Thickened drinks: what are they, why are they needed and how do I make them?

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 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 it difficult for the elderly to swallow.

What are thickened fluids and why are they recommended?

If someone you know has been diagnosed with a difficulty swallowing, it is likely that they have been recommended “thick drinks” or “thickened liquids”. Thickened drinks are basically regular drinks that have had a special thickener added to them 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 beverages entering their lungs. The consequences of beverages entering the lungs can be severe coughing, choking, or more serious risks such as 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 regular 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 to 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 he is holding. You’ll 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’ve moved the container to collect the water. This short delay will probably mean that some of the water falls to the ground. Now imagine someone pouring 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 more slowly 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 do not act fast enough, and some of the water can enter the lungs. But when you drink thick drinks, the liquid moves more slowly, giving your body more time to control and direct the liquid 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 people who have thick liquids will in most cases not be able to drink normal beverages at all or until told otherwise by their speech pathologists. Therefore, when someone drinks thick drinks, they should try to drink as much as necessary to maintain normal hydration (1-2 litres).

The three levels of thickened fluids

When someone is diagnosed with a 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 a cup (but slower than regular liquids) and has a fast, steady flow. You can drink beverages 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 milkshake (but a thick milkshake gets thinner when melted, so people with this level of thickness still can’t drink thick milkshakes!). Drinks of this thickness are sipped slowly from a cup and have a slow flow. Since 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 Coarse, Medium Coarse, or Coarse.

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 to the mouth as they have a very small flow rate. Drinks this thick are so thick that they hold their shape on the spoon, so using a spoon to sip 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 with a thickener powder. Many people also use a combination of both, so they get the benefits of both options.

Premixed thickened beverages

The first option is to buy premixed 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 the drinks have been made to the correct thickness and are neither too runny nor too thick

These products are particularly appealing to people who are elderly or have disabilities who can’t make drinks themselves, or don’t have someone they trust to make them correctly, every 1-2 days. The downside to pre-packaged 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 more than 20 flavors on their menu. However, if you do not reside in Australia, you may need to search online to find the products that suit you best.

Make your own thick drinks

The second option is that you can make thickened fluids using a specialized powder 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 for thickening beverages. The reasons for this are:

• it is difficult to obtain drinks with the correct consistency with these products
• they often drastically change the flavor of the drinks they are put into
• can be difficult to mix completely
• beverages can change in consistency (become thicker or thinner) over time or as the ambient temperature changes. This could result in the drink being watered down or becoming too thick or sticky and therefore unsuitable for drinking.

One benefit of using specialty thickening powder is that it’s cheaper and more affordable than buying pre-mixed beverages and you can add it to any flavored beverage of your choice (including beer and wine!). One drawback to using a powder thickener is that many people, especially the elderly or those with disabilities, may have difficulty mixing the drink to the correct thickness level. 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 becoming dehydrated. Also, beverages that have been premixed with a powder thickener only last a very short time in the refrigerator, usually 1-2 days.

Some final points about the thickening powder. 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 specialty thickening powder, you will find the recipes on the back of the pack. 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 are at level 150, slightly thick, the recipe might tell you to add 1 teaspoon of powder to 200 ml of liquid, 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 watery. 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 (Suppl. 2): p553-576

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