INTRODUCTION

• By-products made from the ingestion of certain foods can cause intestinal problems

• Frequent intolerances are to corn, wheat, milk, potatoes and rye

• This diet is intended to be tried for 1-2 years; may gradually return to a normal diet afterwards

• The Specific Carbohydrate Diet allows glucose (which is a “monosaccharide” or a one-sugar molecule) as the principal carbohydrate

  • Glucose is the primary sugar in fruits, honey, yoghurt & some vegetables  glucose requires no digestion so it can easily nourish the body

• Bad foods:

• Remove certain carbohydrates: sucrose (refined sugar), lactose (milk), highly starchy foods (rice, potatoes, corn, grains/breads)

• milk, highly starchy foods () because “What the patient takes beyond his power to digest does harm.”

  • Any food (especially carbohydrates) given to persons with gastrointestinal problems should be a food that requires little or no digestion so the digestive process itself will not stand in the way of the absorption of the carbohydrate

  • Undigested foods do not pass harmlessly through the gut.

• When the intestinal cells produce too much mucus, they lose the ability to digest starch and disaccharides (two-sugar molecules)

  • Carbohydrates then remain in gut and are used by microbes (yeast & bacteria), which change the carbohydrates in ways that can injure the intestines

  • Injured intestinal cells respond by secreting excessive mucus.

  • CYCLE: Injury to the small intestine’s surface  Impaired digestion of disaccharides  Malabsorption of disaccharides  bacterial overgrowth  increase in bacterial by-products & mucus production  injury to the small intestine surface …

• Goal of the Specific Carbohydrate diet: deprive the gut’s microbial world of food it needs to overpopulate; use ‘predigested’ carbohydrates to nourish the individual without over-stimulating the intestinal microbial population.

MICROBES

• Bacterial overgrowth is usually limited by: inter-bacterial competition, peristalsis, stomach acid

• Overgrowth occurs from: decreased acidity (antacids, aging), malnutrition or poor quality diet (weakens immunity), antibacterial therapy (changes the flora)  altered equilibrium leads to microbial migration into the stomach and small intestine  hampers digestion, compete with the body for nutrients, overload the gut with waste products (Decrease vitamin B12 absorption, decrease uptake by ileum)

• Autointoxication: bacteria in the gut produced toxins that were absorbed into the bloodstream; bacteria also adhere to the gut wall, resisting peristaltic movements

• Fight them: manipulate their carbohydrate energy sources instead of using antibacterial agents.

BREAKING THE VICIOUS CYCLE

• Carbohydrate (CHO) influences microbes most  fermentation from unabsorbed CHO forms CO2 gas, H2 gas, CH3 gas, OH sometimes; short chain organic acids (Lactic acid, Acetic acid, other by-products); energy for bacterial growth (More bacterial imbalance = more bad stuff formed)

• CHO in small intestine (SI) encourages microbial growth there

• Lactic acid – may cause abnormal brain function and behaviour

• E. coli – example of normal flora that can develop disease-producing abilities (acidic environment formed by fermentation, due to unabsorbed & undigested CHO  leading to bacterial mutations?)

• Bacterial growth in SI destroys enzymes, so preventing CHO digestion/absorption, further increase fermentation  excess mucus & increase goblet cells as defence mechanism

  • Exhaustion of goblet cells – naked intestinal cells vulnerable  ulceration may occur & proteins (e.g. gluten) inappropriately enter the interior of the absorptive cells & destroy them

• Goal: reduction and change of bacterial growth and the maintenance of the optimum nutritional state of the patient

CHO DIGESTION

• Reduce malnutrition by increasing absorption and decreasing loss (e.g. via diarrhea, decreased transit time, malfunctioning pancreas therefore decreased enzyme production, deficient/damaged microvilli of the SI from folic acid and/or B12 deficiency (improper development), abnormally thick mucus layer, toxin damage.)

