Thermogenesis from intravenous medium-chain triglycerides

Effects of an Exogenous Ketone Supplement on Five-Kilometer Running Performance

Numerous oral ketone supplements are marketed with the claim that they will rapidly induce ketosis and improve exercise performance. The purpose of this study was to assess exercise performance time and related physiological, metabolic and perceptual responses of recreational endurance runners after ingestion of a commercially available oral ketone supplement. Recreational endurance runners (n = 10; age: 20.8 ± 1.0 years; body mass: 68.9 ± 5.6 kg; height: 175.6 ± 4.9 cm) participated in a double-blind, crossover, repeated-measures study where they were randomized to 300 mg.kg-1 body weight of an oral β-hydroxybutyrate-salt + Medium Chain Triglyceride (βHB-salt+MCT) ketone supplement or a flavor matched placebo (PLA) 60 min prior to performing a 5-km running time trial (5KTT) on a treadmill. Time, HR, RPE, affect, RER, VO₂, VCO₂, and VE were measured during the 5-km run. The Session RPE and affect (Feeling Scale) were obtained post-5KTT. Plasma glucose, lactate and ketones were measured at baseline, 60-min post-supplement, and immediately post-5KTT. Plasma R-βHB (endogenous isomer) was elevated from baseline and throughout the entire protocol under the βHB-salt+MCT condition (p < 0.05). No significant difference (58.3 ± 100.40 s; 95% CI: -130.12 – 13.52; p = 0.100) was observed between the βHB-salt+MCT supplement (1430.0 ± 187.7 s) and the PLA (1488.3 ± 243.8 s) in time to complete the 5KTT. No other differences (p > 0.05) were noted in any of the other physiological, metabolic or perceptual measures.

Effects of medium-chain fatty acids on performance, carcass characteristics, blood biochemical parameters and immune response in Japanese quail

This study had the aim of evaluating the effects of medium-chain fatty acids (MCFA) on performance, carcass characteristics, some blood parameters and antibody titre against sheep red blood cells (SRBC) in quail. A total of 240 quail chicks were allotted to 4 treatments consisting of respectively 0, 1, 2 and 4 g/kg dietary MCFA. There were no significant differences in body weight, feed intake and feed conversion ratio among treatments at different stages of the experiment. MCFAs had no significant effect on breast, thigh, liver, spleen and bursa of Fabricius weight ratios. However, the relative weight of abdominal fat significantly decreased in quail receiving 0.2 and 0.4 MCFA as compared to other treatments. Concentrations of low-density lipoprotein-cholesterol (LDL), triglycerides and total cholesterol were decreased and high-density lipoprotein (HDL)-cholesterol was increased in quail chicks receiving MCFA compared with control quail chicks. The concentrations of SRBC antibody were not statistically different among treatments. It is concluded that MCFA significantly decreased LDL, triglycerides, cholesterol and abdominal fat and increased HDL in quail chicks.

Familial chylomicronemia syndrome and response to medium-chain triglyceride therapy in an infant with novel mutations in GPIHBP1

BACKGROUND

Severe hypertriglyceridemia predisposes to attacks of acute pancreatitis, a serious condition complicated by multiorgan failure, pancreatic necrosis, and mortality rates up to 20% in adults and 6.5% in children.

OVERVIEW

We describe an infant who suffered from an episode of acute pancreatitis from severe hypertriglyceridemia. Two major challenges complicate the case: identifying the etiology of severe hypertriglyceridemia and finding an efficacious treatment. A thorough history, physical examination, and laboratory workup failed to identify a clear etiology, prompting a genetic workup that identified compound heterozygous mutations in the glycosylphosphatidylinositol-anchored high-density lipoprotein-binding protein 1 (GPIHBP1) gene. This patient's hypertriglyceridemia responded to an infant formula rich in medium chain triglycerides (MCTs), and she remained free of pancreatitis 6 months later.

CONCLUSIONS

This case highlights the need to pursue a genetic evaluation in the absence of secondary causes of severe hypertriglyceridemia in infants. Patients with mutations in GPIHBP1 fail to respond to currently available lipid-lowering agents so dietary management-specifically, an extremely low-fat diet and supplementation with MCT-remains the cornerstone of therapy. Treatment in infants should focus on dietary measures rather than pharmacologic agents.

Lipid emulsions - Guidelines on Parenteral Nutrition, Chapter 6

The infusion of lipid emulsions allows a high energy supply, facilitates the prevention of high glucose infusion rates and is indispensable for the supply with essential fatty acids. The administration of lipid emulsions is recommended within ≤7 days after starting PN (parenteral nutrition) to avoid deficiency of essential fatty acids. Low-fat PN with a high glucose intake increases the risk of hyperglycaemia. In parenterally fed patients with a tendency to hyperglycaemia, an increase in the lipid-glucose ratio should be considered. In critically ill patients the glucose infusion should not exceed 50% of energy intake. The use of lipid emulsions with a low phospholipid/triglyceride ratio is recommended and should be provided with the usual PN to prevent depletion of essential fatty acids, lower the risk of hyperglycaemia, and prevent hepatic steatosis. Biologically active vitamin E (α-tocopherol) should continuously be administered along with lipid emulsions to reduce lipid peroxidation. Parenteral lipids should provide about 25–40% of the parenteral non-protein energy supply. In certain situations (i.e. critically ill, respiratory insufficiency) a lipid intake of up to 50 or 60% of non-protein energy may be reasonable. The recommended daily dose for parenteral lipids in adults is 0.7–1.3 g triglycerides/kg body weight. Serum triglyceride concentrations should be monitored regularly with dosage reduction at levels >400 mg/dl (>4.6 mmol/l) and interruption of lipid infusion at levels >1000 mg/dl (>11.4 mmol/l). There is little evidence at this time that the choice of different available lipid emulsions affects clinical endpoints.

