Back to the Basics. The International Dysphagia Diet Standardisation Initiative (IDDSI)

By: John Holahan, President at SimplyThick, LLC

Introduction

Remember the first time you tried something new, bombarded with unfamiliar terminology and abbreviations? That initial confusion is something we've all experienced. It’s easy to forget this once we're in the know, but it’s a significant hurdle for beginners. This article aims to avoid those pitfalls and break down the complexities of the International Dysphagia Diet Standardization Initiative (IDDSI) into comprehensible information.

What does IDDSI Stand For?

For those new to the topic, IDDSI stands for the International Dysphagia Diet Standardization Initiative. Initially, people spelled out each letter (I-D-D-S-I), but today it’s pronounced as a word: “Id-See”.

On its website, IDDSI describes itself as “a global initiative to improve the lives of over 590 million people worldwide living with dysphagia.” IDDSI provides a single global framework for describing food and drinks served to people with dysphagia. To support the framework, IDDSI also offers simple test methods that can be conducted with common household tools to ensure food and drinks meet the framework descriptions.

IDDSI has become the common framework globally for defining food and drinks for people with dysphagia. As of this writing, there are 24 official translations of the IDDSI Framework and Testing Methods available on the IDDSI website.

Is IDDSI Mandatory?

No, adopting IDDSI is voluntary. However, it is a Standard of Practice that is widely used and endorsed. In the USA, it is the dysphagia diet endorsed by the Academy of Nutrition & Dietetics and the American Speech-Language-Hearing Association. The Nutrition Care Manual? no longer supports any other dysphagia diet.? At the time of this writing, there is no other Standard of Practice for dysphagia diets in the USA.

What is the IDDSI Framework?

The IDDSI Framework as it currently exists is shown figure below.

The IDDSI Framework describes a continuum of diet levels from thin drinks to solid foods, each level characterized by specific food or drink behaviors. The names of the diet levels are designed to evoke mental images of what the food should look like.

A Quick Overview of The IDDSI Framework

The IDDSI Framework consists of two pyramids: one for liquids and one for solid foods.

Liquids Pyramid:

• The base represents unrestricted, everyday liquids.
• As you move up, each drink level becomes progressively thicker.
• At Level 4 (Extremely Thick), beverages are more like pudding than free-flowing liquids.

Foods Pyramid:

• The pyramid is inverted with unrestricted, everyday foods at the top.
• Moving down, foods become more processed, smaller in size, and moistened.
• At Level 4 (Pureed), food is ready to swallow without chewing.

The food pyramid can be visualized as a simulation of the natural chewing and food preparation phase we all use.? Think of it like this:

Soft & Bite-Sized, Level 6: Chewing breaks food down into small, manageable pieces.

Minced & Moist, Level 5: Continued chewing processes food into very small pieces mixed with saliva.

Pureed, Level 4: Food becomes smooth and ready to swallow without further chewing.

Liquidized, Level 3: Food becomes more liquid-like with saliva.

Connecting Levels 3 and 4

Levels 3 and 4 are present on both the food and drinks pyramids, showing their similar characteristics. Pureed, Level 4 foods behave like Extremely Thick, Level 4 liquids. Liquidized, Level 3 foods are similar to Moderately Thick, Level 3 liquids in terms of behavior and testing standards.

Transitional Foods

There is also another class of foods that require a separate evaluation - transitional foods. These are things that change form in your mouth - whether from the heat or the exposure to saliva. Think of ice cubes, ice cream, chips and corn puffs.

Conclusion

Understanding the basics of IDDSI can significantly improve the lives of those with dysphagia. By breaking down this framework into simple terms, we hope to make it accessible to everyone, from beginners to seasoned professionals.