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International Dysphagia Diet Standardization Initiative(IDDSI)

Background• Dysphagia affects an estimated 8% of the general population, and if

not managed properly, may cause serious harm, even death, to a patient.

• Looking at Methodist Health System, about 7% of our patients are on a texture modified diet.

• Dysphagia is difficulty swallowing in one of the 3 stages of swallowing. Oral stage problems with lips and tongue. Pharyngeal stage problems with pharynx, vocal folds, hyolaryngeal excursion. Esophageal can affect the swallow in the other stages (reflux, webs, hiatal hernias, constrictions).

Variances Within Our Health System• Nov 2018 Mech Altered diet used instead of Low Fiber

• Nov 2018 patient on Soft diet had a comment for ground meat, an item that wasn’t ground was sent leading to a choking incident

• Dec 2018 Soft diet used instead of Low Fiber

• Feb 2019 patient served regular green beans on Pureed diet

• Feb 2019 patient on Nectar Thick diet ordered, thickener packets were sent with beverages, but no one thickened & patient aspirated

• March 2019 overnight menu for a patient on Mech Altered diet had many items ordered which were not appropriate

• June 2019 patient on Mech Altered diet choked on veggies

• Aug 2019 patient on Pureed diet served salmon which was not at correct consistency (minced/ground)

The root cause for some of these is confusion regarding the correct diet order

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What is IDDSI?The International Dysphagia Diet Standardization Initiative (IDDSI) is a new global initiative to standardize 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. The IDDSI framework consists of 8 levels (0-7). Levels are identified by numbers, text labels and color codes to improve safety

and identification.

-IDDSI.org

Together in 2017, the Academy of Nutrition and Dietetics and American Speech-Language-Hearing Association announced their support of IDDSI.

-ASHA.org and Eatright.org

Safety of our patients is important & safety is the reason IDDSI was developed.

• How IDDSI came to be:

The modification of food texture and liquid thickness is a big part of dysphagia management. Food and liquids are modified all over the world, but there is no consistency in names, number of diet levels and characteristics of the diet.

An American task force identified 40 different names to label solid food. ** There are also variable liquid levels.

IDDSI was initiated in October of 2012.

ASHA and the Academy of Nutrition and Dietetics announced their support in 2017.

IDDSI Framework Foods and liquids are connected at level 4 (green) and level 3 (yellow). The reason for this is because the characteristics of level 4 pureed foods is very similar to that of level 4 extremely thick liquids. In addition, level 3 liquidized foods have similar characteristics to that of Level 3 moderately thick liquids.

The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/Attribution is NOT PERMITTED for derivative works incorporating any alterations to the IDDSI Framework that extend beyond language translation. Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.

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This is equivalent to our current General diet.

• Description:• Normal, everyday foods of various textures that are developmentally and age appropriate

• Foods may be a variety of textures including hard, tough, chewy, fibrous, dry, crispy, crunchy or soft and may be a dual consistency (e.g. vegetable soup, cereal with milk)

• There is no particle size restriction

• Way in which these foods are eaten:• Any method may be used to eat these foods

• Patient should be able to:• Bite hard or soft foods and chew them & be able to remove bone or gristle that cannot be

swallowed safely from the mouth

• Example menu items:• Chicken noodle soup, hamburger, raw vegetables, raw fruit, bread

This is similar to our current Soft Foods diet.

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• Description:• Normal, everyday foods of soft/tender textures that are developmentally and age

appropriate• Does not include: hard, tough, chewy, fibrous, stringy, crunchy, or crumbly bits, seeds, fibrous parts of fruit,

husks or bones

• May be a dual consistency if patient is also safe for Level 0 Thin Liquids

• There is no particle size restriction

• Way in which these foods are eaten:• Any method may be used to eat these foods

• Patient should be able to:• Bite soft foods and chew and orally process food, does not necessarily require teeth

• Not suitable for people with dysphagia, the foods may be a choking hazard, consult speech as needed

• Example menu items:• Tender meats, casseroles, cooked vegetables, soft fruit

This is similar to our current Level III Soft Foods diet.

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• Description:• Soft, tender and moist throughout with no dual consistency items• ‘Bite-sized’ pieces to minimize choking risk

• Pediatric, 8mm pieces (no larger than)

• Adults, 15 mm = 1.5 cm pieces (no larger than)• Use the full length with the prongs of a fork (15mm) to determine whether pieces are bite-sized

• Way in which these foods are eaten:• May be eaten with a fork or spoon, can be mashed/broken down with pressure from fork or

spoon• A knife is not required to cut this food

• Patient should be able to:• Chew before swallowing (biting is not required)

• Tongue force and control is required to move the food and keep it within the mouth for chewing and oral processing

• Example menu items:• Yogurt with fruit chunks, chopped meats, chopped/cooked vegetables

This is similar to our current Mechanical Altered/Mechanical Soft diet.

