The New American Academy of Pediatrics Diabetes Guidelines for Children

AAP Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and AdolescentsImagine 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.

Check Also

What About Cheat Days on Your Low-Carb Lifestyle?

What About Cheat Days on Your Low-Carb Lifestyle? – CarbSmart Podcast Episode 14

I frequently see questions about cheat days – most commonly, “How often should I have a cheat day?” There seems to be an assumption that cheat days are a good idea, something that should be built into a low-carb diet to keep people from feeling deprived.


  1. It really is distressing when rubbish guidelines like this continue to be published and promoted. I am currently reading Fat Chance: The Bitter Truth About Sugar written by paediatric endocrinologist Robert H. Lustig. His recommendations are in exact opposition to those guidelines above. A must read for anyone interested in their own health and the health of their children.

  2. I love your blog. That said, articles like this are preaching to the choir. Any chance of getting intelligent pieces such as this out into the mainstream, where people could really use a wake-up call?

  3. I am not surprised that they want people to take drugs to fix whatever is wrong. I was put on metformin and had to argue with my PCP to stop. I am not perfect but do try to control my diabetes with what I eat – usually it works. When I was shown the diet to follow for my diabetes I told the teacher that it was way too high in carbs for me I am one that needs to be under 35 a day to maintain. They wanted me at over 90 a day. I do know people who take insulin as a cure all and that frightens me. They will say – it’s ok I can up my insulin – like it is a cure all or something. And if children are being taught the same then we are in a world of hurt.

    • Could not agree more, obviously. I actually had an argument online years ago with a girl who insisted that sugar was, indeed, an essential nutrient because her mom was a diabetic, and if she didn’t eat sugar her blood sugar would crash. This, of course, is completely a reflection of a reliance on medication. If there’s one thing that doesn’t happen to unmedicated type II diabetics, it’s blood sugar crashes.

      I have written in the past about the American Diabetes Association and their overwhelming ties to Big Pharma. That, plus a strong societal denial that carbs are unwholesome — after all, if we accepted that simple fact, everyone would feel pressured to give up their favorite addiction — leads to diabetics getting advice that is nothing short of deadly. It’s a damned tragedy.

  4. I have really mixed feelings about food restriction of any kind in children. I am not Type 2, and I was never obese then or now, but my mother being an RN and my father a dentists, sugar, candy, cake, ice cream and the like were strictly verboten, except for special occasions. I developed a craving for sweets because of that, and it’s with me to this day, and I’m 65 years old! I remember looking with longing at the Twinkies the other kids would bring to school in their lunches and I remember sneaking 60 candy bars into the house when my 2 siblings and I were teenagers, and eating 20 each in one sitting. Does that sound like a binge? So what I’m getting at is that I don’t think any food should be forbidden to a child. Instead, I think that portion control is key. I truly don’t think that small portions of sweets and carbs will hurt any child, but I also think that most people have very distorted ideas of what portion size should be. I now recognize that I’ve had an eating disorder all my life, and I don’t think any child should be subjected to that trigger unnecessarily. I think that people who get too involved in limiting foods for children are walking a tightrope — you never know when a child is susceptible to developing an eating disorder, and that’s NOT where any of us would want to send a child!

    • Depends on the child, to some degree. After all, nobody suggests that sober alcoholics should have just a few drinks now and then.

      I have heard, over and over, “I believe in moderation in all things.” That sounds terribly reasonable, but my response is always “Define moderation.” We are awash in sugar; if you drank one 12 ounce soda per day and got NO other sugar at all, you’d still be getting more than twice the sugar your ancestors were eating in the late 1800s. And so far as I can figure out, the average American is getting in about six weeks as much sugar as the average Paleolithic hunter-gatherer got in a lifetime. This, of course, ignores the fact that starches turn to sugar in the blood stream.

      I have no children — just got married too late (but married the right guy :-D) — but we tried. And when we were trying, we talked about the junk food issue. We decided our rule would be “Not in my house, not with my money.” If the kid wanted to spend his own money on garbage and eat it outside the house, we couldn’t prevent it. But we sure didn’t have to spend our money on stuff that would make him unwell.

      As for triggering eating disorders, I grew up in a household that was what most would consider moderate. We were allowed soda, but only one per day. We had sweetened cereal, but were allowed one bowl; if we wanted seconds we had unsweetened cereal. My mother generally served meat, a starch and two vegetables for dinner; dinners were home cooked. We had dessert, but, again, modest portions.

      And I wound up a major, major sugar junkie, stealing money from my parents wallets. I didn’t eat twenty candy bars once — I regularly ate a pound of chocolate per day, plus about a pound of hard candy per day — pure sugar — plus 3-5 desserts in the school cafeteria.

      There is no way around the fact that diabetes is a carbohydrate intolerance disease, and that every time — every time — blood sugar is elevated above the normal range irreversible damage is being done to the body. I think my allergy analogy is apt. Children with allergies can learn to avoid foods that make them ill. For that matter, a million years ago, when I was running the health food department in a Sears store in Northbrook, Illinois, I had mother who regularly shopped there, bringing her son, who had celiac disease. He was sweet, bright, and well-behaved, but spindly and peaked-looking. It was a lot harder to eat gluten free back then; I have no doubt he suffered greatly.He was five, really very young — and he would choose something from my snack-and-candy section, take it to his mother, and say “Mommy, is this all right, or will it make me sick?” He already knew that what he ate was vitally important to his health.

      Children with type 2 diabetes already have an eating disorder, since the disease is largely induced by diet, and the children are generally obese. To allow them or their parents to think that they just need to eat less of the same old stuff, and take medication, goes beyond inadequate to homicidally irresponsible.

      • Hi, Dana,
        I do understand what you’re saying. I just think it’s more complicated than simply getting all sugar and carbs out of the house. I never limited what my son ate, and he was always a skinny kid. But I never had large quantities of sweets around, either. It’s obvious that we don’t have the genetics that lead to obesity and T2 diabetes (for which I’m very grateful).
        But it IS a fine line when dealing with children and food. In my own case (being raised in the 50’s and 60’s) my mother felt that vegetables were very important, and tried her darndest to get me to eat them, but I could never tolerate them. As an adult, I will eat some vegetables if they’re raw, but as a child, it was just not in my book. What do you do with a child like that? On the other hand, I loved rare beef, and mashed potatoes and bread and butter. So I THINK my mother filled me up on those, but I’m not sure.
        And I do agree that many people with T2 already have an eating disorder, although it’s not particularly recognized by the general public, or the medical profession. But eating disorders have a large emotional component, and how do you deal with that? When I was longing for the Twinkies, that was emotional, because they LOOKED good — once I finally got to eat one, they really weren’t particularly tasty!
        I really do appreciate your engaging in dialogue with me because I’m STILL struggling with food!

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