Vegetarian Eating

for Children and

Adolescents
Laurie Dunham, MS, RD, LD, &
Linda M. Kollar, RN, MSN
ABSTRACT
During the past decade, vegetarianism has risen in popularity among American
families. Well-planned vegetarian diets can satisfy the nutritional needs and pro-
mote normal growth of infants and children. Research has highlighted nutritional
advantages to vegetarian diets and has indicated that this style of eating can lead
to lifelong healthy eating habits when adopted at a young age. Several vitamins,
minerals, and macronutrients may be decient within a vegetarian diet. Careful
nutrition assessment and counseling will allow nurse practitioners to play a key
role in encouraging families to adopt healthy eating habits to assist in disease
prevention. J Pediatr Health Care. (2006) 20, 27-34.
The American Dietetic Associa-
tion and the American Academy of
Pediatrics agree that well-planned
vegan and vegetarian diets can sat-
isfy the nutritional needs and pro-
mote normal growth of infants and
young children (American Acad-
emy of Pediatrics Committee on
Nutrition, 1998; Messina & Burke,
1997). In addition, a vegetarian
style of eating follows the dietary
guidelines and meets requirements
of the Recommended Dietary Al-
lowances for nutrients (National
Academy of Science, 2003; United
States Department of Agriculture,
2005). Many well-designed studies
have concluded that children and
adolescents who follow a properly
designed vegetarian diet grow and
develop normally (Nathan, Hack-
ett, & Kirby, 1997; OConnell et al.,
1989; Sabate, Lindsted, Harris, &
Sanchez, 1991; Sabate, Lindsted,
Harris, & Johnston, 1990; Sanders
& Manning, 1992; Sanders &
Reddy, 1994). Birth weights of in-
fants born to well-nourished vege-
tarian women have been shown to
be similar to birth weight norms
and to birth weights of infants
born to nonvegetarian mothers
(OConnell et al.). Research has
highlighted nutritional advantages
to vegetarian diets and has indi-
cated that this style of eating can
lead to lifelong healthy eating hab-
its when adopted at a young age.
Studies show that children and ad-
olescents who follow a vegetarian
diet have a lower intake of choles-
terol, saturated fat, and total fat
and a higher intake of fruit, veg-
etables, and ber than their non-
vegetarian counterparts (Fulton,
Hutton, & Stitt, 1980; Neumark-
Sztainer, Story, Resnick, & Blum,
1997; Novy, 2000; Sanders & Man-
ning). In addition, research sug-
gests that vegetarian children are
leaner than nonvegetarian children
(Krajcovicov-Kudlckov, Simon-
cic, Bederova, Grancicova, & Ma-
galova, 1997; Sabate et al., 1990).
Laurie Dunham is Registered Dietitian, Division of Adolescent Medicine, Cincinnati
Childrens Hospital Medical Center, Cincinnati, Ohio.
Linda M. Kollar is Director of Clinical Services, Division of Adolescent Medicine,
Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio.
Reprint requests: Laurie Dunham, MS, RD, LD, Division of Adolescent Medicine,
Cincinnati Childrens Hospital Medical Center, 3333 Burnet Ave ML 4000, Cincinnati,
OH 45229; e-mail:[email protected].
0891-5245/$32.00
Copyright 2006 by the National Association of Pediatric Nurse Practitioners.
doi:10.1016/j.pedhc.2005.08.012
Journal of Pediatric Health Care January/February 2006 27
Original Article
www.jpedhc.org
We also have learned that vegetar-
ian adults have a decreased risk for
several chronic diseases such as
diabetes, coronary artery disease,
hypertension, obesity, and some
types of cancer (Appleby, Thoro-
good, Mann, & Key, 1999; Beilin,
1994; Dwyer, 1988; Fraser, 1999;
Fraser, Lindsted, & Beeson, 1995;
Kahn, Phillips, Snowdon, & Choi,
1984; Key et al., 1999; Key, Thoro-
good, Appleby, & Burr, 1996;
Knutsen, 1994; Messina & Burke,
1997; Phillips et al., 1980; Rajaram
& Sabate, 2000; Roberts, 1995).
