How Dysphagia Chefs and Dietitians Around the World Are Teaming Up to Tackle IDDSI
by Emily Guzman
We know that nutrition and the culinary arts go hand-in-hand, but stories of IDDSI implementation around the world are showing us they must go hand-in-hand.
For individuals with dysphagia, the creative act of piping, molding, layering, and spooning food on a plate can be the difference between eating enough and risking malnutrition. This is the lesson of dysphagia chefs around the world who are teaming up with dietitians to make IDDSI implementation a success.
These chefs are challenging our conventional understanding of the chef’s perspective on food by placing nutrition and safety at the center of the plate. They’re using creativity and food science to make IDDSI-friendly meals that preserve a sense of pleasure and dignity for individuals with dysphagia.
READ MORE: Your Ultimate Guide to IDDSI
A Visually-Appealing Plate Reduces Nutritional Risk
When you compound an older adult’s existing nutritional risk with the swallowing difficulties that come with dysphagia, you see malnutrition, dehydration, and unintentional weight loss. 1
Chef and Certified Dietary Manager Henry Cintron is proving that presentation is part of the solution.
As the Regional Executive Corporate Chef at Next Level Hospitality Services, Cintron travels around the country to senior care facilities that have started to implement IDDSI. He trains culinary staff, dietitians, dietary aides, administrators, and speech-language pathologists to prepare, test, and present texture modified foods that meet the new IDDSI standards.
He says we have to move away from presenting pureed foods as “three scoops on a plate” if we want to prevent malnutrition and minimize complaints about the quality and appearance of foods. During his Next Level Puree Program trainings, he helps kitchen staff transform IDDSI Pureed (Level 4) foods from unrecognizable lumps to imaginative works of art. He teaches staff to pipe, shape, and mold everything from pureed hamburgers and pureed green beans so that they look like the real thing.
And it’s working. He spends two days training culinary staff before bringing dietitians into the kitchen for their feedback. Their positive comments affirm that meals are, in fact, stopping older adult residents from losing weight.
“It’s been proven, speaking with the speech therapists and dietitians, that [residents are] eating more of the food. Instead of just having a blob of brown meat on the plate, it actually looks like meatloaf, or it looks like a Salisbury steak,” said Cintron.
Photo courtesy of Henry Cintron
Margaret Roche can attest to the power of a beautiful plate in promoting good nutrition for individuals with dysphagia. She’s a dietetic consultant and founder of the consulting firm Roche Dietitians.
“Serving appealing purees is especially critical for those we serve with dysphagia because they’re often frail and at higher risk for nutritional problems. We have to make sure that the nutrition we provide is actually consumed,” said Roche.
Roche understands that IDDSI is a big undertaking and that focusing on presentation of foods may not be a top priority. But she assures the chefs, dietitians, manufacturers, and industry leaders she works with that it doesn’t have to be a complex process.
“Something as simple as dishware and piping bags make a huge impact,” said Roche.
READ MORE: The Five Key Components You Need to Train Food Service Workers on IDDSI
The Mealtime Experience Matters for Health and Wellbeing
Across the Atlantic, Chef Niamh Condon is doing similar work. She’s the head chef at a senior care home in Cork, Ireland where she serves attention-grabbing IDDSI meals to 49 residents every day, many of whom require texture modified foods due to swallowing difficulties like dysphagia.
Condon’s efforts in the kitchen are a response to a personal experience she had with texture-modified foods. She and a dietitian on staff spent three days eating and drinking thickened foods and liquids to better understand what it was like to eat with dysphagia.
“To say that we learned a lot is an understatement,” said Condon.
Savory foods weren’t nearly as enjoyable without that sensory crunch or chew, and she missed the taste and texture of coarsely-ground spices. Thickened water was so unpleasant to drink that she stopped short of her needs and quickly became dehydrated. Her mouth was so dry that food was hard to swallow. Within three days, all she could stomach was cranberry juice.
