Author: Christine Craig, MS, RDN, CDCES
Founder: Nutrition for Daily Living
Gastroparesis is a form of neuropathy characterized by delayed gastric emptying due to motor and sensory dysfunction.1 Diabetes is the most common cause of gastroparesis, with over 55% of cases attributed to type 1 and type 2 diabetes.2 Delayed and unpredictable movement of food from the stomach into the small intestine can contribute to early satiety, postprandial fullness, bloating, nausea, vomiting, and upper abdominal discomfort. These symptoms can be mild or can be severe, causing reduced quality of life and significant malnutrition. In people with diabetes using insulin therapy, gastroparesis can cause unpredictable timing between carbohydrate/food absorption and the action of insulin.
This discordance can lead to significant glycemic variability and increased hypoglycemia risk. Impaired motility can also affect the gut’s microbial balance. Individuals with gastroparesis are at higher risk for small intestinal bacterial overgrowth (SIBO), H. pylori infections, and microbial dysbiosis, all of which have symptoms that overlap with and are easily mistaken for gastroparesis symptoms.3 These complexities highlight the need for individualized and comprehensive assessment and interventions.
Screening for diabetes-related gastroparesis is recommended when GI symptoms or erratic glucose patterns occur, without another identified cause. It is also important to rule out mechanical obstruction or medication-related GI effects (such as from Incretin–based therapies, opioids, or other medications that affect GI motility).1 The gold standard for diagnosing gastroparesis is 4-hour gastric emptying scintigraphy using a solid meal. This is often an Eggbeaters meal consisting of cooked liquid egg white with bread, jam, and water.4 A C-octanoic acid breath test is another alternative.1 While glucose management challenges are present in individuals with suspected gastroparesis, hyperglycemia is considered a confounder, and glucose should ideally be under 200 mg/dL before consuming the test meal.5 Elevated glucose values can directly contribute to delays in gastric emptying.
Nutrition interventions are first-line therapy for diabetes-associated gastroparesis and should be individualized based on symptoms, nutritional status, glucose patterns, and food tolerance. Assess individuals for malnutrition and unintentional weight loss, recognizing that an elevated BMI does not eliminate the risk of poor nutrition status. Smaller, more frequent meals (typically 6 small meals per day) and eating slowly (typically 30 minutes per meal, chewing well) may improve tolerance. Smaller-particle (cut foods well, make it squishable) and liquid foods may be easier to digest when symptoms are more severe.6 Fat and fiber may delay gastric emptying or worsen symptoms for some individuals and should be adjusted based on tolerance rather than routinely eliminated.6 For example, fat containing liquids may be more tolerable, and types of fiber may have differing effects.6 Monitoring of adequacy of energy, protein, hydration, and micronutrient intake are priorities due to risk of deficiencies. Consider liquid nutrition supplements when oral intake is inadequate.
As diabetes educators it is also important that we assess glucose and medication management as a component of nutrition and diabetes care plan. Support medication modifications, especially insulin administration plans, to optimize glucose management, as significant hyperglycemia can further delay gastric emptying. The amount and/or timing of dosing may need modification to improve match of food absorption with action of medications/insulin. For individuals who cannot maintain adequate nutrition or hydration despite diet modifications, enteral nutrition may be considered, with parenteral nutrition considered in select cases.6 While there is not currently a practice guideline for the nutrition management of diabetes-associated gastroparesis, a recent article, Diabetic Gastroparesis: Navigating Pathophysiology and Nutrition Interventions is just one reference that can provide more detail regarding potential nutrition interventions.6
For more significant and severe symptoms, pharmacologic therapy may be considered. Metoclopramide is the only FDA-approved prokinetic for gastroparesis, but potentially serious neurologic adverse effects limit its use, and it is generally restricted to short-term treatment, up to 12 weeks.1 Erythromycin may provide short-term benefit but is limited by tachyphylaxis, while domperidone is available in some countries but not routinely in the U.S.1
The 2022 ACC Clinical Guidelines for Gastroparesis reported that Gastric Per-Oral Endoscopic Myotomy (G-POEM) is the preferred procedure for individuals with gastroparesis who do not benefit from medication and nutrition therapy, with surgical pyloroplasty as an alternative.7 While most studies report gastric symptom improvement alone7, a recent 2026 multicenter cohort study found that surgical treatment of gastroparesis (gastric electrical stimulation, pyloroplasty, or G-POEM) was associated with a reduction in HgbA1c and symptoms compared with non-operative management.8 At 5 years, the mean HgbA1c was about 0.9 percent lower in the surgical group and this group had fewer emergency department visits and hospitalizations. These findings suggest that improving gastric motility or stabilizing gastric emptying may help improve glucose stability and not just the other way around. While this information is promising, the study was observational and cannot establish causality. Each of the procedures evaluated have different mechanisms, indications, and supporting evidence. Our current ADA Standards of Care do not yet include a review of surgical procedures, but state “evidence supporting gastric electrical stimulation in diabetic gastroparesis remains limited”1.
For diabetes care and education specialists, gastroparesis management starts with early recognition and screening. Sometimes, we are the ones who identify an unusual glucose pattern that raises concern and prompts referral for further evaluation. Once diagnosed, collaborating with the medical team to identify treatment options. Review medications for change in absorption or risk and adapting insulin timing and dosing as gastric emptying changes. Refer to a dietitian to ensure implementation of individualized nutrition therapy based on symptoms, nutrition status and the latest evidence. Ultimately, the goal is not simply to improve gastric emptying or glycemia, but to support nutrition adequacy, reduce symptoms, and preserve quality of life for the person living with diabetes and gastroparesis.
Christine Craig, MS, RDN, CDCES
Founder: Nutrition for Daily Living
References:
- American Diabetes Association Professional Practice Committee for Diabetes*; 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes—2026. Diabetes Care 1 January 2026; 49 (Supplement_1): S261–S276. https://doi.org/10.2337/dc26-S012
- Camilleri M. Gastroparesis: A review. JAMA. Published online July 22, 2026. doi:10.1001/jama.2026.12181.
- Leto G, Crispino P, Viceconti A, Camardo V. Diabetes and gastroparesis: new concepts and insights. Diabetology. 2026;7(5):93. doi:10.3390/diabetology7050093
- Staller K, Parkman HP, Greer KB, Leiman DA, Zhou MJ, Singh S, Camilleri M, Altayar O; AGA Clinical Guidelines Committee. AGA clinical practice guideline on management of gastroparesis. Gastroenterology. 2025;169(5):828-861. doi:10.1053/j.gastro.2025.08.004
- Banks KP, Syed K, Parekh M, et al. Gastric Emptying Scan. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531503/
- Caturano A, Galiero R, Rinaldi L, et al. Diabetic gastroparesis: navigating pathophysiology and nutritional interventions. Gastrointest Disord. 2024;6:214-226.
- Camilleri M, Kuo B, Nguyen L, Vaughn VM, Petrey J, Greer K, Yadlapati R, Abell TL. ACG clinical guideline: gastroparesis. Am J Gastroenterol. 2022;117(8):1197-1220. doi:10.14309/ajg.0000000000001874
- Sadda VR, Verma R, Aly AE, Zheng P, Ayazi S. Glycemic Control and Diabetes Outcomes After Surgical Therapy for Diabetic Gastroparesis. JAMA Surg.2026;161(7):719–726. doi:10.1001/jamasurg.1593
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