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About our resources section
Our resources section is aimed at those wanting to learn about the blended diet in an easy to use and simple format. If you are wishing to transition to blended diet, it is important that you speak to your dietitian. Then you can work together and make a shared decision and an individualised plan, based on what is in you and your family’s best interests.
There are many approaches to the blended diet, and we cover only the basics with some top tips. We do not aim to determine what is right for you, as everyone will have different circumstances and needs. We do aim to improve people’s understanding and awareness of blending though, and hope you find it useful.
A more detailed and comprehensive resource is the BDA Practice Toolkit. Whilst this is aimed more at UK registered dietitians and other healthcare professionals, rather than tube fed individuals and their families, it is a great resource that provides practical and best practice guidance. We see this document as an important part of helping tube fed individuals receive effective, equitable and quality care.
What is blended diet
Blending everyday real food for people with feeding tubes is most commonly called ‘blended diet’. It has numerous other names like pureed diet, liquidised diet or blenderised diet; the latter two can even come with a Z or an S. What they all define is every day foods that are blended with liquid to a thin, smooth consistency so it can easily pass through a feeding tube.
The idea of blended diet is not a new one. Before commercial feeds were developed, it was the only option for people with feeding tubes. However, it is recognised that blended diet needs more robust research, especially owing to the growing popularity of people either fully, or partially, moving to a real food diet.
Why blended diet?
Real food just makes sense, after all, we have been eating real food for millions of years.
Beyond the obvious reasons for a real food diet, qualitative research shows many physical and social benefits of blended diet. Improvements in common symptoms include:
reflux, vomiting and aspiration
diarrhoea
constipation
tummy pain
comfort during feeds
weight loss or limited growth
In addition to improved symptoms, overall social and emotional benefits have been reported. Being able to share a meal with the family, as well as having flexibility with a range of appearance, smells, tastes, and textures to choose from all helps to empower parents and carers and bring the family together.
Demands of blended diet
As blended diet is becoming better supported and understood, wide ranging benefits have been reported. As well as this, some of the practicalities and outdated perceptions are becoming less of a barrier.
It is true that the blended diet isn’t appropriate for all people. Complex medical needs, nutritional adequacy, food safety & hygiene, and equipment all need careful consideration. A shared decision with your dietician should be made before opting for blended diet and the use of everyday foods.
The blended diet can, at times, be demanding. It can require some basic knowledge of nutrition, time available to prepare meals, a blender (which can be expensive), and planning when travelling or on holiday. Each individual and family are different, and you will need to make sure it can fit into your daily routines. One of our aims is the convenience that Wilbo’s Blends brings will hopefully ease some of these demands.
For many tube fed individuals, having everyday food fully or as some part of their diet is a real possibility. It can be a great option with many benefits, which is why its popularity continues to grow. Careful consideration, patience and knowledge are important steps to making it happen.
Things to consider before getting started
Make a plan - everybody’s transition to the blended diet is different. It’s important to make a plan with the healthcare professionals involved specific to your needs.
Volume tolerance
People that have been eating solid food orally, can often simply switch over to blended diet using foods that were previously tolerated. However, for those who have never eaten solids, volume tolerance can be an issue. It is best starting with small amounts of 5-10ml, before building this up slowly. Over time volume tolerance often increases.
Introducing new foods
If introducing foods for the first time it is best to introduce them one at a time so you can spot any reaction, especially for foods that can trigger allergic reactions, like nuts. You may find some foods are not tolerated as well as others. To help identify these, and to monitor progress, it is a good idea to keep a record of symptoms like bloating to help inform what you blend in the future.
Blending method
The approach to blending itself also varies, some people prefer to batch blend and freeze meals, whilst others prefer blending each meal at a time, or a combination of the two. Whatever approach you use it is important before you start to consider the time and work involved, as well as the equipment needed.
