Untitled

Stephanie Sippel, MD

Keith Tong, MD

Robert Karp, MD

DEPARTMENT OF PEDIATRICS

SUNY-DOWNSTATE MEDICAL CENTER

BROOKLYN NY

Pre Test (detailed explanations at the bottom):

Q1. A person who does not eat any animal flesh or product is called:

a. Vegan

b. Lacto-vegetarian

c. Lacto-ovo-vegetarian

d. Pescetarian

Q2.For a child living in Florida is being raised as a strict vegan, who is not taking any supplements or fortified foods, what vitamin is he/she MOST likely deficit in (assuming a well planned diet)?

a. Iron

b. Vitamin D

c. Vitamin B12

d. Calcium

e. all of the above

Q3. Which if the following is not added to fortified soymilk

a. Calcium

b. Vitamin B12

c. Vitamin D2

d. Lactose

e. All of the above

Q4. True or False. Soymilk is a safe alternative to infant formula for a vegan infant under 1 year of age.

Q5. A five year old Lacto-vegetarian child has recently been diagnosed with iron deficiency anemia. In addition to beginning a multivitamin with iron, which of the following foods is not appropriate (within the constraints of the diet) to recommend to the parents that will increase the child's daily iron intake?

a. Red Meat

b. Eggs

c. Tofu

d. Fortified cereals

e. Fruits high in vitamin C (i.e. citrus fruits)

f. Choices a, b, and e

g. Choices a and b

Q6. True or False. Child protective services should be contacted for children being raised in vegan households.

OBJECTIVES:

ON COMPLETION OF THIS MODULE, RESIDENTS WILL BE ABLE TO:

DEFINE THE VARIATIONS OF VEGETARIANISM.

RECOGNIZE BOTH BENEFITS AND RISKS OF EACH VARIANT. THIS INCLUDES ABILITY TO TAKE A DIET HISTORY IDENTIFYING RISKS AND MAKE A NUTRITIONAL ASSESSMENT OF THE PATIENT TO IDENTIFY MALNUTRITION IN ITS EARLIEST STAGES.

COMMUNICATE EFFECTIVELY WITH PARENTS, SHOWING RESPECT FOR THEIR BELIEFS, WITH THE EXPECTATIONS THAT RISKS AND CONSEQUENCES WILL BE AVERTED. THIS INCLUDES BEING RESPONSIVE TO THE PARENTAL REQUESTS AND BEING SURE TO INCLUDE REQUIRED NUTRIENTS IN THE DIET.

USE A TEAM APPROACH TO CARE DRAWING IN SUPPORT FROM SPIRITUAL COUNSELORS

RECOGNIZE BOTH SUCCESS AND FAILURE. THIS INCLUDES BEING PREPARED TO CALL IN CHILD PROTECTIVE SERVICES WHEN HEALTH OF CHILD IS AFFECTED.

FACILITATOR'S PREPARATION

A full description of guidance for vegetarian parents can be found at: Position Paper of the American Dietetic Association and Dietitians of Canada: Vegetarian diets; Journal of the American Dietetic Association: 2003 June; 103(6): pp.748-765

A particularly important reference to that position paper was:

Messina V, Melina V, Mangels AR. A new food guide for North American vegetarians. J Am Diet Assoc. 2003;103:771-775.

Other helpful papers include:

V Messina and AR Mangels, Considerations in planning vegan diets: Children, J Am Diet Assoc 101 (2001), pp. 661-669.

CL Perry, MT McGuire, D Neumark-Sztainer and M Story, Adolescent vegetarians. How well do their dietary patterns meet the Healthy People 2010 objectives?, Arch Pediatr Adolesc Med 156 No. 5, May 2002, pp. 431-437

Sabate J, The contribution of vegetarian diets to health and disease: a paradigm shift? Am J Clin Nutr 2003;78S1: pp. 502-507

C Weaver, W Proulx and R Heaney, Choices for achieving adequate dietary calcium with a vegetarian diet, Am J Clin Nutr 70 S2 (1999), pp. 543S-548S.

PREFACE: This module, written by Drs. Tong, Shah, Karp, and Stephanie Sippel addresses the common forms of vegetarianism with an emphasis on gaining confidence of the family, careful assessment of the biologic values and risks of the diet, and successfully providing support by joining rather than challenging the beliefs of the practitioners. Unfortunately, this approach is not always successful, as the case described by Dr Shah, where a child comes to your attention with severe nutritional depletion.

