Small particle size of a solid meal increases gastric emptying and late postprandial glycaemic response in diabetic subjects with gastroparesis

Gastroparesis and its Nutritional Implications

PURPOSE OF REVIEW

To present and discuss recent and previous literature on the nutritional implications and management of gastroparesis. We also briefly review its epidemiology, pathophysiology, and clinical manifestations.

RECENT FINDINGS

- Low viscosity soluble fibers are well-tolerated in patients with mild to moderate gastroparesis symptoms and can thus be used to supplement the diets of these patients. - High-fat liquid meals are reasonably well-tolerated in patients with gastroparesis and can be used to supplement diet as tolerated. - The risk of tardive dyskinesia (TD) with long-term use of metoclopramide is much lower than previously thought. The nutritional status of patients with gastroparesis ranges across a wide spectrum, depending on the severity of their disease. Some patients improve simply with dietary modifications, others respond well to medical therapy, and those with severe, drug-refractory disease often require enteral nutrition or TPN (total parenteral nutrition). Generally, the recommended diet is composed of small particles, low fat, and low fiber; however recent studies showed that low viscosity soluble fibers and high-fat liquid fats can be tolerated. Metoclopramide is the first prokinetic agent of choice, and while the risk of TD is lower than previously thought, long-term use should be avoided in certain patient populations. For those on enteral nutrition, the choice of formula should be based on osmolarity, fat content, and fiber content, in accordance with the patient's tolerance.

Unmasking Gastroparesis in Diabetes During Ramadan: Challenges and Management Strategies

Gastroparesis, characterized by delayed gastric emptying without mechanical obstruction, is a recognized complication of long-standing diabetes. Its pathophysiology involves, amongst other mechanisms, autonomic dysfunction due to vagal nerve damage, impaired smooth muscle contractility, and hormonal dysregulation of intestinal motility. During Ramadan, fasting causes significant dietary changes due to prolonged fasting and the consumption of large meals for Iftar (breaking of fast), which may unmask or worsen gastroparesis symptoms in individuals with diabetes. Symptoms such as early satiety, bloating, nausea, and glycemic fluctuations can further complicate diabetes management during fasting. This paper highlights the relationship between Ramadan fasting and gastroparesis in individuals with diabetes, exploring underlying mechanisms, clinical manifestations, diagnostic approaches, and management strategies. A multidisciplinary approach involving dietary modifications, medication adjustments, lifestyle changes, and individualized medical counseling is essential for safe fasting, alongside the option to avoid fasting in individuals who are deemed too high at risk for fasting. Further research is needed to assess the prevalence of subclinical gastroparesis in fasting individuals with diabetes and to optimize risk stratification and management in these patients.

Rome Foundation and international neurogastroenterology and motility societies' consensus on idiopathic gastroparesis

To establish a consensus on the definition and management of idiopathic gastroparesis, international experts (selected by neurogastroenterology and motility societies and initiated by the Rome Foundation) devised 144 statements using the Delphi method, with at least 80% agreement required. This consensus defined idiopathic gastroparesis as the presence of symptoms associated with delayed gastric emptying in the absence of mechanical obstruction. Nausea and vomiting were identified as cardinal symptoms. Frequently co-existing symptoms are early satiation and postprandial fullness. Diagnosis requires the presence of these symptoms alongside delayed gastric emptying, measured by a 4 h scintigraphy or gastric emptying breath test of a mixed composition meal in the absence of mechanical obstruction. Therapeutic options with proven efficacy were sparse. Dietary adjustments, nutritional support (per guidelines from the European Society for Clinical Nutrition and Metabolism for substantial weight loss or intractable vomiting), and opioid cessation were recommended by a consensus opinion. Antiemetic and prokinetic agents were also considered potentially beneficial. This consensus offers a global perspective on idiopathic gastroparesis.

Impact of fermentation by Saccharomyces Cerevisiae on the macronutrient and in vitro digestion characteristics of Chinese noodles

This study examined the impact of live bread yeast (Saccharomyces cerevisiae) on the nutritional characteristics of Asian dried noodles. Micronutrient analysis of fermented noodles revealed a 6.9% increase in the overall amino acid content, a 37.1% increase in the vitamin B content and a 63.0% decrease in the phytic acid level. Molecular weight analysis of starch and protein contents revealed moderate decrease in the fermented noodles. The in vitro digestion of fermented noodles showed a slightly faster initial acidification, four-fold decrease in the initial shear viscosity (from 8.85 to 1.94 Pa·s). The initial large food particle count (>2 mm diameter) was 19.5% lower in the fermented noodles. The fermented noodles contained slightly higher free sugar content (73.5 mg g-1 noodle) during the gastric digestion phase. The overall nutrition and digestion results indicate nutritional improvement and digestion-easing attributes in the fermented noodles.

Ordered Eating and Its Effects on Various Postprandial Health Markers: A Systematic Review

OBJECTIVE

Aberrations in glucose, insulin, and other postprandial (PP) markers are common in obesity and cardiometabolic disorders. One potentially simple lifestyle/dietary modification to manage these issues is to change the order in which foods are consumed within meals. Carbohydrate exerts the largest effect on PP glucose, and there is some evidence that ingesting dietary fat or protein before carbohydrate delays gastric emptying of carbohydrate and reduces PP glucose. Additionally, certain dietary proteins may augment insulin release if ingested with carbohydrate, thereby improving blood glucose clearance. This review aimed to systematically evaluate evidence from acute experiments that modified the order in which foods were consumed in isocaloric meals.

