Are you struggling to understand the different food textures in dysphagia diets? Dysphagia diets can often be overwhelming and confusing. With these diet levels, people with swallowing issues will be able to better understand the food and drink textures. This will increase safety for anyone wanting to enjoy eating and drinking. This article is for caregiver or an individual managing a swallowing disorder. This article will explain the IDDSI diet levels in easy terms and provide the tools to navigate these diets with confidence and ease.
Introduction to IDDSI and Dysphagia Diets
Many people struggle to understand dysphagia diets. Dysphagia is a condition (and diagnosis) related to difficulty swallowing. Difficulty swallowing can be caused by many health conditions. In the older adult population, research suggests that up to one in three individuals may experience changes in their ability to swallow or have been diagnosed with dysphagia. This can be caused by progression of a neurological disorder, changes with the gastrointestinal tract, or simply as a symptom that presents as part of the aging process.
The International Dysphagia Diet Standardisation Initiative (IDDSI) is an internationally recognized framework that provides standardized terms and testing methods for food textures and drink consistencies for individuals with swallowing difficulties. This framework was developed to address the confusion and inconsistencies of existing dysphagia diets. The initiative challenges us to prioritize safety and prevent the risk of choking, giving us a solution to the outdated, ambiguous language like “soft”, “chopped”, and “nectar-thick” that varies between facilities. In order to eliminate confusion and promote patient safety, the new IDDSI standards establish unified principles for all food service operations to follow:
- Consistent diet terminology
- Reliable testing methods
- Standardized definitions of the diet
By using a standardized framework like IDDSI, individuals with dysphagia and their caregivers can have a clear understanding of the texture and consistency of foods and drinks. Knowing more can reduce the risk of choking or aspiration. This empowers them to make choices that promote safe and enjoyable eating experiences.
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. The IDDSI Framework provides a common terminology to describe food textures and drink thickness.
Read also: Understanding IDDSI Levels
The IDDSI Diet Levels
The IDDSI framework groups food textures and drink consistencies into eight levels, ranging from Level 0 to Level 7. Each level has specific guidelines that help healthcare professionals, caregivers, and individuals make informed decisions about foods and drinks.
Level 0: Thin Liquids
Level 0 is often referred to as the ‘thin’ liquids level. It consists of liquids that are “regular” without any changes or thickeners. This means that you can indulge in almost any drink. Level 0 liquids move freely and require you to manage the speed of them in your mouth.
Level 1: Slightly Thick Liquids
Also known as ‘slightly thick’, it offers a variety of safe and enjoyable liquids for individuals with swallowing difficulties. This level is perfect for those who have minimal difficulty with moving liquids safely in the mouth. In Level 1 you can enjoy a variety of liquids that are naturally slightly thick. To change the texture of a thin liquid into a level 1, add thickener to your drink. Mix the measured thickener into a specific amount of thin liquid and stir or shake. Level 1 of the dysphagia diet can increasing feels confidence knowing that you’re giving your body the hydration it needs. And you can still enjoy the pleasure of drinking. You don’t have to feel limited or restricted in your choices. So go ahead and explore the world of slightly thick liquids.
Level 2: Mildly Thick Liquids
Get ready to experience a whole new world of satisfying drinks with Level 2 of the dysphagia diet. This level is designed for individuals with difficulty moving thin and slightly thick liquids safely in the mouth. Level 2 drinks are mildly thick. They can still be appealing and enjoyable for those on the dysphagia diet. However, most liquids are naturally thin and need to have thickener added in order to fall into the correct consistency. Use a 10 ml syringe to test the appropriate thickness of your liquids. Use any drink, hot or cold, of your choice. With Level 2 of the dysphagia diet, people no longer have to feel limited in drink choices. You can enjoy a variety of flavors while ensuring that your liquids are safe and easy to swallow.
