January 2015 Issue
Blenderized Foods for Home Tube Feeding: Learn About the Benefits, Risks, and Strategies for Success
By Theresa A. Fessler, MS, RDN, CNSC
Vol. 17 No. 1 P. 30
Thousands of people are unable to eat by mouth and therefore require long-term home enteral tube feedings. While most use standard commercial enteral nutrition (EN) formulas, a growing number of home EN patients want fresh unprocessed foods instead of, or in addition to, their typical EN regimen.
To accomplish this, whole foods are liquefied in a blender with water, juice, broth, or various types of milk, and administered by syringe bolus in feeding tubes. This is a flexible practice ranging from adding one small blended food per day with a standard commercial EN regimen to consuming a diet consisting of only blenderized foods.
In my experience as a practicing nutrition support specialist, the use of blenderized foods for home tube feeding has been uncommon, but occasionally some patients have asked questions about it and used various puréed foods or juices in their feeding tubes. If done properly, blenderized foods in feeding tubes can be safe and healthful and improve patient satisfaction; however, it can be difficult to ensure that full nutrition needs are met, and there are some risks.
All across the country, more RDs are stepping up to the challenge of assisting home EN consumers with the use of blenderized foods for tube feeding, yet not much medical research has been done to support this practice. This article will discuss the benefits and risks of home tube feeding with blenderized foods and provide strategies for its success.
Hundreds of phytochemicals and fibers present in fruits, vegetables, whole grains, and other foods are beneficial to health and gastrointestinal (GI) function.1,2 In contrast, conventional EN products contain processed ingredients such as corn syrup, maltodextrin, sucrose, casein, whey and soy proteins, soy and corn oils, and very limited amounts and types of fiber. Commercial EN products are necessary for hospital use in that they contain concentrated sources of calories and protein and all the known essential vitamins and minerals in standardized amounts and in a convenient and safe form, yet they don't contain the myriad phytochemicals and fibers found in whole foods. The use of blenders makes it possible for home tube-fed individuals to consume fruits, vegetables, whole grains, legumes, fish, nuts, and many other protein sources as well as healthful fats—the foods in accordance with the 2010 Dietary Guidelines for Americans.3
Blenderized foods are a benefit for home EN consumers who have intolerances or are allergic to certain ingredients in standard EN formulas such as soy or casein. Other EN consumers view blenderized foods as a quality-of-life issue. They enjoy sharing family meals, a varied diet, the sight and aromas of foods, and even a faint taste sensation after burping.4,5 Joni Hodor, RD, CD, MS, CNSC, of Aurora Visiting Nurse Association in Milwaukee, says some of her patients use blenderized foods because of corn allergy, to avoid maltodextrin, or they simply prefer natural, organic, real foods. Carol Ireton-Jones, PhD, RDN, LD, CNSC, FAND, FASPEN, agrees that most of the EN clients she has worked with who use blenderized foods do it either for personal satisfaction or because of intolerance to components of standard EN formulas. In some cases, people choose blenderized foods over conventional EN formulas because they cost less and especially if their medical insurance doesn't cover home EN.4,5
One can assume that blenderized foods are healthful for tube-fed individuals, but few published studies have shown that consumers fare better or worse with blenderized foods compared with standard EN formulas. In one 2013 report from the International Life Sciences Institute Task Force on Clinical Nutrition, Borghi and colleagues evaluated five blenderized diet recipes obtained from hospitals in Brazil and two commercial powdered EN products. All five blenderized diets exceeded the dietary reference intakes (DRI) for protein; four exceeded the DRI for calcium and zinc; two were mildly inadequate in vitamin C; one had insufficient calcium and iron, and researchers found no significant cost differences. The researchers concluded that blenderized diets have variable macronutrient content, which can hinder effective EN therapy.6 Based on this finding, some practitioners may infer that all blenderized diets are inferior. However, the most important limitation of this study is that recipes vary greatly among different users, and practitioners can't assume this result applies to all blenderized foods or diets that RDs develop or approve.
Despite this study, there's anecdotal evidence showing that blenderized foods are beneficial to EN patients. Several websites and books contain information from health professionals, caregivers, and consumers of tube-fed blenderized foods. Most of the interest is in tube-fed children who have experienced better GI tolerance, health, and well-being, which has been reported in adults as well. For example, Hodor recalls a case in which a patient's father blenderized typical meals, substituting them for some of his son's standard EN formula, and noticed improvement in the condition of his skin, bowel regularity, and alertness. Many home EN consumers who have switched to blenderized foods for tube feeding have expressed similar comments.
