Tons of Questions. Lots of answers. Mostly (according to Dr. Corey Schuler) you’re getting the answers here, first! Lots of “fist fights” among clinician experts on what to do: to use or not to use antimicrobials (pharmaceuticals or botanicals) with the ED; adding probiotics: good practice or totally contraindicated? What’s the correct transition protocol? What’s the correct diet after transitioning off of ED? Diet? How to transition of the ED? Alternative ways to prep the ED to avoid “flavor fatigue”? Concurrent treatments. Addressing biofilm. Addressing SIFO (small intestinal fungal overgrowth) while on ED. What breath test does Dr. Schuler use?
Elemental Diets have a long therapeutic use history for myriad GI issues. EDs allow the gut to take a break from the hard work of digestion, offering the GI tract a chance for renewal and repair. They have been shown to help with a variety of conditions, including SIBO, IBS, non-specific intestinal inflammation, and autoimmunity, including IBD (among others). In this podcast, the director of clinical affairs for Integrative Therapeutics, Dr. Corey Schuler, answers some of the most frequently asked questions about using the Elemental Diet with patients, from how to use it while simultaneously treating other conditions (like fungal overgrowth or severe vitamin D deficiency) to creative ways to help patients stick to a challenging eating protocol. If you missed Dr. Fitzgerald’s first conversation with Dr. Schuler about the basics of using ED, you can listen to that podcast here. For even more clinical pearls about ED, check out their conversation below.
In this podcast you’ll hear:
- The benefits of passive digestion
- Integrative Therapeutics use of top-tier ingredients
- The possibility of using ED in kids
- The possibility of using ED in gastric tubes
- Off-label uses for Integrative Therapeutics’ Elemental Diet
- Considerations for continuing other interventions while on ED
- How to use ED in combination with other interventions to treat SIFO
- The best supplement for biofilm busting
- Considerations for using ED when histamine issues are present
- Best practices for putting patients on partial ED, including the use of intermittent fasting
- How to transition off ED
- The pros and cons of labwork
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, and is a member of Institute for Functional Medicine and American College of Nutrition. Dr. Schuler 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.
Contact Dr. Corey Schuler via Metabolic Maintenance website or his Facebook page.
Notes:
New Frontiers Podcast Episode 26: Elemental Diet in Clinical Practice
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Physicians’ Elemental Diet was created to meet the needs of patients, as well as the unique requirements of integrative medicine specialists. It is designed to maintain nutritional sustenance as a sole source of nutrition for up to four weeks under medical supervision.
Dr. Kara Fitzgerald: Hi, everybody, welcome to New Frontiers in Functional Medicine, where we are interviewing the best minds in functional medicine. And today is no exception. I am delighted to have Doctor Corey Schuler back again. He’s spoken to us previously on the Elemental Diet. Integrative Therapeutics has a wonderful product we’re using in our practice all of the time for various indications. And we’ll absolutely in the show notes, link to Dr. Corey Schuler’s original presentation, so you can start there, and then this is further down the road of the elemental diet.
But before we jump in with Dr. Schuler, let me just give you his background. He’s got a lot of initials after his name. He’s a smart guy. You’ll see that as soon as we start talking.
Incidentally, the show notes from the first conversation he and I had are laden with references. He sent me over a whole host of references for the why behind the Elemental Diet and the various indications and what the research suggests, et cetera, et cetera, so, be sure to access those.
Dr. Schuler serves as the Director of Clinical Affairs for Integrative Therapeutics and is 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’s a member of the Institute for Functional Medicine and the American College of Nutrition. Corey is a certified nutrition specialist, a registered nurse, a licensed nutritionist, and earned a Master of Science degree in Human Nutrition and a degree in chiropractic medicine.
Are you done yet, Dr. Schuler, or are you still in school?
Dr. Corey Schuler: Do I have to answer that? Or can I plead the fifth?
Dr. Kara Fitzgerald: Okay, that’s enough. That says it all. He’s a fellow of the American Association of Integrative Medicine, as well. You can reach him at his website: MetabolicTreatmentCenter.com, or you can find him on Facebook. All of this information and any literature he talks about today will be in these show notes. Welcome to New Frontiers, Corey.
Dr. Corey Schuler: Thanks for having me, Kara. This is always fun.
Dr. Kara Fitzgerald: Yes, it is. It’s always great to connect with you. Corey and I go back quite a ways, and he’s one of the brainiacs in our field who I so, so, so appreciate because he does his due diligence in drilling down into the science behind anything he’s talking about. And he’s a funny guy, as we were talking about. No pressure, though, on being funny, during this conversation.
Dr. Corey Schuler: Great. I’m going to jump the shark, here, on this podcast, right here, so –
Dr. Kara Fitzgerald: Right, right, right. So you can come up with a joke, and we’ll add it in the show notes later.
Dr. Corey Schuler: Okay.
Dr. Kara Fitzgerald: So further down the Elemental Diet road. You’ve had loads and loads of questions since you launched the product. When did IT launch the Elemental Formula?
Dr. Corey Schuler: It was June of 2016, so not more than a year, but not two, yet.
Dr. Kara Fitzgerald: It’s amazing. God, it’s amazing. And I know that it’s been wildly successful, correct?
Dr. Corey Schuler: Yeah, it’s been one of the fastest growing products that Integrative has ever launched. People gravitated towards it, wanted to use it, and found not just the evidence based approaches, but unique and interesting ways to use this product as well. So-
Dr. Kara Fitzgerald: Yup, absolutely.
Dr. Corey Schuler: That’s probably part of its growth.
Dr. Kara Fitzgerald: I know. You and I covered the standard indications for use on our original podcast, and then some of the off-the-quote, off-label indications, we chatted about as well.
We’re using it in allergic disease. Actually, there is some research out there on Eosinophilic Esophagitis. I think you were the one who brought that up. But, anyway, go back there, so, folks, if you haven’t heard my first conversation with Corey.
But we’re going to talk this time about some of the questions. There’s loads and loads of questions. There is a bit of a learning curve to introducing the Elemental Diet into practice. And so, I’m going to just jump right in, and just ping you, Corey, with some of the bigger questions folks have. And then anything you want to add, questions that you’ve encountered as you consult on the product, or as you’re lecturing, just, please, by all means, jump in.
