IDDSI Level 4: Puree Diet

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You may find that certain foods and drinks are less easy to chew and to swallow. This may cause you to cough or choke which could be dangerous. It has been recommended that you follow a special diet. You should be referred to a speech and language therapist who will assess your ability to swallow and working together with the dietitian, they will advise you on:

• The texture of foods best suited to your ability to swallow
• The best sitting position , posture and ways to make swallowing easier
• An eating plan, which takes account of your likes and dislikes and provides adequate nourishment and hydration

This booklet contains ideas and practical advice on how to make puréed food correctly and to make sure your diet remains varied and enjoyable. If you have a small appetite or you have recently lost weight, you will also find some advice on how to enrich your meals to make them as nourishing as possible. If you need a special type of diet, for example, gluten-free, lactose-free, dairy-free, low sodium or low potassium, speak to your Dietitian about which foods are suitable for you.

What is puréed food?
Pureed food has a completely smooth, uniform texture. It has no lumps or bits and does not require chewing. Pureed food can be piped, layered or moulded and holds its shape on a plate. It is usually eaten from a spoon. If you enjoy a diet associated with a cultural background or religious belief (ethnic food), and after reading this booklet you’re not sure whether certain foods are suitable for a puréed diet, ask your Speech and Language Therapist for more advice.

Why do I need puréed food?
Sometimes, the swallowing muscles in the mouth and throat can become weaker, slower or less coordinated. This can be due to being unwell or as a result of certain medical conditions. These changes might make it more difficult to eat, chew and swallow your foods and could lead to food getting stuck in the mouth or throat, choking or ‘aspiration’.

‘Aspiration’ is the term used to describe when food has entered the airway. Aspiration can lead to serious chest infections, or pneumonia. Eating pureed foods can help to reduce the risk of aspiration and choking.

What are the signs of aspiration?

• Coughing, choking or throat clearing before, during or after swallowing.
• Shortness of breath before, during or after swallowing.
• Wet, gurgly voice quality.
• Changes in skin colour; e.g. face turning red and sweaty or very pale.
• Unplanned weight loss.
• Recurrent chest infections: if you are worried that you have a chest infection, please speak to your GP.

If you are concerned that you have any new symptoms/ changes in your swallowing, please tell your Speech and Language Therapist and/or GP.

A note about drinks
Most people need to drink 6-8 glasses or mugs of fluid (around 2 litres) every day to keep hydrated. You may need more on a hot day. Drinks may include water, squash, tea, coffee, hot chocolate, milk and milky drinks, fruit juice or smoothies, enriched drinks or nutritional supplements. If you’re having problems swallowing drinks, your Speech and Language Therapist will tell you how to
make sure you’re drinking safely. There is a separate booklet available for people who also have problems swallowing drinks – ask your Speech and Language Therapist for details.

How do I make puréed food?
Some foods are already naturally a puree consistency such as yoghurt, mousse, mashed potato etc. These foods would not need any further modification.
Most of your everyday foods can be made into a puree. You may need:

– A food processor, blender or liquidiser
– A sieve
– Piping bags or moulds (if you wish to shape the food)

If food requires cooking it is recommended you cook it before you puree it. Some foods may require extra fluid to achieve the right consistency but be cautious with this, and only add when needed. If adding extra fluid try and use ones which add extra nourishment such as milk, white or cheese sauce, stock, gravy, custard.

Meats and fish: remove all skins, bones and gristle before blending. Cook meat so it is tender.
Vegetables and pulses: try to avoid overcooking your vegetables as this can lead to the puree being too watery. Some vegetables and pulses may need to be passed through a sieve after blending in order to achieve a smooth consistency.
Fruit: remove skins and seeds before blending. Fruit options suitable for blending could include stewed fruits, tinned fruits, or fruits mixed with cream/yoghurt/condensed milk. Some fruits may need to be passed through a sieve after blending in order to achieve a smooth consistency.
Breakfast cereals: must be mixed with milk and blended to form a uniform consistency.
Bread, rice and pasta: these can be difficult to puree and are likely to require extra liquid when blending. You may struggle to achieve a smooth consistency and it may be safer to consider alternatives.

Are there any foods I can’t have on a puree diet?
Most foods can be pureed, but there are exceptions. The following do not puree well and will not make the correct consistency foods:
• Crisps, nuts and crackers
• Muesli or hard cereals
• Raw or salad vegetables
• Dried fruit
• Skins, pith or seeds, including seeded jam
• Boiled sweets, toffees and chunks of chocolate
Whilst your Speech and Language Therapist is advising you to have a pureed diet, these foods should be avoided. This may not be a permanent change – please discuss this further with your Speech and Language Therapist.

How can I check my food is the right consistency?

Fork Pressure Test:
The prongs of a fork can make a clear pattern on the surface or the food retains the indentation from the fork.

Fork Drip Test:
The food sits in a mound/ pile above the fork; a small amount may flow through and form a tail below the fork prongs, but it does not flow or drip continuously through the prongs of a fork.

Finger Test:
It is just possible to hold a sample of this texture using your fingers. The foods should slide smoothly and easily between the fingers and leaves noticeable residue.

