Unlock the Secrets of the Mechanical Soft Diet & IDDSI Guidelines for Effective Dysphagia Management!

Dysphagia, a swallowing disorder, affects approximately 8% of the world's population. It is closely associated with malnutrition, dehydration, upper respiratory infection, and an increased risk of sentinel events. This article aims to provide a comprehensive understanding of the mechanical soft diet and the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines, which are crucial for managing dysphagia and ensuring patient safety.

The Need for Standardized Dysphagia Diets

In the past, many countries have worked to develop dysphagia diet standards at regional or national levels. For example, health care professionals used terms like "soft," "chopped," "mechanical soft," and "blended smooth," but the exact meaning of each term was often unclear. Individuals with dysphagia might find that their modified diet was called one thing in a hospital and something else at a rehabilitation facility.

The lack of a standard definition led to confusion, especially when receiving diet orders from other healthcare facilities, putting individuals with dysphagia at a higher risk for choking. The International Dysphagia Diet Standardization Initiative (IDDSI) Committee developed guidelines for serving texture-modified foods and thickened liquids to individuals with dysphagia around the world to eliminate confusion and promote patient safety.

The IDDSI standards establish unified principles for all foodservice operations to follow:

Consistent diet terminology
Standardized definitions of the diet
Simple, reliable testing methods

What is a Mechanical Soft Diet?

A mechanical soft diet is a texture-modified diet that restricts foods that are difficult to chew or swallow. It is considered Level 6 (Soft & Bite-Sized) of the IDDSI Framework. Foods can be pureed, finely chopped, blended, or ground to make them smaller, softer, and easier to chew. It differs from a pureed diet, which includes foods that require no chewing. The goal of the diet is to make foods safer and help a person meet their nutritional needs and is not intended as a weight loss diet. Most foods are allowed on the diet as long as they can be safely consumed.

As of 2015, the International Dysphagia Diet Standardisation Initiative (IDDSI) offers guidelines that provide in-depth recommendations and levels based on various medical conditions and risk of choking.

IDDSI Framework: A Global Standard

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. Each level has a unique name, color, and number in order to limit errors in prescribing, identifying, preparing, and assembling dysphagia diet orders.

Levels 0-4: Varying liquid consistencies
Level 4: Pureed food
Level 5: Minced and Moist food
Level 6: Soft and bite-size food
Level 7: Easy-to-chew food

Who Needs a Mechanical Soft Diet?

A medical professional, such as a registered dietitian, may prescribe a mechanical soft diet for you if you:

Have difficulty chewing (e.g., poorly fitting dentures, missing teeth, recovering from dental or mouth surgery, general weakness)
Have difficulty swallowing (e.g., dysphagia; recovering from mouth, neck, or throat surgery; general weakness)
Are undergoing radiation therapy for your head, neck, or stomach area, which may lead to digestive upset or pain in your mouth or throat
Were previously on a liquid diet after surgery or long-term illness and are gradually reintroducing solid foods
Have trouble moving or feeling portions of your mouth (such as your tongue or lips)

Depending on your situation, a healthcare professional may prescribe a mechanical soft diet temporarily, for a few days or weeks. In other cases, such as for those with dysphagia, they may prescribe it long-term. Unless a healthcare professional recommends it, most people do not need to follow a mechanical soft diet.

Foods Allowed on a Mechanical Soft Diet

As long as a food makes chewing and swallowing safer and easier, it can be included in the diet. Examples of permitted foods include:

Fruits and vegetables: likely to require peeling, fine chopping, mashing, cooking, and/or blending to be safe to eat, although some vegetables (such as avocado) are soft enough to eat as is
Grains: hot cereals (oatmeal, porridge, grits, and Cream of Wheat), soft bread (avoid toasting it), finely cut pasta, cooked rice, refined grains (e.g., white breads), and similar foods
Meat, poultry, fish: tender meats (e.g., canned tuna, ground beef), thinly shaved meat, and other meats that have been mechanically altered (but always remove the fat and gristle from meat cuts, since they may be difficult to chew)
Dairy: milk, powdered milk, cottage cheese, soft cheeses, grated and shredded cheeses, yogurt, ice cream, and other soft dairy products
Eggs: most cooking methods acceptable - but if eating boiled eggs, ensure they’re chopped finely or mashed, as in egg salad
Plant-based proteins: tofu (silken, regular, firm), cooked beans, pureed beans, soy milk, hummus, peanut butter, and other products
Fats: butter, margarine, and all plant-based oils (e.g., olive, sesame, coconut)
Desserts: any soft cake, pastry, cookie, or other dessert (e.g., custard, ice cream, Jell-O) that does not contain nuts, candy, fruit, or other hard pieces of food
Other foods: protein powders (whey or plant-based), liquid nutritional supplements (e.g., Ensure, Boost), casseroles, soups without large pieces of meat, jams without seeds, broth, gravy, sauces, condiments, and other products
Beverages: all beverages (including juices with pulp), except for any that contain solid food pieces

Foods should not be difficult to chew or easily get stuck in the teeth, such as caramel. For meat products, use moist-heat cooking methods like stewing, slow-cooking, or boiling to increase tenderness. Further, foods that require cutting or chopping should be cut into pieces no larger than 1/2 inch (1.5 cm). While most people can tolerate the foods mentioned above, some people may need to avoid certain foods according to the advice of a healthcare professional.

