How to Ride the Wave of Liquidized Diet

With the new guidelines from the International Dysphagia Diet Standardization Initiative (IDDSI), we now have very clear definitions for diet consistency and texture, and guidance on how to test the foods to be sure they are correct. This is vital, since choking is a leading cause of death for individuals with intellectual and developmental disabilities. 

A new diet consistency has been introduced from the IDDSI, and that is Level 3 Liquidised Diet. There may have been individuals ordered a “liquid diet” in the past, which is the closest order to the Liquidised Diet. You can see how it fits within the framework below. You will notice there is also a liquid consistency associated with the diet level. It is called Moderately Thick Liquids, and is the “old” honey thick consistency, for reference. This means that all foods must be a moderately thick liquid consistency. However, an individual may have a separate liquid order for something other than moderately thick. Always make sure you are following the diet order for both diet consistency and liquid thickness.

Identifying and Testing Level 3 Liquidised Foods

Level 3 liquidised foods should be blended to a smooth, liquid consistency with no lumps. No liquid should separate from the food. The food should be either thinned or thickened to moderately thick consistency as appropriate. These foods require no chewing, and cannot be eaten with a fork. Foods should never be sticky, and should pour off a spoon when tilted. When spilled onto a surface, the food should spread out into a thick puddle.

You can check to see if your foods are the proper consistency using the IDDSI Flow Test and the Fork Drip Test. The food should pass both tests.

IDDSI Flow Test – For this test, you will use a 10 mL syringe that is 61.5 mm from the zero line to the 10 mL line (as shown). 

The size of the syringe is important, as your test will be inaccurate if a different size is used. Fill the syringe to the 10 mL line with the liquid, holding your finger over the nozzle at the bottom to prevent it from running out. Remove your finger, and allow the liquid to run out of the syringe for 10 seconds before replacing your finger to stop the flow. After 10 seconds, there should be no less than 8 mL of liquid remaining. You can see a video demonstration of this test here.

Fork Drip Test – Scoop the food onto a fork. The food should not sit in a mound on the fork. It should drip slowly through the tines in strands or dollops.

How To Get the Right Texture and Consistency

To prepare foods to level 3 liquidised, you will need a blender or food processor. Add the food to the blender or food processor. It’s helpful to cut the food into smaller pieces before putting it in the machine. It’s also best to prepare more than one serving of food at a time, because most machines have trouble with small amounts – plus you’ll make less work for yourself in the future. 

Turn the dial to “purée” or “high.” While the machine is running, add liquid in the top, a little at a time. If there’s not an opening in the top, add the liquid before turning on the machine. Turn the machine off, and scrape down the sides as needed. Continue doing this until the food is smooth and free of lumps, and the proper consistency. If it is too thin, you will need to thicken it with a thickening agent.

Liquids that may be used to liquidise foods (not all of these are appropriate for every situation):

• Chicken/beef/vegetable broth
• Milk or cream
• Non-Dairy Milk (soy, almond, etc.)
• 100% Vegetable juice
• 100% Fruit juice

*Note: Do not use water to liquidise foods. Water dilutes the flavor of foods, making them less tasty.

Use one of these thickening agents if the food is too thin (not all of these are appropriate for every situation):

• Thick-It, Thicken Up, etc.
• Powdered Milk
• Powdered Mashed Potatoes
• Canned pumpkin or sweet potatoes
• Applesauce
• Hummus or other pureed beans

Foods to Avoid on the Level 3 Liquidised Diet

While most foods can be liquidised, there are some that shouldn’t be, or that just don’t work out well in a liquid form. These are some foods that should not be liquidised (please note that this list may not be exhaustive, and caretakers will need to use professional judgement):

• Peanut butter and other nut butters, unless liquidised with another food to the appropriate consistency, as outlined above
• Bread – bread should not be liquidised unless it is part of another food (like stuffing)
• Raw vegetables
• Corn and peas – the skins generally don’t liquidise well
• Hard raw fruit, like apples, fruits with skin, like grapes, or fibrous fruits, like pineapple and rhubarb
• Dried fruit
• Some steak and other gristley meats
• Bacon
• Pizza and other foods that are similarly dry. In order to get the proper consistency, you’d have to add too much liquid, and the flavor of the original food would be lost.
• Cereal

Other foods to avoid giving to someone on a level 3 liquidised diet are:

• Soup with pieces of food in it (always liquidise to proper thickness and consistency with no lumps)
• Hard candies or lollipops
• Cheese chunks
• Marshmallows
• Chewing gum
• Sticky mashed potatoes
• Dry cake or biscuits
• Crunchy snacks, like chips and pretzels
• Over cooked oatmeal or porridge
• Gelatin
• Any crust or skin that forms on food after heating, like cheese
• Juicy foods where liquid separates from the food in the mouth, like watermelon (liquidise and thicken to proper consistency)

Tips For Feeding

Since individuals requiring a level 3 liquidised diet are at an increased risk of choking, there are some tips and strategies you can use to help lower that risk. Unless otherwise ordered by a physician or speech therapist, follow these tips:

• Have the person sit upright at all times, and wear/use any adaptive equipment needed, including during administration of medication, and while drinking beverages.
• If the individual is able to eat unassisted, do not feed them. If assistance is needed, provide the minimal assistance necessary. This helps preserve the individual’s dignity.
• Use a small spoon, or a “baby” spoon. Having too much in the mouth at a time is a choking hazard.
• Allow the person adequate time to “chew” the food and swallow before offering more. Do not rush.
• Offer a sip of a drink after each bite to help clear the mouth.
• Check the person’s mouth after each bite to make sure s/he is not pocketing food in the cheeks, and that it is not sticking to the teeth or the roof of the mouth.
• Do not comment negatively on the look, smell, or texture of the food. This can influence the person to not eat or eat less. Find something to comment positively on.
• Make efforts to make the foods look nice. Everyone eats with their eyes first. Here are some tips specific to level 3 liquidized foods:
  • Blend each food separate. Blending everything together will create an unappetizing brown color, and may not be very tasty.
  • Pour each food into a separate small bowl, and present the bowls on a plate.
  • Make sure foods are served at the appropriate temperature, being mindful that hot foods are not too hot. It’s easier to get burned on hot liquids than solids.
  • Used different shapes, sizes, and colors of bowls to maintain visual appeal.

Remember that not all individuals on the Level 3 Liquidised Diet will require Moderately Thick Liquids, but all level 3 liquidized foods need to be thickened to moderately thick consistency. Always consult your supervisor, the speech therapist, or dietitian with any questions you might have about how to prepare certain foods or if it may or may not be given.

With the right strategies, you can prevent a majority of choking episodes!