Over the years, I have found that many people with Hashimoto’s have issues with digestion, although they often haven’t connected these symptoms to their thyroid condition. I frequently see people who have just accepted the daily struggle of their nagging digestive symptoms as simply being “the way their system is.” Some no longer even report these symptoms to their doctor; they have started to view them as normal.
But symptoms such as recurring diarrhea, stomach pain, having undigested food in your stool, and gas and bloating after eating, are not symptoms you need to live with! For many people, these issues can be resolved fairly rapidly by taking the right digestive enzymes. In fact, in a survey I did with 2,232 people having Hashimoto’s, 78 percent felt better after taking digestive enzymes.
There can be different types of digestive challenges, including the inability to adequately digest protein, starches and/or fat. I’ve written about protein digestion extensively in the past, and now, I’d love to turn to fat digestion issues, which affect about 40-50 percent of people with Hashimoto’s. Fat digestion challenges can leave people with stomach and bowel symptoms. They can also result in a depletion of important nutrients that are no longer being well absorbed, including fat soluble vitamins A,D, E and K, as well as essential fatty acids.
One key culprit that may cause fat digestion issues can be a deficiency in pancreatic enzymes, such as pancreatic elastase. While you likely have heard of the pancreas (where these key fat digestion enzymes are produced), you may not be aware of how important the pancreas is, and how supplementing with pancreatic enzymes can make all the difference in uncomfortable and embarrassing digestive symptoms.
In today’s article, you will learn about:
- The role of the pancreas and pancreatic elastase
- How Hashimoto’s affects pancreatic enzyme deficiency
- Symptoms and testing for pancreatic enzyme deficiencies
- The issue with conventional treatments
- My Root Cause recommendations
The Role of the Pancreas and Pancreatic Elastase
The pancreas is an organ located in the upper abdomen. It consists of two tightly connected glands, each having a distinct function. One gland (referred to as the “exocrine” pancreas) focuses on producing enzymes to help with the digestion of food. These enzymes include trypsin and chymotrypsin to digest proteins; amylase for the digestion of carbohydrates; and lipase to break down fats. These pancreatic enzymes are released into the small intestine through a duct, along with another protein-digesting enzyme called pancreatic elastase.
The other gland, referred to as the “endocrine” pancreas, produces hormones such as insulin and glucagon. Unlike pancreatic enzymes, these hormones are released directly into the bloodstream. Pancreatic hormones help control how the body uses and stores sugar (glucose). Abnormal levels of thyroid hormone are associated with blood sugar abnormalities (and poor insulin control), and abnormal levels of pancreatic hormones have been linked to metabolic disorders, as well as diabetes.
While both of these roles are extremely important to our health, in this article I will be focusing solely on the exocrine pancreas and its role in supporting our digestive health. In particular, I’ll be explaining how exocrine pancreatic enzymes support fat digestion and the healthy absorption of nutrients, and why this often goes wrong in those with Hashimoto’s.
Fat Digestion and Nutrient Absorption
Our pancreas works along with our liver and gallbladder to digest and absorb fats. If we’ve eaten a fatty meal, concentrated bile (a substance produced by the liver and stored in the gallbladder) is released from the gallbladder into a duct leading to the small intestine. The bile’s job is to breakdown fats into tiny globules that can be more easily dissolved.
At the same time, the pancreas releases its own pancreatic enzymes and pancreatic juice, mixing with the bile and tiny globules of fat. The bile and pancreatic secretions work together to dissolve (emulsify) fats (lipids) in the watery small intestine. Pancreatic juices also help with digesting protein and carbohydrates, as well as neutralizing all of the digesting food (which is initially very acidic, in order to fend off bacteria). All of these actions allow nutrients to be more readily extracted and absorbed (plus, it ensures that we don’t experience nasty stomach and bowel symptoms).
Without adequate bile and pancreatic enzymes, many essential nutrients can be lost and excreted with other wastes in the stool, leading to nutrient deficiencies such as fatty-acid deficiency. Additionally, our foods will not be fully digested and may linger too long in the digestive tract. This can result in our developing food sensitivities, small intestinal bacterial overgrowth (SIBO), and other issues, which we’ll talk about. People who also have low stomach acid may also lose the ability to fend off harmful microorganisms in the gut, such as H. pylori — a very common infection seen in Hashimoto’s.
