by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
Why do I need thickened liquids?
Your Speech-Language Pathologist may have recommended thickened liquids to make swallowing liquids safer. It is great to ask questions, such as: “Why and for how long will I need to thicken my liquids?”
Here are two common reasons why thickened liquids might be safer for some people:
- Thin liquids move fast and can spill out of the mouth and into the throat before you are ready to swallow. Thickening a liquid can slow down the flow of the liquid, especially if you have a delayed swallow.
- Thin liquids are unpredictable and difficult to control in the mouth and throat. Thickening a liquid can keep the sip of liquid together in one ball (also known as a bolus). This is especially helpful if you have decreased airway closure and thin liquid splashes or falls into your airway before, during or after the swallow.
Your medical team wants to prevent liquids from entering your airway and dropping into your lungs (also known as aspiration). This can lead to coughing, discomfort, congestion, shortness of breath during and after meals, and aspiration pneumonia. Some people sense liquids getting into their airway as an irritation, a burning sensation or a tickle in the throat. Others do not feel or react to liquids getting down the wrong way. This is called silent aspiration, and it is quite common in older adults who are medically compromised.
Be an active member of your medical team
Based on the speech-language pathologist’s recommendation, your doctor will order the liquid that is most appropriate for your safety. However, you should have a discussion with your medical team to fully understand the risks and benefits of a thickened liquid versus thin/regular liquids. Thickening liquid can certainly have a big impact on your liquid intake as well as your quality of life.
You may feel better about drinking a thickened liquid if you are active in the decision-making process. Consider this decision in relation to your medical goals and life goals. Your speech-language pathologist and doctor want to help you meet your goals.
What are the levels of thickness?
Keep in mind thicker is not always better or safer. Your speech-language pathologist has selected the least restrictive or thinnest liquid that still provides safety.
In the USA, the old classification system was the National Dysphagia Diet (NDD). The NDD labeled thickened liquids into three levels (in order from thinner to thicker):
1. First level is Nectar thick liquid: about the same consistency of an eggnog or fruit nectar. The liquid is mildly thick so that it coats the glass and beads on the end of a fork.
2. Second level is Honey thick liquid: looks like fresh honey pouring off a spoon. The spoon should stand up in the glass; however, you should be still able to drink this moderately thick liquid out of a glass.
3. Third level is Spoon-thick/Pudding thick liquid. This requires “drinking” the extremely thick liquid with a spoon.
There is a lot of variability in liquid consistencies across products. There is also a lot of variability internationally in these labels. The International Dysphagia Diet Standardisation Initiative (www.IDDSI.org) created a new standardization for thickened liquids. Standardization is needed. In fact, IDDSI found that globally there were 27 different labels to describe liquids!
IDDSI has expanded the liquids to 5 levels, with thin liquid as level 0.
- Slightly Thick: an added level thinner than the NDD Nectar thick. Similar to V8 juice and breastmilk!
- Mildly Thick (aka, the NDD Nectar thick liquid)
- Moderately Thick (aka, Honey thick)
- Extremely Thick (aka, Pudding thick)
Please see the IDDSI Flow Test to check liquids in your own home for their thickness accuracy. You may think that your Ensure is a thickened liquid, but it really tests as only a thin liquid (level 0). Click here to see how to do the Flow Test. You will need a 10ml Slip Tip Syringe. Your medical team could send you home with one.
How do I get thickened liquids?
In order to obtain thickener powders and pre-thickened liquids from your pharmacy, you will need a prescription from your doctor. A doctor’s order was also necessary at the hospital, your skilled nursing facility, or your rehabilitation center.
You will have to purchase a thickener powder or a thickener gel to make your own thickened liquids. Alternatively, you can buy pre-thickened liquid juice, water and milk containers.
What should I do if I don’t like the taste?
- Try many products. The newer generation of thickened liquid powders and gels use xanthan gum to prevent mouth drying, taste-changing and clouding of the liquid. See my product review page.
- Because the thickener powder can take the taste out of milk, try adding a few drops of Vanilla extract to bring back the flavor.
- If you are on a Mildly Thick/Nectar Thick liquid: you can find smoothies that are already nectar-thick in the supermarket with brands like Odwalla (Juice and Protein Smoothies) and Goya (Mango Nectar Juice). I’m not getting any financial kick-backs. Please double check the consistencies with your healthcare provider, like your Speech-Language Pathologist. Test them out using the IDDSI Flow Test.
- If you are on Mildly Thick/Nectar thick or Moderately Thick/Honey Thick liquid: the best way to make tasty and naturally thick smoothies is to use a blender. A banana, smooth yogurt or an avocado can be used as “thickening agents.” You can add all sorts of fruits, protein powders, supplements (i.e., Carnation Instant Breakfast, Ensure, Boost) in the blender to improve the taste and caloric content. Check with your dietitian and doctor about which supplements or protein powders may be good for you. If you have kidney problems, are on dialysis, and/or have diabetes, this is especially important.
Check out this pdf of recipe ideas to make: High Calorie Nutritious Smoothie.
Ice cream and milk alone in a blender make only a thin-liquid frappe, as ice cream melts in our mouth to turn into a thin liquid. You will need to add a thickening agent like thickener powder, banana, or yogurt.
Please check with your Speech-Language Pathologist as you make and drink the smoothie or frappe to make sure it is the right consistency. Making smoothies is not a standardized process. Be sure to check test your smoothie with the flow test when the drink is cold and at room temperature. Believe it or not, the thickness can change depending on the temperature! Smoothies do not maintain a stable thickness over time and may thin out in the mouth and throat. However, if you or your loved one is refusing thickened liquids, then sometimes a homemade blender drink is more palatable. Additionally, thickener products on the market also do not always reach or maintain standard levels of thickness either. More research is needed in this area. See previous blog on Diet Safety.
Product Reviews and Discounts:
Final cautions on thickened liquids:
If you have been prescribed thickened liquids, this means all liquids you drink should be thickened. Even soups and hot cereals should also be served thick. Many soups are naturally thick, e.g., potato leek, broccoli cheddar, cream of mushroom. However, soups with thin broth are especially challenging. Your Speech-Language Pathologist may have recommended to avoid soups that are a mixed consistency (i.e., broth soups with chunks of meat, vegetables, rice, and/or pasta). The broth liquid can spill to your throat and airway while you are chewing of the solid food. Other examples of mixed consistencies are: cold cereal with milk, fruit cocktail with liquid, and juicy fruits (orange, watermelon).
If you are having any difficulty with liquids, please see your primary care doctor and request a referral for a full evaluation by a Speech-Language Pathologist who specializes in swallowing and swallowing disorders. AGAIN, thicker liquid is not always safer. Your specialist can help you.
It is equally important to be re-evaluated in the future to make sure you still need thickened liquids. Ask your Speech-Language Pathologist if you would be a good candidate for having regular water between meals (free water protocol). This may help you as you struggle to maintain your hydration.