Kaia's technique of how to effectively feed Cora, her EPI Dog .........................
In this video recorded a year ago, Kaia Carter is 1 ½ years old and Cora is 7. Kaia and her big sister Anna are big helps in getting Cora to eat – sometimes a bite at a time. The feeding routine is food, drink enzyme in milk and then peanut butter for pills and vitamins. All in all a very interactive process as the video shows!
Cora was diagnosed with EPI when she was four years old. She lost about 25 pounds over a few month period, going down to 60 pounds. Cora’s family - Kaia and her big sister Anna and their parents, brought Cora to us, the grandparents, to see if we could help – figure out why Cora was so sick and getting weaker by the day. When she arrived at our home Cora could barely stand. With the incredible care of our vet Chad Aderhold, Cora was diagnosed, and then with his help and the help of the EPI Forum Community, a lot of internet search time and a whole lot of love and patience, Cora began the very long journey to get well. Today Cora weighs in at 92 pounds and lives to love her family and protect the world from furry woodland creatures especially squirrels.
Finding the right diet for an EPI dog is usually the final piece of the puzzle to getting your EPI dog healthy..... however.... sometimes this is easier said then done! Unfortunately not all EPI dogs respond equally to the same food. What we DO know is that fiber content NEEDS to be kept at a minimum. The variance from one dog to another may be due to the fact that each dog's gut condition varies from one to another probably causing different levels of need. Just to give you an example of how confusing this can be... but that you CAN find the right food.... after some trial and error, is the following post from one of our EPI FORUM members, Alan and his EPI dog "Brandy":
Update - success!
As I said above, by dropping the enzyme to 1/2tsp I had semi-success with the stool trying to firm up. But the real answer was in fact the FOOD!
Received the Single Protein (Fish) Earthborn Coastal Catch Grain Free on 6/4/12 and within one day the poop went from semi-good to perfectly formed! So, we are back in Business!
So, the problems were.....
1. Bad TOTW started the problem.
2. Earthborn Primitive Nature (3 Protein) did not work with her.
3. Started Tylan to be sure.
4. Reduced Enzymes from 1tsp to 1/2tsp and helped a bit.
5. Got her on Earthborn Coastal Catch (single Protein - fish).
6. Finally complete success....poop back to normal, continuing to gain weight.
Next thing is to let the Tylan complete it's course and see if all remains good.
"I believe the inputs & results just confirm that all variables have to be re-considered when a problem arises."
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 temporarily. 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, usually the feedings can be reduced back 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 low fiber (dog food companies have coined some of these foods as "grain free" although you do have to be careful, read the ingredients and variation in response is often because of what "type" of fiber the manufacturer is including in the food. OR.... some dogs do just fine on the food they always were on now that enzymes are included. Most however do respond best to low fiber...but some only do well once a tiny amount of fiber is added (this is where what type of fiber comes into play). Also, please know that fiber content comes from both grains and vegetables- -so watch the fiber content!
PRETTY CONFUSING, EH?!!!!!!!!!!!!!!!
Since fiber(for and explanation why, see below) is most difficult for an EPI dog to digest we strongly recommend starting with foods that have 4% or less fiber content in them. The fiber that appears to be most tolerated by an EPI dog, is usually a highly digestible food that is low in poorly-fermentable fiber (to understand the difference in fibers (please read the section on fiber types on the fiber page) http://www.epi4dogs.com/fiberinthediet.htm. So, although not the only solution, it is usually most effective to start first with a low fiber food (coined "grain-free" by dog food companies) ... although PLEASE read the label and try to start with a food that has 4% or less fiber content in it..
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. Many folks start with cold refrigerated meat and put a little hot water in a bowl with the cold meat and mix until the meat becomes room temperature. AFTER this "sauce" is room temperature or lukewarm, THEN add the powdered enzymes or serve with enteric coated enzymes. If you are using just water with kibble be careful of the water temperature - - warm water anywhere between 86-130 degrees F temperature is a good range, but temperatures any higher than 130 degrees will destroy the enzymes.
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 meal or about 5 minutes prior to the meal. 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 level 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, or just add a little more liquid to the meal 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 mix powdered enzymes with enough moisture to thoroughly mix well in the food.
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 in the bowl...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, bile salts, 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, and gastric enzymes to one degree or another. 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 EXPLANATION OF THE DOG'S DIGESTIVE SYSTEM - -VISIT THE "ROLE OF NUTRITION" page.
A study by Dr. Guy Pidgeon http://www.vetmed.ucdavis.edu/executive/council/pidgeon.cfm 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. Incubation 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.....
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 especially when first embarking on the EPI journey, but many owners have found that shortly afterwards it does not seem to make any difference whether the food is ground or not. So, once again, how you prepare the food 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 few days for any noticeable improvement, and for yet others it may take months. Don't be discouraged!!! Things should work out once you find the right balance for your dog. It will be 6 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 10-20 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!
Why FIBER should be limited in an EPI dog's diet (EPI: Diagnosis & Treatment by J Enrique Domínguez-Muñoz, pub Feb 16, 2011) http://soportenutricional.com.ar/curso2012/IV_pos/bibliografia/mod_IV/mc_mod_IV.pdf
"Frequent meals of low volume and avoidance of food difficult to digest (i.e. legumes) are generally recommended. A fibre-rich diet appears to increase pancreatic lipase secretion, but also inhibit pancreatic lipase activity by more than 50%,11 so its use is under discussion and cannot be considered as adequate.
Medium chain triglycerides, which are directly absorbed by the intestinal mucosa, may be useful for providing extra calories in patients with weight loss, and for reducing steatorrhea in patients with a poor response to oral pancreatic enzymes. Finally, patients with pancreatic exocrine insufficiency may require supplements of fat soluble vitamins.
Why FAT should not be limited in an EPI dog's diet: (EPI: Diagnosis & Treatment by J Enrique Domínguez-Muñoz, pub Feb 16, 2011) *unless there is another health concern where fat should be restricted such as with secondary EPI that evolved from Pancreatitis*
Classically, the initial approach to patients with pancreatic exocrine insufficiency is to restrict fat intake in an attempt to reduce steatorrhea. A diet containing less than 20 g fat daily is thus generally recommended in this context. Nevertheless, restriction of fat intake is linked to insufficient intake of fat-soluble vitamins, which are already malabsorbed in patients with pancreatic exocrine insufficiency.6 In addition, studies on the metabolism of both endogenous and exogenous enzymes during small intestinal transit show that the half-life of enzyme activity is enhanced by the presence of their respective substrates.9 That means that maintenance of lipase activity during intestinal transit requires the presence of dietary triglycerides. Actually, it was demonstrated in an experimental model of pancreatic exocrine insufficiency in dogs that fat digestion and absorption was higher when enzyme supplements were taken together with a high-fat diet compared with a low-fat diet.10 As a consequence, fat restriction should no longer be considered as a rule in the management of patients with pancreatic exocrine insufficiency.
