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CHOOSING AN ENTERAL FEEDING FORMULA. Michele Port, P.Dt. Clinical Dietitian March 2014. LEARNING OBJECTIVES. Identify common sources of protein, carbohydrate and fat used in enteral feeding formulas.

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    1. CHOOSING AN ENTERAL FEEDING FORMULA Michele Port, P.Dt. Clinical Dietitian March 2014

    2. LEARNING OBJECTIVES • Identify 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 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: • Intact nutrients • Appropriate for normal gut function • Elemental / Semi-Elemental also referred to as predigested: • Protein, carbohydrate predigested or semi-digested • 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

    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 whey • 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

    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 • Standard (Ex.: Osmolite 1 CAL) 29% • Need good digestion and absorption • High Protein (Ex.: Isosource VHN, Isosource VHP, Promote) 20%-25% Protein

    15. TYPES OF FORMULAS • POLYMERIC • 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. TYPES OF FORMULAS • POLYMERIC • 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) • 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 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 • 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 • 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 • 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 • 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 • 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 • 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 • 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 • 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 • 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 Acontent, 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 • PROTEINEx.: 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

    29. MODULAR PRODUCTS • CARBOHYDRATEEx.: Polycose • Glucose powder mixed with water or beverages to increase calories • FATEx.: MCT Oil • Used to increase calories in patients with poor fat digestion or malabsorption • 120 Kcal / tbsp

    30. 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

    31. 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.

    32. Case Study What were the black spots?

    33. 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.

    34. 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

    35. 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

    36. 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)

    37. 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

    38. 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

    39. 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

    40. Case Study • Patient, wife, healthcare team happy with latest change of formula

    41. 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.

    42. THANK YOU