Type 1 Diabetes

"The benefit was dramatic, next only to insulin in the minds of its recipients, for it combined greatly increased well-being with escape from the miseries of an endless low carbohydrate diet.

The carbohydrate component soon escalated, and a typical diet prescribed by the Canadian physician Israel Rabinowitch in the mid-1930s might contain 2,230 calories, 400 g of carbohydrate, 50 g of fat and 70 g of protein, with 67% of energy derived from carbohydrate [20]."

Meanwhile, in the interest of showing both sides, a vegan site says this is a good thing:

https://www.wholefoodplantbaseddiet.com/tag/dr-i-m-rabinowitch-and-diabetes/#footnote_1_6199

In a seminal paper published in 1935 2 , Dr Rabinowitch demonstrated that simple dietary changes (increasing the ratio of complex carbohydrates while reducing calorie intake) could reverse type 2 diabetes.

In his summary he states:

“I believe that in the data presented here there is incontrovertible evidence that the high carbohydrate-low calorie diet is more effective in controlling diabetes than all other methods of treatment hitherto reported…it is, therefore, more economical from the point of view of the cost of insulin…”

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)

Tolstoi was young enough to be EPJ's son. He displayed a brashness on the podium and on one occasion in 1944 was blatantly discourteous to EPJ in a joint discussion, practically dismissing EPJ's rebuttal. He commonly chided the Joslin group about the pseudo logic of linking sugar directly to most of the complications - like it was a "religion." 

He and many of his group at Cornell and like-minded schools would tell the Joslin group and the Chicago group, for example, that long tetm complications appeared even in the "rigidly" well-controlled diabetics and those with his "asymptomatic-only" level did not appear to have more problems. Dr. Root at first and then, principally and more patiently. Dr. Marble took up the position that those with the best control from date of diagnosis had the least problems. 

In the late 1930s, Dr. Robert L. Jackson, then a pediatrician at the University of Iowa School of Medicine, joined the debate. Dr. Jackson, supported by his wife, who was a nutritionist, questioned why the diets of children with diabetes were restricted in carbohydrate and calorie content. He observed that, with such restriction, children were not growing well. The diet of restricted calorie and carbohydrate contained a high fat content so that smaller or fewer doses of insulin would be required. (Only regular insulin was available then.)

Dr. Jackson began to experiment with a regular meal plan (he did not care for the word “diet”) and four injections/day of regular insulin and found that his method could control blood glucose levels in children while still allowing them to grow. He had the foresight to also document the effects of his method on the health of organs usually damaged by diabetes (eye and kidney). And, in the 1950s, he published landmark research1,2 documenting the prevention of retinopathy in children with well-controlled diabetes. Unfortunately, Dr. Jackson’s data were not well received. This was in part because there was not a good method of measuring glucose control at the time, but primarily because both patients and doctors recognized how hard it was to achieve glucose control.

Longer-acting insulins (protamine zinc insulin, globin, NPH, and the lente series) were becoming available in the ’40s and ’50s, and physicians trying to be nice to patients were prescribing one dose of insulin per day. Their reasoning was that if control didn’t make any difference anyway, why try to achieve it with numerous daily injections? This method of diabetes control was easier for patients and physicians alike, so it was easy to develop this mindset. Specialists were not needed, and anyone could do it, they said. Physicians with this mindset tended to demand strict scientific evidence that control mattered, while accepting data to the contrary without rigorous scientific scrutiny.

https://spectrum.diabetesjournals.org/content/16/3/133.full

In 1958 William Daughaday commented on behalf of the American Dietetic Association that ‘uncertainty exists in the minds of many physicians today concerning the therapeutic role of diet in diabetes’. He could find only three arguments to support its role: first, that it is a valuable educational procedure leading to optimal nutrition; second, that it can avoid the need for insulin; and third, that properly spaced food intake can reduce the risk of hypoglycaemia. Glucose control and prevention of vascular disease are notably absent from this list of benefits. He proposed that carbohydrate should provide no more than 40% of total calories, avoided discussion of free diet, and dismissed the high carbohydrate regimen with the comment that carbohydrate restriction is an essential feature of the diabetic diet [28].

https://link.springer.com/article/10.1007/s00125-008-1203-9