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Clinical Nutrition (1999) 18(2): 63-70

1999 Harcourt Brace & Co. Ltd

REVIEW

The effects of enteral tube feeding and parenteral


nutrition on appetite sensations and food intake in health
and disease
R. J. STRATTON, M. ELlA
MRC Dunn Clinical Nutrition Centre, Hills Road, Cambridge, CB2 2DH, UK (Correspondence to: RJS)
Abstract--Enteral tube feeding (ETF) and parenteral nutrition (PN) are unphysiological methods of
feeding. They may not elicit the cephalic phase response because part or all of the gastrointestinal tract
is bypassed, nutrients are typically given in liquid form by a continuous infusion over many hours and
often overnight while patients sleep. Work conducted in animals, healthy subjects and patients suggests
that nutrients delivered as ETF or PN are less effective in relieving appetite sensations than food intake.
Distressing appetite sensations may even occur despite the provision by artificial nutrition of sufficient
nutrients to meet requirements. The energy provided by ETF and PN is largely additional to oral food
intake in humans eating ad libitum, although the extent to which this occurs may decrease with time.
There is a need to establish ways (e.g. nutritional, pharmacological, psychological) to suppress appetite
sensations and food intake when eating is contraindicated, and to enhance them when weaning from
artificial nutrition is desirable.

Key words: parenteral nutrition; enteral nutrition; food


intake; appetite

in salivation (8), gastric acid secretion (9-12), and pancreatic endocrine (insulin) (13-15) and exocrine secretions
(16, 17). The cephalic phase response may even influence
postingestional responses, such as intestinal absorption (7),
dietary induced thermogenesis (3, 18, 19), and appetite
sensations (3, 4). Therefore, there are good reasons for
believing that appetite disturbances may occur in patients
receiving ETF or PN. And yet, despite the established use
of these unphysiological ways of delivering nutrients, little
attempt has been made to quantify the effects of ETF and
PN on appetite and food intake in humans. Knowledge in
this area may be used clinically in those receiving artificial
nutrition, to either suppress appetite sensations in those
in whom food intake is contraindicated, or to stimulate
appetite, and hence food intake, in anorectic patients who
are able to eat, and so reduce their need for artificial
nutritional support. However, many disease-related factors
need to be taken into account including drug therapy,
mobility, disease activity, nutritional status, psychological
status, hospitalization and the quality of food provision, and
also the patient's ability to eat.
The aim of this review was to consolidate our knowledge
about the effects of ETF and PN on appetite and food
intake, summarising and critically evaluating the findings
from studies in animals and from humans in health and
disease. More specifically, the review aimed to address the
following questions: Does ETF satisfy hunger and other
appetite sensations in the absence of food intake? Does
the delivery of nutrients by ETF simply replace or add
to oral food intake? Is it possible that ETF may stimulate
appetite and food intake? Do ETF schedules, varying in
timing and rate of delivery, have different effects on appe-

Background
Enteral and parenteral methods of feeding are unphysiological in at least three ways. Firstly, feeds are typically
infused in liquid consistency and often continuously over
many hours (12 to 24 h), as opposed to intermittent ingestion of solid or' solid-liquid food at meal times. Secondly,
the feed is often administered overnight while the patient
sleeps. Thirdly, the nutrients bypass part (enteral tube) or all
(intravenous nutrition) of the gastrointestinal tract, which is
normally involved in the regulation of appetite and food
intake (1, 2). Therefore, disturbances in appetite sensations
may occur in patients receiving enteral tube feeding (ETF)
and parenteral nutrition (PN). This could also partly be
due to the absence of the cephalic phase response that is
normally elicited by the presence of food in the upper
gastrointestinal tract (3, 4). The cephalic involvement in
digestion has been defined as the 'autonomic and endocrine
reflexes involved in the metabolism of food that are
triggered by sensory contact with food stuffs rather than
by postingestional consequences of food' (5). Taste, smell,
sight and sound of food (6) and stimulation of chemoreceptors and mechanoreceptors by chewing and swallowing
can trigger a cephalic response (for review (7)).
It has been suggested that stimulation of the oropharyngeal cavity in humans, typically using the modified sham
feeding model (tasting, chewing and spitting of food
without swallowing), elicits cephalic-gut reflexes, resulting
63

64

EFFECTS OF ENTERAL TUBE FEEDING

tite and food intake? Does PN relieve or prevent distressing


appetite sensations in the absence of food intake? Does
PN replace or add to oral food intake? This review also set
out to identify the shortfalls in our current knowledge and
suggest important areas for further research.