INTRODUCTION

An adequate diet, by definition prevents nutrient deficiencies by providing sufficient nutrients and energy for human growth and reproduction. While an optimal diet, in addition, promotes health and longevity, reducing the risk of diet related chronic diseases (Sabate, 2003). It is the role of the practitioner to teach this principle when approaching the topic of non traditional diets, and instill that the basic tenant of any diet, no matter how restrictive, is that it must provide the basic nutrients needed for human growth and development before it can promote spiritual, cultural, or healing properties.

As Peter Farb writes, "Semistarvation is the natural state of humankind." Throughout most of human history, from life as hunter-gatherers to an agrarian existence to today's industrial age, humans have had an ever changing array of food consumption. Food taboos and faddism based on spiritual ideas, societal and cultural influences have always affected human's diets. The increasingly popular "health food" movement has made it necessary for the health professionals to become familiar with common forms of food faddism. A fad has been defined as "a pursuit or interest followed widely but briefly and capriciously with exaggerated zeal and devotion." Food faddism is a commonly found deviation from normal nutritional behavior that may be based on lifestyle, religion, philosophical or ecological beliefs. If care is not taken to ensure that adequate amounts of proper nutrients are obtained while observing one of these faddist diets it may have grave consequences on a growing body. In order to minimize the harmful effects of a food faddist diet on a growing child, the physician must understand the social and cultural aspects of the diet and acknowledge that attempts to change dietary habits cannot depend solely on education but on recognizing the way these dietary habits are embedded in the social structure and culture of groups, and thus learn how to design interventions that are culturally appropriate (Quant, 1999). The dietary regimes with which this chapter is concerned include vegetarianism in all its dimensions.

VEGETARIANISM DEFINED

A poll done in 2000 identified approximately 2.5% (4.8 million people) of the United States population consistently follows some form of vegetarian diet, while slightly less than 1% identified themselves as vegan (American Dietetic Association, 2003). Simply stated, a vegetarian is one who practices a diet that excludes all forms of animal flesh. However, there are numerous gradations on the term vegetarian, and it is in no way all encompassing. Some consider the term vegetarian to mean one who consciously reduces their intake of animal products (but does not completely exclude all forms of animal products) while another may take it to mean the exclusion of all animal flesh, products, and byproducts. To clarify the various degrees of vegetarianism many subcategories have been defined. The spectrum ranges from semi-vegetarian, which include Pescetarianism and Pollotarianism, to varying degrees of vegetarian, including lacto-ovo and lacto-vegetarian, through vegan and to the most radical, the macrobiotic diet. Table 1 describes the various subtypes of vegetarian diets.

Table 1. Types of Vegetarianism

The semi-vegetarian and some vegetarian diets may be highly nutritious, but they tend to provide low energy because they are high in bulk, thus compromising protein nutrition since protein may have to be used as an energy source. Also, unlike animal protein, a single vegetable protein is not capable of providing an appropriate balance of essential amino acids for long term nutrition. Dietary combinations like rice and beans or corn and beans include at least two different vegetable proteins that offset amino acid deficits (e.g., cereal grains with a low lysin content and legumes with a low methionine content) and result in a higher protein quality. In the past, vegetarian diets have been described as being deficient in several nutrients including protein, iron, zinc, calcium, vitamins B12, D, and A, n-3 fatty acids, and iodine. Numerous studies have demonstrated that observed deficiencies are usually due to poor meal planning, and that a well balanced vegetarian diet can be appropriate for all stages of the life cycle (Leitzmann, 2005). Thus, a properly planned vegetarian diet, that includes a variety of foods and avoids undue reliance on a single plant food is safe (Sabate, et al, 1990). The United States Dietary Guidelines states, "Vegetarian diets can be consistent with the Dietary Guidelines for Americans, and meet Recommended Dietary Allowances for nutrients (American Dietetic Association, 2003). The American Dietetic Association, 2003, also states that Vegetarian diets offer a number of advantages, including lower levels of saturated fats, cholesterol, and animal protein and higher levels of carbohydrates, fiber, magnesium, boron, folate, antioxidants such as vitamins C and E, carotenoids, and phytochemicals. One study showed that mortality from ischemic heart disease was 24% lower in vegetarians than in nonvegetarians (Key, et al, 1999). Another study goes on to show that vegetarian diets are beneficial in the prevention of certain diseases, such as cardiovascular disease, hypertension, diabetes, cancer, osteoporosis, renal disease and dementia (Leitzmann, 2005).

On the other hand, unbalanced vegetarian diets or unduly restrictive diets such as vegan or macrobiotic diets, can be very dangerous for a growing child if care is not taken to educate the parents on ensuring adequate amounts of proper nutrients and monitoring the child for any deficiencies, such as iron, zinc, calcium, vitamins D, B12, and riboflavin. A tragic example of just how dangerous some of these diets can be was publicized by the media in May 2007, when a six week old baby boy died of starvation secondary to his vegan parents feeding him only a diet of soy milk and apple juice. Table 2 describes some of the associated nutritional compromises seen with the various subtypes of vegetarian diets.

