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Address correspondence to: Maurizio Battino, MD, PhD, Department of Clinical Sciences, Università Politecnica delle Marche, via Ranieri, 60100 Ancona, Italy.
Vegetarian diets, defined as being devoid of flesh foods (such as meat, poultry, wild game, seafood, and their products), are followed by a growing number of people worldwide because of ethical, health, and environmental reasons.
Vegetarian diets include a variety of plant-based foods such as grains, legumes, nuts and seeds, fruits, and vegetables, and may or may not include dairy products and eggs. Vegan diets exclude all animal foods.
Although for over 30 years we have known that well-planned vegetarian diets, including vegan, are nutritionally adequate and promote regular growth from the early years of human development on,
Complementary feeding: A position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition.
This may be at least partially accounted for by the fact that children following very restrictive vegetarian patterns, which limit food choices and calorie intake, have been described.
and therefore no conclusions about the growth of children following them should be made.
In Italy, 7.1% of the population follows a vegetarian diet (6.2% a lacto-ovo-vegetarian and 0.9% a vegan diet), a percentage that has nearly doubled in the last 5 years.
but so far none specifically for vegetarians aged 6 months to 17 years. Therefore, we designed the VegPlate Junior (VPJ), a Vegetarian Food Guide specific for dietary planning in infancy, childhood, and adolescence, and conceived to meet the Italian, as well as US, Dietary Reference Intakes (DRIs).
and are therefore suitable for promoting thriving and regular growth.
These criteria are:
•
Including a wide variety of plant foods, such as grains, legumes and their derivatives, nuts and seeds, vegetables, and fruit. Dairy products and eggs are considered optional.
•
Carefully choosing vegetable fats, consuming good sources of n-3 fatty acids, such as flaxseeds, chia seeds, and walnuts.
•
Including reliable sources of calcium and paying attention to the status of both vitamin B-12 and vitamin D.
The aim of the VPJ is to help health care professionals in advising vegetarian parents, because parental education plays a central role in achieving optimal dietary patterns in vegetarian children.
Dietary patterns in UK adolescents obtained from a dual-source FFQ and their associations with socio-economic position, nutrient intake and modes of eating.
The VPJ is based on six food groups, plus two cross-sectional groups of calcium-rich foods and n-3-rich foods. Methods for food selection and serving size calculation have been described in detail in the VegPlate for adults.
For each food group, we selected the most representative plant foods from the Mediterranean tradition. Serving sizes for each item were calculated so that within the same group they would all be isocaloric, and they are the same as those in the VegPlate for adults.
The average nutritional composition of one serving from each group was then calculated and used to determine the daily number of servings to consume from each group to satisfy the Italian DRIs
from 1 to 17 years of age, for calorie requirements ranging from 800 to 3,600 kcal.
Other foods listed, such as dairy products, eggs, or meat analogs, are proposed as possible foods to consume but were not included in the calculations, and they can be consumed according to personal preference. For the different calorie requirements, from 1 to 17 years of age, the number of servings in each group necessary to reach nutritional adequacy is listed in Table 1.
Table 1Number of servings in the VegPlate Junior for children and adolescents (from 1 to 17 years of age)
Energy requirements according to the Italian Dietary Reference Intakes10:1-3 y: 800-1,500 kcal4-6 y: 1,200-1,800 kcal7-10 y: 1,500-2,500 kcal11-14 y: 2,100-3,200 kcal15-17 y: 2,400 kcal-3,600 kcal.
The VPJ (Figure, A) is based on six food groups: grains, protein-rich foods, vegetables, fruits, nuts and seeds, and fats. The graphic draws attention to nutrients considered critical in vegetarian diets during all life stages: vitamin B-12 and vitamin D, located in the center of the plate, and calcium and n-3 fatty acids, whose food sources are represented as two cross-sectional groups. The basic graphic structure of the VPJ is the same as for adults,
We also developed an adaptation of the VPJ for infants (Figure, B), to be used during complementary feeding (from approximately 6 months of age). The VPJ for infants recommends including the seventh food group of breastmilk (or infant formula) during complementary feeding.
Use of the VPJ
Infants
The VPJ adaptation for infants is meant to help vegetarian dietary planning from the beginning of complementary feeding. During this period of life, children experience extremely rapid growth,
for which a good nutritional status is essential. Because breast milk of vegetarian mothers is similar in composition to that of nonvegetarian mothers and thus nutritionally adequate,
Complementary feeding: A position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition.
Breast or formula milk should be continued until at least 1 year of age, because it provides a large amount of the daily requirements of energy, calcium, and n-3 fatty acids.
In the first year of life, if the mother is not breastfeeding, the only alternatives are cow’s milk infant formula and soy or rice formulas for vegan infants.
Nonformula soy and rice beverages lack important nutrients and should not be offered as breast or formula milk substitutes until at least 12 months of age.
During complementary feeding, all solid foods from the VPJ are introduced in forms that do not constitute choking hazards (ie, nut butters instead of nuts),
Complementary feeding: A position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition.
To avoid early satiety, nutrient malabsorption, and poor growth, all of the offered foods to should be as low-fiber and as energy- and nutrient-dense as possible.
Dairy products and eggs from the protein-rich food group are considered optional, and they should be included in the diet according to parents’ choices and beliefs. These recommendations apply also to meals or snacks offered to infants undergoing baby-led weaning.
Fats are the primary source of energy for all infants and help vegetarian babies to easily reach their calorie requirements. Because fats play an important role in brain development, they should not be limited but carefully chosen to maintain an optimal n-3/n-6 ratio.
For infants, the VPJ does not indicate the number of servings from each group to offer.
Breast or formula milk should continue on demand as usual until at least 1 year of age, and food from all groups should be offered daily at each meal or snack in the amount shown in Table 2.
Table 2Amount of food to offer to vegetarian infants at each main meal or snack
From 1 year of age, the growth rate slightly decreases, although it is still quite rapid until 24 months of age. After that, weight and height increase steadily until puberty, when a spike in growth velocity takes place.
For different calorie requirements in the various age groups, the VPJ suggests the number of daily servings to consume for each group, as shown in Table 1. The nutritional composition of diets obtained with the VPJ method is shown in Table 3.
Table 3Energy content and nutrient composition of diets obtained with the VegPlate Junior for children and adolescents (from 1 to 17 years of age), compared with the Italian and the US Dietary Reference Intakes (DRIs)
Although discretionary calories do not contribute to attaining nutritional adequacy and can be consumed according to individual preference, children and adolescents should be discouraged from choosing sweetened beverages or processed foods.
Calcium, an essential mineral during growth when bone mass is expanding, can be a critical nutrient in those vegetarian children who do not consume dairy products.
For the calculations in the VPJ, only plant foods and no dairy products were taken into account. Calcium needs were met by including 3 to 5 servings daily of calcium-rich foods. Calcium-rich foods are the same as for the VegPlate for adults,
one serving providing approximately 125 mg calcium. Because variety within the same food group must be ensured, even lacto-ovo-vegetarians should derive most of their dietary calcium from plant foods.
Tap and mineral water are also reliable sources of highly bioavailable calcium (absorption fraction from 23.6% to 47.5%).
When the calorie requirements are above 3,000 kcal, counting calcium-rich foods servings is unnecessary, because the variety of the diet provides the required amount of calcium. Although calcium content of breast milk is little affected by maternal calcium intakes,
Because vitamin D status mainly depends on sun exposure, all children living at high latitudes, regardless of the type of diet, are at risk for deficiency.
American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents.
The consumption of two servings of n-3–rich foods recommended in the VPJ provides on average 5.0 g alpha-linolenic acid and satisfies the above-mentioned conditions for all of the calorie ranges. The avoidance of n-6–rich oils (ie, sunflower oil, corn oil) and tropical oils maximizes the conversion of alpha-linolenic acid to eicosapentaenoic-docosaexaenoic acid, because it minimizes the n-6:n-3 ratio,
During complementary feeding, infants can generally meet their n-3 fatty acid requirements through breast or formula milk and the suggested servings of fats.
According to the Italian DRIs, all children from 6 months up to 3 years of age should additionally consume a 100 mg/d of DHA, regardless of the type of diet.
Mothers should check their B-12 levels before conceiving and supplement vitamin B-12 throughout pregnancy and breastfeeding to guarantee an adequate intake to the infant.
Because of the high variability of absorption attributable to different frequencies of intakes, to satisfy the DRIs by supplementation, the Italian Society of Human Nutrition suggests B-12 daily single doses from 5 μg in infants to 50 μg in adolescents.
Excessive amounts of fiber trigger early satiety, may cause constipation, and may interfere with nutrient absorption (especially iron, calcium, and fats).
Choosing refined grains, peeling beans, and straining fruits and vegetables are practices that effectively reduce the fiber content of the diet and should be pursued from 6 to 24 months of age, a period of rapid growth.
