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Evidence Based

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The Elemental Diet: An Effective Therapy for Gut Relief

Written by Dr. Ruscio on July 30, 2020

Written by Dr. Ruscio on July 30, 2020 — Reviewed by Aimee Gallo

Dr. Michael Ruscio is a DC, Naturopathic Practitioner, researcher, and clinician. He serves as an Adjunct Professor at the University of Bridgeport and has published numerous papers in scientific journals as well as the book Healthy Gut, Healthy You. He also founded the Ruscio Institute of Functional Health, where he helps patients with a wide range of GI conditions and serves as the Head of Research.

A Spotlight on a Top Hypoallergenic, Anti-microbial, and Anti-Inflammatory Therapeutic for Gut Health

• Elemental Diet Overview|
• Who is it For?|
• How Does it Work?|
• The Elemental Diet for Specific Concerns|
• Picking a Formula|
• Tips for Success|
• Go Elemental for Better Health|

The elemental diet is one of the most effective therapies for healing the gut, and as we will see today in the research, one of the most misunderstood. Contrary to common belief, you don’t necessarily have to be highly strict with using this hypoallergenic, pre-digested meal replacement to reap the benefits, and you’re no longer limited to using poor-tasting and expensive formulas. 

This is great news for those struggling with a wide array of GI complaints, including irritable bowel syndrome (IBS), small intestinal bacterial overgrowth (SIBO), gas, bloating, diarrhea, and reflux. Its anti-inflammatory impact on the small intestine makes it a great tool for healing inflammatory diseases, like inflammatory bowel disease (IBD) and rheumatoid arthritis (RA). 

The elemental diet can be highly effective for treating these health concerns, and research suggests it has far more versatility than previously thought. Instead of a total meal replacement, the elemental diet can be used to support and add to your current lifestyle, and for some people, it can be used as an alternative to medication or alongside your prescriptions. 

As I’ll touch on today with a patient case discussion, its gentle and positive impact on the GI tract can also make it effective for lessening the symptoms of seemingly non-gut-related concerns like PMS in women and joint pain related to arthritis. Some research shows that it can even reduce the likelihood of death post-stroke [1]. 

Guided by the research, my clinical experience with this therapeutic-grade meal replacement shows that we can afford to take a more relaxed, wallet-friendly, and better-tasting approach to the elemental diet.

The Ultimate Guide to the Elemental Diet: An Overview

The elemental diet is a meal replacement formula that is hypoallergenic, anti-bacterial, and anti-inflammatory. Carbohydrates, fat, and protein sources are broken down — or pre-digested — to varying degrees, making these formulas range from semi- to fully elemental (where nutrients are broken down into their smallest components).

An elemental diet differs from other types of meal replacements, like protein shakes, as it contains all of the necessary nutrients we need in our diet, and only comes with protein as hydrolyzed whey protein isolate or completely broken down amino acids. Other forms of protein often used in shakes, like pea and rice, can be a little harder on the gut. It also differs from other health shakes as it doesn’t include ingredients like fiber that are not easily digested. 

An elemental liquid diet is very easily absorbed in your digestive tract and supplies all of your macronutrients and essential vitamins. By giving your gut, namely your small intestine, a temporary break from digesting food, an elemental diet helps to heal and repair the gut and heal chronic health symptoms [2, 3, 4].

Historically, it was prescribed by a healthcare provider to treat health issues like inflammatory bowel disease (IBD) and was used post-surgically as a complete meal replacement for several weeks. However, this therapeutic diet is now available over the counter as a powder that you simply mix, blend or shake up with water, and that can be implemented in a number of ways.

I’ll get more into the details of different types and uses of elemental diets later, but let’s first talk about who can actually benefit from this meal replacement.

Should You Try an Elemental Diet?

Elemental diets were developed as a medical food to treat patients with severe digestive diseases like IBD, but their application has significantly evolved. 

A vast array of health symptoms can result from an unhealthy gut, ranging from occasional gas and bloating to chronic hormonal imbalances. When viewed as one part of a holistic plan to improve your health, there is really no limit when it comes to who can benefit from an elemental diet. 

