Standard Treatment for Diabetes Before the Discovery of Insulin

Introduction

More than a hundred years ago, Dr. Russell M. Wilder and two Dietitians from the Mayo Clinic wrote a 69-page book titled A Primer for Diabetic Patients – A Brief Outline of the Principles of Diabetic Treatment, Sample Menus and Food Tables [1]. It described how diabetes was managed before the discovery of insulin, using several levels of low-carbohydrate and very low-carbohydrate (ketogenic) diets and short fasting periods. The approach is very similar to current low-carbohydrate and very low-carbohydrate (keto) diets used by those who want to improve or achieve remission of the symptoms of type 2 diabetes using a diet-first approach.

Wilder’s Early Work and the Ketogenic Diet

The name Dr. Russell Wilder is best known for his 1921 paper “The effect of ketonemia on the course of epilepsy” [2]. In it, Wilder proposed a very high-fat, low-carbohydrate diet to mimic the benefits of fasting for people with epilepsy.

Wilder is the one who coined the term “ketogenic diet,” and his classic 4:1 ketogenic diet, where 4g of fat is provided for every 1g of protein plus carbohydrate, is still used today to manage epilepsy and seizure disorder, and as an adjunct in treatment for glioblastoma, an aggressive form of brain cancer.

While Dr. Russell Wilder’s name is tied to the use of a ketogenic diet in the treatment of epilepsy, his prior work used low-carbohydrate and very low-carbohydrate (ketogenic) diets in the treatment of diabetes. But how could he be so well known for using a ketogenic diet in epilepsy, yet be almost unknown for his earlier use of low-carbohydrate and ketogenic diets for diabetes?

The answer lies in timing.

Just a year after Wilder began using low-carbohydrate and very low-carbohydrate (ketogenic) diets in the treatment of diabetes, Dr. Frederick Banting and Charles Best discovered insulin [3], and the Eli Lily company soon began manufacturing it.

The discovery of insulin quickly pushed Wilder’s low-carbohydrate dietary treatment for diabetes into the pages of history.

Insulin was life-saving for people with type 1 diabetes, whose pancreas made little or no insulin of its own. Its use by those with type 1 diabetes was necessary.

It is harder to understand why Wilder’s dietary approach did not continue for those with type 2 diabetes, where the body still makes insulin but cannot use it properly. It is possible that since type 1 and type 2 diabetes were not clearly differentiated until 1936, when Harold Himsworth made the distinction, the use of insulin had already become the standard therapy for treating (all types) of “diabetes”.

Determining Carbohydrate Tolerance

Wilder’s approach to treating those with diabetes was to view it as “carbohydrate intolerance” (which is what it is).

Wilder defined carbohydrate tolerance as “the amount of sugar-forming foods which a person can eat in twenty-four hours without causing sugar in the urine.”

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Below is a description of how Wilder determined a person’s carbohydrate tolerance.

“The tolerance of a given patient is ascertained by feeding foods of known composition in weighed and gradually increasing amounts.”

“The actual procedure will vary with different patients, but, in general, foods of known composition in weighted amounts are fed, the total intake of carbohydrate, protein, and fat being increased very gradually as high as possible without the return of sugar in the urine.”

“Some patients will be found to have low tolerance, others may stand 100 gm. of carbohydrate. Every patient should be treated as an individual case, but for convenience in prescribing diets, the following arbitrary grouping is made:

• Group A: had carbohydrate tolerance below 40 g of carbohydrate

• Group B: had carbohydrate tolerance between 40–60 g of carbohydrate

• Group C: had carbohydrate tolerance between 60–100 g of carbohydrate

• Group D: had carbohydrate tolerance above 100 g of carbohydrate.”

   

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Different Daily Macros

Different amounts of carbohydrate, protein, and fat (i.e., “macros”) were prescribed to each group, based on their carbohydrate tolerance.

• Group A (carbohydrate tolerance <40 g carb): were instructed to eat 20 grams of carbohydrate, 70 grams of protein, and 100 grams of fat at each of 3 meals. [1]

• Group B (carbohydrate tolerance between 40–60 g): were instructed to eat 40 g carbohydrate, 70 g protein, 100 g fat at each of 3 meals. [1]

• Group C (carbohydrate tolerance between 60–100 g): were instructed to eat 60 g carbohydrate, 70 g protein, 100 g fat at each of 3 meals. [1]

• Group D (carbohydrate tolerance > 100 g): were instructed to eat 100 g carbohydrate, 70 g protein, 140 g fat at each of 3 meals. [1]

These diets provided adequate protein for satiety and exceeded today’s DRI levels for most adults. 

Fat came mainly from butter, cream, cheese, eggs, and animal protein.