Equipment
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Blended diet is most commonly given through a Gastrostomy, via a Percutaneous Endoscopic Gastrostomy (PEG) or PEG Button. It can also be given through a Nasogastric tube. We would not recommend using the blended diet for a Jejunostomy (J tube) without specialist support.
It is important to consider which feeding tube you have when using blended diet. Narrower tubes may require the food to be thinned with more liquid, which will change the nutrition and volume provided. With a button an extension set is needed. If you have a right angled connection, you may find that this creates more resistance.
Many people worry about their tube becoming blocked with the blended diet. We have not seen any evidence of more blockages with the blended diet. If you are concerned you might want to wait until the stoma is established and the PEG, which requires surgical replacement, is changed to a button, which doesn’t.
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Blended diet is usually given as a bolus using a 60ml syringe. The best syringes for blended diet are of an ‘O-ring’ design and not those with a rubber end on the plunger, which can detach when drawing up blended food.
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There are various blenders available, it is always a hot topic with people on blended diet! Most can be used for blended diet, but the type of blender being used dictates what you can blend effectively, and how much in one go.
Commercial blenders can blend almost anything and have the power to batch blend meals, these are usually expensive.
Mid-range blenders can usually cope with most things including nuts and seeds. You may need to blend smaller volumes or blend for longer than with commercial blenders.
Stick or low power blenders can’t cope with some harder or fibrous food so best to be used with softer-cooked foods.
Although not always necessary to sieve the blends before use it can give an extra piece of mind, especially if using a lower powered blender.
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Particularly when batch blending you need to make sure that you have food safe containers and freezer space to store the food. You will also want labels to date when it was made and name the meals, so you know what you have made!
You will also want to have cool bags and ice blocks to transport the food safely when away from home. This can be a challenge when away for longer periods like holidays or when going to schools, hospitals or respite. This is where Wilbo’s Blends can really help.
Tips for transitioning
1.
We think it's a good idea to work towards eating at usual mealtimes (breakfast, lunch, dinner; or is that dinner, tea…) with some snacks in between. It’s not always possible, some people need continuous or overnight feeds, but it's a good thing to aim for to help make managing meals much easier.
2.
Don’t forget to drink. Free water is really important, and the amount of water needed can be different from formula feeds. Food slows gastric emptying, so we recommend giving water half an hour to an hour before the feed. This should give it time to be absorbed and not impact volume tolerance with the food. As with everybody, passing light coloured urine regularly is a good indication of being well hydrated.
3.
If you are used to pump feeding, bolus feeding can seem a little daunting. When administering in this way, you will get a feel for how much pressure is needed, and the speed at which to push the food through – as this will differ for each person. A good rule of thumb is to give the feed at a similar pace to which anybody else would eat a meal. Of course, some people eat quicker than others and some people can’t tolerate too much at once.
4.
Bolus feeding is convenient and easy for most people and can give a satisfying feeling of being full, unlike with liquid feeds. Sometimes bolus feeding isn’t right or possible so we recommend watering down one of Wilbo’s Blends with water, juice, milk or formula so that it can be used with the pump.
5.
Finally, we recommend keeping a record of the foods being given, weight gain and loss, and any symptom changes. This is especially useful when introducing new foods that may not be tolerated as well. Remember that food is absorbed differently to formula, and you may need more or less calories than was needed with formula.
How to give Wilbo’s Blends or home blended diet
1.
Prepare the meal so that it’s at a comfortable temperature to eat and not too thick (you might find when the food cools it thickens up).
2.
Fill the syringe. Some people prefer to draw up the food into the syringe, or cut the end off an extension set to help do this. Other people prefer to pour in from the top and replace the plunger. Once full remove any excess air by tapping the syringe (trying not to squirt food onto the ceiling as you do this).
3.
Attach to the gastrostomy and ensure if using an extension set that it’s primed.
4.
Apply gentle pressure to the syringe. The speed you give the meal varies from person to person but thinking about how fast you would normally eat orally gives a good idea of speed.
5.
When all the food has been given from the syringe, or the meal is finished, give a water flush.
