Dietetics for Nurses :: CHAPTER XX DIABETES MELLITUS

CHAPTER XX DIABETES MELLITUS

Definition.—Diabetes is a disease which is characterized by an inability on the part of the body to utilize the carbohydrates, in consequence of which there is abnormal excretion of glucose in the urine.

Sugar in the Urine.—The appearance of sugar in the urine may not necessarily signify diabetes, it may be merely a temporary glycosuria due to certain pathological conditions, such as infectious diseases, diseases or trauma which affect the pancreas, and which disappear upon the recovery from the disease. But any appearance of sugar in the urine should be looked upon with suspicion, since the future welfare of the patient depends largely upon an early diagnosis in any form of diabetes.

True Diabetes.—Allen claims that true diabetes may always be distinguished from nervous glycosuria by the application of the laws governing these conditions (Allen’s Paradoxical Law[137]), which is “whereas in normal individuals the more sugar given the more is utilized, the reverse is true in diabetes.”

Manufacture of Sugar from Other Foods.—If the carbohydrate foods alone caused all the trouble in diabetes, the disease might be more easily controlled. This, we found, however, not to be true, since in certain conditions the body utilizes the protein foods for the manufacture of glucose also. Consequently in diabetes if the absolute sugar output of the body is to be controlled, the intake of nitrogenous foods must be likewise adjusted. Functions of Carbohydrates.—In the chapter describing the functions of the carbohydrates in the human body it was demonstrated that their energy-producing properties did not cover the extent of their usefulness. It has been proved that this food constituent normally acts as neutralizing agent for the toxic acids produced within the organism as a result of the breaking down of the fats. Hence, when this function of the carbohydrates becomes impaired, these acids, Oxybutyric acid, Diacetic acid and Acetone, fail to be neutralized and are consequently absorbed into the blood stream, giving rise to a form of intoxication known as acidosis. When acidosis becomes extreme, the diabetic patient is apt at any time to succumb to the dreaded diabetic coma.

Keeping Urine Sugar Free.—Thus it is seen that the treatment of diabetes mellitus consists not alone of freeing the urine from sugar and keeping it free, but of controlling the acidosis which may at any time develop.

Diabetic Cures.—Numberless so-called diabetic cures have been brought forward and more or less tested for years, but whether they have really accomplished cures has not been satisfactorily proved. Not until Dr. Allen instituted what is known as the Allen’s Starvation Treatment has the disease been so universally treated, at least by one method or modification of one method. Dr. Joslin, who has used this treatment most successfully, does not claim to have accomplished a cure, but states that he is watching the results of the treatment in his patients with interest.

Starvation Treatment.—The Allen Starvation Treatment consists of first a period of about forty-eight hours in which the patient is given an ordinary diet, during which time the daily weight is taken and the urine examined and recorded.

Acidosis.—It has been found in some cases, such as with elderly patients or those in whom there is an evident acidosis, advisable to precede the period of starvation by a preliminary treatment.

Method of Treatment.—Joslin[138] suggests the following method of procedure:

“Without otherwise changing the diet omit fat. After two days, omit protein, then halve the carbohydrates daily until the patient is taking only ten grams, then fast.”

In the Michael Reese Hospital, the following series of test diets are given to determine the severity of the diabetes:

Diabetic Test Diets[139]

Diet in Mild Cases.—This diet contains approximately 70 grams of protein, 100 grams of fat, and 70 grams of carbohydrates, and the patient is kept on it for at least two days; then the carbohydrates are cut down by taking away 25 grams of bread every day.

Diabetic Diets[140]

Key:
A	Carbohydrate
B	Protein
C	Fat
D	Calories
E	5% Vegetable
F	Orange
G	Oatmeal
H	Shredded Wheat
I	Uneeda
J	Potato
K	Bread
L	Egg
M	Cream 20% fat
N	Bacon
O	Butter
P	Meat
Q	Fish
R	Skimmed Milk

Diets with which to become Sugar free	Diet in Grams				Test Diets														Name of Diet
Diets with which to become Sugar free	A	B	C	D	E	F	G	H	I	J	K	L	M	N	O	P	Q	R	Name of Diet
T.D.1	189	89	15	1247	300	300	...	1	...	240	90	...	...	...	...	90	120	480	1
T.D.2	102	58	0	640	300	300	...	1	...	120	...	...	...	...	...	...	180	300	2
T.D.3	64	33	0	388	300	300	...	...	...	60	...	...	...	...	...	...	90	240	3
T.D.4	36	27	0	252	300	200	...	...	...	...	...	...	...	...	...	...	90	120	4
T.D.5	15	5	0	80	300	50	...	...	...	...	...	...	...	...	...	...	...	...	5
Maintenance Diets					Carbohydrate (C)							Protein and Fat (PF)
C1+PF1	10	11	6	138	300	...	...	...	...	...	...	1	...	...	...	...	...	...	1
C2+PF2	22	13	18	302	300	100	...	...	...	...	...	1	60	...	...	...	...	...	2
C3+PF3	32	24	24	440	600	100	...	...	...	...	...	2	60	...	...	...	...	...	3
C4+PF4	42	29	39	635	600	200	...	...	...	...	...	2	60	30	...	...	...	...	4
C5+PF5	52	32	53	813	600	200	15	...	...	...	...	2	60	30	15	...	...	...	5
C6+PF6	63	43	65	1009	600	200	30	...	...	...	...	2	90	30	15	30	...	...	6
C7+PF7	73	51	70	1126	600	300	30	...	...	...	...	2	90	30	15	60	...	...	7
C8+PF8	83	59	87	1351	600	300	30	...	2	...	...	2	90	30	30	90	...	...	8
C9+PF9	96	62	93	1469	600	300	30	½	2	...	...	2	120	30	30	90	...	...	9
C10+PF10	107	63	93	1517	600	300	30	1	2	...	...	2	120	30	30	90	...	...	10
C11+PF11	131	75	98	1706	600	300	30	1	2	120	...	2	120	30	30	120	...	...	11
C12+PF12	155	79	98	1818	600	300	30	1	2	240	...	2	120	30	30	120	...	...	12