6. Domínguez-Muñoz JE, Iglesias-García J, Vilariño-Insua M, Iglesias-Rey M. 13C-mixed triglyceride breath test to assess oral enzyme substitution therapy in patients with chronic pancreatitis. Clin. Gastroenterol. Hepatol. 2007; 5: 484?8.
When FAT should be restricted in an EPI dog
Whenever an EPI dog either developed EPI as a secondary condition from chronic pancreatitis, OR.... if there is yet another health concern that requires fat restriction, then be very careful with how much fat there is in the diet.
A reference to a review for dogs which discusses fat is here: https://www.ncbi.nlm.nih.gov/pubmed/23148854
Top Companion Anim Med. 2012 Aug;27(3):133-9. doi: 10.1053/j.tcam.2012.04.006. Epub 2012 Jun 23.
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 . 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 . Bacteria also deconjugate bile acids further impairing fat digestion and absorption .
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 . 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 . 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 and 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 (unless your dog has another health concern that requires limited fat intake), 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.... slowly try different foods/brands, etc. if it works for your dog, great!
If something works, GREAT! If something does not work, that is fine also.... just 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)It is so hard for EPI owners to watch their dogs struggle. My hope is that by having the most recent research/advice coupled with an accumulation of EPI hands-on-experience with enzyme/diet management that it will help give new EPI owners enough of an overview of all "possibilities" allowing them to make the best decision for their individual dog.
Another suggested 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... and whether it will agree with your dog or not. 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. The stinky (but very healthy) Green-tripe may be purchased dog food specialty stores or it may be ordered from:
(UNITED KINGDOM) http://www.butcherspetcare.com/butchers/tripe/
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.
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 commercially 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.
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) and thoroughly cooked. Veggies such as the "root" vegetables, like sweet potatoes (better than white potatoes), turnips, beets or carrots are "usually" well tolerated. 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). Also, please understand that vegetables also have fiber content, so be careful not to use too many vegetables.
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.
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 too much fiber content/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 cobalamin 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 and this will save you money by doing the tests together. Because a lot of these dogs no longer manufacture B12? they might need B12 shots or high doses of oral B12 for a regular period of time until stable and then going forward they will just need to be maintained.
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 may not 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.
* EFAs (essential fatty acids) are suggested at 180 mg per 10 lbs per day *
Always start off with less than the recommended dose
Medium Chain Fats
Administer quality (cold pressed and unrefined, or virgin) 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.
*The suggested dosing is 1-2 ml/kg per day. A teaspoon is 5 ml and 15 ml is a tablespoon. (U.S. measurements.)*
Here are some examples at the 1.5ml/kg per day rate:
20 pounds (9 kg), 1 tablespoon
25-30 pounds (11-14 kg), 1 ¼ tablespoons
40 pounds (18 kg), 1 ¾ tablespoons
Always work up to a final dose over a period of 10-14 days and if the oil is disagreeing with your dog STOP!
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. ALWAYS GIVE ZINC UNDER THE GUIDANCE OF A VET!!! In addition vitamin E, also is deficient due to the lack of absorption so many owners administer vitamin E also AGAIN, WITH VITAMIN E CHECK WITH YOUR VET FOR THE PROPER DOSE AND FREQUENCY. 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. (here is another good site that talks about Slippery Elm dosage http://www.holvet.net/slippery_soup.html
PLEASE read the 2013 published vet reserach on Slippery Elm re-printed below in it's entirety on this page.
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). 50% claim that it does help the dog while the other 50% claim that there is no change. But it is well worth trying. It is also common 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 control ... 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 one of the ways that they let you know their body no longer requires being fed 150% .
Keep a journal!!! Record every change every addition/deletion whether it is food, new food, the amount of a protein, omega 3, vitamins, per/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!
and the Merck Manual on Canine Nutrition:
Some EPI dogs turn their heads away from their food http://www.dogaware.com/Graphics/BulldogIgnoringBones.jpg" /> when treated with powdered enzymes for EPI.
Diane (EnzymeDiane) http://www.enzymediane.com/ wrote the follownig post where she lists some great ideas to try in this situation... and i am greatfully placing her post in our FILES for future reference. Thank you Diane!!!
Some EPI dogs just think we are trying to kill them when we put those precious enzymes on their food. Sometimes we find one thing that works for a bit then have to try something else. Here are a few suggestions that I have learned over the past 5 years of dealing with EPI-Thankfully I have not had to use any of them as Sarge will eat the enzymes straight if I let him (Okay he did get a bag of them once)
There are many other tricks out there. Hang in there I know it is no fun.
FYI: Green-tripe may be purchased at Dog Food SPecialty stores or.... these on-line suppliers:
The following are some examples of EPI owners and the raw and/or prepared meals... the food type percentage, ingredients used, etc. (taken from epi4dogs FORUM thread:
1. Hi everyone, i have intended to start this thread weeks ago, but am just now getting around to doing it!!!!.... anyway.... what i am looking is for folks to share the ingredients of what is in the home-made-meals that they prepare for their EPI companion (if not using kibble or other commercial food) list it here and once we have a lot of suggestions, i will copy and paste them in a special section in the "Dog Food Options" tab.
For all those that will be reading these raw or home-made recipes... please know that no matter how good a diet "sounds" if you are going to prepare the meal yourself from scratch.... and serve it long-term....it needs to have the proper/sufficient amount of vitamins, minerals and bone. Please share with your vet or a vet nutritionist the composition of whatever you decide to feed your dog.
My Izzy has EPI, she is 8 years old and weighs 45-48 lbs.
In the past, we were lucky, she was able to eat low fiber (grain-free foods) commercial kibble, sometimes i'd give raw, and sometimes i'd make home-made and sometimes i'd mix it all up... and she always did fine.... however recently, she developed Diabetes (we are still not sure if this is real diabetes or transient diabetes).... so.... to find our footing with the diabetes part and to still manage her EPI.... this is what i have been feeding her.
The Stew: I make a chicken stew in the crock pot... i buy raw chicken thighs, peel / cut off the fat, fill 1/2 the crock pot with the raw chicken thighs, throw in about 1/2-1 cup of whatever "organ" meats i have, peel and chop up 3 medium size sweet potatoes, then i add as much raw kale as will fit in the crock pot and pour in 1.5-2 cups of water with 1 finely chopped clove of garlic.
The Carb/Fiber: i bake 1 raw sweet potato in the microwave every couple of days, peel it..
