Vegetarian Diets For Children

28/7/2020 Vegetarian diets for children - UpToDate
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Vegetarian diets for children

Authors: Debby Demory-Luce, PhD, RD, LD, Kathleen J Motil, MD, PhD
Section Editors: Jan E Drutz, MD, Amy B Middleman, MD, MPH, MS Ed
Deputy Editor: Alison G Hoppin, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2020. | This topic last updated: Oct 18, 2019.
INTRODUCTION
Vegetarian diets are becoming increasingly popular [1-4]. In the United States, approximately 3.3 percent of adults follow some
form of vegetarian (plant-based) diet and 1.5 percent follow a vegan diet [5]. When eating away from home, approximately 5
percent of Americans report that they "always" choose vegetarian meals and 3 percent "always" choose vegan meals. Surveys of
youth 8 to 18 years old yield similar estimates [6]. Vegetarian diets were reported by approximately 8 to 10 percent of adults in
Germany, Austria, Italy, and the United Kingdom [7,8] and 8 percent of adolescents in the United Kingdom [9].
Interpretation of these surveys is complicated because of variations in definitions for the term "vegetarian." Definitions range from
whether the individual considers himself or herself as vegetarian ("self-defined" vegetarians), avoids meat only, or lives by the
strict definition (never consuming meat, fish, and poultry). As an example, one review of dietary patterns and nutrient intakes of
self-defined vegetarians (aged six years and older) found that patterns ranged from those who consumed reduced amounts of red
meat but included poultry and fish to those who excluded all animal foods [10]. The types and composition of vegetarian diets
have important implications for the growth and development of children and adolescents.
Reasons for choosing a vegetarian diet are varied and include potential health benefits and sociopolitical, ecologic, and ethical
issues related to allocation of resources and animal rights [1,3,11-14]. In some cases, and particularly among adolescents, it may
be difficult to distinguish whether a choice to eat a vegetarian diet is related to health or ethical concerns versus a desire for
dietary restriction [15,16].
The best available data regarding the nutritional quality of vegetarian diets and strategies to prevent nutritional deficiencies while
consuming vegetarian diets are reviewed here. Nutrition requirements, deficiencies, and supplementation of specific nutrients are
discussed separately. (See appropriate topic reviews.)
TYPES OF VEGETARIAN DIETS
Vegetarian diets vary according to the degree of avoidance of foods of animal origin, and definitions are not consistent across
studies [11,17,18].
Vegetarian diets frequently are grouped as follows (listed from less to more restricted):
● Semi-vegetarian – Meat occasionally is included in the diet. Some people who follow such a diet may not eat red meat but
may eat fish and perhaps chicken.
● Pescatarian – Fish and shellfish are included in the diet but no meats or poultry. Variations are pescatarian-vegetarian
(includes milk and eggs) or pescatarian-vegan (excludes milk and eggs).
● Lacto-ovovegetarian – Eggs, milk, and milk products (lacto = dairy; ovo = eggs) are included, but no meat is consumed.
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● Lactovegetarian – Milk and milk products are included in the diet, but no eggs or meat are consumed.
● Macrobiotic – Whole grains, especially brown rice, are emphasized, and vegetables, fruits, legumes, and seaweeds are
included in the diet. Locally grown fruits are recommended. Animal foods limited to white meat or white-meat fish may be
included in the diet once or twice a week.
● Vegan – All animal products, including eggs, milk, and milk products, are excluded from the diet. Some vegans also avoid
honey and may refrain from using animal products such as leather or wool.
Because these terms are used inconsistently, it is important to clarify the intended meaning as part of any discussion of these
diets in clinical settings and when interpreting research.
HEALTH EFFECTS
Surveys of pediatric populations indicate that those who follow a vegetarian diet are somewhat more likely to meet general
targets for a healthy diet compared with those who do not follow a vegetarian diet. As an example, one survey of adolescent
schoolchildren in Minnesota compared self-reported dietary intake with the Healthy People 2010 nutritional objectives [19].
Adolescents who identified themselves as vegetarians were more likely than nonvegetarians to meet the objectives for total fat
(70 versus 48 percent), saturated fat (65 versus 39 percent), daily servings of vegetables (26 versus 14 percent), and ≥5 servings
of fruits or vegetables per day (39 versus 28 percent). The mean calcium intake in both groups was approximately 1100 mg/day,
which is less than the recommended 1300 mg/day; only 30 percent of the students, regardless of dietary group, met the
recommended target for calcium.
Despite this generally healthy diet profile, the vegetarian population also has some specific nutritional risks, especially for children
following a vegan or otherwise restrictive diet, as detailed below. (See 'Energy' below and 'Protein' below and 'Vitamins and
minerals' below.)
Potential effects on growth — Although children who follow a vegetarian diet tend to be somewhat leaner than their omnivore
counterparts, their physical growth is usually within the normal range, provided that meal planning is adequate and sufficient food
is made available [20,21]. By contrast, poorly planned or severely restricted diets can lead to nutrient deficiencies that may
compromise or delay growth in children [22]. As an example, among Dutch children who consumed a macrobiotic diet, height and
arm circumference were reduced for both boys and girls at all ages, although the children experienced catch-up growth as they
approached adolescence [22]. Catch-up growth was related to the addition of dairy products to the diet.
Association with eating disorders — Although adolescents may experience the health benefits of a vegetarian diet, in some
individuals the vegetarian diet is a manifestation of restrictive dietary habits and other disordered eating behaviors [16,23,24]. In
one report, current adolescent vegetarians were more likely than nonvegetarians to report binge eating and vegetarians were
more likely than nonvegetarians to engage in unhealthy weight-control behavior [25]. (See "Eating disorders: Overview of
epidemiology, clinical features, and diagnosis".)
Benefits for cardiovascular and metabolic health — In general, people who follow a lactovegetarian diet have somewhat
better health outcomes compared with those following an omnivorous diet, while a vegan diet may have fewer health benefits and
more risks [26,27]. As an example, several observational studies report that consumption of a vegetarian diet is associated with
lower incidence of obesity, coronary heart disease, hypertension, and type 2 diabetes compared with consumption of a
nonvegetarian diet [1,12,28-35]. These benefits are accompanied by modest decreases in non-high-density lipoprotein (non-HDL)
cholesterol, blood pressure, and body mass index (BMI) [12]. However, it is difficult to separate the effects of the diet from other
characteristics of this population, including associated healthful behaviors (eg, regular exercise and avoidance of tobacco and
alcohol products) or socioeconomic privilege. As a consequence, an independent effect of the diet on health outcomes or all-
cause mortality has not been shown [36].