High-level medium-chain triglyceride feeding and energy expenditure in normal-weight women

The objective of this study was to assess how short-term feeding of high levels of dietary medium-chain triglyceride (MCT) affect energy expenditure and postprandial substrate oxidation rates in normal-weight, premenopausal women. Eight healthy women were fed both a MCT-rich and an isocaloric long-chain triglyceride (LCT)-rich diet for two 1-week periods separated by a minimum of 21 days. The energy intake in each diet was 45% carbohydrates, 40% fat, and 15% protein. The 2 diets had either 60.81% or 1.11% of total fat energy from MCT with the remaining fat energy intake from LCT. On days 1 and 7 of each diet, resting metabolic rate and postprandial energy expenditure (EE) were measured by indirect calorimetry with a ventilated hood. Results indicated on days 1 and 7, there were no significant differences between diets for resting metabolic rate or mean postprandial EE. On both days 1 and 7, fat oxidation for the MCT-rich diet was significantly greater (0.0001 </= p </= 0.04) than that for the LCT-rich diet at different time points across the 5.5 h postprandial period. In conclusion, for premenopausal, normal-weight women consuming a diet with 25% of the energy content from MCT, there were no changes in resting metabolic rate, transient increases in postprandial energy expenditure, and significant increases in postprandial fat oxidation.

Safety evaluation of a medium- and long-chain triacylglycerol oil produced from medium-chain triacylglycerols and edible vegetable oil

To reduce the incorporation of dietary lipids into adipose tissue, modified fats and oils have been developed, such as medium-chain triacylglycerols (MCT). Typical dietary lipids from vegetable oils, termed long-chain triacylglycerols (LCT), are degraded by salivary, intestinal and pancreatic lipases into two fatty acids and a monoacyl glycerol; whereas, MCT are degraded by the same enzymes into three fatty acids and the simple glycerol backbone. Medium-chain fatty acids (MCFA) are readily absorbed from the small intestine directly into the bloodstream and transported to the liver for hepatic metabolism, while long-chain fatty acids (LCFA) are incorporated into chylomicrons and enter the lymphatic system. MCFA are readily broken down to carbon dioxide and two-carbon fragments, while LCFA are re-esterified to triacylglycerols and either metabolized for energy or stored in adipose tissue. Therefore, consumption of MCT decreases the incorporation of fatty acids into adipose tissue. However, MCT have technological disadvantages precluding their use in many food applications. A possible resolution is the manufacture and use of a triacylglycerol containing both LCT and MCT, termed medium- and long-chain triacylglycerol (MLCT). This manuscript describes studies performed for the safety evaluation of a MLCT oil enzymatically produced from MCT and edible vegetable oil (containing LCT), by a transesterification process. The approximate fatty acid composition of this MLCT consists of caprylic acid (9.7%), capric acid (3.3%), palmitic acid (3.8%), stearic acid (1.7%), oleic acid (51.2%), linoleic acid (18.4%), linolenic acid (9.0%), and other fatty acids (2.9%). The approximate percentages of long (L) and medium (M) fatty acids in the triacylglyerols are as follows: L, L, L (55.1%), L, L, M (35.2%), L, M, M (9.1%), and M, M, M (0.6%). The studies included: (1) acute study in rats (LD50>5000 mg/kg); (2) 6 week repeat-dose safety study via dietary administration to rats (NOAEL of 3500 mg/kg/day), (3) in vitro genotoxicity studies using Salmonella typhimurium and Escherichia coli (negative at 5000 mg/plate), and (4) a four-week, placebo-controlled, double blind, human clinical trial utilizing 20 test subjects (no effects at 42 g MLCT/day). These data are corroborated by other studies published in the peer-reviewed literature on analogous MLCTs.

beta2-adrenergic receptor polymorphisms and salbutamol-stimulated energy expenditure

The beta-adrenergic system is involved in the control of energy metabolism and expenditure. The beta2-adrenergic receptor (beta2-AR) gene shows polymorphisms that have been associated with obesity in several studies. In vitro and in vivo studies suggest differences in beta2-AR-mediated function between these polymorphisms. The aim of this study was to investigate the influence of genetic variation in codon 16 of the beta2-AR gene on energy metabolism in humans. Thirty-four subjects were recruited [Gly16Gly (n = 13), Gly16Arg (n = 16), or Arg16Arg (n = 5)]. The beta2-AR was stimulated with two doses of salbutamol (50 and 100 ng/kg fat-free mass per minute) after blockade of the beta1-adrenergic receptors with atenolol. Energy expenditure and plasma substrate and hormone concentrations were measured. The increase in energy expenditure (DeltaEE) was significantly different among groups in which the Arg16Arg group showed the lowest increase (P < 0.05 vs. Gly carriers). In a multiple regression model, variations in the increase in nonesterified fatty acid concentration during salbutamol infusion (partial r = 0.51) and the polymorphism contributed significantly to the variation in DeltaEE. Thirty-five percent of the variation in DeltaEE was explained by these two factors. We conclude that subjects with the Arg16Arg polymorphism of the beta2-AR gene have a reduced thermogenic response to beta2-adrenergic stimulation. Although this relatively small study needs confirmation, the findings support a role for this polymorphism in the development and maintenance of overweight and obesity.

Energy intake, metabolic balance and growth in preterm infants fed formulas with different nonprotein energy supplements

OBJECTIVE

To study metabolic and energy balances, growth and composition of increased body mass in healthy preterm infants fed control formula or control formula with three different nonprotein energy supplements.

