Dysphagia Diets: IDDSI Replaces NDD

By: Karen Sheffler

May 8, 2014

Standardized Diets:

IDDSI Replaces the National Dysphagia Diet

by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

You may hear doctors and health care professionals use terms like: “Soft,” “Mechanical Soft,” “Chopped,” “Ground,” “Blended smooth,” etc, but what does it mean? Ambiguous terms without standardized definitions lead to dangerous trays being given to patients. For example, many doctors think that “soft” means fully pureed! Read more about why standardization of diet labels and definitions matters.

Have diets been standardized at your facility?

Know the History on Where We Were:

In the past, the National Dysphagia Diet (NDD) was the only standardized diet tool in the United States, and it was a great beginning. NDD was published in 2002 by the American Dietetic Association (now known as the Academy of Nutrition and Dietetics). It was created as an official project of the ADA, but the NDD was not officially supported by ASHA (American Speech-Language Hearing Association). However, the National Dysphagia Diet was the result of consensus among dietitians, Speech-Language Pathologists, and food scientists. This tool listed diets that were appropriate for patients with swallowing disorders.

The use of food science and the science of rheology have helped us create diets not only to avoid diet-label confusions, but also to provide for safer textures for the patient’s particular type of dysphagia. Now science has advanced beyond the National Dysphagia Diet into a global wave of standardization.

To see the first attempt in the United States at standardization as of 2002, see this link to review this old and very outdated National Dysphagia Diet (NDD) chart that I had created for our kitchen in the early 2000’s:

OUTDATED Kitchen Guidelines on National Dysphagia Diet (NDD) — WARNING: Posted here for reference only on how diets had been organized. Facilities are now expected to implement IDDSI (IDDSI.org). See below.

New Generation of Dysphagia Diets:  2016-2019 Updates & IDDSI.org

The International Dysphagia Diet Standardisation Initiative (IDDSI) is an organization with an executive board made up of volunteer clinicians and researchers from 9 countries around the world. The IDDSI dream since joining together in 2013 has been to:

Achieve global dysphagia diet terminology, creating common terminology and common understanding across international borders, across the lifespan, across all professions, and across the all stakeholders to help the care of people with difficulty swallowing (dysphagia).

Please see my prior blogs that tracked this amazing global effort by the International Dysphagia Diet Standardisation Initiative (IDDSI) towards standardization of diets and liquid consistencies:

1. Diet Safety: Terminology & Definitions Matter (IDDSI publication links included).

2. No Dysphagia Diet Modification Without Standardization!

3. IDDSI: Interview with an Early Adopter of the IDDSI Framework

4. IDDSI Resources

5. Understand Transitional Foods (the gray side bar on the IDDSI framework) with my three-part series.

Go to the International Dysphagia Diet Standardisation Initiative website (www.IDDSI.org)

IDDSI Framework:

Latest updated version of the IDDSI Framework, as of March 2019. See IDDSI Resources blog for more complete IDDSI information and resource links.

Note how the IDDSI framework has expanded the levels of liquid consistencies. There are no longer only the three National Dysphagia Diet levels for thick liquids: Nectar -> Honey -> Pudding Thick. With IDDSI, Mildly -> Moderately -> Extremely Thick liquid replace those original three. The IDDSI additional level is Slightly Thick, which is between Thin and Mildly Thick. Potentially, patients could tolerate a liquid slightly thinner than what used to be considered “nectar thick.” That might improve quality of life and intake while preserving safety! These 5 total liquid consistencies are more in line with what Japan and Australia have already used.

The IDDSI Framework and Standards include procedures on how to test viscosity at home or at your facility without expensive rheology equipment. You could double check your pre-thickened liquids or supplements. All you just need a 10 mL syringe! However, please make sure you have the right size of a syringe. Specifically, the measurement from the 0 line to the 10ml line should be 61.5mm long. IDDSI was surprised that not all 10ml syringes are created equal around the world. If you live in the USA, the typical 10ml slip-tip or leur-lock syringe (minus a needle) should be fine.  See IDDSI Flow Test described here in the IDDSI Testing Methods document.

The diet labels can now be translated into many languages. No more “honey” or “pudding” thick, which do not easily translate. We will now be getting rid of all the confusion with different labels for the same diet, such as: “ground,” “moist ground,” “mechanical soft,” “mechanically altered.” These will be replaced with the IDDSI diet #5, “Minced & Moist.” The minced particle size is 4mm, which happens to be the size of food particles after chewing and when they are swallow ready. It also is the size between two tines on a fork to make testing easy. Therefore, the Minced & Moist diet needs minimal chewing. The IDDSI diet #6 is “Soft & Bite-Sized. Yes, they are using the word “Soft,” but it is now highly defined in the framework and easily translatable. The bite sizes should be 1.5cm or 15mm, so that if a chunk falls to the airway, the person will not choke/asphyxiate. The size of 15mm is about the size of an adult thumbnail, and is smaller than a typical adult airway. (Note: for pediatrics, they suggest a 2mm particle size for Minced & Moist. For Soft & Bite-Sized, the chunk size should be no bigger than 8mm or the size of the child’s fingernail on his/her pinky finger.) Please see the IDDSI website for all of IDDSI’s easy food testing methods.

The future is bright for patient safety with IDDSI

IDDSI is working on raising awareness all the time. You can help to spread the word. Institutions, healthcare providers, and industry will be preparing for full adoption of this framework by January 1, 2019 per decisions already made in Canada and with the Academy of Nutrition & Dietetics, as well as the American Speech-Language Hearing Association. You can also help in this preparedness by finding champions in your institution to review your own diet labels, descriptors and menus. As a clinician, you can start using dual labeling in your reports. For example, when recommending the liquids of Nectar thick, add: (aka, Mildly Thick Liquid per the IDDSI Framework). Industry is already starting this dual labeling.

Changing over to globally recognized terminology – based on evidence – is critical. As IDDSI says: “getting it wrong has serious consequences, such as life-threatening chest infection, or choking and dying.” 

Dr Catriona Steele, from the IDDSI board, enthusiastically states:
“Become a part of the wave of implementing global terminology for dysphagia diets.”

Clinician Tools

GO TO MY COMPLETE IDDSI RESOURCES PAGE for more tips, resources, references to get you ready for IDDSI Implementation.


CLICK HERE: Swallow Guide IDSSI-Style

AGAIN, start doing your own Flow Tests on thickened liquids, supplements, and liquid medications.

Use this pdf: IDDSI Flow Test Data Chart

Review my data here: IDDSI Flow Test Data 2017-2018 by SwallowStudy.com