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.