So, kids? Can we prescribe the Elemental Diet for children?
Dr. Corey Schuler: Sure, yeah, that’s a great place to start. And let me back up just a little bit to explain where I’m coming from. I don’t make up my data, right? So, and you know that, but not everybody probably listening knows that. This isn’t all my experience. Part of what I do for my job is, and I guess the best way to describe, part of my job is to be a medical science liaison to clinicians.
So when you have a question, or somebody on your team has a question, and maybe they don’t find the answers in the literature, or they’re wanting to know a nuance of something, like that ends up being my job. I’ve been very fortunate, to be honest, and very grateful for the opportunity to be able to meet the thought leaders in our profession, whatever profession we’re calling it for right now.
The people like us, the people that have been doing this work for a long time, and who are new and rising, I get to chat with them all the time, and ask them what they’re doing, what they like, what they don’t like. And I just was in Portland, which is, there’s a lot of naturopathic medicine going on there.
Dr. Kara Fitzgerald: Well, and it’s really, it’s kind of invented itself with Sandberg-Lewis, and Allison Siebecker, as sort of the hub of current SIBO.
Dr. Corey Schuler: Right, right, and so, yeah, so, there’s a lot of outgrowth there, and so I sat down with a group of, I think it was 16 or 18 of us, and we just sat around. We had dinner, and we just gunned questions at each other. Some of them were gunned at me, which is fine. But some of them were just in general, how are we using it? What do we like? What do we not like? It was great. So some of this, that I’m sharing today, comes from that. Some of it comes from my new product development experience with Integrative, and some of it is my own experience, with my own patients. So I just wanted to clear the air about where stuff is coming from.
Dr. Kara Fitzgerald: Oh, that’s just perfect. Yeah, we’re hearing it first here, or sort of first-second first.
Dr. Corey Schuler: Yeah, most –
Dr. Kara Fitzgerald: We’re the firsts of the second people.
Dr. Corey Schuler: I would say the mostly first information, because they just –
Dr. Kara Fitzgerald: Mostly first, woo-hoo. Listen, before we jump in, I know I just asked you about kids using the formulation, and then you gave me the back story, but just, for people who are not familiar with the Elemental Diet, the Elemental formula, just give me a thumbnail sketch of what it is, and then we’ll jump into the questions.
Dr. Corey Schuler: Yeah, so Elemental Diet is a powder, that’s reconstituted in water, and consumed over, as either sole nutrition, that’s the exclusive nutrition that somebody gets. It’s an oral formula versus a tube fed-formula, which a lot of enteral formulas are suggested for use, because it tastes good. It’s hypo-allergenic, and seems to be well tolerated in that regard. And so that’s what it is.
Elemental Diet, just generically, is elements of macro-nutrients are broken down into their tiniest components. So instead of massive fats, there’s fatty acids. Instead of proteins, this is the most important part, it’s not even peptides or polypeptides, it’s broken all the way down to free form amino acids. And then carbohydrates, we have exclusively small and easily absorbable carbohydrate forms in there. So that’s the thumbnail of it.
Dr. Kara Fitzgerald: Those are the macros, plus you’ve got the micros, the vitamins and minerals.
Dr. Corey Schuler: Correct, everything that you would need to sustain oneself without adding other things.
Dr. Kara Fitzgerald: And everything, it’s all broken down, so passive digestion. You don’t need to, it’s easily digested, and extremely hypo-allergenic.
Dr. Corey Schuler: Yes.
Dr. Kara Fitzgerald: And the primary indications for it?
Dr. Corey Schuler: So the primary indications for it are, and you kind of alluded to it already, is small intestinal bacterial overgrowth. That’s actually where it was born from. We said we were using this Elemental Diet, but we just needed a better version of it. And so, Integrative Therapeutics said we’ll take on that project, and let’s make a best version of it.
But also, Elemental Diet’s been studied for the last 20-30 years, in things like Crohn’s Disease, Eosinophilic Esophagitis you mentioned, and a few other of these moderate to severe gastrointestinal impairment type of conditions.
Dr. Kara Fitzgerald: I just want to say that when you say “best version” of it, it’s because you’re using really top-quality materials, and I want to underscore that. You’re not using oxidized folic acid; you’re using natural folates. I think you’ve just turned the quality bar. You’ve raised the quality bar high with your product, and that’s appreciated by me and my team, for sure.
Dr. Corey Schuler: And I appreciate your comment on it, because every ingredient, everything that went into it was looked at ten different ways, to say, is this the right thing? Are we doing the right things for the patient who’s going to be consuming this? Are we making any errors? And in some ways, we had to sort of create our own supply chain for it, because we didn’t have what we needed, already in the market. To be honest, it’d be super easy for somebody to throw together a terrible elemental diet.
You could buy some of these materials in a dirtier form, if you will, and just throw it together and hope for the best. But that’s not the approach that was taken at all.
Dr. Kara Fitzgerald: Right, no, it’s apparent from just looking at the label, that it’s just beautiful. It’s just really high-quality product. And so, I just threw the first question out there. Oh, wait, before I jump into, let’s just wait again. Let’s hold it.
Dr. Corey Schuler: Wait, hurry up. Wait.
Dr. Kara Fitzgerald: The duration one can stay on an Elemental Diet, duration?
Dr. Corey Schuler: Sure, there’s, so the longest studies were on average, about 12 months on a partial Elemental Diet, or what’s referred to as a half Elemental Diet. So that was in Crohn’s Disease, where people would be on partial Elemental Diet and partial foods that they tolerated, and on average, it was 11.9 months.
But, for exclusive nutrition, I think the majority of the studies are two weeks. So, 14 days … There’s a few places in the literature that Elemental Diet shows up as 3 weeks, 4 weeks, and 12 weeks. And so we know it’s well tolerated into that 12-week mark, at least from a pure physiologic perspective. You can imagine, right? It’s a liquid diet. This is very isolating, socially isolating, potentially. So there’s other consequences that come along with an all-liquid diet when you’re in an ambulatory state. You’re not in a hospital, but you’re trying to eat all your meals through a straw, or through a blender container. There’s other challenges. But from a physiologic perspective that seems to be good, because all the nutrients are there and none in excess.
