Food thickeners are commonly used to prepare thickened liquids for the management of dysphagia. The National Dysphagia Diet (NDD) thickness levels of thickened liquids prepared with commercial food thickeners are known to vary depending on the thickener type, recommended amount of thickener, thickener brand, and preparation instructions. Particularly, detailed preparation instructions must be provided by the manufacturers to achieve the correct thickness levels. However, the rheological information on product labels provided by manufacturers is typically not accurate. Here, various pudding-thick liquids were prepared by mixing commercial xanthan gum (XG)-based thickeners based on the manufacturers’ guidelines, and their rheological properties were characterized. Several thickened liquids prepared with four different XG-based thickeners (A-D) marketed in Korea did not meet the pudding-like criterion (> 1,750 mPa·s) based on the NDD guidelines. Significant differences in rheological parameter values (ηa,50, n, and G′) were also identified among the various thickened liquids. Only one thickener (thickener A) manufactured in Korea showed optimal results, which satisfied the pudding-thick viscosity range for various food liquids and also showed lower stickiness and enhanced bolus formation ability for easy and safe swallowing when compared to other thickeners (B, C, and D).
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Barium sulfate is commonly used to prepare contrast media for videofluorograpy. The flow characteristics of thickened liquids formulated for oropharyngeal imaging are known to be greatly affected by the addition of barium. In this study, thickened barium liquids were prepared by mixing a commercial xanthan gum (XG)-based thickener (Visco-up®) at different concentrations (0.1%–3.0%) with barium powder (Baritop HD®), and differences in the viscosity between thickened non-barium and thickened barium liquids were investigated. In addition, the thickness levels of thickened barium liquids, which are based on the National Dysphagia Diet (NDD) and International Dysphagia Diet Standardization Initiative (IDDSI) guidelines, were classified by measuring the viscosity (NDD) and gravity flow through a syringe (IDDSI) with 0.1%–3.0% thickener concentrations. The apparent viscosity (ηa,50) values of thickened barium liquids were much higher than those of thickened non-barium liquids, indicating that the addition of barium to the XG-based thickener resulted in further thickening. Standard recipes for preparing thickened barium liquids with desirable thickness levels were also established, showing the different thickener concentrations corresponding to the different NDD and IDDSI levels.
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Gastro-esophageal reflux (GER) is a common and serious complication in patients receiving enteral nutrition, making continuation of enteral nutrition difficult. Semi-solid enteral nutrients were developed to prevent feeding-related GER. Semi-solid enteral nutrients have high viscosity and, therefore, are typically administered through a large-diameter percutaneous endoscopic gastrostomy (PEG) tube. Recently, a new formula (Mermed®, Mermed Plus®) was introduced that uses alginate, which behaves like a gelatin in acidic conditions. This formula improved GER during enteral feedings. Our case report shows that this new formula enables the continuation of enteral nutrition via a nasogastric tube (NGT) in patients with difficulty tolerating enteral nutrition secondary to vomiting. An 86-year-old woman with an atherothrombotic cerebral infarction vomited during tube feeding, resulting in aspiration pneumonia. After 1 week, we introduced a viscosity regulator and restarted enteral feeding using a 100 mL liquid diet, but vomiting persisted. Because of the continued difficulty in tolerating enteral nutrition, the patient was transferred to our hospital. From hospital day 4, Mermed Plus® (300 mL/225 kcal, administered for 1 hour, 3 times a day) was started, eventually increasing to 535 mL/400 kcal at hospital day 5. After this, vomiting ceased. Mermed Plus® was easily administered via NGT, and its effects were immediate. This treatment appeared to improve the patient's quality of life while reducing the burden on medical staff.
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The effect of human saliva on the flow properties of pudding-like thickened water prepared with commercial food thickeners was investigated, and their viscosity differences were also compared as a function of salivary reaction time (0-60 min after the addition of saliva). Food thickeners used in this study were starch-based (SB), gum-containing starch-based (GSB), and gumbased (GB) commercial thickeners marketed in Korea. GB showed no significant reduction in viscosity upon contact with human saliva during the salivary reaction. In contrast, SB almost completely lost its viscosity shortly after the addition of saliva, and GSB significantly reduced its viscosity after 20 min of reaction time but retained its viscosity. The results of this study indicate that GB can enhance the swallowing safety of dysphagic patients by retaining a stable viscosity level without the reduction of viscosity during consumption of thickened fluids, whereas SB may increase the possibility of aspiration owing to a rapid decrease of viscosity upon contact with human saliva.
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