I had the pleasure of speaking with Dr. Corey Shuler on all things Elemental Diet this month! Dr. Schuler has been using Integrative Therapeutics Physicians’ Elemental Diet (ED) in clinical practice as well as researching and training clinicians on the application. He’s the director of clinical affairs for Integrative Therapeutics. Corey is very well-versed on the science behind the ED. We had a terrific, clinical-pearl-packed conversation on using the ED for intestinal and extra-intestinal conditions, from IBD to eosinophilic esophagitis and SIBO to rheumatoid arthritis and weight loss resistance.
Dr. Corey Schuler is a man of many talents- an educator as well as a practitioner in integrative and functional medicine. In today’s podcast, Dr. Schuler will be wearing his nutritionist hat as we discuss individually designed elemental diets in this sponsored podcast. Some of the applications we cover will be well-known to practitioners and patients alike. Others don’t have precedent in clinical practice but listen to this expert as he walks you through the critical thinking he calls on to come up with new and novel ways to use elemental diets to heal a number of conditions.
- Elemental diets are made up of free form amino acids used in place of traditional protein-containing foods. The carb, fat, and micronutrient components are also hypoallergenic, allowing for maximum absorption and assimilation with minimal digestive effort.
- Short-term use of elemental diets has a long history of safe use so practitioners should feel confident in using them off-label, extending applications beyond Crohn’s and IBD to include SIBO.
Another potential application is in autoimmune diseases that integrative and functional doctors can trace back to GI dysfunction, such as rheumatoid arthritis and eosinophilic esophagitis. Very-long-term use, either partial or total, has also been used to treat morbid obesity.
- An elemental diet rests the gut, and one surprising outcome seen in some research is that there is often some new tolerance for antigenic foods after 2-4 weeks of treatment. But be prepared to deal with compliance issues if you’re going to ask your patient to use an elemental diet for more than a few days.
- Although the diet itself changes the microbial pattern, Dr. Schuler’s protocol involves transitioning from the elemental diet to some combination of antimicrobials, either as botanicals or as traditional antibiotics. Berberine is a favorite. Probiotics can be useful but foods, particularly FODMAP foods, can also be helpful in repopulating the gut with friendly bacteria.
Corey Schuler, RN, MS, LN, CNS, DC, FAAIM serves as the Director of Clinical Affairs for Integrative Therapeutics and is an adjunct assistant professor at the School of Health Sciences and Education at New York Chiropractic College. He practices integrative and functional medicine in the Greater Minneapolis-St. Paul, Minnesota area. He is a member of Institute for Functional Medicine and American College of Nutrition. Corey is a Certified Nutrition Specialist, registered nurse, licensed nutritionist, and earned a Master of Science degree in Human Nutrition and a degree in chiropractic medicine. He is a fellow of the American Association of Integrative Medicine.
Everything we do at 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, & your practice.
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Physicians’ Elemental Diet is intended for use under medical supervision for the dietary management of patients who have limited or impaired capacity to digest, absorb, or metabolize ordinary foods or certain nutrients. Physicians’ Elemental Diet is a strictly hypoallergenic formula with a well-tolerated flavor.
Kara Fitzgerald: Hi, everybody. I am excited to speak to Dr. Corey Schuler today. We’re going to be talking about all things relating to the elemental diet. He’s quite an expert and I think that you’ll find this conversation to be just really useful clinically. If you are a patient, I think that again, you’ll still find this information to be useful and valuable to you and, perhaps, something you want to introduce your doctor to.
A little background on Dr. Schuler. He is the director of clinical affairs for Integrative Therapeutics and is an adjunct assistant professor the School of Health Sciences and Education at New York Chiropractic College. He practices integrative and functional medicine in the greater Minneapolis-St. Paul, Minnesota area. He’s a member of the Institute for Functional Medicine and the American College of Nutrition. Corey is a certified nutrition specialist, a registered nurse, licensed nutritionist, and earned a master’s of science degree in human nutrition and a degree in chiropractic medicine. Corey has been going to school for quite a while. He’s a fellow at the American Association of Integrative Medicine. Corey, Dr. Schuler, welcome to New Frontiers in Functional Medicine.
Corey Schuler: Thanks for having me. I appreciate it.
Kara Fitzgerald: Yes. It’s actually really nice to talk to you again. You and I have worked in the past together. It was really fun and I’m sure this conversation will be no exception to that. All right. Let’s just jump in. Talk to me about what an elemental diet is.
Corey Schuler: Sure. An elemental diet isn’t new. I’m not hawking a new book and a new style of eating. Elemental diet has really been around for decades. The 1940s is really when it started and I’ll share a little bit more about that. It was used primarily in hospital-type situations. An elemental diet was or is food in its elemental forms, to be very honest. Instead of protein in like a protein shake that you might have every morning or whatever, there’s no protein in it, but there’s protein equivalent. All of the protein that you would get from an elemental diet comes in free form amino acids, as an example.
The fats, we don’t use long chain fatty acids or more difficult to digest fats. That’s usually relatively easy to digest, but even that, we make sure that it’s a medium chain triglyceride or an easy absorbable fat. Then same goes for picking out which carbohydrates to use for an elemental diet. It’s not these complicated, difficult to digest carbohydrates with a lot of fiber in it, but rather, the most easily assimilated carbohydrates that are typically proximally absorbed in the small intestine. Basically, it’s like a big shot of nutrition without requiring a lot of digestive energy to get those nutrients into the bloodstream and circulated.
Kara Fitzgerald: Yeah. Good. Okay. That’s wonderful. Nice description on it. Then talk about what we’re using it for. Do we use it to treat different conditions? Are we using it as a form of lifestyle medicine or something else?
