Complete IDDSI Framework Detailed definitions
Please review article. Submit a 1 page summary on three take-aways from the article. Review the framework and describe 3 different levels and combinations.
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Complete IDDSI Framework Detailed definitions
2.0 | 2019
The IDDSI Framework and Descriptors are licensed under the CreativeCommons Attribution-Sharealike 4.0 International License
https://creativecommons.org/licenses/by-sa/4.0/ IDDSI 2.0 | July, 2019
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INTRODUCTION
The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded in 2013 with the goal of developing new international 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 work by the International Dysphagia Diet Standardisation Committee culminated in the 2016 release and 2017 publication of the IDDSI Framework consisting of a continuum of 8 levels (0-7). Levels are identified by numbers, text labels and colour codes. [Reference: Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, Duivestein J, Kayashita J, Lecko C, Murray J, Pillay M, Riquelme L, Stanschus S. (2017) Development of international terminology and definitions for texture-modified foods and thickened fluids used in dysphagia management: The IDDSI Framework. Dysphagia, 32:293-314. https://link.springer.com/article/10.1007/s00455- 016-9758-y]
The Complete IDDSI Framework Detailed Definitions 2019 is an update to the 2016 document. The Complete IDDSI Framework Detailed Definitions 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 or drink fits into.
This document is to be read in conjunction with IDDSI Testing Methods 2019, IDDSI Evidence 2016 and IDDSI Frequently Asked Questions (FAQs) documents ( https://iddsi.org/framework/).
The IDDSI Framework provides a common terminology to describe food textures and drink thickness. IDDSI tests are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing should be done on foods and drinks under the intended serving conditions (especially temperature). The clinician has the responsibility to make recommendations for foods or drinks for a particular patient based on their comprehensive clinical assessment.
IDDSI 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 https://iddsi.org/ for further information.
The IDDSI Board:
The IDDSI Board are a group of volunteers who do not draw a salary from IDDSI. They offer their knowledge, expertise and time for the benefit of the international community.
Co-Chairs: Peter Lam (CAN) & Julie Cichero (AUS);
Board Members: Jianshe Chen (CHN), Roberto Dantas (BRA), Janice Duivestein (CAN), Ben Hanson (UK), Jun Kayashita (JPN), Mershen Pillay (ZAF), Luis Riquelme (USA), Catriona Steele (CAN), Jan Vanderwegen (BE).
Past Board Members: Joseph Murray (USA), Caroline Lecko (UK), Soenke Stanschus (GER)
The International Dysphagia Diet Standardisation Initiative Inc. (IDDSI) is independent and operates as a 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.
Implementation of the IDDSI framework is in progress. IDDSI is extremely grateful to all sponsors supporting implementation https://iddsi.org/about-us/sponsors/
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Description/ Characteristics
• Flows like water • Fast flow • Can drink through any type of teat/nipple, cup or straw as
appropriate for age and skills
Physiological rationale for this level of thickness
• Functional ability to safely manage liquids of all types
Although descriptions are provided, use IDDSI Testing methods to decide if the liquid meets IDDSI Level 0. TESTING METHOD See also IDDSI Testing Methods document or https://iddsi.org/framework/drink-testing-methods/
IDDSI Flow Test*
• Less than 1 mL remaining in the 10 mL slip tip syringe# after 10 seconds
of flow (see IDDSI Flow Test instructions*)
IDDSI FLOW TEST INSTRUCTIONS
#Before you test … You must check your syringe length because there are differences in syringe lengths. Your syringe should look like this
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Description/ 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 most commercially available
‘Anti-regurgitation’ (AR) infant formulas
Physiological rationale for this level of thickness
• Often 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.
• Also used in adult populations where thin drinks flow too fast to be controlled safely. These slightly thick liquids will flow at a slightly slower rate.
Although descriptions are provided, use IDDSI Testing methods to decide if the liquid meets IDDSI Level 1.
TESTING METHOD
See also IDDSI Testing Methods document or https://iddsi.org/framework/drink-testing-methods/
IDDSI Flow Test*
• 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*)
IDDSI FLOW TEST INSTRUCTIONS
#Before you test… You must check your syringe length because there are differences in syringe lengths. Your syringe
should look like this
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Description/ Characteristics
• Flows off a spoon • Sippable, pours quickly from a spoon, but slower than thin drinks • Mild effort is required to drink this thickness through standard bore
straw (standard bore straw = 0.209 inch or 5.3 mm diameter)
Physiological rationale for this level of thickness
• 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.
Although descriptions are provided, use IDDSI Testing methods to decide if the liquid meets IDDSI Level 2.
