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The benefits and risks of Low-Carb Diets in Children and Adolescents with Type 1 Diabetes

terri article

kid eating low carb foods

As a Certified Diabetes Care and Education Specialist (CDCES) for over 25 years and a Type 1 Person With Diabetes (T1 PWD) for over 33 years, I have to start by saying if you ask 10 Registered Dietitians about nutrition, you may get 10 different answers… Nutrition guidelines have changed several times in the past 3 decades when people with diabetes were told not to eat any “sugar”.

Once we realized that sugars turn 100% to glucose (blood sugar) and starch turns 100% to glucose, the recommendations were changed to reflect all foods in moderation. 

I will also add that I am a “moderation” teacher.  I believe that all foods can be included in a person’s overall nutrition because whatever eating style one chooses, we must do it for the rest of our lives.  So, it should be reasonable and sustainable. Heart-healthy nutrition is always a focus because of the increased risk of heart attacks and strokes in people with diabetes.

As you know, we first learn how and what to eat from our family of origin.  Our food choices may depend upon our family’s ethnicity, religious beliefs, age, finances, the area of the world we grew up in and any number of other variables.

Food is very personal.

Having a dietitian and diabetes educator look at our food records and analyze them can be an intimidating experience. I look at food records as “data” just like all the rest of the person’s “data” like exercise, insulin, blood glucose etc. I try to explain that we want to depersonalize all the data to understand highs and lows but that is easier said than done.  A couple of years ago, I was presenting at a diabetes educator conference and so I used my own food records as an example in teaching how to make insulin pump adjustments.

I was quite mortified when dozens of the 200 educators in the audience started questioning my food records. I was surprised at how personal it felt so it was a good reminder that our food is very personal. As CDCES’ we attempt to meet the people and families we work with where they are. This means we listen to their biggest concerns and attempt to analyze their “data” to eliminate lows first, and highs, and evaluate their intake for adequate carbohydrates, fiber, protein, fat, vitamins and minerals since all these nutrients have important jobs in our bodies.

For those of you who did not have five years of biochemistry, here is a brief review of the roles of carbohydrates, fiber, proteins, and fats:

All of these nutrients are needed in balance for their specific “jobs” in our body.  How you choose what percentage of your whole diet is made up of each type of food, can roughly be defined from recent nutrition papers as follows:

Type of DietCarbohydrateProteinFat
Typical Diet45-65% of total calories10-30%25-35%
Moderate carbohydrate restriction26-44% of total calories20-35%30-50%
Low Carbohydrate<26% of total calories20-40%40-70%
Very Low Carbohydrate or Ketogenic5-10% of total calories

20-50 grams of carbohydrate per day

15-25%70-80%

The American Academy of Pediatrics recently released a CLINICAL REPORT on Low-Carbohydrate Diets in Children and Adolescents with or at Risk for Diabetes.¹ Numerous articles have addressed the Impact of a Low Carbohydrate Diet on Micronutrient Intake and Status in Adolescents with Type 1 Diabetes².  In addition, the world-renowned Barbara Davis Center for Childhood Diabetes developed a protocol for the Medical Management of Children with Type 1 Diabetes on Low-Carbohydrate or Ketogenic Diets³.

Common to all these articles are benefits and risks of low carbohydrate diets in children. 

Low carbohydrate and ketogenic diets are becoming increasingly popular choices for people with Type 1 diabetes with the aim to achieve “optimal” glucose control, whatever that may mean to each family.

These recent trends seem to be partially driven by social media and websites suggesting that any glucose excursion from carbohydrates are harmful and should be avoided. Much of this misinformation may cause a lot of pressure for families with newly diagnosed Type 1 kids who are scouring the internet for as much guidance as possible. The number of individuals giving advice on Podcasts, Facebook, YouTube, TikTok, and Instagram is frankly mind-boggling. Parents or adult patients quote online “experts” and “hacks” to me every day requiring me to have to go on and listen to the many “experts”, some of whom are not healthcare professionals but are interested in promoting their book, or sponsors, or services.

We know from the ten-year Diabetes Control and Complications Trial (DCCT) from 1993 in T1D volunteers aged 13-39 and the follow-up study, called Epidemiology of Diabetes Interventions and Complications (EDIC) in 2005 that the individuals randomized to the intensive insulin therapy group had fewer complications than those with higher A1Cs. One interesting fact about the “tightly” controlled group was that their A1Cs were an average of 7% compared to 9% in the less intensively controlled group.  So, we know that complications caused by higher glucose, high blood pressure and high cholesterol and triglycerides (lipids) usually occur with A1Cs above the 7% range.

Many online groups and newly diagnosed families are striving for A1Cs much lower in the 5-6% range, which greatly increases the risk for dangerous hypoglycemia. Everyone with diabetes has a goal to avoid the possible complications but hypoglycemia is a very serious and life-threatening one.  From these landmark studies, we know that the risk for long-term complications can be reduced by good control as follows:

DCCT Study Findings: Intensive blood glucose control (A1C <7%) reduces the risk ofEDIC Study Findings: Intensive blood glucose control (A1C <7%) reduces the risk of
eye disease 76%any cardiovascular disease event 42%
kidney disease 50%nonfatal heart attack, stroke, or death from cardiovascular causes 57%
nerve disease 60%

So how did carbohydrate restriction become such a focus of some current diabetes management options?

Carbohydrate restriction is often endorsed by celebrities, in popular diets, and in weight loss programs with testimonials on websites and social media.  Low carbohydrate diets have been used for decades to improve metabolic health and treat Type 2 diabetes in adults. Carbohydrate-restricted diets in children have been associated with negative health effects such as poor linear growth, inadequate bone mineralization, nutritional deficiency, anemia, liver and kidney dysfunction, hyperlipidemia, hypertriglyceridemia, increased risk for cardiovascular disease, and an impact on quality of life including time and expense.

Since guidelines for monitoring children and adolescents choosing to follow a carbohydrate-restricted diet were not readily available, The Barbara Davis Center in Denver at the University of Colorado Health Sciences Center formed an interdisciplinary committee to examine the research literature and determine their consensus on management strategies.

Key healthy parameters that require monitoring were identified:

  1. growth
  2. glycemic control
  3. bone health
  4. cardiometabolic health
  5. nutritional status

The American Academy of Pediatrics Clinical Report has a table of recommendations for monitoring children and adolescents who elect to follow a very low carbohydrate or ketogenic diet.  It can be downloaded from: Low-Carbohydrate Diets in Children and Adolescents With or at Risk for Diabetes

As with recommendations for many conditions, the pendulum can swing from one extreme to another. Nutrition and diabetes management are personal decisions that all persons involved must at least partially agree on.  As I led with, I am a believer in nutrition moderation so individuals can live as healthily and normally with Type 1 diabetes. 

Reach out to your healthcare provider for questions or feel free to email me at Terri@IntegratedDiabetes.com

¹Neiman A, Hannon TS, AAP Committee on Nutrition. Low-Carbohydrate Diets in Children and Adolescents with or at Risk for Diabetes. Pediatrics 2023;152(4)

²Nutrients 2023, 15, 1418. https://doi.org/10.3390/nu15061418

³Pediatric Diabetes, 2021 May;22(3): 448-454.Medical Management of Children with Type 1 Diabetes on low-Carbohydrate or Ketoginic Diets

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