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Type 1 Diabetes and Type 2 Diabetes During Pregnancy Diabetes Symptoms, Risks Treatment For Diabetes

What are the causes and symptoms of diabetes? Diabetes is a serious disease in which your body cannot properly control the amount of sugar in your blood because it does not have enough insulin. Diabetes is the most common medical complication during pregnancy, representing 3.3% of all live births. No matter what type of diabetes you have, there are many steps you and your health care team can take in order to have a safe and healthy pregnancy. What are the causes and symptoms of diabetes? There are two primary types of diabetes.

Type 1 diabetes is an autoimmune disease that requires daily use of insulin. Symptoms of Type 1 may include increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. Often diagnosed in childhood and in young adults, this type of diabetes accounts for about 5 to 10% of diagnosed cases in the United States. Type 2 diabetes is the most common form of diabetes, accounting for about 90-95% of diabetes cases in the United States. Symptoms of Type 2 include bladder or kidney infections that heal slowly, increased thirst and urination, constant hunger and fatigue.

This form of diabetes is often associated with older age, obesity, family history, previous history of gestational diabetes, physical inactivity, and it can be more prevalent in certain ethnic groups. How is pre-existing diabetes treated during my pregnancy? Whether you are trying to conceive or already pregnant, treating diabetes during pregnancy is key to the health of both you and your baby. • Take time to build your health care team and devise a care plan to manage your blood glucose levels. Frequent contact with your health care provider is essential in managing blood glucose levels and monitoring the health of you and your baby. • Talk to your health care provider, or dietitian, to develop a healthy meal plan. Prioritizing proper nutrition will assist in controlling your blood sugar both before and after conception. • Tell your doctor about any current medications you are taking for diabetes, or any other health conditions so you can take what is safest during your pregnancy.

• Make appointments with the appropriate high-risk specialists. Specialists may include a perinatologist who treats women with high-risk pregnancies, and an endocrinologist who treats women with diabetes and other health conditions. • Stay physically active. You will want to be in the best physical condition during your pregnancy. What are hypoglycemia and hyperglycemia, and how can they affect my pregnancy? Hypoglycemia and hyperglycemia are both common in women with preexisting diabetes. Hypoglycemia occurs when blood glucose levels are too low. When blood glucose levels are low, your body cannot get the energy it needs. You may be experiencing this if you are: • Experiencing blurred vision • Having unexplained fatigue • Concerned about sudden changes in your mood Hypoglycemia can be triggered by: • Skipping or delaying meals • Eating portions that are too small • Overexerting yourself physically Typically hypoglycemia is treated by eating or drinking something containing sugar, such as orange juice.

Hyperglycemia is when your body doesn’t have enough insulin or can’t use insulin correctly. You may be experiencing this if you are: • Always thirsty • Suddenly losing weight • Using the bathroom often Hyperglycemia can be triggered by: • Improper balance in your food consumption • Problems with the amount of insulin you are taking • Stress • Sickness • Lack of physical movement Typically hyperglycemia is treated by adjusting your insulin dosages. What are the risks of diabetes to my unborn child? There are a few potentially negative health risks to the baby when the mother has diabetes.

• Macrosomia is a condition in which your baby grows too large due to excess insulin crossing the placenta. A large baby can make vaginal delivery difficult and increase the risk of injury to the baby during the birth process. • Hypoglycemia, or low blood sugar, can develop shortly after birth due to high insulin levels. Controlling your own blood sugar can help to lower the risks of hypoglycemia for your baby. • Jaundice is a yellowish discoloration of the skin and eyes and can sometimes be attributed to diabetes while pregnant.

Your pediatric care provider will assist you with a plan to alleviate this condition for your newborn. What are some other considerations? There are a few other items to keep in mind: • During labor and delivery, your blood glucose will be managed closely to ensure a safe delivery. Partnering with your health-care team and support partner will help ease any concerns you may have during labor. • Be sure to complete your postpartum care, in order to achieve a healthy weight with daily exercise and sound nutrition. Taking care of your body postpartum is important to managing glucose levels and remaining healthy. • Research and decide key items about your baby’s nutrition after birth. Some studies suggest breastfeeding can lower the risk of diabetes in your newborn. Thousands of women each year are able to navigate diabetes in pregnancy with favorable results.

