Vegetarian Diets and Children - Sanders & Reddy, AmJClinNutr 1994

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1 l76S Am J C lin N u tr l994 :5 9(su pp l):l 1765 -815 . P rin ted in U SA . © 1994 A m erican Soc iety fo r C lin ica l N utritio n

Vege ta rian d ie ts and ch ild ren ”2

TAB Sanders and Shee la R ed dy

ABSTRACT T he d iets and g row th ofch ild ren rea red o n v eg -

e ta rian d ie ts are rev iew ed . E xcess ive bu lk com bined w ith low

energ y density can be a prob lem for ch ild ren aged y and can

lead to im pa ired grow th . D ie ts tha t have a h igh con ten t o f phy ta te

and o ther m od if ie rs o f m in era l abso rp tio n are asso cia ted w ith an

increased prev a lence o f ricke ts an d iron-deficiency anem ia . V ita -

mm B - I 2 defic iency is a rea l hazard in un sup p lem en ted or u n-

fo rtified vegan and vege ta rian d ie ts . It is sugges ted tha t veg an s

and vege ta rian s shou ld use o ils w ith a low ra tio o f lino le ic to

lin o le n ic acid in v iew of th e re cen tly re co gnized ro le of do co-

sah ex aen o ic ac id in v isu al func tion ing . If know n p itfa lls a reavo ided , the grow th and deve lo pm ent o f ch ild ren rea red on bo th

vegan an d vege ta rian d ie ts appears no rm al. Am J C liii N u tr

1 99 4; 59 (s up pl ): l 1 76 5- 81 5.

KEY W ORDS V ege ta rian , vegan , g row th , v itam in B -12 ,

v itam in D

In troduct ion

The popu la rity o f vege ta rian ism has increased grea tly over th e

p ast few years b ecause of con cern s ab ou t an im a l w e lfare , th e

env ironm ent, and hea lth y ea tin g . A ltho ugh veg eta rian ism is a

re la tive ly recen t ph en om enon in th e W est, it has been prac ticed

in A s ia for cen tur ies, espec ially b y fo llow ers of the H ind u re li-

g ion . T he health an d d ie t o f adu lt W es te rn vege ta rian group s has

been ex tens iv ely stud ied an d genera lly app ears to be good (I) .

A ltho ugh stric t vege tar ian o r v eg an d ie ts, in v iew of the ir low

sa tu ra ted fa t and h igh fibe r con ten ts, m ay offe r ce rta in adv an tages

to the h ea lth o f ad u lts , the ir adequ acy fo r ch ild ren h as b een a

m oot po in t (2 ). M ore recen tly , the adop tion of vege tar ian d ie ts

has been assoc ia ted w ith eating d iso rders in fem ale teenagers ,

w h ich lead to d iso rders o f m ens trua tio n (3 ). W id dow son and

M cC an ce (4 ), in the ir c lass ic experim en t car ried ou t a t the end

of W orld W ar II, c lea rly d em ons tra ted tha t ch ild ren w ill g row

and deve lop qu ite norm ally on a d ie t co nsis tin g of p len ty of b read

and vege tab les w ith m in im al am oun ts o f m ilk and m eat. T here

is no doubt that a prop erly se lec ted vege tarian d ie t c an m eet a ll

the requ irem en ts o f g row ing ch ild ren , ye t m any h ealth p ro fes -

siona ls still rem ain co ncerned abou t the ad eq uacy of v eg eta rian

diets.

R isk o f nu trien t deficiency is g rea tes t d uring periods of phys-

io log ica l stress and acce le ra ted grow th . P rob lem s o f d ie ta ry in -

adequacy are m ore like ly to o ccur in ch ild ren than in adu lts, a s

th eir re qu irem en ts rela tiv e to b ody w eig h t are gre ater and they

are un ab le to ex er t the sam e degree of con tro l ov er w h at they ea t

com pared w ith adu lts. S evere m alnu tritio n has been rep orted in

in fan ts and todd le rs fed inap propria te vege ta rian d ie ts (5 , 6 )

w ell as defic ienc ies o f iro n , v itam in B - 1 2 , an d v itam in D .