Does enteral tube feeding satisfy hunger and other


appetite sensations in the absence of food intake?
Studies in animals
Nutrient infusions through gastric fistulae provided initial
insights into the effects of bypassing the upper gastrointestinal tract on appetite. Studies in rats (20, 21) reported
that 'hunger' was significantly lower when milk was ingested intragastrically, than when taken orally. It was therefore concluded that 'mouth factors' (sight, smell, taste and
swallowing of food) were necessary to bring about rapid
and significant reduction in 'hunger'.

Studies in healthy subjects


Studies in healthy subjects, as in animals, have also suggested that the cephalic phase response is important in the
control of appetite. Oropharyngeal stimulation alone, using
the modified sham feeding model, has been reported to
reduce hunger (3, 22, 23) but very few studies in humans
have examined, in a controlled way, the effect of tube
feeding on appetite. Although Cecil et al. (24) recently
documented reduced hunger and increased fullness following intragastric administration of nutrients in healthy
subjects, the infusions consisted of individual macronutrients which were administered as very large 'boluses'
(4.2 MJ (1000 kcal), over 15 min). This is quite unlike the
feeding schedules used therapeutically, that typically
involve continuous infusions of feeds with a mixed macronutrient composition over many hours or intermittent
infusions of small boluses (0.84 MJ (200 kcal)). Of more
clinical relevance are Jordan's series of studies in healthy
men (25, 26), which although only short term, found continuous, intragastric, complete liquid diet infusions for up
to 48 h did not reduce hunger to the same extent as when
the same feed was taken orally via a straw. In addition,
after only 6 h of intragastric feeding, subjects not only experienced hunger sensations but reported that they missed
chewing and tasting and oral stimulation, and expressed
a strong desire to eat. These findings have important implications for individuals who receive all their nutrient
requirements by a tube placed in the stomach.

Studies of enteral tube feeding in disease


Tube feeding has been used for centuries to treat sick
patients and those unable to eat (for a review, see Randall
(27)). Anecdotal reports of hospitalized patients with a
partial gastrectomy, suggested that enteral tube feeding for
an average of 17 days did not fully satiate or relieve hunger
to the same extent as eating and drinking (28). One such

patient (age 39 years, weight -65 kg) was fed 19.7 MJ


(4690 kcals) per day in response to complaints of hunger
which the author described as 'a phenomenon connected
with convalescence which bears further investigation'. Over
40 years later, Quill (1989) studied the use of nasogastric
tube feeding in elderly patients with chronic illness. He
surmised that although ETF prevented the medical states
of malnutrition and dehydration, there was insufficient
data to assess whether it relieved the sensations of hunger
and thirst (29). The experiences of patients fed by tube at
home for long periods of time (from 1 to 47 years) have
been presented as fascinating case studies (30-32). In these
individuals, who were unable to eat, the provision of all
their nutritional needs by tube feeding alone did not produce
satiation. As the author of one of these reports stated,
Hunger is not necessarily a pleasant experience. Indeed, hunger
is perhaps more commonly unpleasant even painful (33)
In order to satisfy their appetite the patients tasted and
chewed food in the mouth before spitting it out and placing
it into the stomach via a gastrostomy tube. A survey of hospitalized patients fed by a nasogastric tube, was undertaken
by Padilla et al. (34), who reported that the most common
sensations relating to psychosensory deprivation were an
unsatisfied appetite for certain foods, and the desire to taste,
chew and swallow food material. These sensations were
similar to those reported by Jordan et al. in short-term
studies of ETF in healthy men (25, 26).
The British Artificial Nutrition Survey (BANS) has
reported that more than half of the patients receiving longterm tube feeding at home take no food orally (35). Most
often, these patients have swallowing-related problems
due to mechanical (e.g. cancer of the mouth or oesophagus)
or neurological (e.g. cerebrovascular accident, multiple
sclerosis) difficulties. However, the ability of ETF to
suppress hunger and alleviate distressing appetite sensations
in such patients has been poorly investigated. We
have undertaken clinical studies, both in the community and
the hospital settings, to assess appetite sensations in patients
who receive all their nutrients through a tube placed in the
stomach. We recently reported that 50% of such patients
receiving treatment at home were hungry and 33% were
distressed by their hunger. Eighty three percent had a
desire to eat and 75% reported that they missed and even
craved particular foods or drinks (36). In contrast, only 22%
of hospitalized patients with acute but stable neurological
conditions (including CVA, motor neurone disease, multiple
sclerosis) reported hunger, none were distressed by hunger,
and only 33% expressed a desire to eat. Both the hospitalized and home patients receiving ETF missed tasting and
chewing food and the social processes associated with meal
times. Similar observations have been reported in healthy
subjects receiving ETF (25, 26) and in those receiving PN
(37-40).
In summary, studies from animals and healthy subjects,
and anecdotal clinical information from case histories,
suggest that the sole provision of nutrients by ETF (in
the absence of food intake) does not fully satisfy hunger or

