Ketogenic Diet

Diet. — Our injunctions to-day aro thoso of Sydenham : " Let the patient est food of easy digestion, eiich aa voal, mutton, and the like, and abstain from all sorts of fruit and garden stuff." The carbohydrates in tho food should be reduced to a minimum. Under a strict hydrocarbonaceous and nitrogenous regimen all casc«are benefited and some arc cured. The most minute and specific instructions should be given in each case, and the dietary arranged with scrupulous care^

 It is of the first importance to give the patient variety in the food, otherwise the loathing of certain essential articles becomes intolerable, and too oft«u tho patient gives up in diegiiet or despair. It is wcl), perhaps, not to attempt the absolute exclusion of the carbohydrates, but to allow a small proportion of ordinary bread, or, belter still, as containing less starch, potatoes. It is beat gradually to cnforoe a rigid system, cutting oH one article after another. Tho following is a list of articles which diabetic patients may take :

1.  Liquids; Soups — ox-tail, turtle, bouillon, and other clear soops 

2. Lemonade, coffee, tea, chocolate, and cocoa; these to be taken without sugar, but they may bo sweetened with saccharin. 

3. Potash or soda water, and the Apoltinatis, or the Saratoga Vichy, and milk in moderation, may be used. 

4. Of animal food : 

• Fish of all sorts, salt and fresh, 

• butcher's meat (with the exception of liver), 

• poultry, 

• and game. 

• Eggs, 

• butter, 

• buttermilk,

•  curds,

•  and cream cheese. 

• Of bread : gluten and bran bread, and almond and coconut biscuits. 

• Of vegetables: Lettuce, tomatoes, spinach, chiccory, sorrel, radishes, water-cress, mustard and cress, cucumbers, celery, and endives. Pickles of various sorts. 

5. Fruits : Lemons, oranges, and currants. Nuts are, as a rule, allowable 

Among prohibited articles are the following : 

1. Thick soups, liver, crabs, lobsters, and oysters; though, if the livers are cut out, oysters may be used. 

2. Ordinary bread of all sorts (in quantity): rye, wheaten, brown, or white. 

3. All farinaceous preparations, such as hominy, rice, tapioca, semolina, arrowroot, sago, and vermicelli. 

4. Of vegetables : Potatoes, turnips, parsnips, sqimslies, vegetable marrow of all hinds, beets, corn, artichokes, and asparagus. 

5. Of liquids: Beer, sparkling wine of all sorts, and the sweet aerated drinks. 

The chief difficulty in arranging the daily menu of a diabetic patient is the bread, and for it various substitutes have been advised — ^bran bread, gluten bread, and almond biscuits. Most of these are unpalatable, and the patients weary of them rapidly. Too many of them are gross frauds, and contain a very much greater proportion of starch than represented. A friend, a distinguished physician, who has, unfortunately, had to make trial of a great many of them, writes : 'That made from almond flour is usually so heavy and indigestible that it can only be used to a limited extent. Gluten flour obtained in Paris or London contains about 15 per cent of the ordinary amount of starch and can be well used. The gluten flour obtained in this country has from 35 to 45 per cent of starch, and can be used successfully in mild but not in severe forms of diabetes." ' Unless a satisfactory and palatable gluten bread can be obtained, it is better to allow the patient a few ounces of ordinary bread daily. The " Soya " bread is not any better than that made from the best gluten flour. As a substitute for sugar, saccharin is very useful, and is perfectly harm- less. Glycerin may also be used for this purpose. It is well to begin the treatment by cutting off article after article until the sugar disappears from the urine. Within a month or two the patient may gradually be allowed a more liberal regimen. An exclusively milk diet, either skimmed milk, buttermilk, or koumyss, has been recommended by Donkin and others. Certain cases seem to improve on it, but it is not, on the whole, to be recommended.

The class of carbohydrates have much in common with the fats. They serve the same purpose of checking albuminous waste ; like them, they are resolved by combustion within the body, ultimately, into carbonic acid and water, and so, like the fats, are capable of yielding heat and mechanical work. Unlike the fats and the albuminates, however, they do not appear to enter into the structure of the tissues, although they are found in some of the fluids and organs of the body. 

All the carbohydrates are converted into glucose, or grape sugar (or maltose), before they are absorbed, and in this form they are much more readily metabolised than the fats or albuminates. 

It is believed by many, and the weight of evidence, as will be seen, is in favour of the conclusion, that carbohydrates can be converted into fat within the organism. Bauer,* however, is indisposed to accept this view. Basing his opinions on the experiments of Pettenkofer and Voit, who showed that carbohydrates, even when administered in great excess, are almost completely destroyed within the body, he maintains that although the carbohydrates, when given together with albumen and fat, favour an increase of the constituents of the body, and especially of fat, yet it is not because they are themselves converted into fat, but because, owing to the facility with which they are metabolised, they protect the other food-stuffs from destruction. 

