Slowly digestible carbohydrate sources can be used to attenuate the postprandial glycemic response to the ingestion of diabetes-specific enteral formulas

Enhanced hypoglycemic effects of konjac glucomannan combined with Polygonatum cyrtonema Hua polysaccharide in complete nutritional liquid diet fed type 2 diabetes mice

In our aging society, dysphagia and malnutrition are growing concerns, necessitating intervention. Liquid nutrition support offers a practical solution for traditional dietary issues, but it raises a key issue: the potential for post-meal glucose spikes impacting efficacy. This study examined the effects of supplementation of Polygonatum cyrtonema Hua polysaccharide (PCP), konjac glucomannan (KGM) and their combination on acute phase postprandial glycemic response and long-term glucose metabolism in T2DM mice on a complete nutritional liquid diet. KGM was more effective in reducing postprandial glucose response, while PCP was more prominent in ameliorating long-term glucose metabolism. The KGM-PCP combination demonstrated superior outcomes in fasting blood glucose, insulin, and glucose homeostasis. PCP and KGM also influenced the composition and abundance of the gut microbiome, with the H-PCP group showing optimal performance. Moreover, the KGM-PCP combination improved body weight, lipid homeostasis, and liver health the most. PCP potentially regulates glycemia through metabolic pathways, while KGM improves glycemic metabolism by reducing postprandial glucose levels in response to viscous intestinal contents. This research identifies the structure, viscosity properties, and hypoglycemic effects of KGM and PCP in complete nutritional liquid diet fed T2DM mice, enabling their strategic utilization as hypoglycemic components in nutritional administration and glycemic regulation.

Designing blenderized tube feeding diets for children and investigating their physicochemical and microbial properties and Dietary Inflammatory Index

BACKGROUND

Due to the benefits of blenderized tube feeding (BTF) diets, the interest in using them is increasing. This study aimed to design BTFs for children and investigate their physicochemical and microbial properties, as well as Dietary Inflammatory Index (DII).

METHODS

Five BTF diets were formulated mainly with fresh foods; their DII, physical (viscosity), and chemical (moisture, ash, protein, fat, energy, and micronutrients) characteristics were assessed. Also, the Hazard Analysis and Critical Control Points (HACCP) system was implemented for quality assurance of preparation, storage, and delivery of BTFs to patients in hospital. The microbial contamination (total count, Salmonella, Escherichia coli, Bacillus cereus, Listeria monocytogenes, coliforms, Staphylococcus aureus coagulase positive, mold, and yeast) was analyzed.

RESULTS

Energy and percentages of protein, fat, and carbohydrate in BTFs were in the range of 103-112 kcal/100 ml, 16%-22%, 28%-34%, and 48%-52%, respectively. The viscosity of the five developed BTFs was between 29 and 64 centipoises, which allows the formulas to flow without syringe pressure. The DII of all BTFs was between -0.73 and -2.24. Due to the implementation of HACCP, monitoring the production line of BTFs, and performance of corrective measures, no microbial contamination was observed by indicator pathogenic microorganisms.

CONCLUSION

A planned BTF diet can be an excellent selection for children using enteral nutrition with tube feeding especially when they are made from fresh and anti-inflammatory foods such as recipes prepared in this study.

Randomized clinical trial to evaluate the effect on postprandial glycemia of Nutren Control®, a glycemia-targeted specialized supplement, compared to standardized breakfast in patients with type-2 diabetes: the CONTROL DIABETES study

