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• W1653532275 abstract "The pathogenesis of inflammatory bowel disease (IBD) is thought to be multifactorial, involving a genetically susceptible individual being exposed to a yet-to-be identified environmental trigger or set of triggers. There is growing evidence that IBD may be a disease of Westernization associated with diets high in refined sugars; bread and cereals; proteins, especially dairy; and n-6 polyunsaturated fatty acids acquired from highly processed seed oils. However, the evidence is often low quality, conflicting, and inconclusive.1Wong S.H. Ng S.C. What can we learn from inflammatory bowel disease in developing countries?.Curr Gastroenterol Rep. 2013; 15: 1-9Crossref Scopus (20) Google Scholar, 2Sartor R.B. Clinical applications of advances in the genetics of IBD.Rev Gastroenterol Disord. 2003; : S9-S17Google Scholar, 3Bernstein C.N. Shanahan F. Disorders of a modern lifestyle: Reconciling the epidemiology of inflammatory bowel diseases.Gut. 2008; 57: 1185-1191Crossref PubMed Scopus (218) Google Scholar, 4Chapman-Kiddell C.A. Davies P.S. Gillen L. Radford-Smith G.L. Role of diet in the development of inflammatory bowel disease.Inflamm Bowel Dis. 2010; 16: 137-151Crossref PubMed Scopus (182) Google Scholar, 5Asakura H. Suzuki K. Kitahora T. et al.Is there a link between food and intestinal microbes and the occurrence of Crohn's disease and ulcerative colitis?.J Gastroenterol Hepatol. 2008; 23: 1794-1801Crossref PubMed Scopus (69) Google Scholar The Specific Carbohydrate Diet (SCD) is a dietary program that claims to induce and maintain drug-free remission in patients with IBD. It was initially developed by gastroenterologist Sidney Haas in 1951 and later popularized by biochemist Elaine Gottschall in the book Breaking the Vicious Cycle: Intestinal Health Through Diet.6Haas S.V. Haas M.P. Management of Celiac Disease. Lippincott, Philadelphia, PA1951Google Scholar, 7Gottschall E. Breaking the Vicious Cycle.2012 ed. The Kirkton Press, Baltimore, Ontario, Canada2012Google Scholar The diet allows carbohydrate foods consisting of monosaccharides only and excludes disaccharides and most polysaccharides (such as linear or branch-chained multiple sugars or starches). The diet is supplemented by homemade yogurt fermented for 24 hours to free it of lactose, a disaccharide not allowed in the SCD. Recommended cultures include Lactobacillus bulgaricus, Lactobacillus acidophilus, and Streptococcus thermophilus. The SCD allows almost all fruits, vegetables containing more amylose (a linear-chain polysaccharide) than amylopectin (a branch-chained polysaccharide), nuts, nut-derived flours, dry-curd cottage cheese, meats, eggs, butters, and oils. It excludes sucrose, maltose, isomaltose, lactose, grain-derived flours and all true and pseudograins, potatoes, okra, corn, fluid milk, soy, cheeses containing high amounts of lactose, as well as most food additives and preservatives. The typical starting dieter begins eating foods that are thought to be well tolerated, including cooked, peeled, and seeded fruits and vegetables, and over time other foods are added slowly to partially liberalize the diet. The SCD is not a low-carbohydrate diet, but rather a diet that is predominantly composed of monosaccharaides, solid proteins, fats, a high ratio of amylose to amylopectin vegetables, fruits, and nuts. Gottschall7Gottschall E. Breaking the Vicious Cycle.2012 ed. The Kirkton Press, Baltimore, Ontario, Canada2012Google Scholar hypothesized that patients with IBD can only optimally absorb the monosaccharides glucose, galactose, and fructose due to a dysfunction of the host’s disaccharidases that are necessary for digestion and absorption of disaccharides and high amylopectin foodstuffs. This dysfunction is posited to arise from excessive mucus production preventing the brush border intestinal enzymes from making contact with the disaccharidases and amylopectin causing maldigestion. Further, toxic substances produced by dysbiosis of the luminal microbiota (eg, the overgrowth of yeast and bacteria) in the small intestine may cause damage to intestinal cell membranes and destroy brush boarder enzymes.7Gottschall E. Breaking the Vicious Cycle.2012 ed. The Kirkton Press, Baltimore, Ontario, Canada2012Google Scholar A diet containing carbohydrate from primarily monosaccharide sources such as fructose (as in fruits and honey) and higher amylose:amylopectin vegetables, butter or oils, and solid proteins could optimally nourish a patient with IBD and result in lower amounts of disaccharide sugars entering the colon, preventing and reversing a significantly altered and dysfunctional microbiota postulated to be present in the gastrointestinal tract of patients with IBD.7Gottschall E. Breaking the Vicious Cycle.2012 ed. The Kirkton Press, Baltimore, Ontario, Canada2012Google Scholar Neither the characteristics of patients who are following the SCD nor the benefits of this diet have been well described in the medical literature. Herein, we report on the largest series of patients with IBD following the SCD to date and describe their clinical characteristics. We collected survey data from patients with IBD following the SCD living within the continental United States. Subjects were recruited through advertisements posted on SCD message boards and websites as well as through our own gastroenterology clinics. Subjects mailed their medical records and filled out a structured survey of their medical history, a 3-day diet diary, and a validated disease activity index. The modified Harvey-Bradshaw Index was used for Crohn’s disease (CD),8Harvey R. Bradshaw J. A simple index of Crohn's-disease activity.Lancet. 1980; 1: 514Abstract PubMed Scopus (2189) Google Scholar the St Mark’s Index was used for ulcerative colitis (UC),9Powell-Tuck J. Bown R. Lennard-Jones J. A comparison of oral prednisolone given as single or multiple daily doses for active proctocolitis.Scand J Gastroenterol. 1978; 13: 833-837Crossref PubMed Scopus (280) Google Scholar and both indexes were used for cases of indeterminate colitis (ID). Presence of gastrointestinal symptoms within 1 week of the data collection was assessed with the use of a structured survey called the Gastrointestinal Symptom Severity Checklist, which is designed similarly to validated Gastrointestinal Symptom Rating Scale but expanded to include additional symptoms that may not be captured by the Gastrointestinal Symptom Rating Scale.10Svedlund J. Sjödin I. Dotevall G. GSRS—A clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease.Dig Dis Sci. 1988; 33: 129-134Crossref PubMed Scopus (988) Google Scholar In addition, on the Gastrointestinal Symptom Severity Checklist each subject is asked to rate one symptom at a time on a visual analog scale from 0 to 10, with higher scores corresponding to increasing severity and frequency of the symptom. The subject’s quality of life was assessed by a validated instrument, the Short Quality of Life in Inflammatory Bowel Disease Questionnaire (SIBDQ).11Alcala M. Casellas F. Fontanet G. et al.Shortened questionnaire on quality of life for inflammatory bowel disease.Inflamm Bowel Dis. 2004; 10: 383-391Crossref PubMed Scopus (53) Google Scholar Subjects also rated their self-adherence to the SCD and the effectiveness of the SCD on a visual analog scale of 0% to 100%. Subjects were included in the study if they had documented IBD by a physician within the United States and reported to follow the SCD. All diagnoses of IBD were confirmed by review of endoscopy, radiology, and pathology reports by a board-certified gastroenterologist who specializes in IBD at Rush University. Remission was defined as a Harvey-Bradshaw Index <5 for CD and St Mark’s Index <4 for UC. Both surveys needed to reflect remission for ID. The Rush University Medical Center Institutional Review Board approved the study protocol and all participants provided written informed consent (and child assent, if appropriate). We obtained data on 50 cases in remission: 36 subjects had CD, 9 subjects had UC, and 5 subjects had ID. The subject