1. What‘s the science behind Fresubin® 2 kcal/ fibre DRINK?
Wendy Martin
Medical Scientific Affairs
KIC BU Enteral Nutrition
KIC BU EN, MSA, WMa, December

2. Contents Malnutrition & oral nutritional supplements (ONS)
How to make patients take ONS?
General indications for Fresubin® 2 kcal/ fibre DRINK
Special indications for Fresubin® 2 kcal/ fibre DRINK:
Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases
KIC BU EN, MSA, WMa, December

3. Consequences of malnutrition
KIC BU EN, MSA, WMa, December

4. Consequences of malnutrition
Physical functioning ⇩
Resistance to infection ⇩, wound healing ⇩, muscle atrophy …
KIC BU EN, MSA, WMa, December

5. Consequences of malnutrition
Physical functioning ⇩
Resistance to infection ⇩, wound healing ⇩, muscle atrophy …
Risk of complications ⇧
KIC BU EN, MSA, WMa, December

6. Consequences of malnutrition
Physical functioning ⇩
Resistance to infection ⇩, wound healing ⇩, muscle atrophy …
Risk of complications ⇧
Time to recovery and hospital stay ⇧
KIC BU EN, MSA, WMa, December

7. Consequences of malnutrition
Physical functioning ⇩
Resistance to infection ⇩, wound healing ⇩, muscle atrophy …
Risk of complications ⇧
Time to recovery and hospital stay ⇧
Therapeutic costs ⇧
Mortality ⇧
KIC BU EN, MSA, WMa, December

8. Can we do something about it?
Evidence for oral nutritional supplements
KIC BU EN, MSA, WMa, December

9. Evidence for ONS Preservation of appetite
Overall higher intake of nutrients
Improved functional outcomes
Reduced hospital stay → potential cost benefit
Decreased complication rates
Decreased mortality
KIC BU EN, MSA, WMa, December

10. Evidence for ONS Preservation of appetite
Overall higher intake of nutrients
Improved functional outcomes
Reduced hospital stay → potential cost benefit
Decreased complication rates
Decreased mortality
Evidence-based
ESPEN guidelines
2006
KIC BU EN, MSA, WMa, December

11. Evidence doesn‘t help when the patient just won‘t take the sip!
KIC BU EN, MSA, WMa, December

12. How to make patients take ONS?
KIC BU EN, MSA, WMa, December

13. Most important feature of a successful product:
Compliance
Most important feature of a successful product:
KIC BU EN, MSA, WMa, December

14. Most important feature of a successful product:
Compliance
Most important feature of a successful product:
GREAT TASTE!!!
KIC BU EN, MSA, WMa, December

15. Most important feature of a successful product:
Compliance
Most important feature of a successful product:
GREAT TASTE!!!
and a low volume
KIC BU EN, MSA, WMa, December

16. Compliance GREAT TASTE!!!
Most important feature of a successful product:
GREAT TASTE!!!
and a low volume
Patients do take about 400 ml ONS a day
and not much more.
(e.g. Roberts M et al., British Journal of Nutrition 2003)
KIC BU EN, MSA, WMa, December

17. Compliance GREAT TASTE!!!
Most important feature of a successful product:
GREAT TASTE!!!
and a low volume
Patients do take about 400 ml ONS a day
and not much more.
(e.g. Roberts M et al., British Journal of Nutrition 2003)
 So we packed these 400 ml with nutrition
KIC BU EN, MSA, WMa, December

18. 400 ml Fresubin® 2 kcal/ fibre DRINK
KIC BU EN, MSA, WMa, December

19. 400 ml Fresubin® 2 kcal/ fibre DRINK
40 g protein
KIC BU EN, MSA, WMa, December

20. 400 ml Fresubin® 2 kcal/ fibre DRINK
40 g protein
All vitamins
All minerals
and
trace elements
KIC BU EN, MSA, WMa, December

21. 400 ml Fresubin® 2 kcal/ fibre DRINK
40 g protein
With or without
prebiotic fibre
All vitamins
All minerals
and
trace elements
KIC BU EN, MSA, WMa, December

