• Thereisscientificconsensusthatprioritisingplantsinthedietleadstobetteroutcomesforthehealthofpeopleandtheplanet.

• Plant-baseddietsencompassaspectrumofdietarypatternsbasedpredominantlyonplantfoods,includingvegetables,wholegrains,legumes,nuts,seedsandfruits,andthesemaycontainsomeornoanimal-sourcefoods.

• Eventhoughtheperiodofchildhoodthroughtoadolescencepresentsuniquechallengesfromanutritionalperspective,well-plannedplant-baseddietscanmeetdietaryneeds,evenwhenanimal-sourcefoodsarecompletelyabsent.

• Theproteincontentandqualityofplant-baseddiets istypicallynotaconcernwithchildrenandadolescents,noristheprovisionofsufficienttotalfat.However,ifanimal-sourcedfoods,particularlyoilyfish,areabsentorminimal,attentionshouldbegiventoensuringadequatesourcesandproportionsofessentialfatsareincluded.

• Irrespectiveofdietarypatterns,itisadvisablethatallchildrenintheUKaged1-4yearsandallat-riskgroupstakeayear-roundvitaminDsupplement.Throughouttheprimaryschoolyearsandintoadolescence,adailyvitaminDsupplementshouldbetakenduringtheautumnandwintermonths(SeptemberthroughtoApril).

• Calciumintakesaretypicallynotcompromisedwithplant-basedeating;well-absorbedcalcium-fortifiedalternativesarereadilyavailable,asareplantfoodsourcesofcalciumsuchasgreenleafyvegetables andcerealproducts.

• Theredoesnotappeartobeacleardifference inironandzincstatusacrossvegetarianandomnivorouspopulations,suggestingitisplausibletoconsumeadequateamountsofeachwithplant-baseddiets,evenwithpotentiallyreducedbioavailability.However,attentionshouldbepaidtointakesinadolescents,particularlygirls,asaconsiderableproportionofthispopulationgroupintheUKconsumesuboptimalamounts.

• VitaminB12isfoundexclusivelyinfoodsofanimaloriginandisthereforecompletelyabsentinvegandiets.Areliablesourceisessentialsuchasfortifiedfoods,ormorepreferably,aregularsupplement,mustbeincluded.Dietsthatcontainvaryingamountsofanimal-sourcefoodsmayprovidesufficientB12,andifnot,thiscanbeboostedbyincludingfortifiedfoodsorasupplement,ifnecessary.

• Inplant-baseddietswheremilkandmilkproductsand/orfishmaybelimitedorcompletelyexcluded,considerationshouldbegiventoensuring adequateiodineintakes,suchasthroughtheinclusionofiodine-fortifiedproductsorasupplement,dependingonindividualneeds.

KEY POINTS

PLANT-BASED EATING FOR CHILDREN:NUTRITIONAL CONSIDERATIONS

byVanessaClarkson,BScDietetics,MScFoodPolicyedited by Kate Roberts, MSc RD specialist dietitian in paediatrics and allergy

Thisfactsheetreviewsthescientificevidencetoensureplant-baseddietsarenutritionallyadequateforhealthy andotherwisewellchildren,fromchildhoodthroughtoandincludingadolescence(1-18yearsold).

FOR HEALTH PROFESSIONAL USE ONLY 1

DEFINING A PLANT-BASED DIETThereisnosingleagreedupondefinitionofplant-baseddietsper se,beyondtherecognitionthattheyarecomprisedpredominantlyofplantfoods.TheBDAdefinessuchfoodwaysasbeing“based on foods derived from plants, including vegetables, wholegrains, legumes, nuts, seeds and fruits, with few or no animal products”.(7)Thus,plant-baseddietarypatternsexistonaspectrumfromthosethatmayincludemoderateamountsofanimal-sourcefoods,tothosethatarecompletelyplant-based(Figure1).Breastmilkisnotexcludedfromanyplant-baseddietarypattern,includingveganism.

HEALTHY DIETS FROM SUSTAINABLE FOOD SYSTEMS

Within the recommendations from the FAO/WHO, is advice to prioritise plant foods: “[healthy sustainable diets] include wholegrains, legumes, nuts and an abundance and variety of fruits and vegetables… and can include moderate amounts of eggs, dairy, poultry and fish; and small amounts of red meat”.(1)Thispredominantlyplant-basedguidanceisconsistentwiththefood-baseddietaryrecommendationsfrommanyleadinghealthauthorities,includingPublicHealthEngland’s(PHE)EatwellGuide,theEAT-LancetCommissionandtheBritishDieteticAssociation’s(BDA)OneBlueDot®initiative.(2-4)It is important to note that plant-based diets do not need to completely exclude animal-source foods in order to be environmentally sustainable. TheEatwellGuideappliestochildrenaged5yearsandover,andadults,andprioritisesrecommendingplantfoods,suchthattheyshouldordinarilycompriseover80%oftheweightoffoodeaten.Equivalentguidesarealsoavailableforthosethatchoosetofollowvegetarianorvegandiets.(5,6)

Formorescientificandpracticalinformationaboutsustainablediets,visitthe BDAOBD website(www.bda.uk.com/resource/one-blue-dot.html).(4)

DEFINING SUSTAINABLE DIETSTheFoodandAgricultureOrganizationoftheUnitedNations(FAO)andWorldHealthOrganization(WHO)recentlydefinedsustainablehealthydietsas:“Dietary patterns that promote all dimensions of individuals’ health and wellbeing; have low environmental pressure and impact; are accessible, affordable, safe and equitable; and are culturally acceptable.”(1)

Thereisanurgentneedtore-orientatethefoodsystemanddietarypatternstothosethataresensitivetoplanetaryhealth–thatisthehealthofthepeopleandnaturalsystemsonwhichhumansdepend.Inpractice,onepartofthistransitioninvolvesanoverallshifttowardsproducingandconsumingmoreplant-andlessanimal-sourcefoods.Animalsareanintegralpartofearthsystemdynamics,however,asdevelopedeconomieshaveshiftedtowardsincreasedconsumptionofanimal-sourcefoods,thishascreatedapotentialtoovershootplanetaryboundaries(forwaterusageandquality,greenhousegasemissionsandsoon),iftheyaren’talready.

Figure 1. Main variations of plant-based diets

Not all plant-based diets are equalBeyondthebalanceofplanttoanimal-sourcefoods,itisessentialnottooverlooktheimportanceoftheoverallqualityofdietarypatterns.Arecentreviewfoundthatplant-baseddietsconsistingofhigheramountsoflow-qualityplantfoodssuchasrefinedgrainsandsugaryproducts,wereassociatedwithanincreasedriskofcardiovasculardiseasecomparedtodietscontaininghighqualityplant-foodssuchaswholegrains,fruit,vegetables,nutsandseeds.(8)

Furtherpublicationsinvestigatingplant-baseddietssupportthatthequalityoftheplantfoodsconsumedplayafundamentalroleinmediatinghealthoutcomes.(9-11)Accordingly,alowquality,nutritionallypoorplant-baseddietmayputanindividualatagreaterriskofadversehealthoutcomes,thananaverageomnivorousdiet.

VEGAN OVOVEGETARIAN

LACTOVEGETARIAN

LACTO-OVOVEGETARIAN PESCATARIAN POLLO

VEGETARIANFLEXI/SEMIVEGETARIAN

PLANT-BASED SUSTAINABLEDIET RECOMMENDATIONS

FOR HEALTH PROFESSIONAL USE ONLY 2

ArecentreportbytheUnitedNationsInternationalChildren’sFund(UNICEF)examinedthehighratesofchildhoodmalnutrition(inallitsforms)globallyandnotedthatspecificallyintheUK,1in3childrenleaveprimaryschoolinEnglandatanunhealthyweight,withthoseinthemostdeprivedareasmoresignificantlyaffected.(12)Atthesametime,nearly2millionchildrenliveinfoodpoverty.Clearly,thereismoreworktodotoimprovenationaldietsinyoungergenerations,andsupportingtheconsumptionofmoreplantfoodsisoneaspectofthat.Theperiodfromchildhoodthroughtoadolescencepresentsuniquechallengesfromanutritionalperspective,withrequirementsformanynutrientsraisedtooptimisegrowthanddevelopment.Theprocessofgrowthanddevelopmentispunctuatedbycriticalperiodswherecloseattentiontonutritionalintakeisimperative(Figure2).Itisalsoatimeduringwhicheatingbehavioursincludingfoodlikesanddislikesarelearned,andareinfluencedbyinteractionswithfamilymembersandpeergroups,andthesearesituatedwithinwiderculturalexpectations.