Corey Schuler: Yeah. Essentially, you want to think of it as dietary management for a very specific moderate to severe dysfunction, typically GI dysfunction. In the literature, we’ve seen it used for inflammatory bowel disease like Crohn’s disease. We’ve seen it used in small intestinal bacterial overgrowth, which is a variant of irritable bowel syndrome. We’ve also seen it used for non-GI or that remote manifestations of GI dysfunction like rheumatoid arthritis. There’s a lot of good evidence in there, as well as other types of digestive issues like eosinophilic esophagitis, which you only have heard of if you had study it for medical boards or if you have it yourself, but otherwise, you typically don’t. What that is you have reactions to a lot of different foods and it’s a mast cell activation disorder. I thought it was a lot more rare, but then I started seeing it being diagnosed and we see it pop up again.
That’s what elemental diet has been studied for. It probably has more applications than that, but that’s what we really know it’s good for. You asked about if it’s a lifestyle, so I just was going to answer that. This isn’t the new version of paleo or it’s not the Mediterranean diet. It’s not something where you’re like, “Oh, I have one of those conditions you just mentioned. I’m going to be on the elemental diet forever because it’s going to make me feel good.” It’s not at all like that. It would be thought of more of like a procedure rather than a lifestyle. We see it used anywhere between one to three days in the short side of things, but up to like four weeks, maybe, at a time. It’s an entirely liquid diet. Think of it like more of a procedure for the dietary management of those conditions.
Kara Fitzgerald: Yeah, absolutely. It’s always medically supervised. We’re going to talk more about the mechanism of it or the mechanisms of it in a minute. I’ve also used it for, this EOE would fall into this, the eosinophilic esophagitis, but for my severely allergic patients and they’ve benefited from it. Now again, you’ve just given us the reasons why one might use it, but are people using it for weight loss or to attempt to achieve ketosis? I don’t know if you could because there’s plenty of carbohydrate in it, but I’m just wondering if anybody’s using it for these or I’m sure people are considering using it, I should say, for these off-label reasons. I just wanted to throw it out there and get your opinion on whether or not this is even remotely appropriate.
Corey Schuler: Yeah. I’m a simple guy, so I’m going to answer the easiest questions first. It’s typically not in alignment with ketogenic-style eating. I’m a big fan of using ketogenic diet as a great therapy for a growing number of reasons, but this contains carbohydrates and easily assimilated carbohydrates. If you were in ketosis, it would take you out of ketosis. It’s not designed at all for that. It’s not consistent with that, so to be clear, no.
However, the question is about calorie restriction, weight loss. I’ll just back up a little bit. This is really designed for people who are hypermetabolic. They’re not getting enough nutrition in. They’re not quite to the word cachexic, but they’re losing weight. They can’t maintain mass and so elemental diet is really designed for people to maintain that mass rather than to lose it.
However, with everything, and if we believe the second law of thermodynamics, we can probably figure out that if you wanted to manipulate calorie intake, you could do this. I have a couple of instances where we have used this over a period of a long, long time, either as a partial elemental diet or even a whole elemental diet to mediate those people who are morbidly obese. We’ve had people who have needed to lose well over a hundred pounds and this is something that they just have to change their track really significantly and so they need this pause, pivot, and shift. This elemental diet has been useful for that, but it really is not designed for that, especially with its higher glycemic content. There is carbohydrates in it.
Kara Fitzgerald: Right. Right, but you’re reducing the calories there considerably, so they’re probably burning through those carbs as energy rather than turning on insulin and making fat and so forth, I would imagine.
Corey Schuler: That’s the hope.
Kara Fitzgerald: Yeah. Boy, that’s interesting, so there might be a place for this. Has anything been published on that, Corey, or is this an off-label?
Corey Schuler: That is entirely off-label use. We just know that clinicians and I throw myself into that bucket. I was really hesitant to use it in that way, but then I had actually a couple people come to me specifically with that question, can I use this for that, like you’re doing. I always listen to that little voice in my head saying this isn’t a coincidence. Maybe I should supervise while we go ahead and try this. It just happened to work in those situations.
Kara Fitzgerald: Yeah, that’s interesting. I have a host of weight loss-resistant individuals and just jump starting with a few days of this could be something to consider. Okay. Thank you.
Corey Schuler: Yeah. With that, before we move on, I just want to say that if you’re in a weight loss program and you’re supervising someone doing a weight loss program, usually if you look at a label of an elemental diet, you’ll get a little bit of a sticker shock. There’s a fair amount of carbohydrates, so you just have to really think through all of what that means instead of having that gut reaction of oh, there’s carbohydrates in it. Oh, there’s simple carbohydrates in it. I can’t use it for weight loss. No, what you described is that it’s not necessarily stimulating that long-term insulin response because you have a calorie deficit. That’s the way we need to be thinking about it, but still, that’s not the intent.
Kara Fitzgerald: The other thing is yes, I get it. I get it. We can consider it, think it through, but no, this is not a paleo diet, right?
Corey Schuler: Right.
Kara Fitzgerald: All of the macronutrients are present.
Corey Schuler: Yes.
Kara Fitzgerald: Just going down this path a little bit further and then I want to just come back to talking about using it as it’s supposed to, but given that obesity has been associated with microbiome dysregulation pretty … I know we haven’t nailed down any conclusive patterns. There are suggestions. Giving this extent of almost a bowel rest, you’re certainly changing the microbial pattern, as well, and so I wonder if that’s a piece of its efficacy with regard to weight loss, if it’s helping to augment the microbiome in a pretty radical way.
