Clinical applications of IDDSI framework for texture recommendation for dysphagia patients

The possibility of the computer simulation-assisted IDDSI framework for the development of thickened brown rice paste

Increasing requests for thickened fluid food are demanded with population aging, while the limited information provided by the International Dysphagia Diet Standardisation Initiative (IDDSI) is insufficient for food development. Recently, the introduction of computer simulation seems to be able to overcome this dilemma. Here, a thickened fluid system (xanthan gum and konjac glucomannan, XG and KGM) at different ratios was kept at the same IDDSI level 3. An obvious synergy was observed in the ratio of 1:9 (XG: KGM) with high surface tension, zero-shear viscosity, firmness and cohesion, and thus was used to prepare the brown rice paste. From computer simulation, the brown rice pastes (0.3 % and 0.5 % thickener) splashed and that with higher thickener content resulted in more residue. The thickener content of 0.7 % provided enough viscosity and cohesion to avoid splash, and most of the bolus flowed consistently, showing the best sensory quality and swallowing properties.

Research progress on digestive disorders following traumatic brain injury

Traumatic brain injury (TBI) is a prevalent disease that poses a significant threat to global public health. Digestive dysfunction, as a common complication, is of particular importance to understand its pathogenesis, diagnostic criteria, and relevant treatment strategies. TBI can affect digestive function through inflammatory immune responses, the enteric nervous system, and hormonal levels. Furthermore, TBI can also impact neurologic recovery through bidirectional communication along the brain-gut axis. Therefore, this article aims to summarize the underlying mechanisms and further explore individualized feeding strategies, therapeutic approaches, long-term prognosis for TBI patients, as well as recent advancements in related technologies. Further understanding of the pathogenesis of digestive system dysfunction after TBI on the basis of the interaction of gut-brain axis is conducive to more future therapies to treat TBI and improve the long-term prognosis of patients through improving digestive function, and achieve good clinical efficacy.

Polysaccharide-dextrin thickened fluids for individuals with dysphagia: recent advances in flow behaviors and swallowing assessment methods

The global aging population has brought about a pressing health concern: dysphagia. To effectively address this issue, we must develop specialized diets, such as thickened fluids made with polysaccharide-dextrin (e.g., water, milk, juices, and soups), which are crucial for managing swallowing-related problems like aspiration and choking for people with dysphagia. Understanding the flow behaviors of these thickened fluids is paramount, and it enables us to establish methods for evaluating their suitability for individuals with dysphagia. This review focuses on the shear and extensional flow properties (e.g., viscosity, yield stress, and viscoelasticity) and tribology (e.g., coefficient of friction) of polysaccharide-dextrin-based thickened fluids and highlights how dextrin inclusion influences fluid flow behaviors considering molecular interactions and chain dynamics. The flow behaviors can be integrated into the development of diverse evaluation methods that assess aspects such as flow velocity, risk of aspiration, and remaining fluid volume. In this context, the key in-vivo (e.g., clinical examination and animal model), in-vitro (e.g., the Cambridge Throat), and in-silico (e.g., Hamiltonian moving particles semi-implicit) evaluation methods are summarized. In addition, we explore the potential for establishing realistic assessment methods to evaluate the swallowing performance of thickened fluids, offering promising prospects for the future.

Baby Intensive Early Active Treatment (babiEAT): A Pilot Randomised Controlled Trial of Feeding Therapy for Infants with Cerebral Palsy and Oropharyngeal Dysphagia

Cerebral palsy (CP), results in impairment of muscle function including the face, mouth, and throat, leading to oropharyngeal dysphagia (OPD), which affects 85% of children with CP. OPD increases risk of deficiencies in growth, neurological development, and aspiration pneumonia, a leading cause of death in CP. This pilot randomised controlled trial aimed to (i) assess feasibility and acceptability of a novel neuroplasticity and motor-learning feeding intervention program, Baby Intensive Early Active Treatment (babiEAT), and standard care, and (ii) explore preliminary efficacy of babiEAT on health and caregiver feeding-related quality of life (QoL). A total of 14 infants with both CP and OPD were randomly allocated to 12 weeks of babiEAT or standard care. Results indicate that babiEAT and standard care are equally feasible, and acceptable. Parents in the babiEAT group thought recommendations were significantly more effective than standard care parents, were more likely to recommend the program to a friend and reported higher QoL. babiEAT infants showed significantly greater efficiency in fluid intake, fewer compensatory strategies with cup drinking, consumption of more advanced food textures, and shorter mealtimes without impacting intake, aspiration risk, or weight. This small pilot study shows promise for babiEAT in infants with CP and OPD. Further research is needed to determine strength of its effects.

Adapting the International Dysphagia Diet Standardisation Initiative in East Asia: Feasibility study

In dysphagia, food or water cannot be delivered safely through the oral cavity to the stomach; both are treated using texture-modified food and thickened fluid. Before, each country had its own diet modifications and texture measurement standards. In 2012, the International Dysphagia Diet Standardisation Initiative (IDDSI) was developed by several countries. Owing to cultural differences, it was necessary to determine whether the IDDSI could well be applied to clinicians and patients without difficulties in East Asia countries. To evaluate the IDDSI scale to find out the difficulties applying this scale in East Asia countries to educate the clinicians and patients. In May 2021, we enrolled physicians, nurses, nutritionists, and swallowing therapists involved in dysphagia treatment at a single center in Seoul. To evaluate the degree of understanding and difficulties of adapting IDDSI to clinicians in East Asia countries, we used the 17-item questionnaire with IDDSI sample foods and foods in Asian countries. In first 7 items, we compared IDDSI with the previously used scale based on the National Dysphagia Diet (NDD). In the next 10 questions, only the IDDSI levels were answered, and the absolute values of the answer-response differences were calculated. The IDDSI showed a significantly high intraclass correlation with the previously used NDD-based scale; the coefficient was higher for the nutritionists (0.988) and swallowing therapists (0.991). When evaluating whether the IDDSI could applied well in East Asia countries, the absolute values of the answer-response differences were lower than 0.5 in majority of levels, except for Level 4. Because the IDDSI framework might successfully be applied universally regardless of food culture, a worldwide standard for food rheology in dysphagia treatment might be possible.

Bionic design of the oral swallowing in vitro and its application in the dysphagia

Dysphagia, the swallowing disorder, is a common disease among the elders and stroke patients. Therefore, based on the bionic swallowing device (BSD) in vitro of similar human-tongue motion during swallowing, the development of functional food is necessary to improve the food swallowing quality of the deglutition disorders patients. In this study, the tongue motion was thoroughly investigated by extracting the characteristic data, and appropriate mechanisms in vitro were adopted to replicate the motion of the tongue swallowing according to the normal swallowing oropharyngeal data. The application of the BSD was also investigated at different swallowing grades (SGs). The study results indicated that the tongue motion consisted of tongue root point (TRP) and several tongue motor points (TMPs). The cam-link and push-rod mechanisms showed ellipse lines for TRP motion and straight lines for TMPs, respectively. Higher correlation coefficients between the tongue trajectories in the oropharyngeal data and simulated curves of the combined mechanism were observed. The average correlation coefficients between the tongue trajectories of patients at five SGs and those of the BSD were 0.87, proving its effectiveness and potential application. Furthermore, the corn-paste experiments of the BSD showed that dysphagia at five SGs could be a suitable choice for certain food concentrations. This will provide valuable insight into developing more functional foods in vitro for high deglutition disorders.

The Effectiveness of International Dysphagia Diet Standardization Initiative-Tailored Interventions on Staff Knowledge and Texture-Modified Diet Compliance in Aged Care Facilities: A Pre-Post Study

Background

The International Dysphagia Diet Standardization Initiative (IDDSI) has created global standardized definitions for texture-modified diets (TMDs) and thickened liquids to improve the safety and care for individuals with swallowing difficulties. The IDDSI framework guides health care facilities, such as aged care, to provide food to at-risk patients.

Objectives

This study aims to design, deliver, and evaluate a tailored intervention to facilitate IDDSI implementation in aged care.

Methods

Five aged care facilities received tailored interventions, which were guided by the Expert Recommendation for Implementing Change process and used the corresponding barriers identified in the previous study: 1) tailored material, delivery, and planning; 2) opinion leaders and professional input; 3) strategies to attract and involve staff; and 4) reflections and evaluations. Meal compliance against IDDSI standards and staff knowledge acquisition were the primary outcomes evaluating the impact of the intervention. Written consent was obtained from facility managers. Staff trainings were delivered by a dietitian, accompanied with electronic and printed materials. An audit was conducted on all items listed on the TMD daily menu (lunch, dinner, and midmeals). TMD IDDSI audits and staff self-administered surveys were conducted before and 6 mo after the intervention.

Results

Audits of 68 and 79 TMD meals/items were conducted pre- and postintervention, respectively. Significant improvement in meal compliance was found in all 3 levels of TMDs, including soft and bite-sized (50%; P = 0.0001), minced and moist (44%; P = 0.0024), and puréed (42%; P = 0.0024). The overall IDDSI compliance increased by 46% postintervention (P < 0.0001). Staff achieved higher scores in both dysphagia and IDDSI knowledge sections (P < 0.0001).

Conclusions

Tailored interventions facilitated IDDSI implementation in aged care evidenced by increased TMD compliance and staff knowledge, which remained at 6 mo postintervention.

Predictive value of the videofluoroscopic swallowing study for long-term mortality in patients with subacute stroke

To investigate the usefulness of the videofluoroscopic swallowing study (VFSS) for subacute stroke in predicting long-term all-cause mortality, including not only simple parameters obtained from VFSS results, but also recommended dietary type as an integrated parameter.This was a retrospective study of patients with subacute (<1 month) stroke at a university hospital between February 2014 and September 2019. The independent risk factors were investigated using stepwise Cox regression analysis, which increased the all-cause mortality of patients with stroke among VFSS parameters.A total of 242 patients with subacute stroke were enrolled. The significant mortality-associated factors were age, history of cancer, recommended dietary type (modified dysphagia diet; adjusted hazard ratio [HR], 6.971; P = .014; tube diet, adjusted HR: 10.169; P = .019), and Modified Barthel Index. In the subgroup survival analysis of the modified dysphagia diet group (n = 173), the parameters for fluid penetration (adjusted HR: 1.911; 95% confidence interval, 1.086-3.363; P = .025) and fluid aspiration (adjusted HR: 2.236; 95% confidence interval, 1.274-3.927; P = .005) were significantly associated with mortality.The recommended dietary type determined after VFSS in subacute stroke was a significant risk factor for all-cause mortality as an integrated parameter for dysphagia. Among the VFSS parameters, fluid penetration and aspiration were important risk factors for all-cause mortality in patients with moderate dysphagia after stroke. Therefore, it is important to classify the degree of dysphagia by performing the VFSS test in the subacute period of stroke and to determine the appropriate diet and rehabilitation intervention for mortality-related prognosis.

Capsaicin burn increases thickness discrimination thresholds independently of chronic chili intake

The trigeminal nerve transduces both chemical irritation and textural sensations suggesting that perception in one may influence perception in the other. Little is known about how the oral burn of capsaicin may affect texture sensitivity. The aim of this study was to determine the effect of burning sensations on thickness discrimination thresholds in liquid foods assessed by consumers who vary in habitual spicy food intake. Forty-seven Caucasian participants (31 females and 16 males; mean age: 25.0 ± 5.7 yrs; mean BMI: 21.5 ± 2.6 kg/m²) were recruited in the Netherlands. Chili pepper intake frequency and preference for chili peppers and spicy foods were assessed using questionnaires. Perceived burn and disliking/liking of bouillon soups thickened with xanthan gum (concentrations ranging from 0.06 to 0.21 g/mL; viscosity at 50 s^-1 (η_50s-1) ranging from 11 to 48 mPas) containing varying amounts of capsaicin (0, 1, or 10 ppm) were determined using generalized scales (gLMS and gDOL). Estimates of thickness discrimination thresholds were determined using the 2-Alternative Forced Choice ascending staircase method. Capsaicin was applied in two ways: (i) capsaicin was added directly to the soups or (ii) a pre-rinse of a capsaicin solution was held in mouth before evaluating soups without capsaicin. As expected, frequent chili pepper consumers reported significantly lower burn intensity and higher hedonic ratings compared to infrequent consumers. Thickness discrimination thresholds (i.e., BET expressed as Δη_50s-1) increased significantly from 11.3 mPas at 0 ppm to 16.1 mPas at 1 ppm (42% increase) to 21.4 mPas at 10 ppm capsaicin (89% increase) on average across all participants. Similar modification of thickness discrimination thresholds were observed regardless of whether capsaicin was added to the soup or was applied as a pre-rinse. No significant differences in thickness discrimination thresholds were observed between infrequent and frequent chili consumers. We conclude that oral burn caused by capsaicin affects thickness discrimination independently of reported chili pepper intake. Also, we suggest the ability of capsaicin to alter thickness discrimination may be due to increased neural noise, attentional effects or cross-modal interactions.

How Accurate Are the Consistency Labels Used in Hong Kong? An Objective Study of the Consistency of Thickened Liquids Using International Dysphagia Diet Standardisation Initiative and Consistometric Measurements

OBJECTIVES

The present study objectively examined the consistency (thickness) of labels that are used in Hong Kong for the population with dysphagia using an International Dysphagia Diet Standardisation Initiative (IDDSI) flow test and Bostwick consistometric measurements.

METHODS

Liquids were prepared by thickening water to achieve 4 consistency labels (slightly thick, mildly thick, medium thick, and extra thick) according to manufacturer's instructions, employing 2 types of thickening products that are used in Hong Kong, i.e., starch based and gum based. For each consistency label prepared using each thickening product, the IDDSI flow test and consistometric measurements were obtained and compared.

RESULTS

The results showed that the actual thickness of liquids was highly dependent on the type of thickener (starch based vs. gum based) used. Thickened liquids prepared using the starch-based thickener were generally thinner than the actual value at a lower concentration.

CONCLUSION

Though prepared strictly following the manufacturer's instructions, the thickened liquids fail to faithfully correlate with the standardized norms established according to the IDDSI framework and the objective consistometric measurement using a Bostwick consistometer. Therefore, caution must be exercised when administering a thickened diet following the manufacturer's instructions for patients with dysphagia.

Automatic Hyoid Bone Tracking in Real-Time Ultrasound Swallowing Videos Using Deep Learning Based and Correlation Filter Based Trackers

(1) Background: Ultrasound provides a radiation-free and portable method for assessing swallowing. Hyoid bone locations and displacements are often used as important indicators for the evaluation of swallowing disorders. However, this requires clinicians to spend a great deal of time reviewing the ultrasound images. (2) Methods: In this study, we applied tracking algorithms based on deep learning and correlation filters to detect hyoid locations in ultrasound videos collected during swallowing. Fifty videos were collected from 10 young, healthy subjects for training, evaluation, and testing of the trackers. (3) Results: The best performing deep learning algorithm, Fully-Convolutional Siamese Networks (SiamFC), proved to have reliable performance in getting accurate hyoid bone locations from each frame of the swallowing ultrasound videos. While having a real-time frame rate (175 fps) when running on an RTX 2060, SiamFC also achieved a precision of 98.9% at the threshold of 10 pixels (3.25 mm) and 80.5% at the threshold of 5 pixels (1.63 mm). The tracker's root-mean-square error and average error were 3.9 pixels (1.27 mm) and 3.3 pixels (1.07 mm), respectively. (4) Conclusions: Our results pave the way for real-time automatic tracking of the hyoid bone in ultrasound videos for swallowing assessment.

Critical review of sensory texture descriptors: From pureed to transitional foods for dysphagia patients

Dysphagic people need to change their diet to avoid pain or risk of choking. For example, they can eat texture modified foods (including pureed and transitional foods, that is, food that start with one texture and change into another because of moisture or heating). Simple testing methods proposed by the IDDSI initiative can be performed to characterize texture modified food but these methods are not always relevant for understanding oral texture and mouthfeel properties. Sensory characterization is essential to develop or optimize a food product and to meet consumer's expectations and needs especially for dysphagic persons. However, sensory methods and texture descriptors are complex to target and evaluate for different severity of dysphagia. Sensory texture descriptors can be determined by different methods and assessed in different ways. This review is useful for listing the sensory methods used to generate sensory descriptors to characterize the oral texture of cereal and pureed foods. We found that 55% of the reviewed publications used specific oral texture descriptors and that 17 descriptors could be identified as the most used and relevant for all the products studied (sticky), for pureed (e.g., cohesiveness, floury, and soft) and for cereal-based foods (e.g., hard, fatty, and crispy). These results should be considered to facilitate the choice of sensory texture descriptors in future studies on pureed and transitional foods such as cereal-based foods according to the IDDSI level. This review also demonstrates that it is difficult to find a consensus between studies using different evaluation methods for the same descriptor.

Simple Advanced Preparation Method for Improving the Thickness Stability of Powder Thickening Agents in Dysphagia Management

Texture modification of foods by using thickening agents is a routine practice for assessing and treating dysphagic patients. However, a powder-thickened fluid's viscosity might change over time, and little has been proposed to overcome this inconsistency. This study aimed to evaluate variations in the thickness of a fluid thickened with a common xanthan gum-based powder and to explore the feasibility of a simple advanced preparation method for thickened liquids to improve thickness stability. Thickened fluids with concentrations of 1.0 g/100 mL, 0.7 g/100 mL, and 0.5 g/100 mL were prepared from both freshly opened and previously opened thickening powders. Fluid thickness was measured every 10 min in a series of International Dysphagia Diet Standardization Initiative flow tests. A significant time-dependent decline in thickness was observed for all three concentrations in both groups, namely those prepared with freshly opened and previously opened thickening powders, and the shortest periods to achieve a stable viscosity after liquid preparation for the two groups were 80 and 70 min, respectively. On diluting the thickened liquids from the base liquid, which was prepared at a concentration of 1.0 g/100 mL and stored at room temperature for 90 min, no significant time-dependent thickness changes were observed over the following 60 min. The simple protocol of preparing the thickest "base" liquid in advance and then diluting it to the desired thickness resulted in a consistent liquid thickness, with the prepared liquids ready to be clinically applied and consumed, with high stability within 60 min.

Liking, preference and practical implications of protein and energy enriched in-between-meals designed for elderly people

Background

An adequate dietary intake, especially of protein and energy, is important for maintaining health among elderly people, especially those in care homes. One strategy to ensure nutritional intake is to customise attractive products through enrichment to match the needs of elderly people in care homes.

Objective

To evaluate liking and practical aspects of protein and energy enriched in-between meals designed for elderly people in care homes through the use of quantitative and qualitative assessments.

Design

A broad range of energy and protein enriched in-between meals, including both savoury and sweet products, were included. The products were evaluated by a consumer test and a focus group discussion with elderly respondents. The products were also evaluated by a second focus group discussion with care staff.

Results

The most liked products were ice cream and cheesecake. All products achieved high scores for appearance, taste/flavour and texture. No product included in the study was extremely disliked. However, the least liked product was tomato soup, which scored above the middle of the scale except for texture. It was clear from the focus group discussions that a colourful appearance, small portion size and texture were of primary importance. The temperature had an impact on liking and swallowability.

Discussion

Most products were perceived by the elderly participants as appealing and tasting good, and possible to include in a daily diet. It was clear that the colours of the foods were of primary importance. In line with other studies, it was found that highly liked in-between meals were frozen, cold and sweet. These products were also easy to swallow.

Conclusions

It is possible to produce highly liked energy and protein enriched in-between meal products designed for elderly people. The temperature had a great impact on the liking of texture, taste and flavour. In-between meals should preferably be colourful and have a small portion size.

