Grade A clinical evidence supports nutritional therapy with IMPACT formula

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2 Grade A clinical evidence supports nutritional therapy with IMPACT formula Only IMPACT formula has 8+ published articles supporting its clinical outcomes and economic benefits vs. standard formulas* 4+ 4 Published articles Positive patient outcome studies Supportive mechanistic studies and review articles Meta-analyses Economic analyses IMPACT formula has positive outcome data across multiple patient types*: Surgical elective and emergency Trauma head injury, burns, blunt and penetrating trauma Medical critically ill, cardiac failure, mechanically-ventilated, pneumonia, mild to moderate sepsis, wounds * Data vs. control including standard formulas, total parenteral nutrition (TPN) and nothing by mouth (NPO). For more information on IMPACT trials, or to speak with a Nestlé healthcare specialist call ASK2 (2752).

3 IMPACT nutritional therapy improves clinical outcomes and helps reduce surgical complications 1-8 IMPACT formula reduces the incidence of nosocomial infection 1* IMPACT formula decreases days on ventilator 5 Reduction (%) Up to 61% Reduction (days) Up to IMPACT formula reduces antibiotic use 2-4,, IMPACT formula decreases length of hospital stay (LOS) 1,6*, Reduction (%) Reduction (days) On average Up to 6% 6 6 In addition, IMPACT nutritional therapy has been shown to significantly reduce incidence of complications including: Pneumonia & UTI by 5% 1* 7,8 Ω,ß Wound complications by 77% Abdominal abscesses by 6% 1* Anastomotic leaks by 5% 1* * Versus standard formula. Review of 17 randomized trials to determine the relationship between postsurgical outcomes and pre-, peri- and postoperative nutritional support in patients undergoing elective surgery; n=2,35. 1 Prospective, randomized, double-blind clinical trial assessing perioperative administration of enteral formula to reduce infections vs. standard formulas; n=26. 2 Randomized clinical trial assessing effects of perioperative oral supplementation on length of hospital stay and postoperative complications in malnourished GI surgical cancer patients; n=15. 3 Randomized, controlled trial investigating effects of preoperative oral supplementation on postoperative infection rates and length of hospital stay in malnourished GI surgical cancer patients; n=35. 4 Versus standard formula; p=.7. Prospective, randomized, double-blind, controlled trial investigating median duration of mechanical ventilation days required. 5 Results from a prospective, randomized, multicenter, controlled trial; patients received standard formula. Infections included UTI, SSI and pneumonia. IMPACT formula reduced patients median of stay; n= Ω Prospective, randomized, double-blind, controlled trial investigating early postoperative enteral immunonutrition in surgery patients. Results vs. control formula; n=6. 7 ß Prospective, randomized trial evaluating wound complications in major abdominal surgical patients; n=6. 8

4 Positive outcomes are supported by IMPACT formula s mechanism of action Improves immune response: 7-11 IgG & IgM Total Lymphocyte Count T-Lymphocyte Count Modulates inflammatory response: 2,12-15 C-Reactive Protein Fibrinogen IL-2, IL-6, IL-8 Up to 8% of the body s immunoglobulin-producing tissue are located within the GI tract 16 Enhances tissue repair: 2,7 Colonic microperfusion Gut oxygenation Hydroxyproline levels Only IMPACT formula contains a patented blend of immune-modulating nutrients including arginine, omega-3 fatty acids and dietary nucleotides that help enhance immune response L-Arginine 7,17-21 a nitrogen-rich amino acid; indispensable in stressed states A precursor of polyamines and a regulator of nucleic acid synthesis Supports T-cell replication and growth to enhance immune function Promotes wound healing and reduces infectious complications Omega-3 Fatty Acids 22 EPA & DHA from fish oil Increase immune response by enhancing lymphocyte function Minimize inflammatory response by decreasing production of inflammatory mediators Dietary nucleotides 23 building blocks for DNA and RNA; indispensable in stressed states Required for almost all cell activities & growth Essential for rapidly replicating cells to help support immune function Glutamine 24 amino acid; indispensible in stressed states The preferred oxidative fuel required for rapidly dividing cells, including GI mucosal cells & immune cells Improves GALT, mucosal integrity, and nitrogen transport to promote nutrient absorption Protein 25 High levels support increased demand caused by catabolism during the stress response Supports wound healing, strengthens immune function and promotes anabolism Zinc 26 Stabilizes RNA and DNA structure Deficiency associated with delayed wound healing

