Elemental is defined as “primary or basic, related to or embodying the powers of nature.” The elemental diet is a medical dietary strategy that uses very simple food solutions to provide essential nutrients, without adding a lot of stress to someone’s already-overloaded digestive system.
Variations of the elemental diet have been used safely by doctors since the 1940s to treat many moderate or severe gastrointestinal problems. The elemental diet was originally tested in animals and then adjusted to support all the nutritional needs of humans. Today, elemental formulas are used to fill nutritional gaps in certain patients’ diets, to help restore gut health, and to improve biomarkers in patients dealing with malnutrition and malabsorption.
Who can benefit from an elemental diet? People with any of the following symptoms or disorders can be treated by their doctors or a dietitian with an elemental diet:
- SIBO that doesn’t respond to other treatment approaches, such as antibiotics and herbal treatments
- Leaky gut syndrome
- Food allergies that cannot be controlled with other types of elimination diets
- Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
- Cystic fibrosis
- Someone going through cancer treatment and recovery
- Someone recovering from an eating disorder, such as anorexia
What Is the Elemental Diet?
The elemental diet is one that uses formulas that contain broken-down macronutrients — carbohydrates, fats and proteins — which are predigested into their most basic elements. These elements include free form amino acids, simple carbohydrates and medium-chained fatty acids. Vitamins and minerals are also incorporated into elemental formulas in order to meet all nutrient needs. These elements are combined to make a powder or liquid beverage that is easily absorbed and beneficial for gut bacteria. (1)
Elemental diets are an alternative to medications and herbal treatments like rifaximin or herbal antimicrobials (such as oregano oil) that are used to treat digestive problems, including SIBO (short for small intestinal bacterial overgrowth). Some people eat a limited diet while supplementing with elemental formulas, while others exclusively stick with elemental formulas and abstain from eating all solid food. This usually depends on how severe the person’s symptoms are and is determined by a doctor.
Even though it can be very beneficial, overall the elemental diet is considered by many to be an “aggressive approach” to restoring digestive health. That being said, it’s worth asking yourself if it’s really necessary and you’re really ready for this approach before beginning.
Wondering if elemental diets safe for infants and children? Yes, and they are used by certain pediatricians with a high degree of success. Infants in particular can adapt to a elemental diet somewhat easily because they are already used to living on an all-liquid diet (from breastmilk or formula). However, a child or infant shouldn’t be started on the elemental diet without being supervised by a doctor.
Benefits of Elemental Diet: Does It Work?
The primary benefits of using elemental formulas include:
- Improving absorption of nutrients
- Reversing inadequate calorie intake (due to disease or anorexia)
- Providing nutrition in the case of severe dietary restrictions
- Limiting and reversing intestinal losses due to inflammation
- Providing higher nutritional content during “catabolic states” when demand increases
Improving someone’s nutritional status has many benefits — for example, it’s known to lower the risk for many diseases, especially if eating an anti-inflammatory diet. Elemental formulas are beneficial because they eliminate many types of difficult-to-digest foods, additives and ingredients that promote inflammation and interfere with digestion. For example, “Western diets” that are high in foods like processed meat, added sugar, refined grains/flour and refined vegetable oils often increase inflammation of the bowels and contribute to many GI problems, including leaky gut syndrome, IBD and IBS.
Research shows that poor dietary choices can cause changes to the microbiome that have far-reaching health implications. On the other hand, simple/unprocessed healing diets that include many whole plant foods, unrefined fats and fiber are associated with improvements in digestive health and many other health markers. However, sometimes someone has such a compromised/damaged digestive system that he or she is incapable of breaking down whole foods. This is where elemental formulas come into play.
What is an elemental formula?
An elemental formula is a complete nutrient solution that is easily absorbed. Another way to put it: Elemental formulas are “nutritionally complete” liquids feeds that have already been “predigested.” This means that instead of providing nutrients that need to be further broken down, like complex starches or proteins found in whole foods, elemental formulas provide readily available nutrients like simple sugars or amino acid peptides. These formulas are usually obtained from a doctor and administered with help from the patient’s doctor and/or dietitian/nutritionist.
- There are several different types of nutritional formulas used by doctors who treat gastrointestinal issues, including elemental, semi-elemental, polymeric (also referred to as “intact” formulas), standard, disease-specific/specialized and immune-enhancing formulas. Although they are the most expensive and compliance can sometimes be an issue, most consider elemental and semi-elemental formulas to be the most effective because they require the least digestion.
