Sugar

HYPOGLYCEMIC SYMPTOMS PROVOKED BY REPEATED GLUCOSE INGESTION IN A CASE OF RENAL DIABETES R. B. Gibson, Ph.D., and R. N. Larimer, M.D., Iowa City 

One of us (R. B. G.), in November last, reviewed the chemical findings in a case from our diabetic clinic before the Iowa Clinical Medical Society. Interest in the case centered in the fact that a final diagnosis of what was otherwise a case of pronounced renal diabetes could not be made because the sugar curve indicated a deficient glycogenesis of the mildly diabetic type. A study of the effects of a repeated ingestion of glucose on the sugar curve by Hamman and Hirschman was recalled, and we predicted in our report that a decisive differentiation might be obtained if we employed the double sugar curve test in this case. The patient was requested to return for further observation, and promised to come to the clinic in January of this year. 

We have in the clinic, at the present time, a second patient with a fasting hypoglycemia and a glycosuria of long standing which does not respond to diabetic management. The data presented in this communication were obtained in this case. Glycogenesis is stimulated by glucose ingestion, as is indicated by the rapid fall of the blood sugar from the peak of the curve (usually forty-five minutes) to a figure at the end of two hours almost always less than the fasting control observation. A second administration of glucose brings about a yet more rapid removal of sugar from the blood stream and a consequent lowering of the sugar curve. The desugarized diabetic patient may show an effect similar to the normal person, but of much less degree (one case, Hamman and Hirschman). When tried in our case, the effect of the double sugar curve test was so great that hypoglycemic symptoms were observed in two out of three trials. 

REPORT OF CASE Mrs. B., aged 30, white, weight 110 pounds (50 kg.) (best weight 115 pounds [52 kg.] ten years ago) was admitted to the hospital with a history of glycosuria of ten years' standing. This had been discovered by a urine examination during the first of her two pregnancies. She had never had other symptoms of diabetes except for some pruritus seven years ago; she had dieted off and on since that time. The condition seemed to be familial, the patient stating that she had one sister surely and one probably glycosuric patients without other symptoms; however, she had no knowledge of glycosuria in either of her parents. The patient was placed on a diet of 50 gm. of protein, 50 gm. of carbohydrate, and 125 gm. of fat; on this, she excreted from 4.5 to 8.5 gm. of glucose daily. Her blood uric acid was 3 mg., and blood urea nitrogen, 18 mg. Fasting blood sugar determinations or figures obtained two hours after meals were always hypoglycemic. The results of our tests with the double sugar curve are given in the accompanying table. 

Definite hypoglycemic symptoms were obtained in the first and third trials; they were identical with the several mild insulin reactions which we have observed in our diabetic patients, consisting of burning and flushing of the face, weakness, tremor and sweating. The second shock was the more severe of the two; the patient was completely relieved in fifteen minutes when given 100 c.c. of orange juice. The lowering of the leyel of the entire curve in the third trial is in accord with the experience that glycogenic effects may become more pronounced if the ordinary procedure is repeated without a sufficient number of days elapsing between tests. When questioned as to the occurrence of similar attacks at home, the patient stated that she had experienced such of milder degree, but could not associate these with any definite circumstance. One sister had like attacks. It seems likely that hypoglycemic symptoms not artificially produced are a definite clinical entity.

In explanation of a diminished glycogenesis in pronounced renal diabetes, it was stated, in the paper referred to above, that "It is quite possible that glycogenesis in our case may be functionally diminished because of the rapid removal of glucose through the kidneys; if so, repeated administration of glucose might so stimulate the glycogenic power fhat a normal or subnormal sugar curve will result." Since this report was submitted for publication, threshold hypoglycemic symptoms with a blood sugar of 0.045 per cent, have been induced in our first patient; the maximum hypoglycemic effect is quite transient.

At the recent meeting of the American Medical association, Dr. Haven Emerson said the average American was eating far too much sugar and other sweet foods, and also far too much bread and cereals and other starchy foods. He proved it by several arguments in which he used figures from the country and abroad and relating to other times as well as the present. He showed that the average consumption of meat per person in the United States had fallen off. While he did not argue for a greater use of meat, he did indicate that eating more meat might be the lesser of evils. 

