DIET THERAPY OF PEPTIC ULCER DISEASE

Transcription

1 GASTROENTEROWGY 72: , 1977 Copyright 1977 by the American Gastroenterological Association Vol. 72, No.4, Part 1 Printed in U.S.A. DIET THERAPY OF PEPTIC ULCER DISEASE JACK D. WELSH, M.D. Department of Medicine, The University of Oklahoma Health Sciences Center, and The Veterans Administation Hospital, Oklahoma City, Oklahoma Information from 326 dietitians representing 50 states and Puerto Rico on the diet therapy of peptic ulcer disease (PUD) in their hospitals was analyzed. There were 74 teaching, 65 teaching/private, 46 private, 120 Veterans Administration, and 21 miscellaneous hospitals. A bland diet was the most commonly used diet for PUD in 250 (77%) of the hospitals. Of the 161 providing information on the type of bland diet, 72% used a bland I or II. Milk was given routinely or usually in 55% of the 326 hospitals. On discharge, dietitians in one-half of the hospitals instructed patients on a bland diet, usually a bland IV, whereas the remaining dietitians instructed their patients on a regular or modified regular diet. Outpatient PUD instruction was similar. Review of bland diets in 105 manuals revealed marked variation in nomenclature and composition of even supposedly similar diets. Uniformity would benefit patients, dietitians, and physicians. "Over the years, foods-what to eat and what not to eat-have enjoyed an almost revered position in the therapy of gastrointestinal disorders." PHILIP L. WHITE, SCE.D. JAMA 176:935, 1961 The immediate goals of peptic ulcer therapy are to relieve the patient's symptoms and to heal the ulcer as rapidly as possible. Methods of achieving the long term goals of preventing recurrence of the symptoms or ulcer are not well understood. Although it is not clear whether the same therapeutic factors are of equal importance to attain these goals, dietary manipulations of some form usually playa part in the physicians' recommended therapy and are of concern to most patients. Two popular gastroenterology texts in the United States present different viewpoints as to what type of diet should be used, liberap or strict. 2 The 1971 American Dietetic Association (ADA) position paper on therapy in chronic duodenal ulcer disease recommended an individualized diet with few restrictions and frequent feedings. 3 Others believe that fewer feedings are as effective.! A search ofthe literature revealed limited data on the actual diets used in the therapy of peptic ulcer disease in the United States, but none were detailed or recent.4, 5 In contrast, excellent information has been accumulated on the diets prescribed for diabetes mellitus in Great Britain. 6, 7 To obtain similar data on peptic ulcer diet therapy, questionnaires were sent to hospital dietitians throughout the United States, and the resulting data are presented. Materials and Methods A list of hospitals was selected in 1972 with the help of Mary Zahasky (Deceased, formerly director, Nutrition and Dietary Received June 29, Accepted October 14, Address requests for reprints to: Jack D. Welsh, M.D., Department of Medicine, The University of Oklahoma Health Sciences Center, P.O. Box 26901, Oklahoma City, Oklahoma Services, The University of Oklahoma Health Sciences Center), and questionnaires were sent to 72 hospitals. On the basis of the experience gained from this preliminary survey, the single-page questionnaire was modified so that it would take a minimum of the answering dietitians' time, provide the necessary information, and be easy to analyze. In 1975 the original list of hospitals was expanded, using the 1974 edition of the American Hospital Association Guide to the Health Care Field. 