You may be experiencing difficulty in eating, drinking and swallowing. The medical term for this is “dysphagia”.

Dysphagia can occur for many reasons, for example as a result of stroke, multiple sclerosis (MS), motor neurone disease, Parkinson’s disease, dementia, developmental disorders, head trauma or head and neck surgery.

This can make achieving an adequate and nourishing diet difficult. As a result, weight loss, dehydration, weakness, depression, nutritional deficiencies and a reduced ability to fight off infection can occur.

The speech and language therapist will assess and diagnose any eating, drinking and swallowing problems you may have. They will then recommend the safest consistencies of food and drink and any strategies that may help. This will mean that eating and drinking can be as safe, enjoyable and comfortable as possible.

Follow your speech and language therapist’s guidance. If you have any questions, please ask for advice.

The dietitian will advise on a suitable nutritionally adequate diet for you and give you practical advice on how to continue the diet at home.

Level four pureed food may be used if you are not able to bite or chew food, if your tongue control is reduced or if the muscles in your throat are weaker than usual. Pureed foods only need the tongue to be able to move forward and back to bring the food to the back of the mouth for swallowing. It is important that puree foods are not too sticky because this can cause the food to stick to the inside of the cheeks, teeth, roof of the mouth or in the throat.

In this information, we cover:

• what is a pureed diet?
• how do I check my food to make sure it is pureed?
• which foods can be included in a pureed diet?
• sample meal plan
• equipment needed
• ready meals
• getting the right balance
• food fortification.

What is a level four pureed diet?

A pureed diet should be smooth, thick and moist but have no lumps. Your speech and language therapist will advise if it also needs to be sieved. Pureed food does not need to be chewed.

Pureed food is usually eaten with a spoon but can be eaten with a fork. It cannot be drunk from a cup or sucked through a straw.

It may be necessary to add a commercial thickener to some foods to achieve the required consistency.

Tips for preparing puree foods

• Most meals can be pureed successfully provided a little extra fluid is added. Try to use more nourishing fluids for this such as milk, cream, sauces or creamy soups rather than water, stock or thin gravy. Extra butter or margarine should be added to pureed vegetables.
• Nuts, seeds, stringy foods such as celery and onions and foods with a tough skin, such as pulses, dried beans, peas or corn do not puree well and will need to be sieved before serving.
• Breakfast cereals that do not soak up milk or cannot be pureed to a smooth consistency should be avoided, for example muesli.
• Cook foods until they are soft and cut into small pieces before blending.
• Puree small quantities at a time to avoid getting lumps.

You can make meals look more appetising by:

• pureeing and serving the main course and vegetables separately
• choosing different coloured foods at one meal
• piping or using moulds and scoops to help shape the food, for example jelly moulds or cookie cutters.

• If your puree isn’t thick enough you could try thickening with cornflour, arrowroot, mashed potato or a prescribed thickening powder. Ask your speech and language therapist or dietitian for advice.
• Check before serving that no hard pieces, crusts or skin have formed and that fluid within or on the food has not thinned or separated out.
• You may find it useful to only heat up small amounts of food at a time so that food does not get cold while you are eating.
• Ice cream can turn to a thin liquid in the mouth and may not be suitable for someone who needs thickened fluids. Ask your speech and language therapist for advice.
• You can use a soaking solution for cakes and biscuits. Ask your speech and language therapist for advice.

How do I check my food to make sure it is pureed?

• Food sits in a mound on a fork. A small amount may flow through and form a tail below the fork. Liquid does not dollop or drip continuously through the fork prongs.
• A pureed diet holds it shape on a spoon or on a plate when scooped. The food falls off fairly easily if the spoon is tilted or lightly flicked.
• The food should not be firm or sticky.

The prongs of a fork make a clear pattern on the surface of the food. Pureed food can be piped, layered or moulded but cannot be poured.

Liquid and sauces must not separate from the solid. Any loose liquid should be fully drained or well combined within the puree itself.

Which foods can be included in a pureed diet?

It is important to eat as wide a variety of foods as possible, and to choose foods from each of the groups below.

Starchy foods                 

Aim to include at least one starchy food at each meal.

• Porridge (use fine grain oats) and other instant cereals like Ready Brek or Oats-so-Simple.
• Other breakfast cereals such as Weetabix soaked in milk are suitable with excess fluid drained off. Avoid cereals with added nuts and dried fruit such as muesli.
• Banana or other soft fruits can be blended into porridge and other suitable cereals to add variety.
• Well cooked, soft pasta dishes such as macaroni cheese, spaghetti in tomato sauce, ravioli can be pureed to a suitable consistency, adding extra sauce if necessary.
• Mashed or instant potato with margarine or butter and milk added.
• Rice with a thick sauce can be pureed to ensure a smooth consistency. Make sure the rice is cooked until soft.
• Sponge puddings or cakes can be pureed with sauce or custard.

