How To Follow a Level 4 Pureed Diet

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Time to Read: About 8 minutes

This information explains what a level 4 pureed diet is and how to follow it. It explains how to test your food’s thickness. It also lists foods to include and avoid while following this diet.

What is a level 4 pureed diet?

A level 4 pureed (pure-AYD) diet is when you only eat foods you do not need to bite or chew. While you’re following this diet, you will make your foods smooth and moist before eating them. This makes them easier to swallow.

Food that is pureed:

  • Is smooth, soft, and moist.
  • Is usually eaten with a spoon.
  • Holds its shape on a spoon.
  • Flows very slowly.
  • Cannot be sucked through a straw.

How can I puree my food while following a level 4 pureed diet?

You can use a blender, food processor, or other kitchen item to make your foods smooth. For some ideas, read the “Kitchen items to help you make food” section of this resource.

Add liquid to the blender or food processer to make your foods smooth, soft, moist, and lump free. You can add:

  • Water
  • Broth
  • Gravies
  • Sauces
  • Juice
  • Milk
  • Yogurt

Add just enough liquid so that your food is smooth but not too watery or runny. Make sure to check the thickness of your food before you eat it. Read the “How can I make sure my food is the right thickness?” to learn how.

Why do I need to follow a level 4 pureed diet?

You may need to follow a pureed diet if you:

  • Have dysphagia (dis-FAY-jee-uh). Dysphagia is when you have trouble swallowing.
  • Had mouth surgery.
  • Have lost feeling in parts of your mouth, such as your lips and tongue.
  • Have trouble moving parts of your mouth.

How can I make sure my food is the right thickness and texture?

You can check your food’s thickness and texture by doing a fork drip test and spoon tilt test. Follow the steps in this section.

Your food’s texture can change based on its temperature and how you cooked it. Test your food right before you start eating it to make sure it’s the right thickness.

Fork drip test

  1. Pick up some of your food with a fork.
  2. Check if any food falls through the prongs of the fork.

Level 4 pureed foods should sit on top of the fork with very little or no drip through the fork. A small amount may drop, but the food should not drip without stopping.

Spoon tilt test

  1. Pick up some of your food with a spoon. Your food should hold its shape on the spoon.
  2. Tilt your spoon slightly to the side.
  3. Check if any food slides off.

Your food should easily slide off. It’s OK if you need to gently flick the spoon to get the food to fall off.

Your food is too thick if it sticks to the spoon or does not fall off the tilted spoon.

fork drip test and spoon tilt test

Figure 1. Fork drip and spoon tilt tests

What can I eat on a level 4 pureed diet?

Here are some foods you can eat while following this diet. We also list some foods you should avoid.

These tables are not a complete list of foods you can eat on this diet. Other foods may be OK to eat if you test them and they are the right size and texture. 

If you have trouble swallowing liquids, your speech language pathologist may recommend you thicken your liquids. If you need to thicken liquids, read About Thickening Liquids.

Milk and dairy

Milk and dairy to includeMilk and dairy to avoid
  • Smooth yogurt.
  • Drinkable yogurt.
  • Pureed cottage cheese.
  • Ricotta cheese.
  • Melted or pureed cheese used as a sauce or as an ingredient in any foods that are allowed.
  • Whipped cream cheese and sour cream used as condiments, or in foods that are allowed.
  • Ice cream, frozen yogurt, gelato, milkshakes, and smoothies.
  • Yogurt with lumps, nuts, seeds, fruit pieces, coconut, or granola.
  • Cheese that is not melted or pureed into foods that are allowed.

Proteins

Proteins to includeProteins to avoid
  • Pureed meat, chicken, fish, and shellfish (such as shrimp, lobster, clams, and scallops).
  • Pureed cold protein salads, such as chicken, tuna, and egg, without onion or celery.
  • Baby food poultry or meats.
  • Pureed eggs and egg substitutes.
  • Pureed, smooth, moistened legumes, such as cooked beans or lentils.
  • Smooth hummus.
  • Smooth nut butters blended into foods that are allowed.
  • Protein foods that are not pureed and have lumps.
  • Whole nuts and seeds.