Aside from nutritional advantages,
individuals may choose to adopt a
vegetarian style of eating for other
reasons. For instance, religion,
economic status, environmental is-
sues, and concerns of world hun-
ger may play a role in a persons
decision to exclude animal prod-
ucts from his or her diet (Messina
& Burke; Rajaram & Sabate). The
purpose of this article is to provide
practical, factual information about
vegetarian eating for infants, chil-
dren, and adolescents.
The eating patterns of vegetari-
ans can vary greatly. With the ex-
ception of vegans, most vegetarian
diets consist of grains, fruits, vege-
tables, legumes, oils, nuts, seeds,
dairy products, and eggs. Vegans
exclude all foods of animal origin,
including dairy, eggs, butter,
honey, and gelatin (Messina &
Burke, 1997). Some persons may
describe themselves as vegetarian
if they just limit meats, making ex-
ploration of a patients denition
of vegetarian extremely important
(Barr & Chapman, 2002).
Assessing the nutritional intake
of a child or adolescent is essential
to monitor proper growth and de-
velopment. This assessment is es-
pecially critical if they have
adopted a pattern of eating, such
as vegetarianism, that partially or
completely eliminates an entire
food group. Several dietary assess-
ment tools can be used in a clinical
setting to assess a patients eating
habits. A 24-Hour Food Recall (Fig-
ure 1) and Food Frequency Ques-
tionnaire (Figure 2), used together,
can provide detailed and adequate
information for evaluation. The 24-
Hour Food Recall and Food Fre-
quency Questionnaire can be sent
home, lled out by the patient, and
brought to the next appointment,
or if time allows, it can be admin-
istered in the ofce. During a 24-
hour food recall, a teen or a childs
parent is asked to remember ev-
erything (food and beverage) con-
sumed during the previous day. It
is important to obtain a good esti-
mate of portion sizes from the re-
porting individual. Food models,
pictures, or measuring cups can
serve as visual aids to assist the
family in accurately describing in-
take. If the food recall is done at
home, they can look at food labels
to record exact measurements. The
more details the patient or parent
can provide, the more accurate the
assessment will be. It is very help-
ful to ask if this was a typical day in
terms of dietary intake; this infor-
mation should be noted. A clini-
cian can quickly compare the
patients intake to the dietary rec-
ommendations in MyPyramid, ac-
cessible at www.mypyramid.gov, to
determine where the inadequacies,
if any, lie (Stang, 2002).
A food frequency questionnaire
aims to assess how often a person
is eating or drinking certain foods
and beverages from each of the
food groups over a certain period
(day, week, or month). The ques-
tionnaire can be short and simple,
or it can be several pages long. For
clinical purposes, a short form tar-
geting the major food groups
(grains, fruits, vegetables, dairy or
dairy alternatives, meats or meat
alternatives, and fats) would be ap-
propriate. This tool gives a broader
sense of what the child or adoles-
cent consumes over a more ex-
tended period. If lled out and
mailed to the ofce prior to the
appointment, suitable educational
materials or a referral to a dietitian
could be arranged if necessary.
The purpose of these tools is to
identify potential deciencies in
dietary intake and provide direc-
tion for patient education discus-
sions. Dietary education materials
are readily available through the
newly released Food Guidance
System of the United States Depart-
ment of Agriculture (USDA). This
interactive and individualized tool
replaces the 1992 Food Guide Pyr-
amid. MyPyramid.gov is the access
point for this food guidance sys-
tem. Health care providers can
print useful handout materials for
parents and adolescents or encour-
age families to explore the easy-to-
use Web site. Vegetarian choices
are included in the meat and bean
group, including specic tips to in-
crease variety and ensure adequate
protein intake without consuming
excess calories. Serving sizes for all
food types are shown graphically
and are described in weight or vol-
ume. The Web site includes the
recommended daily total intake of
each food group by age (2 through
51 years old) and sex.
Nurse practitioners (NPs) can
reassure parents, children, and ad-
olescents that a well-planned veg-
etarian diet is a healthy choice that
Research has highlighted nutritional
advantages to vegetarian diets and has
indicated that this style of eating can lead to
lifelong healthy eating habits when adopted at
a young age.
