Nutrition

Gastroparesis

The autonomic (automatic) nervous system controls the heart, lungs, intestines, blood vessels, stomach, bladder, and sex organs. Damage to these nerves is called autonomic neuropathy and occurs slowly over time. Gastroparesis or nerve disease of the stomach is an example of autonomic neuropathy (the small and large intestine can also be affected). Functions of the stomach include holding and storing food, mixing food into solution, and moving this solution to the small intestine. It is the nerves that enable the stomach to do its job, and when these nerves become damaged, a common and serious condition results, gastroparesis.

Causes:

Diabetes, postviral syndromes, post-surgery, medications, obstructions including cancer, ulcer/GERD, central nervous system (Parkinson's disease or Shy-Drager syndrome [orthostatic hypotension]), vascular or muscular disorders, metabolic disorders (hyperthyroidism), pregnancy, and anorexia nervosa. Other factors: hyperglycemia, vagal autonomic neuropathy, and post-meal release of hormones.

Incidence:

25-30% of persons with diabetes may have gastroparesis and this increases with time (up to 50%).

40-50% of persons with type 1 diabetes and 30-40% of persons with type 2 diabetes has gastroparesis.

Symptoms:

Nausea (in the morning or after eating), vomiting undigested food, early satiety or feeling full early in meal, tasting food that was eaten two to three days earlier, abdominal discomfort (bloating, heartburn, indigestion), poor glycemic control, avoiding food leading to weight loss, diarrhea, and mild constipation.

Diagnosis:

May be performed by: Gastric Emptying Test, Upper GI Endoscopy, Upper GI/Small Bowel /Barium Meal, Gastric Manometry/Electrogastrography, or Breath Test.

Medications/Treatment:

Metoclopramide ( Reglan), Erythromycin, (Propulsid-discontinued?), Domperidone, Tegaserod, others?

Insulin Adjustment Suggestions:

Nerve damage to the stomach slows the digestion of food. Insulin injected prior to the meal may not “coincide” with the delayed release of this digested food (blood glucose) into the bloodstream. Creative suggestions for injecting insulin to coincide with this delayed release of food include: take insulin more often, take insulin after eating, take regular insulin instead of Humolog/Novolog insulin, take ½ of the Humolog/Novolog dose at the end of the meal and the remaining ½ dose 1-2 hrs later, take regular insulin as ½ of the dose and Humolog/Novolog as the remaining ½ dose after the meal (mix in same syringe but take immediately), or use combination or square wave delivery if using the insulin pump.

Food Principles:

· Eat 6 small meals per day, 2-3 hrs apart; chew foods well , eat slowly

· Avoid foods high in fat, fried foods
· Avoid high fiber foods ( individual tolerance varies ):

whole-grain breads/cereals (choose £ 1 gram fiber per serving), nuts, seeds, popcorn

oranges, persimmons, coconut, berries, figs, apples, sauerkraut, brussels sprouts, green beans, legumes

· Use well-cooked vegetables, soft foods; avoid gas-forming vegetables/foods (broccoli, dried beans/peas)

· Use unsweetened canned fruits (soft) instead of fresh fruits

· Use liquids —soups, sugar free pudding, jello, popsicles

· Use pureed or baby foods if necessary; liquid/formula meals as the day progresses

· Use ground meats

· Avoid caffeine/carbonated beverages/foods (coffee, tea, cola, chocolate)

· Avoid foods containing sugar alcohols (eg sorbitol)

· Avoid smoking

· Avoid foods causing discomfort

· Sit up during/1 hr after meals; walk 1 hr after meals; keep head elevated on pillow while sleeping

· Tube feeding? Parenteral nutrition?

Starches: breads (white, bagels, English muffin, rolls, pita, tortilla, breadsticks)

cereals (plain quick oats, grits, cream of wheat, cream of rice, puffed cereals)

crackers (arrowroot, matzoh, melba toast, oyster, pretzels, saltines, soda, zwieback)

grains/potatoes (rice, pasta, bulgher, barley, potatoes-no skin, baked French fries)

Meats (ground or pureed ): beef (flank, round, tenderloin, rump), pork (tenderloin), veal (leg, loin, rib, shank, shoulder), poultry (skinless), wild game (skinless venison, buffalo, rabbit, squirrel, pheasant, duck), cheese (low fat cottage, grated parmesan), fish/shellfish (no breading), eggs (no creamed, fried), low fat luncheon meat, tofu

Vegetables (cooked): beets, carrots, mushrooms, tomato juice/sauce/puree, V-8, baby food (strained)

Fruits: a pplesauce, bananas (soft), peaches and pears (canned), cooked fruit, strained? juices (prune juice?)

Milk (as tolerated): non-fat or skim or 1% , buttermilk (skim milk), evaporated skim milk, non-fat powdered milk, non-fat artificial flavored yogurt (no fruit added), non-fat frozen yogurt , plain non-fat yogurt

Fat (as tolerated): small amounts of recommended fats

Soup ( fat free ) : chicken noodle, rice, bouillon, broth, strained creamed soups (made from skim milk/water)

Desserts : use recommended low sugar/fat foods (graham/animal crackers, ginger snaps, vanilla wafers, angel food cake, fat-free custard/pudding, gelatin, plain popsicles, sherbet, sorbet, hard candies, gum, marshmallows, seedless jams/jellies)

Beverages : avoid caffeine/carbonated beverages; use water or sugar free beverages, hot cocoa (made from skim milk/water)

Seasonings: herbs, spices, cranberry sauce (smooth), mustard, ketchup, soy sauce, vanilla extract, vinegar

References:Desai, H. P. & Burakoff, R. (Nov 1992). Diabetic Gastroparesis.Practical Diabetology .

NIH. (1999).

Gastroparesis and Diabetes . National Digestive Diseases Information Clearinghouse.

Parrish, C. (1992). Presentation at Annual Meeting of American Association of Diabetes Educators.

Thomas-Dobersen, D. (Sept 2003). Gastroparesis, A Case of Unexplained Lows.

Diabetes Forecast .

Vinik, A. I. & Vinik, E. (July 1992). The Diabetes Complication No One Talks About. Diabetes Forecast .