Introduction

Objective: to evaluate the effects of a new glycemia targeted specialized supplement (GTSS) compared to a standard breakfast on postprandial blood glucose (PPG). Methods: patients with type 2 diabetes (T2D) and suboptimal control (A1C between 6.5 and 8.5 %) in monotherapy with metformin were included to this prospective, randomized, crossover trial. The standardized breakfast was isoenergetic compared to the GTSS, differing on macronutrients distribution. Both interventions were used once a day in the morning, each replacing breakfast for 7 consecutive days (14 days of observation). Intermittent scanning continuous glucose monitoring system (isCGM) determined the difference between the interventions regarding the incremental area under the curve (iAUC) of the PPG (3 hours after intervention), as a primary endpoint; secondary endpoints were the difference between the interventions regarding the glycemic peak, postprandial glucose excursion (PPGE), mean blood glucose (MBG) and time in range (TIR). Results: thirty-one T2D patients with ages between 39 and 69 years-old were enrolled. GTSS group had significantly lower iAUC of the PPG compared to standardized breakfast (33.3 [15.0 to 54.0] vs 46.8 [27.3 to 75.1] mg/dL), while also presenting a significantly lower PPG excursion (26.4 ± 17.2 vs 44.8 ± 24.4 mg/dL). There was no difference between the intervention periods regarding MBG, TIR and hypoglycemic events. Conclusion: The new GTSS, as a meal replacement in the breakfast, produced a 25 % reduction in the iAUC of the PPG, as accessed by isCGM, in comparison with an isocaloric-standardized meal.

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.

Postprandial effects of a whey protein-based multi-ingredient nutritional drink compared with a normal breakfast on glucose, insulin, and active GLP-1 response among type 2 diabetic subjects: a crossover randomised controlled trial

Postprandial hyperglycaemia is recognised as an important target in type 2 diabetes management. Dietary pattern, meal composition, and amount of food intake are major factors for maintaining postprandial blood glucose levels. The aim of this study was to investigate the effect of consuming a whey protein-based multi-ingredient nutritional drink (WD) on postprandial glycaemic, insulinaemic, and active glucagon-like peptide-1 (GLP-1) responses in comparison to a typical breakfast, which is boiled white rice with chicken (BC) in patients with type 2 diabetes mellitus (T2DM). Fifteen subjects with T2DM participated in a randomised, controlled, cross-over study. Two isocaloric diets with similar nutrient composition were randomly tested with at least 7 d in between. Glucose, insulin, and active GLP-1 were measured by standard methods with blood samples collected with a venous catheter for 240 min during a kinetic test. The incremental area under the curve (iAUC_{0–240 min}) for plasma glucose was significantly lower after the consumption of WD (WD: 3551 ± 546; BC: 9610 ± 848 mg min/dl; P < 0⋅01), while insulinaemic response tended to be lesser (iAUC_{0–240 min}) than those of BC. In addition, higher iAUC_{0–240 min} for active GLP-1 was obtained with WD diet (WD: 2230 ± 441; BC: 925 ± 183 pM min/ml; P < 0⋅01). This study showed that WD can be used to replace a regular breakfast for improving postprandial glucose response and active GLP-1 levels in people with T2DM. Further studies are required to elucidate the clinical efficacy of WD on long-term glycaemic control in people with T2DM.

Influence of type of starch and feeding management on glycaemic control in diabetic dogs

The present study evaluated the effects of two diets with different starch sources and two feeding methods on the glycaemic control in dogs with diabetes mellitus. The diets had similar nutrient contents (40% starch and 16% dietary fibre), one formulated with 46% of broken rice and the other with 42% sorghum and 10% lentils (as-fed). Ten client-owned diabetic dogs were fed with each diet for 2 months, in a crossover design. Five dogs received NPH human insulin and food every 12 h (feeding method 1), and the other five received insulin every 12 h but were fed three times a day (feeding method 2). In feeding method 2, morning insulin was higher than the evening dose and dogs received the second meal after 4 to 5 h of the morning insulin and meal. Parameters evaluated included insulin dosage, 12- and 8-h glycaemic curves, complete blood count, biochemical profile and urinalysis. Glycaemic curves were analysed by ANOVA with repeated measures. Glycaemic control parameters (fasting, mean, minimum and maximum glycaemia and serum fructosamine) and glucose area under the curve (AUC) were calculated and analysed by paired t test (p < 0.05). In feeding method 1, dogs fed the sorghum-based diet presented lower mean (p = 0.04) and minimum blood glucose concentrations (p = 0.03), and a tendency to lower maximum blood glucose (p = 0.06) and glucose AUC (p = 0.08) than when fed the rice-based diet. When food was provided twice a day, the ingestion of the rice-based diet resulted in higher post-prandial glucose response than the diet with sorghum and lentil. In feeding method 2, there was no effect of diet on the assessed parameters (p > 0.05). No differences in insulin dosage were observed between groups or feeding methods (p > 0.05). Providing two meals a day followed by insulin administration associated with the sorghum- and lentil-based diet improved glycaemic control in diabetic dogs.

