You can eat
- Smooth Level 4 purées, with no strings, bones or skins, passed through a food mill or fine sieve.
- Water, strained broths, pulp-free juices and herbal infusions, thickened to the prescribed level.
- Purpose-made gelled water, which holds its texture in the mouth.
- If you have been prescribed Level 5, finely minced meat, flaked fish or mashed vegetables with a thick sauce.
- Egg in moist preparations, such as creamy scrambled eggs, a soft mashed French omelette or hard-boiled egg blended into soup.
- Plain yoghurt with no pieces, thick custard, whipped fresh cheese or blended cottage cheese.
- To enrich dishes, blend extra virgin olive oil, milk powder, grated cheese or nut butter into the purée.
- Fruit as compote or finely blended, such as apple, pear or ripe banana, with no lumps or skins.
What to avoid
- Mixed consistencies in the same mouthful, such as soup with noodles or pieces, milk with cereal, or yoghurt with fruit.
- Fruit that releases juice when bitten, such as watermelon, melon, orange, mandarin or raw tomato.
- Stringy foods, such as asparagus, artichokes, celery, stringy green beans or pineapple.
- Dry foods or foods that crumble, such as crisps, hard biscuits, rusks, whole nuts, breadsticks or puff pastry.
- Sticky foods, such as soft untoasted sliced bread, elastic purées and chewy sweets.
- Loose grains, seeds or skins, such as loose rice, unstrained pulses, grapes or kiwis.
- Dessert jelly, because animal gelatine melts in the mouth and agar jelly releases water.
- Thickening by guesswork or changing the prescribed texture on your own.
Changes that help
Water and drinks throughout the day
Instead of plain water, use water thickened with xanthan gum or gelled water, because thin liquids move too quickly when swallowed.
Soups and broths
Instead of soup with noodles or broth with pieces, have a smooth, uniform soup at the same IDDSI level, because mixed consistencies require different swallowing rhythms.
Meat and fish
Instead of dry steaks or unbound flaked fish, prepare a purée with egg or minced meat with a thick sauce, because dry fibres break apart.
Bread and breakfast
Instead of soft bread or dry biscuits, have a smooth porridge or dissolvable bread with thickened milk, because bread forms a gummy mass and biscuits crumble.
Habits that help
- Sit upright with your back straight at 90 degrees and your feet supported.
- Eat without the television on and do not talk while there is food in your mouth.
- Use a dessert spoon, about 5 to 10 ml per mouthful, and swallow completely before the next one.
- Keep your back straight for 30 to 45 minutes after eating; do not lie down.
- Brush your teeth, gums and tongue before and after every meal.
Swallowing seems automatic until it stops being so. This often happens with age, after a stroke or with conditions such as Parkinson’s disease or dementia. It may start with throat clearing, coughing when drinking or meals left unfinished.
Often, the family is the first to notice. If not addressed, dysphagia can have serious consequences. Food can enter the lungs and cause pneumonia, while eating less leads to weight and strength loss [2]. Many measures for eating more safely can be put into practice in the kitchen and at the table, using the texture prescribed by your medical team.
What is dysphagia, and why is it more common with age?
Oropharyngeal dysphagia is difficulty safely moving food, drink or saliva from the mouth into the oesophagus. It is a symptom. It indicates that something is going wrong in one of the phases of swallowing. See “Adapted textures for dysphagia”.
It is useful to distinguish it from oesophageal dysphagia. In this case, the bolus gets stuck further down, in the tube leading to the stomach, and feels like a blockage behind the breastbone.
It can occur at any age, for example after neck surgery. However, it is much more common in older people. Over the years, the muscles of the tongue and throat lose strength, and the reflexes that protect the airway become slower. This is called presbyphagia. Dysphagia is also common after a stroke and in Parkinson’s disease or dementia, according to the European guideline on clinical nutrition in neurology [2]. See “Food and Parkinson’s”.
The loss of muscle that comes with age also affects the muscles used for swallowing. That is why it is closely linked to sarcopenia. In older people, signs of dysphagia are associated with a high risk of malnutrition and dehydration [3]. Taking many medicines and having a dry mouth can make it worse.
Who diagnoses dysphagia, and how?
The doctor and speech and language therapist make the diagnosis. They assess whether you can swallow safely and decide which textures and thickness levels are safe for you. We adapt the food, design the menus and ensure adequate energy and protein within that plan. We do not decide the texture level.
The European guideline on dysphagia after a stroke states that a texture-modified diet and thickened liquids should be prescribed only after swallowing has been assessed [4].
It usually starts with a simple screening tool, the EAT-10 questionnaire. It consists of ten brief questions about how swallowing affects your everyday life, your weight or the effort involved in eating. It is the usual first step [5]. If the result is abnormal, an examination is needed.
The bedside examination is carried out using volume-viscosity tests. In Spanish hospitals, the most commonly used test is the MECV-V, the volume-viscosity clinical examination method [5]. A professional gives you small, increasing volumes at different thickness levels. At the same time, they check for loss of efficacy (food residue in the mouth, needing several attempts to swallow, lips that do not close) or safety (coughing, a wet voice or a drop in oxygen levels).
If the examination does not provide a clear answer, or if food is suspected of entering the airway without causing a cough, imaging tests are carried out. Videofluoroscopy and fibreoptic endoscopic evaluation of swallowing make it possible to see the bolus pass through and are the reference tests [4]. Based on the results, the medical team decides your food texture and liquid thickness.
What are the IDDSI levels for food textures and drinks?
For years, terms such as “thick purée”, “soft diet” and “honey consistency” meant different things in each home, care home or hospital. To standardise them, the international IDDSI initiative created a framework with eight levels, from 0 to 7, each with its own colour and definition [1].
Drinks range from Level 0 to Level 4:
- Level 0, thin liquid. Flows quickly, like water. It requires fast, precise control to prevent it from entering the larynx.
- Level 1, slightly thick. A little thicker than water. It flows and can be drunk from a cup.
- Level 2, mildly thick or nectar. Runs off a spoon quickly, but more slowly than water. It takes some effort to drink through a straw.
- Level 3, moderately thick or honey. It can be drunk from a cup with some effort or taken with a spoon. It drips slowly through the prongs of a fork.
- Level 4, extremely thick or pudding. Holds its shape on a spoon and does not drip through the prongs of a fork. It cannot be drunk from a cup.
Foods range from Level 3 to Level 7:
- Level 3, liquidised. Smooth and uniform. It does not need to be chewed and can be taken from a spoon by sipping.
- Level 4, puréed. Completely smooth, with no lumps, skins or bones. It does not need to be chewed and slides off in one piece without sticking.
- Level 5, minced and moist. Pieces no larger than 4 mm for adults, bound with a thick sauce and squashable with the tongue [1].
- Level 6, soft and bite-sized. Tender pieces no larger than 15 mm for adults. They can be cut or mashed with the side of a fork, without a knife [1].
- Level 7, regular. Usual texture. Its “easy to chew” variant includes only tender, juicy foods.
The IDDSI framework itself suggests simple tests to do at home: the fork test, the spoon tilt test and the flow test using a 10 ml syringe [1]. These let you check in the kitchen whether what you have prepared matches the prescribed level.
Which thickener should you use, and how is it prepared?
Thickeners are powders that turn a thin liquid into a thicker one. With greater thickness, the bolus moves down more slowly, allowing time for the airway to close before it passes.
There are two types, and the difference matters:
- Modified starch thickeners. These were the first to be developed. Amylase, an enzyme in saliva, breaks down starch, so the liquid may thin in the mouth just before swallowing. They also make the drink cloudy, change its flavour and continue to thicken if the glass is left to stand.
- Xanthan gum or other gum-based thickeners. These are more resistant to amylase and maintain their thickness in the mouth. They are usually clear and change the flavour less. According to the European guideline on dysphagia after stroke, they may leave less residue in the throat after swallowing [4]. That is why xanthan gum thickeners are preferred.
To prepare it, measure the exact amount you have been prescribed and follow the instructions on the packaging. In general, the powder is added to the liquid while stirring vigorously. Then wait for the time specified by the manufacturer, until it reaches its final thickness.
How can you enrich purées to avoid weight loss?
One of the greatest risks of dysphagia is malnutrition, meaning too little energy and protein. When food is blended, meals often become less energy-dense. The person feels full sooner, gets tired and leaves unfinished the food they need most. This is one of the first things we look at in consultations.
This accelerates muscle loss, increases frailty and raises the risk of fractures, as we explain in our guide to eating with osteoporosis. As a starting point for older people, the European guideline on nutrition in geriatrics suggests around 30 kcal per kilogram of body weight per day [3]. For protein, it suggests between 1 and 1.2 g per kilogram per day. For frail older adults, between 1.2 and 1.5 g [3]. These are general figures that are adjusted for each person. If you have kidney disease, your nephrologist or dietitian will tell you how much protein, potassium, phosphorus and other minerals are appropriate for you, depending on your stage.
To meet these needs without increasing portion sizes, we enrich dishes with foods that have a uniform texture:
- More protein. Two tablespoons of skimmed milk powder, about 20 g, provide nearly 7 g of protein without changing the thickness. Well-blended cooked or pasteurised egg white, whipped fresh cheese, cottage cheese, hard cheese grated and blended into the purée, or silken tofu can also be used.
