Food Hydrocolloids for Health 1 (2021) 100038

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Food Hydrocolloids for Health

journal homepage: www.elsevier.com/locate/fhfh

The safety and efficacy of xanthan gum-based thickeners and their effect in
modifying bolus rheology in the therapeutic medical management of
dysphagia
Enrico K. Hadde a, Brenda Mossel b, Jianshe Chen a, Sangeeta Prakash c,∗
a
Lab of Food Oral Processing, School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
b
Trisco Foods Pty Ltd, Brisbane, Australia
c
School of Agricultural and Food Sciences, The University of Queensland, Brisbane, Australia

a r t i c l e i n f o a b s t r a c t

Keywords: Thickened fluids are commonly prescribed for the medical management of individuals who have swallowing
Dysphagia difficulty. However, it is not always easy to obtain the prescribed thickness consistency of thickened fluids and, a
Xanthan gum common contributor to variabilities in thickness consistency is the type of thickener selected. Xanthan gum-based
Thickened fluids
thickeners are increasingly used in commercial thickening products for management of oropharyngeal dysphagia
Liquid thickener
(OD). While less common, xanthan gum-based thickening agent in a liquid form is an alternative thickening
agent for use only under medical supervision for the management of OD. It is hypothesised that liquid thickener
is substantially equivalent in safety and therapeutic function to xanthan gum-based powdered thickener. This
systematic review aims to identify the safety and efficacy of powdered and liquid xanthan gum-based thickeners
and their effect in modifying bolus rheology in the therapeutic medical management of OD. A multi-engine
search yielded 210 non-duplicate articles of which 43 were judged to be relevant. The articles underwent detailed
review for study quality and data extraction that confirmed xanthan gum-based thickened fluids are effective in
improving the safety of swallow and reduce aspiration without increasing the prevalence of pharyngeal residue.
Additionally, xanthan gum-based thickeners are superior to starch-based because of better texture perception,
more cohesive, better stability (e.g., time or temperature) and better resistance to salivary amylase. Both forms
(liquid or powder) of thickener are clinically safe and effective in improving the swallow safety in individuals with
OD, although published clinical data supporting the safety and efficacy of liquid xanthan gum is more limited.
However, in some situations, liquid form is more suitable than powdered alternatives because it is more readily
dissolves directly in the fluid.

Introduction
Dysphagia is a complex medical condition in which patients have
difficulty of swallowing that affects safety, and/or quality of eating and
drinking (Cichero et al., 2013; Hadde & Chen, 2021; Logemann, 1998;
Whelan, 2001). It has been reported that dysphagia affects 8% of the
worldwide population (Cichero et al., 2013; Clavé & Shaker, 2015).
It affects individuals of all ages from infants to the elderly, with the
majority of patients being elderly who face swallowing difficulties due
to illness, polypharmacy and weakened reserves (Barczi et al., 2000;
Cabre et al., 2010; Clavé & Shaker, 2015). Dysphagia has devastating
consequences on both health and quality of life (Clavé & Shaker, 2015;
Logemann, 1998). Malnutrition, dehydration, risk of chest infection, de-
pression and social isolation are common amongst dysphagia sufferers
(Atherton et al., 2007). As a serious medical disorder, oropharyngeal
dysphagia (OD) contributes to reduced dietary intake, aspiration and as-
phyxiation (Atherton et al., 2007; Logemann, 1998; Vivanti et al., 2009).
Swallowing is an extremely complex neuromuscular interaction in
the human body (Domenech & Kelly, 1999). The oropharyngeal swallow
mechanism comprises of several behaviours that changes depending on
bolus characteristics (e.g. viscosity and elasticity). During a swallow, the
larynx closes to protect the airway and breathing briefly stops while si-
multaneously allowing the food and liquid to enter the oesophagus. The
pharyngeal transit time generally lasts for only one second for healthy
individuals. Individuals with OD, however, often have a longer transit
time (> 3 s) (Mann, 2002) with poorly timed swallowing and breath-
ing may result in food materials entering the airway. This inefficient
swallowing can result in impaired airway protection and residue being
restrained in the pharynx, risking inhalation into the lungs (Cichero &
Murdoch, 2006).

