Do I need to drink enzymes if the food seems poorly digested?
The AST publishing house published a book by gastroenterologist Sergey Vyalov “Gastric Wars.” It is written for ordinary people, either suffering from diseases of the gastrointestinal tract, wishing to avoid them in the future, or striving to help loved ones. We publish an excerpt from the fifth chapter, which will help you learn more about enzymes.
What are enzymes, and why are they needed?
Enzymes are substances that speed up chemical reactions. Thousands of biochemical reactions occur in the human body: in the stomach and intestines and the brain, blood, and cells. Therefore, there are thousands of enzymes in the body. But we will only talk about those few of them that are needed for the digestion of food. There are four types of enzymes, depending on what they break down.
1. Proteases. They break down proteins. Protein molecules are very large and cannot be absorbed through the intestinal wall. They need to be broken down into parts before they can be assimilated. Imagine a squirrel in a big house. You cannot transport it to another place – no truck can transport the whole house. But it can be disassembled into bricks. That’s what enzymes do! They break down a protein molecule into amino acids – small molecules, the “bricks” of proteins.
These “bricks” are absorbed through the intestinal wall and enter the bloodstream. They penetrate the liver, where a new protein is created from them – the building material for almost everything in our body. Including these “bricks,” the enzymes themselves are formed, which are necessary for the digestion of food.
Types of proteins enter our stomach, so different enzymes digest proteins of different types. In addition, different enzymes are responsible for different steps in breaking down molecules. Those produced in the stomach tear the “house” apart. Then other enzymes are connected – they dismantle the “pieces” that have fallen off the house into separate “bricks.” But the body can dismantle this house even with the help of the pancreas alone, so the contribution of stomach enzymes to this process is rather cosmetic.
2. Lipases. This group of enzymes digests fats, which have relatively small molecules. They are broken down into fatty acids and glycerol. Fatty acids are then absorbed in the intestines and used for various purposes: mostly as a fuel, to a lesser extent, as a building material.
3. Amylases (or carbohydrates). These are carbohydrate-digesting enzymes. Most of them are represented by starch. We get it from vegetables, cereals, bread, pasta, and other carbohydrate food. Starch makes up 50% of our daily diet. A starch molecule is a very long chain made up of glucose molecules. Like other nutrients, starch cannot be absorbed naturally. Enzymes “cut” this molecule into small pieces. Glucose is formed from starch, which is absorbed through the intestinal wall. It is mainly used as a source of energy. Excess glucose is deposited on the sides in fat – these are the body’s reserves for a rainy day.
4. Nucleases. Break down nucleic acids – DNA and RNA. Digestion of food begins in the mouth. Saliva contains enzymes that break down starch. Therefore, if you chew bread for a long time, it will become sweet – glucose appears in your mouth. Protein digestion begins in the stomach. In addition, it contains a little lipase, but it does not play a significant role in the digestion of fats – there is very little of this enzyme here.
Further, the food bolus moves lower into the duodenum. This is where the main digestive processes take place. Digestive juices from the liver and pancreas flow into the initial section of the small intestine. Bile enters the liver. It performs three important functions: it activates pancreatic enzymes, emulsifies fats, facilitates further digestion, and stimulates intestinal motility.
The pancreas is directly responsible for the digestion of food. It abundantly waters the food with juice containing many enzymes: splitting proteins, fats, carbohydrates, and nucleotides.
A small amount of enzymes is also produced by the wall of the small intestine. It can digest proteins and fats. Of the carbohydrates, only disaccharides can be broken down, which consist of two molecules of simple sugars.
The small intestine cannot digest starch on its own. And there are few enzymes to break down fats and proteins in it. The main role in this process still belongs to the pancreas. That is why diseases of this organ critically affect digestive function. There are no enzymes in the large intestine. But there are beneficial microbes. E. coli and lactobacilli help us digest milk sugar – lactose.
What does “food is not digested” mean, and what does it look like?
Not digested means not completely broken down. And if it does not split, it cannot be absorbed into the blood through the intestinal wall. Such products pass through the intestines in transit and merge into the toilet. In addition, under the influence of the bacterial flora, they rot and ferment, causing unpleasant symptoms. We will only consider the causes of poor digestion associated with the pancreas.
The most obvious reason is that the pancreas produces few enzymes because it has been destroyed. But in fact, there are many other reasons.
- The pancreas can produce enzymes but cannot be activated; there is no stimulation of their production when eating food.
- Enzymes are produced at the wrong time: when there is no food in the intestines.
- Enzymes are produced in sufficient quantities and on time, but they cannot penetrate the intestines because the pancreatic ducts are blocked.
