The Power of Whey & MCT for Critically Ill Patients

Wid Adelies Oktavianda | FOE Central and East Java

Time is critical

Make a difference: Early Enteral Nutrition with Peptamen

In Critically Ill Highly Stressed Patients

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Time Makes the Difference in Critically Ill Patients

Early Enteral Nutrition helps to1: 1. maintain gut integrity 2. modulate stress and the systemic immune response 3. attenuate disease severity and improve clinical outcomes

1. S. A. McClave et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009.

Cumulative Energy Deficit is Associated With Worse Clinical Outcomes

Clinical study has shown that cumulative energy deficit is associated with worse clinical outcomes2
Longer ICU length of stay More days on mechanical ventilation More complications

2. Villet S et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005; 24:502-509.

Nutrisi Enteral
Nutrisi enteral merupakan metode pemenuhan zat gizi dengan menggunakan saluran pencernaan, baik secara alami melalui mulut ataupun dengan bantuan alat (tube/sonde)

Feed Your Gut Use it or Loose it

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SUSU vs NUTRISI ENTERAL

Terminologi susu: Cairan berwarna putih opaque yang diproduksi oleh kelenjar mamae Cairan berwarna putih, tapi bukan berasal dari hewan, seperti susu kedelai Formula bukan susu, sekalipun komponen-komponen zat nutrisi yang terkandung mirip dengan susu Susu Protein Karbohidrat Whey, Kasein Laktosa Nutrisi Enteral Whey, Kasein, Protein Soya Sukrosa, fruktosa, maltodekstrin, oligosakarida

Lemak
Vitamin dan Mineral Contoh

Jenuh, Tak Jenuh

+

Nabati, jenuh, tidak jenuh tunggal (MUFA), tak jenuh ganda (PUFA)
+

ASI, susu sapi, susu Nutrisi enteral kambing

The Power of WHEY

Nutrisi untuk Mencapai Kesehatan Optimal

Formula Pilihan ?
Formula Polimerik
Membutuhkan kerja saluran cerna yang baik Intact Nutrition Formula standard, Fully functional GI tract, Normal digestion, Normal absorption Macronutrients are intact and require digestion Formula standar misalnya Nutren, Peptisol, Entramix, Ensure, dll

Formula Mono/ Oligomerik

Nutrisinya lebih kecil molekulnya Absorpsi lebih mudah Peptida, Mono/Disaccharides, Glucose polymers, Medium chain triglycerides (MCTs) Elemental, semi-elemental, hydrolyzed, or chemiccaly defined formula Formula: Peptamen

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Whey and Casein: what is the difference?

Whey : Soluble protein

Casein : clots into stomach

Facilitates gastric emptying time

Delays gastric emptying time

More accessible & faster to digest Easily to absorb

Slower to digest & absorb Slower release of amino acid

'FAST'
Whey protein kualitas tinggi kaya asam amino essensial CYSTEIN, homogen pada pH asam tetap berbentuk cair sehingga lebih mudah dicerna

'SLOW'
Casein menggumpal pada pH asam bersifat padat saat protein diasamkan dalam lambung- dominan untuk formula dewasa (Mahe 1996)

2006 Nestl Nutrition HealthCare, Switzerland

Whey Protein Casein Protein Casein adalah protein utama dalam susu sapi (80%) dan keju. Whey protein: terdiri atas beta-lactoglobulin (~65%), alpha-lactalbumin (~25%), & serum albumin (~8%) Kaya asam amino essensial CYSTEIN Sebagai Sumber Antioksidan yang baik

Fungsi Saluran Cerna adalah kunci ketika akan memberikan dukungan nutrisi

Saluran Cerna TIDAK BERFUNGSI

Saluran Cerna Bermasalah

Saluran Cerna Normal

TPN

1-10 tahun

Nilai Protein yang tinggi

A high nutritional value protein containing a high content of essential and branched amino acids
The serum or watery part of milk that is separated from the coagulable part or curd Rich in minerals and vitamins
Pre-Digestion Post-Digestion
Casein Whey

