Recommendations include eating small frequent meals, chewing foods well, and limiting insoluble fiber.
Gastroparesis, defined as “delayed gastric emptying in the absence of mechanical obstruction of the stomach,” is a common disease complication.
It occurs, with potentially debilitating nutritional consequences, in as many as 12% of patients with long-standing diabetes (N Engl J Med. 2007;356:820-829) and an estimated 50% of people on dialysis.
Factors contributing to the development and exacerbation of gastroparesis include diabetic neuropathy, which affects the vagus nerve in the GI tract, and acute hyperglycemic episodes that can diminish antral gastric contractions. Additionally, increased levels of the glucose-regulating hormone glucagon as well as use of certain oral hypoglycemic agents (e.g., pramlintide, exenatide) can slow digestion and gastric emptying.
In a review of gastroparesis in type 2 diabetes, Intagliata and Koch (Curr Gastroenterol Rep. 2007;9:270-279) discuss the prevalence of GI issues in this growing population of patients who also represent a large proportion of those with CKD.
The authors note that “once a patient is diagnosed with diabetic gastroparesis, a multidisciplinary treatment plan should encompass medical, nutritional, and lifestyle interventions to alleviate gastric symptoms and improve glucose control.”
People with diabetic gastroparesis commonly complain of early satiety, nausea and vomiting after eating, abdominal discomfort, bloating, gastroesophageal reflux, and fluctuations in blood sugar control. Current dietary and pharmacologic recommendations are outlined by the American Motility Society and the American Gastroenterological Association according to disease severity, which is defined by the percentage of gastric retention at four hours.
Since liquids tend to empty from the stomach more easily, use of nutritional supplement drinks are suggested for all patients who are symptomatic. Tube feedings via percutaneous endoscopic jejunostomy (PEJ) should be considered for patients with severe gastroparesis (greater than 35% gastric retention after four hours). Compassionate use of gastric electrical stimulation or gastric pacemaker may be beneficial as adjunct therapies.
An expert on the subject of gastroparesis, Carol Rees Parrish, RD, MS, nutrition support specialist at the University of Virginia Health System Digestive Health Center of Excellence, spoke recently at the 2009 National Kidney Foundation Spring Clinical Meetings in Nashville to offer practical advice regarding nutritional assessment and dietary treatment of gastroparesis in CKD.
She notes that unplanned weight loss of 5%-10% within three to six months in hemodialysis patients may be a red flag for clinicians to investigate delayed gastric emptying as a possible causative factor.
Setting a weight goal in collaboration with the patient is a key first step in determining when nutrition support should be initiated, with weight loss to below the set target an indication for prompt nutrition intervention.
Although there are limited scientific data with regard to the effects of dietary components on gastric emptying, nutrition recommendations based on best clinical practice are summarized by Ms. Parrish as follows (Curr Gastroenterol Rep. 2007;9:295-302):
- Eat small frequent meals, since high volumes can slow gastric emptying and may also trigger esophageal reflux.
- Limit insoluble fiber, which may encourage bezoar (a collection of undigested food residue) formation and GI obstruction. Avoid fiber-containing enteral formulas in patients with small-bowel bacterial overgrowth, as the fiber source may lead to increased symptoms of bloating, gas, and abdominal discomfort.
- Liquids may be better tolerated than solids as a source of calories and protein. Advising patients to chew foods well and considering a trial of mechanically altered foods (pureed, ground) may be beneficial.
- Fat does not necessarily need to be limited and can provide important additional calories, especially as a component of liquid enteral supplements.
- Improve blood sugar control via close monitoring and hypoglycemic agents. Diet should be kept liberal to maximize nutritional intake and adjusted as symptoms improve.
- Sitting up for at least one to two hours after eating can facilitate gastric emptying.
- Avoidance of alcohol and caffeine may be helpful.
When managing gastroparesis medically, consider the following:
- Use of bulk-forming agents for constipation may be contraindicated since they may be retained in the stomach and lead to bezoar formation. Stool softeners may be a better option.
- Avoid narcotics, which will further slow GI motility.
- Liquid or chewable vitamins are preferable to tablets.
- Prokinetic and anti-emetic medications should be given on a specific schedule rather than on as an-needed basis.
Additional diet information for people with gastroparesis and kidney disease can be found here, accessed April 3, 2009.