Ever wonder what would happen if your stomach decided to take a break from its job, leaving food to linger longer than it should? For those living with gastroparesis, this puzzling phenomenon is an ongoing challenge. In this blog, we'll shed light on gastroparesis, from its underlying causes to navigating its nutritional and lifestyle management and improving quality of life.

Understanding Gastroparesis:

• Diabetic gastroparesis is a type of gastroparesis that happens in people with diabetes. It causes delayed stomach emptying without blockages, lasting at least 3 months. • This condition occurs due to nerve damage from diabetes, impairs the stomach's ability to empty properly. • If not managed, it can complicate diabetes care by causing unstable blood sugar levels. • Incidence of type 2 diabetes is more common than type 1, so gastroparesis is seen more frequently with this type.

What Causes Diabetic Gastroparesis?

Chronic High Blood Glucose Levels and Nerve Damage: • Hyperglycemia (blood glucose > 200 mg/dL) in poorly controlled diabetes is associated with diabetic gastroparesis. • Chronic hyperglycemia can lead to neuropathy or nerve damage, contributing to gastroparesis, which does not improve with better glycemic control. • Acute hyperglycemia can also cause delayed gastric emptying but is often reversible with improved blood sugar management.

Understanding The Mechanics:

Normally, the stomach contracts to break down food and move it into the small intestine. But in diabetic gastroparesis, these contractions are weak or irregular, causing delayed stomach emptying.
Chronically high levels of blood glucose in diabetes damage the nerves controlling stomach muscles (particularly the vagus nerve), disrupting the stomach's contractions.
As a result, the stomach contracts less often, contractions between the stomach and intestines become irregular, and the stomach's exit (pylorus) may spasm, delaying stomach emptying.

Symptoms of Diabetic Gastroparesis:

• Feeling full shortly after starting a meal • Feeling full long after finishing a meal • Nausea • Vomiting • Appetite loss • Excessive bloating • Frequent belching • Upper abdominal pain • Heartburn

How is Gastroparesis Diagnosed?

Symptoms alone cannot diagnose gastroparesis. A gastric emptying study is essential. 1. Gastric Emptying Study Methods: • Gastric Emptying Scintigraphy: Involves ingesting a meal with a small amount of radioactive material and taking regular scans to track stomach emptying. • Gastric Emptying Breath Test: Involves consuming a meal with a non-radioactive substance and collecting breath samples over time to measure gastric emptying. • Wireless Motility Capsule: A small capsule transmits data on pH, pressure, and temperature as it travels through the GI tract, providing a comprehensive view of gastric motility. 2. Further Examination if Gastroparesis is Confirmed: • Upper Gastrointestinal (GI) Endoscopy: ◦ If slow gastric emptying is detected, an upper GI endoscopy may be performed to rule out physical obstructions. ◦ A flexible tube with a camera is inserted through the mouth to visualize the upper GI tract, identifying any structural issues such as ulcers, tumors, or strictures.

Complications That Arise with Gastroparesis:

• Fluctuations in Blood Sugar: Delayed stomach emptying can make it challenging to predict when glucose from food will enter the bloodstream, leading to unpredictable blood sugar levels. • Bezoar Formation: Undigested food can accumulate in the stomach, forming bezoars that can cause blockages in the digestive tract. • Nutritional Deficiencies and Malnutrition: Difficulty in absorbing nutrients from food can result in malnutrition, leading to deficiencies in essential vitamins and minerals. • Dehydration: Persistent vomiting or inadequate fluid intake due to gastroparesis can lead to dehydration. • Gastrointestinal Symptoms: Symptoms such as nausea, vomiting, bloating, gastric reflux, and abdominal pain can significantly impact the quality of life.

Management of Diabetic Gastroparesis:

The initial approach to treating gastroparesis involves lifestyle modifications. Achieving optimal glycemic control is crucial to minimize the effects of hyperglycemia, which can worsen delayed gastric emptying. • Medications: • Antiemetics are commonly used to manage nausea and vomiting. • Prokinetic agents (metoclopramide, erythromycin, and domperidone) are the mainstay of treatment, helping improve stomach muscle contractions and speed up stomach emptying. • Gastric electrical stimulation is an option for severe, refractory cases. • It involves implanting a gastric stimulator, similar to a cardiac pacemaker, into the abdomen. This device delivers mild electrical pulses to the stomach muscles, improving motility and reducing symptoms like nausea, vomiting, and bloating. • Botulinum toxin can be injected into the pyloric sphincter to relax the muscle and improve stomach emptying, in some cases. • Surgical options (gastric bypass surgery or a gastric venting tube (jejunostomy) may be considered, in severe cases that do not respond to other treatments. Avoid self-medication and seek regular consultation with a healthcare team, including a diabetologist and a nutritionist, for effective management of diabetic gastroparesis.