• Lactase is first enzyme to be damaged, last to heal – sometimes never heals

• Sugars in intestinal lumen draw in water and nutrients – diarrhea (reverse flow of materials – should be nutrients flowing out); no removal of CHO – further fermentation & microbial growth

• Starches – indigestible b/c it makes disaccharides; some foods have tolerable starches – legume family (dried beans, lentils & split peas, NOT soy beans, chick peas or bean sprouts), but must soak these legumes 10-12 hrs in water to remove indigestible sugars

• Monosaccharides – glucose & fructose (honey, fruits, some vegetables), galactose (lactose-hydrolyzed milk & yoghurt)

• Disaccharides – Lactose (fluid & dried milk, commercial yoghurt, home-made yoghurt that has not been fermented for 24 hrs, processed cheeses, cottage cheese, ice cream, some sour creams, whey (70% lactose by weight)), Sucrose (table sugar, some in pasteurized honey but tolerable, almost none in unpasteurized honey), Maltose & Isomaltose (corn syrup, malted milk & candies, derived from dietary starches)

• Polysaccharides (Starches) – amylose & amylopectin – found in most vegetables in variable proportions (rice, corn, sweet potatoes/yams only have amylopectin); veggies with more amylose are simpler to digest b/c this is an unbranched chain

• Fiber – fruits, vegetables, nuts & grains have it; indigestible by us. Fiber from fruits, nuts & vegetables including dried legumes are allowed, but from grains (including bran) is not.

BEYOND GLUTEN

• Proteins in grains produce permanent injury to intestinal cells (gluten = primary protein in wheat and rye); alpha-gliadin fraction possesses toxic properties (theory: it penetrates the intestinal cell membrane, reaches WBC and causes an immune response  Antibodies injure cells; may be a CHO attached to the gliadin that is problematic)

• “Celiac disease” (by strict definition) – flattened intestinal cells vs. normally tall and efficient absorbers. There isn’t always improvement at the cellular level on a gluten free diet, and different patients respond differently to the diet; also same patients’ responses may vary from time to time.

  • Flattened cells are also seen in other diseases – infectious hepatitis, UC, parasites, kwashiorkor, other protein intolerances, Crohn’s dz, bacterial overgrowth…

• Majority of the starch of wheat flour is not absorbed  increase intestinal fermentation & gas production

  • Why isn’t it absorbed? Wheat flour is made of granules containing a starch core surrounded by a network of gluten protein; if these are separated and sold as low-gluten flour there is improvement in starch digestion. AND if this flour is baked together with the separated gluten there isn’t as much malabsorption either, so it’s not the gluten alone that is the problem – it’s the interaction between the starch and gluten.

• Maybe an inability to digest disaccharides predisposes to gluten sensitivity.

THE BRAIN CONNECTION

• Malnutrition leads to many psychological/neurological issues

• Bacterial toxins in the GI alter normal brain function

• Patients undergoing surgical shortening of the SI – SE of neurological Sx attacks lasting 36-80hrs (aggressiveness, sudden disorientation, blurred vision, blunted judgement, abusive behaviour, slurred speech, staggering gait, rolling of the eyeballs, confusion & delirium)

  • CHO not digested/absorbed therefore surplus of CHO for bacteria – made D-lactic acid + other toxic products  “poisons” the brain cells. Best management  prevent D-lactic acid formation!

INTRODUCING THE DIET

• No food should be ingested that contains carbohydrates other than those found in fruits, honey, properly-prepared yoghurt & listed vegetables and nuts. Recommend ONLY foods listed in chapter 9!

• Cans, jars, bottles & packages often do not list all ingredients due to different labelling laws

• Fruits: ripe, peeled & cooked

  • No raw fruits until diarrhea cleared (if it is present)

  • Only ripe bananas with brown spots are ok – ripening converts starch to monosaccharides

  • Canned fruit: most are forbidden due to added sugar.

  • If you want cooked fruit: prepare at home with honey or saccharine (avoid other artificial sweeteners)

• Dairy: limited dairy (see Appendix for cheeses); no fluid milk or commercial products.

  • Home made yoghurt: follow directions carefully (ferment at LEAST 24 hrs)

  • Dry curd cottage cheese: high protein, sugar free cheese – make sure there is NO added milk or cream (can be used instead of cottage cheese, as pancake & cheesecake base)

  • Lactose-hydrolysed milk (LHM) not advised

• When brisk diarrhea is no longer present, eggs can be added

• When stools are formed & occur no more than 2-3 times per day, cooked vegetables may be added one at a time and tested for reaction before next is added (postpone introduction if reaction occurs)

  • Cooked: squash, tomato, string beans & carrots generally well tolerated

  • No yams & potatoes

• Fats associated with meats, butter, cheese & in home-made yoghurt are well tolerated

• Daily diet should have a variety of foods: vegetables, fruits, cheeses, nuts and some animal products

• Add vitamin supplement that’s sugar (lactose), yeast & starch free

  • Vitamin B12 often malabsorbed – injections to increase levels into high-normal range

  • Vitamin B complex is advised – not too much folic acid (range = 0.1 – 0.8 mg) if not enough complimentary B12, since they work in unison

  • Vitamin C – destroyed in cooking, take at least 100mg; make sure no starch or sugar (be careful of diarrhea induction if taking too much vitamin C)

• No soy products: tofu, soy milk

• No cereal grains!