The Home-Prepared Chicken Stew Diet for Izzy that she (for now) gets twice a day:
so far, this is working very well for us. Soon i will be trying other things. I hope this give an example to others what/how they might post their raw / home-prepared meals.
~Olesia (epi4dogs founder) & Izzy
Alan's variation on the above "stew":
I am sure that raw means cooked but I spoke to Olessia and she said my receipe would be valuable.
I put raw beef,green beans, frozen not canned,peas frozen not canned fresh if possible. fresh carrots not frozen or canned, sweet potatoe and whit potatoe and meat. If I use beef I put it into the pot with the veggies uncooked. If I use chicken,turkey or pork I cook the meat seperatly but I save the juice and add it to the veggies. My wife has shown me a better way for the potatoes cook them in the microwave then add them after everything is cooked. This way I do not need to add anything to thicken the soup, what a great idea she had. I also add apples or other fruits to the soups. I never use any spices at all I don't think they need them. Pork, chicken and turkey will cook faster than the veggies and burn the bottom of the pot. I also add celery to the mix for fiber. Now for Thor the one that has early stage epi he also gets raw beef at night, raw liver and I am looking into kidney and other organ meats I can feed him raw if possible. Thor also gets liquid glucosimine as well as B12 W/intrinsic factor, vit. ester C. He is my service dog and my baby.
Not to blow my own horn but I have been told by many people including my vet that I have very healthy dogs. I wish all of you success in you feeding routine for your dogs and cats. Thor is almost 8 now and is going to have a full blood panel done next week and I will keep everyone up to date on his health.
2. Connie wrote: I always worry if I am giving her enough food if I do this. When Zoe was first diagnosed I cooked for her but I was worried she didnt get enough nutrition.
Response from epi4dogs:
Hi Connie..... well... i finally have some answers... Karen (Hondo's mom) helped me with this over the weekend (thanks Karen!)...
HOW MUCH FOOD TO FEED ?
Dogs that are fed raw should get 1% to 3% of their weight. With EPI dogs, start with 4% of their weight. For example,if your EPI dogs weighs 78lbs.... then in the beginning of treating EPI start with a calculation of:
If you find that your best friend is starting to get more than a little pleasantly plump... try backing down on the amount to something like 3% of their weight:
SUGGESTED FOOD-TYPE RATIO'S for an EPI dog:
THis is a suggested RAW Food chart for dog diets that Patsy found on the web. We are posting this chart because it closely reiterates what we suggest in Raw feeding but it also lists nutritional attributes.
(permission to post this chart by "Designed by Boo") To order this "Raw Feeding Chart" or other products, please feel free to go to Boo's FaceBook page: https://www.facebook.com/Designed-by-Boo-614835398596387/?hc_location=ufi
***Always keep detailed notes when preparing your own dog food- -as what works for one dog may not work for another...and you may need to adjust the diet's ratio until you find the right balance for your individual dog...if possible, work with a nutritionist.... and you can ALWAYS tell what is or is not working by (1) weight gain/loss (2) quality of poo***
Epi4Dogs Home-prepared meal ratio's
5-10% organ meat (liver, kidney, lungs, pancreas,gizzards, heart) Some consider heart a muscle meat other consider it as one of the top organ meats to serve.Kidney has the most packed nutrition)
10-20% bone. Normal dogs should have approx 25% bone matter..many EPI dogs have issues with too much bone, so start with half the amount (or use Bone Meal) and work your way up to see exactly how much bone your dog can or cannot handle.
0-30% vegetables All veggies need to be cooked and mashed. Green veggies, work best, or small amounts of sweet potato may be used. Which veggies and how much all depends on your individual dog.
The remainder % should be all Protein (meat/fish) skinned, defatted and must be "ground".
Vitamins & Minerals Be sure to add a good source multivitamin with minerals or ask a vet nutritionist which supplements should be added to the diet to make sure it is balanced.
Oils With EPI dogs, we find that adding daily (unless another concurrent condition prohibits fats/oils)... either or / or alternate EFA (fish oils) and/or cold-pressed coconut oil as this greatly helps dogs with poor skin and coat. The recommended dasages are: EFA's suggested at 180mg per 10 lbs per day, or on alternate days give ½ to 1 teaspoon of cold pressed (virgin) coconut oil.
http://vet.osu.edu/vmc/home-made-diets is one source for a vet nutritional consultation with regards to preparing a home-prepared diet for your pup.
4. This is a really good breakdown of raw feeding and right on the button... the percentages are spot on.
I haven't fed homecooked so I will leave that to others but the raw info is good and an excellent place to start and tweak to suit the individual dog.
5. One of our members shared an actual home-prepared diet put forth by a Veterinary Nutritionist at Georgia Veterinary Specialists.... this is an AWESOME example of an diet plan for an individual dog based on age, weight, medical needs and activity level for this dog which may differ from your dog from your dog's needs that we will share here. It is a great example of what you need to think of when deciding to prepare your own food. Please feel free to contact the Georgia Veterinary Specialists http://www.gvsvet.com/ to prepare a diet specifically tailored for your individual dog .
I will include the PDF of this diet here http://www.epi4dogs.com/PDF%20Files/Isabella's_diet_PDF.pdf
6. Joyce (who's "Isabelle" will be starting the above diet: Isabella will start this diet this week. I had to wait for the "Balance IT" to arrive. I will keep you posted. If she responds well to it, I plan on scaling up and making a month supply at a time and freezing it in portion sized packages.
7. Hi Joyce.... thanks SO much for sharing this diet with us... i will be very interested in hearing how Isabella responds...i personally tried using Quinoa with my Izzy a few years ago... it did not work for us- -but we have great luck with sweet potato--and i can use some of the peas but with my Izzy she has to have less peas then what they recommend- -too much and she develops SIBO...... and i also know of someone else here who tried Quinoa in their home-made diet and the dog either kept getting SIBO or the poos were never really good... until they removed the quinoa... and yet... i have heard of other folks with EPI dogs who have used noodles, buckwheat groats, quinoa in their home-made diets and it worked just fine for their EPI dog...so..........keep really good detailed notes on this... it will be interesting to see how well Isabella's EPI condition responds to this orif she has issues with certain ingredients and if so, which ones.
I am so thankful to you for sharing this with us....i even learned some interesting information about canola oil....very interesting!
The Balance It is a fantastic product... i have used that before and once i am done with the VetriScience i have on hand now.....i will alternate and use the Balance It again.
We tried feeding Quinoa at first but she wasn't able to digest it properly no matter how long I cooked it. I can tell you though that any grain we cook for our dogs needs to be cooked longer than we would cook it for us. So I have doubts that cooking it according to package directions will work in the first place.
