As many as 95 million Americans experience some digestive problem during their lifetime, according to the American College of Gastroenterology. The growing frequency of such maladies reflects numerous dietary and lifestyle tendencies in modern society, including heavy smoking and drinking, as well as junk food-laden diets. Natural digestive products are only one part of the remedy, but they can help consumers address short- and long-term issues in their digestive systems.
Digestion begins in the mouth, as enzymes in saliva start to break down food during chewing. Once in the stomach, the food is mixed with digestive juices; here, enzymes in the stomach further break down food, and stomach acid breaks down food and destroys harmful bacteria. Next up is the small intestine, which receives digestive juices from the pancreas, liver and gallbladder. These include many substances helpful to digestion, including insulin, bile and enzymes. By the end of the small intestine, most foods have been broken down into sugars and amino acids. Anything not digestible goes through the large intestine, which absorbs all the water it can out of the mixture, before the waste leaves the system.
One of the oft-cited causes of poor digestion is poor diet. Another problem is stress, both acute and long-term. “Stress causes the brain to release hormones that affect the digestive system,” said Sunil Kohli, Health Plus Inc., adding many Americans have been enduring more stress the past two years as the economy and the threat of unemployment has remained high. “ The corticotrophin-releasing hormone (CRH)—the ‘alarm’—tells the adrenal glands to immediately release a flood of adrenaline and other biochemicals that give the body energy to ‘fight or flight.’ CRH also inhibits appetite in some people or magnifies hunger in others, causing a shift in normal dietary habits, which of course, can also affect the digestive system.” In the end, she said stress can cause diarrhea, nausea and stomach pains.
Harold Fox, National Enzyme Co. (NEC), said many of us have damaged our overall gut health due to years of abuse. “Whether that abuse came from a lack of knowledge or illness, medication or various stresses, we have damaged our digestive systems to the point that they are not able to absorb the nutrient content from our meals properly,” he lamented. “So the consumer has learned that enzymes and probiotics can be a great one-two punch in this battle for better gut health.”
Engaging Enzymes
As evidenced by the number of times they figure in the digestive process summarized above, enzyme deficiency, whether innate or dietary, can be a problem. “Not having the proper enzymes or enough enzymes to properly digest our foods can cause a lot of digestive symptoms,” confirmed Brenda Watson, ReNew Life. “For example, undigested proteins can cause irritation to the intestinal lining. This in turn can cause pain, inflammation and bloating, eventually leading to a more serious condition such as leaky gut. Similarly, undigested starches and sugars can cause fermentation of unhealthy bacteria, again contributing to gas, bloating and abdominal pain.” She said taking enzymes with meals can greatly reduce the amount of undigested food in the intestinal system.
For another example of potential deficiency, an estimated 25 percent of people have highly reduced diamine oxidase (DAO) activity, according to Lisa Nelson, Naturally Vitamins, adding DAO breaks down histamine in the digestive tract. “DAO is produced by the body,” she said. “If you don't have enough, or it is not working properly, your body is unable to break down histamine, which can cause symptoms such as stomach upset, gastrointestinal issues, headache, hives, etc.” Nelson further noted supplemental DAO (porcine-sourced) works best when taken within 15 minutes of those foods causing the discomfort. It can also help address symptoms from food intolerance relative to histamine-containing foods, which include pizza, tomatoes, cheese, red wine, spinach, bananas. “These are the foods of everyday life for millions of people,” Nelson said. “What people don't realize is these same foods can be making them sick due to histamine. Histamine-related food intolerance is a relatively new indication and is often times confused with a food allergy or other food intolerance.”
Enzymes are catalysts for chemical reaction. Each enzyme fits one specific substrate, a particular substance that needs to be broken down. Despite this specificity, the general group of enzymes that work on proteins is called proteases, while amylases target carbs, and lipases go after fats.
More than 20 digestive enzymes are produced in the mouth, stomach and intestines. In the stomach, gastric enzymes include peptidase, for proteins; gelatinase, for gelatin/collagen from meats; and gastric lipase, for butter fat. From the pancreas come numerous proteases and amylases, including trypsin, a peptidase; pancreatic amylase, for starch and glycogen; and several elastases, for protein elastin. The epithelium in the small intestines creates many peptidases, as well as the more well-known amalyases, such as sucrase (for sucrose and glucose), lactase (for lactose) and maltase (for maltose).
