Trending Topics pieces (Article Analyses, Evidence Clips and Other Topics) are published in timely response to recent media and journal articles, position statements, clinical guidelines, etc. Since they are based on the most recent evidence/publications, they may not be consistent with PEN evidence in other PEN content areas. As soon as possible, when this occurs, the PEN content will be reviewed and updated as needed.
Plant-based Beverages Are Not a Good Alternative for Young Children
Plant-based beverages continue to grow in popularity. There is a misconception that these beverages are healthy and nutritionally equivalent to cow’s milk but this is not the case (1). A comparison of the nutritional value of plant-based beverages in Canada, was covered recently in a televised news segment on the CTV Network.
The nutrient composition of plant-based beverages can become a problem for young children. With the exception of fortified soy beverages, if plant-based beverages displace breastmilk, formula or cow’s milk, young children can be at the risk of malnutrition. Plant-based beverages, excluding soy (soy-fortified beverages have a similar nutrient profile to cow’s milk), are very low in protein, calories and fat (1,2). There are currently 21 reports and case series published in the literature of severe malnutrition and nutritional disease in children who consumed rice and nut beverages instead of breastmilk, formula or cow’s milk (3-23). This number is up from seven reports noted in 2016 (2). While many plant-based beverages are fortified with vitamins and minerals, the amounts vary widely, and it is not known if the bioavailability of the minerals and protein is the same as cow’s milk (1,3,24).
A recently released technical scientific report, from a panel of experts representing key national health and nutrition organizations in the U.S., recommended for young children that “Consumption of [plant milks] as a full replacement for dairy milk should be undertaken in consultation with a health care provider so that adequate intake of key nutrients commonly obtained from dairy milk can be considered in dietary planning” (1).
For country-specific (Australia, Canada, New Zealand, U.K.) recommendations for consuming plant-based beverages, see the PEN Practice Question: What are recommendations for the use of plant-based beverages (e.g. soy, rice, almond, coconut and oat milk/beverage) during the complementary feeding period in infants?
For more information on the potential health implications of plant-based beverages in young children, see the PEN Trending Topic: Plant-based Beverages – Are They Really Healthier for Young Children, and the Dietitians of Canada News Release: Dietitians, paediatricians advise parents to exercise caution with plant-based beverages.
For information and practical tips for providing children with healthy drinks see the website: https://healthydrinkshealthykids.org (Note: this is a U.S. website and recommendations are based on the technical scientific report noted above (1). These recommendations may be different from other country recommendations, particularly around juice consumption.
- Lott M, Callahan E, Welker Duffy E, Story M, Daniels S. Healthy beverage consumption in early childhood: recommendations from key national health and nutrition organizations. Technical Scientific Report. Durham, NC: Healthy Eating Research; 2019. Available from: http://healthyeatingresearch.org
- Dietitians of Canada. What are the recommendations for the use of plant-based beverages (e.g. soy, rice, almond, coconut and oat milk/beverage) during the complementary feeding period in infants? In: Practice-based Evidence in Nutrition [PEN]. 2016 Apr 14 [cited 2019 Oct 29]. Available from: https://www.pennutrition.com/KnowledgePathway.aspx?kpid=2503&pqcatid=146&pqid=19553&kppid=19554&book=Evidence&num=1#Evidence. Access by subscription only.
- Vitoria I. The nutritional limitations of plant-based beverages in infancy and childhood. Nutr Hosp. 2017;34(5):1205-214. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/29130721
- Ellis D, Lieb J. Hyperoxaluria and genitourinary disorders in children ingesting almond milk products. J Pediatr. 2015 Nov;167(5):1155-8. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/26382627
- Diamanti A, Pedicelli S, D'Argenio P, Panetta F, Alterio A, Torre G. Iatrogenic kwashiorkor in three infants on a diet of rice beverages. Pediatr Allergy Immunol. 2011. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/22122793
- Barreto-Chang OL, Barreto-Chang O, Pearson D, Shepard WE, Longhurst CA, Longhurst C, et al. Vitamin D -deficient rickets in a child with cow's milk allergy. Nutr Clin Pract. 2010 Aug;25(4):394-8. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/20702845
- Mesa Medina O, González JL, García Nieto V, Romero Ramírez S, Marrero Pérez C. Infant metabolic alkalosis of dietetic origin. An Pediatr (Barc). 2009 Apr;70(4):370-3. Spanish. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/19303829
- Kuhl J, Davis MD, Kalaaji AN, Kamath PS, Hand JL, Peine CJ. Skin signs as the presenting manifestation of severe nutritional deficiency: report of 2 cases. Arch Dermatol. 2004 May;140(5):521-4. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15148094
- Novembre E, Leo G, Cianferoni A, Bernardini R, Pucci N, Vierucci A. Severe hypoproteinemia in infant with AD. Allergy. 2003 Jan;58(1):88-9. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/12580819
