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Background: The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients., Methods: Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h., Intervention: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea., Results: Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44-65] versus 55[40-65] years) and GCS (6[3-7] versus 5[3-7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78-1.42); p = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day (p = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day (p < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis (p = 0.21), and 16% versus 8% patients suffered from diarrhea (p = 0.11). No patient presented vomiting in either group., Conclusion: Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition., Trial Registration: EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).

&lt;b&gt;Background and Objective:&lt;/b&gt; One of the Nymphalidae butterfly species found in West Sumatra in &lt;i&gt;Hypolimnas bolina&lt;/i&gt;. Currently, research on the artificial diet for the Nymphalidae butterfly is relatively rare in Padang, West Sumatra. The objectives of this study were to analyze the preferences of &lt;i&gt;H. bolina&lt;/i&gt; larvae, duration of the immature stage and mortality of &lt;i&gt;H. bolina&lt;/i&gt; in artificial diet treatment. &lt;b&gt;Materials and Methods:&lt;/b&gt; Some biological aspects of &lt;i&gt;H. bolina&lt;/i&gt; in corresponding to artificial diet and its effect were investigated in the laboratory. &lt;b&gt;Results:&lt;/b&gt; The result showed that there was no significant difference in the frequency of visits of the larvae in the two diet treatments namely natural (&lt;i&gt;Laportea interrupta&lt;/i&gt; leaves) and artificial diets (Sig = 0.289, p>0.05) but the duration of the visit of &lt;i&gt;H. bolina&lt;/i&gt; larvae was significantly different (Sig = 0.000, p<0.05). The visit duration of the immature stage of &lt;i&gt;H. bolina &lt;/i&gt;was significantly different, except the prepupa and pupal stage. There was no mortality of instar larvae and prepupa stage observed in both of the two-diet treatments. However, the mortality of pupae in an artificial diet was 4%. Of the total of 24 individual larvae fed with artificial diet, all of them successfully emerged, consisted of 12 males and 12 females but there was one male with abnormal wings. The average living period in the artificial diet of imago was 14.82 days for males and 16.77 days for a female. The average larval weight was no significant difference (Sig = 0.981, p>0.05) but the average pupal weight of the natural diet was slightly higher than the artificial diet. &lt;b&gt;Conclusion:&lt;/b&gt; The formulation of an artificial diet is suitable for &lt;i&gt;H. bolina&lt;/i&gt; larvae based on the results of immature mortality and adult emergences. Therefore, the formulation of an artificial diet is suitable for &lt;i&gt;H. bolina&lt;/i&gt; with its composition almost similar to &lt;i&gt;L. interrupta&lt;/i&gt; leaves (natural diet).

Background: To meet protein needs in critical illness (CI), guidelines suggest ≥1.2-2.5 g protein/kg/d; however, most intensive care unit (ICU) patients receive ≤0.7 g/kg/d. Higher protein enteral nutrition (EN) formulas may be part of the solution to provide prescribed protein. Our objective was to demonstrate that an EN formula with 37% protein can deliver ≥80% of prescribed protein, without overfeeding calories within the first 5 days of feeding and to describe ICU clinicians' experience., Methods: This quality improvement (QI) project included patients requiring exclusive EN for up to 5 days from 6 Canadian ICUs. Rationale for choosing formula, patient's BMI (kg/m 2 ), nutrition targets, daily protein and energy delivered, feeding interruptions, and general tolerance were recorded., Results: Forty-four of 49 patients received the formula ≥2 days. Average protein prescribed was 137.5 g/d (82.5-200) or 1.9 g/kg/d (1.5-2.5). Average protein delivered was 116.9 g/d (33.5-180) or 1.6 g/kg/d (0.4-2.4). Seventy-five percent to 83% of patients received ≥80% prescribed protein on days 2-5. Average energy prescribed was 1638.6 kcal/d (990-2500) or 17.8 kcal/kg (11-26). Average energy delivered was 1523.9 kcal/d (693.0-2557.5) or 17.3 kcal/kg/d (1.35-64.7). The formula was well tolerated with no gastrointestinal symptoms reported in 38 (86%) patients. The most common reasons to prescribe the formula were obesity and use of fat-based medications., Conclusions: We demonstrated in a QI study that a high-protein EN formula was tolerated in a small, heterogeneous group of ICU patients and effective in meeting protein targets without overfeeding., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Cow's milk protein allergy (CMPA) is one of the most common food allergies in infancy. Clinical food allergy guidelines recommend an extensively hydrolyzed formula (EHF) as the first-line treatment in nonbreastfed infants with CMPA. Designing and commercializing EHF poses both technical and regulatory challenges. Each manufacturing step, from sourcing of raw materials to release of the final product, needs to be managed in accordance with comprehensive quality systems. To avoid cross-contamination via externally sourced ingredients, suppliers should be carefully selected based on quality requirements. Strict zoning of the manufacturing areas according to contamination risk and air flow control are effective strategies to prevent accidental allergen contamination. Furthermore, dedicated manufacturing lines for hypoallergenic products are used to prevent potential cross-contamination from other products produced on the same line. The enzymatic hydrolysis, heat treatment and ultrafiltration used are specific to each manufacturer. Consequently, EHF are a heterogenous group of products with differences in the molecular weight profile of peptides, content of residual immunogenic cow's milk allergens, and residual in-vitro allergenicity. These differences are likely to affect clinical efficacy and safety. As not all commercialized EHF products have undergone formal testing in the laboratory and clinical trials, there is a need to develop guidelines for minimum technical and regulatory requirements for EHF products, including validated assays for ongoing quality control. Clinical trials assessing new EHF products for their hypoallergenicity and ability to support normal growth remain the definitive proof of efficacy and safety in infants and young children with CMPA., (© 2020 Elsevier Inc. All rights reserved.)

Introduction: The Management Working Group of SENPE has among its objectives the development of evaluation processes in Clinical Nutrition. Previously, the document entitled "Process of nutritional care: self-evaluation guide" was prepared as a tool designed to help assess the quality of nutritional therapy in hospitalized patients, mainly from the perspective of artificial nutrition. Now a complementary text of the previous one is presented, that describes the process by which hospitalized patients are fed. We have divided the hospital feeding process into six sections, for which a general description is made and quality indicators are proposed. We hope that this work will serve to improve the quality of hospital food and to help hospital food professionals to make their work more satisfactory and effective.

