A Letter to Clinicians:
Advocating for Patient-Led Recovery
To clinicians,
The Ethical Imperative: Support Patient Autonomy
The tenets of medical ethics call us to honor the autonomy of those we serve. When patients or their loved ones choose a path that includes evidence-informed nutritional therapy—even if outside the standard of care—we have an ethical responsibility to support them.
Supporting a patient’s chosen approach does not place the burden of responsibility on the clinician to endorse or defend that choice as part of the standard of care. Rather, it offers the opportunity to collaborate in a way that protects clinicians from liability by honoring informed consent and the patient’s right to self-direct their care. This approach is not combative—it is collaborative, and in service of our shared goal: improved outcomes and meaningful recovery.
Patient Autonomy is Foundational:
“The patient has the right to refuse and to choose their treatment.”
This letter is not a request for permission, but a call to partner in empowerment. We all want the same thing: for the patient to get better. Let’s work together towards this shared goal. You have the power to help them implement their chosen care strategy—and that support can make all the difference.
With deep respect and appreciation for your work and willingness to consider new models of care,
Cavin Balaster, CFNC
Functional Nutrition Counselor, Author of “How to Feed a Brain”
To Cinicians,
Thank you for your continued dedication to healing and for being open to integrative approaches that can profoundly impact recovery outcomes. As you know, nutrition is foundational—every cell in the body, including those of the brain, relies on the building blocks we provide through food and supplementation.
In cases of brain injury or neurological decline, the right nutritional interventions can be transformative. As a clinician, you may hold the key to unlocking recovery by supporting protocols that include high-quality omega-3 supplementation and real-food enteral nutrition.
Fish Oil Supplementation
Omega-3s and Neuroprotection
High-dose fish oil, rich in EPA and DHA, has shown promise in supporting recovery from traumatic brain injuries. Peer-reviewed research and case studies demonstrate measurable improvements, including ventilator weaning and restored function, in patients who received therapeutic doses: (15 ml, which is about 13 g) twice a day (30 mL/day) of a high-quality fish oil. The therapeutic dose is the key here. (2) This is not an isolated case, as other TBI survivors have also obtained similar results which you can read more about at feedabrain.com/omega.
In 2011, an article in Military Medicine, the official journal of The Association of Military Surgeons of the United States (AMUS), wrote that “…a comprehensive, coordinated research program to evaluate the multiple uses of n-3 FA [Omega-3 fatty acids] should be a high priority for the Department of Defense.”(1)
What About the Risk of Blood Thinning?
Concerns about blood thinning have been addressed in the literature, with data showing no deleterious effects at doses up to 6 g/day in healthy individuals. In fact, DHA does not significantly affect clotting markers or augment aspirin-induced inhibition of platelet aggregation. This aligns with findings from Hasadsri et al. (2013), who concluded that “DHA at doses up to 6 g/day does not have deleterious effects on platelet aggregation or other clotting parameters in normal individuals, and fish oil does not augment aspirin-induced inhibition of blood clotting.”(3)
We have organized much research on the subject of Omega-3s and their effects in preventing and treating brain injury at feedabrain.com/omega.
Real-Food Tube Feeding
Many standard formulas contain ingredients that may contribute to inflammation and hinder recovery. Patients can benefit from tube feeds based on whole foods, whether pre-made (see feedabrain.com/feeds) or home-prepared (instructions at feedabrain.com/gastric). These approaches are nutrient-dense and better aligned with functional nutrition principles for neurorehabilitation.
Some clinicians are hesitant to use high-dose fish oils because there is evidence that they may thin the blood. An article published in the Journal of Neurotrauma, however, analyzes the literature and states that “[t]he overall clinical data suggests that Therefore, fish oil supplementation in doses up to 6 g/day does not appear to have the blood thinning effects that raised concerns.
