Monday mornings I host my weekly team calls to assess key areas: old and new business, travel plans for the week, Q goal targets, and trends: What are you all receiving calls about in your retrospective regions?

Last week, I was the one with the largest trend-based educational request, and it was all about IDDSI.

“What is this IDDSI diet?”

“My administrator wants to know do they HAVE to use IDDSI”

“How in the world is dietary going to keep up with these levels; our vendor is saying they are adopting the standards on new menus!”

“What is ASHA saying about all of this?”

To begin, let’s review the whys and hows related to the new diet standardization.

IDDSI- the International Dysphagia Diet Standardization Initiative (IDDSI) will officially launch May 1 — less than three weeks from now — in the United States after years of development and endorsement by The Academy of Nutrition and Dietetics (AND) and the American Speech-Language-Hearing Association.

The aim of IDDSI when founded in 2013 was: “Achieve global diet terminology, creating common terminology and common understanding across international borders, across the lifespan, across all professions, and across all stakeholders to help the care of people with difficulty swallowing (dysphagia).”

Dysphagia, which is an impairment in oral, pharyngeal or esophageal phases of swallowing currently affects approximately 8% of the world’s population. Additionally, dysphagia is closely associated with malnutrition, dehydration, upper respiratory infection, and increased risk of a sentinel event and is most common at the beginning and end of life, mostly affecting the infant and elderly population.

What are the major elements of IDDSI that SNF therapy, nursing, and dietary teams should be aware of?

To begin, dysphagia diet framework consists of eight levels (0-7) and includes both foods and liquids on a single continuum. Levels are identified by numbers, text labels, and color codes with drinks being measured from Levels 0-4, while foods are measured from Levels 3-7.


There liquid consistencies are expanded in comparison to the National Dysphagia Diet levels which includes nectar, honey, and pudding thick and within the IDDSI framework includes thin, slightly thick, mildly thick, moderately thick, and extremely thick.

Additionally, levels 3 and 4 include food and drink criteria with level 3 including moderately thick liquids and liquidized foods, and level 4 including extremely thick liquids and pureed foods.

Level 5 contains minced particle sizes of 4mm, which happens to be the size of food particles after chewing and are “swallow-ready” so this diet requires minimal chewing *note for pediatrics, they suggest 2mm particle size

Level 6 contains bite sizes that are 1.5cm or 15mm, so that if a chunk falls into the airway, the person will not choke/asphyxiate. The size of 15mm is about the size of an adult thumbnail, and is smaller than the typical adult airway.

Sound complicated?

Perhaps, but remember facilities should take time to review standards and have continued discussions on person choice when considering the shift to IDDSI.

Secondly, the standardization is meant to allow for safe oral intake however does not supersede the Dining Observation tools that are being used as part of the ROPS Phase II Survey process critical element pathways.

Considerations include:

Determine staff response to a resident who refuses to go to the dining area, refuses the meal or meal items offered, or requests a substitute. If concerns are identified, interview the resident to determine whether: 

  • The resident was involved in choosing when to eat; 
  • The resident was involved in choosing where to eat; and/or 
  • The food offered takes into account the resident’s food preferences. 

Finally, don’t go at it alone!

The IDDSI website does provide useful materials including guides for testing for food and liquid testing in addition to patient and caregiver informational materials.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Encore Rehabilitation and is the Silver Award winner in the 2018 American Society of Business Publishing Editors competition for the Upper Midwest Region in the Service/How To Blogs category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).