Porridge can mean different things to different people. Is it the grainy, Teochew-styled rice porridge, or the soft, mushy Cantonese congee? What about minced meat — how fine should the meat be chopped?

The texture of food may be a matter of style, but it is a big deal to patients who have difficulty swallowing, a condition known as dysphagia.

It is equally important for their carers, who have to prepare porridge and other soft meals when the patients are discharged back home; or when the patients are admitted to different hospitals or care homes.

Serving the wrong texture of food to a dysphagia patient can be dangerous. To ensure this aspect of safety, the Ministry of Health (MOH) adopted the International Dysphagia Diet Standardisation Initiative (IDDSI) framework of diet and fluid terminologies for Singapore public hospitals, community hospitals, and care homes.

IDDSI has been adopted progressively among SingHealth institutions. In June 2024, both Singapore General Hospital (SGH) and KK Women’s and Children’s Hospital (KKH) speech therapists, dietitians and kitchen staff began using the new terms to describe food textures in their meals for patients with dysphagia, following on the heels of Changi General Hospital and Sengkang General Hospital. SGH adopted IDDSI standards for drink thickness in 2021.

“Standardisation of food texture and drink thickness terms takes the guesswork out of food preparation for dysphagia patients. Because of the same terminology, patients would be served similar-looking food at not just the hospital, but also daycare centres. Over time, when the patient then goes home, the caregiver would have internalised the meaning of porridge and know that this is the kind of food that the patient should be taking,” said Ms Lee Yan Shan, Principal Speech Therapist, Speech Therapy Department, SGH.

Ms Chen Yu Hui, Speech Therapist, Speech Language Therapy Service, KKH, added: “By using IDDSI terminologies, caregivers, teachers and healthcare professionals share a common understanding of the safest diet and fluid recommendations for children with dysphagia. They will then be able to eat and drink safely in school and at home.”

Dysphagia is a symptom of underlying diseases — neurological conditions like stroke, Parkinson’s Disease and dementia, head and neck and gastrointestinal cancer, or general weakness from severe medical events. Children can have dysphagia when they are born with deformities like a cleft palate or tongue tie. Signs of dysphagia include coughing, choking or spitting up food or drink, food spilling out of the mouth or remaining in the mouth after swallowing, a feeling of food getting stuck in the throat, or pain when swallowing.

The revised terms came about after a review of clinical dietitian and speech therapy services in nursing facilities in 2018 under the MOH’s EatSafe initiative. “Nursing home staff highlighted to us that the inconsistent terminologies used for dysphagia diets across acute hospitals, community hospitals, and intermediate to long-term care facilities caused confusion and compromised patient safety,” said Ms Lee, a member of the MOH committee looking at the standardisation of terms.

Before the change, pureed diet at one institution might be known as minced diet in another. Food preparation was also not standardised across the board for the different dysphagia diet types. “The degree of softness in a soft diet depends on the ingredients used and how they are cooked. Using IDDSI means that there will be less confusion and better communication between staff when patients move from one healthcare setting to another. This ensures better safety and better continuity of care,” said Ms Lee.

Dysphagia can lead to aspiration, when food or drink enters the lungs instead of the stomach when swallowing. This can lead to chest infections, known as aspiration pneumonia, which can be life-threatening, explained Ms Lee.

“Speech therapists may recommend modified diet and fluid textures to make it easier and safer for people with dysphagia to swallow. For example, someone who has poor tongue control and poor jaw strength may benefit from a thicker liquid or pureed diet, so that the liquid does not flow immediately to the back of their throats and cause them to choke. Pureed textures may be helpful as patients do not need to use too much energy chewing on harder solids,” said Ms Lee.

At SGH, speech therapists began laying the groundwork for the eventual switch to IDDSI standards years ago. Speech Therapist Days were events to highlight the inconsistencies in food textures and how standardisation is important. At 2023’s Speech Therapist Day, SingHealth staff were invited to share their own IDDSI food recipes as a way of reinforcing the new terminology.

Levels of textures

When it came to diet textures, local healthcare institutions in the past used various terms to describe different characteristics of dysphagic diets.

With the IDDSI framework, classification was expanded to eight levels: Levels 0 to 4 cover liquid textures of increasing thickness, while Levels 3 to 7 cover food of varying textures and sizes. Levels 3 to 6 are suitable for patients with dysphagia. Level 7 (regular and easy to chew) refers to normal food with mixed consistency, like noodle soup, and is suitable for patients with no dysphagia.

“Mixed consistencies can be difficult for patients with dysphagia, as they may not be able to control both liquid and solid textures in their mouths at the same time, causing increased choking risk,” said Ms Lee Yan Shan, Principal Speech Therapist, Speech Therapy Department, SGH.

Level 6 (soft and bite-sized) refers to tender food that requires no biting and some chewing. Food items should be no larger than 15mm by 15mm, which is pegged to the size of the human trachea, and should be easily mashable with a fork to minimise choking. Level 5 (minced and moist) consists of food that requires minimal chewing.

Each particle should be small enough to go between the prongs of a fork and measure no larger than 4mm by 15mm.

Level 4 (pureed) and Level 3 (liquidised) are relatively similar due to the common criteria that food texture should be smooth and without lumps. Where they differ is consistency: Level 4 refers to a thick but not sticky texture, whereas Level 3 refers to a runny texture.

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