INTERNATIONAL DYSPHAGIA DIET STANDARDISATION INITIATIVE (IDDSI) RESOURCES

complied by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com & IDDSI Champion

www.IDDSI.org

IDDSI Introduction

Global standardisation is here. The world reached consensus on how to label, describe and test dysphagia diets for people with difficulty swallowing (dysphagia). All solid food levels and drink/liquid levels have been given standard names, descriptions, colors, numbers, and testing methods. We can all finally speak the same language when it comes to ordering dysphagia diets through preparing and serving these dysphagia diets. Changing the world to this new dysphagia diet global standard has been an ongoing implementation process. For healthcare facilities/institutions that have not yet implemented IDDSI, it is crucial that they set goals for their facilities now. This is now the only professionally recognized standard of care. Implementation kick-off was May 1, 2019 in the USA, per the American Speech-Language and Hearing Association and the Academy of Nutrition and Dietitics. The process for a given institution will be expected to take more than a year (or even two) to proceed from an awareness phase to the preparation phase and finally to full adoption of the IDDSI Framework.

The safety of people with difficulty swallowing (dysphagia) depends on this standardization. In an effort to make IDDSI easily digestible (pun intended) and to make our transition smoother, I have created this IDDSI resource guide to help you navigate the IDDSI.org website.

SwallowStudy’s IDDSI Articles

See also this newer blog: IDDSI Updates as well as my history of IDDSI blogging from 2014 to current day:

Start Your IDDSI Implementation

Start your IDDSI implementation now (if you have not already) with plugging into the IDDSI website to start your own learning, then begin raising awareness in your facility and forming a team.

See IDDSI’s Implementation Guides here: https://iddsi.org/Resources/Implementation-Guides

Find your champions in your facility. For example, in our hospital the chef was already familiar with creating foods for people with dysphagia, as she had been cooking for the ALS luncheons for years. You can already start dual-labeling in your reports (i.e., use your facility’s old diet terms after the new IDDSI names). For more on best practice terminology: check out the PowerPoint in the USIRG chart called: USIRG Best Practice IDDSI Terminology (Powerpoint).

Perform food testing and IDDSI Flow Tests on all your products and menu items at your facility. Check out my IDDSI Flow Test data here (on a range of thickened liquid products, supplements and even Lactulose liquid medication): SwallowStudy.com’s IDDSI Flow Test Data 2017-2018.

The information and videos listed here are freely available, and the IDDSI publications have always been free and Open Access. It is the goal of IDDSI to make all learning materials free to aide the global implementation of this framework without the barrier of cost.

Here are those resources:

COMPLETE IDDSI FRAMEWORK & DETAILED DEFINITIONS/DESCRIPTORS:

Go to: https://iddsi.org/resources/framework-documents

For IDDSI’s IDDSI Framework and Detailed Level Definitions, Testing Methods, and Framework Evidence Statements across languages.

IDDSI Framework changes as of March 2019: Addition of EASY TO CHEW – LEVEL 7

Here is a brief description of Easy To Chew diet:

Soft, but not necessarily bite-sized. This diet was created due to extensive feedback that the dysphagia diets were too restrictive with the 1.5cm bite-size requirement of Soft & Bite-Sized Level 6. People felt there was too large of a jump between Soft & Bite-Sized and Regular.
Not designed to prevent choking as there is no particle size requirement as in Soft & Bite-Sized Level 6..
Normal everyday foods of soft/tender textures only, that are developmentally and age appropriate.
Requires biting & chewing ability.
Foods are naturally moist, and NOT: Hard, chewy, fibrous, stringy.
No seeds, bones, gristle.
For patients with some weakness and/or who tire easily.
Mixed consistencies may be okay.

IDDSI YouTube Channel

https://www.youtube.com/channel/UC0I9FDjwJR0L5svIGCvIqHA/videos

LIQUID TESTING METHODS & VIDEOS

IDDSI Testing Methods document (liquid and food testing in this document):

Find that here: https://iddsi.org/resources/framework-documents

IDDSI Flow Test Instructions:

Original IDDSI Syringe YouTube Instructions: https://www.youtube.com/watch?v=BhfJWu1ybbs&index=1&list=PLa8-lAnKo0KYX524EQbTM3thWS9G2SCC6

New IDDSI Funnel YouTube Instructions: https://youtu.be/xHxntTb9Yac?si=4SxywvIel-fcaYCM

IDDSI Funnel Resources on website: https://iddsi.org/resources/funnels

See this list on IDDSI.org for IDDSI Flow Test poster and other popular posters
IDDSI Funnel Instructions for Use, video demonstrations, and all Flow Test Cards for funnel: https://iddsi.org/resources/funnels

Flow Test Across Levels 0-3:

IDDSI – Level 0 is a Thin Liquid and all the liquid will flow out of the syringe in less than or about 7 seconds. Flow test not needed, but you can essentially calibrate your syringe that way.