∗
Corresponding author.
E-mail address: s.prakash@uq.edu.au (S. Prakash).

https://doi.org/10.1016/j.fhfh.2021.100038
Received 26 June 2021; Received in revised form 30 October 2021; Accepted 7 November 2021
2667-0259/© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
E.K. Hadde, B. Mossel, J. Chen et al. Food Hydrocolloids for Health 1 (2021) 100038

Texture-modified foods and thickened fluids play a major role in clin-

ician’s treatment for dysphagia management to avoid aspiration into the
airway whilst maintaining adequate hydration and nutrition (Leonard
& Kendall, 2013; Steele et al., 2015). Thickened fluids flow more slowly
than thin liquid (e.g. water), allowing an adapted reflex response time
while swallowing (Dantas et al., 1990; Reimers-neils et al., 1994). It
should be noted that thickened fluids are not a diet of choice, but one
of safety and have become the most recommended therapeutically by
clinicians due to low cost and ease of implementation (Chen, 2009;
Logemann, 2014). While thickened fluids have a legitimate role in the
clinical management of OD, correct diagnosis of degree of swallow dys-
function and appropriate prescription of a compensatory thickness level
by suitably qualified clinicians is essential to best meet patient needs.
In addition, product access also relies on having thickeners fall under a
clearly defined regulatory status as a Food for Special Medical Purposes
(FSMP).
Viscosity is the physical property that is highly correlated with the
’thickness consistency’. It is not yet defined that viscosity is the same as
’thickness’ as ’thickness’ is a sensory attribute (measure with visual and
tactile), while viscosity is a physical property (measure with rheometer
or viscometer). The International Dysphagia Diet Standardisation Initia-
tive (IDDSI) developed a standardised international terminology to de-
scribe texture-modified foods and thickened fluids for individual with Fig. 1. Structure of xanthan gum.
OD (Cichero et al., 2013). The framework consists of a continuum of 8
levels (0 – 7), where drinks are measured from Level 0 to Level 4, while
foods are measured from Level 3 to Level 7 (Cichero et al., 2017, 2020). temperature independence and resistant to salivary 𝛼-amylase (Hadde
For thickened fluids, the fluids are categorised by their ‘thickness’. For & Chen, 2019; Hadde et al., 2015a; Matta et al., 2006; Vallons et al.,
example, Level 0 is thin fluid or unmodified liquid, Level 1 is slightly 2015).
thick, Level 2 is mildly thick, Level 3 is moderately thick, and Level 4 Liquid xanthan gum-based thickener is an alternative thickening
is extremely thick. It should be noted that IDDSI does not use objective agent for use only under medical supervision for the management of
metrics. It is a subjective method to determine the thickness consistency OD. It is a xanthan gum-based thickener in liquid format, rather than in
of the fluid. The methodology is limited and not suitable for industry or conventional powdered form. The main difference between these two
research purposes. However, these techniques are specifically designed formats is that the xanthan gum in the liquid format has been pre-
for end users, such as nurses, patients or carers who have no access to hydrated, therefore it is more readily dissolved directly into the fluid.
instrumental analysis, such as rheometer or viscometer as it is simple, It is hypothesised that xanthan gum-based thickeners in a liquid format
easy to use and affordable. Typically, thickening agents such as xan- are substantially equivalent in rheological function and clinical efficacy
than gum are used to modify the thickness of the fluids. However, it is as powdered xanthan gum-based thickeners. This paper discusses the
essential to ensure that thickened fluids additionally have appropriate scope of published research exploring the safety and efficacy of xanthan
rheological properties to secure safe swallowing in individuals with OD gum-based thickeners and their effect in modifying bolus rheology in
(Cichero et al., 2000; Hadde & Chen, 2019). The use of thickeners with- the management of OD. In addition, the importance of the thickener
out taking into account rheological measurement or factors affecting the delivery format (liquid vs powder), on quality of life (QoL) factors and
rheological properties of thickened fluids, such as salivary amylase, can oral nutrition and hydration compliance are discussed.
leads to some risks for patients (Bolivar-prados et al., 2021).
Search strategy
There are several types of thickeners for OD commercially available.
Different types of thickeners impact the rheological behaviour and char-
A comprehensive literature search for literature published between
acteristics of fluids differently (Garcia et al., 2005; Hadde & Chen, 2019;
2005 and 2020 was conducted using multiple search engines, includ-
Kim & Yoo, 2018; Sopade et al., 2008a, 2008b; Sopade et al., 2007;
ing PubMed, ScienceDirect, Wiley Online and Google Scholar databases.
Waqas et al., 2017). Thus, different thickener types result in beverages
Grey literature and non-peer reviewed articles were not considered for
with different rheological behaviours. Moreover, the addition of thick-
inclusion in this review. Search terms were broadly specified with the
eners to a fluid affects differently the sensory perception of flavours.
goal of finding as much relevant literature as possible. Only original
This is due to both changes in viscosity and the variability in binding of
research articles were selected in this study. Search terms used in this
flavour compounds by the thickening moity (Matta et al., 2006). Xan-
review were “Dysphagia” AND (“Thickened fluid” OR “thickened liq-
than gum is a long chain polysaccharide composed of glucose, mannose
uid”) AND “Xanthan”. Terms were nominated by the authors based on
and glucuronic acid (Palaniraj & Jayaraman, 2011). Its primary struc-
their professional experience and following peer consultation. Fig. 2
ture shown in Fig. 1 is a linear (1 → 4) linked 𝛽-d-glucose backbone
summarises the results according to the Preferred Reporting Items for
with a trisaccharide chain on every other glucose at C-3, containing a
Systematic reviews and Meta-Analyses Protocol (PRISMA-P) statement
glucuronic acid residue linked (1 → 4) to a terminal mannose unit and
(Moher et al., 2015).
(1 → 2) to a second mannose that connects to the backbone (Jansson,
Kenne, & Lindberg, 1975; Melton, Mindt, Rees, & Sanderson, 1976). It is
Inclusion and exclusion criteria
commonly used as a thickener in sauces and as an agent in ice cream to
prevent ice crystals from forming. It can also be used as a fat substitute
Articles were first identified, and duplicates removed. Studies were
that adds the ‘mouth feel’ of fat without the calories (Katzbauer, 1998).
considered for inclusion if they described a Dysphagia intervention and
Xanthan gum has increasingly become the thickening moity of choice,
met the following criteria:
displacing starch-based (e.g. modified maize and potato) in commer-
cial thickening products for the clinical management of OD because of (1) described an intervention where the thickening agent included xan-
better texture perception, more cohesive and better stability, such as than gum (including mixture);

