Educational Webinar: Blending Evidence into Practice: Utilizing Real Food Enteral Nutrition

Conference Title: Blending Evidence Into Practice: Real Food Enteral Nutrition Date: Wednesday, 21st January 2026 Speaker: Hello, and thank you for joining us today. I am excited to welcome you to today's Clinical Connections presentation, Blending Evidence into Practice: Utilizing Real Food Enteral Nutrition for Patient-Centered Care, presented by Nestlé Health Science. Before we get started, I'd like to direct your attention to our disclaimer. While you're reviewing that information, I will remind you that this presentation is being recorded. Within a day or two, you can expect to receive a link to rewatch the presentation. And if you have a question, feel free to enter it into the Q&A panel to the left of your webinar window at any time and we will do our best to answer at the end of the presentation. You will also find to the left of your webinar window, a link to download the handout for today's presentation. And that also contains information for obtaining your CEU, which is provided to you by Nestlé. Let me give you just a couple more seconds to read over the sponsor disclosure for today. And as I mentioned, today's presentation is Blending Evidence Into Practice: Utilizing Real Food Enteral Nutrition for Patient-Centered Care. I'm pleased to welcome our speaker today, Erin O'Hora. She is a Manager Medical Scientific Liaison within Medical Affairs at Nestlé Health Science. She earned a Bachelor of Science degree in Nutrition and Dietetics and a Master of Science degree in Sports Nutrition and Exercise Science from Marywood University, and a Doctorate in Health Science from Nova Southeastern University. Erin also earned her Certified Lactation Counselor accreditation from the Academy of Lactation Policy and Practice. Before joining Nestlé, Erin worked as an Assistant Professor at Marywood University in Nutrition and Dietetics Department and continues to work as an adjunct faculty member. She joined Nestlé in 2016 as a medical delegate for Gerber, and held a position as a pediatric clinical liaison before transitioning into her current role. She has worked in various areas throughout her career as a dietitian, including long-term care, academic research, and corporate positions. Erin is a previous recipient of the Outstanding Dietetics Educator Award for Graduate Education by the Pennsylvania Academy of Nutrition and Dietetics, for strong delivery of health care education. Erin, thank you so much for joining us today. Erin O'Hora: Thank you. Thank you so much. And I'm so happy to be here with you all this afternoon. I wanted to go ahead and get started by just looking at our objectives for this afternoon. So first, as I start walking through this program, I'm going to identify opportunities for real food enteral nutrition to positively impact overall health. And then I'll explain how fruit and vegetable ingredients promote health of the gut microbiome. And then as we enter the third section of our program today, I'll talk about the latest blenderized tube feeding practice recommendations from the American Society for Parenteral and Enteral Nutrition. And lastly, I'll describe the growing body of evidence supporting clinical and health economic benefits of real food containing enteral nutrition. But first, I did want to ask a poll question. And so, if you can launch the poll. And this particular poll asks how often are you recommending or prescribing blenderized tube feeding, commercial, home prepared, or even both? And you can see there's some emojis there. I think as you can go through it in your lunch, you can just enter which one you choose. But it would be daily, weekly, monthly, or never. So, if you could just take a moment to do that, that would be great. All right. And can we see some of the results? All right. Great. So, the majority of you have answered never. So that's, again, this is going to be a great opportunity. And it's changing as I speak, but the majority, a little over 50% of you had answered never. But we have a good portion then as well, a third, answered month. And then we have about 10% stating weekly. So hopefully certainly I can bring you some great information and perhaps some education and some evidence to support this area as well, in case you're going to move forward in prescribing or recommending or you see it even more often. All right. Awesome. Thank you so much for sharing that. All right. So, I want to begin with looking at this particular article. And I think this really is helpful and really aligns with what the answers that you just shared in the survey just a moment ago. And this was an online survey seeking the knowledge in clinical practice of ASPEN RDN members regarding blenderized tube feeding. And it was published in 2024 by Brown and colleagues. And when we look at the results, 157 RDs completed the online survey. And they showed their willingness to recommend blenderized tube feedings and defined as whole foods, blend it for administration through a feeding tube. And 98.7% support the use and 73% were to recommend BTFs to patients. And 60%, very similar to our audience today, was not using BTF in clinical practice. So, when we think about some of the top reasons that they found within this survey, note, it's supporting the use of BTF included that patient or caregiver's request desire to use real foods, family meals, and tube feeding intolerance issues. However, some of the common barriers include lack of available resources, reimbursement coverage, unknown nutrient composition, time constraints, and caregiver patient inability to safely implement or follow BTF regimens. And RDNs were two times more confident using commercial versus home prepared BTFs. RDNs With BTF training, education, and those who use multiple BTF education training resources were more likely to recommend blenderized tube feeding. So, when we look at that bottom there, that is really ultimately the key takeaway. And so when we think back of the survey that we just spoke about, hopefully, again, having some education shared, and it could be industry, it could be from a product itself, or colleagues, but it is helpful to certainly have that education and feeling more comfortable and confident to using some of these products that are on the market. All right. So, before we go forward, I do want to just take a quick look back and think of the historical perspective of real food based enteral nutrition. Because