I switched Nikki over to Sweet Potato and the improvement in her poops was instant. The SP does provide a lot of fiber but we haven't had any issues with it so far but every dog is different. Good luck with switching her over, Nikki loves mealtime...LOL!!!
9. thanks Michaela for mentioning that.... when i tried the buckwheat groats... i cooked cooked and actually rinsed it twice too..... but Izzy still did not do so good on it......
Because i am now juggling EPI + borderline Diabetes.. i have discovered that with the EPI and her blood glucose levels... the best "filler" for Izzy is Best: cottage cheese Second best: sweet potato
10. From Karen, owned by Hondo: Hondo is doing well on the quinoa as well as I know another EPI dog doing well on it, too.
11. Thanks Karen.... it's is good to hear of who or how many EPI dogs do well on a certain ingredients or not.....and.... it also shows once again how not all EPI dogs respond the same to the same food!
I think one of the requirements of EPI is to keep the owner on it's toes at all times!!!!!!!!
12. From Joyce: I spent a half a day trying to "decode" the recipe (which is really very poorly written) – and preparing her a home cooked meal. Note I am a very experienced cook and a restaurant owner so this should have been a snap! My kitchen looks like a scene from the Invasion of the body snatchers. I used my gram scale and although they say that scaling up the recipe by 5 results in a 2 and 1/2 day supply I came up short by the half day. I couldn’t find liquid fish oil so I had to puncture those lovely gel caps... Did you know they squirt all over the place? Very discouraged.
Because I travel a lot I need to be able to prepare at least a month of food at a time. That’s 112.5 pounds of protein !!! Never mind all the veggies and sweet potatoes...
Thinking it is time to go back to the EPI4dogs food page and explore a high quality commercial diet.
As an added note, Isabella weighed 63.7 pounds on 4/30 and today she weighed in at 61.5. Feeling a little discouraged. Just a day in the life of a mother with an EPI dog!
13. OMG Joyce... i am dying laughing... i know EXACTLY what you mean about those damn fish oil capsules squirting all over the place.
A few years ago i bought a $300 grinder to grind my own meat for Izzy along with all kinds of veggies... i screwed up the %s of carb vs protein (i had WAY to many carbs) that poor Izzy developed SIBO... talking about having to give your dog antibiotics from your home cooking !!!:D
Any way... i finally got a handle on things this time around trying to control Izzy's EPI + Diabetes... i use almost 90% meat 10% carbs (and often i am now finding cottage cheese works best for us with just a little sweet potato).. and just give them quality all around dog vitamins with minerals and add bone meal. Izzy lost weight too on the first home-made diet.... but with this new diet that i am doing... she is holding steady...and her diabetes is pretty much controlled..... so i am very pleased! Oh... by the way... i now make my life easy and toss everything in the crock pot... makes enough food for a week.
14. From Joyce (with Isabella): Did I mention that Issa LOVES LOVES LOVES the home made food? Who wouldn't. I had leftover puréed veggies so I added some yogurt, salt & pepper and we had a great soup for dinner ourselves!
I have 2 large crock pots – all the ingredients wouldn’t fit in for 2 and half days worth. This is a dog on 2400 calories a day and still maintaining her weight is a challenge.!
I used a 20 QUART restaurant sized pot (and a boat oar to stir it LOL). I need to make large quantities at a time because of my schedule.
So in the spirit of a true EPI dog owner, I am experimenting!
I have decided to try Natural Balance Chicken and Sweet potato kibble for 1/2 her meal mixed with the home made. That way I cut down prep time by at least 1/2 as well as those ungodly amounts of protein, veggies and starch. I also bought chubs of frozen Bravo vegetable mix. No more cleaning, cutting, and chopping/grinding an assortment of veggies! And in an emergency I will stock some of the canned version of the Natural Balance.
I will keep you posted. Every day I put on my gypsy outfit with a purple turban and go out and “read” her stools. Color good – check!, smells “normal – check!,” size “normal!” – check!
Oh how I love this girl!
15. From Michaela:
Joyce...I am glad you came back to write about your experience with this recipe. I must have read it three times and was a little confused. It is a lot of work but you get into a routine after a while. I cook enough food for four days for Nikki at a time and the only thing I don't look forward to cooking is the meat. It takes me forever to peel all the fat off the pork tenderloin to the point where I sometimes end up with a blister on my finger...ouch.
Nikki gets the pork and sweet potato and that's it...no veggies...LOL!!! I bake the sweet potatoes and boil the pork. I do run the sweet potatoes through my Vitamix blender until it looks like baby food and then I add in some of her supplements and divide it up in containers for each meal. IDK why you have to measure the SP in cups, mine is in ounces which is easier to me.
The weight loss on a home prepared diet is not unusal, it happened to us too you just have to adjust her calories.
The fish oil is very tricky...LOL!!! I used to get it in my eyes, hair on my cabinets until I decided to just throw it in the bowl. I use Monica Segals by the way...very good quality. If you are not ready to throw in the towel I have a suggestion for you. I would hire Monica (I know an additional expense to adjust your recipe to make it easier for you and balanced of course. http://www.monicasegal.com/
16. From Joyce and Isabella:
Written by Dr. Jean Dodds and re-printed with permission from Dr. Dodds
The World’s Healthiest Foods 2013, What’s New and Beneficial about Sweet Potatoes?http://www.whfoods.com/genpage.php?tname=foodspice&dbid=64.
Sometimes there is a underlying food sensitivity issue in addition to EPI that hinders optimal improvement...... If you are suspect there is a food sensitivity issue, please feel free to check out Dr. Jean Dodds "Nutriscan" test
or.......one of our members tried Pet Medella. Food items that were identified as a problem happened to coincide with the pet owner, Suzy, personal observations of which food items appears to cause problems (loose stools) for little Romeo. If you are interested in checking out this other testing system.... please go here:
9/2012- from Kathy (Ted's Mom)
The original thought was all enzyme activity took place in the bowl, turns out that was an assumption, people making a connection that wasn't there. This was drilled into me when I got Ted and I mean drilled, you must incubate because all activity takes place in the bowl. This was before this forum had formed but it was also said on here in the beginning, you must incubate because the activity is all in the bowl, there was initial confusion. Now we know that is untrue. A very small amount of amylase and protease activity does take place when activated with warm water but all lipase activity takes place in the dog, none in the bowl. Since fats break down with lipase there is no need to incubate fish oil, although it doesn't hurt if you do. I think under one of the tabs Olesia does talk about this original misconception.
Kathy submitted the following rule of thumb for giving supplements.... Although some of these suggestions may be considered conservative guidelines especially we have since learned thru more recent research that some of these extra steps may not be needed.... this is still an excellent rule of thumb to go by. Thanks Kathy!
