If you work with patients with small intestinal bacterial overgrowth (SIBO), Crohn's disease, colitis, or food intolerances, you've probably heard about the elemental diet. But there's a lot of confusion about what the diet is, when it's appropriate, and how it can be used most effectively. In this interview, digestive health expert Lela Altman, ND, LAc, explains how the elemental diet allows the gut to rest and repair. She offers practical information for patients and practitioners about how to choose an elemental diet or how to make your own. In addition, she outlines the steps she takes to reduce the risk of relapse after coming off the diet. And she reveals the one question every practitioner needs to ask to identify a major red flag that would contraindicate the elemental diet.
Lela Altman, ND, LAc, began working in the medical field in 1998, first as a nursing assistant, then as a medical assistant. This experience inspired her to pursue an education in the natural health sciences. Altman earned her bachelor of science degree from The Evergreen State College where she focused on ethnobotany, biology, and chemistry. She then earned her doctorate in naturopathic medicine and masters of science in acupuncture at Bastyr University in 2011. She went on to complete a 3-year residency at the Bastyr Center for Natural Health. While working as a chief resident, she completed additional training in evidence-based medicine and carried out diabetes research. She recently created the Digestive Wellness clinic at the Bastyr Center for Natural Health, which she currently supervises. Additionally, she teaches full time at Bastyr University and has a private practice.
Integrative Therapeutics is focused on helping integrative medicine professionals cultivate healthy practices—from the development of science-based nutritional supplements to innovative, actionable resources and professional insights that have the power to inspire and enrich you, your patients, and your practice.
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Other resources include ElementalDiets.com.
Tina Kaczor: Hello, I'm Tina Kaczor with the Natural Medicine Journal. Before we begin, I'd like to thank the sponsor of this podcast, Integrative Therapeutics. Today we're talking about the elemental diet, which is a specialized diet sometimes used in patients with inflammatory bowel disease or small intestinal bacterial overgrowth, better known as SIBO. My guest today is naturopathic doctor Lela Altman, from Bastyr University. She's a specialist in gastrointestinal medicine and has used the elemental diet to improve her own health. Dr Altman, thank you so much for joining me.
Lela Altman: Thank you so much for having me.
Kaczor: So, let's jump right in. I'd like you to start us out with a definition. In doing a little research for this interview, I noticed that the elemental diet or, the words "elemental diet" have been around for decades. So maybe you can just start us out with just a simple definition of what is an elemental diet and what does that term exactly mean?
Altman: Sure, so a true elemental diet is a formula, it can be used in place of meals, and it proves all the nutrition that you need in its most basic, easily absorbed form. And that allows the gut to rest and repair. So, for example, instead of having proteins you would have individual amino acids, which are the building blocks of proteins. Instead of having fibers or starches it would contain simple sugars, which can be easily absorbed. And it also the essential vitamins, minerals, nutrients you need to survive. Fiber isn't typically included in an elemental formula because it can feed gut bacteria so that's something that we wanna look at and make sure it doesn't contain. There are a lot of formulas on the market that kind of market themselves as elemental diets that do have full proteins in them. And so it's not that those are bad formulas, but they're not necessarily totally an elemental formula. So it is important to know what you're looking for when you're evaluating formulas to determine whether or not they're elemental.
Kaczor: Okay, so we'll get into the diet specifics but it sounds fairly regimented in that, when I looked online I saw that there were a lot of various forms. There were homemade recipes and then there were products for sale, like you mentioned. And I guess ... the patient experience, can you tell me a little bit about the patient experience? I mean, is there a breadth of options for the patient where if they wanted to use their own kitchen they could do this diet themselves at home all the way to here's the pre-packaged thing? So what should a patient expect when they're put on this?
Altman: Yeah, absolutely. So you can make your own. Dr. Allison Siebecker has a great website, siboinfo.com, that has a recipe for a homemade version and there are also various other forms. So there are supplement companies that make them, there's, I mean, pharmaceutical-type versions of them. So there's a lot of range of what you can purchase and there's a lot variation in price based on that range. So it really depends on whether the patient wants to make their own and save a little bit of money or finds the convenience more important and maybe the taste more important and is willing to buy prepackaged option. Not all of the prepackaged options taste good but there are some that taste better than others.
Kaczor: So in, I guess ... Well it may depend on condition but is this something that people typically do for days, weeks, months, how long are we talking for patients?
Altman: It does really depend on the condition. So for SIBO it's typically done for 2 to 3 weeks. And an elemental diet, again, it's used in place of food. So you're not typically eating food with the elemental diet, you're only doing the formula. So for SIBO, that would be the formula only for 2 to 3 weeks. It can be used really anywhere from a few days for a few months depending on what you're not using it for. Or, sorry, not a few months, a month. So, if you wanna do a little bit of bowel rest you maybe would be on a elemental for 3 to 5 days. If you have maybe Crohn's disease and are using the elemental diet for treatment of an acute, really severe flare of Crohn's disease then you might be on that for up to 4 weeks. Also, sometimes I'll use the elemental formula for people who have a lot of food intolerance or allergies and are unable to maintain their weight, as a way to provide antiallergenic calories. And in that case they are eating food in additional to the elemental formula and so they may be on the formula for months while they're recovering their weight.
