Exercises That Facilitate Stomach-Emptying
The paretic stomach may be described as a flaccid bag, deprived of the rhythmic muscular squeezing present in a stomach that has a properly functioning vagus nerve. Any activity that rhythmically compresses the stomach can crudely replicate normal action. You may perhaps have observed how a brisk walk can relieve that bloated feeling. I therefore strongly recommend brisk walking for an hour immediately after meals — especially after supper.
A patient of mine learned a trick from her yoga instructor that eliminated the erratic blood sugar swings caused by her moderate gastroparesis. The trick is to pull in your belly as far as you can, then push it out all the way. Repeat this with a regular rhythm as many times as you can, immediately after each meal. Over a period of weeks or months, your abdominal muscles will become stronger and stronger, permitting progressively more repetitions before you tire. Eventually shoot for several hundred repetitions — the more the better. This should require less than 4 minutes of your time per hundred reps, a small price to pay for an improvement in your blood sugar profiles.
Another patient discovered an exercise that I call the “back flex.” Sit or stand while bending backward as far as you can. Then bend forward, about the same amount. Repeat this as many times as you can tolerate.
Although these exercises may sound excessively simple, even silly, they have helped some people with gastroparesis.
Chewing Gum Can Make a Big Difference
The act of chewing produces saliva, which not only contains digestive enzymes but also stimulates muscular activity in the stomach and tends to relax the pylorus. Orbit is a delicious “sugarless” gum with a long-lasting flavor. It contains only 1 gram of sugar per piece and so will have little effect upon your blood sugar.* Chewing gum for at least 1 hour after meals is a very effective treatment of gastroparesis outside of major dietary changes. Don’t chew one piece after another, because the grams of sugar can add up.
Meal Plan Modifications, Utilizing Ordinary Foods
More often than not, changes in your meal plan will prove more effective than medication. The problem is that such changes are unacceptable to many patients. We usually proceed from most to least convenient in six stages:
- Drinking at least two 8-ounce glasses of sugar-free, caffeine-free fluid while eating, and chewing slowly and thoroughly
- Reduction of dietary fiber or first running fiber foods through a blender until nearly liquid.
- Virtual elimination of unground red meat, veal, pork, and fowl
- Reduction of protein at supper
- Introduction of four or more small daily meals, instead of three larger meals
- Semiliquid or liquid meals
In the paretic stomach, soluble fiber (gums) and insoluble fiber can form a plug at the very narrow pyloric valve. 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 improved blood sugar profiles after modifying their diets to reduce fiber content or to render the fiber more digestible. This means, for example, that mashed well-cooked vegetables must be substituted for salads, and high-fiber laxatives such as those containing psyllium (e.g., Metamucil) should be avoided. Acceptable vegetables might include avocado, summer squash, zucchini, or mashed pumpkin (sweetened, if you like, with stevia and 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. Apparently 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 reduced so that fasting blood sugar will not drop too low.
Some people find that by moving protein to earlier meals, they increase the 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 ISA for one meal are less likely to overlap those 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 before correcting elevated blood sugars.
Both alcohol and caffeine consumption can slow gastric emptying, as can mint and chocolate. These should therefore be avoided, especially at supper, if gastroparesis is moderate or severe.
Semiliquid or Liquid Meals
A last resort for gastroparesis is the use of semiliquid or liquid meals. I say “last resort”because such a restriction takes much of the pleasure out of eating, but it may be the only way to assure near-normal blood sugars. With this degree of blood sugar improvement, the gastroparesis may slowly reverse, as mine did. The restriction can then eventually be removed. In this section I’ll try to give you some ideas that you can use to create meal plans using semiliquid foods that still follow our guidelines.
Baby food. Low-carbohydrate vegetables and nearly zero carbohydrate meat, chicken, and egg yolk protein meals are readily available as baby food. Remember to read the labels. Also remember that for a typical protein food, 6 grams of protein on the label corresponds to about 1 ounce of the food itself by weight. To avoid protein malnutrition, you should consume at least 1 gram of protein for 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 ounces of protein foods. People who
are still growing or who exercise vigorously must consume considerably more than 1 gram per kilogram of ideal body weight.
When vegetables that only slowly raise blood sugar are ground or mashed, they can raise blood sugar more rapidly. So how can we justify using baby foods? The answer is that we recommend such foods only for people whose stomach already empties very slowly. Thus even with baby food your blood sugar may still have difficulty keeping pace with injected regular insulin. Later in this chapter I will show you some tricks for circumventing this problem.
Below is a brief list of some typical baby foods that can be worked into the meal-planning guidelines set forth in Chapters 10 and 11. Do not exceed those guidelines for carbohydrate, since most of the Laws of Small Numbers still apply, even if you have gastroparesis.
|Beech Nut Green Beans (4.5-ounce jar)||8 grams|
|Beech Nut Garden Vegetables (4.5-ounce jar)||11 grams|
|Heinz Squash (4.5-ounce jar)||8 grams|
|Meats — Strained||Protein|
|Beef (3-ounce jar)||2.25 ounces|
|Chicken (3-ounce jar)||2.25 ounces|
|Ham (3-ounce jar)||2.25 ounces|
|Egg Yolks (3-ounce jar)||1.50 (plus 1 gram carbohydrate)|
Unflavored whole-milk yogurt.
Some brands of whole-milk yogurt, 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 “whole milk, unflavored.” Remember that “low-fat” dairy foods usually contain more carbohydrate than the whole-milk product.
Erivan yogurt contains 11 grams of carbohydrate and 2 ounces protein per 8-ounce container. Stonyfield Farm and Brown Cow Farm both contain 12 grams carbohydrate and 1.5 ounces protein.
Bland foods like plain yogurt can be made quite tasty by adding one of the baking flavor extracts, the powder from truly sugar-free gelatin 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.
While not as liquid 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 carbohydrate 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.
When semiliquid meals are not fully successful, the last resort is high-protein, low-carbohydrate liquid meals. These are sold in health food stores for use by bodybuilders. Only use those made from egg white proteins or whey, if you wish to be assured of all the essential amino acids. Similar products made from soy protein may or may not contain these in adequate amounts. Many may contain sterols similar to estrogen.
Possible Last Resorts for Treating Gastroparesis
One of my patients claims that a costly new treatment has helped considerably both her gastroparesis and her neuropathic pain. It involves the application of small electric currents to acupuncture points on her limbs and is called 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 facilitate the healing of damaged nerves. This device should not be used near an insulin 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 wall of the stomach. The connecting wires enter a control 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.