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FAQ - Foods (Levels 4-7 and Transitional)

Q: My facility only uses two levels of texture-modified foods. Do we have to use all of the IDDSI food levels?
A: No, although the IDDSI framework includes five different levels of increasing food texture modification, there is no expectation that every facility will use all five levels. For example, some aged care facilities may only use Level 7- Regular, Level 6- Soft & Bite-sized, and Level 4- Puree/Extremely Thick. By labeling the foods in this way, when a patient/client moves from a facility with fewer food levels to a hospital with more food levels, it will be faster, safer and more accurate for health professionals and care staff to provide the appropriate food level.

Q: Does IDDSI have some lists of foods that meet the criteria for different levels?
A: Due the overwhelming number of foods globally and variation in preparation methods, it is not possible to outline lists of foods under each Level.

For example: A piece of fruit that is very ripe and passes the IDDSI Fork or Spoon pressure test and is cut into the appropriate IDDSI specified size for and adult or child meets the criteria for Level 6 soft and bite sized. Another piece of the same variety of fruit which is unripe, that does not pass the IDDSI fork/spoon pressure test, even when cut into the appropriate size, would NOT meet the criteria for Level 6 Soft & Bite sized. Consider the behaviour of a ripe banana vs. a green banana. The BEST way to check whether a food or liquid is the correct IDDSI level is to use all the recommended testing methods.

Q: What level does bread belong to in the IDDSI Framework?
A: Bread is a food found in most places around the world and is often a staple in many people’s diets. It is however a challenging food and as a general rule is considered a Level 7 regular food. It requires the ability to both bite and chew and the literature on choking has often identified bread as a cause of choking.

Finding a ways to still offer bread and sandwiches to those with dysphagia has been an ongoing dilemma. There are a number of possible ways to address this and IDDSI would also like to share one of our newest resources – a video on how to make a Level 5 Minced and Moist sandwich.

Q. How do I know I have the right texture for Level 5 minced and moist?
A: Level 5 Minced and Moist foods are intended to mimic a “chewed bolus” for individuals who have minimal chewing ability but still have the ability to move tongue to transport the food and apply pressure to the small soft particles.
The goal of this texture is to ensure the bolus can be swallowed safely if not chewed, but to also allow opportunity to use any minimal chewing and tongue manipulation skills that the individual has. For Level 5 Minced and Moist the 3 key considerations are:

Particle size: Research into food particles size of chewed boluses in healthy adults suggests averages of 2-4 mm depending on the type of food being chewed. However food particles in a chewed bolus are not necessarily all uniform in size and particles need to be considered in dimensions of width, depth and length. Level 5 Minced and Moist particle size for an adult has been outlined as a 4mm ‘lump size’ to account for the fact that a chewed bolus is unlikely to be neat in all dimensions. Items such as rice are considered suitable for a Level 5 Minced and Moist diet. By this inclusion it offers people with swallowing difficulties something that still looks like food they recognise, thereby enhancing compliance and intake. Most rice grains are at least 8-10mm in their long dimension, but meet the 4mm width dimension. Risoni and orzo pasta are also examples that are similar to rice and meet the Level 5 requirements of ‘minimal chewing needed’. The rationale to having it ‘not necessarily even in all dimensions’ is that it has clinical utility in encouraging some minimal chewing. This is beneficial from a clinical perspective to allow progression to Level 6. It is not intended that the particles need to be 4x4x15mm, but that they should be 4mm lump and ‘no more than 15mm’ in the length dimension. Hence rice is acceptable because its 4mmx2mmx10mm for example) – it’s a subtle but important difference. 4x4x4mm would also be an acceptable variant – because it is 4x4mm and ‘less than 15mm’ in the other dimension. 4 mm is the space between the tines of an ordinary dinner fork. In consideration of the smaller anatomy of young children, the recommendation is for no larger than 2mm x2mm x no larger than 8mm* is recommended for pediatric populations. (2 mm is half the distance of the space between the tines of a regular dinner fork.) *15 mm for adults and 8 mm for children are considered small enough to not obstruct the airway. Clinical assessment should always be used to determine if an individual has the ability to safely manage the particle size outlined in Level 5 minced and moist.
Food properties: Research regarding particle size of chewed boluses has also found that hard foods such as nuts and raw carrots will be chewed to smaller size particles(~2mm) before swallowing, than softer foods. Level 5 Minced and Moist, specifies that foods must be soft enough to squash easily with minimal pressure from a fork or spoon.
Moisture content: Research also suggests that in healthy adults, foods will be chewed into small particles and mixed with saliva until there is sufficient moisture to lubricate the bolus for swallowing. Level 5 Minced and Moist specifies that foods must have adequate moisture to hold the bolus together without being sticky or too runny. The spoon tilt test should be used to ensure food is not too dry or sticky and the fork drip test should be used to ensure the food is not too runny. It is essential that Level 5 Minced and Moist foods meet ALL the criteria to best “mimic” a chewed bolus just prior to swallowing.