Many of the foods we eat, namely fruits and vegetables, contain the enzymes needed to digest them. Unfortunately, over-processing foods can strip them of these necessary enzymes, making digestion that much more difficult.
Popular enzyme products for digestion include proteases such as bromelain from pineapples and papain from papaya, as well as lactose, which helps break down sugar in milk. Also, pancreatic enzymes have demonstrated promise against celiac disease (gluten intolerance) marked by chronic diarrhea(1) and irritable bowel syndrome (IBS).(2)
According to Nena Dockery, NEC, for decades consumers have been purchasing individual enzymes that are effective in managing certain specific digestive disorders. “They may not have been aware that the products they were purchasing to control the gas and bloating after eating beans or to help with the discomfort from consuming dairy products were enzymes, but they knew they were effective,” she reasoned, who added as enzyme supplementation has become more widely recognized, so have the types of enzyme products available. “Most products now marketed are digestive support blends, but there are an increasing number targeting the break down and bioassessibility of a particular nutrient. Currently there is an emphasis on efficient protein utilization; therefore, products highlighting protein digestion are very popular.”
Lisa Peterson Love, Sedona Labs, explained when it comes to enzyme products, customers are simply looking for the benefit of better digestion. “They don’t seem to know a lot about which enzymes work on what foods in which area of the body,” she said. “That may be why customers prefer a broad-spectrum digestive enzyme that digests all types of food in the stomach and small intestine at the appropriate pH levels.” She further noted her company has noticed a strong preference for vegetarian enzymes, which work in the pH of the small intestine, over animal enzymes.
Probiotics: Cultural Differences
Enzymes may have a fundamental role in digesting nutrients and addressing problems caused by decreased ability to digest certain foods/nutrients, but beneficial bacteria rule the microflora-hood of the intestines. These digestive system areas are naturally home to live bacteria, both good and bad. The theory is the good bacteria compete with the bad for receptor sites on the intestinal wall. The more good bacteria that win, the better the health that follows. However, as is the case with enzymes, various dietary and other factors—taking antibiotics, eating food tainted with harmful bacteria, etc.—can negatively affect or challenge the microflora health in the gut. Thus, taking in extra probiotics has been a favored method of improving this bacterial balance and counteracting the damage from bad bacteria.
In research, probiotics have made their mark on infant diarrhea,(3),(4) antibiotic-associated diarrhea,(5) IBS,X inflammatory bowel problems,(6),(7) colic in babies (pain from intestinal gas or obstruction),(8) and gut transit time.(9) However, scientists are increasingly finding certain benefits might be tied to certain probiotic strains.
For instance, Bacillus coagulans (as GanedenBC30, from Ganeden Biotech) was found, in a 2009 study, to effectively relieve abdominal pain and bloating in patients with IBS.(10) At the end of 2009, this probiotic strain was reported by researchers as significantly more effective than placebo in providing relief to subjects suffering from intestinal gas.(11)
A specific blend of the two strains L. helveticus R0052 and L. rhamnosus R0011(as Lacidofil®, from Institut Rosell) protected neonatal rats from Citrobacter rodentium infection, suggesting the combination could protect against enteric bacterial infections in newborn children.(12) This protection was mediated through the activation of adaptive immunity (T cells) and an improvement in intestinal barrier function.
Institut Rosell gathered international gastroenterology and microbiology experts in late 2009 to review the latest research on probiotics and IBS. At the center of this discussion was the probiotic strain Lactobacillus plantarum 299v, which they dubbed “one of the best-documented probiotic strains for IBS, showing benefits on all symptoms (abdominal pain, bloating, changes in digestive transit, etc.) in randomized, double blind, placebo-controlled trials.”