If anyone is interested in understanding the chemistry of digestion/food/viability.... please feel free to check out the chemistry chapter on foods at (you will have to copy and paste this URL into your search tool- - the file was too big for me to copy the PDF here:
Thank you Nadine
The original thought was all enzyme activity took place in the bowl, turns out that was an assumption, people making a connection that wasn't there. This was drilled into me when I got Ted and I mean drilled, you must incubate because all activity takes place in the bowl. This was before this forum had formed but it was also said on here in the beginning, you must incubate because the activity is all in the bowl, there was initial confusion. Now we know that is untrue. A very small amount of amylase and protease
Vol.3 No.3(2013), Paper ID 34284, 7 pages
Expedited Management of Canine and Feline Vomiting and Diarrhea. Observational Study in 3952 Dogs and 2248 Cats Using Sucralfate-Like Potency-Enhanced Polyanionic Phyto-Saccharide—Elm Mucilage (slippery elm)
Ricky W. McCullough
Mueller Medical International Translational Medicine Research Center, Foster, USA
Copyright © 2013 Ricky W. McCullough et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received November 30, 2012; revised January 30, 2013; accepted March 5, 2013
Keywords: Canine; Feline; Vomiting; Diarrhea; Slippery Elm; Sucralfate
A potency-enhanced polyanionic phyto-saccharide of elm mucilage (PEPPS) was prescribed by 197 small animal veterinarians in an open-labeled field trial. Clients provided informed consent to veterinarians to prescribe PEPPS to 3952 dogs and 2248 cats. A 2 day/4 dose response rate, determined by veterinarians’ consensus, provided clinical threshold for a significant clinical outcome. Data was collected through phone interviews conducted over a period of 3.5 years from June 2003 through December 2006. 82% of 1928 vomiting dogs and 77% of 1064 vomiting cats responded to PEPPS within 2 days or four doses. 93% of 2024 dogs and 79% of 1184 cats with diarrhea responded to PEPPS within 2 days or four doses. PEPPS appears useful for managing vomiting and diarrhea in dogs and cats. However, a randomized blinded placebo controlled trial is needed to quantify true clinical efficacy.
Timely management of disruptive gastrointestinal (GI) symptoms poses a challenge to both veterinary and medical physcians alike [1,2]. Restoration of normal GI function requires effective means to mitigate nausea, vomiting, diarrhea, in dogs and cats  as well as colicky pain and ulcerations in horses . Current approaches in managing nausea (usually observed as inappetence), vomiting and diarrhea in small animals involve supportive care, bowel rest, pancreatic enzyme supplementation and/or appropriate anti-microbials . Management of mucosal erosions and ulceration in small companion animals centers on control of acidity, either by neutralization with antacids, reduction with histamine-2 blockers (e.g., ranitidine, cimetidine, famotidine) or inhibition with proton pump inhibitors (e.g., omeprazole, lanzoprazole, raberazole). A simplified approach in managing disparate GI symptoms would be useful for clinical veterinary practice were it safe, efficient and minimally burdensome [3,4].
The scale of the problem is significant. According to American Medical Veterinary Association  there are 150 - 197 million annual visits to small animal veterinarians in the US. Lund et al.  reported that in the US, 8.3% of veterinarian visits are for unexplained vomiting and diarrhea in dogs and cats. This translates into 12 to 16 million dog and cat visits (Appendix A) that involve diagnostic workups and treatment plans for vomiting and diarrhea. This volume however only reflects the owners who actively utilize veterinarian services. A recent survey of dog and cat owners  revealed that 40% of owners reported pet vomiting, diarrhea, inappetence and bloating yet only 17% of dog owners and 20% of cat owners actually consult a veterinarian. The survey implies that the estimated number of annual visits represents an undersized minority of animals that are actually affected. Given such a pervasive problem, any therapeutic intervention that improves management of disruptive GI symptoms would be a positive development.
Veterinary use of phyto-mucilages, particularly slippery elm, for gastrointestinal have been suggested by some [8,9]. A potency-enhanced version of elm USP, requiring less than 10% of suggested daily doses, has been prescribed by veterinarians since 2003. Veterinarians were familiar with the 2002 original formulation of canine/feline Gastrafate® which contained 5% high potency sucralfate as the active ingredient. Following successful preliminary testing  high potency sucralfate was replaced in January 2003 with magnesium chelated elm mucilage. This report presents observational data from the use of polyanionic phyto-saccharide of elm mucilage (PEPPS) in practice-based settings of small animal veterinarians.
2.1. Potency Enhanced Polyanionic Phyto-Sac Charide
Elm mucilage USP is a polyanionic phyto-saccharide . Unlike sucralfate, PEPPS contains no aluminum or sulfate. Chiefly a high molecular weight mucilage (>200,000 Daltons), it is comprised of galactose-rhamnose disaccharides. Potency-enhanced elm phyto-saccharide is prepared by suspending elm mucilage in an anion-cation solution similar to that used to formulate high potency sucralfate (HPS) . The resultant potency-enhanced phyto-saccharide (PEPPS) is muco-specific and capable of attaining augmented surface concentration of slippery elm. With sucralfate, potency enhancement ranges from 7 - 23 fold 3 hours post-administration, having a lower fold increase on normal GI lining and higher fold increase on inflamed or injured mucosa. The exact postadministration surface concentration of PEPPS is unknown. However, with PEPPS the concentration of elm USP administered is less than 8% the slippery elm dose recommended by holistic veterinarians [8,9]. The formulation strength of Elm USP in PEPPS for small animals is 0.9%. Administration of PEPPS was in accordance to weight. On average dogs or cats weighing less than 25 lbs received daily doses upwards of 72 mg, (b) animals between 25 - 50 lbs received 85 mg and (c) over 50 lbs received 120 mg.
2.2. Dosing Administration
Participating veterinarians prescribed PEPPS in accordance to weight-dose chart in label instructions. PEPPS was given twice daily with food for the majority of the patients. In the cases where vomiting and diarrhea disrupted eating and require intravenous hydration, PEPPS was given orally without food.
3.1. Study Design—Observational Trial
This study was an open labeled non-blinded observational trial. Information was collected regarding (a) weight of the dog or cat and (b) the nature and length of their GI symptoms at time of adding PEPPS. The length of illness is not reported.
As an observational study, treatment intervention was not randomized. By design, differences in outcomes are observed without regard to similarities or dissimilarities of patient characteristics prior to treatment. In fact, in this type of study, treatment decisions were made by veterinarians prior to use of PEPPS, the selection of PEPPS being made by the veterinarian due to concern that prePEPPS treatments were ineffectual. In this trial the question addressed is not one of the efficacy of PEPPS. Instead the question addressed is one of the relative merits of PEPPS as a competing treatment or intervention. Outcome of merit is relative to the expectation of the participating veterinarians. As discussed below a clinical response of 2 days or 4 doses merited note to the veterinarians involved. This study reports the percentage of dogs and cats with vomiting and diarrhea who responded to PEPPS while on failing therapies.
