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EGETARIAN DIETS, DEFINED percentage that has nearly doubled in the
as being devoid of flesh foods last 5 years.9 The exact number of vege- we selected the most representative plant
(such as meat, poultry, wild tarian children is not known, but likely foods from the Mediterranean tradition.
game, seafood, and their vegetarian parents would raise children Serving sizes for each item were calcu-
products), are followed by a growing following the same dietary pattern. lated so that within the same group they
number of people worldwide because Various Vegetarian Food Guides have would all be isocaloric, and they are the
of ethical, health, and environmental been proposed for adult vegetarians same as those in the VegPlate for adults.13
reasons.1 Vegetarian diets include a va- since 1997,8 but so far none specifically The average nutritional composition of
riety of plant-based foods such as for vegetarians aged 6 months to 17 one serving from each group was then
grains, legumes, nuts and seeds, fruits, years. Therefore, we designed the Veg- calculated and used to determine the daily
and vegetables, and may or may not Plate Junior (VPJ), a Vegetarian Food number of servings to consume from each
include dairy products and eggs. Vegan Guide specific for dietary planning in group to satisfy the Italian DRIs10 from 1 to
diets exclude all animal foods. infancy, childhood, and adolescence, 17 years of age, for calorie requirements
Although for over 30 years we have and conceived to meet the Italian, as ranging from 800 to 3,600 kcal.
known that well-planned vegetarian well as US, Dietary Reference Intakes Other foods listed, such as dairy
diets, including vegan, are nutritionally (DRIs).10,11 Diets obtained with the VPJ products, eggs, or meat analogs, are
adequate and promote regular growth method meet all the criteria defining a proposed as possible foods to consume
from the early years of human devel- vegetarian diet as “well-planned”8 and but were not included in the calcula-
opment on,2-4 some researchers still are therefore suitable for promoting tions, and they can be consumed ac-
discourage parents from raising vege- thriving and regular growth. cording to personal preference. For the
tarian children.5,6 These criteria are: different calorie requirements, from 1 to
This may be at least partially 17 years of age, the number of servings
Including a wide variety of plant
accounted for by the fact that children in each group necessary to reach nutri-
foods, such as grains, legumes
following very restrictive vegetarian tional adequacy is listed in Table 1.
and their derivatives, nuts and
patterns, which limit food choices and
seeds, vegetables, and fruit.
calorie intake, have been described.7 GRAPHICS OF THE VPJ
Dairy products and eggs are
These dietary patterns do not meet
considered optional. The VPJ (Figure, A) is based on six food
the criteria to be defined as well plan-
Carefully choosing vegetable fats, groups: grains, protein-rich foods, veg-
ned,8 and therefore no conclusions
consuming good sources of n-3 etables, fruits, nuts and seeds, and fats.
about the growth of children following
fatty acids, such as flaxseeds, chia The graphic draws attention to nutrients
them should be made.
seeds, and walnuts. considered critical in vegetarian diets
In Italy, 7.1% of the population follows a
Including reliable sources of cal- during all life stages: vitamin B-12 and
vegetarian diet (6.2% a lacto-ovo-
cium and paying attention to the vitamin D, located in the center of the
vegetarian and 0.9% a vegan diet), a
status of both vitamin B-12 and plate, and calcium and n-3 fatty acids,
vitamin D. whose food sources are represented as
This article was written by Luciana two cross-sectional groups. The basic
Baroni, MD, medical director, Primary The aim of the VPJ is to help health care graphic structure of the VPJ is the same
Care Unit, Northern District, Local professionals in advising vegetarian as for adults,13 given that the only ad-
Health Unit 2 Marca Trevigiana, Tre- parents, because parental education justments performed were in the num-
viso, Italy; Silvia Goggi, MD, senior plays a central role in achieving optimal ber of servings for each calorie range.
resident, Dietetics and Nutrition Unit, dietary patterns in vegetarian children.12
Ospedale Luigi Sacco, Milano, Italy; We also developed an adaptation of the
and Maurizio Battino, MD, PhD, VPJ for infants (Figure, B), to be used
professor, Department of Clinical Sci- FOOD SELECTION during complementary feeding (from
ences, Università Politecnica delle The VPJ is based on six food groups, plus approximately 6 months of age). The VPJ
Marche, Ancona, Italy. two cross-sectional groups of calcium- for infants recommends including the
rich foods and n-3-rich foods. Methods seventh food group of breastmilk (or in-
https://doi.org/10.1016/j.jand.2018.06.008
for food selection and serving size calcu- fant formula) during complementary
Available online 30 August 2018
lation have been described in detail in the feeding.