Carbohydrates were mainly from low-carb baked items made with “Hepco flour” or “Cellu-flour,” (low-carbohydrate flours high in cellulose, a fiber that is not digestible), low-carb vegetables, and small amounts of fruit or root vegetables.

Use of Fasting and Protein-Sparing Fasts

Wilder also utilized short fasts of 12–24 hours to improve blood sugar control.

Those in Group A who had a tolerance < 40 g of carbohydrate were advised to take a weekly “fast day” with liquids such as broth, coffee, or tea.

Those in Group B  who had a tolerance of 40-60 g of carbohydrate followed a “half-fast day” once per week, eating approximately 20 g carbohydrate, 12 g protein, and 12 g fat.

There was no fasting protocol for those in Group C whose carbohydrate tolerance was between 60 and 100 grams.

If sugar persisted in the urine, Wilder prescribed what we would now call a protein-sparing modified fast:

“If sugar persists, the patient should return to one-half of his diet, continue on this for a week, and then again try the effect of a fast day. After the urine is again sugar-free, he can return gradually to his previous diet.””

Wilder cautioned that longer fasts should never be attempted outside of an institution, possibly because at this time, no distinction had been made between type 1 and type 2 diabetes.

As mentioned above, only a year after Wilder began using low-carbohydrate and very low-carbohydrate diets in the treatment of diabetes, Banting and Best discovered insulin [3], and the Eli Lilly company started manufacturing it and began distributing it without cost (free) to those with diabetes (both type 1 and type 2).  Wilder’s low-carbohydrate dietary treatment for those with type 2 diabetes was no longer seen as needed, because people could eat wherever they wanted and “cover it with insulin”. 

From Insulin to Oral Medications

Oral diabetes medications only became available in the mid-1950s.

Tolbutamide, the first sulfonylurea, was introduced around 1956, and Metformin was first reported for use in people with diabetes in 1957 [6][7]. Before the 1950s, insulin was the main treatment for all types of diabetes.

A 1958 paper by Wilder [5] helps explain how the discovery of insulin and its subsequent free distribution by the Eli Lilly company led to the decline of low-carbohydrate and very low-carbohydrate (ketogenic) diets for diabetes.

Wilder noted:

“Insulin at that time cost five cents a unit in the market. However, the patients in our early cases received theirs gratis for a period of several years, thanks to the Eli Lilly Company.” (p. 247–248 [5])

In Wilder’s book, Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919–50., Wilder described how A Primer for Diabetic Patients evolved between 1921 and 1950.

The first edition followed Dr. Frederick Allen’s approach from the Rockefeller Institute, which used fasting and strict carbohydrate restriction.

The second edition (1923) added insulin and permitted a higher amount of fat.

Over the years, as insulin became less expensive and widely available, diets that focused on reducing carbohydrate intake were abandoned, and diets became increasingly liberalized. By 1950, recommended diets for those with diabetes looked like those of people without diabetes [5].

In the 1958 edition, Wilder describes how diabetes treatment evolved from a diet-first approach before the discovery of insulin, to a diet that was indistinguishable from the carbohydrate and protein-rich diet of those without diabetes due to the use of insulin [5].

What Was Lost

Perhaps the reason that diabetes has been considered a “chronic and progressive disease” is that dietary treatment had been all but forgotten after the discovery of insulin.

In 1921, Wilder wrote that:

“Diabetes is a disease which is manifested by excretion of sugar in the urine. This sugar comes from the foods which the patient eats, but which his body, owing to the disease, is unable to utilize.”

Wilder’s dietary recommendations were simple:

“Suit the diet to the condition of the patient and feed no more sugar-forming foods than the patient’s body is able to use. [1]”

Before the discovery of insulin, diet was the only treatment, and its discovery was lifesaving for those with type 1 diabetes. Unfortunately, it also resulted in those with type 2 diabetes forgetting that they could manage their blood sugar with diet.

Today, people with type 2 diabetes can still follow a carbohydrate-reduced diet while their doctors gradually decrease their diabetes medication. In many cases, diabetes medications are eventually discontinued entirely. Given these diets have been established as both safe and effective, why isn’t a carbohydrate-reduced diet regularly recommended as a viable diet-first approach to treating type 2 diabetes? 

Revisiting Dietary Treatment

The safety and effectiveness of a ketogenic diet for epilepsy are well-established [2].

So too is the safety and efficacy of a low-carbohydrate and very low-carbohydrate (keto) diet for the treatment of diabetes.

