There are so many different dysphagia diets…
I’m confused when I try to figure out what the differences are! Is there something I need to know to be sure that I’m keeping myself or my loved one safe?
From the desk of Carol G Winchester, MS SLP CCC
Depending on where you are in the world, what setting you are coming into or from (for example from the hospital to a rehab hospital or from a skilled nursing facility to home), and the terminology that the facility has adopted, you might find dysphagia recommendations for diets confusing. You may hear about the National Dysphagia Diet that was introduced in 2002, the IDDSI Framework which came some years later, or any combination of the word ‘dysphagia’ and ‘diet’ or ‘texture’ adopted by an individual facility. The good news is that regardless of what they call it, the diet textures are consistent. I sometimes think that these texture descriptions were complicated, unnecessarily, while they were trying to make it easier to understand for everyone from the physician to nursing to therapist to patient. It seems that was not as successful as anyone would have appreciated.
There is a plethora of research in peer reviewed journals that talks about the fact that the most successful diet modification is one that is specialized to the patient’s health condition and needs, and the one that includes foods and liquids that the patient can tolerate and even enjoy. They are all built on a pyramid of food textures that ranges from ‘normal or regular’, meaning anything from fried chicken to steak to a peanut butter sandwich, down to a thin puree that can be eaten with a spoon or sipped from a cup. The liquids range from thin (meaning as thin as water) to pudding thick (meaning needing to be spoon fed in the consistency of a pudding that you would eat for dessert). What you need is likely somewhere in between as you suffer from and recover from dysphagia complications.
Food Texture Pyramid
Within the past several years the diet that was attempted to be adopted across the world is the IDDSI or International Dysphagia Diet Standardization Initiative. Some patients find the IDDSI diet levels confusing, although they really are not when you look at the examples. Think about it this way. As an international explanation to try and standardize the language of dysphagia diets, this method puts a number to the diet that includes foods beginning at the highest level 7, and liquids beginning at the 4th level. The foods and puree and liquefied foods overlap at levels 4 and 3. Level 7 is normal or regular (everything from steak to fried chicken, tortilla chips etc), Level 6 is soft and bite sized (baked salmon or chicken, vegetables cooked softly and anything that you can smash with your fork), Level 5 is minced and moist (meaning cut it up in small pieces and put a gravy or sauce on it to make it easier to chew and swallow), Level 4 is a pureed diet (consistency of smooth applesauce or pudding whether it is the food or the thickened liquid), Level 3 is liquefied (can drink it or spoon feed as a milkshake consistency), Level 2 is mildly thick (like a prune juice or tomato juice), Level 1 is slightly thick as in an Ensure-type nutritional drink, an almond milk, a soda pop (because of the bubbles), or even a natural nectar juice. Level 0 is as thin as water.
The key to understanding the diet that is appropriate for yourself or a loved one suffering from dysphagia is to work with a Speech Pathologist who specializes in dysphagia. This therapist will individualize your diet with you. The labels are not important, but the list of foods you can prepare is. Tell him or her what it is that you like and ask how you can prepare it in a consistency that is safe for you at this time. Same thing for the liquids. Make sure to operationalize your diet into the lifestyle you are leading. Find out how to enjoy holiday dinners, go out to restaurants, and travel or cruise safely.
The other key to your appropriate diet is to understand that what texture you may need for your breakfast may be different than what is safest for dinner when you are tired or your muscles are fatigued from talking and being active during the day. In addition, different consistencies of food may need different levels of liquids to assist them in reaching the stomach safely. For example, if you are eating lunch you may be enjoying a texture that sticks together such as a casserole of soft veggies and rice that has a gravy binding it all together. You may need a colder, thicker liquid to help clear out the mouth or pharynx after every few bites to prepare for the next bites because this texture can stick to the teeth or tongue, the roof of the mouth, or even the walls of the throat. If you are eating a softer bite sized diet that includes foods that break apart such as rice or crunchy textures such as cereal or nuts, you may need a mildly thick liquid to help gather the residue of the food in your mouth and on your tongue so that you can swallow and clear before the next bite. A thinner liquid might just run over the top of the residue and not be efficient in clearing out the left-overs and may result in aspiration into your airway while pulling in bits of the food you were trying to swallow. Your Speech Pathologist may recommend a swallowing instrumentation to try out these textures and fine tune your individualization exactly. Don’t forget to talk about your teeth, your ability to chew, your stomach issues (if any) and whether or not you have to prepare these altered consistencies. You can buy food in textures that will work for your needs at the grocery store, pre-made, and needing minimal prep and heating, if it’s difficult for you to cook all your own food. There just is no reason to make it harder than it needs to be because there are many combinations that may work for you!
Bottom line, don’t be confused. No matter the words or the titles, it’s all about working with your Speech Pathologist to figure out what suits your needs and get a good description and actual examples rather than just labels. Remember, it’s all about you!