The elemental diet is one of the most effective therapies for improving gut health. This simple liquid diet can be used for SIBO, IBS and joint pain amongst others. Lets cover a few question today regarding the elemental diet and methylation and digestive motility.
Dr. Michael Ruscio, DC: Hi, everyone. This is Dr. Ruscio. Let’s discuss some questions regarding the elemental diet. If you haven’t heard of the elemental diet, the elemental diet is essentially a very gut-friendly, meal replacement shake that has been shown, at least in one study, to be highly effective for small intestinal bacterial overgrowth and, in a number of other studies, to be able to reduce inflammation and autoimmunity in the gut as we see in inflammatory bowel disease. And there’s certainly a wealth of anecdotal reports that show that the elemental diet can be a very powerful healing tool for those, especially who have been non-responsive to other therapies.
If the Elemental Heal is to be sipped on slowly throughout the day, similar to the way an IV drip would be slowly administered, how would a person allow for meal spacing so the Migrating Motor Complex can do its job?
This question is suggesting that the “Migrating Motor Complex” is more important or the only important mechanism in healing SIBO. This is a false assumption.
Elemental Diet has been shown to be one of the most effective treatments
It is best to make decisions based upon outcome data, not mechanism
Improved GI immunity
Potentially improved motility (inference drawn from fact that low FODMAP diet improves serotonin cells density in the small intestine).
Don’t think small, look to outcome data and not mechanism data
Curious as to why you used folic acid instead of folate acid?
DrMR: And essentially, how the elemental diet is used is very similar to how some people are doing these juice cleanses or liquid cleanses where you essentially subsist on nothing but these meal replacement shakes for anywhere from a couple days to a couple weeks. Now, the couple weeks is reserved for more severe cases. But in many cases, just a few days as a reset and then a partial utilization of these may be as a meal replacement for breakfast on most days going forward can be very helpful for some recalcitrant cases that have been otherwise non-responsive to other therapies.
And thankfully, they have been shown to be very safe. And we have gone through a very extensive review of the safety literature and found no negative long-term effects; in fact, even some positive long-term benefits.
But let’s cover a few questions regarding elemental diets. More specifically, we released a formula known as Elemental Heal. And there were a couple questions about the formula and the application. And some of these questions, I think, are very important. They’re a little bit more advanced. But I wanted to take a moment to speak to these because, if nothing else, some of these questions actually illustrate an error in thinking that if we can get to this foundational piece of thinking about things in the wrong way, then we can prevent ourselves from thinking our way out of treatments that could potentially help us.
And this is actually quite a serious problem where there’s this quote by Mark Twain, which is, “Don’t let your schooling get in the way of your education.” And what I see more often than I’d like to admit is patients who’ve done a little bit of research on the internet, which is great. But they then know enough to doubt recommendations by reputable sources. And unfortunately, they talk themselves out of treatments that could otherwise help them because they have a little bit of information, enough to be dangerous, as it’s also said.
Listener Question 1
So let’s look at a few questions here. Angela says,
“If the Elemental Heal is to be sipped on slowly throughout the day similar to the way an I.V. drip would be slowly administered,” (which is true), “how would a person allow for meal spacing so that the migratory motor complex can do its job? The cleaning waves of the migratory motor complex clean house in the small intestines during a period of fasting without food or calories which is critically important in the management of SIBO.”
Okay. So this question is problematic because the question is framed in such a way where this person is making a false assumption. And that false assumption is that the predominant piece that’s important for successful management of SIBO revolves around the migratory motor complex.
Is the migratory motor complex—which is essentially these cleaning waves of contraction that help clean debris out of the intestinal tract—is that the only factor that leads to success with IBS and with SIBO? No! In fact, I would be very suspicious that if we had clear data to answer this question, which we don’t. But if we did, that it’s only the minority of cases where this is actually something that’s problematic. So the question is fundamentally flawed.
Now, let me outline this a little bit further. What are the problems? The problem here is that we have the outcome data showing that the elemental diet clearly leads to somewhat remarkable improvement in many cases of SIBO and in IBS and also in inflammatory bowel disease. So we have the outcome data. We should be looking at the outcomes and not inferring from mechanisms.
And I actually talked about this in Healthy Gut, Healthy You. And I’ll see if I can put a screenshot of this section up here. But there’s an entire chapter dedicated to how to evaluate health claims. And one of the points I make is don’t think small. Don’t think about a mechanism and then try to infer from that mechanism what the treatment should be.