22. 400 ml Fresubin® 2 kcal/ fibre DRINK
40 g protein
With or without
prebiotic fibre
All vitamins
All minerals
and
trace elements
Energy%
of protein, fat, carbs
20 : 35 : 45
KIC BU EN, MSA, WMa, December

23. High nutrient density – low volume
KIC BU EN, MSA, WMa, December

24. High nutrient density – low volume
Low volume  better compliance
for prescribed supplementation
in all indications for standard ONS
KIC BU EN, MSA, WMa, December

25. High nutrient density – low volume
Low volume  better compliance
for prescribed supplementation
in all indications for standard ONS ?
But what about tolerance of
Fresubin® 2 kcal/ fibre DRINK?
KIC BU EN, MSA, WMa, December

26. Tolerance test with Fresubin® 2 kcal DRINK
KIC BU EN, MSA, WMa, December

27. Tolerance test with Fresubin® 2 kcal DRINK
Randomised, controlled, double-blind, multicentre study
In 84 healthy elderly
400 ml/ day or
KIC BU EN, MSA, WMa, December

28. Tolerance test results in healthy elderly
2 kcal/ ml vs 1.5 kcal/ ml
KIC BU EN, MSA, WMa, December

29. Tolerance test results in healthy elderly
2 kcal/ ml vs 1.5 kcal/ ml
equally well tolerated
KIC BU EN, MSA, WMa, December

30. General indications for the high energy, high protein
Fresubin® 2 kcal/ fibre DRINK
KIC BU EN, MSA, WMa, December

31. Scientific view on ONS 1 kcal Geriatric patients Cancer HIV
Peri-operative patients
Cardiac & circulatory failure
COPD
Liver diseases
Dialysis
1 kcal
1.5 kcal
2 kcal
KIC BU EN, MSA, WMa, December

32. Indications for high energy ONS
All general indications which go for standard ONS go for Fresubin® 2 kcal/ fibre DRINK
PLUS
conditions with fluid restriction
KIC BU EN, MSA, WMa, December

33. Indications for high energy ONS
All general indications which go for standard ONS go for Fresubin® 2 kcal/ fibre DRINK
PLUS
conditions with fluid restriction
KIC BU EN, MSA, WMa, December

34. Indications for high energy ONS
All general indications which go for standard ONS go for Fresubin® 2 kcal/ fibre DRINK
PLUS
conditions with fluid restriction
…provided there is no need for protein restriction.
KIC BU EN, MSA, WMa, December

35. Additionally valuable: High protein
20 energy% of protein
KIC BU EN, MSA, WMa, December

36. Additionally valuable: High protein
Proteins are needed for e.g. cell building, enzymes, antibodies, and hormones.
Protein needs are increased in conditions like:
Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases
Pressure ulcers, stress, ageing, ….
20 energy% of protein
KIC BU EN, MSA, WMa, December

37. Additionally valuable: High protein
Proteins are needed for e.g. cell building, enzymes, antibodies, and hormones.
Protein needs are increased in conditions like:
Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases
Pressure ulcers, stress, ageing, ….
20 energy% of protein
KIC BU EN, MSA, WMa, December

38. Additionally valuable: High protein
Proteins are needed for e.g. cell building, enzymes, antibodies, and hormones.
Protein needs are increased in conditions like:
Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases .
20 energy% of protein
KIC BU EN, MSA, WMa, December

39. Special indications for the high energy, high protein
Fresubin® 2 kcal/ fibre DRINK:
KIC BU EN, MSA, WMa, December

40. Special indications for the high energy, high protein
Fresubin® 2 kcal/ fibre DRINK:
Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases
KIC BU EN, MSA, WMa, December

41. Dialysis induces catabolism
Hypermetabolism
Body protein breakdown
Nutrient loss with dialysis
NEEDS
(e.g.Cano N et al., Clin Nutr 2006)
KIC BU EN, MSA, WMa, December