Remember to manage your glucose levels, prioritize proper nutrition and exercise, and stay connected to your health care team. Medically managing your diabetes is key for your health and the success of future pregnancies..


Good Desserts For Diabetics

Delicious diabetes friendly office snacks ideally you will be hungry for snacks about two or three hours after your main meals

If you are hungry less than two hours after your meal this might be a reason to evaluate if you are eating balanced and needs foods high in carbohydrates unloading protein and traget tend to digest more quickly raise your blood glucose levels and leave us wanting more too full

Here is a list of office ready dabit is friendly snacks they are tasty low carb and ready in seconds six ounces plain Greek yogurt plus 1/2 cup of apples and plus one tablespoon of silvered almonds sprinkled with 1/2 teaspoons of cinnamon apples are one of the highest fiber fruits makes them lower on the glycemic index which can help keep your blood sugar control especially one mixed with the high protein plain Greek yogurt and healthy fat filled high-fiber almonds make the snack office friendly by bringing the bulk ingredients on Monday so it is all ready all week long take a bowl and add Apple pieces some almonds two tablespoons of yogurt and two tablespoons of cinnamon powder mix

All of them well a friendly diabetic salad is ready slices brown bread plus 1 cup tomatoes drizzled with 1 tablespoon of balsamic vinegar plus 3 to 4 chopped wood bas-reliefs take a bread slice add tomato slices Chapra basa leaves some vinegar and close it with another bread slice now the delicious caprese salad is ready tomatoes contain vital nutrients like vitamin C iron and vitamin G they are even considered a superfood by the American Diabetes Association so feel free to enjoy built free and often to slice whole-wheat bread plus one way for the avocado not only is avocado toast trendy but it is healthy to grab the slice of whole wheat bread and spread 1/4 of the avocado on top finish with your favorite salt free toppings such as a red pepper chili flax or garlic powder this combo will keep you full for hours with the high-fiber complex carbs and healthy fats diabetes friendly snack is ready one cup of green tea plus 1 ounce almonds plus 1 small apple green tea both increases your metabolism unhide ratio which helps dilute your blood and lower blood sugar levels almonds and apples provide the perfect balance of carbohydrates protein and healthy fats by taking all the above diabetic friendly snacks you can reduce diabetes can diabetics eat popcorn

Popcorn is one of life’s little snacking pleasures while people with diabetes should try to avoid the highly salted and butter evasions popcorn can still be safely incorporated into the diabetic diet in its unprocessed form popcorn is considered a significant source of whole-grain fiber in addition one serving of popcorn has a very low glycemic load compared to traditional snack foods so as long as it is consumed in moderation popcorn makes a healthy addition to the diabetic diet diabetic portion size of popcorn individuals with diabetes can consume between 15 to 30 grams of carbohydrate for snacks no more than two servings or six cups of popcorn should be consumed at one time most individual one ounce bags of microwave popcorn bags contain approximately 21 grams of carbohydrate making these portions perfect for individuals with diabetes nutritional content – popcorn like any whole-grain source of carbohydrate a proper and unprocessed popcorn is an excellent source of nutrients for individuals with diabetes most light popcorns contain 8200 calories and 3 grams of fiber per serving.


What is Peripheral Neuropathy and How is it Treated?

I’d like to talk to you about peripheral neuropathy. This is a condition where there is disease or damage to nerves which affects sensation, movement, organ or gland function. Oftentimes patients have symptoms where there is numbness, burning, tingling, pins and needles – they may have weakness, imbalances, or even poor bladder control.

Another thing that is notable is an inability to sweat in some cases. These are very unusual symptoms and a lot of people don’t know what’s going on with them and they’re looking for answers. What are the causes? There’s a long list – but at the very top of this list is diabetes. What we’ve seen with a lot of patients is that once you find this underlying cause, there’s a way to manage their problem systemically and we can help gear that to treatment. One of the things that we’ve noticed over the years is that a lot of clinics out there try different treatments and a lot of these clinics aren’t really finding out what the root cause is, so they have no idea what they’re going after and what they’re trying to accomplish.