T h e adequacy of m ost d ie ts is judged by th e foo ds inc lud ed i

the d ie t, w hereas vege tar ian d ie ts a re d efin ed b y w hat fo ods ar

exc luded . P rob lem s are m ore lik ely to arise ifthe varie ty o f fo ods

m aking u p th e d ie t is res tric ted an d particu la rly w hen the con-

sum ptio n of da iry produ cts is low . V ege ta rian d ie ts th a t con ta in

reason ab le am ounts o f m ilk prod uc ts and eggs are less like ly

be inadequa te than veg an d ie ts . A s a ru le , the grea ter the v ar ie ty

of fo ods tha t m ake up the d ie t, the be tte r the chances tha t a ll th

nu trien ts w ill be prov ided .In W estern deve lop ing coun tries , econ om ic fac to rs do no t p lay

as m ajo r a ro le in res tr ic ting food cho ice as they do in o the

deve lop ing co un tries. F or exam ple , the re is c lear ev idence th a

the grow th of in fan ts rea red on vege ta rian d ie ts is re ta rded com -

pared w ith th ose eating m ixed d ie ts in Ind ia , w h ere pov erty , in

tes tina l in fes tation , an d h igh p ar ity a re comm on, and th a t these

in fan ts a re a lso a t inc reased risk of anem ia7 ). O n the o ther h an d ,

w h en p eop le o f Ind ian orig in m igra te to deve loped coun tries and

m ain tain the ir veg eta rian d ie ta ry prac tices bu t consum e m ore

da iry pro duc ts, the im pac t o f th e vege ta rian d ie t o n grow th

m ore lim ited (8 , 9 ).

M ost rev iew s on the in fluence o f vege ta rian d ie ts on ch ild ren

have focu sed on stud ies o f w hite p opu la tions such as S even th -

day A dven tis ts , com m une-dw elling vege tar ians , o r e th ica l veg-e ta rians . In the U nited K ingdom there is a la rge e thn ic m inority

( o ne m illion ) o f Ind ian orig in . O ne sube thn ic g rou p , th

G u ja ra ti po pu la tion , a re p red om inan tly H ind u and are life lon g

vege ta rian s. T he G uja ra ti pop u lation orig in ates f rom the northe rn

Ind ian s ta te o f G uja ra t a lth ough m any imm igrated f rom Eas

A frica . T he o ther m ajo r sub group s in the U nited K ingdom orig -

m ate from th e P un jab or B enga l, a re n o t v eg e ta rians , and fo llow

eithe r the M uslim or S ikh re lig ions . C om parisons co u ld b e m ade

be tw een these d iffe ren t g roups to s tudy the lifelon g effec ts

vege ta rian d ie ts.

S tud ies on the grow th and deve lopm ent o f veg eta rians a re con-

foun ded by the d iffe ren t reaso ns fo r fo llow ing th e d ie ts. V ege-

tar ian ism m ay be asso cia ted w ith d iffe ren t life sty les and attitudes

tow ard h ealth as w ell as tow ard the use of hea lth ca re fac ilitie s .For exam ple , som e e th ica l vege ta rian s w ill re fuse to be imm u -

n ized ag ains t po lio , tubercu los is , an d pertussis on the g round s

th at the an tise ra are p repared from an im als. C h ildhood illn esses

F rom the D epartm en t o f N utrition and D ie te tics , K ing s C o llege , U ni-

versity o f L ondon .2 Reprin ts n o t ava ilab le . A dd ress co rresp ondence to TA B Sanders ,

D epartm en t o f N u trition and D ie te tic s, K ings C olleg e, U n iv ersity o

London , C am pden H ill R oad , L ondon , E ng land W 8 7A H .



V EGETA RIA N CHILDREN ll77S

‘ S tandards from reference 23 .

can cause g row th faltering and thus influence grow th indepen-

dent of diet.

Meat and f ish prov ide several nutrients that are scarce or absent

from common foods of plant o rig in and these inc lude iodine,

taurine, v itam in B -l2 , v itam in D , and long -chain polyunsaturated

fatty ac ids such as e ico sapentaeno ic (2 0 :5n-3 ) and docosahexa-

eno ic ac id (D HA ) (22 :6n-3 ). M eat and fish also make a signif-

icant contribution to pro tein intake although prote in requirements

are easily met by veg etarian diets e spec ially if they are derived

from a varie ty o f dietary sources . M eat is an important source o f

iron in the die t and the heme form is particularly w e ll absorbed.

