1. International Dysphasia Diet Standardisation Initiative (IDDSI)
This summer we are taking on a new global framework that is used to define texture modified food and liquid

2. What?
IDDSI Framework
The goal of IDDSI was to develop a new global standardised terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphasia of all ages, in all care settings, and all cultures.
The development of IDDSI framework started in 2013 by a group of volunteers from various professionals including nutrition and dietetic, doctor, nursing, food science occupational therapist, engineering and so on. Through 3 years extensive study and research, they come up with new framework with each level of food texture very detailed described and defined, and with testing method that helps people to identify one level from another.
The question is why are we taking on this new framework? We have our own diet standard for residents with dysphasia, and we have been doing fine with it. Why do we bother to change it all of sudden?

3. Why?
Dysphasia diet standards have been developed at regional and national levels.
Unfortunately, different terminologies, labels, numbers and levels are used in these standards:
Based on the survey, there are 54 different names for honey thick and pureed meals
Adds to the confusion for individuals and caregivers as well as health professionals and researchers
Giving wrong texture of foods can put people with dysphasia under a high risk of choking and aspiration!
Aspiration can be silent in senior population !!!
Aspiration Pneumonia Death!!!!
Conservative estimates suggest that dysphasia (difficulty swallowing) affects approximately 8 % of the world’s population (580 million) . Even higher in LTC setting
Dysphagia is associated with malnutrition, dehydration, chest infection and potentially death. While promising treatments are being developed to improve function, the modification of food texture and liquid thickness has become a cornerstone of dysphasia management. Foods are chopped, mashed or puréed to compensate for chewing difficulties or fatigue, improve swallowing safety and avoid asphyxiation. Liquids are typically thickened to slow their speed of transit through the oral and pharyngeal phases of swallowing, to avoid aspiration of material into the airway and improve transit to the esophagus. Food texture and liquid modification for dysphagia management occurs throughout the world.
Texture modification is one of the most common intervention approaches for dysphagia, however, the descriptions of thickened drinks and texture-modified foods vary throughout the world, including within countries, and even across hospitals located with close geographic proximity
A multi-professional volunteer committee developed a dysphasia diet framework through systematic review and stakeholder consultation.
First, a survey of existing national terminologies and current practice was conducted, receiving 2050 responses from 33 countries.
Respondents included individuals with dysphasia; their caregivers; organizations supporting individuals with dysphasia; healthcare professionals; food service providers; researchers; and industry.
The results revealed common use of 3–4 levels of food texture (54 different names) and ≥3 levels of liquid thickness (27 different names). Substantial support was expressed for international standardization.

4. Where is IDDSI being implemented?
North America: United States and Territories, Canada
South America: Brazil
Europe: Belgium, Denmark, France, Germany, Ireland, Norway, Poland, Slovenia, Sweden, Turkey, United Kingdom, The Netherlands
Asia: China, Japan, Thailand
Australia, New Zealand
Middle East: Israel
South Africa
This is a list of countries where IDDSI framework is being implemented.

5. Canada
Implementation discussions are currently underway across Canada in several Health Authorities and regional groups
Pilot underway in New Brunswick
IDDSI framework and descriptors are being incorporated into university curricula and incorporated into PEN (Practice-based Evidence in Nutrition)
Aware
Jan 1, 2017
Prepare
Jan 1, 2018
Adopt
Jan 1, 2019
Project leader- Peter Lam (registered dietitian)
It is highly encouraged to take on this new framework by the January of 2019
It is voluntary for health institutions to take on this new program, however, as this is a global trend, within no more than three years, it will eventually become mandatory for all health institutions by Public Health

7. International Dysphasia Diet Standardisation Initiative (IDDSI)2 3 4
International Dysphasia Diet Standardisation Initiative (IDDSI)
Brief introduction
Compare to the current texture what changes need to be made
What testing method we can use
Before I started, I want to 5 6 7

8. The framework consists of a continuum of 8 levels (0--‐7)
The framework consists of a continuum of 8 levels (0--‐7). Levels are identified by numbers, text labels and colour codes.

