Dysphagia Diets: IDDSI Replaces NDD

Standardized Diets:

IDDSI Replaces the National Dysphagia Diet

by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

You may hear doctors and health care professionals use terms like: “Soft,” “Mechanical Soft,” “Chopped,” “Ground,” “Blended smooth,” etc, but what does it mean? Ambiguous terms without standardized definitions lead to dangerous trays being given to patients. For example, many doctors think that “soft” means fully pureed! Read more about why standardization of diet labels and definitions matters.

Have diets been standardized at your facility?

Know the History on Where We Were:

In the past, the National Dysphagia Diet (NDD) was the only standardized diet tool in the United States, and it was a great beginning. NDD was published in 2002 by the American Dietetic Association (now known as the Academy of Nutrition and Dietetics). It was created as an official project of the ADA, but the NDD was not officially supported by ASHA (American Speech-Language Hearing Association). However, the National Dysphagia Diet was the result of consensus among dietitians, Speech-Language Pathologists, and food scientists. This tool listed diets that were appropriate for patients with swallowing disorders.

The use of food science and the science of rheology have helped us create diets not only to avoid diet-label confusions, but also to provide for the safest textures for the patient’s particular type of dysphagia.

See links below to review the prior National Dysphagia Diet (NDD) charts:

1) The Old National Dysphagia Diet (NDD):  Dysphagia diet quick chart

2) Here is the extended version that we used to give to kitchens to follow the guidelines: National Dysphagia Diet Details

New Generation of Dysphagia Diets:  2016-2017 Updates & IDDSI.org

The International Dysphagia Diet Standardisation Initiative (IDDSI) is an organization made up of volunteer clinicians and researchers from 9 countries around the world. The IDDSI dream since joining together in 2013 has been to:

Achieve global dysphagia diet terminology, creating common terminology and common understanding across international borders, across the lifespan, across all professions, and across the all stakeholders to help the care of people with difficulty swallowing (dysphagia).

Please see my prior blogs that tracked this amazing global effort by the International Dysphagia Diet Standardisation Initiative (IDDSI) towards standardization of diets and liquid consistencies:

1. Diet Safety: Terminology & Definitions Matter (IDDSI publication links included).

2. No Dysphagia Diet Modification Without Standardization!

3. IDDSI: Interview with an Early Adopter of the IDDSI Framework

Go to the International Dysphagia Diet Standardisation Initiative website (www.IDDSI.org)

IDDSI Framework:

International dysphagia diet standardization initiative (IDDSI) - dysphagia diet and liquid framework for people with difficulty swallowing
Creative Commons: You are free to use the IDDSI pictures and framework, but please do not alter the framework in any way. It is based on years of research. IDDSI notes that only fine tuning is allowed. For example, describing foods that are culturally appropriate in your country.

 

Note how the IDDSI framework has expanded the levels of liquid consistencies. There are no longer only the three National Dysphagia Diet levels for thick liquids: Nectar -> Honey -> Pudding Thick. With IDDSI, Mildly -> Moderately -> Extremely Thick liquid replace those original three. The IDDSI additional level is Slightly Thick, which is between Thin and Mildly Thick. Potentially, patients could tolerate a liquid slightly thinner than what used to be considered “nectar thick.” That might improve quality of life and intake while preserving safety! These 5 total liquid consistencies are more in line with what Japan and Australia have already used.

The IDDSI Framework and Standards include procedures on how to test viscosity at home or at your facility without expensive rheology equipment. You could double check your thickened liquid or supplement. All you just need a 10 mL syringe! However, please make sure you have the right size of a syringe. Specifically, the measurement from the 0 line to the 10ml line should be 61.5mm long. IDDSI was surprised that not all 10ml syringes are created equal around the world. If you live in the USA, the typical 10ml slip-tip hypodermic syringe should be fine.  See IDDSI Flow Test here.

The diet labels can now be translated into many languages. No more “honey” or “pudding” thick, which do not easily translate. We will now be getting rid of all the confusion with different labels for the same diet, such as: “ground,” “moist ground,” “mechanical soft,” “mechanically altered.” These will be replaced with the IDDSI diet #5, “Minced & Moist.” The minced particle size is 4mm, which happens to be the size of food particles after chewing and when they are swallow ready. It also is the size between two tines on a fork to make testing easy. Therefore, the Minced & Moist diet needs minimal chewing. The IDDSI diet #6 is “Soft & Bite-Sized. Yes, they are using the word “Soft,” but it is now highly defined in the framework and easily translatable. The bite sizes should be 1.5cm or 15mm, so that if a chunk falls to the airway, the person will not choke/asphyxiate. The size of 15mm is about the size of an adult thumbnail, and is smaller than a typical adult airway. (Note: for pediatrics, they suggest a 2mm particle size for Minced & Moist. For Soft & Bite-Sized, the chunk size should be no bigger than the child’s fingernail on his/her pinky finger.) There are other easy food testing methods that IDDSI has created on their website.

The future is bright for patient safety with IDDSI

IDDSI is working on raising awareness all the time. You can help to spread the word. Institutions, healthcare providers, and industry will be preparing for full adoption of this framework by January 1, 2019 per decisions already made in Canada and with the Academy of Nutrition & Dietetics, as well as the American Speech-Language Hearing Association. You can also help in this preparedness by finding champions in your institution to review your own diet labels, descriptors and menus. As a clinician, you can start using dual labeling in your reports. For example, when recommending the liquids of Nectar thick, add: (aka, Mildly Thick Liquid per the IDDSI Framework). Industry is already starting this dual labeling.

Changing over to globally recognized terminology – based on evidence – is critical. As IDDSI says: “getting it wrong has serious consequences, such as life-threatening chest infection, or choking and dying.” 

Dr Catriona Steele, from the IDDSI board, enthusiastically states:
“Become a part of the wave of implementing global terminology for dysphagia diets.”

Clinician Tools

PLEASE SEE MY NEW IDEA FOR A SWALLOW INSTRUCTIONS GUIDE FOR YOUR PATIENTS’ ROOMS THAT INCLUDES DUAL LABELING OF THE OLD DIET NAMES MAPPED TO THE NEW IDDSI FRAMEWORK.

CLICK HERE: Swallow Guide IDSSI-Style

AGAIN, start doing your own Flow Tests on thickened liquids, supplements, and liquid medications.

Use this pdf: IDDSI Flow Test Data Chart

 

 

 

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