title: Fiber and prebiotic supplementation in enteral nutrition: A systematic review and meta-analysis.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  Fiber helps minimize diarrhea in patients receiving EN, particularly in non-critically ill patients. However, the effect of prebiotics in moderating diarrhea is inconclusive.
authors.affiliation: Mazuin Kamarul Zaman, Hazreen Abdul Majid, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
authors.forename: Mazuin
authors.initials: M
authors.lastname: Kamarul Zaman
authors.affiliation: Mazuin Kamarul Zaman, Hazreen Abdul Majid, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
authors.forename: Kin-Fah
authors.initials: KF
authors.lastname: Chin
authors.affiliation: Mazuin Kamarul Zaman, Hazreen Abdul Majid, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
authors.forename: Vineya
authors.initials: V
authors.lastname: Rai
authors.affiliation: Mazuin Kamarul Zaman, Hazreen Abdul Majid, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
authors.forename: Hazreen Abdul
authors.initials: HA
authors.lastname: Majid
mesh_terms: D016009:Chi-Square Distribution; D016638:Critical Illness; D003967:Diarrhea / Q000453:epidemiology / Q000378:metabolism / Q000382:microbiology / Q000517:prevention & control*; D004043:Dietary Fiber / Q000008:administration & dosage*; D004750:Enteral Nutrition / Q000009:adverse effects*; D005227:Fatty Acids / Q000378:metabolism; D005243:Feces / Q000737:chemistry / Q000382:microbiology; D006801:Humans; D015994:Incidence; D007413:Intestinal Mucosa / Q000378:metabolism; D007422:Intestines / Q000382:microbiology*; D064307:Microbiota; D016017:Odds Ratio; D056692:Prebiotics / Q000008:administration & dosage*; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D004043:Dietary Fiber; D005227:Fatty Acids; D056692:Prebiotics
keywords: Bifidobacteria; Diarrhea; Enteral nutrition; Fiber; Prebiotics; Short-chain fatty acids