IDDSI Implementation

By Jonathan Tellier

The International Dysphagia Diet Standardisation Initiative. (2016)

 Objectives
 Identify differences between National Dysphagia diet (NDD)
and international dysphagia diet standardisation initiative
(IDDSI).

 Identify what IDDSI is.

 Learn testing methods of each IDDSI level.

 Understand methods used to evaluate recipe transfer from

NDDIII to IDDSI soft and bite sized.
Purpose
 Patton has to
transition from NDD to
IDDSI in 2019.

 To see how current

recipes transfer from
NDDIII to IDDSI.
Dysphagia
 Defined as a difficulty in
swallowing.

 8% of the world population.

 1 in 25 Americans.

 There are two types:

1. Oropharyngeal dysphagia-
difficulty starting a
swallow.
2. Esophageal dysphagia-
sensation of food being
stuck in the neck or chest.
http://patients.gi.org/topics/dysphagia/
Why is NDD being replaced?
 Too specific.

 Is not culturally sensitive.

 Does not establish common

terminology and
definitions.

 Is not supported by
American Speech Language
Hearing Association (ASHA)
Why IDDSI?
 Countries have worked to
establish standards regionally
and nationally.

 All these countries have

different standards, adding
confusion for caregivers and
individuals as well as
researchers and
professionals.

 An individual may find

texture modified diets change
facility to facility.

The International Dysphagia Diet Standardisation Initiative. (2016)

What is IDDSI and who is using it?
 IDDSI aims to standardize terminology and definitions
associated with texture modification of foods and
liquids.

 IDDSI framework is translated into 16 different

languages.

 IDDSI is currently being used in Australia and Canada.

The International Dysphagia Diet Standardisation Initiative. (2016)

IDDSI implementation
 This study was conducted at a hospital in Germany.

 To evaluate how to most effectively implement IDDSI.

 Education was given during this study in a top-down and

bottom-up approach led by two speech pathologists.

Lam et al. (2017)

Findings
The outcomes of the study found:

1. organizational support to facilitate change.

2. environmental factors such as adding stickers to

patient cardex or meal trays aided in transition.

3. small interactive group-discussions and interactive

engagement of individuals improves acceptance.

4. implementation in small steps were important in the

success of implementing the IDDSI framework.

Lam et al. (2017)

IDDSI recommendations
 Develop a plan to introduce IDDSI.

 Communicate plan & consult all stakeholders.

 Review Revise Monitor.

 Determine launch date and prepare all stakeholders.

The International Dysphagia Diet Standardisation Initiative. (2016)

 Framework Layout
 IDDSI uses an international
framework consisting of eight
levels (0 to 7).

 Color codes, numbers and text

labels.

The International Dysphagia Diet Standardisation Initiative. (2016)

Goals during development
 To be translated into a number of languages

 Culturally sensitive

 Measurable

 Applicable to all age groups

The International Dysphagia Diet Standardisation Initiative. (2016)

Methods of testing
 Testing methods were made to be inexpensive and
usable by everyone no matter where they are. Testing
methods include:

1. IDDSI flow test (for liquids)

2. Fork drip test (level 3 & 4)

3. Spoon tilt test (adhesiveness & cohesiveness)

4. Fork test for texture assessment (level 5 & 6)

5. Transitional food texture assessment (level 5, 6, & 7)

 Demonstration for flow test
 Method- two 10ml syringes with a luer tip.

 IDDSI framework uses the Bencton and Dickinsons syringe to

set levels for the IDDSI framework. Oliveira (2018).

10 9 8 7 6 5 4 3 2 1

 Water
10 9 8 7 6 5 4 3 2 1

 Ensure

The International Dysphagia Diet Standardisation Initiative. (2016)

 Types of syringes
 Oliveira (2018) found that two syringes Bencton and
Dickinsons (BD), and Saldanha Rodrigues (SR) had different
flow rates.

 Reproducible evaluation methods are a necessity in providing

consistency within hospitals globally during treatment of
patients with dysphagia.
Fork drip test IDDSI level 3 Moderately thick

 Evaluate flow of food item

through the tines of the fork

 (Moderately thick 3) Looking IDDSI level 4 Extremely thick

for dollops through the tines
of the fork

 (Extremely thick 4) sits in

mound on fork, with no
dollop

The International Dysphagia Diet Standardisation Initiative. (2016)

Assessing food particle size
 Minced and moist level 5-
use the measure of slots
in between the tines of a
fork 4mm

 4mm is the average size

of particle size swallowed
by adults.

