Unlock the Secrets of Level 5 Diets: Ultimate Guide to Minced and Moist Foods for Dysphagia Relief

Dysphagia, a swallowing disorder affecting the upper gastrointestinal tract, interferes with normal swallowing. It can stem from various causes, including stroke, injuries, cancer, and dementia. While dysphagia can affect individuals of all ages, it is most often associated with the elderly population due to age-related health complications. Side effects of dysphagia may include malnutrition, aspiration pneumonia, choking, and even death. Speech-language pathologists (SLPs) play a crucial role in assessing, diagnosing, and planning the management of dysphagia. Diet texture modification is a primary intervention, ensuring adequate oral intake while minimizing potential risks. This article delves into the specifics of Level 5 diets, also known as Minced & Moist, within the framework of the International Dysphagia Diet Standardisation Initiative (IDDSI).

Understanding Dysphagia and the Need for Texture Modification

Dysphagia is a condition characterized by difficulty swallowing. This can arise from a variety of underlying causes, impacting the individual's ability to safely and efficiently transport food and liquids from the mouth to the stomach. The consequences of dysphagia can be severe, ranging from malnutrition and dehydration to life-threatening aspiration pneumonia, which occurs when food or liquid enters the lungs.

Texture modification is a cornerstone of dysphagia management. By altering the consistency of foods and liquids, it becomes easier and safer for individuals with swallowing difficulties to consume them. This approach aims to reduce the risk of choking and aspiration, ensuring adequate nutrition and hydration.

The International Dysphagia Diet Standardisation Initiative (IDDSI)

The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard that defines and describes different food textures and fluid consistencies for individuals with dysphagia around the world. The IDDSI framework consists of eight levels (0-7), ranging from Thin Liquids (Level 0) to Regular (Level 7) texture foods. IDDSI challenges us to prioritize safety and prevent the risk of choking, giving us a solution to the outdated, ambiguous language like “soft”, “chopped”, and “nectar-thick” that vary between every facility. In order to eliminate confusion and promote patient safety, the new IDDSI standards establish unified principles for all foodservice operations to follow: consistent diet terminology, standardized definitions of the diet, and simple, reliable testing methods.

IDDSI Level 5: Minced & Moist

Level 5, also known as Minced & Moist (MM5), is a specific texture level within the IDDSI framework. It is represented by the number 5 and the color orange. Individuals who are served IDDSI Minced & Moist (Level 5) have a swallowing disorder called dysphagia. This means they cannot safely chew or swallow, so the food we serve must be small, soft, and moist to minimize their risk of choking. At this level, individuals have minimal chewing abilities and enough tongue force to move a bolus of food in their mouth. The tongue force alone can be used to separate small, soft particles in this texture. However, they will experience the following problems and/or limitations:

Read also: Understanding Dysphagia Diets

Cannot safely chew pieces of food that are larger than “minced-sized”
Cannot break foods into smaller pieces safe enough for swallowing
Pain or fatigue on chewing

For these reasons, IDDSI Minced & Moist (Level 5) foods are prepared to be soft, small, and moist.

Characteristics of IDDSI Minced & Moist (Level 5)

Foods on IDDSI Minced & Moist (Level 5) will maintain the same characteristics no matter where in the world minced and moist foods are served. IDDSI now introduces us to new and more specific characteristics like particle size, moisture, stickiness, and softness.

Testing Methods for IDDSI Minced & Moist (Level 5)

IDDSI Minced & Moist (Level 5) testing requires only a fork, spoon, and straightforward observation. At this level, we’re concerned about particle size, moisture, softness, and stickiness. Therefore, foods must pass the following IDDSI tests:

Appearance: Check the particle size of a food sample using the tines of a fork. As a reference, the space between the tines of a fork measures about 4mm, while the length of four tines is about 15mm. For adults, minced food pieces are less than 4mm wide and 15mm long. For children, minced foods are half that -- less than 2mm wide and 8mm long. There should be no separate think liquids.
Fork Pressure Test: When pressed with a fork, food particles can be easily separated and come through the tines of a fork. It can be easily mashed with a little pressure from a fork and the pressure should not make the thumb nail blanch white.
Spoon Tilt Test: Food is cohesive enough to hold its shape on a spoon. It can slide off easily when you tilt or gently flick the spoon with very little food left on the spoon. It may leave some residue, but it should not be sticky. A scooped mound may spread/slump very slightly on the plate.