Kaczor: And in that, just to clarify, in that scenario they're doing it as an add-on to an otherwise tailored diet for them.
Altman: Right. Typically, if the elemental diet is being given completely alone without any other food it doesn't exceed more than 4 weeks.
Kaczor: Okay, and so what conditions exactly ... I know you mentioned food intolerances so just so are we are complete, what other conditions do you use the elemental diet for?
Altman: The big three that I use the elemental diet for is for treatment of SIBO, also for, again, as I mentioned, addition of calories in people who are underweight and have a lot of food intolerances. And then also just for a short term bowel rest, which might be needed in a Crohn's or colitis flare. There is some research on multiple other conditions though that elemental diets or sub-semi elemental diets have been used to treat. So eosinophilic esophagitis is one, cystic fibrosis, AIDS-related diseases, acute pancreatitis, sometimes rheumatological diseases. So there's a number of different conditions that we are looking at elemental diets to treat. My focus is mostly on the gastrointestinal diseases.
Kaczor: Okay, and so because it's void of fiber completely I'm guessing that the microbiota of the gut changes dramatically without those fibers. So how do people come off of this diet? In other words, how do they step off it without having a massive reaction to fiber from foods?
Altman: Yeah, so, I mean, the first part of that question really is kind of addressing the lack of fiber issue. These diets are not health long term. The elemental diet wouldn't be health long term, nor would necessarily the low-FODMAP diet or something like that. So when I take people off of the elemental diet, I usually have them start with homemade low-FODMAP broth. And if they are tolerating those well on the first day then I'll have them add some well-cooked, low-FODMAP veggies and they can even puree that into a soup to help break it down a little bit more. And if all is going well, the next day I will have them eat lightly cooked low-FODMAP veggies like steamed or lightly sauteed. And they can add some grains if they tolerate grains, though not everybody does. Meat, eggs, those things need to be well tolerated and fairly easy to digest after the elemental diet. And then on phase 3, I kind of transition back to a low-FODMAP diet, that's the diet I'm typically using. Some people are on a SCD [specific-carbohydrate diet] or SIBO-specific diet. I kind of transition them back to whatever diet they were on before that was working for them.
And then when their gut stabilizes, then we start to challenge food. So, for example, we would start challenging low-FODMAP foods to see what they can tolerate and what they can't. The idea is once the SIBO is cleared they shouldn't have to stay strictly adherent to one of those diets.
Kaczor: Okay, so that brings up a question because it seems like there's a lot of relapse in SIBO that a lot of ... there's a lot of talk in the chat groups about what does one do after they feel like they've exhausted many protocols. Do you find in your practice that there is a lot of relapse and a lot of people end up with a recurrence of it?
Altman: Yeah, definitely, so there's one study that shows the recurring aftertreatment with Rifaximin that's about 50% at 6 months. We don't have specific studies looking at different types of treatment and whether the recurrence rate changes, say, for somebody treated with Rifaximin versus somebody treated with an elemental diet. This is why, in my practice, I implement a lot of other things to help prevent recurrence like maybe long-term antimicrobial herbs, prokinetics, maybe a modified diet or a low-FODMAP diet. So, unfortunately, we don't have studies showing what if we do all of these other things too then what is the recurrence rate? But in my practice I think it's lower when we add in those things. And unfortunately, for years SIBO's just been treated with Rifaximin and follow-up testing wasn't even necessarily done and then that's it. And so the studies that we have are based on that type of treatment.
Kaczor: Okay, so, yeah, that answered one of my questions. I didn't know if this was a diet people had to go on intermittently but it sounds like if one can get to the root cause of what's going on and kind of get the gut into a healthier place and perhaps do a few things like longer-term antimicrobial herbs or prokinetics ... And just out of curiosity, prokinetics, when you say that in the naturopathic realm, what are you talking about exactly?
Altman: So, prokinetics can be in various forms. They can be pharmaceutical and they can be herbal and I use both, sort of depends on the person and what they respond to and sort of what level of prokinetics they need. So a prokinetic is essentially something that makes the gut move, it increases motility of the small intestine, which can be a really big problem, particularly in the autoimmune type of SIBO. And so naturopathically I'm generally starting with herbal options, which may include things like ginger and 5-HTP, bitter herbs, things like that.
Kaczor: Yeah and that brings up another question I have and that is with that idea of the lack of peristalsis within the small intestine that seems to be implicated in SIBO and those prokinetics working for those people, it seems to me, and correct me if I'm wrong, that stress has a lot to do with this. That people who maybe have more anxiety or anxiousness and we say they hold it in their gut kind of thing. Is that true in your experience? Do you notice stress having any effect on SIBO or on their GI symptoms?
