Before I start on this topic, it’s always worth bearing in mind that managing type 1 with a low carb diet raises controversy, and even more so when related to children, so the drivers for the research that I mention here are always open to question.
So firstly, what are we discussing? A recent study in Paediatric Diabetes looked at six case studies of children with Type 1 diabetes that were eating carbohydrate restricted diets and drew some interesting conclusions in relation to the effects on their health and wellbeing. Sadly, it is behind a paywall.
If you participate in the Type 1 Grit community, you might argue that these are controversial findings, and with a sample size of six, not statistically significant, but the article also raises some interesting questions in relation to social media and psychological effects, plus whether a low carb approach should be used with children with T1D.
The study looked at six case studies of children with Type 1 diabetes where, it states, adoption of a low carbohydrate diet had impacted growth and cardiovascular risk factors with the potential for long term consequences, and hails from Australia.
The introduction of the paper states that there are no published data to support that low carb diets for treating T1D might affect growth in children, and that the writers sought to address this gap in the literature by inviting paediatric endocrinologists to submit cases where adherence to such a diet was believed to result in endocrine and metabolic consequences. So let’s be clear here. This is not an “unbiased paper”.
Reading through all six cases, it’s clear that in the majority, the low carb diet provided to each child was not substantive enough, with most of the children being underfed when total energy need was considered. This seems to vary between around 75% of total required calories and 85% of total required calories. According to the paper, the children affected were also not receiving appropriate nutrients, with low calcium consumption standing out regularly and phosphorus and magnesium intakes also reported as low. One of the cases also included a very clear reference to the Bernstein approach to diet.
In all cases, while the children were on the reported low carb diets, their weight and height increases deviated from the population percentile in which they had previously been.
The paper also states that cardiovascular biomarkers were high, quoting cholesterol levels. but not stating whether these were elevated compared to prior results. There was also the link drawn between higher fat diets and lower levels of pituitary growth hormone release, which may have resulted in one case of reduced IGF1.
The children are often stated as being hungry and finding that they feel lethargic and not keen to participate in sports, finding activity difficult.
Another item of note in the six cases is that “glycemic control” was not necessarily benefitting from the approach.
Finally, in the collected data, concerns about focus on diet and identifiable eating disorders are also raised.
The discussion then goes on to state in its opening paragraph that the likely mechanism that has resulted in lethargy and fatigue is not necessarily the lack of carbohydrate, but that the energy intake of the children cited was not high enough, and that there had been no compensatory energy intake when carbohydrate was removed. It also talks about worse glycaemic control in higher fat consumption cases as shown by the DCCT study.
In addition, it highlights that in these cases, the increase in saturated fat was linked to elevated cholesterol markers, and cites another study which it is inline with. Unfortunately, this other study states that its results looking at saturated fat and cholesterol should be “interpreted cautiously.” In other words, be careful with the link being drawn here.
The remainder of the discussion then highlights a few points.
- The use of social media and the internet is highlighted as a key driver in the dietary choice that a family has undertaken, even in a well educated family.
- It is well documented that children and adolescents with Type 1 are at a higher risk of psychological disorders and that restricted diets can have a major negative impact on this.
- The lack of counter argument to “non-official” sources from those who publish guidelines.
- Insulin dosing behaviours that may need to be dealt with to better manage glucose excursions.
It concludes that restricted carbohydrate diets in kids can lead to growth issues, reduced energy intake and increased cardiovascular lipid risk markers, and as a result lead to psychological co-morbidity and social isolation. It also suggests that health care professionals that know families undertaking this type of approach should be carefully monitoring them and recommends that low carb for kids should continue to be cautioned against.
So what can we take from this?
Well let’s start at the beginning. This was a call to provide case studies that demonstrated that low carb diets adversely affect children, across all of Australia and New Zealand. Six have made the study. There is no comment on whether more were submitted and only these six qualified, either through content or ethics reasons. As most are aware, an n=6 sample should not be taken as statistically significant. One could also comment that on something that might be considered as important as this, only having six cases to study seems like a fairly low number.
Then there’s the data relating to the cases themselves. What they show is that badly handled, restricted carbohydrate diets underfeed required energy and nutrients that a growing child or adolescent needs. They also show that the children involved had elevated lipid profiles, without discussing the lipid profiles prior to the diet, raising questions as to whether this was the result of the food intake and increased saturated fat, or whether it already existed. We are left to assume it was as a result, but that isn’t stated.