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More evidence of specificity of strains surfaced in two trials on L. helveticus R0052, which showed the strain showed potential against the effects and actions of C. jejuni and E.coli infections, while L. Rhamnosus R0011 showed no such benefit or potential.(13),(14) Further, L. plantarum 299v was found to reduce colonic inflammation and normalize intestinal transit rates in an animal model of IBS.(15) And, researchers also reported probiotic treatment coupled with antifungal therapy could benefit the restoration and healing of colonic damage in ulcerative colitis, an inflammatory bowel disease (IBD), when Candida albicans infection otherwise delays healing.(16)
“Research is progressively showing specific benefits connected to specific strains, which is good for the industry,” Peterson Love offered. “For example, there was a very good study by Danisco published in 2009, showing a combination of two probiotic strains was more effective than one strain in preventing cold and flu in children.(17) However, customers are going to be interested in the clinically supported end-benefit more than the scientific nomenclature of the strains.” She said it will be up to the marketers to guide consumers adeptly through this sea of research and benefits.
Tim Gamble, Nutraceutix, echoed these sentiments. “Generally, consumers will not be able to fathom the intricacies and details of strain-specific research findings,” he quipped. “It always has been, and will continue to be, marketing’s responsibility to translate and convey the key points and how probiotics found on store shelves may deliver similar results.” Going one step further, Gamble suggested there must be a change in fundamental dietary supplement research design must be changed so that what is being studied is exactly what finds its way into a bottle. “Once a different delivery vehicle is introduced, the connection to the research and its finding, it can be argued, is broken,” he explained. “This is why a number of forward-thinking investigators involved in dietary supplement research have specified particular consumer-ready delivery forms for recent studies. Nutraceutix has recently produced a variety of dietary supplements for academic research that are in consumer-ready formats that, after research is completed, can be bottled and delivered exactly as those being studied.”
Kohli noted, “Probiotic science is quite complex, as there are new strains often found and replicated for use. Because of several mainstream companies and brands, even mass consumers are aware of probiotics, much more so than enzymes; but they don’t know much beyond the fact that probiotics are ‘good bugs’ for the digestive system.”
Connie Falkenstein, RD, MS, MPH, UAS Labs, agreed marketers will have to take the lead in explaining how probiotic strains work and differ. “As in other technology industries, the Early Adopters will do their homework, understand the technology and make probiotic choices by strain,” she said, adding the key is to make certain strain designations are available on the label, e.g. L. acidophilus DDS-1. “At some point, educated consumers will begin looking for the numbers or letters after the genus and species; the science can be a bit confusing, but the communications will continue to evolve.”
Rob Hurlbut, Attune Foods, reported finding more consumers differentiating between live cultures and probiotics, as well as between different strains of probiotics. “Not all live cultures are probiotics, and not all probiotics are equal,” he said, noting similar sounding probiotics can have very different clinical results or no clinical testing at all. “Attune uses the most clinically tested probiotic strains from Danisco’s HOWARU probiotics—these include Lactobacillus acidophilus NCFM, Bifidobacterium lactis HN019, and Lactobacillus casei Lc-11.”
He did agree on the responsibility of marketers to articulate the specific strains of probiotics in their products, in an effort to improve transparency for the increasingly sophisticated consumers looking to understand the true benefit. “In fact, the International Probiotics Association (IPA) and the International Scientific Association for Probiotics and Prebiotics (ISAPP) offer guidelines to manufacturers to state both the specific strains and quantity of probiotics at the end of shelf life.”
Hurlbut operates in the functional food segment of the probiotic market, which has helped draw attention to probiotics, but not without controversy. A few yogurts marketed for benefits from specific proprietary strains have been pulled due to lack of sales or have faced regulatory action due to claims made on the products.
Nonetheless, consumers have taken to convenient food and beverage delivery of the much-needed probiotics. Market research firm Packaged Facts called digestive health, including probiotics, one of the hottest topics in the food and beverage segment. In fact, they said indications suggest digestive health will be the focus of functional food shoppers through 2013. Popular functional vehicles for probiotics, up-and-coming prebiotics and the “new frontier” of digestive enzymes include yogurt, cereal, cookies, bars, functional drinks and various dairy items.
A recent survey from BENEO-Orafti confirmed digestive and bone health claims remain strong. They reported “keeping a digestive system healthy” is one of the top four health benefit claims for both men and women in both the United States and Germany. They found respondents liked digestive health claims on a range of products, such as cereal bars and fruit juices.
