Monday, May 26, 2014

At The Library


“I think the health of our civilization, the depth of our awareness about the underpinnings of our culture and our concern for the future can all be tested by how well we support our libraries.”
CARL SAGAN, Cosmos, 1980

“Libraries are brothels for the mind.  Which means that librarians are the madams, greeting punters, understanding their strange tastes and needs, and pimping their books.  That’s rubbish, of course, but it does wonders for the image of librarians.”
GUY BROWNING, The Guardian, October 18, 2003

Finding credible information, let alone an optimal treatment, for diabetes shouldn’t be a terribly difficult task.  The options of said optimal treatment, however, permutations of direct or indirect influencers of blood sugar are finite but vast.  So how does one find then categorize the differing options, narrowing the field to such optimal solution, in spite of credible, though oftentimes divergent information?  Well, there really are only a few places that house and disseminate such information: a doctor, the internet, a friend, other health-providers such as a nurse or dietician, a bookstore, a national library[1] such as the US Library of Congress, a private library, or a regional, state, city, university, or local library.

There certainly must be good information about diabetes somewhere on the internet,[2] and it does provide the added benefit of being accessible by anyone on the globe with a connection and an interface.  Trouble is, navigating to all the relevant sites, documenting, cataloging, then analyzing and drawing conclusions about a best practice from the internet, unless you have a specific site in mind already, is a near-impossible task, as we shall see.

Searching the term “diabetes” on five well-known search engines in early 2009, I found the following number of relevant pages: 82,000,000 on GOOGLE, 395,000,000 on YAHOO, 49,000,000 on MSN, 12,769,380 on LYCOS, and 11,380,000 on ASK.  Working alone, and assuming that I’m able to successfully navigate to each site, spending no more than ten minutes total reading through each site, documenting my findings, and navigating to the next site, for eight hours each day, including weekends, it would take 4,703 years to work through the GOOGLE search results, 22,546 years to catalogue YAHOO’s, 2,842 years for MSN, 729 years to get through the results from LYCOS, and 650 for ASK.  I’ll leave this problem to a more ambitious researcher with substantially more resources at hand to solve.

Before I move on, however, it is important to remember that we have put ourselves in the shoes of a recently diagnosed person with diabetes, and thus are tying to find the optimal solution to our disease.  But the search results, if that task is ever completed, from the internet will not be presented to us categorized as “good” or “bad,” “effective” or “ineffective,” “true” or “not true.”  It is up to the searcher to make that determination.  This concept is best summarized by Hal Abelson, Ken Ledeen, and Harry Lewis, in their book  Blown to Bits:  Your Life, Liberty, and Happiness After the Digital Explosion (2008):

“The web is no longer a library.  It is a chaotic marketplace of the billions of ideas and facts cast up by the bits explosion.  Information consumers and information producers constantly seek out each other and morph into each other’s roles.  In this shadowy bits bazaar, with all its whispers and its couriers running to and fro, search engines are brokers.  Their job is not to supply the undisputed truth, nor even to judge the accuracy of material that others provide.  Search engines connect willing producers of information to willing consumers.  They succeed or fail not on the quality of the information they provide, because they do not produce content at all.  They only make connections.  Search engines succeed or fail depending on whether we are happy with the connections they make, and nothing more.  In the bazaar, it is not always the knowledgeable broker who makes the most deals.  To stay in business, a broker just has to give most people what they want, consistently over time.”[3]

Skipping doctors, friends, family, relatives, other health-care providers, periodicals, and bookstores as sources of objective information for the moment, let’s take a look at a national library.  My apologies in advance for being US-centric; take heart, however, as there is most likely a national library in your country, though, perhaps with a different classification system.[4]

First visiting, the Library of Congress home page, then navigating to the catalogue page at, one can search by keyword, title, author, or subject.  The most general search would be by subject, at which one finds 3,359 matches for the keyword “diabetes.”

On closer inspection of the search results, eight of our 3,359 books are from the 18th century, 1762-1798, to be exact, under the subclass RC, internal medicine, and five of those rare books, all dissertations entitled Dissertatio Medica Inauguralis, De Diabete, are written in Latin.  The authors and their books’ published dates, are, respectively, William Stevenson (1762), George Jessop (1771), William Boyd, M.D. (1773), Joseph Hart Myers (1779), and James Vernon, M.D. (1796).  Tentamen Medicum Inaugurale, De Diabete, by Alexander Marcet (1797), is the sixth book, leaving two books by John Rollo to complete the century.  One of his books is simply entitled Cases of the Diabetes Mellitus (1797), and the other, also published in 1797, has the enormous title:

An account of two cases of the diabetes mellitus, with remarks, as they arose during the progress of the cure: to which are added, a general view of the nature of the disease and its appropriate treatment, including observations on some diseases depending on stomach affection, and a detail of the communications received on the subject since the dispersion of the notes on the first case / by John Rollo; with the results of the trials of various acids and other substances in the treatment of the lues venerea, and some observations on the nature of sugar, &c., [etc.] by William Cruickshank.