All of these must be considered and tested using the recommended IDDSI tests to ensure the food meets all the criteria for Level 5 Minced and Moist.

Q: I’ve not heard of transitional foods before, what are they?
A: Transitional foods are used predominantly used by paediatric clinicians or clinicians who work with individuals with developmental disability. They refer to foods or substances that change quickly to become easier to chew or swallow with added moisture or a change in temperature. For example, items such as ice cream wafers or some potato crisps are firm in their original state but when moisture (e.g. water or saliva) is added, they break down quickly and easily with tongue to palate pressure. Chewing can be achieved with reduced effort and less likelihood of fatigue. Ice chips also fall into this category, starting as firm solids that are slippery and easy to swallow, but melting at body temperature. Similarly, ice cream or gelatin-based jellies may be firm when served at room temperature but melt quickly in the mouth to a liquid consistency. In Japan, locust-bean or carrageenan based Dysphagia Japanese Training Jelly is firm yet slippery to facilitate swallowing. Often these foods or substances are introduced as a first step in the process of advancing towards more challenging textures or are used for therapeutic rehabilitation of chewing or swallowing due to their unique textural qualities (Gisel 1991; Dovey et al., 2013).

References:

Dovey TM, Aldridge VK, Martin CL. Measuring oral sensitivity in clinical practice : A quick and reliable behavioural method. Dysphagia. 2013; 28:501-510.
Gisel EG. Effect of food texture on the development of chewing of children between six months and two years of age. Dev Med Child Neurol. 1991;33:69–79.

Q: Jelly is typically not included on dysphagia diets, why is Japanese Dysphagia Training Jelly included (Transitional Foods)?
A: Jelly made with gelatin is typically not included in dysphagia diets as it often breaks apart in the mouth due to the increase in temperature from cold to warmer body temperature making it more challenging to swallow. Jelly, however, can be made from a number of different substances and these substances may behave quite differently to each other in the mouth. For example, jelly made with konjac (also known as glucomanan, conjac, Konnyaku, taro powder or yam powder) has been identified as a particular choking risk based on its association with choking deaths. This has resulted in the ban of jelly cups containing konjac in a number of countries around the world (Japanese Food Safety Commission, 2010). However, in Japan jelly made with carrageenan and locust bean gum or locust bean gum and Xanthan holds together in the oral phase, is resistant to tongue palate pressure and does not fracture and release water. It also provides a slippery texture that has been shown to facilitate the rehabilitation of swallowing function. In addition to these textural properties, the Japanese Dysphagia Training jelly is specifically cut to a size that facilitates swallowing whilst avoiding choking risk (1 x15 mm).