Background: Underfeeding in critical illness is common and associated with poor outcomes. According to large prospective hospital studies, volume-based feeding (VBF) safely and effectively improves energy and protein delivery to critically ill patients compared to traditional rate-based feeding (RBF) and might improve patient outcomes. A before-and-after study was designed to evaluate the safety, efficacy and clinical outcomes associated with VBF compared to RBF in a single intensive care unit (ICU)., Methods: The sample included consecutively admitted critically ill adults, mechanically ventilated for at least 72 h and fed enterally for a minimum of 48 h. The first cohort (n = 46) was fed using RBF, the second (n = 46) using VBF, and observed for 7 days, or until extubation or death. Statistical comparison of percentage feed volume, energy and protein delivered, plus indices of feed intolerance, were the primary outcomes of interest. Secondary observations included ventilation period, mortality, and length of ICU stay (LOICUS)., Results: Groups were comparable in baseline clinical and demographic characteristics and nutrition practices. Volume delivered to the VBF group increased significantly by 11.2% (p ≤ 0.001), energy by 13.4% (p ≤ 0.001) and protein by 8.4% (p = 0.02), compared to the RBF group. In the VBF group, patients meeting > 90% of energy requirements increased significantly from 47.8 to 84.8% (p ≤ 0.001); those meeting > 90% of protein requirements changed from 56.5 to 73.9% (p = 0.134). VBF did not increase symptoms of feed intolerance. Adjusted binomial logistic regression found each additional 1% of prescribed feed delivered decreased the odds of vomiting by 0.942 (5.8%), 95% CI [0.900-0.985], p = 0.010. No differences in mortality or LOICUS were identified. Kaplan-Meier found a significantly increased extubation rate in patients receiving > 90% of protein requirements compared to those meeting < 80%, (p = 0.006). Adjusted Cox regression found the daily probability of being extubated tripled in patients receiving > 90% of their protein needs compared to the group receiving < 80%, hazard ratio 3.473, p = 0.021, 95% CI [1.205-10.014]., Conclusion: VBF safely and effectively increased the delivery of energy and protein to critically ill patients. Increased protein delivery may improve extubation rate which has positive patient-centred and financial implications, warranting larger confirmatory trials. This investigation adds weight to the ICU literature supporting VBF, and the growing evidence which advocates for enhanced protein delivery to improve patient outcomes.

Aim: This project aimed to implement consensus recommendations and innovations that improve dietetic services to promote timely referral to optimise nutritional management for adult inpatients with inborn errors of metabolism (IEM)., Methods: The i-PARIHS framework was used to identify service gaps, implement innovations and evaluate the innovations within this single-site study. The constructs of this framework are: (i) review of the evidence; (ii) recognising patients and staff knowledge and attitudes; (iii) acknowledging the local context; and (iv) the facilitators role. This included a literature review and metabolic centre service comparisons to investigate dietetic referral and foodservice processes to inform the innovation. A 12-month chart audit (6 months retrospective and prospective of implemented innovation, respectively) to evaluate newly established dietetic referral and IEM nutrition provision procedures was also completed., Results: The innovations implemented encompassed a clinical alert triggering urgent referral, nutrition sick day plans and metabolic diet and formula prescription via an 'alert' tab in electronic records. Eleven metabolic protein-restricted diets and nine formula recipes were introduced. Prior to the innovations, only 53% (n = 19/36) of inpatients with IEM were assessed by the dietitian and received appropriate nutrition within 24 hours. Following implementation of the innovations, 100% (n = 11/11) of inpatients with IEM received timely dietetic assessment and therapeutic nutrition., Conclusions: Implementation of innovations developed using the i-PARIHS framework is effective in timely notification of the metabolic dietitian of referrals. This ensures optimal nutritional management during admissions which is required in this group of high-risk patients., (© 2019 Dietitians Association of Australia.)

Although commercial enteral formulas have been available on the market for several decades, a cultural shift toward consuming unprocessed foods with minimally added sugar has sparked interest in the preparation of home blenderized tube feedings for enteral feeding-dependent patients. Recent surveys, however, indicate lack of clinical awareness or familiarity in the management of this method of nutrition support. This article aims to equip the gastroenterologist with a guide for initiation, monitoring, and evaluation of a blenderized tube feedings regimen, and provides insights into an opportunity for greater partnership between the gastrointestinal provider and registered dietitian.

Purpose: Oral mucositis (OM) is one of the most uncomfortable adverse events experienced by cancer patients undergoing chemotherapy. Previous reports have revealed that the oral administration of an elemental diet (ED) may prevent OM. However, the incidence of OM has not been accurately determined by specialized diagnostic methods and the effects of an ED on OM remain unclear. We investigated the dose that could feasibly be administered and its effects with regard to the suppression of OM in esophageal cancer patients undergoing chemotherapy., Methods: We performed a prospective multi-center feasibility study of the administration of an ED (160 g/day) with 2 cycles of docetaxel/cisplatin/5-FU (DCF) chemotherapy. We assessed compliance to the ED for 49 days and the incidence of OM according to the amount of the ED that was orally administered. The incidence of OM was graded by a dental specialist who was experienced in dental oncology using a central OM review system., Results: Fourteen of 20 patients (70%) were able to complete the orally administered ED (160 g/day) during the course of chemotherapy. Three patients (15%) could not take the ED orally for 9, 14, and 21 days, respectively, while 1 patient (5%) took the ED orally at an average dose of 80 g/day for 35 days. The remaining 2 patients (10%) could not take the 80 g/day dose for 11 and 12 days, respectively. The incidence of grade ≥ 2 OM in the ED completion group (15.4%, 2 of 13 patients) was significantly lower than that in the non-completion group (66.7%, 4 of 6 patients) (p = 0.046)., Conclusions: An ED might be a one of the test treatment to reduce the incidence of OM in esophageal cancer patients treated with DCF and should be evaluated in further randomized study., Clinical Trial: The date of submission: Dec 08th, 2017.

Background and Purpose: For most of human history, physicians used blended whole foods for patients who are unable to eat by mouth. However, by the 1960s and 1970s, advances in enteral nutrition resulted in the gradual displacement of blenderized tube feedings (BTFs) with commercial formulas. There are advantages and disadvantages to commercial formulas and BTFs. The purpose of this article was to review the literature for the incidence of blended tube feeding use and its safety, efficacy, and implications for clinical practice., Methods: A search of the scientific literature in PubMed, CINAHL, Cochrane, ProQuest, and Ovid was conducted using the keywords "blenderized tube feeding" and "blended tube feeding." Articles were divided into two categories: 1) frequency of use and experiences of BTF in patients or caregivers and health care providers and 2) safety/efficacy studies., Conclusions: The literature review shows a rising interest in BTF, with more research on efficacy indicated., Implications for Practice: The use of BTF is primarily patient or caregiver driven. Blenderized tube feeding requires oversight by health care providers just as commercial formulas. Health care providers should be aware of the use of BTF and the effect it can have on different patient populations regarding content, cost, safety, and efficacy in the clinical and home settings.

Purpose: Accurate texture modifications to thin liquids are a critical aspect of patients' nutritional health and well-being. This study explored the use of 3 tools (2 distance- and 1 time-measuring devices) to characterize texture-modified liquids. The objectives were to use the tools to measure modified liquids, to determine if measurements differentiated nectar and honey levels of modification, and to compare measurements with other published reports., Method: We measured the flow distance of 33 prethickened water samples in centimeters (cm) using a line spread apparatus and a Bostwick Consistometer (Christison Particle Technologies). We selected a Zahn viscosity cup to measure the stream time of each prethickened liquid in seconds., Results: The 2 distance-measuring devices (line spread and Bostwick Consistometer) showed that thinner (nectar-thick) modifications spread or flowed a farther distance in comparison to thicker (honey-like) modifications. Testing with the line spread indicated that an average spread distance of 4.5 cm differentiated nectar-thick and honey-like consistencies. A flow distance of greater than 15 cm differentiated nectar from honey consistency measured with a Bostwick Consistometer. We were not successful in using the Zahn viscosity cup to determine the stream time of modified liquids., Conclusions: Two of the tools provided objective information about levels of liquid modification, which has implications for day-to-day preparation. Measurement tools that are accurate and easy to use have the potential to provide quick and dependable feedback to verify a prescribed level of liquid modification. Further efforts are needed to standardize the application of simple measurement tools in the management of patients who consume thickened liquids.

Background & Aims: Serious nutritional and contamination risks may be involved in the preparation of blenderized tube-feeding diets and in the handling of commercial diets. Their nutritional and microbiological quality in home settings is unknown. The objective of this study was to assess the nutritional and microbiological quality of commercial enteral and homemade blenderized whole foods diets intended to adult patients in home nutritional therapy., Methods: In a cross sectional study, 66 samples of commercial (CD) and noncommercial (NCD) enteral diets were collected at the homes of patients in home enteral nutritional therapy, 33 of each type. Commercial diets were either powder (PCD; n = 13) or liquid (LCD; n = 20). The samples were analyzed in laboratory to assess their nutritional and microbiological quality. Anthropometric data of mid upper arm circumference (MUAC) and triceps skinfold (TST) thickness were obtained from the patients' medical records., Results: NCD presented significantly lower values for protein, fat, fiber, carbohydrate and energy while water content was significantly higher. PCD and LCD did not show any statistically significant differences between them. In the NCD, the values measured for macronutrients and energy corresponded to less than 50% of the prescribed values (except for fat). In CD, protein value was about 20% more than the prescribed value; fat and energy values corresponded to approximately 100% of the prescription, while carbohydrate corresponded to 92%. Regardless the type of the diet, prevalence of undernutrition was high in both groups though patients of the NCD presented a higher percentage. Samples of NCD complied significantly less with the microbiological standards; only 6.0% complied with the standard for coliform bacteria. Escherichia coli was detected in 10, 2, and 2 samples of NCD, PCD and LCD, respectively., Conclusions: Homemade blenderized enteral diets showed low values of energy and macronutrients, delivered less than 50% of the prescribed values and had high levels of bacterial contamination., (Copyright © 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

This paper reviews indigenous Beninese food resources as potential ingredients for complementary infant foods with the aim to develop affordable formulations for low-income households in each agro-ecological zone of the country. Potential ingredients were selected on their documented nutritional value. The selected foods encompass 347 food resources, namely 297 plant products from home gardens or collected from natural vegetation and 50 animals, either domesticated or from the wild. The compiled data reveal that the distribution of the available food resources was unbalanced between agro-ecological zones. Only a few animal ingredients are obtainable in northern Benin. Most resources are seasonal, but their availability may be extended. A high variation was observed in energy and nutrient contents. Antinutritional factors were identified in some resources, but processing techniques were reported to reduce their presence in meals. In general, ingredients from local tree foods (Adansonia digitata, Parkia biglobosa) were adequate as sources of nutrients for complementary infant foods. Based on this review, local foods for the development of complementary food formulas for Beninese infants and children may be selected for each agro-ecological zone. The approach used is exemplary for other sub-Saharan African countries in need of complementary infant foods. © 2017 Society of Chemical Industry., (© 2017 Society of Chemical Industry.)

Some patients with dysphagia are prone to aspiration of low-viscosity liquids. Thickened liquids are often used in attempts to prevent aspiration. The patients should be given thickened liquids with suitable thickness, and the thickness should be constant at all time. While rotational and cone-and-plate viscometers are used for the evaluation of thickened liquids, they are high-precision and expensive equipment. To control the thickness of liquids, a simple and objective evaluation method is thus necessary. We developed a method to evaluate thickened liquids using funnels, and verified the appropriateness of this method. We measured the outflow times of five thickened liquids through funnels. One of the thickened liquids was a commercially available nutritional supplement, another was made with a thickening agent that contained guar gum, and all others were made with a thickening agent that contained xanthan gum. Four funnels with different stem sizes were tested. We found that the outflow time of thickened liquids through a funnel depended on their viscosities at a shear rate between 10 and 50 s -1 , when the average inner diameter of the stem was in the range of 5.3-9.0 mm, and the volume of the liquid poured into the funnel was 30 mL. The correlation coefficient between the value of the sensory evaluation and the outflow time of the funnel with an average stem ID of 5.3 mm was 0.946. Therefore, this method may be useful in hospital and nursing home kitchens for evaluating thickened liquids., Practical Applications: The findings of this study will help develop a new method for the evaluation of thickened liquids. Funnels made from polypropylene, which are inexpensive and light, were used in this method. The process for measuring the outflow time of thickened liquids through a funnel is simple, and we can obtain quantitative data that are objective. Even though line spread test (LST) is well known as a simple measurement method, nutritional supplements and liquids thickened using a thickening agent containing guar gum have not been evaluated accurately. The funnel method was found to have a stronger correlation with sensory evaluation compared to LST. This method is useful in hospital and nursing home kitchens for evaluating thickened liquids., (© 2016 Wiley Periodicals, Inc.)

The purpose of this commentary is to describe the current regulatory environment for the multitude of ready-to-use supplementary foods and ready-to-use therapeutic foods used in international feeding programs for undernourished and malnourished children. A perspective on the role of standards, their desirable scope, benefits and limitations as well as possible future developments of products in these categories also is provided., (© The Author(s) 2016.)

Nutrition support is an integral part of care among critically ill patients. However, critically ill patients are commonly underfed, leading to consequences such as increased length of hospital and intensive care unit stay, time on mechanical ventilation, infectious complications, and mortality. Nevertheless, the prevalence of underfeeding has not resolved since the first description of this problem more than 15 years ago. This may be due to the traditional conservative feeding approaches. A novel feeding protocol (the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients [PEP uP] protocol) was proposed and proven to improve feeding adequacy significantly. However, some of the components in the protocol are controversial and subject to debate. This article is a review of the supporting evidences and some of the controversy associated with each component of the PEP uP protocol., (© 2015 American Society for Parenteral and Enteral Nutrition.)

Strategies to reduce excess salt consumption play an important role in preventing cardiovascular disease, which is the largest contributor to global mortality from non-communicable diseases. In many countries, voluntary food reformulation programs seek to reduce salt levels across selected product categories, guided by aspirational targets to be achieved progressively over time. This paper evaluates the industry-led salt reduction programs that operate in the United Kingdom and Australia. Drawing on theoretical concepts from the field of regulatory studies, we propose a step-wise or "responsive" approach that introduces regulatory "scaffolds" to progressively increase levels of government oversight and control in response to industry inaction or under-performance. Our model makes full use of the food industry's willingness to reduce salt levels in products to meet reformulation targets, but recognizes that governments remain accountable for addressing major diet-related health risks. Creative regulatory strategies can assist governments to fulfill their public health obligations, including in circumstances where there are political barriers to direct, statutory regulation of the food industry.