Yes, maybe the patient may feel better short term, but what are the long-term implications? So it’s important to make a diagnosis. We take a lot of time to make a very detailed diagnosis. We will spend a lot of time on the history and physical examination and especially the neurological examination. We will send patients out for nerve conduction studies or EMGs. We will have patients go out for MRI studies. We will often get blood work so we can look at different vitamin panels or hormone levels. Sometimes it’s genetic tests that are needed. I’ve had patients where I’ve had to go the extent of doing a biopsy to check the nerve fibers in their skin. In rare cases, I’ve had to take a local anesthetic and need to find out why a particular nerve is hurting in that leg or that foot – that’s called a diagnostic nerve block.

All of these things are necessary tools to find out what’s going on so that we can create a suitable treatment for these patients. When we talk about treatments – I’ve had a vast number of patients come to me and say, ‘I’m taking these medications and I don’t really know what they’re doing. This one’s an anticonvulsant, or this one’s an antidepressant.’ That’s pretty commonplace in our current or modern medicine. When it comes to treatment for peripheral neuropathy, we don’t like a bandied approach. We have a lot of patients that are taking a whole bunch of medications that they don’t even know what they are and what they’re doing.

That’s a big problem. We try to stick to very strict guidelines that are well accepted across the medical community nationally and internationally. FDA-approved modalities to treat peripheral neuropathy. We do a lot of stuff here in our office, some of these treatment regimens may go from 6 weeks to 6 months, or even longer. We like to use Neutraceuticals, or medical food, as prescriptions. This is a wonderful way to get great supplements into the body for patients who are otherwise lacking it, or need the supplementation to heal these nerve problems.


Most Common Symptoms Of Type 2 Diabetes

Symptoms of Type 2 Diabetes The symptoms of type 2 diabetes develop gradually – so gradually, in fact, that it’s possible to miss them as related symptoms. The symptoms develop gradually because, if you have the insulin resistant form of type 2, it takes time for the effects of insulin resistance to show up. Your body doesn’t become insulin resistant overnight. Common Symptoms Here are some of the common symptoms of type 2 diabetes: 1. Blurry Vision In an attempt to get more fluid into the blood to counteract the high blood glucose level, your body may pull fluid from the eyes. You may have trouble focusing then, leading to blurry vision. 2. You’re Too Thirsty No matter how much you drink, it feels like you’re still dehydrated. This is also associated with increased urination. 3. Peeing More Frequent This is related to drinking so much more in an attempt to satisfy your thirst.

Since you’re drinking more, you’ll have to urinate more. 4. You’re Too Hungry Even after you eat, you may still feel very hungry. That’s because your muscles aren’t getting the energy they need from the food. 5. You’re Loosing Unplanned Weight You may be eating more but still losing weight. Since your body isn’t getting energy from food, it turns to muscles and fat and starts to break them down in order to create energy. 6. You Get Infections The effects of type 2 diabetes make it harder for your body to fight off an infection, so you may experience frequent infections. Women may have frequent vaginal and/or bladder infections. 7. Your Wounds Are Healing Slowly Similar to the body’s inability to fight off infections, it might take longer for wounds to heal. The high blood glucose level affects how well the white blood cells work.


Curing Painful Diabetic Neuropathy

“Curing Painful Diabetic Neuropathy” Neuropathy, or damage to the nerves, is a debilitating disorder. Diabetes is by far the most common cause. Up to 50% of diabetics will eventually develop neuropathy during the course of their disease. It can be very painful, and the pain is frequently resistant to conventional treatments. In fact there is currently no effective treatment for diabetic neuropathy. Clinicians rely on steroids, opiates, and antidepressants to try to mediate the suffering. But, 20 years ago, a remarkable study was published on the regression of diabetic neuropathy with a plant-based diet.

There are two types of diabetic neuropathy: a relatively painless type characterized by numbness, tingling and pins-and-needles sensations, and then a second form, which is painful with burning or aching sensations to the point of excruciating, lancinating—stabbing—pain. This paper concentrated on the painful type. Twenty-one diabetics suffering with moderate or worse symptomatic painful neuropathy for up to ten years were placed on a whole-foods, plant-based diet along with a half-hour walk every day. Years and years of suffering and then, complete relief of the pain in 17 out of the 21 patients within days.