Vegetables

Vegetables to includeVegetables to avoid
  • Pureed, cooked vegetables.
  • Baby food vegetables.
  • Whipped or smooth mashed potatoes without skin. You can use any type of potato.
  • Smooth tomato sauce without seeds.
  • All raw vegetables.
  • Stir-fried or fried vegetables that cannot be pureed into a smooth, texture with no lumps.

Fruits

Fruits to includeFruits to avoid
  • Pureed fruits.
  • Baby food fruits.
  • Smooth applesauce.
  • Smooth, pureed prunes with no lumps.
  • Avocado blended into smooth guacamole and foods that are allowed.
  • Fruits with fiber or that are stringy and cannot be pureed into a smooth texture with no lumps. An example is pineapple.
  • Dried fruits, freeze-dried fruits, and fruit snacks.

Starches

Starches to includeStarches to avoid
  • Pureed soft-cooked hot cereals with no lumps (such as Cream of Wheat®, Cream of Farina®, Cream of Rice®, oatmeal, and hominy grits).
  • Whipped or smooth mashed potatoes.
  • Pureed pasta and pureed rice.
  • Grainy or sticky rice.
  • Dry, cooked cereals with lumps or seeds.

Fats

Fats to includeFats to avoid
  • Butter, oils, margarine, cream, mayonnaise, and gravies. You can use these in the cooking process or as an ingredient in foods that are allowed.
  • Whole nuts and seeds.
  • Coconut.

Soups

Soups to includeSoups to avoid
  • Broth or bouillon.
  • All strained and pureed soups.
  • All other soups that are not pureed and have lumps.

Sweets and desserts

Sweets and desserts to includeSweets and desserts to avoid
  • Smooth pudding and custard.
  • Ice cream, sherbet, and sorbet.
  • Gelatin (such as Jell-O®), flavored fruit ices, popsicles, and whipped toppings.
  • All other sweets and desserts.

Other

Other things to includeOther things to avoid
  • Salt, pepper, ketchup, mustard, herbs, and spices.
  • Seedless jelly, jams, and preserves.
  • Honey, sugar, and sugar substitutes.
  • All syrups, including chocolate syrup and maple syrup.
  • Jellies, jams, and preserves with seeds.

Sample menu for a level 4 pureed diet

Use this sample menu to get ideas for making your own level 4 pureed diet meals.

Level 4 pureed diet menu
Breakfast
  • Orange juice
  • Hot cereal with milk, margarine, and sugar
  • Pureed cottage cheese
Mid-morning snack
  • Ensure®
Lunch
  • Strained pureed split pea soup
  • Pureed flounder
  • Pureed pasta
  • Pureed spinach
  • Gelatin, such as Jell-O®
  • Baby food mango
  • Tea with sugar
Mid-afternoon snack
  • Butterscotch pudding
Dinner
  • A bowl of chicken broth
  • Pureed chicken
  • Mashed sweet potatoes
  • Baby food green beans
  • Baby food plums
  • Tea with sugar
  • Sorbet
Evening snack
  • Carnation Breakfast Essentials®

How to plan your meals on a level 4 pureed diet

Changing your eating habits can be hard. It’s best to plan your meals ahead of time. This can help you make sure you have enough of the right foods to eat at mealtimes.

Here are some questions to think about when planning your meals:

  • Where will you be eating? Will you be eating at home, a restaurant, work, or someone else’s house?
  • If you’re eating at a restaurant, can you call ahead and ask for special meals?
  • Will you have a kitchen and refrigerator available? Can you boil water? Can you microwave? Can you use a blender or food processor?
  • Can you carry a thermos (a container that keeps a drink or other fluid hot or cold with food) already made and ready to eat?

Tips for eating at home

You can puree many different foods by putting them in a blender with some liquid. You can use water, broth, gravies, sauces, juice, milk, or yogurt. Add liquid until the food is the right texture and thickness.

Kitchen items to help you make food

Here are some items that can help you make foods at home.

