American Academy of Pediatrics Issues Policy on Low-Carbohydrate Diets for Children and Adolescents With or At Risk of Diabetes

Despite the increasing popularity of low-carbohydrate and ketogenic diets for managing diabetes in adults, there are safety concerns to consider for youth with diabetes or prediabetes who are restricting carbohydrate intake to control weight or blood glucose

The American Academy of Pediatrics cautions against the use of low-carbohydrate diets for children and adolescents with or at risk of developing diabetes within a new clinical report that cites concerns over how overly restrictive dietary patterns may affect their health.

The clinical report, “Low-Carbohydrate Diets in Children and Adolescent With or at Risk for Diabetes” urges families and physicians to focus on reducing children’s consumption of nutrient-poor processed snacks and sugary beverages. Instead, children and teens should continue to eat healthy carbs found in vegetables, fruits, whole grains and legumes. The report, which provides carbohydrate recommendations for youths with type 1 or type 2 diabetes, obesity or prediabetes, will be published in the October 2023 Pediatrics (published online Sept. 18).

“We often see celebrities and weight loss programs endorsing carbohydrate restriction through low carb or ketogenic diets, but evidence is limited on the physical, metabolic and psychological effects of these dietary plans for children and teens,” said Tamara Hannon, MD, FAAP, co-author of the report, written by the Committee on Nutrition. “This statement is not about restrictive diets – it is about providing evidence to clinicians so they can support parents and families in making informed decisions. Be sure to bring your questions to your pediatrician, who knows you best and can help provide guidance on a healthy dietary plan.”

Low-carbohydrate diets restrict consumption to less than the recommended 45%-65% of total daily calories from carbohydrate. Very low-carbohydrate diets allow 20-50 grams per day, while ketogenic diets generally allow less than 20 grams of carbohydrate per day. For children and teens, there are concerns that these dietary restrictions could lead to growth deceleration, nutritional deficiencies, poor bone health and disordered eating behaviors.

Neither the American Diabetes Association nor the International Society for Pediatric and Adolescent Diabetes has endorsed the generalized use of low-carbohydrate diets in growing children and adolescents with type 1 diabetes.

Families who choose for their children and adolescents to follow a very low-carbohydrate or ketogenic diet should be monitored closely by a multidisciplinary team, the AAP states. 

The AAP also recommends:

• 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 then 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.

Clinical reports created by AAP are written by medical experts, reflect the latest evidence in the field, and go through several rounds of peer review before being approved by the AAP Board of Directors and published in Pediatrics.

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The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults.