Comparison of two methods to categorize thickened liquids for dysphagia management in a clinical care setting context: The Bostwick consistometer and the IDDSI Flow Test. Are we talking about the same concept?

Viscosity study of maternal and formula milks according to the assessment proposed by the International Dysphagia Diet Standardisation Initiative Model: a comparison with Rheological Assessment

PURPOSE

The present study aimed to investigate the behavior and the viscosity classification of liquids recommended for infants, up to six months, in Brazil, and their formulations used in Videofluoroscopy Swallowing Studies.

METHODS

Breast milk from different gestational and breastfeeding time, two regular infant formulas, and one anti-reflux formula were evaluated in five different formulations: pure, mixed with liquid barium sulfate, in two proportions (20 and 33%), thickened with a specific thickener for neonates and thickened and mixed with 20% liquid barium sulfate, using the International Dysphagia Diet Standardisation Initiative model. The results were compared with data obtained from a previous rheological study.

RESULTS

The breast milk samples and the infant formulas, in pure presentation, exhibited similar behavior except for the anti-reflux formula. The thickened samples with the addition of barium and the pure liquid barium sulfate exhibited the highest viscosity among the formulations. The increase in viscosity with the addition of barium occurred for all samples and for the thickened formulations, but not in linear behavior. The results showed minor differences of IDDSI classification compared to the findings obtained in the rheological study.

CONCLUSION

The present study revealed the variability of liquid viscosity across different formulations, supporting the idea of the importance of this knowledge in videofluoroscopic assessment. It has also highlighted the risk associated with using a subjective method in preparing the stimuli offered, allowing for greater reliability in diagnosing swallowing dynamics in neonates and infants. This approach may help prevent inaccurate diagnoses and harmful interventions.

Cross-cultural adaptation and validation of Dysphagia Handicap Index in Bangladesh

The Dysphagia Handicap Index (DHI) is commonly utilized for evaluating how dysphagia impacts the quality of life (QoL) of patients across physical, functional, and emotional dimensions. The primary aim of the research was to linguistically validate and culturally adapt the DHI to the Bangla version. A cross-sectional study design was chosen, with Beaton's protocol as the guiding framework for validating and adapting the DHI. It has followed a systematic process of forward translation, participation in expert discussions, and subsequent back translation to obtain a reviewed version. The Bangla version, DHI-Ban, was administered purposefully to 50 dysphagia patients in the Clinical Speech and Language Therapy (SLT) Department of the Centre for the Rehabilitation of the Paralyzed (CRP) and was also administered to 50 healthy individuals for comparison. Of the fifty, eighteen dysphagia subjects were assigned again after two weeks for the retest. The DHI-Ban demonstrated strong internal consistency (Cronbach's α = 0.89) and good test-retest reproducibility (ICC = 0.86). The Spearman test confirmed significant construct validity (p < 0.01), and the Wilcoxon test identified significant differences (p < 0.001) between patients and healthy individuals. Feedback from participants was also taken into account for acceptance and clarity. In conclusion, the adapted DHI-Ban has emerged to be a reliable patient-reported tool for assessing dysphagia in Bangla-speaking individuals. Incorporating the Bangla language framework facilitates its comprehension and effectiveness, further solidifying its reliability.

Difference in Drinking Times as a Function of Liquid Consistency in Adults With Oculopharyngeal Muscular Dystrophy: A Comparative Study Using Bostwick Consistometer and IDDSI Flow Test Methods

