Thursday, January 13, 2011

Gastroparesis treatment and diet #1

STEP 1 DIET consists of liquids, which usually leave the stomach quickly by gravity alone. Liquids prevent dehydration and keep the body supplied with vital salts and minerals.
STEP 2 DIET provides additional calories by adding a small amount of dietary fat -- less than 40 gm each day. For patients with gastroparesis, fatty foods and oils should be restricted, because they delay stomach emptying. However, patients at the Step 2 level are usually able to tolerate this amount.
STEP 3 DIET is designed for long-term maintenance. Fat is limited to 50 gm per day, and fibrous foods are restricted, because many plant fibers cannot be digested.

Nutrition Facts
The STEP 1 Gastroparesis Diet is inadequate in all nutrients except sodium and potassium. It should not be continued for more than three days without additional nutritional support. STEP 2 and STEP 3 Gastroparesis Diets may be inadequate in Vitamins A and C, and the mineral iron. A multi-vitamin supplement is usually prescribed.

Allowed fruit juices:
apple juice, cranberry juice, grape juice, pineapple, prune juice, 
Not recommended juices: 
citrus juices, all fresh and dried fruits, canned fruits with skins  

Allowed vegetables:
vegetable juice (tomato, V-8); well-cooked vegetables without skins (acorn squash, beets, carrots, mushrooms, potatoes, spinach, summer squash, strained tomato sauce, yams)
Not recommended vegetables:
all raw vegetables; cooked vegetables with skins; beans (green, wax, lima), broccoli, Brussels sprouts, cabbage, cauliflower, celery, corn, eggplant, onions, peas, peppers, pea pods, sauerkraut, turnips, water chestnuts, zucchini 

Sweets & desserts*
hard candies, caramels, puddings & custards made from skim milk, frozen yogurt, fruit ice, gelatin, ice milk, jelly, honey, syrups  

Bread & grains
breads & cereals, cream of wheat, pasta, white rice, egg noodles, low-fat crackers
Not recommended: oatmeal; whole grain rice, cereal, bread  


 Milk & milk products
skim milk, products made with skim milk, low-fat yogurt, low-fat cheeses
Avoid: whole milk products, creams (sour, light, heavy, whipping), half & half  



NUTRITION - MALNUTRITION Dietitians recommend 6 small meals daily

Foods more easily digested   Foods increasing symptoms
fruit juices                 protein foods - meat, eggs
canned fruits & vegetables   raw fruits & vegetables
soft starches (white bread   dairy products
  & rice, mashed potatoes,
  cereals)                   caffeine, chocolate
soups                        nuts & seeds
baby foods
non-carbonated beverages
Liquid Nutritional Supplement Drinks

Diabetic: Choice dm (Mead-Johnson), Glucerna (Ross Labs)

             Ensure Glucerna OS (Ross Labs)

Non-diabetic:  Ensure/Ensure plus,  Sustacal (Ross Products Div)

 Nutrition via:

   IVs (fluids or TPN)

   Tube feedings (eq. Osmolite or Supplena)

PHYSICAL - Remaining upright at least a half hour after eating,

stomach massage, enemas, glycerine suppositories, stool softeners

(for example, psyllium husk powder: Metamucil and other brands)


Once gastroparesis has been confirmed as the major cause of high overnight blood sugars and wide random variations in blood sugar profiles, we can begin to attempt to control or minimize its effects. If your blood sugar profiles reflect significant gastroparesis, there is no way to get them under control by only juggling doses of insulin. There’s just too much danger of either very high or very low blood sugars for such approaches to work. The only chance for effective treatment is to concentrate on improving stomach-emptying.
How do we do this?
We have four basic approaches. First is the use of medications. Second is special exercises or massage during and after meals. Third is meal plan modification utilizing ordinary foods, and fourth is meal plan modification utilizing semiliquid or liquid meals. It’s unusual for a single approach to normalize blood sugar profiles fully, so most often we try a combination of these four approaches, adapted to the preferences and needs of the individual. As these attempts
start to smooth out blood sugars, we must modify our doses of insulin or ISAs accordingly.
The guidelines that we use to judge the efficacy of a given approach or combination of approaches are these:
• Reduction or elimination of physical complaints such as early satiety, nausea, regurgitation, bloating, heartburn, belching, and constipation
• Elimination of random postprandial hypoglycemia
• Elimination of random, unexpected high fasting blood sugars—probably the most common sign of gastroparesis that we encounter
• Flattening out of blood sugar profiles

