The document provides information on dysphagia (difficulty swallowing) and the International Dysphagia Diet Standardization Initiative (IDDSI) framework for classifying and describing texture-modified foods and thickened liquids for people with swallowing difficulties. It notes that over 51% of people in residential care have dysphagia, which can result in harm or death if not managed properly. It summarizes the IDDSI levels from 0 to 7 and emphasizes that staff must be trained to recognize dysphagia, manage risks, and prepare foods and liquids according to the correct IDDSI descriptors to help prevent choking and other complications. Resources and actions for implementing IDDSI standards are also outlined.

1. DCHC CHEF CLUB: NUTRITION & HYDRATION CHAMPION COURSE:
AN INTRODUCTION TO
DYSPHAGIA AND IDDSI.
What does
it all mean
and why is
it so
important?!

2. TEXTURE
MODIFIED
FOOD &
THICKENED
DRINKS
FOR PEOPLE
LIVING WITH A
SWALLOW
DIFFICULTY

3. Our National Patient Safety
Alerts
These alerts require action to
be taken by healthcare
providers to reduce the risk of
death or disability.
Resources to support safer modification of food and drink 27
June 2018
“A review of National Reporting and Learning System (NRLS) incidents over a recent two-year
period identified seven reports where patients appear to have come to significant harm because of
confusion about the meaning of the term ‘soft diet’. These incidents included choking requiring
an emergency team response, and aspiration pneumonia; two patients died.
Actions
Who: All organisations providing NHS funded-care for patients who have dysphagia or
need the texture of their diet modified for other reasons, including acute, mental
health and learning disabilities trusts, community services, general practices* and
community pharmacies*
What: ..” ensure that all relevant staff are aware of relevant IDDSI resources and
importance of eliminating imprecise terminology including ‘soft diet’……..”
When: To start immediately and be completed by 1 April 2019” Alert reference number:
NHS/PSA/RE/2018/004

4. DYSPHAGIA –
WHAT IS IT?:
Medical term describing difficulty
swallowing
Estimated to affect over 51%* of people
living in residential settings
Can affect all age groups
Can result in harm or even death
* RCSLT “Guidance on the management of Dysphagia in Care homes”

5. WHAT
CAUSES
DYSPHAGIA?
Medical conditions such as Covid 19, Stroke or cancer
Progressive Neurological disease such as Parkinsons,
Huntingdons, MND and Dementia
Learning Difficulties and Birth Injury
Frailty and Old age, End of life.
Other – non-medical such as; no teeth or poorly fitting
dentures; are unable to sit upright; are drowsy…

6. POSSIBLE CONSEQUENCES OF
DYSPHAGIA
Dehydration
Malnutrition
Aspiration
Choking
Falls
Weight loss
Constipation
Fatigue and frailty
Expressive behaviours
Emotional ill-being
Depression
Confusion
Infections
Increased and longer hospital
admissions

7. IDENTIFICA
TION,
SCREENING
,
ASSESSME
NT.
TAKE
ACTION!
Whose responsibility is it?
All healthcare staff in all settings should be aware of
Dysphagia risks
how to identify it &
how to assist feeding and drinking safely.
Anyone identified as being at risk of Dysphagia should
be referred for assessment by the SALT team using your
local referral pathway.

8. Dysphagia:
How would you
recognise it?
Is it under-
recognised in
your setting?

9. How can we provide food and drink safely to people
living with dysphagia in our settings?
Capacity – best interests?

10. PROFESSIONAL
ASSESSMENT
AND SUPPORT
MAKE SURE YOUR
LOCAL REFERRAL PATHWAY,
SALT ASSESSMENTS AND
CARE PLANS ARE
KNOWN, RECORDED,
REVIEWED, UP-DATED AND
SHARED
WITH THE WHOLE TEAM
Nurse/
Community
nursing team
GP
SALT
Community
Dietician
Denti
st
Occupational
health
Families/IMCA

11. “it is recommended that each health community ensures that staff (including care
assistants) working in all settings including care homes are adequately trained to
identify dysphagia, manage coughing and choking (including the Heimlich
manoeuvre, also known as abdominal thrusts) and in the principles of good
practice relating to ‘Feeding Safely Routines’”
“RCSLT dysphagia in care homes 2018”
Feeding
Safely
Routines:
Conscious level, Distraction, Time, Position
Your position Utensils,
Glasses and
hearing aids,
Independence
Portion size
Size of
mouthful
Documentation
Other
professionals
Modified Diet
and fluids