Cows Milk: Higher in casein Human Milk: Higher in whey

(AAP 1998)

2006 Nestl Nutrition HealthCare, Switzerland

The Power of WHEY

Whey adalah cairan yang tersisa setelah susu mengalami proses penggumpalan. Whey adalah salah satu protein berkualitas tertinggi karena profil asam aminonya yang ideal, mudah dicerna dan manfaatnya bagi kesehatan, mulai dari membantu perkembangan otot hingga meningkatkan kekebalan untuk perlindungan terhadap penyakit Whey dicerna dengan cepat, sehingga protein cepat diserap ke dalam aliran darah, sedangkan kasein dicerna perlahan-lahan. Whey tinggi asam amino rantai cabang atau BCAA (branchedchain amino acids) dan antioksidan yang penting, mencegah radikal bebas dan perbaikan jaringan.

The Power of WHEY

Whey Protein Helps Support the Body's Antioxidative Defense System Whey protein helps support the bodys antioxidative defense system
Cystein is the rate-limiting amino acid for the synthesis of glutathione,
a principal protective antioxidant mechanism of the cells11,12

Adapted from Row B et al12

Whey is rich in cystein

and may be effective in maintaining or repleting glutathione status12
11. Bounous G. et al. The antioxidant system. Anticancer Research 2003, 23 :1411-1416. 12. Rowe B.et al. Effect of whey and casein-based diets on glutathione and cysteine metabolism in ICU patients. J Am Nutr 1994;3(5) :535 (Abstract).

Comparison of MCT & LCT

MCT Gastric emptying
Pancreatic enzymes Bile
Rapid Little/No No No

LCT
Delayed

Yes
Yes Yes Lymphatics Blood liver

Micelle formation
Absorptive route

Directly to the liver

LCT digestion & absorption

Overview

2006 Nestl Nutrition HealthCare, Switzerland

MCT Absorption

2006 Nestl Nutrition HealthCare, Switzerland

Peptamen: Designed for Better Tolerance

Whey protein facilitates gastric emptying to reduce potential for reflux5,6,7

Peptamen: 100% whey protein

Effects of whey-based formulas on gastric emptying time

Adapted from Fried MD et al6

5. Khoshoo V et al. Incidence of Gastroesophageal Reflux with Whey- and Casein-Based Formulas in Infants and in Children with Severe Neurological Impairment. J Ped Gastroent Nutr. 1996, 22:48-55. 6. Fried MD et al. Decrease in gastric emptying time and episodes of regurgitation in children with spastic quadriplegia fed a whey-based formula. J Ped. 1992,120:569-572. 7. Khoshoo V and Brown S. Gastric emptying of two wheybased formulas of different energy density and its clinical implication in children with volume intolerance. Eur J Clin Nutr. 2002, 56:1-3.

PROOF 1

PEPTAMEN meningkatkan sintesa protein

AIM
To test if a peptide-based diet improves hepatic protein synthesis in patients after trauma Trauma patients (n=16)

Randomized to receive either Peptamen or Osmolite (Ross) within 24 hours after injury
Measured serum transferrin, prealbumin and retinol-binding protein day 1, 3 and 7 after injury

(Zaloga 1992)

PROOF

PEPTAMEN improves protein synthesis

(Zaloga 1992)
2006 Nestl Nutrition HealthCare, Switzerland

PROOF

PEPTAMEN supports growth

"Nutrition intervention in gastrointestinal motility"

Brackett et al, ASPEN 2000

2006 Nestl Nutrition HealthCare, Switzerland

PROOF

PEPTAMEN meningkatkan sintesa protein

Meningkatkan respon protein hepatic dengan protein hidrolisat dibandingkan dengan intact protein" Zaloga et al, Crit Care Med 1992; 20:S94
Improved hepatic protein responses with hydrolyzed protein versus intact protein diets after trauma

