Feeding less food but more often helps...
If possible with your human family "schedule", when first diagnosed with EPI, it seems to help if the EPI dog can be fed 2-3 times a day, sometimes 4. Depending on the breed and size of dog, feed (an example) 1 cup of food each time…with 1 tsp of powdered enzyme, or equal amount of enzyme potency in another form. After the EPI comes under control, many times the feedings can be reduced to twice a day to accommodate the human’s “life-stye”.
What an EPI dog responds best to depends on the Individual EPI dog. Some respond best to raw food diets. However, many EPI dogs do just well on dry kibble, especially if the kibble or canned food is grain free, or very low grain. Most respond well to no grain, but there are a handful of EPI cases of EPI dogs only doing well once a tiny amount of fiber is added. BUT.....since fiber is most difficult for an EPI dog to digest we strongly recommend starting with no grain foods. When food with grain is tolerated by an EPI dog, it is most often a highly digestible food (usually prescription) that is low in poorly-fermentable fiber. So, although not the only solution, it is easiest to feed a grain-free diet.
If you chose to mix dry dog food (grain-free kibble) and real meat… for example try mixing only 20% meat to 1 cup of dry food. For some dogs, this works better... for other dogs it doesn't seem to matter what the ratio is. Although some suggest that meat, fruits, vegetables, dry kibble (carb) are all digested at different rates, others suggest that this is not true. Since not all EPI dogs respond exactly the same as one another to various diets, we like to err on the side of caution. So our recommendation is to not over-tax the system too much, especially during the beginning stages of treating an EPI dog, when feeding a mixture types of of food and to start with a ratio of 20 to 80% mix. Example: 80% dry kibble food, 20% fresh meat.
When using replacement enzymes, the enzymes need to be "room temperature". Make sure the food is room temperature too. Cold makes the enzymes inactive and heat destroys it.
My personal opinion is to just say use "room-temperature" water... which avoids any mis-communication of too warm or too cold.
If you are using enteric coated capsule enzymes the recommended preparation is to give the capsule whole with the food. Some do open the capsule and sprinkle on top of the food but DO NOT mix these tiny pellets in the food and DO NOT let the food incubate with the enteric capsule.
If you are using the powdered form of enzymes, the rule of thumb is to start off with 1 tsp of powdered enzymes to approx 1 cup of “room temperature” food, mix and let sit for a minimum of 20 minutes or more. Many vets and publications state that it is not necessary to let the enzymes sit on the food, but unfortunately, some dogs develop mouth sores or mouth bleeds from the enzymes unless the food is allowed to sit and soften giving the enzymes more food volume to cover - -consequently diluting the caustic properties of the enzymes eliminating mouth sores. Usually mouth sores can be corrected by reducing the amount of enzymes given, but it has also been noted that when mixed very well and allowed to "incubate" (sit and soften) , the mouth sores also go away http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1461413 . Another reason for "incubating" is because some dogs just do not do well until the owners prepare their meal this way (discussed further down). No matter how you decide to prepare the food, it is imperative to thoroughly mix powdered enzymes in the food.
Incubation
Many EPI owners observed that when enzymes are mixed into the food and allowed to "incubate" stool elimination was less voluminous, which led pet owners to assume that the enzymes were breaking down the food if allowed to incubate. In reality, enzymes outside the body cannot sufficiently break down the food (as previously thought by many) without being ingested- -too many other "things" need to interact with the replacement enzymes during the digestion process in order to fully break down the food. Bio-chemicals, sustained gut temperature, proper PH & micellar lipids (both of which are much lower than normal in the EPI dog than a normal dog), and additional enzymatic catalysts are also needed to aid in the breakdown. Although digestion of most nutrients in the small intestine is extensively carried out by enzymes secreted by the pancreas which are lacking in the EPI dog, there are also enzymes located at the brush border membrane of the enterocytes which are responsible for the completion of this nutrient process. In addition, there are complex pathways utilized in breakdown and absorption. Enzyme activation is very complicated, dependent on a multitude of biological and chemical interactions. Even today much still remains to be learned about enzyme activity. FOR AN IN-DEPTH EXPLANANTION OF THE DOG'S DIGESTIVE SYSTEM - -VISIT THE "ENZYMES & DIGESTIVE" TAB IN THIS WEBSITE and read the digestion section.
A study by Dr. Guy Pidgeon http://www.wvc.org/content/?c=95&id=37&dc=n designed to determine if pancreatic replacement enzymes needed to be incubated on food prior ingesting. There was no difference in either the "incubated food" and the "non-incubated food" fat content output in the dog's stool elimination. Conclusion from this particular study was that incubation is not necessary.
So according to research, it is not absolutely necessary to incubate the enzymes (powdered enzymes) on the food, HOWEVER many EPI owners claim differently. Iincubation has been the turning point for some "problematic" EPI dogs and it does help alleviate mouth sores if the dog is prone to this.
So does one incubate or not???? You, the EPI owner ultimately needs to determine which method works best for your individual dog.....
Grinding Food
Regarding grinding the food or softening the food is sometimes also said not be necessary, (for example, when feeding hard kibble) by grinding the food you do allow more surface area of the food to be covered (touched) by the enzymes. Again, although not a requirement, it has been noted that this technique has benefited "problematic" EPI dogs. There is even some thought (no solid research yet to support this) that grinding or softening the food may also contribute to keeping the amount of undigested food to a minimum further reducing the problem of introducing more bad bacteria to an already compromised system. Again, this will depend on the individual EPI dog. Use the technique that works best for your dog.
Personally, when I first started enzyme treatment for my EPI dog, I did not see results for two weeks until after (1) I served everything room temperature (2) l mixed the enzymes well in the food and let sit for 20 minutes (3) I added 20% raw food to the serving (4) my dog was on antibiotics already for two weeks to combat SIBO. It took two weeks before all these things to took effect and my dog started showing improvement.... For others, sometimes it only takes a ifew days for any noticeable improvement, and for yet others it may take months. Don't panic!!! Things should work out once you find the right balance for your dog. It will be 4 years since my dog was first diagnosed with EPI.She achieved stabilization 3 months after diagnosis. I no longer let the enzymes "incubate" for 20+ minutes BUT I do mix the enzymes in the room temperature food very well, off-and-on for 5 minutes... this has worked well for my dog. Everyone needs to make their own decision on how to feed their dog....do what works for you and your dog!
The following is from the: New Paradigms in Dietary Management of GI Diseases - V.C. Biourge, C. Kirk – 2006 North American Veterinary Conference
FAT: Traditionally, diets low in fat have been recommended for patients with GI disease [1]. The postulate behind this recommendation is that lipid digestion and absorption is a complex process easily disturbed in pathological condition. Moreover, bacteria in the intestinal tract can metabolize undigested fat to hydroxy-fatty acids which leads to secretory diarrhea in the large intestine [1]. Bacteria also deconjugate bile acids further impairing fat digestion and absorption [1].
Several field observations and studies disagree with the postulate that pets with GI disease do not tolerate high level of fat (>40 % of their calories from fat) in their diet. Firstly the GI tract of dogs and cats is very well suited for the digestion of fat, and fat in those species is the most digestible nutrient (>90 % digestibility). Secondly, since the mid-1980s, veterinarians and owners have observed that the quality of the feces of GI-sensitive pets was dramatically improved on so-called "premium" rather than "super-premium" diets. A specificity of those diets is their high fat content (> 17 % fat on a dry matter basis). In a canine model of pancreatic insufficiency, dogs better tolerated a diet with 20% than 8% fat [16]. The authors concluded that a better conservation of pancreatic enzymes during gastric transit could explain this observation. Forty-nine dogs with a confirmed diagnosis of chronic intestinal disease (exocrine pancreatic insufficiency, inflammatory bowel disease, bacterial overgrowth, acute or chronic gastritis) were fed a diet containing a high concentration of fat (> 20 % on a dry matter basis) [12,13,15,17]. The benefits of the high fat diet were readily apparent with improvements in appetite, weight gain, and resolution of clinical signs of vomiting and diarrhea noted at 15 and 30 days following institution of dietary therapy.