TESTING METHOD
See also IDDSI Testing Methods document or https://iddsi.org/framework/drink-testing-methods/
IDDSI Flow Test*
• 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*)
IDDSI FLOW TEST INSTRUCTIONS
#Before you test… You must check your syringe length because there are differences in syringe lengths. Your syringe
should look like this
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Description/characteristics
• Can be drunk from a cup • Moderate 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 molded on a plate because it will not
retain its shape • 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)
Physiological rationale for this level of thickness
• 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
Although descriptions are provided, use IDDSI Testing methods to decide if the food/liquid meets IDDSI Level 3.
TESTING METHODS
See also IDDSI Testing Methods document or https://iddsi.org/framework/drink-testing-methods/ and
https://iddsi.org/framework/food-testing-methods/
IDDSI Flow Test*
• Test liquid flows through a 10 ml slip tip syringe leaving > 8 ml in the syringe after 10 seconds (see IDDSI Flow Test Guide*)
Fork Drip Test
• Drips slowly in dollops through the prongs of a fork
• When a fork is pressed on the surface of Level 3 Moderately Thick Liquid/Liquidised food, the 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
Where forks are not available Chopstick Test
• Chopsticks are not suitable for this texture
Where forks are not available 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
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) • Some sauces and gravies, as confirmed by IDDSI Flow Test
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• Some syrups, as confirmed by IDDSI Flow Test
Drips slowly or in dollops/strands through the slots of a fork
IDDSI FLOW TEST INSTRUCTIONS
#Before you test… You must check your syringe length because there are differences in syringe lengths. Your syringe
should look like this
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Description/characteristics
• Usually eaten with a spoon (a fork is possible) • Cannot be drunk from a cup because it does not flow easily • Cannot be sucked through a straw • Does not require chewing • Can be piped, layered or molded because it retains its shape, but
should not require chewing if presented in this form • 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
Physiological rationale for this level of thickness
• If tongue control is significantly reduced, this category may be easiest to control
• Requires less propulsion effort than Minced & Moist (level 5), Soft & Bite-Sized (Level 6) and Regular and Regular Easy to Chew (Level 7) but more than Liquidised/Moderately thick (Level 3)
• No biting or chewing is required • Increased oral and/or pharyngeal 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
Although descriptions are provided, use IDDSI Testing methods to decide if the food/liquid meets IDDSI Level 4.
TESTING METHODS
See also IDDSI Testing Methods document or https://iddsi.org/framework/food-testing-methods/
IDDSI Flow test • n/a. The IDDSI Flow test is not applicable, please use the Fork Drip Test and Spoon Tilt Test
Fork Pressure test • Smooth with no lumps and minimal granulation • When a fork is pressed on the surface of Level 4 Extremely Thick
Liquid/Pureed food, the tines/prongs of a fork can make a clear pattern on the surface, and/or the food retains the indentation from the fork
Fork Drip test Fork Drip test contd.
• Sample sits in a mound/pile above the fork; a small amount may flow through and form a short tail below the fork tines/prongs, but it does not flow or drip continuously through the prongs of a fork (see
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picture below)
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 (using only fingers and wrist) 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. A thin film remaining on the spoon after the Spoon Tilt Test is acceptable, however, you should still be able to see the spoon through the thin film; i.e. the sample should not be firm and sticky
• May spread out slightly or slump very slowly on a flat plate
Where forks are not available Chopstick test
• Chopsticks are not suitable for this texture
Where forks are not available Finger test
• It is just possible to hold a sample of this texture using fingers. The texture slides smoothly and easily between the fingers and leaves noticeable coating
Indicators that a sample is too thick • Does not fall off the spoon when tilted • Sticks to spoon
FOOD SPECIFIC OR OTHER EXAMPLES
The following item may be suitable for IDDSI Level 4:
• Purees suitable for infants (e.g. pureed meat, thick cereal)
Spoon Tilt Test: Holds shape on spoon; not firm and sticky; little food left on spoon
Sits in a mound or pile above the fork
A small amount may flow through and form a short tail below the fork
Does not dollop, flow or drip continuously through the fork prongs
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Spoon Tilt Test: SAFE: Holds shape on spoon; not firm and sticky; little food left on spoon
The following images show examples of foods that would be suitable or unsuitable for Level 4 according to the IDDSI Spoon Tilt Test
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Spoon Tilt Test: SAFE: Holds shape on spoon; not firm and sticky; little food left on spoon
Spoon Tilt Test: UNSAFE:Holds shape on spoon; FIRM AND STICKY; LOTS OF food left on spoon
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Description/characteristics
• 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, equal to or less than 2 mm width and no longer than 8mm in length
Ø Adult, equal to or less than 4mm width and no longer than 15mm in length
• Lumps are easy to squash with tongue
Physiological rationale for this level of thickness
• Biting is not required • Minimal chewing is required • Tongue force alone can be used to separate the soft small particles in
this texture • Tongue force is required to move the bolus • Pain or fatigue on chewing • Missing teeth, poorly fitting dentures
Although descriptions are provided, use IDDSI Testing methods to decide if the food meets IDDSI Level 5.
