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 FluidsLevel 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 = 0.2-0.5cm (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 on a

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.