EXERCISE IN THE TREATMENT OF DIABETES MELLITUS: AN HISTORICAL DEVELOPMENT APPROACH
by Mark Rakobowchuk B.Sc.

Mark Rakobowchuk is a Graduate Student attending McMaster having recently graduated from the Human Kinetics Program at the University of Ottawa. This study was supported by the Geza Hetenyi Memorial Studentship, administered by the University of Ottawa.

  1. Introduction
  2. Understanding of Diabetes: From Bouchardat to Banting and Beyond
    Exercise in Medicine
  3. Exercise in Diabetes Mellitus Therapy
  4. Discussion
  5. Acknowledgements
  6. References

 

Introduction

In the ever-advancing world of medicine many discoveries and medical advances are the result of scrupulous trial and error while other advances are the result of some luck and youthful defiance. The discovery and ultimate wide spread production of insulin for use by diabetics, seemed to many patients and some physicians to be the first step in conquering a disease usually accompanied by a death sentence. However, after eight decades of research, there have been few steps as significant in the battle against this disorder. The prevalence of diabetes mellitus among the general population has increased year upon year without fail1 . Currently, diabetes mellitus with its complications is the fourth among the leading causes of death in the United States. The disease’s total morbidity and mortality is probably sorely underestimated due to its many complications that ultimately cause death. Presently, there are approximately 17 million Americans living with diabetes mellitus of whom 90-95% suffer from type 2 or non-insulin dependent diabetes mellitus (NIDDM)2.

The increasing prevalence of diabetes mellitus has gained much attention over the past two decades. With 645 000 new cases diagnosed each year the diabetic population of the United States rises steadily. By 1993, 7.8 million Americans had diabetes and, as mentioned earlier, this population has since ballooned to roughly 17 million. An increasing number of children show the symptoms and clinical signs of insulin resistant type 2 diabetes mellitus3. Given that diabetes mellitus is an illness of epidemic proportions, treatment by means of exercise has taken an added importance.

The following account focuses on the use of exercise in the treatment of diabetes mellitus over the last century and a half. The first section consists of a review of the history of diabetes mellitus up until its differentiation into two distinctly different disorders. This is followed by a history of exercise with particular emphasis on its use in prevention and the treatment of illness since the time of Galen (180 A.D). Finally, the role of exercise in the treatment of diabetes mellitus will be the primary focus of the remainder of the paper.


 

 

Understanding of Diabetes: From Bouchardat to Banting and Beyond

Prior to the work accomplished by the Paris physician and hygienist Apollinaire Bouchardat (1806-1886), the etiology and the clinical manifestations of diabetes mellitus were unknown. At the same time as his friend Claude Bernard who was responsible for exploring the influence of the liver on blood sugar regulation, Bouchardat became an important figure in the diabetic community concerning its treatment and diagnosis. Some have even announced that he was “the most brilliant diabetic clinician in the history of diabetes.”4 His first major contributions came in the decade 1840 and 1850. Bouchardat is heralded as the first person to speculate that the primary cause of the disorder is in the pancreas5. He observed numerous autopsies, which revealed atrophy of the pancreas in those who suffered and died from diabetes mellitus. Bouchardat even went so far as to conduct several experiments with the help of Sandras in which total extirpation of the pancreas were attempted in dogs. His goal was to figure out the role of this enigmatic organ. Unfortunately, Bouchardat’s experiments resulted in nothing more than dogs that died prior to exhibiting the classic diabetic signs of polyuria, polydipsia and polyphagia. If he had managed to produce these signs, it is likely the research that led to the discovery of insulin would have been greatly accelerated6.

Following this first flash of brilliance, Bouchardat continued to contribute important advances to the diagnosis and treatment of diabetes mellitus. According to Elliot Joslin in a tribute article, Bouchardat would ask his patients to measure the sugar producing content in certain foods they fancied by tasting their urine. Although crude, this practice handed some of the responsiblility to the patient for the first time in diabetes treatment.7 With the advent of new chemical techniques, Bouchardat further helped to develop responsibility in his diabetic patients by having them routinely check their urine for the presence of glucose through the use of unslacked lime.