Plant-baseddiets,eventhosewhereanimal-sourcefoodsarecompletelyabsent,canmeetnutritionalrequirementsacrossthelifecourse.(14,15)Themajorityofnutrientsarefoundinplantfoods,withonlyahandfulofexceptions–vitaminA(retinol),vitaminB12,vitaminD,andsomelong-chainpolyunsaturatedfattyacids(PUFAs).(16)Retinolcanbederivedfromcarotenoids,whichareabundantinplantfoodsandisthereforegenerallynotanissueinplant-baseddietsprovidedamplecolourfulvegetablesareincluded.VitaminB12,vitaminD,PUFAsandsomeothernutrientssuchasiodine,iron,zincandcalcium,areeithernotpresentinplantfoods,arefoundinlowerquantities,arepotentiallylessbioavailable,orarelesswidelydistributedinthefoodsupply.Thesefactors,togetherwiththespecificnutritionalconsiderationsforyoungeragegroups,areexaminedhereafter.

NUTRITION DURING CHILDHOOD & ADOLESCENCE

SUSTAINABLE PLANT-BASED DIETS IN CHILDREN & ADOLESCENTS

Figure 2. Critical periods for growth and development(13)

Notes:darkercoloursrepresentcriticalperiodsforgrowthanddevelopment;lightercoloursareimportantperiodsandrepresentkeyopportunitiesforinterventions.Theremaybepotentialtocatchupinheightrelativetopeerslaterinchildhood,whichisindicatedbythelightercolourbarinadolescence.

RepublishedwithpermissionofAnnualReviews,Inc,fromThe Nexus Between Nutrition and Early, Childhood Development, Alderman H & Fernald L, 37, 2017; permissionconveyedthroughCopyrightClearanceCenter,Inc.2020

AGE (YEARS) 1 2-3 4-6 7-10 11-14 15-18Gender Male Female Male Female Male Female Male Female Male Female Male Female

Energy(kcal) 765 717 1088 1004 1482 1378 1817 1703 2500 2000 2500 2000

Fat(g) - - - - 58 54 71 66 97 78 97 78

SaturatedFat(g) - - - - 18 17 22 21 31 24 31 24

PUFA(g) - - - - 11 10 13 12 18 14 18 14

MUFA(g) - - - - 21 20 26 25 36 29 36 29

Protein(g) 15 15 15 15 20 20 28 28 42 41 55 45

Protein(%energy) - - 5 6 5 6 6 7 7 8 9 9

Calcium(mg) 350 350 350 350 450 450 550 550 1000 800 1000 800

Iron(mg) 6.9 6.9 6.9 6.9 6.1 6.1 8.7 8.7 11.3 14.8 11.3 14.8

Zinc(mg) 5.0 5.0 5.0 5.0 6.5 6.5 7.0 7.0 9.0 9.0 9.5 7.0

Iodine(mcg) 70 70 70 70 100 100 110 110 130 130 140 140

Selenium(mcg) 15 15 15 15 20 20 30 30 45 45 70 60

VitaminB12(mcg) 0.5 0.5 0.5 0.5 0.8 0.8 1.0 1.0 1.2 1.2 1.5 1.5

Table 1. Daily nutrient recommendations in childhood and adolescence(18)

Note:protein%energycalculatedas1gramprotein=4kcal,allmacronutrientdataroundedtonearestwholenumber.

LINEAR GROWTH

SEEING/HEARING

RECEPTIVE LANGUAGE

EXPRESSIVE LANGUAGE

HIGHER COGNITIVE FUNCTIONS

SOCIOEMOTIONAL DEVELOPMENT

CONCEPTION BIRTH 2 YEARS 5 YEARS 10 YEARS 18 YEARS

First1,000days

FOR HEALTH PROFESSIONAL USE ONLY 3

PROTEIN QUANTITY AND QUALITYThoughenergyrequirementsinyoungeragegroupsareconsiderablyhigherthanadults(relativetobodyweight)duetogrowthdemands,thevastmajorityofdietaryproteinisneededformaintenanceratherthangrowth.Consequently,whenexpressedasapercentageofenergyintake,proteinrequirementsforchildrenareconsiderablylessthanadults; withrequirementsgraduallyincreasingfrom5%at2years to9%at18years(Table1).(17)

Plantsourcesofproteinalsohavemoreroundednutritionalprofilesthananimal-sources,containingabroadermixofmacronutrients.Thismeansthatweight-for-weight,plantfoodsarelowerinproteinthananimal-sources.Theoveralltrendinamountofproteinconsumedisgenerallyasfollows–meat-eaters>fish-eaters>lacto-ovo-vegetarians>vegans.(17)

Additionally,itremainsacommonmisconceptionthatplantfoodsarelackinginparticularaminoacids,eventhoughthishaslongbeendeterminedtobefalse.Allplantfoodscontainall20aminoacids,includingall9essentialaminoacids.(17,19)Inthecaseoflysineandmethionine,ingrainsandlegumesrespectively,thesearepresentinloweramountsinplantfoodsproportionatetoaminoacidneeds.However,iftheseare

SUMMARY Providingenergyneeds aremet,plant-based dietsdonotordinarily presentanissueinterms ofprovidingadequate proteinquantityorquality throughoutchildhood andadolescence.

PLANT FOOD SOURCES OF KEY NUTRIENTS SERVING SIZE QUANTITY OF NUTRIENT PER SERVINGProteinSoyamince/chunks¥ 75g 15.7g

Tofu,firm 75g 6.1g

Mycoprotein(QuornTM)§ 75g 8.2g

Legumesincludingpeas,bakedbeans,andlentils(boiledanddrained) 80g 4.0-7.0g

Nutsincl.peanuts* 15g 3.6g

Peanutbutter 20g 4.6g

Seedse.g.sunflower,poppy,linseeds,pumpkinandchia* 1tbsp 2.0-2.2g

Quinoa(cooked/raw)# 75g/~25g 3.3g

Omega-3 (ALA)Linseeds/flaxseeds,chiaseedsandhempseeds# 1tbsp 0.9-2.3g

Walnuts* 15g 1.1g

Rapeseed(vegetable)oil 1tsp/3ml 0.3g

Algaloilandcapsules:vegansourceofEPAandDHA++ 1capsule/2ml 200-900mgEPAandDHA

Notes:*ensurenutsandlargeseedsaregroundforyoungerchildren.Portionsizeswillvarydependingonmealfrequency,age,sexandlevelofphysicalactivityetc.

Table 2. Plant-based food sources of protein and omega-3 (ALA) (32, 33)

¥Based on 6 ready-to use brands chilled or frozen. §Average across a selection of leading market brands – online. ++Based on 14 supplements currently on the market. #USDA. FoodData Central https://fdc.nal.usda.gov/

Figure 3. Average daily protein intakes of 1½ to 18-year-olds in the UK exceeding dietary recommendations(20)

DAILY

PROTE

IN INT

AKES

AS

PERC

ENTA

GE RN

I

286%

199%

141%

1 1/2 -3 YRS MALE & FEMALE

4-6 YRS 7-10 YRS 11-14 YRS 15-18 YRS

286%256%

178% 172%

131% 129%

Male Female

consumedinthesame24-hourperiod,thentheiraminoacidprofileswillcomplementeachother.(19)

Thesephenomenarelatedtoproteinquantityandqualityshouldbemeasuredagainstabackdropofincreasedanimal-sourcefoodconsumption,particularlymeat,beinganotablefeatureofthenutritiontransition;theshiftthatpopulationsundergoastheymovetomoreWesterniseddietarypatterns.Oneresultofthenutritiontransitionisthatproteinintakesforthegeneralpopulationarefarinexcessofestimatedaveragerequirements.

ThisisillustratedbythemostrecentdatafromtheUKNationalDietandNutritionSurvey(NDNS)whichreportsthatmeandailyproteinintakesofchildrenaged1½-3yearsis42g,4-10yearsis53g,and11-18yearsis65g–allsignificantlymorethanrequirements(Figure3).(20)Itisagainstthisbackdropofelevatedproteinintakes,thatonemustconsiderthatthoughproteinintakesmaybeloweringroupsthatconsumefewornoanimal-sourcefoods,proteinintakeswillstillbesufficient.(17) Indeed, researchers note that it is practically impossible to fall short of protein needs when energy requirements are met and protein malnutrition is unlikely for healthy children following a balanced diet meeting energy requirements.(17)

FOR HEALTH PROFESSIONAL USE ONLY 4

FATSTotal and saturated fats Fatsareimportantinthedietsofchildrenandadolescents,notleastbecauseoftheirenergydensity;theyenabletheprovisionofsufficientenergytofuelgrowthanddevelopment.Currentnutritionalrecommendationsassertthatdietaryfatsshouldcomprise35%ofenergyintakesfrom4yearsandover.Notingthatinyoungchildren,explicitadvicetolimitfatconsumptionisabsent(Table1).(18)Lowfatdiets(lessthan25%ofenergy)havebeenshowntoadverselyaffectweightgainandlongitudinalgrowthinyoungchildren.(21)

Thedietaryfattyacidprofileandfoodsourcesarealsopertinenttoconsider.Highintakesofsaturatedfatsareassociatedwithanincreasedriskofadversehealthoutcomesinadultsandyoungeragegroups,andthereforerecommendationsarethatintakesshouldbekeptwithin11%ofenergyfor4yearsandabove(Table1).(22)TheNDNSreportsthatmeantotalfatintakesacrossyoungeragegroupsarebroadlyinlinewithrecommendationsat33-34%ofenergy,butchildrenandadolescentsaretypicallyconsumingmoresaturatedfatthanadvised.(20)Aconsiderableamountofthiscomesfromtheconsumptionofnutrient-poorbakedgoodssuchascakes,biscuits,bunsandpastries,andprocessedmeats.Reducingtheconsumptionoftheseinplaceofmorenutritiousfoodsisanimportantgoal.

