What Types of Foods Should Vegetarians Eat to Maintain Proper Nutrition?

Patient Presentation
A 16-year-old female came to clinic for health supervision.
During the interview she said that over the past few months she had decided to become vegetarian.
When further questioned, she said she initially stopped eating meat, fish and poultry and was eating eggs and dairy products, but recently she has stopped eating those also.
She said that she is drinking soymilk, using some tofu, and “throwing some nuts on my salad.”She was not eating any other soy products and used few nut products or oils. She had been eating a fairly restricted diet of lots of “stir fried vegetables,” salads and bread.
She said she didn’t do any reading about vegetarian diets or really plans any of her meals; she just eats what is available.
She denied trying to lose weight, purging, increasing her exercise or being unhappy with her body image.
Her motivation for beginning her vegetarian diet was that she thought that it would be healthier.
The past medical history and social history revealed a healthy female living in an omnivore family.
The pertinent physical exam showed a healthy appearing female. Her growth percentiles were in the 25-90%. She had maintained her weight over the past year and was Tanner stage IV for pubertal development.
The diagnosis of a teenager who had begun a vegetarian diet without adequate nutritional information was made.
As she also needed screening blood tests, laboratory evaluation included a complete blood count, B12 level, and fasting cholesterol and triglycerides.
These were eventually normal with the exception of a hemoglobin of 12.2 mg/dl and hematocrit of 35%.
She was counseled about the risks of poor nutrition and was interested in learning about different options to increase the variety of foods she ate and how to prepare them. A dietician appointment was arranged.
She also willingly agreed to take a daily multivitamin with extra iron and was to follow up in 2-3 months.

Vegetarians have a diet pattern that emphasizes consuming plant foods (i.e. vegetables, grains and nuts) and avoiding flesh food (i.e. red meat, poultry, fish).
Some vegetarians include milk and egg products in their diets and would be more accurately described as lacto-ova-vegetarians.
Vegans are vegetarians who avoid all animal products including foods such as dairy products, eggs, butter, honey and gelatin.

What constitutes being a vegetarian to one person, may have a different meaning for another person. In a national study, 2.5% of the participants (aged > 6 years of age) considered themselves to be vegetarian.
When 24-hour diet records were examined, only 0.9% of the participants did not eat red meat, poultry or fish.

Infants, children and adolescents with well-planned vegetarian and vegan diets grow and develop normally.
For adults, there is data to support a decreased risk of some types of cancer, diabetes, coronary artery disease, hypertension and obesity.
Besides these advantages, some people choose vegetarian and vegan diets for economic, environmental and religious reasons.

In general, infants should be breast feed for up to one year if possible.
Soy formulas are available and are recommended for vegetarian and vegan infants who are not breastfeeding.
Commercial soymilk should not be started until after one year of age because of the low bioavailability of iron and zinc in soy. Some commercial soymilk may not be fortified with Vitamin D and calcium and therefore labels need to be checked.
Parents and other caretakers need to be careful with choking hazards such as nuts and raw vegetables.
If growth is a concern, supplementing avocado, nut or seed butters, tofu, and vegetables oils can increase calories.
Sometimes a restrictive vegetarian diet can be masking an underlying eating disorder.

Learning Point
Primary nutrients to be concerned about for vegetarians and vegans are noted below along with examples of foods that are high in these nutrients.
Soy products includes items such as tofu and tempeh, soybean oil, soymilk, soy cheese, soy yogurt, etc.

  • B12 (cobalamin) – breads, cereals, dairy products, eggs, fortified soy products, nutritional yeast, and supplements.
    It is important to have adequate sources of B12 particularly if a vegan.

  • Calcium – brocoli, collard greens, dairy foods, figs, kale, black strap molasses, sesame seeds, and fortified soy products.
  • Iron – bulgur wheat, dried beans, dried fruits, fortified cereals and grains, and fortified soy products.
    Adding a Vitamin C source when eating a plant food for iron increases its absorption (i.e. orange, strawberries, tomatoes).

  • Omega-3 Fatty Acids – canola oil, ground flaxseed, flaxseed oil, soy products, walnuts, walnut oil, and sea vegetables.
  • Protein – dairy products, eggs, grains, legumes, seitan (a wheat product), and soy products.
    Because of the low absorbability of amino acids found in plant sources a higher intake of protein may be necessary

  • Vitamin D – dairy products, fortified soy products, sunlight.
  • Zinc – cereals, whole grain, legumes, miso (made from soybean, wheat or barley), soy products, wheat germ, and yeast.

Questions for Further Discussion
1. What vegetarian meals options are available for children in the local school district?
2. Where in the local community can patients and families get nutritional information, particularly for vegetarians?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Vegetarian Diet

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Mangels AR, Messina V.
Considerations in planning vegan diets: infants.
J Am Diet Assoc. 2001;101(6):670-7.

Messina V, Mangels AR.
Considerations in planning vegan diets: children.
J Am Diet Assoc. 2001;101(6):661-9.

Haddad EH, Tanzman JS.
What do vegetarians in the United States eat?
Am J Clin Nutr. 2003 Sep;78:626S-632S.

Dunham L, Kollar LM.
Vegetarian eating for children and adolescents.
J Pediatr Health Care. 2006;20(1):27-34.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism

    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    September 2, 2008