*This post is sponsored by SimplyThick. Although SimplyThick has paid for this post, I am a huge fan of SimplyThick when liquids need to be thickened! You can visit the SimplyThick Dysphagia Ramblings page here to request free samples.*
SimplyThick (you know, the gel thickener) was founded back in 2001 by John Holahan. SimplyThick was founded when a prototype was created using a liquid xanthan gum thickener. This was a ground-breaking alternative to the starch thickeners that were widely used at the time. You can read more about SimplyThick in John’s own words!
If you have attended the ASHA convention, you might remember their table (the one with the wine fountain!)
The International Dysphagia Diet Standardisation Initiation is here and being utilized in many facilities.
IDDSI was created to replace the National Dysphagia Diet and to standardize food and liquid consistencies.
I’m sure you have probably been in a number of facilities that interpret Mechanical Soft, Dysphagia Soft, etc a little different than other facilities. Some facilities allow a number of food items on one diet level that another facility adds into a different level.
IDDSI involves 5 food consistency levels and 5 liquid levels.
So what do these levels mean?
Level 0 (Thin) is a liquid that flows like water. (Flow test 1 ml or less in the syringe.)
Level 1 (Slightly Thick) Thicker than water, but is not quite Mildly Thick (formerly Nectar Thick). (Flow test 1-4 ml remains in syringe). This may include formula or commercially available nutrition drinks such as Boost or Ensure.
Level 2 (Mildly Thick formerly Nectar Thick). Flows off a spoon but is thicker than water. Requires increased effort to drink from a straw. (Flow test 4-8 ml left in the syringe.)
Level 3 (Moderately Thick formerly Honey Thick). This level takes a moderate effort to drink through a straw, but can be drunk from a cup. This level can be taken from a spoon, but is too thin for a fork. (Flow test 8-10 ml left in the syringe.)
Level 4 (Pureed/Extremely Thick formerly Pudding Thick). Usually can be administered via spoon, however may also be eaten via fork. Cannot be taken through a straw, usually taken via spoon. There should be no lumps, requires no chewing and the liquid should not separate. (Flow Test 10 ml remains in the syringe.) Spoon tilt test-should fall off the spoon in single spoonful. Should sit in a mound on top of the spoon/fork with minimal dripping through the fork.
Level 5 (Minced and Moist) Small lumps in the bolus (no larger than 4mm width and 15mm length for adults), can be eaten using spoon or fork. Liquid should not separate from food. (Fork test minimal pressure to mash with no blanching of the thumbnail to white while pressing.) (Spoon test should fall off the spoon in a cohesive mound with little to none left on the spoon.)
Level 6 (Soft and Bite Sized) Can be eaten with a fork, spoon or chopsticks. Each piece should be no larger than 15mm. Chewing is required with this consistency, however biting or cutting is not required. (Fork test, when a fork is pressed against the food, the thumbnail should blanch or turn white to squash or break apart the food). (Spoon test pressure from the spoon can cut, squish, mash or break apart the food and it will not return to its shape.)
Level 7 (Easy to Chew) Normal, everyday soft foods. Size of food is not restricted. Requires the ability to bite/chew food. (Fork/Spoon Test food is easily cut with pressure from a fork/spoon, thumbnail blanches or turns white when applying pressure to the food until it smashes, breaks apart or crumbles without resuming its original shape.
Level 7 (Regular) Normal, everyday food.
Transitional Foods (Fork/Spoon test, add 1 ml water, wait 1 minute, when applying pressure on the fork/spoon on the food, thumbnail blanches while applying pressure until the food breaks or smashes.)
Some examples of transitional foods?
Ice chips
Ice cream/Sherbet if assessed as suitable by a Dysphagia specialist
Japanese Dysphagia Training Jelly sliced 1 mm x 15 mm
Wafers (also includes Religious Communion wafer)
Waffle cones used to hold ice cream
Some biscuits/ cookies/ crackers
Some potato crisps – only ones made or formed from mashed potato (e.g. Pringles)
Shortbread
Prawn crisps
Veggie Stix™
Cheeto Puffs™
Rice Puffs™
Baby Mum Mums™
Gerber Graduate Puffs™
For everything you need to know regarding IDDSI, visit the website here.
Do you want easily printable information sheets for each level and testing for each level? Find that here.
Want samples and examples for testing liquids/foods? Find that here.
Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.
