September 21, 1940
Joslin observes that the advice to eat a high carb diet for diabetics that have to pee most of the sugar out is a poor idea, even 20 years after discovering insulin. In his scathing rebuttal to Edward Tolstoi, he lists the benefits of how controlling high blood sugar helps longetivity.
Treatment of Diabetes - Letter to the Editor
To the editor: It was with dismay that we read in The Journal, August 10, statements of Dr Edward Tolstoi at a conference of "the members of the Departments of Pharmacology and of Medicine of Cornell University Medical College and the New York Hospital, with the collaboration of other departments" regarding the treatment of diabetes. He said:
"We found that our experimental subjects were free from the symptoms of diabetes in spite of glycosuria when they were receiving a diet of 75 grams of protein, 60 grams of fat, and 200 grams of carbohydrate, and protamine zinc insulin in daily doses of 50 units."
Does it make common sense to say that an adult of average body build and activity receiving 1,640 calories, daily in the form of carbohydrate 200, protein 75, and fat 60 grams who is excreting 150 or even 100 grams of sugar in twenty four hours, thus leaving a net balance of 1,040 or 1,240 calories respectively, could maintain body weight and be in nitrogenous equilibrium for a prolonged period? Furthermore, is it sensible or economical to alow the wastage of so large a part of the food eaten?
Like many, others, we believe in controlling the hyperglycemia of diabetes (1) because it is fundamentally an abnormal state, (2) because a high blood sugar is a constant stimulus for insulin secretion and allows no opportunity for rest and recuperation such as the pancreas of a healthy person enjoys between meals and at night and (3) because control of hyperglycemia and glycosuria proves utilization of the diet whereas their disregard leads, in our experience, to accessory annoyances such as polydipsia and polyuria, the attendant necessity for extra food to make up for the loss of calories in the urine and the obvious wear and tear on the system for ingestion, assimilation and excretion of this unutilized extra food, quite apart from needless cost and waste. A high percentage of sugar in the blood implies the same in the tissues ; we think it likely that, directly or indirectly, this conduces to lack of normal tissue repair and resistance to infection, predisposes to degenerative phenomena in arteries and nerves and leads to weakness, weariness and impotence, although we freely admit that positive proof is lacking that all these harmful effects are due to hyperglycemia per se. Unhesitatingly we maintain that the blood sugar should approach normal because it is an index of the control of the diabetic condition ; if normal, it is one assurance that the whole disease is being treated well. Hyperglycemia is the red light which the physician should no more disregard, although he cannot always explain its significance, than he should fail to heed the red signal at the railroad crossing because he cannot see the train around the corner.
Dr. Tolstoi's advice for certain cases of diabetic acidosis follows :
First, let us consider the one whose condition is not far advanced, the patient as we see him in the clinic. He may report a sore throat. Examination of the urine reveals a 4 plus acetone reaction and diacetic acid. The skin and the tongue are dry, there is dehydration and there are listlessness and the desire to be left alone. We tell the patient "Go home, take a tablet or two of tablé salt (1 Gm. of salt) every hour, and follow that with a glass of water; in addition, take all the hot salt broth you can." We teach him to examine his urine for acetone and tell him to do so every two hours, and as long as acetone is present to give himself insulin (regular soluble) after each urine examination until the acetone bodies disappear. The dosage of insulin is determined by the urine analyses for sugar. He is told to take 25 units if the result of the test is yellow or red, 15 units if the specimen is green, and the juice of an orange if the Benedict solution is unchanged after boiling. This simple rule also protects the patients against insulin overdosage.
We condemn such advice. In our opinion it is dangerous to send home patients whose urine gives a 4 plus reaction for acetone and diacetic acid. Dr. Tolstoi does not even suggest that they keep under the supervision of their family physicians. If there is one thing we attempt to do as a result of our experience with patients in coma and near coma, with diabetic children and with diabetic patients in general, it is this—to train them, if any unusual symptoms occur, to call the doctor. A patient who exhibits "listlessness and the desire to be alone" is not likely to carry out intelligent, energetic self treatment. We believe in the orthodox treatment of diabetes. We are convinced that our patients and the patients of other physicians do the best who follow the rules. Differences in diets of from 50 to 75 Gm. of carbohydrate a day are immaterial. By no means can we keep all our patients sugar free, but we do strive to maintain them under as good control as possible, thereby, as we believe, protecting them from complications and progression of the disease. Furthermore, as will appear in the forthcoming (October) (seventh) edition of the "Treatment of Diabetes Mellitus," we have endeavored to support our convictions by recording the complications, the causes of death and the duration of life in 5,669 of our fatal cases between 1898 and 1940. Tables show the decrease of deaths due to coma from 64 per cent to 4 per cent, the steady increase in duration of life after onset from 4.9 to 12.5 years and the advance in the average age at death from 44.5 to 64.8 years.
Elliott P. Joslin, M.D.
Howard F. Root, M.D.
Priscilla White, M.D.
Alexander Marble, M.D. Boston.
(Image is of Edward Tolstoi)