Optimizing appeal of the IDDSI 4 pureed diet 

In the older adult population, research suggests that up to one in three individuals may experience changes in their ability to swallow or have been diagnosed with dysphagia. This can be caused by progression of a neurological disorder, changes with the gastrointestinal tract, or simply as a symptom that presents as part of the aging process.

Treatment and recommendations for diet consistency can vary amongst individuals. Some older adults may require specific swallowing techniques with softer textures and smaller bites of food. Others with more severe dysphagia may need an IDDSI (International Dysphagia Diet Standardisation Initiative) Level 4 pureed diet to eat safely.

Adjustment to this type of diet modification can be a challenge, especially in addition to other nutritional barriers with the older adult patient population. The registered dietitian nutritionist (RDN) can be helpful in navigating this transition to promote an optimal nutritional status.  

What is the IDDSI Level 4 pureed diet?

Introduced in the United States in 2019, the IDDSI diet encompasses seven different levels for food and beverages, with Level 4 being pureed in consistency. This level is often prescribed for the individual who may have difficulty with foods that require chewing or are unable to swallow foods with more texture because of a change in tongue control. A fork drip test or spoon tilt test are recommended methods to use in determining if the food item meets standards for a puree. In general, the texture of a pureed diet is smooth, maintains its shape, lacks stickiness, and can easily be removed from a spoon while eating.  

Food groups and recommendations

Making meals in a pureed consistency requires cooking methods with the addition of liquids to promote a blended texture, a food processor/blender, and a strainer for removal of any excess fluid or lumps. Meal items can be made ahead of time and stored. If rewarming the pureed food item, caution is suggested in ensuring that the consistency is maintained and foods that may develop a crust or become too sticky should be monitored. Variety on a pureed diet can be included with consideration of the following in each of the food groups: 

• Protein: Adding the correct amount of liquid (gravy, broth, etc.) is key during the cooking process and when the food is ready to be pureed. Foods that are too dry, have nuts or seeds, skins, or may have bones should be excluded. 
• Bread, cereal, or pasta: Providing enough moisture to the food item while cooking, soaking or boiling is necessary to create the desired pureed texture. Foods should be blenderized into a smooth consistency of liquids and solids.   
• Dairy or dairy-free alternatives: Milk, yogurt, and other dairy alternatives can be used for added nutrition, moisture during the cooking process, or as part of a meal or snack.  Certain smooth yogurts may require no modification while foods like cheese should be consumed only if pureed as part of the food item. 
• Fruits and vegetables: Canned or cooked fruits and vegetables can offer a wide variety of soft foods that can be blended into a puree. Those that need to be monitored include dry items or contain skins or seeds.  

Optimizing appeal of the pureed diet

No matter where the pureed diet is being served, appeal matters and can greatly influence appetite and desire to eat. A plate full of indistinguishable foods is not going to be enticing. Instead, with a few quick fixes, eating a pureed diet can be made enjoyable for the individual with dysphagia.  

• Presentation: Appearance of meals and snacks can impact the patient’s appetite. Unenticing meals lacking color and variety can limit interest and desire to eat. Using molds for better food identification, different serving dishes, and helping the patient identify different foods have each been recognized as simple tools to improve meal presentation. 
• Flavor: The taste of that first bite will also influence if an individual wants to finish a meal. Certain products can be made with tasteless starch to help maintain normal food flavors but also provide the needed thickening. The addition of spices and seasonings that can be pureed easily with the food can also enhance flavor without loss of the necessary texture. 
• Variety: While some foods certainly require more skill to create a pureed form, adding in a wide variety of foods is beneficial not only for different nutrients but also to support individual appetite. Planning menus with a variety of foods can help caregivers offer a pureed diet at home. If meals are served at a living facility, try to encourage the individual to try different options to enhance intake. 
• Meals: Incorporating each of the different food groups, while maintaining individual preferences, can make the pureed diet less daunting and more of an enjoyable experience. If there are certain nutrients lacking, adding nutrition modulars that easily blend into food items can be an option in addition to oral nutrition supplements.  

Impact of nutrition

An individual’s diet is not just important for their overall nutrition status. The ability to eat can also impact the older adult’s mental health and quality of life. Oftentimes other comorbidities may influence diet recommendations beyond those of the dysphagia diet. Working with an RDN can help these individuals find the right balance and combination of meals to support their individual goals.  

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References 

Thiyagalingam S, Kulinski A, Thorsteinsdottir B, Shindelar K, Takahashi P. Dysphagia in older adults. Mayo Clin Proc. 2021;96(2):p488-p497. doi:10.1016/j.mayocp.2020.08.001.  

Nutrition Care Manual. IDDSI Level 4 Pureed (Green) Nutrition Therapy. Available at https://www.nutritioncaremanual.org/. Accessed April 23, 3024. 

IDDSI. 4 Pureed. Available at https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf. Accessed April 26, 2024. 

Lam C, Phua Q, Guo E, Sia I. Impact on moulded pureed diet on taste, appearance, recognizability, and overall liking among patients in an acute hospital. Front Nutr. 2023; 10:1248779. doi: 10.3389/fnut.2023.1248779.