Good Living in the Land Down Under
Supporting digestive health via nutritional ingredients can lead to
enhanced whole-body wellness.
Heather Granato
References
America, the land of abundance, is seeing a synergistic interaction of
societal factors driving more consumers down the path of digestive dysfunction.
Take the fast food culture, add in economic stressors, an aging population and
the growing load of environmental toxins, and it’s likely no wonder market
research firm Mintel estimates there are more than 62 million Americans
suffering gastrointestinal (GI) ailments. The company noted activity in the
over-the-counter (OTC) remedy market for GI upset is expected to pick up in the
coming years, as new products (chewables, combination, etc.) strengthen the
market and consumers continue to self-diagnose and -treat minor GI ailments.
This tendency to personally address gut health holds great potential for
retailers of natural products, who hold on their shelves myriad options to not
only treat digestive dysfunction, but get at the root cause. Brenda Watson,
founder, ReNew Life Formulas Inc., noted: “Faced with rising health care costs
and a nation dependent upon prescription drugs, modern-day consumers are seeking
smarter, healthier and more cost-effective options to achieve and maintain their
overall health. Not only that, but they understand that natural remedies focus
on the whole body—not just one or two symptoms—and thus address the root cause
of a particular illness or condition to prevent its recurrence.”
Increasing numbers of Americans are open to enhancing their digestive health
with natural products. According to the Natural Marketing Institute (NMI), more
than 15 percent are managing constipation, 14 percent irritable bowel syndrome
(IBS) and 4.5 percent for stomach ulcer. NMI also found 20 percent of households
turned to fiber and more than 10 percent used acidophilus probiotics in 2007.
“Stomach pain, gas, bloating and heartburn are just a few of the things
driving consumers to purchase digestive health products, but consumers are also
buying digestive products for overall wellness,” said Scott Daniel, marketing
manager, National Enzyme Co.
This move toward purchasing products for general well-being is driven by a
more informed consumer. Silvia Cheskes, vice president of marketing, Attune
Foods, noted it’s easy to see just in mainstream media that the former “taboo”
on talking about bodily functions is long gone. “Consumers today are better
informed due to the Internet and companies that are doing more to educate
consumers about issues like digestive health,” she said. “Consumers are also
taking a more active role in their health—reading about it online and looking
for products that can deliver an actual health benefit in addition to good taste
and enjoyment.”
Seconded Matt Schueller, Enzymatic Therapy: “Consumers are seeing advertising
on television for these products, which is driving new consumers into retail
outlets seeking to try them. Consumers are getting relief of constipation, gas
and bloating without the side effects of drugs, and are becoming loyal users of
the products.”
In addition, awareness is increasing that supporting gut health does more
than just address dysfunction, according to Tim Gamble, vice president sales and
marketing, Nutraceutix. “So many health conditions are being tied through
scientific research to healthy digestion and the digestive tract that consumer
awareness is expanding,” he said. “Digestive health is now clearly tied to
immune system stimulation, autoimmune system health, dieting, proper nutrient
assimilation and general well-being.”
The ‘Pro’s of GI Health
Hundreds of bacteria species reside in the human digestive tract gut; some
are potentially pathogenic or putrefactive, and others are friendly. Beneficial
bacteria, often known as probiotics, can be defined as live microorganisms in a
supplement or food form that when administered in adequate amounts exert health
effects on the host when consistently ingested. “Naturally occurring,
non-genetically modified probiotics are shown in research to support healthy
digestion, improve resistance to overpopulation of pathogenic bacteria in the
gut, strengthen the body’s natural resistance and much more,” Gamble said.
Probiotics have garnered more mainstream acceptance, thanks in part to
marketing campaigns from mega-brands entering the functional food category with
items such as Danone’s Activia® yogurt and Yoplait’s Yo-Plus™. According to the
technical research report, “The Probiotics Market: Ingredients, Supplements,
Foods” from BBC Research, the global market for probiotic ingredients is on an
upward swing. It is expected to be worth $15.9 billion in 2008 and reach $19.6
billion in 2013.
Its popularity can also be attributed to the growing amount of research
suggesting probiotics can lower the risk or limit the progression of digestive
ailments, including constipation and diarrhea, IBS, general intestinal viruses
and antibiotic-associated infections. “Probiotics offer the consumer more than
just taking the revenge away from Montezuma,” said Frank Hodal, founder and CEO,
Little Calumet Holdings. “People are discovering that probiotics work in helping
them feel better.”