High fat diet are energy dense and thus might be of interest in many patients with GI diseases, especially in chronic disease and exocrine pancreatic insufficiency when patients have a hard time to maintain their body condition. Not all pets with GI diseases will benefit from a high fat, highly digestible diet. Those diets are contraindicated in pancreatitis or a history of pancreatitis, lymphangiectasia, exudative enteropathy as well as in cases of steatorhea [1]. To maximize tolerance, a transition of 3 to 5 days is recommended when changing from a low to a high fat diet.
The following EPI paper is by Edward J. Hall presented in 2003 to the World Small Animal Veterinary Association. For complete article, please go to the following link: http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2003&PID=6553&O=Generic
Pathophysiology of malabsorption - The lack of pancreatic amylase, lipase and proteases results in maldigestion and hence malabsorption. The effect on fat digestion is the most profound as the majority of lipase is derived from the pancreas whereas there are brush border peptidases and saccharidases. The faeces are often voluminous and putty-like as the osmotic effect of undigested food is not high. The occurrence of watery diarrhoea suggests secondary bacterial overgrowth. A lack of enzymes and enriched environment allow bacterial proliferation, resulting in bile salt deconjugation and fatty acid hydroxylation, both causing colonic secretion. In addition, there may be concurrent inflammatory bowel disease. The mainstay of treatment of EPI is replacement of pancreatic enzymes by oral enzyme extracts. Fresh (frozen) pancreas is an excellent source of enzymes but there is often limited availability. Approximately 100-150 g of fresh bovine or porcine pancreas is fed per meal. Of the commercial enzyme preparations available, uncoated powders have been shown to work best. Enteric-coated preparations may not dissolve because the duodenal pH is not sufficiently alkaline to dissolve the coating. However, the uncoated powders are unpleasant to handle, and may cause dermatitis of the lips as well as give the patient an unpleasant odour. The powder should be mixed with food, but pre-incubation before feeding is unnecessary. Diet - A highly digestible food that is high in non-complex carbohydrate and protein is ideal. Historically, a fat restricted diet has been recommended. However, studies have shown that this is of no benefit, and indeed may prevent the patient gaining weight. For there is experimental evidence to show that the percentage fat absorption increases the higher the percentage of fat that is fed. Therefore, current recommendations are merely to give a good quality food. Frequent small meals are also often recommended. However, as enzyme must be given with each, it becomes counter-productive to feed more than three meals per day. In order to gain weight the patient should be fed up to 150% of the maintenance requirements of its ideal body weight in three divided meals. The third meal is dropped when the target weight is reached. Enzymes - Most commonly, the owner tries to save money by giving inadequate amounts of enzyme. It should be explained that this is a false economy, especially in the early stages of treatment, but that ultimately the dosage may be reduced with continuing clinical efficacy. Secondary bacterial overgrowth must also be addressed. Finally, concurrent inflammatory bowel disease may prevent treatment success, but as immunosuppression more commonly causes the signs of EPI to worsen, it is prudent to obtain histological proof before commencing glucocorticoids.
My biggest piece of advice for new EPI owners when first embarking on this EPI journey is to start with the basic rules of treatment (Enzymes & Diet & Keep a Journal) find what produces normal looking poops for YOUR dog by trial and error with one change at a time. Once the dog is stable on enzymes do not forever restrict your dog by these rules, slowly try increasing a little more fat in the diet, slowly try not having to soften the food so much for such a long time, slowly try to reduce the amount of enzymes you give your dog once he/she is stable.... if it works for your dog, great! If it does not work, that is fine also.... go back to what does work for your dog. Once an EPI dog is stable, the goal is to (1) reduce the amount of enzymes given to the smallest dose possible without causing a flare-up (2) feed as much of a normal balanced diet without causing a flare-up. (I personally was able to reduce 1 tsp of enzymes to 1/2 tsp of enzymes once my dog became stable) An excellent treatment for EPI is raw bovine or porcine pancreas, however this is another perfect world scenario. It all depends on where you live ... whether or not raw pancreas is obtainable due to local agricultural laws. Sometimes raw pancreas can be purchased from a slaughterhouse. If you have trouble doing this, ask your state meat inspectors that if you get a letter from your vet explaining why you need the raw pancreas, would that help allow you to purchase the fresh pancreas. The suggested raw pancreas formula is 3 to 4 ounces of raw pancreas for a 44 lb dog. It can be frozen (up to 3 months), but must be thawed to room temperature. Let thaw naturally. Never heat, cook or microwave pancreatic enzymes whether fresh or manufactured. If the dog refuses to eat the food because of the added enzymes, there are many “tricks” to camouflage the smell via green tripe, sprinkled parmesean cheese on the food, cover with a few tablespoons of BBQ sauce/tomato sauce, or add pureed chicken/beef liver, etc.
