The articles on our site often found “diabetic gastroparesis”. This is a partial paralysis of the stomach, which causes its slow emptying after eating. Chronically elevated blood sugar for several years causes various disruptions in the functioning of the nervous system. Together with other nerves, those that stimulate the production of acids and enzymes, as well as the muscles needed for digestion, are affected. Problems may develop with the stomach, intestines, or both. If a diabetic patient has any of the common forms of neuropathy (dry feet, loss of sensation in the legs, weak reflexes), then he will most likely have digestive problems.
Diabetic gastroparesis causes unpleasant symptoms only when it is severe. Maybe after eating heartburn, belching, feeling of fullness in the stomach after a small meal, bloating, nausea, vomiting, constipation, sour taste in the mouth, as well as constipation, interspersed with diarrhea. The symptoms of this problem are very individual for each patient. If the symptoms listed above are not, then we usually diagnose slow gastric emptying after eating because of the poor control of blood sugar. Diabetic gastroparesis makes it difficult to maintain normal blood sugar, even if a diabetic patient follows a low-carbohydrate diet.
What problems does diabetic gastroparesis cause?
Gastroparesis means “partial paralysis of the stomach,” and diabetic gastroparesis means “a weak stomach in diabetic patients.” Its main cause is the defeat of the vagus nerve due to chronically high blood sugar. This nerve serves many functions in the body that take place without the participation of consciousness, including heartbeat and digestion. In men, diabetic vagus neuropathy can also lead to potency problems. To understand how diabetic gastroparesis manifests itself, you need to study the picture below.
On the left, the stomach is depicted in good condition after eating. Its contents gradually pass into the intestine through the “gatekeeper”. The gatekeeper valve is wide open (muscle is relaxed). The lower esophageal sphincter is tightly closed to prevent belching and food ingress from the stomach back into the esophagus. Muscle walls of the stomach are periodically reduced and contribute to the normal movement of food.
On the right we see the stomach of a diabetic patient who developed gastroparesis. There is no normal rhythmic movement of the muscle walls of the stomach. The gatekeeper is closed, and this prevents the movement of food from the stomach into the intestine. Sometimes there can be only a small gap in the gatekeeper, no larger than a pencil in diameter, through which liquid food flows into the intestine. If the valve of the pylorus is cramped, then the patient may feel spasm from the navel below.
Since the lower esophageal sphincter is relaxed and open, the contents of the stomach, saturated with acid, spills back into the esophagus. It causes heartburn, especially when a person is lying horizontally. The esophagus is a wide tube that connects the pharynx to the stomach. Under the action of acid burns its walls. It often happens that even the teeth are destroyed due to regular heartburn.
If the stomach is not emptied, as is normally the case, then the person feels overcrowded even after a small meal. In the most severe cases, several meals in a row are accumulated in the stomach, and this causes severe bloating. However, in most cases, a diabetic does not even suspect that he has gastroparesis until he begins to perform a type 1 diabetes treatment program or a type 2 diabetes treatment program. Our diabetes treatment regimens require you to carefully monitor your blood sugar, and the problem of gastroparesis is usually detected.
Diabetic gastroparesis, even in the mildest form, prevents normal control of blood sugar. If you consume caffeine, fatty foods, alcohol, or tricyclic antidepressants, it also slows down stomach emptying and exacerbates problems.
Why gastroparesis causes blood sugar jumps
Consider what happens to a diabetic who has virtually no first phase of insulin secretion in response to a meal. He takes a quick insulin shot before eating or takes diabetes pills that stimulate insulin production by the pancreas. Read why you need to refuse to take such pills and what harm they bring. If he injected himself with insulin or took pills, and then missed a meal, his blood sugar would drop very low, to the level of hypoglycemia. Unfortunately, diabetic gastroparesis has almost the same effect as skipping meals.
If a diabetic patient knew when exactly his stomach would give its contents to the intestines after eating, he could delay insulin injection or add medium NPH-insulin to fast insulin to slow down the effect. But the problem of diabetic gastroparesis is its unpredictability. We never know in advance how quickly the stomach will empty after a meal. If there is no spasm of the pylorus, the stomach may be partially emptied after a few minutes, and completely within 3 hours. But if the valve of the pylorus is tightly closed, then the food can remain in the stomach for several days. As a result, blood sugar can fall “below the baseboard” 1-2 hours after eating, and then suddenly take off after 12 hours, when the stomach finally releases its contents to the intestines.