Eating Right with Gastroparesis:

1. Food Consistency The stomach empties small, digestible particles faster than large particles. Therefore, it's beneficial to: • Chew food thoroughly. • Mash with a fork, chop, grind, or blend food to reduce particle size. • If solid foods are not well tolerated, consume liquid meals, puréed foods (e.g., smoothies, soups) or high-calorie oral nutrition supplements as these exit the stomach more quickly than solids and are better tolerated. 2. Frequency And Volume of Meals • Consume small, frequent meals throughout the day, to reduce the risk of reflux and intragastric pressure. • Aim for six to ten smaller meals instead of three larger meals. 3. Carbohydrate • Limit the intake of simple carbohydrates, as they may worsen symptoms of diabetic gastroparesis. Although occasionally you may consume white bread, white rice to reduce total fiber content. • Ensure that carbohydrate portions are consistent in all meals to help manage blood sugar levels effectively. Fiber • Reducing fiber intake is recommended to prevent the formation of phytobezoars. • Phytobezoars or bezoars are clusters of undigested plant material like skins, seeds, and leaves that can accumulate in the stomach. Thus, you may need to avoid certain high-fiber foods to manage their condition effectively. AVOID: Bezoar-forming foods like apples, berries, coconut, figs, oranges, persimmon, dried fruits, vegetables, such as brussels sprouts, celeries, green beans, and potato peels, nuts and seeds, whole grain cereals, CHOOSE: Banana, peeled fruits, cantaloupe, muskmelon, watermelon, fruit or vegetable sauces with no pulp or skins, peeled and cooked vegetables (eg, beetroot, carrots, potatoes, and squash). 4. Protein AVOID: Consuming too much protein at one meal may worsen symptoms of heartburn, avoid processed meats, fried meats, and high-fat cuts of meat and high-fat milk. REPLACE WITH: Lean proteins such as skinless poultry, fish, tofu, paneer, and tempeh. CHOOSE: Eggs, low-fat milk, yogurt, cheese, 5. Fat In addition to reducing fiber intake, patients with gastroparesis are recommended to reduce fat intake because fats might delay gastric emptying. Also, avoid consuming too much of fat one meal. • AVOID: Consuming high amounts of Saturated fats: Avoid consumption of high amounts of saturated fats found in foods like palm oil, butter, lard, fatty cuts of meat and full-fat dairy products. • Trans fat: Avoid trans fats found in partially hydrogenated oils often used in processed foods like farsans, and fried snacks like chakli, bhujias, cookies, cakes, and fried foods. • REPLACE: Full-fat milk with skim milk, a small amount of coconut oil in baking, fried farsans with baked protein-rich snacks, makhana, etc. Kindly refer to the table for food groups to choose and avoid at the end of this document 6. Oral Nutrition Supplements (ONS) • These are premade liquids or powders formulated to provide a supplemental and dense source of calories or protein or both. • Traditionally used to improve caloric intake and stabilize weight in malnourished patients. • Serve as a supplemental source of calories and protein for people with gastroparesis. • Small sips throughout the day are generally well tolerated in patients with gastroparesis. 7. Hydration • It's important to stay hydrated by consuming fluids daily. You can get fluids from various sources such as juice, milk, water, herbal teas, etc. • Even if you're experiencing frequent vomiting, it's crucial to ensure sipping fluids in between meals to prevent dehydration, which can worsen vomiting. 8. Vitamins and Minerals • If you have a lot of vomiting and have lost a lot of weight, your doctor or dietitian may recommend that you have certain vitamin or mineral levels checked with a simple blood test. • If there’s a deficiency, your nutritionist will recommend you the appropriate dosage of the supplement. Common nutrients that are found to be deficient in patients with gastroparesis: • Vitamin B12 Essential for nerve health and red blood cell formation. Diabetic gastroparesis can lead to deficiencies due to poor absorption. Sources: Meat, dairy products, and supplements if needed. • Vitamin D Sources: Sun exposure, fatty fish, fortified dairy products, and supplements. • Iron Vital for oxygen transport in the blood. Gastroparesis can lead to poor absorption, increasing the risk of anemia. Sources: Lean meats, poultry, fish, and supplements if necessary. • Magnesium: • Supports muscle and nerve function, blood glucose control, and energy production. • Diabetic gastroparesis can affect magnesium levels. 9. Tube feeding vs Total Parenteral Nutrition for Managing Gastroparesis • Tube Feeding:

If you're having difficulty stabilizing or gaining weight with oral feeding due to gastroparesis, tube feeding (enteral nutrition) might be recommended.
This is particularly true if you've experienced significant weight loss (over 5%–10% in 3–6 months) or frequent hospitalizations requiring IV hydration or medication, even if you're currently maintaining your weight.
Tube feeding can be stopped once your symptoms improve, allowing you to return to oral feeding.