9. 0-THIN Regular ex: water, boost ex: water 1-SLIGHTLY THICK
ex: tomato juice, Ensure Enlive
Slightly thicker than water
Level 0 THIN correspond to the regular drink we have here in Harbour View Haven
Level 1 SLIGHTLY THICK (Some example we have in HVH is tomato juice and Ensure)
*Our current standard does not have a level of drink that can be directly fit into Level 1 SLIGHTLY THICK
We will not introduce this new level immediately as we do not have residents that are currently on this level of drinks. At this stage of implementation, we are focusing mainly on the changeover of terminologies. However, in the future, we will gradually implement this new level of drinks.
(Food industry will need to take on this framework as well; they will need to adjust their product to adapt to the new framework. In this case, we may just buy in the drinks with right textures.)

10. The comparison between Level 0 and Level 1 drinks on visual view.
Question: Which level do you thick chocolate milk should go into?
Water Tomato Juice

11. IDDSI Flow Test Length of scale = 61.5mm Luer Tip
IDDSI flow test is developed to give people more accurate ideas on which level our sample drinks should go to. In the old diet standard, the definition for each level of food texture is more objective (ex: nectar thick should looks like eggnog or butter milk).
A 10 ml standard syringe is used in this test. The procedure is as shown in the graph.

12. The leftover in the syringe is used to determine the level of sample drinks:
If is <1, the sample is level 0 THIN
If is between 1-4, the sample is Level 1 SLIGHTLY THICK
If is between 4-8, the sample is Level 2 MILDLY THICK
If is >8, The sample is Level 3 MODERATELY THICK
Level 4 EXTREMELY THICK drink is thick to flow at all, so the sample will not drip at all (the test is not applicable for Level 4 drinks).

13. 0-THIN Regular Drink 1-SLIGHTLY THICK
ex: water, boost
ex: water
IDDSI FT: <1ml
1-SLIGHTLY THICK
ex: tomato juice, Ensure Enlive
Slightly thicker than water
IDDSI FT: 1-4ml

14. 2 2-MILDLY THICK Nectar Thick Drink Ex: eggnog, buttermilk
IDDSI FT: 4-8ml
Flow at a slower rate than thin drink

15. 3-MODERATELY THICK/LIQUIDISED
Honey Thick Drink
Ex: gravies , sauces
Smooth texture with no ‘bits’
Liquid must NOT separate from solid
IDDSI FT: >8ml
Fork Drip Test:
Drips slowly in dollops through the prongs of a fork
Fork Pressure Test:
NOT leave a clear pattern
ex: fruit syrup
*Liquid Meal/Meat (1)
Level 3 MODERATELY THICK / LIQUIDISED is corresponding to the texture of our honey thick drinks and full liquid diet.
On the new card, we will use MODERATELY THICK for Honey Thick, and LIQUIDISED for Full Liquid Diet.
Start this level, two other testing methods are introduced: one is Fork Drip Test and the other is Fork Pressure Test.
We will go into more details about this two testing methods in the following slides.

16. Fork Drip Test 4-Pureed/Extremely Thick 3-Liquidised/Moderately Thick
Sits in a mount or pile above the fork
Drips slowly or in dollops through the tines of a fork
Use a fork, and take a spoonful of samples on your fork. Hold it level.
3-Liquidised/Moderately Thick
4-Pureed/Extremely Thick

17. Fork Pressure Test 3-Liquidised/Moderately Thick
4-Pureed/Extremely Thick
Use a fork. Use the tip of the tines to try to make pattern on the surface of your sample.
Fork can NOT leave a clear pattern on the surface
Fork can leave a clear pattern on the surface

18. 4-EXTREMELY THICK/PUREED
Pudding Thick Drink
Ex: pudding, yogurt
Can not be poured
Smooth with NO lumps
NOT sticky
Liquid must NOT separate from solid
IDDSI FT: Not applicable
Fork Drip Test:
Sits in a mound/pile above the fork (may with tail)
Fork Pressure Test:
Can make a clear pattern on the surface
ex: thick cereal, pudding
Puree Meal
*Pureed dessert (3)
*Pureed soup (3)
Level 4 EXTREMELY THICK / PUREED correspond to our pudding thick drink and pureed meal. Pudding thick drink and pureed meal are one texture. We use one name for drink and one name for meal. On the new diet card, we will use extremely thick to replace pudding thick, and pureed meal will remain as puree.
Indicators that a sample is too thick:
-Does not fall off the spoon when tilted
-Sticks to spoon

