Does the supplementation of the formula with fibre increase the risk of gastro-oesophageal reflux during enteral nutrition? A human study

Food and Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is a chronic condition with a high prevalence in western countries. Transient lower esophageal sphincter relaxation episodes and a decreased lower esophageal sphincter pressure are the main mechanisms involved. Currently used drugs are efficient on reflux symptoms, but only as long as they are administered, because they do not modify the reflux barrier. Certain nutrients or foods are generally considered to increase the frequency of gastroesophageal reflux symptoms, therefore physicians recommend changes in diet and some patients avoid bothering foods. This review summarizes current knowledge regarding food and gastroesophageal reflux. For example, fat intake increases the perception of reflux symptoms. Regular coffee and chocolate induce gastroesophageal reflux and increase the lower esophageal exposure to acid. Spicy foods might induce heartburn, but the exact mechanism is not known. Beer and wine induce gastroesophageal reflux, mainly in the first hour after intake. For other foods, like fried food or carbonated beverages data on gastroesophageal reflux is scarce. Similarly, there are few data about the type of diet and gastroesophageal reflux. Mediterranean diet and a very low carbohydrate diet protect against reflux. Regarding diet-related practices, consistent data showed that a "short-meal-to-sleep interval" favors reflux episodes, therefore some authors recommend that dinner should be at least four hours before bedtime. All these recommendations should consider patient's weight, because several meta-analyses showed a positive association between increased body mass index and gastroesophageal reflux disease.

Prevalence of dental erosion among people with gastroesophageal reflux disease in China

STATEMENT OF PROBLEM

Gastroesophageal reflux disease (GERD) is typically diagnosed based on symptoms of regurgitation and heartburn, although it may also manifest as asthma-like symptoms, laryngitis, or dental erosion.

PURPOSE

The purpose of this prospective, cross-sectional study was to assess the prevalence of dental erosion in people with GERD and to evaluate the association between GERD and dental erosion.

MATERIAL AND METHODS

The presence, severity, and pattern of dental erosion was assessed in 51 participants with GERD and 50 participants without GERD using the Smith and Knight tooth wear index. Medical, dietary, and dental histories were collected by questionnaire. Factors potentially related to dental erosion, including GERD, were evaluated by logistic regression.

RESULTS

Dental erosion was observed in 31 (60.8%) participants with GERD and 14 (28%) participants without GERD. Bivariate analysis revealed that participants with GERD were more likely to experience dental erosion (crude odds ratio [cOR]: 2.74; 95% CI: 1.19, 6.32) than participants without GERD. Multivariate analysis also revealed that participants with GERD had a higher risk of dental erosion (adjusted odds ratio [aOR]: 3.97; 95% CI: 1.45, 10.89). Consumption of grains and legumes, the most frequently consumed foods in China, did not correlate with dental erosion. However, carbonated beverage consumption was significantly associated with GERD and dental erosion (aOR: 3.34; 95% CI: 1.01, 11.04; P=.04).

CONCLUSIONS

GERD was positively correlated with dental erosion. Carbonated beverage consumption can increase the risk of both GERD and dental erosion.

Gastric residual volume in critically ill patients: a dead marker or still alive?

Early enteral nutrition (EN) is consistently recommended as first-line nutrition therapy in critically ill patients since it favorably alters outcome, providing both nutrition and nonnutrition benefits. However, critically ill patients receiving mechanical ventilation are at risk for regurgitation, pulmonary aspiration, and eventually ventilator-associated pneumonia (VAP). EN may increase these risks when gastrointestinal (GI) dysfunction is present. Gastric residual volume (GRV) is considered a surrogate parameter of GI dysfunction during the progression of enteral feeding in the early phase of critical illness and beyond. By monitoring GRV, clinicians may detect patients with delayed gastric emptying earlier and intervene with strategies that minimize or prevent VAP as one of the major risks of EN. The value of periodic GRV measurements with regard to risk reduction of VAP incidence has frequently been questioned in the past years. Increasing the GRV threshold before interrupting gastric feeding results in marginal increases in EN delivery. More recently, a large randomized clinical trial revealed that abandoning GRV monitoring did not negatively affect clinical outcomes (including VAP) in mechanically ventilated patients. The results have revived the discussion on the role of GRV monitoring in critically ill, mechanically ventilated patients receiving early EN. This review summarizes the most recent clinical evidence on the use of GRV monitoring in critically ill patients. Based on the clinical evidence, it discusses the pros and cons and further addresses whether GRV is a dead marker or still alive for the nutrition management of critically ill patients.

