Over my years of working in long-term care, there has always been a challenge providing food and beverages to residents who have chewing and swallowing problems.

There are no agreed upon best practice standards for thickness, thinness, dryness or sizes of food among speech language pathologists, registered dietitians and nursing staff for diets used with dysphagia patients.

Ultimately, thanks to “Person-Centered” care, the resident gets the final decision. But that can create a complicated balance between resident rights vs. safety. Not providing appropriate care to residents with chewing and swallowing difficulties can result in thousands of dollars in civil monetary penalties with state surveys, not to mention millions of dollars in possible litigation.

In the past, the National Dysphagia Diet was the only standardized diet tool in the United States. It was developed around trying to provide some consistent guidance for food and beverages used for individuals with swallowing problems. The NDD, while not evidence-based, had consensus among dietitians, SLPs and food scientists and is still the framework used in many LTC facilities. Generally, at the facility level the speech language pathologists and registered dietitian will then define the specific consistencies needed for the individual resident.

While there are no easy answers for providers, new international standards being implemented in the US offer some consistent guidance. In 2017, the Academy of Nutrition and Dietetics and the American Speech-Language-Hearing Association together announced their support of this new global effort, the International Dysphagia Diet Standardization Initiative (IDDSI), to standardize diets for the treatment of people who suffer from swallowing disorders. In the US, it is planned for actual “best practice” implementation in 2019.

For the first time, the IDDSI Framework places liquids and foods on a single continuum. The testing methods and detailed descriptions of each IDDSI Level, along with many other great resources, are available at www.iddsi.org.

One of the innovations of the IDDSI Framework is the development of testing methods that can be applied in any setting. The ability to check liquid thickness after adding thickener or checking the actual meal being served to the resident is possible using these testing methods. Particle sizes and texture recommendations for each level have been clearly identified to minimize choking risk.

Forks can be used to assess particle size and food softness, while spoons assist with determining cohesive and adhesive food properties that affect swallowing safety. The testing methods allow for people to check the food on the plate, including the gravy or sauce, to be sure that it is as the clinicians intended for safe swallowing. The IDDSI Flow Test allows for liquids to be quickly and easily classified, giving confidence that thick liquids will be consistent from batch to batch of kitchen- and factory-produced items.

A campaign to raise global awareness of IDDSI is currently underway, with resources to assist in planning and implementation available from the IDDSI website (www.iddsi.org).  Industry members (e.g. food and beverage industry, and the thickener and texture modified food industry) are currently supporting the initiative and developing transitional labels to assist in education regarding the change in terminology.  

Here are some tips for working toward implementation:

  • Introduce IDDSI to facility management and obtain approval and support
  • Use the www.iddsi.org website resources. (Downloadable APP, videos and implementation guidelines available) to assist in training and development of skills, and competencies with administrative and clinical staff
  • Determine the IDDSI Levels that will be used in the facility
  • Create a plan of action that includes specific tasks, responsibilities and time frames
  • Develop policies and procedures
  • Revise diet terminology, diet orders, menus and recipes
  • Plan staff education/skills/competency training
  • Discuss the changes with the resident council
  • Educate families and marketing partners through newsletters and social media

Needless to say, implementation of the IDDSI will take collaborative efforts with the facility’s registered dietitian nutritionist, speech-language pathologists, certified dietary managers, chefs, dietary staff, nurses and physicians — all working together for successful implementation.

The bottom line is: Moving toward globally recognized terminology — based on evidence, it should be noted — is critical. Residents’ lives are in our hands and no provider wants to face survey penalties or litigation. The International Dysphagia Diet Standardization Initiative certainly gives us all something to chew on.


Brenda Richardson, MA, RDN, LD, CD, FAND is owner of Brenda Richardson LLC. She is a Registered Dietitian Nutritionist, national lecturer, author/contributing author of many professional books and publications, and serves on state and national offices in the Academy of Nutrition and Dietetics.