The Elemental Diet | Fullscript Webinar

The Elemental Diet | Fullscript Webinar


(bright upbeat music) – Thanks, everyone, for joining today. For those of you who don’t know who I am, I’m Dr. Alex Keller, I’m the medical director at Fullscript. And we’re really excited
about this webinar today because we’ve been working
with Dr. Kara and her team, her phenomenal team,
over the past few months to develop more of an
educational partnership. And as we know in this space, it’s becoming evermore challenging to kind of, filter through all the content that’s being thrown at us, and we often have to rely
on leaders in the space, thought leaders, who are able to bring us this kind of content. So, when we started to
develop this partnership with Dr. Kara last year
we were really excited because she is a thought leader
in so many different areas of functional medicine. Many of you probably know her for her work in methylation and the methylation diet, specifically. But product knowledge
and ingredient knowledge is also a very strong factor for Dr. Kara. So, the Elemental Diet is a big part, or a big question that we
often receive at Fullscript. What is the Elemental Diet, how to use it in clinical practice, what’s the evidence for
it in clinical practice? So, we’ve been meaning to do something around the Elemental Diet for a while, and the opportunity to work together as a partnership on this is ideal. So, we’re really excited
to be doing this today. I wanted to mention, and Kara, you’ll speak a little bit
more about this as well, but the Clinic Immersion
that Dr. Kara and her team have launched here in the past few years they’re now offering, this was another really exciting part about us working together with this team. This Clinic Immersion
is a virtual experience for practitioners looking to
sharpen their clinical skills. And there’s really nothing
else like it out there in the functional medicine space right now where if you want to become more adept and more thorough in your understanding and basically do a residency
in functional medicine, you typically have to do that in person. And what’s been built here
is a virtual experience that allows you to do that
from anywhere in the world. So, without going any further, Dr. Kara, I’m gonna let you
explain a little bit more about your Clinic Immersion, and I’m gonna act more as a facilitator throughout this presentation to make sure that we’re
answering your questions, we’re getting in the
polls when we need to, and covering as much content as possible. I will mention that we will be
taking questions throughout, and then we’ll have a Q and
A session at the end as well for any questions that we
weren’t able to address. So, I’ll leave it to you, Dr. Kara. – All right. Yeah, I’m likewise, Alex. I’m just so happy to meet you in person. You can tell he’s really in the office, he’s got the brick, the
telltale brick behind him. He’s in an office kitty-cornered to me so we don’t reverb. It’s just fabulous to have him here and to just actually have the whole team. Some of you probably recall, I had the opportunity to podcast with Dr. Jeff Gladd on business practices in functional medicine. Here’s here, too, and
we’re actually gonna be, so thinking about Clinic Immersion, we’re gonna be brainstorming on how to involve his skills to offer it more completely
to our Clinic Immersion folks. So, if you haven’t
checked out his podcast, it was without question
one of the most popular podcasts I’ve done, and we
just need to continue on. Dr. Ken Litwin is here. Normally, actually again,
around our Clinic Immersion, this is our Physician Rounds time. We’re doing this webinar
instead of our Physician Rounds, so because of that, we’ve got Dr. Litwin, who is my colleague here at our clinic. And we’ve got a lot of
our nutrition team as well in the background listening. I noticed that–
– Hey there. – (laughs) Hey, Ken. You can see Ken’s here in
the office, too. (laughs) Lots of brick in this old
rehabbed mill building. Anyway, so, we’ve got
some nutritionists here, and there are lots of folks here who will be able to talk to you about our clinic experience
using the Elemental Diet. And if we’re not able to
get to everything today, or if you’ve got questions that
require a certain expertise we don’t have on-hand, by all means, ask and we will harvest all of the questions we don’t answer and we’ll put them together in a document that we make available to you. So, no question is off limits today with regard to the Elemental Diet. All right, let me–
– Kara, I should also mention again, sorry to interject that this will be recorded and the recording, as well as the slides and any reference
materials will be sent out to all registrants after
the lecture as well. – Perfect, perfect. Okay. Yeah, again, so as Alex said, we’re doing this in partnership with Fullscript and
Integrative Therapeutics, and we’re gonna give you just a little bit of a heads up on our
Clinic Immersion program. Why did we create this? Primarily because, as Alex mentioned, people need training,
direct clinic experience in functional medicine. I’m on faculty at IFM, as
some of you probably know, and that’s our biggest ask. I mean, we work overtime at making the IFM content user-friendly,
so Monday morning applicable, but you still need to get in there and do it over and over again. We realized we were at an advantage for a couple of reasons. We’ve been doing it for a while, we’ve been practicing functional medicine here for a while and teaching, so we had some of that background. We have a expert nutrition
team, just expert. I call them nutrition ninjas sometimes, and we’ve got, actually,
a quite a competitive nutrition residency and four fulls, I call them attending
nutritionists on-staff as well, so a good team there. And we’re mostly virtual. You know, our brick, literal
