Editorial

This is the third issue of TOP NUTRITION NEWSLETTER in 1999. In this issue enteral glutamine in trauma patients, soy protein and lipd profiles, immunonutrition, and nutrition recommendations for the person with diabetes are updated for your interest.

Infections are the important cause of morbidity and mortality in ICU patients. Aggressive nutritional support has been applied to reduce the mortality but the rate has not been reduced. Immunonutrients have been tried to reduce the infections. Animals and human studies have suggested that glutamine-enriched nutrition decreases the number of infections."Randomised trial of glutamine-enriched enteral nutrition on infectious morbidity in patients with multiple trauma" supported the concept and stimulated the further larger studies.

Consumption of soy protein, rather than animal protein, decreases serum cholesterol concentrations, but studies in humans have been inconclusive. In this meta-analysis of 38 controlled clinical trials, soy protein consumption significantly decreases serum lipid concentrations in humans. You can rely on this respectable medical journal that accepted this original article of "Meta-Analysis of the Effects of Soy Protein Intake on Serum Lipids".

Editorial opinions in January 1999 issue of "Nutrition" titled IMMUNONUTRITION-Concluding Remarks is my choice this month as the author mentioned almost second patient admitted to any hospital is either malnourished or at risk of malnutrition.Due to preservation of food, many Westerners suffer from latent glutathione (GSH) deficiency. Many foods rich in important nutrients (immunonutrients) are not eaten today to the same extent as they were in the past.Why immunonutrients should be included in critically ill patients to minimize stress related immunosuppression is an important issue in clinical nutrition.

ADA recommendation to limit saturated fats and dietary cholesterol remains clear, the current direction to adjust fat and carbohydrate (CHO) calories based on individual weight, glycemic control, and lipid profile presents a dlemma over how to best distribute CHO and monounsaturated fatty acids (MUFA) in the daily diet. This article "Nutrition recommendations for the person with diabetes" will frame the discussion of current US and European position statements on macronutrient distribution for DM patients and review the arguments for and against high-MUFA diets as part of medical nutrition therapy and outline the dietary guidelines.

Any comments or suggestions to include the interesting topics are welcomed for future issues.


Dr Shwe Win

Editor

Randomised trial of glutamine-enriched enteral nutrition on infectious morbidity in patients with multiple trauma

Reference:Lancet 1998; 352: 772-76

Background:

Infections are an important cause of morbidity and mortality in patients with multiple trauma. Studies in both animals and human beings have suggested that glutamine-enriched nutrition decreases the number of infections.

Methods:

Patients with multiple trauma with an expected survival of more than 48 h, and who had an Injury Severity Score of 20 or more, were randomly allocated glutamine-supplemented enteral nutrition or a balanced, isonitrogenous, isocaloric enteral-feeding regimen along with usual care. Each patient was assessed every 8 h for infection, the primary endpoint. Data were analysed both per protocol, which included enteral feeding for at least 5 days, and by intention to treat.

Findings:

72 patients were enrolled and 60 received enteral feeding (29 glutamine-supplemented) for at least 5 days. Five (17%) of 29 patients in the glutamine-supplemented group had pneumonia compared with 14 (45%) of 31 patients in the control group (p<0.02). Bacteraemia occurred in two (7%) patients in glutamine group and 13 (42%) in the control group (p<0?005). One patient in the glutamine group had sepsis compared with eight (26%) patients in the control group (p<0.02).

Interpretation:

There was a low frequency of pneumonia, sepsis, and bacteraemia in patients with multiple trauma who received glutamine-supplemented enteral nutrition. Larger studies are needed to investigate whether glutamine-supplemented enteral nutrition reduces mortality.

Meta-Analysis of the Effects of Soy Protein Intake on Serum Lipids

Reference: N Engl J Med 1995;333:276-82.

