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 employedby 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 foundin 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 numberof 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 ofAgriculture, 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.