The IDDSI (International Dysphagia Diet Standardization Initiative) framework continues to be a benchmark for healthcare and catering professionals involved in the nutritional management of patients with dysphagia.

Several years after one of the most important international conferences dedicated to dysphagia, the IDDSI continues to play a central role in clinical practice. The International Dysphagia Diet Standardisation Initiative, launched in 2013, was created with the aim of developing a shared and universally applicable terminology for defining the texture of thickened foods and liquids intended for individuals with swallowing disorders. After approximately three years of work, the international scientific committee developed a classification system structured in the form of a diagram, which is still widely used in various care settings. The IDDSI Framework divides foods and beverages into eight levels of texture (from 0 to 7), identified by progressive numbering, textual descriptions, and standardized color codes.

The document also includes a description of simple and reproducible assessment methods that enable healthcare professionals to accurately and consistently classify each food or liquid according to its level of safety and suitability for dysphagic patients.

Drinks

Although numerous national classifications refer mainly to viscosity for the categorization of beverages and liquids, this parameter is not sufficient to comprehensively describe the behavior of fluids during oral intake. Variables such as density, yield stress, temperature, propulsion pressure, and lipid content significantly influence flow characteristics and swallowing safety. Given the difficulty, especially in healthcare settings, of measuring viscosity using laboratory instruments, the IDDSI Framework recommends the use of the syringe-based gravity flow test (IDDSI Flow Test) as a practical and standardized method for evaluating liquids.

Food

The assessment of solid foods requires a combined analysis of mechanical properties—such as hardness, cohesiveness, and adhesiveness—and the geometric and dimensional characteristics of the food bolus. The IDDSI has introduced texture descriptions that take into account not only the physical properties of the food, but also the risk of aspiration. For accurate classification, it may be necessary to use multiple assessment tests, including those described in the IDDSI Framework, such as: the Fork Drip Test, the Spoon Tilt Test, the Fork or Spoon Pressure Test, the Chopstick Test, and the Finger Test.

December 12 – World Dysphagia Day

On this day dedicated to those who live with swallowing difficulties, we want to offer a small gesture to make the Christmas season more peaceful and inclusive.

A FREE RESCIGNO PANETTONE!
Starting today, inthe Oltre la Pizza Box, you will also find abag of Rescigno Panettone (made in collaboration with the Salvatore Nigrelli Association): the taste of Christmas in a safe texture suitable for those with dysphagia.

CHRISTMAS2025 DISCOUNT – 20%
For the holiday season only, use the codeNATALE2025to get a20% discount.

Valid fromDecember 12(World Dysphagia Day) untilJanuary 15, 2026. Cannot be combined with other codes or offers.

BOX BEYOND PIZZA

€ 29,00

Buy now

The Oltre la Pizza project has captured the attention of the media and citizens, showing how innovation can meet solidarity and tradition.
Created thanks to the collaboration between the Salvatore Nigrelli Association, Io Sano – Soluzioni per la Disfagia (Solutions for Dysphagia) and Antica Pizzeria da Michele in the World, Oltre la Pizza brings a completely free pizza, dessert, and beverage menu to locations in Aversa, Caserta, Naples, Pompeii, and Salerno (see here for details of the locations), designed for those living with dysphagia.

The initiative and the faces behind it
The project was officially presented on September 23, 2025, at the headquarters of the Archconfraternity of SS. Trinità dei Pellegrini in Naples and received widespread media coverage in many newspapers:
NAPOLI TODAY, IL DENARO, NAPOLI FACTORY, IL MEZZOGIORNO, IL CONFRONTO, NAPOLI VILLAGE, SUD NOTIZIE, IL MATTINO, IL CORRIERE DELLA SERA

During the presentation of the project, the following speakers took part: Renata Nigrelli ( president of the Salvatore Nigrelli Association) and Nadia Nigrelli (vice president), Giovan Battista Varoli (sole administrator of Io Sano), Sergio Condurro (CEO of Antica Pizzeria da Michele), Alessandro Condurro and Francesco De Luca ( CEO of Antica Pizzeria da Michele in the World), together with Antonio Maddalena ( director of the Home Care Unit of ASL Napoli 1). The event was moderated by journalist Brunella Chiozzini.