Fruits and vegetables

Aim to have five portions each day, one of which could be a glass of pure fruit juice.

• Try to have a glass of pure fruit juice (no bits) or a fruit drink with added vitamin C, each day.
• Cook vegetables well, drain and puree. Sieve if necessary to remove skins.
• Vegetables in sauce can be pureed. Try cauliflower in cheese sauce or vegetable curry.
• Broccoli, marrow, courgette and spinach can be pureed with another vegetable to thicken, for example cauliflower or parsnip.
• Well ripened avocados can be pureed.
• Vegetable juices, such as tomato or carrot.
• Choose soft, ripened varieties of fresh fruit such as peaches, pears, nectarines, plums, melon and bananas. Peel, remove seeds and/or stones, puree and sieve. It may be necessary to add thickener.
• Tinned fruits should be drained of liquid before being pureed.
• Hard fruits such as apples and pears can be peeled, stewed and sieved.
• Dessert ideas include pureed stewed, soft or tinned fruit with milk puddings, Greek yoghurt or thick cream, cheesecake and cream (no biscuit base) and pureed fruit trifle.

Meat, poultry, fish, eggs and pulses

Aim to include two portions a day.

Meat and poultry

• Cook meat or poultry well. Remove skin, gristle or fat. Puree with sufficient stock, gravy, sauce or soup until smooth and thick. Sieve if necessary.

Ideas include:

• pureed meat or chicken
• pureed casserole or stews
• pureed mince and potatoes
• pureed shepherd’s or cottage pie
• pureed meat or chicken curry
• pureed chicken in a creamy sauce.

Fish                                          

• Fish must be boneless. Fish such as tuna, salmon, prawns and white fish (for example, smoked or unsmoked cod or haddock) can be pureed with a sauce or may be suitable as a mousse or paté.

Ideas include:

• tinned fish pureed with sauce or mayonnaise
• taramasalata (can be bought ready prepared)
• pureed fish in cheese sauce
• fish mousse.

Eggs                                          

• Try egg soufflé or egg custard.
• Hard-boiled eggs can be pureed in a sauce.

Pulses and beans

• Cooked or tinned baked beans, mixed beans, chick peas, lentils and mushy peas. Must be pureed and sieved before eating. Try adding them to soups, stews or casseroles.
• Tofu, Quorn and textured vegetable protein should be cooked and then pureed and sieved.
• Smooth hummus can be bought ready prepared.

Milk and milk products

Try to have a pint of milk every day or include two to three servings of milk products.  Use full fat milk if possible.

• Milk can be used in drinks and as the base for many sauces.
• Try milk puddings such as custard, ground rice and semolina. Rice, tapioca, sago and macaroni puddings should be pureed before eating.
• Savoury or sweet white sauces.
• Choose smooth, thick and creamy or Greek varieties of yoghurt and fromage frais. Avoid those with muesli, nuts, grains or seeds or pieces of fruit.
• Egg custard, crème caramel and mousses.
• Blancmange, instant whip.
• Cream cheese such as cheese spread, ricotta or mascarpone.
• Grated cheese can be melted into sauces but avoid stringy cheese such as mozzarella.
• Milk based thick fruit smoothies with no lumps, skins or seeds.

Sample menu plan

Breakfast

Fruit or juice

Weetabix and milk

Tea

 

Mid-morning                                       

Milky coffee or drink

Smooth thick and creamy yoghurt

 

Lunch

Thick, smooth soup

Pureed pasta with pureed bolognese sauce

Chocolate mousse

Drink

 

Mid-afternoon

Milkshake

Cake pureed with custard, cream or chocolate sauce

 

Evening meal       

Glass of fruit juice

Pureed lamb casserole

Mashed potatoes

Pureed carrots

Custard and pureed fruit

 

Bedtime                                              

Malted milk drink

 

Equipment needed

The following equipment can be used to produce a pureed diet:

• Hand blender, mouli or small blender – for pureeing smaller quantities
• Liquidizer – for larger quantities and to produce a fine texture. Food should first be cut into small pieces. Add the minimum amount of liquid necessary to allow the food to move around the blades and be processed.
• Food processor – for mixing large quantities of food and producing a smooth texture.
• Sieve – it should be noted that food produced using the equipment above may still require sieving, to remove seeds, skins etc.
• A freezer is useful to enable large quantities of food to be prepared to the correct texture and then frozen for future use. Freeze foods in individual portions if possible.