How is this focus on functional foods in the marketplace affecting the tried and true supplement delivery method for probiotics?
Katie Umentum, Enzymatic Therapy, reasoned it has helped the supplement segment, as more consumers are now educated on the benefits of probiotics. “While consumers may not know exactly what probiotics do, they do know they are good for their digestive health,” she added. “However, in some cases, consumers may not be getting enough of, or the right kind of, probiotics they need in food products that are touting the claims.”
From Gamble’s view, increased consumer awareness and demand due to probiotics being incorporated into functional foods and beverages has probably done more good for sales of probiotic dietary supplements than it has for the well-being of the consumer of functional foods and beverages. “With recent failures of functional food products, particularly in the ethical marketing of them, there is a risk that consumer opinion of probiotics is a bit tarnished,” he worried. “However, it is not the probiotics themselves that should be in question, just the brand marketing that was, perhaps, less than accurate. The best delivery method for probiotics is in dietary supplements, particularly those that are manufactured using advanced, patented processes and technologies like LiveBac® and BIO-tract®.”
As important as it is to get the right strain for the right benefit, getting consumer to take their supplements as directed is an equally crucial challenge. “Compliance is a necessity for any dietary supplement, just like for any drug or rehab exercise,” Kohli said, noting the work is done for the consumer, in that researchers and manufacturers create products in specific daily doses they know fill the need for greater support and better function of the digestive system. All the consumer has to do is conjure up some discipline. “As the adage goes, you can lead the horse to water, but you cannot make him drink.”
Compliance issues may be one reason people have looked to functional foods for probiotic delivery.
“In order to feel the best benefit, daily consumption is typically beneficial,” Hurlbut said. “We recommend to our consumers to eat an Attune bar daily – not only does it provide 5 times the live cultures of yogurt through our probiotic strains, but it also has less sugar, more fiber and 25 percent of daily calcium intake.”
He further noted while consumers seem to prefer food sources for certain nutrients, “probiotics are inherently unstable and can easily die in warm environments and those where there is high-water activity (i.e. shots & yogurt). Attune's probiotic chocolate bars have low-water activity, and are therefore an excellent delivery system for probiotics to deliver the full benefit at the time of consumption.”"
Frank Hodal, Vidazorb, said his company’s probiotic soft chews are an ideal form to ensure compliance and a supplement level of probiotics. “Three tablets of most of our formulations provide approximately 30 billion CFU of proprietary probiotic strains,” he said. “By providing consumers with a convenient and delicious delivery form, I believe we have gone a long way to improving daily compliance—the fact that it does not require refrigeration means it can stay on a desk, in a pocket book or in a briefcase.”
Rising Up: Probiotic Yeast
If differentiating between probiotic strains and delivery methods isn’t confusing enough, consumers are surely not aware there are probiotic yeasts such as Saccharomyces boulardii that can help with travelers and antibiotic-associated diarrhea, according to Gene Bruno, MS, Huntington College of Health Sciences. He explained in the dietary supplement industry, the term “yeast” is typically associated in a positive way with “brewer’s/nutritional” yeast, or in a negative way with Candida albicans (i.e., as in yeast infections). “One association that is not commonly made is probiotic,” he lamented. “Nevertheless, that’s exactly what Saccharomyces boulardii is, a non-pathogenic yeast used as a probiotic agent to help colonize the gastrointestinal tract. Therapeutically, it is used in cases where certain disorders are thought to occur due to depleted normal intestinal flora or colonization by pathogenic organisms.”
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Among the research highlights on diarrhea, S. boulardii may reduce the risk of antibiotic-associated diarrhea by 57 percent to 63 percent;(18) counter acute diarrhea;(19) and may produce proteases that decrease the toxicity of Clostridium difficile toxins A and B, which lead to diarrhea.(20) On hypersensitive bowel problems, consumption of S. boulardii can reduce episodic flare-ups at 1g daily(21)(22) or as little as 250mg three times daily.(23)
Bruno said the key to marketing probiotics is offering educational resources to retailers and consumers. For example, he noted Jarrow Formulas offers Quick Reference Sheets for retailers and brochures for consumers, which elucidate the benefits of probiotic products. The company is also developing a Web site exclusively for consumers and retailers to learn more about probiotic products, especially research. “Anytime there is significant research to pull from, it is always helpful in marketing efforts,” Bruno assured. “Consumer acceptance of Saccharomyces boulardii is good and is getting better as more consumers become aware of its benefits.”