METHODS

Outcomes of interest were PP glucose and insulin (including area under the curve for both), C-peptide, gut hormones, and perceptual responses. Three databases were searched (PubMed, Cochrane CENTRAL, Web of Science) in February 2022. Additionally, reference lists of identified reports were searched, and an author of several studies was consulted to verify that relevant literature was included. The review included acute interventions that administered isocaloric meals of the same foods but with foods eaten in different orders. Studies were not excluded based on participant characteristics.

RESULTS

Eleven reports were identified. All reports that assessed glucose and insulin showed a tendency toward lower levels, at least over parts of the PP period, by consuming carbohydrates last. GLP-1 tended to be higher in carbohydrate-last conditions, though this was only measured in a few studies. Perceptual responses (hunger, fullness, etc.) were not consistently different between conditions in two studies, but the certainty of evidence was very low.

CONCLUSIONS

Findings indicate that, at least acutely, there may be benefits to eating carbohydrate after vegetable and/or protein-rich foods. The most consistent effect (judged as moderate certainty) is that carbohydrate-last meal orders tend to lower blood glucose and insulin excursions.

Imaging in Gastroparesis: Exploring Innovative Diagnostic Approaches, Symptoms, and Treatment

Gastroparesis (GP) is a chronic disease characterized by upper gastrointestinal symptoms, primarily nausea and vomiting, and delayed gastric emptying (GE), in the absence of mechanical GI obstruction. The underlying pathophysiology of GP remains unclear, but factors contributing to the condition include vagal nerve dysfunction, impaired gastric fundic accommodation, antral hypomotility, gastric dysrhythmias, and pyloric dysfunction. Currently, gastric emptying scintigraphy (GES) is considered the gold standard for GP diagnosis. However, the overall delay in GE weakly correlates with GP symptoms and their severity. Recent research efforts have focused on developing treatments that address the presumed underlying pathophysiological mechanisms of GP, such as pyloric hypertonicity, with Gastric Peroral Endoscopic Myotomy (G-POEM) one of these procedures. New promising diagnostic tools for gastroparesis include wireless motility capsule (WMC), the 13 carbon-GE breath test, high-resolution electrogastrography, and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Some of these tools assess alterations beyond GE, such as muscular electrical activity and pyloric tone. These modalities have the potential to characterize the pathophysiology of gastroparesis, identifying patients who may benefit from targeted therapies. The aim of this review is to provide an overview of the current knowledge on diagnostic pathways in GP, with a focus on the association between diagnosis, symptoms, and treatment.

Diabetic gastroparesis: clinical features, diagnosis and management

Diabetic gastroparesis carries a heavy burden on people with diabetes and the healthcare system. It remains underdiagnosed and represents challenges to treat. This article reviews the epidemiology, pathophysiology, clinical features, diagnosis and treatment of diabetic gastroparesis. The disorder is characterized by delayed gastric emptying without evidence of mechanical gastric outflow obstruction. It presents with upper gastrointestinal (GI) symptoms such as nausea, vomiting, early satiety, postprandial fullness, upper abdominal discomfort and or bloating. As the prevalence of diabetes has been growing over the last few decades, we would expect an increased incidence of delayed gastric emptying in poorly controlled diabetes and perhaps in line with the increasing use of medications that act on the GI tract such as incretin-based therapy. The disease results from multiple reversible and irreversible mechanisms. Diagnosing diabetic gastroparesis requires careful history, examination and investigations to exclude other disorders that could mimic its clinical presentation. Treatment involves a wide variety of options starting with optimization of glycaemic control, stopping any offending medications and lifestyle modifications followed by the introduction of medical therapeutics such as prokinetics. Then, surgical interventions are considered in refractory cases.

Gastroparesis: Myths, Misconceptions, and Management

Gastroparesis (GP), a historically vexing disorder characterized by symptoms of nausea, vomiting, abdominal pain, early satiety, and/or bloating, in the setting of an objective delay in gastric emptying, is often difficult to treat and carries a tremendous burden on the quality of patients' lives, as well as the healthcare system in general. Though the etiology of GP has been fairly well defined, much work has been done recently to better understand the pathophysiology of GP, as well as to identify novel effective and safe treatment options. As our understanding of GP has evolved, many myths and misconceptions still abound in this rapidly changing field. The goal of this review is to identify myths and misconceptions regarding the etiology, pathophysiology, diagnosis, and treatment of GP, in the context of the latest research findings which have shaped our current understanding of GP. Recognition and dispelling of such myths and misconceptions is critical to moving the field forward and ultimately advancing the clinical management of what will hopefully become a better understood and more manageable disorder in the future.

Gastrointestinal Dysfunction in Parkinson's Disease: Neuro-Gastroenterology Perspectives on a Multifaceted Problem

Patients with Parkinson's disease (PD) face a multitude of gastrointestinal (GI) symptoms, including nausea, bloating, reduced bowel movements, and difficulties with defecation. These symptoms are common and may accumulate during the course of PD but are often under-recognized and challenging to manage. Objective testing can be burdensome to patients and does not correlate well with symptoms. Effective treatment options are limited. Evidence is often based on studies in the general population, and specific evidence in PD is scarce. Upper GI dysfunction may also interfere with the pharmacological treatment of PD motor symptoms, which poses significant management challenges. Several new less invasive assessment tools and novel treatment options have emerged in recent years. The current review provides an overview and a practical approach to recognizing and diagnosing common upper and lower GI problems in PD, e.g., dyspepsia, gastroparesis, small bowel dysfunction, chronic constipation, and defecatory dysfunction. Management aspects are discussed based on the latest evidence from the PD and general populations, with insights for future research pertaining to GI dysfunction in PD.

