of the Lord (1998) by Herbert E. Douglass.
They argued that the vegetarian diet in the 1800's ritualized the new identity of the emerging Adventist movement and also had great symbolic meaning (Sanchez et al. 2016). For example, vegetarian diet was an important part of 'the present truth', that is, the message that the church was to proclaim to the world and served as a reminder to the Adventist view of world history, starting with the vegetarian diet originating in the Garden of Eden (Sanchez et al. 2016).
One sociologist of religion has claimed that Adventists and other faiths with a vegetarian element, such as Buddhists, exhibit varying levels of a "bio-spirituality" in which "food, health and worship are unified on a daily basis, at every meal" (Nath 2010). In summary, though the SDA church does not include diet, including vegetarianism, as a formal element of theological teaching or as a tenet for membership, it does advocate for a healthy diet based on the principle that our bodies are temples of God.
The "Adventist" part of the denomination's name refers to a belief in the literal return of Jesus, particularly as discussed in the Book of Revelation. A key passage is Revelation 12:6-12, which presents a vision of three angels who give a message to the world about the impending judgement and the importance of faithfulness and keeping the commandments. Early Church leaders advocated for the SDA Church fulfilling a prophetic role by proclaiming the "Three Angels Message". Early on, Ellen White linked the "Health Message" with the "Three Angels Message": The health reform is as closely related to the third angel's message as the arm to the body; but the arm cannot take the place of the body. The proclamation of the third angel's message, the commandments of God and the testimony of Jesus, is the burden of our work. The message is to be proclaimed with a loud cry, and is to go to the whole world. The presentation of health principles must be united with this message, but must not in any case be independent of it, or in any way take the place of it. and also has a related Spanish-language ministry. Although most of their effort is on evangelism and humanitarian projects, they have produced media segments specifically on diet.
The Adventist Church has a mission emphasizing health care and education. As seen in Table 1, as of 30 June 2017 the SDA Church had 85,112 local churches, 171 hospitals or sanitariums, 101 colleges or universities, and 753 secondary schools. At a practical level, colocation of SDA schools, hospitals, food factories and churches provides a synergy among Adventist institutions. For example, as a result of co-location, parent(s) may work for an SDA hospital or college and send their child(ren) to SDA K-12 schools. The entire family then attends a local SDA church. Additionally, there are often SDA grocery stories which specialize in the sale of vegetarian foods located on or near SDA colleges and/or church regional offices. This co-location reinforces the SDA lifestyle among members. and tasty vegetarian fare using ingredients grown on on-site gardens or from local farmers. Malcolm Bull argued that John Harvey Kellogg was crucial in the medicalization and secularization of the SDA church. For example, whereas Ellen White had originally supported lifestyle reform on moral grounds, such as to control sexual appetite and avoid sin; the church transitioned to health as an important goal in-and-of itself, with the religious organization generally following the lead taken by medicine (Bull 1990). A brief overview of sanitariums, with an emphasis on diet, was given in a speech by Dr. Kellogg: The sanitarium is a product of modern medical progress … The central and fundamental idea in such a place should be the thought that health-getting is not a matter of magic nor of pill-swallowing, but, rather, a matter of education. … . A sanitarium must provide food prepared in such a manner as to be both wholesome and palatable, tempting to the patient whose appetite is perverted and fickle, and at the same time easy of digestion and highly nourishing. (Kellogg 1891) The Battle Creek Sanitarium grew dramatically during its first forty years, including a large new construction following a fire in 1902. However, with increasing success there was also increasing conflict between church and Sanitarium leaders to the extent that in 1907 the Kellogg brothers assumed full control and were "dis-fellowshipped" from the SDA church An essay specifically on Adventism in Nordic countries observed that the sanitarium concept of the early 1900's found a ready market, particularly among the upper classes. However, as society became more secularized, as government increasingly paid for healthcare, and as SDA institutions provided conventional medical procedures, it became more difficult to maintain distinct SDA facilities (Eklof 2008). The conclusion, at least within Sweden, was that "The successful enterprises-as they had been for a considerable time-could not, at the end of the 20th century, continue to be self-financing or fulfil the missionary objectives among the upper classes. The institutionalized health care apparatus came to an end around the turn of the century, which also included the sale of health associated food product companies" (Eklof 2008).

