Micronutrients
As dietitians, we base someone’s formula amount (in ml / day) recommendation on their energy (aka. calorie) and protein needs. So we calculate how much you need first based on your activity levels and medical diagnosis, and then reverse engineer how much formula would give that amount of energy and protein in a day.
For those on commercial formulas, we then assume that a complete micronutrient profile is achieved when your recommended energy and protein needs are delivered. We can easily see the micronutrient profile of the formula at the back of the pack. So for example, say the back of the pack says 3.4mg of Vitamin E in 100ml of formula and you are having 800ml of that formula per day. That means you are receiving 27mg of Vitamin E per day.
For those on homemade blended formulas, we’d need to run the recipes through a food analysis program to get the micronutrient breakdown. More cumbersome, but definitely possible.
Even though it may seem that someone on home tube feeding is getting “constant nutrition”, micronutrient deficiencies still do arise just like they happen in those eating through their mouth.
So, whilst no home tube feeding guidelines have specified regular micronutrient blood tests should be done in the home tube fed population, it’d be best practice to do so especially for those who are:
newly established on home tube feeding
have had recent surgery along their digestive tract affecting nutrient absorption
are malnourished (have a had >5% loss of body weight in the last month or > 10% in the last 6 months)
undergoing regular active medical treatment (like chemotherapy) that can affect their appetite
showing clinical signs of micronutrient deficiencies such as hair loss, low energy levels, dry corners of the mouth, etc.
Allow me to break it down further for you …
How much of each micronutrient should I be having in a day?
Browse all the micronutrients available on this government owned platform. It’s brilliant! Continuing the vitamin E example above, an adult male needs 10mg/day and a female 7mg/day. Maximum amount that should be had in a day for adults is 300mg/day. So the 27mg/day coming from the formula is just fine. Remember, your body may not absorb all that is going through anyway so 27mg/day is well above the recommended and well below the maximum amount.
Additionally, it’s important to highlight that how much someone needs is also dependent on their underlying medical condition and the types of medications they are on. Certain micronutrients can be at risk depending on these two factors. If you’re a dietitian, click here to read the latest disease-specific and treatment-specific risks for micronutrient depletion outlined by ESPEN.
If you are a person with a feeding tube, please seek advice from your doctor or dietitian.
What blood tests can be done to check my micronutrient profile?
It’s important to remember that nutrient toxicity is a real thing just like deficiency! So, it’s best practice to check your levels BEFORE taking any micronutrient supplements. Discuss this with your dietitian or doctor and if applicable to you, the below blood tests can be taken to determine your micronutrient status.
If you’re a dietitian, remember to request C-reactive protein (CRP) levels in addition to a micronutrient analysis to aid in the interpretation of results. The impact of inflammation on micronutrient blood levels usually appears with CRP levels > 20 mg/L. To read more, see recommendation 3 in the recently published ESPEN micronutrient guidelines.
Not all pathology test centers can do all the below tests so you may have to go hunting for one that has the capacity to do them all.
Source: Iyer K, DiBaise JK. AGA Clinical Practice Update on Management of Short Bowel Syndrome: Expert Review. Clinical Gastroenterology and Hepatology. 2022:20(10):2185-2194. Available from: https://www.cghjournal.org/article/S1542-3565(22)00561-4/fulltext?dgcid=raven_jbs_etoc_email
What are the clinical signs of micronutrient deficiencies that I should look out?
Adapted from: Reber E, Gomes F, Vasiloglou M, Schuetz P, Stanga Z. Nutritional Risk Screening and Assessment. Journal of Clinical Medicine. 2019:8(7), P1065. DOI: https://doi.org/10.3390/jcm8071065
I hope this post has shed some light on micronutrients in people receiving home tube feeding. This topic is heavily unresearched in the medical world but interest amongst researchers is definitely rising so watch this space!
Happy reading and home tube feeding,
Tube Dietitian.