42. Dialysis induces catabolism
Hypermetabolism
Body protein breakdown
Nutrient loss with dialysis
NEEDS
INTAKE
Anorexia
Fluid restriction
Gastrointestinal impairments
(e.g.Cano N et al., Clin Nutr 2006)
KIC BU EN, MSA, WMa, December

43. Dialysis induces catabolism
Hypermetabolism
Body protein breakdown
Nutrient loss with dialysis
NEEDS
INTAKE
Anorexia
Fluid restriction
Gastrointestinal impairments
Malnutrition in up to 70% of dialysis patients!
(e.g.Cano N et al., Clin Nutr 2006)
KIC BU EN, MSA, WMa, December

44. Satisfying increased needs
KIC BU EN, MSA, WMa, December

45. Satisfying increased needs
Hypermetabolism
Body protein breakdown
Nutrient loss with dialysis
NEEDS
KIC BU EN, MSA, WMa, December

46. Satisfying increased needs
Hypermetabolism
Body protein breakdown
Nutrient loss with dialysis
NEEDS
INTAKE
High energy and
high protein in a
small volume
KIC BU EN, MSA, WMa, December

47. Satisfying increased needs
Hypermetabolism
Body protein breakdown
Nutrient loss with dialysis
NEEDS
INTAKE
High energy and
high protein in a
small volume
 ESPEN
KIC BU EN, MSA, WMa, December

48. Fresubin® 2 kcal DRINK in dialysis patients
ESPEN guidelines 2006 (expert opinion):
In dialysis patients, standard ONS can be used.
KIC BU EN, MSA, WMa, December

49. Fresubin® 2 kcal DRINK in dialysis patients
ESPEN guidelines 2006 (expert opinion):
In dialysis patients, standard ONS can be used.
We had a first look at Fresubin® 2 kcal DRINK in dialysis patients:
KIC BU EN, MSA, WMa, December

50. Fresubin® 2 kcal DRINK in dialysis patients
ESPEN guidelines 2006 (expert opinion):
In dialysis patients, standard ONS can be used.
We had a first look at Fresubin® 2 kcal DRINK in dialysis patients:
Randomised, controlled study
In 20 dialysis patients
or Renilon 7.5
KIC BU EN, MSA, WMa, December

51. Study results indicate:
Renilon 7.5
Standard
versus
disease specific
KIC BU EN, MSA, WMa, December

52. Study results indicate:
Renilon 7.5
Standard
versus
disease specific
no relevant influences on
serum electrolytes
KIC BU EN, MSA, WMa, December

53. Study results indicate:
Renilon 7.5
Standard
versus
disease specific
no relevant influences on
serum electrolytes
equally well tolerated
KIC BU EN, MSA, WMa, December

54. Special indications for the high energy, high protein
Fresubin® 2 kcal/ fibre DRINK:
Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases
KIC BU EN, MSA, WMa, December

55. Liver: Control unit of metabolism
KIC BU EN, MSA, WMa, December

56. Liver: Control unit of metabolism
Fat
metabolism
Protein
Carbohydrate
Energy
KIC BU EN, MSA, WMa, December

57. Liver: Control unit of metabolism
Fat
metabolism
Protein
Vitamins and
trace elements
Carbohydrate
Energy
KIC BU EN, MSA, WMa, December

58. Liver: Control unit of metabolism
Fat
metabolism
Protein
Vitamins and
trace elements
Carbohydrate
Energy
Hormone balance
KIC BU EN, MSA, WMa, December

59. Liver: Control unit of metabolism
Fat
metabolism
Protein
Vitamins and
trace elements
Carbohydrate
Energy
Hormone balance
Digestion
KIC BU EN, MSA, WMa, December

60. Liver: Control unit of metabolism
Fat
metabolism
Protein
Vitamins and
trace elements
Carbohydrate
Energy
Hormone balance
Digestion
Detoxication, acid base balance, ….
KIC BU EN, MSA, WMa, December

