As a speech pathologist, family members of people recently diagnosed with swallowing difficulty asked me questions like this. Most people have never heard of swallowing difficulties, much less “thick drinks.” Swallowing difficulties (also known as “dysphagia”) are not common, but can affect people of all ages. There are many known causes of dysphagia, but some of the most common are: stroke; cerebral palsy; Parkinson’s disease; Head trauma; surgery and radiation therapy as a result of head or neck cancer; and changes in the nerves and muscles of the throat that make swallowing difficult for the elderly.
What are thickened liquids and why are they recommended?
If someone you know has been diagnosed with swallowing difficulty, they have probably been recommended ‘thick drinks’ or ‘thickened liquids’. Thickened drinks are basically regular drinks that have a specially formulated thickener added to make them thicker than regular drinks (this is discussed later in the article). They are recommended by speech pathologists (also known as speech therapists or speech and language therapists) for people who can no longer safely swallow normal liquids and who are at risk of drinks getting into their lungs. The consequences of beverages reaching the lungs can be severe coughing, choking, or more serious risks such as a chest infection and aspiration pneumonia. I recently worked with a lady who, just four months earlier, had been in the hospital with her third attack of aspiration pneumonia in less than 10 months. He had been recommended thick drinks more than 12 months ago, but he still drank normal drinks at least once a day and small amounts of the drinks went to his lungs. This was a problem, not just because of the fluid in the lungs, but because the natural bacteria in his mouth traveled with the fluid into his lungs. Once this occurs, it is only a matter of time before the bacteria cause a chest infection known as aspiration pneumonia. Fortunately for this lady, she finally listened to the advice and only drank the thick drinks that were recommended to her. He has not had aspiration pneumonia since!
So what’s so special about thick drinks? One of the reasons they work is because they travel more slowly down the throat and are easier for a person to control when swallowing. To get a better idea, imagine this: someone starts pouring water from a cup and tells you to catch it in a container that you are holding. You will try to respond as quickly as you can, but there will probably be a delay between when they start pouring and when you have moved the container to collect the water. This short delay probably means that some of the water falls to the ground. Now imagine someone serving a thick drink, like a thick shake, from a cup. You will probably catch a lot more of this liquid because the thick shake flows more slowly out of the cup and gives you more time to respond. This is similar to what happens when someone with swallowing difficulties drinks water instead of a thick drink. When you drink water, your throat muscles and nerves do not work fast enough and some of the water can reach your lungs. But when they drink thick beverages, the liquid moves more slowly, giving your body more time to control and direct the liquid away from your lungs and into your stomach. That’s one of the reasons thickened liquids work. Since people with swallowing difficulties tend to struggle all day, every day, thickened liquids are meant to replace normal drinks. That means that people who have thickened fluids, in most cases, will not be able to drink normal drinks at all or until their speech pathologist indicates otherwise. Therefore, when someone drinks thick drinks, they would like to drink as much as is necessary to maintain normal hydration (1-2 liters).
The three levels of thickened liquids
When someone is diagnosed with swallowing difficulty, a speech pathologist will recommend one of three different thickness levels. The recommended thickness level varies from person to person. It depends on the severity of a person’s swallowing disorder. Generally, the worse the swallowing disorder, the thicker the drink. Recently, Speech Pathology Australia and the Australian Dietitians Association worked together to create the Australian Standards for Textured Modified Foods and Liquids *. They developed the following names and descriptions for the three recognized thicknesses of thickened beverages:
Level 150- Slightly thick
This level is the thinnest of all thickened liquids. It pours quickly from a cup (but slower than normal liquids) and has a fast, steady flow. You can drink drinks of this thickness level in a cup. Other names used to describe this thickness are: Level 1, Thick Nectar, Quarter Thick, Cream or Semi Thick.
