Texture-modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions.

Abstract

Thickened fluids and texture-modified foods are provided for the therapeutic treatment of dysphagia. Review of the literature indicated that numerous labels are applied to a small number of food textures and fluid thickness levels. The consequences of inconsistent terminology affect patient safety and the efficiency of communication. A joint project of the Dietitians Association of Australia and The Speech Pathology Association of Australia Limited (Speech Pathology Australia) was undertaken to develop consensus standards for number of levels, labels and definitions of thickened fluids and texture-modified foods within the Australian context. A project officer and multidisciplinary advisory committee were appointed by competitive process to carry out and oversee the project. The project determined that there were 39 different labels in use for thickened fluids and 95 different labels in use for texture-modified foods used in Australia. Dietitians and speech pathologists demonstrated overwhelming support for a standardised labelling and terminology system (99.2% of respondents). A national consultative process encompassing the views of more than 580 clinicians helped to formulate the final standards. A scale for modified fluids and a scale for texture-modified foods were developed and consensus was achieved between the Dietitians Association of Australia and Speech Pathology Australia. The standards are now recommended for use throughout Australia.

Key words: dysphagia diet, food and fluid standards, standardised diet, thickened fluid.

INTRODUCTION

Texture modification of foods and thickening of fluid forms a routine part of the assessment and treatment of swallowing difficulties (dysphagia). (1-6) Dysphagia contributes to reduced dietary intake, and potentially malnutrition, aspiration and asphyxiation. (7,8) Regular fluids require excellent muscle control and accurate timing between the swallowing system and the breathing system. Thickened fluids slow the act of swallowing and by doing so, enhance safe swallowing. (9) Modified diets use alterations to food texture to reduce the need to chew or orally prepare food. (10) When an individual has dysphagia, there is a breakdown in the swallowing process that can result in food or fluids entering the lungs (aspiration). If enough food or fluid is aspirated, severe infections such as aspiration pneumonia may develop leading to hospitalisation and even death. Consequently, thickened fluids and texture-modified foods is rarely a diet of choice, but a diet of necessity if an individual is to maintain their nutritional needs orally.

The provision of texture-modified foods and fluids is a prescription for individuals with dysphagia. By determining the cause and severity of the dysphagia, health professionals can determine the food texture and fluid thickness safest for an individual to swallow. If the prescription is not followed, the individual may face serious health consequences. Inconsistency in the labelling and definitions of foods and fluids adds an unnecessary and potentially dangerous layer of confusion. Confusion regarding food textures and labels was formally recorded as a contributing factor in the coroner's notes into the death of a South Australian nursing home resident. (11) To reduce the likelihood of adverse events, professional consensus on language for texture-modified foods and fluids is needed.

A lack of standard labels and definitions has a number of implications aside from patient safety. Comparison of research studies is difficult because of the lack of a common language for texture-modified foods and fluids. Research into the role of texture-modified foods and fluids in dysphagia management is an area needing greater focus to promote evidence-based practice. It is anticipated that national consensus on standardised terminology will provide a direct benefit to research in this area.

Standardisation of food and fluid terminology will also facilitate product development from the commercial sector. In Australia, there are four commercial companies that currently supply pre-packaged thickened fluids. There is variability in the number of fluid thickness levels offered between the companies. Clear descriptions of different levels of fluid thickness and their labels will improve communication between commercial, consumer and professional sectors. Although there are some similarities in the names chosen for each level of thickness, there are also differences between companies. Companies who supply 'shelf ready' thick fluids will have greater confidence in developing product ranges if institutions across Australia are using a consistent language. A common language will also reduce errors in product selection in hospitals and at home. Standardisation will ensure that individuals with dysphagia have consistent access to the food and fluid textures that are safest for them.

Global variability in the names provided for texture-modified foods and thickened fluids is well noted in the literature. (10) An American task force identified 40 different names used to label solid food and 18 different names to describe thickened fluids. (12) An Australian study from the city of Brisbane (population 1.6 million) found there to be 12 different names for three different levels of fluid thickness sampled from only 10 major hospitals. (13,14)

Penman and Thomson conducted a detailed review of terminology, definitions and levels of dysphagia diets for the period 1981-1996. (10) They, and others, found there were wide variations in the degree of modification and numerous descriptions of textures. (1,10) Texture-modified diets typically ranged from two to five categories of altered food consistency. (10,15) There were typically three levels of fluid thickness. The most commonly described model of progression for food and fluid texture modification is noted in Tables 1 and 2.

The Australian Dysphagia Working Party was convened in 2003. It is a voluntary multidisciplinary leadership group with representation from speech pathology, dietetics, medicine, nursing, food services and industry. One of the aims of the group was to review current dysphagia management practices. Issues surrounding inconsistency in labelling and definitions for texture-modified foods and fluids in Australia were identified as a key area in need of resolution. The working party commenced work towards national standards but it became clear that the process would be better managed as a more formalised project by relevant Associations. The Dietitians Association of Australia and Speech Pathology Australia agreed to manage the project and develop consensus standards. An initial project plan was proposed and funding was provided by a company with commercial interest in production of texture-modified fluids to support the process.

Time and resource limitations restricted the scope of this project. The project was not intended to address the nutritional adequacy nor patient acceptability of texture-modified foods or fluids. Objective measurement of thickened fluid is a complex and multifactorial task. (5,16-23) Thus, it was not considered within the scope of the study to address objective measurement issues in relation to the definitions. Finally, the project was not intended to develop evidence-based practice guidelines.

The specific aims of the project were to, in an Australian context:

1 Determine the number of food texture levels to be used in a standardised scale.

2 Determine the number of fluid levels to be used in a standardised scale.

3 Determine standard names/identifiers for each food and fluid level.

4 Identify examples of foods appropriate for each food texture level.

5 Gain consensus from Dietitians Association of Australia and Speech Pathology Australia membership and other key stakeholders regarding points 1-4.

6 Commence communication of the new standards to stakeholders and commence education of speech pathologists and dietitians.

METHODS

The project commenced with a development of a Memorandum of Understanding between the Dietitians Association of Australia and Speech Pathology Australia. The Associations jointly developed a final project plan. A project officer and advisory committee were appointed after calling for expression of interest. The project officer had a professional qualification in speech pathology, a doctoral degree in dysphagia and had published nationally and internationally in the area of viscosity and thickened fluids. The advisory committee comprised individuals with professional qualifications in dietetics (x2), speech pathology (x2), nursing (x1) and food services (x2). The project was overseen by professional officers from the Dietitians Association of Australia and Speech Pathology Australia, reporting to the Board of the Dietitians Association of Australia and the Speech Pathology Australia Council.

Ethical issues were considered by the professional officers. It was determined that participation in the project would be voluntary, the purpose of the project would be communicated at the time of requesting participation and individuals or organisations providing information for the use of the project would not be identifiable in reports arising from the project. The funding organisation was not to be involved in the design of the project, its conduct or the writing and interpretation of the results. A summary of the results of the project would be made easily accessible to participants in the project.

Communication between the officers of the Associations, the project officer and the advisory committee was via regular teleconferences. The project officer position was paid, while the advisory committee provided honorary support. The project commenced in June 2006, with a six-month time frame for completion.

Key project stakeholders were: Dietitians Association of Australia and Speech Pathology Australia, speech pathologists, dietitians, consumers, industry (i.e. commercial companies that provide thickened fluids), non-government and community-based organisations, food service staff, food service professional bodies, and training institutions for speech pathology and dietetics. The training institutions were identified as stakeholders because they would provide an avenue for education of the new standards to new professionals. A dedicated website for the project was constructed as a conduit of information accessible by any person with an interest in the area.

A series of six steps were identified to meet the aims of the project. These steps are presented below.

Step 1 -- Literature review

Step 1 involved collation of any existing Australian scales, investigation of current international scales and a review of the literature pertaining to texture-modified foods and thickened fluids. The literature review sought to identify any evidence for the number of levels of food modification or fluid thickness. In addition, evidence was sought for recommendations regarding food particle size and rationale for inclusion or exclusion of identified contentious food or fluid items (e.g. bread). An extensive literature search was conducted. The Medline, Cinahl, Web of Science and Cochrane Library databases were searched. The following search terms were used for food texture modification used with individuals with dysphagia: 'deglutition disorders + food', 'dysphagia diet and deglutition', 'dysphagia diet', 'dysphagia and foods' and 'texture modification'. The search terms for thickened fluids were: 'viscosity and deglutition disorders', 'viscosity and thick fluids', 'dysphagia and fluids', 'thick fluids' and 'dysphagia and viscosity'.