brick and mortar footprint here in Sandy Hook is quite small. I mean, Ken’s here, Dr. Stacey
Cantor-Adkins comes down, we’ve got a couple of office staff, but then our virtual world is big. So, it was a matter of us
just kind of holding our noses and jumping in and
hitting the live switch. And because we already
use the Zoom platform for all of our clinic meetings, for our teach-ins, et cetera, et cetera, for all of the things we do on
a daily basis in our clinic, we use this platform. We just decided to invite you in, and not only see what we do, but able to talk to us
while we’re doing it. So, our Physicians Rounds, Ken usually leads off, so Ken and Stacey, all of us, talk about
our challenging cases. Physicians Rounds is a little
bit more of a drill down, it’s us as clinicians reviewing labs, reviewing patient history, et cetera, and then pulling together
our treatment plan. On Tuesday, yesterday, we have
our clinic rounds meetings, and that’s when all of the nutritionists and physicians get together, and that’s our exchange of how an individual patient is doing, do we need to tweak the
diet, et cetera, et cetera. Again, our Clinic Immersion
and nutrition residency folks are tracking right along with us. We do teach-ins all of the time. So, something that you
do in your own practice, if you’ve got a question and you’re scratching your head on it, you reach out to your
brain trust of friends. And we again, we just hit
the live switch on it. And because I’ve been around, (laughs) I’ve been around for a long time, some of my colleagues are people
that you wanna learn from. I mean, Susan Blum was here recently talking to us about this new
perspective on autoimmunity, of course Sid Baker, Jeff Bland, two of the fathers of functional medicine being able to listen and learn and talk to them in the intimate setting of the Clinic Immersion is so powerful. And of course, Dan
Lukaczer, if you’re getting your functional medicine
training you know him, and Dr. David Brady,
everybody knows Dr. Brady. And again, the nice thing
that we wanna do is, well, they are recorded for people who can’t attend live, but if
you’re in the live program, we wanna make these folks, these experts, available to you so
you’re not just listening to a one-way lecture,
but you’re participating in an active dialogue, just like you would do
in your clinic practice. And we have a good, strong community. We feel supported
practicing medicine here. We do a lot, actually I’m
gonna just switch back to the teach-in, and I
know I need to stay on task and we need to get into our
Elemental Diet conversation, but when you’re vetting an industry, when you’re vetting a tool, be it a supplement, some
sort of a new intervention, be it a lab, we bring on
those experts as well, and our nutrition residents do a good job at vetting quality for supplements, getting the QC data, et cetera. So, that’s another
thing that we’re hitting the live switch on and inviting you in to experience with us. If you’ve got any questions,
just be sure to… pop them in the chat box if you have any more questions. Here’s a portion of our team (laughs) looking lovely. That’s Dr. Litwin’s office. We try to get together in person a couple times a year, if possible. It’s a six-month program. You can do the live version, or you can actually get all of our content at drkfeducation.com, recorded, and all of our downloadable
didactic content is there as well. All of the stuff that
we’re using in practice we’re just making available to you. All right, were you gonna
say something, Alex? No? Or Ken? – Don’t forget, once a month we have participants presenting cases and we discuss those.
– Oh yeah. Thank you. Yeah, there’s a lot that–
– Which is very cool. – (laughs) That’s right. Yeah, there’s a lot,
and then I do a Q and A, which is really an active dialogue among all of our participants. But yeah, Dr. Litwin’s
leading the case discussion where you in the Immersion program bring your cases forward. Listen, don’t be anxious. (laughs) You don’t have to lay it out
beautiful in a PowerPoint, just come forward with
your questions on a case, or if you wanna make a
detailed presentation, you can do that as well. All right, let’s talk about the Elemental. I was incidentally extremely thrilled when Integrative Therapeutics
released the Elemental Diet. We had an Elemental recipe, or a handful of recipes
that we would try to get our patients to create, but we weren’t very successful in that because they taste pretty horrible, it’s really expensive, and there’s a bit of a time involvement. So, when these guys designed
what is a beautiful, actually two really beautiful formulas that are reasonably palatable
for an Elemental Diet, we were thrilled in practice and we just jumped on
as quickly as we could. And I’ve podcasted with their Chief Medical Officer, Corey Schuler, if you’re interested in some of the things he has to say on it. He actually came on an did a teach-in and we all got to ping him. I would say that it’s one of the most important tools in our toolkit. So, we’re gonna talk about it, we’re gonna talk about
our clinical application and the rest of it there, considerations when doing an Elemental. It was developed–
– Kara. – Yeah?
– I’m gonna interject. We’re just gonna do another
poll quickly before– – Oh, okay. Oh, we’re on poll time, okay, good. – Poll time, yeah.
(Kara laughs) – All right, go for it, Karen. – Karen, go for it. So, really the poll, here
I’ll just read it out, but are you currently
using the Elemental Diet in your practice, and if
yes, for what conditions? So, let’s see what we have. Karen will let it go for about 10 seconds and then we’ll see the results. Okay. So, about two-thirds are
using it and one-third not. SIBO IBS by far, so
two-thirds primarily for that and then IBD behind that. Okay, good. Perfect, good to know. – All right.
