What Are The Stages of Dysphagia Diets? And How to Advance Them

The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework is now the gold standard for determining diet textures for dysphagia. But what is it? And how does it differ from the old food textures and drink thickness recommendations?

In this post, you’ll find exact descriptions of each level of the IDDSI Framework, with plenty of examples. Plus, we’ll cover how to advance dysphagia diets—from the first modified diet, to liquid and solid trials, to adding in exercises and strategies.

Treating dysphagia requires high levels of training and skill. This article is intended for Speech-Language Pathologists or other qualified therapists with the appropriate training and competency to work with adults with dysphagia.

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The Stages of Dysphagia Diet

The International Dysphagia Diet Standardisation Initiative (IDDSI) categorizes food textures and drink thickness into eight levels, from 0-7.

© The International Dysphagia Diet Standardisation Initiative 2019

Below are descriptions and examples of the eight food textures and drink thickness categories from the IDDSI Framework.

To determine where any particular food or drink fits in the framework, use the tests for each category.

0 – Thin

Description/Characteristics:

  • Flows like water
  • Fast flow
  • Can drink through any type of teat/nipple, cup or straw as appropriate for age and skills

Examples:

Most liquids, including water, coffee, and milk.

1 – Slightly Thick

Description/Characteristics:

  • Thicker than water
  • Requires a little more effort to drink than thin liquids
  • Flows through a straw, syringe, teat/nipple
  • Similar to the thickness of most commercially available ‘Anti-regurgitation’ (AR) infant formulas

2 – Mildly Thick

Description/Characteristics:

  • Flows off a spoon
  • Sippable, pours quickly from a spoon, but slower than thin drinks
  • Mild effort is required to drink this thickness through standard bore straw (standard bore straw = 0.209 inch or 5.3 mm diameter)

3 – Moderately Thick (Liquidized)

How to modify diets

Description/Characteristics:

  • Can be drunk from a cup
  • Moderate effort is required to suck through a standard bore or wide bore straw (wide bore straw = 0.275 inch or 6.9 mm)
  • Cannot be piped, layered or molded on a plate because it will not retain its shape
  • Cannot be eaten with a fork because it drips slowly in dollops through the prongs
  • Can be eaten with a spoon
  • No oral processing or chewing required – can be swallowed directly
  • Smooth texture with no ‘bits’ (lumps, fibers, bits of shell or skin, husk, particles of gristle or bone)

Examples:

Some sauces, gravies, and syrups.

4 – Extremely Thick (Pureed)

Description/Characteristics:

  • Usually eaten with a spoon (a fork is possible)
  • Cannot be drunk from a cup because it does not flow easily
  • Cannot be sucked through a straw
  • Does not require chewing
  • Can be piped, layered or molded because it retains its shape, but should not require chewing if presented in this form
  • Shows some very slow movement under gravity but cannot be poured
  • Falls off spoon in a single spoonful when tilted and continues to hold shape on a plate
  • No lumps
  • Not sticky
  • Liquid must not separate from solid

Examples:

Purees suitable for infants

5 – Minced & Moist

Dysphagia diet textures

Description/Characteristics:

  • Can be eaten with a fork or spoon
  • Could be eaten with chopsticks in some cases, if the individual has very good hand control
  • Can be scooped and shaped (e.g. into a ball shape) on a plate
  • Soft and moist with no separate thin liquid
  • Small lumps visible within the food
    • Adult, equal to or less than 4mm width and no longer than 15mm in length
  • Lumps are easy to squash with tongue

Examples:

