High-fat Enteral Formulas Research Articles

A Matter of Fat.

Acute respiratory disease syndrome (ARDS) is a common complication of critical illness, associated with significant morbidity, prolonged intensive care unit (ICU) and hospital stay, and increased mortality. Inflammation plays a central role in ARDS, with inflammatory eicosanoid mediators produced from the ω-6 fatty acid arachidonic acid, such as leukotriene B4, being involved. The ω-3 fatty acids found in fish oil exert anti-inflammatory effects, including decreasing production of inflammatory eicosanoids from arachidonic acid. The ω-3 fatty acids are effective in models relevant to ARDS. Several randomized controlled trials of enteral formulas rich in ω-3 fatty acids, often in combination with other bioactive substances, have been conducted in patients with ARDS. Four of these trials reported marked clinical benefits, 2 reported no effect, and 1 reported a negative impact. A systematic review and meta-analysis of these 7 trials identified no overall effect on ventilator-free days or on ICU-free days. There was a small reduction in ICU length of stay and no overall effect on mortality. However, the authors formally identified that trials that used high fat in both treatment and control groups showed a significant reduction in mortality, while trials that used a high, or higher, fat treatment and a low-fat control group showed a trend toward an increase in mortality. It is concluded that differences in outcome reported among these studies largely relate to the relative fat contents of the treatment and control formulas. Further, it is concluded that high-fat enteral formulas should not be used in this patient group.

High-carbohydrate, high-protein, low-fat versus low-carbohydrate, high-protein, high-fat enteral feeds for burns

Severe burn injuries increase patients' metabolic needs. Aggressive high-protein enteral feeding is used in the post-burn period to improve recovery and healing. To examine the evidence for improved clinical outcomes in burn patients treated with high-carbohydrate, high-protein, low-fat enteral feeds (high-carbohydrate enteral feeds) compared with those treated with low-carbohydrate, high-protein, high-fat enteral enteral feeds (high-fat enteral feeds). We searched the Cochrane Injuries Group Specialised Register (searched 28 Nov 2011), Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4), MEDLINE (Ovid) 1950 to Nov (Week 3) 2011, EMBASE (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Nov 2011), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to Nov 2011), PubMed (Searched 28 Nov 2011). Online trials registers and conference proceedings were also searched to April 2010. We included all randomized controlled trials (RCTs) comparing high-carbohydrate enteral feeds to high-fat enteral feeds for treatment of patients with 10% or greater total body surface area (TBSA) burns in the immediate post-burn period, with data for at least one of the pre-specified outcomes. Two authors collected and analysed the following data: mortality, incidence of pneumonia and days on ventilator. Meta-analysis could only be performed for the outcomes mortality and incidence of pneumonia. A random-effects model was used for all comparisons. Two RCTs, reporting results from 93 patients, were included in this review. Patients given a high-carbohydrate feeding formula had an odds ratio (OR) of 0.12 (95% confidence interval (CI) 0.04 to 0.39) for developing pneumonia compared to patients given a high-fat enteral formula (P value = 0.0004). Patients given a high-carbohydrate formula had an OR of 0.36 (95% CI 0.11 to 1.15) for risk of death compared to patients given a high-fat enteral formula; this difference did not reach statistical significance (P value = 0.08). Risk of bias in these studies was assessed as high and moderate. The available evidence suggests that use of high-carbohydrate, high-protein, low-fat enteral feeds in patients with at least 10% TBSA burns might reduce the incidence of pneumonia compared with use of a low-carbohydrate, high-protein, high-fat diet. The available evidence is inconclusive regarding the effect of either enteral feeding regimen on mortality. Note that the available evidence is limited to two small studies judged to be of moderate risk of bias. Further research is needed in this area before strong conclusions can be drawn.

The Effects of High Fat Formula on the Blood Glucose Control of Brain-injured Patients: A Pilot Study

Song Mi Lee, Ph.D., Sun Jeong Kim, M.S., Hye Kyung Chung, Ph.D., Joo Hye Jeon, M.S., Bo Dam Lee, B.A.1, Chang Ki Hong, M.D.2, Jong Sook Park, M.D.3, Chul Ho Chang, M.D.4. J Clin Nutr 2011;4:21-6. https://doi.org/10.15747/jcn.2011.4.1.21

The effect on glycemic control of a low-carbohydrate, high-fat enteral formula in critically ill patients admitted to a trauma and critical care center

