Fat Digestion and Hashimoto’s – Dr. Izabella Wentz

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.

However, 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 with Hashimoto’s, 78 percent said they 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 previously believed that about 40 to 50 percent of people with Hashimoto’s had challenges with fat digestion. However, a recent analysis of test results from my clients and program readers, showed that up to 73 percent of people actually had challenges, as evidenced by decreased elastase, a measure of pancreatic enzyme activity. This can leave people with numerous digestive symptoms, and can 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.

A deficiency in pancreatic enzymes, such as pancreatic elastase, can often be at the root of fat malabsorption issues. 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 with 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. ^{^[1]}

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. ^{^[2]}

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. ^{^[3]} The bile’s job is to break down 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. ^{^[4]} 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). ^{^[5]}

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. ^{^[6]}

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. ^{^[7]}

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, pancreatic elastase, in either blood serum or stool tests, 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). ^{^[8]}

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).

Symptoms of EPI can range from general gut disturbances such as gas and bloating to pain in the stomach and/or bones, to steatorrhea (foul smelling, greasy stools). Some 20 percent of people with chronic pancreatitis will develop EPI over time. ^{^[9]}

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 be associated with: ^{^[10]}

Pregnant women may be at risk for developing low levels of pancreatic elastase, potentially due to gallbladder issues that result from high estrogen. ^{^[11]} 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 how Hashimoto’s is connected to issues with the pancreas. ^{^[12]}

How Hashimoto’s Affects Pancreatic Enzymes

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. ^{^[13]} 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. ^{^[14]} 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. ^{^[15]}

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. ^{^[16]}

Given that about three-quarters 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. ^{^[17]}

Symptoms

If you have a pancreatic enzyme deficiency, you will not be properly digesting and absorbing fats. ^{^[18]} 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 that our body needs. 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. ^{^[19]} If you are experiencing two or more of the symptoms below, you are at a high risk.

Indigestion/fullness 2-4 hours after a meal
Bloating or flatulence 2-4 hours after a meal
Undigested food in stool
Greasy/floating/light-colored stools
Belching
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 (I see this very often, as the body is not able to absorb and utilize the vitamins in such supplements)
Muscle wasting
Low energy, increased carb cravings
Dry skin
Hormonal imbalances (including estrogen dominance) and adrenal issues

Essential Fatty-Acid Deficiency Symptoms ^{^[20]}

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
Depression
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: ^{^[21]}

Dry skin
Acne and skin disorders
Dry eyes
Night blindness
Poor wound healing

Vitamin D deficiency: ^{^[22]}

Immune system imbalance (getting sick more often)
Poor wound healing
Fragile bones, bone loss, or pain ^{^[23]}
Muscle weakness
Fatigue
Depression
Hair loss

Vitamin E deficiency: ^{^[24]}

Muscle weakness
Numbness and tingling (peripheral neuropathy)
Vision problems
Coordination and walking difficulties
Immune system imbalance

Vitamin K deficiency: ^{^[25]}

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.

I’ve had low pancreatic enzymes a few different times in the past — once when I had estrogen dominance from pituitary suppression, another time towards the end of my pregnancy, likely due to all of that beautiful estrogen, and a third time when I was having hormonal issues while nursing my son.

One of the things that I tend to notice is that my face seems more inflamed/swollen when my elastase is low, and the swelling goes away when I supplement with pancreatic enzymes. The changes are subtle and I’m not sure anyone else would notice.

However, one of my team members who recently had low elastase and started supplementing with pancreatic enzymes, commented that her facial and sinus swelling seemed to improve with the supplements. I’ve not asked clients about this in the past, but will be adding this to my intakes as a potential symptom.

Testing for Pancreatic Enzyme Deficiencies

The symptoms listed above are usually 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 two to four 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 by taking enzyme support. (I’ll talk more about these later on in this article — but if you want more information on other enzymes, you can also read my Ultimate Guide to Using Enzymes for Hashimoto’s).