8 Hospitals were selected fairly equally among types of institutions and from all 50 states and Puerto Rico. Each individual responding was asked to characterize their institution as: teaching, teaching/private, private, Veterans Administration, or "other." In addition to the questionnaires, copies of relevant portions of diet manuals were requested. In the analysis of data, if two answers to a question were marked, each was given a half point; if more than two answers were marked, this was considered as no answer. Questionnaires were sent to 473 hospital dietitians and 329 responded. Three hospitals were not included in subsequent analysis because their patient populations were exclusively pediatric or psychiatric and were not considered suitable, leaving 326 for analysis. All 50 states and Puerto Rico were represented. At least two hospitals from every state were included except Alaska and South Carolina, which each contributed one response. The greatest number of responses was from California (22) and New York (23); 262 (72%) provided portions of their diet manuals for review. Those that responded represented: 74 teaching hospitals, 65 teaching/private hospitals, 46 private hospitals, 120 Veterans Administration hospitals (51 % could be considered teaching institutions), and 21 miscellaneous hospitals. This latter group included city, county, state, and United States Public Health Service hospitals. The 326 hospitals ranged in size from 32 to 1,796 beds, with a total of 184,768 beds; 56% had from 200 to 600 beds. Over half had dietetic training programs with 97% having full time dietitians. Inpatient instruction was given in 98% of the hospitals and 94% gave outpatient instruction. 740

2 April 1977 CUNICAL TRENDS AND TOPICS 741 Results Available diets. What options does a physician have when ordering a diet in these hospitals (table I)? Only 17 (5%) hospitals had a specific "peptic ulcer diet" listed in their manual. Almost one-fourth (23%) of the diet manuals had a Sippy diet, and approximately one-half (45%) had a modified Sippy diet; 72% had some gradation of a bland diet in their manual, with the majority of these (73%) having three or four gradations. The ADA position paper was mentioned in 16% ofthe 262 submitted diet manuals. The ADA paper was mentioned in none of the manuals from the miscellaneous group, and mentioned in few of those from the private hospitals. Only among the Veterans Administration Hospitals was there any readily recognized similarity in diets. Of the 88 diet manuals submitted, 3 of those from Pennsylvania were the same, and 2 from North Carolina were identical, 6 from the New England states, and 3 from Texas were the same. Otherwise, the format and content of the remaining 74 were unique. Most commonly used diets in the hospital. In answer to the question "What diet is most commonly used in your hospital for treatment of peptic ulcer disease?" the responses in table 2 were obtained. Some type of a bland diet was the most commonly used diet in 250 (77%) of the hospitals. In some instances these diets were labeled "gastric" but because there was little to no difference between these diets and the bland diets, and because some responding dietitians stated that they considered them the same, they were analyzed with the bland diets. A Sippy diet was the one most commonly used in 10% of the hospitals, whereas only 5% used the ADA diet or one that approximated it. The ADA diet was used in 12% of the teaching hospitals and none of the strictly private or miscellaneous hospitals. Inasmuch as a bland diet of some form was the most commonly used diet in 250 of the hospitals, and many had gradations of this diet, the data were analyzed to determine which bland diet the patient