12. CHAMPION – SHARE THE KNOWLEDGE:
THE DYSPHAGIA GAME
A TRAINING GAME TO PURCHASE FOR GROUPS OR ONLINE
HTTPS://WWW.DYSPHAGIAGAME.COM/
https://games.focusgames.co.uk/DysphagiaIDDSI/iPhone/index.php

13. DYSPHAGIA
–ANY
QUESTIONS
?

14. The IDDSI framework was formally adopted in 2019
and replaces previous descriptors such as pudding,
soft, honey, etc.
Thickeners such as “Thick and Easy” now carry the
new descriptors.

15. What is IDDSI?
(international dysphagia descriptor standardization initiative)
A global standard with terminology and definitions to describe texture
modified foods and thickened fluids used for individuals with dysphagia
of all ages, in all care settings, and for all cultures.
The standardised descriptors and testing methods will allow for
consistent production and easy testing of thickened liquids and texture
modified foods.
For people living with dysphagia, we should only use IDDSI
descriptors and avoid using the term ‘soft diet.’
Incorrect food consistency can lead to choking and even

16. THE IDDSI
FRAMEWORK
CONSISTS OF A
CONTINUUM OF 8
LEVELS (0-7).
LEVELS ARE
IDENTIFIED BY TEXT
LABELS, NUMBERS,
AND COLOUR CODES
TO IMPROVE SAFETY
AND IDENTIFICATION.

17. IDDSI –
MODIFYING
FOOD & DRINK

18. PARTNERS IN DYSPHAGIA
TRAINING, FOOD PREPARATION
AND FLUID THICKENERS
Nutrition,Hydration,Dysphagia
incollaborationwith
Fresenius Kabi Limited
Via MS Teams
Discussing various aspects of this topic
Next Session Thursday 2nd
December 2021 (to be
confirmed)
Hosted by the Eastern Care
Services Team

19. Guide to IDDSI. Bidfood UK

20. IDDSI TESTING
METHODS & AUDITS
WWW.IDDSI.ORG

22. IDDSI FORK & SPOON TESTS FOR
FOOD
LEVELS 3 - 7
Level 3 – Liquidised
Level 4 – Pureed
Level 5 – Minced and Moist
Level 6 – Soft and Bite-sized
Level 7 – Easy chew
(courtesy of Nutricia UKIR Digital Team)

23. WHAT MEALS
CAN I COOK TO
MEET IDDSI?
Most things – but do check with your
SALT professional:
Full English
Salads
Sandwiches
Biscuits
Cream tea
Birthday cake
https://www.nutricia.co.uk/content/da
m/dam/amn/local/gb/approved/pdf/n
utriciahcp-nutilis-clear-recipe-
book.pdf

24. FOODS TO AVOID:
Fibrous Vegetables such as leeks and
celery
Foods with Pith or skin such as grapes
Anything that changes texture in the
mouth such as jelly or water melon
Floppy food such as lettuce or cucumber

25. EQUIPMENT FOR TEXTURE
MODIFYING FOOD
robu
st
Easy to
clean
Large
enough
Domestic or
commercial?

26. FACTORS THAT CAN CHANGE THE
CONSISTENCY OF TEXTURE
MODIFIED FOOD:
Temperature
Content
Reheating method
Safety point:
Always check the consistency and
temperature of meals at point of
service

27. THICKENING UP & THINNING DOWN
Thicken up:
Prescibed thickeners (medication)
eg Thick & Easy, Nutilis,
Thicken-up
Thickening granules eg Mc
Dougalls
Natural food starch eg potato or
Smash
Thickening agents eg Sosa
products – vegetal, instangel,
pro-pannacotta etc
Temperature - chill
Thinning down:
Milk/Cream
Stock/Gravy
Custard
Fruit Juice/puree
Condensed Milk
Chocolate sauce/buttercream
icing
Fortified milk

28. ADDING CALORIES AND
NUTRIENTS:
The importance of fortification:
“The use of modified-texture foods,
particularly pureed diets, contributes to the
high prevalence of malnutrition in those
with dysphagia, especially in long-term
care residents. A reduction in food intake is
common, and pureed diets are often poorer
in calories, protein and micronutrients than
regular diets.”
O’Keeffe, S.T. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current
practice justified?. BMC Geriatr 18,
https://www.rdash.nhs.uk/wp-
content/uploads/2018/08/DP8201-Food-First-leaflet-
08.18-3.pdf

29. Sample IDDSI recipe methods
(level 4):
(Nutricia)
:
1. Chicken Fricassee
2. Coffee Cake
Don’t forget:
Fortify, Taste, Season, Test,
Present.