You may benefit from an elemental diet if…

You suffer from a stubborn gut imbalance

The elemental diet can be helpful for many gut disorders, including eosinophilic esophagitis, SIBO, IBS, and celiac disease [5, 6, 7, 8, 9]. Evidence shows that using an elemental diet as your only source of calories for 2–3 weeks often achieves results when other gut therapies have failed (though this strict approach is not always necessary). 

You are having an inflammatory flare

If you are managing an inflammatory condition, it’s not unusual to have an occasional flare-up. The elemental diet can be very helpful for quickly relieving inflammation and calming the immune system. Research shows that conditions with a high inflammatory burden like IBD (Crohn’s disease and ulcerative colitis) and rheumatoid arthritis respond well to elemental meal replacement [2, 3, 10, 11, 12, 13, 14, 15, 16, 17], and it can be an effective alternative to anti-inflammatory medications like mesalazine or prednisolone [18, 19].

You need to get your diet and lifestyle back on track

All of us slip into unhealthy eating patterns every now and again and start consuming more inflammatory foods than our bodies can tolerate. This can cause us to develop elusive symptoms like fatigue, poor concentration, and achy joints. In this case, 1–3 days of replacing all your meals with elemental shakes — what we refer to in the clinic as a “gut reset” — can work wonders for your health. Consuming elemental shakes exclusively for 24-72 hours and following it up with an anti-inflammatory diet like Paleo is a great way to get your diet back on track.

You want a gut-friendly meal replacement

Elemental shakes are a quick and easy meal replacement. And while that’s great for busy mornings at home or when traveling, your digestive system also benefits. Even a “half” elemental diet (up to 50% of daily calories from elemental shakes) reduces gut symptoms and IBD flares [20]. If you have any of the above concerns and want a more relaxed approach, or you suspect any other chronic health concerns might be due to an unhealthy gut, this is an easy way to incorporate the elemental diet. 

Clinical Success With the Elemental Diet

One of my patients, Kacheena, first presented to the clinic with chronic symptoms of bloating and severe abdominal pain that she suspected to be due to IBS and leaky gut. I, myself, had a suspicion that bacterial overgrowth and gut inflammation were also behind her symptoms, especially since they first came on after a bout of food poisoning.

She also began to have severe PMS symptoms that would trigger her IBS-like symptoms, and cause her to accrue absences at work. Her symptoms were so severe that she and her gynecologist were considering a hysterectomy as a last resort method to resolve the pain. After living with these symptoms for over two decades, and trying other therapies like avoiding triggering foods and probiotics, she heard about our Elemental Heal formula. 

She started consuming an elemental shake for breakfast, continuing with regular food for lunch and dinner, for 14 days. She noticed some improvements, and when she started Elemental Heal up again before her menses the following month she noticed a lessening of her PMS and, to her surprise, it did not trigger an IBS flare. 

Within a few months of using an elemental diet, she was no longer experiencing pain, had  significant improvement in her overall quality of life, and was able to avoid a major surgery. 

As seen in Kacheena’s experience, the overwhelming success of the elemental diet in the clinic for resolving chronic health concerns among my patients has led to my own pre-publication findings on this highly effective diet. As we continue with the investigatory phase of this current research, we can continue to look at the existing literature on what makes this diet outperform.

How Does an Elemental Diet Work?

When you drink an elemental diet shake, the nutrients are absorbed in the first few feet of your small intestine. Elemental formulas are easy to absorb and not irritating for your digestive system because:

• All of the proteins are already broken down to variable degrees for easy absorption.
• There is no fiber or prebiotic content to feed an existing overgrowth of gut bacteria or some fungi. 
• There are no food antigens (particles off food that can trigger an immune reaction), which reduces inflammation.

Elemental diets reduce gut inflammation, and this has been noted especially in patients with Crohn’s disease [3, 4, 16] . As gut inflammation decreases while taking this hypoallergenic meal replacement, the immune system calms. With less inflammation, malabsorption improves and the small intestine can absorb more nutrients. 

Elemental diets also help to rebalance bacterial overgrowths, decreasing bad bugs and making space for a healthier microbiota [21] It seems likely that they help with fungal overgrowths too.