• Total Parenteral Nutrition • Total Parenteral Nutrition (TPN) is a treatment where all your nutrients are delivered directly into your bloodstream through a vein, bypassing your digestive system. • Rarely needed and reserved for severe cases affecting much of the small bowel or colon or when enteral therapy fails. Actionable Dietary and Lifestyle Suggestions for Better Management • Instead of three large meals, try 4 to 8 more frequent, smaller meals. • Avoid high-fiber foods. • Limit foods high in fat; choose lower-fat options. • Mash, chop, grind, or blend foods to reduce particle size for easier digestion. • Opt for foods and drinks that are neither too hot nor too cold. • Avoid raw vegetables. Cook them until they are soft. • Chew foods well, especially meats. Meats may be easier to eat if ground or puréed. • Distribute fats and proteins throughout the day and avoid consuming large amounts at once. • Eat food slowly. Take 20 to 30 minutes to finish a meal. • Sip on non-fizzy liquids between meals instead of with meals to avoid immediate fullness. • Sit up while eating and stay upright for at least 1 hour after you finish. • On days when symptoms are worse; try taking just liquids to let the stomach rest. • Maintain a healthy weight to reduce pressure on the stomach. • Try taking a nice walk after meals. • Maintain good blood sugar control. • Avoid smoking and alcohol as they can decrease gastric motility and delay stomach emptying. • Avoid chewing gum, which increases air swallowing • Avoid foods that lower oesophageal sphincter pressure: pepper-mint, spicy food, spices (chillies, garam masala, coriander powder, black pepper) chocolate, fat, carbonated drinks and caffeine.

Foods to Choose and Avoid

Food group	Choose	Avoid
Meats, poultry, and fish	Lean (eg, meat, pork, chicken or turkey without skin, and grilled or steamed fish or shellfish)	Fried or fatty (eg, pork, chicken, turkey, fish, and shellfish)
Dairy, dairy alternatives, and eggs	Whole-fat dairy in liquid or semiliquid form (eg, milk, milkshakes, and yogurt), low-fat dairy (eg, cheeses, cottage cheese, and cream cheese), non-dairy milks (eg, almond, coconut, and rice), eggs (eg, scrambled eggs, hard-boiled eggs, and egg whites)	Fried cheese, creamed eggs, and fried eggs
Grains	Breads of low fibre (eg, sourdough and white), cereals (eg, cornflakes, cream of wheat, cream of rice, and oatmeal), graham crackers, noodles, pancakes, pastas, pretzels, white rice, flour tortilla, and waffles	Whole grains or grains covered with nuts and seeds (eg, whole wheat), barley, bran, bulgur, high fibre cereals, granola, quinoa, brown rice, and corn tortilla, popcorn
Fruits and vegetables	Canned fruits or vegetables, banana, peeled fruits (eg, apples and pears), cantaloupe, honeydew, watermelon, fruit or vegetable sauces with no pulp or skins, peeled and cooked vegetables (eg, beetroot, carrots, potatoes, and squash)	Fruit or vegetable skins, dried fruits, coconut, berries, figs, grapes, grapefruit, persimmons, prunes, oranges, alfalfa or bean sprouts, artichokes, asparagus, broccoli, brussel sprouts, cabbage, cauliflower, celery, corn, eggplant, lettuce, and okra
Legumes, and nuts	Tofu and creamy nut butters (eg, peanut or almond butter)	Beans, chickpeas, lentils, and crunchy nut butters
Beverages	Fruit and vegetable juices or smoothies with no pulp or skins, and plain water	Prune juice, caffeine, sparkling water, and sodas

In conclusion, diabetic gastroparesis is a serious complication of diabetes that results from nerve damage, leading to delayed stomach emptying and digestive issues. It complicates diabetes management by causing unstable blood sugar levels. Therefore, effective management through diet, medication, and sometimes surgery is essential for improving quality of life and ensuring better overall health outcomes. The nutritional recommendations and information provided in this blog are intended to empower you and raise awareness about healthy eating habits with diabetic gastroparesis. However, it's extremely important to avoid self-medication and consult with your diabetologist and a nutritionist recommended by your doctor or chosen by you for a personalized diet plan tailored to your specific needs. If you're looking for more support and SELF-EMPOWERMENT TOOLS (SET’s) for managing various clinical conditions, be sure to check out our website, www.nutritionwithvibha.com. We offer a range of resources to help you on your journey to better health. And if you're seeking personalized diet consultation, we're here for that too. Feel free to reach out to us anytime.