2
E.K. Hadde, B. Mossel, J. Chen et al.
(2) the study population was adults with an oropharyngeal dysphagia
diagnosis (assessment of speech language pathologist);
(3) articles were in English;
(4) articles were published in a peer-reviewed journal; and
(5) articles were available in full-text.
Studies were excluded from this review if:
(1) they described intervention using products that were pre-thickened;
(2) the study population was paediatric/infant with dysphagia;
(3) articles described pre-clinical animal models/studies;
(4) the study was not original research (e.g. a review article);
(5) articles were off topic.
Identified records were screened and abstracts read. The quality of
the research was appraised by the authors and low-quality research ex-
cluded from the synthesis. The remaining records were assessed for eli-
gibility and full texts of all eligible research was read. The set of included
articles underwent detailed review for study quality and data collection.
The reference lists of all the included articles were reviewed to see if ad-
ditional articles of relevance to this review were identified. These addi-
tional papers were included if the articles were not previously identified
in the initial search, had a relevant title, were original research articles,
3
Food Hydrocolloids for Health 1 (2021) 100038
Fig. 2. PRISMA flow diagram of the search
process used in this review.
and meet the remaining inclusion and exclusion criteria. As all the arti-
cles described observational studies, no assessment of bias was used in
grading the quality of evidence in the different studies.
Included studies
A flow chart of study selection can be seen in Fig. 2. The search
yielded a total of 249 articles as follows: 62 articles from ScienceDi-
rect, 38 articles from PubMed, 55 articles from Wiley and 94 articles
from Google Scholar. After removing duplicate records, the abstracts of
210 articles were screened and 138 articles excluded. Seventy-two arti-
cles were deemed eligible and underwent full-text screening and were
appraised for quality before final inclusion in this review. Of these 72 ar-
ticles, a further 32 were excluded. Articles were excluded if they did not
focus on the effect of xanthan gum-based thickener. Some studies were
focused on: (1) solely the rheological properties of thickened fluids, (2)
the measuring technique, (3) computational model, (4) other types of
thickener. The remaining 40 articles underwent critical appraisal for in-
clusion in this review. The citation lists of the 40 included articles were
reviewed and an additional 3 articles were identified from citations to
be included in the study.
E.K. Hadde, B. Mossel, J. Chen et al.
The articles were divided into two categories: those describing a clin-
ical outcome and those describing a non-clinical aspect. An article was
categorised ‘clinical’ if the finding of the study described the therapeutic
effect of xanthan gum-based thickener, including the safety of swallow,
and nutritional value of xanthan gum. An article was categorised ‘non-
clinical’ if it described the advantages of xanthan gum-based thickeners
over other types of thickener in maintaining a fluid’s consistency. For
examples, temperature independence, good stabilization or, longer shelf
life. Of the included literature, 18 articles were categorised as ‘clinical’,
23 articles were categorised as ‘non-clinical’ with 2 articles categorised
as both ‘clinical’ and ‘non-clinical’ aspect, making up a total of 43 arti-
cles included in the review. The format of the thickener(s) (powder or
liquid) used in the study was also noted.
Therapeutic effect of xanthan gum-based thickener
Table 1 summarises the ‘clinical’ articles included in this review and
details authors, year of publication, title, and a brief summary of the
key findings. Ten of these studies specifically described the impact of
xanthan gum-based thickened fluids on swallowing. Five studies mea-
sured the penetration-aspiration scale (PAS) of dysphagic patients us-
ing a videofluoroscopy swallow study (VFSS) and described improve-
