The Challenges and Opportunities of IDDSI Minced & Moist (Level 5)
Since IDDSI, or the International Dysphagia Diet Standardisation Initiative, was launched, dietitians have increasingly been learning about Minced & Moist (Level 5). But as dietitians, dietary managers, dining leaders, and speech-language pathologists have spent more time preparing to implement this level, our industry has a growing number of questions about it.
At Roche Dietitians, we receive the most questions about Minced & Moist out of any IDDSI level. We’ve noticed dietitians and others across hospitals and long-term care communities are getting stuck on this level.
Why are so many getting stuck on Minced & Moist? This level is different from other IDDSI levels in several ways and presents special challenges.
But here’s the good news: Minced & Moist offers unique opportunities that can help increase your patients’ and residents’ safety while also expanding some individuals’ food options. You can successfully implement Minced & Moist by embracing these opportunities, using the appropriate IDDSI level for each individual, and training your food service team to test foods properly.
Since the Academy of Nutrition and Dietetics announced that it will recognize IDDSI as the only texture-modified diet in the Nutrition Care Manual, or NCM®, as of October 2021, understanding Minced & Moist has only become more important.
Here’s what you need to know for successful Minced & Moist implementation:
1. How IDDSI Minced & Moist (Level 5) is different from other levels.
2. The ways IDDSI Minced & Moist (Level 5) is uniquely challenging.
3. How to embrace the opportunities of IDDSI Minced & Moist (Level 5).
How IDDSI Minced & Moist (Level 5) is different from other levels
Before we dive into the challenges and opportunities of Minced & Moist, let’s look at the foundational reasons this level is different from other IDDSI food levels:
1. All foods have to be minced or mashed. Minced & Moist foods are no bigger than 4mm x 15mm for adults or 2mm x 8mm for children.
2. We mince foods we didn’t modify before. Certain foods we previously served “as is” we now have to mince. Canned fruit is a good example.
3. Foods can’t be sticky. The spoon tilt test checks for stickiness. If a small amount of food holds shape on a spoon and easily slides off when you tilt it, and there is little food left when you tilt or gently flick it, it passes the test.
4. We need to watch out for separate thin liquid. Minced & Moist foods have to be cohesive.
We have to add a thickened liquid or sauce to any food that has separate thin liquid.
5. No breads are included. Although this is true of the other IDDSI levels, it’s worth noting for Minced & Moist because it changes how we serve bread on texture-modified diets.
Although Minced & Moist is different from other IDDSI levels, the IDDSI testing methods are part of the path to success. The testing methods help you make sure your food meets the standards.
“The good news is the IDDSI testing methods help us verify that we got it right,” said Margaret Roche, founder of Roche Dietitians.
READ MORE: Guide to IDDSI Minced & Moist (Level 5)
The ways IDDSI Minced & Moist (Level 5) is uniquely challenging
Like any IDDSI level, Minced & Moist is another level that hospital and long-term care dietitians need to learn, implement, and train their teams on. But this level is different from anything we’re currently doing with other texture-modified diets. It’s a steeper learning curve than other IDDSI levels, and it presents a unique challenge for three reasons:
1. Minced & Moist (Level 5) shifts how we think about texture-modified foods.
As dietitians move through IDDSI, they can typically start by implementing Pureed (Level 4) and the drink levels. Then, they can implement the soft, diced food pieces of Soft & Bite-Sized (Level 6). But Minced & Moist is the stumbling block.
“My experience has been that people try to figure out the details of Minced & Moist on their own, and they get stuck,” said Roche.
When trying to implement all IDDSI levels at the same time, this level is where it gets difficult. The process is a little easier for those who can implement the levels one step at a time, but eventually, they’ll have to tackle Minced & Moist, Level 5.
Dietitians and others often try to figure out this level by themselves, and they struggle to move forward. If you’ve experienced this, you’re not the only one.
2. This level is a different texture from what we’re used to seeing.
Although Minced & Moist, Level 5 has some similarities to other texture-modified diets, it has a new, very specific particle size — plus it includes moisture.
This level has new characteristics and standards on when it should be used. The characteristics of Minced & Moist are:
• Foods are minced, moist, soft, and tender.
• Foods can be mashed with little pressure from a fork.
• Small pieces of “minced” food are visible within the food and are easy to squash with the tongue.
• Minced & Moist foods are not sticky.
• No breads or mixed consistency foods.
We serve Minced & Moist to individuals who have chewing and swallowing problems and need very small pieces of soft, moist foods. They can’t safely bite off food and can’t chew pieces of food that are larger than minced.
This might sound somewhat familiar compared with other texture-modified diets, but the differences often cause challenges with implementation.
3. All foods on this level are minced & moist.
Before IDDSI, we used other texture-modified diets that had minced foods. For example, we served minced-sized meat pieces, perhaps with gravy. But other non-minced foods like noodles, rice, or canned fruit may have been included on those past texture-modified diets. Now, they’re not included because all foods on this level have to be minced & moist.
Many organizations might still use these pre-IDDSI texture-modified diets. When dietitians try to transition patients or residents from a past texture-modified diet to Minced & Moist, there is too much adjustment, and the individual’s diet is overly restricted.
“I’ve found that when people try to transition patients or residents from a pre-IDDSI texture-modified diet to Minced & Moist, they’re finding there is too much modification. The patients or residents can handle less restriction.”