SDA Education-As of 31
December 2016 there were 8515 educational institutions in the world under SDA management, with total enrollment of 1.95 million students (SDA 2018), making it the world's second largest integrated network of schools. As part of the admissions process, students are informed of the SDA lifestyle requirements while on campus. Adventist schools serve vegetarian meals to their students and promote an atmosphere of wholeness in which there is a balance between diet, exercise and school work. Schools are always working to ensure that the meals served are not only tasty and visually appealing but that they also meet the national nutritional guidelines. Many of those schools, particularly within the US, have webpages which mention their menus. An article published by the Vegetarian Resource Group highlights an effort by a dietitian to improve the quality of the vegetarian lunch menu in one SDA school (Gall and Salazar 2012).
Although the largest number of people are touched in primary and secondary schools, there is a strong emphasis on academic and professional training. Most salient for diet, particularly with the establishment of multiple Adventist sanitariums, was a need for trained dietetic staff. Early in the 1900's the question was raised as to how the church would educate members to fill the need. "Are we to send our young people to worldly schools to study the science of health and nutrition and then apply their knowledge to the solving of the problems in our institutions" (Denny 1919)? According to Ellen G. White, one answer was to provide education through its own schools rather than send members to secular schools: At Loma Linda many can be educated to work as missionaries in the cause of health and temperance… That which is of the most importance is that the students be taught how to represent aright the principles of health reform. (Denny 1919) Thus, nutrition and dietetics education was established in 1908 at Loma Linda University. Furthermore, Mervyn G. Hardinge produced one of the early investigations of vegetarianism for a doctoral dissertation at Harvard in the early 1950's, then went on to be founding dean of the Loma Linda University School of Public Health in 1967. As seen in Table 2, 13 other SDA universities also offer college through graduate degree programs in diet/nutrition. In addition to the United States, nutrition degrees are offered in Jamaica, Mexico, Argentina, Peru, Brazil, Kenya, Nigeria, Zimbabwe, the Philippines, and South Korea.
2.2.5. SDA Churches-There have been thousands of articles published regarding churches and health. These include efforts by the public health and academic communities to work with various churches to further health promotion activities and to reduce health disparities (Markens et al. 2002;Kaplan et al. 2006). Religious organizations can have a great influence on members' behavior at many levels (Campbell et al. 2007).
One way in which efforts at local churches are enhanced is through coordinating from within the SDA hierarchy. For example, the SDA General Conference has a health ministry's department, which supports and coordinates health activities throughout the organization. As an example of the ongoing importance of diet, their main webpage on 11 July 2018 included a number of diet-related items, such as a report on the most recent General Conference Nutrition Council Annual Meeting, a summary of the 7th International Congress on Vegetarian Nutrition, a Factsheet on vegetarian diets and a link to the SDA vegetarian version of the USDA MyPlate (http://healthministries.com/). SDA churches provide a number of food-related activities not just for their members but also for the community in the form of food drives and vegetarian cooking classes. Churches may serve as venues for public health interventions. An SDA version is the Complete Health Improvement Program (CHIP), developed by Loma Linda University graduate Hans Diehl, which is centered on the promotion of a whole-food, vegetarian eating pattern, and daily physical activity Diehl 1998).
Furthermore, the link between nutrition education and church mission is clearly shown in an Adventist Review (a denominational newsmagazine) article: In the Far East, Africa, the Middle East, North, Central, and South America, Europe, Australia, and the islands of the Pacific, Vegetarian Nutrition instructors are directing schools of health, cooking schools, and helpful classes of many kinds.
With new programs for the home, the church, and the community, the church is acknowledging the truth of Ellen G. White's statement: "To teach … the science of healthful living is to do missionary work for the Master."-Counsels on Diet and Foods, p. 476. (Vyhmeister 1984) One of the SDA traditions is the "Sabbath Potluck" where church members bring a vegetarian dish to share and fellowship with other church goers. Whereas most SDA churches have an unwritten "vegetarian potluck" policy, there are churches where meat options will be found on the  98 2018). She has been credited with the invention of Haystacks, which is one of the most popular "dishes" for SDAs. A mix of tortilla chips, beans, cheese and vegetables, it is a well-known menu item at camp meetings and other large church gatherings. There are many variations on the original recipe; for example, some add rice to the mix and skip the chips or some will have lettuce instead of chips.