- Enzymes are produced but are immediately destroyed, so they do not have time to digest food.
If this is the case, the non-working enzymes are not digesting the food, and we can suspect this by the symptoms. With a complete violation of digestion, terrible diarrhea occurs. But this does not always happen, and other symptoms occur with a partial violation of digestion.
Steatorrhea is fatty stool. This is the most common sign that the pancreas is not doing its job. Feces become semi-liquid, greasy, and poorly washed off the walls of the toilet. In the later stages, the feces are offensive, frothy, and float on the water’s surface. Steatorrhea can result from two causes. The first is called maldigestion – fats do not break down into parts. The second – malabsorption – means fats are not absorbed in the intestines.
After acute pancreatitis, steatorrhea develops relatively infrequently. The risk is higher if the inflammation of the pancreas occurs while drinking alcohol. You can notice this if the next morning, after drinking alcohol in the evening, there is a stool loosening.
But in most people, the function of digesting fats is completely restored even after acute pancreatitis. The rest of the pancreas works two shifts or one and a half rates, and steatorrhea disappears after six months in 60% of people, after a year in 80%, and after two years in 90% of people with pancreatitis. With biliary pancreatitis, which was initially provoked by bile (which accounts for a third of all cases), steatorrhea disappears after a year in almost 100% of cases.
The situation would be much worse if acute pancreatitis were severe. Then steatorrhea persists for a long time, sometimes forever. Even after seven years, fat in the stool is still found in two out of three people. Usually, if the pancreas’s function has not recovered after four years, it is lost forever. Previously working tissues are replaced by scars supporting the organ’s skeleton but cannot produce enzymes. More often, steatorrhea is a consequence of chronic pancreatitis. Fat in the feces appears on average five years after the onset of this disease.
Creatorrhoea is a severe manifestation of pancreatic insufficiency. Appears only in the advanced stage of pancreatitis. Undigested muscle fibers appear in the feces. This suggests that the protein digestion function is impaired. It is difficult to see them with the naked eye, so they are found only when analyzing feces in the laboratory. But smelling the sharp fetid smell of feces is quite real.
Malnutrition is the most dangerous syndrome that develops with impaired digestion. In the natural course of the disease, if not intervened and not treated, it leads to death. A person’s body weight decreases, a deficiency of fat-soluble vitamins develops, and osteoporosis and bone destruction progress.
Can the number of enzymes be checked?
Yes. In acute pancreatitis, a blood test is done to check whether the pancreas is so destroyed that the enzymes have already entered the bloodstream. In chronic pancreatitis, fecal analysis is to find out how many enzymes iron can secrete, what else it can do, and whether they are enough.
Popular earlier but still used in medieval institutions, the duodenal sounding is no longer used to diagnose pancreatitis. This method is deprecated. It is unpleasant, unsafe, and largely unnecessary since it did not provide almost any information before. It was used in scientific research to study the functioning of the pancreas in the norm, but the method is unknown for what migrated into practice.
The essence of this study is that a probe is inserted into the small intestine to collect digestive juices, the production of which is stimulated by drugs. So it is possible to reveal that there need to be more pancreatic enzymes, but it is impossible to determine the cause of their shortage. It is also possible to stimulate the pancreas up to acute pancreatitis or to bring an infection into it directly from your intestines, bile. All this can end with acute pancreatitis and resuscitation.
Elastase is more stable than other pancreatic enzymes. It is defined in different ways. The best option is ELISA (enzymatic immunoassay). With this testing method, animal elastase, contained in preparations with enzymes, is not determined, but only its own, secreted by our pancreas, is detected.
A stool enzyme test is effective even for mild enzyme deficiencies: it detects the disease in two out of three people with pancreatitis. With moderate and severe insufficiency, the method’s accuracy reaches 100%. You can set not only the presence but also the stage of the problem. Most people have an elastase-1 content of more than 500 mcg / g. The pancreas is doing its job at 200+ mcg/g. This is the last value that is considered normal. Enzymes should be added at elastase-1 levels less than 200 µg/g. If the amount of the enzyme is less than 100 µg/g, then a severe enzyme deficiency is determined. This is an indication of the use of high-dose enzyme tablets.
Do I need to drink enzymes if my own is enough?
You can drink enzymes just like that, but you don’t need to. The good news is that it’s safe or not very dangerous. The bad news: it hurts your wallet and does no good. Various studies have been conducted to find out whether taking enzymes in tablets reduces the production of their own or not. The conclusion is this: the pancreas works on the principle of feedback, which means that if there are a lot of enzymes in the intestines, it will stop producing them. A single dose of extra enzymes will not affect this, but it will remain useless. However, if you drink enzymes often or use high dosages, then the function of the gland will slow down.