Iron intakes o f vege tarians are s trong ly dependent on the iron

content o f staple foo ds, w ith w heat being far superior to rice.

Plant foo ds contain a number o f subs tances that modify the ab-

sorptio n o f several m inerals such as iro n, z inc , and calc ium .

These modifiers occur in higher concentratio ns in the unre fined

cereals that are favo red by many vege tarians. This adds ano ther

dimens ion to the pro blem as some vege tarian groups are against

proce ssing food and advo cate the consumption o f raw food.

These vege tarian g roups , particularly those w ho eat larg e

amounts o f unre fined, unleav ened cereals (eg , brow n rice and

chapatis) may hav e problems w ith the absorption of certainm-

erals. This may lead to iron-de fic iency anem ia and ricke ts . This

problem can also occur in indiv iduals w ho consume small

amounts o f fish and meat and thus is no t a problem spec ific for

v e g e t a r i a n s .

This paper rev iew s the nutritional adequacy o f v egan and veg -

e tarian diets for children and identif ie s the conditions under

w hich nutritional de ficiency can arise . It also lo oks at the influ-

ence of v eg etarian diets on g row th and considers some new de-

v elopments in essential-fatty -ac id nutrition.

B irth w eight

The duration o f pregnancy is a4 -5 dhorte r in H indu veg e-

tarians and both an earlie r onse t of labor and cesarian sections

are more common in Hindus than in the w hite populatio n in the

U nited K ingdom (1 0 , 1 1 ). S udden-infant-death sy ndrom e is le ss

common among the A sian subpopulation in the United Kingdom

(1 1 ). Babie s born to Hindus are lighter than those born to

Muslim s or w hite s even w hen adjustments are made for gesta-

tional age and maternal frame size. It has been sugges ted that

this m ight re flect poor nutritional s tatus , e spec ially zinc and co p-

per status, but measurements o f serum concentrations o f these

minerals failed to show ev idence of deficiency (12 ). W e recently

confirmed the shorter duratio n o f pregnancy and that birth

we ight, head circumference, and length are all low er in the H indu

vegetarian population even after correcting fo r ge stational ag e,

sex o f infant, parity , smoking habits, maternal ag e, and he ight

(13 ) . The mean adjus ted birth w eight was 240 g lighter in the

Hindu vege tarian population compared w ith the nonvege tarian

w hite po pulatio n. This is g reater than the 19 0 g difference that

w as prev ious ly reported for Hindu subjects in the U nited K ing -

dom . Low er birth w e ights have also been repo rted in w hite pop-

ulations w ho consume macrobio tic die ts, w hich are predom i-

nantly v eg etarian (14). How ever, it is uncertain w hether the

low er birth w e ight in those communitie s is assoc iated w ith a

shorter duration o f pregnancy . D agne lie (1 4 ) no ted that macro -

biotic subjec ts who consumed fish more than once a w eek gave

birth to babies who were 1 80 g heavie r. W e also repo rted a

tendency for low er birth w eights in the v egan population (15 ).

It seem s almo st certain that low er birth w eights in the vege -

tarian populatio n are due to die t. A lthough defic ienc ie s o f m icro -

nutrients may have an important influence on early preg nancy ,

they are not believed to affe ct birth w eight because o f the ef

ciency of the placenta in extracting micronutrients from the cir-

culation. N everthe le s s, fac to rs that influence placental dev e lo p-

ment and blood flow could influence birth w e ig ht. Energy intake

is believed to be a majo r fac tor that influences birth w eight. E

ergy intakes are low in Hindu vege tarian w omen. Moreover, 5ev

eral s tudies show ed that w omen w ith habitually low energy

takes gave birth to heavie r babies w hen g iven additional fo od

energy (16 ). The practice of fasting in Hindu women could lea

to decreased availability o f g lucose for the fe tus. How ever, there

is no ev idence to sug gest that energy intakes are low er in H indu

vege tarians compared w ith M us lim w omen (17 ).