• In 2019 [8], the American Diabetes Association released its Standards of Care, which included the use of a low-carbohydrate diet.
• This was followed in 2020 [9] by Diabetes Canada releasing its Position Statement, acknowledging that a low-carb and very low-carb (keto) diet is both safe and effective for adults with diabetes.
• In 2021, Diabetes Australia released its Position Statement, Low-Carb Eating for People with Diabetes [10].

While these diets are very safe and effective in normalizing blood sugar, individuals who are taking insulin or insulin analogues must first have their doctor de-prescribe them before adopting a low-carbohydrate diet, as blood sugar normalizes quickly and can become much too low if still taking insulin. 

While Physicians are very familiar with prescribing medications such as sulfonylureas, SGL2 inhibitors, and GLP-1 agonists, and others to lower blood sugar, not many are experienced with reducing these medications when one of their patients wants to adopt a low-carbohydrate diet. 

A paper published in July 2019 in the British Journal of General Practice about adapting diabetes medication for low-carbohydrate management of type 2 diabetes explains to Physicians how to safely do this [11].

When someone comes to me wanting to adopt a lower-carbohydrate diet to manage their blood sugar, lose weight, and improve their metabolic health, or to put the symptoms of type 2 diabetes into remission, I will offer to liaise between them and their doctors in providing them with a copy of these guidelines, should they want.

The use of low-carbohydrate and very low-carbohydrate (keto) diets in the treatment of diabetes has been in existence for 100 years. They are not a fad.

Final Thoughts

For those who want to take a diet-first approach to lowering their blood sugar or putting the symptoms of type 2 diabetes into remission, a low-carbohydrate diet and, when needed, a very low-carbohydrate (ketogenic) diet can do that.

Type 2 diabetes remains a disease of carbohydrate intolerance.

Some people can eat 100g of carbohydrate per day while keeping their blood sugar in range, while others need to keep their carbohydrate intake to less than 40 g of carbohydrate daily. Every person’s carbohydrate tolerance is different, which is why their low-carbohydrate diet needs to be developed for them.  This is what I do.  

I have almost a decade of experience helping people follow a low-carbohydrate or very low-carbohydrate (ketogenic) diet, and have been following one myself since 2017.

More Info

If you would like me to design a low-carbohydrate diet for you to help you accomplish your goals, please look at the Routine Health packages under the Services tab to find the one that best suits your needs.  

To your good health,

Joy

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Note: Special thanks to Jan Vyjidak of London, England, Founder and CEO at Neslazeno.cz, for locating Wilder’s historic book, A Primer for Diabetic Patients [1].

References

1. Wilder RM, Foley MA, Ellithorpe D. A Primer for Diabetic Patients. Mayo Clinic, W.B. Saunders Co, 1922. [https://www.amazon.ca/Diabetic-Patients-Outline-Principles-Treatment/dp/B017A5829S [https://www.amazon.ca/Diabetic-Patients-Outline-Principles-Treatment/dp/B017A5829S]

2. Wheless JW. History of the ketogenic diet. Epilepsia. 2008;49 Suppl 8:3–5. doi:10.1111/j.1528-1167.2008.01821.x [https://pubmed.ncbi.nlm.nih.gov/19049574/]

3. The History of Insulin. diabetes.co.uk. https://www.diabetes.co.uk/insulin/history-of-insulin.html

4. Krochmal M. 10 Facts About the History of Diabetes. https://type2diabetes.com/living/10-facts-history-diabetes/

5. Wilder RM. “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919–50.” Perspectives in Biology and Medicine. 1958;1(3):237-277. [https://archive.org/details/sim_perspectives-in-biology-and-medicine_1957-1958_1_contents]

6. Scheen AJ. History of sulfonylureas. Diabetes Metab. 2004;30(5):487–492.

7. Bailey CJ, Day C. Metformin: its history and future. Diabetologia. 2019;62(3):482–487. https://doi.org/10.1007/s00125-018-4808-3

8. American Diabetes Association, Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020
   American, Diabetes Care Jan 2020, 43 (Supplement 1) S48-S65; DOI: 10.2337/dc20-S005 [https://pubmed.ncbi.nlm.nih.gov/31862748/]

9. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate Diets for Adults with Diabetes: A Rapid Review, Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.

10. Diabetes Australia. Position Statement: Low-Carb Eating for People with Diabetes. 2021. https://www.diabetesaustralia.com.au/wp-content/uploads/Diabetes-Australia-Position-Statement-Low-Carb-Eating.pdf
11. Campbell M., Unwin D., Cavan D.,  Cucuzzella M. et al, Adapting diabetes medication for low-carbohydrate management of type 2 diabetes: a practical guide, British Journal of General Practice 2019; 69 (684): 360-361. DOI: 10.3399/bjgp19X704525 [https://pubmed.ncbi.nlm.nih.gov/31249097/]

 

 

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