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 and 500 μ/g indicating a decrease in pancreatic output. Anything less than 200 μ/g is considered insufficiency.

Since I originally published this article, I’ve learned that while a “low” result for fecal elastase is reported as being under 200 μg/g, an optimal level is above 500 μg/g, and people may be symptomatic, even with fecal elastase between 200-500 μg/g. Low fecal elastase can be an indication of exocrine pancreatic insufficiency, which can have more root causes, such as celiac disease, mold toxicity, SIBO, and many others.

In my recent review of data from over 300 GI-MAP tests done on people with Hashimoto’s, I’ve found that about 73 percent of people with Hashimoto’s had suboptimal levels 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 also result from damaged microvilli, gallstones, celiac disease, SIBO, heavy metal toxicity, inflammatory bowel disease, cystic fibrosis, diabetes, stress, or excessive alcohol use. ^{^[26]} 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 heard about it from my previous clients, many of whom had 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). ^{^[27]}

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. ^{^[28]}

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, if someone is experiencing symptoms associated with fat malabsorption or fatty-acid deficiency, or if someone tests as having low fecal pancreatic elastase, my Root Cause approach focuses 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, like digestive enzymes.

Dietary and Lifestyle Recommendations

Remove food sensitivities: Sensitivities to foods such as gluten, have been linked to gastric motility and gallbladder issues, ^{^[29]} 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. ^{^[30]}
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, and always supplement with enzymes while eating them. I suggest eating healthier fats to start (such as coconut oil), 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. ^{^[31]}
Add medium chain triglycerides (MCTs) to the diet: MCTs are a form of fat that are easily digested and absorbed. Coconut oil is a great source of MCTs!
Limit or 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. ^{^[32]}
Cease smoking: Smoking increases the risk for pancreatitis and pancreatic cancer. ^{^[33]}
Improve eating habits:
- Smaller, frequent meals may help with better absorption. ^{^[34]}
- Chew food thoroughly and relax at meal time (this helps get digestive juices flowing and working early on through your saliva). ^{^[35]} Taking deep breaths and practicing belly breathing can help to ease the body into its relaxed, rest-and-digest mode.
- Ensure you stay hydrated, but don’t drink with meals (it dilutes those important digestive juices).
- Stop taking acid-blockers if you are taking them! Many people with Hashimoto’s have the opposite issue — low stomach acid. ^{^[36]}
- 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 chili, black pepper, cumin, and ginger have all been studied to enhance pancreatic enzymes and bile flow. ^{^[37]} Note that some of these are not autoimmune-friendly, including coriander seeds, cumin seeds, black pepper and red chili.

Pancreatic-Supporting Supplements I Recommend

In my experience, fat malabsorption can be reversed much of the time, with the short-term use of the three pancreatic enzymes (lipase, protease and amylase) and ox bile, and by doing some of the root cause work as needed.

Pancreatic enzymes are available as a prescription medication for people who have a diagnosis like exocrine pancreatic insufficiency (one brand name I have often dispensed, recommended, and used personally, is Creon®, though my insurance stopped covering it and it costs thousands of dollars without insurance), and through high quality supplement companies including Pure Encapsulations and Rootcology, which are available through health care professionals and directly to patients without a prescription (though consulting with a healthcare professional is always important when starting any new therapies).

I have used Pancreatic Enzymes by Pure Encapsulations personally and with clients, with great results.

I find Creon® and the Pancreatic Enzymes by Pure Encapsulations especially helpful for advanced stages of exocrine pancreatic insufficiency, where one may require high doses of the enzymes (and may need to take multiple pills with each meal and snack, based on his/her weight — the Creon® website provides more info on dosing).

I would also often recommend using an additional ox bile-containing supplement, like Liver & Gallbladder Support by Rootcology, along with root cause detective work. ?

For those with more mild versions of fat digestive issues, I’ve created Pancreatic Enzymes Plus from Rootcology as an initial step in addressing problems with fat digestion.

