to Implement Critical Care Nutrition Guidelines

Transcription

1 Make it Happen! Breaking Through Barriers to Implement Critical Care Nutrition Guidelines Sponsor Disclosure: Financial support for this presentation was provided by Nestlé HealthCare Nutrition, Inc. The views expressed herein are those of the presenter and do not necessarily represent Nestlé s views. The material herein is accurate as of the date it was presented, and is for educational purposes only and is not intended as a substitute for medical advice. Reproduction or distribution of these materials is prohibited. Copyright 2012 Nestlé. All rights reserved. 1 Welcome Dr. Juan Ochoa MD, FACS Tenured Professor of Surgery and Critical Care Associate Medical Director of Trauma Services University of Pittsburgh Medical Center (UPMC) Disclosures Medical consultant for Nestlé HealthCare Nutrition, Inc. 2 1

2 Objectives Identify common barriers to implementing guidelines. Find solutions. Describe educational protocols designed to improve delivery of enteral nutrition. Describe a protocol for use of immunemodulating formulas in surgical patients. 3 Barriers and Facilitators to Making it Happen! Dr. Daren Heyland MD, FRCPC, MSc Full Professor of Medicine, Queen s University, Kingston General Hospital, ON Canada 4 2

3 Disclosures Research Contracts with the Following Companies: Nestlé Nutrition Baxter Fresenius Kabi Abbott Nutrition 5 Results of 2007 International Nutrition Practice Audit d/prescribed % calories received Best Performance Site Worst Performance Site ICU Day Mean Average time to start of EN : 46.5 hours (site average range: hours) In patients with high gastric residual volumes: use of motility agents 58.7% (site average range: 0-100%) use of small bowel feeding 14.7% (range: 0-100%) 6 Cahill N Crit Care Med 2010 (in press) 3

4 Adequacy of EN: Kcals % received/prescrib bed Canada Australia & New Zealand USA Europe & China India Latin South America Africa Total 7 Cahill N Crit Care Med 2010 (in press) Relationship Between Increased Calories and 60 day Mortality BMI Group Odds Ratio 95% Confidence Limits P-value Overall < < < < < >= Legend: Odds of 60-day Mortality per 1000 kcals received per day adjusting for nutrition days, BMI, age, admission category, admission diagnosis and APACHE II score. 8 Alberda Int Care Med 2009;35:1728 4

5 9 A Qualitative Assessment of Barriers and Facilitators to Implementing Nutrition CPGs* in ICU Multiple case study 4 case ICU sites Purposeful sampling Semi-structured key informant interviews (n=28) Min. 5 years ICU experience Employed at case ICU site May 2004 Document review *Clinical Practice Guidelines 10 Jones NCP 2007;22:449 5

6 Potential Barriers Resistance to change Patients clinical condition Lack of awareness Information overload Weak evidence Resource constraints Slow administrative process Impractical / Complex Nursing workload Limited critical care experience 11 Potential Facilitators Agreement of the attending physician & ICU team Part of routine practice Dietitian / Opinion leader Access / Visibility Easy to follow and perform Provision of education Open discussion 12 6

7 Favored Implementation Strategies Informal one-on-one discussions Academic detailing, ward rounds Protocols Preprinted orders, Check-list, algorithms, Bed-side reminders Feedback and audit Site reports 13 The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a Multicenter Observational Study International, prospective, observational, cohort studies conducted in 2007 and 2008 from 269 Intensive Care Units (ICUs) in 28 countries Included 5497 mechanically ventilated adult patients > 3daysinICU Sites recorded the presence or absence of a feeding protocol Sites provided selected nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days 78% of sites reported use of Feeding Protocol P< Heyland JPEN 2010 ( in press) 7

8 Hospital Admission Orders- Directs MD to Pre-printed Feeding Order form 15 Pre- Printed Feeding Orders- ICU Gastric and Intestinal Tube Feeding 16 8

9 Bedside Algorithm Goals: 1) Initiate EN within hours of admission** 2) Deliver >90% of required calories on a daily basis. Developed by Jan Greenwood, RD (Vancouver General Hospital) in collaboration with the CCCCPGC (21/7/03) 17 Initial Efficacy and Tolerability of Early Enteral Nutrition with Immediate or Gradual Introduction in Intubated Patients This study randomized 100 mechanically ventilated patients (not in shock) to Immediate goal rate vs Gradual ramp up (our usual standard). The Immediate goal group received more calories with no increase in complications. 18 Desachy ICM 2008;34:1054 9

10 The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP up Protocol! Not all critically ill patients are the same; we have different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds. Use semi-elemental solution In select patients, we start the EN immediately at goal rate, not at 25 ml/hr. We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume. Tolerate higher h GRV threshold h (250 ml or more) Motility agents and protein supplements are started immediately, rather than started when there is a problem. A Major Paradigm Shift in How we Feed Enterally 19 The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP up Protocol! Figure 2.1 Adequacy of Calories from EN (Before Group vs. After Group on Full Volume Feeds) calories received/prescribed ibed calories received/prescri % c % ca % ICU Day PLOT Before Group After Group Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Total P-value Heyland (CNW 2010 Abstract) 10

11 The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP up Protocol! Figure 2.2 Adequacy of Protein from EN (Before Group vs. After Group on Full Volume Feeds) % protein received/prescri ribed % % ICU ICU Day Day PLOT Before Group After Group Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Total P-value < Heyland (CNW 2010 abstract) Need for Constant Reminders 22 11

12 Poster 23 Reminder HOB sticker 24 12

13 Reminder screensavers 25 Special DVD presentation Early Enteral Nutrition in the ICU: The Clock Is Ticking! Daren K. Heyland, MD, FRCPC, MSc Professor of Medicine Queen s University Kingston, Ontario 26 13

14 27 International Nutrition Survey 2008 Site: Kingston General Hospital, Canada

15 Overall Site Performance % received/prescribed ICU day Your Site Sister Sites All Sites 29 Benchmarked Site Report Patients Time to Initiation of EN (hrs) Your Site Sister Sites All Sites Recommended Time: within 48 hours following ICU admission 30 15

16 Practice Changing Interventions Protocolize/automate care Improve organizational culture Develop Dietitian and other KOL as local opinion leaders Audit and feedback with benchmarked site reports Assess barriers and have interactive workshops with small group problem solving Implement strategies with rapid cycle change (PDSA) Educational reminders (manuals, posters, pocket cards) One on one academic detailing 31 What works best at your (barriers and facilitators will vary site site? to site) What is already working well at your site? (strengths and weaknesses are different across sites) 32 16

17 Conclusions Long way to go to narrow the quality gap Need to enrich our understanding of how best to achieve this; but in the meantime, act now! With our emerging understanding of the problems, we need to develop more targeted or strategic solutions. Strengths th & weaknesses; barriers & facilitators t vary across sites. Stay tuned 33 Early Enteral Feeding: An Educational Approach Sherri Jones MS, MBA, RD, LDN Clinical Nutrition Manager, University of Pittsburgh Medical Center (UPMC) Shadyside Disclosures: none to declare 34 17

18 EARLY ENTERAL FEEDING: AN EDUCATIONAL APPROACH Sherri Jones, MS, MBA, RD, LDN Clinical Nutrition Manager University of Pittsburgh Medical Center February 10, 2010 Las Vegas, Nevada 35 Outline Published 2009 enteral feeding guidelines Best practice research Implementation steps of Early Enteral Feeding program at UPMC Outcomes/Results Lessons learned + future considerations 36 18

19 2009 Guidelines The Adult Critically Ill Patient Delivering early nutrition support therapy, primarily using the enteral route, is seen as a proactive therapeutic strategy that may reduce disease severity, diminish complications, decrease length of stay in the ICU, and favorably impact patient outcome McClave S, Martindale R, Vanek V, McCarthy M, Roberts P, Taylor B, Ochoa J, Napolitano L, Cresci G. SCCM and A.S.P.E.N. JPEN J Parenter Enteral Nutr., Vol. 33, No. 3, May/June 2009, p Guidelines: Initiate Enteral Feeding Guideline A4 Enteral feeding should be started early within the first hours following admission (Grade: C) The feedings should be advanced toward goal over the next hours (Grade: E) Key: Grade C = Supported by level II investigations only Grade E = Supported by level IV or level V evidence 38 19

