Management of Celiac Disease by Dr. Sidney V. Haas, the creator of the Specific Carbohydrate Diet, and his son, Dr. Merrill P. Haas. I found this book really interesting and packed with information. I took pages of notes but hope to summarize a bit more concisely here and then list some things I found most interesting to people following SCD now.
The authors cover a lot of the research on celiac disease up until the publishing of this book in 1951. At the time, gluten was not known to have any role in celiac disease (or maybe even gluten was not discovered yet) so a lot of the research done at the time was in the form of case studies using different dietary methods. It’s no surprise to me that Haas’ diet ended up having the most favourable outcome, since it is inherently gluten-free and provides adequate nutrition for someone recovering from celiac disease. I found this book quite easy to read without having any medical knowledge, so for anyone with celiac who is interested in reading about it, I highly recommend this book. (I bought mine from Digestive Wellness).
Celiac Disease Causes & Symptoms
They spent a good deal of time describing symptoms and diagnosis guidelines, mainly because there was no definitive test available. Of course there still is no definitive test so I found all this information really interesting. Although they describe a lot of common symptoms, they acknowledge that not all of the symptoms have to be present for it to be considered celiac disease. And, sometimes the symptoms are quite mild. Most of the research at the time was done with extreme cases of celiac disease that started in young children. But, the authors stated that this disease could start at any time, in any severity, and was most likely under-diagnosed especially in people who didn’t have the main symptom of diarrhea. They talk about many cases they saw where constipation was the predominant symptom. Psychological symptoms were also very well described.
In a quest to figure out the main cause of celiac disease, the researchers up until the 1950s had followed a few different routes.
- Fatty stools were very common in celiac cases (both in diarrhea and constipation), and fat absorption seemed to be impaired. Noting that fat was well digested (emulsified and broken into fatty acids) it was the absorption that was the problem. Yet removing fat from the diet did nothing to halt the progression of the disease. Many doctors continued to prescribed low-fat diets and continued research in this area, even though there was never any evidence that it played a role in the disease.
- Some cases seemed to show a lack of pancreatic (digestive) enzymes, stomach acid and/or bile. So lots of research was done on administering these as supplements. Some patients saw a bit of improvement in symptoms using various digestive aids, but none seemed to recover.
- A few researchers noted carbohydrate intolerance, either from studying blood sugars or from noting digestive symptoms with varying low-carbohydrate diets. Most low-carbohydrate diets failed because as soon as symptoms abated, a normal diet was resumed and symptoms returned. Or, some kept one of milk, toast, corn or rice in the diet while eliminating most other forms of carbs. Almost all researchers noted that adding sugar would instantly cause more severe digestive symptoms, regardless of the diet. But, some research was done with pure glucose (monosaccharide) showing positive effects.
- One researcher noted a relationship with the bacteria B. bifidum (considered illegal on SCD). When symptoms were severe, this bacteria count was high. When the patient recovered, the bacteria count was much lower. If the patient relapsed, the bacteria count was always found to be high again. This was all without administering any probiotics.
For the large part though, the fat theory reigned supreme at the detriment of the children who were prescribed the low-fat diets. Even though fat was shown not to cause symptoms, and that it was necessary to include fat to avoid osteoporosis and other nutritional problems, doctors kept focusing on removing fat from the celiac diet.
Celiac disease in children at that time had a high mortality rate. So the different treatments attempted had very clear effect on the outcomes. Some diets helped children avoid death, but they still had stunted growth and ongoing symptoms. Some like Haas managed to recover children fully without stunted growth or osteoporosis. There were also a lot of autopsies conducted which showed varying effects of the disease. Many had no noticeable changes to the digestive system, no ulceration, and no effect on the liver. Still some had noticeable changes in the pancreas, and some were found to have ulceration in the colon. Since blood in the stool was not reported as a symptom in these cases, it’s not clear if that was a case of a colitis condition or not. Villous atrophy and changes in the small intestine were somewhat common. Respiratory illness was also quite common, and often preceded initial symptoms or relapses.
Very little at the time was agreed on, except that symptoms and severity varied greatly, anyone of any age could have it, and that protein seemed well tolerated in all cases (in the form of meat). Fat and mineral absorption seemed to be the main problem with growth and bone development. Many suggested using vitamin A and D supplements along with diet. Even though not all agreed on the carbohydrate intolerance, most would omit carbohydrates in the early stages of their diets.
Of the researchers who noted the difficulty in tolerating carbohydrates, most agreed that cow’s milk was the worst food, and cereals and sugar were also poorly tolerated (fermentable carbohydrates). Cow’s milk that had been treated to become ‘protein milk’ (much like today’s SCD yogurt) was fine. Vegetables and fruit were not always tolerated. So the difficulty was in trying to find a carbohydrate that would help all patients. The banana turned out to be that universal carb. Many different diets had made use of the banana, but only those diets that removed other offending carbohydrate sources had any success. Some naturally gluten-free diets proposed at the time still did not bring about a relief of symptoms, much like the gluten-free diet prescribed today leaves patients with lingering symptoms. Most of these diets still included things like milk, sugar, potatoes and corn or rice.
