APPLICATIONS IN CONTRAST IMAGING 5 fined by a viscosity range: Thin Liquid (<15 centipoise [cps]), Nectar (<150- 450 cps), Thin Honey (800-1800 cps), Honey (2500-3500 cps), and Pudding (puree). Varibar was scientifically for- mulated to evaluate oropharyngeal swallowing physiology under fluoros- copy, and these formulations represent consistencies known to affect swal- lowing physiology. Unlike other bar- ium sulfate contrast agents formulated to maximize the mucosal coating re- quired for standard gastrointestinal (GI) imaging studies, 20 Varibar products are formulated to possess minimal coating properties, in order to facilitate clear vi- sualization of the dynamic swallowing process. 21,22 Moreover, the 40% weight/ volume (w/v) concentration provides uniform opacification across all consis- tencies, ensuring optimal image qual- ity. 23 Off-label mixing of other barium sulfate products with foods and liquids is not recommended, as it is associated with increased risk if aspirated, and in- volves risks of contamination from a food safety perspective. In addition, it would be very difficult to replicate the standardized consistencies and barium concentration of Varibar in one’s own clinical practice through implemen- tation of individualized barium-based recipes. The Modified Barium Swallow Impairment Profile (MBSImP) involves assessment of 17 components of the swallowing mechanism in adults, and includes a scoring metric to objectively profile physiologic impairment of swal- lowing function. 24 (Table 1) The MBS- ImP provides a standardized protocol to interpret and communicate MBSS results in an evidence-based manner that is consistent, specific, accurate, and objective. 19 Although research shows that certain swallowing tasks have high probabilities for identifying specific ex- treme impairment (e.g., large-volume, thin-liquid swallowing for oral contain- ment and airway protection, or cookie swallowing for physiological compo- nents of oral clearance), it is recom- mended that multiple swallowing tasks be performed during an MBSS. 9 The MBSImP protocol was and continues to be validated using Varibar, 9,16,23 and MBSImP reports contain reference to the Varibar consistencies used for each swallowing task to evaluate primary components of swallowing physiol- ogy. Many resources, including training courses and a large case registry, are available on the website https://www. mbsimp.com/. The IDDSI Framework Historically, a number of countries have attempted to develop dysphagia diet standards; however, not surpris- ingly, these standards have used dif- ferent terminology, labels, values, and levels, creating potential confusion for health professionals and researchers, as well as individuals and caregivers. 18 Without international standards, indi- viduals may find that their modified texture diet is called something com- pletely different as they move among hospitals, rehabilitation facilities, and countries. In 2002, the American Di- etetic Association (now the Academy of Nutrition and Dietetics) created the National Dysphagia Diet (NDD). 25 The NDD specified different diets contain- ing items that were appropriate for patients with swallowing disorders. Although the NDD was based on con- sensus among dietitians, SLPs, and food scientists, the NDD classified food and drinks based on a subjective compar- ison of their textural properties to certain “anchor” foods and, therefore, each patient, caregiver, or healthcare provider could potentially interpret the levels differently. In 2013, the IDDSI Task Force con- vened with the goal of developing in- ternational standardized terminology, descriptors, and testing methods for foods and liquids. The outcome was the creation of the IDDSI Framework. 18 (Figure 1) This framework consists of 8 levels: drinks span Levels 0–4, while foods span Levels 3–7. Armed with an understanding of the swallowing phys- iology, clinicians can use this frame- work to build a diet that meets patients’ needs across all ages, care settings, and cultures. In addition to the IDDSI frame- work, the committee developed sim- ple, objective, reliable, and accessible methods to test and classify any food or drink: the IDDSI Flow Test, the IDDSI Fork Drip Test, the IDDSI Spoon Tilt Test, the IDDSI Fork Test, the IDDSI Fork Pressure Test, and the IDDSI Fork Separation Test. 26,27 Depending on the expected framework level, several tests may be required to confirm the prop- erties of a particular food or drink; in- deed, several IDDSI testing methods are mandatory for some levels. 26,27 The IDDSI level of drinks is as- sessed using the IDDSI Flow Test, in which 10 mL of liquid is placed in a standard 10 mL syringe with the clini- cian’s finger placed over the bottom of the syringe.The finger is then removed and the liquid permitted to flow out the bottom for 10 seconds, timed using Table 1. MBSImP Components 24 Oral Impairment Domain 1. Lip Closure 2. Tongue Control During Bolus Hold 3. Bolus Preparation/Mastication 4. Bolus Transport/Lingual Motion 5. Oral Residue 6. Initiation of the Pharyngeal Swallow Pharyngeal Impairment Domain 7. Soft Palate Elevation 8. Laryngeal Elevation 9. Anterior Hyoid Excursion 10. Epiglottic Movement 11. Laryngeal Vestibular Closure 12. Pharyngeal Stripping Wave 13. Pharyngeal Contraction 14. Pharyngoesophageal Segment Opening 15. Tongue Base Retraction 16. Pharyngeal Residue Esophageal Impairment Domain 17. Esophageal Clearance (upright position)