Plants provide all of the essential amino acids, and protein requirements are usually met and even exceeded on a vegetarian diet providing sufficient energy from a variety of plant foods.
Animal-derived products are not necessary to attain protein requirements, and their consumption depends on the family habits. Because of the lower digestibility of plant proteins, some authors suggest increasing protein DRIs of vegetarian children by 10% to 15%,
a percentage that the VPJ surpasses for all age ranges (Table 3).
Combining complementary sources of protein at each meal is not necessary, but an advantage in consuming complementary proteins at intervals of less than 6 hours was shown in children younger than 2 years of age.
In everyday practice, young children eat often throughout the day, so combining protein sources is not necessary when the variety of plant foods in the diet is assured.
Iron
Iron deficiency is highly prevalent among all children, regardless of the type of diet.
In vegetarian diets, all iron is in the non-heme form, which has lower bioavailability than the heme iron found in meat and fish products (1%-34% compared with 15%-35%), because of differences in absorption and the fiber and phytate content of plant foods.
Vitamin C, beta-carotene, and organic acids positively influence non-heme iron absorption, as well as some cooking practices that reduce the phytate content of foods (ie, soaking, sprouting, grinding, sour leavening, fermentation).
Vegetarian parents should be aware of the iron-rich foods in vegetarian diets, such as whole grains, legumes, soy products, green leafy vegetables, and nuts and seeds, and of the practices enhancing its bioavailability. Iron-fortified infant cereals may be useful for maximizing the iron content of the diet in the first 2 years of life, when whole grains should be limited.
Zinc requirements are met in all diets obtained with the VPJ, but the overall diet bioavailability of zinc may be lower when compared with nonvegetarian diets because of the high content of fiber and phytate in vegetarian diets.
The previously mentioned practices that decrease the phytate content of the diet also enhance zinc absorption, and the daily inclusion of zinc-rich foods, such as legumes, nuts and seeds, and cheese for lacto-ovo-vegetarian children, maximizes zinc intakes.
Iodine
Vegetarian children and adolescents should not rely on seaweed to meet iodine requirements, because its high content might exceed recommendations and impair thyroid function,
are met by using iodized salt or algal source supplements. Because the amount of iodine per gram of iodized salt varies among countries, a daily consumption of approximately 3.3 to 5 g for Italian children and adolescents (providing 100 to 150 μg of iodine)
is suggested. Infants from 6 to 12 months of age meet their iodine requirements through breast and formula milk, and no salt should be added to infants’ food.
Well-balanced vegetarian diets planned with the VPJ, which include a wide variety of plant foods and reliable sources of vitamin B-12 and vitamin D, are an adequate option for infants, children, and adolescents. Vegetarian diets, because of their favorable content of fiber and essential nutrients, have been shown to be protective against childhood and adolescence obesity,
NCD Risk Factor Collaboration (NCD-RisC) Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults.
In this scenario, the VPJ can serve as a foundation for planning omnivorous diets rich in plant foods and protective against childhood obesity, simply by introducing some servings per week of nonvegetarian foods.
Acknowledgements
Authors wish to thank Ilaria Fasan, RD, for the thoughtful inputs, Paul Foster Griffith, MD, for the careful revision of the language, and the anonymous reviewers whose suggestions have led to an improvement of the contents.
Complementary feeding: A position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition.
Dietary patterns in UK adolescents obtained from a dual-source FFQ and their associations with socio-economic position, nutrient intake and modes of eating.
American Academy of Pediatrics Section on Breastfeeding; American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents.
Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults.
This article was written by Luciana Baroni, MD, medical director, Primary Care Unit, Northern District, Local Health Unit 2 Marca Trevigiana, Treviso, Italy; Silvia Goggi, MD, senior resident, Dietetics and Nutrition Unit, Ospedale Luigi Sacco, Milano, Italy; and Maurizio Battino, MD, PhD, professor, Department of Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy.
STATEMENT OF POTENTIAL CONFLICT OF INTEREST L. Baroni is the author of books describing the method; M. Battino is the director of the International Master in Vegetarian Nutrition and Dietetics, hosted by Funiber; S. Goggi declares no conflict of interest.
In the article “Planning Well-Balanced Vegetarian Diets in Infants, Children, and Adolescents: The VegPlate Junior” by Baroni, Goggi, and Battino, published in the July 2019 issue (pp 1067-1074) of the Journal of the Academy of Nutrition and Dietetics, the authors would like to make the following corrections and points of clarity:
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