30. Key messages
• Training – identification, support, correct
terminology, correct texture/thickness,
• Referrals & Support – who, where, how?
• Funding & Budget – extra time to support
eating and drinking, extra cost of ingredients –
eg fortification, thickeners
• Document and Evidence – care plans, risk
assessments, policies and procedures, share
with whole team
• Capacity, best interests. Involvement in
decision-making and choice,
• Food first – dysphagia food and drink not only
has to been nutritionally valuable and the right
texture, it has to look, smell and taste good –
would you want to eat it every day? (biozoon)
• Dignity in Dining – always remember how it
must feel

31. NHS PATIENT
SAFETY ALERT
27/04/21
Addition of a polyethylene glycol (PEG)-based
laxative to a liquid that has been thickened with a
starch-based thickener may counteract the
thickening action, placing patients with dysphagia
at a greater risk of aspiration.
Constipation and dysphagia coexist more
commonly in the elderly and in people with
disabilities that affect swallowing. Therefore these
populations may be of particular risk if a PEG
laxative is added to liquid thickened with starch.
PEG laxatives – Movicol, Macrogel 3350,
Movipeg

32. NHS PATIENT
SAFETY ALERT
05/02/15
Stage One: Warning Risk of death
from asphyxiation by accidental
ingestion of fluid/food thickening
powder 05 February 2015
NHS England has received details of
an incident where a care home
resident died following the accidental
ingestion of the thickening powder
that had been left within their reach.
Whilst this death remains under
investigation, it appears the powder
formed a solid mass and caused fatal
airway obstruction.

33. IDDSI AND DYSPHAGIA – RESOURCES:
www.iddsi.org official website with all the information on different textures and testing
methods
Other useful resources/training:
https://portal.e-lfh.org.uk/LearningContent/LaunchForGuestAccess/651254
EDSCF.pdf (e-lfh.org.uk)
Dysphagia - e-Learning for Healthcare (e-lfh.org.uk)
https://www.nutricia.ie/content/dam/dam/amn/local/gb/approved/pdf/nutriciahcp-nutilis-clear-recipe-book.pdf
https://www.rcslt.org/wp-content/uploads/media/Project/RCSLT/inter-professional-dysphagia-framework.pdf
https://www.skillsforcare.org.uk/Documents/Events/RM-conference/RCSLT-dysphagia-in-care-homes.pdf
https://www.skillsforcare.org.uk/Documents/Learning-and-development/Care-Certificate/Standard-8.pdf
https://www.uwl.ac.uk/research/research-centres/richard-wells-centre/i-hydrate
Dorset HealthCare :: The golden rules of swallowing (PEARS)
Nb: Be aware that online and printed resources prior to 2019 may use the wrong descriptors – eg “level 7 easy chew” was added later

34. And finally!
Any questions?
www.iddsi.org
NEXT SESSION ON
THURSDAY OCTOBER
28TH: NUTRITIONAL
SCREENING &
FORTIFICATION
Information from this week:
1. Dysphagia – what it is and the consequences, how to
recognise it, who can help, safe feeding and drinking
strategies, texture modification for different IDDSI
levels.
2. IDDSI – the framework. “for people living with
Dysphagia we should only use IDDSI descriptors and
avoid the term “soft diet”
3. Partners and resources.
Actions:
Work with your clinical/care team and manager to
identify any actions required. For example:
1. Review anyone in your setting who has or may have
Dysphagia and check you have the correct and up to
date assessment/care plan/information in the
kitchen
2. Carry out an audit of each level you produce using:
https://iddsi.org/IDDSI/media/images/AuditSheets/Au
ditToolL6SoftAndBiteSized26Jun2020.pdf
Finally:
Complete quiz and survey on Google forms.