Dysphagia, or difficulty swallowing, affects many individuals, particularly older adults. A pureed diet, specifically Level 4, is often recommended to manage this condition. This article provides a detailed overview of the Level 4 pureed diet, offering guidelines, practical tips, and considerations for ensuring nutritional adequacy and quality of life.
Understanding Dysphagia and Pureed Diets
Dysphagia is a condition characterized by difficulty swallowing. This condition is more common among the elderly, affecting 30% of adults over 50 and up to 68% of nursing home residents and is often the result of muscle or nerve problems. People who have dysphagia may experience choking while eating, gagging when swallowing, heartburn, drooling, vomiting, and more. Dysphagia can affect your mouth, your throat, your esophagus, or all three areas.
Not being able to swallow food properly leads to a whole host of other conditions, such as malnutrition and dehydration. So, if you are experiencing dysphagia, it is crucial that you take steps to prepare safe-to-eat foods. There are other steps you can take, such as swallowing therapy and tube feeding. Be sure to consult with your doctor before taking any steps to rectify your dysphagia.
A pureed diet, such as a Level 4 pureed diet, is a food regimen in which you can only eat pureed foods or foods that don’t need to be chewed. People who have trouble chewing or swallowing need a puree diet. These include elderly people with dysphagia, children undergoing tooth development, and people with missing teeth.
What is a Purée?
Any puréed food is cooked food turned into a paste or thick liquid. Typically, the food turned into purée is cooked and chopped or ground finely before it gets puréed. It falls off the spoon when tilted in a single spoonful.
Read also: Understanding Dysphagia Diets
Purée Diet vs. Soft Diet: What Are Their Differences and Similarities?
Both puréed and soft diet foods are easier to digest than regular foods. Purée and soft diets are prescribed to those who have issues with digestion or chewing. Doctors may also prescribe these diets for those recovering from certain surgical operations.
A person who is on a mechanical soft diet can only eat foods that they can chew. Yet, soft diet foods require less chewing than a regular diet. A person on a soft diet can tolerate different food consistencies as long as they are easily chewed. A soft diet includes chopped and ground foods on top of puréed foods.
A person on a puréed diet can only eat foods that don’t require chewing. Their food choices are limited to a certain consistency. These foods may include broth and pudding other than puréed foods.
Dysphagia Diet Levels
A dysphagia diet has 4 levels:
- Level 1: This is the pureed food diet level. This is the most limited level and is suitable for those who have moderate to severe dysphagia.
- Level 2: You may eat moist foods that require minimal chewing - for instance, gravy with ground meat, soft scrambled eggs, peanut butter, and so on.
- Level 3: You may eat soft-solid foods that require a bit more chewing than in level 2. Acceptable foods include fruits and vegetables that are easy to cut, as well as tender cuts of meat.
- Level 4: All levels of food may be eaten during this level of the diet, but you should still be careful.
Level 4 Pureed Diet: What You Need to Know
A level 4 pureed diet is when you only eat foods you do not need to bite or chew. While you’re following this diet, you will make your foods smooth and moist before eating them. It is the most restrictive level, designed for individuals with moderate to severe dysphagia. All foods must be pureed to a smooth, pudding-like consistency to ensure they can be swallowed safely without chewing. This diet eliminates coarse textures, raw fruits and vegetables, and nuts.
Read also: Safe Eating with Dysphagia
Achieving the Right Consistency
To make your foods smooth, soft, moist, and lump free, add liquid to the blender or food processer. Add just enough liquid so that your food is smooth but not too watery or runny.
You can use a blender, food processor, or other kitchen item to make your foods smooth. For some ideas, read the “Kitchen items to help you make food” section of this resource.
Your food’s texture can change based on its temperature and how you cooked it.
Testing Food Thickness and Texture
You can check your food’s thickness and texture by doing a fork drip test and spoon tilt test. Follow the steps in this section.
- Fork Drip Test: Level 4 pureed foods should sit on top of the fork with very little or no drip through the fork.
- Spoon Tilt Test: Pick up some of your food with a spoon. Your food should easily slide off. It’s OK if you need to gently flick the spoon to get the food to fall off.
Planning Your Meals on a Level 4 Pureed Diet
Changing your eating habits can be hard. It’s best to plan your meals ahead of time. Where will you be eating? Will you have a kitchen and refrigerator available? Can you boil water? Can you microwave? Can you carry a thermos with a meal already made and ready to eat?
Read also: Understanding Dysphagia Diets
Like eating regular foods, you can consume various food combinations with a purée diet. Changing up your meals will help you feel better about eating puréed foods.
