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Archives de Pédiatrie xxx (2020) xxx–xxx

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Editorial

Vegetarian diet in children and adolescents: A health benefit?

Vegetarians exclude all meat from their diet. Most vegetarians study site. After multiple adjustments (sex, age, physical
eat eggs and dairy products, and are called ‘‘ovo-lacto-vegetarians’’ activities, and education), vegetarians had significantly lower
whereas vegans do not eat or use any animal products. Flexitarians abnormal anthropometric parameters (waist circumference >
exclude processed meat, and eat small amounts of red meat and 90 cm for men, and > 80 cm for women; BMI > 27 kg/m2,
moderate amounts of other animal-source foods. This article P < 0.0001 for each parameter) [9]. In a cross-sectional study
focuses on vegetarian diets in industrialized countries and does not of 55,459 Swedish women, the prevalence of overweight or
address vegan or flexitarian diets in children. obesity (BMI  25) was 40% among omnivores and 25% among
Over the past few decades, vegetarian diets have become lacto-vegetarians [10]. In multivariate, adjusted logistic
increasingly popular in industrialized countries, and have been regression analyses, Swedish lactovegetarian women had a
widely followed in Asia even longer. Vegetarian diets are lower probability of being overweight or obese (odds ratio
consumed by about 5% of the adult population in industrialized [OR] = 0.54; 95% confidence interval [CI]: 0.35, 0.85). In
countries, with a prevalence ranging from 0.3 to 7% in France, children, most studies demonstrate that the linear growth
depending on the survey [1,2]. Since children’s diets are largely of vegetarian and vegan children is not impaired compared
driven by their parents, the prevalence of vegetarian diets during with that of omnivorous children. Furthermore, the prevention
childhood also seems to be on the rise. In France, it has been of obesity by a vegetarian diet is advocated by some authors
estimated to reach 0.4% in children up to 17 years of age, compared because the weight and BMI of vegetarian children was
with 1.8% in adults [2]. slightly below the reference range (weight 4–11 kg in
The risk of nutritional deficiencies in children consuming a children 10–17 years old, BMI below the 50th percentile) and/
vegetarian diet has been investigated and was an incentive for or their body fat mass was significantly lower than in the
establishing nutritional guidelines [3,4]. If the vegetarian diet is control group [11,12].
not adequately balanced by diversity, combining for instance, A decrease in cardiovascular risk seems to be associated with a
cereals with legumes, milk with eggs, nutritional deficiency may vegetarian diet in adults. In the aforementioned Taiwanese cohort,
ensue, the main one being iron deficiency, especially in adolescent each additional year of a lacto-vegetarian diet was associated with
girls, infants, and toddlers. The risk involves, to a lesser extent, an 8% lower risk of elevated systolic blood pressure (SBP), and a 7%
calcium, vitamin D, some essential amino acids, and n-3 fatty acids decrease of elevated glucose and of abnormal high-density
[5]. Vitamin B12 is found only in meat and animals products, and is lipoprotein (HDL), compared with non-vegetarians [9]. The lipid
thus a critical nutrient to be considered in vegan diets that exclude profile of vegetarians suggests a lower cardiovascular risk. In a
all animal food. Although most available studies on lacto-ovo- study adjusted for age, alcohol, and physical activity, serum total
vegetarians indicate that vitamin B12 levels are within the normal cholesterol and apolipoprotein-B concentrations were lower in
range [6,7], it is important to stress that vegetarians can meet the vegetarians compared with meat-eaters. The largest proportion of
nutritional need for vitamin B12 only if a sufficient amount of dairy the differences observed in serum lipid concentrations was
products and eggs are consumed regularly such as described in explained by the diet, with only a small proportion of differences
adults [8]. In adults, the literature suggests that a vegetarian diet being accounted for by BMI [13]. In the European Prospective
confers an overall benefit on cardio-metabolic health, a perspective Investigation into Cancer and Nutrition (EPIC) study, including
raised from cross-sectional, cohort follow-up studies, as well as men and women, vegetarians had a 32% lower risk of developing
from randomized intervention trials. Cardiovascular diseases are coronary heart disease compared with non-vegetarians [14]. In a
the main cause of mortality worldwide, and are strongly associated meta-analysis of eight studies including a total of 183,321 adults, a
with obesity and type 2 diabetes (T2D). The prevalence of obesity vegetarian diet was associated with a reduced risk of ischemic
and T2D increases also in childhood, and hence the question arises heart disease (relative risk [RR] = 0.60, 95% CI: 0.43, 0.80 vs.
of the potentially long-term benefit of a vegetarian diet for RR = 0.84, 95% CI: 0.74, 0.96) in both men and women, and of
children. cerebrovascular disease (RR = 0.71, 95% CI: 0.41, 1.20 vs. RR = 1.05,
Regardless of genetic factors, obesity is largely associated 95% CI: 0.89, 1.24) in men, with no significant decrease in mortality
with the level of consumption of animal products. A cohort of [15]. A recent meta-analysis of 86 cross-sectional and 10 cohort
Taiwanese adults followed up from 1994 to 2008 compared prospective studies reported a significant 25% risk reduction in the
4,415 lacto-ovo-vegetarians, 1855 lacto-vegetarians, and incidence and/or mortality from ischemic heart disease in
1913 vegans with non-vegetarians matched for age, sex, and vegetarians compared with non-vegetarians [16]. These beneficial

