What is a Level 2 Fluid Diet?

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), a Level 2 fluid diet is classified as "mildly thick," designed for individuals with swallowing difficulties. This special diet provides a safer way to consume liquids by slowing their flow, giving the person more time and control during the swallowing process. It is typically prescribed by a speech-language pathologist or other healthcare provider following an assessment.

Quick Summary

A Level 2 fluid diet, also known as mildly thick or nectar thick, consists of liquids thickened to a specific consistency to make swallowing safer for individuals with dysphagia. It is part of the IDDSI framework and includes thickened beverages and liquid-based foods that pour quickly from a spoon but slower than thin liquids. Management often involves using commercial thickening powders.

Key Points

• Mildly Thick Consistency: A Level 2 fluid diet is defined as mildly thick, slower-flowing than thin liquids but sippable from a cup.

• Purpose for Dysphagia: It is prescribed for individuals with swallowing difficulties (dysphagia) to reduce the risk of liquid entering the airway and lungs.

• Based on IDDSI: This dietary level is part of the standardized, global IDDSI framework for managing modified diets.

• Preparation with Thickeners: Mildly thick fluids are created by adding commercial thickening powders to liquids like water, juice, and milk.

• Avoid Transitional Foods: Dangerous foods like ice cream and gelatin, which melt into a thin liquid in the mouth, must be avoided.

• Essential for Safety: Proper preparation and adherence are critical to ensure safety and prevent serious complications such as aspiration pneumonia.

Understanding the IDDSI Framework

The Level 2 fluid diet is part of the International Dysphagia Diet Standardisation Initiative (IDDSI), a global framework that provides standardized terminology and definitions for texture-modified foods and thickened liquids for individuals with swallowing difficulties, or dysphagia. The framework uses a numbered system, with higher numbers indicating greater thickness. Level 2, or "Mildly Thick," is one of the initial stages of fluid modification, used when standard, thin liquids are unsafe for a patient to swallow.

Why a Level 2 Fluid Diet is Necessary

For some people with dysphagia, thin liquids like water, coffee, and juice flow too quickly, increasing the risk of aspiration. Aspiration occurs when food or liquid enters the airway and goes into the lungs, which can lead to serious respiratory complications like aspiration pneumonia. By thickening liquids to a mildly thick consistency, the flow rate is slowed, giving the individual more time to control the liquid in their mouth and safely initiate the swallow reflex.

What to Eat and Drink on a Level 2 Fluid Diet

Following a Level 2 diet means consuming only those liquids that meet the "mildly thick" criteria. It's important to remember that this consistency can be achieved using thickening powders or by selecting naturally mildly thick foods.

Acceptable Liquid Items

• Thickened Juices: Fruit nectars or juices thickened with a commercial product to the correct consistency.
• Thickened Milk: Milk or milk alternatives mixed with a thickening agent.
• Certain Nutritional Supplements: Ready-made nutritional drinks that meet the required mildly thick standard.
• Certain Soups and Broths: Strained, cream-based, or broth-based soups that have been thickened properly.
• Thickened Water, Tea, and Coffee: These beverages can be enjoyed once a thickening powder has been mixed in to achieve the Level 2 consistency.

Foods to Avoid

Certain foods are dangerous for individuals on a Level 2 fluid diet because they can melt or change consistency to a thinner, unsafe liquid in the mouth. These include:

• Ice Cream, Sorbet, and Gelatin: These foods melt into a thin liquid and should be avoided unless a safe, thickened version is prepared.
• Thin Soups and Broths: Any soup that has a thin, watery consistency is unsafe and can lead to aspiration.
• Cereal with Unthickened Milk: Cereal that leaves thin milk at the bottom of the bowl is a hazard.

How to Prepare and Test Level 2 Fluids

Preparing Level 2 fluids accurately is critical for safety. The IDDSI framework recommends a simple "fork drip" or syringe test to confirm the correct consistency.

Preparation using commercial thickeners:

1. Read Instructions Carefully: Always follow the specific instructions on the thickening powder container, as ratios can differ between products.
2. Measure Accurately: Use the provided scoop to measure the powder and a measuring cup for the liquid to ensure the correct proportions.
3. Mix Thoroughly: Mix the powder into the liquid until fully dissolved. Some drinks may take several minutes to reach their final thickness.
4. Test the Consistency: Perform a standardized IDDSI test to ensure the fluid is mildly thick before serving.

