Chinese Dietetics – Diarrhoea

Jimi Windmills

"Medicaments are ferocious like soldiers of the high guard, and hence should not be thoughtlessly applied in minor cases. [Whereas,] Food can dispel harmful influences, bequeath the internal organs, refresh the spirit and replenish the qi and blood."

- Sun Simiao (?-682)

Western Medicine

According to the World Health Organisation (WHO), "diarrhoea is three or more liquid stools per day, or more frequently than is normal for the individual" (WHO). Boon et al. suggests that normal frequency of bowel movements for the population in general is between three times a day and one movement every three days (2006: 869). As Boon et al. correctly points out, diarrhoea means different things to different people, but that it is generally assumed to mean loose or watery stool, with increased frequency. The most common symptom of diarrhoea is urgency of defecation, and faecal incontinence is not uncommon (2006: 869).

The WHO recognises three clinical presentations of diarrhoea

• Acute watery diarrhoea – lasts several hours or days, and includes cholera;
• Acute bloody diarrhoea – also called dysentery; and
• Persistent diarrhoea – lasts 14 days or longer.

Acute diarrhoea is often a symptom of gastrointestinal infection, usually caused by bacterial, viral or parasitic organisms. Infection is spread either from person to person or through contaminated food or water, or unhygienic environments (WHO). Diarrhoea from infections are usually short lived, patients with symptoms lasting longer than 10 days rarely have an infective cause. Acute diarrhoea can also be cause by certain drugs including cytotoxic drugs, antibiotics, NSAIDs and proton pump inhibitors (Boon et al 2006: 869).

Diarrhoea may be life-threatening as it can lead to severe dehydration, especially in young children, and those who are malnourished or have weak immune systems. Diarrhoeal diseases kills on average 760 000 children every year, it is the leading cause of sickness and death in children under 5 especially in developing nations. Most of these deaths are from severe dehydration, and are both preventable and treatable. Prevention of diarrhoea includes clean water, good sanitation and hygiene. Treatment is usually clean water with sugar, salt and zinc tablets (WHO).

Cholera, caused by the Vibrio Cholerae bacteria has been sweeping the world with a diarrhoeal pandemic that has lasted for over 50 years. In reality, cholera has likely been plaguing human societies for thousands of years. According to Boon et al. it originated in the Ganges valley, and the current '7th pandemic' (the E1 Tor biotype), started in 1961 and spread through the Middle East to Africa. It reached Peru in 1990 and spread through Central and South America Since 2000 there has been a massive outbreak in South Africa. A new strain (serotype 0139) took hold in Bangladesh in 1992 and began a new pandemic (2006: 330). Cholera typically presents with sudden onset severe diarrhoea without pain, and is then followed by vomiting. After the usual contents of the gastrointestinal tract have been emptied, the patient will continue to pass clear fluids with flecks of mucous. This results in an enormous loss of fluids and electrolytes, and in severe cases leads to intense dehydration and muscle cramps, shock, oliguria and eventually acute circulatory failure and death. The majority of cases however, cause only minor illness, with less severe diarrhoea (2006: 330). Treating cholera requires the replacement of fluids and electrolytes. In most cases this is done with an oral rehydration solution, which sometimes has the addition of starch. Sometimes it is necessary to rehydrate a patient via intravenous fluids, and vomiting normally stops once the patient is rehydrated. The amount of fluids replaced is calculated (if possible) from the volume lost in urine, stool and vomit, and is usually around 500ml/hour. Over a course of 2-5 days this may exceed a total of 50 litres. Cholera is also treated with antibiotics, which kill the bacteria, and shorten the course of the disease (Boon et al. 2006 330).

Dysentery can be caused by a number of things, but is most commonly either bacillary or amoebic dysentery. Since bacillary dysentery is most common we will not discus amoebic dysentery here. Bacillary Dysentery is generally caused by one of four Shigellae virii, a close relative of E. Coli. These are Sh. dysenteriae, flexneri, boydii and sonnei. Shigellae are highly resistant to antibiotics, and have caused epidemics of dysentery in Bangladesh and other tropical countries. The virus only attacks humans, and spreads by contaminated food or flies, but is most commonly transmitted by unwashed hands after defecation. It is highly contagious since it requires a dose as small as 10 individual organisms to infect a new host. It is most commonly seen in closed institutions such as schools and mental hospitals and outbreaks often occur after natural catastrophes and during wars, which cause crowding and poor hygiene (Boon et al. 2006 330-1). Sh. Sonnei infections are usually mild and may escape diagnosis, while Sh. Flexneri may cause more severe symptoms. Sh. Dysenteriae can develop very quickly into a life threatening disease, and can cause death within 48 hours (Boon et al. 2006 331).

