Dietitian Blog, Long-Term Care, MNT Guidelines | Jul 27 2021

A clinical dietitian’s guide to IDDSI

Celery Soup

The International Dysphagia Diet Standardisation Initiative

Current estimates suggest that dysphagia, a swallowing disorder, affects approximately 8 percent of the world’s population. Dysphagia is closely associated with malnutrition, dehydration, upper respiratory infection, and increased risk of a sentinel event. Although dysphagia can be present in a wide range of ages, it is most common at the beginning and end of life, mostly affecting the infant and elderly population.

In the past, a number of countries have worked to develop dysphagia diet standards at regional or national levels. Unfortunately, many of these standards use different terminology, numbers, and levels that can add to confusion for a team providing care for an individual with dysphagia.

For example, you may hear doctors and other health care professionals using terms like “soft,” “chopped,” “mechanical soft,” “blended smooth,” etc. but what exactly do each of those mean? Moreover, individuals with dysphagia may even find that their modified diet may be called one thing in a hospital, and called something else at the rehabilitation facility down the street. Unfortunately, the use of these more ambiguous terms without a standardized system and definitions can lead to dangerous trays/meals given to patients.

A global standard

The International Dysphagia Diet Standardisation Initiative (IDDSI) created global standardized terminology and definitions for texture-modified foods and thickened liquids to improve the safety and care for individuals with dysphagia, which affects an estimated 590 million people worldwide.

The IDDSI is composed of a large group of volunteer professional experts in multiple fields that are directly involved in the treatment of dysphagia, including nutrition and dietetics, speech language pathology, occupational therapy, nursing, patient therapy, food science, and technology from nine countries around the world.

The IDDSI dream since being founded in 2013 has been to:

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

In January 2017, the Academy of Nutrition and Dietetics and the American Speech-Language-Hearing Association together announced their support of a new global initiative to standardize diets for the treatment of people who suffer from swallowing disorders.

Key elements of the IDDSI framework:

  • The final dysphagia diet framework consists of eight levels (0-7) and includes both foods and liquids on a single continuum (as shown above)
  • Levels are identified by numbers, text labels, and color codes
  • Drinks are measured from Levels 0-4, while foods are measured from Levels 3-7
  • There are expanded levels of liquid consistencies
    • National Dysphagia Diet (NDD) levels (3): Nectar –> Honey –> Pudding Thick
    • IDDSI Levels (4): Mildy –> Moderately –> Extremely Thick to replace National Dysphagia Diet levels, with the addition of Slightly Thick which is between Thin and Mildly Thick
  • Level 3 includes moderately thick liquids and liquidized foods, which share similar characteristics and descriptions
  • Level 4 includes extremely thick liquids and pureed foods, which share similar characteristics and descriptions
  • Level 5 contains minced particle sizes of 4mm, which happens to be the size of food particles after chewing and are “swallow-ready” so this diet requires minimal chewing *note for pediatrics, they suggest 2mm particle size
  • Level 6 contains bite sizes that are 1.5cm or 15mm, so that if a chunk falls into the airway, the person will not choke/asphyxiate. The size of 15mm is about the size of an adult thumbnail, and is smaller than the typical adult airway *note for pediatrics, the chunk size should be no larger than 8mm or the size of the child’s fingernail on his/her pinky finger
  • There are now specific, and practical tests of consistency (without using expensive rheology equipment) that can be used to distinguish between levels (i.e. the IDDSI Flow Test and Fork Test using a 10 mL syringe)
  • A category for transitional foods is provided
  • The diet labels can be easily translated into many languages

The future is bright for patient safety with IDDSI implementation

Changing over to globally recognized terminology – based on evidence – is critical, regardless of the patient population or type of facility you are practicing in.

Implementation should involve numerous phases, including building awareness, preparation and adoption, and monitoring across all the phases. You can also help in this preparedness by finding champions in your institution/facility to review your own diet labels, descriptors and menus.

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). The Foodservice Industry is already starting to dual label their products, so be sure to check for the new labeling.

Some resources to help:

Visit for additional information on framework, implementation, FAQ’s, etc.

IDDSI will be updating resources regularly so be sure to register to receive their e-bites (newsletters).

Download their Free App for Apple/Android by searching “IDDSI” in the app store

Dietitians On Demand offers both local and travel consultant dietitian positions. Our dietitians cover a vacancy, maternity leave, vacations, FMLA or increases in census. Check out our job openings, or request your coverage today!

Academy of Nutrition and Dietetics. (2017). Academy of Nutrition and Dietetics, What is the International Dysphagia Diet Standardisation Initiative? Accessed August 20, 2018.
Cichero JA, Steele C, Duivestein J, et al. The Need for international terminology and definitions for texture-modified foods and thickened liquids used in dysphagia management: Foundations of a global initiative. Curr Phys Med Rehabil Rep. 2013;1(4):280-291.
International Dysphagia Diet Standardisation Initiative. Complete IDDSI Framework Detailed definitions. Accessed August 15, 2018.
Creative Commons Attribution. (2015). Detailed Descriptors, Testing Methods and Evidence for Drinks: Levels 0-4. Accessed August 14, 2018.
Speakers on what long term care dietitians need to know about the mds webinar

About Deirdre Carlson and Anita Klimanis

Deirdre Carlson, RDN, CDCES lives in Northern California thanks to a travel position with Dietitians On Demand. She spent nearly two years working in long term care before transitioning to acute care. Anita Klimanis, RD, LDN is a regional corporate dietitian with Dietitians On Demand. She provides consultant services for both acute and long-term care facilities in the Baltimore area.

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