Studies with adult populations show that vegetarian and vegan diets are usually lower in total and saturated fat than omnivorous diets, though with total fat still within a range that is typical for the broader population.(23, 24) Indeed, the lower saturated fat content of plant-based diets is one of their many features that have been highlighted as mediating better health outcomes.

Figure 4. Synthetic pathway of long-chain omega-3 and omega-6 fatty acids(29) Getting the right balance of PUFAs from a plant-based dietLong-chainPUFAsarenotconsideredessentialastheycanbesynthesisedfromALAandLA.However,someconcernshavebeenraisedaroundtheimplicationsofanearortotalrelianceonALAtosynthesisesufficientlong-chainPUFAs,indietsthatcontainfewornoanimal-sourcefoods,especiallyfish.Theseconcernsmayberaisedinyoungchildren,whomayhavehigherrequirementsthanadultstosupportthenewstructurallipidsynthesisassociatedwithgrowth.

WhilstLAisubiquitousinthediet,foodsourcesofALAareconsiderablymorelimitedandattentionshouldbepaidtoensureprovisionofappreciableamountsfromplantfoods,whenlittleornoanimal-sourcefoods,particularlyfish, areincludedinthediet.(28)

Notes:delta-6-desaturaseisthekeyregulatoryenzymebecauseitisusedtwiceintheconversionofALAtoDHA.Onthefirst‘loop’itcreatesEPA,thenDPA,andthe24carbonmetabolitederivedfromDPA(24:5omega-3),isthenconvertedtoDHAonthesecond‘loop’.ObservethecompetitionforthisenzymefromLA,ALAandthe24:5omega-3precursor,toenableDHAproduction.

RepublishedwithpermissionofJohnWiley&Sons-Books,fromConversion of linoleic acid and alpha-linolenic acid to long-chain polyunsaturated fatty acids (LCPUFAs), with a focus on pregnancy, lactation and the first 2 years of life, Gibson RA, Muhlhausler B & Makrides M, 7(Supp 2), 2011;permissionconveyedthroughCopyrightClearanceCenter,Inc.2020.

20:3n-620:4n-3

Δ6 DESATURASE

ϐ OXIDATION

24:5n-624:6n-3

18:3n-618:4n-3

20:4n-6(AA)20:5n-3(EPA)

22:5n-622:6n-3(DHA)

22:4n-622:5n-3(DPA)

24:4n-624:5n-3

18:2n-6(LA)18:3n-3(ALA)

Δ5 DESATURASE

Essential fats and long-chain PUFAs Humanscansynthesisesaturated,monounsaturated(MUFAs)andPUFAsincludingthelong-chainomega-3fattyacids,eicosapentaenoicacid(20:5,EPA)anddocosahexaenoicacid(22:6,DHA).However,humanscannotsynthesisetheplant-basedshort-chainomega-3andomega-6fattyacids–alpha-linolenicacid(18:3omega-3,ALA)andlinoleicacid(18:2omega-6,LA).Consequently,theseshort-chainessentialfatsmustbeprovidedinthedietfromplantfoods

Food sourcesEPAandDHAarepredominantlyfoundinoilyfish.Algaloilsareanotableplant-basedexceptionasasourceofEPAandDHA(algalsupplementsarenowavailable).(25)

BothALAandLAarepresentinplantfoods;LAisubiquitous,withsourcesincludingnutsandseedsandtheiroils,andcereals.FoodsourcesofALAareconsiderablymorelimited,andsourcesincludelinseeds(flaxseeds),chiaseeds,hempseeds,walnuts,canola/rapeseedoil,andsomesoyaproducts(Table2).

The role of short and long-chain PUFAs Omega-6andomega-3fattyacidsareanimportantstructuralcomponentsofcellmembranes,serveasprecursorstobioactivelipidmediators,andprovideasourceofenergy.Thelong-chainPUFAshavemultiplephysiologicalbenefitsonthecardiovascularsystemandDHAalsoplaysacrucialroleinthedevelopmentandfunctionofthebrainandretina,wherein

itrapidlyaccumulatesacrossthefirst2yearsoflife.(21,26)Anotherlong-chainPUFA,arachidonicacid(20:4omega-6,ARA)isalsoaccretedintheinfantbrain,aswellasbeingwidelydistributedthroughoutothervitalorgansandtissuesinthebody.(27)

Theessentialshort-chainfattyacids(ALAandLA)canbeconvertedtoEPAandDHAinthebody,thuscontributingtotheirphysiologicalfunctions.Inaddition,ALAhasbeenassociatedwithimprovedhearthealthoutcomesinadults.

Conversion of ALA and LA to the long-chain omega-3 fatty acidsALAandLAfromplantfoodsourcescanbeconvertedtothelonger-chainEPAandDHA.However,thematterofessentialfatsinplant-baseddietsiscomplicatedbytheobservationthathighintakesofLAcancompetewithALAforenzymeuse(delta-6-desaturase),andreducetheconversionofALAtoDHAandEPA(Figure4).Moreover,andperhapscounter-intuitively,anALA-richdietcanactuallysuppressDHAsynthesis,sothefocusisonaddressingthebalanceofLAtoALAandmaximisetheefficiencyofthelong-chainomega-3metabolicpathway.IthasbeenshownthattherelativeproportionsofLAtoALAinthedietsofinfantsandchildrencanhavemajoreffectsonthefattyacidprofileoftissues,althoughthefunctionalsignificanceofthisisunknownat thetime.(29)

FOR HEALTH PROFESSIONAL USE ONLY 5

OPTIMISING PUFA INTAKES• GovernmentrecommendationsforspecificPUFAintakesrelatetoolderchildrenandadults;0.45gEPA/DHAdailyandALAintakestoprovideatleast0.2%andLA1%oftotalenergyintakes.

• Forchildrenfollowingadietwithlittleornooilyrichfish,thefocusshouldbetooptimisethebalanceofALAtoLA.IndividualsshouldbeencouragedtochooseoilsthatarepredominantlycomprisedofMUFAssuchasoliveoil,sesameoiloravocadooil,and/orALA,includingstandardvegetable(rapeseed)oil,walnutsandseeds(Table2),inpreference tothosethatfavourLAe.g.sunflowerandcornoilsandspreads.(30,31)

• AreviewofcurrentevidencebySandersfoundthatdataisinsufficienttojustifysupplementinglong-chainomega-3fattyacidsinthedietsofveganorvegetarianadults,andbyextension,plant-basedeaters.(28)Equivalentdatainchildrenandadolescentsislacking.Therearenogovernmentrecommendationsforomega-3supplements.

• SuchconsiderationsarelikelytobelessofanissueifthedietcontainsappreciableamountsofDHAandEPA,suchaswithpesco-vegetariansandplant-baseddietsthatincludefishtoPHErecommendations.Itshouldbenotedhowever,thatfishstocksareinsufficienttosupportsuchintakesforeveryone,eveniftheyare‘sustainably’managed.

CALCIUMRequirementsforcalciumareraisedduringchildhoodandadolescencetosupportbonedeposition.Unlikewithiron,wherelowstatusorincreasedrequirementscangenerateincreaseduptake,theabilityforthebodytoadapttolowcalciumintakesislimited.(34)Adolescenceisaparticularlycriticaltimewhen40%oflifetimebonemassisaccumulated.(34)Peakcalcium-accretionrateistypicallyattainedat12½yearsofageingirlsand14yearsofageinboys.(34)Hypocalcaemiaandcalcium-deficiencyricketsareuncommoninhealthyinfants,childrenandadolescents.(34)AccordingtotheNDNS,calciumintakesaregenerallynotaconcernacrossyoungeragegroupsintheUK,withmeanintakesof718mg/dayin1½-3years(205%ReferenceNutrientIntake/RNI)and739mg/dayin4-10years(148%RNI)(Figure3).Calciumissuppliedprimarilybymilkandmilkproducts,withtheseproviding57%and44%ofcalciumintakesrespectively.

Figure 5. Average daily intakes of key nutrients during childhood and adolescence(20)

Duringadolescence,whencalciumrequirementsareattheirhighest,meanintakesaresuboptimalat762mg/day(84%RNI),and11%ofboysand22%ofgirlsaged11-18yearshaveintakesbelowtheLowerReferenceNutrientIntakes(LRNI).(20)

Alargeproportionofthecalciumthatisconsumedisprovidedbydairysources,withmilkandmilkproductscontributing34%ofcalciumintakesin11to18-year-olds.Theoreticallytherefore,ifno,orfewermilkormilkproductsareconsumedandnotreplacedby,orcomplementedwithalternativegoodsourcesofcalcium,intakesmaybecompromisedinplant-baseddiets.

