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A decade ago Dr. Natasha Campbell-McBride published her now-famous book titled Gut and Psychology Syndrome: Natural Treatment for Autism, Dyspraxia, A.D.D., Dyslexia, A.D.H.D., Depression, Schizophrenia. A few years ago I started noticing a huge trend in parents trying the GAPS diet on their own, either after reading the book or getting advice from friends or other health or mom bloggers. I have recommended the GAPS diet (or more commonly, the Specific Carbohydrate Diet) to some families as well.
But what happens when the GAPS diet fails?
This blog post will address some of the most common reasons why the GAPS diet doesn’t work.
So first, a little background behind GAPS. The diet originated with the Specific Carbohydrate Diet, popularized by Elaine Gottschall in her book Breaking the Vicious Cycle. (For more information, I highly recommend reading the whole book: Breaking the Vicious Cycle: Intestinal Health Through Diet.) Dr. Campbell-McBride slightly modified the SCD diet, further restricting certain foods and focusing on healing nutrients. The aim of the GAPS diet is to reduce intestinal dysbiosis, limit carbohydrates or starches that feed gut dysbiosis, and simultaneously provide gut-healing nutrients. Her experience has been that healing the gut provides beneficial effects in the nervous system, which reduces symptoms of autism, ADHD, depression and schizphrenia. (I second that experience – I have seen many patients where healing their intestines helps significantly with some of these other psychological symptoms.)
I should pause here a little bit and give a side note. The GAPS diet has never been scientifically validated for “curing” schizophrenics, autistic children, depressed patients, or those with ADHD. There are many doctors concerned about the GAPS diet, saying it lacks certain essential nutrients, and that it is not a long-term healthy diet.
So why do I recommend a non-scientifically validated therapy that requires an incredible amount of work? Because when it does work it can have hugely beneficial effects.
Remember: the goal of a Naturopathic Physician like myself is to uncover the underlying cause of why someone is ill. For many children with ADHD, autism, depression, etc, the underlying cause is malabsorption, gut dysbiosis, leaky gut syndrome, or intestinal inflammation. This may be the underlying cause for many children, but not for all!
The purpose of the GAPS diet is not to replace a normal diet. The GAPS diet, I believe, should be used for a short to moderate amount of time (usually 1- 6 months, sometimes longer), to eliminate gut dysbiosis and inflammation and stimulate healing of enterocytes (the intestinal cells). The goal is to completely heal the gut, discover which food allergens/sensitivities are a problem, and then progress to a long-term well-rounded diet. (I highly recommend the anti-inflammatory diet as a long-term dietary strategy. A lot of research has supported long-term anti-inflammatory diets like the mediterranean diet for disease prevention and health promotion.)
When the GAPS diet fails one of a few things may have happened: 1) the gastrointestinal system was not the underlying cause, or 2) the GAPS diet failed to address the gastrointestinal problem.
If the GAPS diet fails because of #1, parents and physicians need to spend quite a bit of time investigating other options. (See my blog post about ADHD evaluation and treatment for more ideas. This can be helpful for other conditions, including autism, depression and anxiety). I highly recommend seeing a competent physician who can order basic blood tests, including a whole-blood lead test (every child should be screened at least once in their lifetime), complete blood count (to screen for anemia), ferritin to check for low iron, thyroid, and vitamin D.
If the GAPS diet fails because of #2 – then we need to talk.
There are a lot of things I really love about the Gut and Psychology Syndrome book. Dr. Campbell-McBride does a great job of explaining basic anatomy and physiology of the gastrointestinal system. She explains how enzymes work to digest our food, insulin and blood sugar, the role of the immune system in the gut, and the role of beneficial bacteria in the intestines.
There are a few things, though, that I don’t like so much about the book.
First and foremost – that it claims to be a cure-all for children with autism and other neurological disorders. Not only does this sometimes lead to false hopes, but it also perpetuates Mom Guilt if the diet does fail. (And you all know how much I hate Mom Guilt.)
The GAPS diet CAN work – but as I mentioned earlier, it does not work for all kids. When trying the GAPS diet I tell parents that they should think of it as a therapeutic trial – if leaky gut and malabsorption is the cause of their child’s condition, then the GAPS diet will improve their symptoms. If their symptoms do not improve then we need to look elsewhere. Autism, ADHD, depression, schizophrenia, anxiety – all of these are multifactorial diseases and disorders – it is unrealistic to expect that all people will be cured with the GAPS diet.
Secondly, there are a few things that I don’t agree with in the book. One is the idea that putting a small amount of food on the skin (she recommends the wrist) is an accurate test for food sensitivities. There is no research to support this. If a patient does have a skin reaction it is quite likely they will have an intestinal reaction (almost undoubtedly). But the opposite is not true at all: the absence of a skin reaction does not mean there is no food allergy. There are several other small points in the book that I disagree with too (using aspirin for fevers, length of the diet, etc., etc), but I won’t get nit-picky here, I just want to remind readers that one book is not the be-all-end-all for health.
