nutrition servicesupporting the professional

Weight control for tube fed patients – the evidence for low energy feedsSharran Howell

Nutrition Service Manager

Fresenius Kabi Limited

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

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%

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

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

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)

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

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 patient’s 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

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

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’

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.

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.

Case studiesPATIENT 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).

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.

The futureNext 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

Thank you&

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