Introduction of New Standardised Definitions and Terminology for Texture Modified Foods and Fluids A project jointly undertaken by New Zealand Dietetic Association (NZDA) and New Zealand Speech-Language Therapy Association (NZSTA)

Acknowledgement for the content of this presentation These standards were developed collaboratively by the Dietitians Association of Australia and Speech Pathology Australia. Some of the images in this presentation have been provided by Nestle Healthcare Nutrition who supported the development of the Australian standards. Special acknowledgement to Dr. Julie Cichero and Ms. Michelle Suter for the content of this presentation.

Background Researchers in Australia recognised the need for one standard set of terminology for food and fluid consistencies A survey in Australia revealed there were 39 different labels used for fluid thicknesses and 95 for textures of food The key problem with lack of standardisation is that it creates risk for patients, but also makes comparison of research studies difficult

Background A working party was established in 2003 with representation from dietetics, SLT, nursing, food service and industry Oversight of the project was shared by the Dietetics Association of Australia (DAA) and Speech Pathology Australia (SPA) The standards were published in DAA and SPA publications (Article cited at end of presentation)

Background NZDA and NZSTA have adopted the Australian standards support their implementation throughout New Zealand In New Zealand, it is optional to use the letter and number identifiers (e.g. Texture B, Level 900). The descriptor (e.g. minced and moist, extremely thick) should always be used

Texture Modification Unmodified Most Modified Progression of Food and Fluid

FLUIDS Colours are included to assist identification of thickness levels. Note: Testing scales for viscosity exist but are not formalised or standardised, and therefore are not included. Subjective information has been provided, but the recommendation from this project is that formal objective measures be developed.

Clinical Fluid Thickness Grading Scale Regular Fluids Level 150 – Mildly Thick Level 400 – Moderately Thick Level 900 – Extremely Thick Prescribed by a speech-language therapist Unmodified Modified

Unmodified – Regular Fluids May have variable thickness levels (some are thinner e.g. water, breast milk than others e.g. fruit nectar). Are not used in the therapeutic treatment of dysphagia. Unmodified – Regular Fluids Level 150 – Mildly Thick Level 400 – Moderately Thick Level 900 – Extremely Thick

Unmodified – Regular Fluids Characteristics Drink through any type of teat, cup or straw as appropriate for age and skills

Level 150 – Mildly Thick Fluids are thicker than naturally thick fluids such as fruit nectars, but not as thick as a thick shake. Pre-thickened drinks are packaged in green (Nestle and Flavour Creations). Unmodified – Regular Fluids Level 150 – Mildly Thick Level 400 – Moderately Thick Level 900 – Extremely Thick

Level 150 – Mildly Thick Characteristics Pour quickly from a cup but slower than regular, unmodified fluids May leave a coating film of residue in the cup after being poured Able to drink this fluid thickness from a cup Effort required to take this thickness via a standard bore straw

Level 150 – Mildly Thick Testing Information Subjectively, fluids at this thickness run quickly through the prongs of a fork, but leave a mild coating on the prongs.

Special Note Breast milk or infant formula may be thickened for the therapeutic treatment of dysphagia in infants This fluid thickness is thinner than Level 150 – Mildly Thick. However, it is thicker than unmodified breast milk or infant formula It is the same thickness as commercially available ‘Anti-regurgitation’ formula Consideration should be given to flow through a teat as determined on a case-by-case basis Level 150 – Mildly Thick

Level 400 – Moderately Thick Fluids are similar to the thickness of room temperature honey or a thick shake and flow slowly. Pre-thickened drinks are packaged in purple (Nestle) or orange (Flavour Creations). Unmodified – Regular Fluids Level 150 – Mildly Thick Level 400 – Moderately Thick Level 900 – Extremely Thick

Level 400 – Moderately Thick Characteristics Cohesive and pours slowly Possible to drink directly from a cup although fluid flows very slowly Difficult to drink using a straw, even if using a wide bore straw Spooning this fluid into the mouth may be the best way of taking this fluid

Level 400 – Moderately Thick Testing Information Subjectively, slowly drip in dollops through the prongs of a fork

