So Your Child/Teen Wants To Be a Vegetarian: Ventures into Vegetarianism/Veganism

One of my favorite movie moments is when Aunt Voula in My Big, Fat Greek Wedding learns that Ian Miller, the non-Greek protagonist soon to join the family, is a vegetarian. She asks, “What do you mean he don’t eat no meat?” and the hoopla of the engagement party falls to a stunned silence. The festivity only resumes with her reassurance, “That’s okay, that’s okay—I make lamb!”

I laugh at this scene because for me it hits home. You see, when my younger sister was eight years old, she announced to my family that she intended never, ever to eat meat again. My usually well-spoken Texan grandparents, who expressed their love for us (at least in part) by buying us kids barbeque, could only stand there and say, “Huh?” And my Italian grandmother and extended family on the other side— well, they acted like Aunt Voula. My grandma would say she understood the vegetarian thing and then would proudly present my sister with an aromatic vegetable dish that was exquisitely seasoned and essentially perfect except that it was decorated with bits of …were those bits of ground beef? Let’s just say my sister’s vegetarianism, which often has edged into veganism, has been an education for my entire family over decades. And my sister, as per her promise, truly has never eaten meat again.

What did my parents do, after a short period of puzzlement? And —more to the point—what should YOU do, should your child or teen make a similar declaration? Here are a few tips I hope you will find helpful.

1. Consider the reasons behind the choice. My funny and, yes, perhaps dated movie reference for this section is a scene from Notting Hill, when Hugh Grant’s character, William Thacker, has a dinner date with a fruitarian woman who says she believes “fruits and vegetables have feelings, so we think cooking is cruel.” Hugh listens attentively and non-judgmentally as she clarifies her position. He starts, “So these carrots,’ and she cuts in, “have been murdered, yes.” “Murdered,” he says sensitively, “Poor carrots—that’s beastly.” In all seriousness, however—and with all due respect to fruitarian Steve Jobs, listening is important. My parents listened carefully to my sister’s reasons in accordance with their goal of rearing a self-assured, independent thinker. Like many school-aged children, she expressed her horror on learning that beef, pork, poultry, and seafood were cows, pigs, chickens, and fish. She became a fervent spokeswoman for animal protection and for humane farms. Inspired by a recent school unit on the environment, she — like Dr. Seuss’s Lorax— also spoke for the trees. She listed ecological concerns about large food industry’s destruction of the rainforest and the need to share earth’s resources responsibly. My sister’s heartfelt explanation helped my parents arrive at acquiescence and ultimately support of her decision.

Indeed, there are many very good reasons people have in choosing vegetarianism (eating no meat) and/or veganism (eating no meat, dairy products or eggs). Aside from the environmental and ecological arguments, it is a decision that for many is tied to cultural or religious beliefs. Teens who are trying to define themselves and formulate their own beliefs may want to back their newly-stated opinions with actions.

Words of warning:  While I strongly advocate really listening to your child’s reasons, as a physician I am also on the alert for a teen who does NOT seem to have well-thought-out positions. Beware of kids and teens who choose veganism for the WRONG reason, such as using it as a cover for excessive or unhealthy caloric restriction and eating disorders.

2. Make a general team strategy. Something as big as dietary change is best done as a family unit. It is too big a project, with too much potential for family dissension, for poor, dear Mom or Dad to tackle alone or for the child to manage without help. In the movie Everything is Illuminated, Elijah Woods’s character visits Ukraine and explains to utterly baffled companions at a restaurant that he eats no meat. When he is told that there is nothing available without meat, he asks if he can have just one of the potatoes that would otherwise be served with meat. The scene’s ending is poignantly and amusingly pathetic, as he is presented with a single, peeled baked potato on a plate, without even a sprinkle of chives … only to then roll onto the floor. Poor guy— oh, the plight of the unaided vegetarian! Honestly, that simply should NOT be how it is, for a good vegetarian effort takes teamwork. Meal-planning, grocery shopping, and cooking are all affected. In fact, if you have been a family of omnivores all along, it may be wise to take baby steps into vegetarianism or veganism. After all, it is truly daunting for a parent who knows how to cook a certain repertoire of meat-based meals to face the task of relearning a vegetarian selection (and as a pediatrician, I do recommend home-cooked meals as often as possible). To borrow Sheryl Sandberg’s phrase, you might consider “leaning-in” to a change—in this case, changed dietary habits— by instituting Meatless Mondays, or Meatless Mondays, Wednesdays, and Fridays! After all, cutting out half the meat still makes a positive impact on animals and on the environment.

My sister would consider nothing other than being a full-on vegetarian, while the rest of us still enjoyed our brisket and Chicken Marsala. However, we omnivores did slowly learn to cook more vegetarian dishes, to modify the ones that had dashes of bacon bits to include the veggie mock-bacon bits or perhaps sesame sprinkles instead, and to cook the vegetable dishes that we already knew more frequently than before. We cooked things that had vegetarian versions, like pasta that she could eat with straight red sauce, though we added meatballs. Many Sundays, my mom cooked a big pot of some variation of vegetable/bean soup, made with vegetable broth, NOT chicken broth! We often enjoyed it that first night as our family dinner entree, after which it made for great vegetarian left-overs for my sister throughout the week.

3. Be Smart about Nutrition. There is a classic scene from I Love Lucy in which Lucille Ball does a commercial for a syrup called “Vitameatavegamin” that is supposed to provide everything needed for good health. The scene is a riot, as Lucy endures its foul-taste for many repeated filming takes until she becomes drunk on the concoction. For a wonderful laugh—check it out! But, seriously, back to your vegetarian child, there is not one simple formula to ensure good nutrition. ANY restricted diet means more potential for nutritional deficiency, and that means more of a need for planning. To begin with, be sure calories are sufficient. I recommend the website choosemyplate.gov, which also includes a tracking feature called supertracker.usda.gov that can help in following calories and nutrients in a child’s diet. If your family is new to vegetarianism/veganism, it might be a good idea to have your child take a multivitamin. Truth be told, however, if your child is a non-picky vegetarian who eats milk and eggs and a pretty wide variety of vegetarian foods, he/she is probably getting all the nutrients needed without said vitamin. Similarly, if your child or teen has chosen to be a vegan but consumes a varied diet including fats and protein as well as a fortified milk substitute (like fortified soy/almond/cashew/coconut milk), then he/she is also probably set on nutritional requirements (due to supplementation in these dairy replacements). Without milk substitutes, though, I do worry about your child’s not meeting nutritional needs and would definitely recommend a multivitamin, particularly for Vitamin B12, calcium, Vitamin D and zinc. If in doubt, I recommend meeting with a nutritionist (Cook Children’s has a wonderful nutrition department).

