The Connection Between EPI and Diabetes
Exocrine Pancreatic InsufficiencyHow to Manage EPI

The Connection Between EPI and Diabetes

The Connection Between EPI and Diabetes
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Updated on February 13, 2026
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Around 40.1 million Americans — or 12 percent of the population — have diagnosed or undiagnosed diabetes, according to the most recent data from the Centers for Disease Control and Prevention (CDC).

 If you’re one of them, you might also be at risk of a condition called exocrine pancreatic insufficiency (EPI), a digestive disorder in which the pancreas doesn’t produce enough enzymes for digesting food.

The Possible Connection Between Diabetes and EPI

Type 1 and type 2 diabetes commonly occur with EPI. In people with type 1 diabetes, studies have found that rates of EPI range from 10 to 30 percent. Research has shown EPI rates varying between 5 and 46 percent in those with type 2 diabetes.

While researchers aren’t entirely sure why diabetes can lead to EPI, it may result from damage to the pancreatic cells that produce digestive enzymes.

The reverse is also true: If you have EPI, you could also be at risk of diabetes. In one study involving a sample of more than 1,700 people with EPI, 813 people developed type 2 diabetes — that’s around 45.2 percent.

In people with EPI, the pancreas either cannot produce sufficient enzymes for food digestion in the digestive tract or has a blockage that prevents the enzymes from reaching the digestive tract.

A blockage in the pancreas can also cause partial digestion of the pancreatic tissue itself, which in turn can damage the cells that produce insulin, a hormone that helps regulate blood sugar levels.

There’s more to the link between diabetes and EPI than proximity, but researchers aren’t exactly sure what it is — although it sounds a lot like the riddle of the chicken and the egg.

“Diabetes can be caused by exocrine disease, and exocrine pancreatic insufficiency can be caused by diabetes,” explains Philip D. Hardt, MD, a physician and researcher with the University Hospital of Giessen and Marburg in Giessen, Germany. “Both are possible.”

What’s Happening in the Body to Link EPI and Diabetes?

Several theories may explain the relationship between EPI and diabetes.

Diabetes Damages Pancreatic Tissue

Some evidence has shown greater-than-normal amounts of inflammation and damage to pancreatic tissue, suggesting that having diabetes could increase the risk of EPI.

“The relationship between pancreatitis and diabetes is bidirectional: Each can increase the risk of the other,” says Nestoras Mathioudakis, MD, associate professor of medicine and co-medical director of Johns Hopkins Medicine Diabetes Prevention & Education Program in Baltimore.

“People with diabetes are about 1.5 to 2 times more likely to develop acute pancreatitis than those without diabetes,” he says. “This higher risk likely reflects shared risk factors, such as obesity and metabolic syndrome, hypertriglyceridemia, gallstone disease, alcohol use, smoking, and possibly some medications people use to treat diabetes (evidence is mixed for specific drugs).”

Pancreatitis Causes Diabetes

Dr. Mathioudakis also says that acute or chronic pancreatitis can raise the risk of disordered glucose metabolism.

Other pancreatic diseases, such as cystic fibrosis and pancreatic cancer, are also associated with type 3c diabetes, a type that develops after pancreatic damage.

Both Share Autoimmune Links

In some people, the immune system can incorrectly attack otherwise healthy pancreas tissue and cause the development of both pancreatitis and diabetes.

Autoimmune pancreatitis is very rare, affecting around 1 in every 100,000 people. More research is necessary to explore the link between autoimmune pancreatitis, EPI, and diabetes.

Complications of Diabetes May Lead to EPI

Diabetic neuropathy, a complication of diabetes involving nerve damage, may interfere with the signaling of pancreatic cells and neurons that carry out exocrine function.

Dr. Hardt suggests that more research into all these connections is necessary to fully understand the link.

Signs and Symptoms of EPI

“People with diabetes should talk to their physician about screening for EPI if they have ongoing digestive symptoms,” advises Mathioudakis. If you have diabetes, these are the signs and symptoms of EPI to be aware of:

  • Abdominal pain that can be either mild or severe
  • Steatorrhea, or fatty, oily stools (a sign that pancreatic enzymes aren’t getting to your digestive tract to break down fats in the food you eat)
  • Unintentional weight loss or signs of poor nutrition
  • Fat-soluble vitamin deficiencies, including vitamins A, D, E, or K

“Some people with type 1 diabetes also experience large, unpredictable swings in blood glucose,” says Mathioudakis. This is known colloquially as “brittle diabetes,” although he explains it’s not a formal diagnosis.

