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Joan M. O'Connel, MHS, Michael J. Dibley, MUSS, Janet Sierra, RN, Barbara Wallace, PhD, James S. Marks, MD. MPH, and Ray Yip, MD, MPH
From the DMsion of Nsidtlon, Center for Health Promotion and Echicatlan, Centers for Disease Control. Atlanta. Georgia. and Th Farm, & merfown~ Tennessee
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AOSTRACT. To
examine the effects of a vegetarian diet on child
growth,
height and weight data of 404 vegetarian
children
aged
4
months
to
10
years who lived in a coilec tive community in
Tennessee were studied. Heigl4 for age, weight for age, and weight for
height were compared
with the
US growth reference. Birth weights, infant feed ing pattern, and parental
heights
were
also evaluated in relation to growth. Most
of
the height for age, weight for age,
and weight
for
height
(n
— 833) were within
the
25th and 75th percentiles of the US growth reference. The mean height
for
age and weight for age, however, were slightly
Ieee
than the median of~he reference population. Fordifferent age groups,
the
mean height ranged from 0.2 to 2.1 cm and
the
mean weight
ranged
from 0.1 to 11 kg
lees than the reference mediw. The largest height difference was observed
at 1 to 3 years
of U*u~bi partly the r~ult of intrinsic irregularities in the US growth
referesce at those ages. Upr4~ yeaw4 ags, chil dren $~om The Farm averaged
~7 cm and 1.1 kg Ieee than the reference median, representing only (Li
and 0.3 SD from the reference. Thus, these children hew adequate attained
growth, even though It was modestly lees than that of the reference population.
Pediatrics
196SS4~475-
481;
vegetarian
diet, growth lwigk*~ wuigh*~ birth weghL
To examine the effect of a vegetarian diet on child growth, we studied height and weight of a group of infant and vegetarian children ages 4 months to 10 years. The growth of children consum ing vegetarian diets was of interest because of the number of children consuming such diets and the special dietary needs of children during periods of rapid growth. It has been report~.' that approxi mately4 percent of adults in the United States consume vegetarian diets.' Worldwide, many ethnic rcieved f& publication Jun 13. 1966; accepted Oct 11, INS. Reprint requests to (R.Y.) Centers for Disease Control, Division ~f Nutrition, Mall stop A-41. Atlanta. GA 30333. PEDIATRICS (ISSN 0031 4006). Copyright 0 1966 b~ the American Academy of Pediatrics. |
groups have followed vegetarian diets for centuries. The reatons people adhere to these diets include religious, ethical, political, and health beliefs and economic constraints)' Although several
investigators have addressed the issue of the growth of vegetarian children,
most of these studies were based on relatively sn~aIl numbers (~O or fewer)
of preschool-aged child Aside from the small numbers, drawing
The types of vegetarian diets consumed by the studied populations must be considered when inter preting results of the growth studies. The extent to which vegetarian diets meet dietary recommenda tions varies patly"~ because the term vegetarian refers to a briad dietary group of people who avoid meat an their diets. It is estimated that 90% of the vegetarians ~in the United States are lacto-ovo vegetarians, who include milk and dairy products in their diets.' Vegans are vegetarians who avoid all animal products, including milk and dairy prod ucts. There exist additional types of vegetarian diets, some of which involve further restrictions on dietary intake. Although it may be more difficult to provide adequate diets for children with restricted protein intake compared with childrpn who have no restrictions, all necessary nutrients, including vitamins B,3 and D~calcium, iron, andzinc, can be provided with careful plannin'~~. To examine the effect of a vegetarian diet on child growth, in this study we describe the growth of vegan children who lived in a collective commu nity in Tennessee. In this community, the children |
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followed a similar diet and many received vitamin and mineral supplements. Because growth data were collected annually, there was available for study a relatively large number of measurements of children through ten years of age. In addition, we evaluated birth weights, parental heights, and breast-feeding patterns in relation to growth. SUBJECTS The children lived in a community called The Farm, located in rural central Tennessee. The Farm was established in 1971 as a collective community that met many of its own needs concerning health care, education, housing, and, to some extent, food production. The socioeconomic level of the popu lation of The Farm was unusual in that the com munity members were highly educated, but they generated a comparatively small income from sources outside the community. The average family income was below the federal poverty level for many years but gradually increased