4. WILL MY VEGETARIAN CHILD GET ENOUGH PROTEIN?

For lacto-ovo vegetarians, those who are not vegan and therefore consume both milk and eggs (both good sources of protein)—the answer is most likely YES, without even much forethought. Vegans, however, might not be getting enough protein and will need to strategize. The take-home message for them is that they need to eat a VARIETY of protein-sources each day and enough of them to meet requirements. I suggest counting protein grams for a few days, and—once you get the idea of what you need—then go for gestalt.

As an overview, animal-based foods (like meats, fish, dairy and eggs) are considered “complete proteins,” containing all 9 essential amino acids in a quite digestible form. On the other hand, plant-based foods are generally deficient in at least one amino acid, so— in order to get all 9—you need to eat a variety of different plant-based foods with “complementary proteins.” For example, legumes (beans) are low in methionine but high in lysine, while grains are the reverse. If you eat both legumes and grains in one day, you get them all. Also, plant-based protein is less easily-digestible than animal —based, so you need to consume more protein daily as compared to a carnivore, to get the same benefit. Do note that there ARE a few plant based proteins which are becoming more popular and which are complete, including quinoa, hempseed and chia seeds—hooray!

If vegans drink soy milk as their milk-substitute, they will get nearly as much protein from it as someone drinking milk (6-7g per cup as compared to the 8g in milk). However, there are some concerns about the relationship between soy and estrogens and the potential impact on children’s endocrine/hormonal systems (endocrine-disruptors). If you would like to limit soy milk, another option for a milk-alternative is Ripple Pea Milk, made from peas and containing just as much protein (8g/cup) as regular milk. Simple almond, cashew, and coconut milks do not typically contain any protein, but there are starting to be some nut milks on the market that are fortified with pea protein (check out Silk Protein Nutmilk container 10g of protein—woo-hoo!).

To touch on details, people generally need around 1 gram of protein per kilogram per day ( just over 1 g for toddlers, and 0.85-0.95 for kids/teens, but requirements can be 20% higher if protein is from harder-to-digest vegetable sources). Let’s consider a young teen who is 100 pounds, or 45 kilograms. That teen needs 43 grams of protein per day, which is pretty easily achieved if the child eats milk and eggs. In breakfast alone, she can get 17 grams, with her cup of milk and cup of bran flakes (8 g plus 3 g respectively) plus one boiled egg (6 g). Not bad for one meal alone! If that teen is a vegan, though, she may need as many as 51 grams of protein daily, since her proteins will be harder to digest. Tofu faux-eggs scrambled in the morning could help reach that goal (5g/oz), along with a cup of Ripple Pea milk (8g). Beans are a great go-to (8 g per half-cup), as are broccoli (4 g per stalk), spinach (5g per half-cup), and artichokes (4g per one medium-sized). Expand into ancient grains such as quinoa and amaranth, the latter which can be made into breakfast porridge and sprinkled with hemp or chia seeds for even more protein. And don’t forget peanut-butter sandwiches—they have 13 grams each!

Pearls of Protein Wisdom:

1. It helps to eat dairy and eggs, which are protein-rich.
2. Soy milk and pea milk (Ripple) are protein-rich milk-alternatives.
3. Nut milks like almond, cashed and coconut milks do NOT USUALLY contain protein, but there are some high-protein varieties fortified with pea protein.
4. Eat beans, hummus, soybeans/tofu, spinach and peas.
5. Sprinkle hemp or chia seeds over salads or smoothies, and try the ancient grains like quinoa or amaranth (which you can make into a breakfast porridge).

5. WILL MY VEGETARIAN/VEGAN GET ENOUGH FAT? Omega-3s?

It is absolutely possible and important to do so, but it is not a given! Keep in mind that people of all diets can make healthy or unhealthy choices even within their dietary restrictions. If your child vegetarian leans toward a diet heavy on the grilled cheese sandwiches and macaroni and cheese, not to mention donuts and cookies, while perhaps tending away from as wide a variety of vegetables as you would like, he/she may actually have a high-fat diet. Many teens, however, go the opposite direction and eat overflowing and deceptively- filling plates of vegetables that do not have enough fat. Fat is important and should make up approximately 30% of the energy a child/teen consumes in a day. Since fat provides 9 kcal per gram, teens consuming 2000 - 2600 kcal per day need around 75g of fat per day.

Good sources of fat include avocados (32 g each!), peanut butter, nuts, seeds, and oils (including olive, canola, and coconut oil). A cup of milk contains 2.5 g of fat, and fortified substitute milks have about that much or more. You will have to read labels on them, as there is some variability—Silk Coconut milk and Ripple Pea Milk top the charts with 5 g and 4.5 g per cup, respectively.

And, while we are on the subject of fats, what about those Omega-3 fatty acids (DHA, EPA, and the precursor called ALA) that everyone is always talking about, the ones that help for eye and brain development and also for heart health? The main sources of omega-3s are fish, eggs, and algae, but how much algae is your vegetarian/vegan eating? Indeed, vegetarians and vegans have been shown to have generally lower levels of omega-3s than omnivores and would likely benefit from more, though as of yet there are no officially recommended daily allowances for omega-3s for children (or adults). For adults, there is a suggestion that 250-500mg of combined DHA and EPA is a minimum goal. Kids/teens can get one of the omega-3s, alpha- linoleic acid (ALA), through flaxseeds and hempseed (which can be added to pancake mix or oatmeal), chia seeds (which can be added to smoothies), soy, and canola oil. Kids can also get omega-3s (DHA) from Ripple Pea milk, the milk substitute made from peas.

