Introduction
Methods
Strategy and Incorporation
Ethical Considerations
Review of Existing National Terminologies
Survey 1 (International Current Practice)
Question | Response options | Patients and their carers or support organizations | Healthcare professionals and food service staff | Dysphagia research scholars | Industry representatives |
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What country are you located in? | Free text | X | X | X | X |
How would you describe yourself? | An adult with dysphagia | X | |||
I care for an adult with dysphagia | X | ||||
I care for a child with dysphagia | X | ||||
I am a member of an organization that specifically supports people with dysphagia | X | ||||
I am a member of an organization that supports children with dysphagia | X | ||||
Healthcare professional (specify) | X | ||||
Food service or catering professional | X | ||||
Representative of company manufacturing thickeners, thickened liquids, or barium | X | ||||
Representative of company manufacturing texture-modified foods | X | ||||
What is your work setting? | Hospital/acute care | X | X | ||
Rehab hospital | X | ||||
Long-term care/Home for the aged | X | ||||
Community care | X | ||||
Outpatient clinic | X | ||||
University | X | ||||
Government or private laboratory | X | ||||
Who are your patients/clients? | Adults | X | |||
Children | X | ||||
Mixed age group | X | ||||
What type(s) of dysphagia research do you conduct? | Clinical research into oropharyngeal dysphagia | X | |||
Clinical research into esophageal dysphagia | X | ||||
Fundamental swallowing research | X | ||||
Product development | X | ||||
Other (specify) | |||||
Do you/the person you care for/your patients use | Texture-modified foods | X | X | ||
Commercially prepared texture-modified foods | X | X | |||
Thickened liquids | X | X | |||
Commercially prepared thickened liquids | X | X | |||
A combination of the above | X | X | |||
Do you use standard terminology and guidelines for texture-modified foods and liquid thicknesses? | Yes/No/I don’t know with comments option | X | X | ||
Do you produce thickened liquids or products that will thicken liquids, for people with swallowing difficulties or those who are nutritionally compromised? | Ready-to-use drinks | X | |||
Powder thickeners | X | ||||
Liquid thickeners | X | ||||
Other (specify) | X | ||||
Do you produce thickened liquids, thickening agents, or barium products specifically for people with dysphagia? | Yes/No with comments option | X | |||
Do you produce foods for people with chewing and swallowing difficulties or those who are nutritionally compromised? | Ready-to-eat frozen meals | X | |||
Ready-to-eat packaged foods (tins, pouches) | X | ||||
Foods that need reconstituting | X | ||||
Other (specify) | X | ||||
Do you produce texture-modified foods specifically for people with dysphagia? | Yes/No with comments option | X | |||
Which terms do you use for texture-modified foods and liquid thicknesses | Terms for texture-modified foods (from least to most modified, separated by a comma) | X | X | X | X |
Terms for thickened liquids (from least to most modified, separated by a comma) | X | X | X | X | |
Where did you source the terms you use for thickened liquids and texture-modified foods? | National standards | X | X | ||
From the literature | X | X | |||
Self-developed | X | X | |||
Hospital or work facility | X | X | |||
Other (specify) | X | X | |||
Do you test the consistency of foods or liquids before eating or serving? | Yes/No with comments option | X | X | ||
How do you determine whether liquids are of the correct thickness? | Free text | X | |||
How do you determine if foods are of the correct texture? | Free text | X | |||
Do you formally test thickened liquids or texture-modified foods as part of your research? | Liquids: always/usually/rarely/never with comments option | X | |||
Food: always/usually/rarely/never with comments option | X | ||||
Barium: always/usually/rarely/never with comments option | X | ||||
For thickened liquids (including barium), do you record information about: | Viscosity: always/usually/rarely/never with comments option | X | X | ||
Density: always/usually/rarely/never with comments option | X | X | |||
Yield stress: always/usually/rarely/never with comments option | X | X | |||
If you formally evaluate thickened liquids or texture-modified foods, what measurement device(s) do you use? (For industry respondents, target measurement details were requested for each method) | Visual inspection | X | |||
Line spread test | X | X | |||
Bostwick consistometer | X | X | |||
Brookfield viscometer | X | X | |||
Cone and plate or parallel plate rheometer | X | X | |||
Other rheometer | X | X | |||
Food texture analyzer | X | X | |||
Sieve | X | ||||
Image analysis | X | ||||
Other (specify) | X | X | |||
For texture-modified foods, do you record information about | Particle size: always/usually/rarely/never with comments option | X | X | ||
Cohesiveness: always/usually/rarely/never with comments option | X | X | |||
Adhesiveness: always/usually/rarely/never with comments option | X | X | |||
Firmness: always/usually/rarely/never with comments option | X | X | |||
Springiness: always/usually/rarely/never with comments option | X | X | |||
Brittleness or fracturability: always/usually/rarely/never with comments option | X | X | |||