Finally, there are the points relating to social media and lay data suggesting low carb diets are effective in managing T1 and the issues relating to the psychological effects of diet restriction on T1s. What can we take from these?
The first and foremost is that you shouldn’t take everything you read on the internet as gospel, and this is true, whether it relates to diabetes or anything else. Always ask for corroboration and additional information if anything looks too good to be true. Look for primary source information. Likewise, when it comes to the health of your kids, it’s right to be concerned and to question what’s been presented. You can also question the prevailing medical data as well, but do so with an open mind and be prepared to change your mind and approach. But first and foremost, take care with what you find. We only live once.
The psychological effects of restricting diet also shouldn’t be underestimated. We people with T1D, as a population, have a much greater incidence of eating disorders and psychological issues than the rest of the population, stemming from the obsession that we have to have with food management. Adding extra burden to this, such as restricting a child’s diet in relation to their peers, or the additional obsession that parents may have with ensuring there are next to no carbs in a meal, could easily push a child where we don’t want them to go, and we should be cognisant of this in any decisions we make.
These latter two points are clearly something that needs to be clear to anyone embarking on such an approach and something that should be taken into consideration when deciding how to cope with one’s child.
Should these be reasons to not recommend low carb diets for children? Now there’s an interesting question, and one I don’t have the experience or evidence to answer. I don’t think that the six cases on their own provide a conclusive body of evidence against restricted carbohydrate diets for children (and families of children) with Type 1. But they raise some interesting points in relation to such an undertaking that anyone considering it should be aware of.
The most striking thing about the paper is that rather than recommend any sort of approach or further research that may verify or otherwise the efficacy of treating your child with a restricted carbohydrate diet, it simply goes with the wind of existing thought on the matter and says that, based on a small sample, the popular media is promoting potentially dangerous advice and that clinicians should continue to caution against such an approach with children. Personally, I’d like to see a more widely considered piece of research undertaken that demonstrates one way or another whether, in a properly controlled fashion, a low carb diet for helping manage T1D in children really was a bad thing. There seems to be, after all, a lot of common sense in the mantra of “the law of small numbers“, especially when non-parental carers are involved.
At the very least it might produce better guidance and some form of evidence that says why it might be, instead of the heresay and view that the prevailing knowledge is just wrong, as is seen in many of these circles, and the resultant backlash that results in people taking their own view and proceeding counter to “official” advice.
But that’s for another day. In the meantime, I think it’s worth paying the $6 to have a read of the paper and make your own mind up. I’ve provided my thoughts, and I’d be interested to see what others (especially those who are parents with low carb T1D kids) think.
I have a 2 year old boy with t1d (diagnosed in October 2015). After the initial impact (and what an impact!), I started to do a lot of research on ways to approach diabetes.
At the first consultation with the medical staff, they explained that each insulin unit “burned” about 30 grams of carbohydrates.
So they prescribed a diet for my son, based on MANY carbs. Bread in the morning, bread in the snack, very starchy at lunch time etc.
So I asked: could not we reduce that amount of carbohydrates to give it less insulin?
They replied that these were the guidelines of the ADA.
At first, I didnt diverge, after all, a large medical corporation could not be wrong.
So we started following the prescribed diet. There were many hypers and hypos. A LOT. We could not manage the diabetes.
Some time later, I read a study that a boy with type 1 diabetes goes 24 months without insulin on a LCHF.
It opened my eyes. From there, it was a leap to read Dr. Bernstein’s book, which opened my mind and vision.
My 2-year-old son has glycated hemoglobin of 6.5%, has normal weight, height, and development for age. In addition, there are rare episodes of hypoglycemia.
Can Few Carbohydrates Lower the Child’s IQ in the Future? The height? Sincerely, if this occurs (which I do not believe) I still think preferable to other diabetic complications: retinopathy, infarction, stroke, amputation, etc.
I often say that the diet is LOW CARB and NO NO CARB.
Occasionally he goes to children’s parties and can eat sweets without problems or guilt. For these cases, we use insulin. I just do not think that should be the rule.
In addition, I discovered the wonders of resistant starch, which, despite being a carbohydrate, has a very low impact on blood sugar levels. As an example, parboiled rice has the same glycemic index as strawberries.If any diabetic is reading me, please research it.
I’ve been putting up a lot of resistance from doctors, but I’m sure I’m on the right track. In 20 years, doctors will say: how do we prescribe so many carbohydrates to people?
Sorry for the bad English.
