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TwoCal® HN
calorie and protein dense nutrition with FOS
Usage Features Availability Preparation Administration Ingredients Protein Fat Carbohydrate
Fiber Vitamins and Minerals Osmotic Concentration Renal Solute Load Analysis References Support
Materials
Usage:
TWOCAL HN is a nutritionally complete, high-calorie liquid food designed to meet the increased
protein and calorie needs of stressed patients and those requiring low-volume feedings.
z
z
z
For tube or oral feeding
For supplemental or sole-source nutrition
Often provided in 2-fl-oz amounts QID with Med Pass to assist with weight gain or
maintenance
Features:
High in calories (2 Cal/mL) to help people gain and maintain healthy weight
z Provides protein to help support lean body mass and wound healing
z Provides at least 25% of the DVs for 24 essential vitamins and minerals in 8 fl oz
z Can supply needed nutrients for nutritionally at-risk elderly
z Includes 1.2 g of FOS/8 fl oz (5 g/L). FOS are prebiotics that stimulate the growth of beneficial
bacteria in the colon. FOS are fermented to SCFAs that stimulate water and electrolyte uptake in the
colon, which is important in the management of diarrhea.
z Low-residue
z Lactose- and gluten-free
z Kosher
z
Caloric Distribution
Calories
Per 2 fl oz
Per 8 fl oz
Per Liter
% Calories
119
475
2000
—
Protein, g
5
19.9
83.5
16.7
Fat, g
5.4
21.5
90.5
40.1
Carbohydrate, g
13
51.8
218.5
43.2
Water, g*
42
166
700
—
*1 g water = 1 mL water = 1 cc water.
Availability:
Ready-To-Use 8-fl-oz cans; 24/case
Flavor
List Number
Vanilla
00729
Butter Pecan
54064
Ross Ready-To-Hang®
1000-mL prefilled containers; 8/case
Flavor
List Number
Unflavored
57047
See the Reimbursement section of Ross.com for third-party reimbursement information. The
Reimbursement link can be found at the top of each page of Ross.com.
Product information and values listed are subject to change. Please refer to product label or
packaging for the most current information.
Preparation:
Use by date on container.
Administration:
Use under medical supervision. Not for parenteral use.
8-fl-oz cans: Oral feeding: May be fed at room temperature or chilled. Tube feeding: Follow
physician's instructions. Adjust flow rate and volume according to patient's condition and tolerance.
Feed by pump at room temperature with an 8 Fr or larger tube; gravity feeding is not recommended.
Additional fluid requirements should be met by giving water between or after feedings or when
flushing the tube. Avoid contamination during preparation and use.
Ross Ready-To-Hang: Pump feeding is recommended. Pump feed at room temperature with an 8
Fr or larger tube. Gravity feeding is not recommended. Additional fluid requirements should be met
by giving water between or after feedings, or when flushing tube.
Note: Hang product up to 48 hours after initial spike when clean technique and only one new feeding set are
used. Otherwise, hang no longer than 24 hours. The availability of extended hangtime does not supersede your
institution’s policies, procedures, or good clinical practice guidelines. (See attached PDF at the top of this page,
"Ross Ready-To-Hang® Suggested Setup Procedure.")
Protect contents from light during storage.
Click Here To View Administration Schedule.
Ingredients:
Vanilla: (U)-D water, corn syrup solids, sodium and calcium caseinates, corn maltodextrin, high
oleic safflower oil, sugar (sucrose), medium chain triglycerides, canola oil, fructooligosaccharides,
potassium citrate, magnesium chloride, calcium phosphate, natural and artificial flavors, soy lecithin,
sodium citrate, ascorbic acid, choline chloride, taurine, L-carnitine, zinc sulfate, ferrous sulfate, dlalpha-tocopheryl acetate, niacinamide, calcium pantothenate, manganese sulfate, cupric sulfate,
thiamine chloride hydrochloride, pyridoxine hydrochloride, riboflavin, vitamin A palmitate, folic acid,
biotin, chromium chloride, sodium molybdate, potassium iodide, sodium selenate, phylloquinone,
cyanocobalamin, and vitamin D3. (7834-08)
Protein:
The quantity and concentration of protein provided in TWOCAL HN are adequate to meet the needs
of most moderately to severely stressed patients. The high-quality protein of TWOCAL HN meets or
surpasses the standard amino acid profile for high-quality protein set by the National Academy of
Sciences.1
Protein Profile
Percent of total calories from protein
16.7
Protein content
83.5 g/L
Cal/N ratio
150:1
Nonprotein Cal/N ratio
125:1
Fat:
The fat blend in TWOCAL HN contains 64% high oleic safflower oil, 19% MCT oil, 15% canola oil,
and 2% lecithin. The high oleic safflower oil and canola oil blend is high in monounsaturated fatty
acids and low in cholesterol. The level of MCT oil is designed to aid fat digestion. Effective
absorption of MCTs—unlike that of long-chain triglycerides—does not depend on pancreatic lipase
or bile salts. MCTs are thus more rapidly absorbed by the intestinal mucosa.2 This may be
particularly important for patient tolerance of concentrated formulas that provide significant levels of
fat.