Dietary intake and risk for reflux esophagitis: a case-control study

Background. Specific dietary components have been associated with gastroesophageal reflux disease (GERD) in Europe and the United States. However, the relationship between dietary components and GERD in Chinese still remains unclear. Methods. A total of 268 patients who were newly diagnosed as reflux esophagitis (RE) in Outpatient Endoscopy Center of Tongji Hospital were recruited. In addition, 269 sex- and age-matched subjects were also recruited as controls. The body measurements were determined, and the dietary intake during the previous year was evaluated using food frequency questionnaire (FFQ). Stepwise multiple logistic regression analysis was performed to examine the association between nutrients and RE. Results. After adjustment for WC, WHR, total energy intake, and demographics, there were a positive dose-response relationship between RE and calcium, meat, oils, and salt and a negative dose-response relationship between RE and protein, carbohydrate, calories from protein (%), vitamin C, grains and potatoes, fruits, and eggs. Conclusion. High intake of meat, oils, salt, and calcium is associated with an increased risk for RE while high intake of protein, carbohydrate, calories from protein (%), vitamin C, grains and potatoes, fruits, and eggs correlates with a reduced risk for RE.

Characterization of soy polysaccharide and its in vitro and in vivo evaluation for application in colon drug delivery

The objective of the present investigation was to establish potential of commercially available soy polysaccharide (Emcosoy®) for colon drug delivery. The soy polysaccharide-ethyl cellulose films were fabricated and characterized. The effect of the pectinase enzyme on the tensile strength and surface morphology of the film was evaluated. The permeation of chlorpheniramine maleate (CPM), a model hydrophilic drug from pectinase enzyme treated and untreated films was measured in pH 7.4 buffer. The soy polysaccharide-ethyl cellulose films were also incubated with Lactobacillus sp. culture for a specific duration, and effect on the CPM permeation was evaluated. The CPM capsules were coated with the soy polysaccharide-ethyl cellulose mixture, and Eudragit S100 was applied as a secondary coat. The coated CPM capsules were radiolabelled, and their in vivo transit was evaluated in human volunteers on oral administration. The pectinase enzyme had a significant influence on the tensile strength and surface morphology of the soy polysaccharide-ethyl cellulose films. The permeability of pectinase enzyme-treated and Lactobacillus sp.-treated films was significantly higher than that of untreated films. The CPM capsules were coated with the soy polysaccharide-ethyl cellulose mixture and Eudragit S100 and were successfully radiolabelled by a simple method. Gamma scintigraphic studies in human volunteers showed that the radiolabelled capsules maintained integrity for at least 9 h after oral administration. Thus, the soy polysaccharide has a potential in colon drug delivery.

The soluble fiber NUTRIOSE induces a dose-dependent beneficial impact on satiety over time in humans