SDA Humanitarian Outreach-Adventist Development and Relief Agency
(ADRA) is the global humanitarian organization of the Seventh-day Adventist Church (https://adra.org/). They deliver relief and development assistance to individuals in more than 131 countries, funding nearly 1200 projects and reaching an estimated 15.6 million beneficiaries (SDA 2018). ADRA focuses on nine impact areas, with one being hunger and nutrition. Efforts under this impact area include assisting farmers to increase their food supply, income and savings for food purchasing, helping women to identify, prevent, and treat malnutrition at an early stage, before it impacts their long-term health, and promoting community-level nutrition awareness using strategies that help households achieve diverse and nutrient-rich diets.
Indeed, when thinking of diet in less-developed parts of the world, such as much of Africa, the issue is not so much vegetarianism, as it is poverty and malnutrition, compounded by the epidemic of HIV/AIDS. In fact, it has been documented that one of the barriers to successful treatment of HIV/AIDS is food insecurity (McKinney et al. 2014). In an effort towards increasing the use of soybeans within Kenya, a household survey in 2005 found that essentially Adventists were the only respondents using soybeans; they were processing soybeans into roasted soy nuts or soy beverages (Chianu et al. 2008). Though not an official program, efforts directed toward an SDA response to poverty might follow a theology of wealth and poverty presented as a, "Charity in community with claiming faith and selflimitation" model in a paper based on in-depth interviews of Adventists in Malawi (Doss 2011). In that article, Gordon Doss noted that in 2010, 22% of all Christians resided in Africa and that those individuals often have different views regarding wealth and poverty compared to those in the West. Their views regarding acknowledgement of limited resources may be consistent with a plant-based, rather than meat-based diet.

Food Industry
A centerpiece of the sanitarium philosophy was improving the diet of patients. Towards that end, Ella Eaton Kellogg, along with her husband John Harvey Kellogg and brother-in-law William Keith Kellogg, ran an experimental kitchen which developed more than 80 grain and nut-food products, including peanut butter and flaked breakfast foods (The Battle Creek Idea 2009). In the United States, Seventh-day Adventists established around 100 cereal-based processed food companies, many of which merged (Sboros 2017). The Battle Creek Sanitarium played a significant role in shaping the mass-produced breakfast cereal industry (Nath 2010). The eating habits of the American public were transformed by flaking wheat, breakfast became boxed cereal a la Kellogg, as opposed to a breakfast heavy on eggs and meat.
Shurtleff and Aoyagi (2014), have released a 1344 page book in which they present historical details regarding Seventh-day Adventist work with soy foods, vegetarianism, meat alternatives, wheat gluten, dietary fiber and peanut butter. The following section relies heavily on their work. As they note, there are two basic types of Seventh-day Adventist organizations: (1) Those owned by the SDA church/denomination (officially General Conference of Seventh-day Adventists)-such as Sanitarium Foods (Australia) and Loma Linda Foods (from 1905 to about 1989) and (2) Those owned by practicing Seventh-day Adventists-such as Worthington Foods and Cedar Lake. There have been many transfers of ownership among food producers. This paper will not attempt to provide a complete corporate history or cover every food product. There have been many changes of ownership, including selling entities to non-Adventists. Furthermore, the emphasis for this review is on U.S. activities. As of 2016, the SDA Church reported owning 20 entities within the category of "Food Industries" (SDA 2018).

