Questions and Answers
Q: Are there any studies of dietary changes to help with problems of gastroparesis? My daughter has had type 1 diabetes for 32 years and is now suffering complications, gastroparesis being one of particular concern.
A: Gastroparesis is an autonomic neuropathy of the gastrointestinal tract. It produces slowed emptying of the stomach, and the symptoms include early fullness and nausea. It can also cause constipation or diarrhea.
Treatment for gastroparesis includes the use of the drug Reglan (metoclopramide), which is given 30 minutes prior to meals. Reglan works by increasing stomach contractions. Also, some people must use a stool softener for constipation or an antispasmotic drug for diarrhea, depending on which is needed.
Dietary treatment for gastroparesis includes eating small and frequent meals. This means eating three meals and three snacks per day to maintain an adequate calorie intake. Also, a soft-to-liquid diet that is low in fat (40 grams per day) is often better tolerated than regular meals. Because weight loss often accompanies gastroparesis, weight should be monitored regularly. In severe cases, a jejunostomy tube feeding may be needed to supplement the diet further along the gastrointestinal tract.
Dana Arnold, MS, RD, CDE
Daly City, California
Are Japanese Insulins Weaker than American Insulins?
Q: Our insulin-dependent son is out of the country and must renew his prescriptions while in Japan. He tells us that the syringes require more insulin per dosage since the insulin there is weaker. What's the story?
A: Insulin is available in different strengths worldwide. In the United States, we mostly use U-100 insulin (a 1 cc injection delivers 100 units). In Japan, you can also get U-40 insulin, which is less potent (a 1 cc injection delivers 40 units). If your son was changed from U-100 to U-40 insulin, he will need to inject a larger amount to get the same number of units. There are matching insulin delivery devices (syringes) for U-40 insulin, which can be used to ensure that the correct number of units are given. If he wants to continue to use the more familiar U-100 insulin to avoid confusion, he should ask for it. It is available in Japan. However, it may not be as simple as that. Total insulin unit requirements change, and he may actually need more insulin. He should speak with his healthcare professional to learn about the specifics of his situation, as all insulin changes should be made cautiously under medical supervision. Depending upon the duration and conditions of travel, it may be possible to bring your own insulin. Please check with your physician and insulin provider.
Olga Santiago, MD
Medical Director, Novo Nordisk Pharmaceuticals
Determining the Root of My Diabetes
Q: At age 59, I try to avoid unacceptably high blood sugar levels by walking briskly three miles each day and endeavoring to stay away from carbohydrates. I have not started medication yet, but fear that doing so is just a matter of time. My BG is frequently above 150 before breakfast but declines to the low 100s by dinner. Within the last couple of years, however, my HbA1c has been above 8 percent.
My physician (a GP) says there are no tests to determine the root cause of one's diabetes. He says that prescribing a medication is primarily a matter of finding something the body tolerates and that works. My concern here is how does one determine whether the pancreas is generating enough insulin, whether the liver is generating too much glucose or whether the blood cells are simply unable to utilize the insulin already in the blood?
I have read that different medications are for one or more of these conditions, but I wish to know if one can test for such conditions. For instance, I do not want to take medication that prods my pancreas to generate more insulin if my particular problem is that I already have sufficient levels of insulin but that it cannot gain access to my cells.
Ed Watson Jr.
A: What you are experiencing is insulin resistance, a state in which the body becomes less efficient in using insulin to stimulate glucose uptake and its utilization by cells. The typical progression of type 2 diabetes, in which insulin is produced but is not able to be used, causes glucose levels to escalate. In turn, higher glucose levels lead to increased damage to tissue.
The way to determine whether you have type 1 or type 2 diabetes and the level of your insulin production is by taking the C-peptide test. This would enable you and your practitioner to determine how much insulin, on average, is being produced by your pancreas. Your history, however, seems to indicate that your insulin production is good; otherwise, you would have destruction of muscle and fat in the formation of ketones. However, your cells are losing their sensitivity to insulin. You may not want to take more medicine, or medicine of any kind, that would stimulate or make your pancreas produce more insulin. This could, in theory, speed up the process of pancreatic failure or loss of the insulin-producing islet cells, if you take these medications over a long period of time.
As you are well aware, the problem is in the cells, where insulin must be present to allow glucose to enter the cells. A new and controversial group of medications called insulin sensitizers [also known as glitazones] can address this problem. In spite of some adverse patient reactions, most endocrinologists feel that treating insulin resistance is foremost in diabetes care and these drugs do preserve islet cells and thereby insulin production, allowing you to maintain better glucose levels. One way to gauge the level of damage that has been inflicted by routine daily activities and foods is to check your blood sugar not only in the morning but also one or two hours after a meal. This will allow you to see how high the glucose level is in response to the various activities, including eating, that you are engaged in.
One determines whether the pancreas is producing enough insulin either by laboratory testing or by history. You can tell that your liver is generating too much glucose when your glucose level is higher in the morning than when you went to bed at night. Since we assume that you are not making midnight runs to the kitchen, that excess glucose can only come from increased liver production of glucose. Since your glucose values are elevated, we can only assume that the glucose is not going where it is needed, i.e., into the cells.
The battle that you are waging is one that, if you win, will reward you with a longer life that is free of complications. It is a battle you can definitely win with the appropriate diet, medication and activity.
Alan O. Marcus, MD, FACP
President, South Orange County Endocrinology
Associate Clinical Professor
University of California School of Medicine