What is a blended diet?
Blended diet refers to food and drink blended to a consistency that can pass through an enteral feeding tube. It is an umbrella term for a wide variety of practices and is best understood as a continuum. Some people use blended food and drink as the sole source of nutrition, others alongside a commercial enteral formula, in proportions that vary widely: a small amount, an even split, or anywhere between. This is commonly referred to as hybrid use. People move along the continuum in both directions. The balance shifts with circumstances, for example, more home blends in the school holidays or at less busy times, more commercial enteral formula when life is harder to plan around. Some blend meal-by-meal, others batch blend or use ready-to-use shop-bought products such as baby food, and there is now an increasing choice of commercially prepared formulas containing real food ingredients. Appendix 1 sets out the different approaches with the advantages and considerations of each; people may use several in combination.
Who uses it, and where?
Blended diet has been part of children’s home enteral feeding practice in the UK for over a decade, and professional attitudes to blended diet have changed considerably from a position of caution to support. Adult home enteral feeding services are now inheriting the long-standing users established by paediatric teams. There is also growing interest among adults who start tube feeding in later life, particularly in motor neurone disease as well as head and neck and upper gastrointestinal cancer. This Practice Toolkit applies across the lifespan.
Blended diet use is no longer confined to the home environment. There are now working examples of blended diet being started, as well as continued, during a hospital admission. There are also examples of it being provided in education, respite, residential and supported living settings (Part 11). Many tube-fed people are well enough to travel and to work away from home, and they blend while they are away.
Reported benefits
Tube-fed people, their families, carers and professionals consistently describe, in the surveys and the roundtables, occasions where starting a blended diet made a substantial difference to the quality of life of the individual and their family.
Improved gastrointestinal tolerance is the most commonly reported benefit in the scoping review, and often the initial reason why blended diet is adopted and continued. Reductions in reflux, retching, vomiting and abnormal stooling are described consistently in both children and adults, though not everyone improves, and it is not yet possible to predict who will. The mechanisms are increasingly understood: blends are measurably more viscous than traditional commercial enteral formula, and the fibre content of a blend is often higher and more diverse. Other physical benefits are recurring themes: brighter skin, glossier hair, stable growth, better sleep, greater alertness and improved energy, along with perceived resistance to common illnesses. There are social and emotional benefits too. People fed exclusively by tube can otherwise be excluded from social occasions centred on food, and being able to share the same meals as family and friends is described as one of the key benefits. People also describe feeding feeling less medical, and a greater sense of control.
Perceived risks and concerns
The concerns which were most often raised by professionals about blended diet were nutritional inadequacy, tube blockage and microbial contamination. A decade of clinical practice and large prospective cohorts have found no increase in stoma site infection, gut infection, tube blockage, hospital presentation or equipment complications. Reports of serious harm are few, and each has come down to a specific, avoidable failure in food choice, preparation and/or monitoring. Blended diet is sometimes reached for only as a last resort, after several changes of commercial enteral formula have failed to improve gastrointestinal tolerance. It should instead be offered as one of the feed choices when enteral feeding is first planned (Part 2). Blended diet no longer requires a formal risk assessment if the advice here is followed.
Challenges
Blended diet asks more of the person preparing it than commercial enteral formula does. Ingredients and equipment are not funded, and the planning, preparation and storage fall largely on carers. Most people report being self-taught with little professional advice and support. This Toolkit aims to upskill professionals to address that gap. Provision outside the home varies between neighbouring hospitals and between wards of the same hospital. The obstacle is usually a lack of policy, training, staff time or clear accountability. Monitoring can fall between services when it has not been agreed in advance. Each of these challenges is addressed in the parts that follow.