I generated some heat on social media yesterday stating that dietitians have an ethical responsibility to practice evidence-based medicine.

Below are things I lay awake at night thinking about. I take great responsibility in what I tell patients/clients to do, knowing that advice can be helpful or harmful.

Health professionals like to claim their “practice” is “evidence-based” when it fits their cognitive biases, even though it may be hogwash.

I’m sorry, but to date detoxes, cleanses, and fasting are not appropriate for children or adolescents. And, I’d argue also not appropriate for most adults, though you can’t control what adults do (and we all do dumb things).

There is a much greater responsibility when working with children and their parents. Children cannot decide for themselves what kinds of food are put on the table or where their next meal comes from. They cannot control the situation when Mom decides to put them on a diet to lose weight because the pediatrician told her they were “fat” at the eighty-fifth percentile (not fat).

I see this a lot in the pediatric diabetes community. I’m a big proponent of a “lower” carbohydrate approach (~30-45g per meal) in the appropriate context, which translates to balancing your plate with non-starchy, lower-sugar carbs most of the timeand not just “covering all the carbs” with insulin. In my experience, children tend to eat worse once diagnosed with type 1 diabetes because their parents are now having to pre-quantify and “force feed” carbohydrates at each meal and forget about the other food groups. The Division of Responsibility is often lost with the introduction of insulin dosing, and that disrupts a child’s normal responsiveness to their hunger and fullness cues. This situation is tricky, because insulin dosing is optimal at the start of a meal (or 15 minutes prior) due to insulin kinetics and food digestion (except with Fiasp, though most parents are still bolusing at the start of the meal versus after). Pre-bolusing doesn’t allow the child to easily say “I’m full” when only halfway through the carbohydrate portion that has been dosed; they must finish the food that has been “covered” with insulin.

I totally understand the struggle as a parent, it is A LOT to count carbohydrates, dose insulin, and give an injection to a young child all while at mealtime. If you think mealtimes with your child is hard, try it with diabetes or a feeding tube. I have walked alongside hundreds of families with these conditions and It. Is. Hard. Parents who adapt to these kinds of challenges that life throws them are total rockstars, in my opinion.

But, even with the upsurge in low carbohydrate diets for children with type 1, I worry about the children and their relationship with food. Yes, they have a chronic disease, one of “carbohydrate intolerance” that is remedied with exogenous insulin. But, they are human and deserve to have a quality of life that includes cookies, cake, pizza, etc if they want. And 99% of us want these foods because they taste good, and there is nothing wrong with that.

When a child becomes an adult, they can make decisions for themselves. If they want to “go keto” to control their diabetes and can remain healthy without compensatory behaviors like bingeing, high cholesterol, etc., then so be it. I really do mean that. I will support you in any diet you choose as long as it is working and is sustainable long-term without deleterious physical, mental, or emotional effects.

But, my personal philosophies on low carbohydrate in adults changed during my masters research. I set out to study the “diabetes diet” (>150g carbohydrate per day) versus a low-carbohydrate diet (60-80 g carb per day) in young adults with type 1 diabetes. Prior to the study, I would have counseled you that strict low carb was the only way to go for type 1 since it was a disease of “carbohydrate intolerance”. During the low-carb arm of the study, every. single. subject struggled with food behaviors. Some started bingeing on carbohydrates when trying to treat the occasional hypoglycemic events and others just felt very restricted and mentally taxed. This made me feel really guilty because those behaviors were not normal or inherent to a healthy relationship with food. None of them continued the 60-80 g per day carb restriction after the study, though many of them took away the concept of “less carb” per meal for a lesser “area under the curve” of glucose exposure which improved time-in-range significantly. There were great benefits seen in the study with improvements in time-in-range, and positive cholesterol improvements, but there is a difference between “low” and “lower” carbohydrate.

There will always exist individuals who maintain strict diets (low carb, “autoimmune paleo”, vegan, etc) and don’t seem too bothered. Perhaps they do it for health or cultural/religious reasons. Or, maybe they are so entrenched in an eating disorder that there is no way out without seeking treatment. For so many, these cause disordered eating behaviors that are disrupting to their lives and that is not something my professional practice can support.

I will always get slack for this practices stance, but after you’ve lived through the damage of the crazy diets and misinformation, you are never the same. At the end of the day, I can go to bed at night knowing I have done no harm.