PATIENTS AND METHODS

Growing preterm infants (birth weight < 1,500 g and gestational age < 31 weeks) were fed standard preterm formula (control group) or the same formula enriched with three different nonprotein energy supplements. An energy supplement of 23 kcal/kg/day was achieved by adding medium-chain triglyceride and dextrinomaltose in three different caloric ratios: 33:66 in group A, 66:33 in group B, and 85:15 in group C. Energy balance was determined by open-circuit continuous (5-6 hours) measurements of energy expenditure, with simultaneous measurement of 24-hour urinary nitrogen excretion. Metabolic balance was determined by measurements of energy intake, energy oxidation, and energy output in urine and stool. The composition of body mass accretion was determined as the accretion of fat and protein in the total weight gain.

RESULTS

The fat accretion (4.9, 5.9, 6.2, and 3.8 g/kg/day in groups A, B, C and D, respectively) correlated directly with fat intake. Infants receiving standard energy intake had a fat percentage of weight gain significantly lower (28%) than that of the high-energy intake groups (31%, 40%, and 38% in groups A, B, and C, respectively). This difference corresponded to the results obtained from skinfold thickness measurements.

CONCLUSIONS

Excess nonprotein energy is stored as fat regardless of its source (fat or carbohydrate). High caloric and medium-chain triglyceride intake in otherwise healthy growing preterm infants does not promote nitrogen retention.

Cardiopulmonary effects of lipid emulsions in patients with ARDS

STUDY OBJECTIVES

Lipid emulsions have been suspected of inducing certain modifications in gas exchange and pulmonary hemodynamics. The aim of this prospective study was to evaluate the hemodynamic and pulmonary effects of two lipid emulsions.

DESIGN

Prospective, randomized, double-blind, crossover study.

SETTING

Medical and surgical ICU in a French university hospital.

PATIENTS

Eighteen patients presenting ARDS.

INTERVENTIONS

Each patient received a 6-h infusion of a 20% fat emulsion containing 100% long-chain triglycerides (LCTs) and a 6-h infusion of 50% LCTs/50% medium-chain triglycerides (MCTs) 20% lipid emulsion at the rate of 1.0 mL/kg/h. An 18-h period with no lipids separated the two periods. An additional 18-h period after the end of the second lipid emulsion administration was observed prior to the final measurements.

MEASUREMENTS AND RESULTS

The MCT/LCT emulsion increased the PaO(2)/fraction of inspired oxygen (FIO(2)) ratio (p = 0.005) compared with LCT emulsion alone. The mean (+/- SD) PaO(2)/FIO(2) ratio increased from 165 +/- 55 to 191 +/- 64 mm Hg after 1 h of LCT/MCT administration (p < 0.03), and to 175 +/- 46 mm Hg after 6 h. Moreover, there was an increase in oxygen delivery after 6 h of LCT/MCT administration (p < 0.001 vs baseline). While a time-related increase in mean pulmonary artery pressure (p = 0.012) during lipid administration was found, no effect of the kind of lipid emulsion was observed. The time-related increase in cardiac index (p = 0.002) was more marked when the patients received the LCT/MCT emulsion (p = 0.002). Pulmonary vascular resistances were not affected by the kind of lipid emulsion.

CONCLUSIONS

The present work showed that while the LCT emulsion induced no deleterious effects on oxygenation in ARDS patients, the LCT/MCT emulsion improved the PaO(2)/FIO(2) ratio and had a further beneficial effect on oxygen delivery.

Parenteral structured triglyceride emulsion improves nitrogen balance and is cleared faster from the blood in moderately catabolic patients

BACKGROUND

Most postoperative patients lose net protein mass, which reflects loss of muscle tissue and organ function. Perioperative parenteral nutrition may reduce the loss of protein, but in general, with conventional lipid emulsions a waste of protein still remains.

METHODS

We compared the effects on nitrogen balance of an emulsion containing structured triglycerides, a new type of synthesized triglycerides, with an emulsion of a physical mixture of medium- and long-chain triglycerides as part of parenteral feeding in moderately catabolic patients. The first 5 days after placement of an aortic prosthesis patients received total parenteral nutrition (TPN) providing 0.2 g of nitrogen per kg body weight per day; energy requirement was calculated using Harris and Benedict's equation, adding 300 kcal per day for activity. Twelve patients were treated with the structured triglyceride emulsion and 13 patients with the emulsion of the physical mixture of medium- and long-chain triglycerides. The design was a randomized, double-blind parallel study.

RESULTS

In the patients who completed the study, the mean cumulative nitrogen balance over the first 5 postoperative days was -8+/-2 g in 10 patients on the structured triglyceride emulsion and -21+/-4 g in 9 patients on the emulsion of the physical mixture of medium- and long-chain triglycerides; the mean difference was 13 g of nitrogen (95% confidence interval 4 to 22, p = .015) in favor of the structured triglyceride emulsion. On the first postoperative day serum triglyceride and plasma medium-chain free fatty acid levels increased less during infusion of the structured triglyceride emulsion than with the physical mixture emulsion.

CONCLUSIONS

The parenteral structured triglyceride emulsion improves the nitrogen balance and is cleared faster from the blood, compared with the emulsion of the physical mixture of medium- and long-chain triglycerides, in moderately catabolic patients.

Long-chain versus medium-chain lipids in acute pancreatitis complicated by acute respiratory distress syndrome: effects on pulmonary hemodynamics and gas exchange

BACKGROUND AND AIMS

In order to assess the effects of fat emulsions in patients with acute pancreatitis and acute respiratory distress syndrome (ARDS) before the pancreatic injury was complicated by infection, pulmonary hemodynamics and gas exchange were investigated during the administration of long-(LCTs) or medium-chain triacylglycerols (MCTs).