It is possible that low er birth w e ight o f infants born to vege -

tarian w omen is re lated to po or nutritional status fo r iron, fo late ,

or v itam in B - l2 , w hich w ill be discussed later. W hether o r no

low er birth w e ight in the vege tarian population is o f any patho -

physio log ical s ignificance is unc lear.

Growth

Gujarati children tend to be an average o f 3 cm shorter than

w hite children (9 ). How ever, A sian children born in the U nited

K ingdom are taller than those born in Eas t A frica, India

Pakistan, or B ang ladesh. This m ay be attributed to improved nu-

trition and a low inc idence o f infec tio us disease s (I 8 ). Th

g row th o f the w hite S ev enth-day A dventist (SDA ) vege tarian

population appears v irtually indis ting uishable from that o f w hite

omnivores (19 , 2 0 ). Low er g row th rate s particularly in the firs

5 y o f life have been reported in children reared on v eg an (2 1

2 2 ) and macrobio tic diets (1 4 ). D espite low er rate s o f grow th

the firs t 5 y o f life , catch up grow th occurs by the ag e o f 10 y

(Table 1) ( 1 4 , 24 ). He ight is norm al in vegan children but there

is still a tendency for them to be lighter in pro portion to the ihe ight than children consum ing m ixed die ts. The low er rate s o

grow th observed in some vege tarian children aged <y can be

attributed to low energy intakes . The bulky nature and low energy

dens ity o f some vege tarian die ts re s tric ts the amount o f food

TA BLE 1

A nthropometric measurement o f 2 0 vegan children

M ean Rang e

He i g h t

Percent s tandard for age (%)‘ 100.7 89 .7 - 1 1 0 .8

M edian centile for age 5 5 <3 ->97

We i g h t 95.5 7 7 - 1 1 9

Percent s tandard for age ’

M edian centile for age 3 5 3 -88

Head circumference (cm ) 53.9 51-55 .5

Median centile for age 94 50 - >97

B iceps skinfo ld thickness (mm) 2 .1 1 .8 -2 .9

Triceps skinfo ld thickness (mm) 2 .7 1 .9 -3 .7

M edian centile fo r ag e <3 <3

Subscapular skinfo ld thickness (mm) 5 .2 3 .6 -5 .9

M edian centile for age 25 <3 -50

A ge (y ) 9. 5 5 .8 -12 .8



l l78S SA N DERS A N D RED D Y

TAB LE 2

W eig hts o f foo d making up the daily diet o f 1 8 vegan children’

Food Weight

g

Bread 13 7

B reakfas t cereals 33

O ther cereals 63

Cakes and biscuits 21Fa t s 2 9

Vegetables 88

P o t a t o e s 1 6 2

O ther roo t vege tables 42

L eafy v eg etable s 34

Pulse s, including soya m ilk 23 9

Fr e s h f r u i t 2 1 6

Dried f r u i t 1 3

N uts 25

S u g a r 4

Jam 5

Confectionary 5

Fruit juice and so ft drinks 23 8

Ot h e r s 2 0 5

I Number o f foo ds making up diet, .i(range ) = 5 5 (3 0-8 4) .

energy that can be consumed. Children ag ed >y are able to

exert the ir ow n fo od pre ferences and are able to forag e for food

in the home . Energy intakes in o lder veg an children are sim ilar

to those o f children consum ing m ixed die ts.

W eig ht, in particular the proportion o f bo dy fat, is a good

predic tor o f the rate o f sexual maturation. A dipo se tissue plays

an im portant ro le in the peripheral arom atization o f androgens to

form estrog ens. It w ould be predic ted, there fo re , that ag e o f men-

arche m ight be de layed in children reared on vege tarian die ts . A

later age o f menarche has indeed been no ted in SDA vege tarian

g irls (2 5 ). In our ow n studie s ag e o f menarche w as s lig htly higher

in children reared as v eg ans or v eg e tarians (be tw een 13 and 15

y o f age , TA B Sanders, unpublished observatio ns, 1 992 ) but cer-

tainly no t as high as > 1 6 y , seen in China and in the pas t century

i n E u r o pe .