 Soft and bite sized level

6- use width of standard
fork 15mm or 1.5cm.

The International Dysphagia Diet Standardisation Initiative. (2016)

Fork pressure test
 Press fork on food until thumb
nail blanch to white.

 This pressure represents force

exerted by tongue.

 Observe behavior of food for

reformation.

The International Dysphagia Diet Standardisation Initiative. (2016)

Clinical use of IDDSI framework
 A modified texture diet order is comprised of 2 levels
from the framework:

 The food level and then the drink level

 Level 3 and level 4 foods and drinks are equivalent

The International Dysphagia Diet Standardisation Initiative. (2016)

IDDSI Functional Diet Scale Study
 Steele et al. (2018)
 170 participants
 From 29 different countries
 80% speech pathologist,10%
dietitians, and 7% physicians
 Hypothesis- Could the IDDSI
framework and the functional
diet scale help analyze the
degree of diet texture
restriction recommended.
Sensory characteristics
 Liquid analyzed in each level of the IDDSI framework.

 Methods: 53 panelists tested food for sensory

characteristics

 Hypothesis: the amount of thickener needed to reach an

IDDSI level would result in graininess and slipperiness
across different gravity flow levels.

 Findings: Ratings of taste and flavor attributes

decreased with increasing IDDSI level. Different
thickeners have different perceived texture.

Ong et al. (2017)

Transition of NDDIII to IDDSI Level 6

 Objective:

To investigate if the current NDDIII diet at Patton

State Hospital could be transitioned into the IDDSI
framework soft and bite-sized level 6 category.
NDDIII guidelines
 Foods should be moist and
in bite-sized pieces.

 NDDIII lists food groups

and what foods are
allowed and not allowed.

https://patienteducation.osumc.edu/documents/dys-3.pdf
IDDSI level 6 description
 Can be eaten with a fork, spoon or chopsticks.

 Can be broken/mashed down with pressure from fork.

 A knife is not required.

 Chewing is required.

 Soft, tender, and moist throughout but with no separate

thin liquid.

 Bite sized pieces 1.5cm or 15mm and smaller.

The International Dysphagia Diet Standardisation Initiative. (2016)

 Methods
 Computrition was used to evaluate if current recipes for
NDDIII fall within the guidelines of IDDSI level 6.

 138 different recipes were evaluated and separated into

eight groups on an excel spread sheet.

 Meat, Fish, Casserole/stew/curry, fruit, vegetables, cereal,

bread, and rice.
Tracking recipes
Meat
 Needs to be cooked, tender, no more than 15mm or 1.5cm pieces.

 If texture cannot meet these requirements serve minced and moist.

 Total recipes evaluated -40

 Total recipes not meeting criteria-4

 Chopped turkey sausage-new-Needs to be specified cuts of 1.5 cm

 Asian almond chicken MS no nuts-- Carrots need specific cuts of 1.5cm or

smaller

 MS turkey salad blend- the vegetables are raw

 beef lasagna- Needs to be specified cuts of 1.5 cm

The International Dysphagia Diet Standardisation Initiative. (2016)

Fish
 Fish must be soft enough for a fork to cut.

 Pieces must be 15mm or 1.5cm.

 All recipes meet criteria.

 Total recipes evaluated-4

 Total recipes not meeting criteria-0

The International Dysphagia Diet Standardisation Initiative. (2016)

Casserole/stew/curry
 Liquid portion must be thick.
 If containing meat, fish or vegetables pieces must be soft and
cut to 15mm or 1.5cm pieces.
 Total recipes evaluated- 15
 Total recipes not meeting criteria- 4
 Black bean soup-Thicken liquid
 Chicken noodle soup-Thicken liquid
 Chili con carne CND-Specify cut size to 1.5cm
 Hacienda bean soup- Thicken liquid

The International Dysphagia Diet Standardisation Initiative. (2016)

Fruit
Recipes not meeting criteria
 Served mashed.
• Diced peaches
• Dice pears
 No fibrous parts present.
• Mandarin oranges
• Banana
 Excess juice is drained.
• Jalapeno slices
• Chopped cinnamon sl
 Assess individual fruit for high water
apples
content (watermelon). • Glazed strawberries
 Total evaluated recipes-15 Recipes not passing fork
pressure test
 Total recipes not meeting criteria-10 • Mandarin orange gelatin
• Lime gelatin
 Recommendation-Fruits must be • Jelly
mashed
The International Dysphagia Diet Standardisation Initiative. (2016)
Vegetables Recipes not meeting criteria

• Potato pancake
• MS green beans
 Steamed or boiled. • Green beans (CND)
• Cauliflower
 15mm or 1.5cm pieces. • Shredded lettuce
• Broccoli cuts
 Total recipes evaluated- 35 • Brussel sprouts
• O’Brien potatoes
 Total recipes not meeting • Potato salad (COMM)
criteria- 16 • Tater tots
• CHPD parslied potatoes
 Recommendation- vegetables • MS no nuts/soak raisin
nut bar
can’t be raw, recipe needs • MS black beans
specified cuts of 1.5cm • MS carrots
• Zuchini

The International Dysphagia Diet Standardisation Initiative. (2016)

Cereal
 Smooth with soft tender lumps.

 Pieces must be 15mm or 1.5cm.

 Texture is fully softened.

 Excess fluid drained.

 Total recipes evaluated-4

 Total recipes not meeting criteria-0

The International Dysphagia Diet Standardisation Initiative. (2016)

Bread
 Pre-gelled “soaked” breads

 No dry bread unless assessed as suitable by dysphagia

specialist.

 If dry bread is suitable to serve it must be 15mm or

1.5cm pieces.

 Total recipes evaluated-19

 Total recipes not meeting criteria-1

 Doughnut-Bread is too sticky

The International Dysphagia Diet Standardisation Initiative. (2016)

Rice
 Not particulate/grainy, sticky or glutinous.

 All DSH-Patton recipes for rice work.

 Total recipes evaluated-8

 Total recipes not meeting criteria-0

The International Dysphagia Diet Standardisation Initiative. (2016)

Results

 There was a total of 138 recipes or items evaluated.

 35 of those items or recipes currently do not meet the

criteria for transition to IDDSI framework.
Common reasons criteria was not met

 Cut size

 Liquid thickness of soups

 Fruit texture

 Raw vegetables

 Food that can’t be cut by a fork

 Food keeping form after the fork test

Recommendations for all recipes
 References

 The International Dysphagia Diet Standardisation Initiative. (2016). Retrieved from

https://iddsi.org/about-us/

 Steele, M. C., Namasivayam-Macdonald, M. A., Guida, T. B., Cichero, A. J., Duivestein, J.,
Hanson, B., Lam, P., Riquelme, F. (2018). Creation and Initial Validation of the
International Dysphagia Diet Standardisation Initiative Diet Scale. Archives of Physical
Medicine and Rehabilitation, 99, 934-44. doi:10.1016/j.apmr.2018.01.012

 Ong, J., Steele, M. C., Duizer, M. L. (2018). Sensory characteristics of liquids thickened
with commercial thickenerst to levels specified in the International Dysphagia
Standardization Initiative (IDDSI) framework. Food Hydrocolloid. 79, 208-217.
doi:10.1016/j.foodhyd.2017.12.035.

 Oliveira, L. (2018). Influence of the syringe model on the results of International

Dysphagia Diet Standardisation initiative flow test. Revista CEFAC. 20, 3. doi:
10.1590/1982-021620182031818

 Lam, P., Stanschus, S., Zaman, R., Cichero, A. J. (2017). The International Dysphagia Diet
Standardisation Initiative (IDDSI) framework: the Kempen pilot. Neuroscience Nursing. 13.
2. doi: 10.12968/bjnn.2017.13.Sup2.S18

 2018, June 8. Soft and bite sized diet.

https://patienteducation.osumc.edu/documents/dys-3.pdf

 Gywali, P. C. 2010 Novemeber. Dysphagia. http://patients.gi.org/topics/dysphagia/