It should be noted that these potential health effects are not intrinsic to every vegetarian diet, for which the nutritional content can
be highly variable. The nutritional benefits and adequacy of a vegetarian diet must be judged individually, not on the basis of what
it is called but on the type, amount, and variety of nutrients that are consumed [10].
OVERVIEW OF NUTRITIONAL COUNSELING
When providing nutritional counseling about a restrictive diet, it is important to use a supportive, nonjudgmental approach to
establish a therapeutic relationship so that the patient and caregivers are willing to accept guidance [37].
Vegetarian diets can meet nutrient needs for growth and development if they are carefully planned with attention to energy,
protein, iron, calcium, vitamin D, and vitamin B12 (cyanocobalamin) and, to a lesser extent, zinc, long-chain omega-3 fatty acids,
and dietary fiber [1,38-40]. Nutritional counseling about these nutrients is detailed in the sections on each nutrient below.
The greatest risks for inadequate nutrient intake from a vegetarian diet occur during periods of growth. The more restrictive the
vegetarian diet, the greater the risk of dietary inadequacy [41,42]. The establishment of healthy eating patterns in childhood
reduces the likelihood of developing chronic diseases later in life [43-46]. Thus, vegetarian children, like other children, should
consume a diet low in fat, saturated fatty acids, and cholesterol and high in complex carbohydrates, fiber, and antioxidants (eg,
vitamins A and C, carotenoids, and phytochemicals) [47].
Vegetarian or vegan diets should include a variety of nutrient-rich foods. Examples of foods include cooked legumes, whole grain
breads, enriched cereals, nuts and nut spreads (peanut, tahini, almond, and cashew butter), nutlike seeds (sunflower seeds,
soybeans, sesame seeds), avocados, and dried fruits. In addition, the inclusion of dairy products in the vegetarian diet provides a
substantial portion of essential nutrients. Dairy products are good sources of energy, high-quality protein, calcium, potassium,
vitamin B12, magnesium, and vitamin D (if fortified) [26,48].
The United States Department of Agriculture (USDA) "ChooseMyPlate plan" is a tool depicting food groups and portion sizes and
may serve as a useful reference guide. Food patterns with vegetarian options are provided for 12 calorie levels [49]. One group
has developed a similar tool for planning a vegetarian or vegan diet (VegPlate Junior) that meets Italian and United States dietary
reference intakes [50].
LABORATORY MONITORING
Laboratory monitoring for children on vegetarian diets depends on the type of diet and other characteristics of the individual
patient. To identify possible deficiencies, the first step is to perform a periodic survey of the patient's diet using dietary recall or a
diet log. For patients at higher risk for deficiencies, such as those who are underweight or following a vegan diet, we suggest
referral to a dietitian for detailed evaluation and counseling.
Once the characteristics of the diet have been identified, we suggest the following approach to laboratory testing:
● For any patient who eats little or no meat or fish, screen for iron deficiency periodically, following recommendations for
patients at increased risk. A typical approach would be to do laboratory testing every two to three years if clinically stable and
more frequently for patients with abnormal results or with risk factors such as low body weight or heavy menses. In most
clinical settings, the most cost-effective measurement is a complete blood count (CBC); serum ferritin is measured either at
the same time or in follow-up for those with microcytic anemia. (See "Iron deficiency in infants and children <12 years:
Screening, prevention, clinical manifestations, and diagnosis", section on 'Screening recommendations' and "Iron
requirements and iron deficiency in adolescents", section on 'Screening'.)
● For patients with low estimated vitamin D intake (eg, those with little or no dairy intake), check 25-hydroxyvitamin D at
baseline with follow up testing as needed depending on the result or to monitor supplementation. If a supplement is added,