Table 2. Vegetarian diets potentially associated with nutritional compromise.

VEGETARIAN DIETS: TWO OUTCOMES

As seen above, a well balanced vegetarian diet can be an optimal diet. The conflict with parents occurs when there is a lack of balance or an unduly restrictive diet given to the child with resulting nutritional deficiencies. The practitioner must realize that to solve to the conflict, they need not only to educate the parents, but understand the cultural, social, religious, and spiritual aspects of the diet and provide the interventions that are culturally and socially appropriate. Below are two case examples, one where there is a breakdown of communication secondary to a lack of understanding between parties, and one where communication is intact and both parents and practitioner work to the benefit of the child.

CASE 1: FAILURE [Case provided by Binita SHAH, MD]

A West Indian woman came to the emergency room of a municipal hospital requesting a birth certificate for her young infant, who had been born at home. The mother was holding the infant and pushing a supermarket style shopping cart in which two older children were seated. The entire family wore copious garments which covered almost the entire body even during very warm weather. Both parents and children wore dark lenses, even indoors. The mother claimed that the children were unable to walk for the past year. Neither child attended school.

This family was Rastafarian and for the previous five years had been strict vegans. Both parents believed in "black magic" and attributed the children's illnesses to "supernatural causes." They ate no commercially prepared food, used no butter or oil in cooking, and purchased all produce from a health food store. Foods commonly consumed in a day were vegetables cooked in water or eaten raw, soy beans, nuts, assorted grains, wheat germ, rice, fresh fruit and homemade soy "milk." None of the children received any vitamin supplements. Immunizations were incomplete in the older children, and the infant had never been immunized at all.

Two of the children, a nine year old girl (patient 1) and a seven year old boy (patient 2) were markedly wasted, with a consistent preference for assuming a knee-chest position. They were not able to bear any weight and spoke in high pitched voices. Their weights were well below the 5th percentile. Their lengths were not obtainable with accuracy because of flexion contractures at the hips, knees and ankles. Each had a large mass of tangled, matted hair which could not be brushed. They had prominent wrists and ankles, rachitic rosary with pigeon chest deformity and marked kyphosis. They had generalized hypotonia with diminished deep tendon reflexes.

Figure pending for information above.

The youngest child (patient 3) was a five month-old boy. His only food had been the homemade soy "milk." This product was made by boiling crushed soy beans and filtering the resulting soupy liquid. There was no provision of supplemental amino acids, vitamins or minerals such as found in commercially prepared infant soy-based formula. Significant physical findings included marked wasting with weight and length below the fifth percentile and head circumference at the twenty fifth percentile, widely patent anterior and posterior fontanelles, craniotabes, rachitic rosary and prominent wrists and ankles. He had a weakened cry with generalized hypotonia and a head lag.

Deficiencies of vitamins D, E and B12 were confirmed biochemically in all three children. Both nutritional and physical rehabilitation were undertaken during six weeks of hospitalization. Efforts were made to accommodate the parents' dietary preferences because they protested the use of any other diet. They remained angry with the entire staff and, ultimately, hospital security officers were required to be present when the parents visited the children. After correcting the nutritional deficits, patients 1 and 2 were fed nutritionally adequate vegan diet with commercial soy milk supplemented with medicinal vitamins and calcium supplements. As shown in Table 1, hypocalcemia and high alkaline phosphatase activity persisted in patient 1, in spite of normal vitamin D levels.

Table 3. Changes in serum calcium (Ca), phosphorus (P) and alkaline phosphatase (Alk Phos)

Communication barriers persisted with parents in spite of hospital personnel's continued efforts. Involvement of the child protective agency became necessary, and with a court order all children were placed on a lacto-ovo vegetarian diet. Serum calcium and alkaline phosphatase activity were normalized in patient 1. Ultimately, after the family refused to cooperate, the court placed all three children in a foster home, but with continued visiting rights by the parents. A followup visit eight months after the diagnosis showed that all the children were thriving. Patients 1 and 2 had persistent mild valgus deformities of the lower extremities and mild kyphosis, while patient 3 had a normal examination. Serum chemistries were normal in all.

