Digestive Enzymes

What happens when your body doesn’t produce enough of an enzyme?

In certain conditions, your body may struggle to produce any or enough of a digestive enzyme. In this case, a digestive enzyme supplement can be taken orally to replace the digestive enzyme that your body is struggling to produce. Some digestive enzymes are available over the counter (OTC), while others require a doctor’s prescription.

Timing of a digestive enzyme supplement

Digestive enzymes must be taken just before you eat. This ensures that the enzymes are ready to do their work as soon as food gets to your stomach and small intestine. In some circumstances, you may choose to break up the dose. For example, if you’re eating a large meal that takes longer than usual to eat, or if you’re a slow eater, your doctor may recommend taking half the dose at the start of the meal and the rest halfway through your meal.

Below we discuss the circumstances where taking a digestive enzyme is warranted.

Irritable Bowel Syndrome (IBS)-related enzymes

FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (FODMAPs). These molecules are resistant to digestion in your small intestine and reach your large intestine intact. They are then fermented by the gut bacteria in your large intestine, resulting in gas production, which causes symptoms such as bloating, abdominal discomfort, and flatulence. While not everyone is sensitive to the effects of FODMAPs, many people with IBS are.

Digestive enzymes can assist in the breakdown of certain FODMAPs, which may reduce symptoms associated with IBS. The two digestive enzymes that have been researched to help reduce IBS-related symptoms are:

Lactase

Lactose is the main carbohydrate found in milk and milk products and is a type of FODMAP. Lactose intolerance occurs when our small intestine doesn’t produce enough lactase. Some people may only have lactose intolerance, while for others, lactose intolerance may be part of a broader IBS diagnosis. A lactase enzyme supplement may be helpful in this case.

Alpha-galactosidase

Alpha-galactosidase is an enzyme that helps breakdown oligosaccharides, particularly galactooligosaccharides (GOS) which are found in

• Legumes (e.g. red kidney beans, chickpeas, baked beans, split peas)
• Cashews and pistachios
• Soy milk made from whole soybeans
• Drinks made with soy milk containing GOS, e.g., soy cappuccino
• Oat milk

The alpha-galactosidase enzyme is actually not made by the body, which means that GOS reach the large intestine undigested. This is usually not a problem for most healthy individuals. However, it can be for IBS sufferers who have more sensitive guts, especially when GOS-containing foods are consumed in larger volumes. An alpha-galactosidase enzyme supplement may be helpful in this case.

Using digestive enzymes to manage IBS-related enzymes

• Both lactase and alpha-galactosidase enzymes can be purchased over the counter. However, you should consult your GP or dietitian before trialling digestive enzymes.
• If taking these enzymes, alpha-galactosidase should be taken before eating GOS-containing foods and lactase should be taken before eating lactose-containing foods.
• Don’t use them during the first two phases of a low FODMAP diet, as it will be harder to tell which foods are triggering your symptoms. They should only be introduced when you know which foods and FODMAPS are triggering your symptoms
• When using digestive enzymes, begin with a two or three-week trial to see if it has any effect. If you don’t see any changes after this time, they’re likely not effective for you. All IBS symptoms and management strategies are highly individualized.
• Digestive enzymes can enable some people with IBS to follow a less restrictive diet long-term; however, they should be part of a broader management strategy rather than stand-alone.
• If you follow the correct dosage, there is no evidence of harm. Incorrect dosages, however, can lead to gas, loose stools, constipation, and nausea. Digestive enzyme supplements can also interact with certain medications, including antacids and certain diabetes medications. Make sure you inform your GP of your plans to start digestive enzyme therapy.
• A strict low FODMAP diet, regardless of whether or not it includes digestive enzymes, is not a long-term diet (that is, foods should be reintroduced) and should only be done under the guidance of a dietitian or doctor trained in IBS management.

Other enzymes for IBS

Currently, we only have evidence to support the use of lactase and alpha-galactosidase as enzymes for IBS management. There are other enzymes on the market, such as xylose isomerase (enzyme to break down fructose) and other mixtures of enzymes, however, we don’t have much research on their safety, nor do we know if they are effective in IBS management.

Other strategies to manage lactose intolerance

• Lactose-free milk (which has had lactase already added) can be purchased from the supermarket.
• Lactose intolerance is often not an all-or-nothing situation. Some people find they can tolerate:
  • Small-moderate amounts of dairy but not more significant amounts
  • Hard cheeses and yoghurt as these foods contain smaller amounts of lactose (during the culturing process of cheese and yoghurt, bacteria feed off the lactose converting it into lactic acid)

Natural digestive enzymes

Note that there are also natural sources of digestive enzymes. While they are not the same as a digestive enzyme supplement, including these foods in your diet can potentially aid digestion and promote good gut health.

Low FODMAP examples include:

• Unripe Bananas
• Pineapple
• Kiwi Fruit
• Ginger
• Miso
• Avocado

Now let’s talk about exocrine pancreatic insufficiency

Exocrine Pancreatic Insufficiency (EPI)

What is it?

EPI occurs when your pancreas doesn’t produce sufficient digestive enzymes, which means you don’t have enough lipases, proteases and amylases. This is different to IBS-related enzyme shortage and is much more severe. A variety of conditions cause EPI, including:

• Cystic Fibrosis
• Pancreatitis
• Crohn’s Disease
• Digestive tract surgery

Signs and Symptoms

The lack of enzymes means there is undigested food in your intestines which causes gut pain, bloating, and diarrhoea. Severe cases of EPI result in fatty, foul-smelling, loose stools as well as malnutrition and unhealthy weight loss due to the inability to digest and absorb the nutrients from food.

Treatment

As EPI is associated with severe conditions, anyone with EPI should closely work with a doctor. EPI can be managed through a medication called Pancreatic Enzyme Replacement Therapy (PERT) which, as the name suggests, supplies your body with the replacement pancreatic enzymes. Most PERT medications are only available via prescription. While some PERT medication is available OTC in lower doses, they should still only be taken if indicated by your doctor.

More information:

• Scientific information on digestive enzymes: https://www.sciencelearn.org.nz/resources/1840-digestive-enzymes

IBS-related resource:

• FODMAP Friendly: Blogpost on Digestive Enzymes https://fodmapfriendly.com/blogpost/enzymes/
• Monash University: Research on Alpha-Galactosidase

Exocrine Pancreatic Insufficiency:

• Cleveland Clinic https://my.clevelandclinic.org/health/diseases/21577-exocrine-pancreatic-insufficiency-epi

Last modified: November 11, 2021