Critical Qualities of Enteral Formulas for Patients with Diabetes

As a greater percentage of diabetes patients require enteral support for an additional disease or condition, the nutritional qualities of a formula are pivotal.  While most enteral formulas are comprised of heavily refined carbohydrates (ranging from fruit juice concentrates to corn syrup solids) and industrially processed seed oils (corn, soybean, sunflower, and canola), there is only one whole food, high fermentable fiber, and no added sugar option.  The qualities possessed by this type of formula are aligned with those recommended for the treatment and management of insulin resistance.

A large body of clinical evidence has continued to support the pathological role of dietary sugar and refined carbohydrates in the etiology of insulin resistant-type diabetes.  In fact, added sugar, as well as total, naturally occurring sugars, may be the biggest risk factor for both the development of diabetes and for the onset of related complications.  The risk for many other diseases tied closely to insulin resistance are also significantly increased with added sugar.

Although some enteral formulas designed specifically for those with diabetes contain lower percentages of calories from carbohydrates, by in large refined carbohydrates from a variety of sources still remain as the primary ingredient in these and all other formulas.  Slightly more complex forms of carbohydrate or sugar, such as maltodextrin, are often touted as non-sugar forms of carbohydrate.  Yet their digestion is so rapid and their chemistry so simple they may just as well be considered sugar.

Even in clinical circles of diabetes management there exists an enormous gap in the knowledge and understanding of how food influences glycemic control.  While total carbohydrates, and even better net carbohydrates, are useful in assessing the compatibility of a diet or formula for those with diabetes, particular qualities that relate to areas of physiology such as the microbiota may be much more useful.  Recent investigations have shown that lower carbohydrate densities (less use of concentrated sugars) and larger amounts of plant fiber, are most supportive in fostering those families of beneficial bacteria that offer strong protection against diabetes and are useful in gaining better glycemic control.  These fibers are most beneficial when acquired from an array of legumes and vegetables and to a lesser extent than when added in the form of oligosaccharides or inulin, often touted as key ingredients in those enteral formulas manufactured for the diabetes patient.

The type of sugar contained in a formula is also very significant in determining the long-term effect on diabetes management.  Fructose for example, may be the most damaging of sugars investigated.  Contrary to popular belief, not all sugars are metabolized the same.  Fructose consumption favors the development of increased insulin resistance later on and also appears to produce at least mild endotoxemia in many individuals when metabolized by gut flora in the more proximal small intestine.  These influences are detrimental to the patient’s overall health and formulas that avoid the use of fructose or fructose-containing sweeteners should always be avoided (note that agave, fruit juice concentrate, and corn syrup are among the richest sources of fructose and are found in a variety of enteral formulas).

In summary, when choosing an enteral formula that is best for the patient with diabetes, pat particular attention to both the amount and type of fiber. Look for those that offer at least 20g per 2000kcal and it should be from a variety of whole food sources.  Select only those formulas with no added sugar and be sure to read the ingredient list to find maltodextrin as it is often hidden and used to disguise otherwise very refined carbohydrates. Lastly, also avoid casein and milk protein concentrates as A1 beta casein (primary type used as a food additive) has been associated with pancreatic beta cell issues and increased insulin production.  Choose a whole food, no added sugar formula with a more compatible protein source and the most important qualities of diabetes management will be covered.

~ John Bagnulo MPH, PhD.

RESOURCES:

Garcia M MD et al. A new fructose-free, resistant-starch type IV-enriched enteral formula improves glycaemic control and cardiovascular risk biomarkers when administered for six weeks to elderly diabetic patients. Nutr Hosp. 2017 Feb 1;34(1):73-80.

Ojo O, Brooke J. Evaluation of the Role of Enteral Nutrition in Managing Patients with Diabetes: A Systematic Review. Nutrients. 2014;6(11):5142-5152. doi:10.3390/nu6115142.