The Use Of Medium-Chain Triglycerides In Gastrointestinal .
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #160Carol Rees Parrish, M.S., R.D., Series EditorThe Use of Medium-Chain Triglyceridesin Gastrointestinal DisordersNeha D. ShahBerkeley N. LimketkaiMedium-chain triglycerides (MCTs) are lipid molecules that are more readily absorbed and oxidized thanmost lipids. This unique characteristic of MCTs has led to interest in their use in the management of severalgastrointestinal disorders, where MCTs have been primarily used to reduce fat malabsorption and to serveas a source of calories to optimize nutritional status. In this review, we discuss the composition of MCTs,its sources, and the roles that they potentially play in the treatment of various gastrointestinal disorders.INTRODUCTIONMedium-chain triglycerides (MCTs) comprisea glycerol molecule attached to 3 fatty acidchains ranging between 6 to 12 carbons inlength. Unlike most other lipid molecules that requirea complex process of digestion, MCTs are more easilyabsorbed into the bloodstream from the gastrointestinaltract. These features of MCTs confer unique benefitsin the management of gastrointestinal disorders.1As such, MCTs have historically been used to treatsteatorrhea resulting from malabsorptive disorders, suchas pancreatic insufficiency, prior gastrectomy and smallNeha D. Shah, MPH, RD, CNSC Berkeley N. Limketkai,MD Digestive Health Center, Stanford HealthCare Division of Gastroenterology & HepatologyStanford University School of Medicine, Palo Alto, CA20bowel resection. MCTs have also been investigated fortheir potential to reduce obesity, cardiovascular disease,and neurological disorders. The purpose of this reviewis to describe the composition, functional characteristicsand sources of MCTs, as well as to review the evidenceinvestigating the use of MCTs in the management ofgastrointestinal disorders.StructureA fatty acid is a simple lipid molecule with a carboxylicacid group on one end and a hydrocarbon chain on theother.2 The hydrocarbon chain length may range from4 to 28 carbons and determines the classification offatty acids: short chain ( 6 carbons), medium chain(6 to 12 carbons), long chain (13 to 21 carbons), andvery long chain ( 22 carbons). Triglycerides are lipidPRACTICAL GASTROENTEROLOGY FEBRUARY 2017
The Use of Medium-Chain Triglycerides in Gastrointestinal DisordersNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #160molecules with three fatty acids attached to a glycerolbackbone. Similar to simple fatty acids, the length of thefatty acid group determines the nomenclature of shortchain triglycerides (SCTs), medium-chain triglycerides(MCTs), and long-chain triglycerides (LCTs).The presence of double bonds can vary within fattyacids. Saturated fatty acids do not contain any doublebonds along the hydrocarbon chain, while unsaturatedfatty acids do. Monounsaturated fatty acids contain asingle double bond, while polyunsaturated fatty acidscontain two or more double bonds. Most fatty acids canbe endogenously synthesized, except for two long-chainpolyunsaturated fatty acids: linoleic acid (18 carbonswith 2 cis bonds at C9 and C12) and linolenic acid (18carbons with 3 cis bonds at C9, C12, C15); these areconsidered essential fatty acids (EFAs) and must beobtained from the diet.The fatty acid groups of MCTs include caproic acid,caprylic acid, capric acid, and lauric acid. Comparedwith LCTs, MCTs are smaller in molecular weight,water soluble, rapidly oxidized for energy, possessa lower smoke point (the temperature when volatilesubstances are produced and a blue-colored smokeis seen as a result of oxidation of oil) and are liquidat room temperature. MCTs only contain saturatedfatty acids and therefore do not contain either of theEFAs, linoleic and linolenic acid. As MCTs do notcontain EFAs, they also do not serve as a precursorto the synthesis of eicosanoids. MCTs provide fewercalories per gram than LCTs, 8.3 vs. 9.2, respectively.Digestion and AbsorptionThe length of the fatty acid influences the process ofits digestion and absorption within the gastrointestinaltract. The entry of triglycerides as LCTs from thestomach into the duodenum stimulates the entericsecretion of the hormone cholecystokinin (CCK) andpancreatic