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Viscosity Measurements of Nectar- and Honey-thick Liquids: Product, Liquid,

and Time Comparisons

Article  in  Dysphagia · February 2005

DOI: 10.1007/s00455-005-0034-9 · Source: PubMed

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This is a pre-publication version of a journal article with the reference:

Garcia, J.M. and Chambers, E. IV. 2012. Perspectives of Registered Dietitians about Thickened
Beverages in Nutrition Management of Dysphagia. Topics Clin. Nutr. 27: 105-113.

Please refer to the final published version to see any modifications or to reference this paper.

Running Title: Viscosity of Thick Liquids

Viscosity Measurements of Nectar and Honey-thick Liquids: Product, Liquid,

& Time Comparisons

Jane Mertz Garcia, Ph.D.1

Edgar Chambers, IV, Ph.D.2

Ziad Matta, M.A.2

Megan Clark, M.S.1

1
Communication Sciences & Disorders
School of Family Studies & Human Services
Kansas State University
303 Justin
Manhattan, KS 66506-1403
2
Sensory Analysis Center, Human Nutrition
Kansas State University
213 Justin
Manhattan, KS 66505

Institution of Data Collection: Kansas State University

Contact Author/Off Print Address:

Jane Mertz Garcia, Ph.D.
jgarcia@humec.ksu.edu
(785) 532-1493
 Abstract

This study compared the viscosity (thickness) of five different liquids thickened to nectar- or

honey-like consistencies with a variety of thickening products. Samples were prepared using

manufacturer guidelines and viscosity was measured at the recommended time to thicken

(standard) and also after 10 and 30 minutes. Centipoise (cP) measurements on the samples were

compared across products and within product lines for each level of thickness at all three time

periods. Statistical analysis showed that the viscosity of a nectar- or honey-like liquid was highly

dependent on the type of thickening product and the time it was allowed to thicken. Variability in

viscosity measurements also was noted within a product line for thickening various liquids.

Results are discussed in relation to the National Dysphagia Diet guidelines for nectar- and

honey-like consistencies.

Key Words: Thick liquids, viscosity

2
 Diet adjustments are sometimes recommended for patients with disordered swallowing to

help maintain their nutritional needs. For example, thin liquids such as water, juice, or coffee

may be difficult to swallow safely because of a delayed pharyngeal swallow or oral motor

impairment.1-3 One solution for this problem is to compensate for the swallowing deficit by

thickening thin liquids to slow oropharyngeal transit time while creating a more cohesive bolus

that is easier to control.3-5 More viscous (thicker) liquids may promote safer swallowing,

minimizing the chances that aspiration may occur prior to swallowing.6

Although several commercial thickening agents are available for use in medical settings and

by individuals who have impaired swallowing, guidelines for the use of these products are

typically vague (e.g., add a standard amount of thickener to achieve a nectar- or honey-like

consistency), and variations in preparation procedure may produce different results at each

preparation, from one day to the next, or for one type of liquid versus another.7-9 Also, there is

insufficient product label information about potential differences in viscosity that may be related

to the composition of the thickener or the – Jane, I don’t know why someone would ever put

this kind of informaiton on the label type of liquid being thickened (e.g., apple or orange

juice). Also, raters perceive differences in consistency and taste across different products and

liquids may thicken differently because of their physical or chemical make-up (e.g., the presence

of acid in orange juice).10-12 Simply stated, “there is no assurance that ‘nectar’ or ‘honey’

products from one manufacturer are similar across its product line or to the viscosity of a

competitor’s product”.8

Potential variability within and across product lines is of additional concern since clinical

judgments of thickness are not reliable, even for experienced professionals. Glassburn and

3
Deem7 asked speech-language pathologists, who routinely assess patients with swallowing

disorders, to prepare samples of nectar and honey-thick water. The viscosity of each sample was

then measured. Results demonstrated significant interindividual variability in the viscosities of

nectar- and honey-thick liquids prepared by this group of speech-language pathologists.

Additionally, clinicans were not consistent in their ability to replicate the same level of thickness

across multiple tries. This type of variability also was reported by Brown, Mills, Daubert, and

Casper,13 in a study of speech-language pathologists and registered dietitians who were asked to

label prepared orange juice samples that ranged in consistency from thin to spoon-thick. Even

though the participants were allowed to stir and spoon samples to augment their visual

inspection, very poor agreement among the participants was observed for the descriptions

applied to the samples.