check the level approximately six months later, and if the result is normal, recheck approximately every two to three years.
(See 'Vitamin D' below.)
● For patients who follow a vegan diet, supplement empirically with vitamin B12. Measure serum vitamin B12 concentrations if
there is a concern for deficiency, eg, question of nonadherence to the supplement or macrocytic anemia. (See 'Vitamin B12'
below.)
ENERGY
Energy requirements — Some young children who follow a vegetarian or vegan diet may have difficulty meeting their energy
needs because of their relatively small stomach capacity and energy needs for growth [20,21,51,52]. A plant-based diet that has
a high fiber content and low caloric density may provide a sense of fullness before an adequate amount of energy is ingested.
This situation may be a significant problem in young children, who have small stomach capacities.
To meet energy needs, young children typically need three meals and three snacks per day. Both energy-dense and nutrient-
dense foods should be included. Foods higher in healthy fats, such as nuts, seeds, nut and seed butters, and avocado, help meet
nutrient and energy needs, especially for children who are underweight. The intake of fat should not be restricted in children
younger than two years of age. (See "Dietary history and recommended dietary intake in children", section on 'Energy needs'.)
For adolescents who follow a vegetarian or vegan diet, the clinician should monitor growth and body weight to ensure that energy
intake is appropriate. Adolescents who are overweight and who adopt a vegetarian diet as a means of weight management also
should be monitored for evidence of disordered eating patterns and given anticipatory guidance to emphasize dietary variety and
an appropriate energy intake for healthy weight management [15]. (See "Dietary energy requirements in adolescents".)
Weight concerns — For adolescents who choose to adopt a vegetarian or vegan diet, the clinician should inquire about what
prompted the change in the diet. In many cases, the developmental stage or family/cultural preferences may have played a role in
his or her dietary choice. Counseling should include information about the nutritional implications of the diet to set appropriate
expectations and encourage the adolescent to make responsible food choices.
The clinician should also be alert for any signals that the dietary change may have been triggered by underlying emotional
problems, including an eating disorder [15]. Any adolescent whose body mass index (BMI) is less than the 15th percentile, whose
actual weight is less than 85 percent of the expected weight for height and age, and/or who has other features suggestive of an
eating disorder (including disrupted menses or body image disturbances) is a candidate for referral for more intensive medical
and psychological care. (See 'Association with eating disorders' above and "Eating disorders: Overview of epidemiology, clinical
features, and diagnosis".)
PROTEIN
Requirements — Protein requirements for children are approximately 1.05 grams/kg/day for those one to three years of age,
0.95 grams/kg/day for those 4 to 13 years of age, and 0.85 grams/kg/day for adolescents [53].
These estimates are based on proteins from animal sources (meat, dairy, and eggs) or well-processed soy isolates, which are
more than 90 percent digestible [54,55]. Diets that include these protein sources generally include sufficient protein, as long as
the total energy intake is sufficient. This includes semi-vegetarian, pescatarian, or macrobiotic diets, or vegetarian diets that
include milk, milk products, and/or eggs [56].
Proteins from legumes are 80 to 90 percent digestible, while proteins from grains and other plant foods are 70 to 90 percent
digestible. Therefore, for vegetarians who rely on these protein sources, the protein requirement may be increased by 20 to 30
percent for children aged two to six years and by 15 to 20 percent for children aged six and older, in comparison with
nonvegetarians [54].
Protein type — Proteins of plant and animal origin differ in their concentration of essential amino acids, which are necessary for
growth and repair. To avoid essential acid deficiency, vegetarian diets must include either complete proteins (from animal foods or
soy) or complementary proteins (from complementary types of vegetable proteins).
● Complete proteins – Essential amino acid deficiency is not a concern for diets that include adequate meat, fish, dairy, eggs,
or soy. Animal foods are considered complete proteins because they contain all nine essential amino acids. Soybean-based
products are also complete proteins, unlike other vegetable proteins [57]. Therefore, soy protein is considered high quality
and is a valuable source of protein for vegetarians [58,59]. However, young infants have a relatively high nutritional
requirement for essential amino acids, and soybean isolates are relatively deficient in methionine. Soy-based infant formulas
are supplemented with methionine to improve the utilization of soy protein by infants [60-62]. The need for essential amino
acids decreases as growth and development progress. Thus, children older than two years are capable of utilizing soy
protein isolates without methionine supplementation as a primary source of essential amino acids and nitrogen for protein
maintenance [63,64].
● Incomplete proteins – Plant-based proteins other than soy are considered incomplete because they lack one or more of the
essential amino acids. A diet that relies on these incomplete proteins may not supply sufficient essential amino acids,
especially for infants.
This problem can be addressed by combining one incomplete plant food with a complementary plant food that provides
adequate amounts of the limited essential amino acid. As an example, grains are low in the essential amino acid lysine and
high in methionine, whereas legumes are low in methionine and high in lysine. Together, they combine to make a high-quality
protein source. One need not consume complementary proteins at the same time or in the same meal [1,63].
VITAMINS AND MINERALS
Nutritional counseling is important to ensure that the diet provides adequate vitamins and minerals, especially iron, calcium,
vitamin D, and vitamin B12 (cyanocobalamin). If the diet cannot be adjusted to provide recommended amounts of each of these
nutrients, supplements should be added to ensure adequate intake. In this case, we suggest a general multivitamin and mineral
supplement that contains a broad range of water- and fat-soluble vitamins, minerals, and trace elements to ensure dietary intakes
of micronutrients that approximate daily nutrient requirements for age (table 1).
Iron — Children who have rapid growth rates have increased iron needs and are at risk for iron deficiency with or without anemia
[65-67]. The recommended dietary allowance (RDA) for iron is 7 mg in children 1 to 3 years old, 10 mg in children 4 to 8 years, 8
mg in children 9 to 13 years, and 11 mg for boys and 15 mg for girls aged 14 to 18 years. The RDA for pregnant adolescents is
27 mg/d [68]. (See "Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and
diagnosis" and "Iron requirements and iron deficiency in adolescents".)
● Potential deficits for a vegetarian diet – Iron deficiency is common among children who consume a vegetarian diet, but the
prevalence varies widely [69]. All children who eat little or no meat are at risk, including lacto-ovovegetarians, because milk
and eggs are not good sources of absorbable iron. Risk factors include a restrictive vegetarian diet, periods of rapid growth,
and menstruation [54,65,70,71]. In a study of 1100 children aged 4 to 18 years, female adolescents who reported being
vegetarian were more likely to have low hemoglobin and serum ferritin values than their omnivorous peers [65]. One study of
43 lacto-ovovegetarian and 46 omnivorous children aged 4.5 to 9 years found lower serum hepcidin and ferritin levels in the
vegetarian children, despite higher dietary intake of vitamin C, compared with the nonvegetarian children [72].
Children who do not eat meat are at risk for iron deficiency because nonheme iron (from plants) is less readily absorbed than
heme iron (from meat or fish) [65,68,73,74]. Absorption of heme iron is 15 to 35 percent compared with 2 to 20 percent for
nonheme iron. In addition, the absorption of nonheme iron is reduced greatly by other dietary components, whereas heme
iron is little affected (table 2). In particular, tannins and polyphenols in tea and coffee form iron-tannate complexes that
greatly reduce nonheme iron absorption [38,65,75]. Phytate found in legumes, nuts, seeds, whole grains, and soy protein
also bind with nonheme iron to form insoluble complexes and reduce iron absorption [38,65,76,77]. In one study, absorption
of iron from a variety of commonly eaten legumes (dried beans and peas) prepared as soups was only 1 to 2 percent [70].
● Nutritional counseling – For children who do not eat meat or fish, important strategies to increase iron absorption include
intake of ascorbic acid (vitamin C) at each meal, avoidance of large intakes of tannin-containing teas, and increasing dietary
iron content [38,65,67,78].
Iron supplements may be necessary for individuals with laboratory markers for iron deficiency (eg, low mean cell volume
[MCV] and mean corpuscular hemoglobin [MCH], microcytic anemia, and/or low ferritin) or those with low iron intake as
estimated from a dietary recall. This is most likely for individuals eating restricted vegetarian diets with little or no meat or fish
[1,38]. Adolescent girls are at increased risk for iron deficiency after menarche, due to menstrual blood loss. (See "Iron
deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis" and "Iron
requirements and iron deficiency in adolescents".)
Ascorbic acid (vitamin C) is a powerful promoter of nonheme iron absorption because it prevents the formation of less-
soluble ferric compounds [70,79-81]. A 75 mg dose of ascorbic acid increases the absorption of nonheme iron three- to
fourfold [76]. Because of its mechanism of action, ascorbic acid is effective only when consumed at the same time as the
iron-containing food. Important sources of both vitamin C and other facilitators of iron absorption (eg, citric and malic acid)
include citrus fruits and strawberries, broccoli, and tomatoes. By increasing absorption of nonheme iron, ascorbic acid helps
to counteract the inhibitory effect of phytates in a plant-based diet.
Good plant sources of iron include whole or enriched breads or grains, iron-fortified cereals, legumes, green leafy
vegetables, dried fruits, soy products, blackstrap molasses, bulgur, and wheat germ. The widespread fortification of enriched
breads, cereals, and pasta products has helped increase iron intake for children.
Calcium — Adequate calcium intake is important throughout life to ensure peak bone mass accumulation, especially during
periods of growth. Children with stronger bones may experience fewer fractures and may be more resistant to the development of
osteoporosis in later life [82,83]. The recommended intake of calcium is approximately 700 mg for children 1 to 3 years of age,
1000 mg for children 4 to 8 years of age, and 1300 mg for those 9 to 18 years (table 1) [84]. (See "Calcium requirements in
adolescents" and "Dietary recommendations for toddlers, preschool, and school-age children", section on 'Dairy products'.)
● Potential deficits for a vegetarian diet – For children who consume lactovegetarian or lacto-ovovegetarian diets, most
calcium needs can be met by low-fat milk and dairy products; these provide approximately 75 percent of the calcium in the
average American diet [83,85]. Children who avoid dairy products, such as those following a vegan diet, have more difficulty
meeting calcium needs. This is in part because they consume plant foods containing oxalates and phytates, and because the
calcium content of typical vegetables, fruit, and cereal grains is relatively low [39,86-88]. Children who avoid dairy products
generally require either substantial intake of calcium-fortified foods (eg, several servings daily of calcium-fortified soy milk) or
a calcium supplement to meet the age-dependent recommended intake (table 1).
Estimates of calcium needs are imprecise because other dietary constituents also affect calcium balance: oxalate and
phytate decrease calcium absorption, while salt and protein increase calcium excretion [78,83,89]. Foods high in oxalate
include spinach, beet greens, Swiss chard, and yams. Thus, the lower protein intake among vegetarians may decrease
urinary calcium loss, which improves their net calcium balance and reduces their risk for calcium stone formation compared
with omnivores [90]. (See "Risk factors for calcium stones in adults", section on 'Protein'.)
● Nutritional counseling – Vegetarian children who do not drink milk should include at least one calcium-rich or calcium-
fortified food with each meal and with several snacks each day. Children who follow a vegan diet can obtain calcium from
calcium-fortified foods and beverages (such as fortified soy milk), foods naturally rich in calcium, calcium supplements, or a
combination of these:

• Calcium-fortified foods include soy milk, soy yogurt, and soy cheese, as well as calcium-precipitated tofu and calcium-
fortified cereals, breakfast bars, pastas, waffles, and juices [91,92]. Calcium bioavailability in most of these sources is
equivalent to milk. As an example, one eight-ounce glass of calcium-fortified orange juice provides 300 mg of calcium,
equivalent to an eight-ounce glass of milk. In contrast, the bioavailability of calcium in soy milk is only 75 percent of that
in cow's milk [93]. Ideally, these foods should also be fortified with vitamin D because vitamin D facilitates the absorption
of calcium [94].
• Foods that are naturally rich in calcium and low in oxalate include kale, mustard greens, turnip greens, broccoli, bok
choy, dried figs, blackstrap molasses, and lime-processed tortillas (table 3) [83]. Most of these foods have additional
benefits because they provide other important nutrients. However, it is difficult to meet calcium requirements from these
foods alone, even with large portions.
• Calcium supplements also can be used to provide adequate calcium intake. Consuming calcium supplements at the
same time as iron or zinc supplements may interfere with the absorption and utilization of these minerals. (See "Calcium
requirements in adolescents".)
The benefits of using fortified foods to increase calcium intake was demonstrated in a double-blind, placebo-controlled study
of prepubertal girls with low spontaneous calcium intake who were randomly assigned to receive food products that were or
were not fortified with 850 mg of calcium [95]. Calcium fortification increased mean bone mineral density in all girls, but the
increase was greatest in those whose baseline calcium intake was less than 850 mg. The gains in bone mass persisted one
year after discontinuation of treatment.
Vitamin D — Normal levels of vitamin D metabolites are necessary for adequate intestinal calcium, phosphate absorption, and
bone formation [96-98]. Vitamin D is available through sunlight exposure and dietary intake (figure 1). Dietary intake of 15 mg
(600 international units) daily is recommended for children one year and older. (See "Vitamin D insufficiency and deficiency in
children and adolescents", section on 'Targets for vitamin D intake'.)
Sunlight exposure is an important source of vitamin D but is often insufficient, especially during the winter, for children with dark
skin pigmentation or for those who use sunscreen or clothing to protect their skin from sun damage. Maintenance of normal
serum vitamin D concentrations requires exposure to the sun on hands, arms, and face for 10 to 15 minutes per day for fair-
skinned individuals; individuals with dark skin pigmentation require 6 to 10 times as much exposure as a light-skinned individual
[99]. (See "Vitamin D insufficiency and deficiency in children and adolescents", section on 'Skin pigmentation and low sun
exposure'.)
● Potential deficits for a vegetarian diet – Few foods contain vitamin D. The principal dietary source of vitamin D for
omnivores, lacto-ovovegetarians, and lactovegetarians is milk fortified with vitamin D (2.5 mg [100 international units] per 8
oz) [100]. Vegetarians who do not consume milk are at risk for vitamin D deficiency, which can lead to rickets in young
children and osteomalacia in adults [101-104]. In one study of 53 children (one to two years of age) on a macrobiotic diet
compared with 57 matched omnivores, symptoms of rickets were present in 28 percent of the children who followed a
macrobiotic diet [105].
● Nutritional counseling – For children who do not drink milk (eg, those following a vegan diet), a dietary alternative is
fortified soy milk, other fortified alternative milk, or fortified breakfast cereal [94,96]. For children who eat fish (eg, a
pescatarian or macrobiotic diet), consuming fatty fish (sardines, salmon, tuna, mackerel) or cod liver oils several times per
week can provide sufficient vitamin D. Cheese and egg yolks provide small amounts of vitamin D [96].
To meet the recommended intake for vitamin D, children generally require either substantial intake of these vitamin D-rich
foods (eg, several servings daily of fortified milk or soy milk) and some additional vitamin D from sunlight exposure (eg, from
participating in outdoor sports or active play). Otherwise, they will require a vitamin D supplement to meet the target,
especially if they have risk factors for vitamin D deficiency such as dark skin pigmentation, low sun exposure, or residence in
northern latitudes [106,107]. (See "Overview of vitamin D", section on 'Sources'.)