Step 2 -- Survey of key stakeholders

A survey of key stakeholders, as identified earlier, was undertaken to determine support for national standardisation and to provide preliminary benchmarking for the number of food and fluid levels required for the final scales. Speech pathologists and dietitians were identified as one of the largest stakeholder groups for the project and a critical group to ensure the implementation of standards. A questionnaire was devised in consultation with the advisory committee. The questionnaire was available online via a dedicated website for the project for a three-week period. The online survey was publicised to members of both professional associations via email and print publications. In addition, facilities around the country were targeted for feedback. The targeted groups were included to increase the likelihood of capturing the full range of views. Telephone calls were placed to speech pathologists and dietitians working in the areas of acute, rehabilitation, community, extended care, disability and mental health for both adult and paediatric populations. Clinicians were asked whether they were aware of the project and whether they were interested in participating in the process by completing a questionnaire that was emailed, faxed or posted to them. Individuals who participated in Step 2 were asked whether they consented to being contacted to participate in further stages of the project.

In addition to the professional groups, nine commercial manufacturers of thickened fluids or thickeners were approached. These were: Chefs Pride, Chipmonk, Flavour Creations, Janbak Industries, Novartis Medical Nutrition, Nutricia, Orfam, Orion and Swallowade. The commercial companies were asked to complete the same feedback form as the health professionals.

Teaching institutions with courses that were accredited by the Dietitians Association of Australia and Speech Pathology Australia were surveyed. The telephone surveys requested information regarding: (i) the terminology for texture-modified foods and fluids currently taught to students studying speech pathology or dietetics; (ii) perceived need for standardisation of terminology; and (iii) interest in an education package providing the final outcomes. Community-based organisations and independent groups including Meals on Wheels, and Nutrition Australia were informed of the project and invited to provide comment.

Step 3 -- Development of the draft standards

Individuals who had consented to further participation were emailed, faxed or posted a copy of the draft document constructed from feedback from the stakeholder groups. The draft document contained a summary of information gathered from the questionnaires, definitions for each of the proposed levels and two labels for each level for consideration. Participants were asked whether they agreed with: (i) the number of levels proposed for each food and fluid scale; (ii) the definitions provided for each level; and (iii) a preference for one of the two labels provided. Some additional information was requested of participants regarding food inclusions and exclusions for the final document. Finally, participants were asked to indicate their area of expertise and their interest in participating in face-to-face or teleconference focus groups.

Step 4 -- Focus groups

Following review of feedback from the draft document, four key questions were identified for discussion at face-to-face or teleconference focus groups of eight and 10 participants.(24,25) A two-hour time frame was set for each group. The advisory committee determined that the participants in the focus groups should be representatives from the following areas: (i) paediatrics; (ii) aged care; (iii) acute care (adult/paediatrics); (iv) rehabilitation; (v) disability; (vi) mental health; (vii) food services; and (viii) nursing homes.

A call for participants for the focus groups was placed via email with both Dietitians Association of Australia and Speech Pathology Australia. In addition, individuals who had reviewed the draft document from Step 3 and had consented to further contact were also included in the final list of focus group participants. Officers from the Associations determined focus group membership to ensure a range of views were represented.

Eight focus groups were held within a two-week window. Five speech pathologists and five dietitians were formally invited to each focus group to allow an attrition rate of two per group. If individuals were unable to attend, alternative members were sought. Face-to-face focus groups were held in Queensland, New South Wales and Victoria. Two teleconferences were held to gather information from Western Australia, Tasmania, South Australia and rural and remote localities in Australia. The project officer attended and minuted each focus group. In addition, a member from the advisory committee was present at the focus groups wherever possible.

Four questions were posed to each focus group. The questions were determined by identifying themes in the feedback provided over the course of the project. The four focus group questions are included below:

1 It is proposed there be three official names for thickened fluids and texture-modified foods in accordance with the following example: (i) Level E--Smooth Pureed OR (ii) Smooth Pureed OR (iii) Level E. Participants were asked whether a descriptive or categorical label should be applied or both together. Participants were asked to discuss the impact of official naming, giving thought to the 'categorical label' for food textures.

2 The proposed terms 'slightly thick' and 'semi-thick' were considered to be too similar to show a point of difference for thickened fluids. Participants were asked to bring alternative names or concepts for the thickened fluid scale.

3 Feedback suggested that there was a need to clearly differentiate 'dental soft' from 'dysphagia soft'. Participants were asked whether it was acceptable for 'dental soft' to be explained by way of explanatory footnote and if there were other places that footnotes might be used.

4 Discussion regarding implementation of the scale and educational resources is required. Participants were asked to bring ideas regarding: (i) examples of menu category 'exclusions' for discussion; (ii) thoughts on the use of a colour coding system or use of icon coding to assist implementation; (iii) ideas for 'essential' and 'desirable' resources (e.g. DVD, wall chart, brochure); and (iv) ideas to promote uptake of the new system.

Step 5 -- Final recommendations and final scale(s)

Review of all available information, including a further evidence-based review, lead to the development of a final scale. A dietitian was appointed by Dietitians Association of Australia to determine examples of food inclusions and exclusions for the final document. Consultation with the officers of the Associations, the advisory committee, the Speech Pathology Australia Council and the Dietitians Association of Australia Board was undertaken to produce the final scale.

Step 6 -- Communication and education

The final step in the project was to commence communication of the new standards to stakeholders and education of Dietitians Associations of Australia and Speech Pathology Australia members. This publication marks the first formal communication of the standards and the process by which they were determined.

RESULTS

Step 1

Evidence

Two International scales for texture modification of foods and fluids for individuals with dysphagia were identified in the literature. These included the US Dysphagia Diet (12) and the UK National Descriptors for Texture Modification in Adults. (26) The terminology used in the US Dysphagia Diet (12) was not considered suitable for the Australian context. For example, 'Dysphagia Advanced' is the label applied to the least modified food texture. The word 'advanced' can also mean 'severe', as in 'severe dysphagia'. The label and the definition did not intuitively match. Also, many of the food inclusions and exclusions in the diet were viewed as culturally specific, making it difficult to adopt the whole package. The fluid scale used descriptors, and also provided objective measurement of fluid viscosity. The ability to adhere to objective measurement was an area that required further investigation in the Australian context. Thus, the ability to adopt even the fluid scale was questionable.

The UK National Descriptors for Texture Modification in Adults applied alphabetical labels to food textures, with a range of A-E, where A is the most modified (e.g. puree) and E is the least modified food (closest to regular textures). (26) However, without the description of the food texture, it would not be possible to work out which label to apply to the food, however. A descriptive title was considered to be an important part of the communication process in the Australian context. Similarly the fluid thickness levels were labelled numerically from one (thinnest) to three (thickest). Again, without an accompanying descriptor, there is room for miscommunication.

Two Australian state-based scales for texture-modified foods and fluids were identified. Both the Queensland and Victorian scales were endorsed by their state health authorities. The Queensland scale showed three levels of fluid thickness, while the Victorian scale showed four levels of fluid thickness in addition to regular fluids. A scale endorsed by the state health authority also existed for texture-modified foods in Victoria. This scale showed regular foods, with three levels of food texture modification.

The literature review revealed that the most common number of food texture modification levels reported in the literature was four. (10) The food scales showed liquidised or thin puree, at one end of the spectrum. The other end of the spectrum showed modified normal foods of various textures, avoiding particulate foods that provided a choking hazard. The most common number of fluid thickness levels reported was three; however, some ventured to as many as six(10) (see Tables 1,2).

[FIGURE 1 OMITTED]

Step 2

Reviews

Review of training institutions. Institutions accredited by Dietitians Association of Australia and Speech Pathology Australia were phone-surveyed as outlined in the 'Methods' section. Eleven institutions offering accredited dietetics courses were approached. Of these seven provided comment. For the speech pathology courses, eight institutions were approached and six provided comment. A common theme emerged from all teaching institutions. Students are often taught about modified texture foods and fluids by local acute care clinicians. Students are advised that there is a lack of standardisation of modified foods and fluid levels and labels between settings, and to seek further clarification from place of employment on local policies. All coordinators requested information about the new standards for inclusion in tertiary course material when available.

