Gastroparesis

Gastroparesis means stomach (gastro) paralysis (paresis). Other terms used to describe this condition are: gastric stasis, gastropathy, slow stomach, sluggish stomach and diabetic enteropathy (in those patients who have diabetes mellitus). Under normal conditions, the stomach is a flexible sac that can stretch and shrink, mix and churn, and eventually empty food into the small intestine. The word gastroparesis is used when a patient's stomach empties too slowly. Everyone's stomach is unique, so the ability of the stomach to empty can from one patient to another. Some can still eat small amounts of regular foods; they just have to eat more often to get all their nutrients in. Others may have periods when all they can take in is liquids, and still others may have periods when they cannot take anything at all. Despite this most patients are able to swallow and empty their saliva (about 1 quart per day) and also empty the natural stomach juices they make (about 2-3 quarts per day). Symptoms can vary from week-to-week or even day-to-day.

The diet presented here is designed to give tips for diet modification. In addition, lots of suggestions are provided for fo.ods and fluids to try when ideas run dry at-home. I want to make it clear that the suggestions are based on my experience with patients and not science, as there are no studies available that demonstrate what foods are better tolerated than others by patients with gastroparesis. Furthermore, any calorie is a good calorie, especially in someone who has lost a lot of weight and is now facing the possibility of tube or intravenous feeding to provide nourishment. This may be a time when prior dietary restrictions are put on hold' until basic nutritional needs can be met.

It is recommended that anyone with gastroparesis, but especially those with combined medical problems (such as diabetes or kidney disease), seek diet counseling by a registered dietitian to maximize nutritional benefits. To locate a registered dietitian near you, call the American Dietetic Association at 800-366-1655 or visit their website at www.eatright.org.

thinned-down pureed foods, can be designed to meet a patient's nutritional requirements. Patients, who experience increasing fullness as the day wears on may want to have their solid food for breakfast, switching to liquid meals as the day progresses.

Fiber

Fiber (found in many fruits, vegetables and grains) may act to slow stomach emptying in some patients and fill them up so quickly that nutrient needs may not be met. For patients who have had a bezoar (similar to a hairball in a cat) in the past, a fiber restriction (including avoidance of over-the-counter fiber/bulking laxatives - see table 1) is worthwhile. Patients, who require. jejunal tube feedings may tolerate fiber-containing formulas as the stomach is bypassed.

Table 1 High Fiber Foods / Medications and Those Associated With Bezoar Formation
High Fiber Foods

• Legumes/Dried Beans (refried beans, baked beans, black-eyed peas, lentils, black, pinto, northern, fava, navy, kidney, garbanzo beans, soy beans)
• Bran /Whole Grain Cereals (such as bran cereals, Grape-Nuts", shredded wheat type, granolas)
• Nuts and Seeds (pumpkin seeds, soy nuts.ichunkv nut butters)
• Fruits (blackberries, blueberries, raspberries, strawberries, oranges, kiwi)
• Dried fruits (apricots, dates, figs, prunes, raisins)
• Vegetables (green peas, broccoli)
• Popcorn

Foods Associated with Bezoar Formation

Apples, Berries, Brussels sprouts, Coconuts, Corn, Figs, Green beans, Legumes, Oranges, Persimmons, Potato Peels, Sauerkraut, Tomato skins

High Fiber Medications/Bulking Agents

Examples include: Acacia fiber; Benefiber®; Citrucel®; FiberChoice®; Fibercon® Konsyl®; Metamucil®; Perdiem Fiber, or any psyllium product

Fat
Although fat may slow stomach emptying in some patients, many can consume fat especially in the form of liquids. Although many clinicians restrict fat, my experience is that fat in the liquid form (as part of beverages such as whole milk, milkshakes, nutritional supplements, etc.) can be well tolerated by many. To take the fat out of the diet of a patient diet that is seriously malnourished is to remove a valuable source of calories. Unless a fat-containing food or fluid causes problems, fat should not be limited. It is often well tolerated, pleasurable, and it provides a great source of calories in a small amount.

Dental Health
Since gastroparesis impairs the stomach's ability to mash food and break it down into smaller sizes in preparation for absorption, the chewing of food beforehand becomes even more important. In addition, repeated exposure to stomach acid from frequent vomiting may destroy tooth enamel. Make every effort to see your dentist regularly and take good care of your teeth.

Positioning
Patients may try sitting up after meals and maybe even go for a walk depending on symptoms.

Medications
There are quite a few medications that can delay stomach emptying -ask your doctor if any of the medications you are on could be slowing down your stomach emptying and making your symptoms worse.

Getting your Calories

When getting enough calories is a daily struggle

• High calorie drinks are better than water (provides calories AND fluid)use peach, pear or papaya nectar, cranberry juice, orange juice, Hawaiian Punch", Hi C®, lemonade, Kool-Aid'".
• Fortify milk by adding dry milk powder to 1-quart milk.
• Use whole milk or evaporated milk (if tolerated) instead of skim or 2% for drinking and preparing "cream type" soups, custards, puddings, and milkshakes.
• Add instant breakfast, protein powder, dry milk powder, or other flavored powders or syrups to whole milk or even some juices.
• Make custards and puddings with eggs or egg substitutes (such as Egg-beaters®).
• Try adding ice cream, sherbets, sorbets to ready-made supplements liquid nutritional supplements such as Nutra-shakes", Ensure® or Boost" or others (see table 5).

Table 2. Examples of Fat Free Protein Sources*

*Carbohydrate calories may be present in some of these sources

Commercial Nutrition Supplements

. *Some products are also available through retail pharmacies or grocery stores (in store or online)

Note: Many pharmacy and food chains have their own brands of liquid supplements, examples include:

• Wal-Mart® = Equate® Nutritional Shake & Equate® Nutritional Shake Plus
• Kroger® = Fortify® & Fortify® Plus
• CVS® Pharmacy = Liquid Nutrition & Liquid Nutrition Plus
• Giant® = CareOne® Nutritional Drink and CareOne® Nutritional Drink Plus
• Food Lion®=NutraFit® & NutraFit® Plus

Table 6: Recipes For Soups, Sinoothies, Fruit Blends, Shakes, and Fruit Drinks The following recipes are only suggestions for liquid calories at a time when it may be difficult of think of ideas ...

• Fortified milk can be substituted to increase protein if needed. To make fortified, high protein milk:
  • 1 quart whole milk
  • 1 cup nonfat instant dry milk
  • Pour liquid milk into deep bowl.
  • Add dry milk and beat slowly with beater until dry milk is dissolved Refrigerate and serve cold.
• Soy or rice milks can be substituted for milk in any recipe.
• Flavor extracts such as vanilla, almond, coffee, etc can be added for interest.
• Other flavorings such as dry gelatin (e.g., Jell-O®) or pudding mixes, syrups, etc. can be added for additional flavors or extra calories.
• Ice/ ice chips can always be blended in if desired.
• When using canned fruits for recipes, for additional calories use those in heavy syrup.
• Frozen yogurts, ice creams, sorbets, sherbets, soy and rice products can be substituted in any recipe.
• Sugar free ice creams, yogurts and gelatins, etc., can be substituted as needed for regular ones.
• For extra flavor, texture and calories, add a frozen banana (peel ripe bananas and place in a plastic freezer bag in the freezer until ready to use).

Foods Suggestions for Patients with Gastroparesis

Breads
White bread (including- French/Italian)
Bagels (plain or egg) English muffin
Plain roll
Pita bread
Tortilla (flour, corn) Pancake
Waffle

Cereals
Quick oats (plain) Grits
Cream of Wheat
Cream of Rice
Puffed wheat and rice cereals such as: (Cheerlos®, Sugar Pops®, Kix®, Rice Krlsples®, Fruit Loops®, Specia I K®, Cocoa Crispies® cornflakes, cocoa puffs)

Grains/Potatoes Rice (plain)
- any Pasta, macaroni (plain) Bulgur wheat Barley Potatoes (no skin, plain)--all kinds sweet, yams, etc. French fries (baked)

Crackers
Arrowroot
Breadsticks
Matzoh
Melba toast
Oyster
Pretzels
Saltines Soda
Zwieback

The following foods have been associated with bezoar formation (mixture of food residues that can accumulate in a stomach) formation--avoid if you have had a bezoar.
Apples, Berries, Coconuts, Figs, Oranges, Persimmons, Brussels, sprouts, Green beans, Legumes, Potato, peels, Sauerkraut

Sample Semi-Liquid Meal Pattern

BREAKFAST
Citrus Juice or other beverage containing vitamin C Thinned Cooked Cereal
Liquid Supplement or Milkshake (see suggestions above) Milk
Coffee or Tea
Cream, Sugar

LUNCH AND DINNER
Thinned Soup
Thinned or Pureed Meat or Substitute
Thinned Potato or Substitute Thinned or Pureed Vegetable Thinned Dessert or Pureed Fruit
Liquid Supplement or Milkshake (see suggestions above)
Milk
Coffee or Tea Cream, Sugar Salt and Pepper

SNACK: MID-MORNING, AFTERNOON AND BEDTIME
Milk or Fruit Juice
Liquid Supplement or Milkshake (see suggestions above)