Liquids that are too thin or too thick may have important consequences for patients who

drink them. For example, poor patient acceptance of thickened liquids is a common concern.5, 14

Overly thickened liquids may contribute to this problem, since the addition of the thickening

agent to a beverage can impact its flavor and texture.11, 12 Patients with a strong dislike of

thickened liquids may, as a result, be less compliant and drink less, possibly contributing to other

medical complications such as dehydration.15, 16

The lack of clear standards for modified diets incorporating thickened liquids led to the

formation of the National Dysphagia Diet Task Force (NDDTF) and publication of the National

Dysphagia Diet (NDD) in 2002.17 Two tenets of the NDD included recommending labeling (thin,

nectar-like, honey-like, and spoon-thick) and viscosity ranges for each category of liquid.

Viscosity describes a liquid’s thickness –more specifically its resistance to flow and is reported

in centipoise (cP). Viscosity ranges for the NDD liquid categories are: thin (1-50 cP), nectar-like

4
(51-350 cP), honey-like (351-1,750 cP), and spoon-thick (greater than 1,750 cP). Because the

thickness of most consumable liquids changes as a function of its flow rate, viscosity measures

are typically reported at a specific shear rate.10 These liquids are described as “shear-thinning” in

that they decrease in viscosity as their flow rate increases. 17 Based on previous research, the

NDDTF selected a shear rate of 50s-1 and standard temperature of 25o C (room temperature) for

the viscosity measurements of the NDD. Although the NDDTF felt that a broad range of

viscosities for each level of thickness would allow more products to fall within the guidelines, no

information about the clinical importance was given. Also, no information on specific products

was presented, nor was any evidence provided that the established ranges of the NDD applied

equally well to the large variety of liquids that were commonly thickened (e.g., water, juice,

milk, and coffee).

The purpose of the current study was to compare viscosity measurements across products

and within product lines when thickening different liquids to a nectar- or honey-like consistency.

Although thickened liquids are shear thinning (i.e., non-Newtonian fluids whose viscosities

change as a function of flow rate), 17 this study used single point viscosity measurements for

comparison purposes. This meant that all data were collected at 25º C and calculated at a shear

rate of 50s-1 in order to examine the viscosities of different product/liquid combinations under

standardized conditions. This also permitted comparison of viscosity measurements of the

different commerical thickeners to the target ranges published by the NDDTF. 17 In addition to

the temperature of each liquid, another important consideration was the time each sample was

given to thicken. Reports suggest that some thickened liquids continue to increase in viscosity

over time. 3, 4, 18 Viscosity measurements for this study were collected at three time periods for

each sample including the manufacturer’s recommended time to thicken (described as the

5
“standard”) and at 10 and 30 minutes to examine the effect of standing time on viscosity. The 10

and 30 minute times were identified as reasonable periods for a prepared beverage to sit on a

patient’s tray (10 minutes) prior to serving and also a reasonable time for consumption during the

course of a meal (30 minutes). The specific research questions of this study were as follows:

1. Are there changes in viscosity measurements when samples are allowed to thicken for

different periods of time (standard, 10 and 30 minutes) for nectar or honey-like

consistency?

2. Are there differences in viscosity measurements across products and within a product line

when thickening 5 different liquids to nectar or honey-like consistency?

3. Do the mean viscosities of nectar or honey-like samples fit the ranges suggested by the

National Dysphagia Diet?

Methods

Materials

The commercial products selected for analysis included 3 starch-based thickeners (Thick &

Easy®, Thick-it®, and Thicken Up®) and 2 gum-based thickeners (Simply Thick® and Thik &

Clear®). All 3 starch-based thickeners were powdered and employed modified food starch (corn-

starch) as a thickening agent. Thick & Easy and Thick-it also included maltodextrin as an

ingredient, which is often used to provide bulk, viscosity and a smooth mouth feel. 19 Product

label information did not specify the relative amounts of each ingredient (corn-starch and

maltodextrin) in order to know how similar or dissimilar products were to one another. The 2

gum-based thickeners varied in composition/thickening agents: Simply Thick was a gel

containing xanthan gum, while Thik & Clear was a powder and contained cellulose gum

standardized with maltodextrin as thickeners.

6
 The liquids used included water, Mussleman’s apple juice, 2% milk, Tropicana no-pulp

orange juice and Folger’s decaffeinated coffee. Baseline viscosity measures of liquids were all

below 10 cP at a shear rate of 50s-1, similar to other reported findings and consistent the

definition of a “thin” liquid. 20, 21

Sample Preparation

Manufacturer guidelines were followed to determine the exact amount of thickening agent

required to achieve a nectar- or honey-like consistency for the target liquid. The amount of

thickener (in grams) was calculated from the volumetric amount recommended on the package to

produce 4 fl. oz. of a specific beverage. The volumetric amount for each product was measured 5

times to determine its average weight in grams. That weight was then used for all subsequent

samples for each particular product to ensure that the same amount of thickener was added to

samples thickened to a nectar- or honey-like consistency. Thicken Up guidelines recommended

different amounts of thickener for some liquids. If a range was provided (e.g., Thick It), samples

were prepared using the recommended amount of thickener required to produce a thickness at the

midpoint of the range. Thik & Clear packaging included two sets of directions. One direction

reflected a range for honey-like consistency (2 tsp to 1 tbsp) but the other direction stated a

specific amount (2 tsp). The set amount (2 tsp) was chosen for this product. A similar process

was used for the 5 liquids as their volumetric amount was converted to weight (g) to make

certain that each 4-ounce sample of a beverage was the same.

