Effects of a Food-Shaping Agent on the Texture and Palatability of Hospital-Pureed Meat: A Comparison of Subjective and Instrumental Assessments.

The International Dysphagia Diet Standardisation Initiative (IDDSI) framework establishes a global standard, with standardized terms, descriptors and measurement criteria, to enhance dysphagia care. This paper presents one of the first documented successful implementations of IDDSI in a large acute care hospital. The implementation at the University Hospital Graz, a 1554-bed acute care facility, took place between 2021 and 2024. The project aimed to standardize practices in five patient-focused areas to improve knowledge, and facilitate multiprofessional communication. Based on the IDDSI Monitor, Aware, Prepare, Adopt (MAPA) model and IDDSI implementation guide, a project plan was developed. An interdisciplinary working group consisting of dietitians, Speech-Language Pathologists (SLPs) and chefs conducted comprehensive audits of all existing recipes and aligned clinical swallowing assessments and dietetic recommendations with IDDSI standards. Training programs ensured the consistent application of terminology across the therapeutic, nursing, and kitchen teams. Two staff surveys were conducted - one before and one after implementation. The working group successfully integrated IDDSI into clinical workflows, menu planning, charting and electronic health record systems. Staff surveys showed a significant increase in IDDSI awareness, rising from 42.1% to 76.7%, along with greater use of the IDDSI standardized terminology by the staff during the project's duration. Key implementation challenges included adapting recipes to meet IDDSI texture levels and integrating the framework into the utilized Cook and Chill food preparation system. Dual project lead with one Speech-Language Pathologist (SLP) and one dietitian, targeted training, and the active engagement of kitchen staff were crucial to the project's success. This study demonstrates that implementing IDDSI in acute care settings is both feasible and beneficial, leading to multiprofessional knowledge of the framework and fostering collaboration.

Thickened fluids are commonly used in the medical management of individuals who suffer from swallowing difficulty (known as dysphagia). International Dysphagia Diet Standardization Initiative (IDDSI) developed a standardized terminology and description for texture-modified foods and thickened fluids to allow dysphagia patients to receive the correct consistency of food/drink. Syringe flow test and fork drip test are suggested by IDDSI to identify the drink category (IDDSI Levels 1-4). These practical methods are widely welcomed by carers and patients because of their simplicity. However, these methods are not most feasible for industrial applications, where objective measurements are required for industry for the purpose of quality control of such products. Therefore, our aim in this work was to develop quantitative and objective measurements that best describe IDDSI level category for use as an objective framework. Two measuring techniques, syringe flow test and fork drip test, recommended by IDDSI were evaluated in two different sets of experiment. Participants were recruited to categorize fluid samples of known texture parameters using syringe flow test and fork drip test techniques. The apparent stress measured from Ball-Back Extrusion (BBE) technique for each of the fluid category (IDDSI Levels 1-4) was calculated. Bands of apparent stress for each of the fluid category were developed from two measuring techniques, syringe flow test and fork drip test. An inconsistency was observed between these two measuring techniques for IDDSI Level 3 fluid due to different dominating factors in the two tests. However, we proposed to combine the results from the two experiments to develop a quantitative range for each IDDSI Level as objective complements to the IDDSI Framework. Thickened fluid manufacturers are encouraged to follow the proposed guidelines presented once they are clinically validated and use them fine-tune their products, thus enhancing the safety of individuals with dysphagia.

Determination of the international dysphagia diet standardization initiative level of commercially available oral nutritional supplements.

