1. IDDSI – The International Dysphagia Diet Standardization Initiative
Angela Parcaro-Tucker, MA, CCC-SLP, LSVT®

2. Legal Stuff
I am not compensated by IDDSI or any other entity to provide recommendations specific to certain products or methods of testing
The following documents have been developed by IDDSI and are for public use. You do not need to seek permission from IDDSI to share these documents and images as long as you cite the CreativeCommons BY-SA 4.0 license as follows:
The International Dysphagia Diet Standardisation Initiative @ Attribution is NOT PERMITTED for derivative works incorporating any alterations to the IDDSI Framework that extend beyond language translation. Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.
THIS SESSION CAN PROVIDE ONLY A SUMMARY OF IDDSI AND CHANGES! PLEASE BE AWARE THAT YOU AS A CLINICIAN ARE SOLELY RESPONSIBLE FOR FULLY EDUCATING YOURSELF ON IDDSI AND THE CHANGES THAT WILL TAKE PLACE.
This speaker has express permission from IDDSI to show IDDSI photos individually.

3. History/Purpose of IDDSI
IDDSI Committee formed in 2013
Purpose is to standardize language related to diet levels as well as to standardize methods of testing.
ASHA and the Academy of Nutrition and Dietetics (AND) support the implementation of IDDSI as a standard of care across all settings, with adults and children alike.

4. IDDSI Implementation
With both ASHA and AND promoting the adoption of IDDSI, it is a standard of care for all facilities to adopt IDDSI.
In medical malpractice cases, Failure to exercise the proper standard of care is considered negligence, and is actionable.
Colleges/Universities will need to change their programs to include IDDSI
Education of all parties in each facility will be required
Families will need to be educated fully, and such education must be documented

5. Terminology Current: IDDSI:
Liquids: Thin, “Regular,” Syrup, Half-Nectar, Nectar, Honey, Spoon-thick, Pudding thick.
“Full Liquid” and “Wired Jaw Diet” are somewhere between Liquid and Solid.
Solids: “Regular,” General, Soft, Mechanical Soft, Mechanically Altered, Pureed, Blended
IDDSI:
Liquids: Thin, Slightly Thick, Mildly Thick, Moderately Thick, Extremely Thick
Solids: Liquidized, Pureed, Minced and Moist, Soft and Bite- Sized, Regular

6. Framework

7. Matching Up What We Know With What Will Be
Regular, General
Soft
Mechanically Altered, Mech Soft
Pureed, Blended
Blended, Full Liquid*, Wired Jaw
Honey Thick
Nectar Thick, Syrup Thick
Half-Nectar
* “Full Liquid” and “Wired Jaw” recommendations do not necessarily exclude thinner liquids
Thin, Regular

8. Or, to say it another way…

9. Manufacturers are already getting on board

10. Manufacturers are already getting on board

11. Big Changes are Coming!
Before we go ANY further, I’ll say it again: I am instructing you to visit in order to FULLY educate yourself on all of the changes that are going to take place!
This session can only provide a SUMMARY of the changes!
Let’s quickly explore the IDDSI.org resources!

12. Additional Valuable Input
As stated, The Academy of Nutrition and Dietetics (AND) as well as ASHA have committed to the IDDSI transition.
AND produced some guidelines based on the IDDSI framework and they are very specific. Team closely with your dietician(s)!
The following descriptions of changes are excerpts taken from AND publications as they also convert to IDDSI. This is not a comprehensive list. Please get with your dieticians and team, so that you will be on the same page.

13. What Are the Biggest Changes?
Soft and Bite-sized (6, BLUE) 15mm Size Limit
Grains:
Breads are pregelled and soaked. Biscuits and cakes must be moist and no pieces larger than 15mm
Cold cereal – lumps no larger than 15mm, softened, drained, served without excess liquid
Pasta – no pieces larger than 15mm, sauce does not separate from pasta
Rice and rice dishes as tolerated

14. What Are the Biggest Changes?
Soft and Bite-sized (6, BLUE)
Proteins (no larger than 15mm pieces):
Cooked, moistened meat pieces. Includes red meat, poultry, seafood and fish.
Eggs, egg substitutes.
Casseroles
Legumes/peas with soft shells/skins.
Must meet softness standard (covered later)

15. What Are the Biggest Changes?
Soft and Bite-sized (6, BLUE)
Vegetables and Fruits (no larger than 15mm pieces):
Canned or frozen tender vegetables or starchy vegetables
It does not appear that fresh leafy vegetables (lettuce/salad) are included in this diet level
Canned and cooked fruits, drained of excess juices, served mashed

16. What Are the Biggest Changes?
Soft and Bite-sized (6, BLUE)
ITEMS ON THE “NOT RECOMMENDED” LIST
Dry bread, toast, crackers, biscuits, muffins, pancakes, waffles, bread dressing (remember, “pregelled”)
Grainy, sticky, or glutinous rice
Meat/poultry/fish with skin or bones
Fried eggs
Chunky nut seed butters, unless used in a tolerated recipe
Whole nuts and seeds

17. What Are the Biggest Changes?
Minced and Moist (5, ORANGE) 4mm Size Limit
Grains
Hot cereals with lumps no larger than 4mm
Pregelled, soaked bread
Pasta no larger than 4mm, sauce does not separate from pasta
Non-glutinous short or long grain rice that does not separate into individual grains, OR served in a thick sauce.