Altman: I would definitely say so. I have a few patients whose only known risk factor for getting SIBO has been going through a very stressful event. And actually it's those people are the ones that tend to have fewer recurrences or not have recurrence at all because there's not an anatomical or motility issue that you have to deal with. Essentially once you clear the SIBO it's more stress management that helps keep it away. So yeah, that is definitely true. Also, if we think about the sympathetic versus parasympathetic nervous systems, so in the sympathetic nervous system is the fight or flight. And in the fight or flight nervous system, we shunt blood away from our digestive system to our limbs so that we can run. In a parasympathetic nervous system, that's the rest and digest, and so we're shunting blood to the digestive system to help break down food. And so if you're stressed you're kind of constantly in this sympathetic, fight or flight state and you are not shunting blood toward your digestive system to function properly. So that's a really concrete example of why stress would make this worse.
Kaczor: Yeah, yeah, that makes perfect sense. And then, I guess, kinda sticking to the mind-body idea and how the physiology is functioning, I guess, one question I had for you as a practitioner. Do you find that sometimes doing dietary restrictions like an elemental diet, especially when there is a lot of concentration, a lot of time and effort on eating the right things and making sure that the wrong things don't go down, and all of that, have you ever found that there's some trigger for relapse in those who have a prior eating disorder? Especially people, young women, and they might be in high school or college, they had bulimia or anorexia and here they are in their 50s and maybe they have to go through either an elemental diet or more likely the other diets you were talking like the FODMAP diets or the specific carbohydrate diets, very restrictive diets. And they get into kind of a neuroses about food is basically what I'm asking. Have you found that to be true at all?
Altman: Yep, unfortunately I have found that people having eating disorders by trigger them through giving them an elemental diet. So no, it wasn't in the history I was aware of and then they went on the elemental diet and then suddenly this history of an eating disorder became an issue because the elemental diet did trigger that. And that's also true for, I think, any restrictive diet. So a history of or current eating disorder for me is a relatively strong contraindication to an elemental diet or any other type of restrictive diet. I think, I agree with you, I think it's a fine line between treating SIBO and having disordered eating. So when you feel poorly every time you eat and every time you eat you get more bloated, it created a negative feedback pattern associated with food and over time that can cause bigger problems like fear of eating almost anything. You know that anything you eat is gonna make you feel poorly and I think that's something to be really careful of if you have SIBO or if you are treating a lot of SIBO.
Kaczor: Yeah, and thanks for saying it because I think that's a big heads up for everyone who is looking at using this diet. Especially practitioners, that's a very simple thing to have on an intake form so it doesn't have to be too deep of a probe with the patient. It can be very simply asked. So on that note, are there any other contraindications, any other patient populations that we should be aware of that we should be especially careful with this diet?
Altman: Well, you need to think about it, I think, really on a case by case basis. Anybody could have something that could be a contraindication. One of the biggest concerns people have is about weight loss or low BMI. I find that's a relative contraindication. A lot of people think of the elemental diet as a fast, which it's really not. You have all of the calories and nutrition you need and you can increase the amount of formula somebody's taking as needed to meet their caloric requirements. So I've actually had several patients who are really malnourished, had a lot of difficulty maintaining weight, actually gain weight on the elemental formula because it was providing nutrition for them in a way that they could actually absorb and utilize in their bodies. So, I mean, that's something to think about. Diabetes for me is some concern, especially with the insulin needs and blood sugar dysregulation. The elemental diet, as I mentioned in the beginning, the carbohydrates come in the form of sugar and so it does have some potential for blood sugar dysregulation if you're drinking it really quickly. You can really mitigate not a lot by drinking it slowly over time but that would be another concern.
Fungal overgrowth can definitely be exacerbated by an elemental diet, again, because of the sugar content. I initially, when I started using it, thought that maybe kidney disease would be a concern. But I looked it, wasn't really able to find anything that verified that there was any issue with giving an elemental diet in somebody with kidney disease. And actually there was one study I found that showed improvement in kidney function in people with chronic kidney disease on an elemental diet. You might wanna be a little bit more careful in somebody with compromised liver function because amino acid metabolism can lead to ammonia production and build up in their liver and so that might raise liver enzymes. But again, if you're only doing this for 2 weeks or so that really shouldn't make a big difference. And then, as I already mentioned, really that history of the eating disorder is a big red flag for me and then contraindication.
Kaczor: Well that's ... I know this has been incredibly helpful from a practical perspective. I think that in less than 20 minutes we've touched on a few things that are definitely what I would consider clinical pearls for our listeners. So I really appreciate you taking the time of your schedule and offering up your expertise for our listeners. So thanks for being here with me.
Altman: Oh, it's been a pleasure. Thank you.
Kaczor: And once again, this is Tina Kaczor with the Natural Medicine Journal. And I'd like to thank the sponsor of this podcast, Integrative Therapeutics.