Table 1. Number of servings in the VegPlate Junior for children and adolescents (from 1 to 17 years of age)
USE OF THE VPJ planning from the beginning of com- Because breast milk of vegetarian
plementary feeding. During this mothers is similar in composition to
Infants period of life, children experience that of nonvegetarian mothers and
The VPJ adaptation for infants is extremely rapid growth,14 for which a thus nutritionally adequate,3,4 the
meant to help vegetarian dietary good nutritional status is essential. timing of the introduction of solid
1068 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS July 2019 Volume 119 Number 7
PRACTICE APPLICATIONS
A B
foods should not differ from that of These recommendations apply also to least 1 year of age, and food from all
nonvegetarian children, that is, be- meals or snacks offered to infants un- groups should be offered daily at each
tween 17 and 26 weeks.5 Breast or dergoing baby-led weaning.19 meal or snack in the amount shown in
formula milk should be continued Cow’s milk should not be introduced Table 2.
until at least 1 year of age, because it before 12 months of age because of its
provides a large amount of the daily high protein and low iron content.20
requirements of energy, calcium, and Fats are the primary source of energy Children and Adolescents
n-3 fatty acids.15 for all infants and help vegetarian ba- From 1 year of age, the growth rate
In the first year of life, if the mother bies to easily reach their calorie re- slightly decreases, although it is still
is not breastfeeding, the only alterna- quirements. Because fats play an quite rapid until 24 months of age. Af-
tives are cow’s milk infant formula and important role in brain development, ter that, weight and height increase
soy or rice formulas for vegan in- they should not be limited but carefully steadily until puberty, when a spike in
fants.16,17 Nonformula soy and rice chosen to maintain an optimal n-3/n-6 growth velocity takes place.14 The VPJ
beverages lack important nutrients and ratio.21-23 satisfies nutrient needs from 1 year to
should not be offered as breast or for- For infants, the VPJ does not indicate 17 years of age, as established by the
mula milk substitutes until at least 12 the number of servings from each Italian and US DRIs.10,11 For different
months of age.16,17 group to offer. calorie requirements in the various age
During complementary feeding, all Breast or formula milk should groups, the VPJ suggests the number of
solid foods from the VPJ are introduced continue on demand as usual until at daily servings to consume for each
in forms that do not constitute choking
hazards (ie, nut butters instead of
nuts),5 with no particular rigid rule
regarding the order of introduction.16-18 Table 2. Amount of food to offer to vegetarian infants at each main meal or snack
To avoid early satiety, nutrient malab-
sorption, and poor growth, all of the 6 mo 8 mo 12 mo
offered foods to should be as low-fiber
and as energy- and nutrient-dense as Instant infant cereal, refined grains or pasta 20 g 20-30 g 30 g
possible.16,17 Main meals should be Beans (dry weight) 10 g 15 g 20 g
based on refined infant cereals, peeled
Tofu 10-20 g 10-20 g 20 g
beans, and nut and seed butters, and
strained fruits and vegetables should Flaxseed oil/olive oil 5-10 g 5-10 g 5-10 g
be preferred.16,17 Fruit should be offered Nuts and seeds butter 0-10 g 10 g 10 g
as a snack, along with more nutritious
Fresh fruit 0-100 g 0-100 g 0-100 g
foods such as breast milk or infant a
formula, cereals, yogurt, and nut and Plant-milks 0-200 mL 0-250 mL 0-250 mL
seed butters.16,17 Dairy products and Cheese — 20 g 20 g
eggs from the protein-rich food
Egg — 1
/2 yolk 1
/2 yolk
group are considered optional, and
they should be included in the diet ac- a
Plant-milks should not replace breast or formula milk for infants up to 12 months of age but can be used as a liquid in
cording to parents’ choices and beliefs. food preparation.
July 2019 Volume 119 Number 7 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1069
PRACTICE APPLICATIONS
1070
Table 3. Energy content and nutrient composition of diets obtained with the VegPlate Junior for children and adolescents (from 1 to 17 years of age), compared with the
Italian and the US Dietary Reference Intakes (DRIs)a
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
kcal
Unit of Carbohydrates Carbohydratesa Protein Proteinb Fat Fatc Calciumd Iron Zinc Thiamin Riboflavin Vitamin
measure (g) (%) (g) (%) (g) (%) (mg) (mg) (mg) (mg) (mg) B-3e (mg) Fiber (g)
Table 3. Energy content and nutrient composition of diets obtained with the VegPlate Junior for children and adolescents (from 1 to 17 years of age), compared with the
12.6-16.7f
12.6-16.7f
Fiber (g)
tional composition of diets obtained
with the VPJ method is shown in
25-38
19
100
Table 3.