Level 400- Moderately thick
This level is the second thickest of all thickened fluids. It is similar to the thickness of a thick shake (but a thick shake gets thinner when melted, so people at this thickness level still cannot drink thick shakes). Drinks this thick are sipped slowly from a cup and have a slow flow. As it is thick, the best way to take this drink is with a spoon. Other names used to describe this thickness are: Level 2, Honey Thick, Half Thick, or Thick.
Level 900- Extremely thick
This level is the thickest of all the thickened fluids in the new thickness guidelines. Drinks of this thickness cannot be poured from a cup into the mouth, as they have a very small flow rate. Drinks this thick are so thick that they hold their shape in the spoon, so using a spoon to drink them is the best method. Other names used to describe the thickness of this drink are: Level 3, Thick Pudding, Full Thick, Mousse, or Extra Thick.
How do I buy or make thickened liquids?
You have two options, you can buy pre-made thickened drinks or you can make your own thickened drinks with a powdered thickener. Many people also use a combination of both, so they get the benefits of both options.
Premixed thickened drinks
The first option is to buy pre-mixed thickened liquids. They are available in individual cups (sold individually or in cardboard boxes) or in large bottles. Here are some advantages:
- do not require preparation and are ready to drink,
- do not need refrigeration until opened
- have a long shelf life (more than 6 months)
- you can be sure that the drinks have been prepared to the correct thickness and are not too runny or too thick
These products are especially attractive to the elderly or disabled people who cannot prepare drinks themselves or do not have someone they can trust to do it correctly, every 1-2 days. The downside to prepackaged drinks is that they cost more than simple powdered thickener and some brands make only a limited number of flavors. In Australia, we are fortunate to have manufacturers that have over 20 flavors on their menu. However, if you are not based in Australia, you may need to search online to find the products that suit you best.
Make your own thickened drinks
The second option is that you can make thickened fluids using a specialized powdered thickener that can come in small cans to large inexpensive boxes. These thickeners are specially formulated for people with swallowing disorders. Thickeners such as cornmeal or Karicare are not recommended for thickening drinks. The reasons for this are:
- It is difficult to get beverages to the correct consistency with these products.
- often drastically change the taste of the drinks in which they are put
- can be difficult to mix thoroughly
- drinks can change consistency (become thicker or thinner) over time or when the surrounding temperature changes. This could make the drink thin or too thick or rubbery and therefore not suitable for drinking.
One benefit of using specialized thickening powders is that it is cheaper and cheaper than buying pre-mixed drinks, and you can add it to any flavored drink of your choice (including beer and wine!). One downside to using a powdered thickener is that many people, especially older people or those with disabilities, may have a hard time mixing the drink to the correct thickness level. If a drink is too liquid, the person runs the risk of the drink spilling down the throat and then reaching the lungs. If the drink is too thick, it may not be appetizing and a person may drink less and therefore risks dehydration. Also, drinks that have been pre-mixed with a powdered thickener only last a very short time in the refrigerator, usually 1 to 2 days.
Some final points on the powdered thickener. Since not all powdered thickeners can be used to thicken hot beverages (and you think you might like to thicken hot beverages like tea), be sure to look up this information when making your selection. Also, if you decide to purchase a specialized powder thickener, you will find the recipes on the back of the container. They are quite easy to find and follow. Each package typically has three recipes that describe how to prepare the drink for each of the three recommended thickness levels. For example, if it is at level 150: slightly thick, the recipe might tell you to add 1 teaspoon of powder to 200 ml of liquid and then stir. Just remember, if you’re not sure what level of thickness applies to you or your family member, don’t guess, it could be risky for the person drinking it, especially if the drink is too runny. Ask your dietitian or speech pathologist.
As you can see, there are a few things you need to understand about using and making thick drinks, however you have a number of options and it’s just a matter of finding what suits you or your family member in terms of price, ease of use and taste.
References: * Australian Dietitians Association and Australian Speech Pathology Association Limited (2007). Textured modified foods and thickened liquids used for people with dysphagia: Australian standardized labels and definitions. Nutrition and diet, 64 (Supplement 2): p553-576
(c) Copyright – Katie Prendergast. All rights reserved throughout the world.