Végéta*ismes : avis divers

Plusieurs agences et association ont émis des avis favorables aux alimentations végétariennes et végétaliennes bien planifiées, précisant parfois « à tous les âges de la vie » comme l’Académie de Nutrition et Diététique américaine (une liste ici). Certains avis plus prudents, notamment en ce qui concerne l’adoption de tels types d’alimentation pour les enfants, ont été publiés, principalement depuis 2015.

Sur le sevrage des nourrissons : cette publication suggère qu’il n’y a pas à ce jour de recherche solide pour soutenir la faisabilité et la sécurité des méthodes alternatives de sevrage.

Vegetarian and Vegan Weaning of the Infant: How Common and How Evidence-Based? A Population-Based Survey and Narrative Review
Baldassare et al.
Environmental research and public health, 2020
https://www.mdpi.com/1660-4601/17/13/4835/htm?fbclid=IwAR3YlEv5YzMh5PRatvdvGtKwDvZVOGi2OgHeM0QOhIhYgXBsZVp0dXdywPo#B20-ijerph-17-04835

To date, consistent findings to support both the safety and feasibility of alternative weaning methods are still lacking. Since the risk of nutritional deficiencies in the early stages of life is high, pediatricians have a pivotal role in guiding parents and advising them on the most appropriate and complete diet regimen during childhood. Efforts should be made to enhance nutritional understanding among pediatricians as an unsupervised vegetarian or vegan diet can cause severe nutritional deficiencies with possible detrimental long-term effects.

FSAI Publishes First Healthy Eating Recommendations for 1-5 Year-Olds
Food Safety Authority of Ireland, 2020
https://www.fsai.ie/news_centre/press_releases/healthy_eating_1-5yearolds_22062020.html

Milk is a key food, with a daily intake of 550ml of cow’s milk, or equivalent amounts of yoghurt or cheese, is recommended. […]
Lean red meat (about 30g) is recommended three days a week for iron and other essential minerals in addition to protein. On other days, red meat can be replaced with poultry, fish, eggs, beans or lentils which also provide iron, as well protein and minerals. 

Pas opposé, mais souligne les risques accrus de carences, le besoin d’être suivi par un professionnel, et plusieurs nutriments autres que la vitamine B12 conseillés aux mères.

Vegetarian diets in childhood and adolescence.
Position paper of the nutrition committee, German Society for Paediatric and Adolescent Medicine (DGKJ)

Rudloff et al.
Molecular and cellular paediatrics, 2019
https://molcellped.springeropen.com/articles/10.1186/s40348-019-0091-z

due to their higher nutrient requirements per kilogramme of body weight, vegetarian children have a higher risk for developing nutrient deficiencies than adults. […] A vegetarian diet in childhood and adolescence requires good information and supervision by a paediatrician, if necessary, in cooperation with an appropriately trained dietary specialist. […] mothers with vegan or vegetarian diets need to take vitamin B12 supplements, preferably combined with other critical nutrients such as iron, zinc, iodine, vitamin D and DHA.

Effects of vegan complementary feeding on the health of children from 6 to 24 months of age : literature review
Diaz & Yadira
Pontificia Universidad Javeriana, 2019
https://repository.javeriana.edu.co/handle/10554/46287

Conclusion: The scarce literature available on the subject, the heterogeneity of the studies and the biases that may occur in the sample populations, do not allow to conclude the benefits and risks that vegan diets may present in the health and nutritional status of Children from 6 to 24 months old.

Vegan diet in children and adolescents. Recommendations from the French-speaking Pediatric Hepatology, Gastroenterology and Nutrition Group (GFHGNP).
Lemale et al.
Archives de pédiatrie, 2019
https://www.ncbi.nlm.nih.gov/pubmed/31615715

The current craze for vegan diets has an effect on the pediatric population. This type of diet, which does not provide all the micronutrient requirements, exposes children to nutritional deficiencies. These can have serious consequences, especially when this diet is introduced at an early age, a period of significant growth and neurological development. Even if deficiencies have less impact on older children and adolescents, they are not uncommon and consequently should also be prevented. Regular dietary monitoring is essential, vitamin B12 and vitamin D supplementation is always necessary, while iron, calcium, docosahexaenoic acid, and zinc should be supplemented on a case-by-case basis.

