Texture-modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions.Abstract
Thickened fluids Thickened fluids are often used for people with dysphagia, a disorder of swallowing function. The thicker consistency makes it less likely that an individual with dysphagia will aspirate while they are drinking.
There are several levels of consistency. and texture-modified foods are provided for the therapeutic treatment of dysphagia dysphagia /dys·pha·gia/ (-fa´jah) difficulty in swallowing.
dys·pha·gia or dys·pha·gy
Difficulty in swallowing or inability to swallow. . 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 Australia (ôstrāl`yə), smallest continent, between the Indian and Pacific oceans. With the island state of Tasmania to the south, the continent makes up the Commonwealth of Australia, a federal parliamentary state (2005 est. pop. and The Speech Pathology speech pathology
The science concerned with the diagnosis and treatment of functional and organic speech defects and disorders. Also called speech-language 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 Australian
pertaining to or originating in Australia.
Australian bat lyssavirus disease
see Australian bat lyssavirus disease.
Australian cattle dog
a medium-sized, compact working dog used for control of cattle. context. A project officer and multidisciplinary mul·ti·dis·ci·pli·nar·y
Of, relating to, or making use of several disciplines at once: a multidisciplinary approach to teaching. 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
standard - conforming to or constituting a standard of measurement or value; or of the usual or regularized or accepted kind; "windows of standard width"; labelling and terminology system (99.2% of respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy. ). A national consultative process encompassing the views of more than 580 clinicians helped to formulate formulate /for·mu·late/ (for´mu-lat)
1. to state in the form of a formula.
2. to prepare in accordance with a prescribed or specified method. 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 thick·en
tr. & intr.v. thick·ened, thick·en·ing, thick·ens
1. To make or become thick or thicker: Thicken the sauce with cornstarch. The crowd thickened near the doorway.
Texture modification of foods and thickening thick·en·ing
1. The act or process of making or becoming thick.
2. Material used to thicken: stir in a thickening of flour and water.
3. A thickened part. of fluid forms a routine part of the assessment and treatment of swallowing swallowing
Act that moves food from the mouth to the stomach. The tongue pushes liquid or chewed food mixed with saliva into the pharynx. difficulties (dysphagia). (1-6) Dysphagia contributes to reduced dietary intake, and potentially malnutrition malnutrition, insufficiency of one or more nutritional elements necessary for health and well-being. Primary malnutrition is caused by the lack of essential foodstuffs—usually vitamins, minerals, or proteins—in the diet. , aspiration aspiration /as·pi·ra·tion/ (as?pi-ra´shun)
1. the drawing of a foreign substance, such as the gastric contents, into the respiratory tract during inhalation.
2. and asphyxiation asphyxiation /as·phyx·i·a·tion/ (as-fix?e-a´shun) suffocation; the stoppage of respiration.
Oxygen starvation of tissues. . (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 chew Chewing tobacco. See Smokeless tobacco. 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 aspiration pneumonia
Bronchopneumonia resulting from the entrance of foreign material, usually food particles or vomit, into the bronchi.
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 swallow, common name for small perching birds of almost worldwide distribution. There are about 100 species of swallows, including the martins, which belong to the same family. Swallows have long, narrow wings, forked tails, and weak feet. . If the prescription is not followed, the individual may face serious health consequences. Inconsistency in·con·sis·ten·cy
n. pl. in·con·sis·ten·cies
1. The state or quality of being inconsistent.
2. Something inconsistent: many inconsistencies in your proposal. 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 Noun 1. standardisation - the condition in which a standard has been successfully established; "standardization of nuts and bolts had saved industry millions of dollars"
standardization 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 American, river, 30 mi (48 km) long, rising in N central Calif. in the Sierra Nevada and flowing SW into the Sacramento River at Sacramento. The discovery of gold at Sutter's Mill (see Sutter, John Augustus) along the river in 1848 led to the California gold rush of 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 'City of Brisbane' can refer to:
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 dietetics /di·e·tet·ics/ (-iks) the science of diet and nutrition.
