Part 4

Obesity a mark of overeating and functional overstrain of the pancreas.--The rule, however, is that overeating leads to obesity, and it is a well known fact that many diabetic patients are, or have been, overweight. Dr. Joslin, for instance, found among 1,000 diabetic patients, 75 per cent who either were, or had been, over normal weight. Dr. Joslin says that it takes ten diabetic patients to make a ton of diabetes. Overeating with attendant long continued functional overstrain of Langerhans islands is probably the most common of all causes of diabetes.

Sugar eating.--It is of considerable significance that the increasing incidence of diabetes in America is coincident with the enormous increase in the sugar consumption. In the decade 1880 to 1890, the annual sugar consumption was 44 pounds per capita. In 1921, it had risen to 84 pounds, and in 1922 to 103 pounds. The death rate for diabetes in 1890 was 5.5 for each 100,000; in 1921, it was 16.8 for each 100,000. It is easier to overeat of sugar than of almost any other food known, and it is probable that sugar imposes a greater functional strain on the pancreas than do the starches or fats. Starches swell up and fill the stomach readily, thus checking the appetite; furthermore they are slowly absorbed into the blood. Sugar goes into solution, passes the stomach quickly, is absorbed almost instantly and at once demands attention from the pancreas. The common desserts are sweets. When we are glutted with meat and potatoes, we still have room for sweets and we can always find room for candies. The rage for soft drinks since the abolition of alcoholic beverages is certain to increase the crop of new cases of diabetes. I have seen several patients who have been suddenly precipitated into an extreme stage of diabetes and coma by a soft drink spree.

Diabetes may occur without provocation.--Not infrequently, among younger persons and children, diabetes appears out of a clear sky with apparently no provoking cause. No inflammation has occurred in the pancreas of these patients, so far as any good evidence shows; they are young and therefore not afflicted with arterial disease, and they have never been overweight and have not overeaten. How can we explain the diabetes of these children and young persons, and how can we explain why some fat persons and not all escape diabetes, and why some patients with very little disease of their pancreas have diabetes and others with very extensive destruction of the pancreas do not have it?

Heredity of the tendency to diabetes.--The answer, probably, lies in the more or less shadowy realm of heredity. Some of us are born with weak eyes and others with weak islands, and the degree of original island weakness determines the susceptibility of the islands both to functional overstrain from overeating and to injury from infectious diseases or from poor circulation of the blood. If the diabetic tendency of an individual is marked, diabetes may develop, in very early life. The pancreas here is too weak to withstand the normal functional strain of growth. When this is the case, the disease is of extreme severity. If the diabetic tendency is slight, it may not show itself except as the result of long continued overeating. If the pancreatic islands are functionally strong, they withstand infections and injury from disease or poor blood supply; if weak, they fail and diabetes results. Diabetes rather infrequently occurs in several members of the same family, but the fact that this happens rather infrequently does not mean that the tendency fails to pass by heredity. Many persons who are considered normal may have this tendency without showing any evidence of it throughout life.

THE TREATMENT OF DIABETES

Prevention.--A stitch in time will save nine diabetic patients. Typhoid, small-pox, diphtheria, yellow fever and a number of other diseases have been practically eliminated. Tuberculosis, otherwise known as the white plague, is rapidly being chained. Why not do the same with diabetes? We have seen that overeating is the common cause. Let us, therefore, teach the virtues of keeping lean and fit. Incidentally, such teaching may help to control other chronic diseases. There is reason to believe that heart trouble, high blood pressure, gallstone and cancer, occur in the obese with greater frequency than in the lean. Obesity is a mark of long continued functional overstrain of all the organs of the body. Overeating of carbohydrates and proteins is especially injurious to the pancreas. In Berlin, during the war when the food supplies of the populace were greatly reduced and sugar and meat in particular were scarce, the number of new patients with diabetes decreased immensely. In America, with growing luxury and rising sugar consumption, diabetes is increasing by leaps and bounds. The Jews, as a race, have much diabetes, not because they are Jews, but because so many of them are luxury lovers, overeaters, and fat Jews. Diabetes cannot be entirely eliminated by preventing overeating. As we have seen, thin people are not immune if the heredity tendency in them is strong; and they develop the severest form of diabetes at a relatively tender age, and yet it is possible that even the number of these may be reduced in time. A leading authority once published the family trees of a number of diabetic families and these family trees suggest that the tendency to diabetes becomes stronger with each succeeding generation. In the grandparents the disease was mild and came on late in life--not until they had overeaten, presumably, for many years and were fat. In the parents the disease was more severe and appeared earlier in life, the result, presumably, of less overeating. In the third generation, the disease occurred in the children with still less provocation from overeating. Perhaps we can save our grandchildren, therefore, by keeping ourselves fit, and thus stamp out the diabetes of childhood which is always severe and, therefore, the most dreaded. It is worth a trial.