Foods to Include and Avoid
When planning out your daily pureed foods list, try to include meals that adhere to the basic four food groups: milk, meat, fruits/vegetables, and breads/cereals. You should aim to have 2 servings of milk, 2 servings of meat, 4 servings of fruits/vegetables, and 4 servings of breads/cereals per day.
Here are some foods you can eat while following this diet. We also list some foods you should avoid. These tables are not a complete list of foods you can eat on this diet. Other foods may be OK to eat if you test them and they are the right size and texture. If you have trouble swallowing liquids, your speech language pathologist may recommend you thicken your liquids.
Foods Allowed:
- Whipped or smooth mashed potatoes without skin.
- Pureed beef, poultry, veal, or pork.
- Pureed blended casseroles.
- Pureed pizza.
- Pureed peanut butter and jelly sandwich.
- Pureed macaroni and cheese.
- Pureed cottage cheese.
- Foods may need to be moistened with broth, milk or gravy to avoid very thick, sticky texture.
- Pureed vegetables.
- Pureed peeled fruit: bananas/pears/peaches/applesauce.
- Pureed cottage cheese, smooth yogurt without fruit pieces, milk.
- Smooth pudding custards, yogurt, pureed desserts, and soufflés.
- Any smooth, homogenous beverage without lumps, chunks, or pulp (may need to thicken to proper consistency).
Foods to Avoid:
- Fruits with fiber or that are stringy and cannot be pureed into a smooth texture with no lumps.
- Whole, ground, or chopped meats, fish, or poultry.
- Legumes or lentils, unless pureed.
- Cheese and cottage cheese, unless pureed.
- Eggs that are not pureed.
- Nut butters, unless pureed into other foods to correct consistency.
- All other bread, rolls, crackers, biscuits, pancakes, French toast, muffins, etc.
- Dry cereals and cooked cereals with lumps, seeds, or chunks.
- Oatmeal.
- Whole fruits (fresh, frozen, canned, or dried).
- All other vegetables that are not pureed.
- All other potatoes, rice, and noodles.
- Plain mashed potatoes.
- Cooked grains.
- All other desserts.
- If patient is on thickened liquids, restrict ice cream, ices, milk shakes, frozen yogurt, gelatin, and other frozen desserts, because they are thin-liquid consistency at room temperature.
Tips for Pureeing Food
Pureeing food for the elderly is quite simple: you simply need to add the ingredients of your choice into a blender or a food processor, along with liquid and an optional thickening agent (flour, arrowroot, etc.). Press the “On” button until your mixture is very smooth. If you find that the mixture is far too thin, add in a bit of your thickener (approximately 1 tbsp). Conversely, if the puree is too thick, you can thin it out with your liquid of choice. For savory dishes, vegetable broth is a great choice, while apple juice is better for sweet dishes.
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.
The most important items in your kitchen for following a puréed diet include a food processor or blender. You can also use small and powerful blenders like Nutribullet or The Vitamix for making small portions. For soft and well-cooked foods, you can use a hand-held blender. Another item you’d need in your kitchen for fruits and vegetables is a household mesh strainer or sieve. You can also use a baby-food grinder if you already have one at home.
Here are some tips for preparing pureed foods:
- Blender: 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.
- Hand-held blender: Use a hand-held blender to quickly puree your favorite soups right in the pot.
- Food processor: Food processors are useful for shredding, slicing, chopping, and blending foods. They come in different sizes.
- Household mesh strainer or sieve: Use this to strain fruits and vegetables, but not meats. They are inexpensive, good to make 1 serving, and do not need electricity.
What Should the Final Texture Be Like?
A properly pureed meal should not have any lumps, chunks, pulp, or seeds. The texture should be smooth and pudding-like; dry, crunchy, chewy, runny, and sticky textures can be dangerous for people who require a level 1 dysphagia diet.
To create the smoothest purée, you should avoid the following foods: stringy vegetables, pulpy fruits, dry cereal, grains with seeds, and hard cheeses. Avoid buying or puréeing foods with added nuts, seeds, fruits, or other chunks.
Do not cook meats with oil. Instead, cook your meats with moisture, like boiled, steamed, braised, or poached meats.
You can add liquids to create a smoother consistency after puréeing foods. These liquids may include water, broth, sauces, milk, juice, yogurt, gravies, and supplement drinks. Add liquids that match or complement the puréed foods. For example, use juices for puréed fruits and milk for cheeses.
When you add liquid, use a teaspoon to ensure you don’t put too much into the purée. If you have mouth sores, avoid spicy or acidic foods.
Tips for Eating at Restaurants
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.
Tips for Eating Away from Home
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.
Adding Calories and Nutrients
Add 2 to 4 tablespoons of canned coconut milk or cream to smoothies, shakes, cereals, and yogurts for extra calories. Make ice cubes from milk or fruit nectar. Use these high-calorie ice cubes in smoothies or to keep your shakes cold. Add sour cream, half and half, heavy cream, or whole milk to your foods. Add pureed tofu to cooked vegetables, soups, or smoothies.
Meal Planning Strategies
One drawback to following a purée diet is that the texture of the food can become boring. Some get tempted to go back to eating soft foods or regular foods, a decision that can do them more harm. The good news is that there is a trick you can do to help you continue your diet.
Getting Started with Meal Planning
If you’ll be on a purée diet for a long while, it’s a good idea to invest in a high-quality and durable blender or food processor first. It’s more practical to have one of these appliances in your kitchen so you can make your meals at home. Another advantage of having home-prepped meals is that you get to choose what you want to consume based on what you’re in the mood for or the flavors you want to taste.
Next, consider the meals that you want to eat by reading their recipes. Read the ingredients needed for these recipes and make a list of the ones that you need to add to your pantry or refrigerator. Some puréed foods need specific ingredients, like frozen yogurt or hummus.
When you’re checking the different recipes, consider your budget and taste. Consider also the time it takes to prepare each meal.
At this stage, you decide what you want to eat for the next week. Choose the meals, desserts, and snacks that you want. Approach meal planning like you would with a regular diet plan. The only difference is that you’re limited to consuming puréed foods.
Remember that you don’t need to prepare every puréed food if you don’t have the time or energy. You can buy pre-made puréed foods from supermarkets, too. They are great alternatives if you want a meal with a different taste.
Skipping desserts while being on a strict diet is a recipe for disaster. Remember that being on a puréed food diet doesn’t mean you can’t have any desserts or snacks. You still need these things to add variety and stay happy. The important thing is you consume desserts and snacks that follow the puréed diet.
Some good purée dessert options include sorbets, chocolate mousse, custard, smoothies, and yogurt. Skyr is an Icelandic cheese and yogurt recipe and an interesting puréed snack choice that you might want to try.
Stocking Up and Prepping
Stock up your pantry and refrigerator with the basic ingredients and staple foods. Yogurt, avocado, bananas, pudding, and liquid nutritional supplements are good staple foods for elderly adults following a purée diet.
You have your meals and recipes planned. Next, check the recipes for any food items or ingredients that aren’t in your pantry or refrigerator yet. Add them to a grocery list and get them on your designated shopping day of the week.
If you can’t go out to shop for these food items yourself, you can order them online and have them delivered via a grocery delivery service. You can also reach out to family or friends that can help you out with your shopping.
This last step is optional, but it’s a good step if you’ll be busy for the week. Plan a day for prepping your meals so that it’s easier to cook and purée them when it’s time to eat them. A good day to do this is Sunday. When you prep your meals, you can chop vegetables, wash and portion fruits, measure spices, and prepare large batches of beans.
Remember that not all foods will remain fresh if you prepare them early. If you prefer to eat your foods fresh or prep them the night before, you can skip this step.
Maintaining Flexibility and Enjoyment
Sometimes, you won’t feel like having the planned puréed chicken for dinner, and that’s okay. In times like this, it’s okay to change up the meal and try something else that you feel like having.
Sometimes, you’ll be too busy or exhausted to prepare, cook, and purée food that’s meant to be your meal. It’s okay if you don’t feel like following the meal plan to the T, too. The solution for this situation is to choose a different recipe that requires less work or buy pre-made purée food instead.
Changing it up as you go is fine as long as you don’t prepare anything that you can’t have on a purée diet. The most important is to stick to your purée diet.
Some restaurants offer foods that cater to people with dysphagia or similar health issues. They are a good alternative if you want to go out with family and friends or have a change in routine. Don’t forget to call ahead to ask the manager or chef if they provide puréed foods for special cases.
Principles for Good Nutrition
Below are a few principles to keep in mind when you plan your meals for your purée diet.
Balancing Food and Nutrition
Make sure every meal has all the major food groups present in them. Remember that your body needs a good balance of fat, protein, and carbohydrates to function. You can check the table above for the foods from each food group that you might want to add to your meals.
One way to help you balance your nutrition is to know your caloric needs. Everyone has different caloric needs based on their age, height, weight, physical activity, and sex. When you have dysphagia or adopt a puréed diet, you may lose weight because of the diet change. You can talk to your doctor or nutritionist about the number of calories you need to maintain your weight.
Having variety in your meal plan is a good thing. You can’t get all your nutrients from one basic meal plan that contains the same puréed vegetables, meat, dairy, and starchy foods. You need to switch it up often, too.
You aren’t only exposing your body to different micronutrients and phytochemicals. Doing this makes following a mechanically altered diet more enjoyable, as well.