Corey Schuler: It certainly could be. We’ve looked at a couple of different thoughts on that process, how certain antibiotics may be useful as adjunct treatments in weight loss. We’ve looked at things like major shifts in macronutrients can alter the microbiome considerably, so if we’re in that theoretical space of I don’t know, maybe, but when we have a person in front of us who’s suffering and we’ve tried everything else we know, then I think there’s options.
Kara Fitzgerald: Yes. That’s great. It’ll be fun to talk to you about this in a year because you’ll be gathering loads of data, not just in your practice, but I’m sure you’re going to hear from clinicians far and wide. We’ll certainly keep you apprised of what’s going on in our practice. Talk to me about the research behind using the elemental diet.
Corey Schuler: Yeah. The research isn’t done necessarily by one group. Sometimes we find it useful to follow a group and watch what they do with research because we can see how they’re thinking just by reading their abstracts, if you will. It’s been studied for now a number of years pretty well, but I want to just [inaudible] my introduction into the research is scattered. It’s scattered for a reason, because that’s the way it’s coming out. In I believe it was 2000, so I’m jumping right into the middle of the thick of elemental diet research, in 2000, Dr. Mark Pimentel out of Cedars-Sinai Hospital in LA found that if you could normalize microbiome through or normalize lactulose breath test, which is the breath test for small intestinal bacterial overgrowth, IBS symptoms would reduce and so irritable bowel symptoms affected essentially with antibiotics.
He took it a step further and four years later, published this really neat article about how he took consecutive IBS patients who had a positive lactulose breath test, so they’re positive for small intestinal bacterial overgrowth, and treated them with elemental diet. They were on 100% sole nutrition elemental diet for two weeks and then on day 15, would measure that lactulose breath test again. If they normalized, or basically were SIBO negative, then great. They won. They didn’t have to continue with the elemental diet and we would analyze their data later. If they were still positive with the lactulose breath test, he kept them on the elemental diet, all liquid, all elemental diet for another seven days and would analyze their data at the end.
Interestingly enough, he saw pretty substantial change in the lactulose breath test and he also saw as that lactulose breath test normalized, symptomology normalized in these IBS patients. That changed our direction or thought process about how to use this elemental diet. We’ll talk about mechanisms, how it works, why it works, why he went with that, and all that, but before I do that, I wanted to share just the other sporadic evidence, if that’s okay.
Kara Fitzgerald: Yeah, absolutely. Oh, actually, before you jump in there, Corey, can you send me either the papers or a link to the abstract and I’ll include what you mention on the transcript page, so people can access-
Corey Schuler: Yeah. I have a handful of abstracts I’ll be able to send your way. Okay?
Kara Fitzgerald: Perfect. Thank you.
Corey Schuler: A couple years later, a different group entirely looked at rheumatoid arthritis. Rheumatoid arthritis during exacerbations typically is given a steroid taper. Some people don’t tolerate that or they can’t handle the glycemic consequences of steroids or they’ve just been on it for too long and they haven’t cycled appropriately, whatever, they can’t use it. There’s a group in 2007 that published a paper, a pilot trial that looked at elemental diet for two weeks instead of the steroid medication during exacerbation. We saw improvement in rheumatoid arthritis symptoms, so less joint pain, I think less fatigue, as well as a side benefit of the increased nutritional dietary management using elemental diet, so really neat there because of the-
Kara Fitzgerald: Were they able to avoid the steroid taper? I’m assuming yes or the-
Corey Schuler: Yeah. I think there were already individuals that couldn’t do that, so they were allocated away from … Instead of giving prednisone for 15 milligrams a day, they were given … This is, again, it was a pilot trial, so it was just the early stages, but really exciting because RA is hard to deal with sometimes.
Kara Fitzgerald: Yeah. That’s right. That is a great study.
Corey Schuler: Yeah, so exciting about that. We also thought … This is now let’s jump in our DeLorean and go back in time. We’ll go back to 1984, where a group looked at acute Crohn’s disease. It used to be called regional enteritis. Crohn’s disease was the idea that there’s going to be this massive inflammation in the bowel, so that’s why it’s part of inflammatory bowel. They used, again, elemental diet for a long period of time. They used it up to 12 weeks. They showed that the elemental diet could improve Crohn’s disease as much or more than the steroid-treated group. This thing’s been around for a while and seen some neat stuff. I’ll for sure get you that one. That one’s actually free on PubMed, so you can read the entire study. That’s the O’Morain study that we often look at.
A few others, but mostly the one that I would like to show and I get really excited about this and if my nerd hasn’t shown yet, this is where it booms.
Kara Fitzgerald: Let the nerd emerge. Go ahead.
Corey Schuler: Yeah. I love things that we know work acutely and see how or if it can work longer term. That’s always the thought process. I already mentioned that the elemental diet’s not a lifestyle. You don’t live on this thing. It’s the procedure. However, what do you do if you are real sick and you end up in the hospital with your problem? That was actually addressed in 2006, or published in 2006, addressed much earlier. This group, a Japanese group, decided that you know what, Crohn’s disease patients, during exacerbation, often end up in the hospital. There’s bleeding and mucus in the stool. They have electrolyte imbalance. They lose a lot of water. We just can’t replete them, so they end up in a hospital on IVs. What do we do for those people?
