Low Faecal Elastase Levels Are Common in People With T1D
Douwe F. de Wit, Coco M. Fuhri Snethlage, Johannes H. M. Levels, Elena Rampanelli, Abraham S. Meijnikman, Max Nieuwdorp and Nordin M. J. Hanssen
High prevalence of low faecal elastase levels in individuals with type 1 diabetes is associated with diabetes duration but not with marked alterations in food intake or clinical symptoms. Diabetologia. 2026 Aug 8. Online ahead of print.
Type 1 diabetes (T1D) primarily affects the insulin-producing beta cells of the pancreas, but changes in the exocrine pancreas – the part responsible for producing digestive enzymes – have also been reported. Reduced exocrine pancreatic function can lead to exocrine pancreatic insufficiency (EPI), potentially resulting in malabsorption, nutritional deficiencies and other complications.
In this cross-sectional study, Diabeter NL/Diabeter Center Amsterdam/Amsterdam UMC researchers investigated exocrine pancreatic function in 443 adults with T1D from the GUTDM1 cohort. Faecal elastase (FE), a commonly used marker of exocrine pancreatic function, was measured in stool samples. An FE level below 200 µg/g was used as a marker of EPI. The researchers examined whether FE levels were related to diabetes duration, glycemic management, residual beta-cell function, dietary intake and gastrointestinal symptoms.
Key findings:
- Low faecal elastase levels were relatively common: 17% of participants had FE levels below 200 µg/g, indicating potential exocrine pancreatic insufficiency.
- Longer diabetes duration was associated with lower FE levels: For every additional 10 years of T1D, FE levels were on average 13 µg/g lower after adjustment for other factors. Older age, male sex and smoking were also independently associated with lower FE levels.
- Residual beta-cell function was not associated with FE levels: After adjustment for potential confounders, no association was found between FE and markers of remaining beta-cell function. This suggests that loss of endocrine and exocrine pancreatic function may not occur in parallel.
- Low FE levels were not accompanied by clear gastrointestinal symptoms: There was no evidence of an association between FE levels and overall gastrointestinal complaints. People classified as having EPI therefore could not easily be identified based on abdominal symptoms alone.
- EPI was associated with differences in glucose levels and food intake: Participants with FE <200 µg/g had an HbA1c that was on average 4.31 mmol/mol (0.39%) higher and a mean glucose level that was 8% higher than participants without EPI. They also reported a 9% lower fibre intake and an 8% lower total energy intake.
- Routine screening is not supported by these findings: Despite the relatively high prevalence of low FE levels, the absence of clear associations with most clinical parameters and symptoms does not support routine FE screening in all people with T1D.
These findings highlight that T1D may affect not only the insulin-producing endocrine pancreas but also its exocrine function. The gradual association between lower FE levels and longer diabetes duration is particularly interesting and may indicate that changes in the exocrine pancreas continue to develop over the course of T1D.
At the same time, the clinical significance of low FE levels remains uncertain. The study was cross-sectional and therefore cannot establish whether reduced exocrine pancreatic function causes differences in glucose management or food intake. Further studies are needed to determine whether people with T1D and low FE levels are at increased risk of complications such as malabsorption, vitamin deficiencies or osteoporosis, and whether they could benefit from specific interventions.
Concluding, the authors state
“The lack of evidence of associations of FE levels with clinical parameters in this relatively healthy population of individuals with type 1 diabetes does not support the use of FE measurement for routine screening for EPI. However, the high prevalence of low FE levels and their association with lower food intake and higher glucose levels justify clinical awareness for EPI and its complications.”
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