“Minced & Moist, IDDSI Level 5” Diet Replaces “Dysphagia Mechanically Altered,” “Ground,” “Mechanical Soft”

 

by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

 

Being discharged to home from a hospital or rehab facility can be an overwhelming process, especially if your Speech-Language Pathologist (SLP) and medical team have prescribed a modified diet due to difficulty swallowing (dysphagia). Diet modifications are made to attempt to prevent choking and to avoid getting food stuck in the mouth, throat and/or esophagus (food tube to the stomach). Food that gets stuck in the mouth or throat can fall into the airway after the swallow, causing aspiration of food particles or actual choking (airway blockage or asphyxiation).

 

You may be having difficulty with regular foods like meats, breads, dry-hard textures, and crumbly-dry foods. You may be having difficulty chewing to break down your foods to make them safe to swallow. Make sure you have had your swallow fully evaluated to know where the problem is, as we treat issues differently depending on whether the problem is in your mouth, throat, and/or esophagus. 

 

Examples of challenging foods:

 

• Peas, corn, and dry rice may roll to the back of your throat before you are ready to swallow them.
• Meat that is not minced may be too hard to chew, cause significant fatigue, or get stuck in your throat or esophagus.
• Sticky rice may get balled up and stuck in your throat and fall into your airway, especially if not enough moisture content.
• Mixed consistencies are part solid and part liquid. While you are chewing the solid, the liquid may accidentally fall into your throat and airway, causing aspiration. Cold cereal and even very juicy fruits like watermelon are examples of mixed consistencies.
• Bread can cause an especially high risk for choking. Breads may feel soft, but they require a lot of chewing and oral processing. People tend to swallow bread before it is really processed in the mouth or “swallow-ready.” Bread can stay in a sticky ball in the throat and actually completely block your airway. Please see this blog about how bread is a challenging regular food item that is one of the most frequently choked on foods. See this FAQ from the United States IDDSI Reference Group on bread and mixed consistencies. 

 

You may do best with foods that are actually very soft and minced (chopped up to particle sizes of 4mm in width and no longer than by 15mm in length). Food should be moist and cohesive and NOT sticky or crumbly. You want foods to stay together in the mouth while you are chewing and forming a cohesive ball of food (bolus). That bolus is combined with your saliva to make it slippery to slide down easily. 

If you get food stuck in your throat, a cohesive food may stay in a pocket in your throat until you are able to swallow again or use liquid to wash it down. Alternating liquids and solids can be helpful. If you have dry mouth, you may need especially moistened foods to make them slide down better. You may need to get creative with sauces, gravies, and condiments. Applesauce, guacamole, hummus, and olive oils make good additions to add moisture in healthy ways. You can also swish and swallow with an artificial saliva substitute (gel or spray) before meals to literally lubricate your pipes!

What is a Standardized Minced & Moist Diet?

What is “soft?” Unfortunately, healthcare professionals have been labeling a vaguely “soft” diet with so many different terms, causing great confusion around the nation and world. Consider that the following diets may be referring to roughly the same texture:

Dysphagia Mechanically Altered (per the National Dysphagia Diet/NDD of 2002),

Dysphagia Ground or Moist Ground,

or the worst and most ambiguous term of “Mechanical Soft.“

The term “mechanical soft” is very old, as it came before any attempt in 2002 to standardize dysphagia diets into the NDD format. “Mechanical soft” has no approved or agreed upon definition, and each facility has their own “homegrown” descriptions. Some facilities lack of definitions and protocols all together! “Mechanical soft” has never been an official diet for people with dysphagia, and there is no evidence to support its use. Most of my choking cases within my dysphagia expert witness work have been choking deaths partially due to the facility’s use of this out-dated label of “mechanical soft.” This lack of standardization that has plagued the nation and world for decades has lead to many preventable choking deaths, aspiration pneumonias, and other negative sequela. 

 

Fortunately, now the International Dysphagia Diet Standardisation Initiative or IDDSI.org has standardized diet labels, descriptions, rationales for the level, and testing methods to place foods into individual levels. The new diet label of “Minced & Moist” tells it all. The labels are very descriptive and easily translatable into all languages. See also the next IDDSI level higher of “Soft & Bite-Sized, Level 6.”

 

Characteristics of Minced & Moist:

(See handouts on the IDDSI website for Level 5 – Minced & Moist)

 

• Meats are ground-up or minced but with extra gravy or sauce. You want the pieces of meat to stay together in a cohesive ball. All foods within this diet can form into a moist-cohesive ball in your mouth and slide down your throat easily. (For examples: If you make risotto, make sure to have lots of sauce to prevent it from being crumbly. If you have a lentil stew (aka, dal), make sure the lentils are well cooked and with plenty of thick sauce.)
• No biting is required, minimal chewing is necessary, and the food should easily mash with your tongue.
• Moist and cohesive foods stay together while you try to chew them and move them around in your mouth. No liquid separating from the solid (e.g., mixed consistencies should be avoided, as they are difficult, such as soup with both solids and a thin liquid broth).
• Per the IDDSI recommendations, minced foods should be cut into food particle sizes of 4mm wide and no more than 15 mm long which can be easily swallowed without much chewing. This is the distance between two tines on a fork.

 

Overall, this diet may be good to reduce fatigue that may occur in trying to eat a full regular meal. It is so important, however, to ensure that the food has added moisture built in to the recipe. When we mince up the food we are increasing the surface area. That can lead to these particles drying out. Therefore, the diet is called Minced & Moist for a reason. Each item served must be moist and cohesive. 

 

More Resources for Minced & Moist, Level 5 and other IDDSI Information:

 

See all IDDSI Framework Testing Methods here.

 

Read more about NDD changing to IDDSI here.

 

See a list of IDDSI resources here. 

 

Time for IDDSI Updates

 

Creating a Dysphagia Cookbook IDDSI-Style

 

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Again, the most confusing aspect of this diet texture, as there are way too many terms out there that mean the same thing! 

 

These old diet terms may have meant the same thing. We don’t know! Prior to IDDSI, we were never speaking the same language of dysphagia diets. It was the wild-west. Prior to IDDSI publishing their framework in 2016, there was no global standardization based on years of interdisciplinary research.

If your facility is using any of these old diet terms in the bulleted list below, please ask them for an updated dysphagia diet framework that is standardized. IDDSI is now the ONLY professionally recognized dysphagia diet framework in the United States per the American Speech-Language Hearing Association (ASHA), the Academy of Nutrition & Dietetics (AND), and the Association of Nutrition and Foodservice Professionals (ANFP).

Watch out for OLD terminology that has no clear definition. These present patient safety risks:

• Dysphagia Ground,
• Moist Ground, Ground,
• Diced,
• Mechanical Soft,
• Mechanically Altered, and
• Chopped