Numbness noticeably improved too. And the side-effects were all good. They lost ten pounds, blood sugars got better— insulin needs dropped in half, and in five of the patients, not only apparently was their painful neuropathy cured, so was their diabetes. Normal blood sugars off of all medications. And their triglycerides and cholesterol improved too. High blood pressure got better too. In fact gone in about half the hypertensives— an 80% drop overall in the need for high blood pressure medications within three weeks. Now this was a live-in program, where patients meals were provided. What happened after they were sent home? The 17 folks were followed for years, and in all except one, the relief from the painful neuropathy continued or improved even further. How’d they get that kind of compliance? Pain and ill health are strong motivating factors. One of the most painful and frustrating conditions to treat in all of medicine and 75% cured in a couple days with a natural nontoxic— in fact beneficial—treatment, a diet composed of whole, plant foods. How could nerve damage be reversed so suddenly? It wasn’t necessarily the improvement in blood sugar control, since it took about ten days for the diet to control the diabetes, whereas the pain was gone in as few as four.

There are several mechanisms by which the total vegetarian diet works to alleviate the problem of diabetic neuropathy as well as the diabetic condition itself. Their most interesting speculation was that it could be the trans fats naturally found in meat and dairy and refined vegetable oils that could be causing an inflammatory response. They found a significant percentage of the fat found under the skin of those who ate meat or dairy consisted of trans fats, whereas those on a strictly whole food plant-based diet had none. They stuck needles in the buttocks of people eating different diets, and nine months or more on a strict plant-based diet appeared to remove the trans fat from their bodies…or at least their butts. But their pain didn’t take nine months to get better; it got better in days. More likely it was due to an improvement in blood flow. Nerve biopsies in diabetics with severe progressive neuropathy have shown small vessel disease within the nerve. There are blood vessels within our nerves that can get clogged up.

The oxygen levels in the nerves of diabetics were found to be lower than even that of de-oxegenated blood. This lack of oxygen within the nerve may arise from blockages within the blood vessels depriving the nerve oxygen, presumably leading them to cry out in pain. Within days, though, improvements in blood rheology, the ease of blood flow on a plant-based diet may play a prominent role in the reversal of diabetic neuropathy. Plant-based diets may also lower the level of IGF-1 inside the eyeballs of diabetes and decrease the risk of retinopathy— diabetic vision loss—as well. But the most efficient way to avoid diabetic complications is to eliminate the diabetes, and this is often feasible for those type 2 patients who make an abiding commitment to daily exercise and a healthy enough diet.

Since the initial report of neuropathy reversal, the results have been replicated, significant improvements in numbness and burning. Why didn’t I learn about this in medical school? The neglect of this important work by the broader medical community is nothing short of unconscionable..


Diabetes/Endocrine ECHO: Gastroparesis – 2/16/17

Everybody a lot of very interesting ceiling shots this morning. Just kidding, just kidding So we have, we’ve had a couple of cases submitted and we are also going to talk about diabetic gastroparesis.

The most important piece of this discussion actually is the nutritional piece and Carmela is homesick but if our technology works properly she’ll still be able to present her piece of the presentation and we should be able to have her PowerPoint up for everybody’s review. But I’d like to do a couple of cases first and then go from there if that’s okay, and while we’re getting rolling if anybody has any cases that they want to bring forward this morning thinking about it now and we can, and we’ll get back to them.

Alright so diabetic gastroparesis then this is going to work for me right So this is this is a challenging issue not very common but probably a little bit more common than we than we tend to think about it so the point that I want to make first of all is we’re going to talk about the stomach but remember that diabetic neuropathy can affect any part of the bowel but discussion of diarrhea and constipation be related to diabetic bowel dysfunction I think is a topic for a second talk. So I wanted to stick to the stomach for this talk. Remember that GI complaints are enormously common, right? So that if you take the folks who walk into your office somewhere between 10 and 20% are going to have some functional GI complaint; bloating, gassiness, intermittent nausea, etc.

So just in the general population, there’s a lot of complaining about GI distress and the fact is that that makes it a little hard to know whether or how prevalent GI distress separate and above the background noise is related to diabetes. But in a very carefully done population study it seemed pretty clear that people with both type 1 and type 2 diabetes have more GI symptomatology than the non- diabetic population and there’s a clear correlation of degree of symptomatology with a degree of glycemic control. So bad my glycemic control begets more GI symptomatology and patients with type 1 disease, type 1 diabetes are more likely to have diabetic gastroparesis than our patients with type 2.