Level 3: Moderately Thick Liquids / Liquidised Foods
Level 3 of the IDDSI diet is a bit different. Level 3 foods of the IDDSI diet focuses on smoothness with no separate solid pieces. This means that the texture is similar to that of thin pudding or yogurt. Many soups fall into this category as long as they are blended. From creamy soups and thin mashed potatoes with gravy to smooth fruit purees and custards, there are endless possibilities to satisfy your taste buds. So go ahead and indulge in these delightful liquidized dishes. When it comes to managing liquids for swallowing disorders, two things are important. It’s crucial to pay attention not only to the texture of the food but also the consistency of the liquids. These liquids are thick like honey or thin pudding. They have had thickener added and typically take time to drink in order to ensure safe swallowing. Using a spoon is an easy way to take in these liquids. Treat these liquids like you would a thick soup.
Read also: Guide to Pureed Foods Post-Surgery
Level 4: Pureed Foods / Extremely Thick Liquids
Level 4 is all about pureed foods that are blended to be cohesive and moist. Level 4 is a dual level, it refers to both a liquid consistency and also a food texture consistency. Liquids in level 4 are referred to as extremely thick while foods are referred to as Pureed.
Pureed foods are mostly smooth but may have increased texture, and have a pudding-like consistency. These foods are typically prepared by blending, mashing, or processing in a food processor. With pureed food, try to savor the flavors of your favorite foods without worrying about any chunky or hard-to-swallow bits. These foods are incredibly versatile, allowing you to experiment with different flavors and spices. Try enjoying pureed soups, such as tomato bisque or butternut squash soup. You may also be interested in experimenting with pureeing meats and/or vegetables. This requires practice and trial-and-error at times. Blend foods after cooking very soft, and adding liquid (like broth). You can also indulge in smooth and creamy desserts like chocolate mousse or vanilla pudding. These will satisfy your sweet tooth. The best part is that level 4 foods are designed to be easy to eat without chewing. As we continue our journey through the IDDSI diet levels, learning about Level 4 is a significant step towards mastering the dysphagia diet. It offers a wide range of delicious options that will support your swallowing abilities and nutrition. By following the guidelines of this level, you can continue to explore new tastes and textures. So, remember that Level 4 of the IDDSI diet allows people to experience the joy of flavor without compromising health. Take pleasure in the varied flavors that this level offers.
Liquids play a crucial role in our daily lives, providing hydration and nourishment. Level 4 liquids are known as extremely thick, or pudding-like liquids. They are the thickest and most challenging to swallow. This is because they require strength of your muscles but move very slowly. These liquids are thickened until similar to pudding. Understanding the different levels of liquid textures can help you make informed choices depending on your specific swallowing needs.
Extremely Thick Liquids are found under Level 4 of the IDDSI framework. These liquids are more solid than liquid. Level 4 liquids are for people who have more strength and less coordination with their oral muscles. Decreased coordination can lead to poor control of a thin or thinner liquid and can increase risk of aspiration. Stickiness of liquids can be problematic as it can stick to parts of the mouth and cause “residue”. For anyone requiring extremely thick liquids, dehydration, or lack of fluid intake, can be a risk. Staying hydrated is incredibly important for anyone on thickened liquids. Make a plan to get enough fluids in each day and add liquids to your pureed foods to increase your chances of staying hydrated. This plan may include making your thickened liquids for the day ahead of time and setting an alarm for when to drink a little bit.
Individuals who are served IDDSI Pureed (Level 4) have a serious swallowing disorder called dysphagia. This means they cannot safely chew or swallow, so the food we serve must be smooth, moist, and prepared ready to swallow to minimize their risk of choking. Individuals with dysphagia who need IDDSI Pureed (Level 4) have the following problems and/or limitations:
Read also: Comprehensive Puréed Diet Information
- Reduced tongue control
- Pain or difficulty swallowing
- Does not chew well
- Cannot form a bolus
- Missing teeth, dentures not fitted
For these reasons, individuals with dysphagia on IDDSI Pureed (Level 4) require smooth, moist, pureed foods in which only the tongue is needed to move food back and forth for swallowing.