Similar preparation procedures were used for all samples. The appropriate amount of each

liquid was initially poured into a 600 mL beaker. The thickening agent was slowly poured and

stirred into the liquid and then continuously stirred for 20 seconds (or until completely dissolved)

using a Cimarec 2 (Barnstead/Thermolyne, Dubuque, IA) magnetic stirring device set at a

7
constant speed. The only product variation was for Simply Thick; it was shaken vigorously

(following the manufacturer’s recommendations) for the same time interval. Thik & Clear

samples in coffee and water also were shaken to prevent clumping. Once the sample was

prepared, timers were set for the 3 different test times. The first time was the manufacturer

recommended time to thicken prior to viscosity measurements (described as the “standard”).

This time varied according to manufacturer guidelines, and ranged from immediate (Simply

Thick) to 5 minutes (Thik & Clear). A different portion of the same sample was measured at 10

minutes and another portion of the same sample was measured at 30 minutes. Samples at 10 and

30 minutes were briefly re-stirred with the magnetic stirring device for 10 seconds at a low speed

to minimize any effects of settling. Three separate samples were prepared and measured for each

combination of product and liquid at each time to thicken. All samples were prepared and tested

in a laboratory setting.

Measurement Procedures

Viscosity was measured using a Brookfield RVDV-II+ viscometer (Brookfield Engineering,

Middleboro, MA) in order to provide a measure of the liquid’s “thickness” at a given point in

time. This instrumentation meets the American Society for Testing and Materials (ASTM)

standards for evaluating the properties of non-Newtonian materials (e.g., thickened liquids) in

the shear rate range from 0.1 to 50s-1. 22 For a Brookfield viscometer, viscosity is the measured

resistance to flow encountered by a spring when a spindle rotates in liquid. The most common

application of this type of measurement is the quantification of a fluid’s viscosity when

compared to either a target performance or when compared against another fluid. For example,

similar Brookfield instrumentation was used in developing target viscosities for the

8
standardization of nectar-thick and honey-thick barium products that are used during

videofluoroscopic evaluations of swallowing. 21

Prepared samples were maintained at a constant temperature of 25º C (±2º C) with a

Brookfield water bath. Using the small sample adaptor, a different portion of the same 4 oz.

sample was measured at the 3 designated time periods. Viscosity was calculated for a shear rate

of 50s-1. During preliminary research, the effect of minor temperature variations that could occur

in samples was tested on each liquid/thickener combination for both nectar and honey-thick

consistencies. Temperature was changed by ± 1 and 2 degrees Celsius and viscosity was

measured. All measurements were within the instrument’s accuracy (± 1%) and repeatability (±

2%), showing that a change of ±2º C did not appreciably affect the measured viscosity of the

samples. Consistency in temperature and shear rate measurement made it possible to compare

products to one another and also to compare against the ranges published in the NDD guidelines.

Statistical Analysis

The data were analyzed by a repeated measures analysis of variance with Product and

Liquid being the two between factors and Time representing the repeated within subject factor.

The centipoise measurement was the dependent variable. Fisher’s protected least significant

difference (LSD) procedure was used to determine whether a significant difference existed (p <

0.05).

Results

Significant 3-way interactions were observed for both nectar and honey-like consistencies (p

< 0.001 in both cases). This meant that comparisons of thickeners depend on the types of liquids

and the time levels involved, comparisons of liquids depend on the brands of thickeners and the

time levels involved, and the effects of the time depend on the brands of thickeners and the types

9
of liquids used in sample preparation. Tables 1 and 2 summarize the average viscosity (in cP) of

the 3 samples and the standard deviation for each combination of liquid and product thickened to

a nectar- or honey-like consistency measured at the three time periods. Larger mean values

represent thicker/more viscous liquids and smaller mean values represent thinner/less viscous

liquids.

<<Insert Tables 1 & 2 about here>>

Nectar Consistency

Differences in the viscosity of samples for each product and liquid combination measured at

standard preparation time and also at 10 and 30 minutes of thickening time are reported in Table

1. The standard time for thickening is always designated as “1” in the time (T) column.

Statistically significant (p < 0.05) changes in viscosity are specified with a “2” or “3” as

appropriate. For example, Thick & Easy coffee samples did not statistically differ from one

another at standard, 10 or 30 minutes of thickening time (all recorded as“1”). In contrast, there

were statistically significant differences in the viscosity of 2% milk for Thick & Easy across

time. The mean viscosity at the standard time to thicken was 62 cP. It became significantly

thicker (166 cP) at 10 minutes (“2”) and significantly increased to 256 cP by 30 minutes (“3”).