We examined the unpredictability of food absorption during diabetic gastroparesis. It is very difficult to control blood sugar in insulin-dependent diabetic patients. There are also problems for diabetics if they take pills that stimulate insulin production by the pancreas, which we recommend to give up.
Features of gastroparesis in type 2 diabetes
For patients with type 2 diabetes, diabetic gastroparesis creates less acute problems than patients with type 1 diabetes, because they still have their own insulin production by the pancreas. Significant insulin production occurs only when food from the stomach enters the intestine. While the stomach is not emptied, only low basal (fasting) insulin concentration is maintained in the blood. If a patient with type 2 diabetes is on a low-carbohydrate diet, then he receives only low doses of insulin in injections, which do not pose a serious threat of hypoglycemia.
If the stomach is emptied slowly, but at a constant rate, then in patients with diabetes type 2, the activity of beta cells of the pancreas is usually enough to keep normal blood sugar. But if suddenly the stomach is completely emptied, then there is a jump in blood sugar, which cannot be immediately extinguished without a fast insulin injection. Only within a few hours, weakened beta cells will be able to produce so much insulin to return sugar to normal.
Diabetic gastroparesis is the second most common cause of increased morning fasting sugar after the phenomenon of morning dawn. If your dinner did not leave the stomach on time, then digestion will occur at night. In such a situation, a diabetic can go to bed with normal sugar, and then wake up in the morning with an elevated one. In any case, if you follow a low-carbohydrate diet and make low doses of insulin or if you have type 2 diabetes, do not prick it at all, then gastroparesis does not threaten you with hypoglycemia. Diabetic patients who follow a “balanced” diet and inject themselves with high doses of insulin have much more problems. Due to diabetic gastroparesis, they experience significant sugar jumps and frequent episodes of severe hypoglycemia.
How to diagnose this complication of diabetes
In order to understand whether you have diabetic gastroparesis or not, and if so, how strong, you need to investigate the records of the results of total self-control of blood sugar for several weeks. It is also useful to be examined by a gastroenterologist to find out if there are any problems with the gastrointestinal tract that are not related to diabetes.
In the records of the results of the total self-control of sugar, you need to pay attention to whether the following situations are present:
- Blood sugar is below the norm after 1-3 hours after a meal (not necessarily every time).
- After eating, sugar is normal, and then rises after 5 hours or later, for no apparent reason.
- Problems with morning sugar in the blood on an empty stomach, despite the fact that yesterday the diabetic had a dinner early - 5 hours before he went to bed, or even earlier. Or morning blood sugar behaves unpredictably, despite the fact that the patient dines early.
If situations № 1 and 2 occur together, then this is enough to suspect gastroparesis. Situation number 3 even without the rest allows you to diagnose diabetic gastroparesis. If there are problems with morning fasting blood sugar, a diabetic patient can gradually increase his dose of prolonged insulin or tablets overnight. In the end, it turns out that at night he receives significant doses of diabetes, which significantly exceed the morning dose, despite the fact that he has an early dinner. After this, morning fasting blood sugar will behave unpredictably. On some days it will remain elevated, while on others it will be normal or even too low. The unpredictability of sugar is the main signal to suspect gastroparesis.
If we see that morning fasting blood sugar behaves unpredictably, then we can conduct an experiment to confirm or deny diabetic gastroparesis. One day, skip dinner and, accordingly, do not give fast insulin before dinner. At the same time at night you need to use the usual dose of prolonged insulin and / or the correct pills for diabetes. Measure your blood sugar before bedtime, and then in the morning on an empty stomach, as soon as you wake up. It is assumed that at night you will have normal sugar. If, without dinner, morning sugar turned out to be normal or decreased, then, most likely, gastroparesis causes problems with it.
After the experiment, dine a few days early. Observe how your sugar behaves in the evening before bed and the next morning. Then repeat the experiment again. Then again, dine a few days early and watch. If, without supper, blood sugar levels are normal or reduced in the morning, and when you eat supper, it sometimes turns out to be elevated the next morning, then you definitely have diabetic gastroparesis. You can treat and control it by the methods described in detail below.
