With diabetes the most common complications usually discussed involve the cardiovascular system: the heart and blood vessels. Diabetes elevates the risks of heart attack, stroke and peripheral vascular disease. People with diabetes can also have complications in their kidneys, eyes and feet. These are related to nerve ending problems. The GI (gastrointestinal tract) is not a common topic when reviewing your blood sugars. Up to 75% of patients with long standing diabetes report chronic, intermittent GI complaints. “The entire GI tract may be affected by diabetes starting in the oral cavity which includes the mouth and esophagus, to the small bowel, the large bowel and the rectal region”.
The medical world realizes the GI tract is known as the “second brain” of your entire body. Patients may feel uncomfortable or embarrassed talking to their physician about stomach issues as bathroom habits seem to be “a private matter”. Many of you feel squeamish and that the information is just too personal to discuss, even with your doctor. You assume it will simply go away. The topic is neglected and you may suffer in silence. There are multiple studies citing that, “GI problems are prevalent among people with type 1 and type 2 diabetes”.
Poor diabetes control and how long you have had diabetes play a big role in developing GI symptoms. Common GI complaints experienced by people with diabetes may include:
- difficulty swallowing
- gastric reflux or GERD
- sour taste in your mouth
- being full quickly or not digesting food or gastroparesis
- always feeling hungry
- having no appetite
- abdominal pain and cramps
- nausea and vomiting
- gas, bloating, or diarrhea
Understanding Gut Basics
Hippocrates said 2500 years ago, “all disease begins in the gut”. For the last decade, “the gut microbiome” has been discussed as a major player in your overall general health. Several studies have reported, “gut microbiome imbalance” (dysbiosis) as a factor in the rapid progression of insulin resistance. Insulin resistance is present in 90% of diabetes-type 2 around the world. A poor microbiome can influence intestinal functions in a negative way. It can increase cardiovascular disease and obesity. The digestive tract has trillions of bacteria and other microorganisms. It works to digest your food, make vitamins, regulate hormones and eliminate toxins. Your immunity, stress response, mood, metabolism, weight and hormone regulation rely on your gut health. Too many bad bacteria cause problems.
What affects the microbiome composition?
This is still being reviewed but here are some of the common causes of microbiome problems:
- Past and present diet. Diets that lack diversity lack adequate fruits and vegetables and lack high fiber whole grains. Drinking too much alcohol. Eating refined sugars and processed foods. Refined sugar and processed foods increase inflammation and encourages yeast formation in the gut. Artificial sweeteners are questionable and some believe ingesting them may cause “bacteria growth that triggers fat storage”.
- Antibiotics are needed to kill bad bacteria, but they can also wipe out good bacteria and wreck your microbiome leading to bad bacteria overgrowth.
- Steroids/NSAIDS (Advil, Aleve). These medications may be needed for inflammation and pain relief but in high doses can cause stomach lining disruption and irritation producing stomach lesions which ultimately change your microbiome.
- Lack of physical activity
- Smoking cigarettes
- Too much stress. Stress increases secretion of cortisol, reduces oxygen flow to the gut and changes gut bacteria.
- Lack of sleep. Both the quantity and quality of your sleep may change in Circadian rhythm which can disrupt gut bacteria.
What can cause GI problems with diabetes?
Diarrhea can come and go in anyone because of a stomach bug or eating a bad oyster. Other times, it can become a chronic problem. “The prevalence of diarrhea among people with diabetes is between 4 and 22%”. Some reasons for diarrhea when you have diabetes are:
- Metformin. One of the most common reasons for chronic diarrhea in diabetes is taking Metformin. It can cause gas, bloating and diarrhea especially when first started. Doses can start as low as 500mg a day and be gradually increased to 2000mg a day to help prevent a problem. Metformin is an excellent, effective and cheap first line diabetes pill for type 2 diabetes. It is great for those who can tolerate it without stomach discomfort. It inhibits glucose production by the liver, helping to lower blood sugars. For those who suffer from gas, bloating and diarrhea, it can be dreadful. Although, the stomach effects may resolve in time, many are not able to ever tolerate it. Please talk to your physician if you experience a problem and consider taking the extended release or ER form. Remember, if your stomach is miserable, there are many other diabetes pills to take instead.
- GLP-1 agonists. A newer diabetes injectable medication may cause diarrhea, nausea and vomiting. These medications allow the body to push out more insulin from the pancreas, slow gastric emptying, convince the brain you are less hungry, and moderate the production of glucose by the liver. Given weekly or daily by injection, the more common ones are Byetta, Victoza, Trulicity and Ozempic. A GLP-1 pill has been introduced and FDA approved called Rybelsus. Again, make your MD aware if you experience GI symptoms.
- DPP-4 inhibitors. These are pill form diabetes drugs. Names such as Januvia, Tradjenta and Onglyza should be familiar. They help the body produce more insulin when needed, such as after a meal. Although they are a good diabetes medication, they can produce gas, bloating and diarrhea in some patients.