The results showed that Simply Thick and Thik & Clear nectar samples of water, apple juice,

orange juice, milk, and coffee did not significantly change in their mean viscosity across the

three time periods. A different pattern occurred for the other three products (Thick & Easy,

Thick It, and Thicken Up), which are starch-based. Four of the five liquids showed some change

in thickness over time for Thick & Easy and Thicken Up. All 5 liquids showed an increase in

their viscosity for Thick It. Overall, 12 of 15 (80%) product/liquid combinations for those three

products were significantly thicker at 10 minutes compared to their standard time to thicken,

10
which ranged from 30 seconds to 3 minutes. Forty percent of these samples (6 of 15) showed

statistically significant differences when comparing the 10 to 30 minute time periods. In all but

one case, the sample was more viscous at 30 minutes. The exception was Thick & Easy orange

juice where the mean viscosity measurement decreased at 30 minutes (360 to 321 cP). It is

possible that the specific modified starch or the maltodextrin in the Thick & Easy sample was

beginning to be broken down by the extended exposure to the acid found in the orange juice.

Further analysis also showed differences within product lines. Viscosity measurements for

each product and liquid combination were compared to one another at each time interval to

thicken. The results are letter coded in the “L” (liquid) column of Table 1. For example, viscosity

measurements at the standard time to thicken for Thick & Easy water (48 cP), milk (62 cP), and

coffee (61cP) were similar to one another (identified as “A”). Apple juice (106 cP) was

statistically different (“B”) and orange juice (225 cP) was even more viscous (identified as “C”).

Products showed variable viscosities across different liquids, which was apparent in the results

for all three periods of time. Thickening products mixed with orange juice or 2% milk typically

produced more viscous samples than the other liquids, especially for the starch-based thickeners

(Thick & Easy, Thick It, and Thicken Up) measured at 10 and 30 minutes. Although Simply

Thick exhibited a number of contrasts that were statistically significant, this product had the

smallest overall variation across the different liquids. For example, it ranged from 53 cP (water)

to 93 cP (orange juice) at 30 minutes.

Viscosity measurements from each product were compared to one another at the standard

thickening time (Figure 1), 10 minutes (Figure 2), and after 30 minutes of thickening (Figure 3)

for each of the 5 liquids. The results illustrate product differences across liquids at every time

period to thicken. Product differences were more apparent as liquids thickened for 10 and 30

11
minutes. Product results also were more variable for orange juice and milk in comparison to the

other liquids (water, apple juice, & coffee). For example, viscosity measurements for 2% milk

were all significantly different from one another (p <0.05) as illustrated in Figure 2. In this

example, Simply Thick (90 cP) was the least viscous (A) and differed from the 130 cP of Thik &

Clear (B), which was less than the 166 cP of Thick & Easy (C). Thick It (D) and Thicken Up (E)

produced the most viscous milk samples, 242 cP and 338 cP respectively. Overall, Thick &

Easy, Thick It and Thicken Up were the three most viscous samples at each time period.

<<Figures 1-3 about here>>

Honey-like Consistency

Differences in the mean viscosities of honey-like consistencies related to the amount of time

given to thicken and liquid type are highlighted in Table 2. The results showed that Simply Thick

and Thik & Clear honey-like samples of water, apple juice, orange juice, milk and coffee did not

significantly change (p > 0.05) in viscosity across 10 and 30-minute time periods. The same was

true for Thicken Up mixed with water, apple juice, orange juice and coffee; a different pattern

occurred with 2% milk. That is, the mean viscosity of each time period was significantly

different (p < 0.05) from the other, reflecting a significant increase in its thickness at 10 and at 30

minutes. The results of Thick & Easy and Thick It were similar to one another in that all 5

liquids significantly increased in viscosity at 10 minutes and many (7 of 10) product/liquid

combinations continued to thicken when measured at 30 minutes.

Overall, there was less variability in the mean viscosities of honey-like samples within a

product line, especially for Simply Thick, Thik & Clear, and Thicken Up. The mean viscosities

of Simply Thick and Thik & Clear remained statistically similar to one another across the 5

liquids at standard, 10 and 30 minutes. Thicken Up showed a similar pattern with the exception

12
of 2% milk, which was always significantly greater in viscosity compared to the other 4 liquids

at each thickening time. The resulting viscosities of honey-like consistencies prepared with

Thick & Easy and Thick It were more variable. Orange juice and 2% milk honey-like

consistencies were the most viscous for these products, particularly at 10 and 30 minutes.