Powdered enzymes may be kept in tightly sealed double plastic bags and then in a sealed contained in the refrigerator to lengthen the longevity of the stored enzyme, however, it is very important to be kept dry since moisture ruins the enzymes.
WHAT TO FEED YOUR EPI DOG
Dry or Canned Commercial Food
Try to avoid commercial food with lots of grains in it…
If using dry kibble or canned food, use products made with potato, or better yet sweet potato/yams or some are even made with the plant, tapioca, to “hold it” together.
Canned pumpkin is usually good to add to the food for EPI dogs. The rule of thumb when starting out was that the fat % content should not be more than 12% (some dogs can tolerate more fat, even up in the 20+%). New evidence debunks the 12% fat restriction theory ... BUT it does not mean that all EPI dogs can now digest fat...... Without enzymes, the EPI dog cannot tolerate fat. This is what the Lipase enzyme digests. Once an EPI dog is receiving the proper amount of enzyme replacement with it's meal, it should be able to digest fat in a normal diet. HOWEVER, if the dog is still having trouble digesing the fat after it is stable and on enzymes... there most likely is an additional gastrointestinal situation going on and the fat intake should be limited!
Automatically withholding fat because the dog has EPI, or withholding fat from any dog for that matter, without necessity may be detrimental to the dog's overall well-being, from skin condition to properly maintaining body and brain functions. This is why one should, after a time on the pancreatic replacements enzymes, try to determine what your dog's fat tolerance is - - how much fat your EPI dog can actually handle.
I known this can all be confusing for the newly diagnosed EPI dog owner but a lot of good EPI management comes about via trial and error with each individual EPI dog. The body is such a cohesive machine, that once one aspect is not working properly (such as a lack of nutrient absorption) that it can trigger a multitude of other dysfunctions, whether genetically or environmentally. Probably the easiest way to address the fat content is when the dog is initially diagnosed with EPI restrict the fiber to 4% AND restrict the fat content to 12% (temporarily). Once the dog is producing good poops and has been for a few weeks.... try to slowly increase the fat content in the meal. If the poops remain normal, you most likely can feed your EPI dog normal or almost normal amounts of fat as long as the dog is receiving the enzymes. If diarrhea re-occurs, reduce the fat and once stable again, supplement the diet with coconut oil and salmon oil (addressed later in this website). With an EPI dog, it is the fiber content that usually needs to be low...most often not more than 4%.....Fiber is the main problem with an EPI dog. In the end, these ratio's are just suggestions and should be adjusted to your individual dog's tolerance (determined by the firmness and color of their stool). After using this as a guideline, you will discover over time if your dog can tolerate higher or lower percentages fo fiber and/or fat.