The project is inspired by the history of the Nigrelli family. In particular, the tragic experience of the loss of Salvatore Nigrelli, who suffered from ALS, inspired the desire to create something that went beyond—something that could restore possibility and dignity. (Eroica Fenice)

Where can you find menus that go beyond pizza?
Starting this September, at select locations of Antica Pizzeria da Michele in the World (Aversa, Caserta, Naples, Pompeii, and Salerno), you can request a menu specially designed for people with dysphagia, which includes:
• pizza (Margherita, Marinara, and Cosacca versions)
• drink
• dessert
All items on the menu will be offered in modified and safe consistencies, while maintaining the quality and authentic flavors of the Neapolitan tradition. The service will be free of charge, and for those with mobility difficulties, a takeaway option will also be available. (Io Sano®)

An open invitation
This initiative is a concrete gesture of welcome, a step towards the right to enjoy food—even for those who have difficulty swallowing.
We look forward to seeing you at our pizzerias in Aversa, Caserta, Pompeii, and Salerno: join us, bring whoever you want, and share this experience.

If you want to try the menu beyond pizza at home, you can also purchase it from our website with a special offer!

BOX BEYOND PIZZA

€ 29,00

Buy now

The IDDSI funnel is a device designed to measure in a standardized way the viscosity of fluids intended for patients with dysphagia, according to the International Dysphagia Diet Standardization Initiative (IDDSI) framework. It replaces the previous syringe method and significantly simplifies caregiver verification of consistency levels, making testing more accessible, rapid and repeatable
A 2024 validation study of 73 different samples showed that funnel results matched 92% with that obtained by syringe (model BD 303134), with a negligible average difference of 0.2 mL remaining. This shows that the funnel is a reliable and accurate system.

How to use the IDDSI funnel correctly

Liquid and funnel preparation

• Ensure that the liquid is well mixed and suitable temperature.
• Use the official IDDSI funnel, which integrates a 10 mL syringe and funnel, without the need for additional tools

Pouring into the funnel

• Slowly fill the syringe to the 10 mL mark.
• Start the test: place the funnel syringe vertically, let the liquid flow by gravity only.

Timing and measurement

• Let it run for exactly 10 seconds, then close the lower outlet.
• Measure how much liquid remains.
  If the residue is between 6.5 and 7.2 seconds for complete emptying, the level is valid

Interpretation of results

The residual volume identifies the IDDSI level:
Residual volume (mL) IDDSI level Description
0-1 Liquid Water/unthickened
1-4 Slightly thickened Behave as slightly viscous liquid
4-8 Nectar-like liquid density
8 Honey-like thick liquid
Notes: guideline values, always follow official IDDSI tables.

Repeatability and quality control

Repeat the test at least three times to confirm consistency.
If the times go outside the standard range in more than 3 tests, investigate with micro-densimeter or reject the liquid

Practical demonstration

In this video, the flow test with the IDDSI funnel is shown step by step.

Benefits for health care facilities and RSAs

1. Standardization and safety
   Thanks to Funnel, it is possible to accurately identify the viscosity level what to reduce the risk of aspiration, increasing the safety of feeding.
2. Operational efficiency
   Faster and easier than syringe use, the funnel supports the work of staff in the kitchen or department.
3. Hands-on training
   The funnel is a great tool for training professionals-from kitchen workers to caregivers-with an immediate and intuitive method.
4. Quality of Care
   Funnel helps ensure consistency between prescription, preparation, and meal delivery enhances the multidisciplinary approach and improves patient compliance.

Purchase the funnel and download the instructions!

Want to know how to use it step by step or try it out in your facility?
Download the instructions and order the funnel here:

IDDSI Funnel for IDDSI Flow Test

€ 28,00

The IDDSI FUNNEL is theonly funnel designed to correctly perform the IDDSI Flow Test. Simply pour the liquids into the funnel and display the test result. The funnel is reusable and recyclable after proper washing according to the instructions provided.
Io Sano | Dysphagia Solutions is an authorized distributor of IDDSI Funnels in Italy and the European Union.

The Funnel is distributed in boxes of 10 pieces each. Once the order is completed you will receive a confirmation email and then the order will be taken care of and shipped (you will receive an email with tracking separately). Delivery time is approximately 7 to 10 days.