Breakfast Cereals-
The wheat flake was discovered accidentally in 1894 and served in the Sanitarium dining rooms under the name of "Granose," flavored only with salt.
In 1895, Dr. Kellogg filed a patent application for "flaked cereals and the process of preparing same," also including barley, oats, corn and other grains in the application. Worthington Foods has been the most commercially successful in introducing gluten-based meat like products to America. Their first such product was Proast, launched in 1939, followed by Choplets in 1941. In 1968-70 with Prosage (a meatless sausage) Worthington invented a unique and proprietary process for combining gluten and textured soy proteins to give improved texture, flavor, and nutritional value-leading to a host of new meat like products by the early 1980s. By 1992, Seventh-day Adventist food companies had introduced at least 166 commercial food products containing gluten as a major ingredient; of these, at least 55 were made by Worthington Foods. Moreover, of Worthington's 180 products, approximately 90% contained at least some wheat gluten (Shurtleff and Aoyagi 2014).

Peanut
Butter-According to legend, a kitchen worker stepped on a peanut and from that concocted America's favorite sandwich spread. Dr. John Harvey Kellogg, in an 1895 letter to Ellen G. White in Australia, wrote: "We make very little use of cream or milk in our family, and use no butter whatever for seasoning, but use nuts instead. I have recently succeeded in making some very excellent preparations from nuts which take the place of butter entirely and are sweeter, more palatable, and more digestible. I find this plan is working very successfully both with the patients and with the helpers at the Dormitory." Three months later, Dr. Kellogg applied for U.S. patent (No. 567,901) for a "nut-butter" made from peanuts or almonds (Shurtleff and Aoyagi 2014).
In 1896 Dr. Kellogg's peanut butter was sold commercially, by Sanitas Nut Food Company.
In an ad titled "New Nut Products" in the Chicago Vegetarian (p. 8), Nut Butter was advertised as: "A substitute for ordinary butter, presenting fat in the form of a perfect emulsion; combined with water, forms a delicious cream. Used for shortening of all kinds. A pure product of nuts; can be eaten by those who cannot eat ordinary butter (Shurtleff and Aoyagi 2014)." Then, in 1898, Edward Halsey, formerly a baker at Battle Creek, through the Sanitarium Health Food Co. in Australia introduced Sanitarium Peanut Butter-Australia's first (Shurtleff and Aoyagi 2014). Table 3 presents the food industries which are officially part of the Seventh-day Adventist Church. The oldest of organizations, listed in the SDA Yearbook under the name of "Health Food Department", is the Sanitarium Health and Wellbeing Company, which is the trading name of two sister food companies (Australian Health and Nutrition Association Ltd. and New Zealand Health Association Ltd.). Founded in Melbourne, Victoria, Sanitarium has factories in Australia and New Zealand. Its flagship product is Weet-Bix, sold in the Australian and New Zealand breakfast cereal markets. Sanitarium has produced and marketed many food products throughout its 120 year history, including breakfast cereals, peanut butter, vegetarian meals, snacks and beverages (Sanitarium-Our Story 2018). It is considered to be the largest and most diverse organization within the Adventist food industry.

Research
There is now a well-established body of research by Adventists which support a vegetarian lifestyle. However, it is important to recognize that there was some risk involved at the beginning. In fact, administrators at Loma Linda University in the mid 1900's discouraged the first vegetarian researcher, because, "if you find the diets of vegetarians are deficient, it will embarrass us" (Johnston 1999). Fortunately, that researcher, Mervyn G. Hardinge, persevered and encouraged others as well. It is also important to note that there are many conflicting claims made regarding which type of diet is optimal. This paper is not the forum for such a scientific debate, in this section we are simply presenting what Adventists have published in the peer-reviewed literature. The Adventist studies began with the SDA Mortality Study of 1958-1966(Kahn et al. 1984Phillips 1980). White male and female California Adventists who were 30 to 89 years old in 1960 were recruited from 234 churches, and participants completed a self-administered questionnaire in 1960 (Snowdon and Phillips 1985). There were 22,940 study participants (Butler et al. 2008). In addition to surveys, all deaths in the Adventist cohort during 1960 to 1980 were identified by computer-assisted record linkage to the California death certificate file (Snowdon and Phillips 1985).

Adventist Health Studies-The
Next was the First Adventist Health Study of 1974-1988(Fraser et al. 1991Fraser et al. 1992;Singh and Fraser 1998). This cohort was defined as non-Hispanic White subjects 30 years of age and older who lived in California Adventist households and completed two mailed demographic and lifestyle questionnaires (Fraser and Shavlik 2001). Participants were initially contacted from names and addresses in church directories and sent a brief census questionnaire. The study enrolled 34,192 men and women from 437 churches who were sent and returned extensive lifestyle questionnaires, supplemented by hospitalization data and matches against state death tapes and the National Death Index (Fraser and Shavlik 2001).
The Adventist Health Study 2 (AHS-2) began in 2002, with goals of examining the relationship between diet and risk of breast, prostate, and colon cancers in Black and White individuals. A total of 96,194 Adventists in 4500 churches from the United States and Canada were recruited. Special emphasis was placed on recruiting Blacks, who comprised a substantial portion of Church membership, with AHS-2 staff and trained local recruiters soliciting participation from members of approximately 1000 Black churches throughout the United States and Canada (Herring et al. 2010). It was observed that calling those members from churches who had not returned the initial questionnaire within three months did increase participation from Black churches; but not White churches (Bell et al. 2005). Blacks comprised 26.9% of the final sample (Butler et al. 2008). Both AHS-1 and AHS-2 examined incidence and mortality, and across all three studies, no more than 2.1% of males and 1.1% of females were current smokers (Butler et al. 2008).  Mills et al. 1989;Phillips 1975;Van den Brandt et al. 2000).

AHS-2 has received more than $24 million in
Given the large number of papers, it is beyond the scope of this paper to extensively review all findings. Dr. Gary Fraser, the principal investigator for AHS-2, has written a book summarizing findings from Adventist Health studies in relation to chronic illness, particularly cancer and heart disease (Fraser 2003). More recent reviews have quantitatively summarized Adventist Health Studies findings with regards to intermediary health outcomes such as obesity, hypertension, and diabetes (Le and Sabate 2014; Orlich and Fraser 2014), as well as ischemic and other cardiovascular diseases and specific types of cancer (Le and Sabate 2014). For the present review, Dr. Fraser has briefly summarized below several of the most noteworthy aspects in the Adventist Health Studies series:

•
The studies describe mortality and experience of major non-communicable disease among Adventists.

•
Adventists have lower overall mortality, incidence of cardiovascular disease, and also many cancers.
• Vegetarian Adventists have less hypertension, lower blood lipids and C-reactive protein (CRP-associated with inflammation), less diabetes, and lower body mass index (BMI) values, when compared to Adventist non-vegetarians.
• Vegetarian Adventists have less cardiovascular disease, lower rates of colorectal cancer, and vegans especially have lower rates of prostate, and probably breast cancer, than non-vegetarian Adventists.
• Adventists in California live 7.3 years (men) and 4.4 years (women) longer than non-Adventist California men and women, adjusting for educational differences.
• Red meat eaters have higher rates of colon cancer.

•
Higher nut consumption is associated with much lower risk of coronary heart disease.
• Those drinking more dairy milk have lower rates of colon and rectal cancers (but preliminary findings suggest increased risk of breast and prostate cancers).
• Independent of fats in the diet, proteins from red meat are associated with higher, and proteins from nuts and seeds with lower, risk of cardiovascular mortality.
• A good breakfast and avoiding calories later in the day are associated with lower body weight with aging.

•
Adventists tend to move toward more vegetarian diets as they age.

•
Higher tomato consumption is associated with lower rates of prostate and ovarian cancers.
• Confirmed the apparent helpful effects of regular physical activity and adequate protein intake to prevent common bone fractures.
• Found that overweight is associated with increased mortality through to old age.
• Air pollution is associated with an increased risk of lung cancer, cardiovascular disease, asthma and total mortality.
Adventist Health Studies have required developing methods of dealing with effects of dietary reporting errors and also tested innovations to recruit Black study members more effectively. It should be noted that AHS also demonstrated the health benefits of church attendance. For example, findings from AHS-1 suggested that even after controlling for previous disease status, gender, vegetarian diet, exercise, nut consumption and smoking, Adventists who attended church less than once per month were 1.58 times more likely to die during the study period than those who attend church 3 to 4 times per month (Fraser 2003).