ment on swallowing of xanthan-gum based thickened fluids without
an increased prevalence of pharyngeal residue (Bolivar-prados et al.,
2019; Leonard et al., 2014; Ortega et al., 2020; Rofes et al., 2014;
Vilardell et al., 2016). Bolivar-prados et al. (2019) reported that the
prevalence of patients with aspiration was significantly decreased when
swallowing fluid at viscosity ranging from 250 mPa.s to 800 mPa.s at
50 s−1 . Furthermore, increasing bolus viscosity shortened time to laryn-
geal vestibule closure and reduced bolus velocity. An additional study
observed the absence of residual coating in the pharynx of healthy in-
dividuals using VFSS when swallowing xanthan gum-based thickened
fluids as compared to starch-based (Hadde et al., 2019). Two studies re-
ported that xanthan gum-based thickened fluids delay oral and pharyn-
geal transit time when swallowed (Funami et al., 2017; Mackley et al.,
2013). The remaining two studies observed the improvement of oral and
pharyngeal residue in swallowing xanthan gum-based thickened fluids
using in-vitro measurement (Marconati & Ramaioli, 2020; Patel et al.,
2020).
The ease of swallowing for xanthan gum-based thickened fluids
were reported in three studies. Alves and Dantas (2017) report that for
healthy individuals’ thickened water (xanthan gum-based) is more dif-
ficult to drink than thin water which they attribute to an increase of
tongue pressure required to swallow thickened fluids. However, in the
case of OD patients, Nakauma et al. (2011) and Ross et al. (2019) report
that the coherent bolus of xanthan gum-based thickened fluids flows
more cohesively through the pharyngeal phase leading to a sensation of
greater ease of swallowing as compared to fluids thickened with locust
bean gum or starch-based. Three studies observed the impact of swal-
lowing xanthan gum-based thickened fluids on swallowing parameters.
Two studies measured the tongue pressure generated for swallowing
xanthan gum-based thickened fluids (Steele et al., 2019b; Steele et al.,
2014b), and the other referenced parameters, such as sip volume, swal-
low timing, and maximum pharyngeal constriction for healthy individ-
uals swallowing fluids thickened with xanthan gum-based thickeners
(Steele et al., 2019a). It was observed that the amplitude and release
characteristics of tongue-palate pressures applied during swallowing is
increased for swallowing thickened fluids (apparent viscosities of 190 to
380 mPa.s at 50 s−1 ) by 122% to 134% of the values seen when swallow-
ing water (Steele et al., 2014b), however, no significant differences in
tongue pressure between xanthan gum and starch-based thickened flu-
ids at similar thickness consistency were reported (Steele et al., 2019b).
The hydrating capabilities of thickened fluids have been questioned
and a common misbelief is that the water present in thickened flu-
ids is bound and therefore unavailable to the patient as a hydrating
fluid (Sharpe et al., 2007). However, only one study has systemati-
4
Food Hydrocolloids for Health 1 (2021) 100038
cally investigated this and reported that the bioavailability of the wa-
ter in the fluid was unaffected by the addition of xanthan gum-based
thickener (Hill et al., 2010). This shows that the bioavailability of
thickened water is equivalent to the bioavailability of unthickened wa-
ter. Two studies measured the nutrient intake from thickened bever-
ages with xanthan gum-based and starch-based thickener (Joyce et al.,
2015; Miranda et al., 2020). It was observed that fibre content is sig-
nificantly higher in xanthan gum-based than starch-based thickener,
while starch-based provides significantly more calories and carbohy-
drates than xanthan gum-based thickener. As such, xanthan-gum based
thickeners are deemed a better option for OD patients who are over-
weight, obese, or at risk of obesity-related comorbidities. Additionally,
Miranda et al. (2020) stated that xanthan gum-based thickener can be
seen as an important source of soluble fibre for patients and poten-
