The ketogenic diet, characterized by the consumption of very low amounts of carbohydrates and high amounts of fat,^1,2 is gaining increasing attention as an option for type 1 diabetes mellitus (T1DM) management.³ Although key health considerations remain and no overarching guidelines or protocols yet exist for the use of ketogenic diet in managing T1DM in children, several studies begin to suggest that the diet may be considered as an option. 

Potential Benefits

Several studies of adults with T1DM and case reports of children with T1DM have shown that the ketogenic diet may be effective in achieving glycemic control with minimal adverse effects.^2,4,5 A 2018 observational study of adults and parents of children with T1DM who consume a very low-carbohydrate diet (VLCD) assessed current hemoglobin (Hb) A1c, changes in HbA1c following VLCD, total daily insulin dose, and adverse events.⁴ Most of the participants met the American Diabetes Association (ADA) glycemic targets (mean HbA1c 5.67%), with children (42% of the patients surveyed) reporting similar HbA1c levels as adults. The participants reported low levels of adverse events and being satisfied with their T1DM management and overall health. Although this study was observational and requires further high-quality randomized controlled trials to generalize the data to the general population, it calls for attention in considering ketogenic diet as an option for T1DM, even in children.

Furthermore, a 2018 systematic review analyzed 9 primary studies published between 1980 and 2016 investigating the effects of low carbohydrate on the management of T1DM in adults and children.⁵ Of these studies, 4 reported non-significant changes in HbA1c and 3 studies reported statistically significant reductions. Additionally, 2 studies demonstrated significant reductions in total daily insulin usage. Even though the review was unable to conclusively determine the effect of a low carbohydrate diet on T1DM outcomes due to the heterogeneity of the studies, the results suggest that a low-carbohydrate diet may be effective in lowering HbA1c and reducing insulin usage in adults and children. 

Additionally, a 2020 case study of a 14-year-old girl by the ADA noted that the ketogenic diet should be considered as an option in T1DM management in youths while requiring close monitoring of children’s growth, lipid profile, and psychosocial health.² There have also been case reports of successful, long-term treatment of children with epilepsy and T1DM with the ketogenic diet.^6,7 

Potential Challenges 

Despite the potential benefits of the ketogenic diet on T1DM management in children, challenges and concerns remain. One of the concerns is adherence.² A report in 2012 noted that only half of the adults with T1DM were able to adhere to a low-carbohydrate regimen despite receiving educational classes. It has been well-established that individuals may experience the “keto flu” during the initial period of adjustment, also known as the keto induction.⁸ These short-term symptoms may include headache, fatigue, dizziness, gastrointestinal discomfort, nausea, and decreased energy, which may hinder adherence to the diet especially for children.⁹ Other short-term risks include hypoglycemia and diabetic ketoacidosis (DKA). Concerns remain as guidelines currently do not exist to determine acceptable levels of ketosis in patients with T1DM, leading to challenges in differentiating early DKA from diet-induced ketosis.¹⁰ 

Importantly, studies remain inconclusive about the long-term effects of ketogenic diet and the potential negative effects on the growth of children.^11–13 One study noted that a low-carbohydrate diet can cause growth deficits in children.¹¹ Some children in the study experienced weight loss, growth delays, fatigue, eating disorders, and reduced enjoyment in sports. Additionally, some studies have reported long-term risks of developing dyslipidemia, kidney stones, vitamin and mineral deficiencies, gallstones, elevated liver function tests, as well as psychological issues with the ketogenic diet.^10,12,13 

Ketogenic Diet for Children: Yes or No? 

Given the limited number of observational and prospective trials, more research is needed to evaluate the long-term efficacy and safety of the ketogenic diet in children. As such, the ketogenic diet should not be routinely recommended to children with T1DM.¹⁰ For children who choose to follow a ketogenic diet, health care providers should closely monitor their growth and physical and psychosocial health.³ Consult with your pediatric health care team including a registered dietitian, pharmacist, endocrinologist, and specialist in diabetes care and education about the potential risks and benefits of the ketogenic diet.¹⁴