- Alpha-glucosidase inhibitors. These are diabetes pills known as starch blockers that block the action of enzymes which normally break down carbohydrates. Since they affect carbohydrate absorption in the intestine, they can cause severe gas, bloating and diarrhea. Trade names are Precose and Glyset. They are mostly prescribed in Europe since Americans are more sensitive about passing gas in public.
Having diabetes is tied to higher risks of having anxiety and depression. There is constant worry about additional costs, chronic medical complications and frequent doctor visits. Daily blood glucose testing and watching food intake add to the list of worries. Mental stress can create GI distress. This is known as “the gut-brain axis” or gut-brain connection. When you are upset, chemical messengers carry signals from your brain to your gut. Emotional stress triggers hormones that slow movement in the stomach and small intestine leading to stomach cramping. This can lead to nausea and or diarrhea. Getting help by talking to someone about your anxiety /depression is an excellent starting point. Find your coping mechanisms so you can handle your situation without experiencing physical GI symptoms.
When reducing or eliminating regular sugar with diabetes, you turn to foods that contain sugar alcohol for a sweet taste without the sugar. Sugar alcohols are not the same as artificial sweeteners. It is not sugar or alcohol, but it can strike you down with gas, bloating and diarrhea especially when eaten in large amounts. Sugar alcohols draw more water into the large intestine and often cause digestive issues. The most common sugar alcohols are sorbitol, xylitol and erythritol. Toothpastes, sugar-free chewing gum, sugar-free mints, soft candies, sugar-free soft drinks, jelly spreads, and sugar-free baked goods all have sugar alcohols. They are not calorie-free and may be good for dental health.
Other Possible Dietary Triggers
Not everyone’s gut reacts the same way, but many people end up with stomach pain and diarrhea from too much caffeine, alcohol, dairy products such as lactose in milk, yogurt, soft cheeses, foods high in dietary fiber and fructose. Trying food elimination one by one may lead to an answer.
What GI medical problems are common with diabetes?
Having diabetes, over time with high blood sugars, can create nerve damage in the intestines, causing food to stop being processed. Nerve ending dysfunction found in the lower gut is one cause of constipation alternating with chronic diarrhea. Many people with long-term diabetes have this. A stopping point of food is created in the gut which allows bacteria to collect causing stomach pain, infections and possible diarrhea. Included are gastroparesis and gastric reflux, which will be further discussed.
Diabetic constipation affects almost ⅔ of people with diabetes. It includes damage to nerve endings in the lower intestines which causes less stool, hard stool, lower gut motility, incomplete evacuation and stomach pains.
The vagus nerve (major nerve in the GI tract) may become damaged from uncontrolled diabetes. When the vagus nerve is damaged, your food digestion slows down and creates delayed gastric emptying called gastroparesis. The actual cause is still unknown. It is not curable, but it is treatable. Gastroparesis makes you full after just a few bites and can also cause nausea, vomiting and stomach aches and pains. You may experience more blood sugar highs or lows, especially when on insulin. Gastroparesis makes it difficult to regulate your blood sugars. Dealing with this condition can be challenging but changing certain habits can be helpful. Your physician may also recommend and prescribe medication. Instead of eating 3 large meals:
- Eat 6 small meals
- Drink fluids after eating, not while eating, to make you feel less full
- Avoid high fat foods which are difficult to digest
- Reduce high fiber foods which can bloat you easily
- Avoid carbonation or fizzy drinks
- Eat soft and well-cooked foods
- Walk after meals
- Avoid lying down for at least 2 hours after meals
You may become malnourished with gastroparesis so make sure you consult with a registered dietitian. They can make life easier for you and suggest foods which can be readily digested.
Gastric Reflux (or GERD)
The nerves in the esophagus can also be affected by high blood sugars causing them to become irritated. The lower esophageal sphincter or LES becomes weakened causing acid to return from the stomach back into the esophagus. Symptoms of gastric reflux can occur. They include heart burn, an acid taste in your mouth and possible regurgitation. Try to avoid caffeine, alcohol, chocolate, citrus, tomatoes or cooked tomato products, mint, spicy foods, and fried foods. Elevating the head of your bed with blocks or using a wedge pillow while sleeping reduces reflux symptoms. You should also stop eating large meals and avoid eating up to 3 hours before bedtime. Talk to your health care provider about taking antacids as needed or other medications to help heal the esophagus.
Non-alcoholic fatty liver disease (NAFLD)
One aspect of the metabolic syndrome is non-alcoholic fatty liver disease (NAFLD), and is extremely common in type 2 diabetes. There are generally no GI symptoms, but lab testing and bloodwork can identify this condition. Elevated blood sugars, over a long period of time and obesity, causes fat to accumulate in the liver. This could lead to a more severe variation of liver disease called NASH (non-alcoholic steatohepatitis). Over time, if untreated, it could cause scarring, cirrhosis and end stage liver disease. Looking for high liver enzymes (ALT levels) and doing a Fibro Scan (liver ultrasound) can give your MD the information for a diagnosis. The best way to stop or even reverse NAFLD is weight loss, healthy eating habits and physical exercise. Make sure to get enough vitamin D and potassium.
