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Supplements Perspectives in Exocrine Pancreatic Insufficiency
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A Primer on Exocrine Pancreatic Insufficiency, Fat Malabsorption, and Fatty Acid Abnormalities
Samer Alkaade, MD and Ashley A. Vareedayah, MD
Options for Addressing Exocrine Pancreatic Insufficiency in Patients Receiving Enteral Nutrition Supplementation
Steven D. Freedman, MD, PhD

Guidance for Supplemental Enteral Nutrition Across Patient Populations

Douglas L. Nguyen, MD
Key Components of Enteral Nutrition Formulas
As with any food source, the key components of enteral nutrition include proteins, carbohydrates, and fats. The characteristics of these macronutrient components vary, however. For example, nutrient components may be hydrolyzed or broken down to varying degrees to aid in digestion. The protein component of enteral nutrition may be composed of polypeptides, oligopeptides (partially hydrolyzed), or free amino acids (fully hydrolyzed). Although short-chain polypeptides and oligopeptides are easily absorbed, free amino acids may not be absorbed efficiently.4,15
The carbohydrate components of enteral nutrition may include polysaccharides, oligosaccharides, and fiber. Of these components, oligosaccharides can be absorbed. Carbohydrate polysaccharides, such as starch, may be broken down into simple sugars through enzymatic processes, while fiber may be fermented by gut bacteria to form short-chain fatty acids.4

The lipid component of enteral nutrition may include long-chain and medium-chain triglycerides. Of these fat sources, long-chain triglycerides require digestion by pancreatic lipase and are mixed with bile salts for absorption, whereas medium-chain triglycerides may be absorbed directly across the intestinal mucosa.4 Linoleic acid and alpha-linolenic acid are essential fatty acids (EFAs). Importantly, EFAs cannot be synthesized by the human body and are obtained solely through dietary intake. These long-chain triglycerides cannot be absorbed in the absence of pancreatic enzymes.4 To prevent EFA deficiency, approximately 5% to 10% of total calories ingested should be EFAs.19,20

Essential fatty acid deficiency may occur in patients receiving parenteral nutrition, patients with malnutrition, fat malabsorption syndromes, and patients receiving formulations of enteral nutrition that are very low in fat content.19 Essential fatty acid deficiency may result in dermatitis, alopecia, impaired wound healing, anemia, thrombocytopenia, and impaired growth.19
Other components of enteral nutrition products are intended to exert immunomodulatory effects; omega-3 fatty acids, ribonucleic acids, and glutamine or arginine addition to formulas may modulate immune response.2,4 Fiber is another important component of many enteral nutrition formulas. The presence of fiber helps to promote absorption of sodium and water in the colon and to support the colonic mucosa.4 Fiber induces healthy changes in gut flora by promoting favorable bacterial growth.2,12

Defining Appropriate Patients for Enteral Nutrition
Because nutrition can have important effects on health outcomes, the Joint Commission requires accredited institutions to perform nutritional screenings for patients who enter hospitals, with such screenings typically completed within 24 hours of entry.19 Nutritional assessment may include evaluation for the presence of disease states or patient-specific factors associated with malnutrition, an assessment of the risk of developing malnutrition, and an assessment of each patient’s nutritional needs.9,19

Various scoring systems and biochemical tests are used to assess nutritional outcomes. One assessment tool for nutritional status is the Subjective Global Assessment.19 Other tools include the Mini Nutritional Assessment, which is primarily used for elderly patients. Nutrition Risk in Critically Ill (NUTRIC) scoring may be used in the critical care setting to assess the risk of poor clinical outcomes in association with malnutrition.9,19 In addition to scoring systems, biochemical markers including serum albumin levels, prealbumin levels, and transferrin levels may be indicators of physiologic stress (inflammation) to augment clinical assessment of nutritional needs, but should not be used solely as a marker of nutritional status.2,19

These scoring systems and biochemical markers must be assessed in the context of each patient’s medical conditions and the corresponding nutritional needs of patients with these underlying disease states. Although there are some contraindications for use of enteral nutrition, scoring systems are important because these systems help identify patients with a wide range of disease states who may benefit from enteral nutrition therapy. including patients with dysphagia, oral or esophageal lesions, head and neck cancers, critically ill patients, neonates, patients with reduced gastric motility, patients with protein calorie malnutrition/sarcopenia, patients with intestinal failure, and patients with pancreatitis.2,4,11,21 Assessing appropriateness of therapy in each patient through a scoring system may help standardize the approach to individualized nutritional therapy in a broad and heterogenous group of patients.

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