The branch of therapeutics concerned with the practical application of diet in relation to health and disease. , medicine, nursing, food services food services Hospital services A 24/7 department in a hospital that provides for the nutritional needs of inpatients–eg, those needing special diets, preparing meals and transporting them to the floor and, through the cafeteria, the hospital staff and and industry. One of the aims of the group was to review current dysphagia management practices. Issues surrounding sur·round
tr.v. sur·round·ed, sur·round·ing, sur·rounds
1. To extend on all sides of simultaneously; encircle.
2. To enclose or confine on all sides so as to bar escape or outside communication.
n. 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 Adj. 1. formalised - concerned with or characterized by rigorous adherence to recognized forms (especially in religion or art); "highly formalized plays like `Waiting for Godot'"
formalistic, formalized 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 multifactorial /mul·ti·fac·to·ri·al/ (mul?te-fak-tor´e-al)
1. of or pertaining to, or arising through the action of many factors.
2. 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 practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. .
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 Stakeholders
All parties that have an interest, financial or otherwise, in a firm-stockholders, creditors, bondholders, employees, customers, management, the community, and the government. regarding points 1-4.
6 Commence communication of the new standards to stakeholders and commence education of speech pathologists and dietitians.
The project commenced with a development of a Memorandum of Understanding A Memorandum of Understanding (MoU) is a legal document describing a bilateral or multilateral agreement between parties. It expresses a convergence of will between the parties, indicating an intended common line of action and may not imply a legal commitment. 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 June: see month. 2006, with a six-month time frame for completion.
Key project stakeholders Project stakeholders are those entities within or without an organization which:
a) Sponsor a project or,
b) Have an interest or a gain upon a successful completion of a project. 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 conduit /con·du·it/ (kon´doo-it) channel.
ileal conduit the surgical anastomosis of the ureters to one end of a detached segment of ileum, the other end being used to form a stoma on the 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 COLLATION, descents. A term used in the laws of Louisiana. Collation -of goods is the supposed or real return to the mass of the succession, which an heir makes of the property he received in advance of his share or otherwise, in order that such property may be divided, together with the of any existing Australian scales, investigation of current international scales and a review of the literature pertaining per·tain
intr.v. per·tained, per·tain·ing, per·tains
1. To have reference; relate: evidence that pertains to the accident.
2. 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 Particle size, also called grain size, refers to the diameter of individual grains of sediment, or the lithified particles in clastic rocks. The term may also be applied to other granular materials. and rationale rationale (rash´nal´),
n the fundamental reasons used as the basis for a decision or action. 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 The Cochrane Library is a collection of databases in medicine and other healthcare specialties provided by the Cochrane Collaboration. At its core is a database of systematic reviews and meta-analyses which summarise and interpret the results of high-quality medical research. 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 deglutition /de·glu·ti·tion/ (de?gloo-tish´un) swallowing.
The act or process of swallowing. 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 stakeholder n. a person having in his/her possession (holding) money or property in which he/she has no interest, right or title, awaiting the outcome of a dispute between two or more claimants to the money or property. 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 Adj. 1. publicised - made known; especially made widely known
publicized 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 rehabilitation: see physical therapy. , community, extended care, disability and mental health for both adult and paediatric Adj. 1. paediatric - of or relating to the medical care of children; "pediatric dentist"
pediatric 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 thickeners,
n.pl See binder. were approached. These were: Chefs Pride, Chipmonk, Flavour (jargon) flavour - (US: flavor) 1. Variety, type, kind. "DDT commands come in two flavors." "These lights come in two flavors, big red ones and small green ones." See vanilla.
2. The attribute that causes something to be flavourful. Creations, Janbak Industries, Novartis Novartis International AG (NYSE: NVS) is a multinational pharmaceutical company based in Basel, Switzerland that manufactures drugs such as diclofenac (Voltaren), carbamazepine (Tegretol), valsartan (Diovan), imatinib mesylate (Gleevec / Glivec), cyclosporin A (Neoral / Medical Nutrition, Nutricia, Orfam, Orion Orion, in Greek mythology
Orion (ōrī`ən), in Greek mythology, Boeotian hunter. When Oenopion delayed giving his daughter Merope to him, Orion, when drunk, violated her. and Swallowade. The commercial companies were asked to complete the same feedback form as the health professionals.