Top Tips!
Appearance: Don’t puree a whole meal together, unless it is a complete meal such as a stew. Puree each individual element separately and serve them so you can see each portion of food on the plate. This retains the individual flavours of each food.
Shapes: You could consider piping or layering your pureed foods. You could also serve your pureed foods with an ice cream scoop onto the plate. You could also use food moulds to shape your pureed foods.
Variety in meals: It is important to keep variety in your meals to keep you interested in food and eating. You will need a healthy balanced diet to ensure you get all the nutrients you need.
Flavour: Season foods to taste after pureeing. You could consider adding herbs, spices, or other sauces.
Environment: Eat in a quiet and relaxed atmosphere where there are no distractions and no rush to finish quickly. This will help you concentrate on eating safety.

Sample Menu
• Pureed fruits
• Yoghurt/ Fromage frais
• Smooth blended cereals e.g Ready Brek
• Pureed sausages (skins removed)
• Pureed baked beans (husks sieved out)
• Smoked haddock puree

Lunch and Dinners:
• Smooth pates or savoury mousse
• Hummus and taramasalata
• Blended Bolognese with smooth cheese sauce
• Pureed meats served with pureed vegetables and creamed potato
• Fish blended with parsley sauce
• Blended casseroles and stews
• Sweet potato puree

Puddings and Snacks:
• Angel delight or instant whips
• Thick custard
• Pureed fruit and cream
• Pureed rice pudding or tapioca
• Yoghurt and fromage frais (no lumps)
• Cake blended with custard/cream
• Ice cream and jelly (If you have been recommended to be on a thickened fluid, these items may not be suitable as they melt to a thinner fluid)

What if I have a small appetite?
As you get older, it’s natural to start eating less because you tend to become less physically active. This means your body might need less food.
• If you can’t manage to eat three large meals per day, have smaller amounts more frequently with nutritious snacks between mealtimes, such as those on Pages 3 and 4.
• If you find it difficult to eat a full meal, have a milkshake, hot milky drink or cup-a-soup made with enriched milk after eating. Alternatively, enjoy a thick soup and a pudding instead.
• It’s important to eat regularly, at least three times a day. You might not always feel like cooking so you could choose to eat more tinned, chilled and frozen ready-prepared meals. It’s a good idea to make some puréed foods in bulk and store them in the freezer. Divide them into portions using small storage containers or freezer bags. Always make sure you heat chilled and frozen food until
it’s piping hot all the way through.
• Use enriched drinks such as Build Up or Complan as a nutritious snack between your meals to give you the extra calories and nutrients your body needs. You can buy these from your chemist
or supermarket.
• Because drinks can make you feel full, you might not feel as hungry after drinking. Instead of drinking before you eat, drink after meals, or in between meals, so that you feel hungrier and can
eat more at mealtimes.

How can I add extra nourishment to my drinks?
Use the following ideas to help you increase the calories in your drinks:

• Use full fat milk instead of semi-skimmed or skimmed milk.
• Enrich your milk by adding 4 tablespoons of milk powder to 1 pint of full fat milk. Mix the milk powder into a smooth paste with a little of the milk. Then whisk in the rest of the pint with a fork or whisk.
• Try to use at least 1 pint of enriched full fat milk in your food and drink every day.
• Use enriched full fat milk instead of water to make hot and cold drinks, such as those below:

o Milky coffee made with enriched warm milk.
o Hot chocolate or malted drink such as Horlicks or Ovaltine made with enriched milk.
o Cup-a-soup made with enriched warm milk.
o Yoghurt or banana blended with enriched milk to make a thick drink – add honey, syrup, treacle,
o Milk or milkshake made with enriched milk and ice cream.

How can I add extra nourishment to my food?
Use the following ideas to help you increase the calories in your food:

• Use enriched milk, cream or double cream, evaporated or condensed milk when making drinks, porridge, puddings (e.g. custard, rice pudding, Angel Delight), soups, mashed potatoes, white and
cheese sauces.
• Add 1-2 handfuls of grated cheese, or extra cream cheese, cream, butter, margarine, or mayonnaise to warm vegetables, potatoes, stews, soups and sauces.
• Add extra sugar, cream, syrup, jam, honey, treacle or chocolate spread into puddings, drinks and cereals. If you have diabetes, speak to your doctor, Dietitian or diabetic nurse for more advice. You may need to check your blood sugar levels more often, or you may need to change your medication. • Use full fat dairy food instead of low fat options, for example, thick and creamy yoghurts, full fat cream, cheese and mayonnaise.

How can I tell if I’m losing weight?
Weigh yourself weekly to check if you’re losing weight. If you can’t weigh yourself, you may notice you’re losing weight if your clothes or jewellery feel looser. If you have followed this advice but you’re still losing weight, ask your Dietitian, doctor or practice nurse for more help. A modified diet should not result in any weight loss. If you have concerns that you are not meeting your nutritional needs or are losing weight, please contact your GP or dietitian for further advice.

Contact Details
If you have any questions or concerns, please contact your speech and language therapist.
Speech and Language Therapy Service
Milton Keynes University Hospital
Standing way
Milton Keynes
Tel: 01908 725292