Many people who are diabetic also experience gastrointestinal symptoms similar to IBS, so it’s not surprising that they are connected! I’m so happy to have today’s guest dietitian write about a topic that I know some of you may be struggling with – managing co-existing conditions on top of your IBS.

Today we are lucky to have April Saunders, RD share her expertise on managing diabetes alongside your IBS. Take it away, April!

If you have “gut issues”, meaning diarrhea, constipation, cramping, abdominal pain or nausea, and you have diabetes, you are not alone. In fact, this relationship is more common than you – or your doctor –  may realize.

Incredibly, 10-20% of adults worldwide suffer from functional gastrointestinal (GI) problems.

For people with diabetes, this problem is even more common, and a large proportion of people with diabetes (type 1 or 2) suffer from a poorly functioning gut.

Up to 75% of people with diabetes have at least one gastrointestinal symptom. A connection between people with IBS and higher rates of prediabetes has been found too, suggesting that this relationship starts early on in the pathway to type 2 diabetes.

IBS and Glycemic Control

IBS and other gut disorders are closely linked to diabetes. In fact, even the severity of symptoms is closely linked to the glycemic control of the individual, meaning the worse the glycemic control, the worse the GI symptoms.

These GI problems can include diarrhea, constipation, abdominal pain, and vomiting. The most common GI problem that can be responsible for causing diarrhea is Irritable Bowel Syndrome (IBS), and many complex links have been identified between gut problems and blood sugars.

Why do diabetes and IBS often co-exist? High blood sugars make it hard for the stomach and small intestine to work normally. At the same time, IBS itself can make it harder for your body to control post-prandial (or “after meal”) blood sugars.

 

Diabetes and Undiagnosed IBS

Sadly, people with diabetes commonly suffer from undiagnosed and untreated IBS and other digestive health conditions. This is often because diabetics are told their abdominal pain and gastrointestinal discomfort is just a complication of their poorly controlled blood sugars.

To complicate matters further, symptoms of both diabetes and IBS are greatly impacted by diet, stress, and general health.

In diabetes, GI problems are often related to what’s referred to as autonomic gastrointestinal neuropathy, which results in abnormal motility. Motility refers to your body’s ability to move food through the digestive system, all the way from your stomach, through to your small and large intestine, all at the right speed: not too fast, not too slow!

Considering all of these factors, dealing with diabetes and IBS or other gut issues can be complicated and frustrating to say the least! Gastroparesis, abdominal pain, “diabetic diarrhea”, and constipation are some of the most common GI upsets experienced in people with diabetes.

I’ll take a closer look at the issues and outline some strategies to get you some relief and on to the right path for a happy gut and optimized blood sugar control!

Wondering what else affects symptoms of IBS like gas, bloating, abdominal pain, diarrhea or constipation? You’ve got to understand more about the FODMAPs, poorly digested sugars, that are the most common triggers in digestive issues. Download my free eBook – Click here to get a copy emailed to you right away.

Diabetic Gastroparesis

If you’re diabetic, you likely know that uncontrolled blood sugar can be damaging to nerves in the body. Nerves in the small intestine are no exception. When these nerves are damaged, delayed gastric emptying, or gastroparesis, can result.

In diabetic gastroparesis, there is a delay of the emptying of the contents of the stomach into the small intestine. This can result in bloating, early satiety, distention, abdominal pain, nausea or vomiting. There can also be a decrease in absorption of nutrients from food, which leads to central abdominal pain, bloating, and diarrhea.

The severity of symptoms range from mild to severe, depending on the individual. Although there are many conditions that can cause gastroparesis, diabetes is one of the most common.

Gastroparesis is more common in women than men, which is thought to be related to the effects of the female hormones estrogen and progesterone.

As a result of these complications, people with severe gastroparesis are at risk for malnutrition related to malabsorption of nutrients. People may also miss out on consuming major vitamins, minerals, and macronutrients in their diets because they don’t feel like eating when they get full so quickly.

Abdominal Pain and Diarrhea

Along with the nausea and bloating, gastroparesis can also cause pain and diarrhea. If you’ve had diabetes a long time, uncontrolled high blood sugars can result in “diabetic diarrhea”, and has been reported to occur in up to 22% of patients.

The diarrhea may be the result of microscopic colitis, a side effect of medications (metformin being the most common), or undiagnosed IBS. Even certain types of bacteria can grow to unwanted amounts when food stays in the small intestine too long. The result? More diarrhea and abdominal pain.

Celiac disease may be another potential cause for abdominal pain and diarrhea. This is the development of an allergy to wheat, and associated inflammation and damage to the small intestine wall which results in uncomfortable symptoms.

 

Chronic Constipation

Like gastroparesis, autonomic neuropathy is likely the cause of abnormal motility and secretion of fluid into the colon. Not having regular bowel movements can result in chronic illness with potentially serious complications such as fecal impaction, incontinence, bowel perforation, bleeding, hemorrhoids, and anal fissure.