Although he may not have been the first person to note the importance of diet on the progression of the disease, he did manage to create diets which were palatable as compared to those of John Rollo, who preceeded Bouchardat. Rollo was a physician and surgeon who published a book titled “An account of Two Cases of the Diabetes Mellitus” (1798).8 He advocated a diet that consisted mostly of very poor quality rancid meats. As a consequence, it was not especially appetizing and thus, never becoming popular in the treatment of diabetic patients. Seeing no alternatives to this type of diet other than death, Bouchardat resurrected and improved on it. Each diet was specifically adjusted for each patient, as well; Bouchardat maintained the notion that the diabetic should eat as little as possible in the hope of prolonging life. This physician also invented a type of bread that did not aggravate the diabetic condition like regular white bread. Later, similar breads were developed by Pavy and Prout and Camplin referred to as almond cakes and bran bread respectively.

Bouchardat is credited with being the first clinician to use fasting days as a method for reducing glycosuria which he attributed to his observations during the German siege of Paris in 1870. During that time, the rationing of food resulted in reduced glycosuria and improved feelings of wellbeing among his diabetic patients. Of note and significance to this paper is the fact that Bouchardat recognized the beneficial effects of exercise. He was considered the first clinician to “intelligently” prescribe exercise to his diabetic patients.10 His views and research into the beneficial effects of exercise will be described in full later in the report. For years after, Apollinaire Bouchardat was regarded as the clinician of reference in diabetic therapy. Many reviews and tribute articles have been published regarding his life and his contributions to the advancement of diabetic therapy.11

Following Bouchardat a number of minor characters continued to make advancements with regards to the etiology and pathology of diabetes mellitus. Notably Petters (1857), was the first clinician to connect the peculiar smell on the breath of many severe diabetics to the cause of diabetic coma. By obtaining urine from a comatose patient, Petters found strong reactions for acetone.12 Another German investigator, a physiologist by the name of Bernhard Naunyn, became the premier diabetologist after Bouchardat. Although he did not contribute directly, his teachings and clinical experiences guided many of his pupils to important advances. His research group has been credited with the discovery of acidosis as the cause of the diabetic coma, which was brought about by experiments carried out by Hallervorden (1880), Stademann (1883), and Minkowski (1884). His group also came up with the alkali therapy of acidosis that showed the temporary benefits of this practice. Naunyn’s final contributions to the treatment and etiology of diabetes mellitus were the publishing of several texts which were used throughout the medical world.13

Probably the most famous of Naunyn’s pupils was Oskar Minkowski who discovered the pancreatic cause of diabetes mellitus.14 It so happened that during a conversation with Joseph von Mering regarding patients with diminished pancreatic function, Minkowski suggested total extirpation of the pancreas in order to prove one of von Mering’s hypotheses. Von Mering’s hypothesis was that patients with diminished pancreatic function should receive meals containing free fatty acids rather than neutral fats since they would be more easily assimilated. Minkowski suggested testing this hypothesis in dogs by feeding dogs free fatty acids or neutral acids after total extirpation of the pancreas. Without knowing that total pancreatectomy was a difficult procedure that had not been accomplished in the field of experimental medicine, Minkowski attempted it anyways. Later he would claim ignorance concerning the successful pancreactetomy by stating “had we realized that all previous attempts at pancreatectomy had led to nothing of note and that no less a person than Claude Bernard had stated that it was impossible for dogs to survive the total surgical removal of the pancreas, we would have certainly not dared to make a new attempt at this procedure.”15

It so happened that the operation was a success and soon after the operation von Mering departed on a trip. During von Mering’s absence, the dog recovered yet, although housebroken, developed acute polyuria. Minkowski, being the intelligent and observant physiologist, decided to test the urine for glucose. Finding glucose in the urine, Minkowski continued his investigation by performing total pancreatectomies on several other dogs before the return of von Mering. Upon his return, Minkowski informed von Mering of the fact that total extirpation of the pancreas regularly produced diabetes mellitus.16

Minkowski went on to complete a variety of experiments related to pancreatic diabetes. One of these involved removing 90 percent of the organ and grafting a small part of a dog’s pancreatic tissue subcutaneously following the surgery. The dog did not display the classic signs of diabetes until Minkowski removed the graft. These experiments showed that the pancreas must distribute some internal secretion that did not exit the pancreatic duct since upon removal of the graft glycosuria became evident.17