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IDDSI Funnel for IDDSI Flow Test Quantity

+

Add to cart

Category: FUNNEL

Would you like to learn more or train your staff? Io Sano is the authorized distributor of IDDSI funnels for Europe. Contact us for advice, purchases, targeted training, and access to the official guidelines.

The oral cavity is a potential reservoir of pathogens. Failure to thoroughly clean your teeth, tongue, and palate facilitates the passage of bacteria into the body.

Oral hygiene should always be an integral part of your daily routine, not only for reasons of comfort but above all in terms of safeguarding your health. In fact, in addition to being the main route of access to the digestive and respiratory systems, the oral cavity is also a potential reservoir of pathogens (about 300 species of bacteria) that could cause various types of disorders. Firstly, oral diseases, which, in addition to being a serious aesthetic problem, cause dehydration and malnutrition and are a risk factor for heart disease, diabetes, and stroke. Secondly, poor oral hygiene in dysphagic patients is linked to aspiration pneumonia. Failure to thoroughly clean the teeth, tongue, and palate exposes patients to excessive bacterial proliferation, which, remaining in incubation in the oral cavity, is likely to spread throughout the body. These pathogens can enter the body along with food, drink, or saliva and reach the respiratory tract instead of the esophagus. 

Oral hygiene as a daily preventive measure

For the reasons listed above, oral hygiene should be one of the fundamental activities for those suffering from dysphagia, especially for those who are unable to take care of it independently due to motor or cognitive causes. However, this is not always the case, and too often oral care is not seen as an integral part of patient care. The same applies to oral cavity assessments, which are often not carried out with the frequency and tools with which they should be performed.

The greatest risk when feeding a patient with swallowing problems is food entering the airways.

Penetration is defined as the passage of the bolus into the airways above the vocal cords. Normally, this penetration is resolved by the protective cough reflex. 

Aspiration is defined as the passage of food residues under the vocal cords. In this case, the cough reflex is not sufficient to expel these residues, with serious consequences for the respiratory system.

Aspiration pneumonia is the most common cause of death in patients with dysphagia due to neurological disorders. Aspiration is defined as the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract. The risk of aspiration is relatively higher in elderly individuals due to the higher incidence of dysphagia and gastroesophageal reflux. After aspiration, various pulmonary syndromes may occur depending on the amount and nature of the aspirated material, the frequency of aspiration, and the host's response to the material itself.

Aspiration pneumonia proper – or Mendelson's syndrome – is a chemical injury caused by the inhalation of sterile gastric contents, while ab ingestis pneumonia is an infectious process caused by the inhalation of oropharyngeal secretions colonized by pathogenic bacteria; although there is some overlap between them, they represent two distinct clinical entities.

Aspiration pneumonia is characterized by chemical burns to the tracheobronchial tree and lung parenchyma due to the acidity of gastric contents, followed by an intense parenchymal inflammatory reaction. Since gastric acidity prevents the growth of microorganisms, microbial infection plays no role in the early stages of aspiration pneumonia, but may play a role at a later stage, although the incidence of this complication is poorly understood. However, it should be remembered that when the pH of the stomach increases following the use of antacids or proton pump inhibitors, which are frequently used in the elderly, potentially pathogenic microorganisms may colonize the gastric contents.

The signs and symptoms of patients who have aspirated gastric contents range from gastric regurgitation in the oropharynx to the onset of rales, cough, cyanosis, pulmonary edema, hypotension, and hypoxemia with rapid progression to acute respiratory distress and death. In most cases, there is only shortness of breath or coughing, while some patients experience what is commonly referred to as silent aspiration, which can only be detected radiologically.

Aspiration pneumonia develops as a result of the aspiration of secretions colonized by microorganisms from the oropharynx; however, it should be noted that this is one of the main mechanisms through which bacteria—such as Haemophilus influenzae and Streptococcus pneumoniae, which colonize the oropharynx—penetrate the airways. In fact, about half of healthy adults aspirate small amounts of oropharyngeal secretions during sleep, but their microbial content is continuously eliminated through active ciliary transport, normal immune mechanisms, and coughing. However, if these mechanisms are compromised or if the amount of aspirated material is abundant, pneumonia may occur.

