The International Dysphagia Diet Standardisation Initiative (IDDSI) is a group of healthcare professionals who, in 2012, voluntarily came together from around the world to work collectively to develop internationally recognised, standardised terminology and definitions for texture modified foods and fluids used in the management of dysphagia. 

The group is made up of representatives from diverse fields such as nutrition and dietetics, medicine, speech and language therapy, occupational therapy, nursing, patient safety, engineering, as well as food science and technology.

Objectives

The objectives of the IDDSI are as follows:

• To develop a standardised way of naming and describing texture modified foods and thickened liquids for people with dysphagia across the lifespan

• Their process is intended to be person-focused, rather than profession-focused. They seek to develop a global terminology that will ‘work’ for all cultures and that will be accompanied by practical and valid measurement techniques that will facilitate use by persons with dysphagia, caregivers, clinicians, food service professionals and industry partners

• To seek a common language that can be used for technical, cultural, professional and non-professional uses. The IDDSI believes this should be a living document, changing as needs change.

IDDSI framework

The IDDSI framework and supporting descriptor and testing methods documents were completed and published in November 2015. 

In response to the global community, the IDDSI board has agreed to lead and co-ordinate IDDSI implementation. 

Here in Ireland, many dietitians will be familiar with IDDSI’s national texture descriptors for foods and fluids, which were adapted from Australian guidelines by a working group made up of representatives from INDI and the Irish Association of Speech and Language Therapists (IASLT) back in 2009. A review of this document was overdue so with the publication of the IDDSI framework document, it seemed timely to initiate that review earlier this year. 

Members of the INDI representing acute hospitals (Aisling McHugh, clinical specialist dietitian, St James’s Hospital, Dublin – group chair); paediatrics (Amy Craddock, paediatric dietitian, Children’s University Hospital, Temple Street, Dublin); disability (Mairead O Sullivan, senior dietitian, Early Intervention Services Waterford); and community and older people services (Siobhan Quigley, community dietitian, HSE West) came together in Dublin last April with members of the IASLT to meet with IDDSI co-chairs, Peter Lam, dietitian and credentialed food service executive, Vancouver, Canada, and Julie AY Cichero, speech and language therapist specialising in dysphagia research, Australia.

The aim of the meeting was to receive a full overview of the IDDSI framework and how it related to our existing national descriptors. The goal was to then examine if it would be prudent for us in Ireland to adopt the IDDSI framework for the management of dysphagia or to proceed with a standard review and update of the existing Irish guidelines.

The final dysphagia diet framework consists of a continuum of eight levels (0 to 7), where drinks are measured from levels 0-4, while foods are measured from levels 3-7.

IDDSI descriptors

As are evident in Figures 1 and 2, the new IDDSI descriptors are very similar to those already in use here in Ireland. The only difference to terminology will be that texture C smooth pureed foods are to be referred to as ‘level 4 puréed food’ and grade 1 fluid, very mildly thick, is to be referred to as ‘level 1 slightly thick’. 

 (click to enlarge)

 (click to enlarge)

In the IDDSI framework the consistencies of foods and fluids are presented as a continuum, with level 3 liquidised foods equating to level 3 moderately thick fluids and level 4 puréed foods equating to level 4 extremely thick fluids. 

Each level has been colour co-ordinated and widely tested to allow for visual impairments such as colour blindness, as well as literacy levels etc so that each level can become associated with its corresponding colour and in time, catering systems, food labels etc can use the associated colour to identify the correct level to select for users.

Transitional foods

Also new is the term ‘transitional foods’, which refer to foods or substances that change quickly to become easier to chew or swallow with added moisture or a change in temperature. They are predominately used by paediatric clinicians or clinicians who work with individuals with developmental disabilities. An example of a transitional food would be a communion host, ice-cream wafer, or cheese puffs. 

Tests

The IDDSI have spent a considerable amount of time collecting evidence-based data to support the use of this classification of modified consistency diets. In order to ensure the quality of the preparation of the food and fluids, specific tests have been developed, trialled, tested and standardised to describe each consistency. This will ensure the uniform presentation of the foods and fluids across each care setting worldwide. 

For liquids, the IDDSI flow test has been developed and is outlined at www.iddsi.org/wp-content/uploads/2015/12/IDDSI-Flow-Test-Instructions-3-Pages.pdf.

Similarly for foods, the ‘fork drip’ test and ‘fork pressure test’ as well as a ‘spoon pressure’ test have been developed for each food consistency. 

The development of such tests ensure the textures are correct and uniform across all settings, ensuring patient safety, as well as providing a means to spot check consistencies at each meal service prior to the patient receiving the meal or drink. 

For countries that don’t typically use utensils such as forks or spoons at mealtimes, tests have also been developed to allow for this, eg. chopsticks. 

What now?

The chairs of both the INDI and IASLT dysphagia working group have each written to the senior management teams of both organisations to propose adoptation of the IDDSI guidelines as Ireland’s new national consensus guidelines on dysphagia. It is hoped that if the proposal is accepted, a national roll-out plan will be developed between the INDI and IASLT and training will commence within the coming 12 to 18 months across all settings. The IDDSI international working group are developing online resources at present to support such training. 

Further details on the IDDSI initiative are available on the IDDSI website www.iddsi.org