In an article originally published at ndnr.com. Dr. Gary Weiner explains the history, use of and possible benefits to utilizing the elemental diet for IBS and IBD. This is part of our in depth series of posts on IBS (Irritable Bowel Syndrome), IBD (Inflammatory Bowel Disease) and SIBO (Small Intestinal Bacterial Overgrowth).
Previously in this series, Dr. Weiner wrote about the differences between IBS, IBD, and SIBO, Treating IBD, and The IBS Within the IBD. Look forward to the second part of this elemental primer and additional videos and summary articles including posts related to the use of Chinese Medicine and Acupuncture as treatments for IBS, IBD, and SIBO.
In 2004, Pimentel et al published a retrospective study of 93 IBS patients, in which they demonstrated the effectiveness of a 14-day ED in normalizing an abnormal LBT and improving IBS symptoms.17 Seventy-four patients (80%) had a normal LBT on day 15 of the ED. Five additional patients normalized their breath test (85%) when they continued to day 21. The therapeutic benefit from the ED in IBS cases with SIBO appears to be greater than that for both antibiotics32 and herbal therapy.33 Most SIBO-literate physicians agree that the ED, while being a costly and, at times, laborious method of eradicating SIBO, often succeeds when antimicrobials have failed, and is especially useful in cases with high gas levels, methane positivity, sensitivities to herbs or medications, and in patients refractory to other treatments or with concomitant IBD.
The ED has also been shown to resolve fistulas,34 intestinal ischemia,35 complicated pancreatitis,36,37parenteral nutrition-induced gut atrophy,38 and intractible diarrhea in infants.39 It has displayed efficacy in pneumatosis coli40 as well as in cases of type I celiac disease that is refractory to gluten elimination.41
Outside of the GI tract, the ED has induced remission of rheumatoid arthritis42 and produced improvements in refractory atopic eczema43 and dermatitis herpetiformis.44
TOO GOOD TO BE TRUE?
The first ED for humans was developed by W.C. Rose in the 1940s.45 Around the same time, a liquid diet evolved from Rose’s formulation that was found to resolve much of the malnutrition and inflammation in many CD patients.46,47 Significant efficacy was re-confirmed in 1990 with a 10-year retrospective study demonstrating ED-induced remission in 96 of 113 CD cases (85% of patients).22 If this sounds too good to be true, it is. Unfortunately, 22 of the 96 remitted patients relapsed within 6 months, with an 8-10% relapse rate thereafter. A 2016 review put the relapse rate at 50% within 6 months, usually noting that relapses commonly occur when patients return to a normal diet.48
The ED’s impact on normal human microbiota sheds light on a probable explanation for relapse. Elemental diets cause a marked and rapid reduction in microflora populations, which may relate to an important mechanism of action of the ED for both IBS and IBD. The diet rapidly decreases the total number of bacterial organisms as well as species diversity in stool samples,49 especially coliforms, enterococci, and members of the phyla, Bacteroides. What is striking, however, is how quickly the microbiota are restored, both in numbers and diversity, when patients return to an unrestricted diet. Studies have demonstrated that “the intestinal microbiome can rapidly respond to short-term dietary interventions…but reverts to its prior composition once the interventions cease.” Conversely, “[l]ong-term dietary patterns strongly influence the intestinal microbiome” producing more stability.50 While naturopathic physicians may find value in using the ED like a “nutritional steroid” in acute cases, the research suggests that we can‘t count on long-term change from short-term EDs.
The plot thickens when real food enters the picture, and we can dish up a healthier portion of tolle causamby following the ED with a whole-food diet consistent with naturopathic principles – a pairing that begins to have traction for difficult cases of IBD and IBS.
HAPPY MARRIAGE: ELEMENTAL & WHOLE-FOOD DIET
When elemental diets are coupled with therapeutic whole-food diets, relapse rates improve (as they do with the use of partial or half-EDs). In an uncontrolled IBD study, an individualized exclusion diet was examined that allowed 51 of 77 patients to remain well on diet alone for periods of up to 51 months, with an average relapse rate of less than 10%.51 And in a large multi-center, controlled trial, a 2-year probability of relapse was lower in a group treated with with EDs followed by excluded foods (commonly dairy products, cereals, and yeasts).52
In IBS, where diet has clearly been identified as an important etiological factor, the response rate to elimination diets ranges from 15-71% (with the highest response rates in cases of diarrhea-predominant IBS).53
SIBO-literate physicians treating IBS generally agree that dietary therapy is required after SIBO is eradicated, whether by pharmaceutical or herbal antibiotics, or by an ED. Clearly, it is just as important to follow an ED used to induce remission in IBS as it is in IBD, but there is no general agreement on precisely what dietary therapy is needed in either condition.
I strongly urge initiation of individualized diets incorporating elements from the Specific Carbohydrate Diet (SCD) and the Low-FODMAPS Diet (LFD). These evidence-based therapeutic templates have been successfully embraced by many physicians and patients, and have small studies supporting them in both IBD54 and IBS.55 Additionally, a Semi-Vegetarian Diet (SVD) has been studied and shown to be “highly effective in preventing relapse of CD.”56 It is beyond the scope of this article to address the particulars of manipulating these therapeutic diets in IBS and IBD, as each requires study to appropriately construct regimens to follow an exclusive ED or to accompany a partial ED.
It is important to grasp that an exclusive ED is a short-term modifier of a dysbiotic pattern that requires a longer-term, whole-food dietary strategy to extend the remission of IBD or IBS (and probably other conditions), once achieved.
In Part 2 of this article, I will provide an outline for prescribing elemental diets in 6 steps, review common problems encountered with potential solutions, and present several representative cases including successful implementation of an elemental diet.
The second part of this article will be posted soon.