In elderly patients and those who have suffered a stroke and are affected by dysphagia, there is a strong correlation between the volume of aspirate and the development of pneumonia. 

The diagnosis of aspiration pneumonia is based on radiographic evidence of pulmonary infiltrates in the bronchopulmonary area. Factors that increase the risk of oropharyngeal colonization by potentially pathogenic microorganisms and that increase the bacterial load may increase the risk of aspiration pneumonia; for example, this risk is lower in edentulous patients and in elderly patients who receive effective and thorough oral care. In fact, inadequate oral hygiene can lead to abundant oropharyngeal colonization by potential respiratory tract pathogens such as Pseudomonas aeruginosa and Staphylococcus in community-acquired pneumonia in elderly individuals.

With regard to the microbial agents causing aspiration pneumonia, Pseudomonas aeruginosa and other Gram-negative bacteria were found to predominate in patients with aspiration syndrome contracted in hospitals, while Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Enterobacteriaceae are prevalent in community-acquired pneumonia.

It is clear that food passing into the respiratory tract occurs more frequently during meal administration in dysphagic patients, even in the early stages. When this passage manifests itself with a feeling of suffocation, persistent coughing, and the appearance of a red or cyanotic complexion, the phenomenon becomes extremely evident to those administering the food.

 It can be much more dangerous not to address signs of small amounts of food passing into the bronchi—silent aspiration—as this often goes unnoticed by the patient. Certain phenomena should raise suspicion, including:

• Constant occurrence of involuntary coughing immediately after, or within 2-3 minutes of swallowing a bite
• Appearance of hoarseness or huskiness in the voice after swallowing a bite
• Leakage of liquid or food from the nose
• Presence of fever, even if not high – 37.5-38°C – without obvious causes; fever can in fact be a sign of inflammation or irritation due to food passing into the airways.

If even one of these signs is detected, it is advisable to report it immediately to your doctor and/or to the person who is primarily responsible for treating your dysphagia.

It is worth noting that the passage of food into the respiratory system, through the trachea into the bronchi and then into the lungs, even in small quantities but with repeated episodes over time, can lead to a form of pneumonia that begins as inflammation but can develop into a more serious infection, especially if food continues to enter the bronchi. Therefore, great care is required when administering meals, both in terms of how they are administered—posture, timing, etc.—and in terms of food choices.

When feeding patients with swallowing difficulties, it is necessary to plan a progression of foods based on the patient's swallowing ability. The choice of foods, which depends on the type and degree of dysphagia, should be guided primarily by the following criteria:

• Patient safety by limiting the risk of aspiration—food entering the airways—through the selection of foods with suitable physical properties (homogeneity, viscosity, cohesion)
• The patient's nutritional requirements, with particular reference to protein, calorie, and water intake, any dietary requirements, and food preferences.

While it is necessary for food to be varied, appetizing, and nutritionally adequate, it is also a priority to implement all measures aimed at preventing the risk of food entering the airways and the consequent risk of aspiration pneumonia.

Among these actions, we recommend paying attention to posture, applying correct administration methods, and dividing the daily food intake into several meals (at least 5) in order to reduce the patient's effort.

However, we strongly recommend that food choices be made with great care and that their rheological parameters (in particular, homogeneity, absence of double phase, consistency, viscosity, viscoelasticity, and cohesion) be suitable for dysphagic patients, remaining absolutely constant in various contexts of use, from preparation to administration.

There are many studies by researchers on the relationship between people with dementia and food and how they perceive it. They all agree that eating does not only have a biological function, but is also an incredibly important experience. Wendy Mitchell clearly explains the various aspects surrounding food and eating in her book"What I wish people knew about dementia,"in which she describes how the disease has changed her relationship with food.

"You can tell me a secret and I'll always keep it because I simply won't remember it. But one thing I never forget is that food used to mean so much more to me than it does now," says Mitchell, introducing the topic of food in his first-person account of living with dementia.

Different meanings of food

Within any culture, food takes on a very important meaning as it carries culinary traditions developed and handed down over time, closely linked to the territory, its flavors, and its community. In other words, food, in addition to being linked to sensory pleasure, plays a very important role on a social level —just think that mealtimes are also a way of marking time—and on an emotional level. In fact, very often our memories associate flavors, recipes, and foods with certain childhood memories and moments of conviviality.