- Elemental formulas have a low fat content (only about 1 percent to 2 percent fatty acids) and contain individual amino acids and glucose polymers. Semi-elemental formulas contain longer chained peptides, simple sugars, glucose polymers/starch and low amounts of fat. Polymeric formulas contain intact proteins, complex carbohydrates and long-chain fatty acids. Specialized formulas contain biologically active substances or nutrients, such as glutamine, arginine, nucleotides and various fatty acids. (2)
- Elemental formulas can be administered through an IV, nasal-gastric or nasal tube, or made into in a powder formula that is mixed into water and drank just like a beverage.
- The use of an elemental diet is usually part of the feeding process called “enteral feeding.” When someone is not capable of eating whole foods and properly metabolizing them, different methods of feeding are used to prevent malnutrition, weight loss and deficiencies. (3)
- Two examples of feeding methods are parenteral feeding and enteral feeding. Parenteral feeding involves a patient being fed through intravenous solutions directly into the veins, while enteral feeding involves a patient receiving nutrients through a liquid feed or special formula.
- Enteral feeding can be done by mouth or nose, such as when a patient requires use of a naso-gastric tube that connects directly to the stomach. It’s also possible for some elemental formulas to be given through parenteral feeding.
What is Vivonex Plus?
Vivonex is one popular elemental formula that has shown promising results in certain studies. One study involving patients with SIBO found that 80 percent of people experienced significant improvements when using Vivonex exclusively for two weeks and 85 percent after three weeks. (4) According to the makers of Vivonex, it contains 100 percent free amino acids and has a low fat content, making it suitable for people with severe gastrointestinal problems. It is also lactose-free, gluten-free, low-residue (good for SIBO) and kosher. The product can be used for either tube feeding or taken by mouth (oral supplementation). It has about 300 calories per packet or close to 1,000 calories per 3.3 packets.
What is Tolerex?
Tolerex is similar to Vivonex; it’s another elemental formula made by the same company that has 100 percent free amino acids and a low fat content. Just like Vivonex it can be used with tube feeding or oral supplementation and is lactose-free, gluten-free, low-residue and kosher. Both Vivonex and Tolerex are intended to be used with medical supervision only.
What is a polymeric diet?
Elemental formulas are commonly categorized according to how protein and nitrogen are presented. Most formulas called “polymeric feeds” provide nitrogen in the form of amino acids alone, but some might have short chains of linked amino acids that require some digestion. According to the Crohn’s.org website, “The difference [of elemental formulas] depends on the size of the protein molecules and how broken down the protein is.” (5) Semi-elemental feeds contain short chains of amino acids, while polymeric feeds contain whole proteins in which none of the amino acids/proteins have been broken down.
Elemental Diet Uses: What Does It Treat, Who Should Follow It?
1. People with SIBO
Currently, one of the most effective ways to help improve gut/microbiota health and increase activity of beneficial bacterial living in the GI tract is through carefully controlling the diet. Certain harmful bacteria that can live in the gut produce byproducts and chemicals that trigger the immune system, causing autoimmune-type symptoms. In order to reduce the presence of these harmful bacteria, their food/energy supply needs to be removed, which is what the elemental diet hopes to accomplish.
Bacteria use undigested food particles found in the intestines to survive and reproduce, so eliminating this supply works to kill off the bacteria. What’s tricky is figuring out a way to keep providing patients with all the calories and nutrients they need without having them eat any problematic foods. Elemental formulas are effective because they are quickly and easily absorbed in the upper intestines; this way residues that feed bad bacteria don’t have a chance to be made.
2. Those Suffering from Inflammatory Bowel Disease
Diet plays a major role in managing symptoms of digestive disorders, including the most severe types of inflammatory bowel disease — the two most common types being Crohn’s and ulcerative colitis. What you eat has a big impact on your levels of inflammation, gut health and overall well-being. The goal of dietary approaches to control IBD is to eliminate foods that cause further intestinal upset and make symptoms worse.
