Diabetes Management “Diets” since the Discovery of Insulin—Looking Back, Then to the Future.
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One of the pillars of diabetes self-care and management is learning how to adjust your eating patterns. The role of food and nutrition has evolved over the years, but one thing we know is there is no single eating plan that fits every person with diabetes. With the right healthcare team and technology, it’s easier than ever to learn what works for you.
At this year’s ADA conference a discussion among nutritionists and diabetes care and education specialists observed the history of culture, diet and diabetes over the years and since the discovery of insulin.
Melinda D. Mayniuk, MEd, RDN, CDCES, discussed nutrition in diabetes care from 1921—the discovery of insulin—to the 1970s, and highlighted how history repeats itself. Her presentation covered the topics:
- Culture and Diet
- The Starvation Diet
- Joslin’s Influence on Management + Diet
- Tolstoi’s Free Diet
- Exchange Diets
Later in the article, we cover Hope Warshaw’s MMSc, RD, CDCES, BC-ADM, discussion about how nutrition in diabetes has changed since the 1980s.
Culture and Diet
Pleasantly, in this session, we learned that the first time that the importance of culturally appropriate nutrition was discussed in the development of eating plans for people with diabetes was in 1927. In an article, Stern F. Rayer explained the importance of recognizing traditional eating patterns and using national guidelines when treating people with diabetes of foreign origin. He talks about the importance of considering habits, race, origin and background for diabetes management. Although we are happy to know that it has been an issue on the table since the early 20th century, it is sad to see that even in 2021, this is not part of all practices.
The Starvation Diet: History Repeats Itself
Dr. Allen recommended diets very low in carbohydrates (and calories) to extend the life of those living with diabetes. Allen named this type of nutritional intervention as “The Starvation Diet” and it was a publication he authored where, together with another doctor and a nutrition expert, a three-step intervention was suggested:
- Step 1: Strict caloric reduction consisting of 1 ounce of coffee and whiskey every two hours for four days until there was no trace of sugar in the urine).
- Step 2: Boiled vegetables for one to two days.
- Step 3: Adding protein and fat gradually.
Elizabeth Hughes was one of the people with diabetes who used this diet before the discovery of insulin. Her eating plan was based on fat and was restricted to 300-800 kcal for four years. After the discovery of insulin, when starting this treatment, Elizabeth’s diet was changed to 2500 kcal on average and about 97 grams of carbohydrates.
Notably, Elizabeth Hughes lived 73 years (1907-1981) of which 62 of them she lived with diabetes and 58 on insulin. “She took her illness seriously and read a lot about diabetes and diet, checked her urine glucose and adjusted the insulin dose according to the result.”
Joslin’s Influence on Nutrition and Diabetes
Before insulin, the only way people with type 1 diabetes could stay alive was through diets with restricted calories and especially carbohydrates.
Elliott Joslin was the first to mention what we now know as self-management and the importance of the participation of those living with diabetes. In fact, Joslin spoke of the three pillars of diabetes management: diet, insulin and exercise. Joslin also mentioned that managing these three points required intelligence and dedication.
In 1921 Joslin wrote “The Prevention of Diabetes Mellitus.” Since then, there have been discussions about preventing obesity to reduce the risk of type 2 diabetes.
Maryniuk spoke of the role of nurses in diabetes management, surely the precursor of diabetes educators itself. The eating plan that Joslin prescribed was one where foods were prescribed on a list with food weights and carbohydrate values. These structured eating patterns involved moderate portions of carbohydrates: 40 percent for the diet. However, diets began to be more adaptable and individualized with a greater variety of food.
Tolstoi: The “Free” Diet
Dr. Edward Tolstoi is the famous creator of the “Free Diet” that allowed you to choose, in his own words, to “live normally”. He wanted his patients to eat in quantity, frequency and quality, not unlike how the rest of the family ate. According to Tolstoi, it was not necessary to measure or weigh but to eat in a healthy, balanced fashion.
The history of diabetes recorded a debate between Joslin and Tolstoi in 1951 where it was concluded that the diet proposed by Joslin, where food was weighed and more emphasis was placed on more control, which was later supported in 1993 by the results of the DCCT study.
Exchange Lists
The first exchange lists were published in 1950 as a joint effort between the Academy of Nutrition and Dietetics, the American Diabetes Association and the United States Public Health Service. These lists gradually allowed more flexibility in choosing foods.
Diets from 1980 to 2021: Macronutrient Percentages and Person-Centered Approaches
In 1979 there were 6 million Americans with diabetes, and prediabetes was not yet being reported. There were limited medication options and urine glucose concentration was measured, although blood glucose meters were beginning to appear. At that time, according to Warshaw, foods containing sugar were prohibited in the diet of those living with diabetes.
In 1980 the first Nutrition Guides were published which provided an idea and information about the diet and nutritional requirements for Americans and in 1983 the education programs for patients with diabetes were integrated.
Positioning of the American Diabetes Association
In 1986 the position of the ADA on nutrition emphasized the importance of individualization based on blood glucose (sugar), lipid levels and eating patterns of the patient with diabetes.
Carbohydrate consumption was allowed in up to 55 to 60 percent of the diet with a preference for the consumption of unrefined foods and fiber, while it was indicated that moderate consumption of sucrose and other refined sugars can be accepted depending on metabolic control and body weight. The fats should not be more than 30 percent and with less than 16.6 mmol/L300 mg/dL of cholesterol.
At this time, according to the DCCT study, four behaviors were identified that could simplify self-care routines, improve follow-up of treatments as well as glycemic management:
- Treating hyperglycemia promptly
- Never over-treating hypoglycemia
- Minimizing the intake of snacks
- Adjusting the insulin dose when there are changes in diet
The DCCT study learned that intensive insulin therapy alone was not enough to achieve glycemic targets. It has been found that the role of nutritionists and diet care was the key to achieving glycemic goals without hypoglycemia or weight gain.
In 1997, the ADA’s positioning included an individualized person-based approach and, while a lot has happened, a lot has remained the same. As advances in medicine and technology offer more tools, patient-centered nutrition therapy that includes understanding how a person makes food decisions and supporting them in achieving their goals continues to be critical to care.” Maggie Powers, Ph.D., RD, CDCES.
Warshaw concluded with four key goals in diabetes nutrition therapy:
- To promote and support healthy eating patterns with an emphasis on a variety of nutrients with appropriate portions to improve overall health.
- To identify individual nutritional needs based on each person, their cultural and educational aspect, accessibility to healthy foods, disposition and ability to make changes in behavior, understanding the barriers of each individual.
- To maintain the pleasure of eating by giving positive messages about health choices while limiting food choices based on scientific evidence.
- To provide the person with diabetes with practical tools for daily meal planning.
The future of diabetes not only considers food or diabetes, but it also further considers aspects such as epigenetics and nutrigenetics, mental health, intestinal health, new medications, treatments and technology to obtain information from the patient and above all, individualize each person living with diabetes.
For more coverage of the American Diabetes Association’s 81st Scientific sessions, CLICK HERE
