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Is Vegetarianism Healthy for Children?

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DOI: 10.1080/10408398.2018.1437024

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Is vegetarianism healthy for children?

Nathan Cofnas

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CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION
https://doi.org/10.1080/10408398.2018.1437024

Is vegetarianism healthy for children?

Nathan Cofnas
Balliol College, University of Oxford, Oxford OX1 3BJ, UK

ABSTRACT KEYWORDS
According to the Academy of Nutrition and Dietetics’ influential position statement on vegetarianism, Vegetarianism in children;
meat and seafood can be replaced with milk, soy/legumes, and eggs without any negative effects in veganism in children;
children. The United States Department of Agriculture endorses a similar view. The present paper argues growth; cognitive
that the Academy of Nutrition and Dietetics ignores or gives short shrift to direct and indirect evidence development;
phytoestrogens in
that vegetarianism may be associated with serious risks for brain and body development in fetuses and pregnancy; birth ratio
children. Regular supplementation with iron, zinc, and B12 will not mitigate all of these risks. Consequently,
we cannot say decisively that vegetarianism or veganism is safe for children.

Introduction evidence that vegetarianism may be harmful during pregnancy,

that milk, soy/legumes, and eggs are not equal substitutes for
Vegetarian (or lacto-ovo-vegetarian) diets do not include meat, meat, and that realistic vegetarian diets put children at risk for
fowl, or seafood. Vegan diets do not include any animal source deficiencies that may have both short-term and permanent neg-
foods. According to the Academy of Nutrition and Dietetics’ ative health consequences.
(AND) position statement on vegetarianism: “appropriately
planned vegetarian, including vegan, diets are…appropriate for
Vegetarianism during pregnancy
all stages of the life cycle, including pregnancy, lactation, infancy,
childhood, [and] adolescence,” and “may provide health benefits Regarding the effect of vegetarianism during pregnancy, the
in the prevention and treatment of certain diseases” (Melina, AND says that “Limited research indicates that where food
Craig, and Levin 2016). The United States Department of Agri- access is adequate, vegetarian pregnancy outcomes, such as
culture (USDA) treats vegetarianism and veganism as healthy birth weight and pregnancy duration, are similar to those in
alternatives. Both the AND and the USDA recommend that veg- nonvegetarian pregnancy” (Melina, Craig, and Levin 2016).
etarians replace meat and seafood primarily with soy (and other This is an incomplete summary of the evidence.
legumes), dairy, and eggs. According to the USDA, vegans can In most populations, the male/female sex ratio of newborns
substitute fortified soy products for dairy and eggs. is around 105:100. Environmental stress is associated with a
Is there sufficient evidence to say definitively that an “appro- lower sex ratio due to the selective spontaneous abortion of
priately planned” vegetarian or vegan diet adhering to the male fetuses (Bruckner et al. 2014; Fukuda et al. 1998; Kanni-
USDA’s recommendations is healthy for “all stages of the life nen and Karhula 2016). Malnutrition specifically has been
cycle”? There have been a number of long-term epidemiological linked to a lower sex ratio (Andersson and Bergstr€ om 1998;
studies of adult vegetarians/vegans, the results of which suggest Williams and Gloster 1992). One possible test of whether vege-
that, although vegetarians have a lower incidence of certain dis- tarianism is healthy during pregnancy is to determine whether
eases, all-cause mortality in comparable populations of vegeta- it has an effect on the sex ratio of newborns. If it is healthy, it
rians and omnivores is similar (Appleby et al. 2016; Key, should have no effect on or should raise the sex ratio; if
Appleby, and Rosell 2006; Mihrshahia et al. 2017). There is unhealthy, then vegetarianism should lower it.
much less evidence available concerning the health effects of Hudson and Buckley (2000) found that among a sample of
meatless diets in children. The present paper focuses on the almost 6,000 pregnant women at a British hospital, about 5% of
health consequences of vegetarianism and veganism for chil- whom were vegetarian (and almost all of whom were white),
dren from conception to the end of the growing period. It does the sex ratio was considerably lower among children born to
not argue that vegetarianism or veganism is unhealthy for chil- vegetarians compared with those born to omnivores:
dren, but considers whether there is enough evidence to justify 81.5:100 vs. 106:100. That is, vegetarians were 23% less likely to
the AND’s unqualified statement, which suggests that there is give birth to a boy. Given the known association between envi-
definitive evidence that vegetarian and vegan diets can be as ronmental stress, including malnutrition, and a lower chance of
healthy for children as diets that include meat and seafood. It giving birth to a boy, a possible explanation for these findings
will be argued that the AND ignores or gives short shrift to is that vegetarianism increases the chance of spontaneous

