UPI-JPMHS-2018-8 (Abstract)

Review Article 

Initial Hunger, A Subjective, Reproducible Limit in Intake Associated with Low Blood Glucose (76.6±3.7 mg/dL): A Training for Malnourished Infants and Overweight Adults

Mario Ciampolini*, Gaia Cecchi*

Preventive Gastroenterology Unit, Department of Paediatrics, Università di Firenze, 50132, Florence, Italy.


Many infants suffer with malnutrition or relapsing diarrhea and the University Pediatric Gastroenterology Unit was committed in Florence to their treatment. These disorders are associated with conditioned meals, insulin resistance, 20% higher energy intake and 20% higher blood glucose (BG). The Unit had the chance of performing the first diagnoses of celiac disease in Tuscany and recruited adults with bowel disorders to check meal patterns in them. In this review, is described the training of the passage from scheduled to demanded meals in infants and in adults and the null hypothesis is tested on the difference. Energy intake was assessed by diaries and validated against Total Energy Expenditure by doubly labeled water. Reduction in energy intake was obtained by subjectively abolishing conditioned meals and by administering food only after demand by the infant or after hunger perception by the adult (Initial Hunger Meal Pattern or IHMP). BG (76.6±3.7 mg/dL) identified the metabolic background of the hunger sensation that allowed meal energy intake. During a week, the confidence interval of 21 measurements around the mean was 3.8 mg/dL and we used the mean value from 21 preprandial measurements (Mean BG, MBG) to assess and compare meal patterns and compare compliance with IHMP. Conditioned meals were those scheduled and/or presented to the infant as well to the adult by sight, smell, mentioning, gesturing or simply at a fixed mealtime. As regards intake, common wisdom considers conditioned meals as equivalent in the energy content to those demanded by an infant (null hypothesis) or after meal suspension and arousal of hunger in adults. The training consisted of meal suspension and of feeding after the first infant’s demand or after an adult’s self-noticing arousal of hunger (Initial Hunger Meal Pattern, IHMP). IHMP was checked by MBG and resulted to be associated with a significant decrease in diary-energy-intake, in preprandial blood glucose, in glycated hemoglobin, in body weight, in insulin AUC at glucose tolerance tests and in days with diarrhea as compared to randomized control subjects, who maintained conditioned meals, often scheduled. The individual regression toward an even energy balance was proportionate to the BG height at recruitment. Only two out of 21 trained infants who had mean blood glucose lower than 81.2 mg/dL at recruitment showed a statistically significant decrease in mean blood glucose, whereas 36 out of 49 infants above this cutoff level showed a statistically significant decrease after training. Twenty-four similar diarrheic infants of the same age were trained to IHMP and the resting metabolic rate (RMR) was measured by indirect calorimetry in 14, and total energy expenditure (TEE) by doubly labeled water in 10 infants. RMR decreased by 15.4%; TEE decreased by 15.5%, from 80.1 ± 6.9 to 67.8 ± 10.0 kcal/kg/d. In the synchronous ten day food diaries, energy intake decreased by 17.9%, from 85.7±15.3 to 70.3±15.8 kcal/kg/d (pre/post P<0.001) after intervention. No difference was found between TEE and energy intake at recruitment, at final assessments and in the pre/post decreases.  These findings also validated diary energy assessments. The height Z-score increased significantly, while weight growth was normal. Thus, the null hypothesis between conditioned and demanded (IHMP) meals is rejected. Although the metabolic  differences between conditioned and demanded (IHMP) meals are impressive and seemingly difficult to be achieved, a third of the investigated subjects showed the low MBG value of 76.6±3.7 mg/Dl already at recruitment. Moreover, all reported that they adapted themselves to IHMP easily: “would I have known earlier”. Lastly, this review describes technical characteristics like hunger equivalents, adjustments of energy intake to energy expenditure, deceptive BG measurements and characteristics that emerge in contrast with scheduled meals. The intention is to allow accurate reproduction to professionals as well as to simple readers in search for an even energy balance. The even energy balance is the prerequisite for an elimination of body overall inflammation, of functional disorders and for elimination of the progression toward diabetes, vascular diseases and malignancies.

Key words: Blood Glucose, Diabetes, Energy Balance, Hunger, Malnutrition.

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