Clinical Nutrition 32 (2013) 765e771

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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

Original article

A novel protein mixture containing vegetable proteins renders

enteral nutrition products non-coagulating after in vitro gastric
digestionq
Claudia C.M. van den Braak a, Marianne Klebach b, Evan Abrahamse a, Marcel Minor a,
Zandrie Hofman b, Jan Knol a, Thomas Ludwig a, *
a
Danone Research, Centre for Specialised Nutrition, PO Box 7005, 6700 CA Wageningen, The Netherlands
b
Nutricia Advanced Medical Nutrition, Danone Research, Centre for Specialised Nutrition, Wageningen, The Netherlands

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Non-coagulation of protein from enteral nutrition (EN) in the stomach is considered
Received 12 June 2012 to improve gastric emptying and may result in reduced upper gastrointestinal complications such as
Accepted 14 November 2012 reflux and aspiration pneumonia. For the development of a new EN protein mixture with reduced gastric
coagulation, the coagulating properties of individual proteins, a novel blend of four proteins (P4 protein
Keywords: blend) and commercial EN products were investigated.
Enteral tube feed
Methods: A semi-dynamic, computer controlled setup was developed to mimic gastric digestion. The
Gastric coagulation
coagulation behaviour of 150 ml protein solutions and EN products was investigated. These were heat-
Gastric emptying
Reflux
treated calcium caseinate, sodium caseinate, whey, soy and pea protein, and the P4 protein blend
Vegetable protein comprising of the latter four (all solutions 6% w/v protein), four new enteral nutrition product varieties
Digestion (New NutrisonÒ 1.0 or 1.5 kcal/ml, with and without MultiFibre MF6Ô) based on the P4 protein blend
and two other commercially available casein dominant EN products (T1 and T2).
Results: Calcium caseinate and sodium caseinate yielded a total wet coagulate of 43.5
0.7 g and
52.7
6.2 g, respectively. Whey, soy, pea and the P4 protein blend did not produce any measurable
coagulate. T1 and T2 resulted in a total wet coagulate of 37.5
0.8 g and 57.3
0.8 g, respectively, while
all new EN product varieties based on the P4 protein blend did not produce any measurable coagulate.
Conclusions: The P4 protein blend renders EN product varieties non-coagulating after in vitro gastric
digestion.
Ó 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

1. Introduction average only 60% of nutritionally adequate amounts.1,3e7 Upper

Enteral nutrition (EN) is the preferred route of feeding for crit-
ically ill patients.1 Achieving sufficient nutritional intake is impor-
tant for optimal patient recovery and has been shown to result in
significantly lower mortality.1,2 EN of critically ill patients, however,
constitutes one of the biggest challenges in clinical nutrition. Crit-
ically ill patients frequently suffer from upper gastrointestinal
intolerance symptoms like nausea, reflux, and vomiting and
nutritional targets are often difficult to reach. Studies have
demonstrated that the energy and protein intake reached in
Abbreviations: EN, enteral nutrition; GER, gastric emptying rate; P4 protein
blend: novel blend of four proteins; T1, T2, commercially available enteral nutrition
products.
q Conference presentation: part of this work has been presented as a poster at
the ESPEN conference 2010.
* Corresponding author. Tel.: þ31 (0)317 467 840; fax: þ31 (0)317 466 500.
E-mail address: thomas.ludwig@danone.com (T. Ludwig).
gastrointestinal intolerance leads not only to discomfort but also
puts the patient at risk of developing severe complications such as
aspiration pneumonia.8e12
An important underlying cause of upper gastrointestinal intol-
erance is delayed gastric emptying which is associated with the
occurrence of high gastric residual volumes.7e9,13 Pro-kinetic
medications are used to increase gastric emptying rate (GER), but
their safety and positive impact on clinical outcomes are still
debated.7,10,14e16
The GER is well regulated and depends on various factors.17
It is known for example that nutritional factors like caloric density,
volume, particle size and osmolality modulate gastric emptying.17e22
There is in addition a substantial difference between the emptying
of liquids and solids from the stomach.23,24 Liquid emptying
begins instantly in an exponential fashion. Solid emptying begins
after a lag phase and progresses linearly. Solids are thus retained
longer in the stomach, which results in higher residual volumes.