it goes back probably a lot farther than we ever imagined. So, it dates all the way back to ancient Egyptians who attempted rectal administration of wine, milk, and grain, broths. Skipping forward from that time period, really looking at the evolution of real food enteral nutrition over the past couple centuries, in 1881, President James Garfield was reported to be on a rectal tube feeding for 79 days after his assassination attempt. Prior to the introduction of standard commercial enteral formulas, providing nutrition enterally relied on the use of real food formulas. So, looking right at the graph in the middle there, in the 1950s, 1960s, a lot of products, so standard enteral formulas, were coming to market. Really what we have today, when we think about a standard enteral formula. And the use of blenderized foods ultimately fell out of practice. Kind of we're – from a convenience standpoint, those commercial products were being utilized. Then in 1971, so 55 years ago, the initial innovation of a commercial food-based tube feeding arrives to the market here in the US, and it still is in the market today. And this is a formula containing real food ingredients. 35 years later, so kind of in the mid-2000s, we really saw a ramp up of innovation with several new companies, products coming to market. And really over the last 25, 30 years, we've seen that grow to well over 60 products that fall into this category today. So, they're not all created equal, but they fall within that blenderized commercial type of product, and I'll talk about those in a few slides from now. So, what are some of the benefits of real food enteral formulas? And you think about patients maybe requesting them. Or where are the literature and the research over the last 20 years has been focused on? So, when we look around and kind of going clockwise, for this, when we think about prepared homemade blenderized, really you get a lot of benefits as far as the diversity of nutrients from real food ingredients. And then improvements of quality of life. So, we've seen that in the literature, but also having meals maybe similar to what your family is, and just overall feeling improvement and better in day to day is something that has been seen. And then clinical settings as well, when we think about the intolerances to some standard formulas and perhaps the benefit that they are seeing, the patients see, with real food formulas. Lots of research and evidence. We'll go through a little bit of that later on. And continuity of care. So again, being able to have some of these products from a home setting to a hospital setting to perhaps another type of setting where they may be, but to have that standardization there is helpful. And also the research has found a benefit in the health economics. So when we see patients who are able to transition to a real food based formula, as opposed to perhaps maybe they were on a standard based prior to that, they have found – research has found that there's less office visits, less ER visits, less visits ultimately to health care resource areas. And so what that means in translates into also a cost benefit, because we know those visits can be costly. And then you see normalization of feeding. And right there in the very middle is a psychosocial. So very important for the overall well-being of an individual. And what research has shown as well, for those that are eating similar perhaps what they were before, that they needed tube feeding or even maybe what their family is eating. All right. So I want to take a moment and differentiate between – and there's lots of acronyms here. So if you do see the acronyms there, I'm going to first I'll say it out. But you might see these a lot as we kind of walk through. So this is the PBTF, so this is prepared blenderized tube feeding. And so when we think about this, we think about those can be whole foods added to a base, and/or fully blenderized whole foods. And so when we think about the benefits, looking over on the right-hand side, you can see the provision of same foods as family, recipe, ingredient variability, modifications to meet individual needs. And then some of the challenges can be it's labor intensive, perhaps. Risk for mis-preparation and/or mis-storage. necessary to close HCP oversight. So you do have to have that HCP RD an oversight to ensure proper nutrient provision. Viscosity and consistency, that can be perhaps a challenge in some cases to ensure that it can flow easily through a tube. Shorter shelf life and hang time. And then reimbursement perhaps can be a challenge, as far as getting reimbursement for whole foods or foods that you're ultimately making at home there. All right. So now let's take a look at commercial blenderized tube feeding. So the acronym there is CBTF. And so those, again, there's a huge variety of these out on the market. Some contain real food ingredients and others are fully blenderized whole food. And some of the benefits here, when we're looking over on the right-hand side, so they're prepared, are pre-packaged and shelf stable. The benefits include defined and consistent macro and micro nutrient composition. Often available for soil source nutrition. Convenient as a base for busy or sick days, so certainly no shame or harm to carry something on the go. Lower risk for inadequate nutrition provision, contamination, and tube clogging. And it may be available in hospital acute care facilities. Ease of use as far as the viscosity and consistency. Longer short life – longer shelf life and hang time. And potential for reimbursement. And I also have that as a challenge, because I know perhaps you may see or your patients may express that they have a challenge with getting reimbursement. So it certainly can be reimbursed, depending on the state in which you live, the product, perhaps just some extra documentation. But that's why I have it on there as a benefit and a challenge, recognizing it could fall into either there. So looking at some of the common indications for real food based formulas, include intolerance to standard enteral nutrition, GI symptoms, need for thicker formulas, underlying clinical conditions, food allergy, or patient preference. All right. So let's look at this slide. And really, the top question kind of says it all there. And when we think about did you know that many of the plant based tube feeding formulas are not real food based. So many of them are not. It's important that we look at ingredients, dig a