Swallow and Nutrition Support - Pureed Level 4 Diet

What is a puréed (Level 4) diet?

• food has been puréed or has purée texture; it does not require chewing
• it is smooth with no lumps, fibres, particles of skin or husk, gristle, bone etc.
• it is moist and should not be rubbery or sticky. It’s important that puree foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat
• any fluid contained within the meal, including sauces and gravy, should be as thick as the purée itself 
• it should hold its shape on a spoon and fall off in a single lump when tilted.

Why do I need puréed food?

Puréed food may be needed if you are not able to bite or chew effectively. It can also be used if you have difficulty using the muscles in your mouth, tongue and lips. Puréed foods do not need to be chewed and can be moved easily by the tongue.

How to create puréed food 

• a stick blender or food processor is useful for achieving the desired texture
• a sieve or strainer may be needed to remove any fibres or lumps 
• food should be soft and tender before you blend it into purée
• cut food into small chunks before you blend it into purée
• purée small quantities at a time. Be careful not to blend the food when it is still extremely hot 
• tough or fibrous foods can be difficult to purée. Make sure you purée drier foods (eg. meat) with extra fluids such as thick gravy, white sauces, or soups
• remove tough skins and seeds from fruit and vegetables before puréeing
• strain foods and liquids after being puréed to remove any lumps. Check that no hard pieces, crust or skin have formed during cooking
• check that there are no runny liquids.

Meal preparation hints

• cook ahead and freeze meal portions to save yourself time
• try to make meals more appetising by separating meat and vegetables or try layering different colour foods to make the food look as attractive as possible 
• many family meals are suitable to purée provided the food is soft and tender 
• vary the flavour of foods by adding herbs, spices and condiments to meals — for desserts and milk drinks you can add: sugar, honey, vanilla essence, nutmeg and cinnamon. For soups and savoury dishes you can add: marmite, herbs, spices, curry powder, pepper, vinegar, mustard, lemon juice, sauces (barbecue, chilli, mustard or Worcestershire sauce)
• ready-made foods can save you time. For example: smooth canned or  refrigerated soups (eg. tomato), packet and ready-made custards, packet mix instant whip puddings and mousses, flavoured smooth yoghurt.

Sometimes a puréed diet may not be enough to meet your nutritional requirements, especially if you have a small appetite. If your portions are smaller than normal, it is important that you eat foods that are nutritionally dense. Try some of the ‘top tips’ 
below:

• eat your most filling meal of the day when your appetite is at its best
• serve smaller, more manageable portions
• have snacks or nourishing drinks between your meals
• eat foods that you enjoy
• fresh air or activity before your meal may help stimulate your appetite
• use whole milk if possible
• if possible add cheese, butter, or sour cream to puréed potatoes 
• cover vegetables such as purée cauliflower and broccoli with a cheese sauce
• add evaporated milk or cream to puddings such as Angel Delight and custards 
• be generous with butter, margarine or oil in cooking puréed meals
• add jam, syrup, sugar or honey to drinks, puddings or breakfast cereals

Snack ideas

• thick and smooth fortified soup and fortified milk (see recipes below)
• cheesy mashed potato
• smooth guacamole and puréed carrots
• milky puddings or custard made with full-fat milk or fortified milk
• full-fat yoghurt with puréed fruit
• a bowl of porridge made with full-fat milk or fortified milk and honey.

Nourishing drinks

If you are unable to manage a full meal you can increase your intake with nourishing drinks. Try the following suggestions:

• make a smoothie with puréed fruit, honey, ice cream and fortified milk
• replace water with fortified milk to make a creamy coffee
• add cream to hot chocolate
• try Complan or Meritene drinks, available from chemists and supermarkets.

Fortified milk 

Ingredients

1 pint or 600ml of full fat milk
4 tablespoons of skimmed milk powder 

Method

Mix the milk powder to a paste with a little of the milk, then stir in the rest of the milk. 
This fortified milk can be used in drinks, breakfast cereal or wherever you would normally use milk

Fortified soup

• add fortified milk, instead of water to condensed soup or cup-a-soup before
  liquidising OR 
• add milk powder, cream, soft cheese, and/or olive oil to homemade or puréed
  canned soups.

Remember; drinks may need to be thickened according to your speech and language therapist’s advice.

It is important to eat food from each of the core food groups every day. These are starchy carbohydrates, fruit and vegetables, meat and meat alternatives, and milk products. Seek further information from your dietitian if required.