Q: My facility serves sandwiches with moist, minced fillings. Can this be included in the Level 5 - Minced & Moist diet?
A: As a general rule, bread products are considered a regular food texture (Level 7) and are not permitted at levels 6 (Soft & Bite-Sized) or 5 (Minced & Moist). This decision is based on a review of the choking literature, in which bread is frequently identified as a cause of choking (Irwin et al., 1977; Ekberg & Feinberg, 1992; South Australia Coronial Inquest, 1997; Wick et al., 2006; Berzlanovich et al., 1999, 2005; Food Safety Commission of Japan, 2010; Licea, 2016). If a piece of bread or sandwich is pre-cut to fall below the maximum size guideline of Level 6 (1.5 cm for adults), then a clinician might decide to allow it for some patients on a case-by-case basis. Bread cannot, however, be easily mashed or broken down into particles of 4mm or smaller, due to its fibrous nature and it is therefore not suitable for inclusion at Level 5 (Minced & Moist). In some countries, modified bread products may be available under the names “pre-gelled” or “soaked” bread. The IDDSI food texture testing guidelines should be used to confirm whether or not these products fall within levels 5 or 6 on the IDDSI framework.

References:

Berzlanovich AM, Muhm M, Sim E. and Bauer G. ‘Foreign body asphyxiation – an autopsy study’. American Journal of Medicine. 1999; 107, 351-355.
Berzlanovich AM, Fazeny-Dorner B, Waldhoer T, and Fasching P. ‘Foreign body asphyxia: A preventable cause of death in the elderly’, American Journal of Preventive Medicine. 2005; 28, 65-69.
Ekberg, O. and Feinberg, M. (1992) ‘Clinical and demographic data in 75 patients with near-fatal choking episodes’, Dysphagia. 1992; 7: 205-208.
Food Safety Commission, Japan. Risk Assessment Report: Choking accidents caused by foods. 2010.
www.fsc.go.jp/english/topics/choking_accidents_caused_by_foods.pdf (accessed April 2014).
Irwin RS, Ashba, JK, Braman SS Lee HY and Corrao WM. ‘Food asphyxiation in hospitalized patients’. JAMA. 1977; 237: 2744-2745.
Kohyama K., Mioche L, Bourdiol P. Influence of age and dental status on chewing behaviour studied by EMG recordings during consumption of various food samples. Gerodontology. 2003; 20(1): 15-23.
Licea M, Klein M: Patient chokes to death after hospital feeds her sandwich she can't eat: New York Post: News Corp, 2016. http://nypost.com/2016/06/19/patient-chokes-to-death-after-hospital-feeds-her-sandwich-she-cant-eat/ Access date: June 21, 2016.
South Australia: Coronial Inquest, Dimitra Damianou. 1997. Access date: June 21, 2016.http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/284/DAMIANOU%20Dimitra.pdf
Wick R Gilbert JD and Byard RW. ‘Café coronary syndrome-fatal choking on food: An autopsy approach.’. Journal of Clinical Forensic Medicine. 2006; 13: 135-138.

Q: Bread provides an opportunity to offer patients variety. Why is it considered a choking risk?
A: As a general rule bread products are considered a regular food texture (Level 7). This decision is based on the choking literature where bread is often identified as a cause of choking (Irwin et al., 1977; Ekberg & Feinberg, 1992; South Australia Coronial Inquest, 1997; Wick et al., 2006; Berzlanovich et al., 1999, 2005; Food Safety Commission of Japan, 2010; Licea, 2016). Bread and sandwiches require the ability to both bite and chew. Although bread looks and feels soft, it cannot be easily mashed or broken down into particles of 4mm or smaller due to its fibrous nature. In fact the number of chewing strokes, chewing strength and stamina required to make bread swallow-safe are about the same as those required to chew and swallow peanuts safely (Hoebler et al., 2000; Koyama et al., 2003). Individuals who tire easily while chewing may find bread difficult to chew to a small enough size to be swallow-safe. Bread also requires softening with saliva for effective chewing (Hoebler et al., 2000). For individuals with dry mouth (e.g. medication side effects, post radiotherapy etc.) bread is often not adequately wetted for swallowing resulting in food sticking in the throat. Bread does not dissolve when wet but does become sticky. Sticky or adhesive foods are also considered a choking risk (Irwin et al., 1977; Ekberg & Feinberg, 1992; Wick et al., 2006; Berzlanovich et al., 1999, 2005). The ability to safely manage bread and sandwiches should be assessed on a case-by-case basis by a dysphagia specialist.

