Nutrition Management of DysphagiaManual of Clinical Nutrition Management B- 7 Copyright © 2013 Compass Group, Inc.
How to Order the Diet
The dietitian and the speech-language pathologist should work collaboratively and use the results from both
the medical evaluation and a swallowing study to choose appropriate foods and beverages for the individual
patient (1). The National Dysphagia Task Force found that the Dysphagia Outcome and Severity Scale provided
the best scale to determine the level at which the National Dysphagia Diet (NDD) should be recommended
(1,6).
Prior to the initial oral feeding, a diet order specifying that the patient can eat must be obtained from the
physician. The dietitian and the speech-language pathologist must coordinate efforts to determine the
appropriate consistency of foods and liquids for the patient both before feedings begin and with subsequent
feedings. The consistency of foods and liquids should be altered as the patient progresses.
The severity of dysphagia determines the level of the diet required. The food plan is divided into multiple
levels of solid food and liquid consistency to maximize the dysphagic patient’s nutritional intake (2). Diet
orders should include the National Dysphagia Diet levels and the desired liquid consistency (eg, thin, nectar-
like, honey-like, or spoon-thick) (6). With each progression of the diet, both the level of the diet and the liquid
consistency need to be specified in the nutrition prescription (6). The three NDD levels are (6):
NDD Level 1: Dysphagia Pureed: Foods are thick and smooth and have a moist pudding-like
consistency without pulp or small food particles. They cling together, are easy to swallow, and require a
minimum amount of manipulation in the mouth. Sticky foods or foods that require a bolus formation or
controlled manipulation of the mouth (eg, melted cheese and peanut butter) are omitted. The diet
provides no coarse textures (eg, fibrous foods) to prevent irritation. Food and fluid intake should be
monitored.
NDD Level 2: Dysphagia Mechanically Altered: Foods are moist, soft, and simple to chew, and they
easily form a cohesive bolus. The diet provides a transition from pureed foods to easy-to-chew foods.
Moistened ground meats (pieces should not exceed ¼-inch cube), vegetables cooked to a soft mashable
texture, soft-cooked or canned fruits, and bananas are included. Some mixed textures are expected to be
tolerated. More frequent feedings may be beneficial. Food and fluid intake should be monitored.
NDD Level 3: Dysphagia Advanced: Foods are moist, soft, in bite-size pieces, and nearly regular in
texture. Hard, sticky, and crunchy foods are excluded.
Planning the Diet
General considerations: Dietary considerations vary with each patient. The importance of individual food
consistencies cannot be overemphasized. For example, dysphagic patients with an obstruction may be able to
safely consume liquids, while other dysphagic patients may aspirate liquids and require thickened liquids
with a puree consistency. A recent study showed that carbonated liquids are a dietary option for patients
who experience penetration/aspiration into their airways ( 7 ); thickened liquids are also safe for these
patients ( 1 ). If a patient cannot tolerate thin liquids, foods that become thin liquid at room temperature (70oF)
or body temperature (98oF), such as gelatin, ice cream, and sherbet, should also be avoided.
The following guidelines should be considered when planning the diet for a dysphagic patient: One of the
most important considerations of food texture is cohesiveness, or the ability to stay together. Patients can
often chew through foods but are unable to press the food into a bolus unless it is naturally or artificially
cohesive. For patients who cannot swallow a smooth pureed food, a higher-texture food (more viscous) is
desired to rehabilitate muscles. The larger surface area provides stimulation to the nerve and muscle groups
that assist the swallowing process.
Do not combine textures, such as dry cereal with milk or chunky vegetable soup in broth, in the same
bolus. Do not use fluids to wash down the bolus. It may be appropriate to alternate liquid and solids.
Present foods and fluids separately, checking for complete swallows after each mouthful.
Use smooth gravies on all ground meat.
Rice and cottage cheese are difficult for some dysphagic patients to swallow. Use rice in casseroles with a
soup base, and include only pureed small-curd cottage cheese in the diet. Milk does not cause mucous
formation. However, milk can aggravate thickening of mucus in some people, which can reduce their
ability to manage secretions. Blended yogurt or lactose-free supplements may be used if milk is not
tolerated.