Strong evidence supports the ability of dietary fibers to improve satiety. However, large variations in the physical and chemical characteristics of dietary fiber modulate the physiologic responses. We hypothesized that a nonviscous soluble dietary fiber may influence satiety. This randomized, double-blind, placebo-controlled clinical study in 100 overweight healthy adults in China investigated the effect of different dosages of dietary supplementation with a dextrin, NUTRIOSE (ROQUETTE frères, Lestrem, France), on short-term satiety over time. Subjects were randomized by body mass index and energy intake and then assigned to receive either placebo or 8, 14, 18, or 24 g/d of NUTRIOSE mixed with orange juice (n = 20 volunteers per group). On days -2, 0, 2, 5, 7, 14, and 21, short-term satiety was evaluated with a visual analog scale, and hunger feeling status was assessed with Likert scale. NUTRIOSE exhibits a progressive and significant impact on short-term satiety, which is time and dosage correlated. Some statistical differences appear for the group 8 g/d from day 5, and from day 0 for the groups 14, 18, and 24 g/d. The hunger feeling status decreases significantly from day 5 to the end of the evaluation for the group 24 g and from day 7 for the groups 14 and 18 g. By day 5, the group 24 g showed significantly longer time to hunger between meals compared with placebo. These results suggest that dietary supplementation with a soluble fiber can decrease hunger feeling and increase short-term satiety over time when added to a beverage from 8 to 24 g/d with time- and dose-responses relationship.

Effects of ondansetron on gastric tone and motility changes induced by a prolonged intraduodenal infusion of nutrients. Results of a placebo-controlled study

Our aim was to study the 5-HT3 antagonist, ondansetron, on gastric motility changes induced by duodenal infusion of nutrients. First, the effects of a 2-hr intraduodenal infusion (IDI) of a caloric diet on antral motility were assessed. Second, a crossed-over placebo-controlled study assessed 3-day oral intake of ondansetron (8 mg bid) on gastric motility changes induced by the IDI. During the IDI, antral numbers of waves (NW) as area under curve (AUC) were lower than fasting values. After infusion, antral NW and AUC increased to return to basal values. The antral area increased slightly shortly after the start of the IDI, then remained stable. When subjects received ondansetron, the only significant motor effect was a higher antral NW and AUC during the first 30 min of the IDI (P < 0.05). After the end of the IDI, the AUC and NW increased in both the distal and the proximal antrum. The increase was lower by ondansetron in the proximal antrum. Proximal stomach relaxation induced was not influenced by ondansetron. In conclusion, an IDI of nutrients decreased antral motility, increased the antral area, and promoted fundic relaxation. This inhibitory effect was rapidly reversible. Ondansetron induced only minor motility changes in the antrum and had no effect on fundic relaxation promoted by IDI.

Synbiotics, prebiotics, glutamine, or peptide in early enteral nutrition: a randomized study in trauma patients

BACKGROUND

Since the hepatosplanchnic region plays a central role in development of multiple-organ failure and infections in critically ill trauma patients, this study focuses on the influence of glutamine, peptide, and synbiotics on intestinal permeability and clinical outcome.

METHODS

One hundred thirteen multiple injured patients were prospectively randomized into 4 groups: group A, glutamine; B, fermentable fiber; C, peptide diet; and D, standard enteral formula with fibers combined with Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden), a formula containing live lactobacilli and specific bioactive fibers. Intestinal permeability was evaluated by measuring lactulose-mannitol excretion ratio on days 2, 4, and 7.

RESULTS

No differences in days of mechanical ventilation, intensive care unit stay, or multiple-organ failure scores were found between the patient groups. A total of 51 infections, including 38 pneumonia, were observed, with only 5 infections and 4 pneumonias in group D, which was significantly less than combined infections (p = .003) and pneumonias (p = .03) in groups A, B, and C. Intestinal permeability decreased only in group D, from 0.148 (0.056-0.240) on day 4 to 0.061 (0.040-0.099) on day 7; (p < .05). In group A, the lactulose-mannitol excretion ratio increased significantly (p < .02) from 0.050 (0.013-0.116) on day 2 to 0.159 (0.088-0.311) on day 7. The total gastric retention volume in 7 days was 1150 (785-2395) mL in group D, which was significantly more than the 410 (382-1062) mL in group A (p < .02), and 620 (337-1190) mL in group C (p < .03).

CONCLUSIONS

Patients supplemented with synbiotics did better than the others, with lower intestinal permeability and fewer infections.

Effects of intragastric L-arginine administration on proximal stomach tone under basal conditions and after an intragastric diet

Nitric oxide (NO) plays an important role as a nonadrenergic, noncholinergic inhibitory neurotransmitter in the GI tract. Our study aims were to investigate the effect of a single intragastric L-arginine (L-Arg) administration, as a source of NO, on proximal stomach tone in basal and postintragastric administration of a polymeric diet in humans and to evaluate concomitantly the effect on antral area as an indirect assessment of gastric emptying. Eight healthy volunteers were studied in a randomized double-blind crossover study after, respectively, 15 g L-Arg, 30 g L-Arg, or placebo administered in the stomach through a gastric tube. The drug administration was followed by a polymeric diet infusion (500 ml/500 kcal) at a rate of 250 ml/hr. Gastric tone variations were recorded with an electronic barostat, gastric emptying was concomitantly estimated by repeated ultrasound measurements of antral area, and symptoms were recorded throughout the experiment.L-Arg administration was associated with significantly higher increases in barostat bag volumes at both dosages, 30 g (117+/-16 ml) and 15 g (67+/-15 ml), compared to placebo (46+/-11 ml; P < 0.05). In response to the polymeric diet the 30-g L-Arg challenge was associated with a smaller increase in intrabag volume, whereas postinfusion final volumes did not differ in the three treatment conditions. Antral areas were not different at any time of measurement among the three challenges. Bloating and diarrhea were observed after 30-g L-Arg administration in five subjects of eight. Short-term L-Arg administration was able to induce proximal stomach relaxation that allowed a secondary response to enteral feeding only at the 15-g dosage. This 15-g dosage was as well tolerated as the placebo and was associated with no significant changes in gastric emptying patterns.

Appetite during consumption of enteral formula as a sole source of nutrition: the effect of supplementing pea-fibre and fructo-oligosaccharides

Liquid enteral formulas are commonly used as a sole source of nutritional support of patients in hospital and community settings. Their effect on appetite has important consequences for dietary management of such patients and is likely to be affected by the formula composition. The aim of the present study was to compare appetite within healthy subjects consuming both a standard formula and one supplemented with pea-fibre (10 g/l) and fructo-oligosaccharide (FOS; 5 g/l) as a sole source of nutrition. Eleven healthy subjects consumed a standard formula or a pea-fibre/FOS formula as a sole source of nutrition for 14 d in a double-blind, cross-over trial. Appetite was recorded using standard 100 mm lines anchored at each end by a phrase denoting the most extreme appetite sensation. Consumption of the pea-fibre/FOS formula resulted in higher mean fullness (46 v. 37 mm, P=0.035), minimum fullness (13 v. 9 mm, P=0.024) and minimum satiety (12 v. 8 mm, P=0.012) compared to the standard formula. As there were no differences in macronutrient intake between formulas, these differences are likely to be due to supplementation with pea-fibre and FOS. The effect on appetite of the composition of an enteral formula, both with respect to nutrient content and functional components such as pea-fibre and FOS, may be an important aspect to consider in the dietary management of patients consuming enteral formula as a sole source of nutrition.

Fructooligosaccharides and fiber partially prevent the alterations in fecal microbiota and short-chain fatty acid concentrations caused by standard enteral formula in healthy humans

The intestinal microbiota are important during enteral tube feeding because they exert colonization resistance and produce SCFAs. However, the effect of the enteral formula composition on major bacterial groups of the microbiota has not been clearly defined. The aim of this study was to investigate the effect of enteral formulas with and without prebiotic fructooligosaccharides (FOS) and fiber on the fecal microbiota and SCFAs. Healthy subjects (n = 10; 4 men, 6 women) consumed both a standard enteral formula and one containing FOS (5.1 g/L) and fiber (8.9 g/L) as a sole source of nutrition for 14 d in a randomized, double-blind, crossover trial with a 6-wk washout phase. Fecal samples were collected at the start and end of each formula phase, and were analyzed for major bacterial groups and SCFA concentrations using fluorescent in situ hybridization and GLC, respectively. Although there were reductions in total fecal bacteria due to both formula treatments, concentrations were higher after the FOS/fiber formula period compared with the standard formula period (11.2 +/- 0.2 vs. 11.0 +/- 0.2 log(10) cells/g, P = 0.005). The FOS/fiber formula increased bifidobacteria (P = 0.004) and reduced clostridia (P = 0.006). Compared with the standard formula, the FOS/fiber formula resulted in higher concentrations of total SCFA (332.4 +/- 133.8 vs. 220.1 +/- 124.5 micromol/g, P = 0.022), acetate (219.6 +/- 96.3 vs. 136.8 +/- 74.5 micromol/g, P = 0.034) and propionate (58.4 +/- 37.4 vs. 35.6 +/- 25.5 micromol/g, P = 0.02). This study demonstrates that standard enteral formula leads to adverse alterations to the fecal microbiota and SCFA concentrations in healthy subjects, and these alterations are partially prevented by fortification of the formula with FOS and fiber.

Application of dietary fiber in clinical enteral nutrition: A meta-analysis of randomized controlled trials

AIM: To evaluate the effects of dietary fiber (DF) as a part of enteral nutrition (EN) formula on diarrhea, infection, and length of hospital stay.

METHODS: Following electronic databases were searched for randomized controlled trials about DF: Chinese Biomedicine Database (CBM), MEDLINE, EMBASE and Cochrane Controlled Trials Register. RevMan 4.1 was used for statistical analysis.

RESULTS: Seven randomized controlled trials with 400 pat-ients were included. The supplement of DF in EN was compared with standard enteral formula in five trials. Combined analysis did not show a significant reduction in occurrence of diarrhea, but there were valuable results for non-critically ill patients. Combined analysis of two trials observing the infection also did not show any valid evidence that DF could decrease the infection rate, though the length of hospital stay was reduced significantly.

CONCLUSION: Based on the current eligible randomized controlled trials, there is no evidence that the value of DF in the diarrhea can be proved. Though length of hospital stay was shortened by the use of DF, there is no available evidence in preventing infection by DF. Further studies are needed for evaluating the value of DF in EN.

Nutrition and the chronically critically ill patient

PURPOSE OF REVIEW

It has been recently recognized that patients of chronic critical illness (CCI) - those who have stabilized after an acute critical illness but remain dependent on life-support - manifest a distinct set of clinical attributes. This unique patient population is often dismissed as hopeless, with aggressive medical therapies considered futile. In fact, with meticulous care, many CCI patients can be liberated from mechanical ventilation and graduated to a rehabilitation program. The nutritional approach to CCI patients is presented here as part of a comprehensive metabolic program to increase their survival and quality of life.

RECENT FINDINGS

Both theory-driven and data-driven advances to our knowledge of CCI syndrome have appeared in the literature over the past year. Recurrent activation of the immune-neuroendocrine axis may induce allostatic overload in CCI. Experimental studies with hypothalamic releasing factors and intensive insulin therapy demonstrate that mechanisms perpetuating the CCI state can be abrogated. Recent studies and consensus opinions support the use of aggressive nutrition support.

SUMMARY

Nutritional assessment and support of the CCI patient must be implemented upon admission to the respiratory care unit (RCU). Enteral nutrition (EN) with semi-elemental formulas is preferred. Parenteral nutrition is used to supplement EN when necessary. Overfeeding is avoided and tight glycemic control maintained. Diarrhea is aggressively managed. By correcting proximal etiologic events (infection, inflammatory, injuries), avoiding iatrogenic complications and devoting careful attention to nutritional status, CCI patients can potentially overcome their pulmonary compromise and debilitated state, to fully recover.