The Case Against Sugar

INTRODUCTION

WHY DIABETES?

"Mary H—an unmarried woman, twenty-six years of age, came to the Out Patient Department of the Massachusetts General Hospital on August 2, 1893. She said her mouth was dry, that she was “drink- ing water all the time” and was compelled to rise three to four times each night to pass her urine. She felt “weak and tired.” Her appetite was variable; the bowels constipated and she had a dizzy headache. Belching of gas, a tight feeling in the abdomen, and a “burning” in the stomach followed her meals. She was short of breath." --Elliott Joslin’s diabetes “case no. 1,” as recorded in the case notes of his clinic.

Elliott Joslin was a medical student at Harvard in the summer of 1893, working as a clinical clerk at Massachusetts General Hos- pital, when he documented his rst consultation with a diabetic
patient. He was still a good three decades removed from becom- ing the most in uential diabetes specialist of the twentieth century. The patient was Mary Higgins, a young immigrant who had arrived from Ireland ve years previously and had been working as a domestic in a Boston suburb. She had “a severe form of diabetes mellitus,” Joslin noted, and her kidneys were already “succumbing to the strain put upon them” by the disease.

Joslin’s interest in diabetes dated to his undergraduate days at Yale, but it may have been Higgins who catalyzed his obsession. Over the next ve years, Joslin and Reginald Fitz, a renowned Har- vard pathologist, would comb through the “hundreds of volumes” of handwritten case notes of the Massachusetts General Hospital, looking for information that might shed light on the cause of the disease and perhaps suggest how to treat it. Joslin would travel twice to Europe, visiting medical centers in Germany and Austria, to learn from the most in uential diabetes experts of the era. 
In 1898, the same year Joslin established his private practice to specialize in the treatment of diabetics, he and Fitz presented their analysis of the Mass General case notes at the annual meeting of the American Medical Association in Denver. They had exam- ined the record of every patient treated at the hospital since 1824. What they saw, although they didn’t recognize it at the time, was the beginning of an epidemic.

Among the forty-eight thousand patients treated in that time period, a year shy of three-quarters of a century, a total of 172 had been diagnosed with diabetes. These patients represented only 0.3 percent of all cases at Mass General, but Joslin and Fitz detected a clear trend in the admissions: the number of patients with diabetes and the percentage of patients with diabetes had both been increasing steadily. As many diabetics were admitted to Mass General in the thirteen years after 1885 as in the sixty-one years prior. Joslin and Fitz considered several explanations, but they rejected the possibility that the disease itself was becoming more common. Instead, they attributed the increase in diabetic patients to a “wholesome tendency of diabetics to place themselves under careful medical supervision.” It wasn’t that more Bosto- nians were succumbing to diabetes year to year, they said, but that a greater proportion of those who did were taking themselves off to the hospital for treatment.

By January 1921, when Joslin published an article about his clinical experience with diabetes for The Journal of the American Medical Association, his opinion had changed considerably. He was no longer talking about the wholesome tendencies of diabetics to seek medical help, but was using the word “epidemic” to describe what he was witnessing. “On the broad street of a certain peaceful New England village there once stood three houses side by side,” he wrote, apparently talking about his hometown of Oxford, Massachusetts. “Into these three houses moved in succession four women and three men—heads of families—and of this number all but one subsequently succumbed to diabetes.” 

Joslin suggested that had these deaths been caused by an infec- tious disease—scarlet fever, perhaps, or typhoid, or tuberculosis— the local and state health departments would have mobilized investigative teams to establish the vectors of the disease and prevent further spread. “Consider the measures,” he wrote, “that would have been adopted to discover the source of the outbreak and to prevent a recurrence.” Because diabetes was a chronic dis- ease, not an infectious one, and because the deaths occurred over years and not in the span of a few weeks or months, they passed unnoticed. “Even the insurance companies,” Joslin wrote, “failed to grasp their significance.” 

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We’ve grown accustomed, if not inured, to reading about the ongoing epidemic of obesity. Fifty years ago, one in eight American adults was obese; today the number is greater than one in three. The World Health Organization reports that obesity rates have doubled worldwide since 1980; in 2014, more than half a billion adults on the planet were obese, and more than forty million children under the age of ve were overweight or obese. Without doubt we’ve been getting fatter, a trend that can be traced back in the United States to the nineteenth century, but the epidemic of diabetes is a more intriguing, more telling phenomenon.