receives. Information on this point was available on 161 of the 250 hospitals who used a bland diet (table 3). A bland I was the most frequently used, with decreasing use of a bland II through bland IV. Milk as part of the diet. Milk was given routinely or usually on a schedule as part ofthe patient's therapy in over one-half of the hospitals (table 4). The estimated daily milk intake was 32 ounces or more in 187 (57%) of the hospitals who answered this question. Diets on discharge or for outpatients. The question Questions asked Teaching, 74 TABLE 1. Types of diets" Teaching/private,65 Private, 46 VA,120 Miscellaneous, 21 Total,326 "Peptic ulcer diet" in manual Yes 2 (3) 2 (3) 4 (9) 8 (7) 1 (5) 17 (5) No answer Sippy diet in manual Yes 25 (34) 17 (26) 10 (22) 17 (14) 7 (33) 76 (23) No answer Modified Sippy diet in manual Yes 33 (45) 34 (52) 33 (72) 37 (31) 10 (48) 147 (45) No answer Gradations of bland diet in manual Yes 47 (63) 51 (78) 38 (83) 81 (68) 18 (86) 235 (72) No answer Number of gradations of bland diets 2 2 (4) 8 (16) 3 (8) 14 (17) 1 (6) 28 (12) 3 18 (38) 10 (20) 14 (37) 24 (30) 2 (11) 68 (30) 4 16 (34) 23 (45) 16 (42) 36 (44) 11 (61) 102 (43) 5 1 (2) 3 (6) 2 (5) 0 2 (11) 8 (3) No answer 10 (21) 7 (14) 3 (8) 7 (9) 2 (11) 29 (12) ADA mentioned in submitted manual 12/53 b (23) 7/561 (12) 2/38 (5) 21/98 (21) 0/17 42/262 (16) a Abbreviations are: VA, Veterans Administration; ADA, American Dietetic Association position paper (Reference 3). b Denominator represents number of submitted manuals. Diet TABLE 2. Most commonly used diets for peptic ulcer disease in hospital" Teaching, 74 Teaching/private, 65 Private, 46 VA,120 Miscellaneous, 21 Total,326 Bland 50 (58) 54 (83) 41 (89) 90 (75) 15 (71) 250 (77) Sippy 6 (8) 5 (8) 5 (11) 9 (8) 6 (29) 31 (10) ADA 9 (12) 2 (3) 0 5 (4) 0 16 (5) Regular 6 (8) 1 (2) 0 13 (11) 0 20 (6) Other 3 (4) 3 (5) 0 3 (3) 0 9 (3) " Abbreviations are: V A, Veterans Administration; ADA, American Dietetic Association position paper diet (Reference 3).

3 742 CLINICAL TRENDS AND TOPICS Vol. 72, No.4, Part 1 was asked concerning what type of diet the patient is instructed to take on discharge. It appears that in onehalf of the hospitals, patients are instructed on some form of bland diet, usually a bland IV, whereas in the remainder, patients are instructed on a regular or a modified regular diet when they leave the hospital (table 5). This information should be fairly accurate, because dietetic instruction was given routinely or usually in over 90% of the hospitals at the time of the patient's discharge. The discharge diets were similar to instructions given to outpatients. Composition of bland diets. Having established that the bland diet is an important part of the diet therapy as practiced in the responding hospitals, an analysis of the composition of these diets was undertaken. For practical reasons the analysis was restricted to those manuals with two or four gradations of diets and to only 14 items. Of the 326 hospitals, 102 had four gradations of bland diets and 82 (82%) of these representing 40 states were available, at least in part, for review. It was frequently stressed that bland diets are mechanically, thermally, and chemically nonirritating and do not stimulate gastric secretions. Known or supposed gas-forming foods or anything with a strong taste is eliminated. Seventythree took a positive/negative approach listing both what should and should not be eaten. The remaining nine listed only what should be eaten. The bland I diets consisted of only milk feedings in 64, whereas 5 were more liberal and 13 did not submit this portion of their manuals. The five more liberal diets allowed such items as puddings, custards, mashed potatoes (without skins), eggs (not fried), white toast, and two even allowed some fruits and vegetables. All 69 who provided information on the frequency offeedings with the bland I diet had six or more feedings per 24 hr. Information on the frequency of feedings with the bland II, III, and IV diets was available in 72 cases. Ninety-four per cent of the bland II, 74% of the bland III, and 54% of the bland IV had six or more feedings per day. All of these had a bedtime feeding or one close to that time. Data on 14 items in the II, III, and IV bland diets are listed in table 6. Black pepper and chili powder were not allowed. Meat, poultry, and fish were allowed in 4 to 9% of the bland II diets, and it was usually stressed that they should be lean and tender. These items were permitted in the majority (93 to 94%) of bland IV diets. Fried foods, lunch meats, and nuts were not allowed in any of the bland II diets and in only 10 to 17% of bland IV diets. Selected fruits and fruit juices were permitted in one-futh to onethird of the bland II diets, and in over 90% of the bland IV diets. There were a number of inconsistencies as to which fruits or juices were allowed or not allowed, particularly in the bland II diets. Orange juice was a prime example of this variability, being specifically allowed on some and specifically not allowed on other diets. Chocolate and cocoa were approved of in few (5 to 13%) of the bland II diets and in only one-third to over slightly onehalf of the bland IV diets. Tea, coffee, and carbonated drinks were permitted in 15 to 37% of bland IV diets, and decaffeinated coffee was allowed in 28% of bland II Bland diet TABLE 3. Type of diet used in hospitals using a bland diet Teaching, 50 Teaching/private, 54 Private, 41 VA, 90 Miscellaneous, 14 Total,250 I 19.5 (39) 21 (39) 16.5 (40) 17 (19) 10 (71) 84 (34) II 7 (14) 5 (9) 7 (17) 12 (13) 1 (7) 32 (13) III 5 (10) 4.5 (8) 3 (7) 13.5 (15) 2 (14) 28 (ll) IV 2.5 (5) 2.5 (5) 1.5 (4) 9.5 (ll) 1 (7) 17 (7) No information 16 (32) 21 (39) 13 (32) 38 (42) 0 89 (36) a V A, Veterans Administration. Questions asked Teaching, 74 TABLE 4. Use of milk for in-hospital therapy Teaching/private, 65 Private, 46 VA, 120 Miscellaneous, 21 Total,326 Milk given on schedule? Routinely 11 (15) 7 (ll) 8 (17) 21 (18) 8 (38) 55 (17) Usually 22.5 (30) 31 (48) 31 (67) 34 (28) 7 (33) (38) Rarely 28 (38) 20 (31) 5 (ll) 58 (48) 6 (29) 117 (36) Never 11.5 (15) 2 (3) 0 6 (5) (6) No answer 1 (1) 5 (8) 2 (4) 1 (1) 0 9 (3) Average daily milk intake (oz) >48 13 (18) ~ (12) 0 34 (28) 4 (19) 59 (18) (28) 29 (45) 24 (52) 46 (38) 8 (38) 128 (39) (26) 24 (37) 10 (22) 26 (22) 8 (38) 87 (27) <16 4 (5) 2 (3) 1 (2) 2 (1) 0 9 (3) No answer 17 (23) 2 (3) 11 (24) 12 (10) 1 (5) 43 (13) a VA, Veterans Administration.

4 April 1977 CLINICAL TRENDS AND TOPICS 743 Teaching, 74 TABLE 5. Type of diets used at time of discharge or for outpatient instruction Teaching/private, 65 Private, 46 VA,a 120 Miscellaneous, 21 Total,326 Discharge diets: Bland I 0.5 (1) (0.5) 0 1 (0.3) Bland II 2 (3) 2 (3) 2 (4) 1 (1) 0 7 (2) Bland III 8.5 (11) 6.5 (10) 6 (13) 14.5 (12) 4 (19) 39.5 (12) Bland IV 17 (23) 28.5 (44) 22 (48) 41 (34) 10 (48) (36) Other 36 (49) 27 (41) 13 (28) 55 (46) 5 (24) 136 (42) No answer 10 (14) 1 (1) 3 (6) 8 (7) 2 (10) 24 (7) Outpatient diet(s): Bland I (1) 0 1 (1) (0.5) Bland II 3 (4) 1.5 (2) 2 (4) 1.5 (1) 0 8 (2) Bland III 7.5 (10) 7 (11) 3.5 (8) 14 (12) 2 (9) 34 (11) Bland IV 19.5 (26) 24 (37) 20 (43) 48 (40) 7.5 (36) 119 (36) Other 37 (50) 20 (31) 10.5 (23) 50.5 (42) 8.5 (40) (39) No answer 7 (9) 12 (18) 10 (22) 5 (4) 3 (14) 37 (11) a VA, Veterans administration. Food item Bland II TABLE 6. Food items allowed by bland II to IV diets Bland III Allowed Not