You know the fact is that type 1 patients when they develop microvascular complications tend to have a more aggressive clinical course than do patients with type 2 in general and that applies here as well and in my practice experience,  the patients with type 1 diabetes with gastroparesis were devastated by this problem. Patients with type 2 diabetes and disturbed gastric function were moderately annoyed but the type 1 patients were absolutely devastated and was devastating for me because managing them was so difficult. The other thing to remember is that our typical GI function testing is not all that great, I think we have false positives and false negatives with gastric emptying studies and to a great degree if they support our initial feelings about this patient, that’s great but they don’t always and in general we need to make diagnosis and treat patients oftentimes on clinical grounds alone.

So diabetic gastroparesis is a manifestation of autonomic dysfunction, it often comes with other evidence of autonomic dysfunction. So patients can have orthostatic hypotension, they can have abnormal sweating and the term that is used sometimes is gustatory sweating, does that sound familiar to anybody? So gustatory sweating is sweating that happens when you eat. So you’ll eat something and you know you’ll people start sweating, it’s an abnormal autonomic effect of gastric distension. Autonomic neuropathy tends to be a linked complication, right? So we almost never see autonomic neuropathy whether it’s gastroparesis or orthostasis in the absence of other evidence of diabetic microangiopathy and in fact if a patient has no other evidence of diabetic complications I would be very hesitant to think that they could have diabetic gastroparesis. So what other things might you see? Well,  they might have some evidence of retinopathy, even if it’s just microaneurysms which you can detect in your office visit that would lead me to think that this is possibly connected.

If they have peripheral neuropathy I’m more apt to believe that autonomic dysfunction is present. But if they had none of those things, I’m thinking there’s something else going on, okay? Alright and just like other neuropathies,  this has to do with a loss of neuronal mass, right. So this is a fall out of nerve endings and just like a skeletal muscle that loses function after a stroke right, it’s because of the innervation of those muscles, right. And in gastroparesis we’re talking about muscular dysfunction right, the stomach is not contracting normally and it’s because you’ve lost vagal mass right. So it’s not a muscle thing its loss of nerve function the muscle becomes denervated and dysfunctional. So one of the typical symptoms if there are any, early satiety right. So the stomach doesn’t empty people get filled more quickly sometimes they feel full for a long time after a meal because again stomach is not empty. They’re bloated, they’re nauseated and if they’re vomiting they often vomit you know chewed food. So they’ve chewed and it’s been lingering in the stomach and it comes back. Abdominal pain not terribly typical in patients with gastroparesis. You got to differentiate pain from bloating right, so patients bloating may say that it’s painful but it’s a different thing.

Patients with abdominal pain it’s much less common in diabetic gastroparesis. Physical examination not terribly helpful does anybody remember the succussion splash from physical diagnosis? Even a single hand, am I that much older than everybody else? Okay So try this on your friends a succussion splash is basically the result of an enlarged filled stomach and when you jiggle the body you can actually feel splashing up in the left upper quadrant. Alright,  this is probably not the way you’re gonna make the diagnosis but it is a cute little thing that you can impress your friends with. So here’s the thing like other diagnoses that are not glaring on the surface you have to remember to think it and when do you need to start thinking about it? Well,  I start to think about it when I’m struggling with a patient who’s pretty compliant who are actually taking their meds and whose blood sugars are all over the map, where they’re having unexplained highs unexplained lows, often times severe lows.

And it’s because their food absorption is totally unpredictable sometimes it’s hanging up in the stomach sometimes it’s dropping right through the composition of the meal is going to determine how quickly the stomach empties and when that food bolus is going to be presented to the gut for absorption. So what happens is the timing of treatment and presentation of that meal bolus to the gut become disorder, right. So sometimes the insulin gets there first when the patient gets hypoglycemic sometimes the food gets there first and blood sugars are high, so this is one of those causes of unexplained poor glycemic control.

Now the A1C may be fine because they kind of average out but where they’re having peaks and troughs and bottoming out and crashing this is something to think about. If you think about it you want to be sure that they don’t have some other problem right. So in the patient who’s got no other evidence of diabetic micro microvascular complications, think about other diagnoses as well.