CONTACT Nathan Cofnas [email protected] Balliol College, University of Oxford, Broad Street, Oxford OX1 3BJ, UK.
© 2018 Nathan Cofnas. Published with license by Taylor & Francis Group, LLC
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
2 N. COFNAS

abortion, particularly for male fetuses. The AND does not men- weight gain relative to the Control. Children in the Meat group
tion Hudson and Buckley’s study, or the effect of vegetarian- gained approximately 50% more mid-upper-arm muscle area
ism/veganism on the sex ratio/spontaneous abortion, in its than those in the Milk group, and 100% more than those in the
position statement on vegetarianism (Melina, Craig, and Levin Energy and Control.
2016). Neumann et al. (2007) suggest that the “improved cognitive
As discussed below, vegetarians/vegans are at risk for a performance, increased [physical activity] and leadership and
number of nutritional deficiencies that could potentially harm initiative behaviors in the Meat group” may be due to their con-
the fetus. sumption of vitamin B12 and more bioavailable iron and zinc,
since meat improves the absorption of iron and zinc from “fiber
and phytate-rich plant staples.” Micronutrients and high-qual-
Are milk, soy, and eggs equally beneficial substitutes
ity protein in meat may be important for cognitive perfor-
for meat?
mance. As to why the Milk group obtained the lowest scores on
The AND, the USDA, and other health authorities claim that RPM, Neumann et al. suggest that this may be due to the high
dairy and legumes (especially soy) and, to a lesser extent, eggs casein and calcium content of milk that interferes with iron
can be substituted for meat with no ill effects. This section absorption, which is essential for optimum cognitive perfor-
examines evidence that raises doubts about this position. mance. They attribute the increase in mid-upper-arm muscle
area in the Meat group to the “intake of zinc and complete pro-
tein, which both promote protein synthesis…, and iron and
Milk
protein, which are essential to myogloboin synthesis in striated
Physical and cognitive development muscle….”
There has been only one controlled study on the effects of milk This study of Kenyan children does not decisively refute the
versus meat consumption in children. Subjects in the study AND’s claim that “appropriated planned” vegetarian/vegan
were 6–14-year-olds (median 7.4 years) in Embu, Kenya. Due diets can be as healthy as diets that include meat. For one thing,
to poverty, the children were largely vegetarian, with more than none of the children were on diets meeting the USDA’s recom-
75% of their energy intake coming from maize and beans, less mendations. Also, it is unfortunate that the study compared
than 6% from animal source foods. Their daily intake of milk meat and milk supplementation with oil supplementation
and meat was very low at approximately 35 g and 11 g, respec- rather than soy. The study does not say whether a soy product
tively. Researchers divided a large group of children into four such as tofu could produce outcomes equal to meat. However,
conditions: Meat, Milk, Energy, and Control. Every school day, the AND and the USDA say that dairy can be used as an equal
children in the Meat, Milk, and Energy groups received a local substitute for meat. The Kenyan study casts serious doubt on
plant-based dish supplemented with 60 g of ground beef, that claim. Children in the Milk group had significantly worse
200 mL of milk, or an extra 3 g of oil, respectively. The meals in outcomes than those in the Meat group in terms of RPM scores,
each of these three groups had approximately the same number academic performance, muscle growth, and physical and social
of calories. Children in the Control group did not receive any activity. Despite the limitations of the study, it is still the only
extra meals. The researchers measured several outcomes related controlled experiment comparing the benefits of milk versus
to growth, intellectual ability, school performance, and social meat in children, and it suggests that milk is not an equal sub-
behavior (Neumann et al. 2003). stitute for meat. The AND does not mention this study in its
After 2.25 years, the Meat group had the best health out- position statement on vegetarianism (Melina, Craig, and Levin
comes. The Meat group showed the greatest improvement on 2016).
Raven’s Progressive Matrices (RPM—a measure of fluid intelli-
gence), while the Milk group showed the least improvement, Acne vulgaris
significantly below the other three groups (including the Con- Contrary to some oft-repeated claims that diet is unrelated to
trol). While all groups started off with roughly the same RPM acne, there is overwhelming evidence that diet is a major factor
scores, Meat ended up approximately 0.65 standard deviations in acne. Acne appears to be absent in populations that have not
higher than Milk (Hulett et al. 2014), corresponding to a differ- adopted a Western diet. For example, Kitavans of the Tro-
ence of around 10 IQ points. The Meat and Energy groups briand Island live by horticulture and fishing. They consume
showed significantly more improvement on arithmetic tests virtually no dairy or alcohol, and a “negligible” amount of cere-
than the Milk and Control. The Meat group showed a signifi- als, sugar, and salt. Lindeberg examined 1,200 Kitavans for the
cantly larger percentage increase in end-of-term test scores presence of acne. All 1,200 were at least 10 years old and 300
compared to the others, with the greatest increase being in the were between 15 and 25 years old. Lindeberg did not find one
arithmetic subtest. Over the course of the study, the Meat group single papule, pustule, or open comedone in any of the 1,200
had the highest levels of physical activity during free play, the Kitavans (Cordain et al. 2002). The Ache of Paraguay engage in
greatest increase in leadership activities, and the greatest a combination of hunting and gathering and farming. Western
increase in initiative behavior. The Milk group had the lowest foods such as wheat and sugar comprise only around 8% of the
level of physical activity and leadership and initiative behavior diet. Hurtado examined 115 Ache including 15 who were
among the three intervention groups. Regarding growth: Only between the ages of 15 and 25. After Hurtado’s examinations,
children in the Milk group who were below age 6 or had family practitioner physicians conducted the same examination
stunted growth experienced a greater rate of height increase. every six months for two years. “Not a single papule, pustule,
All three intervention groups experienced an improvement in or open comedo was observed in the entire population”
 CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION 3

