Breaking Ground in Pediatric Type 1 diabetes & Metabolic Health: Dr. Matthew Calkins at Boca 2025

At the forefront of transformative discussions at the 2025 Society of Metabolic Health Practitioners (SMHP) Symposium in Boca Raton was Dr. Matthew Calkins, whose presentation titled "Evaluating the Evidence: Low-Carbohydrate Diets for Children with Metabolic Disease" left an indelible mark on both clinicians and families affected by Type 1 Diabetes (T1D) and metabolic conditions. His talk, anchored in scientific rigor and personal anecdotes, provided critical insights into the potential of therapeutic carbohydrate reduction (TCR) to reshape pediatric health outcomes.

Dr. Calkins' journey into this domain is both personal and professional. As a family medicine physician and lifestyle medicine practitioner, he has witnessed firsthand the profound impact of nutritional therapy in his practice. His work spans populations ranging from newborns to elderly adults, equipping him with a unique perspective on how metabolic health interventions can impact every stage of life. His presentation at the Boca 2025 conference not only challenged prevailing guidelines but also provided a robust framework for clinicians, parents, and caregivers to critically evaluate the application of TCR in pediatric settings.

Why Low-Carb for Pediatric Type 1 diabetes & Metabolic Disease?

Dr. Calkins began by framing the discussion within the alarming trends in pediatric metabolic health. According to the American Academy of Pediatrics (AAP), nearly 30% of children in the U.S. now have prediabetes, with 19% experiencing obesity. Conditions like Type 2 Diabetes and nonalcoholic fatty liver disease (NAFLD) have skyrocketed, leading to early-onset complications like advanced liver fibrosis, cardiovascular disease, and neuropathy. These chronic conditions were once considered adult-only issues but are increasingly prevalent in children.

The statistics for children with T1D are equally troubling. Despite advancements in insulin therapies and glucose monitoring technologies, glycemic control remains suboptimal for most. Dr. Calkins highlighted that the average hemoglobin A1C (HbA1c) in pediatric patients with T1D is 8.2%—well above the recommended target of 6.5–7%. This level of hyperglycemia is associated with long-term complications, including retinopathy, nephropathy, and even cognitive decline, as shown by reduced brain volumes in children with elevated blood glucose. By reducing dietary carbohydrate intake, TCR aims to stabilize postprandial glucose levels, reduce glycemic variability, and significantly decrease insulin dosing errors. Dr. Calkins emphasized that these benefits are particularly valuable in children, who face lifelong management of their metabolic health.

Examining the AAP Guidelines

Central to Dr. Calkins’ presentation was a critique of the AAP’s 2023 clinical report on low-carbohydrate diets for children with or at risk of diabetes. While the AAP explicitly advises against low-carb diets for children with T1D outside of closely monitored clinical settings, Dr. Calkins pointed out logical inconsistencies and a lack of sufficient representation from clinicians experienced in using TCR to inform their guidelines.

The AAP’s concerns center around potential risks of ketogenic and low-carb diets, including nutritional deficiencies, growth impairment, and disordered eating. However, as Dr. Calkins outlined, much of the evidence cited in the AAP’s report conflates well-formulated TCR interventions with the more restrictive ketogenic diets used for epilepsy management. He clarified that TCR for T1D does not equate to the 4:1 ketogenic ratio used in epilepsy; instead, it emphasizes nutrient-dense, minimally processed foods to ensure growth, development, and overall nutritional adequacy.

