(2014) High energy density nutritional supplements; impact on appetite, appetite regulation and ...

333 Pages·2015·4.2 MB·English

Fatima, Sadia (2014) High energy density nutritional supplements; impact
on appetite, appetite regulation and energy intake in underweight and
malnourished individuals. PhD thesis.

http://theses.gla.ac.uk/6297/

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Glasgow Theses Service
http://theses.gla.ac.uk/
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High energy density nutritional supplements; impact
on appetite, appetite regulation and energy intake in
underweight and malnourished individuals

by
Dr Sadia Fatima
Submitted in fulfilment of the degree of
Doctor of Philosophy

December 2014

College of Medicine, Veterinary and Life Sciences
School of Medicine
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Abstract
This thesis describes the impact of high energy density nutritional supplement drinks
(HENSDs) on appetite regulation, energy intake and cardiovascular risk factors in lean
healthy females. It also explores the impact of Solid Ready-To-Use Foods (RTUF) and a
milk based Liquid Ready-To-Use proprietary Supplement (LRUS) on weight gain and
appetite in mild to moderate underweight children from Pakistan. The thesis consists of a
literature review (Chapter 1), general methods (Chapter 2), three experimental chapters
(Chapter 3- Chapter 5), each describing an independent research study, and a general
discussion and conclusion chapter (Chapter 6).
Accumulating evidence suggests that oral HENSDs increases energy intake and are
beneficial for the treatment of malnutrition. Their effectiveness however, may be
diminished by acute suppression of appetite. Therefore, the first experimental study aimed
to investigate the extent to which the consumption of the HENSD in the fasted state
reduces energy intake during a consecutive breakfast and lunch and whether this reduction
relates to changes in appetite and metabolic appetite regulators. Twenty three young
females with BMI of 18.2 ± 0.8 kg/m2 consumed either a HENSD or a low energy drink
(PLACEBO) after fasting, in a single blind randomized cross-over study. Appetite was
tracked, and blood taken, prior to the intake of the supplement and 240 minutes afterwards.
Energy intake was recorded during an ad libitum buffet breakfast served 60 minutes and an
ad libitum buffet lunch served 240 minutes post supplementation. Energy intake during the
breakfast was significantly higher in the PLACEBO than in the HENSD trial. No
significant difference was found in energy intake during the lunch between the two trials.
When energy provided by supplements was added to energy intake during breakfast and
lunch, the energy intake in the HENSD trial was significantly higher. The net effect was
that total energy intake was increased by 1.07 ± 0.34 MJ in the HENSD trial. During the
pre-breakfast, feelings of hunger and a desire to eat were significantly lower; satiety and
fullness were significantly higher in the HENSD trial. After breakfast, none of the appetite
measures differed between the trials regardless of plasma PYY, CCK, and insulin
concentrations being significantly higher in the HENSD trial.
The second experimental study investigated the time scale of compensation after HENSD
supplementation. Over a five day period, energy intake was measured after the
supplementation during the evening meal, and during the ad libitum breakfast, lunch and
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dinner consumed on the consecutive day. Since, consumption of HENSD due to the
promotion of energy was expected to promote positive energy balance, this study also
aimed to investigate the impact of HENSD supplementation on cardio-metabolic risk
factors. Twenty-three young healthy females with a BMI of 18.7 ± 1.2 kg/m2 participated
in a single blind randomised, controlled, crossover study. Participants consumed either
HENSD or a PLACEBO for five days in the evening. Participants were asked to record
their dietary intake during the days of supplementation. On the sixth day plasma lipids,
insulin and glucose concentrations were measured in the fasted state and at 30, 60, 90 and
120 minutes after the ad libitum buffet breakfast and lunch. The findings showed that the
average daily energy intake was significantly higher in HENSD trial and that consumption
of HENSDs in the evening induced immediate and short-lasting reduction in energy intake.
Fasting plasma concentrations of insulin and HOMA were significantly higher in the
(IR)
HENSD as compared to the PLACEBO trial. No significant differences were detected in
fasting plasma concentrations of TAG, total-, HDL- and LDL-cholesterol between the
HENSD and the PLACEBO trials.

