Co-author: Angela Van-Sickle, Ph.D., CCC-SLP

The Current State of Practice

Altering diets in patients with dysphagia is a common practice in speech-language pathology (Garcia, Chambers, & Molander, 2005; Steele et al., 2015). One study examining the use of thickened liquids in skilled nursing facilities found a mean of 8.3%  (range 0% to 28%) of residents received  some type of thickened liquids: 60% received nectar thick liquids, 33% received honey thick liquids, and 6% received pudding thick liquids (Castellanos, Butler, Gluch, & Burke, 2004). Therapists often report clinical benefits of altered liquids and diets (Castellanos et al., 2004).  Reduced coughing, decreased meal times, and decreased choking episodes may be benefits of modified diets. This, in turn, may improve the quality of life for many who experience swallowing problems. A recently published article, Things We Do for No Reason: The Use of Thickened Liquids in Treating Hospitalized Adult Patients with Dysphagia (Lippert, 2019), created a stir.  Although the article presents complex concepts in simple terms, examination of current practices is always of benefit. We must realize there are potential negative effects of diet modifications. In our zeal to keep patients “safe” from aspiration and possible pneumonia, it is important for speech-language pathologists to consider all the potential outcomes. 

Recent Research

In recent years three systematic reviews concerning texture modifications and thickened liquids have been performed (Andersen, Beck, Kjaersgaard,  Hansen, 2013; Beck, Kjaersgaard, Hansen, & Poulsen, 2018; Steele et al., 2015). Andersen et al.  (2013) examined the evidence related to diet/liquid modifications and aspiration pneumonia and the impacts on nutrition and hydration. The authors initially planned to include randomized controlled trials (RCT), systematic reviews, and meta-analyses. However, due to a limited number of studies, cohort studies also were included. Ultimately, the review included sixteen studies.  The authors concluded although there is evidence that thickened liquids can stop immediate aspiration, there is no high level evidence to indicate the use of thickened fluids prevents aspiration pneumonia in chronic dysphagia. The investigators did not find enough evidence to make recommendations concerning modified food. It is interesting to note that the authors suggested the use of modified solids “is justified,” despite the lack of confirmation. 

In preparation for developing common terminology for liquid and food modification, The International Dysphagia Diet Standardization Initiative (IDDSI) team, led by Dr. Catriona Steele, examined available evidence in 2015. Steele et al. (2015) investigated the impact of altering diets on physiology and function. This group performed full text reviews of 488 articles and found 36 that met their inclusion criteria. That is, the articles contained specific information comparing oral processing or swallowing behaviors for at least two liquid consistencies or food textures. The group found two trends concerning the impact of thickening liquids on the physiology and function of the swallow. First, similar to Andersen et al. (2013), thicker liquids may reduce immediate penetration and aspiration. Second, thickened liquids may increase post swallow residue. The authors described the sparse amount of research available concerning modification of solids as “disappointing.” 

Finally, the most recent systematic review (Beck et al., 2018) asked the same questions as Andersen et al. (2013) using two RCTs, and offered little more than the other two. As for texture-modified foods, the conclusion was “no literature was identified that addressed the effects of using texture-modified food consistencies as a compensatory strategy to facilitate safe and efficient intake of foods.” As for nectar-thickened and honey-thickened liquids, the risk-benefit ratio was “uncertain.” They identified no literature, meeting their inclusion criteria, to show the effects of “moderately thick or extremely thick” levels of liquid on swallowing. 

The Possible Consequences

In addition to the systematic reviews concerning the current evidence for the benefits of modified diets, there is also literature concerning possible side effects or potential negative outcomes. Thickening liquids can lead to a plethora of issues. Among them is a decreased feeling of satiety leading to dehydration. Thickened liquids may cause a feeling of “fullness” and the associated flavor suppression provides little motivation to drink. In addition, research has shown that the dissolution and disintegration of medications can be negatively impacted (Cichero, 2013). Other possible side effects include dehydration (Sura, Madhavan, Carnaby, & Crary, 2012), increased reflux, slow gastric emptying, constipation (Gosa, Schooling, Coleman, 2011), increased confusion (Wittbrodt & Millard-Stafford, 2018), and decreased ability to participate in exercise programs (Maughan, 2003). Dehydration, which is the number one side effect of thickened liquid,  leads to a number of issues including urinary tract infections, hypotension, and delirium (Bennett, 2000) as well as poor recovery, increased complications and mortality in stroke patients (Bahouth, Gaddis, Hillis, & Gottesman, 2018; Rowat, Graham, & Dennis, 2012).

