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. Author manuscript; available in PMC: 2023 Mar 24.
Published in final edited form as: Pediatr Diabetes. 2021 Feb 16;22(3):448–454. doi: 10.1111/pedi.13179

Medical management of children with type 1 diabetes on low-carbohydrate or ketogenic diets

Amy A Rydin 1, Gail Spiegel 1, Brigitte I Frohnert 1, Anne Kaess 1, Lauren Oswald 1, Darcy Owen 1, Kimber M Simmons 1
PMCID: PMC10038004  NIHMSID: NIHMS1874732  PMID: 33470021

Abstract

Objectives:

Low-carbohydrate and ketogenic diets are becoming increasingly popular choices for people with type 1 diabetes (T1D) aiming to achieve optimal glycemic control. A carbohydrate-restricted diet in children has been associated with negative health effects including poor linear growth and inadequate bone mineralization. Guidelines for monitoring children and adolescents choosing to follow a carbohydrate-restricted diet do not exist. We aimed to create a clinical protocol outlining how to clinically and biochemically follow patients choosing a carbohydrate-restricted diet with the goal of medical safety.

Methods:

An interdisciplinary committee was formed and reviewed current consensus guidelines for pediatric patients on carbohydrate-restricted diets for epilepsy and metabolic disorders. A literature search was done to determine management strategies for children with T1D on a low-carbohydrate or ketogenic diet. Key health parameters that require monitoring were identified: growth, glycemic control, bone health, cardiometabolic health, and nutritional status. These health outcomes were used to develop a protocol for monitoring children on carbohydrate-restricted diets.

Results:

A one-page protocol for medical providers and educational materials for families interested in following a low-carbohydrate or ketogenic diet were developed and successfully implemented into clinical care.

Conclusion:

Implementing a protocol for children on carbohydrate-restricted diets in clinic allows medical providers to ensure medical safety while being open to discussing a family’s dietary preferences. Following children in the protocol over time will lead to informed clinical guidelines for patients with T1D who choose to follow a carbohydrate-restricted diet.

Keywords: type 1 diabetes mellitus, carbohydrate-restricted diet, ketogenic diet, pediatrics

1 |. INTRODUCTION

Clinical guidelines for management of type 1 diabetes (T1D) in children recommend a balanced diet with caloric energy derived from all three macronutrients (protein, fat, and carbohydrate) to allow for appropriate growth and development.1,2 International guidelines published by the International Society of Pediatric and Adolescent Diabetes (ISPAD) recommend an energy distribution of 45–55% carbohydrate, 30–35% fat, and 15–20% protein. Notably, both ISPAD and the American Diabetes Association (ADA) recommend that optimal macronutrient distribution should be individualized according to individual and family preferences.1 ISPAD also recommends that children obtaining less than 40% of caloric needs from carbohydrates should discuss their diet with a dietitian to ensure nutritional completeness, including calcium, B vitamins, iron, and fiber intake.2

In recent years, very low-carbohydrate diets (<10% of total daily energy intake or ≤ 20–50 grams carbohydrate/day), which are often ketogenic, and low-carbohydrate diets (<26% of kcal/day as carbohydrate or < 130 grams carbohydrate/day) have been highlighted by popular press and social media as an effective way to improve glycemic control in T1D.3,4 High quality, randomized controlled trials evaluating the effect of a very low-carbohydrate or a ketogenic diet on glycemic control are limited and are nonexistent in children. A retrospective study surveyed adults and children with T1D in Facebook group TypeOneGrit that follow the very low-carbohydrate (<30 g/day) diet outlined in Dr Bernstein’s diabetes solution.5 Those surveyed self-reported excellent glycemic control, with an average hemoglobin A1C (HbA1c) of 5.7%, low rates of hypoglycemia and diabetic ketoacidosis (DKA) and generally high levels of satisfaction with their health.6 Importantly, 27% of surveyed patients did not disclose adherence to a low-carbohydrate diet to their medical providers. Of those who did discuss their diet with a medical team, more than half did not feel supported by their medical team. The scientific merit of this study has been questioned, and more research is needed to confirm the generalizability of the findings.7 However, the results are important to consider given the attention that it has received in the T1D community.

