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Starting with Purees: Implementing IDDSI in Healthcare

Puréed Classic Meatloaf served with puréed sweet corn and seasoned green beans on a white plate

Guest Author: Margaret Roche, MS, RD, CSG, CDE, FAND

Healthcare dining priorities have shifted in the wake of COVID-19. During this crisis, projects like implementing the International Dysphagia Diet Standardisation Initiative (IDDSI)* may have fallen to the bottom of the list.

However, it is still vital to focus on high-impact projects like implementing IDDSI. These standards can impact service in a powerful way by improving the safety and quality of texture-modified foods and thickened liquids served to those with chewing and swallowing problems.

There’s no doubt that learning about IDDSI can be a complex process. This post outlines how to implement IDDSI in a simple and straightforward way.

Begin the IDDSI journey with Pureed (Level 4)

The best way to develop an understanding of IDDSI is by learning the standards for one diet at a time, beginning with Pureed (Level 4). Pureed (Level 4) is a great starting point because most healthcare professionals in the dysphagia space are already making purees for patients and therefore have the baseline knowledge needed to start implementing IDDSI. It is only a matter of evaluating your purees and adjusting them to meet IDDSI standards.

Here’s what you’ll need to know in order to understand Pureed (Level 4):

  • Foundations of Pureed (Level 4)
  • Who Pureed (Level 4) is for
  • Pureed (Level 4) characteristics
  • Pureed (Level 4) testing methods

By starting here you can simplify the intricate process of implementing IDDSI in your organization. Most importantly, your team will be familiar with basic IDDSI concepts such as standardized identification of the diet (diet name, color, and abbreviation) and testing.

Learning IDDSI Pureed (Level 4)

Foundations of Pureed (Level 4)

The IDDSI Framework, pictured above, consists of eight diet levels (Level 0-7), ranging from Thin Drinks (Level 0) to Regular Foods (Level 7). Each level has a unique name, color, number, and abbreviation. The Pureed (Level 4) diet is represented by the number 4 and the color green. Its abbreviation is PU4; facilities may use this abbreviation in many places, such as diet order communications, tray or service tickets, and dining menu software or electronic health records.

Who Pureed (Level 4) is for

We serve IDDSI Pureed (Level 4) to individuals with dysphagia, whom cannot safely chew or swallow.** Individuals requiring Pureed (Level 4) have the following limitations:

  • Reduced tongue control
  • Pain or difficulty swallowing
  • Inability to chew well
  • Cannot form a bolus (a small rounded mass of chewed food at the moment of swallowing)
  • Missing teeth; dentures not fitted

Pureed (Level 4) characteristics

We’re all familiar with food characteristics such as taste, appearance, smell, and temperature. In addition, IDDSI has now introduced us to new food characteristics, including softness, stickiness, thickness, moisture, and particle size. The characteristics of Pureed (Level 4) are:

  • Smooth and free of lumps
  • Thick enough to hold shape on a plate or spoon
  • Cannot be sticky
  • Moist
  • Cannot have separate thin liquids (solids and liquids must be one)
  • Cannot be poured, slow movement
  • Does not require chewing
  • Eaten with a spoon
  • Cannot be drunk from a cup or sipped from a straw

These unified standards for Pureed (Level 4) ensure these foods will have the same characteristics, no matter where they are served. Whether you’re making your own pureed foods or serving a convenient, ready-to-eat product such as Thick-It® Purées, meeting IDDSI guidelines for Pureed (Level 4) ensures a safe and enjoyable mealtime for those with dysphagia.**

Pureed (Level 4) testing methods

Products should always be tested before being served to patients, as testing empowers us to verify that the foods meet IDDSI standards. Moreover, testing helps ensure safety. In order to make sure a Pureed (Level 4) food is safe to serve, it must pass the following easy-to-perform tests:

  • Appearance: Smooth, no lumps, no thin separate liquid
  • Fork Drip Test: Food holds shape as a mound above the fork. A small amount may flow through and form a short tail below the tines of the fork, but it does not flow or drip continuously through the tines.
  • Spoon Tilt Test: Food is cohesive enough to hold shape on the spoon. It can slide off easily when you tilt or gently flick the spoon over a plate with very little food left on the spoon. Thin film of residue left on the spoon is acceptable, but you should not be able to see the spoon through the film, and it should not be firm and sticky.

Testing should be done while foods are prepared and again before they are served. Pureed (Level 4) foods must pass all three IDDSI tests.

I also recommend practicing Pureed (Level 4) testing methods with your team as an important step in learning the diet. There is no substitute for pulling out your testing tools and trying these methods in your own kitchen. You’ll find they are easy to practice because they only require simple tools like a fork, spoon, and testing report.

If you’d like to learn more about IDDSI diet levels, including Pureed (Level 4), visit Roche Dietitians’ “Your Guide to IDDSI,” as well as for the latest updates. For access to 11 nourishing, flavorful, and safe PU4 meals, download “Variety Comes to the Table,” a dysphagia recipe book from the makers of the Thick-It® brand of innovative dysphagia nutrition solutions.


Margaret Roche, MS, RD, CSG, CDE, FAND, is the founder of Roche Dietitians and a nationally recognized leader in nutrition for healthcare. A champion for senior nutrition, she advocates for quality improvement with texture modified diets. Margaret has trained thousands on IDDSI implementation.

Margaret’s opinions and advice are her own. Roche Dietitians has previously been compensated by Kent Precision Foods Group, Inc., producers of the Thick-It® brand family of products, for their research and industry insights.

Kendra Benner contributed to this post. She is a content writer and strategist in the Chicago metro area, specializing in the healthcare industry.


*Thick-It® brand is a gold sponsor of IDDSI.

**Always seek the advice of a physician or other qualified health provider with any questions you may have about the suitability of a particular diet or diet modification for individual patients or the use of Thick-It® products.  The information contained herein is general and is not intended to be a substitute for professional medical advice, diagnosis or treatment in any manner.


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