If a diabetic feeds on a “balanced” diet overloaded with carbohydrates, his blood sugar will in any case behave unpredictably, regardless of the presence of gastroparesis.
If the experiments do not give an unambiguous result, then you need to be examined by a gastroenterologist and find out if there are any of the following problems:
- gastric or duodenal ulcer;
- erosive or atrophic gastritis;
- irritability of the gastrointestinal tract;
- hiatal hernia;
- celiac disease (gluten allergy);
- other gastroenterological diseases.
Examined by a gastroenterologist will be useful in any case. The problems with the gastrointestinal tract, as listed above, respond well to treatment if you diligently follow the doctor’s recommendations. This medication helps improve blood sugar control in diabetes.
Methods for the control of diabetic gastroparesis
So, it was confirmed that you developed diabetic gastroparesis, according to the results of total self-control of sugar in the blood, as well as after several repetitions of the experiment described above. First of all, you need to learn that this problem cannot be controlled by juggling insulin doses. Such attempts will only lead to jumps in blood sugar and aggravate the complications of diabetes, and they also increase the risk of hypoglycemia. To get diabetic gastroparesis under control, you need to try to improve gastric emptying after eating, and several methods are described below.
If you have gastroparesis, then the troubles in life are much more than in all other patients who perform our type 1 diabetes treatment program or type 2 diabetes treatment program. Take control of this problem and maintain normal blood sugar is possible only if you carefully follow the regime. But it gives significant advantages. As you know, diabetic gastroparesis occurs due to the defeat of the vagus nerve caused by chronically elevated blood sugar. If diabetes is disciplined for several months or years, the functions of the vagus nerve are restored. But this nerve controls not only the digestion, but also the heartbeat and other autonomous functions in the body. You will get significant health improvements besides cure for gastroparesis. When diabetic neuropathy passes, then even the potency of many men will improve.
Methods to improve gastric emptying after eating are divided into 4 groups:
- special exercises and massage during and after meals;
- small changes in diet;
- major changes in diet, the use of liquid or semi-liquid food.
As a rule, all these methods work one by one insufficiently, but together they make it possible to achieve normal blood sugar even in the most severe cases. After reading this article, you will figure out how to adapt them to your habits and preferences.
Objectives of treatment of diabetic gastroparesis:
- Reduction or complete cessation of symptoms - early saturation, nausea, belching, heartburn, bloating, constipation.
- Reducing the incidence of low sugar after a meal.
- Normalization of blood sugar in the morning on an empty stomach (the main feature of gastroparesis).
- Smoothing sugar surges, more stable results of total self-control of blood sugar.
To reach the last 3 points from this list is possible only if you treat gastroparesis and at the same time follow a low-carbohydrate diet. To date, there is no way to get rid of sugar jumps for diabetics who follow a “balanced” diet overloaded with carbohydrates. Because such a diet requires stabbing large doses of insulin, which act unpredictably. Learn what a small load method is if you have not done it yet.
Medications in the form of tablets or liquid syrup
No medicine can yet “cure” diabetic gastroparesis. The only thing that can get rid of this complication of diabetes is normal blood sugar for several years in a row. However, some medications can speed up the emptying of the stomach after eating, especially if your gastroparesis is mild or moderate. It helps smooth out fluctuations in blood sugar.
Most diabetics have to take pills before each meal. If the gastroparesis is mild, then it may be possible to manage with medication only before dinner. For some reason, the digestion of dinner in diabetic patients is the most difficult. Perhaps because after dinner they do less physical activity than during the day, or because they eat the biggest portions for dinner. It is assumed that emptying the stomach after dinner in healthy people also occurs more slowly than after other meals.
Medications for diabetic gastroparesis can be in the form of tablets or liquid syrups.Tablets are usually less effective, because before they begin to act, they must dissolve and be absorbed in the stomach. If possible, it is better to use liquid medication. Every pill you take from diabetic gastroparesis should be chewed thoroughly before swallowing. If you take the pills without chewing, then they will begin to act only after a few hours.