enzymes from the pancreas. CCK promotesfurther release of bile from the gallbladder to helpemulsify the triglycerides into smaller fat droplets tomaximize its digestion.3,4 Pancreatic lipase then cleavesthe fatty acid chains from the triglycerides to formindividual fatty acid molecules that then aggregate intomicelles. Micelles are absorbed into the enterocytesalong the intestinal brush border via passive diffusionor are shuttled by fatty acid transporters. Once in theTable 1. Comparison of Characteristics between MCTs and LCTsCharacteristicsMedium Chain TriglyceridesLong Chain TriglyceridesPropertiesWater soluble.Lower smoke point.Have no essential fatty acids.Lipid soluble.Higher smoke point.Contain essential fatty acids.Structure6-12 hydrocarbons.All saturated fatty acids.13 to 21 hydrocarbons (long chain). 22 hydrocarbons (very long chain).Both are saturated and unsaturated fattyacids.Caloric Value8.3 calories per gram.9.2 calories per gram.Digestion/AbsorptionDo not stimulate CCK.Do not require bile or pancreaticenzymes.Directly absorbed into portal circulationbound to albumin.Do not require carnitine for transportinto the mitochondria.Stimulate CCK.Require bile and pancreatic enzymes (lipase).Need to be incorporated into micelles, theninto chylomicrons for entry into the lymphaticsystem.Require carnitine for transport into themitochondria.StorageAdipose tissue (less).Adipose tissue (more).PRACTICAL GASTROENTEROLOGY FEBRUARY 2017 21
The Use of Medium-Chain Triglycerides in Gastrointestinal DisordersNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #159#160Table 2. Examples of Commercial Liquid MCT Oil ProductsProductKcal/ 1 TBSP(15 mL)Kcal/4 TBSP(60 mL)Nature’s Way Coconut Premium Oil(20 oz. bottle – 93% MCT, 7% LCT)www.naturesway.com130 kcal/13 g520 kcal/52 gNestle Health Science MCT Oil(32 oz. bottle – 100% MCT)www.nestle-nutrition.com115 kcal/14 g460 kcal/56 gNow Foods MCT Oil(32 oz. bottle – 100% MCT)www.nowfoods.com100 kcal/14 kg400 kcal/56 g If unopened, the product can be stored in a cooldry place and once opened, can be stored at roomtemperature or in the refrigerator. The inclusion of these commercial products is notmeant to recommend any specific product.enterocytes, the fatty acids are transported into theendoplasmic reticulum, reconverted into triglycerides,and packaged into chylomicrons.The chylomicrons are released via exocytosis,enters and travels through the lymphatic system andeventually, drains into the subclavian vein to reach thebloodstream. In the intracellular space, long-chain fattyacids bind to carnitine for transport into the mitochondriafor subsequent β-oxidation. In carnitine deficiencystates that contribute to severe protein malnutrition(e.g., chronic malabsorption, small bowel obstruction,starvation), these long-chain fatty acids cannot beefficiently utilized and instead lead to accumulation ofunoxidized fatty acids and impairment of ureogenesis,ketogenesis, and gluconeogenesis.5 Clinical sequelaemay include hepatic steatosis, hepatomegaly, myopathy,and altered mental status.By contrast, MCT digestion is rapid and simple.MCTs do not stimulate CCK secretion.3,4 MCTabsorption occurs via passive diffusion along thegastrointestinal tract into the portal system bound toalbumin. No further packaging or modification of theMCT molecules is required. Moreover, MCTs are notdependent on the carnitine acyltransferase systemfor transport into the mitochondria for β-oxidation.5This provides the ability for more rapid metabolism22 of MCTs and improved utilization even in states ofprotein deficiency (Table 1).SourcesMost fats and oils of animal and plant origin containLCTs (e.g., fish, avocado, nuts, seeds, corn, peanut,safflower, and soybean oil). By contrast, natural sourcesof MCTs include coconut oil and palm kernel oil,although these oils also contain LCTs. CommercialMCT formulations may either be comprised of naturallyderived MCT oil, 100% synthetic MCT oil (producedfrom medium-chain fatty acids that are hydrolyzedfrom coconut or palm kernel oil, purified, and then reesterified onto a glycerol backbone), physical mixtures(blend of MCTs and LCTs), or structured lipids6 (Table2). Structured lipids are synthetic lipid molecules witha mix of medium-chain and/or long-chain fatty acidsattached to a glycerol backbone. In the clinical setting,it is not uncommon for healthcare professionals totell their patients to use coconut oil to obtain MCTs.However, depending on the circumstance, this mayworsen fat malabsorption due to the LCT content. Semielemental and elemental enteral formulas typicallyinclude MCTs to minimize need for digestion priorto absorption, although LCTs may also be included(continued on page 24)PRACTICAL GASTROENTEROLOGY FEBRUARY 2017
