Frederick M. (Frederick Madison) Allen.

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results from a plain fast-day. Though the harmful effect of this
quantity of fat on a single day may seem negligible, the damage
becomes more evident when a series of days is compared.

Period I in Table I was made up of vegetable days with lib-
eral addition of fat. Glycosuria was present, and the increase of
acidosis is shown by both the ammonia and acetone excretion, not-
withstanding the rather high carbohydrate intake and strongly
positive carbohydrate balance.

In Period II the fat allowance was sharply diminished. The glyco-
suria already begun continued through this period, and the carbo-
hydrate balance was lower than on April 23 and 24, yet the fall in the
ammonia and acetone output is well marked.

In Period III, continuing the same protein and carbohydrate
ration, the fat (olive oil) was again increased, and on the second day
of this period the increase of both ammonia and acetone was
again well marked.

Period IV was characterized by a diminishing fat ration and a
practically carbohydrate-free diet up to May 6. The diminution in
ammonia and acetone ran parallel to the reduction of fat, and the
sudden addition of 54 gm. carbohydrate onMay6 did not appreciably
increase the rate of fall of the acidosis.



504



CHAPTER VI



TABLE I.
Patient No. 2.





Diet.


Weight.


Urine.




Date.


Protein.


Fat.


Carbo-
hydrate.


Calor-
ies.


Volume.


Sugar.


NHs-N


Acetone
bodies
(as/S-

oxybu-
tyric).


Periods.


IDU


gm.


gm.


gm.




kg.


cc.


gm.


gm.


gm.




Apr. 21




Fast-day.


42.2


685


0.48


0.47


1.97


I


" 22


8.1


201.7


24.2


2008


41.9


1165





0.97


1.82




" 23


32.6


186.0


89.3


2137


41.8


1192


+


1.06


4.21




" 24


40.7


201.9


95.0


2432


42.2


1068


1.92


1.83


5.56




Apr. 25


38.9


57.9


74.2


1001


42.8


735


0.74


1.06


1.54


II


" 26


25.8


5.4


74.3


459


42.4


1970


3.15


0.50


1.62




" 27


25.8


5.4


74.3


459


42.2


2180


+


0.44


1.66




Apr. 28


25.8


155.4


74.3


1854


41.8


745


+


0.31


0.83


III


" 29


25.8


155.4


74.3


1854


42.1


1810





1.18


3.01




Apr. 30





100.0





930


42.1


1280





1.04


0.65




May 1


29.5


141.5


1.0


1440


41.2


990





1.12


2.22


IV


" 2


30.6


142.1


1.0


1450


41.8


1510





1.66


2.96




" 3


30.6


102.0


1.1


1077


41.6


930





1.35


0.85


'


" 4


26.2


99.9


1.0


1040


42.0


1530





1.19


0.85




" 5


29.2


76.4


1.0


985


41.6


1285





1.00


0.57




" 6


36.8


78.0


54.0


1096


41.7


1535





0.80


0.61




May 7


Fast-day.


41.6


1230





0.43


0.41




May 8


32.7


67.0


83.0


1097


41.0


1830





0.44


0.49


V


« 9


33.1


66.4


76.4


1076


41.3


2080





0.24


0.33




" 10


39.1


65.8


80.8


1062


41.2


1670





0.48


0.14




" 11




Fast-day.


41.3


1820





0.53


0.34




" 12


26.4


44.0


86.7


872


39.7


1140





0.19


0.27




" 13


32.4


39.8


104.0


928


40.4


2080





0.52


0.49




" 14


29.5


40.0


93.2


875


40.7


2157





0.32


0.49




" IS


44.8


45.3


140.6


1180


40.2


2205





0.35


0.32





Period V was another vegetable period with much less fat than in
Period I. The ammonia and acetone excretion was consistently low,
and though the protein ration was about the same and the carbo-
hydrate somewhat higher than in Period I, glycosuria remained
absent. The steady undernutrition which had reduced body weight
by 2 kilograms doubtless contributed to the acquisition of this
increased tolerance.



INFLUENCE OF FAT IN THE DIET SOS

The observations on this same patient in June and July, 1914, were
also instructive concerning the practical use of fat, especially for the
famihar purpose of building up the weight of diabetic patients. The
use of carbohydrate and the maintenance of as favorable a carbohy-
drate balance as possible has often been recommended as the most
important means of combating the resulting acidosis. The following
observations on this patient exemplify the failure of such a poKcy.