little bit deeper into what the labels perhaps say is in there. And so I want to walk through this. And you can see an orange, so kind of in the middle lane there, the standard plant based formulas. And all the way to the right lane, the real food based formulas in green. And I'll walk across each of the – in the columns in blue and mention each one of those. So provide complete nutrition from. And so the source is in a plant based or isolated ingredients that have been extracted from plant sources. And real food based formulas are familiar and recognized. Real fruit and vegetable ingredients have nutrient diversity from plants but one to two plant based resources. However, the real food plant based formulas have four or more fruits or vegetables plus one to three protein sources. And they both are suitable for plant based or vegan type diet. The fiber sources from a standard plant based formula comes from an isolated fiber sources. And then real foods are going to be those natural, soluble, and insoluble fibers derived from real food ingredients. And then consistency is, generally when we think about plant based, is thinner. So also appropriate for oral use. And then real food formulas are plant based formulas, may have a little thicker consistency orally, as is for lower reflux, gag risk, potential swallowing difficulties, or may be thinned with water. And taste. So perhaps some of you have tasted some, perhaps you have not. When we're thinking about some of the standard plant based formulas, taste more like a shake, nutrition shake, in flavors of vanilla, chocolate, strawberry. And then when we think about a real food plant based formula, taste like a blenderized meal with natural flavors from real food ingredients. And then when we think about differentiating the benefits from a standard plant based formula, basic simplified nutrition, and then over, on the green side there, the right hand side, real food ingredients for digestive tolerance and consistency that may help decrease reflux and vomiting. So really just wanted to take a moment to differentiate between those two, because oftentimes that becomes a question or just really even an ask of what type of product or kind of how their their bucket into the same, but they're really different. So I encourage you certainly to look at the label, the container, whatever it may be to see the ingredients that are in there. So, something else I do want to share as we look at this. So, there are a growing number of CBTF, those commercial blenderized tube-feeding products on the market, specifically peptide based formulas. So choosing a formula option when enteral feeding intolerance, so that EFI, is suspect it may pose challenges. Real food peptide formulas that fall into the category, in the orange circle on the left-hand side, can help meet patients’ needs. Including plant based vegan type diets or milk, soy, corn allergy, preference for real food. However, there's certainly cases, and there's a lot of evidence to support the benefits to use 100% whey peptide based formula. That could be helpful. So that would be really more disease specific, a higher risk of severity. And where that evidence shows is in short bowel syndrome, protein or fat malabsorption, GI motility issues, CP, CF. The list is there but really wanted to share. And the key takeaway there is there is, again, certainly understand a crossover between those two. And it would certainly be up to your clinical judgment in which product would be best for your patient. But again, just trying to differentiate generally where we would see not only the evidence, but certainly where the use is between those two different types of formulas. All right. So that leads me to my second poll. And so if you don't mind going ahead and launching this poll. And this question asks if you are prescribing real food based enteral nutrition. So at least half of you are. What is the most common reason? Is it patient or parent caregiver satisfaction or request that you get, improved tolerance, GI symptoms, manage food allergies, or improve the microbiome? And I see a couple answers coming in. Always, this is anticipated, certainly. Sometimes I get a variety, and usually that's what I'm seeing here again today. But the overall – the overarching winner, I guess, if you will, from the survey, is that parent caregiver satisfaction. And I certainly recognize that patients or parents, and could be patients and/or parents, if it's a kiddo. I'm asking for these type of products. But also see a little mixture coming in too for GI symptoms and some food allergies. So good mix. But the overarching 62% shared that – the patient caregiver. And certainly recognize that. And that's kind of when we think back of where the significant growth within this category originated from. But so did the evidence. So it's great to see that evidence is supporting up that trend as well. All right. So I'm going to move on to the another section, the second section of our program today, which is looking at the gut microbiome. And so oftentimes you know when speaking of this category, I would get a lot of questions, going back years of doing this type of education program, about how does this impact the gut, does this impact the gut? And really, because when we think about some of those benefits, talking about real food ingredients and incorporating those in our personal day to day diet, we know as health care professionals that there is a benefit to our gut microbiome. I have on here just two definitions to kind of differentiate between the microbiome and the microbiota. And so when we think about the microbiome, by definition, it refers to the community of microorganisms, such as bacteria, fungi, and viruses, that inhabit a particular environment, in the context of human health. The gut microbiome is particularly important as it plays a crucial role in digestion, immune function, and overall well-being. However, the microbiota describes a particular microorganism population found in a defined environment, such as the oral and gut microbiome. All right. So many of our of – many aspects of our overall health are linked to our gut microbiome. And so you may have heard somewhere along the way, a good 70% of our overall immune system lies within our GI tract. And so it's very important that we feed with – feed that with good nutrition. And then when we think about our GI tract and our gut essentially, focusing on our gut, more than 100 trillion microorganisms