What is IDDSI Level 7?

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), over 5,000 health professionals, patients, and researchers globally supported the creation of a standardized framework for dysphagia diets. The final tier of this system, IDDSI Level 7, encompasses normal, everyday foods for individuals with no chewing or swallowing issues.

Quick Summary

This guide explains the comprehensive features of IDDSI Level 7, which includes both Regular and Easy-to-Chew subcategories, outlining who it is for, its characteristics, and how to verify food texture according to IDDSI standards.

Key Points

• Least Restrictive Level: IDDSI Level 7 is the highest and least restrictive level in the framework, intended for individuals with strong chewing and swallowing abilities.

• Two Subcategories: Level 7 includes a 'Regular' diet (no restrictions) and a 'Regular Easy to Chew' (ETC) option for those with some chewing difficulty.

• Easy to Chew Focus: The ETC diet emphasizes soft and tender foods that can be easily broken apart with a fork, avoiding hard, tough, or chewy textures.

• No Size Restrictions: Unlike lower levels like Level 6, the ETC diet does not require food to be cut into specific, small pieces.

• Supervision Needs: Neither Level 7 diet is intended for individuals with an identified choking risk or who require supervision during meals.

• Tested for Softness: The softness of ETC foods can be confirmed using the IDDSI Fork Pressure Test, ensuring food is moist and easily squashed.

• Clinician Guidance: Selection of the appropriate IDDSI diet level, including Level 7 ETC, should be guided by a healthcare professional based on a clinical assessment.

Understanding the IDDSI Framework

The International Dysphagia Diet Standardisation Initiative (IDDSI) framework is a globally recognized system designed to improve patient safety for individuals with chewing and swallowing difficulties, also known as dysphagia. It standardizes food textures and drink thicknesses, moving away from subjective descriptions like 'soft' or 'nectar-thick' that caused confusion. The framework consists of a continuum of eight levels, from Level 0 (Thin liquids) to Level 7 (Regular foods).

The Two Sides of IDDSI Level 7

IDDSI Level 7 is the final level in the framework, and it is unique because it includes two distinct subcategories: 'Regular' and 'Regular Easy to Chew' (ETC). Both are intended for individuals who can manage normal food textures without an increased risk of choking. However, they cater to slightly different chewing abilities.

• IDDSI Level 7 (Regular): This is for individuals who have no problems with chewing or swallowing. It includes a normal, everyday diet with no restrictions on food texture or piece size. A person on this diet should be able to eat both hard and soft foods and chew without tiring easily.
• IDDSI Level 7 (Regular Easy to Chew): This subcategory is for those who may have some difficulty with harder or chewier textures but do not have dysphagia. This could be due to dental issues, fatigue, or a recovery period. Foods should be soft and tender, easily broken apart with the side of a fork or spoon. While piece size is not restricted, harder textures are avoided.

Key Characteristics of Easy to Chew (ETC) Foods

Foods within the Level 7 Easy to Chew category share several important characteristics to ensure they are safe and comfortable to eat:

• Soft/Tender Texture: Food can be easily separated or broken apart with the side of a fork or spoon.
• Adequate Moisture: The food should be moist enough to chew and swallow comfortably.
• No Hard, Tough, or Chewy Bits: This excludes hard, dry, stringy, fibrous, or crunchy textures.
• No Small, Hard Components: Foods with pips, seeds, or husks are avoided, as are bones or gristle.

Testing Methods for IDDSI Level 7 Foods

While Level 7 Regular requires no testing, the Easy to Chew subcategory has specific, simple tests that caregivers and food service staff can perform to ensure safety. These tests are vital for managing the transitional needs of some patients.

1. Fork/Spoon Separation Test: A portion of the food should easily separate or flake apart when pressure is applied with the side of a fork or spoon.
2. Fork Pressure Test: Press down on the food with a fork until your thumbnail blanches (turns white). The food should squash easily and not return to its original shape when the pressure is removed.

This simple testing protocol helps maintain consistency across different care settings and reduces the risk associated with poorly prepared or inappropriately served meals.

Comparison of IDDSI Level 6 and Level 7

To understand what is IDDSI Level 7, it is helpful to compare it with the preceding level, Level 6 (Soft & Bite-Sized). This comparison highlights the key differences and explains why the Easy to Chew option is a Level 7 subcategory and not a Level 6.

Feature	IDDSI Level 6 (Soft & Bite-Sized)	IDDSI Level 7 (Easy to Chew)
Food Texture	Soft and tender, requiring minimal chewing.	Soft and tender, though can be more varied.
Particle Size	Restricted to a maximum of 1.5 cm x 1.5 cm.	Not restricted; pieces can be of any size.
Chewing Ability	For individuals with reduced chewing ability and often an increased choking risk.	For individuals with adequate chewing ability for soft foods, no increased choking risk.
Test Method	Pass fork pressure test and size test.	Pass fork pressure test only.
Example Foods	Small, soft pasta pieces, finely minced meat with sauce.	Tender cooked meats, soft fish, moist cakes, boiled vegetables.