Detection of early cases.--Doctor Joslin, who has done more than anyone else to teach the diabetic people of America how to keep well and strong, urges that everyone have the urine tested annually on his or her birthday. Life insurance examinations, are now fortunately much more frequent than formerly, and reveal numerous early cases of diabetes. Diabetic patients, who have been properly treated, are trained to make the sugar test of the urine. It is the duty of everyone of these to examine the other members of their families at frequent intervals. Why not teach this simple test to the students in the classes in chemistry in our high schools and urge them to keep a watch on the members of their families? Every druggist certainly should be familiar with the test and should be willing to make it on request, for a nominal fee.

It makes a great deal of difference whether a patient comes to the doctor early or late. With the better methods of treatment, the earliest cases are being arrested, if not cured. Some of them may be cured. It is still too soon to know. There is little hope of strengthening a severely weakened pancreas, or of accomplishing curative results in patients who have had the disease very long.

Treatment.--The treatment of the patient is based on certain principles which follow logically from the foregoing about the nature of the disease.

Principles guiding treatment.--If diabetes is due, as seems most likely, to the overstrain of a pancreas weak by heredity, the obvious way to manage it is to reduce the strain. This is exactly the same principle that guides us in treating heart disease. Physical rest accomplishes wonders for the heart. Careful dieting does the same for the pancreas. By so arranging the diet that the total amount of sugar, that is, the load on the pancreas, is reduced, we accomplish, first, the disappearance of sugar from the urine, second, its decrease in the blood, third, the control of annoying symptoms, such as excessive urination, excessive thirst, and dryness and itching of the skin. Simultaneously, we give the pancreas a chance to pick up and regain some strength.

In mild cases of diabetes the results obtainable by diet are entirely satisfactory and the milder the case the less the food restriction necessary. In severe cases of diabetes the dietary treatment alone is less satisfactory because the diet has to be cut so low that the patient is improperly nourished. Before the discovery of insulin was made, every such case presented a bitter dilemma. Either the diet was restricted to the point where the patient literally starved to death, or the patient could be fed; but, in that case, death from diabetic coma was to be anticipated. It is in such cases, particularly, that insulin is proving a boon. With insulin at our disposal, cases of severe diabetes can be converted into mild cases. All that is necessary is to give enough extra insulin every day to raise the patient’s tolerance for sugar, and then, with a careful but adequate diet, he can enjoy normal strength and health and carry on with his usual occupation. This is not curing diabetes, but it is eliminating the worst of its terrors.

The diet can not be disregarded.--Some persons may ask why dieting is necessary with insulin? If, as seems true, the only metabolic disturbance in diabetes is a lack of sufficient insulin, then we should be able to correct this fault completely by giving sufficient insulin, and to eat what we want. This may be sound, theoretically, but is impractical for the following reason.

An uncontrolled normal diet contains approximately 300 grams, or 10 ounces of carbohydrate, 150 grams, or 5 ounces of protein, and 90 grams, or 3 ounces of fat. In the course of assimilation, about 400 grams of sugar are derived therefrom, and, to metabolize such an amount of sugar, 150 to 300 units of insulin must be necessary. A normal person probably makes, in his pancreas, 200 or 300 units of insulin a day, which is sufficient for any normal demand, but this natural insulin is doled out to his tissues, a bit at a time, so that there is never an excess of insulin in the blood.

Excessive insulin harmful.--In severe diabetes the pancreas manufactures very little insulin, not more than 20 or 30 units, and the balance necessary for the day’s work must be given by hypodermic syringe in two or three doses. If the total amount of extra insulin necessary daily were 150 units, each hypodermic injection would be 50 units, and it is difficult to give such large doses as this without causing a temporary excess of insulin in the blood. Unfortunately, excessive insulin is as disagreeable as inadequate insulin. When too much insulin is present in the blood, the blood sugar falls to very low levels and a reaction occurs with symptoms that may be alarming, and results that may be serious. Consequently, very large single doses of insulin must be avoided and the total amount of sugar entering the body daily must be measured and made to balance with the insulin doses. This means dieting.

Furthermore, it proves to be very difficult to keep the level of the blood sugar low with insulin when diets are very rich in carbohydrate. The normal sugar level, as I have said, is 0.1 per cent. In uncontrolled diabetic conditions, it may be found as high as 0.5 per cent, or higher. This can be reduced by an insulin injection, but as soon as food rich in carbohydrate is eaten, back comes the sugar to a high level. In order to rest the pancreas, the blood sugar must be kept low, which can only be accomplished when the diet contains relatively little carbohydrate.

THE DIET

Calories and sugar should be low.--All of the principal authorities on diabetes are agreed that a diabetic patient must not overeat and become fat. In other words, the total amount of food energy, that is, calories, must be limited. All are agreed also that the diet must be kept low in sugar producing foods. This means little carbohydrate and little protein. The diet in health, as I have said, includes a great deal of carbohydrate, probably more than is wise even for perfectly normal persons. The diet in diabetes must get more of its calories from fat and less from the starches and meats. Authorities are furthermore agreed that an excessive restriction of carbohydrate (sugar and starch) may be dangerous, because with such very low carbohydrate diets the fats may fail to be properly assimilated, with resulting acid poisoning.