A WORD ABOUT PERCENTAGES ON FOOD LABELS

When you look at food labels to see how much of many of our next nutrients are in foods, sometimes instead of a number of units, it will list a percentage. That percentage is telling you what percentage of Daily Value is provided, but Daily Value is NOT the best guide when thinking about your child’s nutritional needs. Daily Value (DV) is a single number issued by the FDA for labeling purposes and is different from the more precise and age-specific Recommended Daily Allowances (RDA), which is what we pediatricians recommend parents follow. RDAs are determined by the Institute of Medicine and can differ from DVs— so get wise to it! In the case of Vitamin B12, for example, younger children have an RDA of 1.2-1.8 mcg, while teens have an RDA of 2.4 mcg. On labels, however, packaging will list a percentage of the Daily Value (DV), which for Vitamin B12 is 6 mcg. If, for example, the label says a serving of your coconut milk has 50% the DV, it has 3 mcg, which is great and exceeds the RDA for your child (it’s not just half of what he/she needs!). In some cases, like for Vitamin D, on the other hand, the DV is less than the RDA, so you can get misled into thinking you are getting enough Vitamin D, when you are not.

6. WILL MY VEGETARIAN/VEGAN GET ENOUGH IRON?

They can if they plan! It is certainly easier for meat and fish eaters to get enough iron, and—unlike the protein situation—milk and eggs are not too helpful as iron sources. Consequently, vegetarians and vegans are both in the same boat. There is a lot of iron in meat, and that “heme-iron” is more easily absorbed than “non-heme iron” in vegetables. So vegetarians and vegans alike will need to eat more of their iron-containing vegetable-based foods to get the necessary protein. It is also important to note that some foods can help or hurt you in your efforts to get iron. Legumes (which have phytates) or coffees and teas (which have tannins) decrease iron absorption from other foods, while your friend Vitamin C —think oranges, strawberries, tomatoes—increases iron absorption.

Toddlers and school kids need between 7-10 mg of iron daily, whereas teens need more, 11mg for boys and a whopping 15mg for girls (who lose iron with their periods). One cup of kale or collard greens has just 1mg, so you can see that you will need quite a bit to approach the daily requirement. Remember oatmeal as a great source of iron—13 mg in one cup! Dried fruits can be helpful to have around (1.75mg in 1/2 cup of dried apricots), as can peas and pistachios (2mg in 1/2 cup peas, 1.2 mg in 1/4 cup of pistachios). Ripple pea milk, a milk substitute made of peas, has quite a bit of iron—2.7 mg per cup (on the label it says 15% of the 18 mg/day Daily Value)! Soy and nut milks do not have nearly that, but some have 0.75-1mg (Chocolate Silk Cashew Milk has just over 1mg, or 8% of the DV), and every little bit helps!

As I have warned before, don’t be misled by percentages of Daily Value on the food labels. The DV for iron is 18mg, but that is actually more than your child needs according to RDAs (even if your child is a female teen who needs 15 mg per day). So, if your oatmeal has 20% of the DV of iron, it has 3.6 mg. That is not just 20% but more like 33% of what your child needs.

Pearls of Iron Wisdom:

1. Eat iron-rich foods (oatmeal, leafy greens, legumes, dried fruit, soy products, etc)

2. Eat Vitamin C, to help iron absorption, along iron-containing foods (think

citrus, strawberries, broccoli or tomatoes)

3. Reduce your intake of tea/coffee with tannins (that reduce iron absorption)

4. Ripple Pea Milk is a very good source of iron!

7. WILL MY VEGETARIAN/VEGAN GET ENOUGH CALCIUM and VITAMIN D?

As Marisa Tomei’s character said in the movie My Cousin Vinny, “It is a trick question.” She also used other words not fit for this blog. Still, this question is tough because truthfully, many teens of even unrestricted diets seem to struggle these days to get enough calcium and Vitamin D, as many replace their milk-drinking habits with a sugary-beverage habit. However, if a teen (vegetarian or not) has about three servings of dairy a day plus vegetables that contain calcium, he or she can usually get the recommended 1300 mg of calcium (RDA is 1000 mg for kids 4-8 years old and 1300 mg for kids 9-18) and the 600-800 IU of Vitamin D recommended (600 for 1-9 year-olds and 800 for 9up). Vegan kids and teens also can get enough calcium these days, too, IF they drink a fortified milk substitute. This is a wonderful gift of the food industry to vegans, as they have added calcium and Vitamin D to their milk substitute drinks. Whereas regular unfortified soy milk has 6 times less calcium than regular milk, most soy, almond, coconut, cashew and even pea (Ripple) milk at grocery stores today are fortified and have ample calcium, even 1.5 to 2 times the amount in regular milk!

Many other foods have been fortified with calcium and sometimes Vitamin D as well, such as cereals, waffles, and orange juice (look for “Calcium added” in big letters on the packaging— but, remember that juice is sugary and not that healthy, so limit it!). Other good sources of calcium are spinach (240 mg per cup) and broccoli (180 mg per cup). Dark sugarcane-derived molasses has quite a bit, too (135 mg in 1 tbsp) — maybe put that over your fortified waffles? Also, mushrooms are your friend— they contain a lot of Vitamin D (634IU in 1 cup of portobello mushrooms)!

Note that for label-reading purposes, Daily Value for Calcium is 1000mg, which is LESS than the RDA for age 9+ of 1300 mg, and the Daily Value of Vitamin D is 400IU, also LESS than the RDA for kids 1year and older. So, when a label on your almond milk says it contains 45% of the DV of calcium, it means 45% of 1000, or 450mg. This is actually more like a third (33%) of what your child’s recommended Calcium intake should be.

Pearls of Calcium/Vit D Wisdom:

1. Drink milk or fortified milk substitutes or have other dairy 3 times a day
2. Enjoy calcium-rich greens like kale, bok choy, mustard greens
3. Look for other calcium-fortified foods like cereals, waffles, and orange juice
4. Molasses (dark, sugar-cane based) for calcium!
5. Mushrooms for Vitamin D!

8. IS MY VEGETARIAN/VEGAN GETTING ENOUGH VITAMIN B12?

Similar to the calcium and Vitamin D discussion, this is an area in which we pediatricians USED to tell vegetarians who consumed milk and eggs that they would be fine, whereas we told vegans they were not getting enough Vitamin B12 and would need a supplement. However, the food industry has come to the rescue! Fortified milk substitutes like coconut, soy, and almond milk now are fortified with Vitamin B12. One cup of Silk Soy or Organics Plain Soy milk has the Vitamin B12 that you need in a day. Fantastic! So—you decide— you can take a multivitamin with Vitamin B12, or you can make a habit of drinking fortified milk substitutes. Without either of these things, though, a vegan may not get enough Vitamin B12.

