Nutrition Diet: What is Level 2 food and drink?

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), a global framework adopted to enhance patient safety, Level 2 food and drink refers specifically to "Mildly Thick" liquids. Understanding this classification is crucial for anyone managing swallowing difficulties, as the term 'Level 2' previously applied to a different food texture in older dietary guidelines.

Quick Summary

Clarifies the definition of Level 2 food and drink, detailing the IDDSI's Level 2 Mildly Thick liquid standard for safe swallowing. Contrasts this with the older National Dysphagia Diet Level 2 (Mechanically Altered food), providing examples and preparation instructions for individuals with dysphagia. Essential for caregivers and patients.

Key Points

• IDDSI Distinction: In the current International Dysphagia Diet Standardisation Initiative (IDDSI), Level 2 specifically refers to "Mildly Thick" liquids, not food.

• Mildly Thick Liquids: These liquids flow more slowly than water, are sippable from a cup, and require some effort to drink through a straw, making them safer for individuals who aspirate thin liquids.

• Legacy Terminology: In older National Dysphagia Diet (NDD) guidelines, Level 2 described "Mechanically Altered" foods, which were soft, moist, and minced or chopped into small pieces.

• IDDSI Food Equivalent: The modern IDDSI equivalent for the older Mechanically Altered food is Level 5, "Minced and Moist," which has specific particle size requirements for safe swallowing.

• Preparation and Safety: Accurate preparation and verification using IDDSI testing methods, such as the Flow Test for liquids, are critical for patient safety and must follow a healthcare provider's recommendations.

• Foods to Avoid: Tough, hard, crunchy, or sticky foods, as well as those with mixed consistencies, should be avoided on texture-modified diets to minimize the risk of choking or aspiration.

The International Dysphagia Diet Standardisation Initiative (IDDSI)

The International Dysphagia Diet Standardisation Initiative, or IDDSI, is a globally recognized framework designed to standardize the terminology for texture-modified foods and thickened liquids. This initiative was developed by a team of international experts to create a clear, common language that avoids confusion caused by various previous standards, such as the National Dysphagia Diet (NDD) used in the US. The IDDSI framework uses a continuum of 8 levels (from 0 to 7) to classify textures and liquids. A crucial element of this system is the distinction between food and drink levels, which often have different numbering.

IDDSI Level 2: Mildly Thick Drinks

Within the IDDSI framework, Level 2 is assigned exclusively to liquids with a "Mildly Thick" consistency. These drinks are significantly thicker than water (Level 0) and Level 1 (Slightly Thick), offering a slower flow rate that is safer for individuals who have difficulty controlling thin liquids. Mildly thick drinks can typically be consumed from a cup, and while some effort is required, they can also be sipped through a standard bore straw.

IDDSI testing methods ensure consistency in preparation. The most common test for Level 2 liquids is the IDDSI Flow Test, which uses a 10 mL syringe. After 10 seconds of flow, a Mildly Thick liquid should have 4–8 mL remaining in the syringe.

Examples of liquids that are naturally or can be thickened to a Mildly Thick consistency include:

• Milkshakes and thick shakes
• Some fruit nectars
• Standard drinks (water, juice, coffee, tea) thickened with a commercial thickening agent
• Thickened nutritional supplements

The Legacy National Dysphagia Diet (NDD) Level 2

Before IDDSI became the global standard, many regions used the National Dysphagia Diet (NDD), which had its own numbering system. Under the NDD, Level 2 referred to "Mechanically Altered" foods. This diet prescribed soft, moist, and easy-to-chew foods, often minced or chopped into pieces no larger than 1/4 inch. Crucially, these foods were not homogenous like purees and required some chewing ability. Extra moisture, like gravy or sauce, was added to prevent dryness and aid swallowing. The modern IDDSI framework replaces this category with "Minced and Moist" (Level 5) and "Soft and Bite-Sized" (Level 6), which have more specific particle size requirements.

What are examples of Level 2 foods and drinks?

For IDDSI Level 2 (Mildly Thick Drinks):

• Allowed:
  • Liquids thickened to a mildly thick consistency using commercial thickeners.
  • Naturally thick beverages like some milkshakes.
• Avoid:
  • All thin liquids, including water, coffee, and juice without thickener.
  • Liquids with pulp, seeds, or chunks.

For NDD Level 2 (Mechanically Altered Foods - Replaced by IDDSI Level 5 & 6):

• Allowed:
  • Moist ground or tender-cooked meats, poultry, or fish with gravy or sauce.
  • Soft-cooked and well-moistened cereals like oatmeal or cream of wheat.
  • Well-cooked and mashed vegetables (no larger than 1/4 inch), such as potatoes.
  • Soft, moistened pancakes or breads.
  • Egg salad, tuna salad, or chicken salad (minced, no large chunks).
• Avoid:
  • Dry, tough, or hard foods like nuts, seeds, raw vegetables, or crackers.
  • Fibrous, stringy vegetables like asparagus or broccoli.
  • Tough meats like bacon or sausages.
  • Sticky foods like peanut butter.

Comparison of Dysphagia Diet Levels

To help clarify the change in terminology, this table compares the older NDD classification for food with the current IDDSI framework, focusing on the textures related to the 'Level 2' designation.

