Complete IDDSI Framework Detailed Definitions
INTRODUCTION
The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded in 2013 with the goal of developing new global standardised terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures.
Three years of ongoing work by the International Dysphagia Diet Standardisation Committee has culminated in a final dysphagia diet framework consisting of a continuum of 8 levels (0-7). Levels are identified by numbers, text labels and colour codes.
This document provides detailed descriptors for all levels of the IDDSI Framework. Descriptors are supported by simple measurement methods that can be used by people with dysphagia or by caregivers, clinicians, food service professionals or industry to confirm the level a food fits into.
This document is to be read in conjunction with IDDSI Testing Methods, IDDSI Evidence and IDDSI Frequently Asked Questions (FAQs) documents (http://iddsi.org/framework/).
The IDDSI Committee would like to acknowledge the interest and participation of the global community including patients, caregivers, health professionals, industry, professional associations and researchers. We would also like to thank our sponsors for their generous support.
Please visit the www.iddsi.org for further information
The IDDSI Committee:
Co-Chairs: Peter Lam (CAN) & Julie Cichero (AUS);
Committee Members: Jianshe Chen (CHN), Roberto Dantas (BRA), Janice Duivestein (CAN), Ben Hanson (UK), Jun Kayashita (JPN), Caroline Lecko (UK), Mershen Pillay (ZAF), Luis Riquelme (USA), Soenke Stanschus (GER), Catriona Steele (CAN).
Past Committee Members: Joe Murray (USA)
The International Dysphagia Diet Standardisation Initiative Inc. (IDDSI) is an independent, not-for-profit entity. IDDSI is grateful to a large number of agencies, organizations and industry partners for financial and other support. Sponsors have not been involved with the design or development of the IDDSI framework.
Development of the IDDSI framework (2012-2015) IDDSI would like to thank and acknowledge the following sponsors for their generous support in the development of the IDDSI framework:
• Nestlé Nutrition Institute (2012-2015) • Nutricia Advanced Medical Nutrition (2013-2014) • Hormel Thick & Easy (2014-2015) • Campbell’s Food Service (2013-2015) • apetito (2013-2015) • Trisco (2013-2015) • Food Care Co. Ltd. Japan (2015) • Flavour Creations (2013-2015) • Simply Thick (2015) • Lyons (2015)
0: Thin
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Descrption/ Characteristics |
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Physiological rationale for this level of thickness
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Functional ability to safely manage liquids of all types |
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Testing method See also IDDSI Testing Methods document or http://iddsi.org/framework/drink-testing-methods/ |
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IDDSI Flow Test*
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Test liquid flows through a 10 mL slip tip syringe completely within 10 seconds, leaving no residue (see IDDSI Flow Test instructions*) |
1: Slightly Thick
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Descrption/ Characteristics |
• Thicker than water • Requires a little more effort to drink than thin liquids • Flows through a straw, syringe, teat/nipple Similar to the thickness of commercially available ‘Anti-regurgitation’ (AR) infant formula |
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Physiological rationale for this level of thickness
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Predominantly used in the paediatric population as a thickened drink that reduces speed of flow yet is still able to flow through an infant teat/nipple. Consideration to flow through a teat/nipple should be determined on a case−by−case basis. |
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Testing method See also IDDSI Testing Methods document or http://iddsi.org/framework/drink-testing-methods/ |
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IDDSI Flow Test*
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Test liquid flows through a 10 mL slip tip syringe leaving 1−4 mL in the syringe after 10 seconds (see IDDSI Flow Test instructions*) |
2: Mildly Thick
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Descrption/ Characteristics |
• Flows off a spoon • Sippable, pours quickly from a spoon, but slower than thin drinks Effort is required to drink this thickness through standard bore straw (standard bore straw = 0.209 inch or 5.3 mm diameter) |
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Physiological rationale for this level of thickness
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• If thin drinks flow too fast to be controlled safely, these Mildly Thick liquids will flow at a slightly slower rate May be suitable if tongue control is slightly reduced. |
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Testing method See also IDDSI Testing Methods document or http://iddsi.org/framework/drink-testing-methods/ |
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IDDSI Flow Test*