Again, don’t be confused in reading labels. In the case of B12, Daily Value —which is what percentages are based on for food labels—is a lot higher than RDA, which is the vitamin recommendation for kids by age. Younger children have a Vitamin B12 RDA of 1.2-1.8 mcg, while teens have an RDA of 2.4 mcg. On labels, however, packaging will list a percentile of the Daily Value (DV), which for Vitamin B12 is 6 mcg. If, for example, the label says a serving of your coconut milk has 50% the DV, it has 3 mcg, which is great and exceeds the RDA for your child.

9. IS MY VEGETARIAN/VEGAN GETTING ENOUGH ZINC?

Lacto-ovo vegetarians who are good about drinking milk probably are, but vegans may not be. To make things even harder, zinc quantities are often not even listed on packaging. The RDA of zinc for kids 9-13 yrs is 8 mg/day, whereas girls and boys fourteen and up need 9 mg/day and 11 mg/day, respectively. The DV of zinc is 15 mg —quite a bit higher than these RDA recommendations—so remember that when reading packages!

The kings of zinc provision are oysters (74 mg/cup), which provide 70x the amount of zinc in servings of a lot of other foods, but that doesn’t help our vegetarians/vegans (or many of our omnivores who are texturally-challenged when it comes to oysters). Legumes, nuts and seeds, however, can help you get enough zinc. A half cup of baked beans has 2.9 mg of zinc, and an ounce of cashews or pumpkin seeds have 1.5-2 mg.

10. IS MY VEGETARIAN/VEGAN GETTING ENOUGH FIBER?

Vegetarians and vegans SHOULD be getting enough fiber if eating a varied diet with many types of vegetables. However, this is not a given! Some vegetarians subsist on breads and cheese and are not getting the fiber they need. Fiber is a challenge for many children and teens these days, as evidenced by our seeing a lot of constipation problems in the pediatric office. Look to whole grains, vegetables and fruits (with the exception of bananas) to be excellent fiber sources. Kids need about 25-30 grams of fiber daily, and they can get 5 grams in a serving of bran flakes alone. One rule of thumb is that for every 1000 kcal that a person eats, they should strive for 14g of fiber.

11. Make things delicious.

One of my sister’s biggest pieces of advice to other vegetarians/vegans and their families is to continue to expand your culinary and dietary horizons and not view the vegetarianism as an impediment to enjoyment. As a physician who wants people to strive for variety in even a restricted diet, I whole-heartedly agree. Take a world view. Asian food is great for vegans—the only big things to avoid are fish and oyster sauces, but many recipes and restaurants can make do with soy sauce alone. Curries often are made with coconut milk—perfect. Mexican food allows for many vegan options such as veggie tacos, guacamole and salsa, and black bean soup. Italian food with its pasta and tomato and pesto sauces, pizzas that can be made vegetarian, and risotto (great with mushrooms) offers great options, as does do Greek, Mediterranean, and Middle Eastern cuisines with their salads, hummus, and baba ganoush. Indian cuisine with its rice, naan, garbanzo beans, and spinach paneer (to name just a few things) is perfect. The list goes on. Often, the heart of a dish is really its seasoning and spices, and those can be enjoyed with just vegetables or a meat substitute!

There are so many options available at grocery stores now, too. Score! You can buy faux chicken fingers, veggie burgers, “meat”balls,” meatless-sausages and of all kinds, and even vegan hotdogs. And—from experience—they can taste pretty good!. Veggie bacon may not taste quite as amazing as real bacon, but it helps fulfill a craving, doesn’t allow for feeling deprived, and holds to your vegetarian choice. You can also learn to cook with meat-substitutes like tofu, tempeh, and seitan (contains gluten) that are now featured entrees of some world-class vegan restaurants. And, on the subject of dining out, we at the Cook Children’s Henderson office are extremely close to a great Fort Worth vegan establishment — Spiral Diner!

There is also the potential for amazing desserts. There are many vegan ice creams available now, including several options by Ben and Jerry that are incredibly tasty. You can also whip up cashew cream to use in place of real cream in cake and other recipes. My sister likes to slice bananas, freeze them, and then put them through the food processor with peanut-butter and/or chocolate syrup for a delicious and pretty healthy vegan dessert.

Best wishes for your ventures into vegetarianism and veganism. Who knows, dietary change that seems intimidating now may become second nature and a part of your child and your family’s identity. Think of Reese Witherspoon’s character in Legally Blonde, introducing herself to her Harvard Law School classmates. “Hi, I’m Elle Woods, and (holding up her chihuahua) this is Bruiser Woods,” she says, “and we are both Gemini vegetarians.”

Bon appetit to all, and many thanks to my awesome sister, Ariana Nizza-Chapman, for the inspiration and the many tips!

But I hear from my patient families all the time that it's anything but relaxing.

The American Academy of Pediatrics recommends doctors ask parents three questions about mealtime:

1. How anxious are you about your child’s eating?

2. How would you describe what happens during mealtime?

3. What do you do when your child won’t eat?

When offered a healthy, well balanced meal with fresh fruits, vegetables, and lean proteins, kids will stop eating when they are full. Children will naturally refuse to eat when they are not hungry. We often describe these as normal appetite slumps. We can disturb children’s natural satiety cues by either forcing them to eat or by offering foods high in added sugar or salt when they won’t eat. This results in a child who will “only eat chicken nuggets.”

Parents are most successful in feeding their children more fruits and vegetables when they model healthy eating, set appropriate limits, and have a positive attitude at mealtime. “The parent determines where, when, and what the child is fed; the child determines what to eat.” ⁽¹⁾ In other words, “parents provide and kids decide”. ⁽²⁾ 

Here are some tips on eating mindfully and encouraging your kids to eat in a manner that gives them more energy and helps them avoid chronic disease. These are easy ways to change your lifestyle that don’t involve a ton of work and expensive supplements.

1.Drink more water. Kids should not drink juice or soda except on special occasions.

2.Drink milk with meals. Children from age 1-2 should be on whole milk. After the age of 2, low fat or skim milk is recommended.

3.Vitamin supplements are not needed unless your child does not drink milk. Vitamin D is essential for bone health and immune function and may play a role in prevention of chronic disease.

4.Serve 5-9 servings of fruits and vegetables daily. Encourage your children to at least take a bite of everything you serve. Remember that children will need to taste a food 10-15 times before they decide they like it. Lean protein like fish and baked chicken might be better accepted if you add ketchup as a condiment.

5.Add healthy protein likes nuts (for older children) and legumes. Peanut butter is fine for younger children and new allergy immunology guidelines suggest that early introduction of peanut may actually decrease the risk of peanut allergy.