over time. The ma jority of the children were white and had lived on The Farm since birth. The Farm community was generally well in formed regarding issues related to vegetarianism, including complementing different protein sources, for example, grains and legumes and nonaniznal sources of vitamins and minerals. Until 1983, the population followed a vegan diet, with soybeans being their primary source of protein. Supplements of vitamins A, D, and B,2 were added to the soy milk produced on The Farm. Nutritional yeast (containing vitamin B3) and other vitamin and mineral supplements were also used. In the fail of 1983, some members of the community Intioduced eggs and dairy products into their diets. METhODS 1964 SpecIal Growth Survey In the spring of 1984, we collected height and weight data of 144 children residing on The Farm. We obtained written parental consent from more than 95% of the families. In addition, a few children were excluded from the study because of ethnic, dietary, and health backgrounds that differed from the other children raised there or because they had a chronic illness known to affect their growth. Body length to the nearest millimeter was deter mined with a measuring board for children younger than 2 years of age; standing height was measured for older children. We measured their weight to the nearest 28 g (1 oz) with a Detecto pediatric balance for children less than 2 years of age and to the nearest 112 g (quarter pound) with a beam balance |
for children older than 2 years of age. At the same time, a subset of the population was measured on separate days to validate measurement techniques; no systematic errors were found. The Farm's Annual Growth Surveys In addition to the data collected in the 1984 special growth survey, we included growth data from the annual growth surveys of The Farm in our ijialyses. Height and weight data from four cross- sectional surveys performed in the years 1980 to 1983 were included. ETHOS, a Farm research or ganization, and The Farm's health clinic conducted the annual surveys because members of The Farm con~munity were interested in the physical growth of their children. The methods used in the 1980 to 1963 growth surveys were not subject to the same rigor as the 1984 special growth survey. We evaluated several characteristics of the earlier surveys to determine the reliability of those data and to determine the suitability of combining the data from The Farm annual, surveys with the data from the 1984 survey for cross sectional analyses. To determine the reliability of the data collected in each of the separate cross-sectional surveys, we compared height for age, weight for age, and weight for height data between the 1984 special survey and the annual growth surveys of The Farm. No signif icant differences were found. Because the surveys were conducted at the same time of year, children with multiple measurements in the data set were not represented more than once in the age group breakdowns by year. We found no significant dif ibrences in growth, dietary, or demographic data between children who had multiple measurements with those who had only one measurement and between children measured in 1984 and children measured in the earlier Farm surveys. Based on these analyses, all survey data from 1980 to 1984 were combined into one data set. Dietary, Health, and Demographic Data To supplement the growth data, we extracted self-reported information from two health surveys conducted by ETHOS on The Farm in 1980 and 1983. The information included birth date, dietary history, birth weight, parental height, breast-feed ing patterns, vitamins and mineral supplementa tion, and place of birth. We also obtained disease histories for each child to determine whether any children had disorders of nutritional significance that might cause their exclusion from the study. We evaluated the reliability of the data reported in the 1980 and 1983 health surveys. If data existed |
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for a child from both surveys, the information was cross-checked for consistency of reporting. No sig nificant differences were found in data reported in 1980 and 1983. We collected recent dietary histories in 1984 to update past survey data. The dietary data provided in the health surveys were modified food frequencies" by year and in cluded the mother's diet during pregnancy. We classified the children as omnivore (nonvegetarian), lacto-ovovegetarian, or vegan for each year based on the amount of eggs, dairy products, and meats reported in their diets. We analyzed growth in relation to the following diet claasifications the mother's diet during pregnancy, the child's diet from birth to age 2 years, and the child's diet during 1984. We were also interestedin whether or not the child had followed a vegan diet since birth. For each child, we averaged the heights of the mother and father for a mean parental heighL~-~ We then compared The Farm mean with the aver age of the mean heights of 25-year-old men and. women from a US reference population.TM StatisUcal Procedures We compared weight and height measurements of the children to the National Center for Health Statistics/Centers for Disease Conttol growtk ref erence population by age and sex. A growth per centile rank was calculated for each set of measure ments for three growth indicators: height for age, weight for age, and weight for height.