In recent years, low-carbohydrate diets, such as the ketogenic diet, have gained popularity among adults, particularly for managing type 2 diabetes or weight. However, the appropriateness and safety of these diets for children, especially those with or at risk of diabetes, are a subject of ongoing research and medical supervision. This article examines the safety and guidelines surrounding low-carb diets for children, providing a comprehensive overview for parents, caregivers, and healthcare professionals.
Current Dietary Patterns in Youth
According to NHANES 2017-2018 data, children and adolescents in the US consume approximately 51% of their calories from carbohydrates, 14% from protein, and 35% from fats. While these percentages fall within the recommended ranges, the quality of these macronutrients is concerning. A significant portion of youth exceeds the recommended limits for saturated fats and added sugar consumption, while most children over 9 years of age lack sufficient dietary fiber intake.
Understanding Low-Carbohydrate Diets
Carbohydrate restriction is categorized as moderate (26% to 44% of total calories), low (<26%), very low-carbohydrate (20-50 g per day), and ketogenic (<20 g per day). These diets often involve significant dietary restrictions, which can make long-term adherence difficult.
Concerns and Cautions
The American Academy of Pediatrics (AAP) cautions against the use of low-carbohydrate diets for children and adolescents with or at risk of developing diabetes. There are concerns about how overly restrictive dietary patterns may affect their health. While low carb diets can benefit adults, there is little research to support the safety and efficacy of low carb diets for children. Therefore, there are no clinical guidelines on restricting dietary carbohydrate consumption, the AAP report reads.
Potential Risks
- Growth deceleration: Restricting carbohydrates may lead to slowed growth.
- Nutritional deficiencies: Limited food choices can result in inadequate intake of essential nutrients.
- Poor bone health: Carbohydrate restriction may negatively impact bone development.
- Disordered eating behaviors: Restrictive diets can contribute to unhealthy psychological relationships with food, potentially leading to anorexia, bulimia, binge eating, and other health threats.
- Adherence Challenges: A significant amount of dietary restriction is required to maintain such low carbohydrate diet, and therefore, long-term adherence is difficult.
- Type 1 Diabetes Concerns: The use of very low-carbohydrate diets in children with type 1 diabetes has been reported to be associated with growth deceleration, hypoglycemia, abnormal lipid profile, risk for disordered eating, ketosis (that may be nutritional but cannot be distinguished from ketosis resulting from insulin deficiency), and a theoretical concern for diabetic ketoacidosis.
Psychological Impact
Restrictive diets can make family and social situations more stressful. Limited food choices may make kids feel out of step with their siblings and friends. Planning and preparing keto-friendly meals means significant work for parents and caregivers, often creating tension and worry that can affect a child's wellbeing (and the family's emotional equilibrium).
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Importance of Medical Supervision
If families choose for their children and adolescents to follow a very low-carbohydrate or ketogenic diet, the AAP states that they should be monitored closely by a multidisciplinary team. "Children should not be placed on low carbohydrate or ketogenic diets without proper monitoring or surveillance by healthcare professionals,” Tok-Hui Yeap, a specialist in pediatric nutrition based in Oregon, told Medical News Today.
Recommendations and Guidelines
Instead of focusing on restrictive diets, experts recommend a balanced approach that emphasizes healthy eating habits and lifestyle changes.
Focus on Dietary Patterns
The emphasis of counseling should be on dietary patterns rather than macronutrients. Dietary patterns that emphasize plant-based foods (vegetables, fruits, whole-grains), lean sources of protein (poultry, fish, legumes), mono- and polyunsaturated fats, low-fat dairy products and nutritional plans that limit sugary beverages and highly processed foods are associated with better long-term health outcomes.
Limit Added Sugars
Complete elimination of all sugary beverages is strongly recommended, as the principal cause of health problems related to too many carbohydrates is from added sugars.