Validating the textural characteristics of soft fish-based paste through International Dysphagia Diet Standardisation Initiative recommended tests

One in every twelve people worldwide suffers from dysphagia that affects the swallowing mechanism and some patients require a special texture-modified food for their sustenance. Fish is a great source of nutrients and proteins, however the commercially dysphagia diet made from fish is limited. This study investigated the textural characteristics of a soft fish paste produced from steamed grass carp fillet with different the water addition, grinding cycles and ratio of starch with the mixture of steamed fillet and water, following International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines and other instruments. The water addition and particle size affected the physical properties, and the starch had a certain masking effect on fishy odor. The mixture of steamed fish fillets and water (91:9 wt/wt) was ground in a colloid mill for 3 cycles. The fish paste was then sterilized by adding sugar, salt, and starch in the mixture (ratios of 0.5:100, 0.5:100, and 0.6:100, wt/wt, respectively) and mixing well. The paste conformed to Level 4-pureed and extremely thick of IDDSI framework. The fish paste product had a light fishy odor that was acceptable to sensory specialists.

Is IDDSI an Evidence-Based Framework? A Relevant Question for the Frail Older Population

To delay impacts of aging, optimal nutritional status is essential. Several factors can reduce food intake, such as isolation, income, and cognitive/physical decline. Additionally, chewing and swallowing difficulties, or dysphagia, often disrupt the ability to consume life-long favorite dishes. Food and liquids could require modification of texture or consistency to ensure a comfortable or safe swallow. The food industry, foodservices facilities, and caregivers need quality control benchmarks to provide adequate nourishment and meet these new feeding challenges. The International Dysphagia Diet Standardisation Initiative (IDDSI) is proposing the IDDSI framework and testing methods to describe food used in nutritional care plans to circumvent dysphagia and improve communication among caregivers. This systematic review assesses the validity and reliability of the IDDSI testing methods using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). Two publications presented content validity whereas 19 publications looked at construct validity or reliability for the IDDSI testing methods. One study was conducted in older adults presenting dysphagia. This review concludes that there is insufficient evidence to recommend the IDDSI testing methods. Further research, conducted with robust methodological design and reporting, is needed to develop and assess nutritious adapted food for frail older populations.

Are Medication Swallowing Lubricants Suitable for Use in Dysphagia? Consistency, Viscosity, Texture, and Application of the International Dysphagia Diet Standardization Initiative (IDDSI) Framework

Medication lubricants are thick liquids or gels that are designed to aid swallowing of solid oral dosage forms. Tablets and capsules are placed within a spoonful of the product for swallowing. The aim of this study was to describe and compare commercially available medication lubricants in terms of textural suitability for patients with dysphagia. Twelve medication lubricants were characterised according to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Apparent viscosity, yield stress, thickness consistency, and various texture features were compared. Gloup Forte was the only medication lubricant classified as IDDSI level 4 (pureed/extremely thick) at room (24 °C) temperature. Four other Gloup products were IDDSI level 3 (liquidised/moderately thick) at room temperature but testing at 4 °C or pouring from the container instead of using the pump dispenser resulted in classification as IDDSI level 4. The IDDSI Flow test would have classified MediSpend and Slo Tablets as IDDSI level 3, but their very low yield stress led to these fluids flowing too quickly through the prongs of a fork and so these were classified as <3. Severo was IDDSI level 2. Heyaxon and the two versions of Magic Jelly tested contained lumps, and Swallow Aid had exceptionally high viscosity, hardness, adhesiveness, and gumminess, classifying them as IDDSI Level 7 (“regular textures”) and therefore as unsuitable for people with dysphagia according to IDDSI. This study provides valuable information to help with the selection of a safe medication lubricant with appropriate thickness level suited to each individual with dysphagia.

Implementation Strategies for the International Dysphagia Diet Standardisation Initiative (IDDSI), Part I: Quantitative Analysis of IDDSI Performance Among Varied Participants