Food	Weight in grams	Approximate equivalent
Orange	300	One and one-half (large size)
5 per cent vegetables	300	Three moderate portions
Skimmed milk	480	One pint (16 ounces)
Fish	120	Two small portions
Potato	240	Two medium sized potatoes
Meat	90	One moderate portion
Bread	90	Three small slices
Oatmeal (dry wgt.)	30	One large saucerful
Cream	60	Four tablespoonfuls
Bacon	30	Four crisp strips
Butter	30	Three medium portions

The Test Diets are designed for the period during which the patient becomes gradually sugar free. On successive days advances can be made from Test Diet 1 to Test Diet 5, and if on the fifth day the patient is not sugar free, fasting can be employed for one or more days.

The Maintenance Diets are for use so soon as the urine of the patient is free from sugar. If this occurs as a result of Test Diet 5 the patient begins with Maintenance Diet C1PF1. The actual articles of food representing the carbohydrate in the diet for the first day are given under the heading of carbohydrate, for convenience described C1, 2, 3, etc. The articles referred to under protein and fat are under that heading, which for the same reason is described as PF1, 2, 3, etc. Certain cases of diabetes can proceed steadily day by day from C1PF1 to C12PF12, without showing sugar. If sugar does appear in the urine, drop back two days in the carbohydrate group, wait till sugar free, then advance in the protein and fat group until sufficient calories are obtained. Thus, if sugar shows on C7PF7 the diet prescribed would be that included in C5PF7 and thereafter progression could be made in the PF group until twenty-five to thirty calories per kilogram body weight were furnished the patient.

Occasionally the patient becomes sugar free on Test Diet 2, 3, or 4. It is then unnecessary to begin with Maintenance Diet C1PF1, but instead with a maintenance diet which contains a value for carbohydrate similar to that of the test diet upon which the patient became sugar free.

If the protein and fat are too high for the individual on a given day it is easy to advance the carbohydrate and decrease to an earlier day on protein and fat.

The plan is arbitrary and the majority of cases will demand some modification. It is arranged to enable patient or nurse to see in advance the general plan of treatment.

(Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.)

If the case is a mild one, this may be sufficient to free the urine from sugar, but the diet is given primarily to enable the physician to find out by means of urinalysis just how great is the functional impairment.

In some cases, which are mild in character, the urine is made free of both sugar and acetone without further dietetic measures. However, when a severe diabetes is manifested and a high percentage of glucose and in some cases acetone bodies are found in the urine a more rigid treatment will be found necessary.

Preliminary Diet.—Many physicians find it advisable, as has already been stated, to cut down the food allowance before stopping it entirely. In the Michael Reese Hospital this is done by first giving a practically fat-free diet, followed by one or two days in which three or four eggs, 250 to 300 grams (8 or 10 ounces) of 5% vegetables are given, after which it is found safe to institute the starvation treatment.

Sample Menus.—The following menus are given to illustrate the dietetic treatment which it is deemed advisable to institute in cases where the starvation treatment cannot be given at once:

After the test diet of forty-eight hours, the following rÉgime is instituted:

Third Day

Key:
A	Protein Gm.
B	Fat Gm.
C	Carbohydrate Gm.
D	Calories

		A	B	C	D
Breakfast:
½ grapefruit				5.00	20
1 egg		5.3	4.10		59
1 slice bread	30 gm.	2.6	.30	15.00	73
Tea or coffee
Total for meal		7.9	4.40	20.00	152
Dinner:
Broth	180 c.c.	3.7	.17	.34	18
Chicken (breast)	90 gm.	18.2	2.10		92
Spinach	100 gm.	2.0		3.00	20
Potato (1 medium)	90 gm.	1.8	.09	15.60	70
Lemon jelly	90 gm.	4.2		2.70	27
Total for meal		29.9	2.30	21.60	227
Supper:
Lamb chop	50 gm.	9.3	14.10		126
Asparagus	100 gm.	1.5		3.00	18
Bread	20 gm.	1.6	.20	10.00	48
Tea or coffee
Total for meal		12.4	14.30	13.00	192
Total for day		40.2	21.00	54.60	571

Fourth Day

Key:
A	Protein Gm.
B	Fat Gm.
C	Carbohydrate Gm.
D	Calories

		A	B	C	D
Breakfast:
½ grapefruit				5.0	20
1 egg		5.3	4.10		59
1 slice bread	20 gm.	1.6	.20	10.0	48
Coffee or tea
Total for meal		6.9	4.30	15.0	107
Dinner:
Tomato bouillon	180 gm.	2.2	.23	2.5	15
Whitefish	90 gm.	2.0		5.0	28
Boiled onions	100 gm.	1.5	.30	7.5	40
Bran muffin (1)		5.0	7.00	4.5	101
Tea or coffee
Total for meal		25.7	16.20	20.5	322
Supper:
1 egg		5.2	4.10		59
Tomato (baked)	100 gm.	.6		2.0	10
Bran muffin (1)		1.0	5.00	7.0	101
Tea or coffee
Total for meal		6.8	9.10	9.0	170
Total for day		38.4	29.60	44.0	513

Fifth Day

Key:
A	Protein Gm.
B	Fat Gm.
C	Carbohydrate Gm.
D	Calories

		A	B	C	D
Breakfast:
½ grapefruit				5.0	20
Broiled tomato	100 gm.	1.50		3.0	18
Tea or coffee
Total for meal		1.50		8.0	38
Dinner:
Broth	120 c.c.	3.00			12
Lettuce	50 gm.	.50		1.5	8
Cauliflower	90 gm.	1.50	.40	3.9	25
Tea or coffee
Total for meal		5.00	.40	5.4	45
Supper:
1 egg		5.35	4.16		59
String beans	100 gm.	2.00		5.0	28
Celery	50 gm.	.50		1.5	8
Tea or coffee
Total for meal		7.85	4.16	6.5	85
Total for day		14.30	12.50	19.9	168