- Doron D, Hershkop K, Granot E. Nutritional deficits resulting from an almond-based infant diet. Clin Nutr. 2001 Jun;20(3):259-61. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11407873
- Massa G, Vanoppen A, Gillis P, Aerssens P, Alliet P, Raes M. Protein malnutrition due to replacement of milk by rice drink. Eur J Pediatr. 2001 Jun;160(6):382-4. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11421421
- Kanaka C, Schütz B, Zuppinger KA. Risks of alternative nutrition in infancy: a case report of severe iodine and carnitine deficiency. Eur J Pediatr. 1992 Oct;151(10):786-8. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/1425805
- Vitoria I, López B, Gómez J, Torres C, Guasp M, Calvo I, Dalmau J. Improper use of a plant-based vitamin C-deficient beverage causes scurvy in an infant. Pediatrics. 2016 Feb;137(2):e20152781. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/26783325
- Mori F, Serranti D, Barni S, Pucci N, Rossi ME, de Martino M, et al. A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis. Nutr J. 2015 Aug 21;14:83. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/26293684
- Le Louer B, Lemale J, Garcette K, Orzechowski C, Chalvon A, Girardet JP, et al. Severe nutritional deficiencies in young infants with inappropriate plant milk consumption. Arch Pediatr. 2014 May;21(5):483-8. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/24726668
- Alvares M, Kao L, Mittal V, Wuu A, Clark A, Bird JA. Misdiagnosed food allergy resulting in severe malnutrition in an infant. Pediatrics. 2013 Jul;132(1):e229-32. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/23733797
- Katz KA, Mahlberg BA, Honig PJ, Yan AC. Rice nightmare: kwashiorkor in 2 Philadelphia-area infants fed Rice Dream beverage. J Am Acad Dermatol. 2005 May;52(5 Suppl 1):S69-72. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15858513
- Carvalho NF, Kenney RD, Carrington PH, Hall DE. Severe nutritional deficiencies in toddlers resulting from health food milk alternatives. Pediatrics. 2001 Apr:107(4):e46. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11335767
- Keller MD, Shuker M, Heimall J, Cianferoni A. Severe malnutrition resulting from use of rice milk in food elimination diets for atopic dermatitis. Isr Med Assoc J. 2012 Jan;14(1):40-2. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/22624441
- Fourreau D, Peretti N, Hengy B, Gillet Y, Courtil-Teyssedre S, Hess L, et al. [Pediatric nutrition: severe deficiency complications by using vegetable beverages, four cases report]. Presse Med. 2013 Feb;42(2):e37-43. [French]. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/23021957
- Tierney EP, Sage RJ, Shwayder T. Kwashiorkor from a severe dietary restriction in an 8-month infant in suburban Detroit, Michigan: case report and review of the literature. Int J Dermatol. 2010 May;49(5):500-6. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/20534082
- Liu T, Howard RM, Mancini AJ, Weston WL, Paller AS, Drolet BA, et al. Kwashiorkor in the United States: fad diets, perceived and true milk allergy, and nutritional ignorance. Arch Dermatol. 2001 May;137(5):630-6. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11346341
- Imataka G, Mikami T, Yamanouchi H, Kano K, Eguchi M. Vitamin D deficiency rickets due to soybean milk. J Paediatr Child Health. 2004 Mar;40(3):154-5. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15009584
- Singhal S, Baker RD, Baker SS. A comparison of the nutritional value of cow's milk and nondairy beverages. J Pediatr Gastroenterol Nutr. 2017 May;64(5):799-805. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/27540708
Animal and Plant-based Protein Foods Effects on Blood Lipid Levels
A recent randomized control trial of atherogenic lipid levels was reported in the American Journal of Clinical Nutrition (1). Participants were randomly assigned to either high (∼14% total energy) or low (∼7% total energy) saturated fat (SFA). Within each of these arms participants were further randomized to various sources of protein (red meat, white poultry meat, plant-based protein (legumes, nuts, grains, isoflavone-free soy products)) and tested in a factorial crossover design. This design was used to test both the effects of different levels of saturated fat and the various protein sources. The leanest cuts of red and white meat were used with all visible fat and poultry skin removed. All food (standardized entrées, side dishes, caloric beverages, snacks) was provided (except for fruit and vegetables, to ensure freshness) to the participants. Diet energy was individualized to ensure weight maintenance. The higher SFA was mostly from butter and full-fat dairy products, replaced with monounsaturated fats in the lower SFA arms. Participants, aged 21-65 years, were of good health; 113 of the 177 enrolled (63%) completed the study. Diets were consumed for four weeks with a two to seven-week washout period in between. Primary outcomes were LDL cholesterol, apoB, small plus medium LDL and the total/HDL cholesterol ratio.
Results and Conclusions
The trial revealed that, independent of SFA content, low density lipoprotein (LDL) cholesterol and apoB were higher with white and red meat than with plant-based protein (P<0.0005 for all) (1). Total/high density lipoprotein and small plus medium LDL cholesterol were not affected by protein source (P=0.51 and P=0.10). There were no significant differences between red and white meat on other primary outcomes. Furthermore, high SFA intakes increased LDL cholesterol (P=0.0004, apoB (P=0.0002) and large LDL (P=0.0002) compared with low SFA, independent of protein source.