20 Research Best Practice An Early Enteral Nutrition Quality Improvement Initiative Program for the Critically Ill Plus literature review with 32 additional research articles McClave S, et al. Physician-delivered Malnutrition: Why Do Patients Remain NPO Or On Clear Liquids In A University Hospital Setting? JPEN, 2006; 30:S32-S33 39 Educational Intervention Best Practice Published Follow-up: Approach Education McClave S, et al. Targeted Physician Education Positively Impacts Delivery of Nutrition Support and Patient Outcome. JPEN. 2007;31:S7-S8 S

21 Early Enteral Nutrition Quality Improvement Initiative for the Critically Ill Program Components Benchmarking Education Outcomes Reporting 41 Alteration in Gut Integrity & Immunology Gut is Used Gut is Not Used Jabbar,et al. NCP 2003; 18(6) 42 21

22 The Pitfalls of Cumulative Calorie Deficit Increases associated with: Hospital LOS (p=0.0001) Infections (p=0.004) Duration mechanical vent (p=0.0002) Complications (p=0.0003) Villet, Chiolero (Clin Nutrit 2005;24:502) 43 Financial Benefits of Early Enteral Nutrition Fewer days in the hospital Decreased costs associated with hospital-acquired infection Infection Scenario Patient A Patient B (Early Feeding) (Delayed Feeding) Cost of 2 days earlier enteral nutrition $25 $0 Hospital acquired infection Not present Present Cost of hospital stay without acquired infection $31,389 N/A Cost of hospital stay with acquired infection N/A $185,260 Total cost of hospital stay $31,414 $185,

23 UPMC Project Aim & Objective UPMC Presbyterian Shadyside selected as 1 of 9 facilities nationally to trial the EEF program AIM To decrease the number of days to initiate nutrition (by at least 1 day) in the critically ill population OBJECTIVE To increase medical staff awareness of the need and benefit of early nutrition in the critically ill 45 Process (step 1) Staff buy-in (Dietitians + Dept. Director) Recruit a Physician champion ICU attending Involve Critical Care Dietitian Project Lead Develop clear guidelines for data collection Tailor resources to facility (forms/presentation) Establish a timeline Collect baseline data 46 23

24 Patient Data Collection Sheet 47 Baseline/Current State Collected baseline data on how soon nutrition is initiated in the ICU to evaluate scope of problem at UPMC Baseline Data: Dates of Baseline Data Collection 3/3/08-3/14/08 Total Number of Patients Followed (NPO/CL >3 3d days) Average Number of NPO/CL Days per Patient

25 Top 8 Reasons for NPO Status Hemodynamic Instability 2 of 43 (5%) Awaiting GI Function 10 of 43 (23%) Bowel Anastomosis 3 of 43 (7%) GI Bleed 2 of 43 (5%) Ileus 4 of 43 (9%) Mechanical Ventilator 20 of 43 (46%) Post-op 20 of 43 (46%) Other: high aspiration risk 1 of 43 (2%) 49 ICU Diet Order Advancement Advanced To Number of % of Pts Pts Oral Diet 21 49% TF 16 37% TPN 2 5% None 4 9% 50 25

26 Process (step 2) Intervention and Outcomes In-serviced ~35 members of medical staff Reviewed baseline data and benefits of early nutrition in the critically ill Shared best practice from Early Enteral Quality Initiative Program Collected post-education data to evaluate whether nutrition had been started sooner in the ICU Follow-up Data: Dates of Follow-up Data Collection 4/13/08-4/24/08 Total Number of Patients Followed (NPO/CL >3 days) Average Number of NPO/CL Days per Patient Comparative Data nts Number of Patie Effects of Intervention on the Number of Patients NPO/CL > 3 days Pre Intervention Post Intervention Reflects a 37% decrease Days Effects of Intervention on the Average Number of NPO/Clear Liquid Days 5.16 Pre Intervention 3.92 Post Intervention Reflects a 24% decrease 52 26