TYPE 1 Diabetes and Celiac Disease
6% of people with type 1 diabetes will develop celiac disease. There is a genetic link, and both are considered autoimmune diseases. Having celiac disease makes controlling diabetes even more difficult, since food and medications do not absorb well. Symptoms of celiac disease for some may include chronic fatigue, bone pain, neuropathies and migraines. Other classic GI symptoms are gas, bloating, diarrhea, constipation, vomiting, weight loss and anemia. People with type 1 diabetes usually have no symptoms of celiac disease and must be tested with specific blood tests.
The immune system responds to gluten, a protein in wheat, bran, wheat germ, rye, barley, in certain individuals. It causes mucosal thinning and inflammation. The response to gluten damages the small intestine leading to malabsorption. The only treatment is a strict gluten-free diet. Following a strict gluten-free diet can help the intestinal damage heal over several months. Fortunately, there are many gluten free products presently on the market. Working with a registered dietitian for both diabetes and celiac disease is always worthwhile.
Yeast infections, can even be in the GI tract
Yeast lives in everyone’s body in small amounts. When the yeast overgrows, it becomes a fungal infection. Yeast easily multiplies with uncontrolled blood sugars, and this suppresses the immune systems’ response. Yeast infections can develop in skin folds, on your feet, finger and toenails as well as mucous membranes. Thrush, yeast infection in the mouth, can cause burning pain and a thick white coating on the tongue. It can be difficult to eat and drink properly. The yeast infection can travel down the GI tract irritating the esophagus and making it difficult to swallow. Untreated yeast infections can enter the blood stream, and then they become much more difficult to treat. Keeping blood sugars controlled is your best way to avoid yeast infections.
Small Intestinal Bacterial Overgrowth (SIBO)
We don’t really understand the small intestinal bacterial overgrowth GI problem. SIBO occurs in diabetes when the blood sugars are too high for a long time period. Excessive bacteria colonizes in the small intestine and often mimics irritable bowel syndrome or IBS. The symptoms include bloating, diarrhea, stomach discomfort and weight loss. This could be due to damage to the enteric nervous system (ENS).
Gallstones and Gallbladder disease
High levels of triglycerides, common in uncontrolled diabetes, may encourage gallstone formation. This seems to be more related to being obese or overweight more than having diabetes by itself. “Obesity leads to secretion of bile by the liver that is combined with cholesterol causing crystallization and stone formation”. Diabetes may impair gallbladder contractility. Talk to your doctor about taking medications such as Lovaza to reduce triglycerides, lose weight and cut back on fatty, greasy foods to lower the risk of gallstones.
Additional ways of Treating GI problems
- The first thing to do is to establish what is causing the problem. Educate yourself on what causes GI symptoms in you. If it is a simple problem, you may be able to treat it yourself. Easy and healthy food changes may be the answer. You can treat diarrhea at home with lots of clear fluids, Kaopectate and a bland diet. You can drink sugar-free Gatorade to restore electrolytes. There are many diabetes medications that do not interfere with the GI tract and your doctor can easily change them if that is the cause. If stomach issues last more than 2-3 days, is accompanied by a fever and/or causes severe abdominal pain, contact your physician immediately. Consider seeing a gastroenterologist (a GI specialist) if it persists.
- Your health care provider can treat bacterial overgrowth using antibiotics. Remember, antibiotics should only be used when needed with a bacterial infection. Over-use of antibiotics can eliminate your good gut bacteria and cause more problems.
- Anti-spasmodics can prevent stomach spasms and cramping, as in a mild stomach bug. It can reduce the number of bowel movements when they become too frequent.
- Keep blood sugars regulated and in range (80mg/dl to 180mg/dl) as much as possible. Also, try to maintain an A1C of around 7%, as this reduces bacterial growth and fungal growth.
- Be prepared with fungal creams, salves, suppositories or pills for yeast infections, depending where they are located.
- Count carbohydrates to keep blood sugars within limits.
- Get plenty of exercise and quality sleep to build up your immune system.
- Avoid fast food, processed food, and greasy food. Limit alcohol.
- Lose weight.
- Work towards eating a Mediterranean diet.
- Ask your health care provider about taking a probiotic.
- Ask for help with stress, anxiety and depression. Learn coping mechanisms.
GI problems can be very common with diabetes, especially when blood sugars are not well controlled for long periods of time. Don’t feel embarrassed about discussing stomach issues. Have a talk with your health care provider. Find out what is causing the problem and how best to treat it. Eventually, you will feel so much better!