AMERICAN ACADEMYOF PEDIATRICS

Committee on Nutrition

Nutritional Aspectsof Vegetarianism, Health Foods,andFad Diets

The Commmittee on Nutrition is concernedabout the recent increase in nutritional practicesthat are potentially hazardous to the health ofchildren. The purpose of this statememit is todiscuss somne commmiiondietary patterns which maybe harmful and/or which may fail to provide thepromised or anticipated benefits. Such dietsimiclude those based on religion, life style, moralits', or ecologic concerns (e.g., vegetarianism andZen macrobiotics), and those in which specialvirtues of a particular food, foods, or nutrients areexaggerated (e.g. , organic, natural, and healthfoods, or diets supplemented with massive dosesof one or more vitamins).' The Commmnittee urgesthat claimms for benefit of special diets should besubjected to critical, scientific evaluation beforeacceptance by the medical community.

VEGETARIANDIETS

Vegetarianism with many individual modifications is popular, especially among adolescents andyoimng adults. Vegetarian diets mmay be classifiedas lactoovovegetarian (plant foods with dairyproducts and eggs), lactovegetarian (plant foods

with dairy products), or pure vegetarian (plantfoods only). The termn ‘¿�‘¿�vegan'‘¿�refers to a group ofindividuals who not only eat pure vegetarian diets1)ut also share a philosophy and life style.2 TheZen macrobiotic diet does not fit into this classification and will be described separately.

Many individuals and population groups havepracticed vegetarianism on a long-term basis andhave demmonstrated excellent health . Plant-baseddiets supplemented with milk or with milk amideggs tend to be nutritionally similar to diets

containing meat. The National Academny ofSciences' Food and Nutrition Board has emphasized that even pure vegetarians can be wellnourished if they select their diets carefully toprovide sufficient calories, a good balance ofessential amino acids, and adequate soumrces of

calcium, riboflavin, iron, vitamin A, vitamin D,and vitamin@ Indeed, there are some nutritional benefits of a well-balanced vegetarian diet,such as the rarity of obesity' and a tendencytoward lower serum cholesterol levels.@ On theother hand, the more stringent Zen macrobioticdiet is likely to be hazardous and leaves less roomfor modification.3

Pure Vegetarians and Vegans2367'°1'

A problem with vegetarian diets is thetendency to be so high in bulk that they may not

mmeetcaloric needs. Because of diminished cabries, protein is used as an energy source; thus, aprotein comitent equivalent to the recommmendeddaily allowance (RDA) becomes mmarginal. Thereare several ways to immprove protein nutrition.The quantity of protein in the diet is enhanced byusing legumes in which the concentration of

protein is high. The quality of vegetable proteinsis immproved by combining in each meal foods thatprovide the essential amino acids in the optimmalratios. For example, cereal grains (such as wheatand rice) are poor in the essential amnino acidlysine and can be effectively combined withlegumes, such as varieties of dry beans, soybeans,and peas, which have adequate lysine butt littlemnethionine.@l2 When the two foods are eaten atthe same meal, they provide a miiixture of proteinthat is better than either alone.

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The risk of other deficiencies is decreased if alarge variety of foods is used and undue relianceon a single cereal staple is avoided. An adequmateintake of most vitamins, minerals, amid othernutrients can be obtained with legumes (includimigfortified soybeami formulas), whole-grain products,nuts, seeds, amid dark-green, leafy vegetables.Legumes provide B vitaniins amid iron in additiomito relatively concentrated protein. Whole graimisare a source of thiamine, iron, and trace mineralsas well as carbohydrate and protein. Numts andseeds contain B vitamimins and iron, amid they

provide fat, which tends to be low in vegetariandiets. Dark-green, leafy vegetables help to supplyadequate calcium and riboflavin, which arelacking when dairy products are excluded.Vitamin B,2 deficiency occurs in pure vegetariamidiets after a variable period because this vitamiiimiis derived exclusively from animnal products. Thedeficiemicy can l)e avoided if vitamin B,2 supplementation is provided in tablet form or imifortified plant foods such as vitamiiimi B,2-fortifiedsoy or nut “¿�milks―that are usually available inhealth food stores. Vitamin simpplemnents areacceptable to most vegans.