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Test liquid flows through a 10 mL slip tip syringe leaving 4 to 8 ml in the syringe after 10 seconds (see IDDSI Flow Test instructions*) |
3: Liquidised Moderately Thick
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Descrption/ Characteristics Texture restrictions shown in summary table |
• Can be drunk from a cup • Some effort is required to suck through a standard bore or wide bore straw (wide bore straw = 0.275 inch or 6.9 mm) • Cannot be piped, layered or moulded on a plate • Cannot be eaten with a fork because it drips slowly in dollops through the prongs • Can be eaten with a spoon • No oral processing or chewing required – can be swallowed directly Smooth texture with no ‘bits’ (lumps, fibers, bits of shell or skin, husk, particles of gristle or bone) |
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Physiological rationale for this level of thickness
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• If tongue control is insufficient to manage Mildly Thick drinks (Level 2), this Liquidised/Moderately thick level may be suitable • Allows more time for oral control • Needs some tongue propulsion effort Pain on swallowing |
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Testing method See also IDDSI Testing Methods document or http://iddsi.org/framework/drink-testing-methods/ and http://iddsi.org/framework/food-testing-methods/ |
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IDDSI Flow Test*
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Test liquid flows through a 10 ml slip tip syringe leaving > 8 ml in the syringe after 10 seconds (see Syringe Test Guide*) |
| Fork Drip Test |
· Drips slowly in dollops through the prongs of a fork · Tines/Prongs of a fork do not leave a clear pattern on the surface Spreads out if spilled onto a flat surface |
| Spoon Tilt Test | Easily pours from spoon when tilted; does not stick to spoon |
| Chopstick Test | Chopsticks are not suitable for this texture |
| Finger Test |
· It is not possible to hold a sample of this food texture using fingers, however, this texture slides smoothly and easily between the thumb and fingers, leaving a coating |
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Food specific or Other examples (NB. this list is not exhaustive) |
The following items may fit into IDDSI Level 3: • Infant “first foods” (runny rice cereal or runny pureed fruit) • Sauces and gravies Fruit syrup |
4: Pureed Extremely Thick
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Descrption/ Characteristics Texture restrictions shown in summary table |
• Usually eaten with a spoon (a fork is possible) • Cannot be drunk from a cup • Cannot be sucked through a straw • Does not require chewing • Can be piped, layered or molded • Shows some very slow movement under gravity but cannot be poured • Falls off spoon in a single spoonful when tilted and continues to hold shape on a plate • No lumps • Not sticky Liquid must not separate from solid |
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Physiological rationale for this level of thickness
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• If tongue control is significantly reduced, this category may be easiest to manage • Requires less propulsion effort than Minced & Moist (level 5), Soft & Bite−Sized (Level 6) and Regular (Level 7) but more than Liquidised/Moderately thick (Level 3) • No biting or chewing is required • Increased residue is a risk if too sticky • Any food that requires chewing, controlled manipulation or bolus formation are not suitable • Pain on chewing or swallowing Missing teeth, poorly fitting dentures |
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Testing method See also IDDSI Testing Methods document or http://iddsi.org/framework/food-testing-methods/ |
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IDDSI Flow Test*
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n/a Flow test not applicable, please revert to Fork Drip Test and Spoon Tilt Test |
| Fork Pressure test |
• The tines/prongs of a fork can make a clear pattern on the surface, and/or the food retains the indentation from the fork
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| Fork Drip test |
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| Spoon Tilt test |
• Cohesive enough to hold its shape on the spoon • A full spoonful must plop off the spoon if the spoon is titled or turned sideways; a very gentle flick may be necessary to dislodge the sample from the spoon, but the sample should slide off easily with very little food left on the spoon; i.e. the sample should not be firm and sticky
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| Chopstick test |
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| Finger test |
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| Indicators that a sample is too thick |
• Does not fall off the spoon when tilted
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| FOOD SPECIFIC OR OTHER EXAMPLES | |
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The following item may be suitable for IDDSI Level 4: Purees suitable for infants (e.g. pureed meat, thick cereal) |
