Transitional Foods

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Transitional foods are a category of food formalized by the International Dysphagia Diet Standardisation Initiative (IDDSI) to describe foods that rapidly change texture in the presence of moisture or temperature change (Cichero et al., 2017). IDDSI was created in response to a need for global standardization of texture-modified foods and liquids to provide a common, international taxonomy in an effort to improve safety, reliability, and quality of all foods for individuals with dysphagia (swallowing disorders – visit www.asha.org to learn more). The final IDDSI framework (www.IDDSI.org) is composed of a food and liquid pyramid. The transitional foods category is represented by a bar spanning the side of the food pyramid demonstrating the dynamic nature of this category.

Given the special textural properties of these foods, minimal chewing is required, with tongue pressure often being sufficient to break the solid apart in the right environment. Transitional foods can be divided into two categories: solid foam or solid gel/liquid. Examples from each category are represented in Table 1 and Figure 1.

Table 1. Categories of transitional foods

Solid Foam	Solid Gel or Liquid
Savorease CrackersTM Baby Mum MumsTM Shrimp chips Cheeto PuffsTM Veggie StixTM The EAT BarTM Wafer cookies Shortbread	Ice chips Magic CupTM Ice cream Japanese dysphagia training jelly

Figure 1. Examples of transitional foods.

A. Savorease crackerTM;B Shortbread cookie cracker; C shrimp chip; D Japanese training jelly; E Magic CupTM; F ice cream.

Gel and liquid transitional foods tend to be more dependent on temperature than additional moisture to dissolve. Solid foams are stable at room temperature and tend to remain so with increased temperature, but transition more so in the presence of moisture than temperature.

History of use of transitional foods in children

Historically, transitional foods were used primarily to aid in the development of masticatory skills as toddlers advance from a puree to a solid diet. The ease of consumption poses an advantage for those with less mature or underdeveloped sensorimotor systems of mastication (Dovey et al., 2013; Gisel, 1991). Although adults with dysphagia have vastly different etiologies for their condition, the resultant benefits of transitional foods can be the same. However, the use of transitional foods in the adult population has been limited due to lack of ready-made options that are marketed to the adult and the psychosocial detriment for adults with dysphagia to be fed “baby food”.

Benefits of transitional foods

Both adults and children may benefit from the dissolvable nature of transitional foods. Solid foams in particular start as a regular solid (level 7) and dissolve to either a soft and bite sized (level 6), minced and moist (level 5), or puree (level 4) consistency. It is the final consistency that a transitional food dissolves to that determines the acceptability for those on a texture modified diet. For instance, if a person has restricted diet and can only eat foods that are a minced and moist consistency (level 5), then they likely could also include transitional foods into their diet that begin as a regular food and dissolve in the mouth to a level 5 or lower.

The benefits of transitional foods really lie in liberalization of the diet and increasing choices for the person with dysphagia. All transitional solid foods are finger foods which allows for self-feeding in many circumstances. The ability for an adult or child to grasp their own food and advance it to their mouths is part of the oral preparatory phase of swallowing, an important variable in obtaining an effective swallow. In addition, studies in food science show that physically touching food rather than using cutlery, makes the brain think it is tastier and more satisfying, even before it reaches the mouth (Madzharov, 2019), and can increase nutritional intake and quality of life for adults with cognitive impairment (Heelan et al., 2020). Finger foods have been studied in long term care in residents with dementia and have shown to improve food consumption and eating independence (Kimura et al., 2019; Pouyet et al., 2014; Soltesz and Dayton, 1995).

The potential psychosocial benefits of solid foam transitional foods can be inferred from research conducted on finger foods in the adult population and are listed in Table 2.

Table 2. Potential psychosocial benefits of solid foam transitional foods derived from literature on finger foods and snacking in adult populations

Benefit	Reference
Addresses texture boredom Well-being Person-centered care Eating independence Snacking and socialization	Duizer & Keller, 2014 Barratt et al, 2001 Reimer & Keller, 2009 Keller et al, 2007 Shune & Barewal (in preparation)

Studies Evaluating Safety of Transitional Foods

Two studies to date have evaluated transitional foods in the oral environment. Awadalla et al. (2018) examined 9 commercially available first finger foods, including Fruit and Veggie MeltsTM, Yogurt Melts TM, Apple Pick-Ups TM, Carrot Pick-UpsTM, Wagon WheelsTM, Lil’CrunchiesTM, Arrowroot CookiesTM, CheeriosTM, PuffsTM. These foods are marketed to parents of toddlers as rapidly melting in the mouth and can be considered transitional foods. The American Academy of Pediatrics recommends starting with finger foods that are easy to swallow, cut into small pieces, and soft. The study tested the dissolve rate of these foods in the adult mouth. The results of this study showed that there was significant variability in dissolution in the mouth with only a small proportion meeting all the safety criteria specified by the American Academy of Pediatrics. Of even greater concern was that leaving the foods exposed to air led to some test samples becoming as hard as candy.