demographic characteristics and disease locations are given in Table 1. The mean age was 36 years (range=10 to 66 years). Twenty-nine subjects (58%) were female. Of patients with CD, the most highly represented subtype was colonic disease in 16 patients (three of whom also had upper GI involvement) and ileocolonic disease in 14 patients (three of whom also had upper GI involvement). Of the patients with UC, six had left-sided disease and two had pancolitis. All subjects were in remission: the mean Harvey Bradshaw Index was 0.9 (range=0 to 4) and the mean St Mark’s Index was 1.4 (range=0 to 3).Table 1Demographic characteristics of a cohort of 50 patients with inflammatory bowel disease in remission following the Specific Carbohydrate DietCase no.DiseaseLocationAgeSexDuration of disease (mo)Duration of diet (mo)Level of educationForbidden food(s)Medication(s)1UCaUC=ulcerative colitis.Pancolitis56MbM=male.28876CollegeNoneLDNcLDN=low-dose naltrexone.2UCRectosigmoid56FdF=female.384216CollegeNoneNone3UCPancolitis41F369CollegeNoneMesalamine (AsacoleAsacol (Warner Chilcott Company, LLC).), LDN, azathioprine4UCRectosigmoid35F10882CollegeNoneLDN5UCRectosigmoid38F20440CollegeNoneMesalamine suppositories6UCRectosigmoid41M4813Graduate degreeNoneMesalamine (LialdafLialda (Shire US, Inc).), mesalamine enema7UCRectosigmoid32F1327CollegeNoneInfliximab8UCProctitis35M244Graduate degreeNoneMesalamine (Lialda)9UCPancolitis25F3242Graduate degreeNonePrednisone (1 mg), sulfasalazine (AzulfadinegAzulfadine (Pfizer, Inc).), mesalamine enema10CDhCD=Crohn’s disease.Ileocolonic29M32419Graduate degreeNoneMesalamine (PentasaiPentasa (Shire US, Inc).), infliximab11CDColonic61F3610High schoolNoneMesalamine12CDColonic48M246Graduate degreeNoneNone13CDIleocolonic27M1568CollegeNoneAdalimumab, LDN, budesonide14CDColonic40F7260Graduate degreeChocolateNone15CDUpper GIjGI=gastrointestinal.+colonic10M6039Middle schoolIce creamNone16CDUpper GI+ileocolonic11F248Middle schoolRiceMesalamine (Asacol)17CDIleocolonic31F15614CollegeNonePrednisone (1.5 mg), infliximab, LDN18CDUpper GI+ileocolonic11M247Middle schoolNoneNone19CDUpper GI+ileocolonic9M8466Middle schoolNoneNone20CDIleum52M3614CollegeNoneMesalamine (Pentasa)21CDUpper GI+ileum49M3845CollegeNoneNone22CDIleocolonic41M19231CollegeNoneBalsalazide23CDUpper GI+colonic13F3614Middle schoolCream, canned vegetables, eucharist hostNone24CDIleocolonic44M34872CollegeCoffeeNone25CDColonic19F241CollegeNoneNone26CDColonic37F3616Graduate degreeNoneNone27CDIleum65M420132Graduate degreeNoneMesalamine (Asacol), mesalamine enema, colestipol28CDIleocolonic49F12012CollegeEspresso6-MPk6-MP=6-mercaptopurine.29CDColonic44M3002CollegeNoneNone30CDColonic30F3614CollegeCoconut water, chocolateMesalamine (Lialda)31CDIleocolonic31F132111CollegeNoneNone32CDColonic39M276158Graduate degreeSalad dressingNone33CDIleocolonic58F38424Graduate degreeNoneLDN34CDIleum51F486Graduate degreeNoneNone35CDColonic43F249CollegeNoneNone36CDColonic29F3617CollegePotatoesNone37CDUpper GI+ileum19M3613High schoolBrown rice, corn6-MP38CDUpper GI+colonic52F168162CollegeMatzah once a yearNone39CDColonic42F4810Graduate degreeNoneMesalamine (Asacol)40CDColonic49F244CollegeNoneMesalamine (Lialda)41CDColonic59F8412CollegeMilk, candy, cookiesMesalamine (Lialda)42CDIleocolonic11F248Middle schoolNoneLoperamide (Imodium)43CDIleocolonic15F126High schoolNoneMesalamine (Asacol), 6-MP44CDGastric12M3622Middle schoolSchool lunchesNone45CDIleocolonic29M6060Graduate schoolNoneLDN, adalimumab46IDlID=indeterminate colitis.Sigmoid to distal transverse, rectal sparing31F846Graduate degreeNoneMesalamine (Asacol)47IDRight colon17M608High schoolCorn tortillas, potatoesMethotrexate48IDRectosigmoid56F4816CollegeNoneNone49IDPancolitis, sparing rectum39M24072Graduate degreeSpelt bread, raw milk, baked goodsNone50IDRight colon, rectosigmoid46M10848CollegePizzaHydrocortisone enemaa UC=ulcerative colitis.b M=male.c LDN=low-dose naltrexone.d F=female.e Asacol (Warner Chilcott Company, LLC).f Lialda (Shire US, Inc).g Azulfadine (Pfizer, Inc).h CD=Crohn’s disease.i Pentasa (Shire US, Inc).j GI=gastrointestinal.k 6-MP=6-mercaptopurine.l ID=indeterminate colitis. Open table in a new tab The mean GSSC score was 27.1 for CD, 25.9 for UC, and 13.6 for ID (range=0 to 144), reflecting mild gastrointestinal symptoms. The individual symptom scores are shown in Table 2.Table 2Gastrointestinal Symptom Severity Checklist (GSSC) results for cohort of 50 patients with inflammatory bowel disease in remission following use of the Specific Carbohydrate DietGSSC itemCrohn’s Disease (n=36)Ulcerative Colitis (n=9)Indeterminate Colitis (n=5)% >0Mean% >0Mean% >0MeanUpper abdominal pain or discomfort27.80.633.30.720.00.2Lower abdominal pain or discomfort44.40.855.61.420.00.2Upper abdominal cramping16.70.411.10.100Lower abdominal cramping22.20.422.20.600Pain associated with eating11.10.422.20.400Bloating30.61.333.31.240.00.8Belching33.30.733.30.620.00.4Passing gas66.71.877.82.240.00.6Excessive gas overall38.91.266.71.220.00.2Heartburn16.70.633.30.720.01.6Indigestion13.90.333.30.700Nausea13.90.622.20.620.00.4Nausea associated with eating13.90.511.10.320.00.4Frequent bowel movements13.90.933.30.620.00.2Vomiting13.90.40000Alternating bowel movements between constipation and diarrhea22.20.433.30.820.00.2Constipation >70% of the time22.20.511.10.300Diarrhea >70% of the time33.31.011.10.100Irregular bowel habits30.60.833.30.420.00.2Infrequent bowel movements27.80.533.30.700Hard stools36.11.033.30.720.00.4Watery stools47.21.644.40.920.00.6Soft stools41.71.666.73.660.01.4Passage of mucous in the stool19.40.533.31.320.00.2Passage of blood in the stool (without presence of hemorrhoids)27.80.833.30.820.00.2Straining with bowel movements38.90.911.10.400Fecal urgency41.71.466.71.140.01.0Bowel incontinence13.90.50000Sensation of incomplete emptying of bowels38.90.755.60.820.00.2Loss of appetite11.10.522.20.200Weight loss27.80.955.61.840.01Decreased food intake because of symptoms13.90.611.10.100Difficulty swallowing2.800000Pain with swallowing000000Food coming up to mouth2.80.10000Acid taste in mouth5.60.10020.01.6Intolerance to multiple foods38.91.833.30.720.01.6Overall86.127.188.925.980.013.6 Open table in a new tab Patients following the SCD in remission had a high quality of life with a mean SIBDQ score of 60.9 (range=35 to 70). The results for the subscales of SIBDQ are given in Table 3.Table 3Short Quality of Life in Inflammatory Bowel Disease Questionnaire (SIBDQ) of a cohort of 50 patients in remission following use of the Specific Carbohydrate DietPatient’s conditionSIBDQ Subscale Scores (mean±standard deviation)BowelSystemicEmotionalSocialTotalOverall (n=50)18.9±2.411.7±2.216.7±3.313.5±1.160.9±6.5Crohn’s disease (n=36)18.8±2.611.9±2.116.6±3.513.5±1.360.9±6.9Ulcerative colitis (n=9)18.4±2.111.3±2.316.7±2.713.4±0.959.9±5.7Indeterminate colitis (n=5)20.4±0.911.6±2.917.2±3.414.0±0.063.2±4.3 Open table in a new tab The breakdown of medication use among the subjects with CD and UC are given in Table 1. In the CD group, eight subjects were taking immunosuppressive medications and only one patient was not steroid-free and was taking prednisone at a dose of 1.5 mg daily. Nineteen subjects with CD were not taking any medications for their IBD. Past medication use in this group before starting the diet included mesalamine-based drugs in 15 subjects, prednisone in 12 subjects, budesonide in two subjects, 6-MP in four subjects, infliximab in one subject, certolizumab in one subject, ciprofloxacin in four subjects, and metronidazole in six subjects. In the UC group, three patients were taking immunosuppressive agents and only one patient was not steroid-free and was taking prednisone at a dose of 1 mg daily. One subject with UC was not taking any medications. Prior use of medications in this subject included prednisone, 5-aminosalicylates, and 6-MP. In the ID group, one subject was taking an immunosuppressive agent. Two subjects with ID were taking no medications. Prior use of medications in this group included prednisone and mesalamine drugs in both subjects and infliximab and ciprofloxacin in one subject. Therefore, out of 22 