This supplement contains the three pancreatic enzymes (lipase, amylase and protease) in lower amounts. Plus, it contains ox bile (important in addressing any bile deficiency that may also be occurring) and bromelain, to support protein digestion.

Pancreatic Enzymes Plus can be 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.

For a limited time, I am offering a 20% off discount on Rootcology’s Pancreatic Enzymes Plus. Simply enter the code PANCREATIC2023 at checkout to receive your discount through June 2nd at 11:59 pm PT.

Here’s what one customer had to say:

“I’ve always had a hard time digesting fats, which led me to the lifestyle of a low-fat diet. I never knew that supplements were available to help with this until I came across the Rootcology Pancreatic Enzymes. There was an article circulating about them, so I decided to order some and within the first day, I noticed a difference. Now I see that there are other brands of pancreatic enzymes, but these ones work so well for me, I wouldn’t even think of trying out another brand. I also like how the ingredients include ox bile. I was told by others to use ox bile to help digest fats better, but I couldn’t find ox bile anywhere. Now I have a product with everything I need in one capsule!”

In about 50 percent of cases, while using these enzymes, I’ve seen mild cases of pancreatic insufficiency and fat malabsorption issues resolve in as little as a few weeks to a few months. (That said, 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.)

Precautions

Do not use this supplement if you are allergic to pork, pineapples, pancreatic enzymes, or ox bile. If you experience a skin rash, please discontinue using the product immediately, as this could be a sign of an allergic reaction. Consult with a physician before use if pregnant or breastfeeding.

Additionally, avoid this product if taking the following medications: acarbose, anticoagulant drugs (such as aspirin), amoxicillin, blood thinners, clopidogrel (Plavix), dalteparin (Fragmin), enoxaparin (Lovenox), heparin, indomethacin (Indocin), tetracycline antibiotics, ticlopidine (Ticlid), or warfarin (Coumadin).

Burning and digestive distress would likely indicate that the supplement should be discontinued. Do not crush or chew capsules or its contents, and do not hold the capsule or capsule contents in your mouth, as they may cause irritation.

The most common side effects include: increased (hyperglycemia) or decreased (hypoglycemia) blood sugars, abdominal area pain, frequent or abnormal bowel movements, gas, vomiting, dizziness, or sore throat and cough.

Pancreatic enzyme products are made from the pancreas of pigs, which may carry viruses. Although it has never been reported, it may be possible for a person to get a viral infection from taking pancreatic enzyme products that come from pigs.

Other Supplements to Consider

If pancreatic enzymes don’t solve the problem after one to two months, I’d recommend adding in a liver and gallbladder support supplement such as 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.) ^{^[38]}
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.) ^{^[39]}
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. (Please follow the link to the product page for more information and precautions.)

If you are still experiencing problems after one to two months of this supplement, I’d then try Betaine with Pepsin to provide additional digestive support, especially if low stomach acid is suspected (indications of low stomach acid include difficulty when digesting protein, fullness right after eating, and 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. As such, supplementing these vitamins may also be beneficial. DaVinci Labs has an A.D.K. combo that I like, which may be helpful along with a soy-free vitamin E.

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).

Furthermore, we 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, Giardia, mold toxicity, estrogen dominance, and other conditions commonly seen in Hashimoto’s. ^{^[40]}

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, so if you follow the same path, you should be feeling better in time as well.

Takeaway

I recently heard someone use an expression that really resonated with me: 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: The 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.

For future updates, make sure to follow us on Facebook, TikTok, Pinterest, and Instagram!