Super Papaya Enzyme Plus - Enzyme Chewable Tablets
Dr. Bernstein in his book Dr. Bernstein's Diabetes Solution writes that taking digestive enzymes helps many of his patients with diabetic gastroparesis. In particular, he claims that patients especially praise Super Papaya Enzyme Plus. These are mint flavored chewable tablets. They solve the problems of bloating and belching, and many diabetics are helped to smooth out the fluctuations in blood sugar that they have due to gastroparesis.
Super Papaya Enzyme Plus contains the enzymes papain, amylase, lipase, cellulase and bromelain, which help digest proteins, fats, carbohydrates and fiber, while they are still in the stomach. It is recommended to chew 3-5 tablets with each meal: before you start eating, during meals, and after it. This tool contains sorbitol and other sweeteners, but in a small amount, which should not have a significant impact on your blood sugar. I mention this particular product with digestive enzymes here, because Dr. Bernstein writes about him in his book. Download instructions on how to order products on iHerb with delivery in the form of parcels by mail.
In diabetic gastroparesis, Dr. Bernstein prescribes this medicine in the following dosage - chew two tablets of 10 mg 1 hour before meals and drink a glass of water, you can soda. The dosage does not increase, because it can lead to problems with potency in men, as well as the absence of menstruation in women. Domperidone is the active substance, and Motilium is the commercial name under which the drug is sold.
Motilium stimulates the evacuation of food from the stomach after eating in a special way, not the same as the other medicines that are described in this article. Therefore, it is advisable to use it in combination with other drugs, but not with metoclopramide, which we describe below. If side effects occur from taking Motilium, they disappear when they stop using this drug.
Metoclopramide is probably the most powerful stimulator of gastric emptying after eating. It acts in the same way as domperidone, inhibiting (slowing down) the effect of dopamine in the stomach. Unlike domperidone, this medicine penetrates the brain, so it often causes serious side effects - drowsiness, depression, anxiety, as well as syndromes resembling Parkinson's disease. In some people, these side effects occur immediately, and in others - after several months of treatment with metoclopramide.
The antidote for the side effects of metoclopramide is diphenhydramine hydrochloride, which is known as Diphenhydramine. If metoclopramide had such serious side effects that it took to take diphenhydramine hydrochloride, then metoclopramide should be permanently abandoned. Sudden discontinuation of metoclopramide by people who have been treated for 3 months or longer can lead to psychotic behavior. Therefore, the dose of this medicine to zero should be reduced gradually.
For the treatment of diabetic gastroparesis, Dr. Bernstein prescribes metoclopramide only in the most extreme cases, since the side effects occur frequently and they are serious. Before using this tool, try all other options that we list in the article, including exercise, massage, and diet changes. You can take metoclopramide only on prescription and in the dosage that it indicates.
Betaine hydrochloride + pepsin
Betaine hydrochloride + pepsin is a powerful combination that stimulates the breakdown of food eaten in the stomach. The more digested food in the stomach, the greater the likelihood that it quickly enters the intestine. Pepsin is a digestive enzyme. Betaine hydrochloride is a substance from which hydrochloric acid is formed, which increases the acidity of the stomach. Before taking betaine hydrochloride + pepsin, have a gastroenterologist check up and talk to him. Measure the acidity of your gastric juice. If the acidity is increased or even normal - betaine hydrochloride + pepsin is not suitable. This is a powerful tool, but if it is applied without the recommendation of a gastroenterologist, the consequences will be grave. It is intended for people who have increased acidity of gastric juice. If your acidity is normal, then try the Super Papaya Enzyme Plus enzyme set we mentioned above.
Betaine hydrochloride + pepsin can be purchased at the pharmacy in the form of tablets Acidin-pepsin
or order from the USA with delivery by mail, for example, in the form of this additive
Dr. Bernstein recommends starting with 1 tablet or capsule in the middle of a meal. Never take betaine hydrochloride + pepsin on an empty stomach! If heartburn does not occur from one capsule, then the next time you can try to increase the dose to 2, and then to 3 capsules for each meal. Betaine hydrochloride + pepsin does not stimulate the vagus nerve. Therefore, this tool partially helps even in the most severe cases of diabetic gastroparesis. However, he has many contraindications and limitations. Contraindications - gastritis, esophagitis, gastric or duodenal ulcer.
