Continue low carb or not for T1D six year old?

Type 1 and LADA
1

I have been following a carbohydrate-restricted diet for my T1D 6 year old for over a year. She consistently eats a little over 100 carbs per day including 3 snacks and very little processed foods. Mostly, she eats veggies, fruits, nut-based muffins, and some protein for meals. That is not anywhere near Berstein's restrictive recommendations, but my clinic advises at least another 10 to 15 carbs for breakfast and lunch to avoid starvation metabolism. Her sugars are fairly well controlled with A1C's averaging 6.5, and she seems healthy except for a couple things that are causing me to consider increasing carb consumption.

1) Although still in range, relatively speaking, her growth is slowing and her weight is increasing. This has been a trend for a year or so. The question of whether low carbs cause stunted growth keeps nagging me,and I am wondering about metabolism changes due to this diet.

2) Her IC ratio is extremely high for all meals. It is between 1:6 and 1:8 depending on the meal. The basal to bolus ratio is within an acceptable range. Does this mean that her liver is producing glycogen and consequently raising blood sugars because there are insufficient carbohydrate content in her meals? If so, does that mean increasing dietary carbohydrate content could actually reduce insulin requirements and give her liver break? If true, would this be a good thing?

Any reading suggestions would be helpful too.

2

I would definitely not put a child on a low carb diet, first of all for growth reasons, second i think every child has the right to enjoy its childhood, and that for me is also eating sweets from time to time and enjoy it. If your kid decides to follow a low carb diet later in life, it is its own decision, but not now for sure. I was able to eat whatever i wanted as a child (of course my mom watched that i ate healthy, but i did not eat differently than my sister who is nonD) and i am thankful to my mom for that.
Love, SC

3

kaymore, what a hard job it must be to be the caretaker of a kid with D. i got t1 as an adult and for that i feel a bit less hard done by! i eat about the amount of carbs your daughter does-kind of moderate carb for an adult- with lots of veg, nuts and meats, cheeses. i hardly eat anything processed either. i have more energy than i did when i was eating a higher carb diet.

is 100 grams a day low for a child? i dont know, but if i consider what youve said about her diet and compare it to the average western child´s, id say shes probably a lot healthier!

i dont know the answers to your questions, but you might want to look into (if you havent already) recent studies in avg height and weight for western children. is she at or above a certain percentile in height? infants and toddlers grow at astounding rates, but primary aged children slow down in height until puberty hits, maybe there is some of that normal slow down?

i think liver dumps happen primarily to type 2 patients? is your daughter a sedentary kid, does she get enough exercise-could she have insulin resistance?

maybe if you did want to try adding more carbs you might look into the glycemic index of foods? i dont take the glycemic index into account, but another variable if you want to increase her carb intake.

good luck in figuring this out and im sure you are doing an amazing job.

4

I won't comment on the biological issues, as I do not have a child, but I agree with swisschocolate. I don't think it's ever a good idea to "restrict" an otherwise healthy eating child. I think it's a good way to start an eating disorder. I know of quite a few female diabetics from my era who had issues with food due to the way we were treated. Foods were demonized or sometimes treated as a "reward". I wasn't too severe, but some I know were. That's my take on it anyway.

5

I would be concerned about limiting it as it seemed that my own daughter's need for food sort of went along with growth spurts and that during periods where her growth was going on more rapidly, she seemed to eat more. Sometimes this can happen "naturally" at 6ish, where the growth slows and a kid may fall back more towards the middle of the growth chart after leading or whatever.

For me, the whole thing about insulin rates and ratios should totally be determined by BG results, maybe considering A1C as a "scorecard" to sum up the BG results and consider if it can suggest a different way to manage it. Eating lower amounts of carbs doesn't guarantee your BG will be ok however I have found eating less carbs has helped me drop pounds and, concurrently, helped manage my BG very well, while being pretty active. The need for carbs is greatly overstated however we do need them. It sounds like she's getting a pretty full boat nutritionally. I note that dairy doesn't appear to be a big component of it. Is that a plan or she doesn't like milk?

6

Another reason that came to my mind is that kids who are restricted a lot in childhood tend to rebel more in adolescent years. That is for non-D as well as for diabetic kids. Especially with a diabetic child i wish you from the bottom of my heart that she does not rebel as a teen, it can make things much harder.

Wishing you luck, love,

SC

7

I think many people think a low carb diet is "restrictive." I don't. Kids will eat what you put in front of them. I rarely find my kids asking for carbs when I serve them a low carb meal (and they aren't diabetic) It really sounds like your child is doing very well, you don't say she is complaining and feeding her a low carb diet from primarily non-processed foods is in my opinion a great choice.

I have sympathy for your quandry, it can be difficult wading through conflicting opinions and trying to make the best choices for your child. Unfortunately, most dieticians and diabetes educators are not well informed about low carb diets and ask you to adhere to a recommendation that you have to eat 45-65% of your calories from carbs. And if you insist on a low carb diet, often these professionals don't know how to help you with the low carb choice. It seems that your diabetes center is advising you to avoid "ketosis" (what they are calling starvation metabolism). Ketosis is actually a natural state, everyone goes into ketosis overnight when they fast during sleep. Despite claims from these, ketosis from fasting and a ketogenic diet has nothing to do with DKA and is not a harmful condition and does not lead to stunted growth.