- More energy. Add a drizzle of extra virgin olive oil raw, just before serving. Each tablespoon, about 10 g, provides around 90 kcal. Ripe avocado or 100% nut butter can also be used, always blended into the purée, as nut butter on its own is very sticky.
That is why it is recommended to offer texture-modified, enriched meals to older people with dysphagia who are malnourished or at risk of malnutrition [3]. If this is not enough, nutritional support with a pudding or cream texture may be needed. Your doctor or dietitian-nutritionist should prescribe it. If you also need to regain weight, an appointment with a dietitian for weight gain may help. The general framework is in our healthy longevity guide.
How can you drink enough without choking?
Dehydration is one of the most common complications of dysphagia, and it can be prevented. Water is the hardest thing to swallow. Because it is a thin liquid, it flows quickly, and the larynx may not close in time if reflexes are slow.
As a general reference, EFSA estimates a total water intake of 2 litres a day for women and 2.5 litres for men, including water from food. For frail older adults, the European guideline on nutrition in geriatrics recommends offering at least 1.6 litres of drinks a day to women and 2 litres to men [3]. The team adjusts the amount if an illness or hot weather calls for a different plan. Thickening drinks and changing food texture can lead to eating and drinking less, so intake should be monitored [4]. Drinking too little puts strain on the kidneys, worsens constipation and can lead to increased confusion.
To drink enough while reducing risk:
- Small amounts, often. Offer small amounts throughout the day, without waiting until the person feels thirsty.
- Thicken everything. All drinks should have the prescribed thickness, including water with meals, herbal infusions, broths, juices and milk.
- Water in food too. Apple or pear compote, whisked yoghurt and smooth vegetable soups also provide fluid.
Watch for signs of a lack of fluids: dry mouth and thick saliva, passing little dark urine, less elastic skin, drowsiness and increased constipation, which we discuss in our constipation guide.
Which foods should be avoided with dysphagia?
The highest-risk foods are those with mixed consistencies, combining liquid and solid in the same spoonful. The solid part needs to be held and chewed. Meanwhile, the liquid part can escape into the throat, potentially reaching the larynx before it closes and entering the airway.
Most can be adapted:
- Milk with biscuits or cereal. Blend everything until smooth and uniform.
- Yoghurt with pieces of fruit or muesli. Replace it with smooth plain yoghurt, without seeds.
Other foods to avoid depend on how they behave in the mouth. The fibres in asparagus, pineapple or dry meat do not break down and can remain in the throat. Crumbs from crunchy foods can be inhaled while breathing. Sticky foods, such as soft sliced bread, form a mass that sticks to the roof of the mouth. Loose grains, seeds and skins, such as those on pulses, kiwis or strawberries, can escape from the bolus.
To check a purée, blend it with a powerful blender and pass it through a fine sieve. If no solid pieces remain, it meets the definition of Level 4 [1].
How to sit and eat to swallow safely
Posture is just as protective as texture. Poor posture can undo the benefit of even the best purée.
If the person eats in bed, raise the head of the bed until they are sitting upright, at an angle of 80 to 90 degrees, with cushions to prevent them from leaning to one side.
Some people also need a swallowing manoeuvre called chin tuck. This involves tilting the head forwards just as they swallow. The European guideline on dysphagia after stroke describes it as an aid for a specific problem, when food escapes into the throat too early [4]. It does not work for everyone, and a speech and language therapist recommends it after assessing how you swallow. What applies to everyone is not to tilt the head backwards when drinking, as this leaves the airway more exposed.
Lying down straight after eating encourages stomach contents to move back up towards the throat, as happens with gastro-oesophageal reflux. This increases the risk of delayed aspiration, which is why the back should be kept upright for a while after eating.
A clean mouth also offers protection. Poor oral health, together with dysphagia, is a significant risk factor for aspiration pneumonia, which is why good oral hygiene is recommended [4].
If they cough during a meal
Coughing is a warning that some food or drink has reached the entrance to the airway. If the person is coughing forcefully, stop feeding them, lean their torso forwards and encourage them to keep coughing. Do not give them water to “clear it” or slap their back while the cough is working.
If they cannot cough, speak or breathe, call 112. In the meantime, provide first aid for choking: up to five back blows between the shoulder blades and, if this does not resolve it, up to five abdominal thrusts. This is what the European Resuscitation Council guidelines recommend [6]. If coughing episodes recur, ask for the doctor and speech and language therapist to review the food textures.