Teaching institutions with courses that were accredited accredited
recognition by an appropriate authority that the performance of a particular institution has satisfied a prestated set of criteria.
cattle herds which have achieved a low level of reactors to, e.g. 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 n. 1. A program that delivers hot meals to persons, such as the elderly or disabled, who are confined to their homes and unable to cook for themselves; also, the meals thus delivered. Such programs are usually conducted by governmental or charitable organizations. , 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 (jargon, chat) face-to-face - (F2F, IRL) Used to describe personal interaction in real life as opposed to via some digital or electronic communications medium. 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 Noun 1. attrition rate - the rate of shrinkage in size or number
rate of attrition
rate - a magnitude or frequency relative to a time unit; "they traveled at a rate of 55 miles per hour"; "the rate of change was faster than expected"
of two per group. If individuals were unable to attend, alternative members were sought. Face-to-face focus groups were held in Queensland Queensland, state (1991 pop. 2,477,152), 667,000 sq mi (1,727,200 sq km), NE Australia. Brisbane is the capital; other important cities are Gold Coast, Toowoomba, Townsville, Rockhampton, Cairns, and Ipswich. , New South Wales New South Wales, state (1991 pop. 5,164,549), 309,443 sq mi (801,457 sq km), SE Australia. It is bounded on the E by the Pacific Ocean. Sydney is the capital. The other principal urban centers are Newcastle, Wagga Wagga, Lismore, Wollongong, and Broken Hill. and Victoria. Two teleconferences were held to gather information from Western Australia Western Australia, state (1991 pop. 1,409,965), 975,920 sq mi (2,527,633 sq km), Australia, comprising the entire western part of the continent. It is bounded on the N, W, and S by the Indian Ocean. Perth is the capital. , Tasmania Tasmania (tăzmā`nēə), island state (1991 pop. 359,286), 26,383 sq mi (68,332 sq km), SE Commonwealth of Australia. It is separated from Australia by the Bass Strait and lies 150 mi (240 km) south of the state of Victoria. , South Australia South Australia, state (1991 pop. 1,236,623), 380,070 sq mi (984,381 sq km), S central Australia. It is bounded on the S by the Indian Ocean. Kangaroo Island and many smaller islands off the south coast are included in the state. 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 Accordance is Bible Study Software for Macintosh developed by OakTree Software, Inc.
As well as a standalone program, it is the base software packaged by Zondervan in their Bible Study suites for Macintosh. 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 That which is unqualified or unconditional.
A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding.
Categorical is also used to describe programs limited to or designed for certain classes of people. 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 ex·plan·a·to·ry
Serving or intended to explain: an explanatory paragraph.
ex·plan footnote Text that appears at the bottom of a page that adds explanation. It is often used to give credit to the source of information. When accumulated and printed at the end of a document, they are called "endnotes." 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 Noun 1. coding system - a system of signals used to represent letters or numbers in transmitting messages
code - a coding system used for transmitting messages requiring brevity or secrecy or use of icon coding to assist implementation; (iii) ideas for 'essential' and 'desirable' resources (e.g. DVD DVD: see digital versatile disc.
in full digital video disc or digital versatile disc
Type of optical disc. The DVD represents the second generation of compact-disc (CD) technology. , wall chart, brochure); and (iv) ideas to promote uptake uptake /up·take/ (up´tak) absorption and incorporation of a substance by living tissue.
n. 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 dietitian /di·e·ti·tian/ (di?e-tish´in) one skilled in the use of diet in health and disease.
di·e·ti·tian or di·e·ti·cian
A person specializing in dietetics. 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.
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 adhere to
verb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful
2. 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 A-E, AE above-elbow; see under amputation. , where A is the most modified (e.g. puree pu·rée or pu·ree
tr.v. pu·réed or pu·reed, pu·rée·ing or pu·ree·ing, pu·rées or pu·rees
To rub through a strainer or process (food) in a blender.
n. ) 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 nu·mer·i·cal also nu·mer·ic
1. Of or relating to a number or series of numbers: numerical order.
2. Designating number or a number: a numerical symbol. from one (thinnest) to three (thickest). Again, without an accompanying descriptor (1) A word or phrase that identifies a document in an indexed information retrieval system.
