A speech and language therapist assesses swallow function and provides advice and therapy. The IDDSI Framework can form part of this.

IDDSI stands for International Dysphagia Diet Standardisation Initiative. As clear from its name, it’s global and it provides a shared terminology for everyone to use when supporting people with dysphagia. It is not a hard set of rules but a shared language. IDDSI does not state everything that needs to be done to support an individual with dysphagia; this is found in the speech and language therapist’s swallow recommendations and nutrition care plan.

The IDDSI Framework Levels

The framework is made up of food and drink consistencies. Advice will have been provided by the speech and language therapist on exactly which levels and if any other food or drinks outside of those levels might also be safe or provide comfort and quality of life.

The IDDSI Levels are as follows:

  • Level 3 Liquidised diet

  • Level 4 Puréed diet

  • Level 5 Minced and moist diet

  • Level 6 Soft and bite-sized diet

  • Level 7 Regular easy to chew diet

[IDDSI Framework Illustration here]

The word ‘diet’ simply indicates that it relates to food. It does not mean that the person with dysphagia is ‘on a diet’ to lose weight. In fact, having dysphagia may mean there is a risk of malnutrition and a dietitian will advise on food fortification, supplementation or tube feeding.

Level 3 Liquidised diet

  • Can be eaten with a spoon or drunk from a cup

  • Cannot be eaten with a fork because it drips through the fork prongs

  • Has a smooth texture with no ‘bits’ (lumps, fibres, husk, bits of shell or skin, particles of gristle or bone)

How to test

Fork test:

  • the liquid drips slowly in dollops through the prongs of a fork

Level 4 Puréed diet

  • Usually eaten with a spoon

  • Cannot be drunk from a cup

  • Cannot be sucked through a straw

  • Does not require chewing

  • Can be piped, layered or moulded

  • 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 and not sticky

  • Liquid must not separate from solid

How to test

Fork pressure test:

  • Smooth with no lumps and minimal granulation

  • When a fork is pressed on the surface of the food, the tines/prongs of a fork can make a clear pattern on the surface, and/or the food retains the indentation from the fork

Spoon tilt test:

  • Cohesive enough to hold its shape on the spoon

  • A full spoonful must plop off the spoon if the spoon is titled or turned

sideways; a very gentle flick (using only fingers and wrist) may be necessary to dislodge the sample from the spoon, but the sample should slide off easily with very little food left on the spoon.

  • May spread out slightly or slump very slowly on a flat plate

The Made for You range provides plenty of choice of pre-prepared, safe, nutritious and appetising Level 4 purée meals.

Level 5 Minced and moist diet

  • Can be eaten with a fork or spoon

  • 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- equal to or less than 4mm width and no longer than 15mm in length

  • Lumps are easy to squash with tongue

How to test

Fork pressure test:

  • When pressed with a fork the particles should easily be separated between and come through the tines/prongs of a fork

  • Can be easily mashed with little pressure from a fork [pressure should not make the thumb nail blanch to white]

Spoon tilt test

  • Cohesive enough to hold its shape on the spoon

  • A full spoonful must slide/pour off/fall off the spoon if the spoon is tilted or turned sideways or shaken lightly; the sample should slide off easily with very little food left on the spoon; i.e. the sample should not be sticky

  • A scooped mound may spread or slump very slightly on a plate

The Made for You range includes many Level 5 Minced and moist meals to save you time and provide peace of mind that the food is safe to swallow, full of nutrition, and tastes great.

Level 6 Soft and bite-sized diet

  • Can be eaten with a fork or spoon

  • Can be mashed/broken down with pressure from fork or spoon

  • 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. No larger than 15 mm = 1.5 cm pieces

How to test

Fork pressure test:

  • Pressure from a fork held on its side can be used to ‘cut’ or break apart or flake this texture into smaller pieces

  • When a sample the size of a thumb nail (1.5x1.5 cm) is pressed with the tines of a fork to a pressure where the thumb nail blanches to white, the sample squashes, breaks apart, changes shape, and does not return to its original shape when the fork is removed.

Spoon tilt test:

  • Pressure from a spoon held on its side can be used to ‘cut’ or break this texture into smaller pieces.

  • When a sample the size of a thumb nail (1.5 cm x1.5 cm) is pressed with the base of a spoon, the sample squashes, breaks apart, changes shape, and does not return to its original shape when the spoon is removed.

The Made for You range has a great many Level 6 Soft and bite-sized meals to choose from, which can be easily cooked, ensures a safe swallow, provides plenty of nutrition and looks and tastes appealing.

Level 7 Regular easy to chew diet

  • Normal, everyday foods* of soft/tender texture

  • Any method may be used to eat these foods (e.g. fingers, fork, spoon etc.)

  • Food piece size is not restricted in Level 7, therefore foods may be a range of sizes. Food pieces can be smaller or bigger than 1.5cm x 1.5cm

  • Do not use foods that are: hard, tough, chewy, fibrous, have stringy textures, pips/seeds, bones or gristle

  • You should be able to ‘bite off’ pieces of soft and tender food and choose bite-sizes that are safe to chew and swallow

  • You should be able to chew pieces of soft and tender food, so they are safe to swallow without tiring easily

  • Your tongue should be able to move food for chewing and apply pressure until the food is soft and moist enough to be easily swallowed

  • You should be able to remove bone, gristle or other hard pieces that cannot be swallowed safely from your mouth without help or direction from others

*May include ‘mixed thin and thick texture’ food and liquids together – ask your clinician for direction on this.

Foods to avoid

In addition to advising on textures that are safe to take, the speech and language therapist may also provide recommendations on foods that are tricky or even unsafe. Look out for the ‘foods to avoid’ in their swallow recommendations.

These might be:

Food characteristic to avoid

Examples to avoid

Mixed thin and thick textures

Soup with pieces of food

Cereal with milk (not fully absorbed)

Hard or dry

Nuts, raw vegetables, dry cake, bread, dry cereal

Tough or fibrous

Steak, pineapple, celery

Chewy

Sweets, lollies, cheese chunks, marshmallows, chewing gum, dried fruits

Sticky foods including sticky mashed potato

Crispy

Crisp bacon, crackling, cornflakes

Crunchy

Raw carrot, raw apple, popcorn

Sharp or spiky

Corn chips

Crisps

Crumbly

Dry cake crumble

Dry biscuits

Pips or seeds

Apple seeds

Pumpkin seeds

White of an orange

Skins or outer shells

Peas, grapes, beans, chicken skin, salmon skin, sausage skin

Husks

Corn

Shredded wheat

Bran

Bone or gristle

Any meat or fish bones

Any meat with gristle

Round or long shaped

Sausage, grapes

Sticky or gummy

Nut butter

Overcooked porridge or oatmeal

Gelatine

Konjac containing jelly

Sticky rice cakes

Stringy

Beans, rhubarb

Floppy

Salad leaves, cucumber slices

Crust formed during cooking or heating

Cheese topping, crusted mashed potato

Juicy

Where juice or liquid separates from the food piece in the mouth such as watermelon

Large or hard lumps of food

Casserole pieces larger than 1.5cm x 1.5cm

Fruit, vegetable or meat, pasta or other food pieces larger than 1.5cm x 1.5cm

IDDSI Framework levels descriptions and tests: © The International Dysphagia Diet Standardisation Initiative 2019 @ https://iddsi.org/framework. Licensed under the CreativeCommons Attribution Sharealike 4.0 License https://creativecommons.org/licenses/by-sa/4.0/legalcode. Derivative works extending beyond language translation are NOT PERMITTED.