Presentation on theme: "CHOOSING AN ENTERAL FEEDING FORMULA"— Presentation transcript:
1 CHOOSING AN ENTERAL FEEDING FORMULA Michele Port, P.Dt.Clinical DietitianMarch 2014
2 LEARNING OBJECTIVESIdentify common sources of protein, carbohydrate and fat used in enteral feeding formulas.Identity formulas which could benefit your patient population and to include in your formulary.Become familiar with high protein formulas and modular products.
3 OUTLINE Introduction Choice of an enteral formula Formula composition Types of feedingsEnteral formularyCase studyConclusion
4 INTRODUCTION Choice of an enteral formula depends on several factors. You need to complete your nutrition assessment and calculate yourpatient’s nutritional requirements before deciding on an appropriateformula. Formulas from different companies are often similar.The decision of which formulas to include in a formulary comes downto your patient population with their specific needs and cost.
5 CHOICE of an ENTERAL FORMULA Depends on:Nutritional requirements: calories, protein, otherGI symptoms? Ex.: GERD, gastroparesis, bowel motility.Digestion and absorption intact? Does the patient have history of IBD, high ileostomy output, bowel resections ?Organ dysfunction or specific disease state Ex.: renal failure on dialysis.Fluid restriction.Viscosity of formula.Cost.Format: Closed versus Open system.
6 CHOICE of an ENTERAL FORMULA Many formulas similar in composition.Different companies may produce similar productsUsually slight differences in macro or micronutrientsBest way to compare products is in a chart formatSpeciality products: need to assess literature to verify claimsChoice of formulas will depend on your patient population Ex.: Hospitals with dialysis program should have a renal formula.
7 FORMULA COMPOSITION Adult formulas are complete nutrition. Contain micro and macronutrients based on dietary reference intake (DRI) of the Institute of Medicine.Majority are lactose-free.Formulas are classified as:Polymeric:Intact nutrientsAppropriate for normal gut functionElemental / Semi-Elemental also referred to as predigested:Protein, carbohydrate predigested or semi-digestedUse if compromised GI functionThere are also modular products which provide only carbohydrate, protein, or fat to increase the macronutrient as required.
8 SOURCE of CARBOHYDRATE FORMULA COMPOSITIONCARBOHYDRATEPrimary energy source in most enteral formulas.Usually 40%-90% of total caloriesSOURCE of CARBOHYDRATEPolymericElemental / Semi-ElementalCorn Syrup SolidsCorn StarchHydrolyzed Corn StarchMaltodextrinSucroseFructose
9 FORMULA COMPOSITION PROTEIN Source of nitrogen and energy In enteral formulas:Polymeric intact protein: Whole protein or protein isolates (casein, soy), lactalbumin, egg albumin and wheyElemental / Semi-Elemental: Hydrolyzed protein, di- and tri- peptides, amino acids
10 FORMULA COMPOSITION FAT Concentrated source of energy Source of essential fatty acids (linoleic and linolenic acid)Medium chain triglycerides (MCT) do not contain essential fatty acidsFAT SOURCEPolymericElemental / Semi-ElementalSafflower OilFish OilCoconut OilSoybean OilSardine OilPalm Kernel OilCanola OilMenhaden OilCorn OilBorage OilSoy LecithinStructured Lipids
11 FORMULA COMPOSITION FAT MCT: Absorbed in portal circulation does not require chylomicron formation and bile salts for digestion and absorption.Structured Lipid: Mixture of MCFA and LCFA on same glycerol molecule.Omega-3 fatty acids (fish oils) metabolized to prostaglandins of series and leukotrienes of the 5 series (anti-inflammatory properties).
12 FORMULA COMPOSITION VITAMINS AND TRACE ELEMENTS: Usually adequate for majority of patients if they are receiving 100% of calorie requirements.Need to check to ensure adequate calcium and vitamin D content, DRI for Vitamin D has increased in past few years.High GI output: feeds may need to be supplemented with Zn and Se.For patients not receiving 100% of nutrition requirements add multivitamin and mineral supplement.Patients with pressure ulcers may need to be supplemented with multivitamins and minerals, vitamin C and Zn.
13 FORMULA COMPOSITION WATER Usually 70%-80% of formulaNeed to include water in formula in total fluid intakeOSMOLALITY (concentration of solute particles in a solution)Should not be included in the decision to use a formula It has little to do with formula tolerance.ELECTROLYTESMost formulas contain adequate amountsHepatic formula very low in sodium
14 TYPES OF FORMULAS POLYMERIC Standard (Ex.: Osmolite 1 CAL) 29% Need good digestion and absorptionHigh Protein (Ex.: Isosource VHN, Isosource VHP, Promote) 20%-25% ProteinCarbohydrate54%Protein17%Fat29%Isosource VHNIsosource VHPPromoteCarbohydrate50%45%52%Protein25%Fat30%23%
15 TYPES OF FORMULAS POLYMERIC High Protein (Ex.: Isosource VHN, Isosource VHP, Promote) %-25% ProteinIndications: CatabolismWound healingPressure ulcersPatients on propofolPlasmapheresisCVVHD - continuous dialysisBurn patients
16 TYPES OF FORMULAS POLYMERIC Energy Dense: (Ex.: Nutren 1.5, Nutren 2.0, Resource 2.0, Two Cal HN)Provide Kcal / mLIndications:Fluid restrictionCHFRenal failureAscitesHyponatremic (hypervolemic)Commercial blenderized food product (Ex.: Compleat) made from pureed foods (chicken, fruit vegetable, juice, etc…)Formula is very well tolerated but very viscous
17 FORMULA COMPOSITION POLYMERIC Fibre Fibre-containing formula (Ex.: Jevity, Jevity 1.5, Isosource 1.5, Isosource VHN, Isosource HN Fibre) combination of soluble and insoluble fibre:Promoted to maintain bowel regularity:Prevent constipation in long term ENDecrease diarrhea in short term ENCombination of soluble and insoluble fibre:Soluble fibre: Fermented to SCFA in colon by bacteria, promotes sodium and water absorptionInsoluble fibre: Increases fecal weight / bulk
18 FORMULA COMPOSITION POLYMERIC Fibre Need adequate amounts of fluid to prevent constipation and impaction / obstructionAvoid fibre in hypotensive patients - high risk for developing ischemic bowelMcClave et al. JPEN 2009; 33:27Chen et al. NCP 2009; 24: 344
19 FORMULA COMPOSITION POLYMERIC Prebiotics Prebiotics are: Resistant to gastric acidity and digestionFermented by GIT endogenous microbiomeStimulate growth of intestinal microbiota which contains health benefitsExamples:Inulin (chicory, leeks, onions, garlic)Inulin type fructans (oligo fructose or fructo oligo saccharides)Lactulose
20 FORMULA COMPOSITION POLYMERIC Prebiotics FOS added to some enteral formulas suh as Jevity 1.2, Jevity 1.5, Nepro with carb steady, Two Cal HN, Peptamen AF, PeptamenFermented by bacteria in colon to SCFAs which stimulate growth of beneficial bacteria in colon and stimulate water and electrolyte absorption
21 FORMULA COMPOSITION ELEMENTAL / SEMI-ELEMENTAL Designed to improve nutrient absorption in maldigestive or malabsorptive states such as pancreatic insufficiency.Ex.: Elemental: VitaL HN, Vivonex Plus Semi-Elemental: Peptamen, Peptamen 1.5, Peptamen AFIf high protein intake is required, Peptamen AF provides g protein / 1200 Kcal.
22 FORMULA COMPOSITION DISEASE SPECIFIC RENAL Dialysis Patients (Intermittent Hemodialysis) Ex.: Nepro, NovaSource RenalEnergy dense: 2 Kcal / mlLow in K+ and phosphorusProtein content increased to 18% by manufacturers so it can be used for AKINepro with Carb Steady: 81g protein / litreNovasource Renal: 91g protein / litreHigh fat (majority of fat long chain FA) with concern in patients with gastroparesis and pancreatic insufficiency
23 FORMULA COMPOSITION DISEASE SPECIFIC RENAL Predialysis patients. Ex.: SuplenaCalorie dense 2 Kcal / mLLow protein: 30g protein / litreLow K and phosphorusHigh fat: 96g / litre
24 FORMULA COMPOSITION DISEASE SPECIFIC HEPATIC Ex.: NutriHep Energy dense: 1.5 Kcal / mLIncreased branch-chained amino acidsDecreased aromatic amino acidsSemi-elemental:Protein: Free amino acids and wheyCarbohydrate: Maltodextrin and corn starchFat: MCT: LCT ratio is 70%: 30%With current evidence, routine use not warranted in hepatic encephalopathyVery expensive
25 FORMULA COMPOSITION DISEASE SPECIFIC DIABETIC Ex.: Glucerna, Resource DiabeticLow Carbohydrate 34%-36%17%-20% proteinHigh fat (> 40%)Contains fibreMay not be well tolerated with diabetic gastroparesisIndication:Hyperglycemia, patients on corticosteroidsOptimize glycemia with insulin protocol prior to using this product
26 FORMULA COMPOSITION DISEASE SPECIFIC PULMONARY Ex.: Oxepa, for ALI and ARDSHigh in fat: 55% (contains fish oil) Omega-3 to Omega-6 ratioSupplemented with antioxidants (Vit E, Vit C and beta-carotene)