Product comparisons are illustrated in Figures 4-6 for honey-like consistencies. Results

reflected significant differences between products for all liquids. Differences between products

for honey-like consistencies became more apparent when given longer than the standard time to

thicken, particularly for orange juice and milk. Thick It, a starch-based thickener, produced

significantly thicker samples than other products when mixed with water, apple juice, orange

juice, and coffee at all three thickening periods and also with milk that thickened for 10 or 30

minutes. Thicken Up, Simply Thick, and Thik & Clear were typically the least viscous of the

honey-like consistencies across water, apple juice, orange juice, and coffee especially at 10 and

30 minutes.

<<Figures 4-6 about here>>

Comparison to National Dysphagia Diet Ranges

The mean viscosities of both nectar and honey-like samples were compared to the ranges

suggested by the NDD. Nectar-like thickness (51-350 cP) was achieved by 91% of the various

product/liquid combinations. All of the mean viscosities of Simply Thick fell within this range,

typically at the low end. Some mean viscosities were slightly below the lower limit, including

Thik & Clear apple juice (50 cP), Thick & Easy water (48 cP), and Thick It coffee (42 cP).

Samples that exceeded the range were prepared with 2% milk and Thicken Up (391 cP), as well

as orange juice mixed with Thick & Easy (360 cP) or Thick It (446-516 cP) and held for 10 or 30

minutes.

13
 The recommended range of the NDD for honey-like consistency is 351-1750 cP. Only 36%

of the mean viscosities for the different product/liquid combinations fit this range. Of the 48-

liquid/product combinations that did not meet the criterion, 41 were below the range and 7 were

above the NDD guidelines. Orange juice and 2% milk prepared with Thick & Easy and Thick It

accounted for the most viscous samples measuring from 2,239 to 4,614 cP. Thickened liquids

that fell below 350 cP were typically prepared with Thik & Clear, Simply Thick or Thicken Up.

Discussion

The current study examined thickening product variability when producing nectar- and

honey-like consistencies for 5 different liquids. Viscosity measurements were made at 3 times

(standard, 10 and 30 minutes). The amount of setting time for a product was an important factor

for both nectar and honey-like consistencies. For each level of thickness, a difference emerged in

the pattern of thickening for starch versus gum-based thickeners. Simply Thick and Thik & Clear

(gum-based thickeners) did not change in viscosity from their standard preparation to 10 or 30

minutes of setting time. This was consistent across all 5 liquids for both nectar and honey-thick

consistencies. A different pattern emerged for starch-based thickeners (Thick & Easy, Thick It,

and Thicken Up) as most of these nectar-thick product/liquid combinations (80%) significantly

increased in viscosity by 10 minutes with about one-third of the same combinations continuing to

thicken by 30 minutes. It is not known if samples thickened at consistent intervals (e.g., after 5

vs. 8 minutes) or if viscosity measurements would continue to increase beyond 30 minutes. For

honey-like consistencies, Thick & Easy and Thick It reflected a generally similar pattern with

higher viscosity measurements at 10 minutes (100% of product/liquid combinations) compared

to the standard time and 70% of these samples were thicker by 30 minutes compared to the

measurement at 10 minutes. Thick It samples of orange juice and milk were similar to a spoon-

14
thick consistency after 10 minutes of setting time. Thicken Up was more similar to the gum-

based thickeners in that 4 of 5 liquids remained at a similar level of viscosity across the three

time periods (milk was the exception). Thicken up, a starch-based thickener, produced lower

perceived viscosity for orange juice and apple juice in a previous study12 suggesting that the

level or type of modification to the corn-starch in the product is different from the other starch-

based thickeners. Another consideration is that Thicken Up did not contain maltodextrin,

whereas the other two starch-based thickened listed it as an ingredient.

Viscosity measurements across the 3 time periods highlight important differences between

starch and gum-based thickeners. Although specific processing information on the starches and

gums used in the thickeners is not available, basic information on carbohydrate chemistry is

helpful in understanding some of the rheological differences among the thickeners mixed in

various liquids. 23, 24 At a very basic level, starches generally thicken by slowly absorbing liquid

and swelling, much like a balloon swells with air. For many of the starch thickened beverages,

thickening continued to occur over the 30 minutes of the test, suggesting that most of the

starches continued to absorb liquid (hydrate) over a period of time. Although some swelling may

occur with gum thickeners, they also have many strands that can become entangled or can bind

together in the presence of acid or ions. For gum thickeners, this process typically happens

relatively quickly and with less change in thickness over time.

Results from this study provide evidence about the variability across thickening products and

the manner in which each product thickened different liquid types. It is clear from this

experiment that the composition of the base liquid has an impact on the ultimate viscosity of the

thickened beverage, which should be expected given the various compositions of the liquids.

