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Thickened Drinks – What Are They, Why Are They Needed and How Do I to Make Them?
As a speech therapist, I have often been asked similar questions by family members of people newly diagnosed with swallowing difficulties. Most people have never heard of swallowing difficulties, let alone “concentrated drinks”. Difficulty swallowing (also known as “dysphagia”) is not common, but it can affect people of all ages. There are many known causes of dysphagia, but some of the more common ones are: stroke; cerebral palsy; Parkinson’s disease; head injury; surgery and radiation therapy due to 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 difficulty swallowing, chances are they’ve been prescribed “thickened drinks” or “thickened liquids.” Concentrated drinks are basically normal drinks that have had a specially formulated thickener added to them to make them thicker than regular drinks (this is discussed more later in the article). They are recommended by speech therapists (also known as speech therapists or speech pathologists) for people who can no longer safely swallow regular liquids and who are at risk of drinks entering their lungs. Drinks entering the lungs can result in severe coughing, choking or more serious risks such as chest infection and aspiration pneumonia. I recently worked with a lady who just four months ago was in the hospital with her third bout of aspiration pneumonia in less than 10 months. More than 12 months ago she was recommended concentrated drinks, but she still drank normal drinks at least once a day and small amounts of drinks went into her lungs. It was a problem not only because of the fluid in her lungs, but also because the naturally occurring bacteria in her mouth traveled with the fluid and into her lungs. Once this happens, it’s only a matter of time before the bacteria causes a chest infection known as aspiration pneumonia. Fortunately for this lady, she ended up following the advice and drinking only the concentrated drinks that were recommended to her. She hasn’t had a recurrence of aspiration pneumonia since!
So what’s so special about concentrated drinks? One of the reasons they work is because they move 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 mug and tells you to catch it in the bowl you are holding. You will try to react as quickly as you can, but there will likely be a delay between when they start pouring and when you move the bowl to catch the water. This short delay will likely mean that some of the water will hit the floor. Now imagine someone pouring a thickened drink from a mug like a thick cocktail. You’d probably catch a lot more of that liquid because the thick shake flows out of the cup more slowly, giving you more time to react. It’s similar to someone who has trouble swallowing drinking water versus a concentrated beverage. When they drink water, the muscles and nerves in the throat don’t work fast enough and some of the water can get into their lungs. But when they drink concentrated beverages, the liquid moves more slowly, and that gives their body more time to control and direct the liquid away from the lungs and into the stomach. This is one of the reasons why thickened liquids work. Because people with swallowing difficulties tend to have difficulty throughout the day, thickened liquids should replace regular drinks every day. This means that people with thickened fluids in most cases will not be able to drink normal drinks at all or until their speech therapist advises them otherwise. Therefore, when someone drinks concentrated beverages, they should try to drink as much as is needed to maintain normal hydration (1-2 liters).
Three levels of thickened liquids
When someone is diagnosed with difficulty swallowing, a speech pathologist will recommend one of three different levels of thickness. The recommended thickness level varies from person to person. It depends on the severity of the swallowing disorder in the person. Usually, the worse the swallowing disorder, the thicker the drink. Speech Pathology Australia and the Dietitian’s Association of Australia have recently collaborated to develop the Australian Standards for Texture Modified Foods and Liquids*. They developed the following names and descriptions for the three recognized thicknesses of concentrated beverages:
Level 150 – Moderately strong
This layer is the thinnest of all condensed liquids. It pours out of the cup quickly (but slower than regular liquids) and has a fast and steady flow. You can drink drinks of this thickness from a cup. Other names used to describe this thickness are: Level 1, Nectar Thick, Quarter Thick, Cream or Semi Thick.
Level 400 – Medium strong
This layer is the second densest of all condensed liquids. It’s similar to the thickness of a strong cocktail (but a thick cocktail gets thinner as it melts, so people still can’t drink thick cocktails at this thickness level!). Drinks of this thickness are poured slowly from the cup and have a slow flow rate. As it is thick, this drink is best taken with a spoon. Other names used to describe this thickness are: Level 2, Honey Thick, Half Thick or Thick.
