According to the American College of Gastroenterology (ACG), about 10 to 15% of the population has irritable bowel syndrome (IBS), yet only about 6% of adults have been diagnosed. This means there are a lot of people suffering, and translates to millions of people around the globe.
Advertisements for digestive enzymes promise the world – no more pain, bloating, or flatulence, to name a few symptoms – but are they right for you? More and more people think popping pills will solve their digestive woes. Not so fast.
What Is IBS?
Let’s first take a look at what IBS is and how digestive enzymes might help it.
IBS symptoms will vary from person to person, but we don’t know what causes it, nor is there a cure. This chronic digestive disorder of the large intestine causes abdominal pain, diarrhea (IBS-D), constipation (IBS-C), alternating episodes of both (IBS-M), or IBS-U (Unclassified; symptoms vary). Those with IBS look for ways to manage their symptoms, and if those aforementioned ads are to be believed, digestive enzymes are the answer.
What Are Digestive Enzymes?
First, what are digestive enzymes? We turned to Registered Dietitian Diana Reid for answers. Sure, they come in supplement form, but they also exist in our bodies.
“Typically, we humans produce a variety of enzymes in our digestive tract that helps us digest the food we eat.
For example, the saliva produced in your mouth contains an enzyme called amylase, which starts to break down starch into simple sugars as you chew your food. The stomach produces the enzymes pepsin and gastric lipase; these aid in breaking down protein and fat into smaller components, which can then be absorbed by your small intestine.
The pancreas also produces digestive enzymes – amylase, lipase, and protease – that break down starches, fats and proteins into smaller parts for better absorption.”
Sometimes Not Enough Digestive Enzymes Are Produced
There are a variety of reasons why someone might not make enough digestive enzymes.
Undiagnosed medical issues, such as celiac disease, could lead to problems digesting lactose due to damage to the intestinal villi, which normally produce lactase (the enzyme that helps digest lactose).
In further reference to lactose issues, Diana explains, “Many people of East Asian, African, or Latin American descent lose the ability to digest lactose as they mature, referred to as lactase nonpersistence.”
The pancreas and gallbladder produce and store enzymes, so it should not be surprising to learn that those with pancreatic or gallbladder disease may also suffer from digestive issues related to a deficiency of those enzymes.
In addition, some people may also lack or have very limited production of certain digestive enzymes due to hereditary or genetic mutations.
All of this is enough to make your head spin. The key is getting an accurate diagnosis before you start strategizing what’s next.
People Are Suffering – And Want Solutions
When it comes to medical issues, self-diagnosis is tempting (we have Dr. Google, after all), but that is a surefire way to go astray. If your goal is to become symptom-free, or at least greatly reduce your adverse digestive symptoms, then an accurate diagnosis comes before knowing the right plan of action, which may or may not include digestive enzymes.
Gastroenterologists, Dietitians, Nutritionists – Oh My!
First, let’s talk about how to get an accurate diagnosis, which could end up being for IBS, IBD (inflammatory bowel disease), GERD, diverticulitis, celiac disease, or maybe you are one of the 36% who have more than one concurrent digestive issue. Some of these issues are life-threatening and can mimic IBS. Do not self-diagnose!
In the US, a gastroenterologist is your best bet. In other countries, your general practitioner might work well. The key is to use a medical doctor. But, while these doctors are fantastic for diagnosis, they are not the ones who help put your dietary and supplement needs into practice. That is where a Registered Dietitian (RD) comes in.
You Have a Diagnosis. What Now?
So, let’s say you have an IBS diagnosis. Are digestive enzymes appropriate? RDs, also known as Registered Dietitian Nutritionists (RDNs) or Accredited Practising Dietitians (APDs), depending on where you live, play a crucial role in providing expert evidence-based guidance on supplements that are appropriate for you.
(Note that a dietitian is not a “nutritionist.” In countries like the United States, Canada, Australia, and the United Kingdom, nutritionists are not subject to regulation; anyone can call themselves a “nutritionist.” Consequently, no legal framework ensures that the information they provide is evidence-based and/or safe. Steer clear of individuals identifying as nutritionists, health coaches, nutrition coaches, functional nutritionists, nutrition therapists, gut health specialists, and other self-proclaimed nutrition experts. This proliferation is especially noticeable on social media platforms and blogs.)
An RD will take a well-rounded look at your digestive picture. They will work with your MD and possibly suggest additional testing.
FODMAP Intolerances & Digestive Enzymes
About 75% of those with IBS are experiencing intolerance to FODMAPs. You may have heard about the low FODMAP diet and not understood what it is. The funky acronym “FODMAP” refers to Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols.
Diana explains: “In order for the body to digest certain nutrients, they must be broken down from complex molecules into smaller, discrete components, which can then be absorbed into the small intestine and circulated through the body. In the case of FODMAPs, there are several hurdles that may get in the way of proper breakdown and digestion due to the chemical structure of these FODMAP sugars.”
For example, dairy products contain lactose, a disaccharide (the “D” in FODMAP), which is comprised of the sugars glucose and galactose. Lactase enzyme would break down lactose into these more easily digested sugars, but maybe you don’t have enough? Lactase enzyme is available as a supplement.
The “O” in FODMAP stands for oligosaccharides, which are comprised of fructans (found in wheat, onions, and garlic) and galacto-oligosaccharides (also called GOS, found in beans, legumes, and some soy products). Alpha-galactosidase enzyme, which is available as a supplement, helps break down certain oligosaccharides, such as those found in beans, cabbage, some whole grains, and vegetables.