IDDSI Flow Test – Level 1: Slightly Thick (new level)

https://www.youtube.com/watch?v=xyvDubBGJQU

IDDSI Flow Test – Level 2: Mildly Thick Liquid (Nectar thick liquid per NDD)

https://www.youtube.com/watch?v=XBqi_i0LLHw

IDDSI Flow Test – Level 3: Moderately Thick Liquid (Honey thick liquid per NDD)

https://www.youtube.com/watch?v=SiFwiGgIPHA&index=3&list=PLa8-lAnKo0KYX524EQbTM3thWS9G2SCC6

IDDSI Flow Test – Level 4: Extremely Thick Liquid (Pudding thick liquid per NDD). Note: this liquid is too thick for the IDDSI Flow Test with a syringe or funnel.

https://www.youtube.com/watch?v=0zMoEaGbs2w&list=PLa8-lAnKo0KYX524EQbTM3thWS9G2SCC6&index=5

IDDSI Flow Test Comparison of Levels 1-3

https://www.youtube.com/watch?v=itMh_QQTXdk

IDDSI PRESENTATION ON LIQUIDS

Using the IDDSI Flow test in clinical practice: How thick is thick and does thickness really matter? by Carly Barbon, PhD(C), SLP(C) Reg.CASLPO

IDDSI Webinar on the IDDSI YouTube Channel: Sep. 18, 2018 Using the IDDSI Flow Test in Clinical Practice

OPEN ACCESS ARTICLES ON THICKENED LIQUIDS

from @SwallowRehab – Swallowing Rehabilitation Research Lab (Dr Catriona Steele’s Lab):

Barbon, C E. A. & Steele, C. M. (2018). Thickened liquids for dysphagia management: A current review of the measurement of liquid flow. Current Physical Medicine and Rehabilitation Reports. https://rdcu.be/5aOs

Barbon, C.E.A. & Steele, C.M. (2018). Characterizing the flow of thickened barium and non-barium liquid recipes using the IDDSI Flow Test. Dysphagia, 1-7. https://link.springer.com/article/10.1007/s00455-018-9915-6

FOOD TESTING INFORMATION & VIDEOS

IDDSI Testing Methods document (liquid and food testing in this document) can be found here in various languages:

https://iddsi.org/resources/framework-documents

Level 3 Liquidised

https://www.youtube.com/watch?v=bsOkfGGs3CY

Level 4 Pureed

https://www.youtube.com/watch?v=EIItIGY3ndo

Level 5 Minced & Moist

https://www.youtube.com/watch?v=9tMowfeuzVY

Level 6 Soft & Bite-Sized with Soft Banana

https://www.youtube.com/watch?time_continue=59&v=luWigA1VgVc

Minced & Moist Sandwich (information on choking risks with regular bread products)

https://www.youtube.com/watch?v=W7bOufqmz18&t=2s

LEARN MORE & HISTORY

Also, please see the list SwallowStudy.com blogs related to IDDSI below.

IDDSI PRESENTATIONS

Go to the IDDSI YouTube Channel & to the Resources page on the IDDSI website and use the drop-down menu called: “Presentations.” IDDSI is adding new-official presentations all the time, so check often! You can easily give these presentations at your facility now to show people why we need to standardize dysphagia diets for safety and consistency.

IDDSI also posts upcoming webinars on their website along the right-hand side.

Please see the March 2018 IDDSI webinar by Dr Catriona Steele, PhD, CCC-SLP, S-LP(C), REG. CASLPO, ASHA FELLOW, hosted by the National Foundation of Swallowing Disorders (NFOSD) by clicking here: https://vimeo.com/262290237

Please see the United States IDDSI Reference Group (USIRG)’s homepage chart of resources. This has webinars to introduce IDDSI to clinicians, food service providers, caregivers and people with dysphagia, and administrators of healthcare facilities. https://iddsi.org/around-the-world/united-states

SWALLOWSTUDY.COM PRESENTATIONS ON IDDSI:

Please enjoy my IDDSI resources and webinars that I did in collaboration with BeckyDorner.com & Hormel Health Labs to bring you two FREE IDDSI webinars. Click here to transfer to the Hormel Health Labs webinar link on BeckyDorner.com and enter password “hhl” (I do not make any commission on sending traffic to this site). Disclosure: I received small honorariums for my time creating and presenting these webinars.

1. International Dysphagia Diet Standardisation Initiative: The Who, Why, What & How

presented by Karen Sheffler, MS, CCC-SLP, BCS-S

2. IDDSI: Teamwork From Regulatory Requirements to Successful Implementation

presented by Brenda Richardson, MA, RDN, LD, CD and Karen Sheffler, MS, CCC-SLP, BCS-S

3. Hormel Health Labs In-service Training Series.

Designed to be quick 15-20 minute presentations that are useful for training all staff and caretakers of people with dysphagia.

OLDER YOUTUBE WEBINARS:

- International Dysphagia Diet Standardisation Initiative Webinar

by Peter Lam, RD, CFE & Julie Cichero, BA, BSpThy (Hons), PhD (IDDSI Co-Chairs),

brought to you by the Association of Nutrition & Foodservice Professionals & Reinhart Foodservice

https://www.youtube.com/watch?v=49H2o-9YUVc&t=3278s

- Standardization of Dysphagia Diets: A Model of Successful International Engagement

by Dr Catriona Steele, PhD, CCC-SLP, BCS-S, S-LP(C), REG. CASLPO, ASHA FELLOW,

brought to you by the American Speech-Language-Hearing Association (ASHA) Professional Development

https://www.youtube.com/watch?v=gE1SV0THUtU&t=26s

IDDSI RESOURCE PAGE & INFO ON THE CREATIVE COMMONS LICENSE:

Check out https://iddsi.org/resources

Open Access articles (under Publications tab),
Prior E-Bites newsletters (under the News tab),
Print out posters for your facility (using the Resources -> Posters tab),
- Check out the all-in-one IDDSI poster and all other IDDSI posters at this link.
You will love the Patient/Caregiver Handouts tab for pediatrics and adults, giving you information on food examples and foods to avoid. These are so helpful for your patients.
Now that you are ready to Implement IDDSI: See the Implementation tab under Resources for your clinician or industry specific Implementation Guides. These walk you through step-by-step instructions from raising awareness in your facility, building your task force, analyzing your menus, and more. Master guide available, as well as clinician and food service specific guides. See also Audit Tools to help your kitchens make safe and appropriate foods, and to assist staff with point of service testing.
Learn about how Bracco’s Varibar barium products map to the IDDSI framework,
Check out Introduction to IDDSI Powerpoint presentations (under Videos tab), and follow their link to their YouTube Channel for many presentations and videos.

PER THE IDDSI WEBSITE: “documents [on the website & resource pages] have been developed by IDDSI and are for public use. You do not need to seek permission from IDDSI to share these documents and images as long as you cite the CreativeCommons BY-SA 4.0 license as follows:”

“The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/.
Attribution is NOT PERMITTED for derivative works incorporating any alterations to the IDDSI Framework that extend beyond language translation. Supplementary Notice: 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. Such errors have previously been associated with adverse events including choking and death.”

Iddsi resources can be found on Iddsi.org. this one is a big poster of all the Iddsi levels with their testing methods. It is super helpful.

See IDDSI Poster section for all posters, including this full IDDSI Framework poster, showing framework, descriptors and testing methods.

FREQUENTLY ASKED QUESTIONS:

Go to the IDDSI website: https://iddsi.org/about/faq

Go to the USIRG chart in section on Frequently Asked Questions that are USA specific.

DOWNLOAD THE FREE IDDSI APP:

Search “IDDSI” on your App store. Once the IDDSI app is downloaded, it can be used without any wifi or data needed. This is great for teaching at your facilities and to patients/caregivers.

START YOUR OWN IDDSI FLOW TESTING EXPERIMENTS:

Use this link to print out a blank IDDSI Flow Test Data Chart. Flow test all your facility’s thickened liquid products and supplements.

Use this link to review my SwallowStudy.com’s IDDSI Flow Test Data 2017-2018. I tested many popular brands of pre-thickened liquids, gels, and powders. I tested the old corn-starch or modified food starch products, as well as the newer “clear” products made with gums (e.g., xanthan gum). I also tested an array of supplements and even a liquid medication (e.g., Lactulose). Please send me your data to add to this massive chart!

See IDDSI’s 2023 resource on their IDDSI Funnel: https://iddsi.org/resources/funnels

AN ABUNDANCE OF OTHER IDDSI RESOURCES:

Favorite Videos from IDDSI YouTube Channel (here they are again):

Minced & Moist Bread: https://www.youtube.com/watch?v=W7bOufqmz18

Flow Test Comparison of Levels 1-3: https://www.youtube.com/watch?v=itMh_QQTXdk

Here are my SwallowStudy.com IDDSI Resources & blogs again:

Here are Those Free IDDSI Webinars Again – on BeckyDorner.com:

Note: As of 2021, these are slightly out-of-date now with old framework that did not have the “Easy to Chew” level.

Check out our two-part series with Karen Sheffler, MS, CCC-SLP, BCS-S in Webinar 1 and Karen and a renown dietitian (Brenda Richardson, MA, RDN, LD, CD) in Webinar 2. https://www.beckydorner.com/free-resources/free-webinars/

My Free IDDSI Podcast at FoxRehab:

https://www.foxrehab.org/podcast/foxcast-slp-iddsi-international-dysphagia-diet-standardization-initiative-karen-sheffler/

Article on ASHAwire about One Hospital’s Implementation Process:

https://leader.pubs.asha.org/doi/10.1044/leader.OTP.24042019.38

“Swallow Your Pride” Podcast with Simply Thick Owner – on IDDSI:

https://www.mobiledysphagiadiagnostics.com/073-john-holahan-mba-founder-of-simplythick-through-thick-and-thin-xantham-gum-and-idds-implementation/

Don’t Forget to Follow IDDSI on Twitter:

https://twitter.com/iddsi_org

STAY CURRENT WITH IDDSI UPDATES

SIGN UP FOR NEWS:

Go to IDDSI website’s Contact Us tab, and enter your information to stay in touch for the latest news and updates.

Receive the IDDSI newsletter, the E-Bite.

Visit www.IDDSI.org often. The IDDSI Framework is a “Living Document,” and will make changes as needed based on the latest evidence.

IDDSI Publications:

Cichero, J.A.Y., Steele, C., Duivestein, J., et al. (2013). The Need for International Terminology and Definitions for Texture-Modified Foods and Thickened Liquids Used in Dysphagia Management: Foundations of a Global Initiative. Current Physical Medicine and Rehabilitation Reports, 1(4), 280-291. https://doi.org/10.1007/s40141-013-0024-z

Steele, C.M., Alsanei, W.A., Ayanikalath, S., et al. (2015). The Influence of Food Texture and Liquid Consistency Modification on Swallowing Physiology and Function: A Systematic Review. Dysphagia, 30(1), 2-26. https://doi.org/10.1007/s00455-014-9578-x

Cichero, J.A.Y., Lam, P., Steele, C.M., et al. (2017). Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia, 32(2), 293-314. https://doi.org/10.1007/s00455-016-9758-y

Lam, P., Stanschus, S., Zaman, R. & Cichero, J.A.Y. (2017). The International Dysphagia Diet StandardisationInitiative (IDDSI) framework: The KempenPilot. BJNN/Stroke Association Supplement,13(2), S18-S26. https://iddsi.org/wp-content/uploads/2017/08/bjnn.2017.13.sup2_.s18.pdf

Steele, C.M., Namasivayam-MacDonald, A.M., Guida, B.T., Cichero, J.A.Y., Duivestein, J., Hanson, B., Lam, P. & Riquelme, L.F. (2018). Creation and Initial Validation of the International Dysphagia Diet StandardisationInitiative Functional Diet Scale, Archives of Physical Medicine and Rehabilitation, doi: 10.1016/j.apmr.2018.01.012 https://www.archives-pmr.org/article/S0003-9993(18)30085-6/abstract

See this Open Access article for more information on this IDDSI-FDS – diet scale. Clinicians can more readily capture diet and liquid restrictions, as well as improvements during therapy. This scale shows greater sensitivity to diet changes than the older scale of the FOIS.

References noted on IDDSI Flow Test slide:

van Vliet, T. (2002). On the relation between texture perception and fundamental mechanical parameters for liquids and time dependent solids. Food Quality and Preference, 13(4), 227-236. https://doi.org/10.1016/S0950-3293(01)00044-1

Kutter, A., Singh, J.P., Rauh, C. & Delgado, A. (2011). Improvement of the prediction of mouthfeel attributes of liquid foods by a PosthumusFunnel. Journal of Texture Studies, 41, 217-227.

References noted on Transitional Foods:

Gisel, E.G. (1991). Effect of Food Texture on the Development of Chewing of Children Between Six Months and Two Years of Age. Developmental Medicine & Child Neurology, 33, 69-79. doi:10.1111/j.1469-8749.1991.tb14786.x

Dovey, T.M., Aldridge, V.K. & Martin, C.I. (2013). Measuring oral sensitivity in clinical practice: A quick and reliable behaviouralmethod. Dysphagia,28(4), 501-510. https://doi.org/10.1007/s00455-013-9460-2

IDDSI Resources