The authorities agree on general principles.--The actual procedures in diet-planning employed by various authorities differ but little, and only as to details. Doctor Allen, for instance, believes in much greater restriction of total food than do others. Doctor Joslin also favors rather low total food amounts and disbelieves in allowing much fat unless rather large amounts of carbohydrate can be taken. Doctor Woodyat of Chicago, the doctors in the Toronto Clinic, and Doctor McCann at the University of Rochester, New York, plan their diets in such a way that approximately one part of carbohydrate will be taken for every two and one-half parts of fat. Professor Petren of Lund, Sweden, now the leading authority in Europe, and Doctor Newburgh and Doctor Marsh of the University of Michigan, believe that restricting protein is of extreme importance, and that if this is done acidosis can be avoided even when larger proportions of fat are fed. In the Mayo Clinic, the practice is to limit protein rigidly and to limit carbohydrate rather more strictly than is done elsewhere, making the diet consist to a greater extent of fat, but planning this so that the total energy of the daily food supply will meet quite closely actual energy requirements. The procedures for arriving at these several diets can be found in various manuals that have been written for patients.

Books on diabetes for patients.--Doctor Joslin’s “Diabetic Manual,” Lea and Febiger, is one of these. Doctor Petty’s “Diabetes, Its Treatment by Insulin and Diet,” F. A. Davis Company, Philadelphia, is another. Wilder, Foley and Ellithorpe’s “A Primer for Diabetic Patients,” W. B. Saunders Company, Philadelphia, may be consulted for more complete descriptions of the methods employed in the Mayo Clinic than can be given here.

Patients must be trained.--The results of accurate management are so encouraging that they are almost as good as cures. They are not cures, because the fundamental island weakness is rarely if ever completely corrected, and treatment must continue for month after month. Success, therefore, rests largely in the patient’s hands and the doctors’ most important task is teaching the patient all that he can be taught about his diet and about the use of insulin. The books mentioned were written to help in this training of patients. In various clinics over the country, patients attend classes and are instructed in the subject of dietetics until they can weigh food and plan meals accurately so that each will contain a set number of calories and yield to the metabolism a predetermined amount of sugar. The hospital management of a case of diabetes is not complete until the patient can live a healthy life in spite of his disease. He may arrive at the hospital in a state of coma and be dragged from the very jaws of death with insulin, but afterwards, when he goes home, unless he has learned how to continue the use of insulin and combine with it an accurate diet, he will slip again into the same dangerous predicament.

It is best always to start treatment in a hospital where a systematic course of instruction can be obtained. Unfortunately, we have no schools for diabetic patients other than the hospitals, and some persons dislike hospitals. Good results can be obtained at home, provided one has the good fortune to consult a physician who will take the time to give this training. What are the essentials?

What the patient must know.--First, a knowledge of how to read food tables and, with their aid, to plan accurate diets. Food tables are lists of foods showing the composition of each, in protein, carbohydrate and fat. The books mentioned here all contain such lists. The most complete table is that published by the United States Department of Agriculture, Bulletin No. 28, “The Chemical Composition of American Food Materials,” a pamphlet that may be had from the Superintendent of Documents, Government Printing Office, Washington, D. C., for the small sum of ten cents.

Second, instruction in the manner of injecting insulin, that is, in the use of the hypodermic syringe. Insulin, as has been stated, must be given hypodermically, under the skin. The technic is not difficult, but sterile precautions must be observed in order to avoid introducing disease germs with the insulin.

Third, instruction in how to test the urine for sugar. This is a simple task but of great importance. Sugar in the urine is the first signal of inadequate treatment. To postpone correcting the mistake until other signs appear such as thirst, excessive urination, and loss of strength, is to court disaster. The sugar test can be completed in three minutes, and should be made every day, preferably on a specimen of urine passed just before the patient retires for the night. This specimen should be sugar-free. If it is not, more insulin is needed or the diet requires readjustment.

Fourth, advice concerning how to meet certain complications which I shall discuss later.

TREATMENT IN CASES OF MILD DIABETES

There are instances of patients with diabetes who have lived for twenty years or more without any effort at treatment. This consoling thought must not make unwary the patient with a moderately severe or severe form of the disease. It is safer to overrate the seriousness of the condition than to commit an irreparable blunder and neglect the careful management of a serious condition. Children and young adults, for instance, may seem well during the first year after the appearance of sugar, but with few exceptions they develop the severest form of the disease later unless they are very carefully treated from the first.

A good many older persons may be treated satisfactorily with much less dietary restriction than is necessary in the severe cases. When this is possible, insulin is not needed and should not be used, or, in other words, if a condition is serious enough to require insulin, it is serious enough to require an accurately weighed diet. Occasionally patients have so little intelligence that it is hopeless to expect them to carry on the weighed diet in their homes. For such, and also for patients with very mild diabetes, the following general advice is usually beneficial: