- Digestive Enzymes
- 5 Symptoms of Exocrine Pancreatic Insufficiency
- Symptoms of EPI
- Pancreatic Insufficiency
- Gut reaction: A limited role for digestive enzyme supplements
- There’s little evidence to support their use for common digestive distress like heartburn.
- What Are Digestive Enzymes? What Do Digestive Enzymes Do?
- Best Digestive Enzymes Benefits
- Best Digestive Enzymes Sources
- Pancreatic Enzymes vs. Digestive Enzymes
- Who Needs Digestive Enzymes?
- Best Digestive Enzyme Supplements: Full-Spectrum Digestive Enzymes
- Foods to Eat to Support Digestion + Foods with Natural Digestive Enzymes
- Digestive Enzymes in Traditional Medicine, Ayurveda and TCM
- Are Digestive Enzymes Safe? Precautions and Digestive Enzyme Side Effects
- Final Thoughts on Digestive Enzymes
- Trouble Digesting Fat? Know the signs and how to fix them
- How to Digest Fats Better, With and Without a Gallbladder
- Signs of fat malabsorption
- Reasons you’re not digesting fats
- Things you can do digest fats better
- What do I do if I don’t have a gallbladder?
- Did This Article Help You?
By: Dr. Mamadou
Food intolerance can be defined as the body’s inability to accept a particular food or some of its molecules. This inability to accept the food is expressed by adverse physio-biochemical reactions. Some of the reactions include vomiting, diarrhea, flatulence, bloating, intestinal imbalance, dysbiosis, and inflammatory conditions.
These conditions in turn will lead to mal- absorption, loss of nutrients, weakness, fatigue, and increased susceptibility to diseases. However, in most cases, when there is intolerance to a specific food, the usual tendency is to avoid that food. A better alternative is to take supplements that correct the intolerance and ensure the bioavailability of the nutrients of that food.
The focus of this paper is to bring attention to the fact that food intolerance results from an impaired digestion of the food molecules. The key molecular agents to perform the digestive function are the enzymes produced in the digestive system. However, for various reasons, some of the enzymes are missing, insufficient, and/or ineffective. As a result, some foods, based on their chemical composition, create various types of discomfort and other digestive disorders.
I often heard people say “I am allergic to that food” when in fact, in a biochemical and medical terms, they are not allergic to that food: they are intolerant to that food. So what is the difference between food intolerance and food allergy?
While food allergy is an immune condition, food intolerance is usually not. Although some of the symptoms may overlap, food allergy and food intolerance are very distinct biochemically and physiologically. To further complicate the issue, let’s say that both conditions are caused by the inability of the digestive system to break down the molecules in the target food.
This impairment in the digestive function is mostly the result of inadequate enzyme activity (function): this could be due (1) to the inability of the pancreas and the intestinal cells and other organs to make the necessary enzymes and/or (2) the malfunction or absence of key messengers that regulate the enzyme producing organs.
So, irrespective of the cause of digestive impairment, the end-result is a lack of adequate enzymes to break the food macromolecules (big molecules) into smaller molecules. Unless and until the big molecules in a food are broken into smaller molecules, that food could be a health liability to the body. That liability is either food allergy or food intolerance.
The path of the undigested or un-broken molecules to food intolerance or food allergy is determined by the nature of the molecules that are not broken and the physio-biochemical reactions that will take place when those molecules react with the cells or other molecules in the gut. Most human foods contain one or more of the following macromolecules: proteins, lipids (fats), and carbohydrates. They are called macromolecules because they are made of many smaller molecules bound (linked) together. In order for these major molecules to benefit the body, they must be broken down into smaller molecules that could be absorbed into the blood circulation and transported to the various cells.
However, when these big molecules are not fully broken down, i.e., digested, there would be in various sizes within the gut. These molecular pieces that could not be taken up by the intestinal cells could still interact with cells and other molecules in the gut environment.
As they remain in the gut, some of these partially broken molecules interact with the cells in the digestive tract and create various biochemical reactions. The effects of these reactions on the physiology of the body are diverse. This diversity of reactions determines whether there is food intolerance or food allergy.
As mentioned above, both food intolerance and food allergy refer to reactions of the body when certain foods are ingested. Furthermore the reactions are simply because the food is not digested properly.
Although many people use the terms food intolerance and food allergy interchangeably, the two conditions are different.
An allergy is always the result of an immune response to a molecule, and that molecule is invariably a protein or a protein combined with some fat (lipoprotein) or some carbohydrate (glycoprotein). If a protein is not fully digested, broken down, it has the ability, when introduced in a foreign body, to trigger an immune reaction. That immune reaction is expressed in the form of rashes, inflammations, and even death, as in anaphylactic reaction (Please refer to the paper “Enzymes as Allergy Modulators”). It should also be mentioned that partially digested proteins could also trigger other biochemical reactions that are not immune in nature, but could rather affect the functioning of the nervous system (see paper on “Autism and Supplemental Enzymes”).
Food intolerance is mostly caused by either carbohydrates or fats, but proteins could also be culprits. The types of reactions caused as a result of food intolerance are different from immune reactions and are often expressed as colics or abdominal pain, diarrhea, oily stools (Steatorrhea), imbalances in the ecological balances of the probiotics, yeast infections, excess production of toxigenic amines, and excess gas.
Besides fats and carbohydrates, there could be other molecules that could trigger some form of reaction similar to the ones associated with food intolerance. Usually, those are relatively small molecules that could interact with the gut cells and trigger an adverse reaction like vomiting, nausea, toxicity, or increased peristaltic movement resulting in diarrhea.
However, there are conditions when the same food could provoke both food allergy as well as food intolerance. That is the case of milk or some dairy products.
A good example of food intolerance is lactose intolerance. Lactose intolerance is not a food allergy! Lactose is a sugar, not a protein. Lactose intolerance does not mean that one is allergic to milk or dairy products. However, there are cases when someone may have lactose intolerance and also suffer from allergy caused by the proteins in the milk.
Let’s look at the physio-biochemical reactions taking place in lactose intolerance. Lactose is the main milk sugar and is made up of glucose and galactose linked together. In order for this milk sugar, lactose, to be absorbed in the gut, it needs to be broken down: that means the bond linking the glucose and the galactose molecules must be broken, i.e., digested. The enzyme responsible for breaking down that bond is called lactase.
Although everyone has this enzyme as a baby to help process breast milk, some people lose its production or produce it in very small amounts once they stop breastfeeding and/or become adult. So, when one does not have this lactase produced in the gut by the intestinal cells, lactose could not be processed: the glucose and the galactose molecules stay bound together.
This is a situation when lactose is small but not small enough to be absorbed. So, when one consumes milk or ice cream, there would be more of lactose in the gut. If the enzyme lactase is missing or not active, the lactose remains in the gut.
As the amounts of lactose increase in the gut, it pulls water from the inside of the body into the gut. This is a bio-physical case of osmosis: the sugar content being higher in the gut (because of the high lactose) than in the cells, water moves from the cells into the gut.
So, now there is plenty of water filling up the intestines. As a result, there would be increased peristaltic movement triggered by the excess water. The end result is diarrhea. Diarrhea is one of the main symptoms observed in cases of lactose intolerance.
Other characteristic symptoms of lactose intolerance are excess gas production and flatulence. The reason for the excess gases leading to flatulence is the action of the microorganisms in the large intestine on the undigested lactose.
As lactose is not broken down in the upper small intestine, it moves in the large intestine where it will serve as feedstock for the various bacteria. When bacteria consume sugars, they produce gas: thus the increased gas production. This increased gas production could also lead to abdominal pain and flatulence.
As one can note, this set of symptoms or discomfort caused by the lactose intolerance is due to the body’s inability to process lactose: the enzyme lactase is either missing or inactive and the sugar lactose is not broken down. This condition could be alleviated by taking supplemental lactase to rectify the deficiency in the gut and ensure the digestibility of lactose.
Another common case of food intolerance is the inability to digest fats. Contrary to some diet craze practices, fats are necessary for the body. The key is to consume good and healthy fats and in moderation. Many key molecules in the body are derived from fats including the molecules that constitute the membranes of the cells, fuel the heart’s function, and make the various sex hormones.
Thus, consuming healthy fats in moderation is a good thing. However, when the fats are not digested they “run through” the gut and cause what is called steatorrhea: an oily stool. It floats but it is not healthy! That oily stool robs the body of many nutrients including the fat-soluble vitamins.
Furthermore, with steatorrhea comes malabsorption as many nutrients are flushed out before they get absorbed because of the diarrhea caused by the undigested fats. As go those nutrients and vitamins, so go vitality, youthfulness, healthy skin, and vigor. The inability to digest fats in the diet is caused by the absence or inaction of the enzyme lipase.
The remedial approach to steatorrhea is to supplement with effective lipase that could ensure the breaking of the dietary fats. It is important to note that some of the supplemental lipases could effectively break down lipids (fats) even if bile is not present. Supplementing with the enzyme lipase will not only prevent oily but also the sometimes “hard to control” diarrhea. Furthermore, taking lipase to supplement the body’s action will help the body retain some key vitamins and nutrients.
In some instances, proteins could be the subject of food intolerance as opposed to food allergy. In those cases, the undigested proteins may damage the intestinal walls leading to intestinal permeability (leaky gut) or overwhelming the metabolism of the organisms in the large intestine.
When undigested proteins reach the large intestine and are reacted upon by the microorganisms, there is formation of many molecules with potential harmful effects on the body. Some of these molecules could promote tumor growth, colon diseases, and excess production of gases with very foul odors.
Some of these concerns related to protein intolerance have led the push of avoiding excess proteins, especially animal proteins, in the diet. However, the main culprit is the digestive enzyme insufficiency and/or inefficacy. Supplementing with effective proteolytic enzymes (proteases and peptidases) could help avoid the problems caused by undigested proteins in the gut.
Another cumulative consequence of any type of food intolerance is disturbance in the ecological balance of the probiotics. Whether the non-tolerated food is carbohydrate, fat, or protein, it will reach the microorganisms and disturb the balance.
Within the taxonomy of the organisms in the large intestine, there are organisms that could grow faster when a specific food is more available. These organisms that could benefit from the result of food intolerance may not be beneficial to the body in a short or long term. Within the functioning of the body, probiotics balance is a key to health!
As can be noted, intolerance of any food is the direct result of inefficient digestive function, mostly lack or inaction of digestive enzymes. The corrective option in cases of any food intolerances is to include supplemental enzymes that could complement the function of the digestive system.
A digested food molecule loses its bioactivity (in terms of harming the body)!
Baerwald, C., et al., 1999. Efficacy and tolerance of oral hydrolytic enzymes in double-blind prospective clinical trial. J. Clin Res 2:17
Medow, MS et al., 1990. Beta-galactosidase tablets in the treatment of lactose intolerance in pediatrics.Am J. Diseases of Children 144:1261
Barillas, C., et al., 1987: Effective reduction of lactose maldigestion in preschool children by direct addition of beta-galactosidase (lactase) to milk at mealtime. Pediatrics 79:766.
Lankisch, P.G., 1993. Enzyme treatment of exocrine pancreatic insufficiency in chronic pancreatitis – review-. Digestion 54 Suppl. 2:21
Microbial-sourced enzymes from fungi (including yeasts) and bacterial sources can be used by vegetarians and vegans and have good gastric resilience. Microbial enzymes can include amylase, glucoamylase, proteases, lipase and multiple types of saccharidases including lactase (to digest lactose), alphagalactosidase (for digesting beans, legumes and cruciferous vegetables) and cellulase (to digest cellulose), along with hemicellulase, xylanase and pectinase, which are all very important enzymes for digesting plant components. Phytase is another supplementary digestive enzyme that can be taken in a broad-spectrum formulation to support the digestion of phytic acid, a component of plant material that binds minerals reducing their bioavailability.
Supplementing with microbial types of digestive enzymes can be particularly useful when switching to a more plant-based diet by helping digestion of tougher plant components like cellulose and increasing nutrient bioavailability. They are also complementary to those enzymes produced by the pancreas so are not considered to “override” the natural digestive enzyme action.
TABLE1: DIGESTIVE ENZYMES
|DIGESTIVE ENZYME CLASS||TYPE||FUNCTION|
|Lipases||Lipase – found in humans, plants and certain microbes||Essential for digestion of fats (e.g. triglycerides and phospholipids) in conjunction with the emulsification effects of bile salts (lecithin) that are released from the gallbladder. Lipase from pancreatic juices and bile from the gallbladder mix in the bile duct and are secreted into the duodenum. Lipase deficiency can lead to steatorrhea and many fat handling problems in the body.|
|Proteases||Gluten proteases – found in certain microbes||Digest highly resistant proline-rich peptides in gliadin fraction of gluten and casein that can lead to activation of the immune system in the gut resulting in autoimmune damage to intestinal tissue as seen in conditions like coeliac disease. In addition, gluten and casein-derived proline-rich peptides may exert opioid-like activity in the central nervous system causing sedation (i.e. post-meal drowsiness) and food addictions. Think of feeling sleepy after a carbohydrate heavy meal or even feeling addicted to bread! Further along this neurological scale gluten and casein are believed to trigger neurological symptoms encountered in children with autism spectrum disorders. Gluten is most prevalent in wheat and processed bread products. Casein makes up 80-90% of cow’s milk proteins versus 0.2% goat’s milk.|
|Alkali proteases –found in certain microbes||Digest proteins within pH 4.0-11. Optimal activity is around pH6, which is found in the small intestines.|
|Acid proteases – found in certain microbes||Digest proteins within pH 2.0-6.0, which is the range found in the stomach and small intestines. Optimal activity is around pH4.5.|
|Bromelain – found in pineapples||When taken with food bromelain contains protease enzymes to help digest proteins to small peptides and individual amino acids.|
|Carbohydrases||Amylase – found in humans and certain microbes||Starch and glycogen specific enzymes that break down polysaccharides into disaccharides. Also works in conjunction with gluten-specific proteases to break down the carbohydrate portion of gliadin found in gluten that, along with the proline peptides, causes autoimmune damage and symptoms found in conditions like coeliac disease and gluten intolerance. It is important to supplement with both amylase and gluten-digesting proteases for full benefits.|
|Amyloglucosidase – found in plants and certain microbes||Breaks down amylase disaccharides into monosaccharides. Think of starch as a tree; amylase works on digesting starch units (i.e. saccharides) from the end of branches inwards until it comes to a fork where it stops as the links are different. Glucoamylase breaks down these “fork” links so starch digestion is complete. Amylase and amyloglucosidase should always be taken together.|
|Lactase – found in babies, plants and certain microbes||Digests the milk sugar lactose into galactose and glucose. Lactase is naturally produced in the digestive tract of infants (unless they have congenital lactase deficiency). However, the LCT lactase producing gene activity decreases into adulthood so that many adults are unable to effectively digest lactose. For many, this results in symptoms of lactose intolerance.|
|Alpha galactosidase – found in certain microbes.||Hydrolyses raffinose, stachyose and verbascose in legumes, whole grains and some vegetables into simple sugars glucose, galactose and fructose. Known to reduce gas production when eating fermentable carbohydrates.|
|Invertase (type of sucrase) – found in humans, plants and certain microbes.||Breaks down sucrose and maltose into fructose and glucose.|
|Fibrolytic Enzymes||Phytase – found in plants and certain microbes||Digests phytic acid from nuts, seeds, grains and cereals such as bran and wheat into myo-inositol and phosphates. Phytic acid is considered an “anti-nutrient” as it binds essential minerals, such as zinc, resulting in decreased bioavailability, i.e. reduced absorption in the gut.|
|Cellulase – found in plants and certain microbes||Breaks down cellulose, a plant fibre found in fruit and vegetables. Chitin, a structural component of Candida albicans yeast cell walls, has virtually identical structure to cellulose. Cellulase may therefore help reduce Candida infection.|
How Potent Is Your Digestive Enzyme Supplement?
Enzyme activity (or potency) is a measure of how much enzyme is needed to accomplish a specific reaction within a specified time. The Food Chemical Codex (FCC) is the industry standard for measuring enzyme activity. Each enzyme is assigned their own FCC potency (activity) unit. This not only demonstrates the amount of activity of each enzyme in a product but also ensures the enzyme levels are standardised and allows comparison between different FCC labelled products.
Unfortunately, there is currently no regulation of enzyme activity in food supplements. This can make choosing a digestive supplement a bit of a lottery. It is for this reason that you should always choose a reputable brand that states all enzyme activity in FCC units so the activity and not just the amount (weight) of the enzyme per capsule is known.
If the product states just the weight of the enzymes (e.g. in milligrams, mg) then this tells you nothing about the actual activity. That means you might choose a digestive enzyme supplement that contains say 40mg lipase over the one that contains 20mg lipase because you would think the bigger dose of lipase would have twice the activity. However, every enzyme preparation can have different activities so you would not know the real potency of either lipase dose unless the FIP FCC unit for lipase enzymes was stated. This means if you choose a digestive enzyme supplement that states enzyme activity in FCC units you are making an informed decision and can be safe in the knowledge that the activity of each enzyme has been carefully measured and standardised.
Digestion is not solely down to digestive enzymes but requires synergistic actions of stomach hydrochloric acid, bile salts and a healthy lining to the GI tract to enable vital nutrients to be absorbed. Complementary digestion supporting supplements that work synergistically with a digestive enzyme formula may include:
- Betaine and pepsin and zinc citrate to support gastric hydrochloric acid levels and protein digestion.
- Mixed strain probiotic supplement to support the levels of health promoting gut bacteria.
- Aloe Vera whole leaf juice – bioactive polysaccharides provide wide-reaching digestive including support promoting a healthy gut lining and supporting growth of beneficial gut bacteria and digestion of proteins.
- Colon supporting herbs like turmeric and ginger, garlic and papaya extract.
- Lecithin powder high in phosphatidyl choline supports digestion of fats as well as healing the lining of the digestive tract.
- Beet concentrate with taurine and pancreatic lipases to support bile flow.
- Bile extract (porcine source) can also support bile flow and function.
Digestion requires energy, nutrients and several interconnected stages, including synthesis and release of digestive enzymes, to function effectively, efficiently and most importantly seamlessly so our lives are not interrupted or hampered by acute symptoms or longer-term poor health.