27 FORMULA COMPOSITION DISEASE SPECIFIC IMMUNE-ENHANCING FORMULA Ex.: Impact, Peptamen AF, OxepaFormulas contain one or more of the following: glutamine, arginine, Omega-3 FA, nucleotides and antioxidants.Oxepa and Peptamen AF are very high in Vitamin A content, need to take this into consideration if tube feeding a pregnant woman.In critically-ill, arginine and glutamine should not be supplemented
28 MODULAR PRODUCTS PROTEIN Ex.: Beneprotein powder Whey protein 6g protein / scoop 7 gProvides 25 Kcal / scoopRelatively low in K, phos but must be considered if using a large number of scoopsMixes easily with waterUseful to supplement formulas when protein requirement is 2g / kgLiquid protein supplements exist but are not availbale in Canada
29 MODULAR PRODUCTS CARBOHYDRATE Ex.: Polycose FAT Ex.: MCT Oil Glucose powder mixed with water or beverages to increase caloriesFAT Ex.: MCT OilUsed to increase calories in patients with poor fat digestion or malabsorption120 Kcal / tbsp
32 Case Study56 yo male Lt. vertebral artery dissection and basilar artery thrombosis after neck manipulation by a chiropractor in Tracheostomy and PEG placed in 2010 and pt was transferred to a long term care hospital.July 2011: Admitted to ICU with Hypoxemic respiratory failure (pneumonia), coccyx pressure ulcers - infected. Labs unremarkable, low albumin as expected.On Peptamen 1.5 enteral feeding via PEG due to intolerance of other formulas especially one with fibre prior to admission.Diarrhea likely due to antibodics. No C. difficile.Pectin added as soluble fibre sourceAdequate amounts of Vitamin C, Zn, Vitamin A for wound healingAdequate calcium and Vitamin DCalories: calculated with Penn state equationProtein: 1.5g / kg
33 Case StudyDiarrhea resolved, pressure ulcers started healing, weaned from ventilator. Transferred to medical ward November 2011.July 2012: returned to ICU with respiratory failure, hypersalivation, blackspots in PEG.
34 What were the black spots? Case StudyWhat were the black spots?
35 Case Study Black spots likely fungus. August 1: PEG tube changed – contrast used and X-ray done to ensure no leak.Peptamen 1.5 feeds restarted.
36 Case Study Aspiration? Green secretions around tracheostomy No BM August 3-7Enema givenRegurgitation of feeds August 18Abdo X-ray shows contrast (from August 1) throughout bowel
37 Case Study Recommend PEG/J Pt’s wife refused, she wants him fed into stomachPromotility drug startedGolitely used via PEG with L/A stool
38 Case StudyChanged formula to Isosource 1.5 with 7g fibre / litre (soy fibre and guargum)Changed feeds to intermittent due to high residuals (400ml)
39 Case Study Constipation despite laxatives and promotility drugs Trial of various laxatives – none workedBM every 4 days with laxativeBloatingAlgorithm for constipation in neurological disease was followed
40 Case Study Gastroenterologist consulted Recommended high fibre high fat diabetic formula (12g soy fibre / litre, 40% calories as fat)Wife believes pt had candida in stomach and is bloated for this reasonOngoing bloatingDry hard stool. Water provided was increased.Ongoing bloating with diabetic formula but BM q 2-3 days with laxatives and stool softener
41 Case Study Spoke with wife re. pureed food formula Agrees to trial 5.7g fibre / litre (vegetable fibre and hydrolyzed guargum)Protein powder (8 scoops daily) to provide enough proteinIntermittent feedings: 3 times per daySoft / pasty BM 1-2 times per dayNo laxatives or stool softener usedPrune juice given one time per day via tubeContinue with adequate water
42 Case StudyPatient, wife, healthcare team happy with latest change of formula
43 ReferencesAbbott Nutrition. Adult Nutritional products Guide. DecBoullata J, Nieman Carney L, Guenter P, eds. Enteral formula selection and preparation In: A.S.P.E.N. Enteral Nutrition Handbook, Silver Spring, MD: American Society for Parenteral and Enteral Nutriiton; 2010:Chen Y, Peterson SJ. Enteral feeding formulas: which formula is right for your adult patient? Nutr Clin Pract ; 24:DeChicco RS, Materese LE. Determining the nutrition support regimen. In: Matarese L, Gottschlich M, eds. Comtemporary Nutrition Support Practice. Philadelphia, Pennsylvania: WB. Saunders Co., 1998;Lefton J, Halasa Esper D, Kochevar M. Enteral formulations. In: Gottschlich Met al., eds The A.S.P.E.N. Nutrition Support Care Curriculum. Silver Spring, MD; American Society for Parenteral and Enteral Nutrition; 2007:Nestlé Health Science. Healthcare Nutrition Product Guide Sept 2013.Winge K, Rasmussen D, Werdelin LM. Constipation in neurologiocal disease J Neurol Neurosurg Psychiatry 2003; 74: