• Danielle Cheplowitz, CRNP

Step 2: Replace. Why fixing your gut first will cure almost all of your other ailments.

In last week’s post, we talked about removing negative influences in order to halt further progression of chronic disease. This week we will focus on maldigestion and malabsorption. By the end of this post, you will learn what these terms mean, their causes, and tips for improving digestion and absorption naturally. Lets dive in.

You have probably heard of the saying “you are what you eat”…am I right? I’ll take it a step further and say “you are what you digest and absorb”. You may be eating the healthiest foods, but what happens if you cannot assimilate and utilize those nutrients?

Maldigestion refers to the defective hydrolysis of nutrients. To say someone is experiencing maldigestion means that they are not able to breakdown down the nutrients into their raw (absorbable) form. Malabsorption refers to the impaired mucosal absorption. Someone is experiencing malabsorption when nutrients are unable to pass from the gastrointestinal system, through the wall of the intestine, into the blood stream.

Symptoms of maldigestion/malabsorption include:

-bloating or belching following a meal

-flatulence after eating

-early satiety

-undigested food in stool

-iron deficiency and other nutrient deficiencies

-unintentional weight loss, and chronic diarrhea.

Causes of Maldigestion

There is something call the “cephalic phase” of digestion, and this refers to our body’s awareness that food is coming. Think of dogs when they start salivating when they smell or see food. This is also true in humans. The thought, sight and/or smell of food will trigger the secretion of digestive enzymes and peristalsis (the wave-like movements from smooth muscle of the gastrointestinal tract pushing contents forward).

The first location of digestion actually starts in the mouth. Saliva has an enzyme called “amylase”, which helps to break down simple starches and sugars. Approximately 25-30% of the digestion of simple starches takes place in the mouth. Xerostomia, also known as dry mouth, can impair digestion of simple starches due to the lack of amylase present in the oral cavity. Poor mastication (chewing) of food is problematic because digestive enzymes are most effective in the breakdown down of food matter when the particles are smaller. Larger food particles are at risk for maldigestion.

Once food is swallowed, it travels down the esophagus into the stomach. Its is extremely important to have a normal production of stomach acid. If the production of stomach acid is reduced, or if the pH is not acidic enough, maldigestion can occur. The breakdown of proteins requires adequate stomach acid to be present. Certain nutrients, such as vitamin b12, can only be absorbed if there is adequate stomach acid available. Stomach acid that is not acidic enough can also increase the risk for gastrointestinal infections, since an acidic environment is required to kill pathogens entering the body.

When food exits through the pyloric sphincter into the duodenum of the small intestine, pancreatic enzymes should be released. In addition to carbohydrates, pancreatic enzymes also help assimilate fat, protein, fat-soluble vitamins (A,D,E,K) and Vitamin b12. As you can see, pancreatic enzymes are essential for reducing both macronutrients and micronutrients into their simplest compounds before absorption occurs.

Bile acids are also released into the small intestine in order to assimilate fat. A reduction in bile acids does not only impair assimilation of fatty acids, but can also cause low levels of fat-soluble vitamins, calcium, and magnesium. Other problems can arise from low bile salts, such as small intestinal bacterial overgrowth, since bile salts are also antimicrobial. We want beneficial gastrointestinal microbes to reside in the large intestine/colon… not the small intestine where most of our nutrients are absorbed. There are many causes of low bile salts, one of the more obvious being the removal of someone’s gallbladder. The liver still makes bile, but it is only capable of making a small amount each day.

Other causes of low bile salts are:

-Reduced delivery of bile acids to duodenum (gall stones, liver disease, gallbladder disease)

-Deconjugation of bile salts (bacterial overgrowth)

-Increased loss of bile salts (disease of terminal ileum (end of small intestine) or loss of bowel because bile salts are reabsorbed here)

-Medications (certain cholesterol medications and fiber supplements)

Now that we have talked about the breaking down of nutrients….What about absorbing them?

Some causes of malabsorption include:

Reduced mucosal absorption. Some conditions include crohn’s disease, celiac disease, intestinal surgery, infection, malignancy.

Decreased transport. Think of poor circulation in conditions such has lymphatic disease, heart disease and heart failure.

Decreased gastric acid and intrinsic factor for vitamin b12. This is associated with conditions such as gastritis, anemia, or gastric resection.

Rapid gastric emptying and mixing. This is associated with conditions such as gastroparesis, diabetes mellitus, surgery, or other autonomic dysfunction.

It is important to note that one does not need a “condition” to experience malabsorption. Everyday lifestyle factors such as quantity and quality of sleep, stress management, exercise, and diet also heavily influence how food is absorbed.

See examples below:

Reduced mucosal absorption

Jane admits to having a poor work-life balance. She works 50 hours per week and perceives her work to be quite stressful. She eats a lot of processed food, such as power bars, because it is easy and fast. Due to several years of excess stress & poor diet (in this case-lack of ingesting adequate amounts of dietary fiber), Jane has low levels of beneficial bacteria in her gastrointestinal tract. The microbiome is all about checks and balances, so when good bacteria goes down, bad bacteria goes up. This overgrowth of “bad” bacteria eventually impairs her ability to absorb nutrients.

