Dysphagia Knowledge Hub — 吞嚥困難知識庫

IDDSI Around the World: How Australia, UK, Canada and Asia Implement Dysphagia Food Standards

The Problem IDDSI Was Created to Solve

Before 2013, patients with dysphagia moving between hospitals, care facilities, or countries faced a terminology crisis. A diet described as “minced” in Australia meant something different from “minced” in the UK. A “Level 2” fluid in Canada was defined by a different testing method than a “Level 2” in the United States. Caregivers and patients who crossed state, provincial, or national boundaries discovered that their carefully prescribed diet texture bore no consistent relationship to how that term was interpreted at their new facility. The consequence — in the most serious cases — was aspiration pneumonia, malnutrition, or death.

The International Dysphagia Diet Standardisation Initiative (IDDSI) was established in 2013 by a consortium of speech-language pathologists, dietitians, occupational therapists, and researchers from 33 countries. The framework they produced — eight levels of food and fluid texture, each defined by standardised physical testing methods — was published in 2015 and updated in 2019. The aspiration was global adoption: one framework, one terminology, one set of testing methods, regardless of where a patient received care.

What actually happened is considerably more complex, more interesting, and still evolving.

The IDDSI Framework: A Brief Summary

The IDDSI framework covers eight levels:

The overlap between fluid and food levels (3 and 4) is intentional — some preparations occupy the boundary between very thick fluid and very thin food.

Testing methods include:

The 2019 update added the chopstick test and expanded guidance on cultural adaptation — both of which were largely driven by feedback from Asia-Pacific contributors.

Australia: Statutory Adoption in Aged Care

Australia was one of the earliest and most comprehensive adopters of IDDSI. The journey began with the former Dietitians Association of Australia and Speech Pathology Australia jointly piloting IDDSI in clinical settings from 2016, followed by a formal transition deadline.

Key milestones:

Current status: IDDSI is effectively mandatory for registered aged care providers in Australia. The ACQSC can cite IDDSI non-compliance in audits. Commercial food manufacturers targeting the aged care sector must demonstrate IDDSI alignment for their products to be purchased by accredited facilities.

Practical note: Australia’s multicultural population has meant that IDDSI’s cultural adaptation guidance (particularly the chopstick test) has been applied in practice — many aged care facilities serve Chinese, Vietnamese, Korean, and South Asian residents whose traditional foods must be adapted.

United Kingdom: NHS Rollout and CQC Requirements

The UK’s path to IDDSI adoption was shaped by the existing national framework — the National Patient Safety Agency’s (NPSA) texture descriptors, which had been in use across the NHS since 2012. Moving away from this embedded system required coordinated effort across the NHS, the British Dietetic Association (BDA), and the Royal College of Speech and Language Therapists (RCSLT).

Key milestones:

Scotland, Wales, Northern Ireland: Each devolved health system issued its own IDDSI implementation guidance on similar timelines, with the NHS Scotland Dietetic Food First programme being particularly comprehensive.

Current status: IDDSI terminology is now standard across NHS settings and regulated care homes. Institutional food suppliers to the NHS must label products to IDDSI specifications for procurement. The UK IDDSI implementation was accompanied by significant investment in staff training — the BDA and RCSLT produced extensive e-learning resources.

Labelling: The UK does not yet have a mandatory IDDSI labelling requirement for retail food products. Institutional supply contracts carry the labelling requirement. Retail products for home dysphagia management vary in their use of IDDSI terminology.

Canada: Provincial Variation

Canada’s adoption of IDDSI reflects the country’s constitutional structure: healthcare is a provincial responsibility, so implementation has varied significantly by province.

Key milestones:

Current status: IDDSI terminology is standard in most Canadian hospital and long-term care settings, but there is no national statutory requirement equivalent to Australia’s aged care standards. Provinces with stronger central health authority structures (BC, Ontario) have more consistent implementation than provinces with more fragmented systems.

United States: IDDSI Adoption by Professional Bodies

The United States presents a distinctive case: IDDSI has been adopted by leading professional bodies, but without a statutory or regulatory mandate equivalent to Australia’s.

Key milestones:

Current status: IDDSI is now the standard reference in US clinical practice, taught in all accredited SLP and dietetics programmes, and used in most major hospital systems. However, implementation in smaller facilities, home care settings, and community restaurants (which serve elderly patrons) is inconsistent. The US healthcare system’s fragmented payer and regulatory structure means no single body can mandate transition the way Australia’s Commonwealth government did.

Labelling: As in the UK, there is no mandatory IDDSI labelling requirement for US retail food products. Commercial medical food manufacturers (Nestlé, Abbott, Hormel) have largely transitioned their product labelling to IDDSI terminology.

Japan: A Parallel Framework — 学会分類2021

Japan is a notable case where a national framework developed in parallel with IDDSI rather than directly adopting it.

The Japanese Dysphagia Diet 2021 (学会分類2021) — formally “Dysphagia Diet Classification 2021” — was published by the Japanese Society of Dysphagia Rehabilitation (日本摂食嚥下リハビリテーション学会) in 2021. It builds on the earlier 2013 classification and draws explicitly on IDDSI, but maintains a Japanese-specific category structure:

The framework includes Japanese-specific testing methods and cultural food examples (tofu, rice porridge, fish cake) alongside the IDDSI testing methods.