Most elemental formulas contain l-glutamine, an amino acid that has been shown to heal leaky gut syndrome [22].

Elemental Dieting Gives Your Gut a Rest

As you consume elemental meals, your digestive system gets a break from performing its many functions, allowing it to rest and regenerate [17]. Since no inflammatory foods are consumed, your gut also gets a break from food intolerances and irritants.

In my video on elemental diets, I liken a taxed, inflamed gut to having an ankle sprain. When we sustain an acute injury, such as a sprain, we take time off from physical activity to rest the ankle until it heals. When we “push through” the injury, it typically takes significantly longer to heal and can even worsen. So just as we wouldn’t run 3 miles per day on an injured joint, we want to avoid “injuring” our gut further by constantly pushing it to digest food throughout the day. 

This is why some people notice an improvement in their symptoms when not eating, and the pre-digested and hypoallergenic nature of an elemental diet can do the same. All of the nutrients in an elemental diet are absorbed in the first 2–3 feet of the 25 ft long intestinal tract, giving the majority of your digestive system plenty of rest. 

An Evidence-based Alternative to the Food Allergy Panel

Taking a break from inflammatory food triggers is critical for healing your gut and chronic health symptoms. This idea is at the core of many elimination diets, meal replacements, and even gut “cleanses”. 

One of the most popular methods for identifying triggering foods right now is through a food allergy panel (FAP) blood test that takes your blood to see what foods you may be having an immune reaction to. But a FAP isn’t necessarily the most logical choice when it comes to eliminating food allergens, with food elimination and elemental diets showing superior efficacy.

Unfortunately, identified foods on a FAP often don’t correspond with symptoms, and this test can be hundreds, if not thousands, of dollars. In contrast, the free and minimally invasive elimination diet has become the gold standard for identifying food allergies, and it appears that the elemental diet also shines as an effective way to eliminate allergens. 

A 2014 meta-analysis study with over 1,000 participants with eosinophilic esophagitis (EoE) found that only 46% achieved remission on a FAP-guided elimination diet, while a 4-food and 6-food elimination diet led to 53% and 72% remission rates, respectively [5]. 

But what about those participants who didn’t respond to removing egg, dairy, wheat, soy nuts, or seafood from their diet? This is where the elemental diet comes into play. The researchers found that 91% of participants experienced resolution of their symptoms after following an elemental diet. The treatment model for EoE is similar to its comorbidities of IBS and IBD, meaning that people with concerns other than EoE can benefit.

As we can see, testing isn’t always required and doesn’t always lead to a high degree of resolution. An evidence-guided handout on elimination diets and/or an elemental meal replacement can outperform an expensive and time-consuming test.

Elemental Diets for Specific Conditions

The majority of the research on elemental diets has been done on IBD and has consistently shown short and long-term benefits [2, 3, 4, 10, 11, 12, 13, 14, 15, 16, 17]. Now, we’re seeing many ways this treatment can go beyond the original use(s) and help those with IBS, SIBO, RA, EoE, and celiac disease [7, 8, 9, 18, 23, 24]. 

There’s a significant therapeutic carryover between IBD and IBS, SIBO, GERD, bloating, diarrhea, constipation, and fatigue. Clinically, I have found elemental diets to be very effective for all of these conditions and others not mentioned in the research, such as reflux and indigestion.

Small Intestinal Bacterial Overgrowth (SIBO)

We don’t yet have a lot of research into elemental diets and SIBO, but the landmark Pimental et al. trial found that lactulose breath tests normalized in 80% of SIBO patients after two weeks on the elemental diet [7]. Sixty-five percent of patients in the same study experienced an improvement in their IBS symptoms.

The use of elemental diets in SIBO is a topic that has seen significant clinical success but where research is still catching up. And while the anecdotal data  from clinicians is promising, we need to be careful not to overstate the evidence. But for now, there is enough scientific and clinical evidence to show that it’s a worthwhile therapeutic for treating bacterial overgrowth.

Irritable Bowel Syndrome

There is a significant overlap between IBS and SIBO patients, with SIBO found in up to 78% of IBS patients [25]. Many SIBO patients have IBS symptoms, including diarrhea, constipation, bloating, cramping, and abdominal pain. If we go back to the SIBO study, we see that for 65% of patients who followed an elemental diet for 14 days, IBS symptoms improved [7].