The first stage to digestion perfection is to address the diet, encouraging reduction/elimination of foods and drinks that cause and contribute to gut inflammation and to increase more plant-based foods. Digestive juices and colon function, not to mention numerous other areas of our body, require adequate fluid levels so1.5-2L hydrating fluids daily is recommended. Digestive supporting supplements like digestive enzymes work in tandem with these dietary changes and can be used acutely or longer-term to support digestion.
Addressing lifestyle factors to manage physical, emotional and psychological stress also plays an important role in improving digestive health. Mindful eating, such as reducing stressful situations when eating and chewing food slowly and thoroughly encourages the production and release of digestive enzymes in saliva and pancreatic juices.
People with exocrine pancreatic insufficiency (EPI) often have other medical conditions related to their digestive issues. These health problems can be the cause of EPI, or they may happen because of it. Sometimes they simply overlap with EPI and doctors don’t know why.
Work with your doctor to make sure you get the right diagnoses and treat all your health problems.
Chronic pancreatitis. It’s the most common cause of EPI in adults. When the pancreas becomes inflamed and stays that way for years, eventually its cells stop working the way they should, including those that can cause EPI. Many things can lead to chronic pancreatitis, including heavy alcohol use, smoking, genetic problems, and autoimmune disorders. Your doctor will want to start treatments to restore your digestion, help your pancreas work as well as it can, and ease any belly pain you might have.
Cystic fibrosis. This inherited disease is the second most common cause of EPI. Cells in the lungs and digestive system make thick, sticky mucus, which causes blockages in certain organs. In the pancreas, it keeps digestive enzymes from moving to the intestines, where they help break down fats and other nutrients. That leads to EPI. Good nutrition is important for treating cystic fibrosis and EPI. You’ll need to work with a dietitian to make sure you get what you need. You’ll also take vitamin supplements and get pancreatic enzyme replacement therapy.
Celiac disease. For people with this genetic condition, eating gluten (a protein found in wheat, barley, and rye) causes damage to the intestines. The pancreas works normally, but because of inflammation and damage to the intestines, it may not secrete enzymes in the way it should. If you switch to a gluten-free diet, however, EPI resulting from celiac disease usually will go away.
Tumors or cysts. They can lead to EPI by blocking the main duct of the pancreas, where enzymes would move into the intestines. You can have surgery to remove a tumor or cyst, but it may not always cure EPI, since the operation itself may damage the pancreas. So talk to your doctor about whether surgery is a good idea for you. If your tumor is cancerous, it may be the best option.
5 Symptoms of Exocrine Pancreatic Insufficiency
EPI can trigger a range of GI (and non-GI) symptoms.
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As soon as you take your first bite of food, your pancreas is hard at work, secreting digestive enzymes that break down food into small molecules your body can absorb.
But if you have long-term damage to your pancreas — from, for example, chronic pancreatitis, alcohol abuse, or another disease — the digestion process doesn’t always go so smoothly. A breakdown in pancreatic function can lead to a condition called exocrine pancreatic insufficiency, or EPI, in which you lack the digestive enzymes needed to properly digest food. As a result, your body can’t absorb the nutrients you need, and you can experience symptoms such as diarrhea, loss of appetite, and weight loss.
“During exocrine pancreatic insufficiency, proteins, carbohydrates, and fats aren’t broken down,” says Deepak Agrawal, MD, MPH, the chief of gastroenterology and hepatology and an associate professor of internal medicine at The University of Texas at Austin Dell Medical School. This leads to an inability to digest and absorb nutrients, causing malnourishment.
EPI is relatively rare, because about 90 percent of your pancreas has to be nonfunctioning or destroyed for it to occur, Dr. Agrawal says.
Conditions that can lead to EPI include chronic pancreatitis, cystic fibrosis, celiac disease, diabetes, inflammatory bowel diseases such as Crohn’s disease, and gastrointestinal surgery in which parts of the pancreas or stomach have been removed. Digestive issues, such as stomach ulcers, and autoimmune diseases like lupus can also lead to EPI.
If you have any of these conditions, you should be aware of these possible EPI signs.
Symptoms of EPI
Because the symptoms of EPI can mimic those of more common digestive diseases and syndromes, the condition can be difficult to identify, both for you and your doctor. But if you’re experiencing many of these symptoms, EPI can be a possible culprit.
“Generally, when someone has diarrhea, weight loss, and trouble tolerating fatty foods, exocrine pancreatic insufficiency is suspect,” Agrawal says. The most common symptoms of the condition are diarrhea and oily stools (steatorrhea).
Here are some of the most common EPI symptoms.
Diarrhea from EPI results from undigested food sitting in the small intestine. “When the pancreas fails to produce the necessary digestive enzymes, fats and other nutrients can’t be absorbed,” Agrawal explains. “Instead, they remain in the small bowel, drawing in water and causing diarrhea.”
2. Weight loss
If your body can’t absorb enough nutrients and fats, you can find yourself losing weight. This can also be more common in people who have a digestive condition in addition to EPI, such as Crohn’s disease.
Unabsorbed fat also gets passed , causing fatty stools. “When people with exocrine pancreatic insufficiency eat fatty foods, the fat doesn’t get absorbed, so they excrete oily, foul-smelling stools that float,” says Frank Gress, MD, senior faculty of medicine and gastroenterology at Mount Sinai Hospital in Oceanside, New York.
4. Abdominal pain
“The pain is usually in the right upper quadrant of the abdomen, and it can either be vague or sharp,” Dr. Gress says.
5. Non-GI symptoms
If you can’t absorb vital nutrients, you can develop vitamin deficiencies that can then trigger non-digestive symptoms.
“Some of the most common vitamin deficiencies associated with exocrine pancreatic insufficiency are deficiencies in iron, vitamin B12, folate, and calcium,” Gress says. “One sign of vitamin deficiency is a raised, scaly rash on the skin.” Other symptoms include bone pain, muscle cramps, night blindness, and easy bruising.
Additional symptoms may be related to the underlying cause of pancreatic damage, such as cystic fibrosis or pancreatitis, Agrawal adds.
If you’re experiencing digestive problems similar to those of EPI, Gress says your first step should be to contact your primary care doctor, who can perform an initial examination and then discuss the next steps.
If your doctor can’t find an explanation for your digestive symptoms, you’ll likely be referred to a doctor who specializes in digestive diseases, such as a gastroenterologist, for further testing. If you are diagnosed with EPI, you’ll probably be given pancreatic enzymes and possibly vitamin supplements to manage the condition and better control your symptoms.
Sources Used in Current Review
(October 25, 2016) American Gastroenterological Association press release. Largest analysis examining barriers to EPI diagnosis finds patients with digestive health issues overlook their symptoms. Available online at https://www.gastro.org/press-release/largest-analysis-examining-barriers-to-epi-diagnosis-finds-patients-with-digestive-health-issues-overlook-their-symptoms. Accessed March 27, 2019.
Medical University of South Carolina Digestive Disease Center. Pancreatic insufficiency. Available online at http://ddc.musc.edu/public/diseases/pancreas-biliary-system/pancreatic-insufficiency.html. Accessed March 23, 2019.
Sources Used in Previous Reviews
National Digestive Diseases Information Clearinghouse. ERCP (Endoscopic Retrograde Cholangiopancreatography). Available online at http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/.
Durie PR. Inherited and congenital disorders of the exocrine pancreas. Gastroenterologist. Sep 1996;4(3):169-87.
Mack DR, Forstner GG, Wilschanski M, Freedman MH, Durie PR. Shwachman syndrome: exocrine pancreatic dysfunction and variable phenotypic expression. Gastroenterology. Dec 1996;111(6):1593-602.
Philip D. Hardt and Nils Ewald. Exocrine Pancreatic Insufficiency in Diabetes Mellitus: A Complication of Diabetic Neuropathy or a Different Type of Diabetes? Experimental Diabetes Research, Volume 2011, Article ID 761950.
Gregory C. Sephel PhD FACB MT(ASCP). Lab Tests Online adjunct board member. Director Clinical Pathology, VA TN Valley Healthcare System; Associate Professor Pathology, Microbiology, Immunology, Vanderbilt University School of Medicine.
Gut reaction: A limited role for digestive enzyme supplements
There’s little evidence to support their use for common digestive distress like heartburn.
Updated: January 29, 2020Published: March, 2018
Image: © Julia_Kuleshova/Getty Images
Digestive enzyme supplements promise to fix everything from bloating and flatulence to heartburn and gut health. The supplements are so popular that global sales are expected to reach $1.6 billion by 2025, according to recent marketing research. But don’t be too quick to reach for them. “Some of them are clearly beneficial, in certain situations. But enzyme supplements also are often used in situations where there is little evidence that they do any good,” says Dr. Kyle Staller, a gastroenterologist at Harvard-affiliated Massachusetts General Hospital.
What are digestive enzymes?
Naturally occurring digestive enzymes help break down food so we can soak up nutrients. Your mouth, stomach, and small intestine make some digestive enzymes. However, the majority come from your pancreas, which floods the small intestine (when food arrives there) with enzymes such as
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The phrase “you are what you eat” is halfway accurate. The end truth is you are what you digest. Therefore, are digestive enzymes key to better digestion, gut health and nutrient absorption?
Surprising as it may seem, up until relatively recently, little was known about how your digestive system actually works. Today, there’s a growing incidence of illnesses that, when traced back to the source, appear to be linked to nutrient malabsorption due to a lack of digestive enzymes.
