When taking into account the number of challenges that the average person will encounter in their lifetime, it’s easy to see how some of the most reliable aspects of day-to-day life can begin to be taken for granted.
Chewing and swallowing are such a rhythmic and repetitive function for the average person that the act of eating and drinking barely requires any effort or pre-planning, but like everything that we take for granted – only when a problem arises can we begin to grasp just how vital a role it actually plays in our overall well being.
The medical term for swallowing difficulties is dysphagia, and these types of issues can occur from an obstruction in the throat or oesophagus or a problem with swallow coordination.
Dysphagia affects 14% of the population who are over the age of 50, and without any form of medical treatment, it can cause serious health problems like malnutrition and dehydration by affecting a person’s will to consume food and drink.
One of the most effective tools in combating these kinds of issues for people living with dysphagia is the usage of texture modified foods and drinks, and the people who prepare these for those with swallowing difficulties have the responsibility of ensuring that the food and drink they serve is safe to consume.
There are varying degrees of swallowing difficulty, and the process of preparing food that is both nutritious and safe to consume can vary immensely from person to person.
Despite the fact that there have been Australian standardised definitions for texture modified foods and drink since 2007, the actual process of adding thickening agents to drinks, and preparing foods that have been softened, minced and pureed, have still managed to become somewhat of a grey area due to the broadness of some of the definitions.
What one person deems as ‘soft’ can be completely different to someone else’s interpretation, and this can have dire consequences for people who are living with dysphagia as they have an extremely increased risk of choking when compared to the rest of the population.
The need for a more thorough and person-focused standard of naming and describing texture modified foods and liquids in Australia has grown immensely over the last few years, and this growing demand has culminated in the creation of the International Dysphagia Diet Standardisation Initiative, that is simply known as IDDSI.
IDDSI was created by a group of volunteers hailing from a diverse mix of professions including nutrition & dietetics, medicine, speech pathology, occupational therapy, nursing, technology, and food science.
Julie Cichero is the Australian Project Officer and Co-Chair of IDDSI, as well as being a world-renowned speech pathologist who possesses a wealth of clinical expertise in the field of dysphagia, and Julie knows all too well some of the issues that can arise for those preparing texture modified foods.
“A lot of people think that sandwiches are soft, but sandwiches require the same number of chewing strokes that a person needs for a piece of meat, and when you look at coronial reports and autopsy reports of elderly people who have died from choking – sandwiches, are all over these reports. They are a high-risk choking item and people don’t necessarily view them in this way,” said Julie.
“People will sometimes say that an individual doesn’t have a swallowing problem when this person is missing a few teeth or might have dentures, but if they can’t chew their food down into small enough pieces, then that can potentially block the airways.”
In recent years, a number of countries had worked to develop dysphagia diet standards at national and regional levels, but unfortunately, the different terminologies, labels, numbers, and levels of texture modification has proved extremely confusing for individuals, caregivers, and health professionals around the globe.
IDDSI’s new standards of food and liquid description aim to reduce some of the confusion around current dysphagia diet language by creating one universal framework that can be used across all countries and all facets of the healthcare system.
“We had thickened drinks here in Australia that were called ‘mildly thick – level 150’ but around the world, the same drink was referred with different terms like nectar, or stage-1, and this caused a lot of confusion,” said Julie.
“IDDSI has standard names and definitions that we use to define textures, and we have even developed some easy-to-use testing methods – that can be done in 10 seconds or less – so that people can check that the food they are serving has been modified appropriately for an individual’s swallowing difficulties.”
“The IDDSI framework utilises a name, level, and colour – as descriptors for food modification, and we encourage people to use at least two of these when preparing texture modified food, and one of the key benefits of having the three descriptors is that colour and number classification makes things easier for people who don’t have English as a first language.”
The ramifications of incorrect food or drink texture modification can be fatal for people with swallowing difficulties, and according to Julie, these kinds of deaths are happening far more often than most people would realise.
“In aged care, there has been some great research done by professor Joseph Ibrahim in Victoria where he identified that choking is the second highest cause of preventable death in aged care -it’s certainly something that needs to be improved upon,” said Julie.
“There was an example that came through in NSW Ombudsman’s report surrounding the word ‘soft’ and making sure that everyone knows exactly what that means so that people don’t end up choking and dying.”
“We also know that there are accidental choking deaths in hospitals as well, where food was either an incorrect consistency or the supervision that was needed was not available. These are tragic accidents, but accidents that we feel can be impacted by having a more refined and correct framework of terminology for modified foods and drink.”
Implementation of IDDSI’s new framework began on May 1st of this year, and the first few weeks since implementation has seen a number of Australia’s most well-respected health care providers adopt the IDDSI framework as they saw the need for a more refined and uniform approach to texture description.
“We put out regular newsletters and people feel supported and informed and I think the process that we used to make people aware of IDDSI, to prepare for it, and to work out if they had any recipes that needed to be adjusted, has made the transition quite smooth for a number of the first adopters,” said Julie.
“I’ve had contact from chefs, management, nurses, and consultants who utilise the new framework, and their responses have been overwhelmingly positive. The aged care sector is really embracing it and others are beginning to follow suit.”