that live in the gut make up the gut microbiome. And so the benefits, the health benefits, that this provides us is with digestion. So gut friendly microbes help to digest our food, absorb vital nutrients from food, and promote regularity. And then immunity. So the gut microbiome supports us by strengthening our gut barrier. So sort of preventing those bad bacteria from getting in and kind of really keeping those junctures tightened so we don't have a weak gut. Keeping our immune system and balancing – managing inflammation. And then lastly, over there on the right, over our health. So our gut microbiome helps to make vitamins and other important micronutrients that support a healthy metabolism and promote overall well-being. And when we think of this section and think about the microbiome, it's imperative that we certainly talk about fruits and vegetables, and the fiber specifically from fruit and vegetables. So fruits and vegetables are high in fiber and phytonutrients. So really focusing on that fiber first. By definition, we know that fiber is a non-digestible carbohydrate or lignin. It is naturally occurring in plant-based foods, such as whole grains, fruits, vegetables, nuts, and pulses. The most abundant compounds identified as fiber are found in the plant cell walls. There's two different types, as we all know, soluble and insoluble. Both with health benefits, including bowel function, lipid – blood lipid, and glucose lowering effects. But it also can support the harmonization of the gut microbiome. So by increasing microbial variation, this really is important to aid in nutrient absorption and improved stool consistency. So very important. So though fiber may be supplemented when fiber sources come from foods, so such as these – thinking back to some of these real food ingredients that contain real food components rather than supplements, the health benefits may be greater. Additionally, there is a new focus on beneficial bioactive compounds, many of which are found in insoluble fiber. So again, another benefit from fruits and vegetables. And then looking at phytonutrients, specifically from fruit and vegetables. So fruits and veggies also contain these compounds known as phytonutrients, phytochemicals. And you can see here, just walking through in the left-hand side, the Greek word for plant is that Phyto. Importantly, they offer several benefits – beneficial effects. For example, they can act as antioxidants. And so we know the benefits of antioxidants, and they have many antimicrobial, antidiarrheal, antispasmodic, and antiallergenic effects. And so this benefit for overall health, as well as many of the chronic diseases that are associated with some of these challenges there. So there's hundreds if not thousands of phytonutrients, many of which have not been fully isolated yet. So more to come, continual in that area of nutrition, but certainly great. And would not want to mention it within this category. So when we think about nourishing our gut, our gut microbiome prefers fruits and vegetables, because of the fibers and phytonutrients. And ultimately provide essential nourishment. The more diverse our fruit and vegetable intake, the more diverse our gut microbiome, and then the better it can support overall health. All right. And so I wanted to share just a couple studies that look at the microbiome. And so this particular one looks – and this is done by Gallagher and colleagues. And it was published in 2018 in JPEN. So perhaps for those of you who have – you used this type of formulas – these type of formulas, you may have seen this or read this or heard it at a conference. But this is a great study just really looking at – and it's one of the first. But the background and the methods, there were 20 pediatric outpatients. So they were aged one to 16 that were included in this study. They were followed for six months. And at least 75% of total energy from commercial formula via G tube use at least a 12 French[?]. RD visits during this study time period were at six weeks at enrolment, six weeks, three months, and six months after the blenderized tube feeding initiation. Stool mucosal swabs were done and gastric secretion samples were collected at a clinic. Visits for the microbiota analysis. And so you can see, it's probably very small, so I don't know how if you can see all the words on there and the numbers. But with that said- the table on the right hand side, so table one that is in the article, outlines the macronutrient distribution from the enrolment time versus six months. And there were statistical significant differences noted in energy intake, protein and carbohydrate, from the time of enrolment and the conclusion of the study. Which, again, was six months. Looking at the results here, what they found was that, the researchers found a 50% higher caloric intake with BTF used to maintain BMI. And the possible explanations of this include perhaps the thermic effect of feeding, as well as food digestion and absorption from real food. As opposed to more of an ingredient type product. This can be secondary to diet related alterations in the intestinal microbial composition. The BTF micronutrient content was superior to commercial formula. Tolerance improved with BTF. Decreased vomiting, acid reducing agents, no change in stool consistency, and stool softener use increased. Bacterial diversity and richness in stool samples significantly increased as well. And caregivers were more satisfied with the BTFs and would recommend BTFs, so those blenderized tube feedings. So what the researchers concluded that initiation and maintenance of BTF is feasible in a medically complex pediatric population and can be associated with improved clinical outcomes and decreased intake or bacterial diversity. The graph in the upper right-hand corner there, and again, perhaps it could be really small to see, really just looks at the micronutrients enrolment versus six months. So it looked at the DRIs for vitamin D, calcium, fiber, iron, sodium, and vitamin B12 and vitamin C. The blue bar is at enrolment and the green bar is at six months. And you can see that statistically significant difference was noted for a few of the nutrients, specifically noted for vitamin D, fiber, and sodium. And then down at the bottom, those forest plots there, looked at the diversity. So that really was where it was looking at the alpha diversity of the microbiota in the stool and the oral samples in the pediatric G-tube fed patients. So