Mitchell describes this aspect as follows:"These days, I even have to set alarms on my iPad to remind me to eat: the part of my brain that feels hunger stopped working a long time ago. Yet when you no longer derive pleasure from food, you realize that it's much more than that. It's how we show love as parents, it's how we bond with friends, it's an excuse for saying the wrong thing, it's a welcome to the neighborhood."

He adds:"Even when I was diagnosed with early-onset Alzheimer's in 2014, at the age of 58, I used food to sweeten the bitter moments that followed."

Dementia changes not only eating habits but also culinary habits

When you have dementia, not only do your eating habits change, but also your cooking habits, because cooking becomes a big problem. As the disease progresses, it becomes increasingly difficult to remember even the simplest things, such as how to make a cup of tea. Mitchell also talks about this, showing how cooking goes from being an act of love for yourself and others to a moment of frustration, anger, and helplessness, and those places of colors, scents, and creativity become labyrinths, confusion, and chaos. Losing the ability to cook can be experienced as a real loss.

In this case, only the love of our loved ones can truly help us rediscover a positive meaning in preparing food. Mitchell recounts: "My son-in-law, Stuart, now cooks for me, just two or three times a week, so I don't feel intrusive. But his are the only meals prepared on the spot." What remains is the gesture of love that is now received instead of given, but which still represents a moment of positively perceived relationship. Thus, mealtimes can continue to bring pleasure on a relational level, even though the perceptual and sensory aspects are lacking.

Even eating out can become very difficult. Mitchell herself acknowledges this: "Eating out used to be a luxury, but now it's very stressful,"she says, adding, "In restaurants, I choose the first thing I recognize that will be easy to eat. Never meat, because it requires the right coordination to cut into small, manageable pieces, and that left me a long time ago. The simple task of cutting food requires serious concentration. Even chewing isn't as easy as it used to be."

Understanding the actual capabilities of people with dementia is also essential when it comes to offering food and choosing where to eat it. It is important to adapt to the new rhythms and habits of people with dementia, who cannot control their behavior or memory.

How to help people with dementia enjoy food more

What can be done to help people with dementia enjoy food to the fullest is to consider as many aspects as possible and be attentive to the other person without underestimating anything, in the hope of making mealtimes as pleasant and worthwhile as possible. This often means making it easier for them to eat or drink, allowing them a certain degree of autonomy as far as possible. Therefore, choose meals that they are able to eat on their own or present the dish in such a way that they can eat it independently.

“We don't know for sure what causes dementia, and we don't know what to eat or drink to prevent it. All I know is that every day is a challenge, a chess game to be played with this disease in my head, and I am determined to win for as long as possible.” Wendy Mitchell.

Unlike dysphagia, atypical swallowing is a disorder caused by a failure of the swallowing reflex to develop during early childhood.

Just like dysphagia, atypical swallowing is one of the so-called swallowing disorders. It is caused by a failure of the swallowing action to evolve from the primary infantile stage, which can occur in children over the age of seven or in adults. Atypical swallowing is therefore due to the persistence of an infantile swallowing pattern.

The change in swallowing pattern corresponds to the stage of child development when the front teeth appear, food changes from liquid to solid, postural patterns change as the child begins to walk independently, and the temporomandibular joint develops.

Alterations to these stages or excessive use of aids (bottles, pacifiers, etc.) can lead to a delay or failure to develop the physiological swallowing reflex in adults, with the infantile reflex remaining.

Common causes of atypical swallowing in children and adults include all disorders of the nasal cavity, such as recurrent or chronic rhinitis, sinusitis, and adenoid hypertrophy, which lead to mouth breathing, preventing the teeth from closing properly and the tongue from remaining low during swallowing.

It is clear that this disorder is very different from dysphagia, which is a secondary symptom of much more serious conditions. Atypical swallowing, on the other hand, is a dysfunction of one or more phases of the swallowing mechanism that also causes food to pass incorrectly through the upper digestive tract.

How does swallowing occur in infants?

Given the daily intake of liquid food through breastfeeding or bottle feeding, infants tend to stick their tongues out between their gums and tighten their lips in order to produce enough pressure to allow them to swallow. As they develop, this swallowing pattern tends to change depending on their diet and the different ways they are fed.

