Dysphagia, a swallowing disorder, can significantly impact an individual's ability to eat and drink safely. To address this, speech-language pathologists (S-LPs) often recommend texture-modified diets. The International Dysphagia Diet Standardization Initiative (IDDSI) has established a globally recognized framework to standardize these diets, ensuring consistent terminology and testing methods across different healthcare settings. This article will delve into the four levels of dysphagia diet guidelines.
The International Dysphagia Diet Standardization Initiative (IDDSI) Framework
The IDDSI Framework categorizes food textures and drink thickness into eight levels, numbered from 0 to 7. Drinks are measured from Levels 0 to 4, while foods are measured from Levels 3 to 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness. The IDDSI Testing Methods are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing should be done on foods and drinks under the intended serving conditions (especially temperature).
Consistent Terminology, Reliable Testing
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. The initiative challenges us to prioritize safety and prevent the risk of choking, giving us a solution to the outdated, ambiguous language like “soft”, “chopped”, and “nectar-thick” that varies between facilities.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, and standardized definitions of the diet.
Importance of IDDSI
IDDSI is an important tool in making sure that the food we serve is safe for individuals with chewing and swallowing problems. It’s vital that you and your team are well-versed in understanding IDDSI.
Level 1: Dysphagia Pureed Diet
Sometimes patients who have trouble chewing and/or swallowing whole foods need a special diet. The National Dysphagia Diet, published in 2002, developed universal terminology for texture-modified diets. The dysphagia pureed diet (level 1) is one of three levels of texture modification that is used.
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Who Orders a Dysphagia Pureed Diet?
Normally a speech therapist will recommend a dysphagia pureed diet after evaluating a patient who has problems chewing or swallowing food. In some cases, medical tests are used to determine the best texture for a patient.
Food Textures
All foods are totally pureed to a pudding-like consistency. No coarse textures, raw fruits or vegetables, or nuts are allowed. It is important to include a variety of foods from all different food groups when providing a pureed diet, including fruits, vegetables, grains, meats and meat substitutes, and dairy foods.
Meats and Meat Substitutes
Pureed meats (pureed to pudding-like consistency), smooth soufflés, soft, moist tofu and hummus are allowed. Whole, ground, or chopped meats, fish, or poultry, legumes or lentils, unless pureed, cheese and cottage cheese, unless pureed, eggs that are not pureed, and nut butters, unless pureed into other foods to correct consistency should be avoided.
Breads
Pureed bread mixes and pregelled slurried breads, pancakes, French toast, waffles, sweet rolls, etc are allowed. All other bread, rolls, crackers, biscuits, pancakes, French toast, muffins, etc should be avoided.
Cereals
Smooth cooked cereals, such as farina-type cereals with a pudding-like consistency are allowed. Dry cereals and cooked cereals with lumps, seeds, or chunks should be avoided.
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Fruits
Pureed fruit and well-mashed fresh bananas are allowed. Whole fruits (fresh, frozen, canned, or dried) should be avoided.
Vegetables
Pureed vegetables without lumps, pulp, or seeds and tomato sauce without seeds are allowed. All other vegetables that are not pureed should be avoided.
Potatoes and Starches
Mashed potatoes and pureed potatoes with gravy, butter, margarine, or sour cream and well-cooked pasta, noodles, or pureed rice (blended to a smooth consistency) are allowed. All other potatoes, rice, and noodles, plain mashed potatoes, and cooked grains should be avoided.
Desserts
Smooth pudding custards, yogurt, pureed desserts, and soufflés are allowed. All other desserts should be avoided. 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.
Beverages
Any smooth, homogenous beverage without lumps, chunks, or pulp (may need to thicken to proper consistency) is allowed.
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Are Regular Liquids Allowed on a Dysphagia Pureed Diet?
Possibly. Regular liquids are OK for some patients. However, depending on your condition, you might need to have thickened liquids, so you can swallow them safely. Talk to your speech and language pathologist to learn more.
What is a Slurry?
A slurry is a soft, moist mixture often used for people with swallowing problems. An example is a slice of bread or a pancake moistened with milk. The moisture of the liquid makes it easier for someone with swallowing problems to swallow soft bread products.
Level 2: Dysphagia Mechanically Altered Diet
Sometimes patients who have trouble chewing and/or swallowing whole foods need a special diet. The National Dysphagia Diet, published in 2002, developed universal terminology for texture-modified diets. The dysphagia mechanically altered diet (level 2) is one of three levels of texture modification that is used.
Who Orders a Dysphagia Diet?
Normally a speech and language pathologist will recommend a dysphagia mechanically altered diet after evaluating a patient who has problems chewing or swallowing food. In some cases, medical tests are used to determine the best texture for a patient.
Food Textures
Patients on a dysphagia level 2 diet can tolerate some textures of foods, but not all. The diet 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. It is important to include a variety of foods from all different food groups when providing a mechanically altered diet, including fruits, vegetables, grains, meats and meat substitutes, and dairy foods.
Meats and Meat Substitutes
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, and well-cooked and moist mashed legumes or beans are allowed. 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 should be avoided.
Breads
Soft, well-moistened pancakes and pureed bread mixes or slurried breads are allowed. Slices of bread and toast should be avoided.
Cereals
Cooked cereals with little texture, including oatmeal and slightly moistened, dry cereals with little texture are allowed. Coarse cooked cereals and whole-grain or coarse dry cereals should be avoided.
Fruits
Soft and drained canned or cooked fruits without seeds or skin, and ripe bananas are allowed. Fresh or frozen fruits and cooked fruit with skin or seeds should be avoided.