Zen MacrobioticDiet

The Zen macrobiotic diet@ ‘¿�°is perhaps theroost dangerous of the cumrremit diets for growimigchildren. The goals of this rigid miutritiomial systemare largely spiritual. Ten stages of dietary restriction progress fromn —¿�3to + 7, with gradualelimmination of aninial products, fruits, amidvegetables. The lower-level diets can meet nutritionalmieeds,@ bitt the highest-level diet is composedonly of cereals amid restricts nimtritiomial balancethat is iiiherent in mnore diverse diets. In addition,caloric intake is usumally low. Strict adherence tothe niore rigid diets cami result fri scurvy, anemiiia,h@poproteinemia, li@pocalcemimia, emaciation, oreven death. Self-treatmnent of disease is comnmomiin this group, and miiedical consultation is discouraged. In 1971, the Council of Foods and Nimtritionof the Ammerican Medical Associatiomi pointed oumtthe dangers of the Zen miiacrobiotic diet.@ Poorgrowth is the miiaimi chimiical fimiding in infancy. asexemmplified in a recent report of two infants whohad been fed Kokoh (a Zen macrobiotic foodmixture for infant feeding) from birth to 7 and 14months.' They were sutbstantially umnderweight (5and 6 kg, respectively), amid their body lengthswere below the third percentile of the Iowastandards, reflectimig a caloric intake that was 40%of the RDA. Experience with some parents whouse the Zen macrobiotic diet has indicated that

they milaybe mnore acceptimig of nutritional advicefor their childreti than for themselves. If paretits

are told of their infant's poor growth and of thelong-term consequences of protein-calorie undermitmtrition, they may adopt a lower, more numtritiomially diverse and adequate step of the diet.

Vitamin A

There are unsubstantiated claims that extreniebyhigh dosesof vitamin A (25,000to 50,000IU/day) imiiprove visual acuity in people who work ineither bright or dim light. Large doses of vitaminA are also used for the treatment of acne amid toprevent infection. Sutch high doses can produceseriouts toxic effects in children, inclumdingamiorexia, desqutamation of the skin, increasedimitracranial pressutre, and X-ray changes in thelomig bones.@1@I Sufficient vitamin A for infantsamid children is present in most diets. Caffey haswarned'5 that the hazards of vitamin A poisoning

fromn the routine prophylactic feeding ofcomicentrates of vitamins A and D to healthyinfants and children who eat good diets areconsiderably greater than the hazards of vitaminA deficiency in healthy infants and children notfed vitamnin comicentrates. Ingestion of 20,000 IU/day or miiore for one or two months is likely to betoxic. A joimit statement of this Committee and theCommittee on Drugs discusses the use and abumseof vitamnin A in detail.―

Vitamin C

Pauling recommmended a daily dose of vitamiiimiC between 1 and 5 gm for the prophybaxis of thecommon cold.―This book has resumbtednot only imia surge of interest in vitamin C but also in its umseimi enormiioums quantities to prevent colds. TheComnmittee on Drimgs of the American Academyof Pediatrics stated in 1971 that there was noscientific evidence that vitammin C in the dosesrecommmended by Pautling was either safe orefficaciouts for the prevention of the conimnomicold.' Simice that timiie, a nummber of carefumlly

comitrolled, double-blind@ suggest thatthe use of vitammin C has, at best, a small effect onseverity and duration of symptoms of the commomicold. The report of a recent conference onvitamnimi C points oumt discrepancies among thesestudies and concludes that large doses of vitaminC have not been proven to have widespreadusefulness as a cold remedy.22 Clearly, much moreresearch is needed to confirm whether vitamiiin Cis umsefuil in preventing the common cold amid to

determine what harmful consequences sumch largedaily doses of the vitamin may have. Large dosesof vitammimiC can interfere with vitamin B,.absorption and miietabolism in man, and thisproblemn may not be overcome by extra vitaminB,. supplementation.23 Healthy adults can

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become conditioned to high doses of ascorbate(0.5 to 1.5 gm/day) over a two-week period withthe result that they develop lower-than-normalserum and leukocyte ascorbic acid values onreturning to a normal intake)4 A similar phenomenon in the fetus may explain the development ofscurvy in normally fed offspring of mothers whohave ingested 400 mg of ascorbic acid dailythroughout pregnancy.25 Until more informationis available, people should be cautious insubstantially exceeding the RDA for vitamin C.