Vitamin B12 — Vitamin B12 (cobalamin) is only found in foods from animal sources (meat, fish, eggs, and dairy products)
[39,108]. The RDA for cobalamin is 0.9 mcg for children 1 to 3 years of age, 1.2 mcg for those 4 to 8 years, 1.8 mcg for 9 to 13
years, 2.4 mcg for 14 to 18 years, and 2.6 mcg for pregnant adolescents [109]. Because substantial amounts of vitamin B12 are
stored in the body (primarily in the liver), the deficiency develops gradually. Once vitamin B12 is removed from the diet, deficiency
develops within four to six months in infants (eg, the breastfed infant of a mother with vitamin B12 deficiency) or one to two years
in adults [109]. (See "Treatment of vitamin B12 and folate deficiencies".)
● Potential deficits for a vegetarian diet – Lacto-ovovegetarians and lactovegetarians can, but do not always, consume
sufficient amounts of vitamin B12 from eggs, milk, and milk products. Vegans, whose diets are based entirely on plant food,
are at considerable risk for vitamin B12 deficiency [110,111]. For example, in one study, 10 of 25 vegans had vitamin B12
deficiency manifested by macrocytosis (picture 1) and low serum vitamin B12 [112]. In another report, serum vitamin B12
concentrations were determined in 83 volunteer subjects attending an American vegetarian society conference [113]. Among
subjects who did not supplement their diets with vitamin B12 or multivitamin tablets, the percentage with serum vitamin B12
levels below the normal range was associated with the degree of dietary restriction:
• Vegans – 92 percent
• Lactovegetarians – 64 percent
• Lacto-ovovegetarians – 47 percent
• Semi-vegetarians – 20 percent
● Nutritional counseling – For children who eat fish (eg, those following a pescatarian diet), eating fish two to three times per
week can provide a good source of vitamin B12. Vegan children and other vegetarians whose diet does not contain
significant amounts of meat or fish should consume a regular and reliable source of the vitamin, either in fortified foods or an
oral B12 supplement. Commonly used vitamin B12-fortified foods include most ready-to-eat cereals, many meat substitutes,
some milk alternatives, and fortified nutritional yeasts [10]. Fortified soy milk is another good source of vitamin B12 for
children [114]. Vitamin B12 supplements typically provide 6 to 9 mcg per day [111]. This dose is higher than the RDA to
ensure adequate intake and because there are no adverse effects of the higher dose [109]. Of note, only cyanocobalamin is
the active form of the vitamin, and some listings of vitamin B12 content in foods do not differentiate between this form and its
inactive analogs. As examples, much of the vitamin B12 present in spirulina, sea vegetables, tempeh, and miso is inactive
and does not contribute to the vitamin B12 requirement [92,115]. Moreover, the inactive forms can compete with active forms
for absorption.
Zinc — Recommended intake for zinc is 3 mg/day for children aged 1 to 3 years, 5 mg/day for children aged 4 to 8 years, 8
mg/day for children aged 9 to 13 years, 9 mg/day for adolescent females, and 11 mg/day for adolescent boys (table 4).
● Potential deficits for a vegetarian diet – Children who do not consume dairy products are at risk of a suboptimal zinc
status because of high requirements for growth, although the clinical significance of mild zinc deficiency is unclear. Severe
zinc deficiency can be associated with growth impairment and an increased risk of infections, particularly diarrhea and
pneumonia. Adult vegetarians do not typically develop zinc deficiency, because they have a compensatory increase in
fractional absorption. (See "Zinc deficiency and supplementation in children".)
Zinc is found in foods of both animal and plant origin. Animal sources include oysters, shellfish, liver, meat, poultry, and dairy
products [73,116]. The zinc in vegetarian diets has a lower bioavailability because of the high content of phytate and dietary
fiber [38,54,117,118]. Certain food-preparation techniques, such as the soaking of sprouting beans, grains, and seeds, as
well as leavening breads, can mitigate this problem by reducing binding of zinc by phytates, thus increasing zinc
bioavailability [1,119,120].
● Nutritional counseling – Milk and milk products are the primary source of zinc for children on vegetarian diets who also
consume dairy products. For children who do not consume milk (eg, vegans), cereals are the primary source of zinc;