CLINICAL NUTRITION

the desire to eat. These findings have been confirmed in a


study of patients receiving long-term ETF at home and in
hospital, which also found that patients may even become
distressed by their hunger. Therefore, it is appropriate to
investigate ways of relieving distressing appetite sensations
in patients who are either unable to eat or in whom eating is
contraindicated.

Does the delivery of nutrients by enteral tube feeding


simply replace or add to oral food intake?
In some patients ETF may be given as a supplement to
food intake, to enable the macronutrient, as well as micronutrient requirements of the patient to be met (35). Since
ETF bypasses the upper gastrointestinal tract, whilst delivering feed in a liquid form at a continuous rate for many
hours, it is possible that nutrients are not subject to the same
physiological regulatory processes as when ingested orally.
Does the energy provided by tube feeding simply replace
that taken orally, or does it provide additional energy?
Studies in animals
Studies in animals (20, 21, 41-45) and healthy subjects
(24-26, 46, 47) have observed variable reductions (equivalent to 20-100% of the energy content of the feed) in oral
food intake in response to the energy infused intragastrically. This variability could be due to differences in the
nutrient composition of the tube feed, or the rate and
duration of delivery. Some of the animal studies have
shown complete compensation (90 to >100%) for the
energy infused intragastrically when given as preloads
(bolus administration) shortly before meals (43) or when
given over many days continuously (41, 44, 45). In contrast,
a number of other studies (20, 21, 42) have suggested that
energy supplied intragastrically is less satiating than when
consumed orally, and so when ad libitum oral feeding is
allowed in addition to tube feeding, total energy intake is
increased (42). For example, when dogs were infused intermittently with up to 33% of their typical energy intake via a
gastric fistula for 4 weeks, there was no significant decrease
in habitual food intake. As the energy infused intragastrically increased to 66% of the typical intake, there was a
reduction in oral intake with time (by 14% in the first week,
to 53% by the fifth week), but this was not fully compensatory, so that overall total energy intake increased (42).

Studies in healthy subjects


A similar lack of compensation in oral energy intake has
been reported in healthy subjects receiving ETF. A tendency to overeat (exceeding baseline energy intake) was
observed in Jordan's short-term laboratory studies (25, 26)
in which intragastric infusions were combined with an oral
diet. However, in this case the oral diet consisted of a liquid
formula dispensed from a machine to volunteers who sucked
up the feed through astraw (25, 26). A longer, free living

