Unpacking the myths around plant-based drinks

Who may be interested in consuming plant-based drinks (PBDs)?

With the rise in popularity of plant-based diets, demand for alternatives to dairy has also increased. One in three people in the UK now drink PBDs, rising from 25% in 2020 to 32% in 2021, with further growth predicted⁷. Derived from a variety of plant sources including grains, legumes, nuts, and seeds, PBDs can be used as a replacement for cow’s milk in hot drinks, cereals, smoothies, and in cooking.

A survey in 2022 found that over 25% of people who choose PBDs do so because they enjoy the taste of different options, and around 12% mentioned the ill treatment of cows in the production of dairy products⁸. In addition, populations more likely to choose dairy alternatives include both children and adults with allergies and intolerances, those seeking improved health outcomes, those who consume a vegan diet, and those with environmental motivations⁹.

The value of fortified PBDs for those who can't or don't want to have cow's milk

Having a fortified alternative to dairy can be beneficial for a number of population groups, for example those with lactose intolerance which affects on average 65% of the world’s adult population, depending on ethnicity¹⁰. Cow’s milk treated with lactase enzyme (to make it lactose free) is another option for those with lactose intolerance.

Cow’s milk protein allergy (CMPA) is the most common food allergy in young children with an estimated prevalence of 2% of infants and 4.5% of children^11,12. For children with CMPA over the age of 1 who are not breastfeeding, fortified PBDs can provide a valuable source of nutrition. For those children with soya allergies (in addition to CMPA) a fortified oat-based drink could provide a valuable source of nutrients especially calcium, iodine, and vitamins D, B12 and B2. The prevalence of soya allergy in those with CMPA ranges from 10-14%¹³.

Nutritional value

Fortification of foods and drinks can play an important role in ensuring a healthy and balanced diet, especially in some population groups who may struggle to meet the requirements for certain micronutrients¹⁴. In Europe, over 90% of PBDs are fortified¹⁵.

Calcium and vitamin D

Most fortified PBDs provide a similar quantity of calcium as cow’s milk. Vitamin D is not naturally present in cow’s milk and the addition of vitamin D to PBDs would be expected to further increase the absorption of calcium.

Lower intakes of calcium have been reported in some children and adolescents avoiding dairy products due to CMPA¹⁶ or when eating plant-based¹⁷ as dairy products are the main source of calcium for most people in the UK. However, there is a misconception that cow’s milk is essential for strong bones and teeth, as it is the calcium that provides the benefit rather than cow’s milk itself^{18, 19}. The addition of calcium to PBDs therefore supports those not including dairy products in their diet to help meet their requirements. Overall, the bioavailability of the calcium added to PBDs is similar to the calcium found in cow’s milk within 10%²⁰.

Very few foods naturally contain vitamin D, with oily fish being the main source and to a lesser extent eggs. Vitamin D aids the absorption of calcium and so the addition of vitamin D to dairy alternatives is helpful.

In the UK, the government recommends a vitamin D supplement of 8.5-10µg per day from birth for all breastfed infants and from 6 months to 4 years of age a supplement of vitamins A and D is recommended for breastfed infants. For formula fed infants, a supplement is only needed when they are drinking less than 500ml of formula per day. For children from the age of 5 years and adults, a vitamin D supplement of 10µg per day is recommended during the autumn and winter months (late September to early April) as we cannot make enough vitamin D in our skin during these months (NHS)²¹.

Iodine

Iodine is important for thyroid health as it is an essential component of thyroid hormones, needed for many body processes including growth, metabolism and for brain and neurological development of the foetus²². It is therefore very important to ensure an adequate intake of iodine.

In the UK, whilst fish, milk and dairy are rich in iodine, milk is the main dietary iodine source ^22,23.  Anyone who avoids iodine rich foods could be at risk of iodine deficiency. When avoiding rich sources of iodine, it may be necessary to consider a suitable supplement. There is concern that pregnant women and adolescent girls in the UK are mildly-to-moderately iodine deficient²². According to a UK survey published in 2023, 28% of PBDs were fortified with iodine²⁴. It is therefore advisable to check product labels.

Vitamin B12

Vitamin B12 is made by micro-organisms and is not found in any plant foods unless they are fortified. According to the FEED study (which included intake of PBDs), higher proportions of vegans were below the estimated average requirements (EARs) for vitamin B12 as compared to omnivores²⁵.

Those avoiding all sources of animal foods should take a vitamin B12 supplement or ensure they consume vitamin B12 fortified foods at least twice a day aiming for a minimum of 3mcg per day²⁶. Most dairy alternatives are fortified with vitamin B12 as a way of improving the intake of this important vitamin.

Vitamin B2 (riboflavin)

Dairy products are an important source of vitamin B2, and some studies have shown that those avoiding dairy products can have lower intakes of this vitamin¹⁷. This is why vitamin B2 is often added to dairy alternative drinks. Alternative plant-based sources of riboflavin include mushrooms, almonds, and nutritional yeast.

Protein

Soya and pea-based drinks contain the most protein of PBDs, with similar levels to that found in cow’s milk. Oat drinks contain lower levels of protein than that found in cow’s milk, but still contain significant amounts (around 1g per 100ml). Coconut and nut-based drinks contain the lowest amounts of protein (typically around 0.5g or less per 100ml unless they have added protein). PBDs that provide higher levels of protein may be helpful for certain populations (for example older adults or athletes) where protein needs are increased and if not met via other dietary sources^{27, 28}.

It’s important to consider protein contribution from the diet, from food sources such as beans, lentils, nuts, seeds, tofu and other soya foods, foods based on mycoprotein (from fungi) as well as cereals and cereal products which contribute 24% of UK adults (19-64 years) protein intake²⁹. For most people eating a varied and balanced plant-based diet which meets energy needs, protein intake is not a problem with most adults eating more protein than recommended^{30, 31}.