  • Meat
    • Finely minced or chopped (for adults, equal to or less than 4mm width and no more than 15mm in length)
    • Serve in mildly, moderately, or extremely thick, smooth, sauce or gravy, draining excess
    • *If texture cannot be finely minced it should be pureed
  • Fish
    • Finely mashed in mildly, moderately, or extremely thick smooth, sauce or gravy, draining excess (for adults equal to or less than 4mm width and no more than 15mm in length)
  • Fruit
    • Serve finely minced or chopped or mashed
    • Drain excess juice
    • If needed, serve in mildly, moderately, or extremely thick smooth sauce or gravy AND drain excess liquid.
    • No thin liquid should separate from food
    • For adults, equal to or less than 4mm width and no more than 15mm in length
  • Vegetables
    • Serve finely minced or chopped or mashed
    • Drain any liquid
    • If needed, serve in mildly, moderately, or extremely thick smooth sauce or gravy AND drain excess liquid. No thin liquid should separate from food.
    • For adults, equal to or less than 4mm width and no more than 15mm in length
  • Cereal
    • Thick and smooth with small soft lumps
    • Texture fully softened
    • Any milk/fluid must not separate away from cereal. Drain any excess fluid before serving.
    • For adults, equal to or less than 4mm width and no more than 15mm in length.
  • Bread
    • No regular, dry bread, sandwiches, or toast of any kind
    • Pre-gelled ‘soaked’ breads that are very moist and gelled through the entire thickness
  • Rice, couscous, quinoa (and similar food textures)
    • Not sticky or glutinous
    • Should not be particulate or separate into individual grains when cooked and served
    • Serve with smooth mildly, moderately, or extremely thick sauce AND Sauce must not separate away from rice, couscous, quinoa (and similar food textures). Drain excess fluid before serving.

6 – Soft & Bite-Sized

Description/Characteristics:

  • Can be eaten with a fork, spoon, or chopsticks
  • Can be mashed/broken down with pressure from fork, spoon or chopsticks
  • A knife is not required to cut this food, but may be used to help load a fork or spoon
  • Soft, tender, and moist throughout but with no separate thin liquid
  • Chewing is required before swallowing
  • ‘Bite-sized’ pieces as appropriate for size and oral processing skills
    • Adults, 15 mm = 1.5 cm pieces (no larger than)

Examples:

  • Meat
    • Cooked, tender meat no bigger than (for adults, 15 mm = 1.5 x 1.5 cm pieces)
    • If texture cannot be served soft and tender at 1.5 cm x 1.5 cm (as confirmed with fork/ spoon
    • pressure test), serve minced and moist
  • Fish
    • Soft enough cooked fish to break into small pieces with fork, spoon or chopsticks no larger than 15 mm = 1.5 x 1.5 cm pieces (for adults)
    • No bones or tough skins
  • Casserole/Stew/Curry
    • Liquid portion (e.g. sauce) must be thick (as per clinician recommendations)
    • Can contain meat, fish or vegetables if final cooked pieces are soft and tender and no larger than 15 mm = 1.5 x 1.5 cm pieces for adults
    • No hard lumps
  • Fruit
    • Serve minced or mashed if cannot be cut to soft & bite-sized pieces. 15 mm = 1.5 x 1.5 cm pieces (for adults)
    • Fibrous parts of fruit are not suitable
    • Drain excess juice
    • Assess individual ability to manage fruit with high water content (e.g. watermelon) where juice separates from solid in the mouth during chewing
  • Vegetables
    • Steamed or boiled vegetables with final cooked size of 15 mm = 1.5 x 1.5 cm pieces (for adults)
    • Stir fried vegetables may be too firm and are not soft or tender. Check softness with fork/spoon pressure test
  • Cereal
    • Smooth with soft tender lumps no bigger than 15 mm = 1.5 x 1.5 cm pieces (for adults)
    • Texture fully softened
    • Any excess milk or liquid must be drained and/or thickened to thickness level recommended by clinician
  • Bread
    • No regular dry bread, sandwiches or toast of any kind
    • Pre-gelled ‘soaked’ breads that are very moist and gelled through the entire thickness
  • Rice, couscous, quinoa (and similar food textures)
    • Not particulate/grainy, sticky or glutinous

7 – Easy to Chew

dysphagia diet textures

Description/Characteristics:

  • Normal, everyday foods of soft/tender textures that are developmentally and age appropriate
  • Any method may be used to eat these foods
  • Sample size is not restricted at Level 7, therefore, foods may be of a range of sizes
    • Smaller or greater than 8mm pieces (Pediatrics)
    • Smaller or greater than 15 mm = 1.5 cm pieces (Adults)
  • Does not include: hard, tough, chewy, fibrous, stringy, crunchy, or crumbly bits, pips, seeds, fibrous parts of fruit, husks or bones.
  • May include ‘dual consistency’ or ‘mixed consistency’ foods and liquids if also safe for Level 0, and at clinician discretion. If unsafe for Level 0 Thin, liquid portion can be thickened to clinician’s recommended thickness level.

