Administration of a new diabetes-specific enteral formula results in an improved 24h glucose profile in type 2 diabetic patients

A UK national survey of enteral feed use in people with diabetes 2022

AIMS

Enteral feeding is commonly used to manage a variety of medical conditions in hospitals. For people with diabetes this can present a specific challenge for glucose management. To address gaps in our understanding of modern enteral feeding outcomes and to help with the development of more specific guidance on maintaining glycaemic control, we conducted a national survey on the management of enteral feeding against the standards in the nationally adopted Joint British Diabetes Societies for Inpatient Care (JBDS) guidelines.

METHODS

A questionnaire was developed using the 2018 JBDS guideline as a template this questionnaire was sent out by email to all 220 UK specialist diabetes teams. Databases of Diabetes UK, the Association of British Diabetologists (ABCD) and the Diabetes Inpatient Specialist Nurse UK Group were used.

RESULTS

Twenty-six hospitals responded, 11 had guidelines for the management of insulin with enteral feeding. There were three main feed regimens used: continuous 24-h feeding, a single feed with one break in 24 h, or multiple feeds in 24 h. There were five regimens in common use: premixed insulin, isophane insulin, analogue basal insulin, variable rate intravenous insulin or basal bolus insulin. Overall glucose control was poor for all regimens and combinations. Continuous feed showed better glucose control than a single feed with a break, mean (±SD) glucose 12.4 mmol/L (5.6) versus 15.1 mmol/L (6.9) p < 0.005, but no group showed optimal control.

CONCLUSIONS

Managing diabetes control during enteral feeding remains a challenge. Our survey showed that glucose control during this treatment is suboptimal.

Diabetes-Specific Complete Smoothie Formulas Improve Postprandial Glycemic Response in Obese Type 2 Diabetic Individuals: A Randomized Crossover Trial

This study aimed to compare newly developed diabetes-specific complete smoothie formulas with a standard diabetes-specific nutritional formula (DSNF) regarding their effects on glucose homeostasis, insulin levels, and lipid metabolism in obese type 2 diabetes (T2DM) patients. We conducted a randomized, double-blind, crossover study with 41 obese T2DM participants to compare two developed diabetes-specific complete smoothie formulas, a soy-based regular smoothie (SM) and a smoothie with modified carbohydrate content (SMMC), with the standard DSNF, Glucerna. Glycemic and insulin responses were assessed after the participants randomly consumed 300 kilocalories of each formulation on three separate days with a 7-day gap between. Postprandial effects on glycemic control, insulin levels, and lipid metabolism were measured. SMMC resulted in a significantly lower glucose area under the curve (AUC0-240) compared to Glucerna and SM (p < 0.05 for both). Insulin AUC0-240 after SMMC was significantly lower than that after SM and Glucerna (p < 0.05). During the diets, the suppression of NEFA was more augmented on SM, resulting in a less total AUC0-240 of NEFA compared to the SMMC diet (p < 0.05). C-peptide AUC0-240 after SMMC was significantly lower than that after Glucerna (p < 0.001). Conversely, glucagon AUC0-240 after SMMC was significantly higher than that after SM and Glucerna (p < 0.05). These results highlight SMMC as the better insulin-sensitive formula, potentially achieved through increased insulin secretion or a direct reduction in glucose absorption. The unique composition of carbohydrates, amino acids, and fats from natural ingredients in the smoothies may contribute to these positive effects, making them promising functional foods for managing diabetes and obesity.

Therapeutic Properties and Use of Extra Virgin Olive Oil in Clinical Nutrition: A Narrative Review and Literature Update

Extra virgin olive oil (EVOO) is a cornerstone of the Mediterranean diet (MedD). In this narrative review, we synthesize and illustrate the various characteristics and clinical applications of EVOO and its components—such as oleic acid, hydroxytyrosol, and oleuropein—in the field of clinical nutrition and dietetics. The evidence is split into diet therapy, oleic acid-based enteral nutrition formulations and oral supplementation formulations, oleic acid-based parenteral nutrition, and nutraceutical supplementation of minor components of EVOO. EVOO has diverse beneficial health properties, and current evidence supports the use of whole EVOO in diet therapy and the supplementation of its minor components to improve cardiovascular health, lipoprotein metabolism, and diabetes mellitus in clinical nutrition. Nevertheless, more intervention studies in humans are needed to chisel specific recommendations for its therapeutic use through different formulations in other specific diseases and clinical populations.