Pancreatic Elastase – A Key Biomarker
Pancreatic elastase is a protein-digesting enzyme produced exclusively by the pancreas. It is released into the small intestine, where it is activated by mixing with another protein enzyme, trypsin. Pancreatic elastase does not get degraded when it travels through the intestinal tract, and if there is any inflammation of the pancreas, this enzyme gets released into the bloodstream. Because it is an exclusive biomarker of pancreas functionality, testing for pancreatic elastase in either blood serum or stool can show when there is inflammation of the pancreas (known as pancreatitis) or a reduction in pancreas functionality (such as with the digestion and fat malabsorption symptoms seen in Hashimoto’s).
If left unchecked, pancreatic enzyme deficiencies can result in chronic pancreatitis; this can then lead to a more serious condition known as EPI (Exocrine Pancreatic Insufficiency). This is a significant deficiency in pancreatic enzymes, especially relating to fat malabsorption (actually due to abnormally low levels of lipase production). Some 20 percent of people with chronic pancreatitis will develop EPI over time.
We can test for low levels of pancreatic elastase in a simple stool test. I’ll talk about testing in a moment.
Low levels of pancreatic elastase can point to:
- Suppressed pancreatic function
- Hypochlorhydria (low stomach acid), especially if H. pylori is present
- Heavy metal toxicity
- Alcohol use
- Stress (adrenal fatigue)
- Celiac disease
- Damaged microvilli
- Cystic fibrosis
- A vegetarian/vegan diet
Interestingly, if you look at this list, there are several known triggers for Hashimoto’s, including low stomach acid, SIBO, H. pylori, heavy metal toxicity, Celiac disease (gluten sensitivity), and stress. Let’s look more closely at the Hashimoto’s connection to issues with the pancreas.
How Hashimoto’s Affects Pancreatic Enzyme Deficiency
Thyroid hormone levels can affect the metabolism or action of other hormones in our bodies, as well as other endocrine glands and organs.
As one example, gastric dysmotility (impairment) is significantly more frequent in hypothyroid patients. This condition slows down the normal muscular contractions of the small intestine, which slows down the movement of partially digested food and digestive juices. This can cause bloating and other digestive symptoms, as well as set the stage for bacterial growth in the small intestine due to the trapped food content just sitting there. Again, having low stomach acid further compounds this by providing an environment that is not well defended against bacteria.
The lack of thyroxine (free T4), as seen in Hashimoto’s, also decreases liver cholesterol metabolism. This has been found to negatively impact gallbladder function and change the thickness of the bile (produced by the liver), which can result in slowing the bile’s rate of flow and reducing its effectiveness in digesting fats.
Thyroid dysfunction can also impact our metabolism, which results in pancreatic dysfunction. We know that there are thyroid receptors in the pancreas, and studies have found that pancreatic function can be significantly reduced in patients with hypothyroidism.
One study tested the pancreatic function of 15 patients with hypothyroidism and 15 healthy patients by means of measuring their plasma amino acid uptake. The resting plasma amino acid concentrations of hypothyroid patients did not differ significantly from those of healthy subjects. However, while pancreatic stimulation caused a pronounced decrease in plasma amino acid concentration in healthy subjects (18.7 percent), a much smaller decrease was seen in the hypothyroid patients (6.8 percent). Treatment with thyroxine, however, restored pancreatic function to normal. The study concluded that the thyroid gland plays an essential role in maintaining the functional integrity of the pancreas.
Given that about a third of people with Hashimoto’s may have deficiencies in bile and/or pancreatic enzymes (leading to issues with fat absorption), and many also have low levels of stomach acid (leading to difficulties digesting and absorbing nutrients from the protein we eat), it is no wonder that nutrient depletions are so common in people with Hashimoto’s.
If you have pancreatic enzyme deficiency, you will not be properly digesting and absorbing fats. You may experience digestive symptoms as well as seemingly unrelated symptoms, such as low energy and increased cravings for carbs. This is due to fats being a slow-burning source of energy for our body. You may also experience symptoms related to both essential fatty-acid deficiency, as well as depletions in the fat-soluble vitamins (A, D, E, and K).
Fat Malabsorption Symptoms
Generally, if you are experiencing one of the symptoms below, you have an intermediate risk for fat malabsorption. If you are experiencing two or more of the symptoms below, you are at a high risk.