Carbohydrate restriction in children with T1D is generally not advised for concern that a low-carbohydrate diet may result in poor linear growth, poor weight gain, increased cardiovascular metabolic risk, poor bone health and mineral deficiencies.8–14 Also, diets low in fiber and high in unsaturated fat have been associated with worsened glycemic control in youth with T1D.15,16 Although a low-carbohydrate or ketogenic diet in healthy individuals and in those with T1D is often thought of as a lifestyle choice, ketogenic diets are an important treatment option for children with drug-resistant epilepsy and some metabolic disorders.17 In children initiating a ketogenic diet for medical treatment of epilepsy, guidelines recommend counseling, extensive nutritional, and laboratory evaluation to ensure safety, and supplementation with a multivitamin containing minerals, calcium, and vitamin D.18,19 Several case reports indicate that ketogenic diets have successfully improved seizure control and cognitive function in children with T1D and epilepsy while meeting glycemic targets.20–23 The recent decision to treat a patient with T1D and refractory epilepsy with a ketogenic diet brought to light that the Barbara Davis Center for Diabetes (BDC) pediatric clinic does not have a standardized approach to assessing medical safety over time in patients adhering to low-carbohydrate or ketogenic diets, and there were no published guidelines at that time. Since then, there is one publication that suggests a specific clinical approach to monitoring children with T1D following a low-carbohydrate or ketogenic diet to ensure nutritional and metabolic safety.24 Because more patients are choosing to follow a carbohydrate-restricted diet, there is a need to develop guidelines that recommend how to clinically and biochemically monitor these patients to ensure their medical safety. We aimed to develop a clinical protocol for monitoring pediatric and adolescent patients at the Barbara Davis Center who are following a low-carbohydrate or ketogenic diet.

2 |. METHODS

An interdisciplinary committee with medical doctors, dietitians and certified diabetes educators was formed to create a clinical protocol; members of our social work team assisted in the review of the created protocol. First, the laboratory and side effect monitoring guidelines suggested by the International Ketogenic Diet Study Group for children with epilepsy receiving dietary therapies were reviewed.18,19 These guidelines were compared with the local hospital’s protocol for initiating and following children on a ketogenic diet for epilepsy treatment. Next, an electronic search of the PubMed database was conducted to determine management strategies for following a child with T1D, with or without epilepsy, on a low-carbohydrate or ketogenic diet. Using the search strings: (diabetes OR T1D) AND (diet OR ketogenic diet OR low-carbohydrate diet) AND pediatric patient from inception through October 2018, with a plan to review new literature and edit the protocol as necessary yearly. All studies were critically reviewed that were observational in design and that described both beneficial and concerning outcomes for children following a ketogenic or low-carbohydrate diet. The committee then met regularly to develop a clinical protocol and educational materials for families interested in following a low-carbohydrate or ketogenic diet. The materials were presented at a clinic wide staff meeting and the clinical protocol was implemented in October 2018. The literature review was repeated a year later in October 2019, and the protocol underwent minor revisions prior to arriving at its current state.

3 |. RESULTS

The literature search for management strategies for children with T1D on a low-carbohydrate or ketogenic diet resulted in 622 articles. The majority of literature examined children following low-carbohydrate or ketogenic diets as a treatment for epilepsy. The literature reviews up to October 2019 did not return any guidelines for the management of carbohydrate-restricted diets in T1D.

Current consensus guidelines for children with epilepsy or metabolic disorders initiating a ketogenic diet include prediet counseling, nutritional and laboratory evaluation, and supplementation with a multivitamin containing minerals, calcium, and vitamin D. The guidelines recommend follow-up visits 1 month after diet initiation and then every 3 months. Height, weight, and laboratory studies are recommended at each follow-up visit.19 The diet is discontinued as soon as possible with a maximum duration of 2 years.

In review, the most pervasive negative health outcome in children on a carbohydrate-restricted diet for any reason is poor growth and development. Therefore, linear growth velocity, weight gain, and pubertal development are primary health outcomes followed in the protocol. The other primary health outcome followed in the protocol is glycemic control. Specifically, we evaluate HbA1c and determine if there were any emergency department visits or hospitalizations for hypoglycemia or DKA since the last appointment. Wearing a continuous glucose monitor (CGM) is encouraged, and metrics such as time-in-range and percentage of time with hypoglycemia are captured when possible. Decreased bone mineral density (BMD), a worsened cardiometabolic profile, nutritional deficiencies and poor metabolic health have also been reported in children and adults on ketogenic diets and are followed as secondary health outcomes.

