The elemental diet is a potent, yet often overlooked, tool for managing various gut-related disorders, including small intestinal bacterial overgrowth (SIBO), a gastrointestinal condition frequently misdiagnosed as irritable bowel syndrome (IBS). This article explores the benefits of the elemental diet in treating SIBO and provides practical advice for successfully implementing this dietary approach for suitable candidates.
Understanding SIBO
Small intestinal bacterial overgrowth (SIBO) is characterized by an excessive amount of bacteria in the small intestine. In a healthy digestive system, the small intestine maintains a relatively low concentration of bacteria, especially when compared to the large intestine, which houses the gut microbiome.
As our understanding of SIBO has evolved, we have been able to distinguish three subsets of SIBO, determined by the gas the overgrown microbes in the intestines produce:
- Hydrogen-Dominant SIBO: This is caused by bacteria that produce hydrogen gas and shares many similarities with diarrhea-predominant irritable bowel syndrome (IBS-D).
- Intestinal Methanogen Overgrowth (IMO): This condition results from an overgrowth of archaea in the small or large intestines and shares many similarities with constipation-predominant irritable bowel syndrome (IBS-C).
- Hydrogen Sulfide SIBO: This type is caused by bacteria that produce hydrogen sulfide gas.
Several factors can contribute to the overgrowth of microorganisms in the small intestine, including:
- Digestive enzyme deficiencies
- Poor intestinal motility
- Anatomical anomalies within the intestines
- Immune deficiencies
Patients with SIBO often experience IBS-like digestive symptoms, such as abdominal pain, bloating, gas, abdominal distension, flatulence, and diarrhea. These symptoms are present in more than two-thirds of affected patients.
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However, SIBO can also manifest in other symptoms that may not be immediately associated with gut health, including headaches, joint pain, brain fog, fatigue, sleep disturbances, skin rashes, and restless legs. Given the extent to which these symptoms can disrupt daily activities and overall well-being, SIBO has been linked to a poorer health-related quality of life.
What Is an Elemental Diet?
The elemental diet (ED) is a hypoallergenic and anti-inflammatory liquid meal replacement beverage. It is often used in clinical practice as a medical formula to treat severe inflammatory digestive disorders, such as Crohn's disease. The ED differs from other meal replacement formulas because it is "nutritionally complete" - it contains all the necessary nutrients humans need to live - and the ingredients are broken down into their most basic ("elemental") forms. Proteins, fats, and carbohydrates are broken down into their simplest building blocks: amino acids, short-chain triglycerides, and simple carbohydrates (glucose or maltodextrin). The formula also contains vitamins and minerals.
The semi-elemental diet is a variation of the full ED. Its formula contains partially hydrolyzed proteins (amino acid chains) and medium-chain triglycerides. This composition makes semi-elemental diets more palatable and easier to tolerate than EDs while still offering the benefit of reduced digestive workload.
How the Elemental Diet Works for SIBO
The elemental diet (ED) treats SIBO by feeding the affected patient but starving the overgrown bacteria. The nutrients are absorbed quickly within the first portions of the small intestine before bacteria can ferment (digest) them for their own benefit. During an ED protocol, the patient will use the ED as their only source of nutrition for 2-3 weeks.
Compared to prescription or herbal antibiotics, ED prescriptions are far less common in clinical practice, likely due to their associated cost and restrictive nature. However, a 2016 primary care review suggested the ED as a plausible SIBO treatment option, given its association with improved SIBO breath test results and gastrointestinal symptoms in patients who followed it. This recommendation is backed by a combination of empirical and scientific evidence that supports using the ED to treat SIBO in clinical practice. The most widely referenced study used in support of the ED for SIBO is a 2004 study that involved 93 people with IBS and positive SIBO lactulose breath tests (LBT). After adhering to the ED for 14 days, 80% of patients had a normal LBT. Those who still had abnormal LBT results continued the diet for an additional week and repeated the LBT. At the end of the 21-day trial, 85% of participants had normal LBT results, indicating an eradication of SIBO. Normalization of the LBT also coincided with symptom improvement.