Exercises that speed up emptying the stomach after eating
For the treatment of diabetic gastroparesis, physical education is a more effective means than medication. It is also free and has no side effects. As in all other situations related to diabetes, only those patients who are lazy to engage in physical exercise need medication. So, let's find out what exercises accelerate the evacuation of food from the stomach after a meal. In a healthy stomach, the smooth muscles of the walls are rhythmically reduced to ensure the passage of food through the gastrointestinal tract. In the stomach affected by diabetic gastroparesis, the musculature of the walls is sluggish and does not contract. It turns out that with the help of simple physical exercises, which we describe below, you can imitate these cuts and speed up the evacuation of food from the stomach.
You, probably, noticed that the pedestrian walk after meal improves digestion. This effect is especially valuable for patients with diabetic gastroparesis. Therefore, the first exercise that Dr. Bernstein recommends is walking at an average or fast pace for 1 hour after eating, especially after dinner. We do not even recommend walks, but relaxed jogging according to the Qi-Run technique. By this method you will enjoy running even after eating. Make sure jogging is fun!
The following exercise was shared with Dr. Bernstein by a patient who recognized him from her yoga instructor and made sure that it really helps a lot. It is necessary to draw the stomach as deep as possible so that they stick to the ribs, and then inflate it so that it becomes huge and bulging like a drum. After eating, rhythmically repeat this simple action as many times as you can. Over the course of several weeks or months, your abdominal muscles will become stronger and stronger. You will be able to repeat the exercise more and more times before you get tired. The goal is to perform it several hundred times in a row. 100 repetitions take less than 4 minutes. When you learn how to perform 300-400 repetitions and give it 15 minutes each time after a meal, the fluctuations in blood sugar will very much smooth out.
Another similar exercise that needs to be done after a meal. While sitting or standing, bend back as far as you can. Then lean forward as low as possible. Repeat as many times as you can. This exercise, as well as the one mentioned above, is very simple, it may even seem silly. Nevertheless, they accelerate the evacuation of food from the stomach after eating, help from diabetic gastroparesis and improve the control of blood sugar, if disciplined to deal with them.
Chewing gum - a remedy for diabetic gastroparesis
When you chew something, saliva is released. It not only contains digestive enzymes, but also stimulates the contraction of smooth muscles in the walls of the stomach and relaxes the pyloric valve. A sugar-free chewing gum contains no more than 1 gram of xylitol, and this is unlikely to have a serious impact on your blood sugar. You need to chew one plate or dragee for a full hour after eating. It improves the course of diabetic gastroparesis, in addition to physical exercise and dietary changes. Do not use several plates or dough of gum in a row, because it can raise your blood sugar.
How to change a diabetic's diet to control gastroparesis
Dietary control methods for diabetic gastroparesis are more effective than medications. Especially if you combine them with exercise, which are described in the previous section. The problem is that patients with diabetes do not like too much changes in the diet that need to be implemented. Let's list these changes, from the easiest to the most complex:
- You need to drink at least 2 glasses of liquid before each meal. This liquid should not contain sugar and other carbohydrates, as well as caffeine and alcohol.
- Reduce portions of fiber, or even completely stop eating it. Vegetables containing fiber, pre-grind in a blender, to a semi-liquid state.
- Chew all the food you eat very slowly and thoroughly. Chew each piece at least 40 times.
- Exclude from the diet of meat that is not ground in a meat grinder, that is, go to cutlets. Completely exclude meat varieties that are heavy for digestion. These are beef, fat bird, pork and game. It is also undesirable to eat clams.
- Have dinner early, 5-6 hours before bedtime. Reduce portions of protein at dinner, transfer part of the protein from dinner to breakfast and lunch.
- If you do not chop fast insulin before a meal, then eat not 3 times a day, but more often, 4-6 times, in small portions.
- In the most severe cases of diabetic gastroparesis, go to semi-liquid and liquid foods.
In the stomach affected by diabetic gastroparesis, soluble and insoluble fiber can create a stopper and completely block the constricted pyloric valve. In a normal situation, this is not a problem, because the gatekeeper valve is wide open. If the diabetic gastroparesis is mild, then the control of blood sugar can improve when you reduce portions of dietary fiber, completely eliminate it, or at least grind vegetables in a blender to facilitate their digestion. Do not use laxatives that contain fiber in the form of flax seeds or flea plantain (psyllium).