Decreased transport

John has been working an office job for 10 years. He sits at his computer during the work day, and does not get up much except to use the restroom. He also does not exercise regularly. Little movement decreases his circulation, which lowers the amount of oxygen rich blood to his intestines. Adequate circulation is needed in order power digestion and accept absorbable nutrients.

Decreased gastric acid

Sally is a stay at home mom of two young kids. She is constantly moving around the house, whether she is playing with her kids or preventing them from getting into trouble. She often stands up when she eats, and doesn’t take the time to sit down and enjoy her meal. This “on-the-go” eating impairs the brain from sensing that food is coming, and gastric acid output is decreased.

What problems can result from malabsorption?

~Poor fat absorption: diarrhea

~Poor protein absorption: edema, muscle atrophy, amenorrhea

~Poor carbohydrate absorption: abdominal bloating, gas, diarrhea

~Poor B12 absorption: anemia, poor cognition, nerve damage and pain

~Poor folic acid absorption: anemia, cognitive decline

~Poor absorption of other b vitamins: skin, nail and hair ailments, cognitive decline

~Poor calcium and vitamin D absorption: fractures, bone mineral loss

~Poor vitamin A absorption: skin problems, nigh blindness, reduced immune function

~Poor vitamin K absorption: abnormal bleeding and bruising

How To Promote Optimal Digestion And Absorption

As you can see, there is more to “you are what you eat”. Lets lay the groundwork for preventing and reversing maldigestion and malabsorption. Working on lifestyle modifications is crucial, and here is where “replace” comes into play.


Ensure that you are getting at least 7.5-8 hours of sleep per night. Promote quality of sleep by removing hinderances. This may look like replacing use of cell phones/social media and TV prior to bed with reading or stretching.


Replace processed foods with high quality, whole, unadulterated foods.


Too little AND too much exercise can be harmful. Depending on your situation, you may need to incorporate more or less movement into your daily routine. The general recommendation is to get 30 minutes of moderate intensity exercise 5 days per week, but this really varies depending on each person’s needs. Everyone can benefit from increasing the number of steps you take each day.


This is a must. You can eat the most healthful diet, but if you are stressed, you will still have impaired digestion and absorption. Whatever your stressors are, face them head-on. Find ways to mitigate your stress, whether that looks like journaling, praying, or meditating.

Support your salivary amylase production and action.

Instead of eating standing up, sit down and eat.Instead of watching TV while you eat, focus on what you are eating instead. Instead of eating fast—Take. Your. Time. Chewing your food is so important. Use lemon to stimulate saliva- whether that may be in a little bit of water or with your meal.

Support stomach acid.

~Try swedish bitters.

~Eat umeboshi plums.

~Use a little vinegar.Increase vagal tone by decreasing stress.

~Instead of drinking ice water during meal times, try drinking room temperature water or warm tea. Cold drinks may suppress acid production.

~Add fermented veggies into the diet.

~Increase zinc intake through foods such as yogurt, cheese, kefir, beans, brown rice, potatoes, shellfish, beef.

Support pancreatic enzymes.

~Bromelain from pineapple.

~Other foods that support natural digestive enzymes include: avocado, banana, kiwi, mango.

~Add ginger to your meal, eat it alone, or drink in tea.

~Add cinnamon to meals (great in chili!), or drink in tea.

Support bile salts.

~Dandelion root tea.




~Fenugreek, which can be found in many teas.

~Certain oils such as olive oil and coconut oils.

~Lemon/Lime juice.

~Grapefruit juice.

~Aloe Vera.

~Foods that thin bile to improve its excretion: beets, artichokes, carrots, apples. Ensure that you are eating enough vitamin C. Vitamin C is needed for enzymatic conversion of cholesterol into bile salts.

If you are still experiencing trouble with your digestion, consider seeing a functional medicine practitioner for more advanced testing! See you next week when we cover repopulating the microbiome.

***This post is for educational purposes only, and is not intended to be used a medical advice. Always speak with your own provider before implementing anything suggested in the post.***


Bischoff SC, Barbara G, Buurman W, et al. Intestinal permeability – a new target for disease prevention and therapy. BMC Gastroenterology. 2014;14:189. doi:10.1186/s12876-014-0189-7.

Bures J, Cyrany J, Kohoutova D, et al. Small intestinal bacterial overgrowth syndrome. World J Gastroenterol. 2010;16(24):2978-2990.

Pezzilli R, Andriulli A, Bassi C, et al. Exocrine pancreatic insufficiency in adults: a shared position statement of the Italian Association for the Study of the Pancreas. World J Gastroenterol. 2013;19(44):7930-7946.

Revaiah PC, Kochhar R, Rana SV, et al. Risk of small intestinal bacterial overgrowth in patients receiving proton pump inhibitors versus proton pump inhibitors plus prokinetics. JGH Open. 2018;2(2):47-53.

Stress: Vanuytsel T, van Wanrooy S, Vanheel H, et al. Psychological stress and corticotropin releasing hormone increase intestinal permeability in humans by a mast cell dependent mechanism. Gut. 2014 Aug; 63(8):12939. doi: 10.1136/gutjnl 2013305690.


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