Today’s topic is the National Dysphagia Diet (NDD).


The NDD was published in 2002 by the American Dietetic Association.


The NDD was created in order to:

  1. Standardize terminology
  2. Use a scientific foundation based on properties of liquids and solids
  3. Develop a correlation between diagnostic measures and diet recommendations
  4. Develop a diet applicable across the healthcare continuum


Here are the 4 different levels for semi-solids and solids:

1 – Dysphagia Pureed – homogenous, very cohesive, pudding-like,

requiring bolus control, no chewing required

2 – Dysphagia Mechanically Altered – cohesive, moist, semi-solid foods,

requiring chewing ability

3 – Dysphagia Advanced – soft-solid foods that require more chewing ability

4 – Regular – all foods allowed


Since no specific foods or recipes are listed, there is a lot of room for interpretation (this is an understatement!). Some facilities specify meats as “chopped” or “ground” within levels 2 or 3. Others offer “bite size” or “finger foods.” And others differentiate between “Dysphagia I” and “Pureed” (regular scrambled eggs vs pureed scrambled eggs???). Sometimes whole pieces of bread or a roll will show up on a “chopped” diet tray, as well as whole pancakes.

I’ve worked in several different hospitals, and each one has its own way of labeling the various diet levels/modifications. A “mechanical soft” diet can mean one thing at one facility and something different at another. There can even be inconsistencies within each diet level at one facility; for example, chicken will be chopped, but not fish on a “chopped” diet. This can lead to a lot of confusion among staff, not to mention patients and family members.

There are many factors that go into determining which diet level is right for a patient. We need to take into account premorbid conditions as well as current status. Was there surgery involved? Prolonged intubation post-op? What is the patient’s respiratory status (trach, vent, Bipap, room air)? Are they awake enough to eat safely? How is their dentition? What is their usual diet level? Ultimately, we want to recommend a diet level that patients will be able to safely and easily manage with the least risk of aspiration.

Sometimes it’s not necessarily an oral phase dysphagia that determines the need for chopped foods, but the patient’s ability to physically feed him/herself. For example, someone with hemiparesis due to a stroke may not be able to use both hands to cut up foods. A chopped diet would allow them to be more independent in eating.

A patient’s ability to swallow can change during a hospitalization. It’s important for SLPs to follow patients as they recover so diet levels can be modified as needed. For example, someone who recovers quickly from a stroke may regain enough strength to tolerate soft solid foods, even if they started out on a pureed diet. Or the patient who is on a pureed diet because they don’t have their dentures should be reassessed for solid foods once their family brings in their teeth.

Patients should also be re-evaluated after a surgery or change in status (having another stroke or seizure, change in respiratory status) to assess for any changes that would affect their ability to eat safely.

It can be frustrating to not have specific foods or recipes listed for each diet level in the NDD, however, this also allows for more choices. Having an open line of communication with the kitchen and dietary staff makes it easier to order the safest and most appropriate diet based on your patients’ needs. I’ve found that most dieticians are more than willing to “tweak” a diet at my request in order to meet a patient’s needs (cream of wheat instead of oatmeal, no blended soups or including extra sauce/gravy). Each patient is unique in terms of his/her swallowing ability and food preferences and being able to customize a diet can help to improve safe nutritional intake.


So has the creation of the NDD met the intended goals?

I think we still have a ways to go even with the first goal: to standardize terminology. Even as more facilities adopt the NDD, there’s still wide variation in the types of foods that are included, or not, within each diet level.


I’d love to hear from you:

Does your facility use the NDD levels?

If not, what do you call the different diet levels you order?

And what foods are included or not in each level?

Do you work closely with your dietary staff?

How easy is it to customize diets for your patients?

What does your facility do to improve the appeal of pureed diets?


Please email your responses to: and I’ll publish your answers in a future article.


Maria Quici, MS, CCC-SLP



Sullivan, P., Steele, C., Pelletier, C. & McCullough, G. (2005). Standardizing Dysphagia Diets: The National Dysphagia Diet and Other Considerations. Rockville, MD: ASHA.





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