Following Minkowski, there was speculation that this internal secretion of the pancreas related to the metabolism of carbohydrates. In 1901 Eugene Opie established the relationship between this internal secretion and the newly discovered islets of Langerhans. Upon histological investigation of diabetic patients’ pancreases during autopsy, Opie discovered atrophy and irregularities specifically in the islet cells and not in the acinar cells. This furthered the theory of an internal secretion responsible for the regulation of blood sugar levels.18

Even before this discovery, the search was on to isolate the products of an internal pancreatic secretion. According to Labhart, a group of fourteen researchers made attempts at isolating this internal secretion during the period from 1892 until Banting and Best’s definitive discovery in 1921.19 The most persistent of these physiologists and clinicians had to have been Georg Ludwig Zuelzer. From the early part of 1903 and for twelve years thereafter, Zuelzer made attempt after attempt to treat diabetes with a pancreatic extract. At one point late in his attempts, he used his extract on eight willing subjects. He may even have isolated the products of the internal secretion of the pancreas, but he seems to have misinterpreted the signs and symptoms of hypoglycemia as toxic side effects of his extract.20 It is unfortunate that blood sugar measurements using small amounts of blood were not available at the time of Zuelzers’ discovery. If they had been, it is likely the discovery of insulin would have been greatly accelerated and many a diabetic life would have been saved.

Following Zuelzer, N.C. Paulesco continued the search for a pancreatic extract to lower blood sugar. Using similar methodology to those before him, Paulesco was able to show reduced glycosuria and ketonuria in dogs. Unfortunately, he was unable to use the extract in human trials resulting in a lack of credibility by the medical community.21 The work of Scott, Kleiner, Murlin and Kramer, of the United States and Gley of France encountered similar problems with clinicians.22

Unfortunately, the toxic side effects of these pancreatic extracts on animals precluded human trials. Thus, there was much skepticism upon the introduction of yet another pancreatic extract by Banting and Best late in 1921 and early 1922.23 In short, Banting and Best created an extract from degenerated canine pancreatic tissue which had the ability to reduce the blood sugar level of dogs which had under gone pancreatectomy. Banting had come up with the idea of ligating the pancreatic duct which would degenerate the pancreas and leave nothing but pancreatic beta cells. From these pancreatic beta cells Banting thought one could extract the internal secretion and use it intravenously to decrease hyperglycemia. Following the initial experiments most of which resulted in failure, Banting and Best finally managed to keep several dogs alive and healthy enough to attempt the extraction and use of the prized products of the internal secretion. Once they had found an extract that showed a reduction of hyperglycemia in dogs that had undergone pancreactomy, Banting and Best reported their findings to Professor J.J.R. MacLeod. With guidance from MacLeod, and the chemical expertise of J.B. Collip, the group managed to produce potent extracts suitable for clinical trials. For a complete history of the discovery of insulin, Micheal Bliss’s “The Discovery of Insulin” (1982) recounts Banting’s classic work at the University of Toronto.

Once initial trials proved effective in bringing diabetics out of comas and the hypoglycemic effects of the extract were understood, physicians from all across North America quickly began to inquire how they could obtain some of this "insulin" that had demonstrated such miraculous effects. The most recognized American physicians to use the insulin created at the laboratories of the University of Toronto were Elliot P. Joslin and Frederick M. Allen the prominent diabetologists of the time.

These two physicians can be credited with prolonging the lives of many diabetic patients prior to and following the age of insulin therapy. Elliot P. Joslin was a clinician who worked on the etiology of diabetes mellitus from the start to the finish of his long career. Allen is best known for his contributions to the dietetic treatment of diabetes prior to the discovery of insulin. Most of Allen's early work focused on experimental dietetic treatments. His book "Glycosuria and Diabetes" (1913) describes numerous experiments conducted on animals. This impressive book on the diabetic condition resulted in his appointment to the Rockefellar Institute for Medical Research. During his stay at Rockefellar, Allen employed the dietetic treatments first proposed by Bouchardat and many others before him. However, Allen continued to fine tune the diet to include fewer total calories and more harsh fasting sessions in order to rid his patients of glycosuria. Many patients describe his method as inhumane and some died from inanition rather than the disease Allen was combating.24 However his method was the only one that increased the life expectancies of diabetics at that time. In addition, he contributed to the research concerning exercise and how it affects diabetes mellitus. A more detailed account of his experiments and case studies will be presented in the section to follow.