The benefits manifest from cradle to grave. Studies have found providing
Lactobacillus reuteri (L reuteri) to infants can reduce
regurgitation, increase the gastric emptying rate and increase number of stools.(1)
Probiotics may support children’s oral health,(2) positively impact
respiratory function,(3) prevent atopic conditions such as eczema,(4)
and reduce the incidence of GI infections and diarrhea.(5) In
addition, probiotics appear specifically beneficial in reducing incidence of
antibiotic-associated diarrhea (AAD) in children.(6)
Probiotics have added benefits for adults and those suffering from particular
GI conditions. For example, studies have shown certain probiotics have
therapeutic effects in the treatment of inflammatory bowel disease (IBD) and
treatment of intestinal infections.(7,8) Probiotics may also have an
anti-carcinogenic effect in the colon, possibly by aiding in detoxification of
genotoxins in the gut.(9) S.K. Dash, Ph.D., president, UAS
Laboratories, noted in his book, A Consumer’s Guide to Probiotics (Freedom
Press, 2005), that probiotics do have a clear role to play in prevention of
colon cancer. He wrote: “We don’t know precisely how probiotics exert their
anti-cancer benefits, but believe that by enhancing populations of
bifidobacteria, this may result in direct removal of procarcinogens, indirect
removal of procarcinogens, or activation of the body’s immune system.”
A review of IBS and therapeutic approaches suggested treatment options are
rapidly evolving beyond traditional symptom-based therapies toward agents with
organ-specific receptors selectivity directed at specific gastrointestinal
functions.(10) Another meta-analysis on the efficacy of probiotics in
IBS found these nutrients improve symptoms of IBS and can be used as a
supplement to standard therapy.(11) Individual strains continue to be
researched and evaluated for possible synergistic effects in the treatment of
IBS, and appear to resolve symptoms such as abdominal pain and constipation.(12,13)
In fact, certain strains have different activities in the body. “Although
more people are becoming aware of probiotics, it’s not always realized that some
strains assist normal digestive function in the small intestine and some strains
in the large intestine,” said Lisa Peterson Love, marketing director, Sedona
Labs. “People may come into the store asking for ‘acidophilus,’ but they want to
support bowel health, so adding some bifidobacteria might be the better choice
for them.”
Further, the regular use of probiotics can help in general nutrient
assimilation. “We regard probiotics as master supplements since they enhance
absorption of other nutrients and supplements by keeping intestinal surfaces
healthy,” said Randolph S. Porubcan, MSc, president, Master Supplements. The
company developed THERALAC®, which uses a patented acid-proof delivery
formulation utilizing sodium alginate from seaweed to deliver its multi-strain
mix of 20 billion CFU (culture forming units) of live active probiotics to the
intestinal tract. “Alginate forms a thin, impervious coating around the
probiotics once the outer cellulose capsule dissolves in the stomach. This
protective coating stays intact until it converts back to soluble alginate in
the intestinal tract.”
Probiotics work synergistically with fiber in the gut. There are two
different kinds of fiber, soluble and insoluble, both with a role to play in
digestive health. Insoluble fiber, found in whole grain products and vegetables,
helps promote laxation and balances the pH in the intestines. Soluble fiber,
found in beans, fruit, oats and barley, dissolves in water, forming a gel that
can help prolong stomach emptying time, regulate blood sugar and lower
cholesterol levels.
One common source of supplemental fiber is psyllium (Plantago ovata Forsk)
seeds, which contain the bioactive mucilage polysaccharide. Psyllium is a
soluble gel-forming fiber that has been shown to bind to the bile acids in the
gut and prevent their normal reabsorption, helping to lower cholesterol levels.(14)
Studies have also found psyllium seeds may be as effective as the drug
mesalamine in maintaining remission in ulcerative colitis (intestinal
inflammation).(15)
“Psyllium husk helps to absorb and remove toxins by forming a gel-like
material,” said Sunil Kohli, vice president, Health Plus. “By this swelling and
absorbing action, it gently scrapes the sides of the colon clean, removing
matter from the small crevices. Psyllium husk also soothes the lining of the
bowels and leaves a thin ‘slippery’ film behind that encourages waste to move
along and out the body more smoothly.” The company offers several cleansing
formulas, including a new product, Colon Cleanse Gold with Enzymes and
Probiotics, that are designed to ease post-prandial digestive complaints in
generally healthy adults.