Silent aspiration is harder to spot, as it occurs without coughing. It is more common after a stroke or in advanced dementia. Look out for indirect signs: constant throat clearing, a wet or gurgling voice after swallowing, watery eyes while eating, laboured breathing or a low-grade fever without a clear cause.
If fever, cough and shortness of breath develop in the days after a choking episode, go to the emergency department that same day. It may be aspiration pneumonia.
What mistakes do we see in consultations?
The things that go wrong at home tend to recur. These are the situations we hear about most often in consultations, and how they can be addressed.
- Drinking less to avoid coughing. After two or three frightening episodes, many people reduce their fluid intake without saying so. The solution is to thicken drinks properly and keep drinking.
- Adding water to purée so it goes down more easily. Too much water or broth makes the portion larger and dilutes its nourishing content, so less gets eaten. To make it smoother, use milk, oil or a more nourishing cream instead.
- Changing the drink or thickener but keeping the same amount. The same amount of powder does not produce the same thickness in water, juice or milk, or with a different brand. Check each change using the fork or spoon test.
- Serving the same brown soup every day. After weeks of identical purées, people can become tired of them and stop eating. Serve white fish purée, orange pumpkin soup and green pea purée separately. Silicone moulds can give purée the shape of a fillet or a carrot.
- Two large meals that are left unfinished. Eating is tiring. Five or six small meals a day, with the main meals when energy is highest, often work better.
All of this becomes more significant when there is mouth pain or mucositis, as can happen with head and neck tumours (we cover this in our guide to eating with cancer). It also matters when breathing is difficult, as explained in our COPD guide. In these cases, the plan is tailored even more closely to each person, to maintain food intake, nutritional status and quality of life [3].
Eating with dysphagia can become a calm experience again. With the right texture, a thickener that does not change the flavour and a little kitchen technique, meals can be nutritious, appetising and safe.
If you or a family member lives with dysphagia and needs to learn how to thicken drinks, enrich dishes or plan menus adapted to the plan set by your medical team, we can support you. Our dietitian-nutritionist team in nutrition for longevity and older people sees people in our Barcelona clinic and online.
Your first step this week
Warm pear and apple compote with smooth yoghurt
Breakfast or snack: blend cooked fruit at maximum speed and sieve it, then mix it evenly with smooth plain yoghurt with no pieces for a hydrating snack that is easy to swallow
When to see a doctor
When to see a doctor
We can adapt textures and thicken drinks so that you can eat safely and enough. We do not assess how you swallow, decide which texture level you need or determine whether another feeding route is necessary. Those decisions are made by your doctor and speech and language therapist.
Make a medical appointment without waiting to change your diet if you notice any of these signs:
- You cough when drinking water or choke while eating [2]
- You lose weight without trying: your clothes become loose or your rings fall off
- You are more confused than usual, drink very little and pass dark urine [2]
New confusion while drinking very little: emergency care today, especially in summer. Weight loss: see your GP this week; it should be investigated and treated, it is not “just part of getting older”. Coughing or choking when eating or drinking: also see your GP this week, so they can assess swallowing and refer you to speech and language therapy if needed.
With textures properly adjusted, eating can be enjoyable and free from fear. These signs indicate when the adjustments need to be reviewed.
Tell us how your relative is eating, or how you are eating
At the first visit we talk about how mealtimes go at home, what is hard to swallow and what worries you most. Within a week you have a written plan. Whoever looks after the person can come along, or join by video call.
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Recipes for this goal
Sources
- Cichero JAY, Lam P, Steele CM, et al. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia. 2017;32(2):293-314. doi:10.1007/s00455-016-9758-y
- Burgos R, Bretón I, Cereda E, et al. ESPEN guideline clinical nutrition in neurology. Clin Nutr. 2018;37(1):354-396. doi:10.1016/j.clnu.2017.09.003
- Volkert D, Beck AM, Cederholm T, et al. ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr. 2022;41(4):958-989. doi:10.1016/j.clnu.2022.01.024
- Dziewas R, Michou E, Trapl-Grundschober M, et al. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J. 2021;6(3):LXXXIX-CXV. doi:10.1177/23969873211039721
- Zugasti Murillo A, Gonzalo Montesinos I, Cancer Minchot E, et al. Manejo hospitalario del paciente con disfagia. Encuesta y recomendaciones del área de nutrición de la SEEN. Endocrinol Diabetes Nutr. 2023;70(Supl 3):1-9. doi:10.1016/j.endinu.2022.04.005
- Olasveengen TM, Semeraro F, Ristagno G, et al. European Resuscitation Council Guidelines 2021: Basic Life Support. Resuscitation. 2021;161:98-114. doi:10.1016/j.resuscitation.2021.02.009
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