Understanding the Need for Standardized Terminology
Before the International Dysphagia Diet Standardisation Initiative (IDDSI) was introduced, a wide array of regional and national standards for food and fluid consistency existed. This created confusion and communication breakdowns, particularly during patient transfers between different care settings or countries. A lack of standardized terminology could lead to serious safety risks, including aspiration (when food or liquid enters the lungs) and choking. In response, a global group of dysphagia experts developed the IDDSI Framework in 2015 to create a single, unified system. This common language is now used internationally in hospitals, care homes, and other settings to ensure patients receive consistent and safe care.
The IDDSI Framework: A Continuum of 8 Levels
The IDDSI framework is a continuum of eight levels, ranging from Level 0 (Thin) to Level 7 (Regular). The levels are identified by text labels, numbers, and color codes for clear and easy identification. A key feature is the separation of fluids and foods along this continuum, though Levels 3 and 4 bridge both categories due to similar flow characteristics. The framework also includes practical, evidence-based testing methods that allow caregivers to easily verify the texture and thickness of a food or drink.
IDDSI Fluid Levels (0-4)
- Level 0 - Thin (Blue): These fluids flow like water and require full control to swallow safely. They can be consumed with a standard cup or straw and include water, milk, coffee, tea, and juice without pulp.
- Level 1 - Slightly Thick (Grey): This fluid is slightly thicker than water but still flows quickly. It may be appropriate for individuals who require a minor modification to control the liquid's flow. A slightly thick fluid will flow through a standard syringe during the IDDSI Flow Test, but slightly slower than thin fluids.
- Level 2 - Mildly Thick (Pink): This is a nectar-like consistency that flows more slowly than slightly thick fluids. It requires a little more effort to drink from a straw. In the IDDSI Flow Test, mildly thick liquids leave a defined amount of fluid in the syringe after 10 seconds.
- Level 3 - Moderately Thick (Yellow): This fluid has a honey-like consistency and flows very slowly. It cannot be drunk from a cup or sucked through a straw. It can be eaten with a spoon and holds its shape but is not sticky.
- Level 4 - Extremely Thick (Green): This is a pudding-like consistency that does not flow and can be eaten with a spoon. It holds its shape completely and should not be sticky. It must not flow through a fork or drip continuously.
IDDSI Food Levels (3-7)
- Level 3 - Liquidised (Yellow): Foods at this level are blended to a very smooth, lump-free texture. This is a transitional level, similar in consistency to moderately thick fluids, but refers to food that cannot be poured. It can be eaten with a spoon and should not contain any lumps.
- Level 4 - Pureed (Green): This food is smooth, moist, and cohesive, holding its shape on a plate but not sticky. It can be scooped with a spoon and does not require chewing. When tilted, a spoonful should fall off easily with a gentle flick.
- Level 5 - Minced & Moist (Orange): Foods at this level are soft and moist, with small, uniform particles no larger than 4mm. The food can be mashed easily with a fork and requires minimal chewing. There should be no separate thin liquid.
- Level 6 - Soft & Bite-Sized (Blue): This texture includes soft, tender foods cut into pieces no larger than 15mm. It can be easily broken apart with the side of a fork or spoon, with no separate thin liquid. Chewing is required.
- Level 7 - Regular (Black): This includes foods of normal texture that may pose a choking risk if not prepared properly.
- Level 7 - Easy to Chew (Black): A subcategory of Level 7 for individuals without an increased choking risk who need softer food choices. Food should be soft and tender and easily separated with a fork.
Comparison of Old vs. New Dysphagia Diet Terminology
One of the most significant changes introduced by IDDSI was the replacement of older, often inconsistent terminology with a single, clear set of standards. The following table highlights some of the key differences between the previous National Dysphagia Diet (NDD) in the United States and the current IDDSI Framework.
| Feature | Old National Dysphagia Diet (NDD) | New IDDSI Framework |
|---|---|---|
| Framework | Varied and inconsistent standards, leading to confusion. | A globally standardized, evidence-based system. |
| Liquids | Used terms like 'nectar-thick' and 'honey-thick', which could be subjective. | Employs specific, measurable levels (0-4) with objective testing. |
| Foods | Used terms like 'pureed', 'mechanical soft', and 'regular' without standardized sizes. | Standardized levels (3-7) with specific particle size and textural requirements. |
| Testing | Lacked universally consistent, evidence-based testing methods. | Includes easy-to-use, objective tests like the IDDSI Flow Test and Fork Pressure Test. |
| Scope | Primarily used in the U.S., with different standards in other regions. | Designed for use across all ages, cultures, and care settings globally. |
Implementation and Impact of IDDSI
The implementation of IDDSI is a multidisciplinary effort, involving speech-language pathologists, dietitians, nurses, foodservice staff, and administrators. Proper implementation is critical to improve patient safety, reduce healthcare costs associated with aspiration and choking incidents, and enhance the quality of life for individuals with dysphagia. By creating a common language, IDDSI minimizes miscommunication and ensures consistency in meal preparation, regardless of where the patient is being cared for.
Crucially, IDDSI is not a one-time change but a cultural shift in healthcare, emphasizing ongoing staff training and a commitment to patient safety. The official IDDSI website, which provides free access to resources and testing methods, is an invaluable tool for any institution looking to adopt the framework safely and effectively.
Conclusion
The IDDSI terminology and framework represent a monumental step forward in standardizing care for individuals with swallowing difficulties. By providing a clear, consistent, and evidence-based system for describing food textures and liquid thicknesses, it significantly enhances patient safety and improves communication across the global healthcare landscape. This framework empowers healthcare professionals and caregivers to provide safe, nourishing, and more palatable meals, ultimately improving the quality of life for those living with dysphagia. For more information and resources on the official framework, you can visit the International Dysphagia Diet Standardisation Initiative's website at iddsi.org.
