As a general pediatrician, I look at the child’s health as a whole-physical and mental health- not just their diet, their behavior, the number of illnesses they’ve had in their life. No, it’s a balance.
Somedays, kids will eat better than other days.
Some days, they will act out more.
During certain times of the year, they will likely get more coughs and colds.
When I look at the balance regarding a child’s nutritional health, the scales are beginning to tip where we see more obesity in children, and unfortunately, there is no quick fix. I often get asked by parents if they can “cut” foods from the diet or limit which foods they can eat. The answer is yes and no. Certain foods are definitely best if limited, but I’m a huge advocate of balance and teaching healthy habits. That, to me, means not cutting out one entire group. So in light of this perspective, I’ll be touching on a particular diet-the ketogenic diet -which parents have asked me about.
(I will be doing a separate post in the future on obesity in children and ways we can change our habits as parents and create new and healthy habits for our families and children.)
First, let’s talk about the diet and its use in the medical field. The ketogenic diet isn’t a fad. It’s actually been around for almost 100 years. Unfortunately, some children with severe epilepsy can have disabling seizures-up to hundreds per day, which severely impact the quality of life for the child and family. Nobody knows exactly why a state of ketosis limits seizures. Researchers at Johns Hopkins University studied 150 children with epilepsy and after a year on the ketogenic diet, half of children had 50% fewer seizures. In the study, 25% of children reduced their seizures by 90%. The typical "classic" ketogenic diet, called the "long-chain triglyceride diet," provides 3 to 4 grams of fat for every 1 gram of carbohydrate and protein. This diet should never be initiated in a patient without the input of a medical physician.
When prescribed by a physician, there are multiple follow ups and carefully monitoring by a dietitian. Depending on age, the diet may need to be initiated in the hospital to monitor labs. The diet looks different for every child because it depends on multiple factors such as the age and weight (Ketogenic formula is even available for infants) and the family’s religious dietary restrictions. It can take a few days to months to show effect, but if the diet successfully controls the seizures, it can be continued for several years under the supervision of the child’s pediatrician, neurologist, and dietician.
The side effects of the ketogenic diet in children will be similar to what we see in adults attempting to achieve ketosis. Constipation occurs given the high protein diet. Sometimes, we see diarrhea as the GI tract attempts to break down these high fat meals. Without carbohydrates, we also see fatigue and irritability. This is important because children aren’t forthright in stating how they feel. It may take a few weeks of sleeping in classes or failing tests to realize that your child or teen isn’t behaving appropriately. Lastly, with ketosis, we can see nausea and vomiting. This is an important symptom we see in our children with type 1 diabetes mellitus who experience DKA. Sometimes, it’s difficult to tease apart these symptoms from a gastrovirus so it’s important to tell your child’s pediatrician if your child has been on any special diets. Given the side effect profile and the importance of balanced diet in children, physicians usually recommend the ketogenic diet for children whose seizures have not responded to several different seizure medicines.
If there is no history of epilepsy, I don’t recommend any form of restricted diet for children, even athletes. The way the ketogenic diet works is limiting carbohydrates which is a major source of your body’s energy, in the form of glucose. Without glucose in the form of carbohydrates, the body turns to its fat and protein stores. Breaking down the body’s fat stores occurs in a state of ketosis, and this is seen by the body as “starvation mode.” One of the many adverse events that occur in the body when it kicks into starvation mode is increased cortisol levels ( a stress hormone), which can lead to problems if present for long term.
The ketogenic diet can also cause micronutrient deficiency. Many sources of carbohydrates like whole grains, fruits, and vegetables have essential vitamins for children, especially during stages of rapid development and serve as a huge source of energy for the body, mentally and physically. Even teens require higher amounts of certain nutrients, especially athlete. Any form of restricted eating negates a well-rounded and balanced diet that we know is beneficial during development, puberty, and the transition into adult eating habits.
The only thing I recommend is limiting trans fat which we know can increase our cholesterol and triglycerides and usually goes hand in hand with unhealthy foods (ie, fried food, heavy cream, butter). You don’t have to cut it out completely. Nature intended many foods, like butter, to be full fat so I don’t advocate for switching to a fat free alternative, but instead limit how much of these foods you eat daily to a reasonable amount. Sugar is something that has also increased in our food content. As the food industry began to cut fat, they added in more carbohydrates often in the way of sugar to keep flavor. Don’t believe me? Check your milk cartons. While whole milk has more calories and fat than skim milk, skim milk has more sugar.
So how many carbs does your child need? That’s a hard question to answer. Children require more carbohydrates as they get older. During puberty and adolescence, a period of increased growth, carbohydrate requirements increase. We see that in the way of an increased appetite during a growth spurt. The body needs carbohydrates in addition to other macronutrients to have energy. There is no specific number of carbohydrates per age or weight range that pediatricians recommend. More active children-think toddlers, growth spurts, athletes, will have a higher carbohydrate intake naturally. I advocate for children to learn healthy habits from the family and have a balanced plate with lean proteins, vegetables, and whole grains. Our carbohydrate intake, even as adults, fluctuates and should be determined by how active we are-a sendentary desk job, number of days a week we exercise, for how long, and at what intensity, are all components of what go into determining our recommended carbohydrate intake.
As a general pediatrician with specific focus in pediatric health and nutrition, I think certain principles of the ketogenic diet may be a good idea for children battling obesity. Namely, keto has some great points like reducing high-glycemic carbs- the amount of bread, rice, pasta, sweets or juice. These are all things that we associate with weight gain and obesity, but it’s not just about eliminating the food but considering the quality. For example, instead of white bread and white rice, consider whole wheat. Not only do whole wheat grains pack more protein, but they also have more fiber, which can mean your body can even burn calories to digest these foods. Instead of cutting them out completely, consider reducing the portion sizes. Instead of a bowlful of pasta, consider bulking up the meal with a vegetables or using a marinara sauce instead of a cream based sauce. Lastly, one key factor is movement. Cutting these foods without increasing movement in our children won’t have a long lasting effect. It may be a temporary fix, but it’s a well studied fact that this generation of children are no longer playing outdoors like before. Encourage your children to engage in some form of activity-whether it’s walking, swimming, or playing outside, for at least a half hour daily.
I do think there is a safe way to limit the not-so-good foods in a child’s diet without impacting micronutrients and the carbs they need to grow. In general, I think we could all do with limiting some carbohydrates like candy, cookies, brownies, and of course sweetened beverages. Contrary to belief, juice holds essentially no nutritional value. However, I think it’s extremely vital to have a form of balanced diet in the house so our children don’t grow up with negative associations with foods. Some adults take the ketogenic diet to an extreme, ie eating a plate of bacon in place of a carbohydrate rich meal like pancakes or waffles. However, that level of LDL and cholesterol is in no way good for your heart. There is a way to achieve balance. A slice of whole wheat toast with 1-2 tablespoons of peanut butter allows you to enjoy the benefits of whole grains (of which there are many) alongside a high protein healthy fat condiment.
As a primary care doctor, I’m a strong believer that we can still promote healthy eating habits without restriction!