International Dysphagia Diet Standardisation Initiative (IDDSI)

What is IDDSI? A continuum of 8 levels (0-7) Fluids are measured from levels 0-4 Foods are measured from levels 3-7. The framework includes descriptors, testing methods and evidence for each level. The goal was to develop standardised terminology on a global scale including definitions to describe modified diets and thickened fluids for all individuals with dysphagia. IDDSI 2017

IDDSI flow Test IDDSI 2017

Testing method (Liquids) – IDDSI flow test Uses a 10ml slip tip hypodermic syringe for levels 0-3. The syringe should have a measured length of 61.5mm from the 0ml line to the 10ml line. It has been found to categorise a wide range of liquids reliably. Steps: Remove plunger Cover nozzle with finger and fill with liquid to the 10ml line Release nozzle and start timer Stop at 10 seconds and cover the syringe back up with your finger See how much liquid is left in the syringe (if any) IDDSI 2017

Testing methods for food IDDSI 2017 Fork drip test – Assesses whether the food flows through the prongs of the fork and how it does this. Results are to be compared against the detailed descriptors. Spoon tilt test – Used to determine the adhesiveness and cohesiveness of the food. Results are then compared with the descriptors. Fork pressure test – Used to assess the hardness/firmness of food. The food sample is pressed with a fork by placing the thumb on the bowl of the fork (just below the prongs).

level 0 – thin IDDSI 2017 Normal fluids Can drink through any type of cup or straw as appropriate for age and skills Testing method: 1. Flow test – All liquid should pass through the syringe within 10 seconds, leaving no residue. IDDSI 2017

level 1 – slightly thick Thicker than water Still flows through a straw, syringe or teat Testing method: Flow test – Liquid flows through syringe leaving 1-4ml after 10 seconds. IDDSI 2017

level 2 – mildly thick Pours quickly from a spoon but slower than thick drinks Sippable Testing method: 1. Flow test – Liquid flows through syringe and leaves 4-8ml after 10 seconds. IDDSI 2017

level 3 – moderately thick/liquidised Can be drunk from a cup Cannot be moulded on a plate Cannot be eaten with a fork – It will drop through the prongs No chewing required Smooth texture with no bits Testing methods: Flow test – Liquid flows through syringe but leaves >8ml after 10 seconds Fork drip test – Drips slowly in dollops through prongs of fork Spoon tilt test – Easily pours from the spoon when tilted, does not stick to the spoon. Examples = Sauces, gravies, fruit syrup. IDDSI 2017

level 4 – extremely thick/pureed Usually eaten/drunk from a spoon but a fork is possible. Cannot be drunk from a cup. Does not require chewing. Can be piped or moulded. No lumps and non-sticky. Testing: Fork drip test – Sits in mound above fork, a small amount may flow through and form a tail below the prongs but it will not drip continuously. Spoon tilt test – Holds its shape on the spoon, full spoonful must fall off if tilted. Fork press test – Prongs make a clear pattern on the surface of the food. Examples = thick cereal, pureed meat. IDDSI 2017

level 5 – minced and moist Can be eaten with a fork or spoon. Soft and moist with no separate liquid, small lumps visible but can be squashed. Minimal chewing required. Can be scooped and shaped (into a ball shape). Testing: Fork pressure test – When pressed with the fork, the particles should come through the prongs easily. It can be mashed with little pressure from a fork and the thumbnail should not blanch to white. Fork drip test – Sits in mound on the fork and does not completely flow through. Spoon tilt test – Holds its shape on the spoon, must slide off in one once tilted and little food should be left on the spoon. The mound may spread slightly on the plate. Examples = minced meat, mashed fish, mashed fruit, minced veg, thick and smooth cereal, soaked bread and non-stick rice. IDDSI 2017

level 6 – soft and bite sized Can be mashed/broken down with pressure from a fork. A knife is not required to cut the food. Chewing required. Soft and moist bite size pieces with no separate thin liquid. Testing: Fork pressure test – Pressure from a fork held on its side can be used to cut the food into smaller pieces. The thumb nail should blanch to white when the thumb is pressed onto the base of the fork. The sample should squash and change shape and should not return to its original shape when the pressure is removed. Examples = cooked tender meat, non-stick rice, casserole/stew/curry if the meat is soft and tender and the liquid is thick, fish that breaks into small pieces, mashed fruit, steamed or boiled veg (bite size), smooth and soft cereal with only small lumps, soaked bread. IDDSI 2017

level 7 – regular (IDDSI, 2018) Normal, everyday foods. Can be of any texture. IDDSI 2017