~ We regarded a percentile value greater than the 95th percentile or less than the 5th percentile as abnormal growth. For each set of measurements, a standard deviation value, Z score, was calculated for each growth in dicator based on the Vowth reference; a Z score of + 1.0 represented 1 SD greater than the mean of the reference population.~ The 2 scores were then compared by age group with the reference median (presumed mean). We compared the mean 2 scores of the growth data after stratifying them by mean parental height, birth weight, sex, and diet. We used Student's tests and analysis of covariance to determine the significance of these variables in relation to growth. RESULTS We evaluated anthropometric data and health data for 404 white children, who had a total of 833 measurements. The mean age at the time of meas urement (n — 833) was 716 months 7.7% of the children were less than 2 years of age; 36.7% were 2 to 5 years of age, and 54.7% were 6 to 10 years of age. In Table 1, additional social, demographic, and dietary information are provided. The mean birth |
TASLE 1. Social, Demographic, and Dietary Data of The Farm Children Item No (%) of Children Birth data Born on The Farm304 (82) Lived on The Farm by 2 y of age339 (91)339(91) Birth wt <2500 gt18 (5) Infant feeding patterns Breaat-fed$335 (95) Solid toods started by 6 mO of age5121 (80) Other dietary information Mother's diet during pregnancy Vegan 281 (75) Lacta-ovovegetarian 64 (17) Omnivore 28 (8) Child's diet Birth.-! yr of age Vegan 288(83) Lacto-ovovegetarian 49 (14) Omnivore 11(3) Vegan since birth 253 (73) Vitamin/mineral supplementation 263 (76) Regular yeast supplementation 139 (87) · * Based on available data. t Mean birth weight 3389 g. ~ Mean number of months breast-fed was 12 months. I Mean age when solid foods were introduced was 5 months. NCHS |
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weight of The Farm children was 3389 ~ the per centage of low birth weight infants (<2500 g) was 5%. These statistics were similar to birth weight statistics for well-educated US white women~ The mean parental height of The Farm children was 172.6 cm, compared with 170.4 cm, the average of the mean heights of 25-year-old men and women from the reference population. Height for age, weight for age, and weight for height 2 score data are depicted in Figs 1 to 6 for ages 2 to 10 years. Overall, the distributions of the height for age, weight for age, and weight for height of children from The Farm were between the 25th and 75th percentiles of those of the reference pop ulation for most ages. In Table 2, the differences between The Farm growth data and the reference population growth data are shown (in centimeters and kilograms) for all ages. The mean Z scores of The Farm height for age and weight for age data were less than the median (presumed mean) of t~e reference population for most ages. In general, the differences In height for age Z score between The Farm and the reference population are statistically significant for ages 5 years and younger. The great est differences were seen at ages 1 to 3 years, with a decrem at older ages. However, the height for age differences are not significant for ages 5 years and older. Overall, data of 8% of The Farm children Fig 2 Height for age of boys from The Farm relative to National Center for Health Statistics (NCHS)/Centers for Disease Control percentilsa. |
Age (years)
FIg~ 4. Weight for age of boys from The Farm relative to ational Center for Health Statistics (NCHS)/Centegs for Disease Control percentiles.
were less than the 5th percentile of the height for age referencs. The Farm weight for age data were slightly lees than those of the reference population for most ages. The weight for age 2 scores were only statis- |
<<<478
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tically significant at ages 9 and 10 years. Of The Farm children, 3% were less than the 5th percentile of the weight for age reference. The Farm weight for height data were slightly greater than those of the reference population for most ages. The differ ences in weight for height were statistically signif icant at ages 5 and younger and at age 9 years. Of The Farm children, 1% were classified as small weight for height (weight for height < 5th percent ile) and 3% as large weight for height (weight for height> 95th percentile). A positive association
existed between mean pa- rental height and the height for age Z scores
(P
<
.0001).