Starchy Carbohydrates

Acceptable foods for a pureed diet and ones to avoid

Acceptable for Puréed Diet	Avoid
Ready Brek Cereal soaked in milk and puréed (Weetabix) Semolina Boiled puréed potatoes/sweet potatoes/yams Scooped out jacket potato Puréed pasta and rice dishes, such as: puréed creamed rice puréed savoury rice with sauces puréed macaroni cheese puréed meat and pasta dishes with white or cheese sauces, gravy or tomato sauces puréed canned spaghetti.	Muesli or cereals with added dried fruit and nuts Lumpy porridge Bread, bread rolls, crumpets, muffins and toast Naan bread Chapatti Dokra Cakes, pies, pastries, and biscuits Pieces of rice, pasta or noodles Jacket potato with skin.

Fruit and Vegetables

Fruit and vegetables acceptable for a pureed diet and those to avoid

Acceptable for Puréed Diet

Avoid

Thickened fruit and vegetable juices Puréed fruit smoothies Smooth vegetable soups Creamy vegetable sauces Puréed soft fresh fruit, eg melon, banana, mango, peeled peaches, pears, plums, nectarines (thicken if watery) Puréed, stewed or canned fruit, eg. apple, pear, apricot, peach, plum Well-cooked fresh, frozen, or canned vegetables, that are puréed and strained, eg. carrots, sweet potato, cauliflower, broccoli,  potato, squash, sweet potato, and plantains Puréed vegetables can be added to smooth stews, soups, curries and casseroles Ripe avocado or guacamole that is puréed or smooth hummus.

Dried fruit Unpeeled fruit Hard fruit, fresh apple, pineapple, passion fruit, oranges, berries and coconut Rhubarb and grapes Skins, pips or seeds Stringy or tough vegetables, eg. celery, sweetcorn, peas, beans,  tomatoes, cabbage Vegetable skin and seeds Raw vegetables and salad Undercooked/crunchy vegetables Soups with lumps Smoothies with lumps.

 

A guide to milk and milk products acceptable for a pureed diet, and those to avoid

Acceptable for a Pureed Diet	Avoid
Plain or strained fruit yoghurt Cream cheese  Yoghurt desserts, eg. smooth fruit fool (no pips or rhubarb strings) Blancmange Egg custard without the pastry Soft smooth milk puddings, eg junket, cheesecake without crust, mousse, instant pudding White and cheese sauces.	Grilled cheese or hard cheese Unstrained fruit or nut yoghurt Cottage cheese.

A guide to meat and meat alternatives acceptable for a pureed diet, and those to avoid

Acceptable for Puréed Diet

Avoid

Puréed and strained meat, curries and casseroles, eg. beef, lamb, chicken, turkey Soups containing meat or poultry – puréed  and strained. Add puréed vegetables for taste and nutrition  Boneless fish fillets (steamed or grilled) puréed with white sauce Canned tuna or salmon, puréed as above Scrambled eggs (puréed with cream) Smooth pâté and smooth peanut butter Legumes, eg. chickpeas, lentils, kidney beans, canned and boiled until soft – then puréed with enough liquid to form desired  consistency.

Tough, stringy or dry meat or  poultry Crumbed meat Grilled meat Sausages, salami, frankfurters Any meat, chicken or fish that is not puréed Nuts and seeds, crunchy nut butters Fish with bones Eggs (boiled, poached, fried or as omelette) Pies and sausage rolls Coarse or lumpy pâté.

 

Before eating and drinking please ensure that the person who is eating:

• can remain consistently awake and alert during eating and drinking
• is able to sit as upright as possible
• has a clean and clear mouth.

During eating and drinking please ensure that the person who is eating:

• has the correct texture of diet and fluids recommended by the speech and 
  language therapist
• if you are feeding, explain what you are doing and what the person will be eating and drinking
• ensure the mouthfuls provided are not too large 
• concentrate on each swallow
• monitor for any coughing, ‘gurgly’ voice, increased respiratory rate or fatigue. If  you notice any of these symptoms, stop and contact the community speech and language therapist for advice. 

You may also need to:

• remind the person eating to swallow more than once each time to clear any 
  residue 
• allow extra time between mouthfuls for extra swallows

At the end of eating and drinking:

• ensure the person’s mouth is clear and clean
• keep the person sitting up for 30 minutes, to minimise the risk of reflux
• medication may also need to be modified in line with eating and drinking guidelines. Please speak to your pharmacist for advice.

If you are on texture modified fluids (thickened drinks) a speech and language therapist may advise you to avoid ice-cream and jelly. This is because ice-cream and jelly change consistency in your mouth, and become too runny. Please speak to your therapist if you are unsure. 

If you would like more information on how to prepare a puréed diet please visit the IDDSI website www.IDDSI.org. You can also find information on how to use the fork test and spoon tilt test to check that your food is the correct consistency.

Who should I contact if I have a problem or question?

If you have concerns regarding swallow safety or aspiration, contact your GP who can put you in touch with your local Community Speech and Language Therapy Team.

Dietetic Department, Hillingdon Hospital: 01895 279416

What should I do in case of an emergency?

Contact your GP or call 111 if non-urgent. Attend A&E or call 999 if an emergency.