Sometimes you need to, the patient needs an upper endoscopy just to make sure they don’t have an obstruction, right. So early satiety delayed gastric emptying could be a manifestation of a gastric mass or a scar pylorus, so sometimes upper endoscopy is necessary. If that’s normal than doing a formal gastric emptying study is worth doing alright. It’s an easy inexpensive test and all that’s done is we mix up a little technetium with eggs, delicious in an omelet, and we measure how rapidly that technetium disappears from the stomach. And then there are normal values for how quickly the technetium should disappear out of the stomach and if it lingers in the stomach for a longer period of time that suggests that there’s a delay in gastric emptying and a function of bad gastric attraction.

Sometimes the results are indeterminate or don’t support what you’ve been thinking a capsule endoscopy can be done. So you can take that capsule swallow it and see how long it stays in the stomach, right, another relatively easy but somewhat more expensive test to do. And finally proof positive can be determined by measuring the electrical activity of the stomach and obviously this is only done in fairly sophisticated centers that have the capacity to do gastric electrical activity studies. So the treatment is challenging because a deteriorated stomach is hard to control, right. Remember it’s deteriorated because we’ve lost the nerve and we can’t make the nerve grow back. So we need to work around that, obviously,  the goal here is to prevent this from happening and the better we control diabetes the much the much smaller the probability of seeing patients like this.

Again the devastated patients who I’ve seen have had long long-standing type 1 diabetes often during their teenage years when their control was horrible and this is just a very late manifestation, it’s a problem. In general,  insulin is going to be a better choice because we have a little bit more control over when it acts then we do with oral agents. So oral agents even in our patients with type 2 diabetes are going to be potentially problematic and in the patient where we made this diagnosis eliminating oral agents is probably advantageous. With insulin therapy should be basal bolus right because we’re going to want to try to synchronize our meal insulin with when food is getting through into the palate. Now we can do it with pump or we can do it with injections but we shouldn’t be using pre-mixed insulins in these patients because we just can’t control all the peaks of insulin therapy.

Boluses often should be administered after meals, again after we know the food has gotten to a gut then it’s safe to give our prandial insulin. If we give the bolus before the meal we may run into problems with insulin hitting before the food arrives, right, so the risk of hypoglycemia becomes greater. Some people like to use regular insulin because of its slower onset of action. So it may actually timeout better with delayed gastric emptying but not my preference I still think that using newer insulin’s but administering our mealtime insulin postprandially is our best bet. But the most important part of treating patients is diet. And I’m going to turn it over to Carmela to talk about that. Okay,  so I’m gonna share my screen.  So as Dr. Klass already indicated tight glycemic control is absolutely imperative with helping patients with gastroparesis. We know elevated blood sugars can also slow the rate of the gastric emptying so that’s one big consideration and probably one of the first things that we want to help our patients with.

We’re going to talk today about the helpfulness of small meals that are frequent generally speaking our stomachs empty every four hours so for someone who has delayed gastric emptying they could go six seven-plus hours, especially on a larger meal. So doing small frequent meals can help ones that are low fat, low fiber and there’s even some consideration that we have them blend their meals in a blender or sticking to liquid meals which I’ll talk a little bit more about in just a minute.

But those may be a bit more tolerated than doing more solid meals. In severe cases,  we may consider enteral nutrition and be doing some j-tube feedings and of course that would be something we want to hold out for someone who’s significantly malnourished inability to maintain a healthy weight or significant weight loss that oral nutrition wouldn’t be sufficient to bring their weight back up to a healthy level. Dr. Klass already mentioned but yes there’s a significant consideration for taking their insulin after eating versus before. And we do find that walking, so doing like moderate exercise just moving around after eating can actually help with the gastric emptying I tell people no intense forms of exercise which can actually decrease blood flow to the stomach which we don’t want to have happened  we want more like moderate exercise just moving around after eating maybe even for 10 minutes can maybe help things move through a little bit more quickly and help with their comfort.

Unfortunately,  we don’t have any controlled trials of different food modifications liquid, solid, low fat, high fat, for treating gastroparesis. So a lot of what our recommendations are coming from is our professional judgement in our clinical practice and I say this mainly because I find for a lot of patients that I work with who do have gastroparesis one person can tolerate you know quarter of an avocado or half of an avocado and that sits really well for them, it’s smooth they don’t have to chew as much and it’s something that goes down really easy but for somebody else with it being a high-fat food, even if it’s healthy fat, someone else may not tolerate that as well. So there is some preferences or just personal trials and errors I think with some people of what foods help them and what foods can they not tolerate.