Most of these symptoms, as well as effects upon blood sugar, relate to delayed stomach-emptying. This condition is called gastroparesis diabeticorum, which translates from the Latin as “weak stomach of diabetics.”  It is believed that the major cause of this condition is neuropathy (nerve impairment) of the vagus nerve. This nerve mediates many of the autonomic or regulatory functions of the body, including heart rate and digestion. In men, neuropathy of the vagus nerve can also lead to difficulty in achieving penile erections. To understand the effects of gastroparesis, refer to Figure 22-1.

On the left is a representation of a normal stomach after a meal. The contents are emptying into the intestines, through the pylorus. The pyloric valve is wide open (relaxed). The lower esophageal sphincter (LES) is tightly closed, to prevent regurgitation of stomach contents. Not shown is the grinding and churning activity of the muscular walls of the normal stomach.

On the right is pictured a stomach with gastroparesis. The normal rhythmic motions of the stomach walls are absent. The pyloric valve is tightly closed, preventing the unloading of stomach contents. A tiny opening about the size of a pencil point may permit a small amount of fluid to dribble out. When the pyloric valve is in tight spasm, some of us can sometimes feel a sharp cramp above the belly button. Since the lower esophageal sphincter (LES in Figure 22-1) is relaxed or open, acidic stomach contents can back up into the esophagus (the tube that connects the throat to the stomach). This can cause a burning sensation along the midline of the chest, especially while the person is lying down. I have seen patients whose teeth were actually eroded over time by regurgitated stomach acid.

Because the stomach does not empty readily, one may feel full even after a small meal. In extreme cases, several meals accumulate and cause severe bloating. More commonly, however, you may have gastroparesis and not be aware of it. In mild cases, emptying may be slowed somewhat, but not enough to make you feel any different. Nevertheless, this can cause problems with blood sugar control. Consuming certain substances, such as tricyclic antidepressants, caffeine, fat, and alcohol, can further slow stomach-emptying and other digestive processes.


Low Residue Diet for Gastroparesis

Because the stomach is emptying more slowly, the Gastroparesis and Dysmotilities Association recommends a low residue diet of foods that are easy to digest. This includes foods that are processed and refined such as white breads, white rice and cereals which are often not considered part of a healthy diet.
Because fiber is hard to digest, patients with gastroparesis should avoid foods with high fiber content like:

  • beans
  • bran
  • high-fiber breads and cereals
  • nuts and seeds
  • dried fruits
  • raw fruits like berries, oranges, apples and persimmons
  • high fiber vegetables such as peas, broccoli, Brussels sprouts, corn, sauerkraut, tomato and potato skins
People with gastroparesis should also avoid high-fiber laxatives like Metamucil and Benefiber as these maybe hard to digest. Too much undigestible fiber can lead to formation of a bezoar, an undigested mass that can block the stomach or intestines and lead to an obstruction.
A lowfat diet is also preferred. Fat digests more slowly and can take awhile to leave the stomach. This can make it difficult for some people to get enough calories in their diet. Liquid fats like milkshakes maybe helpful to prevent weight loss due to gastroparesis.
Some people may find solid foods more difficult to digest and require a blender or food processor to liquefy their food before eating. Most people with gastroparesis can digest liquids, even when solids are a problem. Smoothies are a great way to ensure appropriate nutrition and help to decrease symptoms from digesting solid foods. Nutritional supplements like Boost and Ensure may also be helpful.