65

study (46) conducted in medical students, involved administering a 550 ml nasogastric bolus feed each night before
retiring. Despite administering either 4.2 MJ (1000 kcals)
or 8.4 MJ (2000 kcals) for 20 days and 34 days respectively,
the healthy subjects recorded little change in their daily
food intake, compared to control periods. Again, these
findings suggested that the energy delivered directly to the
stomach, was additional to that taken orally, i.e. total energy
intake was increased substantially. However, the lack of
weight gain, the absence of any information on physical
activity, and interruptions in the study due to periods of
illness, make it difficult to draw firm conclusions from this
study alone.
Studies of enteral tube feeding in disease
The extent to which ETF suppresses oral food intake is of
obvious clinical importance to those being tube fed, but
information on this point is sparse and unclear, partly
because of the effect of confounding variables (e.g. disease,
drug therapy, mobility), and partly because of the study
designs. Anecdotal findings from case studies of initially
'well nourished' patients receiving tube feeding following
burns injury (48) and gastrointestinal surgery (49), suggested that total energy intakes of up to 20 MJ could be
achieved when ETF and oral intake were combined (oral
intake comprising 30 to 37% of total intake). However, few
published trials have documented the effects of tube feeding
regimens on oral energy intake or appetite sensations in
patients able to eat. In 12 studies of adult and paediatric
patients (48-59), the changes in food intake with ETF
feeding were quantified, but only 3 of these were controlled
trials (50, 57, 58). In one other study (60), 86% (n=25) of
patients (with advanced gastrointestinal or hepatobiliary
carcinoma, -80% ideal body weight) receiving continuous
ETF during chemotherapy (12.6-16.8 MJ (3000-4000 kcal))
reported an increased appetite (not assessed in most other
studies) and oral food intake, although in this study neither
were quantified. The controlled trials, that were all conducted in the hospital environment, suggested that overnight
ETF suppresses oral energy intake by less than 20%,
compared to control groups. Bastow et al. (50) investigated
the effect of overnight nasogastric feeding in thin (mean
24 days) and very thin (mean 28 days) women (aged 68 to
92 years) following surgery for fractured neck of femur.
Compared to the control group, overnight tube feeding
(4.2MJ (1000kcals)) significantly reduced oral energy
intake by 19% (equivalent to 26% of the energy content
of the tube feed) in the 'thin' group, and by only 7% in the
'very thin' group (7% of tube feed energy). Similarly,
McWhirter's (57) study found the food intakes in malnourished medical patients (BMI< 20kg/m 2) receiving
overnight nasogastric feeding (3.5 MJ (843 kcals)) for a
minimum of 7 days, were only 18% lower (27% of tube
feed energy) than in the control patients receiving no nutritional support. Yeung et al. (1979) (58) found no evidence
of oral intake suppression with jejunostomy feeding. Following comparable colorectal surgery, voluntary food intake in

66

EFFECTS OF ENTERAL TUBE FEEDING

a control group and a group of 12 patients (BM121.9 kg/m 2,


mean preoperative weight loss 8%) fed via a jejunostomy
(mean provision 7.1 MJ (1.13)), was not significantly
different for any of the 14 postoperative days. The result
was that total energy intake more than doubled in the
jejunostomy group. However, this was not a randomized
trial, quantification of oral food intake was not possible
from the data given and the timing of jejunostomy feed
administration was not reported.
In summary, the consensus from the above studies in
animals, healthy subjects and patients, is that complete
compensation for the energy delivered by tube feeding is
rare. In humans, the majority of energy (~80%) supplied
by ETF is typically additional to that taken orally, and
therefore total energy intake is increased. More randomized, controlled studies of varying duration are
required in both healthy subjects and patients before definitive conclusions can be made about the extent of
suppression of food intake with ETF, and any changes that
occur over time.