This book is particularly important, as Dr. John Rollo (d. 1809), a Scots physician and Surgeon General of the Royal Artillery, pioneered the systematic treatment of the disease by a restricted diet.  Using a urine glucose test devised by Dobson, he came up with the first effective treatment for diabetes: a diet high in what he called “animal food” (fat and meat) and low in “vegetable matter” (grains and breads).  This diet prolonged life for many diabetics, those with what we now call type 2, and with modifications, was the only treatment for diabetes until the 1920s.[5]

Moving on to the 19th century, there were 27 books listed in the Library of Congress search database, with publishing dates in the 1802 to 1897 timeframe. 

So let’s now return to the books from the Library of Congress dating to the 19th century.  There were 27 books listed in the LOC search database, with publishing dates in the 1802-1897 timeframe.  They are listed here.  And, yes, some of these can be found and read online.

Title:         An essay on the disease commonly called diabetes
Author:    Washington, William
Year:         1802

Title:    Medical reports of cases and experiments, with observations, chiefly derived from hospital practice: to which are added, an enquiry into the origin of canine madness; and thoughts on a plan for its extirpation from the British isles                 
Author:    Bardsley, Samuel Argent
Year:         1807

Title:         Cases of diabetes, consumption, &c., with observations on the history and treatment of disease in general
Author:    Watt, Robert
Year:         1808

Title:      English olive-tree, or, A treatise on the use of oil and the air bath: with miscellaneous remarks on the prevention and cure of various diseases, gout, rheumatism, diabetes, &c.
Author:    Trinder, William Martin
Year:         1812

Title:         De diabete mellito
Author:    Bennewitz, Heinrich Gottlob
Year:         1824

Title:    An inquiry into the nature and treatment of diabetes, calculus, and other affections of the urinary organs: with remarks on the importance of attending to the state of the urine in organic diseases of the kidney and bladder: and some practical rules for determining the nature of the disease from the sensible and chemical properties of that secretion
Author:    Prout, William
Year:         1825

Title:    An inquiry into the nature and treatment of diabetes, calculus, and other affections of the urinary organs; with remarks on the importance of attending to the state of the urine in organic diseases of the kidney and bladder: and some practical rules for determining the nature of the disease from the sensible and chemical properties of that secretion. From the 2d London ed., rev. and much enl.: with notes and additions by S. Colhoun.
Author:    Prout, William
Year:         1826

Title:    Hospital facts and observations: illustrative of the efficacy of the new remedies, strychnia, brucia, acetate of morphia, veratria, iodine, &c. in several morbid conditions of the system: with a comparative view of the treatment of chorea, and some cases of diabetes: a report on the efficacy of sulphureous fumigations in diseases of the skin, chronic rheumatism, &c.
Author:    Bardsley, James Lomax
Year:         1830

Title:         Du diabète sucré
Author:    Chaloin, Louis Ernest
Year:         1853

Title:         Diabetes mellitus
Author:    Clapp, Sylvanus
Year:         1854

Title:         Case of diabetes mellitus
Author:    Jones, Joseph
Year:         1858

Title:         On diabetes, and its successful treatment
Author:    Camplin, John Mussendine
Year:         1858

Title:         On diabetes, and its successful treatment. From the 2d London ed.
Author:    Camplin, John Mussendine
Year:         1861

Title:         Zur lehre vom diabetes mellitus   
Author:    Engmann, Wilhelm
Year:         1869

Title:         On the origin of diabetes, with some new experiments regarding the glycogenic function of the liver
Author:    Lusk, William Thompson
Year:         1870

Title:         Ueber diabetes mellitus
Author:    nnenberg, Ludwig
Year:         1870

Title:    De la glycosurie, ou, Diabète sucré: son traitement hygiénique: avec notes et documents sur la nature et le traitement de la goutte, la gravelle urique, sur l'oligurie, le diabète insipide avec excès d'urée, l'hippurie, la pimélorrhée, etc.
Author:    Bouchardat, Apollinaire
Year:         1875

Title:         Considerations sur la pathogénie et sur le traitement du diabète
Author:    Dumoulin, Auguste
Year:         1877

Title:         A treatise on Bright's disease and diabetes
Author:    Tyson, James
Year:         1881

Title:         De la gymnastique de l'hydrothérapie
Author:    Hoffmann, Louis
Year:         1882

Title:      Does the present state of knowledge justify a clinical and pathological correlation of rheumatism, gout, diabetes, and chronic Bright's disease?
Author:    Tyson, James
Year:         1886

Title:         Diabetes. Mellitus and insipidus
Author:    Smith, Andrew Heermance
Year:         1889

Title:         Diabetes: its causes, symptoms, and treatment
Author:    Purdy, Charles Wesley
Year:         1890

Title:         Cookery for the diabetic
Author:    Poole, W.H.
Year:         1891

Title:         Ueber coma diabeticumm im anschluss an die narcose
Author:    Müller, Wilhelm
Year:         1894

Title:         Die Zuckerkrankheit und ihre Behandlung
Author:    von Noorden, Carl
Year:         1895

Title:         Kliniske undersøgelser over kvælstofudskilningens forhold til den diætetiske behandling ved diabetes mellitus
Author:    Lauritzen, Marius
Year:         1897

One such book, Diabetes: Its Causes, Symptoms, and Treatment, by Charles Wesley Purdy, is available on the internet.  And it should come as no surprise, that more than a century ago, in 1890, Charles Purdy wrote:

Prophylactic [preventive] measures are advisable for people of diabetic parentage, or for those whose families present marked tendencies to the disease.  In such cases it is wise to adopt a system of diet which limits the use of starchy and saccharine foods to the most moderate proportions.  Occupations should be selected which entail the least possible mental pressure and excitement; and, if practicable, a residence should be chosen as near the sea-level as possible, with a mean temperature range of about 70 F.  The observance of the above conditions will insure the individual the best chances of avoiding the disease.