Whey is rich in Branched-Chain Amino Acids

(Tome 2001)
2006 Nestl Nutrition HealthCare, Switzerland

Prevalence of reflux

Pediatrics:
Healthy children
2 18% have symptoms associated with reflux Young children tend to have higher reflux

Adults:
Healthy adults
3 23% (varies per race)

Neurologically disabled
7/10 children (up to 70%) have pathological reflux

Intellectually disabled
50 65%

(Nelson 2000; Schwarz 2000; Bohmer 1999&2000; Colletti 2003)

2006 Nestl Nutrition HealthCare, Switzerland

Prevalence of reflux among the sick

Gastric residual volumes
Definition: amount of formula left in the stomach over a period of time Can increase with certain diseases or conditions such as critical illness due to: Disease process itself
Medications Body position

Puts the patient at increased risk for reflux or aspiration pneumonia

Plus Often delays the advancement of feeds or This Puts patient at risk for poor nutrition feeds

2006 Nestl Nutrition HealthCare, Switzerland

ensures optimal protein absorption during times of stress and critical illness

2006 Nestl Nutrition HealthCare, Switzerland

Lipid blend - Rich in MCT oil

2006 Nestl Nutrition HealthCare, Switzerland

Peptamen: Nutritional Profile

Peptamen can be reconstituted to flexible caloric densities

0.5 2.0 kcal/ml

It is nutritionally complete:

Protein

16% 40 g protein/L CHO 100% whey peptides 50% 300 mOsm/L Fat 34% 70% of fat as MCT Omega 6 BCAA Vitamins and minerals meet 100% of the US RDA with 1500 mL (1500 kcal) Gluten free, Lactose free

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Peptamen: Designed for Better Tolerance

Peptides can be helpful to manage diarrhoea1,8

Peptamen: peptide-based formula

Incidence of diarrhoea8

Adapted from Meredith JW et al8

Peptamen has low osmolarity: 300 mOsm/L

1. S. A. McClave et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Journal of Parenteral and Enteral Nutrition / Vol. 33, No. 3, May/June 2009 8. Meredith JW et al. Visceral protein levels in trauma patients are greater with peptide diet than with intact protein diet. J Trauma 1990, 30;825-829.

During times of stress

Brush border

Amino acid carriers decrease

Amino acid carrier

Decreased amino acid absorption Amino acid diets associated with gut atrophy
Peptide carriers remain intact
Peptide carrier

Peptide absorption is preserved Primary mechanism for protein absorption

(Grimble 2000; Zaloga 1993; Vazquez 1985)

2006 Nestl Nutrition HealthCare, Switzerland

Peptide absorption
a dual transport system

2006 Nestl Nutrition HealthCare, Switzerland

Peptamen is a Specific Enteral Nutrition Formula Designed for Early Feeding in Critically Ill Patients

Designed for better tolerance for early nutrition 100% whey formula to help manage oxidative stress and catabolism

With PEPTAMEN
A Specific Enteral Nutrition Formula Designed for Early Feeding in Critically Ill Patients

Do not miss the window of opportunity early after admission to ICU

Pasien Critically Ill perlu mengkonsumsi Makanan Sarat Nutrisi Pasien Critically Ill seringkali terjadi :
Penurunan antioksidan alami tubuh Terjadi hipermetabolisme Menyebabkan penurunan kadar protein visceral plasma Hipoalbuminemia Penurunan Lean Body Mass.

Para pasien Critically Ill yang sedang menjalani terapi dan yang sudah selesai terapi dianjurkan mengkonsumsi makanan yang sehat dengan gizi yang seimbang. Status nutrisi pada pasien kanker memiliki peranan penting dalam mempertahankan kualitas hidup
The Power of WHEY

In summary

2006 Nestl Nutrition HealthCare, Switzerland

Team Nestle Health Science Semarang

1. 2. Wid Adelies (0811466811) Desi Nurwahyuni

Thank You!