Is it possible that enteral tube feeding may stimulate


appetite and food intake?
In some patients with marked persistent anorexia, forced
nutrition through a stomach tube for a period helped to bring
about a change in the condition, so that the patients were
then able to take sufficient amounts of food by mouth (56)
This statement, based on the findings from an uncontrolled study (56), suggests that ETF may stimulate oral
food intake. Both anecdotal case reports and small studies
have suggested that artificial nutrition may stimulate appetite and food intake in malnourished adults (52, 56, 59, 60)
and children (61) with disease. In a few persistently anorexic
adult patients with poor nutritional status (not defined),
Olesen et al. documented a doubling in oral energy intake
during 10 days of ETF (56), and after 2 weeks of home ETF
in both adults and children, substantial improvements in
appetite were reported following body weight gain (61).
Bastow et al. (51) observed that overnight nasogastric
feeding was associated with a 'doubling of voluntary oral
intake' and postulated that tube feeding might 'disinhibit' or
stimulate appetite, although these assessments were made
longitudinally with no control group. Another study (62)
documented improvements in food intakes during a period
of nocturnal enteral feeding (mean 27 days) in over and
under 65-year-old men in hospital. Total energy intakes
reached 2.88xREE (resting energy expenditure) in those
under 65 years of age (1.30xREE from oral food intake),
and 2.82xREE in those older than 65 (1.16xREE orally).
Lipschitz et al. (59) reported that continuous (24 h) tube
feeding infusions providing 7.56-10.5 MJ (1800-2500 kcal)
daily did not induce satiety in seven malnourished, elderly
patients. In fact, over the 21 days of ETF there was a
substantial increase in voluntary food intake from 4.15 MJ
at baseline to 7.29 MJ by day 21, associated with weight
gain and improvements in clinical condition (59). Even in

patients with malignancy undergoing chemotherapy, 86%


reported an increased appetite and oral intake with ETF
(60). Furthermore, in a large, uncontrolled study by Pareira
(n=240), patients with a variety of diagnoses (including
terminal cancer (27%)), usually reported a striking 'return
of appetite' after 1-4 weeks of ETF. Some patients ate
despite receiving 3500 calories by tube. However, changes
in disease activity may have influenced appetite and food
intake.
A common problem with all of the above studies was the
lack of control groups, the lack of clinical or biochemical
information regarding disease activity and the confounding
effects of treatment. This makes it difficult to ascertain the
possible stimulatory effect of ETF on appetite and oral food
intake. Furthermore, the length of time over which food
intake assessments were made was often unclear (51) and
the majority of studies actually made no assessments of
hunger or other appetite sensations (e.g. 48, 51, 62).
In summary, a number of clinical reports suggest that
ETF improves anorexia and voluntary food consumption,
typically in malnourished patients during convalescence.
There remains a need for randomized, controlled investigation of this phenomenon of 'disinhibition of appetite' (52)
with tube feeding.

Do enteral tube feeding schedules, varying in timing


and rate of delivery, have different effects on appetite
and food intake?
The impact of different tube feeding schedules on appetite
and oral food intake is another previously neglected area
of investigation. It may be possible to manipulate the timing
(diurnal, noctumal or 24 h) and rate of delivery (continuous
or bolus infusions) of ETF schedules to enhance appetite
and hence food intake, in those patients who are able to eat
(and so reduce their need for artificial nutrition), and to
suppress distressing appetite sensations in those in whom
food intake is contraindicated.
We have undertaken controlled short-term studies in
healthy subjects to investigate such issues (36, 63). Our
findings suggest there is less than 10% suppression of oral
energy intake (equivalent to < 20% of tube feed energy),
and no significant suppression of hunger during a 3 day
period of tube feeding, irrespective of whether the feed
(6.9 MJ) is administered nocturnally or over 24 h. However, more prolonged periods of nocturnal ETF (6 days)
and continuous diurnal and bolus ETF appeared to reduce
food intake further (by ~20%, equivalent to ~40% of
tube feed energy). Similar controlled trials have not been
conducted in patients receiving ETF. However, some
anecdotal information exists about the effects of different
rates of tube feed delivery (continuous vs bolus) on appetite
in patients (64):
given by slow continuous infusion, polymeric dietary
supplements do not appear to cause satiety.... In contrast, when
enteral hyperalimentation is given in bolus form, satiety usually
occurs and voluntary food consumption is minimal (64)

CLINICAL NUTRITION

In addition, longer term studies are needed to assess the


effects of ETF on appetite and food intake over time and
to clarify any stimulatory properties.
In summary, preliminary studies from healthy subjects
suggest that the rate and timing of ETF schedule and the
duration of feeding may have different effects on appetite
and food intake. There appears to be very little information
on these matters in the clinical setting, and so controlled
investigations are needed.