METHODS

This prospective trial included nine patients with acute pancreatitis and ARDS; each patient was used as his/her own control. In all cases, the needle aspiration culture of the pancreas was negative. Fat emulsion provided 50% of the energy expenditure. The patients were infused, in random order, with pure LCTs and a 1:1 mixture of LCTs/MCTs on days 1 and 2, over an 8 h period.

RESULTS

LCT infusion increased the mean pulmonary artery pressure (MPAP) from 28+/-5 to 35+/-3 mmHg, pulmonary venous admixture (Qva/Qt) from 26+/-5% to 36+/-5% and decreased arterial PO2(PaO2)/fractional inspired oxygen (FIO2) from 210+/-20 to 170+/-20 (P<0.05). The infusion of LCT/MCT 1:1 emulsions increased oxygen consumption (VO2) from 340+/-10 to 398+/-15 ml/min, cardiac output (CO) from 8.8+/-0.2 to 9.5+/-0.5 L/min and CO2 production (VCO2) from 247+/-12 to 282+/-14 mL/min (P<0.05).

CONCLUSION

LCT/MCT 1:1 mixtures are recommended in cases of acute pancreatitis and ARDS, even though infusion over a short period increases the metabolic demand.

Nitrogen sparing effect of structured triglycerides containing both medium-and long-chain fatty acids in critically ill patients; a double blind randomized controlled trial

BACKGROUND AND AIMS

Patients with sepsis and trauma are characterised by hypermetabolism, insulin resistance and protein catabolism. Fat emulsions containing medium chain triglycerides have been suggested to be beneficial for these patients since medium chain fatty acids are a more readily available source of energy when compared to long chain fatty acids. The aim of this study was to compare a medium and long chain triglyceride emulsion consisting of structured triglycerides (ST) with a long chain triglyceride (LCT) emulsion in terms of effects on nitrogen balance, energy metabolism and safety.

METHODS

30 ICU patients with sepsis or multiple injury received a fat emulsion with ST or 20% LCT (1.5 g triglycerides/kg body weight/day) as a component of total parenteral nutrition (TPN), for 5 days in a double blind randomised parallel group design. The main analysis was made on the 3 day per protocol population due to lack of patients at day 5.

RESULTS

There were no differences in baseline characteristics of the two groups receiving either the LCT or the ST emulsion. The efficacy analysis was performed on the per protocol population (n=9 ST, n=11 LCT). There was a significant difference between the two treatments regarding daily nitrogen balances when the first 3 days were analysed P=0.0038). This resulted in an amelioration of the nitrogen balance on day 3 in the group on ST as compared to those on LCT (0.1+/-2.4 g vs -9.9+/-2.1 g P=0.01). The 3 day cumulative nitrogen balance was significantly better in the group receiving ST compared to those on LCT (-0.7+/-6.0 vs -16.7+/-3.9 P=0.03). This better cumulative nitrogen balance on day 3 was also preserved as a tendency (P=0.061) in the analysis of the intention to treat population, but on day 5 there was no significant difference (P=0.08). The ST emulsion was well tolerated and no difference was found compared to the LCT emulsion regarding respiratory quotient, energy expenditure, glucose or triglyceride levels during infusion.

CONCLUSION

Administration of a structured triglyceride emulsion resulted in an amelioration of nitrogen balance despite no effect on energy expenditure in short term administration over 3 days to ICU patients when compared to a long chain triglyceride emulsion. No side effects linked to medium chain triglycerides were noted.

Estimating energy expenditure in critically ill adults and children

Designing effective nutrition support regimens for critically ill patients requires an understanding of the energy needs of each patient. Many disease processes result in elevated caloric requirements, whereas some clinical procedures and medications may diminish the metabolic response. Experienced clinicians are unable to predict the extent to which trauma or injury will affect energy requirements for an individual. Both under- and overfeeding a critically ill patient may prolong hospitalization and increase morbidity and mortality. Applying equations that were originally developed for healthy nonhospitalized individuals to predict the energy requirements of critically ill patients will often result in significant errors and may lead to provision of inappropriate nutritional support. The measurement of resting energy expenditure by indirect calorimetry is a valuable tool and can be used to predict energy requirements for most spontaneously breathing critically ill patients, but may lead to spurious results in mechanically ventilated pediatric patients. In the complex and rapidly changing context of critical illness, individualized assessment of energy requirements is crucial. Whichever technique is used initially to assess energy requirements, sequential monitoring and constant reassessment of each patient is essential to provide the appropriate nutritional care regimen. The purpose of this article is to review the equations for estimating and the techniques, practical aspects, and interpretation of measuring energy expenditure in critically ill patients.

Structured lipids improve fat absorption in normal and malabsorbing rats

The presence of medium-chain fatty acids in dietary fatty acid as well as the triacylglycerol structure may influence the absorption and lymphatic transport of fatty acids. We compared the lymphatic transport and recovery of fatty acids from four intragastrically administered fats based on rapeseed oil and decanoic acid in two rat models of normal absorption and malabsorption, respectively. The fats were: 1) a fat with a regiospecific structure, 2) a similar fat but with a random distribution of fatty acids in the triacylglycerol molecule, 3) a physical mixture of tridecanoin and rapeseed oil and 4) rapeseed oil as control. Lymph samples were collected for 24 h. Significantly higher recoveries were observed of total fatty acids, oleic acid, linoleic acid and linolenic acid from the specific oil in malabsorbing rats and of linoleic acid in normal rats fed specific oil compared with those fed rapeseed oil. Furthermore, the recoveries of oleic acid and linolenic acid from the specific oil in normal rats were higher than those from the other oils. In malabsorbing rats, the transport of all fats was approximately 90% less than that of normal rats. The present study demonstrates improved hydrolysis and absorption of the specific oil compared with the other oils examined both in rats with normal absorption and in rats with malabsorption.

