Xifaxan® (Rifaximin) Plus the Elemental Diet Treats Methane SIBO

Are you considering trying the elemental diet to treat your small intestinal bacterial overgrowth (SIBO)?  The 14-21 day liquid only diet has been shown in research to be effective in treating SIBO. In fact, Dr. Pimental and others found that 80% of study participants drinking the elemental diet for 14 days had normal breath tests and that number increased to 85% after 21 days of the diet.

But not eating solid food for weeks-is it worth it, especially if you have methane overgrowth? In this post, we will discuss the efficacy of the elemental diet (my n=1 experiment), symptoms while on the elemental diet, how to know if the diet is right for you, and the various elemental diet options.

I am a fan of rifaximin as you may have gathered from this post “What you need to know about taking Xifaxan (Rifaximin) to treat your SIBO.” But if the hydrogen and/or methane levels from the breath test are really high from the start, then one round of antibiotics may not be enough. 

21 Days of Rifaximin/Neomycin Lowered My Methane Levels, but Not Enough!

I started the elemental diet because after 21 days of rifaximin plus neomycin, my methane levels were still high (see results below). My symptoms of severe bloating, constipation, heartburn, etc. were better while on the antibiotics, but they were still there and were starting to worsen again after stopping them. Obviously, I needed further treatment but I didn’t want to continue to take the antibiotics. The elemental diet was appealing to me because it didn’t involve antimicrobials, but would it work?

Breath test showing high levels of methane gas throughout 2 hour time frame

Lactulose breath 21 days after taking Xifaxan and neomycin

About the Homemade Elemental Diet  

There are different companies that make elemental formulas that I discuss below, but there is also a homemade elemental diet that you can make yourself. Dr. Allison Siebecker has the recipe published on her website. The diet has 2 versions, low carbohydrate/higher fat or high carbohydrate/low fat. Since I follow a low-carbohydrate diet, I went with the low carbohydrate/higher fat version.

The homemade elemental diet (low carb/higher fat option) ingredients included:

  • 1000-g bag of Jo Mar Labs Amino Acids: Black Label Pure Form 21 Blend
  • 63-93 oz honey* or 10 lb NOW dextrose
  • 1575-1890 mL of oil*, such as medium chain triglyceride, coconut, olive, macadamia, cod liver
  • 1 bottle of Pure Encapsulations Nutrient 950 Multivitamin
  • 1 bottle salt, preferably unrefined (eg, Real Salt, Celtic sea salt)
  • Optional flavorings such as vanilla may be used in small amounts

*I used honey and mixed 50% olive oil with 50% medium chain triglyceride oil.

Making the shake is easy, you just must mix the ingredients with water in a blender. How much shake you make depends on the calorie level that your body needs while also factoring in your activity level.

Here are my results after 14 days of consuming the homemade elemental diet:

Breath test showing 10 ppm or less of methane and hydrogen throughout 2 hour time frame

Lactulose breath test day 15 after 14 days of the homemade elemental diet

These results brought tears to my eyes. After years of treating and testing, a negative breath test was achieved!

What were My Symptoms During the 14-day Elemental Diet?

Some clients worry that they will have uncomfortable symptoms because their body is not used to a liquid diet for such a long period of time. The same worries were in my mind as well. I kept a detailed log of how I felt every day during the elemental diet and rated them based on a scale of 0-10, with 10 being the worst possible symptoms and 0 being no symptoms. My constipation dramatically improved by day 5 and my abdominal pain by day 7. This is a graphic representation of my symptom changes:

Picture of symptoms increasing and decreasing

Symptom changes while on the elemental diet

You can see on day 10 that my heartburn symptoms increased from a 1-2 (starting on day 5) to a 10 on day 10. My throat was on fire! In addition, symptoms of vaginal burning occurred on day 10. I know from history that both of these symptoms appear when I have a flare of candida overgrowth. My prescribing physician provided some fluconazole, 150 mg/day for 6 days and all of the symptoms improved by day 15.

How Does the Elemental Diet Work?

The ingredients in the elemental diet are completely broken down to the smallest unit, or you could say pre-digested. The body doesn’t need to do any digestive work and the nutrients are absorbed very high up in the intestinal tract. Because of this, there are no nutrients left to feed an overgrowth of microorganisms. Basically, the microbes are starved to death. This is great news for us, but not so good for the flavor profile of the drink. Pre-digested carbohydrates and fats don’t taste that bad, but pre-digested protein-uck!

Great, it Works, but the Taste……

My breath test results were picture perfect and my symptoms were in check by day 9 (except for the heartburn due to the candida). These were great results! Better than I could have expected. So why isn’t the elemental diet used more often or even before the big gun antibiotics are used?

There are many reasons for this (which I will discuss below), but the top one in my opinion is the poor taste. I mean, the shake tasted bad. But why? It’s because of the free amino acids. 

Amino acids are the smallest units of protein and are the end product of digestion. They are absorbed quickly and efficiently. Whole protein, like what is found in steak and eggs, is a large molecule made up of amino acids bonded together. For example, the main protein in egg has approximately 400 amino acids bonded together. When egg protein is digested, the body breaks it down into amino acids. Amino acids by themselves, otherwise known as elemental or free-form, have different tastes. These tastes are masked when they form whole proteins, but separate them and watch out taste buds!

What can be Done to Make the Elemental Shake Taste Better?

The company that makes the amino acids that I used, called JoMar Labs, has a Taste Chart that shows the different flavors that are associated with each individual amino acid. There are 20 amino acids that the body uses and these are included in the JoMar mixture. The flavor of the various amino acids ranges from tasteless to extra sweet on one side of the flavor spectrum to very bitter and extra sour/sulfury on the opposite side of the spectrum. It’s the amino acids that have a bitter and sulfur taste that ruins the flavor of the shake. Unfortunately, our body requires these particular amino acids, so they can’t be conveniently left out. The flavor of these particular amino acids is difficult to hide.