References

^{^[1]} Leung PS. Physiology of the pancreas. Adv Exp Med Biol. 2010;690:13-27. doi:10.1007/978-90-481-9060-7_2
^{^[2]} Biondi B, Kahaly GJ, Robertson RP. Thyroid Dysfunction and Diabetes Mellitus: Two Closely Associated Disorders. Endocr Rev. 2019;40(3):789-824. doi:10.1210/er.2018-00163; Hwang WJ, Lim HH, Kim YM, et al. Pancreatic involvement in patients with inborn errors of metabolism. Orphanet J Rare Dis. 2021;16(1):37. Published 2021 Jan 20. doi:10.1186/s13023-021-01685-9
^{^[3]} Boland M. Human digestion–a processing perspective. J Sci Food Agric. 2016;96(7):2275-2283. doi:10.1002/jsfa.7601; Housset C, Chrétien Y, Debray D, Chignard N. Functions of the Gallbladder. Compr Physiol. 2016;6(3):1549-1577. Published 2016 Jun 13. doi:10.1002/cphy.c150050
^{^[4]} Leung PS. Physiology of the pancreas. Adv Exp Med Biol. 2010;690:13-27. doi:10.1007/978-90-481-9060-7_2
^{^[5]} Chiang JYL, Ferrell JM. Bile Acids as Metabolic Regulators and Nutrient Sensors. Annu Rev Nutr. 2019;39:175-200. doi:10.1146/annurev-nutr-082018-124344
^{^[6]} Food intolerance: Symptoms, causes and treatment options. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/21688-food-intolerance. Published August 2021. Accessed September 7, 2022; Bures J, Cyrany J, Kohoutova D, et al. Small intestinal bacterial overgrowth syndrome. World J Gastroenterol. 2010;16(24):2978-2990. doi:10.3748/wjg.v16.i24.2978; Hypochlorhydria (low stomach acid): Symptoms, tests, treatment. Cleveland Clinic. Published June 2022. Accessed September 7, 2022. https://my.clevelandclinic.org/health/diseases/23392-hypochlorhydria.
^{^[7]} Aghili R, Jafarzadeh F, Ghorbani R, Khamseh ME, Salami MA, Malek M. The association of Helicobacter pylori infection with Hashimoto’s thyroiditis. Acta Med Iran. 2013;51(5):293-296. Published 2013 May 30; Pancreatic elastase. Pancreatic Elastase – an overview | ScienceDirect Topics. Published 2013. Accessed September 7, 2022. https://www.sciencedirect.com/topics/medicine-and-dentistry/pancreatic-elastase.
^{^[8]} Capurso G, Traini M, Piciucchi M, Signoretti M, Arcidiacono PG. Exocrine pancreatic insufficiency: prevalence, diagnosis, and management. Clin Exp Gastroenterol. 2019;12:129-139. Published 2019 Mar 21. doi:10.2147/CEG.S168266
^{^[9]} Struyvenberg MR, Martin CR, Freedman SD. Practical guide to exocrine pancreatic insufficiency – Breaking the myths. BMC Med. 2017;15(1):29. Published 2017 Feb 10; Yan MX, Li YQ. Gall stones and chronic pancreatitis: the black box in between. Postgrad Med J. 2006;82(966):254-258. doi:10.1136/pgmj.2005.037192
^{^[10]}Yan MX, Li YQ. Gall stones and chronic pancreatitis: the black box in between. Postgrad Med J. 2006;82(966):254-258. doi:10.1136/pgmj.2005.037192; Rabelo-Gonçalves EM, Roesler BM, Zeitune JM. Extragastric manifestations of Helicobacter pylori infection: Possible role of bacterium in liver and pancreas diseases. World J Hepatol. 2015;7(30):2968-2979. doi:10.4254/wjh.v7.i30.2968; Waldum HL, Kleveland PM, Sørdal ØF. Helicobacter pylori and gastric acid: an intimate and reciprocal relationship. Therap Adv Gastroenterol. 2016;9(6):836–844; El Kurdi B, Babar S, El Iskandarani M, et al. Factors That Affect Prevalence of Small Intestinal Bacterial Overgrowth in Chronic Pancreatitis: A Systematic Review, Meta-Analysis, and Meta-Regression. Clin Transl Gastroenterol. 