19. Pudding Thick Apple Juice made with SimplyThick®
Imperial SYSCO Honey Thick Orange Juice

20. 5 5-MINCED&MOIST (Particle Size: 4mm) Ground/Minced Meal
-Resemble ground beef
-Exceptions: regular soup, fish (no breading, serve as whole)
-Bread may or may not be allowed
Minimal chewing is required
NO separate liquid should be seen
Fork Pressure Test:
-Particles can easily come through two tines of a fork
-Can be easily mashed with little pressure
(NOT make the thumb nail blanch)
Level 5 MINCED&MOIST correspond to our minced meal
*For our residents who is on minced diet, they are also allow regular soup, soft toast, sandwich and hamburger. However, this does not go along with the new framework. On the new diet card, we will still use the new terminology, number and colour. What we will do is that we will put a note after ‘Minced&Mosit” saying: Allow soft whole items. Then you know that resident with minced diet can still allow those foods (soup, toast, sandwich and hamburger).
4mm

21. Fork Pressure Test
4mm
Level 5 MINCED&MOIST: 4mm (the distance between two tines of a fork)
Level 6 SOFT&BITE-SIZED: 15mm (the whole length of the fork)
Press food sample with the base of the fork.
Level 5: can easily mashed with little pressure (should not blanch your thumb nail to white)
Level 6: can be mashed with little pressure (the pressure should be able to blanch your thumb nail to white)

22. 6 6-SOFT&BITE-SIZED (Particle Size: 15mm) *Ground Meal
-Ground meat
-Cooked soft vegetable and fruit (size may vary)
(no raw vegetable, hard fruit, crackers/cookies)
No separate liquid should be seen
Fork Pressure Test:
-Fork can be used to cut this texture into small pieces
-When a sample is pressed with the base of a fork to a pressure where the thumb nail blanches to white, the sample squashed and changes shape
LEVEL 6 SOFT&BITE-SIZED
We do not have this level of food texture in HVH. We will not introduce this immediately. In the future, if we have resident coming with this level of food texture. We will come up with some new recipes by then.

23. Thumb nail blanches to white
Fork Pressure Test
15mm
Thumb nail blanches to white
Level 5 MINCED&MOIST: 4mm (the distance between two tines of a fork)
Level 6 SOFT&BITE-SIZED: 15mm (the whole length of the fork)
Press food sample with the base of the fork.
Level 5: can easily mashed with little pressure (should not blanch your thumb nail to white)
Level 6: can be mashed with little pressure (the pressure should be able to blanch your thumb nail to white)

24. 6-Soft&Bite-Sized (15mm)
Fork Pressure Test
4mm √ ×
5-Minced&Moist (4mm)
6-Soft&Bite-Sized (15mm)

25. Level 6 – chicken and vegetables
Preston Walker (kitchen manager/director and consultant chef) from Barnstone, Nottingham, England
Level 6 – chicken and vegetables
Level 4 - goats cheese, beetroot and apple

26. 7
7-REGULAR
*Cut Up Meal
-All meats are cut up into bite-size pieces by nursing staffs (size may vary)
-Regular vegetables and fruit
General/Regular Meal
Normal, everyday foods of various textures

27. TRANSITIONAL FOODS (5&6&7)
Ex: ice chips, ice cream, wafers, waffle cones
Starts as one texture (e.g. firm solid)
Changes into another texture when moist and heat applied (imitating the month environment)
Fork Pressure Test:
1. Place 1 ml of water on a sample (ex: 1.5cm*1.5cm)
2. Wait 1 minute
3. Apply fork pressure using the base of the fork until the thumb nail blanches to white
4. The sample should no longer looks like its original state:
- Squashed and disintegrated
- Melted significantly

28. Transitional Foods
Firm Solid
Moist + Heat + Time
Easily Mashed

29. 15mm
4mm

31. Thank you for listening !