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Implementing the Elemental Diet: A Practitioner's Guide
Implementing the elemental diet in clinical practice involves several key steps to ensure patient safety, compliance, and effectiveness. Here is a guide for practitioners:
Step 1: Patient Assessment
Determine if the ED is appropriate for the patient. Screen for any contraindications that would disclude the ED from being a reasonable treatment option for your patient. These include:
- Diabetes
- Fungal overgrowth
- History of an eating disorder
Step 2: Patient Preparation and Education
Educate the patient on the purpose and process of the elemental diet. Explain that this liquid-only diet involves drinking a formula of pre-digested nutrients designed to minimize digestive effort and absorption issues. Despite these digestive benefits, following a liquid-only diet for an extended period presents mental and emotional challenges that the patient should be prepared for. Additionally, one of the major drawbacks that patients report with the ED is its unpalatable taste, which can make it difficult to adhere to.
Patients should continue taking all essential medications during the protocol. Supplements are optional and can be used as needed to manage side effects. For example, electrolytes can be added to prevent dehydration if they begin to experience diarrhea, and Vitamin C and magnesium can be used to treat constipation.
Step 3: Diet Selection
Recommend a prescription or nonprescription commercial ED formula. Alternatively, patients can make their formula themselves at home, which tends to be less expensive than the commercial options.
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Calculate the patient's daily caloric needs based on their age, weight, activity level, and clinical condition. This determines how much formula the patient will need to drink daily to meet their daily caloric goals.
Step 4: Monitoring and Support
Healthcare providers should be readily available to their patients during the ED protocol to monitor their clinical response, including symptom improvement and side effects, and address any questions that arise. Common side effects of the ED include:
- Increased hunger and weight loss, when not drunk in sufficient amounts
- Digestive symptoms: bloating, diarrhea, abdominal pain, nausea, less frequent bowel movements
- Headaches
- Fatigue
- Muscle and joint pain
- Mood swings
- Fungal overgrowth
Step 5: Assess Treatment Efficacy
The 2004 study referenced above set the ED's standard treatment timeframe of 14-21 days. Once the ED is completed, SIBO status can be evaluated by repeating the SIBO breath test or assessing the patient's clinical symptoms. When treating based on symptoms, many doctors will continue treatment until the patient reports an 80-90% improvement.
Transitioning Off the Elemental Diet
The ED is not designed to be a long-term diet. Once the patient has completed their protocol, they should be guided in gradually reintroducing solid foods back into their diet to prevent digestive upset. Here is an example of a 3-day transition diet that I will recommend to my patients:
- Day 1: eat a low-fiber diet consisting of meats, eggs, fats, white rice, and (if tolerated) lactose-free dairy
- Day 2: add cooked low-FODMAP vegetables, such as green beans, green bell peppers, and carrots
- Day 3: add low-FODMAP fruits, such as melon, blueberries, or oranges
- Day 4: return to regular diet
An alternative approach would be to follow a half-elemental diet, which involves replacing one to two meals per day with an elemental shake, providing approximately 50% of daily caloric intake. The remaining meals consist of a healthy, whole-food diet. This approach better allows for long-term use of the ED and offers a balanced way to support digestive health while maintaining the benefits of regular whole foods.
Dietary strategies can also be worked into a long-term SIBO prevention plan. Popular diets for the treatment and prevention of SIBO include:
- Low-FODMAP Diet
- Specific Carbohydrate Diet (SCD)
- SIBO Bi-Phasic Diet (SIBO B-PD)
- Gut and Psychology Syndrome (GAPS) Diet
- Cedars-Sinai Diet (CSD)
These dietary plans are all variations of elimination diets that aim to limit the intake of fermentable carbohydrates that bacteria thrive on, thereby reducing their population. By doing so, SIBO diets help to minimize clinical symptoms.
Practitioner Tips for Maximizing Success
Here are tips that can help your patients successfully follow an elemental diet:
- Take the time to properly prepare your patients before they start the ED: Before your patient begins their ED, have them schedule an appointment with ample time for you to explain the procedure and answer all of their questions.
- Modify the ED: Consider prescribing a semi-elemental diet or prescribing a shortened ED protocol to kick-start SIBO treatment. Then, use antibiotics or herbal antimicrobials to finish eradicating SIBO.
- Prevent fungal overgrowth: Because intestinal fungal overgrowth is a common side effect of the ED, many practitioners will prescribe prophylactic antifungals for their patients during the ED protocol. Drinking the formula through a straw can also help prevent oral thrush (yeast overgrowth in the mouth).
- Make the ED more palatable: To improve the taste of the ED formula, one of its major deterring factors, recommend a flavored commercial ED or semi-elemental formula to your patient. Drinking the beverage cold, such as by blending the formula with ice, can also help improve taste.
- Make the ED more affordable: Patients can save money by homemaking their ED formula instead of buying commercial products.
