Keto for kids with diabetes carries risks, AAP warns

Keto and other low-carb diets have gained popularity for type 2 diabetes in adults, but there are safety concerns for young people, the American Academy of Pediatrics (AAP) has warned.

Restricting carbohydrates in youth at risk for or with diabetes raises concerns about slowed growth, nutritional deficiencies, poor bone health, nutritional ketosis, and disordered eating behaviors, Tamara Hannon, MD, Faculty of Medicine from Indiana University in Indianapolis, and colleagues from the AAP Committee on Nutrition wrote in a clinical report to guide care.

Based on the demonstrated risks, low or very low carbohydrate diets were not recommended for children and adolescents with type 1 diabetes, “except under the close supervision of a diabetes care team using safety guidelines “, the group wrote in Pediatrics.

The evidence is not as clear for type 2 diabetes and prediabetes, but published evidence and guidelines suggest the use of a balanced diet such as that recommended in the Dietary Guidelines for Americans (this is i.e. increase fiber and reduce ultra-processed carbohydrates), Hannon’s. group wrote.

Low-carb (<26% of daily calories), very-low-carb (20-50 g per day), and ketogenic (<20 g per day) diets limit the foods that can be included compared to the generally recommended diet, where 45 % of foods can be included. 65% of total calories come from carbohydrates.

Rather than cutting out all carbohydrates, the policy paper recommends focusing on reducing children’s consumption of nutrient-poor processed snacks and sugary drinks, while retaining healthy carbohydrates found in vegetables, fruits, grains whole grains and legumes.

This is a common concern because pediatricians care for the majority of children at risk for diabetes due to family history and other risk factors and remain a key part of the care team after diagnosed with diabetes, Hannon said. Page Med today in an email.

“As the incidence and prevalence of diabetes in young people continues to increase, pediatricians are encountering more families who are concerned about dietary guidelines for those with or at risk for diabetes,” she said. she writes. “There is growing interest in using low-carb diets as a treatment option for adults with diabetes, and as a result, more families and children are wondering whether or not they should try following a low-carbohydrate diet.”

However, a warning has been issued to clinicians about how they approach these conversations.

Hannon’s group pointed to a social media-based study of an international group of adults and parents of youth with type 1 diabetes who chose to follow a low or very low-carbohydrate diet like adjunctive treatment. “Respondents reported excellent glycemic control but poor relationships with diabetes care providers, associated with distrust and feelings of judgment about their diabetes management decisions,” Hannon and colleagues wrote .

The medical team could do the most good when patients and their families choose to follow these diets by not alienating them.

“It is recommended to maintain an open dialogue about diabetes management decisions, habits and dietary choices, and to encourage regular medical follow-up with a supportive multidisciplinary team, including a pediatric dietitian,” the group noted. by Hannon. Their document presented monitoring recommendations for each of the security issues.

In terms of effectiveness, low- and very low-carbohydrate diets have shown positive results in adults with type 1 and 2 diabetes. Limited pediatric data include a retrospective chart review of youth with type 2 diabetes who followed a very low-calorie ketogenic diet for an average of 60 days. Those who followed the diet were found to have short-term diabetes remission and a decrease in body mass index (BMI) for at least 6 weeks compared to those who did not follow it, noted Hannon and his colleagues.

However, they added: “The long-term outcomes of young people on a low-carbohydrate diet on diabetes and cardiovascular problems are needed and may be underestimated due to attrition.” »

The evidence is clear on the benefits of other, less restrictive reductions in carbohydrate intake, however, for type 2 diabetes. Reduce intake of nutrient-poor carbohydrates by minimizing processed foods containing large amounts of refined grains and added sugars and eliminating sugary drinks is recommended for prevention and treatment, including for prediabetes, Hannon and colleagues wrote. Cutting out sugary drinks and juices significantly improves blood sugar levels and weight management in young people, they added.

For young people with prediabetes or type 1 or 2 diabetes for whom weight loss or maintenance is indicated, pediatricians may advise that a reduced-energy diet – regardless of carbohydrate content – is best. more important for this purpose, the authors note.

Additionally, families of children and adolescents with or at risk of diabetes may be advised to follow a healthy dietary strategy, such as the Mediterranean diet, and aim for 60 minutes of moderate to vigorous aerobic activity per day to reduce obesity, improve diabetes. related health outcomes and promote optimal glycemic and cardiometabolic outcomes, they recommended.

However, any dietary restriction “may be associated with physical, metabolic, and psychological consequences, including risk of eating disorders in children and adolescents, with additional risk for individuals with diabetes,” Hannon and colleagues noted. .

Importantly, patients who have socioeconomic disadvantages are at increased risk of prediabetes and type 2 diabetes and are more likely to face barriers to following the American Dietary Guidelines and restricting processed foods, the authors wrote.

“Pediatricians can advocate for policies to protect and strengthen federal, state, and local nutrition programs and to encourage families eligible for federal nutrition programs to participate in them to improve their dietary intake and quality,” they added.

The new report on carbohydrate restriction in children and adolescents at risk for or with diabetes closely follows new guidance released by the AAP earlier this year, which focuses on early interventions to combat obesity in young people.

“This is one of the most important messages that differentiates our current clinical practice guidelines from previous recommendations, that 15 years of data have taught us that ‘watchful waiting’ only leads “to a greater increase in the child’s BMI and an accumulation of comorbidities. “, and even more challenges in trying to reverse some of this situation,” said author Sarah Armstrong, MD, co-director of the Duke Center for Childhood Obesity Research in Durham, North Carolina. Page Med today at the time.

Regarding the restriction of carbohydrates in young people at risk or with diabetes, we hope to have more data.

In the future, “we need longitudinal studies of the growth and development of children and families who choose to follow a low-carbohydrate diet for diabetes management purposes,” Hannon said. Page Med today. “We need studies that look at longer-term outcomes, including possible risks and benefits.”

  • Jennifer Henderson joined MedPage Today as a business and investigative editor in January 2021. She has covered New York healthcare, life sciences and law, among other areas.


No conflicts of interest were reported.

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Reference source: Hannon TS, et al “Low-carbohydrate diets in children and adolescents with or at risk of diabetes” Pediatrics 2023; DOI: 10.1542/peds.2023-063755.

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