Narrative reviewindependent cross-checkfull text checked★ key study I-INS-101 in-depth review
What happened to people with diabetes before insulin existed
Why were "starvation diets" promoted for diabetes in the pre-insulin period?
Overview
Mazur A. Nutr J 2011 · PMID 21396115 · DOI 10.1186/1475-2891-10-23
Before 1922, children with diabetes usually died of diabetic coma within months to a few years, even on strict fasting diets; some starved to death.
Does the study support the specific claim? No · Methodological quality: low
Plain-language summary
Study explained simply
- What did the researchers want to find out?
To explain why fasting diets were used for diabetes before insulin and how patients fared.
- How was the study done?
Historical analysis of published case series and textbooks.
- How many people, animals or samples were studied?
Patients of Allen (76 published cases) and Joslin, 1914-1922.
- What was actually found?
Most children died of coma within months to years; 43% of Allen's cases were dead by 1917; four died of starvation; diabetes was not cured.
- How large was the observed effect?
43% mortality within a few years (Allen's series).
- What do the results mean in everyday life?
Diet and fasting alone cannot keep insulin-deficient diabetes alive; insulin changed this.
- What are the study's limitations?
Historical, uncontrolled data; diabetes types not distinguished.
- What does it say about Elawady's specific claim?
Contradicts claims that diet can replace insulin or that ketoacidosis does not kill.
- Do the results apply to Germany and Europe?
Universal biology.
- What can explicitly not be concluded from this study?
Cannot give exact survival curves or separate type 1 from type 2 cases.
Scientific in-depth review
1. Full reference
- Authors
- Mazur A
- Journal
- Nutr J
- Year
- 2011
- Identifier
- PMID 21396115 DOI 10.1186/1475-2891-10-23
- Verification
- verified – PubMed efetch 2026-10-26; Crossref 2026-10-26
- Retracted
- no
- Corrections
- none
- Extent checked
- full text
- Conflicts of interest and funding
Funded by the author (full text)
2. Research question
How were severe fasting/undernutrition diets justified and how did patients fare before insulin?
3. Study design and population
- Study design
- Narrative review – Historical review of primary sources (Allen 1919 case series of 76 patients; Joslin textbooks 1916-1917)
- Population
People with diabetes (mostly severe, juvenile-onset) treated 1914-1922 in the USA
- Country
USA
- Period
1914-1922 (sources); published 2011
- Sample size
Allen's Rockefeller series: 76 published cases (about 100 treated); Joslin case tables
- Inclusion and exclusion criteria
Not applicable (historical analysis)
4. Methods and endpoints
- Exposure / intervention
Fasting and severe calorie restriction ('starvation diet')
- Comparator
Earlier regimens; no formal control group
- Endpoints
Death, coma, 'inanition' (starvation), survival
- Statistical methods
Descriptive tabulation by the author
5. Actual results
- Results
Before insulin, 'most child diabetics died from coma within months to a few years of diagnosis'. Joslin had by 1916 lost 62 patients under 15 years, 'with coma always the cause of death'. Allen noted that 43% of his 76 cases were dead by late 1917 and acknowledged four deaths from starvation (inanition); the author's own tabulation found 46% of 41 patients with known status dead or nearly dead at end of 1917. Allen wrote that 'the diabetes is not cured'. Fasting reduced glycosuria and coma episodes in some patients but introduced death by starvation. A patient (Elizabeth Hughes) who fell to 45 pounds on the diet recovered on insulin and lived to 73.
- Absolute risks
43% of 76 patients dead within a few years of follow-up (Allen 1919, as reported)
- Authors' conclusion
Starvation diets were a desperate measure whose claimed scientific basis was exaggerated; clinical experience gave little indication that severe undernutrition was better than low-carbohydrate diets.
6. Strengths
- Uses primary historical case records
- Open-access full text read
7. Weaknesses
- Historical, uncontrolled case data
- Single author interpretation
- Mixed diabetes types (no modern classification)
8. Risk of bias
- Orienting tool
- none applicable
- Type of assessment
- simplified assessment (abstract only)
- Full formal assessment
- no
- Overall risk of bias
- not assessable
- Rationale
Historical narrative; numbers are from the original physicians' records as tabulated by the author.
9. Assessment of the statistical interpretation
Descriptive proportions only; no comparison group. Shows the scale of mortality with diet-only treatment of severe (insulin-deficient) diabetes.
10. Relevance to the specific claim
Shows what happens to insulin-deficient diabetes when it is treated with diet and fasting alone: most children died from diabetic coma (ketoacidosis) within months to years; fasting did not cure diabetes and caused starvation deaths.
11. Independent contrary findings
None; consistent with all accounts of the pre-insulin era.
12. Transferability to Germany and Europe
Directly applicable; same biology and clinical standards in Europe.
13. Overall methodological judgement
Strong historical evidence that diet and fasting cannot replace insulin in insulin-deficient diabetes.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | low |
| Risk of bias | not assessable |
| Precision of results | not applicable |
| Directness | direct |
| Reproducibility | replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | high |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
15. Linked fact checks
- There is no such thing as type 1 diabetes; 'type 1' is a state of high sugar seen mainly in athletes with high needs; type 1 patients do not develop complications; insulin before puberty is a catastrophe (short stature, thyroid problems, cysts). – Studies contradicting or limiting the claim
- Diabetic ketoacidosis (DKA) does not kill anyone; it should be treated with corticosteroids and complete fasting from food and drink for days, without insulin and without intravenous fluids; giving insulin in this situation is 'the black disaster'. – Studies contradicting or limiting the claim
- People with diabetes can stop insulin and diabetes medication by following the Tayebat system ('zero medicine'), as shown by followers who stopped insulin and are 'perfectly fine'. – Studies contradicting or limiting the claim
- Diabetes can be cured by following the Tayebat system without medication, illustrated by a patient who stopped insulin after 30 years of insulin use. – Studies contradicting or limiting the claim