IDDSI – The International Dysphagia Diet Standardization Initiative Angela Parcaro-Tucker, MA, CCC-SLP, LSVT®

Legal Stuff I am not compensated by IDDSI or any other entity to provide recommendations specific to certain products or methods of testing The following documents have been developed by IDDSI and are for public use. You do not need to seek permission from IDDSI to share these documents and images as long as you cite the CreativeCommons BY-SA 4.0 license as follows: The International Dysphagia Diet Standardisation Initiative 2016 @http://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. THIS SESSION CAN PROVIDE ONLY A SUMMARY OF IDDSI AND CHANGES! PLEASE BE AWARE THAT YOU AS A CLINICIAN ARE SOLELY RESPONSIBLE FOR FULLY EDUCATING YOURSELF ON IDDSI AND THE CHANGES THAT WILL TAKE PLACE. This speaker has express permission from IDDSI to show IDDSI photos individually.

History/Purpose of IDDSI IDDSI Committee formed in 2013 Purpose is to standardize language related to diet levels as well as to standardize methods of testing. ASHA and the Academy of Nutrition and Dietetics (AND) support the implementation of IDDSI as a standard of care across all settings, with adults and children alike.

IDDSI Implementation With both ASHA and AND promoting the adoption of IDDSI, it is a standard of care for all facilities to adopt IDDSI. In medical malpractice cases, Failure to exercise the proper standard of care is considered negligence, and is actionable. Colleges/Universities will need to change their programs to include IDDSI Education of all parties in each facility will be required Families will need to be educated fully, and such education must be documented

Terminology Current: IDDSI: Liquids: Thin, “Regular,” Syrup, Half-Nectar, Nectar, Honey, Spoon-thick, Pudding thick. “Full Liquid” and “Wired Jaw Diet” are somewhere between Liquid and Solid. Solids: “Regular,” General, Soft, Mechanical Soft, Mechanically Altered, Pureed, Blended IDDSI: Liquids: Thin, Slightly Thick, Mildly Thick, Moderately Thick, Extremely Thick Solids: Liquidized, Pureed, Minced and Moist, Soft and Bite- Sized, Regular

Framework

Matching Up What We Know With What Will Be Regular, General Soft Mechanically Altered, Mech Soft Pureed, Blended Blended, Full Liquid*, Wired Jaw Honey Thick Nectar Thick, Syrup Thick Half-Nectar * “Full Liquid” and “Wired Jaw” recommendations do not necessarily exclude thinner liquids Thin, Regular

Or, to say it another way…

Manufacturers are already getting on board

Manufacturers are already getting on board

Big Changes are Coming! Before we go ANY further, I’ll say it again: I am instructing you to visit http://IDDSI.org in order to FULLY educate yourself on all of the changes that are going to take place! This session can only provide a SUMMARY of the changes! Let’s quickly explore the IDDSI.org resources! http://iddsi.org/ http://iddsi.org/contact-us/ http://iddsi.org/framework/drink-testing-methods/ http://iddsi.org/framework/food-testing-methods/

Additional Valuable Input As stated, The Academy of Nutrition and Dietetics (AND) as well as ASHA have committed to the IDDSI transition. AND produced some guidelines based on the IDDSI framework and they are very specific. Team closely with your dietician(s)! The following descriptions of changes are excerpts taken from AND publications as they also convert to IDDSI. This is not a comprehensive list. Please get with your dieticians and team, so that you will be on the same page.

What Are the Biggest Changes? Soft and Bite-sized (6, BLUE) 15mm Size Limit Grains: Breads are pregelled and soaked. Biscuits and cakes must be moist and no pieces larger than 15mm Cold cereal – lumps no larger than 15mm, softened, drained, served without excess liquid Pasta – no pieces larger than 15mm, sauce does not separate from pasta Rice and rice dishes as tolerated

What Are the Biggest Changes? Soft and Bite-sized (6, BLUE) Proteins (no larger than 15mm pieces): Cooked, moistened meat pieces. Includes red meat, poultry, seafood and fish. Eggs, egg substitutes. Casseroles Legumes/peas with soft shells/skins. Must meet softness standard (covered later)

What Are the Biggest Changes? Soft and Bite-sized (6, BLUE) Vegetables and Fruits (no larger than 15mm pieces): Canned or frozen tender vegetables or starchy vegetables It does not appear that fresh leafy vegetables (lettuce/salad) are included in this diet level Canned and cooked fruits, drained of excess juices, served mashed

What Are the Biggest Changes? Soft and Bite-sized (6, BLUE) ITEMS ON THE “NOT RECOMMENDED” LIST Dry bread, toast, crackers, biscuits, muffins, pancakes, waffles, bread dressing (remember, “pregelled”) Grainy, sticky, or glutinous rice Meat/poultry/fish with skin or bones Fried eggs Chunky nut seed butters, unless used in a tolerated recipe Whole nuts and seeds

What Are the Biggest Changes? Minced and Moist (5, ORANGE) 4mm Size Limit Grains Hot cereals with lumps no larger than 4mm Pregelled, soaked bread Pasta no larger than 4mm, sauce does not separate from pasta Non-glutinous short or long grain rice that does not separate into individual grains, OR served in a thick sauce.

What Are the Biggest Changes? Minced and Moist (5, ORANGE) 4mm Size Limit Proteins Same as with Soft, but with a 4mm size limit Dairy 4mm size limit – including cottage cheese Vegetables/Fruits Gravies and Sauces Must be thick and non-pourable

What Are the Biggest Changes? Minced and Moist (5, ORANGE) 4mm Size Limit ITEMS ON THE “NOT RECOMMENDED” LIST Anything on the “NOT RECOMMENDED” list for the Soft (6, BLUE) diet. Nothing larger than 4mm No breads or grains with crumbly bits Meat/poultry/fish with skin or bones or undrained liquids Specific exclusions: Raw vegetables, including lettuce, Stir- fried or fried vegetables, apples, pears, stringy fruits such as pineapple/mango. Fruits with high water content, such as watermelon. Fruits with skins, such as grapes. Dried fruit or fruit leather.

What Are the Biggest Changes? Pureed (4,GREEN) NO LUMPS Grains Pureed breads, rolls, pastries, pancakes, French toast, muffins, donuts, bread dressing Pregelled, soaked bread, cakes, cookies Pureed, moist pasta, rice, potatoes. Liquids/sauces do not separate from foods

What Are the Biggest Changes? Pureed (4,GREEN) NO LUMPS Proteins Pureed, moistened meats and meat alternatives Pureed eggs and egg substitutes Pureed, smooth casseroles Pureed, moistened legumes

What Are the Biggest Changes? Pureed (4,GREEN) NO LUMPS ITEMS ON THE “NOT RECOMMENDED” LIST Anything on the “NOT RECOMMENDED” list for the Minced and Moist (5, ORANGE) diet. Nothing larger than 4mm No breads or grains with crumbly bits Meat/poultry/fish with skin or bones or undrained liquids

“Drinkable” Liquids Testing method: Use a 10 mL luer slip tip syringe. It must measure 61.5 mm from the 10 mark down to the point at which the syringe narrows for the slip tip. Thin: No residue remains after 10 seconds when 10 mL liquid is released. Slightly Thick: https://www.youtube.com/watch?v=BhfJWu1ybbs Mildly Thick: https://www.youtube.com/watch?v=XBqi_i0LLHw Moderately Thick: https://youtu.be/SiFwiGgIPHA

Another Liquidised/Moderately Thick Testing Method: Fork Drip Test Material drips slowly or in dollops/strands through the tines/prongs of a fork

Fork Drip Test (levels 3 and 4) Spoon Tilt Test (levels 4 and 5) Spoon Tilt Test is used for Level 4 and 5 liquids/diets. Cohesive enough to hold its shape on the spoon Should not be “sticky” and the full spoonful should slide off the spoon when tilted/turned sideways, gently shaken A scooped mound may spread or slump very slightly on the plate Used for Level 3 and 4. Sits in a mound/pile above the fork. A small amount may flow through and form a tail below the fork. Does NOT drip, dollop, or flow continuously through the prongs

Food Testing Methods Level 5 Minced and Moist https://youtu.be/9tMowfeuzVY Includes the following tests: Fork Pressure Test Fork Drip Test Spoon Tilt Test Chopstick Test Finger Test Minced and Moist Sandwich: https://www.youtube.com/watch?v=W7bOufqmz18

Food Testing Methods Level 6 Soft and Bite-Sized Fork Pressure Test: Pressure from a fork held on its side can by used to “cut” or break into smaller pieces. When a sample the size of a thumbnail (1.5 x 1.5 cm) is pressed with the base of a fork to a pressure where the thumbnail blanches to white, the sample squashes and changes shape, and does not return to its original shape when the fork is removed. Spoon Pressure Test: Pressure from a spoon held on its side can by used to “cut” or break into smaller pieces. When a sample the size of a thumbnail (1.5 x 1.5 cm) is pressed with the bowl of a spoon to a pressure where the thumbnail blanches to white, the sample squashes and changes shape, and does not return to its original shape when the fork is removed. Chopstick Test: Chopsticks can be used to break this texture into smaller pieces. Finger Test: Use a sample the size of a thumbnail (1.5 x 1.5 cm). It is possible to squash a sample of this texture using finger pressure such that the thumb and index fingernails blanch to white. The sample will not return to its initial shape once pressure is released.

Thumbnail blanches to white Food Testing Methods Level 6: Soft and Bite-Sized Thumbnail blanches to white

Food Testing Methods Level 6: Soft and Bite-Sized Sample squashes and does not return to its original shape when pressure is released.

