VSL3 – Sample

What is VSL3?
VSL3 is a probiotic (healthy bacteria for your gut) that has shown some clinical benefit for people with IBS or UC. Probiotics can help reinoculate the gut with a healthy balance of good bacteria to improve digestion & colon health.
It is not a prescription, so dietitians or patients can order it or purchase over the counter from select pharmacies.

How should it be taken?
I recommend starting with a small portion of a capsule to start, slowly increasing to the full dose of 2 capsules per day.
Here’s a regimen to increase doses gradually up to 2 capsules per day:
  • 1/8th capsule for 4 days
  • 1/4th capsule for 4 days
  • 1/2 capsule for the next 4 days
  • 1 capsule for the next 7 days
  • 2 capsules per day from then on

If you don’t notice any adverse reactions like gas or bloating, that means it’s safe to increase the dose to the next level. If you reach a dosage where you are having a bad reaction, decrease back down to the previous dosage and try the larger dose again in a week.

More instructions:
  • Simply break open the capsule & pour the correct amount into cold water or juice & drink it. Don’t mix it with hot liquid because that will kill the bacteria.
  • Once you are taking 1 whole capsule, you can just swallow the capsule whole & not worry about breaking it open into liquid.
  • It doesn’t matter what time of day you take it or if it’s with food or not.
  • The capsules contain a HUGE number of bacteria, so it is best to start slow & work up to the full dosage to avoid overwhelming your system.
  • As always, watch for reactions. It is possible to react poorly to almost anything, so just be vigilant.

What are the recommended doses?
VSL3 recommends the following doses for different conditions:
  • IBS: 2-4 capsules per day (225 to 450 billion CFUs)
  • UC: 4-8 capsules per day (450 to 900 billion CFUs)
It can take weeks or months to see improvement in stool consistency/frequency, so it is important to give it some time to work.

Elemental Diet – Sample

What is an elemental diet?                 

A temporary diet (usually for ~4 weeks), during which no food is consumed, and only pre-digested nutrients are consumed in the form of a beverage. The mixture can purchased as an elemental powder or made at home using special ingredients.


Who is an elemental diet best for? 

It works best for those with SIBO, who are attempting to starve off the bacteria in the small intestine, or those with inflamed or injured bowels who need bowel rest and/or extra nutrition.

When used properly is has an 80-84% success rate with eradicating SIBO. Should reduce gas levels within 2 weeks, which can help reduce or eliminate the need to use prescription or herbal antibiotics. 


How does it work?

  • The goal of the elemental diet is to provide the body with pre-digested nutrients, so that the digestive tract has to do very little work.
  • Once the nutrients reach the small intestine, they are already in the form the body likes to absorb, so they can be quickly taken from the gut and into the bloodstream to nourish the body.
  • The idea is that when the pre-digested nutrients reach the small intestine, they will be absorbed so quickly, that any bacteria in the small intestine (as is the case with SIBO) will not have a chance to eat them.
  • This should quickly reduce any symptoms of bloating, if SIBO is the cause, since there will be nothing for the bacteria to ferment and create gas from.

What proportion of nutrients do these diets contain?

  • 14-18% protein (in the simplest form, amino acids)
  • 42-76% carbohydrates (in the simplest form, monosaccharides)
  • 6-43% fat (in the simplest form, fatty acids)

 Is the elemental diet expensive? 

  • It can be…
  • Physicians Elemental Diet by Integrative Therapeutics
    • Comes in 2 sizes: $53 for 1 day’s worth (12 scoops, 1800 calories) or $123 for 3 days (36 scoops)
    • Total cost for 2 weeks = $615 – $723
    • Total cost for 3 weeks = $861 – $1,113
    • Total cost for 4 weeks = $1,230 – $1446

Is there anything to monitor while on an elemental diet?

  • Weight – to make sure calorie needs are being met
  • Symptoms – to make sure the formula is not exacerbating symptoms
  • Adherence – to make sure there is nothing else hindering symptom relief
  • Electrolytes – if feeling dizzy or lightheaded, can add an extra pinch of salt to the drinks

 Are there any side effects? 

Mental:

  • It can be difficult to adjust to not eating. You may feel extra emotional or irritable during the diet.
  • Try to stay active with friends and family during this time to keep your mind occupied.

Physical:

  • Since the formula is concentrated, it could cause cramping if consumed too quickly in large doses.
    • If this occurs, double the amount of water you’re mixing with the powder, and take the full 60 minutes to drink it slowly.
  • Since no fiber is being consumed, constipation is likely.
    • If this becomes a problem, we can add a prokinetic supplement.
  • Temporary die-off reactions can occur when bacteria or yeast are eradicated. This may cause flu-like symptoms, but should resolve within 10 days.

What is the protocol for consuming the elemental beverage throughout the day?

