Gastroparesis: a silent enemy of diabetes

We know that people living with diabetes are at risk for many complications. While eye, kidney and heart disease get a lot of attention, what about complications affecting the stomach?

Many people with diabetes experience gastrointestinal symptoms such as nausea, bloating and abdominal pain, diarrhea, constipation and slow emptying of the stomach. Changes in the movement of food through the digestive system also cause an overgrowth of bacterial flora, which aggravates the problem.

One of the best known, but also most ignored, stomach disorders is gastroparesis, which occurs in 12 to 15% of people living with diabetes. Research also shows that 30 to 50% of people with long-standing type 1 or type 2 diabetes have slow emptying of the stomach.

Why is it ignored? As the mother of a daughter with type 1 diabetes, I believe that the person living with diabetes does not associate the symptoms of gastroparesis with the evolution of their condition. Therefore, they do not communicate it to their doctor, who focuses on blood glucose control instead. As a result, an opportunity is missed to ask key questions that would help assess nutritional status and its relationship with diabetes management.

People with diabetes and the health professionals who look after them must work as a team to tackle this silent enemy of diabetes.

What is gastroparesis?

Gastroparesis is a condition when the stomach takes a long time to empty its contents into the small intestine. It is also referred to as delayed gastric emptying, gastric stasis, slow stomach, lazy stomach, and diabetic enteropathy. It usually occurs in people who have been living with diabetes for at least 10 years, and typically presents together with complications of the eye, kidney and others linked to the nervous system.

Normally, when food is swallowed, the muscles in the stomach wall help break the food down into smaller pieces, pushing it into the small intestine to continue digestion. This action is controlled by the vagus nerve, part of the so-called “autonomic nervous system”, which automatically regulates many bodily functions such as breathing and heart rhythm. If the vagus nerve is damaged or stops working, the muscles in the stomach and intestines do not function normally, and the movement of food stops or slows down. If the food stays in the stomach too long, the food ferments and causes an overgrowth of gas-producing bacteria.

This explains symptoms such as feeling full, both shortly after starting a meal and long after finishing eating, reduced appetite, belching, bloating and pain in the abdomen and stomach reflux that cause heartburn, nausea and vomiting. The food may also harden into solid masses called bezoars, which can cause nausea, vomiting and stomach obstruction. Bezoars can be dangerous if they block the passage of food to the small intestine.

Managing gastroparesis

In people with diabetes, optimal treatment requires a multidisciplinary approach and should initially aim to alleviate gastrointestinal symptoms and improve nutritional status and glycaemic control. This can improve gastric motor function. The effects of vomiting and nausea, which can lead to weight loss, dehydration, and electrolyte dysregulation, should not be ignored in people with diabetes. Treatment is more complicated when pain is a symptom, since many painkillers, the first line of treatment, worsen gastric motor function. From a nutritional point of view, there is no clear guide on how to act, although frequent and light meals, reduced consumption of fats and fibre (which reduce gastric emptying) and adjusting the intake of carbohydrates, can alleviate the symptoms and improve glycaemic control.

In general, targeting nutrition, liquid intake, relief of symptoms and glycaemic control are the cornerstones of treatment for gastroparesis. In some cases, medications that facilitate stomach emptying may be helpful. Good glycaemic management often involves customising insulin delivery using basal-bolus insulin and technology, including sensor-augmented pumps and continuous glucose monitoring systems (CGMs). For example, the timing of mealtime insulin may need to be adjusted to account for delays in stomach emptying.

Gastroparesis may require surgical treatment in some people.

The importance of diet

A meal plan should be considered a top priority. Unfortunately, diabetes is very complex in terms of what diet to follow based on individual needs. In the past, a single “diet plan” was considered enough, but this has lost credibility as a result of a better understanding of the differences between individuals.

It is now recommended that a dietitian or nutritionist work alongside other health professionals in the treatment of people with diabetes, particularly if they have stomach disorders like gastroparesis. Every person with diabetes should have a dietary plan that considers their unique nutritional needs, lifestyle, culture and the evolution of their condition.

My daughter has lived with gastroparesis for ten years. It has not weakened her but made her a stronger person. She pays more attention to what she eats – the amount, texture, and type of food – and how often she eats it. Her secret, apart from her nutritionist, her “pancreas-mom” and her doctor, has been the support of groups on social media.

Only a health professional can give an accurate diagnosis of gastroparesis. If you are living with diabetes and experience any of the symptoms, please avoid self-medication and consult a health professional. If you are a health professional, make sure to ask the people with diabetes that you look after whether they are experiencing any of the symptoms. As a Canadian physician and one of the founding professors of Johns Hopkins Hospital, William Osler once said, “The good doctor treats the disease; the great doctor treats the patient who has the disease.”