Roughing It
The third digestive health staple is fiber, which is a double-edged sword relative to digestion. Soluble fibers, such as psyllium, can form a gel-like substance in the digestive system and slow the movement of food, and insoluble fiber can help speed the movement of food and increases stool bulk. However, too much fiber and too little fluid intake can lead to bloating and gas.
“One of the very important functions of fiber is fermentation with bacteria and the development of short-chain fatty acids,” Watson explained. “This fermentation of fiber may initially cause some gas and bloating, which normally subsides within the first week of increasing fiber amount.”
Most recently, 25 g/d of resistant starch insoluble fiber (as PROMITOR™, from Tate and Lyle) enhanced regularity in healthy adults without producing significant gastrointestinal side effects.(24) Another 2009 report on fiber detailed how when blindly compared to the leading fiber supplement Metamucil and an apple juice placebo, a fiber-rich plum product (as PlumSmart, from SunSweet) helped 72 percent of women experience relief of irregularity within 24 hours.(25) And, in another 2009 trial, more subjects taking psyllium (10 mg/d) experienced IBS relief than those taking either bran or placebo.(26)
Fiber, especially prebiotic varieties, has become a popular addition to functional foods. “One of the emerging areas of digestive health is the aspect of prebiotics—indigestible fiber which serves as ‘food’ for the probiotics in the gut,” Hurlbut said, noting the combination of probiotics and prebiotics synergistically help overall digestive health. “We think that this will become an increasingly important point for consumers, which is why Attune probiotic bars have 3 g of prebiotics from chicory root.”
Fiber supplements are often considered an old peoples’ product, but Kohli begged to differ. “Adults in their 30s through later years are excellent candidates for our line of psyllium-based Colon Cleanse products,” she assured. “The aforementioned stress plus poor dietary habits create the need for our products to help provide the targeted nutrition (enzymes, probiotics and fiber) that the gut needs to improve its function and lower the incidence of bloating, gas and griping.”
Plants Provide Relief
In addition to enzymes, plants contain numerous compounds that can often aid digestion. One such botanical is mastic resin from the Pistacia lentiscus shrub, found in the Mediterranean regions of France, Spain, Portugal, Greece, Turkey and Africa. More than 700 years ago, Arab physicians recorded the use of mastic for the treatment of gastric and intestinal ulcers, and it has traditionally been chewed or ingested as a powder to relieve dyspepsia, peptic ulcer and halitosis. “In modern research, mastic has been shown to help protect gastric and duodenal cells and tissues, providing symptomatic relief to acidic areas of distress,” Bruno noted. “In vitro studies have shown mastic to reduce the activity Helicobacter pylori, which may explain its ability to sooth stomach and intestinal distress.”
Also found in Southern Europe and the Mediterranean is licorice, which has been used traditionally in Greece, Egypt and China for stomach inflammation. Umentum stated Enzymatic Therapy first introduced deglycyrrhizinated licorice (DGL) in the United States in 1986, as side effects associated with glycyrrhizic acid include hypertension and low blood potassium levels. “Glycyrrhizic acid-free formula provides only the beneficial effects of licorice,” she said, explaining DGL helps relieve stomach discomfort by stimulating and accelerating natural protective factors in the digestive tract; and the chewable form reflects the helpful role saliva plays in this process. “DGL Ultra boosts the production of mucin, a natural compound that coats and protects the lining of the stomach and intestines; it includes glycine to help keep the stomach lining strong.”
DGL figures in the practice of Gaetano Morello, N.D., who cited a combination of plant enzymes and DGL as a remedy he would use for occasional sour stomach or heartburn. “The caveat of all healing is the digestive tract; enzymes, probiotics, DGL and fiber are important ways of keeping it healthy,” he said.