0261-5614/$ e see front matter Ó 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
http://dx.doi.org/10.1016/j.clnu.2012.11.016
766 C.C.M. van den Braak et al. / Clinical Nutrition 32 (2013) 765e771
Different proteins can be associated with different gastric emptying
rates. Previous studies have demonstrated faster gastric emptying of
whey compared to casein protein.25,26 These findings are supported by
studies that found a faster appearance of amino acids in the blood
following administration of whey proteins compared to casein.27,28
These differences in the GER of casein and whey protein have been
attributed to differences in coagulation during gastric digestion.29
Upon interaction with gastric acid, casein protein coagulates at its
iso-electric point and forms large curds, whereas whey proteins
hardly coagulate during gastric digestion at all. This difference can
be linked to the structure of both proteins. Whey comprises globular
proteins, whereas casein essentially lacks a tertiary structure.30,40
Coagulated protein may delay gastric emptying since the curd
behaves like a solid in the stomach. The modulation of gastric
emptying by the composition of the nutritional formula could be an
approach to improve tolerance. We hypothesized therefore that the
behaviour of proteins during gastric digestion is a highly relevant
factor in this context. The aim of this study was to explore how the
coagulation of EN products in the stomach can be prevented by
using different protein sources. Since the vegetable proteins are
globular proteins,31,32 and in this respect are much more similar to
whey proteins than casein, it was hypothesized that vegetable
proteins such as pea and soy might behave in a similar manner to
whey during gastric digestion.
In a first set of experiments, the level of coagulation of soy and pea
protein was measured and compared with casein and whey by using
a newly designed, semi-dynamic in vitro stomach digestion model.
In order to define a suitable protein basis for EN products,
a novel blend of four proteins (P4 protein blend) was formulated
which I) complies with the WHO recommended amino acid profile
(Fig. 1), II) was expected not to coagulate based on the results of the
first set of experiments, and III) has good technological properties
for the development of a stable EN product. The P4 protein blend
was subjected to in vitro gastric digestion to determine coagulation.
In a second set of experiments complete EN products with the P4
protein blend have been tested and compared with EN products
with casein dominant protein mixtures.
2. Methods
2.1. Semi-dynamic stomach model
Gastric conditions were simulated using a pH and substrate
pump controlled setup at 37  C (Fig. 2; Dasgip AG, Jülich, Germany).
Fig. 1. Aminogram of novel protein composition. In order to define a suitable protein
basis for enteral nutrition products, a novel protein mixture P4 protein blend) was
formulated that complies with the WHO recommended amino acid profile. In this blend
the ratio of the masses of protein was 35:25:20:20 for whey:sodium caseinate:pea:soy.
The setup consists of eight parallel computer controlled bioreac-
tors, each equipped with a pH electrode and four dosing-lines. Each
dosing-line is connected to a separate substrate pump. The four
different substrates were a) 1 M HCl and b) 1 M NaHCO3 and 3 M
NaOH, for pH adjustment, and c) artificial gastric juice and d) saliva
