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 Hydrolysatea 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.

OR

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.

Elemental vs. Semi-Elemental vs. Polymeric Diets
15 Comments

15 thoughts on “Elemental vs. Semi-Elemental vs. Polymeric Diets

  • is braggs amino acids acceptable for the remission diet? a little something to flavor your food that isn’t damaging would be nice.

  • hmmm… that’s a very good question. It says it contains soy protein and water. So, as long as it does not contain any of the starch component of the soy (which presumably it does not) it should be okay.

    Can you contact them and find out? Also ask them WHAT form the soy protein is in – is it isolate, concentrate, etc? Then post here what they say….

  • Hi Jini,

    I have purchased a number of different books in the last couple of months including Break the Vicious Cycle, How to live the SCD Lifestyle, Listen to your Gut, The IBD Remission Diet and Inflammatory Bowel Disease by Doctor John Hunter.
    I bought these books as I want to get pregnant and have refused to take medication for the last two years and I am looking for an alternative.

    Needless to say I am confused at all this information but have decided to take your approach to treating my Crohns. The problem is I purchased a large amount of Elemental 028 and would like to know will it be as effective as Absorb Plus if I add the additional supplements? The reason I purchased this elemental product was because the doctor who wrote the Inflammatory Bowel Disease book had used this product to induce remission. Patients then re introduced foods and by not eating foods which caused a reaction for a number of years were eventually cured.

    I would appreciate it if you could offer me any advice on the product I have chosen.

    Thank you

  • REBECCA – I would be very surprised if you could not return the Elemental 028 you bought and if the retailer refuses, I would contact the manufacturer.

    I don’t know which form of 028 you have as the ingredient list varies. The biggest problems I see with this product is that glucose is the largest ingredient (sugar) in the Extra 16 version, the oils are not cold-pressed and likely GMO (esp. the canola oil) and it contains only free-form amino acids – which you cannot gain weight from. In the Extra 17 version, it also contains artificial flavors, emulsifiers and stabilizers. Basically, this is the type of product they tried to give me at the hospital and I was so appalled that I mixed up my own shakes instead — which eventually led to Absorb Plus.

    I also couldn’t drink this kind of product as the oil gave me terrible spasming – it’s too much and in aggravating forms – it even gave my healthy husband intestinal spasms when he drank one as a test.

    Still, on the flip side, in all the clinical trials on elemental diets they do use this kind of product, so obviously for many people the benefit of bowel rest outweighs the poor ingredients.

    Well, you could always give it a 3 day trial and see how your body responds and what your own gut wisdom is telling you about whether it would be alright for you at this time.

  • Hi Jini,

    Thank you for your response. I have already used this product and water exclusively for two weeks before Christmas as I was having a flare and to prepare myself for a six week elemental diet I wish to do in the new year when I have enough money to pay for everything needed for optimum bowel healing. I found the first week I felt really unwell because my body was getting rid of toxins. I did also lose muscle mass but as you say its because this product only contains free form amino acids and I should of supplemented with whey isolate but did not know this at the time.

    I have read through the product list and although maltodextrin is the second ingredient sugar is its third. There are also a number of flavour enhancers and other additives which are a concern. Obviously I know now Absorb Plus is a superior product now but its too late as I have used it already. Hopefully using this product for a month with additional supplements and a two week supply of Absorb Plus will still be effective.

    I have started taking Natren, Udos oil, l-glut-amine, glucosamine sulphate and wild oregano oil. My condition has improved but I want to get pregnant so need to be as well as possible and also have this illness the last eighteen years (now 28) so want to pin down my exact food intolerance’s.

    Thank you for all your advice again as my doctors solution for a flare during pregnancy is to put me back on Imuran or operations for my strictures both of which I don’t want to ever have to do again.

    Yours gratefully
    Rebecca

  • Hey Jini

    You say weigh gain from amino doesnt work but to me it doesnt make sens. Babies fed on elemental formula for infant do gain weigh
    (I assume they do or those formula would be out of the market for years…)

    So obviously, amino acid is used in the making of muscles mass ,No?

    Woa, Im so confused….

  • Wow, it’s a shame that such patently incorrect information is being provided to people who seem to be under the false impression that you’re a healthcare practitioner. Despite the multitude of inaccurate statements on this page, I will correct two. 1) People can absolutely gain weight on amino acid-based nutrition, and most healthcare professionals whose practice focuses on nutrition would agree “elemental” should be reserved for amino acid-based nutrition. 2) There are absolutely amino acid-based (“elemental”) infant formulas, which promote normal infant growth. If you’re going to pretend to be an expert, at least check a search engine before providing answers.

  • Hi
    Do you know of any elemental feed or nutrition supplementation that don’t contain any sugars?
    Many thanks
    God bless

    1. Hello Bella,

      It depends on what form of sugar you are concerned about. The source of sugar we use is like that in a apple. Here is some information that explains the fructose in some of the flavors:
      http://blog.listentoyourgut.com/i-have-insulin-resistance-can-i-safely-consume-absorb-plus/

      The sugar in the unsweetened flavors only comes from the tapioca maltodextrin. If you have more questions concerning this please let us know.