Transfer part of the protein intake for lunch and breakfast instead of dinner
Most people have their biggest meal during the day at dinner. For dinner, they eat the largest portions of meat or other protein foods. For diabetics who have developed gastroparesis, this diet is very difficult to control blood sugar in the morning on an empty stomach. Animal protein, especially red meat, often clogs the pylorus valve in the stomach, which is narrowed due to muscle spasm. The solution is to transfer part of your animal protein intake for breakfast and lunch.
Leave for dinner no more than 60 grams of protein, that is, no more than 300 grams of protein food, and better still less. It can be fish, meat in the form of a chop or minced steak, cheese or eggs. Make sure that as a result of this measure, your sugar in the morning on an empty stomach will become much closer to normal. Of course, when you transfer protein from dinner to other meals, then the appropriate dose of fast insulin before meals also needs to be partially transferred. Probably, the dose of prolonged insulin or diabetes pills at night can also be reduced without deterioration in the indicators of morning sugar in the blood.
It may be that as a result of transferring a portion of protein from dinner to breakfast and lunch, your sugar after these meals will begin to rise, even if you correctly changed the fast insulin doses before meals. It is a lesser evil than to endure high blood sugar all night. If you do not chop fast insulin before meals, then eat 4 times a day in small portions so that the sugar is more stable and closer to normal. And if you don’t use insulin at all, it’s best to eat 5-6 times a day in even smaller portions. Recall that if you chop fast insulin before eating, you need to eat every 5 hours so that the effect of insulin doses does not overlap each other.
Consumption of alcohol and caffeine slows down the evacuation of food from the stomach after eating. The same effect of mint and chocolate. All of these substances should be avoided, especially at dinner, if your diabetic gastroparesis is moderate or severe.
Semi-liquid and liquid food - a radical remedy for gastroparesis
The most radical remedy for diabetic gastroparesis is to switch to semi-liquid or liquid food. If this is done, then the person loses a huge part of the pleasure of eating. Few people like this. On the other hand, this may be the only way to ensure that the blood sugar of a diabetic patient is close to normal. If you maintain it for several months or years, the functioning of the vagus nerve will gradually recover and gastroparesis will pass. Then you can eat normally without compromising the control of blood sugar. This path was taken by Dr. Bernstein himself.
Semi-liquid diets for diabetic gastroparesis are baby foods, as well as white whole milk yogurt. You can buy low-carbohydrate vegetables as well as animal products that do not contain carbohydrates in the form of baby food jars at the store. You need to carefully study the labels when choosing these products. How to choose yogurt, we will discuss below. Only yogurt is suitable, which is not liquid, but in the form of jelly. It is sold in Europe and the USA, but it is difficult to get it in Russian-speaking countries.
In the article on the compilation of the menu for a low-carbohydrate diet, we indicated that the more processed the vegetables, the faster they raise sugar in the blood. How does this fit with the recommendation to eat semi-liquid vegetables with diabetic gastroparesis? The fact is that if this complication of diabetes has developed, then food gets from the stomach into the intestine very slowly. This also applies to semi-liquid vegetables from baby food jars. Even the most “tender” vegetables will barely have time to raise sugar in the blood in time to keep up with the effect of fast insulin, which you poke before eating. And then, most likely, you will need to slow down the effect of short insulin before eating, mixing it with medium NPH-insulin protaphan.
If you go to a semi-liquid diet to control diabetic gastroparesis, then try to avoid protein deficiency in your body. A person who leads a sedentary lifestyle should consume 0.8 grams of protein per 1 kg of his ideal body weight per day. Protein food contains about 20% of pure protein, i.e. it is necessary to eat about 4 grams of protein products per 1 kg of ideal body weight. If you think about it, it is not enough. People who are engaged in physical education, as well as children and adolescents who grow up, need another 1.5-2 times more protein.
White whole milk yoghurt is a product in moderate amounts (!) Suitable for a low-carbohydrate diet in diabetes, including diabetic gastroparesis. This refers to white yogurt in the form of jelly, not liquid, not fat-free, without the addition of sugar, fruit, jam, etc.It is very common in Europe and the USA, but not in Russian-speaking countries. In such a yogurt for taste you can add stevia and cinnamon. Do not eat low-fat yogurt, because it contains more carbohydrates than is acceptable in diabetes.