A moderately severe case of dysentery presents as diarrhoea with colicky abdominal pain and tenesmus (the constant feeling of needing to defecate, even if the bowel is empty). Fever, weakness and dehydration accompany tenderness over the colon. There is only a small amount of stool, and after a couple of bowl movements, blood and purulent exudate are passed with less faecal matter. Dysentery is treated with oral rehydration therapy, or if diarrhoea is severe, with intravenous fluids and electrolytes. Treatment with antibiotics (ciprofloxacin 500mg) every 12 hours for 3 days is effective. The most important method to manage dysentery is prevention. Ensuring food and water are uncontaminated and maintaining high standards of sanitation and hygiene, especially handwashing, is crucial.

There are other causes of acute diarrhoea that should be mentioned briefly. Food poisoning (usually bacterial or bacterial toxins) accounts for a large number of cases of acute diarrhoea, as does diarrhoea as a symptom of the common cold or influenza.

Chronic or relapsing diarrhoea is often associated with irritable bowel syndrome (IBS), has increased frequency of loose, watery, or pellety stool, and is usually most severe before and after breakfast, and rarely occurs in the evenings. These patients also tend to experience constipation at other times, as well as other symptoms associated with IBS. There is often mucous in the stool, but never blood (Boon et al. 2006: 869). We will not consider all the various causes of chronic diarrhoea due to a lack of space.

Chinese Medicine

In Chinese medicine we have several patterns of diarrhoea. However, three of these patterns tend to predominate. These patterns coincide very closely with the three clinical presentations described by the WHO. Two of these patterns are of an external nature, and present as full conditions; Cold-Damp pattern diarrhoea and Damp-Heat pattern diarrhoea. These patters align with the WHOs acute watery diarrhoea and acute bloody diarrhoea, including cholera and dysentery respectively. Chronic presentations of diarrhoea in Chinese medicine stem from deficiencies of the Spleen and/or Kidneys

According to Anshen Shi, the pathophysiology of diarrhoea involves an excess of dampness, dysfunction of the spleen and stomach, and an inability of the large intestine to transport, and separate clear from turbid substances (Shi 2003:91). These disharmonies may arise from a number of causes

• Invasion of external pathogens, particularly cold, dampness, summer heat and fire. The spleen is especially susceptible to external invasions of damp, which then disturbs the functions in the middle jiao (Shi 2003:91).
• Improper diet – overeating may impair the stomachs ability to receive and ripen food, which then affects digestion and absorption. Consumption of cold raw food or contaminated food may damage the spleen and stomach, and impact on their ability to transform and transport, and cause qi to flow in the wrong direction (Shi 2003:91).
• Liver qi stagnation from long-term anger and frustration may invade the spleen causing it to become deficient. This in turn impacts on the spleens ability to transform and transport (Shi 2003:91).
• Overexertion, chronic illness, or an irregular diet can lead to spleen and stomach deficiencies. When the stomach can not rot and ripen, and the spleen can not transform and transport the food, the pure and turbid combine and empty out as diarrhoea (Shi 2003:91).
• Yang Deficiency of the kidney may develop as one ages, from chronic illness, or from a constitutional weakness. When kidney yang is insufficient, it will fail to warm the spleen yang. This leads to an inability of the spleen to transform and transport, and also impairs the kidneys function of controlling bowel movements (Shi 2003:91).

Differentiation of Patterns

• Damp-heat – Sticky or pasty yellow coloured stool, with a strong odour and burning sensation of the anus.
• Cold-damp – Bluish grey or bluish black in colour. Clear thin, or watery stool without much odour.
• Liver overacting on the spleen – onset of loose stools with emotional stress.
• Spleen deficiency – unformed stool alternating with watery diarrhoea, with tends to be worse with fatigue or after meals.
• Kidney deficiency – Watery stool with undigested food present, or abdominal pain with diarrhoea that happens at dawn.

Treating Diarrhoea with Diet

There are certain foods that should be avoided for people with acute or chronic diarrhoea. In cases of chronic spleen and stomach deficiency, the patient should avoid raw and cold foods, especially fruit and fruit juice, dairy products, canned food, frozen foods and denatured foods. (Kastner 2009: 184). These deficient type patients should try to eat boiled or steamed foods which are warming in nature and nourish the spleen and stomach, combined with acrid spices. Beef and poultry, pureed carrots, mushrooms, honey and brown sugar are good. Rolled oats, millet and rice dishes, are also beneficial. Fennel tea to drink and maybe steamed apples and blueberries for desert (Kastner 2009: 184).

Cold-damp acute type diarrhoea patients should avoid raw, cool and cold natured foods, as well as foods that tend to be damp forming such as dairy products and greasy food. These patients would benefit from food that is warming to hot in nature, which support the spleen and stomach, with sweet-warm or bitter-warm flavour. Steaming and boiling are appropriate cooking methods, and warming spices are also indicated. Sweet potato, carrots and fennel are good vegetables, and oats, millet and rice are good grains especially when combined with aniseed, chilli, pepper, ginger and cinnamon. Fennel or spiced tea, or coffee with cardamom is good to drink (Kastner 2009: 185).

Damp-heat diarrhoea patients should avoid acrid, warm and hot foods. For this condition, foods that are cold, cool or neutral are best. Sweet and bitter flavoured foods, and raw, boiled or steamed foods are also indicated. Eggplant, bamboo, cranberries, mung beans, cucumber, spinach and yoghurt are all good examples.

