Can you tell what’s going wrong?

Everybody means well. You mean well, you’re reading a healthcare-related blog post. You don’t go into a caring profession unless you care.

So why, despite IDDSI, are things still going wrong when it comes to thickening drinks?

I mixed one of the commonly used gum-based thickeners incorrectly and this is how it pours at IDDSI Level 2. Have you seen thickened drinks look and pour like this? Is this normal practice where you work? How appetising does it look (and sound)?!

Pouring the incorrectly mixed drink back into the jug so you can see its consistency when flowing

Can you tell what I did wrong so that it ended up this way? See answer at the end!

Recently the use of thickeners in dysphagia management has been questioned[i],[ii].Whilst some excellent points are being made about its use, it’s not a good idea to throw the baby out with the bath water.

Thickener itself can be an effective clinical tool in supporting people with dysphagia. The switch from starch-based to gum-based thickeners seems to be a step in the right direction[iii] though understanding the effects of gum in digestion must be a consideration[iv].

Thickener continues as a mainstay of dysphagia management.

I’ve seen thickener used well and effectively, and I’ve seen it used terribly with significant consequences. This includes;

  • dehydration
  • sub-therapeutic effects
  • increased risk of choking  
  • chest infections or aspiration pneumonia
  • reduced quality of life

Each of the manufacturers are well aware of the challenges faced by people with dysphagia, their families and healthcare professionals. Significant strides have been made not only to improve thickeners’ intrinsic properties but also to provide training and advice. And the manufacturers have made changes to packaging to reflect IDDSI and provide clear instructions on use.

Back in 2010, Garcia et al.[v] raised concerns that “Many participants failed to use product label information in sample preparation.” Has anything changed?!

Is the problem with thickener not the thickener itself but its (mis)use?

Perhaps speech therapists should practice more judicious use and consider other approaches first. Is this realistic in all settings?

What more can manufacturers do to make the instructions clearer?

How can we ensure that every single individual who prepares a thickened drink does it as directed?

Here at Dysphagia Kitchen, we’re open to ideas and how to improve the lives of people with dysphagia. Let us know what you think.

Oh, and the answer to what I did wrong mixing the drink… i) added powder to the drink, and ii) didn’t leave it for long enough after stirring.  Did you guess right?

Sandra Robinson is an independent speech and language therapist, specialist dysphagia practitioner and co-founder of Dysphagia Kitchen. She has collaborated with Nestlé Health Science on thickener-related projects.


[i] Lazenby-Paterson T. Thickened liquids: do they still have a place in the dysphagia toolkit? Curr Opin Otolaryngol Head Neck Surg. 2020 Jun;28(3):145-154. doi: 10.1097/MOO.0000000000000622. PMID: 32332203.

[ii] William C Lippert, MD, MPH, Romil Chadha, MD, MPH, SFHM, FACP, Joseph R Sweigart, MD, FHM, FACP, Things We Do for No Reason: The Use of Thickened Liquids in Treating Hospitalized Adult Patients with Dysphagia. J. Hosp. Med 2019;5;315-317. Published online first February 20, 2019.. doi:10.12788/jhm.3141

[iii] Vilardell N, Rofes L, Arreola V, Speyer R, Clavé P. A Comparative Study Between Modified Starch and Xanthan Gum Thickeners in Post-Stroke Oropharyngeal Dysphagia. Dysphagia. 2016;31(2):169-179. doi:10.1007/s00455-015-9672-8

[iv] Daly J, Tomlin J, Read NW. The effect of feeding xanthan gum on colonic function in man: correlation with in vitro determinants of bacterial breakdown. Br J Nutr. 1993 May;69(3):897-902. doi: 10.1079/bjn19930089. PMID: 8329363.

[v] Garcia JM, Chambers E 4th, Clark M, Helverson J, Matta Z. Quality of care issues for dysphagia: modifications involving oral fluids. J Clin Nurs. 2010 Jun;19(11-12):1618-24. doi: 10.1111/j.1365-2702.2009.03009.x. Epub 2010 Apr 7. PMID: 20384670.

Published by Sandra Robinson

Independent Speech and Language Therapist. Specialist Dysphagia Practitioner.

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