Modifying solid foods also comes with caveats. Altered diets contain less nutrients than regular diets  (Vigano, 2011). When compared with a regular diet, a pureed diet contains 31.4% less calories, 45.4% less protein, and 41% less lipids. One study  (Wright, Cotter, Hickson, & Frost, 2005) evaluated dietary intake over the course of a day in hospitalized patients older than 60 years. They compared intake in patients consuming a regular diet to those consuming a texture-modified diet. Patients on the modified diet had significantly lower nutritional intake in terms of energy and protein. A nutritional supplement was recommended for 54% of patients on a texture-modified diet, compared with 24% of patients on a regular diet. This data suggests altering solid foods may contribute to malnutrition. Malnutrition affects the function and recovery of every organ system and specially decreases the immune system (Saunders & Smith, 2010).

Finally, altering liquids and solids has an impact on quality of life (QoL). A systematic review of the literature concerning the impact of modified diets on the quality of life determined that increased bolus modification was associated with decreased QoL measures among populations with dysphagia (Swan, Speyer, Heijnen, Wagg, & Cordier, 2015). (McCurtin, A., Healy, C., Kelly, L., Murphy, F., Ryan, J., Walsh, J. 2018) also noted an increased burden on patients due to cost, undesirable taste, and time. 

Facilitating Change

Although diet modification has been and continues to be a mainstay for speech-language pathologists who treat swallowing, there is little to support its use. It is unlikely that this will change any time soon. However, it is important that clinicians consider other treatment approaches including postural techniques, carbonation, and water protocols ((McCurtin, 2018). In addition, it is imperative for therapists to present a realistic view of the evidence concerning the risks and benefits of modified diets to allow a patient to make a true informed decision (Horner, Modayil, Chapman, & Dinh, 2016). 

References

Andersen, U., Beck, A., Kjaersgaard, A., Hansen. (2013). Systematic review and evidence based recommendations on texture modified foods and thickened fluids for adults (>18 years) with oropharyngeal dysphagia. European Society for Clinical Nutrition and Metabolism, 8(4), e127-e134. 

Bahouth, M. N., Gaddis, A., Hillis, A. E., & Gottesman, R. F. (2018). Pilot study of volume contracted state and hospital outcome after stroke. Neurol Clin Pract, 8(1), 21-26. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29517060. doi:10.1212/CPJ.0000000000000419

Beck, A. M., Kjaersgaard, A., Hansen, T., & Poulsen, I. (2018). Systematic review and evidence based recommendations on texture modified foods and thickened liquids for adults (above 17 years) with oropharyngeal dysphagia – An updated clinical guideline. Clin Nutr, 37(6 Pt A), 1980-1991. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28939270. doi:10.1016/j.clnu.2017.09.002

Bennett, J. A. (2000). Dehydration: hazards and benefits. Geriatr Nurs, 21(2), 84-88. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/10769332. doi:10.1067/mgn.2000.107135

Castellanos, V. H., Butler, E., Gluch, L., & Burke, B. (2004). Use of thickened liquids in skilled nursing facilities. J Am Diet Assoc, 104(8), 1222-1226. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15281038. doi:10.1016/j.jada.2004.05.203

Cichero, J. A. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutr J, 12, 54. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23634758. doi:10.1186/1475-2891-12-54

Garcia, J. M., Chambers, E., & Molander, M. (2005). Thickened liquids: practice patterns of speech-language pathologists. Am J Speech Lang Pathol, 14(1), 4-13. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15962843

Gosa, M., Schooling, T., Coleman, J. (2011). Thickened Liquids as a Treatment for Children With Dysphagia and Associated Adverse Effects A Systematic Review. Infant, Child, & Adult Nutrition, 3(6), 344-350. 

