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

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Dysphagia affects ~ 8% of the world s popula0on! 560 million In US & Canada, 55-68% reported in nursing homes In Japan, up to 55% in aged person facility Short or long term problem Adults and Children ea0ng drinking swallowing chewing sucking controlling saliva taking medica0on protec0ng the airway

Dysphagia Two primary func0onal concerns: Ability to swallow safely, without material entering the airway (penetra0on- aspira0on); Ability to swallow efficiently, without leaving residue behind in the throat and taking sufficient by mouth to meet nutri0onal needs

Reasons for modifying food and liquids : Safety (Choking- Am J Prev Med, 2005, 28(1): 65-69; Aspira0on- Dysphagia, 2011: 26(4): 392-8. ) Foods = choking risk Autopsy results: 69% choked at home; 9.5% in hospital Types of food choked on: 35% = Sausage in bun, sandwich, meat, vegetables, noodles 61% = puree, ground meat, mashed fruit Liquids = slower flow, increased control

Reasons for modifying foods and liquids: Eﬃciency Fa0gue/Weakness Poor muscle movement/ coordina0on Suﬃcient nutrients and adequate hydra0on to support recovery maintain health

What do we call it? 8

Why do we need a standardised system? Safety Mul0ple labels and defini0ons cause confusion Within and between ins0tu0ons Food services Health care professionals Family/Care providers Individuals with swallowing difficul0es

Why do we need a standardised system? Clinical efficiency Avoids re- assessment to determine safe liquid and diet levels Commercial implica0ons ready to use/off- the- shelf items that are consistent from manufacturer/supplier to manufacturer/supplier and similar to those produced in hospitals/care facili0es/at home Development of clinical evidence and conduc0ng research Lack of consistency

Na0onal Standards USA, UK, Australia, New Zealand, Ireland, Sweden, Denmark, Japan

Global implica0ons (texture modified food) Ireland Texture B = minced & moist Texture D = liquidised UK Texture B = thin puree Texture D = pre- mashed dysphagia diet

Global implica0ons (clinical recommenda0ons) honey?

Four stage plan 2013-2015 Stage 1 Collabora0on + consolida0on of exis0ng data Stage 2 Gather the evidence literature review and stakeholder survey Stage 3 Interlace technical + research evidence with clinical and cultural needs Stage 4 Consolida/on, Stakeholder Consulta/on & Publica/on

Open Access Publica0on http://tinyurl.com/q54terf

Interna0onal Stakeholder Consulta0on #1: n=2049; 33 different countries Persons with dysphagia + carers; Professional associa0ons that support; Health care professionals + food service; Industry; Researchers

Foods: 54 labels; 4-5 levels texture modifica0on + normal most reported

Most commonly 4-5 levels food textures most osen reported Health Professionals & Food Service Survey 1 2 3 4 5 16% use a colour, number [1,II] or scheme to iden0fy TM foods

Health Professionals & Food Service Survey Most commonly 3-4 levels of liquid thicknesses most osen reported 25% use a colour, number [1,II] or scheme to iden0fy Thickened liquids

Liquids: 27 labels; 3+ levels thickness levels + normal

Health Professionals & Food Service Survey Only 40% of respondents check that texture modified foods and thickened liquids are of appropriate consistency before serving!?!

Systema0c Review Original Search Synthesis 36 ~ 10,000 non- duplicate ar0cles!!! Relevancy Review ~ 488 ar0cles ar0cles Quality Ra/ng Check / Inter- Rater Reliability Check

hdp://bit.ly/1wvzydp IDDSI Systema0c Review

IDDSI Systema0c 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 par0cular rheological values that define the boundaries of effec0ve thickening (either just thick enough or too thick)

IDDSI Systema0c Review There IS evidence solid food and thicker consistencies require greater effort in oral processing and swallowing There is very lidle literature specifically about texture modified food used for the management of dysphagia

Four stage plan 2013-2015 Stage 1 Collabora0on + consolida0on of exis0ng data (Completed August 2013) Stage 2 Gather the evidence (Systema0c Review & Analysis of Stakeholder Surveys Completed October 2014) Stage 3 Interlace technical + research evidence with clinical and cultural needs (Completed February 2015)

Expert Panel Mee0ng Vancouver January 2015 Bringing together published standards; stakeholder feedback; research from systema0c review Determine Dras Number of levels Labels for levels Colour/number system Methods of assessment (low tech + high tech)

IDDSI CommiDee Ben Hanson UK Jun Kayashita Japan Caroline Lecko UK Joe Murray US Jan Duivestein Canada Mershen Pillay S. Africa Peter Lam Canada Julie Cichero Australia Roberto Dantas Brazil Soenke Stanchus Germany Jianshe Chen China Interna0onal Co- Chairs Catriona Steele Canada

Dras Framework Stakeholder Consulta0on #2: May 2015 Support for: overall framework colours schema names of levels** (except for slightly thick) the syringe test name minced and moist the detailed descrip0ons

Interna0onal Stakeholder Consulta0on #2: Dras framework n=3190; 57 different countries Persons with dysphagia + carers; Professional associa0ons that support; Health care professionals + food service; Industry; Researchers

Refined final Framework Launched Kyoto, Japan September 2015

Detailed Descriptors & Tes0ng Methods Drinks (Launched Sept 2015 + ESSD Conference)

Detailed Descriptors & Tes0ng Methods: Foods to be released 23 Oct 2015, China

FAQ Our facility only uses to levels of thick fluids and 2 levels of thickened liquids That s fine please just use the IDDSI labels it doesn t mader if there are gaps There is no need for facili0es to offer every level, only those that they use Aged care facility vs. paediatric seng vs. acute hospital vs. rehab hospital vs. home

For Australia where to now

Biggest changes for Australia Number of levels One addi0onal level for drinks Two addi0onal levels for foods Colours New colours for drinks Introduc0on of colours for foods Numbers Numbers for foods and drinks

Currency Converter - Drinks Australian Standards Unmodified regular 0 Thin 1 Slightly Thick Level 150 Mildly thick 2 Mildly Thick Level 400 Moderately Thick 3 Moderately Thick Level 900 Extremely Thick 4 Extremely Thick

Currency Converter - Foods Australian Standards Regular Texture A Sos Texture B Minced and Moist 7 Regular 6 Sos 5 Minced & Moist Transi0onal Foods Texture C Smooth puree 4 Pureed 5 Liquidised

What are Transi(onal foods? Foods that start as one texture and change into another with moisture or temperature Minimal chewing required Tongue pressure may be sufficient to break food down aser altera0on in moisture or temperature

Melt- in- the mouth Deforma0on aser 1ml water for 1 min Result aser fork pressure dry

Consulta0ons and Progress to date In principle support for uptake using the collabora0ve Aware- Prepare- Adopt Model AUSTRALIA Die00ans Associa0on of Australia (DAA) + Speech Pathology Australia UNITED KINGDOM Royal College Speech + Language Therapists Bri0sh Diete0c Associa0on Royal College of Nursing Hospital Caterer s Assn Na0onal Ass Care Catering Mee0ng with American Speech + Hearing Associa0on and Academy of Diete0cs Nov 2015 CANADA Canadian Diete0c Associa0on Canadian Associa0on of Speech- Language Pathologists + Audiologists Canadian Associa0on of Occupa0onal Therapists

Aware- Prepare- Adopt Model for uptake Aware Build awareness across facili0es/sectors to all impacted clinicians, professional associa0ons and their boards, industry, administrators, government, supply chain and support staff Communicate who, what, where, when, why & how impacted Prepare Assess processes and protocols that may need to change Approve product changes, prepare materials /inventory/computer management Train clinicians, staff involved (e.g. IDDSI Flow test etc.) Adopt Introduce new IDDSI system to pre- packaged goods and at facility level in food service chain Transi0on and integra0on

Barriers to uptake.. Change management Language and cultural barriers Training IDDSI #2!

Enablers for uptake.. Inter- disciplinary collabora0on Support from industry Photos videos Low tech tes0ng methods Educa0onal material and sessions IDDSI #2!

www.iddsi.org

Email: julie.cichero@iddsi.org

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