The idea was that what if we could get them stabilized, let’s say in the hospital or at home? Once stabilized, could they be on like a half elemental diet or a partial elemental diet and do that and does that change those relapse rates? Does it reduce relapse rates or do they have the same number exacerbations? What this group did was they offered half elemental diet, so half of the individuals’ calories came from this liquid diet. Half of it came from foods that they would just choose on their own. Then the other group just ate as they would. They followed them for a long time. On average, they followed these patients for almost a year on doing this type of procedure. The relapse rate in the half elemental diet group was significantly lower than in the free diet group, which is just fantastic because that means reduction of hospital stays.
Kara Fitzgerald: Yeah, absolutely. That means a lot. I’m assuming if they got to choose whatever they wanted to eat, that they might be eating actually some problem foods for them in this era of carefully looking for either celiac or gluten sensitivity or dairy sensitivity etc., etc. If they were consuming any of those common antigenic foods, those common foods we pull people with IBD off of, plus using the elemental and that reduced their flares to that extent, that’s pretty remarkable. Do you follow me?
Corey Schuler: It is. What I would say and I think that the term that we all want to gravitate towards is we’re [inaudible] Because even the people that were on the half elemental diet, they could pick bad foods for themselves, too.
Kara Fitzgerald: I know. I get, yeah. That’s-
Corey Schuler: We’re reducing that antigenic load. The total load of problem things is reduced. That’s the cool part and that’s the term that I teach patients about because I always talk about food sensitivities and intolerances sort of like a bee sting. You have a little bit. It’s not the amount that you have. It’s the occurrence or the exposure, so you can’t cheat just a little bit. I don’t want you to reduce your dairy intake. I want you to eliminate it. I make a big deal of it. What I learned from reading this study is I’m probably a little bit wrong. I’m still going to tell that story because I want strict adherence to an elimination diet, but what I’m talking about long-term strategies reducing is better than just free diet, so that’s cool.
Kara Fitzgerald: Right. god, that’s so fascinating. It’s great study. I haven’t seen it, so I’d like to see that reference. I’m sure a lot of people will. I literally just a couple days ago popped a blog up on my website. It’s just a survey of different biomarkers to assess gut health. As I was doing it, I was talking about chronic inflammatory conditions that are associated with the gut and, of course, the ranges, neurodevelopmental, neurodegenerative, cardiometabolic, of course autoimmunity, allergic, etc., etc., etc., etc. It’s massive. It really encompasses almost all of the conditions we’re working with in functional medicine where we’re working with complex or chronic illnesses.
Thus, the trajectory our conversation is heading on, where we’re getting in there and reducing the antigenic load, as you say, and really manipulating what’s going on in the gut. The thinking with how the elemental could serve us is extremely far reaching. I’m sure, Corey that you’ve thought about the application given that so many illnesses are sourced to the gut or a significant pathogenic piece is sourced to the gut. Anything on that? Any thought on that?
Corey Schuler: Yeah. I think that the model used for rheumatoid arthritis is really that’s what’s interesting for me because if you talk to a conventionally trained rheumatologist, RA, it’s a joint condition. The immune system’s involved because it’s autoimmune condition. You talk to a functional medicine or integrative medicine practitioner and any immune system problem is a gut issue, so it’s so easy for us to make that leap, but sometimes it’s harder for others. Do I see the far-reaching effects and uses of this? Absolutely. I’m cautious because I never want to outrun my claims. I never want to say, “Oh, we can treat this and we can do this.” One of my professions does that routinely. I try to avoid that, so what I like to do is stick with the evidence, but then also, like I said, that person suffering in front of me who we’ve done already are things that we know how to do for, this is one thing to reach for, so I’m excited.
Kara Fitzgerald: Yup. You can do, as long as you’re paying attention and you control the duration and they’re safe to embark on this, it’s a therapeutic probe. It can be a safe, if used appropriately, a safe, therapeutic probe and you’re testing your hypotheses in a safe manner. I just think that’s really awesome, Corey. All right. Let’s talk about mechanism of action or mechanisms of action and just maybe talk about some standard of care interventions like in thinking about small intestinal bacterial overgrowth, using rifaximin and neomycin, etc. Let’s look at the mechanism for elemental and then expand it and do some comparison.
Corey Schuler: Sure. This is so cool. The reason that it’s so cool is because this is a fairly simple dietary management intervention, but the mechanisms aren’t exactly fully illustrated. The one mechanism that we’ve already brought up is to reduce total antigenic load. That just means that we’re using hypoallergenic ingredients in the elemental diet. Imagine when you talk about food sensitivities, usually we’re sensitive to protein, so even the protein in corn or the protein in soy and so this doesn’t have proteins in it. You have to go back to early biochemistry to know that there’s a quaternary structure of protein. These are very complicated. They fold in on themselves and they interact with themselves and other proteins.
Kara Fitzgerald: They look like steel wool, actually.
Corey Schuler: Yes, exactly. Imagine okay, great, let’s take that. Let’s take the steel wool and then let’s pull it all apart to its individual threads. Then let’s take a tiny, little wire cutter and crimp it every half a millimeter and every half millimeter, that’s your free form amino acid. Instead of swallowing steel wool, you’re swallowing that half millimeter of wire. Don’t swallow wire, anybody, but for the analogy, this works really well. That’s how broken down it is. The immune system is not reacting to that steel wool. It’s allowing that amino acid to be assimilated. The low antigenic load is a primary mechanism. The other thing is just allowing filling in nutritional gaps, so that’s where the dietary management piece comes in. A lot of these people are malnourished. Even if they’re overfed, they’re malnourished.
