IDDSI Framework Testing Methods 2.0 - 2019

IDDSI Framework
Testing Methods
2.0 | 2019
This IDDSI Framework and Descriptors are licensed under the
CreativeCommons Attribution-Sharealike 4.0 International License
https://creativecommons.org/licenses/by-sa/4.0/
IDDSI 2.0 |July 2019

INTRODUCTION
The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded in 2013 with the goal of
developing new international 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 all cultures.
Three years of work by the International Dysphagia Diet Standardisation Committee culminated in the 2016
release and 2017 publication of the IDDSI Framework consisting of a continuum of 8 levels (0-7) Levels are
identified by numbers, text labels and colour codes. [Reference: Cichero JAY, Lam P, Steele CM, Hanson B, Chen J,
Dantas RO, Duivestein J, Kayashita J, Lecko C, Murray J, Pillay M, Riquelme L, Stanschus S. (2017) Development of
international terminology and definitions for texture-modified foods and thickened fluids used in dysphagia
management: The IDDSI Framework. Dysphagia, 32:293-314. https://link.springer.com/article/10.1007/s00455-
016-9758-y]
The IDDSI Framework Testing Methods 2019 is an update to the 2016 document and provides details regarding
Testing Methods for use with the IDDSI Framework.
This document is to be read in conjunction with the Complete IDDSI Framework 2019, IDDSI Evidence 2016 and
IDDSI Frequently Asked Questions (FAQs) documents ( https://iddsi.org/framework/).
The IDDSI Framework provides a common terminology to describe food textures and drink thickness. IDDSI tests
are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing
should be done on foods and drinks under the intended serving conditions (especially temperature). The clinician
has the responsibility to make recommendations for foods or drinks for a particular patient based on their
comprehensive clinical assessment.
IDDSI would like to acknowledge the interest and participation of the global community including patients,
caregivers, health professionals, industry, professional associations and researchers. We would also like to thank
our sponsors for their generous support.
Please visit https://iddsi.org/ for further information.
The IDDSI Board:

The IDDSI Board are a group of volunteers who do not draw a salary from IDDSI. They offer their knowledge,
expertise and time for the benefit of the international community.
Co-Chairs: Peter Lam (CAN) & Julie Cichero (AUS);
Board Members: Jianshe Chen (CHN), Roberto Dantas (BRA), Janice Duivestein (CAN), Ben Hanson (UK),
Jun Kayashita (JPN), Mershen Pillay (ZAF), Luis Riquelme (USA), Catriona Steele (CAN),
Jan Vanderwegen (BE).
Past Board Members: Joseph Murray (USA), Caroline Lecko (UK), Soenke Stanschus (GER)
The International Dysphagia Diet Standardisation Initiative Inc. (IDDSI) is independent and operates as a not-for-
profit entity. IDDSI is grateful to a large number of agencies, organizations and industry partners for financial and
other support. Sponsors have not been involved with the design or development of the IDDSI framework.
Implementation of the IDDSI framework is in progress. IDDSI is extremely grateful to all sponsors supporting
implementation https://iddsi.org/about-us/sponsors/
The IDDSI Framework and Descriptors are licensed under the 2

IDDSI 2.0. | July 2019
Testing Methods for use with the
IDDSI Framework
The IDDSI systematic review suggested that liquids and food should be classified in the context of the
physiological processes involved in oral processing, oral transport and flow initiation (Steele et al., 2015).
To this end, different devices are needed to best describe the behaviour of the bolus.
Drinks and other liquids