27 Sustain Results Over Time?? Baseline March 2008 April th Qtr (8 months post education) # of Pts NPO/CL >3days Average # days Pts NPO/CL >3days *4.92 *Reflects a 1 day increase in the average number of days >3 days 53 Project Successes & Barriers Successes Increased NPO/CL awareness Engaged Nursing in data collection Residents meet weekly for lunch & learns President s Cup Quality Fair Award Facility Awareness/recognition Barriers Setting up physician inservices Appropriate contact Getting them to attend Lead time needed for Medical Grand Rounds Staff turnover Lead Dietitian Nurses MD Resident ICU rotations 54 27

28 UPMC Future Considerations Monitor the clinical benefits/outcomes of early enteral nutrition Decreased length of hospital stay and/or days in ICU Reduced days on mechanical ventilator Reduced infectious complications Pop-Up alert in EHR once NPO/CL >3 days Ongoing education and inservicing of medical staff on benefits of early feeding in the critical/icu patient A MUST! Implement an Early Enteral Feeding Protocol 55 Summary/Key Points Educational approach improves compliance with Early Enteral Feeding Staff buy-in, especially MD Champion Organized approach Baseline data current state Justifies Enough lead time to schedule MD inservices Ongoing education/inservicing YOU CAN MAKE IT HAPPEN!! 56 28

29 Interdisciplinary Team Sherri Jones, MS, MBA, RD, LDN; Emily Plumb, RD, LDN, CNSD; Joyce Scott-Smith, MS, RD, LDN; Ronald Stiller, MD; Steven Clute, MD; Sharon McEwen, RN; Marcy Zoller, MSN, CRNP 57 Immune-modulating modulating Nutrition Protocols: Key Aspects of Success Dr. Robert Martindale MD, PhD, Professor and Chief Division of General Surgery Medical Director, Hospital Nutrition Services Oregon Health and Science University Disclosures: Advisor, Nestlé Nutrition 58 29

30 CNW 2010 Breakfast Symposium Immune-modulating modulating Nutrition Protocols: Key Aspects of Success Robert G. Martindale MD, PhD Professor and Chief Division of General Surgery Oregon Health and Science University Portland Oregon USA 59 Introduction: Nutrition Guidelines Basic Recommendations Not absolute requirements Do not project or guarantee outcome or mortality benefits Not a substitute for clinical judgment Supportive evidence Current literature National, international guidelines Expert opinion Clinical practicality Target population Adult critically ill medical and surgical patients Expected to stay in ICU 2-3 days Not a homogeneous population 60 30

31 Model for New Guidelines CCM 2004;32: JPEN 2003:27: Model for New Guidelines Surviving Sepsis Topic-driven Brevity Clarity Specificity Transparency Renewable Free access 62 31

32 Grading of Literature Definition of large trial Fulfill endpoint criteria per power analysis Size > 100 subjects Use of Meta-Analysis Organize information Derive overall treatment effect Not to grade recommendation Review papers, consensus statements = Expert opinion Grade based on level of evidence of individual studies 64 Grading of Recommendations Grade of Recommendation: A Supported by at least two level I investigations B Supported by one level I investigation C Supported by level II investigations only D Supported by at least two level III investigations E Supported by level IV or level V evidence Level of Evidence: I Large, randomized trials II Small, randomized d trials III Non-randomized, contemporaneous controls IV Non-randomized, historical controls V Case series, uncontrolled studies, expert opinion Adapted from Dellinger (CCM 2004;32: ) 65 32

33 Guidelines: Why do people not follow them? Inherent bias Arguments against implementing standard guidelines Too expensive to implement» we are an indigent care hospital.. No internal support to implement» my doctors don t really care Feeling the guidelines will not apply to their patients» my ICU patients are sicker or somehow different than those described in the guidelines. What we are currently doing is fine» Most make this statement without critical evaluation of internal data 66 E1. Selection of Appropriate Enteral Formulation E1. Immune-modulating enteral formulations (supplemented with agents such as arginine, glutamine, nucleic acid, omega-3 3fatty acids, and antioxidants) should be used for the appropriate patient population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilation), being cautious in patients with severe sepsis. (For surgical ICU patients..grade: A) (For medical ICU patients..grade: B) ICU patients not meeting criteria for immunemodulating formulations should receive standard enteral formulations. (Grade: B) 67 33