(Cordain et al. 2002). The nonexistence of acne among Kita- Lund et al. 2001; Scallet et al. 2004). Whether or to what extent
vans and Ache cannot be explained entirely by genetics. More these findings generalize to humans is uncertain (Patisaul and
Westernized South American Indians and Pacific Islanders Jefferson 2010).
show high rates of acne (though not quite as high as the white Jefferson, Padilla-Banks, and Newbold (2005) found that
population) (Fleischer, Feldman, and Bradham 1994; Freyre administering genistein to neonatal female mice at “environ-
et al. 1998). mentally relevant doses”—i.e., doses comparable to what
Cordain et al. (2002) hypothesize that acne in Western pop- human neonates can be exposed to—led in later life to “abnor-
ulations is caused by diet-induced hyperinsulinemia, and this mal estrous cycles, altered ovarian function, early reproductive
could explain the relationship between milk and acne: Despite senescence, and subfertility/infertility.” Nagao et al. (2001)
its low glycemic load, dairy triggers a large insulin response obtained similar results. It is not clear whether these findings
(Holt, Brand Miller, and Petocz 1997; Hoyt, Hickey, and Cor- apply to humans.
€
dain 2005; Ostman,

Liljeberg Elmstahl, and Bj€ orck 2001).
Observational studies have found a significant association Antinutrients: Iron and zinc absorption
between dairy intake and acne in adolescents (Adebamowo Legumes, particularly soy, are high in phytate, which signifi-
et al. 2006, 2008; Adebamowo et al. 2005; Ismail, Manaf, and cantly inhibits the absorption of minerals including iron (Hur-
Azizan 2012). Controlled experiments have found that a high rell et al. 1992) and zinc (L€onnerdal 2000). Iron and zinc
protein, low-insulin-response-triggering diet significantly deficiency can have devastating effects in children/fetuses. Iron
improves symptoms in acne patients (Kwon et al. 2012; Smith deficiency in infancy leads to impaired processing speed, affect,
et al. 2007). While there is still a debate about exactly why dairy learning, and memory (Fretham, Carlson, and Georgieff 2011).
consumption is associated with acne, the association appears to Zinc deficiency during pregnancy increases the risk of preterm
be causal and significant. delivery. In children it can impair growth, cause hypogonadism
Acne is a negative health outcome that is expensive to treat in males, neurosensory disorders, and other problems (Nishi
and which has a strong association with depression and suicide 1996; Prasad 1988).
in adolescents (Purvis et al. 2006). There is reason to believe The AND acknowledges that the high phytate content of
that substituting dairy for meat increases the risk of developing vegetarian diets interferes with iron and zinc absorption, and
acne during childhood/adolescence (assuming it would involve that the bioavailability of the nonheme iron of plants, dairy,
consuming more dairy on average than omnivores). This is a and eggs is lower than that of heme iron in meat and seafood
negative health outcome not discussed in the AND’s position (Melina, Craig, and Levin 2016). But the danger of deficiency,
statement on vegetarianism. particularly in regard to iron, may be greater than the AND