Many new enteral nutrition (EN) formulas have been created over the past several decades with a variety of intended uses. Although each is intended to promote improved outcomes, research is often unclear and, in many cases, conflicting. It is important to note that EN products are considered medical foods by the U.S. Food and Drug Administration and therefore do not have to complete premarket review or approval and are not regulated to the same extent as pharmaceuticals. While standard EN formulas are designed to meet the basic macro- and micronutrient requirements of individuals who cannot meet nutrition needs orally, specialty EN products have been developed to exhibit pharmacologic properties, such as immune-enhancing formulas containing arginine, glutamine, nucleotides, and ω-3 fatty acids. With the vast number of products available, rising costs of healthcare, and the drive toward evidence-based practice, it is imperative that clinicians carefully consider research regarding use of specialty formulas, paying close attention to the quality, patient population, clinical end points, and cost to patient and/or facility., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Background: Copper is a trace mineral essential for numerous physiological processes. The purpose of this article is to provide data on copper levels in pediatric patients receiving parenteral nutrition (PN) that are useful to guide supplementation in PN formulation., Method: This is a retrospective review of hospitalized pediatric patients receiving PN supplemented and not supplemented with copper. In total, 751 supplemented pediatric patients and 90 pediatric patients not supplemented had serum copper levels measured. We assessed patient demographics, days on PN before copper level was drawn, serum copper levels, conjugated bilirubin levels, and C-reactive protein (CRP)., Results: The mean serum copper level was 80 mcg/dL at 20 days for supplemented patients and 64 mcg/dL at 14 days for the 90 nonsupplemented patients (P = .0002). In the supplemented patients, 50% of the levels were low and 45% were within the normal range. The remaining 5% of patients had high levels. In nonsupplemented patients, 71% were low and 29% within the normal range. There was no correlation between copper levels and conjugated bilirubin <2 mg/dL and >2 mg/dL (P = .3421). Copper levels correlated with CRP for CRP >4 mg/dL (P = .03)., Conclusion: Pediatric patients receiving PN should be supplemented with copper to prevent deficiency. Serum copper levels should be assessed at 14 days. Assessment of copper status should not be determined by conjugated bilirubin levels. Serum copper levels may be elevated in patients with acute inflammation and may be falsely elevated when CRP is >4 mg/dL., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Background: Ready-to-use therapeutic food (RUTF) is the standard of care for children suffering from noncomplicated severe acute malnutrition (SAM)., Objective: The objective was to develop a comprehensive linear programming (LP) tool to create novel RUTF formulations for Ethiopia., Design: A systematic approach that surveyed international and national crop and animal food databases was used to create a global and local candidate ingredient database. The database included information about each ingredient regarding nutrient composition, ingredient category, regional availability, and food safety, processing, and price. An LP tool was then designed to compose novel RUTF formulations. For the example case of Ethiopia, the objective was to minimize the ingredient cost of RUTF; the decision variables were ingredient weights and the extent of use of locally available ingredients, and the constraints were nutritional and product-quality related., Results: Of the new RUTF formulations found by the LP tool for Ethiopia, 32 were predicted to be feasible for creating a paste, and these were prepared in the laboratory. Palatable final formulations contained a variety of ingredients, including fish, different dairy powders, and various seeds, grains, and legumes. Nearly all of the macronutrient values calculated by the LP tool differed by <10% from results produced by laboratory analyses, but the LP tool consistently underestimated total energy., Conclusions: The LP tool can be used to develop new RUTF formulations that make more use of locally available ingredients. This tool has the potential to lead to production of a variety of low-cost RUTF formulations that meet international standards and thereby potentially allow more children to be treated for SAM., (© 2014 American Society for Nutrition.)

Introduction: There is an increasing use of enteral therapy at home, which reduces costs and improves patients' quality of life. Homemade food diets are being commonly used in the households of undeveloped countries, but those diets vary in composition and characteristics depending on the ingredients and preparation procedures adopted in its preparation, which influences the quality of the diet to satisfy the nutritional needs of patients., Objective: This study aimed to formulate and determine the quality of homemade enteral diets., Methods: An enteral diet plan was prepared by using conventional food, consisting of 6 meals, totalizing 2 liters per day, and it was adopted a proportion of 25% of solid food. The diets were analyzed for stability, viscosity, flow, pH, chemical and nutritional composition., Results and Discussion: The enteral diet plan was adequate in its physical-chemical aspects, however, it presented low percentages of adequacy, 20-53%, between the estimated and real content of macronutrients in the soup, formula used for lunch and dinner, which impaired the nutritional quality of the enteral diet plan., Conclusions: The results showed the difficulty of establishing the nutritional content of these diets, especially when made of meat and vegetables. Therefore, it is suggested a mixed enteral therapy by using commercial diets to achieve part of the nutritional needs of the patient together with enteral diets of homemade food to supplement it and also to redeem the psychosocial values of the feeding process., (Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.)

Blenderized tube diets (BTD) are used in some parts of Brazil and few studies have analyzed their features in comparison with industrialized preparations. Among 14 randomly collected BTD recipes 9 were poorly described or failed to standardize foodstuffs and portions and, consequently, nutrient and energy composition was difficult to define. Only five BTD allowed theoretical estimation of their nutritional properties. Macronutrient content was highly variable, often conflicting with accepted daily recommendations. According to the literature there are further disadvantages with BTD use including diet high risk of contamination, physical and chemical instability, and high osmolarity and viscosity. Nominal cost of BTD was comparatively low in relation to industrialized formulas; however we did not compute labor and indirect expenses, probably rendering final value more expensive than with the industrialized alternative. It is likely that within such circumstances, hospital and home care malnutrition will not be adequately dealt with and related complications may occur. It is concluded that the continued use of blenderized tube feeding diets requires careful assessment, prioritizing correction of potencial nutritional deficits by means of safe, balanced, chemically complete and effective nutritional prescriptions., (Copyright AULA MEDICA EDICIONES 2013. Published by AULA MEDICA. All rights reserved.)

Background: The development of enteral formulas (FE) is subject to various risks of contamination. The World Health Organization (WHO) and the Food and Agriculture Organization (FAO), have worried about alerting, recommendations and documents released to prevent contamination the FE, suggesting the standardization and protocols for all procedures involved., Objetives: The study was aimed to evaluate compliance with the technical criteria contained in a Guideline for Good Practice of Manufacture in relation to the development, maintenance and administration of enteral nutrition in hospitals of Santiago, in the Metropolitan Area., Material and Methods: The verification criteria considered Physical Plant, Equipment and Implementation, Hygienic and Sanitary Standards, Human Resources, Organization and Management, Safety and Warranty Quality Assurance. 639 criteria were defined, 309 risk Type 1, by mayor risk of producing pollution. The study was conducted by observing Central Units Enteral Formulas and interview with the caregiver. Medium of compliance for each group of criteria risk 1 and overall, was analyzed., Results: A total of 14 public hospitals were studied. The degree of compliance with the 639 reached a median of 33.2% (p25-75 31.6%-40.4%), with the lowest value for physical plant with 27.9% (p25-75 23.9%-38.2%) and the highest for human resources with 52.4% (p25-75 44.1%-52.4%). Median compliance for risk criteria Type 1 was only 31.8% (p25-75 27.5%-41.2%)., Conclusion: Most of the units tested, meets less than half of the internationals recommendations, or the Ministry of Health of Chile. It should develop protocols and train staff to ensure quality and safety in the development of enteral formulas and reduce risk of infection., (Copyright AULA MEDICA EDICIONES 2013. Published by AULA MEDICA. All rights reserved.)