In contrast, Joslin was not as harsh in his treatment of diabetes, but his criticisms of the obese and those who abused alcohol may be seen in several articles on the prevention and etiology of diabetes mellitus. Elliot Joslin began his distinguished career as a specialist in diabetic therapy. His practice was established around the turn of the century and over the subsequent 18 years he worked with over 1000 severely diabetic patients from all over the United States. He popularized the so-called Allen treatment of diabetes mellitus since he had gained considerable influence in the field of medicine. In addition, Joslin was one of the first physicians to use statistics to analyze the results of his treatments. He showed how his treatment strategy would lengthen life expectancies some 2 years beyond the 3.1 years that was the standard at the time.25 Later, his statistics and detailed case histories would be vital to deciphering some contributing factors in the predisposition to diabetes mellitus. For instance, the link between diabetes and obesity was already speculated upon by many diabetologists like von Noorden. However, Joslin provided statistical backing for this conclusion in his books describing his 1300 cases of diabetes mellitus.26

Following the celebrated discovery of insulin in Toronto, there were cases of diabetics who did not respond in the traditional manner to insulin therapy. These cases seemed to disagree with the theory that diabetes mellitus was a disease of the pancreatic islet cells. E. Frank was one of the first to notice this and published an article pertaining to the fact that some of their diabetic patients did not respond to insulin therapy, and thus, were referred to as insulin resistant.27 Other researchers, including Axelrod and colleagues, continued to advance this theory right up until the discovery of other drugs to combat diabetes mellitus.28 Many research groups independently discovered substances other than insulin that had the effect of eliminating glycosuria and reducing blood sugar to normal levels. These compounds belonged to a group called the sulfonylureas. One chemist Jandon working at the French company Rhône-Poulenc during WWII happened to create a drug that caused patients with typhoid to become severely hypoglycemic and die.29 This discovery went unnoticed until many years later when another group discovered a similar drug that had comparable consequences. Franke and Fuchs had stumbled upon another of the sulfonylureas and noted its hypoglycemic effect. This time, the discovery was published in a popular journal thus allowing widespread knowledge of these substances.30

Not long following the discovery of these substances which had the effect of increasing the release of insulin from islet cells, diabetes mellitus became differentiated into two subclasses. An ambitious study by J. Borstein and R.D. Lawrence in 1951, involved the isolation of insulin from blood taken from patients of two different classes 1) Those who were young and rapidly developing ketosis and 2) those who were middle-aged obese females with similar grades of hyperglycemia and glycosuria but with no ketosis. With their bioassay technique, they found that the first group was insulin deficient while the second had normal levels of insulin.31 This conclusion came as a surprise to the medical community and resulted in numerous attempts to verify the experiment. Unfortunately, it would require a new technique and a new era of research to give validity to the statements of Borstein and Lawrence. This new technique, known as immunoassay, was superior to the bioassay method. Rosalyn Yalow and Solomon Berson were the first to use this new technique on the diabetic population in 1959-60.32 As a result they are recognized as the researchers who distinguished diabetes mellitus as a disease with two distinctly different etiologies and somewhat different pathologies.

In 1979, the two subclasses of diabetes mellitus became official. By this time it had been almost 30 years since the experiments of Yalow and Berson and almost 55 years since the initial discovery of insulin by Banting and Best. Clinicians were in need of a system by which comparisons of data and patient information could be shared. For that reason, a group sponsored by the National Institute of Health proposed a classification system based on insulin dependence or non-dependence.33 Although this classification was a step in the right direction, it was not ideal since it was based on a pharmacological intervention approach to the disease. A more accurate group of subclasses of diabetes mellitus was proposed in 1997 by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. This revised system was based on the etiology, rather the pharmacological management of the disease. It consisted of two major classifications, those of Type 1 and Type 2. Type 1 involves ß-cell destruction usually leading to absolute insulin deficiency, while Type 2 involves insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance.34 With this new classification system, researchers are better able to compare data and understand the effects of various intervention protocols in diabetes mellitus therapy and prevention.