(2) A category name used to identify data.
(operating system) descriptor , there is room for miscommunication mis·com·mu·ni·ca·tion
1. Lack of clear or adequate communication.
2. An unclear or inadequate communication. .
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 par·tic·u·late
Of or occurring in the form of fine particles.
A particulate substance.
composed of separate particles. foods that provided a choking Choking Definition
Choking is the inability to breathe because the trachea is blocked, constricted, or swollen shut.
Choking is a medical emergency. When a person is choking, air cannot reach the lungs. 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]
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 tertiary (tûr`shēârē), in the Roman Catholic Church, member of a third order. The third orders are chiefly supplements of the friars—Franciscans (the most numerous), Dominicans, and Carmelites. 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 1. locality - In sequential architectures programs tend to access data that has been accessed recently (temporal locality) or that is at an address near recently referenced data (spatial locality). This is the basis for the speed-up obtained with a cache memory.
2. of respondents are shown in Figures 1 and 2. A caseload case·load
The number of cases handled in a given period, as by an attorney or by a clinic or social services agency.
Noun 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 pudding. Early writers on cookery class puddings and dumplings together. The earliest puddings were boiled in a bag or cloth. Later they were placed in a buttered bowl, covered with a cloth, and steamed. The baked or chilled puddings evolved even later. ). 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 pre·scribe
v. pre·scribed, pre·scrib·ing, pre·scribes
1. To set down as a rule or guide; enjoin. See Synonyms at dictate.
2. To order the use of (a medicine or other treatment). , 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 mash
1. A fermentable starchy mixture from which alcohol or spirits can be distilled.
2. A mixture of ground grain and nutrients fed to livestock and fowl.
3. A soft pulpy mixture or mass.
4. , 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]
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 follow-up,
n the process of monitoring the progress of a patient after a period of active treatment.
follow-up plan questionnaire. A one-week time frame was provided for comment in order to meet the project timelines This article or section contains self-references.
For other uses of "Timeline", see Timeline (disambiguation).
The following is an index of timelines found on Wikipedia. . 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.
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 Adv. 1. in tandem - one behind the other; "ride tandem on a bicycle built for two"; "riding horses down the path in tandem"
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 dietetic /di·e·tet·ic/ (di?ah-tet´ik) pertaining to diet or proper food.
1. Of or relating to diet.
2. component and confuse con·fuse
v. con·fused, con·fus·ing, con·fus·es
a. To cause to be unable to think with clarity or act with intelligence or understanding; throw off.
b. people who might think they needed to approach medical staff for fluid changes. A numerical numerical
expressed in numbers, i.e. Arabic numerals of 0 to 9 inclusive.
a numerical code is used to indicate the words, or other alphabetical signals, intended. label was agreed upon Adj. 1. agreed upon - constituted or contracted by stipulation or agreement; "stipulatory obligations"
noncontroversial, uncontroversial - not likely to arouse controversy 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 Abnormality or deviation. Pronounced "uh-nom-uh-lee," it is a favorite word among computer people when complex systems produce output that is inexplicable. See software conflict and anomaly detection. 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 jelly /jel·ly/ (jel´e) a soft substance that is coherent, tremulous, and more or less translucent; generally, a colloidal semisolid mass. and ice-cream, medications and nutritional supplements Nutritional Supplements Definition
Nutritional supplements include vitamins, minerals, herbs, meal supplements, sports nutrition products, natural food supplements, and other related products used to boost the nutritional content of the diet. 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 adjunct (aj´ungkt),
n a drug or other substance that serves a supplemental purpose in therapy.
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 Allergies Definition
Allergies are abnormal reactions of the immune system that occur in response to otherwise harmless substances.
Allergies are among the most common of medical disorders. 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 con·fuse
v. con·fused, con·fus·ing, con·fus·es
a. To cause to be unable to think with clarity or act with intelligence or understanding; throw off.
b. , 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.
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).