Here the body weight was increased by over 3 kilograms up to
June 30, essentially by the addition of fat. Table II shows how
acidosis ran parallel to the fat intake. The influence of the fat ration
in producing glycosuria also is suggested by this study and proved
by those mentioned later in this chapter. Carbohydrate was not
the sole cause of glycosuria, because, for example, it was higher
in Periods I and III on -days without glycosuria than in Period V
with marked glycosuria. Protein is not excluded as a factor in the
production of the glycosuria. The particular point, however, is the
manner in which the carbohydrate balance was successfully main-
tained and even increased during the periods of glycosuria and
acidosis. It will be observed that acidosis was increased with a high
positive carbohydrate balance in Period IV when the fat ration was
high, and diminished with a lower carbohydrate balance in Periods
III, VI, and the first part of VII, when the fat ration was low. Also a
more liberal protein ration did not serve to prevent acidosis in the
high fat periods. The study thus affords an example of the
general rule that the acidosis resulting from the attempt to build up
strength and weight by addition of fat to the diet is not prevented
by an increased utilization of protein and carbohydrate, but that this
acidosis falls when the fat intake is reduced. In Periods VI and VII
the injury from the high fat ration was thus relieved by diminished fat.
The body weight was likewise diminished. A glance at the graphic
chart (Chapter III) will show that this patient then (July and
August, 1914) was able to maintain herself at this reduced weight on a
well balanced mixed diet with the requisite restriction of total calories.

The respective parts played by protein and fat in producing glyco-
suria are illustrated in Table III.

In Period I, with the protein intake constant at 40 gm., the total
calories were gradually increased by addition of fat. The table shows



506



CHAPTER VI



n



tvi



1




Period I.
Low calory diet; high carbohydrate.

Total :calories for 5 days 5555; avKrage per day 1111.
Protein " 5 " 315.7 gm. " " " 63.1 gm.
Fat " 5 " 243.6 " " " " 48.7 "
Carbohydrate " 5 " 486.6 " " " " 97.3 "
Sugar excreted " 5 " 2.0+ " " " " 0.4 "
Ammonia nitrogen " 5 " 2.72 " " " " 0.54 "
Acetone bodies "5 " 2.33 " " " " 0.46 "


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288.6 "
416.0 "
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Fat

Carbohydrate '
Sugar excreted '


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INFLUENCE OF FAT IN THE DIET



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508



CHAPTER VI



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INFLUENCE OF FAT IN THE DIET 509

the resulting glycosuria, hyperglycemia, and increase of ammonia
excretion. The fast-day of October 18 diminished the ammonia
output as usual. In the next two periods the ammonia and blood
sugar are unfortunately deficient.

It is seen, however, that in Period II the total calories were kept con-
stant at the low level of 800, while protein was increased by 5 gm.
daily. The severity of the diabetes was such that glycosuria was
thus readily produced. It is also evident that small quantities of pro-
tein produced glycosuria more promptly and strikingly than consid-
erably larger quantities of fat, in keeping with the behef that protein
is a direct sugar-former.

In Period III the protein was constant at 50 gm., i.e. 10 gm.
higher than in Period I, and the fat was again gradually increased.
With the higher protein intake it is seen that glycosuria appeared at a
lower level of total calories than in Period I. Though the quantities
of sugar excreted were trivial, the increased protein allowance did not
prevent the development of distinct ferric chloride reactions at the
close of Periods II and III.

The following three observations show the effect of changes in the
fat intake, particularly upon the carbohydrate tolerance. Table IV
(compare also graphic chart. Chapter III) shows how, with a con-
stant diet of protein and carbohydrate, increase of fat through suc-
cessive weeks increased the body weight, but at the same time gave
rise to both sugar and ferric chloride reactions in the urine. On
carbohydrate-free diet, with the same protein and greatly reduced
fat, not only glycosuria but also acidosis was absent for 6 weeks there-
after. As evidences of acidosis, in addition to the ferric chloride
reactions, the graphic chart shows that the ammonia was slightly
lower and the plasma bicarbonate slightly higher, on the carbohy-
drate-free diet with reduced fat. On this diet the patient at a reduced
weight was able to remain free from diabetic symptoms.

Table V (see also graphic chart, Chapter III) shows how a pa-
tient was able to tolerate a diet with 10 gm. carbohydrate in the
week November 1 to 6. In the following weeks, without change in
protein, the fat intake was increased, and traces of glycosuria devel-
oped accordingly. Slight sugar and ferric chloride reactions then per-
sisted as the fat was further increased, notwithstanding the omission



510



CHAPTER VI



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T3



INFLUENCE OF FAT IN THE DIET



511



Period II.
Protein fat diet, increasing protein, calories remaining

constant.
Total calories for 6 days 4804; average per day 800.
Protein increasing from 40 to 65 gm.
Fat for 6 days 378.4 gm., average per day 63 gm.


1

1
s


Period III.
Protein fat diet, protein constant, fat increasing.
Total calories for 6 days 5857.
Protein for 6 days 300 gm., average per day 50

gm.
Fat for 6 days 385 gm., increasing from 53.5 to

69.5 gm.


64.1






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512



CHAPTER VI



TABLE IV.
Patient No. 26.





Diet.


Urine.


Blood.




Date.


Pro-
tein.


Fat.


Cai>
bohy-
drate.


Total
calories.


Sugar.


Feci,
reac-
tion.


Plasma
sugar.


Plasma
CO..


1


1915-16


em.


em.


gm.




em.




cent


ml. t"
cent


ie.