Many patients with IBD have a hard time breaking down foods — such as high-fiber grains, raw fruits including berries, nuts, certain vegetable and refined fats — or dealing with caffeine and alcohol. Because so many foods are not tolerated well, it can be hard to get enough calories and prevent malnutrition, so the elemental diet is used to restore nutritional status and promote healing. Certain studies have found that an elemental diet followed by an exclusion diet called LOFFLEX (a diet low in fat and fiber) is highly effective in helping patients with IBD reach remission, with up to 60 percent of patients remaining healthy for at least two years. (6)
3. Anyone with Food Allergies or Leaky Gut Syndrome
A 2017 study found that following an elemental diet decreased inflammation and improved symptoms in adults with eosinophilic oesophagitis, a chronic disease driven by food allergens. (7) After four weeks of following the elemental diet, all patients showed significant decreases in symptoms, with 15 patients (88 percent) becoming completely asymptomatic. In addition, 14 patients (82 percent) also experienced significant improvements in terms of inflammation, as measured by blood eosinophil count and serum IgE levels.
How to Follow an Elemental Diet
While following the elemental diet, a patient may use elemental formulas in place of all regular foods. This means that no other solid/normal foods should be eaten during the elemental diet phase, and only water should be consumed. Some people use “half/semi-elemental diets” to provide about half of their daily calories from elemental formulas, while others follow an “exclusive elemental diet” that provides 100 percent of their calorie and nutrient needs.
How long should you follow the elemental diet? This phase will usually last for about two to three weeks. Your doctor might choose to customize the elemental diet to fit your needs, so this might mean sticking with the diet for a shorter or longer period of time. When it comes to the recommended amount of elemental formulas you should use, speak with your doctor to be safe. You may need to be monitored, and you should never stop medications without being advised to do so.
Nutrient deficiencies that are most common among people with moderate to severe digestive problems include vitamin A, vitamin C, vitamin B12, niacin, iron, folate and calcium deficiency. If the variation of the elemental diet that you’re following includes some whole foods, then it’s a good idea to try and include sources of these nutrients.
During a true elemental diet (not semi/half) you’ll want to eat very simple foods, avoiding all fiber, complex proteins or complex carbohydrates. The exact diet you should follow will be determined by your doctor.
If you’re following a half/semi-elemental diet, then food and nutrients to consume on the elemental diet include:
- Cooked vegetables — Try to make about 40 percent of your plate cooked vegetables, along with about 30 percent “clean” sources of protein, 20 percent healthy fats, and the remaining percent whole-food carbohydrates and fruit. Most of your plate should be taken up by vegetables that are ideally organic, removing pesticides that may be triggers. Vegetables that are especially good choices for a healing diet include all leafy greens, artichokes, fennel, celery, cucumbers, squash, mushrooms, snow peas, radishes, sprouts, sea vegetables and fresh herbs. Some people can tolerate cruciferous vegetables like broccoli, cauliflower and Brussels sprouts, but some cannot.
- Small amounts of fruit — Berries may be hard to digest, so try melon, bananas or cooked apples/pears first.
- Proteins — About 30 percent of your plate should come from high-quality proteins. Aim to include plenty of “clean” protein foods, such as organic, grass-fed meat and poultry, wild-caught fish, cage-free eggs (unless you suspect an egg allergy), bone broth or collagen protein powder, and possibly small amounts of sprouted beans.
- Healthy fats — Healthy sources of fats include coconut products such as coconut oil, olive oil, coconut milk/butter, grass-fed butter, avocado, and possibly small amounts of nuts or seeds (if tolerated).
Foods to avoid while on the elemental diet include:
- Common allergens like grains (especially those containing gluten), tree nuts including peanuts, shellfish, citrus fruits, cow’s milk, eggs, soy and corn.
- Avoid foods made with flour, hydrogenated fats, added sugar, synthetic ingredients and dyes, and artificial sweeteners, as well as caffeine and alcohol.
Elemental Diet Recipes
Some people choose to make their own semi-elemental shakes at home. One recipe involves combining the following ingredients with water and then blending: (8)
- 25 grams of pure protein powder (I recommend collagen or bone broth)
- 50 grams non-GMO tapioca, maltodextrin or dextrose (these provide carbohydrates)
- 1 high quality multivitamin, which includes 100 percent DV of all B vitamins, vitamin C and vitamin E
- 1,000 milligrams of L-glutamine
- 1 teaspoon of oil (I recommend pure coconut oil)
Unfortunately, elemental formulas are known to not taste so great. The good news is that you will likely only need them for several weeks. You may also be able to supplement the formulas with real food (but you should ask your doctor about this first). If you’re following a semi/half-elemental diet then you’ll still be eating some solid foods, although still a limited diet. Ideas for recipes that are allowed on a semi-elemental diet include:
- Smoothies made with fruit, coconut milk/coconut oil, and protein powder from collagen or bone broth.
