The National Dysphagia Diet: Guidelines for Purée

dysphagia diet, swallowing diisorder


The National Dysphagia Diet is the standard for dietary treatment of swallowing difficulties.

Patients have their level of puree determined by healthcare providers. (for an explanation of dysphagia, see this video What Is Dysphagia)

When using the Essential Purée Guidebook, please consult your healthcare provider (this includes the physician, speech pathologist and dietitian).

The language and Lingo of Modified Foods and Beverages

In 2002, the American Dietetic Association (now called the Academy of Nutrition and Dietetics) set the standards for the “National Dysphagia Diet: Standardization for Optimal Care”.

As of the summer of 2015, the International Dysphagia Diet Standardization Initiative is working to standardize the terminology for food textures and liquid consistencies for use around the world, in all cultures and with all age groups.

The following terms apply to modification for foods and beverages. Your healthcare provider will determine which of these is appropriate for you.

There is no “one size fits all” diet. All diets must be created with the advice of one’s healthcare providers, namely physicians and speech pathologists. Please consult your physician and speech therapist if you have any questions.

The Levels of Puree

The Essential Puree Guidebook recipes are for the Dysphagia Advanced Diet or Soft Diet, Number 6.

Instructions for Number 5, Mechanical Soft, and Number 4, Pureed, are included in the Essential Purée Guidebook .

If you’ve been told that you need to modify food textures, these are the standards:

Let us begin with the Regular Diet: FOOD AS WE KNOW IT

Regular Diet: All foods are acceptable. Foods may be hard and crunchy, tough, crispy and may contain seeds, skins and husks. Persons on a regular diet have the ability to produce saliva and chew for as long as it takes for the food to form a cohesive “ball” (bolus) for safe swallowing. Mixed textures are no problem. (Internationally known as “7”)

Some patients have a temporary need for puree and return to the regular diet. Some patients remain on puree for reasons indicated in their own medical history.

Dysphagia Advanced Soft Diet: (Internationally known as “Soft” or “6”)  Foods of “nearly regular” textures with the exception of very hard, sticky or crunchy foods. This texture requires chewing and tongue control. Foods should be tender and easy to break into pieces with a fork.

Dysphagia Mechanical Soft Diet: (Internationally known as “Minced and moist” or “5”)  Foods with a moist, soft texture. Ability to tolerate mixed textures needs to be assessed. Meats need to be chopped or ground. Vegetables need to be well cooked and easily chewed. Foods should be in small pieces (1/4” or 5mm). No hard, chewy, fibrous, crisp or crumbly bits. No husk, seed, skins, gristle or crusts. No “floppy” textures such as lettuce and raw spinach. No foods where the juice separates from the solid upon chewing, like watermelon.

Dysphagia Pureed: (Internationally known as “Extremely thick” or “4’)  All food should be pureed to a homogenous, cohesive, smooth texture. Foods should be “pudding-like” and hold its shape on a spoon. Contains no lumps. Not sticky. Pureed foods can be piped or molded and will not spread out if spilled. The prongs of a fork make a clear pattern when drawn across the surface of the puree.


The Essential Purée Guidebook does not deal with the liquid diet, only liquids thickened as beverages, MEANING A NECTAR OR HONEY CONSISTENCY. If you have been told that your liquids must be nectar or honey consistency, these are defined below.

If you’ve been told that you are now on a liquid diet, please see your healthcare providers. This means that all foods need to pureed to a liquid consistency. This diet may be “clear” liquid or “full” liquid. “Clear” liquids contain no solids. “Full” liquids contain pureed solids. Liquids must be the correct consistency for safe swallowing.

Your healthcare provider will tell you if you may use any of the recipes included or must use commercially available liquids.

Liquid Diet Definitions

Nectar Thick liquids: liquids coats and drips off a spoon like a lightly set gelatin. This consistency requires little more effort to drink than thin liquid. It is easier to control though the swallow than thin liquid and can flow through a straw or nipple. (Internationally known as “Slightly thick” or “1”)

Honey Thick liquids: liquids thicker than “nectar thick” and flows off a spoon in a ribbon, like actual honey. This consistency allows for a more controlled swallow. This consistency is difficult to drink through a standard straw. (Internationally known as “Mildly thick” or “2”)

Pudding Thick liquids: liquid stays on a spoon in a soft mass but will not hold its shape. It pours slowly off a spoon and is sip-able. This consistency is difficult to draw though a wide-bore straw. (Internationally known as “Moderately thick and Liquidized” or “3”)

This analysis was created by a recognized expert in the field of dysphagia, Laura Michael, a board member of the National Foundation of Swallowing Disorders and an ambassador to the International Dysphagia Diet Standardization Initiative (IDDSI), the committee working on establishing international standards for the National Dysphagia Diet. Laura is the author of a clinical manual for caregivers that may be obtained from her website,

For Clinicians: A Note from the Authors of the National Dysphagia Diet

The National Dysphagia Diet authors stress that the categorization process is a work in progress and far from a perfect science, especially as applied to the individualized needs of each dysphagia patient.

While establishing liquid and food-related categorical protocols may help to create a standardized “starting point” to evaluate the specific needs of each patient, both the NDD task force and ASHA experts acknowledge that there is much research to be conducted and it should never be applied as a “one-size-fits-all” approach.

The International Dysphagia Diet Standardization Initiative (IDDSI) work group has taken up the challenge to re-look at the dysphagia diet from a global perspective.

They are a group of people from diverse professions including nutrition & dietetics, medicine, speech pathology, occupational therapy, nursing, patient safety, engineering, food science & technology from around the world who have come together to establish an international standardized terminology and definitions for texture modified foods and thickened liquids for persons with dysphagia.

In the next several years clinicians just might see the next evolution of a the National Dysphagia Diet.