Oct. 25














0.135


52.5


27.5


" 26














0.263


56.0




" 25-31


304


664


85


7808














Average per day.


43


95


12


1115










27.8


Nov. 1














0.110


46.4


27.4


" 4














0.164


54.5




" 6














0.200


52.2




« i_7


330


979


90


10813














Average per day.


47


139


13


1544










27.1


Nov. 8














0.185


50.2


27.5


" 11

















53.2




" 13














0.169


52.2




" 8-14


330


979


90


10813














Average per day.


47


139


13


1544










29.1


Nov. IS














0.100


49.2


28.2


" 18














0.167







" 20














0.185


45.9




" 15-2


330


1110


90


12022





+








Average per day.


47


160


13


1717










29.5


Nov. 22














0.113


40.9


28.0


" 24














0.189


50.8




" 27














0.232


48.5




" 22-2


330


1236


90


13190





++








Average per day.


47


176


13


1885










29.0


Nov. 29














0.154


53.2


28.7


Dec. 2














0.232


49.6




" 4














0.294


51.9




Nov. 29-Dec. 5


330


1346


90


14418


+++


++








Average per day.


47


192


13


2059










29.5


Dec. 6














0.107


58.6


28.6


" 9














0.316


58.6




" 11














0.303


53.7




" 6-13


346


746


78


8672


+++


++








Average per day.


43


94


9


1084










29.4



INFLUENCE OF FAT IN THE DIET



513



TABLE IV — Concliided.





Diet.


Urine.


Blood.




Date.


Pro-
tein.


Fat.


Car-
boliy-
drate.


Total
calories.


Sugar.


FeCla
reac-
tion.


Plasma
sugar.


Plasma
COj.


i


I91S-16
Dec. 14

" 14r-19

Average per day.


gm.

280
40


sm.

472
67


em-


5534
790


sm.






per
cent

0.156


ml. per
cent

51.8


kg.

29.7
30.2


Dec. 20-26
Average per day.


369

52


484
69





6007
858








-


-


29.1
29.5


Dec. 30

" 27-Jan. 2
Average per day.


360

51


486
69




5988
855








0.071


53.5


28.8
29.7


Jan. 5
" 3-9

Average per day.


360
51


390

55





5100
730








0.141


53.3


28.8
29.0


Jan. IS

" 10-16
Average per day.


360
51


390

55





5100
730








0.123


53.2


28.9
29.0


Jan. 17-23
Average per day.


360
51


390

55





5100
730














28.6
28.7



of all carbohydrate from the diet after November 24. With diminu-
tion of fat to make a total ration of 2000 calories, sugar and ferric
chloride reactions were entirely negative in the week December 6 to
11. Exercise was carried on throughout this time, but does not
detract from the conclusions of the dietary experiment.

Table VI (see also graphic chart. Chapter III) shows the record of a
woman who had just completed a test with green vegetables indicating
a carbohydrate tolerance of 240 gm. She was then placed on carbo-
hydrate-free diet,' on which she was free from both glycosuria and
acidosis. The blood sugar, doubtless by reason of the large carbo-
hydrate intake just preceding, remained high on November 15 to 17,
and then diminished. Fat was rapidly increased while keeping protein
constant. Both hj^erglycemia and glycosuria resulted. Also acido-
sis was shown both by the marked ferric chloride reactions and by the



TABLE V.
Patient No. 2.





Diet.


Weight


Urine.


Blood.


Date.


Protein


Fat.


Carbo-
liydrate


Total
calories


Sugar.


FeCls
reac-
tion.


Plasma
sugar.


Plasma
COs.


1915


«m.


gm.


gm.




kg.






per cent


Ml.

per cent


Nov. 1


Ill


131


10


1710


38.6





*0








" 2


111


131


10


1710


39.2








0.222


59.7


" 3


111


131


10


1710


39.6














" 4


108


133


10


1718


39.5














" 5


108


133


10


1718


39.8








0.270


49.9


" 6


108


133


10


1718


40.0








0.250


57.0


" 7 ,


Fast-day.




40.2














Nov. 8


108


163


10


2000


40.0








0.356


58.6


" 9


108


163


10


2000


39.8











• —


" 10


108


163


10


2000


40.3








0.370


44.5


" 11


108


163


10


2000


40.1








0.278


52'. 5


" 12


108


163


10


2000


40.2














" 13


108


163


10


2000


40.2








0.208


52.5


" 14


108


184


10


2193


40.3


+











Nov. IS .


108


184


10


2193


39.7








0.217


56.6


" 16


108


184


10


2193


40.2














" 17


108


184


10


2193


40.4











51.4


" 18


108


184


10


2193


40.3








0.208


53.2


" 19


108


184


10


2193


40.3














" 20


108


184


10


2193


40.2








0.227


55.0


" 21


Fast-day.




40.2


+


.0








Nov. 22


108


216


10


2495


39.0


+





0.294


57.9


" 23


108



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 56 of 76)