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Michele Port, P.Dt. Clinical Dietitian March 2014.

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Presentation on theme: "Michele Port, P.Dt. Clinical Dietitian March 2014."— Presentation transcript:

1 Michele Port, P.Dt. Clinical Dietitian March 2014

2 LEARNING OBJECTIVES 1.Identify common sources of protein, carbohydrate and fat used in enteral feeding formulas. 2.Identity formulas which could benefit your patient population and to include in your formulary. 3.Become familiar with high protein formulas and modular products.

3 OUTLINE  Introduction  Choice of an enteral formula  Formula composition  Types of feedings  Enteral formulary  Case study  Conclusion

4 INTRODUCTION Choice of an enteral formula depends on several factors. You need to complete your nutrition assessment and calculate your patient’s nutritional requirements before deciding on an appropriate formula. Formulas from different companies are often similar. The decision of which formulas to include in a formulary comes down to your patient population with their specific needs and cost.

5 CHOICE of an ENTERAL FORMULA  Depends on: Nutritional requirements: calories, protein, other GI 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 products Usually slight differences in macro or micronutrients Best way to compare products is in a chart format  Speciality products: need to assess literature to verify claims  Choice 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: i. Intact nutrients ii. Appropriate for normal gut function Elemental / Semi-Elemental also referred to as predigested: i. Protein, carbohydrate predigested or semi-digested ii. Use if compromised GI function  There are also modular products which provide only carbohydrate, protein, or fat to increase the macronutrient as required.

8 FORMULA COMPOSITION  CARBOHYDRATE Primary energy source in most enteral formulas. Usually 40%-90% of total calories SOURCE of CARBOHYDRATE PolymericElemental / Semi-Elemental Corn Syrup SolidsCorn Starch Hydrolyzed Corn Starch Maltodextrin SucroseFructose

9 FORMULA COMPOSITION  PROTEIN Source of nitrogen and energy In enteral formulas: i. Polymeric intact protein: Whole protein or protein isolates (casein, soy), lactalbumin, egg albumin and whey ii. Elemental / 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 acids FAT SOURCE Polymeric Elemental / Semi-Elemental Safflower OilFish Oil Coconut Oil Soybean OilSardine Oil Palm Kernel Oil Canola OilMenhaden Oil Soybean Oil Corn OilCoconut Oil Safflower Oil Borage OilPalm Kernel Oil Soy Lecithin Fish OilSoy Lecithin Fish Oil Structured 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 3 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 formula Need to include water in formula in total fluid intake  OSMOLALITY (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.  ELECTROLYTES Most formulas contain adequate amounts Hepatic formula very low in sodium

14 TYPES OF FORMULAS  POLYMERIC 1.Standard (Ex.: Osmolite 1 CAL) 29% Need good digestion and absorption 2.High Protein (Ex.: Isosource VHN, Isosource VHP, Promote) 20%-25% Protein Carbohydrate54% Protein17% Fat29% Isosource VHNIsosource VHPPromote Carbohydrate50%45%52% Protein25% Fat25%30%23%

15 TYPES OF FORMULAS  POLYMERIC 2.High Protein (Ex.: Isosource VHN, Isosource VHP, Promote) 20%-25% Protein  Indications:  Catabolism Wound healing Pressure ulcers Patients on propofol Plasmapheresis CVVHD - continuous dialysis Burn patients

16  POLYMERIC 3.Energy Dense: (Ex.: Nutren 1.5, Nutren 2.0, Resource 2.0, Two Cal HN) Provide Kcal / mL  Indications: Fluid restriction CHF Renal failure Ascites Hyponatremic (hypervolemic) 4.Commercial blenderized food product (Ex.: Compleat) made from pureed foods (chicken, fruit vegetable, juice, etc…) Formula is very well tolerated but very viscous TYPES OF FORMULAS

17 FORMULA COMPOSITION  POLYMERIC 5.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 EN Decrease diarrhea in short term EN  Combination of soluble and insoluble fibre: Soluble fibre: Fermented to SCFA in colon by bacteria, promotes sodium and water absorption Insoluble fibre: Increases fecal weight / bulk

18 FORMULA COMPOSITION  POLYMERIC 5.Fibre Need adequate amounts of fluid to prevent constipation and impaction / obstruction Avoid fibre in hypotensive patients - high risk for developing ischemic bowel McClave et al. JPEN 2009; 33:27 Chen et al. NCP 2009; 24: 344

19 FORMULA COMPOSITION  POLYMERIC 6.Prebiotics Prebiotics are: Resistant to gastric acidity and digestion Fermented by GIT endogenous microbiome Stimulate growth of intestinal microbiota which contains health benefits Examples: Inulin (chicory, leeks, onions, garlic) Inulin type fructans (oligo fructose or fructo oligo saccharides) Lactulose

20 FORMULA COMPOSITION  POLYMERIC 6.Prebiotics FOS added to some enteral formulas suh as Jevity 1.2, Jevity 1.5, Nepro with carb steady, Two Cal HN, Peptamen AF, Peptamen Fermented 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 AF If high protein intake is required, Peptamen AF provides 76g protein / 1200 Kcal.