28 Volume 20 Number 1 Journal of Pediatric Health Care
promotes growth and decreases
the risk for diabetes, heart disease,
and cancer. Within a vegetarian
diet, there are several vitamins,
minerals, and macronutrients a
person may not be consuming in
adequate quantities. Each of these
key nutrients will be discussed
briey. If there is concern about a
childs intake of a particular nutri-
ent, a referral to a registered dieti-
tian may be appropriate.
PROTEIN
Protein is necessary for growth,
tissue repair, and optimal im-
mune function. Vegetarians who
have completely eliminated meat
from their diet need to be edu-
cated about alternative sources of
protein. While meat provides an
easily absorbed, concentrated
source of protein, other foods
such as dairy products, eggs,
grains, legumes, and various soy
foods (e.g., tofu, tempeh, and
seitan) also are an excellent
source of this macronutrient. It is
possible to consume enough pro-
tein for proper growth and devel-
opment by following a vegan or
vegetarian style of eating. All of
the essential amino acids can be
consumed by plant sources if en-
ergy needs are met and a variety
of plant foods are chosen
(Messina & Burke, 1997; Young &
Pellett, 1994). Because of the
lower absorbability of amino ac-
ids from plant foods, vegetarians
may require a higher intake of
protein each day (Messina &
Mangels, 2001). A registered die-
titian can help determine exact
nutrient needs and deciencies,
but in general, children and ado-
lescents require two to three
servings from the meat or meat
alternate group per day.
COBALAMIN (B12)
Vitamin B12 is necessary for cell
division and blood formation. Veg-
etarians can meet their needs for
this vitamin by eating fortied
foods, eggs, dairy products, or tak-
ing a supplement (Novy, 2000).
Nonanimal sources of vitamin B12
include cereals, breads, nutritional
yeast, and some fortied soy prod-
ucts. Because a high folic acid in-
take can hide the symptoms of B12
deciency, neurologic symptoms
may occur before detection.
Therefore, it is extremely impor-
tant to assess dietary intake in
young vegetarians as early as pos-
FIGURE 1. 24-Hour Food Recall chart.
29 Journal of Pediatric Health Care January/February 2006
sible. If dietary intake is inade-
quate, a B12 supplement will be
necessary to prevent a deciency.
Breastfeeding mothers who follow
a vegan style of eating should be
cautioned about the potential neu-
rologic disturbances that could oc-
cur in their baby if their diet is
decient in vitamin B12 (Graham,
Arvela, & Wise, 1992; Johnson &
Roloff, 1982; Weiss, Fogelman, &
Bennett, 2004).
IRON
Iron is necessary for optimal ox-
ygen transport in red blood cells.
Meat (red meat, in particular) of-
fers the most easily absorbed type
of iron, called heme iron; how-
ever, the iron that occurs naturally
in plant products (non-heme) can
be consumed along with a vitamin
C source to enhance absorption
(Cook & Monsen, 1977). For exam-
ple, adding a tomato, orange, or
strawberries to a meal without
meat will improve the absorption
of the non-heme iron found in
plant sources. Foods like spinach,
dried fruits, dried beans, bulgur,
fortied soy products, fortied ce-
reals, and enriched grains contain
iron. Vegetarians require 1.8 times
the amount of iron than do non-
vegetarians because of the lower
bioavailability of iron from plant-
based diets (National Academy of
Science, 2003). However, it is of
interest to add that iron deciency
anemia has not been shown to oc-
cur at higher rates in vegetarians
compared with nonvegetarians
(Ball & Bartlett, 1999; Larsson &
Johansson, 2002; Position of the
American Dietetic Association and
Dietitians of Canada: Vegetarian
Diets, 2003). Compounds called
phytates, along with some addi-
tional factors naturally found in le-
gumes, nuts, and whole grains, can
inhibit iron absorption, so it is im-
portant to consume a variety of
iron-rich foods daily (Gillooly et
al., 1983; Hallberg, Brune, & Ros-
sander, 1989; Messina & Mangels,
2001).
ZINC
Zinc absorption also is affected
by the phytates that occur naturally
in whole grains and legumes.