Here’s how this plays out. You have two people: two people with SIBO, with IBS, and with digestive symptoms. Now, one reads this—that the migratory motor complex is very important. And you need not eat so as to allow the migratory motor complex to clean house in the intestines. And so, when confronted with the option of going on the elemental diet, she declines. And therefore, she doesn’t feel any better.
Person 2 does not get wrapped into this thinking. And they continue to think big. And they say, “Well, this in a clinical trial has been shown to be a very effective treatment. So irrespective of what some of this mechanistic information suggests, I’m going to go forward and go on the elemental diet.” And they end up feeling much better.
So the key point here is we don’t want to take a mechanistic tidbit of academic information and allow that to thwart us from doing something that could help us, especially when we have the outcome data to guide our decision making. So don’t think small about a mechanism. Think big in terms of what the outcome data shows. It’s an incredibly key point.
And I wouldn’t be overly concerned about the why because you need to know the what before you know the why. And what I oftentimes see people doing is floundering in the why. And they’re missing the mark on the what. So in this case, the what is the elemental diet. The why is less relevant.
And this is really unfortunate that I have to do this. But we can go tit for tat with mechanisms. So the mechanism of migratory motor complex, could that be a negative? Probably not. Doesn’t really matter. But what could be happening? What are some of the positive whys? Well, we know that the elemental diet can reduce inflammation; can starve and lead to a resolution of small intestinal bacterial overgrowth; and speculatively, due to its low prebiotic content, may actually help resurrect and restore some of the serotonin cells in the intestine to more normal levels.
But as a patient, you shouldn’t get wrapped up in this level of thinking because it’s very easy to get mislead if you’re looking at these bits and bites of mechanisms. How can you know if what you’re thinking about doing will help you? You can look at what happens when a group of people undergo the intervention and see what the outcome in those people has been.
We know with the elemental diet the outcomes there are fantastic. So focus on the what, the outcome data. Don’t get overly wrapped into the why.
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Okay, so hopefully, that is helpful. Again, if you want to understand that in more detail, I outline that in the book. One of the lessons is don’t think small. Don’t think about mechanism. Think about outcome. This is a key point because I’ve seen so many times people get wrapped up in the mechanism. And then they talk themselves out of things that could help them because they think that mechanism is the most important thing. And then only later do they find out that their thinking was erroneous. And they finally undergo the therapy that was able to help them because they were able to get to the what and not get overly wrapped up in the why.
Listener Question 2
So continuing along this same vein, Robbie asks,
“Curious as to why you used folic acid instead of folate. I have the MTHFR gene, and I’ve been told to stay away from folic acid because it blocks the methylation pathway. Dr. Ben Lynch recommends staying away from it. Any chance, you’ll discontinue folic acid in your elemental drink?”
So again, this is someone who is talking a why. And they’re potentially thwarting their ability to try a successful treatment because they’re not looking at the what. The what outcome is that for people, even with MTHFR presumably, because we have large data sets in various populations showing the elemental diet can be helpful—some of those people likely have MTHFR and still have a positive outcome.
Remember that one of the best ways to optimize methylation—and many methylation experts agree on this—is by fixing your gut. So if the elemental diet helps you fix your gut, that trumps the fact that an elemental diet formula may have folic acid in it, which I believe virtually every elemental formula with the exception of maybe one contains folic acid. So I think it’s a moot point.
But again, to try to get into some of this why even though we shouldn’t—we should be focusing on the outcome. I’ll put up here on the screen for you a study that essentially found a group of patients, a large group of patients in Asia who had MTHFR and were given folic acid—yes, folic acid, which is supposed to be poisonous—actually saw I believe it was a 30% reduction in stroke.
Okay, so I think there are many inferences that are being drawn from gene data that have not been borne out yet. So I would not get overly pulled into that world. Here is one example that illustrates that people with MTHFR actually benefited from folic acid supplementation. Could you criticize some of the finer points of this study? Potentially. But I think it illustrates a very powerful point which is the utility of gene testing is really not there yet clinically. We are still very early in our understanding. And I think there’s much that we don’t yet fully understand.
Now, let me outline that further yet still because I don’t want to come off as a contrarian. I’m open to anything that has been shown to be helpful. But the gene testing doesn’t seem to have been shown to be helpful yet. Rather, there are mechanisms that we can infer if we facilitate a certain mechanism may help someone. But you have to qualify that in an outcome study with humans. You have to qualify that that mechanism, when facilitated or downregulated or upregulated or whatever, actually will produce a health outcome in the people that undergo that intervention.
So we’ve already shown a large study Trusted SourcePubMedGo to source in an Asian population who were administered folic acid and had MTHFR (so they shouldn’t be taking folic acid) actually had a reduction in stroke. But let’s look at other evidence that supports this.