Avis du comité de nutrition et d’allaitement de l’association pédiatrique espagnole :

Position paper on vegetarian diets in infants and children. Committee on Nutrition and Breastfeeding of the Spanish Paediatric Association
Susana Redecilla Ferreiro et al.
Anales de pediatrìa, 2019
https://www.sciencedirect.com/science/article/pii/S1695403319303789?via%3Dihub#bib0215

After reviewing current evidence, even though following a vegetarian diet at any age does not necessarily mean it is unsafe, it is advisable for infant and young children to follow an omnivorous diet or, at least, an ovo-lacto-vegetarian diet.

De nombreuses références dans ce papier :

Veganism and Children: Physical and Social Well-Being
Marcus William Hunt
Journal of agricultural and environmental ethics, 2019
https://link.springer.com/article/10.1007/s10806-019-09773-4#Bib1

parents have a significant pro tanto moral reason not to raise their child on a vegan diet due to the risk of harm that such a diet poses to the child’s physical and social well-being

Questions about a vegan diet should be included in differential diagnostics of neurologically abnormal infants with failure to thrive
A. M. Lund
Acta Paediatrica, 2019.
https://onlinelibrary.wiley.com/doi/full/10.1111/apa.14805

In its 2019 recommendation, and earlier recommendations, the Danish National Health Authorities advised parents to avoid a vegan diet when feeding young children […]
Plant‐based diets have shown a rise of the popularity, because of animal welfare, the environment and general health issues, and measures need to be taken to prevent the clinical consequences in young children. There is evidence that such diets in pregnant and lactating mothers may have serious consequences for their children. This supports the argument for not pursuing such diets, especially a vegan diet, during pregnancy and lactation and in young children.

Vegans, vegetarians and pregnancy
George F. Winter
British Journal of Midwifery, 2019
https://www.magonlinelibrary.com/doi/abs/10.12968/bjom.2019.27.2.75

This caveat implies that, in contrast to a balanced omnivorous diet, a vegan diet in pregnancy may court an element of risk. This places a primary responsibility with the mother to ensure that her diet is nutritionally suitable for herself and her child.

Une étude qui souligne le manque d’études de bonne qualité et la difficulté de tirer des conclusions.

Is a vegetarian diet safe to follow during pregnancy? A systematic review and meta-analysis of observational studies
Tan et al.
Critical studies in food science and nutrition, 2019
https://www.tandfonline.com/doi/abs/10.1080/10408398.2018.1461062

The overall estimated relation between vegetarian pregnancy and low birth weight (LBW) was marginally significant (1.27 (0.98, 1.65), P = 0.07, I2=0%). Asian (India/Nepal) vegetarian mothers exhibited increased risks to deliver a baby with LBW (1.33 (1.01, 1.76), P = 0.04, I2=0%). However, the WMD of neonatal birth weight in five studies suggested no difference between vegetarians and omnivores. Given the high heterogeneity of the included studies, lack of high-quality evidence, and limited studies included for each category, we failed to reach conclusive results regarding the risks of hypospadias, intrauterine growth retardation, maternal anemia, and gestational diabetes mellitus.

En mai 2019, l’académie royale de médecine de Belgique émet un avis qui ne recommande pas une alimentation végétalienne pour les enfants, notamment. L’avis étant très mal motivé, et ayant de ce fait subi de nombreuses critiques (justifiées), l’académie émet une mise au point en juin, plus sérieusement étayée.
Voir dans tous les cas plus bas par exemple l’avis de la COFA suisse pour un avis sérieux (mais il y en a d’autres).

Régimes végétariens et végétaliens administrés aux enfants et adolescents
Académie Royale de Médecine de Belgique, 2019
http://www.armb.be/index.php?id=armb_detail&tx_ttnews%5BbackPid%5D=575&tx_ttnews%5Btt_news%5D=1564&cHash=074751aeca05c43b7ab096abc7db5d48

Par contre, le régime végétalien est inadapté et donc non recommandé pour les enfants à naître, les enfants et les adolescents, de même que les femmes enceintes et allaitantes. Les supplémentations obligatoires, les déséquilibres métaboliques et l’obligation d’un suivi médicalisé, y compris par prélèvements sanguins, ne sont donc pas admissibles. Le fait de les administrer à des enfants soulève donc d’importants problèmes bio-éthiques. En effet, ce régime induit de graves carences.

