Unlock the Secrets of Advanced Dysphagia Diet Guidelines: Your Ultimate Comprehensive Overview

Dysphagia, or difficulty swallowing, is a condition that can affect individuals of all ages and can arise from a variety of underlying medical conditions. Managing dysphagia often involves modifying the texture of foods and liquids to ensure safe and effective swallowing. This article provides an in-depth look at advanced dysphagia diet guidelines, incorporating the International Dysphagia Diet Standardisation Initiative (IDDSI) framework, practical food recommendations, and essential considerations for optimizing nutrition and patient care.

Understanding Dysphagia and Its Management

Dysphagia can lead to serious health complications, including malnutrition and aspiration pneumonia, which occurs when food or liquid enters the airway instead of the esophagus. A dysphagia diet aims to reduce these risks by providing foods that are easier to chew and swallow, minimizing the chance of food entering the airway.

The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework

The IDDSI Framework is now the gold standard for determining diet textures for dysphagia. The International Dysphagia Diet Standardisation Initiative (IDDSI) categorizes food textures and drink thickness into eight levels, from 0-7. The IDDSI framework consists of a continuum of 8 levels (0 - 7), where drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7 and provides a common terminology to describe food textures and drink thickness. It is the only texture-modified diet recognized by the Academy of Nutrition and Dietetics and the only texture-modified diet included in the NCM®.

IDDSI Testing Methods

IDDSI Testing Methods are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing should be done on foods and drinks under the intended serving conditions (especially temperature). It's important not to alter the elements of the IDDSI framework, as alterations may lead to confusion and errors in diet texture or drink selection for patients with dysphagia.

National Dysphagia Diet Level 3: Advanced Textures

The National Dysphagia Diet Level 3, also called Advanced textures, include foods that are almost regular textured (food minus hard, crunchy, and very sticky foods). This level is transitional, linking the mechanically altered foods and regular textured foods. Foods from the National Dysphagia Diet level 3 diet are on IDDSI level 6.

Key Characteristics of Level 3 Foods

Level 3 of the National Dysphagia Diet includes moist foods in bite-sized pieces. These foods are easier for you to chew and swallow. This level is nearly regular textures. Included are easy-to-cut whole meats, fruits, and vegetables. Transitional foods must be moist, and they should also be in small pieces, or bite-sized. They should be easy to chew.

Foods to Avoid

Avoid foods that are hard, sticky, crunchy, or very dry. These foods are anything crunchy, hard, difficult to chew, or very sticky. Bread - avoid hard, dry, or crusty bread.

Recommended Foods for a Dysphagia Diet

A well-planned dysphagia diet should include a variety of foods from all food groups to ensure adequate nutrient intake. The following are general recommendations, but it is essential to consult with a speech-language pathologist (SLP) or doctor for personalized advice.

Beverages and Liquids

Liquids should be the thickness recommended by your SLP or doctor: thin, nectar, or honey-thickened. Liquids can be thickened, if needed, with thickeners, flour, cornstarch, or potato flakes. Foods that are liquid at room temperature should also be thickened.

Thin liquids: These liquids take little or no effort to drink. Examples include water, non-fat milk, no-pulp juice, coffee, tea, and soft drinks. Individuals tolerating thin liquids will also be able to tolerate foods containing thin liquids, such as watermelon, grapefruit or oranges.
Slightly thick liquids: Slightly thick liquids are thicker than water but still flow through a bottle's nipple. A little more effort is needed to drink these liquids.
Nectar-thick liquids: Nectar-thick liquids have the same thickness as vegetable juices and milkshakes. It should take some effort to drink the liquid through a straw.
Honey-thick liquids: Honey-thick liquids should be difficult to drink through a straw. This includes high viscosity liquids too thick for a straw.
Pudding-thick liquids: Pudding-thick liquids need to be eaten with a spoon. You should not be able to drink them through a straw.

Starches, Breads, and Cereals

Recommended: Pancakes or French toast, well moistened with syrup; well-cooked, moistened, boiled, baked, or mashed potatoes; oatmeal; cold cereal moistened with milk; moist macaroni and cheese/well-cooked pasta with meat sauce.
Foods to avoid: Chips, dry breads/rolls, coarse cereals that include seeds/nuts.

