Keto for Kids? Why Experts Are Still Nervous

Low-carbohydrate diets are more popular than ever for the management of diabetes and weight loss. But what about growing children and teenagers with diabetes? Is keto safe for kids?

It’s common wisdom that carbohydrate restriction is potentially beneficial for diabetes management — especially if that means reducing your intake of sugar, refined starches, and ultra-processed junk foods. The ketogenic diet, or “keto,” takes that restriction to another level by strictly limiting the intake of even healthier carbohydrates like fruit and whole grains. Inevitably, keto dieters end up eating a much higher percentage of fat.

Keto goes against most of what nutrition authorities tell us about wholesome eating, but the approach has many advocates who believe it’s the best possible diet for keeping glucose levels in a healthy range — for adults and kids alike

In October 2023, the American Academy of Pediatrics (AAP) published a report examining low-carbohydrate diets like keto in children and adolescents. You probably won’t be surprised that the authors are concerned. Despite the increasing popularity of carbohydrate restriction, evidence to support the benefits of low-carb diets in young people under 18 with obesity or diabetes is very limited. And though diabetes authorities have acknowledged that carb restriction has “the most evidence” for improving blood sugar levels, the American Diabetes Association has only endorsed low-carb eating as one of multiple possible eating patterns.

And yet, there are many people in the diabetes community who believe in the effectiveness of low, even very-low, carbohydrate diets for their children. There’s at least one study that supports their advocacy

Concerned parents and teens should understand that researchers agree that there’s no data that demonstrates keto or other low-carb diets are good or bad for kids with diabetes. This, of course, makes them very cautious about recommending them to youngsters. 

If you do want to take this approach, it should be done with a doctor with regular evaluation of your child’s health to ensure they are getting the proper nutrition, that their health isn’t at risk, that they are growing and maturing at the right levels, and that they aren’t developing emotional issues around food and body image.

In this piece, we’ll look at how this debate has been playing out and if there’s a space for agreement between medical experts and parents to help parents and kids manage their health by managing carb intake.

Official Dietary Recommendations for Children

According to the AAP, the recommended diet for children between the ages of four and 18 should break down into these categories based on total caloric intake:

10 to 30 percent protein to support normal growth and development
25 to 35 percent fat, mostly from polyunsaturated and monounsaturated fatty acids with less than 10 percent from saturated fats
45 to 65 percent carbohydrates, with no more than 10 percent coming from added sugars and most carb calories coming from fruits, vegetables, whole grains, legumes, and dairy products

The guidelines reflect the belief that young people require a balanced diet that provides the energy and nutrients for their bodies to grow and develop. 

The Suspected Downsides of Keto

The committee behind the AAP’s new report listed the following possible effects as downsides to a very-low carbohydrate diet in growing children:

The AAP’s report lists concerns that medically unsupervised low-carb diets like keto could result in:

Growth deceleration
Nutritional deficiencies
Poor bone health
Nutritional ketosis (which could mask the development of diabetic ketoacidosis)
Disordered eating behaviors

As noted above, there is very little data on the long-term effects of keto on children with diabetes, so these objections are somewhat speculative. Some of the data fueling these concerns derives from studies of ketogenic diets in children with epilepsy. A variation of keto has been used for decades as a treatment for childhood epilepsy, because the diet can reduce the frequency and severity of seizures. (Keto has also been proposed as a therapeutic intervention for a host of other conditions, from cancer and obesity to improved insulin sensitivity.)

A 2023 review of the nutritional impact on children with epilepsy concluded that children on keto require enhanced monitoring and should consider micronutrient supplementation; nevertheless, the diet’s long-term impact on growth and nutritional status “is not yet fully understood.” The review also noted that the diet can be difficult to stick to over the long term and that short-term side effects can include nausea, constipation, fatigue, dehydration, and electrolyte imbalances (a condition known popularly as “keto flu”). 

In the same edition containing the new AAP report, Pediatrics also published two letters to the editor specifically objecting to the use of evidence derived from studies of children with epilepsy. The authors assert that the epileptic keto diet, which prescribes 3 or 4 grams of fat for every 1 gram of protein or carbohydrate, shouldn’t be confused with a “well-formulated ketogenic diet.”

Why Experts Are Still Nervous

With no strong evidence either in favor of or against keto diets for kids, experts are stuck making educated guesses. We spoke to Tamara S. Hannon, MD, FAAP, one of the lead authors of the AAP report, to drill down into their thinking.

“Asking a child or adolescent to go on a restrictive diet can encourage both physical health problems and mental health problems,” Dr. Hannon said. “We have lots of evidence that dieting is associated with disordered eating in children.”

What they don’t have, said Hannon, is sufficient data to support the use of very low-carbohydrate or ketogenic diets in children with either type 1 or type 2 diabetes. Experts don’t really know how effective or dangerous low-carb diets might be, because the studies have never been performed.

“I’ll say this, if we don’t have really good evidence that this is the superior diet for adults, then why the heck would we recommend it for children,” she said. “No one is recommending that every adult with diabetes use the keto diet because the results are so superior.”

Hannon is doubtful that we’ll ever have definitive studies rigorously testing the results of low-carb diets in youths with diabetes: “I don’t think you could get investigators to do these studies because if nobody can make it work for adults, I’m not sure how we would make it work in kids.”

Keto Basics

The logic behind low-carbohydrate eating for diabetes is simple: carbohydrates spike the blood sugar up. The fewer carbs you consume, the less your blood sugar will rise (and the less insulin and fewer diabetes medications you need to use, which could also lead to less hypoglycemia).

The keto diet is usually high in fat, moderate in proteins, and very low in carbohydrates — some adherents eat only a maximum of 25 grams per day.