 

 

Exercise in Medicine

Although the history of sport may be traced back to prehistoric times, the history of the practice of exercise for hygienic and preventative measure may be assigned to the ancient Greek society. There has been speculation that exercise performed by the layperson was an idea first proposed by Greek philosophers and medical authorities during the 4th century B.C. Following initial references to the benefits of exercise by Hippocrates, there was a period in which little was written to further the notion of exercising for the benefit of one’s health and longevity. Then during the Roman period, another Greek figure emerged who furthered the Hippocratic teachings concerning exercise. This figure was Galen (131-200 A.D.)35 . Galen influenced the medical profession for many centuries to come with his ideas of “naturals”, “non-naturals” and “contra-naturals”. Of these terms, the “non-naturals” concern external or environmental factors. Their importance is based on the fact that the six “non-naturals” relate to practices that man should always strive to keep in balance. The “non-naturals” include: (1) air, (2) food and drink, (3) motion and rest, (4) sleep and wakefulness, (5) excretions and retentions, (6) passions of the mind36 . If kept in balance, the “non-naturals” would help to preserve health, or minimize disease and suffering.

The “non-natural” of particular interest to this essay is the third that deals with motion and rest. Ancient physicians had used the prescription of exercise as treatment for many diseases of the time including gout, dyspepsia, and constipation. However, exercise was a vital part of classical preventative hygiene, which remained part of formal medical training through to the eighteenth century37. One can find a great majority of Galen’s teachings on the subject of exercise in his book Hygiena that Robert Montraville Green translated to English in 1951. Several chapters focus on exercise in both the first and second parts of the book. Galen even gives a rough yet interesting definition of exercise as follows:

To me it does not seem to be that all movement is exercise, but only when it is vigorous. However, since vigour is relative, the same movement might be exercise for one and not for another. The criterion of vigorousness is change of respiration; those movements which do not alter the respiration are not called exercise.38

As well, he described the numerous benefits of exercise to the layman. Galen felt the use of exercise was fundamental to the effective removal of waste products from the body, and for the development of strength and the amelioration of metabolic function.39 The medical community wavered little from the teachings of Galen until the eighteenth century.

Prior to the invention of the printing press by Johannes Gutenberg, the ideas of exercise and its beneficial effects concerning hygiene and disease prevention failed to penetrate to the level of the local physician. These notions were not of particular importance since the majority of people worked laborious jobs that required physical exertion on a regular basis. These activities included cultivation and harvesting, iron working and military action. Around the 16th century, we see the re-emergence of Galen’s teachings in the Western societies of Italy, France, England and Germany. Throughout the 16th and 17th century, numerous books were published by physicians and educated laymen concerning the maintenance of hygiene. According to Byelbyl in his book describing the School of Padua, the 16th century was definitely “the golden age of Galenism” in which “Galen’s works were more widely available, and in more complete and accurate form, than previously.”40 A Spanish physician by the name of Christobal Mendez published one such book during this era. He is credited as being the first physician to devote an entire printed book to exercise. His book “Libro del Exercicio Corporal” or “Book of Bodily Exercise” was printed in 1553. Although it did not see widespread readership, it was quite insightful and informative for a book of its time. Like many other authors of the time, Mendez showed his Galenic influence using what he referred to as the “un-naturals” of which exercise was considered one. Mendez stated the therapeutic benefits of exercise compared to those of vomiting, bloodletting and purging which he held as unnecessary. He referred to exercise as “invented and used to clean the body when it was too full of harmful things. It cleans without any of the above-mentioned inconvenience and is accompanied by pleasure and joy… If we use exercise under that condition which we will describe, it deserves lofty praise as a blessed medicine that must be kept in high esteem”41

One other physician of note prior to the beginning of the eighteenth century was Thomas Sydenham. He promoted the use of exercise to maintain health. He much preferred horseback riding as an exercise of choice. As well, he cautioned against violent exercise followed by cold exposure. Even though science was beginning to gain a foothold in society as a voice of reason, the mystique of spirits still had some bearing on the suggestions of physicians of the time.42

During this same period, numerous other authors including Luigi Cornaro (1467-1565), Girolamo Cardano (1501-1576) and Hieronymus Mercurialis (1530-1606) wrote books pertaining to the benefits of livings a sober life, and exercising as a means for preserving the quality of life and even prolonging it. Evidently, they practiced what they preached and their long lives were definitely responsible for some of their popularity and notoriety. In addition, all were advocates of Galen’s teachings and quoted the ancient Greek physician intentionally and at times failing to give him credit in their works.

