The Journey to IDDSI

How did Simply Thick become a leader in providing thickeners for dysphagia patients?  How did I become known as “Simply Thick John”?  

It’s a long, convoluted story but if you like a story… here it is.

Educational Background and Early Career 

I earned a Bachelor's of Science in Paper Science and Engineering from the University of Minnesota in1992.   

I know.  You’ve never heard of such a degree.  Nobody has 😄.  It's a tiny program at a very big university.  But it was the type of degree in which we were almost guaranteed a well-paying job with a big company at graduation.   

From Paper Science to Xanthan Gum Chemistry

Well, there was a recession in the paper industry at the time.  And I wasn’t very good at interviewing.  So, I returned home and started working the night stock shift at the local grocery store I had worked at through high school.   

I eventually got hired by Kelco, a supplier to the paper industry, who happened to be the world's largest xanthan gum manufacturer, among other things.  I was their “expert” in paper manufacturing with only a college degree and a 3-month internship in a paper mill.  I was also hired to provide general technical service. One of my main jobs was to answer questions about our products.  I was the “no” guy.  When people would ask,  “Is it for the oil field?”, “Is it for pharmaceuticals?", “Is it for food?”, “Is it for personal care?” If the potential prospect said no to all of those questions, they were my customer, and I had to answer their questions.  

Developing Expertise in Thickeners 

This position helped me become very well-versed in the chemistry of the thickeners our company sold.  I became very good at talking to different people in different applications because I never knew who was going to call me. It could be a paper manufacturer.  It could be a carpet printer. It could be a cleaner manufacturer. It could be a pest control company.  I just never knew who would be on the other end of the phone when it rang. This allowed me to become quite comfortable talking to different industries about the applications of these products.

Eventually the company was bought by Monsanto. And I was relocated to their St Louis headquarters during a reorganization.  I was doing well and thriving, but felt that my business skills needed to be refined. So, I was fortunate enough to have Monsanto sponsor me in the Executive MBA program at Washington University in St. Louis. 

Unfortunately (or maybe fortunately for me), in the fall of 2000, in the middle of the MBA program, the company informed me that I was going to lose my job. They told me they were shutting down my department on my wedding anniversary. Imagine me sitting at my anniversary dinner, telling my wife I was going to lose my job…  

At that dinner, we decided we would stay in St Louis and that I should look for a job here. And I was totally happy with that. 

Birth of an Idea: A better food thickener 

Then a few months later, we had an entrepreneurship elective in my MBA program. In the entrepreneurship class, each group needed to have a business idea to develop and incubate into our final project. 

When thinking about this assignment, I thought back to an idea we had looked at but never pursued during my time at Kelco.  One day when I was working at Kelco, I got a call from a coworker who thought we needed to sell xanthan gum to people with swallowing problems, with dysphagia.  

When I asked her why we needed to do this, she told me how using xanthan gum with her mother in hospice care helped lengthen her mother’s life.  Her mother had refused to drink the cornstarch thickeners.  She understood the consequences if her mother continued to refuse. When she told someone at work about the situation, they told her to try thickening her mother’s liquids with xanthan gum.  She mixed it into liquids with a blender.  Her mother drank it.  She felt like xanthan gum gave her more time with her mother.  

Promoting xanthan gum in this way seemed like a great idea.  But it really didn’t fit our business model and our strategic direction.  So, we had not pursued the idea.  But I wished there was a way to do it. 

How a Class Project Turned Into a Business Idea

I decided this was my best business idea.  I presented it to my entrepreneurship class group: “Hey, let's make a better thickener for people with dysphagia. And what we're going to do is we're going to make a liquid xanthan gum.  It's going to be great.  It's not going to have all the problems like powder thickeners do.” 

None of my classmates knew what I was talking about.  But they all knew I was the one without a job and I had an idea. They figured they’d get their homework done if they used my idea. 😉 

Validating the concept of the Thickener 

When I met with my professor, he said, “Hey, John, what do speech therapists think about your product?” 

“Oh, they’re going to love it,” I professed. 

He said, “Well, how do you know that?” 

He suggested I connect with the rehab department of the local teaching hospital that was associated with our university.  

After a bit of resistance on my part, I finally called them. I said, “Hey, I'm a MBA student with a crazy idea of creating a better thickener. Can I come to show you?” 

The rehab director was receptive and invited me to come to the staff meeting the next week.  

Then I realized, Oh no, I need a prototype. 

I literally put together a prototype in my kitchen over the weekend. I ran around and found little plastic bags and an impact sealer so I could seal little amounts in the bags. 

I went to the staff meeting that Tuesday.  I demonstrated it to them.  

You know that deafening silence after you get done with a presentation?  It was probably only a couple of seconds, but it felt like three hours. Then all of a sudden, everybody got super excited. They were saying things like: 

✔️“Oh my God, this is great! We're not going to have clumps.” 

✔️“It thickens really well.” 

✔️“Does it work in this? Does it work in that?” 

I assured them, “Of course, it’s going to work.  It’s xanthan gum.” 

I went back to my professor and I said, “See, I told you.  They loved it. It's great.” 

He challenged me further.  “So, John, aren't a lot of your customers gonna be nursing homes? Don't you need to talk to some people there?” 

I agreed reluctantly, “Yeah, I guess so.”  

So it was the same thing. I got the name of a local facility. I looked the main number up in the phone book – this was when we actually had printed phone books.  

You know when you’re nervous you have a script going in your head?  I was doing that, saying over and over, “Okay, I'm gonna ask for speech therapy. I'm gonna ask for speech therapy…” 

A woman on the other end answered the phone saying, “Speech therapy.” It startled me and I hung up. 

I thought I had dialed wrong.  I verified the number and called again.  Apparently, the number was misprinted in the phone book.  Instead of the front desk phone number, the speech therapy department number was listed instead. 

So when the same woman answered the second time, I gave her my little pitch: “I’m an MBA student with a crazy idea. Can I come by and show you?”  

She was interested. “Oh yeah? You have a better thickener? Sure. Come on over.”  

I went and demonstrated it.  

Their reaction was super positive, enthusiastic, and encouraging!  At this point, I had these two institutions interested in what I was doing.  

Launching Simply Thick 

My classmates and I completed the project. Then May 2001 rolls around, and there were a few things going on:  

• We started Simply Thick on May 1st 

• My wife quit her job on May 11th to take care of our child 

• Our oldest child was born on May 15th 

• I graduated on May 19th. 

  
  

I also had a job offer with a large company, but I was unsure about it.  Something was tugging at me – still wanting to do something with the dysphagia thickener.  I remember having this conversation with my wife soon after. I said, "There's this dysphagia thing we can do, but it's a startup.  We can do that, or I can take this company job. I know what the company job is. I know the ups and downs. I know the hours. I understand all that. There are going to be a lot of those jobs around, even if the company goes bad. But what do we want to do?" 

I knew we had been good squirrels our whole lives. We’d saved our money. I knew we'd be fine for a year or two, even if “the dysphagia thing” crashed. 

We decided that "if I took the big company job, I'd always wonder about this dysphagia thing”.  And if I went ahead with developing a company to produce the thickener, I probably wouldn’t ever wonder about the other big company. That’s been pretty much true.  

I always want to emphasize that it wasn’t just me deciding to do this. My wife and I made the decision together.  I guess you could say we both have a high tolerance for risk.   

Our target was to present the product at the American Speech-Language and Hearing Association (ASHA) convention in November 2001 

Actually, we worked so fast that we were able to launch it a month earlier at FNCE—the Food & Nutrition Conference & Expo for dietitians—which happened to be in St. Louis that year.  

And that’s how SimplyThick started. 

Intro to IDDSI  

Fast forward to Friday, February 13, 2015—ASHA was in Denver. I went down into the bowels of the Denver Convention Center to hear a presentation on this weird thing I’d been hearing about called the International Dysphagia Diet Standardisation Initiative (IDDSI). I wanted to get to the bottom of it because I didn’t fully trust it yet.  

Peter Lam, the project leader for IDDSI, gave his presentation. He explained it. Showed the testing methods. My jaw hit the floor. I thought, "This is going to be a game changer for our industry." 

I’d spent 14 years arguing with people about how thick is thick. That was the number one discussion—how thick is thick?  I also spent a lot of time answering questions about why xanthan gum flowed differently than starch. Or why it could have different flow characteristics and still be okay to use with people with dysphagia. At the end of that presentation, I walked up to Peter and said, "What do you need? We're here for you. We’ll do whatever we can to help because this is the right thing to do." 