Background: Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low- and middle-income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid-based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition., Objectives: To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low- and middle-income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective., Search Methods: In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition-related organisations and researchers in this field.    , Selection Criteria: We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low- and middle-income countries., Data Collection and Analysis: Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses using the random-effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods., Main Results: Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care - the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight-for-height (MD 0.20 z-score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid-based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses - there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid-based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non-recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight-for-height, and mid-upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid-based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses - no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid-based nutrient supplements versus specific types of blended foods - a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods - in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet - no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content., Authors' Conclusions: In conclusion, there is moderate to high quality evidence that both lipid-based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid-based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short-term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.

The vitamin C concentrations in three food-matrix Standard Reference Materials (SRMs) from the National Institute of Standards and Technology (NIST) have been determined by liquid chromatography (LC) with absorbance detection. These materials (SRM 1549a Whole Milk Powder, SRM 1849a Infant/Adult Nutritional Formula, and SRM 3233 Fortified Breakfast Cereal) have been characterized to support analytical measurements made by food processors that are required to provide information about their products' vitamin C content on the labels of products distributed in the United States. The SRMs are primarily intended for use in validating analytical methods for the determination of selected vitamins, elements, fatty acids, and other nutrients in these materials and in similar matrixes. They can also be used for quality assurance in the characterization of test samples or in-house control materials, and for establishing measurement traceability. Within-day precision of the LC method used to measure vitamin C in the food-matrix SRMs characterized in this study ranged from 2.7% to 6.5%.

The National Institute of Standards and Technology (NIST) is developing a wide variety of Standard Reference Materials (SRMs) to support measurements of vitamins and other nutrients in foods. Previously, NIST has provided SRMs with values assigned for the folate vitamer, folic acid (pteroylglutamic acid), which is fortified in several foods due to its role in prevention of neural tube defects. In order to expand the number of food-based SRMs with values assigned for folic acid, as well as additional endogenous folates, NIST has developed methods that include trienzyme digestion and isotope-dilution liquid chromatography-tandem mass spectrometric (LC-MS/MS) analysis. Sample preparation was optimized for each individual food type, but all samples were analyzed under the same LC-MS/MS conditions. The application of these methods resulted in folic acid values for SRM 1849a Infant/Adult Nutritional Formula and SRM 3233 Fortified Breakfast Cereal of (2.33 ± 0.06) μg/g and (16.0 ± 0.7) μg/g, respectively. In addition, the endogenous folate vitamer 5-methlytetrahydrofolate (5-MTHF) was detected and quantified in SRM 1849a Infant/Adult Nutritional Formula, candidate SRM 1549a Whole Milk Powder, and candidate SRM 1845a Whole Egg Powder, resulting in values of (0.0839 ± 0.0071) μg/g, (0.211 ± 0.014) μg/g, and (0.838 ± 0.044) μg/g, respectively. SRM 1849a Infant/Adult Nutritional Formula is the first food-based NIST SRM to possess a reference value for 5-MTHF and the first certified reference material to have an assigned 5-MTHF value based on LC-MS/MS. The values obtained for folic acid and 5-MTHF by LC-MS/MS will be incorporated into the final value assignments for all these food-based SRMs.

This study compares both versions of the nutritional requirement system determined by the National Research Council (NRC) version 1985 (NRC85) and NRC version 2007 (NRC07), for finishing lambs in feedlots. Nineteen crossbred lambs were divided in four groups representing four experimental treatments: one diet according to NRC85 and three diets according to NRC07. The diets recommended by NRC07 considers crude protein intake relative to ruminal undegradable protein at 20, 40, and 60 % levels (NRC07/20, NRC07/40, and NRC07/60). Diets were composed of Brazilian semi-arid native grass silage, soybean meal, corn, annatto byproduct, and limestone. Purchases and sales of lambs were done according to average market prices in Brazil. The economic indicators considered pointed that all treatments were viable but NRC07/20 and NRC07/60 were more profitable with similar net present values (NPVs) and internal return rates (IRRs). NRC07/20 was the best option showing an IRR of 17.20 % and a payback period (PP) of 5.07 considering a fixed annual interest rate of 6 %. Sensitivity analysis considering a 10 % raise in variable costs showed negative NPVs, IRRs inferior to the opportunity cost rates adopted and PPs that exceeded the planning horizon of 7 years for both NRC85 and NRC07/40.

The aim of the study is the improvement of nutritional support by immuno nutrition of patients, who are in critical conditions. The data on the impact of immuno active mixes (on the example of the mixture of Impact) on the immune and inflammatory response. In this, the number of postoperative infectious complications have been reliably decreased, the duration of the stay in the Department of R&IT and the hospital has been dicresed in whole, the cost of treatment in comparison with the use of standard schemes of patients with surgical and oncological profile has been significantly reduced.

Introduction: The preparation of parenteral nutrition mixture (PNM) in an open chamber requires the use of intermediate containers sterile and non-pyrogenic. A sterilization of containers by moist heat in large autoclaves is the suitable method. However, sterilization by moist heat is not a depyrogenation method. In our study, we report the validation of a sterilization and depyrogenation method for containers by dry heat using a convection oven., Materials and Methods: Sterilization and depyrogenation of material by dry heat have been audited by the reduction of at least three logarithms of original endotoxin rate. The containers were initially artificially contaminated with a suspension of endotoxin for 16 hours. Contaminated containers were placed in an oven with revolving heat at 250 °C for 1 hour. After treatment with dry heat, the residual endotoxin levels in the containers were determined by a kinetic chromogenic method., Results: After treatment with dry heat, the average log reductions of endotoxin levels were respectively, for glass and steel containers, 4.78 ± 0.07 and 4.87 ± 0.03., Discussion and Conclusion: The present validation study confirms the effectiveness of treatment with dry heat for sterilization and depyrogenation of glass and steel containers. This method of sterilization and depyrogenation meets the microbiological quality requirements for the preparation of MNP., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Different formulations for chocolate pastries making (brownies) were prepared by substituting 15, 20, and 25% of the wheat flour by inulin. The batter characteristics of each formulation were evaluated and the batters were baked at 175 degrees C for 15 min. After baking, the brownies were allowed to cool, put into crystal polystyrene trays, and their texture after 1, 3, 7, and 15 days of storage at room temperature (25 degrees C) and 65% of relative humidity, was evaluated. Based on the evaluations of batter characteristics and brownies textural properties during storage, the formulation containing 20% of inulin was the best. Proximate analysis was determined, and total, soluble and insoluble dietary fiber were quantified for brownies control and 20% inulin ones, as well as commercial brownies. The brownies containing 20% inulin showed lower firmness, gumminess, and masticability than the control and higher protein and lower fat content (6,3 vs 26,3%) and caloric value (331,4 vs 467.9 kcal/100 g) in comparison to the commercial brownies. The brownie with 20% inulin had twice the total dietary fiber and 22 times more soluble fiber than the brownie control. The acceptability of the brownie with 20% inulin was similar to that of the control. The incorporation of inulin in the production of brownies allowed to reduce the caloric value and to increase the soluble fiber content without adverse effects in texture of the pastries.

