fluid while eating,and chewingslowlyand thoroughly 2. Reduction of dietary fiber or first running fiber foods through a blender until nearlyliquid. 3. Virtual elimination of unground red meat, veal, pork, and fowl 4. Reduction of protein at supper 5. Introduction of four or more small dailymeals, instead of three larger meals 6. Semiliquid or liquid meals
In the pareticstomach, soluble fiber (gums) and insoluble fiber can form a plug at the very narrow pyloricvalve.
This is no problem for the normal stomach, where the pyloric valve is wide open.
Many patients with mild gastroparesis have reported better relief of fullness and im provedblood sugar profiles after modifying their diets to reduce fiber content or to renderthe fiber more digestible.
This means, for example, that mashedwell-cookedvegetables must be substituted forsalads, and high-fiber laxatives such as those containing psyllium (e.g., Metamu- cil) should be avoided.
Acceptable vegetables might include avocado, summer squash,zucchini, or mashed pumpkin (sweetened, if you like, with steviaand flavored with cinnamon).
It also means that you would have to give up one of our alternatives to toast at breakfast , bran crackers.
You might want to try cheese puffs (page 178) instead.
Most people in the United States like to eat their largest meal in the evening.
Furthermore, they usually consume their largest portion of meat or other protein food at this time.
These habits make control of fasting blood sugars very difficult for people with gastroparesis.
Ap parently animal protein, especially red meat, like fiber, tends to plug up the pylorus if it's in spasm.
An easy solution is to move most of your animal protein from supper to breakfast and lunch.
Many of my patients have observed remarkable improvements when they do this.
We usually suggest a limit of 2 ounces of animal protein, restricted to fish, ground meat, cheese, or eggs, at supper.This is not very much.
Yet people are usually so pleased with the results that they will continue with such a regimen indefinitely (of course, as protein is shifted from one meal to another, doses of premeal insulin or ISA must also be shifted).
With a reduction of delayed overnight stomach-emptying, the bedtime dose of longer-acting insulin or ISA may have to be re duced so that fasting blood sugar will not drop too low.
374 Treatment
Some people find that by moving protein to earlier meals, they in creasethe unpredictability of blood sugar after these meals.
For such a situation, we suggest, for those who do not use insulin, four or more smaller meals each day, instead of three larger meals.
We try to keep these meals spaced about 4 hours apart, so that digestion and doses of ISAfor one meal are lesslikelyto overlapthose for the next meal.
This can be impractical for those who take preprandial insulin.
Remember, you must wait 5 hours after your last shot of preprandial insulin be fore correcting elevated blood sugars.
Both alcohol and caffeine consumption can slowgastric emptying, as can mint and chocolate.
These should therefore be avoided, espe cially at supper, if gastroparesis is moderate or severe.
Semiliquid or Liquid Meals A last resort for gastroparesis is the use of semiliquidor liquid meals.
I say"lastresort"becausesucha restrictiontakesmuch of the pleasureout of eating,but it maybe the onlywayto assure near-normal blood sug ars.With this degree of bloodsugarimprovement, the gastroparesis may slowly reverse, as mine did.
The restriction can then eventually be re moved.
In this section I'll try to give you someideas that you can useto createmeal plans usingsemiliquid foodsthat still follow our guidelines.
Baby food.
Low-carbohydrate vegetables and nearly zero carbohy drate meat, chicken, and eggyolk protein meals are readily availableas baby food.
Rememberto read the labels.
Also remember that for a typ ical protein food, 6 grams of protein on the label corresponds to about 1 ounce of the food itself by weight.
To avoid protein malnutrition, youshouldconsume at least 1gramof proteinfor every kilogram (2.2 pounds) of ideal body weight.
Thus, a slim person weighing 150 pounds (68 kilograms) should consume at least 68 grams of protein daily.
This works out to about 11 ouncesof protein foods.
Peoplewho are still growing or who exercise vigorouslymust consume consider ably more than 1 gram per kilogram of idealbody weight.
When vegetables that only slowly raise blood sugar are ground or mashed, they can raise blood sugar more rapidly.
So how can we jus tify using baby foods?
The answer is that we recommend such foods only for people whose stomach alreadyempties very slowly.
Thus even with baby food your blood sugarmaystill havedifficulty keeping pace with injected regular insulin.
Later in this chapter I will show you some tricks for circumventingthis problem.
Delayed Stomach-Emptying Gastroparesis 375
Below is a brief fist of some typical baby foods that can be worked into the meal-planning guidelines set forth in Chapters 10and 11. Do not exceed those guidelines for carbohydrate, since most of the Laws of Small Numbers stillapply, even if you have gastroparesis.
Vegetables Carbohydrate Beech Nut Green Beans (4.5-ounce jar) 8 grams Beech Nut GardenVegetables (4.5-ounce jar) 11 Heinz Squash (4.5-ounce jar) 8 Meats , Strained Protein Beef(3-ounce jar) 2.25 ounces Chicken (3-ounce jar) 2.25 Ham (3-ounce jar) 2.25 Egg Yolks (3-ouncejar) 1.50 (plus 1 gram carbohydrate)
Unflavored whole-milk yogurt.
Some brands of whole-milk yo gurt, such as Erivan, Brown Cow Farm, or Stonyfield Farm, have no added sugars or fruits.