Transitional foods Foods that start as one texture and changes into a different texture when moisture (e.g. saliva) is applied or when a change in temperature happens. Minimal chewing required. May be used for rehabilitation of chewing skills. The tongue can be used to break these foods once they are altered by temperature or moisture. Testing: Fork pressure test – Place 1ml of water onto a bite size piece, leave for 1 minute, apply fork pressure until the thumbnail goes white, once pressure is removed, the sample should be squashed or melted significantly. Examples = Ice cream, wafers, some biscuits, crisps (mashed type, e.g. pringles), shortbread. IDDSI 2017

comparison of iddsi Framework and Current Framework IDDSI Levels Current thickener/ texture Stages Thin (level 0) Normal fluids Slightly thick (level 1) Fluids not modified below stage one Mildly thick (level 2) Syrup consistency (stage 1) Moderately thick (level 3) Custard consistency (stage 2) Extremely thick (level 4) Pudding consistency (stage 3) Liquidised (level 3) Texture B Pureed (level 4) Texture C Minced and moist (level 5) Texture D Soft and bite sized (level 6) Texture E Regular (level 7) Normal diet

Recommended Dosage of resource thicken up clear for 200mls of liquid IDDSI Framework 200mls liquid Level 1/ slightly thick 1 scoop/ sachet Level 2/ mildly thick 2 scoops/ sachets Level 3/ moderately thick 4 scoops/ sachets Level 4/ extremely thick 8 scoops sachets Nestle (2018)

Concerns raised about iddsi The expectation from manufacturers that SLT’s will provide training across all sectors and settings and the belief that SLTs should reassess all patients that are prescribed thickener. Each setting may be do things slightly differently which lacks consistency and patients may be put at risk. A range of thickeners may be used in one setting such as a care home and some manufacturers will have changed their instructions to comply with IDDSI and some have not. Those who are living on their own may not understand the changes which is a risk to their health. The stages of the National Descriptors do not exactly match the IDDSI levels which potentially means that some patients drinks may be thinner or thicker than they were originally prescribed. (BDA,2018)

Concerns about iddsi (cont) The manufactures are taking different approaches. Some are moving straight to IDDSI with their labelling while some manufacturers will be labelling the thickeners with a transitional label with both IDDSI and the national descriptors displayed. BDA 2018

Addressing the concerns The BDA and RCSLT recommend: Contacting manufacturers for support – training /leaflets/ posters etc. Some contracted manufacturers have offered support with implementation including training and a helpline A whole system approach has been found to be effective in implementation Access IDDSI website for tools and templates for local adaptation during the phased implementation BDA 2018

Kempen Pilot Neurology ward in 250 bed hospital in Kempen, Germany No existing diet standards in place The Kempen Pilot provides an example of how IDDSI framework can be implemented successfully. Key processes found to support implementation of IDDSI: Top down / bottom up approach Mapping current practice to IDDSI standards Education sessions to all levels of staff Increased visibility of IDDSI – posters, labels Formal review processes Lam et al 2016

10 points to consider in IDDSI Implementation Familiarise self with IDDSI via website an access UK IDDSI Implementation Pack (BDA/ RCSLT websites) Set up an IDDSI implementation group Notify senior management that you are implementing IDDSI and expected timeframe Develop a plan and time line – maybe over 2 phases – fluids first then foods. Create IDDSI champions who can answer queries Develop a local awareness plan and train staff Revise menus Amend local documentation – i.e. diet sheets Send a patient safety alert re: risk to patients in transition phase Evaluate success of programme IDDSI 2017

Stages of Implementation (IDDSI, 2018)

The RCSLT – Benefits of IDDSI (RCSLT, 2018) While the National Descriptors are based purely on expert opinion, each level of IDDSI is based on research evidence The continuum consists of levels for fluids as well as foods which means that patient safety is assured (Fluids are not accounted for in UK descriptors) No confusion for staff and patients travelling from country to country – increase in patient safety Larger research studies can be conducted if more countries use the same descriptors meaning that more robust evidence regarding the care of patients with dysphagia can be obtained Greater opportunities to collect and evaluate treatment outcomes

References British Dietetics association and Royal College of Speech and Language Therapists (2018) UK IDDSI Implementation Checklist [Online] Available From: https://www.rcslt.org/clinical_resources/dysphagia/iddsiimplementationchecklist [Accessed 13th May 2018]. Hanson, B (2018) 9th May. Available from: https://twitter.com/benhansonmech [Accessed 13th May 2018] International Dysphagia Diet Standardization Initiative (2017) IDDSI e-bite [Online] Available from: http://myemail.constantcontact.com/IDDSI-E-Bite--Implementing-IDDSI--Kempen-Pilot- Project.html?soid=1124597382375&aid=uZTbQRRgzCg [Accessed 13th May 2018]. International Dysphagia Diet Standardization Initiative (2018) [Online] Available from: <http://iddsi.org/> [Accessed 13th May, 2018]. Lam, P et al (2016) The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework: The Kempen Pilot [Online] Available from: http://iddsi.org/wp- content/uploads/2017/08/bjnn.2017.13.sup2_.s18.pdf [Accessed 13th May 2018] Nestle Health Science (2018) Recommended dosage for 200mls of liquid [online] Available from https://www.nestlehealthscience.co.uk/brands/resource-dysphagia/resource-thickenup-clear [Accessed 13th May, 2018] RCSLT (2018) Statement on the Implementation of the International Dysphagia Diet Standardisation Initiative (IDDSI) [Online] Available from: https://www.rcslt.org/clinical_resources/dysphagia/statementoniddsi [Accessed 13th May 2018]