Foods to Avoid on a Mechanical Soft Diet

Some foods are considered unsafe and unsuitable for a mechanical soft diet. These may include:

Fruits and vegetables: raw or stir-fried vegetables, fruit with seeds or pits, unpeeled fruit and vegetables, dried fruit (e.g., raisins, apricots), whole fruits (e.g., grapes, olives), corn on the cob, raw coconut, and fried vegetables (e.g., french fries)
Grains: hard or crunchy bread (e.g., sourdough, pumpernickel, rye), toast, buckwheat (kasha), egg noodles, garlic bread, granola, muesli, crackers, melba toast, shredded wheat, undercooked pasta, popcorn, hard taco shells, and others
Meats, poultry, fish: hard cuts of meat (e.g., steak, jerky, pork chops), meats or poultry with the bone (e.g., chicken wings), hot dogs, sausage, shellfish, fried meat or fish, and others
Dairy: hard cheeses (e.g., cheddar, Parmesan, Swiss), soft cheeses with dried fruit or nuts, and more
Plant-based proteins: nuts, seeds, extra-firm tofu, seitan, crunchy peanut butter, and others
Desserts: chips, pretzels, popcorn, candy, hard cookies, licorice, any sticky dessert (e.g., caramel. taffy), candied nuts, pie crust, and more
Other foods: jams with seeds (e.g., raspberry jam), gum, marshmallows, any foods that cannot be mechanically altered, etc.

If you’re unsure whether a food is safe to eat, speak with a healthcare professional who specializes in mechanical soft diets, such as a registered dietitian.

Benefits of a Mechanical Soft Diet

Most of the benefits of a mechanical soft diet come from the ability to safely consume food. People who have certain conditions or are unable to easily chew and swallow may not be able to meet their nutritional needs due to their troubles chewing and swallowing, a lack of energy, or other reasons. Thus, a mechanical soft diet can help a person eat healthy foods without the risk of choking. It’s also helpful for people who are very weak or lack energy, as chewing and swallowing may be exhausting to them.

Further, it can create a sense of comfort, safety, and autonomy for those who are at risk of choking. These are important factors in preventing malnutrition, which is highly prevalent in people requiring texture-modified diets. Finally, a mechanical soft diet can help a person restore their health as they heal from illness or surgery and act as a segue between a liquid and solid food diet.

Read also: Oral Surgery Diet Tips

Tips for Transitioning to a Mechanical Soft Diet

If you have been prescribed a mechanical soft diet, here are some helpful tips to help make the transition as smooth as possible.

Use the right tools: Having the right kitchen tools can help speed up food preparation. Some tools you may want to use are sharp kitchen knives (e.g., chef’s knife), a blender or mini blender (e.g., NutriBullet, Magic Bullet), an immersion blender, a food processor, a mesh strainer (allows you to strain fruits and vegetables), and a food grinder (e.g., baby food grinder).
Food safety: When preparing foods, ensure that you’re practicing food safety. This includes washing your hands, avoiding cross contamination, cooking foods to their proper temperatures, and storing foods in the refrigerator or freezer.
Plan ahead: If you know you will be eating out at a restaurant or at an event, it’s important to plan ahead. When eating at a restaurant, you can ask the manager or chef to prepare foods for your needs. In many cases, they will happily puree or finely chop food items to ensure they are safe for you. You may also want to request additional sauce or gravy to help moisten food.
Work with a healthcare professional: If you’re going to be on a mechanical soft diet for longer than a few days, you may want to speak with a healthcare professional who specializes in this diet to ensure you’re meeting your nutritional needs. Most hospitals and healthcare centers will have a registered dietitian or speech language pathologist who can answer your questions and help guide you. In some cases, they may also recommend supplements to ensure you’re getting the right nutrients.
Other tips: If you’re unsure whether a food is the right consistency, ask a friend or family member to try it first. Make sure you’re drinking liquids to keep your mouth moist, which helps with chewing and swallowing, and to prevent dehydration. If you’re feeling unwell or too weak to prepare your meal, ask a friend or family member to help. If this isn’t possible, it may be a good idea to have premade, microwavable meals available. For additional nutrition, try adding protein powder, milk, nutritional powders, or other calorie- or protein-rich ingredients to smoothies, yogurts, beverages, soups, or other foods.

IDDSI Level 6: Soft & Bite-Sized

IDDSI Soft & Bite-Sized (Level 6) brings our attention to the size of food particles. With individuals that have trouble with biting larger pieces of food, having smaller, bite-sized pieces may be easier to chew and safer to swallow. 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.

The IDDSI Fork Pressure Test was designed to measure “soft.” Testing needs to be done at the point of recipe creation, at the time of food preparation, and at the time of serving.

IDDSI Level 5: Minced & Moist

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.

For adults, the minced particle size is 4mm x 4mm x no more than 15mm (in length), which happens to be the size of food particles after chewing and when they are swallow ready. It also is the size between two tines on a fork to make testing easy.

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.

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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