In conversation with Dr. Siebecker, ND (February 2020) to help with the poor taste, it was recommended to drink the shake ice cold and to use flavorings such as Crystal Light powder and flavoring extracts.

The shake tasted bad even after I added cinnamon or orange extract. By day 10, one shake per day or half of the calories is all I could gulp down. Yes, many resources say to sip it throughout the day for better tolerance, but if I had to sip it, I wouldn’t have been able to finish the diet. Right after I downed the whole shake as quickly as humanly possible, I brushed my teeth, which helped get rid of the taste.

Is this Diet Right for You?

Besides poor taste, the negative psychological effects, the potential for weight loss, and candida overgrowth are factors to consider if you want to start the elemental diet.

Psychological Effects can be Severe and May Trigger Disordered Eating

The psychological effects caused by the inability to eat and enjoy the pleasures that food brings were very difficult for me to overcome. I practiced positive thinking (e.g., “this diet is helping me heal from SIBO,” “it is only for 2 weeks”), as well as exercising, meditation, and emphasis on self-care while I was on the diet. But it was hard. The smell of the Mexican Café up the street was so enticing and depressing. I just wanted something, anything to chew on. Food invaded my thoughts. If only I could have a handful of almonds, anything to chew and taste!

If you have a history of disordered eating or you struggle with your relationship with food, then this diet may not be for you. Conditions like avoidance restrictive food intake disorder (refusal to eat specific foods due to a negative response) and orthorexia (an unhealthy focus on healthy eating) are on the rise due to the increased popularity of elimination diets. Sometimes going on an elimination diet, especially one this extreme could push someone over the edge to disordered eating. Please consult a professional for assessment before embarking on this diet.

Will I Lose Weight on this Diet?

Many patients with SIBO struggle with being underweight and are afraid that the diet will lead to more weight loss. As a dietitian, I can tell you that if you are underweight, you can still do this diet. If calorie, protein, and fluid needs are met, weight loss should not be an issue on the elemental diet. I have found that in many cases, the poor taste leads to under-consumption. Not consuming enough calories on the diet is the main reason why people lose weight.

You Might be Killing SIBO but Encouraging Candida

This topic is a little controversial amongst natural healthcare practitioners-does the elemental diet set the conditions for fungal overgrowth? Small intestinal fungal overgrowth (SIFO) seemed to be as big of an issue for me as my methane overgrowth. There are interactions between fungi and methanogen organisms, which might explain this connection. There is evidence to indicate that SIFO causes symptoms such as belching, bloating, indigestion, nausea, diarrhea, and gas.  According to a conversation with Dr. Allison Siebecker, ND (February 2020), clinicians should use caution when recommending the elemental diet to patients with a frequent history of yeast overgrowth, since simple sugars in the elemental diet can exacerbate the yeast. My symptoms that started up around day 10 responded well to anti-fungal treatment during and after the elemental diet.

Other Elemental Diets that are Available

The two advantages of the homemade elemental diet are 1) the ability to control the amount of carbohydrates and fat; 2) the lower cost. The homemade elemental diet cost me around $275 for 14 days. Commercial elemental formulas like Physicians Elemental Diet, Absorb Plus by Imix Nutrition Inc. and VitaAid Professional Therapeutics costs between $450-$600 for 14 days. Keep in mind, while you are on the elemental diet, you won’t have to purchase groceries, so this will offset some of the costs.

I tasted the Physicians Elemental Diet at a conference and it tasted better than the homemade elemental diet so the increased cost may be worth it to you. However, some people complain that it is too sweet.

Dr. Ruscio has a line of meal replacement powders called Elemental Heal. Two products (vanilla and chocolate) have some free-amino acids in the ingredients but also contain a dairy protein called whey protein isolate. These formulations are considered semi-elemental, or partially digested/broken down.

Semi-elemental diets consist of formulas with protein in the form of small peptides (several amino acids bonded together) rather than free amino acids. This helps significantly with the taste profile of the formula. Research shows that semi-elemental diets can be just as effective or more effective than elemental diets when considering diet side-effects and absorption of nutrients.

Dr. Ruscio has another product that is whey-free and is considered completely elemental. I haven’t tasted any of these formulations but have heard from others that the semi-elemental taste pretty good. This makes sense since partially broken down protein tastes much better than free amino acids. The semi-elemental diet has not been researched in SIBO but is something that hopefully will be looked at soon.

The Good News-There are Many Treatment Options

There are many treatment options for those of us with SIBO [intestinal methanogen overgrowth (IMO) in my case]. We have pharmaceutical antibiotics, herbal antibiotics, the elemental diet, and the semi-elemental diet. There are various ways that these options can be combined.

Would I do the elemental diet again? Well, I have done it twice but probably won’t do it again. I did this diet in 2017 and have since learned other approaches to control my overgrowth, plus addressing my main underlying cause was helpful. I wrote about that here: SIBO After Surgery, Are Adhesions to Blame?

The elemental diet is a great tool to have in our toolbox and it was certainly successful for me.

If you are interested in trying the diet, make sure you work with a knowledgeable practitioner. They can help you decide if you are the right candidate for the diet and help you avoid some of the negative aspects of the diet. You may also need help in addressing relapse and of course, finding the underlying cause.

I published this experience as a case study in the Integrative Medicine journal. You can find the abstract on PubMed here: Homemade Elemental Diet to Treat Intestinal Methanogen Overgrowth: A Case Report

What’s The Right SIBO Diet For You? With so many diet choices out there, it can feel so overwhelming… if you’re not sure where to start, this guide will help you discover exactly which one is right for you.

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