Meats and Meat Substitutes

Recommended: Moist, ground/finely diced meats, poultry, or fish (served with gravy or sauces); poached, scrambled, or soft cooked eggs; slightly mashed, moist legumes (baked beans); tofu; tuna or egg salads (without large chunks, celery, or onion). Meat should be tender and moist, ground, or cubed smaller than 1⁄4 inch. Meat - well cooked, very tender, with added sauce or gravy. Cooked, tender meat no bigger than (for adults, 15 mm = 1.5 x 1.5 cm pieces) If texture cannot be served soft and tender at 1.5 cm x 1.5 cm (as confirmed with fork/ spoonpressure test), serve minced and moist. Cooked until tender. If texture cannot be served soft and tender, serve minced and moist. Soft enough cooked fish to break into small pieces with the side fork, spoon or chopsticks. Soft enough cooked fish to break into small pieces with fork, spoon or chopsticks no larger than 15 mm = 1.5 x 1.5 cm pieces (for adults) No bones or tough skins.
Foods to avoid: Dry, tough meats (bacon, hot dogs, sausage), sandwiches, peanut butter. Avoid scrambled, fried, or hard-boiled eggs.

Fruits and Vegetables

Recommended: Fresh, soft ripe bananas or soft drained, canned fruit without seeds or skin; soft, cooked vegetables that are fork tender and diced to less than ½ inch. Fruits should be soft, canned, or cooked. Soft, ripe bananas are allowed. Steam or boil vegetables until tender. Stir fried vegetables may be too firm for this level. Steamed or boiled vegetables with final cooked size of 15 mm = 1.5 x 1.5 cm pieces (for adults) Stir fried vegetables may be too firm and are not soft or tender. Soft enough to be cut broken apart into smaller pieces with the side of a fork or spoon. Do not use the fibrous parts of fruit (e.g. the white part of an orange). Serve minced or mashed if cannot be cut to soft & bite-sized pieces. 15 mm = 1.5 x 1.5 cm pieces (for adults) Fibrous parts of fruit are not suitable Drain excess juice Assess individual ability to manage fruit with high water content (e.g. watermelon) where juice separates from solid in the mouth during chewing.
Foods to avoid: Raw fruits and vegetables (no fresh, canned, or cooked pineapple), cooked corn or peas, broccoli, cabbage.

Desserts

Recommended: Pudding, custard, apple sauce; Jello, sherbert, sorbet, ice cream; cobblers without seeds/nuts and with soft breading or crumb mixture.
Foods to avoid: Dry, coarse cakes or cookies, rice or bread pudding, hard candies.

Examples of IDDSI Framework Levels

To further clarify the IDDSI framework, here are descriptions and examples of the eight food textures and drink thickness categories. To determine where any particular food or drink fits in the framework, use the tests for each category.

Foods: Levels 3-7

Level 3: Liquidised: Foods that can be drunk from a cup or eaten with a spoon.
Level 4: Pureed: Foods that are smooth with no lumps, requiring very little chewing ability.
Level 5: Minced & Moist: Foods that are finely minced or chopped, served in a smooth sauce or gravy. For adults, equal to or less than 4mm width and no more than 15mm in length.
Level 6: Soft & Bite-Sized: Foods that are soft enough to be cut or broken into smaller pieces with the side of a fork or spoon. Normal, everyday foods of soft/tender textures that are developmentally and age appropriate. Any method may be used to eat these foods. Sample size is not restricted at Level 7, therefore, foods may be of a range of sizes Smaller or greater than 8mm pieces (Pediatrics) Smaller or greater than 15 mm = 1.5 cm pieces (Adults) Does not include: hard, tough, chewy, fibrous, stringy, crunchy, or crumbly bits, pips, seeds, fibrous parts of fruit, husks or bones. May include ‘dual consistency’ or ‘mixed consistency’ foods and liquids if also safe for Level 0, and at clinician discretion.
Level 7: Regular: Normal, everyday foods of soft/tender textures that are developmentally and age appropriate.

