Advice when you need to follow an IDDSI (International Dysphagia Diet Standardisation Initiative) level 4 pureed diet
Information for patients from the Nutrition Team
You have been advised to follow a level 4 pureed diet. This leaflet will explain:
what level 4 pureed diet is
how to prepare and serve your food
which foods can be included in a pureed diet
practical tips and puree meal ideas
what problems you may have
where to buy ready-prepared pureed meals from; and
how to contact us.
We hope this leaflet will help to answer some of the questions you may have. If you have any further questions or concerns, please speak to a member of your healthcare team.
Introduction
You may be experiencing difficulty with eating, drinking, and swallowing. The medical term for this is “dysphagia”.
Dysphagia can occur for many reasons, for example as a result of:
a stroke
a progressive neurological condition
dementia
a developmental disorder
learning disability
a respiratory complaint
a head trauma (injury); or
head and neck surgery.
This can make having an adequate and nourishing diet difficult. As a result, you may experience:
weight loss
dehydration (not enough fluids)
weakness
depression
malnutrition (a serious condition, when your diet does not contain the right amount of nutrients); and
a reduced ability to fight off infection.
Why have I been referred to the speech and language therapist?
A speech and language therapist will assess you. They will recommend the most appropriate consistencies of food and drink, and any strategies that may help. This will mean that eating and drinking can be as safe, enjoyable, and comfortable as possible.
The speech and language therapist may advise you follow an IDDSI level 4 diet, previously known as puréed diet, if you have:
issues with biting or chewing
problems with tongue control
difficulties driving more challenging foods through your mouth and / or throat
bits of food remaining in your mouth and / or throat after swallowing
concerns about foods entering your airway and lungs when swallowing
choking incidents, or risks of choking.
It is important that you keep eating different foods to make sure you get all the vitamins and minerals that your body needs to stay healthy. This leaflet will give you ideas on:
what to eat, to keep your meals a smooth consistency
as well as advice on how to get the most out of your meal times.
Many people find it difficult to keep their weight steady while eating a puréed diet. The information in this leaflet will give you ideas on how to:
make your meals as nourishing as possible
stop you losing weight; and
help you gain weight, if you need to.
What is a puréed diet?
A puréed diet consists of foods which are very soft and moist. They have been puréed in a liquidiser or food processor, and if needed passed through a sieve. This gives the food a smooth texture, without lumps or ‘bits’.
A puréed diet:
Is usually eaten with a spoon (a fork is possible).
Cannot be drunk from a cup or sucked through a straw.
Does not need chewing.
Can be piped, layered, or moulded.
Falls off a spoon in a single spoonful when tilted. It continues to hold its shape on a plate.
Moves slowly, but cannot be poured.
Does not contain lumps and is not sticky.
You may need to mix in extra thick sauce to make the food the right consistency. For example, mix in cheese sauce or gravy.
Each food should be puréed separately, to keep the different flavours.
Liquid must not separate from solid. Any sauce or gravy should be the same thickness as the food.
How do I prepare and serve my food?
Food must be cooked until it is soft, and then puréed to a smooth consistency. Food may need to be sieved and thickened to make it the correct consistency.
Equipment you will need
A hand blender can be used to purée small amounts of food.
A food processor or liquidiser would be useful to purée large amounts of food.
A sieve can be used to remove husks, lumps, and other bits that stop your food from being a smooth consistency.
Presentation
Make your meals look appealing, by using foods that are different colours. Foods that are light in colour, such as chicken or fish, are better served with brightly coloured vegetables, such as carrots or broccoli.
Thickening foods
Once you have puréed your food, you may need to thicken it, if this has been recommended by your speech and language therapist. You can use the following to thicken your food:
mashed potato (must be really smooth, no lumps)
cornflour
custard powder
ground rice
jelly crystals / gelatine
instant sauce or potato flakes
gravy granules
the thickening agent you may be using for your drinks (if recommended by your speech and language therapist).
Flavours
To help improve the flavour of your food, add herbs, spices, or lemon juice.
Which foods can be included in a puréed diet?
It is important to eat as wide a variety of foods as possible. Choose foods from each of the groups below.
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.
Mashed or instant potato, with milk and margarine or butter added.
Rice with a thick sauce can be puréed to make a smooth consistency. Make sure the rice is cooked until soft.
Sponge puddings or cakes can be puréed with sauce or custard.
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.
Each day have a glass of pure fruit juice (no bits) or a fruit drink with added vitamin C.
Cook vegetables well. Drain and purée, and sieve if necessary, to remove the skins.
Vegetables in sauce can be puréed. Try cauliflower in cheese sauce or vegetable curry.
Broccoli, marrow, courgette, and spinach can be puréed with another vegetable to thicken, for example cauliflower or parsnip.
Well-ripened avocados can be puréed.
Vegetable juices, such as tomato or carrot.
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.
Bananas or other soft fruits can be blended into porridge and other suitable cereals.
Drain liquid from tinned fruits before they are puréed.
Hard fruits, such as apples and pears, can be peeled, stewed, and sieved.
Dessert ideas include:
puréed stewed, soft, or tinned fruit with milk puddings
Greek yoghurt or thick cream
cheesecake and cream (no biscuit base); and
puréed fruit trifle.
Meat, 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.
Try egg soufflé or egg custard. Hard-boiled eggs can be puréed in a sauce.
Cooked or tinned legumes must be puréed and sieved before eating.
Tofu, Quorn, and textured vegetable protein must be cooked, then puréed and sieved.
Smooth hummus.
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.
Practical tips
We all must eat. For most of us it is an enjoyable experience, often involving family and friends. Eating a puréed diet may mean a change from your normal routine. However, by following these ideas you can hopefully still enjoy your food.