The Effect of Oral Nutritional Formula With Three Different Proteins on Type 2 Diabetes Mellitus in vivo

Oral nutritional (ON) products are an effective way to treat patients with type 2 diabetes mellitus (T2DM) whose gastrointestinal functions are normal. The influence of ON formula prepared with three different proteins on T2DM was studied. The hyperglycaemic mouse model using a high-fat diet (HFD) combined with an intraperitoneal injection of streptozotocin (STZ) was used to simulate T2DM. The study was done for 15 weeks using seven groups of mice: control group (CG, normal mice, and normal food), non-treated group (BG, diabetic mice, and normal food), positive control group (PG, diabetic mice, and HFD), soybean protein group (SPG, diabetic mice, and HFD), silkworm pupa protein group (SPPG, diabetic mice, and HFD), whey protein group (LPG, diabetic mice, and HFD), and whey protein combined with silkworm pupa protein group (LCSSPG, diabetic mice, and HFD). The plasma levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were analyzed on weeks 2, 10, 12, 14, and 15. The concentration of total protein (TP) and albumin (ALB) of the plasma was increased in SPG, SPPG, and PG comparing with BG (p < 0.05). The TC, TG, and LDL-C levels were decreased, and HDL-C level was increased in SPG, PG, SPPG, PG comparing with BG (p < 0.05). Blood glucose (BLG) levels were decreased 47, 34, 24, and 21% in SPG, LCSSPG, SPPG, and PG, respectively. While BLG was not significantly changed (p ≥ 0.05) in LG after 5 weeks of treatment. Overall, the data suggested that consumption of SP, SPP, LCSSPG Oral-formula may be beneficial for the treatment of T2DM.

Glycemic Response to a Renal-Specific Oral Nutritional Supplement in Patients With Diabetes Undergoing Hemodialysis: A Randomized Crossover Trial

BACKGROUND

Diabetes and malnutrition are common in patients with kidney failure. We aimed to evaluate the postprandial glucose response to oral nutritional supplement drinks (ONSs) in patients with diabetes undergoing hemodialysis treatment.

METHODS

A randomized, single-blind crossover study was conducted in patients with diabetes, and requiring chronic hemodialysis. Patients consumed either a renal-specific ONS, macronutrient-matched ONS, or standard ONS on 3 separate study days, during dialysis, following an overnight fast. Blood was collected before and 15, 30, 45, 60, 90, 120, and 180 minutes post ingestion. Mean net incremental area under the curve (iAUC) and peak incremental blood glucose concentration were compared across conditions, using analyses of variance.

RESULTS

Consumption of the renal-specific ONS resulted in the lowest mean net iAUC (87.9 ± 169.0 mmol/L per 3 hours) compared with macronutrient-matched (188.0 ± 127.5 mmol/L per 3 hours) and standard ONS (199.5 ± 169.2 mmol/L per 3 hours) (F_2,30 = 5.115, P = 0.012, partial n² = 0.254). Pairwise comparisons demonstrated a mean difference of 100.1 mmol/L per 3 hours (95% CI, -2.8 to 202.9) in mean iAUC between the renal-specific ONS and macronutrient-matched ONS (P = 0.058). Peak blood glucose concentration, corrected for baseline, was significantly lower after the renal-specific ONS (1.40 ± 1.0 mmol/L) compared with both macronutrient-matched (2.02 ± 0.71 mmol/L, P = 0.036) and standard ONS (2.3 ± 1.06 mmol/L, P = 0.017).

CONCLUSION

A renal-specific ONS elicits a lower postprandial glucose response than either macronutrient-matched ONS or standard ONS in patients with diabetes during hemodialysis.

The Effect of Diabetes-Specific Enteral Nutrition Formula on Cardiometabolic Parameters in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

The prevalence of diabetes is on the increase in the UK and worldwide, partly due to unhealthy lifestyles, including poor dietary regimes. Patients with diabetes and other co-morbidities such as stroke, which may affect swallowing ability and lead to malnutrition, could benefit from enteral nutrition, including the standard formula (SF) and diabetes-specific formulas (DSF). However, enteral nutrition presents its challenges due to its effect on glycaemic control and lipid profile.

