nutrition service

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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
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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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.

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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.

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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).

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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.

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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

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Thank youQuestion time