"When fat and carbohydrates co-exist in the food, the latter are always the first to be consumed; and when they are present in sufficient amount, the consumption of fat in the body may be completely suspended." And he explains in a similar manner the fact that a deposit of fat may be observed to take place when the diet consists of albuminates and carbohydrates alone, without any fat; for in that case, he says, the fat, which "originates as a product of the splitting-up of albumen, is withdrawn from further metabolism in favour of the carbohydrates, and contributes to the gain." He also rejects the view that the ready decomposition of the carbohydrates in the body depends on their great affinity for oxygen; he considers it lies rather in the properties of the animal tissues, and he points out that the assumed equivalents of starch and fat, as 240 of the former to 100 of the latter, calculated on the quantity of oxygen required for their combustion, are incorrect; and that in the living organisms "175 parts of starch are in the material actions approximately equivalent to 100 of fat." 

Germain Sée begins by supporting the view taken by Bauer, and asserts that the principal function of the carbohydrates is the immediate development of heat and mechanical work ; that they are not annexed in any way directly or indirectly to the organisms ; and that the fat that is deposited in consequence of their use is derived from the splitting-up of albuminates. He urges the experiments of Boussingault, who found that when he fed ducks on a pure carbohydrate like rice, they grew thin; but on adding a small quantity of butter, they grew fat. The same experimenter also asserted that milch-cows only gave out the quantity of fat in their milk that was contained in their food. Sée also points out that the particular kinds of grain selected for fattening animals are always such as contain, like maize, a considerable quantity of fat. But, notwithstanding all this, he appears in the end to yield to the weight of evidence that fat may be, under certain circumstances, formed from carbohydrates. 

Dujardin-Beaumetz believes in the possibility of the transformation of glucose, the product of the digestion of carbohydrates, into fat. He sees a great analogy between the formula for glucose, C6H12O6, and that of glycerine, C3H8O3, and thinks that the latter may result from the splitting up of the former with the addition of hydrogen. He also shares, to a certain extent, Pavy's views, and considers that a portion of the glucose derived from the digestion of carbohydrates is deposited as " hepatic glycogen" in the liver, and thus furnishes the glucose necessary to the organism when the food does not contain any carbohydrates, Pavy maintains, as is well known, that saccharine matter, when absorbed, "on reaching the liver is transformed by that organ into amyloid sub- stance [glycogen], which is stored up in its cells for subsequent further change preliminary to being appropriated to the purposes of life." The occurrence of this "amyloid substance" in the liver, even when a purely animal diet has been taken, he accounts for by the supposition that the liver is the organ in which the splitting-up of the albuminates into urea and a non-nitrogenous substance occurs, and that the latter is metamorphosed by the liver into "glycogen." Pavy believes that carbohydrates are first converted into this "amyloid substance," and that this is afterwards converted into fat. But he points out what is doubtless a most important condition in the conversion of carbohydrates into fat, namely, "the co-operation of nitrogenous in conjunction with saline matter," for it is probably by the changes occurring during the metabolism of the albuminates that this transformation is excited. The presence of a small amount of fat with the carbohydrates would seem also to favour this conversion, for the rapid deposition of fat which sometimes occurs when animals are fed on such a mixture appears to be more than can be accounted for by the small quantities of fat ingested. Pavy dops not admit that any of the carbohydrates undergo direct oxidation in the system, or contribute strictly to force production.

7. — Cantani's. 

{This is a very exclusive diet.) 

Sanctioned:  

• Meat and animal fats of all kinds (at all meals). 

• Fish of all kinds. 

• Lobsters. 

• Olive oil (instead of butter). 

• Eggs (in milder cases). 

• Substitute for bread: Pavy's almond cakes(only for convalescents who cannot entirely dispense with bread).

• Pure Water.

• Soda-water.

• Persons habituated to the use of strong wines and spirits may add to the water 10 to 30 grammes of pure alcohol daily.

• Red Wine.

• Tea and coffee in small quantities.

Forbidden:

• Liver.

• Butter, as it contains traces of lactose.

• Cheese.

• Milk.

• All farinaceous and saccharine foods absolutely.

• All fruits.

• All green vegetable and roots.

• Lemonade. 

• Chocolate. 

• Rum, cognac.

• Tea and coffee (in severe cases). 

Cantani considers much salt injurious, as well as much pickled pork or salt fish. 

He requires the adoption of this absolute meat and fat diet for three months — in very mild cases for two months, in very severe cases for six or nine months. If after two months the urine contains no sugar, he allows green vegetables ; after another month, cheese and old red wine ; and after another fortnight, almonds and nuts. A month or so after this he permits juicy fruits, not too sweet, as straw- berries, raspberries, peaches, apples, and sour oranges ; still later, plums, gooseberries, green beans and peas, tomatoes, melons, cucumbers, and gourds. After another fortnight, milk and fresh milk foods may be used. Finally, if after repeated examination no sugar be found in the urine, small quantities of farinaceous food may be cautiously permitted, but their use must be restricted for life. It is best to avoid altogether cane-sugar and sweets of all kinds. 

