Dysphagia, or difficulty swallowing, can arise from various conditions, including stroke, neurological disorders, or head injuries. A speech-language pathologist (S-LP) may recommend a texture-modified diet like the level 4 pureed diet to ensure safe and comfortable eating. This article provides comprehensive information on the IDDSI Level 4 pureed diet, including its purpose, preparation, suitable foods, and practical tips for implementation.
The IDDSI Framework
The International Dysphagia Diet Standardization Initiative (IDDSI) framework is an internationally recognized standard that consists of 8 levels (0-7), where drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness. It is designed to provide a common language and understanding of food textures and liquid consistencies for individuals with dysphagia. The IDDSI framework aims to promote patient safety and reduce the risk of choking by standardizing diet terminology and testing methods.
What is a Level 4 Pureed Diet?
A level 4 pureed diet involves consuming foods that have been processed to a completely smooth, uniform texture, requiring no chewing. Level 4 pureed food may be used if you are not able to bite off or chew food or if your tongue control is reduced. It is smooth in consistency with no ’bits’ for example no lumps, fibres, bits of shell/ skin or husk, particles of gristle/ bone. It may need to be sieved to achieve this. It is a thick purée that holds its shape on a plate or when scooped. It can be piped, layered, or molded. It cannot be poured. It does not ’spread out’ if spilled. It can be eaten with a fork because it does not fall through the prongs. The prongs of a fork make a clear pattern on the surface. It is moist. This diet is often recommended for individuals with dysphagia who have difficulty with tongue movement, chewing, or biting.
Why a Pureed Diet?
Sometimes, the swallowing muscles in the mouth and throat can become weaker, slower or less coordinated. This can be due to being unwell or as a result of certain medical conditions. A pureed diet is essential when swallowing muscles in the mouth and throat become weak or uncoordinated. This diet minimizes the risk of aspiration, where food enters the airway and can lead to serious chest infections or pneumonia. Pureed foods only need the tongue to be able to move forward and back to bring the food to the back of the mouth for swallowing.
Characteristics of IDDSI Pureed (Level 4)
When preparing food for those we serve, we typically pay attention to the appearance, taste, and temperature. IDDSI now introduces us to new and more specific characteristics like particle size, moisture, stickiness, and softness. Thanks to IDDSI’s unified standards, foods on IDDSI Pureed (Level 4) will maintain the same characteristics no matter where in the world you serve pureed foods.
Read also: Understanding Dysphagia Diets
Kitchen Tools for Pureeing
To achieve the correct consistency, specific kitchen tools are necessary. A powerful blender that creates a vortex is ideal for thorough blending. A fine mesh sieve is essential for removing lumps and ensuring a smooth texture.
Testing Methods for IDDSI Pureed (Level 4)
Testing is a new concept that shifts the way we do things in the kitchen. We know it’s not easy to make changes and get everyone on board, but testing is worth it because it’s all about safety. The overall objective of testing is to make sure the pureed foods we prepare meet the characteristics for IDDSI Pureed (Level 4). Therefore, foods must pass the following IDDSI tests:
- Appearance: Smooth, no lumps, or thin separate liquid
- Fork Drip Test: Food holds shape as a mound above the fork. A small amount may flow through and form a short tail below the tines of the fork but it does not flow or drip continuously through the tines.
- Spoon Tilt Test: Food is cohesive enough to hold shape on the spoon. It can slide off easily when you tilt or gently flick the spoon over a plate with very little food left on the spoon. However, a thin film of residue left on the spoon is acceptable, but you should not be able to see the spoon through the film and it should not be firm and sticky. It may slightly spread out or slump very slowly on a flat plate.
Spoon Tilt Test
The Spoon Tilt Test checks the stickiness and cohesiveness of the puree. Level 4 pureed foods should easily slide off a spoon when tilted or gently flicked, leaving minimal residue. Excessive stickiness can increase the risk of choking or aspiration.
Fork Drip Test
The Fork Drip Test assesses the thickness of the puree. The puree should sit in a mound above the fork, with only a small amount flowing through the tines to form a short tail. If the puree drips or flows continuously through the tines, it may not be thick enough.
Adjusting Consistency
If a puree fails the IDDSI tests, adjustments can be made:
Read also: Safe Eating with Dysphagia
- Too Runny: Add commercial thickeners or pantry staples like pureed beans or mashed potato flakes.
- Too Thick or Dry: Incorporate flavorful liquids such as broth or cream.
- Too Sticky: Recheck consistency with the Spoon Tilt Test and Fork Drip Test after adjustments.
Foods Suitable for a Level 4 Pureed Diet
A wide variety of foods can be adapted for a level 4 pureed diet, ensuring a balanced and enjoyable eating experience.
Fruits and Vegetables
Aim to have 5 portions of fruit and vegetables each day. One of these portions could be a glass of pure fruit juice. Choose soft, ripened fresh fruit such as: peaches, pears, nectarines, plums, melon; and bananas. Peel, remove seeds and / or stones, purée, and sieve. You may need to add a thickener.
