Exocrine pancreatic insufficiency (EPI) occurs when the pancreas does not make enough of the enzymes that the body uses to digest food. People with diabetes have an increased risk of developing EPI, but the condition is treatable.

EPI is a condition in which the pancreas fails to produce enough of the pancreatic enzymes necessary to digest food and absorb nutrients.

This can lead to deficiencies in important vitamins and minerals, as well as uncomfortable gastrointestinal symptoms.

People with diabetes have a higher risk of EPI, and people with EPI may also have a higher risk of diabetes.

Learn more about the prevalence, symptoms, and treatment of EPI, as well as its link with diabetes.

EPI is a condition in which the pancreas does not produce enough of the enzymes that the body needs to digest food. People may also refer to it as pancreatic exocrine insufficiency (PEI) or exocrine pancreatic dysfunction (EPD).

The body needs various digestive enzymes, including amylase, proteases, and lipase, to help digest carbohydrates, proteins, and fats.

If the pancreas does not produce enough of these enzymes, the body cannot break food down properly and absorb it into the body. This can cause:

  • fatty stool
  • diarrhea
  • abdominal pain
  • gas and bloating
  • unexplained weight loss
  • nutritional deficiencies

Chronic pancreatitis, or inflammation of the pancreas, is a leading cause of EPI.

Diabetes is a disease that involves high levels of blood glucose, or sugar. Glucose is the body’s main source of energy, and it comes from the foods in the diet.

The pancreas makes a hormone called insulin that helps move glucose from the bloodstream into cells, where it provides energy.

In people with type 1 diabetes, the pancreas does not make insulin. In those with type 2 diabetes, the pancreas either does not make enough insulin or the body cannot use insulin properly.

If there is not enough insulin to move glucose into cells, glucose instead stays in the blood. Over time, too much glucose in the blood can lead to health problems, such as:

  • heart disease
  • kidney disease
  • nerve damage
  • eye and vision problems
  • foot problems

Experts do not fully understand the connection between EPI and diabetes, but a number of factors may play a role. These include:

  • Lack of trophic action of insulin: When insulin does not function properly, this can result in a smaller pancreas size. When this occurs in people with diabetes, it is associated with EPI.
  • Inflammation: Diabetes can increase inflammation in the pancreas, damaging pancreatic tissue.
  • Fibrosis: Research shows that 59.4% of people with type 1 and type 2 diabetes may have fibrosis, or scarring, in the exocrine part of the pancreas.
  • Steatosis: Diabetes is associated with fat deposition in the pancreas. The role this plays in EPI remains unclear.

Pancreatitis seems to be a common link between diabetes and EPI. People with diabetes have an increased risk of pancreatitis, which can cause EPI. On the other hand, damage to the pancreas from pancreatitis may cause diabetes in people with EPI.

Research shows an overlap in dysfunction of both the endocrine and exocrine parts of the pancreas following pancreatitis. Endocrine glands are those that secrete substances directly into the blood, whereas exocrine glands have ducts that transport their secretions.

The prevalence of EPI in the general public is not known. However, experts believe that people with diabetes have an increased risk of developing EPI.

Nearly every person living with pancreatogenic diabetes also has EPI. Pancreatogenic diabetes, also known as type 3c diabetes, occurs when the pancreas stops producing enough insulin due to conditions or factors affecting the exocrine pancreas. These include:

  • chronic pancreatitis
  • pancreatic cancer
  • surgery on the pancreas
  • removal of the pancreas

Studies investigating the prevalence of EPI among those with type 1 and type 2 diabetes have produced mixed results.

In previous years, doctors diagnosed EPI through a direct pancreatic function test. This test suggested that about 50% of people with diabetes also had EPI.

However, the development of newer, noninvasive tests has led to different results.

In a 2016 meta-analysis of 17 studies, researchers found that 38.6% of people with type 1 diabetes and 28.1% of people with type 2 diabetes also had EPI.

A 2019 study reported that 13% of people with diabetes also had EPI. The same study found that the prevalence of EPI was higher among those with type 1 diabetes than among those with type 2 diabetes. The duration of diabetes also appeared to be a risk factor.

The treatment for EPI primarily involves dietary interventions, pancreatic enzyme replacement therapies (PERT), and supplements.

Dietary interventions

A 2020 study noted that there is currently no specific dietary recommendation based on interventional studies for those living with both diabetes and EPI.

Generally, doctors advise people with EPI against a diet that is very high in fiber.

Eating several smaller meals throughout the day rather than fewer big meals may make it easier for the body to absorb the necessary nutrients from food.

Foods that are too high in fat may make symptoms such as fatty stools worse, but people should not avoid fats entirely.

Sources of healthy fats include:

  • olives and olive oil
  • fatty fish
  • nuts
  • seeds

It is important that people with EPI, especially those who also have diabetes, work with a doctor or dietitian to establish the best dietary approach to manage the condition.

Pancreatic enzyme replacement therapy

PERT is the main treatment option for EPI. People with EPI take PERT medications orally with each meal and snack.

These supplements replace the enzymes that the body lacks. They help the body break down food and absorb the necessary nutrients.

The dosage of PERT supplements varies among individuals and meals.

A meal that is large or high in fat may require a person with EPI to take more enzyme supplements than a meal that is small or low in fat.


In people with EPI, the body does not always absorb the nutrients that it needs to function well. In some cases, a doctor may prescribe vitamins or mineral supplements.

These may include:

  • vitamin A
  • vitamin D
  • vitamin E
  • vitamin K

The treatment options for diabetes depend on whether a person has type 1 or type 2 diabetes.

Type 1 diabetes

People with type 1 diabetes will need to take insulin to replace the insulin their pancreas does not make.

They may use a needle and syringe or an insulin pen to administer insulin. Some people may use an insulin pump, which is a wearable device that delivers insulin through a needle that sits under the skin.

There are several types of insulin that differ by how quickly they start to work and how long they last:

  • Rapid-acting insulin starts to work within 15 minutes and lasts 2–4 hours.
  • Short-acting insulin starts to work within 30 minutes and lasts 3–6 hours.
  • Intermediate-acting insulin starts to work within 2–4 hours and lasts 12–18 hours.
  • Long-acting insulin starts to work within several hours and lasts 24 hours or longer.

Type 2 diabetes

Some people with type 2 diabetes may be able to manage the condition with lifestyle changes, such as eating well-balanced meals and exercising regularly.

However, others may also need to take medications. There are different classes of type 2 diabetes medications, which work in different ways to lower blood sugar:

  • Alpha-glucosidase inhibitors block the breakdown of starches.
  • Biguanides decrease the amount of glucose made by the liver.
  • DPP-4 inhibitors slow the breakdown of a compound in the body that lowers blood sugar.
  • Meglitinides and sulfonylureas stimulate beta cells in the pancreas to produce insulin.
  • SGLT2 inhibitors promote the excretion of glucose in the urine.
  • Thiazolidinediones help insulin work better.

People may need to take a combination of medications. Some people with type 2 diabetes may also need to take insulin.

People living with diabetes have an increased risk of developing EPI. Research suggests that the prevalence of EPI is slightly higher among those with type 1 diabetes than among those with type 2 diabetes. Nearly all people with type 3c diabetes also have EPI.

The symptoms of EPI in people with diabetes are often mild to moderate. Currently, there is no specific dietary recommendation for those living with diabetes and EPI. The treatment options for EPI include dietary interventions and PERT. The treatments for diabetes include lifestyle changes, medications, and insulin.