Until future investigation shall have revealed some agency through which we are able to check the excessive formation of sugar in the liver, our chief resource against the disease must consist in withholding from the system that which it is capable of converting into sugar, and in supplying that which it is capable of assimilating as nourishment.  The accomplishment of this object is the essential aim of the dietetic treatment of diabetes.

Physiological chemistry as well as experience have shown us that the chief source of sugar-production in the system is the carbohydrate foods, more especially starches and sugar.  In nearly all mild cases of diabetes, and in most cases of recent origin, the avoidance of these foods arrests the excretion of sugar, as well as the more prominent symptoms of the disease. The sugar-forming powers of the organism in diabetes are feeblest in their operation upon nitrogenous materials, and therefore animal foods are the least susceptible of conversion into sugar.  Next in order rank the green parts of certain vegetables, which quite strongly resist sugar transformation.  Finally, the starchy and saccharine members of the carbohydrate group are the most easily transformed into sugar of all, and are therefore the most dangerous for use.  Practically, then, the more completely we are able to eliminate the starchy and saccharine foods from the diet, the more completely we are able to hold the disease under control.  At first sight this might seem to be a very simple matter; but when we come to furnish a diet-list that strictly conforms to the above principle, it will be found a most difficult problem to solve, owing to the very wide diffusion of starch and sugar throughout the organic world.

Of the other foods derivable from the vegetable kingdom, the cereals and seme of the tubers are the most dangerous.  Potatoes, beets, parsnips, carrots, among the latter; and, of the former, rice, sago, oatmeal, cornmeal, buckwheat, rye, barley, peas, and beans, should be prohibited without compromise in most, if not in all, cases.  In the strict form of dieting we are obliged to avoid the whole list.  In cases of moderate severity we may, however, draw upon one class of vegetables greens.  Green vegetables consist mostly of cellulose, and contain little, sometimes almost no, starch.  They are rendered still less objectionable if boiled before being eaten, as the hot water dissolves out much of the remaining starch and sugar.  The starch and sugar contents of vegetables vary considerably, according to the degree of cultivation and the nature of the soil and climate in which they are grown.  As a rule, a high degree of domestic cultivation favors an increase of the starch and sugar, while high temperature and sunny skies have an opposite tendency. Among the least objectionable vegetables may be mentioned lettuce, cucumbers, olives, mushrooms, Brussels-sprouts, cabbage, spinach, and water-cresses.

Most nuts except chestnuts may be permitted, the list including almonds, walnuts, Brazil nuts, filberts, butternuts, and cocoanuts.

Great differences prevail in practice with regard to the use of fruits in diabetic conditions, some authorities allowing them freely, while others curtail them.  Some fruits, such as apples and strawberries, really contain very little sugar, and in the case of apples the sugar is in such form that it is often well assimilated by diabetics.

The truth is that it is more difficult to make a rule which will apply universally with regard to the use of fruits than with any other class of foods in these cases; and therefore it must to some extent be a matter of experiment in each individual case.  It may be stated, however, in a general way, that mild cases will bear a moderate use of such fruits as apples, tomatoes, and strawberries; but in severe cases it is best to prohibit their use without exception.”[6]

Purdy’s treatment is particularly salient even today, but I will hold off on my comments for the moment, as surveying books is the primary task at hand.

The interesting observation to bring up here is that although the Library of Congress holds the most books in the world, it does not contain every book.  While searching for an electronic version of William Washington’s book An Essay of the Disease Commonly Called Diabetes online, which I did not find, I fortuitously found the book entitled Diabetes Mellitus and Its Treatment, by Richard Thomas Williamson, M.D., M.R.C.P., published in 1898.  Interestingly, this book is not in the collection of the Library of Congress, however, it is an important book.

In the chapter “General Principles of Treatment,” Dr. Williamson writes:

“Potatoes should be excluded from the diet first, then bread, and gradually all carbohydrates should be cut off.  In the place of bread, the aleuronat and cocoa-nut cakes mentioned on p. 357 may be given.”[7]

He states that the chief object to be aimed at in the treatment is to diminish the amount of sugar in the urine and blood, and to diminish the amount of urine, and to relieve thirst.  And that object may be attained by removal of the carbohydrates from the diet.  Reflecting on the work of John Rollo, Dr. Williamson writes:

“Ever since Rollo published his book on diabetes in 1797, and pointed out the value of restriction of the carbohydrates in the food, it has been acknowledged that of all forms and methods of treatment this dietetic one is the most important.”[8]

He also writes:

“All authors agree as to the great value of fat in the severe forms of diabetes; and, in addition to fatty food, cod-liver oil, lipanin [an artificial cod-liver oil substitute], and other fats may be given.”[9]

“Most articles of food from the animal kingdom may be taken freely by diabetic patients.  Butchers’ meat and flesh meat of various kinds, poultry, game, and fish, may be taken in any form.  But in the cooking thereof flour or bread crumbs should not be used, if a very strict diet is indicated; aleuronat may be used in place of flour, however, and butter and fats may be freely employed.