Dose parenteral nutrition relieve or prevent distressing


appetite sensations in the absence of food intake?
When nutrients are infused intravenously, they may fail
to generate endogenous gut signals which typically follow
oral food ingestion. Therefore, it has been suggested that
a lack of these signals may be partly responsible for the
disturbances in appetite sensations and food intake that have
been observed in intravenously fed animals and humans
(65-67).

Studies in animals and healthy subjects


Numerous short-term studies have investigated the effects
of parenteral infusions of individual macronutrients on
food intake and appetite, in both humans and animals (39,
40, 68-74), in the absence of, or in conjunction with, oral
intake. They provide important information on the humoral
and post-absorptive factors involved in hunger and satiety.
A few studies have examined the effects on voluntary food
intake and appetite of nutritionally complete parenteral
regimens, similar to those used in patients with intestinal
failure. To overcome the difficulties associated with manipulating patients PN regimens, and the confounding effects
of disease and its treatment, Hansen et al. undertook studies
in monkeys (45) from which she concluded:
There is no doubt that further studies of humans ... in relation
to the effects of various parenteral nutrition solutions on
appetite ... are needed to give a greater understanding of
patients complaints of anorexia or hunger (45).
In studies of healthy subjects, hunger sensations (subjectively assessed only twice daily) during 6 days of peripheral
PN infusions (6.60 -+ 0.5 MJ) were found to be no lower
than during control infusions of Ringer's lactate (39, 40).

Studies of parenteral nutrition in disease


The potential role of PN to relieve hunger and other appetite
sensations could be of considerable importance in the
clinical setting, especially when it is the sole source of
nutrition, as in some patients with intestinal failure. Jordan
et al. found that even in acutely ill patients (n=18, diagnoses: ulcerative colitis, regional enteritis, short bowel
or bowel obstruction) receiving PN alone (mean duration
31 (20) days), hunger sensations frequently occurred (89%
of patients), and sometimes were not abolished by the administration of as much as 10.1-20.2 MJ (2400-4800 kcals)

67

daily (38). However, as no distinction was made in the


questionnaire between the different types of appetite sensations, it is possible that patients may have misinterpreted
their desire for the sensory and pleasurable aspects of eating
with hunger. It is conceivable that small amounts of food
taken orally during PN may relieve appetite sensations
more effectively than PN alone. Clinically stable patients
receiving long-term home PN (median duration of feeding
5 years) for Crohn's disease or short bowel syndrome,
were generally found to have little hunger at the times
of assessment (before and after starting and stopping PN, at
the time of eating and at the end of the day), but 93% ate
on average 2.52 MJ (600 kcals) throughout the day (37). A
consistent observation from these studies, was the cravings
for food, particularly for salty, crunchy, savoury foods, and
a preoccupation with thoughts of food and reports of strong
thirst (37-40). Even in monkeys, nibbling small amounts
of food occurred when 100% of the baseline energy intake
was supplied intravenously (45).
In the above patient studies (37, 38) PN infusions typically consisted of glucose and nitrogen only (no lipid), and
so the effects of PN regimens that incorporate lipid on
appetite in patients intravenously fed, either in hospital,
or at home, were also lacking. Therefore, we studied two
groups of patients receiving complete PN regimens, either
at home or in hospital, who had no oral intake. Our first
study was conducted in 16 patients receiving home PN for
an average 10 (_+16)months due to intestinal failure (Crohn's
disease, short bowel syndrome). They were weight stable
(body mass index 20.8 (_+2.6) kg/m2), whilst receiving 8.72
(-+1.2) MJ daily. Seventy-five percent experienced hunger
and over one-third (44%) of them were distressed by the
severity of their hunger. Typically, the patients who were
not experiencing hunger had an acute phase protein response indicative of an inflammatory state. In contrast, a
few patients regularly chewed, tasted and subsequently spat
out food (modified sham feed) or chewed gum in an attempt
to relieve distressing appetite sensations (36). Others ate
to relieve their sensations, despite the knowledge that they
would vomit and experience abdominal pain. Some regularly dreamt of food at night. Sixty-nine percent of patients
receiving home PN reported food cravings, for mostly
savoury, and often crunchy foods and the majority had a
desire to eat (> 80%). A complementary study, involving
28 hospital patients consecutively referred for PN who had
minimal food intake (75), reported that over 50% missed
particular food items, 43% experienced hunger, 14% were
distressed by hunger and 52% had a desire to eat. These
observations are interesting for two reasons. Firstly, the
current consensus suggests that anorexia is widespread in
patients with acute disease. Our preliminary study in those
receiving PN in hospital (75), mostly with active disease,
suggested that anorexia may not always be present.
Secondly, since some patients in hospital or at home were
hungry or distressed by hunger despite receiving their full
nutrient requirements parenterally, questions are raised
about the factors regulating appetite and energy intake.
The frequency of hunger and any other distressing appe-

