Level 1 National Dysphagia Diet

Medically reviewed by Drugs.com. Last updated on May 4, 2025.

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A level 1 National Dysphagia Diet includes only pureed foods. Pureed foods should be smooth and free of lumps. Pureed foods require very little chewing. Your healthcare provider will tell you how long you need to follow this diet. He or she may also explain the International Dysphagia Diet Standardization Initiative (IDDSI). The IDDSI contains 8 levels, from the thinnest liquids and foods to the thickest. Pureed foods are on IDDSI level 4. Your provider may show you how to use IDDSI guidelines to test the thickness of your food or liquid.

DISCHARGE INSTRUCTIONS:

Call your doctor or dietitian if:

• You cough or choke when you swallow food or liquid.
• You think the foods or liquids on your plan are difficult to swallow.
• You are having new or worsening problems swallowing.
• You have questions or concerns about your condition or care.

What you need to know about liquids:

Your healthcare provider will tell you how thick your liquids need to be. This depends on your ability to swallow. For the IDDSI system, liquids are levels 0 through 4. Your healthcare provider will tell you if you can have liquids from levels 0, 1, 2, or 3. Liquids can be thickened, if needed, with thickeners, flour, cornstarch, or potato flakes. Foods that are liquid at room temperature should also be thickened. These include frozen malts, yogurt, milk shakes, eggnog, ice cream, and gelatin.

• Thin liquids flow quickly. These liquids take little or no effort to drink. Examples include water, non-fat milk, no-pulp juice, coffee, tea, and soft drinks. The IDDSI level for these liquids is 0 (thin).
• Slightly thick liquids are thicker than water but still flow through a bottle's nipple. A little more effort is needed to drink these liquids. The IDDSI level for these liquids is 1 (slightly thick).
• Nectar-thick liquids have the same thickness as vegetable juices and milkshakes. It should take some effort to drink the liquid through a straw. The IDDSI level for these liquids is 2 (mildly thick).
• Honey-thick liquids should be difficult to drink through a straw. The IDDSI level for these liquids is 3 (moderately thick).
• Pudding-thick liquids need to be eaten with a spoon. You should not be able to drink them through a straw. The IDDSI level for these liquids is 4 (extremely thick).

How to prepare pureed foods:

• Add liquid as you puree. Examples include gravy, sauce, vegetable or fruit juice, milk, or half and half. Use only a small amount of liquid at first. Puree the food and add liquid as needed to get the same texture as pudding.
• Potato flakes can be used to thicken your food if you thinned it too much with liquid.
• Add dry milk powder for extra protein and calories, if needed.

Foods you can eat:

All foods listed below should be pureed to the same texture as pudding. Puree until there are no lumps or chunks.

• Grains:
  • Smooth cooked cereals, such as cream of wheat or smooth oatmeal
  • Breads, rolls, and crackers
  • Pancakes, sweet rolls, Danish pastries, French toast, and muffins
  • Well-cooked pasta
• Vegetables and fruits:
  • Any pureed cooked vegetable
  • Tomato sauce or tomato paste without seeds
  • Mashed or pureed potatoes without skins
  • Any pureed fruit
  • Well-mashed bananas
  • Well-mashed avocados
• Dairy products:
  • Smooth puddings or custards
  • Smooth yogurt, sour cream, or pureed cottage cheese or cream cheese
  • Whipped topping
• Meat and other protein foods:
  • Pureed cooked meats
  • Pureed casseroles
  • Egg soufflés
  • Pureed tofu, beans, or lentils
• Fats and oils:
  • Butter or margarine
  • Mayonnaise or vegetable oil, such as olive oil or canola oil
  • Smooth sauces, such as white sauce, cheese sauce, or hollandaise sauce

Foods to avoid:

• Any food that has not been pureed
• Foods with a tough texture, such as raw fruits or vegetables, or nuts
• Pureed foods that still contain pulp, seeds, or chunks
• Yogurt that contains fruit pieces
• Any food with lumps, such as soup
• Peanut butter (unless it is part of a recipe for a pureed food)

Other guidelines to follow:

• Pureed foods can be frozen in small portions and reheated later. When you reheat foods, do not allow a tough outer crust to form on the pureed food. This can make the food hard to swallow.
• Eat a variety of healthy foods. Eat 6 to 8 small meals each day to get enough calories and nutrients. You may need to take a multivitamin and mineral supplement if you do not get all the nutrients you need. Ask if you can crush these and add them to pureed food.
• Rinse your mouth with water after each meal. This will help to prevent infections and problems with your teeth.

Follow up with your doctor or dietitian as directed:

Your plan may change over time if your ability to swallow changes. Follow the instructions you get at each follow-up visit. Write down your questions so you remember to ask them during your visits.

For more information about the IDDSI:

You can find official information about IDDSI levels and instructions for thickness testing by going to www.IDDSI.org.

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The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

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