Pro Establishment

SEATTLE, Oct. 2—The American Diabetes Association has recommended that physicians encourage their diabetic patients to eat the same amount of carbohydrate foods—sugars, starches and celluloses—as people who are unaffected by the disease.

If physicians and patients follow the association's recommendation, it will mean a major change in the rationale of treating the disease, which has afflicted man since ancient times.

The association said that the recommendation to alter diabetics' diets—raising carbohydrates and thereby lowering fats—was taken to minimize the risk of diabetic patients developing hardened arteries (called arteriosclerosis), heart attacks and strokes.

Though the private association's guidelines are not binding on physicians, the recommendations are likely to influence the dietary care of many of the 2.8 million known diabetics in this country. The association said that an additional 1.6 million Americans have undetected diabetes.

The recommendations, which were made in a “special report,” were intended as a general policy. Like all other general guidelines in medicine, they may have to be tailored by a private physician to an individual patient's needs.

A Cardinal Therapy

Diet is a cardinal therapy for diabetes because weight reduction alone can control the disease in many—but not all—adult diabetics.

In the past, the association has not set limits on the amount of carbohydrates that it has recommended diabetics to eat. However, many doctors have urged their diabetic patients to limit carbohydrates to about 30 per cent of the calories in their daily diet, and thereby, to eat a disproportionately larger amount of fats.

Now, the association said that diabetics, like other Americans, can eat diets that contain about 45 per cent carbohydrates. Carbohydrates include a wide variety of sugars. Table sugar is just one of many that nature provides.

The remainder of the diet should consist of fats and proteins in a ratio geared to the patient's taste and his doctor's advice. Because the association says that most diabetics must limit their calories each day, this means that these patients would eat less fat.

Fifty years after the discovery of insulin — the hormone that among other functions controls the blood sugar level — arteriosclerosis has become the major killer of diabetics. Americans rarely die now of diabetic coma because insulin, a hormone derived inexpensively from the pancreas glands of animals, is so widely available for human use.

However, not all diabetics require insulin. Physicians generally prescribe insulin injections just for patients whose diabetes cannot be managed by special diet or pills. Such pills do not contain insulin, but rather other drugs that, by different pharmacologic actions, affect the blood sugar level.

“There no longer appears to be any need to restrict disproportionately the intake of carbohydrates in the diet of most diabetic patients,” the association said in the current issue of Diabetes, a scientific journal that the American Diabetes Association publishes in New York.

“The average proportion of calories consumed as carbohydrate in the U. S. population as a whole approximates 45 per cent. This proportion or even higher appears to be acceptable for the usual diabetic patient as well,” the report said.

Dr. Edwin L. Bierman, who was chairman of the committee that wrote the report, stressed in an interview here:

“For those adult diabetics treated by diet alone, the cornerstone of our recommendation is restriction of total caloric intake, and it doesn't make any difference how you do it.”

Dr. Bierman, who is considered one of the nation's leading researchers on diabetes and arteriosclerosis, treats patients with such diseases at the Seattle Veterans Administration Hospital and teaches medical students at the University of Washington.

“Most adult diabetics are obese,” he said, citing statistics from the Metropolitan Life Insurance Company, which show that two‐thirds of the female diabetics and half of the male diabetics in this country are more than 20 per cent overweight. Obesity does not cause diabetes, but it does tend to bring out the disease in those patients who are genetically susceptable.

Advice for Obese and Lean

Accordingly, the Diabetes Association stressed in its report that doctors should advise their overweight diabetic patients to reduce and their leaner diabetics to avoid weight gains with advancing age.

A calorie is a unit measurement of the amount of heat energy that a specific food can yield for muscular and other bodily activity when it is chemically changed in the tissues lof man. Though the need varies with each individual, depending in such factors as age, activity, weight and height, American men generally use about 2,500 calories per day and women about 1,800 calories.

Diabetes, depending on its severity, can produce weakness, weight loss and fatigue among other symptoms. These symptoms result from the biochemical changes that scientists think result from production of an insufficient amount of insulin to meet the body's needs.