Vitamin D

Vitamin D in amounts much greater than theRDA of 400 IU daily has been claimed to buildstronger bones, especially when the vitamin istaken in its “¿�natural―form in fish liver oil. Weknow of no evidence to support such claims. TheRDA is adequate for most infants and childrenand provides an ample margin of safety, evenwithout exposure to sunlight. Overuse of vitaminD in Britain and the European continent, withintakes between 3,000 and 4,000 IU daily, isbelieved to be rebated to the idiopathic hypercalcemia of infancy seen relatively frequently duringand after World War 11.2 The disease becamequite rare after the dietary intake of vitamin Dwas reduced to less than 1,500 IU daily)'

Vitamin E

Vitamin E has commanded much public attention and controversy. High dietary intakes ofvitamin E have been claimed to prolong life,increase sexual potency, and prevent suchdiseases as mental retardation, heart disease, andcancer. There is little or no basis for these claims.The wide distribution of vitamin E in vegetableoils and cereal grains makes deficiency in humansunlikely.27 Vitamin E supplementation may benecessary for persons with intestinal malabsorption, such as low-birth-weight infants whoseabsorption of the vitamin is often decreased forthe first 12 months of bife.2@In other situations, anexcess of vitamin E may be harmful, although theevidence for this is scant. There is evidence, bothin man and in the experimental animal, thatexcess vitamin E intake can interfere withvitamin K metabolism, result in a prolongedprothrombin time, and predispose to bleeding)'Excessive vitamin E intake in the experimentalanimal decreases the rate of wound healing,'0 andin man it has resulted in gastrointestinal symptorus and creatinuria.°

HEALTH FOODS

The terms “¿�organic,―“¿�natural,―and “¿�health―

foods generally carry the following connotations.Organic foods are plant products grown in soilenriched with humus and compost on which nopesticides, herbicides, or inorganic fertilizershave been used, or they are meat and dairyproducts from animals raised on “¿�natural―feedsand not treated with drugs such as hormones orantibiotics. Natural foods are those made fromingredients of plant or animal origin which arealtered as little as possible, and which contain nosynthetic or artificial ingredients or additives.Health food is a general term which seems toencompass natural and organic foods. The termincludes conventional foods which have beensubjected to less processing than usual (such asunhydrogenated nut butters and whole-grainflours) and less conventional foods such as brewer's yeast, pumpkin seeds, wheat germ, and herbteas.

Nutritional Aspects

The nutritional value of foods that reach theconsumer depends not only on the composition ofthe raw materials but also on various changeswhich occur during processing, storage, anddistribution. @2Nutritional losses occur whetherfood is processed commercially or at home or isstored in an unprocessed state.―― Variations inthe nutrient content of raw foodstuffs will affectthe content of vitamins and minerals in the finalfood product as much as, and sometimes morethan, the processing itself. For example, carrotsmay vary 100-fold in their concentration of carotene (provitamin A), and samples of fresh tomatojuice have shown 16-fold differences in vitamin Cper serving. Although the data are somewhatsketchy, the raw foods being produced today arenot significantly different in terms of vitamincontent from those produced two or more decades ago.'4 The food preservation techniques ingreatest use today minimize the loss of nutritivevalue of foods and are safe and well standardized.

There is no test to differentiate organicallygrown and organically processed food fromsimilar commercial products. Long-term studieshave failed to show the nutritional superiority oforganically grown crops in comparison with thosegrown tinder standard agricultural conditionswith chemical fertilizers.'@ If the soil is deficientin nutrients, crop yield rather than the nutritionalquality of the plant will be primarily affected.

