THE VARIOUS TYPES OF ORAL SUPPLEMENTS USED IN ORAL NUTRITION

TYPES OF ORAL SUPPLEMENT

Many types of oral nutrition supplement are available in a wide choice of flavours. Most are liquid sip-feeds but some come in other forms such as desserts. A full description of all types is beyond the remit of this book and advice from dietitians is often required. Nevertheless, the IVN prescriber should know the basics of what is available and understand the rationale behind different supplement use.

Most commercial oral supplements contain energy, protein, vitamins, trace elements and fluid, with some containing fibre. They are usually nutritionally complete if used alone to meet all of a patient’s energy needs. Most contain 1.0 kcal/mL but higher-energy versions containing 1.5 kcal/mL are also available. Nitrogen content is usually equivalent to 4–6 g protein per 100 mL but they vary widely in energy to- protein ratios, nitrogen form and content, and the type of fat that they contain. The following broad types are commonly used:

·        Polymeric complete: polymeric feeds containing nitrogen as whole protein or long polypeptides are most commonly prescribed. The 8 Oral and enteral tube support carbohydrate source is mostly partially hydrolysed starch and the fat is predominantly long-chain triglycerides (LCTs). These feeds tend to be either sweet, apparently milky drinks or savoury formulas. They are suitable for patients who have no significant digestive problems.

·        Polymeric fat-free: some polymeric oral supplements contain no lipid. They are therefore less nutritionally complete but many patients prefer the fruit drink-type format, particularly if the drink is diluted with water to limit its sweetness.

·        Fibre-containing feeds: many oral supplements are available in standard and fibre-enriched forms. The standard feeds contain little or no fibre and hence they lead to little or no short-chain fatty acid (SCFA) production in the colon. Fibre-enriched feeds theoretically increase SCFA availability in the colon, which may increase salt and water reabsorption and limit growth of pathogenic bacteria by lowering colonic pH. Their effectiveness, however, is probably marginal, especially if patients are on antibiotics which reduce colonic flora.

·        Predigested and elemental feeds: these feeds contain nitrogen as either short peptides or, in the case of elemental diets, as free amino acids. Carbohydrate provides much of the energy content while the fat content varies in both quantity and the proportion provided as LCTs and medium-chain triglycerides (MCTs). The aim of ‘predigested’ feeds is to improve nutrient absorption but their effectiveness is usually limited to maldigestive problems (e.g. pancreatic disease) rather than malabsorptive states. Indeed, they should generally be avoided in patients with a short gut or patients with small-bowel fistulae since their high osmolality can cause excess movement of water into the gut and hence increased diarrhoeal losses.

·        Specialised disease-specific and pharmaconutrient feeds: some very specialised disease-specific and pharmaconutrient supplements are available but the indications for their use are complex and beyond the remit of this book. Sodium-supplemented sip-feeds are not available commercially but can be very useful in the management of patients with high-output stomas who tend to become salt depleted.

Indeed, the use of such sodium supplementation can avoid the need for IVN in some patients and hence their use must be understood by IVN prescribers (see Chapter 10).

Common indications for enteral tube feeding

Indication for feeding	Examples
Unconscious patient	Head injury, ventilated patient, encephalopathy
Swallowing disorder	Post cerebrovascular accident, multiple sclerosis, motor neurone disease, Parkinson’s disease
Physiological anorexia	Liver disease (particularly with ascites), cancer cachexia, especially in malnourished patient due to undergo surgery (since supplementary feeding helps reduce postoperative complications)
Upper gastrointestinal obstruction	Pharyngeal tumour, oesophageal tumour/stricture, pyloric stenosis
Partial intestinal failure	Postoperative ileus, inflammatory bowel disease, short-bowel syndrome
Increased nutritional requirements	Intensive-care patient, cystic fibrosis, renal disease
Psychological problems	Severe depression or anorexia nervosa

ORAL NUTRITION: What You Need To Know

ORAL NUTRITION SUPPORT

Oral nutrition support is usually the cheapest, safest and most physiological method of providing additional nutrition. At its simplest, the importance of eating to prevent problems and to aid recovery should be explained to patients with encouragement to eat all meals provided. Staff should also try to ensure that meals are not missed through investigations or procedures unless absolutely necessary. Needing to be nil by mouth for a gastroscopy is acceptable, but missing lunch because the patient was off the ward for a chest X-ray is not.

If spontaneous intake is felt to be inadequate, encouragement and help should be offered and records of daily food, nutritious drinks and other fluid intake should be commenced. If the problem then persists, dietetic advice should be sought. Some patients may benefit from special menus, snacks and increased choice, and dietitians are in an ideal position to explore these possibilities. Changing food consistency may also lead to improved intake in some patients with swallowing difficulties.

Soft diets may help in oesophageal structuring whereas thickened liquids may help patients with neurological dysphagia. Great care must be taken, however, to ensure that dysphagic patients who are allowed to continue with oral intake do not aspirate. Assessment by a speech and language therapist (SALT), with or without radiological assessment of swallowing, may be required.

Food fortification, using either high-energy foodstuffs (e.g. butter or cream) or commercially available energy and/or protein supplements, is commonly recommended to try to improve nutritional intake. We believe, however, that the use of this type of nutritional supplementation should be viewed with caution. Malnourished individuals are usually depleted in micronutrients, electrolytes and minerals as well as energy and protein, and food fortification may fail to address all of their needs.

This could also put them at risk of a re-feeding problem through shortage of a critical nutrient (see Chapter 9). We therefore recommend that oral supplementation beyond that provided from normal food should be with commercially produced, nutritionally complete protein, energy and micronutrient preparations, e.g. sip-feed drinks. Even then, some caution is needed. Although such commercial ‘complete’ supplements do contain sufficient quantities of vitamins and minerals to meet daily requirements, they only do so if patients are consuming enough of the supplement to meet their entire energy and protein needs. This is often not the case and patients are only using the supplement as additional intake above that from food. They may, therefore, still need additional multivitamin and trace element supplementation to ensure balanced and truly complete nutrient intake.

It is important that any oral nutritional supplements including, for example, sip-feed drinks and micronutrients, are prescribed on drug charts. This will not only ensure that they are actually given by nursing staff but also indicate clearly to both patients and staff that nutritional care is an integral part of medical treatment.

ETHICAL FACTS ABOUT NUTRITION SUPPORT

ETHICAL ISSUES IN NUTRITION SUPPORT

Artificial nutrition support is fraught with ethical and legal difficulties and all prescribers of IVN should be familiar with these. In general, providing adequate and appropriate fluid and nutrients is a basic duty to sick patients and while a patient can swallow and expresses a desire or willingness to drink or eat, fluid and nutrients should be given unless there is a medical contraindication. If the patient cannot safely consume or absorb adequate amounts orally, administration of nutrients and/or fluid via a tube or vein must be considered. Legally, however, this becomes a ‘medical treatment’ and hence can be withheld or withdrawn if providing or continuing such support is not in the patient’s best interests.

If, for example, an illness is regarded as being in the terminal phase and the plan is to provide only compassionate and palliative care, ethical considerations indicate that a tube/vein supply of nutrients or fluid need only be given to relieve symptoms and should not necessarily be used to prolong survival. In cases where benefits are in doubt, a planned time limited trial of artificial feeding may be useful.

Whenever nutrition support is used, patients should give their consent and a competent patient’s refusal is binding. If a patient lacks the competence to make a decision, the patient’s doctor should seek to ascertain whether the patient expressed previous views about the type of treatment that he or she would wish to receive if the present state of incompetence occurred. If no such views can be identified, any decisions on tube or vein provision of food and/or fluids should involve consultation with the family and all members of the health care team.

However, under current English law, relatives or a nominated proxy cannot make a decision on behalf of an adult patient and so cannot override the clinician’s decision. Special considerations apply in relation to children and application to the court should be made regarding the legality of withdrawing artificial hydration and nutrition from a patient in a persistent vegetative state.

Under specified circumstances, it can be legal to enforce nutritional treatment for an unwilling patient with a mental disorder. This includes anorexia nervosa, in which it is considered that severe malnourishment per se can render patients incompetent of making rational decisions regarding their care.

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THE TRUE FACTS ABOUT NUTRITION SUPPORT

NUTRITION SUPPORT: THE FACT

Nutrition Support is intravenous nutrition or orally modified formulas necessitated by inability to consume a general diet; administered to malnourished individuals who cannot consume food in its original form. The provision of enteral or parenteral nutrients to treat or prevent malnutrition.  Nutrition Support Therapy is part of Nutrition Therapy which is a component of medical treatment that can include oral, enteral, and parenteral nutrition to maintain or restore optimal nutrition status and health.

All people need food to live. Sometimes a person cannot eat any or enough food because of an illness.  The stomach or bowel may not be working quite right, or a person may have had surgery to remove part or all of these organs (gastrectomy). Under those conditions, nutrition must be supplied in a different way.

Nutrition can be provided either through a feeding tube (enteral nutrition) or, when the digestive tract cannot be used, through an intravenous tube called a catheter that is inserted directly into the veins (parenteral nutrition).  The amount, type, and route of nutrition are tailored specifically to each patient with the goal being to improve patient outcomes, minimize infections, and allow patients to live their lives as normally as possible.