Review of industry. Of the nine commercial companies approached, four provided feedback. All companies who responded voiced support for standardisation of terminology and definitions. All companies who responded agreed with the proposed definitions as outlined in the survey.

Review of professional feedback. A total of 582 speech pathologists and dietitians responded to the questionnaire. Of these, 68.3% responded via the online survey system and 31.7% were the result of targeted surveys. Two hundred and twenty-two calls were placed to the targeted group; responses were received from 185, representing an 83% response rate. State of residence and locality of respondents are shown in Figures 1 and 2. A caseload summary for respondents is shown in Figure 3. Ninety-nine per cent of all respondents indicated their agreement with the need for an Australian standardised terminology and definitions for texture-modified foods and fluids.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

The number of different thickened fluid labels in current use was 39. Agreement with the proposed definitions for thickened fluids was 94% (SD 0.5). Support for four levels of fluid thickness, with normal being the 'least modified' category, was 89.4%. Three different fluid labelling practices emerged. One used a descriptive scale (nectar, honey, pudding). The other two were categorical. One used a straight grading system (Grades or Level 1-3), while the other used a comparative system (full thick, 1/2 thick, 1/4 thick). Respondents were asked to estimate the per cent prescription of three levels of fluid thickness at their facility. The response rate to this question was quite low at 43%. Those who responded indicated that 'nectar-like' thickness was most often prescribed, followed by 'honey-like' thickness, with 'pudding-like' thickness least often prescribed--see Figure 4.

The number of texture-modified food labels in current use was 95. For modified texture food, the agreement with the proposed definitions was greater than 90.2% (SD 4.4). Support for four levels of food texture, with normal being the 'least modified' category was 84.8%. There was a single descriptive labelling practice for food. However, there were many variations in the description of a single texture-modification level (e.g. minced, minced-mashed, minced-mashed-moist, mashed, texture-modified mashed, etc.). Respondents were asked to estimate the per cent prescription of three levels of texture modification at their facility Those who responded indicated that a 'soft' textured diet was the most often prescribed followed by 'pureed' texture and then 'minced' texture--see Figure 4.

[FIGURE 4 OMITTED]

Step 3

Feedback on draft documents

Draft documents from the first-phase survey were developed in consultation with the advisory committee. One hundred and forty-one respondents had indicated an ongoing interest in the project and had consented to contact following completion of their follow-up questionnaire. A one-week time frame was provided for comment in order to meet the project timelines. Sixty-four responses were received--a response rate of 45%. Two scales were initially produced to meet perceived differing needs of the adult and paediatric populations. An agreement level of 91% was found for the definitions proposed for the foods. Two food labels had been proposed for each level of food modification on the adult and paediatric scales. Respondents were asked to indicate their preference for either a descriptive title (e.g. 'soft') or a categorical label (e.g. 'medical food texture 20'). For the foods, respondents indicated a two-thirds majority preference for the descriptive label, with one-third indicating that a dual labelling system using both a categorical label and a descriptor would be useful. Less than 5% preferred the categorical label in isolation. The same trend was found for the paediatric food scale. Seventy-five per cent of respondents agreed with four levels of food texture modification, with the least modified being a 'soft bite-sized' and the most modified being 'runny pureed'. Seventy-five per cent of respondents also indicated they would like to see a seven-day food plan included in the final documents. Eighty-three per cent indicated that they would like to see examples of foods attributed to specific food categories (e.g. breads and cereals, fruit, etc.).

Ninety-seven per cent of respondents agreed with the definitions proposed for the thickened fluids. Again two labels had been proposed for the fluids for comment. One was a descriptive label (e.g. 'slightly thick') and one was a categorical label (e.g. 'medithick 150'). Equal numbers of respondents preferred the descriptive label or a combination of the descriptive label with a categorical label. Ten per cent of responders preferred the categorical label in isolation. There was an agreement level of 87.5% for three levels of thickened fluid, in addition to regular fluids for the adult scale. There was a 95.9% level of agreement with four levels of thickened fluids for the paediatric fluid scale, in addition to regular fluids.

Based on these results, the project officer devised the list of focus group questions that were refined in consultation with the advisory group. Debate occurred surrounding the need for a single or dual labelling system. Use of a categorical label lent weight to a 'formal scale' as opposed to 'adjectives' used to describe foods and fluids. Use of a dual labelling system was recommended to meet the needs of improved communication via description, while retaining the concept of a 'formalised scale' used in the clinical management of dysphagia.

Step 4

Focus groups

Of 117 applications received by the Associations, a total of 53 people participated in the focus groups. There were no nominations from individuals with expertise in mental health. Although an equal number of dietitians and speech pathologists were invited to participate in the focus groups, final numbers showed 22 representatives from dietetics, 30 from speech pathology and one from food services. A member of the advisory committee was present at five of the eight focus groups. The project officer attended and minuted each focus group.

In relation to Statement One concerning the food and fluid labelling system, the consensus of the groups was that if a descriptive label and a categorical label were to be used for the fluid scale, the same convention should be used with food scale. For clarity, both labels should be used in tandem at all times (e.g. Texture A--Soft). All groups agreed that if numbers were to be used in the fluid scale, then letters should be used in the food scale.

Statement Two related to the labelling system for thickened fluids. Opinion was split on the use of the term 'medithick'. Some liked the idea because it denoted the importance of thickening of fluids as a prescription for a medical condition (dysphagia). Other participants felt that the term would take away from the speech pathology and dietetic component and confuse people who might think they needed to approach medical staff for fluid changes. A numerical label was agreed upon with varying opinions as to whether it should be a 1-2-3-4 system, or one showing greater differences between the gradations of thick fluids, for example 80-150-400-900. There was considerable discussion around the 'nectar-honey-pudding' and the '1/4 thick-1/2 thick-full thick' themes. A scale where the description focused on fluid 'thickness' was deemed the most appropriate.

Statement Three related to the use of postscripts. It also addressed the inclusions and exclusions of 'soft' food items suitable for individuals with dysphagia. An anomaly became clear. There were a large number of exclusions for individuals on a 'soft' dysphagia diet. The use of explanatory footnotes was not considered to be clear enough to safely communicate the difference between 'soft options' from the regular diet and a 'dysphagia soft' diet. Participants felt that the dysphagia soft diet should restrict all potential choking hazards while the 'soft diet' from the regular diet was based on individual choice. Clear specifications/postscripts regarding bread items were considered essential. Dual consistencies (e.g. minestrone soup, or fruit punch), soup, jelly and ice-cream, medications and nutritional supplements were also deemed to require specific comment.

Statement Four provided discussion surrounding implementation of the scales and resources required to assist implementation. Colour coding of the different levels of fluid thickness was considered an important adjunct. It was noted that a significant number of individuals working in food services may have English as a second language and that institutional kitchens are generally busy environments, so the use of a colour system was seen to assist clear communication. Participants advised against the use of a traffic light colour scheme or a colour scheme including red, as these schemes are already in use in some hospitals for allergies or other communications. In terms of resources required to assist implementation, an instructional DVD, wall chart and website were the most popular suggestions.

Other discussion from the focus groups related to whether there was a need for a single unified scale or one suitable for adults and another for paediatrics. A single scale was deemed less confusing, particularly for hospitals that provided services to both adult and paediatric clients. The benefit of separate scales was seen from a safety perspective with regard to particle size of foods that posed a choking hazard.

Step 5

The final scale

Feedback from the focus group was discussed at length by the project officer, advisory committee and the officers of the Associations and the Dietitians Association of Australia Board and Speech Pathology Australia Council. The outcome was the development of a single scale for food and a single scale for fluids. Applicability to both adult and paediatric populations was accomplished in the final documents. The final scale is shown in Appendix I. A comparison of the Australian scale with the US Dysphagia Diet (12) and the UK Texture Modification scale (26) is also included for international reference (see Tables 3,4).