– Okay, carry on. – So, you can see the backstory of it, it was actually Space food. Started out as Space meals to be consumed in outer space back in the day, and then they evolved
it and started to use it in hospital settings, actually
really early on with Crohn’s. So, from Space to Crohn’s disease, the early journey of the Elemental Diet. What is it? You know it’s elemental nutrients, it’s the nutrients needed for survival, and they establish that, of course, first in an animal model,
just designing the product to have an adequate ratio of amino acids, a balance of appropriate amino acids, vitamins, minerals, fat as
medium chain triglycerides, and carbohydrates, so it
was an appropriate ratio to sustain life first in animals and then later they evolved it to be successful in humans as well. It’s mostly absorbed
in the small intestine and it’s easily assimilated. Because it’s broken
down to the smallest… state, the smallest form, it’s
not in a macronutrient form but a micronutrient form, it’s extremely hypoallergenic. Well, they have here as a
bullet, typically hypoallergenic. I mean, I suppose sensitivities can present to almost anything, but in our practice we’ve used it heavily in our most allergic patients, I’ll talk about that in a minute, because it’s just so
hypoallergenic and so bioavailable. So, it’s like you’re pulling
out food reactivity… using an Elemental, and
I think for that reason it can be a helpful diagnostic tool. – Kara, that’s a very underappreciated use for this product, I think. – Well, I know, and if
you saw the poll, Ken, only one to 2% are using it, but yeah, go ahead,
what were you gonna say? – Just for the super allergic patients, it’s not just for SIBO or Crohn’s disease. – Yeah, that’s right. That’s right. It’s good for Space travel, so if you’re one of the
early adopters on the, I think maybe Tesla, or Virgin, you might consider. (laughs) All right, what else do we have here? Yeah, so, you’re really
giving your patients a rest and digest option
with the Elemental and allowing some repair to happen. It’s extraordinarily bioavailable, of course, because it’s down
to the micronutrient structure, and it can actually
successfully be the sole source of nutrition for a limited time. You can deliver it
enterally or parenterally. Crohn’s disease, there’s a
lot of science behind Crohn’s, and we’re giving you some
pretty nice handouts, one of them is looking at
a ranking of literature, and you’ll see that
the science on Crohn’s, the publications on Crohn’s
and Elemental, they’re solid. As effective, as you
can see in that bullet, as standard care, including steroids. We’ve used it quite a
bit in our IBD patients, as needed, I mean, it’s not… I was thinking, actually on the drive in, one of the patients we have, he knows if he’s moving into a flare or if he’s kinda transgressed off of some of the foods
that are reactive for him and he can jump on the
Elemental for a couple of days and just dial himself back in. Small intestinal bacterial overgrowth, you know about that already, a lot of you are already using it. Eosinophilic esophagitis, or any sort of eosinophilic
gastroenteritis conditions, it’s just really useful. Really useful, and it can be useful as a diagnostic tool in those cases, well, to clean the slate
and then you can do a reintroduction to find
out what foods are safe and what foods trigger symptoms. But there are a handful of publications for its use there. Diarrhea, what else? Actually, a variety of
diarrheal presentations. It can help with weight gain, pouchitis, celiac disease, of course, and some of the studies have looked at the various cytokines and
changes to those cytokines and other inflammatory markers. So, GI-related operations, so C-section, just general nutritional
status requiring improvement. The Physicians’ Elemental Diet, as I’m sure you are aware of, has a much higher quality of nutrient than some of the others that use, you know, synthetic folic acid and I would say as integrative physicians and integrative clinicians,
we’ve wholesale moved away from using it, and the
Physicians’ Elemental has Quatrefolic and methylcobalamin, and just a better quality nutrient. – And some of them aren’t
really even Elemental. They say they’re Elemental
but they’re really protein. – Which would be, actually, increase the risk for reactivity. I think so far we have not had any obvious intolerance or
hypersensitivity response in our patient population,
and we’ve used it quite a bit. I think it’s pretty unlikely. Cancer treatment side effects, you can use it as an intervention, you can use it to maintain lean body mass, to maintain weight. Other extraintestinal indications, liver failure, asthma. Pretty cool case on asthma. Rheumatoid arthritis. Okay, I’m gonna jump in and talk through just briefs on cases
from our clinic practice. I’d love to hear some of your experience and some of what you’ve done. Alex will jump in, Ken can jump in. Alex, were you gonna say something before I start?
– I was. Sorry I need to keep interjecting here. There was a question that came in, you did touch on it, but Sarah is asking, “Can we review the use
as parenteral nutrition? “We thought that was not an option.” Is there any more information
you can share on that? – You know, I would look
to the IT tech guide. I don’t have it. We do not do it in practice–
– Nor do I. – Ken, do you have any thoughts? Dr. Litwin? – Your question was using– – Using it as a parenteral
nutrition, should be– – Oh, no.
– You can do it, but we’re not set up to in this clinic. – Nor are we. So, you’ll see in the content that we share after the lecture that there is quite a bit
of research around its use as parenteral nutrition,
and fairly decent evidence, at least with small randomized double-blind placebo-controlled trials, but there’s not an extensive amount of information out there
because most of it’s been done in small settings in hospitals, so we’re not quite there yet. – I can see that the chat is hopping, and I’m not able to read it because I have to look at the slides, but listen, if you’ve got experience and you’re on this webinar,
just pop it in the chat ’cause we’d like to hear about it. And then Sarah, actually,
this could be a question that we’ll do on our followup
question PDF that we create, and we’ll ping IT specifically
for some feedback on it. – Yeah. I’m gonna interject
here with one more poll. So, we’re gonna do one additional poll. The poll is, how are you
currently prescribing the Elemental Diet, if you are, and how long you typically prescribe it. So, we’ll just address
these before we jump into the case studies. Okay, so the vast majority, well, just over half are using this full, and then some are using
it as half and partial. We’ll talk a little bit more about this, but just to be clear,
half and partial means half normal diet or a
specific type of diet and half using the Elemental
Diet for your caloric needs, and then partial is just a
little bit less than that. I’d love to know, if anyone’s
willing to comment here, what other uses they have for it. Are they using it just
periodically, a couple times a week, or anything else? And then how long are you typically. Oh, Karen, are you able
to pull that back up? So, seven to 14 days is the most common, and then 14 to 21. 21 days, beyond 21 days not as common, and less than seven not as common, but we’ll talk a little bit about that in the case studies as well. So, okay, why don’t we jump
