Op-Ed: Why IDDSI Doesn’t Work in Long Term Care

As Dietitians we’ve all heard of IDDSI being implemented for years now, but with COVID we saw a big delay.  If we’re being honest, I’m sure the majority of Long Term Care Homes have not transitioned to IDDSI.  The big question is, why not? 

It’s not a simple answer.  It’s not as simple as we don’t have time.  Some Dietitians have serious questions about the need for IDDSI.  There’s also realistic questions about the realities of a total implementation.

I have been involved in the IDDSI planning and implementation for years now, and I still don’t see a realistic path to implementing it.  Here’s my reasons why.

Diets Eliminated From IDDSI

IDDSI completely changed the way our diets work in long term care.  As long term care Dietitians this didn’t fly past our radar.  To completely get rid of soft texture, total minced, minced, and finger food diets, was short-sighted.  

I’m not sure who exactly sat on the committee, though I do know they had an exhaustive list of experts.  I would question how many of these experts have actually been a front line Dietitian in long term care though.  

Of all the textures eliminated the biggest issue was eliminating the current minced texture diet and its allowances.  

Eliminating the Minced Texture Diet

The previous minced texture diet has been replaced by the IDDSI minced moist diet.  This was the biggest issue I saw with trying to implement IDDSI.  

In the new IDDSI guidelines a minced moist IDDSI diet would no longer allow bread products1.  The majority of my patients that were on a minced texture diet had bread products, muffins, pastries, toast for breakfast.  All that good stuff!

If IDDSI is implemented safely, anyone on a minced texture diet would now be on a minced moist IDDSI diet.  Do you see the problem here?

We get plenty of feedback as Dietitians in long term care, I can’t even imagine the amount of complaints I would get if I eliminated all bread products from a patient’s diet.

The IDDSI recommendations are gelled or pre-soaked breads instead of regular toast.  Gelled products are usually cost prohibitive in a budget restricted facility.  A facility can pre-soak bread.  But if a patient doesn’t want it, what do we do then?

Forget that.

They also recommend that minced meats be served with gravy or other sauces.  What if a patient hates gravy and sauces?  Am I supposed to give it to them anyway so I don’t alter the diet at all?

Some may suggest putting them on soft-bite sized, but that is not the alternative to a minced texture diet.  We continue to have the same issue of no bread/toast.  Dietitians would still need a Speech-Language Pathologist to determine whether to upgrade or downgrade.  

IDDSI strictly states on its website, do not alter any diets2, so how do we make exceptions?  And if our goal is person-centred care, I don’t see how IDDSI is person-centred care.  

Speech-Language Pathologists in Long Term Care

Most facilities have a Speech-Language Pathologist (SLP) on a consult only basis3.  Their wait lists are typically extensive for non-urgent consults and they cover many facilities.  Their schedules are already packed.  

If a Dietitian wants to implement IDDSI minced moist, they essentially need their SLP to reassess every resident on a modified texture diet (MTF).  Asking SLPs to come in and reassess all residents on a MTF diet would require them reassessing 33% of our patients4

This would take a ridiculous amount of time for them to complete.  I have spoken with many SLPs that see this as a big issue.

SLPs perform such specialised and individualised care, we can’t disregard the value their assessments would be.  As Dietitians we can downgrade a patient, but upgrades I always recommend going through the SLP.

My question for the IDDSI committee would be, how do you expect us to adjust all the diets?

 IDDSI in Long Term Care

I have looked over the IDDSI framework and don’t see any difference between its recommendations for a paediatric unit and a long term care home.  Sure you can argue that there is a size difference in the requirements, but that’s all I can see.

I once again ask, how in the world is this person-centred care? 

The needs for a paediatric patient are nowhere near the needs for an elderly individual.  If we are not recommended to alter IDDSI at all, it restricts us from taking into account the patient’s individual needs.

There are aspects of IDDSI that won’t apply to long term care at all.  Look at fluids level 1 slightly thick, it states it’s typically just for a paediatric population. 

Why would IDDSI not have made frameworks for the different populations? 

Costs Associated with IDDSI

Implementing IDDSI is not free to implement in most scenarios.  Facilities either have kitchens in their homes, or they have a central processing facility.  

In most facilities in order to implement IDDSI minced moist diet, a new device would need to be purchased.  The size requirements for this diet is 4 mm width.  Previous minced texture diets were 5 mm width + depending on the facility5.  

This can be a huge cost issue.  Most long term care homes already struggle with budget issues.  There are physical upgrades to the home that are needed, the budget for food, which is already quite low.  At this time, in Ontario for example, raw food costs for each patient per day is $9.546.  This figure is unchanged even with inflation going up.

Another cost associated with implementing IDDSI is the mass education that would need to go into it.  All staff members would need to be trained on:

  1. New diet terminology
  2. What each diet entails
  3. Patients new diets
  4. New fluid terminology
  5. Patients new fluids
  6. All diet records need to be changed and updated
  7. Education posters need to be posted

I’m sure there are things on the list that I am missing.  The Dietitian would obviously need to have their hours increased significantly for a time in order to implement IDDSI diet textures.  

In some cases, that would not be possible.  IDDSI does provide materials to implement their framework.  But I have checked their website, and there continues to be nothing in the aged/long term care section.