The UDF framework (Universal Design Food — ユニバーサルデザインフード) is a parallel industry standard maintained by the Japan Care Food Conference, applying to commercial products. UDF and 学会分類2021 are mapped to each other but are separate frameworks.

Japan’s approach reflects a principled decision that cultural specificity — particularly around the central role of rice, fish, and pickled vegetables in Japanese diet — warranted a domestically developed framework rather than direct IDDSI adoption. The two frameworks are broadly compatible and can be cross-mapped.

Taiwan: TDA Adoption

The Taiwan Dietetic Association (TDA — 台灣营養學會 / 台灣吞嚥障礙飲食協會 for dysphagia-specific work) adopted IDDSI as the reference framework from around 2018, with formal guidance issued to hospitals and long-term care facilities.

Taiwan’s healthcare system — a single-payer national health insurance (NHI) model — has enabled relatively consistent implementation. Hospital accreditation criteria under the Joint Commission of Taiwan include assessment of nutrition care quality, within which dysphagia diet management is a component.

Current status: IDDSI terminology is standard in Taiwanese hospitals and accredited long-term care facilities. Commercial product manufacturers in Taiwan selling to institutional care settings increasingly label to IDDSI specifications.

Hong Kong: Hospital Authority Pilot and HKSLTA

Hong Kong’s adoption of IDDSI has proceeded through two parallel tracks:

Hospital Authority (HA): The HA — which operates all public hospitals and most specialist services in Hong Kong — initiated an IDDSI pilot programme in selected hospitals from approximately 2019. The pilot evaluated clinical feasibility, staff training requirements, and integration with existing texture modification protocols. As of 2024, IDDSI terminology has been progressively adopted across HA facilities, though full system-wide implementation continues.

Hong Kong Speech and Language Therapy Association (HKSLTA): The HKSLTA has been the primary professional advocate for IDDSI adoption in Hong Kong. The Association has published Cantonese-language IDDSI resources, conducted training for speech-language therapists and dietitians, and engaged with care home operators on implementation.

Private sector: Private hospitals and care homes in Hong Kong vary widely in their adoption of IDDSI terminology. Some private hospitals are ahead of the HA on IDDSI implementation; many smaller RCHEs have limited awareness.

FEHD and regulatory context: Hong Kong’s Food and Environmental Hygiene Department (FEHD) does not currently mandate IDDSI compliance. The Social Welfare Department (SWD) — which regulates RCHEs — has not yet incorporated IDDSI into its Code of Practice for Residential Care Homes. This regulatory gap means that texture modification quality in RCHE settings is highly variable.

Mainland China: T/SATA Group Standards

China’s path is covered in more detail in the companion article on T/SATA standards. In brief: China has not adopted IDDSI directly as a national standard (no GB standard references IDDSI), but has developed the T/SATA group standards — particularly T/SATA 094 — which explicitly align with IDDSI testing methods and level classifications.

This approach preserves national regulatory sovereignty while achieving practical IDDSI compatibility — products that meet T/SATA 094 are, by construction, substantially aligned with IDDSI, enabling cross-border product recognition.

Cross-Border Product Labelling Implications

For food manufacturers selling dysphagia food products across multiple markets, the current landscape requires:

Market Standard Labelling Requirement
Australia (institutional) IDDSI Effectively mandatory
UK (institutional) IDDSI Mandatory for NHS supply
Canada (institutional) IDDSI De facto standard
USA (institutional) IDDSI De facto standard
Japan 学会分類2021 + UDF Japanese-specific labelling needed
Taiwan (institutional) IDDSI Standard for accredited facilities
Hong Kong (public hospital) IDDSI (in transition) Increasingly expected
Mainland China (GBA tenders) T/SATA 094 Required for GBA institutional supply

A manufacturer exporting to both Australian aged care facilities and GBA mainland care homes must maintain parallel labelling: IDDSI for Australia; T/SATA 094 for the mainland. The testing methods overlap significantly, reducing the re-testing burden, but documentation, labelling, and compliance certification are distinct.

Future Regulatory Convergence

The trajectory is clear: IDDSI, or IDDSI-aligned frameworks, will become the global baseline for dysphagia food classification over the next decade. The remaining questions are:

  1. When will regulatory mandates follow professional endorsements — particularly in the US and Canada at the federal level?
  2. How will Japan’s 学会分類2021 and China’s T/SATA series converge further with IDDSI in future revisions?
  3. Will Hong Kong’s SWD incorporate IDDSI into RCHE regulation — which would be the most impactful single step for improving care home food texture quality in HK?
  4. Will retail food labelling follow institutional supply — enabling consumers managing dysphagia at home to identify safe products from supermarket shelves?

Each of these questions involves not just scientific consensus — which is largely achieved — but regulatory process, stakeholder negotiation, and political will. The IDDSI framework exists; the challenge is ensuring that the patient eating a blended meal in a Hong Kong care home, a Japanese hospital, or an Australian aged care facility benefits from the same evidence-based quality standards regardless of where they are.