However,inpractice,calcium-containingdairyalternativedrinksandyogurtsarereadilyavailable,withtheseusuallyfortifiedtoprovideanequivalentamountofcalciumasisfoundincow’smilk(120mg/100ml),withnoappreciabledifferenceinbioavailability.(35,36)Plant-baseddrinksareoftenalsofortifiedwithvitaminDtoaidcalciumabsorptionandsupportbonehealth.Furthermore,whiteandbrownflourmilledintheUKisfortifiedwithcalcium(alongsidethiamine,nicotinicacidandiron),andthereforecerealproductscontributesignificantlytoUKdiets;36%and39%oftotaldietarycalciumfor4to10and11to18-year-oldsrespectively.

Withdairynotenteringdietsuntilaround10,000yearsago,plants,andmorespecifically,wildleafygreens,provided

mostofthecalciuminhumandietsacrosshistory.(37)Evenincontemporarydiets,itisworthnotingthatbeyondinfancy,mostcalciumisprovidedfromfoodsotherthandairy,andthereisalsonolong-termdatatosuggestthatcalciumfromdairyproductsissuperiortoothersourcesofcalciumintermsofpromotingbonehealth.(34)Mostvegetablescontainsmallamountsofcalciumandthebioavailabilityofcalciumfromgreenvegetablesisgenerallyhigh,ifnotsuperiortocalciumindairyproducts,particularlyiftheoxalatecontentislow,suchaswithbroccoli,kale,pakchoiandcollardgreens.(38)

Reviewsgroupingvegansandvegetarianstogetherashomogenouscohortsandreportinglowbonehealthstatusandincreasedfractureriskareproblematicalfromtheoutsetoftheirdesignbecausetheyoverlookthecentralroleofdietaryquality.Dietarypatternsmaycontributetodiversebiologicalmechanismsthataffectbonemineraldensityandriskoffracture.(39,40)Itisonlyrecentlythatresearchersarepayingcloserattentiontothemake-upofvariousplant-baseddietarypatternsandbonehealth.Inarecentmeta-analysis,onlyoneincludedstudyassesseddietaryqualityandfoundthatvegansingeneralhadabetteroverallquality,andthatwhenthiswasaccountedfor,therewasnodifferenceinmeasuresofbonehealthacrossthespectrumofplantintakefromvegansthroughtoomnivores.(41,42)

SUMMARY Totalfatandsaturatedfatintakesaregenerallynotaconcernwithplant-baseddiets,however,considerationshouldbegiventoensuringadequateALAwhenoilyfishislimitedorabsentfromthediet.

MEAN

INTAK

E AS P

ERCE

NTAG

E RNI

205%

86% 99%

CALCIUM IRON ZINC

148%

106%88%84% 73% 83%

1½-3years 4-10years 11-18years

FOR HEALTH PROFESSIONAL USE ONLY 6

IRONIronisimportanttoconsiderinplant-baseddietsasthisisreadilysuppliedbyanimal-sourcefoods.Ironsupportsgrowthanddevelopmentinchildhoodandrecommendedintakesincreaseconsiderablyduringadolescence,especiallyingirls,wheretheRNIisthehighestacrossthelifecourseat14.8mg/day(Table1).Ironisaprincipalcomponentofhaemoglobininredbloodcellsandassuchisintegralfortransportingoxygenaroundthebody.Evenmildirondeficiencyinyoungeragegroupsisaparticularconcernbecauseifitprogressestoirondeficiencyanaemia,impairmentsincognitivedevelopmentarise,anditisunclearwhetherthesearereversiblewithirontherapy.(46)The latest NDNS data reports that iron intakes of 11 to 18-year-old girls is just half of their RNI: • Meanintakes8.3mg/day,56%RNI• Medianintakes7.9mg/day,53%RNIMore than half (54%) of girls in this age group consume less than the LRNI of 8.0mg/day.(20)Payingcloseattentiontoachievingadequateironintakesduringadolescenceingirlsisnotablyimportant.Intakesarelessofaconcernwithteenageboys,withthedatashowingmeanandmedianintakesof89%and86%oftheRNIof11.3mg/dayrespectively.Insharpcontrasttogirls,12%ofboysage11-18consumelessthantheLRNIof6.1mg/day.

Areviewofdatafromindustrialisedcountriesshowsthatforvegetariansuptoadolescence,intakesofironaresimilarorhigherthanomnivores.Thissimilaritymayreflectthefactthatcerealproductsarethemainsourceofironduringchildhood, andintakesofmeat,evenamongomnivores,areusuallysmall inearlychildhood.(47)

Iron bioavailabilityFiguresonintakedonotnecessarilyreflectironstatus. Thehaemironfoundexclusivelyinanimal-sourcefoods includingmeat,poultryandfish,isfoundinhigheramounts andismorereadilyabsorbedthanthenon-haemironofplantfoods.Furthermore,therearecomponentsinplantfoodsthat canactasinhibitorstoironuptake,includingphenolic

compounds,oxalatesandphytates,whicharepresentin somewholegrains,beans,nutsandsomevegetables includingspinach.Conversely,plantfoodsalsocontainanabundanceofenhancerssuchasvitaminC,citricacid,and otherorganicacidsthatsupporttheabsorptionofnon-haem iron.Theinclusionofsomemeat,poultryorfishwillalsoenhancenon-haemironabsorption.

Physiological adaptation to optimise iron statusAlsoofinterestisthatthemaintenanceofironstoresiscontrolledthroughtherateofabsorptionfromthediet,withtheimplicationbeingthatwhenironstatusiscompromised,thebodywillabsorbmorenon-haemironfromthediet.Datashowsthatabsorptioncanincrease10-foldiniron-deficientcomparedwithiron-repleteindividuals.(14)Ithasalsobeenshownthatironrepleteindividualscanadapttodietswithlowerbioavailability.Inonestudy,absorptionincreasedbyalmost40%froma‘lowbioavailabilitydiet’overa10-weekperiod.(48)

Arecentsystematicreviewofstudiesassessingtheironstatusinpopulationsfrominfancythroughtoadolescencefoundwidevariationsinthedata,althoughevidencefrom3ofthe4includedstudiesonBritishchildrenweresuggestivethatirondeficiencyisanissueforsomevegetarianchildren.(49)

SUMMARYIronintakescanbeaparticularissueforteenagegirls,irrespectiveofwhetheranimal-sourcefoodsareincludedintheirdiet,andtherefore,particularattentionneedstobetakenwiththisgroup.Morebroadly,whileironintakesareoftengreaterinvegetarianpopulationscomparedtoomnivorous,ironstatusintheformerseemtobelower.Whetherthispresentsagenuinehealthissueisuncertainatthistime.Ironintakescanbeoptimisedthroughtheinclusionofiron-richplantfoodsatallmeals(Table3),includingsomeanimal-sourcefoods,and/orincludingplentyofvitaminCin thedietthroughfruitandvegetables.

Plant-based drinksToddlersneedlessmilkthanintheirfirstyearoflifeanditisimportantthattheydonotfilluponmilkbeforetheirmeals;asdoingsocanreduceappetiteanddisplaceotherfoods,particularlythosethatareiron-richfromtheproteinfoodgroup.

Unsweetened,calcium-fortifiedplant-baseddrinkscanbeintroducedasanalternativetocow’smilkfromage1,inthedietsofhealthytoddlers,consistentwithadvicefromPHEandothers.(15,43)Theonlyexceptiontothisisricedrink,whichisnotsuitableforyoungchildrenduetoitsinorganicarseniccontent.(44)Soyadrinksarehigherinproteinthanotherplant-baseddrinks,however,thenecessaryrelianceonmilkorplant-basedalternativesasaproteinsourceinthedietsofchildrenandadolescentsindevelopedcountriesliketheUKhasbeenoverstated.Plant-baseddrinksaregenerallylowerinenergyandfatthancow’smilk,thus,fortheveryyoungconsumingplant-baseddrinksasamaindrink,considerationshouldbegiventoensuringadequateintakesofthesenutrientsfromotherdietarysources.

Asaguide, preschoolersshouldhavearound2-3 servingsfromthedairyandalternativesfoodgroup

whereaservingisroughly:

• 120mlmilkasadrinkoracalcium-fortifiedplant-baseddrink• Asmall(125g)potofyogurtorcalcium-fortified alternativetoyogurt

• 2small60gpotsofcalcium-fortifiedfromagefrais• 2-4tablespoonsofgratedcheese• 2x60gservingsofnon-organicfirmtofu(withcalciumsettingagent)

TheWHOrecommendsthatmothersshouldbe supportedtocontinuebreastfeedingforupto2years andbeyond,shouldtheywishto.Breastfeeding beyondthefirstyeartocomplementfoodintakemaybeparticularlyadvantageousfor vegan infants,assomeofthecomponentsofbreastmilkarenotfoundinexclusivelyplant-baseddiets,suchaslong-chainPUFAsandB12.(45) Veganinfantswhoarenotbreastfedmaybenefitfromcontinuationofasoya-basedinfantformulaorareadilyavailablesoyadrinkwithadditionalfortification,through to2years,dependingonthewiderdietarycomposition. Forchildrennotfollowingavegandiet,acalciumfortifiedplant-baseddrinkcanbeintroducedfrom1year.