In one observational study, 33 pediatric postfundoplication surgery patients who experienced gagging and retching with home tube feeding of a standard EN formula were given puréed foods instead for at least two months. Fifty-two percent of the children had a 76% to 100% decrease in symptoms, and 73% had at least a 50% decrease in symptoms after switching to puréed foods in their gastric tubes.7 In a double-blinded study of 17 stable hospitalized adults with chronic obstructive pulmonary disease, researchers found no significant differences in tolerance, pulmonary function, weight gain, serum proteins, or microbial contamination between bolus feedings of a commercial powdered formula and a blenderized diet for two weeks.8
While many EN patients have had positive experiences with the use of blenderized foods in tube feedings, there are some risks involved, such as inadequate or unbalanced nutritional intake, microbial contamination, and tube clogging. Currently, there are little to no published professional standards for the use of blenderized foods for tube feeding. According to the American Society for Parenteral and Enteral Nutrition Standards for Nutrition Support: Home and Alternate Site Care, published in 2014, "Commercially available EN formulations shall be used whenever possible," and the use of home blenderized formulas "requires additional attention to safe food handling and storage practices."
RDs agree that the most difficult task is to ensure people are making safe and appropriate food choices. "Without knowledge and guidance, caregivers can unintentionally cause harm," says Sue Martin, RD, CNSC, of Sharp Home Infusion Services in San Diego. She recalls a caregiver who added several scoops (24 g/scoop) of protein powder to a blend, not realizing that along with the other foods, the caregiver far exceeded the patient's protein goals. Natalie Tu, RD, CNSC, of Walgreens Infusion Services in Farmington Hills, Michigan, had a similar experience in which a caregiver fed a patient excessive, unmeasured amounts of a protein supplement. Another of Martin's patients had lost weight unexpectedly, and Martin later realized that the patient had been substituting celery juice for one can of her standard EN formula. Martin advised her to use the blended juices in addition to, not instead of, the standard EN formula.
Many caregivers and patients find recipes for blenderized food tube feedings on the Internet, but that doesn't mean they're well balanced. In fact, Martin has seen some unusual recipes on the Web. "Don't give a person more than what they would eat by mouth," she says. "Who would eat a half a head of celery at one time or several pounds of carrots or raw beets?"
Food safety is a concern because unlike standard prepackaged EN products, freshly blenderized foods don't undergo the canning process. For example, when one patient was admitted to a hospital her husband brought in a jar of a blenderized mixture of cucumber, avocado, and other foods, and kept it in her room. He said his wife used the mixture in her feeding tube every day at home and wanted to have it in the hospital, too. The RD advised him to discard it because it hadn't been refrigerated, and recommended he prepare fresh juice and keep it refrigerated to prevent spoilage. Dietitians need to stress the importance of washing produce thoroughly, prompt refrigeration, and routine cleaning of blenders, utensils, and syringes to prevent microbial contamination. If patients who require a feeding pump are using blenderized foods, they should complete their tube feedings in less than two hours to minimize risk of spoilage.9
Tube clogging is a risk, although uncommon, when blenderized foods are used in feeding tubes. But with proper care consumers can avoid it. Modern high-speed blenders can liquefy foods, and users can strain mixtures if necessary. People who exclusively use blenderized diets often recommend high-quality, commercial blenders. Patients and caregivers can avoid clogs by using sufficient amounts of liquid in blends and frequently flushing tubes with water. Foods that increase the risk of tube clogging include blueberries, string beans, and flax seeds. Eggs should be well cooked before blending or hard lumps can form.4 Patients and caregivers have reported success with blenderized foods in people whose feeding tubes range in size from 14 to 20 French (Fr).7,9 In fact, clogging is less likely for many adults who have larger 24 Fr G tubes. Blenderized food tube feedings usually aren't advised for patients who have jejunal tubes because of the smaller lumen, and some mixtures can separate while in the feeding bags, causing inconsistent nutrient delivery or tube occlusion.9
The use of blenderized foods for tube feeding is uncommon, but it's becoming more popular among home EN patients and RDs. However, the use of blenderized foods for tube feeding isn't for everyone, so RDs must discuss it with each patient's physician and medical team before switching nutritional regimens. For example, blenderized foods are medically inappropriate for people with severe maldigestion or malabsorption disorders who require elemental EN formulas. They're also unsuitable for those who lack the skills and motivation to prepare them. Yet, for many people who have the desire, skills, nutrition knowledge or a dietitian's guidance, and the ability to purchase the right foods and equipment, blenderized foods are a healthful alternative for tube feeding.