Some grain free (or minimal grain) products available (but not lmited to) are:
Before Grain http://www.beforegrain.com
Champion Pet Foods Orijen Adult; http://www.orijen.ca/orijen/products/
Diamond Foods Taste of the Wild High Prairie, Taste of the Wild Wetlands; http://www.tasteofthewildpetfood.com/
Dick Van Patten Natural Balance L.I.D., Potato & Duck, Sweet Potato & Fish, Sweet Potato & Venison; http://www.naturalbalance.net/dogformulas/home.html
Fromm Family Foods Whitefish & Potato and Grain FreeSurf & Turf http://www.frommfamily.com/products-fs-d.php
Go Natural Grain Free http://www.petcurean.com/
Merrick Pet Care Grammy’s Pot Pie, Mediterranean Banquet, and Thanksgiving Dinner; http://www.merrickpetcare.com/store/
Natura Pet Products EVO Red Meat Small Bites, EVO Reduced Fat, and EVO 95% meat canned foods; http://www.evopet.com/
Nature’s Variety Instinct Chicken Meal and Duck Meal & Turkey Meal; http://www.naturesvariety.com/instinct_dog
Old Mother Hubbard Venison & Salmon Stew; http://www.oldmotherhubbard.com/products_cupboard.html
Solid Gold Barking at the Moon; http://www.solidgoldhealth.com/products/
Wellness Core http://www.wellnesspetfood.com/dog_wellness_grain_index.html
Wellness Super5Mix Whitefish & Sweet Potato, Wellness Canned Venison & Sweet Potato, and Cupboard Creations Chicken Pot Pie. http://www.wellnesspetfood.com/dog_wellness_grain_index.html
Some EPI Dogs do not do well on commercial grain free foods but yet have done well on certain prescription diets (need a prescription from the vet)... and then again, sometimes the reverse is true... as some EPI dogs do horribly on prescription diets (hydrolyzed) but flourish on commercial grain-free. Trying to find the right diet for an EPI dog is much trial and error. If you would like to try a prescription diet, talk to your vet and ask about either of these two:
Royal Canin Hypoallergenic HP 19 http://products.royalcanin.us/products/veterinary/canine/hypoallergenic-hp.aspx
Royal Canin Digestive LF Veterinary Diet http://products.royalcanin.us/products/veterinary/canine/digestive-low-fat-lf.aspx
Explain that it has worked for some EPI dogs, although not all EPI dogs, and ask for a prescription to try this food.
If you are interested in looking at some lists of Grain Free food... please check out the following links:
For overall information about Pet Food companies and where they get their sources, please check out:
Meat/proteins
Always introduce only 1 change/addition at a time... once that is tolerated well.... check the stools formation.....if they become loose with the new addition to the diet, reduce the amount given. If stools still do not firm-up, eliminate that particular protein from the diet.
If you can feed all raw meat (ground-up) most EPI dogs do best on that, not all, but most. Organ meats are excellent, trim "excessive" fat from all meat. Some people cannot or are uncomfortable with an all raw diet … because of the expense/availability/process/feel it further compromises an already compromised dog. Some just do a combination of dry and raw meat or simmered/cooked meat. This is an individual choice based on the dog's tolerance and the owner's preference.
Meats that can be used include: beef, chicken (remove all skin), pork (not cured pork!), venison, lamb, and fish such as salmon and jack mackeral. When giving fish from a can, be wary of the salt content. Other proteins that can be given, but not limited to are: cottage cheese, eggs, yogurt, etc. But once again, this is trial and error.
Organ meats should be given if preparing a home meal whether cooked or canned vs. a commerically prepared diet. Start with 10 to 15% ratio of organ meats. If this is too rich for your individual dog, reduce the amount. Some EPI dogs have been known to only be able to tolerate 1% of organ meats. Others tolerate 15% without a problem.
Some commercial frozen raw products (but not limited) to are:
Primal Pets http://primalpetfoods.com/canine/raw_frozen_grinds.htm
Nature's Variety http://www.naturesvariety.com/raw
Bravo http://www.bravorawdiet.com/bravoproducts.html
Vegetables
Again, always introduce only 1 change or addition to the diet at a time. When adding vegetables, the better digested are the very finely ground (or mashed) veggies such as the "root" vegetables, like sweet potatos (better than white potatos), turnips, beets or carrots. Vegetables that grow on the ground are also good like squash or pumpkin. Broccoli, green beans, etc are also good to mix in, however, as with anything else, the percentage of any vegetable that can be tolerated by an EPI dog can range anywhere between 0% to as much as 30+% of the diet. (side note: if dog is prone to crystals... do not feed broccoli)
Bones
If you are preparing your own meals for your dog, bones need to be included. But for the EPI dog they tend not to be able to handle the commonly recommended 20 to 25% bone matter in a diet. Instead, cut this percentage in half and see how well it is tolerated. Per usual, it's all about the poop! If the stools are or have a lot of white to them, it means they are getting too much bone and cannot digest it. Cut back. Some will have loose stools. Cut back. Again this is all trial and error for your individual dog. Meaty bones can also be given occasionally, as long as you trim the fat and as long as your EPI dog can tolerate it.