References:

Berzlanovich AM, Muhm M, Sim E. and Bauer G. ‘Foreign body asphyxiation – an autopsy study’. American Journal of Medicine. 1999; 107, 351-355.
Berzlanovich AM, Fazeny-Dorner B, Waldhoer T, and Fasching P. ‘Foreign body asphyxia: A preventable cause of death in the elderly’, American Journal of Preventive Medicine. 2005; 28, 65-69.
Ekberg, O. and Feinberg, M. (1992) ‘Clinical and demographic data in 75 patients with near-fatal choking episodes’, Dysphagia. 1992; 7: 205-208.
Food Safety Commission, Japan. Risk Assessment Report: Choking accidents caused by foods. 2010. www.fsc.go.jp/english/topics/choking_accidents_caused_by_foods.pdf (accessed April 2014).
Hoebler C, Devaux M-F, Karinthi A, Belleville C, Barry J-L. Particle size of solid food after human mastication and in vitro simultation of oral breakdown. International Journal of Food Sciences and Nutrition. 2000; 51: 353-366.
Irwin RS, Ashba, JK, Braman SS Lee HY and Corrao WM. ‘Food asphyxiation in hospitalized patients’. JAMA. 1977; 237: 2744-2745.
Kohyama K., Mioche L, Bourdiol P. Influence of age and dental status on chewing behaviour studied by EMG recordings during consumption of various food samples. Gerodontology. 2003; 20(1): 15-23.
Licea M, Klein M: Patient chokes to death after hospital feeds her sandwich she can't eat: New York Post: News Corp, 2016. http://nypost.com/2016/06/19/patient-chokes-to-death-after-hospital-feeds-her-sandwich-she-cant-eat/ Access date: June 21, 2016.
South Australia: Coronial Inquest, Dimitra Damianou. 1997 http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners%20Findings/Attachments/284/DAMIANOU%20Dimitra.pdf Access date: June 21, 2016.
Wick R Gilbert JD and Byard RW. ‘Café coronary syndrome-fatal choking on food: An autopsy approach.’. Journal of Clinical Forensic Medicine. 2006; 13: 135-138.

Q: Why are ‘mixed consistency’ or ‘dual consistency’ or ‘two phase’ foods not recommended for people with dysphagia?
A: By definition, mixed or dual consistency foods include both solids and liquids (e.g. vegetables in a soup broth). As a general rule, ‘mixed’ or ‘dual consistency’ foods are more challenging to swallow, because a person must have adequate abilities to handle both the solid and the liquid component of these items, which requires more advanced swallowing coordination abilities. The risks associated with swallowing a mixed consistency item are as follows:

The liquid component of the item may separate and spill into the pharynx during oral preparation of the bolus (Saitoh et al., 2007). This may represent an increased aspiration risk in people with dysphagia.
Solid particles may be washed into the pharynx with the liquid component, before they have been adequately chewed. If these particles enter the airway, there is an increased risk of choking and airway obstruction.

In order to properly describe the texture or a mixed or dual consistency food, it is necessary to characterise both the liquid and the solid components of the food. The IDDSI testing methods can be used to do this by separating the components. For example, a soup containing soft, 1.2 cm sized cubes of carrot floating in a broth would be classified as 6-0 capturing the Level 6 – soft and bite-sized (food) and the Level 0 – thin (liquid).

Dual consistency foods in which the liquid component is thin (Level 0) and easily separates from the solid component are not appropriate for people with dysphagia. If both the solid and liquid components of a dual consistency item fall withinthe range of diet textures that have been recommended for a patient, the patient may be able to handle that item. For example, if a Level 4 pureed food item is served with a level 3 sauce, such as a creamy mashed potato with moderately thick gravy, then a patient whose diet texture prescription spans a range containing both levels 3 and 4 on the framework may be able to handle both components of this item. Clinical evaluation of a patient’s ability to handle specific mixed or dual consistency items should be performed before recommending that these items be included on a diet.

References:

Saitoh E, Shibata S, Matsuo K, Baba M, Fujii W, Palmer JB. Chewing and food consistency: Effects on bolus transport and swallow initiation. Dysphagia. 2007;22: 100–7.