Sixth Day

Key:
A	Protein Gm.
B	Fat Gm.
C	Carbohydrate Gm.
D	Calories

		A	B	C	D
Breakfast:
Asparagus tips	60 gm.	1.50		3.0	18
Spinach	60 gm.	1.10	1.80	1.8	32
Tea or coffee
Total for meal		2.68	1.80	5.8	50
Dinner:
Stewed celery	100 gm.	1.00	.10	2.1	15
String beans	50 gm.	1.50		2.5	16
Tea or coffee
Total for meal		2.50	.10	5.6	31
Supper:
Beet tops	75 gm.	1.50		2.5	16
Onions (boiled)	75 gm.	1.50	.30	7.5	44
Tea or coffee
Total for meal		3.00	.30	10.0	60
Total for day		11.20	2.20	21.4	141

FAST

Method of Administering Treatment.—In many cases the patient is first put to bed during the starvation treatment, but recently Dr. Allen has emphasized the value of exercise, claiming that it assists in utilizing the sugar. In any case, the starvation rÉgime remains the same. The patient is given only coffee or clear broth with or without whisky (one ounce every two hours) and the treatment continued from one to four days, or until the urine becomes sugar free.[141]

It has rarely been found necessary to continue the fast longer than four days, since in most cases the sugar decreases rapidly upon the discontinuance of food.

Loss of Weight.—The slight loss of weight, which may be noticeable as the result of starvation, is not undesirable, especially in those cases where obesity is a prominent feature. In fact care must be exercised in the follow-up treatment to prevent the taking on of weight by the diabetic individual, since, according to Allen, it is often found that even moderately obese patients (180 lb.) continue to excrete a small amount of sugar so long as they hold this weight, even upon a low carbohydrate diet, whereas those same patients show no difficulty in becoming sugar free if the weight is reduced by ten or fifteen pounds.

SCHEDULE FOR TREATMENT AND METHODS OF DETERMINING FOOD TOLERANCES

A number of schedules have been devised to enable the nurse successfully to carry out the Allen Treatment. In following out this treatment and reËducating the organs afterward to tolerate foods which they have been unable to handle on account of the impairment of the sugar-making organs, it is necessary to make a series of tests whereby the diet is gradually increased in its various constituents until the diabetic patient is able to handle a reasonable amount of carbohydrates as well as other foods which have given more or less trouble in the past.

The following schedule, after Joslin,[142] is included, and a careful study of it is advised in order that the nurse may intelligently carry out the Allen Treatment.

Schedule.—Fasting in many cases begins at once and the patient experiences no ill effects from it. However, in severe, long-standing cases many patients do better if the fats are omitted at once and the rest of the diet left unchanged for two days. Then the proteins in the diet are omitted and the carbohydrates cut in half. This halving of the carbohydrates is continued daily until only 10 grams remain, after which they too are omitted. The fast is thus made complete and remains so until the urine is entirely free from sugar.

Carbohydrate Tolerance is determined by giving, as soon as the urine has been sugar-free for twenty-four hours, 150 grams of 5% vegetables. This is equivalent to from 8 to 10 grams of carbohydrates. After this 5 grams of carbohydrates, or 75 grams of 5% vegetables, are added daily to the diet until the patient is taking 20 grams. Then the addition of 5 grams of carbohydrates is made every other day, using the fruits and vegetables belonging to the 10% and 15% carbohydrate group, until potatoes and oatmeal and finally bread can be tolerated unless sugar appears in the urine before this or the tolerance reaches 3 grams to each kilogram of body weight or, in other words, until a man weighing 150 pounds is consuming 225 grams of carbohydrates per day. Protein Tolerance.—In making the test for the protein tolerance it is necessary to wait until the urine has been sugar free for forty-eight hours; 20 grams of protein is then given. This is equivalent to 3 eggs, and daily additions of 5 grams protein are made, usually in the form of meat, until the patient is receiving 1 gram of protein to every kilogram of his body weight per day unless his carbohydrate tolerance is zero, in which case it is wise to add only three-fourths of a gram of protein per day.

Fat Tolerance.—A determination of the fat tolerance is made coincidently with that of the protein. No additional fat is allowed until the protein tolerance reaches 1 gram per kilogram of body weight, unless the patient’s tolerance for protein is less than that. After which 25 grams of fat per day are added until there is no further loss of weight, taking care never to allow more than 40 calories per kilogram of body weight.

Reappearance of Sugar.—Should the urine again show the presence of sugar, another period of fasting lasting for twenty-four hours, or until the urine is again sugar free, must be instituted. After the second fast the increase in the diet may be twice as rapid as used after the first fast. However, it is not advisable to increase the amount of carbohydrates to more than half of that determined by the former tolerance for a period of two weeks, during which time the urine has been entirely sugar free, then the increase is made more slowly and the amount given should not exceed 5 grams a week.

Weekly Fast Days.—One day in seven should be set aside by the diabetic patient for fasting, when the carbohydrate tolerance is less than 20 grams. When, however, the tolerance is between 20 and 50 grams of carbohydrates, the patient may take one-half of his daily allowance of protein and fat and a certain amount of 5% vegetables as well upon the weekly fast day. When the tolerance reaches between 50 and 100 grams per day, vegetables of a higher carbohydrate content may also be included. If the carbohydrate tolerance should exceed 100 grams per day, the carbohydrates upon the fast day may be simply half of the amount allowed upon other days.