Do you need enzymes? It makes no sense to listen to the symptoms and look at the poop in the toilet. Go to the doctor or the nearest laboratory and donate feces for pancreatic elastase-1. No enzymes are needed if the level is above 200 mcg / g. But if at the same time there are alarming symptoms, then it’s time to finish attributing everything to the pancreas and start looking for the real reason for their appearance. This may be the stomach or intestines.
If there are few enzymes, what will be the consequences for the body?
It isn’t good if there are not enough enzymes. In this case, fat will appear in the feces. Chronic diarrhea occurs, and polyfecal matter is a condition in which the amount of feces increases significantly. The reason is that the food is not digested. Instead of being broken down and absorbed into the bloodstream, it passes through the intestines and drains into the sewer. Along the way, it feeds the intestinal microflora, which releases a lot of gases into the feces and becomes loose. Therefore, visually it seems that there is more poop.
If the food is not digested, then the body lacks nutrients. The person is losing weight. A deficiency of protein, vitamins, minerals, and lipoproteins develops. This is a dangerous condition that can lead to a hospital if ignored. But if the problem is identified in time, then the treatment is simple: take enzymes with food in a selected dose.
Feedback principle for enzyme production
The pancreas constantly secretes a small amount of enzymes, even if you do not eat anything. Let me remind you that bile is not released without food. Therefore enzymes do not work, even if released and enter the intestines. But in those people whose gallbladder is removed, bile is constantly secreted, and it turns out that the enzymes are activated in the intestines in the absence of food. And over time, this can create a new problem in the intestines.
Several mechanisms regulate the level of enzyme production: first of all, these are nerves and hormones. How do nerves work? I saw food, got hungry – juices began to stand out. Nerves can also reduce the production of enzymes: pain, sleep, and strenuous physical and mental work block the release of digestive juices. How is hormonal regulation carried out? The stomach, intestines, and bile hormones enhance the production of pancreatic juice: secretin, gastrin, cholecystokinin, serotonin, insulin, bombesin, and bile acids. There are also a half dozen hormones that weaken the production of enzymes.
There is also a mechanism for the adaptation of the pancreas. If we constantly eat carbohydrates but do not eat fats and protein, the body will learn to produce more enzymes to digest starch but reduce the secretion of lipases and proteases. This adaptation occurs within two to three weeks. The delay occurs because the pancreas prepares a supply of enzymes in advance for some time, based on your menu in the past. This is the main reason you should not abuse enzyme preparations without a proven enzyme deficiency. Your pancreas can become lazy, and you will always have to sit on enzymes.
How do enzymes from pills work?
Enzymes from pills are used as replacement therapies, meaning they replace what you lack. Therefore, there is no point in taking enzymes if your pancreas is working properly. If it works poorly, this must be proven by passing tests. At least it is necessary to hand over feces on enzymes. Only when a diagnosis is established should treatment begin.
Remember that enzymes are not the drugs that can be “treated.” Replacement therapy is prescribed for a long time, and if the pancreas has already turned into scars and is torn into flaps, then even for life. If much of the pancreatic tissue is destroyed, it will never regenerate.
All enzyme preparations are different. What is the difference?
Enzymes are different. They contain lipase, protease, and amylase – enzymes for the digestion of fats, proteins, and carbohydrates. They have the same enzymes as in our pancreas, but the difference is that they are derived from animals. In addition, there are differences between tablets from different manufacturers.
- Dose. The package indicates only the amount of lipase – for example, 10 thousand units. But in the instructions, you can also see the other enzymes you should remember. Some pills contain only a symbolic and almost useless amount of enzymes, so you should not expect at least some results.
- Bile acids. It may or may not be included in the formulation. Most people do not need bile acids. Sometimes, on the contrary, bile acids are completely redundant and can provoke disruption of the gallbladder.
- Tablets or capsules with microspheres. Microspheres are better mixed with food, better out of the stomach, and more effective but expensive.
- The presence of an enteric coating. Most “normal” drugs have it – this is a prerequisite. Oddly enough, some drugs do not contain such a shell. Their effectiveness is questionable, equal to zero, or the same as that of a placebo pacifier: pancreatic enzymes are destroyed in the stomach by hydrochloric acid.
When we say “enzymes,” we usually mean “pancreatin.” But there are other enzymes as well. For example, papin is a proteolytic enzyme from plants. Some people take enzymes to digest milk sugar – they contain lactase.
Why take lactase enzyme?