Diabetes was not a new diagnosis at the tail end of the nine- teenth century when Joslin did his rst accounting, rare as the disease might have been then. As far back as the sixth century b.c., Sushruta, a Hindu physician, had described the characteristic sweet urine of diabetes mellitus, and noted that it was most common in the overweight and the gluttonous. By the rst century a.d., the disease may have already been known as “diabetes”—a Greek term meaning “siphon” or “ owing through”—when Aretaeus of Cappodocia described its ultimate course if allowed to proceed untreated: “The patient does not survive long when it is completely established, for the marasmus [emaciation] produced is rapid, and death speedy. Life too is odious and painful, the thirst is ungov- ernable, and the copious potations are more than equaled by the profuse urinary discharge. . . . If he stop for a very brief period, and leave off drinking, the mouth becomes parched, the body dry; the bowels seem on re, he is wretched and uneasy, and soon dies, tormented with burning thirst.” 


Through the mid-nineteenth century, diabetes remained a rare af iction, to be discussed in medical texts and journal articles but rarely seen by physicians in their practices. As late as 1797, the British army surgeon John Rollo could publish “An Account of Two Cases of the Diabetes Mellitus,” a seminal paper in the history of the disease, and report that he had seen these cases nineteen years apart despite, as Rollo wrote, spending the intervening years “observ[ing] an extensive range of disease in America, the West Indies, and in England.” If the mortality records from Philadelphia in the early nineteenth century are any indication, the city’s resi- dents were as likely to die from diabetes, or at least to have diabetes attributed as the cause of their death, as they were to be murdered or to die from anthrax, hysteria, starvation, or lethargy.

In 1890, Robert Saundby, a former president of the Edinburgh Royal Medical Society, presented a series of lectures on diabetes to the Royal College of Physicians in London in which he estimated 
that less than one in every fty thousand died from the disease. Diabetes, said Saundby, is “one of those rarer diseases” that can only be studied by physicians who live in “great cent[er]s of popula- tion and have the extensive practice of a large hospital from which to draw their cases.” Saundby did note, though, that the mortality rate from diabetes was rising throughout England, in Paris, and even in New York. (At the same time, one Los Angeles physician, according to Saundby, reported “in seven years’ practice he had not met with a single case.”) “The truth,” Saundby said, “is that diabe- tes is getting to be a common disease in certain classes, especially the wealthier commercial classes.”

William Osler, the legendary Canadian physician often described as the “father of modern medicine,” also documented both the rarity and the rising tide of diabetes in the numerous editions of his seminal textbook, The Principles and Practice of Medicine. Osler joined the staff at Johns Hopkins Hospital in Bal- timore when the institution opened in 1889. In the first edition of his textbook, published three years later, Osler reported that, of the thirty- ve thousand patients under treatment at the hospital since its inception, only ten had been diagnosed with diabetes. In the next eight years, 156 cases were diagnosed. Mortality statistics, wrote Osler, suggested an exponential increase in those reportedly dying from the disease—nearly doubling between 1870 and 1890 and then more than doubling again by 1900.

By the late 1920s, Joslin’s epidemic of diabetes had become the subject of newspaper and magazine articles, while researchers in the United States and Europe were working to quantify accurately the prevalence of the disease, in a way that might allow meaningful comparisons to be drawn from year to year and decade to decade. In Copenhagen, for instance, the number of diabetics treated in the city’s hospitals increased from ten in 1890 to 608 in 1924—a sixty-fold increase. When the New York City health commissioner Haven Emerson and his colleague Louise Larimore published an 
analysis of diabetes mortality statistics in 1924, they reported a 400 percent increase in some American cities since 1900—almost 1,500 percent since the Civil War.

Despite all this, the disease remained a relatively rare one. When Joslin, working with Louis Dublin and Herbert Marks, both statis- ticians with the Metropolitan Life Insurance Company, examined the existing evidence in 1934, he again concluded that diabetes was rapidly becoming a common disease, but only by the stan- dards of the day. He conservatively estimated—based on what he considered careful studies done in New York, Massachusetts, and elsewhere—that only two to three Americans in every thousand had diabetes.