The third piece, and this is more specific to small intestinal bacterial overgrowth and the thought process that, I believe, that Dr. Pimentel went through was that if antibiotics can reduce the colony count of the commensal bacteria or the good guy bacteria that is supposed to be in the large intestine, but it’s in the small intestine instead, it’s translocated. It’s traveled north, if you will. I want to be able to reduce that load, so antibiotics we know have been effective for that. What if I just take the fuel source of those commensal bacteria and I eliminate or reduce it? What if I can get the human body that I’m working with to absorb those nutrients before those nutrients ever get to where those microbes are?
This idea of elemental diet, most of it is proximally absorbed or relatively proximally absorbed in the small intestine, whereas most small intestinal bacterial overgrowth is a distal colonization of these commensal bacteria within the small intestine. That was the thought process. What if I just reduce their feeding? If I reduce feeding of microbes, then number one, they’re going to go into a hypometabolic state. They’re going to be like bears hibernating. They don’t need to eat. They’re going to just reduce their activity. They’re going to reduce their metabolism. By reducing their metabolism, they reduce their output of maybe the things that we don’t want them to be producing. Then some of them will actually pass away because they can’t survive that hypometabolic state for a given duration. The colony count will go down because not everybody’s going to survive. We might have some left, but they’re already in this lowered state. I can reduce that count and that would then essentially be the reason that we would normalize the lactulose breath test.
Long story to get there, but that was the primary idea of using it in small intestinal bacterial overgrowth and that is contrary or just slightly different to the mechanism of how the standard of care is. You asked about that, so I’ll try to answer that the best I can. Right now, a lot of times, rifaximin, which is the luminol agent antibiotic is used to reduce those colony counts. Instead of doing all that, bringing it into a hypometabolic state, it just kills everything. It goes in a chute and breaks that down. Depending on if it’s diarrhea-dominant or constipation-dominant, they’ll use … Constipation-dominant usually is neomycin and diarrhea-dominant is usually erythromycin or low-dose erythromycin. That combination of antibiotics is antimicrobial specifically, so it doesn’t reduce the feeding. It just kills.
That requires the microbes to be active because if you put in those antimicrobials in when the microbes are in a lower hypometabolic state, they’re not going to uptake the antimicrobial stuff. They’re not going to take up those killing agents. It’s a different idea. You actually want to feed the bugs when you give antibiotics and you want to not feed the bugs when you’re on the elemental diet.
Actually, what we’ve learned or what we’re learning is that they can be a nice one-two punch. You can lower the hydrogen results. You can lower the methane results pretty significantly with elemental diet for a couple weeks and then start feeding it again. You can do this really strategically by using something like partially hydrolyzed guar gum or other high FODMAP food, so then you increase their activity really quickly. Then you hit them with the antibiotic dose, so the elemental diet and then antibiotics in combination can be really fantastic.
Kara Fitzgerald: Then how are you dosing the guar gum?
Corey Schuler: The guar gum, I think that the studies showed five grams of PHGG.
Kara Fitzgerald: Are you using the guar gum approach? I’ve tried it limited.
Corey Schuler: I don’t because I can use food instead, so we pick out strategic high FODMAP foods that are useful, that people tolerate. Now, the challenge with that is it’s not measured and some people overdo it and so we do run into a little bit of problems with that. I prefer food whenever I can, so that’s what we do.
Kara Fitzgerald: Yeah, that makes total sense. You could do a structured, so you could give them and just strongly encourage them to follow a FODMAP protocol where they’re actually measuring for a period of time. That makes sense. Then I’m assuming just knowing you and my approach would be going with botanical antimicrobials before I reach for Xifaxan, unless somebody’s really, really unwell. Any opinion on that? You’ve done your elemental. Now you’re giving them the FODMAP challenge and you’re going to go in with a kill agent. What are you using?
Corey Schuler: I can tell you what I’m using, but I can also tell you that everybody reacts differently. Some people react super well to the antibiotics. Some people react well to the elemental diet, don’t need further treatment. Some people do best with the antimicrobials. The nice thing about the conventional agents is there’s not that much to choose from. It’s like an algorithm. If they have constipation, it’s neomycin or rifaximin, but that’s not the case necessarily with the herbal antimicrobials. There’s a little bit of talk that suggests that the allicin from garlic is really the best approach for the methane-dominant or the constipation-dominant SIBO. Then we have all these other options like I use a lot of berberine. I’ll tell you, I’m a berberine guy. I love berberine. I’d take a bath in berberine if I could. I just love it.
Kara Fitzgerald: Nice yellow hue.
Corey Schuler: Yeah, yeah. I love alkaloids. Oh, my gosh. Berberine’s my friend. There’s two versions really of berberine. One is a variety of berberine-containing plants, so Oregon grape and goldenseal and philodendron. All these different plants that contain berberine and other stuff is one way I like doing it. You can also get berberine as an isolate. It seems like the SIBO community has gotten really aggressive about dosing berberine, so I’ve heard the recommendation of 5000 milligrams of berberine a day, but I don’t necessarily know any of my patients that would tolerate that dose. I usually recommend about 2000 and a mix of those herbs that contain berberine, so berberine’s probably going to play a role right after an elemental diet.
If I can, I’ll get into a little bit more, a little bit other herbs. I like neem, for example. That’s been a popular one in the SIBO community. I’m trying to think of other ones that I use independently.
Kara Fitzgerald: Oil of oregano’s been used and that’s an excellent-
Corey Schuler: Yeah, oil of oregano, actually, I find a lot of resistance to, unfortunately, because it’s super powerful and it’s really broad-based, really broad spectrum. I love it. The challenge is that people who’ve already been down this path a little bit, who’ve maybe used oil of oregano for a long, long time, don’t have the same response to it, just like you’d have antibiotic response or resistance to it. I’m a little bit sad about that, but I do like oil of oregano.
