The New Dysphagia Diet: Understanding & Getting Prepared for IDDSI Guidelines Developed by Denise Kelly, MEd, RDN Presented by Mary Piciocco, MA, RDN, FAND, CSG

Overview of Presentation Who is IDDSI? Why do we need IDDSI/a standardized system History of Dysphagia Diets The new IDDSI Framework Thickened liquids: NDD vs IDDSI, how to test Texture Modified Foods- descriptor change, new testing Resources & How to get started

Standardize and Simplify Training What/Who is IDDSI? The IDDSI initiative is a group of international healthcare professionals (RDs,SLPs,RNs) who came together to standardize the terminology and definition of thickened products and textured modified foods. Their #1 concern is for Safety of patients Multiple labels and definitions can cause confusion Food Service and Safety: for survey too! Patient safety Standardize and Simplify Training Successful survey

Copyright November 2017 - Used with permission from IDDSI International Dysphagia Diet Standardisation Initiative - Industry Update July 2016 IDDSI goal and purpose is: (read each line of the slide) Copyright November 2017 - Used with permission from IDDSI www.IDDSI.org copyright 2016

Why we need a standardized system Safety Multiple labels/definitions can cause confusion between facilities, healthcare staff for residents Clinical efficiency Avoids re-assessment to determine safe liquid & diet levels and reduces need to confirm/clarify clinical info Commercial implications Consistent descriptor/color coding from all manufacturers and same as hand mix product at home/in facility Research Using the same terminology and measuring system to be able to compare studies Multiple labels and definitions cause confusion. Think about locations that you have visited and even the labels and definitions that you have used yourself to describe food textures and thickened liquids There is great research going on but unfortunately, because different terms and definitions are used, we are unable to accurately compare and draw valid conclusions from the results of the research findings. Using the same terminology and measuring systems for research can help develop a larger body of evidence.

History: Dysphagia Diet Before 1980: blenderized foods, baby food, instant food thickener Late 1980’s: First pre-thickened beverages- called nectar, honey, and pudding consistency 2002: National Dysphagia Diet (NDD) Recommended terminology, viscosity guidelines 2015: IDDSI Framework

This is the first publication from IDDSI which summarizes the various national terminologies and introduced the world to the need for standardizing international terminology.

New viscosity colors and IDDSI Framework New viscosity colors and descriptors

Why are we doing this? NDD no longer in print (not enough literature to support the viscosity boundaries established) Lack of accessibility to valid measuring tool IDDSI is evidence base so = Regulatory compliance Other countries on board – over 22! AND and SLPs (ASHA) on board: our “better halves!” Transitioning information already available from AND in the Nutrition Care Manual. (22 countries are in the process of implementation)

Academy of Nutrition and Dietetic support “The Academy of Nutrition and Dietetics and the American Speech-Language-Hearing Association (ASHA) together announce their support of a new global initiative [IDDSI] to standardize diets for the treatment of people who suffer from swallowing disorders.” ~Joint Press Release January 31, 2017 Hopefully a target implementation date coming from AND and ASHA in the next 2 months. We are currently in the Awareness Phase of the IDDSI implementation process. Nursing homes will be learning about the new IDDSI framework and determining how the diet changes may impact their facility.

New viscosity colors and IDDSI Framework Spoon Thick Honey Thick Nectar Thick New viscosity colors and descriptors

How we currently test viscosity Nectar: 51-350cP Honey: 351-1750cP

IDDSI Flow (Viscosity) Test Requires a 10 ml syringe

Textured Modified Foods Every level can be identified with a Number Color Description Integrating the findings of existing practice data, the results of the systematic review and global survey responses, the IDDSI framework was published in September 2015 and revised in August 2016. IDDSI framework has 8 levels ranging from level 0 for thin liquids to level 7 for regular texture foods. Each level is distinctly identified with a colour, number and a label. The combination of the 3 identifiers will help to limit errors in prescribing, identifying, preparing and assembling dysphagia diet orders.

The Names explains what it is. Makes it easier The Names explains what it is. Makes it easier. You might call mechanically altered “ground”. Minced is like ground. Some called Dysphagia advanced a “chopped diet”. That is similar to the soft and bit sized.

IDDSI Testing Methods to assess different textures Flow Test (for drinks) Fork Drink Test (for extremely thick) Spoon Tilt Test (puree) Finger Test Fork Pressure Test Finger tests have been incorporated in recognition that this may be the most accessible method in some countries.

Puree testing

Transitional Foods: NDD to IDDSI National Dysphagia Diet International Dysphagia Diet Standardization Initiative Dysphagia Level 3: Advanced or Mechanical Soft Meats are cut up, chopped or ground (moist) Crusty dry breads not allowed Salad, raw vegetables and most fresh fruit not allowed. No hard sticky or crunchy foods Mixed-consistency foods are allowed/tolerated. Food particles are served in bite-sized pieces (less than 1 inch) Soft & Bite Sized Level 6 Blue Soft, tender moist foods; no mixed consistency; Foods should have a particle size no great than 1.5cm x1.5cm (9/16") for adults Dysphagia Level 2: Mechanical Altered or Ground Meats are ground then softened and moistened by using gravies and sauces and served no larger than 1/4" pieces. Vegetables and fruits are soft cooked and bite sized (served no larger than 1/4 inch pieces) Soft breads, soups and desserts allowed. Minced & Moist Level 5 Orange Minced, soft and moist foods; can be scooped and shaped; easily mashed by fork, No mixed consistency. Foods that are minced, soft and moist and can be scooped and shaped (e.g., into a ball shape) should have a particle size 0.4 cm x 0.4cm (just greater than 1/4 inch) for adults. No bread. Soft & Bite sized- Size of food determined by diameter of esophagus Minced and Moist- Already chewed Source: Academy of Nutrition and Dietetics “Transition to IDDSI Diets”, NCM Diet Manual

Fork Pressure & Size Test Best used to assess foods in Levels 4-7 Slot/Gaps between the prongs/tines of a standard fork measures 4mm, which provides a easy compliance measure for particle size of foods at Level 5- Minced& Moist

Resources on IDDSI : Audit Sheets

International Dysphagia Diet Standardisation Initiative - Industry Update July 2016 FAQ’s or frequently asked question documents have been developed to help clarify the framework. These reflect some of the most frequent questions sent in to the IDDSI Board. www.IDDSI.org copyright 2016

Take Away Start with Baby steps…. Head to IDDSI.org website Educate Staff about IDDSI Post an IDDSI Framework and Flow test Inform healthcare team Review Textures

Looking for more information? www.IDDSI.org Apps! Bevolution Group Information www.bevolutiongroup.com Denise Kelly, RD dkelly@bevolutiongroup.com

Questions? Comments?