Endogenous fat oxidation during medium chain versus long chain triglyceride feeding in healthy women

OBJECTIVE

To compare the effect of medium chain triglycerides (MCT) vs long chain triglycerides (LCT) feeding on exogenous and endogenous oxidation of long chain saturated fatty acids (LCSFA) in women.

SUBJECTS

Twelve healthy female subjects (age 19-26 y, body mass index (BMI) 17.5-28.6 kg/m2)

DESIGN AND MEASUREMENTS

In a randomized cross-over design, subjects were fed weight maintenance diets providing 15%, 45% and 40% of energy as protein, carbohydrate and fat, respectively, with 80% of this fat comprising either a combination of butter and coconut oil (MCT) or beef tallow (LCT). Following 6 days of feeding, subjects were given daily oral doses of 1-(13)C labelled-myristic, -palmitic and -stearic acids for 8 days. Expired 13CO2 was used as an index of LCSFA oxidation with CO2 production assessed by respiratory gas exchange.

RESULTS

No difference in exogenous LCSFA oxidation was observed as a function of diet on day 7. On day 14, greater combined cumulative fractional LCSFA oxidation (16.9 +/- 2.5%/5.5 h vs 9.1 +/- 1.2%/5.5 h, P < 0.007), net LCSFA oxidation (2956 +/- 413 mg/5.5 h vs 1669 +/- 224 mg/5.5 h, P < 0.01), and percentage dietary LCSFA contribution to total fat oxidation (16.3 +/- 2.3%/5.5 h vs 9.5 +/- 1.5%/5.5 h; P < 0.01) were observed in women fed the MCT vs LCT diet. With the MCT diet, but not the LCT diet, combined cumulative fractional LCSFA oxidation (P < 0.03), net LCSFA oxidation (P < 0.03), and percentage dietary LCSFA contribution to total fat oxidation (P < 0.02) were increased at day 14 as compared to day 7. Day 14 results indicated increased endogenous LCSFA oxidation during MCT feeding.

CONCLUSION

The capacity of MCT to increase endogenous oxidation of LCSFA suggests a role for MCT in body weight control over the long term.

Components of total energy expenditure in healthy young women are not affected after 14 days of feeding with medium-versus long-chain triglycerides

OBJECTIVE

To examine the effect of consumption of medium-chain triglycerides (MCT) vs. long-chain triglycerides (LCT) on total energy expenditure (TEE) and its components in young women during the second week of a 2-week feeding period.

RESEARCH METHODS AND PROCEDURES

Twelve healthy lean women (age: 22.7+/-0.7 years, body mass index [BMI]: 21.5+/-0.8 kg/m2) were fed weight maintenance diets containing 15% of energy as protein, 45% as carbohydrate, and 40% as fat, 80% of which was treatment fat, for 2 weeks in a randomized cross-over design separated by a 2-week washout period. Dietary fat was composed of triglycerides containing either 26% medium-chain fatty acids (MCFA) and 74% long-chain fatty acids (LCFA), or 2% MCFA and 98% LCFA. Free-living TEE was measured from day 7 to 14 on each dietary treatment using doubly labeled water (DLW). Basal metabolic rate (BMR) and thermic effect of food (TEF) were measured on days 7 and 14 using respiratory gas exchange analysis (RGE) for 30 minutes and 330 minutes, respectively. Activity-induced energy expenditure (AIEE) was derived as the difference between TEE and the sum of BMR and TEF.

RESULTS

The average TEE while consuming the MCT diet (2246+/-98 kcal/day) did not differ from that of the LCT diet (2186+/-138 kcal/day. BMR was significantly higher on the MCT diet on day 7 (1219+/-38 kcal/day vs. 1179+/-42 kcal/day), but not on day 14; there was no effect of diet on TEF. There were no differences in BMR, TEF, or AIEE between diets when expressed as percentages of TEE. On average, BMR, TEF, and AIEE represented 54.6%, 8.2%, and 37.2%, respectively, of TEE.

DISCUSSION

Results suggest that between day 7 and day 14 feeding of MCT vs. LCT at these levels, TEE is not affected and that increases seen in energy expenditure following MCT feeding may be of short duration. Thus, compensatory mechanisms may exist which blunt the effect of MCT on energy components over the longer term.

Enhanced postprandial energy expenditure with medium-chain fatty acid feeding is attenuated after 14 d in premenopausal women

BACKGROUND

Medium-chain triacylglycerols (MCTs) are reported to enhance human energy expenditure (EE), although few studies have involved women and the duration of such effects is only known for periods of approximately 7 d.

OBJECTIVE

This study was conducted to determine whether women consuming mixed, MCT-enriched or long-chain triacylglycerol (LCT)-enriched diets showed changes in EE or substrate oxidation after 7 and 14 d.

DESIGN

Twelve nonobese, premenopausal women were fed isoenergetic mixed diets enriched in either MCTs or LCTs during separate, 14-d feeding periods. Each meal contained 40% of energy as fat (80% of which was the treatment fat), 45% as carbohydrate, and 15% as protein. On days 7 and 14 of each trial, basal metabolic rate (BMR, kJ/min), total energy expenditure (TEE, kJ/min), and thermic effect of feeding (deltakJ/min) after a standardized breakfast were measured by respiratory gas exchange.

