Systematic Reviews
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 7, 2015; 21(17): 5372-5381
Published online May 7, 2015. doi: 10.3748/wjg.v21.i17.5372
Fiber and prebiotic supplementation in enteral nutrition: A systematic review and meta-analysis
Mazuin Kamarul Zaman, Kin-Fah Chin, Vineya Rai, Hazreen Abdul Majid
Mazuin Kamarul Zaman, Hazreen Abdul Majid, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
Kin-Fah Chin, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia
Vineya Rai, Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia
Author contributions: Kamarul Zaman M and Majid HA analyzed the data, and drafted and wrote the paper; Chin KF, Rai V and Majid HA designed the study and revised the manuscript; all authors approved the final version submitted for publication.
Supported by The University of Malaya Research Grant (No. PG127-2013A, No. UMRP022A-14HTM and No. UMRG 388-11HTM).
Conflict-of-interest: The authors declare that they have no conflicts of interest.
Data sharing: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Hazreen Abdul Majid, PhD, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
Telephone: +60-37-9674757 Fax: +60-37-9674975
Received: October 24, 2014
Peer-review started: October 25, 2014
First decision: November 14, 2014
Revised: December 7, 2014
Accepted: January 30, 2015
Article in press: January 30, 2015
Published online: May 7, 2015

AIM: To investigate fiber and prebiotic supplementation of enteral nutrition (EN) for diarrhea, fecal microbiota and short-chain fatty acids (SCFAs).

METHODS: MEDLINE, EMBASE, Cochrane Library, CINAHL, Academic Search Premier, and Web of Science databases were searched for human experimental and observational cohort studies conducted between January 1990 and June 2014. The keywords used for the literature search were fiber, prebiotics and enteral nutrition. English language studies with adult patient populations on exclusive EN were selected. Abstracts and/or full texts of selected studies were reviewed and agreed upon by two independent researchers for inclusion in the meta-analysis. Tools used for the quality assessment were Jadad Scale and the Scottish Intercollegiate Guidelines Network Critical Appraisal of the Medical Literature.

RESULTS: A total of 456 possible articles were retrieved, and 430 were excluded due to lack of appropriate data. Of the 26 remaining studies, only eight investigated the effects of prebiotics. Results of the meta-analysis indicated that overall, fiber reduces diarrhea in patients receiving EN (OR = 0.47; 95%CI: 0.29-0.77; P = 0.02). Subgroup analysis revealed a positive effect of fiber supplementation in EN towards diarrhea in stable patients (OR = 0.31; 95%CI: 0.19-0.51; P < 0.01), but not in critically ill patients (OR = 0.89; 95%CI: 0.41-1.92; P = 0.77). Prebiotic supplementation in EN does not improve the incidence of diarrhea despite its manipulative effect on bifidobacteria concentrations and SCFA in healthy humans. In addition, the effect of fiber and/or prebiotic supplementation towards fecal microbiota and SCFA remain disputable.

CONCLUSION: Fiber helps minimize diarrhea in patients receiving EN, particularly in non-critically ill patients. However, the effect of prebiotics in moderating diarrhea is inconclusive.

Keywords: Bifidobacteria, Diarrhea, Enteral nutrition, Fiber, Prebiotics, Short-chain fatty acids

Core tip: Despite the importance of enteral nutrition (EN) for patients, diarrhea is a common complication in those receiving EN. Meta-analysis conducted in this review revealed that fiber supplementation in EN reduces diarrhea incidence. However, the positive effect is only seen in stable patients, and is not observed in critically ill patients. In addition, the effect of fiber and prebiotic supplementation towards fecal microbiota and short-chain fatty acids remain disputable due to the mixed findings. The heterogeneity of study populations, antibiotics therapies, and variation of the dosage for fiber and prebiotics likely explain such outcomes.