15
 From a food science standpoint, differences in the interaction of the starch or gum and the

specific beverage can result from many factors. Possibilities include the presence of pectin (apple

and orange juice), ions (higher concentrations in orange juice and milk), protein (milk), acids

(higher concentrations in orange juice), and solids (orange juice and coffee). 25, 26 Low-pulp

orange juice or 2% milk produced the most viscous nectar-like consistency for the three starch

products. Although low-pulp orange juice contains little or no large pulp particles it does contain

fine pulp and acid that may interact with the thickening agents resulting in greater thickening

capacity. Milk contains minerals and other ingredients that can interact with the thickeners

resulting in greater bonding and thickening capacity. Water, coffee, and apple juice produced the

least viscous samples across most products. Those liquids generally have a low solids content

(except from sugar in the apple juice) and less acid, which would not result in any expected

deviations from the “standard” thickening power of the thickening agent. One exception to that

trend was Thicken Up, which also did not result in increases in thickness over time for either

apple juice or orange juice. It is possible that the specific starch modification used for Thicken

Up interacts with the pectin and fruit acids in those beverages and results in either reduced

hydration or in breakdown of the starch, which decreases thickness.

The results also shed light on whether the National Dysphagia Diet captures the range of

nectar and honey-like consistencies produced from some commonly available thickeners.

Although samples generally fell within the NDD suggested range for nectar-like consistency (51-

350 cP), this was not the case for honey-like consistencies even when the liquids were measured

at the manufacturer’s recommended (“standard”) time to thicken. In most instances, samples

were below the lower limit of the honey-like consistency range (351 to 1750 cP). This was

particularly true for both of the gum-based thickeners (Simply Thick and Thik & Clear), as well

16
as Thicken Up (starch-based thickener). Honey-like consistencies were quite variable ranging

from 105 cP (Thik & Clear apple juice) to 4,614 cP (Thick It orange juice). Overall, less than

40% of the mean viscosity measurements for honey-like liquid/product combinations were

within the NDD range of 351-1750 cP across the 3 test times. This information suggests that

recommendations from the NDD are not necessarily inclusive of current actual product

recommendations for honey-like consistency. This is especially true of honey-like samples that

are allowed to thicken longer than the manufacterer’s recommended time.

Clinical Implications, Limitations, & Future Research

Because some of the nectar and most of the measurements for honey were outside the range

suggested by the NDD, considerable discussion and research is needed to confirm the levels

selected for the NDD. That is especially true if manufacturers are expected to change package

recommendations to meet the NDD proposed guidelines. At a minimum, more detailed product

labels could be helpful such as clarity about the composition of starch-based thickeners that

include more than one ingredient. Research of this type also is important because this study

revealed a number of statistically significant differences among products, but it is not known if

those differences are important for safe swallowing.

It is acknowledged that the methods for sample preparation and viscosity measurement create

limitations in interpreting the results from this study. One factor is that the samples were

measured at 25 degrees C (room temperature) and that the measurements are reported for only

one shear rate.27, 28 The temperature was selected in order to have values that could be compared

to the NDD ranges, even though room temperature beverages such as coffee may be unpalatable

to many patients. A consideration is that thickened liquids are typically prepared with

refrigerated beverages, often about 4 degrees Celsius. Temperature differences of this magnitude

17
(room vs. typical serving) are reported to impact viscosity (cold samples are more viscous). 3

Additional research is needed to better understand the effect of serving temperature on viscosity

and if the variation in viscosity measurements is predictable across different thickening products.

Another consideration is that the bolus flows at different speeds through the oral cavity, pharynx,

and esophagus. 20, 27, 28 Shear (flow) rates from 10-100s-1 are associated normal swallowing29. For

ease of reporting and clarity of comparison, a frequently identified shear rate (50s-1) was

selected. 8, 17 The most important shear rate(s) for impaired swallowing is not known at the

present time.

The viscosity of thickened liquids also should be evaluated at other “times to thicken”

especially since the results from this study suggest that viscosity is time-dependent for many

product/liquid combinations. The 10 and 30-minute time periods were identified as reasonable

setting times for beverages prepared at the beginning of a meal; however, some centers may

prepare thickened liquids in the kitchen in bulk and serve them at a much later time, well after 30

minutes. The findings from this study may be less applicable in this situation. Additionally, the

samples at 10 and 30 minutes were briefly re-stirred to minimize any effects of settling, similar

to a situation in which a caregiver might re-stir a beverage prior to serving it. It is acknowledged

that this procedure may have impacted viscosity measurements since thickened liquids are non-

Newtonian and shear-rate dependent.