Promote Nutritious Choices
Encourage a diverse range of foods while limiting added sugar. Strive to take a more education-based approach, said Rachael Richardson, a registered dietitian and nutritionist and founder of Nutrolution. “The main nutrition concept young, preschool-aged kids could and should be learning about is the distinction between ‘real’ and ‘fake’ foods, as well as being shown how food grows and being exposed to parents who model healthy eating,” she told MNT. “As they become school-aged, learning the fundamentals of growing food, cooking, and what is needed to constitute health are all hugely important topics that all high school students should have the opportunity to master if we are to curb the prevalence of diabetes and other chronic diseases which weigh down our health care system.”- Rachael Richardson, registered dietitian
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Encourage Physical Activity
A balanced diet paired with 60 minutes per day of moderate to vigorous exercise is recommended to regulate blood sugar and support healthy body weight.
Address Socioeconomic Factors
Acknowledge that socioeconomic disadvantages play a role in how families can combat health concerns and the pressing need for broader systemic changes to address these issues. Pediatricians can play a crucial role in advocating for policies aimed at bolstering federal, state and local nutrition programs. Furthermore, they can actively encourage eligible families to engage in these programs.
AAP Recommendations
The AAP recommends that:
- Children aged 4 to 18 years should get 10% to 30% of their total energy intake as protein to support normal growth and development.
- Another 25% to 35% of energy intake should come from fat, mostly from polyunsaturated and monounsaturated fatty acids and less than 10% from saturated fats.
- Carbohydrates should provide the remaining 45%-65% energy requirements, with the recommendation that not more than 10% of calories per day come from added sugars.
- Most calories from carbohydrates should come from fruits, vegetables, whole grains, legumes, and dairy products.
- Families of children and adolescents with type 1 diabetes, prediabetes or type 2 diabetes may be counseled to follow a healthy dietary pattern strategy (provided by the Dietary Guidelines for Americans) and strive for 60 minutes per day of moderate to vigorous aerobic activity.
- All pediatric patients with diabetes should be followed by a multidisciplinary diabetes care team, as well as their general pediatrician, with communication across disciplines. Dietary recommendations and support can be reinforced broadly.
- Patients who have socioeconomic disadvantages are at increased risk for prediabetes and type 2 diabetes and face barriers to following Dietary Guidelines for Americans and restricting processed foods. Pediatricians can advocate for policies to strengthen federal nutrition programs and encourage families who qualify to participate in them.
Ketogenic Diet for Epilepsy
While the AAP does not generally recommend keto diets for children with diabetes unless they are closely supervised by a diabetes-focused medical team, it recognizes the diet's potential value for young people with epilepsy. The ketogenic diet is sometimes used as a treatment for children with seizures when medicine isn’t working well. Researchers aren’t sure why the diet works. But some children become seizure-free when put on the diet.
How it Works
The diet is very high in fat, and very low in carbohydrates. It includes enough protein to help your child grow. The diet causes the body to make ketones, chemicals made from the breakdown of body fat. During normal health and with a normal diet, the body generally does not make or need to make ketones. They are an energy source that the body uses normally during fasting states. The brain and heart work normally with ketones as an energy source.
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Implementation
The ketogenic diet can be very challenging to prepare. All foods must be weighed using a food scale. The diet is not nutritionally balanced. Your child will also need vitamin and mineral supplements. Your child will be admitted to the hospital before starting the diet. Your child may be in the hospital for 4 to 5 days while his or her body starts making ketones. During this time, you’ll also learn how to plan your child’s diet. You may also be taught how to test your child's urine for ketones. Most children stay on the diet for about 2 years. The diet is then slowly changed back to a regular diet. Some children may stay on the diet for many years.
Foods to Avoid
While on the diet, your child will not be able to have high-carbohydrate foods such as: Fruit and fruit juice, Breads and cereals, Starchy vegetables such as corn, peas, and potatoes, Beans, Milk, Soda, Snack foods such as chips, snack cakes, and crackers, Sweets.