The second study tested the behavior of transitional foods influenced by different “in-mouth” conditions (time, pressure, saliva) in older adults with and without dysphagia (Barewal et al., 2020). The transitional foods tested were Savorease crackers, Savorease crackers and dip, Baby MumMums, shrimp chips and the EAT bar. Thirty individuals ages 50 to 88 participated in this study (10 with diagnosed dry mouth, 8 with dysphagia). Each test food was placed in the mouth for 5 or 12 seconds with or without tongue pressure and then expectorated. A second benchtop preparation following the International Dysphagia Diet Standardisation Initiative (IDDSI) protocol was also completed on all sample types (Figure 1). An IDDSI fork pressure test was then performed on all samples. The results showed that the Savorease crackers with or without dip were the only test foods to pass the fork pressure test in all participants in 5 seconds with tongue pressure. Baby MumMum samples dissolved least frequently than all others. Moderate tongue pressure positively influenced the dissolution of the transitional foods. Interestingly, Baby MumMum, shrimp chips and the EAT bar performed better in the benchtop preparation than they did in the oral testing. Participants with dry mouth showed slower dissolution at 5 seconds compared to individuals without dry mouth, but there was no significant difference in dissolution by 12 seconds. Overall, there was a wide variability in degree and speed of dissolution across different transitional foods and testing methods. These findings support the need for individual testing of degree of dissolution with transitional foods, especially in slower to dissolve transitional foods, and in people with xerostomia. Figure 2. Transitional-state products prepared in 1.5 cm × 1.5 cm stimuli including: A Savorease cracker (savory flavor); B Savorease cracker with dip in cup, added just before oral conditioning (savory flavor); C shrimp chip (savory flavor); D Baby Mum Mum (sweet flavor); E Nutraphagia Eat Bar (sweet flavor)

Nutritional value

The typical puree diet contains almost 50% less protein than a regular diet (Miles, 2019; Vigano, 2011; Vucea, 2017). Recovery from illness, dysphagia, or poor motor skills can lead to eating fatigue. Plate waste is a serious concern in facility-based care and especially for those on a modified texture diet as it increases risks of malnutrition. This population specifically can benefit from increasing small meals or snacks throughout the day. Transitional foods have been known to offer improved texture but are often high in sugar or lack nutritive value. Savorease crackersTM has a unique nutritional profile as it is plant-based, and protein enhanced with no added sugars which seeks to optimize quality of caloric intake for older adults (Bayne et al., in preparation)

Method of testing of transitional foods

The IDDSI guidelines indicate that transitional foods are solids that when tested as a shape no greater than 1.5 cm × 1.5 cm will squash, disintegrate, or melt (i.e., no longer resembles its original shape) after soaking in one mL of water for one minute and given the application of approximately 17 kPa of fork pressure (IDDSI Framework, accessed 5 Feb, 2020) However such testing only accounts for the presence of one mL of water for an entire minute, which does not mimic saliva in enzymatic activity, oral quantities, and temperature nor typical oral preparation and transit times. Thus, it is likely of benefit to also test transitional foods with each individual patient as part of the assessment protocol.

To note, the 1.5 cm x 1.5 cm size restriction is only for the sample testing to allow for standard specification of food particle size relative to the 1mL amount of water that is used in the testing procedure. There is no size restriction for serving a transitional food item. The expectation would be that the particle size of the final state would be one of the characteristics that determine the texture level after transition. So, if the particles end up being between 4 mm and 1.5 cm in largest dimension after transition, then the lowest possible level to describe the food after transition would be Level 6 Soft and Bite-sized (provided that other characteristics of that level are also met). If the particles end up being smaller than 4 mm after transition, then Level 5 Minced and Moist may be the appropriate level to describe the state after transition, provided that the other characteristics of Level 5 are also met. For pediatric population, the specific pediatric particle size guidelines would need to be considered in defining the texture of the end-state after transition.

Suggested integration of use of transitional foods for adults and children for a speech and language therapist

Step 1: Incorporate transitional food samples into swallow assessments in these settings:

• bedside swallow evaluation
• feeding clinics swallow evaluation
• FEES (fiberoptic evaluation of swallowing)
• modified barium swallow test

Step 2: Determine if the patient can have transitional foods added to their texture recommendations, based, in part, on individual post-processing manipulation and safety with the transitioned texture

Step 3: Review recommendations with dietitian or caregiver and implement in nutritional plan during main meals, snack time or social activity time.

Step 4 (optional): Utilize transitional foods as part of rehabilitative therapy to work on chewing muscle coordination, self-feeding, and tongue coordination (tongue sweep, lateralization).

References

This article "Transitional Foods" is from Wikipedia. The list of its authors can be seen in its historical and/or the page Edithistory:Transitional Foods. Articles copied from Draft Namespace on Wikipedia could be seen on the Draft Namespace of Wikipedia and not main one.

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