      As for sugar in our nutrition supplementation, it depends what you are looking for but the majority of them do not have any sugar sources in them.

      Kind Regards,
      Rachel
      Customer

  • RE: My previous comment April 17, 2016 at 4:51 pm, here are the four amino acid-based infant formulas that are available in the United States, all of which have been demonstrated in clinical trials to support adequate growth of infants, and some of which have been successfully used since the 1980s:
    Neocate Infant DHA/ARA (www.neocate.com)
    EleCare for infants (www.elecare.com)
    Puramino (www.puramino.com)
    Alfamino (www.alfamino.com)

    Any licensed or certified healthcare professional, particularly a registered dietitian nutritionist, who manages the nutrition of patients will tell you that a diet based on any form of protein – including amino acids – can support growth, when appropriately managed to meet energy and protein needs. Amino acid-based nutrition is successfully used in the dietary management of allergic conditions, such as eosinophilic esophagitis and food-protein-induced enterocolitis, as well as digestive disorders such as Crohn’s disease and short bowel syndrome. It is so well established that children and adults can grow well on amino acid-based diets that it’s challenging to find references to support this, because clinicians know this and researchers have more important things to study. However here is one example:
    http://www.ncbi.nlm.nih.gov/pubmed/16301010

    Finally, just because you cite a source for a statement does not make the statement credible. For example, the research you cite related to the use of various forms of liquid nutrition in the management of Crohn’s disease (Raouf et al, Gut 1991) is extremely outdated. More recent, well-designed research and reviews of the available literature support that any formula, regardless of protein format, is as likely to be as successful as any other in the remission of Crohn’s disease. Those who come across this page looking for answers should really consult a licensed or certified healthcare professional who practices medicine based on sound scientific evidence, versus someone who is peddling a commercial product based on anecdotal experience.

    And in regard to the previously posted question and your reply:
    There is no commercial amino acid-based (the truest form of “elemental” protein) or extensively hydrolyzed (also described by some healthcare professionals as “elemental”) formula that does not contain sugar. The only way to achieve this would be to use what healthcare professionals term a “modular” approach – essentially building a formula using separate components. Fructose, regardless of the source, is still a monosaccharide, or simple sugar. I would encourage anyone interested in pursuing this approach, or concerned about “sugar,” to consult a doctor and/or dietitian to ensure nutritional adequacy of the formula.

  • Hi RDN – The one study you linked to does not provide any data on patient weight gain or maintenance. It refers solely to disease remission – which is not the issue in question here. Also, you will note that the products used in this study include “(12 polymeric; 13 semi-elemental; 12 elemental diet)” so they were not even using exclusively free-form amino acid products anyway.

    I looked at the ingredient list for the first product you listed – Neocate and here it is:

    Ingredients: Corn Syrup Solids (54%), Refined Vegetable Oil (Medium Chain Triglycerides (8%), High Oleic Sunflower Oil (6%), Sunflower Oil (5%), Canola Oil (4%)), Calcium Phosphate Dibasic (2%), and less than 2% of each of the following: L-Arginine L-Aspartate, L-Leucine, Tripotassium Citrate, L-Lysine Acetate, L-Glutamine, L-Proline, CAEM (an emulsifier), L-Valine, Glycine, L-Isoleucine, L-Threonine, L-Phenylalanine, L-Tyrosine, L-Serine, L-Histidine, L-Alanine, Sodium Chloride, L-Cystine, Magnesium Chloride, L-Tryptophan, Choline Bitartrate, L-Methionine, Tricalcium Citrate, Magnesium L-Aspartate, M. Alpina Oil*, C. Cohnii Oil**, M-Inositol, L-Ascorbic Acid, Taurine, Ferrous Sulfate, Zinc Sulfate, L-Carnitine, Uridine 5’-Monophosphate Disodium Salt, Cytidine 5’-Monophosphate, Niacinamide, Inosine 5’-Monophosphate Disodium Salt, Adenosine 5’-Monophosphate, Calcium D-Pantothenate, Guanosine 5’-Monophosphate Disodium Salt, DL-Alpha Tocopheryl Acetate, Ascorbyl Palmitate, Manganese Sulfate, Thiamine Chloride Hydrochloride, Pyridoxine Hydrochloride, Cupric Sulfate, Riboflavin, Vitamin A Acetate, DL-Alpha-Tocopherol, Potassium Iodide, Mixed Tocopherols, Folic Acid, Chromium Chloride, Phylloquinone, Sodium Selenite, Sodium Molybdate, D-Biotin, Vitamin D3, Cyanocobalamin.

    So… 54% Corn syrup solids (!!) and less than 2% of each amino acid. I think we know where the infant growth on this formula is coming from!

    Anyway, I’m not sure where your aggression and derision is coming from in your comments… unless it’s just a general disdain for anecdotal evidence. Which I am very transparent about and I am also clear that I have purposely not obtained any “professional health” designations. I just share my story, my thoughts, my research to date, etc. I’m sorry if that offends you.

  • Is unpasteurized cheese that melts in the mounth accepted in the elemental diet? Does it stil cointain probiotics?
    Thank you.

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