Since its launch, the International Dysphagia Diet Standardisation Initiative (IDDSI) has revolutionized how the industry approaches texture-modified foods and drinks. With engagement in over 128 countries and translations in more than 50 languages, IDDSI aims to be culturally sensitive, measurable, and applicable across all age groups and care settings. This guide offers a comprehensive overview of IDDSI, designed to navigate the complexities of transitioning to this robust system.
What is IDDSI?
IDDSI is a standardized framework designed to define food texture and drink thickness, enhancing safety for individuals with chewing and swallowing difficulties. This system aims to protect those with dysphagia from choking and aspiration by providing clear guidelines for texture modification.
Who Benefits from IDDSI?
IDDSI was created to serve individuals who have chewing and swallowing problems. These individuals have a swallowing disorder called dysphagia, which means they cannot safely chew or swallow food. Because of this, someone with dysphasia has an increased risk of choking and/or aspiration (breathing into the lungs particles of food or drink) when eating and drinking. There are over 590 million people in the world who live with dysphagia. The IDDSI standards make sure that those with chewing and swallowing problems are protected from choking and aspiration. Individuals with dysphagia typically have texture modified diets or thickened drinks to allow them to safely chew and swallow. A doctor or speech-language pathologist will evaluate a patient and determine which food texture and drink thickness is needed. An individual may also be on a texture modified diet if they are not able to safely bite off or chew food but do not necessarily have dysphagia. Both thickened drinks and texture modified diets make swallowing easier and help prevent choking. Thickened drinks make swallowing easier, and texture modified foods make chewing and swallowing easier. There is an IDDSI level for varying needs of chewing and swallowing capabilities.
The IDDSI Framework: A Visual Guide
The IDDSI framework serves as a visual representation of each level, identified by a distinct name, color, and number. It illustrates the different texture-modified food and thickened drink levels designed for individuals with varying degrees of chewing and swallowing difficulties. There are eight different texture modified food and thickened drink levels on the IDDSI framework. These food and drink levels range from Level 0 for thin drinks to Level 7 for regular texture foods. Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia.
Food Levels (Level 3 - Level 7)
The top section of the IDDSI framework is all about foods. All IDDSI food levels are represented by the triangle with the tip pointed down. There are five levels for foods: Level 3, Level 4, Level 5, Level 6, and Level 7.
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Level 3: Liquidized: This level focuses on smoothness, ensuring no separate solid pieces are present. The texture is similar to thin pudding or yogurt, and it includes blended soups, thin mashed potatoes with gravy, smooth fruit purees, and custards.
Level 4: Pureed: Foods at this level are mostly smooth but may have increased texture, with a pudding-like consistency. They are prepared by blending, mashing, or processing in a food processor. Level 4 emphasizes cohesive and moist pureed foods, such as pureed soups (tomato bisque, butternut squash), meats, vegetables, and desserts like chocolate mousse or vanilla pudding. These foods are designed for easy consumption without chewing.
Level 5: Minced & Moist: This level introduces increased texture suitable for individuals transitioning to more solid foods. Foods are finely minced or ground into small, manageable pieces, making it easier to control the food in the mouth and minimize the risk of choking or aspiration. Examples include ground meat, soft-cooked vegetables, and soft fruits. For minced and moist, the pediatric particle size should be equal to or less than 2mm in width and no longer than 8mm in length, whereas the adult particle size is equal to or less than 4mm width and no more than 15mm in length
Level 6: Soft & Bite-Sized: This level offers more texture with solid foods, ideal for individuals with adequate chewing ability who need more challenge swallowing solid textures. Foods are transitional, often prepared using a food processor on pulse to achieve a chunky consistency. Almost any food can be chopped or processed into small pieces for this level. For soft and bite-sized, the bite size should be no larger than 8mm for pediatric patients and 15mm or 1.5 cm for adult patients.
Level 7: Regular / Easy to Chew: This is the final level of the IDDSI diet, with no modifications required. Some individuals may prefer well-cooked and easy-to-chew foods. Level 7 Easy to Chew foods are developmentally appropriate SOFT food items that can be eaten in their typical manner. There is no size limit (as seen in Level 6 - soft and bite-sized), but these foods can still be squished with less effort than a hard food, such as a raw carrot. Examples of pediatric Level 7 - Easy to Chew foods might be cheddar cheese, banana, cooked pasta, and Dino nuggets. Level 7 - easy to chew foods are developmentally appropriate SOFT food items that can be eaten in their typical manner. There is no size limit (as seen in Level 6 - soft and bite-sized), but these foods can still be squished with less effort than a hard food, such as a raw carrot. Examples of pediatric Level 7 - Easy to Chew foods might be cheddar cheese, banana, cooked pasta, and Dino nuggets.
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Drink Levels (Level 0 - Level 4)
The bottom section of the IDDSI framework is all about drinks. All IDDSI drink levels are represented by the triangle with the tip pointed up. Level 0 is Thin. Level 1 is Slightly Thick. Level 2 is Mildly Thick. Level 3 is Moderately Thick. Level 4 is Extremely Thick.
Level 0: Thin: This level includes regular liquids without any changes or thickeners. Level 0 liquids move freely and require individuals to manage their speed in the mouth.
Level 1: Slightly Thick: This level offers a variety of safe and enjoyable liquids for individuals with minimal difficulty moving liquids safely in the mouth. Drinks are naturally slightly thick or can be achieved by adding thickener to thin liquids.
Level 2: Mildly Thick: Designed for individuals with difficulty moving thin and slightly thick liquids safely, Level 2 drinks are mildly thick. Most liquids require the addition of thickener to reach this consistency, which can be tested using a 10 ml syringe.
