Snacks for People with Dysphagia (IDDSI Style)

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November 4, 2020

Snacks for People with Dysphagia

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

 

Oh my! How many pieces of candy have I eaten in the last few days? I could sneak just one more candy out of my son’s Halloween candy bag!

Craving sugar, but cannot eat it? You can check out these snacks that are not loaded with sugar or the website EatRight by the Academy of Nutrition & Dietetics. Note: this blog will not be addressing nutrition or stress eating.

With these crazy COVID-19 pandemic and election times, we may be seeking comfort from candy and snacks right about now!

BUT…

What if you have difficulty chewing and trouble swallowing (dysphagia)?

When you Google “Top 25 snacks,” very few of them are soft and easy to chew! Doritos, Triscuits, Fritos, Tostitos, Cheetos, Cheezits, Lays Potato chips, nuts, Oreos, M&M’s, and even Peanut Butter make that list, but those items are all challenging. Per the International Dysphagia Diet Standardisation Initiative (IDDSI.org) all of those snack favorites are only on the Level 7 Regular Diet.

Only a few items in my Google search fell under a potentially softer and safer List, such as: milk chocolate, Reese’s Peanut Butter Cups (yes, there are 3 wrappers next to me now…), very soft baked chocolate chip cookies, Betty Crocker Super Moist cake, and chocolate Dove Bars. However, some of those items are Transitional Foods, which start out as one consistency and change with the heat/moisture of the mouth to another consistency (e.g., ice cream, popsicles, and even Reese’s Peanut Butter Cups). There are special considerations when thinking about these transitional foods, such as the person’s saliva quantity and quality, which helps make foods “melt-in-the-mouth” and form into a slippery and manageable ball or bolus. To read more about patient safety with challenging foods (e.g., Jell-o) and potentially chokable snacks (e.g., Konjac jelly candy), check out the part 3 of my transitional food blog series.

You may be thinking that snacks do not have to be full of sugar and fat, but even healthy snacks can become burdensome to chew/swallow and even highly dangerous if you have dysphagia!

So, how are people with difficulty swallowing and their caregivers able to find safer options? Are there still satisfying snacks for people with dysphagia?!

When it comes to favorite foods and munchies, sometimes a person’s life goals dictate that quality of life is more important than safety at all costs. It is up to the entire medical team (which includes the person) to have thorough discussions about the risks and benefits of any treatment plan and diet modification recommendations. Note: healthcare professionals can help steer a person towards safer items; therefore, I have created the list at the end of this blog (along with a pdf handout).

Inspirations & Caveats Regarding Snacks for People with Dysphagia:

I am inspired by Brian Wallach (man, husband and father who is courageously sharing his fight with ALS @bsw5020 on Twitter). He showed us on November 3rd that having ALS does not stop you from craving and enjoying snacks throughout a stressful evening (e.g., munching on Funyuns, Cool Ranch Doritos, candy bars, Ben & Jerry’s, but who is counting, right?).

I was also inspired by a discussion on The IDDSI WIDDSI SLP Facebook Group about the significant need that clinicians have to provide specific recommendations for caregivers and healthcare staff listing appropriate/safe snacks within each IDDSI diet level.

It is certainly not so easy to provide ONE list, as that has NOT been the intention with IDDSI.

The key with IDDSI, is it provides the framework, definitions, and simple testing methods so that people can determine safety across the world with any food or liquid item.
  • IDDSI’s goal is for patient safety across all ages, in all care settings, and across all cultures.
  • IDDSI does not come with specific lists of foods like the old National Dysphagia Diet (NDD) did.
  • IDDSI is international and dependent on you analyzing your own region’s foods and doing food testing to determine safety and placement within a given diet level. (See an IDDSI resource blog here.)
Additionally, vocabulary or labels for foods vary greatly around the world and even within one country. For example, in the United Kingdom, they use the terms of crisps and biscuits, but those are not the same thing here in the United States. One IDDSI list would not carryover internationally.
However, we must think about the burden on facilities in generating lists for kitchens and nursing staff. We must also consider the burden on caregivers once their loved ones come home from healthcare institutions on a given diet level. The caregivers may not have received enough education at that hospital or rehabilitation center, and they may not know what to serve.

It is really heartbreaking to imaging that all those go-to chewy candies and savory salty snacks that we munch on frequently are only for people on a Level 7 Regular Diet.

Therefore, I reviewed the IDDSI framework documents and IDDSI Resources, such as the caregiver handouts of “foods to avoid” lists for adults and pediatrics (see this example). I started this working document (please help add to it/edit it), listing some snack ideas for the USA, but it does include some snacks that we enjoy in the USA that have been borrowed from around the world. I cannot emphasize enough: these are suggestions and do not represent a prescription by IDDSI or myself. Please see the statement from an IDDSI board member below to reinforce that concept.
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Snacks for People with Dysphagia – IDDSI.org & USA Style!

