Diet Texture Modifications for Dysphagia

Dysphagia diets involve diet texture modifications—or changing the texture of foods and the thickness of liquids using standardized guidelines like the International Dysphagia Diet Standardisation Initiative (IDDSI). Speech-language pathologists (SLPs) work with patients, care partners, and medical teams to determine if these changes are appropriate.

Using information from a comprehensive assessment, SLPs consider how diet texture modifications impact swallowing physiology, including airway protection. SLPs base their recommendations on these criteria:

current evidence
their own clinical judgment
the person’s overall health, preferences, and goals

Dysphagia diets are one part of a broader plan of care—other parts include dysphagia strategies, maneuvers, and/or

The Adult Dysphagia Practice Portal page and organizations such as the Royal College of Speech and Language Therapists provide additional clinical considerations for diet texture modifications.

Dysphagia Diet Guidance

ASHA does not define diet levels, terminology, or the types of foods that meet the criteria for a particular diet level.

Dysphagia diets may follow one of these formats:

Standardized frameworks: The International Dysphagia Diet Standardisation Initiative (IDDSI) provides a standardized framework for labeling texture-modified foods and liquids. It is the only standardized framework for texture-modified diets used in the Academy of Nutrition and Diatetics’ Nutrition Care Manual.. ASHA supports the IDDSI framework and encourages members who assess and treat individuals with dysphagia to consider using it. Neither ASHA nor any payor in the United States mandates adoption of IDDSI.
Facility-established protocols: Some facilities use their own dysphagia diets. These internally developed frameworks vary across setting. Facility-established protocols create inconsistency between institutions and levels of care. Research from (see, e.g., Cichero et al., 2016) has identified substantial variation across institutions and product packaging in the terms used to describe food textures and liquid thickness. Facility-established protocols can create barriers outside the facility—here are just a few examples (many more exist as well):
- lack of effective care transitions between facilities
- inconsistent use of commercially available texture-modified foods and liquids
- limited follow-through with clinical interventions
- lack of effective data collection and outcomes reporting
State-specific regulations: Some state departments of health or other regulatory bodies provide guidance related to dysphagia diets that the facility might be required to follow for credentialing purposes.

Ordering Dysphagia Diets

State laws and facility regulationsinfluence who can write or enter diet orders in documentation systems. ASHA does not have a policy that specifically addresses writing or modifying diet orders. Clinicians should follow applicable state and facility guidance.

Some considerations regarding ordering modifications related to diet texture and/or liquid consistency include the following:

Review state laws, regulations, facility protocols, and documentation system requirements before entering a patient’s diet recommendations as orders.
Clarify how you (or the facility) will address nutritional restrictions—and other components outside the speech-language pathology scope of practice—when changing diet texture or liquid consistency.

For example, an individual may require documentation of both a dysphagia diet level and a dietary restriction (e.g., low sodium). In these cases, the order may need to reflect both elements.

When documenting, ensure that (a) the diet order is clear and accurate and (b) any dietary restrictions are attributed properly (e.g., specifying “per physician or dietician order” in notes). Facilities may approach documentation differently. See examples below:

In some facilities, ASHA members report SLPs use language like this:

“IDDSI level 5 (minced and moist) diet with low-sodium restriction, as per physician/dietary order dated XXXX.”
“IDDSI level 5 (minced and moist) diet; continue dietary restrictions previously in place.”

In other facilities, physicians may write broad orders like this, allowing the SLP to specify a diet:

“Diet as determined by SLP.”

Establish a policy or enforce an existing policy that clearly outlines the agreed-upon procedure for documenting and communicating diet recommendations and orders.