Diabetes Forecast

Dealing With Diabetic Diarrhea

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What happens inside the bathroom typically stays behind closed doors. But Elizabeth Nelke Pfeifer, who moderates an online diabetes support group, says that members have found solidarity by speaking out about toilet taboos.

About once a week, someone posts something along the lines of: “I’m sorry if this is too much information, but I’m really having this problem…” The problem ends up being severe diarrhea, says Pfeifer, a health coach and writer with type 2 diabetes. “And then we get all these other people responding, ‘Oh my gosh, me too!’ ”

Chalk it up to cultural squeamishness or lack of awareness, but people with diabetes—and their primary health care providers—don’t talk enough about digestive issues in general, says Dawn Noe, RD, CDE, a certified diabetes educator at the Cleveland Clinic. They should. Gastrointestinal (GI) issues are prevalent among people with both type 1 and 2 diabetes; one article published in 2016 in the journal Diabetes Therapy estimates that up to 75 percent of people with diabetes experience symptoms.

Here’s how to tell whether you should talk to a doctor about your frequent toilet trips—and what might be causing them. 

Learning the Basics

Everyone gets diarrhea at some point, whether from a bad meal or a stomach bug. But for some people with diabetes, it can become a chronic problem. They can experience diarrhea—loose, watery stools three or more times a day—for many different reasons, not all of which are fully understood. It’s “likely a constellation of disorders with different underlying causes,” explains Hiroshi Mashimo, MD, PhD, chief of gastroenterology at the VA Boston Healthcare System.

One underlying factor could be autonomic neuropathy, damage to nerves that control regular bodily functions, including digestion. “Diabetes can cause neuropathy throughout the body, whether it’s in the eyes, hands, or feet,” says Braden Kuo, MD, a gastroenterologist at Massachusetts General Hospital. “Neuropathy causes issues with the nerve endings in the gut that affect sensation and how it coordinates movement within the gut.”

Another possible cause of diarrhea in people with diabetes is a problem with the way cells communicate in the gut’s nervous system to orchestrate movement, prompted directly by high blood glucose or indirectly by diabetes-related disturbances elsewhere in the body. Emotional issues such as depression—something people with diabetes are two to three times more likely to experience than those without the condition—are also linked to GI distress. And gastroparesis, delayed stomach emptying that’s often caused by nerve damage, can lead to tummy troubles, including diarrhea.

The list goes on: For instance, 10 to 15 percent of people with type 1 diabetes will develop celiac disease, an autoimmune disorder that can trigger both diarrhea and constipation. If celiac disease screenings are negative, doctors might next check for irritable bowel syndrome, inflammatory bowel disease, microscopic colitis, bacterial overgrowth, or chronic inflammation of the digestive tract. 

Diabetes medications can also be an underlying cause of diarrhea. For example, metformin, a drug used to treat high blood glucose in people with type 2, can cause diarrhea and flatulence. The same goes for type 2 drugs in the GLP-1 receptor agonist class, says Noe.

Not surprisingly, diet can play a part, too. Sugar alcohols such as sorbitol and erythritol, often used in sugar-free foods, can cause diarrhea by drawing more water into the large intestine. If you’re unable to break down the lactose, or sugar, in milk—a condition known as lactose intolerance—you may also be more susceptible to bouts of diarrhea.

Living With Diarrhea

People with chronic diarrhea—whether it’s linked to diabetes or not—experience sporadic bouts of watery stool and increased trips to the bathroom for anywhere from several weeks to several months. These episodes, which can occur day and night, often alternate with periods of constipation or normal bowel movements.

Experts aren’t sure how many people have diabetes-related diarrhea; after all, diarrhea itself is extremely common among the general population. Mashimo pegs the prevalence among people with diabetes to be anywhere between 4 and 22 percent.

Alexandra Quinn, a chandelier repair technician in Atlanta, falls within this spectrum. Quinn was diagnosed with type 1 diabetes as a child. Now in her 30s, she has gastroparesis. For as long as she can remember, she has battled recurring cycles of diarrhea and constipation.