again, you can see improvements within those for the patients that were fed once they were on that BTF. All right. So another study within this category and this was done by O'Connor and colleagues. And it was published in 2023 in nutrition. And it's entitled, A Prospective Pilot Study to Monitor the impact of High Fiber Enteral Formula with Food Derived Ingredients on Fecal Short Fatty Acid Concentrations in Children Admitted to Intensive Care with Sepsis. So what they found, because this was the first study on the concentration of fecal short fatty acids in the critically ill children, and the findings found that the study formula was well tolerated. So that's great. Improving stool frequency and consistency within one week of switching formula. So certainly a benefit to these – the kiddos here. And the subjects who were switched to the study formula maintain fecal short fatty acid concentrations during their admission to the PICU. So again, important. And now let's take a peek at the results here. And so you can see, up in the upper left hand corner there, 20 children completed the study. And they switched to that high fiber containing food ingredients. And all children were prescribed at least one antibiotic and about a quarter of them actually were on two. Stool consistency significantly improved from 6.6 at baseline to 3.6. And that's in the table in the upper right-hand corner there that you can see. Fecal propionate and butyrate concentrations were maintained during the child's ICU stay. And table four there, again, also notes that. And then when we look at table six, so the table down at the bottom shows the comparative analysis of longitudinal fecal short fatty acids concentrations. So appropriate butyrate levels were maintained during the two weeks with the kiddos in the ICU. However, the researchers did note a reduction in acetate concentration. The total short chain fatty acid concentrations were lowered, although not clinically significant. So what they concluded, O'Connor and colleagues, concluded that children admitted to the intensive care with sepsis may benefit from a high fiber enteral formula with food derived ingredients. And they may also mitigate the GI symptoms that they were having associated with the antibiotic dysbiosis by preserving intestinal short chain fatty acid concentrations. So another positive study for kiddos that are utilizing real food ingredient formulas. All right. So we're going to transition into our next section of our program today, looking at patient centered care. And so this perhaps is not something that you may or may not – that you may never have seen before. I'm assuming that you did. I know it's a lot of times that focus to have patient centered care for some time now. And I think now more than ever, it's really important to do so. But you can see, as we look around this circle here, both the kiddo and an adult patient is in the middle. But ultimately having those shared decision making with the patient or caregiver. So if you're working with a patient who maybe has to transition on to a tube feeding, asking some of those questions. What did they eat before? Would they prefer a real food or real food tube feeding? Just to better understand perhaps some of the history there. Also including that PCP. So any kind of outpatient type setting. Any, again, home health providers as well and partners that may be involved in their care, including RDNs, is really key. Especially if we're thinking about some that may be on some more of a home blend type formula. If they're making something on their own, it's really important to get all of the players that each of the – as far as the providers involved and on part of their plan there. And then as we walk in the orange – the circle there, the orange establishes a system for monitoring, because that's always key. When we talk about the recommendation, the practice recommendations in the next handful plus slides, that is the last section and really always the – one of the most important. So we have to have that monitoring and the follow ups taking place. And then as we move forward, I'm going to begin walking through the ASPEN practice recommendations. And I have a another poll. It's at the end of this section though. But ultimately, I'm going to walk through these. It's broken down into four sections. They came out in December of 2023, and so at the very tail end of that year. So depending on, again, a lot of you perhaps are not daily routinely working with this type of formula. So you may not be familiar. But some of you may certainly be if you're using them. I think we had a couple that did note daily, so you may be. All right. So I'm showing you a little snip of the paper here. You can see there was quite a bit of authorship there. And so it was really a great opportunity to have a lot of experts within the field of nutrition. And there's some nurses in there too overseeing this and pharmacists as well. The overall purpose of this paper was to provide guidance to clinicians wishing the use of BTF across patient populations in practice. So ultimately, it was for to provide guidance if you're wishing to do so, not to use blenderized tube feeding. And so this was a long time coming. The document is roughly 30 pages. So it's long, it provides a great amount of guidance helping making those everyday decisions, those clinical decisions to help improve patient outcomes. It provides expert practice recommendations. So not at that guideline level, it's their recommendations. The research literature was from January of 2016 to May of 2021. The recommendations are based on literature and expert review. Question and answer format. Takes a vantage point of how to implement, not if to implement. And you can see those four sections, and we'll walk through each one of those in the next so many slides there. All right. Section one is general use practice recommendations. And broken down into those three areas there. So patient factors. So from a clinical, psychosocial, nutrition needs, and dietary preferences, and then ultimately tolerance. And then resource availability, so access to HCPs, equipment. Especially if they're going to use or make prepared blends, it's very important that they have the opportunity to be able to do that efficiently. Ability to shop for ingredients. So store, go to store, purchase the food. And then cost. So really we know that cost for food have been on the rise. So what can they afford? And then administration