Dietary Changes for Patients with Gastroparesis

People with gastroparesis often must alter their dietary habits to help decrease the symptoms of their condition. This involves a lifestyle modification that includes:
  • eating small meals more frequently
  • keeping a food diary for particular foods that cause problems
  • reducing stress
  • not lying down after eating
  • exercising to improve digestion
Most people with gastroparesis will do well with treatment and following the low residue diet. Anyone with questions about gastroparesis or the low residue diet should contact their healthcare provider or a nutritionist for more information.

Diet is one of the mainstays of treatment for those who suffer from gastroparesis. Some foods are more difficult than others for the stomach to digest. Fatty foods take a longer time to digest, as do foods that are fibrous, like raw vegetables. People with gastroparesis should reduce their intake of fiber or avoid these foods. Fiber when eaten should be chewed well and cooked until soft. Food that is poorly digested can collect in the stomach and form what is called a bezoar. This mass of undigested matter may cause a blockage, preventing the stomach from emptying and result in nausea and pain. In such a case, it may be necessary to use endoscopic tools to break the bezoar apart and remove it. Fortunately, even when stomach emptying is significantly impaired, thick and thin liquids (e.g. pudding and nutrient drinks) are usually tolerated and can pass through the stomach. Many people with gastroparesis can live a relatively normal life with the aid of supplemental nutritional drinks, soft foods the consistency of pudding and by pureeing solid food in a blender. Feeding tubes placed in the small intestine (jejunostomy) may be required if gastric paralysis is severe and a person is unable to manage with a pureed or soft diet. These feeding tubes are usually placed endoscopically or surgically through the skin and directly into the small intestine (figure 1). 
Specific dietary changes play an important role in controlling gastroparesis. Changes in diet is the right approach to improve the patient's health. Doctors often recommend to have small frequent meals (6 to 8 meals daily) instead of having large meals twice a day. The stomach will require more effort to digest a super sized meal than a lighter snack. Pureed or a liquid diet will be better tolerated, as liquids can easily and quickly pass through the stomach. When it comes to eating food some guidelines should be followed by gastroparesis patients. It is necessary to avoid high fiber and high fat foods.

Fiber is mainly found in raw vegetables and fruits, legumes and whole grains. As the stomach will take extra time to digest fiber foods, the intake of these foods must be minimized. For this reason people diagnosed with gastroparesis, are often recommended to have low fiber foods, well cooked vegetables, fish and refined breads. This is because fat slows down the process of digestion and fiber cannot be easily digested. The indigestible part of food forms bezoars in the stomach. Foods that can cause bezoars include berries, dried figs, coconut, apples, tomato peels, potato, brussels sprouts and corn.
High fiber foods such as broccoli and orange contain nutrients that are simply difficult to digest. Indigestion is something that cannot be tolerated as the stomach is already weak in this condition. An important point to note is the food that cannot be digested remains in the stomach, and can cause further complications.

Fried or greasy vegetables can aggravate the symptoms, hence it must not be consumed. To fulfill the requirement of calories and nutrients contained in high fat liquids, one can have small servings of rich drinks such as milkshakes. The diet for gastroparesis must contain adequate protein and calories. This can be easily achieved by taking nutritional supplements like Ensure, Boost or Glucerna.

People with gastroparesis are comfortable eating pureed food and soups. The process of pureeing involves crushing fruits and vegetables to make a thick paste (sauce). Almost any type of food can be pureed. As gastroparesis patients are not allowed to eat high fat foods, deficiency in essential nutrients such as calcium, iron and vitamin B-12 may occur. To compensate the loss, one can include mineral supplements in their diet.

Vomiting is the most common symptom of gastroparesis. This often leads to dehydration (loss of water). So it is necessary to have plenty of water in a day. One can also have fruit and vegetable juices. The daily dosage of fluids required by the body needs to be fulfilled in order to stay healthy.

Most patients respond well consuming pureed foods and nutritional supplements. But some people with gastroparesis suffer from severe stomach problem. As a result, they are not able to tolerate any liquids or food. In such a case, the doctor may insert a feeding tube into a small intestine.

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