Some RDs find the concept of developing nutritionally complete blenderized tube diets perplexing compared with the ease of calculating amounts of standard EN formulas, but it isn't that difficult. To achieve balanced nutrition, dietitians can instruct consumers to blend ordinary meals in portions similar to what they'd normally eat orally, using the 2010 Dietary Guidelines for Americans and the MyPlate system. In addition, RDs can show consumers how to categorize foods as carbohydrate, protein, fat, vegetable, fruit, and dairy (or dairy substitutes) and use specified amounts from each category to meet individual calorie and protein needs.4 To determine the nutrient content of more than 8,000 foods, RDs can use the USDA National Nutrient Database for Standard Reference at http://ndb.nal.usda.gov.
As with any type of tube feeding, RDs should monitor patients' progress and ensure they're tolerating the blenderized foods well and are meeting weight goals. For children, adequate growth is important.
As mentioned, there are benefits and risks involved with the use of blenderized tube feeding, and dietitians are the best resource for assisting consumers in choosing appropriate foods for a balanced diet and preventing complications. RDs should instruct patients and caregivers about serving sizes, fluid intake, food preparation tips, water flushes, food handling, and proper storage. Armed with an open mind and resources to improve their knowledge base, today's dietitians can be a great help to home EN patients and caregivers who choose blenderized foods for tube feeding.
— Theresa A. Fessler, MS, RDN, CNSC, is a freelance writer and nutrition support specialist at the University of Virginia Health System.
1. Phytonutrient FAQs. United States Department of Agriculture website. http://ars.usda.gov/Aboutus/docs.htm?docid=4142#what_are. Updated April 8, 2005. Accessed September 4, 2014.
2. Slavin JL. Position of the American Dietetic Association: health implications of dietary fiber. J Am Diet Assoc. 2008;108(10):1716-1731.
3. US Department of Agriculture, US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office; 2010.
4. O'Gorman, EA. Complete Tubefeeding: Everything You Need to Know About Tubefeeding, Tube Nutrition and Blended Diets. CreateSpace Independent Publishing Platform; 2012.
5. Dahl R. Tools for living better on home IV and tube feedings. Oley Foundation website. http://www.oley.org/lifeline/TubetalkSO07.html#Making%20your%20own. Accessed September 4, 2014.
6. Borghi R, Dutra Araujo T, Airoldi Vieira RI, Theodoro de Souza T, Waitzberg DL. ILSI Task Force on enteral nutrition; estimated composition and costs of blenderized diets. Nutr Hosp. 2013;28(6):2033-2038.
7. Pentiuk S, O'Flaherty T, Santoro K, Willging P, Kaul A. Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication. JPEN J Parenter Enteral Nutr. 2011;35(3):375-379.
8. Tanchoco CC, Castro CA, Villadolid MF, et al. Enteral feeding in stable chronic obstructive pulmonary disease patients. Respirology. 2001;6(1):43-50.
9. Dunn Klein M, Evans Morris S. Homemade Blended Formula Handbook. Mealtime Notions LLC; 2007.
• Academy of Nutrition and Dietetics, Dietary Guidelines and MyPlate: www.eatright.org/Public/list.aspx?TaxID=6442451982&page=3
• United States Department of Agriculture—SuperTracker: www.supertracker.usda.gov/
• USDA National Nutrient Database for Standard Reference: http://ndb.nal.usda.gov
•"Real Food for Real People, a blended diet resource": www.foodfortubies.com
• Feeding Tube Awareness Foundation: www.feedingtubeawareness.com
• "You start with a tube. Blenderized diet, tube feeding, and related stuff." Blog by Eric Aadhaar O'Gorman: http://youstartwithatube.blogspot.com/search/label/recipes
(Several of these websites are written by home enteral nutrition consumers and caregivers, not medical nutrition professionals. Consumers are advised to consult with their physicians and dietitians for their specific health needs.)
• Real Food Blends: http://realfoodblends.com
• Liquid Hope: Robin Gentry McGee's Functional Formularies organic whole foods meal replacement: http://functionalformularies.com/#sthash.14m5TqGf.dpbs
• Compleat and Compleat Pediatric: Nestlé Health Science: www.nestle-nutrition.com
(Some companies offer reduced pricing for medical use.)