Other concerns about agricultural practicesand food processing procedures may have morevalidity (e.g., residual hormones and antibiotics inmeat, and pesticide residue on dairy, fruit, and

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vegetable products).'― In addition, the variety offood additives in comniercial use is large, whichmiiakes complete screening of such products forsafety difficult for industry and federal agencies.'7Each of these issues is complicated, unresolved,and beyond the scope of this discussion. It isapparemit that concern about these issues is oftenthe basis for use of health foods despite their highcost.

Organically grown foodstuffs cost more thantheir nonorganic counterparts.3s@ In a 1976

survey i)y the U.S. Department of Agriculture inthe Washimigton, D.C., area, a market basket of 33standard foods bought in a stmpermnarket cost$17.49; :33 coumiterparts labeled “¿�organic―costfromii $2:3.74 to $28.00 iii “¿�natural―food stores.―The difference in cost (1½to 1% higher) for foodspmmrchased in “¿�health―stores is of particularconcern for bow-inconie faniilies who miiay have toskimp iii qttantity or sacrifice other importantitenis iii the budget to afford health foods. At thistinie, there is mio compelling evidence that thehigh cost of these products results in concomitantbenefit to the comisumner.There are no standardtests to identify organic foods; therefore, theconsumiier is forced to rely on the integrity of thefanner and distributor for assurance that theproducts were grown or prepared as claimed.

Diets for Athletes

Special diets amid dietary supplements forathletes can l)e briefly considered as a separate

category of health foods.' ‘¿�There is a widespreadmiiiscomiception that high-protein diets improveathletic performance. This belief is the basis forthe imigestion of disproportionately large amnotmntsof rare red miieat amid milk by many athletes. Inadditiomi, the belief has led to the use of specialprotein supplements, which is particularly widespread amiiong weight-lifters. The major dietary

need of athletes is calories, and protein is rarely alimriitimig factor. With exercise, the need for cabries increases roughly in proportion to the

increased expemiditure of energy. Ordinarily, anathlete will spontaneously increase his food intaketo a degree that miieets caloric needs, that providesniore than adequate protein, and that maintains arelatively constant weight. The requirement forprotein does not increase with exercise, except toa slight degree when niuscie mass increases. Thebelief that honey has special merit as a carbohydrate source for athletes has no scientific basis.The intermittent use of stringent diets for awrestler to miieet a lower weight class is nutritionally unsound and seems unduly extreme ifcomiipetitive athletics are to be viewed as a health

promoting, recreational activity. Other nutritional practices of athletes may be harmful butare not within the scope of this discussion.

CONCLUSION

Most individuals who adhere to unusual nutritional practices, except for balanced vegetariamiism, are aware that their ideas run counter to themainstreamii of medical and nutritional opinion.Some adopt such diets as an expression of disilhmsion with medicine or the “¿�establishment.―Physicians amid other health professionals should beprepared to encounter strong resistance if theyattempt to reverse such practices. Parents arelikely to resist the suggestion of major dietarychanges, and it is best to foctmson those features ofthe diet that are of greatest potential harmii totheir childremi. However, even with the nioreextremne dietary practices, it is usually possible toprevent serious harm by striving for dietaryvariety and balance and working within the valuesystem or philosophy of the group or individual.

COMMITTEE ON NUTRITION (1976, 1977)

LEWIS A. BARNESS, M.D., Clmainnan

ALVIN M. MAUER, M.D., Vice-Chairman

ARNOLD S. ANDERSON, M.D.

PETER R. DALLMAN, M.D.GILBERT B. FORBES, M.D.

JAMESC. HAWORTH,M.D.MARY JANE JESSE, M.D.BUFORD L. NICHOLS, JR., M.D.

CHARLES R. SCRIVER, M.D.

NATHAN J. SMITH, M.D.

MYRON WINICK, M.D.

Consti itan tsWmLLIA@I C. HEIRD, M.D.

0. L. KLINE,PH.D.DONOUGH O'BRIEN, M.D.

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1977;59;460Pediatrics Committee on Nutrition

Nutritional Aspects of Vegetarianism, Health Foods, and Fad Diets

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