Why are enzymes for digestion important in avoiding illness? The role of digestive enzymes is primarily to act as catalysts in speeding up specific, life-preserving chemical reactions in the body. Essentially, they help break down larger molecules into more easily absorbed particles that the body can actually use to survive and thrive.
What Are Digestive Enzymes? What Do Digestive Enzymes Do?
All enzymes are catalysts that enable molecules to be changed from one form into another. The digestive enzymes definition is “enzymes that are used in the digestive system.” These enzymes help break down large macromolecules found in the foods we eat into smaller molecules that our guts are capable of absorbing, thus supporting gut health and making sure the nutrients are delivered to the body.
Digestive enzymes are split into three classes: proteolytic enzymes that are needed to digest protein, lipases needed to digest fat and amylases needed to digest carbohydrates. There are various types of digestive enzymes found in humans, some of which include:
- Amylase — Found in saliva and pancreatic juice and works to break large starch molecules into maltose. Needed to break down carbohydrates, starches and sugars, which are prevalent in basically all plant foods (potatoes, fruits, vegetables, grains, etc.).
- Pepsin — Which enzyme breaks down protein? Found in the gastric juice within your stomach, pepsin helps break down protein into smaller units called polypeptides.
- Lipase — Made by your pancreas and secreted into your small intestine. After mixing with bile, helps digest fats and triglycerides into fatty acids. Needed to digest fat-containing foods like dairy products, nuts, oils, eggs and meat.
- Trypsin and chymotrypsin — These endopeptidases further break down polypeptides into even smaller pieces.
- Cellulase — Helps digest high-fiber foods like broccoli, asparagus and beans, which can cause excessive gas.
- Exopeptidases, carboxypeptidase and aminopeptidase — Help release individual amino acids.
- Lactase — Breaks the sugar lactose into glucose and galactose.
- Sucrase — Cleaves the sugar sucrose into glucose and fructose.
- Maltase — Reduces the sugar maltose into smaller glucose molecules.
- Other enzymes that break down sugar/carbs like invertase, glucoamylase and alpha-glactosidase.
How do digestive enzymes work? Digestion is a complex process that first begins when you chew food, which releases enzymes in your saliva. Most of the work happens thanks to gastrointestinal fluids that contain digestive enzymes, which act on certain nutrients (fats, carbs or proteins). We make specific digestive enzymes to help with absorption of different types of foods we eat. In other words, we make carbohydrate-specific, protein-specific and fat-specific enzymes.
Digestive enzymes aren’t just beneficial — they’re essential. They turn complex foods into smaller compounds, including amino acids, fatty acids, cholesterol, simple sugars and nucleic acids (which help make DNA). Enzymes are synthesized and secreted in different parts of your digestive tract, including your mouth, stomach and pancreas.
Below is an overview of the six-step digestive process, starting with chewing, that triggers digestive enzyme secretion in your digestive tract:
- Salivary amylase released in the mouth is the first digestive enzyme to assist in breaking down food into its smaller molecules, and that process continues after food enters the stomach.
- The parietal cells of the stomach are then triggered into releasing acids, pepsin and other enzymes, including gastric amylase, and the process of degrading the partially digested food into chyme (a semifluid mass of partly digested food) begins.
- Stomach acid also has the effect of neutralizing the salivary amylase, allowing gastric amylase to take over.
- After an hour or so, the chyme is propelled into the duodenum (upper small intestine), where the acidity acquired in the stomach triggers the release of the hormone secretin.
- That, in turn, notifies the pancreas to release hormones, bicarbonate, bile and numerous pancreatic enzymes, of which the most relevant are lipase, trypsin, amylase and nuclease.
- The bicarbonate changes the acidity of the chyme from acid to alkaline, which has the effect of not only allowing the enzymes to degrade food, but also killing bacteria that are not capable of surviving in the acid environment of the stomach.
At this point, for people without digestive enzyme insufficiency (lack of digestive enzymes), most of the work is done. For others, supplementation is needed and helps this process along. This can even be true for pets, since there are several benefits of digestive enzymes for dogs, digestive enzymes for cats and for other animals too.
Best Digestive Enzymes Benefits
What are the benefits of digestive enzymes? The answer is simple: Without them, we couldn’t process food. With that said, there are three main reasons why many people should take digestive enzymes:
- Help treat leaky gut and other conditions like celiac disease by taking stress off the gastrointestinal tract.
- Assist the body in breaking down difficult-to-digest protein and sugars like gluten, casein and lactose (milk sugar).
- Greatly improve symptoms of acid reflux and irritable bowel syndrome.
- Enhance nutrition absorption and prevent nutritional deficiency.
- Counteract enzyme inhibitors naturally in foods like peanuts, wheat germ, egg whites, nuts, seeds, beans and potatoes.
You might be wondering, do digestive enzymes help you lose weight or burn fat, and will digestive enzymes help with constipation? If you’re not making enough digestive enzymes to help the digestive process unfold smoothly, it’s possible you’ll experience constipation that may improve when you supplement. However, enzymes are generally not linked to weight loss and are not intended for this purpose — although eating a healthy diet that supports natural enzyme production may lower inflammation and help you reach a healthier weight. Thus, digestive enzyme weight loss benefits are not necessarily from the enzymes themselves, but from eat healthier overall.
It’s also possible that digestive enzyme supplements may help curb your cravings and allow you to feel satisfied with less food, helping you to consume an appropriate amount of calories.
Best Digestive Enzymes Sources
Many raw plants, such as raw fruits and vegetables, contain enzymes that aid in their digestion. For example, pineapple, papaya, apples and many other plants contain beneficial enzymes, but when these foods are grown in depleted soils or are highly processed, enzymes likely are lacking or destroyed.
Digestive enzyme supplements are derived mostly from three sources:
- Fruit-sourced — usually pineapple– or papaya-based. Bromelain is an enzyme derived from pineapple that breaks down a broad spectrum of proteins, has anti-inflammatory properties and can withstand a broad pH (acidic/alkaline) range. Papain is another enzyme that’s derived from raw papaya and works well to support the breakdown of small and large proteins.
- Animal-sourced — including pancreatin sourced from ox or hog.
- Plant-sourced — derived from probiotics, yeast and fungi.
What are natural digestive enzymes? Many digestive enzymes available on the market are “natural” because they are sourced from plants or animals. Products in the digestive enzyme range can present a dizzying array of ingredients, which can make it hard to know what the best digestive enzymes supplements are. The bottom line is that the “best digestive enzymes” differ from person to person, since enzymes are nutrient-specific and help with absorption of different foods. Thus, the best enzymes can vary from person to person — though natural enzymes are always preferable.
Some products contain only plant-based enzymes, which are aimed at vegetarians and vegans. These usually at least contain bromelain derived from the pineapple, and many include papain enzyme from the papaya. Products designed specifically for vegans usually contain pancreatin derived from Aspergillus niger. This is a fungus-based, fermented product rather than an enzyme sourced from ox or hog bile, which is the usual source.
In addition, some have complementary herbs and spices. Amla (gooseberry) extract — which isn’t an enzyme, but an herbal remedy from Ayurveda medicine taken for general well-being — is often included. It’s believed to work in synergy with the other compounds.
Pancreatic Enzymes vs. Digestive Enzymes
“Digestive enzymes” — aka stomach enzymes — is a broad term that includes pancreatic enzymes, plant-derived enzymes and fungal-derived enzymes. Pancreatic enzymes are found in the whopping eight cups of pancreatic juices that most humans produce daily. These juices contain pancreatic enzymes that aid in digestion and bicarbonate that neutralizes stomach acid as it enters the small intestine. Pancreatic enzyme names usually end in -in (like trypsin or pepsin), while other digestive enzymes usually end in -ase or -ose (like lactose, sucrose, fructose).
Dealing primarily with fats and amino acids, these enzymes include:
- Lipase converts triglycerides into both fatty acids and glycerol.
- Amylase converts carbohydrates into simple sugars.
- Elastases degrades the protein elastin.
- Trypsin converts proteins to amino acids.
- Chymotrypsin converts proteins to amino acids.
- Nucleases convert nucleic acids to nucleotides and nucleosides.
- Phospholipase converts phospholipids into fatty acids.
The main enzyme-producing structures of the human digestive system are the salivary glands, stomach, pancreas, liver and small intestine. The pancreas produces bile salts or acids — which comprise water, electrolytes, amino acids, cholesterol, fats and bilirubin — and these are all sourced from the liver via the gallbladder. It’s the cholic and chenodeoxycholic acids that, when combined with the amino acids glycine or taurine, produce the bile salts themselves. The bile salts break down fats in food to enable the lipase enzyme to reduce further.
The duodenum (the first and shortest segment of the small intestine) is also a busy place when it comes to digestion. Amino acids are extracted from proteins, fatty acids and cholesterol from fats, along with simple sugars from carbohydrates. Nuclease cleaves (or splits) the nucleic acids essential for DNA into nucleotides. All the macronutrients are broken down into molecules small enough to be carried in the bloodstream and boost metabolism to ensure it runs effectively. Micronutrients, if they haven’t already been cleaved in the stomach acid, are released and transported into the bloodstream, too.
In regard to mostly sugar metabolism, intestinal enzymes include the following key (but complicated) processes:
- Aminopeptidases degrade peptides into amino acids.
- Lactase, a dairy sugar, converts lactose to glucose.
- Cholecystokinin aids digestion of proteins and fats.
- Secretin, as a hormone, controls the secretion of the duodenum.
- Sucrase converts sucrose to disaccharides and monosaccharides.
- Maltase converts maltose to glucose.
- Isomaltase converts isomaltose.
Who Needs Digestive Enzymes?
The answer to the increasingly asked question — “Who should take digestive enzymes?” — may ultimately turn out to be many more people than you might expect. You may need a digestive enzyme supplement for any number of reasons, such as undigested food causing issues.
How do you know if you should take digestive enzymes and when to take digestive enzymes? If you’re lacking specific enzymes that are needed to break down certain nutrients (such as some types of sugars), you might experience symptoms like bloating, gas, abdominal pain and fatigue due to undigested foods and other enzyme issues. Other signs that you might benefit from taking digestive enzymes supplements? Symptoms like:
- Acid reflux
- Cravings for certain foods
- Thyroid problems
- Heartburn, indigestion or burping
- Hair that is thinning or falling out
- Dry or lackluster skin
- Trouble concentrating or brain fog
- Morning fatigue
- Trouble sleeping well
- Arthritis or joint pain
- Muscle weakness or feeling too tired to exercise
- Mood swings, depression or irritability
- Headaches or migraines
- Worsened PMS
Depending on how you view nutrition today, you can either take a proactive or reactive approach to digestive enzyme supplements. On one side of the coin, “If it ain’t broke, don’t fix it, right?” This perspective holds that, unless someone has digestion concerns, taking enzymes is simply not needed. On the other side, with the depleting nutrient supply in our diets and influx of chronic disease, a little extra help couldn’t hurt.
Either way you look at it, an increasing number of people take digestive enzymes today, and certain health conditions like the ones below are good reasons to supplement:
1. Digestive Diseases
If you have any type of digestive disease — such as acid reflux, gas, bloating, leaky gut, irritable bowel syndrome (IBS), Crohn’s disease, ulcerative colitis, diverticulitis, malabsorption, diarrhea or constipation — then digestive enzymes may be able to help.
Digestive enzymes can take stress off of the digestive organs, including the stomach, pancreas, liver, gallbladder and small intestine, by helping break down difficult-to-digest proteins, starches and fats. This can help decrease symptoms like bloating and pain that are associated with gastrointestinal disease.
2. Age-Related Enzyme Insufficiency
As we age, the acidity of our stomach acid becomes more alkaline. In respect to enzyme production, this means there’s an increasing likelihood the much-needed acidic “trigger” produced when chyme enters the intestine may fail. If the acidity trigger fails, then the “signal” isn’t given to the hormone called secretin, which in turn prevents pancreatic secretions from releasing.
Concurrent illnesses aside, as we age there’s increasing suspicion that digestive problems may result from either low stomach acid or enzyme insufficiency in the elderly, which could be what causes acid reflux. Therefore older people may benefit from taking digestive enzyme supplements, especially if they suffer from unpleasant symptoms.
It’s not only the elderly who suffer from hypochlorhydria (or having too little stomach acid). Aside from a decrease in stomach acid that fails to trigger reactions, the acid itself cannot break down foods to release minerals, vitamins and nutrients. Many micronutrients are “cleaved” or released from food while it’s in the stomach — if this action fails, then there’s an automatic nutritional or enzymatic insufficiency.
4. Liver Disease and Other Enzyme-Related Illnesses
Anyone with liver disease should be suspected as having a concurrent enzyme insufficiency. One of the more common conditions is known as alpha-1 antitrypsin deficiency, a genetic disorder that affects roughly one in 1,500 people worldwide. This condition typically first emerges in adults between the ages of 20–50 by causing breathing and other respiratory complaints. Roughly 15 percent of adults with this condition will develop liver disease, and about 10 percent of infants who are affected will as well. Other signs and symptoms that may be experienced include unintentional weight loss, recurring respiratory infections, fatigue and rapid heartbeats.
There are other illnesses too that may at first diagnosis appear unrelated to enzymatic deficiency but also deserve attention:
- Crohn’s disease may result in enzyme deficiency.
- Iron deficiency or vitamin B12 deficiency may suggest that the digestive process is failing to cleave these nutrients from food.
- Vitamin D deficiency may indicate another malabsorption issue, just like night blindness can result from a vitamin A deficiency.
Diagnosed illnesses aside, there are many symptomatic indicators of enzymatic insufficiency. Although some could be attributed to other conditions, several relate primarily to the failure of pancreatic enzymes to be released.
- Stool changes — If the stool is pale and floats in the toilet bowl, because fat floats, this is indicative of pancreatic enzymes not functioning correctly. Another indication can be greasy or fatty deposits left in the toilet water after you poop.
- Gastrointestinal complaints — Another indicator, together with stomach distention, around an hour after eating is diarrhea. Flatulence and indigestion are also indicative that the patient may have an enzyme insufficiency.
- Fluoridated water — Further, recent research suggests that fluoride in water may be responsible for the decreased activity of both pancreatic lipase and protease. The study, although carried out on pigs, has broad-ranging implications relative to increased free radical damage and loss of mitochondria production.
5. Pancreatic Insufficiency
Pancreatic insufficiency is the inability of the pancreas to secrete the enzymes needed for digestion, which is a common problem among people with pancreatic cancer. Prescription pancreatic enzyme products (also called replacement therapy) are also used in patients with pancreatic cancer, chronic pancreatitis, cystic fibrosis, and after surgery on the pancreas or gut.
Best Digestive Enzyme Supplements: Full-Spectrum Digestive Enzymes
Because proteins, sugars, starches and fats all require specific types of enzymes, it’s best to get a supplement that covers all the bases. I recommend looking for a full-spectrum enzyme blend for general digestive improvement. Look for a supplement that includes a variety of enzymes, including some of the following (price may vary depending on the supplement you purchase):
- Alpha-galactosidase (this is the enzyme found in Beano®, derived from Aspergillus niger, which is said to help with carbohydrate digestion)
- Amylase (produced by the salivary glands)
- Malt diastase
- Protease (or acid proteases)
Here are other tips for purchasing a digestive enzyme supplements, based on your symptoms and current health:
- If you have gallbladder issues and are looking for a gallbladder diet natural treatment, purchase one with more lipase and bile salts.
- Where you see betaine HCL listed as a product ingredient, make sure pepsin is also included.
- Others contain lactase, which until recently was only available as an individual product. This enzyme is designed to assist those with specific issues relating to sugar absorption from dairy products.
- Consider a supplement that contains protease, which helps with protein digestion, if you have an autoimmune or inflammatory condition.
- Choose a blend with herbs, such as peppermint and ginger, that also support digestion.
- Also, because some people need more pancreatic enzymes than others, you need to bear in mind the level of each dependent on your needs. Most products contain some level of pancreatin, which is a combination of all three pancreatic enzymes.
For the best results, take digestive enzymes about 10 minutes before each meal or with your first bite. Protease supplement can be taken in between meals in addition to digestive enzymes with meals. Start by taking enzymes with about two meals per day and adjusting your dosage as needed as the days move on.
Foods to Eat to Support Digestion + Foods with Natural Digestive Enzymes
While there’s no doubt that many people can benefit from taking enzyme supplements, something we should all focus on is obtaining enzymes naturally from a healthy diet. Which foods contain natural digestive enzymes?
Raw fruits and vegetables grown in nutrient-rich soils are the best natural sources of digestive enzymes so make sure to buy more of them when you shop for groceries. These natural digestive aids can help to provide you with digestive enzymes naturally:
- Kefir and yogurt
- Miso, soy sauce and tempeh (fermented soy products)
- Sauerkraut and kimchi
- Bee pollen
- Apple cider vinegar
- Raw honey
Can you take probiotics and digestive enzymes at the same time? Yes. Take enzymes before a meal and probiotics after or between. It’s also beneficial to get probiotics from fermented foods like yogurt, kefir, kimchi or sauerkraut. Probiotics can help restore balance to the gut microbiome and further aid in digestion, while also curbing symptoms like gas and bloating.
Digestive Enzymes in Traditional Medicine, Ayurveda and TCM
Throughout history, traditional medicine systems emphasized treating poor digestion holistically by making dietary and lifestyle changes, rather than supplementing. Digestive enzymes only became available in supplement form in the past 50 years or so, but long before this people were encouraged to consume raw foods and probiotic foods that naturally contain enzymes. Fresh/raw enzymes are emphasized most because heat is said to destroy plants’ delicate enzymes.
According to the ancient medicinal system Ayurveda, digestion depends on sufficient agni, “or digestive fire.” Agni is said to be improved by removing causes of indigestion (such as eating while stressed or close to bed time), improving your diet, and using herbs and home remedies to strengthen the digestive organs. Spices play an important role in supporting digestion in Ayurveda, especially ginger, turmeric, cumin, coriander, fennel, cardamom, fenugreek, cinnamon, rosemary, sage and oregano.
One remedy to improve digestive fire is to drink herbal tea that can help with enzyme functions, such as tea made with one-third teaspoons each of cumin, coriander and fennel that is boiled and strained. Eating papaya is also encouraged, since it naturally provides papain, which is said to reduce bloating, act as a diuretic and help decrease inflammation.