Accurate measurement of fluid flow properties is a complex task. To date, both research and existing
national terminologies, have studied or recommended the classification of drinks based on viscosity.
However, viscosity measurement is not accessible to most clinicians or caregivers.
Furthermore, viscosity is not the only relevant parameter: the flow of a drink as it is consumed is
influenced by many other variables including density, yield stress, temperature, propulsion pressure and
fat content (O’Leary et al., 2010; Sopade et al., 2007, Sopade et al., 2008a,b; Hadde et al.2015a,b). The
systematic review demonstrated wide variability in testing techniques used and found that other key
parameters such as shear rates, sample temperature, density and yield stress were rarely reported
(Steele et al., 2015; Cichero et al., 2013). Drinks thickened with different thickening agents may have the
same measurement of apparent viscosity at one particular shear rate, and yet have very different flow
characteristics in practice (Steele et al. 2015; O’Leary et al.,2010; Funami et al., 2012; Ashida et al.,
2007; Garcia et al., 2005). In addition to variations in flow associated with drink characteristics, flow
rates during swallowing are expected to differ depending on a person’s age and level of impairment of
swallowing function (O’Leary et al., 2010).
For these reasons, a measurement of viscosity has not been included in the IDDSI descriptors. Instead, a
gravity flow test using a 10 mL slip tip syringe is recommended to quantify the liquid’s flow category
(sample remaining from 10 mL after 10 sec of flow). The controlled conditions are broadly
representative of the way a liquid moves when swallowed, such as flow through a syringe or funnel.
The IDDSI Flow test is also similar in design and measurement principles to the Posthumus Funnel that is
used in the dairy industry to measure liquid thickness (van Vliet, 2002; Kutter et al., 2011). In fact the
Posthumus funnel looks like a large syringe (van Vliet, 2002; Kutter et al., 2011). Measures taken using
the Posthumus funnel include the time for a specified amount of sample to flow, and mass left after a
defined period of flow. Van Vliet (2002) notes that the geometry of the Posthumus funnel contains a
shear and elongation component that more closely matches flow conditions within the oral cavity
(Hanson et al., 2019).
Although the syringe chosen for use with the IDDSI Flow test is simple, the test has been found to
categorise a wide range of liquids reliably, and in agreement with currently existing laboratory tests and
expert judgement (Hanson et al., 2019). It has also been found to be sensitive enough to demonstrate
small changes in thickness associated with change in serving temperature.

IDDSI Flow Test
The IDDSI Flow test uses a 10 mL slip tip hypodermic syringe, as shown in the image below.
Although 10 mL syringes were initially thought to be identical throughout the world based on reference
to an ISO standard (ISO 7886-1), it has subsequently been determined that the ISO document refers only
to the nozzle of the syringe and that variability in barrel length and dimensions may exist between
brands. Specifically, the IDDSI Flow test uses a reference syringe with a measured length of 61.5 mm
from the zero line to the 10 mL line (BDTM syringes were used for the development of the tests –
manufacturer code North America 303134, Australia 302143). IDDSI is aware that there are some
syringes that are labeled as 10 mL but have different dimensions or in fact have a 12 mL capacity. Using
a syringe of different dimensions to that described here or a 12 mL syringe will give results that cannot
reliably be used with the IDDSI Framework. As a result, it is important to check the barrel length as
shown on the diagram on page 5. Details for conducting the test are shown below. In the near future
funnels that have been specifically designed for IDDSI testing may be available.
Videos showing the IDDSI Flow Test can also be viewed at: https://iddsi.org/framework/drink-testing-
methods/
Testing tips:
• When using commercial thickener products, follow the manufacturer’s instructions and
mix thoroughly, watching closely that there are no lumps or air bubbles present. Be sure to
allow the recommended time for the fluid to thicken completely.
• Use a clean, dry syringe of the correct type each time you test.
• Check the nozzle of the syringe is completely clear and free from any plastic residue or
manufacturing defects that may occasionally occur.
• Test twice or more to ensure more reliable results.
• Check for lumps – especially if flow suddenly stops. In this case the fluid may not be suitable for
dysphagia use.
• Ensure to test the liquid at the intended serving temperature
NOTE:
Drinks and liquids such as gravy, sauces and nutritional supplements are best assessed using the IDDSI Flow Test
(Levels 0-3). Note that all products should be thoroughly stirred as non-homogenous liquids may give inconsistent
results. Foams found in carbonated drinks may appear thick on the flow test as they are less liable to flow under
their own weight, as their density is lower. Foams may also be unstable over time and release thinner liquids as
the carbonated bubbles burst.
For extremely thick drinks (Level 4), that do not flow through a 10 mL syringe in 10 seconds and are best
consumed with a spoon, the IDDSI Fork Drip Test and/or Spoon Tilt Test are recommended as methods for
determining consistency.