The results from this study highlight the complexity of factors surrounding the viscosity of

thickened liquids. For example, facilities may inadvertently select products that result in

significantly different nectar or honey-like consistencies simply because of the types of

beverages typically consumed by their patients and any setting time that may occur after a

beverage is mixed. In addition to viscosity, the impact of the various thickeners on sensory

18
attributes such as flavor and texture in different liquids should receive future consideration.

Clinicians who recommend thickened liquids for their patients must be aware of the combination

of factors in order to make informed clinical decisions.

Acknowledgements. This research was supported by a grant from the Kansas Health and

Nutrition Fund.

19
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22
Table 1. Nectar viscosity measurements in centipoise (cps) for each liquid, thickener, and time combination with significant

differences for each product (p < 0.05).

Water Apple Juice Orange Juice 2% Milk Coffee

Mean (SD) T* L** Mean (SD) T* L** Mean (SD) T* L** Mean (SD) T* L** Mean (SD) T* L**

Thick & Easy

Standard 48 (8) 1 A 106 (17) 1 B 225 (25) 1 C 62 (16) 1 A 61 (18) 1 A

10 minutes 67 (8) 1, 2 A 137 (3) 2 B 360 (19) 3 D 166 (10) 2 C 75 (14) 1 A

30 minutes 77 (4) 2 A 149 (8) 2 B 321 (24) 2 D 256 (54) 3 C 80 (2) 1 A

Thick It

Standard 62 (7) 1 A 97 (27) 1 B 220 (22) 1 C 50 (13) 1 A 42 (4) 1 A

10 minutes 123 (11) 2 A 151 (8) 2 B 446 (35) 2 D 242 (45) 2 C 119 (34) 2 A

30 minutes 130 (9) 2 A 167 (17) 2 B 516 (21) 3 D 238 (5) 2 C 123 (9) 2 A

Thicken Up

Standard 136 (10) 1 B 58 (9) 1 A 118 (5) 1 B 190 (87) 1 C 111 (6) 1 B

10 minutes 169 (6) 2 C 66 (6) 1 A 150 (20) 2 B/C 338 (90) 2 D 129 (26) 1 B

30 minutes 210 (29) 3 D 72 (4) 1 A 140 (35) 2 B/C 391 (78) 3 E 157 (74) 2 C

(Table continued)
Simply Thick

Standard 54 (2) 1 A 65 (1) 1 A/B 97 (6) 1 C 87 (8) 1 B/C 100 (30) 1 C

10 minutes 52 (5) 1 A 61 (1) 1 A/B 95 (6) 1 C 90 (28) 1 C 83 (15) 1 B/C

30 minutes 53 (4) 1 A 61 (2) 1 A 93 (7) 1 B 78 (7) 1 A/B 74 (17) 1 A/B

Thik & Clear

Standard 153 (16) 1 C 50 (1) 1 A 113 (6) 1 B 130 (6) 1 B/C 76 (6) 1 A

10 minutes 144 (10) 1 C 53 (2) 1 A 112 (9) 1 B 130 (2) 1 B/C 78 (5) 1 A

30 minutes 144 (6) 1 C 53 (2) 1 A 114 (9) 1 B 134 (3) 1 B/C 74 (3) 1 A

____________________________________________________________________________________________________________

Note. T = Time; L = Liquid

*LSD means comparison among 3 time periods: Means with a different number in a column are significantly different (p< 0.05) for
that product/liquid combination.

**LSD means comparison among 5 liquids: Means with a different letter(s) within a row are significantly different (p< 0.05) for
product/liquid combinations at each time period to thicken.

24
Table 2. Honey-like viscosity measurements in centipoise (cps) for each liquid, thickener, and time combination with significant

differences for each product (p < 0.05).

Water Apple Juice Orange Juice 2% Milk Coffee

Mean (SD) T* L** Mean (SD) T* L** Mean (SD) T* L** Mean (SD) T* L** Mean (SD) T* L**

Thick & Easy

Standard 344 (42) 1 A 370 (52) 1 A 1,216 (98) 1 B 201 (55) 1 A 351 (23) 1 A

10 minutes 557 (11) 2 A 890 (129) 2 B 2,239 (191) 2 D 1,639 (395) 2 C 536 (63) 2 A

30 minutes 637 (43) 2 A 1,080 (234) 3 B 2,441 (238) 3 C 2,988 (183) 3 D 668 (85) 2 A

Thick It

Standard 584 (140) 1 B 603 (138) 1 B 1,547 (444) 1 C 340 (129) 1 A 625 (100) 1 B

10 minutes 985 (177) 2 A 1,476 (106) 2 B 4,012 (245) 2 D 3,375 (373) 2 C 1,094 (9) 2 A

