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CME / ABIM MOC / CE

Are Vegetarian Diets Harmful for Kids at Risk for Underweight?

  • Authors: News Author: Diana Swift; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 6/3/2022
  • Valid for credit through: 6/3/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

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Target Audience and Goal Statement

This activity is intended for pediatricians, family medicine and primary care clinicians, nurses, physician assistants, and other members of the health care team involved in counseling families or caregivers about diet for young children.

The goal of this activity is for learners to be better able to describe relationships between vegetarian diet and growth, micronutrient stores, and serum lipids among healthy children, based on a longitudinal cohort study of children aged 6 months to 8 years participating in the TARGet Kids! cohort study.

Upon completion of this activity, participants will:

  • Assess the relationships among vegetarian diet and growth, micronutrient stores, and serum lipids among healthy children aged 6 months to 8 years, based on a longitudinal cohort study
  • Assess the clinical implications of relationships between vegetarian diet and growth, micronutrient stores, and serum lipids among healthy children aged 6 months to 8 years, based on a longitudinal cohort study
  • Outline implications for the healthcare team


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News Author

  • Diana Swift

    Freelance writer, Medscape

    Disclosures

    Disclosure: Diana Swift has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Stocks, stock options, or bonds: AbbVie (former)

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Are Vegetarian Diets Harmful for Kids at Risk for Underweight?

Authors: News Author: Diana Swift; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 6/3/2022

Valid for credit through: 6/3/2023

processing....

Clinical Context

Vegetarian diets are increasingly popular for adults and children. Lower total caloric intake, heme-iron intake from animal-based foods, and vitamin D from fortified cow's milk with this diet could potentially be associated with lower growth and iron and vitamin D stores, but also with lower serum lipids.

With more families placing their children on vegetarian diets, the results from a Canadian longitudinal cohort study are reassuring: It found no clinically meaningful differences in height, growth, or biochemical measures of nutrition in young children on vegetarian and nonvegetarian diets.

Study Synopsis and Perspective

Although z scores (the standard deviation above or below the mean) were similar in both dietary groups, there was a weak association between a vegetarian diet and lower mean z height, as well as slightly higher odds of underweight.

No significant associations were identified between vegetarian and nonvegetarian diets for child z body mass index (BMI), serum ferritin, 25(OH)D, and serum lipids, according to Jonathon L. Maguire, MD, from St. Michael's Hospital Pediatric Clinic in Toronto, Ontario, Canada.

Moreover, the magnitude of the height and vegetarian diet association was small, at just 0.3 cm for a 3-year-old child, and was unlikely to be clinically meaningful, Dr Maguire and colleagues wrote in an article published online May 2 in Pediatrics.[1]

In a secondary study outcome, cow's milk consumption was associated with higher serum lipid levels for both diets. Serum lipids were similar among those who did or did not consume a vegetarian diet and consumed the recommended 2 cups of cow's milk per day.

"The vast majority of children with vegetarian diets have similar growth and nutrition as children without vegetarian diets," said Dr Maguire, who is also a professor of pediatrics and nutritional sciences at the University of Toronto, in an interview. "But, I think we should be mindful to carefully plan vegetarian diets for children [who are] underweight."

The study conclusion was based on 8,907 children, 6 months to 8 years of age, including 248 vegetarian (25 vegan) children, at baseline. They were part of the TARGet Kids! practice-based research network in Toronto.[2]

The mean age of the children at baseline was 2.2 years (standard deviation [SD], 1.5 years), and 52.4% were male. Participants were followed for an average of 2.8 years (SD, 1.7 years).

Those with a vegetarian diet had longer breastfeeding duration: 12.6 months (SD, 9.5 months) versus 10.0 months (SD, 7.0 months). They were also more likely to be of Asian ethnicity: 33.8% versus 19.0%. Otherwise, children with and without a vegetarian diet were similar at baseline.

In study outcomes, vegetarian children had higher odds of underweight (body mass index z score less than –2; odds ratio 1.87; 95% confidence interval, 1.19-2.96, P = .007), whereas no association with overweight or obesity was found.

In a secondary outcome, cow's milk consumption was associated with higher levels of non–high-density lipoprotein cholesterol (P=.03), total cholesterol (P=.04), and low-density lipoprotein cholesterol (P=.02) in young children on a vegetarian diet. Levels were similar in children with and without a vegetarian diet who consumed the recommended 2 cups of cow's milk per day.

Previous studies have found that vegetarian children have normal growth and development, but tend to be leaner than their omnivore peers.[3]

As for the potential effect of following a fully vegan diet on these nutritional measures, Dr Maguire said, "Unfortunately, there were not enough children with vegan diets to make meaningful conclusions."

Would results likely be similar in older children who have more independence and engage more with their peers? "I don't know, but we will be following these children for many years to come through the TARGet Kids! research network," Dr Maguire said.

Studies such as this are timely as plant-based eating becomes more widespread in the United States. The 2007-2010 National Health and Nutrition Examination Surveys found that 2.1% of American adults followed a vegetarian diet, and that figure appears to have increased since then, with 5% of American adults self-identifying as vegetarian in a 2019 Gallup poll.[4]

Offering her perspective on the Canadian study, but not involved in it, Stephanie Di Figlia-Peck, MS, RDN, agreed that the results indicate that "a vegetarian diet is not a negative thing for growth and development." She is a lead registered dietitian in the division of adolescent medicine at Cohen Children's Medical Center in New Hyde Park, New York. She noted, however, that the study looked only at very young children on average.