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 mo·ti·vate
tr.v. mo·ti·vat·ed, mo·ti·vat·ing, mo·ti·vates
To provide with an incentive; move to action; impel.
mo 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 Continuum (pl. -tinua or -tinuums) can refer to:
Two food levels provoked pro·voke
tr.v. pro·voked, pro·vok·ing, pro·vokes
1. To incite to anger or resentment.
2. To stir to action or feeling.
3. To give rise to; evoke: provoke laughter. 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 The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. ; 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 pre·scribe
To give directions, either orally or in writing, for the preparation and administration of a remedy to be used in the treatment of a disease. 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 cubes
See QQQ. or less; 1.5 cm pieces broken with the flat edge of a fork (1) To split into a different direction. See forked version.
(2) In Unix, to make a copy of a process for execution.
(3) In the Macintosh file system, a fork is a top- level structure that separates data folders and files from other resources. See HFS. 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 trachea (trā`kēə) or windpipe, principal tube that carries air to and from the lungs. It is about 4 1-2 in. (11.4 cm) long and about 3-4 in. (1.9 cm) in diameter in the adult. if accidentally aspirated without lodging Lodging or holiday accommodation is a type of accommodation. People who travel and stay away from home for more than a day need lodging mainly for sleeping. Other purposes are safety, shelter from cold and rain, having a place to store luggage and being able to take a in it and occluding it. It is for this reason that a 1.5 x 1.5 cm bolus bolus /bo·lus/ (bo´lus)
1. a rounded mass of food or pharmaceutical preparation ready to swallow, or such a mass passing through the gastrointestinal tract.
2. a concentrated mass of pharmaceutical preparation, e. 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 morphology
In biology, the study of the size, shape, and structure of organisms in relation to some principle or generalization. Whereas anatomy describes the structure of organisms, morphology explains the shapes and arrangement of parts of organisms in terms of such , 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 de·note
tr.v. de·not·ed, de·not·ing, de·notes
1. To mark; indicate: a frown that denoted increasing impatience.
2. 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 sunscreen /sun·screen/ (-skren) a substance applied to the skin to protect it from the effects of the sun's rays.
n. SPF (1) (Stateful Packet Firewall) See stateful inspection.
(2) (Sender Policy Framework) An e-mail authentication system that verifies that the message came from an authorized mail server. (sun protection factor sun protection factor
n. Abbr. SPF
The ratio of the minimal ultraviolet dose required to produce erythema with and without a sunscreen; a measure of the degree to which a sunscreen protects the skin from ultraviolet radiation, the higher ) system provides a good analogy analogy, in biology, the similarities in function, but differences in evolutionary origin, of body structures in different organisms. For example, the wing of a bird is analogous to the wing of an insect, since both are used for flight. . 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 numeric
see ten-key pad. 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 Shear rate is a measure of the rate of shear deformation:
For the simple shear case, it is just a gradient of velocity in a flowing material. of [50.sup.s-1]. The details relating to relating to relate prep → concernant
relating to relate prep → bezüglich +gen, mit Bezug auf +acc temperature and shear rate are essential to replication In database management, the ability to keep distributed databases synchronized by routinely copying the entire database or subsets of the database to other servers in the network.
There are various replication methods. 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 cen·ti·poise
A unit in the centimeter-gram-second system that is of dynamic viscosity equal to one hundredth (10-2) of a poise. (cP) for manufacturers. However, it is possible to use the trends generated from the literature to provide a broad numerical scale See: 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 nomenclature /no·men·cla·ture/ (no´men-kla?cher) a classified system of names, as of anatomical structures, organisms, etc.
binomial 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 according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. 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 Thickening agents, or thickeners, are substances which, when added to a mixture, increase its viscosity without substantially modifying its other properties, such as taste. They provide body, increase stability, and improve suspending action. . 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 Infant formula is an artificial substitute for human breast milk. Formulas are designed for infant consumption, and are usually based on either cow milk or soy milk. Use of infant formula has been decreasing in industrial countries for over forty years as a result of antenatal , yet it is still able to pass through a fast flow teat teat (tet) nipple (1).
1. See nipple.
2. The female breast; mamma.
3. A papilla. . 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.
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 dissemination Medtalk The spread of a pernicious process–eg, CA, acute infection Oncology Metastasis, see there 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 This article or section contains .
The purpose of Wikipedia is to present facts, not to teach subject matter. 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 Adv. 1. most importantly - above and beyond all other consideration; "above all, you must be independent"
above all, most especially , the development of evidence-based guidelines guidelines,
n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. 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.
The Associations would like to formally acknowledge and thank the members of the advisory committee:
* Carman Car´man
n. 1. A man whose employment is to drive, or to convey goods in, a car or car. 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.
1 Martin AW. Dietary management Dietary Managers specialize in providing optimum nutritional care through foodservice management. They work in hospitals, long-term care, schools, correctional facilities, and other non-commercial foodservice settings. of swallowing disorders Swallowing Disorders Definition
Swallowing disorders include a number of diseases and conditions that cause difficulty in passing food or liquid from the mouth to the stomach. . Dysphagia 1991; 6: 129-34.
2 Pardoe EM. Development of a multistage mul·ti·stage
1. Functioning in more than one stage: a multistage design project.
2. Relating to or composed of two or more propulsion units. 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 Adj. 1. behavioural - of or relating to behavior; "behavioral sciences"
behavioral treatment for adults with oropharyngeal oropharyngeal /oro·pha·ryn·ge·al/ (-fah-rin´je-al)
1. pertaining to the mouth and pharynx.
2. pertaining to the oropharynx. 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 respiration, process by which an organism exchanges gases with its environment. The term now refers to the overall process by which oxygen is abstracted from air and is transported to the cells for the oxidation of organic molecules while carbon dioxide (CO and swallowing. In: Cichero J, Murdoch B, eds. Dysphagia: Foundation, Theory and Practice. Chichester, UK: John Wiley John Wiley may refer to:
9 Reimers-Neils L, Logemann J, Larson C. Viscosity effects on EMG EMG
A diagnostic test that records the electrical activity of muscles. 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 hum (hum) a low, steady, prolonged sound.
venous hum a continuous blowing, singing, or humming murmur heard on auscultation over the right jugular vein in the sitting or erect position; it is Nutr Diet 1998; 11: 51-60.
11 Coroner's Report of South Australia, Finding of Inquest inquest, in law, a body of men appointed by law to inquire into certain matters. The term also refers to the inquiry itself as well as to the findings of the inquiry. Maiolo G. 7 April 1997 and 8 May 1997, pp. 1-11.
12 National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization standardization
In industry, the development and application of standards that make it possible to manufacture a large volume of interchangeable parts. Standardization may focus on engineering standards, such as properties of materials, fits and tolerances, and drafting for Optimal Care. Chicago, IL: American Dietetic Association The American Dietetic Association (ADA) is the United States' largest organization of food and nutrition professionals, with nearly 65,000 members. Approximately 75 % of ADA's members are registered dietitians and about 4 % are dietetic technicians, registered. , 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 rhe·ol·o·gy
The study of the deformation and flow of matter.
rheo·log and material property characteristics of meal-time fluids and videofluoroscopy videofluoroscopy /vid·eo·flu·o·ros·co·py/ (-fldbobr-ros´kah-pe) the recording on videotape of the images appearing on a fluoroscopic screen. fluids. Dysphagia 2000; 15: 188-200.
15 Finestone HM, Greene-Finestone LS. Rehabilitation medicine rehabilitation medicine Physiatry, physiotherapy A field of therapeutics that bridges the gap between conventional and nonconventional medicine; rehabilitation physicians may adminsiter or prescribe mechanical–eg, massage, manipulation, exercise, movement, : 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 thick·en
tr. & intr.v. thick·ened, thick·en·ing, thick·ens
1. To make or become thick or thicker: Thicken the sauce with cornstarch. The crowd thickened near the doorway.
2. 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 Lang language
LANG Louisiana Army National Guard
Lang Langobardian (linguistics)
LANG Los Angeles Newspaper Guild Pathol 1997; 5: 203-15.
18 Goulding R, Bahkeit AMO AMO - America's Multimedia Online . 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 lingual /lin·gual/ (ling´gwal)
1. pertaining to or near the tongue.
2. in dental anatomy, facing the tongue or oral cavity.
1. 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 A rather long and fancy word for analyzing a system or process and measuring its "characteristics." For example, a Web characterization would yield the number of current sites on the Web, types of sites, annual growth, etc. 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 sensory /sen·so·ry/ (sen´sor-e) pertaining to sensation.
1. Of or relating to the senses or sensation.
2. 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 group dynamics: see group psychotherapy. : 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 moderator - A person, or small group of people, who manages a moderated mailing list or Usenet newsgroup. Moderators are responsible for determining which email submissions are passed on to the list or newsgroup. on response quantity and quality. J Market Res 1982; XIX: 1-13.
26 British Dietetic Association The British Dietetic Association (BDA) is a professional association and trade union for dieticians in the United Kingdom. It was founded in 1936 and is affiliated to the Trades Union Congress and the Scottish Trades Union Congress. External links
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 laryngeal /lar·yn·ge·al/ (lah-rin´je-al) pertaining to the larynx.
la·ryn·geal or la·ryn·gal
Of, relating to, affecting, or near the larynx. dimensions in unparalyzed, sedated children. Anesthesiology anesthesiology (ăn'ĭsthē'zēŏl`əjē), branch of medicine concerned primarily with procedures for rendering patients insensitive to pain, and for supporting life systems under the strains of anesthesia and surgery. 2003; 98: 41-5.
29 Mishellany A, Woda A, Labas R et al. The challenge of mastication mastication /mas·ti·ca·tion/ (mas?ti-ka´shun) chewing; the biting and grinding of food.
(mas´tikā´sh : preparing a bolus suitable for deglutition. Dysphagia 2006; 21 (2): 87-94.
30 Kohyama K, Mioche L, Martin J-L. Chewing chewing
Up-and-down and side-to-side movements of the lower jaw, using the teeth to grind food for easier swallowing. During chewing, the tongue shapes food into a lump and saliva lubricates it for swallowing. patterns of various texture foods studied by electromyography electromyography
Process of graphically recording the electrical activity of muscle, which normally generates an electric current only when contracting or when its nerve is stimulated. in young and elderly populations. J Texture Stud stud
2. a place, usually a farm, at which purebred animals are maintained and reproduced.
an animal registered in a stud book. 2002; 33: 269-83.
31 Diffey B. Has the sun protection factor had its day? BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift 2000; 320 (7228): 176-7.
32 Chi-Fishman G, Sonies B. Effects of systematic bolus viscosity and Volume changes on hyoid hyoid /hy·oid/ (hi´oid) shaped like Greek letter upsilon (?); pertaining to the hyoid bone.
1. Shaped like the letter U.
2. Of or relating to the hyoid bone. movement kinematics kinematics: see dynamics.
Branch of physics concerned with the geometrically possible motion of a body or system of bodies, without consideration of the forces involved. . 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 The University of Queensland (UQ) is the longest-established university in the state of Queensland, Australia, a member of Australia's Group of Eight, and the Sandstone Universities. It is also a founding member of the international Universitas 21 organisation. , 2006.
34 Logemann J, Gensler G, Robbins Rob·bins , Frederick Chapman 1916-2003.
American microbiologist. He shared a 1954 Nobel Prize for work on the cultivation of the polio virus. JA et al. Randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. study for two interventions for liquid aspiration. Protocol 201. American Speech and Hearing Association Conference, 17 November 2006; Miami Beach Miami Beach, city (1990 pop. 92,639), Dade co., SE Fla., on an island between Biscayne Bay and the Atlantic Ocean; inc. 1915. It is connected to Miami by four causeways. , FL, USA, 2006.
35 Hoebler C, Devaux M-F M-F Monday Through Friday , Karinthi A, Belleville C, Barry J-L. Particle size of solid food after human mastication and in vitro in vitro /in vi·tro/ (in ve´tro) [L.] within a glass; observable in a test tube; in an artificial environment.
In an artificial environment outside a living organism. simulation of oral breakdown. Int J Food Sci Nutr 2000; 51: 353-66.
36 Bren L. Prevent your child from choking. FDA FDA
Food and Drug Administration
n.pr See Food and Drug Administration.
n.pr the abbreviation for the Food and Drug Administration. 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 British Columbia, province (2001 pop. 3,907,738), 366,255 sq mi (948,600 sq km), including 6,976 sq mi (18,068 sq km) of water surface, W Canada. Geography
. J Otolaryngol 2004; 33: 37-41.
