Dysphagia, or difficulty swallowing, can significantly impact an individual's ability to eat and drink safely and effectively. To manage dysphagia, healthcare professionals often recommend diet texture modifications. These modifications involve altering the viscosity of liquids and/or softening, chopping, or pureeing solid foods. Standardized guidelines, such as those developed by the International Dysphagia Diet Standardisation Initiative (IDDSI), play a crucial role in ensuring consistency and clarity in dysphagia management.
Understanding Dysphagia and the Need for Dietary Modifications
When there are problems with the food’s easy passage from the mouth to the esophagus, dysphagia occurs, which makes it challenging to swallow food or liquids. Dysphagia can arise from various medical conditions, including stroke, neurological disorders, and head and neck cancer. Individuals with dysphagia are at risk of aspiration, a condition where food or liquid enters the lungs instead of the esophagus. Aspiration can lead to pneumonia and other serious health complications.
Dietary modifications are essential to reduce the risk of aspiration and ensure adequate nutrition for individuals with dysphagia. By altering the texture and consistency of food and liquids, it becomes easier and safer for individuals to swallow, minimizing the likelihood of food or liquid entering the airway.
The Role of Speech-Language Pathologists (SLPs)
Speech-language pathologists (SLPs) are integral in assessing and managing dysphagia. While ASHA has not established diet levels or terminology, nor does ASHA have any guidelines about the types of foods that meet the criteria for a particular diet level, SLPs play a crucial role in developing individualized plans of care that meet patients’ individual needs. They evaluate a patient's swallowing ability, determine the appropriate diet texture and liquid viscosity, and provide guidance on safe swallowing strategies.
SLPs are encouraged to explore the current evidence and consider patients holistically when developing individualized plans of care that meet patients’ individual needs. There is no ASHA policy prohibiting a speech-language pathologist (SLP) from writing such orders. However, it is the SLP’s role to ensure that (a) the diet order is correct and (b) it’s clear that the SLP is not the one requesting the dietary restrictions, which falls outside the SLP's scope of practice.
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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. The IDDSI framework aims to provide a common language and understanding of dysphagia diets across different healthcare settings and countries. ASHA supports the IDDSI framework and encourages members who assess and treat individuals with dysphagia to consider using it. However, neither ASHA nor any payor in the United States (at this time) mandates facilities to adopt use of IDDSI.
The IDDSI framework comprises eight levels, ranging from the thinnest liquids and foods to the thickest. The levels are numbered 0-7, with lower numbers indicating thinner liquids and smoother textures, and higher numbers indicating thicker liquids and more textured foods.
IDDSI Fluid Levels:
- Level 0: Thin: This is the consistency of regular water, juice, or milk. It flows quickly and requires no extra effort to drink.
- Level 1: Slightly Thick: Slightly thicker than water, this liquid still flows easily through a bottle nipple.
- Level 2: Mildly Thick: This consistency is similar to nectar or vegetable juice. It requires a bit more effort to drink through a straw.
- Level 3: Moderately Thick: This is the consistency of honey. It is difficult to drink through a straw and is usually consumed from a cup.
- Level 4: Extremely Thick: This is the consistency of pudding. It needs to be consumed with a spoon.
IDDSI Food Levels:
- Level 3: Liquidised: This level requires foods to be liquidized.
- Level 4: Pureed: Pureed foods should be smooth and free of lumps, requiring very little chewing.
- Level 5: Minced & Moist: Foods are minced and moist, with small, easily manageable pieces in a small amount of liquid.
- Level 6: Soft & Bite-Sized: Foods are soft, tender, and cut into bite-sized pieces, easy to chew and swallow.
- Level 7: Regular: This includes everyday foods of normal textures.
National Dysphagia Diet (NDD)
Note: The National Dysphagia Diet (NDD) was part of the full Nutrition Care Manual (NCM)® established by the Academy of Nutrition and Dietetics (AND). The National Dysphagia Diet (NDD) Task Force suggested using a sophisticated rheometer or viscometer to accurately determine viscosity values for each NDD thickness level (National Dysphagia Diet Task Force, 2002). However, it is not provided in most clinical settings because this instrument is often inaccessible and its use impractical because of cost and the need for training (Kim et al., 2014). The National Dysphagia Diet (NDD) is a dietary guideline designed for individuals with swallowing difficulties, known as dysphagia. It aims to provide safe and nutritious meal options that reduce the risk of choking and aspiration (when food or liquid enters the lungs). The NDD classifies foods and liquids into different levels based on texture and viscosity to accommodate varying degrees of swallowing impairment.
Levels of the National Dysphagia Diet (NDD)
The National Dysphagia Diet consists of three main levels, each tailored to specific swallowing abilities:
NDD Level 1: Dysphagia Pureed: This level includes foods that have been pureed to a smooth, pudding-like consistency. All foods should be free of lumps, coarse textures, and unblended chunks. This diet is suitable for individuals with severe dysphagia who have significant difficulty chewing or swallowing. A level 1 National Dysphagia Diet includes only pureed foods. Pureed foods should be smooth and free of lumps. Pureed foods require very little chewing. Foods that are on mechanical soft diets are all made of moist and soft textures.
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- Recommended foods: Pureed meats, vegetables, fruits, and desserts. Examples include applesauce, pureed carrots, and yogurt.
- Foods to avoid: Any foods with lumps, seeds, nuts, or fibrous textures.