The Giving of Alkalies.—If acidosis is evident, as may be indicated by an excretion of diacetic acid, oxybutyric acid, or acetone in the urine, alkalies may be given. Bicarbonate of soda may be given in doses of 2 grams every 3 hours, as suggested by Hill and Eckman,[143] but this is not as a rule necessary, for, as Jacobi aptly remarks: “Prevention is the treatment of acidosis in children, and those susceptible to acidosis should not have fat.” What he has said for children holds good for adults. However, it is likewise true that fat must constitute a large part of a diabetic diet and the only way to prevent it poisoning, is to raise the fat in the diet gradually until the tolerance is determined.

Determining the Extent of Acidosis.—It will be remembered that in an earlier chapter it was found that the excretion of ammonia in the urine to a certain extent indicated the extent of the acidosis in the body, that is, if the ammonia output exceeds three or four grams a day (twenty-four hours), the extent of the acidosis is considerable, while if it falls below that amount it is not alarming. More exact methods, however, for the determining of the severity of the acidosis will be found in another part of this text, where the test for sugar and the acetone bodies will be explained in detail.

Dietetic Treatment.—The patient is placed upon a vegetable diet consisting of vegetables containing not more than five per cent. carbohydrate.[144] These vegetables have their carbohydrate content still further reduced by changing the water in which they are cooked three times. In many cases this will reduce their content as much as one-half.

A small amount of fat usually in the form of butter is allowed with these vegetables. The amount of 5% vegetables given must be carefully adjusted since the patient might readily take too much if allowed to follow the dictates of his appetite.

The carbohydrate intake during the first one or two days must be limited to 15 grams. This allows about 10 grams of protein, 7 grams of fat, and 15 grams of carbohydrates. Tea or coffee, without sugar or cream, may be given at each of the three meals.

The following table is included, showing the various foods arranged according to their carbohydrate content:

TABLE[145]
Strict Diet

Meats, fish, broths, gelatin, eggs, butter, olive oil, coffee, tea, and cracked cocoa.

Foods arranged approximately according to per cent of carbohydrates

	5%	10%	15%	20%
Vegetables, Fresh or Canned	Lettuce	Pumpkin	Greens	Potatoes
	Cucumbers	Turnip	Peas	Shell beans
	Spinach	Kohl-rabi	Artichokes	Baked beans
	Asparagus	Squash	Parsnips	Green corn
	Rhubarb	Beets	Lima beans (canned)	Boiled rice
	Endive	Carrots		Boiled macaroni
	Marrow	Onions		Prunes
	Sorrel	Mushrooms
	Sauerkraut
	Beet greens
	Dandelion
	Swiss chard
	Celery
	Brussels sprouts
	Water cress
	Sea kale
	Okra
	Cauliflower
	Eggplant
	Cabbage
	Radishes
	Leeks
	String beans
	Broccoli
	Tomatoes
Fruits	Ripe olives (20% fat)	Lemons	Apples	Plums
	Grapefruit	Oranges	Pears	Bananas
		Cranberries	Apricots
		Blackberries	Blueberries
		Gooseberries	Cherries
		Peaches	Currants
		Pineapple	Raspberries
		Watermelon	Huckleberries
Nuts	Butternuts	Brazil nuts	Almonds	Peanuts 40%
	Pignolias	Black walnuts	English walnuts	Chestnuts
		Hickory	Beechnuts
		Pecans	Pistachios
		Filberts	Pine nuts
Misc.	Unsweetened and unspiced pickle, clams, oysters, scallops, liver, fish roe.		Reckon available carbohydrates in vegetables of 5% group as 3%, of 10% group as 6%.

30 grams (1 oz.) contains approximately:

TABLE[146]

Carbohydrate equivalent of 1 slice of white bread (1 oz. or 30 gm.) containing approximately 15 gm. of starch

Uncooked Flours, etc.	Household Measure[147]	Gm.	Cooked Vegetables	Household Measure	Gm.
Barley	1 h. tbs.	21	Artichokes	1 medium	320
Buckwheat	1 h. tbs.	19	Beans (baked canned)	2 h. tbs.	75
Corn meal	1 h. tbs.	20	Beans, lima	1¼ tbs.	50
Farina	1 h. tbs.	20	Beets	6 tbs.	200
Hominy	1 h. tbs.	18	Carrots	13 tbs.	446
Macaroni	1 h. tbs.	20	Okra	4 tbs.	200
Noodles	1½ h. tbs.	20	Onions	3 tbs.	300
Oatmeal	1 h. tbs.	22	Parsnips	4 slices	120
Rice	1 h. tbs.	18	Peas, green	3 h. tbs.	100
Rye flour	1 h. tbs.	18	Potatoes (baked)	½ medium	60
Spaghetti	1½ tbs.	20	Potatoes (boiled)	½ medium	70
Vermicelli	1½ tbs.	21	Potatoes (mashed)	1½ h. tbs.	80
Wheat flour	1 tbs.	20	Potatoes, sweet (boiled)	? medium	35
			Squash	2 h. tbs.	100
Bread and Crackers			Turnips	3	210
Bread	1 slice	30	Cooked Cereal
Breakfast biscuit,			Force	5 h. tbs.	18
Huntley and Palmer	3	18	Farina	2½ h. tbs.	125
Corn bread	1 slice	32	Grape-Nuts	1½ h. tbs.	20
Roll, Vienna	3	18	Hominy	1½ h. tbs.	90
Zwieback	1?	20	Macaroni	2 h. tbs.	100
			Oatmeal	2½ h. tbs.	130
			Rice	½ h. tbs.	60
Fruits			Shredded wheat biscuit	¾	22
Apple	1 medium	120	Dried Fruit
Apricots	2 large	120	Apples	3 small	22
Banana (without skin)	½ medium	75	Apricots	3 large	24
Cherries		90	Currants	1½ h. tbs.	20
Currants	5 h. tbs.	120	Dates	3	19
Grapefruit	½ small	150	Figs	1 large	12
Huckleberries	3½ tbs.	90	Prunes	2 large	24
Lemons	2 medium	210	Raisins	10 large	23
Muskmelon	?	300	Milk and Cream		C.C.
Nectarine	1	100	Buttermilk	1½ tumbler	300
Olives (green)	20	180	Cream, 16%	1½ tumbler	300
Orange	½ large	150	Cream, 40%	1½ tumbler	300
Peaches	1½ medium	150	Koumiss	1½ tumbler	300
Pear	1 small	100	Whole milk	1½ tumbler	300
Pineapple	3 slices	150
Plums	3 medium	75	Nuts		Grams
Raspberries	4½ h. tbs.	120	Almonds	60	90
Strawberries	8 h. tbs.	200	Brazil	30	180
Watermelon	large slice	300	Chestnuts (roasted)	15	40
			Cocoanut	1 slice (3 × 2 in.)	50
			Filberts	100	110
			Peanuts	40	80
			Pecans	35	110
			Pistachios	190	95
			Walnuts	30	125