A one-page clinical protocol was developed to aid in educating families about and monitoring the health outcomes and possible risks identified (Figures 1 and 2). A child is followed according to the clinical protocol if they are consuming less than 100 grams of carbohydrates. Upon entering the protocol, the family receives counseling from a dietitian/certified diabetes educator and is given two patient education brochures that were developed titled “Carbohydrates and Diabetes: What’s Best?” (supplemental Figure S1) and “T1D + Food: Ketogenic Diet Safety Concerns” (supplemental Figure S2). The family is also advised to monitor ketone levels daily in the morning or after the longest fast for 1 week. Communication with the dietitian and/or the provider regarding ketone levels occurs after 1 week to confirm that the child is indeed producing ketones for energy due to carbohydrate restriction. If ketone levels are ≤1.0 in blood or ≤ trace in urine, the child follows up with the dietitian at his or her next visit. If ketones are >1.0 on a blood ketone meter or > trace in the urine, we initiate close laboratory and clinical monitoring of the patient per the clinical protocol.

FIGURE 1.

FIGURE 1

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Clinical protocol for monitoring children on low-carbohydrate diet. CGM, continuous glucose monitor;

FIGURE 2.

FIGURE 2

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Risks of a carbohydrate-restricted diet. T1D, type 1 diabetes

As routine diabetes follow-up appointments occur every 3 months, the assessment and laboratory schedule in the protocol is similar to the schedule used to monitor pediatric patients with epilepsy on carbohydrate-restricted diets. At follow-up visits, the medical provider adjusts insulin doses per routine, reviews timing and frequency of insulin administration, determines if the carbohydrate-restricted diet is meeting the family’s expectations for optimized glycemic control and assesses for side effects. A dietitian or certified diabetes educator reviews growth, vitamin, and mineral supplementation and completes a 24 h dietary recall and review of 3 day food records to determine if the family meets criteria for following a carbohydrate-restricted diet. A laboratory assessment is completed at initiation of diet when possible, then every 3 months for the first year and every 6 months thereafter. If at any time the child has symptoms of ketosis, the medical team assists the family in bringing the ketone levels down and seeking additional medical help if needed. Furthermore, if concerns arise based on laboratory assessment (using standard reference ranges for chosen diagnostic tests), growth parameters (using standard CDC growth charts), or blood glucose monitoring (using standard reference ranges for hypoglycemia and time in range), the provider proceeds with a strong recommendation for discontinuation of the diet.

3.1 |. Assessment of primary health outcomes

3.1.1 |. Growth

Carbohydrate-restricted diets raise concern for caloric and nutritional deficiencies that can directly impact adequate weight gain and subsequent linear growth.19 Furthermore, due to the decreased insulin requirements related to consumption of less carbohydrates, a child on a carbohydrate-restricted diet likely experiences a reduced anabolic state, further impacting growth. Although not a concern for adults with T1D, children with T1D have unique nutritional needs at every stage of growth and development. Therefore, growth is monitored carefully so that height deceleration is identified early.14 Measuring and monitoring growth parameters is a standard part of outpatient diabetes care, and the protocol emphasizes the need to evaluate the child’s height, weight, BMI, and growth velocity closely at each follow-up visit.

3.1.2 |. Glycemic control

Adults and caregivers of children often express interest in carbohydrate-restricted diets, related to their goals for optimizing glycemic control. HbA1c and CGM metrics are followed as per routine, with a specific focus on evaluating for excessive hypoglycemia. With restriction of carbohydrates, there is an increased risk of hypoglycemia, and this may be due in part to increased hypoglycemia unawareness and a decreased response to glucagon.14,25 Therefore, intensive glucose monitoring of ≥6 times/day or alternatively wearing a CGM is recommended in the protocol.