Fat Profile
Percent of total calories from fat
40.1
Total Fat
90.5 g/L
Polyunsaturated fatty acids
12.0 g/L
Monounsaturated fatty acids
50.9 g/L
Saturated fatty acids
23.1 g/L
Cholesterol
<30 mg/L
omega-6/omega-3 ratio
9.1:1
Carbohydrate:
The carbohydrate sources in TWOCAL HN are corn syrup solids, corn maltodextrin, sucrose, and
fructooligosaccharides (FOS). The amount and benefits of FOS, the dietary fiber source in TWOCAL
HN, are provided in the Fiber section.
Carbohydrate Profile
Percent of total calories from carbohydrate
43.2
Total carbohydrate
218.5 g/L
Fiber:
Fiber
The fiber source in TWOCAL HN is fructooligosaccharides (FOS). FOS are indigestible, highly
fermentable carbohydrates that occur naturally in many foods, such as onions, bananas, tomatoes,
honey, garlic, barley, and wheat. FOS do not contribute to residue in the stool. FOS are prebiotics
that stimulate the growth of beneficial GI bacteria (eg, bifidobacteria). FOS are fermented to shortchain fatty acids (SCFAs) that perform many beneficial functions within the digestive tract,3 and help
create an unfavorable environment for Clostridium difficile in at-risk patients.4-6 SCFAs are a
preferred energy source for cells of the colon, helping to maintain GI tract integrity. FOS stimulate
water and electrolyte uptake in the colon, which is important in the management of diarrhea. This
enhanced absorption may have important implications for people with cancer who are experiencing
diarrhea.7 In an in vitro study, FOS fermentation resulted in the greatest growth of acid-producing
bacteria and the lowest pH. These factors, in turn, did not support the growth of some pathogenic
bacteria, eg, Clostridium difficile.5 The FOS content of TWOCAL HN is 1.2 g/8 fl oz (5 g/L).
Vitamins and Minerals:
TWOCAL HN provides at least 100% of the DVs for 24 key vitamins and minerals in 1900 Cal (948
mL) or four 8-fl-oz servings. TWOCAL HN is supplemented with the conditionally essential nutrients
L-carnitine and taurine (38 mg/8 fl oz, 160 mg/L), which may become depleted during periods of
metabolic stress.8,9
Osmotic Concentration:
The main determinants of the osmolality of a formula are simple carbohydrates, electrolytes, amino
acids, and small peptides. Formulas that are calorically concentrated, such as TWOCAL HN at 2
Cal/mL, have a higher osmotic concentration than standard 1 Cal/mL formulas due to the
concentration of nutrients in a limited volume.
Osmolality (mOsm/kg H2O)
725
Osmolarity (mOsm/L)
512
Renal Solute Load:
Renal solute load represents the solutes excreted per liter of product consumed. The major
determinants of renal solute load are dietary protein and electrolytes. Each milliequivalent of sodium,
potassium, and chloride contributes approximately 1 mOsm to the renal solute load; in adults, each
gram of protein contributes approximately 5.7 mOsm. Renal solute load increases as nutrients
(electrolytes and protein) are concentrated. When used as the sole source of nutrition, products
containing 2 Cal/mL do not provide adequate water to meet hydration needs. It is important to
monitor hydration status and provide additional water as indicated.
Renal Solute Load (RSL)
Electrolyte Content (mEq/L)
Contribution to RSL
(mOsm/L)
Sodium
63.0
63.0
Potassium
62.6
62.6
Chloride
51.1
51.1
Protein content
83.5 (g/L) x 5.7 =
476.0
Total RSL
653
Analysis:
Nutrient Facts
8 fl oz
1000 mL
FAN (label number)
7834-08
7834-08
Cal/mL
2.00
2.00
Energy, Cal
475
2000
Protein, g
19.9
83.5
% of total Calories 16.7
16.7
Fat, g
21.5
90.5
% of total Calories 40.1
40.1
Cholesterol, mg <10
<30
Carbohydrate, g
51.8
218.5
% of total Calories 43.2
43.2
Water, g*
166
700
Dietary Fiber, g
1.2
5.0
L-carnitine, mg
38
160
Taurine, mg
38
160
m-Inositol, mg
* 1 g water = 1 mL water = 1 cc water.