Dr. Kara Fitzgerald: Okay, perfect. All right, now let’s talk about kids. Can they use the formulation?
Dr. Corey Schuler: Yeah, so the reason this question comes up, and I get asked it … You know what? I bet I get asked it 10 times a week. So, I’ll just answer it here, so that it’s mostly first.
Dr. Kara Fitzgerald: Yeah, it’s mostly first. We’re mostly first. I’m going to put that in the title.
Dr. Corey Schuler: Is that because there’s a big label that says on the physician’s Elemental Diet, do not use in children. And so that’s, not only does that scare our clinician colleagues off, but it scares off the parents of said children.
And that makes sense and that warning is real because since Elemental Diet is used as sole nutrition or exclusive nutrition, this formula was not designed for the developmental needs of children. It just was not. That wasn’t in mind at all when it was created. There’s other formulas that are designed for that. This one is not. And so the concern, and the reason that that warning label really exists, is because we do not want that used exclusively.
Now, if we have a practitioner who’s well versed in pediatric needs, can take into account the history and the growth trajectory of a child, and who wants to use it as a partial element diet, I think that that’s their choice and their decision. They still have to jump through our, jump over our big label that says “Do not use.” But if they’re willing to do that, I think that there’s some rational uses of it. But, anyway, that’s the longer story of why it says that on the label.
Dr. Kara Fitzgerald: Perfect, okay, so then you’re talking to tons of clinicians in your role of Director of Clinical Affairs over at IT, and doing consultations and so forth. So, people are doing it, I’m absolutely sure that there are some clinicians out there prescribing – very short term – for kids. It makes sense to me, that in the short term, it would be okay. I could see using it in my practice, maybe for just a couple of days, or a handful, just certainly not long term. But just to clean things up, and maybe, just acutely quench inflammation. I’m going to assume that some of the indications being used to off-label for peds include … the usual?
Dr. Corey Schuler: Yeah, this is just a time for bowel rest. And so, more appropriately, probably, and I’ve chatted with some, especially naturopathic doctors who are working a lot with kids and families, young families, that say: Let’s just skip a meal, or two, and use it in place of that, so that they’re using foods that they already tolerate. But some of these children who are, let’s talk about, they have FPIES, or these allergenic conditions, where they’re eating less and less tolerable foods. They’re just not, they’re running into these problems, they just need to supplement because their child is either not growing or not gaining weight or whatever. And so, let’s just replace one or two meals, and see if we can do that. And then let’s make sure that they’re getting the other nutrients they need from foods, which is obviously best.
Dr. Kara Fitzgerald: Yup, got it. So, okay, good. I think that’s intelligent, to use it as a partial. So, can you use this in a nasogastric tube?
Dr. Corey Schuler: This is a great question. It actually kind of fits sort of the same answer as I just said. It’s about design, okay? So when you’re talking about, and I’m, as a nurse, I’m an Aspen nurse. I do parenteral and enteral nutrition. I love sticking food in people through tubes. And so, the one thing that I like about this, is that it probably could be, but in order to sort of qualify for that, we really have to do, almost like physics studies: How is this soluble? How does it break down? How does it flow? What’s the viscosity of it? And as a brand-new product to the market, those studies haven’t been done. And if we find that maybe it’s not right, and not good for, depending on the bore of the tube, or how wide that tube is, then you have to change things a little bit.
So that goes into a whole other level of detail that Integrative has not done yet, primarily because most of our customers are naturopathic doctors, integrative medical physicians, who are working in ambulatory medicine. And they’re not using it in nasogastric, or nasojejunal type situations. So that wasn’t a priority for us. But we’re getting so many questions on it. It seems like we maybe should know those answers. But it’s just too early in its maturity as a product to do all that when it really isn’t designed for that.
Now, I’m going to answer the real question behind the question, and that is, if you do this kind of work, and you know how to modify things, I don’t see a reason why you couldn’t do it. But it’s just not our, we can’t support it, or encourage it.
Dr. Kara Fitzgerald: Yup, okay, perfect. So, how are you recommending, or how are clinicians using the various antimicrobial protocols that they’re enacting during their time on, during one’s time on an elemental? So, I actually have a handful of questions I’m going to throw out.
Can we continue to use antibiotics? Can we use our botanical formulations? So if we’re treating SIBO, can we continue with the antimicrobial protocol with SIBO, for instance? Or if you also have your patient on a host of additional nutrients, you’ve identified a vitamin D deficiency, or magnesium, or whatever, and you want to continue with the various supplemental interventions, can you do that?
Just talk about those two and then I’ll ping you with some more questions along that line.
Dr. Corey Schuler: Yeah, I think that this question is probably the best way to get integrative medical people into a fistfight.
This is nuts, because it’s based entirely on theory. Our research, not just integrative research, research in general, you’re talking about layering of interventions, and that’s a very sophisticated thing to do. To know what’s better, you have to know in that individual and do cross over trials, but then, are they partially healed or not? And so, this is extremely complicated, and not an easy answer. But I will tell you theories. So here’s the theories, and then I’ll tell you what I actually hear about what’s going on.
There’s one theory, and I’ll name her by name: Mona Morstein is a big deal for us. She’s a very important naturopathic physician, especially in terms of diabetes, and now SIBO. She talks about this a lot, and she finds that in recalcitrant cases of small intestinal bacterial overgrowth. Again, this is her gut clinician feel, which we have to go by sometimes, that if it’s bad, we’ll have to use both at the same time, Elemental Diet and antibiotics, and we’re not talking antimicrobials. I think she’s using standard antibiotics like Rifaximin and Neomycin together. And I don’t want to speak for her, but I know that she’s going after it, and saying that starving and killing at the same time is probably not a bad idea.