61. Liver: Control unit of metabolism
The development of malnutrition in liver diseases is complex
Fat
metabolism
Protein
Vitamins and
trace elements
Carbohydrate
Energy
Hormone balance
Digestion
Detoxication, acid base balance, ….
KIC BU EN, MSA, WMa, December

62. Liver diseases and malnutrition
Up to 60% of liver patients are malnourished
KIC BU EN, MSA, WMa, December

63. Liver diseases and malnutrition
Up to 60% of liver patients are malnourished with increased risk of complications like:
Ascites
Hepatic encephalopathy
Severe infections
Mortality
(e.g. Cabré E et al., Gastroenterology 1990)
KIC BU EN, MSA, WMa, December

64. Liver diseases and malnutrition
Up to 60% of liver patients are malnourished with increased risk of complications like:
Ascites
Hepatic encephalopathy
Severe infections
Mortality
Tackle malnutrition with high energy, high protein oral nutritional supplements!
(e.g. Cabré E et al., Gastroenterology 1990)
KIC BU EN, MSA, WMa, December

65. Liver diseases and malnutrition
Up to 60% of liver patients are malnourished with increased risk of complications like:
Ascites
Hepatic encephalopathy
Severe infections
Mortality
Tackle malnutrition with high energy, high protein oral nutritional supplements!
 ESPEN
(e.g. Cabré E et al., Gastroenterology 1990)
KIC BU EN, MSA, WMa, December

66. Special indications for the high energy, high protein
Fresubin® 2 kcal/ fibre DRINK:
Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases
KIC BU EN, MSA, WMa, December

67. COPD Chronic Obstructive Pulmonary Disease
KIC BU EN, MSA, WMa, December

68. COPD Chronic Obstructive Pulmonary Disease
Altered enzyme/ cytokine activity
KIC BU EN, MSA, WMa, December

69. COPD Chronic Obstructive Pulmonary Disease
Altered enzyme/ cytokine activity
Altered substrate metabolism
KIC BU EN, MSA, WMa, December

70. COPD Chronic Obstructive Pulmonary Disease
Altered enzyme/ cytokine activity
Altered substrate metabolism
Hyper-
metabolism
KIC BU EN, MSA, WMa, December

71. COPD Chronic Obstructive Pulmonary Disease
Altered enzyme/ cytokine activity
Altered substrate metabolism
Hyper-
metabolism
Malnutrition
KIC BU EN, MSA, WMa, December

72. COPD Chronic Obstructive Pulmonary Disease
Altered enzyme/ cytokine activity
Altered substrate metabolism
Hyper-
metabolism
Malnutrition
KIC BU EN, MSA, WMa, December

73. COPD Chronic Obstructive Pulmonary Disease
Systemic inflammation
Altered enzyme/ cytokine activity
Altered substrate metabolism
Hyper-
metabolism
Malnutrition
KIC BU EN, MSA, WMa, December

74. COPD Chronic Obstructive Pulmonary Disease
Systemic inflammation
Altered enzyme/ cytokine activity
Altered substrate metabolism
Hyper-
metabolism
Malnutrition
Anorexia
KIC BU EN, MSA, WMa, December

75. COPD Chronic Obstructive Pulmonary Disease
Systemic inflammation
Altered enzyme/ cytokine activity
Altered substrate metabolism
Hyper-
metabolism
Malnutrition
Anorexia
Muscle waisting
KIC BU EN, MSA, WMa, December

76. COPD Chronic Obstructive Pulmonary Disease
Systemic inflammation
Altered enzyme/ cytokine activity
Altered substrate metabolism
Hyper-
metabolism
Malnutrition
Anorexia
Muscle waisting
Skeletal muscle weakness
KIC BU EN, MSA, WMa, December

77. COPD Chronic Obstructive Pulmonary Disease
Malnutrition
Systemic inflammation
Anorexia
Altered enzyme/ cytokine activity
Altered substrate metabolism
Hyper-
metabolism
Muscle waisting
Skeletal muscle weakness
Reduced breathing capacity
KIC BU EN, MSA, WMa, December

78. COPD Chronic Obstructive Pulmonary Disease
Up to 40% of COPD patients are malnourished.
KIC BU EN, MSA, WMa, December