Like licorice, peppermint is another herb familiar as a candy flavor, but it also has digestive benefits. In fact, German researchers investigated a combination of extracts, including both licorice and peppermint, in subjects with functional dyspepsia, finding the preparation relieved symptoms in more than 43 percent of subjects on the active treatment after eight weeks.(27) On its own, peppermint oil was found therapeutic for children with IBS, alleviating symptoms such as bloating, constipation, abdominal cramps and diarrhea.(28)
Native to Northern Africa and some nearby islands, Aloe vera has appeared in medicinal texts dating back to 1600 BC. It has long been used to address digestive issues such as IBS and abdominal pain. Research shows aloe may also improve the absorption of nutrients, including vitamins C and E. A combination of aloe-psyllium and celandine (dietary fiber) helped subjects alleviate constipation.(29)
The connection between diet and digestive health presents an opportunity for natural products based on dietary ingredients to help consumers with various digestive issues. “Digestive support products, particularly probiotics, can do much to provide a healthy bowel environment and healthy bowel function—which of course will go a long way to promoting overall good digestive health,” Bruno concluded.
For a list of references, e-mail NPMreferences@vpico.com.
Ask the Expert: Dr. Gaetano Morello
Gaetano Morello, N.D., is a naturopathic physician practicing in West Vancouver, Canada. He received his Bachelor of Science degree from the University of British Columbia and his Doctor of Naturopathic Medicine from Bastyr University of Natural Health Sciences in Seattle. For the past 15 years, he has been training and educating physicians, pharmacists and health experts on the scientific use of natural medicines in the fields of cardiology, immunology, gastroenterology, anti-aging and detoxification. He wrote “The Fiber Miracle,” and was a contributing author to the authoritative text on alternative medicine,” A Textbook of Natural Medicine.” A lecturer and regular contributor to a number of magazines, journals and publications, Dr. Morello has hosted and appeared on numerous television and radio shows discussing the power of natural medicine.
How prevalent are digestive health issues among your patients? Are certain digestive complaints more reported?
Morello: Statistics show 40 percent of Americans suffer from digestive problems. In my experience, I feel the percentage is much higher than that; most people at one time or other have had some form of digestive complaint. Indigestion, bloating and heartburn are common complaints.
Do many people migrate to naturopathic medicine from the allopathic segment, relative to digestion? If so, does this bring with it any treatment “baggage” that needs to be overcome to get them on the natural path to digestive health?
Morello: Yes, they migrate our way because they realize their problem is not resolving and instead becoming chronic. Examples of this are heartburn and bloating. The treatment baggage is the alteration in stomach pH because of antacids, H2-antagonists and proton-pump inhibitors prescribed. Usually, I get them off the meds and replace them with more effective protocol.
Is there a common dietary thread among people with disruptive digestive issues, and what are some of the common dietary changes most such people should undertake?
Morello: I would say the Western diet, with a high amount of sugar, unhealthy fats, excessive red meat consumption and a lack of fresh fruits and vegetables, is definitely a contributing factor (stress is another big one). My recommendation is to change this type of diet and begin bringing in more fresh, organic fruits and vegetables into the diet.
Are there lifestyle factors amongst these people, and are they reflective of society in general?
Morello: People are going through stress, which has now become a big cross-section of society. Stress elevated the "flight or fight" response hormones, which slow down digestive processes and can lead to chronic digestive disturbances.
The digestion aisle is often thought of as a mature adult place, but are younger adults and children also suffering from digestive problems? What are the common issues, and why would a natural (vs Rx) approach benefit children?
Morello: Yes, even infants are now sadly been put on H2-antagonists (acid reducing drugs). Common children issues are gas/bloating, abdominal cramping and even gastric reflux. Natural approach would benefit children, because it addresses the underlying causes and maintains proper pH levels in the stomach and duodenum.
Natural health is often considered long-term, preventive and slow-acting (vs. the acute, reactive Rx care); however, are there natural products people can take when they face some of the common acute problems such as constipation, heartburn, gas, etc.?
Morello: This is a good question because natural products for common digestive disorders are actually very fast acting, DGL for heartburn, enteric-coated peppermint oil for gas, pancreatic enzymes for digestion, fiber fusion along with probiotics for constipation.
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