30 minutes 1,219 (37) 3 A 1,450 (340) 2 A 4,463 (540) 3 B 4,614 (458) 3 B 1,330 (102) 3 A

Thicken Up

Standard 251 (32) 1 A 164 (15) 1 A 267 (37) 1 A 527 (40) 1 B 184 (16) 1 A

10 minutes 328 (19) 1 A 190 (18) 1 A 317 (39) 1 A 1,047 (230) 2 B 227 (25) 1 A

30 minutes 405 (41) 1 A 249 (32) 1 A 358 (52) 1 A 1,237 (256) 3 B 288 (48) 1 A

(Table continued)

25
Simply Thick

Standard 213 (16) 1 A 271 (13) 1 A 346 (7) 1 A 310 (5) 1 A 291 (11) 1 A

10 minutes 211 (23) 1 A 280 (4) 1 A 372 (7) 1 A 295 (9) 1 A 296 (18) 1 A

30 minutes 210 (14) 1 A 287 (7) 1 A 363 (19) 1 A 304 (6) 1 A 294 (10) 1 A

Thik & Clear

Standard 224 (34) 1 A 105 (10) 1 A 185 (15) 1 A 200 (21) 1 A 145 (19) 1 A

10 minutes 241 (23) 1 A 102 (3) 1 A 195 (18) 1 A 207 (28) 1 A 138 (25) 1 A

30 minutes 221 (7) 1 A 107 (6) 1 A 188 (13) 1 A 201 (23) 1 A 127 (9) 1 A

____________________________________________________________________________________________________________

Note. T = Time; L = Liquid

*LSD means comparison among 3 time periods: Means with a different number in a column are significantly different (p< 0.05) for
that product/liquid combination.

**LSD means comparison among 5 liquids: Means with a different letter(s) within a row are significantly different (p< 0.05) for
product/liquid combinations at each time period to thicken.

26
 Figure Legends

Figure 1. Viscosity measurements in centipoise (cP) for each product and liquid combination for

nectar—like consistencies at the standard time to thicken including significant differences (p <

0.05).

Figure 2. Viscosity measurements in centipoise (cP) for each product and liquid combination for

nectar—like consistencies at 10 minutes including significant differences (p < 0.05).

Figure 3. Viscosity measurements in centipoise (cP) for each product and liquid combination for

nectar—like consistencies at 30 minutes including significant differences (p < 0.05).

Figure 4. Viscosity measurements in centipoise (cP) for each product and liquid combination for

honey—like consistencies at the standard time to thicken including significant differences (p <

0.05).

Figure 5. Viscosity measurements in centipoise (cP) for each product and liquid combination for

honey—like consistencies at 10 minutes including significant differences (p < 0.05).

Figure 6. Viscosity measurements in centipoise (cP) for each product and liquid combination for

honey—like consistencies at 30 minutes including significant differences (p < 0.05).

Figure 1—Nectar standard

Thick & Easy Thick It Thicken Up Simply Thick Thik & Clear

600

500

400
Centipoise

300

200

100

A A B A B B B A A A B B A A A B/A A D B C B/A A D D/C B/C

0
Water Apple Juice Orange Juice 2% Milk Coffee

28
Figure 2—Nectar at 10 minutes

Thick & Easy Thick It Thicken Up Simply Thick Thik & Clear

600

500

400
Centipoise

300

200

100

A B C A B/C B B A A A C D B A A C D E A B A B B A A
0
Water Apple Juice Orange Juice 2% Milk Coffee

29
Figure 3—Nectar at 30 minutes

Thick & Easy Thick It Thicken Up Simply Thick Thik & Clear

600

500

400
Centipoise

300

200

100

A B C A B B B A A A C D B A B/A C C D A B A B C A A
0
Water Apple Juice Orange Juice 2% Milk Coffee

30
Figure 4—Honey at standard

Thick & Easy Thick It Thicken Up Simply Thick Thik & Clear

2500

2000

1500
Centipoise

1000

500

A B A A A B C A B/A A B C A A A A B/A B A A B C B/AB/A A

0
Water Apple Juice Orange Juice 2% Milk Coffee

31
Figure 5—Honey at 10 minutes

Thick & Easy Thick It Thicken Up Simply Thick Thik & Clear

4500

4000

3500

3000
Centipoise

2500

2000

1500

1000

500
B C B/A A A B C A A A B C A A A C D B A A B C A A A
0
Water Apple Juice Orange Juice 2% Milk Coffee

32
 Figure 6—Honey at 30 minutes

Thick & Easy Thick It Thicken Up Simply Thick Thik & Clear

5500

5000
4500

4000

3500
Centipoise

3000

2500
2000

1500

1000
500 B C A/B A A B C A A A C D B A A C D B A A B C A A A
0
Water Apple Juice Orange Juice 2% Milk Coffee

33

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