Drinks: Levels 0-4

Level 0: Thin: Flows like water. Examples include water, juice, and tea.
Level 1: Slightly Thick: Thicker than water and requires slightly more effort to drink.
Level 2: Mildly Thick: Flows off a spoon and can be sipped from a cup, but requires more effort than thin liquids.
Level 3: Moderately Thick: Can be drunk from a cup or eaten with a spoon, but cannot be poured easily.
Level 4: Extremely Thick: Maintains its shape and is usually eaten with a spoon.

Tips for Ensuring Adequate Nutrition

Meeting nutritional needs on a dysphagia diet can be challenging. Here are some strategies to help:

Eat from a variety of food groups: Try to eat from a variety of food groups, so your body gets the nutrients it needs.
Include liquid nutrition supplements: To make sure you get enough calories and protein, you may include liquid nutrition supplements, such as Ensure, Boost, or Carnation Instant Breakfast if they are thickened to the correct texture, if needed. “Plus” versions of these products provide the most calories and protein per serving.
Moisten foods: Cut all food into small pieces. Moisten the food by adding gravy, sauce, vegetable or fruit juice, milk, or half and half. Pour sauce or gravy over bread slices or syrup over pancakes.
Enhance flavor: You can get creative with your food to improve flavor with herbs, spices, and pairing the right foods.

Advancing Dysphagia Diets: Strategies and Considerations

Advancing a patient's dysphagia diet requires careful assessment and monitoring. The following steps provide a general framework:

Complete a Swallowing Assessment: First, complete a swallowing assessment to determine your patient’s current, safe diet level. An NPO diet may be appropriate for patients who have no swallowing reflex or no UES opening.
Initial Food and Liquid Trials: Attempt thinner consistencies if the patient demonstrates no or minimal signs of dysphagia. Attempt thicker consistencies if the patient demonstrates signs or symptoms of dysphagia-including aspiration-with the food or liquid being trialed. Introduce safe swallowing strategies if the patient demonstrates signs or symptoms of dysphagia during the food and liquid trials.
Implement Swallowing Strategies: Introduce safe swallowing strategies if the patient demonstrates signs or symptoms of dysphagia during the food and liquid trials.
Monitor and Observe: Next, complete a few more food and liquid trials while using the swallowing strategies. Observe whether the signs or symptoms of dysphagia improved.
Upgrade Textures: The speech therapist may upgrade the patient to these textures once they demonstrate safe swallowing AND consistent use of strategies across three sessions.
Adjust as Needed: If the patient continues to demonstrate the same signs or symptoms of dysphagia, then trial thicker liquids and/or softer foods. Introduce swallowing exercises in order to improve underlying weakness or discoordination. Recommend repeat MBSS and FEES as appropriate. Many patients who are NPO and/or are tube-fed can recover enough to resume a fully PO diet.
Regular Re-evaluation: Regular re-evaluation by an SLP is crucial to ensure the diet remains appropriate and safe.

The Role of the Speech-Language Pathologist (SLP)

The SLP plays a vital role in the management of dysphagia. Their responsibilities include:

Conducting swallowing assessments: This helps to determine the safest and most appropriate diet texture and liquid thickness for the individual.
Developing individualized treatment plans: These plans may include swallowing exercises and strategies to improve swallowing function.
Providing education and training: SLPs educate patients, families, and caregivers on proper feeding techniques and diet modifications.
Monitoring progress: SLPs continuously monitor the patient's progress and adjust the treatment plan as needed.

Challenges in Dysphagia Diet Standardization

Despite the introduction of the National Dysphagia Diet and the IDDSI framework, challenges in standardization persist. One of the things that I have found difficult, as a traveling Speech Pathologist is the wide variance in diet textures and fluid consistencies, as well as they quality of food served to the residents I work with. It amazes me sometimes the items that residents on modified diets receive with their meals. Educating and modifying the Dietary staff is a time consuming task that involves input and consultation with the Dietary Manager, Dietician, Dietary staff, and Restorative staff. Many times facilities are members of a large corporation, and menus are corporate-wide. The American Speech-Language Hearing Association itself reports that it has no policies or guidelines regarding items on particular diet levels.

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