Moving into the eighteenth and nineteenth centuries, Galen’s teachings were seen to be complementary to the views science was developing. Experimental and clinical investigations gave new understanding to disease and the role of hygiene as well as exercise in society. During the preceding centuries, authors were physicians and scientists writing for the educated, aristocratic and professional class men who had a tendency to overeat and drink in excess.43 However, a new movement was afoot and the introduction of a new subject was underway in the school system. No longer, was the physician responsible for educating youth about what exercise could do for them, rather it was the educated laymen and schoolteachers who took up this responsibility. This new subject was “Physical Education”, a title that would stick for decades to follow. One of the first individual to make a mark on the education of youth with regards to exercise was one Johann Christoph Friedrich Guts Muths at around the turn of the century.

Guts Muths received a well-rounded education, which included studying the likes of Sydenham, Locke, Fuller, and Hobbes, en route to becoming a teacher in Schnepfenthal, Germany. This placement could not have been better since gymnastics classes had just been implemented as part of the official curriculum a few years prior to his arrival. Guts Muths was responsible for teaching this class throughout his career. In 1803, he published a book on physical activity titled “Gymnastik für die Jugend (Gymnastics for Youth)” which would be translated into various languages and used on two continents as the basis of physical education.44 Throughout this work, Guts Muths mentions the need for harmony and balance between the body and mind. Moreover, the influences of the aforementioned pioneers of physical education were widely apparent through this notion of body and mind education. At one point in this book, he parallels the two in a chart like form as follows:

Health of body—serenity of mind
Hardiness—manliness of sentiment
Strength and address—presence of mind and courage
Activity of body—activity of mind
Excellence of form—mental beauty
Acuteness of the senses—strength of understanding45

Although Guts Muths did not teach the medical and physiological benefits of exercise, he did manage to obtain a place for physical education within many schools. His argument that education was deficient without physical education became his motto. The combined education of both mind and body became a pertinent part of educational systems all over the world, and this, had repercussions for the medical community that were far-reaching. By educating students to participate in physical activity, Guts Muths was directly responsible for a healthier community even if he personally went largely unnoticed by the medical community.

While the education system adopted physical education programs, the medical community did not remain idle in its opinions and recommendations concerning exercise. A researcher in physiology, Andrew Combe, continued the ethos that a developed body aids the mind in its day-to-day tasks. He published an article in a journal called the American Annals of Education, which was intended to inform American teachers on proper curriculum. His article stressed the mind-body connection and the need for physical education in schools nationwide. Many other physicians including John Jeffries from Boston followed his lead in the area of physical education for youth.46 By educating the youth of that era through its teachers, physicians were making the first attempts to prevent illness through exercise rather than simply treat illness with exercise. Later still, physicians would use exercise in the fight against diabetes mellitus. Prominent diabetologists including Elliot Joslin and many other mid to late 20th century physicians and physiologists would help exercise become part of diabetic treatment.


 

 

Exercise in Diabetes Mellitus Therapy

Exercise as a part of diabetes mellitus prevention and therapy has gained in popularity over the past two decades as more research has become available. However, its use is definitely not a novel approach in the management of this disease. According to the American College of Sports Medicine (ACSM), indications of the effectiveness of exercise in reducing glycosuria have been evident since 600 B.C. when an East Indian text, the Shushruta noted the reduction in the sweetness of urine from diabetic patients following exercise.47 In Greece, another medical writer, Celsus, had specifically prescribed exercise in the treatment of diabetes. Celsus advocated the use of exercise, massage and other treatments to improve the wellbeing of diabetics.48 Eventually, exercise became one of the three corners of diabetes therapy, which also include diet and medications.

Many modern diabetologists praise Bouchardat for his contributions to the advancement of dietetic therapy prior to the introduction of insulin therapy. However, Bouchardat also made note of the particularly beneficial effects of exercise during his career. During this age of experimentation, he was the first individual to show the benefits of exercise on the tolerance of carbohydrates in his patients. Allen, who would be the next person to continue with these experiments, praised Bouchardat as the first clinician to introduce “the intelligent use of exercise in the treatment of diabetes.”49

His publication “De la Glycosurie ou diabète sucré” was somewhat of a final memoir of his experiences treating this affliction during the previous few decades. In this manual, Bouchardat devoted a rather large portion to the discussion of exercise in diabetes therapy. The section was titled “De l’exercise forcé comme bases du traitement de la glycosurie” and as one can interpret from the title, exercise was one of the important components of the treatment of diabetes that also included diet and medications. In this section of the book, Bouchardat gives several examples of case histories in which the patients were feeble upon their arrival in his clinic. He began exercise treatment as soon as diet treatment ensured the stability of the diabetic condition.50 His recommendations for exercise included many common activities of that time including hunting, military exercises, callisthenics, skating, cricket and even billiards if performed for a long duration. He also pointed out that most diabetics should be able to continue to perform manual labour and chores once their condition improved. In general, Bouchardat concluded that energetic work performed in an outdoor environment increased carbohydrate utilisation and tolerance even though it did not always result in complete elimination of glycosuria.51 In addition, one should note the case histories that Bouchardat chose to include in this publication. Most were middle-aged or older and obese prior to the manifestation of diabetic symptoms.

