Good Food for Bad Stomachs
by Henry D. Janowitz, MD
Oxford University Press, 198 Madison Ave., New York, New York 10016
USA
Hardcover, $21.95, 224 pages, 1997
Good Food for Bad Stomachs is a healthy eating guide
for those with digestive problems, whether it be diarrhea, constipation,
intestinal gas, malabsorption, irritable bowel syndrome, ulcers, food
intolerance or allergy, diverticulosis, diverticulitis, or cancer of
the colon and rectum. Because the gallbladder, liver and pancreas are
also involved with digestion, they are included in the discussions.
Dr. Janowitz discusses what is known about the role
of eating habits in prevention, causation and treatment of the disorders
that can plague the human gastrointestinal tract. He notes that frequent
conflicting advice and the confusion that results as new nutritional
information becomes available, makes it difficult to know what the "ideal
diet" should be. However, we can formulate the elements of a realistic,
reasonable diet. Janowitz observes that there has probably not been
any evolutionary change in the human digestive tract during human history.
However, the sustaining nutritional environment has changed radically,
especially in the last century. He poses the question, "Can this
be the source of any of our current digestive problems? We might get
some insight into this question by speculating about what the human
prehistory diet was or may have been that has changed so radically."
Compared to the current industrialized diet, "our paleolithic ancestors
ate three times as much protein and half the fat we do. They ate meat,
but it was much less fatty than our current animal sources of meat,
being lean game. Thus the fat they did eat was more polyunsaturated
than saturated. They ate very little refined carbohydrates and no finely
ground flour. They consumed twice as much calcium as we do. They consumed
five to ten times more nonnutrient fiber - a substantial difference.
And they didn't smoke or drink alcohol."
The author cautions about the present emphasis on raw
vegetables, especially those rich in fiber, for individuals with digestive
problems. Often, the nutrients are bound into a matrix of fiber in the
plants. Heating hard vegetables such as carrots or broccoli gently breaks
down the fiber, and allows the human body to absorb much more of the
vegetable's nutrients. Only vitamin C is found in high concentrations
in raw vegetables. Its loss in cooking is offset by the gain in absorption
of other nutrients. Cooking also renders starch more digestible. Only
30% of potato starch is digested if the potato is eaten raw; 98% when
cooked. We benefit more from vegetables such as cauliflower, which contains
large amounts of starch, when the vegetable is cooked.
Janowitz reports that we are all interested in diet's
role in causing a digestive disorder, but he admits that "clear-cut
and established cases" are limited to conditions such as phenylketonuria,
lactose malabsorption, or gluten enteropathy. If the ileum is diseased,
disordered, or removed surgically, there is difficulty in absorbing
vitamin B12, some forms of fat, and results in increased oxalates in
the urine, leading to kidney stones.
For those with heartburn and peptic esophagitis, the
author advises the individual not to lie down or go to bed with a full
stomach directly after eating. Also, carbonated beverages should be
avoided because they further distend the stomach with the release of
dissolved carbon dioxide. Acidic foods such as citrus fruits may need
to be avoided as well.
Numerous foods increase the likelihood of reflux of
stomach contents back into the esophagus, including alcohol, fats, large
bulky meals, both caffeinated and decaffeinated coffee, tea, cola drinks,
chocolate, peppermint, and spearmint. Certain drugs need to be avoided,
including anticholinergics, theophylline, relaxants, and calcium channel
blockers.
A recent estimate suggests that the majority of people
over 60 years of age have gallstones. There is genetic predisposition
to form stones, but dietary manipulation or change in eating habits
can prevent, or treat gallbladder diseases. Commonly, high-fiber, low-fat
diets are recommended, along with regular eating habits, and avoidance
of crash reducing diets. Skipping meals leads to overly long bile storage
in the gallbladder. Rapid weight loss can readily precipitate gallstones
by mobilizing large amounts of cholesterol from the fat depots of the
body.
Alcohol is a common cause of pancreatitis, but a long
list of prescription drugs, including antibiotics, diuretics, anti-tumor
drugs, and others can induce pancreatitis. Fortunately, the pancreas
has great regenerative power, and can recover functionally after one
episode of pancreatitis.
Janowitz discusses malabsorption, with emphasis on celiac
disease. A slow protein leak in the intestine from the blood can prevent
the intestine from absorbing calories, especially fat calories, as well
as minerals such as iron and calcium. Such malabsorption may be especially
present for the fat-soluble vitamins. The author's experience with celiac
patients has been that about 40% react unfavorably to millet, soy, and
buckwheat, even when they avoid gluten-containing grains. He suggests
that for such individuals, these foods, too, be avoided.
Malabsorption can occur when some areas of the small
intestine are lost by disease, or shortened by surgical procedures.
Commonly, the dietary fat is increased for such patients. Janowitz suggests
the use of medium-chain triglycerides (MCTs) as the principal form of
fat. MCT can be used for cooking, in salad dressing, or taken by the
spoonful. Another way to increase caloric absorption is by means of
a high-carbohydrate diet: 60% carbohydrate, 20% fat, and 20% protein.
The colon can absorb carbohydrates more readily than fats. The carbohydrates
are absorbed after being converted into short-chain fatty acids, which
is the preferred food for the colon.
The most common complaint of individuals who seek help
from gastroenterologists is irritable bowel syndrome (IBS). Yet little
actually is known about the fundamental nature of IBS. Irritants such
as tobacco, caffeine, and alcohol are known to contribute to its discomforts
and need to be avoided. Unfortunately, many IBS sufferers avoid so many
foods, suspecting them as causes of discomfort, that they end up eating
poorly, with unbalanced meals. Janowitz suggests that most cooked or
steamed vegetables are tolerated, but some patients do better if cruciferous
vegetables and legumes are eliminated. In recent years, IBS was considered
a problem of altered motility or dysmotility of the intestinal tract.
Now the emphasis has shifted to consider increased sensitivity of the
patient's nerves, transferring the origin of the symptoms from the gut
to the brain.
A chapter in the book is devoted to food intolerances
and allergies, and the problems caused by some grains. For example,
the carbohydrate of rice flour is absorbed completely, whereas some
of the carbohydrate of all-purpose white wheat flour is not. This phenomenon
is thought to be caused by an interaction between starch and wheat protein,
which interferes with complete absorption of the starch, resulting in
unpleasant gut reaction. Ingestion of whole oats and whole wheat results
in doubling the normal fermentable material in the colon. Sugars such
as sorbitol and fructose can cause discomfort; and at high levels, diarrhea.
Dr. Janowitz offers some guidelines to maintain good
digestion. They bring us closer to the diet of our paleolithic ancestors.
Good Food for Bad Stomachs contains much information
of interest. It is written clearly and simply, uncluttered by medicalese.
Dr. Janowitz, with more than 50 years of clinical experience, is Clinical
Professor of Medicine, Emeritus, at Mount Sinai School of Medicine.
He had founded its gastroenterology division in 1958, and the division
is now named in his honor.