Once again, there’s a lot more observational data from clinicians here than research. So the evidence is promising but not solid. Since it’s a very safe treatment [2, 10, 26], patients can simply do a trial of the elemental diet and see if it works for them.

Inflammatory Bowel Disease

The bulk of research into elemental diets is focused on IBD. Studies have shown that elemental diets may be as effective as anti-inflammatory drugs like prednisone for achieving remission [18, 19, 21]. Elemental diets also help IBD patients to prevent relapses of gut inflammation and autoimmunity.

In some countries, such as Japan, elemental diets have become the first line of treatment because corticosteroid drugs have some troublesome side effects [27].

Celiac Disease

An elemental diet has been shown to help repair intestinal damage, reduce intestinal inflammation, and improve symptoms in those with celiac disease who did not respond fully to a gluten-free diet [8].

These symptom improvements may be due to the elemental diet’s anti-inflammatory and reparative effects. Or, perhaps the improvements were due to treating underlying SIBO, which is one reason that celiac patients don’t fully respond to a gluten-free diet.

Eosinophilic Esophagitis (EoE)

A small 2017 observational study found that a 4-week full-elemental diet reduced inflammatory cells and symptoms in 72% of 17 adults with EoE, an allergic condition of the esophagus closely linked to other autoimmunity [23]. 

As I covered in my prior discussion on food allergies, a 2014 meta-analysis looked at 33 observational studies with 1,128 children and 189 adults and found that elemental diets outperformed other dietary interventions and induced remission in 91% of patients [5]. An elemental diet is a great choice for those whose symptoms don’t completely respond to a standard elimination diet. 

Autoimmune Disease

One clinical trial has shown that an elemental diet was as effective as the anti-inflammatory steroid drug prednisolone for rheumatoid arthritis [18]. Otherwise, elemental diets as a treatment for autoimmunity have not been well-researched. But remember, your gut has a strong influence on your immune system, and thus, anything you do to improve your gut health may help with autoimmunity [28].

Bonus: Mood, Energy, and Mental Clarity

What about mood, fatigue, mental clarity, and weight loss with the elemental diet? While there’s little research looking at these directly, we take an evidence-based (not evidence-limited) approach and use the existing research to implement the elemental diet in a broader, more flexible, and more accessible way.

Research shows that elemental diets can be incredibly effective when it comes to reducing inflammation and healing the digestive system, and I consistently see in the clinic that many symptoms will lessen, sometimes dramatically, when you improve your gut health. The elemental diet is safe and easy to use, so there is no reason not to try it for conditions that have no existing research behind them on this diet.

Regardless of the reason you’re interested in trying an elemental diet, there are a few steps you can take to ensure you get the most bang for your buck. And it starts with finding the right formula.

Picking an Elemental Formula

There are a number of prescription and non-prescription elemental formulas. Some of the original elemental formulas, such as Vivonex Plus, have a reputation for tasting like glue and can be expensive. 

Wanting a better-tasting, cheaper option for my patients led me to develop Elemental Heal. Many patients in the clinic who have tried it report that it tastes great and effectively reduces or eliminates their symptoms. It comes in multiple flavors, including vanilla, chocolate, and peach, with whey-free and low-carb options.

Semi-Elemental Diet vs. Elemental Diet

There are two versions of the elemental diet, the full elemental diet, and the semi- or half-elemental diet. These formulas contain nutrients in their basic form, like short-chain triglycerides (fats) and electrolytes. While both contain all of the necessary nutrients to meet our nutritional needs, they differ in the varying degrees to which the proteins in the formula have been broken down: either fully into amino acids or partially into whey protein.