In Traditional Chinese Medicine (TCM), digestion is improved by supporting the stomach/spleen and improve “Qi,” or vital energy. Acupuncture, herbs, movement and stress management complement the use of plant-based enzymes that are obtained from eating whole foods. Raw fruits and lightly cooked veggies are recommended most for digestive support.
Other ways to encourage digestive health include eating local/seasonal foods; choosing organic, unprocessed, non-GMO foods; limiting intake of added sugar, liquids during meals and cold foods; chewing foods thoroughly; not eating within two to three hours of bedtime; and practicing tai chi, yoga, exercise and stretching to increase appetite.
Are Digestive Enzymes Safe? Precautions and Digestive Enzyme Side Effects
If you’re dealing with a chronic health problem, it’s a good idea to visit a health practitioner for help with customized enzyme therapy. Depending on your health condition, your doctor can determine which are the safest and best digestive enzymes for you to take. If you have a history of liver or gallbladder disease, or ulcers, then consult a physician before taking digestive enzyme supplements.
What are the potential side effects of digestive enzymes? While they are generally well-tolerated and helpful, digestive enzymes side effects can sometimes include nausea, diarrhea, abdominal cramping, gas, headache, swelling, dizziness, changes in blood sugar, allergic reactions and abnormal feces. If you suffer these digestive enzymes side effects, don’t continue to take them and do consult with your doctor.
You’re most likely to deal with digestive enzymes side effects if you take a very high dose and ignore dosage recommendations, so always read product labels carefully. Consult your doctor or pharmacist if you take medications daily and want to begin taking digestive enzymes before you shop for them.
Be sure to understand the pros and cons of taking prescription pancreatic enzymes before beginning supplementation, and always carefully follow directions. It’s always a good idea to check out pancreatic and digestive enzymes reviews before purchasing supplements as well.
Final Thoughts on Digestive Enzymes
- Digestive enzymes help break down large macromolecules found in the foods we eat (carbs, protein and fat) into smaller molecules that our guts are capable of absorbing. They come with some super digestive enzyme benefits as well.
- Digestive enzymes are split into three classes: proteolytic enzymes that are needed to digest protein, lipases needed to digest fat and amylases needed to digest carbohydrates.
- People who can benefit from taking digestive enzyme supplements include those with inflammatory bowel disease, IBS, low stomach acid (hypochlorhydria), enzyme insufficiency, pancreatic insufficiency, autoimmune diseases, constipation, diarrhea and bloating.
- Digestive enzyme supplement sources include fruits (especially pineapple and papaya), animals like ox or hog, and plant sources like probiotics, yeast and fungi. Proteins, sugars, starches and fats all require specific types of enzymes, so it’s best to get a supplement that covers all the bases (a full-spectrum enzyme blend).
- Foods that can continue to provide you with natural digestive enzymes include pineapple, papaya, kiwi, fermented dairy, mango, miso, sauerkraut, kimchi, avocado, bee pollen, apple cider vinegar and raw honey.
Read Next: Pancreatic Enzymes Benefits for Gut & Immune Health
Trouble Digesting Fat? Know the signs and how to fix them
by Lucy Nepstad, MS NTP student
Every day there seems to be another study coming out about the inflammatory dangers of consuming too many carbohydrates. For most of us, this means embracing a diet higher in quality fat. These types of diets have been clinically shown to have a therapeutic effect on many inflammatory conditions – helping with weight loss, managing metabolic syndromes, supporting neurological and heart health, and balancing hormones. Yet, many who attempt to implement high-fat diets can experience unpleasant side effects. Some of the most common of these are digestive distress, fatigue, sugar cravings, rashes, dry skin, and hair loss.
If high fat diets are as beneficial as the literature would imply, why would these negative symptoms occur?
Short answer: fat is not the culprit. Instead, it is likely the body’s impaired ability to digest the increased levels of fat being consumed. Fat digestion relies predominantly on secretions from the liver, pancreas, and gallbladder. In a healthy body, these secretions are plentiful, but many conditions in modern life lead to a decrease in the production of these important digestive juices.
The gallbladder is especially important in the context of fat digestion. The organ sits under the liver on the right side of the body and is tasked with storing bile. Bile, a liquid produced by the liver, is composed of bile salts, bile acids, cholesterol, bilirubin and phospholipids like phosphatidylcholine. It is responsible for breaking down dietary fat into fatty acid components more readily assimilated by the body. If someone has been on the SAD diet for many years – chronically consuming low levels of poor-quality fats – this bile can often become viscous, leading to congestion and inflammation.
In some people this inflammation eventually progresses to gallbladder disease, which conventional medicine has opted to treat by simply cutting the organ out. In these cases, the liver becomes overburdened with bile production as it struggles to compensate for the lost bile stores previously afforded by the gallbladder. This can, of course, lead to a bile shortage, and can also lead to problems with the other 500 functions the liver performs in the human body, such as detoxification, hormone conjugation, and energy storage and conversion. This may help to explain why many people experience fatigue, sugar cravings, and hormonal issues when they eat more fat with not enough bile – the liver can’t keep up!
Even if you haven’t had your gallbladder out and have not experienced typical symptoms of gallbladder disease, you may still be dealing with biliary congestion that results in similar outcomes. One of the biggest clues for this is if you increase the amount of quality fat and either feel no added benefit or feel worse. After all, we are what we digest, not what we eat, and fat is of absolutely no use to us unless we can break it down and assimilate it.
In fact, undigested fat can wreak havoc! We need to keep in mind that digestion is a north to south process, so any kind of dysfunction happening in an earlier step is going to affect what happens later on. When we don’t secrete proper bile, large undigested fat particles can remain intact as they move through the small intestine, potentially compromising the structural integrity of the gut wall and leading to conditions such as Leaky Gut Syndrome. Later, in the colon, these huge fat particles can become rancid and ferment, resulting in foul smelling gas, digestive upset, and a generally toxic colon.
The many functions of bile
Besides fat digestion, bile also plays a crucial role in many important bodily processes including:
· shuttling toxins into feces for elimination to prevent toxic overload
· stimulating water secretion in the large intestine, helping with motility and preventing constipation
· distributing antioxidants and immunoglobulins throughout the gut
· playing an antimicrobial role and keeping dysbiosis in check
· neutralizing stomach acid for pancreatic enzymes to work
How can I optimize my Bile Flow?
One of the most important steps we can take to optimize our bile flow and fat digestion is to improve the quality of the fat we eat. We should avoid trans fats, industrial seed oils, margarines, too many omega-6 fats in nuts and seeds, and conventionally raised animal fats. While animal fat is a wonderful source of the fat soluble vitamins A, D, E, and K, it is also where the body tends to store toxins for safe keeping. Conversely, happy, healthy, pastured animals with minimal toxic loads can provide a wonderful source of fat via lard, tallow, or butter. Great plant source options include coconut and MCT oil, avocados and avocado oil, and extra virgin olive oil.
Incorporating certain foods in the diet can also help with bile production and flow. Some of the highest therapeutic value exists in the following:
Beets: Beets are a great source of naturally occurring Betaine, which assists and protects the liver. Beets also contain high levels of folate and Manganese that support gallbladder function.
Radish: Radishes contain Sulphur which can help to dislodge any deposits or stones from the gallbladder. High levels of Vitamin C aid in preventing gallstone formation and support an enzyme called cholesterol 7-alpha-hydroxylase, which works to reduce plasma cholesterol and triglycerides.
Dandelion Root: Dandelion root increases bile production by stimulating gallbladder contraction and stored bile release. It also alleviates liver congestion and soothes bile duct inflammation, hepatitis, gallstones, and jaundice.
Taurine: This amino acid is ubiquitous in shellfish, dark animal meats, and offal. Taurine is an important raw material for the formation of bile salts and has been shown to increase the degradation and excretion of cholesterol through bile acids.
Glycine: This amino acid can be found readily in collagen and is attached along with Taurine to bile acids to create bile salts.
Phosphatidylcholine: These lipids serve as one of the crucial raw materials for bile formation. Egg yolks and wild-caught salmon are a great source of this nutrient.
We carry a number of products that provide powerful biliary support. The newest additions at the office are from the Biotics Research line, and pack an impressive punch that have made quite an impression the short time we’ve been carrying them. The first of these is Beta-TCP, a well-formulated mix of beet root, taurine, vitamin C, fat digesting enzyme pancrelipase, and super antioxidant superoxide dismutase. If you need lots of support, perhaps if you’ve had your gallbladder out or suffer from acute fatty acid deficiency, Beta Plus uses the same successful formula as Beta TCP with the addition of Ox Bile. Since taking Beta Plus I have personally experienced increased satiety between meals, fewer sugar cravings, skin improvements, and more stable energy.
Pairing either of these products with Allergy Research Group’s Phosphatidyl Choline would provide comprehensive support. The Choline would provide the crucial raw materials to build healthy bile, and the Beta TCP or Beta Plus would work to stimulate and thin the flow.
Another nice option is PhytoCore from Ortho Molecular. Phytocore contains bile stimulating ingredients such as Artichoke Leaf and Dandelion Root, along with liver support like Milk thistle and Turmeric, and bile building-blocks such as Choline. This all in one formula is a convenient way to get everything is one pill.
If you’ve been working to include more fat in your diet and can’t understand why you may not be handling these changes well, don’t give up. There are a number of interventions to help with the transition. For biliary flow, this can be in the form of stimulating foods such as beets and bitters, but often may require more targeted supplementary support. Of course, negative reactions to dietary changes can be caused by many different factors, so you should always work with a practitioner to decide what kind of support is right for you and your goals.