secondary sources are meat substitutes (eg, legumes, nuts, and soy products). Plant sources of zinc include whole grains,
legumes, wheat germ, and nuts.
Omega-3 fatty acids — Dietary requirements for omega-3 fatty acids in infants, children, and adolescents have not been
established [121]. However, indirect evidence suggests that they have some health benefits.
● Potential deficits for a vegetarian diet – Vegetarian diets generally are rich in omega-6 fatty acids but may be marginal in
omega-3 fatty acids unless the diet includes fish, eggs, or generous amounts of algae. Omega-3 fatty acids, which include
docosahexaenoic acid (DHA) or eicosapentaenoic acid (EPA), or their precursor alpha-linolenic acid (ALA), are important for
cardiovascular health and eye and brain development [40,122]. Vegetarians, particularly vegans, have lower blood levels of
EPA and DHA than nonvegetarians [1,123].
● Nutritional counseling – We suggest that vegetarian children include either oily fish or other good sources of omega-3 fatty
acids in their diet, such as flaxseed, walnuts, canola oil, and soy. Infant formulas, soy milk, and breakfast bars that are
fortified with DHA also are available [1]. (See "Fish oil: Physiologic effects and administration".)
Fiber — Recommended fiber intake for children is approximately 19 g/day for ages 1 to 3 years, 25 g/day for ages 4 to 8 years,
and 26 to 31 g/day for ages 9 to 13 years [53]. Somewhat lower targets may be more realistic for children whose diets are not
plant-based [124].
The optimum level of dietary fiber for infants and children younger than two years of age is not known. For this age group, studies
of weaning diets with increased fiber suggested that 5 g/day is beneficial and found no negative effect on the absorption of
energy, zinc, and calcium or iron bioavailability [125,126]. However, other studies have shown that growth is poor among infants
and toddlers weaned onto very high-fiber, low-calorie diets that often are deficient in vitamins and minerals [127,128]. (See
"Dietary recommendations for toddlers, preschool, and school-age children", section on 'Fiber'.)
● Potential issues for a vegetarian diet – Vegetarians tend to have a relatively high fiber intake compared with omnivores. In
populations following a vegan or macrobiotic diet, the average fiber intake is in a healthy range. In a study of 51 adults,
average fiber intake among omnivores was 23 g compared with 37 g among vegetarians and 47 g among vegans [129]. In a
similar study of 106 children 6 to 16 months of age, mean daily fiber intake was 13 g among those following a macrobiotic
diet compared with 7 g among omnivores [130].
The consumption of a high-fiber diet in childhood promotes regular bowel movements and possibly reduces the risk of
developing certain diseases in adulthood. However, during childhood, a diet with very high fiber content can compromise
dietary energy intake and reduce the bioavailability of minerals such as iron, calcium, and zinc [1,38,54,131]. A small loss of
energy, primarily as fat, and protein may occur with a high intake of dietary fiber. Daily fecal energy loss is estimated to
increase by 1 percent for every 6 g increase in dietary fiber. This loss is unlikely to be significant in children who consume
adequate energy.
The amount of dietary fiber recommended above, or even fiber intake that exceeds this recommendation, does not have an
adverse effect on mineral bioavailability, provided that the dietary mineral intake is adequate. However, mineral bioavailability
may be problematic in children who follow strict macrobiotic or vegan diets with low intake of calcium, iron, and zinc.
● Nutritional counseling – Most vegetarian children have a healthy intake of fiber. Because a very high-fiber diet can
compromise energy intake and mineral absorption, vegetarian children should be monitored to ensure that they have
adequate growth and adequate intake of minerals such as iron, calcium, and zinc.
Dietary fiber goals can be met best by eating a variety of fiber-rich fruits, vegetables, cereals, and grain products while
consuming adequate energy intake for growth and development [131]. Fiber supplements are not recommended to meet
dietary fiber goals.

INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education
pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-
to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your
patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s)
of interest.)
● Basics topics (see "Patient education: Vegetarian diet (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Children can safely ingest vegetarian diets and attain normal growth and development, provided that the diet is well planned
and balanced. More restrictive diets (eg, vegan) require particular care to ensure that all nutritional needs are met. In
general, a lactovegetarian diet has greater health benefits and fewer health risks than a vegan diet. (See 'Types of
vegetarian diets' above and 'Benefits for cardiovascular and metabolic health' above.)
● Some adolescents choose a vegetarian diet as a means of weight control, and clinicians should be alert for evidence of
inappropriate dietary restriction and other disordered eating behaviors. An adolescent whose body mass index (BMI) is less
than the 15th percentile, or whose actual weight is less than 85 percent of ideal body weight, is a candidate for referral for
more intensive medical and psychological care. (See 'Vitamins and minerals' above.)
● Nutritional counseling is important to ensure that the diet provides adequate nutrients, especially energy, protein, iron,
calcium, vitamin D, and vitamin B12 (cyanocobalamin). If the diet cannot be adjusted to provide recommended amounts of
each of these nutrients, supplements should be added to ensure adequate intake.
• Children who do not eat meat or fish are at risk of iron deficiency, especially during periods of rapid growth and in
menstruating girls. To enhance the absorption of nonheme iron (from plants), a source of ascorbic acid should be
provided at each meal. Teas containing tannin should be limited. Iron supplements may be necessary for some
individuals eating restricted vegetarian diets. (See 'Iron' above.)
• Children who ingest little or no dairy products are at risk for calcium and vitamin D deficiencies. Ready-to-eat cereals
and alternative milks (such as soy milk) are good sources of these nutrients, provided that they are fortified. However,
the recommended intake for these nutrients is high and requires several servings daily of milk, fortified alternative milk,
or fortified cereal. Many children require supplementation to meet their requirements. (See 'Calcium' above and 'Vitamin
D' above.)
• Children who follow a vegan diet are at risk for vitamin B12 (cobalamin) deficiency because animal products (meat, fish,
and dairy products) provide the only dietary source of vitamin B12 (cobalamin) for humans. Individuals following a vegan
diet should consume a regular and reliable source of the vitamin, either in fortified foods (soy milk or cereals) or an oral
vitamin B12 supplement. (See 'Vitamin B12' above.)
Use of UpToDate is subject to the Subscription and License Agreement.

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Topic 5353 Version 22.0

GRAPHICS
Estimated energy requirements (low to moderate activity) and recommended dietary allowance (RDA) of
selected nutrients for infants, children, and adolescents
Energy Protein Total fat Iron Calcium Zinc

Age
(kcal/day) (g/day) (g/day) (mg/day) (mg/day) (mg/day)
1 to 3 years
Boys 850 to 1400 13 30 to 40 7 700 3
Girls 800 to 1400 13 30 to 40 7 700 3
4 to 8 years
Boys 1400 to 1900 19 25 to 35 10 1000 5
Girls 1300 to 1800 19 25 to 35 10 1000 5
9 to 13 years
Boys 1800 to 2600 34 25 to 35 8 1300 8
Girls 1600 to 2200 34 25 to 35 8 1300 8
14 to 18 years
Boys 2400 to 3200 52 25 to 35 11 1300 11
Girls 2000 to 2300 46 25 to 35 15 1300 9
Adapted from:
1. The Dietary Reference Intakes, National Academy of Sciences, Washington, DC, 2002.
2. National Academies Press. Dietary Reference Intakes for Calcium and Vitamin D (2010). Available at books.nap.edu/openbook.php?
record_id=13050&page=291. Accessed on December 13, 2010.
Graphic 78274 Version 14.0