THE IDDSI Flow Test is used to classify liquid thickness
IDDSI uses an objective measurement tool for liquid thickness, 10 mL syringe. In the near future funnels
that have been specifically designed for IDDSI testing may be available.
#Before you test ...

You must check your
syringe length
because there are
differences in syringe
lengths. Your syringe
should look like this
IDDSI FLOW TEST INSTRUCTIONS
NOTE: Before use, check the nozzle is clear and free from any plastic residue or
manufacturing defects that very occasionally occur.

Foods
Research to date in the area of food texture measurement requires complex and expensive machinery such as
Food Texture Analysers. Given the difficulty with access to such equipment and the expertise required for testing
and interpretation, many existing national terminologies have used detailed descriptors to describe food texture
instead.
The systematic review demonstrated that the properties of hardness, cohesiveness and slipperiness were
important factors for consideration (Steele et al., 2015). In addition, size and shape of food samples have been
identified as relevant factors for choking risk (Kennedy et al., 2014; Chapin et al., 2013; Japanese Food Safety
Commission, 2010; Morley et al., 2004; Mu et al., 1991; Berzlanovich et al. 1999; Wolach et al., 1994; Centre for
Disease Control and Prevention, 2002, Rimmell et al., 1995; Seidel et al., 2002).
In view of this information, measurement of foods needs to capture both the mechanical properties (e.g.
hardness, cohesiveness, adhesiveness etc.) and the geometrical or shape attributes of the food. The IDDSI
descriptions of food texture and characteristics, food texture requirements and restrictions have been generated
from existing national terminologies and the literature describing properties that increase risk for choking.
IDDSI provides testing methods that use forks and spoons to minimize the need for subjectivity that often
accompanies description based methods. Forks and spoons were chosen as they are inexpensive, easily
accessible and available in most food preparation and dining environments. A combination of tests may be
required to determine which level a food fits into. Testing methods for purees, soft, firm and solid foods include:
The Fork Drip test, Spoon Tilt test, Fork or Spoon Pressure Test, Chopstick Test and Finger test. Videos showing
examples of these testing methods can be found at:
https://iddsi.org/framework/food-testing-methods/
Fork Drip Test

Thick drinks and fluid foods (Levels 3 and 4) can be tested by assessing whether they flow through the
tines/prongs of a fork and comparing against the detailed descriptions of each level. Fork drip tests are described
in existing National terminologies in Australia, Ireland, New Zealand and the United Kingdom (Atherton et al.,
2007; IASLT and Irish Nutrition & Dietetic Institute 2009; National Patient Safety Agency, Royal College Speech &
Language Therapists, British Dietetic Association, National Nurses Nutrition Group, Hospital Caterers Association
2011).
Images for Level 3 - Liquidised/Moderately Thick are shown below.
Drips slowly or in
dollops/strands through the
tines/prongs of a fork

Images for Level 4 - Pureed/Extremely Thick are shown below.
Sits in a mound or
pile above the fork
A small amount may flow through and form a short tail below the fork
Does not dollop, flow or drip continuously through the fork prongs
Spoon Tilt Test