THE CONSEQUENCES OF FOOD CULT BEHAVIOR

The growth parameters of all three children in the case study indicated both wasting and stunting, suggesting past and current malnutrition. Protein-calorie malnutrition, iron and Vitamin B12 deficiency anemia, zinc deficiency, rickets and multiple recurrent infections have been described in a vegan religious community similar to the rastafarians (Shinwell & Gorodischer, 1982). Analysis of samples of human milk from that community showed a low caloric value with a low carbohydrate, fat, and protein contents. Serum vitamin B12 concentrations have been found to be low with or without anemia among infants from a vegan community (Curtis, et al, 1983) and with neurological signs ranging from paresthesia to subacute combined degeneration in adult Rastafarian followers (Campbell, et al, 1982). Onset of symptoms in these adults occurred from two to twenty years after the start of the vegan diet. It is important to note that no known vegetable sources of vitamin B12 exist; thus, deficiency of this vitamin is common among strict vegetarians. Vitamin D deficiency rickets have also been described among communities who subscribe to vegetarianism with various dietary restrictions (e.g., Black Muslim sects and "Black Hebrews") (Bachrach, et al, 1978; Curtis, et al, 1983). Biochemical evidence of vitamin D deficiency was also seen in some nursing mothers (Bachrach, et al, 1979). Although some vegetables contain significant amounts of calcium, many strict vegetarian diets fall short of providing the recommended daily allowance of this nutrient from vegetables alone. Infants fed a macrobiotic diet are at risk for a combined deficiency of vitamin D and calcium (Dagnelie, et al, 1990); this clinical picture might be labeled "vegetarian rickets" (Finberg, 1979).

The consequences of an unbalanced vegetarian diet on a growing child can be grave, as seen above, however with proper education of both the practitioner and the parents, this need not be the outcome.

CASE 2: SUCCESS - FROM K TONG, MD

This family represents food faddism associated with sufficient if not superior levels of income and education where the family adopts a macrobiotic diet for the child. Our concerns are inadequate protein and calorie intake, insufficient intake of energy and micronutrients including Vitamins D, B12, iron, zinc and other vitamins and minerals.

A 33-year-old Caucasian woman brings her 2-year-old toddler, Danny J, to see you at your upper eastside office in New York, [this is an affluent section of New York City] on a late-winter day. She complains, "Danny has been less active than usual for 2 weeks." He no longer likes to explore and walk around the apartment or pick up his toys. He has also increased his napping duration and frequencies. Mrs. J says that Danny does not have any fever, diarrhea, trouble breathing or rash. Danny sleeps through the night but mom has noticed that he wakes up later than he used to. You inquire about Danny's feeding habits. Mom says that she and her family have began to switch over to a predominately "macrobiotic" diet 6 months ago. You ask her, "What do you mean by `macrobiotic?'"

She tells you that she slowly eliminated animal products from Danny's diet. Danny is now eating mostly a home made grain-milk, juice, rice, wheat noodles, a wide range of fruits and vegetables, and occasionally beans, seeds, and nuts. He occasionally has some fish. The last time you saw Danny was at his 18th month check-up, and you recall a healthy well-nourished toddler, who has met all his developmental milestones. His height is now 33.5cm, compare to 32.8cm 6 months ago. The head circumference is now 49.5cm, compare to 49cm 6 months ago. On physical examination, you see a skinny toddler sitting quietly on the mom's lap. You fail to induce the toddler to smile or play with his toys. Your examination of the head, cardiovascular system, pulmonary system, abdomen, genitals, and extremity pulses were all unremarkable. You make Danny stand and notice no bony deformities in the legs. You observe Danny as he walks towards his mother and do not see gait abnormalities.

Step 1 towards success: Education of the practitioner

MACROBIOTIC DIET: THE YIN AND YANG

The macrobiotic diet was popularized in the 1920's by George Ohsawa, who wrote extensively on the role of diet in curing diseases. Ohsawa preached the Chinese philosophy of yin and yang -- ubiquitous, opposing forces of nature. When in balance, harmony follows. Yin is attributed to properties such as the feminine, sweet, cold, expansive, and passive. Yang is attributed to properties such as the masculine, salty, hot, contractive, and aggressive. Everything, including foods, have different degrees of yin and yang, and even those that are extremely yin, will have some degree of yang.

Ohsawa taught that good health and longevity are achieved by maintaining a balance between yin and yang. As one's environment changes, one should eat accordingly to reset the balance. For example, summer is a predominately yang phenomenon. One should consume mostly yin foods in summer. These include fruits and raw vegetables. By contrast, winter is predominately yin. The preferred foods in winter are fish and meat. Of most importance for counseling, the macrobiotic diet is not a single restricted menu of low calorie density fruits and vegetable. Rather, a healthful macrobiotic diet can be adjusted to meet the needs of the individual from a range of foods.