So that’s her opinion. She feels like that gets good results in recalcitrant or difficult cases of SIBO. We have others that say, you know what? If you’re starving the bugs already, if you’re starving the microbes that are in the small intestine in high amounts, and really shouldn’t be there, and you’re not feeding them because you’re giving the person Elemental Diet, then what you are effectively doing is you’re putting the bugs in a hypo-metabolic or a resting state. And during that resting state, they’re not as likely, or don’t do it as well, uptake the active constituents or the antibiotics, or the antimicrobial, or whatever, and so that is just sort of a big waste. That’s the other theory that has been proposed.
Now, the reality is, there’s probably truth somewhere in the middle, in that we can probably do both. In reality, what we’re doing in our office, is we are, people are transitioning from an antimicrobial product, a natural combination product, and then they’re starting on a partial Elemental Diet. So it’s not completely starved, they’re still getting the antimicrobials. When they do move on to a full and exclusive Elemental Diet, they’ll discontinue the antimicrobial.
However, if their symptoms aren’t reducing after three, four, five days, because you should start seeing some reduction in symptomatology as early as that three to five-day mark, then we’ll reintroduce them. So, it gets really fuzzy and blurry, but I think that’s really where the truth lies, somewhere in the middle.
Dr. Kara Fitzgerald: Right, I got it. So, okay, so she’s using pharmaceutical interventions, concurrent with the Elemental, and that’s where she’s getting good outcome in very recalcitrant cases. And I know Dr. Morstein, and she’s a smart cookie, undoubtedly. She’s just paying close attention to what she’s seeing.
You guys are using botanical antimicrobials. You start them there, and then you move them over to the elemental slowly. So you have Elemental meal replacement, and then you move them on to a full Elemental, and then you stop the botanical antimicrobials during that portion, correct? Unless symptoms warrant, then you reintroduce? Did I hear you right?
Dr. Corey Schuler: Yup, you nailed it.
Dr. Kara Fitzgerald: Okay.
Dr. Corey Schuler: And you asked further questions, and there’s more to go. There’s more strings to pull on in that question. And the one is: what about the other things? What if you have somebody who’s got a vitamin D level of eight, and they’re going into Elemental Diet?
What I recommend, and this is more of a principle, is if somebody needs a medication or a nutrient, they’re going to need it regardless if they’re on Elemental Diet or not. They should remain on that thing. Same with, if they’re on an antidepressant or if they’re on psychotropic medication, or whatever it is.
I had a client here, maybe two weeks ago, that was on Omega-three fatty acids. And she was taking four grams a day. And she couldn’t, every time she went lower than that, her mood was affected pretty dramatically. And so, we just said, stay on that dose, stay on that dose. We’ll account for it in calories when we figure out the dosing procedure for Elemental Diet, but just stay on that. That seems like a necessary thing for you.
Dr. Kara Fitzgerald: Mm-hmm (affirmative). Good, okay, so it’s pretty logical. But how about tolerating? Now, if you’re using some sort of an essential oil combination, oil of oregano, or really, even some of the combination botanicals, or medication … these can be really irritating. Four grams of fish oil isn’t going to be tolerated by everybody. So, when you’re on an Elemental Diet, you don’t have any substance to really blunt the absorption or the tolerance of these interventions. What do you say about that?
Dr. Corey Schuler: That’s entirely true, and you will see major changes in what people do and do not tolerate during this time. Gary Weiner, who’s another naturopathic doctor, happens to be in Portland as well, describes it best as sort of saying, you become sort of the most essence of yourself. And I think I probably misquoted that a little bit, but essentially that’s what you have these, you’re an irritable person, you might get more irritable. And so that goes not just for the physiologic, but it goes for more of the psychologic as well. If you have, maybe a little bit of intolerance to your medication, like, oh yeah, I have sort of a bad gut ache after I take my medication or that nutrient, it may be a little bit worse because of, yeah, there’s just that bolus of food, it’s all liquid, so it’s just going right in.
Dr. Kara Fitzgerald: Okay, and it’s just a case by case basis. And we’ll do the best we can. And maybe change the dosing structure, et cetera. Yeah –
Dr. Corey Schuler: Right.
Dr. Kara Fitzgerald: Okay, that makes sense. Now, one of the things I’ve observed in my practice, is that the subset of individuals who never seem to get symptomatic relief, because symptomatic relief, in my experience, actually, happens pretty quickly once you jump on to the Elemental Diet. I know you had said, I think, three to five days, was your ? And I would say that I’ve seen it, sometimes I’ll negotiate with my patients what they’ll be impeccably adherent with. Some folks will give me two days on it, and I’ll take that. And we generally see a favorable trend when I start the Elemental Diet with them. Might not be full recovery, but we can tell we’re dialed in, we’re in the right direction.
But, sometimes that’s not the case. Even when we have a good week-long trial, symptoms never abate. And I’ve used that as a suggestion of fungal overgrowth or SIFO. What do you think about that? What do you think about fungal overgrowth with Elemental Diet? We know there are some simple carbs in it. So, if somebody’s got Candida, as fueling the flame of SIBO symptomatology, is the Elemental Diet going to worsen that? What are your thoughts? What are you hearing on the street?
Dr. Corey Schuler: Yeah, so, on the street logo, or lingo, and in our own practice, we use antifungal with absolutely everybody on Elemental Diet. We just use it. The reason, we don’t wait the week to see if somebody’s getting better. It’s really difficult to distinguish between small intestinal fungal overgrowth and small intestinal bacterial overgrowth, and so, as far as testing and even that’s, there’s just not great testing for that. So if we know that they’re a SIBO and we’re treating it with Elemental Diet, we’re probably just going ahead and treating as if. We tend to use natural products for that –
Dr. Kara Fitzgerald: What are you –
Dr. Corey Schuler: … natural combinations …
Dr. Kara Fitzgerald: Don’t even give me that vague answer. Just tell me what you’re doing. What product are you using, or product are you using?
Dr. Corey Schuler: Yeah, it’s best to say I use Integrative Therapeutics products that are designed for that.
Dr. Kara Fitzgerald: Okay, okay, fair enough. No, you can’t tell me which ones that you favor?
Dr. Corey Schuler: I can’t right now, sorry.