Lack of insulin impairs the body's metabolism, or biochemistry, of carbohydrates. As a result of the complex interlocking relationship of the body's biochemical reaction, diabetes also disturbs the metabolism of protein, chemicals, water and fats.

“Today many diabetologists believe that blood fat is as important to a diabetic as is blood sugar,” Dr. Bierman said, meaning that abnormal blood fat levels are now considered one of the several factors associated with a high risk for arterosclerosis.

The Diabetes Association's action comes at a time when experts are expressing a growing appreciation and concern about the role of nutrition in health.

“The basic nutritional requirement for patients with diabetes are in general the Isame as those for all individuals,” the association said. Such needs include adequate quantities of protein, vitamins, minerals and essential fatty acids.

However, the association stressed that physicians should write dietary prescriptions for diabetic patients whenever necessary as part of their broader general health care that includes:

¶Periodic medical examination.

¶Regular exercise.

¶Avoidance of cigarette smoking.

¶ Attention to personal hygiene.

¶Prevention of infection.

For many decades, physicians have noted that diabetic patients handle infections poorly. This is true despite the proper use of antibiotic drugs when infection occurs in a diabetic patient.

The reason for this phenomenon mystifies scientists who still do not know what causes the incurable, yet treatable disease, diabetes. Though most doctors say they believe diabetes is a heredetary disease, scientists do not know the precise pattern of such proposed inheritance.

Until insulin was discovered, starvation diets were doctors' best therapy for the disease.

A half‐century ago when Dr. Frederick G. Banting and Dr. Charles H. Best, working in Dr. John J. R. Macleod's laboratory at the University of Toronto, discovered insulin, physicians began prescribing regular diets for diabetes patients.

“Thereafter, somehow, carbohydrate restriction began to hold sway as the cornerstone of treatment of diabetes,” Dr. Bierman said.

Though evidence began mounting in the late nineteentwenties that diabetics could eat diets higher in carbohydrates without apparent untoward effects, results of such observations caused few physicians to change their dietary prescription habits for their diabetic patients.

Now, those earlier observations are being confirmed with more sophisticated laboratory techniques by investigators like Dr. Bierman.

Earlier this year, for example, Dr. Bierman and his colleagues, Dr. John D. Brunzell, Dr. Roger L. Lerner, Dr. William R. Hazzard and Dr. Daniel Porte Jr., reported in the New England Journal of Medicine scientific evidence that showed high carbohydrate diets lowered blood sugar in the mild diabetic and normal humans studied.

“Diets high in carbohydrates do not raise the blood sugar,” Dr. Bierman said, adding, “That's the misconception that most physicians have had during the last 30 years.”

Kelly West, among others, rediscovered the high carbohydrate diet in the 1960s. He was astonished to discover when writing up his results that ‘very similar experiments had been done by Himsworth, with the same results. Over and over again this phenomenon has been rediscovered—and subsequently forgotten or disregarded’ [29]. Even those who remained unconvinced as to the virtue of a high carbohydrate diet were persuaded of the need to reduce fat, and the new diet was greeted with particular enthusiasm by those who had rediscovered that a high fat intake might be bad for the heart. Concerns about ‘diet heart’ powered many investigations into the virtues of polyunsaturated fats and fish oils [30], and the new high carbohydrate/low fat recommendations were formally recognised by the ADA in 1971 [31].

"A review of the available evidence shows clearly the rarity with which diabetics understand and follow their diet prescriptions. The reasons for these shortcomings and their persistence are many and complex. They include the tendency of physicians to underestimate the formidability of developing, implementing, and adjusting a diet prescription that is both acceptable and effective over a long period of time. Another problem is the limited conceptual and technical knowledge of most physicians concerning dietary principles, strategies, and tactics as they apply to the various types of diabetes. Recent research confirms the important potentials of diet regulation in mitigating diabetes and its complications. But apparently much of our effort in diet counseling is ineffective and wasteful. It seems desirable, therefore, to review in some detail the reasons for this failure and then to use candid appraisals for developing more effective approaches in the diet therapy of diabetes.