According to the Cleveland Clinic, more than 15 million Americans across the age spectrum have swallowing disorders such as dysphagia. Often, these individuals require foods and beverages to be modified—liquids thickened or foods puréed, for example—to prevent accidental choking or aspiration of liquids. Despite the prevalence of swallowing disorders and need for specialized nutrition, no consensus standards existed for the consistency of foods and beverages until 2019, when the International Dysphagia Diet Standardization Initiative (IDDSI) was released.
Part of IDDSI (often pronounced “itsy”) is the categorization of foods and drinks; there are eight levels of consistency, from 0 (thin liquids, such as plain, unthickened water) to 7 (regular foods, not modified to be easier to chew). IDDSI provides standardization and guidance for treating individuals with dysphagia and other swallowing disorders and is meant to be appropriate for all age groups and care settings.
Since its release in the United States in May 2019, IDDSI has brought far-reaching change to how health care practitioners prepare and serve foods/fluids for people with swallowing issues, and the framework has been introduced in more than 125 countries and translated into 50 languages.
Of course, as with every other aspect of health care and life, IDDSI was impacted by the emergence of the coronavirus pandemic. By early 2020, many hospitals and long term care facilities still had not fully implemented IDDSI or were planning to begin training and implementation later in 2020.
Compounding this is the reality that many dysphagia patients are older adults and/or live in long term care or skilled nursing facilities, putting them at higher risk of contracting the coronavirus and experiencing possibly deadly complications.
RD Lounge speaks with speech-language pathologists (SLPs), RDs, and certified dietary managers who work in various health care settings to share their experiences with implementing IDDSI and keeping vulnerable dysphagia patients safe amid the pandemic.
Unfortunately, in some facilities, IDDSI implementation has been continuously delayed amid staff shortages and due to a focus on pandemic-related operations. Karen M. Sheffler, MS, CCC-SLP, BCS-S, an IDDSI expert and owner of SwallowStudy.com, notes that COVID-19 has affected the current staffing situation in many health care communities, thus delaying implementation and reducing quality controls for those patients receiving IDDSI diets.
Mary Rybicki, MS, RDN, LDN, editor-in-chief of the Academy of Nutrition and Dietetics’ Nutrition Care Manual, who contributed to IDDSI content updates to this manual, as well as a dietitian at Mary Immaculate Nursing/Rehabilitation Center in Lawrence, Massachusetts, shares a similar story: “We were about halfway implemented when COVID broke out in our facility. Everything stopped regarding our routine testing and fine-tuning of recipes and menu items. It has not started back up.”
Rybicki notes, however, that by having the basics of IDDSI in place, they were able to safely modify foods and beverages for the many residents with COVID-19 in her facility—and then reintroduce regular foods upon recovery. “Transitioning to IDDSI had made us work out the communication between the SLP, RD, dietary manager, and nursing regarding texture level/diet changes. Therefore, this system provided a productive and effective effort.”
Other facilities have faced greater challenges. Several dietitians working in long term care facilities in the northwestern United States (who chose to comment anonymously) say implementation of IDDSI was delayed or halted because of COVID-19. Their comments include the following:
- “Unfortunately, my facilities do not have the capacity to deal with a pandemic and implement a whole new system. The nursing staff is in pieces, and they are relying on agency staffing who are untrained on IDDSI.”
- “We are lucky if we get the old mechanical soft and purée right, let alone a grouping of new diets.”
- “Because our hospital systems delayed implementation, our nursing facilities have also delayed. Are the residents safe from choking? I don’t know. They are all eating in their rooms. Are they safe from anything right now?”
- “The kitchen and nursing staff are doing their best just to get the residents fed. Maybe we can implement IDDSI next year.”
Despite these issues among some facilities others have managed to keep IDDSI alive during the pandemic.
Christine Beach, CDM, CFPP (dubbed “Chef IDDSI” by me), is nutrition services director for a subacute rehab facility in Ogden, Utah. Beach says following IDDSI during the pandemic has required “lots of patience” from staff. “Right now, I am learning that comfort foods are working best with our [dysphagia patients],” she says. “They are not able to see family, their food doesn’t look appetizing all cut up, they are spending more time in their rooms, and are not exercising as much, so they just don’t have a great appetite. Having soups and mashed potatoes, mac and cheese, and cheesecake—foods like that—are what work best for us.” Her main advice for other practitioners during this difficult time: “It is crucial for dietary, nursing, and the SLP to work together to individualize patient diets,” often on the fly.
Terri Perez, CDM, CFPP, director of food service for the Idaho State Veterans Home, says it’s “nice to report the pandemic has not affected how our facility is serving IDDSI. I would say that it is most helpful to use [menus from the] S&S Nutrition Network, as their diet extensions are IDDSI color-coded” and print individualized sheets for residents’ diets in color.
All told, IDDSI is still a brand new and comprehensive paradigm for dysphagia treatment, although the current pandemic has caused a significant barrier to its complete execution. However, given the timeline for the implementation of IDDSI is generally four to six months, delays are almost inevitable amid the pandemic. With the COVID-19 vaccine rolling out, 2021 may be the year for IDDSI.
— Sue Linja, RDN, LD, is cofounder, officer, and president of S&S Nutrition Network, Inc, a company that provides geriatric nutrition services to skilled nursing facilities, hospitals, home care, assisted living, and other health care entities. Sue is the director of the Idaho IDDSI Workgroup and is a sought-after speaker on various nutrition and aging topics.