(see below). Mixing of food and digestive juices was obtained by
applying a magnetic stirring bar, 50  20 mm, 400 rpm. The food
and gastric juice volume ratios were adjusted to simulate ingestion
of a single bolus of 200 ml of EN. Since the volume of the reactors
was limited all volumes were scaled down to 75%. The reactors
were placed in a 37  C water bath and filled with 150 ml of protein
solution or EN.
Gastric digestion was simulated for 100 min in which the pH
was lowered following a set curve from a pH of 6.6 at start to a final
pH of 2.0 (pH at start ¼ 6.6, pH at 8 min ¼ 5.0, pH at 15 min ¼ 4.0,
pH at 42 min ¼ 3.0, pH at 100 min ¼ 2.0) by the addition of 1 M HCl
upon continuous mixing. If necessary, acidification was automati-
cally corrected by the addition of an alkaline solution (1 M NaHCO3,
3 M NaOH).
Freshly prepared artificial gastric juice (50 mM NaCl, 15 mM KCl
(Merck, VWR International, Roden, the Netherlands), 1 mM
CaCl2$H2O (SIGMA, Zwijndrecht, the Netherlands), 15 mM NaHCO3
(Merck, VWR International, Roden, the Netherlands), 0.014% (w/v)
pepsin (porcine stomach, SIGMA P 7012), 0.019% (w/v) lipase
(Rhizopus oryzae, DF 15K Amano Pharmaceutical Co, Ltd Nagoya,
Japan); pH 4.0) and artificial saliva (0.1 M NaCl, 30 mM KCl, 2 mM
CaCl2, 15 mM NaHCO3, 0.065% (w/v) a-amylase (SIGMA A 6211); pH
6.3) were added continuously during simulated digestion. In the
first 2 min of gastric digestion, a total of 7.5 ml of gastric juice was
added to simulate the gastric juice already present in the stomach.
After the initial 2 min, gastric juice was added at a flow of 22.5 ml/h.
During the experiment, 30 ml of saliva were added to simulate an
average, unstimulated saliva flow of 0.3e0.4 ml/min.33
2.2. Determination of coagulate fractions
After 100 min of simulated gastric digestion, the content of the
reactors was poured over three sequentially placed analytical
sieves with mesh widths of 2 mm, 1 mm, and 0.25 mm (Retsch,
VWR, Amsterdam, Netherlands). Insoluble particles were accord-
ingly separated by particle diameter (D) in three fractions: larger
than 2 mm (D>2), between 1 and 2 mm (D<1e2>), between 0.25 and
1 mm (D<0.25e1>). The wet weight of the individual coagulate
fractions was determined by weighing the sieves. The dry matter
content of each fraction was determined after its collection from
the sieve. In short, the samples of the different fractions were
heated on a thermostatically controlled heating plate (140
10  C)
to evaporate the water and subsequently placed in a vacuum oven
(102
2  C, 600
50 mm Hg, 10 min). The residue constituted the
absolute dry weight of the sample.
2.3. Protein solutions
Individual solutions of intact proteins of soy, pea, casein, and
whey were prepared on a pilot-scale processing line. A dry blend of
four protein powders was made for the P4 protein blend. In this
blend the ratio of the masses of protein was 35:25:20:20 for
whey:sodium caseinate:pea:soy. Whey protein concentrate (WPC),
calcium caseinate (Ca Cas), sodium caseinate (Na Cas), soy protein
isolate, and pea protein isolate powders were used in this study.
The individual proteins and the P4 protein blend were dissolved in
demineralised water in 90% of the total needed water. The solution
was brought to a pH of 8 by adding small amounts of a 10% (w/v)
potassium hydroxide solution. The batch was pasteurized for 30 s at
85  C and subsequently homogenized with a two-stage
 C.C.M. van den Braak et al. / Clinical Nutrition 32 (2013) 765e771 767

