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Vegetarian Diets and Children - Sanders & Reddy, AmJClinNutr 1994

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  • 8/8/2019 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 2TAB 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 lowenerg y density can be a prob lem for ch ild ren aged y and canlead to im pa ired grow th . D ie ts tha t have a h igh con ten t o f phy ta teand o ther m od if ie rs o f m in era l abso rp tio n are asso cia ted w ith anincreased 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 sand vege ta rian s shou ld use o ils w ith a low ra tio o f lino le ic tolin 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 thvegan an d vege ta rian d ie ts appears no rm al. Am J C liii N u tr1 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 ep ast few years b ecause of con cern s ab ou t an im a l w e lfare , th eenv ironm ent, and hea lth y ea tin g . A ltho ugh veg eta rian ism is are la tive ly recen t ph en om enon in th e W est, it has been prac ticedin 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 hasbeen 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 lowsa tu ra ted fa t and h igh fibe r con ten ts, m ay offe r ce rta in adv an tagesto the h ea lth o f ad u lts , the ir adequ acy fo r ch ild ren h as b een am oot po in t (2 ). M ore recen tly , the adop tion of vege tar ian d ie tshas 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 andM cC an ce (4 ), in the ir c lass ic experim en t car ried ou t a t the endof W orld W ar II, c lea rly d em ons tra ted tha t ch ild ren w ill g rowand deve lop qu ite norm ally on a d ie t co nsis tin g of p len ty of b readand vege tab les w ith m in im al am oun ts o f m ilk and m eat. T hereis no doubt that a prop erly se lec ted vege tarian d ie t c an m eet a llthe 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 riandiets.

    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 sth eir re qu irem en ts rela tiv e to b ody w eig h t are gre ater and theyare un ab le to ex er t the sam e degree of con tro l ov er w h at they ea tcom 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 ithe d ie t, w hereas vege tar ian d ie ts a re d efin ed b y w hat fo ods arexc luded . P rob lem s are m ore lik ely to arise ifthe varie ty o f fo odsm 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 inreason ab le am ounts o f m ilk prod uc ts and eggs are less like lybe inadequa te than veg an d ie ts . A s a ru le , the grea ter the v ar ie tyof fo ods tha t m ake up the d ie t, the be tte r the chances tha t a ll thnu 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 layas m ajo r a ro le in res tr ic ting food cho ice as they do in o thedeve lop ing co un tries. F or exam ple , the re is c lear ev idence th athe 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 , intes tina l in fes tation , an d h igh p ar ity a re comm on, and th a t thesein 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 andm ain tain the ir veg eta rian d ie ta ry prac tices bu t consum e m oreda iry pro duc ts, the im pac t o f th e vege ta rian d ie t o n grow thm 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 renhave 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 , thG u ja ra ti po pu la tion , a re p red om inan tly H ind u and are life lon gvege ta rian s. T he G uja ra ti pop u lation orig in ates f rom the northe rnInd ian s ta te o f G uja ra t a lth ough m any imm igrated f rom EasA 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 lloweithe r the M uslim or S ikh re lig ions . C om parisons co u ld b e m adebe tw een these d iffe ren t g roups to s tudy the lifelon g effec tsvege 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 attitudestow 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 sth 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 oLondon , C am pden H ill R oad , L ondon , E ng land W 8 7A H .

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    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 absentfrom 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 polyunsaturatedfatty 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 requirementsare easily met by veg etarian diets e spec ially if they are derivedfrom a varie ty o f dietary sources . M eat is an important source o firon 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 ironcontent 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 finedcereals that are favo red by many vege tarians. This adds ano therdimens ion to the pro blem as some vege tarian groups are againstproce ssing food and advo cate the consumption o f raw food.These vege tarian g roups , particularly those w ho eat larg eamounts o f unre fined, unleav ened cereals (eg , brow n rice andchapatis) may hav e problems w ith the absorption of certainm-erals. This may lead to iron-de fic iency anem ia and ricke ts . Thisproblem can also occur in indiv iduals w ho consume smallamounts o f fish and meat and thus is no t a problem spec ific forv 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 underw 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 eightThe 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 sectionsare more common in Hindus than in the w hite populatio n in theU nited K ingdom (1 0 , 1 1 ). S udden-infant-death sy ndrom e is le sscommon among the A sian subpopulation in the United Kingdom(1 1 ). Babie s born to Hindus are lighter than those born toMuslim s or w hite s even w hen adjustments are made for gesta-tional age and maternal frame size. It has been sugges ted thatthis 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 theseminerals failed to show ev idence of deficiency (12 ). W e recentlyconfirmed the shorter duratio n o f pregnancy and that birthwe ight, head circumference, and length are all low er in the H induvegetarian 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 theHindu vege tarian population compared w ith the nonvege tarianw hite po pulatio n. This is g reater than the 19 0 g difference thatw 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 thelow er birth w e ight in those communitie s is assoc iated w ith ashorter 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 gavebirth to babies who were 1 80 g heavie r. W e also repo rted atendency 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 efciency 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 intakeis believed to be a majo r fac tor that influences birth w eight. Eergy intakes are low in Hindu vege tarian w omen. Moreover, 5everal s tudies show ed that w omen w ith habitually low energytakes gave birth to heavie r babies w hen g iven additional fo odenergy (16 ). The practice of fasting in Hindu women could leato decreased availability o f g lucose for the fe tus. How ever, thereis no ev idence to sug gest that energy intakes are low er in H induvege 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 nolow er birth w e ight in the vege tarian population is o f any patho -physio log ical s ignificance is unc lear.

