• There is scientific consensus that prioritising plants in the diet leads to better outcomes for the health of people and the planet. • Plant-based diets encompass a spectrum of dietary patterns based predominantly on plant foods, including vegetables, wholegrains, legumes, nuts, seeds and fruits, and these may contain some or no animal-source foods. • Even though the period of childhood through to adolescence presents unique challenges from a nutritional perspective, well-planned plant-based diets can meet dietary needs, even when animal- source foods are completely absent. • The protein content and quality of plant-based diets is typically not a concern with children and adolescents, nor is the provision of sufficient total fat. However, if animal-sourced foods, particularly oily fish, are absent or minimal, attention should be given to ensuring adequate sources and proportions of essential fats are included. • Irrespective of dietary patterns, it is advisable that all children in the UK aged 1-4 years and all at-risk groups take a year-round vitamin D supplement. Throughout the primary school years and into adolescence, a daily vitamin D supplement should be taken during the autumn and winter months (September through to April). • Calcium intakes are typically not compromised with plant-based eating; well-absorbed calcium-fortified alternatives are readily available, as are plant food sources of calcium such as green leafy vegetables and cereal products. • There does not appear to be a clear difference in iron and zinc status across vegetarian and omnivorous populations, suggesting it is plausible to consume adequate amounts of each with plant-based diets, even with potentially reduced bioavailability. However, attention should be paid to intakes in adolescents, particularly girls, as a considerable proportion of this population group in the UK consume suboptimal amounts. • Vitamin B12 is found exclusively in foods of animal origin and is therefore completely absent in vegan diets. A reliable source is essential such as fortified foods, or more preferably, a regular supplement, must be included. Diets that contain varying amounts of animal-source foods may provide sufficient B12, and if not, this can be boosted by including fortified foods or a supplement, if necessary. • In plant-based diets where milk and milk products and/or fish may be limited or completely excluded, consideration should be given to ensuring adequate iodine intakes, such as through the inclusion of iodine-fortified products or a supplement, depending on individual needs. KEY POINTS PLANT-B ASED EATING FOR CH ILDREN: NUTRI TIONAL C ONSIDERAT IONS by Vanessa Clarkson, BSc Dietetics, MSc Food Policy edited by Kate Roberts, MSc RD specialist dietitian in paediatrics and allergy This fact sheet reviews the scientific evidence to ensure plant-based diets are nutritionally adequate for healthy and otherwise well children, from childhood through to and including adolescence (1-18 years old). FOR HEALTH PROFESSIONAL USE ONLY 1
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PLANT-BASED EATING FOR CHILDREN: NUTRITIONAL … · nutritional perspective, well-planned plant-based diets can meet dietary needs, even when animal-source foods are completely absent.
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DEFINING A PLANT-BASED DIETThereisnosingleagreedupondefinitionofplant-baseddietsper se,beyondtherecognitionthattheyarecomprisedpredominantlyofplantfoods.TheBDAdefinessuchfoodwaysasbeing“based on foods derived from plants, including vegetables, wholegrains, legumes, nuts, seeds and fruits, with few or no animal products”.(7)Thus,plant-baseddietarypatternsexistonaspectrumfromthosethatmayincludemoderateamountsofanimal-sourcefoods,tothosethatarecompletelyplant-based(Figure1).Breastmilkisnotexcludedfromanyplant-baseddietarypattern,includingveganism.
