Fluid diet - extremely thick level 4

Aim

Provide fluids of an extremely thick (IDDSI level 4) consistency for patients with dysphagia as recommended by a speech pathologist.

Characteristics

Extremely thick – level 4 is like the thickness of a pudding or mousse. It is cohesive, has no lumps and holds its shape on a spoon. It cannot be consumed from a cup or sucked through a straw as it does not flow easily. It is best to use a spoon to take this fluid.

Refer to The International Dysphagia Diet Standardisation Initiative 2016 for approved IDDSI testing methods.¹

Indications

Swallowing disorders as identified by a speech pathologist.

Nutritional adequacy

Care must be taken to ensure adequate fluid intake when patients require a thickened fluid diet. Patients on this diet should be monitored regularly to ensure adequate fluid and nutritional intake.

Precautions

Ensure the patient does not receive any other fluids other than fluids of the consistency recommended by the speech pathologist.

Paediatrics

Suitable for use in paediatrics when combined with an age-appropriate diet (if indicated).

Specific menu planning guidelines

	Allowed	Not allowed
Hot main dishes	All, but wet dish sauces need to be assessed as compliant for this diet by a speech pathologist	Wet dishes with thin sauces
Sauces, gravies	All, only if a small amount is served on food (max 40ml serving)	Served separately
Starchy vegetables / pasta / rice	All	-
Vegetables	All	-
Soups	Pureed and thickened to extremely thick – level 4 consistency or deemed already suitably thick and assessed as compliant for this diet by a speech pathologist	All others
Sandwiches	All	-
Salads, dressings	Salad ingredients and vegetables that produce minimal juice when eating, e.g., carrot, lettuce If salad is dressed, dressing needs to be assessed as compliant for this diet by a speech pathologist	Thin dressings Salad ingredients and vegetables that produce juice, e.g., pineapple, orange, tomato
Breads, cereals	All breads All cereals, served with milk thickened to extremely thick – level 4 consistency	Milk with dry cereal
Spreads	All	-
Hot breakfast choices	All, except those listed as not allowed	Grilled tomato Caution to be applied to canned baked beans, canned spaghetti or porridge Sauces and liquid need to be assessed as compliant for this diet by a speech pathologist
Fruit	Drained canned fruit Fresh fruit that produces minimal juice when eaten, e.g., banana, apple Dried fruit	Undrained canned fruit Fresh fruit where juice is produced when eaten, e.g., orange, watermelon, passionfruit, pineapple
Yoghurt	Extremely thick yoghurts	Other yoghurts and drinking yoghurt
Desserts	All, but sauces need to be assessed as compliant by a speech pathologist Thick custard	Transitional desserts, meaning desserts that change to a liquid in the mouth, e.g., unthickened ice-cream, jelly
Milk and cheese	Milk thickened to extremely thick – level 4 consistency All cheese	-
Beverages	Must be thickened to extremely thick – level 4 consistency	All others
Biscuits	All	-
Miscellaneous	Nutritional supplements – thickened to extremely thick – level 4 consistency	-
Celebratory foods / special occasions	Not applicable	Not applicable

*©The International Dysphagia Diet Standardisation Initiative 2019 licensed under the Creative Commons Attribution ShareAlike 4.0 License. Derivative works extending beyond language translation are NOT PERMITTED.

References

1. International Dysphagia Diet Standardisation Initiative. Complete IDDSI Framework Detailed definitions. IDDSI; 2019. [cited 19 August 2022].