From the standpoint of the glycosuria, we may divide diabetes into the following groups for dietetic purposes:

1. After a few days of strict diet, the sugar disappears or is reduced to a trace. On resuming diet containing 100 - 200 grams of carbohydrates, the sugar does not exceed 10 grams. With reasonable care to avoid strain and excitement and with avoidance of malt and sweet liquors, avoidance or slight use of sugar, and moderate restriction of starches, life will probably not be materially shortened and a symptomatic cure may result.

2. The sugar is reduced almost or quite as much as in the first group, but more slowly. On resuming mixed diet, as before, the sugar averages 50 grams, but is reduced as before, if the carbohydrate is allowed in smaller quantities. Carbohydrates should be restricted to cereals including bread stuffs or cream or milk, and the total carbohydrate should not exceed 100 grams. The prognosis is fairly good, but symptomatic cure or indefinite prolongation of life is scarcely to be expected.

3. Considerable sugar persists in the urine on a strict diet and small allowances of sugar or even starch, produce a relatively enormous rise in the urine, even to 500 grams or more. The case is usually hopeless. Acid intoxication, including acetonaemia etc., develops if the diet is kept free from carbohydrates and the various symptoms are aggravated if they are allowed.

Polyuria, polydipsia, polyphagia, high specific gravity of urine etc., usually run fairly parallel with the elimination of sugar.

In noting the progress of a case of diabetes, do not neglect the nitrogenous elimination. Using the hypobromite test (Hind's Doremus' ureometer is the most convenient and accurate for clinical work), the nitrogen elimination, read as urea (though including ammonia etc.), should not exceed 30 grams. It may reach 100 grams or more. This indicates not only a waste of pro-teid food but of tissue. Usually the nitrogenous and saccharine elimination run approximately parallel.

From the dietetic standpoint, diabetes includes three main factors: 1. Elimination of sugar which, as stated, is not particularly serious unless the amount is great or unless it is formed from the tissues (and protein foods). 2. Waste of nitrogenous matter, in other words, destruction of tissue. 3. Acid intoxication, including the formation of beta-oxy-butyric acid, diacetic acid and, finally, acetone. (Note. - Owing to the lack of unanimity of opinion regrading clinical tests for these substances, they will not be discussed.)

Acid intoxication develops to a greater or less degree in starvation and in all conditions in which carbohydrates are not properly assimilated. It is sub judice whether the condition is due to faulty catabolism of proteins or fats. For practical purposes it is sufficient to remember that it may be prevented by securing the assimilation of about 80 grams of carbohydrate, daily.

Hence it is far less harmful to have a moderate elimination of sugar than to restrict the diet so closely as to produce acid intoxication.

A strict diabetic diet excludes all carbohydrates. It should contain about 70 grams of protein to allow amply for tissue waste, and enough more protein and fat to supply from 2,500 calories for a good sized man, exercising considerably but not excessively (all exhausting labor being contraindicated in diabetes), down to 1,800 calories for small adults practically confined to bed.

As the body never digests fats completely, and as the loss in the alimentary canal increases more rapidly than the total ingested, it is rarely advisable to administer more than 200 grams on any one day, nor more than 150 grams a day for any long period.

For mild cases of diabetes the diet should approximate the following standard:

There is always some waste of nourishment, amounting to about 10%. The carbodydrate assimilated can be estimated by subtracting the urinary sugar from the carbohydrate ingested but, if the patient eliminates as much as 10% of 200 grams of carbohydrate, the ingestion should be less.

For moderate cases, the diet should approximate the following standard:

If possible, without too much glycosuria or other symptoms, the starch should be held at 80 grams, even allowing for the loss in the urine of 20 grams. The protein can usually be held at 150 grams and, by the use of digestants, it can be fairly well digested. Fats are less easily cared for, but, by administering them in palatable form, 100 grams daily can almost invariably be given. At least 30 grams can be introduced by inunction, but it is rather doubtful whether fat thus administered, is utilized.

The following may be taken as the type of troublesome cases which approach the immediate danger line, but in which we can still give enough carbohydrate to avert acid intoxication, and in which sugar is not formed out of the tissues. By experiment it has been found that not much more than SO grams of carbohydrate can be given without considerable loss in the urine, that 80 grams produces a glycosuria of 20 grams, and that the urine will not become sugar-free, except after several days of strict dieting, during which signs of acid intoxication appear. Fats are not well borne in large amounts but 100 grams can be given with about 109c loss in the faeces. Protein digestion is poor, but 100 grams can be given.

Alcohol can be used to supplement nutrition, to the extent of 25 - 50 grams a day, by giving it in small doses, without much danger of intoxication, even in the physiologic sense, or of elimination unchanged to any great degree. It yields 7.1 calories per gram.