Diet Changes Help With Diabetic Gastroparesis

bariatric surgery, Steve Parker MD

The only picture of stomach I have

When you eat a meal, your stomach holds it there for a while then gradually releases contents into the duodenum, the first part of the small intestine. The stomach makes those releases by contraction of muscles in the wall of the stomach. Those muscles are under control of the autonomic nervous system. In some folks with diabetes, the nerves controlling the stomach muscles don’t work very well, so stomach contractions are weak. Food just sits in the stomach for too long, delaying digestion and absorption of nutrients. One result is unpredictable blood sugar levels after meals, no matter how carefully you count carb grams. The medical term for these weak stomach contractions is gastroparesis.

From Diabetes Care:

“How is diabetic gastroparesis best managed?

Consultation by an RDN [registered dietitian, I reckon] knowledgeable in the management of gastroparesis is helpful in setting and maintaining treatment goals. Treatment goals include managing and reducing symptoms; correcting fluid, electrolyte, and nutritional deficiencies and glycemic imbalances; and addressing the precipitating cause(s) with appropriate drug therapy. Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying. Modification of food and beverage intake is the primary management strategy, especially among individuals with mild symptoms.

People with gastroparesis may find it helpful to eat small, frequent meals. Replacing solid food with a greater proportion of liquid calories to meet individualized nutrition requirements may be helpful because consuming solid food in large volumes is associated with longer gastric emptying times. Large meals can also decrease the lower esophageal sphincter pressure, which may cause gastric reflux [heartburn], providing further aggravation.

Results from a randomized controlled trial demonstrated eating plans that emphasize small-particle-size (<2 mm) foods may reduce severity of gastrointestinal symptoms. Small-particle-size food is defined as “food easy to mash with a fork into small particle size.” High-fiber foods, such as whole intact grains and foods with seeds, husks, stringy fibers, and membranes, should be excluded from the eating plan. Many of the foods typically recommended for people with diabetes, such as leafy green salads, raw vegetables, beans, and fresh fruits, and other food like fatty or tough meat, can be some of the most difficult foods for the gastroparetic stomach to grind and empty. Notably, the majority of nutrition therapy interventions for gastroparesis are based on the knowledge of the pathophysiology and clinical judgment rather than empirical research.”

Source: Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report | Diabetes Care

Steve Parker, M.D.

PS: In my current practice setting, I see more gastroparesis caused by chronic opioid use than by diabetes.

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Were Early Homo Carnivorous?: The feeding behavior of early Homo at Olduvai Gorge, Tanzania

From the Journal of Human Evolution:

Abstract

The regular consumption of large mammal carcasses, as evidenced by butchery marks on fossils recovered from Early Stone Age archaeological sites, roughly coincides with the appearance of Homo habilis. However, the significance of this niche expansion cannot be appreciated without an understanding of hominin feeding behavior and their ecological interactions with mammalian carnivores. The Olduvai Geochronology and Archaeology Project (OGAP) has recovered a large and well-preserved fossil assemblage from the HWK EE site, which was deposited just prior to the first appearance of Acheulean technology at Olduvai Gorge and likely represents one of the last H. habilis sites at Olduvai. This taphonomic analysis of the larger mammal fossil assemblage excavated from HWK EE shows evidence of multiple occupations over a long period of time, suggesting the site offered resources that were attractive to hominins. There was a water source indicated by the presence of fish, crocodiles, and hippos, and there was possible tree cover in an otherwise open habitat. The site preserves several stratigraphic intervals with large fossil and artifact assemblages within two of these intervals. Feeding traces on bone surfaces suggest hominins at the site obtained substantial amounts of flesh and marrow, particularly from smaller size group 1-2 carcasses, and exploited a wide range of taxa, including megafauna. A strong carnivore signal suggests hominins scavenged much of their animal foods during the two main stratigraphic intervals. In the later interval, lower carnivore tooth mark and hammerstone percussion mark frequencies, in addition to high epiphyseal to shaft fragment ratios, suggest hominins and carnivores did not fully exploit bone marrow and grease, which may have been acquired from nutritionally-stressed animals that died during a dry period at Olduvai. The diversity of fauna that preserve evidence of butchery suggests that the HWK EE hominins were opportunistic in their acquisition of carcass foods.

Source: The carnivorous feeding behavior of early Homo at HWK EE, Bed II, Olduvai Gorge, Tanzania. – PubMed – NCBI

Steve Parker, M.D.

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Is Protein Restriction Necessary If You Have Diabetic Kidney Disease?

Steak is high in protein but it ultimately depends on serving size

From a Diabetes Care Consensus panel:

Consensus recommendation:

In individuals with diabetes and non–dialysis-dependent diabetic kidney disease (DKD), reducing the amount of dietary protein below the recommended daily allowance (0.8 g/kg body weight/day) does not meaningfully alter glycemic measures, cardiovascular risk measures, or the course of glomerular filtration rate decline and may increase risk for malnutrition.

Are protein needs different for people with diabetes and kidney disease? Historically, low-protein eating plans were advised to reduce albuminuria and progression of chronic kidney disease in people with DKD, typically with improvements in albuminuria but no clear effect on estimated glomerular filtration rate. In addition, there is some indication that a low-protein eating plan may lead to malnutrition in individuals with DKD. The average daily level of protein intake for people with diabetes without kidney disease is typically 1–1.5 g/kg body weight/day or 15–20% of total calories. Evidence does not suggest that people with DKD need to restrict protein intake to less than the average protein intake.

Source: Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report | Diabetes Care

Steve Parker, M.D.

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Soft Drink Consumption Linked to Premature Death

The study at hand involved Europeans. It’s the first time I’ve seem artificially-sweetened soft drinks linked to premature death.

From JAMA Network:

This study found that consumption of total, sugar-sweetened, and artificially sweetened soft drinks was positively associated with all-cause deaths in this large European cohort; the results are supportive of public health campaigns aimed at limiting the consumption of soft drinks.

Source: Association Between Soft Drink Consumption and Mortality in 10 European Countries | Cardiology | JAMA Internal Medicine | JAMA Network

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What’s a Chaffle?

I assume the word rhymes with waffle. No, it’s not chicken and waffles. From Diabetes Daily:

If you haven’t heard of the term “chaffle” yet, are you really living? The latest craze has taken the diabetes online community (DOC) by storm. One moment I was inquiring about what exactly a chaffle was, and the next, I found myself a golden ticket to an underground world with over 100,000 keto-crazed chaffle fanatics! What is a chaffle you ask? A chaffle is basically a cheese and egg alternative to bread, cooked in a mini (or regular, just adjust recipes accordingly) waffle maker that can be used for anything from breakfast foods straight through your after-dinner treat. It basically acts as a base to any creative concoction you can conjure up. Why are people with diabetes so excited about chaffles? Well for one, those of us who love to experiment with new low-carb options now have this new blank canvas to create from. But more importantly, this latest invention can also help keep your blood sugars in check straight from morning till night!

Click the link for recipes

Source: 5 Chaffle Ideas to Get You from Breakfast to Dessert – Diabetes Daily

Steve Parker, M.D.

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Review Article Supports Tight Control in Diabetes

What are reasonable blood sugar and HgbA1c goals for folks with diabetes? The experts continue to debate. If I had diabetes, I’d want my glucose levels as close to normal as possible. On the other hand, if I had terminal cancer, I’d be fine with higher levels.

In Diabetes Care:

Glycated hemoglobin targets have been given in guidelines for the last three decades, mostly without change at around 6.5–7.0% (47–53 mmol/mol). Personalization of such targets has also long been advocated, but often with little and inappropriate guidance. More recently some have suggested higher targets might be indicated, and more specifically lower targets avoided, even in those in whom they are easily attained without seeming burden or risk. Prospective data from randomized and observational studies, in people with type 2 diabetes and indeed those without diabetes, find cardiovascular and mortality risk are uniformly lowest at lower levels including into the normal range. In some studies with large populations, a high proportion of people are found to attain such levels, and the UK Prospective Diabetes Study (UKPDS) and more recent studies appear to confirm the importance of starting low and continuing long. Studies of cardiovascular events and mortality in people with diabetes will already factor in any effect of hypoglycemia, which therefore should not be double-counted in setting targets. Nevertheless, some factors should lead to modification of target levels, and these will include experience of hypoglycemia where therapy change and glucose monitoring cannot ameliorate it and sometimes prospectively in those at social or occupational risk. The fact that clinical experience will modify targets emphasizes that targets will not be stable over time but will change, for example, with occurrence of adverse events or perceptions of increase/decreased burden of therapy. The evidence suggests that glucose control takes 5 years or more to have any impact on vascular outcomes or mortality, so targets may also be higher in those with shorter life expectancy or higher health burden or simply reflect individual preferences. This article discusses the evidence behind these conclusions.

Source: Controversies for Glucose Control Targets in Type 2 Diabetes: Exposing the Common Ground | Diabetes Care

Steve Parker, M.D.

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U.S Is #1 in Diabetes Drug Prices

I don’t have the resources to confirm the figures below, but I won’t be surprised if accurate. From Public Interest on Twitter:

https://platform.twitter.com/widgets.js

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Gut microbiome response to a modern Paleolithic diet

From PloS One:

