I was killing time in the local hospital library recently when I saw a book on display called Diabetes: the Biography, by Robert Tattersall, and started reading it. Tattersall is "Special Professor of Metabolic Medicine at the University of Nottingham, and a leading authority on diabetes," according to the publisher, Oxford University Press.
There's a lot about both type 1 and type 2 in this book, and the author comes across as a person with real compassion who understands that diabetes comes in many forms and that every patient is different. No one size fits all. The book is pricey for its size, but if you can find a copy, it makes for good reading.
The book is written in a conversational style, with lots of annecdotes about people with diabetes through the ages. And it gives information about diabetes treatment in the early days of the 20th century, before insulin was discovered.
I was fascinated to read how patronizing many physicians of those days were. They didn't want to relinquish control to patients; they didn't trust them; and they didn't give them all the facts.
For example, according to Tattersall, complications in people with type 1 diabetes, which had previously not been seen simply because everyone with type 1 diabetes died within a few years, began showing up in the 1940s and 1950s, 20 or more years after the patients had been put on insulin therapy.
But the idea of diabetic complications was not published in the lay press, so the public, and undoubtedly many of the patients, believed that their diabetes had been cured with insulin.
Even diabetes associations kept quiet. The British Diabetes Association, founded in 1935, published a magazine for lay readers called Diabetes Journal. But between 1940 and 1960, not a single article mentioned complications, according to Tattersall. Instead they wrote glowing articles about people with type 1 who were doing wonderful things, trying to emphasize that people with diabetes can have fulfilling lives.
Of course they can, and it's nice to inspire people. But if patients go blind or die from kidney disease in their 30s, their lives will not be as wonderful as the BDA wanted people to think.
Many physicians were also patronizing. After the discovery of insulin, as now, diabetic diets were controversial. Most physicians continued to keep their patients on the low-carbohydrate, high-fat low-calorie diets that had helped patients survive a few years before the discovery of insulin. They reasoned that carbohydrate was bad for people with diabetes, and also because of a concern "that diabetic patients are untrustworthy and that if given an inch, they would take a mile."
Unfortunately, this attitude that if blood sugar isn't perfect it's the patient's fault has persisted until today among some medical professionals.
I'm trying to find out what percentage of type 1 patients were kept on low-carb diets in the 1920s and 1930s. It's very difficult to find that information. While in a hospital library, a woman who said she was a pharmacist helped me to log on to the library computer, which requires a password. She asked what I was looking for, and I told her. I said I had found the level of carbohydrate recommended by professional organizations through the years, but of course there was no proof that the recommendations were being followed.
What I meant was that there was no proof about how many physicians were prescribing the recommended amounts. The pharmacist interpreted my words to mean that noncompliant patients were not following the prescribed diets and went into a rant about how patients "cheat" on their diets.
Tattersall writes that in Britain until the 1970s, in diabetes clinics "Patients' views were not solicited, and the idea that they might have any input in designing their regimen was unthinkable. The doctor in charge expected his instructions to be followed to the letter and blamed the patient when the desired level of glucose control was not obtained."
Of course, not all physicians were like that. Elliott P. Joslin believed in empowering the patient. And two physicians at the Johannesburg Hospital in South Africa wrote in 1921, "An important factor in treatment is the education of the patient in the rationale of the methods employed. His intelligent co-operation is essential at all stages. . . . The intelligent patient is readily taught to examine his own urine and to fast if sugar recurs at any time. He is instructed in the elementary principles of dietetics and the significance of food values. He is shown how his rations are weighed and measured and learns to estimate with sufficient accuracy his food portions, so that he is able after a time to dispense with weighing scales. He is given a limit which he must not exceed with regard to the various food elements."
Another interesting statistic. In 1953, a British survey of 86 physicians showed that 26 aimed for normal blood glucose (BG) levels. (But I suspect they only measured fasting and premeal; this is why it's so difficult to find real information about the early days, before meters.) And 38 aimed for "slight hyperglycemia." In those days, you were considered "cured" if you weren't spilling sugar into the urine, which in most people doesn't start until BGs are over 180 mg/dL. And in order to test your urine, you had to boil it with chemicals in a test tube. It was only in 1944 that a urine test that you didn't have to boil (sodium hydroxide in the tablets provided the heat when added to water) was invented.
Then they asked if the physicians thought high BGs caused complications. And 30 said yes, 6 said definitely not, and the rest were on the fence.
Finally, Tattersall said that Joslin, who did so much for patients with diabetes in the early part of the 20th century, felt that because type 1 diabetes (then called juvenile diabetes) was always fatal, you should let the children eat whatever they wanted, so at least they would die happy.
One treatment for type 1 diabetes in those days was the Allen starvation diet. The poor children did survive on that diet for a few years, and it kept them out of diabetic ketoacidosis. But most eventually died from starvation. Nevertheless, some people argued that it was worth putting the children through what was basically torture because a cure might be found before they died.
I have a friend whose father was on the Allen diet, and he told her he put up with it because he was absolutely convinced that they'd find a cure. In fact, they did. Her father was one of the first people to receive insulin and lived into his 50s, a long time in those days when insulin preparations and BG-measuring devices were crude.
Today we have better equipment and higher standards. But we'd still like to find a real cure to save millions of children (and adults) from the 24/7 hassles of dealing with this disease.
Published On: February 21, 2011