Cantani urges the consumption of as much fat as possible, and especially of " pancreatic fat," as easy of digestion. It is prepared of pancreas, cut up into small pieces, well mixed with a certain quantity of melted bacon fat or lard, left to undergo an artificial digestion for about three hours, and finally lightly roasted before the fire. In mild cases he prescribes pure sugar-free cod-liver oil, in 20- to 100-gramme doses.

Simple Rules for a Successful

Reduction Cure.

IT ALL DEPENDS ON THE DIET

Food Containing Sugar and Starch Must Be put aside - The Quantity of Food Eaten Is Not of Importance if the material is of the proper kind— Ice cream, potatoes, and bread must be abolished--  No water or Liquors at meals.

"This is the season of the year in which people who want to reduce their flesh would do best to begin," said a doctor who has made himself more famous in this particular field than any other American physician. "For one reason, there are fewer privations which the patient is compelled to endure now. Very few of the things that are delicacies at this time of the year are prohibited by a course of diet intended to reduce one's flesh. As a matter of fact, the forbidden articles are very few indeed, so surprisingly few that I always wondered why people look upon a course of banting as a hardship. Practically the only spring vegetables which should not be eaten are potatoes, beets, and peas, and no fruits are on the proscribed list.

"Patients who come to me receive one invariable prescriptlon. All fat comes from the same natural cause, and can be made to disappear in the same way.

I never can give any medicine beyond what is needed to put the patient in a state of good natural health. After I have accomplished that the reduction begins by following a method so publicly known that there is no reason why I should hesitate to reveal its use in my own case. It is wrong to say that only by a regimen of eating can a person's flesh be reduced. What is drunk has quite as much to do with the result. 

"I begin by refusing to allow my patients to eat anything containing either starch or sugar. Bread must first of all be given up. There is enough fat-making material in one breakfast roll to counteract the effects of mineral water treatment taken for months. Bread must absolutely be kept off the bill of fare of any one who wants to get thin. Sometimes very dry toast may be eaten in very small quantities, but nowadays there are excellent substitutes for bread provided, and th ese are quite as toothsome if a person can only break himself for a while of the feeling that he must accompany every meal abundantly with rolls or crackers, as the case may be. The new breads made without any starch are, of course, admissible, because if they are what they pretend to be there can be no fattening substance in them.

"The bread out of the way, one great step has been accomplished. Sugar must follow, and the substitutes for that are so nearly the same in effect that nobody should mind taking saccarine in coffee, instead of several lumps of sugar. It is in puddings, pies, and other similar combinations of flour and sugar that these two substances are most missed, but all pastry, puddings, and desserts of any kind in which sugar is employed are forbidden. Sugar and starch must be left alone. And this includes all corn bread and similar bread foods made of flour, cornmeal, and similar substances.

All Liquors are Fattening.

"With practically no other foods forbidden, it is possible for a person to lose as much as five pounds a week by following the rules outlined. I have known thirty pounds to be lost in six weeks on this sort of a regimen. All meats, all kinds of fish, except salmon, and all vegetables, except beets, peas, lima beans, and potatoes, can be enjoyed. Liquor must in nearly every form be left entirely alone. Beer is, of course, so fattening hat no one with any idea of reducing his weight would ever touch it, and some other alcoholic drinks are very nearly as bad. Whisky is very fattening, and so is champagne. Such concoctions as cocktails, all kinds of punches, and other mixed drinks put on more fat that years of diet could take off. There is no hope in a reduction diet for the person who continues to take alcohol. Candles, of course, and sweets should never be touched, while ice cream and similar edibles are just as high up on the forbidden list.

"This practically completes the entire cure. One need only observe carefully these rules of diet to lose flesh certainly and quickly. More than that, such a selection of food would improve the patient's general health. Abstinence from starch and sugar is known to cure many bad cases of indigestion, and I don't believe there ever was a person following such a course that did not feel better for it. Wine in small quantities and usually white in color, and rather dry in quality, may be taken with a meal, but water."

"We are often consulted by persons in whose family obesity prevails to give rules for the prevention of the condition in children or in women approaching the climacteric. In the case of children very much may be done by regulating the diet, reducing the starches and fats in the food, not allowing the children to eat sweets, and encouraging systematic exercises. In the case of women who tend to grow stout after child-bearing or at the climeratic, in addition to systematic exercises, they should be told to avoid taking too much food, and particularly reduce the starches and sugars. There are a number of methods or systems in vogue at present. In the celebrated one of Banting, the carbohydrates and fats were excluded and the amount of fat was greatly reduced.”