The Use of Medium-Chain Triglycerides in Gastrointestinal DisordersNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #160(continued from page 22)as a source of EFAs (Table 3). Clinical applicationsmay include malabsorption disorders from pancreaticinsufficiency or severe small bowel disease.DosageExcessive intake of oral MCT oil has been associatedwith gastrointestinal distress, such as abdominaldiscomfort, cramping, gassiness, bloating, and diarrhea.A tablespoon (15 mL) of MCT oil contains 14 grams offat and 115 calories. A maximum daily dose of 50-100grams has been suggested for improved gastrointestinaltolerance; this is equivalent to 4-7 tablespoons (60-100mL) per day (56-98 grams of fat and 460-805 calories).1The daily dose of MCTs should be increased as toleratedto the maximum daily dose, while equally dividingthe dose across all meals. The MCTs can be easilymixed into a variety of foods and beverages. If MCTsare used in cooking, the temperature should be keptbelow 150o C (302o F) to reduce risk of its oxidation,otherwise the flavor of the food could be affected.1A tablespoon of MCT oil can also be administeredthrough a feeding tube using a syringe along with a 30ml water flush before and after its administration (SeeTable 4). In the severely fat-restricted patient, a sourceof EFAs will need to be provided in the diet along withMCT supplementation to prevent EFA deficiency. MCToil does not require a prescription. Although MCTspossess unique characteristics, it is not considered tobe a panacea and its use is intended to be administeredalong with other therapies to treat a disorder.1Use in Gastrointestinal DisordersPancreatic InsufficiencyPancreatic insufficiency is characterized by a disruptionin the exocrine function of the pancreas, which mayresult in decreased synthesis and/or release of pancreaticenzymes that normally assist in digestion of nutrientsin the small bowel, particularly dietary LCTs. It mayarise in acute or chronic pancreatitis, cystic fibrosis andas a consequence of pancreatic resection. The primaryintervention for pancreatic insufficiency is pancreaticenzyme replacement therapy, and occasionally, acidsuppression therapy. There are limited studies atthis time investigating the impact of oral MCT oil inpancreatic insufficiency. However, as MCTs do notrequire pancreatic enzymes for digestion, it is reasonableto consider them as a source of supplemental caloriesin these patients if needed.4In chronic pancreatitis, there is interest in usingTable 3. Comparison of MCT vs. LCT Content of Selected FormulasFormulaCalories/mLTotal Fatg/LMCTg/LLCTg/LMCT: LCTRatiomL for1000kcalsPeptamen *1.039.027.311.770:301000Peptamen 1.5 *1.556.040.016.070:30666Perative **1.337.315.322.040:60769Vital 1.0 **1.038.118.020.147.5:52.51000Vital AF 1.2 **1.253.924.029.945:55833Vital 1.5 **1.557.127.030.147.5:52.5666Vital HP **1.023.211.611.650:501000Vivonex RTF *1.011.64.86.840:601000Standard PolymericPromote **1.026.05.021.019:811000Replete *1.034.06.827.220:801000*Nestle Nutrition: 800-422-2752 (nestlenutritionstore.com)**Abbott Nutrition: 800-258-7677 (abbottnutrition.com)24 PRACTICAL GASTROENTEROLOGY FEBRUARY 2017
