Should Kids Be on the Keto Diet?

I recently had a family inquire about the ketogenic diet for weight loss. I cautioned against it. Why, you ask?

To say that the high-fat, moderate-protein, and low-carb eating plan has become one of the most popular diets of recent years would be an understatement. Anecdotally, many have had success on this diet, but they've also primarily been adults who are no longer in the process of growing. And there's limited research on both long-term success with keeping the weight off and possible long-term repercussions of the keto diet. Some randomized control trials do show statistically significant difference between weight loss on a low-carb vs. low-fat diet at six months. However, long-term follow-up isn't typically done. One study indicated that at 12 months, there was no statistical difference in weight loss. Studies typically show that any diet modification, if maintained, can result in weight loss.

As a pediatric dietitian, I'm concerned that the keto diet is too restrictive, subjects kids to diet culture and lacks the necessary nutrients for growth and development. I'm also concerned about the limited research, particularly in children and adolescents.

[See: 7 Diet Mistakes Sabotaging Your Weight Loss.]

What Is the Keto Diet?

The ketogenic diet actually began as a treatment for children with epilepsy. This high-fat, low-carbohydrate diet method is medically used to help control seizure activity. The typical model provides 3 to 4 grams of fat per 1 gram of carbohydrate and protein. This strategy is often employed when a child hasn't responded to seizure medications. It's carefully planned and monitored by a medical team.

Following its medical origins, the keto diet went mainstream as a weight-loss method. By following a ketogenic diet, your body is put into a metabolic state called ketosis. Instead of burning carbohydrates for fuel, your body begins to burn its own fat. To achieve this, carbohydrate intake must be extremely low, typically less than 20 to 30 grams of carbohydrates per day. One apple equals about 20 grams of carbs. For this reason, fruit isn't allowed on the keto diet. Another forbidden food group: most dairy products. (Cheese and heavy cream are allowed because they're higher in fat; milk and yogurt are too high in carbs, so they're out.) When you omit numerous full food groups (grains, fruit, dairy, many vegetables), you run the risk of nutrient deficiencies, as well as missing out on phytochemicals and antioxidants that are found naturally in fruits and veggies. Nutrients are important for pediatric development, decreasing inflammation and lowering the risk of chronic disease.

Other concerns with the keto diet are the long-term effects of a high fat intake. The keto diet drastically eliminates carbohydrates and replaces them with fats -- typically, 75% of calories will come from fat. The type of fat isn't specified, so many people who adopt the diet consume saturated fat in the form of butter, heavy cream, red meat and coconut oil. While it's true that a small intake of these foods isn't detrimental, making them such a high percentage of daily intake is concerning. The long-term health consequences of a diet high in saturated food are well-studied. And it's even more concerning among children and adolescents.

Feasibility of the Keto Diet

The keto diet can be difficult to follow. It's true that while in ketosis, your body doesn't feel hunger, but that doesn't make things easier in a social environment. When we're talking about children and teenagers who are eating meals at school, with other family members, or out with friends, keto can definitely affect social habits. This also may fuel disordered eating behaviors. The other part of the keto diet is that you cannot cheat. For your body to be in a ketotic state and induce weight loss, it must stay there. So this isn't something you can follow one day and stop the next.

[See: 15 Best Weight-Loss Diets at a Glance.]

So, What About Just Eating Less Carbs?

Great idea! A low/moderate carb intake is likely a better approach to long-term success with weight loss and lifestyle changes. Ironically enough, I find that many people who want to start a ketogenic diet are eating extremely high carb at baseline. If a teen is eating 300 grams of carbs per day and reduces that level to 150 grams per day, while focusing on whole food, complex carbs, he or she will likely have success. Dropping from 300 grams per day to 30 grams per day will of course achieve a rapid loss, but is it sustainable -- and at what cost?

Is There Ever a Time When the Keto Diet Might Be Appropriate?

Yes. At the Cleveland Clinic, we have a medically supervised ketogenic diet that some patients qualify for. It's mostly used in adolescents who are finished going through puberty and have no risk of compromising their height potential. It can be used for those with a medical reason for weight loss who have attempted other lifestyle changes without success. It's important to note that this version of the keto diet is monitored closely by a physician, and patients get frequent lab work done to assess safety; they also take daily supplements. They work closely with a registered dietitian, as well as often a psychologist and exercise physiologist as part of a whole care team.

In addition, the keto diet may be used for adult athletes or in various extenuating circumstances. But overall, the diet is not routinely recommended for the general public -- and definitely not for children.

[See: What Not to Say When Someone Loses Major Weight.]

Overall Takeaway

Yes, most children can benefit from a carbohydrate decrease -- just not an essentially "no carb" keto diet. Speak with a registered dietitian to figure out an appropriate amount of carbs for your kid, or start with small changes. Aim to get your carbs from fresh fruits, lots of vegetables, beans, legumes, high-fiber grains and some dairy products. Avoid added sugars and processed carbohydrates. Low-carb, but not no carb, is the preferred way to go.

Jennifer Willoughby, RD, CSP, LD is a registered dietitian at Cleveland Clinic Children's, board-certified in pediatric nutrition. Jennifer attended the Ohio State University for her undergraduate degree and then completed her dietetic internship at Cleveland Clinic, prior to becoming a member of the pediatric nutrition support team. Her primary position is in a sub-specialty outpatient clinic where she sees patients in the departments of endocrinology, general pediatrics and adolescent medicine, complex care clinic, general surgery and allergy. She is an educator for the Cleveland Clinic FitYouth program, a 12-week pediatric weight management program. In addition, Jennifer is actively involved in community programs, and her expertise has been featured in a variety of media outlets.