No Meat? So what should my Child Eat? Optimizing the Vegetarian Diet for Infants, Children, and Adolescents.

Shannon I. Holton, MPH, RDN, LDN Clinical Pediatric Dietitian Supervisor Vidant Medical Center Adjunct Instructor East Carolina University Disclosures

I have no disclosures for this presentation. Objectives

• At the conclusion of this presentation, you will be able to: – Define the current different types of Vegetarian Concepts – State which vitamins and minerals are of greatest importance in vegetarian diets – List strategies for offering advice to patients and/or families desiring to follow a vegetarian diet Review: What is a Vegetarian

The Vegetarian society (vegsoc.org) defines a vegetarian: “Someone who lives on a diet of , nuts, beans, seeds, , , fungi, algae, yeast and/or some other non-animal-based foods (ie. Vitamins, minerals) with/without dairy, honey, eggs. A vegetarian does not eat foods that consist of, or have been produced with the aid of products coming from living or dead animal.” Types of Vegetarian

• Lacto-ovo: Eat both dairy and eggs, the most common type of vegetarian diet. • Lacto-: Eat dairy but avoid eggs. • Ovo-: Eat eggs but not dairy. • Vegan: No dairy, eggs or any other products derived from animals (ie. honey) AAP Comments

• is a way of life for many individuals for various reasons. However, there can be potentially serious implications for the growing pediatric and adolescent population as a result of self- imposed or misguided limitations of the vegetarian diet. Therefore, pediatricians should proactively ask and assess the nutritional status of their vegetarian patients to ensure optimal health and growth, as well as provide anticipatory guidance to prevent any potential deficits. …

• As with any dietary pattern, the degree of adherence to vegetarian patterns varies, and thus, overall nutrient intake differs from one vegetarian to the next. Most dietary patterns can be accommodated while fulfilling nutrient needs with appropriate dietary planning based on scientific principles of sound nutrition. Most vegetarian parents welcome such advice. However, when goals are zealously pursued and nutrition principles are ignored, the health consequences can be unfortunate, especially for infants and young children. Overall, it is possible to provide a balanced diet to vegetarians and vegans… http://letthemeatmeat.com/post/91384994887/the-american-academy-of-pediatrics-on-a-vegan-diet Academy of Nutrition and Dietetics Position

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. -based 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, , 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.

J Acad Nutr Diet. 2016 Dec;116(12):1970-1980. doi: 10.1016/j.jand.2016.09.025. Benefits of a Vegetarian Diet

• Reduced risks: – Obesity – Type 2 diabetes – Hypertension – Heart disease – Some types of Cancer Growth on a Vegetarian Diet

• There is sufficient evidence based on well- documented studies to show that growth and energy intake are comparable to non- vegetarian children.

Academy of Nutrition and Dietetics, 2016 Research

• Since the 1980’s there has been research that show well-balanced vegetarian diets can be adequate for adults. • Limitations: Many studies in children have been small cohorts with socio-economic bias that may be limiting to the general population, particularly in lower-income, more food insecure areas of the country. Research: Growth

• Long-term study beginning in 1968 on 39 vegan children (Sanders, 1988): – Regular height, weight, and head/chest circumference.

• “The Farm Study” (O’Connell,1989) : 404 children aged 5 months to 10 years, 75% vegan. – Smaller at young age (<5 years) • -2.01cm between 1-3 years of age. – Non-significant linear growth deviation after 5 years – 1.1kg lighter at ages 9-10. Research: *Note on Growth

• Significant linear growth occurred in early 1900’s with the doubling of cow’s milk consumption. – Ex. Between 1875 to 1920, 19 yr old army recruits were 4cm taller! – “Growing up Today” study: • Boys drinking 2 glasses cow’s milk per day were 2.3cm taller than those who drank 1 glass or less. • Girls drinking 2 glasses cow’s milk per day were 1.3cm taller than those who drank 1 glass or less. Nutrients to Consider

• Iron • Calcium • Zinc • Vitamin B12 • Vitamin D • Vitamin A • Fat and Fatty acids Iron

• RDA: 7-11mg per day for Omnivores • RDA: 1.8x higher for Vegetarians – Nonheme iron less bioavailable • Heme iron sources: Meat, seafood • Nonheme iron sources: Nuts, beans, vegetables, and fortified grains. • *Breastmilk – high bioavailability but insufficient amounts once babies stores deplete (around 6 mos of age for term) Iron Deficiency

• Functional: – GI disturbances, impaired cognition (learning difficulties), temperature regulation, fatigue • Physical exam: – Pale skin, brittle nails, cold extremities, swollen tongue. • Frequency in Veg. diets – Overall low if high and consumption due to higher intake of ascorbic acid (Vit C), assists with absorption of nonheme iron foods. – Infants: breastmilk fortification recommended; soy formula is fortified (overall at least 0.5mL poly-vitamin with iron is suggested) Calcium

• RDA: 200-1300mg for all diets/types. • Food Sources: – Animal: Mainly Dairy – Plant: Leafy vegetables, fortified- , juices, soy – Water • *Breastmilk – not dependent on mother’s diet. Adequate. Calcium Deficiency

• Functional and Physical Exam: – Numbness, tingling, poor appetite, abnormal heart rhythms. Long-term rickets (bone demineralization, seizure. • Frequency in Veg. diets – No recent data, in 2002 small study showed while Calcium intake was lower, no effect on bone health. Zinc