Horner, J., Modayil, M., Chapman, L. R., & Dinh, A. (2016). Consent, Refusal, and Waivers in Patient-Centered Dysphagia Care: Using Law, Ethics, and Evidence to Guide Clinical Practice. Am J Speech Lang Pathol, 25(4), 453-469. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27820871. doi:10.1044/2016_AJSLP-15-0041

Lippert, W., Chadha, R., Sweigart. J. (2019). Things we do for no reason: The use of thickened liquids in treating hospitalized adult patients with dysphagia. Journal of Hospital Mediccine, 14(5), 315-317. 

Maughan, R. J. (2003). Impact of mild dehydration on wellness and on exercise performance. Eur J Clin Nutr, 57 Suppl 2, S19-23. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/14681709. doi:10.1038/sj.ejcn.1601897

McCurtin, A., Healy, C., Kelly, L., Murphy, F., Ryan, J., Walsh, J. (2018). Plugging the pateint evidence gap: what patients with swallowing disorders post-stroke say about thickened liquids. International Journal of Language & Communicaiton Disorders, 53(1), 30-39. 

Rowat, A., Graham, C., & Dennis, M. (2012). Dehydration in hospital-admitted stroke patients: detection, frequency, and association. Stroke, 43(3), 857-859. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22156691. doi:10.1161/STROKEAHA.111.640821

Saunders, J., & Smith, T. (2010). Malnutrition: causes and consequences. Clin Med (Lond), 10(6), 624-627. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21413492

Steele, C. M., Alsanei, W. A., Ayanikalath, S., Barbon, C. E., Chen, J., Cichero, J. A., . . . Wang, H. (2015). The influence of food texture and liquid consistency modification on swallowing physiology and function: a systematic review. Dysphagia, 30(1), 2-26. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25343878. doi:10.1007/s00455-014-9578-x

Sura, L., Madhavan, A., Carnaby, G., & Crary, M. A. (2012). Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging, 7, 287-298. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22956864. doi:10.2147/CIA.S23404

Swan, K., Speyer, R., Heijnen, B. J., Wagg, B., & Cordier, R. (2015). Living with oropharyngeal dysphagia: effects of bolus modification on health-related quality of life–a systematic review. Qual Life Res, 24(10), 2447-2456. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25869989. doi:10.1007/s11136-015-0990-y

Vigano, C., Silva, P., Cremonezi, J., Vannucchi, P., Guilhereme, C. (2011). Variation in the energy and macronutrient contents of texture modified hospital diets. Revista Chilena de Nutricion, 38(4), 451-457. 

Wittbrodt, M. T., & Millard-Stafford, M. (2018). Dehydration Impairs Cognitive Performance: A Meta-analysis. Med Sci Sports Exerc, 50(11), 2360-2368. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29933347. doi:10.1249/MSS.0000000000001682

Wright, L., Cotter, D., Hickson, M., & Frost, G. (2005). Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. J Hum Nutr Diet, 18(3), 213-219. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15882384. doi:10.1111/j.1365-277X.2005.00605.x


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Ed Bice, M.Ed., CCC-SLP
Ed Bice, M.Ed., CCC-SLP is a Speech-Language Pathologist currently in the role of Clinical Program Consultant for ACP’s Synchrony dysphagia program. Ed has worked in the health care industry with extensive training in dysphagia. His experience includes a variety of settings; acute care, outpatient, home health and skilled nursing. In addition to his clinical experience, Ed has held various leadership positions. He has worked as a Regional Manager, Vice President of Clinical Services, and Chief Operating Officer. He has been an invited speaker for universities, as well as national and state conventions. Angela Van Sickle, Ph.D., CCC-SLP is an assistant professor at Texas Tech University Health Sciences Center. She is the instructor for Dysphagia, Voice/Voice Disorders, and Special Topics in Speech-Language Pathology. She also supervises students in the university clinic. Her research interests include swallowing and swallowing disorders, pedagogy related to swallowing and swallowing disorders, acquired apraxia of speech, and transgender voice.

9 COMMENTS

  1. “However, it is important that clinicians consider other treatment approaches including postural techniques, carbonation, and water protocols (McCurtin, 2018).”

    Can you explain the use of carbonation in dysphagia practice?

  2. Ah, yes. This debate has been going on for a while now, in its particularly un-nuanced way. What we all should do, of course, is to give our oropharyngeal dysphagia patients beef and cola and expect no ill effects whatever the underlying pathology or specific pathomechanism of their swallowing problem.

    Seriously, though – taking a critical look at our practice is always a good ting. However, throwing the baby out with the bath water invariably isn’t. As any true clinician will know, patients that are given a consistent and well-optimized diet to suit their particular swallowing issue are few and far between. Few institutions have a range of clearly defined diet textures. Terms like “honey” and “nectar” are bandied about as if they actually mean similar things to different people. I dare you to compare the “honey” texture of one health professional to the next. This is the problem IDDSI seeks to address by clearly defining textures in practical terms, and in a sufficient number of levels as to enable people to tailor food to the needs of the individual patient within a resonable error margin.

    The only common, voluntary, natural response to swallow difficulties is texture modification. As any clinician knows, often patients will have modified their diets all by themselves long before they ever encounter an SLP, and often, the voluntary modifications work well if e.g. observed on FEES. Swallow maneuvers – well, there are no studies thus far that have shown any tendency by patients to adhere to them once the SLP has turned her back to them. It’s just not natural the way texture modification is. Carbonated drinks – well, that’s even less researched and the research that there is shows a minimal effect if any at all. Frazier free water protocol? Well, that’s hardly researched at all and the few studies that exist are very poor. But they should definately be considered. If no one is willing to try techniques that have not yet been reserached, then they will never be researched.

    Perform a study on a pathophysiologically uniform population of patients where the nutrient and hydration intake, pneumonia rate, choking rate and mortality rate of a group of patients with properly optimized diets are compared to a group of patients that receives no food texture modification at all… I dare you. You won’t get many patients to agree to that.

    • DePippo 1994 comes really close to what you describe. He had 3 groups (1. No diet recommendations but compensatory recommendations given, without monitor; 2. Diet recommendations and compensatory recommendations given, no monitoring for adherence; 3. Diet and compensatory with strict monitoring) \

      • I assume that you’re referring to “DePippo KL et al. 1994: Aspiration and relative risk of medical complications following stroke”, in which she concludes that instructing the patient and family in texture modification and compensatory techniques is as effective as therapy sessions involving rehearsal of compensatory techniques and therapist-controlled diet for her specific patient group in her specific setting. In my practice I find that this is true for some chronic dysphagia patient groups who are cognitively adequate and are able to live independently or have resourceful close relatives to care for them at home – namely stroke patients in the post-rehab phase, some neurodegenerative diseases such as Alzheimer or Huntington in their moderately advanced stages, post treatment neck/throat cancer and so forth.

        Speaking of post-stroke dysphagia research done in a different age, I would also like to direct you and the readers’ attention to the cochrane systematic review “Bath et al. 1999. Interventions for dysphagia in acute stroke” in which, amongst others, DePippos findings are taken into account.

  3. Things are changing! Important to think about it!
    we can’t generalize, in clinical practice I see that some patients really benefit from consistency modification.
    thank you for always sharing knowledge!

  4. Texture modification is and has been proven to be useful. To suggest it is done for no good reason is a mistake. Suggesting a patient should just have water – just won’t work. If thickeners were not available they would just take a chance and put up with the choking because they want the taste of a drink they enjoy. Be it tea, juice or a glass of wine.

    • Thank you for sharing your thoughts. The article summarized 3 systematic reviews, a RTC. and several other articles. Please share the information you have that would lead you to think the evidence is remiss. I would gladly read it.

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