Dysphagia, or difficulty swallowing, can significantly impact an individual's ability to eat and drink safely. Managing dysphagia often involves modifying the texture of foods and the viscosity of liquids to reduce the risk of aspiration (food or liquid entering the lungs). This article provides a detailed overview of dysphagia diet levels, drawing upon established guidelines and recent research to offer a comprehensive understanding for both healthcare professionals and individuals managing dysphagia.
The Importance of Texture-Modified Diets in Dysphagia Management
Diet texture modifications play a crucial role in dysphagia management. These modifications involve altering the viscosity of liquids and/or softening, chopping, or pureeing solid foods. The goal is to create a consistency that is easier and safer for individuals with swallowing difficulties to manage.
Standardized Guidelines: The International Dysphagia Diet Standardisation Initiative (IDDSI)
The International Dysphagia Diet Standardisation Initiative (IDDSI) is an international collaboration of professionals who developed a standardized framework for labeling texture-modified foods and thickened liquids. ASHA supports the IDDSI framework and encourages members who assess and treat individuals with dysphagia to consider using it. The IDDSI framework categorizes food textures and drink thickness into eight levels, from 0-7. Drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness.
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).
IDDSI Levels Explained
Here are descriptions and examples of the eight food textures and drink thickness categories from the IDDSI Framework:
Read also: Understanding Dysphagia Diets
- Level 0: Thin - This is the consistency of regular water.
- Level 1: Slightly Thick - Slightly thicker than water.
- Level 2: Mildly Thick - This may also be referred to as nectar-thick.
- Level 3: Moderately Thick - This is also known as honey-thick.
- Level 4: Extremely Thick - This is also known as pudding-thick.
- Level 5: Minced and Moist - Can be eaten with a fork or spoon. Could be eaten with chopsticks in some cases, if the individual has very good hand control. Can be scooped and shaped (e.g. MeatFinely minced or chopped (for adults, equal to or less than 4mm width and no more than 15mm in length)Serve in mildly, moderately, or extremely thick, smooth, sauce or gravy, draining excess*If texture cannot be finely minced it should be pureedFishFinely mashed in mildly, moderately, or extremely thick smooth, sauce or gravy, draining excess (for adults equal to or less than 4mm width and no more than 15mm in length)FruitServe finely minced or chopped or mashed Drain excess juiceIf needed, serve in mildly, moderately, or extremely thick smooth sauce or gravy AND drain excess liquid.No thin liquid should separate from foodFor adults, equal to or less than 4mm width and no more than 15mm in lengthVegetablesServe finely minced or chopped or mashedDrain any liquidIf needed, serve in mildly, moderately, or extremely thick smooth sauce or gravy AND drain excess liquid. No thin liquid should separate from food.For adults, equal to or less than 4mm width and no more than 15mm in lengthCerealThick and smooth with small soft lumpsTexture fully softenedAny milk/fluid must not separate away from cereal. Drain any excess fluid before serving.For adults, equal to or less than 4mm width and no more than 15mm in length.BreadNo regular, dry bread, sandwiches, or toast of any kindPre-gelled ‘soaked’ breads that are very moist and gelled through the entire thicknessRice, couscous, quinoa (and similar food textures)Not sticky or glutinousShould not be particulate or separate into individual grains when cooked and servedServe with smooth mildly, moderately, or extremely thick sauce AND Sauce must not separate away from rice, couscous, quinoa (and similar food textures).
- Level 6: Soft and Bite-Sized - 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 moistFishSoft 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 skinsCasserole/Stew/CurryLiquid portion (e.g. sauce) must be thick (as per clinician recommendations)Can contain meat, fish or vegetables if final cooked pieces are soft and tender and no larger than 15 mm = 1.5 x 1.5 cm pieces for adultsNo hard lumpsFruitServe 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 suitableDrain excess juiceAssess individual ability to manage fruit with high water content (e.g. watermelon) where juice separates from solid in the mouth during chewingVegetablesSteamed 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. Normal, everyday foods of soft/tender textures that are developmentally and age appropriateAny method may be used to eat these foodsSample size is not restricted at Level 7, therefore, foods may be of a range of sizesSmaller 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 - MeatCooked until tender.If texture cannot be served soft and tender, serve minced and moistFishSoft enough cooked fish to break into small pieces with the side fork, spoon or chopsticksCasserole/Stew/CurryCan contain meat, fish, vegetables, or combinations of these if final cooked pieces are soft and tenderServe in mildly, moderately of extremely thick sauce AND drain excess liquidNo hard lumpsFruitSoft 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).VegetablesSteam or boil vegetables until tender. Stir fried vegetables may be too firm for this level. Food that starts as one texture (e.g. firm solid) and changes into another texture specifically when moisture (e.g. water or saliva) is applied, or when a change in temperature occurs (e.g. Ice chipsIce cream/Sherbet if assessed as suitable by a Dysphagia specialistJapanese Dysphagia Training Jelly sliced 1 mm x 15 mmWafers (also includes Religious Communion wafer)Waffle cones used to hold ice creamSome biscuits/ cookies/ crackersSome potato crisps - only ones made or formed from mashed potato (e.g.