- Regulate blood sugar: The ED's high glucose load can lead to fast peaks and dips in blood sugar, contributing to symptoms like fatigue, headache, and irritability. To help stabilize blood sugar, instruct patients to sip on their elemental shake throughout the day instead of drinking three "meals."
Homemade Elemental Diet Recipes and Considerations
While commercial elemental diet formulas are readily available, some individuals may prefer to create their own homemade versions. This can be a more cost-effective option, but it requires careful attention to nutrient composition and hygiene.
Considerations for Homemade Elemental Diets:
- Nutrient Balance: Ensuring a complete and balanced nutrient profile is crucial. The diet must provide adequate amounts of protein, carbohydrates, fats, vitamins, and minerals.
- Hygiene: Maintaining a sterile environment during preparation is essential to prevent bacterial contamination.
- Palatability: Homemade formulas may not be as palatable as commercial ones, so flavorings and techniques to improve taste may be necessary.
- Professional Guidance: Consulting with a healthcare professional or registered dietitian is highly recommended to ensure the homemade diet meets individual needs and is safe.
Example Homemade Elemental Diet Recipes:
Several variations of homemade elemental diet recipes exist, each with its own macronutrient ratios and ingredients. One example is a low-carbohydrate/higher-fat version, which may be suitable for individuals with intestinal methanogen overgrowth (IMO).
A Case Report: Homemade Elemental Diet for IMO
A case report documented the outcome of consuming a 14-day homemade elemental diet to normalize intestinal methanogen overgrowth. The homemade elemental diet was conducted for 14 days. The lactulose breath test results on day 15 indicated a reduction of methane levels from an average of 42 ppm to 3 ppm throughout the testing period (120 minutes). The standard prevention protocol of prokinetics, diet, and lifestyle were not effective at preventing relapse. A repeat lactulose breath test on day 122 was positive, with an average of 81 ppm methane. The elemental diet was repeated for 9 days, with fasting on day 10. The homemade elemental diet resulted in a substantial reduction in methane and symptom resolution. There are many options available to treat IMO and patient responses to these options vary considerably. This case report documents the outcome of consuming a 14-day homemade elemental diet to normalize IMO. An elemental diet formulation consists of hydrolyzed nutrients such that digestion of the product by the recipient will be minimal. A prevention protocol after IMO eradication was employed to prevent recurrence. The prevention protocol consisted of diet therapy [specific carbohydrate diet (SCD), low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP), intermittent fasting, and a slow increase in fermentable foods) and 2 types of prokinetics [MotilPro (a proprietary ginger-based supplement) and low-dose erythromycin] for a 3-month period.
Challenges and Strategies:
- Taste: The taste of homemade elemental diets can be a significant challenge. Flavorings such as orange essential oil or cinnamon may help mask the taste. Drinking the formula ice cold and brushing teeth immediately afterward can also improve palatability.
- Psychological Aspects: The inability to eat solid food can be psychologically challenging. Positive thinking, exercise, meditation, and self-care are important strategies for coping with these challenges.
- Weight Loss: Some individuals may experience weight loss during the elemental diet. Ensuring adequate caloric intake and meeting protein and fluid needs can help prevent excessive weight loss.
Recipes to Improve Palatability and Variety:
While adhering to the strict principles of an elemental diet, there are ways to introduce some variety and improve palatability. Here are a few ideas, keeping in mind that any additions should be carefully considered to avoid digestive upset:
- Elemental Diet Energy Bars: Combine almond butter, chopped nuts and seeds, and almond flour in a food processor. Press the mixture evenly into the bottom of a muffin tray and top it with a mix of yogurt and Elemental Heal.
- Sugar-Free 'Nutella' Delight: Roast hazelnuts, process them into a smooth paste, mix with cocoa powder and sweetener.
- Coconut Mango Chia Pudding: Blend coconut milk, mango, Elemental Heal, and turmeric. Add chia seeds and refrigerate.
Key Takeaways
- SIBO is a gastrointestinal condition that mimics the symptoms of IBS and requires a reduction of bacterial overgrowth for treatment.
- The elemental diet is a hypoallergenic liquid formula that starves bacteria and reduces inflammation in the intestines. It can be used to treat SIBO and its associated symptoms.
- Successfully prescribing the ED to patients involves many logistical elements. Patient education and providing tools to navigate obstacles that commonly arise with an ED protocol help patients complete their diet.
- Most patients who complete the ED find that the challenges were worth it.