5 Nutritional therapy with IMPACT formula is cost effective for hospitals and patients IMPACT formula is a cost effective therapy for managing the risk for infection and length of hospital stay in critically ill patients 27 Investment Potential Savings* Population IMPACT formula Incremental cost of complication Incremental LOS with complication Surgical $152 $25, days Trauma $17 $23, days Medical $17 $81, days Reduced incidence of nosocomial infection and hospital LOS with IMPACT formula results in net cost savings, as demonstrated in a study by Farber MS et al., day course x 17 critically ill ICU patients IMPACT... $11,662 PROMOTE... $ 1,12 Additional cost for IMPACT... $1,65 ICU savings with reduced LOS 5 days x 17 patients... $24, Net Savings...$193,35 * IMPACT has been associated with reduced cost of hospital care despite its higher purchase price vs. standard formulas. Savings are on a per patient basis, based on illness category and at a low baseline infection rate (1%). These results were derived from a national database of over 1 million patients in a variety of health care facilities across the US. Average cost of a perioperative oral regimen in the U.S. is $22 (1 L/d for 5 consecutive days preoperatively plus 2 kcal/d enterally for 7 consecutive days postoperatively). Average cost of a post-admission regimen (2 kcal/d for 7 consecutive days) for medical ICU or trauma patients is $175. The average cost of a standard high nitrogen formula (2 kcal/d for 7 consecutive days) is $68. Pricing not guaranteed and varies per customer. Incidence of nosocomial infections, mortality and the consumption of multiple ICU resources were examined to determine the cost effectiveness of this proprietary immunonutrition enteral formula. 29 Assumes patients receive 8 cans/day of IMPACT 1.5 formula or PROMOTE. Patients with significant, severe illness. Pricing not guaranteed and varies per customer. Assuming cost of incremental care $24/day in ICU. 27

6 Make nutritional therapy with IMPACT formula an important part of your treatment protocols Immune-modulating formulas are appropriate for multiple patient types: 2,32* Major elective GI surgery Trauma (abdominal trauma index score >2) Burns (total body surface area >3%) Head and neck cancer Critically ill on mechanical ventilation (not severely septic) IMPACT formula recommended administration: Deliver enterally or PO: enterally via gastric or jejunal tube 33 (IMPACT formulas) o r orally with IMPACT Advanced Recovery Advanced Nutrition Drink Initiate early: within hours after injury/surgery or as soon as safe to feed 2 Start slowly: 1 3 ml/hour and advance towards goal over next hours 34,35 Duration: after achieving 5% of caloric goal, feed for 5 days 34,36 Continue until the risk of infectious complications is significantly reduced 2 Transition to high-nitrogen standard formula or wean from enteral feeding IMPACT [has] been shown in clinical studies to improve patient outcome, principally by reducing infections and improving wound healing. Other formulas have not been prospectively studied and are dissimilar enough from the tested formulas that no conclusions can be made about their use in trauma patients A.S.P.E.N Nutrition Support Practice Manual * Contraindicated where immunosuppression is desired. Caution is required in patients with severe sepsis. Feed IMPACT formula only to those patients who are hemodynamically stable and where enteral feeding is appropriate. Patients may not receive maximum benefit if used fewer than 5 days and less than.5 1 L/day of IMPACT formula. 1,2,6 Reprinted from Kozar RA et al. Trauma. In: Merritt R ed. The A.S.P.E.N. Nutrition Support Practice Manual. 2 nd ed. 25:271 6., with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form other than its entirety. 25