If you’re trying to manage diabetes and constipation, it can be tough to know what and how much to eat. Meal plans and medications may need to be adjusted depending on food intake, blood sugars, and degree of constipation.

 

Gastroparesis and Blood Sugar Management

High blood sugars can cause delays in gastric emptying, which can make all the above symptoms worse. And when stomach emptying is delayed, it can be harder for you to control your blood sugars. Yikes!

So how do you break this vicious cycle? For any nerve damage caused by uncontrolled diabetes, the first line of treatment is to optimize your blood sugars.

If you take insulin, this can become more complicated. Effective management of your blood sugars will often require the help of a diabetes specialist team or endocrinologist, as it may be necessary to significantly change how and when to take your insulin.

You may have to take your insulin more often, administer insulin after eating instead of before, or check blood sugars more often than usual. This will of course depend on what type of insulin you are taking, your doses, and other individual factors.

Remember, as your blood sugars improve, your gastroparesis symptoms will likely improve too!

How to Manage Diabetic Diarrhea

These lifestyle-based treatments for diarrhea related to diabetic gastroparesis have been shown to offer some relief:

  • Avoidance of high-fat foods
  • Avoidance of high-fibre foods
  • Eating meals with small particle size
  • Smoking cessation
  • Light postprandial exercise (walking after meals)

A quick note on fibre. Fibre is recommended for people with diabetes to help increase satiety, lower cholesterol, and control blood sugars, however this is partly due to fibre slowing down the time it takes for food to get from the stomach into the small intestine – a problem not experienced by people with gastroparesis!

For celiac disease, a gluten free diet provides great relief! Following a strict gluten free diet can be tough – much like the elimination phase of the low FODMAP diet – so getting help from an expert dietitian is likely to help.

For constipation specifically, in a recent systematic review, researchers found natural fibre or fibre supplements to be helpful for the management of chronic constipation related to IBS. Avoiding FODMAPs can also be helpful. The authors stressed the importance of working with a dietitian specializing in the low FODMAP diet for this to be most successful.

Although sometimes a frustrating process of trial and error, managing both IBS or GI upset with your diabetes is possible! It’s important to work with a knowledgeable team to find the right nutrition care plan that works for you and your individual needs. Working with a dietitian who specializes in diabetes or digestive health has been shown to increase the chances of you sticking to your plan, and ensuring that your diet provides all the nutrients you need.

 

New Treatments for IBS

Role of Vitamin D

Recently, researchers have looked at the effects of supplemental vitamin D on the symptoms of patients suffering from IBS.

Over a 6 month period, researchers found that IBS symptoms – namely abdominal pain and distention, flatulence, rumbling, and overall gastrointestinal (GI) symptoms – improved significantly in the group of patients treated with vitamin D compared to the placebo group. The authors conclude that vitamin D seems to be an effective and safe option to improve quality of life and symptoms of IBS.

This is a promising treatment for people with diabetes in particular as vitamin D does not have a direct effect on blood sugar levels.

Gastric Pacemaker

New treatments are on the horizon for severe cases of diarrhea caused by diabetic gastroparesis, such as the implantable gastric pacemaker to help normalize gastric rhythms in people with severe diabetic gastroparesis.

In recent trials, these gastric pacemakers have been shown to accelerate gastric emptying and provide relief of nausea and vomiting for people with diabetic gastroparesis. More trials are needed to validate and replicate these promising results.

Biomarkers

More exciting research is being done every day to help find biomarkers that help to explain why type 2 diabetes and IBS are closely related.

Finding biomarkers that could be identified by non-invasive strategies could help in clinical practice by allowing better management and even earlier diagnosis which ultimately could enhance quality of life for people juggling the demands of optimizing their blood sugars on top of managing their IBS.

Probiotics

It appears that people with IBS may have an altered microbiota when compared with healthy adults. Research suggests that probiotics may help establish a more favourable bacterial balance in the gut. Probiotics have also been shown to have anti-inflammatory effects.

Altering the gut flora by means of probiotic treatment may convey beneficial effects for diabetes, specifically through improvement of insulin sensitivity through decreasing inflammation. Probiotics have been shown to improve insulin sensitivity in people with normal glucose tolerance, impaired glucose tolerance (pre-diabetes), and type 2 diabetes compared to placebo.

 

What Can You Do Now?

Gastrointestinal problems are common in diabetes, however in clinical practice they are not often recognized as being “a problem”. Treatment of gastrointestinal autonomic neuropathy is certainly a challenge. For people with diabetes, it can be even more difficult as symptoms can be nonspecific and related to a range of problems. However, the most important part of getting GI symptoms under control is to optimize your blood sugars.

Optimizing your blood sugars will help to decrease the risk for the development of GI complications to occurs, and reduce the short term effects of high blood sugars on GI function.

Taking a holistic approach to your health often yields the best results. Consider working with a digestive health dietitian alongside your diabetes prevention coach, dietitian, or Certified Diabetes, and make use of your physician and pharmacist to help optimize your blood sugars and improve your gut health.

Some things to consider:

  • Work with a dietitian who specializes in diabetes (Certified Diabetes Educator) to get a meal plan that provides sufficient carbohydrates, proteins, and fats to support optimal nutrition and blood sugar control.
  • Work with your diabetes management team and endocrinologist to fine tune medications, timing, types, doses, and insulin regime to help optimize control.
  • Exercise can help decrease insulin resistance and help you body use up excess circulating sugar which could help decrease active IBS symptoms. It doesn’t have to be a lot! Start small and consistent: try 15 minutes of heart pumping activity every day. Build on what you can do and work up to at least 30 minutes 5 times per week.
  • To reduce insulin resistance and improve your blood sugar control, work with a dietitian to lose 7% of your current body weight in a healthy way, and work on strategies to help you keep it off.

When you’re living with diabetes and IBS, it’s not always a walk in park trying to manage two distinct, yet interrelated chronic diseases, but it CAN be done! Know that you are not alone on your journey to control both your IBS and your diabetes. You’ve got this 😉

 April Saunders is a Registered Dietitian and Certified Diabetes Educator. She is passionate about showing people the path to clarity and confidence about what they need to eat to optimize their blood sugars and lose weight – for life. April is an expert at helping you get to where you need to be by showing you that a healthy weight comes from fuelling with the right foods, not “dieting”. Grab her FREE e-cookbook for some healthy recipe inspiration!

 

References

Abbasnezhad A, Amani R, Hajiani E, Alavinejad P, Cheraghian B, Ghadiri A (2016). Effect of vitamin D on gastrointestinal symptoms and health-related quality of life in irritable bowel syndrome patients: a randomized double-blind clinical trial.Neurogastroenterol Motil. Oct;28(10):1533-44. Epub 2016 May 7. Access on-line at:  https://www.ncbi.nlm.nih.gov/pubmed/27154424

Andreasen SA, Larsen N, Pedersen-Skovsgaard T, Berg RMG (2010). Effects of Lactobacillus acidophilus NCFM on insulin sensitivity and the systemic inflammatory response in human subjects. British J of Nutrition: 104(12): pp1831-1838. Accessed on-line at: https://www.cambridge.org/core/journals/british-journal-of-nutrition/volume/journal-bjn-volume-104/FB0C36CC621A8E87F32B8E43B58BDC63

Bull MJ and Plummer NT (2015). Treatments for Chronic Gastrointestinal Disease and Gut Dysbiosis. Integr Med (Encinitas). Feb; 14(1): 25–33. Part 2: Accessed on-line at: https://www.ncbi.nlm.nih.gov/pubmed/26770128

Bytzer P, Talley NJ, Leemon M, Young LJ, Jones MP, Horowitz M (2001) Prevalence of gastrointestinal symptoms associated with diabetes mellitus: a population-based survey of 15,000 adults. Arch Intern Med 161:1989–1996. Accessed on-line at: https://www.ncbi.nlm.nih.gov/pubmed/11525701

Jones J (2014). Gastroparesis. Today’s Dietitian Vol. 16 (7). Accessed on-line at: http://www.todaysdietitian.com/newarchives/070114p16.shtml

Rao SS, Yu S, Fedewa A (2015) Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome. Aliment Pharmacol Ther. Jun;41(12):1256-70. Epub 2015 Apr 22. Accessed on-line at: http://onlinelibrary.wiley.com/doi/10.1111/apt.13167/epdf

Törnblom, H. Treatment of Treatment of gastrointestinal autonomic neuropathy. Diabetologia (2016) 59: 409. doi:10.1007/s00125-015-3828-9 Accessed on-line at: https://www.ncbi.nlm.nih.gov/pubmed/26634570

Tao W, Dong X, Kong G, Fang P, Huang X, and Bo P (2016).  Elevated Circulating hsa-miR-106b, hsa-miR-26a, and hsa-miR-29b in Type 2 Diabetes Mellitus with Diarrhea-Predominant Irritable Bowel Syndrome. Gastroenterology Research and Practice, vol. 2016, Article ID 9256209, 9 pages, 2016. Accessed on-ilne at: https://www.ncbi.nlm.nih.gov/pubmed/27635130

Wolosin, JD and Edelman, SV (2000). Diabetes and the Gastrointestinal Tract. Practical Pointers. Clinical Diabetes Vol 18(4). Accessed on-line at: http://journal.diabetes.org/clinicaldiabetes/V18N42000/pg148.htm

 

 

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