Mise au Point de l’Académie royale de Médecine de Belgique sur le régime végétalien pour les enfants, femmes enceintes et allaitantes
Juin 2019.
http://www.armb.be/index.php?eID=tx_nawsecuredl&u=0&g=0&hash=8be75426bdfd1667aa53169e9b1330e9e56c7c22&file=fileadmin/sites/armb/upload/armb_super_editor/armb_editor/pdf/Avis/2019/ARMB__Regime_vegetalien_.docx.pdf

L’avis a fait l’objet d’une réponse d’un collectif de médecins et diététiciens :
Sécurité des régimes végétariens et végétaliens chez la femme enceinte, allaitante et chez l’enfant en phase de croissance.
Risos Lamprini & Devillers Catherine
https://docs.wixstatic.com/ugd/9a68bb_a254b2553ce84f1f83313a0df93b9e23.pdf

La COFA  (Commission Fédérale de l’Alimentation (Suisse)), remarque qu’entre la théorie des tables nutritionnelles et la réalité du terrain, il y a de sérieuses différences, et ne conseille un régime végétalien qu’à des personnes hautement motivées.

Régimes végétaliens: analyse des avantages et des inconvénients sur le plan nutritionnel et pour la santé (2018)
https://www.eek.admin.ch/eek/fr/home/pub/dieteveganeavantagesetinconvenients.html
https://www.eek.admin.ch/eek/fr/home/pub/vor-und-nachteile-vegane-ernaehrung.html

Un régime végétalien bien planifié et supplémenté pourrait en théorie couvrir les besoins nutritionnels, mais les résultats montrent qu’en réalité, les carences sont fréquentes pour certains nutriments. Si des sujets hautement motivés veulent adopter ou conserver un régime végétalien, ils devraient être informés des directives alimentaires, des besoins en supplémentation et des précautions de suivi possibles.

Page 6 du rapport complet : « Children and pregnant women
are advised against adopting a vegan diet due to the risks described above »

Par ailleurs, l’avis souligne (page 49) l’hétérogénéité des études (en se basant sur Dinu et al., 2017, citée plus loin), et notamment le fait que les études sur les adventistes du 7ème jour (SDA) peuvent aboutir à des résultats sensiblement différents des autres études, avec l’exemple du cancer du sein. De même, les études de longue durée sont susceptibles sur cette pathologie d’être moins favorables au végétarisme (on retrouve les mêmes différences sur la mortalité globale, moins prononcées) :

Incohérence SDA sur cancer

Notons que les études menées sur les adventistes semblent être régulièrement plus favorables au végétarisme que les études menées dans le reste du monde. Ci-dessous extrait d’un tableau donné par le docteur Jérôme Bernard-Pellet dans cette conférence.

Adventices

Alimentation végétarienne et ­végane chez les enfants et ­adolescents
Bieri et al.
Forum médical suisse, 2018
https://medicalforum.ch/fr/article/doi/fms.2018.03258?fbclid=IwAR0TjsE9fdHVNuZsRuSYGbzUGjZDTxjUuVmZh72ncxqT4_6S-Ob_Brat8Ek

un régime végan n’est en principe clairement pas recommandé pour les nourrissons et les enfants en bas âge.
[…]Pour conclure, il convient de mentionner qu’il y a un besoin urgent de clarification et de recherche sur les conséquences à long terme d’une alimentation végétarienne ou végane chez les enfants. Il n’existe jusqu’à présent guère de données sur les répercussions métaboliques, les bénéfices, mais aussi les risques à long terme d’un régime sans viande durant l’enfance

  –  

[Vegetarian Diets in Children? – An Assessment from Pediatrics and Nutrition Science]
Kersting et al, 2018
https://europepmc.org/abstract/med/29471576

Vegetarian diets as the lacto-ovo-vegetarian diet (exclusion of meat, fish) and the vegan diet (exclusion of all food groups of animal origin) need to be evaluated for their potential to safely meet the high and specific requirements for growth and development. In this regard, high-quality studies are needed. In individuals on lacto-ovo-vegetarian diets, the safe supply with critical nutrients should be checked by thorough dietary history, possibly additional laboratory tests in risk situations like pregnancy, infancy and toddlerhood. Children on pure vegan diet need ongoing elaborate dietary strategies and continuous supplementation at any age, similar to nutritional management in children with metabolic disorders. A vegan diet is disadvised during all periods with intense growth and development.