Dr. Haas’ diet as described in this book is quite similar to how SCD is presented today but with a few noticeable differences. For one, bananas are emphasized much more in Haas’ original diet. In fact, his diet was often referred to as ‘the banana diet’ during that time. He noted that banana powder was found to change the gut bacteria back to normal levels. The intro diet could very well be summed up as protein plus bananas. He spent time finding evidence of other doctors who had used bananas in treating celiac disease with success. He told how in his own practice he had patients eating 4-6 bananas a day. Keep in mind these were mostly very young children, so that made up a big portion of their diet. Also he made a point of showing that while fat absorption was poor, carbohydrates were required to metabolize fats. Also, upon administering certain carbs (such as the banana), fats were once again better tolerated. Anxiety, confusion and depression were often more noticeable when carbohydrates were not being well tolerated. He noted that animal fats were best tolerated. Meat, protein milk and bananas were the first step, with gelatin (sweetened with fruit juice & honey) used as a dessert. Eggs, fruit and vegetables were introduced slowly one by one after symptoms disappeared.
For the ‘protein milk’ he prescribes, there are a few different ways of making it. The basic idea is to get rid of or break down the milk sugars. Whey is always dripped out and discarded. Butter, sour cream and buttermilk were shown to be well tolerated. I can’t help but wonder if the focus on a milk that is tolerated was important to these researchers at the time, because most of their patients were toddlers who were either just weaned off breast milk or formula, and probably using milk as a big portion of their diet. I didn’t see any mention that this was a required part of the diet, just that it was a tolerable protein.
Haas did say this diet cured celiac disease. Without knowing if these cured cases were actually caused by problems with gluten it’s hard to say if SCD would actually be a cure. That said, he clearly had severe cases that responded fully to the diet and these children (and some young adults even) were able to return to a normal diet. One case stood out to me, of a girl who was off and on the SCD throughout her childhood (never strictly) who always had symptoms. Finally the symptoms got worse in her late teen/early 20s and she returned to him. After following the diet strictly for over a year, her symptoms were gone and after a while she was able to return to a normal diet with no relapses.
Probiotics might not be necessary: The ‘protein milk’ did not seem to play a role in re-establishing gut flora. Also, they noticed improvement in bacteria levels based on the diet alone. It seems providing a good environment for gut flora is more important than consuming probiotics. This I’ve noticed in my own experience too. They also noted that bananas added to the diet changed the gut flora in a beneficial way.
Yogurt should always be dripped: The protein milk recipes always drip the whey out, and that’s the main method of removing the sugars. On SCD now, it’s advised to try dripping yogurt because many have found it to be better tolerated. I have a feeling dripping the yogurt is even more important than fermenting it for a full 24 hours. Based on my own experience, dripping helps tremendously, and fermentation time didn’t matter as much. Tartness was always the most reliable indicator to me that the yogurt was good. The best method would be to ferment 24 hours and then drip the whey out. Whey should probably be discarded by anyone following the intro and early stages of the diet. I also wonder now if sour cream or other milk products would have been tolerated.
Carbs (in the form of bananas and probably honey) should be used in abundance from the beginning, in balance with fats: I always tried to ‘get more carbs’ by eating squashes, carrots, applesauce and other fruits and vegetables considered well tolerated on SCD. I did poorly on all of them. Bananas were always ok, as long as I ate them with enough fat and protein. I wish now I could go back to the early days and eat a bunch of bananas to see how I reacted. For some reason I always limited myself to one or two a day.
Fat absorption probably plays the biggest role in constipation and diarrhea: Haas reported that fat in the stool was of either free fatty acids (causing diarrhea) or bound with minerals into soaps (causing constipation). I have seen a lot of advice for people on SCD with constipation to eat more fats, and I’m not sure that’s really the best thing to do. If carbs actually help with fat tolerance, then maybe for constipation it would be best to eat more carbs, not more fats. With less fats being bound in the digestive tract as soaps, maybe constipation would be lessened. I think many already know bananas help with diarrhea. As for digestive aids to help fat digestion, they shouldn’t be necessary. It was found that fats were broken down properly, just not absorbed very well. Fat absorption is not something that would improve with taking bile supplements or digestive enzymes.
Nuts were not used in Haas’ diet: I expected this and not just because nut flours were not available at the time. Haas made no mention of nuts in this book. I know a lot of people today think nuts are required to get enough calories or to be able to enjoy treats ‘now and then’ (which turns into every day pretty quickly!). The main concern with celiac diets was to have some form of tolerable carbohydrate and that was found to be the banana. With plenty of protein and fats available from meat, and carbs from banana, there is no need to add nuts.
Haas made a point of noting that although early on in the diet children would want treats, it was often the parents who felt they should be allowed some in order to feel included in social situations or be able to eat normal food. If children were not given these treats and kept strictly on the diet, once they had fully recovered they didn’t care as much for breads and cakes as other children did. This is definitely my experience now. Early in SCD I did eat a lot of the almond flour goods and my desire for treats never went away. Now, I would prefer fruit for dessert.
Periodic flares: Another interesting piece of information was about the ‘3 months flare’ that many following SCD now describe. In Haas’ work he found that respiratory illnesses always brought about a flare in symptoms, and these generally happened within the first 3 months of starting the diet. I actually think later flares at 6 or 9 months might be due to introduction of too many nuts that almost everyone ends up doing on this diet. (That’s what I did..)
I think a lot can be learned from Haas and other researchers of his time, especially for doctors treating celiac patients. Currently, if a patient’s symptoms persist, blame is placed upon them for consuming minute amounts of gluten, cross-contamination, or non-compliance. There’s no initial diet to follow until symptoms improve. It’s just a one-size-fits-all gluten-free diet with maybe some advice to take vitamins for obvious deficiencies. What would be better is taking patients through a starting diet specifically for healing before allowing a full gluten-free diet, and not to consider a patient fully recovered until all digestive symptoms are gone, good general health is returned and no relapses in symptoms occur.