National Dysphagia Diet (NDD) Levels
The National Dysphagia Diet (NDD), published in 2002, developed universal terminology for texture-modified diets. The NDD was part of the full Nutrition Care Manual (NCM)® established by the Academy of Nutrition and Dietetics (AND). The NDD includes three levels of texture modification for solid foods:
- Dysphagia Pureed (Level 1): Foods are totally pureed to a pudding-like consistency. No coarse textures, raw fruits or vegetables, or nuts are allowed.
- Dysphagia Mechanically Altered (Level 2): The diet includes foods that are soft textured and moist, making them easy to swallow. Soft, well-cooked foods, well-moistened ground meats, moist and well-cooked potatoes, noodles, and dumplings are examples of foods that are the proper texture for this diet. All foods of a pureed consistency are allowed on this diet.
- Dysphagia Advanced (Level 3): Foods that are nearly normal textures are allowed on the dysphagia advanced diet, with the exception of crunchy, sticky, or very hard foods. The diet includes bite-sized foods that are moist. Foods that are allowed on dysphagia level 1 and level 2 diets also are allowed on the dysphagia advanced diet.
Liquid Consistency Levels in NDD and IDDSI
The NDD also addresses liquids, which are evaluated separately from solid foods. The thickness levels of fluids for patients with dysphagia are established according to the guidelines of the National Dysphagia Diet (NDD) and International Dysphagia Diet Standardization Initiative (IDDSI). The nectar- (level 2), honey- (level 3), and pudding-like (level 4) fluids in NDD are consistent with the mildly (level 2), moderately (level 3), and extremely (level 4) thick fluids in IDDSI, respectively.
The NDD framework categorizes thickened fluids into four “consistency” levels: thin (1∼50 mPa･s), nectar-like (51∼350 mPa･s), honey-like (351∼1,750 mPa･s), and pudding-like (>1,750 mPa･s).
Facility-Established Protocols
Many facilities utilize their own dysphagia diet levels. However, the challenge with these individualized systems is the limited ability to communicate and coordinate across health care facilities/settings and inconsistency with product labeling of commercially available dysphagia products. Research has indicated that there is considerable variation in terminology with 27 different labels being used to refer to ≤5 levels of drink thickness and 54 labels used to refer to ≤5 levels of texture-modified foods (Cichero et al., 2016).
The Role of the Speech-Language Pathologist (SLP)
Normally a speech therapist will recommend a dysphagia pureed diet after evaluating a patient who has problems chewing or swallowing food. In some cases, medical tests are used to determine the best texture for a patient. SLPs are encouraged to explore the current evidence and consider patients holistically when developing individualized plans of care that meet patients’ individual needs.
Read also: Safe Eating with Dysphagia
Writing Diet Orders
State laws and facility regulations impact permissions for writing orders and entering orders in documentation systems. Therefore, ASHA does not have a policy that specifically addresses writing or modifying diet orders. Clinicians should adhere to specific state and facility guidance.
Clarify regulations/protocols for how any nutritional restrictions and other components that fall outside the speech-language pathology scope of practice will be carried over when changing diet textures/liquid consistencies. For example, if you need to change a patient's diet to IDDSI level 5 (minced and moist) and that patient is also on a low-sodium diet, the order will likely need to address both issues-texture and dietary restrictions.
Advancing Dysphagia Diets
Treating dysphagia requires high levels of training and skill. 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. It’s not appropriate for all patients who aspirate. If the patient is having a hard time staying awake, halt trials until they are alert and oriented. 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.
Next, complete a few more food and liquid trials while using the swallowing strategies. Observe whether the signs or symptoms of dysphagia improved.
If the strategies consistently improve the signs or symptoms of dysphagia AND the patient safely consumes the food and liquid in 80-100% of trials: Your dysphagia goal will be to continue trials with a speech therapist using these strategies.The speech therapist may upgrade the patient to these textures once they demonstrate safe swallowing AND consistent use of strategies across three sessions.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.
