Becoming a Pureed Diet Champ

With the new guidelines from the International Dysphagia Diet Standardization Initiative (IDDSI), we now have very clear definitions for diet consistency and texture, and guidance on how to test the foods to be sure they are correct. This is vital, since choking is a leading cause of death for individuals with intellectual and developmental disabilities.

A pureed diet is now known as a Level 4 Pureed Diet. You can see how it fits within the framework below. You will notice there is also a liquid consistency associated with the diet level. It is called Extremely Thick Liquids, and is the “old” pudding thick consistency, for reference. This does not mean that all individuals on a Level 4 Pureed Diet will require Extremely Thick Liquids, but is meant to help you see the similarities among diet consistencies and liquid thickness. Always make sure you are following the diet order for both diet consistency and liquid thickness.

Source: The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/

Identifying and Testing Level 4 Pureed Foods

Level 4 pureed foods should be blended to a smooth consistency with no lumps. Liquids, like sauces, need to be blended into the food, instead of poured over the top, and the liquid should not separate from the food. These foods require no chewing and should hold their shape on a spoon. Foods should never be sticky and should plop off a spoon in one spoonful when tilted. If the food is too sticky, it may stick in the cheeks, roof of the mouth, teeth, or throat.

You can check to see if your foods are the proper consistency using 2 tests. The food must pass both tests!

Fork Drip Test – Scoop the food onto a fork. The food should sit in a mound on the fork without dripping or dolloping through the prongs. A small amount is permitted to flow through the prongs and form a “tail” below, but should not drip.

Source: The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/

Spoon Tilt Test – Scoop a sample of the food onto a spoon. The sample should sit in a mound on the spoon. Tilt the spoon to the side. The sample should slide off the spoon, leaving little or no residue on the spoon. The sample should not be firm or sticky.

Source: The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/

How To Get the Right Texture and Consistency

To prepare foods to level 4 pureed, you will need a blender or food processor. You will not be able to chop the food fine enough by hand. Add the food to the blender or food processor. It’s helpful to cut the food into smaller pieces before putting it in the machine. It’s also best to purée more than one serving of food at a time, because most machines have trouble with small amounts – plus you’ll make less work for yourself in the future.

Turn the dial to “purée” or “high.” While the machine is running, add liquid in the top, a little at a time. If there’s not an opening in the top, add the liquid before turning on the machine. Turn the machine off, and scrape down the sides as needed. Continue doing this until the food is smooth and free of lumps, and the proper consistency. If it is too thin, you will need to thicken it with a thickening agent.

Liquids that may be used to purée foods (not all of these are appropriate for every situation):

• Chicken/beef/vegetable broth
• Milk or cream
• Non-Dairy Milk (soy, almond, etc.)
• 100% Vegetable juice
• 100% Fruit juice
• Gravy

*Note: Do not use water to purée foods. Water dilutes the flavor of foods, making them less tasty.

Use one of these thickening agents if the food is too thin (not all of these are appropriate for every situation):

• Thick-It, Thicken Up, etc.
• Powdered Milk
• Powdered Mashed Potatoes
• Canned pumpkin or sweet potatoes
• Applesauce
• Hummus or other pureed beans

Foods to Avoid on the Level 4 Pureed Diet

While most foods can be pureed, there are some that shouldn’t be pureed, or that just don’t work out well in a pureed form. These are some foods that should not be pureed (please note that this list may not be exhaustive; caretakers will need to consult with the speech therapist or appropriate medical professional).

• Peanut butter and other nut butters, unless pureed with another food to the appropriate consistency, as outlined above
• Bread – bread should be slurried, without the crust, and should not be pureed in a blender unless it is part of another food (like stuffing)
• Raw vegetables
• Corn and peas – the skins generally don’t purée well
• Hard raw fruit, like apples, fruits with skin, like grapes, or fibrous fruits, like pineapple and rhubarb
• Dried fruit
• Some steak and other gristley meats
• Bacon
• Pizza and other foods that are similarly dry. In order to get the proper consistency, you’d have to add too much liquid and the flavor of the original food would be lost.
• Cereal

Other foods to avoid giving to someone on a level 4 pureed diet are:

• Soup with pieces of food in it (always purée to proper thickness and consistency with no lumps)
• Hard candies or lollipops
• Cheese chunks
• Marshmallows
• Chewing gum
• Sticky mashed potatoes
• Dry cake or biscuits
• Crunchy snacks, like chips and pretzels
• Over cooked oatmeal or porridge
• Gelatin
• Any crust or skin that forms on food after heating, like cheese
• Juicy foods where liquid separates from the food in the mouth, like watermelon (purée and thicken to proper consistency)

Tips For Feeding

Since individuals requiring a level 4 pureed diet are at an increased risk of choking, there are some tips and strategies you can use to help lower that risk. Unless otherwise ordered by a physician or speech therapist, follow these tips:

• Have the person sit upright at all times and wear/use any adaptive equipment needed, including during administration of medication and while drinking beverages.
• If the individual is able to eat unassisted, do not feed them. If assistance is needed, provide the minimal assistance necessary. This helps preserve the individual’s dignity.
• Use a small spoon or a “baby” spoon. Having too much food in the mouth at a time is a choking hazard.
• Ask the treating medical professional about prescribing adaptive eating utensils that may decrease the risk of choking.
• Allow the person adequate time to “chew” the food and swallow before offering more. Do not rush.
• Offer a sip of a drink after each bite to help clear the mouth.
• Check the person’s mouth after each bite to make sure s/he is not pocketing food in the cheeks, and that it is not sticking to the teeth or the roof of the mouth.
• Do not comment negatively on the look, smell, or texture of the food. This can influence the person to not eat or eat less. Find something to comment positively on.
• Make efforts to make the foods look nice on the plate. Everyone eats with their eyes first. Use different shapes, sizes, and colors. Example:

Source: The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/

Remember that not all individuals on the Level 4 Pureed Diet will require Extremely Thick Liquids, but all level 4 pureed foods need to be thickened to extremely thick consistency. Always consult your supervisor, the speech therapist, or dietitian with any questions you might have about how to prepare certain foods or if it may or may not be given.

With the right strategies, you can prevent a majority of choking episodes!