Q: Should patients with missing teeth or dentures be placed on IDDSI diets or regular diets?
A: Individuals with missing teeth or dentures may benefit from modified food textures even if they do not have dysphagia. Missing teeth, ill-fitting dentures and dental disease are correlated with autopsy results of sudden choking deaths (Berzlanovich et al., 2005; Wick et al., 2006). Dentures have been associated with poor chewing strength and poorly chewed boluses. People with removable dentures achieve only 25% of the chewing effectiveness of individuals with their own teeth and produce a coarser chewed bolus with larger particles (Pereira et al., 2006; Okamoto et al., 2012). Research suggests that older adults with fewer than 13 teeth have an increased risk of coughing and choking (Okamoto et al., 2012). Kayser (1981) and Kayer et al. (1987) go further suggesting that 12 front teeth and 8 pre-molar teeth are required for adequate chewing function. If it has been determined that the person does not need pre-cut bite-sizes, then there may be softer foods within the Level 7 options that are well suited for these people.

References:

Berzlanovich AM, Fazeny-Dorner B, Waldhoer T, and Fasching P. Foreign body asphyxia: A preventable cause of death in the elderly, American Journal of Preventive Medicine. 2005; 28, 65-69.
Kayser, AF. Shorted dental arches and oral function. J Oral Rehab. 1981; 8: 457-462.
Kayser AF, Witter DJ and Spanauf AJ. Overtreatment with removable partial dentures in shortened dental arches. Aus Dent J. 1987; 32: 178-82.
Okamoto N, Tomioka K, Saeki K, Iwamoto J, Morikawa M, Harano A, and Kurumatani N. Relationship between swallowing problems and tooth loss in community-dwelling independent elderly adults: the Fujiwara-Kyo study. J Am Geriatr Soc. 2012; 60: 849–53.
Pereira LJ, Gaviao MBD and Van der Bilt A. Influence of oral characteristics and food products on masticatory performance. Acta Odontologica Scandinavica, 2006; 64: 193-201.
Wick R Gilbert JD and Byard RW. Café coronary syndrome-fatal choking on food: An autopsy approach. Journal of Clinical Forensic Medicine. 2006; 13: 135-138.

Q: Although they are not foods, people are also asked to swallow pills, capsules and tablets. What diet levels would include the expectation that a person is able swallow whole tablets or capsules and for which diet levels would tablets and capsules pose a choking risk?
A: The ability to swallow pills or tablets and capsules varies from healthy person to healthy person and is also a concern for choking/aspiration risk for people with swallowing difficulties (Sundar et al., 2001; Carnaby-Mann & Crary 2005; Lau et al., 2015). From a food texture perspective, individuals who are able to safely manage Level 7 - Regular food and Level 6 - Soft & Bite-sized foods may be able to manage solid dose medications like tablets and capsules. Some individuals on Level 5 – Minced & Moist may also be able to manage oral medications. However, pills, tablets and capsules would be considered a choking risk for people who require Level 4 - Pureed/Extremely Thick. Ability to swallow whole pills, tablets and capsules can be assessed on a case-by-case basis by a dysphagia specialist. In the event that the person is not able to swallow whole pills, tablets or capsules consult the person’s Doctor for advice on alternative formulations. Cutting or crushing of medication is NOT recommended, and may have critical adverse effects (Wright , 2002). Always seek advice from a Doctor or Pharmacist before altering medication. Resources are also available for medication management for people with swallowing difficulties (White & Bradnam, 2007; Society of Hospital Pharmacists of Australia, 2015).

References:

Carnaby-Mann G & Crary M. Pill swallowing by adults with dysphagia. Archives of Otolaryngology Head & Neck surgery. 2005; 131: 970-975.
Lau ETL, Steadman KJ, Mak M, Cichero JAY, Nissen LM. Prevalence of swallowing difficulties and medication modification in consumers at community pharmacies. Journal of Pharmacy Practice and Research. 2015; 45(1): 18-23.
Society of Hospital Pharmacists of Australia. Australian Don’t Rush to Crush Handbook Second Edition. 2015. Editorial committee. Collingwood, Vic, AU: SHPA.
Sundar KM, Elliott CG & Thomsen GE. Tetracycline aspiration. Respiration. 2001; 68: 416-419.
White R and Bradnam V. Handbook of Drug Administration via Enteral Feeding Tubes. 2007. Cambridge University Press, Cambridge.
Wright D. Tablet crushing is a widespread practice but it is not safe and may not be legal. The Pharmaceutical Journal. 2002; 269: 132.