tially improve constipation. One study reported that xanthan gum-based
thickened fluids affects the drug dissolution/release which may impact
significantly on the oral ingestion of medicines (Manrique et al., 2016).
Non-clinical aspect of xanthan gum-based thickener
Table 2 summarises the non-clinical articles included in this review
and details authors, year of publication, title, and a brief summary of the
key findings. Twenty-five studies of the 43 included studies were cate-
gorised as non-clinical. Seven of these studies describe the oral sensory
perception of xanthan gum-based thickened fluids. Four of these studies
report changes in the fluid’s texture when thickened with xanthan gum-
based thickener (Kim et al., 2017; Matta et al., 2006; Ong et al., 2018;
Vickers et al., 2015), and one study reported the sensory (taste) prefer-
ence of xanthan gum-based over starch-based thickener (Horwarth et al.,
2005). The texture of fluids thickened with xanthan gum-based thicken-
ers are generally preferred and are orally perceived as ‘slicker’ or ‘slip-
perier’, rather than the more objectionable ‘grainy’ and ‘chalkiness’ de-
scribed for fluids thickened with starch-based thickeners (Matta et al.,
2006; Ong et al., 2018). Additionally, xanthan gum-based thickened
fluids are generally preferred for their perception as less sticky in the
oral cavity as compared to starch-based (Vickers et al., 2015). The
other two studies showed the possibility to discriminate xanthan gum-
based thickened fluids at different concentrations (Martinez et al., 2019;
Steele et al., 2014a).
Rheological characterisation of xanthan gum-based thickener
Understanding the rheological properties of thickened fluid is ad-
vantageous in designing better-controlled fluids. Rheology is defined
as the study of fluid deformation. Important rheological parameters of
thickened fluids are generally related with the flow of bolus in the pha-
ryngeal stage (Brito-de la fuente et al., 2017). Both shear and exten-
sional rheology of thickened fluids are important in swallowing (Hadde
& Chen, 2021).
Shear properties. Shear rheometers are instruments that are commonly
used in research labs to measure the shear properties of the fluid with
fundamental precision. For many years, shear viscosity has been an es-
tablished way of reporting flow properties of thickened fluids in the field
of dysphagia (Hadde & Chen, 2021). It is believed that a higher shear
viscosity slows down the flow of bolus in the pharynx (Dantas et al.,
1990; Namasivayam-macdonald et al., 2018), thus led to longer transit
time in the pharyngeal area.
It was suggested that fluids with relatively high shear-thinning prop-
erties are more suitable for successful swallowing (Nishinari et al., 2011;
Vickers et al., 2015). Five studies reported that xanthan gum-based
thickener is more shear-thinning than other types of thickener, such as
starch-based or guar gum-based (Cho et al., 2012; Hadde & Chen, 2019;
Mackley et al., 2013; Park et al., 2014; Waqas et al., 2017). It is hypoth-
esised that patients with OD have better controlled of the fluid in the
oral when swallowing high shear-thinning fluids because the fluids are
more viscous at lower shear rate. At the same time, when the fluids are
E.K. Hadde, B. Mossel, J. Chen et al.
Table 1
A summary of the articles included in the review for clinical category.
Author
Alves & Dantas
Bolivar-Prados, Rofes,
Arreola, Guida, Nascimento,
Martin, Vilardell, Ortega,
Ripken, Lansink & Clave
Funami, Matsuyama,
Ikegami, Nakauma, Hori &
Ono
Hadde, Cichero, Zhao, Chen
& Chen
Hill, Dodrill, Bluck & Davies
Joyce, Hind & Robbins
Leonard, White, McKenzie &
Belafsky
Mackley, Tock, Anthony,
Butler, Chapman & Vadillo
Manrique, Sparkes, Cichero,
Stokes, Nissen & Steadman
Marconati & Ramaioli
Miranda, Breda, Cardoso,
Goncalves, Caldas & Ferrerira
Nakauma, Ishihara, Funami
& Nishinari
Year Title
2017 Difficulties in thickened
water ingestion in healthy
subjects.
2019 Effect of a gum-based
thickener on the safety of
swallowing in patients with
poststroke oropharyngeal
