Select Page

EPI Diets are Tricky

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 3 to 4 times a day, …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. Depending on what type of enzymes you are using, be sure to follow the right protocol in preparing the enzymes (in the Enzyme section). After the EPI comes under control, usually the feedings can be reduced back to twice a day to accommodate the pet-owner/caregiver’s life style/schedule.

The type of food an EPI dog responds best to depends on the individual EPI dog. Some respond best to raw food diets, However, many EPI dogs do well on commercial food, especially if the kibble or canned food is low fiber (dog food companies have coined some of these foods as “grain free”. Grain free is a misnomer. You have to be careful and read the ingredients;  check  ingredients, portion of ingredients and nutritional analysis. Often the “type” and “portion” of fiber the manufacturer is including in the food is important in how well your dog will tolerate the food.  On the flip side, there are a handful of dogs that do just fine on the food they always were on now that enzymes are included.  Most however do respond best to low fiber, and sometimes there are cases where an EPi dog does not do well until a small  amount of certain types of fibers  (like rice) is added to the meal. This can get very confusing, please read the FIBER section to better understand types of fiber and what may or may not work. Also, please know that fiber is in varying degrees in grains, vegetables and fruit. This is why it is important to understand the different types of fiber as it will explain why certain foods agree with your dog while others don’t. 

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 (but not always) 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 (labeled “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..

.                                                          

 How to prepare a meal with enzymes

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 and let the food and enzymes incubate for about 20 minutes……or if you are using enteric coated capsules enzymes, serve immediately. If you are using tablets, you will need to crush them into a powder and use as a powder. When you add water or any liquid to the kibble (needed to moisten dry food when you add the enzymes) be careful of the water/liquid temperature – – warm water/liquid anywhere between 86-130 degrees F temperature is a good range, but temperatures any higher than 130 degrees will destroy the enzymes.

The reason why we use the term “room-temperature” water… it 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. In a few cases, giving the enteric coated enzyme capsule about 5 minutes after a also works, but the other methods are usually the preferred methods. 

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, if using on dry food be sure to include a liquid (such as water or a broth) to moisten the food with the enzymes, 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 or incubate in 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), mouth sores tend not to happen. You can also add a little more liquid to the meal http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1461413 to help avoid mouth sores, or to alleviate future mouth sores. Just do not let the food swim in liquid, most dogs do not like this- -just add enough liquid to moisten the food. Another reason for “incubating” is because some dogs simply just do better when the meal is incubated.  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, just not swimming in liquid.

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 using the correct enzymes — each EPI dog needs to be managed with what ultimately works best for them as individuals. This includes enzymes, diet, B12, antibiotics, food and supplement regimens.

Incubation
Many EPI owners observed that when enzymes are mixed into the food and allowed to “incubate” stool elimination was less voluminous, which led pet owners to assume that the enzymes were breaking down the food 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. 

An old 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.

As science develops more innovative tools, hopefully further research and more in-depth research will be done on enzymes and digestion so that we will have a better, more conclusive understanding of what is going on.

So does one incubate or not???? You, the EPI owner ultimately needs to determine which method works best for your individual dog…..

Grinding Food
Regarding grinding the food or softening the food is sometimes also said not be necessary, (for example, when feeding hard kibble) by grinding the food you do allow more surface area of the food to be covered (touched) by the enzymes. Again, although not a requirement, 
it has been noted that this technique has benefited “problematic” EPI dogs 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.

Whether your dog does better with incubated food or food that is ground up or food that is served immediately… 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.
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 has now been over 10 years since my dog was first diagnosed with EPI. She achieved stabilization 3 months after diagnosis. I continue to let the enzymes “incubate” for 20+ minutes with room temperature food … 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%….”

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.

11.saksson GLundquist IIhse IEffect of dietary fiber on pancreatic enzyme activity in vitroGastroenterology 198282918?24.

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.9That 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 JEIglesias-García JVilariño-Insua MIglesias-Rey M13C-mixed triglyceride breath test to assess oral enzyme substitution therapy in patients with chronic pancreatitisClin. Gastroenterol. Hepatol. 20075484?8

  1. Holtmann G,Nelly DGSternby BDiMagno EPSurvival of human pancreatic enzymes during small bowel transit: effects of nutrients, bile acids and enzymesAm. J. Physiol. 1997273G553?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, like some canine diabetes cases, 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

 2012 Aug;27(3):133-9. doi: 10.1053/j.tcam.2012.04.006. Epub 2012 Jun 23.

Chronic pancreatitis in dogs

Watson P1.