Probably he thinks we eat too much of everything and should not increase our daily allowance of any food. However, if either our daily bread and sugar allowance, is to remain as it is, he would choose the meat allowance to stay and he would have us cut down on sugar and bread. The arguments he used were these.

Statistics show our consumption of sugar to be increasinng at an enormous rate. Going hand in hand with this increase are increases in diabetes and in obesity. Just in the years when we are. 

Sam Apple's Tweet: 15/ Less than a year before, Bundesen had warned in print that sugar should be consumed in moderation. Now, he was suggesting —among other outrageous claims—that a lack of sugar could be harmful to teeth.  Had something changed Bundesen's mind about sugar? …

Bundesen -> AntiSugar

Your Health - Herman N. Bundesen M.D.

Your belt-line is your life-line. As it increases, the life span shortens and there is greater hazard from diabetes, kidney disease and heart trouble.

The man or woman who sits down most of the day and rides to work in an automobile or street car should be careful not to overeat and should take exercise regularly. Sugar and starchy foods should be taken sparingly and fats and oils should be avoided. Meat may be taken in moderation once a day. Fresh vegetables and most fruits are excellent non-fattening foods. 

Dr. Bundesen will answer any health questions submitted by readers who inclose stamped self-addressed envelopes for personal replies. 

Bundesen -> ProSugar

The laws in regard to the manufacture of foods, of which candy is a valuable article, are very stringent and protect you from any adulteration or undesirable substances. So, with a mind at ease, you may match your table decorations for your party with mints to follow the dessert, and you may give your children colored stick candies or bonbons.

Excitable Children

For children, whose active littel bodies make more movements in an hour than many grown-up ones do in a day, and who thus expend large quantities of energy daily, candy repairs the loss in a simple, quick, and acceptable way. The little ones need a much larger proportionate sugar ration than adults. 

The Matter of Teeth 

Candy of one sort has another valuable use. Teeth, like other parts of the body, need exercise. Provided the body is supplied with the teeth-building elements, the teeth will be healthy, if used. Hard candies, such as molasses candy, and stick candy, give this exercise to the teeth and gums, and leave no residue. The chewing of hard candies, and other hard foods, helps the teeth. 

The Canada Lancet, a monthly journal of medical and surgical science, the oldest medical journal in the Dominion of Canada, says:

"There is a rather widespread notion that eating candy injures the teeth. There is not the least scientific foundation for this notion. The lack of sugar is much more likely to injure the teeth, through impaired nutrition, than even its excessive use is likely to do by any digestive troubles which might result from over-use."

Hard candies, such as molasses and stick candy, give exercise to teeth and gums and leave no residue, Bundesen adds.

The current explanation of this phenomenon (Macleod) is that the first dose of glucose sensitizes the insulin-secreting mechanism, so that in response to the second dose the islet cells secrete insulin more readily and more abundantly at a lower level of hyperglycaemia. On the basis of this explanation Sweeney, in 1927, attempted to explain the variations in sugar tolerance found in normal subjects on different diets. Using the ordinary glucose tolerance test as a guide, he investigated the sugar tolerance of healthy individuals during starvation, on a fat diet, on a protein diet, and on a carbohydrate diet. He found that protein had little effect; that fat diets and starvation diminished sugar tolerance; and that carbohydrate diets improved sugar tolerance. Sweeney considered that the diminished sugar tolerance was due to the impaired sensitivity of the insulin-secreting apparatus, consequent upon the absence of the stimulus of carbohydrate ingestion, and that the improved tolerance was the result of the increased sensitivity of this mechanism, owing to greater stimulation.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2444943/pdf/brmedj07161-0009.pdf

December 1927

DIETARY FACTORS THAT INFLUENCE THE DEXTROSE TOLERANCE TEST - A PRELIMINARY STUDY

J. SHIRLEY SWEENEY, M.D.

Abstract

The dextrose tolerance test is now being extensively employed as a diagnostic procedure. It is most beneficially used in the differentiation of mild diabetes mellitus and renal diabetes. It is also being used, and is believed to be of diagnostic value, in many pathologic conditions, such as encephalitis, malignant tumor, pituitary and thyroid dysfunctions and nephritis.