Fig. 2. Experimental setup. A) Gastric conditions were simulated at 37  C in a set up that utilizes a computer controlled pH and substrate pump (I). The setup consists of bioreactors
(II), which are each equipped with a pH electrode and dosing-lines for the addition of artificial digestive juices. B) After simulated gastric digestion, the content of the reactors was
poured over three sequentially placed analytical sieves with mesh widths of 2 mm, 1 mm, and 0.25 mm. Insoluble particles were separated by particle diameter (D) accordingly in
three fractions: a) larger than 2 mm (D>2) (*enlarged image of a), b) between 1 and 2 mm (D<1e2>), and c) between 0.25 and 1 mm (D<0.25e1>). Soluble particles, smaller than
0.25 mm, were collected in a filtrate collection bowl placed below the sieves. Representative examples are given for 6% (w/v) protein solutions of sodium caseinate and a novel non-
coagulating protein mixture that comprises of sodium caseinate, whey, pea, and soy protein.

high-pressure homogenizer (550/50 bar) at 60  C (Gea Niro Soavi
S.p.A, Type NS 2006 L, Italy) and cooled back to ambient temper-
ature. Finally, demineralised water was added to obtain a 6% (w/v)
protein solution. The solution was filled in 200 ml glass bottles and
sterilized (121  C, 16 min) in a retort (Stock, Pilot-Rotor 400,
Germany). All six finished products had a viscosity < 6 mPa s at
a shear rate of 100/s obtained with a plate-cone geometry (Physica
MCR-301, Anton Paar, Belgium). No visual flocculation was
observed and no sediment developed during shelf life.
2.4. Enteral nutrition products
The P4 protein blend was incorporated in four new EN formu-
lations with different energy and fibre content i.e.: New NutrisonÒ
(Nutricia N.V., Zoetermeer, the Netherlands) with and without fibre
(MF6Ô) with either 1.0 kcal/ml and 4.0 g of protein/100 ml (N, Nþ)
or 1.5 kcal/ml and 6 g of protein/100 ml (NE, NEþ) each. These
four EN products as well as two commercially available,
casein dominant EN products were tested: 1.0 kcal/ml, with
4.0 g protein/100 ml and fibre (T1), and 1.5 kcal/ml and 5.6 g of
protein/100 ml (T2).
2.5. Statistics
Experiments were performed at least in triplicate (n  3) to
obtain a minimum of three independent observations for dry and
wet weight of coagulates. For few samples, coagulates adhered to
the sieves in a manner that dry weight could not be determined.
The interaction model was used in this case to determine estimated
means. The data are expressed as mean
SEM. Statistics were
performed using SPSS 15.0 for Windows. Coagulate total wet and
dry weight and the wet and dry weight of the different fractions
768 C.C.M. van den Braak et al. / Clinical Nutrition 32 (2013) 765e771

D>2, D<1e2>, and D<0.25e1, were analyzed with univariate ANOVA Table 1
using LSD post hoc test. Experiment significance level was set to Gastric coagulation of protein solutions.

a ¼ 0.25. Differences per comparison were considered significant Diameter Sodium Calcium Whey Soy Pea P4 protein
with P  0.03 (Bonferroni inequality, k ¼ 8). caseinate caseinate blend
Wet weight [g] D>2 23.3
1.1 18.5
4.2 Below detection limit (n ¼ 3
3. Results (n ¼ 3) (n ¼ 3) each)
D<1e2> 8.0
0.9 12.8
2.3
(n ¼ 3) (n ¼ 3)
3.1. Gastric coagulation of solutions of individual proteins and P4 D<0.25e1> 12.2
0.6 21.4
0.9
protein blend (n ¼ 3) (n ¼ 3)
Total 43.5
0.7 52.7
6.2
(n ¼ 3) (n ¼ 3)
Sodium caseinate and calcium caseinate yielded coagulate after
Dry weight [g] D>2 4.1
0.5 2.3
0.6
gastric digestion, whereas whey proteins, soy protein, pea protein, (n ¼ 3) (n ¼ 3)
and the P4 protein blend did not yield any measurable coagulate D<1e2> 1.3
0.1 2.0
0.1
(representative examples given in Fig. 2). (n ¼ 3) (n ¼ 3)
Sodium caseinate and calcium caseinate total wet coagulates did D<0.25e1> 1.0
0.0 1.8
0.1
(n ¼ 3) (n ¼ 3)
not differ significantly. No significant difference in the wet weight
Total 6.4
0.5 6.2
0.6
of the biggest fraction (D>2) and medium sized fraction (D<1e2>) (n ¼ 3) (n ¼ 3)
was found. The wet weight of the smallest fraction (D<0.25e1>) of
*P ¼ 0.026, **P ¼ 0.019, ***P ¼ 0.030.
sodium caseinate, however was significantly lower than that of
calcium caseinate.
The total dry weight of the coagulates of sodium caseinate and fraction D<0.25e1> from EN product T1 was significantly lower
calcium caseinate did not differ significantly. No significant differ- compared to that of EN product T2.
ence in the dry weight of fraction D>2 was found. The dry weight of EN product T1 yielded a significantly lower amount of total dry
fractions D<1e2>, and D<0.25e1> of sodium caseinate, however was coagulate compared to EN product T2. However no significant
significantly lower than that of calcium caseinate (Fig. 3, Table 1). difference in the dry weight of the biggest fraction (D>2) and
middle size fraction (D<1e2>) was found. The amount of dry
3.2. Gastric coagulation of enteral nutrition products coagulate in fraction D<0.25e1> from EN product T1 was signifi-
cantly lower compared to that of EN product T2 (Fig. 4, Table 2).
The commercially available, casein dominant EN products T1
and T2 yielded coagulate after gastric digestion. The four new EN 4. Discussion
product varieties containing the P4 protein blend however, did not
yield any measurable coagulate. The fact that casein is coagulating in response to gastric juice has
EN product T1 yielded a significantly lower amount of total wet been known for centuries. For instance, the army surgeon William
coagulate compared to EN product T2. However no significant Beaumont published in vitro experiments in 1833 on the coagula-
difference in the wet weight of the biggest fraction (D>2) and mid tion of milk after exposure to gastric juice which he obtained from
sized fraction (D<1e2>) was found. The amount of wet coagulate in a patient.