34 ESPEN Guidelines Intensive Care (2006) Immune-modulating formulae are superior to standard enteral formulae: Grade A Kreymann KG Clin Nutr ESPEN Guidelines Surgery (2006) Patients undergoing surgery who are considered to have no specific risk of aspiration, may drink clear fluids until 2 hours before anesthesia: Grade A Use of preop carbohydrate loading in patients undergoing major surgery: Grade B Use of EN preferably with immune modulating substrates (Arg, omega 3 FA etc) peri-operatively independent of nutritional risk for those patients Head and Neck, Major GI, Trauma GRADE A 69 Weimann A Clin Nutr

35 Carbo Loading Pre-op Principle is similar to preparation for major sports event! 8 hours pre-op 800 cc isotonic CHO solution 3 hours pre-op 300 cc isotonic CHO solution Shown to: Not increase risk of aspiration Protect lean body mass post-op» Maintain hand grip strength, etc Decrease insulin resistance post-op Ljungqvist O 2009 Faria MS WJS Example Case Study: Esophageal CA Use of Guidelines 64 yo male presents to Primary Care with severe dysphagia, 15 pound weight loss PMH: GERD, HTN PSH: appendectomy 18 yo Meds: prescribed PPI, HCTZ (rarely takes 2 nd $ issues) Social: tobacco +, 40 pack yr history PE: no major finding W/U: EGD with mucosal based lesion distal esophagus» 70% of lumen occluded» Biopsy: moderately differentiated adenoca» Metastatic W/U (CT chest abd, bronch), EUS, lymphadenopathy 71 35

36 Case continued: Esophageal Ca Discussion at Med/Surg GI Cancer Conference Sur/Onc, Med/Onc, Radiation/Onc, Nursing, PT, etc Decision to proceed with surgery following pre-op neoadjuvant therapy (T2N1M0 adenoca of esophagus) 6 wk of Chemo/Radiation PEG, Lap J, NJ tube, PO intake? Following neoadjuvant therapy tolerating liquids without problems At pre-op visit counseled on importance of specific pre-op nutrition (initial discussion done with primary Surgeon) Nurse in clinic gives pre-op handout Inclusion in pre-op instruction is the pre-op Immune-modulating formula (IMF) 72 OHSU Pre-surgical Nutrition Protocol Esophagectomy Oral immune-modulatingmodulating formula (containing arginine, fish oil, and nucleotides) Three 8 oz cartons per day (24 oz per day) 5-7 days prior to surgery Waitzberg World J Surg 2006 Braga M Arch Surg

37 Local problems and solutions Problem: pre-op formula is expensive Solution: Shift to pharmacy budget Appeal with financial argument to administration to cover up front cost» Cost effective argument must have data and tables etc 74 Local problems and solutions Problem: our doctors will never order the formula Solution: education program; variable arguments based on audience MDs ;??? Nurses; patient benefit, length of stay, tolerance Pharmacy; cost, logistics and science Administration; financial argument 75 37

38 Local problems and solutions Problem: How do the patients get the formula as outpatient? Solution: Store product with dietary enteral formula supply i.e. pay in cafeteria; take receipt to stock room Arrange with two or three local pharmacies to carry Key here is to not dilute the usage too much Purchase on-line Stocking in MD s office» Not practical in most settings 76 Local problems and solutions Problem: Patients leave with good intentions and do not follow through with buying the formula Solution: MD discusses with patient Simple discussion of the data on infection, length of stay etc Problem: Patients forget what they need when they arrive at the pharmacy Solution: Patients given pre-op handout with name, quantity needed, etc Make it very easy to follow 77 38

39 Old Subject new data coming Problem: I thought arginine is toxic Solution: No adverse data ever shown in surgical patients t Drover, Heyland, Wischmeyer et al. Ann Surg 2009 Submitted 28 RCT with 3055 patients Primary outcomes: Reduced infections P= Secondary outcomes Reduced length of stay days P=.0008 No change in mortality 78 Arginine in Surgery and Critical Care: AA relationships Competitive for cell transport Arginine i / Lysine ratios Arg increases Gln Patient on steroids Significant increase ARGase Arginine in obese trauma patient Increase insulin sensitivity Glucose control Lipid lowering (TG) Arginine in cardiovascular / endothelial function Restore NO, decreases SO- Decrease platelet and leukocyte adherence Liver /GI function Activates mtor, MAP kinase to enhance protein synthesis, cell migration (enterocytes) Improves GI function Decrease injury from I/R Improve GI ulcer healing Wound healing / muscle strength mtor activation Decrease proteolysis (indirect) Increase proline Increase tensile strength Local mechanisms DM foot Antioxidant effects Increases creatine; decreases 79 inflammation 39

