The Science Behind IDDSI

Dr Ben Hanson

Associate Professor, University College London

IDDSI board member
ben.hanson@iddsi.org @BenHansonMech The International Dysphagia Diet Standardisation Initiative is
supported by funding from a variety of industry sources.

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SAFETY AND QUALITY OF LIFE

For all ages, all care settings, all cultures

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 “Large” can be quantified in millilitres THE STORY OF IDDSI…

International best
practice and web-
based surveys
Scientific research

Multidisciplinary,
international
But: How thick is “thick”? volunteer board

and: What do you mean, “thick”?!

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BEST PRACTICE CREATING INTERNATIONAL GUIDELINES THE BIRTHPLACE OF THE FRAMEWORK

2013 2014 2015 2016

Establish
Multidisciplinary Clear Process for
Guideline identification drafting the
Development of clinical recommendations of
Group Systematic the multidisciplinary
issues Consultation
review + Guide Development
beyond the
appraisal of Group
Multidisciplinary
Involve literature
Development
consumers
Group

Turner et al. (2008), Implement Sci, 3:45; Qaseem et al. (2012), Ann Intern Med. , 156: 525-531

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 INTERACTIONS DURING SWALLOWING WHAT REALLY GOES ON IN THE MOUTH ?

Difficult to measure in-vivo (ultrasound, MRI, VFSS)

Difficult to
B urbidge et al. “A Day in the Life of the Fluid B olus”, Applied Rheology 26 (2016)
simulate too…
complex
sensorimotor … anatomy &
somatosensory fluids need to
be simplified
perceptual
YouTube /
Michael Farnan
interaction Adapted from original illustration
Anatomy & Physiology Online
Robbins et al. Arch Phys Med Rehabil 88, Preciado-Méndez et al., “Numerical analysis of extensional flow through
February (2007) the pharyngeal duct”, IOP Conf. Series: J. Physics: Conf. Series 790 (2017)

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MECHANICAL SIMULATION EXAMPLES MECHANICAL ORAL SIMULATOR AT UCL

Swall-E: A robotic in-vitro simulation Gothemburg throat:
of human swallowing Slow motion: 1/20th speed
• Bolus injected and flows by gravity
• Bolus velocity measured by Doppler u/s Pressure sensors
60
mm
70
mm
Pressure

Hard Palate

Tongue

Time
Qazi, W.M. et al.,
Dysphagia (2019).
Redfearn, A., Hanson, B., IEEE/ASME Transactions on mechatronics 23(2) 2018
Fujiso et al. (2018) PLoS ONE 13(12): e0208193

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 PARTICLE IMAGE VELOCIMETRY PALATAL PRESSURE SENSING
• Non-invasive measurement of flow field
Slow-motion:
• Flow is not uniform 1/20th real time
Pressure sensors

Green Sensor Signal

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CLINICAL EVIDENCE: LIQUIDS THE IDDSI FRAMEWORK:

1. Thickened liquids helps those who • Peer-review published1 in Nov.

aspirate thin liquids 2015 (Revised: July 2019)
• A continuum of 8 levels (0-7)
2. Liquids can be “too thick”, where
residue begins to accumulate • Spanning foods and drinks
• Colour-coded
…and drinks become less
• Culturally-neutral
appealing!
• Includes descriptors, testing
methods and evidence for foods
Systematic reviews: Newman, 2016, Dysphagia, 31: 232-49;
Steele et al., 2015, Dysphagia, 30: 2-26 and drinks

Ongoing research required to determine therapeutic thickness levels 1

Cichero, J.A.Y., Lam, P., Steele, C.M. et al. Dysphagia (2017) 32: 293.

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 PRE-EXISTING VISCOSITY MEASURES

MEASUREMENTS: LIQUIDS

NDD 0-50 cP* 51-350 cP* 351-1750 cP* > 1750 cP*
AU < 95 mPa.s* 95-200 mPa.s* 260-550 mPa.s* 670-1040 mPa.s*
proposed (<1.3 Pa)# (1.3-4.0 Pa)# (5.5-11.5 Pa)# (14-21 Pa)# * Viscosity @ 50 sec -1
JPN <50 mPa.s* 50-150 150-300 300-500mPa.s* >500 mPa.s* shear rate;
# Yield stress (Pa)
mPa.s* mPa.s*

American Dietetic Association (2002); Hadde (2015) Int J Speech-Lang Pathol, 18:402-410;
Watanabe et al.(2017) Dysphagia, epub ahead of print

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Liquids: formal rheological

measurements
First reported 1992….