The spoon tilt test is used to determine the stickiness of the sample (adhesiveness) and the ability of the sample
to hold together (cohesiveness). The Spoon Tilt Test is described in existing National terminologies in Australia,
Ireland, New Zealand and the United Kingdom (Atherton et al., 2007; IASLT and Irish Nutrition & Dietetic Institute
2009; National Patient Safety Agency, Royal College Speech & Language Therapists, British Dietetic Association,
National Nurses Nutrition Group, Hospital Caterers Association 2011).
The Spoon Tilt Test is used predominantly for measures of samples in levels 4 and 5. The sample should:
• Be cohesive enough to hold its shape on the spoon
• A full spoonful must plop off the spoon if the spoon is titled or turned sideways; a very gentle flick (using only
fingers and wrist) may be necessary to dislodge the sample from the spoon, but the sample should slide off
easily with very little food left on the spoon. A thin film remaining on the spoon after the Spoon Tilt Test is
acceptable, however, you should still be able to see the spoon through the thin film; i.e. the sample should
not be firm and sticky
• A scooped mound may spread or slump very slightly on a plate
✕
þ þ þ ✕

Soft, firm and hard food texture assessment
For soft, hard or firm food, the fork has been chosen to assess food texture as it can uniquely be used
for assessment of mechanical properties associated with hardness, in addition to
assessment of shape attributes such as particle size.
Assessing for 4mm particle size compliance

For adults, the average particle size of chewed solids foods before swallowing
measures 2-4 mm (Peyron et al., 2004; Woda et al., 2010). The slots/gaps
between the tines/prongs of a standard metal fork typically measure 4 mm,
which provides a useful compliance measure for particle size of foods at Level 5 -
Minced & Moist. For determining particle size safety for infants, samples that
are smaller than the maximum width of the child’s fifth fingernail (littlest finger)
should not cause a choking risk as this measurement is used to predict the
internal diameter of an endotracheal tube in the paediatric population (Turkistani et al., 2009).
T
Compliance with 4mm particle size can be demonstrated
with a fork as shown in the images opposite.
Assessing for 15mm (1.5cm) particle size compliance

For hard and soft solid foods, a maximum food sample size of 1.5 x 1.5 cm is recommended, which is the
approximate size of the adult human thumb nail (Murdan, 2011). The entire width of a standard fork
also measures approximately 1.5cm as shown in the images below. 1.5 x 1.5 cm particle size is
recommended for Level 6 - Soft & Bite-sized to reduce risk associated with asphyxiation from choking on
food (Berzlanovich et al., 2005; Bordsky et al., 1996; Litman et al., 2003).

Fork Pressure Test and Spoon Pressure Test
A fork can be applied to the food sample to observe its behaviour when
pressure is applied. Pressure applied to the food sample has been
quantified by assessment of the pressure needed to make the thumb nail
blanch noticeably to white, as demonstrated by the arrows in the image
at left.
The pressure applied to make the thumb nail blanch has been measured
at ~ 17 kPa. This pressure is consistent with tongue force used during
swallowing (Steele et al., 2014). In the image at right, pressure is being
demonstrated in kilopascals using an Iowa Oral Performance Instrument.
This is one device that can be used to measure tongue pressure.
Image used with permission by IOPI Medical
For assessment using the Fork Pressure Test, it is recommended that the fork
be pressed onto the food sample by placing the thumb onto the bowl of the
fork (just above the prongs) until blanching is observed, as shown in the
image at left. It is appreciated that forks are not used/readily available in
some parts of the world. Pressure applied using the base of a teaspoon may
provide a useful alternative.
Chopstick Test and Finger test

Assessment with chopsticks has been included in the IDDSI. Finger tests have been incorporated in
recognition that this may be the most accessible method in some countries.
Fork/Spoon Separation Test