Real Food Blenderized Tube Feeds
Surprisingly, most enteral formulas fed today contain processed ingredients like corn syrup, canola oil, sugar, corn maltodextrin, and soy protein isolate. Many of these ingredients have been shown to contribute to neurodegeneration and inflammation. These ingredients are not quality nutrition for anyone to live on, let alone someone who needs to heal after injury or throughout a disease process. Instead of using these feeds, we can use tube feeds based on real food nutrition to better support your patient’s recovery and health. A list of pre-made feeds that can be ordered online is available at feedabrain.com/feeds
If someone is willing and able to create them from fresh ingredients, blenderized tube feeds can provide superior nutrients for brain health and recovery when compared to processed formulas. I have created a “Gastric Tube Feed Creation Instructions” handout, which can be found below or at feedabrain.com/gastric.
Collaborating for the Patient’s Well-Being
Both you, and the loved ones of the person you are caring for, want the patient to get better, so I hope that you are open to allowing (or requesting) that your patients be administered fish oils and/or to be fed the real food feeds outlined here.
Additionally, we are building a team of collaborative medical professionals to influence change. Together, we can make a positive change in the standard model of neurorehabilitation, and we can help to prevent neurological degeneration for everyone. If your heart breaks as you watch patients deteriorate on the currently-used feeds, I ask you to join us in this quest to improve hospital and gastric feed nutrition.
I have so much appreciation for your profession and the work you do for patients every day. Thank you for your time and attention. I hope this information will be useful to you in the treatment of your patients.
Sincerely,
Cavin Balaster
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GASTRIC FEED INSTRUCTIONS FOR CLINICIANS:
Use the Blenderized Tube Feeding: Suggested Guidelines to Clinicians article and The Use of Blenderized Tube Feeding in Pediatric Patients: Evidence and Guidelines for Dietetic Practice to appropriately feed a patient a real food blenderized feed.
This chart is taken from the article written by Laura Schoenfeld, MPH, RD concerning blenderized tube feeding in pediatric patients. In it, if we are to change the word “parent“ to “patient or support,” the same criteria apply to patients of any age. This is a list of the minimum criteria for us to consider before switching to a blenderized tube feed for a patient.
If the patient is a realistic candidate for these gastric feeds, to optimally support brain function and repair, we can order Feed a Brain approved gastric feeds (feedabrain.com/feeds) or we can make or order premade meals to be made into feeds following the instructions outlined in the Gastric Feed Handout. For your convenience, all of these handouts can be found at feedabrain.com/reasearch. In any case, high dosages of Omega-3’s have been shown to be beneficial and neuroprotective and there are numerous studies showing their benefit which can be found at feedabrain.com/omega.
Storage
If there is left over after first feed, seal in a container and refrigerate for use within 24 hours. If the feed is not going to be used for over 24 hours, freeze for later use.
I highly recommend the use of a high-quality blender like a Blendtec or Vitamix as they each come with a several-year warranty, and their abilities are quite impressive. I never thought I would spend hundreds of dollars on a blender, but my Blendtec has changed my life by allowing me to get more things done with less time in the kitchen. I can swallow without any restrictions these days, but I also enjoy these foods even as smoothies and pureed soups… usually when I’m too busy to cook. I still cook when I want to cook, go out to dinner, and regularly eat delicious meals, but I no longer have an excuse to not get the produce I know to be optimal for brain function and repair. You can find the blenders at feedabrain.com/tools.
This is a handout we’ve created to help to guide a blenderized tube feed creation. Click here (Gastric Feed Creation Instructions) or on the image below to download.
Amylase and Gastric Feeding
Gastric tubes skip the first stage of digestion when the food is chewed and mixed with saliva in the mouth. Saliva is important because it contains special enzymes, namely amylase, an enzyme that breaks down complex carbohydrates into simple sugars to prepare the food for the next phase of digestion in the stomach. Because we are skipping this step, we are going to want to add digestive enzymes to our gastric feed. For products that are designed to include important enzymes especially for when the first stage of digestion is skipped (like in gastric feeds), go to feedabrain.com/enzymes.