7 Make an IMPACT with your choice of nutritional therapy Extensive evidence and positive clinical outcomes support the unique formulation found in all IMPACT formulas IMPACT 1. For patients requiring a high-protein, 1. kcal/ml immune-modulating formula IMPACT 1.5 For patients with fluid sensitivity requiring a calorically dense (1.5 kcal/ml), high-protein, immune-modulating formula IMPACT with fiber For patients requiring a high-protein, 1. kcal/ml immune-modulating formula with added fiber to help support normal bowel function IMPACT Glutamine For patients requiring a high-protein, calorically dense (1.3 kcal/ml) immune-modulating formula with high levels of glutamine (15g/L) and added fiber IMPACT Advanced Recovery For patients requiring a high-protein, calorically dense (1.4 kcal/ml) immune-modulating nutritional beverage for use peri-operatively to help decrease incidence of infection and support colonic health

8 Make an IMPACT with nutritional therapy in your ICU Reduced risk for infection Up to 61% 1 Fewer ventilator days, Less antibiotic use Decreased surgical wound complications Up to 4.5 days 5 Up to 6% 2-4 Up to 77% 7 Shorter length of stay On average 3.1 days 1 Lower cost of care Hospital savings over $19, 29 Higher standard of patient care Across multiple patient types Contact Nestlé Nutrition at ASK2 for more information, or visit 1. Waitzberg DL et al. World J Surg 26;3: Braga M et al. Surg 22;132: Braga M et al. Arch Surg 22;137: Gianotti L et al. Gastroenterology 22;122: Atkinson S et al. Crit Care Med 1998;26: Bower RH et al. Crit Care Med 1995;23(3): Farreras N et al. Clin Nutr 25;24: Daly JM et al. Ann Surg 1995;221(4): Kemen et al. Crit Care Med 1995;23(4): Senkal et al. Arch Surg 1999;134: Snyderman et al. Laryngoscope 1999;19: Weimann A et al. Nutrition 1998;14(2): Gianotti et al. Arch Surg 1997;132: Tepaske et al. Lancet 21;358: Nakamura et al. Nutrition 25;21: Phillips-Qualigiata JM et al. Migration of lymphocytes in mucosal immune system. In: Husband AJ, ed. Migration and Homing of Lymphoid Cells. CRC Press 1988;2: Ochoa et al. Nutrition in Clinical Practice 24;19: Basu et al. NCP 22:17: Guoyao et al. Curr Opin Clin Nutr Metabol Care 2;(3)1: Kudsk et al. JPEN 21;25(2):S1 S Stechmiller et al. Am J CC 24;13: Calder et al. Eur J Clin Nutr 26:56:S14 S Grimble et al. Curr Opin Clin Nutr Metabol Care 21;4: Alpers. Gastroenterology 26;13:S16 S Kozar RA et al. Trauma. In: Merritt R ed. The A.S.P.E.N. Nutrition Support Practice Manual. 2nd ed. 25: Anderson JJ. In: Mahan LK et al. Krause s Food, Nutrition and Diet Therapy, 1th ed. Minerals. Philadelphia: WB Saunders, 2: Strickland A et al. JPEN 25;29:S62 S Braga M. Nutrition 25;21: Farber. JPEN 25;29(1):S62 S Braga M et al. JPEN 25;29(1): S57 S Braga M et al. Nutrition 25;21: Montejo JC et al. Clinical Nutrition 23;22(3): Cresci G et al. Nutrition Support in Trauma. In: The Science and Practice of Nutrition Support. A.S.P.E.N./Kendall-Hunt Publishing. 21; Gottschilch MM. Ed. Silver Spring, MD: A.S.P.E.N.;27: Taylor SJ et al. Crit Care Med 1999;27(11): Cresci G JPEN 25;29(1):S92 S95. PROMOTE is a registered trademark of Abbott Laboratories ASK2 (2752) Except as noted, all trademarks are owned by Société des Produits Nestlé S.A., Vevey, Switzerland. IPCT