Dietetics for Nurses

Fifth Day

Sixth Day

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

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

TABLE[148]

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

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