Role of Oral Nutritional Supplements Enriched with ß-Hydroxy-ß-Methylbutyrate in Maintaining Muscle Function and Improving Clinical Outcomes in Various Clinical Settings.

Aging and disease-related malnutrition are well associated with loss of muscle mass and function. Muscle mass loss may lead to increased health complications and associated increase in health care costs, especially in hospitalized individuals. High protein oral nutritional supplements enriched with ß-hydroxy-ß-methylbutyrate (HP-ONS+HMB) have been suggested to provide benefits such as improving body composition, maintaining muscle mass and function and even decreasing mortality rates. The present review aimed to examine current evidence on the effect of HP-ONS+HMB on muscle-related clinical outcomes both in community and peri-hospitalization patients. Overall, current evidence suggests that therapeutic nutrition such as HP-ONS+HMB seems to be a promising tool to mitigate the decline in muscle mass and preserve muscle function, especially during hospital rehabilitation and recovery.

Post-lunch triglyceridaemia associates with HDLc and insulin resistance in fasting normotriglyceridaemic menopausal women.

OBJECTIVES: Post-prandial hypertriglyceridaemia (P-HTG) is associated with cardiovascular disease. This association is of paramount importance during menopause, which is also related to reduced high-density lipoprotein-cholesterol (HDLc) and elevated triglyceride (TG) levels. We aimed to provide a self-assesing tool to screen for P-HTG in menopausal women who were normotriglyceridaemic at fasting and adhered to a Mediterranean-style eating pattern. METHODS: We performed oral fat loading tests (OFLT) in combination with self-measurements of diurnal capillary TG at fixed time-points (DC-TG) in 29 healthy menopausal women. TG levels >220 mg dL-1 at any given time during the OFLT served as diagnostic criteria for P-HTG. Subsequently, DC-TG profiles were examined to determine the best mealtime (breakfast, lunch or dinner), as well as optimal cut-off points to classify these women as having P-HTG according to the OFLT. Insulin resistance was defined as the upper tertile of the homeostatic model assessment of insulin resistance. RESULTS: We found that, despite having normal fasting TG levels, P-HTG was highly prevalent (approximately 40%). Moreover, self-assessed 3-h post-lunch TG levels >165 mg dL-1 increased the odds of having hypo-HDL cholesterolaemia by 14.1-fold (P = 0.026) and the odds of having insulin resistance by 31.6-fold (P = 0.007), adjusted for total fat intake in women adhering to a Mediterranean eating pattern having their highest energy intake at lunch. CONCLUSIONS: Self-assessed 3-h post-lunch TG can be used to study post-prandial TG metabolism in Southern European menopausal women who are normotriglyceridaemic at fasting. Characterising an individual's post-prandial response may help menopausal women to evaluate their risk of cardiovascular disease.

[Proposed profile of omega 3 fatty acids in enteral nutrition]. / Propuesta de perfil de ácidos grasos omega 3 en nutrición enteral.

We review the international recommendations on oral intake of n-3 fatty acids and their content in the enteral nutrition formulas. Their metabolic actions depend on their metabolization to EPA and DHA. The activity of desaturases catalyzing this process increases with exercise, insulin, estrogens in the fertile women, and peroxisomal proliferators, whereas it decreases with fasting, protein and oligoelements deficiencies, age < 30 years, sedentary lifestyle, cigarette smoking, alcohol, cholesterol, trans and saturated fatty acids, insulin deficiency, and stress hormones (adrenalin and glucocorticoids). Most of the guidelines recommend that 20-35% of the total energy comes from fat, being 7-10% saturated fats, 6-10% polyunsaturated, and 20% monounsaturated, in Spain. The recommendation for n-3 FA is 0.5-2 g/day or 0.5-2% of total caloric intake, with an upper limit of 3 g/day. For n-6 FA, 2.5-10% of total caloric intake, the n-6/n-3 ratio not being well established although most of the guidelines recommend 5:1. The EPA and DHA content should be at least 500 mg per day. Finally, the EPA/DHA ratio is 2:1 in most of them. Standard nutrition formulas present an appropriate fat content, although most of the products containing EPA and DHA exceed the limit of 3 g/day. Among the products with hyperprotein and/or concentrated, only of them contains EPA y DHA. Not all the formulas used for the frail elderly contain EPA or DHA, and in those containing them their concentration may be excessive and with a proportion very dissimilar to that of fish oil.