dysphagia
2017 In vivo measurement of
swallowing by monitoring
thyroid cartilage movement
in healthy subjects using
thickened liquid samples and
its comparison with sensory
evaluation
2019 The Importance of
Extensional Rheology in
Bolus Control during
Swallowing.
2010 A Novel Stable Isotope
Approach for Determining
the Impact of Thickening
Agents on Water Absorption
2015 Nutrient Intake from
Thickened Beverages and
Patient-Specific Implications
for Care
2014 Effects of bolus rheology on
aspiration in patients with
dysphagia
2013 The rheology and processing
behaviour of starch and
gum-based dysphagia
thickeners
2016 Oral medication delivery in
impaired swallowing:
thickening liquid medications
for safe swallowing alters
dissolution characteristics
2020 The role of extensional
rheology in the oral phase of
swallowing: an in vitro study
2020 Should the Energy
Contribution of Commercial
Thickeners Be Considered in
the Nutrition Plan of Patients
with Dysphagia?
2011 Swallowing profiles of food
polysaccharide solutions with
different flow behaviors
5
Food Hydrocolloids for Health 1 (2021) 100038
Powder or Liquid Finding
Powder • Thickened water is more difficult to drink than thin
water by healthy individuals. Individuals with dental
prosthesis has more difficulties to ingest thickened
water than individuals who do not use a dental
prosthesis.
Powder • Increasing shear bolus viscosity with xanthan
gum-based thickener significantly increased the safety
of swallow in patients with poststroke oropharyngeal
dysphagia in a viscosity-dependant manner without
increasing the prevalence of pharyngeal residue.
Powder • Small variation of transit speed is expected when
swallowing xanthan gum-based fluid due to its higher
internal binding force, which can lead to greater
sensation of pharyngeal cohesiveness at increased
concentration.
Powder • The bolus thickened with xanthan gum-based
thickener is less elongated during swallowing than
starch-based thickener, thus reducing the risk
fracturing into multiple boluses during swallowing
and get caught in the pharynx as residue.
• Residual coating was visible when swallowing
starch-based thickened water, but not xanthan
gum-based thickened water.
Powder • The bioavailability of the water in the fluid was
unaffected by the addition of xanthan gum-based
thickener.
Powder • Xanthan gum-based thickener may be advantageous
for patients who are overweight, obese, or at risk of
obesity-related comorbidities because it contains
lower carbohydrates than starch-based thickener
Powder • Xanthan gum-based thickener was effective at
reducing aspiration.
• Xanthan gum-based solutions had the lowest
Penetration-Aspiration Scale, compared with thin
liquid and starch-based solution (i.e. more effective to
reduce aspiration).
Powder • in-vitro: Thickened fluids (xanthan gum-based) delay
the transport of fluid to the back of the throat.
Powder • Xanthan gum-based thickened fluids have a
substantial effect on drug dissolution release to
facilitate oral ingestion of medicines.
Powder • in-vitro: High extensional properties of thickened fluids
(xanthan gum-based) lead to lower oral post-swallow
residues and more compact bolus with a smoother
surface, which may suggest a lower risk of
fragmentation.
Powder • Fibre content is significantly higher in xanthan
gum-based thickeners than starch-based thickener.
• Starch-based thickeners provide significantly more
energy and carbohydrates at all consistencies than
xanthan gum-based thickener.
• Xanthan gum-based thickener may be a better option
than starch-based thickener for obese or diabetic
patients.
• Xanthan gum-based thickener can be seen as an
important source of soluble fibre for patients and
potentially improve constipation.
Powder • Xanthan gum solutions flow as one coherent bolus
through the pharyngeal phase with smaller variation
of flow velocity than locust bean gum solutions,
leading to a greater sensation of swallowing ease.
(continued on next page)
E.K. Hadde, B. Mossel, J. Chen et al. Food Hydrocolloids for Health 1 (2021) 100038