2019;10(9):e00072. doi:10.14309/ctg.0000000000000072; Gaman L, Dragos D, Vlad A, et al. Phytoceuticals in Acute Pancreatitis: Targeting the Balance between Apoptosis and Necrosis. Evid Based Complement Alternat Med. 2018;2018:5264592. Published 2018 Mar 4. doi:10.1155/2018/5264592; Apte MV, Wilson JS, Korsten MA. Alcohol-related pancreatic damage: mechanisms and treatment. Alcohol Health Res World. 1997;21(1):13-20; Agawa S, Futagami S, Yamawaki H, et al. State of anxiety may be associated with exocrine pancreatic insufficiency in functional dyspepsia patients with pancreatic enzyme abnormalities. J Clin Biochem Nutr. 2022;70(2):175-181. doi:10.3164/jcbn.21-67; Rana SS, Dambalkar A, Chhabra P, et al. Is pancreatic exocrine insufficiency in celiac disease related to structural alterations in pancreatic parenchyma?. Ann Gastroenterol. 2016;29(3):363-366. doi:10.20524/aog.2016.0042; Gullo L, Graziano L, Babbini S, Battistini A, Lazzari R, Pezzilli R. Faecal elastase 1 in children with cystic fibrosis. Eur J Pediatr. 1997;156(10):770-772. doi:10.1007/s004310050709; Walkowiak J, Wadolowska L, Szaflarska-Poplawska A, Lisowska A, Bugajewska A, Przyslawski J. The elimination of meat from the diet selectively decreases pancreatic elastase secretion. Br J Nutr. 2007;98(1):154-158. doi:10.1017/S000711450769176; Oskarsson V, Orsini N, Sadr-Azodi O, Wolk A. Postmenopausal hormone replacement therapy and risk of acute pancreatitis: a prospective cohort study. CMAJ. 2014;186(5):338-344. doi:10.1503/cmaj.131064
^{^[11]} Rabelo-Gonçalves EM, Roesler BM, Zeitune JM. Extragastric manifestations of Helicobacter pylori infection: Possible role of bacterium in liver and pancreas diseases. World J Hepatol. 2015;7(30):2968-2979. doi:10.4254/wjh.v7.i30.2968; Ebert EC. The thyroid and the gut. J Clin Gastroenterol. 2010;44(6):402-406. doi:10.1097/MCG.0b013e3181d6bc3e; Singletary BK, Van Thiel DH, Eagon PK. Estrogen and progesterone receptors in human gallbladder. Hepatology. 1986;6(4):574-578. doi:10.1002/hep.1840060405
^{^[12]} Patil AD. Link between hypothyroidism and small intestinal bacterial overgrowth. Indian J Endocrinol Metab. 2014;18(3):307-309. doi:10.4103/2230-8210.131155; Figura N, Di Cairano G, Moretti E, et al. Helicobacter pylori Infection and Autoimmune Thyroid Diseases: The Role of Virulent Strains. Antibiotics (Basel). 2019;9(1):12. Published 2019 Dec 30. doi:10.3390/antibiotics9010012; Pamphlett R, Doble PA, Bishop DP. Mercury in the human thyroid gland: Potential implications for thyroid cancer, autoimmune thyroiditis, and hypothyroidism. PLoS One. 2021;16(2):e0246748. Published 2021 Feb 9. doi:10.1371/journal.pone.0246748; Krysiak R, Szkróbka W, Okopień B. The Effect of Gluten-Free Diet on Thyroid Autoimmunity in Drug-Naïve Women with Hashimoto’s Thyroiditis: A Pilot Study. Exp Clin Endocrinol Diabetes. 2019;127(7):417-422. doi:10.1055/a-0653-7108; Mizokami T, Wu Li A, El-Kaissi S, Wall JR. Stress and thyroid autoimmunity. Thyroid. 2004;14(12):1047-1055. doi:10.1089/thy.2004.14.1047; Daher R, Yazbeck T, Jaoude JB, Abboud B. Consequences of dysthyroidism on the digestive tract and viscera. World J Gastroenterol. 2009;15(23):2834–2838.