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5: Minced & Moist
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Descrption/ Characteristics Texture restrictions shown in summary table |
• Can be eaten with a fork or spoon • Could be eaten with chopsticks in some cases, if the individual has very good hand control • Can be scooped and shaped (e.g. into a ball shape) on a plate • Soft and moist with no separate thin liquid • Small lumps visible within the food Ø Paediatric, 2 mm lump size Ø Adult, 4mm lump size Lumps are easy to squash with tongue |
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Physiological rationale for this level of thickness
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• Biting is not required • Minimal chewing is required • Tongue force alone can be used to break soft small particles in this texture • Tongue force is required to move the bolus • Pain or fatigue on chewing Missing teeth, poorly fitting dentures |
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Testing method See also IDDSI Testing Methods document or http://iddsi.org/framework/food-testing-methods/ |
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IDDSI Flow Test*
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n/a Flow test not applicable, please revert to Fork Drip Test and Spoon Tilt Test |
| Fork Pressure test |
• When pressed with a fork the particles should easily be separated between and come through the tines/prongs of a fork Can be easily mashed with little pressure from a fork [pressure should not make the thumb nail blanch to white] |
| Fork Drip test |
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| Spoon Tilt test |
• Cohesive enough to hold its shape on the spoon • A full spoonful must slide/pour off the spoon if the spoon is tilted or turned sideways or shaken lightly; the sample should slide off easily with very little food left on the spoon; i.e. the sample should not be sticky
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| Chopstick test |
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| Finger test |
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| FOOD SPECIFIC OR OTHER EXAMPLES http://iddsi.org/framework/food-testing-methods/ | |
MEAT
Finely minced or chopped, tender mince
- Paediatric, 2mm /ump size
- Adu/t, 4mm /ump size
Serve in extremely thick, smooth, non−pouring sauce or gravy
*If texture cannot be finely minced it should be pureed
FISH
· Finely mashed in extremely thick smooth, non−pouring sauce or gravy
o Paediatric, 2mm /ump size
o Adu/t, 4mm /ump size
FRUIT
· Serve mashed
· Drain excess juice
o Paediatric, 2mm /ump size
o Adu/t, 4mm /ump size
VEGTABLES
- Finely minced or chopped or mashed
- Drain any liquid
- Paediatric, 2mm /ump size
- Adu/t, 4mm /ump size
CEREAL
- Very thick and smooth with small soft lumps
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Paediatric, 2mm /ump size
- Adu/t, 4mm /ump size
- Texture fully softened
- Any milk/fluid must not separate away from cereal. Drain any excess fluid before serving
BREAD
- Pre−gelled ‘soaked` breads that are very moist and gelled through the entire thickness
- No regular, dry bread
RICE
- Not sticky or glutinous (particularly short grain rice) and should not be particulate or separate into
- individual grains when cooked and served (particularly long grain rice)
o Note - lump size requirements for all foods in Level 5 Minced & Moist:
- Paediatric, 2mm lump size
- Adult, 4mm lump size
6: Soft & Bite-Sized
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Description/characteristics Texture restrictions shown in summary table |
• Can be eaten with a fork, spoon or chopsticks • Can be mashed/broken down with pressure from fork, spoon or chopsticks • A knife is not required to cut this food, but may be used to help loading a fork or spoon • Chewing is required before swallowing • Soft, tender and moist throughout but with no separate thin liquid • ‘Bite−sized` pieces as appropriate for size and oral processing skills Ø Paediatric, 8mm pieces Adults, 15 mm = 1.5 cm pieces |
| Physiological rationale for this level of thickness |
• Biting is not required • Chewing is required • Tongue force and control is required to move the food for chewing and to keep it within the mouth during chewing • Tongue force is required to move the bolus for swallowing • Pain or fatigue on chewing Missing teeth, poorly fitting dentures |
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TESTING METHODS See also IDDSI Testing Methods document or http://iddsi.org/framework/food-testing-methods/ |
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| Fork Pressure test |
• Pressure from a fork held on its side can be used to ‘cut` or break this texture into smaller pieces • When a sample the size of a thumb nail (1.5x1.5 cm) is pressed with the base of a fork to a pressure where the thumb nail blanches to white, the sample squashes and changes shape, and does not return to its original shape when the fork is removed. |
| Spoon Pressure test |
• Pressure from a spoon held on its side can be used to ‘cut` or break this texture into smaller pieces.
