Dysphagia, a swallowing disorder affecting approximately 8% of the world's population, presents significant challenges to individuals, impacting their ability to eat and drink safely and comfortably. This condition is closely associated with malnutrition, dehydration, upper respiratory infection, and an increased risk of sentinel events. To address the complexities of dysphagia management, standardized diet textures and liquid consistencies are essential. This article delves into the International Dysphagia Diet Standardisation Initiative (IDDSI) framework, which has become the gold standard for determining diet textures for dysphagia.
The Need for Standardized Dysphagia Diets
In the past, healthcare providers often used a variety of terms to describe diets for those requiring altered consistency foods, including “mechanical soft,” “blended smooth,” and “chopped.” However, the lack of universal guidelines created confusion and inconsistency. Individuals with dysphagia might find their modified diet called one thing in a hospital and something else at a rehabilitation facility. This inconsistency highlighted the need for a standardized approach to dysphagia diets.
The International Dysphagia Diet Standardisation Initiative (IDDSI)
To provide universal guidelines for the dysphagia diet, the International Dysphagia Diet Standardization Initiative (IDDSI) set out to standardize diets and liquid consistency. In 2019, the American Speech-Language-Hearing Association and the Academy of Nutrition and Dietetics endorsed the use of this International Dysphagia Diet. The IDDSI framework provides common terminology for describing food textures and drink thickness to improve safety for individuals with swallowing difficulties.
The IDDSI framework consists of a continuum of 8 levels (0-7). Drinks are categorized by their thickness and are assigned to a level between 0 and 4. Foods range from liquidized (level 3) to regular and easy to chew (level 7). This provides consistent terminology for providers to use to describe the precise level of texture modification needed for foods and thickness for drinks.
IDDSI Levels Explained
The IDDSI framework utilizes specific tests to determine where any particular food or drink fits within its categories. Here's a detailed description of each level:
Read also: Understanding Dysphagia Diets
Drinks (Levels 0-4):
- Level 0 - Thin: This is regular water, clear juice, milk, coffee, and tea. It flows like water.
- Level 1 - Slightly Thick: Thicker than water, but still flows easily.
- Level 2 - Mildly Thick: This level, also known as nectar-thick, is thicker than Level 1 and flows more slowly.
- Level 3 - Moderately Thick: Also known as honey-thick, this level flows off a spoon but can be sipped from a cup.
- Level 4 - Extremely Thick: This level, also known as pudding-thick, can be eaten with a spoon but does not flow from a cup.
Foods (Levels 3-7):
Level 3 - Liquidised: This level requires foods to be liquidized.
Level 4 - Pureed: Foods at this level should be smooth with no lumps, requiring very little chewing. Mom’s Meals® offers a pureed menu of fully prepared soft food meals designed to meet the Academy of Nutrition and Dietetics requirement for Dysphagia (Level 1 - Pureed Nutritional Therapy) and intended to meet the guidelines of level 4 - pureed.
Level 5 - Minced & Moist: Foods should be soft and moist, with small, easily manageable pieces. For adults, equal to or less than 4mm width and no more than 15mm in length. To meet level 5 criteria, meals may need to be mashed or chopped up further and could be easily modified to this texture.
- Meat: Finely 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 the texture cannot be finely minced, it should be pureed.
- Fish: Finely 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).
- Fruit: Serve finely minced or chopped or mashed. Drain excess juice. If 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 length.
- Vegetables: Serve finely minced or chopped or mashed. Drain any liquid. If 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 length.
- Cereal: Thick and smooth with small soft lumps. Texture fully softened. Any 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.
- Bread: No regular, dry bread, sandwiches, or toast of any kind. Use pre-gelled ‘soaked’ breads that are very moist and gelled through the entire thickness.
- Rice, couscous, quinoa (and similar food textures): Not sticky or glutinous. Should not be particulate or separate into individual grains when cooked and served. Serve 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 & Bite-Sized: Foods should be soft, tender, and easy to chew, with no hard or chewy pieces. Level 6 contains bite sizes that are 1.5cm or 15mm, so that if a chunk falls into the airway, the person will not choke/asphyxiate.
- Meat: 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
- Fish: 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
- Casserole/Stew/Curry: Liquid 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 adults. No hard lumps
- Fruit: 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
- Vegetables: 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.
Level 7 - Regular / Easy to Chew: Normal, everyday foods of soft/tender textures that are developmentally and age appropriate. Most of the meals would be considered level 6 or 7, soft and bite-sized or easy to chew.