(Working document of suggestions only; Primarily for adults;

All items will need point of service testing due to variabilities in freshness, temperature, ripeness, etc.

Use simple IDDSI Testing Methods with spoons & forks: https://ftp.iddsi.org/Documents/Testing_Methods_IDDSI_Framework_Final_31_July2019.pdf

Click Here for PDF of these suggestions.

 

Examples of Level 4 Puree

  • Pudding (moist enough to slide/plop off spoon when spoon tilted sideways, not sticky. See Spoon Tilt Test on page 7 of this IDDSI document.)
  • Smooth Yogurt without fruit chunks, Greek yogurt, Turkish Labneh
  • Hummus
  • Guacamole (avocado blended smooth)
  • Bean dip
  • Smooth Custard
  • Magic Cup (by Hormel) or similar ice cream that stays thick
  • Crème Fresh
  • Instant hot cereal packets without raisins or apple pieces (e.g., cream of wheat or instant oatmeal – with caution, making sure to serve it at a smooth pureed texture/extremely thick liquid consistency. Not sticky, like many types of oatmeal served in institutions. Make sure no liquid separates from the solid.)

Examples of Level 5 Minced & Moist (4mm/adults)

  • Same as above, as there are not a lot of snacks to add due to the 4mm particle size limitations. A Minced & Moist snack has to also be soft enough to squash easily with the IDDSI Fork Pressure Test without the thumb nail blanching white. The final requirement is that it has to pass the spoon tilt test, being cohesive enough to hold its shape on a spoon, while still being moist enough to slide/fall off spoon without sticking to the spoon.
  • Rice Krispies, but with draining out the milk after the cereal is softened, so that it is NOT a mixed consistency.

Examples of Level 6 Soft & Bite-Sized (1.5 cm bite sizes/adults)

            Same as above plus:

  • Cheerios (Note: these are really a Transitional Food, so if the person does not have adequate saliva and has no teeth, you may need to moisten them. See Transitional Food testing methods on page 10 of this IDDSI testing methods document.)
  • Cheese Curls/Cheese puffs – break into 1.5 cm pieces if long cheese curls (Note: these are really a Transitional Food, so if the person does not have adequate saliva and has no teeth, you may need to moisten them with a dip.) Not Cheetos, as these are harder, sharper, and crunchier.
  • Fruit cup with soft fruits like peaches, banana, papaya, pear (make sure they are mashable with IDDSI Fork Pressure Test) & drain excess liquid. Fruits are highly variable, and the Fork Pressure Test is needed to test individual ripeness/softness.
  • Small banana chunks – ripe (1.5 cm pieces)
  • Soft 1.5 cm chunks of cream filled chocolates, smooth chocolate truffles, Reese’s Peanut Butter Cups, Junior Mints, or Three Musketeers (i.e., melt in your mouth soft without nuts/seeds; not hard/chewy)
  • Very soft brownies without nuts, soft baked cookies without nuts/raisins – cut into 1.5 cm chunks (add sauce for moisture)
  • Moist cakes, cut into 1.5 cm chunks (add sauce for moisture)
  • Cheesecakes and Cream-filled pies (pumpkin, banana cream, Boston cream, key-lime pies) with soft graham cracker or cookie crumbled crusts
  • Cottage cheese and other very soft cheeses cut into 1.5 cm pieces (make sure not sticky)
  • Baby Mum Mums and other transitional food teething biscuits for 6-month-old range and up. Break into 1.5 cm chunks.

Examples of Level 7 – Easy to Chew

Same as above, but this list reflects how there are NO 1.5 cm bite-size limitations at this level.

  • Soft – easy to chew fruits without skins and that pass the IDDSI Fork Pressure Test and/or Fork Separation Test, which is easily cutting with pressure from the side of a fork (see page 9 on that IDDSI link) .
    • May hold and eat banana without cutting into chunks.
    • Avoid juicy fruits like watermelon and oranges, as managing the fibrous textures in addition to controlling the liquid may be too challenging.
  • Soft cheeses, cheese slices. Avoid hard chunks of cheese.
  • Chocolates that are not hard, sticky, gummy or chewy. No nuts, seeds.
  • Brownies, cakes, soft muffins, soft donuts (add moisture to all of these as needed).
  • Pennsylvania Dutch style funnel cake may be soft and thin enough (avoid the powdery sugar and cinnamon). Fried Dough of New England may be too challenging, as it is thicker and doughier.
  • Cheesecakes and Cream-filled pies (pumpkin, banana cream, Boston cream, key-lime pies) with soft graham cracker or cookie crumbled crusts
  • Some fruit-filled pies if no skins and graham cracker crust. Avoid harder pastry shell crusts.
  • Pringles? – if cleared by SLP (May try these if the person has adequate saliva and some tongue pressure, as these are almost a transitional food item, as they start dissolving when you suck on them.) Similarly, the SLP can test out the baked puffed snacks like “veggie straws” and “puffed snap peas” that are common now. These should also be close to a transitional food and melt in the mouth with adequate saliva and sucking on them a bit.
  • Graham crackers? – if cleared by SLP (May try these if the person has adequate saliva and some tongue pressure, as these are almost a transitional food item, as they start dissolving when you suck on them. Could use a dip to moisten. These are easier than other dry crackers, like saltines).
    • May try a cream cheese or other dips from the Level 4 Puree section on these softer items of Pringles and graham crackers

