Second line dietary management of functional dyspepsia and gastroparesis

In the following sections the advice provided relates to the advice previously provided in the 1st Line dietary management of functional dyspepsia and gastroparesis booklet, which can be found on our website (search dyspepsia).

The 2nd Line dietary management of functional dyspepsia and gastroparesis is aimed at achieving two things:

1. Relaxing the strictness of the eating behaviours, meal patterns and texture modifications you have you followed as part of the 1st line advice.
2. 2. Re-challenging and reintroducing dietary restrictions of high fat, high fibre and other foods.

Eating behaviours (see pages 6 and 7 from 1st line diet sheet)

• As eating behaviours do not pose any restrictions on your diet you should continue with any good eating behaviours you found improved your symptoms (chew your food ‘well’, do not eat too fast, eat in a good position, do not eat until ‘full’)
• If changing eating behaviours did not improve symptoms then you can relax or stop following this advice. However as good eating behaviours are considered part of ‘normal’ eating you should consider following the most applicable parts of this advice for you personally.

Volume and frequency of food and fluid (see pages 8 to 10 from 1st line diet sheet)

• A regular meal pattern is the cornerstone of all good diets and you should continue with regular eating and drinking patterns (little and often if needed) as much as possible unless this made your symptoms worse.
• Irregular meal patterns are considered part of a disordered pattern of eating which over time may increase the risk of engaging in other disordered eating habits.
• Three meals a day (with or without snacks) suffices for many, and only the minority require several small meals each day. If you tried several small meals and found this improved symptoms but practically found it hard to continue following this routine, then consider relaxing the meal pattern to find a better balance.
• Continue to avoid larger amounts of fluid with your meals, and remember to sip fluid throughout the day for the best way to stay hydrated.

Modify texture of foods (see pages 10 to 12 from 1st line diet sheet)

Most people will need to continue with some form of texture modification in their diet on a regular basis.

• If symptoms have reduced you can start to change your food textures towards more ‘normal textures’.
• For example from a liquid, to soft, to normal texture. It is best to achieve this slowly to prevent any sudden increases in symptoms.
• Of note still include one third of daily food intake in a texture modified form to help manage symptoms
• If symptoms are still severe to very severe then 2/3rds or more of the diet everyday may need to be liquid and 1/3rd soft (this is often the most effective dietary change for severe symptoms)

Consider what long-term changes are appropriate

• For example with protein based foods more naturally soft or texture modified options such as fish, eggs, minced meats / plant based alternatives may be more suitable than chicken breasts, pork chops, steaks etc.
• Consider long term cooking and food processing techniques; in general have less raw foods (e.g. large salads) or make more use of slower rather than faster cooking techniques (e.g. boil rather than stir-fry vegetables).

Reintroducing high-fat foods (see pages 14 to 16 from 1st line diet sheet)

• Previously you were advised to modify the texture of some foods that are high in fat (see table 1 in the 1st line diet sheet). If your symptoms reduced or remained stable then you can now slowly change the texture from liquid, to soft, to normal texture while assessing symptom tolerance.
• For high-fat ‘solid’ foods where texture could not be modified then a type of graded exposure to these foods may be required to test symptom tolerance (see graded food exposure below). The idea is to reintroduce foods in small qualities to prevent any severe symptoms.
• Consider what long term changes to high fat foods are appropriate for you. For example only have deep fried and take away foods very occasionally, switch to products with lower fat contents, use ground versions of nuts etc.

Reintroducing high-fibre foods (see pages 17 to 19 from 1st line diet sheet)

• Previously you were advised to modify the texture of foods high in fibre.
• A good way to reintroduce and/or test symptom tolerance to high fibre foods is to continue to adapt the texture (i.e. from liquid, to soft, to normal) and start with smaller portion sizes (see Table 2 in the 1st line diet sheet for reference).
• Start with small portion sizes to test tolerance, e.g. one slice of bread, one tablespoon of lentils etc. and increase portion sizes slowly.
• For some foods a graded food exposure method may be required  
• Consider what long term changes to high fibre foods are appropriate for you. For example using fine oats or Ready Brek rather than jumbo oats or muesli. Another example could be not combining two high fibre foods in one meal. Or using both lower fibre and high fibre products.
• If you were previously taken supplemental fibre e.g. fybogel, and removing this has not impacted negatively on symptoms then you can continue to avoid this supplement and instead aim to increase fibre in the diet.

