Some people may experience problems swallowing when eating and drinking. This is often called dysphagia. Dysphagia can result in choking, pneumonia, chest infections, dehydration, undernutrition and weight loss. Speech and language therapists (SALT) play an important role in the assessment of people to identify which consistency foods and drinks are safe to eat and drink. The SALT may recommend altered consistency diets and fluids which are safe for the person. These are referred to as IDDSI levels. IDDSI stands for International Dysphagia Diet Standardisation Initiative.

  • Liquidised (Level 3)
  • Pureed diet (Level 4)
  • Minced and Moist diet (Level 5)
  • Soft and Bite Sized diet (Level 6)
  • Easy to Chew diet (Level 7)

  • Thin (Level 0)
  • Slightly Thick (Level 1)
  • Mildly Thick (Level 2)
  • Moderately Thick (Level 3)
  • Extremely Thick (Level 4)

For practical information on each IDDSI level refer to our leaflets.

Sometimes when people are on altered consistency diets they may also experience a reduced appetite and weight loss, which can impact their quality of life. It is important to enhance the nutrition of food and drinks to maximise a person's nutritional intake. 

Although foods can be adapted at home to be suitable for an altered consistency diet. Ready meals are available to buy which are delivered frozen to the house.

Frozen ready meals are available in Level 4 (pureed), Level 5 (Mince and Moist), Level 6 (Soft and Bite Sized). For people with a poor appetite some companies produce small portions versions which have extra nutrition added

Examples of companies who deliver altered consistency ready meals:

Making altered consistency meals and IDDSI testing 

When adapting foods at home to be suitable for an IDDSI level diet, it is important to complete IDDSI tests to ensure the food is safe for the person to eat. IDDSI tests should be completed on every food which is adapted for an altered consistency diet.

The food should have a smooth texture, with no lumps and holds it shape on a spoon.

The IDDSI tests are fork drip test and spoon tilt test.

  • IDDSI Fork Drip Test: Level 4 pureed diet should sit in a mound or pile on a fork, and not dollop or drip through the prongs continuously
  • IDDSI Spoon Tilt Test: The food holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked (food should not be sticky)

To learn more on IDDSI testing for level 4 watch the video Level 4 Pureed Ketchup - YouTube

The food is soft and moist, but with no liquid leaking/dripping from the food. No biting is not required, but minimal chewing is required.

The IDDIS test are fork test and spoon tilt test.

  • IDDSI Fork Test: For adults lump size is 4mm which is about the gap between the prongs of a standard dinner fork
  • IDDSI Spoon Tilt Test: The food holds its shape on the spoon and falls off fairly easily if the spoon is tilted (food should not be sticky)

To learn more on IDDSI testing for level 5 watch the video  IDDSI Fork Pressure, Fork Drip, Spoon Tilt, Chopstick, and Finger Tests - Level 5 Minced & Moist - YouTube

The food is soft, tender and moist, but with no thin liquid leaking/dripping from the food.

  • Pieces of food should be no bigger than 1.5cm x 1.5cm when served, which is about the width of a standard dinner fork or size of a thumb nail
  • To make sure food is soft enough you should be able to be cut or break the food apart with the side of a fork or spoon. It is then safest to test soft and bite-sized food using the IDDSI Fork Pressure test:
    • Place the fork on the food
    • Press down on the fork until the thumbnail blanches to white
    • Then lift the fork - the food should be completely squashed and not regain its shape

To learn more on IDDSI testing for level 6 watch the video  IDDSI Fork Pressure, Chopstick, and Finger Tests - IDDSI Level 6 Soft & Bite Sized - YouTube

  • When pureeing a food to a smooth consistency a food thickener may be required to be added to ensure it is not too runny. Complete IDDSI tests, if the fork drip tests show the pureed food dripping continually through the prongs, rather than hanging under the prongs, a food thickener should be added to ensure a safe consistency.
  • If when a food is pureed and served liquid is seem seeping out from the pureed food, a food thickener must be added. This is common with pureed fruit and vegetables. It is essential that no liquid must not separate from solid.
  • Types of food thickeners: If a person is recommended to have thickened fluids by the speech and language therapist, the thickening powder Nutilis Clear may be added to pureed food.
  • If Nutilis Clear is not prescribed, food thickeners can be purchased online. An example is Ultratex, which is available here. 
  • It is essential to ensure the food is a smooth consistency prior to thickening. If small particles or pips can be felt, it is essential to sieve the food though a metal sieve.
  • Always use a metal whisk to mix in the food thickener. Then wait at least 60 seconds. Then complete IDDSI tests to determine a safe consistency

Adding extra nutrition to meals

If someone has a poor appetite it is important to adapt food dishes and drinks try to add extra nutrition.

If a person is only eating small portions, encourage small nourishing snacks between meals. Examples of pureed (level 4) snacks are smooth thick and creamy yoghurt, fromage frais, custard pot, angel delight, chocolate/fruit smooth mousse/desserts.

Adapting food such as pureeing can reduce the nutritional content of your meals, it is necessary to fortify or enrich your diet to ensure you get adequate calories and protein. Fortification is where we add extra calories and protein without increasing volume.

  • Do not use water to blend, use milk, sauces, cream, fortified milk or dairy free alternatives
  • Add 1 tablespoon of skimmed milk powder prior to blending
  • Add butter or margarine, cheese spread to savoury dishes
  • Add double cream
  • Add sugar, honey, seedless jam, chocolate spread to sweet dishes
  • Mixing 1 tablespoon of skimmed milk powder with 2 tablespoons of cream, mixed into soup, porridge, custard or milk puddings can add an extra 185 calories and 5g protein.

Encouraging milky based drinks, fruit juice and smoothies, which are thickened to the SALT recommended IDDSI level, is a great way of adding extra nutrition.

Use one pint of fortified milk each day. This is prepared by mixing 5 tablespoons of skimmed milk powder to a pint of milk provides an extra 250 calories and 25g protein. Use this on cereals, porridge, milky drinks or in tea and coffee.

For further information on Adapting diets to prevent weight loss on a pureed (level 4) diet, download the leaflet in the resource section.