Treats
NO TREATS !!! or at least not until the EPI dog is stable. Some dogs, once stable, are able to tolerate some treats …for example, freeze dried liver, baked liver, hearts, but be careful of anything with grain/heavy long-chain fats in it. On the other hand, some dogs can never have any kind of treats, even real meats unless it is treated with enzymes. Some folks just resort to a special toy as a reward/treat instead. This all depends on the individual EPI dog.
If you dog does not start to gain weight …. please have the cobalamine and folate levels checked. Actually, if you can have the B12 levels checked at the same time as the cTLI test done, all the better since they are both blood tests. Because a lot of these dogs no longer manufacture B12… they might need B12 shots for a regular period of time until stable. Some report that once they are better, they will still require the B12 shots but only periodically, others state that the B12 shots, although reduced in frequency, will need to be continued. Omega 3 Wild Salmon Oil is used with great success by many EPI owners. Since some of these dogs may have other gastrointestinal issues (known or sometimes not known by owner of vet) and cannot tolerate a lot of fat, their skin and coats become dry, itchy and brittle. Administering wild salmon oil is most often well tolerated by an EPI dog and will help alleviate these issues. In addition, since wild salmon oil is an excellent source of omega 3, it also helps reduce inflammation. * Always start off with less than the recommended dose* Medium Chain Fats Administer quality (cold pressed and unrefined) coconut oil. Build up to 1 tsp a day or more depending on breed and body weight. These are medium chain triglyceride fats that most EPI dogs can handle and benefit from especially since some EPI dogs are restricted from other fats. A body void of all fats can cause a whole host of other problems and conditions. Some EPI owners alternate the oils... one day wild salmon oil, the next day coconut oil. Vitamins, Minerals and Herbs Because of the lack of absorption, it has been observed that in humans with EPI there is a zinc depletion. For this reason, many EPI owners administer zinc supplements to their dogs. In addition vitamin E, also is deficient due to the lack of absorption so many owners administer vitamin E also. One herb that is commonly used among EPI'rs is slippery elm to help aid with the tender, sore intestine when first diagnosed with EPI or when a SIBO flare-up occurs http://www.umm.edu/altmed/articles/slippery-elm-000274.htm Slippery elm coats the intestines with it's mucilage properties allowing the tender area to heal. This is used for a short period or intermittently for healing. There are no ill side effects of slippery elm except do not give slippery elm when administering an antibiotic because the mucus properties of slippery elm will lessen the effectiveness of the antibiotic. If after treatment with enzymes, antibiotics, B12, and the dog continues to have digestive issues, some EPI people add L-Glutamine supplement to the diet regimen. L-Glutamine is often prescribed by vets to aid dogs with IBD (inflammatory bowel disorder). It is possible for a dog to be battling IBD along with EPI, hence the continued intestinal issues Getting the Weight Back Many folks do not know how much to feed their dog when it has lost so much weight. Each dog is different, but as a starting point, try feeding the newly diagnosed EPI dog 150% of whatever percentage of food is normally required for that dog's size. As long as the Cobalamin & Folate levels and SIBO are under contral ... what most often happens is that the dog will let you know when it no longer needs 150% of it's required food intake. It will start to leave food in the bowl. This is how they let you know their body no longer requires being fed 150% . Journal Keep a journal!!! Record every change every addition/deletion whether it is food, new food, the amount of a protein, omega 3, vitamins, probiotics, minerals, medicine, vaccines, new situations/stress, etc. Even though EPI can be managed, many times a flare-up happens and only through record keeping can you make it easier on yourself finding the culprit/cause of the setback and get back on the road to recovery! Probiotic strains