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| Chopstick test |
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| Finger test | Use a sample the size of a thumb nail (1.5 cm x 1.5 cm). It is possible to squash a sample of this texture using finger pressure such that the thumb and index finger nails blanch to white. The sample will not return to its initial shape once pressure is released. |
FOOD SPECIFIC OR OTHER EXAMPLES
Note - food size requirements for all foods in Level 6 Soft & Bite-sized:
- Paediatric, 8mm pieces
- Adult, 15mm = 1.5cm pieces
MEAT
• Cooked, tender meat no bigger than
• Paediatric, 8mm pieces
• Adu/ts, 15 mm = 1.5 x 1.5 cm pieces
• If texture cannot be served soft and tender at 1.5 cm x 1.5 cm, serve minced and moist
FISH
• Soft enough cooked fish to break into small pieces with fork, spoon or chopsticks no larger than
• Paediatric, 8mm pieces
• Adu/ts, 15 mm = 1.5 cm pieces
• No bones
CASSEROLE/STEW/CURRY
• Liquid portion must be thick (as per clinician recommendations; refer to IDDSI levels 0−4)
• Can contain meat, fish or vegetables if final cooked pieces are soft and tender and no larger than
• Paediatric, 8mm pieces
• Adu/ts, 15 mm = 1.5 cm pieces
• No hard lumps
FRUIT
• Serve mashed
• Paediatric, 8mm pieces
• Adu/ts, 15 mm = 1.5 cm pieces
• Fibrous parts of fruit are not suitable
• Drain excess juice
• Assess individual ability to manage fruit with high water content (e.g. watermelon) where juice separates from solid in the mouth during chewing
VEGETABLES
• Steamed or boiled vegetables with final cooked size of
• Paediatric, 8mm pieces
• Adu/ts, 15 mm = 1.5 cm pieces
• Stir fried vegetables are often too firm and are not soft or tender
CEREAL
• Smooth with soft tender lumps no bigger than
• Paediatric, 8mm pieces
• Adu/ts, 15 mm = 1.5 cm pieces
• Texture fully softened
• Any excess milk or fluid must drained
BREAD
• Pre−gelled ‘soaked` breads that are very moist and gelled through the entire thickness
• No regular dry bread unless assessed as suitable by dysphagia specialist, on an individual basis (if considered appropriate bread must also conform to paediatric 8mm, and adult 1.5 x1.5 cm size requirements)
RICE
• Not particulate/grainy, sticky or glutinous
7: Regular
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Description/characteristics There are NO texture restrictions at this level |
• Normal, everyday foods of various textures that are developmentally and age appropriate • Any method may be used to eat these foods • Foods may be hard and crunchy or naturally soft • Sample size is not restricted at Level 7, therefore, foods may be of a range of sizes Ø Smaller or greater than 8mm pieces (Paediatric) Ø Smaller or greater than 15 mm = 1.5 cm pieces (Adults) • Includes hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy, or crumbly bits • Includes food that contains pips, seeds, pith inside skin, husks or bones
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| Physiological rationale for this level of thickness |
• Ability to bite hard or soft foods and chew them for long enough that they form a soft cohesive ball/bolus that is ‘swallow ready` • An ability to chew all food textures without tiring easily
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| TESTING METHOD | |
| Not Applicable | |
Transitional Foods
| Description/characteristics |
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| Physiological rationale for this level of thickness |
• Biting not required • Minimal chewing required • Tongue can be used to break these foods once altered by temperature or with addition of moisture/saliva
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TESTING METHOD See also IDDSI Testing Methods document or http://iddsi.org/framework/food-testing-methods/ |
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| Fork pressure test |
• After moisture or temperature has been applied, the sample can be easily deformed and does not recover its shape when the force is lifted. • Use a sample the size of the thumb nail (1.5 cm x 1.5 cm), place 1 ml of water on the sample and wait one minute. Apply fork pressure using the base of the fork until the thumbnail blanches to white. The sample is a transitional food texture if after removing the fork pressure: • The sample has been squashed and disintegrated and no longer looks like its original state
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| Spoon pressure test |
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| Chopstick test |
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| Finger test |
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| FOOD SPECIFIC OR OTHER EXAMPLES | |
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IDDSI Transitional Foods may include and are not limited to: • Ice chips • Ice cream/Sherbet if assessed as suitable by a Dysphagia specialist • Japanese Dysphagia Training Jelly sliced 1 mm x 15 mm • Wafers (also includes Religious Communion wafer) • Waffle cones used to hold ice cream • Some biscuits/ cookies/ crackers • Potato crisps − only the mashed type (e.g. Pringles) • Shortbread • Prawn crisps Specific examples used in paediatric or adult disability dysphagia management Commercially available foods# that are transitional foods textures include but are not limited to: • Veggie Stix™ • Cheeto Puffs™ • Rice Puffs™ • Baby Mum Mums™ • Gerber Graduate Puffs™ The mention of certain manufacturers` products does not imply that they are endorsed or recommended in preference to others of a similar nature that are not mentioned. |
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Food Texture Requirements
Accompanying documents (http://iddsi.org/framework/):
Ø IDDSI Testing Methods
Ø IDDSI Evidence
Ø IDDSI Frequently Asked Questions (FAQs)