Diabetes Mellitus
Manual of Clinical Nutrition Management III- 27 Copyright © 2013 Compass Group, Inc.
DIABETES MELLITUS: GASTROINTESTINAL COMPLICATIONS
Gastroparesis
Gastroparesis, also known as diabetic gastropathy, is characterized by an abnormal delay in the emptying of
foods, particularly solid foods, from the stomach (1). Gastroparesis occurs when the vagus nerve, which
controls the movement of food from the stomach through the digestive tract, is damaged (1). As a result, the
muscles of the stomach and intestines do not work normally and food moves slowly or stops moving through
the digestive tract (1). The most common cause of gastroparesis is diabetes mellitus, and it is usually
attributed to autonomic neuropathy (1). Symptoms associated with gastroparesis include nausea, vomiting
undigested food, early satiety, bloating, abdominal pain, and wide fluctuations in blood glucose levels (2).
Approaches: The following approaches are used for the medical management of gastroparesis (1).
Improve the patient’s glycemic control, as hyperglycemia slows the rate of gastric emptying (1,2).
Make changes to the patient’s insulin therapy, such as providing a bolus of insulin after eating instead of
before eating (3).
Consider the use of metoclopramide (Reglan), a dopamine antagonist with a central antiemetic effect.
This medication stimulates stomach muscle contractions to assist in stomach emptying and reduces
nausea and vomiting (1). Gastrointestinal side effects associated with metoclopramide include diarrhea.
Consider the use of erythromycin (EryPed), an antibiotic and motilin receptor agonist that increases
stomach muscle contractions. Side effects associated with erythromycin are nausea, vomiting, diarrhea,
abdominal pain and cramps, increased liver function tests, and jaundice.
In severe cases, consider jejunostomy enteral feeding or gastric neurostimulators (1).
Recommend postprandial exercise, such walking, because exercise increases solid-meal gastric emptying
in healthy individuals (1).
Because of limited evidence for the nutrition management of gastroparesis, dietary approaches and
recommendations are based on professional judgement and logical interpretation of gastric physiology (1).
Patients vary tremendously in their abilities to tolerate different types of foods, so recommendations must be
individualized. A certain amount of trial and learning is involved. Common food modifications for patients
with gastroparesis are designed to speed-up gastric emptying. These modifications include:
Lower the fiber content of the diet; especially avoid fibrous vegetables (such as oranges and broccoli) and
poorly digestible solids with limited gastric motility to reduce the risk of bezoar formation (1). Eat small,
frequent, balanced meals (six to seven per day) and avoid large meals.
Replace solid foods with liquid foods or blenderized meals (4). Puree or grind up solid foods, such as
meats, so that they may be better tolerated. Some individuals tolerate solids for the first one to two small
meals and then do better with liquids for the remainder of the day.
Avoid high-fat foods and extra fats such as butter, margarine, gravy, or mayonnaise that are added to
foods. Some individuals tolerate high-fat liquids such as whole milk and ice cream. Fat appears to be a
potent inhibitor of gastric emptying (1).
Sit up while eating and for 30 minutes after meals. Walking after meals may enhance stomach emptying.
Nausea and Vomiting
Possible causes of nausea and vomiting include neuropathy (gastroparesis), ketosis, and morning nausea
secondary to nocturnal hypoglycemia.
Approaches: The following approaches are used to relieve nausea and vomiting.
Morning nausea caused by overnight hypoglycemia will usually be relieved by eating breakfast.
Nausea and vomiting caused by ketosis will improve with metabolic stabilization.
For patients with nausea and vomiting caused by gastroparesis, an antiemetic drug should be part of the
treatment plan.
Constipation
The incidence of constipation is believed to be much higher in individuals with diabetes than in nondiabetic
individuals. Constipation in diabetes is related to problems with the autonomic nervous system (5). The
Nutrition Care Manual from the Academy of Nutrition and Dietetics provides a detailed discussion of
constipation in people with diabetes (1).