AIM

The aim of this review was to evaluate the effectiveness of diabetes-specific enteral nutrition formula versus SF in managing cardiometabolic parameters in patients with type 2 diabetes.

METHOD

This review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses. Three databases (Pubmed, EMBASE, PSYCInfo) and Google scholar were searched for relevant articles from inception to 2 January 2019 based on Population, Intervention, Comparator, Outcomes and Study designs (PICOS) framework. Key words, Medical Subject Heading (MeSH) terms, and Boolean operators (AND/OR) formed part of the search strategy. Articles were evaluated for quality and risks of bias.

RESULTS

Fourteen articles were included in the systematic review and five articles were selected for the meta-analysis. Based on the findings of the review and meta-analysis, two distinct areas were evident: the effect of DSF on blood glucose parameters and the effect of DSF on lipid profile. All fourteen studies included in the systematic review showed that DSF was effective in lowering blood glucose parameters in patients with type 2 diabetes compared with SF. The results of the meta-analysis confirmed the findings of the systematic review with respect to the fasting blood glucose, which was significantly lower (p = 0.01) in the DSF group compared to SF, with a mean difference of -1.15 (95% CI -2.07, -0.23) and glycated haemoglobin, which was significantly lower (p = 0.005) in the DSF group compared to the SF group following meta-analysis and sensitivity analysis. However, in relation to the sensitivity analysis for the fasting blood glucose, differences were not significant between the two groups when some of the studies were removed. Based on the systematic review, the outcomes of the studies selected to evaluate the effect of DSF on lipid profile were variable. Following the meta-analysis, no significant differences (p > 0.05) were found between the DSF and SF groups with respect to total cholesterol, LDL cholesterol and triglyceride. The level of the HDL cholesterol was significantly higher (p = 0.04) in the DSF group compared to the SF group after the intervention, with a mean difference of 0.09 (95% CI, 0.00, 0.18), although this was not consistent based on the sensitivity analysis. The presence of low glycaemic index (GI) carbohydrate, the lower amount of carbohydrate and the higher protein, the presence of mono-unsaturated fatty acids and the different amounts and types of fibre in the DSF compared with SF may be responsible for the observed differences in cardiometabolic parameters in both groups.

CONCLUSION

The results provide evidence to suggest that DSF is effective in controlling fasting blood glucose and glycated haemoglobin and in increasing HDL cholesterol, but has no significant effect on other lipid parameters. However, our confidence in these findings would be increased by additional data from further studies.

Classifying Enteral Nutrition: Tailored for Clinical Practice

PURPOSE OF REVIEW

To discuss the different forms of enteral nutrition, while outlining available evidence for its use in specific conditions and how enteral nutrition composition may or may not influence relevant outcomes.

RECENT FINDINGS

Enteral nutrition formulas were originally conceived as a liquid form of nutrition for individuals who otherwise could not consume adequate calories through solid food. Over time, the emergence of specialty formulas marketed to benefit specific diseases or conditions has led to a broad range of potentially confusing options. While most options have theoretical benefit for their marketed conditions, the evidence demonstrating practical benefit is not consistent. Overall, the certainty of evidence for specialty formulas remains low or very low. In most instances, one could begin with standard polymeric formula, except in cases where disease-specific formulas are recommended. Much research is nonetheless still needed to clarify whether some disease-specific formulas are truly beneficial or merely theoretical features.

Very high-protein and low-carbohydrate enteral nutrition formula and plasma glucose control in adults with type 2 diabetes mellitus: a randomized crossover trial

BACKGROUND AND OBJECTIVES

Standard enteral nutrition (EN) formulas can  worsen hyperglycemia in diabetic patients. We hypothesized that altering the proportion of macronutrients in a formula; increasing protein while decreasing carbohydrate concentrations would improve glycemic response. The objective of this study was to demonstrate that an EN formula containing a very high concentration of protein (in the form of whey peptides) and low concentration of carbohydrate provide better control of postprandial blood glucose relative to a very high-protein/higher-carbohydrate formula.

SUBJECTS AND METHODS

This was a randomized crossover clinical trial of 12 ambulatory adult subjects with type 2 diabetes. The primary outcome was glycemic response following a bolus of isocaloric amounts of two EN formulas; the secondary outcome was insulin response. Subjects were randomized to the experimental or the control formula, on two separate days, 5-7 days apart.