Level 900 – Extremely Thick
This layer is the densest of all condensed liquids in the new thickness guidelines. Drinks of this thickness cannot be poured from the cup into the mouth, as they have very little flow. Drinks of this thickness are so thick that they hold their shape on a spoon, so the best method is to have them with a spoon. Other names used to describe this drink thickness are: Level 3, Pudding Thick, Full Thick, Mousse or Extra Thick.
How can I buy or make condensed liquids?
You have two options, you can buy pre-made thickened drinks or make your own thickened drinks with powdered thickener. Many people also use a combination of both – so they get the benefits of both.
Premixed condensed drinks
The first option is to purchase pre-mixed concentrated liquids. These are available in individual cups (sold individually or in cartons) or large bottles. Here are some benefits:
- they do not require preparation and are ready to drink,
- they do not need refrigeration until they are opened
- have a long shelf life (6+ months)
- you can be sure that the drinks have been prepared to the right thickness and are not too runny or too thick
These products are especially appealing to people who are elderly or disabled and are unable to make their own drinks or don’t have someone they can rely on to do it right every 1-2 days. The downside to prepackaged drinks is that they cost more than regular thickener powder, and some brands only make a limited number of flavors. In Australia we are lucky to have manufacturers with over 20 flavors on offer. However, if you are not based in Australia, you may need to search online to find products that suit you.
Make your own concentrated drinks
Alternatively, you can make thickened liquids using a specialized powdered thickener, which can come in small cans to large, economical boxes. These thickeners are specially developed for people with swallowing disorders. Thickeners such as cornmeal or Karicare are not recommended for thickening drinks. The reasons are as follows:
- it is difficult to get drinks to the right consistency with these products
- they often dramatically change the taste of the drinks they are added to
- it can be difficult to mix them completely
- Drinks can change consistency (thick or thin) over time or with changes in ambient temperature. This could result in the drink becoming thin or too thick or sticky and therefore not drinkable.
The advantage of using a specialist thickening powder is that it is cheaper and more economical than buying pre-mixed drinks and you can add it to any flavored drink you choose (including beer and wine!!). The disadvantage of using a powdered thickener is that many people, especially the elderly or disabled, may have difficulty mixing the drink to the correct level of consistency. If the drink is too liquid, it puts a person at risk of spilling the drink down the throat and then into the lungs. If the drink is too thick, it may not be palatable and a person may drink less of it and thus risk dehydration. Also, drinks that have been pre-mixed with a powdered thickener will only last a very short time in the fridge – usually 1-2 days.
A few final notes about thickening powder. Since not all powdered thickeners can be used to thicken hot beverages (and you think you’d like to thicken hot beverages like tea), be sure to look for this information when making your selection. Also, if you decide to buy a specialized thickening powder, you will find the recipes on the back of the container. They are quite easy to find and track. Each pack usually has three recipes describing how to prepare the drink for each of the three recommended levels of thickness. For example, if you are at level 150 – Slightly thick, the recipe may tell you to add 1 teaspoon of powder to 200 ml of liquid and then stir. Remember, if you’re not sure what level of thickness applies to you or a family member, don’t guess, it could be risky for the person drinking it – especially if the drink is too thin. Just ask your nutritionist or speech therapist.
As you can see, there are a few things to understand when using and making concentrated beverages, but you have several options and it’s just a matter of finding what works for you or your family member in terms of price, ease of use, and taste.
References: *Dietitian’s Association of Australia & The Speech Pathology Association of Australia Limited (2007). Textured foods and thickened liquids used for individuals with dysphagia: Australian standardized labels and definitions. Nutrition and dietetics64 (Suppl. 2): pp. 553-576
(c) Copyright – Katie Prendergast. All rights reserved worldwide.
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