The differen0 in height for age between children from The Farm and the
reference popula tion children decreased with age (P ~ .0001) We
FIg 5. Weight for height of girls from The Farm relative to National Center for Health Statistics (NCHS)/Centezs for Disease Control percentiles. |
stratified the data by sex, diet, and birth weight after controlling for age and parental height. The growth patterns were similar for the different strat ifications. DISCUSSION \In this study,
the growth of a group of children raised with a relatively strict form
of vegetarian diet (vegan) was similar to that of the reference population,
even though the mean height for age and weight for age were modestly less
than the median of the reference. The differences between The Farm and
the reference population were greater for the height for age indicator
than for the weight for age indic,tor,with the greater differences in height
for age between 1 and 3 years of age. By
PIg 6. Weight
for height of boys from The Farm relative
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| TABLE
2. Differences in Height and Weight
National Center for Health Statistics/Centers Population (a — 833) |
for Disease Control |
Growth Reference |
|
| Age
|
Height
|
Wt | |
| Farm
Mean Height for Age Z Score
Difference
|
Difference
From
Reference (kg) |
Farm
Mean Wt
(or Age Z Score |
|
| ci
—0.24
1—2 —2.01 3—4 —2.06 5—B -1.76 7-8 —0.69 9-10 —0.67 |
-0.09
—0.67 —0.55 -0.39 —0.13 —0.11 |
-0.00
—0.10 —0.20 -0.37 —0.16 —1.11 |
-0.10
—0.09 —0.13 -0.18 —0.06 —0.27 |
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10 years of age, the vegetarian children averaged within 0.7 cm and 1.1 kg of the reference popula tion, representing 0.1 and 0.3 SD from the refer ence. The Farm children experienced normal birth weights, a finding previously reported for The Farm population by Carter et a14' and for other vegetarian populations. "'~ In past studies,'3~ the growth of vegetarian pre school children has been shown to be somewhat lower than that of reference populations yet within normal growth limits, with length being more af fected than weighL However, in some of the past studies,'~" a greater proportion of children was shown with small height for age and weight for age (<5th percentile o( the reference). In other stud ies,"~ statistically significant growth differences were also described among certain age groups, such as weaning age, and for children with very restricted diets. Weight for height data'5 have been described as being within normal expectations. Anthropo metric studies of adult vegetarians, however, have shown no significant differences in the heights and weights of the vegetarians when compared with control subjecta.UI Although, at younger ages, The Farm children's height for age Z scores were significantly less than those of the growth reference population, there are a few possible explanations for the smaller height for age status. The first possibility involves the introduction of solid foods into a child's diet. Se', eral researchers"'~ have shown significant differ ences in weights and heights at weaning age for vegetarian children when they were compared with reference populations. Weaning foods in some vegetarian diets may have low caloric densities; therefore, some vegetarian children may not con sume enough calories for normal growth during weaning.'1 The age at which solid foods are intro duced has been also noted as a factor influencing growth. For this study population, appropriate solid foods were introduced in the diets of most of The Farm children by 6 months of age. However, be- cause of the low income level of the residents of The Farm in the early years of its existence, the variety of foods available during certain seasons was limited and may have adversely affected the diets of children who were 2 years of age or younger at that time. The second possible explanation for the growth variations between the study population and the reference population is that the reference popula tion consisted largely of bottle-fed infants with early supplementation, whereas The Farm infants were breast-fed, with solid foods introduced at an averaz~apof5 months. No growth reference is 'I~hlly for breast-fed children- Avail- |
able data suggest,'~ however, that breast-fed in fants may have somewhat slower growth patterns when compared with bottle-fed infants with early supplementation. The third, and perhaps the most important, pos sible explanation for the differences between The Farm and the reference population involves the intrinsic irregularities in the current reference growth curves. The National Center for Health Statistica/Centers for Disease Control reference consists of two populations (the Fels data of chil dren from Yellow Springs, Ohio, for ages 0 to 24 months and the US representative data for 2 years of age ai~d older), with noted differences in height between, the two populations,"4' If the reference population were free from these irregularities, the observed differences in height for age between the study and the reference populations would be smaller at the younger ages. In summary, the
growth of The Farm children even though modestly less than that of the
refer ence population, showed no evidence of marked abnormality. Part of
the growth differences ob served at younger ages may be related
to the limi tations of the current growth reference. According to
the
results of this study, with attention to wean ing foods and nutrient intake,
a group of children raised with a relatively strict vegetarian diet (vegan)
can achieve adequate growth.
