November 2019

  • Back to the beginning: Our Goal and other important reminders
  • Level 5 Clarifications
  • Food Testing
  • Resources and Implementation Updates
  • Webinar recordings
  • Translations
  • New Sponsors
  • IDDSI on the Move
Back to the Beginning
Our Goal
The goal of IDDSI was to develop  INTERNATIONAL  standardized terminology and descriptors for dysphagia diets that would meet the needs of individuals with dysphagia across the age span, across all care setting and across all cultures. National standards were already in existence, as various countries had recognized the need for a “common language” for dysphagia diets. The IDDSI framework was developed using the best evidence available along with input from the global community from all sectors.

Why a common language?
Due to the enormous variation in types of foods and drinks as well as their properties, it is challenging to categorize foods and drinks to ensure universal understanding of the types of foods and drinks that would best meet the needs of an individual with dysphagia. Confusion and miscommunication regarding diet textures and drink consistencies has resulted in increased risk of illness and even death.  
A “common” standardized language of dysphagia diet terms, descriptions and reliable testing methods goes a long way in helping to reduce miscommunication and improve safety for individuals with dysphagia.

Why can’t I modify the IDDSI Framework?
If you modify or change the IDDSI Framework, it is no longer standardized, therefore NOT the IDDSI framework and thus defeats the purpose of improving safety by using a “common language”. The risk is confusion and miscommunication with possible adverse consequences to individuals with dysphagia.   We respectfully ask that you do not change or modify the IDDSI Framework or descriptors as per our creative commons license. 
Our CreativeCommons BY-SA 4.0 license states that:
"Modification of the diagrams or descriptors with the IDDSI framework is DISCOURAGED and NOT RECOMMENDED. Alternation to the 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".

Can I be more specific in my own setting? 
Yes, IDDSI is a universal baseline but in some situations, people add their own specifications providing further detail, e.g. flavor, and/or specifying brands of products.  But remember that IDDSI is already available everywhere free of charge: if you create your own specification you will be responsible for ensuring that is communicated wherever necessary. 
Do I need to use all levels of the IDDSI Framework?
No, you do not need to use all the IDDSI levels if they are not required for your facility or the individuals you work with. You can select the food and drink levels that best meet the needs of the people you work with.
Level 5 Particle Size

Since publication of our new updated IDDSI framework and descriptor documents, we have received a number of questions regarding particle size for minced foods.  Within Level 5, many people around the world had pointed out that some rice dishes, or pasta (particularly chopped spaghetti) were deemed suitable for Level 5 in their settings, but it was unclear whether the 4mm restriction applied in all dimensions. It was ambiguous in the first IDDSI framework. 
We undertook discussion at the IDDSI board and with international colleagues. Research into food particles size of chewed boluses in healthy adults suggests averages of 2-4 mm depending on the type of food being chewed. However, food particles in a chewed bolus are not necessarily all uniform in size and particles need to be considered in dimensions of width, depth and length.

Level 5 minced and moist particle size for an adult has been outlined as no larger than 4mmx4mm x15 mm*. 4 mm is the distance from point to point of an ordinary dinner fork. This size specification allows for foods like rice or cut up pasta to be included, provided the “moist” criteria is also met.

In consideration of the smaller anatomy of young children, the recommendation is for no larger than 2mm x2mm x8mm* is recommended for pediatric populations. (2 mm is half the distance between the tines of a regular dinner fork.)

*15 mm for adults and 8 mm for children are considered small enough to not obstruct the airway.
Food for Thought
Food characteristics
Testing foods is more complex as there are many important characteristics such as moistness, stickiness, hardness and toughness which are not straightforward to assess even in a laboratory.  Research also suggests that in healthy adults, foods will be chewed into small particles and mixed with saliva until there is sufficient moisture to lubricate the bolus for swallowing.  Further research on particle size of chewed boluses has also found that hard foods such as nuts and raw carrots will be chewed to smaller size particles(~2mm) before swallowing, than softer foods. 
IDDSI considered all this evidence in developing simple testing methods which could address the complexities of different food properties: 
The concept of “fork mash-able” has been used in the past, but this depends on individual hand strength and judgement. We introduced the concept of thumbnail blanching pressure to provide a more-consistent definition of pressure without having to resort to mechanical tools or motors. This thumbnail blanching pressure corresponds to systolic blood pressure and has been measured to be equivalent to a low tongue compression pressure. 
The spoon-tilt and fork-drip tests are practical measures of adhesiveness and cohesiveness respectively, designed to be used at the point of serving and can be performed very quickly with minimal training required. There is no alternative “gold standard” industrial or scientific test to define these qualities relating to safety of swallowing. 
With regards to the spoon tilt test – this is used to assess the ability of the sample to hold shape on the spoon, and also stickiness.  People have choked and died on sticky mashed potato, cheese and other foods. When testing, use only your wrist to flick the sample if it does not immediately fall off the spoon.  If you are using your elbow or shoulder with the ‘wrist flick’ it is too sticky! If you refer to our latest IDDSI Framework description document, page 10 includes images for reference. 
Clinical assessment should always be used to determine if an individual has the ability to safely manage a particular texture level of food.