The main objective was to document the differences between drinking times and oral perception between liquids in individuals with dysphagia. A second objective was to assess variations in consistency categorization across instruments. A third objective was to explore the relationship between drinking time and dysphagia severity. A sample of individuals with OPMD (n = 30; 40-75 years) was recruited. Participants drank 80 mL of water, followed by three blinded commercially pre-thickened cranberry cocktails (CranA, CranB, CranC). Flow rates were measured with Bostwick consistometer, IDDSI Flow Test, and Discovery HR 20 rheometer. Patient-reported outcome measures were used to assess dysphagia. Mean drinking times for participants with OPMD were as follows: 7.9 ± 4.4 s for water, 10.7 ± 4.8 s for CranA, 12.3 ± 5.7 s for CranB, and 15.2 ± 7.2 s for CranC. All four times were statistically different from each other. Participants reported noticeable differences in oral perception. The Bostwick flow rates were different for all three cocktails. Based on IDDSI Flow Test, CranA was categorized as IDDSI level-2, while both CranB and CranC were categorized as IDDSI level-3. Correlations ranging from 0.39 to 0.55 were found between drinking times and dysphagia severity. In conclusion, liquids within the same IDDSI category can have different Bostwick flow rates and oral perception. The hypothesis that participants with OPMD may find certain liquids more challenging to swallow, despite being in the same IDDSI category, deserves further exploration in future studies.

Relationship between International Dysphagia Diet Standardisation Initiative Flow Test and Consistometric Measures for Consistency Classification: An Examination of Thickened Liquids Prepared Using Starch-Based and Xanthan Gum-Based Thickening Agents

INTRODUCTION

Consistency of liquid food plays an important role in managing patients with dysphagia, which can be objectively evaluated by using International Dysphagia Diet Standardisation Initiative (IDDSI) Flow Test and consistometry. The present study established the relationship between IDDSI Flow Test and consistometric measures and examined the measurement limitations of each test associated with thickened liquids prepared using starch-based and xanthan gum-based thickening agents.

METHODS

Thirteen thickened liquid samples of consistency ranging from IDDSI level 1 (mildly thick) to level 3 (moderately thick) were prepared using starch-based and xanthan gum-based thickeners. IDDSI Flow Test and consistometric measures were obtained and analyzed using correlation and regression.

RESULTS

A strong correlation was observed between both tests. Regression analyses revealed a linear and a quadratic relationship between IDDSI Flow Test and consistometric measurements, respectively.

CONCLUSION

Starch-based and xanthan gum-based thickeners exhibited different relationships between IDDSI Flow Test and consistometric measurements. Findings allow easy conversion and adaptation of consistometric measures to the IDDSI framework, which renders the use of consistometry in the clinical settings as a complementary quantitative measurement of liquid consistency to IDDSI Flow Test.

Validation of the IDDSI funnel for liquid flow testing

In 2017, the International Dysphagia Diet Standardisation Initiative (IDDSI) introduced the IDDSI flow test which enables patients, clinicians, caregivers, food service professionals and researchers to classify liquid thickness into five levels based on the volume of liquid remaining in a standard 10 mL slip tip syringe after 10 s of flow under gravity. Within a few months of publishing the IDDSI flow test instructions, several barriers emerged: (1) the preferred model of syringe (BD 303134) was not equally accessible around the world, causing some users to perform flow tests with alternate models of syringe; (2) differences in syringe geometry across models led to variations in IDDSI flow test results; and (3) the need to use a second syringe for sample loading added complexity and cost to end users. To address these barriers, IDDSI designed the IDDSI funnel, a novel device, which combines the geometry of the BD 303134 syringe with a kitchen funnel to facilitate easy loading of liquid samples without need for a second syringe. In this report, we compare the IDDSI flow test results across two devices: syringe BD 303134 and IDDSI funnel. IDDSI level classifications were in complete agreement with the syringe reference test results in 67/73 (92%) of the test fluids and temperature conditions with mean difference of residual liquid across devices of 0.2 (2% full scale). These results demonstrate excellent correspondence between the two devices.

Food Processing and Nutrition Strategies for Improving the Health of Elderly People with Dysphagia: A Review of Recent Developments

Dysphagia, or swallowing difficulty, is a common morbidity affecting 10% to 33% of the elderly population. Individuals with dysphagia can experience appetite, reduction, weight loss, and malnutrition as well as even aspiration, dehydration, and long-term healthcare issues. However, current therapies to treat dysphagia can routinely cause discomfort and pain to patients. To prevent these risks, a non-traumatic and effective treatment of diet modification for safe chewing and swallowing is urgently needed for the elderly. This review mainly summarizes the chewing and swallowing changes in the elderly, as well as important risk factors and potential consequences of dysphagia. In addition, three texture-modified food processing strategies to prepare special foods for the aged, as well as the current statuses and future trends of such foods, are discussed. Nonthermal food technologies, gelation, and 3D printing techniques have been developed to prepare soft, moist, and palatable texture-modified foods for chewing and swallowing safety in elderly individuals. In addition, flavor enhancement and nutrition enrichment are also considered to compensate for the loss of sensory experience and nutrients. Given the trend of population aging, multidisciplinary cooperation for dysphagia management should be a top priority.

