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TOP Nutrition NewsletterVol: 8 No: 3 March 2005

Immunonutrition.PURPOSE OF REVIEW: To outline recent findings on theefficacy of immunonutrients in patients undergoinginflammatory stress due to surgery, infection and cancer.RECENT FINDINGS: Enteral nutrition is more efficaciousand poses lower risks than parenteral nutrition. It reducesinfection rates and shortens ICU and hospital length ofstay of critically ill patients. Beneficial effects ofimmunonutrition are most apparent in malnourished

patients. Perioperative enteral nutrition is more effectivethan postoperative nutrition. In Crohn disease similarremission rates are achieved with enteral nutrition as withsteroids. Glutamine, omega-3 fatty acids and antioxidantsexert beneficial influences in diverse patient populations.L-arginine is an important immunonutrient having bothbeneficial and adverse effects. The former effect occursin necrotizing enterocolitis; the latter influence is seen inseptic patients. The gut plays a major role in whole bodyamino acid metabolism, particularly argininehomeostasis. Arginase and nitric oxide synthetase

compete for arginine within immune cells and play apivotal role in clinical outcome during infection. In cancera range of antioxidants are able to ameliorateimmunosuppression. Intravenous lipids may bedeleterious due to the pro-inflammatory effects of omega-6 fatty acids. Omega-3 fatty acids are anti-inflammatoryand combined with medium chain triglyceride (MCT) andolive oil may provide a more efficacious form ofintravenous lipid. SUMMARY: Immunonutrition iseffective in improving outcome in a wide range of patientswhen applied enterally, particularly in malnourishedindividuals. Parenteral immunonutrition carries a higherrisk but can be efficacious in selected patient groups forwhom enteral nutrition is problematic.Curr Opin Gastroenterol. 2005 Mar;21(2):216-22.

Reducing costs and patient morbidity inthe enterally fed intensive care unit


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patient.BACKGROUND: Critically ill patients are at high risk fornosocomial infections and resultant organ dysfunctionand death. These patients typically have protractedintensive care unit (ICU) courses and consume

increasingly limited resources. Enteral nutrition withspecific immune-modulating components has beenpreviously shown to improve outcomes in selectpopulations of patients, but results have been mixed incritically ill patients. Impact 1.5 (Novartis Nutrition,Minneapolis, MN) is a commercially available enteralformula containing ingredients known to improve severalparameters of immune function. We hypothesized thatadministration of Impact 1.5 tube feedings would reducethe incidence of nosocomial infection and ICU resourcesin critically ill patients admitted to the ICU for severe

trauma, burns, or sepsis insults. METHODS: The Impact1.5 group (n = 17) was compared with a historical cohortof ICU patients (n = 21) of similar illness severity thatreceived a standard high-energy enteral formula. Theincidence of nosocomial infections and mortality, and theconsumption of multiple ICU resources were examined. Acost analysis based on these results was then performedto determine the cost effectiveness of this proprietaryimmunonutrition enteral formula. RESULTS: Apronounced reduction in nosocomial pneumonia (12% vs52%, p < .01) was identified, with consequent trends

toward a reduction in duration of mechanical ventilationand ICU length of stay. Urinary tract infections that mayhave less influence on ICU resources were increased inthe Impact 1.5 group. No difference in mortality wasidentified, despite the inclusion of patients with severesepsis in the study group. According to the averagenumber of ICU days required for each study cohort, theImpact 1.5 group led to a cost savings of at least$193,350.00. CONCLUSIONS: ICU patients withsignificant illness severity experienced a decrease in theincidence of an important nosocomial infection that iscommonly associated with increased use of ICUresources and length of stay. This decrease in patientmorbidity led to substantial cost savings despite the smallsize of our study trial.JPEN 2005 Jan-Feb;29(1 Suppl):S62-9.


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Preoperative immunonutrition: costbenefitanalysis.BACKGROUND: To evaluate whether preoperativeimmunonutrition might lead to a savings in patient care.Data on resources consumed to treat postoperativecomplications are scanty, but morbidity costs continue tobe a major burden for any health care system. A recentrandomized clinical trial carried out in well-nourishedpatients with gastrointestinal cancer showed that a 5-daypreoperative oral immunonutrition reduced postoperativemorbidity compared with conventional treatment (nosupplementation). METHODS: The abovementioned trialwas the basis for the economic evaluation. In-hospitalrelated costs of routine surgical care and costs of nutritionwere calculated. Estimates of complication costs werebased on both resources used for treatment andadditional length of hospital stay. Cost comparison andcost-effectiveness analysis were then carried out.RESULTS: Total cost of nutrition was 3407 euro in theconventional group and 14,729 euro in the preoperativegroup. In patients without complication, the cost of inhospitalroutine care was similar in both groups. Themean cost of complication was 6178 euro in theconventional group and 4639 euro in the preoperativegroup (p = .05). Total cost of patients with complicationswas 535,236 euro in the conventional group and 334,148

euro in the preoperative group. Total costs consumed93% of the diagnosis-related-group (DRG)reimbursement rate in the conventional group and 78% inthe preoperative group. Cost-effectiveness was 6245euro for the conventional group and 2985 euro for thepreoperative group. CONCLUSIONS: The costs ofpostoperative morbidity consumed a large amount of theDRG reimbursement rate. Preoperative immunonutritionwas cost-effective in our series.JPEN 2005 Jan-Feb;29(1 Suppl):S57-61

T lymphocyte numbers in human gut

associated lymphoid tissue are reducedwithout enteral nutrition.BACKGROUND: Clinically, in the absence of enteralnutrition, the morbidity of infectious complication is high.Although experiments using mice have shown alterationsin gut-associated lymphoid tissue (GALT) to be animportant mechanism underlying impaired host defense,


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there are no clinical studies on the effects of nutritionalroutes on GALT. METHODS: A total of 27 colon cancercases who underwent right colectomy or hemicolectomywere reviewed. Six patients did not receive enteralnutrition for 4 to 28 days before surgery because of bowel

obstruction (parenteral nutrition [PNI group). Twenty-onepatients were enterally fed before surgery (enteralnutrition [EN] group). The terminal ileum from resectedspecimens was examined microscopically. T-cellnumbers in intraepithelial spaces (IE) and the laminapropria (LP) were determined immunohistochemically inblinded fashion. RESULTS: There were no significantdifferences in baseline characteristics between the 2groups. T-cell number in the LP was significantly lower inthe PN group than in the EN group, with no difference inIE cell numbers. CONCLUSIONS: Lack of enteral

delivery of nutrients reduces GALT cell number inpatients with colon cancer, as is the case in mice.JPEN 2005 Jan-Feb;29(1):56

Association between dietary arginineand C-reactive protein.CONCLUSIONS: The results of this study show a relationbetween arginine intake and CRP level that persistedafter controlling for factors associated with CRP.Individuals may be able to lower their risk forcardiovascular disease by consuming more arginine-rich

foods such as nuts and fish.Nutrition. 2005 Feb;21(2):125-30.

Glycemic and lipid control inhospitalized type 2 diabetic patients:evaluation of 2 enteral nutritionformulas (low carbohydrate-highmonounsaturated fat vs highcarbohydrate).An enteral formula with lower carbohydrate and higher

monounsaturated fat (Glucerna) has a neutral effect onglycemic control and lipid metabolism in type 2 diabeticpatients compared with a high-carbohydrate and a lowerfatformula (Precitene Diabet).JPEN 2005 Jan-Feb;29(1):21http://www.thai-otsuka.co.th/pxnews/index.html Opinions andsuggestions are welcomed Dr. Shwe Win, [email protected]


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