[Short-term results of treatment with 131I in patients with multinodular goiter: effect of the associated degree of hyperthyroidism and other variables]. / Resultados a corto plazo del tratamiento con 131I en pacientes con bocio multinodular: influencia del grado de hipertiroidismo asociado y otras variables.

OBJECTIVE: To assess the effectiveness of radioactive iodine (RAI) therapy and the incidence of hypothyroidism post RAI in patients with subclinical hyperthyroidism or clinical hyperthyroidism with Multinodular Goiter (MNG). METHODS: A retrospective study of 69 consecutive patients treated with (131)I for MNG during the year 2008 observed for six months. All patients received a single fixed dose of 16 mCi (592 MBq) weighted by the gland size. They were categorized into two groups: subclinical hyperthyroidism or clinical hyperthyroidism. We compared the success rate and the incidence of hypothyroidism. RESULTS: The thyroid dysfunction was corrected in 82.09% of the patients. Success rate was 100% in the clinical hyperthyroidism group and 78.13% in the subclinical hyperthyroidism group (P=0.105). The overall incidence of hypothyroidism was 16.42%; 25.00% of patients with clinical hyperthyroidism and 14.55% with subclinical hyperthyroidism developed this secondary effect (P=0.400). No statistically significant differences were found in the success rate in the incidence of hypothyroidism when the results were analyzed according to the thyrotropin decrease in patients with subclinical hyperthyroidism. Seven patients had positive anti-thyroid peroxidase antibodies (anti-TPO) before therapy. The incidence of hypothyroidism was significantly higher in them (57.14% vs 11.67%; P=0.011). Cardiac arrhythmias were four times more frequent in patients with clinical hyperthyroidism. Previous treatment with thiamazol positively affected the outcome. CONCLUSIONS: A single fixed weighted dose of (131)I is highly effective and safe for the control of clinical and subclinical hyperthyroidism due to MNG. Patients with anti-TPO antibodies may have a high risk of developing post-iodine hypothyroidism.

[Evaluation of food intake in hemodialysis using a food consumption and appetite questionnaire]. / Valoración de la ingesta en hemodiálisis mediante un cuestionario de consumo alimentario y apetito.

Protein calorie malnutrition is a common complication in chronic hemodialysis patients (CHP). Although many factors could promote malnutrition, inadequate nutrient intake seems to be one of the most important. An Appetite and Diet Assessment Questionnaire (ADAQ) was developed, and we have performed a cross-sectional study in 44 CHP to investigate its capacity to predict an inadequate intake. Dietary evaluation was based on a diet diary-assisted recalls (DDAR). On the other hand, the validity of PCR and the differences in the DDAR and ADAQ between the days of dialysis and the days without dialysis were studied. The predictive value of inadequate intake of the ADAQ and the PCR were analysed with the ROC curve. The protein intake was 1.3 +/- 0.3 g/kg/day and the energy intake 29.2 +/- 0.6 kcal/kg/day. The average PCR was 1.14 +/- 0.3. The ROC curve to predict inadequate intake from the ADAQ shows an area under the curve of 0.84 for the protein intake and 0.73 for the energy intake. A cut-off ponit of 18 gives a sensitivity of 100% and a specificity of 44% for the detection of poor protein intake (< 1.2 g/kg/day) and of 74% and 56% for the detection of poor energy intake (< 30 kcal/kg/day). The ROC curve to predict inadequate protein intake from the PCR obtains an area under the curve of 0.81. The cut-off 1.06 gives the best sensitivity (100%) and specificity (64%) for the detection of insufficient protein intake. We did not find any significant difference in the DDAR or in the ADAQ between the days of dialysis and the days without dialysis. Despite the subjective interpretation, the relationship between ADAQ and protein-energy intakes analysed by DDAR was highly significant. The questionnaire is simple and can therefore be used as a screening rest to detect and correct alterations in the diet which could otherwise lead to malnutrition. The determination of PCR gives a good sensitivity and specificity for the detection of poor protein intake, although the results are modified in anabolic or catabolic states which can clinically go undetected. We do not register differences in diet between the days of dialysis and the days without dialysis.

[Diabetes and nutrition]. / Diabetes y nutrición.