DISCUSSION

The current project has resulted in consensus for an Australian clinical scale of texture modification for foods and fluids for use with individuals with dysphagia. Consensus has been reached between the Dietitians Association of Australia and Speech Pathology Australia acting as representatives of these professions. A broad process of consultation with practitioners and review of the available scientific literature provided the platform for the final scales. The intention is that facilities should use only the levels that they determine to be appropriate for their specific situation. There is no requirement for facilities to use all levels of food/fluid texture modification. It is however, expected that facilities will find the standards useful and implement the labelling system and definitions developed. The consultation process for the Australian project was thorough. It incorporated comment from motivated practitioners and 'targeted' practitioners to ensure a broad cross-section of responses. There were many opportunities and many formats for practitioners and other stakeholders to contribute to the development of the Australian scales within the short timeframe allowed for the project. It is acknowledged, however, that consumers of thickened fluids and texture-modified diets were not included in the process. Given the task of attaining consensus with practitioners, it was determined during the project that consultation with consumers would form another project in its own right.

Australian food textures

The Australian Clinical Food Texture Grading Scale shows 'regular foods' as the beginning of the continuum, with three levels of texture modification. The labels given to the foods are 'Texture A--Soft', 'Texture B--Minced and Moist' and 'Texture C--Smooth Pureed'. Given that fluids were denoted with a numerical value, an alphabetical system for foods was adopted. The descriptive labels adopted reflected consensus opinion of stakeholders and are not evidence-based. However, they are similar to many of the labels reported by Penman and Thomson in their review of dysphagia diets. (10) The number of levels adopted for the Australian context is the same as the US Dysphagia Diet scale, (12) but less than the UK Texture Modification scale. (26)

Two food levels provoked discussion. 'Dental soft' and 'runny pureed' textures were both reported to have clinical utility. It was reported that these textures were used for specific demographics; however, as they were not commonly used in workplaces as separate levels for dysphagia management these two levels were not included in the final scale. Clinicians are encouraged to use their clinical judgement to prescribe any additional textures on a case-by-case basis. Where institutions wish to include these texture levels, they are encouraged to reference them to their place on the standard scale.

This project uses literature regarding asphyxiation to consider particle size and food exclusions. Food particle size is mentioned in some of the literature, but without empirical support. Common food particle sizes include: 1.0 cm cubes or less; 1.5 cm pieces broken with the flat edge of a fork suitable for a 'soft', 'bite-sized' diet, and particle sizes of 0.5 cm for 'easy chew' or 'minced food'. (12) The relationship between particle size and risk of asphyxiation is formally noted in only one journal article. (27) In order to avoid choking hazards, particle sizes must be small enough to pass through the trachea if accidentally aspirated without lodging in it and occluding it. It is for this reason that a 1.5 x 1.5 cm bolus has been noted as a target for the Texture A--Soft, with smaller particle sizes of 0.5 cm recommended for the Texture B--Minced and Moist category. (10,27-30) Because of individual variation noted in body morphology, these sizes are suggested targets only, and are included for use in institutional quality assurance activities.

Australian fluid thickness

The Australian Clinical Fluid Texture Grading Scale shows 'regular fluids' as the beginning of the continuum, with three levels of thickened fluids. The labels given to the thickened fluids are 'Level 150--Mildly Thick'; 'Level 400--Moderately Thick' and 'Level 900--Extremely Thick'. The numerical system for thickened fluids was chosen as a contrast with the alphabetical food texture levels. The descriptive labels applied are quite different to the labels currently used within Australia. They were derived from a desire to describe fluid thickness rather than fluid types (e.g. nectar-honey-pudding).

The terms nectar and honey were discussed at length. Commercially available nectar from the supermarket was considered not sufficiently thicker than a thin fluid for individuals who require thickened fluids. Attempting to describe this first level of fluid thickness as 'nectar', therefore posed problems. The term 'honey' already describes a known substance that is susceptible to changes in consistency with changes in temperature. The other most commonly used labelling theme related thickness back to 'full thick', that is, 1/4 thick and 1/2 thick. However, subjectively fluids were not always 'a quarter of the thickness' or 'half of the thickness' of full thick. There was a need to first agree on what 'full thick' was in order to be able to distinguish half of and a quarter of its thickness level. To enhance communication of fluid thicknesses a different terminology was required.

The inclusion of meaningful numbers in the scale was considered. Although a scale of 1-3 could have been used, some Australian facilities have used 1 to denote the thinnest fluid, while others had used 1 to denote the most thickened. A scale that uses a large number tied to a simple descriptor was perceived to promote better communication. The sunscreen SPF (sun protection factor) system provides a good analogy. The Anti-Cancer Council has worked hard to ensure a consistent and simple public message: the higher the SPF value, the more sun protection afforded. (31) The numeric value of SPF15 relates to a measurement of sun protection factor. The larger the number, for example SPF30, the greater the sun protection factor. The numbers chosen for the Australian fluid scale similarly have a meaning: the larger the number, the thicker the fluid. The US Dysphagia Diet (12) has prescribed specific viscosity levels for their thin, nectar-like, honey-like and spoon-thick consistencies. Note that the viscosities are to be measured at room temperature and with a shear rate of [50.sup.s-1]. The details relating to temperature and shear rate are essential to replication of correct consistencies. The research literature, however, demonstrates considerable variability in the viscosity range for thickened fluids. (13,19,20,22,32-34) It is not possible at this time to recommend specific viscosity levels as measured in centipoise (cP) for manufacturers. However, it is possible to use the trends generated from the literature to provide a broad numerical scale where thin fluids are denoted by a smaller value and thicker fluids by increasingly larger values. The numbers chosen for the scale broadly correspond to viscosity measures (see Table 3). The numerical scale system proposed for the Australian nomenclature is sympathetic to the measured viscosity levels of existing commercial products at high shear rates. It is anticipated that with future research, formal viscosity levels will be developed according to an evidence base and form part of the label of thickened fluids.

The number of fluid thickness levels is equivalent to those noted in Penman and Thomson's review. (10) They are also the same in number as the US Dysphagia scale. (12) The Australian scale is fewer in number than the UK scale. The UK scale differentiates thin fluids from naturally thick fluids, then follows with three levels of thickened fluid. Naturally thickened fluids, and indeed thin fluids such as water, may have a use in the management of dysphagia in the transition to thin fluids, however, they do not require addition of a thickening agent. As such, it was decided that naturally thick fluids should not be considered as part of the continuum of regular fluids for the Australian context. In the treatment of infant dysphagia, there is a fluid thickness that is very similar to naturally thick fluids. It is thicker than breast milk or regular infant formula, yet it is still able to pass through a fast flow teat. The place of this therapeutic (infant dysphagia) 'naturally thick' level of thickness is indicated as a note in the scales; however, it is not defined as a level in its own right.

Future directions

Consensus between practitioner groups has been achieved on the new standards and Speech Pathology Australia and Dietitians Association of Australia encourage their use throughout Australia. As with any new standards the challenge now becomes dissemination and implementation. Focus group attendees provided insight into the type of resources to be developed and ways to enhance broad dissemination. A short instructional DVD was considered important. This format would allow demonstration of particle size, ease of fork mashing and movement associated with pouring a thick fluid. A poster and downloadable images of food and fluid textures were also seen as useful. Focus groups felt that the website developed for the project should be retained as a point of reference for professionals as well as the community. Presentation of the final scale at professional associations conferences, preparation of a standard package to provide to tertiary training institutions and consistent and timely communication of the standards to industry are vital steps for implementation of the new descriptions.

Future projects should address a consultation process with consumers. Consumers should be consulted regarding their understanding of the new terminology and labelling system to determine the amount of education required for clarity. Other future work should be undertaken in the areas that were out of scope for this project. This includes the nutritional adequacy and palatability/acceptability of texture-modified foods and fluids, development of objective measures of fluid viscosity and standard recipes for texture-modified fluids and, most importantly, the development of evidence-based guidelines to inform clinical practice.

Facilities are encouraged to use the labels and definitions provided to enhance consistency and thereby safety for individuals with dysphagia, improve communication between health professionals, increase the efficacy of research in this area and to stimulate growth in the range of products from the commercial sector. It is anticipated that facilities will use those levels that best suit their needs and if adding new levels will reference them against the scales provided. These scales are provided as a guide and it is expected that institutions will apply them within the policy and procedures of their individual institution. Speech Pathology Australia and Dietitians Association of Australia are committed to the broad communication and uptake of these consensus standards.