The Use of Medium-Chain Triglycerides in Gastrointestinal DisordersNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #160Table 4. Suggested Guidelines for using MCT Oil Do not exceed 4-7 tablespoons per day (60-100 ml/day) for gastrointestinal tolerance. Divide the daily dosage equally between all meals.o If eating 3 meals a day, this can be 1-2 tablespoons per meal. Do not heat MCT oil over 150o C (302 o F); otherwise it will affect the flavor of the food. Mix MCT oil into a variety of foods and beverages (e.g., hot cereals, soups, sauces, broth,smoothies, fruit/vegetable juices, hot chocolate, coffee, tea). If administered through a feeding tube, one tablespoon of MCT oil can be given with a water flushof 30 ml before and after its administration. MCT supplementation should never be the sole source of fat 3 weeks. After 3 weeks, high EFAcontaining vegetable oil should be included in the diet to reduce risk of EFA deficiency.MCTs to help reduce post-prandial pain. A smallstudy of 8 adult pancreatic enzyme-sufficient patientswith chronic pancreatitis found that consumption ofan elemental enteral formula containing MCTs (69%of the total fat content; 9.8 grams per can), at least3 times per day for 10 weeks, and 20 grams of fatfrom the diet per day, resulted in minimal increasesin serum CCK levels and a significant reduction inpost-prandial abdominal pain.7 A study of 17 childrenwith cystic fibrosis found no difference in absorptionrates between a polymeric enteral formula (Isocal) withpancreatic enzyme replacement and elemental enteralformula (Peptamen) containing MCTs without enzymereplacement.8Chyle LeaksChyle is a turbid or milk-colored fluid that primarilyconsists of LCT-containing chylomicrons andlymphatic fluid. Chyle originates in the small bowelwhere chylomicrons are formed and absorbed into thelymphatic system via the lacteals. Chyle then passesthrough the lymphatic system and enters the venouscirculation via the thoracic duct. An obstruction orinjury to the lymphatic system may result in a chyleleak into the pleural, pericardial, or peritoneal space.Common causes of chyle leaks include neoplasia,infection, radiation, and trauma.The nutritional management of a chyle leak mayinitially include consumption of a fat-restricted or afat-free diet, elemental enteral nutrition with MCTs,or a high-protein diet with MCT supplementation.9,10PRACTICAL GASTROENTEROLOGY FEBRUARY 2017 These interventions should only be used for the shortterm (approximately 2 weeks), as there is a risk ofdeveloping EFA deficiency with prolonged restrictionof dietary LCTs. Once the chyle leak is closed, foodscan be gradually re-introduced into the diet. If the chyleleak continues to persist despite these interventions,then parenteral nutrition is indicated. With parenteralnutrition, there is no need to restrict intravenous lipidemulsions, as they completely bypass the gastrointestinaltract and lymphatic system.Three cases have been reported on the successfuluse of oral and/or nasogastric enteral feeding withMCTs for chylous fistulas that developed after neckdissections.11 The patients had closure of their fistulasafter two weeks on MCTs. In a retrospective review of245 patients that underwent pancreatoduodenectomyor a total pancreatectomy, 40 patients who developeda chyle leak were placed on an MCT-containingenteral formula until they were able to transition toa fat free diet with oral MCT supplementation.12 Allpatients experienced a decrease in chyle output withoutrequiring surgical intervention or parenteral nutrition.Short Bowel SyndromeShort bowel syndrome (SBS) is defined by a significantanatomic (or functional) reduction in small bowellength, thus leading to compromise in the digestiveand absorptive capacity of the small bowel. Significantmalabsorption observed in these patients often manifestas diarrhea, unintentional weight loss, and fluid andelectrolyte disturbances. The rationale behind the use of25
The Use of Medium-Chain Triglycerides in Gastrointestinal DisordersNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #159#160MCTs in SBS is to provide calories that are efficientlyabsorbed with minimal need for prior digestion.At this time, there are only a few early case reportsthat have demonstrated potential benefit of MCTs inSBS. One case involved a 65 year-old woman with76 cm of jejunum, 20 cm of terminal ileum, and anintact colon, who was admitted for chronic diarrheaand unintentional weight loss 3 years after extensivebowel resection for adhesions.13 Another case involveda 69-year-old man with 120 cm of remaining smallbowel (mostly jejunum), who was admitted withchronic diarrhea and unintentional weight loss 2 yearsafter his extensive bowel resection due to mesentericthrombosis.13 Fecal fat excretion was elevated in bothpatients when given a LCT-rich regular diet or enteralformula. When switched to a sole