38 Mu L, Ping H, Sun D. Inhalation inhalation /in·ha·la·tion/ (in?hah-la´shun)
1. the drawing of air or other substances into the lungs.inhala´tional
2. the drawing of an aerosolized drug into the lungs with the breath.
3. of foreign bodies in Chinese children: a review of 400 cases. Laryngoscope la·ryn·go·scope
A tubular endoscope that is inserted through the mouth and into the larynx and that is used for examining the interior of the larynx.
la·ryn 1991; 101: 657-60.
39 Berzlanovich AM, Muhm M, Sim (1) (Society for Information Management, Chicago, IL, www.simnet.org) Founded in 1968 as the Society for MIS, it is a membership organization made up of corporate and division heads of IT organizations. 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 respiratory tract
The air passages from the nose to the pulmonary alveoli, including the pharynx, larynx, trachea, and bronchi.
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 United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. 2001. Morb Mortal mortal /mor·tal/ (mor´t'l)
1. subject to death, or destined to die.
1. Liable or subject to death.
2. Wkly Rep (programming) REP - A directive used in IBM object code card decks (and later PTF Tapes) to REPlace fragments of already assembled or compiled object code prior to link edit. 2002; 51: 945-8.
42 Rimmell F, Thome A, Stool S stool (stldbomacl) feces.
rice-water stools the watery diarrhea of cholera.
silver stool et al. Characteristics of objects that cause choking in children. JAMA JAMA
Journal of the American Medical Association 1995; 274: 1763-6.
43 Seidel sei·del
A beer mug.
[German, from Middle High German sdel, from Latin situla, bucket.]
Noun 1. JS, Gausche-Hill M. Lychee-flavoured gel candies. A potentially lethal lethal /le·thal/ (le´th'l) fatal.
1. Capable of causing death.
2. Of, relating to, or causing death.
deadly; fatal. snack for infants and children. Arch Pediatr Adolesc Med 2002; 156: 1120-22.
44 Carruth BR, Skinner Skin·ner , B(urrhus) F(rederick) 1904-1990.
American psychologist. A leading behaviorist, Skinner influenced the fields of psychology and education with his theories of stimulus-response behavior. JD. Feeding behaviour feeding behaviour
Any action of an animal directed toward obtaining nutrients. Each species evolves methods of searching for, obtaining, and ingesting food for which it can successfully compete. Some species eat only one type of food, others a variety. and other motor development in healthy children (2-24 months). J Am Coll Nutr 2002; 21: 88-96.
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 hydration /hy·dra·tion/ (hi-dra´shun) the absorption of or combination with water.
1. The addition of water to a chemical molecule without hydrolysis.
2. 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 Adj. 1. unmodified - not changed in form or character
unqualified - not limited or restricted; "an unqualified denial"
modified - changed in form or character; "their modified stand made the issue more acceptable"; "the performance of the modified aircraft 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 con·verse 1
intr.v. con·versed, con·vers·ing, con·vers·es
1. To engage in a spoken exchange of thoughts, ideas, or feelings; talk. See Synonyms at speak.
2. 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.
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 standardized
pertaining to data that have been submitted to standardization procedures.
standardized morbidity rate
see morbidity rate.
standardized mortality rate
see mortality rate. Terminology and Definitions for Texture Modified Foods and Fluids. Nutrition & Dietetics 2007; 64 (Suppl. 2): S53-S76.
Dietitians Association of Australia and The Speech Pathology Association of Australia Limited
Julie A.Y. Cichero, BA, BSpThy (Hons), PhD
(1) M. Atherton, BAppSc (SpPath), GradDip (Neuro)
(2) N. Bellis-Smith, BSc, GradDipDiet, GradDipHlthProm, APD APD atrial premature depolarization (see atrial premature complex, under complex ); pamidronate.
(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 In some countries, a Senior Advisor is an appointed position by the Head of State to advise on the highest levels of national and government policy. Sometimes a junior position to this is called a National Policy Advisor. Professional Issues), (2) Dietitians Association of Australia (Professional Services (job) professional services - A department of a supplier providing consultancy and programming manpower for the supplier's products. 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