Feature	NDD Level 2: Mechanically Altered (Older)	IDDSI Level 2: Mildly Thick (Current)	IDDSI Level 5: Minced & Moist (Modern Equivalent Food)
Texture Type	Soft, moist, minced or chopped food.	Liquid with a mildly thick consistency.	Soft, moist minced food (4mm pieces).
Particle Size	Max 1/4 inch (6mm).	Not applicable.	Max 4 mm (approx. adult little fingernail).
Preparation	Ground, chopped, mashed, or blended; requires added moisture.	Liquid (often water, juice, milk) with thickener added.	Food is minced and moistened to hold shape.
Chewing Ability	Some chewing ability is required.	Not applicable, as it's a liquid consistency.	Minimal chewing is required.
Serving	Served on a plate with cutlery.	Served in a cup; sipped or drunk with mild effort.	Served on a plate; eaten with a fork or spoon.
Purpose	For individuals with mild to moderate chewing difficulty.	For individuals with difficulty managing thin liquids safely.	For individuals with moderate chewing difficulty.

How to Prepare a Level 2 Diet

If a healthcare professional, such as a speech-language pathologist or a registered dietitian, has recommended a dysphagia diet, it's vital to follow their specific instructions.

For IDDSI Level 2 Mildly Thick liquids:

1. Select a thickener: Use a commercial food and drink thickener designed for dysphagia diets. There are various brands, so check with your clinician for a recommendation.
2. Mix carefully: Follow the manufacturer's instructions precisely, as thickening agents work differently. Add the thickener to your chosen liquid and stir well.
3. Test the consistency: Wait for the recommended time (e.g., 5-10 minutes) for the liquid to reach its final thickness. Use the IDDSI Flow Test with a 10 mL syringe to verify it falls within the 4-8 mL range.

For older NDD Level 2 foods (or IDDSI Level 5 minced and moist):

1. Cook until soft: Meats and vegetables should be cooked until very tender. Steaming, boiling, or braising are effective methods.
2. Process to the correct size: Use a food processor, blender, or food grinder to break food into pieces no larger than 1/4 inch (6mm) for NDD Level 2 or 4mm for IDDSI Level 5.
3. Add moisture: Mix the processed food with gravy, sauce, broth, or another appropriate liquid to achieve a soft, moist, and cohesive texture.

Safety Precautions for Dysphagia Diets

• Follow professional advice: Always adhere strictly to the recommendations of your speech-language pathologist and dietitian. They determine the safest consistency for your individual needs.
• Never substitute: Do not guess the correct consistency. Use the official IDDSI testing methods to confirm.
• Beware of dual consistency: Mixed-consistency foods, like soup with chunks or cereal with milk that doesn't fully soften, should be avoided as they can increase aspiration risk.
• Monitor nutritional intake: Modified diets may lack sufficient fluids, calories, or nutrients. A dietitian can help ensure adequate nutrition is maintained, possibly recommending supplements.
• Address choking risks: Avoid hard, tough, chewy, or sticky foods that pose a high choking hazard.
• Consult for new symptoms: Any new or worsening swallowing problems should be reported to a healthcare provider immediately.

Conclusion

The term 'What is Level 2 food and drink?' refers to two distinct concepts depending on the dietary framework used. In the current global standard (IDDSI), Level 2 designates mildly thick liquids suitable for individuals with swallowing difficulties who need a slower flow rate than thin liquids. In older guidelines (NDD), Level 2 referred to mechanically altered foods, which are now more accurately classified under IDDSI Level 5 (Minced and Moist) and Level 6 (Soft and Bite-Sized). For patient safety, it is essential to follow the guidance of healthcare professionals and use the IDDSI framework to prepare and verify the correct consistency of both foods and drinks.

Frequently Asked Questions

Who is a Level 2 diet typically recommended for?

A dysphagia diet, including IDDSI Level 2 Mildly Thick liquids, is recommended by a healthcare professional (like a speech-language pathologist) for individuals with dysphagia, or swallowing difficulties.

What is the IDDSI Flow Test?

The IDDSI Flow Test uses a 10 mL syringe to measure the thickness of a liquid. For a Level 2 Mildly Thick liquid, the test requires that 4-8 mL remain in the syringe after 10 seconds of flow.

How does IDDSI Level 2 differ from IDDSI Level 1 liquids?

IDDSI Level 2 liquids (Mildly Thick) are thicker and flow more slowly than IDDSI Level 1 liquids (Slightly Thick). This difference requires more effort to drink, even through a straw.

Is a Level 2 dysphagia diet the same as a pureed diet?

No. In the older NDD system, Level 2 was Mechanically Altered food, which contained small, soft pieces. Pureed food (Level 1) is a smooth, homogenous texture with no lumps or chunks.

What are some foods to avoid on a Level 2 (Mechanically Altered) diet?

On the older NDD Level 2, foods to avoid included nuts, seeds, hard or tough meats, sticky items like peanut butter, and tough vegetables like fibrous asparagus.

Can I prepare a Level 2 diet at home?

Yes, but only under the specific guidance of a healthcare professional. You will need to use appropriate thickeners for liquids and follow preparation instructions to achieve the correct texture and consistency.

Why did the dysphagia diet terminology change from NDD to IDDSI?

The terminology changed to the IDDSI framework to create a single, standardized, and internationally recognized system to describe diet textures and liquids. This reduces confusion and improves patient safety across different facilities and regions.

What if I can't find a standard bore straw for IDDSI testing?

While the test mentions a standard bore straw, the primary and most reliable test for IDDSI Level 2 is the 10 mL syringe flow test. It is the most accurate way to verify the thickness.