18. What Are the Biggest Changes?
Minced and Moist (5, ORANGE) 4mm Size Limit
Proteins
Same as with Soft, but with a 4mm size limit
Dairy
4mm size limit – including cottage cheese
Vegetables/Fruits
Gravies and Sauces
Must be thick and non-pourable

19. What Are the Biggest Changes?
Minced and Moist (5, ORANGE) 4mm Size Limit
ITEMS ON THE “NOT RECOMMENDED” LIST
Anything on the “NOT RECOMMENDED” list for the Soft (6, BLUE) diet.
Nothing larger than 4mm
No breads or grains with crumbly bits
Meat/poultry/fish with skin or bones or undrained liquids
Specific exclusions: Raw vegetables, including lettuce, Stir- fried or fried vegetables, apples, pears, stringy fruits such as pineapple/mango. Fruits with high water content, such as watermelon. Fruits with skins, such as grapes. Dried fruit or fruit leather.

20. What Are the Biggest Changes?
Pureed (4,GREEN) NO LUMPS
Grains
Pureed breads, rolls, pastries, pancakes, French toast, muffins, donuts, bread dressing
Pregelled, soaked bread, cakes, cookies
Pureed, moist pasta, rice, potatoes.
Liquids/sauces do not separate from foods

21. What Are the Biggest Changes?
Pureed (4,GREEN) NO LUMPS
Proteins
Pureed, moistened meats and meat alternatives
Pureed eggs and egg substitutes
Pureed, smooth casseroles
Pureed, moistened legumes

22. What Are the Biggest Changes?
Pureed (4,GREEN) NO LUMPS
ITEMS ON THE “NOT RECOMMENDED” LIST
Anything on the “NOT RECOMMENDED” list for the Minced and Moist (5, ORANGE) diet.
Nothing larger than 4mm
No breads or grains with crumbly bits
Meat/poultry/fish with skin or bones or undrained liquids

23. “Drinkable” Liquids
Testing method: Use a 10 mL luer slip tip syringe. It must measure 61.5 mm from the 10 mark down to the point at which the syringe narrows for the slip tip.
Thin: No residue remains after 10 seconds when 10 mL liquid is released.
Slightly Thick:
Mildly Thick:
Moderately Thick:

24. Another Liquidised/Moderately Thick Testing Method:
Fork Drip Test
Material drips slowly or in dollops/strands through the tines/prongs of a fork

25. Fork Drip Test (levels 3 and 4) Spoon Tilt Test (levels 4 and 5)
Spoon Tilt Test is used for Level 4 and 5 liquids/diets.
Cohesive enough to hold its shape on the spoon
Should not be “sticky” and the full spoonful should slide off the spoon when tilted/turned sideways, gently shaken
A scooped mound may spread or slump very slightly on the plate
Used for Level 3 and 4.
Sits in a mound/pile above the fork. A small amount may flow through and form a tail below the fork. Does NOT drip, dollop, or flow continuously through the prongs

26. Food Testing Methods Level 5 Minced and Moist
Includes the following tests:
Fork Pressure Test
Fork Drip Test
Spoon Tilt Test
Chopstick Test
Finger Test
Minced and Moist Sandwich:

27. Food Testing Methods Level 6 Soft and Bite-Sized Fork Pressure Test:
Pressure from a fork held on its side can by used to “cut” or break into smaller pieces.
When a sample the size of a thumbnail (1.5 x 1.5 cm) is pressed with the base of a fork to a pressure where the thumbnail 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 by used to “cut” or break into smaller pieces.
When a sample the size of a thumbnail (1.5 x 1.5 cm) is pressed with the bowl of a spoon to a pressure where the thumbnail blanches to white, the sample squashes and changes shape, and does not return to its original shape when the fork is removed.
Chopstick Test:
Chopsticks can be used to break this texture into smaller pieces.
Finger Test:
Use a sample the size of a thumbnail (1.5 x 1.5 cm). It is possible to squash a sample of this texture using finger pressure such that the thumb and index fingernails blanch to white. The sample will not return to its initial shape once pressure is released.

28. Thumbnail blanches to white
Food Testing Methods
Level 6: Soft and Bite-Sized
Thumbnail blanches to white

29. Food Testing Methods Level 6: Soft and Bite-Sized
Sample squashes and does not return to its original shape when pressure is released.