6.Eat more meals at home. Keep staples such as eggs, whole grain pasta, pasta sauce, yogurt, carrots, frozen vegetables, chicken breasts, and fruit stocked at all times so that in a pinch you could throw together a simple meal.

7.Double your recipes and freeze 1 meal at the same time that you cook the other meal. This will save you from making a trip to a fast food restaurant when you have that go to meal in your freezer.

8.Serve only whole grain breads and pastas.

9.Avoid buying, eating, or serving processed foods (chips, cookies, cakes).

10.Avoid fried foods and fast foods.

To read more about nutrition needs of children at different ages, I highly recommend the book “Nutrition: What Every Parent Needs to Know" available on the American Academy of Pediatrics (AAP) online bookstore.

See choosemyplate.gov for more information about how your child’s plate should look at meal time.

Realize that children’s tastes will change over time. They will sometimes refuse foods they readily accepted in the past, and they will readily accept foods that they refused in the past. Involve your children in shopping and meal planning. Let them help in the kitchen! Take them to a local farmer’s market and let them choose something new for everyone to try.

Take a matter of fact and pleasant approach to meal times and ENJOY YOUR FAMILY! Create wonderful childhood memories.

References:

1. “A Practical Approach to Classifying and Managing Feeding Difficulties” Pediatrics Volume 135, number 2, February 2015

2.Nutrition: What Every Parent Needs to Know. AAP

You lovers of Texas steak may feel nervous about parenting a vegetarian. To continue the movie theme of my first article, you may feel a little like Buddy in the movie Elf, when he sees an escalator for the first time. He knows he wants to get to the second floor of the department store, but is unsure how the escalator ride will play out. Similarly, you want to provide balanced nutrition even in the face of vegetarianism, but you are not sure what to buy, cook, or serve in the process. Buddy the Elf, after some tentative stepping and flinching, eventually commits to the moving stairwell and – although he does an awkward (and humorously glorious) man-split along the way – he does make it to the top. And so will you. I will do my best to guide you to a healthful place of comfort, and you won't have to do the splits!

By the way, for my longer responses, I will first give a basic answer, then delve into the details, and last give you some take-home pearls. So, if the details get too tedious, skip ahead to the pearls. You can always return to the details for reference.

Will My Vegetarian/Vegan Child Get Enough Protein?

Set the scene for this section by thinking of Hans and Franz, the two body builders from those old SNL episodes whose chief concerns were their “giant muscles” and their promise to “Pump. . .(clap)… YOU up.” Protein is indeed important for muscles, strength, overall health, and general “pumpitude.”

Answer: For lacto-ovo vegetarians, those who are not vegan and therefore consume both milk and eggs (both good sources of protein) - the answer is most likely YES, without even much forethought. Vegans, however, might not be getting enough protein and will need to strategize. The take-home message for them is that they need to eat a VARIETY of protein-sources each day and enough of them to meet requirements. I suggest counting protein grams for a few days, and - once you get the idea of what you need - then go for gestalt.

Now for the specifics. . . Animal-based foods (like meats, fish, dairy and eggs) are considered “complete proteins,” containing all 9 essential amino acids in a quite digestible form. On the other hand, plant-based foods are generally deficient in at least one amino acid, so - in order to get all 9 - you need to eat a variety of different plant-based foods with “complementary proteins.” For example, legumes (beans) are low in methionine but high in lysine, while grains are the reverse. If you eat both legumes and grains in one day, you get them all. Also, plant-based protein is less easily-digestible than animal-based, so you need to consume more protein daily as compared to a carnivore, to get the same benefit. Do note that there ARE a few plant based proteins which are becoming more popular and which are complete, including quinoa, hemp seed and chia seeds. Hooray!

If vegans drink soy milk as their milk-substitute, they will get nearly as much protein from it as someone drinking milk (6-7 grams per cup as compared to the 8 grams in milk). However, there are some concerns about the relationship between soy and estrogens and the potential impact on children’s endocrine/hormonal systems (endocrine-disruptors). If you would like to limit soy milk, another option for a milk-alternative is Ripple Pea Milk, made from peas and containing just as much protein (8 grams/cup) as regular milk. Simple almond, cashew, and coconut milks do not typically contain any protein, but there are starting to be some nut milks on the market that are fortified with pea protein (check out Silk Protein Nut milk which contains 10 grams of protein - woo-hoo!).

To give you some numbers, people generally need around 1 gram of protein per kilogram per day (just over 1 gram for toddlers, and 0.85-0.95 for kids/teens, but requirements can be 20 percent higher if protein is from harder-to-digest vegetable sources). Let’s consider a young teen who is 100 pounds, or 45 kilograms. That teen needs 43 grams of protein per day, which is pretty easily achieved if the child eats milk and eggs. In breakfast alone, she can get 17 grams, with her cup of milk and cup of bran flakes (8 grams plus 3 grams respectively) plus one boiled egg (6 g). Not bad for one meal alone! If that teen is a vegan, though, she may need as many as 51 grams of protein daily, since her proteins will be harder to digest. Tofu faux-eggs scrambled in the morning could help reach that goal (5g/oz), along with a cup of Ripple Pea milk (8g). Beans are a great go-to (8 g per half-cup), as are broccoli (4 g per stalk), spinach (5g per half-cup), and artichokes (4g per one medium-sized). Expand into ancient grains such as quinoa and amaranth, the latter which can be made into breakfast porridge and sprinkled with hemp or chia seeds for even more protein. And don’t forget peanut-butter sandwiches - they have 13 grams each!

WILL MY VEGETARIAN/VEGAN GET ENOUGH FAT or Omega-3s?

Set the scene for this section by remembering the movie Bill and Ted’s Excellent Adventure, when Napoleon Bonaparte, who has traveled in time to a modern ice cream parlor, orders one of those enormous volcano bowls with a mountain of ice-cream. Being a bit greedy, Napoleon eats so much that the servers sing and clap for him and honor him with a Piggy Prize. Napoleon, at least in that vegetarian dining experience, gets more than enough fat!

Answer: It is absolutely possible and important to get enough fat, but it is not a given! Keep in mind that people of all diets can make healthy or unhealthy choices even within their dietary restrictions. If your child vegetarian leans toward a diet heavy on the grilled cheese sandwiches and macaroni and cheese, not to mention donuts and cookies, while perhaps tending away from as wide a variety of vegetables as you would like, he/she may actually have a high-fat diet. Many teens, however, go the opposite direction and eat overflowing and deceptively- filling plates of vegetables that do not have enough fat.

