The New American Academy of Pediatrics Diabetes Guidelines for Children

Imagine your child, after eating peanuts, was rushed to the emergency room in anaphylaxis. After the crisis, you’d ask your pediatrician how to handle the situation. What if the doctor’s advice was “Give him Benadryl every day to keep histamine down, and make sure he always carries an epipen. Oh, and get him prick-tested regularly, to see if his reaction to peanuts has worsened or improved. If you want, we can give him allergy shots, too; that may desensitize him a bit.”

But what if that doctor didn’t mention peanuts at all? Didn’t tell you that it was vital that your child avoid peanuts? Didn’t give you advice on how to avoid traces of peanuts, what foods he could eat instead of peanuts and peanut butter? What if he said “Well, if he eats less in general, he’ll get fewer peanuts, so that will help, and if he’s in trouble he can take more Benedryl and inject epinephrine”?

What would you think of that doctor? That’s how I feel about the American Academy of Pediatric’s first-ever guidelines for dealing with type 2 diabetes in children.

The New American Academy of Pediatrics Diabetes Guidelines for Children

In very abbreviated form, those guidelines are:

• Give kids insulin if they’re in ketosis or ketoacidosis (note the conflating of the two), or if their blood sugar is above 250 or their HbA1C (measure of blood sugar over the previous 3 months) is above 9. If you’re not sure whether they have type 1 or type 2 diabetes, give them insulin till you can do more tests.
• Start ‘em on metformin, and start a lifestyle modification program, including nutrition and physical activity.
• Monitor HbA1C every three months.
• Tell them to regularly test blood sugar at home.
• Use the Academy of Nutrition and Dietetics Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines as the basis for nutrition counseling.
• Tell the kids to get an hour of moderate-to-vigorous exercise per day.

Do you see something missing? Has the word “carbohydrate” been mentioned?

They do mention nutritional counseling, so let’s look at those guidelines. I looked up the Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines.

Under “foods associated with an increased risk of overweight” they list sugary beverages – and thank goodness for that – and “increased total fat intake.” Under “foods associated with a decreased risk of overweight” they list fruits and vegetables*. They also mention paying attention to “total energy intake” – ie calories – and consumption of 100% fruit juice, both of which they say “may or may not be related to pediatric overweight.” Interesting, isn’t it, that caloric intake may or may not be related to overweight?

They do recommend dairy products, and, I am pleased to say, they don’t insist on low fat and fat free dairy.

Then there’s stuff about exercising and “family culture,” including the confusing information that both “restricting highly palatable foods” and snack food consumption are possibly associated with increased risk of overweight. Hard to know whether to buy the chips or not. Oh, and you’ll be shocked to know that supportive parents who don’t themselves eat junk all the time are less likely to raise overweight kids. The stuff you can learn.

The guidelines then go into the various types of diets, most strongly recommending an “energy restricted balanced macronutrient (ie, low calorie) diet.” This, despite the earlier mention that caloric intake may or may not be associated with obesity.

What About The Carbohydrates?

They mention a low glycemic load diet, but say it’s only useful for “modest” improvement in weight. Then they mention very low carbohydrate diets. They admit very low carb diets cause weight loss, but state that such diets should be used for no more than 12 weeks, because of “lack of evidence.” Lack of evidence of what is not specified.

What no one says, not at the American Academy of Pediatrics, not at the Academy of Nutrition and Dietetics, is “Diabetes is a carbohydrate intolerance disease. All carbohydrate foods turn to sugar in the body. Bread and cereal and pasta will raise blood sugar as surely as cotton candy and Skittles. High blood sugar is extremely destructive to all the tissues of the body. The less carbohydrate – “good” carbohydrate or “bad” carbohydrate – you give your child, the less medication he will need, and the less likely he will be to go blind, suffer nerve damage, have his legs amputated, and die young.”

Treat ’em with Medicine They Say

Interestingly, the AAP guidelines also suggest that medication, especially insulin, is beneficial in part because it may “convey a greater degree of concern for the patient’s health and the seriousness of the diagnosis, relative to that conveyed when medications are not needed, and that improved treatment adherence and follow-up may result from the use of medication.” In other words, we need to give people medication to get them to take diabetes seriously.

Yet it is not uncommon for type 2 diabetics on a very low carb diet to achieve normal blood sugar without medication.

Insulin, in particular, is dangerous in that situation. Apparently we shouldn’t be too successful with dietary and lifestyle intervention, because drugs won’t be needed, and then the patient and family won’t take the diet and lifestyle intervention seriously. This strikes me as a dangerous Catch-22.

Many people, doctors and dieticians included, genuinely believe that a “balanced” diet is best, and that weight control is a simple matter of “calories in, calories out.” Indeed, they think it obvious. When such a diet does not result in normal blood sugar, they assume that diet and lifestyle changes are inadequate to the task, rather than questioning the diet used.

It’s simplistic to suggest that all of the doctors and other professionals involved with these organizations are cynically pushing the corporate line. That said, I looked up the corporate sponsors of these two organizations. Sponsors of the Academy of Nutrition and Dietetics include Abbott Labs (pharma), Aramark, a major food service corporation, Coca-Cola, Hershey, The National Dairy Council, General Mills, Kellogg’s, Pepsico, and Unilever. Among the corporate sponsors of the American Academy of Pediatrics are Nestle, Merck (pharma), McNeil (pharma), Pfizer (pharma), Novartis (pharma), and the ubiquitous Coca-Cola. Reportedly there have been booths for Sweet Surprise, an organization promoting high fructose corn syrup, and the American Beverage Association (soft drink lobby) at AAP conferences. It’s difficult to imagine that all that corporate money doesn’t have some influence. Why spend it otherwise?

We’re also up against the common feeling that it’s unkind, even cruel, to “deny” children sweets and other “treats” commonly eaten by their peers. To this I say: Remember our opening analogy – a child with a deadly peanut allergy? Is it unkind to deny that child peanut butter sandwiches, peanut butter cookies, peanut butter cups? Or is it a simple medical necessity?

Diabetes does not usually kill quickly, but kill it does, and before it kills, it maims. How can it be cruel to defend your child from that?

* This is a pet peeve – the lumping together of fruits and vegetables. They are not nutritionally equivalent. The ubiquitous use of the phrase “fruits and vegetables” leads too many people to figure that if their kid is getting juice with breakfast and fruit leather at lunch, that’s two servings right there – when what they’re mostly getting is sugar.