Clinical Nutrition Advice requires High-Level Expertise from Health Care Professionals
For those in hospital or at home, who cannot meet their nutrition requirements with normal foods, clinical nutrition – or so-called foods for special medical purposes (FSMP) – serve as food alternative. Formulated to provide a balanced and complete nutrition with protein, carbohydrate, fat, vitamins and minerals, a person can receive such foods as supplement or sole source of nutrition until he can resume to the normal diet.
Making informed choices from the wide range of clinical nutrition products needs high level expertise. Several aspects come into play when finding the most suitable nutrition formula for a person, considering his disease status and his ability to consume and digest food. Oral nutritional supplements, including so-called “sip feeds” and snacks for oral consumption, can be given to all those who can drink and swallow and consume food. Others receive tube feeds for administration into the gastrointestinal tract (enteral nutrition). Where the body’s ability to digest and absorb nutrients from the gastrointestinal tract is affected and needs to be by-passed, pre-digested nutrient formulations for direct administration into the bloodstream are available (parenteral nutrition).
Apart from standard formulations for oral or enteral intake, a range of disease-specific formulas can be used. The nutrient formulation of these products have been adapted to the specific requirements of a certain disease, disorder or medical condition. Examples are formulas for blood glucose control / diabetes mellitus or for renal failure and kidney diseases.
As the amount of people with diabetes mellitus continues to grow, the number of patients requiring disease-specific clinical nutrition likely rises too. While the prevalence of obesity among American adults has risen to 36.5% in the U.S., out of 30.3 million adults, almost 10% of the population have been diagnosed with diabetes mellitus. Out of another 84.1 million, more than one out of three have prediabetes (National Diabetes Statistics Report, 2017.)
The use of Carbohydrates in Disease-Specific Formulas
Carbohydrates play an important role in the diet as the key macronutrient that supplies the body with energy. Accordingly, the nutritional properties of carbohydrates in a formula diet is an important aspect to consider, too, since not all carbohydrates are used the same way, and they vary in functional properties, digestibility, availability, speed of absorption, and metabolic pathways.
A preference for carbohydrates with low glycaemic properties has been postulated for the general population and should be considered for standard formulas in general. Beyond that, reducing glycaemia is a particular aspect of disease-specific formulas for blood glucose control / diabetes mellitus and also of formulas for kidney disease / renal failure, which is often linked with diabetes mellitus. Nutrient adaptations in diabetes-specific formulas focus on a low or reduced blood glucose response, respectively. Where this was formerly achieved with a shift towards a higher fat content on the expense of carbohydrates and with the use of fructose, modern formulas commonly have a high carbohydrate content with high proportions of slow release carbohydrates. In view of the limited availability of fully digestible slow release carbohydrates, a significant number of these diabetes-specific formulas contain isomaltulose.
Isomaltulose Serves as a Low-GI Carb in Oral and Enteral Formulas
Isomaltulose lowers the glycaemic properties of clinical nutrition formulas when replacing conventional carbohydrates like sugars or maltodextrins in a formulation. Therefore, it is used in specific formulas for blood glucose control and diabetes mellitus or for renal failure linked with diabetes mellitus. This includes both oral nutrition supplements (“sip feed”) and enteral nutrition tube feeds.
With its slow release properties and a low GI value of 32, isomaltulose serves as a nutritive carbohydrate in these formulas and as an effective tool to help manage blood glucose levels. It supplies its energy in a more steady and sustained way, with less impact on blood glucose levels and insulin. Its low glycaemic properties are well established for conditions of impaired glucose tolerance and diabetes mellitus: Isomaltulose has been shown to lower the blood glucose response in overweight to obese adults with impaired glucose tolerance (König et al 2012, van Can et al 2012), as well as in individuals with type 1 diabetes mellitus (West et al 2011a, Bracken 2012), or non-insulin dependent type 2 diabetes mellitus (Kawai et al 1989, Ang and Linn 2014, Keyhani-Nejad et al 2016).
Research in type-2 diabetic adults shows that the low effect of isomaltulose on blood glucose levels and insulin release results from its slow release in the small intestine. In case of isomaltulose, digestion and uptake occur along the entire length of the small intestine, and this leaves its “footprints” in the different incretin response, with less GIP release in the early parts of the small intestine and higher GLP-1 release in the later parts of the small intestine (Ang and Linn 2014, Keyhani-Nejad et al 2016). The stable isotope study by Ang and Linn (2014) further illustrates how isomaltulose improves the glucose flux in type-2 diabetic patients, respectively. [Blood Sugar Management]
Diabetes-specific formula diets with isomaltulose have been tested in human intervention studies to verify their lower blood glucose response in comparison with standard formulas, or their longer-term efficacy in blood glucose management:
Vanschoonbeek et al (2009) compared the glycaemic and insulinemic responses of diabetes-specific oral nutritional supplement (ONS) formulas with either isomaltulose or sucromalt as the main carbohydrate source, with those of a standard formula, and a high-fat formula, in a randomised, double-blind cross-over study with 15 type diabetics. The diabetes-specific formula with its high content of the slowly digestible carbohydrate isomaltulose was equally effective in attenuating the blood glucose and insulin response as was the low-carbohydrate, high-fat formula, but without the adverse effect of the high-fat formula causing a greater triglyceride response.
