Frederick M. (Frederick Madison) Allen.

Total dietary regulation in the treatment of diabetes online

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some instances at least this downward progress has been due to the
wrong use of exercise in an attempt to maintain the patients at higher
strength and on higher diets than advisable. Both children and adults
are deficient in muscular power and disincHned to exertion on the
minimal diets required for the severest diabetes, and obviously neither
diet nor activity should be forced in such cases.

In contrast with these three classes stand three other more numer-
ous classes in which the clinical results of exercise have been gratifying.
Nearly all these patients are of the type in which exercise is impossible
or injurious under former methods of treatment. One thing accom-
plished by the present dietary method has been to make available the
benefits of exercise to the large number of patients of this group. The
effects upon the general health are far more important than the influ-
ence upon the tolerance.

4. First may be mentioned its use in the great mass of severe cases
in adults. Exercise was not employed for patient No. 1, and she was


clearly the worse for having been kept at rest, according to the
former traditions for this type of case. She is included in the group
suitable for exercise, which also comprises cases Nos. 2, 3, 5, 6, 7, 9,
10, 14, 16, 18, 19, 20, 22, 24, 27, 29, 31, 32, 34, 36, 37, 39, 40, 43, 44,
47, 48, 49, 50, 52, 56, 59, 67, 70, and 74. For this large body of pa-
tients, exercise is the most powerful deliverer from ennui, depression,
neurasthenia, and invaUdism. . Exercise and fresh air make the most
of whatever strength is possible under the conditions of the disease,
and doubtless aid in raising resistance against intercurrent infection.
In contradiction to the fears of those who hesitate to employ diets as
low as the tolerance requires, the contrast between patients con-
fined and stufEed with fat under former methods, and those with re-
stricted calories and the benefits of exercise and outdoor freedom, is
manifestly in favor of the latter with respect to immunity from com-
pUcations and comfort and efl&ciency in all respects.

5. Most cases of diabetes in children are distinctly benefited by
exercise on a diet which makes this possible. Such are cases Nos.
4, 13, 26, 28, 42, 51, 53, 62, 63, 64, 66, 72, and 76, in the present
series. It means much to a child to be able to indulge in active
play, especially outdoors. When growth and development are pos-
sible at all, these are doubtless aided by healthful exercise. Even
when they are impossible, on account of the severity of the diabetes,
the child's looks, spirits, and attitude toward life have been improved
by active play within the limits of easy endurance.

6. Perhaps the greatest usefulness of exercise has been manifested
in a group of milder cases. This applies theoretically to cases such
as Nos. 40 and 65, on account of their mildness; but the group par-
ticularly referred to comprises certain middle-aged or elderly patients,
including those with obesity. Graduated exercise, sometimes carried
to a high point, has proved beneficial not merely in raising the
carbohydrate tolerance, but also in correcting invalid tendencies asso-
ciated with advancing years or sedentary habits. Patients Nos. 35
and 41, though sound in wind and limb, were drifting toward invaUd-
ism, and when the diabetes was brought under control by diet, exer-
cise aided materially in restoring them to normal life. Patient No.
12 was elderly, sedentary, poor, and seriously debihtated. Rigid
undernutrition was necessary to control his diabetes. Exercise and


fresh air, combined with undernutrition, gradually restored his
working power. He was one of the obese group. In other patients,
such asNos. 21 and 57, exercise was obviously an aid in controlling the
tendency to obesity, and thus benefiting both the diabetes and the
general health. Though such patients are better off in all respects
if they can really carry on exercise" successfully, a question frequently
met is how far complicating ailments contraindicate exercise. Pa-
tient No. 46 had slight arteriosclerosis and large double inguinal
hernia, but nevertheless proved able to perform moderate exercise,
especially in the form of regular walking. Though it did not save
him from a final pulmonary infection, it was evidently beneficial as to
comfort, strength, and resistance. Patient No. 33 presented the most
doubtful problem, for she had blood pressure of 190 mm., uterine
hemorrhages, and a variety of complaints suggesting organic disease.
With these, she was fat and flabby, with the usual relaxed abdomen
and neurasthenic disposition. It was decided to make a trial of
exercise, and as shown in her history, the ultimate outcome was good
in all respects. The tolerance was raised, the obesity and neuras-
thenic troubles were reheved, and even the blood pressure returned to
normal with the general improvement. It is believed that in this
case exercise was of decisive importance, and that the psychic factor
would have precluded success from purely dietetic management.
Obviously this policy and result would have been impossible in the
presence of serious organic disease. Exercise was carried to its
highest point in patient No. 23. He has been turned into a real
athlete, and subjectively has enjoyed the best health of his life.
Exercise to this degree must be considered inadvisable for the great
majority of patients.

