Are You Lacking Digestive Enzymes and Should You Supplement?

Advertisements for supplements are everywhere these days -from podcasts to social media to free samples as gifts with purchases. This is because the supplement market is huge! Under the supplement market umbrella includes the digestive enzyme market, which was estimated at $699.4 million in 2021 and is projected to grow to $1.64 billion in 2031. 

This comes as no surprise to us as many of our patients have tried digestive enzymes in the past. And we’re not against them - in fact, we recommend them to help add variety for our patients with limited foods in their diets. But enzymes aren't for everyone. There are many on the market that (1) aren't evidence-based, (2) the timing and dosage can be critical for symptom management effectiveness, (3) the supplement market isn't regulated, and of course, (4) these supplements can be very expensive. 

How do you know if you should be taking one to help with your digestion? Keep reading to learn if digestive enzymes might be helpful for you.

What are digestive enzymes?

Let's start with the basics... what exactly are digestive enzymes? Well, enzymes are proteins that act as catalysts- they speed up the break down of the macronutrients (carbohydrate, fat, and protein) to their simplest forms (glucose, fatty acids, and amino acids, respectively), so that they can be absorbed and used by the body. There are two categories of enzymes: endogenous and exogenous. Endogenous enzymes are those that the body naturally makes. Exogenous enzymes come from external sources like plants or animals. Fun Fact: you'll recognize an enzyme from its suffix - almost all enzymes will end in -ase!

Endogenous Enzymes

Endogenous enzymes include salivary and pancreatic amylases, which aid in breaking down carbohydrates into maltose. Then, in the brush border of the small intestine, maltase, lactase, and sucrase-isomaltase further convert maltose and other disaccharides such as lactose and sucrose into monosaccharides (glucose, galactose, and fructose) where they are absorbed and used as fuel for the body. Remember: most nutrient absorption occurs in the small intestine!

The body also produces lipases and proteases. Lipases, which are made in the mouth, pancreas, and stomach help to break down fats into fatty acids and glycerol to be used for energy, in cell membrane structures, and other body functions. Proteases, which include pepsin, trypsin, chymotrypsin, elastase, and carboxypeptidase are produced in the stomach and the pancreas. These enzymes break proteins into amino acids, which are the building blocks of all cells.

If any of these enzymes are lacking or if the body makes insufficient amounts, malabsorption can occur. This means that instead of being absorbed in the small intestine, these macronutrients will continue down the digestive tract and make their way to the colon where they can interact with the gut microbiota. Malabsorption of any macronutrient can lead to symptoms of bloating, gas, abdominal pain and cramping, floating stool, sticky and tar-like stools, and diarrhea. This is where exogenous enzymes can come into play.

Exogenous Enzymes

Pancreatic Enzyme Replacement Therapy (PERT)

Several exogenous enzymes have years of research backing their efficacy. Creon, Zenpep, Pankreaze, Pertzye, Ultresa, and Viokase are all enzymes available by prescription and are FDA-approved for exocrine pancreatic insufficiency (EPI), and are known as PERT or pancreatic enzyme replacement therapy (we tend to see Creon and Zenpep prescribed most often in our practice). PERT enzymes contain a combination of enzymes: proteolytic enzymes to break proteins, amylases to break carbohydrates, and lipases to break fats. Those with EPI do not secrete or make enough pancreatic enzymes, especially pancreatic lipase, and this condition is often found in those with pancreatic cancer, chronic pancreatitis, and cystic fibrosis. This can cause pain, cramping, and gas, along with something called steatorrhea, a condition with fatty stools that are loose, greasy, sticky, and smelly. EPI is usually diagnosed through a stool test measuring the amount of fecal elastase that is present.

Lactase

Lactase supplements (Lactaid and other brands) can help those with lactase deficiency or lactose intolerance to better digest lactose-containing foods. In the body, lactase is made by the intestinal villi, the finger-like projections found in the small intestine. Usually, people are born with high concentrations of the lactase enzyme to help digest the lactose naturally found in breast milk; however, the production of this enzyme often decreases with age leaving some people unable to absorb lactose. This is known as primary lactose malabsorption or lactase nonpersistance. Secondary hypolactasia (low levels of the lactase enzyme) can also occur from damage to the intestinal villi (i.e. untreated Celiac Disease or Inflammatory Bowel Disease). Additionally, some groups of people are more prone to lactose intolerance. This includes people of West African, East Asian, Arab, Jewish, Greek, and Italian descent. Lactose intolerance can be determined through biopsy or breath testing.

When people who are lactose intolerant consume lactose-containing foods, the lactose will remain intact, unable to be absorbed in the small intestine. This naturally occurring sugar molecule will then cause an osmotic response, drawing water into the intestines. This results in gas, diarrhea, and abdominal pain. Lactose is found in dairy foods like milk, ice cream, heavy cream, cottage cheese, ricotta, and fresh mozzarella. It should be noted that most hard, aged cheeses and butter actually contain very little lactose.

