Transitioning from starch-based to xanthan gum-based thickening agents: An SLP’s perspective
Managing dysphagia with modified diets
When I started my career as a Speech Language Pathologist, I traveled between multiple sub-acute rehab and long-term care facilities. It was in this setting where dysphagia became my primary focus. I had the benefit of working within various facilities and being exposed to different approaches to the management of dysphagia, and specifically, modified diets. This included different dining protocols, presentation of patients’ meals, compliance rate from staff, and for the focus of this discussion, a variety of thickened liquid products readily available to dysphagia patients. It was a great opportunity to communicate with countless patients and reflect upon their varying opinions regarding different thickening agents. Here at my current facility, we have achieved the ideal balance for managing dysphagia, while respecting quality of life (QOL) and increasing patient, staff, and caregiver compliance.
For a while early on in my practice, I found myself feeling reluctant to recommend thickened liquids during my evaluations – a feeling I am certain many other SLPs have experienced. It was easy to feel guilty knowing the limited options and products out in the market, and how those products would affect my patients’ QOL. However, within our scope of practice, it is sometimes necessary to recommend thickened liquids on a regular basis.
Despite this somewhat controversial recommendation, the European Society for Swallow Disorders (ESSD) concludes that “there is evidence for increasing viscosity and that it is a valid management strategy for OD [oropharyngeal dysphagia]. However, new thickening agents should be developed to avoid the negative effects of increasing viscosity on residue, palatability, and treatment compliance [1].”
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Our facility aimed to solve the three issues above: (1) thickened liquids increase pharyngeal residue, (2) quality of life, and (3) non-compliance. We did this by changing the type of thickened liquid offered and how we served it to our patients.
Thickened liquids and pharyngeal residue
At Amsterdam Nursing Home and Rehabilitation in New York City, we offer a variety of Thick-It’s pre-thickened honey- and nectar-thick liquids with our Independent Tray Service. We are mindful to present each tray in a dignified manner for our patients, making sure the meal looks appealing and encouraging self-feeding. Xanthan gum has played a large role in this process.
Xanthan gum is a clear and smooth stabilizer used in a variety of foods, such as salad dressings and ice cream, to prevent ingredients from separating. Increasing pharyngeal residue due to thickened liquids, which may increase risk of secondary aspiration/penetration of residue [2] is a reasonable concern for all clinicians, and xanthan gum has been proven successful in decreasing this risk. In a study which compared post-swallow residue and aspiration, it noted that starch-based thickened liquids increased oral and pharyngeal residue. Conversely, no residue was noted with the same viscosities when xanthan-based thickeners were used [3].
Improving patients’ quality of life
Another issue that we have addressed with our dining service is QOL. When compared to starch products, xanthan remains stable across a variety of conditions and temperatures, which greatly adds variety to our tray line. Beverages can be heated, frozen, and thawed without a significant change in viscosity. Our Independent Tray Service offers the patients ice pops, ice cold water, soups, and flavored drinks. I had a recent experience where a patient was placed on nectar-thick liquids and continuously requested ice pops. Luckily, I was able to meet her request due to the xanthan gum-based liquids.
“there is evidence for increasing viscosity and that it is a valid management strategy for OD [oropharyngeal dysphagia]…”
Our kitchen takes the flavorless, pre-thickened Thick-It AquaCareH2O water and mixes it with different flavors, which gives our patients endless beverage options. Taking it a step further, I ordered ice pop molds online and filled them with pre-thickened nectar-thick juice in both kiwi strawberry and lemonade flavors, allowing my patient to enjoy her requested ice pops safely. Because the pre-thickened water is xanthan-based, the viscosity never changed. She expressed to me, “These are delicious; I needed something cold!” As a clinician, I was extremely excited that I was able to accommodate her needs, and the staff was ecstatic that they were able to provide her with ice pops throughout the day upon her request. They were available on the unit, and positively impacted the patient’s quality of life.
Encouraging patient compliance with xanthan gum
A big issue I have witnessed across all facilities in which I’ve worked was non-compliance. Since implementation of our new dining program at Amsterdam, patients self-reported less “cheating” with thin liquids and avoiding drinking, especially because they have more confidence due to our beverages being presented within regular cups rather than foil-sealed containers. Patients have even been reporting more compliance with their thickened liquids.
Recently, a patient I worked with was admitted from the hospital on nectar-thick liquids. I thought it would be interesting to ask him what he thought of our presentation and products offered. He stated, “It is definitely not as lumpy as the hospitals, but truthfully I miss regular liquids! However, I completely understand why I need this right now.” This patient requested cold water daily, but specified that he wasn’t served the “cloudy stuff.” I felt confident when I was able to offer Thick-It’s nectar-thick water, which is appealing to the eye because it is clear and smooth. Additionally, we were able to freeze nectar-thick ice cubes on the unit with the unflavored thickened water. He was able to enjoy the cold water safely because of the stable viscosity.
The results: Increased hydration, oral intake and safety
Since implementation of the Independent Tray Service, there has been an increase of 13 percent in liquid intake and 22 percent in food intake over the course of an 8-week data collection period at our facility. Offering xanthan gum-based products with our Independent Tray Service has not only increased hydration and oral intake, but recent studies have shown it to be safer for our patients in comparison to starch-based thickeners.
For example, in a study which compared the effects of aspirated thickened water on survival and pulmonary status, one study stated that the survival rate of rats that aspirated water with xanthan gum-based products were 100 percent. Whereas, the group who aspirated with starch-based products had a survival rate of only 10 percent [4], thus making it easier as a clinician to advocate for this product within my facility, especially if the patient is being discharged home on thickened liquids.
Overall, I have found it easier making my recommendations for thickened liquids due to our independent tray line which offers Thick-It’s xanthan-based products. We were able to address QOL, non-compliance, and thickened liquid complications all while providing patients with a sense of pride and independence at meals. Quality of life, hydration, and overall safety has improved – xanthan-based products have definitely proven successful.
***Please note this post is sponsored by Thick-It
Links of Interest
Thick-It Clear Advantage Food and Beverage Thickener
References
[1] Jane, M. G., Chambers, E.,IV, & Molander, M. (2005). Thickened liquids: Practice patterns of speech-language pathologists. American Journal of Speech – Language Pathology, 14(1), 4-13. Retrieved from http://jerome.stjohns.edu:81/login?url=http://search.proquest.com.jerome.stjohns.edu:81/docview/204277532?accountid=14068 [2] Steele, C. M., Alsanei, W. A., Ayanikalath, S., Barbon, C. E., A., Chen, J., .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.doi:http://dx.doi.org.jerome.stjohns.edu:81/10.1007/s00455-014-9578 [3] Vilardell, N., Rofes, L., Arreola, V., Speyer, R., & Clavé, P. (2016). A comparative study between modified starch and xanthan gum thickeners in post-stroke oropharyngeal dysphagia. Dysphagia, 31(2), 169-179. doi:http://dx.doi.org.jerome.stjohns.edu:81/10.1007/s00455-015-9672-8 Newman, R., Vilardell, N., Clavé, P. et al. Dysphagia (2016) 31: 232. doi:10.1007/s00455-016-9696-8 [4] Domer, Amanda et al. “The Effects of Aspirated Thickened Water on Survival of Pulmonary Status in a Lagomorph Model.” UC Davis Study, 2014.