In summary, exercise has been impracticable because of acute
terminal conditions, complicating factors, or severity of the diabetes
and bodily weakness in altogether 17 patients of this series. In the
other 59 cases exercise has found some place in the treatment at earUer
or later stages, and has been beneficial when properly employed.


D. The More Permanent Effects of Exercise upon Assimila-
tion AND THE Diabetic Condition.

The question of exercise has possessed considerable practical and
theoretical interest in connection with the conception of diabetes as a
weakened function involving the total metabohsm, rather than the
mere utilization of carbohydrate. From this standpoint the transi-
tory reduction of glycosuria and hyperglycemia by exercise is of minor
importance. The two chief theoretical aspects of the problem and
their practical applications may be stated as follows :

1. One question touches the relation of the pancreas and the
muscles as the two factors chiefly involved in the combustion of sugar or
other foods. Combustion being deficient because of deficiency of the
pancreatic factor, the question is to what extent this deficiency can be
compensated by increasing the muscles in mass and function. The
answer furnished by the present series of observations is that the
apparent compensation actually runs parallel to, and is governed by,
the strength of the pancreatic factor alone. With milder diabetes, the
organism still possesses a conside'rable metabolic capacity. Combus-
tion of sugar is accelerated in correspondence to the increased needs
of the muscles in a manner more or less similar to the condition in
health, and the apparent carbohydrate tolerance is thus increased.
As the pancreatic function falls more and more below the normal, the
response to exercise diminishes in proportion, until the point is
reached at which no perceptible alteration of carbohydrate tolerance is
possible. In more severe diabetes, the increased mobilization of
food substances resulting from exercise is greater than can be provided
for by the feeble pancreatic fxmction, and injury is evident in the in-
crease of both sugar and acetone bodies. These more severe states in
which lack of benefit or actual injury by exercise occurs may be tran-
sitory or permanent. In the former instance the pancreatic function,
which under improper diet is unable to respond to exercise, may be
considered to be strengthened by suitable treatment, so that exercise
later proves beneficial. The essential points at issue were the follow-
ing: (o) With a given pancreatic function, is there a specific improve-
ment of food assimilation with increased mass and function of the
muscles? The answer from these observations is that food combus-


tion is accelerated and increased in proportion as the power of com-
bustion is retained, but there is no evidence of specific improvement
in this power, (b) Will the increased mass and activity of the mus-
cles, through hormone or other agencies, stimulate the pancreas in
such manner as to increase its internal secretion, thus strengthening
the deficient pancreatic factor? The general result of the observa-
tions speaks against any demonstrable influence of this character.