Read also: Safe Eating with Dysphagia
- 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 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.
- Meat: Cooked until tender. If texture cannot be served soft and tender, serve minced and moist
- Fish: Soft enough cooked fish to break into small pieces with the side fork, spoon or chopsticks
- Casserole/Stew/Curry: Can 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 liquid. No hard lumps
- Fruit: 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).
- Vegetables: Steam 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.
Managing Dysphagia: Assessment and Advancement
Initial Assessment
The first step in managing dysphagia is a thorough swallowing assessment to determine the patient's safe diet level. This assessment may reveal that an NPO (nothing by mouth) diet is appropriate for patients with no swallowing reflex or UES (upper esophageal sphincter) opening. However, an NPO diet is not suitable for all patients who aspirate.
During trials, it's crucial to ensure the patient is alert and oriented. 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.
Implementing Swallowing Strategies
Introduce safe swallowing strategies if the patient demonstrates signs or symptoms of dysphagia during the food and liquid trials. These strategies may include:
- Chin tuck: Tilting the chin down during swallowing to protect the airway.
- Head turn: Turning the head to the weaker side during swallowing to direct food to the stronger side of the pharynx.
- Effortful swallow: Swallowing with increased effort to clear food from the pharynx.
- Mendelsohn maneuver: Voluntarily holding the larynx elevated during swallowing to prolong UES opening.
Advancing the Diet
After implementing swallowing strategies, conduct more food and liquid trials to observe whether the signs or symptoms of dysphagia have improved.
- Successful Trials: 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, the 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.
- Persistent Symptoms: 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 (Modified Barium Swallow Study) and FEES (Fiberoptic Endoscopic Evaluation of Swallowing) as appropriate.
Many patients who are NPO and/or are tube-fed can recover enough to resume a fully PO (per oral) diet.
Read also: Understanding Dysphagia Diets
Common Causes and Complications of Dysphagia
The most common causes of dysphagia are related to underlying medical or physical conditions. Individuals may have impaired swallowing secondary to a variety of challenges including reduced mastication (chewing) or lost or missing teeth/dentures and reduced oral and pharyngeal sensitivity.
Dysphagia can often be caused by:
- Alzheimer’s disease
- Cerebral palsy
- Meningitis and brain tumors
- Mouth, throat, or esophageal cancer
- Multiple sclerosis
- Parkinson's disease
- Traumatic brain injury
- Spinal cord injury
- Stroke
Typically, a full assessment including a bedside swallowing evaluation, or a barium swallow study will be used to make a diagnosis.
A common warning sign of dysphagia is chronic coughing or choking while eating and gagging when swallowing. If a person does not receive treatment to help with their symptoms and continues to have challenges swallowing, especially when eating and drinking, they can be at risk for developing other health issues, including:
- Dehydration
- Malnutrition
- Pneumonia or respiratory infections
- Weight loss
- Anxiety and depression
Treating Dysphagia
Since dysphagia accompanies an underlying condition or is due to weakened or damaged muscles and nerves used for swallowing, diagnosing and treating what is causing the condition is essential to improving a person’s quality of life.
Depending on the cause of the dysphagia, treatment may include swallowing exercises, positioning the head to allow for easier swallowing and prescribing medication to treat the condition causing the dysphagia.
Another effective way of managing dysphagia is modifying the texture of foods (chopped, minced, pureed) and thickening liquids to make eating and swallowing safer and easier. This helps reduce the risk of choking or having material enter the airway.
Comparing NDD and IDDSI Levels
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.
In most cases, thickened fluids are described into five different levels (0∼4) set up by an SFT for a pragmatic measurement of flow: levels 0 (thin), 1 (slightly thick), 2 (mildly thick), 3 (moderately thick), and 4 (extremely thick). For the NDD framework, thickened fluids are categorized into four “consistency” levels established by the NDD task force: 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).
However, research has indicated that the thickener concentration ranges of thickened drinks for the classification of NDD levels differed from those of IDDSI levels, and they appeared to be greatly influenced by the type of drink. Awareness of the differences in thickener concentration for classifying thickness levels between the NDD and IDDSI appears valuable for IDDSI classification using IDDSI flow tests (SFT or FDT) in clinical practice.
Implementation of IDDSI
Implementation should involve numerous phases, including building awareness, preparation and adoption, and monitoring across all the phases. As a clinician, you can start using dual labeling in your documentation to get familiar using the terminology. For example, when recommending the liquids of Nectar-Thick, add: (aka, Mildly Thick Liquid per the IDDSI Framework).
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