Daily Protocol:

  • Mix 1 scoop with 6 oz of water (the packaging says 4-8oz, but 6oz is the sweet spot). Consume slowly, over a period of 45 minutes to 1 hour (depending on how your body handles it).
  • 1 scoop = 150 calories
  • Figure out how many calories you need, then space your feedings throughout the day into ~ 3 or 4 “meals” (with however many scoops you need per meal to meet your needs).

Sample Schedule:

  • 8am – 1st “meal” in the morning (4 scoops in 3 cups of water, consumed slowly over a 1 hour period) + 1 tablespoon MCT oil
  • 12 pm – 2nd “meal” (4 scoops in 3 cups of water, consumed slowly over a 1 hour period) + 1 tablespoon MCT oil
  • 4pm – 3rd “meal” (4 scoops in 3 cups of water, consumed slowly over a 1 hour period) + 1 tablespoon MCT oil
  • If still hungry, can add a 4th shake (full or half portion)

Tips:

  • Let your hunger be your guide! Drink when you’re hungry, and don’t force a shake if you’re not, but in general, try for at 3-4 shakes per day.
  • To prevent flavor-fatigue, you can also blend it with ice for a change of texture, or serve it over ice for a change in temperature, or mix with carbonated water for a new flavor.
  • If you start to get sick of the smell, sipping through a straw w. a lid may help.
  • It’s easy to make it in a mason jar or portable cup so that you can drink it on the go.
  • Water is unlimited while on the elemental diet. Drink until you are no longer thirsty.
  • MCT oil is often added to the elemental diet to increase the % of fat & decrease carbohydrate load, especially if there is a history of high or low blood sugars or if you are on corticosteroids. Just be sure to titrate up the fat content slowly to avoid diarrhea!

Duration: Start with 2 weeks, and extend as needed based on symptoms or breath test results, up to 4 weeks.


Are any supplements needed?

Some people consume a prokinetic with the elemental diet to help stimulate bowel movements, but it is not required. We can revisit if constipation is an issue.

  • Ginger (100-300 mg, three times per day)
  • 5-HTP (50-150 mg, three times per day)
  • Artichoke extract (320 mg, three times per day)

All other non-prescription medications and supplements should be put on hold during the elemental diet.


How do I start eating food again after the elemental diet?

Best method: Get tested for food sensitivities via MRT (mediator release testing), and introduce low-inflammatory foods in a systematic way (LEAP diet).

Alternatively, create your own systematic path for food reintroductions, starting with easily digestible low-FODMAP foods that were well tolerated previously, while weaning off of the elemental diet.


What is the longest duration someone can stay on an elimination diet?

If it’s a partial elemental diet, one study has shown that 12 months is safe with Crohn’s disease (1).

For 100% elemental diets, most studies do a 2-week duration, some times 3 or 4 weeks (34), 6 weeks (5) or up to 12 weeks (6).


Can the elemental diet be used in children?

The Integrative Therapeutics elemental diet was not designed to meet the nutrient needs of growing children, so on the label, it officially says it is not made for use with children.

However, if a dietitian or other practitioner is specialized in pediatric nutrition, they could use the elemental diet powder in combination with well tolerated foods or supplements to meet the needs of the child while also addressing the SIBO, EoE, Crohn’s or whatever the elemental diet is being used for.

It is also likely safe to just use for a few days for a period of bowel rest without any danger of malnutrition.


Can an elemental diet be used in an NG tube?

There is really no data on this, so the official answer from Integrative Therapeutics is no. We need more information on the solubility, viscosity, flow, etc, of the formula. That being said, if this is your area of expertise, you could modify the elemental diet to meet the needs of your clients, at your own risk.


If someone is doing an elemental diet for SIBO, can they take antibiotics or herbals at the same time?

This is a hot topic of debate, with not much research either way. It’s mostly theoretical and based on practitioner experience.

There are 2 main theories on this:

  1. Some people think that if the SIBO is really bad and recurring, it might be helpful to use herbals or antibiotics and the elemental diet at the same time. (Essentially starving AND killing them at the same time).
  2. Others think that when the bacteria are being starved, they go into a protective “dormant” state, and won’t take up the antibiotics as well, so they will be less effective.

There is no consensus either way… Many people will start with antibiotics, them transition to a partial elemental diet, and then a full elemental.


If someone has known nutrient deficiencies and is taking a supplement, can they continue taking their supplement while on an elemental diet?

Yes, definitely. They will still need extra amounts of that nutrient while on the elemental diet if they are correcting a deficiency, so they should stay on their supplement.

If it is something like high dose omega-3’s, you could just consider the calorie contribution when planning the elemental diet needs.


What if someone feels like they start reacting poorly to a supplement while on the elemental diet?

