What kind of food am I?

1208

SELECTED

through

activation

endothelial ceptors

of Pz receptors

epithelia

on the apical membrane

cells (Ann NY Acad Sci 1990;603:1-

for ATP stimulate

ion transport

(Mol Pharmacol

bladder

GASTROENTEROLOGY

SUMMARIES

(J Gen Physiol

sible receptors

pathways

1991;40:648-655)

in human

re-

airway

and amphibian

1991;97:949-971).

are localized

of vascular

17). Similarly,

gall-

In each case, the respon-

to the apical

membrane,

but the origin

of ATP in tracheal secretions and bile is not established. The presence of inflammatory cells could result in local release of nucleotides, as observed

in the intestine.

Alternatively,

the multidrug-resistance channel

(Pox

Nat1 Acad

the possibility the absence

(r&l)

that

Like all good studies,

tions

that

This

raises

release can occur locally

to tissue

secretion,

an alternative

source

for regulation

might

Second,

cells themselves,

responsible

to regula-

nucleotide

degradation

sine receptor

signaling

in the target

for pharmacological

If so, then

be anticipated.

representing

tests, electrolyte intestinal

several

generation

manipulation

of

and adeno-

attractive

of the biological

opporresponse

to inflammation.

enrolled

patients

of gastro-

status

(including

illness (including

of the study,

(31 experimental

hospital-

56 of the 80 initially

and 25 standard)

were con-

for evaluation.

Each group consumed

comparable

daily volumes of the sup-

(1.3 - 1.5 cans per day). No increase in any gastrointes-

tinal symptoms

was found in either group.

of the experimental

P = 0.04). The average during

the 6 months

triceps

in the members

No dramatic

tion had a slightly aminotransferase

biochemical

Perhaps

changes

Chlebwski RT, Bed

G, Grosvenw M, Lillington L, Weintraub

in the experimental

of the standard

the 25 standard

difference

observed

was hospitalized.

supplement

recipients

was in the

3 months,

one

In contrast,

5 of

(20%) were hospitalized

be noted that during

of the study, there was no statistically

the entire course

significant

difference

The number

two 3-month

periods

paralleled

total number

of days missed

FO (UCLA-Harbor

weeks, suggesting

Ohio). Long-term enterotropic

Medical

Laboratories,

formula

patients:

1993;9:507-512

Chlebowski problem

Torrance,

Abbott

effects of early nutritional

peptide-based

mula in HIV-infected Nutrition

Center,

et al. noted

and

Columbus,

support

vs. standard

randomized

with new

enteral

prospective

fortrial.

(November/December). that

malnutrition

late in the course of acquired They wondered

is a common

is associated

if a new nutritional

synwith a

formula-

COmIIIetIt. predicts than

patients. under

Although the

any disease,

outcome;

missed

in the

rates. The as the

45 and 60 days per 13 were not at work

Food

assuming

the nutritional Drug

formulations

the morbidity

have been unable

of these underlying

ters

weight

body

1989;96:A269).

From

the association

between

does not correct

for the adverse More recently,

clinical

or

nitrogen

malnutrition

more therapy disease,

a large

number

support

of

favorably

diseases (Gastroenteroleven though

a variety of nutritional balance)

these observations,

ative. On the other hand, simply

of an underlying

Dig Dis Sci 1984;29:577-588), usually do improve

(e.g.,

as adjunctive

at least to me, that

such interventions

governing

that is philosophically

mortality

one,

to their

have been marketed

to show that nutritional

alters the clinical outcome ogy 1980;78:393-410,

support

regulations

are used, namely

and/or

It has been distressing,

more 196Os,

is a causative

of nutritional

Administration

akin to the way medications

Since the

that the association

regimens

of malnutrition

was observed

1936; 106:458-460).

various

and

the presence

this association

foods, they have been used in a manner

PRCTs

sardine oil), and fiber. Eighty patients with early-stage HIV infection were randomized to receiving one of the supplements

apparently

have been providing

tients are still well-nourished. Thus, they performed a prospective randomized controlled trial (PRCT) comparing this diet

sate, a higher carbohydrate content (including soy polysaccharide), a lower fat concentration (with different fat sources, namely, canola oil, medium chain triglycerides, and deodorized

In virtually

50 years ago (JAMA

to reduce

OH). The experimental diet differed from the standard diet in a variety of ways; it contained a “patented” protein hydroly-

between

that most of these patients

a poor clinical

tion would be of value if it was provided earlier in the course of human immunodeficiency virus (HIV) infection, when pa-

(Advera; Ross Laboratories, Columbus, OH) with a standard enteral supplement (Ensure; Ross Laboratories, Columbus,

(7

very often.

clinicians,

immunodeficiency

drome (AIDS) and that such malnutrition poor prognosis.