Biopsychosocial Religion and Health Study (BRHS)-In many respects, it
is difficult to study the effects of religion and diet on mortality because AHS-2, by and large, is a church-going cohort, with few members using tobacco or drinking alcohol; moreover, the non-vegetarians eats less red meat compared to the average American. Loma Linda researchers, nevertheless, took on this challenge with funding from the National Institute of Aging for what became the Biopsychological Religion and Health Study (BHRS). The goal was to select a sample from the AHS-2 cohort and obtain additional psychological and religious data (the Psychosocial Manifestations of Religion Sub-study, PsyMRS) and additional biological measures for an even smaller subset (the Biological Manifestations of Religion Sub-study, BioMRS) (Lee et al. 2009)-at two points in time four years apart.
In an examination of how various psychosocial and religious measures affect mortality, BRHS researchers sampled approximately 21,000 AHS-2 members, of which 10,988 agreed to complete a 20-page questionnaire. Of these, 6531 also submitted completed surveys four years later (Morton et al. 2017). The authors concluded that there are, "complex, interrelated set of religious constructs that mutually reinforce and complement one another, with the links between religious variables with psychosocial mediators leading to healthier behaviors and decreased mortality" (Morton et al. 2017). Interestingly, they found that religious involvement itself had more of an influence than social support in reducing negative emotional experience.
Whereas lifestyle factors such as vegetarian diet and regular exercise were important predictors of reduced rates of hypertension, even after controlling for these, intrinsic religiosity was just as strongly related to lower hypertension rates as the lifestyle factors (Charlemagne-Badal and . The favorable relationships between anticipated church support and hypertension appear to be mediated by BMI and are an indication of how this dimension of religion combined with lifestyle promotes good health, specifically, reduced risk of hypertension (Charlemagne-Badal and Lee 2016b). In addition, BHSR data has been used to show that trans fatty acid intake and Mediterranean (mainly vegetarian) foods were related to more positive and less negative affect (Ford et al. 2016;Ford et al. 2013) as well as related to better emotion regulation (Holt et al. 2014(Holt et al. , 2015.

Vegetarianism and Environment-Concern
for nature is one of the reasons that convinces many to pursue a plant-based diet. This includes both a desire to avoid taking the life of animals and a desire to reduce the impact on the environment. LLU researchers used findings from the Adventist Health Study to estimate what the impact would be in California if everyone consumed a vegetarian diet. Researchers concluded that the nonvegetarian diet required "2.9 times more water, 2.5 times more primary energy, 13 times more fertilizer, and 1.4 times more pesticides than did the vegetarian diet (Marlow et al.

Research Activity outside of the Unites States-California is not the only source of Adventist studies. There have been diet and lifestyle-related studies regarding
Adventists in a number of countries. As shown in Table 4, these studies have further documented actual dietary patterns of Adventists and have generally shown better health outcomes among Adventists, though in some cases showing a shortfall of nutrients or calories. Most studies involving Adventists other than the Adventist Health Studies series have been descriptive or involved small sample sizes, one exception has been the use of population registries in Nordic countries. For example, in Denmark researchers were able to identify thousands of Adventists and Baptists based on church records and national datasets, then prospectively match to hospital and death records (Thygesen et al. 2012b).

Dietetics
Associations-In addition to educating professionals who were well versed in a vegetarian diet, Adventists have been involved with professional organizations. The American Dietetic Association was founded in 1917. One of its co-founder was Lenna Francis Cooper, the first lead dietitian at the Battle Creek Sanitarium. One way Cooper's influence was institutionalized was through an annual "Lenna Frances Cooper Memorial Lecture" for the ADA. The 20th such lecture argued that nutrition is becoming an important element of medical education (Young 1983). Kathleen Zolber, PhD, a nutrition professor at Loma Linda University, became the first Adventist president of the ADA in 1982-1983. She was instrumental in establishing the Evidence Analysis Library, a source for sound information for RDs, and the publication of Food For All, authored by Lydia Sonnenberg, MS, RD and U.D. Register, PhD, RD. This publication led the way in acceptance of vegetarian diets by nutrition professionals The ADA did not always advocate for a vegetarian diet. In fact, Loma Linda University's dietetics program was not accredited until 1957, in part due to a belief that one could not be a real dietitian if not able to prepare a typical meat-based American diet. However, in 1988 the ADA issued a position statement favoring vegetarian diets, and have reaffirmed that position every four or five years since then, usually expanding the length of the position each time. The most current statement reads: It is the position of the Academy of Nutrition and Dietetics that appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits for the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes. Plantbased diets are more environmentally sustainable than diets rich in animal products because they use fewer natural resources and are associated with much less environmental damage. Vegetarians and vegans are at reduced risk of certain health conditions, including ischemic heart disease, type 2 diabetes, hypertension, certain types of cancer, and obesity. Low intake of saturated fat and high intakes of vegetables, fruits, whole grains, legumes, soy products, nuts, and seeds (all rich in fiber and phytochemicals) are characteristics of vegetarian and vegan diets that produce lower total and low-density lipoprotein cholesterol levels and better serum glucose control. These factors contribute to reduction of chronic disease. Vegans need reliable sources of vitamin B-12, such as fortified foods or supplements.

