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"I jumped on board with IDDSI because I’ve always believed it would reduce errors in the food served to people."

John Holahan

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

Remember the first time you tried something new – with all new terminology and abbreviations? It leads to a lot of confusion.  That initial confusion is something we've all experienced, yet it's easy to forget once we're in the know. Sometimes it's comical to read the "Frequently Asked Questions" crafted by insiders and experts, laden with complex jargon that might as well be a foreign language to newcomers. These FAQs, intended to clarify, often end up doing the opposite.


In this article, I'm diving back into the basics of IDDSI and hopefully, I’m going to avoid these pitfalls.  I intend to break down the complex into the comprehensible.

Thanks to search engines and some insightful websites, we've gathered the real questions beginners are asking about the International Dysphagia Diet Standardisation Initiative (IDDSI). 


So, let’s begin to unravel the real questions people are asking about the International Dysphagia Diet Standardisation Initiative.


What does IDDSI Stand For?

For anyone new to the topic, you may even be wondering what IDDSI stands for?  The International Dysphagia Diet Standardisation Initiative is most often referred to by its acronym – IDDSI.  Although when it first came out, people verbally spelled out the letters – literally saying each letter I – D – D – S – I, today it is pronounced like a word.  Phonetically, it sounds like “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 provides simple test methods that can be run with very common household tools to ensure the food and drinks meet the framework descriptions. 


IDDSI has become the most common framework used across the globe for defining food and drinks served to 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, and it is NOT mandatory.  However, with widespread adoption across the globe, it is a very common diet.  In the USA, IDDSI is the dysphagia diet that is endorsed by the Academy of Nutrition & Dietetics and the American Speech-Language-Hearing Association. There is no other diet officially supported by either organization.  And more importantly for those working as a Registered Dietitian Nutritionist, the Nutrition Care Manual® no longer supports any other dysphagia diet.


What is the IDDSI Framework?

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

International Dysphagia Diet Standardisation Initiative Framework - IDDSI Dysphagia Diet Levels

The IDDSI Framework describes a continuum of diet levels from thin drinks to solid foods. Each level is descriptive of the characteristics and behavior of a food or drink that meets the diet level. IDDSI diet level names were also chosen to invoke a mental image of what food fitting the level should look like.


A Quick Overview of The IDDSI Framework

The IDDSI Framework consists of two pyramids. One pyramid characterizes the liquids, and the other describes solid foods.  The base of the drink pyramid is unrestricted, everyday liquids. As you move up the pyramid, each drink level becomes progressively thicker. When you reach Extremely Thick, Level 4, the beverages are more like a pudding than a free-flowing liquid. 


The food pyramid is inverted, so its “base” is actually at the top.   Just like with the drinks pyramid, the base level is unrestricted, everyday foods.  As you move down the food pyramid, the foods become more processed into smaller particle sizes and moistened with liquid. By the time you reach Pureed, Level 4 the food is ready to swallow without any further chewing by the person with dysphagia.


A helpful way to visualize what the food pyramid is trying to mimic, is to imagine eating a piece of cheese or soft meat. 


  • As you begin chewing, the food quickly breaks down into pieces that would be Soft & Bite-Sized, Level 6. 

  • As you continue to chew and process the food in your mouth, the pieces become smaller and smaller and mix with your saliva until they are broken down to a Minced & Moist, Level 5.  At this point, the food is in very small pieces, is well mixed with saliva, and is almost ready to swallow.   Many people without dysphagia will swallow the food at this point. 

  • If you continue to chew and process the food until it becomes smooth with no lumps, it becomes Pureed, Level 4.  At this point, the food could be swallowed by almost anyone without any further chewing. 

  • If you continue to hold the food in your mouth long enough, it will become more and more liquid-like as more saliva is added to it.  Eventually, you would have a Liquidised, Level 3 food in your mouth. 

One final note about the pyramids is that Levels 3 and 4 are present on both the food and the drinks pyramids and are shown as connected between the pyramids.  This is to communicate that the behavior and physical characteristics of the food and the beverage at these levels are very similar. Pureed, Level 4 foods behave the same as Extremely Thick, Level 4 liquids. Liquidised, Level 3 foods and Moderately Thick, Level 3 liquids also have similar physical characteristics and Framework testing standards.


 

I hope you find this information helpful.  If you have suggestions or questions you’d like to see answered, post a comment, or send me a note! For more information on IDDSI, please visit iddsi.org

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