into those case studies then? – Yeah. Okay, so, these are case briefs. Ken can talk about his experience as well, and we’ll continue our
dialogue in the chat box. Definitely, far and
away we’re prescribing, just like you are, we’re
prescribing Elemental for our refractory SIBO patients. We’re a food-forward clinic. We’ve got, what do we have right now? Maybe 12 nutritionists? (laughs) so, we tend to be able to
design really creative, very individualized dietary
prescriptions for our patients. Even with that incredible offering, we still lean on the Elemental, most commonly, again, for refractory SIBO, is when we’re gonna jump on it. So, this is one patient
that I was thinking about, certainly we see SIBO
onset after food poisoning, and actually, in my experience, I would say that’s one of the most potentially refractory forms of SIBO, especially if there is
migrating motor complex damage and just turning that
around can be difficult. Interestingly as well, one
of our teach-ins has been, we’ve had a couple of
teach-ins with Dr. Rick Boles, who’s a pediatric geneticist
focused in mitochondriopathies, and a lot of mitochondriopathies present with gastrointestinal disturbance because GI tract is
extraordinarily energy demanding. And when you tease out
a genetic condition, you’re going to need
interventions longterm. And it can actually present, you can see GI, I’m thinking
of Ken, one patient, SD, who was diagnosed with a mitochondriopathy that presented with an IBS picture, and she’s got lasting gas and bloating. So, guiding her on how to use Elemental, even short term, to deal with a flare, whatever cause of flare, just kind of understanding that she’s not making energy as well, and so GI function is a little bit subpar, it’s been a great tool. So, SIBO, we use it frequently. We don’t necessarily start off with it, unless a patient’s coming to
us having failed elsewhere, where they’ve been using
a functional approach, then we might start. Ulcerative colitis, or
inflammatory bowel disease in general I think is a
brilliant use for Elemental. Same way we’re using
it as we do with SIBO, so patients will find us
because they failed elsewhere, either in standard of care medicine, or they’ve gone to other
integrative practitioners and they end up coming to
our practice at some point. So, they’ve done good, solid,
smart work for a long time and they’re still symptomatic, we might start them on an
Elemental for that reason. Or if our interventions are failing, we might move them over onto an Elemental, really kind of, not just
to keep nutrient status up and quench inflammation and begin repair, but it’s like cleaning the slate. It reminds me of Zen. When I practiced Zen Buddhism, there was this concept
called Primary Point where you bring everything
back to the Primary Point, and cleaning that slate can help us really identify what we’re missing in terms of their food inputs that may be triggering reaction. So, those are the ways we use them. EoE, eosinophilic esophagitis, or gastroenteritis of any
form, again, same way. For severe hypersensitivities, you can see I put a dust mite
allergy patient down there, that was his primary reaction. He was up, actually. Help him, and one of
the things that we tried was the Elemental Diet, just to see whether there was any food contributing to the baseline inflammation. – Kara.
– And it was– – Yeah, go ahead.
– Sorry to interject. I think you just cut out
there for a few seconds. Can you–
– Oh, I did? Am I back?
– Again. Yeah, and we actually–
– Am I back? – Yeah. – So, did you miss dust mite allergy? Do you want me to restate that? – You started with dust mite and then you kinda cut
off right after that. – I cut off? Okay. So, with him, his primary issue was this just huge dust mite allergy, has kept him up at night
with hives for decades, and I wanted to just quench
any and all inflammation, regardless wherever it’s coming from, just sort of, sinking
all inflammatory boats, just lowering the ocean, the metaphoric, physiologic ocean in
this guy of inflammation to see if we could make a
difference in dust mite allergy. So, that was one of my thoughts
around using Elemental. I have to say, I do think
outside the box I think quite a bit and use it
as a diagnostic tool. We don’t in our practice,
and Ken can talk about this, use it for that long. I would say on average, we’re doing an Elemental in our patients for maybe two to three days, and then for those folks,
like the woman with IBS second to a mitochondriopathy, we can support them in
jumping on an Elemental, kind of as needed, and doing
it for the length of time that they need for symptom abatement. We have used it for 14 days, so we have used the
standard recommendation, but I would say that that’s less often. Somebody wants to make a comment, Alex. – Yeah, Kara, there’s a
question that came in here from Margo and it says,
“Can this be used longterm “as a meal replacement,
i.e., once per day?” I have mine, but I’ll
let you say it first. – Yeah. I think that you probably can, yeah. I don’t really see an issue with that. I don’t know that one would
necessarily want to, based on… Yeah, I don’t know that one
would necessarily want to. It tastes pretty good, it really does for a full nutrient replacement, but I don’t know that I
would recommend doing it. – I would say–
– yeah, go ahead. – No, I would say the same. It is actually pretty good,
all things considered, but as a once a day type of intervention, if you’re intention is to
have a low inflammatory, or non-inflammatory
type of meal once a day, then yes, you can
certainly do that longterm. You’re getting the
caloric needs out of it, and if you were going
to be getting your fiber and your phytonutrients from your food on a longterm basis
otherwise, then it does work. But is it ideal? Not necessarily, and it’s also
potentially cost-prohibitive since it is quite expensive. – The other thing is, though, (laughs) what’s fascinating, there are some publications demonstrating that if somebody’s eating a
diet that they’re reacting to, if you do one Elemental meal per day and they continue eating
those problem foods, you actually do reduce
the immunological burden. So, me as a functional medicine slash naturopathic physician, I was pretty surprised when I read that. But I was also, it’s a good indication, like if you’ve got somebody
who’s really struggling with enacting the kind of
therapeutic dietary plan you want them to do, but they’re
willing to replace a meal, you’re gonna lower their
inflammatory burden with that partial application. And I just wanna actually, Alex, see if Ken has any thoughts. In fact, I’m sure he does. So, what do you wanna say, Dr. Litwin? – Yeah, and you have to keep in mind, it’s a totally liquid diet. Somebody has to be very motivated
to do that for two weeks. Sometimes they are motivated. But after a while, they’re less motivated. If I could get people to just do it for two weeks for their
SIBO, that would be awesome, but in the real world, people
go out, they go to work, and the taste, which as
Alex said, is very good, it gets old (chuckles)
after a week, I would think. I don’t know about you, Kara, but I’ve never taken it myself for a week, I don’t know. Have you?
– No. Nope, I haven’t.
– No. I mean, I know it tastes
good, I’ve tried it. – Yeah, yeah.
