by Zina Kroner, DO
Patients with inflammatory bowel disease (IBD) suffer from diarrhea and abdominal pain; this is often accompanied by difficulty in absorbing nutrients which results in weight loss. With ulcerative colitis, the large bowel (colon) is involved; Crohn’s disease can affect everything from the mouth to the anus, although usually small and/or large bowel disease usually predominates. Medical treatment of IBD is aimed at reducing the intestinal inflammation.
Medications including sulfasalazine and related drugs and corticosteroids, taken orally or topically may be able to cause improvement in many patients. Stronger medications are frequently needed, with more side effects, including azathioprine, 6-mercaptopurine, methotrexate, and injectable anti-tumor necrosis antibody preparations.
Surgery may be needed if medical treatment fails. In the case of ulcerative colitis, surgical procedures can be as drastic as removal of the entire colon with a permanent stoma (ostomy). Patients with Crohn’s disease may require surgery after surgery removing affected parts of the bowel.
For many patients, medical interventions are not enough, and surgery may be undesirable. There is another approach to treating IBD on a more basic level. This involves a significant change in diet for most people, to what is called the “Specific Carbohydrate Diet.” This diet can be undertaken along with any medical treatment.
This diet is available to anyone wanting to try it because of the late Elaine Gottschall (d. 2005). Gottschall was both a mother and a scientist who was able to find a way to help her own child, and decided to share her knowledge. In 1958, her eight-year-old daughter was suffering from ulcerative colitis that failed to respond to medical treatment. Looking for an alternative to surgery, Gottschall took her daughter to Dr. Sidney Haas, a 92-year-old physician who had published a textbook outlining his nutritional approach to healing the intestines.
Dr. Haas quickly started the young girl on his specific carbohydrate diet. After a few months on the diet, her intestinal symptoms started to improve and she began to gain weight. After two years, she was well and free of symptoms of the disease. However, Dr. Haas had died in the interim and could no longer provide guidance.
Gottschall decided to learn more about the science behind the diet. She studied biology, cellular biology and nutritional biochemistry, earning a master’s degree and doing research on carbohydrate metabolism in the intestine. She published the Specific Carbohydrate Diet in a book first entitled Food and the Gut Reaction. It is now in its 13th printing, and called Breaking the Vicious Cycle: Intestinal Healing Through Diet. Over a million copies have been sold, and the book has been translated into seven other languages.
The Specific Carbohydrate Diet is based on the way carbohydrates are digested in the intestine, and what may be going wrong with the digestion in people with IBS and other intestinal disorders. Single sugars, including glucose, fructose and galactose can be transported from the intestine into the bloodstream without requiring digestion, in this case, splitting of molecules by enzymes. The cells of the small intestine must work harder to digest carbohydrates, as well as two-sugar molecules.
Carbohydrates are broken down into disaccharides by salivary enzymes and pancreatic enzymes as they pass through the digestive tract. Disaccharides, comprised of two sugars, must be split into their component parts by enzymes located in the outer membrane of the cells in the small intestine. The cell membranes have small finger-like projections called microvilli that line the intestinal walls. The enzymes are located in the microvilli. There are four key disaccharide/enzyme pairs.
•Lactose, found in milk and milk products, must be broken down into glucose and galactose by the enzyme lactase.
•Sucrose, or table sugar, must be metabolized into glucose and fructose. Sucrose is fruit derived (cane sugar, beet sugar). As fruits ripen, sucrose can be broken down into glucose and fructose, so that ripe fruits may have less sucrose.
•Isomaltose is broken down into two molecules of glucose by isomaltase.
•Maltose is similarly metabolized into two glucose molecules by maltase.
A deficiency of any of these enzymes prevents the final digestion of disaccharides. They stay in the intestine where they can cause physical symptoms. For example, sugars can ferment and cause gas.
Many people are affected by a lack of lactase, leading to the inability to fully digest the lactose in milk. This is called “lactose intolerance” which causes symptoms of gas, pain and diarrhea. The incidence of lactase deficiency varies between different ethnic groups, and is also more prevalent in older people than children. People with simple lactose intolerance can take a tablet containing lactase, or they can consume milk products which have lactase added. They can also usually tolerate milk products in which the lactose has been digested already. For example, in properly prepared yoghurt, the right kind of bacteria have already split and digested the lactose.
It has been postulated that in IBS, all of the disaccharidases are not functioning. Consequently, carbohydrate residues and disaccharides cannot be digested. These comprise so much of an average diet that the undigested material is a very significant amount. The symptoms of pain, gas and diarrhea are severe.
The undigested disaccharides can feed the bacteria living in the intestine, causing an overgrowth of bacteria. Many kinds of bacteria normally live in the large intestine, and to a lesser degree, in the terminal ileum that connects to the large intestine. These can multiply and migrate up into the small intestine where they do not belong.
Bacteria in the wrong place can cause damage to the lining of the small intestine, to the microvilli lining the small intestinal walls. This further reduces the amount of functional enzymes and perpetuates the cycle. Decreased digestion of carbohydrates and disaccharides allow bacteria to grow that damage the intestine and decrease the digestion of disaccharides even more. Additionally, the bacteria can release toxic byproducts that cause some of the symptoms of IBS.
Whatever begins the cycle of the intestinal damage, the decreased ability to digest carbohydrates and disaccharides leads to further damage, with more symptoms and even less digestive ability. The Specific Carbohydrate Diet interrupts the cycle.
The main principle of the Specific Carbohydrate Diet is that only so-called “legal” carbohydrates are permitted. These are found in fruits, honey, properly-prepared yoghurt, and certain vegetables and nuts, and are to be used as follows:
•Fruits: Not introduced during the first one to two weeks. Then ripe, peeled and cooked. No raw fruits until diarrhea is under control. First raw fruit should be ripe mashed banana. No canned fruits with added sugar.
•Vegetables: No raw vegetables (such as salad greens and cucumbers) until diarrhea is under control. Only frozen or fresh vegetables are allowed, not canned.
•Dairy products: No fluid milk. Specific cheeses are allowed. Homemade yoghurt is a large part of the diet. Dry curd cottage cheese is also important.
The following foods can also be eaten:
•Eggs: Added when diarrhea is less severe.
•Fats: Well tolerated in association with meat, butter, and allowed cheese and yoghurt. Use of low-fat milk is not advised unless there is another reason.
Forbidden “illegal” carbohydrates:
•All cereal grains, including but not limited to corn, oats, wheat, rye, rice, millet, buckwheat, triticale or any other “new” grains such as quinoa. No products made from these grains are allowed, which means no bread, pasta, cakes, or other baked goods. Ground nut flours replace grains for baking.
•No table sugar is allowed as a sweetener or in candy. It is sucrose, a disaccharide. Honey is the allowed sweetener. It contains glucose and fructose separately.
•No processed food, as starch (or disaccharides) are often added.
•No starchy vegetables, including potatoes and yams.
The diet should be as varied as possible. It is very difficult to follow the diet if you are a vegetarian, but not impossible. Consultation with a dietitian would probably be best if you want to follow the diet without any animal products. Anyone with a severe nut allergy will also have a very difficult time with the diet, since nut flour replaces all other carbohydrate flours.
Beginning the Diet
There are recipes in the SCD book, and specific foods you must buy and make before you can start the diet. There are suggestions for where to obtain needed products, and guidelines as to which brands are best. Beyond the information in the book, there are also cookbooks available as well as information on the SCD website. Whoever is going to prepare the food must be able to follow the recipes. In Gottschall’s words, the diet must be followed with “fanatical adherence” in order to work. Instructions on how to make the food for the beginning diet are on the website (http://www.breakingtheviciouscycle.info/index.htm).
Sample menu for beginning the diet
oDry curd cottage cheese (moisten with homemade yogurt)
oEggs (boiled, poached, or scrambled) – not if diarrhea is very severe
oPressed apple cider or grape juice mixed 1/2 and 1/2 with water.
oHomemade gelatin made with juice, unflavored gelatin, and sweetener (honey)
oHomemade chicken soup
oBroiled beef patty or broiled fish
oVariations of the above
The above diet needs to be followed strictly. If you have a lot of diarrhea and cramping, you may need five days before you can add other foods. Some people only need a couple of days.
After diarrhea and cramps have stopped, you can add cooked fruit, ripe banana, and other vegetables, as well as egg if you did not start it earlier. You still need to avoid vegetables in the cabbage family. As you add a food, do it slowly, starting with a small portion and increasing it over a week.
Many people decide to try the diet for a month. Gottschall says that it usually takes three weeks to see an improvement, so if you feel absolutely no better after a month, you might want to reconsider whether or not you want to stay on the diet. Keeping a food journal may be the best way to document your symptoms and see if there is a trend toward improvement.
There is also a chance of a relapse of symptoms around the second or third month, which may occur because of a viral infection. Even if there is no specific cause, the symptoms will go away, so you should not be discouraged.
The Specific Carbohydrate Diet
The best way to collect all the information about the diet is from Gottschall’s book, other recommended cookbooks, recipes and tips, as well as places to buy the cookware and other items needed to make the foods, on the website (http://www.breakingtheviciouscycle.info/index.htm).
You do not have to buy anything beyond the book if you are used to cooking and understand some of the more unusual foods you have to make, such as homemade yoghurt. There are no controls on portion or size in general. You can eat as much of “legal” foods as you want.
Here are some general instructions.
Essentially all fresh or frozen beef, lamb, pork, poultry, fish, eggs, specified cheeses, homemade yoghurt and dry curd cottage cheese, as well as fish canned in oil or water are allowed. No processed meats are allowed because they may contain filler carbohydrates (like in hot dogs) or they may have had added sugars. No canned meats.
Fresh or frozen, no canned vegetables or vegetables in jars. Dried peas and certain beans can be introduced after special preparation and when symptoms are better. No grains, no starchy root vegetables. Soybeans and soy products are not allowed
Fresh, raw or cooked, frozen or dried. Canned “in its own juice” with no added sugar is acceptable. Just about all fruits are allowed.
Just about all nuts in shells. Shelled nuts are acceptable if they have not been coated with starch when salted, which is usually the case with peanuts.
Nuts should only be used as nut flour until diarrhea has stopped. Then they can be eaten whole.
Tomato juice is allowed, as is grapefruit juice, freshly squeezed. Orange juice should not be used in the morning when diarrhea is still active. If buying juice, avoid brands with added sugar. Many companies do not state this on the label. Bottled grape juice is usually without added sugar. Apple cider can be used, but not apple juice because sugar has been added. Juice boxes should be avoided.
You may also drink weak tea or coffee, and peppermint or spearmint herb tea. Other herb teas can worsen diarrhea. Only sweeteners allowed are honey or saccharin. Soft drinks with aspartame or NutraSweet may contain lactose and should be avoided. Instant coffee, tea and Postum are not permitted.
No liquid milk is allowed; no soy milk is allowed.
You can use oils made from “illegal” foods for cooking, because the carbohydrates have been removed. Unflavored gelatin is used in dessert recipes. Sweets are allowed, made from honey, nuts and dates.
Some alcohol is allowed, including very dry wine, gin, Scotch, vodka and other similar. No cordials or liqueurs.
Once symptoms are under control and you are on the diet with all allowed foods, there is a great amount of variety allowed. There is generally no limit on portion sizes; you can eat as much as you want of allowed foods. There are sweets and treats, baked goods made with nut flour, substitutes suggested for pasta, and many clever ways to prepare food.
Gottschall recommends that you stay on the diet for one year after your illness is gone. She then suggests that you start “illegal” foods slowly, one at a time
While the diet is restrictive, it is balanced and able to provide a good source of most nutrients. Vitamin supplements are usually necessary, and you should discuss this with your physician. Many people begin this diet underweight because of their illness, and are able to gain weight.
Does this diet work?
Thousands of people have used this diet successfully. Their stories have been documented on the website, in the form of testimonials as well as surveys.
One article was published in the journal Tennessee Medicine using data from the SCD site as well as follow-up conducted by two doctors. Two case studies were reported, one of a patient with Crohn’s disease and one patient with ulcerative colitis. Both were inadequately controlled on medication and had symptoms resolve on the diet. In these two cases, a physician reviewed colonoscopy reports and biopsies before and after the diet. In these two cases, the patients had demonstrable abnormalities which resolved.
In addition, survey material from the SCD website was used. 51 patients responded, 31 with Crohn’s disease and 20 with ulcerative colitis, Most of them were either in remission or much improved on the diet. Many of these individuals did not follow up with their physicians. 16 patients did have repeat colonoscopies, 12 of which were normal. This article ends with the following statement, “Proper randomized clinical trials are warranted to investigate the merits of this treatment (Nieves and Jackson, 2004).”
Large-scale randomized trials may never be done. Without a medication to study, there is no financial incentive to doing such a trial, and no source of funding. Many physicians will not accept treatments that have not been studied in such trials, and will not accept the Specific Carbohydrate Diet. However, other physicians will, and many patients have done very well on it.
Should you decide to try the Specific Carbohydrate diet, you should actively discuss your progress with your doctor. As noted, you may need specific vitamins. You may also be able to lower medications, which you should do under a doctor’s care.
The Specific Carbohydrate Diet website: http://www.breakingtheviciouscycle.info/index.htm
Breaking the Vicious Cycle: Intestinal Health Through Diet by Elaine Gloria Gottschall. Kirkton Press; Revised edition (August 1994). 13th printing, May 2010. (Available on Amazon.com, from Barnes and Noble, and elsewhere.)
Nieves R, Jackson RT. Specific Carbohydrate Diet in Treatment of Inflammatory Bowel Disease. Tennessee Medicine. 2004 Sep; 97(9):407. (This article can be viewed on the website).