RESULTS

Mean blood glucose concentrations at 10-180 min post-infusion and mean area under the curve for glucose over 240 min post-infusion were significantly lower with the experimental formula than with the control formula (71.99 ± 595.18 and 452.62 ± 351.38, respectively; p = 0.025). There were no significant differences in the mean insulin concentrations over time, insulinogenic indices, and first-phase insulin measurements.

CONCLUSIONS

An EN formula containing high-protein and low-carbohydrate loads can significantly improve glucose control in subjects with type 2 diabetes in ambulatory settings as evidenced by observed improved glucose control without significant difference in insulin response.

Tube Feeding with a Diabetes-Specific Enteral Formula Improves Glycemic Control in Severe Acute Ischemic Stroke Patients

BACKGROUND

Glycemic control is essential for managing acute stroke. This study evaluated the impact of a diabetes-specific formula (DSF) on glycemic control in severe acute ischemic stroke patients.

METHODS

A randomized, prospective controlled trial was conducted in Nanjing Drum Tower Hospital. Acute ischemic stroke patients who scored > 10 on the National Institutes of Health Stroke Scale as well as had swallowing problems were randomized to group A, which received a diabetes-specific enteral formula, and group B, which received a standard formula. Glycemic parameters were assessed at baseline and 7 days after admission.

RESULTS

One hundred four patients were enrolled in the study (group A, 53; group B, 51). Postprandial glucose parameters, including capillary glucose concentration from 8 hours to 16 hours after enteral nutrition (EN) consumption, incremental areas under the curve (iAUC_{0-16 h} ), peak value, and mean glucose concentration, were significantly lower in group A than in group B following a 7-day intervention period. Moreover, changes in HOMA_IR after the 7-day treatment were significantly higher in group A than in group B. No significant difference in the incidence of hypoglycemia, glycemic variability parameters, or nutrition parameters was found between the 2 groups, either at baseline or after treatment. There were no serious adverse events observed during the study.

CONCLUSION

A diabetes-specific formula may improve acute-term glycemic control in severe acute ischemic stroke patients.

Evidence-based recommendations and expert consensus on enteral nutrition in the adult patient with diabetes mellitus or hyperglycemia

OBJECTIVE

The aim of this study was to develop evidence-based recommendations for glycemic control of patients with diabetes mellitus or stress hyperglycemia who are receiving enteral nutrition (EN).

METHODS

A Delphi survey method using Grading Recommendations Assessment, Development and Evaluation criteria was utilized for evaluation of suitable studies.

RESULTS

In patients with diabetes or stress hyperglycemia who were on EN support, the following results were found: CONCLUSIONS: These recommendations and suggestions regarding enteral feeding in patients with diabetes and hyperglycemia have direct clinical applicability.

Plasma glucose and insulin response to two oral nutrition supplements in adults with type 2 diabetes mellitus

OBJECTIVE

The purpose of this clinical trial was to compare the glucose usage of two oral nutritional supplement (ONS) products and to assess whether a diabetes-specific formulation provides improved glucose stabilization and management compared with a standard formula.

RESEARCH DESIGN AND METHODS

A total of 12 subjects with type 2 diabetes (7 males and 5 females) completed a randomized, cross-over design trial. Each subject consumed isocaloric amounts of either the standard ONS or the diabetes-specific formula ONS on different dates, 1 week apart. Glucose and insulin measures were recorded at baseline, and 10, 20, 30, 60, 90, 120, 150, 180, 210 and 240 min after the beverage was consumed and then used to calculate area under the curve (AUC) for each subject.

RESULTS

The mean glucose AUC was lower in the diabetes-specific ONS group than in the standard group (p<0.0001), but there was not a significant difference observed for mean insulin AUC (p=0.068). A sensitivity analysis of the mean insulin AUC measures was performed by removing a potential outlier from the analysis, and this resulted in a significant difference between the groups (p=0.012). First-phase insulin measures and an insulinogenic index calculated for the beverages showed no significant differences.

CONCLUSIONS

On the basis of the results of this trial of 12 subjects, the diabetes-specific ONS appears to provide better glucose maintenance in persons with type 2 diabetes when compared to the standard formula ONS.

