Waaaaaay before Atkins put the butter-and-bacon version of the ketogenic diet on the map (based on the 1958 work of Pennington), very low carb diets were standard-of-care for treating diabetes and prediabetic conditions. Indeed, as far back at 1797, the advantages of a “meat diet” for diabetes was understood by Rollo: A 34-year old man, Captain Meredith, came to him after being treated for gout with sugar, molasses and spruce beer [Hmmmm. Sounds akin to our fat phobic macronutrient recommendations circa 1995]. Instead of feeling better on the diet, Meredith developed polyuria, polydipsia, sweet-smelling urine, and weight loss. After reportedly discussing the case with an “ingenious anatomist” and a chemist, Rollo prescribed a meat diet (and after a period of adherence to that, he allowed Meredith to add tea without sugar, cabbage and a little brandy). The patient gained weight and his symptoms disappeared. He was, according to Rollo, recovered.
In our practice, we routinely prescribe variations of the ketogenic diet (KD) for many issues, from weight loss and cardiometabolic diseases to autoimmunity, neurodegenerative conditions and cancer. In general, the KD is extremely well-tolerated, and most folks who hang in there with the diet and achieve ketosis report feeling great. We talk about the KD on our website fairly frequently, from blogs and case reports to recipes and podcasts that regularly touch on the benefits of ketosis. I’ve chatted with Dr. Thomas Seyfried, whose done remarkable work on demonstrating the importance of the calorie restricted ketogenic diet in treating glioblastoma in mice; and Dr. Terry Wahls, who uses a keto plan to treat MS. This month, coinciding with this blog, I podcast with Miriam Kalamian MS, CNS, a highly regarded nutritionist and just-published author of the Keto for Cancer—a worthy resource for clinicians and patients alike. Listen to Miriam’s moving personal story (and glean loads of smart clinical pearls along the way) to understand her motivation in becoming one of the foremost experts on the ketogenic diet.
Research on the benefit of ketosis is galloping forward. One of the more recent papers that grabbed my attention (Nature Medicine 2015 Mar: 21(3): 263-269.) reports that the ketone body beta-hydroxybutyrate (but not acetoacetate) inhibits the production of cytokines, including IL-1beta and IL-18, via suppressed activation of the NLRP3 inflammasome. Interestingly, this suppression was not dependent on starvation-related mechanisms such as AMP-activated protein kinase or autophagy. As we begin to drill down into the fantabulous bioactivity of ketones, which is a recent discovery—remember in school we were taught ketones were a byproduct of fatty acid metabolism, able to be oxidized for fuel during times of insufficient caloric intake, but not much more—it’s interesting to also spend a few minutes and circle back to the ketogenic/low carb diet from a historical perspective.
Prior to the introduction of insulin, a very low carbohydrate diet was THE fundamental treatment for diabetes: Joslin prescribed a diet consisting of “meats, poultry, game, fish, clear soups, gelatin, eggs, butter, olive oil, coffee, tea” with no more than 5% of total energy coming from carbohydrates. Insulin, by the way, is a fascinating story in-and-of-itself: it was discovered by Banting and Best in 1921, and exogenous insulin was first used successfully in a human subject in 1922. Insulin was being prescribed routinely by 1923, the same year Banting received the Nobel for his discovery… Wow, no time wasted!
Currently, the Joslin Diabetes Center (the evolution of Joslin’s Boston private practice, now a premier clinic and research institute, prescribes the Joslin’s guideline essentials:
- Carbohydrate: 40 percent from carbohydrates, including at least 20-35 grams of fiber. Best carbohydrate/high-fiber sources: fresh vegetables, fruits, beans and whole-grain foods. Eat less of these carbs: pasta, white bread, white potatoes and sugary cereals.
- Protein: 20-30 percent from protein (unless you have kidney disease). Best protein sources: fish, skinless chicken or turkey, nonfat or low-fat dairy products, tofu and legumes (beans and peas).
- Fat: 30-35 percent from fat (mostly mono- and polyunsaturated fats). Best fat sources: olive oil, canola oil, nuts, seeds and fatty fish like salmon.
Really, Joslin Center?
I wonder what Joslin might think, were he here today… Especially as he ponders the top 3 causes of death today are diet-and-lifestyle mediated, as compared to his era, when they were infectious. To be sure, Joslin’s current recommendations are not terrible for those without diabetes- the micronutrient balance is far superior to Joslin’s original plan- but the macronutrient distribution, with 40% going to carbs (verses the 5% of Joslin’s original diet) will limit its efficacy for curtailing the ravages of diabetes.
Leading causes of death in US, 1900 & 1997. From CDC.
Circling back to Joslin’s dietary recommendations as discussed in Osler and McCrea’s textbook The Principles and Practice of Medicine, Ninth Edition. 1921 pp421-436, there are some interesting details. Recall that insulin isn’t yet available, so diet is the main intervention—and it’s VERY carefully prescribed and monitored (the latter by observing for glycosuria). I’ve pulled a few points from the text I found interesting:
- The dietary prescription is individually determined, with the goal of keeping the urine “sugar and acid- free”. Acid is referring to ketones- keeping the patient out of diabetic ketoacidosis.
- Fasting is advocated but “it should not be employed carelessly”. When entering into (or completing) a fast, it’s recommended that a gradual tapering (or reintroduction) of macronutrients is undertaken (fat, then protein, then carbohydrate, then fast; the reverse for reintroduction). A fast should be comprised of water, tea, coffee and thin, clear meat broths as desired.
- While the goal of therapy is to increase carbohydrate tolerance, it’s important “not to overtax the patient’s powers of using carbohydrates by giving more than he can utilize”.
- Type II diabetes is described as “lipogenic diabetes” caused by over-consumption of carbohydrates, “particularly in stout persons and heavy feeders” and considered to be a form “very readily controlled.”
- A lower carb diet is recommended to family members where a predisposition to developing the disease exists. Turkish bath, exercise, a quiet, low-stress life in equable climate are all recommended for the diabetic.
I often find interesting ideas (that can influence my practice) when looking at history. It’s uncanny how Joslin’s approach reflects how we think functionally. In addition to the meticulous dietary prescription (largely forgotten with the advent of recombinant insulin and other medications), lifestyle figures in, too, with the recommendations of exercise and lower stress. While I am sorry these ideas were lost in medicine, I appreciate that FxMed returns us to our roots.