Food safety & hygiene
Following good food and hand hygiene is important when preparing, cooking, storing and administering a blended diet in order to help prevent bacterial contamination and growth. The result of this could be food poisoning, leading to symptoms such as diarrhoea, vomiting and abdominal pains.
Anyone using a blended diet needs to educate themselves in food hygiene. This section covers basic food safety and hygiene principles to minimise the risks associated with food contamination.
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Hands are one of the easiest ways for bacteria to spread.
Before you start anything (handling food, equipment or touching a surface) make sure to wash your hands with soap and warm water.
Hand washing should be frequent and effective throughout all stages of food preparation, cooking and administering a blend.
Take extra care to wash them when handling raw meat.
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Food ingredients used in blends should be appropriately stored and cooked ahead of blending and used within its ‘use by’ date.
It is recommended that raw meat or fish is stored in a sealed container on the bottom shelf of the fridge.
Raw and cooked food ingredients should be separated during storage and preparation.
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Wash hands before starting.
Wipe surfaces before food preparation and keep the work area clean and tidy as you go.
Ensure equipment used to prepare and administer blends is also clean. If required wash in warm soapy water, rinse and air dry.
Keep raw food separate from cooked foods. This includes using a different chopping board.
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Foods should be prepared as if they were to be eaten orally: for example, a chicken breast should be thoroughly cooked prior to blending.
Make sure you cook food at the right temperature (see guidelines on the packaging).
Cook the food to be used in the blend as if it was to be eaten orally (before blending it with liquid)
Any equipment used in preparation, such as blenders, bowls, utensils and chopping boards need to be thoroughly cleaned. Use warm soapy water or according to manufacturer guidelines.
Ensure all extension sets and syringes are cleaned thoroughly according to manufactures guidelines after use.
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Once cooked, any food, including the final blend, should not be left at room temperature for more than 2 hours before being consumed, put in the fridge or freezer.
Blends can be stored in the refrigerator (below 5°C) for up to 24-48 hours.
Blends can be stored in the freezer (below -18°C) for 1-3 months.
Blends should be stored in an airtight container and situated above any raw foods to avoid cross contamination.
Labelling blends stored in the freezer with a description, ‘made on’ and ‘use by date’ would be helpful when batch blending in advance.
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Ideally the blend should be maintained at temperatures less than 5°C during transport, until ready to be given.
Transportation can be facilitated by the use of a cool box and ice or gel packs that are evenly distributed in the box.
Time spent in transport and storage counts as part of the whole storage period. Therefore, appropriate storage conditions should be maintained throughout.
Settings such as Schools should have suitable refrigeration capacity to store blends at the right temperature and avoid cross contamination.
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Frozen blends should be defrosted thoroughly in the refrigerator (below 5°C).
Defrosted foods should be discarded after 24-48hrs if not used, as with freshly prepared blends.
Blends that contain meat, chicken and previously cooked foods require reheating to 70°C for several minutes (‘piping hot’ or ‘steaming hot’).
Blends are often easier to administer if given warm as the viscosity is reduced.
Blends should not be dehydrated at home.
Reheating blends stored in the fridge:
Blends containing meat, poultry or previously cooked foods:
Remove from the fridge, transfer to a suitable container (if not already in one) and microwave until ‘steaming hot’ or ‘piping hot’ throughout. If using a food thermometer reach a minimum of 70°C for at least two minutes.
Allow to cool before administering, until at a temperature that could be safely eaten orally.
Blends not containing meat, poultry or previously cooked foods or a blend made from foods that could be eaten cold (e.g. sandwiches, yogurts, jarred baby food):
Option 1 – remove blend from the fridge and stand on a work surface to allow it to come to room temperature.
Option 2 – remove blend from fridge and place the container in a jug of hot water for no more than 10 minutes. Shake or stir before administering.
Further information on food safety & hygiene can be found at www.food.gov.uk, or ask your dietitian.