Examples:

  • Meat
    • Cooked until tender.
    • If texture cannot be served soft and tender, serve minced and moist
  • Fish
    • Soft enough cooked fish to break into small pieces with the side fork, spoon or chopsticks
  • Casserole/Stew/Curry
    • Can contain meat, fish, vegetables, or combinations of these if final cooked pieces are soft and tender
    • Serve in mildly, moderately of extremely thick sauce AND drain excess liquid
    • No hard lumps
  • Fruit
    • Soft enough to be cut broken apart into smaller pieces with the side of a fork or spoon. Do not use the fibrous parts of fruit (e.g. the white part of an orange).
  • Vegetables
    • Steam or boil vegetables until tender. Stir fried vegetables may be too firm for this level. Check softness with fork/spoon pressure test
  • Cereal
    • Served with texture softened
    • Drain excess milk or liquid and/or thicken to thickness level recommended by clinician
  • Bread
    • Bread, sandwiches and toast that can be cut or broken apart into smaller pieces with the side of a fork or spoon can be provided at clinician discretion
  • Rice, couscous, quinoa (and similar food textures)
    • No special instructions

7 – Regular

Description/Characteristics:

  • Normal, everyday foods of various textures that are developmentally and age appropriate
  • Any method may be used to eat these foods
  • Foods may be hard and crunchy or naturally soft
  • Sample size is not restricted at Level 7, therefore, foods may be of a range of sizes
    • Smaller or greater than 15 mm = 1.5 cm pieces (Adults)
  • Includes hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy, or crumbly bits
  • Includes food that contains pips, seeds, pith inside skin, husks or bones
  • Includes ‘dual consistency’ or ‘mixed consistency’ foods and liquids

Examples:

All foods

Transitional Foods

dysphagia diet textures

Description/Characteristics:

Food that starts as one texture (e.g. firm solid) and changes into another texture specifically when moisture (e.g. water or saliva) is applied, or when a change in temperature occurs (e.g. heating).

IDDSI Transitional Foods may include and are not limited to:

  • Ice chips
  • Ice cream/Sherbet if assessed as suitable by a Dysphagia specialist
  • Japanese Dysphagia Training Jelly sliced 1 mm x 15 mm
  • Wafers (also includes Religious Communion wafer)
  • Waffle cones used to hold ice cream
  • Some biscuits/ cookies/ crackers
  • Some potato crisps – only ones made or formed from mashed potato (e.g. Pringles)
  • Shortbread
  • Prawn crisps

Advacing Diets: Identify the Patient’s Current Diet Level

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6 Printable Speech Therapy Evaluations

First, complete a swallowing assessment to determine your patient’s current, safe diet level. See our Complete Guide to Adult Speech Therapy Assessments for step-by-step instructions.

You may also need to recommend an instrumental swallowing evaluation, such as a modified barium swallowing study (MBSS; also known as a videofluoroscopic swallowing study) or a flexible endoscopic evaluation of swallowing (FEES).

Factors to Consider When Advancing Diets

Physical Functioning

Consider your patient’s physical and cognitive functioning when deciding when and how to advance diet textures:

  • Can they sit upright?
  • Can they feed themself?
  • Can they produce a strong cough?
  • Can they move their neck?
  • Can they chew?
  • Can they swallow?
  • What’s their fatigue level?
  • Can they feed themself?
  • What’s their current respiratory functioning (acute or recurrent aspiration penumonia, COPD, heart failure, etc.)?
  • What’s their pain level?
  • What’s their cancer status (post lingual resection, currently receiving radiation, etc)?
  • Any other relevant physical factors

Cognitive Functioning

  • Can they stay awake?
  • Can they attend to food?
  • Can they control impulses?
  • Can they recall swallowing strategies?
  • What is the type and severity of their neurological impairments (brainstem stroke, ALS, etc.)?
  • Any other relevant cognitive factors?

