A vegan Facebook group has encouraged the reporting of a registered dietician to her licensing body because of a comment she made about a vegan diet for children: “it’s not safe and kids have died.”
This week’s note is based on a true story. When I was at the BMJ/SwissRe conference in Zurich in June 2018 I met a dietician called Diana Rodgers (Ref 1). Diana lives on a working organic farm, raising vegetables and pasture-based meats, west of Boston, US, and she describes herself as a real food practitioner. She is also an author, film maker, international speaker and a board member of the organizations “Animal Welfare Approved” and the “Savory Institute”. She hosts The Sustainable Dish Podcast and I appeared on her podcast after meeting her in Zurich (Ref 2). I declare an interest therefore, that Diana is my kind of person. Having said this, it has been noticed that I have said things with which people I admire would not agree (e.g. I don’t rave about olive oil or worry about nitrates in bacon). Hence I will follow the evidence and if I disagree with Diana (or anyone else I admire) on something, I won’t hesitate to say so.
Diana posted a comment on Facebook as follows: “I don’t care if an adult wants to be vegan. I do care if they make their kids eat this way because it’s not safe and kids have died.”
A screenshot of her comment was taken by the head of a vegan activist Facebook page, with over 8,000 members, with a link on how to report her to the state licensing board. This is a serious process to be subjected to and one that could result in the loss of Diana’s license to practise as a dietitian/nutritionist (Ref 3).
In 2012, the American Dietetic Association changed its name to the Academy of Nutrition and Dietetics (AND) (how arrogant is “the Academy”?!) (Ref 4). You might think that Diana’s own professional body would be on her side vs. a vegan group trying to cause her harm. However, this is not the case. The AND position is as follows: “The Academy of Nutrition and Dietetics and American Academy of Pediatrics agree: Well-planned vegetarian and vegan eating patterns are healthy for infants and toddlers” (Ref 5).
The AND position dates back to when it was the American Dietetic Association. A position statement was published in 2009 (Ref 6). There is some ambiguity. The position statement on the first page of the paper reports: “It is the position of the American Dietetic Association that appropriately planned vegetarian diets, including total vegetarian or vegan diets, are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases. Well-planned vegetarian diets are appropriate for individuals during all stages of the lifecycle, including pregnancy, lactation, infancy, childhood, and adolescence, and for athletes.” The first sentence includes “vegan”; the second sentence doesn’t. However, P1269 of the PDF of the paper reports: “Well-planned vegan, lacto-vegetarian, and lacto-ovo-vegetarian diets are appropriate for all stages of the life cycle, including pregnancy and lactation.”
The British Dietetic Association position is remarkably similar (Ref 7). In an August 2017 statement the BDA reported that: “a balanced vegan diet can be enjoyed by children and adults, including during pregnancy and breastfeeding, if the nutritional intake is well-planned.” (Enjoyed is an interesting word – is it safe or not?)
The German Nutrition Society (DGE) firmly rejects the positions taken by the UK and the US. Their position is: “With a pure plant-based diet, it is difficult or impossible to attain an adequate supply of some nutrients. The DGE does not recommend a vegan diet for pregnant women, lactating women, infants, children or adolescents” (Ref 8) (my emphasis). The Swiss also disagree with the AND and BDA positions. Their 2018 report states: “Children and pregnant women are advised against adopting a vegan diet” (Ref 9).
The AND position statement on their website (Ref 5) follows up the “well-planned” caveat with a list of nutrients that must be paid “close attention to.” These include: B12; Vitamin D; calcium; Iron and protein. The advice next to every one of these nutrients contains the words “supplement” and/or “fortified foods.” i.e. babies and toddlers consuming a vegan diet must take artificial nutrients, either alone or added to foods.
Immediately Diana is right. By definition, any diet that requires supplementation is deficient in nutrients. A vegan diet is not safe per se. A vegan diet requires things to be added, to make it safe. Arguably, therefore, Diana and the AND (and the BDA) are having a heated agreement that a vegan diet per se is not safe.
The Vegan Society agrees that a vegan diet alone cannot meet nutritional requirements (by listing what is missing from, and thus must be supplemented to, a vegan diet at different life stages):
The advice for pregnant and breastfeeding women is (Ref 10):
– “Eat plenty of foods rich in iron [a number are listed]… and fortified breakfast cereal.”
– “Eat plenty of calcium-rich foods, such as calcium-fortified foods and calcium-set tofu.”
– “Ensure a reliable daily intake of vitamin B12 from fortified foods or a supplement.”
– “Ensure a reliable iodine intake by using a supplement.”
– “Whilst trying for a baby and during the first 12 weeks of pregnancy, take a daily folic acid supplement.” (Please note that this is standard advice for any woman, not just a vegan).
– “Take a daily supplement containing vitamin D.”
– “Consider microalgae omega-3 fat supplementation.”
“Fortified, fortified, fortified, supplement, supplement, supplement, supplement, supplement…” Even a baby being breastfed by a vegan mum, requires indirect fortification and supplementation.