Critique de l’avis de l’AND.

Is vegetarianism healthy for children?
Nathan Cofnas.
Critical review of food science and nutrition, 2018.
https://www.tandfonline.com/doi/full/10.1080/10408398.2018.1437024

The present paper argues that the Academy of Nutrition and Dietetics ignores or gives short shrift to direct and indirect evidence that vegetarianism may be associated with serious risks for brain and body development in fetuses and children. Regular supplementation with iron, zinc, and B12 will not mitigate all of these risks. Consequently, we cannot say decisively that vegetarianism or veganism is safe for children.


Cette revue systématique souligne l’hétérogénéité des échantillons, les biais en faveur des classes supérieures, la rareté des études récentes… et conclut que l’on ne peut pas tirer de conclusions solides sur les risques ou bénéfices possibles d’une alimentation de type végétarienne pour les enfants et les adolescents. Du fait du très faible nombre d’études (2 retenues) sur les enfants végétaliens, ceux-ci ne sont pas évoqués dans les conclusions.

Vegetarian diets in children: a systematic review
Schürmann S, Kersting M, Alexy U, 2017
https://www.ncbi.nlm.nih.gov/pubmed/28299420
http://www.medicosadventistas.org/wp-content/uploads/2018/09/Vegetarian-diets-in-children.pdf

Due to the study heterogeneity, the small samples, the bias towards upper social classes, and the scarcity of recent studies, the existing data do not allow us to draw firm conclusions on health benefits or risks of present-day vegetarian type diets on the nutritional or health status of children and adolescents in industrialized countries.[…]
[Présent dans la première version que j’avais eue, mais apparemment retiré ensuite:] (no contemporary systematic review on vegetarian type diets in infancy, childhood, and adolescents has been published” and that paper itself, in attempting to give such a systematic review, could not “draw firm conclusions on health benefits or risks” of vegetarian diets for these groups, let alone vegan diets)

POSITION PAPER SIPPS-FIMP-SIMP DIETE VEGETARIANE IN GRAVIDANZA ED ETÀ EVOLUTIVA
Società Italiana di Pediatria Preventiva e Sociale, Federazione Italiana Medici Pediatri, Società Italiana di Medicina Perinatale, 2017
https://www.researchgate.net/publication/320004250_POSITION_PAPER_SIPPS-FIMP-SIMP_DIETE_VEGETARIANE_IN_GRAVIDANZA_ED_ETA_EVOLUTIVA

Da tali studi si deduce che le diete LOV e vegana sono inadeguate al corretto sviluppo neuro-psico-mo-torio del bambino. In particolare la carenza di vitamina B12, DHA e ferro che può ad esse conseguire, è in grado di provocare danni irre-versibili al sistema nervoso […] In conclusione, la dieta vegana non deve essere raccomandata in età pediatrica perché priva di vitamina B12 e carente di DHA, ferro, vitami-na D e calcio. Se viene consigliata deve assolutamente essere integrata con tutti i nutrienti su citati. I bambini, che seguono questa dieta, devono essere attentamente moni-torati nella loro crescita e nel loro sviluppo generale.
[…] La Società Italiana di Pediatria Preventiva Sociale, la Federazione Italiana Medici Pediatri e la Società Italiana di Medicina Perinatale, firmatarie del Position Paper, raccomandano una dieta che compren-da tutti i gruppi alimentari e ritiene che la Dieta Mediterranea, basata sul consumo prevalente di molti alimenti vegetali e sull’uso limitato di prodotti animali, sia il modello alimentare ideale per assicurare salute ai bambini ed agli adulti.

Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on
Nutrition
Mary Fewtrell et al., 2017
https://journals.lww.com/jpgn/fulltext/2017/01000/Complementary_Feeding___A_Position_Paper_by_the.21.aspx

Although theoretically a vegan diet can meet nutrient requirements when mother and infant follow medical and dietary advice regarding supplementation, the risks of failing to follow advice are severe, including irreversible cognitive damage from vitamin B12 deficiency, and death. If a parent chooses to wean an infant onto a vegan diet this should be done under regular medical and expert dietetic supervision and mothers should receive and follow nutritional advice (115). Mothers who are consuming a vegan diet need to ensure an adequate nutrient supply, especially of vitamins B12, B2, A, and D, during pregnancy and lactation either from fortified foods or supplements. Careful attention is required to provide the infant with sufficient vitamin B12 (0.4mg/day from birth, 0.5mg/day from 6 months) and vitamin D, and iron, zinc, folate, n-3 fatty acids (especially DHA), protein, and calcium, and to ensure adequate energy density of the diet.

Pas opposé, mais souligne plusieurs déficiences à combler.

Vegetarianism and veganism: not only benefits but also gaps. A review
Alessandra Petti et al.
Progress in nutrition 2017
http://www.networksecondoparere.it/data/repository/2932019290925c00f/petti_vegetarianismandveganismnotonlybenefitsbutalsogaps.pdf

Vegetarian and vegan diets are low in n-3 PUFA, proteins, calcium, zinc, iron, vitamins B12 and D.

La société allemande de nutrition considère qu’avec une alimentation purement végétale, il est difficile ou impossible de parvenir à un apport adéquat en certains nutriments. Elle ne recommande pas une alimentation végétalienne aux femmes enceintes, femmes allaitantes, nourrissons, enfants et adolescents. Elle recommande à ceux qui voudraient le faire supplémentation et suivi nutritionnel régulier.

Vegan Diet
Position of the German Nutrition Society (DGE)
Margrit Richter et al., 2016
https://www.ernaehrungs-umschau.de/fileadmin/Ernaehrungs-Umschau/pdfs/pdf_2016/04_16/EU04_2016_Special_DGE_eng_final.pdf

On the basis of current scientific literature, the German Nutrition Society (DGE) has developed a position on the vegan diet. With a pure plant-based diet, it is difficult or impossible to attain an adequate supply of some nutrients. The most critical nutrient is vitamin B12. Other potentially critical nutrients in a vegan diet include protein resp. indispensable amino acids, long-chain n-3 fatty acids, other vitamins (riboflavin, vitamin D) and minerals (calcium, iron, iodine, zinc and selenium). The DGE does not recommend a vegan diet for pregnant women, lactating women, infants, children or adolescents. Persons who nevertheless wish to follow a vegan diet should permanently take a vitamin B12 supplement, pay attention to an adequate intake of nutrients, especially critical nutrients, and possibly use fortified foods or dietary supplements. They should receive advice from a nutrition counsellor and their supply of critical nutrients should be regularly checked by a physician.

Ici on souligne le manque d’études randomisées. La conclusion n’est pas très claire, soulignant encore une fois ces faiblesses mais supposant que le végéta*isme est acceptable s’il n’est pas contraint financièrement.

Vegan–vegetarian diets in pregnancy: danger or panacea? A systematic narrative review
GB Piccoli et al.
BJOG, 2015
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.13280

The evidence on vegan–vegetarian diets in pregnancy is heterogeneous and scant. The lack of randomised studies prevents us from distinguishing the effects of diet from confounding factors. Within these limits, vegan–vegetarian diets may be considered safe in pregnancy, provided that attention is paid to vitamin and trace element requirements.[…]
Considering only those who choose vegan–vegetarian diets without financial constraints, and within the limits of highly heterogeneous, often low‐quality or old information (when the reporting and research standards were remarkably different), the available data support the safety of vegan–vegetarian diets in pregnancy, provided attention is paid to compensating for the nutritional deficiencies (mainly of vitamin B12 and iron).

Clinical practice: vegetarian infant and child nutrition.
Van Winkle et al.
European journal of pediatry, 2011
https://www.ncbi.nlm.nih.gov/pubmed/21912895

The more restricted the diet and the younger the child, the greater the risk for deficiencies.