Your Patient’s First Modified Diet

In many cases, your patient’s first diet will be the food textures and liquid consistencies that they safely consume 80% or more of opportunities.

When is NPO Appropriate?

An NPO diet may be appropriate for patients who have no swallowing reflex or no UES opening.

It’s not appropriate for all patients who aspirate. Consider that even on an NPO diet, a patient can aspirate on saliva or reflux content.

Learn more about alternative nutrition and hydration.

Food & Liquid Trials

If your patient is alert and oriented, begin by trialing small amounts of the previous level of function (PLOF) diet.

If the patient is having a hard time staying awake, halt trials until they are alert and oriented. Ask a caregiver, nurse, or their other therapists what times the patient is typically more alert.

Start Small and Gradually Trial Larger Boluses

  • Teaspoon
  • Tablespoon
  • Regulated straw sips
  • Cup sips
  • Consecutive cup sips

Observe the Following

  • Labial closure while liquid is in mouth
  • Mastication adequacy (inadequate, within normal limits, effortful, prolonged)
  • Lingual function
  • Oral transit time
  • Residue
  • Swallow initiation
  • Laryngeal elevation
  • Signs and symptons of dysphagia:
    • Possible bolus holding
    • Anterior spillage
    • Multiple/piecemeal swallows
    • Choking
    • Coughing and/or throat clearing
    • Respiration changes
    • Gurgly or wet vocal quality
    • Fatigue

Trial Thinner or Thicker Consistencies

Attempt thinner consistencies if the patient demonstrates no or minimal signs of dysphagia.

Attempt thicker consistencies if the patient demonstrates signs or symptoms of dysphagia—including aspiration—with the food or liquid being trialed. See the Liquid and Solid Trials article for a free PDF.

Introduce safe swallowing strategies as needed (more below).

Introduce Safe Swallowing Strategies

  1. Introduce safe swallowing strategies if the patient demonstrates signs or symptoms of dysphagia during the food and liquid trials. See our Swallowing Strategies & Exercises article for more details.

  2. Next, complete a few more food and liquid trials while using the swallowing strategies. Observe whether the signs or symptoms of dysphagia improved.

  3. If the strategies consistently improve the signs or symptoms of dysphagia AND the patient safely consumes the food and liquid in 80-100% of trials: Your dysphagia goal will be to continue trials with a speech therapist using these strategies.

    • The speech therapist may upgrade the patient to these textures once they demonstrate safe swallowing AND consistent use of strategies across three sessions.

  4. If the patient continues to demonstrate the same signs or symptoms of dysphagia, then trial thicker liquids and/or softer foods. Add in safe swallowing strategies with these textures.

  5. Modify the diet until the patient safely consumes the food and liquids in 80-100% of trials while using the strategies.

Add Swallowing Exercises

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Introduce swallowing exercises in order to improve underlying weakness or discoordination. Exercises should be intensive with a high number of repetitions.

See our Swallowing Exercises and Strategies article for ideas.

Follow-Up Instrumental Evaluations

Recommend repeat MBSS and FEES as appropriate. Patients with severe pharyngeal dysphagia may need as many as three or more instrumental evaluations throughout their time in speech therapy.

Getting Off An NPO Diet

Many patients who are NPO and/or are tube-fed can recover enough to resume a fully PO diet. Communicate regularly with the patient’s physician, dietician, gastroenterologist, and/or respiratory therapist to ensure that the patient is safe and receives adequate nutrition for a PO diet.

  • Get physician clearance that the patient is medically stable enough to begin PO trials.
  • Complete an instrumental evaluation and swallowing mechanism evaluation to determine appropriate PO textures, swallowing strategies, and exercises to trial.
  • Complete food and liquid trials as described above.
  • Monitor vitals, fatigue level, and lung sounds each session.

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