3.2. Comparative Control
As an observational study, there were no control groups. To provide a comparative “control” experience, each veterinarian was asked to reflect on their respective experience and select from a choice of a clinical response times which they would deem to deviate significantly from the expectations of their clinical experience. Most of the small animal veterinarians (85%) felt that a clinical response of 2 days or 4 doses would mark a significant departure from their clinical expectations and this was based on their experience managing vomiting and diarrhea in dogs and cats. This consensus of significant departure from expected time of clinical response was used to benchmark the primary outcome and a meaningful response. In essence, expectations of past clinical experience (replete with interventions requiring more time to work) served as a “comparative control” albeit a subjective one.
All animals were privately owned and owners’ consent was obtained by veterinarians.
3.4. Veterinarians Participating in the Study
Veterinarians placing orders for commercially available PEPPS were recruited to participate in this open-labeled trial. Each had more than 5 years of professional practice. Veterinarians were recruited from June 2003 through December 2006. All veterinarians prescribing PEPPS were engaged exclusively in primary care of small companion animals. They were experienced in the standards of care in treating vomiting and diarrhea in dogs and cats. Out of 256 small animal veterinarians, 197 practicing in 48 states completed the study, the remainder lost to follow up due to their inability to complete the protocol. Veterinarians received no honorarium for their participation.
3.5. Sequential Participation
Participation in the study was sequential, determined solely by the order of spontaneous requests for product made by veterinarians responding to notification of product’s availability. The veterinarians were self-selected. Information prompting orders pertain to the usefulness of PEPPS in the management of vomiting and diarrhea in small animals.
3.6. Inclusion/Exclusion Criterion for Dogs and Cats
Dogs and cats were brought to the veterinarian by clients primarily due to vomiting and/or diarrhea. Included in the trial were dogs and cats with vomiting and/or diarrhea for more than 3 days with or without bleeding and dehydration. Animal’s symptoms were attributed to gastrointestinal infections from viral, bacterial and protozoan agents or to exposure to environmental toxins. Notable inclusions were animals described by veterinarians as having hemorrhagic gastroenteritis, parvovirus enterocolitis, gastritis, intestinal “flare-ups”, and pancreatic “flare-ups”. Cases of food intolerance were included. No cases of medication induced vomiting or diarrhea included. Excluded were animals requiring surgical intervention.
3.7. Test Population
Animals included dogs and cats of varied age, breeds and weights. The size of the test population was 3952 dogs wherein 1928 were vomiting-dominant and 2024 diarrhea-dominant. Vomiting-dominant and diarrhea-dominant was defined by the major concern of the client who initiated the visit. Also included were 2248 cats wherein 1064 were vomiting-dominant and 1184 were diarrheadominant. All patients were studied across multiple office-based practices. The population was also geographically diverse with input provided from 48 out 50 states of the US.
3.8. Conditions Managed
Inappetence, vomiting and diarrhea fail owners’ attempts to adjust the pets’ diet. Following evaluation by physical exam, lab tests and in some cases x-rays the clinical impressions of veterinarian covered a broad range of diagnoses that included hemorrhagic gastroenteritis, parvovirus enterocolitis, gastritis, reflux, suspected ulcer, intestinal “flare-ups”, pancreatic “flare-ups” and “stomach issues”. The severity of GI symptoms or the presence of other (non-surgical) disorders did not preclude patients’ involvement in the study. Cases of food intolerance were included. There were no cases of medication induced vomiting or diarrhea in this study. Both dogs and cats were brought to the veterinarian due to vomiting and/or diarrhea.
3.9. Existing Treatment Regimens in Dogs and Cats
Methods of management for small animals were diverse. Existing treatment regimens for dogs and cats prior to PEPPS varied widely and included antibiotics, anti-emetics, acid reducers, pancreatic enzyme supplementation, bismuth preparations, plain sucralfate and dietary changes. To these diverse regimens PEPPS was added. Veterinarians in the study opted to add PEPPS to existing regimens that had been deemed inadequate or insufficient by them. There was no PEPPS only test group.
3.10. Primary Outcome Measure in Dogs and Cats
There were two symptom-related primary outcome measures for this trial—the cessation of diarrhea and the cessation of vomiting. The cessation of these symptoms within 2 days or 4 doses of PEPPS represented a positive outcome. This veterinarian-defined response to therapy was accepted as a meaningful clinical response (as described in section on Study Design) for the management of vomiting and diarrhea in dogs and cats in this study. Clinical observations made by veterinarians were reported by phone for data collection.
The hypothesis is that a majority of animals with serious and disruptive GI symptoms (of non-surgical etiology) when given PEPPS will experience resolution of symptoms within a timeframe (or dose administration) significant and relevant to the collective historical experience of practicing veterinarians who routinely manage such symptoms. This was a timeframe was 2 days or 4 doses.
Results are based on a per protocol analysis of the data. Chi-square analyses were performed to compare percent response between weight subgroups in dogs and cats at confidence level of 95% and 99% for confidence intervals and alpha level of 0.05.
3.13. Conduct of Observational Field Tests
The study was conducted from June 2003 through December 2006. Clinical observations made by veterinaryans were reported by phone for data collection. Phone interviews were conducted with veterinarian staff to collect results of adding PEPPS to existing treatment regimens. Results were tabulated as either a positive or negative outcome.
4.1. Dogs with Vomiting and Diarrhea
The were dogs grouped roughly according to five weight categories—less than 6 lbs, 6 - 14 lbs, 14.1 - 29 lbs, 29.1 - 50 lbs and greater than 50 lbs. All dogs eventually responded to PEPPS with various clinical response times extending beyond 2 days. However, Table 1 show that 82% [CI 3.9 (CL 99%)] of 1,928 dogs with vomiting responded to PEPPS within 2 days or 4 doses, while 93% [CI 1.46 (CL 99%)] of 2024 dogs with diarrhea responded to PEPPS within 2 days or 4 doses. The collective percent response to PEPPS for vomiting and diarrhea in dogs was 88%. High percent response to PEPPS in 2 days or with 4 doses was similar across all weight classes of dogs regardless of symptom (Table 2). There were no weight-based differences in the percent response in dogs to PEPPS.