I have one patient who loved apples and there’s just no way that she could eat the skin on it. She couldn’t chew it well enough it wasn’t tolerated well, so when she wanted an apple she had to peel the skin. So sometimes it’s just working with the patients and helping them kind of write down foods that they find that they’re not tolerating and foods that they do tolerate and not always sticking with just within these specific lines of low fat or low fiber because everyone can maybe be a little different. So specifically speaking about common food modifications that we do find helpful as I mentioned as small frequent meals some that have a few healthy carbohydrates so we have to have a balance around not too high fiber but maybe just a couple of grams of fiber if they can tolerate it. Some lean protein that’s not too high in fat and then trying to kind of limit how much liquid that they’re drinking along with that meal and that they’re chewing really well they may have to chew 20-30 times before they swallow to kind of improve some of that digestion before it heads on down.

There’s, of course,  some concerns of early satiety and bloating which then causes a lot of people to stop eating throughout the day they may start with one meal in the morning some eggs and some toast and that just has a hard time sitting with them and then they won’t eat until dinnertime, there increases the risk of hypoglycemia. If they’re on insulin it could increase the risk of them just getting adequate nutrition in and so we want to work with them specifically on doing those smaller meals maybe even breaking breakfast into two small meals if they can’t tolerate a certain amount and helping them to have more of a steady consumption of carbohydrates throughout the day with some lean proteins that help them to stabilize their blood sugars.

A lot of patients also find that solid meals are more tolerated in the morning than in the evening time, so we may have to switch them to like starting around that you know afternoon snack or evening meal is to doing more liquids whether that’s protein shakes or that they’re actually blending up their meal that their family is having in the blender so that the body doesn’t really need to digest much of it and it’s all pretty much done prior to even drinking it. So liquid meals can actually be helpful earlier in the day. As I mentioned chewing food sitting up during the meal and at least one to two hours after they eat so really discouraging people to lay down after eating. The Reduced fat diet that can inhibit gastric emptying when it’s in a solid meal we don’t necessarily find that to be the case in liquid form. So if know wants certain types of foods and they are open to blending it maybe that’s where we can add in some of their fat.

I honestly discourage the use of the thing or consumption of like oranges, broccoli, cauliflower, certainly cabbage, Brussel sprouts. Those are really difficult for a lot of patients who have gastroparesis to digest and to tolerate. And there is an increased risk they don’t chew well or if they have a severe case of gastroparesis but they could get a blockage from some of that undigested food so unfortunately we have to be somewhat careful with helping them with getting fiber but a lot of times they need to stick to like under 15 grams of fiber a day. This I put up here, not that these are the only foods that people who have gastroparesis can consume but these are often very tolerated by patients and the intention is to make sure that they have a healthy amount of carbohydrates, but also not excessive. And there are some patients who can tolerate milk or protein shakes they may kind of go overboard a little bit with how much that their drinking that they’re only sticking with that and not doing any solid meals.

So it’s something I think just to encourage them to try different foods see how they tolerate it and to use some of these more liquid or smooth consistency foods for times that they’re having a bad day and they’re not really tolerating much or again later on in the day when solid foods tend to not be so tolerated. Unfortunately,  some of the things that we can see with patients who have gastroparesis and might really encourage the use of the nutrition referral is an inadequate vitamin or mineral intake, of course, impaired nutrient utilization because of lack of digesting excessive fiber intake than their body can handle, of course,  altered GI function. And one risk very much is unintended weight loss and as I mentioned that’s oftentimes in more severe cases of gastroparesis but it’s a consideration I think we have to make in asking them how their weights been going and how they’ve been eating in some of those severe cases.

We also need to just monitor how they’re eating so that if we need to look at magnesium for supplementation iron and ferritin, vitamin b12, or vitamin D. As Dr. Klass mentioned more you know liquid forms would be better tolerated. The last thing I added on here just or some help I think is when would we consider someone who might need enteral nutrition support? Parenteral nutrition we would want to really keep as our last option but for enteral nutrition is someone who’s had significant unintentional weight loss again in severe cases but it’s  a risk. So if someone has a BMI of 18 1/2 or less, or their BMI is 18 1/2 to 20 and they’ve had about 5-10% weight loss within six months we really need to keep a close eye on them. We really need to evaluate what they’re eating and what changes might we need to make to help them to get an adequate nutrition or we need to consider alternative sources. And then you see there the medium-risk less weight loss and a little bit of a higher BMI. And the last thing is just to help to take the low fat, low fiber small frequent meals throughout the day, a moderate amount of carbohydrates that we evenly spread out to help with stabilizing blood sugar controls is just a menu here.

