>> Nutritional status is the basis and expression of health, but also plays a major role in the onset and progression of diseases, as well as in convalescence. According to the German Society for Nutrition (DGEM), the resting energy expenditure for a healthy person between 30 and 70 years of age is approximately 22.5 kcal/kg body weight/day, while for a sick person it can be up to 7 percent higher. This increases the risk of malnutrition and associated anorexia, particularly in tumor and autoimmune diseases as well as other serious chronic illnesses. Medications such as cytostatics, opiates, digoxin, or antibiotics can also contribute to the development of malnutrition by causing nausea, altering taste perception, or causing dry mouth. Independent of diseases and medication effects, the risk of malnutrition increases in an aging society, due, among other things, to declining mental and physical vitality, an unbalanced diet, and diminished sensory perception. For example, 40 to 70 percent of all patients in nursing homes and nursing homes have a significant risk of developing malnutrition (see Löser, 2012). A 2016 survey of general practitioners, oncologists, and neurologists revealed that half of the doctors surveyed very often or always consider malnutrition in old age to be a cause of illness. Almost all doctors consider the importance of adequate and needs-based nutrition for recovery to be undisputed. Accordingly, three out of four doctors provide their patients with extensive information on the topic, even though the majority do not feel fully informed about malnutrition themselves (see Federal Association Initiative 50Plus).
Enteral nutrition at a glance
From a purely medical perspective, a distinction is made between quantitative malnutrition – where the body does not receive enough food to meet its energy needs – and qualitative malnutrition, where the body does not receive sufficient proteins, vitamins, minerals, or trace elements. One possible nutritional intervention is artificial nutrition, which serves to improve the course of the disease and the prognosis by meeting nutrient requirements and improving or maintaining nutritional status in patients with inadequate oral nutrition (see Pirlich et al., 2006).
The DGEM terminology in clinical nutrition distinguishes between enteral and parenteral nutrition in artificial nutrition. In the latter case, water and nutrients such as amino acids, glucose, lipids, electrolytes, vitamins, and trace elements are administered intravenously, thus bypassing the gastrointestinal tract. In enteral nutrition, food is administered distal to the oral cavity via a tube or through a stoma, using the intestinal tract. Enteral nutrition is divided into high-molecular-weight standard diets for patients with unrestricted metabolic and digestive capacities, and special diets, in which the nutrient composition is tailored to the specific disease. For patients with impaired digestive and absorption capacity, low-molecular-weight oligopeptide diets (short-chain proteins) that can be absorbed with limited digestive capacity are indicated.
15.5% more enteral nutrition
According to Section 31 Paragraph 5 of the Social Code (SGB V), insured persons are entitled to balanced diets for enteral nutrition. The G-BA's Pharmaceutical Guidelines regulate the conditions under which balanced diets can be prescribed by a contracted physician. These guidelines define product groups, medical necessity, and measures that must be taken before prescribing enteral nutrition. A public opinion procedure initiated in November 2014 to amend this guideline and Annex XIII, which lists prescribable products including their instructions for use, is currently pending. Given the current circumstances, the associations of statutory health insurance physicians recommend that contracted physicians only specify normal-calorie or high-calorie tube feedings and the amount required for the prescription period on the prescription. For disease-adapted special nutrition, however, the brand name should be printed. Furthermore, the requirement for cost-effectiveness and the increasing demand for enteral nutrition are emphasized. In 2016, enteral nutrition totaling EUR 68 million (sales based on manufacturer's prices) was billed to statutory health insurance (SHI) providers for outpatient care through outpatient pharmacies. This represents an increase of 15.5 percent compared to the previous year. High-molecular nutrition, at EUR 66.3 million, is by far the most important segment of enteral nutrition, broken down into powdered high-molecular diets with EUR 16.7 million in sales, sip feeds with EUR 42.4 million, and tube feedings with EUR 7.2 million. Oligopeptide diets complete the overall market for outpatient enteral nutrition considered here, with EUR 1.7 million, representing an increase of 12 percent compared to 2015 (Source: NVI-CI INSIGHT Health, CI Care Information division).
Outpatient care:
Pharmacy and prescriber
In 2016, 3.6 million units of enteral nutrition products were dispensed in German pharmacies, including mail-order pharmacy sales. As Figure 1 shows, sales via self-medication are the most important sales channel for the pharmacy sales channel, accounting for 46 percent. This primarily involves sip nutrition. Sip nutrition also accounts for by far the largest share of the 34 percent of enteral nutrition products dispensed in pharmacies via statutory health insurance prescriptions. Mail-order pharmacy sales via the pharmacy are gaining in importance, as evidenced by a 24 percent increase over the previous year. Overall, the pharmacy market, including mail-order pharmacy sales, grew by 2.5 percent compared to the previous year. In contrast, the quantities dispensed to self-payers in pharmacies recorded a decline of 3.1 percent (Source: NAV-CI Channel; INSIGHT Health).
As expected, general practitioners are the specialist group that most frequently prescribes enteral nutrition in the outpatient setting. They are followed by internists, whose statutory health insurance prescriptions for enteral nutrition have increased over the past three years. With the exception of pediatricians, increasing prescription volumes can be seen for all relevant specialist groups and for hospital outpatient clinics, indicating an increased demand (see Figure 2).
Care management/research
Many manufacturers of artificial nutrition offer care management for enterally fed patients in addition to their products for standard and special diets. This ranges from prescription management to delivery and monitoring of therapy. For patients from an inpatient setting, the transfer of outpatient care can be coordinated from the outset, and a treatment concept can be developed in collaboration with the hospital and the practicing physicians. According to Section 39 Paragraph 1 of the Social Code Book V (SGB V), insured persons are entitled to discharge management to resolve problems during the transition to care after hospital treatment. According to Section 11 Paragraph 4 of the SGB V, they are entitled to care management, particularly to resolve problems during the transition between the various care areas. Homecare care by patient managers and specially trained nursing services, as well as the provision of transfer systems for patients with tubes, therefore represents an additional service model for providers. Dedicated patient care guidelines with information on the composition of the products and recommended intake, as well as apps that support the planning and documentation of the application, round out the range of services. On the scientific side, the DGEM represents the multidisciplinary association of all professional groups involved in nutritional medicine. Among other things, the society aims to improve nutritional care in hospitals, nursing homes, and outpatient settings. Sponsored industry awards, scholarships, and DGEM research grants are measures for young researchers and scientific exchange. Participation in Nutrition Day, which has been held since 2004 by the European Society for Clinical Nutrition and Metabolism and other initiators, combines research with practice. The partners' idea: to raise awareness of malnutrition in inpatient settings and promote the implementation of adapted nutrient provision. Hospitals and nursing homes worldwide can now register and, after collecting data in their own facility, receive a structured report of results, including national benchmark information on the status of nutritional provision. Expansion of participation to include outpatient nursing services and other care facilities is planned. This addresses a lack of information and awareness, which can ultimately improve the care of malnourished patients in inpatient settings. How outpatient care will develop in the face of increasing demand for supplementary nutrition in an aging society remains to be seen.

Authors:
Kathrin Pieloth, Gabriele Maack

INSIGHT Health ([email protected]); literature available from the authors