FEATURE: A Day in the Life with Dysphagia

Consultant dietitian Rachael Masters shares her reflections on the recent IDDSI Masterclass and Festival that took place in Harrow during September

Organised by a multidisciplinary team of volunteers, the first UK International Dysphagia Diet Standardisation Initiative (IDDSI) Masterclass and fourth UK IDDSI festival was hosted by IDDSI’s worldwide chairperson and CEO, Peter Lam and Dr Ben Hanson, an associate professor at University College London and an engineering consultant, who is also a UK-based IDDSI board member.  

The IDDSI Masterclass 
The first day of this two-day event, saw the debut of the first UK IDDSI masterclass, which was attended by over 60 delegates, including those working within the catering and care catering sectors, together with speech therapists and representatives from the foodservice sector. The proceedings were opened by Peter Lam, who provided an insightful explanation into swallowing, which involves the co-ordination of around 24 muscles and six nerves to provide the safe swallow we all take for granted. 
Delegates completed practical exercises to mimic swallowing disorders, such as poor lip seal, weak neck control and simulated choking to raise their awareness about the ill-effects that dysphagia can have on eating and drinking. These exercises also helped to reinforce the importance of particle size in IDDSI level 6 soft and bite-sized diets. The recommended 1.5cm diameter is small enough to travel safely through the trachea, so if an individual does inadvertently start to choke, although the food may go into the lungs, it is unlikely to cause the severe choking that could result in death. 
Lam, who is a trained dietitian, concluded his session by emphasising that breathing is always more important than eating, because the fear and consequences of choking outweigh nutritional need. 

Formulating IDDSI
Dr Ben Hanson then explained the scientific evidence behind the recommendations for each IDDSI level and described how the IDDSI board combined this with their experience of food and dysphagia to formulate a series of practical tests. These include the IDDSI flow, fork drip, fork pressure and spoon tilt tests, all of which can easily take place in a domestic kitchen to ensure that food and drink is a safe consistency for the individual involved. 
In a Q & A discussion, Hanson emphasised that any decisions about whether texture modification is appropriate must be informed by clinical assessment in agreement with the individual involved and their care team. He was adamant though, that IDDSI is a ‘language, not a law.’ 
Lam and Hanson described the process of creating the IDDSI framework to standardise terminology and interpretations for altered consistency diets. The levels were based on the available evidence at the time and practical measurements were added to remove subjectivity wherever possible. 
An example is the term ‘soft diet’, because ‘soft’ is not a good enough description. Rather, it’s essential to determine both particle size and texture, hence the term ‘soft and bite-sized’ to describe IDDSI level 6 diets. The particle size for level 6 is 1.5cm diameter and is often described as thumbnail sized/or the size of a 20p coin that will fit between the edge prongs of a fork. 
In science, food that can be squashed at 17 kilopascals is considered soft, as this represents the pressure required for the tongue to soften food against the roof of the mouth. But how do we apply that scientific knowledge in a kitchen environment? 
Apparently, 17 kilopascals equate to a piece of food, 1.5cm in diameter, which after being squashed by a fork, remains in its squashed state before a thumbnail blanches. This is commonly known as the IDDSI fork pressure test, but because thumb pressures vary amongst individuals, further research identified that if weighed on digital scales, the food needs to be squashed before 390 grams, in order to provide a more accurate and standardised approach to the level 6 fork pressure test. Viscgo, an exhibitor at the IDDSI festival, displayed a Food Consistency Test Fork, which had a built-in pressure gauge calibrated to the correct pressure to perform the IDDSI fork pressure test accurately, thus removing subjectivity and reducing risk. 
Level 5 minced and moist diets are designed to reflect food that has been well chewed and moistened with saliva before it’s formed into the bolus that helps trigger a swallow. Food particles of 4mm in adults represent well-chewed food, which IDDSI has identified to be the gap between the prongs of a fork. It needs to be moist to reduce the stickiness, as measured by the spoon tilt test and cohesive when measured by the fork drip test. It was fascinating to gain insights into how scientific evidence has been gathered and practically applied to develop the IDDSI tests that are now used daily. Dr Hanson stressed that it is essential that IDDSI tests are conducted on ALL altered consistency foods to ensure that they are of a safe consistency. He also added how vital it is to complete IDDSI audit sheets to provide written evidence that the food has been tested and is safe for consumption. 