Transitional Foods Definition: Food that starts as one texture (e.g., firm solid) and changes into another texture specifically when moisture (e.g., water or saliva) is applied or when a change in temperature occurs. Biting is not required Minimal chewing is required Tongue can be used to break these foods once altered by temperature or with the addition of moisture/saliva

Food Testing Methods for Transitional Foods Fork Pressure Test: After moisture or temperature has been applied, the sample can be easily deformed and does not recover its shape when force is lifted. pressure from a fork held on its side can by used to “cut” or break into smaller pieces. Use a sample the size of a thumbnail (1.5 x 1.5 cm), place 1 mL of water on the sample and wait 1 minute. Apply fork pressure at 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. Or it has melted significantly and no longer looks like its original state (e.g., ice chips). Spoon Pressure Test: As above, using the bowl of a spoon in place of a fork. Chopstick Test: Use a sample the size of a thumbnail (1.5 x 1.5 cm), place 1 mL of water on the sample and wait 1 minute. The sample should be easily broken apart with chopsticks with minimal pressure. Finger Test: Use a sample the size of a thumbnail (1.5 x 1.5 cm), place 1 mL of water on the sample and wait 1 minute. The sample will break apart completely by rubbing the sample between the thumb and index finger. The sample will not return to its initial shape.

Examples of Transitional Foods This is not an exhaustive list! Ice chips Ice cream/sherbet Japanese Dysphagia Training Jelly sliced 1mm x 15mm Wafers (including religious communion wafers) Waffle cones used to hold ice cream Some biscuits/cookies/crackers Potato chips – only the mashed kind, like Pringles Shortbread Prawn crisps

Commercially available Transitional Foods Thumbnail blanched to white Veggie Stix Cheeto Puffs Rice Puffs Baby Mum Mums Gerber Graduate Puffs Remember, apply 1 mL of water to sample and wait 1 minute before applying pressure Sample squashes and fractures, and does not return to its original shape when pressure is released.

Another Great Resource on IDDSI.org Please be sure to check out IDDSI.org for other examples of specific foods, and how those foods fit in on various modified diets. http://iddsi.org/Documents/IDDSIFramework- CompleteFramework.pdf

Implementation Guide Clinicians and Health Care Providers http://ftp.iddsi.org/Documents/Clinicians%20and%20Health%20Care%20Providers_ IDDSI%20Implementation%20Guide_Final_3April2018.pdf Key tasks include: 1. Becoming familiar with the IDDSI: Website and resources 2. Forming IDDSI Implementation teams: Suggestions on cross sector stakeholder consultations and teams 3. Determining IDDSI implementation tasks and personalising your own ‘IDDSI Implementation Calendar’ 4. ‘Spread the word’: Education about IDDSI for key stakeholders 5. ‘Check out the food and drinks’: Map existing products to determine their IDDSI label and level using IDDSI audit tools; developing menu items and recipes etc. 6. Clinical communication: including review of clinical assessment tools, chart entries, and patient education material The tasks run at the same time so it is important to look down the whole list. The Implementation guide is a suggestion! Please feel free to customize the tasks and timeframes to suit your own needs. Colours and shading have been used on the implementation guide to help make it easier to identify different tasks and timeframes; the colours have no other meaning or purpose. IDDSI will be updating resources regularly so please be sure to register to receive our e-bites (newsletters). Visit : www.IDDSI.org

Implementation Guide Food Service and Catering There are five key tasks with subheadings below each. The key tasks include: 1. Becoming familiar with the IDDSI: Website and resources 2. Forming IDDSI Implementation teams: Suggestions on cross sector stakeholder consultations and teams 3. Determining IDDSI implementation tasks and personalising your own ‘IDDSI Implementation Calendar’ 4. ‘Spread the word’: Education about IDDSI for key stakeholders 5. ‘Check out the food and drinks’: Map existing products to determine their IDDSI label and level using IDDSI audit tools; developing menu items and recipes etc. The tasks run at the same time so it is important to look down the whole list. The Implementation guide is a suggestion! Please feel free to customize the tasks and timeframes to suit your own needs. Colours and shading have been used on the implementation guide to help make it easier to identify different tasks and timeframes; the colours have no other meaning or purpose.

Implementation Guide Industry There are six key tasks with subheadings below each. The key tasks include: 1. Becoming familiar with the IDDSI: Website and resources 2. Forming IDDSI Implementation teams: Suggestions on cross sector stakeholder consultations and teams 3. Determining IDDSI implementation tasks and personalising your own ‘IDDSI Implementation Calendar’ 4. ‘Spread the word’: Education about IDDSI for key stakeholders 5. ‘Check out the food and drinks’: Map existing products to determine their IDDSI label and level using IDDSI audit tools; developing menu items and recipes etc. 6. Industry labelling considerations: including production schedule and stock management The tasks run at the same time so it is important to look down the whole list. The Implementation guide is a suggestion! Please feel free to customize the tasks and timeframes to suit your own needs. Colours and shading have been used on the implementation guide to help make it easier to identify different tasks and timeframes; the colours have no other meaning or purpose.

In Closing… Big changes are imminent! You will want to become VERY familiar with the IDDSI.org website Build a team! At the very least, your team should have speech pathologists, dieticians, and possibly IT, if you have an electronic medical record (EMR). If you are a large facility, it might be good to include a member of leadership, as well as someone from Quality and Informatics. Start testing the items that are already on your facility’s menu to see where they fall on the IDDSI Framework. Start telling people at your facility that changes are coming. Nothing is worse than a surprise change overnight!

QUESTIONS???