From this conceptual framework, the health provider's work is in supporting parental beliefs and using that system in providing essential nutrients in the diet. Rather than string together a series of "no's," the physician can provide complementary items to enhance nutrient intake. This is a slow process and will require multiple visits and lots of trust. You must, however, be true to the parental principles. Remember, in a perverse way, a cheeseburger provides a balance of meat, dairy, bread and ketchup (assuming that ketchup is a vegetable). A well-structured vegetarian diet is certainly more nutritious than the diet of most American children.

Step 2: Understanding of the parents' reasoning for adopting the diet (Q's by MD and A's by Mrs. J):

Q. Tell me about your own interest in macrobiotic diets?

A. Mrs. J. explains that she has done much reading on macrobiotism and has concluded that one's nutritional need can be completely provided by non-animal foods. She tells to you the importance of yin and yang." These are opposing forces of nature that are found in all things - living and not.

Q. Why do you think that Danny should be on it as well?"

A. I think that children today are fat and flabby and over nourished. DJ will do better on a diet that uses natural forces."

Q. What do you know about the criticisms of the macrobiotic diets

A. The concern for amino acids can be fully compensated for by a variety of vegetables, beans and nuts. She tells you that vegetables have more vitamins and minerals than animal products."

Step 3: Understanding the common nutritional deficiencies associated with the diet.

The major medical concerns for the macrobiotic diet, especially for children, are deficiencies in calories, calcium, iron, zinc, vitamins B12 and D.

The high grain, vegetable and fruit may not have sufficient caloric density for a child.

There are extra essential amino acids required for infants and children that may not be provided in a macrobiotic diet.

Without the use of supplements, only animal products can provide Vitamin B12.

Concomitant restrictions often preclude sufficient Vitamin D in the diet along with failure to expose the child to the sun or use a vitamin supplement.

Step 4: Identification of the extent of the nutritional deficiencies

Your evaluation includes: CMP, CBC, FT4, PTH, PO4, 25-Vit D, folate level, cobalamin level, Fe panel, lead level, reticulocyte count, and XR of b/l lower extremities.

Step 5: Educate the parents on the nutritional deficiencies of the diet.

Inform Mrs. J that the main concern is that Danny's new diet is not suppling him with all the nutrients and calories that he needs to develop physically, such as iron, calcium, zinc, vitamins B12, A, and D, and essential amino acids. You explain that vitamin B12 can only be found in animal products, and that the other nutrients, such as vitamin D, iron, and zinc are less concentrated and are not absorbed as well from vegetables which leads to the nutritional deficiency. These deficiencies are responsible for his decreased energy level and stunted growth, and if allowed to continue the changes can become permanent, along with the appearance of neurological manifestations. The laboratory and radiological testing indicate that Danny is mildly deficient in iron, and he may be showing the first signs of vitamin D deficiency (a slightly elevated Alkaline Phosphatase level. The other tests are negative.

A macrobiotic diet principle is easier to maintain for a healthy adult because adults are willing to consume a more variety of vegetables and some fish. A growing toddler, however, requires calorie rich foods with a higher fat content. You explain that a macrobiotic diet constructed for an adult is not sufficient for a growing child; however, a modified macrobiotic diet could provide enough macro and micronutrients to sustain growth.

Step 6: Provide guidance within the bounds of the diet on supplementation of missing nutrients.

You are able to work with Mrs. J to start Danny on a chewable multivitamin with minerals supplement and to provide an appropriate diet for Danny that is within the principles of macrobiotism.

The mother agrees to use a fortified soy beverage for adults containing Vitamin B12 and D as well as calcium fortified orange juice. Since Danny is susceptible to deficiencies of iron he should be fed iron rich food such as cereal, beans, and tofu. For calcium, he should be fed tofu, and almonds. Dairy products are preferred, and can be used in macrobiotic diets "occasionally." As for vitamin D, there are vegan foods fortified with vitamins and minerals. It is necessary to continue working with Mrs. J to ensure that Danny continues to receives adequate amounts of the essential nutrients he needs in order to grow and develop appropriately.

GUIDANCE

A nontraditional diet, if implemented properly can be healthful, promote longevity, and protect against illness. Vegetarian diets offer a number of advantages, including lower levels of saturated fat, cholesterol, and animal protein with higher levels of carbohydrates, fiber, magnesium, boron, folate, antioxidants such as vitamins C and E, carotenoids, and phytochemicals (American Dietetic Association, 2003). The American Dietetic Association and Dietitians of Canada state that an appropriately planned vegetarian diets are healthful, nutritionally adequate, and provide health benefits in the prevention and treatment of certain diseases (American Dietetic Association, 2003). They key to reaping the benefits of a vegetarian diet is in the understanding of the phrase "appropriately planned," meaning, identifying the key nutrients deficient, finding ways to supplement them, and avoiding the 'vegetarian trap' of pizzas, pastas, and macaroni and cheese.