Transitional food texture assessment
Transitional food textures are those that start as one texture (e.g. firm solid) and change into another
texture specifically when moisture (e.g. water or saliva) is applied, or when a change in temperature
occurs (e.g. heating). This food texture is used in developmental teaching or rehabilitation of chewing
skills. For example it has been used in the development of chewing in the paediatric population and
developmental disability population (Gisel 1991; Dovey et al., 2013).
To assess whether a sample fits the definition of a transitional food, the following method is applied:
Use a sample the size of the thumb nail (1.5 cm x 1.5 cm), and place 1 ml of water on the sample and
wait one minute. Apply fork pressure using the base of the fork until the thumbnail blanches to white.
The sample is a transitional food texture if after removing the fork pressure:
• The sample has been squashed and disintegrated and no longer looks like its original state when the
fork is lifted
• The sample can be easily broken apart using chopsticks with minimal pressure.
• The sample breaks apart completely by rubbing the sample between the thumb and index finger and
does not return to its initial shape.
• Or it has melted significantly and no longer looks like its original state (e.g. ice chips).
• Apply 1 ml of water to sample

• Wait 1 minute
Thumb nail blanched

to white
Sample squashes and fractures,

and does not return to its original
shape when pressure is released
*Accompanying documents (https://iddsi.org/framework/)

Ø IDDSI Detailed Definitions
Ø IDDSI Evidence
Ø IDDSI Frequently Asked Questions (FAQs)

References
Ashida I, Iwamori H, Kawakami SY, Miyaoka Y, Murayama A. Analysis of physiological parameters of masseter
muscle activity during chewing of agars in healthy young males. J Texture Stud. 2007;38:87–99.
Atherton M, Bellis-Smith N, Cichero JAY, Suter M. Texture modified foods and thickened fluids as used for
individuals with dysphagia: Australian standardised labels and definitions. Nutr Diet. 2007;64:53–76.
Berzlanovich AM, Muhm M, Sim E et al. Foreign body asphyxiation—an autopsy study. Am J Med 1999;107: 351–5.
Centre for Disease Control and Prevention. Non-fatal choking related episodes among children, United States
2001. Morb Mortal Wkly Rep. 2002; 51: 945–8.
Chapin MM, Rochette LM, Abnnest JL, Haileyesus, Connor KA, Smith GA. Nonfatal choking on food among
children 14 years or younger in the United States, 2001-2009,Pediatrics. 2013; 132:275-281.
Cichero JAY, Steele CM, Duivestein J, Clave P, Chen J, Kayashita J, Dantas R, Lecko C, Speyer R, Lam P. The need for
international terminology and definitions for texture modified foods and thickened liquids used in dysphagia
management: foundations of a global initiative. Curr Phys Med Rehabil Rep. 2013;1:280–91.
Dovey TM, Aldridge VK, Martin CL. Measuring oral sensitivity in clinical practice : A quick and reliable behavioural
method. Dysphagia. 2013; 28:501-510.
Funami T, Ishihara S, Nakauma M, Kohyama K, Nishinari K. Texture design for products using food hydrocolloids.
Food Hydrocolloids. 2012;26:412–20.
Garcia JM, Chambers ET, Matta Z, Clark M. Viscosity measurementsof nectar- and honey-thick liquids: product,
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Gisel EG. Effect of food texture on the development of chewing of children between six months and two years of
age. Dev Med Child Neurol. 1991;33:69–79.
Hadde EK, Nicholson TM, Cichero JAY. Rheological characterisation of thickened fluids under different
temperature, pH and fat contents. Nutrition & Food Science, 2015a; 45 (2): 270 – 285.
Hadde Ek, Nicholson TM, Cichero JAY. Rheological characterization of thickened milk components (protein,
lactose and minerals). J of Food Eng. 2015b; 166:263-267.
Hanson B, Jamshidi R, Redfearn A, Begley A, Steele CM Experimental and computational investigation of the IDDSI
Flow Test of liquids used in dysphagia management. Annals of Biomedical Engineering, 2019; 1-12 Open
access:https://link.springer.com/article/10.1007/s10439-019-02308-y
IASLT & Irish Nutrition and Dietetic Institute. Irish consistency descriptors for modified fluids and food. 2009.
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Kennedy B, Ibrahim JD, Bugeja L, Ranson D. Causes of death determined in medicolegal investigations in residents
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Kutter A, Singh JP, Rauh C & Delgado A. Improvement of the prediction of mouthfeel attributes of liquid foods by
a posthumus funnel. Journal of Texture Studies, 2011, 41: 217-227.
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Nutrition Group, Hospital Caterers Association. Dysphagia diet food texture descriptions.2011. http://www.ndr-
uk.org/Generalnews/ dysphagia-diet-food-texture-descriptors.html, Accessed 29 April 2011.
O’Leary M, Hanson B, Smith C. Viscosity and non-Newtonian features of thickened fluids used for dysphagia
therapy. J of Food Sci, 2010: 75(6): E330-E338.
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1763–6.
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Pediatr Adolesc Med 2002; 156: 1120–22.
Sopade PA, Halley PJ, Cichero JAY, Ward LC. 2007. Rheological characterization of food thickeners marketed in
Australia in various media for the management of dysphagia. I: water and cordial. J Food Eng 79:69–82.
Sopade PA, Halley PJ, Cichero JAY, Ward LC, Liu J, Teo KH. 2008a. Rheological characterization of food thickeners
marketed in Australia in various media for the management of dysphagia. II. Milk as a dispersing medium. J Food
Eng 84(4):553–62.
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medium. J Food Eng 86(4):604–15.
Steele, C, Alsanei, Ayanikalath et al.The influence of food texture and liquid consistency modification on
swallowing physiology and function: A systematic review. Dysphagia. 2015; 30: 2-26.
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Acknowledgements
Development of the IDDSI framework (2012-2015)
IDDSI would like to thank and acknowledge the following sponsors for their generous support in the development
of the IDDSI framework:
• Nestlé Nutrition Institute (2012-2015)
• Nutricia Advanced Medical Nutrition (2013-2014)
• Hormel Thick & Easy (2014-2015)
• Campbell’s Food Service (2013-2015)
• apetito (2013-2015)
• Trisco (2013-2015)
• Food Care Co. Ltd. Japan (2015)
• Flavour Creations (2013-2015)
• Simply Thick (2015)
• Lyons (2015)


