IDDSI Level 4 Pureed (Green) Nutrition Therapy

IDDSI Level 4 Pureed (Green) Nutrition Therapy

A level 4 puree diet is prescribed to patients who may have pain when chewing or swallowing or are unable to bite or chew foods. Foods in this diet should not require chewing and should fall off a spoon easily. These foods are easy to swallow because they are pureed smooth and free of lumps.

Your registered dietitian nutritionist (RDN) can help you figure out how to include your favorite foods while following this diet.

How to Test Your Food

Use a fork for drip and pressure tests and a spoon for tilt test to check if your foods are safe to eat while on this diet. Cooking method and serving temperature can affect texture, so be sure to test your foods just before you begin to eat. It is important to do both the fork drip test and the spoon tilt test when evaluating pureed foods.

IDDSI Fork Drip Test- Food should not have lumps, stays as a mound on fork and has very little or no flow through prongs. A small amount may flow through but it does not drip continuously.

IDDSI Spoon Tilt Test: Food should hold its shape on the spoon but slide off easily with almost no food left on the spoon. You may need to gently flick the spoon to get food to fall off and there may be a small thin film left on the spoon. Food that doesn’t fall off the spoon when tilted or sticks to the spoon is too thick.

IDDSI Fork Pressure Test: When fork is pressed into the food sample, tines make a pattern on the surface when fork is pulled through the food sample. The food may briefly show the fork indentation marks.

To test gelled, molded, or shaped pureed foods: Confirm it is not too firm or too sticky. You will know it’s too firm if the pureed food can be cut into pieces or can be easily picked up with fingers. Puree food should not need to be chewed. You will know if it’s too sticky if it does not pass the spoon tilt test.

Tips

Prepare foods to make them smooth, lump free, and not too firm or sticky.

Use a food processor or blender to puree foods.

Add gravy, sauce, vegetable juice, cooking water, fruit juice, milk, or half-and-half to pureed foods to prevent lumps and provide moisture.

Serve foods with thick enough liquids so that the liquid does not run off the food or separate from the pureed solid foods. Thicken liquids to the consistency recommended by your clinician.

Strain the liquid or blend it in so the food is one consistency. Some strategies:

Drain excess milk from smooth cereal

Strain pureed fruits to remove excess fluid

Create a roux from water and flour to thicken the broth, gravy or sauce from soups, stews and casseroles. Blend/puree together to make one food product.

Monitor leftover foods while re-heating to make sure they don’t form a tough outer crust that could make the food harder to eat.

Foods Recommended and Not Recommended

Food lists are based on the International Dysphagia Diet Standardization Initiative (IDDSI) Framework. All foods that you eat must pass the IDDSI level 4 testing methods.

The following table is not a complete list of foods recommended. Other foods may be OK to eat as long as they meet IDDSI testing requirements. Ask your RDN if you want to know they safety of other foods not included on this list.

Grains – Food Recommended

Pureed soft-cooked hot cereals with no lumps. Served without excess liquid.

Soft breads, rolls, pastries, pancakes, French toast, muffins, donuts, and bread dressing that have been pureed.

Pre-gelled, soaked bread, cakes, cookies, and other grains that are consistently moist throughout without hard parts formed during sitting.

Pureed, moist pasta, potatoes, and rice without lumps, Liquids/sauces do not separate from food.

Grains – Food Not Recommended

Grains

Any item that is not pureed or has lumps. Dry cereal, cooked cereal with lumps, cereal with seeds.

Grainy, sticky, or glutinous rice. Rice that separates into individual grains when cooked or served.

Pre-grilled, shaped, and molded puree foods that are too firm or sticky at serving temperature.

Protein Foods – Food Recommended

Pureed, moistened, tender protein foods that meet IDDSI Level 4 puree testing expectations:

Red meat, including beef, pork, or lamb.

Poultry, including skinless chicken or turkey.

Seafood, including fish (salmon, herring, and sardines), shrimp, lobster, clams, and scallops.

Pureed eggs and egg substitutes.

Pureed, smooth casseroles with no liquid separating from the solid; moist with incorporated sauces/ gravies.

Pureed, moistened soy foods, such as tofu or tempeh.