In fact, Bernstein argues that stunted growth in T1 children is usually caused by excessive blood sugars which causes significant metabolic disturbances and poor uptake of nutrients. If your daughter was truly "starved," she would not have an increasing weight. In fact, I've never seen any evidence that low carb stunts growth. Kids grow in a highly variable way and are prone to spurts. Carbs are not needed for growth, but a range of nutrients are. But all those nutrients are found in abundance in a diet rich in meats, seafood, dairy and non-starchy veggies. Eating a couple of extra slices of fortified bread with breakfast and lunch will add nothing.

Now as to the I:C ratio, again I think you have been given poor advice related to low carb diets. A 50/50 basal/bolus ratio is an acceptable range for a diet with 45-65% of calories from carbs, but not for a low carb diet. With a low carb diet, you reduce carbs, reducing the total bolus needed and your basal/bolus ratio changes. Mine is more typically 70/30 to 80/20. Think about it. If you cut half the carbs from the educator recommended diet you would need half the total daily bolus and since your basal would stay the same you would need a ratio more like 67/33.

So there may be two things going on with your daughters mealtime insulin. First, if you are feeding her constantly through the day, your mealtime/snack bolus may actually be acting as a daytime basal. You might look carefully at her basal levels and make sure they are set properly and that you aren't using daytime bolus to replace basal levels that are too low. Second, with a low carb diet you often have to start accounting for protein and meal size in the calculations. I count half the protein as glucose as recommended by Bernstein. And when you have a large meal (which might not actually be "large" for a six year old), the stomach distension itself can cause a blood sugar rise which requires insulin to offset.

In the end, you will have to try to listen to the advice from all the sources, even the contradictory advice and then try to make the best decision.

8

Brian, my problem isnt the everyday meals, but the birthdayparties with cake, not having an ice-cream in hot summer days and so on. I mean if you leave your kids these freedoms, it might be alright :slight_smile:

9

I don't think 100 carbs per day is really low for a 6 year old. It is low for the standard American diet, but I'd say it is certainly within the normal range of how much a child should take in. Also, I think kids should avoid sweets in general. A non-D health food nut friend, only gives her son water to drink, gives him no sweets, feeds him lots of greens and beans, and only whole grain breads, and this 15 year old is one of the healthiest kids I know.

My understanding is that IC ratios can be high for kids. I don't think her body is doing anything drastic with that many carbs. There are some here eating 30-40 carbs per day, and I'm generally in the 50-70 range.

10

I agree, it is about everyday choices, kids should have some latitude for special occasions.

ps. I also make my own low carb ice cream that is really, really good.

11

you know at the end, if a kid notices that it cant have something others can bc of D, it is gonna blame the diabetes and hate it therefore. And no person should hate Diabetes for any reason, so one should try to avoid that a in any case. so i think thats what matters the most ;)

12

My son was on a ketogenic diet from age 4-8 for treatment of intractable seizures, and it completely changed his metabolism–as it was meant to. He had the same growth issues…weight gain and less height growth. However, he only had 8 grams of carbs per day, so it was definitely lower than your daughter’s 100 grams/day. :slight_smile: It wasn’t until we tweaked his calories and ratios of fat and protein that his growth pattern ‘normalized’, so I think you could be on to something with your thoughts, but my perspective may not be particularly helpful, as it was an extreme case and not related to T1. As a mom with a kid having severe health problems, I always went with my intuition. You know her and her T1 better than anyone else. Trying to increase carbs a bit probably won’t hurt her, and if it does, it’s something that can be easily changed. Good luck with your decision!

13

Hi Kaymore, I am moving to a lower-carb diet for myself and my 9-year old (both T1D). I second Brian's comments - most dietitians have no clues, and can't even suggest non-nut school snack alternatives that are gluten-free for my coeliac daughter. Low-carb is against their religion.

Your body gets glucose from carbs easily, and protein and fat more slowly - you don't need massive amounts of carbs. Is she hungry all the time? Weight gain does not sound like starvation. My daughter appears tubby occasionally and then puts on a tremendous growth spurt, but perhaps over a shorter timeframe than a year.

14

Thank you all for such insightful and diverse responses.

To clarify, I am not zero tolerance. My daughter still has pizza as often as once a week. I try to make it a thin crust, low carb variety. She also has about 10 carbs of dessert with every dinner. Usually it is an organic version of a peanut butter cup. I am not a big fan of dairy, but she gets some organic butter, occasional cheesecake, ice cream, and of course, cheese on pizza. I try to steer away from cakes, pies, and other flour-based desserts. She does not have Celiac disease, but I generally avoid wheat because most flour products (whole grain or not) offer little nutrition and cause large blood sugar spikes. However, if she is at a birthday party and they are serving a meal or snack with the cake, she can have a little cake too. If nothing else is served, I try to remember to bring some cake home so that she can have it with dinner.

