Dysphagia, or difficulty swallowing, can significantly impact an individual's ability to eat and maintain proper nutrition. To address this, healthcare professionals often recommend texture-modified diets, with the National Dysphagia Diet (NDD) and the International Dysphagia Diet Standardisation Initiative (IDDSI) providing frameworks for categorizing food textures and liquid consistencies. This article aims to provide a comprehensive overview of the national dysphagia diet levels, incorporating information from both the NDD and IDDSI frameworks, to promote a better understanding of these dietary modifications.
Introduction to Dysphagia and Texture-Modified Diets
When the passage of food from the mouth to the esophagus is impaired, a condition known as dysphagia arises, making it challenging to swallow food or liquids. One of the primary interventions for dysphagia is modifying the texture of foods and the consistency of liquids to facilitate safe and effective swallowing. The National Dysphagia Diet (NDD) and the International Dysphagia Diet Standardisation Initiative (IDDSI) are two systems developed to standardize the terminology and application of texture-modified diets.
The National Dysphagia Diet (NDD)
The National Dysphagia Diet (NDD), introduced in 2002, established universal terminology for texture-modified diets. It was part of the full Nutrition Care Manual (NCM) established by the Academy of Nutrition and Dietetics (AND). The NDD categorizes foods into four levels based on texture:
Dysphagia Pureed (Level 1)
The dysphagia pureed diet (level 1) consists of foods that have been totally pureed to a pudding-like consistency. This level requires very little chewing. Pureed foods should be smooth and free of lumps.
Foods Allowed:
- Pureed meats (pureed to pudding-like consistency)
- Smooth soufflés
- Soft, moist tofu
- Hummus
- Pureed bread mixes
- Pregelled slurried breads, pancakes, French toast, waffles, sweet rolls, etc.
- Smooth cooked cereals, such as farina-type cereals with a pudding-like consistency
- Pureed fruit
- Well-mashed fresh bananas
- Pureed vegetables without lumps, pulp, or seeds
- Tomato sauce without seeds
- Mashed potatoes and pureed potatoes with gravy, butter, margarine, or sour cream
- Well-cooked pasta, noodles, or pureed rice (blended to a smooth consistency)
- Smooth pudding custards, yogurt, pureed desserts, and soufflés
- Any smooth, homogenous beverage without lumps, chunks, or pulp (may need to thicken to 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
- Cooked grains
- 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
Dysphagia Mechanically Altered (Level 2)
The dysphagia mechanically altered diet (level 2) includes foods that are soft textured and moist, making them easy to swallow. Soft, well-cooked foods, well-moistened ground meats, moist and well-cooked potatoes, noodles, and dumplings are examples of foods that are the proper texture for this diet. All foods of a pureed consistency are allowed on this diet.
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Foods Allowed:
- Moistened ground or cooked meat, poultry, or fish (serve with sauces)
- Casseroles without rice
- Moist, well-cooked pasta
- Moist meat loaf or meatballs
- Poached, scrambled, or soft-cooked eggs
- Tofu
- Well-cooked and moist mashed legumes or beans
- Soft, well-moistened pancakes
- Pureed bread mixes or slurried breads
- Cooked cereals with little texture, including oatmeal
- Slightly moistened, dry cereals with little texture
- Soft and drained canned or cooked fruits without seeds or skin
- Ripe bananas
- All soft, well-cooked vegetables that are in small pieces and mashable with a fork
- Well-cooked and moistened boiled, baked, shredded, or mashed potatoes
- Well-cooked pasta noodles in sauce
- Puddings and custards
- Soft fruit pies (bottom crust only)
- Crisps and cobblers with soft topping and no seeds
- Most canned fruits
- Soft moist cakes with icing or slurried cakes
- All beverages with little texture or pulp
Foods to Avoid:
- Dry meats, such as bacon, sausage, or hot dogs
- Dry casseroles or casseroles with rice or large chunks
- Cheese cubes and slices
- Peanut butter
- Hard-cooked or crisp fried eggs
- Sandwiches and pizza
- Slices of bread
- Toast
- Coarse cooked cereals
- Whole-grain or coarse dry cereals
- Fresh or frozen fruits
- Cooked fruit with skin or seeds
- Cooked corn and peas
- Brussels sprouts, broccoli, cabbage, asparagus, or other rubbery cooked vegetables
- Potato skins and chips
- Fried potatoes
- Rice
- Dry, coarse cakes and cookies
- Desserts with nuts, seeds, coconut, pineapple, or dried fruit
- Rice or bread pudding
Dysphagia Advanced (Level 3)
The dysphagia advanced diet (level 3) includes foods that are nearly normal textures are allowed on the dysphagia advanced diet, with the exception of crunchy, sticky, or very hard foods. The diet includes bite-sized foods that are moist. Foods that are allowed on dysphagia level 1 and level 2 diets also are allowed on the dysphagia advanced diet.
