Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework

Abstract

Dysphagia is estimated to affect ~8% of the world's population (~590 million people). Texture-modified foods and thickened drinks are commonly used to reduce the risks of choking and aspiration. The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded with the goal of developing globally standardized terminology and definitions for texture-modified foods and liquids applicable to individuals with dysphagia of all ages, in all care settings, and all cultures. A multi-professional volunteer committee developed a dysphagia diet framework through systematic review and stakeholder consultation. First, a survey of existing national terminologies and current practice was conducted, receiving 2050 responses from 33 countries. Respondents included individuals with dysphagia; their caregivers; organizations supporting individuals with dysphagia; healthcare professionals; food service providers; researchers; and industry. The results revealed common use of 3-4 levels of food texture (54 different names) and ≥3 levels of liquid thickness (27 different names). Substantial support was expressed for international standardization. Next, a systematic review regarding the impact of food texture and liquid consistency on swallowing was completed. A meeting was then convened to review data from previous phases, and develop a draft framework. A further international stakeholder survey sought feedback to guide framework refinement; 3190 responses were received from 57 countries. The IDDSI Framework (released in November, 2015) involves a continuum of 8 levels (0-7) identified by numbers, text labels, color codes, definitions, and measurement methods. The IDDSI Framework is recommended for implementation throughout the world.

Keywords: Deglutition; Deglutition disorders; Dysphagia diet; Food and fluid standards; Swallowing; Texture-modified food; Thickened fluid.

Fig. 1

Timeline of the international dysphagia diet standardisation initiative

Fig. 2

Set up of thickened liquids for comparison and evaluation

Fig. 3

Distribution of survey respondents by stakeholder group

Fig. 4

Draft pyramid image, highlighting the overlap zone

Fig. 5

Stakeholder survey 2—International indications of likelihood of implementation. Note Caution should be used in interpreting small sample sizes from specific countries

Fig. 6

The final IDDSI framework graphic

Fig. 7

Example of a slip tip syringe that complies with IDDSI measurement requirements

Fig. 8

a Illustration of the thumb nail blanching to white (shown by arrow) during Fork Pressure Test. b Amount of pressure required (in kPa) to blanch the thumb nail to white. Image used with permission from IOPI Medical (www.iopimedical.com)