Diet Texture Modifications for Dysphagia
Diet texture modifications include changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods using standardized guidelines (e.g., International Dysphagia Diet Standardisation Initiative [IDDSI]). Speech-language pathologists (SLPs) consider the influence of diet texture modifications on swallowing physiology, including airway protection, during a comprehensive assessment of an individual’s swallowing status prior to recommending these changes as part of treatment.
There is no ASHA policy or guidance directing the use of texture-modified diets in dysphagia management. SLPs are encouraged to explore the current evidence and consider patients holistically when developing individualized plans of care that meet patients’ individual needs. The Adult Dysphagia portal page and organizations such as the Royal College of Speech and Language Therapists provide considerations for diet texture modifications.
Diet Texture Modification Guidelines
ASHA has not established diet levels or terminology, nor does ASHA have any guidelines about the types of foods that meet the criteria for a particular diet level. ASHA does not endorse any product, program, procedure, or specific diet-level system.
Dysphagia diets may follow one of the following:
- International Dysphagia Diet Standardisation Initiative (IDDSI): The IDDSI is an international collaboration of professionals who developed a standardized framework for labeling texture-modified foods and thickened liquids. ASHA supports the IDDSI framework, and encourages members who assess and treat individuals with dysphagia to consider using it. However, neither ASHA nor any payor in the United States (at this time) mandates facilities to adopt use of IDDSI. At this time, IDDSI is the only available standardized framework for labeling dysphagia diets.
- Facility-established protocols: Many facilities utilize their own dysphagia diet levels (e.g., diet levels at St. Luke's Health System). However, the challenge with these individualized systems is the limited ability to communicate and coordinate across health care facilities/settings and inconsistency with product labeling of commercially available dysphagia products. Research has indicated that there is considerable variation in terminology with 27 different labels being used to refer to ≤5 levels of drink thickness and 54 labels used to refer to ≤5 levels of texture-modified foods (Cichero et al., 2016). Since facility-established protocols are not standardized, there is a greater chance of negative impact on patient care, including reduced patient safety, inconsistency in accurate follow through of professional interventions, and fewer opportunities to collect and evaluate treatment outcomes in a streamlined manner.
- State-specific regulations: Some state departments of health provide guidance related to dysphagia diets that the facility might be required to follow for credentialing purposes (e.g., Maryland’s Diet Manual for Long-Term Care Residents).
Note: The National Dysphagia Diet (NDD) was part of the full Nutrition Care Manual (NCM)® established by the Academy of Nutrition and Dietetics (AND). The AND announced that beginning in October 2021, IDDSI will be the only texture-modified diet recognized by NCM®. The NDD and associated resources are no longer included in the NCM® after October 2021.
Ordering Dysphagia Diets
State laws and facility regulations impact permissions for writing orders and entering orders in documentation systems. Therefore, ASHA does not have a policy that specifically addresses writing or modifying diet orders. Clinicians should adhere to specific state and facility guidance. Some considerations related to ordering diet texture/liquid consistency modifications include the following:
- Review state laws and other regulations, facility protocols, and documentation system restrictions prior to entering a patient’s diet recommendations within documentation systems as orders.
- Clarify regulations/protocols for how any nutritional restrictions and other components that fall outside the speech-language pathology scope of practice will be carried over when changing diet textures/liquid consistencies. For example, if you need to change a patient's diet to IDDSI level 5 (minced and moist) and that patient is also on a low-sodium diet, the order will likely need to address both issues—texture and dietary restrictions. There is no ASHA policy prohibiting a speech-language pathologist (SLP) from writing such orders. However, it is the SLP’s role to ensure that (a) the diet order is correct and (b) it’s clear that the SLP is not the one requesting the dietary restrictions, which falls outside the SLP's scope of practice. In some facilities, members have reported using language such as "IDDSI level 5 (minced and moist) diet with low-sodium restriction, as per physician/dietary order dated XXXX" or "IDDSI level 5 (minced and moist) diet, continue dietary restrictions previously in place." In other facilities, physicians may write broad orders, such as "diet as determined by speech-language pathologist," which allows the SLP to request a diet without it being written as an order. There should be a policy in place that outlines the agreed-upon procedure for writing such orders.