Factores limitantes del uso de las consistencias en la alimentación del paciente con disfagia: percepción del cuidador principal

Las acciones de abordaje del paciente con disfagia, al ser la disfagia de larga duración, exigen la participación directa y permanente del cuidador principal, que es, finalmente, quien define los procesos que se desencadenan desde casa para el cuidado de la alteración de ingesta. Bajo esta perspectiva, el cuidador del sujeto con disfagia sería quien debe estar capacitado de manera plena en los procesos de abordaje, no sólo como conocimiento de las técnicas utilizadas en la rehabilitación, sino también como forma de aprobación de su uso. Con el fin de describir la relación del cuidador principal en el uso y manejo de la modificación de consistencia, se plantea un proceso mixto de registro que permita evidenciar la percepción del cuidador hacia el uso de esta técnica. El trabajo evidencia como hallazgos aspectos limitantes que se concatenan con determinantes sociales de la salud y que, desde una mirada económica, de responsabilidad y de conocimiento del manejo de las consistencias, ubican a la disfagia en un lugar complicado de abordar para el cuidador, debido a las distintas realidades.

Instrumental and sensory techniques to characterize the texture of foods suitable for dysphagic people: A systematic review

The interest to characterize texture-modified foods (TMFs) intended for people with oropharyngeal dysphagia (OD) has grown significantly since 2011. Several instrumental and sensory techniques have been applied in the analysis of these foods. The objective of the present systematic review was to identify the most appropriate techniques, especially for the food industry and clinical setting. The search was carried out in three online databases according to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA). Across the multiple trials reviewed, Texture Profile Analysis and the Uniaxial Compression Test were most used as the instrumental technique for solid foods, and the Back Extrusion Test for fluid and semisolid foods. All trials used descriptive analysis as the sensory technique. However, the experimental conditions of the trials lacked standardization. Consequently, the results of the trials were not comparable. To properly characterize the texture of TMFs intended for OD by each technique, an international consensus is needed to establish standardized experimental conditions. Methods based on these techniques should also be validated by collaborative studies to verify repeatability, replicability, and reproducibility.

The Effects of Select Hydrocolloids on the Processing of Pâté-Style Canned Pet Food

Hydrocolloids are commonly used in canned pet food. However, their functional effects have not been quantified in this food format. The objective was to determine the effects of select hydrocolloids on batter consistency, heat penetration, and texture of canned pet food. Treatments were added to the formula as 1% dextrose (D) and 0.5% guar gum with 0.5% of either dextrose (DG), kappa carrageenan (KCG), locust bean gum (LBG), or xanthan gum (XGG). Data were analyzed as a 1-way ANOVA with batch as a random effect and separated by Fisher's LSD at p < 0.05. Batter consistency (distance traveled in 30 s) thickened with increasing levels of hydrocolloids (thinnest to thickest: 23.63 to 2.75 cm). The D treatment (12.08 min) accumulated greater lethality during the heating cycle compared to all others (average 9.09 min). The KCG treatment (27.00 N) was the firmest and D and DG (average 8.75 N) the softest with LBG and XGG (average 15.59 N) intermediate. Toughness was similar except D (67 N·mm) was less tough than DG (117 N·mm). The D treatment showed the greatest expressible moisture (49.91%), LBG and XGG the lowest (average 16.54%), and DG and KCG intermediate (average 25.26%). Hydrocolloids influenced heat penetration, likely due to differences in batter consistency, and affected finished product texture.