The following articles may also be allowed freely: tongue, ham, bacon, potted beef, and chicken, preserved meats of various kinds, sardines, tinned and preserved fish, beef extracts, beef-tea, meat juices, broth, soups, and jellies (when prepared without the addition of any saccharine or starchy materials).

Eggs in various forms are most useful articles of diet.  An egg weighing about 600 grs. contains about 90 grs. of albumin and 75 grs. of fatty material.  When hard boiled they can be taken with comparatively large quantities of butter.  The “buttered” egg or omelet is a useful form…Honey, of course, ought never to be taken.  Butter, cheese, and cream may be allowed in large quantities.”[10]

“Fats, both animal and vegetable, are the most valuable articles of diet for diabetic patients, especially for those who suffer from the severe forms of the disease, and may be allowed in large quantities.

The more important articles of diet, containing a large quantity of fat, are butter, cream, bacon, cheese, eggs, suet.[11]

“Cocoa-nuts contain a small quantity of sugar, but this may be removed easily, and cocoa-nut flour may be used for the preparation of biscuits.”[12]

Dr. Williamson concludes his discussion on “cocoa-nuts” with recipes consisting of water, “cocoa-nut,” eggs, and cream for “excellent” cakes, biscuits and buns made without sugar or carbohydrates that a diabetic can tolerate quite well, prepare inexpensively at home, and prefer more, i.e., they taste better, than most diabetic cakes offered at the time.

In the Appendix, Richard Thomas Williamson presents the following list of articles of diet and beverages, arranged in tabular form, which ought to be sanctioned or forbidden, when for diagnostic or therapeutical purposes a very strict diet is desirable:[13]

Butchers' meat of all kinds (except liver); potted and preserved meats.
Ham, tongue, bacon.
Poultry, game.
Fish (Fresh, dried, and preserved; sardines, shrimps.
Broths, animal soups, and jellies (prepared without the addition of saccharine or starchy materials).
Eggs, cheese, cream.
Butter, suet, oils, and fats.
Custard (without sugar).
Reliable bread substitutes (gluten bread, almond and aleuronat cakes).
Green vegetables--mustard and cress, watercress, endive, lettuce, spinach, turnip-tops, cabbage, broccoli, Brussels sprouts, spring onions.
Nuts (walnuts, almonds, filberts, hazel nuts, Brazil nuts), but not chestnuts.
Water, soda-water, and mineral waters.
Tea, coffee.
Dry Sherry, claret, Burgundy, hock, Moselle, Ahr wines, most Rhine wines, Austrian and Hungarian table wines (all in moderate quantities, however).
Brandy in small quantities.

Sugar, saccharine and farinaceous articles of food.
Pastry and farinaceous puddings.
Rice, sago, arrowroot, tapioca, macaroni, vermicelli, semolina.
Wheaten bread and biscuits.
Carrots, turnips, parsnips, beetroot, beans, peas, large onions.
Oysters, cockles, mussels, the "puddings" of crabs and lobsters.
All sweet fruit and dried fruits.
Port, Tokay, champagne, and sweet wines.
Must, fruit juices and syrups.
Sweet lemonade.
Beer, ale, porter, and stout.
Rum and sweetened gin.
Cocoa and chocolate.
Milk in large quantities.

Now, let’s conclude our discussion of the LOC book search.

From the 18th century’s eight books on diabetes, at least from the perspective of the Library of Congress, the 19th century’s growth rate of 237.5%—there are now an additional 27 books on the shelf—pales in comparison with the next century.  Between the beginning and end of the 20th century, there are now an additional 1,930 books published and stocked on the shelves.  That represents a century-to-century growth rate of slightly more than 7,048%.  Instead of keeping you in suspense, let me mention here that, although we’re far from the end of the 21st century, the Library of Congress already holds an additional 1,367 from this century.  Add to that the 27 books in the LOC diabetes search results that are undated, and we have the grand total of 3,359 books that we originally found in the database.  Books from the 20th century make up a majority 57%, and those of the 21st century, not a decade old—10% young at the time of this writing—make up 41% of the collection. 

Let me surprise you, and, perhaps, quell your fears, by noting that I won’t be listing or going through any of the afore-mentioned 1,930 20th, or 1,367 21st century books here.  True, I am not the same caliber investigator as a Gary Taubes, Barry Groves, or host of other past- and present-day saints.  But we know what truly separates these books from those of the prior centuries.  Those writers in the 20th century, to borrow and alter Charles Purdy’s words, were the future investigators that revealed the agency through which we are able to check the excessive formation of sugar in the liver.  Moreover, the identification of beta cells—those little heaps of cells—within the islets of Langerhans in the pancreas as the center of insulin production, tied inexorably to the diabetes condition, and leading to the purification and dissemination of analog insulin for patient self-management, is the primary driver of the burgeoning—scientific, dietetic, therapeutic, historical, and otherwise informational—diabetes book growth in the 20th century.