VISCOSITY IN DETAIL…

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 Cross section of
fluid in a pipe

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Sample of liquid
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 © Ben Hanson 2020

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METHODS FOR ASSESSING “THICKNESS” RHEOLOGICAL MEASUREMENT

• Verbal descriptions of thickness Scalar “viscosity” is too simplistic to describe foods and
drinks, which are non-Newtonian.
Practicality, affordability

Accuracy, Reproducibility

• unspecific and highly subject to interpretation

• Swirling in a cup, Pouring from a spoon One isolated measure
• Can be performed in comparison with a “reference” liquid (e.g. is not representative
pre-thickened O.N.S., or “TIM tubes”1) of the overall behavior.
• Consistometer, Line-spread test2, or Funnel flow test
• Useful for local audit of repeatability
• Viscometer
• Results dependent on technique and measurement parameters
(geometry, speed)
• Rheometer
• “Complete” measurement of a small sample of homogeneous
material in controlled conditions
1) Chadwick et al, J Intellectual Disability Research (2013) Sample of liquid
2) Master s Lund, Mer tz Gar cia, Chamber s, Am J Speech Lang Path (2013) O’Leary et al. (2010) J. Food Science, 75:E330-E338

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 ACCESSIBILITY vs VALIDITY
• Measurements need to represent in-vivo flow
• Bostwick & line spread test “slump”
• But swallow involves shear & extension

Bostwick Line Spread test

Consistometer

1-4 ml remaining after 10 seconds flow

Mackley et al. (2013) J. Rheology, 57: 1533

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4 consistencies shown here

THE FLOW TEST (Level 4 needs fork & spoon tests)

The science behind the flow test: peer-reviewed publication Hanson et al. , Annals of Biomedical Engineering (2019)

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 SHEAR RATES USE THE CORRECT SYRINGE
• Incorrect sized syringes give
• Shear rate highest at the boundaries (tongue and palate)
• Zero in the centre of flow incorrect measurements
• True for non-turbulent flow in any channel • The difference is
unpredictable, depending
on the liquid type
0 0 ms
100 ms
Shear rate
X
• IDDSI flow test funnels
1
< 25 /s
2
may be the solution.

Distance Y (mm)
3
Shear rate
4 ~ 0 /s
5
Shear rate
Y
6
< 25 /s
7
0 2 4 6 8 10
Distance X (mm)
Redfearn, A., Hanson, B., “Oral simulator quantifies
intra-bolus pressures, flow speeds…” DRS (2017)

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METHODS FOR ASSESSING “THICKNESS” VARIABILITY IN SCOOP VOLUME & MASS

• Verbal descriptions of thickness
Accuracy, Reproducibility
Practicality, affordability

• unspecific and highly subject to interpretation

3. 5
• Swirling in a cup, Pouring from a spoon
3
• Can be performed in comparison with a “reference” liquid (e.g.

Weight in scoop, grams

pre-thickened O.N.S., or “TIM tubes”1) 2. 5
• Consistometer, Line-spread test2, or Funnel flow test
2
• Useful for local audit of repeatability
• Viscometer 1. 5

• Results dependent on technique and measurement parameters 1

(geometry, speed)
0. 5
• Rheometer
• “Complete” measurement of a small sample of homogeneous 0
1 2 3 4 5
material in controlled conditions
1) Chadwick et al, J Intellectual Disability Research (2013) Scooping Method
2) Master s Lund, Mer tz Gar cia, Chamber s, Am J Speech Lang Path (2013)

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 THE IDDSI FRAMEWORK: EVIDENCE: FOODS
• Peer-review published1 in Nov.
1. Solid food and thick/paste
2015 (Revised: July 2019)
consistencies = greater effort in
• A continuum of 8 levels (0-7)
oral processing and swallowing
• Spanning foods and drinks 2. Very little published about texture
• Colour-coded modified food used for dysphagia
• Culturally-neutral management
• Includes descriptors, testing
Systematic review
methods and evidence for foods Steele et al., 2015, Dysphagia, 30:2-26
and drinks
• ETHICS - RCT studies unsafe if a potential outcome is death by choking
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• Autopsy data: Particle size and specific food textures identified that increase choking risk
Cichero, J.A.Y., Lam, P., Steele, C.M. et al. Dysphagia (2017) 32: 293.

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LEVEL 7 EASY TO CHEW (L7EC)

“Soft”
MEASUREMENTS: FOODS
e

nd er
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 “Soft”? FORK PRESSURE TEST

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FORK PRESSURE TEST AUTOPSY EVIDENCE: PARTICLES

Minimise choking risk: Food pieces small enough to pass
through, rather than block the airway
Tracheal diameter ranges

Pediatrics:
20 months, 4-6.5mm
18-36 months, 7-8mm

Adult male, 15-27mm

Sample squashes and
Adult female, 13-25mm
does not return to its
original shape when
pressure is released Textures & shapes that increase choking risk: stringy, crunchy, crumbly, hard or dry, floppy, fibrous,
Thumb nail blanched to white ‘tough’, skins, shells, round shape, long shape, husks, mixed consistencies
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 CHEWED FOOD (GROSS-OUT WARNING…)

 Bite-sized pieces of
1.5 x 1.5cm for adults (~thumb nail size)
8mm x 8mm for children
 Chewing is necessary
 Tongue strength and control needed to move
food for chewing and for swallowing |
D OI: 10.1111/ joor.13151

Press with your thumb just hard

enough to blanch your thumbnail
Food should squash easily and not | | | 3
| |

return to its original shape | |

Chen J. Food oral processing—A review. Food Hydrocolloids. 2009;23(1):1-25.

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COHESION

üSoft and moist with no separate

thin liquid
ü Minimal chewing required
ü Lumps can be mashed with tongue
ü Food can be easily mashed with just a
little pressure from a fork
ü Should be able to scoop it onto a fork
with no liquid dripping and no crumbles
falling off the fork
Small particle size
4mm is the typical 4mm for adults
separation between 2mm for children
  the prongs of a fork Turcanu, M., et al., The role of human saliva on the elongational… 5th IEEE
International Conference on E-Health and Bioengineering - EHB 2015

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 ADHESION

No Lumps Extremely Thick liquid or Pureed Food

sits in a mound or pile above the fork
Does not require chewing • Stickiness is associated with residue
It does not
Not sticky dollop, flow or
Holds shape on a spoon drip continuously
through the fork
Falls off in a single spoonful prongs
when tilted and holds shape
on plate with slight slumping
or slow spreading A small amount may
flow through and form
a tail below the fork

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IDDSI SPOON TILT TEST FOOD TEXTURES RELATE TO DEGREE OF ORAL PROCESSING

 Food break-
A bite:
A bite, or cut to
Chewed bolus:
Cohesive, small
Ready to
swallow:
down process enable comfortable particles held Smooth, lump free,
during chewing chewing and oral together with saliva moist (not sticky) bolus
manipulation

Physiologic 15 x 15 mm 2-4 mm Smooth & moist

✕
information Within tracheal size Relevant to particle Relevance to early oral
from literature Pressure until thumb size of chewed bolus sensory experiences +
nail blanches to white reduced choking risk

IDDSI Spoon Tilt Test determines For safety the bolus should 4mm
Cohesion (ability to hold together) and be cohesive enough to hold
Adhesion (stickiness) ~17 kPa
its shape but not sticky

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 HOW TO USE IDDSI MEASURES “THE SCIENCE IN FRONT OF IDDSI”
• IDDSI is a language, not a law
• A tool, not a textbook
• Clinical judgement remains the priority!
• IDDSI can give you a quantitative measure of
outcomes and progression:
• e.g. the Functional Diet Scale[1]
• For auditing or research
• Measurements: use them as appropriate 10
17,000 downloads in first year
80 PMC citations, 305 Google Scholar citations
[1] Steele CM et al., Archives of physical medicine and rehabilitation. 2018; 99(5):934-44.

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“THE SCIENCE IN FRONT OF IDDSI” IDDSI TESTING FOODS AND DRINKS

1,020 articles!

43 articles

90 articles

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 IDDSI IMPLEMENTATION ASSESSING NEW PRODUCTS / THERAPIES

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SAFETY AND QUALITY OF LIFE

For all ages, all care settings, all cultures

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