IDDSI Level 3 - separating foods and liquids. Dark background on top and orangish yellow on bottom with picture of red soup and 3 different smoothies: pink, yellow, and green

IDDSI Level 3 – Separating Foods and Drinks

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IDDSI Level 3 refers to both food and liquids. Foods and drinks are very different but have many similarities, so having overlap in the descriptions for Dysphagia is very important. The graphic below was developed by the IDDSI team to clarify the different textures/consistencies.

This level of liquids are known as moderately thick liquid. They are the 4th tier up from the bottom in the new framework for dysphagia diets. They were formerly known as honey thick liquids under the National Dysphagia Diet (NDD).

Level 3 foods are pureed to a consistency called Liquidized. They start as solids but need to be altered so they can be drunk or eaten with a spoon. The International Dysphagia Diet Standardisation Initiative was developed to simplify the explanation of altered texture food and liquids.

Dysphagia diet levels 1 through 7 includes the consistency of liquid and food and how they should interact with each other. 2 pyramids next to each other with one showing liquids and one showing foods, IDDSI Level 3 and 4 show overlapping food and drink levels.

Why Thickened Liquids or Liquidized Foods?

Dysphagia, a diagnosis of difficulty swallowing, can make eating and drinking a very difficult process. What should be an easy task becomes fear and anxiety inducing. Dysphagia should be managed by your doctor, any specialists on your team and a speech therapist. A dietitian is a good resource as well.

Liquids may need to be thickened so that they move more slowly and allow your muscles time to coordinate. Liquids that move too fast can causing symptoms like coughing, and can possibly run into your lungs, called aspiration.

Foods may need to be blended and thinned until they are completely smooth so that they are easier to manage. For anyone who has trouble swallowing because of trouble with their esophagus, this may be the best level for them so that the food travels down the esophagus easier.

Moderately Thick Liquids, IDDSI Level 3 Thickened Liquids

Moderately thick liquids, also known as IDDSI Level 3 liquids, are thickened to improve safety for swallowing. The thicker the liquid, the more time your mouth muscles have to control where the liquid goes.

Level 3 liquids are not typically naturally occurring. You will need to start with a thin or slightly thick liquids (like tomato juice), and add a powdered or gel thickener and stir or shake. Follow the instructions on the thickener packet for preparing your drink.

Level 3 liquids will likely still be able to flow through a straw (although it may be a larger diameter straw) with effort. The cheek muscles will probably get a work out getting this liquid through your straw. These liquids can be drunk from a cup or sipped from a spoon (think stew consistency).

Liquidized Foods for IDDSI Level 3

Liquidized food will fit all the criteria for moderately thick liquids that are listed above. Also, another way to test that the food is pureed or blended to the correct consistency is using a fork. The fork drip test means that when you try to lift the food out of a cup but it will drip through the tines.

Level 3 foods cannot be eaten with a fork, if they stay on a fork easily it means the food is too thick. These foods will be very smooth and have almost no texture. There should be no lumps or chunks. If there are “bits” left after pureeing, try passing it through a strainer to remove the parts that are fibrous, chunky, or contain gristle.

Level 3 foods are easiest eaten with a spoon. Think soups that are smooth and thicker than broth, or smoothies that are pureed perfectly smooth.

Testing For The Right Thickness

Testing for the right thickness of level 3 foods is easiest done using the fork test. If the food is perfectly smooth you may be able to use the flow test. When thickening liquids, testing with the flow test is the most accurate.

The flow test was developed by IDDSI and is the most accurate way to test the thickness of liquids. Watch this video from IDDSI to see a quick demonstration of the flow test.

You do not need to purchase a flow test funnel, instead the correct size syringe can be purchased and used to test your liquids. This syringe holds 10 mL and when held up next to a ruler, the amount of space from 0 ml to 10ml should show 61.5 mm in length. Be sure to choose a syringe that shows each individual ml so you can properly identify your liquid thickness.

Use a funnel (otherwise known as a 10 mL syringe without a needle), and add liquid to the 10mL mark with your finger plugging the hole at the bottom. Set a timer for 10 seconds, push start and remove your finger. At the end of 10 seconds there should be between 8mL and 10 mL of liquid left.

Conclusion of IDDSI Level 3

Moderately thick liquids and liquidized foods, otherwise known as Level 3 on the IDDSI framework, are appropriate for some people with Dysphagia. Not everyone that requires level 3 liquids also needs liquidized food. You may have a recommended liquid level and a different recommended food level. Discuss what is best for you with your healthcare team.

A Speech Therapist and Dietitian can help tremendously when finding the safest food and drink options for you. If you have questions send me a message by clicking the Contact link above!

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