The impact of a modified carbohydrate formula, and its constituents, on glycaemic control and inflammatory markers: A nested mechanistic sub‐study.

Background: Hyperglycaemia occurs frequently in the critically ill. Dietary intake of advanced glycation end‐products (AGEs), specifically Nε‐(carboxymethyl)lysine (CML), may exacerbate hyperglycaemia through perturbation of insulin sensitivity. The present study aimed to determine whether the use of nutritional formulae, with varying AGE loads, affects the amount of insulin administered and inflammation. Methods: Exclusively tube fed patients (n = 35) were randomised to receive Nutrison Protein Plus Multifibre®, Diason® or Glucerna Select®. Insulin administration was standardised according to protocol based on blood glucose (<10 mmol L–1). Samples were obtained at randomisation and 48 h later. AGEs in nutritional formula, plasma and urine were measured using mass spectrometry. Plasma inflammatory markers were measured using an enzyme‐linked immunosorbent assay and multiplex bead‐based assays. Results: AGE concentrations of CML in nutritional formulae were greatest with delivery of Nutrison Protein Plus® (mean [SD]; 6335 pmol mol–1 [2436]) compared to Diason® (4836 pmol mol–1 [1849]) and Glucerna Select® (4493 pmol mol–1 [1829 pmol mol–1]) despite patients receiving similar amounts of energy (median [interquartile range]; 12 MJ [8.2–13.7 MJ], 11.5 MJ [8.3–14.5 MJ], 11.5 MJ [8.3–14.5 MJ]). More insulin was administered with Nutrison Protein Plus® (2.47 units h–1 [95% confidence interval (CI) = 1.57–3.37 units h–1]) compared to Diason® (1.06 units h–1 [95% CI = 0.24–1.89 units h–1]) or Glucerna Select® (1.11 units h–1 [95% CI = 0.25–1.97 units h–1]; p = 0.04). Blood glucose concentrations were similar. There were associations between greater insulin administration and reductions in circulating interleukin‐6 (r = –0.46, p < 0.01), tumour necrosis factor‐α (r = −0.44, p < 0.05), high sensitivity C‐reactive protein (r = −0.42, p < 0.05) and soluble receptor for advanced glycation end‐products (r = −0.45, p < 0.01) concentrations. Conclusions: The administration of greater AGE load in nutritional formula potentially increases the amount of insulin required to maintain blood glucose within a normal range during critical illness. There was an inverse relationship between exogenous insulin and plasma inflammatory markers. Key points: Enteral nutrition formula comprise varying amounts of advanced glycation end‐products, specifically Nε‐(carboxymethyl)lysine (CML), which has the potential to exacerbate hyperglycaemia as seen in the healthy population.Patients in the control arm, receiving the highest carbohydrate and CML quantity, had a higher exogenous insulin requirement compared to the two interventional formulae.Our findings also showed an association between increasing doses of insulin and a reduction in inflammatory markers (interleukin‐6, tumour necrosis factor‐α and high sensitivity C‐reactive protein).Further research is required to determine whether manipulation of AGEs in enteral nutrition formula impacts insulin sensitivity and inflammation. [ABSTRACT FROM AUTHOR]