As noted previously, Erivan is sold at health food stores and the other two at supermarkets throughout the United States.
Again, always specify "wholemilk,unflavored." Remember that "low-fat" dairy foods usually contain more carbohydrate than the whole-milkproduct.
Erivanyogurt contains 11 grams of carbohydrate and 2 ounces pro tein per 8-ounce container.
Stonyfield Farm and Brown Cow Farm both contain 12 grams carbohydrate and 1.5 ounces protein.
Blandfoods like plain yogurt can be made quite tasty by adding one of the baking flavor extracts,the powder from truly sugar-freegelatin desserts (i.e., without maltodextrin), Da Vinci sugar-free syrups, or stevia with cinnamon.
The amounts used should suit your taste.
Whole-milk ricotta cheese. Whilenot as Uquid as yogurt or baby food, ricotta cheese goes down better than solid foods. It can also be put into a blender with some water or cream to render it more liquid. Each 8-ounce serving of ricotta contains about 8 grams of carbohy drate and 2 ounces protein. To my taste, ricotta is a very bland food, but when flavored with cinnamon and stevia, it can be a real treat , a meal that tastes like a dessert.
376 Treatment
Liquid meals. When semiliquid meals are not fully successful, the last resort is high-protein, low-carbohydrate Uquid meals. These are sold in health food stores for use by bodybuilders. Only use those made from eggwhite proteins or whey, if you wish to be assured of aU the essential amino acids. Similar products made from soy protein may or may not contain these in adequate amounts. Many may con tain sterols similar to estrogen.
Possible Last Resorts for Treating Gastroparesis One of my patients claimsthat a cosdynew treatment has helped con siderably both her gastroparesis and her neuropathic pain.
It involves the appUcation of smallelectriccurrents to acupuncture points on her limbs and is caUed STS therapy.
The electronic device is designated model STS and is manufactured by Dynatronics of Salt Lake City, (800) 432-2924.
The instrument costs about $4,000 and the treatment must be performed for 45 minutes every day.
Its effects begin after about 2 months, and it may actually faciUtate the heaUng of damaged nerves.
This device should not be used near an insuUn pump or by people with implanted electrical devices.
Another costly option is electrical gastric stimulation.This involves surgical implantation through the skin of two electrodes that contact the muscular waU of the stomach.The connectingwires enter a con trol box that can be kept in a pocket or on a belt.
The control unit can be set to stimulate the stomach muscles after each meal.
TREATING LOW BLOOD SUGARS WHEN YOUR STOMACH IS SLOW TO EMPTY
A patient from Indiana with a hiatal hernia once told me, "These Dex- trotabs don't raise my blood sugar one bit.
What really works is one stick of that sugar-free chewing gum" (because chewing the gum en courages the stomach to empty a meal that maybe sitting there).
Her comment iUustrates a majorhazardassociated with any condi tion that retards stomach-emptying (gastroparesis, ulcers, and so on): treating hypoglycemia rapidlyis nearlyimpossible.
Note the qualifier, "nearly." There are some tricksto circumvent the problem.
If your hypoglycemia occurred because your last mealis stillsitting
Delayed Stomach-Emptying: Gastroparesis 377
in your stomach, you might thereafter try some chewing gum to help it empty.
Since chewed glucose tablets can take several hours to leave your stomach, you should suck them or, preferably, try a Uquid glucose so lution.
Such a product is available as glucose tolerance test beverage under a number of brand names in the United States.
These include Glucola, Limeondex, Dexicola, and Sun-Dex.
The drinks are bottled by manufacturers of clinical laboratory reagents and are stocked in every hospital lab and private cUnical laboratory.
A very convenient version, called Glutol, comes in plasticbottles.
It is made by Paddock Laboratories, (800) 328-5113, and is alsosold by Rosedale Pharmacy.
It contains 2.8 grams of glucose per teaspoonand 8.3 grams per table spoon.
See Table 20-1 to calculate how much these amounts wiU raise your blood sugar.If you don't havea medicinespoon handy and are in a hurry, assumethat one swaUow from the bottle is equivalentto 1 ta blespoon.
If you'retraveling and forget to bring alonga bottle of your glucose tolerance test beverage, get some lactose-free milk.
This product has been treated with an enzyme that converts the lactose to glucose.
In the United States, the most widely marketedbrand is Lactaid.
Every 4 ounces contains 6 grams of glucose.
Remember, however, that Lactaid wiU spoil after a few days if not refrigerated.
Even if you've used the glucose tolerance test drink or Lactaid, you can speed up the action by chewing gum, by doing the back-flex and stomach exercises described earlier in this chapter, by using a hand held massager, and/or, prior to eating,by using some of the medica tions mentioned earlier.
MODIFICATIONS OF PREPRANDIAL INSULIN OR ISA REGIMENS TO ACCOMMODATE GASTROPARESIS
It takes a while for your physician to select and fine-tune a programto improve stomach-emptying. In the meantime, it's possible to reduce the frequency and severity of postprandial hypoglycemia. To do this, you must slow the action of preprandial insulin or ISAto match more closely the delayyou experience in digesting your meals. Let's suppose, for example, that you'U be using preprandial rosiglitazone. If you have
378 Treatment