However, psyllium can pose some challenges for adults with existing digestive
dysfunction. Watson said the ReNew Life fiber supplements contain approximately
25 percent soluble fiber and 75 percent insoluble fiber. “We use 100 percent
organic fiber sources such as flax, oat fiber and natural acacia to avoid
digestive difficulties such as abdominal discomfort, gas and bloating.”
Other types of fiber also serve as prebiotics— food for beneficial intestinal
bacteria. Fructooligosaccharides (FOS), for example, occur naturally in a wide
variety of plant foods. When FOS reach the colon, they are used by
bifidobacteria for growth, enhancing the digestion and absorption of nutrients,(16)
detoxification and elimination processes, and boosting immunity.(17)
Regularly consuming short-chain FOS (sc-FOS, as NutraFlora®, from GTC Nutrition)
was found to improve digestive comfort in a working population not undergoing
medical treatment in a comparative double blind trial with 2,235 subjects.(18)
Researchers from the Dundee University Gut Group reviewed published evidence for
prebiotic effect on gut function and human health.(19) They found
three prebiotics—oligofructose, galacto-oligosaccarides and lactulose—alter the
balance of the large bowel microbiota by increasing bifidobacteria and
Lactobacillus numbers.
Guar gum is another option as a prebiotic soluble fiber. Research has shown
partially hydrolyzed guar gum (PHGG) forms a water-soluble, non-gelling fiber
that can decrease symptoms of IBS and abdominal pain.(20) Further,
administration of PHGG with FOS in a food matrix can exert synergistic prebiotic
effects.(21) Porubcan’s company recently launched a new product,
TruFiber™, that combines PHGG with inulin and fiber-digesting enzymes to exert a
prebiotic and nutrient enhancing effect.
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Another soluble fiber option is larch arabinogalactan (LA), which is a long,
densely-branched non-starch polysaccharide. Lonza supplies the ingredient as
FiberAid®; Bryan Rodriguez, technical marketing and scientific affairs manager,
said it “offers superior benefits for gastrointestinal health combined with
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LA can decrease the generation and absorption of ammonia in the gut.(22,23,24)
Due to its highly branched structure, LA is slowly fermented.(25)
FiberAid was shown to have a high-digestive tolerance at dosages up to 15 g/d,
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Breaking It Down
The human body produces more than 20 digestive enzymes in various organs and
glands. The stomach glands produce gastric enzymes, including peptidase (for
proteins), gelatinase (for gelatin/collagen from meats) and gastric lipase (for
tributyrin, a butter fat). Meanwhile, the pancreas is responsible for secreting
numerous proteases and amylases, including trypsin (a peptidase), pancreatic
amylase (for starch and glycogen) and several elastases (for protein elastin).
Then, the epithelium in the small intestines creates many peptidases and the
more well-known amlyases that break disaccarides into monosaccharides—sucrase
for sucrose and glucose, lactase for lactose, and maltase for maltose.
Vegetables and fruits also offers vital enzymes needed to digest foods. For
instance, pectinase from the cell walls of plants helps degrade pectin. Enzymes
from bacteria are also beneficial for digesting food—phytase helps denature
phytic acid found in grains and seeds; cellulose breaks down the indigestible
fibers found in plant cell walls. According to Edward Howell, M.D., founder of
National Enzyme Co. (NEC), the human body relies on food enzymes to help with
digestion and cannot carry the entire load alone; intake of exogenous enzymes
from foods or supplements allows the body to concentrate more of its energy on
the activity of metabolic enzymes.(27)
Unfortunately, enzymes are destroyed by processing and cooking, meaning many
Americans are living a low-enzyme lifestyle. “Enzymes play a crucial role in
proper digestion,” said Maday Labradore, director of technical resources,
Enzymedica. “Two of the biggest reasons for poor digestion are the inability of
our bodies to produce enough enzymes and the lack of digestive enzymes in the
foods we eat. As a result of this enzyme deficiency, we suffer from things like
gas, bloating, diarrhea or constipation. Supplemental digestive enzymes can
assist with enzyme deficiencies by facilitating complete digestion of food,
increasing nutrient absorption and eliminating waste. Enzymes work specifically
on each component of food so that digestion can proceed in a smooth and
efficient way.”