Abstract

The modern Paleolithic diet (MPD), featured by the consumption of vegetables, fruit, nuts, seeds, eggs, fish and lean meat, while excluding grains, dairy products, salt and refined sugar, has gained substantial public attention in recent years because of its potential multiple health benefits. However, to date little is known about the actual impact of this dietary pattern on the gut microbiome (GM) and its implications for human health. In the current scenario where Western diets, low in fiber while rich in industrialized and processed foods, are considered one of the leading causes of maladaptive GM changes along human evolution, likely contributing to the increasing incidence of chronic non-communicable diseases, we hypothesize that the MPD could modulate the Western GM towards a more “ancestral” configuration. In an attempt to shed light on this, here we profiled the GM structure of urban Italian subjects adhering to the MPD, and compared data with other urban Italians following a Mediterranean Diet (MD), as well as worldwide traditional hunter-gatherer populations from previous publications. Notwithstanding a strong geography effect on the GM structure, our results show an unexpectedly high degree of biodiversity in MPD subjects, which well approximates that of traditional populations. The GM of MPD individuals also shows some peculiarities, including a high relative abundance of bile-tolerant and fat-loving microorganisms. The consumption of plant-based foods-albeit with the exclusion of grains and pulses-along with the minimization of the intake of processed foods, both hallmarks of the MPD, could therefore contribute to partially rewild the GM but caution should be taken in adhering to this dietary pattern in the long term.

Source: Gut microbiome response to a modern Paleolithic diet in a Western lifestyle context. – PubMed – NCBI

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Alternate-Day Fasting Reduced Insulin Resistance Better Than Daily Calorie Restriction

Horses, like Java, also get Metabolic Syndrome but it’s not quite the same as in humans. Java had to lose weight and change his diet.

Body tissue resistance to the effect of insulin is considered harmful by many experts. For instance, it may contribute to obesity, high blood pressure, type 2 diabetes, and cancer. BTW, if you have Metabolic Syndrome, you probably have insulin resistance. Regular exercise and loss of excess body fat are two ways  to reduce insulin resistance. Fasting also has an effect, but is it better than daily calorie restriction?

From a small study in the journal Obesity:

Abstract

Objective

This study compared the effects of alternate‐day fasting (ADF) with those of daily calorie restriction (CR) on body weight and glucoregulatory factors in adults with overweight or obesity and insulin resistance.

Methods

This secondary analysis examined the data of insulin‐resistant individuals (n = 43) who participated in a 12‐month study that compared ADF (25% energy needs on “fast days”; 125% energy needs on alternating “feast days”) with CR (75% energy needs every day) and a control group regimen.

Results

In insulin‐resistant participants, weight loss was not different between ADF (−8% ± 2%) and CR (−6% ± 1%) by month 12, relative to controls (P < 0.0001). Fat mass and BMI decreased (P < 0.05) similarly from ADF and CR. ADF produced greater decreases (P < 0.05) in fasting insulin (−52% ± 9%) and insulin resistance (−53% ± 9%) compared with CR (−14% ± 9%; −17% ± 11%) and the control regimen by month 12. Lean mass, visceral fat mass, low‐density lipoprotein cholesterol, high‐density lipoprotein cholesterol, triglycerides, blood pressure, C‐reactive protein, tumor necrosis factor α, and interleukin 6 values remained unchanged.

Conclusions

These findings suggest that Alternate-Day Fasting may produce greater reductions in fasting insulin and insulin resistance compared with Calorie Restriction in insulin‐resistant participants despite similar decreases in body weight.

Source: Differential Effects of Alternate‐Day Fasting Versus Daily Calorie Restriction on Insulin Resistance – Gabel – – Obesity – Wiley Online Library

It would be interesting to compare the compliance and drop-out rates between the two groups studied. Is a daily 24% calorie deficit easier to stomach than a 75% reduction every other day?

Steve Parker, M.D.

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Why Is Rapid Weight Loss Dangerous?

paleobetic diet, low-carb, diabetic diet, paleo diet

Totally unrelated – my horse Java

P.D. Mangan posted a good article on the risks of rapid weight loss. I agree with him that a max of 1–2 pounds a week is a reasonable weight-loss goal, and that a bit more than that is OK in the first week but highly inadvisable for the long run. Most folks do well if they settle into one pound a week.

From P.D.:

Slower Metabolism

A slower metabolism is another side effect of losing weight too quickly; since your body’s metabolism is essentially determining how much fuel you are needing to burn every day based on your activities and food intake, dropping calories out of your diet can considerably lower your metabolism. While this might not seem like a big deal, it is! A lower metabolism essentially causes your body to burn fewer calories each day than it typically would, and some research even shows up to a 23% decrease in calories that are burned each day. This doesn’t always go away when you stop losing weight quickly, either, your metabolism might take a while to get back on track and burning appropriately, which could affect your health and weight for a long time.

Muscle Loss

Lastly, your body could end up losing muscle as part of your quick weight loss routine. Granted, eliminating calories from your diet will have you lose weight, yes, but aside from a lot of that weight being water, some of it can also be muscle. A recent study done with people on a 500 calorie diet versus a 1250 calorie diet showed significant results; by the end of the trial, the participants on the 500 calorie diet lost six times more muscle than those on the 1250 calorie diet – an astounding loss in muscle in just a five-week span of time.

Source: Risks of Losing Weight Too Quickly – Rogue Health and Fitness

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