Dysphagia Knowledge Hub — 吞嚥困難知識庫

How IDDSI Was Developed — The Story of Global Dysphagia Diet Standardisation (2010–2017)

TL;DR: Before 2015, clinicians around the world used 54 different terms for texture-modified foods and 27 different terms for thickened liquids — and patients died because of the confusion. The International Dysphagia Diet Standardisation Initiative (IDDSI) grew from a 2010 conversation between three clinicians into a volunteer committee that surveyed 5,240 professionals across 57 countries, ran a systematic review of the evidence base, and in November 2015 released the 8-level framework now used in hospitals, nursing homes, and food factories around the world. This is how that happened.

The problem IDDSI was built to solve

Dysphagia — difficulty swallowing — affects roughly 8% of the world’s population, or about 590 million people, across conditions as different as stroke, Parkinson’s disease, head-and-neck cancer, dementia, cerebral palsy, and normal ageing [Cichero et al., 2017]. For most of these people, the single most important safety intervention is the same: modify the texture of what they eat and the thickness of what they drink.

By the 2000s, every country that took dysphagia care seriously had produced its own terminology. The United States had the National Dysphagia Diet (Level 1–3 foods, “nectar / honey / spoon-thick” liquids). Australia used “smooth puree / minced & moist / soft”. The United Kingdom had its own “Category B, C, D, E” codes from the BDA/RCSLT. Japan had the Universal Design Food scale from JDFA. Ireland, Germany, France, and Brazil each had their own.

A 2013 survey IDDSI would later run found 54 distinct textual descriptors for food and 27 for liquids in active clinical use [Cichero et al., 2017]. That was not an academic problem. It was a patient-safety problem.

Two cases, widely discussed in the dysphagia literature, became the moral motivation for IDDSI:

Confusion at the interface between hospital, nursing home, community dietitian, and family caregiver was causing preventable aspiration pneumonia, hospital readmissions, and deaths [ASHA, 2024].

2010: three clinicians and a phone call

The historical record from IDDSI identifies three people who initiated the conversation in 2010 [IDDSI, 2024]:

All three had independently concluded that national-level standards could not, on their own, solve a global problem. They began by asking whether a joint framework — initially between just their three countries — was even possible.

The first in-person IDDSI meeting, convened in Toronto, was supported by the Nestlé Nutrition Institute as a neutral venue and sponsor [IDDSI, 2024]. The Nestlé Nutrition Institute is an educational arm — distinct from Nestlé’s commercial food operations — and its involvement was limited to meeting logistics and the first committee’s travel. The intellectual direction was set by the clinicians.

2012–2013: framing the mission

By 2012 the group had settled on a mission statement that would guide every decision for the next decade:

“To develop new global standardised terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures.”

Three phrases in that sentence carried the weight:

2013: the first survey — 2,050 responses, 33 countries

In 2013 the committee ran its first global stakeholder survey. The target: every person touched by texture-modified food — patients, caregivers, speech-language pathologists, dietitians, nurses, physicians, chefs, food-service managers, industry R&D, and researchers.

Result: 2,050 responses from 33 countries [Cichero et al., 2017].

Respondents reported their national terminology, what they actually used day-to-day, and what they found confusing. The survey confirmed the problem:

That same year the committee commissioned a systematic literature review of the effect of food texture and liquid consistency on swallowing — to make sure the new framework was anchored to evidence, not just professional opinion. The review covered rheology studies, clinical outcomes trials, and industry testing protocols.

2014: the evidence scan and the second survey

The 2014 phase pulled together what the published science actually showed about each level of texture and thickness. Key findings shaping the framework:

This evidence scan was then followed by a second stakeholder survey: 3,190 responses from 57 countries [Cichero et al., 2017]. The second survey tested specific draft framework wording and level boundaries.

Combined, the two surveys captured 5,240 responses from 57 countries — the largest dysphagia-diet consultation in history.

2015: the IDDSI Framework is released

In November 2015 the committee released the IDDSI Framework publicly [ASHA, 2024; IDDSI, 2024]. Its design choices bear the fingerprints of the preceding five years of evidence and consultation:

2016–2017: testing methods, Kempen pilot, landmark publication

In 2016, IDDSI published the companion Testing Methods document formalising the fork, spoon, and syringe tests. The same year, the Kempen Pilot in Belgium became one of the first cross-facility implementation studies — testing whether a real hospital network could transition from legacy terminology to IDDSI without harming patients [Buitelaar et al., 2017].

The authoritative methodology paper — Cichero, Lam, Steele, Hanson, Chen, Dantas, Duivestein, Kayashita, Lecko, Murray, Pillay, and Riquelme (2017), “Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework” — was published in the journal Dysphagia (Springer) in April 2017 [Cichero et al., 2017]. It remains the single most-cited document in the field.

The author list itself encoded the “all cultures” commitment: authors from Australia, Canada, the United States, Brazil, China, Japan, Germany, South Africa, and the United Kingdom.

2018–2019: national adoption

Release of a framework does not, by itself, change clinical practice. 2018–2019 was the implementation cliff-edge:

2019–2023: IDDSI grows up as an organisation

In 2019 IDDSI transitioned from a volunteer committee to a formally-governed non-profit with a Board of Directors. The same year it held its inaugural IDDSI Congress in London [IDDSI, 2024].

What IDDSI got right — and what is still contested

Looking back, three design choices stand out as decisive:

  1. Anchoring levels to kitchen tests, not lab instruments. A nursing aide in Manila can do the IDDSI fork-drip test with equipment that costs zero. That accessibility drove adoption faster than any regulatory mandate could have.
  2. Redundant identifiers. The level number, label, colour, and test method together make the framework robust against partial implementation failure. A kitchen that only paints its trays — but does not do the tests — is still safer than before.
  3. Publishing the framework under a Creative Commons licence. The descriptors are licensed CC BY-SA 4.0 — meaning any hospital, textbook, government standard, or food manufacturer can paraphrase and adapt them freely, as long as attribution and share-alike are honoured. That licence choice is why the framework spread globally in five years.

Contested issues that IDDSI is still iterating on:

Common misconceptions about IDDSI’s origin

Why the IDDSI story matters for how we write about care food

For writers, educators, and food producers operating in the dysphagia space, the history of IDDSI carries three practical lessons:

Citations and sources

This article paraphrases publicly-available information about the history of the International Dysphagia Diet Standardisation Initiative. For clinical use of the framework, refer to the current official documentation at iddsi.org. This page is not medical advice.

Last updated: 2026-04-17 · License: CC BY 4.0 · Maintained by Editorial Team — a Hong Kong social enterprise producing IDDSI-compliant care food for people living with dysphagia. Editorial Team/Editorial Team is among the official 起草人 (drafters) of the GBA T/SATA 084-2025 and T/SATA 085-2025 care-food standards. Trade enquiries: hello@seniordeli.com. This page is educational only; see About for our clinical partners and social mission.

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