Diabetes and Pancreatic Insufficiency: An Often Neglected Connection

April 17, 2017 | Dr. Linda J. Dobberstein, DC, Board Certified in Clinical Nutrition

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 Diabetes and Pancreatic Insufficiency: An Often Neglected Connection
Millions of Americans have diabetes and if you are one of them, you know that your pancreas is stressed. Often the concern is about blood sugar management and preventing long-term damage. There is another condition that affects the pancreas called exocrine pancreatic insufficiency or EPI. Experts believe this is an overlooked concern and is interlinked with diabetes.

The Pancreas


The pancreas has a dual function in the body as an endocrine and exocrine organ essential for digestion, absorption, and use of nutrients with blood sugar and insulin. Pancreatic endocrine function is related with insulin. Pancreatic exocrine function relates to the production of pancreatic enzymes amylase, protease, and lipase that help with digestion. The pancreas secretes these enzymes through a small duct into the small intestine to digest carbohydrates, proteins, and fats once food has left the stomach.

The body produces large amounts of these enzymes when the pancreas is healthy. When the production of enzymes is lost, it is called exocrine pancreatic insufficiency or EPI. Western medicine has traditionally focused on the separate endocrine and exocrine function. For patients with diabetes, one sees an endocrinologist. For someone with fat malabsorption and digestive symptoms, patients will see a gastroenterologist. However, the link between insufficient pancreatic enzymes and pancreatic blood sugar dysregulation and diabetes has often been overlooked.

Researchers have been exploring the inter-related loss of pancreatic exocrine function and diabetes and have realized that there is much more of an inter-relationship than previously thought. In fact, studies demonstrate that loss of exocrine pancreatic insufficiency affects over 75 percent of type 1 diabetics and nearly 50 percent of type 2 diabetics. Many type 1 and type 2 diabetic patients are simply unaware of this concern. Individuals with EPI are diagnosed instead with irritable bowel syndrome, inflammatory bowel disease, or Crohn’s disease.

This dual relationship with EPI and diabetes cause and effect is recognized in type 3C diabetes which is a lesser known form of diabetes. Type 3C diabetes occurs as a result of pancreatitis, which impairs pancreatic enzyme production first. Inflammation scars the pancreas and damages insulin producing cells.

What is EPI?


Exocrine pancreatic insufficiency or EPI causes trouble with how you digest food. In EPI, the pancreas fails to produce enough enzymes or the duct that the enzymes travel through to the small intestine is blocked. Enzymes produced by the pancreas are amylase, protease, and lipase which break down carbs, proteins, and fats. Pancreatic insufficiency or EPI diagnosis usually occurs when 90 percent of the pancreas is non-functioning. Diagnosis is commonly made with a stool test that measures a specific pancreatic enzyme called fecal elastase-1. Optimal levels of fecal elastase-1 are between 200-500 mcg/g. Mild-moderate EPI levels is 100-200 mcg/g; severe EPI is below 100 mcg/g.

Symptoms are similar to many other gastrointestinal disorders and include nausea, gas, bloating, and diarrhea, an oily appearance to the stool, anemia, fatigue, and SIBO. As pancreatic reserves are exhausted, concerns with weight loss, malnutrition, bone loss, blood clotting disorders, night blindness, neurological dysfunction, vitamin deficiency, and other signs of malabsorption occur.

Additional Causes of EPI


Acute or chronic pancreatic inflammation leads to pancreatic insufficiency and is considered the most common cause of EPI. Acute pancreatitis is often related to excessive alcohol consumption, high triglycerides, and medications like steroids, antibiotics, and blood pressure meds. Chronic pancreatitis is related to chronic alcohol intake, hereditary, or blocks in the duct where enzymes are released from the pancreas into the small intestine. Smoking, abdominal surgery, cystic fibrosis, gallbladder problems, pancreatic cancer, celiac disease/gluten intolerance, Crohn’s disease, and lupus can lead to pancreatic insufficiency. Research does not say that if EPI always causes diabetes in these other disorders, but one can see multi-directional effects in diabetes and EPI linked with celiac disease, and pancreatic cancer.

The understanding with this pancreatic dual relationship is to not ignore one or the other but rather to take steps to protect the pancreas. A recent review study found that pancreatic insufficiency occurred in 40 percent of individuals newly diagnosed with prediabetes or diabetes after an acute episode of pancreatitis. If you have diabetes and symptoms of gas, bloating, diarrhea, etc, it may be more than a little minor indigestion. It may reflect the need for pancreatic enzyme support. On the other hand, if you have a history of pancreatitis or pancreatic insufficiency, it is important to be evaluated for type 1, 2, or 3C diabetes. Basic lab tests may include pancreatic fecal elastase-1, fasting blood sugar, fasting insulin, and hemoglobin A1C.

EPI Support


In pancreatic insufficiency, the medical treatment is replacement pancreatic enzymes usually from pork. One of the most popular prescriptions drugs for EPI is Creon. Creon contains sodium lauryl sulfate and polyethylene glycol which raises the concern for cancer risks. It is an expensive drug often with other side effects. Keep in mind that treatment for EPI is usually long term or life long. Plant-based enzymes offer natural options without the risk. We use uncut plant based enzymes that survive stomach acid and function in a wide pH range.

Pancreatic Endocrine Support


Protection of the pancreas from oxidative stress is a primary focus. This is done through diet and nutrients. High dietary intake of fructose puts significant strain on the pancreas as it damages pancreas insulin producing cells and other tissues throughout the body. Besides high fructose corn syrup that should be avoided, other natural forms of fructose may need to be limited. Many of these foods are rich in antioxidants and provide nourishment, but the key is moderation. Fructose rich foods may include fruit and fruit juices, dried fruits, honey, maple syrup and sweet wines and fructan-rich foods like wheat products. To reduce the amount of stress induced by fructose, consume them with meals or reduce intake. The proteins, fats, and fibers and other forms of glucose buffer the stress effect on the pancreas from fructose.

Other pancreatic dietary support includes removing processed foods and other irritants like alcohol and smoking. Replace them with whole foods especially vegetables which are rich in enzymes. Remember to chew your food until it is liquid in your mouth. Lack of adequate chewing requires tremendous output of stomach acid and pancreatic enzymes to make up for the lack of mechanical breakdown of food. Follow the Five Rules of the Leptin Diet to help your body produce and use insulin in a natural ebb and flow circadian rhythm.

If you have blood sugar and digestive trouble, your pancreas is in trouble. It is likely that pancreatic enzyme support is needed in addition to healthy blood sugar management. While western medicine likes to compartmentalize functions and organs into nice neat categories, the reality is that the whole pancreas is affected and creates a ripple effect. EPI affects the whole body with the consequences of malabsorption, malnourishment and disrupted gut health. Diabetes affects the whole body too. This dual-purpose organ gets a workout with every bite of food, blood sugar management and the fitness level of digestion. Is your pancreas trying to tell you something?

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