Q: For foods like soup that need to meet Level 3- Liquidised food texture requirements do I just blend with water to meet this consistency?
A: No. While the IDDSI Framework addresses texture, we understand that individuals with swallowing disorders are at high risk of protein-energy malnutrition and that texture modified meals may make it difficult to meet nutritional needs (Finestone & Green, 2003; Wright et al., 2005; Taylor & Barr, 2006; Charlton et al., 2010). Blending food with water dilutes the nutrient and energy content of the blended food. Nutrient rich alternatives such as milk, butter, cream, cheese, gravy, creamy soup or sour cream could be used to bring the food to a liquidised thickness. However, please consult a Dietitian or Nutrition Specialist to ensure that texture modified foods retain nutrients, and their ability to meet individuals’ energy needs.

References:

Charlton KE, Nichols C, Bowden S, Lambert K, Barone L, Mason M & Milosavljevic M. Older rehabilitation patients are at high risk of malnutrition: Evidence from a large Australian database. Journal of Nutrition, Health & Aging, 2010; 14(8): 623-628.
Finestone, HM & Greene-Finestone LS. Rehabilitation Medicine: 2. Diagnosis of Dysphagia and its nutritional management for stroke patients. Canadian Medical Association Journal. 2003; 169(10): 1041-4.
Taylor KA & Barr SI. Provision of small frequent meals does not energy intake of elderly residents with Dysphagia who live in an extended-care facility. Journal of the American Dietetic Association. 2006; 106: 1115-1118
Wright L, Cotter D, Hickson M & Frost G. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition and Dietetics. 2005; 18: 213-219

Q: Do all foods at Level 6 – Soft & Bite-sized (adult guidelines) need to meet the 1.5 x 1.5cm particle size requirements?
A: Yes, all foods (sandwiches included) need to meet the particle size requirements for Level 6 – Soft & Bite-sized. The relationship between particle size and risk of asphyxiation has been identified in the literature (Samuels & Chadwick, 2006; Kennedy et al., 2014). It cannot be assumed that nursing staff or carers will be able to chop food to the required size for swallow safety. In order to avoid asphyxiation, particles should be small enough to pass through rather than block the trachea. The average tracheal size for adult males is 22mm and for adult females is 17 mm (Brodsky et al., 1996). Particle sizes of 15 mm (i.e. 1.5cm) size are therefore more likely to pass through the trachea, than block it. IDDSI appreciates that provision of food like sandwiches is very difficult at this particle size and asks clinicians and carers to consider providing ‘soaked’ breads as an alternative. For example, finely chop bread and add equal amounts of water and butter (fat) to create a softened bread texture, re-shape and serve. The combination of water and fat content reduces stickiness and improves bolus cohesion.
If the person is able to chop their food into small pieces AND they do not need supervision AND they are not at risk of choking, consider advancing to a Level 7 – Regular Diet, beginning with softer items from that level.

References:

Brodsky JB, Macario A, Mark JBD. Tracheal diameter predicts double-lumen tube size: A method for selecting left double-lumen tubes. Anesthesia Analgesia. 1996; 82: 861-4.
Samuels R & Chadwick DD. Predictors of asphyxiation risk in adults with intellectual disability and dysphagia. Journal of Intellectual Disability Research. 2006; 50(5): 362-370.
Kennedy B, Ibrahim JE, Bugeja L & Ranson D. Causes of death determined in medicolegal investigations in residents of nursing homes: A systematic review. Journal of the American Geriatric Society. 2014; 62: 1513-1526.

Q: Can we offer bread, toast, biscuits or baked goods to someone on Level 6 Soft and Bite Sized if we add lots of moisture?
A: Use the testing methods for Level 6 (Particle size, Fork pressure test) to determine if the food passes the test.