MCT-containingenteral formula, fecal fat excretion was reduced andthe patients experienced weight gain. Both patientsafterwards were placed on a fat-restricted (LCTs) dietfor 8-10 months that was supplemented with MCT.The influence of bowel anatomy on the benefits ofMCTs is yet unclear, although early studies suggest thatthe presence of an intact colon plays a significant role.In a randomized cross-over study of 19 SBS patients(9 without a colon; 10 with a colon), participants wereinitially administered high fat diets with either LCTsalone or an equal mixture of LCTs and MCTs in whichthe source of the MCT was either a MCT-containingmargarine or MCT oil.14 When switched from the LCTto LCT-MCT diets, patients with an intact colon hadno difference in fecal volume, while those without acolon had an increase in fecal volume. Interestingly,patients with a colon also experienced an increase in fatand overall energy absorption on the LCT-MCT diet,although those without a colon only had a marginalincrease in fat absorption and no improvement in overallenergy absorption. The study investigators suggest thatthe colon serves as a major organ for absorption of thewater-soluble MCTs, similar to short-chain fatty acidsand unlike the insoluble LCTs. The lack of improvementin energy absorption among those with ileostomies andjejunostomies was attributed to increased carbohydrateand protein loss. The use of MCTs can be consideredin the management of patients with SBS and an intactcolon.Potential Use in Other DisordersDue to their integral role in physiologic function, MCTsmay have potential benefit in several non-gastrointestinal26 disorders. A discussion of these benefits is beyond thescope of this review, although we present a few uniqueexamples of MCT use in diverse conditions.ObesityDue to its influence on thermogenesis and satiety, MCTshave been proposed to reduce obesity by increasingenergy expenditure, reducing food intake and decreasingfat deposition in adipose tissue .15,16 A systematic reviewand meta-analysis of 13 randomized controlled trialsin healthy adults showed that when compared withLCTs, MCTs reduced body weight, waist and hipcircumference, total body fat, total subcutaneous fatand visceral fat.17 Serum lipid levels did not differ.Cardiovascular DiseaseIn cardiovascular disease, MCTs have been proposedto reduce hyperlipidemia based on observations thatindigenous populations with high consumption ofcoconut flesh have low incidence of cardiovasculardisease. However, a review of 8 clinical trials and13 observational studies on the effect of coconut oilconsumption on cardiovascular risk indicated that thereis not enough evidence to support this practice.18Alzheimer’s DiseaseIn mild to moderate Alzheimer’s disease, MCTs havebeen investigated to improve cognition based on thetheory that decreased glucose metabolism in the brainmay result in cognitive and memory impairment,so using MCTs as an alternative energy source asketones for the brain should potentially counteractthis impairment. Small studies have shown modestimprovement in memory recall after consumption ofMCT.19EpilepsyThe ketogenic diet, which is a high fat, low carbohydratediet, is often used as a treatment for refractory childhoodepilepsy. A Cochrane review of the traditional ketogenicdiet for epilepsy concluded that the use of the dietappears promising in treatment of epilepsy, but furtherstudies are needed.20 While the ketogenic diet oftenconsists of LCTs, the use of MCTs in the ketogenic dietmay be more appealing due to their greater potentialto yield ketones for rapid oxidation. The MCT-richketogenic diet would additionally require less fat infavor of more carbohydrates to afford greater variety inthe diet. However, a randomized trial of 145 pediatric(continued on page 28)PRACTICAL GASTROENTEROLOGY FEBRUARY 2017