^{^[13]} Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract. 2019;34(1):23-36. doi:10.1002/ncp.10199; Sinha RA, Singh BK, Yen PM. Direct effects of thyroid hormones on hepatic lipid metabolism. Nat Rev Endocrinol. 2018;14(5):259-269. doi:10.1038/nrendo.2018.10
^{^[14]} Völzke H, Robinson DM, John U. Association between thyroid function and gallstone disease. World J Gastroenterol. 2005;11(35):5530-5534. doi:10.3748/wjg.v11.i35.5530
^{^[15]} Chen C, Xie Z, Shen Y, Xia S.F. The Roles of Thyroid and Thyroid Hormone in Pancreas: Physiology and Pathology. International Journal of Endocrinology. 2018;2018:2861034. doi:10.1155/2018/2861034
^{^[16]} Gullo L, Pezzilli R, Bellanova B, D’Ambrosi A, Alvisi V, Barbara L. Influence of the thyroid on exocrine pancreatic function. Gastroenterology. 1991 May;100(5 Pt 1):1392-6.; Zuvarox T, Belletieri C. Malabsorption Syndromes. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 30, 2021.
^{^[17]} Patil AD. Link between hypothyroidism and small intestinal bacterial overgrowth. Indian J Endocrinol Metab. 2014;18(3):307-309. doi:10.4103/2230-8210.131155
^{^[18]} Leung PS. Physiology of the pancreas. Adv Exp Med Biol. 2010;690:13-27. doi:10.1007/978-90-481-9060-7_2
^{^[19]} Gramlich L, Meddings L, Alberda C, et al. Essential Fatty Acid Deficiency in 2015: The Impact of Novel Intravenous Lipid Emulsions. JPEN J Parenter Enteral Nutr. 2015;39(1 Suppl):61S-6S. doi:10.1177/0148607115595977
^{^[20]} Gramlich L, Meddings L, Alberda C, et al. Essential Fatty Acid Deficiency in 2015: The Impact of Novel Intravenous Lipid Emulsions. JPEN J Parenter Enteral Nutr. 2015;39(1 Suppl):61S-6S. doi:10.1177/0148607115595977
^{^[21]} Hodge C, Taylor C. Vitamin A Deficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 15, 2022.
^{^[22]} Sizar O, Khare S, Goyal A, Givler A. Vitamin D Deficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 18, 2022.
^{^[23]} Ahmed A, Deep A, Kothari DJ, Sheth SG. Bone disease in chronic pancreatitis. World J Clin Cases. 2020;8(9):1574-1579. doi:10.12998/wjcc.v8.i9.1574
^{^[24]} Kemnic TR, Coleman M. Vitamin E Deficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 4, 2022.
^{^[25]} Eden RE, Coviello JM. Vitamin K Deficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 4, 2022.
^{^[26]} Lam KW, Leeds J. How to manage: patient with a low faecal elastase. Frontline Gastroenterol. 2019;12(1):67-73. Published 2019 Nov 15. doi:10.1136/flgastro-2018-101171
^{^[27]} Struyvenberg MR, Martin CR, Freedman SD. Practical guide to exocrine pancreatic insufficiency – Breaking the myths. BMC Med. 2017;15(1):29. Published 2017 Feb 10.
^{^[28]}Ibid; Massironi S, Branchi F, Fraquelli M, et al. Effects of a Gluten-Containing Meal on Gastric Emptying and Gallbladder Contraction. Nutrients. 2018;10(7):910. Published 2018 Jul 16. doi:10.3390/nu10070910
^{^[29]} Massironi S, Branchi F, Fraquelli M, et al. Effects of a Gluten-Containing Meal on Gastric Emptying and Gallbladder Contraction. Nutrients. 2018;10(7):910. Published 2018 Jul 16. doi:10.3390/nu10070910
^{^[30]} Lipski L. Remove, Replace and Replenish: The Diet Prescription and Supplementation – Part 2. Presented as part of the 2017 Institute for Functional Medicine Conference; October 2017; Denver, CO.
