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Adopting the International Dysphagia Diet Standardisation Initiative: Now is the Time!

Marsha is a registered dietitian nutritionist (RDN) and Clinical Nutrition Coordinator for a small chain of skilled nursing facilities. When attending the Academy of Nutrition and Dietetics (Academy) Food and Nutrition Conference in October 2018, she learned that the Academy and the American Speech-Language Hearing Association (ASHA) both support the International Dysphagia Diet Standardisation Intitiative (IDDSI). During FNCE, the Academy announced an implementation date of May 1, 2019  for IDDSI. Marsha realized that now is the time for both RDNs and speech-language pathologists to take the leap and become comfortable with the framework, food and fluid consistencies, new terminology and testing methods. At her suggestion, her company decided to implement the International Dysphagia Diet Standardisation Initiative (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 company-wide. Attendees will include directors of nursing, therapy and food and nutrition.

What is the International Dysphagia Diet Standardisation Initiative (IDDSI)?

Dysphagia, a swallowing disorder, affects around 8% of the world’s population1. The majority of people affected are pediatric or elderly2. 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 is a multi-disciplinary, international organization that addresses lack of consistency with a goal to improve patient 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 cultures3. Food textures and/or fluid consistencies are defined as 8 color-coded levels on a single continuum. Detailed descriptions of each level of the framework can be found at The basic framework is pictured below.

IDDSI Pyramid

(c) The International Dysphagia Diet Standardisation Initiative 2016
@ Attribution is NOT PERMITTED for derivative works incorporating any alterations to the IDDSI Framework that extend beyond language translation.

A unique and critical aspect of IDDSI is that it recommends testing foods and fluids to assure that what is served to a patient/resident is consistent with their diet order4. Testing foods for the correct texture (using eating utensils such as a fork and spoon) and fluids for the correct consistency (using a syringe and/or spoon) is described in detail in both print and video form 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 eventually diet orders in acute and post-acute 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 care5.

IDDSI recommends that health care professionals use a 3-step implementation process, beginning with building awareness, then preparing for implementation, and finally adoption5. RDNs should begin by educating themselves on the new terminology, becoming familiar with the recommended testing methods, and then building awareness among colleagues and other disciplines in their work settings.

Because of the level of adaptation required by facilities and clinicians, adoption of IDDSI could take 1-2 years5. Education of stakeholders at all levels, from corporate managers to facility administration to care givers and food service staff, is key to implementing IDDSI successfully. There is no doubt that there will be a learning curve as the transition moves from comfortable terminology (National Dysphagia Diet {NDD} levels 1, 2 and 3, honey, nectar-or spoon-thick liquids) to the eight-level IDDSI 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 (are the approximate equivalent of) IDDSI’s “extremely thick liquids (level 4)”.

Fortunately, the IDDSI website 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, physician’s orders, and menu spreadsheets. Many oral nutritional supplement manufacturers and producers of pre-thickened liquids have already begun testing and labeling their products with IDDSI terminology, and some facilities are already beginning the implementation process5.

Where Should Marsha Begin with Implementation?

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.

©2019 Becky Dorner & Associates, Inc.

Becky Dorner & Associates, Inc. (BDA) is a trusted source of valuable continuing education, nutrition resources and creative solutions. Visit to sign up for free news and information.


  1. Cichero JA, Steele C, Duivestein J, et al. The need for international terminology and definitions for texture-modified foods and thickened liquids in dysphagia management: foundation of a global initiative. Curr Phy Med Rehabil Rep. 2013;1(4):280-291.
  2. Marcason W. What is the International Dysphagia Diet Standardisation Initiative? J Ac Nutr Diet. 2017. 117(4):652.
  3. Complete IDDSI Framework: Detailed Definitions. Accessed February 1, 2019.
  4. IDDSI Testing Methods. Accessed February 1, 2019.
  5. Sheffler K. International Dysphagia Diet Standardisation Initiative (IDDSI): The Who, Why, What, and How. Webinar for Becky Dorner & Associates, April 12, 2018. Available at
  6. Richardson B and Sheffler K. IDDSI: Teamwork from Regulatory Requirements to Successful Implementation. Webinar for Becky Dorner & Associates, March 21, 2019. Available at

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