Diabetes mellitus is one of the most frequent metabolic syndromes found in our hospitals, occurring at around 10%. There are basically two types: the most common is Type 2, associated with obesity in almost 80% of cases and family groupings, and then, far behind, comes Type 1 which requires insulin administration for life. Furthermore, there is a condition known as "stress hyperglycaemia" in which a patient without a prior history of diabetes mellitus responds to stress with a syndrome comprising hypermetabolism, hyperglycaemia, hyperlactacidaemia and protein catabolism. The desirable pre-prandial levels of glycaemia in an outpatient are between 80 and 120 mg/dl (under 100 mg/dl is normal) and between 100 and 140 mg/dl before retiring (levels of 110 mg/dl are normal). In patients with artificial nutrition, whether parenteral or enteral, the control of glycaemia is not so strict and the recommendation is for a level of around 150-200 mg/dl in the acute stress phases, falling to 100-150 mg/dl in stable patients. The ideal enteral formula for diabetic patients has been a bone of contention for years and has still not been satisfactorily resolved. The discussion centres on the replacement of saturated fatty acids by mono-unsaturated fatty acids (MUFA) or by carbohydrates. The studies of patients undergoing prolonged treatments with MUFA-rich enteral diets have shown a greater control of glycaemia with these diets than with those rich in carbohydrates, so Type 2 diabetics and in stress hyperglycaemia with enteral nutrition, there is an ever stronger proposal to use MUFA rich formulas, whereas in Type 1 diabetics and in Type 2 patients with high prior requirements of insulin, it would be more recommendable to use diets with a more intermediate composition. With regard to parenteral nutrition, there is a consensus on increasing the amount of fatty acids to the detriment of carbohydrates, but the use of carbohydrates other than glucose is not so clear. The use of fast-acting insulin, either intravenously or subcutaneously, is recommended in the acute stages of the underlying condition because any instability in the patient makes it difficult to plan the required dose of intermediate-acting NPH insulin. The use of metformin or acarbose is not recommended. In parenteral nutrition, the subcutaneous administration of NPH insulin is often required at doses of 30% of the home dosage as the basal insulin therapy in addition to fast-acting insulin in the nutrition bag and a regimen of subcutaneous fast-acting insulin every 6 hours depending on glycaemia.

[Leptin in the endocrinology of obesity]. / Leptina en la endocrinología de la obesidad.

The article summarizes the endocrinology axis in relation to leptin in the obesity. There is a glucocorticoid hypothesis in the obesity origin. Human plasma leptin levels are elevated in Cushing's syndrome and there is a robust leptin secretory responses to dexamethasone. Obesity impacts on reproductive function in man and women. Leptin levels are higher in women than in men and a critical blood leptin level is necessary to trigger reproductive ability in women. The relationship between body mass index and circulating leptin varies during the course of spontaneous cycles in women, the best correlation occurring during the luteal phase when progesterone and leptin concentrations are highest. Obesity is associated with a decrease in growth hormone (GH) and reversible with weight loss. The influence of body composition on GH secretion in the obesity may be mediated through leptin, acting as a peripheral signal from adipose tissue. Thyroid dysfunction appear not associated with alterations in serum leptin levels. There is a significant relationship between insulin and leptin, but it is not immediate, since type 2 diabetics show similar leptin levels to those of nondiabetic humans of the same body mass index.

High-fat versus high-carbohydrate enteral formulae: effect on blood glucose, C-peptide, and ketones in patients with type 2 diabetes treated with insulin or sulfonylurea.

Recently, two commercial enteral formulae for diabetic patients have been made available in Spain: a high-complex-carbohydrate, low-fat formulation (HCF) and a low-carbohydrate formulation (RCF). This study compares the effects of the two enteral nutritional formulae in patients with non-insulin-dependent diabetes mellitus (type 2 diabetes) treated with sulfonylurea or insulin. Fifty-two type 2 diabetes patients were randomly assigned to receive one of the two enteral formulae. Test enteral formula breakfast (250 cc) were consumed at approximately 0900 h after routine medications (insulin or oral agents) had been taken. Venous blood samples were obtained during fasting, before medication, and at 30 and 120 min after the start of the meal. The glycemic response of patients to the HCF was significantly greater than to RCF, but lower than in the sulfonyl type 2 diabetes treated groups. The incremental glucose response was within acceptable levels except in insulin treatment type 2 diabetes patients given HCF. Glucose, insulin, and C-peptide responses were higher in HCF than RCF groups. Two-factor analysis of variance on mean increments of blood glucose and C-peptide from basal levels to 30 min show the type of enteral nutrition as the main factor (P = 0.0010 and P = 0.0005, respectively). The RCF formula supplies 50.0% of energy as fat and 33.3% as carbohydrates, so it may be a ketogenic diet. It was found that both ketone bodies were higher after RCF than after HCF ingestion, but without statistical significance. We conclude that the partial replacement of complex digestible carbohydrates with monounsaturated fatty acids in the enteral formulae for supplementation of oral diet may improve glycemic control in patients with type 2 diabetes. The long-term effects of enteral diets high in monounsaturated fatty acids need further evaluation in patients with type 2 diabetes.

