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Shortly before the discovery of insulin, the prominent American physicians Frederick Allen and Elliott Joslin advocated severe fasting and undernutrition to prolong the lives of their youthful diabetic patients. Detractors called this “starvation dieting,” and indeed, some patients did starve to death. The public record contains only the briefest account of relevant animal experiments, and clinical experience at the time provided little indication that severe undernutrition had better outcomes than low carbohydrate diets then in use.

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Frederick M. Allen and Elliott P. Joslin were among the most prominent diabetes specialists in America during the first third of the 20th century. From 1915 until the introduction of insulin in 1922, they promoted what have been pejoratively called “starvation diets” based on repeated fasting and prolonged undernourishment, not as a cure, but for symptom relief and maximum extension of life [1].

Fasting did reduce glucose levels in diabetics, but prolonged calorie-restricted diets introduced new hazards, most obviously death by starvation, which Allen and Joslin euphemistically called “inanition.” It is accepted today that calorie restriction is beneficial for diabetics who are overweight. But for those of normal or lower weight, it was already understood in Allen’s time that severe calorie restriction could lessen resistance to infection, and for children it might stunt growth. The diet was unpleasant, difficult to maintain, and enervating, with the result that many patients withdrew from the regimen. Observers wondered if such privation was too high a price for a modest extension of poor-quality life. Joslin commented retrospectively, “We literally starved the child and adult with the faint hope that something new in treatment would appear... It was no fun to starve a child to let him live” [2].

Allen’s most famous patient was Elizabeth Hughes, the daughter of Charles Evans Hughes, Governor of New York, Republican candidate for the presidency in 1916, and finally Chief Justice of the US Supreme Court. Elizabeth developed diabetes in 1919 at age 11 years, her height then was 4 ft 11.5 inches, her weight 75 lb. She was treated initially by Dr. Allen who put her on a week of fasting followed by a diet of 500 calories daily with one fast day per week, bringing her weight down to 55 lb. Freed of glycosuria (sugar in the urine), her diet was raised to 1,250 calories, except on fast days, and her weight rose above 60 lb. At that time, most child diabetics died from coma within months to a few years of diagnosis [3]. It is difficult to judge how much Allen’s regimen prolonged Elizabeth’s life. She disliked the treatment as well as Dr. Allen, but she adhered to the diet with oversight from her nurse companion.

Although an exemplary patient, Elizabeth deteriorated seriously by the winter of 1921/22 when she weighed 45 lb. Her mother pleaded with Canadian doctor Frederick Banting, a recent discoverer of insulin, to include Elizabeth as a trial patient. Marvelously successful, Elizabeth regained weight and later graduated from Barnard College. She married, had 3 children, and was active throughout her life in civic affairs, all the while on insulin, until she died of pneumonia in 1981 at the age of 73 years. Few of her friends knew she was diabetic [4].

Allen knew that carbohydrates are the component of the diet that most affects blood glucose. Many practitioners of the time, and earlier, prescribed an “animal diet” or other low carbohydrate variation to clear glycosuria. Critics of the Allen-Joslin therapy claimed as much success, without near-total food privation, using diets low on carbohydrates but allowing more fat calories [5, 6]. Why then did Allen – and Joslin following him – virtually starve their patients?