- Indigestion/fullness 2-4 hours after meal
- Bloating or flatulence 2-4 hours after meal
- Undigested food in stool
- Greasy/floating/light colored stools
- Diarrhea, or oil/grease present during bowel movements
- Gallbladder pain (right side, under ribs), gallstones, or gallbladder removal
- Low vitamin levels (A, D, E, and K) – even after supplementing
- Muscle wasting
- Low energy, increased carb cravings
- Dry skin
- Hormonal imbalances (including estrogen dominance) and adrenal issues
Essential Fatty-Acid Deficiency Symptoms
- Soft, cracked, or brittle nails
- Dry hair, dandruff, or oily scalp
- Dry, itchy, scaly, or flaky skin, rashes or eczema
- Hard earwax
- Chicken skin (tiny bumps on the back of arms)
- Joint aches or stiffness
- Weight loss
Deficiency Symptoms for Fat-soluble Vitamins A, D, E, and K
Unless you’re specifically supplementing, you may also experience deficiencies in the fat-soluble vitamins, A, D, E and K.
Here are the potential symptoms, broken down by each vitamin:
Vitamin A deficiency:
- Dry skin
- Acne and skin disorders
- Dry eyes
- Night blindness
- Poor wound healing
- Immune system imbalance (getting sick more often)
- Poor wound healing
- Fragile bones, bone loss or pain
- Muscle weakness
- Hair loss
- Muscle weakness
- Numbness and tingling (peripheral neuropathy)
- Vision problems
- Coordination and walking difficulties
- Immune system imbalance
Vitamin K deficiency:
- Bleeding nose or gums
- Easy bruising
- Blood in the urine and/or stool
- Heavy menstrual periods
- Excessive bleeding from a cut or wound
Remember that these symptoms can point to gallbladder issues, pancreatic enzyme deficiency, or other root causes (SIBO, H. pylori, low stomach acid, etc.). The good news is that these root causes are often interrelated; addressing one will likely positively affect others as well.
Testing for Pancreatic Enzyme Deficiencies
Symptoms are the clearest initial clue that you may be experiencing fat digestion issues. And the timing of symptoms, such as when fullness, bloating and indigestion occur, can help shed light on whether you have pancreatic insufficiency or another issue, such as low stomach acid. Stomach acid issues will start while you’re still at the dinner table, when you feel the need to unbutton your pants just after eating! Pancreatic insufficiency, on the other hand, will more likely hit 2-4 hours later, or maybe even later in the evening, hours after a meal.
Another heads-up symptom is vitamin D deficiency. If you take a vitamin D lab test after supplementing with vitamin D, but still see results indicating a deficiency, that often means there is a fat malabsorption issue to address. It could point to gallbladder issues and/or pancreatic insufficiency.
Once you identify fat malabsorption symptoms, you may want to simply try taking some digestive enzymes to see if you gain relief. While there are six types of digestive enzymes available, I’d suggest starting with two that focus particularly on fat digestion: Pancreatic Enzymes Plus and Liver & Gallbladder Support. In many cases, I’ve seen issues relating to pancreatic insufficiency resolve in a few weeks to a few months, just in taking enzyme support. I’ll talk more about these later on in this article.
There is a simple lab test you can take that specifically reports on your level of pancreatic elastase. It is done using a stool sample, and is available through expanded stool tests (like my favorite, the GI-MAP). In general, I recommend running comprehensive stool tests, as there may be multiple imbalances we may need to address. I will be working on an article on how to interpret these tests in future posts.
The Gastrointestinal Microbial Assay Plus (GI-MAP™) provides an amazing report on your gastrointestinal microbiota DNA, detecting pathogens (bacterial, parasitic, and viral) that may be causing you symptoms, as well as detecting intestinal health biomarkers relating to underlying issues that could be disturbing your normal microbial balance. One such biomarker is testing for low levels of fecal pancreatic elastase. The GI-MAP test is also great at uncovering many other known triggers for Hashimoto’s, including H. pylori, Epstein-Barr, Yersinia and yeast overgrowth.
In the GI-MAP test, normal values are greater than 500 μ/g, with a measure between 200-500 μ/g indicating a decrease in pancreatic output. Anything less than 200 μ/g is considered insufficiency.
In my clinical practice, I’ve found that about 40 percent of people with Hashimoto’s taking the GI-MAP assay have a low level of fecal pancreatic elastase.
PRECAUTIONS: Low levels of pancreatic elastase may not be just a result of enzyme deficiencies and/or low stomach acid. This can result from damaged microvilli, gallstones, celiac disease, SIBO, heavy metal toxicity, inflammatory bowel disease, cystic fibrosis, diabetes, stress, or excessive alcohol use. Testing for some of these may need to be done to find all of the root causes of your pancreatic insufficiency and fat malabsorption issues.
The Issue with Conventional Treatments
Digestive enzyme deficiencies are often overlooked and not diagnosed by conventional practitioners.
Too often, doctors will simply prescribe proton pump inhibitors (PPIs) at the first sign of gastric distress, which in many cases is the opposite of what is needed (such as in instances of low stomach acid). This is what happened to me for years, and I often hear about it when interviewing new clients, many of whom have been prescribed PPIs for their symptoms.