“Even the simple task of brushing my teeth became a problem, as I couldn’t have too much liquid in my mouth,” she said.
She also felt embarrassed when eating, an all-too-common experience for individuals with dysphagia that increases their anxiety and social isolation. 2
Though brief, the experience continues to inform her creativity and attention to detail in the kitchen, where she carefully smears, swooshes, and drizzles thickened sauces and purees onto the plate to create playful designs that entice her residents to eat. She uses bright and whole foods to modify and enhance the aesthetic appeal of food and drinks. When necessary, she finds ways to add calories from healthy fats and proteins to smaller portions of food so that her older adult residents stay well-nourished.
(IDDSI Pureed (Level 4) Beef Casserole. Photo courtesy of Niamh Condon)
Condon’s story highlights the work that chefs and dietitians are doing together to improve both the nutritional status and psychological wellbeing of individuals with dysphagia.
The Most Challenging IDDSI Foods
Every day, those who prepare IDDSI level foods are reckoning with new and challenging preparations of familiar foods. How do we serve fruits like strawberry and kiwi without the seeds? Roast vegetables without forming a hard skin or crust? Prepare rice that isn’t gummy or glutinous? Serve bread that isn’t dry?
Kendra Swartz knows as well as anyone that IDDSI is changing the way we prepare foods in the kitchen. As the lead dietitian at Prestige Care, she oversees nearly 80 long-term care and assisted living centers in the process of implementing IDDSI.
“Staff members in the kitchen have to adjust to reading new recipes, testing foods, and paying close attention to the size of texture modified foods. Initially, it has been taking more time in the kitchen as staff get more comfortable with it,” said Swartz.
Many of these adjustments go against everything chefs and dietitians originally learn about food and cooking -- adjustments like using ground pepper instead of cracked black pepper because its fine texture is safer for individuals who need pureed foods that are smooth and free of lumps. This attention to safety is what makes IDDSI worth it, and it’s why chefs like Condon and Cintron are embracing the challenge.
Cintron now spends much of the day using IDDSI’s testing methods to ensure his foods meet safety guidelines, and Condon now strains all foods with a sieve to make sure lumps, fibers, and other dangerous particles are gone.
But some foods are more challenging than others, and chefs are still figuring them out.
Cintron says starches like bread, rice, and pasta are the hardest to work with. These foods create problems for many chefs because, as Cintron points out, they like to become sticky, gummy, and glutinous, all of which are textures that put individuals with dysphagia at risk of choking. These foods will stick to the roof of the mouth, teeth, or cheeks and fall into the airway instead of the stomach.3 They also require chewing and swallowing abilities that individuals with dysphagia may not have.
Eliminating a whole category of foods like grains isn’t the solution because overly restrictive diets increase the risk of malnutrition and dehydration, especially in the older adult population.4
“This is where the real strength of IDDSI comes in. By using IDDSI testing methods – and in the case of grains, the Spoon Tilt Test – we can find a recipe that allows us to serve a formerly sticky food that now meets IDDSI guidelines,” said Roche.
IDDSI testing methods provide real-time feedback that foods are meeting IDDSI guidelines for safety. But sometimes, tweaking recipes to pass these tests isn’t possible without a little help from food science and manufacturing.
READ MORE: Margaret Roche Talks Improving Food Quality and Safety with IDDSI on the Boelter Wire Podcast
Finding Solutions with Food Science
The problem with the blanket statement to “avoid processed foods” is that individuals with dysphagia rely on food processing to survive.
Food processing is not all bad when you consider what it really is: making raw food suitable to eat 5. The addition of thickeners, stabilizers, and gelling agents is one form of food processing that makes food safe and easy to chew and swallow – a requirement for all IDDSI foods.
These food additives are the reason individuals on IDDSI diets can eat bread, which is important for dietitians like Swartz who say residents have been particularly unhappy with restrictions on bread.