Enzymes continue to be a burgeoning area for research, especially with
greater awareness that enzyme deficiencies may be a factor in digestive
ailments;(28) however, most of the current research involves the use
of enteric-coated pancreatic enzyme supplements.(29) This has piqued
interest in research examining non-animal sources, such as microbial and plant
enzymes for digestive support.
NEC used proprietary fermentation techniques to develop its Biocore™ line of
enzymes, including lipases designed to target digestive problems associated with
the high-fat content of a fast food diet, enzymes designed to improve
assimilation of carbohydrates, and products geared toward specific GI and
digestive conditions such as lactose intolerance. According to a proprietary
study from NEC and The Netherlands Organization for Applied Scientific Research
(TNO), a blend of fungal proteases, carbohydrases and lipases can improve
digestibility and bioaccessibility of proteins and carbohydrates in the lumen of
the small intestine in computer-controlled dynamic gastrointestinal models (TIM)
of healthy and impaired human digestion.
Sedona Labs is among the companies targeting interest in vegetarian products;
its ZymaFlora® Acid Balance Formula addresses the entire digestive function.
Peterson Love explained: “It provides specific enzymes needed in the stomach to
break down proteins and simple sugars. Plus, it delivers enteric-coated enzymes
to the small intestine needed to break down fats and complex carbohydrates and
some leftover protein.”
In addition to considering the source of enzymes, consumers should also
examine the types of food they are consuming to get optimal benefit. “The type
of diet one has should be a major factor in choosing the enzyme mix,” said Mike
Smith, sales and marketing manager, Specialty Enzymes & Biochemicals Co. “For
example, if your diet is high in grains and legumes, you want to make sure the
enzyme blend contains not only cellulose but hemicellulase, which may be written
as xylanase and beta-glucanase. Athletes and bodybuilders tend to eat large
amounts of protein, no doubt more than their pancreatic proteases can digest.
This group should look for enzyme blends that include a blend of strong
proteases to increase the hydrolysis proteins and, in turn, provide more amino
acids for absorption.”
Talking the Talk
While consumers may be more willing to explore natural support for digestive
health, they are likely still stymied when faced with a shelf—and refrigerator
case—full of options. “One of the most important things retailers can do is to
help the consumer understand the differences in the digestive category,”
Labradore said. “For example, there is a difference between probiotics and
enzymes and how each works.”
In addition, retailers can educate consumers that digestive health is not
something that can be addressed as a one-time fix. “Optimum digestive function
involves a lifelong commitment on the part of our consumers to give their bodies
the tools necessary to overcome impaired digestion and keep the digestive system
running in peak condition,” Watson said. “When discussing products for specific
digestive concerns such as constipation, diarrhea, IBS or heartburn, it is
important to stress that ongoing maintenance is equally important as temporary
symptom management.”
As an example, she suggested a retailer talking with a consumer who is
suffering from constipation not only first suggest a natural laxative to help
achieve better bowel function, but also to help that shopper map out a daily
nutritional plan that might include a fiber supplement and a probiotic formula
to promote overall digestive health.
“From a brand/retailer’s perspective, the ideal product in the digestive
health category that is destined to be the next daily basic supplement for
healthy consumers is probiotics,” Gamble said. “These products meet three
important criteria. First, they are a natural part of a healthy digestive
system. Second, they need to be introduced via external means to the body. And,
third, regular supplementation with probiotics is considered safe for healthy
individuals.”
Because so many Americans are battling digestive issues and looking to
optimize their well-being, the category offers great opportunity, according to
Schueller. “This is an opportunity for a retailer to explain the benefits of
product such as enzymes for digestion, probiotics to relieve gas, indigestion
and bloating, cleansing products to remove toxins and elevate energy and also
restore regularity,” he said. “This is a great category for natural products
because consumers can judge the results for themselves.”
However, Kohli noted, legal regulations mandate retailers avoid discussion of
disease conditions and focus instead on general well-being. “Keep to
structure/function claims, which talk more in detail about the organs in the
digestive system and how they may function optimally,” he advised. “When
speaking of digestive dysfunction to a customer who has issues, words such as
‘nourishment,’ ‘support’ and ‘strengthening’ are important. In tandem is diet.
Retailers can certainly inquire about diet habits and what foods seem to cause
the reactions and perhaps steer them to the section that is gluten-free, or
offer soymilk for those who are lactose intolerant.”