The Vegan Society advice for infants is similar (Ref 11):
– For infants less than six months old, breastfeeding is rightly advised as the best option. “If breastfeeding is not an option, infant formula is recommended.” The advice notes that soy-based infant formula can be fed to vegan infants, but the advice cautions that such formula contains vitamin D3 from sheep’s wool. “The definition of veganism recognises that it is not always possible or practicable to avoid the use of animals.”
Diana is right again therefore. The Vegan Society has confirmed not only that a vegan diet is deficient, but that there isn’t a vegan formula, because D3 comes from an animal source. This was confirmed in my own research to try to find a vegan infant formula in the US. A January 2018 post, written by “a vegan mama”, Alex Jones, stated that “there are NO vegan formulas available in the United States” (Ref 12). Alex said that the closest thing to a vegan formula was soy formula. Explaining to her readers why there was no 100% plant based formula in the US, Alex said: “There are some federal regulations, that baby formulas must abide by. In order for formula to be sold, companies are required by law to add Vitamin D3.” Thank goodness!
This was confirmed by other vegan sites. An undated post on urbanvegan.net reported: “Rules and regulations by the FDA and other governing bodies make it impossible to find a truly vegan mass-produced formula for babies” (Ref 13). An August 2018 post reported that vegan infant formula is available in Europe and can be shipped to North America, “the most popular and soy-free option being Premiriz infant formula, which is organic, rice based and lactose free” (Ref 14). (Please see the Vegan Society caution on rice milk below).
I tweeted the US Academy for Nutrition and Dietetics (AND) @eatright as follows (Ref 15).
I received the following reply, to which I replied back. I have heard nothing since.
Diana has also emailed AND to ask how a vegan diet can be safe for infants when genuine vegan formula cannot even be obtained in the US?
Alas, given Nestlé’s history in infant formula, Nestlé has plans to provide a vegan infant formula, which is to be based on potato protein microparticles (Ref 16). In the document to file a patent for the product, Nestlé wrote that “soy and rice compositions are not ideal for infants due to the allergen concerns of soy and the amino acid profile of rice-based products.” The current AND recommendation, however, says “Use iron-fortified formula (soy for vegans) if breast-feeding is decreased or stopped.”
Another issue with giving soy to babies and children is the oestrogen impact. Soy contains phytoestrogens – plant-based oestrogens – which act like oestrogen within the body. A study published in 2018 examined 410 infants born in the Philadelphia area (Ref 17). It compared signs of oestrogen impact on infants i) breastfed, ii) cow-milk formula fed or iii) soy formula fed. It concluded that the infants fed soy formula demonstrated tissue and organ development consistent with response to oestrogen exposure.
The Vegan Society advice from first foods
The Vegan Society PDF continues with advice for the introduction of first foods (not before the age of four months, they clarify). Smooth or mashed food is advised to be mixed with fortified soy milk from the age of six months or older. Rice milk is advised against for any children under five “due to traces of arsenic”. Nice!
Daily supplements of vitamins A, C and D are advised for the ages between six months and five years old. The PDF says that breastfeeding until the child is at least two years old will give them enough calcium. If the mum doesn’t have enough, then baby will take from her bones (Ref 18). If not breastfeeding for that long, then we’re back to soy products fortified with calcium. Mothers of vegan babies also need to “include foods fortified with vitamin B12 in your child’s daily diet.” Iodine supplementation is also needed, but a caution is added that you need to get it just right because too much is serious, as is too little.
Finally, omega-3 fats are listed. The body needs omega-3 fats in the forms DHA (DocosaHexaenoic Acid) and EPA (EicosaPentaenoic Acid). Plant foods (especially flaxseeds) provide ALA (Alpha-Linolenic Acid), which the body can convert, but extremely inefficiently. As is the case with so many nutrients (retinol, D3, K2, heme iron, zinc), animal foods provide the form that the body wants, plant foods don’t. The Vegan Society PDF states: “DHA is not found in plant foods. DHA from microalgae can be provided to vegan infants through supplementation.” Worryingly they add “However, we require research into the health benefits of supplementation for vegans.” i.e. they don’t know if this is healthy; they probably don’t know if it’s safe.
The advice to supplement calcium, vitamins A, B12, C and D, with iodine and omega-3 fats continues as the child gets older (the amounts needed increase too). At the age of one, advice to supplement iron is added.
Thanks go to Frédéric Leroy (@fleroy1974 on twitter – well worth a follow) for his help with the research in this section…
Diana is right that a vegan diet is not safe per se. An interesting discovery, while researching for this note, was that a vegan formula diet is not currently lawful in the US. That more than supports Diana’s position.
The second part to Diana’s comment was “kids have died.” Tragically she is right on that too:
– In 2001, a British couple were spared a jail sentence following the death of their nine month old girl, who was fed a raw vegan diet. The Old Bailey Judge ruled that the parents had suffered enough for their loss (Ref 19).
– In 2006, an academic paper was published, which reported on US parents who were facing trial for aggravated manslaughter. Their five and a half month infant had died and four older children were all malnourished from being fed a raw food vegan diet (Ref 20).