That’s how I got on this IDDSI journey. 

Implementation of IDDSI and its impact  

The rollout of IDDSI has been much slower than any of us anticipated. Officially, ASHA, ANFP (Association of Nutrition and Foodservice Professionals), AND (Association of Nutrition and Dietetics), IDDSI, and everyone involved targeted May 1, 2019, as the official rollout date. 

We’re six years into it now. Those in implementation science say it can take up to 15 years for things to go from the lab to full practice in an industry. We’re hoping to do better than that. 

I’ve learned a tremendous amount.  I learned it takes cooperation, teamwork, enthusiasm, and patience from the people involved. It’s a process.  

IDDSI promotes dysphagia safety through common terminology for all ages, in all care settings and in all cultures.  The common terminology is such a key component.  If we aren’t speaking with the same language it can be very difficult to understand what is needed for the person with dysphagia.   

An example I always give: My daughter had a complicated wisdom teeth removal. The surgeon came in and said, "I want her on a soft, no-chew diet." 

"What’s a soft, no-chew diet?" I asked. 

He just repeated, "Soft, no-chew." 

I’m in this business, so I researched it, looked at websites.  There was no clear definition. If you ask me, she needed an IDDSI  level five, minced and moist diet. That’s what he was really prescribing. 

I had no problem making minced and moist food for my daughter, but I can’t imagine what another parent would do. Maybe a week of yogurt? Two weeks? There was no clear guidance.  

Personal Reflections: Learning from the IDDSI Journey 

IDDSI gives you a framework. When you explain it to people, it makes sense. I always say, IDDSI levels mimic the natural human chewing process. You take regular food, chew it down to bite-sized pieces, keep chewing and mixing with saliva until it’s ready to swallow—that’s minced and moist. If you keep chewing until it is smooth, it turns into puree. 

IDDSI terminology is also meant to be intuitive.  If I go to my mother-in-law and say, "Make something minced and moist.” She probably has a good idea of what minced is. She knows what moist is. She can almost make it without guidance.  

When we orally process food, we are naturally adding moisture in the form of saliva to get the food ready to swallow. A dry piece of chicken requires more saliva than a moist tender piece of fish. So adding liquid to food to help process it to different IDDSI levels, like puree or minced and moist isn’t surprising. It’s just mimicking natural chewing and swallowing. 

At the end of the day, this is about the patient and the caregiver and how they can be sure the food they serve is the correct texture for the patient. "Nothing I’ve ever seen before puts the tools so perfectly in their hands."

And that is the summary of how a young paper engineer has grown up to be one of the biggest cheerleaders for and one of the most enthusiastic supporters of the International Dysphagia Diet Standardisation Initiative!! 

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About the author 

John Holahan is the President and Founder of SimplyThick, LLC and an inaugural member of the IDDSI Hall of Appreciation. He is also a member of the Canadian IDDSI Reference Group (CIRG) and a founder of the United States IDDSI Reference Group (USIRG). He is the inventor of the patented thickener - SimplyThick. Mr. Holahan has worked with thickeners since 1992 and with thickeners in dysphagia since 2001. 

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Resources:   

Huckabee, M. L., Doeltgen, S. H., & Lisko, S. (2022). United States survey of practice patterns in recommending thickened liquids. Perspectives of the ASHA Special Interest Groups, 7(3), 553-564. https://doi.org/10.1044/2022_PERSP-21-00216  

Steele, S. J., Ennis, S. L., & Dobler, C. C. (2021). The role of thickened fluids in the management of dysphagia. Journal of the Royal College of Physicians of Edinburgh, 51(4), 378-384. https://doi.org/10.4997/jrcpe.2021.410  

International Dysphagia Diet Standardisation Initiative (IDDSI). (n.d.). Resources. https://www.iddsi.org/resources 

International Dysphagia Diet Standardisation Initiative (IDDSI). (n.d.). IDDSI Framework. https://www.iddsi.org/standards/framework 

International Dysphagia Diet Standardisation Initiative (IDDSI). (n.d.). Patient Handouts. https://www.iddsi.org/resources/patient-handouts