In adults, lactase deficiency, an enzyme that digests milk sugar, often develops and constantly progresses with age. Nature provides that a person eats milk only in the first few years of life. Then the splitting of milk is not required. But nature did not foresee that we would tame goats, cows, and camels; we would take their milk and use it throughout our lives.
Lactase deficiency is a conditional norm for an adult but a disease for a child. Babies must digest milk. Otherwise, they risk starving to death. However, in the modern world, infants no longer face starvation. There are preparations containing the enzyme lactase. Taking them regularly will help anyone from zero to 150 years old to digest milk.
Attention! Refrain from confusing carbohydrates and enzymes: the difference in their name is just one letter. The carbohydrate is called lactose, and the enzyme that breaks it down is called lactase.
And a little more attention! Do not confuse lactose intolerance with cow’s milk protein allergy. The difference is manifested in a different reaction to milk from different animals: cows and goats.
And most importantly, attention! The manifestations of lactose intolerance, lactase deficiency, and cow’s milk protein allergy can be about the same and the same as with other bowel problems. It can have one or several problems at once; sometimes, a person collects them. Therefore, before “writing off” all your symptoms for milk, you need to carefully check the intestines and ensure that there are no other problems.
How does the gut disguise its problems as an enzyme deficiency?
It is impossible to determine by symptoms whether you have pancreatic insufficiency or one of the 120 bowel diseases known to science. The symptoms and manifestations of these problems are almost the same: pain and cramps in the abdomen, flatulence and gas, diarrhea, and shapeless stools.
Even the appearance of fat in the feces is an unreliable symptom. It can appear not only from the pancreas but also from a violation of bile secretion from the liver, intestines or atrophy of the stomach. In liver diseases, there are not enough bile acids, so fat is not broken down even with good pancreas function. In diseases of the intestine, fat is broken down but not absorbed – many fatty acids appear in the feces.
The conclusion is as follows: if you feel your stomach is growling, do not rush to pounce on enzymes. Donate feces for elastase to check whether the pancreas is to blame for your troubles.
How many enzymes do you need for a standard meal?
A healthy person does not need to take enzymes. Moreover, drugs advertised on TV are often contained in scanty quantities, so they do not significantly affect digestion. For example, the most popular drug from advertising contains only 3.5 thousand units of lipase. For comparison, a person suffering from chronic pancreatitis is prescribed at least 40 thousand units for one meal. This is the starting dose. In the future, it can be increased.
Most advertised drugs are available in tablets. This is an inefficient form because most of the enzyme does not come into contact with food. Doctors prescribe only microspheres, and their size is important. Microspheres with a diameter of 1.2 mm perform 25% better than microspheres with a diameter of 2 mm.
Finally, the final nail in the coffin of over-the-counter low-dose enzymes is that many of them are not even enteric-coated. They enter the stomach and are destroyed there. Is it bad or good? It’s just money for pills flowing from your pocket into the pocket of archaic pill makers. If you are already spending finances on your health, then take the best, thus investing in the progress of medical science, and do not vote with your ruble for medicine of the century before last.
The dosages are meager: they would not improve digestion, even if they penetrated the intestines. In addition, most of these drugs are taken without a real need to calm the conscience in the self-treatment of temporary disorders or diseases that are not treated with enzymes.
Now the answer to the main question: how many enzymes should be taken? If you don’t get sick, not at all! For chronic pancreatitis, good digestion will require 50 thousand IU for a full meal and 20-25 IU for a snack.
What to do if it doesn’t work? Change tablets to capsules with microspheres. And at the same time, think: perhaps you are treating the wrong disease, and the pancreas is actually in full order.
What to do if digestion is still disturbed? In this case, doctors prescribe proton pump inhibitors. They block the production of hydrochloric acid. The pH level of the contents of the stomach and intestines shifts to the alkaline side, and in such conditions, enzymes work better. But this is another reason to think that the symptoms are not associated with the pancreas but with another organ.
What to do if there is still no sufficient effect? Increase the dosage of pancreatin by one dose. Most patients take up to 80 thousand IU per appointment. The maximum dose allowed by the instructions for the use of drugs is 10 thousand units per 1 kg of the patient’s body weight per day. How much is this? Let’s say you weigh 80 kg and eat four times a day. In this case, the maximum dose per meal is 200 thousand units. Rarely reach such high dosages. But this is possible if a person’s pancreas is destroyed or surgically removed.
This is the third call to check other digestive system organs because such a low amount of its enzymes for a long time will lead to new problems. In any case, the dosage is determined individually. Although it is selected by lipase, pancreatin preparations always contain other enzymes: proteases and amylase, for the digestion of proteins and carbohydrates.