Factors influencing the absorption and bioavailability of dietary iron
Absorption of heme iron

Amount of heme iron, especially in meat
Content of calcium in the meal (calcium impairs iron absorption)
Absorption of nonheme iron

Iron status
Amount of potentially available nonheme iron
Balance between positive and negative factors

Positive factors
Ascorbic acid
Meat or fish (factors in meat other than heme iron enhance absorption of nonheme iron)
Negative factors
Phytate (in bran, oats, rye fiber)
Polyphenols (in tea, some vegetables and cereals)
Dietary calcium
Soy protein
Adapted from: Hallberg L, Rossander-Hulten L, Burne M. Nutritional anemias. In: Nestle Workshop Series, vol 30, Fomon SJ, Zlotkin S (Eds), Vevey/Raven Press,
New York 1992. p.170.

Dietary sources of absorbable calcium, in comparison with milk
Number of
Fractional Estimated
Calcium content ¶ servings needed
Food Serving size* (g) absorption Δ, absorbable
(mg) to equal 240 mL
(percent) calcium ◊ (mg)
milk
Milk 240 300 32.1 96.3 1
Beans
Pinto 86 44.7 26.7 11.9 8.1
Red 172 40.5 24.4 9.9 9.7
White 110 113 21.8 24.7 3.9
Bok choy 85 79 53.8 42.5 2.3
Broccoli 71 35 61.3 21.5 4.5
Cheddar cheese 42 303 32.1 97.2 1
Cheese food 42 241 32.1 77.4 1.2
Chinese cabbage flower 85 239 39.6 94.7 1

leaves
Chinese mustard 85 212 40.2 85.3 1.1

greens
Fruit punch with 240 300 52 156 0.62

calcium citrate malate
Kale 85 61 49.3 30.1 3.2
Spinach 85 115 5.1 5.9 16.3
Sweet potatoes 164 44 22.2 9.8 9.8
Rhubarb 120 174 8.54 10.1 9.5
Tofu with calcium 126 258 31 80 1.2
Yogurt 240 300 32.1 96.3 1
* Based on one-half-cup serving size (~85 g for green leafy vegetables) except for milk and fruit punch (1 cup or 240 mL) and cheese (1.5 ounces).
¶ From references 4 and 5 (averaged for beans and broccoli processed in different ways) except for the Chinese vegetables, which were analyzed in our
laboratory.
Δ Adjusted for load by using the equation for milk (fractional absorption = 0.889 to 0.0964 in load (6)) then adjusted for the ratio of calcium absorption of the
test food relative to milk tested at the same load, the absorptive index. The absorptive index was taken from the literature for beans (7), bok choy (8), broccoli
(8), Chinese vegetables (9), fruit punch with calcium citrate mulate (10), kale (8), sweet potatoes (9), rhubarb (9), tofu (11), and dairy products (12).
◊ Calculated as calcium content × fractional absorption.
Reproduced with permission from: Weaver CM, Proulx WR, Heaney R. Choices for achieving adequate dietary calcium with a vegetarian diet. Am J Clin Nutr 1999;
70 (suppl):543S. Copyright ©1999, American Society for Clinical Nutrition.

Pathways of vitamin D synthesis
Metabolic activation of vitamin D to calcitriol and its effects on calcium and

phosphate homeostasis. The result is an increase in the serum calcium and
phosphate concentrations.
UV: ultraviolet; Ca: calcium.

Macro-ovalocytes in vitamin B12 deficiency
Peripheral smear shows marked macro-ovalocytosis in a patient with vitamin

B12 deficiency. In this case, teardrop cells are an advanced form of macro-
ovalocytes.
Courtesy of Stanley L Schrier, MD.
Normal peripheral blood smear
High-power view of a normal peripheral blood smear. Several platelets

(arrowheads) and a normal lymphocyte (arrow) can also be seen. The red
cells are of relatively uniform size and shape. The diameter of the normal red
cell should approximate that of the nucleus of the small lymphocyte; central
pallor (dashed arrow) should equal one-third of its diameter.
Courtesy of Carola von Kapff, SH (ASCP).

Dietary reference intakes (DRI) of trace elements
Zinc Selenium Iodine Copper Chromium Manganese Fluoride Molybdenum

Life
(mg/d) (mcg/d) (mcg/d) (mcg/d) (mcg/d) (mg/d) (mg/d) (mcg/d)
stage
group RDA*
UL Δ RDA/AI ¶ UL RDA/AI ¶ UL RDA/AI ¶ UL RDA/AI ¶ UL RDA/AI ¶ UL RDA/AI ¶ UL RDA/AI ¶ UL
AI ¶
Infants
0 to 2¶ 4 15 ¶ 45 110 ¶ ND 200 ¶ ND 0.2 ¶ ND 0.003 ¶ ND 0.01 ¶ 0.7 2¶ ND