Adapting food for IDDSI
The afternoon session began with chefs Preston Hall and James Ball, from Oak Hall Kitchen, discussing their own experiences of adapting foods for the IDDSI levels. They explained the challenges they faced when they discovered that the various food groups all behave differently when they are adapted. They applied this knowledge to a practical framework called REFORM, which uses the terms ‘Exclude, Tenderise, Resize, Finely Process and Texturise’ to determine the stages required when adapting specific food items. 
In a practical session, delegates were encouraged to test the REFORM framework on a selection of foods to identify the stages required to achieve the correct IDDSI level. This was followed by an audience Q&A, which centred around how caterers can deliver the perfect IDDSI plate from kitchen to service, while also taking account of issues like time pressures, food temperature and safety. 
The masterclass concluded with an expert panel discussion on why food manufacturers can’t immediately magic a new dish into existence. Representatives from apetito, Country Kitchen Foods and OCRAS explained the many stages of product development, which are influenced by regulations, nutritional requirements and allergen awareness, together with cost considerations and the practicalities of scaling up from pilot development to mass production.This provided useful insights into why it 

can take many months, or even years, before a new dish becomes commercially available. 

The IDDSI Festival
The following day saw the start of the fourth UK IDDSI festival, which was sponsored by apetito/Wiltshire Farm Foods, Fresenius Kabi, Slo Drinks, Viscgo, Nestle, Simply Food Solutions, Nutricia, Flavour Creations, Burlodge, Stable Micro Systems, RSI drinks and Foodcare. Over 250 delegates attended, including dietitians, speech therapists, and patient representatives, as well as those working in all aspects of care and hospital catering and general healthcare roles. 
The festival theme was ‘A day in the life with dysphagia’, and it considered all the everyday interactions with food that can be really challenging for someone with swallowing difficulties.

The Swallows
Once again, Peter Lam opened the event by thanking the team of volunteers who organised the festival. The first session was hosted by Chris Curtis, chief executive and founder of ‘The Swallows’ charity for patients with head and neck cancer. After being diagnosed with stage 4 throat cancer, Curtis founded The Swallows in 2011 after struggling to find the practical support he needed. It has since become the fastest growing charity in the UK, receiving referrals from head and neck departments in every NHS Trust. The charity received the Queen’s Volunteer Award in 2017, due to its amazing services, which include monthly meetings, a 24/7 telephone helpline manned by Curtis and his wife, plus individual practical support that is delivered via online consultations and support boxes containing the practical resources that may be required when undergoing cancer treatments. 
The charity also has an informative website and recently launched an app, ‘The Swallows’ which is available free from the App stores. (When registering as a professional, choose the ‘healthcare professional’ designation). 

The Swallows chose the IDDSI festival to officially launch its new ‘Restaurant Card’ scheme, which includes a small card that people can show at restaurants as a discreet indicator of their special requirements. Restaurants can join the scheme once they have fulfilled the necessary criteria, including the provision of IDDSI-friendly meals, the provision of extra water on the table, allowing patients to PEG feed and their ability to deal with a choking incident, while also treating cardholders as valued customers. 

Head and neck cancer is the only cancer that is formally registered as a disability, so restaurants have a duty to provide support to those individuals requiring an altered consistency meal. Currently, membership of the scheme is limited, but for further information visit: www.theswallows.org.uk 
To contact the 24/7 helpline, Tel: 07504 725 059

Pearly whites

The next speaker was Dr Julie Gallagher from University College London’s Eastman Dental Institute, who began her ‘day in the life’ theme with a discussion on tooth brushing. She revealed the important part that good oral health plays in the management of dysphagia and in mitigating the risk of aspiration pneumonia. Oral health issues, which can impact many health conditions, can be chronic but preventable, if we brush our teeth for two minutes twice daily using a high fluoride toothpaste (choose a brand that contains at least 1,450 parts per million fluoride). Other positive measures include interdental clearing before brushing teeth once a day, avoidance of high-sugar foods and drinks, waiting for one hour after eating before brushing teeth and having regular dental check ups. 