Fat is important and should make up approximately 30 percent of the energy a child/teen consumes in a day. Since fat provides 9 kcal per gram, teens consuming 2000 - 2600 kcal per day need around 75g of fat per day. Keep in mind, though, that fats are not created equally— what you mainly want for your child are the “good guy” unsaturated ones (both poly- and mono-unsaturated) that reduce cholesterol and triglyceride levels and help for heart health. They are much better than the artery-clogging “bad boy” saturated and trans fats, which should be limited.

Good sources of fat include avocados (32 g each!), peanut butter (16 g per 2 tbsp serving), cashew/almond butter, whole nuts, seeds, and oils such as olive, canola, and coconut oil. It is a great idea to cook those yummy but non-fat veggies in olive or canola oil, as 1 tbsp of either has about 14 g of healthy, mostly unsaturated fat (coconut oil is an option, too, though it has mostly saturated fat). A cup of milk contains 2.5 g of fat, and fortified substitute milks have about that much or more. You will have to read labels on them, as there is some variability - Silk Coconut milk and Ripple Pea Milk top the charts with 5 g and 4.5 g per cup, respectively.

And, while we are on the subject of fats, what about those Omega-3 fatty acids (DHA, EPA, and their precursor called ALA) that everyone is always talking about, the ones that help for eye and brain development and also for heart health? The main sources of omega-3s are fish, eggs, and algae, but how much algae is your vegetarian/vegan eating? Indeed, vegetarians and vegans have been shown to have generally lower levels of omega-3s than omnivores and would likely benefit from more, though as of yet there are no officially recommended daily allowances for omega-3s for children (or adults). For adults, there is a suggestion that 250 mg - 1000 mg (or 1 g) of Omega -3s is a good minimum daily goal.

Kids/teens can get one of the omega-3s, alpha- linoleic acid (ALA), through ground flaxseeds and hulled hemp seeds (which can be added to pancake mix or oatmeal), chia seeds (which can be added to smoothies), walnuts, soy, and canola oil. Take note that whole flaxseeds will not really help get omega-3s, as they just pass through the body untouched without releasing their good fat content. So you must either grind flaxseeds in a coffee-grinder or buy flaxseed meal (like Bob’s Red Mill flaxseed meal). One tablespoon of flaxseed meal or raw hulled hemp seed has approximately 4 g of healthy fat and about 2000 mg (2 g) of Omega- 3 fatty acids— not bad! Kids can also get Omega-3s (DHA) from Ripple Pea milk, the milk substitute made from peas (32 mg Omega-3s per cup).

Will My Vegetarian/Vegan Get Enough Iron?

Set the scene by remembering Popeye the Sailor Man, who in times of trouble ate a can of spinach, sprouted huge muscles, and pummeled his way to victory. The makers of the cartoon thought spinach gave Popeye tons of iron, which made him strong. Later, however, it was revealed that the then popularly accepted quantity of iron in spinach (35 mg per 100g) was WRONG by a power of 10 and was really just 3.5 mg! A scientist’s TYPO had led to Popeye’s eating spinach and to sales of spinach reportedly climbing three-fold in the United States. Spinach does have a lot of iron insofar as vegetables go, but if Popeye really wanted concentrated iron in a can, he needed to have eaten tuna fish (13 mg per can)!

Answer: Yes, vegetarians can get can enough iron if they plan! It is certainly easier for meat and fish eaters to get enough iron, and - unlike the protein situation - milk and eggs are not too helpful as iron sources. Consequently, vegetarians and vegans are both in the same boat. There is a lot of iron in meat, and that “heme-iron” is more easily absorbed than “non-heme iron” in vegetables. So vegetarians and vegans alike will need to eat more of their iron-containing vegetable-based foods to get the necessary iron. It is also important to note that some foods can help or hurt you in your efforts to get iron. Legumes (which have phytates) or coffees and teas (which have tannins) decrease iron absorption from other foods, while your friend Vitamin C - think oranges, strawberries, tomatoes - increases iron absorption.

Toddlers and school kids need between 7-10 mg of iron daily, whereas teens need more, 11mg for boys and a whopping 15 mg for girls (who lose iron with their periods). One cup of kale or collard greens has just 1mg, so you can see that you will need quite a bit to approach the daily requirement.

Remember oatmeal as a great source of iron - 13 mg in one cup! Dried fruits can be helpful to have around (1.75mg in 1/2 cup of dried apricots), as can peas and pistachios (2 mg in 1/2 cup peas, 1.2 mg in 1/4 cup of pistachios). Ripple pea milk, a milk substitute made of peas, has quite a bit of iron—2.7 mg per cup (on the label it says 15 percent of the 18 mg/day Daily Value)! Soy and nut milks do not have nearly that, but some have 0.75-1mg per cup. Chocolate Silk Cashew Milk has just over 1 mg per cup (or 8 percent of the DV), and every little bit helps!

As I have warned before, don’t be misled by percentages of Daily Value on the food labels. The DV for iron is 18mg, but that is actually more than your child needs according to RDAs (even if your child is a female teen who needs 15 mg per day). So, if your oatmeal has 20 percent of the DV of iron, it has 3.6 mg. That is not just 20 percent but more like 33 percent of what your child needs.

Set the scene for this question by thinking of all those celebrities with their milk mustaches in the milk ads. Oh that we should all have a milk (or substitute milk) mustache!

Answer: As Marisa Tomei’s character said in the movie My Cousin Vinny, “It is a trick question.” She also used other words not fit for this blog. Still, this question is tough because truthfully, many teens of even unrestricted diets seem to struggle these days to get enough calcium and Vitamin D, as many replace their milk-drinking habits with a sugary-beverage habit. However, if a teen (vegetarian or not) has about three servings of dairy a day plus vegetables that contain calcium, he or she can usually get the recommended 1300 mg of calcium (RDA is 1000 mg for kids 4-8 years old and 1300 mg for kids 9-18) and the 600-800 IU of Vitamin D recommended (600 for 1-9 year-olds and 800 for 9 and up). Vegan kids and teens also can get enough calcium these days, too, IF they drink a fortified milk substitute. This is a wonderful gift of the food industry to vegans, as they have added calcium and Vitamin D to their milk substitute drinks. Whereas regular unfortified soy milk has 6 times less calcium than regular milk, most soy, almond, coconut, cashew and even pea (Ripple) milk at grocery stores today are fortified and have ample calcium, even 1.5 to 2 times the amount in regular milk!