Others may start down a road of being evaluated for irritable bowel issues, or other conditions.
Both pancreatic enzyme deficiencies and chronic pancreatitis are often hard to diagnose and may just progress over the years. Unless someone presents with the weight loss and severe diarrhea pattern seen with the more advanced condition of EPI, there may be no pancreas-specific diagnosis for some time (despite many invasive tests to the stomach, intestinal tract, and bowels). This is unfortunate, as EPI may not be diagnosed until the pancreas loses some 90 percent of its enzyme production! That’s a long time to feel miserable with a chronic disease that can also cause osteopenia, anemia and more.
In contrast to how conventional medicine looks at these symptoms, in functional medicine, we understand that there are proven linkages between Hashimoto’s, gallbladder disease, pancreatic insufficiency, fat malabsorption, and nutrient deficiencies. So why wouldn’t we start there?
My Root Cause Recommendations
As a Root Cause detective, I look at these types of important linkages early-on during my initial assessments with new clients. If someone is experiencing symptoms associated with fat malabsorption or fatty-acid deficiency, or tests as having low fecal pancreatic elastase, my Root Cause approach focuses our efforts on the following three goals:
- Supporting liver and gallbladder health (bile from the liver and gallbladder supports our pancreatic enzymes in digesting and absorbing fats)
- Addressing potential deficiencies in pancreatic enzymes and supporting pancreas health
- Evaluating other common root causes for fat malabsorption that are also known triggers for Hashimoto’s, such as SIBO, low stomach acid, etc.
To address these goals, I focus on dietary and lifestyle interventions, as well as adding the support of key nutrients and supplements such as digestive enzymes.
Dietary and Lifestyle Recommendations
- Remove food sensitivities: Food sensitivities such as gluten have been linked to gastric motility and gallbladder issues, and can be a trigger for Hashimoto’s. I always recommend removing common food sensitivities such as gluten and dairy as an initial step to feeling better. You may want to consider an elimination diet to help identify your specific trigger foods.
- Be mindful of fats. While fats are essential to our survival and we never want to be on a “fat free” diet, we may need to be mindful of eating them in our initial healing stages. I suggest eating healthier fats to start, and as you improve upon your issues with fat malabsorption, you can reintroduce others. Note that gallstones have been associated with diets high in sugar, as well as with saturated fats — and this is especially true if we can’t digest them.
- Add medium chain triglycerides (MCTs) to the diet: MCTs are a form of fat that are more easily digested and absorbed. Coconut oil is a great source of MCTs!
- Avoid gallbladder-unfriendly foods: There are a number of foods that have been found to cause gallbladder/fat digestion issues, including: onions, milk, pork, poultry, coffee, nuts, corn, tomatoes, and oranges. You might want to avoid these, at least until your fat digestion improves.
- Support your liver: No matter what your symptoms are, I always say to focus on supporting your liver to improve your thyroid condition, and overall health.
- Reduce alcohol intake: Excessive alcohol intake is a risk factor for pancreatitis.
- Stop smoking: Smoking increases the risk for pancreatitis and pancreatic cancer.
- Improve digestive rituals:
- Smaller, frequent meals may help with better absorption.
- Chew food thoroughly and relax at meal time (this helps get digestive juices flowing and working early on through your saliva).
- Ensure good hydration, but don’t drink with meals (it dilutes those important digestive juices).
- Stop taking acid-blockers if you are taking them! Many people having Hashimoto’s have the opposite issue — low stomach acid.
- Consider adding digestive herbs to the meal (note that curcumin increases lipase activity by 80 percent).
- Consider adding spices that may help with fat digestion and absorption: coriander, turmeric, red chilli, black pepper, cumin, and ginger have all been studied to enhance pancreatic enzymes and bile flow. Note that some of these are not autoimmune friendly, including coriander (seeds), cumin (seeds), black pepper and red chilli.
Supplements I Recommend
In my experience, fat malabsorption can be reversed much of the time, with the short-term use of digestive enzymes.
I’ve found Pancreatic Enzymes Plus from Rootcology to be very helpful as an initial step in addressing problems with fat digestion. In about 50 percent of cases, while using these enzymes, I’ve seen pancreatic insufficiency and fat malabsorption issues resolve in as little as a few weeks to a few months. This supplement additionally contains ox bile (important in addressing any bile deficiency that may also be occurring). Some people may need to take the enzymes long-term and do more Root Cause detective work to find other potential reasons for pancreatic insufficiency.