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• Description:• Soft and moist with no dual consistency items• Can be scooped and shaped (e.g. into a ball shape) on a plate• Small lumps visible within the food & should be easy to squash with tongue

• Pediatric, equal to or less than 2 mm width and no longer than 8mm in length

• Adult, equal to or less than 4mm width and no longer than 15mm in length• Use slot between fork prongs (4mm) to determine whether minced pieces are the correct size

• Way in which these foods are eaten:• May be eaten with a fork or spoon

• Patient should be able to:• Chew minimally (biting is not required)

• Tongue force alone can be used to separate the soft small particles & move the bolus

• Example menu items:• Minced meat, minced vegetables, minced or mashed fruit

This is similar to our current Pureed diet.

We do not currently have a thickened liquid diet order that is similar to extremely thick.

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• Description:• No lumps, not sticky, liquid must not separate from solid

• Retains its shape• Falls off spoon in a single spoonful when tilted and continues to hold shape on a plate

• Shows some very slow movement under gravity but cannot be poured

• Way in which these foods/beverages are eaten:• Usually eaten with a spoon (a fork is possible)

• Cannot be drunk from a cup because it does not flow easily

• Patient should be able to:• Swallow (no biting or chewing is required)

• Example menu items:• Greek yogurt, pudding, pureed food items

This is similar to our current Honey Thickened Liquids.

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• Description:• Smooth texture with no ‘bits’ (lumps, fibers, bits of shell or skin, husk,

particles of gristle or bone)

• Does not retain its shape

• Way in which these foods/beverages are eaten:• May be drunk from a cup or eaten with a spoon

• Cannot be eaten with a fork because it drips slowly in dollops through the prongs

• Patient should be able to:• Swallow (no oral processing or chewing required)

• Some tongue propulsion effort

• Example menu items:• A thin liquid mixed with a yellow packet of SimplyThick

This is similar to our current Nectar Thickened Liquids.

• Description:• Sippable, flows off a spoon, pours quickly from a spoon (but slower than thin

drinks)

• Way in which these foods are eaten:• Drank from a cup

• Patient should be able to:• Swallow

• May be suitable if tongue control is slightly reduced

• Example menu items:• A thin liquid mixed with a pink packet of SimplyThick

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We do not currently have a slightly thickened liquid diet.

• Description:• Requires a little more effort to drink than thin liquids

• Thicker than water

• Flows through a syringe or nipple

• Way in which these foods are eaten:• Drank from a cup or bottle

• Reason for use:• Used in adult populations where thin drinks flow too fast to be controlled

safely. Used in the pediatric population as a thickened drink that reduces speed of flow yet is still able to flow through an infant nipple.

• Example menu items:• Enfamil A.R. (Anti-Regurgitation) infant formula, Ensure Enlive

This is equivalent to our current thin liquid diet when no beverage modifier is ordered.

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• Description:• Flows like water (fast flow)

• Way in which these foods are eaten:• Can drink through any type of nipple, cup or straw as appropriate for age and skills

• Patient should be able to:• Safely manage liquids of all types

• Example menu items:• Juice, milk, coffee

• This is the default beverage level everyone is on, unless otherwise determined by a speech therapist

Transitional Foods• Description:

• Foods that start at one texture, but change into another texture when moisture like water or saliva is added or when a change in temperature occurs (e.g. when food is heated)

• Speech may order these foods as appropriate• May be used in conjunction with Level 5 Minced & Moist, Level 6 Soft &

Bite-Sized, Level 7 Easy to Chew

• Example menu items:• Shortbread cookies, saltine crackers, graham crackers, ice cream

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Diet Order Changes

• Below is a list of diets in Cerner that will be affected by this change:

• The clear liquid & blenderized (full) liquid diet will not be affected by this change.

Current Diet Order New Diet Order

General Regular

Soft Foods Easy to Chew 7

Level III Soft Foods Soft and Bite-Sized 6

Mechanically Altered (Mechanical Soft) Minced and Moist 5

Pureed Pureed 4

Beverage Modifier Changes• Below is a list of beverage modifiers in Cerner that will be affected by this change:

• Thickened liquids must be selected within the diet order as a beverage modifier so the computer program room service uses gets that part of the order.• Comments are not seen by food service. The comment section should not be

used to indicate liquids needing to be thickened.

Current Beverage Modifier New Beverage Modifier

- Extremely Thick 4

Honey Thickened Moderately Thick 3

Nectar Thickened Mildly Thick 2

- Slightly Thick 1

Thin Thin 0

Dysphagia Menus

• All foods on the dysphagia and soft menus were tested and categorized using IDDSI audits.

• There are items that were allowed on a previous dysphagia diet level that did not pass the audit and were classified under a different level.

• Menus have been updated. Previously all three levels of the dysphagia diets were listed on one menu. Going forward:• Pureed and Minced & Moist will be on one menu

• Soft & Bite-Sized and Easy to Chew will be on one menu

• Low Fiber will be a separate menu

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Low Fiber• Low Fiber is not part of the IDDSI framework.

• In order to avoid confusion with diet names a distinction between soft and low fiber is needed.

• The Soft diet order will no longer be an option, choose Low Fiber.

Thickening Liquids• Some beverages, including nutrition supplements, may not be able to be

thickened properly.

• There are a variety of factors which may affect the way the beverage thickens (or doesn’t):• temperature

• length of time it takes to thicken

• may be slightly thick, so when a packet of thickener is added it becomes too thick

• 1 packet per 4 oz of liquid. Pink=mildly thick (nectar) and Yellow= moderately thick (honey)

• Some juices, milk, pop & soups may need to sit a while (e.g. 15 minutes) after adding thickener to get to the correct consistency

• The manufacturer recommends stirring SimplyThick in supplement for 1 full minute (vs. 20 seconds suggested on packet).• Ensure Clear & Boost Breeze can not be thickened.

Meal and Snack Selections Policy

• When ordering meals speech therapy or the provider will be the only disciplines allowed to over-ride or allow a restricted item for the following diets:• Easy to Chew 7

• Soft & Bite Sized 6

• Minced & Moist 5

• Pureed 4

• Thickened Liquids (Levels 1-4)

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When to Request a Consult for Speech TherapyA speech therapist will help determine the appropriate level of food and liquid.

• Unsafe mealtime behaviors: • not chewing very well

• putting too much food into the mouth

• eating too fast or swallowing large mouthfuls of food

• talking while eating

• inability to self-monitor chewing ability

• inability to sit upright when eating

• Coughing or throat clearing with food/beverage intake.

• Drooling or pocketing with food intake/pills.

• Change in vocal quality with food/beverage intake (e.g. wet, gurgly).

• Temperatures/worsened lung sounds following meals.

• When advice is needed for patient requests and requirements for supervision.

Resources• Patient handouts are available from the Nutrition Care Manual:

• Intranet> Clinical Applications> Nutrition Care Manual> Client Ed/Diets

• For more information visit IDDSI.org

Article: The Need for International Terminology and Definitions for Texture-Modified Foods and Thickened Liquids Used in Dysphagia Management: Foundations of Global Initiative

• Cichero, J.A.Y., Steele, C., Duivestein, J. et al. Curr Phys Med Rehabil Rep (2013) 1: 280.

**Texture-modified foods and thickened fluids as used for individuals withdysphagia, Atherton M, Bellis-Smith N, Cichero JAY, Suter, M. Nutr Diet. 2007;64:53-76.

Post Test Questions• Your patient does not have teeth or dentures, has no difficulty swallowing, and is not displaying unsafe mealtime behaviors. Which diet order would be most appropriate?

• Minced & Moist 5

• Easy to Chew 7

• Soft & Bite-Sized 6

• Regular

• Your patient is able to bite hard or soft foods and chew them safely. Which diet order would you expect them to have?• Minced & Moist 5

• Easy to Chew 7

• Soft & Bite-Sized 6

• Regular

• Your patient is on a Soft & Bite-Sized diet. If you are questioning whether a food particle is bite-sized, what can be used to measure it?• The width of a finger

• The width of a spoon

• The width of a fork

• The width of a knife

• Who can over-ride or allow a restricted item on an easy to chew or dysphagia diet?• Speech Therapy

• Nurse

• Provider

• A & C only

• B & C only

• A, B, & C

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Post Test Questions Cont’d• Your patient has Level 2 Mildly Thickened Liquids ordered. Once you’ve added thickener to the beverage what characteristics should the beverage have?

• Sippable & able to drink from a cup

• When scooped on a spoon, it will flow off

• Pours quickly from a spoon tilted sideways, but not as quick as a liquid that hasn’t been thickened

• All of the above

• You have a patient recovering from gastrointestinal surgery and does not have any difficulty biting & chewing. Once their diet is advanced what would you expect it to be?

• Low Fiber

• Minced & Moist 5

• Soft & Bite-Sized 6

• Easy to Chew 7

• What patient behaviors would warrant a consult for Speech Therapy?• Coughing or throat clearing after eating a food or drinking a beverage

• Inability to sit upright when eating

• Not chewing their food well

• All of the above

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