suggests in its position statement.
Studies on vegetarians have generally shown them to be at
Soy and other legumes
much greater risk for iron deficiency. Although most studies
Phytoestrogens show that vegetarians/vegans tend to have a similar or higher
Phytoestrogens, particularly isoflavones, are found in high con- daily intake of iron compared with omnivores, the former tend
centrations in legumes and especially in soy. Vegetarians/ to have significantly lower mean serum ferritin concentrations
vegans tend to have very high blood levels of phytoestrogens due to the lower bioavailability of iron in the vegetarian diet
compared with omnivores. While phytoestrogens have been (see, e.g., Baines, Powers, and Brown 2007; Ball and Bartlett
associated with some health benefits in adults, there are serious 1999; Pawlak and Bell 2017; Snyder, Dvorak, and Roepke 1989;
concerns about their potential negative health effects on infants Wilson and Ball 1999). Wilson and Ball (1999), for example,
and children (Patisaul and Jefferson 2010). found that among Australian men, iron intake among vegeta-
Animal studies show that interfering with estrogen during rians and vegans was 29–49% higher than that of omnivores,
critical periods in development “leads to a myriad of adverse but their serum ferritin concentrations were much lower: Vege-
health outcomes including malformations in the ovary, uterus, tarians had mean concentrations of 64, vegans 65, and omni-
mammary gland and prostate, early puberty, reduced fertility, vores 121 ng/ml. None of the omnivores in their sample, but
[and] disrupted brain organization” (Patisaul and Jefferson 20.5% of vegetarians and 30% of vegans had low concentrations
2010). Patisaul and Jefferson note that these consequences corre- of <25 ng/ml. 3% of vegetarians and 25% of vegans were tech-
spond to some public health trends that emerged in Western nically deficient, with ferritin concentrations <12 ng/ml. The
countries, which have occurred in tandem with greater con- other studies cited above report similar findings.
sumption of soy. North and Golding (2000) found that males Most studies find vegetarians/vegans to have a zinc intake
born to vegetarian mothers in England were more than 3.5 times that is similar to omnivores, and to have a slightly to moder-
as likely to have hypospadias (i.e., malformed genitalia), which ately elevated risk of deficiency. Low serum zinc levels can be
was statistically linked to the consumption of high-phytoestro- caused in both vegetarians and omnivores by high phytate
gen legumes (hypospadias rates were 2.2% and 0.6% for boys intake (Bindra, Gibson, and Thompson 1986; Donovan and
born to vegetarian and omnivorous mothers, respective). Gibson 1995; though see Ball and Ackland 2000).
Rodent studies have found that phytoestrogens such as
genistein (which is abundant in soy) interfere with the develop-
Eggs
ment of brain regions that are sensitive to estrogen levels in
both male and female rodents—regions that are sexually Eggs are a high-quality source of protein and are high in iron
dimorphic (Bateman and Patisaul 2008; Kouki et al. 2003; and zinc. They may be promising as a substitute for meat.
4 N. COFNAS

