SIBO and The Elemental Diet with Dr Lela Altman

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Dr Nirala Jacobi is in conversation with Dr Lela Altman on the topic of the Elemental Diet. Dr Altman presented at the 2017 SIBO Symposium, and in 2018 at The Gastroenterology Association for Naturopathic Physicians, on the topic of the Elemental Diet.

Dr Altman is a Naturopathic Doctor, she has a private practice and also lectures at Bastyr University in Seattle. Dr Altman is also an Acupuncturist. Her interests include gastrointestinal disorders, east asian medicine, diabetes, and cardiovascular disease.

Topics discussed include

• How did Dr Altman get into the field of SIBO with a special interest in Elemental Diets?
• The Elemental Diet is a highly effective standalone antimicrobial treatment, on par with conventional antibiotics or herbal antimicrobials.
• What are the components of the Elemental Diet? What makes it different from medical food replacement products such as Mediclear or powders that aim to heal the gut?
  • Proteins are in the form of amino acids only, and there are no other food products in the formula. The nutrients are predigested - you do not need to break anything down.
  • Fats in the form of oil, medium chain triglycerides (MCTs).
  • Carbohydrate component is either dextrose or maltodextrin.
  • Starches may be included.
  • Essential vitamins and minerals.
  • No fibre.
• Contraindications for the Elemental Diet include
  • A history of disordered eating
  • Underweight patients (however patients can gain weight on the Elemental Diet due to ease of absorption of nutrients)
  • Caution in diabetes due to higher simple carbohydrate and sugar content.
  • Caution for known fungal overgrowth or signs or symptoms. If using, use in combination with antifungal treatment - Dr Jacobi always uses an antifungal with the Elemental Diet.
• How can people get the Elemental Diet for their patients?
  • Vivonex - Nestle product (not recommended)
  • Integrative Therapeutics Physicians' Elemental Diet
  • Dr Allison Siebecker's homemade Elemental Diet
• Possible complications encountered with prescription of the Elemental Diet.
  • Blood sugar dysregulation
  • Weight loss
  • Intolerable flavour
  • Nausea
  • Diarrhoea
  • Die off reactions
  • Constipation
  • Abdominal pain
• What happens for 2 versus 3 weeks for patients on the Elemental Diet?
  • 80% effective after 2 weeks
  • 85% effective after 3 weeks
  • No more effective for 4 weeks
• Protocol
  • Elemental Diet shakes - 6 per day, or daily amount divided up to have less day every hour.
  • Drinks allowed - water, (sometimes) dilute black coffee or black tea.
  • SIBO testing patient with same day breath test - if still positive, continue for one more week, if negative, transition off the Elemental Diet.

Transitioning off the Elemental Diet

General

• Keep using some of the Elemental Diet shakes for calories as patient transitions.
• Consider using Elemental Diet as the elimination phase of an Elimination Challenge Diet (eliminate all high allergenic foods for 2 weeks and then reintroduce one every 3 days, if tolerated add back in, if not tolerated keep it out)

Day 1

• Slow introduction of foods starting with broths (be aware that some SIBO clients do not do well with cartilage bones due to the high histamine in glycosaminoglycans. If this is the case, use only marrow bones or meat broth).
• Start patients with Low FODMAP diet for approx 3 days, well cooked vegetables, avoiding raw foods.
• If candida suspected, avoid simple carbohydrates.

Day 2

• Continue with well-cooked Low FODMAP vegetables and broth.
• Congee addition (if no yeast overgrowth) - rice soup with chicken / vegetables.
• Add cooked meats, fish, eggs, grains.

Day 3

• Transition to a simple Low FODMAP diet or Dr Jacobi's Bi-Phasic Diet

If SIBO breath test is negative start challenging the Low FODMAP diet as described with Elimination Diet Challenge above.

• Same day retesting available in Australia with com
  • Notify the lab before sending the test for fast-tracking
  • Overnight the test back to com
• What are common symptoms that are usually no cause for alarm?
  • Constipation (due to no fibre intake)
    • Bowel movements can change largely - client is not eating enough food to pass on a regular basis.
    • Great therapeutics include magnesium, herbal laxatives, suppositories, enemas.
  • Nausea
    • Can start within first couple of days and usually then goes away. Solution is to dilute formula a bit more if you can.
    • Can be due to vitamins and supplements taken in addition to Elemental Diet. Recommendation to discontinue non-essential supplements.
    • If using Dr Siebecker's Formula, switch to the lower fat higher carb option, as the high fat option can cause a bit more nausea.
  • Bowel changes
    • May notice passing stools of dry grey powder - if formula used is powder.
    • Diarrhoea - could be a reaction to something in the formula (look to corn oil, soy oil). Treat for dehydration - keep them hydrated and advise sipping formula slowly throughout the day (which also assists blood sugar regulation).
  • What to do to improve flavour of the homemade Elemental Diet? Options may include:
    • Stevia
    • Flavoured magnesium powder (use caution here with appropriate quantity).
    • Extract drops, such as almond, peppermint etc.
    • Blend with ice.
    • Use a cup with a straw so as to not smell it.
    • Do not let it sit out for more than the time that it is being consumed.
  • The Half Elemental Diet
    • Not used for SIBO treatment
    • Can be used for providing bowel rest for anyone in an inflammatory bowel flare.
    • Can be used to increase caloric intake for someone who is requiring hypoallergenic caloric supplementation (a few days to a week's duration) - used as a caloric and nutritional booster for those with extreme food sensitivities.
  • Additions
    • If client is getting hungry on having the Elemental Diet - add coconut or MCT oil to formula to increase calories.
  • Dr Altman's opinion on using the Elemental Diet in the daytime and eating meat at night?
  • The difference between meat protein and elemental diet protein - the latter is in a free form and are therefore rapidly absorbed and not much reaches the colon.
  • Initiate prokinetics immediately at completion of Elemental Diet to inhibit regrowth of SIBO.
  • Consider low dose antimicrobial herbs at completion of Elemental Diet to inhibit regrowth.
  • Consider that stomach acid is killing most of the bacteria that we ingest - support this if necessary.
  • Consider the underlying root cause of client's initial SIBO and keep that managed to prevent relapse.
  • Dr Altman's clinical pearls re The Elemental Diet.
  • The cost of a 2-week course of The Elemental Diet
    • Example at 6 shakes per day of Physicians' Elemental Diet it comes to approximately $650 USD.
  • No need for hunger - patients can have as many shakes as they want.

Resources

• Dr Lela Altman
  • Dr Altman's talk Elemental Diet Webinar with CME available.
  • Bastyr University Digestive Wellness Clinic in Seattle, Washington.
  • Private Practice in the Bastyr Centre for Natural Health.
• Dr Pimentel
• Elemental Diet options
  • Integrative Therapeutics
    • Physicians' Elemental Diet
  • Dr Allison Siebecker's homemade Elemental Diet
  • Vivonex - Nestle (not recommended)
• Elemental Diet components
  • Jo Mar Labs Black Label 21 Blend for amino acids
• Same day retesting available in Australia with com
  • Notify the lab before sending the test for fast-tracking
  • Overnight the test back to com
• Dr Jacobi's Bi-Phasic Diet
• Dr Allison Siebecker's SIBO Specific Diet
• Specific Carbohydrate Diet (SCD)