Standard Adult Gastric Emptying Scintigraphy Criteria Is Applicable for Partial Meal Ingestion

BACKGROUND/AIMS

Gastric emptying scintigraphy is commonly performed to assess for dysmotility. A standardized meal with associated threshold criteria was established in 2000 to enable robust interpretation. However, no guidance is available to interpret results when patients do not ingest the entire meal. The purpose of this study is to determine the continued appropriateness of the threshold criteria in contemporary clinical practice and its relevance for partially ingested meals.

METHODS

This retrospective study analyzed patients (n = 1365 total) who underwent solid-phase gastric emptying scintigraphy at an academic medical center. Patients were stratified based on their completion of the standard meal. Patients were further stratified into normal and delayed gastric emptying cohorts based on the current criteria. Percent gastric retention values at 1, 2, 3, and 4 h were compared.

RESULTS

Median (95% upper reference) normal gastric retention values for the complete standard meal were 64% (87%) at 1 h, 25% (60%) at 2 h, 13% (54%) at 3 h and 4% (9%) at 4 h. Consumption of at least 50% of the standard meal yielded similar retention; 53% (86%) at 1 h, 19% (58%) at 2 h, 6% (29%) at 3 h and 3% (10%) at 4 h. There was no significant age- or gender-specific differences using the current criteria, and no differences were observed based on diabetic status. Retention values matched well with the current criteria and validated with data-driven clustering.

CONCLUSION

Adult normative standards for gastric emptying scintigraphy are appropriate for differentiating normal and delayed populations and can be applied to partial meals with at least 50% completion.

Nut-enriched energy restricted diet has potential to decrease hunger in women at cardiometabolic risk: a randomized controlled trial (Brazilian Nuts Study)

Successful weight management represents a challenge to obesity control. Evidence suggests that nut consumption promotes a prolonged satiety response. Therefore, we hypothesize that nuts could be associated with greater weight loss in comparison to a control group, and we evaluate the acute and long-term effects of Brazilian nuts (BN: 15 g of Brazil nuts + 30 g of cashew nuts) included in an energy-restricted intervention on food intake, appetite, and peptide hormones. We conducted an 8-week, randomized, open-label, controlled, parallel-arm clinical trial with 28 women at cardiometabolic risk who received an energy-restricted diet containing BN or an energy-restricted nut-free diet (control). At baseline and after 8 weeks of intervention, subjective postprandial appetite ratings were assessed using a visual analog scale (VAS) before and after consumption (0, 10, 60, 120, 180, and 240 minutes) of a 437-kcal nut-enriched (BN group) or nut-free (control) breakfast meal. Subsequently, an ad libitum lunch was served, and the participants completed another VAS at 280 minutes. Plasma concentrations of ghrelin, glucose-dependent insulinotropic polypeptide, glucagon-like peptide 1, and leptin were measured at fasting and postprandially at 60, 120, and 240 minutes. Last, subsequent reported 24-hour energy intake was assessed in a free-living setting. BN consumption did not have acute effects on food intake, appetite, or peptide hormones. However, after an 8-week intervention, postprandial ghrelin (difference between post- and preintervention area under the curve) decreased in the BN group in comparison to the control (mean difference, 1978 pg/mL/min, 95% CI, 27-3929 pg/mL/min; P = .047) and therefore, an energy-restricted diet containing demonstrated potential to decrease hunger in cardiometabolic risk women.

The efficacy and safety of oral semaglutide for glycaemic management in adults with type 2 diabetes compared to subcutaneous semaglutide, placebo, and other GLP-1 RA comparators: A systematic review and network meta-analysis

Aim

Semaglutide is a long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA) indicated for glycaemic management in adults with type 2 diabetes (T2D). Oral semaglutide administration can help decrease glycated haemoglobin (HbA1c) and body weight in people with uncontrolled T2D. We evaluated the efficacy and safety of oral semaglutide compared to that of subcutaneous semaglutide, placebo, and other GLP-1 RAs in the treatment of T2D.

Methods

Randomised controlled trials of subcutaneous and oral semaglutide for glycaemic control in adults with T2D were selected from the Cochrane Central Register of Controlled Trials and PubMed. Mean differences (MDs) and risk ratios with 95% confidence intervals (CIs) were used to synthesise the results, and oral and subcutaneous semaglutide formulations were indirectly compared using mixed treatment comparisons.