Offering samples of products, such as enzymes, in tandem with food demos is
one opportunity to get consumers interested. Labradore noted, “There’s no better
time to try a digestive enzyme than when you are about to eat a meal or snack.”
Incorporating digestive support products with other food items can further
build consumer awareness. “Any way you can get information to the consumer in a
novel way will help improve sales and improve health,” Daniel said. For example,
she suggested moving a popular digestive aid near the marinara sauce section,
using a shelf-talker to explain how such products can help prevent the heartburn
many consumers get when eating tomato-based products. Cheskes added retailers
could try a cross promotion of digestive health items with soups and other
remedies for cold and flu season to underscore the message about the
relationship between immune function and digestive health.
Ultimately, it’s about having an honest conversation with the consumer,
according to Natasha Trenev, founder, Natren: “I used to talk to consumers all
the time, and advised them to think of the body like an engine; it’s a complex
ecosystem. You wouldn’t just put junk in the engine and expect everything else
to run properly. If you’re tired, if your skin is not radiant, if you’re not
moving your bowels at least once a day, it affects everything.”
Additional reporting by Somlynn Rorie
Botanical Relief
Customers looking for relief from gastrointestinal (GI) complaints would do
well to take time out and smell the flowers … or take them internally.
Licorice (Glycyrrhiza glabra), for example, is approved by German
Commission E for treating gastric inflammation and ulcers. Enzymatic Therapy
supplies deglycyrhizinated licorice (DGL), which Matt Schueller noted “has been
shown to soothe the stomach and intestinal lining and promote healing.”
Aromatic peppermint (Mentha x piperita) delivers not only a pungent
taste, but preparations of its leaves and of peppermint oil have been studied
for their use in addressing spasms in the GI tract (Phytother Res. 2006
Aug;20(8):619-33). Schueller said Enzymatic supplies a combination of
peppermint, rosemary and thyme oil in an enteric-coated capsule to deliver the
healing power of the active ingredients to the intestines for greatest benefit.
The use of ginger (Zingiber officinale) for nausea and stomachache
dates back to ancient times in Asia and the Mediterranean. The Commission E
approved the internal use of ginger for dyspepsia and motion sickness, while the
British Herbal Compendium suggests it can also be used for treating pregnancy
vomiting.
Finally, break out the bitter herbs formulas, which have been used for more
than 2,000 years in Western Culture. Today, Swedish Bitters are the best known
herbal bitter tonic. This combination of herbs such as angelica, myrrh and
rhubarb root stimulates secretion of gastric substances such as enzymes and
acids, to reduce dyspepsia, upset stomach and heartburn.
Feeding the Gut Functional Food
Delivering nutritious probiotics to the gut via “functional” foods is not a
new concept.
Fermented foods such as sauerkraut and yogurt have been used for centuries in
countries around the globe. However, consumers are looking for more mainstream
products to deliver those health benefits.
In 2006, the Dannon Co. introduced Activia, a line of yogurt with probiotics,
with a major mainstream marketing push; sales in the United States alone
surpassed $100 million in the first year. Similar products followed, including
more yogurts and even probiotic-enhanced cheese from large companies like Kraft
and smaller outfits like Applegate Farms.
Looking beyond dairy?
- Kashi Co. added Lactobacillus casei cultures to its twig and flake
blend to create Kashi Vive, marketed as a “digestive wellness” cereal.
- Attune Foods produces Probiotic Wellness Bars in two varieties—chocolate
or granola—and 10 flavors. Silvia Cheskes, Attune Foods, noted the bars are
sold via the refrigerated section to maintain the efficacy of the bugs,
feature probiotic strains selected to promote digestive health and immunity,
and have less than 100 calories.
- Turtle Island Soup launched its Souper Food soups fortified with
GanedenBC(30), a probiotic shown to survive food manufacturing and storage;
flavors of the dry mix soup include Tortilla con Queso, White Cheddar
Asparagus and White Cheddar Broccoli.
“Good Living in the Land Down Under” References
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habits and gastrointestinal motility in preterm newborns” J Pediatr.
2008;152(6):801-6.
2. Svante T et al. “Probiotics and oral health effects in children” Int J
Paediatr Dent. 2008;18(1):3-10.
3. Wijnkoop IL et al. “Probiotic and probiotic influence beyond the
intestinal tract” Nutr Rev. 2007;65(11): 469-89.
