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PECIAL ARTICLE

Enteralism—The First “ism” of theNew Millennium

Andrew Thomson, MRCP(UK), FRACPFrom the Gastroenterology Unit, The Canberra Hospital, The Australian National University,

Canberra, Australia

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he 20th century can be remembered inter alia as the centureat “isms.” Existentialism, capitalism, and socialism, noention individualism, postmodernism and corporatism, hav

owered at various times in the past 100 years. For the firstany prominent individuals such as Mao Tse-tung and Marhatcher have been awarded their own personal “isms.” No pr application is necessary to form an “ism” but rather publicassionate rhetoric, and consistency. It would be perverse1st century were outdone by its predecessor and failed to sn appropriate array of “isms.” I should therefore like to nomienteralism” as the first great “ism” of the new millennium.

Briefly, the principals of enteralism are as follows:1. If patients cannot eat an adequate diet for an exte

period, then enteral nutrition should always be administeConversely, parenteral nutrition can be regarded almos“poison” and should be avoided, if at all possible.

2. Whatever complications develop in a patient, they cannattributed to enteral feeding. If it is conceded that scomplications have developed, they are probably noserious as those that would have developed if the patiennot been fed enterally and are definitely less seriousthose that would have occurred if the patient had beenparenterally.

As with other “isms,” although it is reasonably easy to locatroponents and strongholds (intensive care units of major teaospitals, among other places), the opportunities for rationaussion with many of its followers are somewhat limited. Meang clinical changes attributable to non-volitional nutritional sort is difficult due to the complexity of other therapies andeterogeneity of patient populations. In keeping with other “ism

t is thus very difficult to disprove its tenets. There is, in finimal evidence to justify the enteralist dogma, and the stu

omparing enteral nutritional support with parenteral nutritioupport are contradictory with respect to whether enteral nuts “better” other than that it is clearly less expensive.1,2 Thereforene has to wonder whence this great movement arose and

uels its continuance. As Lipman observed in his review beoncluding there to be little clinical evidence favoring one formutritional support over the other: “Almost any clinical studyutrition [sic] support starts with a seemingly obligatory introd

ion that enteral nutrition is the preferred method for non-volitioelivery.”1

The development of enteralism, in my view, has been sohat different from other “isms” in that it has no icons or heroo “father” of enteralism has emerged. Instead, a brave new wf uniformity and repetition has arisen with a kind of simultaneantra from multiple foci worldwide. Gone are the days, it wo

eem, when a group of penniless fanatics would proselytizeessage and develop into a national and then an interna

orrespondence to: Andrew Thomson, MRCP(UK), FRACP, Gastroe

logy Unit, The Canberra Hospital, PO Box 11, Woden 2606, Australia

utrition 20:839–840, 2004Elsevier Inc., 2004. Printed in the United States. All rights reserved.

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movement. Probably, the rapidity of worldwide communicahas led to this change. In short, the bandwagon is now elect

Enteralism, to give it its due, is more than a simple hmentality. There is a certain warm fuzziness about doctors dwhat nature “intended.” Enteral nutrition is seen as “physioloand “natural” because the gut is being used for its preordapurpose. The functioning of the gut during enteral feeding isdifferent from that occurring during health because feedincontinuous and unvaried and the mouth and esophagus apassed. Efficacy in medicine is also not dependent on doing t“physiologically.” Surgery, for instance, is not physiologic (norsome surgeons physiologic, one sometimes suspects, judgtheir workloads), but it saves many lives and is compatiblefull recovery. It can also be argued that force feeding the sineither “physiologic” nor “natural” because reduced or abnutritional intake almost always follows significant injury orness in the wild. Indeed, the whole of medicine (other thansibly the placebo effect) may be regarded as not being “phlogic” in this sense. It is also worth noting that, prenataparenteral nutritional support is very “physiologic.” Unquestably however, doing things “physiologically” makes some docfeel better. The enteralist possibly feels that same sense of onwith enteral feed that naturalists experience with nature whenroll around African jungles hugging chimpanzees. Nonethelesuspect that patients do not see hospitals as “natural” habitado not expect their treatment to chime in with their physioloWhat matters to them is through which entrance they leaveafter how long.

The other pattern of development of an “ism” is that obacklash against established wisdom and outdated practicesnomic rationalism was to a certain extent a reaction againsfree-spending, socially orientated governments of the 19601970s. The roots of enteralism may also be traced back toverenthusiastic embrace of total parenteral nutrition, whichalso ironically popularized during this period. Keeping somealive without feeding that person was a stupendous achieveand, unlike many, if not most, advances in medicine, was laa result of science. The excitement among hospital doctorstime was considerable. Doctors of today’s generation possiblthe need to compensate for the bandwagon mentality offorebears.

The evolution of enteralism has thus clearly been complexperhaps no one will ever be able to identify all the reasons fmeteoric rise. But what of its future? As with most “isms,” it mwell slip away into the mists of time. The era of mass commcation has served to promulgate it to all corners of the world.similar way, rapid, electronic communication will serve to desit more quickly than one might expect. But what of the futurenteral nutrition? In Virgil’sAeneid, when Aeneas ventured inthe underworld, he encountered a howling three-headed mocalled the “Cerberus,” at the entrance. Although not statedirrational creature, “mad with hunger,” almost certainly wohave prevented him and indeed anyone else from entering ifnot been drugged. In some ways, the proximal gut is some

like this Cerberus. It prevents food from entering the body despite

0899-9007/04/$30.00doi:10.1016/j.nut.2004.05.006

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840 Thomson Nutrition Volume 20, Number 9, 2004

he well-meaning determinations of the enteralist. The challengeor the heirs of the enteralists will be to predict in advance whenhe Cerberus is behaving rationally in protecting the body from theazards and/or futility of administering enteral feed. Maybe then,he few of us left on the planet who are comfortable with admin-stering parenteral nutrition will be seen as committed physicians

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ather than as purveyors of poison.

EFERENCES. Lipman T. Grains or veins. Is enteral nutrition really better than parenteral

nutrition? A look at the evidence. JPEN 1998;22:167. Braunschweig C, et al. Enteral compared with parenteral nutrition: a meta-

analysis. Am J Clin Nutr 2001;74:534. Marik P, Pinsky M. Death by parenteral nutrition. Intern Care Med 2003;29:

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