Sweet Potato Dal – A Recipe for Cold-Damp Diarrhoea.

Ingredients

1 cup split mung beans

7 cups water

1 cup (1 tin) chopped tomato

1 zucchini diced

1 large sweet potato, diced

5 tbsp. ghee
1/4 tsp. hing (asafoetida, or asafetida)

1/2 tbsp. grated or minced ginger

1 1/2 tbsp. cumin seeds

1 tbsp. black mustard seeds

1 green chilli (minced or finely chopped)

1 1/2 tsp. turmeric

1 tbsp. salt

Fresh coriander to garnish

Add 3 tbsp. ghee to a pot, when melted add turmeric, hing and beans. Stir and fry for 30 seconds over moderate heat. Add tomato, zucchini, and sweet potato and fry for 1 minute. Add water, salt, chilli, and ginger. Bring to boil, cover, reduce to low heat and let it simmer for an hour, or until the beans have dissolved.

In a small frying pan, add 2 tbsp. ghee. When hot add cumin seeds and black mustard seeds. When the seeds crackle, 30 seconds to a minute, add the mixture to the dal. Stir and garnish with fresh coriander.

Serve by itself or on a bed of brown rice.

Breakdown of Ingredients

• Mung beans are very sweet in flavour, cooling in nature and drain damp (Wilson 127). On their own they nourish the spleen, and their cooling nature makes them well suited to treat heat pattern diarrhoea.
• Tomato is cooling to cold in nature, and sweet and sour in flavour. It has a downbearing direction, and is aligned with wood and earth. Tomatoes Clear heat, enrich yin, and produce fluids (great when diarrhoea causes fluid loss). They also strengthen the stomach and move liver qi (Kastner 2009: 111).
• Zucchini is cooling, sweet and bitter. It cools stomach and liver heat (Kastner 2009: 264).
• Sweet potato is neutral to slightly warm in flavour. They are warm in flavour, and benefit the spleen, stomach and kidney. They have an upbearing direction, and align with the earth phase. Sweet potato benefits the middle jiao, supports qi and blood formation, moves qi stagnation and produces fluids (Kastner 2009: 111).
• Ghee is neutral in temperature, and sweet and fatty in flavour. It supports blood and qi, and moistens (Kastner 2009: 256).
• Ginger is warm in nature and has an acrid flavour, it benefits the lungs, stomach and spleen. It has an upbearing direction and is aligned with the metal phase. Ginger strengthens the middle jiao, and controls nausea. It also clears wind-cold from the tai-yang level (Kastner 2009: 122).
• Cumin is warming, and has a bitter and acrid flavour. Cumin dries phlegm-cold (Kastner 2009: 250).
• Black mustard seeds are warming and acrid. They expel cold-damp (Kastner 2009: 259).
• Chilli is hot in nature, and has an acrid flavour. It benefits the stomach spleen and heart, and has an upbearing direction. It is aligned with the fire phase. Chilli disperses cold and warms the middle jiao, it dissolves food stagnation and dries damp (Kastner 2009: 121).
• Turmeric is warming and has bitter and acrid flavours. It dries phlegm-cold (Kastner 2009: 163).
• Salt is cold in nature and salty in flavour. It benefits the stomach, kidney, small intestine and large intestine. It was a downbearing nature and is aligned with the water phase. Salt clears heat, moistens dryness, and strengthens kidneys (Kastner 2009: 125).
• Coriander is warm in nature, and had an acrid flavour. It benefits the lung and spleen, has an upbearing direction, and is aligned with the metal phase. It is used to warm foods, disperse cold, balance qi and reverse counterflow qi (Kastner 2009: 121).

This recipe is more specific to treating cold-damp rather then damp-heat presentations of diarrhoea. Having a lot of water in the recipe helps to replace some of the fluids lost due to diarrhoea, this is aided by ingredients such as tomato and sweet potato which produce fluids. The mung beans as the primary ingredient although cooling in nature, drain dampness and nourish the spleen and stomach. The recipe itself is simple, and with a combination of short frying time to warm some of the ingredients, and a long time simmering (a neutral cooking method) this would tend to balance and integrate the effects of the various ingredients. With a predominance of warming and acrid ingredients I believe this recipe would have an overall warm nature, and would treat cold-damp diarrhoea very effectively. The recipe could be tailored to treat a damp-heat pattern of diarrhoea with a few modifications. If the recipe was altered to decrease the heating and acrid elements and possibly remove the chilli altogether. Add extra zucchini and tomato, and perhaps a half cup each of amaranth and corn as extra cooling elements, it could be served along with a cucumber and baby spinach raita to treat a damp-heat pattern of diarrhoea.

Bibliography

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WHO 2013. World Health Organisation, Media Centre: Diarrhoeal Disease, Viewed 2 May 2013, http://www.who.int/mediacentre/factsheets/fs330/en/index.html

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