Inconsistencies and Contradictions in the AAP’s Position

Dr. Caulkins’ meticulous analysis of the American Academy of Pediatrics' (AAP) position on low-carbohydrate diets for children exposed glaring inconsistencies and contradictions. His talk emphasized the need for intellectual curiosity and unbiased critical thinking, which he argued were absent in the AAP's approach. Here are some key points of inconsistency that Dr. Caulkins highlighted:

1. Conflation of Diets for Distinct Conditions

The AAP’s position statement conflates well-formulated low-carbohydrate diets, such as those used for managing metabolic health and type 1 diabetes, with the restrictive four-to-one ketogenic diet typically used to treat epilepsy. The latter is far more rigid, with up to 90% of calories derived from fat, leading to potential nutrient deficiencies if not closely monitored. By extrapolating risks associated with the four-to-one ketogenic diet to all low-carbohydrate approaches, the AAP misrepresents the true risk-benefit profile of therapeutic carbohydrate reduction (TCR). This "false equivalence," as Dr. Caulkins described it, undermines the credibility of their recommendations and fails to acknowledge the safety and efficacy of well-formulated low-carb diets in treating metabolic disease.

2. Recommendations Based on Weak or Misapplied Evidence

The AAP advises that children with type 1 diabetes, type 2 diabetes, or other metabolic diseases adhere to the same carbohydrate intake recommendations as the general population: 45–65% of daily caloric intake. However, as Dr. Caulkins pointed out, their evidence base for this recommendation is sparse and often inappropriate. For example:

• Several studies cited in the AAP position statement pertain to ketogenic diets for epilepsy, a completely distinct disease with unique dietary requirements, rather than low-carb diets for metabolic health or type 1 diabetes.

• The AAP repeatedly raises concerns about potential nutritional deficiencies and growth delays associated with low-carb diets, yet it cites research demonstrating no significant long-term risks in well-monitored patients.

This contradictory stance—presenting risks but simultaneously acknowledging a lack of evidence for harm—creates confusion rather than clarity.

3. Contradictory Views on Nutrient Deficiencies

One of the most striking contradictions in the AAP’s stance is their focus on theoretical risks of nutrient deficiencies with low-carbohydrate diets. They advocate extensive, onerous lab monitoring (e.g., for carnitine, vitamin D, and bone mineral density) but fail to provide comparable scrutiny of the nutrient deficiencies observed in children adhering to their standard dietary recommendations.

For example:

• Dr. Caulkins highlighted a study in children who underwent bariatric surgery, showing that up to 57% developed iron deficiency and 10% developed vitamin B12 deficiency within three years post-surgery. Despite these alarming risks, the AAP supports bariatric surgery for obese pediatric patients while holding low-carb diets to a higher standard of evidence and monitoring.

4. Misrepresentation of Eating Disorder Risks

The AAP claims that restrictive eating patterns, such as low-carb diets, may increase the risk of disordered eating. However:

• They cite research that either does not explicitly address low-carbohydrate diets or actively excludes studies focusing on clinical interventions designed to improve metabolic health.

• The AAP’s own data refutes their concerns, showing no established link between low-carbohydrate diets and disordered eating in pediatric patients.

Dr. Caulkins noted the irony of this stance, pointing out that the AAP’s own traffic light eating plan—a tool they promote for childhood obesity—labels foods as “good” (green) or “bad” (red).

This binary framework mirrors the labeling practices they criticize in low-carbohydrate interventions.

5. Failure to Address the True Risks of the Status Quo

Dr. Caulkins provided sobering data on the outcomes associated with the AAP’s standard dietary recommendations, including:

• A mean HbA1c of 8.2% in pediatric patients with type 1 diabetes, well above the target of 6.5–7% and associated with long-term complications such as neuropathy, nephropathy, and retinopathy.

• The prevalence of hypoglycemia and hyperglycemia, which Dr. Caulkins described as being “hard-coded” into the current standard of care due to excessive carbohydrate intake and insulin dosing errors.

By comparison, well-formulated low-carb diets consistently demonstrate improved glycemic control, reduced insulin requirements, and fewer hypoglycemic episodes. The AAP’s reluctance to embrace these approaches, despite mounting evidence of their benefits, highlights a critical failure to prioritize patient outcomes over theoretical concerns.

6. Selective Use of Adult Data

While the AAP rejects adult data supporting TCR for type 1 diabetes management, they readily apply adult data supporting the Mediterranean diet to pediatric populations. This selective use of evidence undermines their argument against low-carb interventions, as both dietary patterns require extrapolation to younger populations.