– I have done it for a week, and I can actually say, so you’re getting approximately
1,800 to 2,000 calories when you’re doing it per day, and I train virtually every day, and I was able to feel just fine on that. So, for the most part it’s, I think, with all my patients
that I’ve used it with and experimenting on myself, it doesn’t really have that
much of an impact on energy or how you feel from the–
– However, you know what I would say, Alex? Definitely advise your patients to see where they fall on that continuum, ’cause some folks may, in fact,
experience reduced energy. And actually, if they
do, that should pin you to check with them that
they’re administering the diet correctly.
– Yes. – So, in our experience, folks who haven’t tolerated
it well when you tease it, they might not be consuming enough water, they might not be sipping it slowly, they might not be taking
the appropriate quantity or distributing it correctly, and that could be insight. So, it may be that they’re
actually doing it incorrectly, which can cause dehydration and some pretty unsavory problems. We have a nutritionists room dedicated to educating our patients
on how to admin it, and then check in with them. I mean, we take the directions on the Elemental Diet extremely seriously, and the only times we’ve
seen fallout, I think is… basically when folks aren’t following exactly a correct structured protocol. So, don’t mess around
with it, it is a medicine, I mean, it’s an important, potent tool. – That’s a good point, actually. I had a recent case where the patient couldn’t find the scoop
’cause it was at the bottom, and so she used a scoop from
another protein container and we calculated that she was getting about half the amount of calories. Luckily, we caught it after
a few days (laughs) but– – Yeah, ’cause she felt lousy, no doubt. – Well, actually surprisingly, she didn’t. This is kind of the catch, otherwise she would’ve
reached out much sooner, but she was (muffled speaking) and I thought, wow, there’s
something going on here. If you’re sustaining yourself
on 1,000 calories like this and don’t really feel a difference. So, anyways, that’s another topic. There was another question here that I thought was relevant. You mentioned EoE, this
is slightly different, but Salma was asking, just lost it here, “Could it be used for
high eosinophilic reaction “in parasitic infection?”
– Maybe. You know what, I think that you could. You would be eliminating
some of their foodstuff. I mean, bacteria can definitely act on, or parasites can use these micronutrients, but they’re not gonna be
using it as efficiently. I mean, that’s one of the
things that you’ll see in the Elemental Diet, it’s
a little bit of a fast, it has a little bit of a fast
effect on the microbiome. You’re keeping some important
foodstuffs from them. So yeah, you might find benefit with it. I mean, certainly some of the side effects of parasitic infection, diarrhea, gastroenteritis in general. You know, honestly, I haven’t used it for parasitic infections yet, but I would not be surprised
if there’s some research, and maybe somebody can
actually look and see and let us know whether there is. You know, the other piece
that I wanted to say, I don’t wanna forget another use. So, I said severe hypersensitivities, as the fourth bullet there. They don’t need to be
immunological hypersensitivities. I mean, in this day and
age we’re seeing loads of intolerances,
non-immunological intolerances, histamine intolerance, what else? We’re certainly seeing
lactose intolerance in spades along with SIBO, and
histamine intolerance is up for the same reason. We’re seeing more reactions to additives like carrageenan, oxalates,
salicylates, et cetera. We’re just seeing heightened reactivity, be it immunological or non-immunological. And I think some degree of bowel rest with the Elemental Diet can be helpful, and also, again, clean the slate so that you can do really careful, structured reintroduction
or challenge processes with your patients to
really kinda nail down what are the deal breaker nutrients, or nutrient combinations? – Yeah, absolutely. I had another question here from Tracy that we can maybe touch on. “Do you ever use these
products with infants, “children, or teens?” I don’t have any experience
with anyone under the age of 20. Do you?
– Yeah, I don’t. I don’t. Does anybody on the team? If you guys can weigh in in the chat box? Ken? – Dr. Berg was saying
that she’s used Elemental. – Oh yeah, quite a bit.
– Mm-hmm. – Yeah. We have Dr. Elizabeth Berg
is gonna be joining us, or she’s joined our
practice as a pediatrician, and yeah, we were talking
about this recently in one of our rounds meetings, and yeah, she’s used
Elemental in peds quite a bit. You can. We just haven’t done it. In fact, we see EoE in
kids all of the time, and if they were up for it, this would be an appropriate intervention, at least for the short term. – Yep, absolutely. Okay, I see you jumped to the next slide. – Stay on task, yeah. – Yeah, let’s stay on time here, so let’s get through the rest. We have one more poll coming up, so go ahead with the next few slides and then we’ll keep addressing
some questions at the end. – I think I talked about this, we’ve already kinda
touched on a lot of these, preparation, education. Do the diet correctly. You might consider
generating some handouts for your patients, or have
one of your support staff who really understands it,
guide them in it as need be. So, you start with them and then maybe have a
support staff, if you can, just pay attention, or
you pay attention yourself so that they’re doing it right. – By the way– – They’re adequately
hydrated, and so forth. Yeah? – Elizabeth just chimed in here saying, “It is absolutely indicated
and used in kids.” So, just confirming that. – Thanks, Lizzie.