– In 2007, a vegan couple in Atlanta were sentenced to life in prison for the death (in 2004) of their malnourished six week old baby boy, who had been fed soy milk and apple juice (Ref 21).
– In 2011, a French vegan couple were tried (Ref 22) and convicted (Ref 23) of causing their 11 month old daughter’s death due to a vegan diet.
– In 2017, a Belgian court gave a suspended sentence to the parents of a seven month old infant who died from malnutrition on a plant-based diet (Ref 24).
There have been a number of near misses. In July 2016, an Italian baby raised on a vegan diet was hospitalised for severe malnutrition and taken away from his parents (Ref 25). The 14 month old boy weighed slightly more than a 3 month old. In December 2018, an Australian couple admitted causing their one year old daughter harm. The girl had rickets, a degenerative bone disease caused by malnourishment, as a result of her vegan diet (Ref 26). She and her two older brothers were put into care. In February 2019, a vegan Florida couple were charged with neglect with great harm after almost starving their five month old son to death (Ref 27).
There have also been a number of cases published in academic journals about the harm suffered by infants of breastfeeding vegan mothers. There are some older cases in the references (Ref 28). Here are some from the past 10 years:
– In 2009, a Danish article reported about severe vitamin B12 deficiency in 2 infants (a 10 month old girl and a 12 month old boy) breastfed by vegans (Ref 29).
– In 2009, a French article reported the consequences suffered by a 10 month old boy who was exclusively breast-fed by his vegan mother (Ref 30). The case report documented: a failure to thrive; megaloblastic anemia; and delayed psychomotor development. He had vitamin B12 deficiency with hematocytopenia and pervasive developmental disorders, as well as vitamin K and vitamin D deficiencies. His mother had the same deficiencies.
– In 2012, a case report was published about severe vitamin B12 deficiency in an exclusively breast-fed five month old Italian infant born to a vegan mother who was taking multivitamin supplementation during pregnancy (Ref 31).
– In 2014, a case report was published about a 12 month old daughter, of a long term vegetarian woman. The child had neurological and hematological impairment due to vitamin B12 deficiency (Ref 32).
– In 2018, a case report was published about a 23 month old with iodine deficiency hypothyroidism, induced by a vegan diet. This particular harm was due to the diet directly, not indirectly via breastfeeding (Ref 33).
The fact that there have been ‘only’ a few deaths is probably a credit to the medical system. Infants have likely been caught at the stage of harm, rather than death. A Polish academic paper noted the AND position “that appropriately planned vegan, lacto-vegetarian and lacto-ovo-vegetarian diets ensure a normal course of pregnancy and lactation.” The paper expressed the counter-argument: “However, in practice the balancing of such a diet can pose certain difficulties, especially for individuals without the necessary experience or knowledge about nutrition” (Ref 34). Indeed.
Do the American and British Dietetic Association’s really have conclusive evidence that a vegan diet is safe for pregnant and lactating women, infants, children and adolescents?
The top recommended product on the vegan site mentioned above, urbanvegan.net, was Enfamil, ProSobee. The ingredients are: CORN SYRUP SOLIDS (54%), VEGETABLE OIL (26%) (PALM OLEIN, COCONUT, SOY, AND HIGH OLEIC SUNFLOWER OILS), SOY PROTEIN ISOLATE (14%), AND LESS THAN 2%: CALCIUM PHOSPHATE, POTASSIUM CHLORIDE, SODIUM CITRATE, CALCIUM CARBONATE, MAGNESIUM CHLORIDE, MAGNESIUM PHOSPHATE, POTASSIUM CITRATE, FERROUS SULFATE, ZINC SULFATE, CUPRIC SULFATE, POTASSIUM IODIDE, SODIUM SELENITE, MORTIERELLA ALPINA OIL, CRYPTHECODINIUM COHNII OIL, L-METHIONINE, CHOLINE CHLORIDE, ASCORBIC ACID, NIACINAMIDE, CALCIUM PANTOTHENATE, VITAMIN D3, RIBOFLAVIN, THIAMIN HYDROCHLORIDE, VITAMIN B6 HYDROCHLORIDE, FOLIC ACID, VITAMIN K1, BIOTIN, VITAMIN B12, INOSITOL, TAURINE, VITAMIN E ACETATE, L-CARNITINE, VITAMIN A PALMITATE (Ref 35).
With this product, 80% of the vegan infant’s diet would be corn syrup and vegetable oil. What kind of parent could do that to their child? Any child?!
There’s a sinister twist to this true story. The sponsors of the American Academy of Nutrition and Dietetics include the infant formula manufacturers Abbott Nutrition and BENEO-Institute (Ref 36). The sponsors of the British Dietetic Association include the infant formula manufacturers Abbott Nutrition, Danone Dairies, Mead Johnson, Nutricia and “Vitaflo” (which is Nestlé) (Ref 37). I don’t blame profit-orientated companies from recruiting dietetic associations as ‘merchandisers’, but I have nothing but contempt for the dietetic organisations that embrace this. In my opinion, the AND and BDA should be investigated, not Diana.