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 Part 1 of this article, I discussed the history, indications, and mechanisms of action of an elemental diet (ED). [This part] offers prescribing recommendations, tips, and 3 cases demonstrating practical use.
PRESCRIBING THE ELEMENTAL DIET IN 6 STEPS
STEP 1 – KNOW THE CLINICAL OBJECTIVE & CONTEXT OF CARE
Be clear about the therapeutic objective in the context of the patient’s total care, which often includes some conventional treatment. Objectives include induction or maintenance of remission in refractory cases; support of a conventional plan unable to produce complete induction or maintenance; resolution of inflammatory bowel disease (IBD) or irritable bowel syndrome (IBS) undernutrition; management of small intestinal bacterial overgrowth (SIBO) and/or IBS (alone or coexisting with IBD); and/or resolution of a persistently abnormal lactulose breath test (LBT).
STEP 2 – SELECT AN EXCLUSIVE OR PARTIAL ED
In exclusive elemental diets (EEDs), the patient consumes 100% of caloric requirements. In a “partial” or “half-elemental diet” (half-ED), up to half of daily calories (900-1200 kcal) are provided by the ED, and half from whole foods.1 EEDs are selected to induce remission of acute disease, resolve SIBO, or address suboptimal nutrition; half-EDs are selected only to maintain remission. Crohn’s disease (CD) appears to be the sole condition for which a half-ED has been studied; however, it may prove useful for maintenance in other conditions discussed in Part 1.
STEP 3 – CALCULATE NUTRITIONAL REQUIREMENT
Following Step 2, the clinician determines the BMR, plugging the patient’s height and weight into the Harris-Benedict Equation, then multiplying by an activity factor representing the patient’s exercise pattern. The product of the equation is an estimate of daily calories required to maintain current weight. If the patient has a lot of body fat or a low BMI, necessary adjustments are applied.
STEP 4 – PRESCRIBE THE FORMULA – DOSAGE, DURATION, PARQ
Dosage is based on total calorie requirements distributed throughout the day. With an EED, I divide total calorie requirement into ~300-calorie servings, consumed every 2-3 waking hours. I find this superior to recommending 3 large “meals.” Each serving must be taken slowly, over 15-30 minutes, which decreases risk of hypoglycemia, hunger, and osmotic diarrhea.
With half-EDs, I divide the total ED calories (half of the daily total) into 300-calorie servings, consumed every 2-3 hours during either the first or second half of the day, according to preference. A whole-foods diet is consumed during the half-day when the ED is excluded. This method allows some bowel rest, which supports gut healing.
Duration of an ED is flexible and depends on the objective. To induce remission with an EED, 4 weeks was the starting point in many studies. This can be extended if safely monitored.2,3 For repleting malnutrition, I do not see a literature standard. I start with 2 weeks, and follow nutritional markers to determine duration.
For remission or maintenance in IBD with a half-ED, there are no published guidelines. Theoretically, it may be used indefinitely as a nutritional supplement (though its long-term effect on microbiota hasn’t been studied and should be used cautiously). I begin with 1 month, then follow up regularly and assess what degree of ED can maintain either adequate nutritional status or remission from acute disease along with other treatments.
To manage SIBO, a 14-day ED normalized a LBT in 80% of subjects.4 A third week can be added if necessary.
I PARQ patients (ie, discuss Procedures, Alternatives, Risks, and answer Questions) at the time the ED is prescribed, communicating key points: strengths and limitations of dietary management; necessary compliance for best results; and follow-up to monitor and troubleshoot. I stress slow feeding and adequate hydration to avoid osmotic diarrhea, headaches, nausea, and/or hypoglycemia.
STEP 5 – MONITOR THE PATIENT
Physicians need to follow patients for:
- Compliance – Consuming required calories
- Medical and Nutritional Stability – Completing appropriate exams and labs, and monitor weight
- Progress – Assuring that objectives are achieved; in IBD, inflammatory markers (ESR, CRP, fecal calprotectin) and nutritional markers are followed; in IBS with SIBO, LBTs are monitored. Follow-ups will allow time to manage medications, coordinate with other providers, and address obstacles.
STEP 6 – TRANSITION TO WHOLE-FOODS DIET
Completing an ED is followed by a transition to whole foods. In most cases, returning to an unrestricted diet will not extend improvements gained, and may lead to relapse in either IBD or IBS. Patients are warned that it may take time and considerable dietary therapy to establish a stable remission.
In IBD, I suggest tapering the ED servings over several days while introducing easily digestible foods. I generally follow the guidelines for the “introductory Specific Carbohydrate Diet” (SCD): peeling, de-seeding, fully cooking vegetables, and using simple broths. The degree of restriction and texture modification will depend on the virulence of the disease and how much remission was achieved during the ED. In difficult cases, I consider half-EDs transitionally, if not for longer periods.
In IBS with SIBO, the transition is usually less dramatic than in IBD and will depend on 1) the diet selected from a range of strategies; 2) the patient’s unique intolerances; and 3) the degree of persistent bacterial overgrowth.
The fourth part of this article will be posted soon.