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Management of Celiac Disease

I just finished reading the

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.

Diet

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.

My Notes

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.

Kat

I have been following the Specific Carbohydrate Diet since January 2008 to recover from Celiac disease. As part of the diet, I don't eat grains, sugar or potatoes and prepare all my meals from scratch.

32 Comments

  1. This is really interesting information. One thing to note: when you have prolonged diarrhea, the first mineral to be depleted is potassium. Not surprising that bananas would be highly recommended. Having gone through Celiac Disease back in the day, when little was known about it, I can really relate to a lot of the information you have provide here. Thanks for sharing!

  2. Thank you, Kat, for sharing your notes with us! I’ve always wondered if I should read Haas’ book, and now I may just do that. But first, I have this overwhelming urge to buy more bananas! 😉

  3. Thanks for taking the time to read and share your thoughts on the Haas bro’s book. About the whey, if I discard it and eat the dripped yogurt cheese, do I still get beneficial probiotics?

  4. Wow Kat this was a great post! I have heard of the work of the Haas brothers because it is mentioned in The Vicious Cycle, but did not know it was published and available to anyone. I am really excited about what you learned, thanks for sharing!

  5. @Kat
    OK, thanks. Also, I bought this book thanks to your post, from Digestive Wellness too. Some are going for hundreds of dollars on Amazon! One for $800 USD. Though, sounded like it was autographed by Dr. Haas himself.

  6. @Karen Baldwin Thanks, glad you enjoyed it 🙂

    @Reid B. Kimball The original book is probably a collector’s item. This is a reprint, and after having trouble buying it through the main page someone recommended Digestive Wellness and I had it within a week. Hope you enjoy it!

  7. Very interesting post. It’s always good to go back to the sources! My problem with bananas is that, in my case, it could feed the candida…

  8. Right now, my 18 month old gluten intolerant daughter ihas been on the GAPS/SCD diet for 9 months. Her eczema is gone, but she will NOT gain weight. I am very frustrated and considering trying something else. Maybe this book would help? I don’t know…

  9. @Paula I will be putting a post up about how my candida symptoms finally went away. And I did that while eating bananas!

    @Andrea For me gaining weight definitely required an increase in both carbs and fats. Is your daughter doing well with dairy? If so, lots of dairy, bananas and honey will help put on weight.

  10. Dear Kat,

    I am a RHN and have great respect for Gottshall’s book as well as the ‘Gaps’ by Campbell-McBride. I have recommended the diet’s described many times to clients with good results. I appreciate so much your review of Haas’s book…definately will search it out and purchase it. Another book I found to be extremely helpful, especially for those client’s with Candida, is “the Body Ecology Diet” by Donna Gates. For clients who had trouble gaining weight on the SCD I recommend coconut smoothies made with coconut oil,coconut milk, some form of protein like nut butter, and fruit that is well tolerated. Diane

  11. Dear Kat, What a great post on Dr’s Haas’s book.
    Thank-you for sharing.
    For people that are having trouble with candida, and/or gaining weight, I recommend coconut oil and milk. The lauric acid in the coconut is healing to the gut and it’s anti- fungal and anti-viral.
    For yeast, Bentonite is very useful in some people.

    Keep up the good work.

  12. Your opinion about the benefit of carbs over fats for constipation was interesting. I do well with fats, so on the currant popular advice of other authors, I’ve increased fats to help with my chronic constipation (I’ve been doing this for a few years). Lately, I’ve been making A LOT of GAPS compliant soups (butternut squash, onions, zucchini, carrots, etc.) and I find it wonderful as to how my system responds so positively. For ME, the soups are FAR more effective than the abundance of healthy fats for a constipation cure!

    Do you recommend bananas for constipation? Thank you for all that you do for us!

  13. @Susan Kosich I definitely agree liquids and broth especially help constipation. The soups in my opinion are mandatory for anyone with digestive problems.

    Bananas that are very ripe can be great for constipation. It’s probably an individual thing though, I hear some people say they help and some say they don’t.