79. COPD Chronic Obstructive Pulmonary Disease
Up to 40% of COPD patients are malnourished.
Anorexia
Hyper-
metabolism
Muscle waisting
Malnutrition
KIC BU EN, MSA, WMa, December

80. COPD Chronic Obstructive Pulmonary Disease
Up to 40% of COPD patients are malnourished.
Anorexia
Hyper-
metabolism
Muscle waisting
Malnutrition
KIC BU EN, MSA, WMa, December

81. COPD Chronic Obstructive Pulmonary Disease
Up to 40% of COPD patients are malnourished.
High energy, high protein ONS
KIC BU EN, MSA, WMa, December

82. COPD Chronic Obstructive Pulmonary Disease
Up to 40% of COPD patients are malnourished.
High energy, high protein ONS
 ESPEN
KIC BU EN, MSA, WMa, December

83. COPD Chronic Obstructive Pulmonary Disease
Up to 40% of COPD patients are malnourished.
High energy, high protein ONS
have been shown to improve
nutritional status,
physical functioning, and
survival
 ESPEN
(e.g. Schols AM et al., Am J Respir Crit Care Med Steiner MC et al., Thorax 2003)
KIC BU EN, MSA, WMa, December

84. Special indications for the high energy, high protein
Fresubin® 2 kcal/ fibre DRINK:
Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases
KIC BU EN, MSA, WMa, December

85. Cardiovascular diseases
KIC BU EN, MSA, WMa, December

86. Cardiovascular diseases
Neurohormones
KIC BU EN, MSA, WMa, December

87. Cardiovascular diseases
Neurohormones
Renin-angiotensin system
KIC BU EN, MSA, WMa, December

88. Cardiovascular diseases
Neurohormones
Renin-angiotensin system
Water retention
KIC BU EN, MSA, WMa, December

89. Cardiovascular diseases
Neurohormones
Renin-angiotensin system
Water retention
Cytokines
KIC BU EN, MSA, WMa, December

90. Cardiovascular diseases
Neurohormones
Renin-angiotensin system
Water retention
Cytokines
Acute phase response
KIC BU EN, MSA, WMa, December

91. Cardiovascular diseases
Neurohormones
Renin-angiotensin system
Water retention
Catabolism
Acute phase response
Cytokines
KIC BU EN, MSA, WMa, December

92. Cardiovascular diseases
About 15% of cardiac patients are malnourished.
(e.g. Anker SD et al., Clin Nutr Von Haehling S et al., Cardiovas Res 2007)
KIC BU EN, MSA, WMa, December

93. Cardiovascular diseases
About 15% of cardiac patients are malnourished.
Water retention + catabolism
(e.g. Anker SD et al., Clin Nutr Von Haehling S et al., Cardiovas Res 2007)
KIC BU EN, MSA, WMa, December

94. Cardiovascular diseases
About 15% of cardiac patients are malnourished.
Water retention + catabolism =
need for high energy and high protein
supplementation within a
low volume
(e.g. Anker SD et al., Clin Nutr Von Haehling S et al., Cardiovas Res 2007)
KIC BU EN, MSA, WMa, December

95. Cardiovascular diseases
About 15% of cardiac patients are malnourished.
Water retention + catabolism =
need for high energy and high protein
supplementation within a
low volume
 ESPEN
(e.g. Anker SD et al., Clin Nutr Von Haehling S et al., Cardiovas Res 2007)
KIC BU EN, MSA, WMa, December

96. Take home messages ….great taste and good tolerance
make Fresubin® 2 kcal/ fibre DRINK indicated for most patients with or at risk of malnutrition
…low fluid load and high protein supply
provide the rationale for the use of Fresubin® 2 kcal/ fibre DRINK in
- Renal failure with dialysis treatment
Liver diseases
Chronic obstructive pulmonary disease
Cardiovascular diseases
KIC BU EN, MSA, WMa, December

97. Thanks for your attention!
KIC BU EN, MSA, WMa, December