Which would you choose

A first of its kind trial is getting underway at the University of Pittsburgh Children’s Hospital.  Researchers there, led by Dr. Michael Morowitz, MD a pediatric thoracic surgeon, are investigating how an organic, whole foods-based enteral formula influences the intestinal environment of children.  Changes in the GI and microbiome that are generated by the Functional Formularies product, Nourish®, are being compared to those produced by the typical commercial enteral formula (largely comprised of highly refined carbohydrates, oils, and which contain very little fiber.)

The research on dietary patterns by Americans and other populations would suggest that a significant difference should be observed.  Time will tell, however the presence of more whole foods and the specific types of fiber found in the vegetables and legumes present in the pediatric formula Nourish®, should foster major shifts in these areas.  Maybe most importantly, one would expect markedly greater levels of important families of bacteria.  There is considerable evidence that microbes identified as necessary for better outcomes are highly dependent upon this type of dietary characteristic.

Bifidobacter, for instance, is an essential family of microbes necessary for the fermentation of dietary fiber and who play a pivotal role in maintaining the integrity of the gut lining.  Previous research has shown that this family disappears with refined diets made up largely of sugar and low in fermentable fiber.  Dr. Morowitz hypothesizes that the whole foods (blended very thoroughly so as to be compatible with all G tubes) that are integral to the Nourish® formula, will support and develop very different microbial profiles in the children receiving them.

As an introduction to topic, the microbiome is the 4-5 pounds of bacteria and other organisms that primarily populate the distal small intestine and colon.  This population of various life forms has as much or more influence on human physiology as any other facet of who we are.  Some would argue that because the DNA of these bacteria outnumber our own DNA by over 130 to 1, that the microbiome may be every bit as influential as the genetics we were dealt from our parents.  More and more research is supporting this position.

In addition to measuring changes in the microbe populations present in these children, the study will also look closely at other important factors such as the quantities and qualities of the beneficial short chain fatty acids produced by bacteria.  There is an overwhelming body of evidence, going back 20 years now, that greater amounts of the short chain fatty acid n-butyrate is directly related to improved outcomes and lower levels of inflammation overall.  Individuals with higher GI levels of n-butyrate have lower risks for a variety of chronic diseases.

All of this work is at least partially being driven by observations made over the past 4 decades with those on enteral/tube feeding support (1-6).  Too frequently patients requiring enteral support develop diarrhea or other digestive issues.  While there are many factors that can contribute to these serious symptoms, dysbiosis or the overgrowth of potentially pathogenic bacteria such as C.difficile and the loss of Bifidobacter populations are a major component.

Eliminating the added sugar and highly refined carbohydrates found in most commercial formulas is a big part of the proposed solution, especially those containing larger amounts of fructose.  To date however, only Functional Formularies has addressed this need by first producing the adult formula Liquid Hope® and more recently Nourish®.  Other companies have tried different things but whether it has been the use of fruit juice concentrates (very high in fructose) or brown rice syrup, no other company has made an organic whole food formula with out any added sugar.  This made the study that more appealing to the investigators, as the contrast between Nourish® and other formulas is so great.

Additionally, there are other factors that can cause inflammation and an overall intolerance to a commercial formula.  Many of these formulas also contain casein, soy protein, or milk protein concentrates as their primary source of protein.  These can delay gastric emptying in some children causing GERD (gastroesophageal reflux disease) and can cause malabsorption issues in others.

While there is a growing amount of research in nutrition and the microbiome, so far this has not been explored with regard to enteral tube feeding products. With the population of tube fed individuals rising worldwide and the tolerance issues that can be associated with conventional commercial formulas, it is clear that research is needed. We look forward to the results of Dr. Morowitz's study and better understanding the potential for using an organic, whole foods enteral formula.


John Bagnulo MPH, PhD. - Director of Nutrition



1. Gungabissoon U, Hacquoil K, Bains C, Irizarry M, Dukes G, Williamson R, et al. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness. J Parenter Enteral Nutr. 2014.

2. Gottschlich MM, Warden GD, Michel M, Havens P, Kopcha R, Jenkins M, et al. Diarrhea in tube-fed burn patients: incidence, etiology, nutritional impact, and prevention. J Parenter Enteral Nutr. 1988;12:338–45. doi: 10.1177/0148607188012004338.

3. Staudacher HM, Whelan K, Irving PM, Lomer MC. Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. J Hum Nutr Diet. 2011;24:487–95. doi: 10.1111/j.1365-277X.2011.01162.x.

4. Halmos EP. Role of FODMAP content in enteral nutrition-associated diarrhea. J Gastroenterol Hepatology. 2013;28:25–8. doi: 10.1111/jgh.12272.

5. Halmos EP, Muir JG, Barrett JS, Deng M, Shepherd SJ, Gibson PR. Diarrhoea during enteral nutrition is predicted by the poorly absorbed short-chain carbohydrate (FODMAP) content of the formula. Aliment Pharmacol Ther. 2010;32:925–33. doi: 10.1111/j.1365-2036.2010.04416.x.

6. Arevalo-Manso JJ, Martinez-Sanchez P, Juarez-Martin B, Fuentes B, Ruiz-Ares G, Sanz-Cuesta BE, et al. Enteral tube feeding of patients with acute stroke: when does the risk of diarrhoea increase? Intern Med J. 2014;44:1199–204. doi: 10.1111/imj.12586.