International Dysphagia Diet Standardisation Initiative (IDDSI) Food Texture Descriptions – Information for staff

7a – Regular: Easy to chew

• Foods should be soft and tender
• Food can be cut or separated easily with the side of a fork or spoon.
• Foods do not need to be cut or presented in any specific particle size.

6 – Soft and Bite sized

• Soft enough to be mashed with a fork
• A knife is not required to cut the food
• Food is served in no larger than 1.5cm x 1.5cm pieces
• Soft, tender and moist throughout

5 – Minced and Moist

• Can be eaten with a fork or spoon
• Can be scooped and shaped on a plate
• Soft and moist with no separate thin liquid
• Small lumps (less than 4mm) visible within food
• Lumps are soft and easy to squash

4 – Pureed

• Usually eaten with a spoon
• Can be piped, layered or molded
• Cannot be poured
• Smooth with no lumps
• Not sticky

3 – Liquidised

• Smooth texture with no lumps or bits
• Can be poured
• Too thin to be piped or layered
• Cannot be eaten with a fork
• Can be drunk from a cup

What is Dysphagia?

Dysphagia is a disorder of swallowing. People with dysphagia may have difficulty holding food or fluid in their mouth, chewing, moving food to the back of the mouth, swallowing at the right time, protecting the airway when swallowing, clearing food from their throat or getting food or fluid to pass down in to the food pipe.

Why does it happen?

Dysphagia can happen if there is damage to the muscles used for swallowing, or if a person becomes less aware of what is in their mouth. Dysphagia can be caused by stroke, head injury or other neurological conditions – including Parkinson’s Disease, Multiple Sclerosis and Motor Neurone Disease. It can be caused by some respiratory conditions.

Why is dysphagia a problem?

People with dysphagia are at higher risk of food or fluid going down the wrong way (i.e. going into the lungs instead of the stomach). This is known as aspiration. Aspiration can cause chest infections and pneumonia. Swallowing difficulties can lead to malnutrition and dehydration if they are not managed properly.

Will it improve?

Improvement and recovery will vary from person to person and can be difficult to predict. Your speech and language therapist will be able to discuss this with you in more detail.

Symptoms of dysphagia

• Coughing or choking on food or drink
• Wet / gurgly voice after swallowing
• Shortness of breath after swallowing
• A feeling of food sticking in the throat
• Difficulty chewing food
• Food or drink residue left in the mouth
• Loss of appetite or reluctance to eat certain things
• Serious weight loss
• Repeated chest infections

What can help with swallowing?

• Sitting as upright as possible when eating and drinking (not leaning forward, back or to one side) – ideally in a chair.
• Avoid tipping your head back to swallow.
• Take small mouthfuls of food or drink.
• Eat and drink slowly and leave plenty of time between mouthfuls.
• Chew food thoroughly and carefully.
• Don’t eat or drink if you’re feeling too tired or unwell – wait until later.
• Try not to mix mouthfuls of food and drink together.
• Don’t talk whilst eating or drinking.
• Avoid distractions e.g. TV / radio if this stops you following the advice above.
• Don’t use spouts or straws, unless they’ve been specifically recommended.
• If you have dentures, make sure they fit properly. If not, try a fixative- and wear them, if comfortable, to help with chewing.
• Try to stay sitting upright for at least 15 minutes after eating or drinking.

Who can help?

Speech and language therapists are trained to assess swallowing. Your speech and language therapist can recommend food and drinks that are safe to swallow. It may be beneficial to have a modified diet or thickened fluids. If your swallowing is unsafe, it may be necessary to remain nil by mouth (NBM). Your doctor may recommend that you have a temporary nasogastric feeding tube (NG tube). Other members of the team can also help:

• Dieticians may help to ensure nutrition and hydration is adequate.
• Physiotherapists may help with sitting position.
• Occupational therapists may suggest ways to help you eat and drink.
• Nurses may assist with eating and drinking and with keeping the mouth and teeth clean and healthy, particularly if you are NBM.
• Pharmacists may suggest medicines are given in a different form e.g. syrups rather than tablets.

International Dysphagia Diet Standardisation Initiative (IDDSI) Thickened Fluid Guidelines – Information for Staff

0 – Thin

• Flows like water
• Fast flow
• Can drink through any type of spout, cup or straw

1 – Slightly thick

• Thicker than water
• Flows through a straw, syringe or spout
• Similar to naturally thick fluids such as milkshake or mango juice

2 – Mildly thick

• Flows quickly off a spoon
• Sippable
• Can be drunk through a straw with some effort
• Can be drunk from a cup
• Runs easily through a fork
• Leaves a thin coat on the back of a spoon
• Texture resembles syrup from tinned fruit or evaporated milk

3 – Moderately thick

• Can be drunk from a cup
• Cannot be drunk through a straw
• Drips through a fork in dollops
• Leaves a thick coat on the back of a spoon
• Texture resembles standard yoghurt

4 – Extremely thick

• Taken with a spoon
• Not possible to sip from a cup
• Cannot be drunk through a straw
• Sits on a fork
• Holds together well
• Texture resembles mousse or jam
• Falls off a spoon in a single spoonful when tilted
• Would hold its shape on a plate

The way we describe food texture is changing

We are moving from a national set of guidelines to an international set called the International Dysphagia Diet Standardisation Initiative (IDDSI).

The new descriptors are similar to the current descriptors and generally transfer across easily.

*IDDSI Level 6 Soft and Bite-Sized is not the same as Texture E Fork mashable.

The maximum piece size in level 6 is 1.5cm x 1.5cm to reduce the risk of choking on food, so this is more restrictive than the old Fork Mashable (texture E) guidelines (which didn’t specify piece size).

You don’t need to change the way you prepare your food

Unless your dysphagia is being assessed or your recommendations have changed then keep preparing your food in the same way.

Watch out for pre-modified meals

The companies that provide modified texture meals such as Oakhouse, Wiltshire Farm Foods and Apetito are still working on getting the textures right and dual labelling with old and new descriptors. Dual labelling for different levels may appear at different times. They should all be using the new descriptors by April 2019

What do you need to do?

• Share this information with anyone who supports you or any staff you work with.
• Continue modifying your food texture as you currently do.
• Watch out for more information on Level 6 if this is relevant for you.
• You don’t need a reassessment by a speech and language therapist unless you feel your swallow has changed.

The way we describe thickened drinks is changing

We are moving from a national set of guidelines to an international set called the International Dysphagia Diet Standardisation Initiative (IDDSI).

The new descriptors are very similar to the current descriptors and transfer across easily.

The previous descriptions had “stages” the new descriptions have “levels”. The numbers are not the same but can be converted using the table below.

Over the next year the labelling on tins and sachets of drink thickeners will change. This is because they are starting to use the new descriptions.
You may have tins or sachets with the old labelling or the new labelling during the changeover period.

What do you need to do?

• Share this information with anyone who supports you or any staff you work with.
• Continue using your thickener as you currently do.
• Convert your current Stage to a new Level using the table on page 2.
• You don’t need a reassessment by a speech and language therapist unless you feel your swallow has changed.