Thanks for your response. Nothing wrong with the English in that. I think it’s worth going back to the point that the paper described here set out to find proof that restricted carb diets could result in some of the side effects that had been described, and they did that. The risk, of course, in doing so, is that it doesn’t present a balanced view on whether restricted carb intake can be a good thing, and doesn’t seek to do that either, preferring to stay within the existing mantra.
Hola Bruno, me gustaría contactarte! de donde eres ? Estamos en el mismo camino, yo con un hijo de 4 años hace 3 meses diagnosticado y manejando la dt1, me gustaría contactar para intercambiar experiencia, recetas y datos, yo tengo un equipo profesional de medicina funcional apoyándome desde México. Nosotros ahora estamos en Asuncion, Paraguay. Saludos!
As a TD1 parent am starting to read about this
Great post, thanks again!
The key point is not quite stated in your opening paragraph. These were invited cases to be described – inclusion was where the submitter believed the endocrine and metabolic consequences related to a carbohydrate restricted diet in T1D children. They did NOT ask for cases reporting restricted carbohydrate in T1D children.
These children were starving as evidenced by complaining of constant hunger, stealing food, poor energy and not surprisingly poor growth. Most appear to be fairly significantly malnourished – only one had salads mentioned in the diet, none mentioned vegetables. Fruit mentioned – so possibly high fructose was the carbohydrate component – no wonder lipid profile not great.
All had reasonable to high fat intake as proportion of total calories allowed, but generally quite low saturated fat. Presumably the rest was nutrient poor seed oils (PUFA).
One probably (Case 5) should not have been on insulin at all as he suffered chronic mild hypoglycemia for years (HbA1c 30mmol/mol, serum glucose frequently below 3.9 mmol/L).
I agree with your points. The reason for the title is the discussion part of the paper. It doesn’t recommend anything other than not encouraging restricted carb diets, which although these were, as you say, malnourishment as a result of lack of food was a bigger issue. It would have been good to see a recommendation made about how, If parents wished to embark on low carb with T1 kids, they might be best assisted.
Only six cases reviewed across all of Australia and New Zealand? There must be very many parents applying low carb/keto dietary principles successfully for their T1D children across something close to 30 million population base. Unfortunately, published literature is very sparse even for this approach in adults, although plenty of anecdotal evidence in what these authors tone was clearly dismissive of “social media”.
There is a tremendous belief that low carb=high protein or starvation. My own specialist (who fired me because I’ve refused to use insulin) was genuinely concerned my diet would be extremely constipating and I’d lose too much weight. Simple answers 2 years on, no and I could still usefully lose another 5kg to have a little buffer below the BMI25 level.
http://doi.org/10.5281/zenodo.572338 for an adult low carb case.
This was not a review of restricted carbohydrate diets of T1D children. They selected only those who had problems AND were restricting carbs. Their discussion is invalid.
And yet it’s a peer reviewed paper published in a journal…. Only a bit disturbing.
I agree peer reviewed – peers are those just like me! I prefer, and get, reviews from a far wider selection before I submit for publication, including non-scientists who can be amazingly perceptive in spotting bias and errors of logic.
Peer reviewed journals give all their published papers a “halo of authority” – at least until it is retracted!
As a T1 parent who is only recently following a low carb diet for their child, this paper may have been concerning had I not seen the benefit in my own child first. First, let’s just point out that a peer reviewed journal does not make a paper great. The impact factor for this particular one is not, that’s for sure. How often will this paper be cited? How many other researchers will use this paper? That is the real question.
Unfortunately without proper statistics, this study is correlative at best. A properly blinded study needs to be conducted, as you mentioned.
The typeonegrit community has offered itself up to be participants in a study conducted at Harvard, of which the preliminary results are stricking. However, it does not yet reveal results by age group.
What I know is, hyperglycemia WILL have grave consequences for my child. My mission is to provide him with the best nutrition, protein, fat, some carbs, veggies…etc…ensure that he is always satiated, ensure that he is growing, make it such that he never feels restricted (by making delicious treats with more nutritious LC ingredients), and to teach him how to manage his diabetes in the safest way possible, while allowing him to make his own choices in a safe environment. My understanding is that if he feels in control of his disease, that can only help him with any possible mental health issues that we may run into.
Technology only got us partially there (OpenAPS). Low carb is ultimately what will keep him complication free. Until there is truely comprehensive study, we will continue down this path.
Thank you for your thourough post!
I think so too