  • Corn, oats, wheat, rye, rice, millet, buckwheat or triticale in any form (breads, cake, toast, zwieback, crackers, cookies, cereals, flour, pasta, pizza)

  • Not recommended grain substitutes: amaranth, quinoa, cottonseed

  • No cereal bran in an form – indigestible fibre leads to carbohydrate overload & usually has starch in it

  • Okay: salad & cooking oil made from grains

• No seeds of any kind until 3 months after last symptom has disappeared

• DO NOT USE fructose or glucose syrup nor powdered or granulated fructose, glucose or dextrose.

• No white table sugar or brown sugar (e.g. as sweetener, in candy, pastries & breads)

• No foods that are already known to cause reactions/irritation/allergies

THE DIET PLAN

• Fanatical adherence to diet is essential!

• 4-6 week trial – if zero improvement, try something else if you do not want to continue with this diet

  • Most cases begin to improve within 3 weeks, and usually continues to improve

  • Relapses may occur around the 2^nd or 3^rd month, even if diet has been carefully followed – DO NOT be discouraged!! Once you get over this, improvement is usually steady and minor setbacks may occur occasionally during the first year.

• Keep a progress chart for first month – refrigerator

  • List symptoms at the top of the sheet (e.g. gas, diarrhea, number of bowel movements per day, mucus in stools, nightmares, etc)

  • Down the side of the page, number each day of the month

  • At end of day, fill in the chart with + (e.g. ++++ is very bad, + is mild, - is none)

START

• If symptoms (e.g. diarrhea, cramping) are severe, follow this plan for the first 5 days; if not severe, start for 2 days. NOTE: NO quantity restrictions

  • Breakfast: dry cottage cheese (moistened with homemade yoghurt), Eggs (boiled, poached, scrambled – avoid if diarrhea is severe), Apple cider or grape juice (1/2 juice, 1/2 water), homemade gelatin made with juice, Unflavoured gelatin, sweetener

  • Lunch: Homemade chicken soup including broth, chicken, Pureed carrots (see recipe), Broiled beef patty or broiled fish, Cheese cake (see recipe) without lemon rind and baked to custard consistency

  • Dinner: Variations of above

• Introduction: When diarrhea and cramping symptoms subside, cooked fruit, banana, and additional vegetables may be tried gradually; if symptoms worsen/appear then delay trying until later.

• When you begin to feel better, other aspects of the diet can be introduced.

• Do not introduce members of the cabbage family (cabbages, Brussels sprouts, broccoli, arugula, bok choy, Swiss chard, collards, kale, kohlrabi, mustard greens, rutabaga, turnips, turnip greens, watercress) until diarrhea has substantially subsided

• Dried legumes (baked beans, dried peas, kidney beans, lima beans, lentils, navy beans) may be added cautiously after 3 months.

• Many case of celiac disease, spastic colon & diverticulitis appear to be cured by the end of 1 year; Crohn’s and US take much longer (minimum 2 years). Rule of thumb – stay on the diet for at least 1 year after the last symptom has disappeared.

  • At that time introduce one forbidden food at a time (one food per week), starting with very small amounts and increasing the amount as the week progresses.

• It is hoped that after recovering, you will still avoid diet high in refined sugar & refined flours – these lack/are low in nutrients and do no nourish the immune system adequately & increase susceptibility to intestinal infections.

THE SPECIFIC CARBOHYDRATE DIET

• TO NOTE: use nuts only as nut flour until diarrhea clears up. Chew foods well.

• Nuts: for the first 3 weeks, buy nuts by the pound and grind them yourself, later if you wish to stay on the diet buy pre-ground nuts (more economical to get a lot – keep it refrigerated or frozen to prevent rancidity)

• Juice: author found these juices to have honest labels – Welch’s purple grape juice in the jar, and Dole’s unsweetened pineapple juice in the can. Apple cider (not juice) from a local mill. Home made juices. Get a juicer m/b.

• Dry curd cottage cheese: can be frozen & thawed as needed. White dry curd with no additional fluid added to it. Has been separated from the lactose-rich whey & treated with a bacterial culture to eliminate residual lactose. May be packed in plastic bags or containers. Western Dairy makes it.