For corresponding levels of energy,
the daily number of servings differs
B-3e (mg)
from the VegPlate for adults,13 because
Vitamin the nutritional needs of children and
8-18
8-16
7
6
particular.10,11
39
adolescence are
Although discretionary calories do not
Riboflavin
0.6-1.6
0.6-1.3
(mg)
0.5
adolescents should be discouraged
from choosing sweetened beverages or
Thiamin
0.6-1.2
(mg)
4.2
0.4
0.5
NUTRIENTS OF CONCERN:
SPECIFIC RECOMMENDATIONS
(mg)
6-12
3-11
Zinc
24
5
10-15
7
38
Calcium content is underestimated, because it does not account for calcium in water and the recommended number of servings of calcium-rich foods.
700
1,433
1,000
1,300
(mg)
30-40
20-35
25-35
Fatc
33
ND
ND
(g)
foods.
Italian and the US Dietary Reference Intakes (DRIs)a (continued)
19-62
19-52
13
117
(g)
45-65
40-60
45-65
53
130
130
(g)
Italian DRIs
measure
4-17 y
US DRIs
1-3 y
Unit of
July 2019 Volume 119 Number 7 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1071
PRACTICE APPLICATIONS
the DRI for vitamin D (600 UI)10,11 OTHER NUTRIENTS Vitamin C, beta-carotene, and organic
through supplementation.29 acids positively influence non-heme
Fiber iron absorption, as well as some cook-
Vegetarian children show a higher ing practices that reduce the phytate
n-3 Fatty Acids intake of fiber compared with nonveg- content of foods (ie, soaking, sprouting,
From weaning on, n-3 fatty acids should etarian peers and may in some cases grinding, sour leavening, fermenta-
represent 0.5% to 2% of total energy and exceed recommendations.16,17,34 Exces- tion).17,38,39 Vegetarian parents should
provide 250 mg of eicosapentaenoic- sive amounts of fiber trigger early be aware of the iron-rich foods in
docosaexaenoic acid daily.10 The con- satiety, may cause constipation, and vegetarian diets, such as whole grains,
sumption of two servings of n-3erich may interfere with nutrient absorption legumes, soy products, green leafy
foods recommended in the VPJ provides (especially iron, calcium, and fats).17 vegetables, and nuts and seeds, and of
on average 5.0 g alpha-linolenic acid and Choosing refined grains, peeling the practices enhancing its bioavail-
satisfies the above-mentioned condi- beans, and straining fruits and vegeta- ability. Iron-fortified infant cereals may
tions for all of the calorie ranges. The bles are practices that effectively be useful for maximizing the iron con-
avoidance of n-6erich oils (ie, sunflower reduce the fiber content of the diet and tent of the diet in the first 2 years of life,
oil, corn oil) and tropical oils maximizes should be pursued from 6 to 24 months when whole grains should be limited.16
the conversion of alpha-linolenic acid to of age, a period of rapid growth.16,17
eicosapentaenoic-docosaexaenoic acid,
because it minimizes the n-6:n-3 ra-
Zinc
tio,22,23,30 which ranges from 2.79 to 3.08 Protein Zinc requirements are met in all diets
in the VPJ. Plants provide all of the essential obtained with the VPJ, but the overall
During complementary feeding, in- amino acids, and protein requirements diet bioavailability of zinc may be lower
fants can generally meet their n-3 fatty are usually met and even exceeded on when compared with nonvegetarian
acid requirements through breast or a vegetarian diet providing sufficient diets because of the high content of fiber
formula milk and the suggested serv- energy from a variety of plant foods.3 and phytate in vegetarian diets.40 The
ings of fats.30 Breastfeeding women Animal-derived products are not previously mentioned practices that
should heed the recommendation to necessary to attain protein re- decrease the phytate content of the
include a DHA source in their diet.13 quirements, and their consumption diet also enhance zinc absorption, and
According to the Italian DRIs, all chil- depends on the family habits. Because the daily inclusion of zinc-rich foods,
dren from 6 months up to 3 years of of the lower digestibility of plant pro- such as legumes, nuts and seeds, and
age should additionally consume a 100 teins, some authors suggest increasing cheese for lacto-ovo-vegetarian chil-
mg/d of DHA, regardless of the type of protein DRIs of vegetarian children by dren, maximizes zinc intakes.
diet.10 10% to 15%,4 a percentage that the VPJ
surpasses for all age ranges (Table 3). Iodine
Combining complementary sources Vegetarian children and adolescents
Vitamin B-12 of protein at each meal is not necessary, should not rely on seaweed to meet
All vegetarians, including those who but an advantage in consuming com- iodine requirements, because its high
consume dairy products and eggs, plementary proteins at intervals of less content might exceed recommendations
are at risk of developing B-12 than 6 hours was shown in children and impair thyroid function,41 along with
deficiency.31 Failure to meet re- younger than 2 years of age.34 In possible arsenic contamination.42 Iodine
quirements for vitamin B-12 can everyday practice, young children eat requirements10,11 are met by using
result in life-threatening conditions often throughout the day, so combining iodized salt or algal source supplements.