An Innovative Short-Clustered Maltodextrin as Starch Substitute for Ameliorating Postprandial Glucose Homeostasis

Dietary starch is usually associated with elevated postprandial glycemic response. This is a potential risk factor of type 2 diabetes. Here, a 1,4-α-glucan branching enzyme (GBE) was employed to reassemble α-1,4 and α-1,6 glycosidic bonds in starch molecules. Structural characterization showed that GBE-catalyzed molecular reassembly created an innovative short-clustered maltodextrin (SCMD), which showed a dense internal framework along with shortened external chains. Such short-clustered molecules obstructed digestive enzymes attack and displayed dramatically reduced digestibility. Therefore, SCMD was served as a dietary starch substitute to improve postprandial glucose homeostasis. A 22.3% decrease in glycemic peak was therefore detected in ICR mice following SCMD intake (10.7 mmol/L), compared with that in the control (13.8 mmol/L). Moreover, an attenuated insulin response (40.5% lower than that in control) to SCMD intake was regarded suitable for diabetes management. These novel discoveries demonstrate that enzymatically rebuilding starch molecules may be a meaningful strategy for diabetes management.

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.

Health Outcomes and Quality of Life Indices of Children Receiving Blenderized Feeds via Enteral Tube

OBJECTIVE

To determine whether clinical and patient-reported outcomes differ in children receiving blenderized diets compared with conventional formula.

STUDY DESIGN

We conducted a prospective cohort study of 70 children aged 1-18 years receiving blenderized diets vs conventional formula via feeding tube. We assessed rates of hospitalization and visits to the emergency department (ED) at Boston Children's Hospital in 2017 and Likert scale addressing satisfaction with feeding regimen; Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire; Pediatric Quality of Life Inventory; and Pediatric Quality of Life Inventory Gastrointestinal Symptoms Scale.

RESULTS

Participants receiving blenderized diets (n = 42, 60%) did not differ in demographics or comorbid diagnoses from those receiving conventional formula (n = 28, 40%). Rates of total visits to the ED (0.8 ± 1.5 vs 1.4 ± 2.7, P = .05), total admissions (0.8 ± 1.2 vs 1.7 ± 2.3, P = .01), and respiratory-related admissions (0.2 ± 0.5 vs 0.6 ± 0.8, P = .04) per year were significantly lower in participants receiving blenderized diets, and respiratory-related visits to the ED trended toward significance (0.1 ± 0.4 vs 0.4 ± 0.8, P = .08). Compared with those receiving conventional formula, participants on blenderized diets reported greater satisfaction ratings (Likert scale 4.3 ± 1.0 vs 3.3 ± 1.2, P = .001), lower symptom (0.7 ± 0.8 vs 1.2 ± 1.1, P = .03), and total (0.8 ± 0.8 vs 1.2 ± 1.0, P = .02) scores on Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire and greater scores on the Pediatric Quality of Life Inventory Gastrointestinal Symptoms Scale, indicating less nausea and vomiting (64.0 ± 22.6 vs 49.0 ± 37.9, P = .02), abdominal pain (65.0 ± 26.8 vs 56.4 ± 33.9, P = .04), diarrhea (87.9 ± 15.5 vs 73.6 ± 26.3, P = .004), and fewer total symptoms (70.2 ± 16.3 vs 62.3 ± 19.6, P = .03).

