IDDSI Diet Facts
IDDSI is the International Dysphagia Diet Standardisation Initiative. It is a framework for the provision of Texture Modified Foods. It is particularly focussed at Dysphagia.
The following synopsis of IDDSI diet facts is for general understanding purposes only. We strongly advise that you seek professional support from accredited speech pathologists and conduct your own independent research by visiting https://iddsi.org/
Level 3 – Liquidised
What is a Liquidised Diet?
It is a diet which:
• 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/chewing required—can be swallowed directly
• Smooth texture with no ‘bits’ (lumps, fibres, bits of shell or skins, husk, particles of gristle or bone)
Testing Method: If you are unsure whether your food is the correct consistency for a Liquidised Diet, you can test it using the fork drip test:
• Scoop up the food with a fork
• The food should drip slowly or in dollops/strands through the slots of the fork
Level 4 – Pureed
What is a Pureed Diet?
It is a diet which:
• Is usually eaten with a spoon (fork is possible)
• Does not require chewing
• Can be piped, layered or moulded
• Has no lumps
• Is not sticky
• Liquid must not separate from solid
Testing Method:
If you are unsure whether your food is the correct consistency for a Pureed Diet, you can test it using the spoon tilt test:
• Take a spoonful of food and tip it off of the spoon. The food should be: cohesive enough to hold its shape on the spoon
• the full spoonful must plop off spoon if tilted/turned sideways (sliding off easily with very little left on the spoon)
Level 5 – Minced and Moist
What is a Minced and Moist diet?
It is a diet which:
• Can be eaten with a fork or spoon
• Can be scooped and shaped on a plate
• Soft and moist with no separate thin liquid
• Small lumps visible within food (Paediatric= 2mm lump size, Adult = 4mm lump size)
• Lumps are easy to squash with tongue
Testing Method: If you are unsure whether your food is the correct consistency for a Minced & Moist Diet, you can test it using the Fork pressure test:
• Particles should easily be separated between and come through the prongs of a fork when pressed
• Particles can be easily mashed with little pressure from a fork
• This consistency can also be tested using the fork drip test: • The scooped sample sits in a pile or can mound on the fork
• It does not easily or completely flow or fall through the prongs of a fork
Level 6 – Soft and Bite-sized
What is a Soft & Bite-sized diet?
It is a diet which:• Can be eaten with a fork, spoon or chopsticks
• Can be mashed/brown down with pressure from fork/spoon/chopsticks
• A knife is not required to cut food, but may be used to help load fork/spoon
• Chewing is required before swallowing
• Is soft, tender, moist throughout
• Has no separate thin liquid
• Bite-sized pieces as appropriate for size and oral processing skills (Paediatric = 8mm pieces, Adults = 15mm pieces)
Testing Method: If you are unsure whether your food is the correct consistency for a Soft and Bite-sized Diet, you can test it using the fork pressure test:
• Pressure from fork held on its side can be used to cut/break this texture
• Sample size (1.5×1.5cm) squashes and changes shape (not returning to its original shape) when pressure applied with base of fork (firm pressure – thumb nail blanches to white)
Level 7 – Regular
What is a Regular diet?
It is a diet which:• Normal, everyday foods of various textures that are developmentally and age appropriate
• Any method may be used to eat the foods
• May be hard and crunchy or naturally soft
• Sample size not restricted
•Includes hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly bits
• Includes food that contains pips, seeds, pith inside skin, husks or bones
• Includes ‘dual consistency’ or ‘mixed consistency’ foods and liquids
Level 7* – Regular Easy Chew
What is Easy Chew Food?
• Normal, everyday foods of soft/tender texture
• Any method may be used to eat these foods (e.g. fingers, fork, spoon, chopsticks etc.)
• Food piece size is not restricted in size. They can be smaller or bigger than 1.5cm x 1.5cm Do not use foods that are: hard, tough, chewy, fibrous, have stringy textures, pip/seeds, bones or gristle
• You should be able to ‘bite off’ pieces of soft and tender food, so they are safe to swallow without tiring easily
• You should be able to remove bone, gristle or other hard pieces that cannot be swallowed safely from your mouth without help or direction from others
Food and Temperature
"Thick liquids change thickness levels depending on their temperature
It has always been the case that the thickness of liquids change depending on their temperature. Generally speaking, a thick liquid that is served cold/chilled will be thicker than if it is served at room temperature, or heated. We see this effect in our daily lives as well. Think about a tube of toothpaste. During winter, more force is needed to push the toothpaste out of the tube, as the toothpaste is firmer. During the summer months, it is very easy to push the toothpaste out of the tube as it flows more easily due to the ambient heat. Think now also of a rich pumpkin soup. Served warm it behaves more like a liquid, but when it cools off, it becomes thicker. This is physics at work. Thick liquids have always behaved this way – thicker when cool, and thinner when warm. In research this is why it is critical to include the temperature for testing because the effect is well known.
How does this affect individuals with swallowing difficulties?
Thickened milk is typically served warm to babies. The teat/nipple needs to be carefully selected so that the thick milk will flow through it when the infant sucks. If the baby is fussy, the thick milk cools over time and the thick milk becomes thicker and harder for the infant to suck through the teat/nipple. This can cause the baby to fatigue more quickly as they become inefficient with their feeding.
How can the IDDSI flow test help?
The IDDSI Flow Test can be used to accurately capture the change in thickness level as the fluid cools.
What about thickener products?
Due to the known and scientifically proven variation in thickness with temperature, IDDSI is aware that a liquid that tests ‘in range’ at ‘room temperature’, may be considered too thick when chilled, or too thin when heated. We have asked manufacturers to state what temperature their products should be served at. For people with swallowing problems, we need the thick fluid to be the correct thickness at the time they are drinking it. So, if the person needs Level 2 Mildly Thick, then the drink should be that thickness level when they drink it (warm, chilled or room temperature). Because the same thick fluid is very unlikely to be ‘in range’ at all three temperatures, we ask manufacturers to nominate the temperature for optimal serving. This then is the temperature that ‘audits’ should be conducted at. If clinicians or patients choose to use the drink at other temperature, then they do this at their own risk or ‘off label’.
The concept of ‘off label’ use is well understood in the pharmaceutical industry. For example, pills and solid dose forms are designed to be taken ‘whole’. Some people cut or crush the pills; however, the pharmaceutical company does not warrant its use under those conditions, only when it is ‘taken as directed’. Thick fluid companies may wish to conduct IDDSI testing for their liquids to give the IDDSI level for other temperatures as well as the optimal serving temperature, however, the product only needs to be ‘in range’ for what the company chooses to be the optimal serving temperature. IDDSI is working with clinicians to help them understand that the variability has always existed, and to understand that it is highly unlikely that manufacturers could produce thick liquids that will be ‘in range’ for temperatures spanning chilled to heated. Clinicians need to audit thick fluids at the intended serving temperature."
(c) The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/
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