One method of reintroducing and testing tolerance to foods when you have severe symptoms is using a graded food exposure methodology. A graded food exposure method is a food reintroduction challenge method which can involve consuming a very small or insignificant amount of a food and assessing any symptoms experienced.

At first one should expect symptoms from food exposure due to increased sensitivities in the gut driven by visceral hypersensitivity. But with repeated food exposure the severity of symptoms will decrease as exposure-based therapy can help desensitise the gut. The aim is to very slowly increase the amount of food consumed at each food challenge until either a suitable portion size is reached that can be re-introduced into the diet or when severe symptoms are experienced at a particular portion size in which case you stop challenging any further portion sizes.

This process can be repeated for any food or food product item. It can be a slow process but often has a snowball effect; in that it starts off with small food challenges taking a long time to reach significance but then as sensitivities to foods, and related fears and anxieties around food and symptoms reduce, food challenges become quicker and larger with significant results obtained sooner.

Tips for graded food exposure

• Choosing a portion size: Table below displays fractions and percentages to help choose a starting portion size and how to increase portion sizes. Pick a maximum portion size of a food and use the fractions and percentages to break up and determine the graded exposure response via food challenges. Depending on how sensitive you feel to food, will depend on the choice of starting portion sizes.
• Most commonly food challenges are conducted on consecutive days, however you can challenge a food on alternative days or only once a week. It depends on your preferences, sensitivities and what is practical for you.
• Generally foods being challenged should be eaten in combination with a typically eaten and suitable meal although this may not work for all foods / food products.
• This method can also be used to improve disordered eating patterns and help achieve a more regular meal pattern. For example if you never have breakfast, you could start with one bite of a biscuit, 1 teaspoon of yoghurt etc.
• Graded food exposure can also be used to increase variety and volume of foods that may trigger symptoms.
• It is important to remember that slowly increasing portion sizes / variety of food is better than rushing things as this may trigger very severe symptoms and cause a setback.

This sections advice relates to you if you are underweight (BMI ≤18.4kg/m2 ) and/or have lost weight unintentionally and wish to gain weight but did not achieve this from following the 1st line dietary advice. It is important that you have tried to create a ‘nourishing drink’ and have attempted to include this in addition to your current dietary intake on a daily basis as described in the 1st line diet sheet on pages 22 to 24.

• In addition to a nourishing drink, you may wish to consider including more sugar-based foods* in your diet for a short time period.
• Sugar-based foods* tend to trigger fewer GI symptoms and gravitating towards foods which are high in sugar is very common.
• These foods can provide a useful source of calories when symptoms are severe and food intake is significantly reduced.
• In this situation a regular intake of these foods along with more liquid based meals and nourishing drinks can be a useful part of the diet treatment for a short time period until symptoms are better controlled.
• Include sugary fizzy drinks, if you are not experiencing symptoms, along with sweets and small pieces of chocolate.
• Add additional sugar to your home made nourishing drinks. For further information see the UCLH Nourishing drinks page
• Remember to continue to modify the advice in this booklet to match 1st line dietary advice that is appropriate to you.

*If you have diabetes and/or your blood sugars are poorly controlled then you should discuss any changes to your sugar intake with your diabetic team.

Functional dyspepsia and gastroparesis overlap with ‘reflux’ disorders including gastroesophageal reflux disease (GORD), reflux hypersensitivity, functional heartburn and rumination syndrome.

All conditions share similar pathophysiology and are part of the conditions known as disorders of gut–brain interaction. If you have symptoms of reflux and/or heartburn (you may have recorded this on the ‘PAGI-SYM’ questionnaire) then the additional information provided here is designed to you to help manage these particular symptoms.

If you do not have reflux or heartburn symptoms, or if they are mild, then you do not need to follow the advice in this section.

Lifestyle factors for ‘reflux’ symptoms

• Smoking is a potential trigger of reflux type symptoms. Engage in smoking cessation to help stop smoking: www.nhs.uk/better-health/quit-smoking/
• If you experience reflux symptoms when sleeping you should elevate the head of the bed (6 to 8 inches) or sleep on a wedge. In addition avoid any meals ≤3 hours before bedtime.
• If you experience reflux symptoms at night then sleep on your left hand side rather than your right or when laying on your back as this can decrease acid exposure at night.
• If you are overweight (BMI 25-30kg/m2 ) then losing weight may help reflux type symptoms. The aim is for 5- 10% weight loss. If you have gained weight (even if you still have a normal BMI 18.5-25 kg/m2 ) then aim to lose weight. If you are obese (BMI >30 kg/m2 ) then you should speak to your GP for access to obesity services.
• Regardless of weight, avoid tight fitting clothes or bending over which may increase abdominal pressure forcing stomach contents into the throat.