TABLE[148]

Caloric equivalent of 10 gm. steak in carbohydrate-free meat or fish

Key:
A	Gm.
B	Fat Gm.
C	Protein Gm.
D	Calories

Food	A	B	C	D
Steak	10	1.0	2.4	19
Roast beef	5	1.4	1.1	18
Tongue	7	1.4	1.6	20
Lamb chop	5	1.5	1.1	18
Roast lamb	8	1.3	1.6	20
Sweetbreads	11	0.1	4.4	19
Boiled ham	7	1.4	1.5	19
Fried ham	5	1.7	1.1	20
Roast pork	9	0.9	2.6	19
Bacon	9	1.7	0.9	20
Chicken	10	1.0	2.4	19
Duck	9	1.3	1.8	19
Guinea hen	12	0.8	2.8	19
Squab	9	1.1	2.1	19
Turkey	7	1.3	2.0	20
Bluefish	13	0.6	3.5	20
Halibut	16	0.7	3.3	20
Mackerel	15	1.0	2.5	20
Sardines in oil	7	1.4	1.6	20

Approximate equivalent in 30 c.c. (1 oz.) of whisky in liquors containing 2 per cent or less of carbohydrates

	C.C.	Household Measure
Gin, rum, brandy	30	2 tbs.
Claret, Burgundy Hock, Rhine and Moselle wines	130-160	¾ tumbler

CARBOHYDRATE-FREE MENUS

The following menus are suggested as meeting the carbohydrate-free diet requirements with a nutrient value of from 200 to 500 calories:

Breakfast—	Black coffee (cream, 20 c.c.)	30 grams
	Bacon, 2 slices (1 oz.)
	Egg—1
Dinner—	Broth, 6 ounces	180 grams
	Steak, 1 small piece, 1? oz.	40 grams
	Stewed tomatoes, 3? oz.	100 grams
	Lettuce (lemon juice and olive oil)	25 grams
Supper—	Broth	180 grams
	Whitefish	40 grams
	Spinach	100 grams
	Cabbage salad	100 grams
	Coffee
Breakfast—	½ grapefruit
	1 egg
	Bacon	40 grams
	Coffee	50 grams
	Cream	20 c.c.
Dinner—	Broth	180 c.c.
	Kohl-rabi	100 grams
	Lettuce	25 grams
	Cheese salad	50 grams
	Roast beef	40 grams
	Coffee
	Butter	5 grams
Supper—	Cold chicken	25 grams
	Baked tomatoes	100 grams
	Water cress	50 grams
	Coffee
	Cream	20 c.c.
	Butter	5 grams

TABLE

Key:
A	Protein Gm.
B	Fat Gm.
C	Carbohydrate Gm.
D	Calories

Material	Measure	A	B	C	D
Apple	1 medium (150 gm.)	.5	.50	16.0	70
Almonds[149]	10 small (10 gm.)	2.0	5.00	2.0	63
Apricots (dried)	1 oz. (30 gm.)	1.5	.28	17.5	78
Asparagus	6 large stalks (74 gm.)	1.3	.14	2.5	16
Bacon (raw)[149]	4 slices, 6 in. long, 2 in. wide	10.0	64.00		636
Bacon (cooked)[149]	4 slices, 6 in. long, 2 in. wide	10.0	32 to 46		388 to 468
Beef juice[150]	100 gm.	4.9	.60		25
Beef roast[149]	1½ in. × ? in.	6.0	7.00		89
Cheese (NeufchÂtel)[149]	1 cheese 2¼ in. × 1½ in. × 1¼ in.	16.0	23.00	1.0	284
Cream, gravity 16%	1 glass (7 oz.)	5.0	32.00	10.0	359
Cream, 40%	30 c.c. (2 tbs.)	.6	12.00	1.0	114
Cracker (Uneeda biscuit)	1 biscuit	1.0	.50	1.0	16
Dry peptonoids[150]	1 tbs.	6.0		8.0	57
Egg	1 medium (45 to 50 gm.)	54.0	4.20		60
Fowl	3½ oz. (100 gm.)	19.3	16.30		224
Grapefruit	½			5.0	20
Ham (lean)	50 gm.	12.4	7.10		113
Lemon juice[151]	3 tbs. (43 gm.)			4.2	19
Lemon Jelly[152]	3 oz. (90 gm.)	2.6		1.4	16
Milk (whole)	1 glass (8 oz.) 240 c.c.	7.9	9.60	10.0	158
Oatmeal[153]	1 tbs. (50 gm.)	1.0		6.0	33
Oatmeal	½ cup (3.6 oz.)	2.1	.10	8.2	50
Potato[153] (size large egg)	1 (100 gm.)	2.0		.8	83
5% vegetable[153] uncooked	1 tbs.			2.5	10
5% vegetable (boiled once)	1 tbs.			1.7	7
5% vegetable (boiled thrice)	1 tbs.			1.0	4
Orange	1 large	1.7	.20	22.7	100
Orange[153]	1 medium	1.0		13.0	57

Increasing the Diet.—The following menus show the manner in which the diet is increased after the starvation treatment:

First Day

Approximately 150 grams of vegetables with tea or coffee; value: protein 2, fat trace, carbohydrate 4.

