Each month, the OMA Pediatric Committee reviews a pediatric-focused obesity research update to help keep you up to date about the latest findings. This month’s update addresses low-carbohydrate diets in children with or at risk for Diabetes.

Low-Carbohydrate Diets in Children and Adolescents With or at Risk for Diabetes

Article Summary

This article provides practical recommendations for pediatric healthcare providers regarding the use of low-carbohydrate diets in patients with prediabetes, type 1 diabetes, type 2 diabetes and obesity.

Article Review

This Clinical Report by the American Academy of Pediatrics (AAP) provides practical information for pediatric healthcare providers (HCP) counseling families and youth on carbohydrate recommendations for prediabetes, type 1 diabetes, type 2 diabetes, and obesity.

The report elaborates on the current eating habits of children and adolescents in the US using NHANES 2017-2018 data. According to NHANES analysis, the pediatric population consumes approximately 51% carbohydrates (45-65% recommended), 14% protein (10-30% recommended), and 35% fats (25-35% recommended). While the percentage of macronutrient consumption is well within normal limits, it is the quality of the macronutrients consumed that raises concerns. More than 85% of youth exceed the limit of saturated fats consumption, 70% of adolescents exceed added sugar consumption, and most of the children over 9 years of age lack recommended dietary fiber intake. This picture has become even more dismal due to Covid-19 pandemic. In children and adults (2 years and older) in the United States, more than 50% of the average daily energy intake comes from ultra-processed foods, and less than one third of the average daily energy intake comes from unprocessed or minimally processed foods.

This article defines carbohydrate restriction using the following categories: moderate carbohydrate restriction 26% to 44% of total calories, low (<26%) and very low-carbohydrate (20–50 g per day) restriction, and ketogenic (<20 g per day). Diets are further limited regarding types of foods that can be consumed. Dietary intolerance or lack of observed efficacy has caused high attrition rates in reduced CHO therapeutic trials. A significant amount of dietary restriction is required to maintain such low carbohydrate diet, and therefore, long-term adherence is difficult. Another concern is that restrictive dieting practices may negatively impact mental health.

This article briefly talks about a survey study which was conducted with a group of adults with type 1 diabetes and parents of youth with type 1 diabetes who choose 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. 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. The Report’s authors recommend that children with diabetes (type 1 or type 2) should be followed closely by a pediatric endocrinologist and multidisciplinary diabetes specialty team and are routinely screened for above mentioned complications from low carbohydrate diet.

The article describes a retrospective chart review, where results are optimistic. The study includes youth with type 2 diabetes who followed a ketogenic, very low-calorie diet for a mean of 60±8 days, finding that patients who followed the diet plan had short-term diabetes remission and decreased BMI. Long-term outcomes of youth on such restricted diets are underreported, often because of attrition.

This report suggests that 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. Patients should strive for 60 minutes per day of moderate to vigorous aerobic activity to reduce obesity and improve diabetes-related health outcomes.

Barriers to the implementation of these nutrition recommendations include food insecurity, disparities in access to health care services, and lack of support and resources to aid in making behavioral lifestyle changes. Pediatric HCP can advocate for and encourage enrollment in federal nutrition programs, which help to alleviate food insecurity.

In summary, this article discusses current dietary patterns in youth, how moderate-, low-, and very low-carbohydrate diets differ, and reviews safety concerns associated with the use of these dietary patterns. The report reviews the physiologic rationale for carbohydrate reduction in youth with type 1 diabetes and for youth with obesity, prediabetes, and type 2 diabetes. The report further reviews the evidence for low-carbohydrate diets in the management of youth with type 1 diabetes, prediabetes, and type 2 diabetes; providing practical information for pediatricians counseling families and youth on carbohydrate recommendations for type 1 diabetes and for obesity, prediabetes, and type 2 diabetes, and obesity. The authors encourage education of families and healthcare providers in meeting families where they are and building a nutrition plan that is achievable and effective. An example is to draft a nutrition prescription or a diet plan promising to bring one change every month and schedule regular follow up visits to help our patients sustain such healthy lifestyle changes. Mediterranean diets have had many benefits on adult health, its impact on children still needs to be investigated. A good way to start is by introducing Mediterranean score chart or MyPlate instructions. This way we are empowering our families to assess their own diet and bring meaningful changes to their diet. Nutrition modification should extend beyond dietary adjustment and should encompass integration of physical activity, limitation of screen time, and adequate sleep hygiene. It is essential to foster motivation among patients and families to ensure sustainability of these lifestyle modifications in the long term.