After the Bouchardat era of diabetes mellitus therapy, there were several proponents and opponents of the idea that exercise therapy was beneficial. One physician who did not approve of exercise in diabetic patients was J. Seegen. According to Allen, Seegen thought that the increasing use of exercise in diabetic therapy was a dangerous trend. Perhaps Seegen noted the detrimental effects of exercise on patients with severe forms of diabetes mellitus or possibly in those of type 1 diabetics.52 However, in the ensuing decades opponents to exercise therapy would change their attitudes due to some of the first research in the area of exercise physiology. A group of French researchers led by Chaveau and Kaufman measured the uptake of glucose by working muscle and found it to be higher than resting muscle. In addition, a reduction in blood glucose levels with muscular exercise was apparent.53 With this new scientific evidence, the therapeutic benefits of exercise, so long held by Bouchardat, became common practice in other clinics for diabetics.

Some 50 years after the work of Bouchardat, a new researcher emerged and continued with experimental studies of diabetes mellitus and the influences of exercise on treatment and prognosis. This researcher was Frederick M. Allen. Just prior to insulin therapy, Allen conducted experiments that pushed exercise therapy to the limits. He sought to have his patients prolong their life expectancies and the quality of such life through all the benefits of exercise therapy. In “Total Regulation in the Treatment of Diabetes” (1919), Allen and colleagues describe several cases studies of the benefits of exercise of an aerobic nature on the blood sugar levels and glycosuria of different classes of diabetic patients. He had some of his subjects climb upwards of 150 flights of stairs each day. Although this was extreme, Allen consistently showed that this sort of exercise could increase the tolerance for carbohydrates in all of his subjects. Allen also claimed to have combined the dietetic and exercise treatments in such a way as to allow almost all patients to perform exercise and to enjoy the metabolic benefits already mentioned regarding exercise therapy. While the metabolic benefits were well presented in this monograph, so too were the qualitative benefits of exercise. Allen suggested that exercise gave diabetic patients newfound strength and new hope that they may live productive lives with the disease.54 Specifically in a study he conducted in 1915, Allen found that an initial fast that combined exercise and diet restriction had the same effect as several days of fasting. This alone would have reduced the suffering his patients would have to endure by following his strict fasting regime.55 In addition, with the use of exercise his patients were allowed to consume more food, which was a liberty, uncommon in his diabetes clinic. The type of exercise he suggested in the conclusion of this study involved exercise of high intensity followed by rest periods of low intensity exercise. This is very similar to the principle of interval training, which is the base of many modern athletic programs. He liked to compare his training regimes for his patients to those of athletes readying themselves for competition.

Allen continued to work on the effects of exercise as a part of diabetes mellitus therapy for some time after his work published in that monograph. However, Allen did not pursue this area of study once the widespread use of insulin began in early 1923.

Another American diabetologist who contributed to the progression of exercise therapy in the diabetic population was Elliot P. Joslin. He emphasized prevention, believing that diabetes had the potential to reach epidemic proportions in the future. His article published early in 1921 “The Prevention of Diabetes Mellitus”, demonstrated conclusively the link between diabetes and obesity. Using 1063 cases, Joslin showed that marked obesity preceded the disease in a vast majority of cases. Throughout the article Joslin makes reference to the lack of physical activity and the over eating that was and still is normal practice in homes across America. He concludes that “diabetes is largely a penalty of obesity, and the greater the obesity, the more likely is Nature to enforce it.”56 Joslin’s contributions concerning the etiology of diabetes mellitus would help to delineate this disease into two separate subclasses in the years to come.

