Ketogenic Diet for Kids with Diabetes Carries Risk

News Highlights

• The American Academy of Pediatrics (AAP) released new guidelines against the ketogenic diet for children at risk for or with diabetes.
• The AAP raised concerns about growth deceleration, nutritional deficiencies, poor bone health, nutritional ketosis and disordered eating behaviors for children.
• The AAP committee on nutrition went a step further, warning against the ketogenic diet for children living with type 1 diabetes (T1D)—unless they are under strict supervision by their clinical care team.
• The evidence is less clear on the effects of keto on children with type 2 diabetes (T2D).
• The committee recommends cutting down on nutrient-poor carbohydrates instead, such as cookies, cakes and candy.

On September 18, 2023 the American Academy of Pediatrics (AAP) released new guidelines around the ketogenic diet and other extremely low-carbohydrate diets for children at risk for or with diabetes.

This way of very low-carbohydrate eating has grown in popularity over recent years but can pose a danger to children.

The importance of nutrition for diabetes management

Nutrition, specifically tracking and managing how many grams of carbohydrates you eat, can be a critical component of diabetes management for children and adults alike.

The delicate balance of nutrition and diabetes management can create a tenuous relationship with food for some people. But like medications and exercise, part of living with diabetes can mean measuring and accounting for the type and amount of food you eat on a daily basis.

Since people with diabetes cannot properly process the glucose from their food (necessitating either insulin injections or other diabetes medications), carbohydrates need to be carefully counted—as they have the highest impact on blood sugar levels and A1C.

However, carbohydrates are the body’s preferred energy source, making low-carb diets a hot topic of discussion in the diabetes and health care community.

The rise of low-carb eating

Since the excess of carbohydrates can cause high blood sugar levels, it makes sense that some people wish to limit the number of carbs they eat in a day. Some people with diabetes believe that eating lower carbs can make blood sugar management easier.

Many people have started adopting versions of the ketogenic diet—a diet where one severely limits the amount of sugar and carbs they eat in a day. In fact, seven percent of Americans report eating low-carb, up from five percent in 2018.

Low-carb eating can look different for different people:

• Low-carb is considered less than 26 percent of carbohydrates making up your total daily calories
• Very low-carb is considered between 20-50 grams of carbohydrates per day
• Ketogenic is considered fewer than 20 grams of carbohydrates per day

Compare this to the Dietary Guidelines for Americans, which recommend that carbohydrates make up between 45-65 percent of total daily calories, which for most people is between 225 and 325 grams of carbohydrates per day.

Rising rates of T1D and T2D in younger people

As the incidence and prevalence of both T1D and T2D rise more than ever before, it makes sense that people are looking to low-carb and ketogenic diets as treatment options for both blood sugar levels and weight management—especially for adults.

The ketogenic diet has been found to improve A1C levels in adults with diabetes if the diet is followed for 90 days or more.

A two-year study found that adults with T2D following the ketogenic diet lost an average of 26 pounds over the study period. Additionally, another study found that the ketogenic diet helped improve insulin sensitivity by 75%.

With shown benefits in adults, it makes sense that as rates of both T1D and T2D rise in children they would be interested in lower-carbohydrate diets too.

There is less pediatric data, but teenagers with T2D who followed a ketogenic diet for at least 60 days experienced short-term diabetes remission and decreased body mass index (BMI).

However, these severe dietary restrictions can be associated with physical, metabolic and psychological consequences, including risk for disordered eating in children and adolescents, which is even higher for those with diabetes.

The AAP recommends a more balanced approach instead.

AAP recommendations

The AAP committee on nutrition understands the popularity of lower-carbohydrate diets, especially in the T1D and T2D communities, for blood sugar levels and weight management.

However, because studies on the effects of the ketogenic diet in children and youth ages 2-18 with diabetes do not exist, they warn parents and pediatricians against recommending it for their children and patients.

The committee warns that severely limiting carbohydrates in a child’s diet can slow growth, cause nutritional deficiencies, contribute to poorer bone health, cause ketosis and may contribute to disordered eating behaviors.

They agree, however, that increasing dietary fiber and reducing ultra-processed carbohydrates, such as soda, candy, cookies and other packaged desserts can contribute to better blood sugar levels and overall health.

The committee recommends that carbohydrates should provide between 45-65 percent of a child’s energy requirements, with no more than 10 percent of calories per day coming from added sugars.

It is recommended that the majority of carbohydrates in a child’s diet come from:

• Fruits
• Vegetables
• Whole grains
• Legumes
• Dairy products

The focus should instead be on reducing a child’s consumption of nutrient-poor processed snacks and beverages with added sugars, which is healthy standard for all children, but especially children at risk for or living with diabetes or prediabetes.

Cutting out sugary beverages and juices significantly improves blood sugar levels and aids in weight management, if weight loss is indicated for the child, the report said.

Where to learn more

Food can feel complicated, especially when you live with diabetes. If you have questions or concerns about what to eat if your child has or is at risk of diabetes, check out the following resources and talk with your doctor:

• Food and diabetes
• Glycemic index and diabetes 
• Why do people with diabetes count carbs instead of sugar 
• How to navigate the dining hall with diabetes 

There’s a whole community of parents with children and youth living with diabetes here to support you too!