How Accurate Are the Consistency Labels Used in Hong Kong? An Objective Study of the Consistency of Thickened Liquids Using International Dysphagia Diet Standardisation Initiative and Consistometric Measurements

OBJECTIVES

The present study objectively examined the consistency (thickness) of labels that are used in Hong Kong for the population with dysphagia using an International Dysphagia Diet Standardisation Initiative (IDDSI) flow test and Bostwick consistometric measurements.

METHODS

Liquids were prepared by thickening water to achieve 4 consistency labels (slightly thick, mildly thick, medium thick, and extra thick) according to manufacturer's instructions, employing 2 types of thickening products that are used in Hong Kong, i.e., starch based and gum based. For each consistency label prepared using each thickening product, the IDDSI flow test and consistometric measurements were obtained and compared.

RESULTS

The results showed that the actual thickness of liquids was highly dependent on the type of thickener (starch based vs. gum based) used. Thickened liquids prepared using the starch-based thickener were generally thinner than the actual value at a lower concentration.

CONCLUSION

Though prepared strictly following the manufacturer's instructions, the thickened liquids fail to faithfully correlate with the standardized norms established according to the IDDSI framework and the objective consistometric measurement using a Bostwick consistometer. Therefore, caution must be exercised when administering a thickened diet following the manufacturer's instructions for patients with dysphagia.

Exploring Tools for Designing Dysphagia-Friendly Foods: A Review

Dysphagia is a medical condition that affects normal swallowing. To prevent the risk of aspiration or choking, thickened fluids and texture-modified foods have been used for dysphagia management with the goal of slowing down the flow of liquids and protecting the airway. This article summarizes the available information about the rheological and textural parameters, the characterization of the most-used thickeners and the application of alternative texture modification technologies that are crucial to developing safe dishes for people who suffer from swallowing difficulties. Regarding rheological and textural measurements, fundamental and empirical methods are described.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

Thickened liquids: do they still have a place in the dysphagia toolkit?

PURPOSE OF REVIEW

The use of commercially or naturally thickened liquids is a well-established treatment for patients with dysphagia to fluids, the aim of which is to improve swallow safety by minimizing risk of aspiration. Although the most recent systematic reviews conclude that this treatment lacks evidential support and leads to patient-reported worsening health and quality of life, thickened liquids continue to be used with patients with dysphagia across clinical settings. This review briefly summarizes the evidence and considers potential reasons for the apparent mismatch between the evidence and clinical practice.

RECENT FINDINGS

Continuing practice with thickened liquids is influenced by a range of factors, including gaps in clinical knowledge, inadequate patient involvement, a culture of common practice and a reliance on invalid surrogate studies or research lacking a credible association between thickened liquids and clinically meaningful endpoints.

SUMMARY

While awaiting further research, clinical decision-making about thickened liquids can be improved by considering the evidence of clinically meaningful endpoints, promoting shared decision-making with patients and underpinning practice with knowledge about the complex relationship between dysphagia, aspiration and pneumonia.

Is IDDSI an Evidence-Based Framework? A Relevant Question for the Frail Older Population

To delay impacts of aging, optimal nutritional status is essential. Several factors can reduce food intake, such as isolation, income, and cognitive/physical decline. Additionally, chewing and swallowing difficulties, or dysphagia, often disrupt the ability to consume life-long favorite dishes. Food and liquids could require modification of texture or consistency to ensure a comfortable or safe swallow. The food industry, foodservices facilities, and caregivers need quality control benchmarks to provide adequate nourishment and meet these new feeding challenges. The International Dysphagia Diet Standardisation Initiative (IDDSI) is proposing the IDDSI framework and testing methods to describe food used in nutritional care plans to circumvent dysphagia and improve communication among caregivers. This systematic review assesses the validity and reliability of the IDDSI testing methods using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). Two publications presented content validity whereas 19 publications looked at construct validity or reliability for the IDDSI testing methods. One study was conducted in older adults presenting dysphagia. This review concludes that there is insufficient evidence to recommend the IDDSI testing methods. Further research, conducted with robust methodological design and reporting, is needed to develop and assess nutritious adapted food for frail older populations.