allowed No data Allowed no. (%) no. (%) no. (%) no. (%) Meat 3 (4) 70 (85) 9 (11) 61 (74) Poultry 6 (7) 67 (82) 9 (11) 63 (77) Fish 5 (6) 68 (83) 9 (11) 61 (74) Fried foods 0 73 (89) 9 (11) 1 (1) Lunch meat 0 73 (89) 9 (11) 1 (1) Nuts 0 73 (89) 9 (11) 0 Fruit 18 (22) 55 (67) 9 (11) 60 (73) Fruit juices 29 (35) 44 (54) 9 (11) 67 (82) Chocolate 4 (5) 62 (76) 16 (20) 11 (13) Cocoa 11 (13) 58 (71) 13 (16) 32 (39) Tea 2 (2) 71 (87) 9 (11) 12 (15) Coffee 0 73 (89) 9 (11) 3 (4) Decaffeinated 23 (28) 50 (61) 9 (11) 58 (71) coffee Carbonated 2 (2) 71 (87) 9 (11) 4 (5) drinks Bland IV Not allowed No data Allowed Not allowed No data no. (%) no. (%) no. (%) no. (%) no. (%) 14 (17) 7 (9) 77 (94) 4 (5) 1 (1) 12 (15) 7 (9) 76 (93) 5 (6) 1 (1) 14 (17) 7 (9) 76 (93) 5 (6) 1 (1) 74 (90) 7 (9) 14 (17) 67 (82) 1 (1) 73 (89) 8 (10) 8 (10) 72 (88) 2 (2) 75 (91) 7 (9) 11 (13) 70 (85) 1 (1) 15 (18) 7 (9) 75 (91) 6 (7) 1 (1) 8 (10) 7 (9) 78 (95) 3 (4) 1 (1) 57 (70) 14 (17) 28 (34) 36 (44) 18 (22) 39 (48) 11 (13) 45 (55) 23 (28) 14 (17) 63 (77) 7 (8) 30 (37) 50 (61) 2 (2) 72 (88) 7 (8) 12 (15) 69 (84) 1 (1) 15 (18) 9 (11) 74 (90) 7 (9) 1 (1) 69 (84) 9 (11) 16 (20) 62 (76) 4 (5) and 90% of bland IV diets. Differentiation was made infrequently between cola and noncola carbonated drinks. Of the 28 hospitals that had two bland diets, 23 bland I diets and 22 bland II diets were available for analysis. These diets were numbered or called strict, restricted, soft, progressive or liberal, but for analysis they are considered as a bland I and II. Of the 23 bland I diets, 19 (83%) had six or more feedings per 24 hr, one had three meals a day, and the feeding frequency was not stated in three instances. There was a similar feeding frequency with bland II diets, 77% having six or more feedings per day, 18% with three meals a day, and 5% not stating frequency. Black pepper and chili powder were not permitted in either diet (table 7). In three instances, the bland I diets were only milk. Meat, poultry, fish, fruit, fruit juices, and decaffeinated coffee were allowed in 39 to 57% of bland I diets, but were included as foods the patient could eat in 91 to 100% of the bland II diets. Fried foods, lunch meats, nuts, tea, coffee, and carbonated drinks were allowed in none of the bland I diets, whereas chocolate and cocoa were permitted in 13%. These items were still restricted in the majority of bland II diets. To determine whether there were regional differences,4 the 105 manuals used for diet composition were scanned for regional differences or unusual items. Grits or hominy were mentioned equally in the northern and southern states. Game birds, shellfish, and oysters were specifically listed in all regions, and swordfish was included in one manual from Maine. Only in Hawaii was it specifically stated that the diet did not allow Kim che, but poi, tofu, and haupia could be eaten! Discussion The data in this report reflect present diet practices, but certain restrictions on their general application should be recognized. The 326 hospitals in this analysis consisted of 4.6% of those listed in the 1974 American Hospital Association Guide,s but 12% of the total num-