Results

Twelve studies were included in this review (6840 participants). Oral semaglutide (14.0 mg) significantly reduced HbA1c (MD, −1.30% [95%CI: -1.44, −1.16], P < 0.05) and body weight (MD, −3.17 kg [95%CI: -3.89, −2.45], P < 0.05) compared to placebo (MD, HbA1c: -0.32% [95%CI: -0.49, −0.15], P < 0.05; MD body weight: -2.56 kg [95%CI: -3.41, −1.71], P < 0.05), liraglutide (1.2 mg), exenatide ER (2.0 mg), and dulaglutide (1.5 mg). Oral semaglutide was slightly less effective than subcutaneous semaglutide in reducing HbA1c levels (MD: -0.26% [95%CI: -0.44, −0.07], P < 0.05) and body weight (MD: -1.08 kg [95%CI: -2.04, −0.12], P < 0.05). Oral semaglutide increased the incidence of adverse events (nausea, diarrhoea, dyspepsia, and vomiting) compared to placebo, liraglutide (1.2 mg), exenatide (ER, 2.0 mg), and dulaglutide 1.5 mg but not compared to subcutaneous semaglutide.

Conclusion

Oral semaglutide was non-inferior to subcutaneous semaglutide and superior to placebo and another GLP-1 RA in reducing HbA1c and body weight. It was superior to subcutaneous semaglutide and inferior to other GLP-1 RA comparators and placebo in terms of the incidence of adverse events. Thus, oral semaglutide provides a convenient administration route for patients who prefer oral treatments over injectable therapies.

ACG Clinical Guideline: Gastroparesis

Gastroparesis is characterized by symptoms suggesting retention of food in the stomach with objective evidence of delayed gastric emptying in the absence of mechanical obstruction in the gastric outflow. This condition is increasingly encountered in clinical practice. These guidelines summarize perspectives on the risk factors, diagnosis, and management of gastroparesis in adults (including dietary, pharmacological, device, and interventions directed at the pylorus), and they represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation process. When the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

Evidence-Based and Emerging Dietary Approaches to Upper Disorders of Gut-Brain Interaction

Food ingestion is a major symptom trigger in functional esophageal and gastroduodenal disorders and gastroparesis. This review summarizes current knowledge and identifies areas of research on the role of food factors and the opportunities for dietary intervention in these disorders. While many patients experiencing functional esophageal and gastroduodenal disorders identify specific food items as symptom triggers, available data do not allow the identification of specific nutrient groups that are more likely to induce symptoms. In functional dyspepsia (FD), recent studies have shown the potential efficacy of a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, although the underlying mechanism of action is unclear. Reports of favorable responses to gluten elimination in patients with FD are confounded by the concomitant benefit of reduced intake of fructans, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols present in wheat. Emerging data based on a 6-food elimination diet and confocal laser endomicroscopic evaluation of mucosal responses to food proteins suggest a role for duodenal allergic reactions in FD symptom generation. In patients with gastroparesis, a low-residue diet has been shown to improve symptoms. Novel dietary approaches under evaluation are the Mediterranean diet and the heating/cooling diet approach.

Dietary Interventions for Gastroparesis: A Systematic Review

Gastroparesis (Gp) is a delay in gastric emptying in the absence of a mechanical obstruction and has the capacity to cause symptoms that significantly impact a patient's quality of life. Dietary interventions are the first-line treatment in Gp, but the efficacy of different diets is unclear. This systematic review seeks to determine the effectiveness of dietary interventions on clinical outcomes in Gp. A literature search of MEDLINE Ovid from 1 March 2008 to 1 October 2021 was conducted to identify randomized controlled trials, cohort studies, and cross-sectional studies that reported dietary interventions in Gp. From the initial search, 2789 studies resulted. These were assessed by 2 independent reviewers and selected based on the primary outcomes of interest: changes in symptom-specific patient-reported outcomes and changes in gastric emptying time. A third reviewer resolved any discrepancies. Six adult studies (185 subjects) met the inclusion criteria, whereas no pediatric study did. Five of the included studies were randomized controlled trials and one was an observational study. The systematic review suggested low-fat diets, small-particle diets, diets with isoflavones, and foods considered bland, starchy, sweet, and salty did not exacerbate Gp symptoms. Small-particle diets and diets with isoflavones were found to improve gastric emptying time in patients. Additionally, small-particle diets were shown to reduce anxiety in comparison to large-particle diets. Of the randomized controlled trials, 80% were low risk of bias and 20% were fair risk of bias. The observational study was considered fair quality. The data presented in this review suggest specific dietary interventions could potentially improve Gp symptoms and gastric emptying in adult patients, particularly low-fat and small-particle diets. For pediatric Gp, data are lacking. The limited data available highlights a critical gap in the literature.

Starch and protein hydrolysis in cooked quinoa (Chenopodium quinoa Willd.) during static and dynamic in vitro oral and gastric digestion

Quinoa is a pseudocereal that has a favorable nutrient profile and may be a beneficial addition to the diet. To evaluate potential health-promoting properties of foods, it is important to understand the rate of macronutrient hydrolysis, which is commonly quantified through in vitro digestion studies. Additionally, limited information is available comparing starch and protein hydrolysis of solid foods using static and dynamic digestion models. The objective of this study was to examine starch and protein hydrolysis in cooked quinoa using a combination of a static (saliva only) or dynamic (saliva + mincing) oral digestion model with a static (gastric fluids only) or dynamic (Human Gastric Simulator) gastric digestion model. Disruption of the pericarp of the cooked quinoa seeds during dynamic oral digestion released additional surface area, which led to faster gastric emptying during dynamic gastric digestion. Starch and protein hydrolysis were impacted by type of gastric model due to differences in pH and variations in structural breakdown. Starch hydrolysis was 29.04 ± 1.83% after 180 min dynamic gastric digestion compared to 2.85 ± 1.88% during static gastric digestion (averaged across both oral digestion models). The degree of protein hydrolysis was 4.85 ± 0.01% after 180 min in the static gastric model compared to 3.94 ± 0.18% in the dynamic gastric model (averaged across both oral digestion models). This information provides evidence on the role of food structure and breakdown (through use of static vs. dynamic oral and gastric digestion models) on quinoa starch and protein hydrolysis.

