Carbohydrates and insulin resistance in clinical nutrition: Recommendations from the ESPEN expert group

Abstract

47Growing evidence underscores the important role of glycemic control in health and recovery from illness. 48Carbohydrate ingestion in the diet or administration in nutritional support is mandatory, but carbohydrate intake 49 can adversely affect major body organs and tissues if resulting plasma glucose becomes too high, too low, or highly 50 variable. Plasma glucose control is especially important for patients with conditions such as diabetes or metabolic 51 stress resulting from critical illness or surgery. These patients are particularly in need of glycemic management to 52 help lessen glycemic variability and its negative health consequences when nutritional support is administered. 53Here we report on recent findings and emerging trends in the field based on an ESPEN workshop held in Venice, 54Italy, 8-9 November 2015. Evidence was discussed on pathophysiology, clinical impact, and nutritional 55 recommendations for carbohydrate utilization and management in nutritional support. The main conclusions 56 were: a) excess glucose and fructose availability may exacerbate metabolic complications in skeletal muscle, 57 adipose tissue, and liver and can result in negative clinical impact; b) low-glycemic index and high-fiber diets, 58 including specialty products for nutritional support, may provide metabolic and clinical benefits in individuals with 59 obesity, insulin resistance, and diabetes; c) in acute conditions such as surgery and critical illness, insulin resistance 60 and elevated circulating glucose levels have a negative impact on patient outcomes and should be prevented 61 through nutritional and/or pharmacological intervention. In such acute settings, efforts should be implemented 62 towards defining optimal plasma glucose targets, avoiding excessive plasma glucose variability, and optimizing 63 glucose control relative to nutritional support. 64 65 66 3

The Central Role of Glucose in Metabolism and Nutrition of Critically Ill Patients

“…Z posledních doporučení vyplývá, že bychom se měli vyhýbat hyperglykémii nad 10 -12 mmol/l, předcházet hypoglykémii i velkým výchylkám. Pro všeobecnou populaci kriticky nemocných se nyní zdá vhodná glykémie v rozmezí hodnot 8 -10 mmol/l (140 -180mg/l) (111,112).…”

“…Vzhledem k popsaným změnám v metabolismu je velmi obtížné stanovit optimální denní dávku glukózy u kriticky nemocných, vyhýbají se tomu i velké expertní skupiny (111). Z historického pohledu je potřeba uvést, že glukóza byla po dlouhou dobu jedinou možností, jak alespoň částečně zajistit výživu a energii pacientům, kteří byli závislí na plné parenterální výživě nebo jejichž výživa byla jinak nedostatečná.…”

Sarcopenic Obesity: Time to Meet the Challenge

“…(1) Primary Metabolic Abnormalities: Clustered metabolic derangements including systemic and muscle oxidative stress, inflammation and insulin resistance may occur in obesity [17,18,19,20] due to various causes that primarily include i) excess nutrient availability and tissue delivery, particularly saturated fat [28] and glucose [29] as well as ii) adipose tissue dysfunction upon activation of maladaptive responses in the presence of enhanced demand for lipid storage [30]. These alterations are at least in part causally interrelated and have a strong muscle-catabolic potential [31]; they can also promote a typical ‘anabolic resistance' state in skeletal muscle, meaning that the response of muscle protein synthesis to nutrients is blunted [24,25,26,27].…”

Octava Lección Jesús Culebras Medicina Intensiva, nutrición e hiperglucemia: una relación muy estrecha

“…Recientemente, el grupo de expertos de la ESPEN y diferentes autores comienzan a recoger estos resultados y a recomendar el uso de fórmulas específicas para el control glucémico en el paciente crítico (16,(31)(32)(33), al tiempo que resaltan los posibles beneficios clínicos de la reducción de la variabilidad glucémica y de las complicaciones infecciosas. Es probable que este sea uno de los caminos a desarrollar en los próximos años en la investigación clínica del tratamiento nutrometabólico en la hiperglucemia del paciente crítico.…”