After a phase of so-called infantile swallowing, the child gradually changes the type of swallowing following the appearance of the anterior deciduous teeth and changes in nutritional patterns (from a totally liquid diet to a diet that also includes solid foods). Between 18 and 28 months, the child's swallowing is said to be mixed.

In the following months, as the child begins to eat solid foods, he or she will start to close the mouth after chewing, allowing the tongue to push the food against the palate and into the throat, before directing it towards the digestive system.

Types of atypical swallowing

Having analyzed the swallowing mechanism in infancy, it is now easier to describe the different types of atypical swallowing. Among the main ones, we highlight the following:

– Simple tongue thrust swallowing: this is not a particularly serious disorder and can be easily corrected, as the subject regularly clenches their teeth during swallowing and does not place their tongue between their dental arches. In these cases, the following frequently occur: limited open bite, tongue thrusting on the alveolar arches during swallowing, contraction of the elevator muscles, tendency to adopt a low tongue posture and risk of mouth breathing, predominantly vertical chewing, tendency to develop an ogival palate.

– Complex tongue thrust swallowing: significantly more serious than the previous condition, it causes various disorders. These include: anterior bite extending to the premolars, significant tongue protrusion between the dental arches, failure of the teeth to lock together during swallowing, anterior chewing, and frequent dental malocclusions.

• True infantile swallowing: this is the form of atypical dysphagia most similar to the swallowing pattern of newborns. In these cases, the following occur: persistence of the infantile swallowing reflex, strong tongue thrust between the dental arches, failure to lock the teeth during swallowing, decreased facial expression, and frequent mouth breathing even at rest.

Consequences of atypical swallowing

Failure to treat atypical swallowing can cause disorders that are not limited to dental problems. These include:

• protruding teeth (overjet);
• ogival palate;
• changes in chewing;
• postural problems;
• speech disorders;
• cosmetic alterations;
• aerophagia and globus hystericus.

Dysphagia is a common disorder related to difficulty swallowing that can occur at any age, although it is more prevalent among the elderly. This problem can be temporary or permanent and can affect both men and women. But what exactly is it?

What is dysphagia?

The term dysphagia refers to any disorder in the progression of food from the mouth to the stomach and can involve any of the stages of swallowing. Swallowing is the ability to channel solid, liquid, gaseous, or mixed substances (food or drink, alone or together) from the mouth to the stomach.

It is a complex process that involves rapid coordination of a set of muscles, which allows the bolus —i.e., chewed food mixed with saliva— to pass into the digestive system while protecting the airways and lungs from the risk of aspiration and/or penetration.

Swallowing is a process that is partly voluntary and partly reflexive, as some stages are beyond our control and are therefore involuntary. If complications arise during this process, there can be serious consequences, such as aspiration pneumonia.

Recognizing this disorder in time is crucial for the patient's safety and life.

What are the causes of dysphagia?

Dysphagia can have various causes and, according to the American Gastroenterological Society, can be classified as follows:

• Neurological – brain tumors, head trauma, stroke, cerebral palsy, Guillain-Barré syndrome, Huntington's disease, polio, post-polio syndrome, tardive dyskinesia, metabolic encephalopathies, multiple sclerosis, amyotrophic lateral sclerosis, dementia, Parkinson's disease, and Alzheimer's disease;
• Structural – cricopharyngeal bar, Zenker's diverticulum, cervical scars, oropharyngeal tumors, congenital malformations, osteophytes, and skeletal malformations;
• Myopathic – connective tissue diseases (overlap syndrome), dermatomyositis, myasthenia gravis, sarcoidosis, myotonic dystrophy, oculopharyngeal dystrophy, polymyositis, paraneoplastic syndromes;
• Iatrogenic – side effects of drug therapies, consequences of muscle or neurogenic surgery, effects of exposure to radiation, corrosive (injury from pills, intentional);
• Infectious – diphtheria, botulism, Lyme disease, syphilis, mucositis (from herpes, cytomegalovirus, candida, etc.);
• Metabolic – amyloidosis, Cushing's syndrome, thyrotoxicosis, Wilson's disease.

If you suspect you have dysphagia, it is advisable to contact your doctor and follow the necessary steps to diagnose this disorder in order to understand its severity and how to respond to it.