6 mo
7 to 3 5◊ 20 ¶ 60 130 ¶ ND 220 ¶ ND 5.5 ¶ ND 0.6 ¶ ND 0.5 ¶ 0.9 3¶ ND

12
mo
Children
1 to 3 7◊ 20 90 90 200 340 1000 11 ¶ ND 1.2 ¶ 2 0.7 ¶ 1.3 17 300

3y
4 to 5 12 ◊ 30 150 90 300 440 3000 15 ¶ ND 1.5 ¶ 3 1¶ 2.2 22 600

8y
Males
9 to 8 23 ◊ 40 280 120 600 700 5000 25 ¶ ND 1.9 ¶ 6 2¶ 10 34 1100

13 y
14 to 11 34 ◊ 55 400 150 900 890 8000 35 ¶ ND 2.2 ¶ 9 3¶ 10 43 1700

18 y
19 to 11 40 ◊ 55 400 150 1100 900 10,000 35 ¶ ND 2.3 ¶ 11 4¶ 10 45 2000

30 y
31 to 11 40 ◊ 55 400 150 1100 900 10,000 35 ¶ ND 2.3 ¶ 11 4¶ 10 45 2000

50 y
51 to 11 40 ◊ 55 400 150 1100 900 10,000 30 ¶ ND 2.3 ¶ 11 4¶ 10 45 2000

70 y
>70 11 40 55 400 150 1100 900 10,000 30 ¶ ND 2.3 ¶ 11 4¶ 10 45 2000

y
Females
9 to 8 23 ◊ 40 280 120 600 700 5000 21 ¶ ND 1.6 ¶ 6 2¶ 10 34 1100

13 y
14 to 9 34 ◊ 55 400 150 900 890 8000 24 ¶ ND 1.6 ¶ 9 3¶ 10 43 1700

18 y
19 to 8 40 55 400 150 1100 900 10,000 25 ¶ ND 1.8 ¶ 11 3¶ 10 45 2000

30 y
31 to 8 40 55 400 150 1100 900 10,000 25 ¶ ND 1.8 ¶ 11 3¶ 10 45 2000

50 y
51 to 8 40 55 400 150 1100 900 10,000 20 ¶ ND 1.8 ¶ 11 3¶ 10 45 2000

70 y
>70 8 40 55 400 150 1100 900 10,000 20 ¶ ND 1.8 ¶ 11 3¶ 10 45 2000

y
Pregnancy
14 to 12 34 60 400 220 900 1000 8000 29 ¶ ND 2.0 ¶ 9 3¶ 10 50 1700

18 y
19 to 11 40 60 400 220 1100 1000 10,000 30 ¶ ND 2.0 ¶ 11 3¶ 10 50 2000

30 y
31 to 11 40 60 400 220 1100 1000 10,000 30 ¶ ND 2.0 ¶ 11 3¶ 10 50 2000

50 y
Lactation
14 to 13 34 70 400 290 900 1300 8000 44 ¶ ND 2.6 ¶ 9 3¶ 10 50 1700

18 y
19 to 12 40 70 400 290 1100 1300 10,000 45 ¶ ND 2.6 ¶ 11 3¶ 10 50 2000

30 y
31 to 12 40 70 400 290 1100 1300 10,000 45 ¶ ND 2.6 ¶ 11 3¶ 10 50 2000

50 y
RDA: recommended dietary allowance; AI: adequate intake; UL: upper tolerable level; ND: not determined; WHO: World Health Organization.
* Values in this column represent the RDA, unless otherwise indicated. The RDA is the level of dietary intake that is sufficient to meet the daily nutrient
requirements of 97% of the individuals in a specific life stage group.
¶ These values represent the AI. The AI is an approximation of the average nutrient intake that sustains a defined nutritional state, based on observed or

experimentally determined values in a defined population.
Δ The UL is the maximum level of daily nutrient intake that is likely to pose no risk of adverse health effects in almost all individuals in the specified life stage or
gender group.
◊ The ULs for zinc in children set by the WHO are considerably higher than those in this table [1]. The WHO based its UL on estimates of the threshold at which
zinc intake alters laboratory measures of copper sufficiency.
References:
1. Gibson RS, King JC, Lowe N. A Review of Dietary Zinc Recommendations. Food Nutr Bull 2016; 37:443.
Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Otten JJ, Hellwig JP, Meyers LD (Eds), The National Academies Press, Washington, DC
2006. pp.530-541. Reprinted with permission from the National Academies Press, Copyright © 2006, National Academy of Sciences.
Sources: Dietary reference intakes for Thiamin, Riboflavin, Niacin, Vitamin B 6 , Folate, Vitamin B 12 , Panthothenic acid, Biotin, and Choline (1998); Dietary
reference intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000). These reports may be accessed via www.nap.edu.

Contributor Disclosures
Debby Demory-Luce, PhD, RD, LD Nothing to disclose Kathleen J Motil, MD, PhD Nothing to disclose Jan E Drutz, MD Nothing to
disclose Amy B Middleman, MD, MPH, MS Ed Grant/Research/Clinical Trial Support: Pfizer [Meningococcal serogroup B vaccine]. Alison G
Hoppin, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-
level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is
required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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TYPES OF VEGETARIAN DIETS

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OVERVIEW OF NUTRITIONAL COUNSELING

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VITAMINS AND MINERALS

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INFORMATION FOR PATIENTS

● Basics topics (see "Patient education: Vegetarian diet (The Basics)")

SUMMARY AND RECOMMENDATIONS

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41. Phillips F . Vegetarian nutrition. Nutr Bull 2005; 30:132.

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Topic 5353 Version 22.0

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Energy Protein Total fat Iron Calcium Zinc

Boys 850 to 1400 13 30 to 40 7 700 3

Girls 800 to 1400 13 30 to 40 7 700 3

Boys 1400 to 1900 19 25 to 35 10 1000 5

Girls 1300 to 1800 19 25 to 35 10 1000 5

Boys 1800 to 2600 34 25 to 35 8 1300 8

Girls 1600 to 2200 34 25 to 35 8 1300 8

Boys 2400 to 3200 52 25 to 35 11 1300 11

Girls 2000 to 2300 46 25 to 35 15 1300 9

Graphic 78274 Version 14.0

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Factors influencing the absorption and bioavailability of dietary iron

Absorption of heme iron

Content of calcium in the meal (calcium impairs iron absorption)

Absorption of nonheme iron

Amount of potentially available nonheme iron

Balance between positive and negative factors

Graphic 64874 Version 7.0

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Dietary sources of absorbable calcium, in comparison with milk

Milk 240 300 32.1 96.3 1

Bok choy 85 79 53.8 42.5 2.3

Broccoli 71 35 61.3 21.5 4.5

Cheddar cheese 42 303 32.1 97.2 1

Cheese food 42 241 32.1 77.4 1.2

Chinese cabbage flower 85 239 39.6 94.7 1

Chinese mustard 85 212 40.2 85.3 1.1

Fruit punch with 240 300 52 156 0.62

Kale 85 61 49.3 30.1 3.2

Spinach 85 115 5.1 5.9 16.3

Sweet potatoes 164 44 22.2 9.8 9.8

Rhubarb 120 174 8.54 10.1 9.5

Tofu with calcium 126 258 31 80 1.2

Yogurt 240 300 32.1 96.3 1

Graphic 52445 Version 6.0

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Pathways of vitamin D synthesis