NDD Level 2: Dysphagia Mechanically Altered: This level includes foods that are moist, soft-textured, and easily formed into a bolus (a soft mass of chewed food). Foods should be ground, minced, or chopped to reduce the need for significant chewing. This diet is appropriate for individuals with moderate dysphagia who have some chewing ability. A level 2 National Dysphagia Diet includes only moist, soft foods. Regular foods need to be changed to make them easier to chew and swallow. This can be done by blending, chopping, grinding, mashing, shredding, or cooking the food. You need to have some chewing ability to eat these foods.
- Recommended foods: Soft-cooked vegetables, ground meats with gravy, and moistened cereals.
- Foods to avoid: Hard, crunchy, or sticky foods that are difficult to chew.
NDD Level 3: Dysphagia Advanced: This level includes foods that are nearly regular textures but still require some modification. Foods should be soft, moist, and bite-sized, allowing for more natural chewing and swallowing. This diet is suitable for individuals with mild dysphagia who have adequate chewing ability.
- Recommended foods: Soft fruits, tender meats, and cooked vegetables.
- Foods to avoid: Hard, dry, or chewy foods that require significant effort to chew.
Liquid Consistency Levels in NDD
In addition to food textures, the NDD also addresses liquid consistencies to ensure safe swallowing. Liquids are categorized into four levels of thickness. 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).
- Thin Liquids: These are regular, unthickened liquids like water, juice, and milk. They flow quickly and are the most challenging for individuals with dysphagia to control. Thin liquids flow quickly. These liquids take little or no effort to drink. Examples include water, non-fat milk, no-pulp juice, coffee, tea, and soft drinks.
- Nectar-Thick Liquids: Slightly thicker than thin liquids, nectar-thick liquids have a consistency similar to nectar or tomato juice. Slightly thick liquids are thicker than water but still flow through a bottle's nipple. A little more effort is needed to drink these liquids. Nectar-thick liquids have the same thickness as vegetable juices and milkshakes. It should take some effort to drink the liquid through a straw.
- Honey-Thick Liquids: These liquids have a consistency similar to honey, flowing slowly off a spoon. Honey-thick liquids should be difficult to drink through a straw.
- Pudding-Thick Liquids: The thickest consistency, pudding-thick liquids, have a texture similar to pudding and must be eaten with a spoon. Pudding-thick liquids need to be eaten with a spoon. You should not be able to drink them through a straw.
Comparison of NDD and IDDSI Levels
Recently, nectar- (NDD level 2), honey- (NDD level 3), and pudding-like (NDD level 4) fluids are recognized to correspond to mildly (IDDSI level 2), moderately (IDDSI level 3), and extremely (IDDSI level 4) thick fluids, respectively.
This study revealed that drink composition is greatly influenced 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. The thickener concentration ranges corresponding to NDD and IDDSI levels at the same thickness level were different (Table 4). For instance, the concentration range values of NDD and IDDSI level 2 thickeners were 0.2∼ 1.0% and 0.7∼1.2%, respectively. This result suggested that the IDDSI flow tests might not be sensitive enough to measure changes in the viscosity of thickened drinks.
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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).
Practical Considerations for Implementing Dysphagia Diets
Implementing dysphagia diets requires careful attention to detail and a collaborative approach involving healthcare professionals, caregivers, and the individual with dysphagia. Here are some practical considerations:
- Assessment: A thorough assessment by an SLP is crucial to determine the appropriate diet level and liquid consistency for each individual.
- Individualization: Dysphagia diets should be tailored to meet individual needs and preferences, considering factors such as cultural background, food preferences, and nutritional requirements.
- Education: Providing education and training to caregivers and individuals with dysphagia is essential to ensure safe meal preparation and feeding techniques.
- Monitoring: Regular monitoring of swallowing function and dietary intake is necessary to adjust the diet as needed and prevent complications.
Sample Meal Plans for Each NDD Level
To illustrate the practical application of the National Dysphagia Diet, here are sample meal plans for each level:
NDD Level 1: Dysphagia Pureed
- Breakfast: Pureed oatmeal with applesauce and a side of pureed peaches.
- Lunch: Cream of tomato soup, pureed chicken with mashed sweet potatoes, and pureed green beans.
- Dinner: Pureed beef stew with carrots and potatoes, pureed spinach, and a chocolate pudding dessert.
NDD Level 2: Dysphagia Mechanically Altered
- Breakfast: Soft scrambled eggs, moistened toast with jelly, and a cup of nectar-thickened orange juice.
- Lunch: Ground turkey with gravy over mashed potatoes, soft-cooked carrots, and a banana.
- Dinner: Moist meatloaf, soft green beans, mashed sweet potatoes, and a slice of soft apple pie.
NDD Level 3: Dysphagia Advanced
- Breakfast: Soft pancakes with syrup, yogurt, and a cup of thin milk.
- Lunch: Chicken salad sandwich on soft bread, a side of cooked carrots, and a peach.
- Dinner: Baked chicken breast, steamed broccoli, mashed potatoes, and a slice of soft pear.
Tips for Getting Enough 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. Eat 6 to 8 small meals each day to get enough calories and nutrients. You may need to take a multivitamin and mineral supplement if you do not get all the nutrients you need.
Considerations for 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. In some facilities, members have reported using language such as "IDDSI level 5 (minced and moist) diet with low-sodium restriction, as per physician/dietary order dated XXXX" or "IDDSI level 5 (minced and moist) diet, continue dietary restrictions previously in place." In other facilities, physicians may write broad orders, such as "diet as determined by speech-language pathologist," which allows the SLP to request a diet without it being written as an order.
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