The third experimental study explored the efficacy of RTUFs and LRUS in promoting
weight gain and their effect on appetite regulation in mild to moderate malnourished
children. An open labelled randomized controlled trial was conducted in primary schools
of Pakistan. Sixty eight mild to moderate underweight children aged 8.2 ± 1.2 years were
randomly allocated to receive either RTUF or LRUS providing 500 kcal/ day in addition to
regular diet in their school for four weeks. The children‘s height, weight, and skinfolds
were measured before supplementation and at the end of the supplementation. The children
marked visual analogue scale questionnaires before the provision of the first and the last
supplement. The findings from this study indicated that after four weeks of
supplementation the average weight gain, change from the baseline in weight-for-age Z
score (WAZ), height-for-age Z score (HAZ) in the RTUF and LRUS were not significantly
different between the two groups. The difference in the appetite measures before the
provision of the first and the last supplement between the two groups were also not
significantly different. The total extra energy supplied for 4 weeks would have been
expected to lead to an excess gain of 2kg. Thus, at least 2/3 of the energy ingested
appeared to have been compensated by less intake at other times.

Based on the data obtained the following conclusions have been drawn:
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 Following oral intake of HENSDs, the appetite suppressive action of the metabolic
and hormonal appetite modulators is short lived.

 HENSDs consumption for five consecutive days in the evening induced
compensation, which happens immediately, disappears quickly and is short-lived
which allows only partial compensation for the energy provided by HENSD.

 Short-term supplementation with HENSD is safe in relation to the impact on
cardiometabolic risk factors such as plasma concentration of fasting and
postprandial lipids but can be expected to reduce insulin sensitivity.

 RTUF and LRUS given to the community has similar impact on improving the
nutritional status in mild of moderate underweight children but the overall rate of
weight gain was lower than expected.
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Table of Contents
Abstract .................................................................................................................................. 2

List of Tables.......................................................................................................................... 9

List of Figures ...................................................................................................................... 11

Acknowledgement................................................................................................................ 13

Author‘s Declaration ............................................................................................................ 15

List of Abbreviations............................................................................................................ 17

1 Introduction and Literature Review ............................................................................. 18

1.1 Malnutrition ........................................................................................................... 18

1.1.1 Prevalence, causes and consequences ............................................................ 18

1.1.2 Nutritional supplements and their use in the treatment of malnutrition in
developing countries .................................................................................................... 22

1.1.3 Use of nutritional supplements in developed countries ................................. 23

1.1.4 Specially formulated therapeutic foods for treatment of moderate acute
malnutrition in children from low- and middle-income countries ............................... 36

1.2 Appetite regulation in relation to energy provision ............................................... 54

1.2.1 Principles of appetite regulation .................................................................... 54

1.2.2 Role of gut peptides in appetite control ......................................................... 56

1.2.3 Role of glucose and insulin in appetite regulation ......................................... 73

1.2.4 Role of thermogenesis in appetite regulation ................................................. 74

1.2.5 Role of Gastric emptying in appetite regulation ............................................ 82

1.2.6 Appetite regulation and amendments in energy intake after high energy
nutritional supplement drinks ....................................................................................... 82

1.3 Impact of acute changes in energy intake and energy balance on plasma lipids,
glycaemia and insulinemia ............................................................................................... 85
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1.3.1 Insulin resistance ............................................................................................ 88

1.3.2 Lack of adipose tissue and insulin resistance ................................................. 88

1.3.3 Insulin resistance and dyslipidaemia .............................................................. 92
1.3.4 Impact of acute changes in energy balance on fasting and post-prandial
lipaemia ………………………………………………………………………………92

1.3.5 Acute modification of the macronutrient composition: impact on the plasma
lipids and the insulin sensitivity ................................................................................. 100

1.4 Aims and objectives ............................................................................................ 100

2 General Material and Methods ................................................................................... 107

2.1 Participants .......................................................................................................... 110

2.2 Anthropometry and body composition ................................................................ 110

2.2.1 Height and Weight Measurement ................................................................ 111

2.2.2 Body Composition ....................................................................................... 111

2.3 Ad libitum Meals ................................................................................................. 112

2.4 Energy Intake Measurement ................................................................................ 114

2.5 Subjective Appetite Sensations ........................................................................... 114

2.6 Resting Metabolic Rate and Diet Induced Thermogenesis ................................. 115

2.7 Blood sampling and Plasma Preparation ............................................................. 119

2.8 Plasma Analysis .................................................................................................. 119

2.8.1 Glucose Analysis .......................................................................................... 120

2.8.2 Insulin Analysis ............................................................................................ 120

2.8.3 Human Peptide YY Analysis ....................................................................... 121

2.8.4 Cholecystokinin Analysis ............................................................................ 122

2.8.5 Gastric Emptying ......................................................................................... 124
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2.8.6 Cholesterol Analysis .................................................................................... 124