Rheological Characteristics of Soluble Fibres during Chemically Simulated Digestion and their Suitability for Gastroparesis Patients

Dietary fibres are an integral part of a balanced diet. Consumption of a high-fibre diet confers many physiological and metabolic benefits. However, fibre is generally avoided by individuals with gastrointestinal motility disorders like gastroparesis due to increased likelihood of exacerbated symptoms. Low-viscosity soluble fibres have been identified as a possible source of fibre tolerable for these individuals. The aim of this study is to determine the rheological properties of 10 common commercially available soluble fibres in chemically simulated digestive conditions and evaluate their suitability for individuals with mild to moderate gastroparesis, a gastric motility disorder. Rheological testing under neutral condition (distilled water pH 7) and chemically simulated gastric digestion were evaluated to determine the yield point and relative viscosity of each fibre. Our results reveal two rheological categories of soluble fibres; pseudoplastic and dilatant. Simulated digestion was shown to significantly alter the yield-points of psyllium husk, iota-carrageenan, beta-glucan, apple-fibre pectin, and inulin. Gum Arabic and partially hydrolysed guar gum showed the lowest viscosities and were not affected under simulated digestion, characteristics that make them potential candidate fibres for patients with gastroparesis. Altogether, our results demonstrate that digestion can have a significant impact on fibre viscosity and should be taken into consideration when evaluating the suitability of fibres for patients with gastric motility disorders.

Nutrition Management in Patients With Chronic Gastrointestinal Motility Disorders: A Systematic Literature Review

BACKGROUND

The aim of this study was to systematically review effects of nutrition interventions on outcomes in patients with chronic gastrointestinal (GI) motility disorders. There is currently a lack of evidence-based guidelines for nutrition management in this group, likely a result of the rarity of the conditions.

METHODS

A systematic review of all study types to evaluate current evidence-based nutrition interventions was performed using Medline, Embase, and CINAHL databases. Two independent reviewers participated in the process of this systematic review. A total of 15 studies and a total of 524 subjects were included.

RESULTS

Best treatment of this population group was found to include a stepwise process, progressing from oral nutrition to jejunal nutrition and lastly to parenteral nutrition. Small particle, low-fat diets were significantly better tolerated than the converse, with jejunal nutrition prior to consuming oral food significantly improving oral intake and motility. In more progressive cases, percutaneous endoscopic gastrostomy with jejunal extension nutrition had lower reported symptoms than other enteral routes. Exclusive long-term parenteral nutrition is a feasible option for advanced cases, with a 68% survival rate at 15 years duration, though oral intake with parenteral nutrition is associated with higher survival rates.

CONCLUSION

Treatment of patients with GI motility disorders should first trial oral nutrition. For patients who progress to jejunal or parenteral feeds, the primary aim should be to maintain or reinstate oral intake to reduce morbidity and mortality risk. Higher-quality studies are still required in this area, particularly in the areas of chronic intestinal pseudo-obstruction and systemic sclerosis.

Effect of Moringa oleifera consumption on diabetic rats

BACKGROUND

Therapeutic use of leaves of M. oleifera has been evaluated in diabetes because of its possible capacity to decrease blood glucose and lipids concentration after ingestion, as result of the polyphenols content and others compounds. Nevertheless most results have been obtain from leaf extract, therefore this study would use leaf powder as the regular way of consumption of population to know effects over toxicity glucose, triglycerides, cholesterol, corporal weight, and predominant groups of microbiota.

METHODS

Powdered leaf was administrated in different doses to know toxicity and genotoxicity using LD50 and micronuclei assay. Hyperglycemia was induced by alloxan on Sprague Dawley rats. Glucose and body weight were measured once a week meanwhile cholesterol and triglycerides were analyzed at the end of the study by commercial kits. Different organs were examined by hematoxylin-eosin technique. Lactic acid bacteria and Enterobacteriaceae were enumerated from stool samples.

RESULTS

The tested doses revealed no lethal dose and no significant differences in genotoxicity parameter. The consumption of the leaves showed a hypoglycemic effect (< 250 mg/dL in diabetic M. oleifera treated group), however in corporal weight showed an increased (> 30 g over no M. oleifera treated groups). There was no change in enumeration of lactic acid bacteria (8.4 CFU/g) but there were differences in the predominance of type of lactobacillus and enterobacteria enumeration.

CONCLUSIONS

These results help to increase information over the most popular use of M. oleifera and its safety. However there are needed more studies over the hypoglycemic mechanisms and effects over intestinal microbiota.

Endoscopic Gastric Food Retention in Relation to Scintigraphic Gastric Emptying Delays and Clinical Factors

BACKGROUND

Gastric food residue frequently is observed on endoscopy despite fasting.

AIMS

To delineate factors promoting endoscopic food retention in the stomach.

METHODS

Two series of analyses were performed. Magnitudes of retained food in 834 patients from an endoscopy database were related to obstructive versus non-obstructive etiologies and gastric emptying findings. Emptying delays in 619 patients from a scintigraphy database were associated with endoscopic food retention, gastroparesis etiologies, and medications that modify gastric transit.