RESULTS

On day 7, the mean (+/-SEM) BMR (3.58+/-0.11 kJ/min) with the MCT diet was greater (P = 0.0003) than that with the LCT diet (3.43+/-0.11 kJ/min). The mean postprandial TEE on day 7 was significantly greater (P = 0.04) with the MCT diet (4.36+/-0.04 kJ/min) than with the LCT diet (4.23+/-0.04 kJ/min); by day 14, postprandial TEE was still greater with the MCT diet, but not significantly so. No significant differences in the thermic effect of feeding were evident between diets.

CONCLUSIONS

Results from this longest controlled MCT feeding study to date suggest that short-term feeding of MCT-enriched diets increases TEE, but this effect could be transient with continued feeding.

Medium chain fatty acid metabolism and energy expenditure: obesity treatment implications

Fatty acids undergo different metabolic fates depending on their chain length and degree of saturation. The purpose of this review is to examine the metabolic handling of medium chain fatty acids (MCFA) with specific reference to intermediary metabolism and postprandial and total energy expenditure. The metabolic discrimination between varying fatty acids begins in the GI tract, with MCFA being absorbed more efficiently than long chain fatty acids (LFCA). Subsequently, MCFA are transported in the portal blood directly to the liver, unlike LCFA which are incorporated into chylomicrons and transported through lymph. These structure based differences continue through the processes of fat utilization; MCFA enter the mitochondria independently of the carnitine transport system and undergo preferential oxidation. Variations in ketogenic and lipogenic capacity also exist. Such metabolic discrimination is supported by data in animals and humans showing increases in postprandial energy expenditure after short term feeding with MCFA. In long term MCFA feeding in animals, weight accretion has been attenuated. These differences in metabolic handling of MCFA versus LCFA are considered with the conclusion that MCFA hold potential as weight loss agents.

Effect of continuous enteral medium-chain fatty acid infusion on lipid metabolism in rats

This study compared (i) the relative effects of long-chain triglycerides (LCT) and medium-chain triglycerides (MCT), (ii) the influence of amount of MCT, and (iii) the impact of medium-chain fatty acid position, on plasma and lymphatic triglycerides and portal vein free fatty acids. The animals were fed approximately at 250 kcal/kg.day for 20 h. The lymph from lymphatic duct and blood from portal vein and systemic circulation were collected. The results showed that feeding 100% MCT for 20 h was sufficiently long to reduce significantly the level of linoleic acid in portal vein fatty acids and plasma and lymph triglycerides. However, this alteration induced by MCT feeding was partially prevented by adding LCT to the diet. The level of arachidonic acid was significantly reduced in plasma triglycerides by any of the diets containing medium-chain fatty acids compared to 100% LCT. When feeding MCT only, palmitoleic acid, presumably reflecting de novo lipogenesis, was increased in lymphatic triglycerides and portal vein fatty acids. Total saturated fatty acids as a total percentage of total fatty acids were also significantly increased in plasma and lymphatic triglycerides and portal vein fatty acids. Thus, when linoleic acid is limiting, the conversion of MCT into long-chain fatty acids by de novo lipogenesis is likely to be an important metabolic route. Providing LCT with MCT or 2-monodecanoin appears to limit this pathway.

Do infants with cystic fibrosis need a protein hydrolysate formula? A prospective, randomized, comparative study

OBJECTIVES

We compared the nutritional benefits of a protein hydrolysate and a conventional infant formula in infants newly diagnosed with cystic fibrosis (CF).

STUDY DESIGN

Twenty-three infants with CF (<6 months of age) and pancreatic insufficiency were randomized to receive a hydrolysate formula (Alimentum) or a cow's milk-based formula (Similac). Each patient was monitored at 1 month and then every 3 months for 1 year.

RESULTS

Eighteen patients (8 Alimentum, 10 Similac) completed the study. At entry, the age distribution and clinical characteristics of each group were comparable. Energy intake with each formula was the same at 1 and 3 months, but at 6 and 12 months the hydrolysate-fed infants had higher age-adjusted energy intake. There were no differences in fecal energy or fecal fat at entry or throughout the study. Although the hydrolysate-fed infants were slightly more malnourished at diagnosis, growth velocity and nutritional status of infants with CF in each group were the same throughout the study.

CONCLUSIONS

The results of this randomized study fail to support the use of a hydrolyzed formula for the routine care of infants newly diagnosed with CF.

The metabolic distinctiveness of emulsified lipid particles in the bloodstream and its clinical implications

The advantages of administering intravenous fat emulsions are well known. Primarily, they are important sources of essential fatty acids; they allow the administration of many calories within a small volume; and they are isotonic compared to body fluid. In this review, the metabolic distinctiveness of parenterally infused fat particles in the bloodstream is evaluated under four main headings: (1) the structure and metabolism of fat emulsion particles; (2) the metabolism of phospholipid-rich fat emulsion; (3) the interactions between fat emulsion particles and plasma lipoproteins; and (4) the acquisition of protein moieties (apolipoproteins) by fat emulsion particles and its clinical implications.

