Dysphagia Diet Levels

Posted by | January 2, 2011 | Articles, Dyphagia Evaluation

A Dyphagia Diet is a diet that has different consistencies of foods.  It is for patients with dysphagia, or difficulty swallowing. The National Dysphagia Diet (NDD), published in 2002 by the American Dietetic Association, aims to establish standard terminology and practice applications of dietary texture modification in dysphagia management.

What are the different National Dysphagia Diet Levels?

  • National Dysphagia Level I is a puree consistency diet (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
  • National Dysphagia Diet Level 2: Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
  • National Dysphagia Diet Level 3: Dysphagia-Advanced  (soft foods that require more chewing ability).
  • Regular (all foods allowed).


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12 Responses to “Dysphagia Diet Levels”

  1. Comment made by Sharon Burns on Jul 2nd 2012 at 10:13: Reply

    I have a man with developmental disabilities (low IQ) who is on a Dysphagia II Diet. He is doing very well on the diet, however an issue has come up about pizza and whether it is a bread or not. He loves pizza and the staff get thin crust pizza and never give him edge pieces plus they cut the pizza into very small bites. Do you have any suggestions for this. He has not had any problems with choking or difficulty swallowing the pizza.
    Thank you for any help you can give me.

  2. Comment made by Everything Speech on Jul 2nd 2012 at 11:01: Reply

    The Dyphagia II diet does not allow for breads and that would include pizza. However, if this man is doing fine with the pizza, he should be allowed to eat it. You can definitely make an exception and have the doctor write an order for “allow chopped pizza, no crust” or something to that effect. Hope that helps!

    • Comment made by Anita Hunter on Oct 4th 2012 at 17:22: Reply

      Where do “steak fries” fall into level 3 catagory? Not like a regular “fry”, can it be left whole and how do you subjectivly determine if it is soft enough, has soft or hard edges, etc.

      • Comment made by Everything Speech on Oct 4th 2012 at 20:52: Reply

        Steak Fries would fall into Dysphagia III. It can be left whole, so you don’t have to cut it up. The fries should not be “crispy” or overcooked. An SLP can assess the individual in question to determine if the patient can or cannot tolerate the fries and other foods.

  3. Comment made by Melissa Geib on Jan 14th 2013 at 19:38: Reply

    What is the premise for allowing regular chicken n the Dysphagia Level 3 diet? In my experience as a clinical Speech Language Pathologist for 23 years, chicken continues to be a food items that is very difficult for most people to masticate putting them at increased risk. I can understand allowing fish, but the chicken at the SNF that I work at is regularly dry, and overcooked.

    • Comment made by Everything Speech on Jan 20th 2013 at 12:45: Reply

      The Dysphagia 3 diet allows for chicken that is thinly sliced and well-moistened. If the chicken is dry and over-cooked than it would be regular consistency (see “foods to avoid” under the Dysphagia 3 list). Your kitchen may need some education on proper cooking and moistening techniques before allowing a Dysphagia 3 diet to include chicken.

  4. Comment made by PLove on Jan 31st 2013 at 00:47: Reply

    Hello I have a patient who is currently on Dysphagia III and he is tolerating his current diet. He has a hiatal hernia which has caused him to aspirate on rice and dry chicken. These are the only two foods he has trouble safely consuming. No true oral or pharyngeal deficits but the “bowing” in the esophagus because of the hernia has caused the aspiration. He would like to eat “hard candy” (i.e. werthers, butterscotch, circular peppermint, etc..)for gratification after meals and although he has been sneaking these candies without any aspiration/penetration I don’t feel it is afe for patient to consume this candy because they can become very slippery in his mouth and slide into his pharynx and become logged.I have asked the nursing staff to remove candy from the patient if/when they see him eating these types of hard candy. Any advice on whether hard candy would be safe or not?

    • Comment made by Everything Speech on Jan 31st 2013 at 20:39: Reply

      Hello, and thank you for your comments. Hard candy is not included on the Dysphagia III diet. This is in part because of the reasons that you describe “become very slippery… and slide into his pharynx.” I cannot say if this particular patient is safe for the hard candy or not because I would need to evaluate the patient. Try to see how the patient is doing on the hard candy and if he is not having any difficulty, cognitively intact, etc. then you might allow this item. An order for “allow hard candies” might be appropriate depending on how he did at bedside. Or maybe “regular diet, no rice or dry chicken” if that is the only difficulty.

  5. Comment made by Patricia Stretchberry on May 9th 2013 at 00:17: Reply

    My daughter, who has Down Syndrome with developmental delays, is on a stage 3 diet following an episode of aspiration pneumonia. Would it be okay for her to eat thin crust pizza cut into small pieces?

  6. Comment made by Everything Speech on May 9th 2013 at 09:17: Reply

    Patricia, if the bread is soft on the thin crust pizza and cut into small pieces, this would fit into a Stage 3 diet. Every person is different and since I have not evaluated your daughter I can not say that she will tolerate this safely. A speech-pathologist is the best person to evaluate your daughter for the safest, least restrictive consistencies.

  7. Comment made by Anonymous on Nov 5th 2013 at 17:00: Reply

    April Stone , Nashville , TN
    I am a speech therapist and the corporate dietician of our company asked me a question that I couldn’t give an answer too. She wanted to know does everything item on a level 2/3 diet have to be in bite size pieces , even the soft cakes and pies etc..

    • Comment made by Everything Speech on Nov 5th 2013 at 21:08: Reply

      Hi April. Meats, fruits and vegetables should be moist, soft and finely chopped into 1/4 inch pieces. Soft cakes are included on dysphagia 2 and do not need to be chopped. Soft fruit pies are allowed in dysphagia 2 with the bottom crust only. Pies that are ‘slurried’(moistened with liquid) are ok for dysphagia 2. Anything allowed in dysphagia 2 is ok for dysphagia 3.
      Remember that each patient’s tolerance is different for different foods. So if a patient can tolerate the pie without being chopped, perhaps the order can be for Dysphagia 2 diet, allow apple pie.”

  8. Comment made by Jim Kelley on Dec 4th 2013 at 22:29: Reply

    All of this is new to me. I am caregiver and son to a wonderful 83 year old mother. She almost died on my hands. With that incident I am more cautious. Can you send, email or fill me in on where to go to find diets and suggestions for her to have a good balanced meal without ‘breaking the bank’. Life is good, but sometimes need help. Thanks

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