6 Nutrition & Lifestyle Tips for Exocrine Pancreatic Insufficiency

Exocrine pancreatic insufficiency (EPI) is a condition where the pancreas is not able to produce enough enzymes to properly digest food.

This can lead to problems such as malnutrition and diarrhea. The pancreas makes and releases pancreatic enzymes and bicarbonate into the small intestine for digestion and acid buffering. Pancreatic enzymes help break down the food we eat and include lipase for fats, amylase for carbohydrates, and proteases for proteins. 

Symptoms of EPI according to a 2022 StatPearls Review include:

• Fatty diarrhea (AKA steatorrhea)
• Weight loss
• Abdominal pain
• Bloating and gas 
• Malnutrition
• Essential fatty acid deficiency
• Fat soluble vitamin (A,D,E,K) deficiency 
• Osteoporosis or osteopenia due to changes in bone density 
• Risk of death from malnutrition 
• Cardiovascular complications 

EPI can be mild, moderate, or severe and it is likely underdiagnosed. I’ve personally seen patients pass between providers for years before receiving an EPI diagnosis and finally getting the help they need. 

To test for EPI, providers often use a stool test called fecal elastase-1 as initial screening rather than more specific but invasive, expensive, and methods poorly accepted by patients. However, fecal elastase-1 might miss mild or intermediate cases, and has a risk of false positives if the sample is too watery; individuals must keep open communication with their providers to tailor testing and treatment plans for their unique case.  

So what causes EPI? Most commonly, pancreatitis and cystic fibrosis. The University of Florida, Division of Gastroenterology, Hepatology, and Nutrition experts suggested an acronym in a 2018 article to remember risk factors and causes of pancreatitis or EPI “TIGAR-O”-

• Toxic: This is where metabolic or environmental toxins damage the pancreas. Alcohol, tobacco, hyperlipidemia, kidney failure, or hypercalcemia are examples. 

• Idiopathic: This could overlap with genetic deficits or arise from unknown causes. 

• Genetic: For example, genetic CFTR mutations cause EPI in about 85% of patients with cystic fibrosis. 

• Autoimmune: Autoimmune and inflammatory diseases such as Sjogren syndrome, primary biliary cirrhosis, inflammatory bowel disease, and celiac disease can cause EPI. On the other hand, some medications used to manage inflammatory diseases can lead to EPI.

• Recurrent & Severe Acute Pancreatitis: Radiation, necrotic or vascular diseases, and acute pancreatitis can lead to recurrent EPI.

• Obstructive: This happens when the path for pancreatic secretions is blocked and it leads to EPI. 

• Other known causes include infection, bariatric surgery, and diabetes. 

Practical EPI treatment should include pancreatic enzyme replacement therapy (PERT), lifestyle changes, and nutrition therapy according to a practical 2018 pancreatic insufficiency management review in BMC Medicine. 

6 Nutrition and Lifestyle Tips for Exocrine Pancreatic Insufficiency 

1. Talk about poop with your provider and RDN. Light-colored, smelly, floating, oily, and loose stools and feedback about stool changes on PERT can help providers customize your regimen. The Bristol Stool Scale makes this easier. 

2. Stay on top of prevention and care for chronic conditions. Some (but not all) of the conditions that cause EPI can be prevented with diet, lifestyle, and medical intervention. For example, early intervention to manage high blood pressure or blood sugar will help prevent kidney failure that can lead to EPI. 

3. Stop smoking. Smoking can cause EPI, cancer, and many other health problems. Anyone looking for help quitting can receive help through CDC resources at 1-800-QUIT-NOW (1-800-784-8669). 

4. Stop drinking alcohol. NIH defines one standard drink as 5 fl oz wine, 1.5 fl oz spirits, or 12 fl oz beer and any amount over <1 drink daily for women and <2 drinks daily for men is over the limit for moderation. Many wine glasses hold 8-12 fl oz, so women can easily meet the NIAAA qualifications of heavy drinking (3 daily servings) or binge drinking (4 servings in 2 hours). 

5. If your doctor prescribes PERT, work with both an RDN and your provider on optimizing your regimen. PERT dosing is based on EPI severity and dietary fat intake, and it must be taken with meals and snacks in order to work. Taking an infant dose of PERT once in the morning and once before bed will not work (and unfortunately I have seen it prescribed this way)!  

6. Don’t ignore deficiencies. Fat malabsorption can cause deficiencies in fat soluble vitamins A, D, E, and K. But don’t DIY your ADEK supplementation if you are not deficient, as these vitamins pose the highest risk for toxicity. See an RDN and your provider for a nutrition-focused physical assessment and lab work to catch and monitor vitamin deficiencies and design the right supplement regimen for you. 

1. _{Ghodeif, A. O., & Azer, S. A. (2022). Pancreatic Insufficiency. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK555926/} 
2. _{National Institutes for Health (n.d.). What is a Standard Drink? National Institute on Alcohol Abuse and Alcoholism. Retrieved December 31, 2022, from https://www.niaaa.nih.gov/alcohols-effects-health/overview-alcohol-consumption/what-standard-drink}
3. _{National Institutes for Health (n.d.). Drinking Levels Defined. National Institute on Alcohol Abuse and Alcoholism. Retrieved December 31, 2022, from https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking}
4. _{Phillips, M. E., Hopper, A. D., Leeds, J. S., Roberts, K. J., McGeeney, L., Duggan, S. N., & Kumar, R. (2021). Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines. BMJ open gastroenterology, 8(1), e000643. https://doi.org/10.1136/bmjgast-2021-000643}
5. _{Pham, A., & Forsmark, C. (2018). Chronic pancreatitis: review and update of etiology, risk factors, and management. F1000Research, 7, F1000 Faculty Rev-607. https://doi.org/10.12688/f1000research.12852.1}
6. _{Struyvenberg, M. R., Martin, C. R., & Freedman, S. D. (2017). Practical guide to exocrine pancreatic insufficiency - Breaking the myths. BMC medicine, 15(1), 29. https://doi.org/10.1186/s12916-017-0783-y}