 Although it is definitely established as a diagnostic procedure, there is some diversity of opinion concerning what constitutes a normal response to the oral administration of dextrose. Some writers state that in a healthy person there may be a postprandial rise in blood sugar of from 14 to 16 per cent and a return to the normal within two hours. There are other writers who consider a postprandial hyperglycemia of 20 per cent within normal limits. It is generally believed that the persistence of the postprandial hyperglycemia is of more diagnostic significance than the degree of hyperglycemia. In early cases of diabetes the blood sugar curve rises higher, stays up for a longer time and does not return to normal for several hours. Macleod says that "slight deviations from the normal must not be given too much weight in diagnosis, since they may occur in other diseases or even in perfectly normal persons." All who have studied dextrose tolerance curves have noted the variability exhibited by normal persons, to say nothing of those who are diseased. These variations have been discussed and explained in different ways. 

It occurred to me that perhaps the character of the food and the amount of water that a person had been consuming for a few days prior to the time the tolerance test was made might be factors that would influence the dextrose tolerance curve. If these factors should prove to be capable of altering a tolerance curve, they could be controlled. This would eliminate some of the confusing variability that is so frequently observed. It was these thoughts that lead to the following experiments. 

Young, healthy, male medical students were used to study the effect of different preceding diets. Four groups were formed. The subjects in one group were given a protein diet, those in another a fat diet, those in a third a rich carbohydrate diet, and those in the fourth group were not given any food—the starvation group. Those on the protein diet received only lean meat and the whites of eggs. The students on the fat diet received only olive oil, butter, mayonnaise made with egg yolk, and 20 per cent cream. Those in the group fed on carbohydrates were allowed sugar, candy, pastry, white bread, baked potatoes, syrup, bananas, rice and oatmeal. These diets were followed for two days. Meals were taken at the usual hours, and eating between meals was allowed, provided the diets were followed. Those in the starvation group did without food for two days. 

On the morning of the third day, each student was given by mouth 1.75 Gm. of dextrose per kilogram of body weight, on an empty stomach. Determinations of blood sugar were made from samples of venous blood removed immediately before the dextrose was given, and at 30, 60 and 120 minute intervals following its administration. I made all determinations of blood sugar by the Folin-Wu method.

A better comparison of these groups is obtained by examining table 5 and chart 5 in which are contained the average or type curves of each group. It will be noted that those students who were on the carbohydrate diet exhibited a marked increase in sugar tolerance and those on a protein diet a slight decrease in tolerance, while those who were placed on the fat diet and those who were starved manifested a definite decrease in sugar tolerance. The differences in the average fasting blood sugars are noteworthy. The blood sugar in those of the protein and starvation groups was distinctly lower than that of the members of the fat and carbohydrate groups. 

Because of the great difference in these groups, those students on the fat diet and those in the starvation group who showed the most extreme responses were placed on the carbohydrate diet. Similiarly, those in the carbohydrate group who showed an extreme response were placed on starvation restriction. This was obviously done to determine whether the curve of a person could be changed significantly by diet. The results are presented in table 6 and in charts 6 and 7. 

Comparison of the curves of these five students is striking. The curves of all who had been placed on carbohydrate diets manifested a definite increase in their sugar tolerance. When three of these (the three most extreme) were placed on starvation restrictions, the curves were notably abnormal ; there was a marked postprandial hyperglycemia. which persisted at the end of two hours ; in other words, what was an increased sugar tolerance following the carbohydrate diet became a definitely decreased tolerance following two days of starvation. The remaining two persons who were placed on the fat diet showed a similar decreased tolerance. It should be stated that an interval of at least one week was allowed between the tolerance tests performed on the same subject.

Physicians were slow to appreciate that insulin allowed the proportion of carbohydrate in the diet to be increased, for, as Himsworth said, ‘a well-founded theory directs that the carbohydrates in the diabetic’s diet must be curtailed if health is to be preserved’. On the other hand, as he continued, ‘a brilliant piece of clinical empiricism produces irrefutable proof that a liberal allowance of carbohydrate acts favourably on the diabetic’s health’ [17]. This empiricism began in 1926, when a high carbohydrate diet was first shown to improve glucose tolerance in healthy individuals [18]. Noting this, William Sansum promptly increased the carbohydrate content of the diet of his Californian patients; a typical recommendation might include 2,435 calories, 245 g of carbohydrate (40% of energy requirements), 124 g of fat and 100 g of protein [19].