Vegetables
All soft, well-cooked vegetables that are in small pieces and mashable with a fork are allowed. Cooked corn and peas, and Brussels sprouts, broccoli, cabbage, asparagus, or other rubbery cooked vegetables should be avoided.
Potatoes and Starches
Well-cooked and moistened boiled, baked, shredded, or mashed potatoes and well-cooked pasta noodles in sauce are allowed. Potato skins and chips, fried potatoes, and rice should be avoided.
Desserts
Puddings and custards, soft fruit pies (bottom crust only), crisps and cobblers with soft topping and no seeds, most canned fruits and soft moist cakes with icing or slurried cakes are allowed. Dry, coarse cakes and cookies and desserts with nuts, seeds, coconut, pineapple, or dried fruit and rice or bread pudding should be avoided.
Beverages
All beverages with little texture or pulp are allowed.
Are Regular Liquids Allowed on a Mechanically Altered Diet?
Possibly. For some patients, regular liquids are OK. However, depending on your condition, you might need to have thickened liquids, so you can swallow them safely. Talk to your speech and language pathologist to learn more.
What is a Slurry?
A slurry is a soft, moist mixture often used for people with swallowing problems. An example is a slice of bread or a pancake moistened with milk. The moisture of the liquid makes it easier for someone with swallowing problems to swallow soft bread products.
Level 3: Dysphagia Advanced Diet
Sometimes patients who have trouble chewing and/or swallowing whole foods need a special diet. The National Dysphagia Diet, published in 2002, developed universal terminology for texture-modified diets. The dysphagia advanced diet (level 3) is one of three levels of texture modification that is used.
Who Orders a Dysphagia Advanced Diet?
Normally a speech and language pathologist will recommend a dysphagia advanced diet after evaluating a patient who has problems chewing or swallowing food. In some cases, medical tests are used to determine the best texture for a patient.
Food Textures
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. It is important to include a variety of foods from all different food groups when providing a dysphagia advanced diet, including fruits, vegetables, grains, meats and meat substitutes, and dairy foods.
Meat and Meat Substitutes
Thin-sliced, tender, or ground meats or poultry, well-moistened, fish, eggs (any preparation acceptable), yogurt (no nuts or coconut), and casseroles with small chunks of tender or ground meat are allowed. Tough or dry meats or poultry, dry fish or fish with bones, chunky peanut butter, and yogurt with nuts or coconut should be avoided.
Bread
Well-moistened breads, biscuits, muffins, pancakes, waffles, etc (add jelly, margarine, and other toppings to moisten well) are allowed. Dry bread, toast, crackers, etc and tough, crusty breads, such as French bread should be avoided.
Cereals
All well-moistened cereals are allowed. Coarse or dry cereals should be avoided.
Fruits
All canned and cooked fruits and soft, peeled, ripe fresh fruits, such as peaches, kiwi, mangos, cantaloupe, etc and soft berries with small seeds, such as strawberries are allowed. 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, and prunes, apricots, and other dried fruits (unless cooked) should be avoided.
Vegetables
All cooked, tender vegetables and shredded lettuce are allowed. All raw vegetables, except shredded lettuce, cooked corn and rubbery cooked vegetables should be avoided.
Potatoes and Starches
All, including rice and tender fried potatoes are allowed. Tough or crisp fried potatoes should be avoided.
Desserts
All desserts, except those on the avoid list are allowed. Dry cakes or cookies that are chewy and anything with nuts, seeds, dry fruits, coconut, and pineapple should be avoided.
Beverages
Any beverage of recommended consistency is allowed.
Can I Drink Regular Liquids if I am on a Dysphagia Pureed Diet?
Possibly. For some patients, regular liquids are OK. However, depending on your condition, you might need to have thickened liquids, so you can swallow them safely. Talk to your speech and language pathologist to learn more.
Level 4: IDDSI Pureed (PU4)
Level 4 pureed diets are typically recommended by S-LPs to individuals with dysphagia if certain difficulties are noted, such as a decreased control of tongue movement or perhaps an inability to bite or chew food. The International Dysphagia Diet Standardization Initiative (IDDSI) 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. 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: reduced tongue control, pain or difficulty swallowing, does not chew well, cannot form a bolus, and 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.
Achieving the Right Consistency
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, use 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. 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.
IDDSI Testing Methods for Level 4 Pureed Foods
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. The overall objective of testing is to make sure the pureed foods we prepare meet the characteristics for IDDSI Pureed (Level 4). Therefore, foods must pass the following IDDSI tests:
- Appearance: Smooth, no lumps, or thin separate liquid
- 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. The puree should sit in a mound above the fork. A small amount of the puree may flow through the fork tines and form a tail below the fork.
- 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. 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.
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 -- including consistent temperature. Remember, temperature and holding time will affect the consistency of food. For example, chilled applesauce will likely pass the IDDSI Fork Drip Test. However, at room temperature, it may become thinner and drip between the tines of the fork, which makes it more difficult to swallow and could induce choking. Also it is important to note that on the IDDSI.org Audit Tool for Pureed, Level 4 it states: “A puree needs to be able to be put in the mouth and swallowed whole. No chewing and no bolus formation skills should be needed to eat this consistency.” And: “If the sample is gelled or compressed so that it is firm enough to pick it up with your fingers and bite a piece of it at serving temperature, the sample is not a puree and poses a choking risk.” So be careful to not over thicken or over gel foods.
Adjusting Puree 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. 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). If your pureed soup is not thick enough then it may not be safe for you to eat just yet according to your S-LP. This pureed soup example is an important reminder to use the Fork Drip Test instead of judging your purees based on just looks alone.