IDDSI Syringe Test for Mildly Thick (Level 2):

Using a 10 mL syringe (like a standard oral syringe), let the liquid flow out. For a Level 2 consistency, 4-8 mL of the liquid should remain in the syringe after 10 seconds.

Comparison of IDDSI Fluid Levels

Feature	Level 0: Thin	Level 2: Mildly Thick	Level 3: Moderately Thick
Consistency	Water-like	Flows slower than water; nectar-like	Honey-like consistency
Flow Rate	Flows easily	Pours quickly from a spoon, slower than thin	Pours slowly in dollops
Sipping	Easily sipped from a cup or straw	Can be sipped from a cup; effort required for a straw	Difficult to sip through a straw
Aspiration Risk	High risk for those with dysphagia	Reduced risk compared to thin liquids	Further reduced risk for severe dysphagia
Examples	Water, juice, tea	Fruit nectars, thickened drinks	Spoon-thick yogurts, thickened milkshakes
Management	No modification needed	Requires commercial thickener or naturally occurring thickness	Requires more thickener and careful measurement

Managing the Level 2 Fluid Diet at Home

Following a special diet at home requires attention to detail. Consistent preparation is key to ensuring the fluids are always the correct and safe consistency. Here are some practical tips:

• Label and Organize: Label all containers of thickened liquids with the consistency level and preparation date. Thickened drinks have a limited shelf life.
• Communicate with Caregivers: Ensure all family members and caregivers understand the diet and how to prepare the liquids correctly.
• Monitor Hydration: Thickened liquids can sometimes lead to reduced fluid intake. Monitor the individual's hydration levels and encourage consumption throughout the day.
• Check for Changes: Regularly observe the individual for signs of swallowing difficulty, such as coughing or choking, and report any issues to the healthcare team.

Conclusion

A Level 2 fluid diet, or mildly thick fluids, is a crucial component of dysphagia management, providing a safer way for individuals to consume liquids and stay hydrated. Adhering to the IDDSI guidelines and working closely with a speech-language pathologist and dietitian is essential for a successful outcome. Correct preparation and careful monitoring are key to minimizing the risk of aspiration and ensuring proper nutrition and hydration.

For more information on IDDSI standards and testing methods, you can visit the official IDDSI website.

International Dysphagia Diet Standardisation Initiative

Frequently Asked Questions

What is the difference between nectar thick and mildly thick fluids?

These two terms are used interchangeably to describe the same consistency, which aligns with Level 2 of the IDDSI framework. Nectar thick was an older term that has been standardized under IDDSI as mildly thick.

How do you know if a fluid is Level 2 mildly thick?

The IDDSI framework provides specific testing methods. For Level 2, the fluid should leave a thin coating on the back of a spoon and pour quickly from it, but more slowly than a thin liquid. The IDDSI syringe test also confirms the consistency.

Can I drink water on a Level 2 fluid diet?

No, you cannot drink plain water. All water must be thickened to the mildly thick, Level 2 consistency using a commercial thickening agent before consumption.

What types of thickeners are used for Level 2 fluids?

Commercial thickeners typically come in powdered form and can be starch-based or gum-based. Both types are mixed into hot or cold liquids according to manufacturer instructions to achieve the desired consistency.

Are pureed foods allowed with a Level 2 fluid diet?

A Level 2 fluid diet specifically refers to liquid consistency. An individual with dysphagia may be on a Level 2 fluid diet while also following a different textured diet for solid foods, such as a pureed or mechanically altered diet, based on their healthcare provider's recommendations.

What happens if a fluid is too thick or too thin?

If a fluid is too thin, it increases the risk of aspiration. If it is too thick (Level 3 or higher), it can be difficult for the individual to consume enough liquid, potentially leading to dehydration. Consistency is critical for safety and hydration.

Can I use a straw with a Level 2 fluid diet?

Drinking through a straw with a mildly thick, Level 2 fluid is possible but requires more effort. You should always consult with your speech-language pathologist to confirm whether using a straw is safe for your specific condition.