Just take it on a case-by-case basis and adjust your protocol as needed. It could be possible that someone notices their reaction to a supplement more while not eating food.


How long does it typically take to start feeling better on an elemental diet?

Most people start noticing AT LEAST a favorable trend 3-5 days in.

If someone has seen no relief 1 week in, it might be a good idea to consider SIFO (small intestinal fungal overgrowth). Elemental diets can actually make SIFO worse, since the sugars will feed the yeast.

Some practitioners routinely add herbal antifungals (like Biocidin) along with the elemental diet just in case there is also SIFO happening. It’s so hard to distinguish between SIFO and SIBO, and there’s not great testing for it.


When is the best time to reintroduce probiotics after an elemental diet?

Again, there is no consensus on this. It’s always best to let your client’s body be the guide. No exact science… trial and error mostly at this point.


Should practitioners be concerned about biofilms in the gut?

Some bugs in the gut form protective biofilms to keep themselves safe from harm, so some practitioners recommed “biofilm busters” to break up the biofilm and make the pathogens more vulnerable.

NAC (N-acetylcysteine) is a well known biofilm buster (78910). It has mucolytic functions.

It can be added at doses of 1.8g/day, then titrated up to up to 5g/day or until you’ve reached the limit of your bowel tolerance. If you start having rotten egg smelling farts, you’ve had too much!

NAC is already in the Integrative Therapeutics elemental diet formula, but you need more in order to bust the biofilms.


If someone has histamine intolerance, should they be concerned about histidine in the elemental diet?

Histidine in an essential amino acid (meaning it must be consumed in the diet, and cannot be made in adequate quantities by the body). Therefore, it will always be present in elemental diet formulas. If you don’t get it in your diet, your body will catabolize its muscle to get enough.

The concern from some people is that histidine gets converted to histamine, and people with histamine intolerance are worried about reacting to it.

BUT, the fact is, you make way more histamine endogenously (released from mast cells) than you consume exogenously through diet, so it is unlikely to be a problem. Also, an elemental diet, by default, has removed all of the potential histamine-containing or histidine containing or mast cell degranulating foods that you might otherwise be eating, so it is actually likely to help reduce symptoms.

Too much histamine release from mast cells is a condition called mast cell activation syndrome (MCAS). For people with this condition (which can be comorbid with SIBO), they should focus on mast cell stabilization.

There is some research that elemental diets themselves can have mast cell stabilizing benefits (see EoE research).


Why might someone want to mix their elemental powder with more (8oz) or less (4oz) of water per scoop?

When you mix it with less water, it will taste sweeter and have a different mouth-feel, but it could cause cramping in the GI tract at this concentration.

If you are coming off of keto or something like that, you may want to try diluting your scoops a little more, with the higher end of recommended water. But you don’t want to dilute it MORE than that, because then you can’t absorb all the nutrients via osmosis because they won’t be at a high enough concentration in your small intestine. Then you could get osmotic diarrhea caused by the unabsorbed nutrients in your gut.


What is the purpose of a half elemental diet?

Elemental diets are really great for bowel rest. If the goal is to reduce stress on the digestive tract (rather than to knock out SIBO), a half elemental diet can be done, rather than a full elemental diet.

For a half elemental diet, you eat a real meal during a small time window, and consume the elemental diet formula the rest of the day (or fast).

You can also do a half elemental diet as you transition off of a full elemental diet onto a regular food diet.

During this time, lots of liquid meals, broths, and soups should be enjoyed in order to keep stress on the digestive system low and allow the gut to fully heal.

It is not a good idea to rapidly increase your fiber intake or go back to the same way of eating as before, or symptoms are likely to return (x).

Low-FODMAP or SIBO diet considerations could also be layered onto the diet to help keep the SIBO from coming back.

Ferritin – Sample

Why could ferritin levels be high?

  • Inflammation (acute or chronic)
  • Chronic alcohol consumption
  • Liver disease
  • Kidney failure
  • Metabolic syndrome
  • Cancer
  • Iron overload (less common)

Should definitely dig deeper if levels are >1000 mcg/L


Doctors will usually differentiate by examining in the context of other labs, such as:

  • Complete blood count
  • Liver & kidney function
  • Other inflammatory markers (CRP, erythrocyte sedimentation rate)
  • Can also do a genetic HFE mutation test to rule out hereditary hemochromatosis in people who also have elevated transferrin saturation levels (>45%)

What does ferritin indicate?

  • Low ferritin is the #1 indicator of iron deficiency anemia.
    • Those with a history of GI issues are at increased risk of ferritin malabsorption

What are “low” levels?

Levels <40 will probably manifest as fatigue, since the red blood cells are starved of oxygen.

Optimal levels are between 40-160 ng/mL


What supplements can help replete low iron?

Pure Encapsulations Iron-C, 2 tablets per day