Read also: Understanding Dysphagia Diets
Food Textures for Dysphagia Diets
Dysphagia Pureed Diet (Level 1)
- Meats and meat substitutes: Pureed meats (pureed to pudding-like consistency), smooth soufflés, soft, moist tofu, hummus
- Breads: Pureed bread mixes, pregelled slurried breads, pancakes, French toast, waffles, sweet rolls, etc
- Cereals: Smooth cooked cereals, such as farina-type cereals with a pudding-like consistency
- Fruits: Pureed fruit, well-mashed fresh bananas
- Vegetables: Pureed vegetables without lumps, pulp, or seeds, tomato sauce without seeds
- Potatoes and starches: Mashed potatoes and pureed potatoes with gravy, butter, margarine, or sour cream, well-cooked pasta, noodles, or pureed rice (blended to a smooth consistency)
- Desserts: Smooth pudding custards, yogurt, pureed desserts, and soufflés
- Beverages: Any smooth, homogenous beverage without lumps, chunks, or pulp (may need to thicken to proper consistency)
Foods to Avoid:
- Whole, ground, or chopped meats, fish, or poultry
- Legumes or lentils, unless pureed
- Cheese and cottage cheese, unless pureed
- Eggs that are not pureed
- Nut butters, unless pureed into other foods to correct consistency
- All other bread, rolls, crackers, biscuits, pancakes, French toast, muffins, etc
- Dry cereals and cooked cereals with lumps, seeds, or chunks
- Whole fruits (fresh, frozen, canned, or dried)
- All other vegetables that are not pureed
- All other potatoes, rice, and noodles
- Plain mashed potatoes
- Cooked grains
- All other desserts
- If patient is on thickened liquids, restrict ice cream, ices, milk shakes, frozen yogurt, gelatin, and other frozen desserts, because they are thin-liquid consistency at room temperature
Dysphagia Mechanically Altered Diet (Level 2)
- Meats and meat substitutes: Moistened ground or cooked meat, poultry, or fish (serve with sauces), casseroles without rice, moist, well-cooked pasta, moist meat loaf or meatballs, poached, scrambled, or soft-cooked eggs, tofu, well-cooked and moist mashed legumes or beans
- Breads: Soft, well-moistened pancakes, Pureed bread mixes or slurried breads
- Cereals: Cooked cereals with little texture, including oatmeal, slightly moistened, dry cereals with little texture
- Fruits: Soft and drained canned or cooked fruits without seeds or skin, ripe bananas
- Vegetables: All soft, well-cooked vegetables that are in small pieces and mashable with a fork, cooked corn and peas
- Potatoes and starches: Well-cooked and moistened boiled, baked, shredded, or mashed potatoes, well-cooked pasta noodles in sauce
- Desserts: Puddings and custards, soft fruit pies (bottom crust only), crisps and cobblers with soft topping and no seeds, most canned fruits, soft moist cakes with icing or slurried cakes
- Beverages: All beverages with little texture or pulp
Foods to Avoid:
- Dry meats, such as bacon, sausage, or hot dogs
- Dry casseroles or casseroles with rice or large chunks
- Cheese cubes and slices
- Peanut butter
- Hard-cooked or crisp fried eggs
- Sandwiches and pizza
- Slices of bread
- Toast
- Coarse cooked cereals
- Whole-grain or coarse dry cereals
- Fresh or frozen fruits
- Cooked fruit with skin or seeds
- Brussels sprouts, broccoli, cabbage, asparagus, or other rubbery cooked vegetables
- Potato skins and chips
- Fried potatoes
- Rice
- Dry, coarse cakes and cookies
- Desserts with nuts, seeds, coconut, pineapple, or dried fruit
- Rice or bread pudding
Dysphagia Advanced Diet (Level 3)
- Meat and meat substitutes: Thin-sliced, tender, or ground meats or poultry, well-moistened, fish, eggs (any preparation acceptable), yogurt (no nuts or coconut), casseroles with small chunks of tender or ground meat
- Bread: Well-moistened breads, biscuits, muffins, pancakes, waffles, etc (add jelly, margarine, and other toppings to moisten well)
- Cereals: All well-moistened cereals
- Fruits: All canned and cooked fruits, soft, peeled, ripe fresh fruits, such as peaches, kiwi, mangos, cantaloupe, etc, soft berries with small seeds, such as strawberries
- Vegetables: All cooked, tender vegetables, shredded lettuce
- Potatoes and starches: All, including rice and tender fried potatoes
- Desserts: All desserts, except those on the avoid list
- Beverages: Any beverage of recommended consistency
Foods to Avoid:
- Tough or dry meats or poultry
- Dry fish or fish with bones
- Chunky peanut butter
- Yogurt with nuts or coconut
- Dry bread, toast, crackers, etc
- Tough, crusty breads, such as French bread
- Coarse or dry cereals
- Hard-to-chew fresh fruits, such as apples or pears
- Stringy, pulpy fruits, such as papaya, pineapple, or mango
- Fresh fruits with tough peels, such as grapes
- Prunes, apricots, and other dried fruits (unless cooked)
- All raw vegetables, except shredded lettuce
- Cooked corn
- Rubbery cooked vegetables
- Tough or crisp fried potatoes
- Dry cakes or cookies that are chewy
- Anything with nuts, seeds, dry fruits, coconut, and pineapple
Considerations for Thickened Drinks
When thickening drinks, it's important to note that the thickener concentration ranges for classifying thickness levels can vary depending on the type of drink. For example, a study revealed that drink composition greatly influences the results of the IDDSI flow test and NDD viscosity, showing that the ηa,50 and SFT values within each thickness level varied depending on the type of drink.
Tips for Ensuring Adequate Nutrition
- Try to eat from a variety of food groups, so your body gets the nutrients it needs.
- 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.