Rethinking Diabetes

An eye-opening investigation into the history of diabetes research and treatment by the award-winning journalist and best-selling author of Before the discovery of insulin, diabetes was treated almost exclusively through diet, from subsistence on meat, to reliance on fats, to repeated fasting and near-starvation regimens. After two centuries of conflicting medical advice, most authorities today believe that those with diabetes can have the same dietary freedom enjoyed by the rest of us, leaving the job of controlling their disease to insulin therapy and other blood-sugar-lowering medications. Rather than embark on “futile” efforts to restrict sugar or carbohydrate intake, people with diabetes can lead a normal life, complete with the occasional ice-cream cake, side of fries, or soda. These guiding principles, however, have been accompanied by an explosive rise in diabetes over the last fifty years, particularly among underserved populations. And the health of those with diabetes is expected to continue to deteriorate inexorably over time, with ever-increasing financial, physical, and psychological burdens. In The result of Taubes’s work is a reimagining of diabetes care that argues for a recentering of diet--particularly, fewer carbohydrates and more fat--over a reliance on insulin. Taubes argues critically and passionately that doctors and medical researchers should question the established wisdom that may have enabled the current epidemic of diabetes and obesity, and renew their focus on clinical trials to resolve controversies that are now a century in the making....

Auteur
GARY TAUBES is the author of six books, including the best sellers Good Calories, Bad Calories and Why We Get Fat. He is a former staff writer for Discover and correspondent for Science, and his writing has appeared on the cover of The New York Times Magazine and in The Atlantic, Esquire, and numerous “best of” anthologies, including The Best of the Best American Science Writing. He has received three Science in Society awards from the National Association of Science Writers and the Robert Wood Johnson Foundation Investigator Award in Health Policy Research. He lives in Oakland, California.

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The Nature of Medical Knowledge

In diabetes . . . ​the chief difficulty lies in the fact that the danger is one of the future. This is the insidious peculiarity of diabetes. We do not at all disturb for the present the general well-being of the diabetic if we treat him badly and overweight his weakened functions; yes, we may even improve by psychical influence his momentary well being if we permit a more liberal diet. We are, however, playing a dangerous game. We are thinking only of the present and forgetting the future, the fortunes of which depend upon the vigilance of the practitioner.

—Carl von Noorden, New Aspects of Diabetes: Pathology and Treatment, 1912

In the writer’s experience, there is nothing more disturbing than the diabetic who acquires the disease in childhood; who apparently is a picture of robust health—who looks and feels perfectly well—but whose blood vessels have been degenerating insidiously for years; who, in the early 20’s or 30’s and probably married and with a family, is beginning to feel the effects of the degenerative changes, either because of a progressive hypertension, kidney failure, disturbance of sight due to retinitis, or a sudden attack of coronary thrombosis. . . . To prevent such cases, or at least reduce their occurrence, is the purpose of this report.

—Israel Rabinowitch, Canadian Medical Association Journal, 1944

A 32-year-old white male was seen at the [Mayo] Clinic in July, 1921, by Dr. [Russell] M. Wilder. His symptoms were polyuria, polyd[i]psia, polyphagia, weakness and loss of weight.” The patient, a farmer from “the hinterland of Montana,” had severe diabetes. The diagnosis was not difficult to make. He was urinating abundantly (polyuria), had an unquenchable thirst (polydipsia), and was constantly hungry (polyphagia). But no matter how much he ate, he was losing weight.

The remarkable aspect of the case, though, isn’t what happened at the time of diagnosis, or even eighteen months later, when the patient was started on insulin therapy, but what happened when he reappeared at the Mayo Clinic in June 1950, twenty-nine years later. “Since 1921,” wrote the two Mayo Clinic physicians who reported on the case at the staff meetings of the clinic, “he had faithfully and strictly followed a diabetic diet which by modern standards seems almost unbelievable.” The situation, they said, was “unique” in their experience. That’s why they were writing it up as a case study.

When the patient had initially been hospitalized, the Mayo staff, led by Wilder, began its procedures for treating the diabetes. They fasted the patient for “several days” until all signs of sugar disappeared from his urine. “Desugarizing the urine,” as these physicians called the procedure, was the primary goal in therapy. Then the patient was served very small amounts of carbohydrate foods daily to establish how much he could metabolize without the sugar reappearing. Once his doctors had established that level, they added protein and fat to his diet. When the combination of protein, fat, and carbohydrates led to the appearance of ketones (technically ketone bodies) in his urine, it was seen by physicians at the time as a sign of imminent danger.

The Mayo doctors assumed that the patient had now reached the limit of how much fat he could eat safely. His protein consumption was kept at the minimum considered necessary for a healthy man of his size and weight. If sugar reappeared in his urine, he would be fasted again. If ketones appeared, “all fat was omitted from the diet,” which meant most of the food he was allowed to eat, and he would restart the process. The Mayo physicians hoped by this approach to make the load on the patient’s “weakened sugar-using function as light as possible in order to rest it and thus favor its restitution.” Restitution, in fact, had rarely, if ever, been reliably documented, but that was their hope.

When the patient was released from the hospital after a month of these dietary manipulations, he was allowed to eat 15 grams of carbohydrates a day (the amount in a single thin slice of bread, although bread was not among the foods his diet allowed), 45 grams of protein (the protein in about half a pound of lean ground beef), and 150 grams of fat. This added up to a total of 1,590 calories a day, a meager ration for a hardworking farmer. He was also instructed to fast one day a week. Complicating matters further, the carbohydrate-containing foods he could eat—green vegetables—had to be boiled three times before serving to remove most of the digestible carbohydrates. He was allowed to eat bran muffins made from specially purchased bran, also boiled three times. “It was calculated,” according to his doctors at the Mayo Clinic, that “there was no food value in the muffin prepared in this manner.” This was life for a diabetic patient before the discovery of insulin.

The rigid diet did not restore the Montana farmer’s health. When he returned to the Mayo Clinic a year and a half later, in December 1922, insulin had become available. He would be among the first patients at the Mayo Clinic to receive it. He would also be the beneficiary of the recent work of two physicians at the University of Michigan, Louis Newburgh and Phil Marsh, who had experimented with a high-calorie, high-fat diet for diabetic patients and reported that they fared remarkably well. They didn&rsq…