The New Global Standard for Dysphagia Diets

Food and drink are necessities of life. For most people, consuming foods and drinks is enjoyable and requires little thought and effort. It is unfortunate that for some individuals this action is usually not enjoyable and can require a significant amount of time and energy. The process of nourishing the body may in fact scare someone with these challenges to the point where they wish to avoid meals, foods and liquids altogether. These individuals have difficulty swallowing, clinically known as dysphagia.

Dysphagia is a prevalent health concern among the aging population and it is associated with malnutrition, dehydration, chest infection (pneumonia) and possibly death. Diet modification can help a swallowing impairment by altering foods to different levels of pureed, minced and moist textures and liquids that are thickened to different levels of consistency to ease the swallowing process.

The goal of modifying food and liquid is to improve swallowing safety by avoiding choking and aspiration (material getting into the lungs). Texture modification occurs all over the world but the labels and definitions vary widely which can cause confusion. Oftentimes individuals that are being transferred to another institution require re-assessment because of the differences in terms. These variances pose safety risks for people with dysphagia and health professionals travelling within and to other countries. They create variations in nutritional and sensory quality of foods and liquids. Commercial products that are being purchased by institutions also vary significantly in the way texture modified foods are produced and labelled.

To address this issue, a group of health professionals with diverse backgrounds gathered to create standardized terminology and definitions that can be used globally for people of all ages. They established the International Dysphagia Diet Standardisation Initiative (IDDSI). A scale was developed that consists of a continuum of 8 levels (0-7) which are identified by numbers, labels and colours. Each of the drink levels (0-4) and food levels (3-7) have detailed descriptions and characteristics accompanied by accurate testing methods.

If you have prepared texture modified foods or liquids before, you may be aware that the viscosity of the item changes over time. It is evident that consistency testing is best performed at the point of service. IDDSI has developed simple, practical and valid measurement techniques for this purpose.

This is particularly important for thickening liquids for dysphagia diets. It is known that the occurrence of aspiration does decrease once liquids are thickened. However, research shows that liquids that are too thick can cause residue build up after swallowing, which can have negative health impacts. It is a common issue for thickened liquids to have low acceptance by individuals with dysphagia. Overly thickening a liquid has a large impact on its flavour and texture, therefore an individual’s willingness to consume these items decreases along with their satisfaction and possibly hydration levels. The new standards help reduce these issues because they have specifically defined the viscosity of thickened fluids at each level and provided appropriate testing methods.

Foods are tested by using the Fork Drip Test, Fork/Spoon Pressure Test, Spoon Tilt Test, Chopstick Test and/or Finger Test. Drink levels 0-3 are tested by performing a gravity Flow Test using a 10 mL syringe. Level 4 liquids are best tested using the Fork Test and/or Spoon Tilt Test. The testing methods are outlined in detail on the IDDSI webpage (www.iddsi.org).

To help initiate the implementation of this framework, the IDDSI community agreed to lead and guide participating individuals, groups, associations, industries and governments within a proposed timeframe of 3 years. A 3-stage implementation model called Monitor-Aware-Prepare-Adopt (MAPA) was developed to help health care facilities adopt the new system.

The new standards will have huge impacts for individuals with dysphagia and professionals within various sectors. Some positive outcomes include:

• Reducing confusion among staff and management within and between institutions allowing them to communicate more effectively.
• Texture modified items produced and tested within hospitals and care facilities would be standardized which would ensure consistency and confidence among all management and staff.
• Patients would receive the appropriate texture as prescribed therefore decreasing safety risks.
• Avoids the need for re-assessment of individuals between institutions to determine safe food and liquid diet levels which would increase clinical efficiency.
• Commercial ready-to-use items are consistent and similar to those produced in hospitals/care facilities/at home.

There are also a few key points that facilities need to be aware of to successfully implement the framework, which are:

• The implementation of the new system will require time and effort to train management and staff within a facility. These individuals will need to be competent with the new naming system, testing methods and equipment.
• If texture modified foods and liquids are being prepared within an institution, materials such as 10 mL syringes, forks and spoons must be purchased for testing. Equipment should be able to produce minced and pureed foods that correspond with the guidelines.
  Important reminder: Achieving the proper texture is crucial to adhere to the specific IDDSI standards. For example, Level 4 Pureed foods cannot have any lumps whereas Level 5 Minced and Moist foods are allowed to have lumps less than 4 mm for adults. It may take a few attempts in order to get appropriate results. Using the correct testing method along with good quality equipment can help accomplish consistent testing.
• Revisions to menus may be required due to specific items being affected. For example, as stated within Level 5 and 6, regular dry breads should not be served. They should instead be pre-gelled/soaked throughout the entire thickness of the bread. Another adjustment to menu items is the requirement to drain all excess liquids before serving them. Fruits, vegetables and cereal with milk cannot have any liquid portion separating from the food item.
• Maintaining quality and food safety should remain a priority for all individuals and facilities preparing texture modified items. Aspects of quality include nutrient density, variety of items, preferences of those with dysphagia, sensory appeal (ex. visual presentation, taste, smell) and safe food (ex. appropriate serving temperatures). Being individual-focused can help ensure the food and fluid intake of individuals with dysphagia is adequate. A poor intake is the primary cause of malnutrition in older adults, especially in long term care.

The new standards for dysphagia diets will address the issue of varying terms and meanings around the world. This aims to improve swallowing safety for people with dysphagia. The IDDSI framework can potentially improve the quality of foods and drinks, which in turn can improve an individual’s satisfaction and quality of life.