Many other foods have been fortified with calcium and sometimes Vitamin D as well, such as cereals, waffles, and orange juice (look for “Calcium added” in big letters on the packaging— but, remember that juice is sugary and not that healthy, so limit it!). Other good sources of calcium are spinach (240 mg per cup) and broccoli (180 mg per cup). Dark sugarcane-derived molasses has quite a bit, too (135 mg in 1 tbsp) — maybe put that over your fortified waffles? Also, mushrooms are your friend— they contain a lot of Vitamin D (634 IU in 1 cup of portobello mushrooms)!

Note that for label-reading purposes, Daily Value for Calcium is 1000 mg, which is LESS than the RDA for age 9+ of 1300 mg, and the Daily Value of Vitamin D is 400 IU, also LESS than the RDA for kids 1 year and older. So, when a label on your almond milk says it contains 45 percent of the DV of calcium, it means 45 percent of 1000, or 450 mg. This is actually more like a third (33 percent) of what your child’s recommended Calcium intake should be.

IS MY VEGETARIAN/VEGAN GETTING ENOUGH VITAMIN B12?

Setting the scene for B12 is just about impossible. The best I can do is refer to the Tom Hanks movie (and Broadway musical) Big, in which twelve year old Josh Baskin gets his wish to turn into an adult and has many adventures as such. By the end of the movie, though, he is missing his youth and makes another wish to again “be twelve.” B12--get it?

Answer: Similar to the calcium and Vitamin D discussion, this is an area in which we pediatricians USED to tell vegetarians who consumed milk and eggs that they would be fine, whereas we told vegans they were not getting enough Vitamin B12 and would need a supplement. However, the food industry has come to the rescue! Fortified milk substitutes like coconut, soy, and almond milk now are fortified with Vitamin B12. One cup of Silk Soy or Organics Plain Soy milk has the Vitamin B12 that you need in a day. Fantastic! So - you decide - you can take a multivitamin with Vitamin B12, or you can make a habit of drinking fortified milk substitutes. Without either of these things, though, a vegan may not get enough Vitamin B12.

Again, don’t be confused in reading labels. In the case of B12, Daily Value - which is what percentages are based on for food labels - is a lot higher than RDA, which is the vitamin recommendation for kids by age. Younger children have a Vitamin B12 RDA of 1.2-1.8 mcg, while teens have an RDA of 2.4 mcg. On labels, however, packaging will list a percentile of the Daily Value (DV), which for Vitamin B12 is 6 mcg. If, for example, the label says a serving of your coconut milk has 50 percent the DV, it has 3 mcg, which is great and exceeds the RDA for your child.

IS MY VEGETARIAN/VEGAN GETTING ENOUGH ZINC?

Answer: Lacto-ovo vegetarians who are good about drinking milk probably are, but vegans may not be. To make things even harder, zinc quantities are often not even listed on packaging. The RDA of zinc for kids 9-13 yrs is 8 mg/day, whereas girls and boys fourteen and up need 9 mg/day and 11mg/day respectively. The DV of zinc is 15 mg -- quite a bit higher than these RDA recommendations--so remember when reading packages that your child doesn't need as much as the label would lead you to believe.

The kings of zinc provision are oysters (74 mg/cup), which provide 70X the amount of zinc in servings of a lot of other foods, but that doesn't help our vegetarians/vegans (or many omnivores who are texturally-challenged by oysters). Legumes, nuts, and seeds, however, can help you get enough zinc. A half cup of beans has 2.9 mg of zinc, and an ounce of cashews or pumpkin seeds have 1.5- 2mg.

IS MY VEGETARIAN/VEGAN GETTING ENOUGH FIBER?

Answer: Vegetarians and vegans SHOULD be getting enough fiber if eating a varied diet with many types of vegetables. However, this is not a given! Some vegetarians subsist on breads and cheese and are not getting the fiber they need. Fiber is a challenge for many children and teens these days, as evidenced by the large number of constipated kids seen in the pediatric office. Look to whole grains, vegetables and fruits (with the exception of bananas) to be excellent fiber sources. Kids need about 25-30 grams of fiber daily, and they can get 5 grams in a serving of bran flakes alone. One rule of thumb is that for every 1000 kcal that a person eats, they should strive for 14g of fiber.

Final Remarks:

I hope these answers help you to provide and oversee a balanced diet for your vegetarian or vegan child. Vegetarian and vegan diets can be both healthy and delicious. You just need to watch for areas where your child's food choices may be a little lacking in key nutrients and stay open to trying new and different healthful foods.

I am reminded of the movie My Cousin Vinny, in which New York lawyer Vinny Gambini, on his first morning in the American South, looks down at his breakfast. "What is this here?" he asks. The cook retorts, "You never heard of grits?" Vinny answers, "Sure, sure I heard of grits - I've just actually never SEEN a grit before."

Enjoy your adventure! And remember that your pediatrician and a whole team of Cook nutritionists are here to help if you need it.

We give vitamin K supplementation as an injection in babies following birth to prevent a condition called Hemorrhagic Disease of the Newborn. This devastating condition was, prior to the institution of the supplementation, a significant contributor to infant death, which ravaged society in the pre-twentieth century period. Vitamin K is necessary to make the clotting system in humans work properly. It basically allows clotting factors to be turned on so they can work correctly. As children and adults, we get most of our vitamin K from our diet (eat your green vegetables!) and surprisingly from bacteria, which normally live in your intestines. These bacteria process the components of food which we don’t, and produce the vitamin as benefit to us.

This vitamin dissolves in fat so adults generally store it well. Infants however do not have a good storage or supply of the vitamin. The placenta does not transmit it to the infant well and breast milk has very little vitamin K in it. Newborns also have no bacteria in their intestines to produce the vitamin; so, the end result is, without good storage of this vitamin, infants are at risk for severe bleeding problems. While this can present in the first week of life as bruising and bleeding from the umbilical cord stump, the most devastating effect is bleeding inside the brain which can occur up to 12 weeks after delivery.

Most of this bleeding risk can be avoided with an injection into the muscle of vitamin K at the time of birth. This provides a source of this valuable vitamin to tide the baby over until intestinal bacteria build up enough to produce the vitamin for the baby. As far as dietary sources, breast milk does not encourage the bacteria which produce this vitamin to grow well. Formula is supplemented with vitamin K, but importantly the different sugars in the formula do encourage the bacteria to develop, but it takes time.