considerations. So what is the enteral access device type, where's the location the method of administration, and then the care setting as well? The enteral access device considerations that were noted within this paper, G-tubes are preferred. So there's mention of nasal tubes, J-tubes, G-J tubes. They may be considered on a case by case basis, as mentioned. But again, there's not really – the stronger preference is for G-tubes, just based on the experience and the recommendations there. Looking at if it is unfit compatible, it may affect the feeding times and mode. A 14 French or larger tube is suggested. However, each individual product may be able to use a different size French. Or when we think about what is the most common, generally we do see, and that's why they use that number 14, but smaller tubes may be possible. And again, just really ultimately looking at that manufacturer's recommendations. Fully blended enteral nutrition typically is more viscous than real food ingredient containing formulas. And then that last- in the lower right hand corner administration, flow rate, clogging considerations, so pump assisted and gravity may not be appropriate for all CBTFs. And so here's a look, they mentioned they walk through the hang times and storage. -And I just really wanted to point out, on the left-hand side there, that CBTF is up to 48 hours compared to two hours for PBTF. And this might be primarily for considerations for someone who is on or who would choose maybe BTF. So you can see that short hang time for prepared. And that's just like food perhaps that we're preparing in our own kitchen, that we don't let it out for longer than that time period. So when we think about these guidelines, they follow the USDA guidelines. Especially when we're looking at that clipboard over on the right-hand side there from a PDF standpoint, from a refrigerator three to four days, unopened per manufactured recommendations. If it's open, 24 hours in refrigerator or per the manufacturer recommendation. Whichever is earlier. All right. And then the section two looks at recipe, additives, and consistency. And so when we're thinking about the recipes here, creating BTF recipes, there are some resources that are listed here. And you can see some governmental websites, RDA, DRI. There's a recipe builder that I'll show you on the next slide. And ASPEN and Oley are really, really great organizations that help provide guidance for patients that are using or wish to use blenderized tube feedings. Many foods considered to be appropriate, depending on the, again, nutrient analysis account for patients nutrition needs and preferences. And foods may be kept the same or vary depending on patient caregiver preferences. And this slide looks at the Blenderized tube feeding recipe, which I just mentioned on the previous slide. And maybe some of you are familiar with this, and perhaps you are not, but I do want to share this slide with you. And so this application is blenderized recipes from scratch for both children and adults. And provides nutritionally complete home blenderized recipes, based on specific needs and preferences. Generates and saves recipes as well, meal plans, and more. And this was developed in collaboration with Children's Hospital of Philadelphia. Now let's look at additives. So recipe analysis should be performed at initiation and routinely. So these would begin patients that are making things from scratch at home. And so comparison of recipe to patient's nutritional needs should be done, continue adjustments and recipes to meet needs. And some of the additives that may be necessary, depending on the provision and recipe and individual needs, would be vitamins and minerals, sodium, modulars, and fluids. And then consistency. So this section concludes with consistency the IDDS scale, which recommends to evaluate consistency thickness of BTF. We know this was originally developed for dysphagia diet, provides standard terminology to describe texture. And it's a useful tool for the BTF category as well to help with the enteral access devices, the flow, as well as clinical outcomes. And provides common language for families. The administration methods, the recommendations regarding optimal consistency for delivery via syringe, gravity, or pump cannot be made given the individuality and nature of the BTFs as well as patient-specific factors. So there's a lot of considerations, especially if you have patients making it, the consistency can vary significantly from one to another. All right. So this, again, continues on this slide, looking at this section, consistency and the individualized approach. And you can see on this scale, on the left-hand side we have GI tolerance symptoms. And over in blue, we have the delivery method. So I'm really trying to keep the specific patient in mind, and having a balanced scale is really important. And so thicker formulas may provide benefits for those that have GR[?], aspiration, retching, or gagging. However, thicker formulas limit the method of delivery, so bolus may be their preferred – may be preferred as pump administration is more difficult. So really kind of keeping that balance in check is important. And then section three talks about BTF in hospital use. So who? Stable patients. A previous demonstration of tolerance for BTF. Available in the hospital setting. And then hemodynamically stable ICU patients, there is limited data. So I did mention even in that kiddo, the O'Connor study had some kiddos that were in the PICU, but there is limited data within this space. And then immune compromised patients, proper food. Safety and hang time is critical. And how the delivery method, based on resources, so kitchen staff, bolus is preferred. Pumping, feeding pump may be useful if hang time recommendations can be adhered to. And just wrapping up here with the guidelines is the monitoring. So really important to advise. From an RR standpoint, every one to two months initially. Four to six months when stable. Individualized laboratory parameters determination is based on nutrition assessment, signs and symptoms of nutrition abnormalities, or deficiency and growth. All right. So I wanted to wrap up this particular section with the survey at the end of it. And so this simply is just asking how familiar were you with those ASPEN BTF recommendations prior to me chatting about them in the last ten minutes or so? So very, you read them somewhat, know they existed but haven't read them, or not