Purpose The International Dysphagia Diet Standardisation Initiative (IDDSI) is an international standardized framework for texture-modified diets (TMDs). However, user accuracy in conducting IDDSI testing methods are unknown. The aims of this study were threefold: (a) to describe performance on two tasks (an IDDSI knowledge quiz and a TMD sample classification task), (b) to determine interrater and intrarater agreement for classification task performance, and (c) to determine predictive relationships between socioeconomic factors or prior knowledge on task performance. Method Sixty-eight participants were recruited, including health care professionals and non-health care-related individuals. A mixed between-subjects and within-subject design was used. All participants completed a baseline knowledge quiz, 30 min of self-study using the IDDSI.org curriculum, a post self-study knowledge quiz, and a TMD classification task of 21 TMD samples with representation across all IDDSI levels. Data were collected via electronic survey. Results There was a significant increase (p < .001) between pre and post self-study knowledge quiz scores. On the classification task, unmodified foods and drinks were most accurately classified with thickened liquids (IDDSI Levels 1, 2, 3) most inaccurately classified. At baseline, moderate interrater agreement was found with intrarater agreement ranging from fair to almost perfect among identical samples. No significant predictive relationships were found between classification task performance and socioeconomic status or prior experience. Conclusions Thirty minutes of self-study using the online IDDSI.org curriculum improved baseline IDDSI knowledge check performance. Overall accuracy of TMD classification was low and warrants further evaluation given potential adverse health outcomes secondary to inappropriate TMD presentation. Given no predictive relationships between socioeconomic factors and prior experience on task performance, the IDDSI curriculum and classification task appear accessible to various users, including non-health care-related participants. Future studies should more closely observe testing behavior to further characterize variation in participants' use of the testing methods.

The impact of modification techniques on the rheological properties of dysphagia foods and liquids

Modifying food and the textures of food has been done for decades within the food science and technology field. More recently, modifying the texture of foods has been used to manage swallowing disabilities (dysphagia). Swallowing disabilities are often associated with dehydration and malnutrition, thus nutritional intervention has formed part of serving texture-modified diets. The question remains whether these modification techniques are viable for individuals with swallowing disabilities living in majority world countries. This study used two modification methods on a widely used specialized nutritious food (SNF) to determine whether it may be modified and used in dysphagia management. The techniques had to be ergonomic and economically appropriate for individuals with swallowing disabilities living in majority world countries. The International Dysphagia Diet Standardization Initiative's (IDDSI) standards were used to determine whether the texturally modified SNF is safe for swallowing. Rheological measurements were performed to determine apparent viscosity and structure recovery of each sample. The effects of two modification techniques, aeration and particle separation, on the rheological properties of the SNF were also measured and analyzed. It was determined that both milk and water could be used with this SNF to create a dysphagia diet, but only under certain conditions. The overall results indicated that heating the samples increased the apparent viscosity and exacerbated lumping. Room temperature samples had less lumps and could be classified to the desired levels of the IDDSI (Level 2 and Level 4). Using a whisk to aerate the samples reduced lumps significantly and using a sieve to separate particles of liquid samples eliminated lumps. This study provides new data on how texture modification techniques and the IDDSI framework could be adapted to individuals living in majority world countries. By using modification techniques that are ergonomic and economically viable and an SNF with longevity, this study could be useful in guiding future training of nursing staff and caregivers of individuals living in poverty or resource-constrained communities. This study also adds to the data on the rheological properties of dysphagia foods, although this study did not make use of commercial thickeners generally used in the modification of diets.

[Swallowing disorders, training and assessment of geriatric practices]

In geriatrics, swallowing disorders are frequent, representing a daily source of anxiety for the nursing teams. Training in this area, aimed at caregivers in a long-stay care unit, has been developed based on an assessment of professional practices.

Comparison of two methods to categorize thickened liquids for dysphagia management in a clinical care setting context: The Bostwick consistometer and the IDDSI Flow Test. Are we talking about the same concept?

