Manual of Clinical Nutrition

Nutrition Management of Dysphagia

Manual of Clinical Nutrition Management B- 8 Copyright © 2013 Compass Group, Inc.

Liquids: Patients who have dysphagia frequently have difficulty drinking thin liquids, which are not easily
channeled to the back of the mouth. Fluid intake is often limited in patients with dysphagia, leading to an
increased risk of dehydration (1). Adequate hydration can be ensured by the introduction of thickened liquids
followed by the progression to thinner liquids as swallowing proficiency is gained. While there is some fluid
content in many foods, especially pureed foods, the use of thickened liquids may be necessary to assure adequate
hydration.”

The effects of thickening powders in achieving targeted levels of thickness are generally inconsistent due to
variations in the temperature, pH, and protein content of foods and beverages (2). There are currently no
nationally recognized standards for thickened liquids (2). The majority of commercially prepared powder
thickeners require 1 tbsp of thickening product per 4 fl oz to achieve a nectar-like thickness, 1½ tbsp per 4 fl
oz for a honey-like thickness, and 2 tbsp per 4 fl oz for spoon-thick thickness. Registered dietitians need to be
aware that there is wide variation in the viscosity of commercially prepared thickened beverages and that
many product labels do not include viscosity (2). The use of dry starch thickeners added to thin liquids also
results in wide variations in viscosity (2).

Viscosity Borders and Ranges for Thickened Liquids
The NDD Task Force has suggested the following viscosity borders and ranges (All measurements were
performed at 25oC with a shear rate of 50 s-^1 .) (2,6):

 thin liquid: 1-50 cP
 nectar-like liquid: 51-350 cP
 honey-like liquid: 351-1750 cP
 spoon-thick liquid: >1750 cP
cP = centipoise, a measurement of liquid thickness

Thin liquids include all unthickened beverages and supplements such as clear juices (fruit or vegetable),
water, coffee, tea, soda, milk, eggnog, juice from canned fruit, fruit with thin-liquid properties (watermelon,
grapefruit, and orange sections), broth, ice cream, sherbet, malts, most nutritional supplements (at room
temperature), frozen yogurt, gelatin, and other foods that will liquefy in the mouth within a few seconds.
Nectar-like liquids include nectars, vegetable juices, chocolate milk, buttermilk, thin milkshakes, cream soups,
and other beverages properly thickened (1,6). Medical food supplements providing 1.5 to 2.0 kcal/mL are
usually considered nectar-like when chilled. Honey-like liquids are thickened to a honey consistency (1,6).
Spoon-thick liquids, which include pudding, custard, and hot cereal, are thickened to pudding consistency and
need to be eaten with a spoon (1,6).

Factors that affect thickened liquid viscosity include (1,8):

 temperature
 continuous hydration of the thickening agent in prethickened beverages
 ability of instant food thickener to maintain thickness”
 inconsistency across product lines within manufacturers or between competitors

*The Academy of Nutrition and Dietetics has assigned grades, ranging from Grade I (good/strong) to Grade V (insufficient evidence), to
evidence and conclusion statements. The grading system is described in Section III: Clinical Nutrition Management A Reference Guide,
page III-1.

References

1. Dysphagia. In: Nutrition Care Manual. Academy of Nutrition and Dietetics; Updated annually. Available at: nutritioncaremanual.org.
   Accessed September 20, 2010.


2. Niedert KC, ed. Nutrition Care of the Older Adult: A Handbook for Dietetics Professionals Working Throughout the Continuum of
   Care. 2nd ed. Chicago, Ill: American Dietetic Association; 2004:211.


3. Walker G, ed. Pocket Resource for Nutrition Assessment. Chicago, Ill: American Dietetic Association; 2005:173-181.


4. Unintended Weight Loss in Older Adults Evidence-Based Nutrition Practice Guideline. Academy of Nutrition and Dietetics Evidence
   Analysis Library. Academy of Nutrition and Dietetics; 2006. Available at: http://www.andevidencelibrary.com. Accessed July 31, 2010.


5. Wilkinson TJ, Thomas K, MacGregor S, Tillard G, Wyles C, Sainsbury R. Tolerance of early diet textures as indictors of recovery from
   dysphagia after stroke. Dysphagia. 2002;17:227- 232.


6. National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. Chicago, Ill: American Dietetic
   Association; 2002.


7. Mahan K, Escott-Stump S. Medical nutrition therapy for neurologic disorders. In: Krause's Food & Nutrition Therapy. 12th ed. St.
   Louis, Mo: Saunders; 2008:1074-1077.


8. Adeleye B, Rachal C. Comparison of the rheological properties of ready-to-serve and powdered instant food-thickened beverages at
   different temperatures for dysphagic patients. J Am Diet Assoc. 2007;107:1176-1182.