Level 5: Minced and Moist
Level 5 of the IDDSI diet provides increased texture that is not as easy to swallow for those with severe Dysphagia. This level is often referred to as ‘minced and moist’. It is suitable for individuals transitioning to more texture in their food. The goal of Level 5 is to make it easier to control the food in the mouth. It also helps to minimize the risk of choking or aspiration while increasing strength of swallowing muscles. Most importantly, foods at this level are finely minced or ground into small, manageable pieces. At Level 5, people can enjoy a variety of foods that have been minced and moistened. This includes foods like ground meat, soft cooked vegetables, and soft fruits. It’s important to note that while Level 5 provides a safe texture for swallowing for many people, it is still important to monitor your own swallowing abilities and make necessary changes to ensure your safety and comfort.
Level 6: Soft and Bite-Sized
Experience the next level of satisfaction with Level 6 of the dysphagia diet, as it offers more texture with solid foods that’ll leave you feeling nourished and content. This texture is perfect for individuals who have adequate chewing ability and need more challenge swallowing solid textures. Level 6 foods are transitional, like level 5, and may be the final leg of your dysphagia journey. Using a food processor on pulse to prepare these foods is easiest. Continue pulsing until the ingredients are chopped up and have a chunky consistency. Level 6 foods can be enjoyed in a variety of flavors, from savory to sweet, and most importantly, this makes meals highly enjoyable and satisfying. Almost any food can be chopped or processed into small pieces.
Level 7: Easy to Chew / Regular
The final IDDSI Diet Level: 7, the last step on our dysphagia diet review. This level on not modified in any way. Some people may find that having well cooked and easy to chew foods are best, luckily these foods still fit into level 7. Some people with dysphagia may find they are able to tolerate most foods at level 7 but have moments where they return to a previous level to address a health concern or setback. As people delve into the world of Level 7, they’ll discover a newfound sense of freedom and joy. No longer restricted by the limitations of dysphagia, able to explore a variety of culinary delights and expand horizons.
Some older adults may require specific swallowing techniques with softer textures and smaller bites of food. Others with more severe dysphagia may need an IDDSI Level 4 pureed diet to eat safely. Adjustment to this type of diet modification can be a challenge, especially in addition to other nutritional barriers with the older adult patient population. The registered dietitian nutritionist (RDN) can be helpful in navigating this transition to promote an optimal nutritional status.
Level 4 Pureed Diet: A Detailed Look
A level 4 pureed (pure-AYD) diet is when you only eat foods you do not need to bite or chew. While you’re following this diet, you will make your foods smooth and moist before eating them. Level 4 pureed diets are typically recommended by S-LPs to individuals with dysphagia if certain difficulties are noted. Some of these difficulties may include (but are not limited to) a decreased control of tongue movement or perhaps an inability to bite or chew food. The International Dysphagia Diet Standardization Initiative (IDDSI), an internationally recognized standard for texture-modified diets, describes level 4 pureed food as having a smooth consistency with no lumps or liquid separation. It is often compared to the consistency of mashed potatoes or hummus. Level 4 foods are recommended for people who have difficulty controlling the tongue. The tongue is responsible for controlling food and liquid. When control is decreased, having one single bolus (dictionary.com: roundish mass or lump, especially of chewed food) can make it safer to swallow. The food should hold together so that the tongue can keep control during the swallow.
How to Puree Food
You can use a blender, food processor, or other kitchen item to make your foods smooth. To achieve the consistency of level 4 pureed foods, we’ll need to begin with the right kitchen tools to get the job done. While a blender may pop into your mind first when it comes to making purees, a fine mesh sieve is equally essential and one of the most inexpensive and useful tools to have in your kitchen. If you were recommended this diet, you will be using a blender often; be sure to look for a powerful one that pushes the food into a vortex. This will ensure all the food is blended well. Next, it is recommended using the fine mesh sieve to make sure the puree is free of any lumps missed by the blender, or any other bits like seeds or fresh herbs that may not be safe for you to eat.
Add liquid to the blender or food processer to make your foods smooth, soft, moist, and lump free. You can use water, broth, gravies, sauces, juice, milk, or yogurt. Add just enough liquid so that your food is smooth but not too watery or runny. Make sure to check the thickness of your food before you eat it.
Kitchen items to help you make food:
- Blender: Use a blender for all types of foods, including meats, vegetables, and fruits. You may have to add liquid to make the food the right texture.
- Hand-held blender: Use a hand-held blender to quickly puree your favorite soups right in the pot.