D ie tary intakes

N umerous s tudie s hav e measured nutrient intakes in w hite

vegan and vege tarian children (1 9 -22 , 2 4 ). How ev er, indiv iduals

w ho are able to keep an accurate die tary invento ry are generally

w ell educated and info rmed and therefo re may not be truly rep-

resentative o f the v egan or v eg e tarian populatio ns. A major dif-

ference be tw een w hite v egan and v ege tarian groups and those

fo llow ing A sian vege tarian or macrobio tic diets is the use o f

bread as a die tary staple and the use o f soy pro ducts in the w hite

vegan and vege tarian groups. There are few qualitative differ-

ences in the die ts o f bo th w hite v eg ans and v eg e tarians compared

w ith omnivore s w ith the exception o f the intakes of v itam in B -

1 2 and, in vegans , calc ium . The intake o f all o ther essential nu-

trients is s im ilar or reater in vegan o r vege tarian children than

in children reared on m ix ed die ts . Fat intakes tend to be s lig htly

low er, pro v iding 30 -35% of dietary energy , in vegan and v eg -

etarian children and carbohydrate intakes are hig her, 5% of

die tary energy .

M ost vegan children are breas t-fed w e ll into the second year

o f life and problem s o f nutritional inadequacy are only like ly t

occur if the infants are premature ly w eaned onto an unsuitable

breast-m ilk subs titute (2 ). Many o f the po tential hazards o f vegan

die ts can be avo ided by the use o f fortified soy a m ilks in th

pos tw eaning period. The diets consumed by veg an and vege tar-

ian schoo lchildren are usually sim ilar to those consumed b

adults. Table s 2 and 3 show the typical nutrient compos ition

consumed by British vegan children compared w ith other chil

dren o f the same age co nsum ing m ixed die ts. The vegan die ts

w ere based aro und who le-m eal bread as a s taple and contained

plenty o f so y products (24 ). This c learly illus trates the s im ilarity

o f vegan die ts and m ixed die ts w ith respec t to nutrient co ntent.

Iron-deficiency anem ia

The A s ian vege tarian populatio n has a higher inc idence o

iron-de fic iency anem ia compared w ith the g eneral population

(24 ). Infants and pregnant w omen are most susceptible w ith in

c idences be ing highes t in those w ho re ly o n rice as a staple

the ir die t rather than w heat (28 ). A prev alence as high as 40%

(hemog lobin < 1 10 gIL) w as found in A sian infants aged 22 mo

(29 ). Iron-de fic iency anem ia in infancy is asso ciated w ith late

w eaning prac tice s. It has also been reported in macrobio tic v eg -

e tarians (30 ). How ever, iron intakes appear to be high in vege -

tarians and vegans whose staple fo ods w ho le -meal bread. He-

mog lobin concentrations are generally no rmal in bo th SD A and

B ritish vegans and v ege tarians . S erum fem tin concentrations are

low in vege tarian w omen of childbearing age (3 1 ) and this may

mean that infants born to v ege tarians have low er s tores o f iron.

TA BLE 3

N utrient density o f the vegan children’s die ts compared w ith B ritish

omnivo rous children, exc luding supplements

Omn i v o u r o u s

V egan children

a g e d 6 - 1 3 y ’