• Semi-elemental: These tend to taste better, making it easier to stick with long-term. This is due to the presence of partially hydrolyzed whey protein, which is still hypoallergenic, lactose-free, casein-free, and well-tolerated by most people [19].
• Full elemental: This whey-free option is best for those who are sensitive to whey and/or didn’t tolerate a semi-elemental formula. It is the most predigested version of an elemental diet, as proteins are broken down completely into amino acids. 
• Half elemental: Unlike the above versions, the half elemental diet doesn’t have to do with the formula itself, but the way it is consumed. This take on the elemental diet replaces 1-2 meals per day (about 50% of your calories) with an elemental shake. A healthy, whole-food diet is used for the remaining meals. This method is very safe and can be followed long as needed, from a few weeks to a year.

Note: If you’re interested in trying our Elemental Heal formulas, our original + low-carb versions are both considered semi-elemental diets. Our Elemental Heal Whey-Free is a full elemental diet. Any of our three formulas can be used in half elemental protocols, or for complete resets. 

Compared to full elemental formulas, semi-elemental formulas taste better and are easier to tolerate for longer, though research clearly shows that both versions are equally effective [1]. A comprehensive literature review found plenty of evidence that a wide range of patients have an easier time tolerating, digesting, and assimilating semi-elemental formulas with hydrolyzed whey protein than full elemental formulas [1]. 

The same study showed that semi-elemental diets are significantly cheaper than full-elemental ones [1]. For these reasons, I recommend starting with a semi-elemental formula first and only trying a full elemental formula if you tolerate whey poorly and/or do not get relief from your symptoms after a few weeks of use.

Rather than a strict 2-week fast, which, as the research shows, may not be necessary, I prefer the half-elemental approach. A 2006 RCT showed that even a “half” elemental diet can reduce gut symptoms and flares in people with Crohn’s disease [20]. 

There is a lot of variation and flexibility in a half-elemental approach:

• Replace 1–2 meals per day (or 80%) of calories with an elemental formula
• Use as a breakfast shake; consider combining with a high-quality oil like MCT
• Use as a post-workout shake
• Use as a total meal replacement during a 1–3 day “gut rest”, then transition into half elemental
• Use alongside an anti-inflammatory, whole-foods elimination diet

One randomized clinical trial involving patients with eosinophilic esophagitis found that 6 weeks of a combined elimination diet & elemental diet led to a better remission rate and improved quality of life compared to an elimination diet alone, which mirrors what I see in my practice [29].

We have whey-free and low-carb versions of Elemental Heal. These are the only whey-free (fully elemental) and low-carb elemental diet formulas available without a prescription. 

Tips for a Successful Elemental Diet

• Start with a semi-elemental formula. Consider a 1–3 day gut reset and/or a half elemental approach.
• Mix some healthy oils, such as MCT oil, with your elemental shakes. This provides energy and a feeling of fullness.
• Mix up enough formula for 3–4 hours at a time. Sip your shakes all day instead of taking “meals.”
• Cold shakes taste best. Use a blender to make the shakes nicely frothy. Add ice cubes to keep your drink cold while you sip it.
• Drink as much Elemental Heal as you like.
• Continue to take any prescription medicines. Supplements are optional.
• A little food, if you are hungry, is OK, but keep this to a minimum, unless you are doing a half-elemental approach.
• Caffeine is OK for most people, but omit the cream and sugar.
• If you plan to complete a 2–3 week therapeutic diet with a total meal replacement, make sure to do so under medical supervision.
• Plan to support your gut health once the diet is over. Probiotics, prokinetics (for some patients), and a low FODMAP diet can all be very supportive.
• Use caution if you have blood sugar issues. Elemental diets are high in simple carbohydrates and may cause blood sugar to spike.

Go Elemental for Better Health

Elemental diets are an effective therapy for a wide variety of gut imbalances. Anything from IBS, SIBO, and IBD to joint pain, fatigue, and PMS can benefit. This diet has a reputation for being challenging to follow, however, the newer, better-tasting formulas make it a lot easier.

Following a strict elemental diet for 2–3 weeks may not be necessary if you’re not struggling with a severe gut condition. Consider starting with a more moderate approach by using it as a total meal replacement for 1–3 days and/or using it to replace 1–2 meals per day, and see if it benefits you.

To become a patient with the Ruscio Institute for Functional Health, you can reach out to us directly. Otherwise, you can find more information on how to use this diet and other gut-healing therapeutics in my book  Healthy Gut, Healthy You.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.