Hydration
For any of the benefits that we have talked about so far to be effective, it is very important for us to be sure to supply adequate hydration. We are all aware that we need to be hydrated to live, but another very important function of hydration is to help us to move toxins out of our bodies, so we want to supply more than just enough to survive. The amount of water that we consider to be optimal is dependent on many factors including how much water is in the foods we eat. If we are supplying nutrition via a gastric tube, we may want to work with a qualified healthcare professional to determine this amount, but Jeremy Lampel, MS, RD, CDE, a registered dietitian and certified diabetes educator with a Master’s degree in nutritional science, agrees that for healthy adults, we can generally divide our weight in pounds by two, and use that number to determine how many ounces of water to drink each day as a minimum requirement. (I tend to drink almost twice my minimum requirement)
So if you weigh about 160 pounds (like me), you would divide that number by two and know to drink at least 80 ounces of water. Using a different method of measurement, since there are about 30 ounces in a liter, and about 2 pounds in a kilogram, we can divide our weight in kilograms by 30 to determine how many liters to drink. So, if you weigh about 72.5 kilograms (like me), you would divide that number by 30 and know to drink at least 2.4 liters of water a day. Again, this amount is a guideline for a minimum requirement. I tend to drink much more than my minimum requirement of 80 ounces and consume more like 140 ounces of water per day. This converts to about 4 liters per day which is far more than my required 2.4 liters. Jeremy reminds us, however, that it is important that we do not supply too much or too little water (over hydrate or under hydrate); yet, there is quite a bit of wiggle room for us. Keep in mind that needs may increase based on physical activity, climate, or other medical needs, so it is always advised that you work with a qualified healthcare provider.
For nurses and dietitians, this is a good article concerning hydration management that was published in Nursing Times: “Maintaining hydration in enteral tube feeding.” You can find this article, and other important articles at feedabrain.com/articles.
* Depending on the amount of salt, bone broth may also count towards your hydration, meaning that a cup of unsalted broth can potentially be counted as a cup of water.
* Bone broth contains protein as well.
Macronutrients
Macronutrients are broken down into three main categories: carbohydrates, proteins, and fats. While most of us can rely on our appetite to guide our protein requirements, Jeremy points out that protein requirements vary significantly depending on the stage of recovery. Additionally, a patient may be unable to communicate or could potentially have damaged areas to his/her brain that affect appetite. Work with your dietician to determine requirements, especially for patients who cannot communicate or perceive their appetite. Again, my desire to help is immense and I offer one-on-one consultations at feedabrain.com/consult, and we are working on courses and other resources at feedabrain.com/education.
There are some general guidelines and formulas that can be used to find estimated amounts of needed macronutrients, and we will provide some of these ballpark estimates, but keep in mind that these are only estimates of average needs for a healthy individual, and those in critical care can rarely be considered to have a “normal” metabolism. Jeremy has shared with us a handout which he uses to inform his patients of how the macronutrients of their diets might be distributed for different conditions. It is advised that you bring these guidelines to your dietitian or another qualified healthcare provider.
*For your convenience, all printable charts can be found at feedabrain.com/handouts.
WHO AM I?
My name is Cavin Balaster, CFNC. I am a certified Functional Nutrition Councilor and my intention is to improve gastric feed nutrition for patients. In 2011, I sustained a TBI — a severe Diffuse Axonal Injury. Statistically, over 90% of patients with this injury never regain consciousness. For months after waking from a 
coma, I didn’t eat, walk, or talk, my left hand was completely flexed inward, I was breathing through a tracheotomy, and I was receiving nutrients through a PEG tube in my belly. At one point in my recovery, I was steered towards a nutritional protocol and I began to regain mental clarity. I used that clarityand I began to study lioke my life depended on it. Cause it did. I started with college courses (from Duke, Cal Poly Tech, the University of Chicago, and Johns Hopkins) on physiology, nutrition, and neurology and neuroplasticity, and other aspects that influence brain function. My recovery has been called miraculous and I owe that in large part to nutrition. I now guide clients to optimal health and to reach their optimal recovery potential. You can learn more about me at feedabrain.com and adventuresinbraininjury.com.