[Diabetes in hemodialysis: study of differential factors]. / Diabetes en hemodiálisis: estudio de factores diferenciales.

OBJECTIVES: In uremic patients with diabetes mellitus, morbi-mortality on maintenance hemodialysis is considerably higher than in nondiabetic patients. This is mainly due to age, seniority and quality of the hemodialysis therapy, nutritional status, plasmatic lipid levels and associated pathology. We compare all these factors in the uremic patients under hemodialysis in diabetics and non-diabetics. METHODS: We have studied 307 uremic patients under hemodialysis therapy during 199 and 1996. Sixty of them had been diagnosticated of diabetes mellitus (19.6%), 17 were type I (DM-I) and 27 were type II (DM-II). We selected two control groups no-diabetics, one for each subgroup of diabetics with similar characteristics in age, sex and hemodialysis seniority. The control group for DM-I were 34 patients and for DM-II were 54 patients. RESULTS: Ideal body weight percentage, body mass index, mid-arm muscle circumference percentil, serum albumin and prealbumin are subnormal for DM-I. By considering whole nutritional date, a moderate to severe malnutrition was observed in 79% of DM-I patients, 50.4% of all non diabetics and only in 30.6% of patients included in the DM-II group. However, DM-II patients present hypertrigliceridemia and a decrease in HDL cholesterol and apolipoprotein A levels with a high atherogenic index. Significantly higher rates of associated pathology were observed among both types of diabetic patients than their control groups and especially referred to cardiovascular and neurological diseases. CONCLUSIONS: In conclusion, diabetes mellitus is an increasing incidence pathology in hemodialysis programs, that is associated to a higher morbi-mortality because vascular disease. Undernutrition is the main factor in DM-II whereas hyperlipidemia is in DM-II.

[Predictive value of serum ferritin in the prognosis of acute cerebrovascular accident]. / Valor predictivo de la ferritina sérica en el pronóstico del accidente cerebrovascular agudo.

INTRODUCTION: Recent studies show that a raised level of serum ferritin indicates a poor prognosis in CVA patients, as do the well-known hyperglycemia, dyslipemia and arterial hypertension. The evolution and prognosis of acute cerebrovascular accidents are determined by a series of factors, some of which can be modified. This leads to a search for factors which can be modified and therefore influence the course of the illness. OBJECTIVE: To determine the ferritin levels and other parameters during the course of the illness of patients with serious cerebral vascular pathology and evaluate their effect on prognosis. MATERIAL AND METHODS: A prospective study was carried out on patients diagnosed as having CVA, admitted to the Neurology Department of the Miguel Servet Hospital (Zaragoza) during 1994, and who were in neurological coma (Glasgow scale less than 7) during the first 24 hours, and unable to swallow. The levels of various plasma parameters were determined (glucose, cholesterol, ferritin, etc.) on admission and then every 10 days. CONCLUSIONS: Plasma ferritin levels higher than those considered normal by the laboratory, in the first few hours after CVA, are an independent predictive factor suggesting unfavourable evolution of the vascular condition. Equally, raised ferritinemia in the first weeks after CVA indicates a worse prognosis. This laboratory test may be carried out on patients with acute CVA to obtain more information on which to base the prognosis.

[Rate of protein catabolism as an indicator of protein ingestion in uremic patients on hemodialysis]. / Tasa de catabolismo proteico como indicador de la ingesta proteica en pacientes urémicos en hemodiálisis.

