Dietetics for Nurses

by Fairfax T. Proudfit

FOOTNOTES:

[134] See Karell Cure, p. [342].

[135] “Food for the Sick,” p. 150, by Strouse and Perry.

[136] See Salt-poor Diets, p. [341].

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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]

BREAKFAST
Grapefruit	½
Eggs	2
Bacon	20 grams
Bread	25 grams
Butter	10 grams
Cream	15 c.c.
Coffee	1 cup
DINNER
Cream soup	3 oz.
Roast beef	75 grams
Spinach	100 grams
Kohl-rabi	100 grams
Lettuce salad	50 grams
Ripe olives	15 grams
Bread	25 grams
Butter	20 grams
Wine gelatin	4 oz.
Coffee
Cream	15 c.c.
SUPPER
Lamb chop	1
Asparagus tips	50 grams
Eggplant	50 grams
Tomato salad	50 grams
Custard (diabetic)
Coffee
Cream	15 c.c.
Butter	20 grams
Bread	25 grams

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
	A	B	C	D	E	F	G	H	I	J	K	L	M	N	O	P	Q	R
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