patients who were taking no medications at all, 16 had discontinued all steroids (14 were taking prednisone and two were taking budesonide), three had discontinued TNF inhibitors, and five had discontinued 6-MP and had remained in remission. The mean time the SCD was followed was 35.4 months (range=1 to 216 months). Forty-four subjects (88%) reported eating the SCD yogurt, 33 of whom (67%) ate it daily. Twenty-six subjects (52%) reported using a supplementary probiotic. The most common probiotics used were Lactobacillus and Acidophilus species (13 CD patients and four UC patients) and Saccharomyces boulardii preparations (4 CD patients and one UC patient). Patients’ self-rating of compliance with the SCD diet on a visual analog scale of 0% to 100% had a mean adherence rating of 95.2% (range=71% to 100%). The Figure shows an example of a 3-day diet diary of one of the subjects in the study that is an accurate representation of the foods allowed on the SCD. Although the diet requires strict adherence, there were still 16 subjects (32.1%) (12 CD patients and four ID patients) who reported occasional ability to eat some “forbidden” foods (Table 1). Of these 16 subjects, 14 had CD and two had ID. All subjects were eating SCD yogurt and had been following the SCD diet for at least 8 months. Seven (43.7%) of these 16 patients who were eating “forbidden” foods were also taking some type of maintenance medication (Table 1).FigureActual 3-day food diary for one patient following the Specific Carbohydrate Diet demonstrating a representative menu.Day 1 Breakfast2 eggs, yogurt with farmer’s cheese, honey LunchCube steak, apples, green beans, carrots DinnerSteak, carrots, green beans SnacksGrape juice, gelatin, peanut butter brownies, applesDay 2 Breakfast2 eggs, yogurt with farmer’s cheese, honey LunchSteak, apples, asparagus DinnerTurkey burger (no bun), apples, carrots, boiled shrimp SnacksPeanut butter brownies, grape juiceDay 3 Breakfast3 eggs, yogurt, honey LunchChicken thighs, asparagus, baked apples, honey DinnerPork with pineapple, carrots, asparagus, peaches SnacksPeanut butter brownies, grape juice Open table in a new tab Table 4 shows the reasons that patients started the SCD. Forty-one patients (82%) reported that one of the reasons they started the diet was fear of long-term consequences of medications. Other common reasons included the belief that the SCD was more effective than medications (64%), medications were not effective (64%), adverse reaction from a prior medication (56%), and recommendations from Internet forums (44%).Table 4Reasons reported by cohort of 50 patients with inflammatory bowel disease in remission for choosing to implement the Specific Carbohydrate Diet (SCD)ReasonCases (n)%Fear of long-term consequences of medications4182Efficacy of SCD compared with medications3264Medications not effective3264Adverse reactions to medications2856Recommendation from Internet forum2244Recommendation from family/friends1530Breaking the Vicious Cycle book7Gottschall E. Breaking the Vicious Cycle.2012 ed. The Kirkton Press, Baltimore, Ontario, Canada2012Google Scholar48Cost of medications12Seeking alternative treatment to medications12Fear of need for surgery24Fear of colon cancer12 Open table in a new tab Mean time for food preparation per week was 10.8 hours (range=0 to 32 hours). Twenty-four (58.5%) of 41 adult subjects were able to hold full-time jobs while implementing the diet. Mean time to see some improvement when following the SCD was 29.2 days (range=1 to 180 days). Thirty-three subjects (66%) noted complete symptom resolution, which did not occur until a mean of 9.9 months (range=1 to 60 months) after starting the SCD. Patients’ self-report of the effectiveness of the SCD was obtained via visual analog scales: SCD was rated as a mean of 91.3% effective in controlling acute flare symptoms (range=30% to 100%) and a mean of 92.1% effective at maintaining remission (range=53% to 100%). Subjects reported a mean of 40% difficulty rating in following the diet (range=0% to 100%). This is the first