Regular, dry bread is not allowed on IDDSI diets because it’s been identified as a choking risk. It requires the ability to bite and chew and cannot be easily mashed or broken down. However, when bread is soaked in a mixture of commercial thickeners and milk, it becomes moist, not sticky, easily mashed, and, ultimately, safe to chew and swallow.
“Since IDDSI is such a paradigm shift for us, it’s going to take a collective effort to transition to all IDDSI levels, and manufacturers are stepping up to the plate. I’ve been hearing from several who take the responsibility of offering IDDSI solutions seriously, and I expect to see some exciting solutions soon,” said Roche.
Swartz, Cintron, and Condon have all turned to food manufacturers for help in accomplishing their goals around safety, nutrition, and appearance.
Even though Cintron found a solution to what IDDSI describes as the “bread dilemma”, he’s still figuring out rice and pasta and plans to experiment with ready-made products. Swartz started to use pureed pasta, rice, and bread mixes that meet IDDSI textures, which she says has been a huge help. And Condon uses commercial food thickener in her IDDSI Pureed (Level 4) foods because it’s cost-effective and enhances the safety of foods for swallowing (without food thickener, thin liquid will separate from food and increase the risk of choking).
But what about nutrition?
READ MORE: IDDSI Pureed (Level 4)
How Dysphagia Chefs Are Championing Nutrition
Dietitians are rightfully concerned about modifying food to an extent that compromises its nutritional value.
Cintron and Condon share these same concerns and are mindful of preserving nutrition when preparing texture-modified meals to meet IDDSI guidelines. Cintron’s company, Next Level, decided long ago that it wanted to move away from frozen molds and use real food and real ingredients instead. They still uphold those values today.
Photo courtesy of Henry Cintron
And Condon has been a champion for nutrition ever since she “kidnapped” a dietitian on staff several years back so she could learn how to get more nutrition into smaller amounts of pureed foods for her older adult residents. Nowadays, she’s blending iron-rich spinach into pureed broccoli, steaming vegetables to prevent dilution with liquids, and adding skimmed milk powder to potatoes for more protein.
The work, values, and perspective of chefs and dietitians have always overlapped, but IDDSI is illuminating these similarities. And if there’s any thread that connects the IDDSI experience of these dysphagia chefs and dietitians, it’s that IDDSI wouldn’t be possible without a teaming up and blending of their two disciplines.
“IDDSI requires the best of what an RD has to offer and the best of what a chef has to offer. It’s very powerful what the chef/dietitian partnership can achieve together,” said Roche.
Emily Guzman is a second-year graduate student at the University of Illinois at Chicago pursuing her Master’s degree in nutrition. She received her Bachelor’s Degree in English Writing with a concentration in journalism from Kalamazoo College. Outside of the classroom, she uses her expertise in writing and journalism to produce high-quality content for local and global businesses in the food and nutrition industry.
References
1. Kline, M., & Hutcheson, D. (2014). Nutritional considerations in dysphagia to prevent malnutrition. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 23, 157. doi:10.1044/sasd23.4.157
2. The American Speech-Language-Hearing Association. Adult dysphagia. Retrieved from https://www.asha.org/Practice-Portal/Clinical-Topics/Adult-Dysphagia/
3. International Dysphagia Diet Standardization Initiative. (2019, July). Complete IDDSI Framework Detailed definitions. https://ftp.iddsi.org/Documents/Complete_IDDSI_Framework_Final_31July2019.pdf
4. Academy of Nutrition and Dietetics. (2018, April) Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings. Retrieved from https://www.eatrightpro.org/-/media/eatrightpro-files/practice/position-and-practice-papers/position-papers/individualizednutritionapproachesforolderadults.pdf
5. International Food Information Council. (2010, September). What is a Processed Food? You Might Be Surprised! Retrieved from https://foodinsight.org/wp-content/uploads/2014/07/IFIC_Handout1_high_res.pdf