Background. In laboratory animals, the consumption of soy protein, rather than animal protein, decreases serum cholesterol concentrations, but studies in humans have been inconclusive. In this meta-analysis of 38 controlled clinical trials, we examined the relation between soy protein consumption and serum lipid concentrations in humans.

Methods. We used a random-effects model to quantify the average effects of soy protein intake on serum lipids in the studies we examined and used hierarchical mixed-effects regression models to predict variation as a function of the characteristics of the studies.

Results. In most of the studies, the intake of energy, fat, saturated fat, and cholesterol was similar when the subjects ingested control and soy-containing diets; soy protein intake averaged 47 g per day. Ingestion of soy protein was associated with the following net changes in serum lipid concentrations from the concentrations reached with the control diet: total cholesterol, a decrease of 23.2 mg per deciliter (0.60 mmol per liter; 95 percent confidence interval, 13.5 to 32.9 mg per deciliter [0.35 to 0.85 mmol per liter]), or 9.3 percent; low-density lipoprotein (LDL) cholesterol, a decrease of 21.7 mg per deciliter (0.56 mmol per liter; 95 percent confidence interval, 11.2 to 31.7 mg per deciliter [0.30 to 0.82 mmol per liter]), or 12.9 percent; and triglycerides, a decrease of 13.3 mg per deciliter (0.15 mmol per liter; 95 percent confidence interval, 0.3 to 25.7 mg per deciliter [0.003 to 0.29 mmol per liter]), or 10.5 percent. The changes in serum cholesterol and LDL cholesterol concentrations were directly related to the initial serum cholesterol concentration (P<0.001). The ingestion of soy protein was associated with a nonsignificant 2.4 percent increase in serum concentrations of high-density lipoprotein (HDL) cholesterol.

Conclusions. We found that the consumption of soy protein rather than animal protein significantly decreased serum concentrations of total cholesterol, LDL cholesterol, and triglycerides.

Immunonutrition - Concluding Remarks

Reference: Nutrition 1999;15(1):57-61.

It has been sugested that the balance between TH1 lymphocytes, primarily associated with cellular immunity, and TH2 lymphocytes, mainly associated with humoral immunity, should be of special importnce to our health and well being. Intake of L acidophilus is known to result in a greater than 4-fold increase in IgA response.

It is unfortunate that direct immunologic parameters are rarely studied in connection with surgical operation and trauma, but several studies report a reduced morbidity and mortality in patients receiving early EN following trauma or surgery. Recently significant changes in different immune parameters in patients with severe acute pancreatitis were observed and related to the mode of feeding. 5 out of 12 patients in the parenteral group developed multiple organ failure (MOF) in contrast to none among the enterally fed patients.

Stimulation of the immune system of the gut by enteral feeding in liver transplantation did reduce hospital stay and mortality by one-third compared with traditional intravenous feeding. But most interesting, the early rejection (30d) rate fell from 44% to 7%. It seems evident that up-regulation of the gut-associated lymphoid tissue (GALT) system is an important adjunct to pharmaceutical immunosuppression.

Undoubtedly, it will take a considerable amount of time and effort to change opinions and practice toward a more liberal EN policy: to accept larger initial amounts, to use more fresh foods, and to maintain an uninterrupted supply. Proper EN is not only much cheaper than PN, but will also lead to substantial savings by reducing the length of hospital stays and the use of pharmaceuticals that are not only expensive, but also often responsible for adverse effects, including unwanted immunosuppression.

Nutrition recommendations for the person with diabetes

Reference: Clinical Nutrition 1998;17(S2):18-25.

Current recommendations for macronutrient distribution

The CHO / MUFA dilemma

(1)Optimal CHO/MUFA distribution suggests a broader applicability of the high-MUFA diet to both type 1 and type 2 diabetes.

(2)European community recommends limiting the addition of simple sugars (sucrose to <10% of total daily calories, or sucrose plus fructose to </=25 g/day.ADA discourages resistriction of sugars.