Diet Levels and the Need for Standardization

Diet Levels and the Need for Standardization

melissa n., M.A., CCC-SLP

One of the things that I have found difficult, as a traveling Speech Pathologist is the wide variance in diet textures and fluid consistencies, as well as they quality of food served to the residents I work with. It amazes me sometimes the items that residents on modified diets receive with their meals. A resident on a puree diet texture and honey-thick fluids should, as I recall, not receive Jell-O as a dessert.

Due to the fact that, as traveling SLPs, we can plan on 13 weeks at a facility at a time. Educating and modifying the Dietary staff is a time consuming task that involves input and consultation with the Dietary Manager, Dietician, Dietary staff, and Restorative staff. Many times facilities are members of a large corporation, and menus are corporate-wide. Changes in diet levels would likely take much longer than thirteen weeks.

The American Speech-Language Hearing Association itself reports that it has no policies or guidelines regarding items on particular diet levels. The introduction of the National Dysphagia Diet by the American Dietetic Association (ADA) in 2002 led me to be optimistic in the standardization of diet levels from acute care to home care, from one long term facility to another. Unfortunately this has not occurred. What we need is a strict, precise guideline of diet texture levels that can be relied on from one medical setting to another. For the long term care settings, we need a “finger food diet” that can accommodate those on our caseload who would benefit from it. In reality, we are aware that the cycle of life begins with a large amount of assistance required for ADLs (activities of daily life), and if one lives long enough, ends in quite the same way. Much as infants begin with finger foods, many of our residents are more successful in independent feeding as well as amount of intake when finger foods are available. As a united front, we need to determine a unified, standardized diet level guideline on which we can unite with Dieticians and Dietary staff to ensure the safety of our residents.

Understanding and Implementing Dysphagia Diets

The National Dysphagia Diet is now the standard for dietary treatment of swallowing difficulties. Diet texture guidelines are provided here, along with general information on causes of dysphagia and nutrition support issues.

NDD Food Texture Levels:

NDD Level 1 • Dysphagia Pureed

Smooth pureed, homogenous, very cohesive, pudding like foods that require very little chewing ability.

General Guidelines:

1. Bread should be pre-gelled through the entire thickness, pureed, or pureed into other foods in accordance with recipes.

2. Fruits and vegetables should be pureed with no pulp, seeds, or chunks.

3. Mashed potatoes should be served with gravy, sauce, butter, or margarine to moisten.

4. Soups should be pureed smooth.

5. Avoid scrambled, fried, or hard-boiled eggs. Soufflés are allowed.

6. Avoid fruited yogurt, un-blenderized cottage cheese, peanut butter, and any food with lumps, including soups and hot cereal.

NDD Level 2 • Dysphagia Mechanically-Altered

Cohesive, moist, semisolid foods that require some chewing ability. Included in this level are fork-mashable fruits and vegetables. Excluded are most bread products, crackers, and other dry foods.

General Guidelines:

1. Bread should be pre-gelled through the entire thickness or pureed according to recipe.

2. Fruits should be soft, canned, or cooked. Soft, ripe bananas are allowed. Avoid canned pineapple.

3. Vegetables should be soft, well cooked, easily mashed with a fork, and in pieces smaller than 1⁄2 inch.

4. Meat should be tender and moist, ground, or cubed smaller than 1⁄4 inch. Moisten with gravy.

5. Avoid dry whole grain cereal with nuts, seeds and coconut.

6. Avoid items that are difficult to chew, including large chunks or nuts.

NDD Level 3 • Dysphagia Advanced

Soft-solid foods which require more chewing ability. This level is nearly regular textures. Included are easy-to-cut whole meats, fruits, and vegetables. Excluded are hard, crunchy fruits and vegetables, sticky foods, and very dry foods.

General Guidelines:

1. Breads and cereals should be well moistened.

2. Fruits such as bananas or soft, peeled fruits such as peaches, berries, nectarines, kiwi or melon without seeds may be tolerated.

3. Avoid potato skins, corn, and raw vegetables.

4. Meat must be very tender, small pieces, or ground, and well moistened.

5. Avoid items that are difficult to chew: nuts, seeds, popcorn, potato chips, coconut, etc.

NDD Level 4 • Regular

Any solid food texture.

NDD Liquid Levels:


Thin liquids include clear liquids, milk, commercial nutritional supplements, water, tea, coffee, soda, beer, wine, broth, and clear juice. Individuals tolerating thin liquids will also be able to tolerate foods containing thin liquids, such as watermelon, grapefruit or oranges. Foods like ice cream, frozen yogurt, or plain gelatin which turn to liquid in the mouth are also considered thin liquids.


Medium thickness liquids include nectars, vegetable juices, and handmade milkshakes shakes made with thickeners. Thin liquids can be thickened with commercial thickeners or purchased pre-thickened to nectar-like thickness.


Honey-like is thicker than the nectar-like level and resembles the consistency of honey at room temperature. Commercial thickeners can be added using package instructions to bring any liquids to this level of thickness or purchased commercially pre-thickened to honey-like thickness.


This includes high viscosity liquids too thick for a straw. Commercial thickeners can be added to any beverage to obtain this level of thickness or purchased commercially

pre-thickened to spoon-thick.

Reprinted from Dining with Dysphagia, by Carlene

Russell, MS, RD, LD, FADA. The Master Track Series,

Dietary Managers Association, ©2003.