In this short article I am going to chat about digestive enzymes and functional testing that may be helpful to determine which aspect of your digestive system is most impaired. If we aren't testing, then we are guessing.
What are digestive enzymes?
Digestive enzymes are naturally produced by our own bodie and we can take supplemental forms of digestive enzymes. They can also be produced by plants such as pineapple and papaya. Our mouth, stomach, liver/gallbladder and pancreas all produce different but similar enzymes to break down fats, carbohydrates and proteins. Enzymes break down foods into microscopic nutrients that our body then absorbs to use throughout our body.
Types of digestive enzymes
Amylase - digests carbohydrates
Lipase - digests fats
Protease - digests proteins
Where are digestive enzymes produced?
Mouth - Amylase, lipase
Stomach - Proteases including HCl and pepsin
Liver/gallbladder - bile salts
Pancreas - Proteases like trypsin, lipase, amylase and neutralizers like bicarbonate
Different types of enzymes you may see on a bottle:
Amylase – for carbohydrates digestion; produced in the saliva, stomach, pancreas
Pepsin – for proteins digestion produced in the stomach
HCl – this is stomach acid or hydrochloric acid. It is for prevention of infections and protein digestion; produced in the stomach and maintains a healthy stomach pH of 1-2
Protease – for proteins digestion, produced in the stomach and pancreas
Lipase – for breaking down fats, produced by the pancreas
Trypsin – for proteins break down, produced by the pancreas
Bile Salts – to emulsify fats, stimulates the movement of the small intestines and colon, produced in the liver and stored in the gallbladder (or cystic duct if you don’t have a gallbladder)
Cellulose or hemicellulose - to help breakdown fibers
Papain – a natural digestive enzyme from papaya; very gentle
Bromelain – a natural digestive enzyme from pineapple; very gentle
How to choose the right digestive enzyme for you
Stomach deficiency
If you are considering a HCl or pepsin digestive enzyme, a serum gastrin laboratory test may be helpful to diagnose an underlying low stomach acid state. Gastrin is the hormone that tells the cells in your stomach to produce stomach acid. Two tests that are helpful are the Bravo pH test and the Heidelberg test.
The Heidelberg test
This device tracks acid levels in the stomach as the patient swallows small amounts of baking soda, which neutralizes the hydrochloric acid in the stomach. If the acid level does not return to normal after the baking soda is swallowed, the patient has hypochlorhydria. This test can also be used to measure the movement of the stomach and diagnose gastroparesis. Test time is about 2 hours. The device is swallowed and excreted in the feces or pulled up. This test is more of a specialty test than the Bravo so it may be more difficult to find someone. This is a more accurate diagnosis of the stomach pH compared to the Bravo.
The Bravo pH test
This test uses a small device that is attached to the wall of the esophagus during an endoscopy and measures the pH of the acid that is refluxing out of the stomach. It transmits data to a small computer that you wear. You trigger the computer to record when you are experiencing heartburn symptoms. It is recommended that you keep a little journal with you to note anything that may have been going on leading up to the heartburn event. The device measures for about 48 hours before you return to have another endoscopy to have the device removed.
I do not like the HCl challenge nor the baking soda challenge as both are subjective and often inaccurate.
Symptoms of low stomach acid include often sick with ‘gut bugs’, diagnosed with H. pylori or candida, heartburn, feelings of fullness or heaviness with eating even small amounts.
Gallbladder deficiency
If you have had any type of gallbladder surgery or removal chances are super high that you need bile salts. If you tend towards constipation and have issues digesting fat. If you notice an oil slick on the top of the water in the toilet after a bowel movement is another indication. But remember that most people dealing with chronic heartburn also have thickened bile regardless of removal.
Bile salts are best to start low and go slow. Diarrhea is a symptom of taking too many bile salts.
Symptoms associated with bile salt deficiency include constipation, foul smelling stool, smelly flatulence or gas, difficulty digesting fat with meals such as upset stomach or worsening of heartburn.
Pancreatic deficiency
Exocrine pancreatic insufficiency is usually a significant problem. But with anything else in medicine, it’s on a spectrum. Many people have mild exocrine pancreatic insufficiency. This means that for some reason the pancreas is not properly producing the pancreatic enzymes.
This could be for a few reasons such as low stomach acid or blood sugar issues.
A fecal elastase test can be done to measure the pancreatic enzyme function in your digestive tract. This test is less sensitive for those that may have a mild case of exocrine pancreatic insufficiency. Fecal fat test is another test that can be done but it requires gathering exocrine pancreatic secretions.
Symptoms of exocrine pancreatic insufficiency are very similar to those of IBS and chronic heartburn.
Where to start
When trying to figure out where to start with digestive enzymes, if you don’t want to test your blood, stool or the pH of your stomach, it will be trial and error. With trial and error comes the potential for treatments to worsen chronic heartburn.
Maybe some of you have had some of these tests already, in which case you have data that you can use to help guide you in the best direction.
But if you don’t want to get any more tests starting with bile salts + pancreatic enzymes is a reasonable place to start. Start slow and with a low dose. If the bottle says take 2 with meals, start with 1 per meal. Again you are going to develop some awareness by listening to your body and ‘feeling it out.’
Research shows that taking digestive enzymes just before you eat or with your first few bites of food is best.
To review
There are digestive enzymes found in our mouth, stomach, gallbladder and pancreas. Testing can be done to determine which area of your digestive system is most deficient. The HCl challenge and the baking soda challenge are not ‘high quality’ data points so they are unreliable. If we don’t test, we are guessing and listening to our intuition is important too. We can take oral digestive enzymes just before meals for maximum efficacy. If you want to start some place, most people suffering from chronic heartburn have thickened bile and need some additional bile support. Usually when bile is impacted so are pancreatic enzymes.
Disclaimer - always talk to YOUR doctor before following any of the suggestions on this blog.