1. nutrition service supporting the professional Weight control for tube fed patients – the evidence for low energy feeds Sharran Howell Nutrition Service Manager Fresenius Kabi Limited

2. Agenda Trends in enteral tube feeding Why do we need low energy tube feeds? Patients with low energy requirements Why not standard feeds? What has been developed? Case studies The future

3. Trends in enteral tube feeding BANS survey 1996-2002 showed In 2002 over 15,000 registered patients were receiving Home Enteral Tube Feeding (HETF) Estimated total numbers are estimated to be 22,000-27,000 Over 51% patients are over the age of 71 Disorders of the central nervous system accounted for ~60% of diagnoses in adults established on HETF CVA accounts for 32-35% of the diagnoses established on HETF About 1/6 of adults on HETF undertook full normal activity 51% of adults established on HETF were housebound and bed bound The proportion of patients requiring total help increased from 49%-59%

4. Why do we need low energy tube feeds? Most standard tube feeds meet the average adult nutritional requirements in 1200-1500kcal/day This amount of energy supply is often too high for certain patient groups Sedentary Overweight / obese Patients with low energy requirements e.g elderly Risk of overfeeding In response to UK customer demands

5. Patients with low energy requirements Supply of higher energy and protein is often required in tube fed patients to promote anabolism and recovery For long-term stable patients on HETF this may not be the case Several studies confirm that mainly inactive patients have lower energy expenditure than those who are active

6. Patients with low energy requirements Energy expenditure was measured in elderly patients in long-term care and showed to be 1000kcal per day, mainly in the immobile patients (Ireton-Jones 1998) A study in patients with dementia in long-term care found that energy expenditure was an average of 900kcal/day for women and 1000kcal/day for men (Wang et al 1997) Hypo-caloric nutrition support has improved clinical outcomes with patients receiving hypo-caloric feeds having a shorter length of ITU stay, decreased duration of antibiotic days and a decrease in the number of ventilator days (Dickerson et al 2002)

7. Patients with low energy requirements Dietitians have shown concern that certain patient groups often show unintentional weight gain: Immobile patients Patients with neurological disease Stroke patients Elderly patients Overweight/obese patients on enteral tube feeding Weight gain presents additional risks to the patient Causes practical problems for nurses and carers – lifting and handling, dressing can become increasing difficult

8. Why not standard tube feeds? As most standard feeds are nutritionally complete in 1200-1500kcal, Dietitians are left with the following dilemma: Is it less damaging to provide the full feed volume and see the patients weight increase, or to reduce the feed volume to control weight and risk creating a deficiency of protein and micronutrients? Supplements can be used to made up the deficit in the latter option, however this has potential problems Administration Microbial contamination Inaccuracies in measuring and administrating

9. What has been developed? Fresubin 1000 Complete was launched in 2000 following extensive market research product development clinical trials customer feedback Main features UK Dietitians asked for: Nutritionally complete in 1000kcal Contain fibre Low volume 1 bag per day dose

10. What has been developed? This feed can benefit a variety of patients requiring a nutritionally complete feed in 1000kcal without compromising nutritional status Helps promote weight loss and or weight maintenance Reduces handling of equipment with the EasyBag closed system

11. Case Studies Patient A 58-year-old female - anoxic brain damage secondary to cardiac arrest 1997. Currently stays at home, fed via gastrostomy, nil by mouth. Weight on admission to Neurological Rehabilitation Unit 1997 - 43.5kg (6st 12lb), height 1.51m, BMI 19. Estimated nutritional requirements 1500kcal, 45g protein. Aim was weight maintenance and fed to nutritional requirements with 1kcal/ml fibre feed. On discharge home in April 1998 weight stable at 6st 12lbs.

12. Case Studies (Patient A continued) Weight in August 2000 47.6kg (7st 7lb), BMI 21. In view of gradual weight gain changed to 1.2kcal/ml feed nutritionally complete. Weight maintenance for around two years and then weight gradually increased to 53kg (8st 5lb), BMI 23. January 2005 changed to Fresubin 1000 Complete. July 2005, weight has actually reduced to 50kg (7st 13lb),BMI 22. Continues with Fresubin 1000 Complete, aim for 45kg-47kg for weight maintenance. Patient is at home. Ambulant (but not active). Remains nil by mouth and gastrostomy fed.

13. Case studies PATIENT B 34-year-old female with anoxic brain damage due to a cardiac arrest. Patient nil by mouth. Enterally fed via a gastrostomy tube. Patient remains in a persistent vegetative state. Post acute episode she was admitted in 1995 to Neurological Rehabilitation Unit. Height 1.62m, weight 37.6kg (5st 13lb), BMI 14. Estimated requirements at this time 1800kcal, 38g protein At this time her quantity and type of feed was matched to her estimated nutritional requirements,using 1kcal/ml fibre containing feed. She gradually, over a period of abut 9-12 months, achieved a weight of 50kg (7st 13lb), BMI 19 with the aim of maintaining weight. Enteral feed reduced to 1500kcal - weight maintenance achieved for about one year with this then weight continued to increase very gradually to 56kg (8st 12lb). Enteral feed adjusted to provide 1200kcal and maintained again for about one year with this and then weight gradually increased to 64kg (10st 2lb).

14. Case studies (Patient B continued) Enteral feed reduced to 1050kcal and achieved weight maintained for a period of 9-12 months. At this time no feed on market complete in 1000kcal so this was a concern. Vitamin and mineral supplement provided. March 2001 patient commenced on Fresubin 1000 Complete. At this time weight was 64kg, weight maintenance on Fresubin 1000 Complete for about 2 years and then weight gradually increased to 68kg (10st 10lb). Enteral feed adjusted to 925ml Fresubin 1000 Complete and maintaining weight on this. Patient still remains in hospital, mostly nursed in bed but is up daily in wheelchair. Concern is, if weight increases what options are available as there is no nutritionally complete feed with less than 1kcal/ml.

15. The future Next phase of low energy feeds…… Low energy feeds without fibre? New formulations? Lower energy nutritionally complete feeds? Look at trends in HETF Listening to what the customers say and what patients need are

16. Thank you & Question time