Dr. Kara Fitzgerald: Okay, okay.
Dr. Corey Schuler: But, I will tell you that there’s two that I go to, and one acts essentially, or feels similar to a Nystatin type of medication. That’s sort of how I use it. Nystatin is a well-known, easily predictable antifungal medication. And then a more robust antifungal medication, might be something like Diflucan. And there is a more powerful version for a natural product in Integrative line-up that sort of matches those sorts of things better.
Dr. Kara Fitzgerald: Got it. Got it. And it’s about, the bottle’s about four inches tall … and it’s white.
Dr. Corey Schuler: You got me in a box here. What am I going to do?
Dr. Kara Fitzgerald: Okay, so you’re starting people on a protocol for antifungals out-the-gate, as soon as you initiate the Elemental Diet, correct?
Dr. Corey Schuler: Yeah, the reality was if we turned back the clock, and jump in our DeLorean, or whatever … If we look at the 2004 study with Pimentel’s group, they did it for two weeks. And if they didn’t see results, they did it for a third week. So, some of those people were symptomatic for the full two weeks. And so, that research study wasn’t as complicated as your clinical practice. So maybe those people had fungal overgrowths, but they still had to do Elemental Diet for yet another week. I think it’s just good practice, good medicine, to address antifungal, or fungal colony counts, and reduce those to a better balance, while doing Elemental Diet.
Dr. Kara Fitzgerald: Okay, sounds good. Let me see.
Dr. Corey Schuler: Do you want to hear a better fist-fight story? The better fist-fight story, it has to do more about, and again, we’re talking about SIBO, primarily here. It’s not necessarily the only way to do it, but the question about when do you reintroduce probiotics?
You have every answer in every spectrum of this. So for the non-clinicians who are listening to this, I would say listen to your doctor. But your doctor might be wrong. Because this is really a negotiation between you, your clinician, and your GI.
Dr. Kara Fitzgerald: Absolutely.
Dr. Corey Schuler: And not your gastroenterologist, your actual gastrointestinal system.
Dr. Kara Fitzgerald: Absolutely, absolutely.
Dr. Corey Schuler: So, do what works for you is the right answer. But people get kind of freaked out. People get really anxious about, “Well, I heard you’re not supposed to use probiotics during Elemental Diet. But my doctor gave it to me, so I don’t know what to do.” And they’re reading and listening and asking, basically unqualified individuals who have had some experience, but maybe not enough to help make that call. What I’m asking globally here, is for people to kind of relax and know that this is a process, and there’s not an exact science about when to introduce or not introduce or discontinue probiotics, and if so, which type, et cetera.
So that’s a long answer, but it’s a tangent that I think is designed to help people use their minds.
Dr. Kara Fitzgerald: Yup, yup, I get it. I think that that’s really, has been the theme so far, of this conversation, where careful, clinical observation, and safe hypothesis forming, and trialing is where it’s at. So some people are going to tolerate a probiotic and it’s extremely helpful as far as establishing a little bit of colonization resistance. And maybe allowing the good bugs to proliferate, and then for others, it’s a deal breaker. It’s an immediate deal breaker.
And so it’s not one, it would be so much easier if there were just one organism that was at the heart of every small intestinal microbial overgrowth. But the fact of the matter is, it’s just not. It’s not that. And therefore, there’s variation in the appropriate approach.
Dr. Corey Schuler: Right. We have the ability to freak people out, as far as clinicians who are maybe, they know they have patients with SIBO or Crohn’s, and they want to help them. And Elemental Diet keeps coming up in their searches and in their conversations with their colleagues. And so we’ve just made it really complicated. We’ve taken it to the Nth degree as to how complicated it can be.
This does still require medical supervision, but the reality is, is that most of the time, at least in the clinical research, they just put the people on the Elemental Diet, based on their caloric need, and gave it to them for two weeks. And said, if you have questions, comments, or concerns, give us a call and we’ll talk to you or talk you through it. But they didn’t do all these nits and nats. They didn’t add in extra stuff. They didn’t change the dilution factor, and all that sort of stuff. So, I want people to hear that it can be easy. It can get complicated in a hurry. But we shouldn’t be scared about using that tool.
Dr. Kara Fitzgerald: Yeah, absolutely, thanks. That’s a great point. Go back to the research. Keep it super, super simple. Chances are you’re going to help your patient.
Yeah, and then, by the same token, the flip side to that coin, is that there are some incredibly complex protocols. I do see some of my colleagues starting people on many, many, many, many different interventions, and it’s exhaustive. A lot of SIBO, in my experience, is still pretty responsive to old school interventions, including the Elemental as a standalone.
I wanted to bring up biofilm, and just get your take on that. Speaking of very complex protocols, in addressing biofilm. Are you thinking about that in your practice, and using some of the so-called biofilm busters out there?
Dr. Corey Schuler: So, we do, but not maybe in the way that a lot of people do. The ingredient, the single ingredient that seems to have the most evidence for it, and I know there’s more complicated approaches to it. But N-acetylcysteine, just plain old NAC, which I love and adore and use oftentimes for a lot of different indications, is something that we add into a potential recalcitrant case.
So if somebody’s having trouble, maybe they already done an Elemental Diet, or they haven’t gotten the progress that they wanted, I’ll add in, N-acetylcysteine to almost bowel tolerance, which can be anywhere between, I don’t know, one point eight grams a day, and it can go up to maybe like five grams or so, of NAC. That’s a lot, by the way. Just, that’s not a starting dose. But we’ve titrated people up to that. And bowel tolerance, by the way, is when you start having that hydrogen sulfite type flatulence. If you’re farting rotten eggs, then you’ve probably taken too much.
So, there is NAC in Elemental Diet, so it’s still kind of rare. But to really work with biofilms, I think you need to be more aggressive. And as you well know, there’s things out there that probably work better than NAC, but aren’t maybe as time tested.
Dr. Kara Fitzgerald: Right, no, I think NAC is a great, super affordable, generally really well-tolerated intervention. And it is potently mucolitic. And so it stands to reason that it would be a nice biofilm buster.
All right, what else do we have? Histamine? So histamine, we can see in certain cases of SIBO that diamine oxidase is probably not being produced in adequate quantity. And there’s a whole new group of foods people can be reactive to if histamines kick in, or if the bugs producing histamine and they’re consuming histamine foods, or around, actually, I should say the bugs inhibiting histamine metabolism are around. Anyway, histamine, what are you thinking about?
Dr. Corey Schuler: I’m thinking about histamine all the time, because just like there’s an overlap between SIFO and SIBO, there’s overlap between mast cell activation syndrome and SIBO. And sometimes they’re diagnosed with one but have both, and so it gets complicated relatively quickly. And I rely on smarter people than me to help me through this. I know Heidi Turner is a dietician that she works a lot with this. Dr. Elena Guggenheim is another one that I’m a big fan of, that works a lot with this kind of work, in sort of more rheumatologic conditions. And of course the research on Eosinophilic Esophagitis suggests that there’s some mass cell stabilization benefit to Elemental Diet.
The challenge, and if you read the label really closely, of an Elemental Diet, to be complete, it contains the amino acid, histidine. And histidine gets converted in a pretty simple step to histamine. So some people get nervous about using Elemental Diet in histamine situations, but I would pause on that and say, don’t get too nervous too quickly because we’re really dealing more with mast cell degranulation and the endogenous production.
You’re making a lot more histamine, even when you’re not reacting to things, than you would be by ingesting a little bit of histidine. So, it is a pause for some people, but I don’t think it’s a necessary pause, when in fact there’s human clinical research to show the contrary in clinical use, to show the contrary.
Dr. Kara Fitzgerald: Well, [histidine,] it’s an essential amino acid. You wouldn’t be able to sustain an Elemental Diet without it. You’d start to break down muscle, et cetera, to liberate histidine elsewhere. You can’t make an intact successful Elemental Diet and skip histidine.
Dr. Corey Schuler: That’s the rub. That’s the difficulty in making products like this, but anyway, it’s a reality and clinicians pick up on it. And our patients are smart, and they can read, and they can read on various different sources. So, that’s where this topic comes up. The reality is, if someone has a known histamine issue, I’m typically trying to do some mast cell stabilization in advance anyway. I’ve probably been doing that for a while, or they’ve been doing that on their own, for a while. So, it’s fine to continue on, just like the principle, right? If you need something, stay with it during this process.
Dr. Kara Fitzgerald: Well, and you’re pulling them, you’ve put them on the ultimate hypoallergenic enteric formula. So you’re removing, from them, by and large, the myriad exposure sources that were triggering production of histamine. So you’re going a long way by putting them on the diet.
Dr. Corey Schuler: Totally.
Dr. Kara Fitzgerald: Yeah, okay, I got it. So no histidine is, should not be, the amount of histidine present in the Elemental really shouldn’t be an issue for concern. And just increased, yeah, increased production of histamine via histidine, is far less of an issue than coming from the underlying cause of the increased histamine. And you’re going to be reducing that considerably by using the Elemental Diet. It’s very helpful. It’s very helpful in folks with allergic disease, and other histamine associated intolerances.
There are clear instructions on how to mix the Elemental Diet, and we based it on caloric need. Would you change that dilution rate, or would you change how you’re mixing it for any reason, such as one develops constipation or diarrhea?
Dr. Corey Schuler: Yeah, absolutely. So the range of dilution, and explains that for every scoop of this Elemental Diet you’re going to add anywhere between four and eight ounces of water. And so that’s a pretty big range, to be honest.
We have done osmolality testing. So that’s just sort of how much solute is available per unit of water. That is, the osmolality is perfect. And so the dilution is perfect, in our opinion, at about the six-ounce mark. But, because clinicians have different needs, and patients have different needs, we opened up that range to say four ounces to eight ounces. Now when you make it more concentrated, you also change the taste of it. The more concentrated it is, the sweeter it’ll feel and be. You’ll change the way it feels in the mouth. So, there’s a different mouth feel with that lower dilution rate.
And then you’ll also have … the opposite effect happens at the higher dilution rate, at eight ounces per scoop, where you have, it’s not very sweet. Maybe if someone’s coming off a ketogenic diet, and moving on to Elemental Diet, that’s a smarter way to go, because there’s definitely a neurologic response when your body has that sweet taste. So, those are two places of that.
But you mentioned about the macro-motility. If you’re constipated or diarrhea … we’ve run into cases where people have hyper-diluted the product, and they have loose stool. And essentially, what’s happening is that, that is not concentrated enough to absorb the nutrients.
You mentioned it earlier. This is passive absorption. It has to be concentrated enough in the lumen of the gastrointestinal tract, to actually, using osmosis, push the nutrients into the bloodstream. And if that’s not there, it’s going to run right through you. And so, essentially that’s what’s happening, is people can have loose stools that’s really just didn’t interact with the inside of the person.
Dr. Kara Fitzgerald: Wow, isn’t that interesting? So you’re losing all your nutrient content there?
Dr. Corey Schuler: Yeah, it’s just dropping right through. And then the more concentrated is usually the issue that we deal with more medically, because if you have too high of osmolality, or if it’s too concentrated, then you can deal with cramping. And so if there’s GI cramping, then that’s something that you’re probably on the high side of that.
With that range of four ounces to eight ounces, you can deviate from that, depending on how the doctor wants to do it. Sometimes you maybe want, maybe it’s easier to do something that’s less sweet in the morning, and maybe kind of more sweet through the rest of the day. But if we keep in mind that six ounces per scoop is right, it’s sort of the ideal, that’s a better thing to do rather than just doing everything at four, or everything at eight.
Dr. Kara Fitzgerald: Okay, okay, and then if bowel habits change in either direction, flag that you need to adjust the formula and you’re not absorbing appropriately, which will compromise, obviously, the integrity of the diet.
Dr. Corey Schuler: Yeah, maybe, yellow flag … If you lean more towards less frequent stool, or less frequent bowel movements, I’m not as worried about it. But having robust diarrhea, that’s, we’re losing electrolytes. We’re losing nutrients that we can’t really afford to lose. So, I’m most concerned about that.