at all. I see some pretty common answers that I get. I see some, not at all. And that's okay. That's okay. I'm glad perhaps to provide something new to you all this afternoon. Know they exist it and have it read them. It's a very long document. So it is in the low 30s. And somewhat. All right. Great. Thank you. All right. So this last section leads me into the evidence. So I'll take the next five or eight minutes or so to go over the evidence that we have within this category here. That is published, I should say. And with that, this is a basic look at a publication, a PubMed search, using the term blenderized tube feeding. And so I haven't done that this year, so meaning this month. So I'm going ahead and going to do so in the near future now that I'm reading this slide. So but back in 2025, you can see that the different amount of studies and really the increase in bars. Especially in 2022, 2023, 2024, the significant amount of research that we saw. And then when you look over the 20 years, 2004 to 2014, to the same ten years, 2015 to 2025, there's a significant increase within this category of research evidence that's published within the blenderized tube feeding space. And so, again, with the usage, so did come the evidence, which is great. And so when we think about the vast amount of research in this category, you may wonder where to start. And so I like to share these two recent systematic reviews as good examples. And so the first systematic review, Miguel and colleague, evaluated papers. And so this on the left-hand side. Evaluated papers and included pediatric patients who were either partially or solely dependent on enteral nutrition with PBTF or CBTF. And evaluated feeding intolerance in either a retrospective or prospective manner. They included studies between 2012 and 2022, and ultimately included nine studies. And overall found that BTF, so blenderized tube feeding, was associated with improvements in both lower and upper GI symptoms. And this similar study in the adult population was done, and that's on the right-hand side. And again, the review, the evaluation also had nine studies. And they also found that BTF was associated with weight gain and anthropometric measures, maintain improvements in GI side effects, and improvements in quality of life within these papers as well. So next I want to share this retrospective cohort study done by Fabian and colleagues. And this compares the incidence of diarrhea in critically ill cardiac surgery patients receiving either a blenderized natural food diet or commercial enteral feeding formulas. And the results indicated that the patients on a blenderized natural enteral feeding diet experience is significantly lower probability of diarrhea compared to those on commercial formulas. While the preparation and administration of natural diets may be more time consuming, the reduction in diarrhea episodes had a positive impact on patient well-being and nursing workload as well. So these findings support the consideration of incorporating blenderized natural diets into enteral feeding protocols for critically ill patients, which may lead to better gastrointestinal intolerance and overall patient care in the ICU. And another – so this was presented at ASPEN 2023. I think this was in Vegas, if I'm not mistaken. And with that, the objective of this study was to describe clinical and health economic outcomes among adult patients diagnosed with specific conditions receiving a commercial blenderized tube feeding formula, or plant based standard. Was a retrospective observational study using claims data from the DRG Real World Evidence Group. And ultimately you can see here, looking at the symptoms, any intolerance symptoms at all, there was a significant decrease. So a 41% less in any GI tolerance symptoms after that switch. So really important when we think about the quality of life there. So now looking at healthcare resource utilization outcomes. And this, again, was at 84 days post hospital discharge. And there was up to 70% less mean total number of visits for the CBTF group, including 73% less visits to the outpatient and 67 less visits to the inpatient setting. Another study here looked at the – well, looking at another view of this study is looking at improved cost outcomes. So at that same 84-day mark post-hospital discharge, the adjusted cost of total healthcare visits, outpatient visits, and inpatient visits were significantly less for the CBTF group. Significantly higher adjusted costs were associated with patients receiving a plant based standard tube feeding formula across all these visit types. So in conclusion, when reviewing these three sets of data, so really ultimately looking at the GI tolerance and the visits and then the cost, it was observed that the use of an adult whole food, CBTF containing formula was well tolerated and associated with significant reductions in GI intolerance symptoms. So again, huge benefit to your patients. And I'm thrilled to share this study with you. And so this was a very, very recent fully published article in the Nutrition and Dietary Supplements Journal. It's a retrospective, observational study of 91 children and 82 adults in the post-acute care setting. Unique plant based peptide formulas with real fruit and vegetable ingredients. The outcomes were observed with reduced GI intolerance symptoms, reduce healthcare resource utilization, and cost savings. When comparing the six-month post hospital discharge compared to the six-month prior to hospital discharge. So when we think about – I want to take a closer look here, because this – to this specific study here. Looking at the data that I had described and even described a little bit earlier on, this is on peptide based. And the benefits and what they found within this study was, again, an observational study, included 82 patients there in the adult. And then they had different disease states such as cancer, chronic pulmonary disease. And what they found – and they were on a peptide based formula with fruit and vegetable ingredients for at least five days, and found to be well tolerated with significant reductions in GI intolerance symptoms. And that's ultimately what we're seeing here up to six months. So again, a huge benefit to these patients here. So these improvements support plant and peptide based formula with fruit and vegetable ingredients as a well-tolerated formula in adults and in the pediatric population. So because this was inclusive of both adult and