Hardness: always/usually/rarely/never with comments option | X | X | |||
Yield stress: always/usually/rarely/never with comments option | X | X | |||
Other (specify) | X | X | |||
Do you use a scheme (colors, numbers, shapes, etc.) to differentiate/communicate the different food textures and liquid thicknesses? | Yes/No with comments option | X | X | X | |
What problems, if any, are there with the terminology or definitions you currently use for thickened liquids or texture-modified foods? | X | X | |||
Where do you distribute your products? | Locally/regionally/nationally/internationally with product type identified | X | |||
Are there any other comments or recommendations you would like to make for the International Dysphagia Diet Standardisation Initiative? | Free text | X | X | X | X |
Additional optional information | Name and address for future contact | X | X | X | X |
Systematic Review of the Literature
Draft Framework Development
Classification of levels and exploration of measurement methods
Liquids
Foods
Survey 2: Feedback on Draft IDDSI Framework
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provide demographic information (e.g., the stakeholder group they identified with; country they lived/worked in);
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provide feedback regarding the draft framework:
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colors (ability to distinguish; ease of implementation; ease of reproducibility);
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number of levels (too few/too many, about right; ease of implementation);
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pyramid diagram (ease of understanding and implementation);
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names or labels of each level (ease of understanding and implementation);
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specific questions about the terms “slightly thick” liquids, “minced and moist” food, and the label “Level 7 minus”;
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detailed definitions of each level (ease of understanding; usefulness; relevance); and
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the Syringe Test (ease of understanding; likelihood of implementing the test).
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Comment about the overall framework; and
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what works well with the proposed framework; likelihood of implementation; and factors that would assist or impede implementation.
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Results
Survey 1 (Current International Practice)
Region | Names (least to most modified) |
---|---|
Africa | Normal/regular, nectar, syrup, pudding, thick |
Australia + New Zealand | Thin, mildly thick/level 150, moderately thick/level 400, extremely thick/level 900 |
Asia | Thin, slightly thick, mildly thick, medium thick, extra thick |
Canada | Thin, nectar, honey, pudding |
Europe | Normal, syrup/slightly thick, nectar, honey, pudding |
Ireland | Regular/normal, Gr 1, Gr 2, Gr 3, Gr 4 |
Middle East | Thin, mildly thick, moderately thick, other thick |
South America | Liquid, slightly thick, nectar, honey, pudding |
United Kingdom | Normal, stage 1, syrup, custard, pudding/stage 3 |
United States of America | Thin, nectar, honey, pudding |
Region | Names (least to most modified) |
---|---|
Africa | Normal, Soft, chopped, puree/mashed, liquid/blender |
Australia + New Zealand | Full/normal, soft, minced + moist, puree/smooth puree |
Asia | Regular, soft, minced/shredded, congee/puree, liquidized/blenderized |
Canada | Regular, soft, minced, puree |
Europe | Normal, soft/tender/cut up, ground/puree, liquid |
Ireland | Regular, soft, minced + moist, puree/smooth puree, liquidized |
Middle East | Solid, soft, minced + mashed, other puree |
South America | Solid, soft, mashed, thick puree, liquidized |
United Kingdom | Normal, fork mashable/soft, pre-mashed/texture D, puree, thin puree |
United States of America | Regular, advanced/stage 3, mechanical soft/chopped/stage 2, ground, puree/stage 1 |
Draft IDDSI Framework
Draft Definitions
Draft Measurement Guidelines
Liquids
Foods
Survey 2: International Feedback on Draft IDDSI Framework
Final IDDSI Framework
Liquid Specifications and Measurement
Food Texture Specifications and Measurement
Food Particle Size
Food Hardness, Cohesiveness, and Adhesiveness
Release of the Final IDDSI Framework
© The International Dysphagia Diet Standardisation Initiative 2016 @http://iddsi.org/framework/. Attribution is NOT PERMITTED for derivative works incorporating any alterations to the IDDSI Framework that extend beyond language translation.Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to 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.
Discussion
International Food Textures for Dysphagia Management
Accessible, Objective Testing Methods for Texture-Modified Liquids and Foods
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The lack of access to testing equipment and the expertise required to perform and interpret rheological testing.
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In addition to variations in flow associated with drink characteristics, flow rates during swallowing are expected to differ depending on a person’s age and level of impairment of swallowing function [59].