So here are the most common reasons I see the GAPS diet fail:
1. Failure to identify food allergens/sensitivities. Many of my patients (if not most) do not tolerate dairy in any form, whether fermented or not. Similarly, many patients have coconut, egg, tomato, potato or tree nut sensitivities. Some even have beef allergies! Imagine using beef broth for these patients! When these patients start adding these foods on the GAPS diet they sometimes forget to go slow and add foods one at a time. If the symptoms do not resolve in the elimination phase (bone broth only), then something is wrong.
2. Including fermented products. What Dr. Erika??? I would say about 50% of my patients cannot tolerate any amount of fermented products, even homemade. Obviously they are incredibly beneficial, but I believe it may be the product of fermentation – the alcohols and acids, possibly other compounds, that aggravate many patients. Instead I use a FOS-free probiotic for my patients (my favorite is Klaire Labs SCD compliant probiotic, no affiliation).
3. Coffee, wine and vinegar. Dr. Campbell-McBride says that weak freshly-brewed coffee is okay, as is potato vodka and some wines. I disagree. Most of my patients do not tolerate these beverages as they seem to irritate the gut lining. Vinegar is often better tolerated, but for some sensitive patients they just cannot handle it, at least initially.
4. Too many animal fats. This is by far the biggest limitation of the GAPS diet for long-term health. Animal fats are helpful in that they contain vitamin K2 and provide a much-needed source of calories on the GAPS diet. They also provide a barrier by coating the intestinal cells to protect against many gastrointestinal irritants. However, animal fats tend to be inflammatory. I know the Weston A. Price folks disagree with me on this one, but so far all the research still suggests that animal fats are pro-inflammatory. Granted, grass-fed and free-range beef are significantly less inflammatory (perhaps even bordering on anti-inflammatory?) than their grain-fed counterparts. Nevertheless, I have many hesitations in recommending a long-term GAPS diet because of the high amount of animal fats. All of the best researched and referenced diets in scientific literature are low in animal proteins and incredibly high in colorful fruits and vegetables. Remember that historically humans have consumed high amounts of foraged vegetables, and feasted on animals only when meat was available (rarely). The Mediterranean diet, which I consider to be the best-referenced, best-researched all-purpose diet, is low in animal meats but high in vegetables and fatty fish.
For patients who do not respond to the traditional bone-broth introduction, OR have documented oxidative stress (tested through something like Genova’s Oxidative Stress 2.0 test) OR have inflammatory conditions like Crohn’s, Colitis, hypertension, atherosclerosis, asthma, thyroiditis, any other autoimmune condition (like rheumatoid arthritis, lupus, etc.) I recommend a modified GAPS introduction using vegetable juices in lieu of the bone broth. Organic, fresh-pressed juices using copious green leafy vegetables and only a small amount of sweetener (like a 1/2 apple, one carrot, or some beets) are suggested. Foods can be added back in according to the GAPS introduction diet, though of course there will not exactly be a “soup” to add them to.
5. Failure to add anti-microbials. I believe this is the number one cause for GAPS-diet failure. When I have a patient who has been on the GAPS diet and either improved only slightly or improved and then regressed I always look for gut dysbiosis. Yeast overgrowth, overgrowth of pathogenic bacteria, or Small Intestinal Bacterial Overgrowth (SIBO) are incredibly common conditions in our era of frequent antibiotic-use and stress.
The GAPS diet is definitely designed to eliminate gut dysbiosis by “starving” bad bacteria and providing good bacteria from fermented foods. But for people with incredibly high bacterial/yeast loads the GAPS diet simply isn’t going to be enough. Remember, even if a patient is completely fasting there will still be some food supply for the microorganisms just from the sloughing off of dead intestinal cells. In other words, starving out bacteria usually isn’t good enough. (Unless you do actually starve, and I don’t recommend that!) Even bone broth, though it is low in fermentable sugars, does contain a very small amount of food which can be just enough for dysbiotic flora to live in.
If you have improved on the GAPS diet in the past but then gotten worse as you introduced new foods or returned to a semi-normal diet I highly recommend checking for gut dysbiosis. Naturopathic doctors often have stool culture kits in their office to check for a variety of organisms, not just the standard Clostridium difficile that most medical doctors are looking for. Bacteria, yeast and parasites may all be present, and it is usually necessary to do more than 1 stool sample (an O&Px3 is standard for parasites, for example – meaning it checks for ova & parasites three times).
If that ends up negative and you still have gastrointestinal symptoms, especially symptoms of pain shortly after eating or significant gas and bloating with a distended abdomen then I recommend doing a test for Small Intestinal Bacterial Overgrowth (or “SIBO”).
Whether SIBO or another type of gut dysbiosis is detected there are several different antimicrobials that can be added to the GAPS regimen to help speed up the elimination of the organisms. Though I usually use herbal antimicrobials, sometimes it may even be necessary to add in prescription antibiotics, anti-fungals or anti-parasitics if there is a very high microbial load. This should be done carefully, obviously, so as to not cause more dysbiosis. This blog post seems to be getting really long, so if you want another entire blog post about natural antimicrobials please request it!
Once the pathogens have been eliminated most patients will fully recover, and the GAPS diet can be resumed (if paused during treatment) to fully restore proper gut health.
Well – I hope this helps clear up some confusion about the GAPS diet.
What were your experiences with the GAPS diet? Did it work for you? Was this post helpful?