Enzyme Supplementation & the Low FODMAP Diet: Can it Work for YOU?

What is a Bloaty, Gassy Person To Do?

As an IBS sufferer, you may have tried just about every possible combination of food, beverage and supplements, hoping for relief.

You may have heard of or read about digestive enzymes and wondered if they can help you. But, randomly trying yet another supplement and hoping for the best can be a painful road to travel.

So, what’s a bloaty, gassy person to do? Behold: Your primer on digestive enzymes and IBS!

What Are Digestive Enzymes?

Most individuals (more on this later) produce a variety of enzymes in their digestive tract that help them to digest the food they 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.

Further on down the line, your stomach produces the enzymes pepsin and gastric lipase, which help to break down protein and fat into smaller components that can be absorbed by your small intestine.

Your pancreas also produces a number of additional digestive enzymes that further help break the foods you eat into smaller parts that can be absorbed and turned into fuel for your body and its daily activities.

What Happens If You Don’t Have Enough Digestive Enzymes?

Individuals who do not produce sufficient amounts of digestive enzymes may have difficulties digesting certain foods, and thus, encounter painful symptoms of malabsorption that can come from large food molecules entering the large intestine undigested.

This is where gas and bloating can arise, as well as diarrhea. For example, many individuals of Asian, African or Latin American descent may lack the enzyme required (lactase) to break down the lactose found in dairy products[1].

Individuals with poorly managed celiac disease may also have problems digesting lactose as a result of damage to their intestinal villi, which normally produce lactase. Other individuals who have pancreatic or gall bladder disease may also suffer from digestive issues related to deficiency of important digestive enzymes.

Finally, some individuals with hereditary or genetic mutations may also lack or have very limited production of certain digestive enzymes.

The Connection Between IBS & Digestive Enzymes

Many individuals with IBS also have some of the conditions mentioned previously, which then limits their ability to digest certain types of food. And others may genetically lack sufficient enzymes to digest one or more of the FODMAP groups, paving the way for a possible treatment via supplementation with digestive enzymes.

Let’s take a look at what enzymes are available and how they might be used.

• • Lactase (B-galactosidase): This enzyme helps break down lactose (the “D” in FODMAPs) into its component sugars; glucose and galactose, and thus helps improve digestibility and absorption.
  • Alpha-galactosidase: This is an enzyme that helps break down certain oligosaccharides (the “O” in FODMAPs). It tends to be most active in breaking down raffinose and stachyose, galacto-oligosaccharides (GOS) found in beans, peas, cabbage, some whole grains, broccoli and some other vegetables. Our bodies do not make alpha-galactosidase as a digestive enzyme, which is why GOS particles move to the large intestine undigested and cause gas and bloating, even in healthy individuals.
  • Xylose Isomerase: Another enzyme that isn’t produced by the human body, this enzyme can help break down fructose into glucose, which can improve digestion and absorption of the “D” (for disaccharide) in FODMAPs.
  • Pancrealipase: This enzyme breaks down dietary fat into smaller particles. It is important to note that fat is not a FODMAP, however some IBS sufferers do struggle with digestion of high fat meals.

But Do They Work?

While many companies market digestive enzyme products, there is still fairly limited evidence regarding their effectiveness. Let’s take a look at the latest scientific data on this front.

• • A 2017 study by Tuck et al[2] found that in GOS-sensitive IBS patients, alpha-galactosidase (AG) supplementation led to a significant reduction in abdominal pain, bloating and overall IBS symptoms, while a 2015 study by Finnish researchers[3] wasn’t as positive.

This older study concluded that while there was a trend toward reduced symptoms with the AG supplementation, there wasn’t a significant enough effect to recommend regular supplementation. So, what to do?

In this case, individuals who know that they are GOS-sensitive may want to trial supplementation of AG to see if it helps reduce symptoms. Supplementation with this enzyme may also be useful for individuals who follow a vegan or vegetarian version of the low FODMAP diet and have a high intake of beans and starchy or cruciferous vegetables.

• • There is not a lot of recent evidence regarding the efficacy of xylose isomerase (XI) supplementation and IBS symptoms, however a 2012 study[4] evaluated changes in hydrogen production (which results from fructose malabsorption) between two study groups.

One group took a placebo, and another took XI. Each group ingested a relatively large dose of fructose and then completed hydrogen breath tests at 0, 30, 60, 120, 180 and 240 minutes. The group that took the XI showed lower production of hydrogen and reduced symptoms of abdominal pain, bloating and nausea, which is promising.

However, it is important to note that these patients had only very mild symptoms at baseline, so for individuals who are very sensitive to excess fructose, supplementation of XI may not be useful.

• • Pancreatic lipase was studied in a small 2010 pilot study[5] on post-meal IBS-D (IBS with diarrhea), where it was found useful in reducing symptoms of cramping, bloating, pain and urge to defecate, while increasing stool firmness.

This particular study was sponsored by a pharmaceutical company, which provided the pancrealipase for study participants. Another recent study by Nishiyama et al[6] showed that supplementation of pancreatic lipase in mice increased the quantity of a key beneficial bacteria in the intestinal tract, however it has not been studied in humans. Thus, the data is somewhat unclear.

• • Lactase supplementation has been studied and used for decades, and has been proven to be helpful for individuals with mild to moderate lactose intolerance. Supplementation does not always eliminate (convert) 100% of the lactose, so individuals who are extremely lactose sensitive may wish to avoid all naturally occurring lactose-containing products and/or choose products that are clearly labeled “lactose free.”

The Bottom Line

Digestive enzymes may be a helpful tool in your IBS-fighting arsenal, but they are not a cure-all and will not replace a well-structured low FODMAP diet and the advice of your doctor or dietitian.

References

[1] Emedicine.medscape.com. (2018). Lactose Intolerance: Background, Pathophysiology, Etiology. [online] Available at: https://emedicine.medscape.com/article/187249-overview#a6 [Accessed 1 Mar. 2018].

[2] Tuck, C., Taylor, K., Gibson, P., Barrett, J. and Muir, J. (2018). Increasing Symptoms in Irritable Bowel Symptoms With Ingestion of Galacto-Oligosaccharides Are Mitigated by α-Galactosidase Treatment.

[3] Markku Hillilä, Martti A. Färkkilä, Taina Sipponen, Janne Rajala & Jari Koskenpato (2015) Does oral α-galactosidase relieve irritable bowel symptoms?, Scandinavian Journal of Gastroenterology, 51:1, 16-21, DOI: 10.3109/00365521.2015.1063156

[4] Komericki, P., Akkilic-Materna, M., Strimitzer, T., Weyermair, K., Hammer, H. F. and Aberer, W. (2012), Oral xylose isomerase decreases breath hydrogen excretion and improves gastrointestinal symptoms in fructose malabsorption – a double-blind, placebo-controlled study. Aliment Pharmacol Ther, 36: 980–987. doi:10.1111/apt.12057

[5] Money ME, Walkowiak J, Virgilio C, et al. Pilot study: a randomised, double blind, placebo controlled trial of pancrealipase for the treatment of postprandial irritable bowel syndrome-diarrhoea, Frontline Gastroenterology 2011;2:48-56.

[6] Nishiyama H, e. (2018). Supplementation of pancreatic digestive enzymes alters the composition of intestinal microbiota in mice. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29106956