Most commonly, vegetarian diets are low or lacking in protein, iron, calcium, vitamin D, and vitamin B12.

Plant protein can meet the requirements when a variety of plant foods is consumed and energy needs are met. Research indicates that an assortment of plant foods eaten over the course of a day can provide all essential amino acids and ensure adequate nitrogen retention and use in healthy adults, thus complementary proteins (i.e. rice and beans) do not need to be consumed at the same meal (VR Young, et al, 1994). Most importantly, the quality of plant protein varies: whereas soy protein can meet protein needs as effectively as animal protein, wheat protein eaten alone may be 50% less usable than animal protein (VR Young, et al, 1975). Practitioners should also be aware that protein needs might be higher than the RDA in vegetarians whose dietary protein sources are mainly those that are less well digested, such as some cereals (which tend to be low in lysine, an essential amino acid) and legumes. Dietary adjustments such as the use of more beans and soy products in place of other protein sources that are lower in lysine or increase in dietary protein from all sources can ensure an adequate intake of lysine (American Dietetic Association, 2003).

Plant foods contain only nonheme iron, which is more sensitive than heme iron to both inhibitors and enhancers of iron absorption. Inhibitors include phytate, calcium, teas, coffee, cocoa, and fiber, while enhancers include vitamin c and other organic acids (RF Hurrell et al, 1999). Thus, a diet higher in fruits and vegetables rich in vitamin C can favorably impact iron absorption. Recommended iron intakes for vegetarians are 1.8 times those of nonvegetarians because of lower bioavailability of iron from a vegetarian diet (Food and Nutrition Board, 2001). However, it is likely that iron needs will vary from vegetarian to vegetarian based on the make up of their overall diet (American Dietetic Association, 2003).

Calcium is present in many plant foods and fortified foods. Low oxalate greens (bok choy, broccoli, Chinese/Napa cabbage, collards, kale, okra, turnips greens) provide calcium with high bioavailability (49-61%) in comparison with calcium fortified juices, tofu, and cows milk (31-32%), and with fortified soymilk, sesame seeds, almonds, and red and white beans (21-24%) (C Weaver et al, 1999). Calcium fortified foods include fruit juices, tomato juice, and breakfast cereals, thus there are various foods that contribute to dietary calcium (Messina et al, 2003). However, oxalates present in some foods can greatly reduce calcium absorption, so vegetables that are high in oxalates, such as spinach and beets are not good sources of usable calcium despite their high calcium content (American Dietetic Association, 2003). Calcium intakes of lacto-vegetarians are comparable with or higher than those of nonvegetarians, whereas calcium intake of vegans tends to be the lowest of the groups and often below the recommended intakes (American Dietetic Association, 2003). The ADA recommends that vegetarians meet the recommended intakes for calcium by consuming at least eight servings per day of foods that provide 10-15% of the adequate intake for calcium as indicated in the Vegetarian Food Guide Pyramid and the Food Guide Rainbow, see figures 1 and 2 (Messina et al, 2003). Although many vegetarians and vegans may find it easier to meet needs if fortified foods or supplements are included.

Vitamin D status depends on sunlight exposure and intake of vitamin D fortified foods or supplements. Sun exposure to the face, hands, and forearms for 5-15 minutes per day during the summer is believed to provide sufficient amounts of vitamin D for light skinned people living south of 42nd Latitude (Boston), while darker skinned people or those living further north require longer exposure (MF Holick, 1996). Infants, children, and older adults synthesize vitamin D less efficiently (MF Holick, 1996). Foods that are fortified with vitamin D include cows milk, soymilk, rice milk, some breakfast cereals, and margarines. Vitamin D3 (cholecalciferol) is of animal origin, whereas vitamin D2 (ergocalciferol) is of plant origin. Vitamin D2 is less bioavailable than vitamin D3, which could raise the requirements of vegetarians who depend of vitamin D2 to meet vitamin D needs (HM Trang et al, 1998). Therefore, if sun exposure and intake of fortified foods are insufficient, then vitamin D supplements are recommended (American Dietetic Association, 2003).

Sources of vitamin B12 that are not derived from animals include B12 fortified foods, such as soymilk, breakfast cereals, and yeast, or supplements, since no plant food contains significant amounts of active vitamin B12 (American Dietetic Association, 2003).

