Aging Diseases and Conditions

Adopt the IDDSI for Dysphagia

Marsha is an RD and clinical nutrition coordinator for a small chain of skilled nursing facilities. When attending the Academy of Nutrition and Dietetics (Academy) Food & Nutrition Conference & Expo™ in October 2018, she learned that the Academy and the American Speech-Language Hearing Association both support the International Dysphagia Diet Standardisation Initiative (IDDSI). On the heels of the Academy’s May 1, 2019, IDDSI implementation date, Marsha realized that now is the time for both RDs and speech-language pathologists to take the leap and become comfortable with the framework, food and fluid consistencies, new terminology, and testing methods for dysphagia. At her suggestion, her company decided to implement the IDDSI in every facility. Marsha is preparing for an upcoming meeting for corporate management staff and facility management staff to introduce IDDSI and discuss a plan to adopt it companywide. Attendees will include directors of nursing, therapy, and food and nutrition.

What Is the IDDSI?
Dysphagia, a swallowing disorder, affects around 8% of the world’s population. The majority of people affected are pediatric or elderly. Modification of food texture and liquid consistency is a cornerstone of dysphagia management, but until now there has been little consistency in how food and fluids used to treat dysphagia are described and delivered in the United States and around the world.

IDDSI is a global initiative to improve the lives of people worldwide living with dysphagia. It’s a multidisciplinary, international organization that addresses the aforementioned lack of consistency with a goal to improve patient/resident safety. It provides a framework with standardized definitions and terminology for food textures and fluid consistencies that can be used across ages, care settings, and cultures. Food textures and/or fluid consistencies are defined as eight color-coded levels on a single continuum. Detailed descriptions of each level of the framework can be found here. The basic framework is pictured below.

Copyright: The International Dysphagia Diet Standardization Initiative 2016 @

A unique and critical aspect of IDDSI is that it recommends testing foods and fluids to ensure that what is served to a patient/resident is consistent with their diet order. Testing foods for the correct texture (when using eating utensils such as a fork and spoon) and fluids for the correct consistency (when using a syringe and/or spoon) is described in detail in print and video form for both foods and fluids on the IDDSI website. If testing is done as directed by IDDSI, Marsha can be assured that food textures and fluid consistencies served to patients/residents will be consistent in all of the company’s facilities.

Implementing IDDSI
IDDSI’s vision is that, ultimately, diet orders in acute and postacute care settings around the world will use the same terminology and that every patient/resident on a given level of the framework will receive the same food texture and/or fluid consistency, confirmed through testing methods. Although implementing IDDSI is voluntary, the goal is for it to eventually be considered the standard of dysphagia care.

IDDSI recommends that health care professionals use a three-step implementation process— beginning with building awareness, then preparing for implementation, and finally adopting the framework. RDs should begin by educating themselves on the new terminology, becoming familiar with the recommended testing methods, and then building awareness among their colleagues and other disciplines in their work settings.

Because of the level of adaptation required by facilities and clinicians, adoption of IDDSI could take one to two years. Education of stakeholders at all levels, from corporate managers and facility administration to patient/resident caregivers and foodservice staff, is key to implementing IDDSI successfully. There’s no doubt that there will be a learning curve during the transition from comfortable terminology (National Dysphagia Diet [NDD] levels 1, 2, and 3 and honey-, nectar-, or spoon-thick liquids) to the eight-level framework. That change will be easier using the tools that “map” NDD food and fluid terminology to IDDSI levels. For example, the mapping tool indicates that NDD’s “spoon-thick” liquids map to (ie, are the approximate equivalent of) IDDSI’s “extremely thick liquids (level 4).”

Fortunately, IDDSI website’s provides excellent resources and implementation guides to help clinicians like Marsha successfully transition to IDDSI. Becky Dorner & Associates has webinars available that introduce the subject to clinicians. As IDDSI implementation progresses, terminology will be integrated into diet and nutrition care manuals, physicians’ orders, and menu spreadsheets. Many oral nutritional supplement manufacturers and producers of prethickened liquids already have begun testing and labeling their products with IDDSI terminology, and some facilities are already beginning the implementation process.

Where Should Marsha Begin?
Marsha’s planned meeting is the perfect first step for raising awareness in her company. She should rely heavily on the IDDSI website to help with the transition to IDDSI. Marsha should reassure her colleagues that IDDSI implementation is a process that will take time and education. Setting a timeline and a goal date for adoption will help the company move forward. The transition should begin with awareness of stakeholders in the company, then progress to education of staff, preparation for implementation, and, eventually, when all the pieces are in place, adoption.

— Becky Dorner, RDN, LD, FAND, is widely known as one of the nation’s leading experts on nutrition and long term health care. Her company, Becky Dorner & Associates, Inc, is a trusted source of valuable continuing education, nutrition resources, and creative solutions. Visit to sign up for free news and information.

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