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Running head: Implementation of IDDSI 1

Implementation of the International Dysphagia Diet Standardization Initiative

Jonathan Tellier

October 4, 2018

Department of State Hospitals- Patton

Implementation of IDDSI 2



to investigate if the current NDDIII diet at Patton State Hospital could be transitioned

into the IDDSI framework soft and bite-sized level 6 category.


NDDIII recipes in computrition were analyzed and compared to the criteria set by IDDSI.

Excel was used to help analyze the data.


138 total recipes or food items were evaluated using computrition, with one fourth of all

recipes not meeting IDDSI criteria for soft and bite sized level 6.


in analyses of the current recipes being used for NDDIII, transition to the IDDSI

framework is possible if small changes in the current recipes were to be made.

Implementation of IDDSI 3


Dysphagia affects 8% of the world’s population and is defined as a difficulty in

swallowing. The International dysphagia diet synchronization initiative (IDDSI) aims to

standardize terminology and definitions associated with texture modification of foods

and liquids (Zaletal 2016). Texture modification of food and liquids is a very important

intervention in the management of dysphagia. Dysphagia research has been hard, due

to the lack of standardized nomenclature concerning drink thickness and food texture.

Phrases such as “nectar-thick” may not be interpreted the same way in every country

leading to barriers in research. IDDSI uses an international framework consisting of

eight levels (0 to 7). These levels include both foods and liquids existing on a single

continuum. Color codes, numbers and text labels developed by IDDSI represent

standardized definitions for liquid classifications and texture-modified foods. IDDSI flow

test uses a 10-ml syringe that is filled with 10-ml of test liquid and evaluated after 10-

seconds. The remaining fluid in the syringe determines what level of the IDDSI the liquid

is consistent with. Each level of the IDDSI framework has specification that need to be

met. Recommended measurement of bite-sized pieces for soft and bite-sized are 1.5cm

pieces for adults and 8mm pieces for pediatric patients. Currently the U.S. uses the

National Dysphagia Diet (NDD), and for the purpose of this study NDD3 will be defined.

NDD3 includes moist foods in bite size-pieces and an assortment of foods that may be

suitable. For this study the guidelines for soft and bite sized were analyzed in order to

see if the current NDDIII recipes at Patton State Hospital could be used for the new

IDDSI framework level 6.

Implementation of IDDSI 4

This study did not involve human patients or animals and was exempt from ethics

committee approval.

Computrition was evaluated to see if current recipes fall within the guidelines of

IDDSI level 6. Due to time restraints only, categories of food that are listed in the criteria

of soft and bite sized in the IDDSI framework were evaluated in this study.

Menus were evaluated, and each recipe served to NDDIII was compared to

criteria given by IDDSI. The recipes were broken into eight groups and color coded on

an excel spreadsheet. The eight groups include meat, casserole/stew/curry, fruit,

vegetables, cereal, bread, and rice. If the recipe is highlighted red it does not currently

meet the criteria for that category of the IDDSI framework and needs to be revised.


There was a total of 138 recipes or items evaluated and 35 of those items or recipes

currently do not meet the criteria for transition to IDDSI framework. Jelly and gelatin

were added upon completion of computrition recipe comparison due to importance of

removal from diet. Various reasons why criteria was not met include specification of cut

size of at least 1.5cm, soups having a liquid that is not thickened, fruits not being

mashed, raw vegetables being served, foods that can’t be cut by a fork, and food

keeping form after fork test.


Texture modification is paramount in the treatment of dysphagia to avoid aspiration.

Proper nutrition depends on food and fluid intake, many patients with dysphagia are not

able to masticate food properly and this may lead to aspiration. Foods that are texture

modified favor nutritional status for patients with dysphagia.

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Institutions currently treating dysphagia have their own understanding of related terms.

Varied understandings of the terminologies such as “puree” and “nectar thick” depend

on the culture and habits of the certain population as well as ethnical and racial aspects

(Olivera 2018). So the interpretation of current terms varies place-to-place making

health care for the same disease different. Across countries standardization of

characteristics should be the same.

The IDDSI framework aims to standardize terminology and definitions related to the

treatment of dysphagia. Categories using color, name, and number are used to make

the selection of a modified food easier. These standardized terminologies could be used

in any region because they define food consistencies and not certain foods.

For classification of food proper method for texture testing using the fork pressure test

should be done. Various other methods of testing texture for soft and bite-sized exist

such as spoon pressure test, chopstick test, and finger test. The fork pressure test has

proven to be the most accurate.

The reason computrition was used to assess all recipes and food items and each food

was not tested individually, was for liability reasons and time restraints. Some recipes

were saying cut vegetables to one inch, which is not meeting the bite-sized

requirements, set by IDDSI. Easily fixable this recipe and many others should include a

cut size of 1.5cm. Some problems seen in the recipes were the use of raw vegetables

and cut fruits. According to IDDSI all vegetables should be cooked and all fruits should

be mashed.

Implementation of IDDSI 6

The current NDDIII diet recipes can be transferred into soft and bite-sized with minor

alterations to the recipe.


Zaletal. (2016). Dysphagia. Clinical Nutrition ESPEN, 14, 51-52. doi:


Oliveira, L. (2018). Influence of the syringe model on the results of International

Dysphagia Diet Standardisation initiative flow test. Revista CEFAC. 20, 3. doi:


Steele, M. C., Namasivayam-Macdonald, M. A., Guida, T. B., Cichero, A. J., Duivestein,

J., Hanson, B., Lam, P., Riquelme, F. (2018). Creation and Initial Validation of

the International Dysphagia Diet Standardisation Initiative Diet Scale. Archives of

Physical Medicine and Rehabilitation, 99, 934-44.


Ong, J., Steele, M. C., Duizer, M. L. (2018). Sensory characteristics of liquids thickened

with commercial thickenerst to levels specified in the International Dysphagia

Standardization Initiative (IDDSI) framework. Food Hydrocolloid. 79, 208-217.