– Yeah. – (laughs) Nice to see that you’re there. All right, so what do
I wanna say about it? Yeah, so, you know, the antimicrobial
support, motility support. Antimicrobial support is… It’s day rigor in our practice now for gastrointestinal imbalances. Maybe, I’m actually thinking about some of the
extraintestinal indications like my hives patient. You know, he did have
pretty marked dysbiosis, and so we had him on antimicrobials. You can start with antimicrobials, based on how they tolerate, we’ll give you some
Integrative Therapeutic suggestions in a minute. If they can tolerate
it through the duration of the Elemental Diet, great, if not just have ’em hang back, or really reduce the dosage
to maybe one cap a day, or whatever they can handle. It’s gonna be exposed to
the gastrointestinal tract, the microbiome, et cetera, more aggressively than if
they were taking it with food. So, there might be a little
bit less of tolerance. Incidentally, on that note, you may need to stop a lot of supplements. I would, in fact, start with a
skeleton supplement protocol, keeping them on only the most necessary medication and supplements, things that are notoriously problematic, like fish oil and B vitamins
are kind of classic irritants, you wanna stop those altogether while they’re on the protocol, again, unless they absolutely need it. So, antimicrobial support, we do it all of the time with
our Elemental Diet patients, maybe some exceptions for
extraintestinal conditions, just be mindful of how you’re
dosing it during the diet. As you probably already know, the Physicians’ Elemental
Diet has a dextrose-free form, that’s what we’re using most commonly. Implementation, as we talked about, we don’t do it longterm. Perhaps that’s because we’re doing such individualized
diets with our patients, but two weeks is the max, I think, that we’ve ever prescribed
it in our practice. Reintroduction, I’ve
already talked about that, we tend to do challenges
where people are introducing one food or a group of most
likely safe foods at a time and tracking that, and documenting it, and working closely with a nutritionist. So, remission, we wanna
rebuild the epithelial wall, and there’s some recommendations. You wanna support digestive
function as indicated. You may need to support motility concurrent to the Elemental Diet, or prior to, and then after. There’s some recommendations there. We use 5-HTP sometimes in
practice for that reason, and sometimes we’ll do pharma. You obviously want to work
on microbial balance as well with pro and prebiotics as indicated, as you can introduce them, as
the patient can tolerate them. I think probably one of the best things, one of the easiest things to do with pro and prebiotics is really wait until symptoms have abated and they’re starting on reintroducing food and they’re doing pretty well, and then you can start
with pro and prebiotics, and just have ’em open the
capsule if they need to. We do lots of pinky dosing for folks who are particularly sensitive and then they can just build up as they determine tolerance. Generally speaking, if
somebody’s not gonna tolerate a probiotic or a prebiotic
they’ll know quickly. Yeah, go ahead, Alex. – Yeah, just chiming in here. A couple more questions coming in that I thought are relevant. The first one is, and actually going back to the case studies before, but relevant here as well, would you start with a 5-R,
or some sort of a limited type of situation first, or would you jump right
into an Elemental– – Yeah, okay, so let me
just walk you through the flow diagram of how we think about Elemental in practice. Because we’re kind of a tertiary care functional medicine center, we’re sort of a boutique practice, where people come to us,
or are referred to us through other functional
medicine providers, or after they’ve already been through a lot of standard of care medicine. People can be pretty
sick when they get here, and they can have already
tried a lot of interventions. So, those folks, we might jump
into an Elemental right away. If they haven’t, though, yeah, we’re gonna be doing the 5-R, we’re gonna be doing an elimination diet, we’re gonna be doing standard, easier to do interventions first before we jump into an Elemental. So, Elemental is a secondary,
or even tertiary intervention for us in our practice. But sometimes we see patients who’ve already been through
many different care providers and they need to jump onto it right away. You know, for instance,
actually I have a great blog, this was before Integrative Therapeutics released their Elemental Diet, but it was a patient who
came to me from out of state and she had a rash, The
Rash That Wouldn’t Quit is the title of the blog
if you wanna read it, and you can see what we did for her diet. I talk a little bit
about our interventions. She needed to be on an Elemental. So, she had this almost head-to-toe, it covered most of her body, I think it spared her palms and it spared her face, and it was a rash that
was actually a combination of atopic dermatitis, contact dermatitis, hives, dermatographism,
it was just a collection of really horrible skin conditions that happened after food poisoning, then she developed C. diff
colitis, she was hospitalized, developed C. diff colitis as a result of the intervention and
was treated for that, and she continued to have colitis anyway. Just a collection of
challenging, challenging things, and then she ended up with this rash, she was on steroids for a full 18 months and the prescribing physician said “I have to stop the steroids,” so she looked us up when she had two weeks left of her steroid taper and was like, “You have to fix this rash.” She needed to be on an Elemental. We didn’t have a good Elemental back then, but we did a micro, micro,
micro hypoallergenic diet, and what is my point? So, there’s an extraintestinal example of somebody who needed
to be on it immediately. So, we wanna go with
the easiest intervention that’s going to yield good results, and then move towards
thinking about Elemental as secondary or tertiary. Okay.
– Perfect. – Go ahead, anything.
– Just two things here. One, there’s a few questions coming in regarding reintroduction of foods. I’m gonna just plug in that
the way I usually do it, is I’ll start someone on
more of a liquid diet, so broths, or soups, or pureed things initially for the first three days just to get them more
ramped up in digestion, and then slowly reintroducing
things after that. What do you do?
– Yeah. We don’t, actually. Or I don’t. Ken can speak to how he prescribes the therapeutic diet
intervention post Elemental diet, but what we do, is we’ll
do a food challenge, and we’ll start with one,
or maybe a couple of foods that they were good with before and have them reintroduce. So, we may have them continue, well, we will have them
continue on the Elemental and start their challenge and do that for a few days
before we transition them into a really good hypoallergenic diet, and then once they’re on
that hypoallergenic diet, which may be just a little bit of chicken and some veg as they’re tolerating, and then we’ll continue with the rebuild. We’ll be in a 5-R at that point for the person who was asking about that, and then continue to
slowly expand their diet as we’re able to.
– Yeah. – Ken, do you have any comments on that, on what you’re prescribing? – I do think that going from a liquid diet to a solid diet can be a little, it can upset the system a little too much, so I like to prescribe soup, soft foods, just for a few days, and then move into solids. – Okay, I think that’s reasonable. Well, you know what, the nutrition team, maybe if you guys have any thoughts on it you can comment. Yeah, go ahead, Alex.