Fig. 3. Gastric coagulation of proteins. Heat-treated solutions of calcium caseinate (Ca
Cas), sodium caseinate (Na Cas), whey, soy protein, pea protein, and P4 protein blend (a
new protein mixture of the last 4 proteins) were tested. The amount of A) wet and B) dry
coagulate formed was measured by separating the digested samples into fractions of
particles larger than 2 mm (D>2), between 2 and 1 mm (D<1e2>), and between 1 and
0.25 mm (D<0.25e1>) respectively. Grams of coagulate wet and dry weight (mean
SEM) is
given for the sum of all the fractions.
Fig. 4. Gastric coagulation of enteral nutrition products. Four new EN product varieties
(NutrisonÒ 1.0 (N) or 1.5 kcal/ml (NE), with (þ) and without Multi Fibre MF6Ô) based
on a new protein mixture, and 2 other commercially available casein dominant EN
products (1.0 kcal/ml (T1) and 1.5 kcal/ml (T2)) were tested. The amount of A) wet and
B) dry coagulate formed was measured by separating the digested samples into frac-
tions of particles larger than 2 mm (D>2), between 2 and 1 mm (D<1e2>), and between
1 and 0.25 mm (D<0.25e1>) respectively. Grams of coagulate wet and dry weight
(mean
SEM) is given for the sum of all the fractions.
 C.C.M. van den Braak et al. / Clinical Nutrition 32 (2013) 765e771 769

