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REVIEW
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
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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
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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
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
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