Eat a wide range of foods. This will give you with lots of different nutrients to keep you healthy and stop you getting bored.
Make the food look appetizing, choosing food of different colours. Purée each food separately, so it keeps its own colour and flavour.
Pureeing will make hot food cooler. Once you have puréed your food, warm it up again in a pan or microwave.
Pureeing will also warm-up cold foods or drinks. If you are making milkshakes or cold puréed puddings, chill the food or drink in the fridge before serving.
You may find it easier to prepare food in bulk, and store it in your freezer. Make sure that the food is defrosted thoroughly before reheating. Plan ahead to leave enough time and space to defrost small amounts of food in the fridge.
Mix food with a fork before serving, to make sure the liquid is not separating out and that it is one texture.
Eat in a quiet, relaxed place, and take your time. Sit upright during your meal.
Finish each mouthful before taking the next. Make sure your mouth is fully clear at the end of your meal.
If you are eating out, let the restaurant know beforehand that you have a special diet and what your needs are. Most places will be happy to cater for you. If you know you take longer to eat, think about ordering a main course and ask for that while everyone else is eating their starter. You may be ready for dessert at the same time as everyone else.
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. There are links to companies and ideas that you may find helpful at the end of this leaflet.
If possible, weigh yourself once a week. If you are losing weight or your appetite is poor, follow the ideas under the headings Problems you may have later in this leaflet.
Puréed meal ideas
Breakfast
Ready Brek (not apple flavour, sieve if there are bits) or instant porridge.
Puréed fruit and full fat smooth yoghurt.
Between meal snacks
Milky drinks such as Ovaltine, Horlicks or Complan, or smooth soup (see below). These may need to be thickened; check with your speech and language therapist.
Puréed stewed fruit.
Full fat smooth yoghurt, custard pot, or soft pudding (see pudding list below).
Avocado puréed with yoghurt / mayonnaise.
Hummus / smooth salmon mousse.
Snack and main meal ideas
Cream of tomato soup (smooth, no bits).
Other smooth soups. Puree or sieve the soup if it contains meat, fish, lentils, or cheese, and add cream. Soups need to be of a thick consistency or thickened. Please follow your speech and language therapist’s advice.
All the following foods will need blending and sieving
Hard-boiled egg, puréed with salad cream / mayonnaise to a soft, moist paste.
Very smooth pâté.
Cauliflower / broccoli cheese, well-cooked.
Minced meat, cooked with root vegetables (no onion, tomato skins, or peas).
Tinned fish mixed with mayonnaise, for example tuna or salmon.
Boil-in-bag fish with sauce.
Lentils cooked in stock or sauce, for example dhal or lentil casserole.
Vegetable or tofu curry or stew.
Quorn mince or minced meat bolognaise.
The above could be served with:
Creamed or instant mashed potatoes (no lumps).
Well-cooked pasta, puréed with sauce or with your main dish.
Well-cooked rice, puréed with sauce or with your main dish, for example curry.
Puréed soft-cooked vegetables. For example, root vegetables, broccoli tops, baked beans / mushy peas (sieved), or puréed and sieved tomatoes (either tinned or fresh, skinned and deseeded first).
Puddings
Where applicable, make all desserts with full fat cream or milk.
Yoghurt, smooth with no ‘bits’.
Fromage frais, smooth with no ‘bits’.
Mousse with no bits, for example chocolate.
Blancmange.
Instant Whip.
Stewed or tinned fruit, which has been puréed and sieved.
Mashed banana, mixed with cream, evaporated milk, or custard, and puréed and sieved.
Custard (thick).
Crème caramel.
Ground rice pudding, smooth and not runny.
Fruit smoothies (these may need sieving).
Milkshakes.
Problems you may have
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.
Useful tips
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.
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.
Make sure your meals are puréed with nourishing fluids, such as thick gravy or sauces, not just water.
Make sure that your food is a smooth, thick consistency when serving.
If you continue to lose weight, please contact your dietitian for advice.
If you are diabetic, it is important to regularly monitor your blood sugar levels when you make changes to your diet. If you need advice, please speak to your diabetic nurse.
Note: Remember to thicken all drinks and foods, if advised by your speech and language therapist.
Buying ready prepared puréed meals
The following companies provide meals delivered to your door.
Wiltshire Farm Foods
Softer foods range, includes purée classic and petite meals, purée breakfasts, sandwiches, snacks, and desserts.Telephone: 0800 077 3100
Simply Food Solutions
A range of texture modified meals and puddings.Telephone: 0191 4560456
Oakhouse Foods
A selection of puréed meals, as part of softer foods range.Telephone: 0333 370 6700
The above products / services are listed solely to advise our NHS patients. It does not imply endorsement by East Kent Hospitals University NHS Foundation Trust, nor discrimination against similar brands, products, or services not mentioned. We are not responsible for the contents or reliability of any other websites to which we provide a link and do not necessarily endorse the views expressed within them.
Store cupboard ideas
The following are examples of convenience foods to keep in your store cupboard. These can all be puréed to the correct consistency.
Tinned minced meat, corned beef, or fish.
Tinned or packet soup (without bits). If you are on thickened fluids, these may need to be thickened.
Tinned cream / evaporated milk.
Ready Brek / porridge oats.
Custard / instant whip / milk puddings.
Tinned fruit (to make milkshakes).
Instant mashed potato.
Pasta and pasta sauces.
Tinned vegetables.
Gravy granules.
Milk powder.
Build Up, Complan.
What if I have any questions or concerns about my diet?
If you have any questions or concerns, please speak to your dietitian or GP.