Polypharmacy
Professor David Wright then talked about medications for individuals with dysphagia. He explained that ‘polypharmacy’ (the term coined for people who are taking several medicines concurrently) is very common, but that medication errors are significantly increased in those with dysphagia. To support staff to reduce medication errors and provide safe delivery of medications, Professor Wright developed the DRFTAR framework. This stands for Deprescribing (discontinuing nonessential medications); Route (avoiding the oral route where possible by considering gels, patches, injections); Formulation (considering alternative formats, such as liquid,); Tamper (never without guidance); Authorisation (the prescriber); and Record (always record any deviation from normal administration). He maintains a website that provides guidance on medications for dysphagia and offers free online courses on medication administration. For further information visit: www.swallowingdifficulties.com

The Goldilocks moment
After teeth and medication, the focus shifted to ‘Breakfast’ and more specifically, to the science and culinary art of porridge making. The soft, moist consistency of porridge could be considered as ideal for IDDSI but, as Goldilocks found, it’s very difficult to get it ‘just right’. Dr Hanson demonstrated ‘too thick’ by holding a pot of instant porridge, which had been made earlier that morning and had cooled and solidified, over his head. 

Chefs Ball and Walker then described their kitchen-lab research, which revealed how to achieve a stable thickness that isn’t too sticky. They recommended using ground porridge oats made with a low concentration of ground oats to milk (e.g. 8%), and cooking until the oats are fully hydrated. Adding fruit purée can control stickiness and similar techniques can also be applied to other puréed carbohydrates, such as pasta and rice. 

Dr Hanson presented a ‘Porrject’ (sic) by IDDSI’s Asian Reference Groups who have been studying rice porridge, which is extremely popular but just as variable. 

Tim Dallinger gave an enthusiastic and impactful talk on patient-centred care. As a social care consultant, with a wealth of experience in care homes, he explained how individuals’ needs are often adapted to fulfil the service’s need, whereas care services should always be tailored to meet the needs of the individual.

Day-long hydration
The importance of day-long hydration was discussed by speech therapist Janne Schack, dysphagia chef Niamh Condon, and me. We shared our personal experiences of drinking thickened fluids for 48 hours. 

My fluid intake reduced by more than 40% and worryingly, 52% of thickened drinks failed to pass the IDDSI flow test, despite following the manufacturer’s instructions to the letter. 

Schack provided an update on the Royal College of Speech Therapy’s guidance on thickened fluids, while Condon talked about using thickened water to make ice cubes to make drinks more palatable. I explained how fluid booster foods can significantly improve hydration. The festival delegates then completed a practical demonstration where they thickened water, squash, lemonade, milk, tea and a nutritional supplement, using one of five food thickeners. Each thickened drink was IDDSI flow tested with the IDDSI funnel and delegates drank them. In this somewhat unscientific test, the drinks thickened differently and sadly, they didn’t all pass their IDDSI flow tests either. 

Practice makes perfect
Teatime was an inspiring demonstration of altered consistency teatime foods by Andy Cullum and Sophie Murray, which re-emphasised the importance of using nutrient-dense foods and IDDSI testing. 
This was followed by a lively performance by Sanjay Dhrona, managing director at The Close Care Home in Oxfordshire, who described his experience of turning a care home with a CQC warning into a five-star establishment. He shared examples of teamwork and seeking continual feedback, including the use of voting tubes by residents. He also displayed a clothing protector, which ingeniously uses people’s old clothes to provide a dignified and personal way of protecting the garments they are wearing at mealtimes. The pattern is available from the care home’s website. For further information visit: https://www.theclosecarehome.co.uk/a-how-to-guide-to-make-dignity-clothing-protectors/

The final session was a frontline example by Hannah Mathers and Charlotte Crack, chefs from a Suffolk NHS Trust, who demonstrated how they’d redeveloped their altered consistency meals and snacks at the hospital by working with speech therapists, dietitians and catering staff. 
Lam then concluded the session by presenting the awards for the best altered consistency drink (Nestlé’s light summer mocktail) and food (apetito’s shepherd’s pie) following votes from delegates that were cast during the festival. 

Delegate feedback indicated that the event had provided everyone who attended with an amazing opportunity to learn and network and plans are already underway for an IDDSI training academy event, which will take place on 18th September 2025. 

Rachael Masters is a consultant dietitian and the founder of Focus on Undernutrition, who throughout her 29-year-long career, has specialised in the nutritional needs of the elderly. 
Focus on Undernutrition has developed an online six-session practical training course for care catering staff on menu planning and special diets, which is endorsed by the British Dietetic Association. Each module incorporates a masterclass and practical catering videos, downloadable resources and a special diet recipe book, as well as monitoring changes in knowledge 
For further information email: [email protected]
or visit: www.focusonundernutrition.co.uk

 

 

 


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