Effect of mixing method on resulting thickness of infant formula

Previous research shows that factors such as time, temperature, nutritional make-up of a liquid, and type of thickening agent can significantly alter the resulting thickness of liquids. This study sought to determine the effect of three distinct mixing methods on the resulting thickness of ready to feed infant formulas mixed to Mildly and Moderately Thick (International Dysphagia Diet Standardization Initiative [IDDSI] Levels 2 and 3) with three different thickening agents. Eight commercially available infant formulas were mixed with three different thickening agents by three different mixing methods. The IDDSI Syringe Flow Test was used to categorize the thickened formulas. Chi square analyses were completed to determine the impact of mixing method on the thickened formulas. The majority (94%) of thickened formula combinations prepared to a target Mildly Thick consistency produced thickened formula that was thinner or thicker than the target. In contrast, the majority (76%) of thickened formula combinations prepared to a target Moderately Thick (IDDSI Level 3) consistency produced thickened formula that was equivalent to the target consistency. A statistically significant relationship was found between mixing methods and resulting IDDSI category for samples mixed to a target of Moderately Thick. The thickening agent and method of mixing must be considered carefully when preparing infant formulas to Mildly and Moderately Thick target IDDSI categories. Based on results of this study, it is recommended that providers utilize a clinical testing method, such as the IDDSI Syringe Flow Test, when attempting to create a Mildly Thick formula consistency.

Are Medication Swallowing Lubricants Suitable for Use in Dysphagia? Consistency, Viscosity, Texture, and Application of the International Dysphagia Diet Standardization Initiative (IDDSI) Framework

Medication lubricants are thick liquids or gels that are designed to aid swallowing of solid oral dosage forms. Tablets and capsules are placed within a spoonful of the product for swallowing. The aim of this study was to describe and compare commercially available medication lubricants in terms of textural suitability for patients with dysphagia. Twelve medication lubricants were characterised according to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Apparent viscosity, yield stress, thickness consistency, and various texture features were compared. Gloup Forte was the only medication lubricant classified as IDDSI level 4 (pureed/extremely thick) at room (24 °C) temperature. Four other Gloup products were IDDSI level 3 (liquidised/moderately thick) at room temperature but testing at 4 °C or pouring from the container instead of using the pump dispenser resulted in classification as IDDSI level 4. The IDDSI Flow test would have classified MediSpend and Slo Tablets as IDDSI level 3, but their very low yield stress led to these fluids flowing too quickly through the prongs of a fork and so these were classified as <3. Severo was IDDSI level 2. Heyaxon and the two versions of Magic Jelly tested contained lumps, and Swallow Aid had exceptionally high viscosity, hardness, adhesiveness, and gumminess, classifying them as IDDSI Level 7 (“regular textures”) and therefore as unsuitable for people with dysphagia according to IDDSI. This study provides valuable information to help with the selection of a safe medication lubricant with appropriate thickness level suited to each individual with dysphagia.

Experimental and Computational Investigation of the IDDSI Flow Test of Liquids Used in Dysphagia Management

The International Dysphagia Diet Standardisation Initiative (IDDSI) flow test, using a standard 10-mL syringe, is being adopted in many countries for clinical measurement of the consistency of drinks. The working hypothesis is that thickening drinks to retard flow can be advantageous for individuals who struggle to cope with thin drinks. This study assesses how the IDDSI test relates to rheology and clinical knowledge of physiological flows during swallowing. With no pre-existing analytical solution for internal flow through the syringe, a computational model was designed, incorporating rheometry data from a variety of Newtonian and non-Newtonian liquids. The computational model was validated experimentally across the range of liquids but the technique showed limitations in simulating dripping and cohesiveness. Gum-based liquids which were strongly shear-thinning (0.12 < n < 0.25) showed plug-flow characteristics with 90% of the shear occurring in only 22% of the radial dimension. Shear rates were maximal at the nozzle outlet (> 60 times higher than the barrel) and reached 7400/s for the thinnest gum-based liquid. Shear rheology data alone was unable to describe the flow of these drinks. The flow conditions in the test varied according to the type and consistency of liquid, relating to the desired clinical effect.