Breakfast—	String beans	20 grams
	Celery hearts	20 grams
Lunch—	Spinach	25 grams
	Lettuce	25 grams
Supper—	Tomatoes	25 grams
	Cucumbers	25 grams

Second Day

Three eggs, 150 grams of 5% vegetables, tea or coffee; value approximately: protein 18, fat 12, carbohydrate, 4, calories 198.

Breakfast—	1 poached egg
	Spinach or beet tops	50 grams
	Coffee or tea
Dinner—	1 hard-cooked egg
	String beans	25 grams
	Lettuce	25 grams
	Tea
Supper—	1 soft-cooked egg
	Asparagus tips	25 grams
	Tomatoes	25 grams

Third Day

Approximately 19 grams protein, 15 grams fat, 5 grams carbohydrate, 230 calories.

Breakfast—	1 egg
	String beans	50 grams
	Tomatoes	25 grams
	Coffee
Dinner—	Cauliflower	50 grams
	Celery	50 grams
	Tea
Supper—	Asparagus	75 grams
	Lettuce	50 grams

Fourth Day

Approximately 26 grams protein, 15 grams fat, 10 grams carbohydrate, 279 calories.

Breakfast—	1 egg
	String beans	75 grams
	Coffee with cream	15 c.c.
Dinner—	Tomato bouillon	6 oz. (180 c.c.)
	1 egg
	Asparagus	75 grams
	Lettuce	25 grams
	Tea
Supper—	1 egg
	Celery	50 grams
	Cauliflower	100 grams

Fifth Day

Approximately 20 grams protein, 46 grams fat, 15 grams carbohydrate.

Breakfast—	Egg omelet (1 egg)
	Butter	10 grams
	Vegetable hash	100 grams
	Coffee or tea
	Cream	15 grams
Dinner—	Chicken broth	180 c.c.
	1 poached egg
	Tomatoes	100 grams
	Tea
Supper—	1 soft-cooked egg
	Spinach	100 grams
	Cucumbers	50 grams
	Tea or Coffee
	Cream	15 grams

Sixth Day

Approximately 33 grams protein, 35 grams fat, 12 grams carbohydrate, 495 calories.

Breakfast—	½ grapefruit
	1 egg
	Butter	5 grams
	Spinach	50 grams
	Coffee
	Cream	15 grams
Dinner—	Broth	180 grams
	Fish	50 grams
	String beans	100 grams
	Lettuce	50 grams
	Asparagus	50 grams
Supper—	2 eggs
	Tomato, baked (1 medium)	75 grams
	Cabbage salad	75 grams
	Tea
	Cream	15 grams

Seventh Day

Approximately 38 grams protein, 45 grams fat, 17 grams carbohydrate, 625 calories.

Breakfast—	½ grapefruit
	2 eggs
	Butter	10 grams
	Coffee
	Cream	15 grams
Dinner—	Beef broth	180 grams
	1 lamb chop	50 grams
	Cauliflower	100 grams
	Tomato	150 grams
	Lettuce	50 grams
	Butter	10 grams
Supper—	1 egg
	Tuna salad	50 grams
	String beans	100 grams
	Butter	5 grams
	Tea

Eighth Day

Approximately 32 grams protein, 16 grams fat, 20 grams carbohydrate, 625 calories.

Breakfast—	1 egg
	String beans	100 grams
	Raw tomatoes	100 grams
	Coffee
	Cream	15 grams
Dinner—	Chicken	50 grams
	Cabbage	100 grams
	Asparagus	100 grams
	Water-cress salad	50 grams
	Tea
Supper—	1 egg
	Greens	100 grams
	Celery salad	50 grams
	Tea
	Cream	15 grams

The following menus are used after the diet has been more or less increased:

First Day

Breakfast—	1 soft-cooked egg
	2 slices of bacon
	1 bran muffin, 5 gm. butter
	Coffee with 15 c.c. of 40% cream
Lunch—	6 oz. tomato bouillon
	2 oz. (60 gm.) roast lamb
	60 gm. string beans
	50 gm. lettuce and celery salad
	25 gm. lemon jelly with 15 gm. cream
Dinner—	60 gm. chicken
	75 gm. asparagus
	4 olives
	50 gm. cauliflower
	30 gm. ice cream
	1 Lister roll, 5 gm. butter
	Black coffee

Second Day

Breakfast—	½ grapefruit
	1 scrambled egg
	1 Lister roll, 8 gm. butter
	Coffee with 15 gm. cream
Lunch—	60 gm. baked halibut with 10 gm. parsley butter
	70 gm. cauliflower
	50 gm. lettuce
	1 Lister roll, 8 gm. butter
	Tea
Dinner—	6 oz. chicken broth
	60 gm. roast beef
	75 gm. cabbage
	75 gm. string beans
	30 gm. coffee jelly with 15 gm. cream
	Black coffee

Third Day

Breakfast—	1 soft-cooked egg
	2 slices bacon
	1 Casoid flour and bran muffin with 5 gm. butter
	Coffee with 15 gm. cream
Lunch—	100 gm. cabbage
	40 gm. corned beef
	50 gm. tomato salad
	1 soya meal muffin, 8 gm. butter
	Tea
Dinner—	60 gm. beefsteak
	75 gm. asparagus
	75 gm. spinach
	30 gm. tomato aspic
	30 gm. soft (diabetic) custard
	Black coffee