2. If the entire metabolism is affected in diabetes, and injury re-
sults from feeding all classes of foods beyond the tolerance, the ques-
tion arises how and why this injury is produced. Is every increase of
total metabohsm injurious? If so, exercise must in the long run be
injurious. On the other hand, does the injury possibly result from the
burden of an excess of food substances present, either stored foods
such as glycogen, protein, or adipose tissue, or circulating foods, as
represented by the hjrperglycemia and h3^erlipemia of diabetes? In
this case exercise, by reducing bodily reserves and also relieving the
glut of mobilized materials, may act in a truly beneficial manner on the
same principle as fasting. Exercise could to some extent serve as a con-
venient and agreeable substitute for fasting and reduced diet, the pa-
tient keeping down his weight and his blood sugar while taking a more
satisfying diet and maintaining a higher degree of physical efi&ciency.
The question may be otherwise put as follows: If a diabetic patient
can tolerate a given diet, is it permissible to increase this diet by a
given nmnber of calories while taking care to bum up these added
calories by exercise? Will the condition thus be the same as though
the extra food had not been taken, or will injury still be produced by
the increased metabohsm? Present experience with both patients and
animals indicates that neither of the two extremes represented in these
questions is correct. Even in the cases where exercise acts favor-
ably it can be shown, as in the prolonged study of patient No. 2
(Table V), that even the heaviest exercise caimot atone adequately or
permanently for a high diet. Such use of exercise has proved disas-
trous in every case in which it was attempted in the present series.
This fact is illustrated in cases such as Nos. 2, 32, 36, 37, 39, 42, 47,
and others. In many of these cases it will be noted that the blood
sugar could not be made or kept normal by even the heaviest exercise.
In other cases, such as Nos. 37 and 42, the blood sugar was brought to


normal on liberal diets, and the patients were normal to the routine
tests for considerable periods. Nevertheless hyperglycemia and
other symptoms returned later, and the end result was fatal. On
the other hand, the use of exercise has not proved harmful, except in
the few severest cases mentioned. In cases of decidedly mild char-
acter, exercise, by keeping down weight and improving tolerance,
may serve to a limited degree as a substitute for fasting and reduced
diet. It has thus been used with benefit in the group of elderly pa-
tients above mentioned. Nevertheless, histories such as those of
patients Nos. 23 and 41 show that even in these milder cases exercise
is limited in its usefulness in the long run, and restriction of total ca-
lories must always be the essential reliance for the permanent control
of hyperglycemia and other symptoms. The general conclusion on
the questions mentioned may be expressed as follows. The greatest
and most rapid injury from excessive diet occurs when weight and
food materials are allowed to pile up without restraint. Exercise, by
reducing weight and food accumulation, diminishes this injury, and
the relief is genuine to this extent, even though obtained at the price
of increased metabohsm. Nevertheless the burning up of surplus food
by exercise is not equivalent to withholding such food, and in severe
cases the diastrous result is merely delayed and not prevented.

Though exercise cannot atone for thfe damage of excessive caloric
feeding, it apparently can make possible the use of a higher propor-
tion of carbohydrate in suitable cases. Its well known power of
diminishing glycosuria and hyperglycemia can probably be used for
this purpose without injury, provided only the total calories are kept
sufiiciently low. Further information concerning the effect on acidosis
when carbohydrate is thus used would be of interest, but with a suit-
able caloric intake acidosis is a matter of only minor practical im-
portance. The disappointment of the hope that exercise might per-
mit of higher diets and correspondingly higher bodily efficiency in
severely diabetic pa,tients is of practical importance for the treatment,
especially of paltierits of the poorer class. Repea^tedly in the present
series the attempt has been made to build up such patients so that
they could work with maximum efficiency. The final result has always
been disastrous, no matter how well the patient might seem to thrive
for the time being on high diet with the aid of exercise. It may be


urged that such pati'ents must work to make their living, and require
high diets for this purpose. A comparison with cardiac disease is
proper. A patient with mild diabetes, like the one with mild heart
trouble, may carry on more or less manual labor without injury. The
patient with more severe diabetes is as unfit for heavy manual labor
as the corresponding cardiac patient. As long as there is no cure for
d abetes, such patients must necessarily conduct themselves as sick
persons and not as well persons, and financial conditions should be
adjusted accordingly, with public aid if necessary. Granting a suit-
able low diet, diabetics in general, with the comparatively uncommon
exceptions mentioned above, are benefited by healthful exercise within
the limits imposed by the diet. In the preliminary communication
concerning exercise,^ warning was given against its use as a sub-
stitute for dietetic measures, and this warning has been justified
by the more prolonged experience. On the other hand, the benefits to
the strength, spirits, and general health have also been substantiated,
and it would be a gloomy prospect to return to the former practice of
strict rest for severely diabetic patients. In the final outcome, over-
strenuous or exhausting exercise in the endeavor to build up a true
increase of tolerance has been abandoned, and muscular activity has
been employed within the easy limits of strength for its beneficial
influence upon the general health and spirits of the patients.


