Keto for Kids With Diabetes Carries Risk, AAP Warns

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

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

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

The evidence isn't as clear with type 2 diabetes and prediabetes, but published evidence and guidelines point to use of a balanced dietary pattern like that recommended in the Dietary Guidelines for Americans (i.e., increasing fiber and reducing 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 foods that can be included compared with the typically recommended diet, where 45% to 65% of the total calories come from carbohydrates.

Rather than cutting all carbs, the policy document urged focusing on reducing children's consumption of nutrient-poor processed snacks and sugary beverages but keeping healthy carbs found in vegetables, fruits, whole grains, and legumes.

It's a common concern, as 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 a diabetes diagnosis, Hannon told MedPage Today in an email.

"As the incidence and prevalence of diabetes in youth continue to increase, pediatricians encounter more families who have concerns regarding dietary guidelines for persons with or at risk for diabetes," she wrote. "There is increasing interest in the use of low-carb diets as a treatment option for adults with diabetes, and therefore, more families/children are wondering about whether or not they should be trying to follow a low-carb diet."

However, there was a warning for clinicians in how they approach these conversations.

Hannon's group pointed to a survey study conducted with an international social media-based group of adults and parents of young people with type 1 diabetes who chose to use low- or very low-carbohydrate diets as adjunct treatment. "Respondents reported excellent glycemic control but poor relationships with diabetes care providers associated with distrust and feeling judged about their diabetes management decisions," Hannon and colleagues wrote.

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

"Maintaining open dialogue about diabetes management decisions, dietary habits and choices, and encouraging regular medical follow-up with a supportive multidisciplinary team, including a pediatric dietitian, is recommended," Hannon's group noted. Their document outlined monitoring recommendations for each of the safety concerns.

In terms of efficacy, low- and very low-carb diets have had positive results in adults with both type 1 and 2 diabetes. The limited pediatric data includes a retrospective chart review of young people with type 2 diabetes who followed a ketogenic, very low-calorie diet for an average of 60 days. It found that those who followed the diet plan had short-term diabetes remission and decreased body mass index (BMI) for at least 6 weeks compared with those who did not, Hannon and colleagues noted.

However, they added, "Long-term outcomes of youth following carbohydrate-restricted diets on diabetes and cardiovascular outcomes are needed and may be underreported because of attrition."

The evidence is clear on benefits for other, less restrictive reductions in carb intake, though, for type 2 diabetes. Reducing nutrient-poor carbohydrate intake by minimizing processed foods with high amounts of refined grains and added sugars and eliminating sugar-sweetened beverages is recommended for prevention and treatment, including for prediabetes, Hannon and colleagues wrote. Cutting out sugary beverages and juices significantly improves blood glucose 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 can counsel them that a reduced energy diet -- irrespective of carbohydrate content -- is most important to that end, the authors noted.

Furthermore, families of kids and adolescents with or at risk of diabetes may be counseled to follow a healthy dietary pattern 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 "can be associated with physical, metabolic, and psychological consequences, including risk for disordered eating in children and adolescents, with additional risk for those with diabetes," Hannon and colleagues noted.

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

"Pediatricians can advocate for policies to protect and strengthen federal, state, and local nutrition programs and encourage families who qualify for federal nutrition programs to participate in them to improve 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 that focuses on earlier interventions to address obesity in young people.

"This is one of the most important messages that differentiates our current clinical practice guidelines from the prior recommendations, and that is to say 15 years of data have taught us that 'watchful waiting' only leads to greater increase in child BMI, accumulation of comorbidities, and more challenges in trying to reverse some of this," author Sarah Armstrong, MD, co-director of the Duke Center for Childhood Obesity Research in Durham, North Carolina, told MedPage Today at the time.

As for carbohydrate restriction in young people at risk for or with diabetes, the hope is for more data.

Going forward, "we need longitudinal studies of growth and development in children/families who choose to utilize low-carb diets for the purposes of diabetes management," Hannon told MedPage Today. "We need studies that investigate more longer-term outcomes, including the possible risks and benefits."

Comment