4.2. Cats with Vomiting and Diarrhea
Cats were grouped according to 3 weight categories— less than 6 lbs, 6 to 11 lbs, and greater than 11 lbs. All cats eventually responded to PEPPS with varying clinical response times that extended beyond 2 days. However, Table 3 shows that 77% [CI 3.3 (CL 99%)] of 1064 cats with vomiting responded to PEPPS within 2 days or 4 doses. Similarly 79% [CI 3.05 (CL 99%)] of 1184 cats with diarrhea responded to PEPPS within 2 days or 4 doses. The ability for PEPPS to stop diarrhea and vomiting in 2 days or with 4 doses in cats was the same across all weight classes. Table 4 shows that there were no weight-based differences in the percent response in cats to PEPPS.
5.1. General Impressions
There are limited outpatient options for the treatment of acute vomiting and diarrhea in companion animals. For the most part, evidence-based guidance is drawn largely from human clinical trials, experimental studies in dogs and cats [13,14] and the collective clinical experience of small animal practitioners. Often what is recommended (and practiced) is manipulation of diet alone or concur-
rently with the use of medications . Few randomized placebo controlled trials exist that offer evidence sufficient support national practice guidelines.
In this study, potency-enhanced polyanionic phytosaccharide was prescribed to 3952 dogs and 2248 cats in the private practices of 197 small animal veterinarians in the US over a 3.5 year period. The data from this study showed an association between the use of PEPPS and the resolution of vomiting and diarrhea in dogs and cats whose symptoms had failed pre-existing therapies. Causality would require a randomized, blinded, placebocontrolled trial. As in must observational trials, a standard control group was not used. Instead, the study used as its “control” the historical experience of veterinarians whose prior management of vomiting and diarrhea did not include PEPPS. Vomiting and diarrhea resolved within 2 days or 4 doses in a majority of dogs (over 80%) and cats (nearly 80%) that received PEPPS. The data supported the original hypothesis that majority of dogs and cats with serious and disruptive GI symptoms when given PEPPS will have symptom resolution within a timeframe significantly less than anticipated from the private practice experiences of the veterinarians involved. In dogs and cats with vomiting and/or diarrhea for more than 3 days with or without bleeding and dehydration the animal’s symptoms were attributable to gastrointestinal infections from viral, bacterial and protozoan agents or to environmental toxins. Notable inclusions were animals described by veterinarians as having hemorrhagic gastroenteritis, parvovirus enterocolitis, gastritis, intestinal “flare-ups”, and pancreatic “flare-ups” who were on failing treatments. The majority of these animals responded to PEPPS with the cessation of symptoms between 2 to 4 days. This study does not rule out whether on not the patients would have improved otherwise. Neither does the study exclude the possibility that patients’ improvement was from other causes, such as premature disqualification of existing treatment regimens or the combination of PEPPS with existing regimens led to improvement. It does support a plausible proof of principle. The study did demonstrate that PEPPS was associated with a 2 - 4 day cessation of vomiting and diarrhea in the majority of dogs and cats that received PEPPS twice daily by direct administration or with their food.
5.2. Disadvantages of Observational Studies
There are obvious disadvantages to an observational study of this nature. Firstly, there are no traditional control groups, the lack of which precludes objective quantification of the efficacy. What is known from this study is that a large majority of the patients got better sooner than 85% of the study’s small animal veterinarians would have thought possible based on their collective past clinical experience. The historical experience of each veterinarian and their consensus of what constitute a significant deviation from that experience are subjective. Consequently, the data offers little predictive value of efficacy. The study design, at best, provides an affirmative proof-of-concept supporting the plausible utility of PEPPS in the management of disruptive GI symptoms in dogs and cats.
A second disadvantage of this study is that the manner of recruitment gives rise to bias. Practitioners were selfselected by virtue of responding to advertisements regarding a new gastrointestinal protectant which is resold at profit if the product is prescribed to a patient. Data obtained utilizing this method of recruitment is vulnerable to a self-selection bias that is profit driven. In general, an appropriately randomized, placebo-controlled blinded investigation would best quantify the efficacy of PEPPS and thereby provide a better basis on which to predict the benefit of PEPPS in managing vomiting and diarrhea.
5.3. Strengths of This Observational Study
Despite the aforementioned drawbacks due to design, there are a number of strengths that provide a significant context for the positive results reported here, results that imply positive benefits in using PEPPS to manage unexplained diarrhea or vomiting in small animals.
The first strength of this study the is the geographic diversity of state-licensed veterinarians involved. The data reflected a nationwide experience among small animal practitioners in 48 of the 50 states. The positive findings were not a coincidence of geography but rather a reflection of generalized experience.
In addition, a study involving thousands animals across 48 contiguous states imply that response to PEPPS was not likely influenced by geographic life-styles (rural versus urban settings) of ownership, diversity of breed, client-companion animal relationships or seasonality (having been conducted over 42 months). The majority of patients demonstrated a high PEPPS response regardless of these factors.
5.4. Implications of Findings
The positive results of this study have implications regarding the physical origin of symptom-states of the GI tract. PEPPS is non-systemic agent. The entirety of its clinical effects is attributed solely to a topical action in coating the mucosal lining. Physical engagement of surface elements accessible to PEPPS as it layers along the gut lining result in a therapeutic effect. Similarly, sucralfate, another agent whose therapeutic effect is limited to engagement of the mucosal lining has been shown as well to reverse nausea, vomiting and diarrhea in small animals . Thus the positive clinical effect of PEPPS and similar surface-active agents (e.g. sucralfate) to reverse symptom-states of vomiting and diarrhea in dogs and cats, imply that those symptom-states are controlled by or to some degree, significantly influenced by physical elements associated with the mucosa onto which these agents are layered. Causal links of mucosal elements to symptom-states of the GI tract has been mentioned elsewhere, in cases involving human patients suffering from functional bowel syndromes that presenting with intestinal symptoms of nausea, vomiting, diarrhea or even constipation [17,18]. The use of surface-active agents to manage symptom-states by engagement of surface elements of the mucosal raises the question as to the nature of those elements so associated. Surely those elements should be targets for the design of other therapeutic agents.
The majority of 3952 dogs and 2248 cats with vomiting and diarrhea treated with PEPPS were observed to have unexpectedly shortened clinical course unanticipated by experienced small animal veterinarians practicing in 48 out 50 states in the US. While all patients eventually responded to PEPPS, most dogs and cats with vomiting and diarrhea responded within 2 days or 4 doses. Data from this 42-month-long observational study supports the notion that PEPPS may be useful in the practice setting to manage vomiting and diarrhea of common etiologies in small companion animals. However, blinded, randomized, placebo-controlled trials are needed to assess the true efficacy of PEPPS.
Fieldwork and data collection were funded as part of Mueller Medical International LLC research on polyanionic saccharides as in-vivo surface active agents for epithelial mediated processes in animals and humans. Thanks to Jeremiah McCullough of University of Connecticut for his assistance in the preparation of this manuscript.