68

EFFECTS OF ENTERAL TUBE FEEDING

tite sensations in hospitalised patients who do not receive


artificial nutrition is also of interest. As the Community
Health Councils report 'Hungry in hospital?' (76) stated:
it is nevertheless unacceptable if just one person is
unnecessarily going hungry or thirsty when they are in
hospital (76)
Indeed, a study of patients with liver disease reported
hearty or good appetites in 75% of those with cirrhosis, 56%
in those with hepatitis and 65% in those with primary
biliary cirrhosis (although little was reported about their
current disease activity or how easily they were satiated by
food ingestion) (77).
In summary, studies in healthy subjects and patients in
hospital or living at home suggest that when PN is the
only source of nutrients, appetite sensations such as hunger
and desire to eat may persist, despite the provision of
nutrients to meet estimated requirements. Cravings for food
items and preoccupation with thoughts about eating also
exist. Some patients are even distressed by these sensations,
although the severity of them may depend on the disease
or the nutritional status of the patient. Research is required
to investigate alternative ways of reducing distressing
appetite sensations in patients receiving PN in whom oral
food intake is contraindicated.

Does parenteral nutrition replace or add to oral food


intake?
The effect of intravenously delivered nutrients on oral
energy intake and hence energy balance is important as
PN may be provided as a supplement to oral intake when
patients' gastrointestinal function recovers and weaning
from artificial nutrition is required.
Studies in animals
Most animal studies suggest that when nutrients are supplied
intravenously there is incomplete compensation in food
intake (45, 78, 79). For example, total energy intake (PN,
and oral), in rats receiving 100% of their energy requirements as PN for 4 days, was found to be 40% higher than in
control animals (78). Furthermore, Hansen et al. (45) found
that the oral intake in monkeys did not significantly differ
from control levels, despite a parenteral provision of up to
60% of the baseline energy intake in the form of glucose/
amino acids, when given for at least 1 week. Total energy
intake increased and resulted in accelerated weight gain. It
was only when 100% of the baseline energy intake was
infused intravenously that oral intake decreased to nearly
zero. Similarly, despite full intravenous supply of nutrients
to rats oral food intake persisted (79). Nicolaidis proposed
that this residual oral intake was due to non-homeostatic
control of feeding, involving an 'oral specific need' (79).
Studies in healthy subjects
Studies of healthy subjects in controlled environments and