3.2 |. Assessment of secondary health outcomes

3.2.1 |. Bone health

Bone health monitoring is critical in children on a ketogenic diet with T1D. Children with T1D have decreased BMD and altered bone turnover.26 Children on ketogenic diets for epilepsy treatment have low vitamin D, high-parathyroid hormone (PTH) and low BMD that is more dramatic than the effect of antiepileptic medications alone. Unfortunately, the decline in BMD occurs despite appropriate supplementation. The ketogenic diet likely adversely affects bone health secondary to chronic acidosis via ketone bodies, which removes the bone mineral’s buffering capacity and interferes with conversion of 25, OH vitamin D to 1,25 dihydroxy-vitamin D.9 Therefore, calcium, phosphorus, and vitamin D levels are monitored closely. After the age of 5 years, a DEXA scan is completed in any child who has been on a carbohydrate-restricted diet for longer than 2 years. Further related to calcium metabolism, hypercalciuria has been noted in children on ketogenic diets.27 This is possibly due to fat malabsorption, which can bind oxalate in the gut, allowing calcium reabsorption with subsequent increased urinary excretion and can be evaluated for with urine calcium/creatinine ratio.

3.2.2 |. Cardiometabolic profile

A low-carbohydrate diet or ketogenic diet inherently includes an increased percentage of calories consumed from fats and a higher proportion of saturated fat intake.14 An increase in total cholesterol and triglycerides are often seen in the blood, and this has correlated with increased local and systemic arterial stiffness in children and adults on carbohydrate-restricted diets.27–29 Fasting lipid panels are therefore followed as high cholesterol is an independent risk factor for cardiovascular disease (CVD). T1D places individuals at increased risk for CVD; even children with T1D have evidence of subclinical CVD within the first 10 years after diagnosis independent of glycemic control.30 Therefore, monitoring for factors that can increase CVD risk such as high cholesterol and triglycerides is important for pediatric T1D patients on a carbohydrate-restricted diet.

3.2.3 |. Trace minerals

The ketogenic diet is known to be deficient in most vitamins and minerals, including trace minerals. Monitoring serum levels of magnesium and zinc is important to assess for micronutrient deficiencies that require supplementation. Furthermore, selenium levels are monitored as approximately 20% of the children on a ketogenic diet have been identified as deficient in selenium and do not meet at least 75% of the recommended dietary allowance.31 If selenium levels are low, supplementation is initiated as it is shown to improve serum levels and protect from effects of selenium deficiency such as cardiomyopathy.

3.2.4 |. Metabolic health

A complete metabolic profile assesses acid–base status along with liver and kidney function. Mouse models have shown that ketogenic diet fed mice develop nonalcoholic fatty liver disease (NAFLD), possibly due to additional endoplasmic reticulum stress, steatosis, cellular injury, and macrophage accumulation.32 A persistent state of ketosis increases burden on the liver and kidneys, directly affecting their function. A urinalysis is also warranted to assess for ketosis, as well as for hematuria or proteinuria, which could indicate renal calculi. Beta-hydroxybutyrate levels are also obtained, particularly if the family is not monitoring ketones at home. Free and total carnitine levels are assessed as carnitine deficiency can result in fatigue, muscle weakness, and rarely liver and heart problems. It has been reported that the total carnitine levels are found to decrease over the first months of the ketogenic diet initiation and often enter the range for carnitine deficiency. The levels can normalize, or at least stabilize, after the first few months of initiation.33

3.2.5 |. Blood counts

A complete blood count (CBC) is followed as the ketogenic diet has been associated with anemia and increased bleeding risk, possibly related to changes in platelet membrane composition and subsequent platelet responsiveness.34

The implementation of the protocol has been well received by the Barbara Davis Center for Diabetes medical staff. We are currently following 19 patients on a carbohydrate-restricted diet and will report patient outcomes in the future to help further define the risks and benefits of a carbohydrate-restricted diet in a pediatric and adolescent population with T1D.

4 |. DISCUSSION

With a protocol in place to safely evaluate and monitor pediatric and adolescent patients who choose to follow a low-carbohydrate diet, questioning of medical providers at the Barbara Davis Center has demonstrated that they are now comfortable having discussions with families about dietary decisions and specifically about the potential risks and benefits of carbohydrate-restricted diets. In order to best support patients and ensure their safety and well-being, the clinic intends to remain open and nonjudgmental of these patients and their families by following them in the developed protocol while providing continued education about potential risks. Since creation of the protocol, similar monitoring of children on carbohydrate-restricted diets was proposed by a pediatric diabetes team in Australia.24 Most families do not discuss a carbohydrate-restricted diet with the medical team prior to initiation, so it is likely that the baseline and 1 month evaluation in our protocol will not often be completed.

