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Bread in the Limelight: Texture-Modified Diets

A loaf of sliced bread sits on a wooden dish.

Guest Author: Katrina Woodward, MS, CCC-SLP, CDP

The rollout of the International Dysphagia Diet Standardisation Initiative (IDDSI)* has put bread at the forefront of every diet transition conversation across healthcare settings. Since IDDSI acknowledges that bread presents a high choking risk, it is classified as an IDDSI Regular, Level 7 food and is not included on any other IDDSI level.[i]

Individuals adhering to an IDDSI Easy to Chew, Level 7 diet should undergo an evaluation by a dysphagia clinician, usually a speech-language pathologist, before consuming bread.[ii] While IDDSI classifies bread products as Regular, Level 7 foods it also specifies that an Easy to Chew, Level 7 bread can easily be cut with the side of a fork without restrictions to particle size.[iii] While earlier texture-modified diets included bread products, IDDSI describes bread as a food that requires the ability to both bite and chew extensively. In fact, IDDSI has referenced two articles stating, “The number of chewing strokes, chewing strength and stamina required to make bread swallow-safe are about the same as those required to chew and swallow peanuts safely.”

To comprehend the significant oral processing needed to eat bread, imagine taking a bite of your favorite bread. Think about how it feels in your mouth. Does it ball up? Is it hard to break into tiny pieces because it sticks to itself? Most likely it sucks up your saliva to form a bolus. It may be fibrous or gummy. Maybe it’s crumbly. The below images (courtesy of SDX Dysphagia Experts) from fiberoptic endoscopic evaluation of swallowing (FEES) tests depict two bread challenges. The first shows a column of sticky toast obstructing the airway. In the second image, a piece of crumbly cinnamon bun is on the verge of passing through the vocal cords and into the trachea. Thankfully, both patients showed intact sensation with an effective cough reflex, so the Heimlich maneuver was not required.

Schematic of the Pharynx from the Endoscopic:

Vocal cords labeled anatomical and medical structure and location scheme. Organ back or front view with closed and open positions comparison diagram vector illustration. Human voice sound inner parts

Image 1:

Image 2:

The IDDSI framework references autopsy reports of foods that pose a choking risk. These references bolster the importance of having dysphagia clinicians evaluate a patient’s ability to safely swallow bread on a case-by-case basis. Additionally, consistent with best practice standards, diet individualization is always an option.[iv]

Translating this concept to patient-centered care, bread is acknowledged as a staple of the American diet; therefore, it is not appropriate to eliminate it entirely. Furthermore, bread provides important nutrients from the grain group, so if bread must be removed from the diet, it would need to be replaced with other grains at the appropriate texture for that individual.

If a clinician determines a patient is unable to safely consume Regular, Level 7 bread products, safe alternatives that correspond with the individual’s prescribed IDDSI level can be provided. There are bread alternatives accessible both commercially and by homemade methods. Puréed bread mixes and prepared puréed bread products are available. Canned puréed items in a wide range of IDDSI-compliant varieties are also on the market, with foods ranging from French toast to apple pie. You can find recipes for IDDSI Minced & Moist, Level 5 and IDDSI Puréed, Level 4 breads online from a variety of resources, but you are responsible for ensuring your bread product recipes pass IDDSI testing for the appropriate level.

To eliminate the sticky, fibrous quality of bread, current best practices reinforce the importance of processing bread into fine crumbs before adding a nutritious liquid such as thickened milk. If a puréed bread product is served in a mold, the IDDSI Puréed, Level 4 Audit Tool recommends, “If the sample is gelled or compressed so that it is firm enough to pick it up with your fingers and bite a piece of it at serving temperature, the sample is not a purée and poses a choking risk.”[v]

Dysphagia clinicians play a vital role in determining the appropriateness of individualized allowances for specific bread products. The dysphagia clinician will assess an individual’s ability to safely consume regular bread products with a comprehensive dysphagia evaluation that includes both non-instrumental and instrumental procedures. If the non-instrumental swallowing assessment determines the presence of signs and symptoms of dysphagia, an instrumental test via FEES or videofluoroscopic swallow study (VFSS) may be warranted to verify aspiration and to thoroughly evaluate swallowing anatomy and physiology.[vi]  This comprehensive assessment should include evaluation of performance with specific bread products if regular bread is being considered for inclusion in an individual’s diet.

Increased awareness of a bread product’s properties and the high choking risk it presents is essential to improving patient safety across levels of care. Bread should not be served on a diet that is not a Regular, Level 7 without specific, documented approval from a dysphagia clinician.

Addressing the safe incorporation of bread into diets at every level requires preparation, education, documentation, training, and ongoing interdisciplinary discussion, and is necessary for a successful IDDSI transition.

Katrina Woodward, MS, CCC-SLP, CDP is a speech-language pathologist with 19 years of specialty experience evaluating and treating adult and geriatric patients with cognitive-communication deficits and dysphagia. A consummate professional, a proven leader, a dedicated mentor, and a patient advocate with a passion for evidence-based practice, Katrina currently serves as vice president for SDX Dysphagia Experts, consultant to Roche Dietitians, Massachusetts Speech-Language-Hearing Association vice president for education and planning, and a US & Territories IDDSI Reference Group volunteer and co-chair of the communications and newsletter committee.

*Thick-It® brand is a gold sponsor of IDDSI. This article is NOT an official IDDSI resource, educational material, or education program, and it is NOT meant to replace materials and resources on

Always seek the advice of a physician or other qualified health provider before making a diet modification and with any questions you may have about a medical condition, treatment, or the use of Thick-It® products. The information contained herein is for informational purposes and is not intended to be a substitute for professional medical advice, diagnosis, or treatment in any manner.

[i] Cichero, J., Lam, P., Steele, C. et al., “Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework.” Dysphagia, December 2, 2016.
[ii] “FAQ – Foods (Levels 4-7 and Transitional).” International Dysphagia Diet Standardisation Initiative, 2021.
[iii] “Complete IDDSI Framework Detailed Definitions 2.0.” International Dysphagia Diet Standardisation Initiative, July 31, 2019.
[iv] “State Operations Manual.” Centers for Medicare & Medicaid Services, 2017.
[v] “Audit Tool Level 4 Pureed.” International Dysphagia Diet Standardisation Initiative, September 26, 2020.
[vi] “Adult Dysphagia.” American Speech Language Hearing Association, 2021.

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