Understanding the IDDSI Framework
In the past, various classification systems for dysphagia diets caused confusion for patients and caregivers. The International Dysphagia Diet Standardisation Initiative (IDDSI) was developed to create a single, global set of standards, from Level 0 (Thin liquids) to Level 7 (Regular food). The IDDSI framework has a separate scale for foods and drinks, with Level 3 defining a specific texture for liquidised foods. This approach contrasts with the older National Dysphagia Diet (NDD) system, which used 'Level 3' to refer to 'Advanced' textures, a significant difference that can lead to dangerous errors if not understood correctly. Always confirm with your healthcare professional which standard is being used for your or a loved one's diet.
Defining IDDSI Level 3: The Liquidised Diet
IDDSI Level 3, also known as the Liquidised or Moderately Thick diet, consists of foods that have been blended to a very smooth, consistent texture with no lumps or fibrous bits. This texture is safe for individuals who cannot chew and require a diet that can be swallowed with minimal effort. While the food is thick, it must still be cohesive enough to drip slowly from a fork and can be drunk from a cup, but cannot be sucked through a straw.
Key Characteristics of IDDSI Level 3 Foods
- Smooth and Consistent: Absolutely no lumps, strings, seeds, or hard particles. The texture is uniform throughout.
- Easy to Swallow: Does not require any chewing and can be swallowed straight away.
- Moderately Thick: Thicker than thin liquids, it can be poured slowly from a spoon in dollops but does not retain its shape when on a flat surface.
- Can be Eaten with a Spoon: Its consistency is designed to be managed with a spoon, offering more control than a thin liquid.
Testing for the Correct Level 3 Consistency
To ensure food is safe for a Level 3 diet, IDDSI provides standardized testing methods. It is crucial to perform these checks every time, especially when preparing food at home.
Fork Drip Test: Scoop the liquidised food with a standard dinner fork. The food should drip slowly and continuously through the prongs in strands or dollops. It should not pass through the tines quickly like a thin liquid, nor should it sit on top without dripping.
Spoon Tilt Test: Scoop the food onto a spoon and tilt it to see how it moves. The food should flow easily off the spoon when tilted, leaving only a thin coating behind. It should not be sticky or hold its shape.
Acceptable Foods on a Level 3 Dysphagia Diet
- Soups: Smooth, pureed soups with no fibrous vegetables or chunks of meat.
- Dairy: Smooth yogurts, puddings, custard, and blended milky drinks.
- Fruits: Smooth fruit purees or blended, seedless smoothies.
- Vegetables: Cooked and blended vegetables, such as mashed potatoes (with added liquid), pureed carrots, or cauliflower cheese.
- Meats/Proteins: Blended meat, fish, or poultry combined with plenty of gravy, sauce, or broth to achieve a smooth, cohesive consistency.
- Cereals: Well-cooked, smooth hot cereals like porridge or cream of wheat, thinned with extra milk or liquid.
- Desserts: Smooth custards, gelatin without fruit pieces, or cheesecake topping without the biscuit base.
Foods to Avoid on a Level 3 Dysphagia Diet
- Solid Foods: Hard, crunchy, or chewy foods, including hard crusty bread, nuts, crackers, and raw vegetables.
- Sticky Foods: Peanut butter, caramel, or any food that can stick to the mouth or throat, as this can increase choking risk.
- Fibrous Foods: Raw or cooked vegetables with tough skins or fibrous parts, and fruits with seeds, skins, or stringy pulp.
- Lumpy Foods: Any food with unblended lumps, seeds, or grains that cannot be mashed to a smooth consistency.
- Soups with Chunks: Avoid soups that contain solid pieces of meat, vegetables, or noodles, as they create a mixed consistency that is dangerous for this diet level.
IDDSI Level 3 vs. Level 4 Comparison
| Feature | IDDSI Level 3 (Liquidised/Moderately Thick) | IDDSI Level 4 (Pureed/Extremely Thick) |
|---|---|---|
| Chewing | Not required | Not required |
| Consistency | Smooth, with no lumps; drips slowly from a fork | Very smooth, uniform, and cohesive; holds its shape on a plate |
| Shape | Does not hold its shape; spreads if spilled | Holds shape and does not spread |
| Spoon/Fork | Can be eaten with a spoon but drips through fork prongs | Can be eaten with a fork and holds its shape on the prongs |
| Liquid | Can be drunk from a cup | Must be eaten with a spoon; cannot be drunk from a cup |
Preparation Tips for a Level 3 Diet
- Use a High-Powered Blender: Achieve a consistently smooth texture by using a high-speed blender or food processor to liquidise foods. Ensure all chunks, seeds, and fibrous parts are completely broken down.
- Add Flavorful Liquid: Enhance the taste and consistency by adding nutritious fluids like broth, gravy, milk, or fruit juice. This prevents the food from being bland and dry, ensuring proper hydration.
- Adjust Thickness Carefully: If using commercial thickeners for liquids, follow the instructions precisely to achieve the correct moderately thick consistency. Homemade thickening can be done with cornstarch or flour, but requires careful measurement.
- Prioritize Nutrition: Since this diet can be low in calories and protein, consider fortifying meals with dry milk powder, extra butter, or healthy oils to boost nutritional content.
Conclusion
Understanding what is level 3 dysphagia diet, based on the global IDDSI standard, is crucial for ensuring safe and adequate nutrition for individuals with swallowing difficulties. This liquidised or moderately thick diet requires careful preparation and consistency testing to eliminate any risk of aspiration or choking. By following the guidelines for acceptable and unacceptable foods and mastering the preparation techniques, caregivers can provide safe, enjoyable, and nutritious meals. Always work in close consultation with a healthcare team, including a doctor, speech therapist, and dietitian, to determine the appropriate diet level and address specific nutritional needs. For more detailed information, consult the official IDDSI framework guidelines at IDDSI.org.