Nutrition
Blended diet is quite the opposite to having the same formulation every meal – it is about variety and using everyday foods that over the course of the day give you enough energy, protein, vitamins, and minerals to stay healthy. The aim is to have a balanced diet, whilst also meeting individualised requirements.
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The Eatwell Guide provides a useful overview of different types of foods and drinks we should all consume – and in what proportions – to have a healthy, balanced diet.
Your dietitian can provide estimated daily requirements as a starting point. This can then be divided between daily blends.
The principles of the Eatwell Guide will apply to many accessing blended diet, but anyone with special dietary requirements or medical needs will want to check with a registered dietitian on how to adapt the Eatwell Guide to meet their individual needs.
Your dietitian is the expert and will provide you with more guidance as to how to tailor blended diet to meet your needs.
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Food can be split into four main groups:
Carbohydrates
Protein
Fruit and vegetables
Dairy (and alternatives)
The Eatwell Guide shows how these foods should ideally be proportioned in your diet.
Achieving this exact balance at each meal is not essential, but it should ideally be achieved each day. Adequate nutritional needs will also be more easily met when including a wide variety of foods from each food group. Remember - most food can be blended.
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The nutritional profile of a blended diet is variable, depending on the food ingredients and cooking methods being used.
The choices made by the person preparing blends therefore wholly dictates the nutritional adequacy of the blend.
Support from dietitians is therefore important, and to make use of their expert knowledge and skills in food and nutrition.
It is good practice to plan meals (especially when starting out), this may include menu choices.
Beyond ensuring nutritional adequacy, planning will also help with shopping and managing your budget.
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Age and any medical condition will influence energy requirements.
Estimated energy requirements are usually calculated as part of any dietetic assessment by your dietitian.
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Hydration is an important and often overlooked aspect of nutritional adequacy.
Look out for signs of dehydration, for example, decreased or dark urine. Giving a bolus of water around 30-60 minutes prior to giving a blend will assist hydration and may improve tolerance of the blend.
Total fluid requirement will be based on age and weight, including individual considerations due to any medical conditions.
Water flushes, given to keep the tube clear before and after feeding and medication administration, will also count toward the daily total of fluid.
Your dietitian will be able to provide advice on the correct daily intake.
Tips for nutritional adequacy
1.
Speak to your dietitian to estimate energy and protein requirements and create a daily guide for reference.
2.
You will want to split total energy over a number of blends per day, including snacks. A daily plan can be split over 3-7 blends (breakfast, lunch, dinner, (supper) and 2 to 3 snacks, depending on the individual’s volume tolerance per feed and at different times of day.
3.
Blended diet does not have a uniform energy density, therefore you will more likely focus on daily energy and protein as the guide. For blend consistency you will typically be aiming for liquidised level 3 (see below IDDSI Framework).
4.
Hydration is important. Ensure fluid requirements are adequate as part of nutritional intake and that this is monitored.
5.
It is good to speak to your dietitians on healthy eating and age-appropriate portion sizes using government recommendations for the general public.
6.
Use a wide variety of foods from each of the four main food groups (see the Eatwell Guide).
Texture and thickness of blends
We recommend using the international IDDSI Framework to check the texture and thickness of your blends. The IDDSI Framework was developed to standardise consistent terminology for different food textures and drink thickness.
This will therefore help you understand what level you are blending to and give you a common terminology to use to describe your desired texture and thickness. The following link explains a relatively simple method for working out the different levels.
When blending at home, blends will typically range between levels 2-3. Whilst there is no definitive rule on what the right level is to use, from our own experience, level 4 may be too difficult to push through the giving set, where as anything below level 2 may be difficult to keep calorie density at an adequate level.
The thickness and texture of the blend will be influenced by the type of ingredients, amount of liquid, temperature, time blended, as well as your own aims for volume tolerance, calorie density and how much pressure you are comfortable applying to the giving set.
Wilbo’s has been developed to be level 3 as this is likely to be meet the broadest range of people’s needs.