Level 4 is the first level to encompass both food and drinks. As a diet recommendation it is known as Puree and as a fluid recommendation it is known as Extremely Thick. Puree food should be smooth without any lumps or “bits” but not sticky and should easily slide off the spoon when completing the spoon tilt test. The difference between this and other smooth and thick consistencies is that it should still hold its shape on a spoon or fork, and not flow through the prongs of a fork- a few drops may fall but it should not flow.
This consistency does not require chewing and only needs to be transferred to the back of the mouth for swallowing and even still, requires less effort to do so than other more solid foods. Therefore, it’s appropriate for people who can not chew adequately, people with a weak tongue or both. For the same reason though, it’s important that the food isn’t sticky otherwise there could be added difficulty clearing the residue from the sides and roof of the mouth with a weak tongue.
It’s hard to make a list of what specific foods are and aren’t appropriate as a puree diet because it’s more about how they are prepared and (then) blended, and whether or not there is any remaining texture, lumps or excess liquid afterwards that might pose a choking or aspiration risk. I think what’s more important is how foods are prepared to ensure they are appropriate and how appetising they are. Some naturally occurring puree dishes that come to mind include yoghurts (without fruit pieces), mousse, custard, mashed potato, oatmeal- the list goes on.
As an extremely thick fluid, it cannot be drunk from a cup or sucked through a straw and holds all the same characteristic requirements described above, including the spoon tilt test. The difference with drinks is that the appropriate consistency is often created using a thickening powder rather than culinary processes or via the selection of specific liquids. This thickness is often prescribed because they move at a much slower rate than standard or non-modified drinks which allows the person time to transfer them from the front to the back of the mouth, and initiate the swallow reflex so they don’t aspirate their drink.
The same as minced and moist, due to the heavier modifications, this is where texture fatigue and reduced interest in food can take reign so it’s important to keep things creative by using colour, temperature, vast flavours and moulding when displaying the food to keep mealtimes interesting and appetising.
** These posts are not meant to be used as a diagnostic tool. Diet and fluid recommendations should be prescribed by a practicing speech pathologist. **
** ‘These are NOT official IDDSI resources, educational materials or education programs and they are NOT meant to replace materials and resources on www.IDDSI.org’ **
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