# IDDSI Level 4: Extremely Thick / Pureed

Canonical: [https://followyourswallow.com/iddsi/level-4](https://followyourswallow.com/iddsi/level-4)

Eaten with a spoon. Holds its shape. No chewing needed.

## What it is

Smooth, cohesive purée with no lumps. Cannot be drunk from a cup; usually eaten with a spoon. No chewing required. The tongue alone can manage it.

## What it looks like

Sits in a mound on the plate or spoon with a small peak. No liquid separating out.

## Official test

Fork drip test: sits in a mound on the fork; a small tail may form below the prongs but it does not drip continuously. Spoon tilt test: holds shape on the spoon, slides off in one piece when tilted, leaving little residue.

## Foods that typically fit

- Smooth puréed meats, vegetables, fruits
- Thick-style smooth yogurts (no fruit pieces)
- Commercial Level 4 purée meals
- Smooth mashed potatoes with extra moisture, sieved

## Common mistakes

- Watery purées that separate, liquid weeping out can be aspirated like a thin liquid.
- “Just a little” bread soaked in soup, mixed consistencies are the most common Level 4 error.
- Lumpy mash, Level 4 must pass through a sieve.




## Safety

Use only the food and drink levels prescribed by the person's qualified clinician. Test the actual serving before it is eaten or drunk.