The Bostwick consistometer and the International Dysphagia Diet Standardization Initiative (IDDSI) Flow Test are both proposed methods to measure and categorize thickened liquids for dysphagia management. The objectives were to: (a) compare the Bostwick consistometer reference values used in clinical settings and the IDDSI reference values of thickened liquids suggested for nutrition care plans in the management of dysphagia when measuring commercially available preprepared thickened liquids; (b) explore the relationship between the two methods; (c) assess the interchangeability; (d) document the intra-rater reliability. Preprepared thickened liquids (n = 32) were measured twice with the Bostwick consistometer and 3 times with the IDDSI Flow Test, using a rigorous methodology. A registered dietitian nutritionist and a registered nutrition and dietetic technician performed the measurements. The Pearson's correlation coefficient was calculated to explore the relationship between the two methods. Using a linear regression equation, back-calculations of the IDDSI Flow Test values were done, based on the experimental Bostwick results. Interchangeability was assessed by documenting the level of agreement between the results with a Bland and Altman graphical analysis. Intraclass correlation coefficients calculation and a Bland and Altman graphical analysis were performed to assess reliability. The strong correlation (r = -.93, p < .001) between the IDDSI Flow Test and the Bostwick consistometer measurements suggests that they measure flow rate in a similar manner, but not exactly the same, as confirmed with the Bland and Altman graphical analysis. Thus, they produced results that are not interchangeable. However, both tests show excellent intra-rater reliability (ICC ≥ 0.99) when using a rigorous methodology. PRACTICAL APPLICATIONS: Thickened liquids are used to manage oropharyngeal dysphagia. Clinicians need to provide quality assurance/quality control (QA/QC) support in the selection or production of thickened liquids as well as staff training or patient education regarding these products. Methods and classification have been proposed to measure and categorize thickened liquids for dysphagia management, such as the line spread test, the Bostwick consistometer method, and the IDDSI Flow Test. Although empirical, these methods are more accessible to clinicians than viscometer or rheometer assessments. Clinicians need to understand the limitations of these techniques as neither appear to capture the full extent of consistency for potential beverages available on the market or produced in-house. In this article, we compare the Bostwick consistometer and the IDDSI Flow Test methods and classifications and propose a standard operating procedure in order to maximize the quality of results. We point out the large variations in consistency levels of commercial preprepared thickened liquids in light of the absence of evidence of clinical outcomes associated with either proposed methods or consistency classifications.

Challenges to assumptions regarding oral shear rate during oral processing and swallowing based on sensory testing with thickened liquids

For people with dysphagia, or difficulty swallowing, thickened liquids are used to slow bolus flow to make them easier to control. For these liquids, the oral shear rate of 50 s^-1 has been adopted as the standard at which viscosity measurements are taken. However, there is evidence to suggest that other shear rates may be more appropriate to model the processes in the mouth and throat. This research compared the sensory and rheological properties of xanthan gum, guar gum, and carboxymethyl cellulose thickened liquids that had been matched for apparent viscosity at 50 s^-1 to assess the validity of the current shear rate standard. Properties of gums were observed at various viscosity levels based on the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Textural sensory characteristics of samples were quantified using magnitude estimation scaling and a trained descriptive panel, while rheological measurements were taken at shear rates of 1 to 1000 s^-1. Perceived slipperiness of the gums was found to be driven by thickness level at low viscosity levels, but affected by the shear thinning behavior of the gums at higher viscosity levels. Although the liquids had been matched for apparent viscosity at 50 s^-1, panelists could distinguish both the perceived viscosities of the gums and their ease of swallowing, suggesting that 50 s^-1 is neither appropriate to model the oral nor pharyngeal shear rates. A single oral shear rate could not be predicted from the data, and it is proposed that panelists evaluated oral viscosity using different methods at different viscosity levels. Based on the sensory data, the pharyngeal shear rate during swallowing appears to lie above 50 s^-1.

Influence of the syringe model on the results of the International Dysphagia Diet Standardisation initiative flow test

ABSTRACT Objective: to investigate whether two different syringes yield different results in the International Dysphagia Diet Standardization Initiative (IDDSI) flow test to evaluate liquid consistency. Methods: two 10-mL syringes (Bencton and Dickinson, manufactured in the United States, and Saldanha Rodrigues, manufactured in Brazil) were compared. Flow rate of water added with food thickener (maltodextrin, xanthan gum and potassium chloride) at three concentrations, and of barium sulfate at three concentrations was measured immediately after preparation and at 8 hours and 24 hours thereafter. Results: flow rate of both water and barium sulfate was higher with the Bencton and Dickinson syringe, with discrepancies between the two syringes in the classification of fluid consistency according to the IDDI framework. Conclusion: in the evaluation of the consistency of liquids by the IDDSI flow test, a Bencton and Dickinson syringe should be used, following the recommendations of the IDDSI group.