CHOOSING AN

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

LEARNING OBJECTIVES
1. Identify common sources of protein, carbohydrate and fat used in enteral
feeding formulas.
2. Identity formulas which could benefit your patient population and to include
in your formulary.
3. Become familiar with high protein formulas and modular products.

OUTLINE

Introduction

Choice of an enteral formula

Formula composition

Types of feedings

Enteral formulary

Case study

Conclusion

INTRODUCTION
Choice of an enteral formula depends on several factors.
You need to complete your nutrition assessment and calculate your
patients 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.

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.

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.

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:
i.
Intact nutrients
ii. Appropriate for normal gut function
Elemental / Semi-Elemental also referred to as predigested:
i.
Protein, carbohydrate predigested or semi-digested
ii. Use if compromised GI function
There are also modular products which provide only carbohydrate, protein,
or fat to increase the macronutrient as required.

FORMULA COMPOSITION
CARBOHYDRATE
Primary energy source in most enteral formulas.
Usually 40%-90% of total calories
SOURCE of CARBOHYDRATE
Polymeric

Elemental / Semi-Elemental

Corn Syrup Solids

Corn Starch

Hydrolyzed Corn Starch

Hydrolyzed Corn Starch

Maltodextrin

Maltodextrin

Sucrose

Fructose

Fructose

FORMULA COMPOSITION
PROTEIN
Source of nitrogen and energy
In enteral formulas:
i.
ii.

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

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
FAT SOURCE
Polymeric

Elemental / Semi-Elemental

Safflower Oil

Fish Oil

Coconut Oil

Soybean Oil

Sardine Oil

Palm Kernel Oil

Canola Oil

Menhaden Oil

Soybean Oil

Corn Oil

Coconut Oil

Safflower Oil

Borage Oil

Palm Kernel Oil

Soy Lecithin

Fish Oil

Soy Lecithin

Fish Oil
Structured Lipids

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).

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.

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

TYPES OF FORMULAS

POLYMERIC
1. Standard (Ex.: Osmolite 1 CAL)
29%
Carbohydrate

54%

Protein

17%

Fat

29%

Need good digestion and absorption

2. High Protein (Ex.: Isosource VHN, Isosource VHP, Promote) 20%-25% Protein
Isosource VHN

Isosource VHP

Promote

Carbohydrate

50%

45%

52%

Protein

25%

25%

25%

Fat

25%

30%

23%

TYPES OF FORMULAS

POLYMERIC
2. 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

TYPES OF FORMULAS

POLYMERIC
3. 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)
4. Commercial blenderized food product (Ex.: Compleat) made from pureed
foods (chicken, fruit vegetable, juice, etc)
Formula is very well tolerated but very viscous

FORMULA COMPOSITION

POLYMERIC
5. 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

FORMULA COMPOSITION

POLYMERIC
5. 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

FORMULA COMPOSITION

POLYMERIC

6. 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

FORMULA COMPOSITION

POLYMERIC
6. 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

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.

FORMULA COMPOSITION

DISEASE SPECIFIC
1. 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

FORMULA COMPOSITION

DISEASE SPECIFIC
1. RENAL
Predialysis patients. Ex.: Suplena
Calorie dense 2 Kcal / mL
Low protein: 30g protein / litre
Low K and phosphorus
High fat: 96g / litre

FORMULA COMPOSITION

DISEASE SPECIFIC
2. 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

FORMULA COMPOSITION

DISEASE SPECIFIC
3. 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

FORMULA COMPOSITION

DISEASE SPECIFIC
4. 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)

FORMULA COMPOSITION

DISEASE SPECIFIC
5. 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 A content,
need to take this into consideration if tube feeding a pregnant
woman.
In critically-ill, arginine and glutamine should not be
supplemented

MODULAR PRODUCTS
1. PROTEIN Ex.: 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

MODULAR PRODUCTS
2. CARBOHYDRATE Ex.: Polycose
Glucose powder mixed with water or beverages to increase calories

3. FAT Ex.: MCT Oil

Used to increase calories in patients with poor fat digestion or

malabsorption
120 Kcal / tbsp

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:
albumin

Admitted to ICU with Hypoxemic respiratory failure (pneumonia),

2 coccyx pressure ulcers - infected. Labs unremarkable, low
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

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.

Case Study

What were the black spots?

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.

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

Case Study

Recommend PEG/J

Pts wife refused, she wants him fed into stomach

Promotility drug started

Golitely used via PEG with L/A stool

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)

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

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

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

Case Study

Patient, wife, healthcare team happy with latest change of formula

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.
Nestl 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.

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