Protein catabolic rate (PCR) has been proposed as a indirect index of dietary protein intake, but its sensitivity has been discussed. In a group of 140 chronic uremic patients undergoing maintenance hemodialysis, we evaluated the nutritional status (body mas index: BMI, triceps skinfold thickness: TST, arm muscle circumference: AMC, serum total proteins, albumin and lymphocytes) and its relation with dietary survey and PCR levels. PCR was correlated positively with Kt/V (p: 0.0001, r: 0.45) and with seric albumin (p: 0.01, r: 0.22), whereas dietary protein intake by dietary survey (g/Prot/Kg/day) was correlated strongly with anthropometric measurements like BMI, AMC (p: 0.0001) and less with Kt/V (p: 0.01), but not with serum albumin. PCR was correlated with dietary survey results: g Prot/Kg/day (p: 0.04, r: 0.18) and Kcal/Kg/day (p: 0.03, r:0.2). The results suggest that nutritional parameters with slow evolution as anthropometric measurements could be related with usual dietary intake (dietary survey), whereas serum albumin (that vary early with recent changes of dietary intake) could be related better with a biochemical index like PCR, in these way both determinations are complementary.

[Pseudo-idiopathic hypoparathyroidism]. / Hipoparatiroidismo pseudoidiopático.

Hypoparathyroidism can exist due to one or more of the following pathogenic mechanisms: 1) Parathyroid Hormone (PTH) deficit, b) biologically inactive PTH, c) PTH antagonists and d) target tissues defects. Biologically inactive PTH secretion, also named pseudo-idiopathic hypoparathyroidism, is an exceptional cause of hypoparathyroidism. We report a case of a patient with this illness. A 71-year-old male with a past history of cataracts since he was 48 was admitted to our hospital. Laboratory data showed a total calcium of 4.82 mg/dl, ionized calcium of 2.72 mg/dl, serum phosphate 5.30 mg/dl, intact PTH 83 pg/ml (N 15-60), osteocalcin 2,4 ng/ml (N 9-30), tubular resorption of phosphate 96% and 1.25 di-hydroxycholecalciferol 7 pg/ml (N 18-78); creatinine and magnesium values were between normal limits. The Ellsworth-Howard test showed a normal response of both urinary c-AMP excretion and phosphaturia to PTH. We review the diagnostic clues of hypoparathyroidism and the value of the Ellsworth-Howard test in order to enable distinction between the several variants of the syndrome.

[Lipid metabolism and new dietetic recommendations in diabetes mellitus]. / Metabolismo lipídico y nuevas recomendaciones dietéticas en diabetes mellitus.

Abnormalities of plasma lipids are highly prevalent in both types of diabetes, but there are important quantitative and qualitative differences that this paper reviews. The importance of abnormalities in lipoprotein metabolism as determinant of vascular risk in general population is similar in diabetes, where there is chronic hyperglycemia associated, but it is considered as an independent vascular risk factor. People with IDDM in adequate glycemic control generally have plasma lipid concentrations in normal levels, but in NIDDM, even in good glycemic control, there are another factors associated and usually there are hypertriglyceridemia and total hypercholesterolemia with reduced HDL fraction. Carbohydrate-rich diet increase plasma triglyceride levels and low HDL-cholesterol levels in the majority of studies. Substitute monounsaturated fats in the diet to replace saturated fats lowers total cholesterol and LDL fraction and increase HDL, in addition it acts over others vascular risk factors. These findings were taken into account by ADA and recently revises their 1986 dietary recommendations with the same goals of medical nutrition therapy but with individualized approach appropriate for the personal life style to facilitate adherence to achieve the glycemic, lipid body weight and blood pressure aims with a good quality of live.

[New dietetic recommendations in diabetes mellitus: the implications in enteral nutrition]. / Nuevas recomendaciones dietéticas en diabetes mellitus: implicaciones en nutrición enteral.

In diabetes mellitus there are qualitative and quantitative alterations in the lipid metabolism, which contribute to ischaemic heart disease. The monounsaturated fatty acids (MUFA) may favorably influence the cardiovascular risk factors, and they could replace the saturated fats, in detriment of polyunsaturated fatty acids (PUFA) and carbohydrates (CHO). A series of studies have been done, always on NIDDM patients, which have given rise to reconsidering the dietary recommendations in diabetes mellitus: There is no change in the contribution of proteins (10-20% of the caloric intake), saturated fats (< 10% of the caloric intake), dietary cholesterol (< 300 mg/day), PUFA (10% of the caloric intake), fibre (20-35 g/day), and sodium (< 2.4 g/day), however, the caloric distribution of MUFA and CHO is not defined, but is left up to the judgement of the physician. Enteral nutrition has a series of special characteristics which influence the blood glucose levels of the diabetic patient, as well as having different objectives. In the few published studies, the influence on plasma lipids of an enteral diet rich in MUFA is similar to that published for the oral diets. With respect to the blood glucose, this was less than with the standard formulae, especially in diabetics treated with insulin. In conclusion, we can for see a change of course in the international recommendations on "the diet of the diabetic", even though these may be very slight for the time being.(ABSTRACT TRUNCATED AT 250 WORDS)