The authors concluded that their findings support current guidelines of promoting increased consumption of plant-based foods for reducing CVD risk (1). The study was not able to conclude that choosing lean white meat offered advantages over lean red meat for reducing CVD risk.
PEN Evidence Analyst Analysis
The strengths of this study include:
- It was a randomized trial (with concealed allocation using numbered envelopes so the researchers would not be aware of the next randomization sequence.
- It was a cross-over design (participants were their own controls).
- Participants were provided with the food.
This study avoided confounding by three of the elements of the design. First by randomization to the order of the diets, second by using the participants as their own controls, and third by providing most of the food to the participants, to avoid confounding by other dietary factors.
A limitation of this study is that it does not refer to higher fat meats since blood lipid effects were only examined after the consumption of only very lean meats. A second limitation is the indirectness of the blood levels, which may not directly predict cardiovascular disease.
For additional interpretation of the study, see: https://theconversation.com/research-check-is-white-meat-as-bad-for-your-cholesterol-levels-as-red-meat-118390.
- Bergeron N, Chiu S, Williams PT, M King S, Krauss RM. Effects of red meat, white meat, and nonmeat protein sources on atherogenic lipoprotein measures in the context of low compared with high saturated fat intake: a randomized controlled trial. Am J Clin Nutr. 2019 Jun 4. pii: nqz035. doi: 10.1093/ajcn/nqz035. [Epub ahead of print]. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/31161217
The "Planetary Health Diet" – What’s it All About?
A report was launched on January 17, 2019 by The EAT- Lancet Commission on Food, Planet, Health that presents “a global planetary health diet that is healthy for both people and planet” (1). (Note: to download the complete report you must log into your Lancet account or complete the free registration to the Lancet website). EAT is “a global, non-profit start-up dedicated to transforming our global food system through sound science, impatient disruption and novel partnerships” (2).
The EAT-Lancet Commission brought together “37 experts from 16 countries in various fields of human health, agriculture, political sciences and environmental sustainability to develop global scientific targets for healthy diets from sustainable food production” (3). With the population set to reach 10 billion people by 2050, researchers stressed the link between what we eat and human and planetary health. Future food production must be intensified in regards to sustainability to meet the needs of the growing population within the planetary limits for climate change, biodiversity loss, land and water use, as well as nitrogen and phosphorous cycles (1).
In this important report, authorities have attempted to look at “nutrition, health impacts, ecosystems and feasibility with culture” and provide strategic and practical information for policy development. It is basically calling for a transformation of the food we eat and ”getting it right with food will be an important way for countries to achieve the targets of the UN Sustainable Development Goals and the Paris Agreement on climate change” (1).
“Ensuring that all certified health professionals have a demonstrable level of competence surrounding planetary health diets”, the EAT-Lancet Commission prepared a brief for professionals (3): with information about what they should know and what they should do to contribute to the “Great Food Transformation” (1).
An overview of the diet recommendations include reducing the consumption of animal protein so that proteins should be from plant sources as much as possible and reducing the consumption of ultra-processed foods and added sugar. While this is nothing new, as we have been hearing these recommendations for years, what is new is the more specific guidelines for food group consumption (1,3):
The whole grains portions are adjusted to meet energy targets. In addition, the diet has room for 31 g of sugar and about 50 g worth of oils, such as olive oil, and no dairy fats such as butter.
- Nuts (peanuts and tree nuts) - 50 g a day
- Beans, Chickpeas, Lentils and Other Legumes (dried) - 50 g a day
- Soy Foods (dry) - 25 grams a day
- Fish - 28 g a day
- Eggs - 13 g a day (about 1.5 eggs per week)
- Meat and Poultry - 14 g a day of red meat and 29 g a day of poultry
- Dairy and Dairy Products (including cheese) - 250 g a day (the equivalent of one glass of milk)
- Carbs - Whole grains including rice, wheat and corn (dry) - 232 g a day and 50 g a day of starchy vegetables
- Vegetables and Fruit - vegetables (300 g) and fruit (200 g) a day.
For Additional Content:
- Willet W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019 Jan 16. pii: S0140-6736(18)31788-4. doi: 10.1016/S0140-6736(18)31788-4. Citation available from: https://www.ncbi.nlm.nih.gov/pubmed/30660336
- EAT Forum – About EAT. [cited 2019 Jan 21]. Available from: https://eatforum.org/about/
- EAT- Lancet Commission. Brief for healthcare professionals. January 2019. Available from: https://eatforum.org/content/uploads/2019/01/EAT_brief_healthcare-professionals.pdf
Trending Topics - Plant-based Beverages – Are They Really Healthier for Young Children? (Reposted from Aug 29, 2017)