Pureed, moistened meat alternatives, such as veggie burgers, and sausages based on plant protein.

Pureed, smooth, moistened legumes, such as dried beans, lentils, or peas.

Protein Foods – Food Not Recommended

Protein foods not pureed into smooth, lump free items.

Protein foods served with undrained thin liquids.

Chicken, turkey and fish with skin on or with bones.

Chunky and smooth nut seed butters, unless used in a recipe that is pureed and meets testing expectations.

Whole nuts and seeds, such as peanuts and almonds: pistachios and sunflower seeds.

Dairy and Dairy Alternatives – Food Recommended

Smooth yogurt (without nuts or coconut) or pureed; and pureed cottage cheese.

Whipped cream cheese, sour cream, and whipped topping used in allowed recipes and as condiments.

Frozen desserts such as ice cream, sherbet, malts, and frozen yogurt if recommended by your clinician.

Milk, fortified soy milk, fortified nut milk in the liquid consistency recommended by your clinician.

Dairy and Dairy Alternatives – Food Not Recommended

Yogurt with lumps, seeds, fruit pieces, nuts or coconut; yogurt that is too thin, separates into liquid or is too thick.

Cheeses unless pureed into allowed recipe.

Frozen desserts such as ice cream, sherbet, malts, and frozen yogurt unless approved by your clinician.

Vegetables – Food Recommended

Pureed cooked tender vegetables and potatoes. If indicated, serve in a thick and smooth sauce or gravy, draining excess. There should not be thin liquid separating from food.

Smooth tomato sauce without seeds.

Mashed potatoes and whipped sweet potatoes without skin

Vegetable juices in the liquid consistency recommended by your clinician.

Vegetables – Food Not Recommended

All raw vegetables.

Stir-fried or fried vegetables that do not puree into smooth, lump free product.

Fruit – Food Recommended

Pureed canned and cooked fruits, drained of excess juices; pureed fresh fruit if smooth and lump free with no separate of liquids.

100% fruit juice in the liquid consistency recommended by your clinician.

Smooth, lump free pureed prunes and apricots that pass IDDSI puree testing expectations.

Fruit – Food Not Recommended

All non-pureed fruits; seeds and skins.

Stringy, high-pulp fruits such as papaya, pineapple, or mango that do not puree into smooth, lump free product.

Uncooked dried fruits such as raisins, prunes, or apricots.

Fruit leather, fruit roll-ups, fruit snacks, dried fruits.

Beverages – Food Recommended

Coffee, tea, water, and nutritional supplements in the liquid consistency recommended by you clinician.

Beverages – Food Not Recommended

Liquids not approved by your clinicians.

Other – Food Recommended

Pureed foods, including all soups with tender meats, casseroles, baked goods, and snacks made from recommended ingredients that are smooth and lump free.

All seasoning and sweeteners; honey if mixed into food that passes IDDSI testing expectations.

Other – Food Not Recommended

Jelly

Level 4 Pureed (Green) Sample 1-Day Menu

Meal

Breakfast

1 scrambled egg, pureed

½ cup farina, prepared (served without excess liquid) 1 muffin, pureed

1 teaspoon butter

½ cup orange juice (in liquid consistency recommended by your clinician)

1 cup coffee (in liquid consistency recommended by your clinician)

1 cup 1% milk (in the liquid consistency recommended by your clinician)

Lunch

1 cup moist pureed beef stew, excess liquid drained

½ cup pureed cottage cheese, excess liquid drained

1 slice pureed bread

1 teaspoon butter

½ cup pureed fruit cocktail, excess liquid drained

½ cup cinnamon custard, pureed as needed to meet IDDSI testing

1 cup 1% milk (in the liquid consistency recommended by your clinician)

Dinner

3 ounces moist, tender pureed chicken served with:

2 tablespoons of gravy, that does not separate from chicken (in the liquid consistency recommended by your clinician)

½ cup mashed potatoes

½ cup cooked pureed carrots

1 slice pureed bread

1 teaspoon butter

½ cup canned puree peaches, excess liquid drained

1 cup 1% milk (in the liquid consistency recommended by your clinician)

Snacks

½ cup vanilla pudding, smooth and passes IDDSI testing