A Ketogenic Diet was Used First in Diabetes Then Epilepsy

Some believe that a ketogenic diet was first used to treat epilepsy and that the diet was later adapted for use in treating those with diabetes, but as the previous article titled A Hundred Years of Treating Diabetes with a Low Carb and Ketogenic Diet points out, Dr. Russell Wilder who coined the term “ketogenic diet” and who is famous for his application of the diet in epilepsy, remains virtually unknown for his earlier use of a ketogenic diet for the treatment of diabetes. This short article provides the historic evidence that a ketogenic diet was used first in diabetes treatment, and later applied to the treatment of epilepsy.

Wilder’s First Musings About Use of a Ketogenic Diet in Epilepsy

On July 27, 1921, Dr. Russell Wilder wrote a short article in The Clinic Bulletin of the Mayo Clinic where he explained his thinking regarding Geyelin’s use of fasting in epilepsy, and why he thought that a ketogenic diet could work just as well. Note the highlighted “as has long been known” which alludes to his and other’s previous use of a ketogenic diet in the treatment of diabetes.

Wilder (1921) The Effect of Ketonemia on the Course of Epilepsy

Wilder’s First Use of a Ketogenic Diet in Diabetes

In 1958, Wilder’s published “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-1950” in which he said;

“The nine editions of the little book A Primer for Diabetic Patients, the first written in 1921, the last in 1950, provide a panorama of diabetic therapy in that interval. The first printing was based on mimeographed instruction sheets prepared in 1920 for the diabetic patients. 

pg 257-8 “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-1950”

 

While the first printing of the book A Primer for Diabetic Patients was in 1921, it is clear from what Wilder wrote in “Recollections and Reflections” (1958) that a ketogenic diet was already being used by Dr. Frederick M. Allen to treat those with diabetes (prior to 1920):

“The nine editions of the little book A Primer for Diabetic Patients, the first written in 1921, the last in 1950, provide a panorama of diabetic therapy in that interval. The first printing was based on mimeographed instruction sheets prepared in 1920 for the diabetic patients. We were then following the generally accepted treatment of that time, which was based on the research of Dr. Frederick M. Allen at the Rockefeller Institute in New York. It involved an initial period of starvation and the effort afterward to maintain control of glycosuria by a very rigidly restricted diet and periodic fast days.

A book titled “The Starvation Treatment of Diabetes Mellitus” written by Dr. Walter R. Steiner was published in 1916 and outlines the treatment protocol of Dr. Frederick M. Allen on which Dr. Russell Wilder based his method at the Mayo Clinic.

[Note: Special thanks to Doug Gilliland, Engineer of Connellsville, Pennsylvania for bringing this book to my attention.]

P 176 – Steiner (1916) – details of fasting and ketogenic diet method of Dr. Frederick M. Allen

 

Note: The following protocol should not be attempted on one’s own.  This was used in a supervised hospital setting.

As outlined on page 177-179 of Steiner’s book, Dr. Allen’s treatment consisted of first fasting the patient for 2-4 days (up to 8-10 days) while the patient could drink as much water, coffee, tea and meat broth as they wished.

Once the patient’s urine was free of sugar for a period of 24-hours, they were given 150g of low carbohydrate vegetables (5 g carbohydrate) that were boiled three times and the water discarded to further reduce the amount of carbohydrate in them. Then 5 grams of carbohydrate was added every other day from the list of low carb vegetables (5 grams carbohydrate), then medium carbohydrate vegetables (10 gram carbohydrate) and finally high carbohydrate vegetables (15 grams carbohydrate). Finally, the carbohydrate content of the diet was gradually titrated up by adding fruit, potato, oatmeal and bread — provided that no sugar appears in the urineOnce the urine has been sugar free for 2 days, protein was added in the form of 3 eggs and then 15 grams of protein were added per day until the patient is receiving 1 gram of protein per kilogram body weight. Once protein tolerance (1 gram protein per kilogram body weight) was reached) 25 grams of fat were added daily until the patient stopped losing weight — or until 40 calories per kilogram body weight was reached.

Dr. Frederick Allen’s ketogenic diet was in use prior to 1916 when Dr. Walter Steiner published his book, and Dr. Russell Wilder later based his treatment protocol on Allen’s “generally accepted treatment”.

The first printing was based on mimeographed instruction sheets prepared in 1920 for the diabetic patients. We were then following the generally accepted treatment of that time, which was based on the research of Dr. Frederick M. Allen at the Rockefeller Institute in New York which involved an initial period of starvation and the effort afterward to maintain control of glycosuria by a very rigidly restricted diet and periodic fast days.

A ketogenic diet was used in treating diabetes prior to 1916 — several years before Dr. Wilder proposed using it in epilepsy in July 1921.

P 176 – Steiner (1916) – details of fasting and ketogenic diet method of Dr. Frederick M. Allen
Pg 177 The Starvation treatment of diabetes mellitus – outline of Dr. Frederick Allen’s method – from Steiner 1916
Pg 178 The Starvation treatment of diabetes mellitus – outline of Dr. Frederick Allen’s method – from Steiner 1916

Wilder’s Outline of the Timeline of Use of a Ketogenic Diet – from treatment of diabetes to use in epilepsy

Page 243 of “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-1950” Dr. Russell Wilder clearly spells out the timeline that use of a ketogenic diet in diabetes came first, then his idea that a ketogenic diet might also have application in epilepsy. 

 

pg 243, “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-1950”

 

“At an Atlantic City meeting, I had heard Gehelin’s report of the benefit in epilepsy of periods of absolute fasting and was led thereby to look into the effect of prescribing a diet so designed that it would provoke ketosis— that is, a diet very high in fat and rigidly restricted in its content of carbohydrate.”

This is what Wilder wrote about in July 27, 1921 in The Clinic Bulletin– at least a year after he was already using a ketogenic diet in the treatment of diabetes (see above) .

Final Thoughts…

People think of a “keto diet” to treat diabetes as something new — as a “fad” even, but it has been used for over 100 years to do just that. Its therapeutic application in the treatment of epilepsy is rarely disputed yet its therapeutic use in the treatment of diabetes remains a hotly debated topic. This ought not to be.

While not everyone with type 2 diabetes wants to seek remission, those with diabetes who want choose a diet-first approach to treating the disease should be made aware that (1) such a choice exists, and as outlined in previous articles posted on this website (2) is considered safe and effective by Diabetes Australia, the American Diabetes Association (ADA), the European  Association for the Study of Diabetes (EASD), as well as Diabetes Canada. In addition, those with diabetes (3) should have the support of their healthcare team to implement such a diet with medical oversight and where needed to have their physician adjust their dosage of insulin / insulin analogues and to adjust / gradually deprescribe their oral diabetes medications, as carbohydrates are decreased.

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LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Wilder RM, The Clinic Bulletin Vol 2. No. 307, The Effect of Ketonemia on the Course of Epilepsy, July 27, 1921, https://www.neslazeno.cz/wilder-1921-the-effect-of-ketonemia-on-the-course-of-epilepsy/
  2. Wilder, Russell M. “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-50.” Perspectives in Biology and Medicine, vol. 1 no. 3, 1958, p. 237-277. Project MUSEdoi:10.1353/pbm.1958.0019.
  3. Steiner WR, The Starvation Treatment of Diabetes Mellitus, Transactions of the Connecticut State Medical Society, 1916
  4. Wilder RM, Foley MA, Ellithorpe D, A Primer for Diabetic Patients – a brief outline of the principles of diabetic treatment, sample menus and food tables,  The Mayo Clinic, W.B. Saunders Company Publishing, 1922