TRIAL REGISTRATION NUMBER

NCT02612675.

Evaluation of the role of enteral nutrition in managing patients with diabetes: a systematic review

The aim of this systematic review is to evaluate the role of enteral nutrition in managing patients with diabetes on enteral feed. The prevalence of diabetes is on the increase in the UK and globally partly due to lack of physical activities, poor dietary regimes and genetic susceptibility. The development of diabetes often leads to complications such as stroke, which may require enteral nutritional support. The provision of enteral feeds comes with its complications including hyperglycaemia which if not managed can have profound consequences for the patients in terms of clinical outcomes. Therefore, it is essential to develop strategies for managing patients with diabetes on enteral feed with respect to the type and composition of the feed. This is a systematic review of published peer reviewed articles. EBSCOhost Research, PubMed and SwetsWise databases were searched. Reference lists of identified articles were reviewed. Randomised controlled trials comparing enteral nutrition diabetes specific formulas with standard formulas were included. The studies which compared diabetes specific formulas (DSF) with standard formulas showed that DSF was more effective in controlling glucose profiles including postprandial glucose, HbA1c and insulinemic response. The use of DSF appears to be effective in managing patients with diabetes on enteral feed compared with standard feed.

Hypoglycemia in Insulin-Treated Adults on Established Nasogastric Feeding in the General Ward: A Systematic Review

PURPOSE

This study aimed to address 2 questions: First, what are the existing summary statistics of frequency of hypoglycemia in insulin-treated adults on established nasogastric feeding in the general ward? Second, to what extent does lack of homogeneity in defining, identifying, and reporting hypoglycemia affect these statistics?

METHODS

A systematic review of the literature documenting hypoglycemia in insulin-treated adults on nasogastric feeding for ≥ 3 days in the general ward was carried out. Data sources were PubMed, Embase, ProQuest, Cochrane, Directory of Open Access Journals, and PLoS. Search period was 1999 onward, postdating introduction of analog insulin.

RESULTS

Initially, 231 studies were identified, with 9 judged suitable for inclusion, according to inclusion/exclusion criteria. All included studies had as their primary objective the assessment of efficacy of insulin/feed regimens in the target population. Studies exhibited major heterogeneity. Definitions of hypoglycemia varied from < 60 mg/dL (3.3 mmol/L) to < 80 mg/dL (4.4 mmol/L), and 5 methods of reporting frequency of hypoglycemia were utilized, precluding pooled analysis. A descriptive synthesis of results was generated with some comparable results presented on a modified forest plot, showing 2.1% to 10.2% of patients with a hypoglycemic event and 1.1% to 5.4% blood glucose level < 70 mg/dL (3.9 mmol/L).

CONCLUSIONS

Hypoglycemia is not uncommon in this population, but further research is needed for quantification. Standardized documentation and reporting methods incorporating sample size and study duration, such as hypoglycemic events per patient-days, would facilitate interstudy comparisons, as would documentation of hypoglycemia at the 2 most commonly defined levels: < 63 mg/dL (3.5 mmol/L) and < 70 mg/dL (3.9 mmol/L).

Liver but not adipose tissue is responsive to the pattern of enteral feeding

Nutritional support is an important aspect of medical care, providing calories to patients with compromised nutrient intake. Metabolism has a diurnal pattern, responding to the light cycle and food intake, which in turn can drive changes in liver and adipose tissue metabolism. In this study, we assessed the response of liver and white adipose tissue (WAT) to different feeding patterns under nutritional support (total enteral nutrition or TEN). Mice received continuous isocaloric TEN for 10 days or equal calories of chow once a day (Ch). TEN was given either at a constant (CN, same infusion rate during 24 h) or variable rate (VN, 80% of calories fed at night, 20% at day). Hepatic lipogenesis and carbohydrate-responsive element-binding protein (ChREBP) expression increased in parallel with the diurnal feeding pattern. Relative to Ch, both patterns of enteral feeding increased adiposity. This increase was not associated with enhanced lipogenic gene expression in WAT; moreover, lipogenesis was unaffected by the feeding pattern. Surprisingly, leptin and adiponectin expression increased. Moreover, nutritional support markedly increased hepatic and adipose FGF21 expression in CN and VN, despite being considered a fasting hormone. In summary, liver but not WAT, respond to the pattern of feeding. While hepatic lipid metabolism adapts to the pattern of nutrient availability, WAT does not. Moreover, sustained delivery of nutrients in an isocaloric diet can cause adiposity without the proinflammatory state observed in hypercaloric feeding. Thus, the liver but not adipose tissue is responsive to the pattern of feeding behavior.