in children whose B-12 stores can be protein sources is not necessary when Because the amount of iodine per gram of
low.32 Mothers should check their the variety of plant foods in the diet is iodized salt varies among countries, a
B-12 levels before conceiving and assured. daily consumption of approximately 3.3
supplement vitamin B-12 throughout
to 5 g for Italian children and adolescents
pregnancy and breastfeeding to
Iron (providing 100 to 150 mg of iodine)13 and
guarantee an adequate intake to the
approximately 2 to 3.33 g for US children
infant.4,33 Iron deficiency is highly prevalent
and adolescents (providing 95 to 155 mg
After the beginning of weaning, among all children, regardless of the
of iodine)43 is suggested. Infants from 6 to
because the amount of breast or for- type of diet.35 Vegetarian, and especially
12 months of age meet their iodine
mula milk can be variable, B-12 vegan, children show iron intakes above
requirements through breast and for-
should be supplemented in all vege- recommended levels, as much as twice
mula milk, and no salt should be added to
tarian infants.16,17 Because of the high the intakes of nonvegetarian peers,36
infants’ food.16
variability of absorption attributable to and have normal iron stores.37 In vege-
different frequencies of intakes, to tarian diets, all iron is in the non-heme
satisfy the DRIs by supplementation, form, which has lower bioavailability SUMMARY
the Italian Society of Human Nutrition than the heme iron found in meat and Well-balanced vegetarian diets plan-
suggests B-12 daily single doses from fish products (1%-34% compared with ned with the VPJ, which include a wide
5 mg in infants to 50 mg in adoles- 15%-35%), because of differences in ab- variety of plant foods and reliable
cents.4 These recommendations satisfy sorption and the fiber and phytate sources of vitamin B-12 and vitamin D,
both the Italian and US DRIs.10,11 content of plant foods.38,39 are an adequate option for infants,
1072 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS July 2019 Volume 119 Number 7
PRACTICE APPLICATIONS
children, and adolescents. Vegetarian Vegetarian diets. J Acad Nutr Diet. 11. National Institute of Health. Office of Di-
2016;116(12):1970-1980. etary Supplements. Nutrient recommenda-
diets, because of their favorable con-
4. Agnoli C, Baroni L, Bertini I, et al. Position tions: Dietary Reference Intakes (DRI).
tent of fiber and essential nutrients, https://ods.od.nih.gov/Health_Information/
paper on vegetarian diets from the
have been shown to be protective working group of the Italian Society of Dietary_Reference_Intakes.aspx. Accessed
against childhood and adolescence Human Nutrition. Nutr Metab Cardiovasc May 28, 2018.
obesity,44 as well as obesity-related Dis. 2017;27(12):1037-1052. 12. Northstone K, Smith AD, Cribb VL,
Emmett PM. Dietary patterns in UK ado-
diseases that may occur later in life.2,3 5. Complementary feeding: A position paper
lescents obtained from a dual-source FFQ
by the European Society for Paediatric
Exposing children to a great variety of Gastroenterology, Hepatology, and Nutri- and their associations with socio-
plant foods may promote healthful tion (ESPGHAN) Committee on Nutrition. economic position, nutrient intake and
J Pediatr Gastroenterol Nutr. 2017;64(1): modes of eating. Public Health Nutr.
eating habits later in life. 2014;17(7):1476-1485.
119-132.
In Italy, one of three children is either 13. Baroni L, Goggi S, Battino M. VegPlate: A
6. Richter M, Boeing H, Grünewald-Funk D,
overweight or obese,45 and Europe and Mediterranean-based food guide for Ital-
et al. Vegan diet: Position of the German
the United States show similar per- Nutrition Society (DGE). Ernahrungs ian adult, pregnant, and lactating vege-
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centages.46 In this scenario, the VPJ can Umschau. 2016;63(04):92-102. Erratum
in: 63(05):M262. 2235-2243.
serve as a foundation for planning
7. Schürmann S, Kersting M, Alexy U. Vege- 14. Center for Disease Control and Prevention.
omnivorous diets rich in plant foods and Growth charts. https://www.cdc.gov/
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AUTHOR INFORMATION
Address correspondence to: Maurizio Battino, MD, PhD, Department of Clinical Sciences, Università Politecnica delle Marche, via Ranieri, 60100
Ancona, Italy. E-mail: m.a.battino@univpm.it
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
L. Baroni is the author of books describing the method; M. Battino is the director of the International Master in Vegetarian Nutrition and Dietetics,
hosted by Funiber; S. Goggi declares no conflict of interest.
FUNDING/SUPPORT
None.
ACKNOWLEDGEMENTS
Authors wish to thank Ilaria Fasan, RD, for the thoughtful inputs, Paul Foster Griffith, MD, for the careful revision of the language, and the
anonymous reviewers whose suggestions have led to an improvement of the contents.
1074 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS July 2019 Volume 119 Number 7