Dysphagia, a swallowing disorder, affects approximately 8% of the world’s population. This condition is closely associated with malnutrition, dehydration, upper respiratory infection, and an increased risk of sentinel events. To address the challenges posed by inconsistent terminology in describing modified diets for individuals with dysphagia, the International Dysphagia Diet Standardisation Initiative (IDDSI) was developed.
The Need for Standardisation
In the past, various countries have developed dysphagia diet standards at regional or national levels. Terms like "soft," "chopped," "mechanical soft," and "blended smooth" were commonly used, but their precise meanings often varied. Individuals with dysphagia might find that their modified diet was described differently in different healthcare settings. This inconsistency created confusion and potential safety risks.
The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded with the goal of developing globally standardized terminology and definitions for texture-modified foods and liquids applicable to individuals with dysphagia of all ages, in all care settings, and all cultures.
Development of the IDDSI Framework
The IDDSI Framework was developed by a multi-professional volunteer committee through systematic review and stakeholder consultation. The process involved several phases:
Survey of Existing Terminologies: A survey of existing national terminologies and current practices was conducted, receiving 2050 responses from 33 countries. The respondents included individuals with dysphagia, their caregivers, healthcare professionals, food service providers, researchers, and industry representatives. The results revealed the common use of 3-4 levels of food texture (with 54 different names) and ≥3 levels of liquid thickness (with 27 different names). There was substantial support for international standardisation.
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Systematic Review: A systematic review was completed regarding the impact of food texture and liquid consistency on swallowing.
Framework Development: A meeting was convened to review data from previous phases and develop a draft framework.
Stakeholder Feedback: An international stakeholder survey sought feedback to guide framework refinement; 3190 responses were received from 57 countries.
The IDDSI Framework, released in November 2015, involves a continuum of 8 levels (0-7) identified by numbers, text labels, color codes, definitions, and measurement methods.
The IDDSI Framework: Levels and Definitions
The IDDSI framework consists of a continuum of 8 levels (0 - 7), where drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness.
Read also: Understanding Dysphagia Diets
The framework includes specific and practical tests of consistency that can be used to distinguish between levels without using expensive rheology equipment.
Drinks: Levels 0-4
- Level 0: Thin: Like water.
- Level 1: Slightly Thick: Thicker than water.
- Level 2: Mildly Thick: Nectar-thick liquids.
- Level 3: Moderately Thick: Liquidised foods.
- Level 4: Extremely Thick: Spoon-thick liquids.
Foods: Levels 3-7
- Level 3: Liquidised: Foods that require very little chewing ability.
- Level 4: Pureed: Extremely smooth foods with no lumps.
- Level 5: Minced & Moist: Soft and moist foods with small, easily manageable pieces.
- Level 6: Soft & Bite-Sized: Soft foods with bite sizes that are 1.5cm or 15mm to prevent choking.
- Level 7: Regular: Everyday foods of normal textures.
- Level 7 Easy to Chew (L7EC): Softer foods that require minimal chewing; intended for those who do not require particle size restriction to help reduce choking risk.
Testing Methods
IDDSI Testing Methods are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing should be done on foods and drinks under the intended serving conditions (especially temperature).
There is a specific test for ‘soft’ which involves using a table fork to compress the material, applying a light pressure just sufficient to cause the thumbnail to blanch. Illustration of the thumb nail blanching to white during Fork Pressure Test, amount of pressure required (in kPa) to blanch the thumb nail to white.
Implementation
Implementation should involve numerous phases, including building awareness, preparation and adoption, and monitoring across all the phases.
The RCSLT recommends actions at a local level to support a system-wide approach to implementation and to maximise patient safety:
Read also: Safe Eating with Dysphagia
- Raise concerns about patient safety risks through your organisation’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 organisation. This may be through Directors of Nursing, AHP Leads, Head of Quality or equivalent.
- Contact the relevant manufacturers to raise any concerns directly, and work together with them to ensure that patients/service users continue to receive great care and are not at risk of harm. The person contacting them could be yourself or the appropriate senior manager.
- Include manufacturers in your whole system approach to implementation. This has been found effective by manufacturers who have been involved with early adopters, who are also committed to supporting the development of local implementation plans.
- Check out the case studies from Greater Glasgow and Clyde, Hull and East Yorkshire and East Sussex under Learning resources.
- Do not underestimate the amount of training and information sharing required to inform staff and key stakeholders about IDDSI.
- Join IDDSI to access the latest information, including resources and training, e.g.
- Set up and attend relevant RCSLT Clinical Excellence Network (CEN) meetings to support the sharing of best practice.
- Consider the whole range of IDDSI Levels that the service user can safely manage in your recommendation. Personalise your recommendation so that it fits with the needs and wishes of the service user, but refer to IDDSI in your case notes, reports, clinical documentation and in any professional correspondence.
- Allow the service user and their carer(s)/family to use terminology that is suitable to them - it must be meaningful to them.
Dual Labeling
As a clinician, you can start using dual labeling in your documentation to get familiar using the terminology. For example, when recommending the liquids of Nectar-Thick, add: (aka, Mildly Thick Liquid per the IDDSI Framework).
Benefits of the IDDSI Framework
There are many benefits of using the IDDSI Framework:
- Each level is based on evidence.
- The testing methods of the levels are scientific and designed so that they are easy to use.
- Patient safety: NHS Improvement has recommended using IDDSI terminology to reduce choking incidents in their patient safety alert.
- The framework is prescriptive, not restrictive.
- The framework is being implemented worldwide.
- The data on dysphagia improves. As more countries use the same descriptors, the ability to do larger research studies and systematic reviews is much greater.
The Role of Professional Organizations
Recognizing that total IDDSI implementation will take time and effort, organizations like the Academy of Nutrition and Dietetics (AND), the Association of Nutrition & Foodservice Professionals (ANFP), and the American Speech-Language-Hearing Association (ASHA) are committed to supporting their members during their transition.
ASHA supports the IDDSI Framework and shares it with members who assess and treat individuals with dysphagia.
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