RESULTS

On endoscopy, 310 (37 %) had large, 338 (41 %) showed medium, and 103 (12 %) exhibited small amounts of retained food in the stomach. Of 433 patients with definable etiologies of food retention, 106 (24 %) had obstructive causes. One hundred three of 327 (31 %) with non-obstructive conditions underwent scintigraphy showing mean 52 ± 29 % 4-h retention. From the scintigraphy database, 164/619 patients (26 %) with delayed emptying exhibited food retention on endoscopy. Four-hour scintigraphic retention was greater with versus without retained food (41 ± 25 vs. 32 ± 22 %, P < 0.001). Retained food occurred more frequently with postsurgical (28/69, 41 %) versus diabetic (33/139, 24 %) and idiopathic (65/294, 22 %) gastroparesis (P = 0.006). Opiate use was more prevalent with increasing food retention (P = 0.02), while other medications that delay or accelerate emptying did not relate to retained food.

CONCLUSIONS

Gastric food retention has obstructive and non-obstructive causes, and is found in one-quarter of gastroparesis, especially postsurgical cases. Gastric emptying delays correlate with amounts of retained food on endoscopy. Retention is influenced by opiates, but not other medications. These analyses delineate pathogenic factors promoting gastric food retention.

Gastroretentive systems - a proposed strategy to modulate anthocyanin release and absorption for the management of diabetes

Several reports have indicated a positive correlation between the consumption of anthocyanins (ACN) and biomarkers relating to the improvement of type 2 diabetes (T2D). However, the results from in vitro studies often do not translate into clinical evidence. Potential causes of these discrepancies are experimental conditions that lack physiological relevancy; extensive degradation of these compounds in vivo due to changes in pH and metabolism; and a short residence time in the absorption window in relation to the absorption rate. Here, gastroretentive systems (GRS) are proposed as a strategy to overcome the limitations in ACN delivery and to reduce the existing bench-to-subject gap. This review summarizes recent literature on the use of ACN for the management and control of T2D, followed by GRS platforms to promote a sustained release of ACN for increased health benefits.

Nutritional considerations in the patient with gastroparesis

Gastroparesis, or delayed gastric emptying, has many origins and can wax and wane depending on the underlying cause. Not only do the symptoms significantly alter quality of life, but the clinical consequences can also be life threatening. Once a patient develops protracted nausea and vomiting, providing adequate nutrition, hydration, and access to therapeutics such as prokinetics and antiemetics can present an exceptional challenge to clinicians. This article reviews the limited evidence available for oral nutrition, as well as enteral and parenteral nutritional support therapies. Practical strategies are provided to improve the nutritional depletion that often accompanies this debilitating condition.

Postprandial plasma glucose response and gastrointestinal symptom severity in patients with diabetic gastroparesis

Gastroparesis is a well-known diabetic complication. The pathogenesis is not fully understood. However, it is important to early diagnose these patients. This study evaluated the plasma glucose response after a test meal, and gastrointestinal (GI) symptom severity in patients with clinical suspicion of diabetic gastroparesis, and assessed its usefulness to predict gastroparesis. In all, 83 subjects with insulin-treated diabetes mellitus (DM) type 1 and 2 were included; 53 subjects had gastroparesis and 30 had normal gastric emptying determined by gastric scintigraphy. GI symptom severity during the preceding 2 weeks was evaluated with a validated questionnaire. The test meal consisted of 100 g meat, 40 g pasta, 150 g carrot, and 5 g oil. The subjects ingested the meal under fasting conditions, and plasma glucose was followed during 180 minutes. Patients with gastroparesis demonstrated a blunted plasma glucose response after a test meal versus patients with normal gastric emptying (P < .005), reflected by lower maximum increase in plasma glucose response and incremental area under the curve of the plasma glucose, but a similar time to the maximum plasma glucose level. All GI symptoms were more severe in patients with gastroparesis. GI symptom severity had the best discriminative value to identify patients with gastroparesis with an area under the receiver operating curve of 0.83 (optimal cutoff: sensitivity 87%, specificity 80%). Patients with diabetic gastroparesis have a blunted postprandial plasma glucose response. Combining this information with the presence of GI symptoms can help clinicians identify diabetic patients with gastroparesis.

A small particle size diet reduces upper gastrointestinal symptoms in patients with diabetic gastroparesis: a randomized controlled trial

OBJECTIVES

Gastroparesis is a well-known complication to diabetes mellitus (DM). Dietary advice is considered to be of importance to reduce gastrointestinal (GI) symptoms in patients with diabetic gastroparesis, but no randomized controlled trials exist. Our aim was to compare GI symptoms in insulin treated DM subjects with gastroparesis eating a diet with small particle size ("intervention diet") with the recommended diet for DM ("control diet").

METHODS

56 subjects with insulin treated DM and gastroparesis were randomized to the intervention diet or the control diet. The patients received dietary advice by a dietitian at 7 occasions during 20 weeks. GI symptom severity, nutrient intake and glycemic control were measured before and after the intervention.

RESULTS

A significantly greater reduction of the severity of the key gastroparetic symptoms-nausea/vomiting (P=0.01), postprandial fullness (P=0.02) and bloating (P=0.006)-were seen in patients who received the intervention diet compared with the control diet, and this was also true for regurgitation/heartburn (P=0.02), but not for abdominal pain. Anxiety was reduced after the intervention diet, but not after the control diet, whereas no effect on depression or quality of life was noted in any of the groups. A higher fat intake in the intervention group was noted, but otherwise no differences in body weight, HbA1c or nutrient intake were seen.