CONCLUSIONS

Blenderized diets are associated with decreased healthcare use, improved symptom scores, and increased patient satisfaction compared with conventional formulas.

Glycemic Index of Slowly Digestible Carbohydrate Alone and in Powdered Drink-Mix

Consumer interest in food and beverages with carbohydrates offering steady glucose release and lower glycemic index (GI) continues to rise. Glycemic index is one of the metrics for carbohydrate quality. Slowly digestible carbohydrates (SDC) offer an ingredient solution to improve carbohydrate quality and meet consumer needs. SUSTRA^TM 2434 slowly digestible carbohydrate is a blend of tapioca flour and corn starch. The study objective was to determine the glycemic index of the SDC ingredient alone and in a powdered drink-mix. In a randomized, single-blind study, heathy adults (n = 14) consumed four test drinks, delivering 50 g available carbohydrates on separate days to measure GI. Participants either consumed dextrose in water (placebo), SDC ingredient in water, SDC drink-mix powder reconstituted in skim milk, or control drink-mix reconstituted in skim milk (without SDC). Post-prandial glucose response was measured over 4 h. SDC exhibited lower GI (0–2 h) and higher steady glucose release (beyond 2 h). SDC alone (GI = 27) and SDC in drink-mix (GI = 30.3) showed significantly lower GI (−27%) compared to dextrose (100) and the control drink-mix (41.5). SUSTRA^TM 2434 SDC is a low glycemic ingredient, suitable for product innovations with potential for low glycemic and steady glucose release claims.

Synthesis of novel α-glucans with potential health benefits through controlled glucose release in the human gastrointestinal tract

The glycemic carbohydrates we consume are currently viewed in an unfavorable light in both the consumer and medical research worlds. In significant part, these carbohydrates, mainly starch and sucrose, are looked upon negatively due to their rapid and abrupt glucose delivery to the body which causes a high glycemic response. However, dietary carbohydrates which are digested and release glucose in a slow manner are recognized as providing health benefits. Slow digestion of glycemic carbohydrates can be caused by several factors, including food matrix effect which impedes α-amylase access to substrate, or partial inhibition by plant secondary metabolites such as phenolic compounds. Differences in digestion rate of these carbohydrates may also be due to their specific structures (e.g. variations in degree of branching and/or glycosidic linkages present). In recent years, much has been learned about the synthesis and digestion kinetics of novel α-glucans (i.e. small oligosaccharides or larger polysaccharides based on glucose units linked in different positions by α-bonds). It is the synthesis and digestion of such structures that is the subject of this review.

Effects of pea with barley and less-processed maize on glycaemic control in diabetic dogs

The source of starch may interfere with glycaemic control in dogs, but few studies have evaluated these aspects in diabetic dogs. This study compared the effects of two isonutrient diets with different starch sources, peas and barley (PB) v. maize (Mi), on diabetic dogs. The Mi diet was processed in order to generate a lower starch gelatinisation index. In all, fifteen adult diabetic dogs without other conditions were included. The animals were fed two dry extruded rations with moderate levels of fat and starch and high levels of protein and fibre using a random, double-blind cross-over design. Glycaemic curves over 48 h were developed via continuous glucose monitoring after 60 d on each diet and with the same neutral protamine Hagedorn (NPH) insulin dosage. The following were compared: fasting, mean, maximum and minimum blood glucose, maximum and minimum glycaemia difference, glycaemic increment, area under the glycaemic curve, area under the glycaemic increment curve and serum fructosamine concentration. Paired t tests or Wilcoxon signed-rank tests were used to compare the amount of food and nutrients ingested and the dietary effects on glycaemic variables between the diets. Dogs fed the PB diet presented a lower average mean interstitial glucose (P=0·01), longer mean hypoglycaemic time (P<0·01), shorter mean hyperglycaemic time (P<0·01) and smaller difference between maximum and minimum blood glucose levels (P=0·03). Thus, the processing applied to the Mi diet was not sufficient to achieve the same effects of PB on glycaemic control in diabetic dogs.

Slowly Digestible Carbohydrate for Balanced Energy: In Vitro and In Vivo Evidence

There is growing interest among consumers in foods for sustained energy management, and an increasing number of ingredients are emerging to address this demand. The SUSTRA™ 2434 slowly digestible carbohydrate is a blend of tapioca flour and corn starch, with the potential to provide balanced energy after a meal. The aim of the study was to characterize this starch’s digestion profile in vitro (modified Englyst assay) and in vivo (intact and cecectomized rooster study), and to determine its effects on available energy, by measuring post-prandial glycemia in healthy adults (n = 14), in a randomized, double-blind, placebo-controlled, cross-over study, with two food forms: cold-pressed bar and pudding. The in vitro starch digestion yielded a high slowly digestible fraction (51%) compared to maltodextrin (9%). In the rooster digestibility model, the starch was highly digestible (94%). Consumption of slowly digestible starch (SDS), in an instant pudding or bar, yielded a significantly lower glycemic index compared to a control. At individual time points, the SDS bar and pudding yielded blood glucose levels with significantly lower values at 30–60 min and significantly higher values at 120–240 min, demonstrating a balanced energy release. This is the first study to comprehensively characterize the physiological responses to slowly digestible starch (tapioca and corn blend) in in vitro and in vivo studies.

Glycaemic response after intake of a high energy, high protein, diabetes-specific formula in older malnourished or at risk of malnutrition type 2 diabetes patients

BACKGROUND & AIMS

Several studies with diabetes-specific formulas (DSFs) for hyperglycaemic patients in need of nutritional support have been conducted in non-malnourished patients, mainly comparing products with varying macronutrient compositions. Here, the effect of a high energy, high protein DSF on postprandial responses was compared to a product with a similar macronutrient composition in malnourished or at risk of malnutrition patients with type 2 diabetes.

METHODS

In this randomised, double-blind cross-over study, 20 patients were included. After overnight fasting, patients consumed 200 mL of a DSF or standard supplement (control) (19.6 g protein, 31.2 g carbohydrates and 10.6 g fat), while continuing their anti-diabetic medication. The formulas differed in type of carbohydrates and presence of fibre. The postprandial glucose, insulin and glucagon responses were monitored over 4 h. Data were analysed with a Linear Mixed Model, and results of the modified ITT population (n = 19) are shown.

RESULTS

Postprandial glucose response as incremental area under the curve (iAUC), was lower after consumption of DSF compared with control (489.7 ± 268.5 (mean ± SD) vs 581.3 ± 273.9 mmol/L min, respectively; p = 0.008). Also, the incremental maximum concentration of glucose (iCmax) was lower for DSF vs control (3.5 ± 1.4 vs 4.0 ± 1.4 mmol/L; p = 0.007). Postprandial insulin and glucagon levels, expressed as iAUC or iCmax, were not significantly different between groups.

CONCLUSIONS

Consumption of a high energy, high protein DSF by older malnourished or at risk of malnutrition type 2 diabetes patients resulted in a significantly lower glucose response compared to control. These data suggest that the use of a DSF is preferred for patients with diabetes in need of nutritional support.

Nutrition in Diabetes

Medical nutrition therapy (MNT) is a key component of diabetes management. The importance of balancing macronutrients, reducing carbohydrate load, lowering glycemic index, and implementing an overall healthy dietary pattern are emerging as better approaches for MNT in diabetes. Recent research points to improved glycemic control, reduction in body weight, and improvement in many cardiovascular risk factors when these approaches are provided by registered dietitians or health care providers. This review article discusses the current evidence about the role of sensible nutrition in diabetes management. Specific eating plans for weight reduction and for patients with type 1 diabetes are also discussed.