patients in the hospital and community, have suggested


that nutrients delivered parenterally may not fully suppress
appetite or food intake. The administration of peripheral
PN to eight healthy men (equivalent to 85% of REE) for
6 days reduced mean oral intake of a commercial liquid
supplement by 44% (equivalent to only 78% of the infused
energy) (39). Complete compensation for the infused nutrients
was achieved by the 6th day. However, since the only oral
intake was a single liquid supplement, it is plausible that
taste fatigue may have occurred, as oral intake remained
depressed in the subsequent control period when only saline
was infused.
Studies of parenteral nutrition in disease
In a clinical study, 10 stable, afebrile hospitalised patients
(including post-operative patients and those with sepsis
and cancer), receiving PN because of anorexia, had total
daily energy intakes in excess of energy requirements (oral
intake 3.4MJ (823 kcal); PN 12.2MJ (2902kcal); total
intake 15.6 MJ (3,725 kcal)) (67). Similarly, total energy
intakes of 122% (range 46-229%) of the recommended
dietary allowance (RDA) were achieved in 12 undernourished cystic fibrosis patients (4-26 years old) receiving a
mean of 4.2 MJ (1000 kcals) daily as peripheral PN, in
addition to an oral diet (65). The authors classified patients
as 'responders' when total calorie intake equalled 141% of
RDA (45% from PN), and weight gain was greater than 2
kg, and suggested 'non responders', who did not meet these
criteria, had a greater degree of appetite suppression with
PN. Another small study in children with non-lymphocytic
leukaemia (receiving chemotherapy) suggested that PN
suppressed oral energy intake in proportion to the amount of
PN given. However, there was only a 34% compensation in
oral food intake for the energy delivered intravenously
(total intakes 136% BMR) (66). Conclusions from this and
other studies about the impact of PN on oral energy intake
and appetite in acutely ill patients are limited by the
confounding influences of disease (acute phase), drug
therapy and therapeutic diets.
In summary, studies in animals, healthy subjects and
patients suggest that when food intake and parenteral nutrition are combined, total energy intake is increased. A
proportion of the energy supplied by PN replaces the energy
from food, although the degree of replacement may depend
on the amount of PN given, the composition of the PN and
the duration of its administration. More controlled studies
in patients are required before definitive conclusions can
be made about the extent of suppression of food intake by
PN, and to establish the importance of the composition of
PN and any changes that may occur with time.

Conclusions
The general consensus that emerges from studies in
animals, healthy subjects and patients at home and in
hospital, is that nutrients provided intravenously (PN) or

CLINICAL NUTRITION

e n t e r a l l y v i a a t u b e into the s t o m a c h ( E T F ) are n o t as


e f f e c t i v e as oral f o o d i n t a k e in r e l i e v i n g a p p e t i t e s e n s a t i o n s

16.

( h u n g e r , d e s i r e to eat) or s u p p r e s s i n g f o o d intake. It s e e m s
t h a t s i n c e E T F a n d P N o n l y p a r t i a l l y s u p p r e s s oral f o o d
intake, total e n e r g y i n t a k e is i n c r e a s e d w h e n a d l i b i t u m oral
f o o d i n t a k e is a l l o w e d . F u r t h e r m o r e , d i s t r e s s i n g a p p e t i t e
s e n s a t i o n s m a y occur, e v e n w h e n full n u t r i e n t r e q u i r e m e n t s
are m e t b y E T F or PN. T h e m e c h a n i s m s r e s p o n s i b l e for
t h e s e p h e n o m e n o n are n o t c l e a r l y u n d e r s t o o d , a l t h o u g h
the a b s e n c e o f t h e c e p h a l i c p h a s e r e s p o n s e w h i c h o c c u r s

17.
18.
19.
20.

w h e n the u p p e r g a s t r o i n t e s t i n a l tract is b y p a s s e d , is c o n s i d e r e d to b e i m p o r t a n t . T h e r e still r e m a i n s a n e e d for m o r e


r a n d o m i z e d , c o n t r o l l e d trials, b o t h in p a t i e n t s (in t h e
h o s p i t a l a n d c o m m u n i t y settings) a n d h e a l t h y s u b j e c t s to:
(i) q u a n t i t a t e t h e e f f e c t o f artificial n u t r i e n t p r o v i s i o n
(enteral tube and parenteral feeding) on appetite and food
intake; (ii) d i s t i n g u i s h the effects o f v a r y i n g t h e t i m i n g ,
rate a n d d u r a t i o n o f d e l i v e r y o f f e e d i n g s c h e d u l e s a n d
the c o m p o s i t i o n o f f e e d s c u r r e n t l y u s e d in c l i n i c a l p r a c t i c e ;
(iii) a s c e r t a i n a n y s t i m u l a t o r y effects the p r o v i s i o n o f t h e s e
methods of nutritional support have on appetite and food
intake; (iv) e l u c i d a t e m o r e fully the m e c h a n i s m s ( m e t a b o l i c ,
h o r m o n a l ) i n v o l v e d in t h e c o n t r o l o f a p p e t i t e a n d f o o d
i n t a k e d u r i n g the p r o v i s i o n o f E T F a n d PN.

21.
22.
23.
24.
25.
26.
27.

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