– Yeah, just to clarify, you know, I’m doing the challenge as well, so if somebody tolerated bone broth, chicken bone broth before, then that’s what they can bring in first to see if they’re tolerating it. But like you said, while
maintaining the Elemental Diet as it’s phasing out, you start
doing the challenge already and then slowly transition from there. – It’s funny, because maybe it’s just me being a little anxious
to engage in anything that looks like a fast, although I am doing a
little intermittent fasting. I’m gonna do a full fast with our team, we’re actually coordinating it (laughs) as an aside. If you’re in our Immersion program, you can join us in doing… our own in-house designed
low calorie diet, but that’s as an aside. I tend to want to give
people some solid food sooner rather than later, because I think that’s just my own bias. But I think both of you guys are making really good points on a reason why you might not do that. All right, let me keep
going ’cause we have a lot– – Yeah, gotta be sensitive. I’m just gonna say one more thing. A lot of people are asking
about motility support, so before we get into that, we will talk a little bit
about that in coming slides. I’ll mention that there’s a great podcast between you and Dr. Steven Sandberg-Lewis where you talked a lot about that, and he had some great points
about how to do something like the upper and the lower
digestion, digestive tract. So, for people who are listening, check out that podcast episode on your podcast, New
Frontiers. (muffled speaking) – Yeah, really creative. Yeah, motility support. So, we’re doing kinda the
usual suspects botanically, and we’re doing prucalopride as well. And then if it’s an autoimmune process against the migrating motor complex, we’re working on all of our, again, turning back to the 5-R and doing the really
aggressive hypoallergenic diet, reshaping the microbiome, and so forth. What else, Ken? What else are we doing? You know, one of the things
I was just thinking about, sorry to cut out off, is we wanna work with
vagal nerve nourishment, and I was reading recently about transcutaneous
vagal nerve stimulation, transcutaneous vagal nerve
stimulation, so TVNS. And I was wondering about
that for motility and SIBO. So, they’ve used it. They use it for gut-brain
access correction, there’s some science around it with IBS, there’s IBS-associated anxiety, and of course a lot of
the patients in that study probably had SIBO if they
had done breath tests. But it’s another intervention
that I’m thinking about just in terms of supporting
vagal nerve function. Ken, any thoughts? – Yeah, I think that’s fascinating. I always tell people to do
those vagal nerve exercises, singing forcefully and
gargling, and all that. But (laughs) I think I talk about it and they don’t actually do it. – (laughs) If we have time–
– If they did it, it would be helpful.
– You’ll have to demonstrate. – Yeah. (laughs) Right, right. – We have to think–
– Dr. Lord was on our call last week and he was very emphatic about just sitting down,
eating in a calm manner, chewing your food, and that
kind of was more important in his mind than any other supplements or anything I could get. – Yeah, that’s a really
good point, Ken, yeah. We have to think out
the box with motility, it’s pretty challenging, hence my attraction to this
transcutaneous vagal nerve stim. Actually, I was at the immune
module a couple of weeks ago and there was a doctor there
who was talking to me about it, and it just piqued my attention
and I’d like to try it. So, I do think motility
can be really hard. We end up with longterm prucalopride for some of our patients. So, I think we’re always
thinking outside of the box for what we can do, certainly if our patients will respond to some of the botanicals, ginger, 5-HTP, et cetera, that’s fabulous. And a good subset of our patients will do just perfectly fine on that. – [Alex] All right. – Can I keep going?
– Please do. Okay, what else? Here’s he standard
Physicians’ Elemental Diet. This has dextrose, and then
there’s the dextrose-free form. Alex and I were talking yesterday and he’s over at Fullscript and was saying most of the folks are using the standard
Physicians’ Elemental and not the dextrose-free. I thought there would be sort of a wholesale movement to
this one, but we like it. We like this one quite a bit, but I think either is appropriate. Obviously if you’re using this one you might be doing a little bit better in terms of stimulating bad bugs, you might turn the volume
down, particularly yeast. So, you might think about
this dextrose-free formula in your folks who you know have some sort of yeast burden, and then
go with the other one for the rest of your patients. This is a brilliant product, Phytostan, it’s a broad spectrum antimicrobial agent, but you can see with the pau d’arco, and the undecylenic and the caprylic acid, it’s sort of niched toward yeast, however, it’s going to be balancing more broadly on the microbiome. And it’s got rosemary in it. If anybody’s following
our methylation research, rosemary is actually what
we call an adaptogen, it’s really good brain food, as an aside. I eat a lot of rosemary these days, in fact, I have a whole bottle
of it kicking around here. But it’s also potently
antimicrobial, as is thyme. And the nice thing about Phytostan is it’s well-tolerated, in my experience. So, normally if you’re
gonna give somebody thyme as a standalone essential oil, they’re not gonna tolerate
it on an Elemental Diet. You’ll have a better chance
in a combination product like the Phytostan. And I would start with just a single cap if you’re using it concurrent
to the Elemental Diet. You can go higher if you’re using it before they start on the Elemental, or following the Elemental when they’re consuming more foods. Berberine is a go-to in our practice. We use a lot of Berberine. Of course it’s antimicrobial, it’s a broad spectrum
antimicrobial botanical. Shouldn’t alter the microbiome
if you use it longterm. Many of our patients have some sort of a metabolic imbalance, so we know that everybody is, I think, familiar with the research demonstrating Berberine at about 1,500 milligrams to be as effective as Metformin. So, we’re going to be
thinking about Berberine for our gut patients who also
have metabolic irregularities, and of course it’s also good for correcting lipid imbalances. And then, actually, let me just flip over to the Motility Activator. So, this has ginger in it and it’s got Cynara as well,
artichoke leaf extract. Ken? Any comment? Anything else you’re doing? – No, I think the motility stuff, the betaine HCl, don’t forget about that, and digestive enzymes. – There’s some debate around using HCl– – And bitters. I’m really into bitters lately. – Yeah, yeah. Well, and again, using
bitters when you’re following Dr. Lord’s precept of