Kara Fitzgerald: Okay. In really refractory SIBO, basically, oil of oregano is probably not your friend, so in which case you’re looking at [inaudible], which I agree with you, I think it’s great, or allicin and berberine. You’re using a berberine concentrate plus the botanicals. This is fabulous. You guys, I’ll make sure I pull out some of these pearls Dr. Schuler is sharing with us so that you have ready access to them on the transcript page.
I’ll tell you what. It would be interesting. Obviously, the microbiome is changing considerably because the breath test changes, but has anybody done baseline and follow-up stool testing using elemental? Has that been done to your knowledge in [crosstalk 00:33:33]?
Corey Schuler: I don’t know if it has. The stool test is really testing the colonic colonies, not the small intestine colonies, so I think-
Kara Fitzgerald: But you would expect to see an influence, wouldn’t you? At least maybe a secondary influence.
Corey Schuler: Maybe.
Kara Fitzgerald: They are connected.
Corey Schuler: They’re certainly connected. They’re very, very connected, but …
Kara Fitzgerald: You’re radically altering the diet preferably.
Corey Schuler: Yeah. You’d think that their range, even if we give … There’s been studies that show small, tiny amounts of probiotics, 1 billion colony forming units, changes the microbiome and relevantly in the stool, so we do know that yes, there’s going to probably be significant changes there, but it might not be the changes that we expect. For example, in, at least, the study that I’m thinking of, the probiotic that was fed wasn’t the probiotic that we saw increases in colonies in the large intestine, but it does change the community based on those interactions. It’s really complex. I don’t know if it’s predictable, but I think you’re right. Yeah, I think you have to see some changes. I just haven’t seen the studies on it if there are any.
Kara Fitzgerald: Just anecdotally, I’ve used this particular elemental diet in ulcerative colitis and with great outcome, just short term nip some flares in the bud. This was on the descending. The descending colon was actually really the site of the most significant inflammation, so considerably downstream. It seemed to be useful in one person. I’ve used it, actually, multiple times, I think, with decent outcome, but in the one guy I’m thinking of off the top of my head just great, just really a go-to for nipping flares in the bud. Something’s happening and it would be fabulous to study it. I hope that you do. Talk to me about for practitioners who haven’t used an elemental diet, some things they should know going into it. Okay.
Corey Schuler: Okay. There are some things that you can do and keep in mind if you’re either supervising someone on elemental diet or if you’re using it yourself, just some things that we can pay attention to. For example, we’ve been talking about using antimicrobials. That’s a common question that I get, especially in the SIBO world. Do you use the antibiotics, the antimicrobials during elemental diet or do you wait? It’s a little bit mixed. I know that some people, they will mix it. I don’t mix it just because of some of the mechanisms that we’ve talked about, but I think that there’s rationale to do it the other way, too. My preference is to separate those out, so both antimicrobials and antibiotics I would put after the fact of elemental diet.
Probiotics in the use of there’s, again, split decision here. Some people say anytime you use antibiotics you should be giving a probiotic, so if the treatment is to use these antibiotics or antimicrobials, we should be giving probiotics, whereas others, especially in the SIBO community, say we should probably wait about three months to really just before we intervene and give more probiotics. We don’t necessarily know where they’re going to colonize, so that three month waiting period after a negative test is probably where we want to land. If there’s no SIBO, but they have Crohn’s or you said ulcerative colitis or we’re dealing with it from a different perspective, I think probiotics are game, along with or outside of elemental diet, but not necessarily they have to be.
Kara Fitzgerald: What if somebody has a particularly pronounced nutrient deficiency? Iron, I’m assuming if they’re anemic, obviously, you’d probably still be supporting with iron. Not probably, but anything else, like concurrent nutrients?
Corey Schuler: Concurrent nutrients or medications, I say if you need them to sustain your status, you stay on them. If you’re taking something, any kind of medications that you’re on and that includes natural medicines, if you need to be on them, otherwise you’re going to deteriorate your condition, then you should stay on them during the elemental diet because it’s just over and above the nutrients. There’s a little bit of a caveat to that. Sometimes nutrients are, especially some supplements are carried in things that aren’t the best for you and can I wouldn’t say interact, but they’re antigenic. If you’re trying to reduce the antigenic load, but you’re taking a supplement that might have some antigen properties to it, that defeats the purpose of having this low antigen diet. That’s one thing to pay attention to. Most of the time, practitioners are well aware. They’re very keen to those sorts of issues and so they can help you through that if that’s what’s going on.
Kara Fitzgerald: On that topic, what about somebody, and we see this all the time in practice, with proton pump inhibitor-induced SIBO. Are you going to work on tapering them off the PPI before you start or, I guess, actually getting them on the elemental and then maybe slowly tapering them off while they’re on the elemental? What are your thoughts around that?
Corey Schuler: You got me in a box here. There’s no good way around that one.
Kara Fitzgerald: I know.
Corey Schuler: That’s definitely where the art supersedes any sort of science. If you’ve already tried tapering off and moving from a proton pump inhibitor to an H2 antagonist, if you’ve already tried that and it hasn’t worked, then maybe elemental diet can be used. Anytime there’s a PPI involved, you are going to get poor absorption of certain nutrients, which I’m sure you’ve covered multiple times in various media, so I won’t belabor that. That will always be a challenge for individual.
The nice thing about this is that the gastric acid, the hydrochloric acid that’s produced is required to help unravel those proteins and quaternary structures and then it relies on activation of pancreatic enzymes. If you’re already clipping down into free form amino acids, those things don’t need that level of upper digestion, so kind of a neat way of going about it.