CONCLUSIONS

A small particle diet improves the key symptoms of gastroparesis in patients with diabetes mellitus. (ClinicalTrials.gov NCT01557296).

Diabetic gastroparesis: functional/morphologic background, diagnosis, and treatment options

The regulation of gastrointestinal motility mainly involves the smooth muscle, neural (extrinsic and intrinsic), and hormonal elements, the glial cells, and the interstitial cells of Cajal. An orchestrated function of all these components is required for the appropriate propulsive movement of the food in the gastrointestinal tract. Gastroparesis, a pathological slowing-down of gastric emptying, is a result of the damage to the tissue elements involved in the regulation of motility. Gastroparesis is one of the well-known complications of long-standing diabetes mellitus. Although it is rarely a life-threatening complication, it has a deteriorating effect on the quality of life, leads to unpredictable oscillation of the blood glucose level, and increases the time required for the absorption of food and medicines. This review describes the clinical characteristics of diabetic gastroparesis and summarizes the organic and functional motility abnormalities caused by this complication. Finally, the currently available and potential future therapeutic approaches are summarized.

Application of in vitro biopharmaceutical methods in development of immediate release oral dosage forms intended for paediatric patients

Biopharmaceutics is routinely used in the design and development of medicines to generate science based evidence to predict in vivo performance; the application of this knowledge specifically to paediatric medicines development is yet to be explored. The aim of this review is to present the current status of available biopharmaceutical tools and tests including solubility, permeability and dissolution that may be appropriate for use in the development of immediate release oral paediatric medicines. The existing tools used in adults are discussed together with any limitations for their use within paediatric populations. The results of this review highlight several knowledge gaps in current methodologies in paediatric biopharmaceutics. The authors provide recommendations based on existing knowledge to adapt tests to better represent paediatric patient populations and also provide suggestions for future research that may lead to better tools to evaluate paediatric medicines.

Diabetic gastroparesis: recent insights into pathophysiology and implications for management

Delayed gastric emptying affects a substantial proportion of patients with long-standing diabetes, and when associated with symptoms and/or disordered glycemic control, affects quality of life adversely. Important clinicopathological insights have recently been gained by the systematic analysis of gastric biopsies from patients with severe diabetic gastroparesis, which may stimulate the development of new therapies in the coming decade. Experience with prokinetic therapies and treatments, such as pyloric botulinum toxin injection and gastric electrical stimulation, has established that relief of symptoms does not correlate closely with acceleration of delayed gastric emptying, and that well-designed controlled trials are essential to determine the efficacy of emerging therapies.

The effect of food form on satiety

To understand the influence of food form on satiety, 19 male participants attended two separate test sessions to consume either a liquid-solid meal (LS), which consisted of whole pieces of vegetable in a broth, or a liquid version of the same ingredients [liquid meal (LM)]. Following this meal, appetite questionnaires and blood samples were collected at regular intervals over 3 h. An ad libitum meal was then served and the amount eaten recorded. Fullness and preoccupation with food were higher following the LM compared with the LS (p = 0.001 and p = 0.031, respectively). Postprandial plasma concentration of cholecystokinin (p < 0.001) and insulin (p < 0.001) was higher and plasma glucose concentration was lower (p = 0.003) following the LM compared with the LS. However, there was no difference in the food intake at the subsequent meal. These results suggest that food form has a limited effect on satiety; however, the influence of the postprandial insulin response warrants further attention.

Gastroparesis: concepts, controversies, and challenges

Patients with gastroparesis often present a challenge to the treating physician. Postprandial symptoms with nausea and vomiting may not only lead to nutritional and metabolic consequences, but also cause significant disruptions to social activities that often center around food. While the definition of gastroparesis focuses on impaired gastric emptying, treatment options that affect gastric function are limited and often disappointing. The female predominance, the mostly idiopathic nature of the illness with a common history of abuse, and coexisting anxiety or depression show parallels with other functional disorders of the gastrointestinal tract. These parallels provided the rationale for some initial studies investigating alternative therapies that target the brain rather than the stomach. This emerging shift in medical therapy comes at a time when clinical studies suggest that gastric electrical stimulation may exert its effects by modulating visceral sensory processing rather than altering gastric motility. Physiologic and detailed anatomic investigations also support a more complex picture with different disease mechanisms, ranging from impaired accommodation to apparent visceral hypersensitivity or decreased interstitial cells of Cajal to inflammatory infiltration of myenteric ganglia. Delayed gastric emptying remains the endophenotype defining gastroparesis. However, our treatment options go beyond prokinetics and may allow us to improve the quality of life of affected individuals.

