The Specific Ca
ohydrate Diet for Inflammatory Bowel Disease: A Case Series
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PRACTICE APPLICATIONS
This article was written by Sami
Kakodkar, MD, gastroenterology
fellow, Azam J. Farooqui, MD, resi-
dent in internal medicine, Sue L.
Mikolaitis, MS, RDN, dietitian and
esearch coordinator, and Ece A.
Mutlu, MD, MSCR, MBA, associate
professor of medicine, Department of
Medicine, Section of Gastroenterology,
Hepatology, and Nutrition, Rush Uni-
versity, Chicago, IL.
p:
dx.doi.org/10.1016/j.jand XXXXXXXXXX
1226 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
ª 2
artic
licen
Case Study
The Specific Ca
ohydrate Diet for Inflammatory
Bowel Disease: A Case Series
T
HE PATHOGENESIS OF INFLA-
mmatory bowel disease (IBD)
is thought to be multifactorial,
involving a genetically suscep-
tible individual being exposed to a yet-
to-be identified environmental trigge
or set of triggers. There is growing evi-
dence that IBD may be a disease of
Westernization associated with diets
high in refined sugars;
ead and ce-
eals; proteins, especially dairy; and
n-6 polyunsaturated fatty acids ac-
quired from highly processed seed oils.
However, the evidence is often low
quality, conflicting, and inconclusive.1-5
The Specific Ca
ohydrate Diet
(SCD) is a dietary program that claims
to induce and maintain drug-free
emission in patients with IBD. It was
initially developed by gastroenterolo-
gist Sidney Haas in 1951 and late
popularized by biochemist Elaine
Gottschall in the book Breaking the
Vicious Cycle: Intestinal Health Through
Diet.6,7 The diet allows ca
ohydrate
foods consisting of monosaccharides
only and excludes disaccharides and
most polysaccharides (such as linea
or
anch-chained multiple sugars o
starches). The diet is supplemented by
homemade yogurt fermented for 24
hours to free it of lactose, a disaccha-
ide not allowed in the SCD. Recom-
mended cultures include Lactobacillus
ulgaricus, Lactobacillus acidophilus,
and Streptococcus thermophilus. The
htt
SCD allows almost all fruits, vegeta-
les containing more amylose (a
linear-chain polysaccharide) than
amylopectin (a
anch-chained poly-
saccharide), nuts, nut-derived flours,
dry-curd cottage cheese, meats, eggs,
utters, and oils. It excludes sucrose,
maltose, isomaltose, lactose, grain-
derived flours and all true and pseu-
dograins, 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-ca
ohydrate
diet, but rather a diet that is predomi-
nantly composed of monosaccharaides,
solid proteins, fats, a high ratio of
amylose to amylopectin vegetables,
fruits, and nuts. Gottschall7 hypothe-
sized that patients with IBD can only
optimally abso
the monosaccharides
glucose, galactose, and fructose due
to a dysfunction of the host’s di-
saccharidases that are necessary
for digestion and absorption of di-
saccharides and high amylopectin
foodstuffs. This dysfunction is posited
to arise from excessive mucus produc-
tion preventing the
ush border in-
testinal enzymes from making contact
with the disaccharidases and amylo-
pectin 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 mem
anes and
destroy
ush boarder enzymes.7 A diet
containing ca
ohydrate from primar-
ily monosaccharide sources such as
fructose (as in fruits and honey) and
higher amylose:amylopectin vegeta-
les, butter or oils, and solid proteins
could optimally nourish a patient with
015 by the Academy o
le under the CC B
ses
y-nc-sa/4.0/).
IBD and result in lower amounts of
disaccharide sugars entering the colon,
preventing and reversing a signifi-
cantly altered and dysfunctional
microbiota postulated to be present in
the gastrointestinal tract of patients
with IBD.7
Neither the characteristics of pa-
tients who are following the SCD no
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.
PATIENT OVERVIEW
We collected survey data from pa-
tients 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 gastroenter-
ology clinics. Subjects mailed thei
medical records and filled out a
structured survey of their medical
history, a 3-day diet diary, and a vali-
dated disease activity index. The
modified Harvey-Bradshaw Index was
used for Crohn’s disease (CD),8 the St
Mark’s Index was used for ulcerative
colitis (UC),9 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.10 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,
f Nutrition and Dietetics. This is an open access
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Table 1. Demographic characteristics of a cohort of 50 patients with inflammatory bowel disease in remission following the
Specific Ca
ohydrate Diet
Case
no. Disease Location Age Sex
Duration
of disease
(mo)
Duration
of diet
(mo)
Level of
education
Fo
idden
food(s) Medication(s)
1 UCa Pancolitis 56 Mb XXXXXXXXXXCollege None LDNc
2 UC Rectosigmoid 56 Fd XXXXXXXXXXCollege None None
3 UC Pancolitis 41 F 36 9 College None Mesalamine (Asacole), LDN,
azathioprine
4 UC Rectosigmoid 35 F XXXXXXXXXXCollege None LDN
5 UC Rectosigmoid 38 F XXXXXXXXXXCollege None Mesalamine suppositories
6 UC Rectosigmoid 41 M 48 13 Graduate
degree
None Mesalamine (Lialdaf),
mesalamine enema
7 UC Rectosigmoid 32 F 132 7 College None Inflixima
8 UC Proctitis 35 M 24 4 Graduate
degree
None Mesalamine (Lialda)
9 UC Pancolitis 25 F 324 2 Graduate
degree
None Prednisone (1 mg),
sulfasalazine (Azulfadineg),
mesalamine enema
10 CDh Ileocolonic 29 M XXXXXXXXXXGraduate
degree
None Mesalamine (Pentasai),
inflixima
11 CD Colonic 61 F 36 10 High
school
None Mesalamine
12 CD Colonic 48 M 24 6 Graduate
degree
None None
13 CD Ileocolonic 27 M 156 8 College None Adalimumab, LDN,
udesonide
14 CD Colonic 40 F 72 60 Graduate
degree
Chocolate None
15 CD Upper GIjþcolonic 10 M 60 39 Middle
school
Ice cream None
16 CD Uppe
GIþileocolonic
11 F 24 8 Middle
school
Rice Mesalamine (Asacol)
17 CD Ileocolonic 31 F XXXXXXXXXXCollege None Prednisone (1.5 mg),
infliximab, LDN
18 CD Uppe
GIþileocolonic
11 M 24 7 Middle
school
None None
19 CD Uppe
GIþileocolonic
9 M 84 66 Middle
school
None None
20 CD Ileum 52 M 36 14 College None Mesalamine (Pentasa)
21 CD Upper GIþileum 49 M 384 5 College None None
22 CD Ileocolonic 41 M XXXXXXXXXXCollege None Balsalazide
23 CD Upper GIþcolonic 13 F 36 14 Middle
school
Cream, canned
vegetables,
eucharist host
None
24 CD Ileocolonic 44 M XXXXXXXXXXCollege Coffee None
25 CD Colonic 19 F 24 1 College None None
(continued on next page)
PRACTICE APPLICATIONS
August 2015 Volume 115 Number 8 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1227
Table 1. Demographic characteristics of a cohort of 50 patients with inflammatory bowel disease in remission following the
Specific Ca
ohydrate Diet (continued)
Case
no. Disease Location Age Sex
Duration
of disease
(mo)
Duration
of diet
(mo)
Level of
education
Fo
idden
food(s) Medication(s)
26 CD Colonic 37 F 36 16 Graduate
degree
None None
27 CD Ileum 65 M XXXXXXXXXXGraduate
degree
None Mesalamine (Asacol),
mesalamine enema,
colestipol
28 CD Ileocolonic 49 F XXXXXXXXXXCollege Espresso 6-MPk
29 CD Colonic 44 M 300 2 College None None
30 CD Colonic 30 F 36 14 College Coconut water,
chocolate
Mesalamine (Lialda)
31 CD Ileocolonic 31 F XXXXXXXXXXCollege None None
32 CD Colonic 39 M XXXXXXXXXXGraduate
degree
Salad dressing None
33 CD Ileocolonic 58 F XXXXXXXXXXGraduate
degree
None LDN
34 CD Ileum 51 F 48 6 Graduate
degree
None None
35 CD Colonic 43 F 24 9 College None None
36 CD Colonic 29 F 36 17 College Potatoes None
37 CD Upper GIþileum 19 M 36 13 High
school
Brown rice, corn 6-MP
38 CD Upper GIþcolonic 52 F XXXXXXXXXXCollege Matzah once a
yea
None
39 CD Colonic 42 F 48 10 Graduate
degree
None Mesalamine (Asacol)
40 CD Colonic 49 F 24 4 College None Mesalamine (Lialda)
41 CD Colonic 59 F 84 12 College Milk, candy,
cookies
Mesalamine (Lialda)
42 CD Ileocolonic 11 F 24 8 Middle
school
None Loperamide (Imodium)
43 CD Ileocolonic 15 F 12 6 High
school
None Mesalamine (Asacol), 6-MP
44 CD Gastric 12 M 36 22 Middle
school
School lunches None
45 CD Ileocolonic 29 M 60 60 Graduate
school
None LDN, adalimuma
46 IDl Sigmoid to distal
transverse, rectal
sparing
31 F 84 6 Graduate
degree
None Mesalamine (Asacol)
47 ID Right colon 17 M 60 8 High
school
Corn tortillas,
potatoes
Methotrexate
48 ID Rectosigmoid 56 F 48 16 College None None
(continued on next page)
PRACTICE APPLICATIONS
1228 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS August 2015 Volume 115 Number 8
Table 1. Demographic characteristics of a cohort of 50 patients with inflammatory bowel disease in remission following the
Specific Ca
ohydrate Diet (continued)
Case
no. Disease Location Age Sex
Duration
of disease
(mo)
Duration
of diet
(mo)
Level of
education
Fo
idden
food(s) Medication(s)
49 ID Pancolitis, sparing
ectum
39 M XXXXXXXXXXGraduate
degree
Spelt
ead, raw
milk, baked
goods
None
50 ID Right colon,
ectosigmoid
46 M XXXXXXXXXXCollege Pizza Hydrocortisone enema
aUC¼ulcerative colitis.
M¼male.
cLDN¼low-dose naltrexone.
dF¼female.
eAsacol (Warner Chilcott Company, LLC).
fLialda (Shire US, Inc).
gAzulfadine (Pfizer, Inc).
hCD¼Crohn’s disease.
iPentasa (Shire US, Inc).
jGI¼gastrointestinal.
k6-MP¼6-mercaptopurine.
lID¼indeterminate colitis.
PRACTICE APPLICATIONS
with higher scores co
esponding to
increasing severity and frequency of
the symptom. The subject’s quality of
life was assessed by a validated in-
strument, the Short Quality of Life in
Inflammatory Bowel Disease Ques-
tionnaire (SIBDQ).11 Subjects also
ated 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
eported to follow the SCD. All di-
agnoses