Parents often hear stories about the vitamin K injections causing side effects, particularly a risk for cancer later in life (this was related to an old version which had a chemical called phenol in the formulation and never proven even when it was in there), worsening jaundice (again an old formulation used in the mid -twentieth century) and possible liver damage (which can happen from a large overdose, but highly unlikely with the standard amount given to infants).

Some have proposed alternatives methods as the safest and most effective means to administer vitamin K, generally giving the vitamin by mouth to the baby. The big problem with this strategy is absorption of the vitamin is not guaranteed in infants so we have to give a large dose for a long time to do this. With high doses over a long time you do run the risk of getting too much vitamin K and causing liver problems. There are no commercial liquid forms of this drug, so often the injection solution is just fed to the infant. Over the counter vitamins K pills are not well absorbed at all and there is no certainty in these preparations how much vitamin K the infant will get. In a misguided effort to protect their baby from harm, parents end up exposing them to much more risk.

The American Academy of Pediatrics does not recommend oral supplementation, because it has significant risks compared to the simple vitamin K injection, which has proven both safe and very effective to prevent this condition for decades.

About the author

Donald Beam, M.D., is a hematologist and the medical director for the Life After Cancer Program at Cook Children's. Learn more about the Hematology and Oncology Progam at Cook Children's today.

When author Dan Buettner and fellow staff members looked at areas of the world where people lived longer - they circled it with a blue sharpie on the map - that is how those areas became known as The Blue Zones. Some of the areas with longevity that Dan studied were Sardinia, Italy, Okinawa, Japan, and Loma Linda, California. He learned that the people in these communities didn't choose longevity. Longevity happened to them. Environment is the key to a healthy life, not necessarily personal will power. 

Cook Childrens is a proud sponsor of the Blue Zones Project and Fort Worth is the only city in the south participating. I recently attended the Fort Worth kickoff event for the Blue Zones Project. Dan discussed the common threads that he found in the communities he studied.

Here are some of his suggestions for longevity and a life free from chronic illness:

1. Stay active.

2. Wake up with purpose each day.

3. Find down time daily.

4. Eat mindfully. Eat more fruits and vegetables.

5. Belong. Make time for family, friends, and fellowship.

As a pediatrician, parents come to me with questions about how to care for their children. They depend on my advice to help them raise healthy kids, safe from the burdens of chronic diseases like obesity, hypertension, diabetes and heart disease. Providing a medical home truly is a partnership. It is up to all of us: the parents, the doctors, and the kids. We are a team.

In the upcoming weeks, I will give you tips on how to create a Blue Zone in your home. We can do this together.

For more information about blue zones, see www.bluezones.com and check out the vitality compass.

The DSHS has received reports of 205 cases of Cyclosporiasis in Texas. No cases have been reported at Cook Children's. In Cook Children's six-county service region, the following numbers have been reported:

The U.S. Food and Drug Administration's alert says cilantro from the Mexican state of Puebla may be the cause for the recent outbreaks.

Symptoms usually begin 2 to 14 days after ingestion of contaminated food or water.Mary Suzanne Whitworth, M.D.,medical director of Infectious Diseases at Cook Children’s, advises parents to contact their Cook Children’s pediatrician if they have a diarrhea-like illness lasting more than a few days or diarrhea accompanied by severe weight loss or fatigue. Those are symptoms of Cyclospora.

Symptoms include severe diarrhea that can last a week to months, and if not treated, the person may relapse. Additional symptoms may include fatigue, severe weight loss, abdominal cramps, bloating, increased gas, nausea, vomiting and low grade fever. If your child is experiencing these symptoms, do not wait. Contact your Cook Children’s pediatrician. If your child is diagnosed with Cyclospora, an antibiotic can be prescribed.

However, most cases of diarrhea or an upset stomach do not need treatment with an antibiotic. Usually, diarrhea is caused by viruses, so time, rest and diet will take care of the problem.

“Past outbreaks of Cyclospora in the U.S. have been caused from imported, fresh produce,” Dr. Whitworth said. “The best way to prevent Cyclospora in your household is to wash your fruits and vegetables as thoroughly as possible. Let fruits and vegetables soak for a few minutes in clean water in the sink, and then drain and spray them off with clean water before eating them. Thorough washing of fresh produce is highly recommended, but it may not remove the risk of someone in your family getting Cylospora entirely. If your child has these symptoms, it’s best to see a pediatrician and get treated as quickly as possible.”

Cyclospora is generally not transmitted directly from person-to-person, however children with diarrhea should always avoid swimming in pools to avoid the spread of infection.

The Centers for Disease Control and Prevention has more information about Cyclospora.

When should you call your pediatrician about diarrhea? Watch this video from Justin Smith, M.D., for more information.

Fiber is a part of plant foods (ex: whole grains, vegetables, fruit) that our bodies can’t digest.

There are two types: soluble and insoluble. Soluble fiber is most helpful for lowering cholesterol, and insoluble fiber is like a scrub brush that helps to prevent constipation. Most foods deliver a mix of soluble and insoluble fiber.

Most children and adults alike aren’t getting enough fiber in their diet each day. Are you?

Here is a table of recommended intakes:

To increase fiber intake, eat more vegetables, choose fruit instead of fruit juice, and choose whole grains such as brown rice instead of white rice. Be careful to increase fiber slowly, and increase water intake as you do to avoid bloating and gas.  

So, add some fiber to your summertime cookouts!

Grilling vegetables adds a new dimension to their flavor. Slice vegetables with skin still intact, brush with some olive oil, season to taste, and toss on the grill. You can add grilled bell pepper or onion to your sandwiches, or make a side of grilled vegetables to go with your meal. Try this recipe to get started.

If grilling vegetables doesn’t appeal to you, here are a few other options:

• Try a variety of vegetables dipped in salsa, hummus or light ranch dressing.
• Add a fruit salad for a side or dessert.
• Choose whole wheat buns for sandwiches.

* Moshfegh A, Goldman J, Cleveland L. What We Eat in America, NHANES 2001-2002: Usual Nutrient Intake From Foods as Compared to Dietary Reference Intakes. U.S. Department of Agriculture, Agricultural Research Service, 2005.

About the author

Lauren Mullins is a clinical dietitian for the Endocrinology department’s REACH clinic at Cook Children’s.