Webinar Title: The International Dysphagia Diet Standardisation Initiative Framework

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Webinar Title: The International Dysphagia Diet Standardisation Initiative Framework Description: This presentation will introduce the (IDDSI) framework and provide an update on awareness and

1 Webinar Title: The International Dysphagia Diet Standardisation Initiative Framework Description: This presentation will introduce the (IDDSI) framework and provide an update on awareness and implementation around the world. From 2013, a multidisciplinary, international group has been working to develop International standardised levels, names and definitions for texture modified food and thickened fluids for use in dysphagia. A common language provides increased safety for individuals with dysphagia. The project has been conducted over four stages, commencing with reviewing existing national published standards, surveying stakeholders for their needs of an international standardised terminology, a systematic review of the literature to support the use of texture modified foods and thickened liquids, and stakeholder consultation of the draft framework that was released for public comment in May, The IDDSI standards are suitable for use with clients of all ages, in all care settings and across cultures. This presentation will introduce the IDDSI standards and explain how the International Standards map with existing standards. The presentation will include learnings from trials of the new standards in pilot sites. It will also address implementation strategies based on experiences from other countries that have implemented national dysphagia diets. Course Objectives: After this presentation, participants will be able to: 1. To introduce the IDDSI International framework. 2. To explain how the new IDDSI International standards map to the various terminologies and existing standards using examples across care settings and client groups. 3. To provide information regarding strategies to implementation of the new standards based on experiences of trial sites from around the world and experiences from other countries that have implemented national terminologies. Audience: Registered Dietitians (RD), Registered Dietitian Nutritionists (RDN), Dietetic Technicians Registered (DTR), Nutrition and Dietetic Technicians Registered (NDTR) and members of the interdisciplinary team Instructions for Obtaining Continuing Professional Education (CPE): Becky Dorner & Associates is a Continuing Professional Education (CPE) Accredited Provider (NU004) with the Commission on Dietetic Registration (CDR). CDR Credentialed Practitioners will receive 1.5 Continuing Professional Education units (CPEUs) for completion of this activity/material. To obtain the CPE Certificate, each participant must complete a simple evaluation and pass a short test (a grade of 70% is required). You can re-take the test as many times as needed. If you are interrupted and cannot finish the test, simply save the test and come back later to finish it. If you wish, you may also submit evaluations of the quality of activities/materials on the CDR Website at

2 A quick way to access the test is through your original order confirmation that you received after placing your order. Scroll towards the bottom and you find the area that says, To take a TEST, click on the link(s) below. There should be a link after the text (see highlight on sample to the right of this text). Click on the link, fill in your name to take the test, and receive the CPE certificate. If you are part of a group that purchased additional certificates, the confirmation will have the same number of links as certificates ordered. The person who received the confirmation can simply the links to the people who need to take the test. If you are a member on the Becky Dorner & Associates website, you can also access the test by logging into the website at Once you are logged in, click on the left tool bar on the category Members Only, then click on Purchased Tests. This page has all of the tests that you have purchased from Becky Dorner & Associates. Upon successfully completing the test, you will automatically be directed to the evaluation. Simply enter your address and complete the evaluation. When finished, click Submit Survey. Click on either print or download your certificate to generate the CPE Certificate with all of the course information including your name. Course Continuing Professional Education (CPE) Hours: 1.5 CDR Level: 1 Program Expiration Date: January 18, 2018 Learning Needs Codes and Performance Quality Indicators: 5210 Dysphagia Keeps abreast of current nutrition and dietetics knowledge and trends 3050 Feeding, swallowing, dentition Implements individualized services to reflect customer-centered approach as t pertains to the Customers physical, social, cultural, institutional and economic environment Maintains the knowledge and skill to manage a variety of disease states and clinical conditions 9050 Publication, communications of research outcomes Takes an active role in sharing information and knowledge Disseminates research or performance improvement outcomes to advance knowledge, change practice and enhance effectiveness of services Child and Adult Care Food Program Evaluates and incorporates individual and target group needs and requirements in order to develop menu items Co-Speaker: Julie Cichero, BA, BSpThy (Hons), PhD Speech Pathologist, Consultant, Adjunct Professor, Honorary Senior Fellow Julie Cichero is Co-Chair of the (IDDSI). Established in 2012, IDDSI is a team of international experts working for the common goal of improved safety through common terminology in texture modified foods and thickened liquids. Julie led the development of the Australian Standardised texture modified food and thickened liquid terminology, published in Julie is a speech pathologist and for 25 years has worked clinically and conducted research into dysphagia from infancy to old age in a range of public and private health

care settings. Julie is an adjunct professor with Queensland University of Technology and Honorary Senior Fellow with the University of Queensland, Australia.

She is a reviewer for 19 international journals in the fields of medicine, nursing, speech pathology, allied health, chemical engineering, nutrition and food technology.

3 care settings. Julie is an adjunct professor with Queensland University of Technology and Honorary Senior Fellow with the University of Queensland, Australia. She is an affiliate with the schools of Pharmacy, Chemical Engineering and Food Technology. Julie is a consultant to industry and provider of postgraduate education. She is a reviewer for 19 international journals in the fields of medicine, nursing, speech pathology, allied health, chemical engineering, nutrition and food technology. Julie has published more than 40 journal articles and co-authored four books Co-Speaker: Peter Lam, RD, CFE Registered Dietitian & Credentialed Food Service Executive Peter Lam is the Co-Chair of the International Dysphagia Diet Standardisation Initiative (IDDSI). Working with a team of international experts, the International Dysphagia Diet Standardisation Initiative has developed an international standardised framework for texture modified foods and thickened liquids. Prior to IDDSI, Peter was the lead of the Dysphagia Diet Terminology Standardization Project in Canada. Peter is a Registered Dietitian, Professional Practice Consultant and a Credentialed Foodservice Executive in Vancouver, BC, Canada. Peter is a past national president of the Canadian Association of Foodservice Professionals and was Chair of the Dietitians of Canada Dysphagia Assessment & Treatment Network. He also served as Board Chair for the College of Dietitians of British Columbia. Peter is an appointed clinical instructor at the University of British Columbia. Questions about the Continuing Professional Education Program? Please contact Becky Dorner & Associates, Inc. at info@beckydorner.com or

National Dysphagia Diet Disclaimer The material in this appendix should be regarded as the beginning of a discussion and research agenda on the topic of viscosity and shear rates The suggested ranges

4 National Dysphagia Diet Disclaimer The material in this appendix should be regarded as the beginning of a discussion and research agenda on the topic of viscosity and shear rates The suggested ranges do not reflect those currently used for any organization or company, but are meant to be a catalyst for more research in this area.it is fully expected that the suggested ranges here will be modified as soon as more research is available. National Dysphagia Diet Disclaimer these categories do not necessarily represent the ranges expected for true dietary nectars or honey, nor do they address the serving temperature of actual food. Instead, the borders and ranges suggested here are intended to be used as a basis for discussion...further study and peer-reviewed, scientific data will be needed to truly quantify the management parameters surrounding the complex diagnosis of dysphagia. National Dysphagia Diet, P. 36 National Dysphagia Diet, P. 26 Why do we need a standardised system? Safety Multiple labels and definitions cause confusion Within and between institutions oindividuals with swallowing difficulties ofamily/care providers ohealth care professionals ofood services Why do we need a standardised system? IDDSI Framework development process Turner et al., 2008: Implement Sci 3: 45-53; Qaseem et al., 2012 Ann Intern Med, 156: Clinical efficiency o Avoids re-assessment to determine safe liquid and diet levels Commercial implications o ready to use/off-the-shelf items that are consistent from manufacturer/supplier to manufacturer/supplier and similar to those produced in hospitals/care facilities/at home Development of clinical evidence and conducting research o Lack of consistency Followed key elements of evidence-based practice guideline development National Health and Medical Research Council (NHMRC) National Institute of health and Clinical excellence in the UK (NICE) The New Zealand Guidelines Group (NSGG) Scottish Intercollegiate Guideline Network (SIGN) Council of Europe World Health Organisation (WHO) 2

Key elements of the framework development process from these groups includes: Establishment of multidisciplinary guideline development group Involvement of consumers/stakeholders Clear identification

development group IDDSI Board of Directors Ben Hanson UK Jun Kayashita Japan Caroline Lecko UK Luis Riquelme US Jan Duivestein Canada Mershen Pillay S.

5 Key elements of the framework development process from these groups includes: Establishment of multidisciplinary guideline development group Involvement of consumers/stakeholders Clear identification of clinical issues Systematic review and appraisal of quality literature Process for drafting the recommendation of the multidisciplinary group Consultation with others beyond the multidisciplinary development group IDDSI Board of Directors Ben Hanson UK Jun Kayashita Japan Caroline Lecko UK Luis Riquelme US Jan Duivestein Canada Mershen Pillay S. Africa Peter Lam Canada Julie Cichero Australia Roberto Dantas Brazil Sönke Stanschus Germany Jianshe Chen China Catriona Steele Canada International Co-Chairs Four stage plan Stage 1 Collaboration + consolidation of existing data (Completed August 2013) Stage 2 Gather the evidence (Systematic Review & Analysis of Stakeholder Surveys Completed October 2014) Stage 3 Interlace technical + research evidence with clinical and cultural needs (Completed February 2015) Stage 4 Consolidation & Dissemination (Completed November 2015) First IDDSI Publication The Need for International Terminology and Definitions for Texture-Modified Foods and Thickened Liquids Used in Dysphagia Management: Foundations of a Global Initiative Cichero et al., 2013, Curr Phys Med Rehabil Rep, 1: , DOI /s z Publications (Pending, Dysphagia Journal 2016; Kempen Pilot submitted to British Journal Neuroscience Nursing ) International Stakeholder Consultation #1: n=2049; 33 different countries IDDSI Systematic Review Second IDDSI Publication The Influence of Food Texture and Liquid Consistency Modification on Swallowing Physiology and Function: A Systematic Review Steele et al., 2015, Dysphagia, 30: DOI /s x Persons with dysphagia + carers; Professional associations that support; Health care professionals + food service; Industry; Researchers 3

IDDSI Systematic Review There IS evidence that thickening helps those who aspirate thin liquids There is ALSO evidence that there is such a thing as

effective thickening (either just thick enough or too thick) IDDSI Systematic Review There IS evidence solid food and thicker consistencies require

dysphagia Putting it all together IDDSI Framework (May 2015 International Comment; September 2015 released) 2015 Vancouver meeting interlaced

thickened drinks International Stakeholder Consultation #2: Draft framework n=3190; 57 different countries Overwhelming positive feedback

6 IDDSI Systematic Review There IS evidence that thickening helps those who aspirate thin liquids There is ALSO evidence that there is such a thing as too thick, where residue begins to accumulate There is no specific evidence to point to particular rheological values that define the boundaries of effective thickening (either just thick enough or too thick) IDDSI Systematic Review There IS evidence solid food and thicker consistencies require greater effort in oral processing and swallowing There is very little literature specifically about texture modified food used for the management of dysphagia Putting it all together IDDSI Framework (May 2015 International Comment; September 2015 released) 2015 Vancouver meeting interlaced stakeholder feedback + research evidence To develop a culturally-sensitive, agespan relevant framework for classifying texture modified foods and thickened drinks International Stakeholder Consultation #2: Draft framework n=3190; 57 different countries Overwhelming positive feedback internationally Very little negative feedback Persons with dysphagia + carers; Professional associations that support; Health care professionals + food service; Industry; Researchers 4

Complete IDDSI Framework; IDDSI Testing Methods; IDDSI Evidence; IDDSI FAQs

kitchens as the basis for classifying thickness Need a simpler, but valid and

Posthumus Funnel used in dairy industry to measure liquid thickness Looks like

closely matches flow conditions within the oral cavity IDDSI 10 ml syringe

7 Complete IDDSI Framework; IDDSI Testing Methods; IDDSI Evidence; IDDSI FAQs The Measurement Dilemma Measuring viscosity is TOO complicated to use in kitchens as the basis for classifying thickness Need a simpler, but valid and reliable method for measuring thickness at the point-of-use IDDSI Flow test ( van Vliet, 2002, Food Quality and Preference, 13, Similar to Posthumus Funnel used in dairy industry to measure liquid thickness Looks like a large syringe geometry allows for both shear and elongation that more closely matches flow conditions within the oral cavity IDDSI 10 ml syringe specifications Example videos of the IDDSI flow test can be found on YouTube and accessed through the resources page on the IDDSI website: Ben Hanson 31/3/2015 5

Slump height, yield stress IDDSI Flow test Level 1 Slightly Thick demonstration video Drips slowly or in

flow through and form a tail below the fork Does not dollop, flow or drip continuously through the fork prongs

Fork Test: The slots/gaps between the tines/prongs of a standard metal fork typically measure 4 mm.

IDDSI Fork Pressure Test: A fork can be applied to the food sample to observe its behavior when pressure is

8 Slump height, yield stress IDDSI Flow test Level 1 Slightly Thick demonstration video Drips slowly or in dollops/strands through the tines/prongs of a fork Sits in a mound or pile above the fork A small amount may flow through and form a tail below the fork Does not dollop, flow or drip continuously through the fork prongs IDDSI tests Level 5 Minced & Moist demonstration video Measurement for Foods IDDSI Measurement for Foods IDDSI Fork Test: The slots/gaps between the tines/prongs of a standard metal fork typically measure 4 mm. This provides a useful compliance measure for particle size of foods at Level 5 - Minced & Moist. IDDSI Fork Pressure Test: A fork can be applied to the food sample to observe its behavior when pressure is applied. Pressure applied to the food sample has been quantified by assessment of the pressure needed to make the thumb nail blanch noticeably to white. 6

Transitional foods Gisel, 1991, Deve med Child Neurol, 33, 69-79;

a, 28, 501-510 Start as one texture (e.g.

or temperature (heat) change occurs Minimal chewing required Tongue

moisture or temperature Developmental teaching or rehabilitation of

not return to its original shape when pressure is released How were

The final scheme has 6 colours (plus black & white) which are all

blindness tested - particularly for red blind and green blind which

org/faq/ 40 Monitor-Aware-Prepare-Adopt Model for Implementation

across facilities/sectors to all impacted clinicians, professional

supply chain and support staff Communicate who, what, where, when, why

Approve product changes, prepare materials /inventory/computer

Create a local/regional IDDSI interprofessional champion team Review

9 Transitional foods Gisel, 1991, Deve med Child Neurol, 33, 69-79; Dovey 2013, Dysphagia, 28, Start as one texture (e.g. solid) and change to another when moisture is applied (saliva, water) or temperature (heat) change occurs Minimal chewing required Tongue pressure may be sufficient to break food down after alteration in moisture or temperature Developmental teaching or rehabilitation of chewing skills Thumb nail blanched to white Sample squashes and does not return to its original shape when pressure is released How were the colours chosen? The final scheme has 6 colours (plus black & white) which are all individually distinguishable across all the different types of colour blindness tested - particularly for red blind and green blind which are the most common variants Monitor-Aware-Prepare-Adopt Model for Implementation MONITOR Aware Prepare Adopt Implementation Framework Build awareness across facilities/sectors to all impacted clinicians, professional associations and their boards, industry, administrators, government, supply chain and support staff Communicate who, what, where, when, why & how impacted Assess processes and protocols that may need to change Approve product changes, prepare materials /inventory/computer management Train clinicians, stakeholders and all staff involved Create a local/regional IDDSI interprofessional champion team Review current practices, terminology & systems Map existing systems & terminology to IDDSI framework Share findings with all stakeholder Introduce new IDDSI system to commercially ready to use, pre-packaged goods and at facility level and in food service chain Transition and integration 7

infant formula, supplements) pp ) 1 Slightly Thick Nectar-thick Regular 7 Regular Dysphagia Advanced 6 Soft 2 Mildly Thick Dysphagia Mechanically Altered 5 Minced & Moist 3

10 Mapping to IDDSI - Drinks Mapping to IDDSI - Foods Current NDD Standards Current NDD Standards 0 Thin (Naturally thick liquids, e.g. infant formula, supplements) pp ) 1 Slightly Thick Nectar-thick Regular 7 Regular Dysphagia Advanced 6 Soft 2 Mildly Thick Dysphagia Mechanically Altered 5 Minced & Moist 3 Moderately Thick Dysphagia Pureed 4 Pureed Honey-thick Spoon-thick 5 Liquidised 4 Extremely Thick >1750 Transitional Foods Thin Implementation Framework Develop a plan to introduce IDDSI Communicate plan & consult all stakeholders Review Revise Monitor Determine launch date and prepare all stakeholders Implementation Framework Review Launch Monitor Revise Implement 8

Consultations and international communications to date GERMANY Kempen, First IDDSI Pilot site Progressive roll out Neuro Wardhospital - Artemed healthcare network (10 hospitals) UK Implementation

achievement award from ASHA CANADA 2016; American IRELAND Support for Academy of implementation CHINA Nutrition + Meeting with IALST from DC, SAC, CAOT, Implementation Dietetics voted to and Irish

Brunswick professionals care manual endorsement NEW ZEALAND ISRAEL Endorsement by NZSLT & awaiting Implementation task force commenced and led by NZDA board decision Government Ministry of Health

11 Consultations and international communications to date GERMANY Kempen, First IDDSI Pilot site Progressive roll out Neuro Wardhospital - Artemed healthcare network (10 hospitals) UK Implementation Task Force: BDA + RCSLT developing plans for UK implementation with early adopters AUSTRALIA SPA & DAA Board approval; time frame to implementation to be advised USA International Outstanding achievement award from ASHA CANADA 2016; American IRELAND Support for Academy of implementation CHINA Nutrition + Meeting with IALST from DC, SAC, CAOT, Implementation Dietetics voted to and Irish Nutrition CSNM, CAFP, taskforce formed adopt IDDSI and & Dietetic Ass Industry Partners Government will include IDDSI (INDI) Pilot in New regulators + health in online nutrition Taking to Boards for Brunswick professionals care manual endorsement NEW ZEALAND ISRAEL Endorsement by NZSLT & awaiting Implementation task force commenced and led by NZDA board decision Government Ministry of Health Incorporation of IDDSI into University courses has commenced in Ireland, UK, Sweden, Poland, Brazil, Japan, South Africa, Canada,USA, India, Slovenia, Hong Kong, China, Korea Creative Commons License IDDSI is licensed under the CreativeCommons AttributionSharealike 4.0 International License Translations Underway Allows cultural fine tuning Allows translation Belgium Brazil.. French Canada China France Germany India Israel Japan Korea The Netherlands Norway Poland Slovenia Sweden South Africa Thailand Turkey IDDSI Apps Android & ios - for Smartphones & Tablets 9

Name: Registration # I have viewed webinar and read all materials CPE Program Expiration Date: January 18, 2018 Program Number: 131903 # CPEs Awarded: 1.

12 Becky Dorner & Associates, Inc. Continuing Professional Education Certificate of Completion Program Title: The International Dysphagia Diet Standardisation Initiative Framework Participant Name: Registration # I have viewed webinar and read all materials CPE Program Expiration Date: January 18, 2018 Program Number: # CPEs Awarded: 1.5 CDR Learning Codes: Level: 2 Dysphagia Feeding, Swallowing, Dentition Publication, Communications of Research Outcomes Child and Adult Care Food Program CDR Accredited Provider: Becky Dorner & Associates, Inc. CDR Accredited Provider Number: NU004

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Introducing the new Interna0onal Dysphagia Diet Standardisa0on Ini0a0ve (IDDSI) Framework

Introducing the new Interna0onal Dysphagia Diet Standardisa0on Ini0a0ve (IDDSI) Framework Julie Cichero, IDDSI Co- Chair On behalf of IDDSI CommiDee Supported by Dysphagia affects ~ 8% of the world s