Exocrine Pancreatic Insufficiency and Diabetes: What’s the Connection?
People with diabetes are at higher risk for exocrine pancreatic insufficiency, which affects properly digesting and absorbing nutrients from food. The good news is, the condition is treatable.
Dana Lewis never could have expected a friend’s dog would be the key clue to solving her mysterious gastrointestinal symptoms, but that’s exactly what happened.
Lewis, who has lived with type 1 diabetes for more than 20 years and celiac disease for another 16, is no stranger to managing various symptoms alongside her diet. But when she started experiencing gastrointestinal discomfort after eating a few years ago, all of her normal tactics didn’t seem to make a difference.
“With diabetes, I’m used to adjusting my diet based on how I feel,” Lewis said. “I knew it wasn’t gluten because I’m so careful to avoid it. But I still just didn’t feel well after I ate.”
She saw a gastroenterologist in January 2020, who tested her for a number of infections and parasites – all negative. She experimented with elimination diets, which also revealed nothing. It wasn’t until a friend posted on Facebook about solving her dog’s GI distress that Lewis found an answer: exocrine pancreatic insufficiency (EPI).
“The dog’s symptoms completely went away after sprinkling enzyme powder on its food,” Lewis said. “I was curious if this same problem happened to humans, so I looked it up and found that it does. I immediately got another appointment with my doctor and said ‘Let’s test for this.’”
After testing positive and receiving an EPI diagnosis, Lewis was surprised to learn that people with diabetes have an increased risk for the condition. Yet, it’s often not on a physician’s radar. Here’s what you need to know about EPI and diabetes.
What is EPI exactly?
Exocrine pancreatic insufficiency occurs when the pancreas fails to produce the right amount of digestive enzymes needed for the proper digestion and absorption of nutrients from food. Another name for EPI is pancreatic exocrine insufficiency.
Your body needs digestive enzymes produced by the pancreas, including amylase and lipase, to break down and absorb protein, fats, and carbohydrates. Without an adequate amount of enzymes made by the pancreas, your body can have trouble digesting food. This can lead to malnutrition as well as gastrointestinal symptoms including:
- Abdominal pain
- Increased gas
- Stool changes, especially fatty stools or diarrhea
- Weight loss
What causes EPI?
“Damage to the pancreas is the main cause of EPI,” said Dr. Philip Johnston, a consultant in endocrinology, diabetes, and medicine at the Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital and Belfast City Hospital in Northern Ireland.
Chronic pancreatitis, a prolonged period of inflammation of the pancreas, is the most studied cause of EPI. But many things can damage the pancreas, including destruction or removal of tissue from surgery, nerve damage, blocked ducts, autoimmune reactions, and more, Johnston said.
Researchers aren’t exactly sure why, but studies indicate a link between EPI and diabetes.
“Post-mortem examinations of the pancreas in people with diabetes show structural changes and signs of damage: fibrosis, shrinkage, fatty infiltration, evidence of chronic inflammation, and a reduction in size,” Johnston said.
“Genetic aberrations, infection, or autoimmune conditions can damage the tissues of the pancreas and thus cause insulin deficiency and a reduction in digestive enzymes, resulting in both diabetes and EPI to be present,” he explained.
The reported prevalence of people with diabetes and EPI varies widely (from 25-74%), but it appears to be more common in those with type 1 diabetes compared to type 2. A much higher percentage of EPI is estimated for people with diabetes caused by pancreatic disease or pancreatic diabetes.
“From my own practice, EPI is very common in pancreatic diabetes and also in patients with type 1 who have a longer duration of diabetes and those with poor glycemic control,” Johnston added.
Why is EPI underdiagnosed in people with diabetes?
Given the high prevalence among those with diabetes, it’s surprising that many have never heard of it and that few physicians test for it.
Lewis, who happens to be a diabetes researcher and published a paper on EPI, had to push pretty hard to get tested and start treatment.
“I’d never heard anyone in the diabetes world talk about EPI. It shocked me,” Lewis said.
The problem has multiple factors, Lewis and Johnston agreed. For starters, EPI symptoms can range from minor to severe and may be overlooked as just a part of diabetes or related to certain diabetes medications that are known to cause GI discomfort.
Lewis experienced symptoms for years before they became severe enough to see a GI specialist. Her comfort with digging into the medical literature helped her find answers and advocate for herself.
Another reason EPI is often missed is because there’s a lack of awareness about the condition among diabetes clinicians. This is due in part to a lack of sufficient screening tests.
“All we have is a single stool test. If you have diarrhea (a symptom of EPI), it can affect the sample,” Lewis said. “So the test isn’t always reliable.”
“Any form of diabetes can increase the risk for EPI, yet the diagnosis of EPI in this population continues to be under-recognized and overlooked with targeted screening tools for EPI not typically part of routine diabetes care,” Johnston said.
To improve awareness and proper diagnosis of EPI, Johnston said healthcare providers need to think about the pancreas more as a whole with two main functions: producing insulin and digestive enzymes.
What is the treatment for EPI?
The good news is there is treatment for EPI in the form of pancreatic enzymes. This oral treatment essentially replaces the missing enzymes. Dosing pancreatic enzymes can be tricky, however.
“There is limited data with regard to what dose is best,” Johnston said. “I know there are apps and calculators in development to aid in dose titration.”
He added that people with EPI taking enzymes still experiencing gastrointestinal symptoms should speak with their healthcare team about potentially increasing the dose.
Lewis has been using pancreatic enzymes for the past few years. It took some trial and error, but her symptoms have resolved.
“As someone with diabetes I’m used to adjusting my doses based on my meal,” Lewis said. “The treatment isn’t straightforward, but when you figure it out it can be life-changing.”
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