So that is just for you to help and we do have handouts and we’re happy to post them on the website if that’s something that you would like and it has something like this so that you can hand them out to patients if you if you ever find that needed. Okay, thank you,  we will put those up on the website. So I think we’re gonna swap back to my powerpoint and also been told that we have we’ve got to abandon ship precisely 9, so let’s see…

I wanted to talk to you can we get it to the presentation… Great so I wanted to talk a little bit about therapies other than diet briefly because I don’t think that there is much indication for them. These are meds that all have a mixed profile, so in terms of things that make the stomach contract better our hands are, our options are fairly limited. The best drug we ever had was which has been was removed by the FDA many years ago it was actually a very good prokinetic agent but cause cardiac irregularities and stuff like that, so weighing risks and benefits the decision to remove that drug was made.

Metoclopramide or Raglan is a drug that’s used a lot and I think I just want to make the case that this is a problematic drug and should not be initiated lightly. Does it have good prokinetic effects? Yes,  it does promote gastric emptying, but for chronic use and at high dose,  the risks of extrapyramidal side effects are quite substantial. And if anyone has ever seen a patient who’s developed akathisia it’s a terrifying adverse effect and doesn’t initiate this therapy lightly. We could use it occasionally if symptoms are severe but remember that it’s a double-edged sword. Erythromycin obviously a safer drug, but a less potent drug but erythromycin and other similar meds activate the stomach by binding to the motilin receptors within the stomach and can increase gastric contraction. So it can be effective at times and again our options are not that great so it is a drug that we do use from time to time.

But it’s a drug that has to be given four times a day which makes it challenging. Domperidone is a pretty good promotility agent but it’s never been approved by the FDA in this country for reasons that I frankly can’t explain to you. It is available in Canada and we have obtained it through Canadian pharmacies. Can be done that way or it can be obtained through the FDA by making an application for it using the IND process. Which is investigational new drug and where there’s a specific need if this is going to be long-term therapy going through the FDA route can be done. Nausea can be managed using our conventional anti-nausea meds and when patients present with severe nausea and vomiting they’re oftentimes very agitated very restless and the addition of an anxiolytic can really be quite beneficial. So we’ve often done this in the emergency department, especially in our patients with severe type 1 diabetes whose glycemic control this problematic. They oftentimes will come in in a kind of agitated state because they’ve been through this sort of episode before and they know how difficult and miserable it is and it kind of builds, it feeds on itself, and you sometimes need to break that cycle with a short-acting benzodiazepine.

If our medical therapy and nutritional therapy doesn’t work, so these are patients who have intractable gastroparesis with unpredictable gastric emptying, gastric pacing can be done and our good friends at Medtronic are happy to provide a Medtronic gastric stimulator as well as an insulin pump for our patients. I’ve got one patient who’s got a Medtronic epidural morphine pump, a gastric stimulator from Medtronic and an insulin pump from Medtronic, she’s got the trifecta you know that’s, she’s one of a kind. Using Botox injected intragastrically has been tried and it has demonstrated some efficacy. And finally,  pyloric dilation using mechanical dilators has been performed just to allow food to pass straight through without getting hung up at the pylorus. So again another consideration for patients with advanced intractable symptomatology. And I think I’m going to stop there, a big problem it is not common thank goodness but when it’s present it can really be very challenging to manage.

I have a question if you have a minute. You bet. For erythromycin what kind of a duration would you be talking because we had a patient once at Renown that was on it for three weeks and everybody was worried about inducing resistance.

So what would you have to say about that? You know it again it’s a double-edged sword, when your options for therapy for this condition are so limited I think you just have to accept that it’s not perfect but it is your best option. So I do think you know we have patients who are on therapy for the long term and again resistance is clearly an issue we’re so sensitized to it at this point it’s a mixed it’s a mixed thing. Fortunately doesn’t come up all that often. Alright, I hate to do this but I think we have to we’ve got to close out now so that somebody else could use our room. Thank you!


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