  14. Hi Kat

    My first time leaving a comment on your excellent blog – I agree with your comments on nuts – I have been on the SCD diet for 3 months (I have UC – proctitis) and am constantly craving nuts which I think give me cramps – probably also because I can’t limit myself to a handful. I know if I eat lots of fresh vegetables and fruits, particularly ripe bananas, with fresh fish and chicken, I do well. Bananas are $11/kilo (about $20/pound I think?) because of some devastating cyclones in Oz, I can’t wait for the price to drop! Many thanks Kat

  15. I’m 37 and was recently diagnosed with celiac. It has been a roller coaster for me trying to figure out what I can and can’t eat. In 4 months I went from a size 14 to a size 6 :(. I have been buying the things that say gluten free, but I need to spend more time with fresh foods. Those “gluten-free” products can still contain preservatives and other ingredients that may not be tolerable, as I have found out. My dear friend at work has been so supportive through all of this and has been providing me with such valuable information. It’s starting to get me on the right track; which has been very difficult. She provided me with this link, and others, to help me in making the right decisions on what to consume. I have also read on another site, that she provided, to cook chicken bones until the collagen has been extracted and to drink a glass of that with every meal, or even as your meal at first. The collagen will help rebuild your digestive system naturally. I also heard about the bananas, but wanted to ask if it matter how ripe they were. If you eat the bananas when they are just yellow with no brown is that still beneficial or is it best to wait until they are very ripe? I know this makes a difference in the nutrients it will provide, but not sure how much. Thank you for sharing the knowledge you have gained. Nobody can understand how terrible this can be until you live it.

  16. @Amy I cook chicken bones in a crock pot for 12-24 hours to get it nice and thick. Bananas I actually eat at varying stages of ripeness, although early on in SCD it’s best to eat them really ripe. It’s more because they are much easier to digest when fully ripe, than anything about the nutrients in them. I hope you start feeling better soon!

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  20. It sounds like I should be eating more carbs and less fat? However what about satiety and fat loss with higher carbs. I always though higher fat was supposed to loosen you up. I have a slower digestion than usual I will have to write about that soon.

  21. @primallykosher For satiety eat more protein. For digestion, make sure you eat fruit that is ripe enough. You can still eat higher fat if you want, carbs will just help with digesting it.

  22. Hello Kat
    This post was fantastic, thank you so much for taking the time to make it. I realize this was posted quite a while ago but hopefully you can still answer my question. Were the bananas supposed to be eaten at the same time or at separate meals? Thanks again.

  23. @Jack There was never mention of how/when bananas should be eaten. I’ve had success eating bananas with full fat dairy or on their own. Glad you enjoyed the post!

  24. Kat,
    was reading a novel and found Dr Haas in it and the banana diet. Looked up online with the word constipation as that is what I seem to try to keep at bay. When I tried bananas, they seem to increase it. Have been on SCD for over 2 yrs and that with fresh vegies juices (guess quick instant nutrients and enzymes), helped alot , but still needed more and found recently trouble with oxalates, posibly from the nuts I love. Also can make them if bacteria infection or deficient in B’s (I need lots more B1). Did learn need to reduce oxalates SLOWLy.
    Any suggestions that might help for constipation(or why bananas make worse)?
    Thanks
    Are you still on SCD?
    Lynn D

    • Hi Lynn,
      Constipation used to be a lifetime issue to me, I’ve been on the SCD diet for 3 months now and I eat at least one banana per day. I don’t like the taste and the texture of raw bananas (even ripe). I always cook them with duck fat or coconut oil, I add cinnamon and ginger powder, some nuts (less than a handful) and maybe extra butter if I need more fats. It looks like baby food but it’s delicious and definitely help me to go to the bathroom every day whereas raw bananas have the opposite effect on me and worsen the constipation.
      I was on a trip in South American a few years ago and people kept saying banana was a cure for everything! Yeah I was eating lots of bananas as you can find it everywhere, it’s convenient, but eating them raw got me much more constipated than ever and it took me years to eat them again…

  25. Thank you so much. I really wanted to read that book but it wasn’t available for Kindle. I don’t live in the USA and I am never at home so it gets complicated to receive shippings.

    I have been on the diet for longer than five years. While others report amazing successes, I am struggling. I suffer from intense gut pain. I am currently eating only meat, small fish, carrot, zucchini, squash, green beans. olive/coconut oil, salt&pepper. I puree the veggies.

    I tried two bananas with a lot of honey two weeks ago and the experiment was quite unsuccessful. Watery D for some days.

    Maybe I should try to eat the bananas and stay away from the honey. And maybe use only 1/4 of daily banana.

    I always wondered how the original banana diet compared to the SCD. This information you provide in your post will be tremendously useful for making dietary decisions.

    I don’t tolerate any kind of dairy, so I’m happy to see that probiotics are not required. For many reasons, I don’t eat nut baked goods. After reading your post I understand that it is possible to do the diet without them. Your post had all the details I was looking for.

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