ACKNOWLEDGMENT We thank The Farm community, ETHOS, and the Ruth Mott Fund for their assistance is the sti4 w-~u Roper Center for Public Opinion Research, Unaversaty of Connecticut 2. Ophir 0, Peer 0. Oiled J, Slum M, Auirem L Low blood preseure in vegetarian, the poesible role of potassium. Am J Clii. Nag,. 196337:7*.762 3. Armatrong B, Ven Merwyk AJ, Coatas H. Blood pressure in Seventh-Day Adventist vegetarians. Am J. EpidemioL 1977;10L-444—44 4. HardIng MG, Stare FJ. Nutritional studies of vegetarians. 2. Dletaay and serum levels of cholesteroL Am J Cilia Nutr. 7. Dwyer JT. ICandel RI. Mayer LDVH, Mayer J. The new vegetarians. JAm Diet Auuoc. 1974;64:376-352 6. Bachrsch s, FIscher J, Parks J. An outbreak of Vitamin D de&iency ~cke4a In a mieceptible population. Pediot,iCL 197%64571-.877 9. Robeon JRX, Konlande JR. Larkin F et aL Zen mac biotic dietary problems In lntkU9. Pediatics. 1974,53:326-329 |
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tO. Higginbouom MC. Sweetman L. Nyhan WL A cyndrome of methylmalonic aciduria. homocystinuria. megaloblastac anemia and neurologic abnormalities in e vitamin BR! deficient breast fed infant of a strict vegetarian. N Eiagl J Med. 1975;299:317-323 11. Zmora B, Gorodiacher B, Bar-Ziu J. Multiple nutritional deficiencies in infants from a strict vegetarian community. Am J Di' Claa&t. 197%133:141-144 32. ShuIl MW. Valadian I, Reed RB. et al. Seasonal variations in preschool vegetarian children's growth velocities. Am J Ciii. Nutr. 1975;33:1—2 33. Dwyer JT, Andrew EM. Valadian I. Reed RB. Size, obesity, and leanness in vegetarian preschool children. J Am Diet Aasoc. 1980,7:434-439 14. Fulton JR. Huttom CW. Stitt RK. Preschool vegetarian children. JAm Diet Macc. 1980,76:360-365 15. Shinwell ED, Gorodiacher R. Totally vegetarian diets and infant nutrition. Pedialncs. 1982;70.582—686 16 Dwyer JT. Andrew EM, Berkey C. at al. Growth in vegetarian preschool children using the JenuBayley curve fitting technique. Am J Cli,. Nut,. 198337~.815436 17. Shull MW. Reed RB. Valadian I. Palombo B, Thorns H, Dwyer IF. Velocities of growth in vegetarian preschool children. Pediatrics. I977;60~.410-417 18. Sandet TAB. Purves R. An anthropometric and dietary assessment of the nutritional status of vegan preschool children. J Human Nutr. 1981;36:349-357 19. van Staveren WA. Dbuyvett.r JH. Dons A, et aL Food consumption and height/weight status of Dutch preschool children on alternative diets. JAm Dies Assoc. 1966;86.1579- 1584 20. Dwyer JT, Diet: NH. Andrews EM. Suskind RM. Nutri tional status of vegetarian children. Am J Clii. Nutr 1962.35:204-216 21. Faber M, Gojawa B. Benade AJ. Labadarios D. Anthropo metric measurements, dietary intake and biochemical data of South African lacto-ovovegetarians. S Air Med J. 198689~.733—738 22. Brown AT. Bergan JG. The dietary status of new vegetar Inns. JAm Diet Macc. 1975;67:455-459 23. DwyerJT. Diets WH. Ham G, Suskind R. Riak of nutritional rickets among vegetarian children. Am J Die Cit itL 197%133:134-140 24. Barbed BF. Peterson U. Nutritional status of lacto-ovo vegetarian Trappist monks. Research. 