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What is the goal of IDDSI?

What is the goal of IDDSI?

What are the levels in the IDDSI framework?

What are the levels in the IDDSI framework?

IDDSI Framework

Please visit https://iddsi.org/ for further information.

The IDDSI Board:

The IDDSI Framework and Descriptors are licensed under the 2

Drinks and other liquids

The IDDSI Framework and Descriptors are licensed under the 3

The IDDSI Framework and Descriptors are licensed under the 4

#Before you test ...

IDDSI FLOW TEST INSTRUCTIONS

The IDDSI Framework and Descriptors are licensed under the 5

Fork Drip Test

Images for Level 3 - Liquidised/Moderately Thick are shown below.

The IDDSI Framework and Descriptors are licensed under the 6

Spoon Tilt Test

The IDDSI Framework and Descriptors are licensed under the 7

Assessing for 4mm particle size compliance

Assessing for 15mm (1.5cm) particle size compliance

The IDDSI Framework and Descriptors are licensed under the 8

Image used with permission by IOPI Medical

Chopstick Test and Finger test

Fork/Spoon Separation Test

The IDDSI Framework and Descriptors are licensed under the 9

• Apply 1 ml of water to sample

Thumb nail blanched

Sample squashes and fractures,

*Accompanying documents (https://iddsi.org/framework/)

The IDDSI Framework and Descriptors are licensed under the 10

The IDDSI Framework and Descriptors are licensed under the 11

The IDDSI Framework and Descriptors are licensed under the 12

The IDDSI Framework and Descriptors are licensed under the 13

The IDDSI Framework and Descriptors are licensed under the 14

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