ACKNOWLEDGEMENTS

The Associations would like to formally acknowledge and thank the members of the advisory committee:

* Carman Beerman (Nutrition Assistant)

* Elizabeth Huppatz (Nursing)

* Suzanne Kennewell (Dietetics)

* Kimberley O'Donnell (Speech Pathology)

* Michelle Suter (Dietetics)

* Jayne Taylor (Institute of Hospitality and Healthcare)

* Katie Walker-Smith (Speech Pathology)

The Associations would also like to gratefully acknowledge the input of the membership of both Associations, many of whom contributed significantly to the project.

The project team would also like to gratefully acknowledge the input and support provided by:

* Lisa Shaw-Stuart, Councillor, The Speech Pathology Association of Australia Limited

* Claire Hewat, Executive Director, Dietitians Association of Australia

* Gail Mulcair, Chief Executive Officer, The Speech Pathology Association of Australia Limited

* The Board of the Dietitians Association of Australia and Council of The Speech Pathology Association of Australia Limited

This project was funded by Novartis Medical Nutrition.

REFERENCES

1 Martin AW. Dietary management of swallowing disorders. Dysphagia 1991; 6: 129-34.

2 Pardoe EM. Development of a multistage diet for dysphagia. J Am Diet Assoc 1993; 93: 568-71.

3 Curran J, Groher ME. Development and dissemination of an aspiration risk reduction diet. Dysphagia 1990; 5: 6-12.

4 Hotaling DL. Nutritional considerations for the pureed diet texture in dysphagic elderly. Dysphagia 1992; 7: 81-5.

5 Robertson HM, Patillo MS. A strategy for providing food to the patient with neurologically based dysphagia. J Can Diet Assoc 1993; 54: 198-201.

6 Langmore SE, Miller RM. Behavioural treatment for adults with oropharyngeal dysphagia. Arch Phys Med Rehabil 1994; 75: 1154-60.

7 Logemann JA. Evaluation and Treatment of Swallowing Disorders, 2nd edn. Austin, TX: Pro-Ed., 1998.

8 Cichero J. Respiration and swallowing. In: Cichero J, Murdoch B, eds. Dysphagia: Foundation, Theory and Practice. Chichester, UK: John Wiley and Sons, 2006; 92-111.

9 Reimers-Neils L, Logemann J, Larson C. Viscosity effects on EMG activity in normal swallowing. Dysphagia 1994; 9: 101-6.

10 Penman JP, Thomson M. A review of the textured diets developed for the management of dysphagia. J Hum Nutr Diet 1998; 11: 51-60.

11 Coroner's Report of South Australia, Finding of Inquest Maiolo G. 7 April 1997 and 8 May 1997, pp. 1-11.

12 National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association, 2002.

13 Cichero JAY, Hay G, Murdoch BE et al. Which of these is not like the others? An inter-hospital study of the viscosity of thickened fluids. J Speech Hear Res 2000; 43: 537-47.

14 Cichero JAY, Hay G, Murdoch BE et al. How thick is thick? A multi-centre study of the rheological and material property characteristics of meal-time fluids and videofluoroscopy fluids. Dysphagia 2000; 15: 188-200.

15 Finestone HM, Greene-Finestone LS. Rehabilitation medicine: 2. Diagnosis of dysphagia and its nutritional management for stroke patients. Can Med Assoc J 2003; 169: 1041-4.

16 Glassburn DL, Deem JF. Thickener viscosity in dysphagia management: variability among speech-language pathologists. Dysphagia 1998; 13: 218-22.

17 Cichero JAY, Hay G, Murdoch BE et al. Videofluoroscopic fluids vs. mealtime fluids: differences in viscosity and density made clear. J Med Speech Lang Pathol 1997; 5: 203-15.

18 Goulding R, Bahkeit AMO. Evaluation of the benefits of monitoring fluid thickness in the dietary management of dysphagic stroke patients. Clin Rehabil 2000; 14: 119-24.

19 Steele CM, Van Lieshout PHHM, Goff HD. The rheology of liquid: comparison of clinicians' subjective impressions and objective measurement. Dysphagia 2003; 18: 182-95.

20 Steele C, Van Lieshout PHHM. Influence of bolus consistency on lingual behaviours in sequential swallowing. Dysphagia 2004; 19: 192-206.

21 Garcia JM, Chambers E, Matta Z et al. Viscosity measures of nectar- and honey-thick liquids: product, liquid and time comparisons. Dysphagia 2005; 20: 325-35.

22 Germain I, Dufresne T, Ramaswamy HS. Rheological characterization of thickened beverages used in the treatment of dysphagia. J Food Eng 2006; 71: 64-74.

23 Matta Z, Chamber E, Garcia JM et al. Sensory characteristics of beverages prepared with commercial thickeners used for dysphagia diets. J Am Diet Assoc 2006; 106: 1049-54.

24 Seal DW, Bogart LM, Ehrhardt AA. Small group dynamics: the utility of focus group discussions as a research method. Group Dyn Theory Res Pract 1998; 2: 253-66.

25 Fern EF. The use of focus groups for idea generation: the effects of group size, acquaintanceship, and moderator on response quantity and quality. J Market Res 1982; XIX: 1-13.

26 British Dietetic Association. National Descriptors for Texture Modification in Adults. Joint working party of The British Dietetic Association and the Royal College of Speech and Language Therapists, May 2002.

27 Samuels R, Chadwick DD. Predictors of asphyxiation risk in adults with intellectual disability and dysphagia. J Intell Disabil Res 2006; 50: 362-70.

28 Litman RS, Weissend EE, Shibata D et al. Developmental changes of laryngeal dimensions in unparalyzed, sedated children. Anesthesiology 2003; 98: 41-5.

29 Mishellany A, Woda A, Labas R et al. The challenge of mastication: preparing a bolus suitable for deglutition. Dysphagia 2006; 21 (2): 87-94.

30 Kohyama K, Mioche L, Martin J-L. Chewing patterns of various texture foods studied by electromyography in young and elderly populations. J Texture Stud 2002; 33: 269-83.

31 Diffey B. Has the sun protection factor had its day? BMJ 2000; 320 (7228): 176-7.

32 Chi-Fishman G, Sonies B. Effects of systematic bolus viscosity and Volume changes on hyoid movement kinematics. Dysphagia 2002; 17: 278-87.

33 Slattery J. Thickening of infant formula: effect of time, temperature and formula type. Unpublished honours thesis. University of Queensland, 2006.

34 Logemann J, Gensler G, Robbins JA et al. Randomized study for two interventions for liquid aspiration. Protocol 201. American Speech and Hearing Association Conference, 17 November 2006; Miami Beach, FL, USA, 2006.

35 Hoebler C, Devaux M-F, Karinthi A, Belleville C, Barry J-L. Particle size of solid food after human mastication and in vitro simulation of oral breakdown. Int J Food Sci Nutr 2000; 51: 353-66.

36 Bren L. Prevent your child from choking. FDA Consumer 2005; 39: 27-30.

37 Morley RE, Ludemann JP, Moxham JP et al. Foreign body aspiration in infants and toddlers: recent trends in British Columbia. J Otolaryngol 2004; 33: 37-41.

38 Mu L, Ping H, Sun D. Inhalation of foreign bodies in Chinese children: a review of 400 cases. Laryngoscope 1991; 101: 657-60.

39 Berzlanovich AM, Muhm M, Sim E et al. Foreign body asphyxiation--an autopsy study. Am J Med 1999; 107: 351-5.

40 Wolach B, Raz A, Weinberg J et al. Aspirated bodies in the respiratory tract of children: eleven years experience with 127 patients. Int J Pediatr Otorhinolaryngol 1994; 30: 1-10.

41 Centre for Disease Control and Prevention. Non-fatal choking related episodes among children, United States 2001. Morb Mortal Wkly Rep 2002; 51: 945-8.

42 Rimmell F, Thome A, Stool S et al. Characteristics of objects that cause choking in children. JAMA 1995; 274: 1763-6.

43 Seidel JS, Gausche-Hill M. Lychee-flavoured gel candies. A potentially lethal snack for infants and children. Arch Pediatr Adolesc Med 2002; 156: 1120-22.

44 Carruth BR, Skinner JD. Feeding behaviour and other motor development in healthy children (2-24 months). J Am Coll Nutr 2002; 21: 88-96.

APPENDIX I

Australian standardised definitions and terminology for texture-modified foods and fluids

The following fluid thickness and food texture grading scales provide terms for and descriptions of fluid and food texture modification for individuals with dysphagia (disordered swallowing).