SUMMARY Humanshavehistoricallymettheircalciumneedsthroughvegetableconsumption,specificallywildleafygreens,therefore,plant-baseddietscanprovideadequatecalcium,evenwhendairyproductsareminimalorabsentfromthediet.Today,thereisalsoawiderangeofcalciumandvitaminD-fortifiedplant-baseddrinksandotherproductsthatcanbeusedinplaceofdairyproducts.

FOR HEALTH PROFESSIONAL USE ONLY 7

PLANT FOOD SOURCES OF KEY NUTRIENTS SERVING SIZE QUANTITY OF NUTRIENT PER SERVINGNosupplementsrecommendedforcalcium,ironorzincunlessclinicallyindicated

CalciumAhandfuloffortifiedbreakfastcereals§ 30g 142-238mg

ReadyBrek§ 20g 268mg

Calcium-fortifiedplant-baseddrinksandalternativestoyogurt§ 100ml 120mg

Firmtofusetwithcalciumsulfate/chloride(E509/E516) 75g 149-300mg

FirmtofusetwithNigari(mostorganicvariants) 75g 65mg

Bakedbeans,chickpeas,redlentils,redkidneybeans(cannedanddrained) 80g 34-57mg

Okra/ladiesfingersandkale(cooked) 40g 48-60mg

Pakchoi(cooked) 40g 29mgBroccoli(cooked) 40g 14mg

BakeryproductsmadewithwhiteorbrownUKmilledflour.Mandatoryfortificationwithcalciumcarbonate 100gflour 235-390mg

IronAhandfuloffortifiedbreakfastcereals§ 30g 2.2-4.4mg

Hardtofu,steamed 75g 0.9mg

Redkidneybeans(canned),soyabeans/redlentils(boiled) 75g 1.5-2.3mg

Bakedbeans 100g 1.4mg

Kale(cooked) 40g 0.8mg

Peas,babyspinach 40g 0.75mg

Driedraisins,figs,apricots,andprunes 30g 0.8-1.2mg

Nuts*incl.cashews,hazelnuts,almonds,walnuts 30g 0.9-1.9mg

Sesameorpumpkinseeds* 1tbsp 0.7-1mg

Tahinipaste 1heapedtsp(19g) 2mg

ZincMycoprotein(QuornTM)§ 75g 5.7mg

Wheatgermorwholemealbread 2slices 1.3-1.8mg

Firmtofu 75g 0.53mg

Redlentils(boiled) 75g 0.8-1.1mg

Pecansandcashews* 15g 0.8-0.9mg

Hempseeds#andpumpkinseeds* 1tbsp 0.7-1mg

Peanutbutter 20g 0.6mg

Peanutsandalmonds* 15g 0.5mg

Notes:*ensurenutsandlargeseedsaregroundforyoungerchildren.Portionsizeswillvarydependingonmealfrequency,age,sexandlevelofphysicalactivityetc.

Table 3. Plant-based food sources for calcium, iron and zinc(33)

¥ Based on ready-to use chilled or frozen. Average from 3 leading supermarket brands. §Average across a selection of leading market brands – online. #USDA nutrient database.

ZINCIronandzincshareseveralconsiderationswithplant-based dietsintermsofdietarysources,bioavailabilityandrequirements.Likeiron,zincisalsoessentialandisinvolvedinamultitudeofbiologicalprocesses,meaningthatthehealtheffectsofdeficiencycanbewideranging.(50)

IntheUK,aroundhalfofzincintakesthroughoutchildhoodandadolescencearederivedfromanimal-sourcefoods(meat,milkandmilkproducts),withafurtherquartertoathirdcomingfromcerealsandcerealproducts.(20)Likeiron,zincintakesaresimilarlycompromisedinteenagegirls,withmorethana quarter(27%)consumingbelowtheLRNIandmeanintakesof80%RNI(6.3mg/day)(Figure2).(20)

Zincmaybeanissuewithplant-baseddietsdependingontheamountofanimal-sourcefoodsincluded.Plantsourcesofzincalso,generally,containphytates,whichinhibitzincabsorptioninasimilarwaytoiron,byforminginsolublecomplexesinthegutthatcannotbeabsorbed.(47)Adoptingvariouspreparationtechniquescanminimisetheamountofphytatesinfoods,boostingabsorptionofzinc(andiron).Examplesincludetreatmentwithhightemperatures(cannedproducts),toasting,soakingand

discardingthewater,souring(suchasgrainswhenmakingbread-sourdough),andsprouting.Theintroductionofmycoproteinsinthedietdoofferanexceptionallygoodplantsourceofzincat5.7mg/75gcomparedto5.7-7.2mg/75gforredmeat.Thereisalsoevidencethatthereissomeadaptationtolower zincintakes,althoughdatainchildrenandadolescentsarelacking.(47,51)Studiesininfantsandchildrensuggestnoappreciabledifferenceinzincintakestatusacrossomnivorousandvegetarianpopulations.(50)Findingsareinconsistentinadolescence,andgiventhisisatimewhenzincrequirementspeak,additionalattentionshouldbepaidatthistimetoensureintakesareoptimised(Table3).(50)

SUMMARY Inasimilarwaytoiron,zincintakesmaybecompromised withplant-baseddietsdependingontheoveralldietarycomposition.Attentionshouldbepaidtointakesinteenagegirls,andmorebroadly,intakescanbeoptimisedthroughtheregularinclusionofzinccontainingfoodsandadaptedfoodpreparationtechniques.

FOR HEALTH PROFESSIONAL USE ONLY 8

IODINEConcernshavebeenraisedabouttheiodinestatusofvariouspopulationsubgroupsintheUKincludingschoolchildren,with theUKevenbeingclassifiedasamildlyiodine-deficient country.(52)Iodineisanessentialmineralneededfortheproductionofthyroidhormones(T4andT3)andisindispensableforbrainandneurologicaldevelopment.Twometa-analyses haveestablishedthatiodine-deficientpopulationsare12-13.5IQpointslowerthaninrepletecommunities.(52)However,evenmarginallyimpairediodinestatusinschoolchildrenhasbeenshowntoaffectcognitionandschoolperformance.(53)Iodineisfoundinarangeoffood,however,foodcomposition dataisgenerallyunreliabletoenableanaccurateassessment ofintakes,aslevelsvaryaccordingtotheiodinecontentofthesoilinwhichitisgrown.(54)Fishandseaweedarerichsourcesofiodine,thoughparticularlyinthecaseofmarineproduce,levelscanvaryconsiderably.Otherkeydietarysourcesaremilkand milkproducts.Inthese,iodineisnaturallyonlypresentatlowlevels,withthemajorityofitsuppliedthroughindirectfortificationfromanimalfeedsandiodine-containingantisepticuse.(53)

TheNDNSreportsthatmilkandmilkproductscontribute62%,51%,and40%ofiodineintakesin1.5-3,4-10,and11-18yearsrespectively.(20)Fish,especiallywhitefish,arealsokeycontributorsofiodineintakes,withfishandfishdishescontributing9%,11%,and10%ofintakesin1.5-3,4-10,and11-18yearsrespectively.MedianurinaryiodineconcentrationsmettheWHOcriteriaforadequateiodinestatusinallage/sexgroups,however,9%ofchildrenaged4-10yearsand12%ofchildrenaged11-18yearshadconcentrationsbelow50mcg/L.(20)Indietswheremilkandmilkproducts,and/orfishmaybelimitedorcompletelyexcluded,considerationshouldbegiventoensuringadequateiodineintakes.A2016smallsamplestudy(n=5)usingdatagatheredin2012-13,foundthatchildrenaged8to10yearsconsumingplant-baseddrinksnotfortifiedwithiodinehadsignificantlyloweriodinestatusthanthoseconsumingcow’smilk.(55)However,afollow-upstudybythesameresearchgroupconcludedthatiodine-fortifiedplant-baseddrinkscouldbeconsideredreasonablereplacementsforcow’smilkintermsofiodineprovision.(56)Somemanufacturersnowfortifyplant-baseddrinkswithiodine,usuallyintheregionof22.5-30.0mcg/100ml.

SUMMARY Includingsomedairyproductsand/orfishin plant-baseddietscansupportwithprovidingsufficientiodine.Ininstanceswherethisisnotthecase,regularinclusionofiodine-fortifiedproductssuchassome plant-baseddrinks,orseaweedproductssuchas noriwouldbebeneficialandaniodinesupplement shouldbeconsideredthatdoesnotexceedtheRNIfor therelevantagegroup(Table1).Duetotheriskoftoxicity,seaweed-basedsupplementsarenotrecommended.