• RDA: 0-5 years 2-5mg per day • RDA: 5-18+ years 8-12mg per day • Vegans may require up to 50% more • Food Sources: – Animal: Oysters, red meat, poultry crab, lobster – Plant: beans, nuts, fortified whole grains • Bioavailability is less in plant-based foods. Zinc Deficiency

• Physical Exam: – Growth retardation, hair loss, delayed sexual maturation, eye and skin lesions, delayed wound healing • Functional Exam: – Impaired immune function, diarrhea, hypogonadism in males, taste changes, mental lethargy. • Frequency in Veg. diets: no data on children. In adults lower serum concentrations in vegan adults. Vitamin B-12

• RDA: 0.4-2.4mcg • No separate RDA for vegan/vegetarian • Food Sources: – Animal: meat, poultry, fish, eggs, milk – Plant: fortified cereals, • *Breastmilk – present in breastmilk, however if Mom is vegan, infant with lower reserves at birth and after, supplementation needed. Vitamin B-12 Deficiency

• Physical Exam: Failure to thrive in infants, weight loss in older children • Functional: megaloblastic anemia- fatigue/weakness, constipation, poor appetite, neurologic- poor memory, developmental delay • Frequency in Veg diets: small studies with children, higher supplementation rates than adults. While RDA not met, no overt signs of deficiency (Ambroszkiewicz, 2006) Other Nutrients

• Vitamin D: – Risk for all infants: recommended 400 IU supplementation for all infants/children whether breastfeeding or formula feeding. • Vitamin A: Only in meat, vegans have to convert carotenoids (yellow, orange, leafy greens). Three servings per day Other Nutrients

• Protein: More than adequate amounts in • Fat/Fatty acids: No usual effects on growth vegan/vegetarian noted however diets. Complementary recommend use of proteins! flax, canola oil, soy,and nuts like walnuts (precursors to linolenic acid). Subjective Assessment

• Diet history/Diet recall – What, how much, how often • Allergies/Intolerances – Quantify: stooling, vomiting amount, color, frequency • Feeding environment – Sitting in high chair, dinner table/family style Assessment: Medical

• Primary Care? • Immunizations up to date • Development: on time with milestones • Medical/Surgical History: acute, chronic • Frequent illness: infections, fevers Assessment: Social

• Parental background: education, occupation, stressors • Who cares for the child? • Support (financial): income, supplemental food programs: food stamps, WIC. Advice for Families

• Ensure access to a variety of fruits, vegetables, and whole grains • Use diet history to focus on possible areas of deficiency – *Iron, B-12, Calcium • Consult with a Dietitian if risks identified • Provide reliable resources/handouts to allow them to weigh benefits/risks for their children. – Some vegan adults choose to provide lacto/ovo diets in smaller children Tools Tools Tools Tools Summary

• Well-planned, well-balanced vegan/vegetarian diets have some evidence of protection against child/adolescent obesity (Sabate, 2010)

• Exposing kids of all ages to a variety of plant foods can help promote healthier habits later on References

• Hoppe C, Mølgaard C, Michaelsen KF. Cow’s Milk and Linear Growth in Industrialized and Developing Countries. Annu Rev Nutr 2006;26(1):131–73. • Sanders TA. Growth and development of British vegan children. Am J Clin Nutr 1988;48(3):822–5. • Definition of [Internet]. Vegan Soc. [retrieved 2018 Sept];Available from: https://www.vegansociety.com/go-vegan/definition-veganism • O’Connell JM, Dibley MJ, Sierra J, Wallace B, Marks JS, Yip R. Growth of Vegetarian Children: The 64 Farm Study. Pediatrics 1989;84(3):475–81. • Fact sheet for health professionals [retrieved 2018 Sept]; Available from: https://ods.od.nih.gov/factsheets/ • Gibson, RS, Heath AM, Szymlek, EA (2014). Is iron and zinc nutrition a concern for vegetarian infants and young children in industrialized countries? J Clin Nut 100(suppl): 459S-468S • Melina V, Craig W, Levin S. Position of the Academy of Nutrition and Dietetics: Vegetarian Diets. J Acad Nutr Diet 2016;116(12):1970–80 • Matkovic V, Badenhop-Stevens N, Ha E-J, Crncevic-Orlic Z, Clairmont A. Nutrition and bone health in children and adolescents. Clin Rev Bone Miner Metab 2002;1(3–4):233–48. • Ambroszkiewicz J, Klemarczyk W, Chełchowska M, Gajewska J, Laskowska-Klita T. Serum homocysteine, folate, vitamin B12 and total antioxidant status in vegetarian children. Adv Med Sci 2006;51:265–8. • Sabate J, Wien M. (2010) Vegetarian diets and childhood obesity prevention. Am J Clin Nutr.; 91(5): 1525S-1529S • Amit M, Canadian Paediatric Society, Community Paediatrics Committee (2010). Vegetarian diets in children and adolescents. Paediatr Child Health; 15(5), 303-314 • Baroni, L, Goggi, S, Battino, M [retrieved 2018 Sept]. Planning well-balanced vegetarian diets in infants, children, and adolescents: The vegplate junior. J Acad Nutr Diet.