Texture-modified foods and thickened fluids play a major role in clinical treatment for individuals who suffer from swallowing difficulties (known as dysphagia). International Dysphagia Diet Standardization Initiative (IDDSI) developed a standardized terminology and description for texture-modified foods and thickened fluids to allow dysphagia patients to receive the correct consistency of food/drink. While the IDDSI framework provides a consistent texture description (Levels 0-7) and is widely accepted as an international standard, testing and assessment of IDDSI texture level are qualitative in nature and subjective in manner. These methods were proposed primarily for use by frontline carers, but are not most ideal for industrial purposes of quality control of such products. Therefore, the main aim of this work was to develop a quantitative instrumental method that best describes IDDSI levels as an objective framework. A set of test samples, including commercially available instant mashed potato, baby rice cereal, and cooked potato cubes of varying texture, were prepared. Two IDDSI measuring techniques, fork pressure test and spoon tilt test, were used to evaluate texture grades of these samples. Puncture and compression tests based on texture analyzer were used to assess cohesiveness, adhesiveness, firmness, and hardness for each food category (Levels 4-7). Thresholds of cohesiveness and adhesiveness, as well as bands of acceptable firmness and hardness for each food category were clearly identified and are proposed as objective complements to the IDDSI framework.

Texture-modified diets (TMDs) are commonly prescribed for older adults with swallowing difficulties to improve swallowing safety. The International Dysphagia Diet Standardization Initiative (IDDSI) provides a framework for terminology, definitions and testing of TMDs. This observational mixed-method study used the consolidated framework for implementation research (CFIR) to establish the barriers and enablers to IDDSI adoption in aged-care facilities (ACFs). Five New Zealand ACFs who had adopted IDDSI > 12months previously were recruited. Evaluation tools were developed based on CFIR constructs, integrating data from (i) mealtime observations; (ii) manager interviews and (iii) staff (nursing, carers and kitchen) self-administrated surveys. All facility and kitchen managers were IDDSI aware and had access to online resources. Three sites had changed to commercially compliant products post-IDDSI adoption, which had cost implications. Awareness of IDDSI amongst staff ranged from 5 to 79% and < 50% of staff surveyed felt sufficiently trained. Awareness was greater in large sites and where IDDSI was mandated by head office. Managers had not mandated auditing and they felt this had led to reduced perceived importance. Managers felt staff required more training and staff wanted more training, believing it would improve food safety and quality of care. Lack of a dedicated project leader and no speech pathologist on-site were perceived barriers. Collaboration between healthcare assistants, kitchen staff and allied health assisted implementation. ACF staff were aware of IDDSI but staff awareness was low. Using the CFIR, site specific and generic barriers and enablers were identified to improve future implementation effectiveness. Managers and staff want access to regular training. Multidisciplinary collaboration and improving communication are essential. ACFs should consider TMD auditing regularly. Successful implementation of IDDSI allows improvement of quality of care and patient safety but requires a systematic, site-specific implementation plan.

The thickness levels of fluids for patients with dysphagia are established according to the guidelines of the National Dysphagia Diet (NDD) and International Dysphagia Diet Standardization Initiative (IDDSI). The nectar- (level 2), honey- (level 3), and pudding-like (level 4) fluids in NDD are consistent with the mildly (level 2), moderately (level 3), and extremely (level 4) thick fluids in IDDSI, respectively. In this study, NDD levels were compared with IDDSI levels by estimating both the apparent viscosity (ηa,50) and the residual volume (mL) in the IDDSI syringe flow test of thickened drinks prepared with a commercial xanthan gum-based thickener at different concentrations (0.1∼3.1%, w/w). The concentration range of the thickener in thickened drinks at each IDDSI and NDD level increased in the following order: water> orange juice> milk. A small difference was noted in the range of thickener concentration in the same NDD and IDDSI levels for thickened milk when compared with other thickened drinks. These results indicate that the thickener concentration ranges of thickened drinks for the classification of NDD levels differed from those of IDDSI levels, and they appeared to be greatly influenced by the type of drink. These findings could provide useful information for practically indi-cating the reliable thickness levels by the IDDSI flow test in clinical practice.