Closing Thoughts on IDDSI Implementation

I’ve heard the saying if it’s not broken, don’t fix it.  I’m wondering what was broken about our diet texture system that wasn’t working?  

Most health regions had their diet textures standardised with some minor alterations.  We have had the ability to personalise each diet texture, add and change what we needed in order to accommodate their needs.

With IDDSI implementation I feel we are handcuffed to not alter their diets.  

If we are to move towards person-centred care and respect the rights and needs of all of our patients, we need diets that allow this.  

I have never understood the need for a world-wide giant regulatory body surrounding diet textures.  Each country has beautiful and unique diets, and they don’t all fall into one clean cut category.

I am of the understanding that many facilities have not transitioned to IDDSI for one reason or another.  I support these facilities in looking out for what is best for their patients.  

I will always be a patient advocate and respecting their right to choose and refuse what they want.  When I am elderly I expect that I will be able to choose my diet.  Some things may fit in one category and other choices may not.  

If the IDDSI team wants this to work, I suggest they have actual practicing long term care Dietitians sit at the table. We know what will work and what won’t.

I would love to hear your thoughts on the IDDSI diet texture.  Have you implemented IDDSI?  Has it worked?  What were your issues?

Let me know your thoughts below.

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10 thoughts on “Op-Ed: Why IDDSI Doesn’t Work in Long Term Care”

  1. Thank you for the op-ed. My homes have not formally adopted IDDSI. Regardless, the concept of IDDSI for foods has led to changes in the foods offered in minced and pureed textures, and are less likely to match the regular diet. This has led to decline in variety and food enjoyment.
    I applaud the move towards a universal language in food & fluid textures to support research, and decrease possible texture errors. Safe practise requires clear communication, which starts with diet orders written, using the words diet, texture and fluid consistency. Currently IDDSI texture modified diet are more restrictive that the traditional food texture. This direction is in contrast to the move for liberalized diets, know to decrease malnutrition risk.

    1. Great insight, Marleen! I agree, I have no problem with trying to improve communication in language of diet textures. But I’m not sure their approach was the best approach. I think if they had more input from frontline practicing Dietitians, they would have had a) more buy-in, b) more realistic diets, c) diets that were realistic to implement in LTC. Hopefully there will be some foresight before a new project is brought up. Thanks for your comment!

  2. I feel like this piece pulled thoughts right out of my head! I really like the point that was made about how attempting to make it an international framework just will not work with the variety of foods around the world. That point never crossed my mind, but is spot on. My LTC and STR units are part of a large health system. Our health system has transitioned to IDDSI which includes both my STR and LTC units. It has been so challenging to transition to this in the units especially our LTC unit where people are coming from home. Many times people have just been managing swallowing difficulties at home and then they come here, are placed on IDDSI texture diet and become over restricted. This causing a lot of frustration for our residents and is a constant complaint during care plan meetings. We have a great SLP who has been trying to make patient specific exceptions, but it gets so cloudy. My food and nutrition staff are constantly calling for clarification on allowable food items. Somedays I am not even sure what to tell them out of fear of realizing it isn’t IDDSI compliant.

    1. All great points, Elizabeth! There’s too much room for error when every patient now has so many exceptions. We’re here for the patients and to provide them with the best care, I’m not concerned with implementing IDDSI anymore.

  3. My thought is how we would meet nutrition requirements for grain servings (being strict in some US states menu regulations) on a minced and moist…
    I agree that IDDSI isn’t person-centered. And limiting in also available options making them more difficult to produce for our already short-staffed culinary teams.

  4. I completely agree with everything you’ve stated. We implemented IDDSI framework for fluids about 3ish years ago, and 80% of the staff still call fluids by the “old” names- and I’ll fully admit I find myself doing the same at times as well. Implementing the food texture framework will not work for us. I can’t even imagine the backlash we’d get for eliminating bread. Who wants to eat soaked bread anyways?? No one I know. I’d also like to know why “slightly thickened- level 1” is only for pediatrics….over the years, I’ve had several requests by staff saying this is the fluid texture some residents require…that in between thin and level 2. However I’ve never been able to order that as it’s not in our diet framework. Then just adding in the time for education of all staff and training- good luck- I’m hanging by a thread most days.

    1. Great points, Steph! I’ve stopped correcting staff on the fluid terminology (that’s all I’ve changed over) because their question is always why was it changed? I never have a good reason for why it was changed besides possibly our suppliers drinks are labelled with the new terminology. I don’t see enough of a strong reason to change the diet textures. Thanks for the comment!

  5. I totally agree with everything that is said regarding IDDSI implementation in LTC. I have a full time SLP and also had one in the last 200 bed facility I worked in and honestly we are lucky to service our clients correctly with pureed, mechanical soft ground meats, cut at tableside consistencies. My residents enjoy their bread products and to not be able to divert from the IDDS would not be giving resident choice which is not ok. What we currently do is not broken in my opinion. The SLP would be a bigger part in implementing and testing all of our products and this would take time and effort and money, which lately we are short on all including kitchen and nursing staff.

    1. Great comment, Bernice!
      I echo everything that you have said. The time, money, and effort on everyones part just doesn’t seem like a wise investment during these times. I would rather see all that funding shift towards increased hours for feeding assistance, Dietitian hours, increased per diem money for raw food costs. So many more things instead of IDDSI. Thanks for your comment!

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