5 744 CLINICAL TRENDS AND TOPICS Vol. 72, No.4, Part 1 Food item TABLE 7. Food items allowed in two bland diets Bland I (23 reviewed) Bland n (22 reviewed) Allowed Not allowed No data Allowed Not allowed No data no. (%) no. (%) no. Meat 9 (39) 14 (61) 0 Poultry 9 (39) 14 (61) 0 Fish 9 (39) 14 (61) 0 Fried foods 0 23 (100) 0 Lunch m eat 0 23 (100) 0 Nuts 0 23 (100) 0 Fruit 10 (43) 13 (57) 0 Fruit juices 13 (57) 10 (43) 0 Chocolate 3 (13) 20 (87) 0 Cocoa 3 (13) 1 (4) 19 Tea 0 23 (100) 0 Coffee 0 23 (100) 0 Decaffeinated 13 (57) 10 (43) 0 coffee Carbonated 0 23 (100) 0 drinks (%) no. (%) no. (%) no. (%) 22 (100) (100) (100) (18) 0 18 (82) 3 (14) 19 (86) 0 2 (9) 17 (77) 2 (9) 20 (91) 2 (9) 0 20 (91) 2 (9) 0 8 (36) 10 (45) 4 (18) (83) 6 (27) 9 (41) 7 (32) 10 (45) 12 (55) 0 6 (27) 16 (73) 0 21 (95) 1 (5) 0 5 (23) 17 (77) 0 her of hospital beds. Of the hospitals represented, 97% had full time dietitians. Therefore, the data best represent the practices in larger hospitals with full time dietitians. It also must be realized that the responses required a judgment on the part of the dietitians who completed the forms, and may reflect in part their own feelings as to how things should be, rather than how they are. However, for practical and logistical reasons, a survey of this size was not possible otherwise, and it was believed that the hospital dietitian is in the best position to provide the most meaningful information. At least five studies H3 since 1942 have demonstrated that slightly modified or regular diets produce radiological healing or relief of symptoms at a similar rate in patients with duodenal or gastric ulcers as strict or bland "peptic ulcer diets." No controlled studies have documented the superiority of a bland diet or a strict diet program over a regular diet. In spite of this, the present s u r has v ~ shown y that a bland diet is the most commonly used diet for in-hospital therapy for patients with peptic ulcers in 77% of the responding hospitals. Additional milk, which has only a transient neutralizing effect on gastric acidity followed by a rise in acid secretion,i4-16 was given routinely or usually in over one-half of the hospitals. Frequent feedings repeatedly stimulate gastric acid secretion, I and there are no data to support the assumption that they are more beneficial in healing peptic ulcers than three meals a day. Of the hospital diet manuals with four gradations of bland diets reviewed in the present study, all of the bland I and over one-half of the bland II diets are to be given on a schedule of at least six meals a day. It has heen stated that, "dietary restriction, by its monotony, difficulty, and social handicap, is an imposition upon a patient, fully justified if it achieves its end but unjustified if it is ineffective."17 The restrictions, additional milk, and frequent feedings used in the majority of the responding hospitals have not been proven to he ineffective, but neither have they been demonstrated to be superior to three regular meals a day in promoting ulcer healing. In spite of the lack of controlled data to support their rational use, bland diets are probably included in many diet manuals because of tradition, patient insistence, and some authorities. 2 Patients with peptic ulcers may complain of intolerance to many of the foods eliminated by these diets, but there is no evidence that any of these foods delay healing of an ulcer. Also, persons without ulcers and normal X-ray studies of the upper gastrointestinal tract just as frequently give a history of intolerance to the same foods. 18 Bland diets eliminate foods because they are supposed to be mechanically, chemically, or thermally irritating, gas formers, or stimulants of gastric secretion. Decaffeinated coffee was frequently allowed in the submitted bland diets, yet it has been demonstrated to stimulate gastric acid as much as regular coffee,19 and the fact has been known since It is difficult from the present survey to determine exactly what is considered to constitute a bland diet, because the composition of the submitted diets varied widely from hospital to hospital, even in the same city or state. No consistent regional differences 4 in content were noted, except in the case of Hawaii, where the inclusions