A ketogenic diet is intended to shift your body from burning mostly glucose to burning mostly fat. Eating very few carbs prompts your body to produce ketones, a natural glucose alternative, for energy — hence the name of the diet. Some advocates believe that the state of nutritional ketosis grants additional benefits, such as reduced hunger and enhanced alertness.

Others, however, put very little emphasis on ketosis. Richard Bernstein, MD, is the modern father of low-carb eating plans for diabetes, recommending them for decades in his book Dr. Bernstein’s Diabetes Solution. Dr. Bernstein prescribes a low-carb and high-protein diet that is broadly similar to the ketogenic diet. He argues that this is the best approach for optimized blood sugar control.

The word “ketogenic” might be scary for people with diabetes. Excessive ketone production, however, leads to diabetic ketoacidosis (DKA), the exceptionally dangerous and occasionally lethal condition that results from uncontrolled type 1 diabetes. Could ketogenic diets cause the development of DKA, which is typically a consequence of insulin deficiency? A review in the Cleveland Clinic Journal of Medicine stated that “the jury is still out,” and that enhanced monitoring of blood sugar levels is “critical.”

The Type 1 Keto Community

Parents of children with type 1 diabetes are naturally focused on how to best manage their kids’ conditions. Though diabetes authorities are hesitant to endorse keto for kids, some parts of the diabetes community are completely committed to the approach.

In 2018, a study published in Pediatrics, the AAP’s journal, set out to evaluate the glycemic control of children and adults who independently chose to consume a very low-carbohydrate diet. The study used a survey of 316 respondents from TypeOneGrit, a private Facebook group for people with type 1 diabetes (and their caregivers) who follow the limited carbohydrate program advocated by Dr. Richard Bernstein.

In the survey, the children and adults who followed this type of diet for long-term treatment were observed to have measures of A1C in the near-normal range (5.67 percent), low rates of symptomatic hypoglycemia and severe hypoglycemia, and low rates of diabetes-related hospitalization (one percent experienced diabetic ketoacidosis, or DKA). Among children, who generally thrived as well as adults on the diet, researchers identified no issues with growth or development. Participants also were noted to have generally high levels of satisfaction with health and diabetes control. 

The study was covered by The New York Times; a diabetologist unaffiliated with the study who reviewed the data responded that the diet was “extraordinarily successful” and “much safer than many experts would have suggested.”

But this study was observational — it was not a controlled experiment — and the sample of participants, drawn from a self-selected community of highly motivated individuals, was far from representative. Even the paper’s authors acknowledged that the findings weren’t enough to justify a change in official diabetes guidelines.

Keto for Kids with Type 2 Diabetes

The recent AAP report noted that carbohydrate reduction can also be an important and effective part of the overall treatment of type 2 diabetes, but the research as it impacts children and teens with type 2 diabetes is very limited. 

The authors pointed to a 2004 retrospective chart review of 20 children who followed a keto diet for about 60 days. The results were impressive: almost every participant quickly lost the need to take insulin or other diabetes medications, and BMI fell rapidly for at least six weeks. That sounds positive, but is that sufficient for more families to act on? Not according to the AAP report. What’s needed, it said, are long-term outcomes, which may be underreported due to attrition given how difficult these diets are to sustain over time. 

Hannon believes it is more beneficial for children with or at risk of developing type 2 diabetes to reduce excessive amounts of carbohydrates, especially processed carbohydrates. 

“Carbohydrate reduction in regard to processed carbohydrates has metabolic benefits,” she said. “Many children are eating 200 grams, 300 grams of carbohydrates at one meal. Reducing that to a more appropriate carbohydrate serving and changing the carbohydrates to unprocessed carbohydrates or minimally processed carbohydrates has a lot of benefit. But we don’t need to be so restrictive to get that benefit metabolically and glycemicly. We just need a less processed food diet to improve metabolic health.”

How to do Keto Safely with Your Kid

Hannon and her colleagues know that some parents will choose very-low carb or ketogenic approaches for their children. In fact, she emphasized that the AAP report didn’t state that these should never diets ever be used.

To stay safe, she recommends collaborating with your child’s doctor and care team. “We recommend partnership with a knowledgeable care team,” she said.

“There are concerns for growing children when a food group is restricted,” said Hannon. “Special care should be taken to ensure adequate nutrition; sufficient calories, vitamins, and minerals from foods, and mental health surveillance.

So, for those parents whose child has type 1 or type 2 diabetes and choose to follow a low-carb diet, consult with a trusted multi-disciplinary diabetes care team.

Hannon doesn’t mean that meeting with a pediatrician to discuss a low-carb or keto diet is a one-and-done thing. The child’s health must be monitored regularly.

“If you’re going to do this, we need to see you every three months to check your growth, to monitor your weight, to make sure that pubertal development is normal, to make sure you don’t have nutritional deficits,” she said. “For children with type 1 diabetes, you want to monitor what’s a safe amount of carbohydrate to stay above so that you’re not at risk for metabolic decompensation, for insulin deficiency, or you don’t get hypoglycemia because you’re not getting enough nutrients along with your insulin. The whole point is a parent wouldn’t be expected to be able to monitor all those things without the help of a medical team.” 

Hannon’s other concern is that children on severely restricted diets are going to grow up with issues around food and body image. 

“The thing that I worry about is if a child is doing this and a lot of brain power is focused on when they’re going to eat, what they’re going to eat and they become preoccupied by food when a food is restricted, is that’s a real warning sign for an eating disorder.”

“We recommend that the doctor work closely with the family to develop trust and make sure they’re following things because we don’t want any adverse things to happen.”

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