Hard to Swallow Part 2 - Understanding dysphagia and thickeners

Patient Expert

My last post discussed the evaluation of dysphagia, aspiration, and the modified barium swallow examination. This post covers thickeners, which can be beneficial for a select group of people who have trouble swallowing.

When someone aspirates (breathes in) regular liquids, but their swallowing improves with thicker consistencies, their doctor will typically recommend thickening drinks to a consistency tolerated without aspirating. Thin liquids include drinks like water, milk, coffee, tea, sodas, and broth-based soup. Mildly thickened liquids are called nectar consistency and include fruit nectars, syrup, eggnog, or Ensure, while the next level of thickened liquids are of honey consistency, i.e., as thick as honey.   Purée foods are those that stick to a spoon, like pudding, mashed potatoes, or other blended solids. Purée foods are used when a person can't tolerate liquids because of aspiration, and they aren't able to manipulate solids well enough to avoid choking on a chunk of food.

Why thickened liquids? The thought is that thin liquids pass through the pharynx quickly, and that someone with a delayed or weak swallow cannot execute protective reflexes fast enough to protect the airway and prevent aspiration. Thickened foods pass through more slowly, giving you more time and better control of the swallowing process. Sometimes a person is found to aspirate thin liquids, but they do well with thickened drinks. But thick liquids aren't universally beneficial. People with dry mouth, particularly those who've undergone radiation treatments for head and neck cancer, may have more trouble with thick liquids. Thick liquids can stick to the mouth and can be harder to manipulate than thin liquids. Also, thicker liquids can cause more problems if they get into your lungs. Given these risks, thickener is only recommended when a person is found to aspirate thin liquids, but a modified barium swallow demonstrates they do not aspirate heavier consistencies.

If your doctor and speech pathologist have recommended thickened liquids, you can buy them pre-mixed or you can buy additives that will thicken your drinks without changing the taste. Thickeners can be used with hot or cold drinks, and you can typically find them at a local pharmacy or order them online. You don't need a prescription to get them.

Thickeners come in starch or gel form and can be purchased in premeasured packets or bulk quantities. Starch thickeners are slightly cheaper than gel thickeners, but they can be a little tricky to use. The amount you use often varies with the type of liquid to be thickened and whether the drink is hot or cold. You also have to wait at least 5 minutes after adding a starch thickener to ensure the beverage has reached the appropriate consistency. "Thick It" and "Thick & Easy" are types of starch thickeners available online and in pharmacies.

Gel-based thickeners are slightly more expensive than starch thickeners, but they are a bit easier to use. Gel-thickeners thicken all liquids equally well, and they do not over-thicken or separate over time. Beverages are ready to drink as soon as the mixing is done, but they can't be stirred with a spoon. They must be shaken or whisked with a fork to properly blend the gel. "SimplyThick," Nestlé's "ThickenUp," and "Hydra-Aid" are examples of gel thickeners you can use.

Pre-thickened liquids are also available, and using them eliminates the extra steps and guess-work involved with additives. You can order pre-thickened liquids through your local pharmacy, and they're sold on multiple websites, including the following:



While it is appropriate to choose foods and drinks you may have less trouble with than others, as I mentioned in the last post, it's important to recognize that thickened liquids aren't universally helpful for people with dysphagia. Arbitrarily thickening liquids for anyone who experiences choking can be dangerous and is generally not recommended. A thorough assessment by a speech pathologist, in addition to a modified barium swallow examination, will help your health care team determine what you can eat and drink safely.

Beyond safety, dietary restrictions can have a profound impact on someone's quality of life.   My next post on swallowing will address those people with severe dysphagia, their dietary restrictions, and the decision to override a doctor's recommendation and continue to eat or drink food.