40 OHSU - Pre-operative nutrition protocol implementation Steps to get protocol implemented Education program Residents, faculty (science arguments) Nurses (science argument, add practical portion) Administration (cost effectiveness argument) Finding a Physician advocate, supporter can t teach old dogs new tricks Determine funding or who will pay the increased cost Hospital based Patient based Internet Local pharmacy Make it easy for patients and MDs ordering Handouts for patients: make if very easy Make it standard unless otherwise indicated 80 Current ICU protocols in effect - OHSU Trauma ICU: Immune-modulating formula (IMF), Antioxidant, probiotics Surgery ICU: IMF, Antioxidant, probiotic Medicine ICU Probiotic Neurosurgery ICU Early enteral feeding, probiotics, IMF BMT ICU None Cardiac ICU Anti-inflammatory diet (Mar 10) 81 40

41 OHSU Post-operative Nutrition Protocol - Trauma Upon IV access Vitamin C Selenium Within 48 hours Enteral feeding tube placement Vitamin E via feeding tube Glutamine via feeding tube Gastric or small bowel feeding Start Immune modulating formula 20 cc /h Immune-modulating formula (IMF) contains arginine, fish oil and nucleotides Advance as directed in protocol 82 Local problems and solutions Problem: How long should we give the Immunemodulating formula (IMF)? Solution: No exact data yet published Pre-op at least 5 days Braga 02, Gianotti 02, Ryan 09 Post-op Not needed if nutritionally replete pre-op 7 to 10 days? 83 41

42 ICU Nutrition Protocol Development Strategy Nutrition therapy team discussion of pro and con Does the data support making it a standard protocol? Once the decision is made to develop protocol Committee member prepares outline draft in hospital format (for incorporation into chart, electronic record) Distribute to key services for comments (this is key) Committee accumulates data pro and con and presents to ICU committee or equivalent Key here is to have clearly designated inclusion and exclusion criteria» Be as broad as possible» Error on safe side (example Arginine 2003 vs 2007)» Have financial data ready Implement protocol Have references available and be ready for attack 84 Summary and Conclusion Guidelines are just that, Guidelines No guarantees Clinical judgment always takes precedent over guidelines Guidelines will change with ongoing trials, keep an open mind For patients and health care team to support It must be easy It should respect work load of implementing individuals It must be science-based and data driven, showing positive outcome Protocols incorporating guidelines improve outcome 85 42

43 Summary and Conclusion Focus your energy on matters with greatest potential for success Get $ support first! Education: Get an advocate with as much horse power as possible Specific education program for each group» One size fits all does not work You will have some failures and many who won t listen i.e. CHO loading, NPO after Midnight, probiotics Pick your battles carefully 86 Call to Action Consider being more aggressive (when appropriate) with Early Enteral Nutrition protocols to meet Guideline recommendations Starting at or near target rate for caloric goals Starting motility agents when the feed starts PEP up Protocol to be published soon 87 43

44 Call to Action Use ALL the tricks in your bag Benchmark, Educate, and Monitor data ongoing Use Enteral Quality Initiative Programs and reminders! Develop Standing Orders and Bedside Algorithms incorporating Guidelines 88 Call to Action Remember, immune-modulating nutrition protocols may have pre-surgical and/or post-surgical applications. Make science based case focused on outcomes Find a champion; determine funding Create clear exclusion/inclusion criteria Keep it simple for staff and patients 89 44

45 Thank you! Sponsor Disclosure: Financial support for this presentation was provided by Nestlé HealthCare Nutrition, Inc. The views expressed herein are those of the presenter and do not necessarily represent Nestlé s views. The material herein is accurate as of the date it was presented, and is for educational purposes only and is not intended as a substitute for medical advice. Reproduction or distribution of these materials is prohibited. Copyright 2012 Nestlé. All rights reserved