1. The diminution of glycosuria and hyperglycemia by exercise de-
scribed by former authors in milder diabetes has been found to obtain
also in more severe cases under suitable dietetic management. In
cases of still more severe type, this effect of exercise may be lacking,
and the blood sugar and general condition may even be affected

2. In suitable cases the effect of exercise in diminishing glycosuria
and h)^erglycemia is demonstrable when these have resulted from
the addition of fat to the diet.

3. No appreciable tendency to acidosis has been produced by exer-
cise under the ordinary conditions of proper dietetic management.

lAUen, Boston Med and Surg. J., 1915, clxiii, 743-744.


A distinct tendency to acidosis may be produced in patients inade-
quately treated by diet, or in the severest cases, or sometimes on
fasting or very low diet. Under such conditions exercise must be used
with caution.

4. No special relation has been observed between the changes in
blood sugar concentration produced by exercise and the blood volume
(as judged by hemoglobin and hematocrit readings) or the distribu-
tion of sugar between plasma and corpuscles.

5. Exercise may perhaps be useful as a means of introducing a higher
proportion of carbohydrate in the diet in some cases, but cannot serve
as a substitute for total caloric restriction in cases at all severe in

6. Most of the cases in which exercise has been beneficially em-
ployed in the present series are of a grade of severity which pre-
cluded the use of exercise under former methods of treatment. The
present dietetic management has served to make available the bene-
fits of exercise to this numerous group of patients. At the same time
the observations carry a warning against the abuse of exercise even in
milder cases, whenever an undue total caloric burden is thereby in-
volved. In the final outcome, muscular exercise and development
have exhibited no specific influence upgn the diabetic condition, but
can be recommended within proper limits for their beneficial effects
upon the general health and spirits of diabetic patients.



Some references to the literature on this topic will be found in preced-
ing chapters. It suffices here to mention that the accepted doctrines
in practice have been as follows-: that fat is the most useful food in
diabetes; that it is responsible for little or no glycosuria; that its use
need not be restricted even from the standpoint of acidosis unless in
the presence of threatened coma, because deficiencies of fat in the diet
are made up by the use of body fat in metaboUsm; that diabetic
patients should be built up in weight if possible and their nutrition
maintained at a masdmimi by a full caloric ration, especially of fat, the
calories lost as sugar and acetone bodies in the urine being also replaced
by fat in the diet; and that undernutrition should be employed only
in the slight degree and brief duration recommended by Naunyn. In
opposition to these beliefs and this usage, the conclusion has been
reached, especially from animal experiments, that diabetes is a dis-
order of the total metabolism and that any increase of weight or of
total diet increases the strain upon the weakened function. Accord-
ing to this assumption, rational treatment would consist in first cutting
down the metabolic strain to a minimiun by fasting until active
S3mciptoms are controlled, and thereafter in permanently maintaining
a reduced level of weight and metabolism to correspond to the weak-
ened function. To some extent the question at issue is divisible
into the influence of body weight in itself and the influence of the diet
in itself. The various factors have been studied more particularly in
the animal experiments, but the same classification may conveniently
be employed for the observations on human patients, which are in all
respects confirmatory.



A. Influence of Body Weight.

Since the weight (broadly speaking and without considering fluc-
tuations of water content of the body) necessarily rises and falls with
the supply of available calories, a sharp differentiation of the influence
of weight as distinct from the diet producing it is difficult. Three
Unes of evidence may be mentioned.

One of these consists in the marked benefit to the diabetes, the
clearing up of all active symptoms, and the striking gain in assimi-
lative power when the body weight is reduced. Examples are afforded
in the histories of patients Nos. 12, 16, 21, 33, 35, 41, 46, 57, and 60.