Our goal is for patients or residents to eat the least restricted texture level as possible. Some individuals can potentially eat more than Minced & Moist, Level 5 foods alone. They should be evaluated by a speech-language pathologist to determine what they’re able to eat.
READ MORE: Your Ultimate Guide to IDDSI
How to embrace the opportunities of IDDSI Minced & Moist (Level 5)
There are many challenges to implementing Minced & Moist, Level 5, but there are also lots of solutions. If we take advantage of these solutions, they’re opportunities to help improve our patients' and residents’ experience during mealtime. Here are the top opportunities that come with Minced & Moist, Level 5:
Regular Easy-to Chew
EC7 (Level 7)
1. Consider shifting some individuals on Minced & Moist (Level 5) to Regular Easy-to-Chew (Level 7).
Consider transitioning patients or residents who are overly restricted on Minced & Moist to Regular Easy-to-Chew (Level 7). They’ll eat softer textured meat (in many cases ground) and soft foods on this level.
“Based on what I’ve seen at organizations, it's important not to automatically think your texture-modified diets go to Minced & Moist. Perhaps there’s a good number of people who Regular Easy-to-Chew would be a more appropriate level. It’s important to have these individuals assessed by a speech-language pathologist to determine what they’re able to eat.” said Roche.
Bottom line: don’t automatically assume individuals on texture-modified diets need Minced & Moist. Maybe they truly do need Minced & Moist, Level 5 foods, but after SLP evaluation, many of them could potentially do well on Regular Easy-to-Chew (Level 7).
2. Embrace the chance to free up individuals on purees.
In a similar vein, individuals on purees might also be overly restricted. They may do better by being evaluated to tolerate Minced & Moist and enjoy an expanded diet.
“Here’s how I’ve been thinking about Minced & Moist: the opportunity of this level is you can free up a lot of people on purees. After SLP evaluation, a lot of those people can probably tolerate Minced & Moist and have their food options expanded,” said Roche.
This level can allow dietitians to broaden the horizons of some individuals on purees. Don't assume that because a patient or resident is currently on purees, they couldn’t do well on Minced & Moist.
“This is what I’ve been seeing: lots of people who have implemented Minced & Moist have found that many individuals formerly evaluated for purees do well on it. It gives them more texture to their food. It opens up their possibilities,” said Roche. “Perhaps there are many people on pureed foods who would actually do better on Minced & Moist.”
3. Individualize based on what each patient or resident needs.
Success with Minced & Moist often comes down to individualization. Taking a person-by-person approach will help you overcome the challenges this level presents. Assessing what each patient or resident personally needs will help you identify the best level for them.
“In my experience, people really need to be evaluated individually to determine what’s best for them. Find what level works best for folks, rather than changing the level,” said Roche. “The solution to the challenges of Minced & Moist is individualizing.”
However, even as you individualize, you can’t make adjustments to the IDDSI level itself. You still need to use the testing methods to make sure you're adhering to the level's standards.
“The caveat is you can’t change the IDDSI level. You still have to follow the standards,” said Roche.
The good news is that you can individualize diet orders based on clinical judgement. In other words, an individual may have a diet order for Easy To Chew, Level 7 with Minced & Moist, Level 5 meats.
For more on this, see our blog post: Managing Bread and Mixed Consistencies: Insights from USIRG
4. Train your colleagues on Minced & Moist (Level 5).
Gaining a greater understanding of Minced & Moist, Level 5 takes time and energy, and there’s no shortcut to learning this new level. Training your organization on Minced & Moist, Level 5 standards, characteristics, and testing methods will help improve your organization’s food safety and quality.
“Because of the safety and quality needs, you can’t skip training — and you especially have to get it right,” said Roche.
Training comes in two waves. First, dietitians, dietary managers, dining leaders, and speech-language pathologists need to learn the levels. Second, they need to train their colleagues on it, including their interdisciplinary IDDSI implementation team, food service team, and non-food service workers involved in patient or resident feeding. Long-term care dietitians also need to train their nursing and resident care teams, activities, and anyone else who might benefit from understanding IDDSI.
Administering ongoing training is the biggest hurdle to implementing IDDSI. Training is ongoing because educating colleagues from many disciplines will take time, especially for corporate dietitians. The high turnover rate in food service also impacts the process.
An IDDSI Minced & Moist (Level 5) Training Solution
We saw the hurdles dietitians encounter with developing IDDSI education. So we created plug-and-play IDDSI training resources. The Roche Dietitians “We Test For Safety” IDDSI Training Program will equip your organization's staff to put IDDSI into action.
The Minced & Moist (Level 5) training course offers easy-to-follow instruction and hands-on learning experiences for your team. They’ll learn how to test foods and make sure they meet the IDDSI standards.
Think of the course as a one-stop shop. You don’t have to develop any training material.
Right away, your colleagues will have every piece of information they need to carry out Minced & Moist, Level 5 with an emphasis on testing methods. In 30 days, you’ll be on the path to educating the entire foodservice team on Minced & Moist, Level 5.
The course is ideal for ongoing training because you can access the content for one year. It's an excellent fit for corporate dietitians who oversee many organizations, as well as dietitians who work for a single organization. We offer discounts and custom set-ups to corporate buyers.
The deeply researched course works for both food service and non-food service workers. We can customize the program to fit your learning management system.
Here’s what it boils down to: you need a ready-made training course for Minced & Moist, Level 5, and you need it to be good. Our program exists to fill in the gap for you.
Are you ready to embrace the opportunities of Minced & Moist? Learn more about the Minced & Moist (Level 5) training course here: