What dietary recommendations are suitable for a patient with gastroparesis, particularly those with diabetes?

Dietary Recommendations for Gastroparesis

For gastroparesis, implement 5-6 small, low-fat (<30% of calories), low-fiber meals daily, replacing solid foods with liquids such as soups when symptoms are severe, and prioritize foods with small particle size to optimize gastric emptying. 1, 2

Core Dietary Principles

Meal Frequency and Size

• Eat 5-6 small meals throughout the day rather than 3 large meals to minimize gastric distension while maintaining adequate nutritional intake 1, 2, 3
• Reduce individual meal volume to decrease the workload on the dysfunctional stomach 2

Fat Content

• Limit fat intake to less than 30% of total daily calories because high-fat foods significantly delay gastric emptying 1, 2
• Avoid fried foods (fried chicken), fatty meats (sausage, bacon, roast beef), and high-fat dairy products 4
• However, high-fat liquid meals may be reasonably tolerated in some patients and can supplement diet as tolerated 5

Fiber Content

• Minimize fiber intake, particularly insoluble fiber, as roughage-based foods worsen symptoms 1, 2, 4
• Avoid high-fiber vegetables like cabbage, lettuce, broccoli, peppers, and onions 4
• Low viscosity soluble fibers are well-tolerated in mild to moderate gastroparesis and can be used to supplement the diet 5

Food Consistency and Particle Size

• Focus on foods with small particle size to facilitate gastric emptying 1, 2
• Replace solid foods with liquids (soups, broths) when symptoms are severe 1, 2, 3
• Use energy-dense liquids in small volumes to maintain caloric intake 1
• Consume complex carbohydrates rather than simple sugars 1

Specific Foods to Recommend

Well-Tolerated Foods (Generally Bland, Sweet, Salty, Starchy)

• Saltine crackers, graham crackers, and pretzels 4
• White rice, potatoes, and sweet potatoes 4
• Jello, popsicles, and applesauce 4
• Clear soups and broths 4
• White fish and salmon 4
• Ginger ale and tea 4
• Gluten-free foods (if tolerated) 4

Foods That Worsen Symptoms (Avoid These)

• Acidic foods: orange juice, oranges, tomato juice, salsa 4
• Fatty foods: fried chicken, sausage, bacon, roast beef, pizza 4
• Spicy foods: peppers, salsa 4
• Roughage-based foods: cabbage, lettuce, broccoli, onions 4
• Coffee 4

Additional Dietary Strategies

Timing and Positioning

• Avoid lying down for at least 2 hours after eating to reduce reflux and promote gastric emptying 2, 3

Liquid Calories

• Prioritize liquid nutrition sources when solid food tolerance is poor 1, 2
• Energy-dense liquids in small volumes help maintain caloric intake without overwhelming gastric capacity 1

Special Considerations for Diabetic Gastroparesis

Glycemic Management

• Coordinate carbohydrate intake with insulin timing, as gastroparesis causes unpredictable food delivery to the intestines 1, 3
• Insulin dosage or timing may require adjustment because exogenously administered insulin may act before food leaves the stomach, leading to hypoglycemia 6
• Maintain near-normal glycemic control, as hyperglycemia itself worsens gastric emptying 3

Medication Interactions

• Discontinue or reduce GLP-1 receptor agonists (semaglutide, dulaglutide, liraglutide) if possible, as these medications delay gastric emptying 3
• Avoid opioids and anticholinergic medications that worsen gastroparesis 2, 3

Nutritional Monitoring

Assess for Malnutrition

• Monitor for weight loss >10-15% within 6 months, BMI <18.5 kg/m², and serum albumin <30 g/L 2
• If oral intake remains below 50-60% of energy requirements for more than 10 days despite dietary modifications, consider jejunostomy tube feeding 2, 7

Micronutrient Supplementation

• Monitor for deficiencies in vitamin B12, vitamin D, iron, and calcium 2
• Consider oral nutritional supplements between meals to increase caloric and protein intake 2

Common Pitfalls to Avoid

• Do not recommend high-fiber "healthy" diets – while fiber is generally beneficial, it significantly worsens gastroparesis symptoms 1, 4
• Do not delay enteral nutrition beyond 10 days of inadequate oral intake in documented gastroparesis, as malnutrition significantly worsens outcomes 2
• Never place gastrostomy tubes in gastroparesis patients, as they deliver nutrition into the dysfunctional stomach; jejunostomy tubes that bypass the stomach are required 2, 7
• Do not overlook medication-induced gastroparesis from opioids, GLP-1 agonists, or anticholinergics, which may be reversible 2, 3, 7