Parenteral use of medium-chain triglycerides: a reappraisal

Over the last two decades, the clinical use of intravenous fat emulsions for the nutritional support of hospitalized patients has become routine. During this time long-chain triglycerides (LCT) derived from soybean and/or safflower oils were the exclusive lipid source for these emulsions, providing both a safe calorically dense alternative to dextrose and essential fatty acids needed for biologic membranes and the maintenance of immune function. During the past decade, the availability of novel experimental triglycerides for parenteral use has generated interest in the use of these substrates for nutritional and metabolic support. Medium-chain triglycerides (MCT), long advocated as a superior substrate for parenteral use, possess many unique physiochemical and metabolic properties that make them theoretically advantageous over their LCT counterparts. Although not yet approved in the United States, preparations containing MCT have been widely available in Europe. Intravenous MCT preparations, either as physical mixtures or structured lipids, have been used clinically in patients with immunosuppresion, critical illness, liver and pulmonary disease and in premature infants. Despite great promise, the clinical data comparing the efficacy of MCT-based lipid emulsions to their LCT counterparts has been equivocal. This may be due in part to the limited nature of the published clinical trials. Measures of efficacy for parenteral or enteral nutritional products has taken on new meaning, in light of the reported experience using immunomodulatory nutrients. Current concerns about cost of medical care and resource use warrant careful deliberation about the utility of any new and expensive therapy. Until clinical data can fulfill expectations derived from animal studies, it is difficult to advocate the general use of MCT-based lipid emulsions. Future clinical studies with MCT-based emulsions should have clear outcome objectives sufficient to prove their theorized metabolic superiority.

Indirect calorimetry in critically ill patients: role of the clinical dietitian in interpreting results

Evaluation and interpretation of energy needs of critically ill patients require the expertise of clinical dietitians: Dietitians must be knowledgeable about the methods available to quantify energy needs and able to communicate effectively with physicians and nurses regarding nutritional requirements. Several prediction equations are available for calculating energy needs of critically ill patients. Indirect calorimetry is also used frequently to measure energy requirements in this patient population. This article defines when energy expenditure measured by indirect calorimetry may provide clinically useful information. Data obtained by indirect calorimetry must be interpreted carefully. Indirect calorimetry is based on the equations for oxidation of carbohydrate, protein, and fat. Errors in interpretation can be made when metabolic pathways other than oxidation dominate or when clinical conditions exist that affect carbon dioxide excretion from the lungs. Before incorporating data obtained from indirect calorimetry into a nutrition care plan, the clinical dietitian should carefully evaluate the following factors for a patient: clinical conditions when the measurement was made, desired weight loss or gain, tolerance to food or nutrition support, relationship between protein intake and energy need, and need for anabolism or growth. This article provides clinical examples illustrating how measured values compare with calculated values and recommendations for how to incorporate measured values into nutrition care plans.

Structured triglycerides were well tolerated and induced increased whole body fat oxidation compared with long-chain triglycerides in postoperative patients

BACKGROUND

It has been proposed, on the basis of animal experiments, that medium-chain triglycerides (MCT) may exert more favorable effects on whole body metabolism of injured animals than long-chain triglycerides (LCT). Therefore, the present study was designed to evaluate whether structured triglycerides are associated with increased whole body fat oxidation without promotion of ketogenesis in postoperative patients.

METHODS

A structured lipid emulsion (73403 Pharmacia, Sweden) containing medium- and long-chain fatty acids, esterified randomly to glycerol in a triglyceride structure, was used. Whole body fat oxidation was determined by indirect calorimetry in the postoperative period. Patients were randomized to receive structured lipids 1 day followed by LCT (Intralipid, Pharmacia) the next day or vice versa during 6 postoperative days. In part 1 of the study patients received fat at 1.0 g/kg per day in the presence of 80% of the basal requirement of nonprotein calories. In part 2 patients received fat at 1.5 g/kg per day in the presence of 120% of the nonprotein caloric requirement. Amino acids were always provided at 0.15 g N/kg per day.

RESULTS

Structured lipids were not associated with any side effects, were rapidly cleared from the plasma compartment, and were rapidly oxidized without any significant hyperlipidemia or ketosis. Provision of structured lipids in the presence of excess of nonprotein calories (part 2) caused a significantly higher whole body fat oxidation (2.4 +/- 0.05 g/kg per day) compared with LCT provision (1.9 +/- 0.06 g/kg per day) (p < .0001) examined in the same patients.

CONCLUSIONS

The results demonstrated for the first time in man that provision of structured triglycerides were associated with increased whole body fat oxidation in stressed postoperative patients, which is in line with the original metabolic and biochemical concept for structured triglycerides. The study provided evidence to support that structured lipids may represent a next generation of IV fat emulsions that may be clinically advantageous compared with conventional LCT emulsions in certain clinical conditions.

Hemodynamic, respiratory, and metabolic effects of medium-chain triglyceride-enriched lipid emulsions following valvular heart surgery

STUDY

A lipid emulsion containing 10 percent medium-chain triglycerides (MCT) and 10 percent long-chain triglycerides (LCT) was infused at a rate of 1 ml/kg/h (3.3 mg/kg/min) for 2 h, in 12 patients (2 males, 10 females; mean age, 54 +/- 3 (SEM) years; range, 34 to 67 years) 24 h after open-heart surgery (mitral valve replacement).

METHODS

Hemodynamic factors (pulmonary and radial artery indwelling catheters), oxygen and carbon dioxide partial pressures, oxygen saturation, oxygen delivery and consumption, and intrapulmonary shunt fraction were obtained before, during, and after lipid infusion (for 2 h), at 30-s intervals, along with some metabolic indexes (triglycerides, free fatty acids, glucose, insulin, lactate, acetoacetate).

RESULTS

No statistically significant changes in heart rate, cardiac index, systemic and pulmonary pressures and resistances, central venous and pulmonary capillary pressures, or arterial oxygen partial pressure were observed during infusion. Arterial carbon dioxide partial pressure values were constantly reduced throughout and after the end of lipid infusion, as compared with baseline values, while oxygen consumption was increased significantly without any change in oxygen delivery. No adverse effects on intrapulmonary shunt fraction were observed. Statistically significant increases of triglycerides, free fatty acids, acetoacetate and insulin (peak values at end of the lipid infusion) were found in comparison with baseline values. Plasma glucose increased significantly during lipid infusion and remained higher than baseline values until the end of the study. Lactate levels were unchanged except for a slight decrease at the end of the study, without any derangement of acid-base equilibrium. Neither arrhythmias nor adverse clinical reactions were observed as a consequence of lipid infusion.

CONCLUSIONS

Fat emulsions containing both MCT and LCT, when given at 3.3 mg/kg/min for 120 min following valvular heart surgery, do not exert negative cardiopulmonary effects, and could represent a source of rapidly metabolized substrates.

Kinetics of medium-chain triglycerides and free fatty acids in healthy volunteers and surgically stressed patients

To determine the hydrolysis rate of medium-chain triglycerides (MCTs) to medium-chain free fatty acids (MCFAs) and the disposition rate of MCFAs, five healthy volunteers (H) and eight surgically stressed patients (S) received 0.5 mL of Lipofundin 20% per kilogram body weight as an intravenous bolus. Serum MCTs (C8 and C10) and MCFAs were measured by high-performance liquid chromatography during the 120 minutes postinjection. A linear two-compartment model was found to be descriptive and robust: the apparent volumes of distribution were found to be similar in healthy and surgical subjects for both MCTs and MCFAs. The first-order transformation rate constant (hydrolysis) from MCTs to MCFAs was not significantly different between the H and S groups (overall 0.112 +/- 0.022/min, C8; 0.078 +/- 0.020/min, C10). The rate constant for tissue MCFA uptake from plasma was significantly different between S and H subjects both for C10 alone (H: 0.0337 +/- 0.0078; S: 0.1194 +/- 0.0240; p = .020) and for C8 and C10 together (H: 0.0382 +/- 0.0054; S: 0.1012 +/- 0.0168; p = .008), whereas it failed to attain significance when C8 alone was considered (H: 0.047 +/- 0.0077; S: 0.0829 +/- 0.0230; p = .210). These results show that use of MCTs is increased in surgical patients because of enhanced tissue uptake of the corresponding free fatty acids, whereas there does not seem to be an increase of MCT hydrolysis in response to acute disease. This would indicate that the stressed patient is in fact able to effectively use this alternative lipid substrate in the face of increased metabolic demand.

Different effects of long-chain and medium-chain triglycerides on glucose oxidation during total parenteral nutrition

This study was undertaken to clarify differences in the effects of lipid emulsions containing either long-chain or medium-chain triglycerides (MCT) on glucose metabolism during total parenteral nutrition (TPN). Glucose kinetics were assessed in beagle dogs using primed, constant infusions of [14C]- and [6-3H]glucose. The rate of appearance of glucose, the percent of VCO2 derived from the oxidation of glucose, the rate of glucose oxidation, and the percent of glucose uptake oxidized were measured at the end of 72 hours of each of the two TPN regimens, ie, TPN in which soybean oil served as long-chain triglyceride comprising 40% of nonprotein calories (L-TPN), and TPN in which tricaprylin emulsion served as MCT (M-TPN). Glucose intake was 5.9 +/- 0.5 mg/kg per minute in L-TPN and 5.8 +/- 0.2 mg/kg per minute in M-TPN. There was no significant difference in the rate of glucose appearance between L-TPN and M-TPN. The rate of glucose oxidation was higher with M-TPN than with L-TPN (p < .05). Not only the percent of VCO2 derived from the oxidation of glucose but also the percent of glucose uptake oxidized tended to be higher during M-TPN than during L-TPN. These findings suggest that the glucose metabolism of dogs receiving L-TPN is different from that of dogs receiving M-TPN.

Insulinotropic potency of lauric acid: a metabolic rationale for medium chain fatty acids (MCF) in TPN formulation

The need for a better lipid system to satisfy the fuel requirements of patients while avoiding the adverse effects of current systems has led to suggestions that medium chain fatty acids (MCFs) be incorporated into TPN-lipid emulsions. Since clinical situations requiring TPN are associated with metabolic processes mediated by insulin, in the present study we have therefore examined the effects of a variety of medium chain fatty acids on insulin release. Using an isolated perifused mouse islet model, various doses of medium chain fatty acids and the essential fatty acid, linoleic acid, were tested and compared. The possibility of an additive effect of an insulinotropic MCF and linoleate when both are provided together was also examined. Effluent perifusate samples collected on ice during these experiments were assayed for insulin by radioimmunoassay. It was found that the ability of 5 mM of a given MCF to stimulate insulin secretion was dependent upon its chain length. Thus, while adipic acid (C6) had no effect, Caprylic acid (C8) had a minimal effect that was not statistically significant, but capric acid (C10) and lauric acid had very potent effects that were of the same magnitude to the effect of linoleate on insulin secretion. When insulin output was assessed as the mean integrated area under the curve during a 20-min perifusion, 5 mM lauric acid enhanced insulin secretion from a basal 7351 +/- 666 pg to 15,756 +/- 1680 pg (P less than 0.01, n = 5). In the same experiments, 5 mM linoleic acid stimulated insulin release to 11,260 +/- 867 pg (P less than 0.05). When C12 and linoleate were added together, each at a submaximally effective concentration of 2.5 mM, insulin output was 12,712 +/- 1011 pg (P less than 0.05, n = 5), which was not statistically different from the values obtained when the islets were perifused with 5 mM of each fatty acid alone.(ABSTRACT TRUNCATED AT 250 WORDS)