[The outlook for hormonal therapy in nutrition]. / Perspectivas de hormonoterapia en nutrición.

When the supply of energetic substrates is insufficient to slow the development of the catabolism, the next step is to focus on the neuro-endocrine mechanism which regulates the anabolism-catabolism balance. In this work, we review the endocrine response to stress and its implications in protein metabolism, in order to evaluate the different therapeutic possibilities available. Pharmacological blocking of the secretion of catabolic hormones (glucagon and catecholamines) has been unsuccessful up to now. Insulin is the only hormone which produces anabolism in all energetic substrates, but the results published about its administration with glucose and amino acids and its effects upon the nitrogen balance are controversial. The administration of anabolic steroids such as nandrolone, stanolone, and methenolone are usually associated with protein anabolism with minimum androgenizing action. The most recent works lead to the study of the effects of the use of GH and IGF-1 with clearly hopeful results. We have not yet acquired enough experience to use these methods in the habitual clinical practice. At the moment, the clinical studies are in the experimental stage and their application in nutrition is not accepted by the official authorities.

[Thiamine deficiency associated with parenteral nutrition: apropos of a new case]. / Déficit de tiamina asociado a nutrición parenteral: a propósito de un nuevo caso.

In thiamine deficiency, the Krebs cycle slows large quantities of pyruvate are diverted to lactate production and anaerobic metabolism begins. The most frequent cause of this syndrome is a dietary deficiency associated to a greater or lesser degree with alcoholism. Other less frequent causes are the ingestion of raw fish contaminated with microbial thiaminases, inborn errors of metabolism and total parenteral nutrition. We present the clinical case of a patient with an acute thiamine deficiency after 15 days of total parenteral nutrition, which improved with intravenous administration of thiamine. The incidence of beriberi among patients undergoing total parenteral nutrition is very low because of the almost systematic addition of vitamin complexes. Our patient's clinical picture was sudden, corresponding to the dry form, with typical neurological symptoms and signs, major metabolic acidosis, hyperglycemia and hyponatremia. The clinical response to the administration of thiamine confirmed the diagnosis.

[The glycemic response to a test breakfast of an enteral diet with fiber and a high starch content in diabetics treated with insulin and oral antidiabetics]. / Respuesta glucémica a un desayuno de prueba con una dieta enteral con fibra y alto contenido en almidón en diabéticos tratados con insulina y antidiabéticos orales.

An enteral nutrition preparation appeared recently on the Spanish market specifically for diabetic patients. It is a normocaloric and normoproteic formula of low osmolarity, rich in soluble fibre and slow-absorption carbohydrates such as fructose and starch, following the classic norms of the American Diabetics Association. The glycemic response was examined at 0, 30, 60 and 120 minutes following the ingestion of 250 cc of Precitene Diabet as breakfast for 40 diabetic patients, half treated with oral antidiabetic substances (DMado) and the other half with insulin (DMins). In both groups, the greatest glycemic increase was at 60 minutes. In the DMado patients, the increase at 60 minutes (70 mg/dl) was not significantly different from that considered by Skyler as acceptable. The same occurred at 120 minutes (40 mg/dl). In the DMins patients, the glycemic increase at 60 minutes was 27 +/- 29 mg/dl, more than that considered acceptable by Skyler (p 0.0006). After 120 minutes this difference was also greater than the acceptable level, by 41 +/- 38 mg/dl (p 0.0002). In conclusion, it may be considered that, for DMado patients, glycemic control remains within the postprandial limits considered to be "acceptable" so that no treatment modification is felt necessary in the administration of enteral nutrition with Precitene Diabet. The glycemic response in the DMins patients was higher than "acceptable", calling for rapid insulin supplements to their habitual NPH insulin doses.