Testing is done during preparation and again at the time of service. It should be done under the same conditions we intend to serve our food, especially temperature. Remember, temperature and holding time will affect the consistency of food.

Food Choices and Considerations for Level 5 Diets

While following a Level 5 diet may seem restrictive, there are still many options available to ensure a balanced and enjoyable diet. The key is to focus on foods that can be easily minced and moistened to meet the required texture.

Suitable Food Options

Meats and Protein Sources: Ground meats, poultry, or fish that are well-moistened with sauces or gravies are good options. Soft, moist tofu and well-cooked, moist mashed legumes or beans can also be included.
Grains: Cooked cereals with little texture, such as farina-type cereals with a pudding-like consistency, are suitable. Pureed bread mixes or pregelled slurried breads, pancakes, French toast, waffles, and sweet rolls can also be consumed.
Fruits and Vegetables: Pureed fruits and vegetables without lumps, pulp, or seeds are ideal. Well-mashed fresh bananas are also a good choice.
Potatoes and Starches: Mashed potatoes and pureed potatoes with gravy, butter, margarine, or sour cream are appropriate. Well-cooked pasta, noodles, or pureed rice (blended to a smooth consistency) can also be included.
Desserts: Smooth pudding custards, yogurt, pureed desserts, and soufflés are suitable options.
Beverages: Any smooth, homogenous beverage without lumps, chunks, or pulp can be consumed, but it may need to be thickened to the 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
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

Seasonal Considerations: Summer Foods and Dysphagia

June is National Dysphagia Awareness Month, and as summer arrives, it's important to be mindful of food choices for individuals with dysphagia. Some popular summer foods can pose challenges due to their texture or consistency.

Frozen Treats

IDDSI considers ice cream, frozen yogurt, and popsicles as transitional foods, defined as “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., heating)”. Since ice cream, frozen yogurt, and popsicles are thin liquids when swallowed, they may not be suitable for those with dysphagia. An alternative to these common frozen treats is the Magic Cup - a product like ice cream when frozen but pudding when thawed.

BBQ Items

Hamburgers, grilled meats, and chips are frequently consumed foods when the weather is warm. There are hamburger recipes for “Level 5 Minced & Moist” and “Level 6 Soft & Bite-sized” textures, which look and taste similar to regular hamburgers. Grilled meats are the main component of BBQs, but this process results in a crispy and crunchy outer texture, leading to a choking risk. To mitigate this, pre-cooked meats that are stamped with dark stripes to give the appearance of a grill mark can be purchased and prepared. IDDSI also identifies the consumption of chips as a choking risk due to their sharp and spiky texture. Some chips made from mashed potato (e.g., Pringles), are considered transitional foods because they can melt in the mouth.

Watermelon

Watermelon is considered a mixed consistency item, as it contains both a solid and a liquid component. To eat watermelon, individuals need to be able to swallow the juice while controlling the solid piece in the mouth, which then requires complete chewing before being swallowed. For this reason, IDDSI recommends for those with dysphagia to avoid watermelon in its natural form.

Small Round Fruits

This category includes whole grapes, cherry tomatoes, cherries, olives, and most berries. These fruits are also considered unsafe because if swallowed whole, they can completely obstruct the airway and lead to choking.

S'mores

This product is made with graham crackers, marshmallows, and chocolate. In addition to classifying as a mixed consistency food, sticky residues can fall into the airway, increasing the risk of complications.

The Role of Speech-Language Pathologists (SLPs)

Speech-language pathologists (SLPs) are essential in the management of dysphagia. They are responsible for:

Assessing: Evaluating an individual's swallowing abilities to identify the presence and severity of dysphagia.
Diagnosing: Determining the underlying cause of the swallowing difficulties.
Planning: Developing an individualized plan of care that addresses the specific needs of the patient, including diet texture modification.

SLPs play a critical role in educating patients, caregivers, and other healthcare professionals about dysphagia and its management. They provide guidance on appropriate food choices, preparation techniques, and strategies to ensure safe and effective swallowing.

The Importance of Standardized Terminology and Training

Without a standard definition, there is confusion, especially when receiving diet orders from other healthcare facilities. This puts individuals with dysphagia at a higher risk for choking. 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 Minced & Moist (Level 5), 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.

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