But the reality is, that in a hospital situation when somebody has, if they’re using an enteral formula, and they get diarrhea, we move them to an Elemental Diet. Elemental Diet is sort of like the fix for loose stools. And so you shouldn’t be having that. But if you’re not having bowel movements or regular bowel movements, this is the one time where I’m kind of okay with that. So just absorbing everything, there’s nothing really, to come out. So no fiber, so, it makes sense.
Dr. Kara Fitzgerald: Yeah, yeah, and that’s what we see in our practice as well. So how do we avoid flavor fatigue?
Dr. Corey Schuler: Oh, there’s a bunch of fun stuff to do. I recommend that people sort of harness their inner creative person to do this. I think some of the great ways to consume Elemental Diet and not be so sick of consuming the same liquid diet over and over again for days on end, or weeks on end, is to start playing around with things like carbonated water. We had a patient who had one of those machines called a Soda Stream, and so it was like a carbonator.
Dr. Kara Fitzgerald: Yes, mm-hmm (affirmative).
Dr. Corey Schuler: And they carbonated their Elemental Diet. They loved La Croix Water. And so they’re like, “Well, can I have La Croix Water?” Yeah, you can have La Croix Water. So they started to add La Croix Water into the Elemental Diet, and that seemed to go fine. But they really loved it when they used their Soda Stream machine to bubble it up. That’s fine to do. Some people will say, “You know what? I don’t mind the taste of it, or the feel of it in my mouth, but I just can’t smell it anymore.” And so, sometimes a straw is useful for that. Make sure that the cover is on, so you just don’t have to smell the same thing. It doesn’t smell bad. I don’t want to give that impression, but it’s just the same thing over and over again. It’s like if you ate your favorite food every meal, four to six times a day for two weeks. You just don’t want to do it anymore.
So flavor fatigue is a very real thing. There aren’t other flavors right now for Elemental Diet that we’re producing. So this is it. And with that said, you kind of have to be creative about it.
Dr. Kara Fitzgerald: Okay, I like that idea using the Soda Stream. That’s really cool. That’s clever. Clever patient … straw, yup, makes sense. I guess you could make little Elemental cubes, frozen cubes.
Dr. Corey Schuler: Yeah, so ice is one way that people get around that. The key here, though, is to make sure that you actually mix it up. And then add in ice chips. Ice chips seems to be the best. Or, some places have those little, those small, tiny cubes of ice. That seems to be the most popular, to kind of change the texture of it. That seems to, that works really well. But you don’t want to put the ice in and then try to mix it, because it gets weird fast.
Dr. Kara Fitzgerald: Yup, okay, got it. All right, let me see. If you’re using half Elemental, how do you structure that out with meals?
Dr. Corey Schuler: Okay, yeah, so, I’m an intermittent fasting fan when it’s reasonable and makes some sense. And so, this isn’t totally fasting, because there’s calories and the body does … but it’s way less work. It is bowel rest. And you can really harness the idea of intermittent fasting by taking the foods that you eat, the foods that you chew, and keeping them in a window, just like you would with intermittent fasting. And then the rest of the time, or your fasting time, you would be able to either fast or have Elemental Diet.
So I like to kind of cram them, cram those foods together, but some interesting questions have come up about this. What if I’m in the transition between Elemental Diet and food I chew, or whole foods … How long do I have to wait? And there’s no science to this. This is all just shooting from the hip, ideas that clinicians have had.
The reality is that you want to be able to digest the Elemental Diet before throwing in some whole proteins into the mix because it makes good sense. That’s the design of it. So, usually if you wait an hour or so, prior, after an Elemental Diet, and then we recommend maybe two hours after a whole food meal, to consume Elemental Diet, because it just takes longer. Two hours, I think, some patients who have maybe slow gastric emptying, maybe sometimes like four hours to really get that stuff, get that bolus of food moving.
So, anyway, two hours, though, is the general rule of thumb after a whole food meal to start Elemental Diet again.
Dr. Kara Fitzgerald: Okay, got it. And people, I would imagine, are pinged on how they feel, right? They can kind of tell if food’s still moving through. They know if they’ve got slow digestion. And they’re going to be able to just kind of clue in to how they’re feeling?
Dr. Corey Schuler: Most people do. Some people don’t. And this is a whole different conversation for a different day, probably more private than public. But the idea of it is macro-motility, your bowel habits versus micro-motility. Some people have a bowel movement every single day under normal circumstances, but their micro-motility is bad. And that means the stomach and the small intestine are slow. And so the material that’s coming out, their stool is days old.
Dr. Kara Fitzgerald: Yes.
Dr. Corey Schuler: So micro-motility, macro-motility, so, what I would say is some people do know that about themselves. And some people just don’t.
Dr. Kara Fitzgerald: Okay, fair enough. That’s, yeah, that’s fair enough, and folks who were using this on, are probably, just as likely not to have some of those cues.
Transitioning off an Elemental Diet, any kind of recommendations for doing that?
Dr. Corey Schuler: This is the third fistfight, because everybody falls into a dietary tribe, it seems, and a different theory about what to do after an Elemental Diet. But I’ll tell you what we, most of us agree upon.
The idea of having high liquid meals, but not all liquid meals, things like soups and broths and high water containing foods, seems to be a good choice transitioning off Elemental Diet. That is what we would do in the hospital, moving somebody off a liquid diet as well. And so that seems to be pretty consistent. But the exact food choices are sort of all across the board.
I like to only introduce foods that you have well tolerated in the past, and not start challenging things. There’s other people, other clinicians who just sort of love this opportunity to try to challenge new foods.
I think that’s kind of a lot to ask of a digestive system. But, it’s certainly up to them, and that relationship with their patient about what could happen. We’ve had people go from Elemental Diet and they’ve just gone back to their old way of eating. But there’s research that says that’s a bad idea.
There was a pilot trial in rheumatoid arthritis that said if you did the Elemental Diet and you had success with Elemental Diet, you went to your old way of eating immediately, your symptoms would return. And so, I just caution against that, but that’s really the only caution. In SIBO, some people will use a low FODMAP diet, or they’ll use the Fast Track Diet, or they’ll use a SIBO food guide. Alison has that on her website. And Cedar Sinai Hospital has a version of their SIBO diet as well. If you’re not using it for SIBO, and you’re using it or Crohn’s or ulcerative colitis or something else, then it really goes back to what does the person tolerate well? What do they like? And how can they move forward with it?
But the most difficult thing is to reengage their bowel system, and start to have bowel movements and things, but you can’t throw in a ton of fiber. And you can’t throw in a ton of these things that might increase those with that bowel motility. So, be patient with yourself. If you’re a patient listening to this, or a client listening to this, this is probably the hardest part of it, is transitioning off it. But, things come around. Things change for the better. And the body takes a while to return to homeostasis.
Dr. Kara Fitzgerald: Okay, perfect, really, really helpful. I’m actually sitting here taking a lot of notes as you’re talking.
All right, do I have any last questions for you? I’ve got one. This is definitely tangential, but you alluded a little bit. Well, actually you alluded to us not being able to test for small intestinal fungal overgrowth.
I just wanted to ask you about labs. Labs is a perennial hot – it’s a fistfight. It’s definitely a fistfight. But I wanted to get your opinion on using breath tests on any other biomarkers you might be using. Are you using breath tests for after treatment to confirm resolution? What are you doing in the lab world? If you can give me a little bit of a thumbnail, that would be great.
Dr. Corey Schuler: Yeah, I always like patient preferences to whether we should test or not, because tests don’t make you better. They just guide the treatment. And so, some people don’t want to use the funds on that sort of thing.
This is an investment, though, typically, in time and money. And so most people are willing to spend the extra however much it costs for the lab tests. The lab that I use is less than $200, and so I recommend, in most cases, that we do at least an initial test. I don’t insist upon it, but I do often recommend it. And then, follow-up testing, I think, is commonly used. But again, I don’t insist upon it.
We don’t have a machine, a QuinTron machine, or those sorts of devices in our office. So we have to send out for it. So we can’t replicate what the cold studies did, where they would test at the two-week mark and then decide what to do next. So we go based on symptoms. I call it the Day Nine Effect. At day nine, let’s make a choice about if you’re going to go for a third week or more, or if we’re good.
If symptoms have decreased, and you feel good at day nine, that’s probably going to continue on to day 14. So, let’s just plan on being done, after the two weeks. So there’s a little bit of a push and pull that I have with clients and say, “What do you want to do? What do you think?”
I try to give them as much information as I can on costs, and what information we’re going to do in full disclosure. I like the QuinTron technology. Clinicians sometimes buy the QuinTron machine and have it in their office. We have a local office that does do that. We also send out. Aerodiagnostics is a great company out of Massachusetts that does a lot of testing for that. And they’re really great with our clients, their customers. So, that tends to be who I use, if I’m going to name names.
And I typically will use, and I’m going to get an evil eye from some people on this one, I like starting with glucose testing. And now there’s glucose and there’s lactulose testing, but glucose is super sensitive to proximal SIBO. And so, I really want to know if they have this proximal SIBO and glucose challenged substrate does a good job of telling us that.
Dr. Kara Fitzgerald: Okay, good. Thank you. Listen, we’ve covered so many pearls, very, very helpful for refining how we’re approaching using the Elemental. Anything else that you just want to throw out? Again, I know you’re on the streets with this really more than, I think, anybody that we have coming on this show. So, anything to add in closing?
Dr. Corey Schuler: I’ll reiterate this until my lungs are sore, and my throat doesn’t work anymore, is that the Elemental Diet should be consumed slowly. If I could just say one thing, is that most people, especially new to this, sort of underestimate the fact that, because they look at the ingredients. They look pretty simple. And they’ve done shakes before, and so, they dump some powder into a blender bottle, and they put some water in. They shake it up, and they drink-
Dr. Kara Fitzgerald: Suck it down –
Dr. Corey Schuler: … it as fast as they can, yeah.
Dr. Kara Fitzgerald: Right. It’s the American way.
Dr. Corey Schuler: That just causes so many problems for the patient themselves, for the clinician who has to answer and figure out what’s going on, and frankly, for me, to some degree, to help trouble shoot what’s going on. And so the first question I always ask, so don’t be mad if people call me and ask me what to do. I always ask how fast are they consuming it? And how much are they consuming at a time? A lot of people do better with smaller amounts and consume it over the course of 45 to 60 minutes versus four scoops and drinking it within 10 seconds.
Dr. Kara Fitzgerald: And what’s going to happen when you suck down four scoops in 10 seconds?
Dr. Corey Schuler: Well, four scoops in 10 seconds is 44 grams of glucose, so dextrose shot straight into your digestive system, and thus, your bloodstream very quickly. So there’s usually a hyperglycemic, hypoglycemic response. And it’s designed as a high-glycemic product. It’s high glycemic so it’s best absorbed. So we know that about it. So let’s use the tool the right way.
Dr. Kara Fitzgerald: That is so interesting. Yeah, and all of that, the concentrated nutrients in addition to the glucose, too, I mean, God … just the thought of sucking it back that quickly sort of gives me a little bit of a stomach ache.
As always, Corey, it’s been really wonderful to connect with you, and I just appreciate, so much, you coming back and offering all these pearls to our listeners. We’ll definitely have you again, as you guys evolve and learn more. Already, our first conversation was great: it was just the nuts and the bolts of the intervention. I can just see how you guys are nuancing and evolving and understanding and, as a result of all of this, patient outcomes improve. That’s the bottom line. I think we have the capacity to deliver better care now.
So thank you. Thanks to Integrative Therapeutics for coming up with this really cool and useful formula.
Dr. Corey Schuler: Yeah, it’s been a great trip for us. Really appreciate your support of us, and just thank you. This is a place where we feel comfortable now, going into this type of medical food was very scary for us, but now that we’re comfortable, we can do some new and nuanced things with it, I think.
Dr. Kara Fitzgerald: Perfect. All right, on that note, we will close, and again, folks, just look in the show notes for links to my previous podcast with Dr. Schuler and all of the various citations.