HEALTHY DIETS FROM SUSTAINABLE FOOD SYSTEMS
Within the recommendations from the FAO/WHO, is advice to prioritise plant foods: “[healthy sustainable diets] include wholegrains, legumes, nuts and an abundance and variety of fruits and vegetables… and can include moderate amounts of eggs, dairy, poultry and fish; and small amounts of red meat”.(1)Thispredominantlyplant-basedguidanceisconsistentwiththefood-baseddietaryrecommendationsfrommanyleadinghealthauthorities,includingPublicHealthEngland’s(PHE)EatwellGuide,theEAT-LancetCommissionandtheBritishDieteticAssociation’s(BDA)OneBlueDot®initiative.(2-4)It is important to note that plant-based diets do not need to completely exclude animal-source foods in order to be environmentally sustainable. TheEatwellGuideappliestochildrenaged5yearsandover,andadults,andprioritisesrecommendingplantfoods,suchthattheyshouldordinarilycompriseover80%oftheweightoffoodeaten.Equivalentguidesarealsoavailableforthosethatchoosetofollowvegetarianorvegandiets.(5,6)
DEFINING SUSTAINABLE DIETSTheFoodandAgricultureOrganizationoftheUnitedNations(FAO)andWorldHealthOrganization(WHO)recentlydefinedsustainablehealthydietsas:“Dietary patterns that promote all dimensions of individuals’ health and wellbeing; have low environmental pressure and impact; are accessible, affordable, safe and equitable; and are culturally acceptable.”(1)
Not all plant-based diets are equalBeyondthebalanceofplanttoanimal-sourcefoods,itisessentialnottooverlooktheimportanceoftheoverallqualityofdietarypatterns.Arecentreviewfoundthatplant-baseddietsconsistingofhigheramountsoflow-qualityplantfoodssuchasrefinedgrainsandsugaryproducts,wereassociatedwithanincreasedriskofcardiovasculardiseasecomparedtodietscontaininghighqualityplant-foodssuchaswholegrains,fruit,vegetables,nutsandseeds.(8)
CONCEPTION BIRTH 2 YEARS 5 YEARS 10 YEARS 18 YEARS
First1,000days
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PROTEIN QUANTITY AND QUALITYThoughenergyrequirementsinyoungeragegroupsareconsiderablyhigherthanadults(relativetobodyweight)duetogrowthdemands,thevastmajorityofdietaryproteinisneededformaintenanceratherthangrowth.Consequently,whenexpressedasapercentageofenergyintake,proteinrequirementsforchildrenareconsiderablylessthanadults; withrequirementsgraduallyincreasingfrom5%at2years to9%at18years(Table1).(17)
Table 2. Plant-based food sources of protein and omega-3 (ALA) (32, 33)
¥Based on 6 ready-to use brands chilled or frozen. §Average across a selection of leading market brands – online. ++Based on 14 supplements currently on the market. #USDA. FoodData Central https://fdc.nal.usda.gov/
Figure 3. Average daily protein intakes of 1½ to 18-year-olds in the UK exceeding dietary recommendations(20)
ThisisillustratedbythemostrecentdatafromtheUKNationalDietandNutritionSurvey(NDNS)whichreportsthatmeandailyproteinintakesofchildrenaged1½-3yearsis42g,4-10yearsis53g,and11-18yearsis65g–allsignificantlymorethanrequirements(Figure3).(20)Itisagainstthisbackdropofelevatedproteinintakes,thatonemustconsiderthatthoughproteinintakesmaybeloweringroupsthatconsumefewornoanimal-sourcefoods,proteinintakeswillstillbesufficient.(17) Indeed, researchers note that it is practically impossible to fall short of protein needs when energy requirements are met and protein malnutrition is unlikely for healthy children following a balanced diet meeting energy requirements.(17)
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FATSTotal and saturated fats Fatsareimportantinthedietsofchildrenandadolescents,notleastbecauseoftheirenergydensity;theyenabletheprovisionofsufficientenergytofuelgrowthanddevelopment.Currentnutritionalrecommendationsassertthatdietaryfatsshouldcomprise35%ofenergyintakesfrom4yearsandover.Notingthatinyoungchildren,explicitadvicetolimitfatconsumptionisabsent(Table1).(18)Lowfatdiets(lessthan25%ofenergy)havebeenshowntoadverselyaffectweightgainandlongitudinalgrowthinyoungchildren.(21)
Studies with adult populations show that vegetarian and vegan diets are usually lower in total and saturated fat than omnivorous diets, though with total fat still within a range that is typical for the broader population.(23, 24) Indeed, the lower saturated fat content of plant-based diets is one of their many features that have been highlighted as mediating better health outcomes.
