- Click here for explanation of classification scheme.

The study aimed to answer three questions:

• At what age does growth faltering in height occur in children fed macrobiotic diets?
• Which nutritional factors are associated with linear growth retardation?
• What is the effect of modification of the diet on linear growth?

• Younger than eight years of age
• Dutch and Caucasian
• Birth weight of at least 2,500g
• Gestational age of 38 weeks or more
• No congenital disease
• Consumed macrobiotic diet from birth onward.

• Older than eight years of age
• Not Dutch or Caucasian
• Birth weight less than 2,500g
• Gestational age fewer than 38 weeks
• History of congenital disease
• Did not consumed macrobiotic diet from birth.

Recruitment

• Macrobiotic children: Recruited through macrobiotic teachers and other macrobiotic families participating in the study
• Omnivorous children: Recruited through eight child health clinics throughout the Netherlands.

Design

To identify age groups most at risk for growth faltering, a cross-sectional anthropometric study was done with the Dutch macrobiotic child population age zero to eight years.  Anthropometric measurements included: weight, recumbent length (for children younger than two years of age), standing height (for children two years of age and older) and mid-upper arm circumference. Food habits were checked by means of a structured questionnaire, including foods and cooking styles that were either typical or atypical for the macrobiotic diet.

Based on the results of the cross-sectional study, the following recommendations were given to all macrobiotic families in the Netherlands:

1. Add fat as an additional source of energy to reach a total of 25% to 30% of energy as fat. Suggestions were made to increase consumption of oil, nuts and seeds.
2. Include two to three servings of fish per week (especially fatty fish in the winter)
3. Increase consumption of plant sources of vitamin B₂ and calcium. (Even though plants are poor sources of calcium, dairy was not explicitly mentioned because this is incompatible with macrobiotic philosophy.)

A mixed-longitudinal study was done with macrobiotic infants (age four to 18 months) and omnivorous control subjects matched for month of birth, sex, parity, educational level of the father and the residential area. Three cohorts of infants were monitored from four to 10 months, eight to 14 months and 12 to 18 months. Weight and recumbent length were measured at two monthly intervals. Two food record periods of three days each were included in the study design, just before or after the second and third anthropometric visit.  A single blood sample was collected within three months of completing the six-month longitudinal study.

Based on the findings of the mixed-longitudinal study, dietary recommendations were given to all macrobiotic families. Five to six months later, the initial cross-sectional anthropometric study was repeated in the same macrobiotic population (children now age two to 10 years). Food habits and anthropometric measurements were obtained.

Statistical Analysis

Standard deviation scores were calculated from the median and standard deviation of the Dutch reference data. Student's T-test was used to compare the means of two independent samples. Longitudinal changes in standard deviation scores were tested by paired T-test.  In the mixed-longitudinal study, successive measurements in all cohorts were simultaneously compared by multivariate analysis of variance. Multiple regression models were fitted to determine the independent effects of different variables on birth weight, weight gain, linear growth and the presence of skin and muscle wasting and rickets after adjustment for confounding variables.

Timing of Measurements

• Cross-sectional study: Initial anthropometric measurements taken and food habits assessed
• Mixed-longitudinal study: Anthropometric measurements taken at two monthly intervals. Two three-day food journals were taken just before or after the second and third anthropometric visit.  A single blood sample was taken within three months of completing the six-month longitudinal study.
• Two-year follow up: The same macrobiotic population underwent similar anthropometric measurements five to six months after they received dietary recommendations from the investigators.

Dependent Variables

• Nutrient composition of diet
• Birth weight and growth of infants and children.

Independent Variable

Macrobiotic diet.

 

 

 

Initial N

• Cross-sectional study: 243 children
• Mixed-longitudinal study: macrobiotic, n = 53; omnivorous, n = 57
• Two-year follow up: n = 194. 

Age: Zero to eight years of age

Ethnicity:  Dutch

Location:  Netherlands. 

 Macrobiotic diet in Dutch children

• Vegan-like diet consisting of grains (primarily rice), vegetables, pulses and sea vegetables
• Only small amounts of cooked fruits
• Fish on rare occasions
• Meat and dairy products are avoided
• Vitamin D supplements are not used.

The Dutch macrobiotic diet has characteristics similar to diets common in developing countries (high-starch and high-fiber, low-protein).

CROSS SECTIONAL STUDY IN ZERO- TO EIGHT-YEAR-OLD CHILDREN

Birth weight: 4.3% of macrobiotic children had reported birth weights less than 2,500g compared with 2% in a comparable Dutch population (P<0.02). Macrobiotic infant birth weight was significantly less than the Dutch median regardless of sex (P<0.001). A small but significant intrauterine growth retardation was indicated by a lower birth weight of macrobiotic infants.

Growth: Height-for-age of macrobiotic infants followed the median of the standard until the age of six months to eight months, after which a marked decrease was observed, reaching a minimum level between one and a half years and two years. No catch-up growth was observed at older ages. The curve of weight-for-age showed the same pattern, but a partial return to the median of the reference was observed after two years of age. The curve of weight for height followed the median Dutch reference.