The aged canine (dog) is an excellent model for investigating the neurobiological changes that underlie cognitive impairment and neurodegeneration in humans, as canines and humans undergo similar pathological and behavioral changes with aging. Recent evidence indicates that a combination of environmental enrichment and antioxidant-fortified diet can be used to reduce the rate of age-dependent neuropathology and cognitive decline in aged dogs, although the mechanisms underlying these changes have not been established. We examined the hypothesis that an increase in levels of brain-derived neurotrophic factor (BDNF) is one of the factors underlying improvements in learning and memory. Old, cognitively impaired animals that did not receive any treatment showed a significant decrease in BDNF mRNA in the temporal cortex when compared with the young group. Animals receiving either an antioxidant diet or environmental enrichment displayed intermediate levels of BDNF mRNA. However, dogs receiving both an antioxidant diet and environmental enrichment showed increased levels of BDNF mRNA when compared with untreated aged dogs, approaching levels measured in young animals. BDNF receptor TrkB mRNA levels did not differ between groups. BDNF mRNA levels were positively correlated with improved cognitive performance and inversely correlated with cortical Aβ((1-42)) and Aβ((1-40)) levels. These findings suggest that environmental enrichment and antioxidant diet interact to maintain brain levels of BDNF, which may lead to improved cognitive performance. This is the first demonstration in a higher animal that nonpharmacological changes in lifestyle in advanced age can upregulate BDNF to levels approaching those in the young brain., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To compare the effects of a 4-week high-saturated fat/high-glycemic index (HIGH) diet with a low-saturated fat/low-glycemic index (LOW) diet on insulin and lipid metabolism, cerebrospinal fluid (CSF) markers of Alzheimer disease, and cognition for healthy adults and adults with amnestic mild cognitive impairment (aMCI)., Design: Randomized controlled trial., Setting: Veterans Affairs Medical Center clinical research unit., Participants: Forty-nine older adults (20 healthy adults with a mean [SD] age of 69.3 [7.4] years and 29 adults with aMCI with a mean [SD] age of 67.6 [6.8] years)., Intervention: Participants received the HIGH diet (fat, 45% [saturated fat, > 25%]; carbohydrates, 35%-40% [glycemic index, > 70]; and protein, 15%-20%) or the LOW diet (fat, 25%; [saturated fat, < 7%]; carbohydrates, 55%-60% [glycemic index, < 55]; and protein, 15%-20%) for 4 weeks. Cognitive tests, an oral glucose tolerance test, and lumbar puncture were conducted at baseline and during the fourth week of the diet., Main Outcome Measures: The CSF concentrations of β-amyloid (Aβ42 and Aβ40), tau protein, insulin, F2-isoprostanes, and apolipoprotein E, plasma lipids and insulin, and measures of cognition., Results: For the aMCI group, the LOW diet increased CSF Aβ42 concentrations, contrary to the pathologic pattern of lowered CSF Aβ42 typically observed in Alzheimer disease. The LOW diet had the opposite effect for healthy adults, ie, decreasing CSF Aβ42, whereas the HIGH diet increased CSF Aβ42. The CSF apolipoprotein E concentration was increased by the LOW diet and decreased by the HIGH diet for both groups. For the aMCI group, the CSF insulin concentration increased with the LOW diet, but the HIGH diet lowered the CSF insulin concentration for healthy adults. The HIGH diet increased and the LOW diet decreased plasma lipids, insulin, and CSF F2-isoprostane concentrations. Delayed visual memory improved for both groups after completion of 4 weeks of the LOW diet., Conclusion: Our results suggest that diet may be a powerful environmental factor that modulates Alzheimer disease risk through its effects on central nervous system concentrations of Aβ42, lipoproteins, oxidative stress, and insulin.

Background: Theoretically, consumption of complex, multinutrient formulations of vitamins and minerals should be safe, as most preparations contain primarily the nutrients that have been in the human diet for millennia, and at safe levels as defined by the Dietary Reference Intakes. However, the safety profile of commercial formulae may differ from foods because of the amounts and combinations of nutrients they contain. As these complex formulae are being studied and used clinically with increasing frequency, there is a need for direct evaluation of safety and tolerability., Methods: All known safety and tolerability data collected on one complex nutrient formula was compiled and evaluated., Results: Data were assembled from all the known published and unpublished studies for the complex formula with the largest amount of published research in mental health. Biological safety data from 144 children and adults were available from six sources: there were no occurrences of clinically meaningful negative outcomes/effects or abnormal blood tests that could be attributed to toxicity. Adverse event (AE) information from 157 children and adults was available from six studies employing the current version of this formula, and only minor, transitory reports of headache and nausea emerged. Only one of the studies permitted a direct comparison between micronutrient treatment and medication: none of the 88 pediatric and adult participants had any clinically meaningful abnormal laboratory values, but tolerability data in the group treated with micronutrients revealed significantly fewer AEs and less weight gain., Conclusions: This compilation of safety and tolerability data is reassuring with respect to the broad spectrum approach that employs complex nutrient formulae as a primary treatment.

The provision of appropriate nutritional support is an essential part of the primary and adjunctive management of many gastrointestinal (GI) disorders in neonatology and pediatrics. Few conditions in neonatology pose as great a challenge as intestinal failure or short bowel syndrome (SBS). The latter, SBS, is a complex disorder affecting normal intestinal physiology with nutritional, metabolic and infectious consequences. It is a result of the alteration of intestinal digestion and absorption following extensive bowel resection. Medical management of SBS is a very labor-intensive problem. Nutritional support and monitoring are of paramount importance, and long-term morbidity and mortality will depend on recognition and careful management of associated complications. With the increased use of intestine or intestine-liver transplant, maintaining these infants in good 'health' to allow transplantation will go a long way in achieving good long-term outcomes.

The Codex Alimentarius is a collection of internationally recognized standards, codes of practice, guidelines, and other recommendations relating to foods, food production, and food safety. Among other functions, it is responsible for setting international standards for safety and hygiene. Codex food standards and guidelines directed at foods produced primarily for young infants and children have important implications for maintaining nutritional status and health, especially given the positioning of these products as components of established World Health Organization (WHO)/UNICEF-recommended feeding strategies. Recently, new products targeted at this age group (e.g., lipid-based nutrient supplements and micronutrient powders) have been produced and used, but these are not totally covered under existing Codex guidelines or standards. The objective of this paper is to review the role of the Codex process and specifically to suggest revisions to existing Codex guidelines on formulated complementary foods (Guidelines for Formulated Supplementary Foods for Older Infants and Young Children, CAC/GL 08-1991) to encompass this new category of fortified complementary foods and home fortificants. In reviewing the existing guidelines, potential areas for revision included the sections on the recommended nutrients in these foods and their intended use. Updating the Codex guidelines provides the opportunity to encourage production and use of new products for children and help ensure that such foods, when used as directed, do not interfere with breastfeeding. The revised guidelines would help governments develop national regulations covering all forms of formulated complementary foods. They would also lessen impediments to international trade by providing clear guidance for foods used in feeding programs and for young children, particularly in developing countries.

