Diabetes & Gastroparesis: Gridlock in Your Gut

Common GI Problems

Over 60 million people in the U.S. are affected by gastrointestinal (GI) disorders, and people living with diabetes are certainly not immune to these problems. Many people will experience, at some time in their life, common issues with their GI tract, whether it’s ulcer disease, gallstones, irritable bowel syndrome, food poisoning, heart burn or some other malady. Up to 75% of people visiting diabetes clinics will report significant GI symptoms, and common complaints include constipation, abdominal pain, nausea, vomiting, and diarrhea.

Treatments provided in these situations are often no different between diabetics and non-diabetics. Nonetheless, it is apparent that in both the short and long term, poorly controlled diabetes can lead to specific GI problems. As with other complications, the longer you have diabetes and the poorer the glucose control, the more severe the GI problems may be. Many GI complications of diabetes seem to be related to abnormal function of the nerves supplying the gut. Just as the nerves in the feet may be affected in the condition known as peripheral neuropathy, involvement of the intestinal nerves may lead to enteric neuropathy.  This neuropathy may lead to abnormalities in intestinal motility (movement), sensation (pain), and secretion/absorption (digestion of foods). We co-exist with billions of bacteria living in our digestive tract and blood sugar levels as well as diet can have a significant impact on this human microbiome.

Gastroparesis

One of the most common forms of GI disorders for people with diabetes is gastroparesis. After eating, the stomach distends with food and digestive acid, then slowly contracts to mix, grind, and digest the meal. This involves a delicately coordinated process called peristalsis during which waves of muscular contractions force the food toward the outlet of the stomach. The contractions are coordinated with opening of the pylorus or “exit valve” of the stomach and the digested nutrients go into the small intestine where they are absorbed into the bloodstream and elevate the glucose values. The end result is gradual emptying of the stomach. In individuals with a long-standing history of diabetes, damage to the nerves supplying the stomach (for example, the Vagus nerve) and damage to the stomach muscles can lead to gastroparesis or impairment in stomach emptying. This can be very difficult to deal with because delayed and erratic stomach emptying leads to unpredictable food absorption and blood glucose levels that are difficult to control. This is particularly true in people with diabetes treated with insulin. If insulin is given at meal time and the food has not left the stomach yet into the small intestine, the person could get hypoglycemic as there is a mix match between insulin and nutrients being absorbed in the small intestine.

Symptoms & Diagnosis

Gastroparesis can occur in people with either type 1 or type 2 diabetes. It affects an estimated 40% of people with type 1 and up to 30% of people with type 2. Symptoms include bloating, distention, abdominal pain, nausea, or vomiting following a meal. Food and acid may back up into the esophagus (the bottom part of the throat), leading to symptoms of severe heartburn and regurgitation. Symptoms can vary depending on what and how much you eat. Everyone is different, but generally speaking you want to avoid anything that would normally sit in your gut, like a large steak. Fatty foods and very fibrous foods normally exit the stomach slowly and may be poorly tolerated as well. If you think you may have gastroparesis, your provider may run a variety of tests including a gastric emptying test in order to make an official diagnosis.

Treatments

There’s no known cure for gastroparesis, but medical treatment and lifestyle adjustments can help manage symptoms. Consumption of frequent small meals may provide some symptomatic relief. Liquid meals may be better tolerated in severe gastroparesis. It is important to not overeat at any meal as an over-distended stomach will empty even more slowly than usual. A dietician can offer suggestions on foods that digest more easily, including low fat foods and well-cooked veggies and fruits.

Medications such as Reglan (metoclopramide) stimulate the stomach (gastric) nerve endings damaged by long-standing diabetes and may improve delayed stomach emptying. Erythromycin is an antibiotic that has unique properties that stimulate stomach motility and may be beneficial in select individuals. Propulsid (cisapride) may also help accelerate stomach emptying but is no longer available in the United States because of cardiac side effects. Motilium (domperidone) is another agent that accelerates emptying of the stomach and is better tolerated than Reglan; however, it is not available in the United States (it is available in Canada and Mexico). Anti-nausea medications such as Zofran may help to provide symptom relief. A gastric pacemaker has been introduced that may help some individuals with diabetic gastroparesis, but its usefulness is very limited.

Newer agents that enhance stomach emptying will hopefully be available in the near future. Incretin mimetic type medications such as Symlin (pramlintide), Victoza (liraglutide), and Byetta (exenatide), Bydureon, Trulicity, Ozempic, etc. delay stomach emptying even further and may need to be stopped if gastroparesis symptoms are severe. Since these medications also reduce the appetite they sometimes prevent over eating, which can be a good strategy for limiting gastroparesis. Most importantly, careful attention to blood glucose control is essential. High blood sugar levels over both short and long periods of time can worsen stomach emptying and lead to increasing symptoms.

Prevention

So what can you do to help prevent the GI problems that may sometimes develop with diabetes? First and foremost, take care of yourself and use common sense. Exercise has been proven to provide benefit in fatty liver disease, diabetes, heart disease, and numerous other health conditions. You do not need to be a marathon runner to see benefit! Just 150 minutes per week or about 20 minutes per day of moderate exercise, including walking, have shown significant benefit.

Excellent control of your blood glucose will help prevent the complications of enteric neuropathy and worsening of your bowel function. Eat sensibly and follow a low-fat, high-fiber diet. It is difficult but try to avoid overeating, weight gain, and obesity since these are independent risk factors for the development of some GI problems, especially gallstones and fatty liver.

Obesity is a major contributing factor associated with type 2 diabetes and a low-fat, low-calorie diet along with exercise may lead to better blood glucose control and subsequently to a decreased incidence of long-term complications. Pay careful attention to your diet and try to avoid any food items that tend to precipitate symptoms. Fatty foods in particular may delay emptying of food from your stomach and will contribute to bloating, nausea, and vomiting in some individuals. Stress management is important as emotional factors will often affect GI motility and exacerbate intestinal problems.

Remember, GI problems are extremely common both in the general population and in individuals with diabetes. Many of these problems are readily treated by primary care physicians, diabetologists, gastroenterologists, and certified diabetes care & education specialists. Do not hesitate to discuss these problems with your physician, especially if the problems are persistent or are associated with other significant health-related conditions.

Additional Resources:

Heartburn, GERD, and Diabetes – Oh My