3,359 sources are considerably less than the millions found online, but still pose some practical problems.  First, unless you’re an elected official, you cannot “check-out” any books from the Library of Congress; that’s a perk reserved for any voracious reader winning office.  Yes, you can read any of them—while you’re there—but, you cannot bring any books out of the library for any period of time.  And, of course, you have to be in Washington, DC.  I’ve toyed with the idea of taking a sabbatical there, finding a relatively inexpensive hotel, and reading through the list of 3,359 books.  Assuming three hours per book, which would include documenting my findings, at eight hours a day, seven days a week, my sabbatical would have to be almost three-and-a-half years.  Sounds more like retirement.  Even if I skim each book for an hour, I would still need more than a year to complete the task.  And that wouldn’t include sight-seeing.  A two to three year’s sabbatical, however, is an intriguing thought.

So, like me, the average diabetic looking for information is relegated to visiting something more local to learn the totality of the world of diabetes.  And so it is here that we really begin our journey.

What type of information is available about diabetes at the local library?  I hypothesized that most books contain good information about the disease, i.e., etiology, physiology, impact on society, history, A1c tutorials, nutritional options, etc., and that there would also be some books advocating a specific diet.  So to test that hypothesis, I decided to visit my local library.

As of 2008, there were 30,022[14] total United States Libraries, categorized as armed forces, college and university, electronic, government, community college, law, medical, public and state, religious, and special, including industry and company libraries as well as libraries serving associations, clubs, foundations, institutes, and societies.  Add to those 30,022 the 80 total libraries administered by the United Stated in its territories, and the 3,685 total Canadian libraries, and we have a grand total of 33,787 libraries listed in the American Library Directory.[15]

During the last week of 2008, and into the first few weeks of 2009, I visited the Santa Clara City Library, 2635 Homestead Road, in Santa Clara, California.  Not an average library as it turns out, but a very good library with 354,579 book titles and 724 periodical subscriptions[xix] in its collection, giving it a 2008 HAPLR score of 897, putting it in the 99th percentile of all libraries.[16]

Peering at the shelf of books contained within the 616.4 classification, I found 75 books published from 1997 to 2008.[xxi]  An additional 19 reference books—not surprisingly in the reference section—published from 1998 to 2008, that included significant articles on diabetes, were also found.  General diet or other health books neither on the shelf in section 616.4, nor in the reference section, were disregarded.  Reading through the books off the shelf, I was surprised to find that, with but one exception, each and every book advocated a specific diet.  Of the 75 books off the shelf, only 10 advocated a low-carbohydrate diet to treat the disease.  One book, The First Year: Type 2 Diabetes.  An Essential Guide for the Newly Diagnosed (2001), contained only objective information, and all the rest—64—an astounding 85% of the books off the shelf, advocated a low-fat, high-carbohydrate diet to treat a disease manifested by impaired carbohydrate metabolism.  I’ve included the entire list of both “books off the shelf,” which I’ve simply labeled as “Books on Diabetes,” and “Reference Books” in, respectively, Appendices A & B, complete with the evidence; that is, the specific references in those books that determine whether it advocates a low-fat or a low-carbohydrate diet.

By the way, general agreement about what it means to have a low-fat, low-carbohydrate, or even a low-protein diet has never really been attained, so let’s try to bring some clarity.  From a purely mathematical standpoint, if you have three parameters—in our case the three parameters are carbohydrate, protein, and fat—and, additionally, three levels—low, medium, and high—the first question to ask is how many combinations are there?  The answer is 3x3x3, of course, which is 27 total combinations.  But we then have to define what it means to have a low, medium, or high level.  Again, there isn’t any general agreement in the literature of those distinctions.  To help with our discussion, let’s define “low” as a range of 0%-30%, medium as a range of 30%-40%, and high as a range of 40%-100% of total calories.  With only three variables, 50% of any one variable would be a plurality, and slightly over 50% would be a majority; therefore by definition any percentage greater than 50% has to be high.  We could consider anything in the 40%-50% range to be either in the “high-medium” area or the “low-high,” but I’ve chosen that range to simply be within the “high” amount. 

We can now see from Table 1 those 27 total combinations of low, medium, and high for the three different parameters of carbohydrate, protein and fat.  But notice that there are only 22 total real possibilities given the above definitions.  Note that the ranges given above (low = 0%-30%, medium = 30%-40%, high = 40%-100%) do not work for any specific percentage in number 1 (low carbohydrate, low protein, low fat); that is, since the low range is 0%-30%, even at the far end of that range—30%—if the three parameters of carbohydrate, protein and fat were each 30%, the total is only 90%, not 100%, so we are forced to drop that as a valid option.  The same holds true for numbers 18 (medium carbohydrate, high protein, high fat), 24 (high carbohydrate, medium protein, high fat), 26 (high carbohydrate, high protein, medium fat), and 27 (high carbohydrate, high protein, high fat).  These numbers, then, the five discounted options, have all been highlighted.  Thus the total amount of real possibilities of combinations of low, medium, and high portions of carbohydrate, protein, and fat is 22.