Glycemic control in a medical intensive care setting: revision of an intensive care unit nurse-driven hyperglycemia protocol

The purpose of this study was to determine whether the addition of rapid-acting insulin bolus for enteral feed coverage and a reduction in basal insulin improve glycemic control and decrease hypoglycemia in a medical intensive care unit. A quasi-experimental posttest design assessing glucose control postimplementation of a revised nurse-driven ICU hyperglycemia protocol was conducted on a 16-bed medical intensive care unit at a multicenter hospital system. A daily report of all patients on the ICU hyperglycemia protocol was automated for the inpatient diabetes management team, and pertinent data were collected. Univariate statistics were conducted for all variables. The variability in blood glucose based on different clinical variables was compared using t tests. The hypoglycemic rate was only 0.72%, and no glucose value was less than 40 mg/dL. In addition, the mean glucose value throughout the study was 160.9 ± 35.6 mg/dL. Findings from this study will hopefully provide insight on an effective way to control glucose within a medical intensive care unit as well as reduce hypoglycemia rates within this setting.

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).

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.

Nutrition of the critically ill &#8212; a 21st-century perspective

Health care-induced diseases constitute a fast-increasing problem. Just one type of these health care-associated infections (HCAI) constitutes the fourth leading cause of death in Western countries. About 25 million individuals worldwide are estimated each year to undergo major surgery, of which approximately 3 million will never return home from the hospital. Furthermore, the quality of life is reported to be significantly impaired for the rest of the lives of those who, during their hospital stay, suffered life-threatening infections/sepsis. Severe infections are strongly associated with a high degree of systemic inflammation in the body, and intimately associated with significantly reduced and malfunctioning GI microbiota, a condition called dysbiosis. Deranged composition and function of the gastrointestinal microbiota, occurring from the mouth to the anus, has been found to cause impaired ability to maintain intact mucosal membrane functions and prevent leakage of toxins - bacterial endotoxins, as well as whole bacteria or debris of bacteria, the DNA of which are commonly found in most cells of the body, often in adipocytes of obese individuals or in arteriosclerotic plaques. Foods rich in proteotoxins such as gluten, casein and zein, and proteins, have been observed to have endotoxin-like effects that can contribute to dysbiosis. About 75% of the food in the Western diet is of limited or no benefit to the microbiota in the lower gut. Most of it, comprised specifically of refined carbohydrates, is already absorbed in the upper part of the GI tract, and what eventually reaches the large intestine is of limited value, as it contains only small amounts of the minerals, vitamins and other nutrients necessary for maintenance of the microbiota. The consequence is that the microbiota of modern humans is greatly reduced, both in terms of numbers and diversity when compared to the diets of our paleolithic forebears and the individuals living a rural lifestyle today. It is the artificial treatment provided in modern medical care - unfortunately often the only alternative provided - which constitute the main contributors to a poor outcome. These treatments include artificial ventilation, artificial nutrition, hygienic measures, use of skin-penetrating devices, tubes and catheters, frequent use of pharmaceuticals; they are all known to severely impair the microbiomes in various locations of the body, which, to a large extent, are ultimately responsible for a poor outcome. Attempts to reconstitute a normal microbiome by supply of probiotics have often failed as they are almost always undertaken as a complement to - and not as an alternative to - existing treatment schemes, especially those based on antibiotics, but also other pharmaceuticals.