Meats, Poultry, Fish, Eggs, and Pulses
Aim to have 2 portions of meat, poultry, fish, eggs or pulses each day. Cook meat or poultry well. Remove skin, gristle, or fat. Purée with enough stock, gravy, sauce, or soup until smooth and thick. Sieve if needed. Fish must be boneless. Fish such as tuna, salmon, prawns, and white fish can be puréed with a sauce. It may be suitable as a mousse or pâté. White fish includes smoked or unsmoked cod or haddock.
Milk and Milk Products
Try to have a pint of milk every day, or include two to three servings of milk products. Drink full fat whole milk, if possible. Do not use reduced fat options. Wherever possible make custard, semolina, or ground rice with full fat whole milk.
Starchy Foods
Aim to include at least one starchy food at each meal. Porridge (use fine grain oats) and other instant cereals, such as Ready Brek or Oats-so-Simple. Avoid cereals with added nuts and dried fruit, such as muesli. Well-cooked, soft pasta dishes such as macaroni cheese, spaghetti in tomato sauce, or ravioli. These dishes can be puréed to a smooth consistency. If needed, add extra sauce.
Read also: Understanding Dysphagia Diets
Foods to Avoid
Whilst your Speech and Language Therapist is advising you to have a pureed diet, these foods should be avoided. Fruits with fiber or that are stringy and cannot be pureed into a smooth texture with no lumps.
Practical Tips for Preparing and Serving Level 4 Pureed Meals
- Presentation: Don’t puree a whole meal together, unless it is a complete meal such as a stew. Puree each individual element separately and serve them so you can see each portion of food on the plate. You could consider piping or layering your pureed foods. You could also serve your pureed foods with an ice cream scoop onto the plate.
- Flavour: Season foods to taste after pureeing. Add more flavour with ingredients like grated cheese, soft cheese, hummus, or pesto. Add flavour with mustard or curry powder, soy sauce, lemon juice, Bovril, Marmite or spices. Avoid using dried herbs.
- Texture: You need to ensure there are no lumps. Add sauces to your food; however, these must be as thick as the purée itself. Do not purée foods with skins, seeds, bones, gristle or cartilage.
Meal Planning and Preparation
Planning meals ahead of time is crucial. Consider where meals will be eaten, available kitchen facilities, and the ability to transport prepared meals. When pureeing food, add liquid to achieve a smooth, soft, and lump-free consistency.
Tips for Eating at Home
You can puree many different foods by putting them in a blender with some liquid. You can use water, broth, gravies, sauces, juice, milk, or yogurt. Use a blender for all types of foods, including meats, vegetables, and fruits. You may have to add liquid to make the food the right texture. Use a hand-held blender to quickly puree your favorite soups right in the pot. Food processors are useful for shredding, slicing, chopping, and blending foods. They come in different sizes. Use a household mesh strainer or sieve to strain fruits and vegetables, but not meats. They are inexpensive, good to make 1 serving, and do not need electricity.
Tips for Eating Away From Home
Eat at restaurants offering different types of foods and that will adjust for people on special diets. Many places will puree or make foods for your needs. Call ahead and speak to a manager or chef. You may be surprised at how helpful they will be. It’s also possible to eat away from home, such as at work or at a friend’s house. Bring a food grinder or small food processor. Buy a thermos. Ask if there is a microwave where you’re going. You can make food at home and freeze it in single-serving, microwave-safe containers or Zip-Loc® bags. Freeze soups or pureed foods in ice cube trays. Cover the tray with foil or plastic wrap to prevent freezer burn.
Addressing Potential Problems
Poor Appetite/Weight Loss
If you have a small appetite or find that you are losing weight, you should make your foods more nourishing. There are some ideas below on how to do this.
- Try to have regular small meals or snacks. Aim for 3 small meals and 2 to 3 snacks per day. This is called 'little and often’.
- If you are not able to manage a full meal, try a milkshake, soup, or pudding instead. Add a fortifier, such as Complan. Fortifiers are available from chemists and supermarkets.
- Drinks can be quite filling, so only take sips with a meal. Remember to drink more between meals and snacks. Follow any advice your speech and language therapist may have given you about the use of drinks during meals.
Adding Extra Nourishment
Extra nourishment can be added to your food in different ways. For example:
- Use whole milk to make milk puddings, milky drinks, and sauces.
- Add 4 tablespoons of milk powder (for example Marvel) to 1 pint of whole milk. Use this in hot drinks, puddings, mashed potato (no lumps), and sauces. Make packet soups with fortified milk, or add 2 tablespoons of milk powder to smooth tinned or packet soup.
- Add grated cheese to vegetables, potato, soups, and sauces.
- Add extra butter / margarine / oil to sauces, potatoes, vegetables, and pasta.
- Use double cream in soups, sauces, cereals, potatoes, and puddings (for example custard).
- Add extra sugar, syrup, jam without bits, or honey into puddings, drinks, or cereals.
Ready-Prepared Pureed Meals
If you are struggling to cook or shop on a regular basis, use convenience foods which need very little preparation. Or consider ordering pre-prepared food from delivery companies. Specialist companies which deliver frozen meals to clients, such as Wiltshire Farm Foods, Oakhouse Foods, Simply Puree and Mrs Gills cater for people with swallowing problems.
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