- Food processor: Food processors are useful for shredding, slicing, chopping, and blending foods. They come in different sizes.
- Household mesh strainer or sieve: Use this to strain fruits and vegetables, but not meats. They are inexpensive, good to make 1 serving, and do not need electricity.
Ensuring the Right Thickness and Texture
Your food’s texture can change based on its temperature and how you cooked it. Even after blending and sieving, the puree may not be ready to eat just yet. It is important to always check the consistency of the puree so that you know it is safe to eat. One of the great resources offered by IDDSI is a set of tests for different food and liquid consistencies. These tests can be completed right in your home and help check whether the puree is ready for you to safely eat. Not all purees are automatically safe to eat because they can vary in thickness and texture depending on how foods are prepared.
You can check your food’s thickness and texture by doing a fork drip test and spoon tilt test.
Fork Drip Test: Food holds shape as a mound above the fork. A small amount may flow through and form a short tail below the tines of the fork but it does not flow or drip continuously through the tines. Food holds shape as a mound above the fork. A small amount of the puree may flow through the fork tines and form a tail below the fork. Level 4 pureed foods should sit on top of the fork with very little or no drip through the fork. The Fork Drip Test is used to check the thickness of foods and how they can hold together. Picture a bowl of pureed soup. Your pureed soup may look thick, but you may discover that it’s not thick enough after checking it with the Fork Drip Test. If your pureed soup is not thick enough then it may not be safe for you to eat just yet. This pureed soup example is an important reminder to use the Fork Drip Test instead of judging your purees based on just looks alone.
Spoon Tilt Test: Food is cohesive enough to hold shape on the spoon. It can slide off easily when you tilt or gently flick the spoon over a plate with very little food left on the spoon. However, a thin film of residue left on the spoon is acceptable, but you should not be able to see the spoon through the film and it should not be firm and sticky. It may slightly spread out or slump very slowly on a flat plate. Pick up some of your food with a spoon. Your food should easily slide off. It’s OK if you need to gently flick the spoon to get the food to fall off. The Spoon Tilt Test is used to check the stickiness of foods and how they can hold together. Take, for example, a spoon of mashed potatoes and a spoon of smooth peanut butter- both are technically purees but the degree to which it holds together is very different. Compared to a spoonful of peanut butter that will slowly slide off and leave a film on the spoon due to its stickiness. This stickiness is important to watch for as it can cause the puree to stick to various surfaces in the mouth and throat. This may put you at risk of choking (airway blockage) or aspirating (when food or liquid enters the lungs).
Adjusting the Consistency
After testing your puree, you may find that it did not pass one or both of the IDDSI tests outlined above. That’s okay - you can still have your meal with a few minor changes.
- Your puree is too runny: Try adding commercial thickeners or thickeners you can find in your pantry such as pureed beans or mashed potato flakes.
- Your puree is too thick or dry: Try adding flavourful liquids such as broth or cream.
- Your puree is too sticky: Repeat the Spoon Tilt Test and Fork Drip Test to recheck the consistency of your puree.
Foods to Eat and Avoid on a Level 4 Pureed Diet
Here are some foods you can eat while following this diet. We also list some foods you should avoid. These tables are not a complete list of foods you can eat on this diet. Other foods may be OK to eat if you test them and they are the right size and texture. If you have trouble swallowing liquids, your speech language pathologist may recommend you thicken your liquids.
Foods to Eat:
- Whipped or smooth mashed potatoes without skin
- Pureed soups (tomato bisque, butternut squash soup)
- Pureed meats and vegetables
- Smooth and creamy desserts (chocolate mousse, vanilla pudding)
- Canned or cooked fruits and vegetables (blended into a puree)
Foods to Avoid:
- Foods with lumps
- Foods that are dry or crumbly
- Foods that require chewing
- Fruits with fiber or that are stringy and cannot be pureed into a smooth texture with no lumps.
Tips for Planning Meals
Changing your eating habits can be hard. It’s best to plan your meals ahead of time. Consider the following:
- Where will you be eating?
- Will you have a kitchen and refrigerator available?
- Can you boil water?
