Late Evening Snack Research Articles

A snack enriched with oral branched-chain amino acids prevents a fall in albumin in patients with liver cirrhosis undergoing chemoembolization for hepatocellular carcinoma

Nutritional support may play an important role in management of liver cirrhosis (LC) associated with unresectable hepatocellular carcinoma (HCC). Total protein and albumin deteriorate in patients with LC undergoing trans-arterial chemoembolization (TACE). Therefore, in this study, we examined the hypothesis that short-term administration of branched-chain amino acids (BCAA) will prevent a fall in total protein and albumin in the perioperative period. The subjects were 56 patients who underwent TACE for HCC between 2004 and 2005 at Nagasaki University Hospital. The patients were randomly placed in the BCAA group (n = 28) or a control group (n = 28). The patients in the BCAA group consumed a snack containing 50 g of BCAA once a day at 10:00 pm starting 1 day before TACE and continuing until 2 weeks after TACE. A comparison of baseline and end point data showed greater decreases in the concentrations of total protein, albumin, cholinesterase, and total cholesterol and in the red blood cell count in the control group compared to the BCAA group. Ammonia levels decreased in the BCAA group and increased in the control group. Our findings indicate that a BCAA supplement taken orally as a late evening snack prevents suppression of liver function by TACE in patients with LC complicated with HCC during the 2-week period after TACE.

Effects of a late evening snack combined with α‐glucosidase inhibitor on liver cirrhosis

A late evening snack (LES) is recommended for protein-energy malnutrition in patients with liver cirrhosis. However, many cases of liver cirrhosis have accompanying impaired glucose tolerance and there are concerns that LESs might aggravate glucose intolerance. In this study, we concomitantly used an alpha-glucosidase inhibitor with a LES and examined the effects on glucose tolerance. In addition, we examined whether or not there was an improvement in energy metabolism by slowing glucose absorption with the concomitant use of the alpha-glucosidase inhibitor. The subjects were 11 patients with liver cirrhosis. From before the study, all the patients had been taking a LES supplementation with a branched-chain amino acid (BCAA)-enriched nutrient mixture. The patients were started on the concomitant use of alpha-glucosidase inhibitor (0.2 mg) taken just prior to the LES. The change of glucose tolerance and energy metabolism were examined using a 75-g oral glucose tolerance test and indirect calorimetry. One week and three months after the start of the concomitant use of the alpha-glucosidase inhibitor, the area under the concentration curve for plasma glucose was significantly decreased. Three months after the concomitant use, the non-protein respiratory quotient was significantly improved. There were no serious side effects during the follow-ups. The concomitant use of the alpha-glucosidase inhibitor use with LES showed the possibility of improving glucose tolerance and energy metabolism. In patients with impaired glucose tolerance, the concomitant use of an alpha-glucosidase inhibitor with LES might be a useful measure for nutritional management.

Assessment of nutritional status of patients with hepatitis C virus‐related liver cirrhosis

Nutrition support for patients with liver cirrhosis, such as late evening snacks and branched-chain amino acids, has been demonstrated to be effective. However, the assessment of the malnutrition of liver cirrhosis is still a problem. The aim of this study was to assess the nutritional status of patients with liver cirrhosis due to hepatitis C virus by six methods and to test the sensitivity and specificity of these methods. In total, 86 patients with liver cirrhosis due to hepatitis C virus were assessed for nutritional status by triceps skinfold thickness (TSF), arm muscle circumference (AMC), subjective global assessment (SGA), nutritional risk index (NRI), Maastricht index (MI), and instant nutritional assessment (INA). Malnutrition was found in 11 (12.8%) patients by TSF, 15 (17.4%) by AMC, 22 (25.6%) by SGA, 52 (60.5%) by the NRI, 66 (76.7%) by the MI, and in 54 (62.8%) by INA. The MI detected malnutrition at a significantly higher rate compared with the other five methods. Sixty-two patients were diagnosed as malnourished by the combined index, which defines the patients as malnourished when any two of the NRI, MI, and INA also define them as malnourished. The misclassification rate compared with the combined indexes was significantly lower in the MI (4.7%) than in any of the TSF (59.3%), AMC (59.3%), SGA (46.5%), NRI (16.3%), and INA (14.0%). The MI was the best single score to identify the patients who had malnutrition, including early stage, and may benefit from nutrition support.

Is diabetes mellitus the critical factor for the effect of a late evening snack?

Is diabetes mellitus the critical factor for the effect of a late evening snack?

