As of the 1st April 2019, all texture-modified diets in the United Kingdom must follow the International Dysphagia Diet Standardisation Initiative (IDDSI) which gives world-wide consistency to the terms used to describe texture modified diets. The IDDSI descriptors have been phased in over the last two years, so you may have already seen Speech and Language Therapists referring to them in their guidelines.  This means that generic terms like “pureed” or Texture C food are no longer appropriate and “IDDSI Level 4” is now the correct description.    

IDDSI Level 4 – describes pureed/extremely thick foods or fluids which have no lumps and do not require chewing.  They hold their shape on a spoon, fall off the spoon easily in a single plop when the spoon is tilted and continue to hold their shape on a plate, which means they can be piped, layered or molded. The tines/prongs of a fork can also make a clear pattern on the surface, and/or the food retains the indentation from the fork.  They cannot be drunk from a cup and they have to be eaten with a spoon or fork. 

Clients and caregivers often find this one of the most challenging food recommendations to not only follow, but to also make both varied and visually appealing.  Many care homes now employ chefs who go to great lengths to turn IDDSI Level 4 meal creations into works of art.  But this may not always be practical or realistic for clients living in their own home. 

Here are some resources which your clients may find helpful as they transition to IDDSI Level 4.

1.  Recipe ideas are available from:

• Nutilis – Tasty recipes for people with swallowing difficulties
• Beyond the Blender cookbook by Australian Speech and Language Therapy student Simone Howells
• Textured Food website (Australia)

2.  Texture-modified ready meals

While Speech and Language Therapists can often provide training for support workers or family members on how to prepare food which is IDDSI Level 4, clients who attend special schools or day centres where multiple staff would need to be trained sometimes prefer to use texture-modified ready meals.  These are also perfect for when clients and support workers are first coming to grips with texture-modified diets and for busy days when everyone is too tired to cook.

Meals from both companies have the option of being cooked in a microwave or convection oven.  Wiltshire Farm Foods also have a Puree Petit range which offer fortified foods with more calories in a smaller volume. 

• • Wiltshire Farm Foods
  • Oakhouse foods 
  • It’s Made for You

3.  Warming plates

Pureed food tends to cool off much faster and people with swallowing difficulties often need more time to eat.  Blended food served at room temperature is not particularly appealing, so warming plates can be helpful to keep someone’s food warm for longer.  These can be purchased from Amazon or companies selling assisted-living devices.  Make sure you read the reviews as several brands have issues with leakage.  Here are a few examples:

• warming plate with lid
• warming plate without lid

4.  Equipment

• If the dysphagia is expected last for many years and the client has sufficient funds, investing in an institutional-grade food processor is ideal (but be aware they run close to £1000). Otherwise, get a high speed food processor which comes with multiple food processing bowls.   You will want to blend each food individually (eg meat, vegetables) and this saves you from having to wash the bowl between blending each item.  Blenders (while fine for smoothies and milkshakes) are not very suitable for blending food, because you have to have a large volume and a lot of liquid to get the food down by the blades in order to puree the item.  This can make the food too runny and then you will have to use a copious amount of thickener to thicken the food back up to the correct consistency.  Hand blenders are fine for blending a food which is already soft (like tinned fruit), but are not powerful enough to blending tougher foods like meat.  
• Potato ricers make fabulous (non-gluey) potatoes which you can mix with butter and milk to get to the correct consistency. 
• Piping bags and tips – we eat with our eyes, so being faced with a plate covered in 2-3 unidentified blobs will likely not entice someone to eat.  Piping bags can be used to present food in a much more appealing way using layers, stars and swirls.

• A variety of pretty ramekins and other dishes can be a great way to present food in an appealing way.  Which style you use depends on whether the person is feeding independently or not and whether challenging behaviour is an issue (in which case glass dishes likely won’t be appropriate).

5. I-Qoro

The I-Qoro is a remarkably simple, neuromuscular training device which essentially “exercises” the muscles of the mouth and throat and is one option for treating dysphagia following a stroke (see NICE guidelines here).  Check with your Speech and Language Therapist to see if it would be appropriate for your client.

We all have a responsibility to make sure that clients on texture-modified diets are not subjecting themselves to a lifetime of mashed potatoes, yogurt and nutrition supplements.  Dietitians can help clients, family members and support workers come up with a variety of nutritious and delicious meal ideas which also comply with the IDDSI guidelines recommended by the Speech and Language Therapist. 

To receive a copy of the Nualtra recipe book or to refer a client who needs help getting adequate nutrition on an IDDSI Level 4 diet, get in touch at sheri@specialistnutritionrehab.co.uk. 

Thank you to Jo Frost, Speech and Language Therapist from The Speech Therapy Practice, and Tracey Dailly, Speech and Language Therapist from the Neuro Rehab Group for reviewing this article.