ASSESSING IODINE STATUSDuetothesignificantvariability,dietaryintakeisnotviewedasareliablemeasureofiodinestatus.MedianUrinaryIodineConcentration(UIC)ismoreappropriateasastatusmarker.

MEDIAN UIC FOR ALL AGES FROM 6 YEARS UPWARDS:• 100-199mcg/L,consideredreplete• <100mcg/L,milddeficiency• <50mcg/L,moderatedeficiency• <20mcg/L,severedeficiency

PLANT FOOD SOURCES OF KEY NUTRIENTS SERVING SIZE QUANTITY OF NUTRIENT PER SERVINGSeleniumBrazilnuts* 15g(2-3) 38mcg

Sunflowerorchiaseeds*# 1tbsp 3.9-5mcg

Greenorbrownlentils(cooked) 50g 20mcg

Riceandpasta(cooked) 75g 3.8-4mcg

IodineKelp and Kombu – not recommended. Exceptionally high in iodine (up to 5,000mcg/g dry weight) and could cause toxicity

Redseaweedsuchasnori(usedonsushi)anddulsecontain muchlowerlevels(32)

3g(1sheet) 88-1,650mcg

Iodine-fortifiedplant-baseddrinks§ 100ml 22.5-30mcg

Iodinesupplementsarerecommendedforchildrenandadolescentswhosedietsaredevoidoffish,seaweed,dairyandiodine-fortified plant-baseddrinks.Supplementsshouldnotexceedtheirdailyrecommendedintakes(Table1)norshouldtheybeseaweed-based

Notes:*ensurenutsandlargeseedsaregroundforyoungerchildren. Portionsizeswillvarydependingonmealfrequency,age,sexandlevelofphysicalactivityetc.

Table 4. Plant-based food sources for selenium and iodine(33)

¥ Based on ready-to use chilled or frozen. Average from 3 leading supermarket brands. §Average across a selection of leading market brands – online. #USDA nutrient database.

SELENIUMSeleniumisatraceelementthat,likeiodine,isparticularlyimportantinthyroidmetabolism.Itisfoundinbothplantandanimal-sourcefoods,enteringthefoodchainthroughplants,seafood(viaalgae),andselenium-supplementedanimalfeed.(57) However,theprovisionfromfoodsisvariabledependingontheseleniumcontentofthesoilwheretheplantsaregrown.SeleniumintakesaretypicallyadequateduringchildhoodintheUK,withtheNDNSreportingmeanintakesinchildrenage1.5-3yearsas154%RNI,andinchildrenage4-10yearsof123%RNI,however,inadolescence,meanintakesare75%RNI.(20)Seleniumrequirementsincreaseinlateadolescencetosupportgrowth,andthismaypartlyreflectthesuboptimalintakesseeninolderagegroups(Figure5).MostseleniuminUKdietscomesfromcereals,meatand seafood,andintakesmaybecompromisedifanimal-sourcefoods

arelimited;withthelattertwotogethercomprisingbetweenathirdtohalfofseleniumintakes,dependingonagegroup.(20)Despitethevariabilityinseleniumcontent,Brazilnutsareagoodsourceofnote,with3-6nuts(30g)providing76mcg,exceedingateenager’sRNI.Thereislimitedresearchonseleniuminchildhoodandadolescenceandimpactsofplant-baseddietarypatterns.

SUMMARY Whetherseleniumintakesarecompromisedin plant-baseddietsdependsontheoveralldietarypattern,andthereislimitedresearchtosuggestwhetherseleniumintakesarecompromisedinvegetarianorveganpopulations.SourcesofseleniumareshowninTable4.

FOR HEALTH PROFESSIONAL USE ONLY 9

VITAMIN B12VitaminB12(alsoknownascobalamin)isawater-solublevitaminthatisessentialforDNAsynthesisandpreventionofmegaloblasticanaemia.Deficienciescancauseproblemswithmyelinationofnervetissue.RequirementforB12duringchildhoodandadolescenceisrelativelyhigherthaninadultstosupportincreaseddemandsforgrowth.Exclusivelyfoundinanimal-sourcefoodsincludingmeat,poultry,seafood,eggsanddairyproducts,B12iscompletelylackinginvegandietsunlesssupplementsand/orfortifiedfoodsareeaten.

ItisnotpossibletogeneraliseastowhetherB12intakesareordinarilysufficientinplant-baseddiets,whereanimal-sourcefoodscanmakeupvaryingamountsofthetotaldiet.Itisconceivableforvegetarianswhileavoidingallmeat,poultryandseafood,toconsumesufficientB12throughmilk,yogurt,cheeseandeggs,andfortifiedproducts(andbyextension,peopleconsumingallofthese,plusmeatmoresparingly).However,theriskofsuboptimalintakecanberaisedwithplant-baseddietsdevoidofanimal-sourcefoods,asthenaturalsourcesofB12arelower.

TheNDNSprovidesdataonserumB12for4yearsandover,butdoesnotstratifythisbeyondagegroupandsex.Thelatestsurveyreportedthatnoneofthetestedsampleofchildrenaged4-10yearsweredeficientinB12(<150pmol/L)and5%ofadolescentsaged11-18yearsweredeficient.(20)

LowormarginalB12statusisrelativelymorecommon,particularlyinpopulationgroupsthatconsumelimitedamountsornoanimal-sourcefoods.(58)ImpairedB12statushasbeenshowntocompromisecognitiveandneurologicaldevelopment

inchildren.(59)ArecentsystematicreviewassessingserumB12levelsinaspectrumofplant-baseddietsfoundverylimitedexaminationofyoungeragegroups,andtheincludedstudiestypicallyassessedverysmallsamplesizes.(60)Onlyonestudyoninfantsandtoddlersaged10to20monthsmettheinclusioncriteria.ItreportedB12deficiency(definedasserumB12<136pmol/L)in45%ofthisgroupwhowerefollowingamacrobioticdiet.

TherearefoodsfortifiedwithB12whichwhenregularlyincludedcansupportwithmeetingB12recommendationsonplant-baseddiets(Table5).(5)ItisessentialforveganchildrenandadolescentstoincludeareliablesourceofB12intheirdiet,preferablyasupplement(forsurety),thoughtheoreticallyadequateamountscanbeconsumedthrough2-3dailyservingsoffortifiedfoods.Itisdesirableforparentsofchildrenconsumingavegandiettoseearegistereddietitian,andforthechildrenandadolescentstohavetheirB12statuscheckedviatheirGP.

SUMMARY Plant-baseddietsdonotnecessarilyposeariskto B12intakes,withthisdependentontheoveralldietary patternandinclusionofanimal-sourcefoods,whichare theonlynaturalsourceofthisnutrient.VitaminB12is certainlyanissuewhennoanimal-sourcefoodsare includedinthedietandinsuchcases,areliablesource ofB12isrecommended,throughfortifiedfoodsand/orpreferablyadailysupplement.

PLANT FOOD SOURCES OF KEY NUTRIENTS SERVING SIZE QUANTITY OF NUTRIENT PER SERVING

Vitamin B12-fortified products

Somebreakfastcereals§ 30g 0.63mcg

Plant-baseddrinks§ 200ml 0.76mcg

Plant-basedalternativestoyogurt§ 150g 0.57mcg

Nutritionalyeastflakes 1½g(1tsp) 0.7mcg

Yeastextract–canbehighinsaltsolabelsshouldbechecked 4g(spreadon2slices) 0.96mcg

AreliablesourceofvitaminB12isessentialforveganchildrenandadolescents,preferablyasupplement,althoughrequirementsmaybemetbyincluding2-3dailyservingsoffortifiedproductsaday

Vitamin DSunlight exposure from April through to September in the UK is our main source of vitamin D

Fortifiedbreakfastcerealsincludingmulti-grainhoopvariants, branflakes,cornflakes,andmostchildren’sbrands§ 30g 0.75-2.5mcg

Fortifiedplant-baseddrinks§ 200ml 1.5mcg

Fortifiedplant-basedalternativestoyogurt 150g 1.1mcg

Margarine 20g 1.5mcg

A daily vitamin D supplement of 10mcg all year round for:Childrenage1-4years(consuminglessthan500mlinfantorfollow-onformuladaily)ANDatriskchildrenandadolescentswithlittleornosunexposuree.g.individualswhoseeverydayclothingcoversmostoftheirskinorthosewithdarkskin.A daily vitamin D supplement of 10mcg between October and March for older children and teenagers

Notes:*ensurenutsandlargeseedsaregroundforyoungerchildren.

Portionsizeswillvarydependingonmealfrequency,age,sexandlevelofphysicalactivityetc.

Table 5. Plant-based food sources for vitamins B12 and D(33)

¥ Based on ready-to use chilled or frozen. Average from 3 leading supermarket brands. §Average across a selection of leading market brands – online. #USDA nutrient database.