Sacrosidase

Sucraid, is a newer, FDA-approved prescription enzyme containing sacrosidase. Sucraid supports those with sucrase-isomaltase deficiency (SID) to help break down sucrose, which is found in table sugar, molasses, maple syrup, carrots, beets, oranges, green peas, and many more common ingredients and foods. There are three types of SID. The first type is a homozygous recessive disorder, meaning there are two copies of the same recessive allele gene. This is known as Primary Congenital Sucrase-Isomaltase Deficiency (CSID). Genetic SID is a heterozygous disorder with two different alleles of the gene. The last type of SID is similar to lactose intolerance, where it occurs secondary to another condition such as small intestinal bacterial overgrowth (SIBO), IBD, or Celiac. SID can be diagnosed through biopsy or with a breath test. Also like lactose intolerance, SID results in an osmotic response, drawing water into the intestines, and patients might experience diarrhea, cramping, bloating, and even floating stools. 

Alpha-galactosidase

Alpha-galactosidase supplements (i.e. Beano, Bean-Aid, etc.) help digest galacto-oligosaccharides (GOS). GOS can be found in beans, cashews, pistachios, soymilk, and lentils. Many GOS foods like beans and lentils are prebiotic foods, meaning they feed the gut microbiota who in turn produce short-chain fatty acids which do amazing things in our body like boost our immune system and feed the cells of the colon keeping them strong. However, many people avoid these foods because of the gas that they might cause. Alpha-galactosidase can be a helpful tool for adding these foods back into the diet and feeding those gut microbiota the fuel that they need to thrive. 

Additional Digestive Enzyme Supplements

There are also some newer over-the-counter (OTC) enzymes that are quite promising, although more peer-reviewed research in humans is needed to demonstrate their efficacy. This includes fructan hydrolase and inulinase, which can be found in Fodzyme and Fodmate, respectively. These enzymes also contain lactase and alpha-galactosidase, which might help to break down foods high in fructans (wheat, garlic, onion, etc), dairy foods, and the galacto-oligosaccharides previously mentioned. Xylose-isomerase, which is found in an enzyme called Fructaid, might help to break down fructose which is found in honey, agave, apples, mangoes, etc.

These enzymes might be helpful for those with digestive disorders like IBS (Irritable Bowel Syndrome) who are sensitive to FODMAPs. As previously mentioned, more research needs to be done with these enzymes; However, as per the FDA, they are considered "generally recognized as safe.” We have also seen a good response with these from our patients. They can help to bring back some of those avoided trigger foods and add more variety to the diet (more variety = happy gut microbiome). Yes, we have many patients that come to us over-restricted! These enzymes can also improve quality of life by allowing you to eat out with less worry.

Several other OTC blends claim to help with overall digestion - however, these blends have not been well-researched. In our clinical experience, these seem to have more of a placebo effect for some people, if any effect at all.

Timing & Dosage Matter

With any enzyme, the timing plays a huge role in its effectiveness. Long, drawn-out meals like Thanksgiving or a Super Bowl party will often require a dose to be split or more likely, an additional dose or two. And, enzymes should be taken with the first bite of the meal - not thirty minutes before or an hour after the meal. The enzyme has to come into physical contact with the food for it to work, if not it’ll be wasted and you’ll be more likely to experience unwanted symptoms (not to mention wasting your effort and money!). 

Taking the correct amount of the enzyme also plays a key role in whether an enzyme will work for you, as taking too little of a dose can lead to symptoms. PERT enzyme dosages are based on their lipase content and the research suggests that 25,000-50,000 U of lipase is needed to reduce steatorrhea in those with EPI, although more ore less might be needed depending on how much fat you consume throughout the day. Each brand is a little different, and therefore it's important to work with a dietitian to ensure that you are taking enough enzyme to cover what you are eating in your meals and snacks.

For lactase supplements, the research shows effectiveness with 3,000-11,250 IU of lactase. Sucraid’s recommended dosage per meal is 8,500 IU (1 milliliter) for children and 17,000 IU (2 milliliters) for adults or those weighing over 15 kilograms. Alpha-galactosidase at 300 GalU was shown to reduce symptoms associated with GOS foods like beans and lentils. With the other enzymes (and even the other OTC and prescription varieties), it is recommended to use as directed by the manufacturer, your dietitian, or other healthcare provider to ensure effectiveness.

Additionally, enzymes act on specific food compounds, so it's important to make sure that the foods you are eating correspond with the enzyme you are taking i.e., there is no need to take a lactase enzyme if you are only having a slice of Swiss cheese, which in naturally low in lactose. A person with SID would not need a Sucraid enzyme to eat a kale salad with chicken, which contains no sucrose. But, someone who has EPI would need to take a dose of PERT if having a snack of peanut butter with apple to help digest the fat found in the peanut butter.

Furthermore, for many people, an enzyme deficiency does not mean complete absence of the enzyme, just low levels, and because of this there is a dose response. This means that someone with a lactose intolerance might be able to enjoy a small cup of ice cream, but having a meal of cheese pizza, mozzarella sticks, and a milk shake for dessert will cause symptoms. Working with a dietitian can help you to determine your tolerance.

Are Enzymes for You?

The digestive enzyme supplement industry is huge and rapidly growing. There are some evidence-based digestive enzymes like PERT, lactase, alpha-galactosidase, and sacrosidase that can help you to eat foods without experiencing digestive symptoms. However, there are many on the market without research that may not be effective at all. If you think a digestive enzyme could be helpful for you or if you’re not sure if you’re taking it correctly, be sure to speak with your dietitian or other healthcare provider. We'd be happy to let you know if enzyme supplementation may be beneficial for you and help you with the correct timing and dosage. Schedule a Complimentary Consultation today!

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