However, there are a few reasons to question whether it would which was in part due to extremely high levels among some
be healthy for pregnant women and children to rely on eggs as vegetarians taking supplements. Vegans who took supplements
a primary source of these nutrients. still had a marginally low average level of 192, ranging from
One whole egg contains approximately 1 mg nonheme iron 125 to 299 pmol/L. (The lowest level among an omnivore in
and 1 mg zinc, corresponding to around 10% of the USDA’s their study was 190 pmol/L.)
recommended dietary allowance (RDA) for each of these min- The AND says that “[v]egans must regularly consume…B-
erals for children aged 9–12. Because the iron in eggs is of the 12-fortified foods or B-12-containing supplements,” and
less bioavailable nonheme form, and because egg consumption “[m]ost vegetarians should” do the same (Melina, Craig, and
itself reduces iron absorption (Hallberg and Hulthen 2000), Levin 2016). The results of Herrmann et al. (2003) suggest that
children would have to consume somewhat more than the even with supplementation vegans may still tend to cluster in
RDA of iron from eggs in order to meet their requirements. An the deficient-to-borderline-deficient range. Vegetarians can
egg contains 6 g protein, which is 11% of the RDA for males achieve adequate B12 levels with supplementation, but some are
14 years and older. Children who are relying on eggs as a major still in the deficient and borderline-deficient range. Whether it
source—or even their primary source—of protein, iron, and is realistic for vegetarians/vegans to maintain adequate B12 lev-
zinc will (depending on their age, sex, and body size) have to els throughout their entire childhood via supplementation is an
eat several every day in order to meet the USDA’s recommen- open question.
dations. This may be an unrealistic dietary plan. The consequences of B12 deficiency in childhood for brain
The n¡6/n¡3 polyunsaturated fatty acid (PUFA) ratio in and body development are extensive, severe, and can be irre-
eggs is a little over 15:1, and eggs would therefore contribute to versible. Potential consequences include (among many others)
the already high n¡6/n¡3 PUFA ratio of the vegetarian diet. impaired cognitive development/school performance, depres-
As shall be discussed below, there is a possibility that a high sion, weakness, fatigue, nerve damage, and failure to thrive
n¡6/n¡3 ratio promotes chronic systemic inflammation and (Graham, Arvela, and Wise 1992; Rasmussen, Fernhoff, and
the pathogenesis of autoimmune diseases. Scanlon 2001). Breastfeeding infants whose mothers are vege-
tarian/vegan are also known to be at risk for B12 deficiency
(Graham, Arvela, and Wise 1992; K€ uhne, Bubl, and Baumgart-
Potential deficiencies and their consequences for
ner 1991; Roschitz et al. 2005; von Schenck, Bender-G€otze, and
brain and body development
Koletzko 1997).
As mentioned in the previous section, the AND acknowledges
that vegetarians must pay close attention to iron and zinc
Creatine
intake (Melina, Craig, and Levin 2016), though its position
statement may underestimate the risk of deficiency. This sec- Creatine is rarely mentioned in discussions of the health conse-
tion discusses vegetarians’ risk of deficiencies in vitamin B12, quences of vegetarianism. However, there is some little-known
creatine, taurine, and long-chain n¡3 PUFAs, which could evidence that creatine consumption may play an important
have serious consequences for children. Although the AND role in cognitive functioning.
notes that vegetarian diets are low in B12 and long-chain n¡3 In a double-blind, placebo-controlled study, Rae et al. (2003)
PUFAs, it may underestimate the risk of B12 deficiency and the found that 6 weeks of oral creatine supplementation signifi-
negative consequences of lower long-chain n¡3 fatty acid cantly improved the performance of vegetarians on a timed
intake in children. Raven’s Advanced Progressive Matrices test (RAPM—a mea-
sure of fluid intelligence) and the backward digit span task (a
measure of working memory). The difference in performance
Vitamin B12
between the control and the creatine-supplemented vegetarians
Herrmann et al. (2003) found vitamin B12 deficiency—defined was enormous. On RAPM, the treatment group scored slightly
as concentrations <156 pmol/L—in 26% of adult vegetarians, more than 1 standard deviation higher than the control. There
52% of vegans, and 1% of omnivores. Average levels for vegans, was an approximately 1 standard deviation difference between
vegetarians, and omnivores were 148, 192, and 287 pmol/L, the treatment and the control group on the backward digit
respectively. 148 pmol/L is considered clinically deficient in the span task: The former could recall on average 8.5 items (SD D
U.S., but symptoms of deficiency are known to occur at “mar- 1.76) while the latter could recall on average 7.05 (SD D 1.19).
ginal” levels of 148–221 pmol/L (Allen 2009). This would place However, Rawson et al. (2008) found that creatine supplemen-
the average vegetarian and vegan in the range for potentially tation had no effect on RAPM or backward digit span task per-
experiencing negative consequences due to low B12 levels. It formance for meat eaters, suggesting that vegetarians have
should be noted that the subjects in Herrmann et al.’s study impaired scores due to low creatine intake.
were recruited from a conference of the German Federation of Gale et al. (2007) found that 30-year-olds in Britain who
Vegetarians and a Vegan Society summer camp in the Nether- identified as vegetarian (33.6% of whom admitted to eating fish
lands, so there is reason to think that these vegetarians and or chicken) had, at age 10, a mean IQ of 104.8 compared with a
vegans had an above-average amount of nutrition education. mean of approximately 100 for the general population. At age
Indeed, 20% of vegetarians and 59% of vegans in their study 10, vegans had a mean IQ of 95.1 (though the sample size for
reported taking vitamin B supplements, which did improve vegans was low). But, to reiterate, Gale et al. report the IQ of
their B12 status. There was no significant difference between the 30-year-old vegetarians when they were 10-year-olds. Rae
B12 levels of vegetarians who took supplements and omnivores, et al.’s (2003) findings suggest that vegetarianism reduces
 CRITICAL REVIEWS IN FOOD SCIENCE AND NUTRITION 5