FOR HEALTH PROFESSIONAL USE ONLY 10

VITAMIN DVitaminDisakeynutrient,alongwithcalcium,neededforbone,dentalandimmunehealthandisoneofthecomponentsofoilyfishthathasbeenpartlyattributedtosomeofitspositivehealtheffects.Withtheexceptionofoilyfishandcodliveroil,therearefewotherdietarysources,suchaseggyolks,meatandliver,whichprovideappreciablylowerquantitiesofvitaminD.

Somefoodsarenowfortifiedsuchasmargarines(notingpreviousdiscussionofessentialfattyacids),afewbreakfastcereals,plant-baseddrinksandyogurtalternatives.Mushroomsareaninterestingexceptionasauniqueplantsource,whichcancontainappreciableamountsofvitaminDuponexposuretoUVlight(above10mcg/100gfreshweight).(61)UnliketheUSandsomeotherEuropeancountries,dairyproductsintheUKarenotasourceofvitaminDastheyarenotfortifiedasstandard.

ThekeysourceofvitaminDistheconversionof7-dehydrocholesterolundertheskinbyUVBsunrays ofspecificwavelengths,whichintheUKoccurfromAprilthroughtoSeptember.DietarysourcesandsupplementsofvitaminDbecomemoreimportantintheautumnandwintermonths(fromOctobertoearlyMarch).Unfortunately,foodsourcesofvitaminDarelimited,andintakesarepooracrossalldietarypatternsintheUK.

Thegovernmentrecommendsanall-yearrounddailysupplementcontaining10mcgofvitaminDfor:(62)

• All1to4-year-oldstakinglessthan500mlinfantorfollow-onformuladaily

• Allat-riskchildrenandadolescentswithlittleorno sunexposuresuchasindividualswhoseeverydayclothingcoversmostoftheirskinorthosewithdarkskin(e.g.AfricanorSouthAsianbackground).HighmelaninlevelsinterferewithdermalvitaminDproduction

CHOLINECholineplaysacriticalroleinbraindevelopmentandwhilethebodycansynthesiseit,theextentofthisisinsufficienttomeetrequirements.(63)TheUSInstituteofMedicinerecognisedcholineasanessentialnutrientin1998,however,theUKdoesnotcurrentlyoutlinerequirementsnorreportonintakesthroughtheNDNS.Cholineisubiquitousinthedietalthoughnotablyhighsourcesareliverandeggs.(63)Cholineisalsofoundinappreciableamountsinwheatgerm,soyaproducts,quinoaand broccoli.(64)Cholineintakesareunlikelytobeanissueinhealthy,varieddiets,evenifcompletelyplant-based.(65)

SUPPLEMENT RECOMMENDATIONSAll children aged 6 months to 5 years.Thegovernmentrecommendsadailyvitaminsupplementcontainingvitamins A, C and Dunless500mlormoreofinfantformulaisbeingconsumeddaily.

All children (5 years and older) and adolescents, during the months of September through to March,thegovernmentrecommendsadaily10mcgvitamin Dsupplement.

Children (5 years and older) and adolescents with dark skin, those who wear clothing that cover up the majority of their skin and those who have little to no exposure to sunlight from March through to September. The governmentrecommendsanall-yearvitamin Ddailysupplementof10mcg.

Children and adolescents not consuming fish, seaweed, dairy and iodine fortified plant-based drinks. Aniodine supplementthatdoesnotexceedtheirdailyrecommendedintake(Table1)andonenotbasedonseaweedisadvised.

Children and adolescents following a vegan plant-based dietary plan:• Avitamin B12supplementisrecommended.• The Vegan Society produces a chewable vitamin supplement called VEG 1.Halfofasupplementprovides12.5mcg

vitaminB12,10mcgvitaminD,0.8mgriboflavin,100mcgfolicacid,1mcgvitaminB6,30mcgseleniumand75mcgofiodine.1-2years,aquartertoonethirdtabletcrushedandmixedinwithfood;2-12years,halfatablet;>12years,1tablet.

CONCLUSIONReducingconsumptionofanimal-sourcefoodsatapopulationlevelintheUK,andprioritisinghighqualityplantfoodsinthedietwillleadtobetteroutcomesforpeopleandtheplanet.Highqualityplant-baseddietsareappropriateforthewholepopulation,includingduringchildhoodandadolescence,withspecificnutritionalconsiderationsvaryingaccording

towhereonthespectrumofplant-toanimal-sourcefoodconsumption,anindividualsits.

SUMMARY TherearefewnaturalfoodsourcesofvitaminD,andintakesintheUKaregenerallypooracrossalldietarypatterns.Thegovernmentrecommendsayear-roundvitaminDsupplementforallchildrenage1-4years, andfrom5yearsandover,supplementationcontinues inat-riskgroups,andfromSeptembertoAprilforthe generalpopulation.

FOR HEALTH PROFESSIONAL USE ONLY 11

1. FAO/WHO.Sustainablehealthdiets-guidingprinciples.Rome,Italy;2019.Availablefrom:http://www.fao.org/documents/card/en/c/ca6640en/2. PublicHealthEngland.TheEatwellGuideBooklet.4ed:CrownCopyright;2018.Availablefrom:https://www.gov.uk/government/publications/the-eatwell-guide3. WillettW,RockströmJ,LokenB,etal.FoodintheAnthropocene:theEATLancetCommissiononhealthydietsfromsustainablefoodsystems.TheLancet.2019;393(10170):447-92.4. BritishDieteticAssociation.Eatingpatternsforenvironmentalsustainability.2018.Availablefrom:https://www.bda.uk.com/resource/one-blue-dot.html5. TheVeganSociety.Nutritionoverview:VeganEatwellGuide.2020.Availablefrom:https://www.vegansociety.com/resources/nutrition-and-health/nutrition-overview6. TheVegetarianSociety.VegetarianEatwellGuide.2018.Availablefrom:https://www.vegsoc.org/info-hub/health-and-nutrition/vegetarianeatwellguide/7. BritishDieteticAssociation.Plant-baseddiet:foodfactsheet.2017.Availablefrom:https://www.bda.uk.com/resource/plant-based-diet.html8. HemlerEC,HuFB.Plant-BasedDietsforCardiovascularDiseasePrevention:AllPlantFoodsAreNotCreatedEqual.CurrAtherosclerRep.2019;21(5):18.9. BadenMY,SatijaA,HuFB,etal.ChangeinPlant-BasedDietQualityIsAssociatedwithChangesinPlasmaAdiposity-AssociatedBiomarkerConcentrationsinWomen.JNutr.

2019;149(4):676-86.10. SatijaA,MalikV,RimmEB,etal.Changesinintakeofplant-baseddietsandweightchange:resultsfrom3prospectivecohortstudies.AmJClinNutr.2019;110(3):574-82.11. SatijaA,BhupathirajuSN,SpiegelmanD,etal.HealthfulandUnhealthfulPlant-BasedDietsandtheRiskofCoronaryHeartDiseaseinU.S.Adults.JAmCollCardiol.2017;70(4):411-22.12. UNICEF.TheStateoftheWorld’sChildren2019.Children,FoodandNutrition:Growingwellinachangingworld.2019October2019.

Availablefrom:https://www.unicef.org/reports/state-of-worlds-children-201913. AldermanH,FernaldL.TheNexusBetweenNutritionandEarlyChildhoodDevelopment.AnnuRevNutr.2017;37(1):447-76.14. MelinaV,CraigW,LevinS.PositionoftheAcademyofNutritionandDietetics:VegetarianDiets.JAcadNutrDiet.2016;116(12):1970-80.15. MangelsAR,MessinaV.Considerationsinplanningvegandiets:infants.JAmDietAssoc.2001;101(6):670-7.16. SandersTA.GrowthanddevelopmentofBritishveganchildren.AmJClinNutr.1988;48(3):822-5.17. MariottiF,GardnerCD.DietaryProteinandAminoAcidsinVegetarianDiets-AReview.Nutrients.2019;11(11):2661.18. PublicHealthEngland.GovernmentDietaryRecommendations-governmentrecommendationsforenergyandnutrientsformalesandfemalesaged1-18yearsand19+

years.London:PublicHealthEngland2016. Availablefrom:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/618167/government_dietary_recommendations.pdf

19. GardnerCD,HartleJC,GarrettRD,etal.MaximizingtheintersectionofhumanhealthandthehealthoftheenvironmentwithregardtotheamountandtypeofproteinproducedandconsumedintheUnitedStates.NutrRev.2019;77(4):197-215.