clinical description of a large series of patients with IBD following the SCD. Our survey results suggest that SCD can potentially be an effective tool in the management of some patients with IBD and specifically in patients with colonic and ileocolonic CD who made up the majority of our study group. A highly educated group of patients follow the SCD; all but one of the adults in our study had a college or graduate degree. Our results also suggest that in some patients with moderate to severe disease who follow this diet, discontinuation of immunosuppressive agents has been feasible. One of the strengths of our study is the verification of the diagnosis of IBD in all of the patients with medical record reviews by an experienced gastroenterologist who specializes in IBD. Our limitations include the choice of our subjects, all of whom were in remission, biasing our findings toward including patients with IBD who have benefited from SCD and were following it for months. Nevertheless, we now show that at least a subgroup of patients with IBD may notably improve as a result of following the SCD and/or dietary interventions in general. Our findings enhance those of prior limited case reports of dietary therapy with SCD and other dietary interventions.12Suskind D.L. Wahbeh G. Gregory N. et al.Nutritional therapy in pediatric Crohn disease: The specific carbohydrate diet.J Pediatr Gastroenterol Nutr. 2014; 58: 87-91Crossref PubMed Scopus (108) Google Scholar, 13Fridge J. Kerner J. Cox K. The Specific Carbohydrate Diet—A treatment for Crohn’s disease?.J Pediatr Gastroenterol Nutr. 2004; 39: S299-S300Crossref PubMed Google Scholar, 14Nieves R. Jackson R.T. Specific carbohydrate diet in treatment of inflammatory bowel disease.Tenn Med. 2004; 97: 407PubMed Google Scholar, 15Olendzki B.C. Silverstein T.D. Persuitte G.M. et al.An anti-inflammatory diet as treatment for inflammatory bowel disease: A case series report.Nutr J. 2014; 13: 5Crossref PubMed Scopus (145) Google Scholar, 16Gonzalez-Huix F. de Leon R. Fernandez-Banares F. et al.Polymeric enteral diets as primary treatment of active Crohn's disease: A prospective steroid controlled trial.Gut. 1993; 34: 778-782Crossref PubMed Scopus (185) Google Scholar Other, more long-term diet interventions that are not SCD have shown promise in a very limited number of subjects.17Jones V.A. Comparison of total parenteral nutrition and elemental diet in induction of remission of Crohn's disease.Dig Dis Sci. 1987; 32: S100-S107Crossref PubMed Scopus (109) Google Scholar, 18Chiba M. Abe T. Tsuda H. et al.Lifestyle-related disease in Crohn's disease: Relapse prevention by a semi-vegetarian diet.World J Gastroenterol. 2010; 16: 2484-2495Crossref PubMed Scopus (152) Google Scholar Further evidence suggesting diet can be an effective treatment for some patients with IBD stems from the fact that diet has the potential to change the intestinal luminal environment, specifically the intestinal microbiome. Our prior preliminary findings19Kakodkar S. Mikolaitis S.L. Engen P. et al.The effect of the Specific Carbohydrate Diet (SCD) on gut bacterial fingerprints in inflammatory bowel disease.Gastroenterology. 2012; 142: S395Abstract Full Text PDF Google Scholar, 20Kakodkar S. Mikolaitis S. Engen P. et al.The bacterial microbiome of inflammatory bowel disease patients on the Specific Carbohydrate Diet (SCD).Gastroenterology. 2013; 144: S552Google Scholar hint at a change in the microbiome of patients with IBD who follow the SCD. If following the SCD changes the microbiome significantly and/or reverses some of the dysbiosis reported in patients with IBD, this may be a low-cost intervention to induce and maintain remission with little or no known adverse reactions. As such, further interventional studies of SCD and diet therapies in general for IBD are urgently needed." @default.
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• W1653532275 title "The Specific Carbohydrate Diet for Inflammatory Bowel Disease: A Case Series" @default.
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