https://doi.org/10.1016/j.arcped.2020.03.010
0929-693X/ C 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Peretti N, et al. Vegetarian diet in children and adolescents: A health benefit?. Archives de Pédiatrie
(2020), https://doi.org/10.1016/j.arcped.2020.03.010
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2 Editorial / Archives de Pédiatrie xxx (2020) xxx–xxx

cardiovascular effects need to be weighed against a recent heterogeneous, with small sample sizes. Theoretically, a vegetar-
publication of the EPIC-Oxford prospective study [17], which ian diet exposes the individual to a risk of nutritional deficiency,
classified 48,188 participants without any history of cardiovascu- particularly in infants, toddlers, adolescent girls, and young
lar disease according to their diet: meat-eaters (n = 24,428), fish- pregnant women. Still, in the long run, such a diet might reduce
eaters (n = 7,506), and vegetarians including vegans (n = 16,254). the cardio-metabolic risk. This benefit has not yet been
After 18 years of follow-up, and adjustment for sociodemographic demonstrated in children, but the positive results accumulating
and lifestyle confounders, fish-eaters and vegetarians had lower for adults are encouraging and underline the need for studies
rates of ischemic heart disease than meat-eaters (13% and 22%, exploring this specific endpoint in children. The consumption of
respectively, P < 0.001). However, vegetarians had 20% higher reduced amounts of red meat, mainly with replacement by
rates of stroke, mostly due to a higher rate of hemorrhagic stroke poultry and fish, also called ‘‘flexitarianism’’ might be an
[17]. In children, no study has been conducted on the role of diet on interesting approach when seeking to reduce the risk of
cardiovascular risk. cardiovascular diseases without increasing the risk of nutritional
Multiple nutritional factors may account for the beneficial deficiency.
cardio-metabolic effects of plant-based diets: lower energy
Disclosure of interest
intake, increased intake of fiber, reduced intake of saturated
fat and cholesterol, higher intake of plant sterols, higher The authors declare that they have no competing interest.
intake of polyunsaturated and monounsaturated fatty acids,
increased intake of antioxidants and of some other micronu-
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Please cite this article in press as: Peretti N, et al. Vegetarian diet in children and adolescents: A health benefit?. Archives de Pédiatrie
(2020), https://doi.org/10.1016/j.arcped.2020.03.010
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N. Perettia,*, D. Darmaunb, J.P. Chouraquic, A. Bocquetd, A. Briende, i

Université de Tours, 37000 Tours, France
F. Feilletf, M.L. Frelutg, D. Guimberh, R. Hankardi, A. Lapillonnej, j
Université Paris Descartes, 75006 Paris, France
J.C. Rozéb, U. Simeonie, D. Turckh, C. Dupontj, Comité de Nutrition de la k
Société Française de Pédiatrie, hôpital Necker Carré Necker, 149, rue de
Société Française de Pédiatrie (CNSFP)k Sèvres, 75015 Paris, France
a
Université de Lyon, Hospices Civils de Lyon, CaRMEN, 69000 Lyon,
France *Corresponding author
b
Université Nantes-Atlantique, 44300 Nantes, France
c
Université of Lausanne, 1011 Lausanne, Switzerland
d
Université de Franche-Comté, 25000 Besançon, France Received 30 October 2019
e
Institut de recherche pour le développement, 13002 Marseille, France Received in revised form 3 February 2020
f
Université de Lorraine, 54000 Nancy, France Accepted 28 March 2020
g
Albi, 81000 France Available online xxx
h
Université de Lille, 59000 Lille, France

Please cite this article in press as: Peretti N, et al. Vegetarian diet in children and adolescents: A health benefit?. Archives de Pédiatrie
(2020), https://doi.org/10.1016/j.arcped.2020.03.010