Carbohydrate Protein Fat
1 Low Low Low
2 Low Low Medium
3 Low Low High
4 Low Medium Low
5 Low Medium Medium
6 Low Medium High
7 Low High Low
8 Low High Medium
9 Low High High
10 Medium Low Low
11 Medium Low Medium
12 Medium Low High
13 Medium Medium Low
14 Medium Medium Medium
15 Medium Medium High
16 Medium High Low
17 Medium High Medium
18 Medium High High
19 High Low Low
20 High Low Medium
21 High Low High
22 High Medium Low
23 High Medium Medium
24 High Medium High
25 High High Low
26 High High Medium
27 High High High
Table 1

The 27 total combinations of low, medium, and high for the three different parameters of carbohydrate, protein and fat.  The five discounted options, numbers 1, 18, 24, 26, & 27 have been highlighted gray.

Back to our discussion.  We found that 64 books—85% of the books off the shelf, advocated a low-fat, high-carbohydrate diet to treat a disease manifested by impaired carbohydrate metabolism.  None described high protein intake, so we are safe to conclude that these books all refer to either medium or low protein, which is not particularly relevant to our discussion.

And the reference books, those written and commented on exclusively by doctors, faired much, much worse.  With but one tenuous exception—the diabetes section in Childhood Diseases and Disorders Sourcebook (2003) didn’t advocate a diet per se, it stated that “…A child or teen needs to follow a meal plan developed by a physician, diabetes educator, or a registered dietician,” but, of course, in 2003, a physician, diabetes educator, or a registered dietician would most likely have advocated a low-fat diet—18 out of the 19 reference books advocated, not simply informed about, but advocated a low-fat, and by definition, a high-carbohydrate diet to best treat a disease characterized by, at best, impaired, and, at worst, non-existent carbohydrate metabolism. 

Kind of makes me wonder that if there were a section written devoted to cigarette, alcohol, or drug abuse, would these same reference books tout cigarettes, alcohol, and drugs as the basis for treatment? 

Granted, our results are just from one library, and not from a random sample of, say, 30 from the population of 30,000+ libraries.  Nonetheless, the odds that I found the one library with a large majority of shelved books, or all reference books, written advocating a high-carbohydrate diet, out of all the libraries out there is rather small.  Yes, it would be interesting to survey a random sample of this nation’s libraries, perhaps even others around the globe, to find the true mean and variance of the numbers of diabetes books on the shelves that advocate low- or high-carbohydrate diets, and then the mean and variance of the reference books, but I have neither the time nor resources necessary to devote to that task. 

The more relevant question anyway is why do nearly all the reference books, those credible, driving forces behind replication by also-rans, why is it that they advocate a high-carbohydrate, low-fat diet?


[1] A national library is a library specifically established by the government of a nation to serve as the preeminent repository of information for that country.  Unlike public libraries, these rarely allow citizens to borrow books.  Often, they include numerous rare, valuable, or significant works; such as the Library of Congress’ Gutenberg Bible.  National libraries are usually notable for their size, compared to that of other libraries in the same country.  Some national libraries may be thematic or specialized in some specific domains, beside or in replacement of the 'main' national library.  For a comprehensive list of national libraries and further resources, see the Wikipedia article “List of National Libraries,” online at  Retrieved on 4/5/09.

[2] In “We knew the web was big...” posted by Jesse Alpert & Nissan Hajaj, Software Engineers, Web Search Infrastructure Team, GOOGLE (July 25, 2008), on the blog, the authors were surprised to find that content hit a milestone: 1 trillion (as in 1,000,000,000,000) unique URLs on the web at once.  Retrieved on 3/31/09.

[3] See Abelson, Hal, Ledeen, Ken, and Lewis, Harry.  Blown to Bits:  Your Life, Liberty, and Happiness After the Digital Explosion.  Upper Saddle River, NJ: Addison-Wesley, 2008, page 112.

[4] A library classification is a system of coding and organizing library materials (books, serials, audiovisual materials, computer files, maps, manuscripts, realia) according to their subject and allocating a call number to that information resource.  Similar to classification systems used in biology, bibliographic classification systems group entities that are similar together typically arranged in a hierarchical tree structure.  A different kind of classification system, called a faceted classification system, is also widely used which allows the assignment of multiple classifications to an object, enabling the classifications to be ordered in multiple ways.

Library classification of a piece of work consists of two steps.  Firstly the ‘aboutness’ of the material is ascertained.  Next, a call number, (essentially a book's address), based on the classification system in use at the particular library will be assigned to the work using the notation of the system.

It is important to note that unlike subject heading or Thesauri where multiple terms can be assigned to the same work, in library classification systems, each work can only be placed in one class.  This is due to shelving purposes: a book can have only one physical place.  However, in classified catalogs one may have main entries as well as added entries.  Most classification systems like DDC and Library of Congress classification, also add a cutter number to each work which adds a code for the author of the work.