The scales have been developed by a consultation process with dietitians and speech pathologists across Australia. The scales are a consensus standard agreed to by Speech Pathology Australia and the Dietitians Association of Australia and are encouraged for use around Australia. It is hoped that these standards will facilitate the development of the limited evidence base in this area of practice.

This project did not address:

* Nutritional or hydration adequacy of texture-modified diets, for example whether supplementary fluids may be required for individuals on thickened fluids

* Development of guidelines for clinical application or outcomes

* Client acceptability of modified foods/fluids

* Reliability of the consistency of thickened fluids

The scales have been developed to encourage standardisation of definitions and terminology across Australia. The standards are intended to be applied within the policies, procedures and capacities of individual institutions under the direction of dietitians and speech pathologists.

In Australia, speech pathologists establish dysphagia severity and determine the level of food and fluid texture modification required. Dietitians ensure that individuals who require texture-modified diets are able to meet their nutrition and hydration needs.

Four levels of texture modification have been identified for fluids and foods--unmodified plus three modified levels. Each modified level has a dual label, for example Texture A--Soft or Level 150--Mildly Thick. It is strongly encouraged that both labels be used.

The Fluid Scale has three different colours to denote the three different modified levels. These colours are a recommendation and may be used at the discretion of individual institutions or commercial companies to help identify more clearly the different levels of fluid thickness.

The levels noted in these scales occur on a continuum from unmodified to most modified. The scales do not relate to a scale across which an individual should travel or progress, but rather a scale across which a fluid or food item might travel as it becomes more modified.

It is important to note that speech pathologists and dietitians and the institutions in which they work should only use the levels they deem appropriate for their setting and client demographic. There is no requirement for facilities to use all of the levels and conversely there are some clinicians who will choose to add extra levels to the scales. To ensure consistency, it would be appropriate that any extra levels be referenced against the standard scale presented.

The following scales provide:

* The number of levels of food texture modification and fluid thickness

* The names of the levels (and for fluids a corresponding suggested colour to facilitate communication)

* A description of the levels

* Characteristics of the food or fluids that would be appropriate for that level

* Testing information--this is provided as a guide only. It is included for use in food service quality assurance activities

* Examples of recommended foods and foods to avoid for each food texture level. This list is not exhaustive and simply provides general direction

Food texture modification gradingt scale for the clinical management of dysphagia

NAME              UNMODIFIED -- REGULAR

Description       * These are everyday foods
Characteristics   * There are various textures of regular foods. Some
                    are hard and crunchy, others are naturally soft
Food inclusions   * By definition all food and textures can be included
  and exclusions

NAME                 TEXTURE A -- SOFT

Description          * Food in this category may be naturally soft (eg
                       ripe banana), or may be cooked or cut to alter
                       its texture
Characteristics      * Soft foods can be chewed but not necessarily
                       bitten
                     * Minimal cutting required--easily broken up with a
                       fork
                     * Food 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)
                     * Refer to Special Notes (page S72)
Testing Information  * Targeted particle size for infants and children =
                       less than half that for adults and children over
                       5 years or equal to 0.8 cm (based on tracheal
                       size) (28)
                     * Targeted particle size for children over 5 years
                       and adults = 1.5 x 1.5 cm (10,27,30)

Texture A -- Soft

Recommended foods and those to avoid (examples only)

                  Recommended foods                 Avoid

Bread, cereals,   * Soft sandwiches (a) with very   * Dry or crusty
  rice, pasta,      moist fillings, for example       breads, breads
  noodles           egg and mayonnaise, hummus        with hard seeds or
                    (remove crusts and avoid          grains, hard
                    breads with seeds and grains)     pasty, pizza
                  * Breakfast cereals well          * Sandwiches that
                    moistened with milk (b)           are not thoroughly
                  * Soft pasta (a) and noodles        moist
                  * Rice (well cooked)              * Course or hard
                  * Soft pastry, for example          breakfast cereals
                    quiche with a pastry base         that do not
                  * Other, soft, cooked grains        moisten easily,
                                                      for example
                                                      toasted muesli,
                                                      bran cereals
                                                    * Cereals with nuts,
                                                      seeds and dried
                                                      fruit
Vegetables,       * Well cooked vegetables (a)      * All raw vegetables
  legumes           served in small pieces or soft    (including chopped
                    enough to be mashed or broken     and shredded)
                    up with a fork                  * Hard, fibrous or
                  * Soft canned vegetables, for       stringy vegetables
                    example peas                      and legumes, for
                  * Well cooked legumes (the outer    example sweet
                    skin must be soft), for           corn, broccoli
                    example baked beans               stalks
Fruit             * Fresh fruit pieces that are     * Large/round fruit
                    naturally soft, for example       pieces that pose a
                    banana, well-ripened pawpaw       choking risk, for
                  * Stewed and canned fruits in       example whole
                    small pieces                      grapes, cherries
                  * Pureed fruit                    * Dried fruit, seeds
                  * Fruit juice (b)                   and fruit peel
                                                    * Fibrous fruits,
                                                      for example
                                                      pineapple
Milk, yoghurt,    * Milk, milkshakes,               * Yoghurt with
  cheese            smoothies (b)                     seeds, nuts,
                  * Yoghurt (may contain soft         muesli or hard
                    fruit) (b)                        pieces of fruit
                  * Soft cheeses, (a) for example   * Hard cheeses, for
                    Camembert, ricotta                example cheddar
                                                      and hardened/
                                                      crispy cooked
                                                      cheese
Meat, fish,       * Casseroles with small pieces    * Dry, tough, chewy,
  poultry, eggs,    of tender meat (a)                or crispy meats
  nuts, legumes   * Moist fish (easily broken up    * Meat with gristle
                    with the edge of a fork)        * Fried eggs
                  * Eggs (a) (all types except      * Hard or fibrous
                    fried)                            legumes
                  * Well cooked legumes (the outer  * Pizza
                    skin must be soft), for
                    example baked beans
                  * Soft tofu, for example small
                    pieces, crumbled
Desserts          * Puddings, dairy desserts, (b)   * Dry cakes, pastry,
                    custards, (b) yoghurt (b) and     nuts, seeds,
                    ice-cream (b) (may have pieces    coconut, dried
                    of soft fruit)                    fruit, pineapple
                  * Moist cakes (extra moisture,
                    e.g. custard may be required)
                  * Soft fruit-based desserts
                    without hard bases, crumbly or
                    flaky pastry or coconut, for
                    example apple crumble
                  * Creamed rice, moist bread and
                    butter pudding
Miscellaneous     * Soup (b)--(may contain small    * Soups with large
                    soft lumps, e.g. pasta)           pieces of meats or
                  * Soft fruit jellies or non-        vegetables, corn,
                    chewy lollies (a)                 or rice
                  * Soft, smooth, chocolate         * Sticky or chewy
                  * Jams and condiments without       foods, for example
                    seeds or dried fruit              toffee
                                                    * Popcorn, chips,
                                                      biscuits,
                                                      crackers, nuts,
                                                      edible seeds

(a) These foods require case-by-case consideration.
(b) These foods may need modification for individuals requiring
thickened fluids.