How to Digest Fats Better, With and Without a Gallbladder
- A lot of people do not digest or absorb fats well and don’t realize it.
- Since problems around fat malabsorption typically go under the radar, you might deal with this for years without knowing you’re not getting anything out of your fats.
- Symptoms like sticky or floating stool, digestive upset after meals, even dry skin and hair loss can signal that you’re not digesting fats.
- Here’s how to incorporate digestive enzymes, stomach acid, and even ox bile whether you have a gallbladder or not.
Because we’ve lived with an unrealistic fear of fat for so many years, a lot of us don’t realize when we’re not digesting or absorbing fats well. Since problems around fat malabsorption typically go under the radar or masquerade as something else entirely, you might deal with this for years without knowing you’re not getting anything out of your fats.
Here’s the scenario. You’ve been having noticeable problems after you eat. Your food doesn’t sit well for a good 30 minutes or more after meals. At least a few times a week, you have to rush to the bathroom right after meals. What comes out is messy, floats on top, is light in color, and while you didn’t notice a strong smell before, lately your whole neighborhood knows you went to the bathroom. Or, you might have things you wouldn’t consider medical issues, like dry skin, dry eyes, or your hair doesn’t grow as fast as it used to.
Biohacking involves paying close attention to the small stuff, because it all matters. Whenever your body changes in any way, there’s a reason. Here’s how to tell if you’re not digesting fats and what to do about it. This is based on my own experiences repairing my own biology, losing 100 lbs of fat, and the research that went into the section on bile in The Bulletproof Diet. Teaching my body to properly absorb fat and use it as a building block for healthy cells – and as a fuel source for energy – made a huge difference in turning my brain back on. (And finally exposing my abs!)
Signs of fat malabsorption
You may have no clue you’re not digesting or absorbing fats. You could have no symptoms at all, or you could think that low-level symptoms like dry skin or loose stools are just the way you were made.
Or, you could have several digestive problems and other issues that your doctor hasn’t linked to the way you absorb fats. A range of symptoms indicates that you don’t digest fats well, like:
- Diarrhea several times per week or more
- Poops that smell bad
- Light-colored stools
- Floating stools
- Sticky stools
- Skin rash
- Weight loss
- Gassy after meals (flatulence and belching)
- Dry skin
- Tender gallbladder (located just under the ribs above the belly button and 3-4” to your right.)
- Gallbladder attack or gallstones
- Queasy feeling after meals
If you’re not sure whether your poop is the product of healthy digestion or not, you can take a look next time you go, and compare it to this stool chart to see how you’re doing.
Reasons you’re not digesting fats
You’ve had your gallbladder removed
Without a gallbladder, your liver makes bile and it releases before your food gets to the intestines. Without the right amount of bile at the right time, dietary fat molecules are too large to fully break down. If this is the case, take an ox bile supplement before meals, along with a digestive enzyme containing lipase. Bile from oxen is most similar to humans’ so it makes a huge difference.
This is hugely important, and most doctors fail to tell people this after they take out a gallbladder. One of my closest friends, Michelle, had this procedure performed almost twenty years ago. She predictably got dry skin, dry eyes, and brittle hair. When she added ox bile to her regimen and ate the right fats, everything returned to normal.
Your bile is too thick
When you eat, especially when you eat bitter foods like dark greens, herbs, and spices, your liver gets the signal to make bile, which gets sent to the gallbladder until you need it. As your food travels down the digestive tract, the presence of fat tells the gallbladder to squeeze out the bile it’s been making.
In fact a folk remedy from Sweden, my wife’s home country, is called “Swedish Bitters.” Most ancient medical traditions, including Chinese Medicine and Ayurveda, use bitter flavors for the bile stimulating effects.
When your bile is too thick, your gallbladder contracts and contracts, but nothing comes out. High-quality bile is fluid and will squeeze out of the gallbladder easily.
How did your bile get that way? It sat too long, most likely because you were on a low-fat diet for a while. You went through a cycle of eating, which signals to your liver to make bile. Then, if you didn’t eat enough fats or if you ate poor-quality fats, your gallbladder didn’t get the memo to squeeze it out. When bile stagnates, it thickens, sometimes to the point that it hardens into gallstones.
The best things to do are eat plenty of high-quality fats like butter, avocado and salmon. Fresh bile will dilute and draw out old sticky bile.
You don’t have enough stomach acid
When you don’t have enough stomach acid, a portion of your food passes to the next phase undigested, so your pancreas doesn’t get the signal to release enzymes. Without enzymes, the fats you just ate travel down the digestive tract largely unchanged.
You can use a betaine HCl supplement before meals and see if it helps. You can use this article to figure out how much to take.
Your pancreas doesn’t make enough digestive enzymes
Bile only breaks up large fat globules into smaller fat droplets. Lipolytic (fat busting) enzymes break down fats into components your body can use for energy, to hydrate skin, to help you make hormones, and more.
When your pancreas doesn’t make enough of these enzymes, it’s either from improper signaling or because something damaged pancreatic cells, like chronic inflammation of the pancreas.
You can pick up a digestive enzyme containing lipase to boost your body’s supply. These are usually combined with other enzymes and sometimes HCl, so check the label to find one that has what you need.
Things you can do digest fats better
First thing – consume C8 MCTs
C8 MCTs (caprylic acid), like the fat in Brain Octane Oil, skips a few steps in digestion. You don’t need bile for your cells to use it. Having a little bit of caprylic acid every day will help your body replenish the fats it’s been missing out while you haven’t been digesting fats.
Eat more healthy fats
Eating more fats will stimulate your liver to produce more bile, which will mix with stagnant bile and thin it out. Eating high quality fats like avocados, salmon and coconut oil to get things flowing.
Eat bitter foods
Bitter leafy greens simulate your liver to produce bile, which helps thin sticky bile and get things moving. Before heavy meals, you can take herbal digestive bitters. Make sure you taste the bitters because the first line of signaling for bile comes from the tongue.
Take hydrochloric acid (HCL) tablets
HCl, whether produced naturally by your stomach or taken as a supplement, tells your pancreas that food is coming, and that it needs to release enzymes. When you don’t make enough stomach acid, the pancreas won’t do what it’s supposed to do.
Take enzymes – look for lipase or pancrelipase
Digestive enzymes usually come in combo capsules. If you’re not digesting fats, you need lipase at a minimum. Check out this guide to the best digestive enzymes to determine which other ones you want to see on the label.
What do I do if I don’t have a gallbladder?
If you don’t have a gallbladder, you’ll feel a lot better with ox bile before every meal that contains fat. If you’re under a doctor’s care, check in before making any changes. If you’ve been following Bulletproof for a while, you’re already having fat with every meal, and you’re going to want to make sure your bile is working even without a gallbladder. It can be helpful to use lipase.
If you have a gallbladder, use ox bile for 2-3 weeks to help draw out sludgy bile. Then, use lipase and other enzymes for a month or two to stimulate your pancreas to release its own. You can take enzymes intermittently, or with every meal. Your body is the best guide.
The biggest lesson I’ve learned in upgrading my biology to levels I didn’t ever know to expect is that when my body doesn’t work the way I want, it’s my fault. Not because I didn’t try enough or was weak, but simply because there is always a reason, and the change simply means that I didn’t know which levers to pull or which habits to change. I’m continuously amazed and grateful to see how powerful my own biology is when I maintain it like a high performance machine.
The bottom line is that it is your birthright to feel good and have energy — it’s a lot easier when you know what to do to get the results you want. So go enjoy some butter already!
Malabsorption refers to decreased intestinal absorption of carbohydrate, protein, fat, minerals or vitamins.
There are many symptoms associated with malabsorption. Weight loss, diarrhea, greasy stools (due to high fat content), abdominal bloating and gas are suggestive of malabsorption.
Vitamin and mineral deficiencies resulting from malabsorption may cause glossitis (sore tongue), cheilosis (a fissuring and dry scaling of the surface of the lips and angles of the mouth), and anemia.
Chronic diarrhea is often the first symptom prompting one to seek medical evaluation, although diarrhea need not be present for one to have malabsorption. Steatorrhea, or fatty stools, is indicative of malabsorption. Stools will be frothy, foul smelling, and a ring of oil may be left on the toilet water.
The gastrointestinal tract and liver play key roles in the digestion, absorption and metabolism of nutrients. Diseases of the gastrointestinal tract and liver may profoundly disturb normal nutrition.
An understanding of the anatomy of the gastrointestinal tract as well as the role each major segment plays in the digestion and absorption of food will help one understand the causes of malabsorption and shed light on the rationale for specific treatment regimens. In order for food to be absorbed, it must first be digested. Digestion is the mechanical and chemical process by which food is prepared for absorption.
After a meal, food must first be broken down into simpler substances that can pass through the cells of the small intestine into the blood which transports them to all the cells of the body. The cells of the body can utilize these simpler substances as a source of energy. Digestion converts dietary protein into simple amino acids, dietary fats into fatty acids and monoglycerides, and starch into glucose.
Anatomical and physiological considerations
Digestion of food begins in the mouth where through the mechanical action of chewing and the chemical action of enzymes found in saliva, a bolus of food is formed and then passes through the esophagus. Contraction of the muscles in the esophagus moves the food bolus into the stomach by a process called peristalsis.