Foods Allowed:
- Thin-sliced, tender, or ground meats or poultry, well-moistened
- Fish
- Eggs (any preparation acceptable)
- Yogurt (no nuts or coconut)
- Casseroles with small chunks of tender or ground meat
- Well-moistened breads, biscuits, muffins, pancakes, waffles, etc (add jelly, margarine, and other toppings to moisten well)
- All well-moistened cereals
- All canned and cooked fruits
- Soft, peeled, ripe fresh fruits, such as peaches, kiwi, mangos, cantaloupe, etc
- Soft berries with small seeds, such as strawberries
- All cooked, tender vegetables
- Shredded lettuce
- All, including rice and tender fried potatoes
- All desserts, except those on the avoid list
- Any beverage of recommended consistency
Foods to Avoid:
- Tough or dry meats or poultry
- Dry fish or fish with bones
- Chunky peanut butter
- Yogurt with nuts or coconut
- Dry bread, toast, crackers, etc
- Tough, crusty breads, such as French bread
- Coarse or dry cereals
- Hard-to-chew fresh fruits, such as apples or pears
- Stringy, pulpy fruits, such as papaya, pineapple, or mango
- Fresh fruits with tough peels, such as grapes
- Prunes, apricots, and other dried fruits (unless cooked)
- All raw vegetables, except shredded lettuce
- Cooked corn
- Rubbery cooked vegetables
- Tough or crisp fried potatoes
- Dry cakes or cookies that are chewy
- Anything with nuts, seeds, dry fruits, coconut, and pineapple
Regular
The regular diet includes all foods.
The 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 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.
IDDSI Drink Levels (0-4)
Level 0: Thin
- Thin liquids flow quickly and require little to no effort to drink. Examples include water, non-fat milk, no-pulp juice, coffee, tea, and soft drinks.
Level 1: Slightly Thick
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- 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.
Level 2: Mildly Thick (Nectar-Thick)
- Nectar-thick liquids have the same thickness as vegetable juices and milkshakes. It should take some effort to drink the liquid through a straw.
Level 3: Moderately Thick (Honey-Thick)
- Honey-thick liquids should be difficult to drink through a straw.
Level 4: Extremely Thick (Pudding-Thick)
- Pudding-thick liquids need to be eaten with a spoon. You should not be able to drink them through a straw.
IDDSI Food Levels (3-7)
Level 3: Liquidised: Moderately Thick
Level 4: Pureed: Extremely Thick
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- No lumps, liquid must not separate from solid, falls of spoon in a single spoonful when tilted and continues to hold its shape, cannot be sucked through straw, does not require chewing.
Level 5: Minced & Moist
- Can be eaten with fork or spoon, chopsticks with good hand control. Soft and moist with no separate thin liquid. Lumps are easy to squash with tongue. Biting is not required, minimal chewing, tongue force alone can be used to break soft small particles and is required to move the bolus.
Level 6: Soft & Bite-Sized
- Can be eaten with fork or spoon, chopsticks. Can be mashed/broken down with pressure from fork, spoon or chopsticks, chewing is required before swallowing. Pieces should be soft, tender and moist throughout, “bite sized” pieces appropriate for size and oral processing skills.
Level 7: Regular
Thickening Liquids
Liquids can be thickened, if needed, with thickeners, flour, cornstarch, or potato flakes. Foods that are liquid at room temperature should also be thickened. Add liquid as you puree. Examples include gravy, sauce, vegetable or fruit juice, milk, or half and half. Use only a small amount of liquid at first.
Considerations for Pureed Foods
All foods listed below should be pureed to the same texture as pudding. Pureed foods can be frozen in small portions and reheated later. When you reheat foods, do not allow a tough outer crust to form on the pureed food. Eat a variety of healthy foods. 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. Rinse your mouth with water after each meal.
Comparing 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.
However, 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. The thickener concentration range for thickened drinks in each range of NDD and IDDSI levels increased in the following order: water> orange juice> milk.
The Role of Speech-Language Pathologists (SLPs)
SLPs are crucial in the assessment and management of dysphagia. They conduct evaluations to determine the appropriate diet texture and liquid consistency for individuals with swallowing difficulties. ASHA 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.
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.