Table 2 The cause of the differences in gastric coagulation between

Gastric coagulation of enteral nutrition products. casein on the one hand, and whey, pea and soy protein on the other,
Diameter T1 T2 N Nþ NE NEþ is most likely linked to their different tertiary molecular struc-
Wet weight [g] D>2 3.0
0.6 4.3
0.6 Below detection limit ture.31,32 It is known that denatured whey proteins aggregate when
(n ¼ 12) (n ¼ 12) (n ¼ 3 each) approaching the iso-electric point.42 The ability to form a curd is
D<1e2> 6.7
0.6 7.2
0.6 nonetheless absent. A similar behaviour was found for the vege-
(n ¼ 12) (n ¼ 12)
table proteins in this study. A feasible explanation of the anti-
D<0.25e1> 27.8
0.6 45.8
0.3
(n ¼ 12) (n ¼ 12) coagulating effect of globular proteins on the coagulating proper-
Total 37.5
0.8 57.3
0.8 ties of casein is their interaction at pH values close to their iso
(n ¼ 12) (n ¼ 12) electric point. This interaction may inhibit the further aggregation
Dry weight [g] D>2 0.7
0.6 1.2
0.6 of caseinate into a solid macroscopic curd.
(n ¼ 12) (n ¼ 11)
D<1e2> 1.3
0.9 1.9
0.7
In order to study the behaviour of these proteins during gastric
(n ¼ 5) (n ¼ 8) digestion, a novel, semi-dynamic in vitro approach for gastric
D<0.25e1> 6.0
0.6 11.0
0.6 digestion was developed (Fig. 2). The model’s parameters are based
(n ¼ 12) (n ¼ 12) on in vivo observations.33,43e46 Identical parameters are applied in
Total 9.5
1.2 15.0
1.0
the TNO gastrointestinal model (TIM-1), which has been exten-
(n ¼ 5) (n ¼ 8)
sively validated for multiple purposes ranging from pharmacoki-
*P < 0.001; T1 and T2 ¼ casein dominant EN products; N ¼ Nutrison 1.0 kcal/ml, netic to food digestion studies (for example43,46e48). The major
NE ¼ Nutrison 1.5 kcal/ml (NE), with (þ) and without MultiFibre MF6Ô.
advantage of the TIM-1 system is the simulation of dynamic
gastrointestinal conditions, whereas its capacities are limited to
Unsurprisingly, caseinate produced a solid coagulate after one experiment at a time. The approach presented here combines
simulated gastric digestion in our study and whey protein did not. specifically the dynamic simulation of stomach conditions with
Interestingly, the vegetable proteins from soy and pea did not yield high throughput capabilities.
any coagulate after gastric digestion either, and displayed thus Gastric digestion was simulated for 100 min based on the data
a behaviour similar to that of whey. Despite its content of sodium reported for young healthy volunteers consuming a standard
caseinate, the P4 protein blend did not produce any coagulate meal.26 The stomach model’s stir rate was set to the minimum
either. Moreover, this property was observed in the complex speed that was technically necessary to maintain proper mixing for
product matrix of the complete EN product. Other than the novel P4 pH control. This may have nonetheless exerted a shear rate which is
protein blend based EN product varieties, EN product T1 and T2 above that which is encountered in the stomach. As a result, the
yielded significant amounts of coagulate, whereas T2 yielded clots which are formed in vivo might consequently be bigger in size,
a higher amount of wet coagulate compared to T1. This observation compared to those detected by us after simulated gastric in vitro
is likely attributable to the higher absolute amount of casein. digestion. This is particularly applicable for conditions of gastric
Although pea and soy are commonly used sources of vegetable hypo-motility which are frequently found in critically ill patients.13
protein, very little was known about their coagulation properties As such, particle size has been demonstrated to have a significant
upon digestion. The available literature on the topic of protein impact on the speed of gastric emptying.17e19,23,24,49 Digestible
coagulation relates mostly to the clotting of casein e not caseinate solids have to be broken down to particles of <1e2 mm prior to
e or milk replacers in species other than man, such as rumi- their emptying from the stomach.17e19,23,24,49 Food particles that
nants.34e38 It was found earlier in one of these studies that soybean are >1e2 mm, or non-digestible solids, are usually emptied in the
protein prevented a milk protein composition from clotting. In this interdigestive interval from the stomach during phase III of the
particular study, rennet from pre-ruminant calves, containing the migrating motor complex (MMC).50,51 Disorders of gastrointestinal
milk clotting enzyme chymosin was used to test the clotting motility are, however, frequent among critically ill patients to an
properties of a skim milk containing milk replacer in vitro.35 Bovine extent that i.e. MMC phase III has even been found to be absent in
chymosin is widely used for milk clotting in cheese mechanically ventilated patients.13,52,53
manufacturing.39 These data can thus not be compared to the data Data from human studies strongly suggest a link between the
presented here as final protein concentrations were significantly gastric coagulation of nutritional compositions and gastric