Pancreatic enzymes are taken with every fat-containing meal. The typical dosage is one or two capsules per meal. This dosage, however, may need to be tailored to your individual health needs, so I recommend consulting with your functional practitioner to find the right dosage for you.
If pancreatic enzymes don’t solve the problem after 1-2 months, I’d recommend adding in liver and gallbladder support.
I recommend Liver & Gallbladder Support by Rootcology, which helps support fat digestion in three ways:
- Supporting the liver’s ability to process fat. (The active ingredient is milk thistle, a plant that contains silymarin, considered to have properties protective of liver health, especially relating to toxins. It has been shown to improve pancreatic function after exposure to toxic agents.)
- Increasing bile to better support fat digestion. (The active ingredient is ox bile, which has been shown to increase bile flow and support fat digestibility in animal studies.)
- Supporting improved bile flow. (The active ingredients are beet, dandelion, and artichoke.)
I routinely recommend taking one capsule of this supplement with each meal to address fat digestion and malabsorption issues, as well as it being a key component of my Liver Support Protocol.
If you are still experiencing problems after 1-2 months of this supplement, I’d then try Betaine with Pepsin to provide additional digestive support, especially if low stomach acid is suspected (i.e. if one has difficulty when digesting protein, experiences fullness right after eating, or has acid reflux-related symptoms). Note that this supplement is not for everyone; for example, people with a history of peptic ulcers or who take NSAIDs, steroids or other medications that could cause an ulcer should not take betaine with pepsin. Additionally, there are strict betaine with pepsin dosing requirements you should review, which involve titrating your dose so that you are not taking too much.
Remember that low levels of pancreatic elastase and fat malabsorption issues may result in a deficiency of essential fatty acids. Symptoms of fatty acid deficiency may include pain, inflammation, dry skin, oily scalp or dry hair, eczema, brittle nails and achy joints. You may benefit from one to four grams of fish oil per day if you show signs of fatty acid deficiency.
For those who have had fat malabsorption issues for a period of time, you may find that you have deficiencies in the fat-soluble vitamins A, D, E, and K. Supplementing these vitamins may also be beneficial. Designs for Health has a Vitamin D and K combo, as well as an A, D, E, K combination complex that may be helpful, if you’re looking to take fewer supplements.
Please note: This article is for informational purposes only, and I am not able to provide advice on whether any of the referenced supplements or health protocols would be appropriate for you and your specific health needs without a comprehensive health assessment. Please discuss the use of all supplements and health protocols with your personal doctor or pharmacist.
What You Can Do Today (To Address Your Issues with Fat Digestion)
If you have symptoms that point to issues with digesting fats, it is very likely you have either a liver, gallbladder or pancreas related issue. Much of the time, symptoms will be due to deficiencies in the bile, or in one or more digestive enzymes. The good news is that we can supplement for all of these deficiencies and take other corrective actions (such as improving our diet).
We also know that many people with Hashimoto’s experience low stomach acid, and that can also be addressed with digestive enzymes.
Remember, in my 2015 survey of 2,232 people, some 78 percent felt better when taking digestive enzymes. That’s an empowering statistic.
If digestive enzymes don’t address your fat malabsorption symptoms, you may need to dig deeper to find what else could be going on. We know that pancreatic insufficiency can be associated with SIBO, celiac disease, IBS, H. pylori infections, and other conditions commonly seen in Hashimoto’s.
When we put on our detective caps, we also need to remember that many of these conditions are interlinked with each other, as well as have a direct effect on our Hashimoto’s symptoms (and in some cases, they can even affect our thyroid antibody levels). The positive side of these linkages is that in many cases, if you address one issue, you may improve on another. I routinely see this with my clients. And that means you will be feeling better.
I recently heard someone use an expression that I loved. They said you either need to take steps to heal or retreat.
I think that this is so true with our Hashimoto’s journey in particular. Little steps help us heal a bit each day. We just can’t give up. I know in my own journey, I sometimes felt overwhelmed with root causes! I’d address one and then I’d realize another thing that was causing me problems. But with every root cause that I addressed, whether that was my “aha” moment taking betaine with pepsin for the first time, or whether it was resolving one of several gut infections that I had… with every one of those, I felt better.
And that is my wish for you.
So take one step today, and never retreat.
P.S. To help you on your journey, you can download a free Thyroid Diet Guide, 10 thyroid friendly recipes, and the Nutrient Depletions and Digestion chapter of my Hashimoto’s Root Cause book for free by signing up for my weekly newsletter. You will also receive occasional updates about new research, resources, giveaways, and helpful information.
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