Fourth Day

Breakfast—	1 scrambled egg with 20 gm. chipped beef
	1 Casoid flour muffin with 8 gm. butter
	Coffee with 30 gm. or less cream
Lunch—	6 oz. tomato bisque
	60 gm. tuna fish salad
	75 gm. vegetable hash
	1 Lister roll, 8 gm butter
	Tea
Dinner—	60 gm. broiled chicken
	75 gm. string beans
	75 gm. cauliflower
	30 gm. tomato and celery salad
	30 gm. wine jelly, with 15 gm. whipped cream
	Black coffee

Fifth Day

Breakfast—	½ grapefruit
	1 soft-cooked egg
	1 bran muffin with 8 gm. butter
	Coffee, 15 gm. cream
Lunch—	40 gm. broiled beefsteak
	75 gm. spinach
	75 gm. boiled onion
	1 soya meal muffin with 8 gm. butter
	Tea
Dinner—	6 oz. tomato bouillon
	80 gm. baked fish with parsley sauce
	75 gm. Brussels sprouts with 5 gm. butter
	1 Lister roll with 5 gm. butter
	Coffee jelly, 30 gm., with 15 gm. whipped cream

Sixth Day

Breakfast—	1 poached egg
	2 slices bacon
	1 bran and Casoid muffin with 5 gm. butter
	Coffee with 15 gm. cream
Lunch—	Ham omelet (1 egg, 1 tbs. cream, 15 gm. minced ham)
	75 gm. spinach
	1 soya meal muffin with 8 gm. butter
	Tea

A departure from the now almost universally used “Allen-Joslin Starvation Diet,” is seen in the “Newburg-Marsh High Fat Diet.”

The use of a high fat diet in the treatment of diabetes is based primarily on one fact—namely, that if the food eaten is not sufficient for the needs of metabolism, the body itself supplies the deficiency. Fat is used as long as it lasts, body protein being drawn upon for fuel when this is exhausted. It is of distinct advantage to the patient to have a diet of sufficient fuel value to run his body machine and permit him a moderate degree of exercise. For by this means he is not obliged to use his own body substance to carry on metabolic processes. We thereby avoid the condition of extreme emaciation (though it is to be emphasized that gain in weight is to be carefully guarded against) with its constant lowering of the general health.

The system of feeding consists of a series of four diets, examples and standards of which are given below. The diet is made up of protein on the basis of approximately ? of a gram per kilogram of body weight at the time the patient leaves the hospital, a quantity of carbohydrate known to be well tolerated and the balance of the calories in fat.[154]

Diabetic Diet No. 1

Diabetic Diet No. 2

Key:
A	Weight Gm.
B	Protein Gm.
C	Fat Gm.
D	Carbohydrate Gm.
E	Calories

25-30 Proteins
18-22 Carbohydrates
1200-1600 calories
Food	A	B	C	D	E
Dinner:
Pork chops	60	10.0	18.0		202
Cabbage	100	.2	.3	5.6	32
(Use pork drippings)
Spinach	100	2.1	.3	3.2	24
with butter	20	.2	17.0		154
Broth—Tea

Supper:
Asparagus salad—
Lettuce	10	.1		.3	2
Asparagus	80	1.2	.1	2.1	13
Mayonnaise	50	.7	38.8		338
Tomatoes	100	1.2	.2	4.0	23
with butter	10	.1	8.5		77
Nut charlotte—
Walnuts, chopped	10	1.8	6.4	1.3	70
Cream	50	1.1	20.0	1.5	190
Broth—Tea

Breakfast:
Bacon	20	2.1	13.0		125
with 1 egg		6.7	5.2		74
Coffee with cream	30	.7	12.0	.9	114
		28.2	139.8	18.9	1438

Diabetic Diet No. 3

Key:
A	Weight Gm.
B	Protein Gm.
C	Fat Gm.
D	Carbohydrate Gm.
E	Calories

30-35 Proteins
25-30 Carbohydrates
1600-2000 calories
Food	A	B	C	D	E
Dinner:
Beef tenderloins	80	13.0	19.5		227
with butter	10	.1	8.5		77
Asparagus	100	1.5	.1	2.8	18
with butter	10	.1	8.5		77
Squash	100	1.4	.5	9.0	46
with butter	10	.1	8.5		77
Broth—Tea

Supper:
String bean salad—
Lettuce	10	.1		.3	2
String beans	50	1.1	.1	3.7	26
Pimento	10	.2		.4	2
Onion	10	.2		1.0	5
Mayonnaise	30	.5	23.3		228
Tomatoes	120	1.4	.2	4.8	28
with butter	20	.2	17.0		154
Chocolate pudding—
Cream	100	2.2	40.0	3.0	381
Cocoa, ½ tsp	1	.2	.3	.4	5
Broth—Tea

Breakfast:
Bacon	30	3.2	19.4		187
with 1 egg		6.7	5.3		74
Coffee with cream	30	.7	12.0	.9	114
		32.9	163.2	26.3	1728

Diabetic Diet No. 4

Key:
A	Weight Gm.
B	Protein Gm.
C	Fat Gm.
D	Carbohydrate Gm.
E	Calories

50-60 Proteins
30-40 Carbohydrates
2000-2500 calories
Food	A	B	C	D	E
Dinner:
Veal steak (roast)	100	19.9	10.8		177
Onions	126	1.9	.4	11.9	49
with cream	50	1.1	20.0	1.5	190
Tomatoes	150	1.8	.3	6.0	35
with butter	30	.3	25.5		231
Fruit salad—
Lettuce	10	.1		.3	2
Celery	50	.6		1.6	9
Grapefruit	80	.6	.2	8.1	37
Whipped cream	30	.7	12.0	.9	114
Tea—Broth

Supper:
Cream of celery soup—
Celery	50	.6		1.6	9
Cream	75	1.6	30.0	2.2	285
Broth to fill bowl
Boiled ham	30	6.1	6.7		85
Custard—
2 egg yolks		4.7	10.0		109
Cream	90	2.0	36.0	2.7	343
Tea

