Glucose levels: Tight control vs “living normal”

The initial euphoria from the discovery of insulin began to fade in the 1930s.  It became clear that although insulin allowed patients with diabetes to live longer, they had to deal with the many complications.  The primary question for diabetes researchers shifted to what was causing the complications and what could be done about them.

One ongoing problem was control of blood glucose levels.


For decades the debate raged.  On one side stood George Minot’s doctor, Elliot Joslin, who believed that tight control over blood sugar was the key to minimizing complications.  His treatment of patients with diabetes was only slightly modified by the discovery of insulin.  He taught his patients that, even with insulin, they needed to follow a strict diet.  Joslin thought that blood glucose levels of patients with diabetes should be similar to those without diabetes.  He was the primary proponent of “tight control” of blood glucose levels.

Joslin’s view was formed in the pre-insulin era.  His hypothesis was that the pancreas in most diabetic patients wasn’t gone, like Minkowski’s dogs’ pancreases, but just damaged. [tattersall, quest for normoglycemia]. He thought that the pancreas needed rest and could regain its ability to generate insulin.  This rest, he reasoned, could only be provided by restricting the patient’s  diet.  He would alter the patient’s diet between weeks of rest (low carbohydrates and low overall calories) and weeks of work, where the pancreas would be tested to see how many calories and how much carbohydrates it could handle.

Dr Edward Toltoi thought tight control of blood glucose was too hard to maintain and not relevant to the patient's health.
Dr Edward Tolstoi thought tight control of blood glucose was too hard to maintain and not relevant to the patient’s health.

The other side of the debate was ably represented by a New York doctor, Edward Tolstoi, from New York Hospital and Cornell Medical School.  He took the position that dietary control should be loosened.  He thought that as long as the patients were feeling good, one shouldn’t worry too much about the precise level of their blood sugar.

Tolstoi wrote:

“… after speculations are repeated often enough they are accepted as facts.  This is particularly true when one’s opportunities to test a given hypothesis are limited.  Examples of this are rotted ideas that hyperglycemia causes arteriosclerosis and predisposes the diabetic to infections.  Of course, the most ardent protagonists of these hypotheses admit that the evidence for such assumptions is not very conclusive, yet these statements continue to be perpetuated and quoted as established facts. . . Although we do not know what may happen to our patients over a longer period of time, our experience with shorter periods prompts us to hazard the thought that they will not suffer from unusual complications.  We make this statement reservedly, fully realizing that there is a huge hiatus between impressions and factual knowledge.” [treatment of diabetes mellitus with protamine insulin, Tolstoi]

After insulin became available, Joslin viewed externally administered insulin as an aide, but not a replacement.  He thought insulin should be administered in small doses several times per day and a minimal diet must also be maintained.  In contrast, the other camp led by Tolstoi, held that patients should eat a normal diet and insulin could be adjusted to their needs. He recommended a single dose of protamine insulin each morning.  Tolstoi noted that his patients were in good health, they lived normal lives, and they were happy.  In contrast, Joslin’s patients had to carry insulin and syringes to every meal, they were chronically hungry and underweight, and often suffered from infections or other ailments.  Joslin was adamant in his belief that his patients would ultimately have fewer complications due to their tight control of blood glucose, but Tolstoi pointed out there was no evidence of this contention.

This debate took place mainly in the medical literature, but there was one memorable in person debate.  It was held in 1951. It started at 8 pm at the New York Academy of Medicine.   The auditorium was packed an hour before they started.   The debate took the form of 45 minute uninterrupted presentation by each physician.  These presentations was followed by heated discussion that went well into the night[Guthrie, controversies of the sweet urine disease].