Nutrition support professionals work in a variety of settings including hospitals, home care agencies, long-term care facilities, research facilities, and academia.  They include dietitians, pharmacists, nurses, and physicians and may work either independently or as part of a nutrition support service or team. They are specialists in providing and managing enteral and parenteral nutrition in diverse patient populations from pediatrics to geriatrics.

Parenteral Nutrition  

Parenteral nutrition is one of the ways people receive nutrition when they cannot eat or use their gut via tube feeding.  It is a special liquid mixture given into the blood through an intravenous tube into a vein. The mixture contains all the protein, carbohydrate (sugars), fats, vitamins, minerals, and other nutrients needed.  It was once called "total parenteral nutrition," "TPN," or "hyperalimentation."  

Enteral Nutrition 

Enteral nutrition is another way people can receive the nutrition they need.  Also called "tube feeding," enteral nutrition is a mixture of all the needed nutrients.  It is thicker than parenteral nutrition and sometimes it looks like a milk shake.  It is given through a tube into the stomach or small intestine.  

IDEAL WEIGHT FOR MEN AND WOMEN

IDEAL WEIGHT

Before now, have you ever thought of being over weight? do you think your current body size is ideal for you age and gender? Is it not giving you problem?

Not to worry, here at NutrientsLounge we care for the safety and healthy living of our people. Hence we present a table showing several ideal weights for several age range and gender. But before we proceed, what is ideal weight?

An ideal weight is a weight that is believed to be maximally healthful for a person, based chiefly on height but modified by factors such as gender, age, build, and degree of muscular development.

Expected weight of a healthy normal individual based on age, sex, and height. Thus, a malnourished person would weigh less than their ideal body weight.

Now, you can see for yourself.

The key benefits of metrics in nutrition

HOW TO THINK METRIC LIKE OTHER SCIENTISTS

Nutrition Scientists use metric units of measure. They measure food energy in kilocalories, people’s height in centimeters, people’s weight in kilograms, and the weights of foods and nutrients in grams, milligrams, or micrograms.


For ease in using these measures, it helps to remember that the prefixes imply 1000. For example, a kilogram is 1000 grams, a milli gram is 1/1000 of a gram, and a microgram is 1/1000 of a milligram.

Most food labels and many recipes provide “dual measures,” listing both Volume: Liters (L) 1 L  5  1000  milliliters  (mL) 0.95 L  5  1 quart 1 mL  5  0.03 fluid ounces 240 mL  5  1 cup household measures, such as cups, quarts, and teaspoons, and metric measures, such as  milliliters,  liters,  and  grams.

This  practice gives people an opportunity to gradually learn to  “think  metric.” A person might begin to “think metric” by simply observing the measure—by noticing the amount of soda in a 2-liter bottle, for example.

Through such experiences, a person can become familiar with a measure without having to do any conversions..

The international unit for measuring food energy is the joule—the amount of energy expended when 1 kilogram is moved 1 meter by a force of 1 newton. The joule is thus a A liter of liquid is approximately one US quart. (Four liters are only about 5 percent more than a gallon.)


Weight:  grams (g) 1 g  5  1000  milligrams  (mg) 1 g  5  0.04 ounce (oz) 1 oz  5  28.35 g (or 30 g) 100 g  5  3½ oz 1 kilogram (kg)  5  1000  g 1 kg  5  2.2 pounds (lb) 454 g  5  1 lb © 2016 Cengage Learning measure of work energy, whereas the kcalorie is a measure of heat energy. While many scientists and journals report their findings in kilojoules (kJ), many others, particularly those in the United States, use kcalories (kcal).

To convert energy measures from kcalories to  kilojoules, multiply by 4.2; to convert  kilojoules to kcalories, multiply by 0.24.

For example, a 50-kcalorie cookie provides 210 kilojoules: 50 kcal  3  4.2  5  210  kJ One cup of liquid is about 240 milliliters; a half-cup of liquid is about 120 milliliters. A kilogram is slightly more than 2 lb; conversely, a pound is about ½ kg. A half-cup of vegetables weighs about 100 grams; one pea weighs about ½ gram.

REFERENCE

1. Thomas Harm & Tom Peterson/ Quest Photographic Inc. Stephen Barnes/Farming/Alamy A 5-pound bag of potatoes weighs about 2 kilograms, and a 176-pound person weighs 80 kilograms.

2. Tarasyuk Igor/Shutterstock.com Convert your body weight from pounds to kilograms and your height from inches to centimeters.