- Steamed veggies with coconut oil and a source of protein (like meat or fish).
- Pureed soups or stews made with veggies, herbs, stock and oil.
- Omelets with cooked veggies and herbs (if you can tolerate eggs).
- Stir-fried vegetables with beef or chicken.
Elemental Diet vs. Elimination Diet
Doctors and dietitians/nutritionists will typically begin treatment with a patient by starting with easier methods, such as a specific carbohydrate diet or the GAPS diet. Sometimes medications may also be used to control allergies and inflammation, such as corticosteroids. When these approaches don’t work, then an elemental diet is usually the next step.
Once a patient’s symptoms decrease and it appears that the GI tract is healing, the elemental diet can be stopped. Most people follow the elemental diet for about two to three weeks, sometimes taking a break for several months and then starting another cycle. Following the elemental diet, “safe foods” are then used as part of an elimination diet while the gut has a chance to keep recovering.
What is an elimination diet, and how is it different then the elemental diet?
- Elimination diets are also sometimes called “exclusions diets.” They are used to identify food allergies, intolerances and triggers so these can be permanently eliminated from the diet. They are also used to help replenish good bacteria in the gut and identify safe foods.
- Experts usually recommend that following a period of the elemental diet, a patient begins to follow an exclusion diet that is balanced, unprocessed and that eliminates many common digestive culprits, such as too much fiber or fat.
- This elimination/exclusion period can last for several weeks or even several months (usually about three to six weeks), as new foods are gradually reintroduced and tested. Sometimes a single food will be reintroduced each day while the patient gradually starts decreasing use of elemental formulas. Once the patient has enough well-tolerated foods in his or her diet to provide adequate calories and nutrients, he or she can stop the exclusion/elimination process and continue eating normally, as long as symptoms don’t return.
- Examples of elimination diets include a FODMAP diet, the GAPS diet protocol, the specific carbohydrate diet (SCD) and other individualized diets.
- Solid/safe foods need to be reintroduced slowly, or else symptoms can return and the patient can relapse quickly. The patient will need to go through a gradual reintroduction period as he or she starts to eat normal/whole foods in a slow, controlled manner.
- Long term, the SCD, FODMAP or modified GAPS diets can help decrease the bacterial load of SIBO and be useful for resolving other GI problems — however each person is different when it comes to the potential for remission.
Downsides, Precautions and Potential Side Effects of the Elemental Diet
While elemental diets can be very helpful, they might not be necessary if you only have a mild digestive problem. Some people also find them difficult to follow, even if the diet only lasts several weeks.
It’s best to work with a medical professional while attempting to treat any digestive disorder — this way you have guidance and accountability. Rarely someone will jump right in to the elemental diet without trying other treatment methods first, so consider if a simpler approach might be a better starting point for you.
Overall, following the elemental diet, exclusion diet or elimination diet takes patience and consistency. It can be hard to identify which specific foods a person with digestive distress will need to avoid. Everyone is a bit different in terms of what can and cannot be tolerated, so some trial and error is usually part of the recovery process. Many patients will have more than one problematic, triggering food, so in some cases they may need to avoid up to a dozen or more different foods (such as gluten, dairy, peanuts, certain fruits and veggies) in order to control their symptoms.
Final Thoughts on the Elemental Diet
- The elemental diet is one that uses formulas that contain broken down macronutrients.
- Elemental formulas are predigested solutions that provide calories and nutrients to people with digestive disorders and malnutrition. Instead of providing nutrients that need to be further broken down, like complex starches or proteins found in whole foods, elemental formulas provide readily available nutrients like simple sugars or amino acid peptides.
- The elemental diet can be beneficial for people with GI problems including SIBO, IBD, leaky gut syndrome, allergies or IBS.
- Some people use “half/semi-elemental diets” to provide about half of their daily calories from elemental formulas, while others follow an “exclusive elemental diet” that provides 100 percent of their calorie and nutrient needs.
Jillian BabcockDr. AxeDecember 26, 2017