In order to make a protocol that medical providers and staff can easily and reliably follow, the protocol was condensed it into a concise, one-page decision tree format. Although its brevity is an inherent strength some important concepts were simplified. For example, the decision to use 100 grams as the cut-off for when children should enter the protocol is based on the current recommendations for macronutrients, definitions for carbohydrate intake, and the current literature identifying potential growth and development concerns for children consuming less than 100 grams of carbohydrates.2,3,14 The cut-off of 100 grams of carbohydrates is not specific to a percentage of carbohydrate intake compared to total energy intake for the child that is needed based on current growth and activity, and some toddlers may be included and some adolescents excluded inappropriately. However, using total grams of carbohydrate intake per day is the easiest way to identify children at risk for carbohydrate restriction since the protocol does not require that a family completes food records before entering the protocol due to concern for loss to follow-up. Other weaknesses of this approach include that the proposed laboratory assessments may be prohibitively costly for families with inadequate insurance coverage. Until more data is collected, a cost benefit analysis cannot be completed to determine if this frequency of laboratory monitoring is beneficial.

A real concern for children with T1D on ketogenic diets is that it becomes difficult to assess whether they are in nutritional ketosis or metabolic ketosis and are at risk for DKA. This becomes a medical challenge during times of increased medical risk such as during a vomiting illness. Families are instructed to monitor ketone levels at home so that when they are ill, the family and medical team can determine how much ketone levels are increased from baseline. Management of illness for children with T1D on a carbohydrate-restricted diet is similar to other pediatric and adolescent patients, which includes a personalized sick day protocol that emphasizes the importance of blood glucose and ketone monitoring, hydration, and calling the on-call nursing or physician phone line if symptoms or ketones persist. However, because these families have higher ketone levels at baseline, they are instructed to call upon initiation of their sick day management plan. Increased contact is important as families focused on restricting carbohydrates may be reluctant to give fast-acting carbohydrates to raise blood glucose in order to give insulin, which is necessary to prevent DKA during illness.

Limitations to our protocol development include that the literature review was not systematic and did not include publications after October 2019. Also, although the interdisciplinary team that created this protocol included our social work and behavioral health team, it did not include a trained psychologist or exercise physiologist. We hope to include input from these individuals during our next protocol revision so that the impact of restrictive diets on social and psychological health, disordered eating and exercise and activity can be better addressed. Finally, formal analysis of the protocol use, family acceptability, and clinical outcomes are in process and not included in this initial account of our protocol development.

A standardized approach for monitoring pediatric and adolescent patients with T1D who choose to follow a low-carbohydrate or ketogenic diet is now possible at our Center using the developed clinical protocol. This protocol has the potential to promote patients and providers having open and honest discussions about dietary decisions and other strategies that can successfully improve glycemic control. This protocol will also help evaluate the medical safety of patients while maintaining the provider-patient relationship that is necessary for optimal diabetes management. Our medical providers and staff have been actively engaged in following this protocol, and the majority of patients who have been identified by a medical provider has had appropriate counseling and lab orders placed per the protocol. Continued measures of adherence to the protocol and participant responsiveness will be useful in assessing continued success of protocol implementation in our clinical setting. We hope to inform the creation of optimal management strategies for pediatric and adolescent patients with T1D on carbohydrate-restricted diets by following children who are being managed with the protocol over time.

Supplementary Material

Supplementary Material

ACKNOWLEDGMENTS

Thanks to Georgeanna Klingensmith, MD and Shideh Majidi, MD for proofreading the manuscript prior to submission. This work was supported by grant funding from the National Institutes of Health National Institute of Diabetes and Digestive Kidney Diseases (5 T32 DK063687, 5 K12 DK094712-08).

Footnotes

CONFLICT OF INTEREST

The authors have no relevant conflicts of interest to disclose.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1111/pedi.13179.

SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section at the end of this article.

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