‘Reflux’ foods

There are several foods frequently associated with reflux symptom induction or exacerbation. However these associations are weak and symptoms related to these foods will differ from person to person. Therefore diet advice is only to avoid foods that trigger symptoms.

There is no need to avoid these foods if you do not experience symptoms. It is very unlikely removing these foods will improve symptoms. The foods and food groups listed below in Table 2 are frequently associated with reflux and heartburn symptoms and are listed for reference purposes.

If you have been avoiding some of these foods already (because they triggered your reflux symptoms) but now your symptoms are better controlled you may wish to consider retesting your tolerance to them. Slowly reintroduce one food at time back into the diet to see if it is the individual food that triggers symptoms or the combination of several of foods.

When reintroducing start with very small portion sizes e.g. one bite of the food, and gradually increase portion size to tolerance and/or appropriate portion size (see graded food exposure section for additional tips).

To help identify if any foods trigger reflux symptoms you could try keeping a food diary (written or use a smartphone application) for a week or two and see if you can notice any patterns.

Note: Only avoid these foods if they trigger reflux symptoms. If after four weeks of restriction, symptoms are not improved then reintroduce the foods back into the diet.

Diaphragmatic breathing for ‘reflux’ symptoms

• Diaphragmatic breathing (‘belly breathing’) has been shown to recue symptoms of reflux and is an easily accessible self-help option. It can also help reduce general stress and promote relaxation.
• Many diaphragmatic breathing videos can be found on YouTube. Below are two from American hospitals specialising in GI disorders.
• Both videos provide explanations for how and when to implement diaphragmatic breathing.
• Diaphragmatic Breathing | UCLA Integrative Digestive Health and Wellness Program https://www.youtube.com/watch?v=g2wo2Impnfg
• Diaphragmatic Breathing Demonstration from Michigan Medicine https://www.youtube.com/watch?v=UB3tSaiEbNY

If you have overlapping IBS symptoms including lower abdominal pain associated with a change in bowel habit then further specific dietary advice may be appropriate for you.

• If you have a diagnosis of IBS then an effective dietary treatment is the FODMAP (fermentable, oligosaccharides, disaccharides, monosaccharides, and polyols) diet.
• You can be educated on the FODMAP diet at UCLH and a discussion with your dietitian can clarify the best option for you.  
• If you have lower abdominal pain or discomfort but do not have a diagnosis of IBS then you probably do not need to complete a FODMAP diet. However modifying your intake of FODMAPs may be appropriate. Your dietitian can discuss this with you.

• If some of your predominant symptoms are bloating and/or distention then much of the dietary advice provided in the 1st line dietary advice for functional dyspepsia and gastroparesis diet sheet will be applicable to help with these symptoms.
• However you may find some additional advice on modifying foods that contain FODMAPs useful to help manage these symptoms and a discussion with your dietitian can clarify the best option for you.

The British Dietetic Association provide a useful diet sheet on IBS, which includes advice for bloating: www.bda.uk.com/resource/irritable-bowel-syndrome-diet.html

• The 2nd Line dietary advice for functional dyspepsia and gastroparesis is to help guide you towards personalising the 1st line advice and reintroducing foods.
• If you did not achieve a satisfactory reduction in symptoms from following the 1st line advice but you have overlapping reflux, IBS or bloating/distention symptoms then there may be further dietary options available to you. Otherwise it is unlikely further dietary interventions will have any additional benefit for symptom reduction and you need to consider non-dietary based treatments.
• If your symptoms impact on continued and significant weight loss then you should discuss this with your dietitian and/or doctor as alternative treatments may be required based on nutrition support advice.

Please contact your dietitian should you require further information. Otherwise see below for some online resources that you may wish to access:

• Coping with Nausea (UCLH diet sheet) www.uclh.nhs.uk/patients-and-visitors/patient-information-pages/coping-nausea

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