Kara Fitzgerald: It could actually be part of your whole … Yeah, I think we could actually use this for the folks who are struggling with tapering, but additionally, they all present with this small intestinal bacterial overgrowth, at least quite frequently, as well. Okay. Just really useful stuff here, Corey. It’s great. Talking about what happens after, so you’re using it to treat IBD, SIBO, some of the other applications we’ve been talking about. You already have, with regard to SIBO, talked about what happens next. You cited some research around Crohn’s disease, but if somebody’s been on the diet for long chunk of time, two to four weeks, what’s the transition process?
Corey Schuler: Food reintroduction is actually a fantastic topic and it’s one that hasn’t been really tackled appropriately. We’ve all had our noses down on how to fix SIBO and we’re managing SIBO, but we see a higher level of recurrence. There’s a Korean study, I believe, that looked at that specifically, about this really high recurrence rate. The challenge is how do you make that work. It’s a very individualized food reintroduction plan. I’ll share what I do just to give people a launching off point is when somebody comes in and we’re going to go down this path of using elemental diet, the first thing I have them to is make a list of their well-tolerated foods, foods that they know that they don’t have any reactions to. They list out their foods and they say good. We’re going to take that list. We’re going to put it in our back pocket and it’s going to come back out when we’re finishing up the elemental diet.
The next thing that we do is after the elemental diet is done, we dig it back out of our back pocket and we say okay. We’re going to use these well-tolerated foods only. Don’t introduce new foods, but you can move onto the half elemental diet, so you’re still getting the nutrients while we transition and add more things. The goal of food reintroduction is to broaden their dietary choices not just well beyond what they had well-tolerated before. I want them to be able to go back into society and eat regular foods and be social and all of that and not feel like they’re isolated.
Usually, we look at things that are high water content foods that are well-tolerated. Oftentimes, soups and broths, even clear liquids are going to be useful for that. The more water content and basically the more volume you consume, that’s going to help stimulate motility and that’s what we really need to do. We need to kick motility into gear again, so we’re moving things in the right direction. That’s the short answer. There’s not a great answer to this. Those of us who have been doing SIBO work for a long time have our ways of doing it, but that’s not widely applicable. What works for patients A almost never works for patient B. That’s a frustration that a lot of clinicians like myself experience.
Kara Fitzgerald: Now, let me just ask you about motility because I meant to ask you this earlier. Any interventions you’re using concurrently, this and diet for motility specifically?
Corey Schuler: Yeah. I split motility into two big sections. I say macromotility and that’s just are you pooping or do you have diarrhea? Are you constipated? Then the micromotility, which is harder to measure, but clinicians will know this term, migrating motor complexes. We need to stimulate that neurophysiologic response and migrating motor complexes are typically active when we’re not eating. When you eat food, you bite into a piece of food. That bolus of food makes its way from front to back in the gastrointestinal system and so that’s the macromotility. Then when you’re not eating, there’s also this neurophysiological wave, this housekeeping wave that keeps things going in the one direction.
We talk a lot in the SIBO community about prokinetic agents and there’s some really good ones out there. I like N-acetylcysteine. We talk about N-acetylcysteine for a variety of uses, but this is one that helps with that a lot. A prescription medication, low dose Naltrexone, which is often popular in autoimmune-type cases. There’s an essential oil called D-limonene that if you dose it high enough, typically about one gram, that can be useful as a prokinetic agent. Artichoke, ginger, and then 5-HTP, which if you’re not using SSRIs can be used as a prokinetic agent. Motility is the name of the game with SIBO. Not necessarily with Crohn’s, ulcerative colitis, or the others, but when it comes to SIBO, we got to keep that motion going from mouth to the other end.
Kara Fitzgerald: Yeah. Perfect. Okay. Just one other question in this area. I’ve used elemental very short term to clean the slate for somebody in a flare. I’ve used in my SIBO patients up to a week or so. I’ve not worked with anybody who’s been on it longer than one week, so the two to four week time period it seems like compliance would be an issue. I think I suppose thus far in my practice, a week seems to be sufficient to start the journey and begin to turn them around, but I do understand that that’s a shorter time, especially as compared to what’s been used in the research. Just talk to me about compliance with people doing this. I suppose the fact that they feel so much better helps to ensure compliance, but what are your thoughts?
Corey Schuler: Yeah. I’d actually relate that adherence issue more similarly to fasting, that there’s people that the first 48 hours, 72 hours of a fast. I use my clients who practice and they participate in Ramadan and the first few days of Ramadan are extremely difficult for them because they’re only eating within certain windows. That type of fasting you sort of get into a rhythm. You hit your stride and you realize what’s going on. That is sometimes reduced calorie intake. The thing about elemental diet is you shouldn’t necessarily be hungry. You aren’t lacking calories. You aren’t lacking nutrients, but what you are lacking is the environmental cues of food, like you’re not chewing anything. That has some pretty important physiologic consequences. You’re not smelling the food because it all smells exactly the same because it’s a formula mixed up in water. There’s some other things that you might need to use to stimulate that.
Those are some tips and tricks, so I recommend things like unless you’re allergic to be around flowers and plant life and even animals just to get more olfactory or smelling stimulation in your life. Also, the consideration of chewing, most gums are actually a terrible idea because they contain lots of crazy things, but if you can find a natural gum, that actually helps stimulate that mastication, that chewing reflex. That can help people get through this time period, as well. I don’t really worry as much about that. It’s getting them through that first couple days, which you’ve already done if you’re doing it for a week.