Relation to diet: Standard deviation scores of weight, height and arm circumference were significantly higher in children from families consuming dairy products at least three times per week compared with children from families who rarely or never used dairy products. No association was observed between standard deviation scores and family consumption of fish, meat or eggs.

MIXED-LONGITUDINAL STUDY IN FOUR-MONTH TO 18-MONTH-OLD INFANTS

Weaning diet: Macrobiotic mothers continued to breastfeed for an average of 13.6 months vs. the control group average of 6.6 months.

Intake of Energy and Nutrients by Infants (6-16 months of age) on Macrobiotic and Omnivorous Diets

	Macrobiotic Group (n=49) Mean±Standard Deviatoin	Control Group (n=57) Mean±Standard Deviation	Statistical Significance of Group Difference
Animal Protein (grams)	4±3	24±8	P<0.001
Total Protein (grams)	20±7	32±10	P<0.001
Fat (grams)	22±9	30±7	P<0.001
Calcium (milligrams)	280±68	751±230	P<0.001
Riboflavin (milligrams)	0.4±0.1	1.1±0.3	P<0.001
Iron (milligrams)	5.1±2.8	4±1.6	P<0.001
Vitamin C (milligrams)	53±22	77±40	P<0.001
Vitamin B12 (milligrams)	0.3±0.2	2.9±1.3	P<0.001

Growth: From 16 months of age linear growth stabilized at the 10th percentile of the Dutch references, whereas in the control group growth velocities were similar to the Dutch references. Comparison with birth weight data of the macrobiotic infants showed that retardation of weight growth already occurred before the age of four months. Weight growth was most depressed between eight months and 14 months, while stabilization at the 30th percentile level occurred between 14 months and 18 months. 

Growth Relation with Diet: Both the energy intake and the protein content of the macrobiotic diet contributed independently to growth in weight and arm circumference. Chemical and biochemical observations from blood analysis revealed that macrobiotic children had:

• Elevated activity coefficient of erythrocyte glutathion reductase (secondary to low riboflavin intake)
• Iron deficiency, which was observed in 15% of macrobiotic infants (no anemia observed in control group)
• Low plasma vitamin B₁₂, which was associated with an increase in mean corpuscular volume
• Clinical symptoms of rickets, which was observed in 28% of macrobiotic children in summer and 55% in winter
• Major skin and muscle wasting, which was present in 30% of the macrobiotic infants with growth velocities in weight and height were lower in these infants with w (P<0.05) and slower in motor development than other macrobiotic children (P=0.05)
• Significantly later gross motor development (P<0.001) and speech and language development (P<0.03) in the macrobiotic group.

Recommendations for the Macrobiotic Diet

1. Add fat as an additional source of energy to a total of at least 25% to 30% of energy as fat
2. Include fish (two to three portions per week) as a source of vitamin B₁₂ and vitamin D (especially in winter)
3. Increase consumption of plant sources of calcium and riboflavin.

Two-Year Follow-up Study

Diet: Few changes were found in the frequency of consumption of foods typical of the macrobiotic diet; some changes were observed in consumption of animal products as well as vegetable oil and vitamin D supplements.

Growth: Results were similar to earlier observations concerning linear growth retardation during the first two years of life and only partial catch-up during the following years.

Relation to Diet: In children whose consumption of fish and dairy products had increased since 1985, linear growth was significantly faster (P<0.05) than in other macrobiotic children. The data demonstrate that the observed linear growth retardation in children on macrobiotic diets is caused by nutritional deficiencies alone.

Consumption Frequency of Selected Foods by Children in Macrobiotic Families in 1985 (n=173) and in 1987 (n=152)

	More than three times per week 1985 (1987)	One to two times per week 1985 (1987)	Fewer than once per  week 1985 (1987)
Fish	3 (10)	41 (64)	58 (26)
Sunflower/pumpkin seeds	31 (48)	32 (27)	29 (25)
Sesame seeds and pasta	88 (89)	3 (5)	8 (6)
Vegetable oil	75 (92)	12 (5)	13 (3)
Vitamin D supplement in winter	9 (21)	1 (1)	89 (77)
Dairy products	14 (26)	5 (12)	81 (72)
Tofu/tempeh	77 (76)	16 (20)	8 (3)
Leaf vegetables	95 (97)	1 (2)	4 (2)

Graphically, the increase in frequency per week of fish consumption is presented in Figure 1.

Figure 1. Changes in Consumption of Foods by Dutch Macrobiotic Families, 1985 to 1987

Stunting occurs in children whose diets are low in animal protein and factors associated with animal protein in foods. Efforts are needed to improve quality as well as quantity of the diets of preschool children.

University/Hospital:

Agricultural University Wageningen

Although the children consumed less of key nutrients (vitamin B₁₂, riboflavin, calcium, etc.), their curve for weight-for-height (most important indicator for growth in that it confirms that a child is growing proportionally) followed the median of the Dutch reference. No data were presented on mean vitamin D intake of macrobiotic infants age six months to 16 months during the mixed-longitudinal study prior to recommendations. There was no discussion about why there were 21 fewer subjects analyzed at two years after dietary recommendations (1987) vs. 1985.