Preparing for the International Dysphagia Diet Standardisation Initiative (IDDSI)

By Dawn Hopkinson, Clinical Specialist Speech and Language Therapist at Priory Highbank Centre, Bury.

Following a brain injury, many factors can impact on a person’s ability to swallow safely and effectively. These factors can include:

• Neurological damage resulting in neuro-muscular and sensory deficits
• Behavioural issues
• Cognitive and communication difficulties
• Reduced attention and concentration

It is not surprising therefore, that dysphagia is a common occurrence following brain injury and any or all stages of the swallowing process (oral prep, oral and laryngeal) can be affected. Find out more about the swallowing process.

Research has shown that 93% of patients with a traumatic brain injury (TBI) can present with dysphagia. Many people in our care at Priory Highbank Centre will therefore require dysphagia management at some point.

Dysphagia can be a potentially life threatening condition, regardless of aetiology, and can require various techniques to manage. One such technique is the implementation of modified diets and fluids. It is important that appropriate modifications of food and liquids are understood and implemented to facilitate a more enjoyable eating experience and to reduce the potential for aspiration and associated implications to health. Altering the consistency of food is a clinically recognised aspect of dysphagia management.

As providers of care to patients who experience dysphagia, we are familiar with the current UK (National) Dysphagia Diet Food Texture Descriptors. These provide standard terminology for classifying texture modified diets:

• Grade B – thin purée dysphagia diet
• Grade C – thick purée dysphagia diet
• Grade D – pre-mashed dysphagia diet
• Grade E – fork mashable dysphagia diet

Fluids tend to be classified as either stage 1, 2 or 3, however descriptions are often variable:

• Stage 1 – syrup consistency fluids
• Stage 2 – custard consistency fluids
• Stage 3 – pudding consistency fluids

Despite the above descriptors, research carried out by the International Dysphagia Diet Standardisation Committee found inconsistencies in terminology used to describe modified diets and thickened fluids.

The result of over three years of ongoing work carried out by the International Dysphagia Diet Standardisation Committee has led to the new IDDSI framework being developed. This provides standardised terminology and detailed definitions to describe all texture modified diets and thickened liquids. This framework has been developed for use with all patients with dysphagia across all age groups, all care settings and all cultures, and is recommended for implementation throughout the world. This will help to facilitate improved patient safety and communication between health professionals, care providers and food manufacturers, and will help all parties work towards a more consistent and safer approach.

Following the development of IDDSI, companies providing ready-made dysphagia modified diets and thickening agents will label the products in line with the new IDDSI framework. It is important that awareness is raised regarding this prior to the introduction of IDDSI, as recommendations and measures of thickening will now be different.

The IDDSI framework should be in place globally by April 2019 and replaces the previous UK National Descriptors guidelines. The IDDSI framework consists of a continuum of 8 levels (0-7), where drinks are levels 0-4 and foods measured from levels 3-7. 

The complete IDDSI framework provides detailed descriptions for all food consistencies and guidance on carrying out gravity tests to achieve the correct consistency of fluids. More information can be found on the IDDSI website.

Priory’s plan of action

To help facilitate a safe transition from the use of UK National Descriptors to the IDDSI Framework, Priory Healthcare formed an IDDSI working party. 

Various activities and measures can be put in place to ensure we are prepared, including:

• Discussions with food manufacturers who provide ready-made modified diets
• Discussions with companies who provide thickening agents for fluids
• Where possible and appropriate, GPs have been contacted to discuss and request consistency in the thickening agents prescribed
• Posters have been introduced around some hospitals and centres to encourage questions and discussions regarding IDDSI, and raise awareness of the coming changes
• We’ve developed on-site training, online learning modules and webinars
• Pre and post IDDSI training questionnaires are being completed to audit the effectiveness of IDDSI training and to identify any areas of difficulty or confusion that may require further support for our healthcare providers, patients and families

The overall aim as always, is to ensure the safety and wellbeing of those in our care.

References

• Howle A, Baguley I J & Brown L – Management of Dysphagia Following Traumatic Brain Injury – Current Physical Medicine and Rehabilitation Reports Dec 2014, Vol 2 Issue 4 pp.219-230).
• Garcia J, Chambers E – Managing Dysphagia Through Diet Modifications – AJN, American Journal of Nursing: Nov 2010 Vol 110 Issue 11 pp 26-33).
• Cichero, J.A.Y., Lam P, Steele C M. et al. Development of International Terminology and Definitions for Texture – Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia April 2017, Volume 32, Issue 2, pp 293-314
• Atherton M, Bellis-Smith N, Cichero J.A.Y, Suter M. Texture-modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions.  Nutr Diet.  2007;64:S53-76
• The International Dysphagia Diet Standardisation Committee. Complete IDDSI Framework – Detailed Definitions.