Discussion
This review was not able to adequately cover the many individuals and organizations, both within the United States and throughout much of the world, who have worked or continue to work to advance the Adventist message on diet. However, we have introduced some of the key individuals in order to demonstrate the thesis of an Adventist global impact on diet. These include Ellen G. White who was instrumental in linking elements of the American diet reforms of the 1800's to the theology and practice of a 'remnant' church. Another key individual was John Harvey Kellogg, who operationalized the Adventist message in a medically-oriented sanitarium. JH Kellogg and his family also worked to operationalize the Adventist message through a food industry. Mervyn G. Hardinge led an effort to demonstrate through research the health benefits of a vegetarian diet. Later Adventists were able to point to those research findings in making professional recommendations for a vegetarian diet. In addition to key historical figures, there are many organizations, such as food producers, schools, and health care facilities which together truly have a global impact on diet. Thus, the Seventh-day Adventist Church was able to incorporate and influence positive public health in society as well as play a role in the mainstream financial life of many nations.
Indeed, the Seventh-day Adventist Church is well-known for its healthcare and educational institutions spread around the globe, with a size and scope that belies its relatively small membership numbers compared to other major world religions. There is no doubt that these institutions have an influence on the lifestyle, including diet, of the millions of patients who are treated and on the millions of students who are educated, particularly those who live on campus and/or eat in school cafeterias. Unfortunately from an academic standpoint, there are surprisingly few peer-reviewed publications which address the impact of SDA healthcare and educational systems on population-level diet.
Particularly as a result of combining religion/health/medicine in the form of sanitariums, the SDA Church also began to produce vegetarian foods for the benefit of church members and the general public. Both the formal SDA Church and Adventists working independently of Church supervision, were heavily involved in developing and producing vegetarian food products in the 1900's. Their involvement with food production resulted in the mass production of many different foods, including breakfast cereals, meat analogues, and soy milk. The fact that much of current production is no longer under control of the SDA Church, perhaps a disappointment for some within the faith, is a demonstration of the growing wide-spread acceptance of vegetarian foods and a function of substantial for-profit potential. However, the for-profit nature of the business has led to plant foods such as high sugar cereals, which are not as healthy. The simple processing of the late 1800's has given way to more extensive processing and low nutritional value aspects, such as sugar, salt, stabilizing, texture, and flavoring additives. Though the movement of nutrition science and policy since the turn of the current century has been towards whole cereal grain consumption, the modern Kellogg company has generally not embraced that movement as much as other breakfast cereal companies. Regardless, it is appropriate to acknowledge the positive impact of developing several sectors of the food industry. Furthermore, the Adventist food industry has contributed financially towards research and advocacy, such as in supporting the International Congresses on Vegetarian Nutrition.
After presenting the health message for many decades based largely on the writings of Ellen G. White, the Church dedicated resources to scientifically study the health benefits of the SDA lifestyle, especially diet. With the passage of half a century, during which Adventist researchers were able to secure millions of dollars of funding from the National Institutes of Health, there is now a large body of peer-reviewed publications and the broader society generally accepts that there are benefits of vegetarianism, independent of any religious message. It has been argued that a paradigm shift has occurred within the professional world, from a model which viewed a vegetarian diet primarily in terms of deficits compared to a meat-based diet, to a model in which a vegetarian diet is perceived as most healthful and a meat-based diet has deficits, such as in phytochemicals and fiber (Sabate 2003). As noted by Hardinge, societal "attitudes toward vegetarian diets have progressed from ridicule and skepticism to condescending tolerance, to gradual and sometimes grudging acceptance, and finally to acclaim" (Johnston 1999). Furthermore, there is also scientific evidence of a synergistic benefit of religion and diet/lifestyle.