NAME                 TEXTURE B -- MINCED AND MOIST

Description          * Food in this category is soft and moist and
                       should easily form into a ball
Characteristics      * Individual uses tongue rather than teeth to break
                       the small lumps in this texture
                     * Food is soft and moist and should easily form
                       into a ball
                     * Food should be 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)
                     * Refer to Special Notes (page S72)
Testing Information  * Recommended particle size for infants and
                       children = 0.2-0.5 cm (based on tracheal size)
                       (28)
                     * Recommended particle size for children over 5
                       years and adults = 0.5 cm (10,29)

Texture B -- Minced and moist

Recommended foods and those to avoid (examples only)

                                              Avoid (in addition to the
                                              Foods the to Avoid listed
                  Recommended foods           for Texture A -- Soft)

Bread, cereals,   * Breakfast cereal with     * All breads, sandwiches,
  rice, pasta,      small moist lumps, for      pastries, crackers, and
  noodles           example porridge or         dry biscuits
                    wheat flake biscuits      * Gelled breads that are
                    soaked in milk              not soaked through the
                  * Gelled bread                entire food portion
                  * Small, moist pieces of    * Rice that does not hold
                    soft pasta, for example     together, for example
                    moist macaroni cheese       parboiled, long-grain,
                    (some pasta dishes may      basmati
                    require blending or       * Crispy or dry pasta, for
                    mashing)                    example edges of a pasta
                                                bake or lasagne
Vegetables,       * Tender cooked vegetables  * Vegetable pieces larger
  legumes           that are easily mashed      than 0.5 cm or too hard
                    with a fork                 to be mashed with a fork
                  * Well cooked legumes       * Fibrous vegetables that
                    (partially mashed or        require chewing, for
                    blended)                    example peas
Fruit             * Mashed soft fresh         * Fruit pieces larger than
                    fruits, for example         0.5 cm
                    banana, mango             * Fruit that is too hard
                  * Finely diced soft pieces    to be mashed with a fork
                    of canned or stewed
                    fruit
                  * Pureed fruit
                  * Fruit juice (a)
Milk, yoghurt,    * Milk, milkshakes,         * Soft cheese that is
  cheese            smoothies (a)               sticky or chewy, for
                  * Yoghurt (a) (may have       example Camembert
                    small soft fruit pieces)
                  * Very soft cheeses with
                    small lumps, for example
                    cottage cheese
Meat, fish,       * Coarsely minced, tender,  * Casserole or mince
  poultry, eggs,    meats with a sauce.         dishes with hard or
  nuts, legumes     Casseroles dishes may be    fibrous particles, for
                    blended to reduce the       example peas, onion
                    particle size             * Dry, tough, chewy, or
                  * Coarsely blended or         crispy egg dishes or
                    mashed fish with a sauce    those that cannot be
                  * Very soft and moist egg     easily mashed

                    dishes, for example
                    scrambled eggs, soft
                    quiches
                  * Well cooked legumes
                    (partially mashed or
                    blended)
                  * Soft tofu, for example
                    small soft pieces or
                    crumbled
Desserts          * Smooth puddings, dairy    * Desserts with large,
                    desserts, (a)               hard or fibrous fruit
                    custards, (a)               particles (e.g.
                    yoghurt (a) and ice-        sultanas), seeds or
                    cream (a) (may have         coconut
                    small pieces of soft      * Pastry and hard
                    fruit)                      crumble
                  * Soft moist sponge cake    * Bread-based puddings
                    desserts with lots of
                    custard, cream or ice-
                    cream, for example
                    trifle, tiramisu
                  * Soft fruit-based
                    desserts without hard
                    bases, crumbly or flaky
                    pastry or coconut, for
                    example apple crumble
                    with custard
                  * Creamed rice
Miscellaneous     * Soup (a)--(may contain    * Soups with large pieces
                    small soft lumps, e.g.      of meats or vegetables,
                    pasta)                      corn, or rice
                  * Plain biscuits dunked in  * Lollies including fruit
                    hot tea or coffee and       jellies and marshmallow
                    completely saturated
                  * Salsa's, sauces and dips
                    with small soft lumps
                  * Very soft, smooth,
                    chocolate
                  * Jams and condiments
                    without seeds or dried
                    fruit

(a) These foods may require modification for individuals requiring
thickened fluids.

NAME                 TEXTURE C -- SMOOTH PUREED

Description          * Food in this category is smooth and lump free. It
                       is similar to the consistency of commercial
                       pudding. At times, smooth pureed food may have a
                       grainy quality, but should not contain lumps.
                     * Refer to Special Notes (page S72)
Characteristics      * Smooth and lump free but may have a grainy
                       quality
                     * Moist and 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)
                     * Food could be moulded, layered or piped
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)
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 a plate).

Texture C -- Smooth pureed

Recommended foods and those to avoid (examples only)

                                                  Avoid (in addition to
                                                  the Foods to Avoid
                                                  listed for Texture
                       Recommended foods          B -- Minced and Moist)

Bread, cereals, rice,  * Smooth lump-free         * Cereals with course
pasta, noodles           breakfast cereals, for     lumps or fibrous
                         example semolina,          particles, for
                         pureed porridge            example all dry
                       * Gelled bread               cereals, porridge
                       * Pureed pasta or noodles  * Gelled breads that
                       * Pureed rice                are not soaked
                                                    through the entire
                                                    food portion
Vegetables, legumes    * Pureed vegetables        * Coarsely mashed
                       * Mashed potato              vegetables
                       * Pureed legumes, for      * Particles of
                         example baked beans        vegetable fibre or
                         (ensuring no husks in      hard skin
                         final puree)
                       * Vegetable soups that
                         have been blended or
                         strained to remove
                         lumps (a)
Fruit                  * Pureed fruits, for       * Pureed fruit with
                         example commercial         visible lumps
                         pureed fruits,
                         vitamised fresh fruits
                       * Well mashed banana
                       * Fruit Juice (a) without
                         pulp
Milk, yoghurt, cheese  * Milk, milkshakes,        * All solid and semi-
                         smoothies (a)              solid cheese
                       * Yoghurt (a)                including cottage
                         (lump-free), for           cheese
                         example plain or
                         vanilla
                       * Smooth cheese pastes,
                         for example smooth
                         ricotta
                       * Cheese and milk-based
                         sauces (a)
Meat, fish, poultry,   * Pureed meat/fish         * Minced or partially
  eggs, nuts, legumes    (pureed with sauce/        pureed meats
                         gravy to achieve a       * Scrambled eggs that
                         thick moist texture)       have not been pureed
                       * Souffles and mousses,    * Sticky or very
                         for example salmon         cohesive foods, for
                         mousse                     example peanut
                       * Pureed legumes, hummus     butter
                       * Soft silken tofu
                       * Pureed scrambled eggs
Desserts               * Smooth puddings, dairy   * Desserts with fruit
                         desserts, (a)              pieces, seeds, nuts,
                         custards, (a)              crumble, pastry or
                         yoghurt (a) and ice-       non-pureed garnishes
                         cream (a)                * Gelled cakes or cake
                       * Gelled cakes or cake       slurries that are
                         slurry, for example        not soaked through
                         fine sponge cake           the entire food
                         saturated with jelly       portion
                       * Soft meringue
                       * Cream (a), syrup
                         dessert toppings (a)
Miscellaneous          * Soup (a)--vitamised or   * Soup with lumps
                         strained to remove       * Jams and condiments
                         lumps                      with seeds, pulps or
                       * Smooth jams, condiments    lumps
                         and sauces

(a) These foods may require modification for individuals requiring
thickened fluids.

SPECIAL NOTES

Foods and other items requiring special consideration for individuals with dysphagia

The following foods were identified as requiring emphasis.

Bread              * Bread requires an ability to both bite and chew.
                     Chewing stress required for bread is similar to
                     that of raw apple. The muscle activity required for
                     each chew of bread is similar to that required to
                     chew peanuts. (35) For this reason, individuals who
                     fatigue easily may find bread difficult to chew
                   * Bread requires moistening with saliva for effective
                     mastication. Bread does not dissolve when wet; it
                     clumps. It poses a choking risk if it adheres to
                     the roof of the mouth, pockets in the cheeks or if
                     swallowed in a large clump. This is similar to the
                     noted choking effect of 'chunks' of peanut
                     butter (36)
Ice-cream          * Ice-cream is often excluded on diets for
                     individuals who require thickened fluids. This is
                     because ice-cream melts and becomes like a thin
                     liquid at room temperature or within the oral
                     cavity
Jelly              * Jelly may be excluded from diets for individuals
                     who require thickened fluids. This is because jelly
                     particulates in the mouth if not swallowed promptly
Soup               * Individuals who require thickened fluids will
                     require their soups thickened to the same
                     consistency as their fluids unless otherwise
                     advised by a speech pathologist
'Mixed' or 'dual'  * These textures are difficult for people with poor
  consistencies      oral control to safely contain and manipulate
                     within the mouth
                   * These are consistencies where there is a solid as
                     well as a liquid present in the same mouthful
                   * Examples include individual cereal pieces in milk
                     (e.g. cornflakes in milk), fruit punch, minestrone
                     soup, commercial diced fruit in juice, watermelon
Special occasion   * Special occasion foods (e.g. chocolates, birthday
  foods or fluids    cake) should be well planned to ensure that they
                     are appropriate for individuals requiring texture-
                     modified foods and/or thickened fluids
Nutritional        * For individuals who also required thickened fluids,
  supplements        nutritional supplements may require thickening to
                     the same level of thickness
Medication         * Individuals on Texture C -- Smooth Pureed are
                     unsuitable for oral administration of whole tablets
                     or capsules. Consult with medical and
                     pharmaceutical staff
                   * Individuals requiring any form of texture-modified
                     food or fluids may have difficulty swallowing
                     medications. Seek advice if in doubt

