What is the IDDSI Framework?
For many years, the terminology used to describe texture-modified diets was inconsistent, leading to confusion and potential safety risks. To address this, the International Dysphagia Diet Standardisation Initiative (IDDSI) developed a global framework to provide a common language for describing food textures and drink thicknesses. The IDDSI framework consists of a continuum of eight levels, from 0 to 7, identified by numbers, text labels, and color codes. This system helps healthcare professionals, patients, and caregivers communicate clearly and accurately about dietary needs. While the framework covers both food and drink, this article will focus specifically on the food levels.
IDDSI Food Levels: From Liquidised to Regular
Level 3: Liquidised
This is the starting point for food on the IDDSI framework. As the name suggests, liquidised food is completely smooth and lump-free. It is similar in consistency to a thick soup or sauce, and though it cannot hold its shape, it can be eaten with a spoon.
- Characteristics:
- Smooth with no lumps, lumps, or fibrous bits.
- Cannot be piped or molded and spreads out if spilled.
- May drip slowly in dollops through the prongs of a fork.
- Examples: Blended soups (without lumps), fruit purées, smooth yogurt with no fruit pieces.
- Preparation: Blend or purée food until completely smooth, and pass through a sieve if necessary. Use a binder like potato flakes or tapioca to thicken if needed.
Level 4: Puréed
Level 4 food is a step up from liquidised. While still smooth and lump-free, it is thicker and holds its shape on a plate or spoon. It does not require any chewing and is moved with the tongue. This is ideal for individuals with minimal chewing ability or significant difficulty controlling food in their mouth.
- Characteristics:
- Holds its shape and does not spread on a plate.
- Can be piped, layered, or molded.
- Requires a spoon for eating, not a fork.
- Examples: Creamy mashed potatoes, puréed meat and vegetables, smooth pudding.
- Preparation: Process food in a blender or food processor until entirely smooth and cohesive. Add moisture, such as gravy or sauce, to prevent it from becoming sticky.
Level 5: Minced and Moist
For individuals with a moderate chewing ability, Level 5 provides more texture. The food is minced into small, soft, and moist pieces, with a particle size no bigger than 4mm for adults, which can be checked with a standard fork.
- Characteristics:
- Small, soft, and moist lumps are visible within the food.
- Lumps are easily mashed with the tongue.
- No separate thin liquid should leak from the food.
- Examples: Finely minced meat or fish in a thick, smooth sauce, soft cooked rice.
- Preparation: Chop or grind food to the correct particle size. Mix with a thick sauce or gravy to ensure it is moist and holds together. The food should not be dry or sticky.
Level 6: Soft and Bite-Sized
This level introduces larger, bite-sized pieces of soft, tender food. It requires chewing but not biting. For adults, the food particles should be no bigger than 1.5 cm by 1.5 cm.
- Characteristics:
- Soft and moist throughout, with no separate thin liquid.
- Can be mashed or broken down with a fork.
- Bite-sized pieces must be consistent in size.
- Examples: Soft, tender cooked fish, steamed vegetables, casseroles with soft meat chunks.
- Preparation: Cook food until very tender. Cut into small, consistent pieces. Avoid dry, hard, or crumbly items, and ensure any sauce is thick to prevent separation.
Level 7: Regular (Easy to Chew)
Level 7 includes foods of a normal, everyday texture but with an added 'Easy to Chew' subcategory. This subcategory is for people who can manage regular food but benefit from softer options. The food is soft, tender, and moist but does not have particle size restrictions like Level 6.
- Characteristics:
- No particle size restriction.
- Soft enough to be cut or broken apart with the side of a fork or spoon.
- May include mixed consistency foods.
- Examples: Soft cooked meats, pasta, ripe fruits.
- Preparation: Cook food until tender. Check softness with a fork pressure test to ensure it breaks down easily.
Comparison of Dysphagia Diet Food Levels (IDDSI Levels 3-7)
| Feature | Level 3: Liquidised | Level 4: Puréed | Level 5: Minced & Moist | Level 6: Soft & Bite-Sized | Level 7: Easy to Chew |
|---|---|---|---|---|---|
| Texture | Smooth, lump-free | Smooth, cohesive, pudding-like | Soft, moist, small minced particles (4mm) | Soft, moist, uniform bite-sized pieces (1.5cm) | Normal, soft, tender |
| Chewing | Not required | Not required | Minimal chewing | Chewing required | Chewing required, easier texture |
| Food Form | Cannot hold shape; pours | Holds shape; molded | Holds shape; minced particles | Holds shape; can be mashed by fork | Normal, everyday foods |
| Testing | Fork Drip Test, Spoon Tilt Test | Fork Drip Test, Spoon Tilt Test | Fork Pressure Test | Fork Pressure Test | Fork/Spoon Pressure Test |
| Example | Blended soup | Creamy mashed potatoes | Minced meat with thick gravy | Soft cooked vegetables | Cooked pasta, ripe fruits |
Practical Tips for Managing Dysphagia Diets
Managing dysphagia at home requires careful preparation and an understanding of the prescribed texture level.
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Meal Preparation Techniques:
- Blending: Use a powerful blender or food processor for liquidised and puréed meals. Add liquids like broth, milk, or sauce to achieve the right consistency.
- Moisture: Always add moisture, such as sauces, gravies, or melted butter, to foods to make them easier to swallow. Dry or crumbly foods are hazardous.
- Testing: Regularly perform the recommended IDDSI tests (fork drip, fork pressure, spoon tilt) to ensure food is the correct and safe texture before serving.
- Fortification: To prevent weight loss and dehydration, fortify meals with high-calorie and high-protein ingredients like full-fat yogurt, milk powder, or olive oil.
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Eating Strategies:
- Positioning: Always eat in an upright, seated position to minimize the risk of aspiration.
- Pacing: Take smaller bites and chew thoroughly. Alternate between bites of food and sips of thickened liquids if advised by a speech-language pathologist (SLP).
- Focus: Minimize distractions during mealtime to help focus on eating and swallowing safely.
Conclusion
Understanding what are the levels of dysphagia in food is a critical step towards ensuring safe and dignified mealtimes for individuals with swallowing difficulties. The IDDSI framework provides a clear, consistent guide, ranging from entirely liquidised to soft, bite-sized textures. Following these guidelines, along with professional advice from a speech-language pathologist and dietitian, is essential for minimizing risks such as choking and aspiration while maintaining good nutrition and quality of life.
For more information and detailed testing methods, consult the official IDDSI resources: https://www.iddsi.org/framework/.