The International Dysphagia Diet Standardisation Initiative (IDDSI) framework was established to provide standardized terminology and objective measures to assess foods and liquids for persons with swallowing difficulties. This clinical focus article reports the findings and clinical implications of the flow testing of infant formulas thickened with infant cereal completed as part of the transition process to IDDSI for one large pediatric quaternary care hospital. To determine a common recipe that could be used to thicken formulas with infant cereal to the appropriate IDDSI levels, three clinicians completed flow testing on 94 infant formulas. To examine intra- and interclinician variability in the process, they repeated flow testing with three commonly used formulas and infant cereal. Clinicians were unable to identify a standard recipe (infant formula + infant cereal combination) that consistently thickened different formula brands to a desired IDDSI thickness level, as there was pronounced variability across and within infant formulas. Reliability testing revealed that, overall, clinician mixers were consistent in replicating similar results to themselves and to each other and that, instead, greater variability lies within the formula (and infant formula + infant cereal combination). Based on findings of pronounced variability within and across infant formulas, our institution determined that the creation of a standard recipe for achieving IDDSI thickness levels of formula mixed with infant cereal was not feasible or clinically appropriate. We offer recommendations for similar institutions for advancing clinical management of infant dysphagia using the IDDSI flow test and directions for future research.

Diet modification is a common compensation strategy to promote swallowing safety in patients with swallowing difficulties. The International Dysphagia Diet Standardisation Initiative (IDDSI) guideline provides qualitative descriptions on texture-modified food and thickened liquid. This study aimed to establish quantitative textural and rheological data on different IDDSI levels based on common Chinese ingredients and dishes. Textural and rheological properties of 226 samples of various food textures and 93 samples of various liquid consistencies were obtained using a texture profile analysis (TPA) and viscometer, respectively. The establishment of such quantitative data can be used for future texture-modified food product development and research purposes.

Effect of the addition of hydrocolloids on beef texture: Targeted to the needs of people with dysphagia

Purpose: Gelatin-based desserts are a popular method to promote liquid consumption for individuals with dysphagia. Unique characteristics of these desserts in the United States pose a challenge for appropriate presentation to patients in relation to their clinically approved International Dysphagia Diet Standardisation Initiative (IDDSI) level. The purpose of this study was to determine the constancy of IDDSI level and transitional food status for 16 nationally available gelatin-based desserts based on preparation (premade and ready-to-make) and formulation (regular and sugar-free). Method: Three semiblinded raters used IDDSI testing methods to assign an IDDSI level and transitional food rating immediately, 15 min, and 60 min after removing from the refrigerator. Results: The majority (89.6%) of the samples were rated as Level 7 Easy to Chew, across all time intervals, with good interrater agreement (Mann–Whitney U Test, immediately U = 101.0, p = .934; 15 min U = 101.0, p = .934; 60 min U = 94.5, p = .711). Approximately a quarter of samples were categorized as a transitional food, though 4% could not be categorized using current IDDSI characteristics. Conclusions: Overall, this study presents that the current characteristics and physiological rationale may overestimate the skills required for gelatin-based desserts and inappropriately classify them as nontransitional foods. As with all products, individual gelatin-based desserts should be tested at the time of presentation to the patient. However, clinical evaluation should further determine the appropriateness of the dessert for each patient.

Texture-modified food is a common strategy in dysphagia management for increasing safety of swallowing. It is essential for the patient to receive the prescribed diet based on clinical and instrumental examination of swallowing in order to be able to benefit from rehabilitation and avoid complications. Variations in terminology and definitions regarding texture-modified food and liquids demonstrate the need for international standardized terminology. We aimed to assess suitability of texture-modified diets used at a rehabilitation hospital in terms of the International Dysphagia Diet Standardization Initiative guidelines. A texture-modified main dish was analyzed for 5 days (15 samples of pureed and 10 samples of minced texture) at lunch time by 2 trained assessors using International Dysphagia Diet Standardization Initiative-recommended testing methods. The majority of pureed and minced food samples did not suit the comparable International Dysphagia Diet Standardization Initiative levels. The results underline the need for implementing the International Dysphagia Diet Standardization Initiative guidelines in order to provide an appropriate texture-modified diet for patients with neurogenic dysphagia and support dysphagia management within inpatient rehabilitation.