30. Transitional Foods
Definition: Food that starts as one texture (e.g., firm solid) and changes into another texture specifically when moisture (e.g., water or saliva) is applied or when a change in temperature occurs.
Biting is not required
Minimal chewing is required
Tongue can be used to break these foods once altered by temperature or with the addition of moisture/saliva

31. Food Testing Methods for Transitional Foods
Fork Pressure Test:
After moisture or temperature has been applied, the sample can be easily deformed and does not recover its shape when force is lifted. pressure from a fork held on its side can by used to “cut” or break into smaller pieces.
Use a sample the size of a thumbnail (1.5 x 1.5 cm), place 1 mL of water on the sample and wait 1 minute. Apply fork pressure at 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.
Or it has melted significantly and no longer looks like its original state (e.g., ice chips).
Spoon Pressure Test:
As above, using the bowl of a spoon in place of a fork.
Chopstick Test:
Use a sample the size of a thumbnail (1.5 x 1.5 cm), place 1 mL of water on the sample and wait 1 minute. The sample should be easily broken apart with chopsticks with minimal pressure.
Finger Test:
Use a sample the size of a thumbnail (1.5 x 1.5 cm), place 1 mL of water on the sample and wait 1 minute. The sample will break apart completely by rubbing the sample between the thumb and index finger. The sample will not return to its initial shape.

32. Examples of Transitional Foods
This is not an exhaustive list!
Ice chips
Ice cream/sherbet
Japanese Dysphagia Training Jelly sliced 1mm x 15mm
Wafers (including religious communion wafers)
Waffle cones used to hold ice cream
Some biscuits/cookies/crackers
Potato chips – only the mashed kind, like Pringles
Shortbread
Prawn crisps

33. Commercially available Transitional Foods
Thumbnail blanched to white
Veggie Stix
Cheeto Puffs
Rice Puffs
Baby Mum Mums
Gerber Graduate Puffs
Remember, apply 1 mL of
water to sample and wait 1
minute before applying
pressure
Sample squashes and fractures, and does not return to its original shape when pressure is released.

34. Another Great Resource on IDDSI.org
Please be sure to check out IDDSI.org for other examples of specific foods, and how those foods fit in on various modified diets.
CompleteFramework.pdf

35. Implementation Guide Clinicians and Health Care Providers
IDDSI%20Implementation%20Guide_Final_3April2018.pdf
Key tasks include:
1. Becoming familiar with the IDDSI: Website and resources
2. Forming IDDSI Implementation teams: Suggestions on cross sector stakeholder consultations and teams
3. Determining IDDSI implementation tasks and personalising your own ‘IDDSI Implementation Calendar’
4. ‘Spread the word’: Education about IDDSI for key stakeholders
5. ‘Check out the food and drinks’: Map existing products to determine their IDDSI label and level using IDDSI audit tools; developing menu items and recipes etc.
6. Clinical communication: including review of clinical assessment tools, chart entries, and patient education material
The tasks run at the same time so it is important to look down the whole list. The Implementation guide is a suggestion! Please feel free to customize the tasks and timeframes to suit your own needs. Colours and shading have been used on the implementation guide to help make it easier to identify different tasks and timeframes; the colours have no other meaning or purpose.
IDDSI will be updating resources regularly so please be sure to register to receive our e-bites (newsletters).
Visit :

36. Implementation Guide Food Service and Catering
There are five key tasks with subheadings below each.
The key tasks include:
1. Becoming familiar with the IDDSI: Website and resources
2. Forming IDDSI Implementation teams: Suggestions on cross sector stakeholder consultations and teams
3. Determining IDDSI implementation tasks and personalising your own ‘IDDSI Implementation Calendar’
4. ‘Spread the word’: Education about IDDSI for key stakeholders
5. ‘Check out the food and drinks’: Map existing products to determine their IDDSI label and level using IDDSI audit tools; developing menu items and recipes etc.
The tasks run at the same time so it is important to look down the whole list. The Implementation guide is a suggestion! Please feel free to customize the tasks and timeframes to suit your own needs. Colours and shading have been used on the implementation guide to help make it easier to identify different tasks and timeframes; the colours have no other meaning or purpose.

37. Implementation Guide Industry
There are six key tasks with subheadings below each.
The key tasks include:
1. Becoming familiar with the IDDSI: Website and resources
2. Forming IDDSI Implementation teams: Suggestions on cross sector stakeholder consultations and teams
3. Determining IDDSI implementation tasks and personalising your own ‘IDDSI Implementation Calendar’
4. ‘Spread the word’: Education about IDDSI for key stakeholders
5. ‘Check out the food and drinks’: Map existing products to determine their IDDSI label and level using IDDSI audit tools; developing menu items and recipes etc.
6. Industry labelling considerations: including production schedule and stock management
The tasks run at the same time so it is important to look down the whole list. The Implementation guide is a suggestion! Please feel free to customize the tasks and timeframes to suit your own needs. Colours and shading have been used on the implementation guide to help make it easier to identify different tasks and timeframes; the colours have no other meaning or purpose.

38. In Closing… Big changes are imminent!
You will want to become VERY familiar with the IDDSI.org website
Build a team! At the very least, your team should have speech pathologists, dieticians, and possibly IT, if you have an electronic medical record (EMR). If you are a large facility, it might be good to include a member of leadership, as well as someone from Quality and Informatics.
Start testing the items that are already on your facility’s menu to see where they fall on the IDDSI Framework.
Start telling people at your facility that changes are coming. Nothing is worse than a surprise change overnight!

39. QUESTIONS???