【背景】重症患者に対する栄養管理として入院早期からの経腸栄養が推奨される。また，重症患者における高血糖は予後や合併症に影響を及ぼすことはよく知られている。当科では血糖変動を起こしにくい低糖質高脂肪栄養剤が重症患者の血糖管理に有効であると考え，2010年4月から導入した。【目的】人工呼吸管理を要した重症患者に対する低糖質高脂肪栄養剤による経腸栄養開始後の血糖管理の有用性を，標準濃厚流動食と比較・検討し明らかにすること。【方法と対象】2009年4月から2010年3月までに当科に入院し標準濃厚流動食を投与した重症患者74例（S群）と，2010年4月から2011年3月までに入院し低糖質高脂肪栄養剤を投与した重症患者73例（G群）の経腸栄養開始後の最高血糖値およびインスリン導入率を比較した。経腸栄養は入院7日以内に時間あたり20mLの少量持続投与から開始し，その後速やかに数日で目標カロリーに達するまで増量した。【結果】両群における入院時の年齢・性別・傷病内訳・経腸栄養開始時血糖値に有意差はなかった。最高血糖値は，S群163±32.0mg/dlに対してG群151±28.4mg/dlと有意差を認めた（p=0.022）。また，経腸栄養開始後のインスリン導入率はS群74例中9例（12.2%）に対し，G群73例中1例（1.37%）と有意差を認めた（p=0.018）。両群における28日生存率，ICU入院日数および経腸栄養開始後の消化器症状合併率には有意差を認めなかった。【結語】低糖質高脂肪栄養剤は標準濃厚流動食に比べ，重症患者の急性期における経腸栄養開始後の血糖管理に優れた栄養剤である。

Specialized Enteral Formulas in Acute and Chronic Pulmonary Disease

The relationship between pulmonary disease and nutrition is significant. Nutrition support therapy is common in this patient population as a supportive and/or therapeutic measure. Historical reports of adverse respiratory function associated with high parenteral carbohydrate intakes have been the rationale for using high-fat enteral formulas in patients with chronic pulmonary dysfunction. Theoretically, providing a low-carbohydrate formula will reduce carbon dioxide production, result in a reduced respiratory quotient, and lead to associated improvement in pulmonary outcomes. In the patient with acute respiratory distress syndrome, an imbalance of mediators exists, with proinflammatory mediators being dominant, ultimately affecting the disease course. An enteral formula with modified lipids designed to modulate eicosanoid production, and therefore influence the inflammatory cascade, is available. This article reviews the rationale for use of modified enteral formulas in both chronic and acute pulmonary disease, reviews the available studies evaluating the efficacy of these formulas, and provides overall recommendations for the use of specialized enteral formulas in individuals with pulmonary disease.

Slowly Digestible Carbohydrate Sources Can Be Used to Attenuate the Postprandial Glycemic Response to the Ingestion of Diabetes-Specific Enteral Formulas

The purpose of this study is to compare the glycemic and insulinemic responses following the ingestion of recently developed diabetes-specific enteral formulas versus a standard and a high-fat formula. Fifteen type 2 diabetes patients were selected to participate in a randomized, double-blind, crossover study. Two enteral formulas (47 energy percent [En%] carbohydrate, 34En% fat, and 4 g fiber/200 mL) were defined with either isomaltulose (formula 1) or sucromalt (formula 2) as the main carbohydrate source. For comparison, an isoenergetic diabetes-specific, high-fat (33En% carbohydrate, 50En% fat, 2.9 g fiber/200 mL) and a standard formula (55En% carbohydrate, 30En% fat, 2.8 g fiber/200 mL) were tested. Ingestion of formulas 1 and 2 and the high-fat formula resulted in an attenuated blood glucose response when compared with the standard formula (P < .05). In accordance, peak plasma glucose concentrations were significantly lower when compared with the standard formula (189 +/- 3.6 mg/dL [10.5 +/- 0.2 mmol/L], 196.2 +/- 3.6 mg/dL [10.9 +/- 0.2 mmol/L], 187.2 +/- 3.6 mg/dL [10.4 +/- 0.2 mmol/L], and 237.6 +/- 3.6 mg/dL [13.2 +/- 0.2 mmol/L], respectively). Plasma insulin responses were lower after consumption of the newly developed and high-fat formulas. Ingestion of the high-fat formula resulted in a greater postprandial triglyceride response (P < .05). Diabetes-specific enteral formulas rich in slowly digestible carbohydrate sources can be equally effective in attenuating the postprandial blood glucose response as low-carbohydrate, high-fat enteral formulas without elevating the plasma triglyceride response.

A case of the patient with jejunal tube through the percutaneous endoscopic gastrostomy who vomited gastric juice frequently after the high fat enteral formula

A case of the patient with jejunal tube through the percutaneous endoscopic gastrostomy who vomited gastric juice frequently after the high fat enteral formula

Gastric emptying, pulmonary function, gas exchange, and respiratory quotient after feeding a moderate versus high fat enteral formula meal in chronic obstructive pulmonary disease patients