Some vegetarians may require a
higher intake of zinc than the di-
etary reference intake. Methods
such as soaking dried beans, then
discarding the soaking water be-
fore cooking, will help enhance
zinc absorption (Gibson, Fiona,
Drost, Mtitimuni, & Cullinan,
1998). Additional plant sources of
zinc include cereals, tofu, legumes,
nuts, wheat germ, and whole-grain
pasta. Yeast-leavened bread, tem-
peh, and miso also contain zinc.
FIGURE 2. Food Frequency Questionnaire.
Food Frequency Questionnaire
How often do you eat or drink the following foods and beverages?
(Example: once a day, three times a day, once a week, etc.)
Milk
Yogurt
Cheese
Fruit
Vegetable
Meat
Meat alternate (dry beans, tofu, soy)
Eggs
Peanut butter, nuts, seeds
Fried foods
Juice
Soda
Kool-Aid/punch
Coffee
Tea
Water
30 Volume 20 Number 1 Journal of Pediatric Health Care
CALCIUM
Dairy foods are a natural source
of calcium for vegetarians and
nonvegetarians. Vegans can con-
sume fortied soy formulas, soy
milk, soy cheese, soy yogurt, and
various other calcium-fortied
foods. Eating these foods in the
age-appropriate amounts will en-
sure adequate calcium intake
(Weaver & Plawecki, 1994). For in-
fants, it is important to note that
commercial soy milk should not be
introduced before the end of the
rst year because of the low bio-
availability of iron and zinc from
soy (Sandstrom, Kivisto, & Ceder-
blad, 1987). Fortied infant soy
formulas are recommended for in-
fants who are not breastfed (Man-
gels & Messina, 2001). As long as a
child is growing normally, it is suit-
able to offer him or her full-fat
commercial soy milk at age 1 year
or older. Not all soy milk is forti-
ed with vitamin D and calcium,
so it is important that parents
check the label. Other foods such
as gs, blackstrap molasses, col-
lard greens, sesame seeds, kale,
and broccoli contain calcium as
well; however, a large quantity of
these foods must be consumed to
provide the body with as much
calcium as one 8-oz glass of milk
(Weaver, Proulx, & Heaney, 1999).
VITAMIN D
Vitamin D is found naturally in
milk and dairy products. The body
also can make vitamin D when ex-
posed to sunlight. Past research
has shown that exposing ones
hands and face to the sunlight two
to three times each week for 20 to
30 minutes provides enough vita-
min D for light-skinned children
and adolescents in moderate cli-
mates (Messina & Burke, 1997;
Messina & Mangels, 2001). The
most recent literature recognizes
that specic age groups require a
vitamin D supplement: infants
who are exclusively breastfed; in-
fants drinking less than 500 mL of
vitamin Dfortied milk each day;
and children and adolescents who
do not receive adequate sunlight
exposure, are not drinking at least
500 mL of vitamin-D fortied milk
each day, or do not take a multivi-
tamin containing at least 200 IU of
vitamin D (Gartner & Greer, 2003).
Persons with dark skin or those
living in a cloudy climate need
more exposure. Vegetarians can
choose vitamin Dfortied soy
milk, cheese, yogurt, and cereals
as dietary sources of this nutrient.
OMEGA-3 FATTY ACIDS
Many vegetarian diets are low in
omega-3 fatty acids if eggs, sh, or
large amounts of sea vegetables
are not consumed. Therefore, it is
important that vegetarians con-
sume a reliable source of linolenic
acid in their diet to ensure ade-
quate production of the long chain
n-3 fatty acids, docosahexaenoic
acid, and eicosapentaenoic acid.
Foods such as axseed (ground or
oil), canola oil, soybean oil, soy-
beans, tofu, walnuts, and walnut
oil contain a reasonable amount of
linolenic acid (Position of the
American Dietetic Association and
Dietitians of Canada: Vegetarian
Diets, 2003).