TESTING METHODS
See also IDDSI Testing Methods document or https://iddsi.org/framework/food-testing-methods/
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 • When a sample is scooped with a fork it sits in a pile or can mound on the fork and does not easily or completely flow or fall through the tines/prongs of a fork
Spoon Tilt test
• Cohesive enough to hold its shape on the spoon • A full spoonful must slide/pour off/fall 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
• A scooped mound may spread or slump very slightly on a plate
Where forks are not available Chopstick test
• Chopsticks can be used to scoop or hold this texture if the sample is moist and cohesive and the person has very good hand control to use chopsticks
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Where forks are not available Finger test
• It is possible to easily hold a sample of this texture using fingers; small, soft, smooth, rounded particles can be easily separated using fingers. The material will feel moist and leave fingers wet.
FOOD SPECIFIC OR OTHER EXAMPLES https://iddsi.org/framework/food-testing-methods/
MEAT • Finely minced* or chopped*, soft mince
o Paediatric, equal to or less than 2mm width and no longer than 8mm in length
o Adult, equal to or less than 4mm width and no more than 15mm in length
• Serve in mildly, moderately or extremely thick, smooth, sauce or gravy, draining excess
• *If texture cannot be finely minced it should be pureed FISH • Finely mashed in mildly, moderately or extremely thick
smooth, sauce or gravy, draining excess o Paediatric, equal to or less than 2mm width
and no longer than 8mm in length o Adult, equal to or less than 4mm width and no
more than 15mm in length FRUIT • Serve finely minced or chopped or mashed • Drain excess juice • If needed, serve in mildly, moderately or extremely
thick smooth sauce or gravy AND drain excess liquid. No thin liquid should separate from food
o Paediatric, equal to or less than 2mm width and no longer than 8mm in length
o Adult, equal to or less than 4mm width and no more than 15mm in length
VEGETABLES • Serve finely minced or chopped or mashed • Drain any liquid • If needed, serve in mildly, moderately or extremely thick
smooth sauce or gravy AND drain excess liquid. No thin liquid should separate from food
o Paediatric, equal to or less than 2mm width and no longer than 8mm in length o Adult, equal to or less than 4mm width and no more than 15mm in length
CEREAL • Thick and smooth with small soft lumps
o Paediatric, equal to or less than 2mm width and no longer than 8mm in length o Adult, equal to or less than 4mm width and no more than 15mm in length
• Texture fully softened • Any milk/fluid must not separate away from cereal. Drain any excess fluid before serving
Use slot between fork prongs (4mm) to determine whether minced pieces are the
correct or incorrect size
T
R
Note – lump size requirements for all foods in Level 5 Minced & Moist:
Ø Paediatric, equal to or less than 2mm width and no more than 8mm in length
Ø Adult, equal to or less than 4mm width and no more than 15mm in length
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BREAD • No regular, dry bread, sandwiches or toast of any kind • Use IDDSI Level 5 Minced & Moist sandwich recipe video
https://www.youtube.com/watch?v=W7bOufqmz18 • Pre-gelled ‘soaked’ breads that are very moist and gelled
through the entire thickness RICE, COUSCOUS, QUINOA (and similar food textures) • Not sticky or glutinous • Should not be particulate or separate into individual grains when cooked and served • Serve with smooth mildly, moderately or extremely thick sauce AND Sauce must not separate away from rice,
couscous, quinoa (and similar food textures). Drain excess fluid before serving
IDDSI Spoon Tilt Test Sample holds its shape on the spoon and falls off fairly easily if the spoon is tilted or lightly flicked Sample should not be firm or sticky
IDDSI Fork Test Paediatric, equal to or less than 2mm width and no more than 8mm in length Adult, equal to or less than 4mm width and no more than 15mm in length 4mm is about the gap between the prongs of a standard dinner
fork
Minced & Moist food must pass all three tests!
Soft enough to squash easily with fork or spoon Don’t need thumb nail to blanch white
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Description/characteristics
• 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
load a fork or spoon • Soft, tender and moist throughout but with no separate thin liquid • Chewing is required before swallowing • ‘Bite-sized’ pieces as appropriate for size and oral processing skills
Ø Paediatric, 8mm pieces (no larger than) Ø Adults, 15 mm = 1.5 cm pieces (no larger than)
Physiological rationale for this level of thickness
• Biting is not required • Chewing is required • Food piece sizes designed to minimize choking risk • Tongue force and control is required to move the food and keep it
within the mouth for chewing and oral processing • Tongue
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