IDDSI Level 4: pureed and extremely thick. The differences between altered texture foods and liquids. Formerly known from the National Dysphagia Diet as Pureed foods and Pudding thick liquids. Pictures of the IDDSI framework pyramids on either side of the frame, one highlighting foods and the other focusing on liquid levels.

IDDSI Level 4: Pureed Foods and Extremely Thick Liquids

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IDDSI Level 4 is a dual level, it refers to both a liquid consistency and also a food texture consistency. The International Dysphagia Diet Standardisation Initiative (IDDSI) was developed to clarify dysphagia diets so they are easier to understand. IDDSI puts liquids and solids into 2 separate categories but explains that they overlap with levels 3 and 4.

Liquids in level 4 are referred to as extremely thick while foods are referred to as Pureed. In the National Dysphagia Diet (NDD) these were called pudding thick consistency for the liquids and Pureed for the foods (no change there!).

IDDSI Level 4 is white letters, In yellow letters pureed foods and extremely thick liquids on a blue background with yellow accents. Picture of the IDDSI framework levels in a circle on the right half of the graphic.

Why Thickened Liquids or Liquidized Foods?

Dysphagia is a condition (and diagnosis) related to difficulty swallowing. Difficulty swallowing can be caused by many health conditions. These health conditions include but are not limited to Parkinson’s disease, after a stroke, or due to anxiety.

For some their ability to swallow food and liquids safely improves, but for some it does not. A pureed diet and thickened liquids can be helpful for anyone re-training the muscles to move properly and regain strength. It may be helpful for anyone that has more sensitivity to texture and temperature.

These modified consistencies may also lessen a person’s risk of aspiration, or things going down the airway instead of into the lungs. Let’s dive into some of the specifics regarding Extremely Thick Liquids.

Extremely Thick Liquids, IDDSI Level 4

Extremely Thick Liquids are found under Level 4 of the IDDSI framework. These liquids are more solid than liquid. They do not have to be chewed and when using a fork, they are thick enough that they do not drip through the tines.

These thickened liquids:

  • Cannot be sucked through a straw
  • Usually “eaten” with a spoon
  • Fall off a spoon in one clump if turned upside down, they do not run like a thin liquid
  • Are smooth with NO lumps
  • Not easily poured from a cup
  • Hold their shape
  • Are not sticky

Level 4 liquids are for people who have more strength and less coordination with their oral muscles. Decreased coordination can lead to poor control of a thin or thinner liquid and can increase risk of aspiration.

Stickiness of liquids can be problematic as it can stick to parts of the mouth and cause “residue”. Extremely thick liquids should be smooth and not sticky so they move through the mouth easily.

Because IDDSI Level 4 liquids move slowly, the extra time gained from having slow moving liquids can increase a person’s ability to swallow safely.

Concerns with Extremely Thick Liquids

For anyone requiring extremely thick liquids, dehydration, or lack of fluid intake, can be a risk. Staying hydrated is incredibly important for anyone on thickened liquids. Drinking extremely thick liquids can be time consuming and exhausting as it requires increased strength to get these liquids down the esophagus.

Make a plan to get enough fluids in each day and add liquids to your pureed foods to increase your chances of staying hydrated. This plan may include making your thickened liquids for the day ahead of time and setting an alarm for when to drink a little bit.

Now lets talk about the foods for this IDDSI level.

Pureed Foods for IDDSI Level 4

Pureed foods are characterized by having a smooth texture with no lumps. These foods are cooked and seasoned normally, then blended using a good food processor or blender. This level of foods is very similar to the liquids:

  • Usually eaten with a spoon
  • Hold their shape
  • Do NOT require chewing
  • Fall off the eating utensil in one lump when tilted over
  • Separate from liquids that are a different consistency
  • Usually have liquid added during blending, this can increase moisture content and make the food easier to maneuver

It is important to note several things with this level. The food may have increased texture even though it is smooth, and should not be sticky as this can leave unwanted residue in the mouth.

Level 4 foods are recommended for people who have difficulty controlling the tongue. The tongue is responsible for controlling food and liquid. When control is decreased, having one single bolus ( roundish mass or lump, especially of chewed food) can make it safer to swallow.

The food should hold together so that the tongue can keep control during the swallow. The tongue only has to bring the food from the front of the mouth to the back of the mouth in order to swallow at this food level.

IDDSI Level 4 Pureed Foods To Avoid

Some foods should be avoided for anyone on this level due to risk of choking, pocketing, or difficulty chewing. Some of these foods include:

  • Mixed consistencies (soups that have more than one texture, or both solid and liquid)
  • Nuts & seeds
  • Raw vegetables
  • Tough foods that do not puree well like steak, ham, pineapple, rhubarb, etc
  • Chewy foods or candies (marshmallows, gum, etc)
  • skins of fruits
  • Lettuce
  • Sticky food like nut butter, oatmeal, and overly mashed potatoes

*Disclaimer – the above is not a comprehensive list. Please be aware of the foods that do not work for you and be cautious when adding new foods to your diet. Ideally, you will cook or blend raw foods, and add thickener and a liquid.

Testing For The Right Thickness

So how do we know if our food and liquids are modified to the right consistency? As with the other liquid levels, we can use the Flow Test or you can put your food or liquid on a spoon and determine if the food drips off in drops or falls off in one lump when tilted, or with the fork test.

Flow Test

When using the flow test, add your liquid to the funnel or syringe with your finger covering the spout. Set a timer for 10 seconds, release your finger and measure the amount left in the funnel after 10 seconds. For level 4, none of the liquid should have moved out of the funnel.

Spoon Tilt Test

For the spoon test, scoop some food or liquid onto a spoon. Then tilt the spoon over above your bowl or plate. The food or liquid should hold it’s shape as it falls into your dish. The food or liquid should fall off the spoon fairly easily and not be sticky or firm.

Fork Test

Lastly, we have the fork test. Scoop some of your food or liquid onto your fork, holding it over your plate or bowl. The food or liquid should not drip through the tines of the fork, it should hold its shape in a mound on the fork. There will also probably be a “tail” underneath the fork but it will be thick enough that it will not drip off the fork.

Conclusion of IDDSI Level 4

Extremely thick liquids and pureed foods, otherwise known as Level 4 on the IDDSI framework, are appropriate for some people with Dysphagia. Not everyone that requires pureed food also needs extremely thick liquids. You may have a specific recommended liquid level and a different recommended food texture level.

Discuss what is best for you with your healthcare team. A Speech Therapist and Dietitian can be a tremendous asset to your healthcare team. These professionals can help you find the safest food and drink textures for your diet. If you have questions send me a message by clicking the Contact link above!

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