 

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Good for all levels if the person can tolerate a thin liquid without requiring a thickener, and can handle a transitional food that starts as a solid and transitions to a liquid in the mouth:

  • Ice cream without chunks
  • Frozen yogurt without chunks
  • Popsicles without nuts/chunks

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AVOID THESE SNACKS ON ALL LEVELS BELOW LEVEL 7 REGULAR

(unless tested by clinician and approved through a doctor’s order to deviate from prescribed diet.

This is not a complete list of challenging foods to avoid.)

  • Bagels, baguettes, and other tough breads (highly chokable)
  • Marshmallows (highly chokable, per foods to avoid in Level 7 Easy to Chew IDDSI Adult Consumer Handout, January 2019)
  • Rice Krispie treats
  • Tough chocolates and gummy candys like Airheads, Charleston Chews, Milk Duds and Tootsie Rolls
  • Jell-o
  • Nuts, seeds
  • Dried fruits (dried figs, mango, pineapple, apple, cranberries, raisins, etc.)
  • Fruit Roll-ups
  • Hard candies (may consider a lollipop if the person has good control and judgement to hold it and suck/swallow and lick)
  • Konjac jelly containing candies (Japanese)
  • Rice cakes, Mochi
  • Chewing gum
  • Raw vegetable sticks
  • Whole grapes, cherries, most berries, olives, and other items that could roll back and block the airway (the size of the opening to your airway is roughly the size of your thumbnail).
  • Mango, pineapple may be too fibrous
  • Popcorn, Kettle corn, Carmel corn
  • Corn chips, hard/spiky potato chips (only Pringles have the potential to melt in the mouth with adequate saliva and some tongue pressure).
  • Pretzels (even a traditional Philadelphia soft pretzel may be too chewy)
  • Crackers (only graham crackers have the potential to melt in the mouth with adequate saliva and some tongue pressure).
  • IDDSI recommends avoiding foods with the following descriptors: “hard or dry food, tough or fibrous foods, chewy, crispy, crunchy food, sharp or spiky, pips and seeds, bone or gristle, sticky or gummy food, and stringy food.”

 

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The following are specifically created snacks for people with dysphagia. They melt in your mouth.

EAT provides a sweet option, and SAVORESE gives you choices for savory snacks!

(Nothing to financially disclose in making these recommendations.)

  1. THE EAT BAR: https://www.theeatbar.com
  2. SAVORESE savory snacks, for the non-sweet tooth: https://savorease.com/

 

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IDDSI.org Reference:

© The International Dysphagia Diet Standardisation Initiative 2019 @ https://iddsi.org/framework. Licensed under the CreativeCommons Attribution Sharealike 4.0 License https://creativecommons.org/licenses/by-sa/4.0/legalcode. Derivative works extending beyond language translation are NOT PERMITTED.

IDDSI Board Member’s (Catriona M. Steele, Ph.D., CCC-SLP, S-LP(C), Reg. CASLPO, ASHA Fellow) Input to further emphasize that IDDSI avoids prescriptive lists:

Hi everyone! Thanks to Karen for this work. Please note, however, that IDDSI specifically avoids providing lists of foods or liquids that are examples of the different IDDSI levels. There is a very good reason for this. Unlike the former NDD approach, which contained lists of foods that were allowed or not allowed under the different “diets”, the IDDSI framework is NOT prescriptive. Rather, it is DESCRIPTIVE. In making this statement, we want to emphasize our recognition that foods and liquids may have properties that CHANGE due to things like freshness, temperature, and whether or not they have been chilled and reheated (among other factors). These changes could easily mean that a product moves from one level on the IDDSI framework to another. For this reason, we strongly advise that one should NOT presume or assume the IDDSI level of a product. Our advice is always that one should test the product using IDDSI’s testing methods to be certain of where it falls in the framework on that particular day under those particular serving conditions. This does not mean that everyone needs to constantly do IDDSI testing at every meal, but it does mean that the typical properties of a product under serving conditions should be evaluated before slotting it into its usual or expected place on the IDDSI framework, that this initial evaluation should involve several repeated tests to account for variation, and that audits (click here for IDDSI link on how to use IDDSI Audit Sheets, which can be found under the IDDSI Resources tab->Implementation Resources) can be used after initial testing to confirm that a product has not changed. Karen’s suggestions here should be used as suggestions, but IDDSI’s guidance is always to test to be certain.

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This handout created November 2020 by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com;

Board Certified Specialist in Swallowing and Swallowing Disorders.

You may print this list of suggestions as a PDF and share.

By Karen Sheffler

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