performance on tests that have a strong relationship with IQ. It including a central role as a neurotransmitter, as a trophic fac-
is possible that, although vegetarianism appeals to people with tor in CNS development, in maintaining the structural integrity
higher intelligence, becoming vegetarian reduces fluid intelli- of the membrane, in regulating calcium transport and homeo-
gence and working memory. Consistent with this possibility, stasis, as an osmolyte, as a neuromodulator and as a neuropro-
Gale et al. (2007) report that although vegetarians were tectant.” Vegetarians and especially vegans have low taurine
2.4 times as likely as omnivores to have higher academic intake and, consequently, low levels of plasma taurine and uri-
degrees or vocational qualifications, the former had no advan- nary taurine excretion (Laidlaw et al. 1988). The effects of
tage in terms of annual income—in fact they were slightly over- chronically low levels of taurine intake as seen in vegetarians
represented in the lowest income bracket and and vegans are largely unknown, though there is some direct
underrepresented in the highest. Gale et al. suggest that vegeta- evidence that low levels in infancy—even if they are within the
rians may choose lower paying jobs because of “ethical consid- normal range—may impair brain development. Wharton et al.
erations,” and note that vegetarians are more likely to agree (2004) found that “[l]ow plasma neonatal taurine was associ-
with the statement that “The government should redistribute ated with lower scores on the Bayley mental development index
income.” However, other studies have found that agreeing with at 18 months and the WISC-R arithmetic subtest at 7 years.”
redistributionist policies is associated with a lower IQ (Carl They suggest that dietary taurine intake may be responsible for
2014; Kanazawa 2010). the benefits of breast milk for neurodevelopment. If they are
The findings reviewed so far provide suggestive evidence right, then consuming breastmilk from mothers with low tau-
that the lack of creatine intake among vegetarians lowers fluid rine intake, including vegetarians/vegans (Rana and Sanders
intelligence and working memory by approximately 1 standard 1986), may put infants at risk for impaired neurodevelopment.
deviation, corresponding to about 15 IQ points. People may Low taurine levels during pregnancy may have an effect on fetal
not notice a reduction in cognitive functioning when they development.
become vegetarian if fluid but not crystallized intelligence is
affected. (That is to say, becoming vegetarianism may impair
Long-Chain n¡3 PUFAs
one’s ability to solve problems without causing one to forget
what one has learned, so the effect may not be noticeable.) The Development
results from Rae et al. (2003) suggest that the impairment is to Vegans do not consume any eicosapentaenoic acid (EPA) or
some extent reversible in adults by means of supplementation, docosahexaenoic acid (DHA), and vegetarians consume very
and would presumably be reversible by eating meat. little. Rosell et al. (2005) found that, compared with omnivores,
There is direct evidence that childhood creatine levels affect vegetarians had plasma concentrations of EPA and DHA that
not only performance on cognitive tests, but also real-life labor were 27.8% and 31.4% lower, respectively. Plasma concentra-
market outcomes in adulthood. As part of the Young Finns tions in vegans were, respectively, 52.8% and 58.6% lower than
Study in 1980, researchers measured the urinary concentrations in omnivores. Investigations by Kornsteiner, Singer, and
of creatinine in 3,596 Finns aged 3–18. (Creatinine is a break- Elmadfa (2008) and Sanders (2009) led to similar findings.
down product of creatine, and so the former is a proxy for the Could there be negative consequences associated with having
latter.) B€
ockerman et al. (2017) found a significant relationship low levels of EPA and DHA during childhood?
between subjects’ creatinine levels in 1980 and their income DHA is crucial for brain and retinal development, particu-
20 years later. A one SD increase in creatinine corresponded to larly in the first 2 years of life (Birch et al. 2010; Drover et al.
an increase of 7.36% in earnings. As the authors note, since uri- 2011; Echeverrıa et al. 2017; Innis, Gilley, and Werker 2001;
nary creatinine levels do not perfectly reflect actual creatine lev- McCann and Ames 2005; Uauy and Dangour 2006). Both
els, their results probably underestimate the true effect of DHA and EPA deficiencies are linked to a variety of neurocog-
creatine. nitive disorders including “attention-deficit hyperactivity disor-
While impaired creatine metabolism has been linked to psy- der (ADHD), dyslexia, dyspraxia and autism spectrum
chiatric disorders (Allen 2012), whether chronic low creatine disorders” (Schuchardt et al. 2010).
intake in childhood has nonreversible negative effects on brain The AND states:
development has not been studied. We cannot say for sure
The clinical relevance of reduced EPA and DHA status among veg-
whether long-term creatine supplementation for vegetarian or etarians and vegans is unknown. Long-chain n¡3 fatty acids are
vegan children would be a solution to this potential problem. important for the development and maintenance of the brain, ret-
(The AND’s 2016 statement does not mention creatine, though ina, and cell membranes and favorably impact pregnancy outcomes
its 2009 statement said that “vegetarian athletes may have lower and risk for [some] chronic diseases. Yet, vegetarian and vegan chil-
muscle creatine concentration [and] may benefit from creatine dren do not appear to experience impairment in visual or mental
development…. (Melina, Craig, and Levin 2016)
supplementation” [Craig and Mangels 2009]. Neither the 2016
nor the 2009 statement mentions the possible consequences of But since, as the AND itself says, the significance of the low
chronic low creatine intake for physical and mental develop- EPA and DHA status among vegetarians is “unknown,” it does
ment, which are in fact unknown.) not seem justified to say definitively that there is no risk. Some
indirect evidence suggests that low EPA and DHA levels in veg-
etarian children could be associated with risks.
Taurine
Because a small percentage of ingested alpha-linolenic acid
As to the significance of taurine, Wu and Prentice (2010) (ALA) is converted to EPA and DHA through endogenous pro-
report: “Taurine demonstrates multiple cellular functions cesses, supplementation with vegetarian sources of ALA can
6 N. COFNAS