The DIETFITS Study Trusted SourcePubMedGo to source by Christopher Gardner over at Stanford. His study essentially found that genotype was unable to predict who would respond to a diet in any beneficial way. Meaning patients went through these gene tests. The gene tests suggested this diet. And the gene-guided diet had no impact on outcomes for weight.
Further yet still, another study Trusted SourcePubMedGo to source has shown in an ApoE cohort that may be at high risk for cardiovascular involvement that a gene-guided diet had no benefit compared to a normal control diet for improving cardiovascular risk markers.
So I understand that if you don’t feel well and someone tells you about this mechanism of MTHFR slowing down your detoxification and needing folate to help with that, I understand it’s attractive.
But right now, I don’t think that the data is there supporting these approaches. Now, I’ll be very happy to change my mind when we can show some positive outcome. But for right now, for methylation, I think the best thing you can do is optimize the health of your gut.
Dr. Kara Fitzgerald describes this, I think, very eloquently as addressing methylation upstream. So now you get to the upstream source of a toxic burden in your body, the gut. And by alleviating that, you alleviate all these detox pathways that may not be running optimally, perchance that could be MTHFR, by addressing the upstream source of the problem.
So if you have MTHFR, I have zero concern with you using Elemental Heal due to the folic acid content.
Listener Question 3
And then finally, B.L. asks,
“Does the elemental diet work to reduce hydrogen sulfide SIBO?”
Again, there are some potentially faulty presumptions built into this question. How do you know you have hydrogen sulfide SIBO? This is not available outside of the research setting, testing for the hydrogen sulfide SIBO, that is. There is a urine test that may speculatively tell you that you have hydrogen sulfide SIBO. But it is in no way, shape, or form validated. So this is likely a presumed hydrogen sulfide SIBO.
Why is it presumed? It’s probably presumed because this person tested negative for SIBO via the breath test but has symptoms. So what you’re actually asking is, “Can the elemental diet help for digestive symptoms in someone who is negative for SIBO?” And the answer there is, “Absolutely, yes.”
Now, is it guaranteed? No. No treatment is 100% guaranteed. There’s always a subset of people that may not respond well to any therapy. But the elemental diet tends to be very helpful for digestive involvement as a general rule.
So again, I don’t mean to be overly critical or nitpicky. But it’s important to understand when we are getting too granular and mechanistic in our thinking. Natural and alternative medicine claims to be holistic. So you would think the way that we look at these things would be holistic. But instead, there’s a tendency to look at things in these very reductionistic frameworks.
“I can’t use the elemental diet because it contains folic acid, and I have MTHFR.”
“I can’t use the elemental diet because you’ll be sipping that throughout the day and never be fasted. And therefore, you won’t be able to have a migratory motor complex facilitation.”
Those are very reductionistic ways of looking at your healthcare and the human body. So it’s important to zoom out and look at what the outcome data shows. What happens in people in clinical trials undergoing these interventions? And the good news is, a lot of benefit is vectored by the elemental diet.
It doesn’t mean it’s going to work for everyone. It doesn’t mean that for some people there may not be a negative reaction. But I want to try to zoom us out and get people away from thinking in these very reduced, very mechanistic frameworks because I see routinely patients who, again, have talked themselves out of undergoing certain therapies that have been shown to be helpful because they read something about a mechanism that may be associated with that treatment that may not be good. Yet they’re missing the fact that there’s this outcome data showing that, “When a person like you does this treatment, there’s a general tendency to see global improvement in how they’re feeling.”
So don’t overlook the simple outcome data at the expense of the convoluted mechanisms because that can mislead you. And ultimately, it will be a disservice to you. Or if you’re a clinician thinking this way, it will be a disservice to your patient.
And again, regarding all this, I remain open as the body of evidence and literature evolves. But for right now, I want to try to prevent people from getting pulled into speculation, especially with gene testing. I don’t think we’re there yet. And I want to prevent people from thinking that, for whatever reason due to meal frequency, an elemental diet may not be a health-promoting treatment.
If you wanted to learn more about the elemental diet, there’s a whole section about this in my book Healthy Gut, Healthy You that details the different formulas that can be used, how they can be used, the safety data, troubleshooting. And so I’d highly recommend checking out the book.
Remember, don’t think small. Even though sometimes these mechanisms seem alluring, they can often mislead you. So keep your thinking big picture. And truly this can help you get healthy and get back to your life.
This is Dr. Ruscio. I hope this has helped you. If you have any questions or comments, please let me know. Thank you.
I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!
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