  • Blender: Use a blender for all types of foods including meats, vegetables, and fruits. You may have to add liquid to make the food the right texture. Blenders are great for soups and shakes.
    • The Magic Bullet® and Nutribullet® are small blenders that do not take up a lot of space. 
    • The Vitamix® and Ninja® are bigger blenders that can puree a larger portion of food.
  • Hand-held blender: Use a hand-held blender to quickly puree your favorite soups right in the pot. It can also be used to soften well-cooked foods in a small bowl for 1 or 2 servings.
  • Food processor: Food processors are useful for shredding, slicing, chopping, and blending foods. They come in different sizes. If you often make just 1 portion of food, buy a small food processor.
  • Household mesh strainer or sieve: Use this to strain fruits and vegetables, but not meats. They are inexpensive, good to make 1 serving, and do not need electricity. But using a strainer can take more time than using the other kitchen items listed here.

Tips for eating at restaurants

Eat at restaurants offering different types of foods and that will adjust for people on special diets. Many places will pure or make foods for your needs. Call ahead and speak to a manager or chef. You may be surprised at how helpful they will be.

Tips for eating away from home

It’s also possible to eat away from home, such as at work or at a friend’s house. Here are some tips for taking food with you while you’re away from home:

  • Bring a food grinder or small food processor. If you need electricity, make sure it’s available where you’re going.
  • Buy a thermos. Make soup or hot cereal and carry it with you.
  • Ask if there is a microwave where you’re going. You can make food at home and freeze it in single-serving, microwave-safe containers or Zip-Loc® bags. Bring the food with you in an insulated (keeps food cold) pack and heat it when you want to eat.
  • Freeze soups or pureed foods in ice cube trays. Cover the tray with foil or plastic wrap to prevent freezer burn. When you’re hungry, use 2 or 3 cubes for a small meal or snack, or more cubes for a larger meal.

Tips for adding more calories to your diet

  • Eat small meals 6 to 8 times a day instead of 3 main meals.
  • Add 2 to 4 tablespoons of canned coconut milk or cream to smoothies, shakes, cereals, and yogurts for extra calories. You can also add it to pureed dishes for extra calories, flavor, and moisture.
  • Choose creamy soups rather than soups with clear broths.
  • Have puddings and custards rather than gelatin desserts, such as Jell-O.
  • Add sauces, gravies, butter, or extra vegetable oil to your meals.
  • Drink fruit shakes or fruit smoothies made with yogurt or ice cream.
  • Make ice cubes from milk or fruit nectar. Use these high-calorie ice cubes in smoothies or to keep your shakes cold. As they melt, they will add calories to your drinks.
  • Drink high-calorie drinks, such as whole milk, milkshakes, or pasteurized eggnog.
  • Use oral nutrition supplements, such as Ensure® or Boost®, as a nutritious, high-calorie liquid base in smoothies and milkshakes.
  • Add honey to smoothies, tea, yogurt, hot cereals, shakes, or ice cream.
  • Add sour cream, half and half, heavy cream, or whole milk to your foods. You can add them to mashed potatoes, sauces, gravies, cereals, soups, and casseroles.
  • Add avocado to dishes or smoothies and blend.
  • Blend nut butters, such as peanut butter, into shakes and smoothies.

Tips for adding more protein to your diet

  • Add pureed tofu to cooked vegetables, soups, or smoothies. You can also eat tofu instead of chicken or meat if you’re having trouble eating animal proteins.
  • Add pureed cooked eggs to your soups, broths, and cooked vegetables.
  • Use plain full-fat Greek yogurt in smoothies, cream sauces, or wherever you would use sour cream.
  • Use a plain protein powder, such as whey or pea protein powder, in liquids and shakes.
  • Add full-fat ricotta cheese to moisten a dish and add calories and protein.
  • Add cottage cheese to smoothies or pureed fruit.

Contact information

If you have questions or want to make an appointment with a clinical dietitian nutritionist, call 212-639-7312.

Last Updated

Thursday, April 25, 2024

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