Classification systems in libraries generally play two roles.  Firstly they facilitate subject access by allowing the user to find out what works or documents the library has on a certain subject. Secondly, they provide a known location for the information source to be located (e.g., where it is shelved).

Until the 20th century, most libraries had closed stacks, so the library classification only served to organize the subject catalog.  In the 20th century, libraries opened their stacks to the public and started to shelve the library material itself according to some library classification to simplify subject browsing.

Some classification systems are more suitable for aiding subject access, rather than for shelf location.  For example, UDC which uses a complicated notation including plus, colons are more difficult to use for the purpose of shelf arrangement but are more expressive compared to DDC in terms of showing relationships between subjects.  Similarly faceted classification schemes are more difficult to use for shelf arrangement, unless the user has knowledge of the citation order.

Depending on the size of the library collection, some libraries might use classification systems solely for one purpose or the other.  In extreme cases a public library with a small collection might just use a classification system for location of resources but might not use a complicated subject classification system.  Instead all resources might just be put into a couple of wide classes (Travel, Crime, Magazines etc).  This is known as a “mark and park” classification method, more formally called reader interest classification.

There are many standard system of library classification in use, and many more have been proposed over the years.  However in general, classification systems can be divided into three types depending on how they are used: (1) Universal schemes covering all subjects.  Examples include Dewey Decimal Classification, Universal Decimal Classification and Library of Congress Classification.  (2) Specific classification schemes.  Examples include Iconclass, British classification of Music, and Dickinson classification.  (3) National schemes specially created for certain countries.  An example is the Swedish library classification system, SAB (Sveriges Allmänna Biblioteksförening).

In terms of functionality, classification systems are often described as (1) enumerative: produce an alphabetical list of subject headings, assign numbers to each heading in alphabetical order, (2) hierarchical: divides subjects hierarchically, from most general to most specific, (3) faceted or analytico-synthetic: divides subjects into mutually exclusive orthogonal facets.

There are few completely enumerative systems or faceted systems, most systems are a blend but favoring one type or the other. The most common classification systems, LCC and DDC, are essentially enumerative, though with some hierarchical and faceted elements (more so for DDC), especially at the broadest and most general level. The first true faceted system was the Colon classification of S. R. Ranganathan.

Universal classification systems used in English-speaking world: Bliss bibliographic classification (BC), Dewey Decimal Classification (DDC), Library of Congress Classification (LCC), EnglishHarvard-Yenching Classification - An English classification system for Chinese language materials.

Universal classification systems in other languages: A System of Book Classification for Chinese Libraries (Liu's Classification), Nippon Decimal Classification (NDC), Chinese Library Classification (CLC), Korean Decimal Classification (KDC), Library-Bibliographic Classification (BBK) from Russia.

Universal classification systems that rely on synthesis (faceted systems): Bliss bibliographic classification, Colon classification, Cutter Expansive Classification, Universal Decimal Classification, Brinkler classification.

Newer classification systems tend to use the principle of synthesis (combining codes from different lists to represent the different attributes of a work) heavily, which is comparatively lacking in LC or DDC.  Abridged from the Wikipedia article “Library Classification,” online at  Retrieved on 4/5/09.

[5] Not listed in the Library of Congress search database, Matthew Dobson (1731-1784) wrote Experiments and Observations on the Urine in Diabetes (Medical Observations and Inquiries), published in London, in 1776.  Matthew Dobson from Yorkshire graduated MD at Edinburgh in 1756.  By evaporating the urine of a diabetic patient, Dobson was the first to prove the presence of sugar in urine.  He also made the crucial observation of the excess of sugar in blood, and demonstrated that diabetes is a systemic disorder rather than, as had been previously thought, a primary disease of the kidneys.  See the Royal College of Physicians of Edinburgh webpage online at  Retrieved on 4/30/09.

[6 Purdy, Charles Wesley.  Diabetes: Its Causes, Symptoms, and Treatment.  Philadelphia and London: F.A. Davis Publisher, 1890, pages 80-87.  Entire book available online at  Retrieved on 5/1/09.

[7] Williamson, M.D., M.R.C.P., R.T.  Diabetes Mellitus and Its Treatment.  Edinburgh & London: Young J. Pentland; New York: The Macmillan Company, 1898, pages 322-323.  Available through GOOGLE Book Search online at,+M.D.,+M.R.C.P.,+R.T.++Diabetes+Mellitus+and+Its+Treatment.&source=bl&ots=0Gr_k5umq7&sig=IN_EaRtR9e0eQCcuLTfqI_fecDc&hl=en&ei=q438SeiiCKP4tAOMg7HoAQ&sa=X&oi=book_result&ct=result&resnum=1

[8] Ibid, page 325.

[9] Ibid, page 330.

[10] Ibid, pages 330-331.

[11] Ibid, page 337.

[12] Ibid, page 343.

[13]The diabetic dietaries recommended by most authors agree generally with that just given, but the following are minor points of difference: Sir William Roberts adds “torrified” bread and celery to the articles sanctioned.

Pavy sanctions also turnips, French beans, cauliflower, asparagus, and vegetable marrow, but only in moderate quantity, and when boiled in a large amount of water; also radishes and celery.