20. PublicHealthEngland.NationalDietandNutritionSurvey-resultsfromyears7and8(combined)oftherollingprogramme(2014/2015to(2015/2016).London;2018.Availablefrom:https://www.gov.uk/government/collections/national-diet-and-nutrition-survey

21. UauyR,DangourAD.FatandFattyAcidRequirementsandRecommendationsforInfantsof0–2YearsandChildrenof2–18Years.AnnNutrMetab.2009;55(1-3):76-96.22. TeMorengaL,MontezJM.Healtheffectsofsaturatedandtrans-fattyacidintakeinchildrenandadolescents:Systematicreviewandmeta-analysis.PLoSOne.2017;12(11):e0186672-e.23. DaveyGK,SpencerEA,ApplebyPN,etalEPIC–Oxford:lifestylecharacteristicsandnutrientintakesinacohortof33883meat-eatersand31546nonmeat-eatersinthe

UK.PublicHealthNutr.2003;6(3):259-68.24. CadeJE,BurleyVJ,GreenwoodDC.TheUKWomen’sCohortStudy:comparisonofvegetarians,fish-eatersandmeat-eaters.PublicHealthNutr.2004;7(7):871-8.25. LaneK,DerbyshireE,LiW,etal.BioavailabilityandPotentialUsesofVegetarianSourcesofOmega-3FattyAcids:AReviewoftheLiterature.CritRevFoodSciNutr.2014;54(5):572-9.26. SmitLA,MozaffarianD,WillettW.ReviewofFatandFattyAcidRequirementsandCriteriaforDevelopingDietaryGuidelines.AnnNutrMetab.2009;55(1-3):44-55.27. ForsythS,GautierS,SalemJrN.EstimatedDietaryIntakesofArachidonicAcidandDocosahexaenoicAcidinInfantsandYoungChildrenLivinginDevelopingCountries.

AnnNutrMetab.2016;69(1):64-74.28. SandersTAB.Plantcomparedwithmarinen–3fattyacideffectsoncardiovascularriskfactorsandoutcomes:whatistheverdict?AmJClinNutr.2014;100(suppl_1):453S-8S.29. GibsonRA,MuhlhauslerB,MakridesM.Conversionoflinoleicacidandalpha-linolenicacidtolong-chainpolyunsaturatedfattyacids(LCPUFAs),withafocuson

pregnancy,lactationandthefirst2yearsoflife.MaternChildNutr.2011;7(s2):17-26.30. BaroniL,GoggiS,BattaglinoR,Betal.VeganNutritionforMothersandChildren:PracticalToolsforHealthcareProviders.Nutrients.2018;11(1).31. AbediE,SahariMA.Long-chainpolyunsaturatedfattyacidsourcesandevaluationoftheirnutritionalandfunctionalproperties.FoodSciNutr.2014;2(5):443-63.32. MouritsenOG,DawczynskiC,DuelundL,etal.Onthehumanconsumptionoftheredseaweeddulse(Palmariapalmata(L.)WeberandMohr).JApplPhycol.2013;25(6):1777-91.33. ForestfieldSoftwareLtd.DietPlanversion7.00.56:McCanceandWiddowson’s7thsummaryeditionsofTheCompositionofFoodsandtherevisedCompositionofFoods

integrateddataset(CoFids)formingthecompleteUKNutrientDatabank.2019.34.GreerFR,KrebsNF.OptimizingBoneHealthandCalciumIntakesofInfants,Children,andAdolescents.Pediatrics.2006;117(2):578.35. ZhaoY,MartinBR,WeaverCM.CalciumBioavailabilityofCalciumCarbonateFortifiedSoymilkIsEquivalenttoCow’sMilkinYoungWomen.JNutr.2005;135(10):2379-82.36. ClarksonV.Theroleofplant-baseddrinksintheBritishandIrishdiet.2018.

Availablefrom:https://www.alpro.com/healthprofessional/uk/updates/2020/06/the-role-of-plant-based-drinks-in-the-british-and-irish-diet37. NorrisJ,MessinaV.VeganforLife.Boston:DaCapoPress;2011.38.WeaverCM,ProulxWR,HeaneyR.Choicesforachievingadequatedietarycalciumwithavegetariandiet.AmJClinNutr.1999;70(3):543s-8s.39. Denova-GutiérrezE,Méndez-SánchezL,Muñoz-AguirreP,etal.DietaryPatterns,BoneMineralDensity,andRiskofFractures:ASystematicReviewandMeta-Analysis.

Nutrients.2018;10(12):1922.40. MangelsAR.Bonenutrientsforvegetarians.AmJClinNutr.2014;100(suppl1):469S-75S.41. IguacelI,Miguel-BergesML,Gómez-BrutonA,etal.Veganism,vegetarianism,bonemineraldensity,andfracturerisk:asystematicreviewandmeta-analysis.NutrRev.2018;77(1):1-18.42. KnurickRJ,JohnstonSC,WherryJS,etal.ComparisonofCorrelatesofBoneMineralDensityinIndividualsAdheringtoLacto-Ovo,Vegan,orOmnivoreDiets:ACross-

SectionalInvestigation.Nutrients.2015;7(5).43.WorldHealthOrganisation.Breastfeedingrecommendations:WHO;Availablefrom:https://www.who.int/health-topics/breastfeeding#tab=tab_2.44. HojsakI,BraeggerC,BronskyJ,etal.ArsenicinRice:ACauseforConcern.JPediatrGastroenterolNutr.2015;60(1):142-545. HeatherRussell.TheVeganSociety.org[Internet].Pregnancyandbreastfeeding.2017

Availablefrom:https://www.vegansociety.com/resources/nutrition-and-health/life-stages/pregnancy-and-breastfeeding46. LarsonLM,PhiriKS,PasrichaSR.IronandCognitiveDevelopment:WhatIstheEvidence?AnnNutrMetab.2017;71(suppl3):25-38.47. GibsonRS,HeathA-LM,Szymlek-GayEA.Isironandzincnutritionaconcernforvegetarianinfantsandyoungchildreninindustrializedcountries?AmJClinNutr.

2014;100(suppl1):459S-68S.48. HuntJR,RougheadZK.Adaptationofironabsorptioninmenconsumingdietswithhighorlowironbioavailability.AmJClinNutr.2000;71(1):94-102.49. PawlakR,BellK.IronStatusofVegetarianChildren:AReviewofLiterature.AnnNutrMetab.2017;70(2):88-99.50. FosterM,SammanS.Chapterthree-Vegetariandietsacrossthelifecycle:impactonzincintakeandstatus.In:AdvancesinFoodandNutritionResearch[Internet].1stedition.

Volume74.ElsevierInc;2015:p93-131.Availablefrom:https://www.sciencedirect.com/science/article/pii/S104345261400004751. HuntJR,BeiseigelJM,JohnsonLK.Adaptationinhumanzincabsorptionasinfluencedbydietaryzincandbioavailability.AmJClinNutr.2008;87(5):1336-45.52. AnderssonM,KarumbunathanV,ZimmermannMB.Globaliodinestatusin2011andtrendsoverthepastdecade.JNutr.2012;142(4):744-50.53. BougaM,LeanMEJ,CombetE.Contemporarychallengestoiodinestatusandnutrition:theroleoffoods,dietaryrecommendations,fortificationandsupplementation.

ProcNutrSoc.2018;77(3):302-13.54. PublicHealthEngland.Independentreport:SACNStatementonIodineandHealth2014.[internet].

Availableat:https://www.gov.uk/government/publications/sacn-statement-on-iodine-and-health-201455. BathSC,CombetE,ScullyP,Zetal.Amulti-centrepilotstudyofiodinestatusinUKschoolchildren,aged8–10years.EurJNutr.2016;55(6):2001-9.56. BathSC,HillS,InfanteHG,etal.Iodineconcentrationofmilk-alternativedrinksavailableintheUKincomparisonwithcows’milk.BrJNutr.2017;118(7):525-32.57. WintherKH,RaymanMP,BonnemaSJ,etal.Seleniuminthyroiddisorders-essentialknowledgeforclinicians.NatRevEndocrinol.2020;16(3):165-76.58. GreenR,AllenLH,Bjørke-MonsenA-L,etal.VitaminB12deficiency.NatRevDisPrimers.2017;3(1):17040.59. SmithAD,WarrenMJ,RefsumH.Chaptersix-VitaminB12.In:AdvancesinFoodandNutritionResearch-Newresearchanddedvelopmentsofwater-soluble

vitamins[Internet].1stedition.Volume83.ElsevierInc;2018:p215-79.60. PawlakR,LesterSE,BabatundeT.TheprevalenceofcobalamindeficiencyamongvegetariansassessedbyserumvitaminB12:areviewofliterature.EurJClinNutr.2014;68(5):541-8.61. CardwellG,BornmanJF,JamesAP,etal.AReviewofMushroomsasaPotentialSourceofDietaryVitaminD.Nutrients.2018;10(10):1498.62. NHS.VitaminD:NHS;2017Availablefrom:https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-d/63. ZeiselSH,daCostaK-A.Choline:anessentialnutrientforpublichealth.NutrRev.2009;67(11):615-23.64. ZeiselSH.NutritionalImportanceofCholineforBrainDevelopment.JAmCollNutr.2004;23(sup6):621S-6S.65. TheVeganSociety.Statementonmediareportsaboutcholineandvegandiets30thAugust2019.

Availablefrom:https://www.vegansociety.com/whats-new/news/statement-media-reports-about-choline-and-vegan-diets

ThisfactsheetwassponsoredbyaneducationgrantfromAlproUKScience&Nutritionteam.Published:July2020Reviewdate:July2023

FOR HEALTH PROFESSIONAL USE ONLY 12