Dysphagia affects up to 70% of care home residents, increasing morbidity and hospital admissions. Speech and language therapists make recommendations to support safe nutrition but have limited capacity to offer ongoing guidance. This study aimed to understand if recommendations made to support safe and effective care are implemented and how these relate to the actual care delivered. Eleven mealtimes with residents with dysphagia were observed during 2020 using a tool capturing 12 elements of expected practice. Staff actions during mealtimes were compared with adherence to residents' care plans and speech and language therapist recommendations. Written recommendations predominantly focused on food and fluid modification.Observations (n = 66) revealed food texture, posture, and alertness were adhered to on 90% of occasions, but alternating food and drink, prompting and ensuring swallow completed adherence was less than 60%. Thickened fluids frequently did not align with required International Dysphagia Diet Standardisation Initiative levels. Nutrition care provided in the dining room was less safe due to a lack of designated supervision. Care homes need to be supported to establish a safe swallowing culture to improve residents' safety and care experience. What is already known on this subject? Dysphagia is associated with considerable morbidity and mortality and has been identified as an independent risk factor for mortality in nursing home residents. There is evidence that compensatory swallowing strategies, safe feeding advice and dietary modifications can reduce the risk of aspiration pneumonia. Care for nursing home residents at mealtimes is often task-centred and delegated to those with limited training and who lack knowledge of useful strategies to support the nutrition and hydration needs of residents with dysphagia. What this study adds? Written advice from speech and language therapists on safe nutrition and hydration for residents with dysphagia is focused mainly on food and fluid modification. Nurses and healthcare assistants have limited understanding of International Dysphagia Diet Standardisation Initiative levels or safe swallowing strategies and recommended practices to support safe nutrition care for residents with dysphagia are inconsistently applied especially when residents are eating in dining areas. Care homes are not aware of Royal College of Speech and Language Therapists guidance on how safe nutrition care of residents with dysphagia should be supported. What are the clinical implications of this work? Care homes need to prioritise a safe swallowing culture that ensures that residents with swallowing difficulties are assisted to eat and drink in a way that enhances their mealtime experience and minimises adverse events that may result in hospital admission. Speech and language therapists could play an important role in training and supporting care home staff to understand and use safe swallowing strategies with residents with dysphagia. The Royal College of Speech and Language Therapists could provide more assistance to care homes to support and guide them in how to implement safe feeding routines. Care home staff have limited knowledge about how to implement safe feeding routines and need more guidance from speech and language specialists on how they can support residents with dysphagia to eat safely. Creating a safe swallowing culture within care homes could help to improve nutrition care and enhance patient safety.

SummaryDysphagia is a symptom that refers to difficulty during the progression of the alimentary bolus from the mouth to the stomach. This may lead to malnutrition and negative effects on quality of life. Doctors and dieticians around the globe are looking for nutritious texture‐modified diets which are easier to chew and swallow thus could reduce the risks associated with choking in dysphagia patients. In this study, different functional liquid diets were formulated under International Dysphagia Diet Standardization Initiative (IDDSI) levels 0–2. The diets were made with incorporation of various fruits and vegetables to enhance their nutritional profile. The formulated liquid diets were analysed for their proximate composition, colour, antioxidant and sensory properties. The formulated liquid diets were high in nutrients and antioxidants. Also, all the formulated products were highly acceptable based on various sensory attributes indicating their potential to be incorporated in the diet plan of dysphagia patients. Electromyography (EMG) study was conducted to acquire myoelectrical activities of both masseter and suprahyoid muscles during oral processing of liquid diets by human subjects. The acquired EMG oral processing parameters significantly (P &lt; 0.05) correlated with ease of swallowing and IDDSI levels. Hence, EMG technique provides in vivo texture evaluation and real‐time swallowing patterns and thus can be an effective approach for the formulation of texture‐modified diets for dysphagia patients.

Texture-Modified Diets are Associated with Poor Appetite in Older Adults who are Admitted to a Post-Acute Rehabilitation Hospital

Engineering plant-based protein-rich soft and bite-sized 3D printed dysphagia food