Figure 4. Synthetic pathway of long-chain omega-3 and omega-6 fatty acids(29) Getting the right balance of PUFAs from a plant-based dietLong-chainPUFAsarenotconsideredessentialastheycanbesynthesisedfromALAandLA.However,someconcernshavebeenraisedaroundtheimplicationsofanearortotalrelianceonALAtosynthesisesufficientlong-chainPUFAs,indietsthatcontainfewornoanimal-sourcefoods,especiallyfish.Theseconcernsmayberaisedinyoungchildren,whomayhavehigherrequirementsthanadultstosupportthenewstructurallipidsynthesisassociatedwithgrowth.
RepublishedwithpermissionofJohnWiley&Sons-Books,fromConversion of linoleic acid and alpha-linolenic acid to long-chain polyunsaturated fatty acids (LCPUFAs), with a focus on pregnancy, lactation and the first 2 years of life, Gibson RA, Muhlhausler B & Makrides M, 7(Supp 2), 2011;permissionconveyedthroughCopyrightClearanceCenter,Inc.2020.
20:3n-620:4n-3
Δ6 DESATURASE
ϐ OXIDATION
24:5n-624:6n-3
18:3n-618:4n-3
20:4n-6(AA)20:5n-3(EPA)
22:5n-622:6n-3(DHA)
22:4n-622:5n-3(DPA)
24:4n-624:5n-3
18:2n-6(LA)18:3n-3(ALA)
Δ5 DESATURASE
Essential fats and long-chain PUFAs Humanscansynthesisesaturated,monounsaturated(MUFAs)andPUFAsincludingthelong-chainomega-3fattyacids,eicosapentaenoicacid(20:5,EPA)anddocosahexaenoicacid(22:6,DHA).However,humanscannotsynthesisetheplant-basedshort-chainomega-3andomega-6fattyacids–alpha-linolenicacid(18:3omega-3,ALA)andlinoleicacid(18:2omega-6,LA).Consequently,theseshort-chainessentialfatsmustbeprovidedinthedietfromplantfoods
The role of short and long-chain PUFAs Omega-6andomega-3fattyacidsareanimportantstructuralcomponentsofcellmembranes,serveasprecursorstobioactivelipidmediators,andprovideasourceofenergy.Thelong-chainPUFAshavemultiplephysiologicalbenefitsonthecardiovascularsystemandDHAalsoplaysacrucialroleinthedevelopmentandfunctionofthebrainandretina,wherein
Conversion of ALA and LA to the long-chain omega-3 fatty acidsALAandLAfromplantfoodsourcescanbeconvertedtothelonger-chainEPAandDHA.However,thematterofessentialfatsinplant-baseddietsiscomplicatedbytheobservationthathighintakesofLAcancompetewithALAforenzymeuse(delta-6-desaturase),andreducetheconversionofALAtoDHAandEPA(Figure4).Moreover,andperhapscounter-intuitively,anALA-richdietcanactuallysuppressDHAsynthesis,sothefocusisonaddressingthebalanceofLAtoALAandmaximisetheefficiencyofthelong-chainomega-3metabolicpathway.IthasbeenshownthattherelativeproportionsofLAtoALAinthedietsofinfantsandchildrencanhavemajoreffectsonthefattyacidprofileoftissues,althoughthefunctionalsignificanceofthisisunknownat thetime.(29)
IRONIronisimportanttoconsiderinplant-baseddietsasthisisreadilysuppliedbyanimal-sourcefoods.Ironsupportsgrowthanddevelopmentinchildhoodandrecommendedintakesincreaseconsiderablyduringadolescence,especiallyingirls,wheretheRNIisthehighestacrossthelifecourseat14.8mg/day(Table1).Ironisaprincipalcomponentofhaemoglobininredbloodcellsandassuchisintegralfortransportingoxygenaroundthebody.Evenmildirondeficiencyinyoungeragegroupsisaparticularconcernbecauseifitprogressestoirondeficiencyanaemia,impairmentsincognitivedevelopmentarise,anditisunclearwhetherthesearereversiblewithirontherapy.(46)The latest NDNS data reports that iron intakes of 11 to 18-year-old girls is just half of their RNI: • Meanintakes8.3mg/day,56%RNI• Medianintakes7.9mg/day,53%RNIMore than half (54%) of girls in this age group consume less than the LRNI of 8.0mg/day.(20)Payingcloseattentiontoachievingadequateironintakesduringadolescenceingirlsisnotablyimportant.Intakesarelessofaconcernwithteenageboys,withthedatashowingmeanandmedianintakesof89%and86%oftheRNIof11.3mg/dayrespectively.Insharpcontrasttogirls,12%ofboysage11-18consumelessthantheLRNIof6.1mg/day.