Ready meals

Supermarkets sell a wide variety of ready meals that can be further modified at home to make them suitable for a pureed diet. After cooking, you will need to puree the meal, adding additional sauce as necessary. Sieve to remove bits if necessary.

It is also possible to buy pre-prepared creamed potato and other creamed and mashed vegetables.

Delivered meals

Meals on wheels may be able to provide a level four pureed meal.

Specialist companies which deliver frozen meals to clients, such as Wiltshire Farm Foods, Oakhouse Foods, Simply Puree and Mrs Gills cater for people with swallowing problems. Menus are specially coded for a level four pureed diet.

Getting the right balance

If you choose a variety of foods from each of the five food groups, as shown, you should be having a balanced diet. However, it is sometimes more difficult to achieve this on a pureed diet so here are a few tips.

Energy (calories)

If you are having difficulty maintaining your weight, please read the section on food fortification to boost the energy and nutrient content of your diet.

Constipation

Constipation may be a problem because you are lacking fibre in your diet.  Introduce more fibre slowly into your diet to let your body adapt.

Good sources of fibre are:

• breakfast cereals such as porridge and instant hot oat cereals or Weetabix
• fruits and vegetables. Try to have the recommended five portions a day. Pureed prunes and prune juice may be helpful
• all pulses, such as beans are high in fibre but will need to be sieved before serving.

Over-the-counter fibre supplements are available if recommended. Your GP can also prescribe other fibre supplements.

Fluid is essential to help the fibre to work, prevent dehydration, ensure your skin retains its elasticity and your kidneys function properly. You should aim for at least six to eight drinks a day, include a variety of tea, coffee, squash, juice, water, milk, milkshakes and malted bedtime drinks.

Vitamin C

Having five portions of fruit and vegetables a day will help, try to include a rich source of vitamin C such as Ribena, C-Vit, supermarkets own fortified blackcurrant squash, rose-hip syrup and pureed fruit such as strawberries or kiwis.

Iron

Meat is a good source of iron. If you are still finding pureed meat difficult to swallow, please ask your dietitian for ideas.

Other good sources include egg yolk, breakfast cereals, pulses and dark green leafy vegetables.  A glass of fruit juice taken with a meal will help your body to absorb the iron.

Food fortification

Food fortification is a way of boosting the amount of nutrients in your food.

Having a good nutritional intake will help you:

• regain lost weight or maintain your current weight
• maintain your muscles and keep your skin healthy
• feel healthier and have more energy.

How to fortify your food

Skimmed milk powder

• Add two to four tablespoons to a pint of full fat milk and use whenever you take milk. Add one tablespoon to porridge, soups, mashed potato etc.

Cheese

• Add grated cheese to cooked vegetables, potatoes, soup, pasta and sauces.

Yoghurt and fromage frais

• Choose thick and creamy, full fat varieties or Greek yoghurt.

Butter, margarine and oil

• Use full fat spreads added generously on all foods.
• Fry foods such as onions, vegetables and meat.
• Use oil-based dressings generously, you could add to hot potatoes or pasta, before pureeing.
• Mayonnaise and salad cream can be added to food.

Cream

• Add to soups, sauces, custard, porridge and milk puddings and porridge.
• Serve whipped or clotted cream with mousse or pureed fruit.
• Add to milky drinks and coffee.

Sugar and sugary foods

• Check with your health professional if you have diabetes.
• Add sugar to drinks, cereals and desserts.
• Use ordinary fizzy drinks and squashes, rather than low calorie or sugar free.
• Add seedless jam, honey or syrup to pureed fruit or puddings.

General hints to improve intake

• Make sure that all your food is served at the correct texture and consistency suited to your swallowing and chewing ability.
• Remember that tiredness may affect your food intake and your swallowing ability.
• Try to eat little and often, aim for three small meals and two to three snacks.
• Have nourishing drinks between meals, for example milk, Horlicks, hot chocolate or Ovaltine.
• Try to have a portion of meat or fish (or an alternative) at each main meal.
• Use full fat products, such as full fat milk, thick and creamy yoghurts and full fat cheese.
• It is a good idea, if you are able, to check and record your weight regularly (every two to four weeks).
• Speak to your dietitian or speech and language therapist if you are unsure of anything.

Alcohol

Please check that alcohol will not react with any medications you are taking. Alcohol can be thickened if necessary.

Oral nutritional supplements

If you are not managing to eat and drink enough to meet your protein and calorie requirements your healthcare professional may recommend an oral nutritional supplement. These are specialist products, usually drinks or puddings that contain increased levels of nutrition.

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