Effects of low-carbohydrate/high-monounsaturated fatty acid liquid diets on diurnal glucose variability and insulin dose in type 2 diabetes patients on tube feeding who require insulin therapy

OBJECTIVE

A low-carbohydrate/high-monounsaturated fatty acid liquid diet (LC/HMD) was investigated for its role in long-term glycemic control in tube-fed type 2 diabetes patients who require insulin therapy.

PATIENTS AND METHODS

The study included 10 type 2 diabetes patients requiring insulin therapy who were being tube-fed with a high-carbohydrate liquid diet (HCD). With stable glucose control maintained, these patients were monitored for glucose levels for 4 consecutive days by using continuous glucose monitoring (CGM). The patients were continued on HCD during the first 2 days and were switched to an LC/HMD during the final 2 days. The patients were then continued on the LC/HMD, and seven of the 10 patients were monitored for glucose levels for 2 consecutive days by using CGM after 3 months of feeding with the LC/HMD. Insulin regimens used included basal-bolus insulin in five of these seven patients and intermediate-acting insulin in two patients.

RESULTS

Based on CGM data, the indices for glucose variability, such as SDs of 288 glucose levels for 24 h, total area for the range of glucose variability, mean amplitude of glycemic excursions, and 24-h mean glucose levels were significantly decreased 3 months after switching from the HCD to the LC/HMD. Additionally, despite the significant decrease in required insulin dose, the hemoglobin A1c (HbA1c) values were significantly decreased 3 months after switching.

CONCLUSIONS

Study results demonstrated that the LC/HMD not only narrowed the range of glucose variability, but also decreased the required insulin dose and HbA1c values in diabetes patients on tube feeding who required insulin therapy, suggesting the LC/HMD may be useful in long-term glycemic control in these patients.

Medical nutrition therapy in hospitalized patients with diabetes

Medical nutrition therapy (MNT) plays an important role in management of hyperglycemia in hospitalized patients with diabetes mellitus. The goals of inpatient MNT are to optimize glycemic control, to provide adequate calories to meet metabolic demands, and to create a discharge plan for follow-up care. All patients with and without diabetes should undergo nutrition assessment on admission with subsequent implementation of physiologically sound caloric support. The use of a consistent carbohydrate diabetes meal-planning system has been shown to be effective in facilitating glycemic control in hospitalized patients with diabetes. This system is based on the total amount of carbohydrate offered rather than on specific calorie content at each meal, which facilitates matching the prandial insulin dose to the amount of carbohydrate consumed. In this article, we discuss general guidelines for the implementation of appropriate MNT in hospitalized patients with diabetes.

Lower postprandial glucose responses at baseline and after 4 weeks use of a diabetes-specific formula in diabetes type 2 patients

AIMS

To determine whether lower postprandial glucose (PPG) levels after intake of a diabetes-specific formula (DSF) compared with a standard formula were maintained after 4 weeks use.

METHODS

Randomized, controlled, double-blind, parallel-group study. Forty-four type 2 diabetes patients on oral anti-diabetes medication consumed 2×200mL/day of a DSF (Diasip(®)) or an isocaloric standard, fiber-containing formula for 4 weeks. PPG responses were assessed at baseline and after 4 weeks by iAUC and (delta) peak glucose concentrations.

RESULTS

PPG response was significantly lower in the DSF group after first intake and remained significantly lower after 4 weeks use. Postprandial insulin, fasting glucose, insulin resistance, fructosamine and lipid levels did not differ between groups after 4 weeks. Within the standard group, fasting glucose and HOMA(IR) significantly increased over the intervention period. Changes in body weight between groups were significantly different, with an increase in the standard group. Both products were equally well tolerated.

CONCLUSIONS

Superior PPG control by DSF was maintained after 4 weeks use, showing that this formula has added value with respect to PPG control for type 2 diabetes patients compared to a standard, fiber-containing formula. The observed effects on body weight, fasting glucose and HOMA(IR) may further support the use of a DSF.