The Adventist Health Studies were designed as prospective cohort research studies. As outlined in epidemiology textbooks, there are strengths and weaknesses associated with any study design (Gordis 2014). Cohort studies are especially good at exploring associations between exposures (such as diet) and multiple outcomes (such as disease and mortality). Drawbacks include cost (need to enroll many subjects) and long time period needed to observe health outcome (since subjects do not have a disease at beginning of study). Indeed, many cohort studies must be maintained for decades to yield meaningful results. Cohort studies are not strong for describing a population (best to use a cross-sectional study design) or in proving a relationship between two variables (best to use randomized controlled trial study design, although often this is not practical or ethical). Potential biases in cohort studies include selection biases, such as differential non-response and follow-up loss, information biases, and as true of any study design, bias in analysis by the researchers and statisticians if they have strong preconceptions (Gordis 2014). However, it is important to note that most Adventist research has compared Adventists to other Adventists who have somewhat different lifestyles, beliefs, or adherences. Cost is not a trivial issue, as Loma Linda University has needed to continue funding the Adventist Health Studies even during periods when there was not funding from the National Institutes of Health.
Although cohort studies generally do not need to represent a particular population, some have questioned how well the Adventist Health Study represents Adventists in the United States, particularly African Americans. It has been observed that there are regional differences in church involvement, notably AHS participants in the southern US tend to be longer-time church members and also more involved with church activities compared to California participants (Lampkin et al. 2009). However, it is unlikely that such variations would invalidate observed relationships between diet and health status. Furthermore, recruitment into all health-oriented studies can be influenced by broader social forces such as racism and individual's perception of health care and perceived sense of control over their health (Lampkin et al. 2009).
The Adventist Church has been successful in presenting the personal health and spiritual benefits of a lifestyle which includes a vegetarian diet. However, it can do more with regards to diet. For example, future research could better quantify the costs and benefits at the society level of vegetarians' longer life. Greater organizational effort could be placed into advancing a "stewardship" model of population diet, which would include examining and mitigating the environmental impacts of modern food systems and more forcefully articulating the ethical and moral problems of a meat-based diet within the context of global poverty and food shortages.
In summary, during the 1800's the SDA church ultimately combined an evolving vegetarian perspective, an active evangelistic agenda, and a health ministry program, such that a vegetarian lifestyle was presented in many places around the world in a package that promoted a whole person and good health. As concluding exemplars, the Blue Zone books sponsored by National Geographic highlighted a handful of cities around the world in which a relatively large number of residents live to be at least 100 years of age, extensive information is available on their website https://www.bluezones.com). The Blue Zones identified in the initial book (Buettner 2008) were: Sardinia, Italy; Okinawa, Japan; Nicoya Peninsula, Costa Rica; Icaria, Greece; and Loma Linda, California. Loma Linda made that list as a representative of Adventists, who have been demonstrated though research to have a longer and healthier life. Per the website, lessons learned from Loma Linda include the importance of a healthy social circle, social engagement, family, faith, moderate physical activity, and no smoking or alcohol. Food-specific lessons include plant-based diet, and consuming plenty of legumes, including soy, whole grains, and nuts. Finally, The Adventists Trilogy, three films produced by Martin Doblmeier which aired on PBS stations, presented not only on Adventist education and global health missions; but started by showing how the biblically-based approach to health and wholeness led to members living an extra 7-10 years longer than others. Thus, not only does the Adventist perspective on diet emphasize the wholeness of mind and body; it is difficult to present the Adventist message on diet without also presenting the whole Adventist "package" of theology, worship, health ministry, and education.