The second line of evidence consists in observations of the effect of
increase of weight. In the milder grades of diabetes such influence
may be less obvious, though still frequently demonstrable, but in the
moderate or severe grades of the disorder the influence is too plain
to be missed. In anything resembling a severe type of diabetes, the
present series has afforded no exception to the rule, which is be-
lieved to be general, that gain in weight means loss in tolerance.
At a suitable level of weight patients or animals may remain free
from diabetic symptoms for long or indefinite periods. If the diet,
especially by addition of fat, is made such that the weight increases,
symptoms may remain absent until some higher level of weight is
reached, differing according to the severity of the diabetes. At this
point active symptoms return, and continue unless checked by re-
duction of weight. Examples of this parallelism between body weight
and diabetic symptoms are pointed out in the histories of patients
Nos. 5, 16, 23, 26, 41, 57, and 66. In most of the other cases such a
parallelism is more or less clearly illustrated. The entire treatment
by which freedom from diabetic symptoms is maintained has for one
of its constant objects the maintenance of a suitably low weight.

A third line of evidence is furnished by exercise, by which the body
weight can be controlled to an important degree without variations
in diet. It was concluded in the previous chapter that exercise has no
apparent specific influence upon the essential diabetic disorder. This
being the case, it is instructive that the sugar in blood and urine and
other diabetic symptoms can to some extent be controlled by exercise
without change in the diet. Examples of the checking of undue rise


of weight and corresponding control of diabetic symptoms by exercise
are shown in the histories of patients Nos. 23, 37, and 42. In no in-
stance was exercise carried out in such manner as wholly to prevent
gain in weight. To this extent the studies are not decisive, and
the failure of exercise here, in respect to merely delaying and not
ultimately preventing the return of active diabetes, may thus receive
at least a partial explanation.

B. Intltjence of the Total Diet.

Inasmuch as the harm of either carbohydrate or protein in excess
of the tolerance has long been recognized, this question pertains es-
pecially to the influence of fat feeding; and this is divisible into the
influence upon acidosis and the influence upon glycosuria. In some
of the following cases the diets were such as to increase the body
weight slightly. In other cases the increase in weight was trivial
or absent, so that the effects noted must be attributed directly to the
changes in diet.

The production of glycosuria, and also of acidosis as indicated qual-
itatively by the ferric chloride reactions, was shown in Table IV of the
preceding chapter. Similar injurious effects attributable predomi-
nantly to high fat rations were described in cases Nos. 1 and 17 and
more particularly in case No. 5 (Chapter III). The production of
acutely threatening acidosis by small quantities of fat and relief of
this acidosis by diminishing the fat intake were shown in the his-
tories of patients Nos. 54 and 60. Also reference may be made to the
history of patient No. 57, where tests showing the effect of fat in
diminishing carbohydrate tolerance are described.

The history and graphic chart of patient No. 24 show how the fre-
quent traces of glycosuria were stopped, and the high blood sugar
reduced to normal, by means of reduction of fa:t and total calories,
while protein was given in larger quantity than before. Also the
tolerance was markedly improved as the body weight diminished with
this undernutrition.

In addition to the liberal use of fat in ordinary diabetic diets, it has
been administered heretofore in large quantities on oatmeal days,
vegetable days, and even fast-days, in the belief that much available


energy was thus supplied without appreciably injuring the carbo-
hydrate tolerance or causing any important degree of acidosis. Ob-
servations early in the present series indicated the harmfulness of
such use of fat. For example, in the histories of patients Nos. 2
and 4, it was pointed out how the acidosis increased and glycosuria
was unduly persistent when olive oil was given in addition to green
vegetables, whereas in the same and other patients periods of green
vegetables alone have acted powerfully in aboHshing acidosis.
These results in case No. 2 are shown more clearly by Table I.

The comparison of the two fast-days, April 30 and May 7, when the
patient was free from glycosuria, gives the impression that both were
beneficial in diminishing acidosis, although 100 gni. oKve oil were
given on the former day. This result on April 30 is readily explain-
able by the fact that the fat and total calories were decidedly lower
on that day than on the preceding and following days. It is signifi-
cant that the ammonia on April 30 did not show such a fall as usually

Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 55 of 76)