肝硬変患者に対する長期の夜間就寝前栄養（LES）による栄養アセスメントとQOLについて

代償期肝硬変患者における栄養管理として、C型肝硬変患者2例を対象に夜間就寝前栄養（late evening snack；以下、LESと略）を用いた栄養療法を実施し、長期的LESの効果を検討した。通常食あるいは肝不全用経腸栄養剤による200 kcal程度のLESをそれぞれに3ヶ月間実施し、3ヶ月目からは2例ともに肝不全用経腸栄養剤によるLESに変更し2年間継続実施した。通常食によるLES実施ではコンプライアンスが不良であったが、肝不全用経腸栄養剤によるLES摂取はコンプライアンスが良好で長期継続可能であった。LESの長期実施の結果、3ヶ月以降徐々に窒素出納(以下、N-balanceと略)、非蛋白呼吸商(non-protein respiratory quotient；以下、npRQと略)及び基質燃焼比率、自他覚症状（こむら返り、不眠）の改善効果が得られた。SF-36による生活の質(quality of life；以下、QOLと略)評価では、これらの改善に伴い“精神的健康度”の改善が認められた。肝硬変患者におけるLESは長期的栄養療法として有効であり、特に肝不全用経腸栄養剤によるLESはコンプライアンスが良好であった。代償期肝硬変患者(Child-Pugh分類：A)では、コンプライアンス及び治療効果の両面に対し肝不全用経腸栄養剤によるLESでの適応の可能性が考えられた。

Effect of a late evening snack on outpatients with liver cirrhosis

We have reported that one-week administration of a late evening snack (LES) improved not only malnutrition but also glucose intolerance in hospitalized patients with liver cirrhosis. Thus, we investigated whether long-term LES administration to outpatients for 3 months could reproduce the results obtained from hospitalized patients, especially improved glucose intolerance. If this treatment aggravated glucose intolerance, we tried to find any marker predicting this aggravation before the treatment. Outpatients were prescribed one pack of oral supplementation of a branched-chain amino acid (BCAA)-enriched nutrient, Aminoleban EN (210 kCal) as a LES without dietician supervision. Both before LES administration and after 3 months, glucose tolerance and liver function were examined using a 75 g oral glucose tolerance test (OGTT), biochemical parameters in blood and the relationship between glucose tolerance (area under the curve (AUC)) and the following serum markers. Branched-chain amino acid/tyrosine ratio (BTR), the number of red blood cells (RBC), and hematocrit (Ht) significantly increased, with significant reduction of blood NH(3) level in patients with a blood glucose level less than 200 mg/dL 2 h after 75 g OGTT. However, the increase of AUC was seen after 3 months of LES administration in patients who had blood glucose higher than 200 mg/dL 2 h after 75 g OGTT. AUC weakly correlated positively with serum 7S collagen and negatively with choline esterase (ChE) and albumin (Alb). 75 g OGTT is a useful marker to predict the worst outcome and avoid the adverse effect of LES treatment in liver cirrhosis patients if performed without adequate nutrient conduct by a dietician.

Long-term nutritional assessment and quality of life in patients with cirrhosis taking a late evening snack

Long-term nutritional assessment and quality of life in patients with cirrhosis taking a late evening snack

BCAA-enriched snack improves nutritional state of cirrhosis

Objective A late evening snack improves the catabolic state in patients with advanced liver cirrhosis. We tested whether long-term (3 mo) late evening snacking that included a branched-chain amino acid (BCAA)–enriched nutrient mixture produces a better nutritional state and better quality of life than ordinary food in patients with hepatitis C virus–positive liver cirrhosis. Methods In a multicenter, randomized study, 48 patients with liver cirrhosis received late-evening supplementation with the BCAA-enriched nutrient mixture or ordinary food, such as a rice ball or bread, for 3 mo. During the study period, each patient was instructed on energy and protein intake. Blood biochemical data, nitrogen balance, respiratory quotient, and health-related quality of life (Short Form 36 questionnaire) were evaluated at baseline and at the end of the study. Results Total and late-evening energy intakes were similar in the two groups at 3 mo. Serum albumin level, nitrogen balance, and respiratory quotient were significantly improved by the BCAA mixture but not by ordinary food. The parameters of the Short Form 36 did not statistically significantly improve over 3 mo in either group. Conclusion Long-term oral supplementation with a BCAA mixture is better than ordinary food in a late evening snack at improving the serum albumin level and the energy metabolism in patients with cirrhosis.