Characteristics of foods that pose a choking risk

Stringy                   Rhubarb, beans
                          Celery is considered a choking risk until
                            three years of age (37,38)
Crunchy                   Popcorn, toast, dry biscuits, chips/
                            crisps (39)
Crumbly                   Dry cakes or biscuits (39)
Hard or dry foods         Nuts, raw broccoli, raw cauliflower, apple,
                            crackling, hard crusted rolls/breads, seeds
                          Raw carrots are considered a choking risk
                            until three years of age (37-41)
Floppy textures           Lettuce, cucumber, uncooked baby spinach
                            leaves (adheres to mucosa when moist--
                            conforming material) (42)
Fibrous or 'tough' foods  Steak, pineapple (39)
Skins and outer shells    Corn, peas, apple with peel, grapes (38,40,41)
Round or long shaped      Whole grapes, whole cherries, raisins, hot
                            dogs, sausages (40,41)
Chewy or sticky           Lollies (adhere to mucosa); cheese chunks,
                            fruit roll-ups, gummy lollies, marshmallows,
                            chewing gum, sticky mashed potato, dried
                            fruits (36,41-43)
Husks                     Corn, bread with grains, shredded wheat,
                            bran (38,41)
'Mixed' or 'dual'         Foods that retain solids within a liquid base
  consistencies             (e.g. minestrone soup, breakfast cereal,
                            e.g. cornflakes with milk); watermelon (44)

Fluid thickness grading scale for the clinical management of dysphagia

NAME                 UNMODIFIED -- REGULAR FLUIDS

                     * There are various thickness levels in unmodified
                       fluids. Some are thinner (eg water, and breast
                       milk) and some are thicker (eg fruit nectar)
                     * Unmodified--Regular fluids do not have thickening
                       agents added to them
Flow rate            * 'Very fast--fast flow'
Characteristics      * Drink through any type of teat, cup or straw as
                       appropriate for age and skills
Testing information  * N/A

NAME                 LEVEL 150 -- MILDLY THICK

                     Level 150 -- Mildly Thick is thicker than naturally
                     thick fluids such as fruit nectars, but for
                     example, not as thick as a thickshake
Flow rate            * Steady, fast flow
Characteristics      * Pours quickly from a cup but slower than regular,
                       unmodified fluids
                     * May leave a coating film of residue in the cup
                       after being poured
                     * Drink this fluid thickness from a cup
                     * Effort required to take this thickness via a
                       standard bore straw
Testing information  * Subjectively, fluids at this thickness run fast
                       through the prongs of a fork, but leave a mild
                       coating on the prongs
                     * Testing scales for viscosity exist but are not
                       formalised or standardised, and therefore are not
                       included
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
                       'Antiregurgitation' (AR) formula.
                     * Consideration should be given to flow through a
                       teat as determined on a case-by-case basis

NAME                 LEVEL 400 -- MODERATELY THICK

                     Level 400 -- Moderately Thick is similar to the
                     thickness of room temperature honey or a thickshake

Flow rate            * 'Slow flow'
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
Testing information  * Subjectively, fluids at this thickness slowly
                       drip in dollops through the prongs of a fork
                     * Testing scales for viscosity exist but are not
                       formalised or standardised, and therefore are not
                       included

NAME                 LEVEL 900 -- EXTREMELY THICK

                     Level 900 -- Extremely Thick is similar to the
                     thickness of pudding or mousse

Flow rate            * 'No flow'
Characteristics      * Cohesive and holds its shape on a spoon
                     * It is not possible to pour this type of fluid
                       from a cup into the mouth
                     * It is not possible to drink this thickness using
                       a straw.
                     * Spoon is the optimal method for taking this type
                       of fluid.
                     * This fluid is too thick if the spoon is able to
                       stand upright in it unsupported
Testing information  * Subjectively, fluids at this thickness sit on and
                       do not flow through the prongs of a fork
                     * Testing scales for viscosity exist but are not
                       formalised or standardised, and therefore are not
                       included

Reference numbers throughout the Appendix refer to references contained in The Australian Standardized Terminology and Definitions for Texture Modified Foods and Fluids. Nutrition & Dietetics 2007; 64 (Suppl. 2): S53-S76.

Authors:

Dietitians Association of Australia and The Speech Pathology Association of Australia Limited

Project Officer:

Julie A.Y. Cichero, BA, BSpThy (Hons), PhD

Contributors:

(1) M. Atherton, BAppSc (SpPath), GradDip (Neuro)

(2) N. Bellis-Smith, BSc, GradDipDiet, GradDipHlthProm, APD 

(3) J.A.Y. Cichero, BA, BSpThy (Hons), PhD

(4) M. Suter. BAppSc, BHlthSc(Nutr & Diet), GradCertHlthMgt, APD

(1) The Speech Pathology Association of Australia Limited (Senior Advisor Professional Issues), (2) Dietitians Association of Australia (Professional Services Director), (3) Project Officer, (4) Advisory Committee Representative

Table 1 Themes of thickened fluid classification based on Penman and
Thomson's review of dysphagia diets (10)

Fluid name and level  Description of fluid thickness

Level 1 -- Nectar     Like nectar
Level 2 -- Honey      Like honey
Level 3 -- Pudding    Like pudding (3,10)
Thin                  Water and all juices thinner than pineapple juice
Thick                 All other liquid including milk and any juice not
                        classified as thin
Thickened             Liquids thickened with starch to pureed
                        consistency (2,10)
Watery                Water, tea, coffee
Milky                 Milk and most fruit juices
Single cream          Ensure Plus and Enterat (10)
Double cream          Tomato juice, thinned pureed fruit, creamed soups
Custard               Cheese or custard sauce, smooth yoghurt
Semi-solid            Thick set yoghurt, blancmange, mashed potato (10)

Table 2 Model of progression of diets used for dysphagia (adapted from
Penman and Thomson (10))

Food grading      Description of food texture

Liquidised/thin   Homogenous consistency that does not hold its shape
  puree             after serving
Thick puree/soft  Thickened, homogenous consistency that holds its shape
  and smooth        after serving, and does not separate into liquid and
                    solid component during swallowing, that is, cohesive
Finely minced     Soft diet of cohesive, consistent textures requiring
                    some chewing (particle size most often described as
                    0.5 x 0.5 cm)
Modified normal   Normal foods of varied textures that require chewing,
                    avoiding particulate foods that pose a choking
                    hazard (particle size most often described as
                    1.5 x 1.5 cm)

Table 3 Comparison between Australia clinical food texture scale,
National Dysphagia Diet (US) and the UK food texture classification
systems for individuals with dysphagia (23,26)

Australian food                                          UK food texture
texture scale        USA food texture scale              scale

Regular              Regular                             Normal
Texture A -- Soft    Dysphagia Advanced ('bite-sized'),  Texture E
  (1.5 cm)             <1 inch or 2.5 cm                   (1.5 cm)
Texture B -- Minced  Dysphagia Mechanically altered      Texture D
  and Moist            (0.6 cm)                          Texture C
  (0.5 cm)           Dysphagia Puree                     Texture B
Texture C -- Smooth                                      Texture A
  Pureed

Table 4 Comparison between the Australian fluid texture modification
scale, the National Dysphagia Diet (US) and the UK (adult) texture
classification systems for individuals with dysphagia (23,26)

Australian fluid         USA fluid             UK fluid viscosity
viscosity scale          viscosity scale       scale

Regular                  Thin 1-50 cP          Thin fluid
                                               Naturally thick fluid
Level 150 -- Mildly      Nectar-like thick     Thickened fluid --
  thick                    fluids 51-350 cP      Stage 1
Level 400 -- Moderately  Honey-like thick      Thickened fluid --
  thick                    fluids 351-1750 cP    Stage 2
Level 900 -- Extremely   Spoon-thick fluids    Thickened fluid --
  thick                    >1750 cP              Stage 3