TABLE. Dietary reference intakes
Nutrient
Age/condition
Vitamin B12
(g/d)
Vitamin D
(g/d)
Calcium
(mg/d)
Iron
(mg/d)
Zinc
(mg/d) Protein (g/d)
Omega-3 fatty
acids (g/d)
Infants
00.5 y 0.4 5 210 0.27 2 9.1 (06 mo) 0.5 (06 mo)
0.51 y 0.5 5 270 11 3 13.5 (712 mo) 0.5 (712 mo)
Children
13 y 0.9 5 500 7 3 13 0.7
48 y 1.2 5 800 10 5 19 0.9
Male
913 y 1.8 5 1300 8 8 34 1.2
1418 y 2.4 5 1300 11 11 52 1.6
1930 y 2.4 5 1000 8 11 56 1.6
Female
913 y 1.8 5 1300 8 8 34 1
1418 y 2.4 5 1300 15 9 46 1.1
1930 y 2.4 5 1000 18 8 46 1.1
Pregnancy
18 y 2.6 5 1300 27 13 71 1.4
1930 y 2.6 5 1000 27 11 71 1.4
Lactation
18 y 2.8 5 1300 10 14 71 1.3
1930 y 2.8 5 1000 9 12 71 1.4
Adapted from Dietary Reference Intakes: Vitamins, Food and Nutrition Board; Dietary Reference Intakes: Elements, Food and Nutrition
Board, 2001; Dietary Reference Intakes: Macronutrients, Institute of Medicine. These reports can be accessed via www.nal.usda.
gov/fnic/etext/000105.html.
31 Journal of Pediatric Health Care January/February 2006
GROWTH AND
DEVELOPMENT ISSUES
Supplementation
Similar to the majority of the
population, vegetarians often can
benet from a multivitamin sup-
plement (Willett & Stampfer,
2001). For children and adoles-
cents who follow a vegetarian diet
and may not be ingesting 100% of
the recommended amounts of vi-
tamins and minerals, a multivita-
min or single vitamin/mineral sup-
plements will help ensure that
their needs are being met. Table 1
provides a list of the Dietary Ref-
erence Intakes of specic vitamins,
minerals, and fatty acids that have
been discussed in this article.
As mentioned earlier, many in-
fants and children require supple-
mentation of at least 200 IU of
vitamin D daily. Vitamin B12 sup-
plementation (0.4/day for the
rst 6 months, 0.5/day beginning
at 6 months of age) is necessary for
breastfed vegan infants if the
mother does not take a supple-
ment or if she does not include
B12-fortied foods in her diet. Zinc
supplementation also may be indi-
cated for older breastfed vegan in-
fants; however, intake of solid
BOX. Nutrition counseling for pediatric patients with vegetarian diets
Dene vegetarian diet by determining what foods are excluded and what foods are acceptable
Obtain a careful diet history through 24-hour recall or food frequency
Evaluate diet by assessing for essential nutrients, not specic foods
Assess parental knowledge base and access to a variety of vegan/vegetarian foods and fortied foods
Infants
Support breastfeeding through the introduction of solid foods
Supplement with vitamin B12 for breastfed infants if the mother is not supplementing her diet or is not consuming food
with adequate sources of vitamin B12
Assess sunlight exposure and recommend vitamin D supplementation if the infant is exclusively breastfed
Review introduction of solids with protein-rich foods: pureed tofu, pureed legumes, soy yogurt
Full-fat fortied soy milk may be used at age 1 year or older
Toddler/preschool
Evaluate calcium sources and sunlight exposure
Ensure healthy and frequent snacks with a variety of foods including rened grains for energy needs
Reviewchoking hazard with nuts; recommend grinding nuts, cutting vegetables, supervising older preschoolers with fresh
celery and carrots
Assess vegan/vegetarian food availability at day care
School age
Assess school lunch availability of vegetarian options
Discuss food choices and alternatives with friends/activities
Evaluate calcium intake; supplement if the child has an inadequate calcium-fortied food intake
Assess knowledge base of the child and educate accordingly
Provide guidance to parents and reassurance to child that this may be the rst time the child learns the diet is considered
alternative; recognize that nutrition education at school may be a variance from the typical home diet
Adolescents
Understand the adolescents reason for a vegetarian diet, recognizing that the rationale may be ideological rather than
health-related, including:
Ecological
Ethical opposition to killing animals
Disgusted by animal processing
Inuence of friends
Religious reasons
Assess knowledge base and provide targeted education, including how to read food labels
Assess school lunch availability of vegetarian options
Discuss food choices with friends/activities
Evaluate weight concerns, body image, frequency of dieting for weight loss, and exercise patterns (a vegetarian diet may
be an attempt to camouage an eating disorder)
Encourage consumption of calcium, including calcium-fortied foods
Supplementation as necessary with calcium and vitamin B12
Provide anticipatory guidance for parents that nutrition changes are often a safe way to experiment and assert autonomy;
encourage parental support and assistance with menu planning.