pediatrics, which you can see here on this slide as well. All right. So I think we're pretty good on time. And I think we're – I'm nearing the end and the conclusion. I hope I didn't have any challenges with my internet capabilities. But with that said, I will give you a summary of what we spoke about in the last 50-plus minutes or so. But real food based enteral nutrition provides good overall health benefits of BTF. They continue to be identified. New research is certainly coming routinely. And in the area of real food EN, promoting health and the gut microbiome is expected. And applying those ASPEN practice recommendations, which, again, a good half of you were familiar with them. And I understand if you didn't have time to read each one of those pages, but hopefully that was helpful, but can give that patient centered approach. And recognizing – we spoke about the evidence that's out there. Again, there's well over 100, 100-plus. Glad those two systematic reviews each covered nine. So nine for the pediatric and nine for the adult population. So again, a lot of research that I was not able to get to today but there's a lot of research that we did cover. And then future research is needed in specific populations, comparing different types of real food enteral nutrition and outcomes driven research. All right. Then that leads me to our question slide. Speaker: Thank you so much, Erin. And to answer your question, no hiccups on our end. Everything sounded great. We do have some time for some questions. I've got a few here. Starting with the patients in the pre-index, what were the patients on in that pre-index? Erin O'Hora: Yeah. So with those, really because it wasn't just the one, it was a good amount of the real world data. It is unknown what they were on prior to transitioning on to, whether it was a plant based – the real food ingredients, or the peptide based formula there. But with that said, they weren't on the products that they were switched to. So that is one thing that we do know, but we don't have a list of all the products they were on prior to that. But that's a very common question, so I appreciate that. I'm hopeful that's helpful. Speaker: Let's see. Are commercial blenderized products covered by insurance? Erin O'Hora: Yeah. So that's a great question. And honestly, we always get that question, giving – or discussion even, when we do any type of kind of, I guess, education within a formula bucket or category, if you will. And so the short answer is yes, many of them are. It depends on what state that you're in, what insurance, what is the condition? But the majority of them – I always encourage people to work with their home care providers in order to see what they can get or what is covered. But the short answer is, yes, most of them should be. I don't want to give a hard yes because, again, you can be – one may not be in a specific state or whatever it may be. But they would be – and I always point that out, even when talking about some of the benefits, because when we think about the benefits of a commercial blend versus a prepared, it is that benefit that you could most likely get reimbursement for a commercial blenderized formula. Versus some of those foods that you're purchasing to blenderize, you're not going to get that reimbursement. So yeah, hope that was helpful. I know there's little ambiguity in there, but I don't know where everybody is located or how to see where – what products would be in your area. But for the most part, yes. Speaker: Sure. And as far as tube size, can you make a recommendation for those on real food formulas? Erin O'Hora: Yeah. So my strongest advice, and I would align with the ASPEN practice recommendations, start with that 14. However, I would look at each individual package. So if you're working with a specific product, if you read the back of it, and it might say to use a 12 French. Or some of them might be lower than that, it might say ten. But again, I would look at the manufacturer's recommendations on a tube size, the French size rather, and then move forward with that. But the variety of products that are on the market leads to that to be, again, individualized based on the product that is being used. So it's hard to say. Again, ASPEN recommendations, it comes out with that 14, so that would be my guide. But the caveat there is also to look at the manufacturer's recommendations for that product. Speaker: Excellent. Are these products able to be used in the ICU? Erin O'Hora: So that's a great question, and that also comes up often. And I will say this, there's very limited, extremely limited, research within the ICU space on real food formulas. So as a healthcare professional, I would say I'd want to have the evidence before I use a product in an ICU patient. So it is based on clinical judgment. So if your preference is to use something like this, depending on the stability of your patient within that setting, I would lean into to that's the healthcare professional's decision. But there's not really enough evidence that I can share confidently that it is something that should be used routinely within that space. As of today. Speaker: Excellent. So for our audience, I'm just going to hover here over the how to claim your continuing education credit. But I will go ahead and ask you one more question. Thank you for sharing the blenderized recipe tool – excuse me, the Blenderized Recipe Builder tool with us. Is that tool freely available to clinicians as well as patients? Erin O'Hora: Yes. Absolutely. So I know the handouts are posted. So on the handout, you would be able to see the link or the web page that you can go to that. But it is something that is accessible for you to be able to use. Good question, though. Speaker: Thank you. Erin O'Hora: It's a great tool. Speaker: So we're here at the end of the hour. I do want to thank you, Erin, for your time and expertise today. And also want to thank our audience for taking the time to join this presentation. I'll give you one more look at our disclaimer there. And for a full list of our upcoming events, I invite you to join us at mms.mckesson.com/learning-webinars. You can register for future webinar, share events with your colleagues, or sign up to receive regular updates on our webinar schedule. Erin, thank you so much for your time today. This was a fascinating presentation. Erin O'Hora: Yeah. You're very welcome. Hope everyone has a good evening ahead. Speaker: Thank you. Have a great day everybody.