Appropriate Candidates for IDDSI Level 7

The decision to place a patient on a specific IDDSI diet level must be made by a qualified healthcare professional, such as a speech-language therapist or dietitian, based on a comprehensive clinical assessment. A person may be prescribed IDDSI Level 7 (Regular) if they have no chewing or swallowing impairments. The Easy to Chew option is suitable for individuals with conditions that make chewing more challenging, such as:

• Dental problems (e.g., missing teeth, poor-fitting dentures)
• Weak chewing muscles or fatigue when eating
• Recovering from illness or oral/jaw surgery
• Learning advanced chewing skills, particularly in pediatrics

Preparing IDDSI Level 7 Meals

For those on the Easy to Chew diet, careful preparation is key. Most common foods can be adapted to fit this category by focusing on cooking methods that promote tenderness and moisture.

Cooking and Preparation Tips

• Tenderize Protein: Cook meat and chicken until very tender by stewing, braising, or slow-cooking. Flaky fish is also an excellent option. Remove all bones, skin, and gristle before serving.
• Boil or Steam Vegetables: Ensure vegetables like carrots, cauliflower, and broccoli are cooked until soft enough to be easily mashed. Avoid stir-fried or raw vegetables.
• Moisten Carbohydrates: Serve cereals with enough milk to soften the texture thoroughly. Ensure rice or pasta is cooked until soft. Use plenty of sauce or gravy with meals.
• Choose Soft Fruits: Select ripe, soft fruits like bananas, mangoes, or tinned pears. Avoid fibrous or stringy fruits, or those with seeds.
• Add Extra Nutrition: To combat potential weight loss, add extra calories and protein to meals. For instance, mash potatoes with butter and cream, or add grated cheese to soups and sauces.

Example Meals for Level 7 ETC

• Breakfast: Porridge with fruit or a moist muffin with soft-cooked eggs.
• Lunch: Sandwiches with soft fillings like tuna or egg salad, or a jacket potato with a soft filling.
• Dinner: Tender chicken or fish curry, shepherd's pie, or soft pasta with a bolognaise sauce.
• Snacks/Desserts: Yoghurt, milk puddings, soft fruit, or plain cake with custard.

Conclusion

IDDSI Level 7 is the apex of the IDDSI framework, representing diets for individuals with the strongest chewing and swallowing abilities. It is comprised of the Regular diet, for those without any issues, and the Regular Easy to Chew subcategory, which accommodates minor chewing difficulties by focusing on soft, tender, and moist foods. While it offers the greatest freedom, the Easy to Chew option still requires careful selection and preparation to eliminate potentially hazardous textures, ensuring a safe and comfortable eating experience for the designated individuals. Proper application of IDDSI standards requires a healthcare professional's guidance and emphasizes person-centered care.

For additional resources, the official IDDSI website provides detailed information and patient handouts for all levels of the framework.

Frequently Asked Questions

What is the difference between IDDSI Level 7 Regular and Easy to Chew?

IDDSI Level 7 Regular is for individuals with no chewing or swallowing problems and includes all everyday foods. Level 7 Easy to Chew is a subcategory for those who find hard or chewy foods difficult, requiring soft and tender textures but without particle size restrictions.

Who is the IDDSI Level 7 Easy to Chew diet for?

This diet is suitable for individuals with adequate but weaker chewing muscles, dental issues, or those recovering from an illness or oral surgery who do not have an identified choking risk.

What foods should be avoided on an Easy to Chew diet?

Hard, tough, chewy, or stringy foods should be avoided. This includes nuts, raw vegetables, dried fruits, steak, crackling, and foods with bones, skin, or gristle.

How can I test food for IDDSI Level 7 Easy to Chew?

To test for softness, press down on the food with a fork until your thumbnail blanches. If the food squashes easily and does not return to its original shape, it passes the test.

Can mixed-consistency foods be included in an IDDSI Level 7 diet?

Yes, mixed-consistency foods, such as soup with vegetable pieces or cereal with milk, can be part of a Level 7 diet for those who can manage them. For the Easy to Chew option, ensure the solid parts are tender.

Is supervision required for a Level 7 diet?

No, a Level 7 diet is not intended for individuals who require mealtime supervision. People with an identified choking risk should be on a more restrictive diet level under strict guidance from a healthcare professional.

Who determines if a person needs an IDDSI Level 7 diet?

The diet recommendation is made by a qualified healthcare professional, such as a Speech and Language Therapist or Dietitian, based on a full clinical assessment.