We also strongly recommend using the IDDSI testing methods, rather than relying on the less accurate methods of pictures, descriptions or lists of food and drinks, to ensure those with swallowing or choking risk are provided with the required food or drinks. For example, an unripe banana is a choking risk, a ripe banana is not. 

Logopaedie Austria has published a position paper outlining their support IDDSI.  The paper outlined that their decision came through information gained from national and international experts, representatives of industry, colleagues from other disciplines and through informal surveys among the members. The findings lead to the decision to support the International Dysphagia Diet Standardization Initiative (IDDSI) in terms of patient safety by June 2019. The paper can be found at:
Speaking of Food Testing...

The American Academy of Nutrition and Dietetics hosted a pre-conference IDDSI workshop at FNCE 2019. 

Over 100 participants practiced mixing, manipulating and tested thickened liquids and texture modified foods.  The session provided some very robust discussions and a practical learning experience as participants get ready to start the mapping process of foods and liquids in their worksites.
The workshop received very positive feedback and participants provided some eye-opening comments like:

‘Wow, I didn’t realize that different types of liquids may require different amounts of thickener to achieve the same level of thickness’

‘Ready to swallow food is actually NOT pureed but actually resembles Minced & Moist foods once we have chewed the food and mixed it with saliva’

‘Will be sure to review the mashed potatoes we serve!  Didn’t realize that mashed potatoes can actually be obstruct the airway and cause someone to choke…’

‘Not all items on the plate need to be the same texture?...  It’s great to know that the prescribed texture and thickness are the upper and lower boundaries for food texture and liquid thickness.  Good to know that I can actually serve pureed mashed potatoes with minced and moist meats for someone who is determined to be able to manage Level 5 Minced & Moist’
An expert panel was also assembled to present an IDDSI session focused on IDDSI implementation.  Many thanks to Dr. Joseph Murray, Jennifer Davis, Susan Ringenberg and Kristen Walker for enlightening the audience with their amazing experience, insights and wisdom.
Resources and Implementation Updates

Following the announcement of May 1, 2019 being the official IDDSI launch across the USA and territories, the Academy of Nutrition and Dietetics created a monthly, step-by-step IDDSI Boot Camp to empower dietitians to lead the charge of program implementation in their facilities!  The boot camp included monthly emails providing concrete tasks and timelines to guide dietitians in IDDSI implementation in their facilities.

Worksheets for mapping foods in preparation for IDDSI are now available.  These worksheets were kindly shared for use by New York Presbyterian Brooklyn Methodist Hospital. They can be found under the United States and Territories section of the Country-Specific tab in our Resources page.
Thank you to all who joined in with our IDDSI Townhall sessions on October 17 and 31, 2019. There were great questions from our participants and we hope participants were able to take away information from the sessions.  We appreciate every ones interest in IDDSI!
Watch for announcements of new webinar session in 2020. 

If you missed their webinar, please check out the recording here .
IDDSI Translations

With global implementation moving forward, translations of our IDDSI framework documents becomes even more important. Check out our  Translations tab.

Completed translations:
Chinese (simplified), Farsi, French (Canada), French (France), Italian, Norwegian, Portuguese (Brazil), Russian, Spanish and Swahili.

Languages currently up for review:  
Arabic, German, Greek, Hebrew, Japanese, Slovenian, Thai and Vietnamese.

Please consider reviewing these documents and adding any comments or suggestions for the translation before final posting.
Languages in progress:
Catalan, Irish, Turkish, Hindi, Urdu, Zulu, Portuguese (Portugal), and Marathi.
IDDSI on the Move

  • November 2019 – American Speech-Language-Hearing Association Conference 2019, Orlando, USA. 2 IDDSI events at ASHA:
  • Nov 21/19 Implementation of the International Dysphagia Diet Standardisation Initiative (IDDSI) in Different Care/Cultural Settings
  • Nov 23/19 Do You IDDSI? A Town Hall Meeting With Members of the IDDSI Board
  • November 2019 – Speech Pathology Australia National Tour finishes in Sydney and Canberra Australia.  Workshops that have included IDDSI have been presented throughout 2019 around Australia as part of the National Tour.
  • December 2019 – Meeting with Singapore Dysphagia Diet Standardisation Workgroup
  • January 2020 – HPSI Annual Conference, Huntington Beach, USA
  • February 2020 – UKSRG Conference, London, UK
  • March 2020:  Dysphagia Research Society Conference. San Juan, Puerto Rico. 
New Sponsors

IDDSI is pleased to welcome General Mills as our newest Gold Level Sponsor and Gordon Food Service as our newest Silver Level Sponsor. We truly appreciate the generous support from our many sponsors who make our work possible!
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