4. Burks E. “Probiotics in the prevention of atopic disease in children”
Agro Food Industry Hi-Tech. 2007;18(3) 27-9.
5. Hatakka K et al. “Effect of long term consumption of probiotic milk on
infections in children attending day care centres: double blind, randomised
trial” BMJ. 2001;322(7298):1327.
6. Johnston BC et al. “Probiotics for the prevention of pediatric
antibiotic-associated diarrhea” Cochrane Database Syst Rev. 2007;(2):
CD004827.
7. Zanello G et al. " Saccharomyces boulardii effects on gastrointestinal
diseases." Curr Issues Mol Biol. 2008 Sep 8;11(1):47-58. [Epub ahead of
print]
8. Kamiya T et al. [The efficacy of probiotics in gastrointestinal
disease][Article in Japanese] Nippon Rinsho. 2008 Jul;66(7):1385-90.
9. Wollowski I et al. "Protective role of probiotics and prebiotics in colon
cancer." Am J Clin Nutr. 2001 Feb;73(2 Suppl):451S-455S.
10. Bassett JT et al. “A review of irritable bowel syndrome and an update on
therapeutic approaches” Expert Opin Pharmacother. 2008;9(7):1129-43.
11. Nikfar S et al. “Efficacy of Probiotics in Irritable Bowel syndrome: a
meta-analysis of randomized, controlled trials” Dis Colon Rectum. 2008: [epub
ahead of print].
12. Niedzielin K et al. “A controlled, double-blind, randomized study on the
efficacy of Lactobacillus plantarum 299V in patients with irritable bowel
syndrome” Eur J Gastroent Hepat. 2001;(13)1143-7.
13. O’Mahony L et al. “Lactobacillus and bifidobacterium in irritable bowel
syndrome: symptom responses and relationship to cytokine profiles”
Gastroenterology. 2005;128(3):541-51.
14. Petchetti L et al. Cardiology Rev. 2007, 15(3):116-122, May/June.
15. Fernandez-Banares F et al. “Randomized clinical trial of Plantago ovata
seeds (dietary fiber) as compared with mesalamine in maintaining remission in
ulcerative colitis. Spanish Group for the Study of Crohn’s Disease and
Ulcerative Colitis (GETECCU).” Am J Gastroenterol. 1999, 94(2):427-33.
www.amjgastro.com
16. Tahiri M et al. “Effect of short-chain fructooligosaccharides on
intestinal calcium absorption and calcium status in postmenopausal women: a
stable-isotope study.” Am J Clin Nutr. Feb 2003;77(2):449-57.
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17. Boehm G et al. “Prebiotics in infant formulas.” J Clin Gastroenterol.
Jul 2004, 38(6):S76-9.
18. Paineau D et al. “The effects of regular consumption of short-chain
fructo-oligosaccharides on digestive comfort of subjects with minor functional
bowel disorders” Br J Nutr. 2008;99:311-18.
doi:10.1017/S000711450779894X.
19. MacFarlane S et al. “Review article: prebiotics in the gastrointestinal
tract” Aliment Pharmacol Ther. 2006;24(5) 701-714.
20. Giannini EG et al. “Role of partially hydrolyzed guar gum in the
treatment of irritable bowel syndrome.” Nutrition. 2006 Mar;22(3):334-42.
Epub 2006 Jan 18.
21. Tuohy KM et al. “The prebiotic effects of biscuits containing partially
hydrolysed guar gum and fructo-oligosaccharides--a human volunteer study.” Br
J Nutr. 2001 Sep;86(3):341-8.
22. Kelly GS. Altern Med Rev. 1999; 4(2):96-103.
23. Vince AJ et al. Brit J Nutr. 1990;63:17-26.
24. Robinson RR et al. J Am Coll Nutr. 2001;20(4):279-285.
25. Englyst HN et al. FEMS Microbiology Ecology. 1987;95:163-171.
26. Causey-O’Brien JL. Doctoral Thesis, University of Minnesota, 2002.
27. Cichoke A. Bromelain: The active enzyme that helps us make the most of
what we eat. Keats Publishing Inc., New Canaan, CT, 1998, p.10.
28. Donnelly MT. “Is exocrine pancreatic insufficiency in adult celiac
disease a cause of persisting symptoms?” Aliment Pharmacol Ther.
2007;25(3):264-71.
29. Suarez F et al. “Pancreatic supplements reduce symptomatic response of
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44(7):1317-21(5).
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