Children’s protein requirements are lower relative to energy needs. For example, the RNI for protein is 14.5g per day for 1–3-year-olds, 19.7g per day for 4–6-year-olds, 28.4g per day for 7–10-year-olds and between 42g and 55g per day depending on age and gender for 11-18 year-olds³⁰. According to NDNS data children are eating well in excess of the amount of protein recommended with 1.5-3-year-olds eating an average of 41g protein per day (283% of the RNI) and 4–10-year-olds an average of 51.9g protein per day³¹.  A recent systematic review and meta-analysis found a ‘probable’ causal relationship between a high protein intake (particularly animal sourced protein) in early childhood (less than 18 months of age) and a higher BMI later in childhood³².

Fats

PBDs (except for coconut-based drinks) are rich in unsaturated fats and low in saturated fats, which is a beneficial fat profile in terms of cardiovascular disease risk^{33, 34, 35}. A large cohort study looking at 83,349 women found that replacing 5% of energy from saturated fats with equivalent energy from polyunsaturated and monounsaturated fats was associated with estimated reductions in total mortality of 27%³³. Most PBDs contain a small amount of either rapeseed or sunflower oil which contain mostly monounsaturated and polyunsaturated fats. Full fat cow’s milk contains just under 4g of total fat per 100ml with 64% being saturated fat.

Carbohydrates and sugars

Carbohydrates are an important source of energy and dietary guidelines recommend that at least 50% of our daily energy intake should come from carbohydrates³⁶. The carbohydrate content of PBDs varies depending on the source, for example, almond/soya/pea-based drinks tend to be lower, whilst oat-based drinks tend to be higher in total carbohydrates, when compared to cow’s milk. The amount of total sugar in PBDs is usually similar (or lower) to that found in cow’s milk. Additionally, there are increasing numbers of PBDs available with no sugars.

Cow's milk does not contain any fibre, whilst PBDs contain varying amounts of fibre with oat-based drinks containing the most.

Nutritional comparison with cow’s milk vs PBDs

The table below shows the average nutritional value per 100ml for a selection of unsweetened and fortified PBDs available in the UK (cow’s milk data from McCance and Widdowson’s Composition of Foods Integrated Dataset 2021)³⁷

* level of fortification with vitamins and minerals varies between brands

**iodine in cow’s milk varies depending on the season, higher in winter with values ranging from 20-41µg per 100ml

***a selection of no sugars varieties are now available

**** some coconut drinks have rice flour added which increases the carbohydrate content

*****UHT cow’s milk has lower vitamin B12 levels of 0.2µg per 100ml

Soya drinks - Tesco, Sainsbury’s, Alpro no sugars, Acti leaf, Morrisons, ASDA, M&S

Pea drinks - Sproud, Mighty

Oat drinks - Oatly, Alpro, Tesco, Sainsbury’s, ASDA, Califia

Coconut drinks - Koko, Alpro, Morrisons, ASDA, Aldi

Almond-based drinks - Alpro, ASDA, Sainsbury’s, Almond Breeze

Sustainability credentials

Data shows that switching from cow’s milk to a PBD is a more sustainable option³⁸. According to Oxford University’s global data, as demonstrated in figure 1, some PBDs require up to eighteen times less land area, produce less than a quarter of the greenhouse gases, require a twentieth of the water and produce less than a tenth of the eutrophication effects when compared to cow’s milk³⁹.

Almonds have been criticised for a large water requirement, but with 371 litres of water needed to produce one litre, this remains far less than the global average of 628 litres needed for one litre of cow’s milk. While it has been claimed that UK dairy has improved its ecological footprint, it still ranks lower than plant-based equivalent products on many ecological parameters^{38, 40}.

Figure 1. Global environmental impact of 200ml serving of cow’s milk and PBDs on various environmental parameters³⁸.

Dispelling the myths

Recent media and social media content has been spreading misinformation on PBDs, raising unsubstantiated concerns for the public.

It has been claimed that seed oils, added to improve nutritional profile, mouthfeel, and texture, are ‘toxic’ and cause detrimental inflammation in the body. In reality, seed oils such as rapeseed oil are high in monounsaturated fat and lower in saturated fat, a combination that has been found to reduce levels of LDL-cholesterol^{41,42, 43} and potentially inflammation^{44, 45} and the risk of cardiovascular disease^{46, 47}.

Another concern involves the impact of PBDs, particularly oat drinks, on blood sugar levels. As oats are grains, they produce a liquid that is naturally higher in carbohydrates than other PBDs. Despite this, the glycaemic load (which also considers the effect of a normal-sized portion) of oat drink has been categorised as ’low’, meaning that they have a minor effect on blood sugar that is similar to cow’s milk⁴⁸. It is also important to note that blood sugar effects vary based on individual factors as well as the food matrix of the meal and diet as a whole.

Ultra-processed foods (UPFs), as categorised by the NOVA classification system, are a rising concern in the conversation about healthy diets. Due to processing methods and the addition of nutrients to fortify products, PBDs have been categorised as ‘ultra-processed’. However, there is no evidence linking plant-based drinks to adverse effects seen with UPFs such as processed meat and sweetened soft drinks. This classification system also overlooks the nutrient value of the final product, highlighting issues of using it in isolation to determine health effects^{49, 50}. In fact, the inclusion of some processed food items can provide important nutrients that contribute to a nutritionally adequate diet⁵¹.

Plant-based dairy alternatives have an important role in plant-based diets and have a positive impact on human and planetary health. Product development and innovation means that plant-based foods are continuing to adapt to emerging public health needs.

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