Volume for office visits was calculated from data by Lund et al.  who reported that 8.3% of dog and cat visits per year for either vomiting or diarrhea. This number was multiplied by 196 million annual veterinarian visits reported in 2007 AVMA Pet ownership sourcebook, then further multiplied by 0.85 as the proportion of total small animal veterinarian visits by dogs and cats.
Marilyn brought this up a few weeks ago.... (Thank you Marilyn) ... and now i am seeing it in vet news..... so just want to remind everyone ... if you give Peanut Butter to your pup.....double check the ingredients for any xylitol.
Dangerous Peanut Butter Ingredient Puts Dogs at Risk
by VETDEPOT on JULY 3, 2015
We all know how much dogs love the taste of peanut butter, which is why many pet parents use it as a tasty treat or even to hide their dog’s medication in. What many pet owners don’t know is that some peanut butters contain a dangerous ingredient, xylitol, which can have serious health consequences for dogs.
Xylitol is sugar substitute used in many human foods like sugar-free candy, gum, and peanut butter. While not used in all nut butter brands, it’s important for owners to check the ingredients list before spooning some out for their canine companion. Symptoms of xylitol toxicity in dogs include disorientation, weakness, and seizures. If you suspect your dog has ingested a food containing xylitol, immediately seek veterinary care. Ingestion of as little as .1 gram of xylitol per kilogram of body weight can be deadly for dogs.- See more at:
Webs MD had a great explanation on the difference of soluble vs. insoluble fiber that we have to be cognizant when dealing with EPI patients whether canine or feline. So although this is based on human physiology, i am posting here so that EPI owners can read and have a good understanding of the difference between the two classifications of fiber.
This is the website link that this information was taken from:
Web MD Feature
Reviewed By Brunilda Nazario, MD
Confused about fiber? You’re not alone. Dietary fiber is a misunderstood nutrient. Many people know it is important, but not much more than that. This article fills you in on the two main types of fiber – soluble and insoluble -- where to find them, and the health benefits they provide.
Dietary fibers are found naturally in the plants that we eat. They are parts of plant that do not break down in our stomachs, and instead pass through our system undigested. All dietary fibers are either soluble or insoluble. Both types of fiber are equally important for health, digestion, and preventing conditions such as heart disease, diabetes, obesity, diverticulitis, and constipation.
Soluble fiber dissolves in water. Insoluble fiber does not. To some degree these differences determine how each fiber functions in the body and benefits your health.
Soluble fibers attract water and form a gel, which slows down digestion. Soluble fiber delays the emptying of your stomach and makes you feel full, which helps control weight. Slower stomach emptying may also affect blood sugar levels and have a beneficial effect on insulin sensitivity, which may help control diabetes. Soluble fibers can also help lower LDL (“bad”) blood cholesterol by interfering with the absorption of dietary cholesterol.
Insoluble fibers are considered gut-healthy fiber because they have a laxative effect and add bulk to the diet, helping prevent constipation. These fibers do not dissolve in water, so they pass through the gastrointestinal tract relatively intact, and speed up the passage of food and waste through your gut. Insoluble fibers are mainly found in whole grains and vegetables.
Veterinary Medical Center
601 Vernon L. Tharp Street
Columbus, OH 43210
Hospital for Companion Animals: (614) 292-3551
Hospital for Farm Animals: (614) 292-6661
Galbreath Equine Center: (614) 292-6661
Veterinary Medical Center at Dublin
5020 Bradenton Avenue
Dublin, OH 43017
The following tables contain some nutrient parameters of the veterinary foods available in our hospital. The diets are classified as veterinary foods because they are to be used only under veterinary supervision. Commercially available foods also may be appropriate for some of the conditions listed (as described where appropriate in the tables). The tables are based on the most commonly recognized nutrient modifications for a particular disease. This format was chosen because veterinarians commonly make the diagnosis, decide on necessary nutrient modifications, then choose the most appropriate diet for their particular patient. Some foods are used for more conditions than are mentioned in the tables.
All tables contain a title, brief introduction if necessary, a table of indications, contraindications, major nutrient modifications, and commercial substitutions if available. The nutrient tables are ordered by dog, canned and dry followed by cat, canned and dry. Table columns include:
To estimate the % of kcal as protein, or carbohydrate, multiply the grams by 4; for fat multiply by 9.
All data was obtained from manufacturer’s advertising literature available in the Autumn of 1998.
The data in the tables can be used to compare the nutrient content of different diets and, to compare nutrient content of a diet with the nutrient needs of a patient:
To compare diets:
To compare nutrient content of a diet with the nutrient needs of a patient, use the amount per unit body weight per day - because many veterinary foods contain restricted amounts of some nutrients, one must compare the number of grams of nutrient in the amount of food consumed with the needs of the animal to ensure that deficiencies are avoided. This is of practical concern for protein and sodium. For example, the minimum protein intake to sustain protein reserves in dogs is approximately 1 gram per pound per day. If a dog with advanced renal failure consumes 20 kcal per pound body weight per day, the diet would need to contain at least 5 grams per 100 kcal to provide enough protein to meet the dog’s needs. If the dog consumed 30 kcal per pound body weight per day, only 3.3 grams protein per 100 kcal diet would be necessary.
Because diet therapy for a number of diseases consists of restriction of nutrient intake, and because many (most?) patients with nutrient-sensitive diseases are older and don’t eat much, the risk of nutrient deficiencies must be considered. This is particularly true when the therapy is anticipated to continue for months or years. For these reasons, estimates of daily minimum intakes of some essential nutrients (amount per pound body weight) for adult, average-sized pets are presented below:
|Protein||1 gm||2 gm|
Veterinary foods often are sold as containing "high" or "low" levels of some nutrients. Currently, no generally accepted definition of these terms exists. My own definitions, many extrapolated from humans, follow:
Definition of "high" and "low" nutrient densities
|Low calorie||< 3 kcal/gm dry matter||< 3 kcal/gm dry matter|
|High calorie||>4.5 kcal/gm dry matter||>4.5 kcal/gm dry matter|
|Low protein||<5 gm/100 kcal||<7 gm/100 kcal|
|High protein||>8 gm/100 kcal||>10 gm/100 kcal|
|Low fat||<2 gm/100 kcal||<2 gm/100 kcal|
|High fat||>5 gm/100 kcal||>5 gm/100 kcal|
|Low fiber||<0.25 gm/100 kcal||<0.25 gm/100 kcal|
|High fiber||>1.5 gm/100 kcal||>1.5 gm/100 kcal|
|Low sodium||<100 mg/100 kcal||<100 mg/100 kcal|
General feeding suggestions: Remember, It is always better for a patient to eat some of the "wrong" diet than none of the "right" diet!