197s,Th250-264 26. Immennan AM. Vitamin B,5 status on a vegetarian diet. World Rev Nu*r DieL 19B1;37.38-54 26. Young YB, Puig M, Qusiros B, at aL Evaluation of the protein quality of an isolated soy protein In young men.~ relative nutrition requirements and effect of methionine supplementation. Am J Clii. Nutr. 196430:16-24 27. Helman AD. Damton-Hill L Vitamin and iron status in new |
vegetarians. Am J Cii,. Nut,. 3967;4k715-760 26. Christoffel K. A pediatric perspective on vegetarian nutri tion. Cli,. PrdipAr. 1961.20:632-643 29. Krey SB. Alternative dietary lifestyles. Prim Core. 19829i96-E08 30. MacLean WC, Graham (3(3. Vegetarianism in children. Am J Dim Child. 1960,134:513-519 31. Register UD. Sonnenberg IM. The vegetarian diet. J Am Diet Asaoc. 1973;62.253-251 32. Vyhmeister lB. Register UD. Sonnenberg IM. Safe vegetar ian dicta for children. Pediaar Cliaa North Am. 197724:203- 210 33 Levin N, Rattan J. Gilat T. Mineral intake and blood levels in vegetarians. IsiJ Med 3d 1966Z:1O6-IOS 34. Mueller WH. Parent-chili coerelations for stature and weight among school aged children: a review of 24 studies. Hum Bid 1970,4&379—397 35. Bias. JH, Roche A?. Thisees D. Moose WM. Parent- specific adjustments for evaluetioe of recumbent length and stature of children. Pedietrns. 1965;75304-312 36. Notion~ Center toe Health Statistics Gn,uth Curves br Children. Bith-18 Years. United Slates. Byattaville. MD: US Dept of Health, Education, and Welfare publication (PHS)78-1650, November 1977 37. Hamili PVV. Drird TA. Johnson CL. Reed RB, Roche A?. Moore WM. Physical growth: National Center for Health Statistics percentiles. Am J Clii. Nut,. 1979,32.407-629 36. Waterlow JC. Buzina B, Keller W. Lane JM. Nicheman MZ. Tanner JM. The presentation and tue of hei~ht and weight data for comparing the nutritional status of groups of children under the speC 10 year.. Bull WHO. 1977~.55:489—495 39. Delgado H. Fajardo LF, Klein B, et aL Urn and interpreta tion of anthroposnetric indicators of nutritional status. Basil WHO. 1986;64.929-941 40 National Center 1.' Health Statistic.. Vital Statistic. ef the United States 1976: Volume I: Natelit.~ Hyattaville. MD US Dept of Health and Human Servlces 1960 41. Carter JP. Furman T. Butcheson HR. Preeclampein and reproductive performance in a community of vegans. South Med J. 196780:692-697 43.~u~j~Buthwe~ht doubling Uzer. a fresh 43. Taits LS. Infantile overnutuition among estificially fed in- fasts in the Sheffield region. Br MedJ. 1971;1:315-316 44. Dibley MH. Goldaby JB. Stasling N. Trowbeidge FL. De velopment of normalized curves for the international growth reference: historical and technical considerations. Am J Cli,. Nut,. 1967;4&736—748 45. Dibley MB. Steeling N, Niebieg P. Trowbeidge FL Inter pretation of Z-Score anthropometric Indicators derived from the international growth reference. Am J CNn Nu*r. 1967;46:749—762 |