Effect of late evening snack with rice ball on energy metabolism in liver cirrhosis

This study investigates the effects of a late evening snack (LES), of 200 kcal of rice ball, on energy metabolism in cirrhotic patients. Impaired nutritional metabolism has been associated with cirrhosis, and frequent intake of small meals may prevent early-onset starvation, and maintain nourishment in these patients. Twenty-one cirrhotic patients and 26 control subjects (Control) were recruited for this study. Patients were subsequently treated by LES (LC-LES) and by a non-LES regimen (LC-NLES). Resting energy expenditure and respiratory quotient (RQ) were assessed by indirect calorimetry at 0830, 1130 and 1430. Blood glucose and non-esterified fatty acids (NEFA) were measured just before the energy metabolism measurements. The regular diet included three major meals and LES, at 0900, 1200, 1800 and 2100, respectively. The Control and LC-NLES groups received only the major meals, whereas the LC-LES group received three meals plus 200 kcal LES for 7 days. There was no difference in the total energy intake among Control, LC-NLES and LC-LES groups. Respiratory quotient in LC-NLES was significantly lower than that of Control at 0830. Respiratory quotient value in LC-LES significantly elevated from that in LC-NLES. The RQ values did not differ among Control, LC-NLES and LC-LES at 2 h after the meal (1130 and 1430). Non-esterified fatty acids in LC-LES were lower than that in LC-NLES after overnight fasting. The ingestion of a 200 kcal rice ball LES can improve the nutritional metabolism in cirrhotic patients.

The effect of a late evening snack in patients with liver cirrhosis

: As an intervention for energy malnutrition, frequent meals or a late evening snack (LES) has been recently recommended. On the other hand, it has been reported that glucose intolerance is found in approximately 70% of patients with liver cirrhosis. Thus, we investigated which would be better for the improvement of energy malnutrition and glucose intolerance, treatment with LES alone or LES plus divided meals. : One group of oral supplementation with one pack of a branched-chain amino acid (BCAA)-enriched nutrient, Aminoleban EN (210kcal), at 10 p.m. LES and the other group with two packs of Aminoleban EN (one pack at 10 p.m. as LES and another pack during the day, i.e. at sometime from 10 a.m. to 3 p.m.) were examined to determine the influence of LES on the blood glucose level, biochemical parameters, and energy metabolism. Twenty-six patients participated in this study. The administration period was 7 days. Metabolic measurements were performed using an indirect calorimeter. : The fat oxidation rate was significantly decreased and the carbohydrate oxidation rate significantly increased in both groups. As a result, respiratory quotient (RQ) was significantly improved. In many cases, the increase of the glucose level after meals seemed to be reduced after LES administration for 1 week. LES could improve energy malnutrition, and correct amino acid imbalance. There was also a significant correlation between non-protein respiratory quotient (npRQ) and the creatinine height index. : LES alone improved the energy malnutrition state and glucose intolerance equivalent to LES plus divided meals. Thus, LES may improve glucose intolerance in patients with liver cirrhosis.

Chronic hepatic disease and dietary instruction

Protein-energy malnutrition (PEM) is a prevalent observation in cirrhotic patients. In advanced cirrhotic patients with hepatic encephalopathy, dietary protein should be restricted to the low level of 0.5 g/kg/day. In such a strictly protein restricted diet, branched amino acid-enriched nutritious products should be prescribed to improve PEM. Avoidance of day-time or nocturnal fasting by frequent meals and late evening snacks is another recommendation for prevention of PEM. The n-3 polyunsaturated fatty acids (PUFA) modulate lymphocyte proliferation and eicosapetaenoic acid (EPA) up-regulates the metabolic action of insulin. The dietary n-6/n-3 PUFA ratio should be maintained between 2.8 and 3.2 in chronic liver disease. Oxidative stress is suggested as a trigger in the progression of chronic liver disease. Antioxidant vitamins; Vitamins A, E and C and carotenes may be useful to prevent the progression of chronic liver disease. Zinc depression occurs in advanced liver disease and it reduces taste and immune function. A goal of dietary management in chronic liver disease should be preventing PEM and blocking progression to hepatic cancer, and improving quality of life.

Late evening snack and the change of blood glucose level in patients with liver cirrhosis

It has been reported that patients with liver cirrhosis suffer from energy malnutrition and late evening snacks (LES) can be effective for this malnutrition. On the other hand, it is also known that some patients with liver cirrhosis have glucose intolerance as a complication. We have shown that 1 week LES treatment using as an oral supplement with branched chain amino acids significantly reduced an increase of blood glucose level after meals. Fat oxidation rate was significantly decreased with an increased carbohydrate oxidation rate. LES may improve glucose intolerance in patients with liver cirrhosis, at least hospitalized patients.