Gastroparesis: pathogenesis, diagnosis and management

Gastroparesis is a prevalent condition that produces symptoms of delayed gastric emptying in the absence of physical blockage. The most common etiologies of gastroparesis are idiopathic, diabetic, and postsurgical disease, although some cases stem from autoimmune, paraneoplastic, neurologic or other conditions. Histologic examination of gastric tissues from patients with severe gastroparesis reveals heterogeneous and inconsistent defects in the morphology of enteric neurons, smooth muscle and interstitial cells of Cajal, and increased levels of inflammatory cells. Diagnosis is most commonly made by gastric emptying scintigraphy; however, wireless motility capsules and nonradioactive isotope breath tests have also been validated. A range of treatments have been used for gastroparesis including dietary modifications and nutritional supplements, gastric motor stimulatory or antiemetic medications, endoscopic or surgical procedures, and psychological interventions. Most treatments have not been subjected to controlled testing in patients with gastroparesis. The natural history of this condition is poorly understood. Active ongoing research is providing important insights into the pathogenesis, diagnosis, treatment and outcomes of this disease.

Diabetic gastroparesis-backwards and forwards

Diabetic gastroparesis was once thought to be rare, associated with a poor prognosis, and to affect only patients with type 1 diabetes and irreversible autonomic neuropathy. A landmark study conducted by Horowitz et al. and published in JGH in 1986 paved the way for further studies to examine the pathophysiology, natural history and prognosis of diabetic gastroparesis, as well as its optimal management. This review summarizes the developments in knowledge gained over the last ∼25 years that have led to understanding about normal and disordered gastric emptying in diabetes, with a particular emphasis on the inter-relationship between the rate of gastric emptying and the regulation of blood glucose.

Management of diabetic gastroparesis

Symptoms suggestive of gastroparesis occur in 5% to 12% of patients with diabetes. Such a complication can affect both prognosis and management of the diabetes; therefore, practicing clinicians are challenged by the complex management of such cases. Gastroparesis is a disorder characterized by a delay in gastric emptying after a meal in the absence of a mechanical gastric outlet obstruction. This article is an evidence-based overview of current management strategies for diabetic gastroparesis. The cardinal symptoms of diabetic gastroparesis are nausea and vomiting. Gastroesophageal scintiscanning at 15-minute intervals for 4 hours after food intake is considered the gold standard for measuring gastric emptying. Retention of more than 10% of the meal after 4 hours is considered an abnormal result, for which a multidisciplinary management approach is required. Treatment should be tailored according to the severity of gastroparesis, and 25% to 68% of symptoms are controlled by prokinetic agents. Commonly prescribed prokinetics include metoclopramide, domperidone, and erythromycin. In addition, gastric electrical stimulation has been shown to improve symptoms, reduce hospitalizations, reduce the need for nutritional support, and improve quality of life in several open-label studies.

Diabetic gastroparesis and its impact on glycemia

Diabetes is the most common cause of gastroparesis and it is now recognized that the relationship between gastric emptying and glycemia is complex and intertwined. Postprandial blood glucose levels influence, and are influenced by, the rate of gastric emptying, highlighting the difficulty in determining which is the cause and which is the effect. Novel diagnostic techniques and therapeutic strategies have been developed for the management of diabetic gastroparesis. This article highlights recent advances in knowledge about diabetic gastroparesis, with an emphasis on the inter-relationships between disordered gastric motor function on glycemia and vice versa, as well as therapeutic strategies for optimizing glycemic control using modulation of gastric emptying.

Gastroparesis and functional dyspepsia: excerpts from the AGA/ANMS meeting

BACKGROUND

Despite the relatively high prevalence of gastroparesis and functional dyspepsia, the aetiology and pathophysiology of these disorders remain incompletely understood. Similarly, the diagnostic and treatment options for these two disorders are relatively limited despite recent advances in our understanding of both disorders.

PURPOSE

This manuscript reviews the advances in the understanding of the epidemiology, pathophysiology, diagnosis, and treatment of gastroparesis and functional dyspepsia as discussed at a recent conference sponsored by the American Gastroenterological Association (AGA) and the American Neurogastroenterology and Motility Society (ANMS). Particular focus is placed on discussing unmet needs and areas for future research.

Insulin secretion in healthy subjects and patients with Type 2 diabetes--role of the gastrointestinal tract

Postprandial glycaemia is now recognised as the major determinant of average glycaemic control in type 2 diabetes, as assessed by glycated haemoglobin. Therefore, an understanding of the factors influencing both the rise in blood glucose and insulin secretion after a meal is fundamental to the development of dietary and pharmacological approaches to optimise glycaemic control. The gastrointestinal tract regulates the rate at which carbohydrate and other nutrients are absorbed and is the source of regulatory peptides that stimulate pancreatic insulin secretion in the setting of elevated blood glucose levels. This article highlights the importance of the gastrointestinal tract in insulin secretion and glucose homeostasis and discusses potential strategies directed at modification of gastrointestinal function in order to improve glycaemic control in the management of diabetes.

Diabetic gastroparesis: diagnosis and management

Gastric emptying is frequently abnormal in patients with long-standing type 1 and type 2 diabetes mellitus. Symptoms commonly associated with disordered gastric emptying include nausea, vomiting, bloating and epigastric pain, while patients are also at risk of malnutrition, weight loss, impaired drug absorption, disordered glycaemic control and poor quality of life. Although often attributed to the presence of irreversible autonomic neuropathy, acute hyperglycaemia represents a potentially reversible cause of gastric dysfunction in diabetes. Scintigraphy represents the gold standard for measuring gastric emptying. The management of diabetic gastroparesis is less than optimal, partly because the pathogenesis has not been clearly defined. Treatment approaches include dietary modification and optimization of glycaemia, and the use of prokinetic drugs, while novel therapies such as gastric electrical stimulation are the subject of ongoing investigation.