22 FORMULA COMPOSITION  DISEASE SPECIFIC 1.RENAL Dialysis Patients (Intermittent Hemodialysis) Ex.: Nepro, NovaSource Renal Energy dense: 2 Kcal / ml Low in K + and phosphorus Protein content increased to 18% by manufacturers so it can be used for AKI  Nepro with Carb Steady: 81g protein / litre  Novasource Renal: 91g protein / litre High fat (majority of fat long chain FA) with concern in patients with gastroparesis and pancreatic insufficiency

23 FORMULA COMPOSITION  DISEASE SPECIFIC 1.RENAL Predialysis patients. Ex.: Suplena Calorie dense 2 Kcal / mL Low protein: 30g protein / litre Low K and phosphorus High fat: 96g / litre

24 FORMULA COMPOSITION  DISEASE SPECIFIC 2.HEPATIC Ex.: NutriHep Energy dense: 1.5 Kcal / mL Increased branch-chained amino acids Decreased aromatic amino acids Semi-elemental: Protein:Free amino acids and whey Carbohydrate: Maltodextrin and corn starch Fat: MCT: LCT ratio is 70%: 30% With current evidence, routine use not warranted in hepatic encephalopathy Very expensive

25 FORMULA COMPOSITION  DISEASE SPECIFIC 3.DIABETIC Ex.: Glucerna, Resource Diabetic Low Carbohydrate 34%-36% 17%-20% protein High fat (> 40%) Contains fibre May not be well tolerated with diabetic gastroparesis Indication: Hyperglycemia, patients on corticosteroids Optimize glycemia with insulin protocol prior to using this product

26 FORMULA COMPOSITION  DISEASE SPECIFIC 4.PULMONARY Ex.: Oxepa, for ALI and ARDS High in fat: 55% (contains fish oil)  Omega-3 to Omega-6 ratio Supplemented with antioxidants (Vit E, Vit C and beta-carotene)

27 FORMULA COMPOSITION  DISEASE SPECIFIC 5.IMMUNE-ENHANCING FORMULA Ex.: Impact, Peptamen AF, Oxepa Formulas 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 1.PROTEIN Ex.: Beneprotein powder  Whey protein  6g protein / scoop 7 g  Provides 25 Kcal / scoop  Relatively low in K, phos but must be considered if using a large number of scoops  Mixes easily with water  Useful to supplement formulas when protein requirement is 2g / kg  Liquid protein supplements exist but are not availbale in Canada MODULAR PRODUCTS

29 2.CARBOHYDRATE Ex.: Polycose  Glucose powder mixed with water or beverages to increase calories 3.FAT Ex.: MCT Oil  Used to increase calories in patients with poor fat digestion or malabsorption  120 Kcal / tbsp MODULAR PRODUCTS



32 Case Study 56 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), 2 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 source  Adequate amounts of Vitamin C, Zn, Vitamin A for wound healing  Adequate calcium and Vitamin D  Calories: calculated with Penn state equation  Protein: 1.5g / kg

33 Case Study  Diarrhea resolved, pressure ulcers started healing, weaned from ventilator. Transferred to medical ward November  July 2012: returned to ICU with respiratory failure, hypersalivation, blackspots in PEG.

34 Case Study What 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 3-7  Enema given  Regurgitation of feeds August 18  Abdo X-ray shows contrast (from August 1) throughout bowel

37 Case Study  Recommend PEG/J  Pt’s wife refused, she wants him fed into stomach  Promotility drug started  Golitely used via PEG with L/A stool

38 Case Study  Changed 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 worked  BM every 4 days with laxative  Bloating  Algorithm 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 reason  Ongoing bloating  Dry 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 protein  Intermittent feedings: 3 times per day  Soft / pasty BM 1-2 times per day  No laxatives or stool softener used  Prune juice given one time per day via tube  Continue with adequate water

42 Case Study  Patient, wife, healthcare team happy with latest change of formula

43 Abbott Nutrition. Adult Nutritional products Guide. Dec Boullata 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. 2009; 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 Winge K, Rasmussen D, Werdelin LM. Constipation in neurologiocal disease. J Neurol Neurosurg Psychiatry 2003; 74: References


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