California;

of workdays

the hospitalization

(if the data were reported

ranged

in

group

P > 0.05) were hospitalized

vs. 4 of 25 [lb%];

in the first 3 months.

average per patient)

Department,

be-

formula-

and aspartate

rates. In the latter

group

N, Ambler C, Richards EW, AbbruzzeseBC, McCamish MA, Cope Ross Medical

sup-

were found

blood urea nitrogen

hospitalization

of 31 [23%]

group

the experimental

these rates because a few more in the experimental

WHAT KIND OF FOOD AM I?

lb;

decreased

levels.

the most important

subsequent

thickness

of the standard

the recipients

higher

(+4 lb vs. -1.5

skinfold

but did not change in those consuming plement.

Only the members

group gained weight

(P < 0.05). It should GREG FITZ, M.D.

levels, and creati-

performance

missed), and intercurrent At the conclusion

and release in

by ectonucleotidases, tissues represent

steps

Evaluation

their

ization). sidered

(weight

levels, liver

as well as for the development

symptoms,

workdays

(albumin

levels, blood urea nitrogen

nine levels) parameters

No. 4

They were as-

for a variety of nutritional

and biochemical

tween the two groups;

an autocrine

suggests

interactions.

for nucleotide

neutrophils,

would

model

and epithelial

it seems

also contribute

nucleotides

the working

of neutrophil

the mechanisms

to be established.

for luminal

Finally,

on

of these observa-

in the absence of inflammation.

This could be the epithelial loop.

investigation

but the applicability

receptors

transport

additional

model for investi-

in vivo remains

tion of intestinal

and anthropometrics)

in

an excellent

cans per day for 6 months).

eight-ounce

sessed at 3 and 6 months

plement

this one invites

likely that apical adenosine

tunities

suggest

1993;90:312-316).

nucleotide

First, T84 cells provide

of intestinal

regulatory

studies

may serve as an ATP

of inflammation.

several fronts. gation

Sci USA

regulated

recent

gene product

(2-3

Vol. 107,

one could

and poor outcome

it may be that generic

the specific nutrient

parame-

(Gastroenterology conclude

nutritional

deficiencies

that

is not caussupport

that account

outcomes.

research

efforts have begun

to focus on a different

approach to food formulation. These second generation “diets” con-

SELECTED SUMMARIES

October 1994

tain specific

nutrients

that may have pharmacological

can be referred to as “medical chain

amino

acids in patients

such an example the proposed

(Gut

status

104:936-938). control

arginine,

a patented

lipids from less traditional probably

a slightly

suggest

that

sources,

higher

this

encephalopathy

“diet”

product,

as a “clinical

drug

indicated

and

if there was an improved that the experimental but only that months

clinical

diet reduced

tion”

The authors

loss” (Roxane

that there was a reduced 1994; 18:25S),

6 months

Meyers Squibb

first ask

pharmacological

the need for hospitalization

similarly

The study declared

trial initially

during

result induced

disappeared

patients.

et al. had a large dropout

and there

was inadequate

an intent-to-treat

study

larger,

and perhaps

longer,

PRCT

to the diet.

identify responsible.

morbidity.

or combination

might

provide

Furthermore,

Of course,

may overwhelm

In the meantime,

support

(through

at least in theory, not the entire

if the component

in patients

it diet

has to be

with

it be used? The

HIV has not been well

and we concur Cancer

that

Institute)

anticancer

agents;

trials of nutrition

be emphasized

not medical

tended pharmacological enteral

formulas

Moreover,

that intravenous

foods, and no comparison

action of intravenous

intended

the rigors

make such a “medical” recommendation provide

(i.e., using

at this time.

more information

insists

a “food” to achieve a clinical

Hopefully,

as to whether

data from future

full-

intervention

the National

In-

support

of any kind

for

in pa-

products

tration

and others

when

are in-

delivery

and specialized

are not applicable

to the extent

are not feasible; this was recognized although

solutions

be made between

as a sole source or supplemental

of drug testing

creating

As such, I am reluctant to

medications.

supported

nutritional

should

that

nutrition.

to the testing

the control

permutations

by the Food and Drug Administhe medical

different.

before it approves

in this

of Health

with HIV.

It should

These are the kind of data the Food and Drug Administration on having

studies

limited

intervention

of

Am J

Institutes

however,

and appropriate

that

to eat,

to be prognostic

further

only the most

of controls

are no data proving

disease-

nutrition-related

has actively

types and numbers

there

in

states

specialized

efficacy of both nutrition

such an intervention is of clinical benefit at any stage of this disease.

and currently

providing

the National

do apply

PRCTs,

by primary

status

guidelines

with

disease

1989;50:444-447,

stringent

studied

nu-

and can result

in reducing

nutritional

has provided

clinical

of nutritional

cost savings.

is indicated,

from the ability

Thus,

(Am J Clin Nutr

trials to establish

of Health

full-scale

Food and Drug Administra-

any subsequent

the National

stitutes tients

caused

diseases.

In this regard,

and industry-identified

into the

HIV

particular

that detract

be essential

1991;53:15),

benefit we then

deficiencies

have reported

outcome

scale clinical

of compo-

insight

this “food” is being sold. Should

role of nutritional

Several groups AIDS patient

from a

even into the issue of its “mal-

as a drug, the price of obtaining

tion approval

does exist,

to give only the component,

(i.e., use it as a medication). marketed

a benefit

component

Such knowledge

be cheaper

We need data

to prove that a true clinical

of AIDS and perhaps

nutrition-associated”

diet.

with

Bristol-

when interven-

may not be needed because

symptoms may

for “weight

problems.

Clin Nutr

provided

that we noted for the immunonu-

If such

the particular

pathophysiology

information

were

support

stimula-

Thus,

Moreover,

opportunistic

area are needed.

also exist for this special

can be ascribed

rate of 30% patients

analysis.

At this time, the same limitations trition

associated

infection

is well tolerated

maintenance. nutritional

in HIV

for “appetite

communication;

in patients

stimulation

malabsorption,

clinical

It is not clear why so many

Inc., personal

alone

weight

and selected

oral suspension

weight

weight

nutritional

(dronabinol)

acetate)

gain

populaHIV and

In fact, there are at least two

communication).

appetite

with

of significant

management

Co., personal

in unique

and/or

by

Marinol

supplementation

appropriate

alleged

rate in the first 1.5 months

but this benefit also apparently

by Chlebowski

ineligible,

to perform

would

in its recipients

designed

hospitalization

overall

demonstration

(megestrol

to promote

tritional

many patients

benefit.”

Laboratories,

clinical

(FASEB J 1994;8:A280).

of the enrolled

should

we must

and Megace

way to deter-

for this patient

aspects of anthropometrics

for weight

and AIDS; these include

to what was

This trial did not show

there were fewer such events

4, 5, and 6. Another

UPEN

outcome.

products

the optimal

designed

benefit,

consider

biochemistries

load).

trial,

to clinical

et al., while the

for the improved

for the immunonutrition

of a product

would

We believe this analytical,

represented

with the positive

tion

As we discussed

respect

their physicians

outcome.

nents

With

for evaluation.

design

gain coupled

carbohydrates

and caloric

needed

study

1993;

and fiber (in addition

was responsible

intake

mine relative usefulness tion

the experimental

hydrolysate,

nitrogen

may be

(Gastroenterology

by Chlebowski

supplement positive-control

~-3 fatty acids to improve

nutritional

protein

and

branched

Last year, we considered

and/or

study

received a generic

consumed

hepatic

(“immunonutrition”)

In the current

group

group

with

1986;27:S85-S95).

use of RNA,

immunologic

properties

foods.” The use of intravenous

1209

ROWAN

foods category.

to the conduct

Thus,

of trials,

contrasts

the

are markedly

T. CHLEBOWSKI, M.D., Ph.D.

end)

trials will

or not such a recommendation

would be appropriate at a later date. RONALD L. KORETZ, M.D.

erb B-2 EXPRESSION: A USEFUL PROGNOSTIC INDICATOR IN GASTRIC CARCINOMA? Motojimu K, Furui J, Kohara N, Izawa K, Kanematsu T, Shiku H

Reply. sophical

Dr. Koretz questions

raises a series of interesting

fed as dietary

enteral

included

lack of shown regarding requires

and philo-

in his commentary regarding our study (Nutrition

1993; 9:507 - 5 12), which concerns

scientific

compared

supplements

the limited

“clinical

the rigorous before approval

two complete to patients

with

sample size, number

benefit.” criteria

Additionally,

products

HIV.

His major

of “dropouts,”

and

he made observations

the Food and Drug

of medications

enteral

compared

Administration

with those govern-

ing foods. Fifty-six

of the 80 randomized

our prospectively

determined

patients

criteria

with HIV successfully

regarding

minimal

met

daily enteral

(Second Department

of Surgery

Nagasaki

School of Medicine,

B-2

expression

stomach gery

University

and Department

in well-differentiated

predicts

shorter

of Oncology,

Nagasaki,

Japan).

adenocarcinoma

survival after curative

erb

of the

resection.

Sur-

1994;115:349-354.

This study was undertaken tion between carcinoma,

erb 8-2

and survival

from 120 patients

to determine

expression, after

the possible correla-

histological curative

who underwent

type of gastric

resection.

curative

resection

Specimens of gastric