Seegen allows the following in moderate quantities: Cauliflower, carrots, turnips, white cabbage, green peas, berries (such as strawberries, raspberries, currants); also oranges and almonds.  But he forbids other fruits, such as grapes, cherries, peaches, apricots, plums, and all kinds of dried fruits.

In addition to the articles mentioned, v. Noorden sanctions mussels, oysters, lobster, cauliflower, spinach, onions, leeks, asparagus, sorrel, French beans.  He also allows the following (amongst other articles), but only in very limited quantities: Celery, green peas, beans, carrots, mushrooms, radishes, two medium-sized tomatoes, a thin slice of cocoanut, a thin slice of melon, one small acid apple, one or one and a half peach, one tablespoon of wild raspberries or strawberries, four spoonfuls of currants, six greengages[xvi], twelve cherries, half a medium-sized pear.

Cantini prescribes a very rigid diet of nitrogenous and fatty foods only.  He allows: Bouillon of various kinds.  Beef, tongue, veal, mutton (but liver is forbidden), duck, goose, chicken, pigeon, and game of all kinds.  Fish, crustacea, lobster, crabs.

In the cooking and preparation of the above he forbids the use of flour, sugar, wine, butter, vinegar, and lemon juice; but he sanctions the use of olive oil and fats, and recommends dilute acetic acid in place of inegar [sic.], and citric acid in place of lemon juice.

Cantini allows 500 to 600 grms. of nitrogenous food daily.  In order to improve the digestion, and to increase the strength of emaciated patients, he recommends 60 to 200 grms. of pancreatic fat.  The fresh pancreas of a cow, calf, or lamb is cut into small pieces, and mixed with pig’s suet.  After three hours it is lightly roasted.”  See Ibid, Appendix, pages 406-408.

[14] This number is significantly lower than the total of 116,393 libraries as stated by The Whole Library Handbook 4, because it doesn’t include “school library media centers” which in 2004 totaled 93,861.  See The Whole Library Handbook 4, edited by George M. Eberhart, American Library Association, 2006, page 3.

[15] American Library Directory, 61st Edition.  Medford, New Jersey: Information Today, Inc., 2008, page xiii.

[16] Nationwide public library statistics are collected and disseminated annually through the Federal-State Cooperative System for public library data (FSCS).  Statistics are collected from nearly 9,000 public libraries.  The FSCS web site is at:  The HAPLR Index includes 15 factors.  The focus is on circulation, staffing, materials, reference service, and funding levels.  The Index does not include data on audio and video collections, or interlibrary loan, among other items that could have been calculated from the FSCS data.  Perhaps most prominently absent from the data are any measures of electronic use or Internet service.  While such measures would have been desirable, the FSCS data simply are simply not sufficient for such comparisons at this time. Internet, electronic services and audiovisual services are excluded because there is simply not enough data reported by enough libraries to make comparisons meaningful.  What remains are fairly traditional data for print services, book checkouts, reference service, funding and staffing. It is likely that in the future, additional measures can be added to the FSCS data to begin to evaluate such other library services as internet use, electronic services, and non-print services.  The FSCS data have only been collected on a consistent national basis since 1981. Since then the data have been refined to be more consistent and to include more information. That trend is likely to accelerate, making the additional comparisons possible soon.  See Hennen's American Public Library Ratings, available online at  Retrieved on 1/24/09.

Note:  When starting a collection, libraries frequently consult the Public Library Catalog, a list of recommended reference and nonfiction books for adults, classified by subject.  There are seven books on diabetes within the 616.4 classification listed for inclusion in any collection, of which three were on the shelf.  The seven books listed are: (1) American Diabetes Association Complete Guide to Diabetes; The Ultimate Home Reference from the Diabetes Experts.  3rd edition, completely rev.  American Diabetes Assn., 2002, 517 pages, (2) The Joslin Guide to Diabetes; A Program for Managing Your Treatment; [by] Richard S. Beaser, with Joan C.V. Hill and the Joslin Education Committee.  Simon & Schuster, 1995, 351 pages, (3) Diabetes Sourcebook; edited by Dawn D. Matthews.  3rd edition.  Omnigraphics, 2003, 621 pages, (4) The Thyroid Guide; [by] Beth Ann Ditkoff and Paul loGerfo.  HarperPerennial, 2000, 171 pages, (5) Mayo Clinic on Managing Diabetes; Maria Collazo-Clavell, editor in chief.  Mayo Clinic; [distributed by] Mason Crest, 2002, 194 pages, (6) Women & Diabetes: Staying healthy in Body, Mind, and Spirit; by Laurinda M. Poirier and Katharine M. Coburn.  2nd edition.  American diabetes Assn., 2000, 230 pages, and (7) The John Hopkins Guide to Diabetes: for Today and Tomorrow; [by] Christopher D. Saudek, Richard R. Rubin, and Cynthia S. Shump.  John Hopkins Univ. Press.  1997, 422 pages.  See Public Library Catalog 12th Edition: Guide to Reference Books and Adult Nonfiction.  Edited by Juliette Yaakov.  The H.W. Wison Company.  2004.