Branched-chain amino acids as a protein- and energy-source in liver cirrhosis

Protein-energy malnutrition (PEM) is a common manifestation in cirrhotic patients with reported incidences as high as 65–90%. PEM affects largely the patients’ quality of life and survival. Thus, diagnosis of and intervention for PEM is important in the clinical management of liver cirrhosis. Supplementation with branched-chain amino acids (BCAA) is indicated to improve protein malnutrition. As an intervention for energy malnutrition, frequent meal or late evening snack has been recently recommended. Plasma amino acid analysis characterizes the patients with liver cirrhosis to have decreased BCAA. Such reduction of BCAA is explained by enhanced consumption of BCAA for ammonia detoxication and for energy generation. Supplementation with BCAA raises in vitro the synthesis and secretion of albumin by cultured rat hepatocytes without affecting albumin mRNA expression. BCAA recover the impaired turnover kinetics of albumin both in rat cirrhotic model and in cirrhotic patients. Longer-term supplementation with BCAA raises plasma albumin, benefits quality of life issues, and finally improves survival in liver cirrhosis. Recent interests focused on the timing of administration of BCAA, since daytime BCAA are usually consumed by energy generation for physical exercise of skeletal muscles. Nocturnal BCAA seem to be more favorable as a source of protein synthesis by giving higher nitrogen balance. This minireview focuses on the basic and clinical aspects of BCAA as a pharmaco-nutritional source to control PEM in liver cirrhosis.

Effect of a late evening snack on the blood glucose level and energy metabolism in patients with liver cirrhosis

Background/aim: Patients with liver cirrhosis suffer from energy malnutrition. Late evening snacks (LESs) have been recently reported to be effective for this. However, it is known that a significant proportion of patients with liver cirrhosis have glucose intolerance as a complication. For this reason, the influence of LES on the blood glucose level should be examined. Subjects/method: We administered an oral supplement with branched-chain amino acids (Aminoleban EN) to patients with liver cirrhosis at 10 p.m. to investigate the changes of the blood glucose level and energy metabolism with an indirect calorimeter. Ten patients (average age, 70; Child A/B/C, 5/4/1) participated in this study. The administration period was 7 days. Blood glucose levels were examined before and after breakfast, lunch, supper and at 10 p.m. Results: (1) The fat oxidation rate was significantly decreased and the carbohydrate oxidation rate significantly increased. As a result, RQ was significantly improved. (2) With many cases, an increase of glucose level after meals seemed to reduce with LES administration for 1 week. (3) BTR was significantly improved. Conclusions: LES could improve energy malnutrition, correct amino acid imbalance, and ultimately may improve glucose intolerance in patients with liver cirrhosis.

Severe catabolic state after prolonged fasting in cirrhotic patients: effect of oral branched-chain amino-acid-enriched nutrient mixture

Cirrhotic patients frequently undergo various medical procedures, such as diagnostic gastrointestinal endoscopy, without taking breakfast. The aim of the present study was to clarify the effect of longer fasting (> 12 h) on energy metabolism, and to test whether supplementation of an oral branched-chain amino-acid-enriched nutrient mixture (BCAA mixture), which contains various nutrients in addition to BCAA, could improve the catabolic state. Metabolic measurement was performed in 30 cirrhotic patients and 13 normal subjects, using indirect calorimetry. Compared with that in the normal subjects, the respiratory quotient (RQ) was significantly lower after an overnight fast in the cirrhotic patients, indicating accelerated fat oxidation and a catabolic state. In addition, RQ in cirrhotic patients (n = 7) decreased rapidly with longer fasting, whereas that in the normal subjects (n = 5) showed relatively stable values. These results indicate that special care should be taken with medical procedures that are carried out in patients who have fasted. The effect of oral glucose, a carbohydrate-rich snack (rice ball), and the BCAA mixture (each, 210 kcal) on RQ was studied in 6 normal subjects and 6 patients with liver cirrhosis after an overnight fast. Supplementation of the carbohydrate-rich snack and the BCAA mixture (210 kcal each) elevated RQ and blood glucose levels to a similar degree in the cirrhotic patients. Oral administration of glucose (210 kcal) led to significantly greater elevation of blood glucose levels than the other snacks, which may be unfavorable for cirrhotic patients, who frequently have glucose intolerance. In the 30 cirrhotic patients, supplementation with the BCAA mixture in the late evening significantly improved RQ in the early morning. Carbohydrate-rich meals are used as a late evening snack in cirrhotic patients, but our study indicates that supplementation with a BCAA mixture can also be used to reduce fat oxidation in the early morning, with results similar to those with carbohydrate-rich snacks.

Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services.

To determine the dietary intake, practices, knowledge and barriers to dietary compliance of black South African type 2 diabetic patients attending primary health-care services in urban and rural areas. A cross-sectional survey. Dietary intake was assessed by three 24-hour recalls, and knowledge and practices by means of a structured questionnaire (n = 133 men, 155 women). In-depth interviews were then conducted with 25 of the patients to explore their underlying beliefs and feelings with respect to their disease. Trained interviewers measured weight, height and blood pressure. A fasting venous blood sample was collected from each participant in order to evaluate glycaemic control. An urban area (Sheshego) and rural areas near Pietersburg in the Northern Province of South Africa. The sample comprised 59 men and 75 women from urban areas and 74 men and 80 women from rural areas. All were over 40 years of age, diagnosed with type 2 diabetes for at least one year, and attended primary health-care services in the study area over a 3-month period in 1998. Reported dietary results indicate that mean energy intakes were low (< 70% of Recommended Dietary Allowance), 8086-8450 kJ day(-1) and 6967-7382 kJ day(-1) in men and women, respectively. Urban subjects had higher (P < 0.05) intakes of animal protein and lower ratios of polyunsaturated fat to saturated fat than rural subjects. The energy distribution of macronutrients was in line with the recommendations for a prudent diet, with fat intake less than 30%, saturated fat less than 10% and carbohydrate intake greater than 55% of total energy intake. In most respects, nutrient intakes resembled a traditional African diet, although fibre intake was low in terms of the recommended 3-6 g/1000 kJ. More than 90% of patients ate three meals a day, yet only 32-47% had a morning snack and 19-27% had a late evening snack. The majority of patients indicated that they followed a special diet, which had been given to them by a doctor or a nurse. Only 3.4-6.1% were treated by diet alone. Poor glycaemic control was found in both urban and rural participants, with more than half of subjects having fasting plasma glucose above 8 mmol l(-1) and more than 35% having plasma glycosylated haemoglobin level above 8.6%. High triglyceride levels were found in 24 to 25% of men and in 17 to 18% of women. Obesity (body mass index > or = 30 kg m(-2)) was prevalent in 15 to 16% of men compared with 35 to 47% of women; elevated blood pressure (> or = 160/95 mmHg) was least prevalent in rural women (25.9%) and most prevalent in urban men (42.4%). The majority of black, type 2 diabetic patients studied showed poor glycaemic control. Additionally, many had dyslipidaemia, were obese and/or had an elevated blood pressure. Quantitative and qualitative findings indicated that these patients frequently received incorrect and inappropriate dietary advice from health educators.

Nutritional Pharmacotherapy of Liver Cirrhosis for Prognosis and Improvement of Quality of Life

Patients with liver cirrhosis are in a state of protein and energy malnutrition (PEM), and this can lead to patients' poor prognosis and quality of life. Metabolic abnormalities such as hypermetabolism or decreased glucose level and increased fat oxidation, as measured by indirect calorimetry, might trigger and/or worsen PEM. Supplementation with branched-chain amino acids (BCAA) improves hepatic encephalopathy and protein malnutrition (e.g., increasing the serum albumin level and improving the nitrogen balance), and subsequently improves patients' prognosis and quality of life. Late evening snack (LES) shortens the starvation period during the night in cirrhosis. Decreased respiratory quotient, suggesting patients' poor prognosis, was recovered to almost normal by LES. This might help to prevent the reduction of muscle volume and fat tissue, improving energy malnutrition in cirrhosis. Preservation of muscle volume is a critical issue for the patients whose muscle strength is weakened, which contributes to poor quality of life. In future studies, the mechanism of the clinical effects of BCAA and LES should be elucidated for the improvement of PEM in patients with cirrhosis.

Effects of the glucosidase inhibitor acarbose in patients with liver cirrhosis

In this preliminary study, we examined the effects of acarbose and placebo together with a standardized breakfast on blood glucose levels, on breath hydrogen excretion and on plasma insulin and glucagon levels; in addition, the effects on fasting blood levels of metabolites were studied following an evening meal with acarbose or placebo. Acarbose significantly reduced blood glucose levels in 10 patients with alcoholic cirrhosis following a meal containing 100 g of carbohydrate. There were no significant changes in plasma insulin after breakfast but glucagon levels were increased at 1 h after the meal. Breath hydrogen excretion did not change significantly. Acarbose given with a late evening snack reduced fasting beta-hydroxybutyrate levels the next morning in these cirrhotic patients.