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Clin Nutr. 2018 Dec;37(6 Pt A):1980-1991. doi: 10.1016/j.clnu.2017.09.002. Epub 2017 Sep 9.

Systematic review and evidence based recommendations on texture modified foods and thickened liquids for adults (above 17 years) with oropharyngeal dysphagia - An updated clinical guideline.

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Division of Nutrition and Health, Faculty of Health and Technology, Metropolitan University College, Copenhagen, Denmark; Research Unit for Nutrition, Herlev and Gentofte Hospital, Copenhagen, Denmark. Electronic address:
Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Denmark.
Division of Physical and Occupational Therapy, Faculty of Health and Technology, Metropolitan University College, Copenhagen, Denmark.
RUBRIC (Research Unit on Brain Injury Rehabilitation Copenhagen), Department of Neurorehabilitation, TBI Unit, Copenhagen University Hospital, Denmark; Health, Arhus University, Denmark.



Oropharyngeal dysphagia (OD) has significant consequences for both the person with dysphagia and the society. An often-used treatment for OD is the recommendation of the texture of food and liquids. This recommendation seems to be based more on best practice than on evidence from a systematic review of existing scientific evidence. The aim of this paper was to report the result of an up-date of an original national guideline focussing on whether thickened liquids (review question 1) and modified foods (review question 2) are beneficial for adults above 17 years with OD in relation to three critical outcomes (aspiration, pneumonia and death) and seven important outcomes (dehydration, weight loss, mealtime performance, patient preferences, intervention adherence and quality of life).


Three steps were used. First: An updated systematic literature search. Second: An assessment of the quality of the evidence for each review question by means of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Third: Development of clinical recommendations based on the evidence, assessment of the risk benefit ratio, and perceived patient preferences.


The body of evidence consisted of two RCTs for review question 1 both using nectar thickened liquids or honey-thickened liquids. No evidence was found for two important outcomes, mealtime performance and quality of life. With regard to risk of pneumonia, death, aspiration, dehydration, weight loss and intervention adherence no significant differences were found. The outcome addressing patient preferences, found a non-significant increased dissatisfaction with nectar thickened liquids (RR 1.11; 95% CI 0.95-1.30) and a significant increased dissatisfaction with honey thickened liquids compared to thin liquids/chin down (RR 1.18; 95% CI 1.01-1.37). No evidence was identified for review question 2.


Based on the quality of the evidence, assessment of the risk benefit ratio, and perceived patient preferences a weak recommendation against the use of texture modified liquids and good clinical practice pointing for the use of texture modified foods in patients with OD were made.


Aspiration; Dehydration; Patient preferences; Quality of life


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