Steatorrhea is usually a sign of severe EPI. Diabetes-linked EPI is often mild to moderate, meaning you’re not likely to see the fatty stools of people with more severe EPI.

Mathioudakis suggests that poor carbohydrate absorption can worsen this mismatch. “When glucose from a meal appears in the bloodstream later than expected, the insulin taken before the meal may peak too early, causing a low initially, followed by a rebound high when a person’s gut finally absorbs the carbs,” he says.

Mathioudakis suggests that, along with EPI, other conditions that may affect carb absorption include:

  • Gastroparesis, or delayed stomach emptying
  • Celiac disease
  • Crohn’s disease
  • Small intestinal bacterial overgrowth (SIBO)
  • Having had gastric or small‑bowel surgery

“Doctors most commonly see this in forms of diabetes with complete insufficiency, such as type 1 diabetes or diabetes following complete removal of the pancreas,” says Mathioudakis. “It often reflects a mismatch between the timing and amount of insulin and the timing and amount of glucose entering the bloodstream. Some individuals are very insulin‑sensitive, so small dosing errors or delays can have exaggerated effects.” He advises that taking extra insulin for highs or eating carbs for impending lows, known as reactive dosing, can also create a yo‑yo pattern.

Although these are among the most common signs of EPI, they can also have other causes. In fact, many people with diabetes complain of general stomach problems that don’t necessarily indicate an emergency health situation.

“New or worsening diabetes plus digestive symptoms or unexplained weight loss should prompt a conversation about evaluating the pancreas for EPI and other pancreatic conditions,” advises Mathioudakis.

Fortunately, Mathioudakis says that technologies are available to help patients with brittle diabetes. “Today, continuous glucose monitors (CGMs) and automated insulin delivery systems (insulin pumps integrated with CGM) can reduce variability by adjusting insulin delivery as glucose rises or by pulling back insulin when glucose is falling,” he says.

Plus, diagnosing EPI is often possible with a simple test for an enzyme called fecal elastase. Treatment is also simple and involves taking pancreatic enzyme replacement therapy (PERT) with meals to replace the lost function of the enzymes.

The Takeaway

  • Exocrine pancreatic insufficiency (EPI) could develop in individuals with diabetes due to potential pancreatic tissue damage or inflammation.
  • If you have diabetes and experience symptoms like abdominal pain, oily stools, or unexplained weight loss, talk to a healthcare provider, as these can be indicators of EPI.
  • Living with both EPI and diabetes can be challenging, but managing these conditions with medical guidance can help preserve your quality of life.
  • Although research is ongoing, more research is necessary to fully understand the intricate link between EPI and diabetes.

Additional reporting by Katherine Lee.

EDITORIAL SOURCES
Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy. We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.
Resources
  1. National Diabetes Statistics Report. Centers for Disease Control and Prevention. January 28, 2026.
  2. Tian C et al. Exocrine Pancreatic Insufficiency. StatPearls. September 14, 2025.
  3. Gore J et al. MON-585 Exocrine Pancreatic Insufficiency Is a Risk Factor for Future Development of Diabetes Mellitus. Journal of the Endocrine Society. October 22, 2025.
  4. Acute Pancreatitis. Mayo Clinic. October 31, 2025.
  5. Type 3c Diabetes. Cleveland Clinic. May 9, 2023.
  6. Autoimmune Pancreatitis. Cleveland Clinic. September 29, 2025.
  7. Basyal B et al. Autoimmune Pancreatitis. StatPearls. August 11, 2025.
  8. Singh VK et al. Less common etiologies of exocrine pancreatic insufficiency. World Journal of Gastroenterology. October 21, 2017.
  9. Exocrine Pancreatic Insufficiency. Cleveland Clinic. June 10, 2021.
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Elise M Brett, MD, is a board-certified adult endocrinologist. She received a bachelor's degree from the University of Michigan and her MD degree from the Icahn School of Medicine at Mount Sinai. She completed her residency training in internal medicine and fellowship in endocrinology and metabolism at The Mount Sinai Hospital. She has been in private practice in Manhattan since 1999.

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