Lacto-ovo-vegetarians can get adequate amounts of vitamin B12 from dairy foods and eggs if these foods are consumed regularly. It is essential that all vegetarians use a supplement, fortified food, dairy product, or eggs to meet recommended intakes of vitamin B12. A regular source of vitamin B12 is crucial for pregnant and lactating women and for breastfed infants if the mother's diet is not supplemented (AL Luhby et al, 1958). If there are concerns about vitamin B12 status, serum homocysteine, methylmalonic acid, and holotranscobalamin II should be measured (American Dietetic Association, 2003).

Well planned vegan, lacto-vegetarian, and lacto-ovo-vegetarian diets are appropriate for all stages of the life cycle, and can satisfy nutrient needs of infants, children, and adolescents (Messina et al, 2001). Vegetarian diets in childhood and adolescence can aid in the establishment of lifelong healthy eating patterns (American Dietetic Association, 2003).

The breast milk of vegetarian women is similar in composition to that of nonvegetarians and is nutritionally adequate. Soymilk, rice milk, homemade formulas, cow's milk, and goat's milk should not replace breast milk or commercial formula during the first year of life because these foods do not contain the proper ration of macronutrients nor do they have appropriate micronutrient levels for the infant (American Dietetic Association, 2003). Guidelines for the introduction of solid foods are the same for vegetarian and nonvegetarian infants. When it is time to introduce protein rich foods, vegetarian infants can have mashed tofu, pureed legumes, soy or dairy yogurt, cooked egg yolks, and cottage cheese. Later, such foods as cubed cheese, tofu, or soy cheese and bite size soy burger can be started (Messina et al, 2001). Commercial, full fat, fortified soymilk or cows milk can be used as a primary beverage starting at age 1 or older (Messina et al, 2001). Breast fed infants whose mothers do not consume dairy products, foods fortified with vitamin B12 or B12 supplements regularly will need vitamin B12 supplementation (Messina et al, 2001). The guidelines for the use of iron and vitamin D supplements in vegetarian infants does not differ from guidelines for nonvegetarian infants (American Dietetic Association, 2003).

Lacto-ovo-vegetarian children exhibit growth similar to that of their nonvegetarian peers (M Hebbelinck et al, 2001). Poor growth in children has been seen primarily in those on very restricted diets, such as macrobiotic, fruitarian, or unbalanced vegetarian/vegan diets (Van Dusseldorp et al, 1996). Frequent meals and snacks and the use of fortified breakfast cereals, breads, and pastas with foods higher in unsaturated fats can help vegetarian children meet energy and nutrient requirements (American Dietetic Association, 2003).

Vegetarian diets appear to offer some nutritional advantage for adolescents. Vegetarian adolescents are reported to consume more fiber, iron, folate, vitamin A, and vitamin C than nonvegetarian adolescents (CL Perry et al, 2002). Unfortunately, vegetarian diets are somewhat more common among adolescents with eating disorders than the general adolescent population; therefore practitioners should be aware of young clients who greatly limit food choices and who exhibit symptoms of eating disorders ( CL Perry et al, 2001).

A variety of menu planning approaches can provide adequate nutrition for vegetarians, the Vegetarian Food Guide Pyramid and Vegetarian Food Guide Rainbow (Messina et al, 2003) suggest one approach. In addition, the following guidelines can help vegetarians plan healthful diets (American Dietetic Association, 2003):

Choose a variety of foods including whole grains, vegetables, fruits, legumes, nuts, seeds, and if desired, dairy products, and eggs.
Choose whole, unrefined foods often and minimize the intake of highly sweetened, fatty and heavily refined foods.
Choose a variety of fruits and vegetables.
If animal foods such as dairy products and eggs are used, choose lower-fat dairy products and use both eggs and dairy products in moderation.
Use a regular source of vitamin B-12 and, if sunlight exposure is limited, of vitamin D.

In addition to providing guidance on ways to maintain a well balanced vegetarian diet, the practitioner must also monitor the development of the child and use blood tests and/or xrays when necessary if they fear that the child is not receiving adequate amounts of nutrients. Simple ways to monitor for proper development include plotting the child's growth on their growth chart and being alert for any drop offs or plateau's. Other tests the practitioner can use are blood tests including a CBC, iron studies, calcium, phosphorus, 25-OH vitamin D, PTH levels, serum homocysteine, and methylmalonic acid. Radiographic evidence of rickets can be seen through bilateral lower extremity radiographs looking for fraying of the epiphysis. However, if the practitioner can work with the parents to ensure maintenance of proper nutrition and a well balanced diet, then many of these additional tests will be unnecessary.