lower in the cited study and chymosin is not produced in humans.40 emptying rate. It was demonstrated for instance that a whey
In this context, the digestive properties of vegetable proteins were dominant EN emptied significantly faster from the stomach than
investigated because: I) from a sustainability point of view, the use a casein dominant EN in a clinical trial in children with spastic
of these proteins is preferred over proteins from animal sources, quadriplegia. The children that received the whey dominant
II) they could enhance the technological possibilities to develop formula had in addition significantly fewer episodes of emesis
complete EN products, and most importantly III) vegetable proteins during product use.25 Similar results were shown in children with
such as soy and pea are globular proteins just like whey31,32 and cerebral palsy.54 In addition a study performed in healthy volun-
were therefore hypothesized by us to behave similar to whey teers showed faster gastric emptying of a whey solution versus
during gastric digestion. a casein solution.19 The differences in digestion and metabolism of
As it was hypothesized and predicted by their tertiary molecular casein and whey were also described by Boirie et al. who intro-
structure, pea and soy protein were found to be non-coagulating in duced the concept of slow and fast proteins in 1997.27 In essence,
the model. The extent of their usage for nutritionally complete plasma amino acid levels were found to rise faster after the
compositions is, however, limited by the concentration of some ingestion of a whey protein solution. The rate limiting step in the
amino acids. A novel protein mixture comprising 25% caseinate, absorption of amino acids from casein was considered to be slow
35% whey, 20% pea, and 20% soy protein was thus chosen to gastric emptying due to protein coagulation.
constitute a composition which is in line with the most recent WHO The clotting of casein depends in general on the lowering of
recommendations on protein quality.41 This mix also proved to gastric pH during digestion below casein’s isoelectric point. Stress
have all the technological features (i.e. viscosity, stability during ulcer prophylaxis by proton-pump inhibitors or histamine-2
shelf life) from a product development perspective to be incorpo- receptor antagonists, which is received by a subset of patients,
rated in different types of complete EN compositions. elevates the gastric pH.55,56 Given that the isoelectric point of
770 C.C.M. van den Braak et al. / Clinical Nutrition 32 (2013) 765e771
casein is relatively high (pH 4.6), pharmacological stress ulcer
prophylaxis would have to ensure a constant pH above this to avoid
the clotting of casein. This has proven to be challenging in clinical
practice.57,58 Moreover, pharmacological stress ulcer prophylaxis
remains in controversial topic per se.55,56,59e62 It has been reported
in a systematic review and meta-analysis that stress ulcer
prophylaxis may not be required in patients receiving EN.62 Phar-
macological stress ulcer prophylaxis has even been suspected to
negatively impact overall patient mortality and relevant clinical
outcomes such as the incidence of pneumonia.62
Our results suggest that vegetable proteins may have similar
digestive properties as whey protein, and may therefore also act as
fast proteins. Moreover this property seems to extend to the novel
protein mixture and EN products containing this novel protein
mixture.
As described above, non-coagulation of protein from EN in the
stomach may improve gastric emptying. Delayed gastric emptying
is an important underlying cause of gastric retention, which is
a frequently observed during EN therapy. Gastric retention results
in reduced nutritional intake and increases risk of reflux, vomiting
and aspiration pneumonia. Patients may therefore benefit from
a non-coagulating EN product by means of improved gastric
emptying.
Further research will be required, however, to confirm these
hypotheses to consolidate the effect of a non-coagulating EN
product on clinical outcome parameters such as aspiration pneu-
monia, mortality and targets for nutritional intake.
Sources of funding
The study has been funded by Danone Research, Centre for
Specialised Nutrition.
Statement of authorship
CvdB carried out the experiments, supervised analysis of the
samples, supervised the statistical analysis, and drafted the
manuscript, MK supplied study materials, contributed to the design
of the study and the manuscript, EA initiated the study, developed
the methodology and instrumentation, and contributed to the
study design and the manuscript, MM produced and developed
protein solutions, ZH initiated the study, contributed to the coor-
dination and design of the study and the manuscript, JK revised the
study design and manuscript, TL supervised the study, reviewed
and contributed to the manuscript. All authors read and approved
the final manuscript.
Conflict of interest
All authors are employees of Danone Research, Centre for Spe-
cialised Nutrition.
Acknowledgements
We thank Rob Verdooren for supporting the statistical analysis.
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