The Use of Medium-Chain Triglycerides in Gastrointestinal DisordersNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #159#160(continued from page 26)patients with refractory epilepsy found no differencein efficacy between the MCT diet and the traditionalketogenic diet.21CONCLUSIONMCTs possess unique characteristics of digestion,absorption, and oxidation that lead to great interestin their use in the management of gastrointestinaldisorders. The facile absorption of MCTs without theneed for bile or pancreatic enzymes makes them agood source of calories in the setting of malabsorptionand steatorrhea from diseases, such as pancreatic orbile insufficiency. Due to their ability to bypass thelymphatic system, MCTs can also serve as a lipid sourcefor patients with chyle leaks. As MCTs do not containEFAs, supplementation with EFA containing vegetableoils will be necessary after 3 weeks to avoid deficiency.10Although studies are limited, MCTs may be consideredas a supplemental calorie source either alone, or aspart of an enteral product, in certain 3.14.15.16.References1.7.Bach AC, Babayan VK. Medium-chain triglycerides: anupdate. Am J Clin Nutr. 1982;36(5):950-62.Gropper SS. Advanced nutrition and human metabolism. 6thEd. ed. Belmont, OH: Cengage Learning; 2012.Isaacs PE, Ladas S, Forgacs IC, et al. Comparison of effectsof ingested medium- and long-chain triglyceride on gallbladder volume and release of cholecystokinin and other gutpeptides. Dig Dis Sci. 1987;32(5):481-6.Symersky T, Vu MK, Frolich M, et al. The effect ofequicaloric medium-chain and long-chain triglycerides onpancreas enzyme secretion. Clin Physiol Funct Imaging.2002;22(5):307-11.Limketkai BN, Zucker SD. Hyperammonemic encephalopathy caused by carnitine deficiency. J Gen Intern Med.2008;23(2):210-3.Babayan VK. Medium chain triglycerides and structuredlipids. Lipids. 1987;22(6):417-20.17.18.19.20.21.Shea JC, Bishop MD, Parker EM, et al. An enteral therapycontaining medium-chain triglycerides and hydrolyzed peptides reduces postprandial pain associated with chronic pancreatitis. Pancreatology. 2003;3(1):36-40.Erskine JM, Lingard CD, Sontag MK, et al. Enteral nutrition for patients with cystic fibrosis: comparison of asemi-elemental and nonelemental formula. J Pediatr.1998;132(2):265-9.Sriram K, Meguid RA, Meguid MM. Nutritional support inadults with chyle leaks. Nutrition. 2016;32(2):281-6.McCray S, Parrish CR. Nutritional Management ofChyle Leaks: An Update. Practical Gastroenterology.2011;35(4):12-32.Martin IC, Marinho LH, Brown AE, et al. Medium chaintriglycerides in the management of chylous fistulae followingneck dissection. Br J Oral Maxillofac Surg. 1993;31(4):236-8.Abu Hilal M, Layfield DM, Di Fabio F, et al. Postoperativechyle leak after major pancreatic resections in patients whoreceive enteral feed: risk factors and management options.World J Surg. 2013;37(12):2918-26.Zurier RB, Campbell RG, Hashim SA, et al. Use ofmedium-chain triglyceride in management of patients withmassive resection of the small intestine. N Engl J Med.1966;274(9):490-3.Jeppesen PB, Mortensen PB. The influence of a preservedcolon on the absorption of medium chain fat in patients withsmall bowel resection. Gut. 1998;43(4):478-83.Hill JO, Peters JC, Yang D, et al. Thermogenesis inhumans during overfeeding with medium-chain triglycerides. Metabolism. 1989;38(7):641-8.Papamandjaris AA, MacDougall DE, Jones PJ. Mediumchain fatty acid metabolism and energy expenditure: obesitytreatment implications. Life Sci. 1998;62(14):1203-15.Mumme K, Stonehouse W. Effects of medium-chain triglycerides on weight loss and body composition: a metaanalysis of randomized controlled trials. J Acad Nutr Diet.2015;115(2):249-63.Eyres L, Eyres MF, Chisholm A, et al. Coconut oil consumption and cardiovascular risk factors in humans. Nutr Rev.2016;74(4):267-80.Reger MA, Henderson ST, Hale C, et al. Effects of betahydroxybutyrate on cognition in memory-impaired adults.Neurobiol Aging. 2004;25(3):311-4.Martin K, Jackson CF, Levy RG, et al. Ketogenic diet andother dietary treatments for epilepsy. Cochrane DatabaseSyst Rev. 2016;2:CD001903.Neal EG, Chaffe H, Schwartz RH, et al. A randomizedtrial of classical and medium-chain triglyceride ketogenicdiets in the treatment of childhood epilepsy. Epilepsia.2009;50(5):1109-17.PRACTICAL GASTROENTEROLOGY28 PRACTICAL GASTROENTEROLOGY FEBRUARY 2017
Nestle Health Science MCT Oil (32 oz. bottle – 100% MCT) www.nestle-nutrition.com 115 kcal/14 g 460 kcal/56 g Now Foods MCT Oil (32 oz. bottle – 100% MCT) www.nowfoods.com 100 kcal/14 kg 400 kcal/56 g If unopened, the product can be stored in a cool dry place and once opened,
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