Level 900 – Extremely Thick Fluids are similar to the thickness of pudding or mousse. No flow. Pre-thickened drinks are packaged in blue (Nestle and Flavour Creations). Unmodified – Regular Fluids Level 150 – Mildly Thick Level 400 – Moderately Thick Level 900 – Extremely Thick

Level 900 – Extremely Thick Characteristics Cohesive and holds its shape It is not possible to pour this type of fluid from a cup into the mouth or to drink from a straw Spoon is the preferred method for taking this type of fluid This fluid is too thick if the spoon is able to stand upright in it unsupported

Level 900 – Extremely Thick Testing Information Subjectively, fluids at this thickness sit on and do not flow through the prongs of a fork

FOODS Facilities should use only the levels that they deem appropriate There is no requirement for facilities to use all levels The food textures do not have assigned colours

Clinical Food Texture Modification Grading Scale Unmodified – Regular Foods Texture A – Soft Texture B – Minced and Moist Texture C – Smooth Pureed Prescribed by a speech-language therapist for dysphagia Unmodified Modified

Unmodified - Regular These are everyday foods. Food can be bitten and chewed. Unmodified – Regular Foods Texture A – Soft Texture B – Minced and Moist Texture C – Smooth Pureed

Unmodified - Regular Characteristics There are various textures of regular foods Some are hard and crunchy while others are naturally soft Food Inclusions and Exclusions By definition all foods and textures can be included

Texture A - Soft Foods may be naturally soft (e.g. ripe banana) or may be cooked or cut to alter texture. Unmodified – Regular Foods Texture A – Soft Texture B – Minced and Moist Texture C – Smooth Pureed

Texture A - Soft Characteristics Can be chewed but not necessarily bitten Minimal cutting required – easily broken up with a fork Should be moist or served with a sauce or gravy to increase moisture content (NB sauces and gravies should be served at the required thickness level)

Texture A - Soft Testing Information Targeted particle size for infants and children = less than half or equal to 0.8cm (based on tracheal size: Litman et al., 2003) Targeted particle size for children over 5 years and adults = 1.5x1.5cm (Penman & Thomson, 1998; Samuels & Chadwick, 2006; Kohyama et al., 2002)

Texture A - Soft Includes Rice, cereal, rice, pasta, noodles Cooked vegetables, legumes Stewed or canned fruit Cheese All types of eggs Soft cooked meat, fish, poultry Cakes, biscuits softened in drinks

Texture B – Minced and Moist Food is soft and moist and should easily form into a ball. Unmodified – Regular Foods Texture A – Soft Texture B – Minced and Moist Texture C – Smooth Pureed

Texture B – Minced and Moist Characteristics Small lumps can be broken down with the tongue Soft and moist and easily forms into a ball Easily mashed with a fork May be presented as a thick puree with obvious lumps in it Lumps are soft and rounded (no hard or sharp lumps)

Texture B – Minced and Moist Testing Information Recommended particle size for infants and children = cm (based on tracheal size: Litman et al., 2003) Recommended particle size for children over 5 years and adults = 0.5cm (Penman & Thomson, 1998; Mishellany et al., 2006)

Texture C – Smooth Pureed Food is smooth and lump free; similar to the consistency of commercial pudding. At times may have a grainy quality, but should not contain lumps. Unmodified – Regular Foods Texture A – Soft Texture B – Minced and Moist Texture C – Smooth Pureed

Texture C – Smooth Pureed Characteristics Smooth and lump free but may have a grainy quality Moist and cohesive; holds its shape on a spoon Can be molded, layered or piped

Texture C – Smooth Pureed Testing Information Cohesive enough to hold its shape ona spoon (i.e. when placed side by side on a plate these consistencies would maintain their position without ‘bleeding’ into one another)

Texture C – Smooth Pureed Special Note Some individuals may benefit from the use of a runny pureed texture This texture would be prescribed on a case-by- case basis Runny pureed textures do not hold their shape; they bleed into one another when placed side by side on plate

Publication Dietitians Association of Australia and Speech Pathology Association of Australia Limited. Texture modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutrition and Dietetics 2007; 64 (2): S33-S76.