Alish et al (2010) confirmed in a postprandial blood glucose test with 22 diabetics and in a test protocol using continuous glucose monitoring with 12 diabetics, that the diabetes-specific formula with a complex carbohydrate blend containing isomaltulose among others reduced postprandial glycaemia, mean glucose, glycaemic variability and short-acting insulin requirements in comparison with a standard formula containing corn maltodextrin and corn syrup solids as main nutritive carbohydrates.
Both, Oizumi et al (2007) and Sakuma et al (2007) investigated long-term effects of an isomaltulose-containing liquid formula, consumed as part of the usual breakfast, on blood glucose control in adults with impaired glucose tolerance or type -2 diabetes mellitus, respectively. Oizumi et al (2007) found reducing effects with the isomaltulose-containing formula diet on 2 h glucose levels after a 75g oral glucose tolerance test (OGTT), serum free fatty acids and visceral fat. Sakuma et al (2007) reported that glycated haemoglobin levels were markedly reduced after 3 and 5 months of treatment. Both publications concluded that consuming the isomaltulose-containing formula diet as part of breakfast over a long-term period may be effective improving glucose metabolism in patients with impaired glucose tolerance or type 2 diabetes mellitus.
Alish CJ, Garvey WT, Maki KC, Sacks GS, Hustead DS, Hegazi RA, Mustad VA (2010) A diabetes-specific enteral formula improves glycemic variability in patients with type 2 diabetes. Diabetes Technol Ther 12 (6) 419-425. https://www.liebertpub.com/doi/10.1089/dia.2009.0185
Ang M, Linn T (2014) Comparison of the effects of slowly and rapidly absorbed carbohydrates on postprandial glucose metabolism in type 2 diabetes mellitus patients: a randomized trial. Am J Clin Nutr 100(4):1059–1068. https://ajcn.nutrition.org/content/early/2014/07/16/ajcn.113.076638.full.pdf+html
Bracken RM, Page R, Gray B, Kilduff LP, West DJ, Stephens JW, Bain SC (2012) Isomaltulose improves glycemia and maintains run performance in type 1 diabetes. Med Sci Sports Exerc 44(5):800–808. https://www.ncbi.nlm.nih.gov/pubmed/22051571
Kawai K, Yoshikawa H, Murayama Y, Okuda Y, Yamashita K (1989) Usefulness of palatinose as a caloric sweetener for diabetic patients. Horm Metab Res 21(6):338–340. http://www.ncbi.nlm.nih.gov/pubmed/2673967
Keyhani-Nejad F, Kemper M, Schueler R, Pivovarova O, Rudovich N, Pfeiffer AF (2016) Effects of Palatinose and Sucrose Intake on Glucose Metabolism and Incretin Secretion in Subjects With Type 2 Diabetes. Diab Care 39(3):e38-e39. https://www.ncbi.nlm.nih.gov/pubmed/26721819
König D, Theis S, Kozianowski G, Berg A (2012) Postprandial substrate use in overweight subjects with the metabolic syndrome after isomaltulose (Palatinose™) ingestion. Nutrition 28(6):651–656. https://www.ncbi.nlm.nih.gov/pubmed/22264450
National Diabetes Statistic Report (2017)…
Oizumi T, Daimon M, Jimbu Y, Kameda W, Arawaka N, Yamaguchi H, Ohnuma H, Sasaki H, Kato T (2007) A palatinose-based balanced formula improves glucose tolerance, serum free fatty acid levels and body fat composition. Tohoku J Exp Med 212(2):91–99. https://www.ncbi.nlm.nih.gov/pubmed/17548953
Sakuma M, Arai H, Mizuno A, Fukaya M, Matsuura M, Sasaki H, Yamanaka-Okumura H, Yamamoto H, Taketani Y, Doi T, Takeda E (2009) Improvement of glucose metabolism in patients with impaired glucose tolerance or diabetes by long-term administration of a palatinose-based liquid formula as a part of breakfast. J Clin Biochem Nutr 45(2):155–162. https://www.ncbi.nlm.nih.gov/pubmed/19794923
van Can JG, van Loon LJ, Brouns F, Blaak EE (2012) Reduced glycaemic and insulinaemic responses following trehalose and isomaltulose ingestion: implications for postprandial substrate use in impaired glucose-tolerant subjects. Br J Nutr 108(7):1210–1217. https://www.ncbi.nlm.nih.gov/pubmed/22172468
Vanschoonbeek K, Lansink M, van Laere K, Senden JMG, Verdijk LB, van Loon LJ (2009) Slowly digestible carbohydrate sources can be used to attenuate the postprandial glycemic response to the ingestion of diabetes- specific enteral formulas. The Diabetes Educator 35, 631-640. https://journals.sagepub.com/doi/10.1177/0145721709335466
West DJ, Morton RD, Stephens JW, Bain SC, Kilduff LP, Luzio S, Still R, Bracken RM (2011) Isomaltulose improves postexercise glycemia by reducing CHO oxidation in T1DM. Med Sci Sports Exerc 43(2):204–210.https://journals.lww.com/acsm-msse/Fulltext/2011/02000/Isomaltulose_Improves_Postexercise_Glycemia_by.2.aspx