Dr. Caulkins argued that this double standard reflects a bias rather than a true commitment to evidence-based practice.

The SMHP’s Position on TCR

In contrast to the AAP, the Society of Metabolic Health Practitioners (SMHP) advocates for the inclusion of TCR as a viable and effective option for individuals with T1D. The SMHP’s position statement, co-authored by Dr. Calkins and published in the Journal of Metabolic Health, provides a detailed rationale for offering TCR within a supportive clinical framework.

Key points of the SMHP’s position include:

• Improved Glycemic Control: Observational data show that TCR can help children achieve HbA1c levels around 5.67%, compared to the national average of 8.2% for T1D patients.

• Reduced Glycemic Variability: Smaller carbohydrate inputs reduce the margin of error in insulin dosing, minimizing the risks of both hyper- and hypoglycemia.

• Addressing Double Diabetes: By lowering insulin requirements and mitigating insulin resistance, TCR helps combat the growing prevalence of “double diabetes”—a condition characterized by the coexistence of T1D and Type 2 Diabetes-like metabolic dysfunction. The SMHP calls for open access to TCR for motivated families and patients, emphasizing the need for individualized care plans and ongoing clinical support to ensure safety and efficacy.

Debunking Common Myths

Dr. Calkins addressed several misconceptions surrounding low-carb diets for children:

1. Nutritional Adequacy: Far from being nutritionally deficient, well-formulated TCR protocols prioritize protein and essential dietary fats while incorporating fiber-rich vegetables and low-glycemic fruits. This aligns with the AAP’s own recommendations for whole, nutrient-dense foods.

2. Growth and Development: The concern that low-carb diets impair growth lacks robust evidence. Dr. Calkins cited studies showing normal growth trajectories in children following low-carb diets when caloric intake is sufficient.

3. Psychological Risks: Contrary to fears that TCR fosters disordered eating, Dr. Calkins emphasized that clinical interventions focused on metabolic health differ fundamentally from restrictive dieting driven by body image concerns.

Practical Considerations for Implementation

Transitioning children to a low-carbohydrate dietary pattern requires careful planning and collaboration. Dr. Calkins offered practical recommendations, including:

• Individualized Insulin Management: Continuous glucose monitors (CGMs) are invaluable tools for real-time monitoring and adjustment of insulin doses.

• Nutritional Education: Families need access to resources and dietitian support to create sustainable meal plans that meet their children’s nutritional needs.

• Support Systems: Peer groups, educational workshops, and family counseling can mitigate feelings of isolation and promote adherence.

Intellectual Curiosity: The Path Forward

Dr. Calkins concluded his talk with a call for intellectual curiosity and collaboration. He acknowledged the gaps in research on TCR for pediatric populations but argued that existing data—such as the Type 1 Grit study and numerous case reports—provide a compelling foundation for further exploration. He also urged medical institutions like the AAP to engage with organizations like the SMHP to foster open dialogue and bridge the divide between traditional and emerging approaches to diabetes management.

Quoting Dr. Eric Westman, one of the pioneers of low-carb research, Dr. Calkins reminded the audience that innovation in medicine often begins with asking the right questions. “The outcomes we see today,” he said, “are simply not acceptable. Our children deserve better.”

Learn More and Take Action

For those interested in delving deeper into the evidence and practical applications of TCR, Dr. Calkins recommended reviewing the SMHP position statement and the Therapeutic Carbohydrate Reduction in Type 1 Diabetes: A Guide for Dietitians and Nutritionists. Both documents provide actionable strategies and a wealth of supporting data for families and clinicians.

• Access the SMHP Position Statement here.

• Download the TCR Guide here.

The Boca 2025 Symposium, hosted by Low Carb USA, highlighted the growing momentum behind evidence-based approaches like TCR. Dr. Calkins’ presentation was a testament to the power of advocacy and innovation in shaping the future of pediatric metabolic health. For more information about the conference and upcoming events, visit Low Carb USA’s website: https://www.lowcarbusa.org/boca-2025/.