    GrowthGujarati 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 nitedK ingdom are taller than those born in Eas t A frica, IndiaPakistan, 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 ). Thg row th o f the w hite S ev enth-day A dventist (SDA ) vege tarianpopulation appears v irtually indis ting uishable from that o f w hiteomnivores (19 , 2 0 ). Low er g row th rate s particularly in the firs5 y o f life have been reported in children reared on v eg an (2 12 2 ) and macrobio tic diets (1 4 ). D espite low er rate s o f grow ththe 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 thereis 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 ogrow th observed in some vege tarian children aged 97

    B iceps skinfo ld thickness (mm) 2 .1 1 .8 -2 .9Triceps skinfo ld thickness (mm) 2 .7 1 .9 -3 .7

    M edian centile fo r ag e

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    l l78S SA N DERS A N D RED D YTAB LE 2W eig hts o f foo d making up the daily diet o f 1 8 vegan children

    Food Weight

    gBread 13 7B reakfas t cereals 33O ther cereals 63Cakes and biscuits 21Fa t s 2 9Vegetables 88P o t a t o e s 1 6 2O ther roo t vege tables 42L eafy v eg etable s 34Pulse s, including soya m ilk 23 9Fr e s h f r u i t 2 1 6Dried f r u i t 1 3N uts 25S u g a r 4Jam 5Confectionary 5Fruit juice and so ft drinks 23 8Ot 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 toexert the ir ow n fo od pre ferences and are able to forag e for foodin the home . Energy intakes in o lder veg an children are sim ilarto those o f children consum ing m ixed die ts.

    W eig ht, in particular the proportion o f bo dy fat, is a goodpredic tor o f the rate o f sexual maturation. A dipo se tissue playsan im portant ro le in the peripheral arom atization o f androgens toform 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 . Alater age o f menarche has indeed been no ted in SDA vege tariang irls (2 5 ). In our ow n studie s ag e o f menarche w as s lig htly higherin children reared as v eg ans or v eg e tarians (be tw een 13 and 15y 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 centuryi n E u r o pe .

    D ie tary intakes

    N umerous s tudie s hav e measured nutrient intakes in w hitevegan and vege tarian children (1 9 -22 , 2 4 ). How ev er, indiv idualsw ho are able to keep an accurate die tary invento ry are generallyw 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 thosefo llow ing A sian vege tarian or macrobio tic diets is the use o fbread as a die tary staple and the use o f soy pro ducts in the w hitevegan 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 comparedw 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 thanin children reared on m ix ed die ts . Fat intakes tend to be s lig htlylow er, pro v iding 30 -35% of dietary energy , in vegan and v eg -etarian children and carbohydrate intakes are hig her, 5% ofdie tary energy .

    M ost vegan children are breas t-fed w e ll into the second yearo f life and problem s o f nutritional inadequacy are only like ly toccur if the infants are premature ly w eaned onto an unsuitablebreast-m ilk subs titute (2 ). Many o f the po tential hazards o f vegandie ts can be avo ided by the use o f fortified soy a m ilks in thpos tw eaning period. The diets consumed by veg an and vege tar-ian schoo lchildren are usually sim ilar to those consumed badults. Table s 2 and 3 show the typical nutrient compos itionconsumed by British vegan children compared w ith other children o f the same age co nsum ing m ixed die ts. The vegan die tsw ere based aro und who le-m eal bread as a s taple and containedplenty o f so y products (24 ). This c learly illus trates the s im ilarityo f vegan die ts and m ixed die ts w ith respec t to nutrient co ntent.

    Iron-deficiency anem iaThe 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 inc idences be ing highes t in those w ho re ly o n rice as a staplethe 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 latew 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 andB ritish vegans and v ege tarians . S erum fem tin concentrations arelow in vege tarian w omen of childbearing age (3 1 ) and this maymean that infants born to v ege tarians have low er s tores o f iron.

    TA BLE 3N utrient density o f the vegan childrens die ts compared w ith B ritishomnivo rous children, exc luding supplements

    Omn i v o u r o u sV egan childrena g e d 6 - 1 3 y

    children ag ed7 - 1 2 y 2

    Energy (percent o f RD A )3 (%) 83 15 .7 8 2Pr o t e i n ( g I MJ ) 7 . 4 1 . 2 2 7 . 3Fat (g IM J) 8. 3 1 .52 9 .8Carbohydrate (g IM J) 35 .3 8 .79 3 2 .1Fiber(g/MJ) 5. 2 1 . 0 5 2 . 2Ca l c i u m( mg I MJ ) 6 4 . 3 1 1 . 5 9 5 . 2I r o n ( mg / Mi ) 3 . 0 1 . 7 1 1 . 4Zinc (mg /M i) 1 .0 0 . 2 0 0 . 9Copper (mg fMJ) 0 .23 0 .03 0 .23V itam in A (REIM J) 13 0 48 .1 88T h i a mi n ( mg I MJ ) 0 . 2 3 0 . 0 5 0 . 1 5Ribo f lav in (m gfM J) 0 .24 0 .1 17 0 .20N iac in (N EIM J) 3 .33 0 .72 3 .36V itam in B 6 ( mgIM J) 0 .1 9 0.045 0 .16V itam in B 12 (tg IMJ) 0 .31 0 .28 1 0 .39Total fo late (g IM J) 35 7 . 1 18B io tin ( g IMJ) 2 .6 0 .70 1. 9V i t a mi n C ( mg / MJ ) 1 3 5 . 8 9 . 1V itam in D (pg /M J) 0 .26 0 . 14 0 .21V 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 .

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    V EGETA RIA N CHILDREN 1 l7 9SK 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 firsttrim 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 increasedrisk 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 isthree 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 smay 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 ansand 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 areaw are o f the need to supplement the ir die ts w ith v itam in B -1 2but 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 areno t necessarily acceptable to e thical vege tarians. B o th v eg ansand 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 tariangroups in the A sian e thnic m ino rity in the U nited Kingdom havebeen 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 butthro 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 comparedw ith 4% of w hite children. S ignificantly low er concentrations o f25 -hydroxycho lecalcifero l w ere found in A s ians compared w ithw hi te s; c onc entratio ns < 1 2 .5 nmolIL occurred in 3 3% of A s iang irls and 22% of A s ian bo ys (4 1. From seasonal measurementso f the plasma concentratio ns o f v itam in D , it is c lear that A siansdo no t accumulate stores o f v itam in D during the summer monthsbecause o f lim ited expo sure to sunlight (42 ) . The prev alence o fA s ian ricke ts appears to have dec lined (43 ). The exac t reaso n forthe dec line remains unknown.

    Fac tors know n to influence ricke ts are the die tary intake o fv itam in D , ex posure to sunlig ht, and the availability o f dietarycalc ium . N aturally occurring die tary sources o f v itam in D arelim ited and are conf ined to liv er and o ily fish, altho ugh severalfoods such as margarine and breakfas t cereals are fortified w iththe 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 inchaptis (unleav ened breads) , have been implicated as a cause o fA s ian ricke ts, and the reduc tion o f die tary phy tic ac id has beenshow n to promo te healing (44 ). Heath (45 ) pro posed that hig hphy tate die ts increased v itam in D requirements. It is know n thatlow availability o f calc ium from the die t increases parathyro id

    ho rmone production and increases the catabo lism of v itam inD ( 4 6 ) .

    A high prevalence o f ricke ts has also been no ted in childrenreared on macro bio tic die ts (4 7 , 48 ) . How ever, ricke ts is no tproblem 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 dieis a contributing fac tor in the dev e lo pment o f ricke ts.

    n-3 Fatty ac idsD 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 foundpredom inantly in meat and fish and in small amounts in eggs andm ilk but is absent from frequently consumed foods o f plant orig 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 lino le ic ac id (I 8 :2n-6 ) (50) . Low er propo rtio ns o f D HA have beenfound in bo th plasma and umbilical cord artery phospho lipidsfrom vege tarians compared w ith omnivores ( 1 5 ) . This is no t unexpec ted because low er proportio ns o f these fatty ac ids are foundin the plasma pho spho lipids o f v eg etarians . Low er co ncentrationso 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 thinfants also contained a low er propo rtio n o f D HA than infantsbreast-fed by omniv orous mothers or those bo ttle -fed w ith a cowm ilk formula. Recent studie s hav e show n that pre term infantsdeprived o f D HA also show abnormalitie s in v isual and co rticalfunctions (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 markedchanges in physio log ical functioning . How ever, differencesmaternal die t re sult in infants be ing born w ith different s tores oessential 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. Suca 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.

    ConclusionSeveral 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 feyears 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 normalin vege tarians there may be subtle differences compared w ithomnivores. There is no ev idence to sugges t that neural func tio nor inte lle c tual function are impaired because o f a low er intake on-3 fatty ac ids. Impaired psy chomotor deve lopment has beenrepo rted in prev ious ly malnourished macro bio tic infants butfo llow -up s tudy reported hig her than average inte llig ence quo -tients in o lder macrobio tic children (52 ) , w hich confirmed aearlier observatio n made on a different macrobio tic community(5 3 ). This , how ever, may ref lec t the high educatio nal status othe parents . Furthermore, the educational attainm ent o f childrenborn 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 theremay be subtle differences in v isual or neural func tioning anstudie s in this area are w arranted. U

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