- Can you microwave?
- Can you carry a thermos with a meal already made and ready to eat?
Tips for Eating at Home
You can puree many different foods by putting them in a blender with some liquid.
Tips for Eating at Restaurants
Eat at restaurants offering different types of foods and that will adjust for people on special diets. Many places will puree or make foods for your needs. Call ahead and speak to a manager or chef. You may be surprised at how helpful they will be.
Tips for Eating Away From Home
It’s also possible to eat away from home, such as at work or at a friend’s house.
- Bring a food grinder or small food processor.
- Buy a thermos.
- Ask if there is a microwave where you’re going.
- You can make food at home and freeze it in single-serving, microwave-safe containers or Zip-Loc® bags.
- Freeze soups or pureed foods in ice cube trays. Cover the tray with foil or plastic wrap to prevent freezer burn.
Adding Calories
- Add 2 to 4 tablespoons of canned coconut milk or cream to smoothies, shakes, cereals, and yogurts for extra calories.
- Make ice cubes from milk or fruit nectar. Use these high-calorie ice cubes in smoothies or to keep your shakes cold.
- Add sour cream, half and half, heavy cream, or whole milk to your foods.
- Add pureed tofu to cooked vegetables, soups, or smoothies.
The Importance of Presentation, Flavor, and Variety
No matter where the pureed diet is being served, appeal matters and can greatly influence appetite and desire to eat. A plate full of indistinguishable foods is not going to be enticing. Instead, with a few quick fixes, eating a pureed diet can be made enjoyable for the individual with dysphagia.
- Presentation: Appearance of meals and snacks can impact the patient’s appetite. Unenticing meals lacking color and variety can limit interest and desire to eat.
- Flavor: The taste of that first bite will also influence if an individual wants to finish a meal. Certain products can be made with tasteless starch to help maintain normal food flavors but also provide the needed thickening.
- Variety: While some foods certainly require more skill to create a pureed form, adding in a wide variety of foods is beneficial not only for different nutrients but also to support individual appetite. Planning menus with a variety of foods can help caregivers offer a pureed diet at home.
Incorporating each of the different food groups, while maintaining individual preferences, can make the pureed diet less daunting and more of an enjoyable experience. An individual’s diet is not just important for their overall nutrition status. The ability to eat can also impact the older adult’s mental health and quality of life. Oftentimes other comorbidities may influence diet recommendations beyond those of the dysphagia diet.
IDDSI Resources
IDDSI has created handouts in consultation with clinicians and patients. The handouts can be used by people who have feeding, chewing or swallowing problems, their caregivers and clinicians. There are separate handouts that have been designed for adults, and handouts that have been designed for use with babies and children. The handouts provide easy-to-read information about the IDDSI levels and their testing methods. The food levels also include examples of foods for each level, and food textures to avoid.
Implementing IDDSI in Healthcare Settings
Healthcare dining priorities have shifted in the wake of COVID-19. However, it is still vital to focus on high-impact projects like implementing IDDSI. There’s no doubt that learning about IDDSI can be a complex process. The best way to develop an understanding of IDDSI is by learning the standards for one diet at a time, beginning with Pureed (Level 4). Pureed (Level 4) is a great starting point because most healthcare professionals in the dysphagia space are already making purees for patients and therefore have the baseline knowledge needed to start implementing IDDSI. By starting here you can simplify the intricate process of implementing IDDSI in your organization.
Key Components for Training Food Service Workers on IDDSI
It’s vital that you and your team are well-versed in understanding IDDSI. However, IDDSI can be complex to learn. That’s why we created the Roche Dietitians “We Test for Safety” IDDSI Training Program. This online, on-demand program will train your team on the new IDDSI standards in a straightforward, easy-to-understand way. From providing an overview of IDDSI with our Introduction Course to more comprehensive courses on each IDDSI level, including the IDDSI Pureed (Level 4), your team will learn everything they need to know about the new IDDSI standards. And the Roche Dietitians “We Test for Safety” IDDSI Training Program is not just about teaching your team about IDDSI - it empowers you to develop a culture of safety in your organization.
tags: #IDDSI #pureed #diet #guidelines