EPI * Exocrine Pancreatic Insufficiency
managing EPI
Feeding Tips (updated 7/30/09)
Feeding less food but more often helps...
If possible with the family "schedule", when first diagnosed with EPI, it seems to help if the EPI dog can be fed 2-3 times a day. Depending on the breed and size of dog, feed (for 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”.
Many dogs respond best to raw food diets. However, many EPI dogs also do well on dry kibble, especially if the kibble is grain free or grain-free canned food. There are only a handful of cases of EPI dogs doing well on dog food with grain products in it since fiber is most difficult for an EPI dog to digest. The only food with grain that is tolerable for an EPI dog is 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 only mix 20% meat to 1 cup of dry food. Meat, fruits, vegetables, dry kibble (carb) are all digested at different rates, so to not over-tax the system too much, feed only one kind of food at a time or only mix 20% of a different kind with it (for example 80% dry food, 20% meat or visa versa). 
If you are using the powdered enzymes, it needs to be room temperature. Make sure the food is room temperature too. Cold makes the enzymes inactive and heat destroys it.
Before you read further, please always remember that not all EPI dogs respond exactly the same. There are many variables. Some variables you may be aware of, others you may not. Beyond proper enzyme treatment -- each EPI dog needs to be managed with what ultimately works best for them as individuals. This includes diet, B12, supplements, etc., regimens.
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 catalysts that 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.
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 does one incubate or not???? The EPI owner ultimately needs to determine which method works best for their individual dog.....
Although grinding the food or softening the food is said to not be necessary, (for example, when feeding hard kibble) by allowing more surface area of the food for the enzymes to cover, it has been noted that this technique has benefited many 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.
~Thoroughly mixing the enzymes in the food is imperative!
~Incubating the enzymes on the food is not absolutely necessary for every single EPI dogs - -however- - it has been the turning point for some problematic EPI dogs and it does help alleviate mouth sores if the dog is prone to this.
~Softened (or ground up) food, although, again, not required, it does allow for the enzymes to work more effectively once everything is ingested. Some dogs just do not do well if the enzymes are not allowed to be absorbed into the soft food (20 minutes) before being fed. Others do just fine. If the food is mixed with warm water and kept at a warm temperature, as mentioned before, some enzyme activity might begin, but not complete activation. One should be very careful when using warm water...since too warm/hot conditions will destroy the enzymes. Warm water anywhere between 86-130 degrees F temperature is a good range, but temperatures any higher than 130 will destroy the enzymes. Some vets do recommend using warm water to mix the enzymes, which is appropriate, but again, just be careful not to make the water too warm.
My personal opinion is to just say use "room-temperature" water... which avoids any mis-communication of too warm or too cold. Allow the food to soften, mixing often, then feed. Once ingested the enzymes complete the activation process and "do their job". Ultimately it is up to the individual owner to decide what works best for their dog. In the end, it is all about good poops .... this is how we determine if we are managing EPI correctly for our 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. When all these things started taking effect, my dog finally started doing much better.... but it did not happen overnight. For us results took two weeks. For others it takes only a few days, and for yet others it may take months. Don't panic!!! Things should work out once you find the right combination for your dog. It will be 3 years Dec 2009 since my dog was first diagnosed with EPI. She has been stable since March 2007. 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
University of Bristol, Dept. Clinical Veterinary Science
Langford, Bristol, England
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.
Dry or Canned Commercial Food
Try to avoid commerical food with 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.
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 maintain 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:
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
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 determine when it no longer needs 150% of required food, by not wanting to eat it all... and then you can not feed as many times a day and/or reduce the amount of food being fed. 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
- Acidophilus- Acidophilus is the most effective pro-biotic strain, defending against the greatest number of pathogens; inhibiting 11 disease-causing bacteria. Called the "sticker strain," Acidophilus has the ability to actually cling to the intestinal wall without harming it. In fact, it is best known for its ability to move un-disrupted through the stomach and into the intestines where it eats away at disease causing bacteria. It is known for reducing the occurrence of constipation and diarrhea, increasing nutrient uptake (especially calcium), preventing food poisoning and alleviating dermatitis and other skin and coat conditions.
- B. bifidum- is normally found in the mucus membranes lining of the large intestine and vaginal tract, where it attaches to the walls removing yeast that would further lower the pH levels and allow bacteria to grow. Supplementation has been shown to modify intestinal flora, ward off liver problems and protect against the damaging affects of radiation. It also helps control diarrhea and other intestinal disturbances.
- B. infantis- inhibits gastroenteritis and can ward off some strains of E. coli. According to the Journal of Applied Bacteriology, B. infantis is part of an important group of microorganisms, which are considered to exert a range of biological activities related to human health. This particular strain of pro-biotic has also been shown to produce compounds useful toward preventing solid tumor growth.
- B. longum- aids in the cleansing and health of the colon and liver. It has even been shown to significantly inhibit the growth of colon, liver and breast cancers in laboratory animals. It is also known for supporting breast health.
- L. casei- is reported to be one of the most potent defenders from the potentially fatal Listeria bacteria. It is also known for its ability to induce an immune response that is helpful in protecting against sexually transmitted diseases.
- L. plantarum- can be found in naturally fermented foods. In your body it is found in the large intestine where it helps to break down protein into usable nutrients, thus reducing inflammation.
- L. rhamnosus- is one of the more highly studied pro-biotic strains, primarily used in the treatment of gastrointestinal disorders. It also aids the body in resisting yeast and urinary tract infections.
- L. salivarius- has been shown through research to produce a high amount of lactic acid, which is able to inhibit the growth of H. pylori, thusly reducing the associated inflammation and risk of peptic ulcers.
- S. thermophilus- is known for repairing free radical damage from aging, stress, antibiotics, chlorinated water and other chemicals. It also contains an antioxidant that helps protect against the toxins present in the Standard Pet Diet and in treating the pain caused by arthritis.
- L. lactis- has been shown through research to produce a high amount of lactic acid, which is able to inhibit the growth of H. pylori, thusly reducing the associated inflammation and risk of peptic ulcers. Is also beneficial to supplement the diet in maintaining normal intestinal flora.
- L. helveticus- has been shown through research that strains of L. helveticus diminish tumor growth, stimulating an anti-tumor immune response.