Gastroparesis is a condition characterized by delayed stomach emptying in the absence of mechanical obstruction. This condition arises from nerve and/or muscular changes in the body, leading to the slow or delayed emptying of food in the stomach. The main symptoms of gastroparesis, particularly bloating, greatly overlap with those of irritable bowel syndrome (IBS) and small intestinal bacterial overgrowth (SIBO).
This article looks at what is the best diet for gastroparesis based on current knowledge and evidence.
Understanding Gastroparesis
Gastroparesis is often due to conditions that impair the nerve and muscle functioning of the stomach, which greatly reduces, or in some cases completely eliminates, the ability of the stomach to properly digest food and move it through the digestive tract. When functioning normally, the muscles of the stomach frequently contract to crush food and push it to the next stage of digestion. A consensus of 40 GI experts state that gastroparesis is a result of delayed stomach emptying absent of mechanical blockage.
To diagnose gastroparesis, stomach-emptying tests are used to measure the rate in which food leaves the stomach. These tests include:
- Scintigraphy: You’ll eat a small, bland meal consisting of some radioactive material.
- Breath Test: You’ll eat a meal that contains carbon-13 stable isotope.
- Wireless Capsule: You’ll swallow a capsule that transmits data about your digestive process to a small receiver.
Dietary Considerations for Gastroparesis
The best diet for gastroparesis typically depends on the severity of the condition. Modifying dietary habits can ensure you receive the necessary calories and nutrients to stay healthy while also avoiding unnecessary stress to the digestive system. As the severity of gastroparesis varies from person to person, the gastroparesis diet has three levels to accommodate different needs.
Read also: Weight Loss with Low-FODMAP
General Dietary Guidelines
When symptoms are acting up, it’s generally best to eat smaller meals, limit fiber, choose low-fat options, and consider liquid meal replacements as needed. Here are some general dietary guidelines:
- Eat Small, Frequent Meals: This allows you to meet your calorie and nutrient needs without overfilling the stomach.
- Chew Your Food Well: This will help relieve your stomach from overworking to break down food.
- Take Advantage of Gravity: By remaining upright and going for a light walk after eating, your food is more likely to be pulled down into the small intestine to continue digesting.
- Avoid High-Fat Foods: Skip the fried foods, high-fat meats, full-fat dairy, and baked goods.
- Limit Fiber Intake: Avoid high fiber foods like whole grains and legumes (e.g., beans, peas, lentils), as well as the skins and seeds of fruits and veggies.
- Enjoy Your Nuts & Seeds Pureed: Nut and seed butters are more easily digested than whole nuts and seeds.
- Choose Nutrient-Dense Foods: Since every calorie counts, don’t waste them on junk food. Choose 100% juice, low-fat dairy products (e.g., yogurt, cheese, milk), peeled fruits and vegetables, lean meats, and seafood.
Specific Food Types
- Liquids: Thin liquids like water, broth, and juices rapidly empty the stomach. They require little to no digestion and use the effect of gravity to move down to the small intestine. Gatorade, ginger ale and other sodas, broths, juices and water are consumed.
- Solids: Solid food requires more work for the stomach, which needs to break it down to pass into the small intestine.
- Nutrient Composition: Fiber and fat-rich foods and oils also take longer to empty from the stomach. Fat intake progressively increases up to 40 grams daily. Continue focusing on a low-fiber diet and eating smaller meals spaced throughout the day.
- Food Temperature: The temperature of food when it enters the stomach affects when it leaves.
Stages of Gastroparesis Diet
- Stage 1: Liquid Diet: Liquids prevent dehydration while supplying the body with important minerals. Liquids are easily digested and can even be digested around bezoars. Bezoars are solid masses of undigested food that can block proper digestion and occasionally develop in individuals with gastroparesis as a result of poor motility in the stomach.
- Stage 2: Limited Diet: Low-residue and low-fat foods can be incorporated into the diet along with liquid or pureed foods. These foods have more nutritional value than liquids alone but are relatively easy for the stomach to digest. Fat intake should be limited to 40 grams per day.
- Stage 3: Maintenance Diet: Designed to control gastroparesis long-term. This stage incorporates all stage 2 foods plus additional limited fat and fibrous foods. High-fiber foods should be cooked so they are soft and chewed thoroughly to avoid fibrous materials slowing or blocking digestion.
The Overlap with SIBO and IBS
Given the overlap in symptoms, some doctors and even patients have begun to wonder if minimizing FODMAPs will also help with gastroparesis.
What is SIBO?
SIBO stands for small intestinal bacterial overgrowth. It's also sometimes called small bowel bacterial overgrowth or SBBO. It all means the same thing: there are bacteria in your small intestine that are not supposed to be there.
Causes and Symptoms of SIBO
One of the biggest risk factors for SIBO is slow gut motility. Muscular contractions within the gut are supposed to sweep things, both food and bacteria, through the GI tract. When it doesn't, bacteria can take hold and multiply in places where they don't belong. It’s also thought that protein pump inhibitors (PPIs) may encourage the growth of bacteria by limiting (or even eliminating) the anti-bacterial effects of acid in the stomach. For these reasons, many people with gastroparesis may also have SIBO.
The symptoms of SIBO are largely a result of the gas that bacteria produces when it "eats." Excessive bloating, distention, burping, and passing gas are common symptoms. Bowel changes, either diarrhea or constipation, as well as malabsorption and unintentional weight loss may also result. For people with functional GI disorders like gastroparesis or visceral hypersensitivity, the excess gas in the GI tract can also cause abdominal pain or cramping.
Read also: Delicious low-FODMAP vegan recipes
Diagnosing and Treating SIBO
The most widely available test for SIBO is a Hydrogen Breath Test. At the beginning of the test, you drink a solution that will "feed" bacteria if they are present, causing them to release gases. Your breath is measured for these gases over the course of several hours (usually 3). The drawback is that this test is not 100% accurate and may be even less so for those delayed gastric emptying, as the test counts on the solution being in the small intestine after 3 hours. Some doctors will treat SIBO empirically, meaning based on symptoms and presentation alone. If symptoms improve with treatment, it's likely that SIBO was an issue.
Most of the time bacterial overgrowth is treated with antibiotics, preferably Xifaxin (rifaximin), which works only in the intestine and therefore has fewer potential side effects. There is also an herbal protocol for the treatment of SIBO, which was developed by Dr. Gerad Mullin at Johns Hopkins. Aside from medical treatment, dietary changes are an important part of managing bacterial overgrowth. If the underlying cause of the overgrowth, slow motility, for example, isn't resolved, then the bacteria may regrow. Eating foods that feed bacteria will make this more likely.
SIBO and Gastroparesis Connection
It may be no surprise that our bodies actually harbor more live microbial cells than human cells. We have a plethora of bacteria, viruses, parasites, fungi, and even amoebas that call our gut home. Under normal conditions, most of the microbiome is isolated to your large intestine. Our small intestine, on the other hand, has only small amounts of microbes. However, there are times when the small intestine can become overrun with bacteria and other microbes.
In a study of 50 patients with gastroparesis, SIBO was found in 60% of individuals. Furthermore, SIBO was more likely the longer the patient had gastroparesis. Another study suggested that up to 39% of 700 gastroparesis patients also had SIBO. This association may be secondary to slowed gut motility that sets up a conducive environment for bacterial overgrowth. However, it’s important to note that not all data agrees. In another study of 73 participants, there was NO association between the diagnosis of SIBO and delayed gastric emptying. Even though delayed gastric emptying is associated with the diagnosis of gastroparesis, this study did not look at the direct relationship between SIBO and gastroparesis.
Just like IBS, the symptoms associated with SIBO include abdominal discomfort, diarrhea and/or constipation, gas, and bloating. SIBO is just one of many causes of IBS. Specifically, in a meta-analysis of 50 studies, more than ⅓ of IBS patients tested positive for SIBO. Furthermore, IBS patients are 5x more likely to have SIBO compared to healthy controls. Some of these symptoms of SIBO and IBS also overlap with those of gastroparesis.
Read also: Delicious Low FODMAP Chicken
The Low-FODMAP Diet
FODMAP stands for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides, And Polyols (complex sugars). FODMAPs are highly fermentable carbohydrates that are often poorly digested and absorbed, particularly by those with functional gastrointestinal disorders. According to Registered Dietitian and FODMAP expert Kate Scarlata, "FODMAPs are fast food for gut bacteria." For those of us who have an imbalance of bacteria in our gut, have bacteria growing in the wrong places (SIBO), or have an increased sensitivity to sensations in the gut (visceral hypersensitivity), feeding those bacteria causes gas, bloating, pain, and bowel disturbances.
FODMAP sugars include:
- Fructose: found in fruit, honey, juices.
- Lactose: found in milk and milk products.
- Sugar polyols such as sorbitol and mannitol - found in some fruits, vegetables and artificial sweetener.
- Fructans: found in wheat, rye, onions, garlic.
- Galacto-oligosaccharides (GOS): found in beans and pulses such as chickpeas, kidney beans or baked beans.
Some types of food contain fermentable fiber (FODMAPs) that can feed bacterial imbalances in the gut. Many professional organizations endorse the use of a low FODMAP diet for SIBO and IBS. In a randomized controlled trial, 68% of those with IBS symptoms reported adequate control of symptoms after 4 weeks of a low FODMAP diet. A meta-analysis determined that the low FODMAP diet reduced overall digestive symptoms and abdominal pain, and increased quality of life. A second meta-analysis came to a similar conclusion. In a study of 45 gastroparesis patients, foods that worsen symptoms include some higher FODMAP foods (e.g. broccoli, onions, cabbage). Furthermore, foods that improved symptoms included low FODMAP foods.
Implementing a Low-FODMAP Diet
If you are brand new to gastroparesis and/or just getting started with the general gastroparesis-friendly diet, this post may not be for you right now. But if you have a comprehensive management plan and are still struggling with symptoms - particularly bloating, distention, stomach pain, burping, or gas - the information below might be the missing piece of your puzzle!
Unfortunately, some of the foods highest in FODMAPs are the ones that many people think of as GP-friendly staples. The things your doctor probably told you to eat when you were first diagnosed. Low-fiber wheat products (white bread, crackers, pasta, cereal, pancakes, etc.), applesauce, pears, and dairy products like skim milk, low-fat yogurt, and frozen yogurt. Many of the meal replacement drinks also contain FODMAPs in the form of FOS, inulin, or chicory root.
Following the low-FODMAP diet involves two steps:
- Step 1: Elimination: Eliminate ALL High FODMAP foods from your diet for approximately 2-6 weeks. Eat only foods that are considered Low in FODMAPs.
- Step 2: Reintroduction: Reintroduce 1 FODMAP group at a time. Choose a food in one of the sub-groups to eat for 3-4 days while monitoring for any recurrence of symptoms. Start with only eating a small amount and then if tolerated increase serving size with each consecutive day to determine the amount you are able to tolerate. It may be helpful to keep a food diary.
Is a Low-FODMAP Diet Right for You?
No, the low-FODMAP diet is meant to be a short-term elimination diet followed by a series of reintroduction challenges. Eliminating all high-FODMAP foods indefinitely is not recommended for several reason. First, it further limits the variety in the diet. This can make it more difficult (and more stressful) to figure out what to eat. Restricting variety also further restricts nutrition. Many high-FODMAP foods, particularly the fruits and veggies, have nutrients that we may not get from other sources. What's more, higher-FODMAP whole foods may help to properly balance overall gut bacteria (not to mention our digestion).
Once symptoms have improved, a specific food from each FODMAP group is re-introduced one at a time to determine whether or not there is a reaction. Those FODMAP groups that do not provoke symptoms can be added back into the diet, while those that do will continue to be off-limits for the time being. The length of the re-introduction phase, which is best supervised by an educated nutrition professional, will vary depending on how many groups of FODMAPs a person reacts to. It's necessary to be symptom-free for 3 days before trying the next group.
Of course, the idea of being "symptom-free" is a little tricky in the context of gastroparesis. Whereas the low-FODMAP diet often significantly and very noticeably reduces symptoms for those with IBS, the effect on those with gastroparesis may be less easy to tease apart from the general ebb and flow of GP symptoms. I think the key is being really purposeful about eliminating FODMAPs in the first place and paying close attention to any changes you may notice in the weeks after, primarily as they relate to pain, gas, bloating, and bowel habits.
Just as important, in my view, is to implement the diet as part of a comprehensive management plan.
Low-FODMAP Foods
As you can see in this graphic, the basic breakdown is to avoid: dairy, wheat (gluten), beans and lentils, and certain fruits and vegetables. Also don’t forget that red meat, high fat foods and fiber can all aggravate the stomach as well.
There’s a long list of low FODMAP foods that are typically well tolerated by GPers:
- baby food purée (check to make sure the fruit and veggies in it are low FODMAP)
- starchy foods such as potatoes without skin, white rice, gluten free bread and gluten free pasta
- puréed soups such as butternut squash, potato, pumpkin, parsnip and sweet potato
- ginger! Add it to any dish you can.
Additional Therapies
Probiotics
Unfortunately, probiotics have not enjoyed the merit and credit that they deserve. When we examine the research, we come across a multitude of studies on probiotics. In fact, there are over 2,600 trials looking at probiotics use in IBS patients. In a meta-analysis, the results of 20 placebo-controlled clinical trials were reviewed with a total of 1,400 subjects. The probiotic group showed improvement in global IBS symptoms when compared to the placebo group. Many more meta-analysis and clinical trials support the use of probiotics in IBS.
To further my point, probiotics have shown to work better if a patient has both IBS and SIBO, compared to IBS without SIBO. Probiotics may be useful in those with gastroparesis. This postulation is made on the fact that some studies using probiotics in those who are constipated showed faster gut transit time. For example, a meta-analysis of 17 studies and 1,500 patients, suggested that patients using probiotics experienced a shorter gut transit time by 12.36 hours compared to placebo. Nonetheless, not all studies show beneficial effects of probiotics and some studies are limited in small sample sizes.
Elemental Diet
Think of a time that you strained a muscle or maybe even broke a bone. Perhaps you sprained your ankle while on a run. What would you think if you were to go to your doctor and they told you to “keep on running”? In the same way we need to give a sprained ankle some rest and T.L.C., we should also give our gut a break from the constant slow drip of solid food that it needs to break apart, digest, and absorb. An elemental diet is a liquid diet formula of pre-digested fat, protein and carbohydrates. In other words, it is pre-digested food so your gut can rest and relax while it heals.
Compared to other IBS and SIBO therapies, an elemental diet does not have as much rigorous data to support its efficacy. In one study, 12 patients with gastroparesis were studied on four separate days receiving one of four meals each day in a randomized order: high-fat solid, high-fat liquid, low-fat liquid, and low-fat solid meal. Of the 4 diets studied, the low-fat liquid diet showed the least amount of symptom severity. Another study in the Lancet endorses liquid nutrition in those with gastroparesis.
Medications
Typically, medications are used to control symptoms of gastroparesis in a conventional setting. Prucalopride is a common medication used to help speed up the gut’s motility system to prevent the symptoms of gastroparesis. In a smaller study of gastroparesis patients, prucalopride had gastric gastric emptying time but NO difference in symptoms when compared to placebo. Another similar medication used for gastroparesis called metoclopramide has been cautioned not to use more than 12 weeks secondary to its side effects of movement disorders. In case drugs are ineffective, a pacemaker may be recommended.
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