2.8.7 Triglyceride Analysis ................................................................................... 126

2.8.8 High-density lipoprotein Analysis ............................................................... 127

2.9 Statistical Analysis .............................................................................................. 128

3 Effects of high energy nutritional supplement drinks on appetite, appetite hormones,
postprandial energy expenditure & energy intake ............................................................. 130

3.1 Introduction ......................................................................................................... 130

3.2 Material and Methods .......................................................................................... 130

3.3 Results ................................................................................................................. 134

3.4 Discussion ........................................................................................................... 147

3.5 Conclusions ......................................................................................................... 151

4 Impact of High Energy Nutritional Supplement Drink (HENSD) consumed for five
consecutive days on appetite, energy intake and cardio-metabolic risk factors in
underweight females .......................................................................................................... 153

4.1 Introduction ......................................................................................................... 153

4.2 Material and Methods .......................................................................................... 153

4.3 Results ................................................................................................................. 163

4.4 Discussion ........................................................................................................... 173

4.5 Conclusion ........................................................................................................... 181
5 Limited effectiveness of Solid Ready-To-Eat and a Liquid Ready-To-Drink
Supplements in Mild to Moderate Underweight Children from Pakistan ......................... 182

5.1 Introduction ......................................................................................................... 182

5.2 Material and Methods .......................................................................................... 182

5.3 Results: ................................................................................................................ 193

5.4 Discussion ........................................................................................................... 206
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5.5 Conclusion ........................................................................................................... 206

6 General Discussion and Conclusions ......................................................................... 215

7 List of References ...................................................................................................... 229

8 Appendices ................................................................................................................. 229
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List of Tables
Table 1.1 A summary of studies, assessing the beneficial clinical and functional outcomes
of the oral nutritional supplement. ....................................................................................... 30

Table 1.2 Studies assessing the comparison of effectiveness of specially formulated
therapeutic foods for the treatment malnutrition in children. .............................................. 46

Table 1.3. Main Neuropeptides and Peripheral Appetite Regulating hormones and their
Role in Appetite Regulation ................................................................................................. 58

Table 3.1 Energy (MJ) and proportion (percentage) from carbohydrate (CHO), fat and
protein provided by PLACEBO and HESND drink. ......................................................... 134

Table 3.2 Energy from carbohydrate (CHO), protein and fat intake in HENSD and
PLACEBO trial .................................................................................................................. 140

Table 3.3: Time-averaged AUC for responses of glucose, insulin, peptide YY (PYY),
cholecystokinin (CCK) during pre-breakfast, pre-lunch period and during the entire period
of trial. ................................................................................................................................ 144

Table 3.4 The area under plasma paracetamol concentration-time curve from 0-60 minutes
(AUC60) and the area under plasma paracetamol concentration-time curve from 0-180
minutes (AUC180) in HENSD and PLACEBO trials. ...................................................... 146

Table 4.1Energy (MJ) and proportion (percentage) from carbohydrate (CHO), fat and
protein provided by PLACEBO and HESND drink. ......................................................... 159

Table 4.2 Averaged daily energy intake (MJ) and macronutrient intake during 4 days of
supplementation with and without energy and macronutrients provided by HENSD and
PLACEBO drinks. ............................................................................................................. 166

Table 4.3 Energy Intake (MJ) and energy intake from macronutrients during ad libitum
breakfast, lunch, and dinner on the day following five days of supplementation. ............. 168

Table 4.4: Time-averaged area under the curve (AUC) for responses of hunger, satiety,
fullness, prospective food consumption and desire to eat during pre-breakfast, pre-lunch
and pre-dinner period.. ....................................................................................................... 170

Table 4.5: Fasting plasma insulin, glucose, triglycerides (TAG), total-, HDL-, LDL-
cholesterol and postprandial responses of glucose, insulin and TAG. .............................. 173

Table 5.1 Comparison of nutritional composition of RTUF and LRUS ............................ 189

Table 5.2 Socio-demographic characteristics of the parents of schoolchildren who were
provided with RTUF and LRUS. ....................................................................................... 195

Table 5.3 Nutritional characteristics of children on enrollment ........................................ 198

Table 5.4 Nutritional Characteristics after 4 weeks of supplementation ........................... 200