Physiological adaptation to optimise iron statusAlsoofinterestisthatthemaintenanceofironstoresiscontrolledthroughtherateofabsorptionfromthediet,withtheimplicationbeingthatwhenironstatusiscompromised,thebodywillabsorbmorenon-haemironfromthediet.Datashowsthatabsorptioncanincrease10-foldiniron-deficientcomparedwithiron-repleteindividuals.(14)Ithasalsobeenshownthatironrepleteindividualscanadapttodietswithlowerbioavailability.Inonestudy,absorptionincreasedbyalmost40%froma‘lowbioavailabilitydiet’overa10-weekperiod.(48)
PLANT FOOD SOURCES OF KEY NUTRIENTS SERVING SIZE QUANTITY OF NUTRIENT PER SERVINGNosupplementsrecommendedforcalcium,ironorzincunlessclinicallyindicated
Table 3. Plant-based food sources for calcium, iron and zinc(33)
¥ Based on ready-to use chilled or frozen. Average from 3 leading supermarket brands. §Average across a selection of leading market brands – online. #USDA nutrient database.
MEDIAN UIC FOR ALL AGES FROM 6 YEARS UPWARDS:• 100-199mcg/L,consideredreplete• <100mcg/L,milddeficiency• <50mcg/L,moderatedeficiency• <20mcg/L,severedeficiency
PLANT FOOD SOURCES OF KEY NUTRIENTS SERVING SIZE QUANTITY OF NUTRIENT PER SERVINGSeleniumBrazilnuts* 15g(2-3) 38mcg
Sunflowerorchiaseeds*# 1tbsp 3.9-5mcg
Greenorbrownlentils(cooked) 50g 20mcg
Riceandpasta(cooked) 75g 3.8-4mcg
IodineKelp and Kombu – not recommended. Exceptionally high in iodine (up to 5,000mcg/g dry weight) and could cause toxicity
Table 4. Plant-based food sources for selenium and iodine(33)
¥ Based on ready-to use chilled or frozen. Average from 3 leading supermarket brands. §Average across a selection of leading market brands – online. #USDA nutrient database.
A daily vitamin D supplement of 10mcg all year round for:Childrenage1-4years(consuminglessthan500mlinfantorfollow-onformuladaily)ANDatriskchildrenandadolescentswithlittleornosunexposuree.g.individualswhoseeverydayclothingcoversmostoftheirskinorthosewithdarkskin.A daily vitamin D supplement of 10mcg between October and March for older children and teenagers
Table 5. Plant-based food sources for vitamins B12 and D(33)
¥ Based on ready-to use chilled or frozen. Average from 3 leading supermarket brands. §Average across a selection of leading market brands – online. #USDA nutrient database.
SUPPLEMENT RECOMMENDATIONSAll children aged 6 months to 5 years.Thegovernmentrecommendsadailyvitaminsupplementcontainingvitamins A, C and Dunless500mlormoreofinfantformulaisbeingconsumeddaily.
All children (5 years and older) and adolescents, during the months of September through to March,thegovernmentrecommendsadaily10mcgvitamin Dsupplement.
Children (5 years and older) and adolescents with dark skin, those who wear clothing that cover up the majority of their skin and those who have little to no exposure to sunlight from March through to September. The governmentrecommendsanall-yearvitamin Ddailysupplementof10mcg.
Children and adolescents not consuming fish, seaweed, dairy and iodine fortified plant-based drinks. Aniodine supplementthatdoesnotexceedtheirdailyrecommendedintake(Table1)andonenotbasedonseaweedisadvised.
Children and adolescents following a vegan plant-based dietary plan:• Avitamin B12supplementisrecommended.• The Vegan Society produces a chewable vitamin supplement called VEG 1.Halfofasupplementprovides12.5mcg