The challenge with doing it for a week is that you know how I talked about the mechanism of the hypometabolic commensal bacteria? If we’re not doing it long enough, not as many colonies will pass on. We won’t drop that colony count significantly, so just for numbers’ sake, oftentimes, rifaximin treatment will drop hydrogen counts by like 30 parts per million, whereas an elemental diet might drop hydrogen counts by 150 parts per million. We have a significant, powerful tool, but that’s over the course of two weeks. If you used it shorter, you’d probably just get less of a drop. That’s okay. Some people don’t need that much.
Kara Fitzgerald: Okay. All right. Good. Thanks. All right. Let’s just talk about the products. As you started this conversation, there are some products that have been used in the hospital setting and so forth. There’s the original product created by Cook in the 1940s. Just talk to me about quality. We need something of really impeccable quality now. I’m imagining Cook’s probably … I’d be curious what was in Cook’s, but anyway, what do you have to say about that?
Corey Schuler: Yeah. I misspoke. It’s Rose, Dr. W. C. Rose is Cook Rose, but Dr. Rose in the ’40s was the original mean person that created an elemental diet and he was feeding his graduate students. I’ll give you that historical consequence. He was at the University of Illinois and he combined corn starch, sucrose, butterfat, corn oil, some salts, and some known amino acids. Then he threw in some liver extract so that he could get some of the vitamins that he didn’t really know what was going on with and hadn’t been identified. Then because he was so nice, he flavored it with peppermint oil.
Kara Fitzgerald: Interesting. Wow.
Corey Schuler: Then he fed this to his grad students, which is like some form of torture. The taste was obviously a huge issue. Compliance didn’t exist, but if you were forced to do it, you were forced to do it. Another guy named Berle Crohn, and that name should sound familiar, who recognized Crohn’s disease, obviously, he helped reformulate that a little bit. Taste was never really an issue because a lot of times, this elemental diet, as I mentioned it being in hospitals, you weren’t tasting it. It was either given through nasal jejunal or it was through a tube or a PEG tube, which went right into the thorax, so taste wasn’t as big of an issue.
Then as we started using it for people like oh, no, we’re going to try to keep them out of the hospital, we had to give them an ambulatory formula they could taste and tolerate well. Then there was ones that we had to help with the taste after the fact that they left the hospital, so taste has become of interest, as well as the hypoallergenicity that has become more of an issue. Corn syrup and butterfat probably aren’t going to be what we want to use in today’s hypoallergenic society. We have to be careful about which nutrients there are.
Then we have to pick which macronutrient ratios we want. Usually, elemental diets have about 40 to 75% of a person’s … Excuse me. That’s terribly wrong. A protein content between about 14 and 18% of a person’s caloric needs, maybe up to 20 in some of these formulas. What I’ve done is I’ve looked at all the different formulas on the market and that’s pretty standard. What that does is if you consume 1800 calories, you’re getting anywhere between about 60 and 90 grams of protein equivalent in your elemental diet.
Kara Fitzgerald: That’s plenty.
Corey Schuler: It’s on the short side of things, but it’s pretty good. It’s a minimal amount. However, the carbohydrate and fat levels are all over the board depending on the formula used. There are fat levels as high as 43% of total calories and as low as 6%. Now, that 6% you don’t really want to use for very long at all unless that person just doesn’t tolerate fat at all, but you end up with a fat insufficiency pretty quickly using that type of formula. The fat range is dramatic and then the carbohydrate range is complementary to that. Usually, the carbohydrates are the last thought. We want to get the right amount of protein. We want to get the right amount of fat for the condition. Then we fill in the carbohydrate level with whatever is left.
Kara Fitzgerald: The other piece is that there’s all the essential nutrients being added, being supplied. What are the, generally speaking, in your observation, the quality of some of them?
Corey Schuler: Depends on your definition of quality. Most of them are made by large or at least emerging food or dietary supplement type of manufacturers and so quality from like a … There’s not microbial content or not heavy metal content. That’s usually all on the up and up. I won’t have any issues with any of the products on the market for that. What I do have a concern with is the choice of certain ingredients, like where are they getting that from or not necessarily what’s the original source, but have they evaluated if they use corn in there, is there corn proteins in my elemental diet at the end? That would bother me. If it’s free from corn, free from wheat or gluten, free from soy, I want to make sure at the end of the day those are not in the formula anymore, if they ever were. That’s where the quality makes a difference.
It’s interesting because all of the micronutrients that we have to have in perfect balance in elemental diets because we don’t want to overdose or underdose anybody because we’re using this exclusively for two to four weeks, those each have their individual sources, as well, and so there can be carriers and challenges with those that have some antigen potential. From that quality perspective, I think you have to be ultra-careful and really know your manufacturer pretty well in order to have confidence that you’re getting the right thing.
Kara Fitzgerald: Right. Right. Yeah, I have just been really thrilled to have access to this particular elemental diet in my practice. Actually, what you’ve offered today, Dr. Schuler, has been helpful to me and I’m sure it’s going to be helpful to anybody who’s listening to this and either is using elemental diets. I think you’ve given a lot of pearls to just make our application much more robust for bringing people off and how to do that and some of the medications or some of the botanicals, etc. Just really soup to nuts here you’ve put forward a lot of great ideas and I just want to thank you so much for joining me. Everybody listening to the podcast, again, head over to the transcript page where we will have contact information for Dr. Schuler. We’ll have links. We’ll have all of the abstracts to the research he’s mentioned. You’ll have all of these wonderful pearls at your fingertips. Thanks, Corey. Thanks for joining me today.
Corey Schuler: Thank you. Take care.
Kara Fitzgerald: All right. Bye-bye.