CONCLUSION

The role of the health professional in management includes:

Recognizing clues such as a history of lack of immunizations,
Determining the nutrient content of the diet,
Evaluating the effects of the diet on the health of the patient (Be sure to look at the teeth; many food faddists will not give fluoridated water to their children),
Determining the reasons for adopting a nontraditional diet.

It is imperative that practitioners educate parents on the importance of maintaining proper nutrition and keep continuous surveillance for signs of nutritional deficiencies. Adherents of vegetarian diets may regard these diets as panaceas for preventing or curing diseases and may avoid necessary medical consultation. When the opportunity for counseling occurs, information should be given about the nutritional quality and safety or hazards of the unconventional diet and its health implications, thus effectively offsetting the false propaganda of food faddists, some of whom are physicians and nutritionists by training (Herbert, 1988).

Food cult families are, for the most part, converts, and did not themselves grow up on the nontraditional diets. A family's willingness to make compromises needs to be explored. Scientific facts should not be presented as a competing set of firmly held beliefs, such as "our beliefs" as opposed to "their religion." Success may be achieved through reasonable compromise.

Responsibilities for the well being of their children must be borne by the parents, but upon their failure to do so, health professional must intervene. Courts are very hesitant to interfere with the constitutionally guaranteed freedom of religion for the sake of better growth or nutritional status alone. At times, however, they must. Through dialogue, rather than through dictum, the message needs to be conveyed to the parents: You grew physically before you grew spiritually; your children need the same opportunity and a fair chance to remain healthy with proper nutrition until they are old enough to make their own choices.

FIGURE 1: Vegetarian Food Guide Pyramid, (Messina et al, 2003)

FIGURE 2: Food Guide Rainbow, (Messina et al, 2003)

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Http://www.macrobioticcooking.com

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Http://www.macrobiotics.co.uk/

Annotated Answers

A1. The answer is D - A Lacto-vegetarian is a person who consumes only plant foods, honey, and dairy products without the consumption of meat, poultry, or eggs.

A Lacto-ovo-vegetarian is a person who consumes plant foods, honey, dairy, and eggs and avoids consumption of meat or poultry.

A Pescetarian is a person who consumes fish, plant foods, honey, dairy, and eggs, with avoidance of meat and poultry.

A Vegan diet excludes all forms of animal flesh, diary, eggs, meat byproducts, and usually avoids wearing animal products such as fur or leather.

A2. The answer is C - Vitamin B12 is only obtained from animal products, such as meat, dairy, and eggs. Lacto-ovo and Lacto-vegetarians usually acquire adequate amounts of vitamin B12 through their diets. Vegans, however, who do not consume meat, dairy, or eggs can only acquire vitamin B12 through supplements and fortified foods such as soymilk and breakfast cereals, thus it is essential that vegans either take supplements or use fortified soymilk and cereals.

Vitamin D is acquired multiple different ways: sunlight, plants (vitamin D2), and animals (vitamin D3). While vitamin D2 is from plant sources, it is less bioavailable then vitamin D3 which is from animal sources, however the primary source is through synthesis dependent on sunlight exposure.

Iron and Calcium are both minerals. However, studies show that a well planned vegan diet typically can meet or exceed the requirements for both iron and calcium, but characteristically, vegan diets are generally at or below requirements for calcium if supplements are not used.

All of the above is incorrect because the most likely vitamin deficient in a well planned vegan diet without supplements or fortified foods (assuming adequate sunlight exposure) is vitamin B12, which is only available from animal sources or fortified foods.

A3. The answer is D - Fortified soymilk is soymilk with vitamins B12, D2, and mineral calcium added. Lactose is a sugar only in cow's milk and is therefore absent in soymilk. It is not necessary in the diet so fortification is not needed.

A4. The answer is False - Soymilk (nor goats milk, homemade soymilk, rice milk, or powdered milk) must NOT be used as an alternative to infant formula during the first year of life because these foods do not contain the proper ratio of macronutrients nor micronutrients levels for the infant to grow and develop appropriately.

A5. The answer is G - Tofu and fortified cereals are high in iron while fruits high in vitamin C increase iron absorption, which are all appropriate recommendations within the constrains of the diet. Although both red meat and eggs are rich in iron they are not acceptable recommendations because the child is a lacto-vegetarian meaning he/she does not consume meat/poultry/eggs

A6. The answer is False - Most vegan families are responsive to dietary suggestions when made in an appropriate sympathetic manner. Thus very few children being raised a vegan warrant a call to child protective services. However, it is appropriate to contact child protective services when the child's diet is inhibiting their growth and development AND the parents refuse implementing a proper nutrition supplementation for health and safety. (See module on Failure to Thrive)