Fructan hydrolase is an enzyme that can aid in breaking apart the fructosidic bonds found in inulin and other fructan subtypes. Fructan hydrolase thus reduces fructans into fructose, glucose, and inulooligosaccharides, which may be easier to digest for some individuals. Fructan hydrolase is available as a supplement.
Xylose Isomerase is an enzyme that isn’t produced by the human body; it can help break down fructose (found in honey, for instance) into glucose molecules, which can improve digestion and absorption of the “M” (for monosaccharides) in FODMAPs. Xylose Isomerase is available as a supplement.
Pancrealipase is an enzyme that breaks down dietary fat (triglycerides) into smaller particles. Dietary fat is not a FODMAP, however, some IBS sufferers struggle with the digestion of high fat meals; this enzyme may be a useful adjunct in some cases.
Amylase enzyme supplementation is thought to help reduce gas and bloating caused by the gut fermentation of resistant starch. Starch is not considered a FODMAP either, yet some people may struggle to digest resistant starch found in foods such as cooled and reheated pasta, potatoes, or rice. It’s also found in oats, lentils, corn, cornstarch, green bananas, and some nuts and seeds.
Just Because Something Is Available Over The Counter, Doesn’t Mean It Is Helpful
Now you have a primer on the types of digestive enzymes that are available. But just because something is available doesn’t mean you should take it. Should you take digestive enzymes? Dietitians and gastroenterologists say, “It depends.”
For instance, if you are following the low FODMAP diet, you are not supposed to take digestive enzymes during the initial phases of the diet (Elimination and Challenge) because the enzymes can alter your digestion of FODMAPs, which is what you are trying to assess at that time. These phases of the diet can be nuanced and complex, and doing anything, or taking anything, that will skew the data you are collecting about your digestion is counterproductive.
The exception is if a dietitian recommends a supplement for a specific reason pertinent to you. They will know your whole medical picture; this is one of the many reasons why you need an RD. Manufacturers of enzymes and lay people on the Internet do not know your specific needs. Similarly, you should not make that determination for yourself either.
Just because something is available over the counter – or someone in a Facebook group suggests it – doesn’t mean it is right for you.
Do Digestive Enzymes Work?
Do digestive enzymes work? Again, it depends. Anecdotally, in a clinical setting, Diana has seen that digestive enzymes can provide significant relief for some individuals, but she has also seen no symptoms change for others. In addition, she has seen digestive enzymes make symptoms worse.
It is important to work with your dietitian to identify the right enzyme, or enzyme combination, that is right for you.
Lactase supplementation has been extensively researched and employed for many years, demonstrating its effectiveness in assisting individuals with mild to moderate lactose intolerance. While supplementation cannot guarantee the complete conversion of lactose, it has proven beneficial. Therefore, individuals with high sensitivity to lactose may consider abstaining from all naturally occurring lactose-containing products or opting for products that are explicitly labeled as “lactose-free” to ensure their comfort.
(By the way, it would be prudent to brush up on dairy-free versus lactose-free diets; you might do better with a low-lactose diet, but that doesn’t mean you have to be dairy-free. Did you know that many cheeses like cheddar, Parmesan, and mozzarella are considered lactose-free?)
Beyond lactase, when it comes to scientific research, there is a certain amount of valuable but limited evidence regarding the effectiveness of alleviating symptoms in IBS.
For instance, a study conducted by Tuck et al. in 2017 discovered that the supplementation of alpha-galactosidase resulted in a noteworthy decrease in abdominal pain, bloating, and overall IBS symptoms among individuals with GOS-sensitive IBS.
However, a study conducted by Finnish researchers in 2015 presented a less optimistic outcome. This earlier study indicated that although there was a tendency towards symptom reduction with alpha-galactosidase supplementation, regular supplementation was not recommended. This points out that even when supplementation might be helpful and warranted, the optimal timeframe would be for taking the enzyme(s) could be individual. Again, this would best be directed by a dietitian.
There are additional studies on other enzymes, such as xylose isomerase effects on fructose malabsorption, but most think more studies need to be conducted to be conclusive. In human (in vivo) studies of the effectiveness of inulinase on aiding the digestion of inulin-type fructans are limited but have shown promise.
Kiwi Biosciences, the makers of FODZYME®, conducted in-vitro experiments validating the activity of the fructan hydrolase enzyme. Tests showed fructans rapidly broken down into simple fructose and glucose with ~90% of the fructan degraded within 30 minutes. The formula is a blend designed precisely for the fructan, galacto-oligosaccharides, and lactose FODMAPs. The formula consists of three enzymes: fructan hydrolase, alpha-galactosidase, and lactase.
Anecdotally, many people who have had problems digesting FODMAPs have found this supplement to be quite helpful when used appropriately.
Digestive enzymes can be a beneficial tool in your efforts to combat IBS, aiding in the increased consumption of certain foods and the reintroduction of others. This can help reduce dietary restrictions and enhance the nutritional content of your meals. It is important to consult with your dietitian to determine whether, how, and when to incorporate these enzymes into your dietary routine.
Before introducing any supplements, always seek advice from your doctor or dietitian, particularly if you are taking other medications or supplements, especially if you have diabetes. This is necessary to ensure there are no potential interactions or negative effects.
When purchasing digestive enzyme supplements, it is crucial to choose reputable brands from well-known sources. It is worth noting that in many countries, dietary supplements are not regulated as strictly as pharmaceutical-grade medications. Therefore, it is important to be cautious as the information on the label may not always accurately represent the actual content of the supplement.
And lastly, many dietitians will tell you that if you are working with someone who is selling supplements themselves, this can be a red flag and is best avoided.