In July 2004, the U.S. Food and Drug Administration issued a mandate that required manufacturers to include the aluminum content on the labels of the additives commonly used in the compounding of parenteral nutrition solutions. It was the hope that practitioners would use this information to minimize the amount of aluminum exposure provided by parenteral nutrition to less than the 5 mCg/kg/d, the threshold deemed as "safe." Since that time, it has been difficult to easily incorporate these guidelines into clinical practice due to limitations in current product formulations. The purpose of this article is to revisit the rationale for the development of this mandate and to survey the literature since its implementation to determine if any new findings have emerged. A brief overview of aluminum toxicity, the patient populations at risk, treatment options, and compounding considerations is also presented., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: United States Pharmacopeial Chapter <729> places a limit on the percentage of large fat globules >5 microm, expressed as a PFAT5 of <0.05% for all native lipid emulsions. Some adult total nutrient admixtures (TNAs) have also remained below this limit for up to 48 hours. In 2003, medium-chain/long-chain triglyceride (MCT/LCT)-based neonatal TNAs with between 2% and 3% amino acid (AA) concentrations were shown to be similarly stable by the PFAT5 parameter. Stability assessment of neonatal TNAs with AA <2% or > or =3% were tested., Methods: Eight neonatal TNAs with various combinations of AA (1%, 1.5%, 3%, and 4%), glucose (G; 5% and 10%), and MCT/LCT (ML; 2% and 4%) and standard concentrations of additives were tested in triplicate (n = 24) over 30 hours (immediately after mixing, then at 6, 24, and 30 hours) at 25 degrees C +/- 2 degrees C. PFAT5 determinations for all 24 formulations were made in duplicate, immediately after mixing, and then at 6, 24, and 30 hours later. Mean droplet size (MDS) and pH were assessed at the outset and end of the study., Results: The differences in the PFAT5 levels were significant (P < .001) by a 2-way analysis of variance based on formula and time as the independent variables. The TNAs with 1% and 1.5% AA with all Gs and MLs (group 1, n = 12) had PFAT5 levels >0.05% (up to 0.50%) in most samples (68 of 96 samples, or 71% of cases) in the study, whereas in the same TNAs, but made with 3% and 4% AA (group 2, n = 12), 100% of samples (all 96 cases) had PFAT5 levels <0.05% (up to 0.04%), and this difference was significant (P < .001). Pairwise comparisons between groups based on overall values of PFAT5, MDS, and pH showed significant differences between groups for all variables., Conclusions: For neonatal TNAs, AA level is the most sensitive determinant of stability, and the PFAT5 parameter is the most sensitive indicator of stability.

This comprehensive experimental study had the objective to determine the optimum ratio of calcium and vitamin D used as additives in food compositions and provide an experimentally-based rationale for the use of new functional dairy products and evaluation of their nutritional value. Experimental medico-biological assessment was conducted using growing male Wistar rats by balance and biochemical methods. It was shown that the calcium/vitamin D ratio in foodstuffs determines their functional efficiency. High nutritive and biological value was documented for some new cottage cheese products rich in calcium (240 mg%) and vitamin D (1 mg%). Results of the study were used to develop guidelines for the enrichment of various food compositions with calcium and vitamin D and substantiate methods for the assessment of their real functional effectiveness.

Background: Precipitation of calcium (Ca) and phosphate (P) salts can lead to potentially lethal outcomes, especially in low-osmolarity parenteral nutrition (LO-PN) formulations. Three concentrations of amino acids (AA) and 2 concentrations of calcium gluconate and sodium phosphate injections on the compatibility of Ca and P in LO-PN admixtures were studied., Methods: Final AA concentrations of 1%, 2%, or 3% (n = 3) and 5% glucose (G) were prepared with either 2.5 or 5 mmol/L (5 or 10 mEq) of Ca (n = 2) and 15 or 30 mmol/L of P (n = 2) for a total of 12 base (3 x 2 x 2) formulations. Triplicate bags of each were analyzed for subvisible micro-precipitates using the light obscuration (or extinction) method for particle counts per milliliter (PC) in the size range of 1.8-50 mum at 7 time intervals over 48 hours stored at 30 degrees C +/- 0.2 degrees C. Visual evaluation was performed using a high-intensity lamp against a black background for detection of macro-precipitates. The pH of all 36 admixtures was measured at 0 and 48 hours. Any precipitated material was isolated and characterized by polarized light microscopy and infrared spectroscopy., Results: Of the 12 base LO-PN formulations tested, those containing 1% and 2% AA with 5 mmol/L of Ca and 30 mmol/L of P showed significant increases in PC, and some resulted in visible dibasic calcium phosphate precipitation. Analyses of variance based on concentrations of AA, Ca, P, and time were highly significant independent variables for increases in the PC of potentially embolic particles, that is, sizes >5 mum (P < .0001). The lowest concentrations of Ca and P, 2.5 and 15 mmol/L, respectively, had significantly lower PC (P < .05) for all sizes compared with the other Ca and P combinations., Conclusions: LO-PN admixtures (AA

Almost 40 y ago the scientific community was taking actions to control environmental factors that contribute to variation in the responses of laboratory animals to scientific manipulation. Laboratory animal diet was recognized as an important variable. During the 1970s, the American Institute of Nutrition, National Academy of Science, Institute of Laboratory Animal Resources, and Laboratory Animals Centre Diets Advisory Committee supported the use of 'standard reference diets' in biomedical research as a means to improve the ability to replicate research. As a result the AIN76 purified diet was formulated. During this same time, the laboratory animal nutritionist at the NIH was formulating open-formula, natural-ingredient diets to meet the need for standardized laboratory animal diets. Since the development of open-formula diets, fixed-formula and constant-nutrient-concentration closed-formula laboratory animal natural ingredient diets have been introduced to help reduce the potential variation diet can cause in research.

Background: In phenylketonuria (PKU), protein substitute is an essential part of dietary treatment. Short-term studies have demonstrated that liquid protein substitutes (LPS) are efficacious, and improve compliance in teenagers and adults with PKU, although there are no data available to demonstrate that their effectiveness is sustained over time. The present retrospective study aimed to evaluate the long-term efficacy of ready-to-drink protein substitute in a group of people with PKU., Methods: Thirty-four patients (17 females and 17 males, median age 14.9 years, range 7.2-53.8 years) with PKU on dietary management were recruited from Birmingham Children's Hospital. All patients who were taking a LPS for a median of 2.4 years (range 6 months to 4.1 years), had their plasma phenylalanine concentrations, anthropometric and nutritional biochemical markers reviewed, both before and when taking the LPS., Results: There was a significant improvement in median plasma phenylalanine (P < 0.05), vitamin B(12) (P < 0.01), calcium (P < 0.05) and albumin (P < 0.05) concentrations in subjects (n = 13) aged >18 years when taking the LPS. In the children aged 7-18 years (n = 21), median plasma phenylalanine concentrations were maintained on LPS. Their plasma selenium concentrations (P < 0.05) deteriorated, but calcium (P < 0.05), albumin (P < 0.01), haemoglobin (P < 0.01) and haematocrit (P < 0.01) significantly improved., Conclusions: This retrospective review suggested that, in adult patients, the long-term use of LPS is associated with better compliance by lowering blood phenylalanine and improving nutritional biochemical markers.