children ag ed

7 - 1 2 y 2

Energy (percent o f RD A )3 (%) 83 ± 15 .7 8 2

Pr o t e i n ( g I MJ ) 7 . 4 ± 1 . 2 2 7 . 3

Fat (g IM J) 8. 3 ± 1 .52 9 .8

Carbohydrate (g IM J) 35 .3 ± 8 .79 3 2 .1

Fiber(g/MJ) 5. 2 ± 1 . 0 5 2 . 2

Ca l c i u m( mg I MJ ) 6 4 . 3 ± 1 1 . 5 9 5 . 2

I r o n ( mg / Mi ) 3 . 0 ± 1 . 7 1 1 . 4

Zinc (mg /M i) 1 .0 ± 0 . 2 0 0 . 9

Copper (mg fMJ) 0 .23 ± 0 .03 0 .23

V itam in A (REIM J) 13 0 ± 48 .1 88

T h i a mi n ( mg I MJ ) 0 . 2 3 ± 0 . 0 5 0 . 1 5

Ribo f lav in (m gfM J) 0 .24 ± 0 .1 17 0 .20

N iac in (N EIM J) 3 .33 ± 0 .72 3 .36

V itam in B 6 ( mgIM J) 0 .1 9 ± 0.045 0 .16

V itam in B 12 (tg IMJ) 0 .31 ± 0 .28 1 0 .39

Total fo late (g IM J) 35 ± 7 . 1 18

B io tin ( g IMJ) 2 .6 ± 0 .70 1. 9

V i t a mi n C ( mg / MJ ) 1 3 ± 5 . 8 9 . 1

V itam in D (pg /M J) 0 .26 ± 0 . 14 0 .21

V itam in E (mg /M J) I . 05 ± 0 . 193 0 .60

‘ i ± SD: n = 1 8 .

2 , 194 .

3 Recommended daily amount from reference 26 .



V EGETA RIA N CHILDREN 1 l7 9S

K im et al (3 2 ) found that low birth w e ight and inadequate ges-

tational w e ight w ere strong ly asso ciated w ith anem ia in the first

trim es ter. Scho ll e t al (3 3 ) found that low fem tin concentratio ns

( < I 2 pg fL) in early pregnancy are asso ciated w ith an increased

risk o f prematurity and low birth w e ight. The use o f iron supple-

ments during pregnancy may be des irable in these g roups .

V itam in B -12 de fic iency

The inc idence o f megaloblastic anem ia resulting from corn-

bined v itam in B -1 2 and fo late de fic iency in A sian v eg etarians is

three tim es higher than the UK national av erag e (34 ). M eg alo -

blas tic anem ia may be precipitated during pregnancy and babie s

may also be prone to deve lop sev ere v itamin B -12 de ficiency,

particularly if breast-fed w ith m ilk o f low v itam in B - 12 content

(35 ). M egaloblastic anem ia is rare ly enco untered in w hite v eg ans

and v eg e tarians because o f the ir high intakes o f fo late . Conse-

quently , v itam in B -1 2 de fic iency usually presents w ith neuro lo g -

ical signs and symptoms in infants (36 , 37 ). Many vegans are

aw are o f the need to supplement the ir die ts w ith v itam in B -1 2

but intakes are o f ten to o low . V ege tarians may also need to con-

sider supplementing the ir die ts w ith v itam in B -l 2 . M any pro -

cessed foods are fortified w ith v itam in B -l2 but these fo ods are

no t necessarily acceptable to e thical vege tarians. B o th v eg ans

and vege tarians c learly need to be v ig ilant to avo id v itam in B -

1 2 d e f i c i e n c y .

Rickets

Cases o f ricke ts affec ting bo th vege tarian and nonvege tarian

groups in the A sian e thnic m ino rity in the U nited Kingdom have

been reported fo r > 30 y (38 ). ‘ ‘A sian ricke ts ’ ‘ differs from v ita-

mm D defic iency because it is fo und not only in infancy but

thro ughout childhood and ado le scence (39 ). In a formal asse ss -

ment o f the prevalence o f nutritional rickets , Ho lm es et al (40 )

fo und that 30% of A s ian children had c linical rickets compared

w ith 4% of w hite children. S ignificantly low er concentrations o f

25 -hydroxycho lecalcifero l w ere found in A s ians compared w ith

w hi te s; c onc entratio ns < 1 2 .5 nmolIL occurred in 3 3% of A s ian

g irls and 22% of A s ian bo ys (4 1. From seasonal measurements

o f the plasma concentratio ns o f v itam in D , it is c lear that A sians

do no t accumulate stores o f v itam in D during the summer months

because o f lim ited expo sure to sunlight (42 ) . The prev alence o f

A s ian ricke ts appears to have dec lined (43 ). The exac t reaso n for

the dec line remains unknown.