Vegan teens in omnivore households can be encouraged to plan a vegan meal for the family
32 Volume 20 Number 1 Journal of Pediatric Health Care
foods plays a role in this determi-
nation. Currently the American
Academy of Pediatrics does not
recommend zinc supplementation
(Mangels & Messina, 2001). Rec-
ommendations for supplementa-
tion for vegan infants are other-
wise the same as for omnivore
infants.
Introduction of Solid Foods
Solids can be introduced to veg-
etarian infants at the same stage
and pace as for omnivore infants
(Mangels & Messina, 2001). Iron-
fortied cereals can be given at 4
to 6 months, followed by fruits and
vegetables around 6 to 8 months
and alternate protein sources like
mashed tofu, soy yogurt, and pu-
reed beans and legumes around 7
to 10 months. Because of potential
allergens, it is best to wait to intro-
duce nut and seed butters until af-
ter age 1 year, or as directed by a
health care provider.
Growth Concerns
If growth is not occurring at the
expected rate and calories need to
be increased, the following foods
can help increase the calorie and
fat content of the diet: avocado
(sliced or mashed), tofu, bean
spreads, vegetable oils, margarine,
and nut or seed butters (after age 1
year). High-ber foods can ll a
small stomach very quickly; there-
fore, in addition to the concen-
trated calorie sources listed above,
dried fruit, peeled fruits and vege-
tables, fruit juices, and some re-
ned grain products can help add
calories without adding bulk at any
age (Mangels & Messina, 2001).
Nutrition assessment and coun-
seling are important aspects of
health promotion in pediatric and
adolescent health care. Individuals
and families following a vegetarian
diet benet from an NP who is
knowledgeable in specic dietary
recommendations as well as com-
munity resources for a variety of
vegan foods. A developmental ap-
proach allows the NP to appropri-
ately tailor the counseling and as-
sist with planning vegetarian diets
that support the growth and en-
ergy needs of children and adoles-
cents. Key vegetarian diet counsel-
ing points for each age group are
included in the Box. Careful nutri-
tion assessment and counseling
will allow NPs to play a key role in
encouraging families to adopt
healthy eating habits with regular
exercise to assist in disease
prevention.
REFERENCES
American Academy of Pediatrics Commit-
tee on Nutrition. (1998). Soy protein
based formulas: Recommendations for
use in infant feeding. Pediatrics,
101,148-153.
Appleby, P. N., Thorogood, M., Mann, J. I.,
& Key, T. J. A. (1999). The Oxford Veg-
etarian Study: An overview. American
Journal of Clinical Nutrition, 70, 525S-
531S.
Ball, M. J., & Bartlett, M. A. (1999). Dietary
intake and iron status of Australian veg-
etarian women. American Journal of
Clinical Nutrition, 70, 353-358.
Barr, S. I., & Chapman, G. E. (2002). Per-
ceptions and practices of self-dened
current vegetarian, former-vegetarian
and nonvegetarian women. Journal of
the American Dietetic Association, 102,
354-360.
Beilin, L. J. (1994). Vegetarian and other
complex diets, fats, ber, and hyper-
tension. American Journal of Clinical
Nutrition, 59(5 Suppl), 1130S-1135S.
Cook, J. D., & Monsen, E. R. (1977). Vitamin
C, the common cold, and iron absorp-
tion. American Journal of Clinical Nutri-
tion, 30, 235-241.
Dwyer, J. T. (1988). Health aspects of veg-
etarian diets. American Journal of Clin-
ical Nutrition, 48(3 Suppl), 712-738.
Fraser, G. E. (1999). Associations between
diet and cancer, ischemic heart dis-
ease, and all-cause mortality in non-
Hispanic white California Seventh-day
Adventists. American Journal of Clinical
Nutrition, 70, 532S-538S.
