Type 2 Diabetes

Before the discovery of insulin, the primary controversy in diabetes was what kind of reductive diet to use—rice diet, rancid fat diet, vegetables “cooked three times in their own water,” and so forth. All were restrictive and essentially treated diabetes by starvation. For type 2 diabetes, they probably worked out, in that they no doubt led to weight loss. (Perhaps we should try some of these again.)

With the advent of insulin, the problem of diabetes was thought to be solved, and indeed, those with type 1 diabetes did just fine, for a while. It didn’t take long, however, for those now living longer to begin to develop vascular and neurological complications. And thus began a new round of controversy.

This controversy, which began in the 1930s, raged on for the next 60 years and was often very heated. The issue, simply put, was whether the vascular and neurological problems associated with diabetes were a genetic concomitant of the disease (and thus inevitable and unalterable) or instead were associated with the metabolic abnormalities of diabetes, such as high blood glucose levels (and thus preventable). Which side one took on this issue had great ramifications regarding the method of diabetes management one’s practice adopted.

A classic debate on this topic took place in New York in the 1940s between Dr. Elliott Joslin and Dr. Edward Tolstoi. The debate, which was recorded and is available at the New York Hospital, Cornell University School of Medicine, was reenacted a few years ago.

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.

I entered the fray in 1964 when I began training with Dr. Jackson at the University of Missouri. It was about this time that an article was published on muscle biopsy specimens and measurement of basement membrane thickness (BMT) of capillaries.3 The article concluded that control of blood glucose made no difference because thickening had occurred even in those who had not yet developed full-blown diabetes. This solidified the position of the loose-control advocates and made the position of the tight-control advocates very difficult. Nonetheless, Dr. Jackson and I and others stuck to our guns and continued to advocate physiological control, but proof was clearly needed.

Thus began our involvement in Dr. Charles Kilo’s and Dr. J.R. Williamson’s research on BMT.4 We published an article showing conclusively that tight control would not only prevent BMT, but also reverse it when poor control was improved.5 We also published an article on prevention of retinopathy.6

Dr. Jackson retired in 1972, and his mantle fell to me as a spokesman for the physiological method of tight control. I participated in many debates throughout the country, often against multiple opponents, to advocate for better control. These debates certainly raised emotions, but, confident in our position, we persisted for the sake of the children.

The debate was finally put to rest by the Diabetes Control and Complications Trial (DCCT) results in 1993.7 But the underlying problem remained.

In 1996, I participated in a debate with one of the principle investigators of the DCCT, who conceded that I had been right that the course of vascular disease was related to the degree of control of the metabolic abnormalities but claimed that the degree of control necessary simply couldn’t be achieved. Tight control, he said, was too imposing on patients (more so than blindness or amputation?, I wondered), too labor intensive, and too costly.

There was also a respected fear of hypoglycemia, which was a concern, especially in children. However, we were finding that we had less difficulty with hypoglycemia when the methods we used brought about normal blood glucose levels more of the time.

Tools eventually became available to answer all of these arguments. Self-monitoring of blood glucose, hemoglobin A1c measurement, and insulin analogs have solved many problems. But still, in 2003, a decade after the DCCT, physiological control still is not universally accepted.

Today, the controversies are centered not so much on “why” as on “how.” Debates about how to get the most physiological management include:

• What kind of meal plan should we use—carbohydrate counting? Low-carbohydrate, high-protein diet? Calorie counting? Exchange lists?

• How should we monitor blood glucose levels—fasting and postprandial glucose measurements, or pre-meal and bedtime measurements?

• On what should we base our insulin adjustments—sliding scales, algorithms, or patterns?

Through the current debates, I remain an advocate of physiological diabetes management, as follows:

• A good, healthy, well-balanced meal plan

• Monitoring at fasting and 2 hours after meals

• Pattern control

• Either four doses per day of insulin using the bolus-basal concept, with lispro or aspart for bolus insulin and glargine for basal insulin, or bolus insulin injections with basal insulin administered with an insulin pump

I have been at this now for 40 years, and I will continue to insist that the closer to nature we can become in our management, i.e., the closer we can restore people with diabetes to physiological normalcy, the better off our patients will be.

We need to continue our research to find better ways to mimic nature and test all methodology, to look at the data critically, and to base management on scientific data outcomes. Why must we do this? Not simply to settle arguments and debates, but instead because the quality and length of the lives of our patients depend on it.

We must always look beyond the horizon to see how we can improve the quality of life for those we serve. If we always keep their welfare in mind, then there are no losers of debates, only winners—our patients.

A technique is described for the measurement of muscle capillary basement membranes by electron microscopic examination of needle biopsies of the quadriceps muscle. With this procedure it has been possible to obtain an objective evaluation of the significance of capillary basement membrane hypertrophy in diabetic microangiopathy. The results of such studies of muscle capillary basement membrane thickness in 50 normal, 51 diabetic, and 30 prediabetic patients have demonstrated the following. First, that the average capillary basement membrane width of diabetic patients is over twice that of normal subjects; moreover, such basement membrane thickening is a very constant finding among overtly diabetic patients, in that approximately 98% of individual diabetic subjects demonstrated this lesion. The degree of basement membrane thickening in diabetic patients is, however, unrelated to age, weight, severity, or duration of diabetes. Second, capillary basement membrane hypertrophy has been found in approximately 50% of patients who are genetically prediabetic but who have not yet demonstrated evidence of the manifest carbohydrate disturbances of diabetes mellitus. Third, in contrast to the results obtained in genetically diabetic patients, subjects with severe hyperglycemia due to causes other than genetic diabetes only infrequently show basement membrane hypertrophy.

These results indicate that thickening of the muscle capillary basement membranes is a characteristic of genetic diabetes mellitus, and further, that the hyperglycemia of diabetes is probably not the factor responsible for the microangiopathy characteristic of diabetes mellitus. Finally, the discovery of thickened capillary basement membranes in prediabetic patients suggests that basement membrane hypertrophy is a relatively early lesion of the diabetic syndrome and provides further support for the conclusion that this vascular defect is independent of carbohydrate derangements of diabetes mellitus.

J Clin Invest. 1968;47(9):1973-1999. https://doi.org/10.1172/JCI105886.

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.

"Originally published in 1997, DR. BERNSTEIN'S DIABETES SOLUTION is a unique resource that covers both adult- and childhood-onset diabetes, explains step-by-step how to normalize blood sugar levels and prevent or reverse complications, and offers detailed guidelines for establishing a treatment plan. Readers will find fifty gourmet recipes, in addition to a comprehensive discussion of diet, obesity, and new drugs to curb carbohydrate craving and overeating."