^{^[31]} Misciagna G, Centonze S, Leoci C, et al. Diet, physical activity, and gallstones–a population-based, case-control study in southern Italy. Am J Clin Nutr. 1999;69(1):120-126. doi:10.1093/ajcn/69.1.120
^{^[32]} Agawa S, Futagami S, Yamawaki H, et al. State of anxiety may be associated with exocrine pancreatic insufficiency in functional dyspepsia patients with pancreatic enzyme abnormalities. J Clin Biochem Nutr. 2022;70(2):175-181. doi:10.3164/jcbn.21-67
^{^[33]} Edderkaoui M, Thrower E. Smoking and Pancreatic Disease. J Cancer Ther. 2013;4(10A):34-40. doi:10.4236/jct.2013.410A005
^{^[34]} Dashti HS, Mogensen KM. Recommending Small, Frequent Meals in the Clinical Care of Adults: A Review of the Evidence and Important Considerations. Nutr Clin Pract. 2017;32(3):365-377. doi:10.1177/0884533616662995
^{^[35]} Cherpak CE. Mindful Eating: A Review Of How The Stress-Digestion-Mindfulness Triad May Modulate And Improve Gastrointestinal And Digestive Function. Integr Med (Encinitas). 2019;18(4):48-53.
^{^[36]} Patil AD. Link between hypothyroidism and small intestinal bacterial overgrowth. Indian J Endocrinol Metab. 2014;18(3):307-309. doi:10.4103/2230-8210.131155
^{^[37]} Platel K, Rao A, Saraswathi G, Srinivasan K. Digestive stimulant action of three Indian spice mixes in experimental rats. Nahrung. 2002 Dec;46(6):394-8
^{^[38]} Gillessen A, Schmidt HH. Silymarin as Supportive Treatment in Liver Diseases: A Narrative Review. Adv Ther. 2020;37(4):1279-1301. doi:10.1007/s12325-020-01251-y; Amniattalab A, Malekinejad H, Rezabakhsh A, Rokhsartalab-Azar S, Alizade-Fanalou S. Silymarin: A Novel Natural Agent to Restore Defective Pancreatic β Cells in Streptozotocin (STZ)-induced Diabetic Rats. Iran J Pharm Res. 2016;15(3):493-500.
^{^[39]} Alzawqari M, Moghaddam HN, Kermanshahi H, Raji AR. The effect of desiccated ox bile supplementation on performance, fat digestibility, Gut Morphology and blood chemistry of broiler chickens fed tallow diets. Taylor & Francis Online. Published August 9, 2011. Accessed September 7, 2022. https://www.tandfonline.com/doi/full/10.1080/09712119.2011.580999.
^{^[40]} Struyvenberg MR, Martin CR, Freedman SD. Practical guide to exocrine pancreatic insufficiency – Breaking the myths. BMC Med. 2017;15(1):29. Published 2017 Feb 10; Yan MX, Li YQ. Gall stones and chronic pancreatitis: the black box in between. Postgrad Med J. 2006;82(966):254-258. doi:10.1136/pgmj.2005.037192; Rabelo-Gonçalves EM, Roesler BM, Zeitune JM. Extragastric manifestations of Helicobacter pylori infection: Possible role of bacterium in liver and pancreas diseases. World J Hepatol. 2015;7(30):2968-2979. doi:10.4254/wjh.v7.i30.2968; Waldum HL, Kleveland PM, Sørdal ØF. Helicobacter pylori and gastric acid: an intimate and reciprocal relationship. Therap Adv Gastroenterol. 2016;9(6):836–844; El Kurdi B, Babar S, El Iskandarani M, et al. Factors That Affect Prevalence of Small Intestinal Bacterial Overgrowth in Chronic Pancreatitis: A Systematic Review, Meta-Analysis, and Meta-Regression. Clin Transl Gastroenterol. 2019;10(9):e00072. doi:10.14309/ctg.0000000000000072

Note: Originally published in July 2019, this article has been revised and updated for accuracy and thoroughness.