Diarrhea in people with diabetes can be highly variable. “At its worst, I wouldn’t have a bowel movement for two weeks,” says Quinn. “And then for the next two weeks, I would have a huge purge. It was just this cycle of constant awful problems. I didn’t even know that what I went through on a daily basis wasn’t normal.” This went on for years.

People such as Quinn—people with diabetes who have neuropathy in various parts of the body—are the most likely candidates for chronic diabetes-related diarrhea, Kuo says. 

Seeking Treatment

If you’re diagnosed with diarrhea, your health care provider may suggest you see a GI specialist. Symptoms might be treated with prescription and over-the-counter antidiarrheal drugs; antispasmodic medicines, which can reduce bowel movement frequency; or clonidine, a medication that treats high blood pressure but can also help with severe diarrhea.

For bowel incontinence (the inability to control bowel movements), biofeedback, a type of behavioral therapy, can help you pinpoint and strengthen anal muscles. Internal and external sensors record muscle contractions, and a monitor allows you to see which specific muscles are moving, and how.

Changing eating habits might also help; small-portion meals can alleviate symptoms, as can staying away from fast food, alcohol, fatty foods, and anything else known to aggravate your GI tract. Seeing a registered dietitian is important, as he or she “can help identify food triggers or symptoms, make suggestions for alternative food choices, and assist with looking for patterns related to gastrointestinal symptoms and blood sugar management,” says Noe. This can help people with diabetes prevent diarrhea-related pain and flare-ups while still meeting their nutritional needs.

Managing an Episode

During and after a bout of diarrhea, make sure you’re sufficiently hydrated and that your electrolytes are balanced by drinking sugar-free sports drinks, Pedialyte, or beverages made with electrolyte-enhanced drink tablets.

Most important, people with diabetes-related diarrhea need to work with their primary doctor to manage blood glucose, whether by altering treatments and diet or checking their levels more frequently. Keeping your blood glucose within target range can prevent additional nerve damage and alleviate diarrhea; a survey published in 2001 in the Archives of Internal Medicine found that only 12 percent of people with well-managed diabetes reported diarrhea symptoms, compared with 32 percent of those whose glucose wasn’t in target range.

Quinn’s road-tested advice? “Educate yourself as much as possible about what causes your diarrhea, what your triggers are, and what steps you can take to help alleviate them,” she says. “The best thing you can do is manage your blood sugar and keep it in your target range as much as possible. Whatever dietary or lifestyle changes you need to do to achieve that is what you should shoot for.”

On the Job

There’s no single way to live with chronic diarrhea. Some people might be able to go to work with it, so long as their desk is near a restroom. During severe bouts, others might need to stay home and wait it out (or sleep it off, if they were up all night).

“Socially, I’ve definitely had to cancel plans because I had to stay home and be next to a toilet,” says Quinn. “Financially, I have missed a significant amount of work, as compared to the average person, just to stay home and poop.”

Past employers have expressed impatience over her numerous absences, and Quinn didn’t feel comfortable explaining them. It wasn’t until she started working at a small, family-owned business that she began opening up about her toilet troubles. She’s allowed to work a flexible schedule, provided that she makes up her hours. When calling in absent, she “tries to keep it as simple as possible,” she says. “I’m basically like, ‘You know that I have diabetes and sometimes I have bad days. Today’s a bad day, so I need to be at home.’ When I’m there, I’m the best employee that I can be.” 

If teleworking isn’t an option, consider adult diapers or talk to your doctor about taking moderate to high doses of antidiarrheal medicines before leaving the house. A support group is a judgment-free zone where you can swap stories and receive valuable lifestyle tips.

After living with diarrhea for close to 15 years, Quinn resolved to better manage her blood glucose to reduce her risk for other diabetes-related complications. She adopted a low-carb eating plan and eliminated foods that irritated her GI tract. Today, five years later, Quinn says her diarrhea has significantly improved—a triumph she chalks up to these lifestyle changes. However, she says she couldn’t have done it all alone; helping her along the way were family, friends, and peers from her diabetes support group. Being open with them about her diarrhea was key. “It’s only through sharing with other people that I’ve found ways to help myself,” says Quinn.



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