Search our catalog of clinical and scientific nutrition articles based on current clinical research studies and previously published webinars.


Search our catalog of clinical and scientific nutrition articles based on current clinical research studies and previously published webinars.


Search our catalog of clinical and scientific nutrition articles based on current clinical research studies and previously published webinars.
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Jun 01, 2017

Hidden Sources of Inflammation in Commercial Enteral Formulas: Looking beyond the sugar and chemicals

There is a growing level of awareness around the increased risk for chronic disease and inflammatory-mediated conditions with sugar consumption. Many Liquid Hope and Nourish customers choose our organic, whole-food enteral formulas for this reason alone. Others have decided that there is no place for artificial ingredients or chemicals in their meal replacements or the diet of their critically ill loved ones.  These are major issues with many commercial enteral formulas, whether the sugar is coming from corn syrup or fruit juice concentrates and whether the chemicals are preservatives, artificial flavors, or agrochemical residues.  Lesser known hazards found in these formulas however, may be even more important to avoid.

Food companies have several criteria that they must meet when developing a formula. Three of these that most often create less than ideal recipes are: a cheap, complete protein source, shelf life or preservation, and emulsification. Chemicals and sugar are most often used to achieve a longer shelf life, but the proteins and emulsifiers used are often overlooked because they are derived from natural ingredients and have more familiar names to consumers. Sodium caseinate, lecithin, and carrageenan are excellent examples of substances found throughout the food supply that particular attention should be paid to.

Their effect on various systems within the human body are well documented, yet their presence in enteral formulas and processed food, in general, still goes largely unquestioned.  Maybe it is that we have, unfortunately, been reading these ingredients on boxes, cartons, and bags for too many years? Maybe it is that they have words in front of them such as soy or sodium. Maybe it’s they are associated with otherwise healthy foods, as in the case with carrageenan and seaweed? Either way, it is likely that their effects on our health are much greater than suspected.

Casein is one fraction of milk. There are numerous casein-based ingredients in a variety of products.  Almost all of those used in processed foods are largely made up of what food scientists know as A1 beta casein.  It is cheap and abundant.  Largely a by-product left over from the more desirable components of milk, such as the whey and butter; this type of  casein has been shown to cause inflammation, altered digestive function, and even excitatory effects on the neurological system in both human and animal investigations.  These are not metabolic consequences that we want for anyone, but especially not for those already in the midst of an illness or critical situation.  Sodium caseinate has the potential to not only delay gastric emptying and prevent normal transit time in tube fed individuals, but can also occupy opioid receptors and alter their brain function, influencing mood and cognition in an adverse way.

Emulsifiers are needed with most enteral formulas to keep the seed oils from separating from the water and other liquids. Rather than use healthy vegetable ingredients that can help with this, food companies turn to soy lecithin or gums like carrageenan to achieve this.  Unfortunately, their effects on the gastrointestinal environment and/or micro biome are highly disruptive and/or inflammatory.  The use of lecithin creates more of the potent, highly oxidative substance known as TMAO (trimethyl-amine oxidase). TMAO is generated when GI microbes metabolize lecithin added to foods.  After being absorbed into the blood stream, TMAO then causes inflammation in artery walls and the brain.

Carrageenan causes increased intestinal wall permeability and GI inflammation overall.  Many microbial populations that are critical for a healthy micro biome are highly sensitive to emulsifiers and gums, especially carrageenan.  Some studies have shown adverse effects with very short windows of exposure and at levels lower than typically found in processed foods.  Collectively, these ingredients, combined with one another and possibly others such as fructose-rich sweeteners or omega 6 fatty acid-based seed oils, produce a cocktail of ingredients with the ability to undermine our health. Our best advice? Read the label and to think twice before choosing anything with these ingredients, you will not regreat it.

~ John Bagnulo MPH, PhD.


Sodium caseinate:
Jianqin S, Leiming X, Lu X, Yelland GW, Ni J, Clarke AJ. Effects of milk containing only A2 beta casein versus milk containing both A1 and A2 beta casein proteins on gastrointestinal physiology, symptoms of discomfort, and cognitive behavior of people with self-reported intolerance to traditional cows’ milk. Nutrition Journal. 2015;15:35. doi:10.1186/s12937-016-0147-z.

Pal S, Woodford K, Kukuljan S, Ho S. Milk Intolerance, Beta-Casein and Lactose. Nutrients. 2015;7(9):7285-7297. doi:10.3390/nu7095339.

Trivedi MS, Shah JS, Al-Mughairy S, et al. Food-derived opioid peptides inhibit cysteine uptake with redox and epigenetic consequences. The Journal of nutritional biochemistry. 2014;25(10):1011-1018. doi:10.1016/j.jnutbio.2014.05.004.

Ho S et al. Comparative effects of A1 versus A2 beta-casein on gastrointestinal measures: a blinded randomised cross-over pilot study. Eur J Clin Nutr. 2014 Sep;68(9):994-1000. doi: 10.1038/ejcn.2014.127. Epub 2014 Jul 2.

Barnett MP et al. Dietary A1 β-casein affects gastrointestinal transit time, dipeptidyl peptidase-4 activity, and inflammatory status relative to A2 β-casein in Wistar rats. Int J Food Sci Nutr. 2014 Sep;65(6):720-7. doi: 10.3109/09637486.2014.898260. Epub 2014 Mar 20.

Lecomte M et al. Dietary emulsifiers from milk and soybean differently impact adiposity and inflammation in association with modulation of colonic goblet cells in high-fat fed mice. Mol Nutr Food Res. 2016 Mar;60(3):609-20. doi: 10.1002/mnfr.201500703. Epub 2015 Dec 22.

Tang WHW, Wang Z, Levison BS, et al. Intestinal Microbial Metabolism of Phosphatidylcholine and Cardiovascular Risk. The New England journal of medicine. 2013;368(17):1575-1584. doi:10.1056/NEJMoa1109400.

Chhibber-Goel J. The metabolite Trimethylamine-N-oxide is an emergent biomarker of human health. Curr Med Chem. 2016 Aug 30. [Epub ahead of print]


Fahoum L et al. Digestive fate of dietary carrageenan: Evidence of interference with digestive proteolysis and disruption of gut epithelial function. Mol Nutr Food Res. 2017 Mar;61(3). doi: 10.1002/mnfr.201600545. Epub 2017 Jan 25.

Choi HJ et al. Pro-inflammatory NF-κB and early growth response gene 1 regulate epithelial barrier disruption by food additive carrageenan in human intestinal epithelial cells. Toxicology Letters. 2012 Jun 20;211(3):289-95. doi: 10.1016/j.toxlet.2012.04.012. Epub 2012 Apr 26.

Wei W et al. Enhanced effect of κ-carrageenan on TNBS-induced inflammation in mice. Int Immunopharmacology. 2016 Oct;39:218-28. doi: 10.1016/j.intimp.2016.07.031. Epub 2016 Aug 3.