Breakfast:
Eggs (2)		13.4	10.5		148
with butter	30	.3	25.5		231
Coffee with cream	20	.4	8.0	.6	76
Broth
		56.1	195.9	37.4	2130

Nurse’s Directions for Collecting and Testing the Urine in Diabetes Mellitus.—The first urine voided in the morning at 7 A.M. should be thrown away, after which the entire quantity during the ensuing twenty-four hours, including that at 7 A.M. the following morning, should be collected in a thoroughly clean, wide-mouth bottle sufficiently large to contain the entire quantity. This should be kept in a cool place to prevent decomposition. After the urine has been measured, four or five ounces are removed for testing purposes. There is no necessity for having an elaborately equipped laboratory for making the simple tests of the diabetic urine. The nurse is only required to make the simple tests, leaving the more elaborate one for the physician. The articles necessary for these tests must be kept perfectly clean in order to make the tests accurate. The bottle in which the urine is collected must be washed and sterilized daily before the collection begins. One small three-inch white enameled or porcelain dish, one 10 c.c. graduated pipette, 6 test tubes, 1 small alcohol lamp or Bunsen burner, 1 box of sodium carbonate, 1 box talcum, and the reagents necessary for making the test, namely, Benedict’s solution, Fehling’s solution, and Haines’s solution.

SUMMARY

Diabetes Mellitus is a disease in which the body becomes more or less unable to utilize the sugars and starches, consequently there is an abnormal amount of glucose in the urine.

Manufacture of Sugar in the body from other food constituents besides carbohydrates has been proved with regard to proteins, hence the intake of nitrogenous substances must be restricted in diabetes—to a less extent, however, than the sugars and starches.

Acetone Bodies.—Diacetic acid, oxybutyric acid, and acetone develop in diabetes as a result of the breaking down of the fats and the lack of certain neutralizing agents found chiefly in carbohydrate foods.

Acidosis is a form of intoxication due to the retention of these toxic acids in the body. If not combated and overcome, it will result in the diabetic coma which is fatal in so many cases.

Diet Treatments.—The best known treatments are those devised and used by Drs. Allen and Joslin “The Starvation Treatment for Diabetes Mellitus,” and the “High Fat Diet” formulated by Drs. Newburg and Marsh. All cases cannot be handled alike and it is for the physician to determine the treatment calculated to give the best results in the definite case.

Training for Diabetic Nursing.—So much depends upon the administration of the treatment in this pathological condition that in many hospitals special training is being given to the nurses in the care of diabetic patients that they may be able intelligently to carry out the necessary rÉgime, both in the hospital and in private practice.

Symptoms.—She must be able to recognize symptoms both from the findings resulting from the urinalysis and from those manifested otherwise by the patient.

The Record.—She must keep an absolute record of all that occurs during the course of treatment and instantly report any unusual happening.

Urine Tests.—It is advisable to make the tests in the morning; those for sugar and diacetic acid should be made every day or, in some cases, every other day, as directed by the physician, and those for ammonia and albumen about once a week.

Weighing the Patient.—Patient should be weighed each day before breakfast, and the weight of the clothes also carefully recorded separately. The Bowels must move daily, even if it is necessary to resort to mild laxatives or an enema.

Formulating and Calculating the Dietary.—The menus of the day must be formulated and the chemical composition and nutrient value of the foods calculated. The vegetables belonging to the five per cent. group should be in readiness and the amount to be used weighed after they have been boiled in clean, separate water to reduce their carbohydrate content still further.

Commercial Diabetic Foods.—It may be well to mention the danger of putting faith in the so-called diabetic foods so widely advertised. Some of these foods are of undoubted worth, but it is never safe for the nurse or the patient to judge of the merits of the various diabetic foods without first knowing their chemical composition, and not even then without the definite directions from the physician.

Diabetic Flours.—The diabetic flours used in the recipes included in this text have been approved by some of the leading specialists in diabetes in this country, but the nurse should not include them in the diet for her patient unless they are prescribed by the physician in charge.

PROBLEMS

(a) Outline test diets for determining the severity of the disturbance.

(b) Give examples of diets used in testing for tolerance of carbohydrates, fats, proteins.

FOOTNOTES:

[137] Allen’s Paradoxical Law, quoted from “Treatment of Diabetes Mellitus,” p. 18, by Joslin.

[138] “Treatment of Diabetes Mellitus,” p. 305, Joslin.

[139] “Food for the Sick,” by Strouse and Perry.

[140] Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.

[141] The giving of coffee or clear broth, with or without whisky, does not materially affect the starvation and serves to make the patient more comfortable during this trying period.

[142] Dr. Joslin has given a very complete schedule in his “Treatment of Diabetes Mellitus,” from which the above schedule is taken.

[143] Hill and Eckman’s “Starvation (Allen) Treatment of Diabetes.”

[144] See 5% vegetable, p. 383.

[145] Table used by Dr. Joslin in his treatment of diabetes mellitus. It is convenient, and many changes in the diet may be made by substituting one food for another of like carbohydrate content. This table can be purchased on cards from Thomas Groom & Co., Boston, Mass.

[146] Table devised by H. O. Mosenthal showing accessory diets rich in carbohydrates. “Medical Clinics of North America,” July, 1917.

[147] “h” represents household measure.

[148] Mosenthal: “Medical Clinics of North America,” July, 1917.

[149] “Starvation Treatment of Diabetes,” by Hill and Eckman.

[150] “Practical Dietetics,” by Alidia Pattee.

[151] “Food for the Sick,” p. 62, by Strouse and Perry.

[152] Sweetened with saccharin.

[153] “Starvation Treatment of Diabetes,” by Hill and Eckman.

[154] Courtesy of R. Eckman and D. M. Stewart, University of Michigan Hospital, Ann Arbor, Michigan.

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