As a speech pathologist, I was often asked questions like this by family members of people who had just been diagnosed with difficulty swallowing. Most people have never heard of swallowing difficulties, let alone ‘thick drinks’. Swallowing difficulties (also known as ‘dysphagia’) are not common, but they 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 fluids and why are they recommended?

If someone you know has been diagnosed with a difficulty swallowing, they may have been recommended “thick drinks” or “thickened liquids.” Thickened drinks are basically regular drinks that have had a special thickener added to make them thicker than regular drinks (discussed later in the article). They are recommended by speech pathologists (also known as speech therapists or speech-language therapists) for people who can no longer safely swallow normal liquids and who are at risk of drinks entering their lungs. The consequences of drinks getting into 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 episode of aspiration pneumonia in less than 10 months. She had been recommended thick drinks over 12 months ago, but she still drank normal drinks at least once a day and small amounts of the drinks went into her lungs. This was a problem, not only because of the fluid in her lungs, but because the natural bacteria in her mouth traveled with the fluid into her lungs. Once this occurs, it’s only a matter of time before the bacteria cause a chest infection known as aspiration pneumonia. Fortunately for this lady, she finally listened to her advice and only drank the thick drinks that were recommended. She hasn’t 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 collect it in a container that he is holding. You will try to respond as quickly as you can, but there will probably be a delay between the time they start pouring and the time you have moved the container to catch the water. This short delay will probably mean that some of the water falls to the ground. Now imagine someone serving a thick drink, like a thick milkshake, from a mug. You would probably drink a lot more of this liquid because the thick shake comes out of the cup slower and gives you more time to respond. This is similar to what happens when someone with difficulty swallowing drinks water instead of a thick drink. When they drink water, the muscles and nerves in the throat don’t act fast enough and some of the water can get into the lungs. But when they drink thick drinks, the fluid moves more slowly and this gives their body more time to control and direct the fluid away from the lungs and into the stomach. That’s one of the reasons thickened fluids work. As people with swallowing difficulties tend to have difficulty all day, every day, thickened liquids are meant to replace regular drinks. That means that people who have thick liquids in most cases will not be able to drink normal drinks at all or until told otherwise by their speech pathologists. Therefore, when someone drinks thick drinks, they should try to drink as much as is necessary to maintain normal hydration (1-2 liters).

The three levels of thickened fluids

When someone is diagnosed with difficulty swallowing, a speech pathologist will recommend one of three different thickness levels. The level of thickness that is recommended 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 Dietitian’s Association of Australia worked together to create the Australian Standards for Texture 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 fluids. It pours quickly from one cup (but slower than regular liquids) and has a fast, steady flow. You can drink drinks of this level of thickness in a cup. Other names used to describe this thickness are: Level 1, Nectar Thick, Quarter Thick, Cream or Semi Thick.

Level 400- Moderately Coarse

This level is the second thickest of all thickened fluids. It’s similar to the thickness of a thick shake (but a thick shake becomes thinner when melted, so people with this level of thickness still can’t drink thick shakes!). Drinks this thick are sipped slowly from a cup and have a slow flow. Since it is thick, the best way to drink this drink is with a spoon. Other names used to describe this thickness are: Level 2, Honey Thick, Medium Thick, or Thick.

Level 900- Extremely Thick

This level is the thickest of all thickened fluids in the new thickness guidelines. Drinks of this thickness cannot be poured from a cup to the mouth as they have a very small flow rate. Drinks this thick are thick enough to hold their shape on the spoon, so using a spoon to scoop them is the best method. Other names used to describe the thickness of this drink are: Level 3, Pudding Thick, Full Thick, Mousse, or Extra Thick.

How do I buy or make thickened fluids?

You have two options, you can buy pre-made thickened drinks or you can make your own thickened drinks using 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 fluids. They are available in individual glasses (sold individually or in boxes) or in large bottles. Here are some advantages:

• They require no 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 drinks have been made to the correct thickness and are not too runny or too thick

These products are particularly appealing to the elderly or people with disabilities who can’t make the drinks themselves or don’t have someone they trust to do it correctly, every 1-2 days. The downside to prepackaged drinks is that they cost more than plain thickening powder, and some brands make only a limited number of flavors. In Australia we are lucky 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 are best for you.

Make your own thick drinks

The second option is that you can make thickened fluids using a specialized powdered thickener that can come in small cans all the way up to large, inexpensive boxes. These thickeners are specially formulated for people with swallowing disorders. Thickeners such as cornmeal or Karicare are not recommended to thicken beverages. The reasons for this are:

• it is difficult to obtain drinks with the correct consistency with these products
• they often drastically change the taste of the drinks they are put into
• can be difficult to mix completely
• drinks can change in consistency (get thicker or thinner) over time or as ambient temperatures change. This could result in the drink becoming thin or too thick or sticky and therefore unfit to drink.

One benefit of using specialized thickening powder is that it’s cheaper and more affordable than buying pre-mixed drinks and you can add it to any flavored beverage of your choice (including beer and wine!). One downside to using a powdered thickener is that many people, especially the elderly or those with disabilities, may have difficulty mixing the drink to the correct level of thickness. If a drink is too liquid, the person is at risk of the drink spilling down the throat and then into the lungs. If the drink is too thick, it may not be palatable and the person will drink less and therefore risk dehydration. Also, drinks that have been pre-mixed with a powdered thickener only keep a very short time in the refrigerator, usually 1-2 days.

A few final points about thickening powder. Since not all powdered thickeners can be used to thicken hot drinks (and you think you might like to thicken hot drinks like tea), be sure to look for this information when making your selection. Also, if you decide to buy specialized thickening powder, you will find the recipes on the back of the packaging. 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 you’re at level 150, slightly thick, the recipe might tell you to add 1 teaspoon of powder to 200ml of liquid, then stir. Just remember, if you’re not sure which thickness level 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 thin. Ask your dietitian or speech therapist.

As you can see, there are a few things you need to understand about the use and preparation of thick drinks, however, you have several options and it’s just a matter of finding what works best for you or your family member in terms of price, ease of use and flavor.

References: *Australian Dietitians Association and The Speech Pathology Association of Australia Limited (2007). Texture modified foods and thickened liquids as used for people with dysphagia: Australian standardized labels and definitions. Nutrition and diet64 (Supplement 2): p553-576

(c) Copyright: Katie Prendergast. All rights reserved throughout the world.