Benzodiazepines of natural origin (NBZDs) have been found in human blood and brains as well as in medicinal plants and foods. In plasma and brain tissue there are i.e. diazepam and nordiazepam equal to commercial drugs but there are also other benzodiazepine-like compounds termed "endozepines", which act as agonists at the benzodiazepine receptors of central type (CBR). A synthetic pathway for the production of NBZDs has not yet been found, but it has been suggested that micro-organisms may synthesize molecules with benzodiazepine-like structures. Hence NBZDs could be of both endogenous and exogenous source and be considered as natural anxyolitic and sedative. Interestingly there are also natural compounds, such as the polypeptide Diazepam Binding Inhibitor (DBI) acting as an "inversive agonist" implicated in fair and panic disorders. It has been suggested that NBZDs may play a role in the pathogenesis of hepatic encephalopathy (HE). Multidirectional studies evaluated NBZDs levels (1) in the blood of normal subjects, of cirrhotic with or without HE and in commercial benzodiazepine consumers; (2) in the blood of cirrhotic treated or not with a non-absorbable antibiotic; (3) in several constituents of our diet. In conclusion, NBZDs increase sometime in cirrhotics with or without HE but they reach concentrations not higher than those found in commercial benzodiazepines consumers. Hence NBZDs must be considered as occasional precipitating factor of HE and benzodiazepine antagonists only symptomatic drugs. The finding that NBZDs may be in part synthesized by intestinal bacterial flora and in part constituent of our diet underlines the importance to feed cirrhotic patients with selected food.

Minimal encephalopathy was originally associated with chronic liver disease but is increasingly associated with most other chronic diseases and particularly with diabetes and also chronic disorders in other organs: kidneys, lungs, thyroid and with obesity. It is increasingly with dramatically increased and more or less permanent increase in systemic inflammation, most likely a result of Western lifestyle. Frequent physical exercise and intake of foods rich in vitamins, antioxidants, fibres, lactic acid bacteria etc in combination with reduction in intake of refined and processed foods is known to reduce systemic inflammation and prevent chronic diseases. Some lactic acid bacteria, especially Lb paracasei, lb plantarum and pediococcus pentosaceus have proven effective to reduce inflammation and eliminate encephalopathy. Significant reduction in blood ammonia levels and endotoxin levels were reported in parallel to improvement of liver disease. Subsequent studies with other lactic acid bacteria seem to demonstrate suppression of inflammation and in one study also evidence of clinical improvement.

Background: Stage I of a preplanned 2-stage study has provided good evidence for improved glycemic control with a disease-specific enteral formula low in carbohydrates and high in monounsaturated fatty acids (MUFAs), fish oil, chromium, and antioxidants in insulin-treated type 2 diabetes. The study was continued with stage II to give confirmatory proof of these beneficial effects., Methods: 105 patients with HbA1C>or=7.0% and/or fasting blood glucose (FG)>6.7 mmol/L (>120 mg/dL) requiring enteral tube feeding due to neurological dysphagia received 113 kJ (27 kcal)/kg body weight of either test formula (Diben) or an isoenergetic, isonitrogenous standard formula (control) for up to 84 days. Total insulin (TI) requirements, FG, and afternoon blood glucose (AG) were assessed daily. HbA1C and safety criteria were evaluated on days 1, 28, 56, and 84., Results: 55 patients completed the study; on day 84, median changes from baseline (data as available, test vs control) were the following: TI, -8.0 vs +2.0 IU; FG, -2.17 vs -0.67 mmol/L (-39.0 vs -12.1 mg/dL); HbA(1C), -1.30% vs -1.20%; AG, -2.36 vs -0.49 mmol/L (-42.5 vs -8.9 mg/dL). The number of relevant hypoglycemic episodes (FG<3.33 mmol/L<60 mg/dL) was 1 vs 5. Feeding tolerance was comparable in both groups., Conclusions: Long-term tube feeding with a disease-specific enteral formula was safe and well tolerated in type 2 diabetic patients with neurological disorders. When compared with a standard diet, TI requirement decreased significantly with less hypoglycemia whereas FG and AG were significantly lowered, resulting in improved glycemic control.

Diarrhea and abdominal distension are common complications associated with enteral feeding. Often the cause is unknown, the enteral formula is blamed and changes to the mode of delivery or formula are instituted. However, the evidence base for many strategies used is limited. Altering the osmolality and temperature of the formula and/or the rate of infusion are commonly practiced but evidence for their benefit is largely anecdotal. Preventing microbial contamination of the feed is important and clear guidelines exist to achieve this. The formulation itself can be modified. While the addition of fiber is well supported theoretically, outcome data are less convincing. Avoidance of osmotically active, poorly absorbed short-chain carbohydrates in the formula (often used as the major carbohydrate source) is a new tactic to minimize diarrhea. It has compelling theoretical support, but requires further investigation. A methodical clinical approach to gastrointestinal complications of enteral feeding is warranted and an algorithm for management is proposed.

Objectives: To improve nursing home (NH) staff delivery of oral liquid nutritional supplements between meals to residents with a history of weight loss., Design: Pre-Post intervention study., Setting: Two skilled nursing homes., Participants: Eighteen long term care residents., Intervention: At baseline all participants had a non-specific physician's order to receive a nutritional supplement. The intervention consisted of specifying the physician's order as follows: "Give 4 oz high protein supplement at 10 am, 2 pm, and 7 pm"., Measurements: Research staff conducted direct observations for two days during and between meals for a total of 4 days, or 12 possible observation periods per participant before and one week following the intervention. Research staff documented NH staff delivery of snacks (including high protein supplements) and amount consumed (fluid ounces) for the high protein supplements using a standardized protocol during each observation period., Results: Before the specific order was written participants were offered any type of snack an average of 1.82 times per day and a high protein supplement 0.59 times per day. After the specific order was written participants were offered any type of snack an average of 1.59 times per day and a high protein supplement 0.91 times per day. There were no statistically significant differences in the average number of times snacks or supplements were offered before and after the specific order was written. The proportion of snacks offered that were high protein supplements did increase after the specific order was written (p<0.001). When a high protein supplement was provided, most residents consumed 100% of it., Conclusions: Oral liquid nutritional supplements were not provided consistent with orders in NH practice. The specificity of the order related to type of supplement and time of delivery did not influence when and how often supplements are provided to residents but it did influence the type of nutritional supplement offered.