High fat enteral formulas have been advocated for the nutritional support of chronic obstructive pulmonary disease (COPD) patients because dietary fat utilization under ideal conditions produces less CO 2 per O 2 consumed than carbohydrate. No data exist for these patients comparing the effects of a moderate fat vs. a high fat enteral formula on gastric emptying times (GE) and subsequent CO 2 production (V̇ co 2), oxygen consumption (V̇O 2), respiratory quotient (RQ), and pulmonary function. Our doubleblind crossover study compared these parameters after feeding a 355 mL (530 kcal) meal with either 41% fat calories (Respalor®) or 55% fat calories (Pulmocare®). Thirty-six COPD outpatients with a forced expiratory volume in 1 s (FEV 1) <60% of predicted were studied after an overnight fast. Gastric emptying half-time (GE t 1 2 ) was measured using the 99MTc-radionuclide technique; V̇ co 2, V̇O 2, RQ, and other pulmonary functions were measured at 0, 30, 90, and 150 min postprandial using the Canopy Mode of the Deltatrac Metabolic Monitor and the Renaissance Spirometry System. We observed a significantly ( p = 0.0001) longer GE t 1 2 of the high fat meal when compared to the moderate fat meal (134.1 vs. 108.6 min). At 30 and 90, but not at 150 min postprandial, the V̇ co 2 and V̇O 2 for patients fed the moderate-fat formula were significantly ( p = 0.05) higher than for those fed the high-fat formula; no differences were observed for the other pulmonary functions. Although RQ increased significantly ( p = 0.01) after both meals, no differences between formulas were noted at all postprandial times tested. Compared to the high-fat meal, the moderate-fat meal significantly enhanced gastric emptying. The earlier rise in V̇ co 2 and V̇O 2 after the moderate-fat meal did not impact pulmonary function and reflected the earlier utilization of the moderate-fat meal. The fact that RQ was not different between the two meals at all postprandial times tested suggest that the higher rise in V̇ co 2 and V̇O 2 after the moderate-fat meal was most likely due to earlier gastric emptying of the moderate-fat meal rather than the difference of the fat-to-carbohydrate ratio between the two tested meals. The impact of these findings on long-term management of COPD patients awaits long-term prospective studies.

Bacterial translocation in burned mice after administration of various diets including fiber- and glutamine-enriched enteral formulas

Severe burn injury can produce acute gastrointestinal derangements which may facilitate bacterial translocation to mesenteric lymph nodes. We studied the effects of feeding different dietary formulations on bacterial translocation in burned mice. Prospective, blinded, nonrandomized laboratory study. Research laboratory. One hundred sixty-nine female, outbred, CF-1 mice, 8 to 12 wks of age. Anesthetized mice received a 32% total body surface area, full-thickness burn injury. Mice were then fed with: a) mouse chow; b) a low-residue enteral formula; c) a high-protein, high-fat enteral formula; d) an enteral formula with high concentrations of supplemental glutamine; or e) an enteral formula that contains soy fiber. Burned mice that were fed the low-residue enteral formula demonstrated increased mortality rate (21.2%, p = .05) compared with chow-fed mice in the 2-day postburn period (0 mortality); other burn-diet groups had intermediate mortality rates. In surviving mice, bacterial translocation was found to be: a) lowest in the group fed chow (31.0%) and the high glutamine formula (30.8%); b) intermediate in the group fed formula and soy fiber (44.8%, NS compared with burn-chow group); and c) highest in the group receiving the low-residue enteral formula (73.1%, p < .005) and high-protein, high-fat enteral formula (59.3%, p < .05). Dietary composition markedly affects bacterial translocation in this animal burn model. Commercial enteral diets containing fiber and high concentrations of glutamine provide protection for the gut after burn injury and reduce the occurrence of bacterial translocation in this animal model.

Lack of glucose elevation after simulated tube feeding with a low-carbohydrate, high-fat enteral formula in patients with type I diabetes

Commercially available enteral formulas frequently cause hyperglycemia. This often leads to difficult and complex diabetes management with glucosuria and urinary losses of calories, fluid, and electrolytes. In this study, we compared a new product, EN-8715 (8% soluble fiber, 18% Polycose, 7% fructose, 50% fat, 17% protein), with a standard feeding product, Ensure HN (53% simple carbohydrates, 30% fat, 17% protein), to determine whether the new product would lower the glucose response. Ten subjects (four women and six men) with type I diabetes were evaluated in paired, simulated tube feeding studies. After an overnight fast, a Biostator (artificial endocrine pancreas) was attached to each subject, and a steady-state blood glucose level of 150 mg/dL (8.4 mM) was established. The Biostator was then programmed to deliver a small basal amount of insulin (0.1 mU/kg/minute [718 pmol/kg/minute]), and the patients were given 20 mL of the randomly assigned formula every 15 minutes for 240 minutes (320 mL). Counterregulatory hormone responses to bringing the initial glucose response to the two enteral feeding formulas were measured and compared. The glucose response (mg/dL/four hours +/- SEM) essentially did not rise after EN-8715 (-2 +/- 33 mg/dL/four hours [-0.11 +/- 1.83 mM/four hours]) compared with that for Ensure HN (190 +/- 32 mg/dL/four hours [10.64 +/- 1.79 mM/four hours]). Urinary glucose losses (g +/- SEM) were significantly (p = 0.01) less after the new product (1.4 +/- 0.6 g [7.8 +/- 3.3 mmol] versus 5.7 +/- 1.5 g [30.2 +/- 8.3 mmol]). There were no significant differences in counterregulatory hormone responses. Side effects were minimal and product acceptance was similar. A low-carbohydrate, fiber-containing enteral feeding formula can limit hyperglycemia in patients with type I diabetes.