improve the EPA and DHA levels of vegetarians and vegans ulcerative colitis, psoriasis, and lupus in childhood or
(Barcel
o-Coblijn and Murphy 2009). However, the below-nor- adolescence.
mal levels of EPA and DHA typically found in vegetarians
could potentially put children at risk for impaired brain and
CNS development. Conclusion
This paper has reviewed direct and indirect evidence that vege-
Mental health
tarian and vegan diets may be associated with serious risks for
There is currently an epidemic of depression among young
fetuses and growing children. This evidence for the dangers of
people in developed countries, including the U.S. (Kessler et al.
vegetarianism is not necessarily decisive. However, the question
2005; Nesse 2000). Supplementation with EPA (but not DHA)
is whether the AND is justified in making a blanket claim that
has been shown to significantly improve depression (Martins
“appropriately planned” vegetarian and vegan diets that substi-
2009; Sublette et al. 2011). A recent meta-analysis found an
tute milk, soy/legumes, or eggs for meat are as healthy as
association between low fish intake and depression, presumably
appropriately planned omnivorous diets for children. The evi-
due to the high EPA content of fish (Li, Liu, and Zhang 2016).
dence reviewed here suggests that there are still many
This gives some reason to believe that young vegetarians and
unknowns about the health effects of meatless diets in children.
vegans, who consume very little EPA or none at all, may be at
Parents ought to be informed that the debate about the health
increased risk for depression. In fact, there is empirical evi-
effects of vegetarianism in children is not settled one way or the
dence linking vegetarianism (and low meat consumption) to
other.
depression and to contemplating and attempting suicide in
adolescents (Larsson et al. 2002; Perry et al. 2001).
Acknowledgments
n¡6/n¡3 PUFA ratio
Thanks to Neven Sesardic for helpful comments on earlier drafts of
Hunter–gatherers consume n¡6 and n¡3 fatty acids in a ratio this paper.
of about 1:1, while Westerners consume them in a ratio of
around 15:1 or higher (Simopoulos 2002a). There is an ongoing
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