Once in the stomach, the food is broken down further by strong contractions which expose it to gastric juices including hydrochloric acid and digestive enzymes which are secreted by glands in the lining of the stomach. The food is eventually converted into a liquid material called chyme which is then passed into the first part of the small intestine, the duodenum.
The intestine is where food is eventually absorbed. In the intestine, the presence of chyme stimulates the production and release of a variety of enzymes from the pancreas and small intestinal glands.
Each enzyme has a specific role in digestion. There are special enzymes that digest protein into amino acids, starch into glucose and fat into fatty acids. The liver produces a substance called bile which helps to digest fat. Bile is formed in the liver, stored in the gallbladder and released into the small intestine as needed.
The small intestine is about 23 feet long in the adult and has three segments. The duodenum is the first part of the small intestine and is about 10 inches long. The jejunum is the middle segment of the small intestine and is about 8 feet long. The last portion of the small intestine, the ileum, is about 12 feet long.
The absorptive surface of the small intestine is greatly enhanced by the numerous folds and finger-like projections called villi and microvilli. It has been estimated that given all the folds, villi and microvilli, the total absorptive surface of the small intestine is about the size of a half of a basketball court!
Absorption of nutrients takes place all along the intestine, but each segment of the intestine absorbs only certain nutrients. Carbohydrates are ingested primarily in the form of starch or carbohydrates, sucrose (table sugar), fructose (fruit sugar) and lactose (milk sugar). The suffix “ose” refers to a form of carbohydrate.
Salivary and pancreatic amylase (digestive enzymes) break up the starch into long chains of sugars called oligosaccharides and shorter chains called disaccharides and trisaccharides. Most starch hydrolysis (breaking up a molecule into its smaller components) occurs in the duodenum and absorption takes place in the duodenum and jejunum.
Specific enzymes that hydrolyze disaccharides (disaccharidases) into their simplest forms or monosaccharides are located along the small intestine microvilli. Once the sugar is in the form of a monosaccharide, it can then be absorbed into the blood.
Carbohydrate malabsorption occurs in pancreatic disease, in selective deficiency of disaccharidases such as lactase (digests lactose) or sucrase (digests sucrose), in disorders of small intestinal cell function such as sprue or regional enteritis, and in loss of intestinal mucosal surface which occurs after resection of bowel. Abdominal distention, bloating and gas may be signs of carbohydrate malabsorption.
Proteins are broken down into long chains of amino acids by pancreatic enzymes. Small intestinal enzymes activate the pancreatic enzymes so that digestion and absorption of protein can take place. Absorption of amino acids and peptides occurs in the duodenum and jejunum.
Dietary fat is normally absorbed in the duodenum and jejunum. Before fat can be absorbed, however, it must first be made into a water-soluble form. Broken down dietary fats combine with bile salts and phospholipids (substances present in bile from the liver) to form a packet called a micelle. The micelle is water-soluble and is easily absorbed in the duodenum and jejunum.
Large amounts of water are involved in digestion and must be recycled in order to prevent dehydration. Water is reabsorbed in the large intestine. From the large intestine, water goes back into the bloodstream and the waste passes into the rectum and out the anus.
Tests for malabsorption
There are several tests that can be performed to help diagnose malabsorption:
Blood tests – These can be used to identify suspected malabsorption and are usually the first tests done. They are not specific because low levels of certain substances could be due to disorders other than malabsorption e.g. an unusual diet.
Blood carotene levels are useful to screen for malabsorption. Low levels of carotene in the blood suggest deficient absorption of fat-soluble vitamins or dietary deficiency. Serum carotene levels are generally low in people with fat malabsorption. Vitamin B12 and folate levels may also be used to screen for malabsorption. There are numerous causes of folate and B12 deficiency, and since the deficiencies often occur together and cause similar types of anemia, both must be measured to ensure proper diagnosis. Low calcium levels may result from either malabsorption of vitamin D or to binding of calcium to unabsorbed fatty acids. Vitamin K deficiency resulting from malabsorption may cause bleeding disorders. Anemia due to iron deficiency may be caused by malabsorption of iron in the first part of the small bowel. Normal levels of carotene, vitamin B12, folate, iron, calcium, phosphorus, albumin, and protein suggest that malabsorption is not a significant problem.
Another type of blood sampling can be used to test absorption. A substance can be administered orally and its concentration is then measured in the blood to provide a measure of absorptive capacity. The most commonly used test is the D-xylose test. A sugar called xylose is given orally and then measured in the blood 2 hours later.
Stool tests – Tests of the fat content of stool may be used to determine if fat malabsorption is present. Stool is collected over a period of 72 hours with the person consuming a diet containing 100g of fat per day. If the amount of fat in the stool is high, it suggests that the body is not absorbing fat.
Breath tests – Breath tests are another method of detecting malabsorption. They are most often performed to test for lactose intolerance. Lactose is given by mouth and the subject’s breath is analyzed for the presence of hydrogen gas. If lactose is being malabsorbed, colonic bacteria will work on the lactose to produce hydrogen gas which will be exhaled by the patient and measured in his or her breath.
Other tests – Tests such as biopsies of the small intestine (usually performed using an endoscope passed through the mouth into the intestine) are used to diagnose certain malabsorptive conditions. Special tests to image organs such as the pancreas are also useful in some cases.
Learn more about GI tests
Specific malabsorptive states
Lactose Intolerance – Perhaps the most common malabsorptive state is due to lactose malabsorption. This is a genetically determined condition and affects many individuals of African or Asian descent. In these persons, the body lacks an enzyme to digest lactose, a sugar present in milk, and bloating and diarrhea can result. The enzyme may be totally absent or present in reduced amount so that symptoms may vary depending on the amount of lactose ingested. The amount of the enzyme decreases with age and some people first notice symptoms when they reach their twenties.
Dairy products are an important source of calcium and this should be considered in planning diets for lactose-intolerant subjects. Lactose intolerance is widespread and under-diagnosed. Recognizing this condition and using milk treated with enzymes to pre-digest the lactose or taking enzyme tablets with dairy products can correct symptoms related to this condition.
Learn more about lactose intolerance
Small intestinal disease – Surgical resection or diseases of the small intestine may result in varying degrees of malabsorption depending on the site of resection or disease.
Diseases involving the duodenum may be associated with lactose intolerance, poor tolerance of concentrated sugars, and decreased absorption of iron and calcium. Almost all nutrients are usually absorbed in the first three to five feet of the bowel. The absorption of most minerals especially iron, calcium and zinc, as well as most vitamins occurs in the upper part of the small intestine.
Resections of the lower parts of the small intestine (ileum) may result from surgical intervention for Crohn’s disease. The ileum plays a major role in reabsorption of bile salts, substances produced by the liver to help digest fats that are recycled by the body for use with future meals. The ileum is also important in vitamin B12 absorption. If bile salts are not absorbed properly, the amount of these substances in bile falls and fats and fat soluble vitamins (A, D, E, K), cannot be properly absorbed. A further problem is that if bile salts reach the colon, they can cause large amounts of fluid to be secreted causing watery diarrhea.
If large portions of the bowel are lost to surgical resection, rapid transit of nutrients through the remaining bowel occurs, causing malabsorption.
Learn about short bowel syndrome
Pancreatic disease – Diseases of the pancreas can cause severe malabsorption of fats and carbohydrates. Symptoms depend on the severity of the condition but diarrhea with greasy, foul smelling stools is common and weight loss can be profound.
Liver and biliary disease – In conditions when insufficient bile reaches the intestine, fats are not absorbed and again diarrhea and weight loss occur. Vitamins that are absorbed with fats are also affected and vitamin D deficiency can occur.
When the cause of malabsorption is treatable, the primary goal of treatment is to treat the cause.
In patients who cannot be completely restored to normal (for example after extensive surgical removal of the intestine), special dietary measures need to be adopted. Dietary treatment will also depend on the site of malabsorption. If fat is being malabsorbed, a low fat diet should be consumed. Certain oils called medium chain triglyceride oils are easier to absorb in certain disease states and may be helpful as a calorie supplement.
For carbohydrate malabsorption, disaccharides, specifically lactose, often must be restricted. This involves limiting milk products or choosing many of the low lactose products now available. Lactase enzyme tablets may also be taken with milk products to digest the lactose. Vitamin and mineral supplementation needs to be tailored to individual needs, based upon serum levels, and clinical symptoms.
Pancreatic enzymes are available in capsules or tablets and in combination with a low fat diet may benefit the patient with pancreatic disease.
For the patient with severe malabsorption, in whom dietary measures are not feasible, feeding can be administered intravenously.
Occasional diarrhea and bloating are not causes for alarm in most cases. Certain food substances contain materials that humans cannot digest well and they cause bloating and gas (beans, cabbage). This is not a sign of malabsorption.
Learn more about foods that may cause gas
However, persistent diarrhea, weight loss, greasy stools and signs of vitamin deficiency (sore tongue etc.) should prompt further attention.
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Adapted from IFFGD Publication #119 by Nimish Vakil, MD, FACP, FACG, Clinical Assoc Professor of Medicine, University of Wisconsin Medical School and Carol Jorgensen-Vakil, MS, RD, CNSD, Registered Dietician, Sinai Samaritan Medical Center, Milwaukee, WI.