In the last year or so, I’ve received a few emails from people suggesting that Absorb Plus is not actually an elemental diet product. And that only products with free form amino acids as their protein source qualify as “elemental”. Back when I first formulated Absorb Plus (in 1998), whey protein isolate was considered one of the best protein sources for an elemental diet. And at the time, the clinical studies on “elemental diets” varied between using free form amino acids, whey isolate, whey concentrate, egg albumin, etc. and all were considered acceptable ingredients in an “elemental” shake.
However, I’ve conducted a review of the current med literature and it seems that the definitions are shifting, but as yet, are still not clear. Here’s a summary…
According to the Medical Dictionary:
Elemental Diet – contains nutrients as small molecular weight compounds, i.e. proteins as amino acids or peptides, carbohydrates as oligosaccharides or monosaccharides, and fats as medium-chain triglycerides. Used in the treatment of gastrointestinal disease. Called also monomeric diet.
So according to that definition, whey isolate (which Absorb Plus contains) would qualify as an “elemental” product since it is a protein peptide.
However, according to this paper, Absorb Plus would be considered “semi-elemental” and a “specialized formula”:
The EN [elemental nutrition] formulas differ in their protein and fat content and can be classified as elemental (monomeric), semi-elemental (oligomeric), polymeric or specialized. Elemental formulas contain individual amino acids, glucose polymers, and are low fat with only about 2% to 3% of calories derived from long chain triglycerides (LCT) (3). Semi-elemental formulas contain peptides of varying chain length, simple sugars, glucose polymers or starch and fat, primarily as medium chain triglycerides (MCT) (3). Polymeric formulas contain intact proteins, complex carbohydrates and mainly LCTs (3). Specialized formulas contain biologically active substances or nutrients such as glutamine, arginine, nucleotides or essential fatty acids (Table 1). Although elemental and semi-elemental formulas cost about 400% more than polymeric formulas (4) they are still widely used because they are believed to be 1) better absorbed, 2) less allergenic, 3) better tolerated in patients with malabsorptive states and 4) cause less exocrine pancreatic stimulation in patients with pancreatitis.
(Source: Elemental and Semi-Elemental Formulas: Are They Superior to Polymeric Formulas? By Diklar Makola, M.D., M.P.H., Ph.D., Gastroenterology Fellow, University of Virginia Health System, Digestive Health Center of Excellence, Charlottesville, VA. PRACTICAL GASTROENTEROLOGY • DECEMBER 2005
In terms of taking this into the realm of practical application, I stand behind what I first discovered using elemental diets for myself and consequently wrote about in The IBD Remission Diet and that is that whilst free form amino acids are considered more ‘hypo-allergenic’, they are not often useful for inducing disease remission – because the person cannot gain weight and address malnutrition using only free form aminos. This becomes especially important when dealing with children on an elemental diet, who need to make up for lost growth and height.
I searched high and low to find the answer as to why people would not gain weight ingesting only free form amino acids as the protein source and finally learned why from a PhD in nutrition, who specialized in treating athletes: He said that the body will use free form amino acids more as a supplement (hormone pathways, mucosal lining, etc.), but it cannot use them to build muscle unless they piggy-back on a di-peptide (or higher) bond protein (like whey isolate). A really good paper that goes into this in detail is Protein digestion and amino acid and peptide absorption By D. B. A. SILK et al, Department of Gastroenterology and Nutrition, Central Middlesex Hospital, Proceedings of the Nutrition Society (1985), 44, 63-72
Yet more evidence that a semi-elemental diet is preferable to a strictly elemental diet is provided in numerous clinical trials, like this one with Crohn’s disease:
“A controlled trial was performed to compare enteral feeding with either an amino acid based feed or a whole protein feed as sole treatment for active Crohn’s disease.” In the group given the amino acid feed, 69% achieved remission within 3 weeks. In the whole protein feed, 72% achieved remission. But the interesting thing was, when researchers then switched the groups over onto the other diet – i.e. the amino acid group got switched to whole protein and the whole protein group got switched to amino acids only – 43% in the group switched to amino acids relapsed, but NONE of the group switched to whole protein relapsed.
(Source: Enteral feeding as sole treatment for Crohn’s disease: controlled trial of whole protein v amino acid based feed and a case study of dietary challenge. A H Raouf et al, Gut 1991;32:702-707)
So, as to whether Absorb Plus is an elemental or semi-elemental product, the jury’s still out. However, I would say the literature is evolving to eventually classify it as “semi-elemental”. But that will not take into account that back when many of the clinical trials were conducted on elemental diets, Absorb Plus was at that time considered elemental and so can reference these results for expected outcomes. Although, not really.
Because keep in mind that the IBD Remission Diet is NOT just a straight elemental diet, like those used in the medical clinical trials – it is so much more and I will do another blog post specifically on the differences. Likewise, Absorb Plus differs significantly in ingredients and quality from the pharma elemental products used in clinical trials – so in my opinion, the outcomes are likely not comparable; I would think using Absorb Plus and the IBD Remission Diet would result in much higher remission rates than current clinical trials indicate.
Hydrolyzed Whey Protein
Then there is yet another ambiguous term in play in the world of elemental diets: hydrolyzed whey protein, or, hydrolysates. Again, it is difficult to pin down a consistent definition of this substance – that is used consistently throughout the literature. Here are two definitions that are pretty similar, but again, one includes peptide proteins and the other only free form amino acids.
Protein Hydrolysate – a sterile solution of amino acids and peptides prepared from a protein by acid or enzymatic hydrolysis and used intravenously for the maintenance of positive nitrogen balance in severe illness, after surgery of the alimentary tract, in the diets of infants allergic to milk, or as a high-protein dietary supplement.
Protein Hydrolysate – a mixture of amino acids prepared by splitting a protein with acid, alkali or enzyme. Such preparations provide the nutritive equivalent of the original material in the form of its constituent amino acids and are used in special diets or for patients unable to take the ordinary food proteins.
Sounds like protein hydrolysates would be highly tolerated and nicely hypo-allergenic if used in an elemental diet shake, right? But again, we have the same problem with it being difficult to build muscle from these formulas. And the other huge problem is that hydrolysates are incredibly bitter in flavor, thus difficult to ingest and usually paired with lots of synthetic, artificial flavoring agents to make them palatable. Many however, are just pumped in via a stomach shunt, or intravenously.
If, for some reason, you cannot tolerate Absorb Plus and you must use a free form amino acid elemental formula, then the best ones (natural, no nasties added) I’ve found are the Alpha formulas from Nutramed. Most of the mainstream pharmaceutical formulas contain a truck-load of sugar, really high oil content and artificial flavors, colors, etc. – so although they can be cheaper, they are not what I would call a ‘health product’. In fact, here’s a quick price comparison of elemental shake products.
Vegan Elemental Shakes
Your other option, if you cannot tolerate whey protein isolate, is to use a vegan elemental shake. We have put together these Vegan Elemental Diet Kits specifically for that purpose.