With the discovery of insulin, experimental information concerning the effect of exercise on the potency of insulin was explored. Several researchers jumped onto the notion that insulin was more potent in those patients who participated in exercise or sport and resulted in many accidental hypoglycemic events when insulin requirements were overestimated. One of the first papers on the subject appeared in the British Medical Journal authored by K.S. Hetzel. This researcher had noted the results of Allen’s numerous exercise studies, yet held the belief that severe diabetics were best not to perform strenuous exercise. Unfortunately in this first attempt, the methods used to explore the effect of exercise on insulin potency were not well developed. Rather than using strenuous exercise of long duration such as in the Allen experiments, the author used extremely acute exercise bouts reaching only 5 minutes in duration. This did not allow for logical comparisons to be made between his results and those of Allen. Although the initial idea was innovative, it would be R.D. Lawrence who would make a fair comparison between Allen’s results and the effect of exercise on insulin strength.

Lawrence states the inherent problems of Hetzel’s experiments. Particularly, Hetzel failed to measure blood sugar levels at the appropriate times following exercise bouts, which was from 1 to 4 hours following injection. By comparing trials of exercise and non-exercise in the same patients, Lawrence shows the positive effect of exercise on insulin activity and its hyperglycemia reducing abilities. With these results in hand, Lawrence would be the first to make recommendations about when insulin dependent diabetics should participate in exercise and sporting activities. He suggested avoiding exercise during the peak periods of insulin action i.e. 1 to 4 hours after injection. As well, he suggested a reduction in the amount of insulin taken by those diabetics. These suggestions are still cornerstones physicians use to explain to type 1 diabetics today, some 75 years later.

At this point research concerning exercise in diabetic therapy became somewhat of an afterthought. Little was published due to the imminent war and, immediately following it, exercise physiology became focused on the “normal” man. There was so little known about the effects of exercise and training in the normal population that little research was conducted on diseased populations. It would be several decades later when the physiology of exercise was understood to an extent that studies on diabetic patients would continue and progress. By 1960, blood insulin levels were being easily measured and the development of two types of diabetes was being established. In addition, some patients with diabetes mellitus were being labeled as resistant to insulin. At this point, the categories were aptly named juvenile and age-onset diabetes mellitus to describe the majority of the individuals in each category. Eventually a more logical distinction was made when patients were referred to as those with Type 1 and Type 2 diabetes mellitus. With these developments fully established, as described in a previous section, studies in Type 2 diabetics became a ripe area for research. Physicians and exercise physiologists focused their efforts on Type 2 diabetics because early research indicated that population to be the most responsive to exercise therapy.


 

 

Discussion

In summary, it is apparent that exercise used as prevention and therapy in the diabetic community is not a new concept. Prior to 1850, lifestyle modifications were primarily an adjustment of diet with exercise becoming a cornerstone of therapy by the early part of the 20th century. Currently, research concerning lifestyle modifications continues at various centers around the world. One recent study focused on the prevention of diabetes mellitus using different methods. Subjects in this study were at risk of developing diabetes prior to their inclusion and these subjects varied widely in race, gender, economic and social standards. Three randomized were compared, a placebo group, a group who took daily doses of metformin an antihyperglycemic agent, and a group who underwent intensive lifestyle modifications consisting of diet and exercise intervention. By the end of this 24 week study, significant differences in the incidence of diabetes mellitus among the three groups were found. As expected, both the metformin and lifestyle groups showed much lower instances of diabetes mellitus. Yet even more striking was the significantly lower incidence of diabetes mellitus among those in the lifestyle group compared to the metformin group.57 This is another example of what was preached by Bouchardat, Joslin, Allen and many other prominent figures of the past. That is diabetes is best controlled and prevented by simple alterations of diet and physical activity.


 

 

Acknowledgements

The author would like to thank Professor Toby Gelfand and Dr. Caroline Hetenyi for their suggestions and discussions of this paper en route to the final product. Also, thanks are given to several individuals from the School of Human Kinetics, Francois Haman PhD. Candidate (Biology) and Professor Frank Reardon whose suggestions were vital to the Exercise in Medicine portion of this report.


 

 

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  7. Ibid p. 491.

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  38. Ibid.p.54

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  49. Bouchardat, A. Ibid, p.223.

  50. Ibid, p.224.

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  53. Ibid p.468-93.

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  55. Joslin, E.P. The Prevention of Diabetes Mellitus. The Journal of the American Medical Association 76(2):79-84, 1922.

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©2003, Mark Rakobowchuk B.Sc