Nutrition of the critically ill - emphasis on liver and pancreas

About 25 million individuals undergo high risk surgery each year. Of these about 3 million will never return home from hospital, and the quality of life for many of those who return is often significantly impaired. Furthermore, many of those who manage to leave hospital have undergone severe life-threatening complications, mostly infections/sepsis. The development is strongly associated with the level of systemic inflammation in the body, which again is entirely a result of malfunctioning GI microbiota, a condition called dysbiosis, with deranged composition and function of the gastrointestinal microbiota from the mouth to the anus and impaired ability to maintain intact mucosal membrane functions and prevent leakage of toxins-bacterial endotoxins and whole or debris of bacteria, but also foods containing proteotoxins gluten, casein and zein and heat-induced molecules such as advanced glycation end products (AGEs) and advanced lipoxidation end products (ALEs). Markedly lower total anaerobic bacterial counts, particularly of the beneficial Bifidobacterium and Lactobacillus and higher counts of total facultative anaerobes such as Staphylococcus and Pseudomonas are often observed when analyzing the colonic microbiota. In addition Gram-negative facultative anaerobes are commonly identified microbial organisms in mesenteric lymph nodes and at serosal "scrapings" at laparotomy in patients suffering what is called "Systemic inflammation response system" (SIRS). Clearly the outcome is influenced by preexisting conditions in those undergoing surgery, but not to the extent as one could expect. Several studies have for example been unable to find significant influence of pre-existing obesity. The outcome seems much more to be related to the life-style of the individual and her/his "maintenance" of the microbiota e.g., size and diversity of microbiota, normal microbiota, eubiosis, being highly preventive. About 75% of the food Westerners consume does not benefit microbiota in the lower gut. Most of it, refined carbohydrates, is already absorbed in the upper part of the GI tract, and of what reaches the large intestine is of limited value containing less minerals, less vitamins and other nutrients important for maintenance of the microbiota. The consequence is that the microbiota of modern man has a much reduced size and diversity in comparison to what our Palelithic forefathers had, and individuals living a rural life have today. It is the artificial treatment provided by modern care, unfortunately often the only alternative, which belongs to the main contributor to poor outcome, among them; artificial ventilation, artificial nutrition, hygienic measures, use of skin penetrating devices, tubes and catheters, frequent use of pharmaceuticals, all known to significantly impair the total microbiome of the body and dramatically contribute to poor outcome. Attempts to reconstitute a normal microbiome have often failed as they have always been undertaken as a complement to and not an alternative to existing treatment schemes, especially treatments with antibiotics. Modern nutrition formulas are clearly too artificial as they are based on mixture of a variety of chemicals, which alone or together induce inflammation. Alternative formulas, based on regular food ingredients, especially rich in raw fresh greens, vegetables and fruits and with them healthy bacteria are suggested to be developed and tried.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): hyperglycemia and diabetes mellitus]

Hyperglycemia is one of the main metabolic disturbances in critically-ill patients and is associated with increased morbidity and mortality. Consequently, blood glucose levels must be safely and effectively controlled, that is, maintained within a normal range, avoiding hypoglycemia on the one hand and elevated glucose concentrations on the other. To accomplish this aim, insulin is often required, avoiding protocols designed to achieve tight glycemic control. To prevent hyperglycemia and its associated complications, energy intake should be adjusted to patients' requirements, avoiding overnutrition and excessive glucose intake. Protein intake should be adjusted to the degree of metabolic stress. Whenever patients require artificial feeding, the enteral route, if not contraindicated, should be used since parenteral nutrition is associated with a higher frequency of hyperglycemia and greater insulin requirements. Enteral nutrition should be administered early, preferably within the first 24 hours of admission to the intensive care unit, after hemodynamic stabilization. Specific diets for hyperglycemia, containing low glycemic index carbohydrates and fibre and enriched with monounsaturated fatty acids, can achieve good glycemic control with lower insulin requirements.

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.

Glucose control in the intensive care unit: a nutrition support perspective

Hyperglycemia commonly occurs in acutely ill patients who receive nutrition support, even in patients without a history of diabetes. The traditional view that stress hyperglycemia may be a beneficial adaptive response has been replaced by data linking hyperglycemia with increased morbidity and mortality in critically ill populations. Initial randomized studies to control stress hyperglycemia with intensive insulin infusion reported dramatic decreases in infectious complications and decreased mortality. However, recent large multicenter trials have reported that intensive insulin therapy designed to normalize blood glucose resulted in an unacceptable increase in the incidence of hypoglycemia. Review of the methods, protocols, and nutrition provided during these randomized studies is crucial to understanding the different conclusions reached and how these results may be used to influence protocols in intensive care units today. Evidence is reviewed and practical considerations are provided for nutrition support regimens to minimize stress hypoglycemia and assist glucose management.