were based on cultural differences in the dietary habits of the population. The variations in nomenclature and composition found in the bland diets add to the patient's confusion. He may be given the same numbered diets from two hospitals, but they will differ considerably in restrictions. "It is unlikely that gastrointestinal dietotherapy will change or improve greatly until a broad investigative attack, probably tedious but nevertheless essential, is undertaken to find out exactly what foods do within the human digestive tract."4 With only limited previous data,4, 5 it is impossible to document any changes in the diet therapy of peptic ulcer disease in the United States over the last few years. Further research is essential but it is apparent that more than research is necessary; there needs to be further dissemination of data already available. Physicians, particularly gastroenterologists, should participate more with their hosptial dietitians to

6 April 1977 CLINICAL TRENDS AND TOPICS 745 share information and to bring local or regional uniformity to their diet manuals. Complicated and restrictive "ulcer" or "bland" diets that have not been proved to have superior healing value in peptic ulcer disease should be eliminated from diet manuals. An individualized diet with few restrictions and three meals a day seems to be the most rational approach. REFERENCES 1. Fordtran JA: Reduction of acidity by diet, antacids and anticholinergic agents, chapter 57. In Gastrointestinal Disease. Edited by MH Sleisenger, JS Fordtran. Philadelphia, WB Saunders Co, 1973, p Bockus HL: Management of uncomplicated peptic ulcer, chapter 30. In Gastroenterology, part 1. Edited by HL Bockus, Philadelphia, WB Saunders Co, 1974, p The American Dietetic Association Position Paper on Bland Diet in the Treatment of Chronic Duodenal Ulcer Disease. J Am Diet Assoc 59: , Weinstein L, Olson RE, Van Itallie TB, et al: Diet as related to gastrointestinal function. JAMA 176: , Sandweiss DJ: The Sippy treatment for peptic ulcer-fifty years later Am J Dig Dis 6: , Thomas BH, Truswell AS, Brown AM: Diabetic diet sheets used in Great Britain: 1. Aspects of presentation and content. Nutrition (London) 28: , Thomas BJ, Truswell AS, Brown AM: Diabetic diet sheets used in Great Britain: II. Food lists. Nutrition (London) 28: , American Hospital Association Guide to the Health Care Field. American Hospital Association, Chicago, Nicol BM: Peptic ulceration. Results of modern treatment. Lancet 2: , Lawrence JS: Dietetic and other methods in the treatment of peptic ulcer. Lancet 1: , Doll R, Friedlander P, Pygott F: Dietetic treatment of peptic ulcer. Lancet 1:5-9, Truelove SC: Stilboestrol, phenobarbitone, and diet in chronic duodenal ulcer. Br Med J 2: , Buchman E, Kaung GT, Dolan K, et al: Unrestricted diet in the treatment of duodenal ulcer. Gastroenterology 56: , Kirsner JB, Palmer WL: The effects of various antacids on the hydrogen-ion concentration ofthe gastric contents. Am J Dig Dis 7:85-93, Bingle JP, Lennard-Jones JE: Some factors in the assessment of gastric antisecretory drugs by a sampling technique. Gut 1: , Ippoliti AF, Maxwell V, Isenberg JI: The effect of various forms of milk on gastric-acid secretion. Ann Intern Med 84: , Lennard-Jones JE, Babouris N: Effect of different foods on the acidity of the gastric contents in patients with duodenal ulcer. Gut 6: , Koch JP, Donaldson RM Jr.: A survey of food intolerances in hospitalized patients. N Engl J Med 271: , Cohen S, Booth GH Jr: Gastric acid secretion and lower-esophageal-sphincter pressure in response to coffee and caffeine. N Engl J Med 293: , Ivy AC, Grossman MI, Bachrach WH: Peptic Ulcer. Philadelphia, Toronto, Blakiston Co, 1950, p 92