Fac tors know n to influence ricke ts are the die tary intake o f

v itam in D , ex posure to sunlig ht, and the availability o f dietary

calc ium . N aturally occurring die tary sources o f v itam in D are

lim ited and are conf ined to liv er and o ily fish, altho ugh several

foods such as margarine and breakfas t cereals are fortified w ith

the v itam in. A lthough skin pigmentation may decrease the ca-

pac ity to synthes ize v itam in D , ricke ts is uncommon in the A fro -

Caribbean subpopulation. Modifiers o f calc ium absorption, eg ,

phy tic ac id, contributed by unre fined cereals , particularly in

chaptis (unleav ened breads) , have been implicated as a cause o f

A s ian ricke ts, and the reduc tion o f die tary phy tic ac id has been

show n to promo te healing (44 ). Heath (45 ) pro posed that hig h

phy tate die ts increased v itam in D requirements. It is know n that

low availability o f calc ium from the die t increases parathyro id

ho rmone production and increases the catabo lism of v itam in

D ( 4 6 ) .

A high prevalence o f ricke ts has also been no ted in children

reared on macro bio tic die ts (4 7 , 48 ) . How ever, ricke ts is no t

problem in SD A vege tarians and vegans . It seem s likely that,

in A s ian rickets , the high phy tate content o f the macrobio tic die

is a contributing fac tor in the dev e lo pment o f ricke ts.

n-3 Fatty ac ids

D H A (22 :6 n-3 ) is be lieved to play an important ro le in the

retina and in the central nerv ous sy s tem (49 ). D HA is found

predom inantly in meat and fish and in small amounts in eggs and

m ilk but is absent from frequently consumed foods o f plant ori

g in. It can be synthesized to a lim ited extent from linolenic ac

(18 :3n-3 ) but this is subjec t to competitiv e inhibition from lin

o le ic ac id (I 8 :2n-6 ) (50) . Low er propo rtio ns o f D HA have been

found in bo th plasma and umbilical cord artery phospho lipids

from vege tarians compared w ith omnivores ( 1 5 ) . This is no t un

expec ted because low er proportio ns o f these fatty ac ids are found

in the plasma pho spho lipids o f v eg etarians . Low er co ncentrations

o f D HA w ere also found in the m ilk o f v egan m others comparedw ith omniv ore contro l subjec ts and the ery throcy te lipids o f th

infants also contained a low er propo rtio n o f D HA than infants

breast-fed by omniv orous mothers or those bo ttle -fed w ith a cow

m ilk formula. Recent studie s hav e show n that pre term infants

deprived o f D HA also show abnormalitie s in v isual and co rtical

functions (5 1. It is uncertain w hether the s ize o f changes re -

ported in vegans and vege tarians are suffic ient to result in marked

changes in physio log ical functioning . How ever, differences

maternal die t re sult in infants be ing born w ith different s tores o

essential fatty ac ids .

M any vege tarian and particularly v eg an diets are rich in lino -

le ic acid and have a high ratio of linole ic to lino lenic acid. Suc

a die t inhibits co nvers io n o fa-lino lenic ac id ( 1 8 :3 n-3 ) to D HA .

It m ig ht be appropriate to recommend vegans to use soybeancano la o ils instead o f sunf low er, safflow er, or co rn o ils for co ok-

ing as these o ils have low er ratio s o f lino le ic to a-lino lenic ac id.

Conclusion

Several hazards o f veg etarian die ts hav e been identif ied. These

inc lude iron de fic iency anem ia, v itam in B - 1 2 de fic iency , ricke ts,

and a bulky diet that can restric t energy intake in the first fe

years o f life . How ev er, these know n pitfalls are easily avo ided.

A lthough g eneral health and deve lopment appears to be normal

in vege tarians there may be subtle differences compared w ith

omnivores. There is no ev idence to sugges t that neural func tio n

or inte lle c tual function are impaired because o f a low er intake o

n-3 fatty ac ids. Impaired psy chomotor deve lopment has been

repo rted in prev ious ly malnourished macro bio tic infants but

fo llow -up s tudy reported hig her than average inte llig ence quo -

tients in o lder macrobio tic children (52 ) , w hich confirmed a

earlier observatio n made on a different macrobio tic community

(5 3 ). This , how ever, may ref lec t the high educatio nal status o

the parents . Furthermore, the educational attainm ent o f children

born to A s ian parents in the U nited Kingdom is above av erage

(54 ). How ev er, this does no t rule out the poss ibility that there

may be subtle differences in v isual or neural func tioning an

studie s in this area are w arranted. U



1 1 8 0S SA NDERS AND REDDY

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Vegetarian Diets and Children - Sanders & Reddy, AmJClinNutr 1994

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