Level 3: Moderately Thick: These liquids are thick like honey or thin pudding. They have had thickener added and typically take time to drink in order to ensure safe swallowing. Using a spoon is an easy way to take in these liquids. Treat these liquids like you would a thick soup.
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Level 4: Extremely Thick: Known as extremely thick or pudding-like liquids, these are the thickest and most challenging to swallow. They require significant muscle strength and move very slowly.
Overlapping Levels
There are two IDDSI levels that are connected on the IDDSI framework between the food and drink levels: IDDSI Level 4 (Pureed Foods and Extremely Thick Drinks). This is because they have similar flow/textural characteristics and descriptions. But it’s important to note that just because they are connected, it doesn’t mean that they needs to be prescribed together. An individual’s ability to manage food and drinks must be assessed independently. For example, an individual may require their drinks to be thickened to IDDSI Level 3 (Moderately Thick) due to poor oral control but they are able to manage Level 5 (Minced & Moist) foods. By assessing their ability to manage food and drinks separately, they would be prescribed Level 5 (Minced & Moist), Level 3 (Moderately Thick).
IDDSI Testing Methods: Ensuring Safety
IDDSI uses testing methods to ensure that foods are at an individual’s prescribed level before they are served and protect them from choking. These tests are as simple as using your eyes, a fork, and a spoon. They are an important step in improving safety during eating and drinking. This will ensure that someone with chewing or swallowing problems is served the right food.
Appearance Check
Checking for appearance is important because there’s a lot we can learn from simply looking at a food. The test varies depending on the IDDSI texture level, but generally the test checks for moisture and particle size.
Fork Drip Test
The IDDSI Fork Drip Test assesses thickness. Place a small amount of food on a fork and make sure the food holds shape on the fork and does not drip or flow continuously. You will also want to look at what may be flowing through the fork tines. If a short tail of pureed food flows below the fork tines, then the pureed food is thick enough, and it passes the fork drip test. If the pureed food flows or drips continuously through or below the fork tines or prongs, it’s too thin and does not pass.
Spoon Tilt Test
The Spoon Tilt Test looks at the stickiness of the food. Place a small amount of food on a spoon, then tilt it to watch the food slide off the spoon. If necessary, you can gently flick the spoon to help the food come off. The food should slide off fairly easily. It’s okay if there is a thin film of food residue left on the spoon.
Fork Pressure Test
The IDDSI Fork Pressure Test checks the softness and moisture of the food. Place a small amount of food on a plate, and try to mash the sample of food with a metal dinner fork. The amount of pressure we may use depends on the IDDSI texture level. When testing foods for IDDSI Minced & Moist (Level 5), we apply a lighter amount of pressure onto the fork. It should be light enough so that the pressure does not turn the nail white. Also, when pressed with a fork, the food particles should easily separate and come through the lines of a fork. Whereas, when testing foods for IDDSI Soft & Bites-Sized (Level 6), we may apply even more pressure onto the fork, and it may be enough to turn the nail white. In addition, when you lift up the fork, the food should not return to its original shape.
IDDSI Flow Test
The IDDSI flow test is used to test each drink level for accuracy. This test shows how thick a drink is based on the amount of liquid that flows through a 10 mL syringe within 10 seconds. It demonstrates how quickly a drink flows and is important because faster-flowing drinks are harder to swallow. The IDDSI Flow test is inexpensive, accessible, and easy to perform. It requires only a 10 mL syringe and a timer. For more information on the IDDSI Flow Test, visit the flow test page on IDDSI.org.
Transitioning from Pediatric to Adult Sizes
The pediatric particle size for Level 5 - minced and moist and Level 6 - soft and bite-sized is based on the size of the pediatric airway. The smaller particle size is used to prevent choking. You can transition from the pediatric particle size to the adult size as the airway grows to that of an adult. This is usually around the time a child reaches puberty, but IDDSI resources recommend discussing with the child’s pediatrician before transitioning to adult particle size.
Resources for Implementing IDDSI
Implementing the IDDSI Framework will look different depending on the size of the organization, number of suppliers involved, management support and staff engagement. The RCSLT recommends the below actions at a local level to support a system-wide approach to implementation and to maximize patient safety. They have been extracted and edited as appropriate from a joint statement developed with the British Dietetic Association in April 2018. Raise concerns about patient safety risks through your organization’s governance structures, e.g. Quality Patient Safety Governance. Escalate the need for a co-ordinated system-wide approach to developing a local implementation plan at board level within your organization. This may be through Directors of Nursing, AHP Leads, Head of Quality or equivalent.
Roche Dietitians “We Test for Safety” IDDSI Training Program
This program will train your staff on everything they need to know about IDDSI. From an overview of IDDSI with our Introduction course to comprehensive courses on each IDDSI level, your team will be well-versed in all things IDDSI. They will also get to practice testing with our hands-on experiences. This program will give you all of the tools you need to develop a strong IDDSI culture among your team, which will keep individuals safe from choking. Our online training is easy to access and simple to use. Your team can watch it on demand whenever they’re available. This format allows your team to truly digest the information at the pace that works best for your organization.
IDDSI Posters and Testing Reports
It’s important to empower your team to implement the IDDSI standards and always test for safety. Our IDDSI posters are easy-to-understand guides you can hang in your production and service areas. They serve as a helpful reference for your staff as they use the IDDSI testing methods on a daily basis. As you use the IDDSI testing methods, you’ll need a way to track your results. That’s where our IDDSI testing report comes in.
IDDSI Community Group
The IDDSI Community group is a place to build relationships with other professionals, share ideas, ask and answer questions, and exchange resources about IDDSI.