Dysphagia, a condition affecting between 300,000 and 700,000 individuals in the United States each year, involves difficulty swallowing. This can manifest as complications, pain, or discomfort when swallowing, impacting a person’s ability to eat or drink. While it can occur at any age, dysphagia is more prevalent in older adults, affecting 30% of those over 50 and up to 68% of nursing home residents. Dysphagia can be either an acute or chronic condition. People with dysphagia may experience difficulty swallowing food or drinks, chewing, sucking, controlling saliva, taking medication, or protecting their airway from choking. If unaddressed, it can lead to malnutrition, dehydration, and mealtime anxieties due to choking risks or swallowing discomfort.
Common Causes and Diagnosis
The most common causes of dysphagia are related to underlying medical or physical conditions. Individuals may have impaired swallowing secondary to a variety of challenges including reduced mastication (chewing) or lost or missing teeth/dentures and reduced oral and pharyngeal sensitivity.
Dysphagia can often be caused by:
- Alzheimer’s disease
- Cerebral palsy
- Meningitis and brain tumors
- Mouth, throat, or esophageal cancer
- Multiple sclerosis
- Parkinson's disease
- Traumatic brain injury
- Spinal cord injury
- Stroke
Typically, a full assessment including a bedside swallowing evaluation, or a barium swallow study will be used to make a diagnosis.
Potential Complications
A common warning sign of dysphagia is chronic coughing or choking while eating and gagging when swallowing. If a person does not receive treatment to help with their symptoms and continues to have challenges swallowing, especially when eating and drinking, they can be at risk for developing other health issues, including:
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- Dehydration
- Malnutrition
- Pneumonia or respiratory infections
- Weight loss
- Anxiety and depression
Since dysphagia accompanies an underlying condition or is due to weakened or damaged muscles and nerves used for swallowing, diagnosing and treating what is causing the condition is essential to improving a person’s quality of life.
Treatment Approaches
Depending on the cause of the dysphagia, treatment may include swallowing exercises, positioning the head to allow for easier swallowing and prescribing medication to treat the condition causing the dysphagia.
Another effective way of managing dysphagia is modifying the texture of foods (chopped, minced, pureed) and thickening liquids to make eating and swallowing safer and easier. This helps reduce the risk of choking or having material enter the airway.
Diet Texture Modifications and the IDDSI Framework
Diet texture modifications include changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods using standardized guidelines. In the past, health care providers often used a variety of terms to describe diets for those requiring altered consistency foods, including “mechanical soft,” “blended smooth” and “chopped.” To help provide universal guidelines for the dysphagia diet, the International Dysphagia Diet Standardization Initiative (IDDSI) set out to standardize diets and liquid consistency. In 2019, the American Speech Language-Hearing Association and Academy of Nutrition and Dietetics endorsed the use of this International Dysphagia Diet.
The IDDSI framework provides common terminology for describing food textures and drink thickness to improve safety for individuals with swallowing difficulties. The IDDSI framework consists of a continuum of 8 levels (0 - 7). Drinks are categorized by their thickness and are assigned to a level between 0 and 4. Foods range from liquidized (level 3) to regular and easy to chew (level 7). This provides consistent terminology for providers to use to describe the precise level of texture modification needed for foods and thickness for drinks.
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Understanding IDDSI Levels
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.
It is important not to alter the elements of the IDDSI framework. Alterations may lead to confusion and errors in diet texture or drink selection for patients with dysphagia.
ASHA's Role and Facility Protocols
There is no ASHA policy or guidance directing the use of texture-modified diets in dysphagia management. SLPs are encouraged to explore the current evidence and consider patients holistically when developing individualized plans of care that meet patients’ individual needs. 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. 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.
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). The National Dysphagia Diet (NDD) was part of the full Nutrition Care Manual (NCM)® established by the Academy of Nutrition and Dietetics (AND).
The SLP's Role in 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. It is important to 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.
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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. 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. 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.
Nutritional Support and Resources
To accommodate the nutritional needs of individuals living with dysphagia, Mom’s Meals offers a pureed menu of fully prepared soft food meals. Our menu options have all been designed to meet the Academy of Nutrition and Dietetics requirement for Dysphagia (Level 1 - Pureed Nutritional Therapy). While Mom’s Meals has not officially adopted the IDDSI guidelines, our pureed menu is intended to meet the guidelines of level 4 - pureed. Most of the meals would be considered level 6 or 7, soft and bite-sized or easy to chew. To meet level 5 - minced and moist criteria, the meals would need to be mashed or chopped up further and could be easily modified to this texture.
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