resting and digesting, allowing for the cephalic digestion to kick the symphony of digestion in, I think bitters can work really
good in that environment. We do Panplex 2-Phase, I think it’s a very
well-tolerated product. We will use bitters, or use
a little bit of lemon juice, apple cider vinegar if it’s tolerated. Once upon a time it was, now there are more and more individuals who don’t do quite as well on it. And sometimes we’ll do
HCl as a standalone. We actually compound HCl in practice. There was a time when you
could buy a liquid HCl, but we can’t get it anymore, and so sometimes with our
most sensitive SIBO patients, like say somebody with atrophic gastritis, or pernicious anemia, they tend to show up with SIBO for sure,
really refractory SIBO, you might need to do micro amounts of HCl, in which case we compound it. For people who are doing pretty well, Panplex 2-Phase is
well-tolerated and very helpful. I do find generally, though, that I’m going to start somebody on something more general
and then increase. So, maybe we’ll do bitters, maybe we’ll do lemon
juice, apple cider vinegar, maybe we’ll do a compounded low dose HCl, and then as they recover,
move them into the P 2-P. Ways that you can use it, I think we’ve already covered this. So, PRN Elemental, again,
patients who may need this longterm at various times, you just educate ’em on it. So, my IBD patient who (muffled) for a birthday dinner and flares, he can jump on the
Elemental Diet for a day. I mean, you don’t want
’em to use it as a crutch, you want them to stay clean
with a remission-inducing diet, but it’s a good tool once in
a while for those reasons. And here’s a table that I
think we’re giving to you. So, when to use, what the indications are. And then what else? Medical supervision throughout
the duration is essential, underscore, exclamation point, that’s when you’re gonna get best outcome. As I said, it’s prescribed
by the physicians here in practice, and
then the nutrition team is supporting folks through it. We’ve created our own handout material just because we want impeccable adherence. You wanna pay attention to weight changes, do you want weigh to go up? Do you want weight to go down? You want it to be maintained? Pay attention to exacerbation of symptoms or new symptoms, and then
of course, adherence. And like I said, so Alex did really well, he went and did an Ironman
while he was on his Elemental, that’s not the case with everybody, people might have to
transition into returning to their usual exercise. And intolerance of certain things may be an indication that
they’re not adhering. Any comments, you guys? – Let’s be clear, it was not an Ironman. (laughing) I think it is important to note that there will be changes that are met, and we haven’t really even talked about if you are dealing with a SIBO or a yeast overgrowth situation, if you’re all of a sudden
starving those microbes, you could have refractory symptoms because of that as well. And fatigue could be that, headache, even anxiety, skin conditions. We’ve touched on this a
little bit throughout, but just really monitor, and either having yourself
or someone on your team be able to check in with the patient or have them check in with you on a regular basis, especially
in those first few days to gauge how they’re responding and what’s going on. What I’ve seen as well, when
people are transitioning to this kind of diet,
there’s often quite a bit of anxiety and fear around, I’m just gonna be eating
this for the next two weeks? That’s it, nothing else? And so, there’s that
hand holding and coaching that can go a long way
to keeping them compliant to ensure that they’re
not falling off of it. – Yeah, yeah. No doubt, no doubt. Okay, contraindications. Anything that’s going to
alter glycemic response. If you’ve got a patient who’s on steroids who’s being maintained on steroids you wanna be really mindful
about introducing it, although, some folks you’re gonna want to, so just pay attention. Medium chain triglycerides,
not always tolerated. For that reason, for some folks, if you know that they’re
sensitive to MCT oil, have them start slow and
titrate up to a full Elemental. You can add concurrently
a little bit more MCT. We do that, and sometimes
it’s not tolerated. So, things that you
wanna pay attention to. You may need to get
aggressive with a 5-R first. If somebody comes to
you and they’re stoking a pretty good yeast infection, you may need to completely, or really pull that down into control with either pharmaceutical
or an aggressive botanical and dietary approach first before you move them onto the Elemental. What else? What else do I need to think about? – I’ll mention this–
– You may need to do concurrent interventions, as I think we’ve already talked about. Concurrent antimicrobial interventions. Yeah, go ahead.
– Yeah. No actually, we’ll skip it. Just wanna save time.
– Okay. Yeah, we’re almost, we’re over. All right, what else do I have? Blood sugar dysregulation, pay attention. Potentially constipating, but you’re really not producing much fecal matter on the diet. Again, just pay attention. If your patient’s experiencing cramping, make sure that they’re following
the diet appropriately, make sure they’re well-hydrated. Improved adherence, I think we’ve talked quite a bit about that, and again, we’ll give you some content to review to help you,
and to help your patient. So, here’s some of the things we’ll make available to
you after this webinar. And that’s the last slide. All right, well thank you
so much for joining us. Sorry we went over just by a hair. I can see we’ve had zillions of questions, and again, anything that’s important that we didn’t get to, we’ll
pull something together. We’ll pull a followup document together. So, it’s just really been
great to be with you. – I’m gonna make one last mention here. Somebody had asked about Canada. So, we do not carry
Integrative Therapeutics Elemental Diet in Canada, but we do have two other brands that do offer product. I won’t mention it on here because this is a collaboration with Integrative Therapeutics, but if you’re in Canada
and you use Fullscript, just type in Elemental, and you’ll see what’s
offered there as well. – Thanks for my team for jumping in. Ken, it was really nice, kind of an unexpected pleasure to have you on the line with us. This was a little bit of an experience of what one of our calls our with– – We would’ve totally had a discussion about Elemental Diet on our PGR. – Well, we’ve had many discussions about Elemental Diet on our PGR, and we prescribe ’em quite
a bit, yeah, for sure. All right, again, thanks for coming, and it was great to have you. – Thanks so much to
everyone who joined us, and wishing you a wonderful day. Thanks again, Dr. Kara and Dr. Ken. (bright upbeat music)

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