Presentation

Report
Michele Port, P.Dt.
Clinical Dietitian
March 2014
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.
OUTLINE

Introduction

Choice of an enteral formula

Formula composition

Types of feedings

Enteral formulary

Case study

Conclusion
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.
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.
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.
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.
FORMULA COMPOSITION
 CARBOHYDRATE


Primary energy source in most enteral formulas.
Usually 40%-90% of total calories
SOURCE of CARBOHYDRATE
Polymeric
Elemental / Semi-Elemental
Corn Syrup Solids
Corn Starch
Hydrolyzed Corn Starch
Hydrolyzed Corn Starch
Maltodextrin
Maltodextrin
Sucrose
Fructose
Fructose
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
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 Oil
Fish Oil
Coconut Oil
Soybean Oil
Sardine Oil
Palm Kernel Oil
Canola Oil
Menhaden Oil
Soybean Oil
Corn Oil
Coconut Oil
Safflower Oil
Borage Oil
Palm Kernel Oil
Soy Lecithin
Fish Oil
Soy Lecithin
Fish Oil
Structured Lipids
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).
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.
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
TYPES OF FORMULAS

POLYMERIC
1. Standard (Ex.: Osmolite 1 CAL)
29%
Carbohydrate
54%
Protein
17%
Fat
29%
• Need good digestion and absorption
2. High Protein (Ex.: Isosource VHN, Isosource VHP, Promote) 20%-25% Protein
Isosource VHN
Isosource VHP
Promote
Carbohydrate
50%
45%
52%
Protein
25%
25%
25%
Fat
25%
30%
23%
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
TYPES OF FORMULAS

POLYMERIC
3. Energy Dense: (Ex.: Nutren 1.5, Nutren 2.0, Resource 2.0, Two Cal HN)
• Provide 1.5-2 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
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
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
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
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
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.
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
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
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:
Carbohydrate:
Fat:
Free amino acids and whey
Maltodextrin and corn starch
MCT: LCT ratio is 70%: 30%
With current evidence, routine use not warranted in hepatic
encephalopathy
Very expensive
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
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)
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
MODULAR PRODUCTS
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
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
Nutritional Content - Enteral Feeding Formula at MUHC adult sites
Polymeric Formulas
Nutrition Information
Energy (kcal/mL)
PTN (g/L)
Protein Source
CHO (g/L)
Osmolite 1 Cal
Isosource HN
Isosource HN Fibre
Isosource 1.5
1.06
1.2
1.2
1.5
44 (16.7%)
53 (18%)
53 (18%)
68 (18%)
Na + Ca caseinates, soy
protein isolate
soy protein isolate,
Na caseinate (from milk)
143.8 (54.3%)
151 (51%)
corn maltodextrin, corn syrup
CHO Source
corn syrup, corn maltodextrin
solids
Fat (g/L)
34.7 (29%)
42 (31%)
soy protein isolate and
Na & Ca caseinates
concentrate,
Na
milk)
caseinate (from milk)
157 (51%)
corn syrup, corn
maltodextrin, partially
hydrolyzed guar gum
(PHGG), soy
42 (31%)
(from
170 (44%)
corn maltodextrine, sucrose,
soy, partically hydrolyzed guar
gum (PHGG)
65 (38%)
high oleic safflower (48%),
MCT 20% (canola oil,
MCT 20% (canola oil,
canola oil, MCT 30%
canola oil (29%), corn oil,
Fat Source
coconut oil, palm kernel oil), coconut oil, palm kernel oil), (coconut oil, palm kernel oil),
fract. Coconut oil, MCT oil
soy lecithin
soy lecithin
soybean oil
(20%) & soy lecithin (3%)
mOsm/kg Water
Na/K (mg/L)
2+
Ca /P04 /Mg(mg/L)
Residue Content (Fibre)
300
435
520
650
930/1570
1100/1800
1100/1800
1290/2140
760/760/303
1000/1000/270
1000/1000/270
1070/1020/430
Low (0g fibre)
Low (0g fibre)
High (12g/L)
Moderate (8g/L)
Nutritional Content - Enteral Feeding Formula at MUHC adult sites
Polymeric Formulas
Fibre Source
Water Content (%)
Lactose Free
Gluten Free
Koscher
Expiry:
After Opening /Mixing
Refrigerate/Discard after:
none
none
PHGG(soluble),
soy (soluble & insoluble)
PHGG(soluble),
soy
(soluble & insoluble)
84.2%
80.4%
80.5%
77.6%
√
√
√
√
√
√
√
√
√
√
√
√
store between 18°-27°C
until "Use By" date
store between 18°-27°C until
"Use By" date
24 hours (cans)
24 hours (cans)
store between 18°-27°C until store between 18°-27°C until
"Use By" date
"Use By" date
24 hours (cans)
Hold BTW 4-60°C
8 to 12 hours (cans)/
Discard after Hanging for: 48 hours (RTH containers)
Format on Formulary:
Company Product Code 00735793 52600A55
MUHC available Format 24x235mL 6x1.5L
Price per 1000 kcal 2.63$
3.73$
24 hours (cans)
8 hours (cans)/
48 8 hours (cans)/
48 8 hours (cans)/
48
hours (Closed Systen
hours (Closed Systen
hours (Closed Systen
containers)
containers)
containers)
9521659 12093313
24x250mL 6x1.5L
2.13$
2.60$
9521653 12093589
24x250mL 6x1.5L
2.13$
2.60$
9521660 12093199
24x250mL 6x1.5L
2.16$
2.38$
Case Study
56 yo male Lt. vertebral artery dissection and basilar artery thrombosis after neck manipulation
by a chiropractor in 2010. 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
Case Study


Diarrhea 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.
Case Study
What were the black spots?
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.
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
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
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)
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
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
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
Case Study

Patient, wife, healthcare team happy with latest change of formula
References
Abbott Nutrition. Adult Nutritional products Guide. Dec. 2008.
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: 91-157.
Chen Y, Peterson SJ. Enteral feeding formulas: which formula is right for your adult patient?
Nutr Clin Pract. 2009; 24: 344-355.
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; 185-191.
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: 209-232.
Nestlé Health Science. Healthcare Nutrition Product Guide 2013-2014. Sept 2013.
Winge K, Rasmussen D, Werdelin LM. Constipation in neurologiocal disease.
J Neurol Neurosurg Psychiatry 2003; 74: 13-19.
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