Fraser, G. E., Lindsted, K. D., & Beeson,
W. L. (1995). Effect of risk factor values
on lifetime risk of and age at rst coro-
nary event: The Adventist Health Study.
American Journal of Epidemiology,
142, 746-758.
Fulton, J., Hutton, C., & Stitt, K. (1980). Pre-
school vegetarian children. Journal of
the American Dietetic Association, 76,
360-365.
Gartner, L. M., & Greer, F. R. (2003). Pre-
vention of rickets and vitamin D de-
ciency: New guidelines for vitamin D in-
take. Pediatrics, 111, 908-910.
Gibson, R. S., Fiona, Y., Drost, N., Mti-
timuni, B., & Cullinan, T. (1998). Dietary
interventions to prevent zinc deciency.
American Journal of Clinical Nutrition,
68, 484S-487S.
Gillooly, M., Bothwell, T. H., Torrance, J. D.,
MacPhail, A. P., Derman, D. P., Bez-
woda, W. R., et al. (1983). The effects of
organic acids, phytates and polyphe-
nols on the absorption of iron from veg-
etables. British Journal of Nutrition, 49,
331-342.
Graham, S. M., Arvela, O. M., & Wise, G. A.
(1992). Long-term neurologic conse-
quences of nutritional vitamin B12 de-
ciency in infants. Journal of Pediatrics,
121(5 Pt 1), 710-714.
Hallberg, L., Brune, M., & Rossander, L.
(1989). Iron absorption in man: Ascor-
bic acid and dose-dependent inhibition
by phytate. American Journal of Clinical
Nutrition, 49, 140-144.
Johnson, P. R. J., & Roloff, J. S. (1982).
Vitamin B12 deciency in an infant
strictly breast-fed by a mother with late:
Pernicious anemia. Journal of Pediat-
rics, 100, 917-919.
Kahn, H. A., Phillips, R. I., Snowdon, D. A., &
Choi, W. (1984). Association between re-
ported diet and all-cause mortality.
Twenty-one-year follow-up on 27,530
adult Seventh-Day Adventists. American
Journal of Epidemiology, 119, 775-787.
Key, T. J., Fraser, G. E., Thorogood, M.,
Appleby, P. N., Beral, V., Reeves, G., et
al. (1999). Mortality in vegetarians and
nonvegetarians: Detailed ndings from
a collaborative analysis of 5 prospective
studies. American Journal of Clinical
Nutrition, 70,516S-524S.
Key, T. J., Thorogood, M., Appleby, P. N., &
Burr, M. L. (1996). Dietary habits and
mortality in 11,000 vegetarians and
health conscious people: Results of a
17 year follow up. British Medical Jour-
nal, 313, 775-779.
Knutsen, S. F. (1994). Lifestyle and the use of
health services. American Journal of Clin-
ical Nutrition, 59(5Suppl), 1171S-1175S.
Krajcovicov-Kudlckov, M., Simoncic, R.,
Bederova, A., Grancicova, E., & Maga-
lova, T. (1997). Inuence of vegetarian
and mixed nutrition on selected haema-
tological and biochemical parameters in
children. Nahrung, 41, 311-314.
Larsson, C. L., & Johansson, G. K. (2002).
Dietary intake and nutritional status of
young vegans and omnivores in Swe-
den. American Journal of Clinical Nutri-
tion, 76, 100-106.
Mangels, A., & Messina, V. (2001). Consid-
erations in planning vegan diets: In-
fants. Journal of the American Dietetic
Association, 101, 670-677.
Messina, V., & Mangels, A.R. (2001). Con-
siderations in planning vegan diets:
Children. Journal of the American Die-
tetic Association, 101, 661-669.
33 Journal of Pediatric Health Care January/February 2006
Messina, V. K., & Burke, K. I. (1997). Posi-
tion of the American Dietetic Associa-
tion: Vegetarian diets. Journal of the
American Dietetic Association, 97,
1317-1321.
Nathan, I., Hackett, A. F., & Kirby, S.
(1997). A longitudinal study of the
growth of matched pairs of vegetarian
and omnivorous children, aged 7-11
years, in the north-west of England.
European Journal of Clinical Nutrition,
51, 20-25.
National Academy of Science. (2003). Dietary
reference intakes for vitamin A, vitamin K,
arsenic, boron, chromium, copper, io-
dine, iron, manganese, molybdenum,
nickel, silicon, vanadium, and zinc. Re-
trieved October 15, 2004, from http://
books.nap.edu/execsumm_pdf/10026.
pdf
Neumark-Sztainer, D., Story, M., Resnick,
M. D., & Blum, R. W. (1997). Adoles-
cent vegetarians. A behavioral prole of
a school-based population in Minne-
sota. Archives of Pediatrics and Ado-
lescent Medicine, 151, 833-838.
Novy, M. A. (2000). Are strict vegetarians at
risk of vitamin B12 deciency? Cleveland
Clinic Journal of Medicine, 67, 87-88.
OConnell, J. M., Dibley, M. J., Sierra, J., Wal-
lace, B., Marks, J. S., Yip, R. (1989).
Growth of vegetarian children: The Farm
Study. Pediatrics, 84, 475-481.
Phillips, R. I., Garnkel, L., Kuzma, J. W.,
Beeson, W. L., Lotz, T., Brin, B. (1980).
Mortality among California Seventh-
Day Adventists for selected cancer
sites. Journal of the National Cancer
Institute, 65,1097-1107.
Position of the American Dietetic Association
and Dietitians of Canada: Vegetarian di-
ets. (2003). Journal of the American Die-
tetic Association, 103, 748-765.
Rajaram, S., & Sabate, J. (2000). Health
benets of a vegetarian diet. Nutrition,
16, 531-533.
Roberts, W. C. (1995). Preventing and ar-
resting coronary atherosclerosis. Amer-
ican Heart Journal, 130(3 Pt 1), 580-
600.
Sabate, J., Lindsted, K., Harris, R., &
Sanchez, A. (1991). Attained height of
lacto-ovo vegetarian children and ado-
lescents. European Journal of Clinical
Nutrition, 45, 51-58.
Sabate, J., Lindsted, K. D., Harris, R. D., &
Johnston, P. K. (1990). Anthropometric
parameters of schoolchildren with dif-
ferent life-styles. American Journal of
Diseases Children, 144, 1159-1163.
Sanders, T. A. B., & Manning, J. (1992). The
growth and development of vegan chil-
dren. Journal of Human Nutrition and
Dietetics, 5, 11-21.
Sanders, T. A. B., & Reddy, S. (1994). Veg-
etarian diets and children. American
Journal of Clinical Nutrition, 1994,
1176S-1181S.
Sandstrom, B., Kivisto, B., & Cederblad, A.
(1987). Absorption of zinc fromsoy pro-
tein meals in humans. Journal of Nutri-
tion, 117, 321-327.
Stang, J. (2002). Assessment of nutritional
status and motivation to make behavior
changes among adolescents. Journal
of American Dietetic Association, 102(3
Suppl), S13-S22.
United States Department of Agriculture.
(2005). Dietary Guidelines for Americans
2005. Retrieved July 28, 2005, from
http://www.health.gov/dietaryguidelines/
dga2005/recommendations.htm
Weaver, C. M., & Plawecki, K. L. (1994).
Dietary calcium: Adequacy of a vege-
tarian diet. American Journal of Clini-
cal Nutrition, 1994(5 Suppl), 1238S-
1241S.
Weaver, C. M., Proulx, W. R., & Heaney, R.
(1999). Choices for achieving adequate
dietary calcium with a vegetarian diet.
American Journal of Clinical Nutrition,
70, 543S548.
Weiss, R., Fogelman, V., & Bennett, M.
(2004). Severe vitamin B12 deciency
in an infant associated with a maternal
deciency and a strict vegetarian diet.
Journal of Pediatric Hematology/On-
cology, 26, 270-271.
Willett, W. C., & Stampfer, M. J. (2001).
What vitamins should I be taking, doc-
tor? New England Journal of Medicine,
345, 1819-1824.
Young, V. R., & Pellett, P. L. (1994). Plant
proteins in relation to human protein
and amino acid nutrition. American
Journal of Clinical Nutrition, 59(5
Suppl), 1203S-1212S.
34 Volume 20 Number 1 Journal of Pediatric Health Care