She stressed that vegetarian regimens require family commitment and agreed on the need for planning. "For these diets to work, a lot has to go into it. But if they're carefully planned, there is adequate protein and micro- and macronutrients and there's a nonnegative effect on growth and development."

The study results mirror what she sees in clinical practice, with vegetarian children tending to weigh less. "Some obese and overweight children will adopt vegetarian diets to lose weight," Di Figlia-Peck said.

And perseverance has rewards. "When people follow a vegetarian diet, they tend to have lower blood pressure and cholesterol. A plant-based diet can favorably impact diseases for an entire lifetime."

This study was supported by the Canadian Institutes of Health Research and the St. Michael's Hospital and SickKids Hospital foundations. Dr Maguire received an unrestricted research grant for a previous investigator-initiated study from Dairy Farmers of Canada and D drops provided nonfinancial support (vitamin D supplements) for a previous investigator-initiated study on vitamin D and respiratory tract infections. One coauthor reported research support from multiple private-sector and nonprivate organizations; several of his family members are involved in the promotion of vegetarian diets. Di Figlia-Peck has disclosed no relevant financial relationships.

Pediatrics. Published online May 2, 2022.

Study Highlights

  • The longitudinal cohort for this study consisted of 8907 participants (248 vegetarian at baseline) aged 6 months to 8 years (mean, 2.2±1.5 years) in the TARGet Kids! study. 
  • 52.4% were male; average follow-up was 2.8±1.7 years.
  • Vegetarian diet was not associated with body mass index z-score, height-for-age z-score, serum ferritin, 25-hydroxyvitamin D, serum lipids, overweight, or obesity, based on linear mixed-effect modeling.
  • There was a weak association between vegetarian diet and lower mean height-for-age z-score, of small magnitude (0.3 cm for a 3-year-old child) and unlikely clinically meaningful.
  • Children on a vegetarian diet had higher odds of underweight (body mass index z-score, <−2; odds ratio, 1.87; 95% confidence interval, 1.19-2.96; P=.007). 
  • Cow's milk consumption was associated with higher non-high-density lipoprotein cholesterol (P=.03), total cholesterol (P=.04), and low-density lipoprotein cholesterol (P=.02) among children on a vegetarian diet. 
  • However, children with and without a vegetarian diet who consumed 2 cups of cow's milk/day as recommended had similar serum lipids.
  • The investigators concluded that there was no evidence of clinically meaningful differences in growth or biochemical measures of nutrition for children on a vegetarian diet, but that vegetarian diet was associated with higher odds of underweight.
  • Guidelines currently differ on the adequacy of vegetarian diet in childhood. 
  • This study did not provide any evidence of inadequacy, but given the higher odds of underweight, careful dietary planning is needed for underweight children considering vegetarian diets.
  • It is unclear whether the stronger relationship between cow's milk intake and serum non-high-density lipoprotein cholesterol, total cholesterol, and low-density lipoprotein cholesterol among children with vs without vegetarian diet persists into older childhood or adulthood. 
  • The investigators speculate that cow's milk may be among the main sources of saturated fat for children on a vegetarian diet.
  • Biological mechanism(s) affecting the observed serum lipid sensitivity are unclear. 
  • Children on a vegetarian diet excluding cow's milk may drink more plant-based milks, which are shown to have a lipid-lowering effect in adults, but serum lipids were similar among vegetarian and nonvegetarian children consuming the recommended 2 cups of cow's milk/day. 
  • Study limitations include potential reverse causality, where changes in outcomes, such as poor growth, could have affected dietary choices, but the associations did not change over time. 
  • Study participants were urban children with health care-seeking parents, limiting generalizability to families where the choice of following a vegetarian diet is affected by lower income or reduced access to healthful, plant-based alternatives. 
  • Despite adjustment for numerous potential confounders, detailed measures of dietary intake and physical activity and information on parental dietary intake were unavailable. 
  • Despite adjustment for ethnicity, the growth standards used may overestimate underweight in Asian-American populations. 
  • The sample was too small for meaningful subgroup analysis for children with vegan diet or very young age, and the average follow-up duration of 2.8 years prevented evaluation of longer-term outcomes.
  • Clinical trials could help determine causality but are not feasible; larger longitudinal cohort studies with more detailed measures of dietary intake and longer follow-up are needed to fully assess growth, nutritional outcomes, and effect of different types of vegetarian diet. 
  • Evidence for specific dietary requirements for children on a vegetarian diet may improve guideline uniformity. 
  • It is also important to clarify motivations for vegetarian diet, such as income, and the effect these variables may have on growth and nutritional status. 

Clinical Implications

  • Growth and biochemical measures of nutrition are not clinically meaningfully different for children with vs without vegetarian diet, but vegetarian diet is associated with higher odds of underweight.
  • Evidence for specific dietary requirements for children on a vegetarian diet may improve guideline uniformity. 
  • Implications for the Health Care Team: Given the higher odds of underweight, careful dietary planning from all members of the healthcare team is needed for underweight children considering vegetarian diets.

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