Is this lenient enough to maintain a healthy relationship with food? There were many foods my mom forbade when I was growing up and I don't recall gorging myself on them later on. Also, my mom used to take away my bedtime ice cream snack as a punishment. I never considered doing this to my daughter even before diagnosis, but I don't see a problem with it, and I don't think it caused any problems for me. Lastly, how can you not demonize some of the "foods" in stores such as Frankenberry cereal?

Growth rates of children are measured on a curve against averages, so the slowing due to her age is accounted for. She is still within the 50% percentile of height but is moving closer to the lower edge of the range. She has never been particularly high energy kid, but she was on the skinny side prior to being diagnosed two years ago. When she was an infant and toddler, she was in the 75th percentile for height. I don't think that high sugars prior to diagnosis caused her growth to slow because her A1C was only 8 when diagnosed.

I have periodically asked if she wants more or less food and she always responds that it is just the right amount. With snacks, she is usually eating something about every two hours anyway. To be fair, though, she generally has low self awareness and sometime doesn't realize that she is hungry.

15

Our endo has advised our teen (who sometimes restricts carbs just because she isn't hungry) not to go below 120 grams a day. Our teen is 16 and fully grown. We did not consider restricting carbs for a growing child and she had at least 1800 carbs a day while growing since she was dx'd at age 8. Per endo and dietitian's advice. I know there are different theories now but I still would not restrict carbs for a growing child. I don't know if that will improve her ICR; our DD uses 1 to 6 breakfast, 1 to 7 lunch and dinner. Even when her basals drop drastically she needs a lot of insulin to cover her meals. At 8 years it was 1 to 15. Increasing carbs will probably increase her insulin requirement as far as bolus amount and her basals may increase as a result of the increase carbs. That's okay. Children need a certain amount of carbs per day to grow. That is why your endo will pull out the growth charts each visit. As an adult carbs can be restricted. A lot of the adults restrict carbs, either moderate restriction or severe restriction. A six year old with Type 1 is entirely different than an adult with type 1. Please take the advice of your endo, and your nutritionist that is part of her endo team. The liver produces glycogen when Type 1s eat; the liver shuts down glycogen production when nondiabetics eat. Nothing we can do about that yet. She needs what she needs as far as insulin goes for basal, for bolus, for correction. You will keep records, analyze and let personal experience with your own child be your guide. Each child is different.

16

Sorry for the typo. Our DD was put on 180 gram a day carbs, and I believe that translated to 1,800 calories, roughly. NOT 1800 grams, LOL. She remained stick thin on that amount. Tried for healthy food, with some exceptions. Cereal is the devil so definitely no Frankenberries. Try not to keep cereal in the house.

17

WHY are you low carbing a child who needs to grow and get all the nutrients she needs. Kids should not be 'low carbing'. Also, if one low carbs this much, it will lead to being very 'carb' sensitive. The reason why you're bolusing so much is because she probably is now needing to bolus for EVERYTHING, including protein because eventually the body will turn everything into glucose. These analog insulins were designed and developed to work for and on carbs.

18

I dunno if 100 is "low" as much as "less than a lot of people eat". It's like 3 bowls of cereal or 3 sandwiches or cereal a sandwich and a potato or whatever. I don't think that's that dangerous, if the weight/ height thing is "normal" or normal adjusted for how tall your relatives are or whatever. As long as your BG is ok, if the kid is happy eating what she's eating, I would suspect that's healthier in the long run and in terms of developing a healthy general approach to food than going "the book says you need more carbs so eat these carbs"

I'm not sure I buy the carb sensitivity argument either as I have seen no evidence of that in my own experiences but I am not tremendously well-versed in any scientific literature on the subject although, according to the Gary Taubes books, the studies of it tend to be somewhat older as the approach had fallen into disfavor.

19

My reasons for choosing a low carb diet are the following:

1) Eating healthier foods naturally leads to a reduction in carbohydrate consumption and doesn't necessarily lead to nutrient deficiencies. Of course, the devil is in the details.

2) Fewer consumed carbohydrates reduces blood sugar swings, produces generally lower blood sugars, and makes diabetes management easier.

I think I will look at increasing her carb intake, but trying to do this in a way that add nutrition instead of just sugar will be the tricky part.

I wish there were studies or tests that could be done now to see what is actually happening internally.

20

There are studies. I would recommend Gary Taubes' "Good Calories/ Bad Calories", more a history of science book but it may provide sources if you want to check them out.

The number to focus on to make sure you're eating enough is calories and if you are eating however many grams of carbs, the key thing is to make up any deficit with additional protein and/ or fat to hit your calorie target. I've been playing around with this a bit lately and if I go 50/30/20 (pro/carb/ fat) I'll drop a couple of pounds but if the carbs creep up to like 50 I won't. I'm probably a horrible example for this as I will do stuff like eat a chicken breast or can of tuna at night to "cook" my %age but it's sort of eerie the way it works. Same # of calories but the proportions make a difference and I think that lower carb is ok if you can increase the other groups. I am not, of course, a scientist...