Carbohydrate includes dietary fiber.
Vitamins
8 fl oz
1000 mL
Vitamin A, IU
1250
5270
Vitamin D, IU
100
425
Vitamin E, IU
12
51
Vitamin K, mcg
20
85
Vitamin C, mg
75
320
Folic Acid, mcg
160
675
Thiamin (Vitamin B1), mg
0.6
2.6
Riboflavin (Vitamin B2), mg
0.68
2.9
Vitamin B6, mg
0.8
3.4
Vitamin B12, mcg
2.4
10
Niacin, mg
8
34
Choline, mg
150
635
Biotin, mcg
120
510
Pantothenic Acid, mg
4
17
Minerals
8 fl oz
1000 mL
Sodium, mg (mEq)
345 (15.0)
1450 (63.0)
Potassium, mg (mEq)
580 (14.8)
2440 (62.6)
Chloride, mg (mEq)
430 (12.2)
1810 (51.1)
Calcium, mg
250
1050
Phosphorus, mg
250
1050
Magnesium, mg
100
425
Iodine, mcg
38
160
Manganese, mg
1.3
5.3
Copper, mg
0.5
2.1
Zinc, mg
5.7
24
Iron, mg
4.5
19
Selenium, mcg
18
74
Chromium, mcg
30
130
Molybdenum, mcg
38
160
Amino Acids
8 fl oz
1000 mL
Essential
Histidine, mg
534.6
2254.5
Isoleucine*, mg
930.6
3924
Leucine*, mg
1782
7515
Lysine, mg
1425.6
6012
Methionine, mg
554.4
2338
Phenylalanine, mg
990
4175
Threonine, mg
792
3340
Tryptophan, mg
217.8
918.5
Valine*, mg
1168.2
4926.5
Alanine, mg
574.2
2421.5
Arginine, mg
653.4
2755.5
Aspartic Acid, mg
1386
5845
Cystine, mg
79.2
334
Glutamic Acid, mg
4237.2
17869
Glycine, mg
356.4
1503
Proline, mg
2098.8
8851
Serine, mg
1089
4592.5
Tyrosine, mg
970.2
4091.5
Nonessential
* Branched-chain amino acids.
Fatty Acids
8 fl oz
1000 mL
Linoleic (18:2), mg
2561
10778
a-Linolenic (18:3), mg
283
1189
Caprylic (8:0), mg
2277
9586
Capric (10:0), mg
1686
7096
Lauric (12:0), mg
46
195
Myristic (14:0), mg
33
140
Palmitic (16:0), mg
898
3780
Stearic (18:0), mg
372
1568
Oleic (18:1), mg
11954
50318
Arachidic (20:0), mg
82
344
Fatty acids equal approximately 95% of total fat.
Key for values in parentheses (carbon atoms:double bonds).
Other Values
Density at 23°C, g/mL
1.109
pH
6.6
Osmolality, mosm/kg H2O
725
Osmolarity, mosm/L
512
Renal Solute Load, mosm/L
653
Cal to meet 100% RDIs
1900
mL to meet 100% RDIs
948
Total Cal/g nitrogen
150:1
Nonprotein Cal/g nitrogen
125:1
References:
Food and Nutrition Board, National Research Council: Recommended Dietary Allowances, ed 10.
Washington, DC: National Academy of Sciences, 1989.
1. Bach AC, Babayan VK: Medium-chain triglycerides: An update. Am J Clin Nutr 1982;36:950962.
2. Prosky L, Hoebregs H: Methods to determine food inulin and oligofructose. J Nutr 1999;129
(suppl 7):1418S-1423S.
3. Gibson G, Wang X: Bifidogenic properties of different types of fructo-oligosaccharides. Food
Microbiol (London) 1994;11:491-498.
4. Cummings JH, Macfarlane GT: The control and consequences of bacterial fermentation in the
human colon. J Appl Bacteriol 1991;70:443-459.
5. Macfarlane GT, Cummings JH: The colonic flora, fermentation, and large bowel digestive
function, in Phillips SF, Pemberton JH, Shorter RG (eds): The Large Intestine: Physiology,
Pathophysiology, and Disease, New York: Raven Press, 1991, pp 51-92.
6. Jenkins DJ, Kendall CW, Vuksan V: Inulin, oligofructose and intestinal function. J Nutr
1999;129:1431S-1433S.
7. Paauw JD, Davis AT: Taurine concentrations in serum of critically injured patients and ageand sex-matched healthy control subjects. Am J Clin Nutr 1990;52:657-660.
8. Iapichino G, Radrizzani D, Colombo A, Ronzoni G: Carnitine excretion: A catabolic index of
injury. JPEN 1988;12:35-36.