Gastroparesis - A Case Of Unexplained Lows

Gastroparesis
A Case Of Unexplained =
Lows
By=20
Deborah Thomas-Dobersen, RD, MS, CDE, and Terri Ryan-Turek, RD, CDE

Beth Wolff*, age 44, ran her car into a curb. Onlookers saw that she =
was=20
disoriented and called 911. A paramedic tested Ms. Wolff's blood sugar =
(glucose)=20
level; it was 26 mg/dl. They gave her glucose, and she recovered.

Ms. Wolff reported that she had eaten lunch two hours before the =
accident.=20
She had checked her blood sugar level before lunch, and it was 130 =
mg/dl. She=20
had taken her usual dose of rapid-acting insulin. She hadn't exercised =
that day=20
or the day before. She couldn't find a reason for this unexpected, =
severe low.=20
She went to see her doctor.

hspace=3D"10">

class=3DcommunityColorBold>Gastroparesis face=3DArial=20 size=3D2>Gastroparesis develops in 40 to 50 percent of people who = have had=20 type 1 diabetes for more than 20 years and in 30 to 40 percent of = those=20 with long-standing type 2 diabetes. Keeping your blood sugars = close to the=20 normal level lowers your risk of developing gastroparesis, and may = lead to=20 improvement if you've already developed = it.

Ms. Wolff had had diabetes for 22 years. For the previous two years, =
her A1Cs=20
had averaged 7 percent. But her latest A1C was 9 percent, which meant =
her=20
average blood sugar level was much higher than before. Her normal weight =
was 115=20
pounds. Over the past several months, she had lost five pounds without=20
trying.

She was very upset that she was getting highs and lows that she =
couldn't=20
explain. "I'm doing what I've always done," she said. "Why isn't it =
working?"=20
Her doctor referred her to a dietitian certified in diabetes =
education.

"Do You Feel =
Full?"
Ms. Wolff=20
was using insulin glargine, and rapid-acting insulin before each meal. =
She=20
determined how much rapid-acting insulin to take by estimating how much=20
carbohydrate was in the meal she was about to eat. First, the dietitian =
checked=20
to make sure the dose of insulin Ms. Wolff had taken before lunch was=20
appropriate. It turned out to be one unit for every 15 grams of =
carbohydrate,=20
which should have worked.

The dietitian then asked Ms. Wolff to fill out a href=3D"http://www.billend.com/daily/a1003031.htm#questionnaire">question=
naire=20
(see below). Her answers are in italics.

Based on her answers, the dietitian suspected Ms. Wolff had a =
condition that=20
affects digestion.

Digestion starts in the stomach. When the food moves to the =
intestines,=20
glucose from the starches and sugars (carbohydrates) is absorbed and =
moves into=20
the bloodstream. Normally, this absorption of glucose starts within 10 =
minutes=20
of eating. If the meal is low in fat, blood sugars peak one to two hours =
after=20
the start of the meal.

Long-standing diabetes often leads to nerve damage. When the nerves =
that=20
control the stomach are affected, food stays in the stomach longer than =
normal.=20
This condition is called gastroparesis.

The dietitian asked Ms. Wolff to check her blood sugar level before =
and two=20
hours after each meal for a week and write the results in her log. She =
also=20
asked her to record what and how much she ate, and any exercise she =
did.

class=3DcommunityColorBold>Two-Hour=20 Lows size=3D2>Blood sugars=20 before meal (Target range: 90-130 = mg/dl) size=3D2>Breakfast 110 = mg/dl size=3D2>Lunch 270 = mg/dl size=3D2>Dinner 190 = mg/dl size=3D2>Blood sugars 2=20 hours after meal (Target: 30 to 50 mg/dl higher than=20 before-meal target when using rapid-acting = insulin) size=3D2>Breakfast 55 = mg/dl size=3D2>Lunch 45 = mg/dl size=3D2>Dinner 125=20 mg/dl

Two-Hour Lows
A =
one-week blood=20
sugar log showed that Ms. Wolff's blood sugars were surprisingly low two =
hours=20
after a meal, and too high just before the next meal. (See the sidebar =
"Two-Hour=20
Lows" for a listing of one day's readings.)

Ms. Wolff's rapid-acting insulin was peaking before much glucose from =
her=20
meal had moved into her bloodstream, leading to a low. When the food =
finally=20
made its way out of her stomach, her mealtime insulin was gone, and her =
blood=20
sugars went too high.

Ms. Wolff wasn't taking any drugs that affect stomach emptying, such =
as=20
narcotics or antidepressants. Other conditions that affect digestion, =
such as=20
celiac disease, were ruled out. High-fat meals, such as pizza, can cause =
the=20
same pattern of delayed emptying and a later rise in blood sugars, but =
Ms. Wolff=20
ate low-fat meals.

Split The Dose
It =
seemed likely=20
that diabetic gastroparesis was causing Ms. Wolff's problems. The =
dietitian=20
reported back to the doctor, who prescribed a medication that helps food =
move=20
from the stomach.

Ms. Wolff was also given a new insulin regimen to try: Figure the =
mealtime=20
insulin dose according to the carbohydrate content of the meal, as =
usual. Give=20
half the dose right after the meal (instead of right before), and give =
the other=20
half 90 minutes after the start of the meal. Ms. Wolff was also advised =
to keep=20
her activity consistent for the trial period, while she and her health =
care team=20
were seeing what worked and what didn't.

class=3DcommunityColorBold>Split The=20 Dose size=3D2>Blood sugars=20 before meal size=3D2>Breakfast 125 = mg/dl size=3D2>Lunch 100 = mg/dl size=3D2>Dinner 85 = mg/dl size=3D2>Blood sugars 2=20 hours after meal size=3D2>Breakfast 150 = mg/dl size=3D2>Lunch 115 = mg/dl size=3D2>Dinner 120=20 mg/dl

To see if the treatment worked, Ms. Wolff continued to check her =
blood sugars=20
before and after meals. The sidebar "Split The Dose" shows a typical =
day's=20
results.

The new treatment regimen was working. Ms. Wolff continues to check =
her blood=20
sugars before meals. She also checks after at least one meal a day. She =
rotates=20
the after-meal check, one day checking after breakfast, the next day =
after=20
lunch, and the next after dinner.

---

Deborah Thomas-Dobersen, RD, MS, CDE, is a clinical faculty =
member and a=20
research coordinator and Terri Ryan-Turek, RD, CDE, is a clinical =
faculty member=20
in the Endocrinology Department of the University of Colorado Health =
Sciences=20
Center in Denver.

*This is a real case. The patient's name has been changed.

name=3Dquestionnaire>Questionnaire

• Do you feel full before you've eaten =
  much?=20
  Yes.=20
  
• Have you had any changes in appetite =
  recently?=20
  Yes.=20
  
• Have you gained or lost weight =
  recently?=20
  Yes.=20
  
• Do you have any unexplained trouble =
  controlling=20
  your blood sugars? Yes.=20
  
• Do you have any of the following =
  symptoms:=20
  bloating, heartburn, abdominal cramping? Yes.=20
  
• Do you have unexplained nausea?=20
  Yes.=20
  
• Do you have unexplained vomiting of =
  undigested=20
  food, especially in the morning? No.=20
  
• Have you had any diarrhea or =
  constipation=20
  recently? Is it alternating? No.

If You Have Been Diagnosed With =

Gastroparesis

Diet

• Eat equal-sized meals and avoid heavy, =
  late=20
  dinners.=20
  
• Liquids usually empty from the stomach =
  more=20
  quickly than solids. Do you feel more full as the day goes on? Try=20
  substituting liquids for solids as the day goes on.=20
  
• High-fat foods exit the stomach more =
  slowly. Avoid=20
  foods high in fat, and don't add too much fat to foods. (It is true, =
  however,=20
  that many people with gastroparesis tolerate fat in liquid form, such =
  as milk=20
  shakes, whole milk, and nutritional supplements.)=20
  
• Fiber, especially pectin, slows =
  stomach emptying.=20
  Avoid oranges, persimmons, coconuts, berries, green beans, figs, =
  apples,=20
  sauerkraut, Brussels sprouts, potato peels, and legumes.=20
  
• Chew food well.=20
  
• Sit up after meals; don't lie down for =
  at least=20
  one hour following a meal.=20
  
• Walk after meals when possible to help =
  your=20
  stomach empty.

Insulin Regimens
Rapid-acting insulins (lispro and insulin =
aspart)=20
peak about one to two hours after injection. Regular insulin peaks about =
three=20
hours after injection.

If you use injections, your doctor or diabetes educator may advise =
you to

• Take half of your rapid-acting dose =
  right after=20
  eating and the other half one to two hours after the meal, =
  or=20
  
• Take a dose of half rapid-acting and =
  half regular=20
  insulin right after the meal. You can mix the insulins in the same =
  syringe;=20
  inject immediately after mixing. (Neither of the insulin =
  manufacturers, Eli=20
  Lilly or NovoNordisk, has data on mixing rapid-acting and regular. =
  Some people=20
  with diabetes have found that these mixes work well for them.) =
  

If you use an insulin pump

• Use a dual or combination wave, which =
  involves an=20
  immediate delivery of insulin followed by a bolus that's delivered =
  over a=20
  longer period of time. This may more closely match insulin levels to =
  your rate=20
  of digestion.