New Paradigms in Dietary Management of GI Diseases – V.C. Biourge, C. Kirk / 2006 North American Veterinary Conference Research Center, Royal Canin, Aimargues, France., College of Veterinary Medicine, University of Tennessee, Knoxville, TN, USA.

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

Exocrine Pancreatic Insufficiency

Edward J. Hall, MA, VetMB, PhD, DECVIM-CA, MRCVS
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 guidelines, keep a Journal, assess results and modify accordingly…..

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 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 with 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. Raw pancreas availability 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….and you need to be aware of the fact that the potency of the pancreatic enzymes from one animal’s pancreas will vary from one animal to the next. 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, and if that would 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 Parmesan 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:
(USA)  http://www.greencuisine4pets.com/ (or)  http://www.greentripe.com/
(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.

Suggested Food Source portions

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 (but not all) EPI dogs do very well on raw. 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/handling….some vets or owners feel it further compromises an already compromised dog. This is not necessarily true. Some pet owners opt to 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.

In an EPI diet, a 50 to 75% ratio of meats/fish usually works very well. 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, etc. 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.
In an EPI diet, a 10 to 15% ratio of organ meats usually works well. 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.

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) 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 tolerable ratio will vary from dog to dog.

In an EPI diet, a 0 to 30% ratio of vegetables (carb content) usually works well.  (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.

Bones

If you are preparing your own meals for your dog, calcium needs to be included. Whether by bones, ground bones, bone meal or crushed egg shells.  But for the EPI dog, some are not to be able to handle the commonly recommended 20 to 25% bone matter in a diet. So, t begin with, cut this percentage in half and see how well it is tolerated.

In an EPI diet, start with 10 to 15% of bone content, but over time, if tolerable with your dog, try increasing bone content up to 20%.  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 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.

B12

If you dog does not start to gain weight … please have the cobalamin (B12) 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, and because doing both at the same time will give you a better picture of your dog’s overall health, or lack there of when dealing with EPI. Over 80% of all EPI dogs will need life-long B12 supplementation. Because a lot of these dogs do not manufacture  B12 they often need B12 shots or high doses of oral B12 for a regular period of time until their B12 levels are brought up to an upper mid-range level and then going forward they will to be on a B12 maintenance protocol.

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 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 usually 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

50 pounds (23 kg), 2 ¼ tablespoons

Always check with your vet before making any changes in your dog’s diet.

Always work up to a final dose over a period of a week or two….but 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 to zinc, vitamin E also appears to be deficient due to the lack of absorption so many owners administer vitamin E – -but this is a fat soluble vitamin and builds up in the body….so do not just give what you think is the right dose, but rather, WITH VITAMIN E CHECK WITH YOUR VET FOR THE PROPER DOSE AND FREQUENCY.

Slippery Elm
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 SID 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 quicker. It also has prebiotic propertiesand aids in treating SID and has the extra benefit of being loaded with beneficial vitamins and minerals. Some folks use an on-going maintenance dose of slippery elm, either for stomach aid issues or re-occurring SID.However, the 2017 suggested slippery elm dosage is as follows used for a short period ( 1 to 3 weeks) or intermittently for healing.

Give provided Slippery Elm powder with breakfast and dinner meals. 1/8 tsp for dogs under 10lbs, ¼ tsp for dogs 10lbs to 30lbs, ½ tsp for dogs 30lbs to 80lbs, 3/4 tsp for dogs 80lbs to 100lbs, and 1 tsp for dog 100/+lbs. Mix in meal, add 1 to 2 tablespoons of water, mix and serve meal as you normally would. Incubating not necessary.

PLEASE read the 2013 published research Slippery Elm re-printed along with other Slippery Elm data on the Slippery Elm page.  

There are no ill side effects of slippery elm except if the dog has an allergy to the American Elm tree. The only warning is not to give Slippery Elm at the same time as some antibiotics because the mucus properties of slippery elm will lessen the effectiveness of the antibiotic to a small degree. Give a few hours away, or if a very minute ineffectiveness is not critical, do not worry about giving together.  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

http://www.fetchdog.com/learn-connect/dog-resource-library/nutrition-supplements/Glutamine-for-Dogs-With-Digestive-Problems/D/300600/P/1:5:55:602/I/AR000010475

 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 (B12) and SID are under good management… 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% .

Journal

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!