Table 1 (continued)

Author Year Title Powder or Liquid Finding

Ortega, Bolivar-Prados,
Arreola, Nascimento,
Tomsen, Gallegos, Brito-de
La Fuente & Clave
Patel, McAuley, Cook, Sun,
Hamdy & Liu
2020 Therapeutic Effect, Powder • Xanthan gum-based thickened fluids showed a strong
Rheological Properties and therapeutic effect on the safety of swallow without
alpha-Amylase Resistance of increasing pharyngeal residue.
a New Mixed Starch and
Xanthan Gum Thickener on
Four Different Phenotypes of
Patients with Oropharyngeal
Dysphagia
2020 The Swallowing Powder • in-vitro: Xanthan gum-based thickeners showed shorter
Characteristics of Thickeners, bolus length when swallowed than starch-based
Jellies and Yoghurt Observed thickener, thus reducing the risk of post-swallow
Using an In Vitro Model residue.

Rofes, Arreola, Mukherjee, 2014 The effects of a xanthan Powder • Xanthan gum-based thickened fluid improves the
Swanson & Clave gum-based thickener on the safety of swallow without increasing the residue
swallowing function of providing a viscosity-dependant therapeutic effect for
patients with dysphagia patients with oropharyngeal dysphagia.

Ross, Tyler, Borgognone & 2019 Relationships between shear
Eriksen rheology and sensory
attributes of
hydrocolloid-thickened fluids
designed to compensate for
impairments in oral
manipulation and swallowing
Steele, Molfenter, 2014 Variations in Tongue-Palate
Peladeau-Pigeon, Polacco & Swallowing Pressures When
Yee Swallowing Xanthan
Gum-Thickened Liquids
Powder • Xanthan gum solutions displayed the most suitable
oral cohesiveness relative to their perceived oral
propulsion effort, stickiness, and oral residue
compared to starch or carboxymethyl cellulose (CMC)
solutions.
Powder • Xanthan gum-based thickened liquids increased the
amplitude and release characteristics of tongue-palate
pressures that are applied during swallowing.
• The use of xanthan gum-based thickened liquids is
unlikely to tax the swallowing system in terms of
tongue pressure generation requirements.

Steele, Peladeau-Pigeon,
Barbon, Guida,
Namasivayam-MacDonald,
Nascimento, Smaoui, Tapson,
Valenzano, Waito & Wolkin
Steele, Peladeau-Pigeon,
Barbon, Guida, Tapson,
Valenzano, Waito, Wolkin,
Hanson, Ong, & Duizer
2019 Reference Values for Healthy
Swallowing Across the Range
from Thin to Extremely Thick
Liquids
2019 Modulation of Tongue
Pressure According to Liquid
Flow Properties in Healthy
Swallowing
Powder • Reference values, such as sip volume, swallow timing,
maximum pharyngeal constriction and etc. for healthy
individuals swallowing xanthan gum-based thickened
liquids were obtained in the study.
Powder • No significant differences in tongue pressure
parameters were found between xanthan gum-based
thickened liquids and starch-based thickened liquids at
similar thickness consistency.

Vilardell, Rofes, Arreola,
Speyer & Clave
2016 A Comparative Study
Between Modified Starch and
Xanthan Gum Thickeners in
Post-Stroke Oropharyngeal
Dysphagia
Powder • In the VFSS assessment, penetration-aspiration scale
score was significantly reduced with increased
viscosity with xanthan gum-based thickeners.
• In the VFSS assessment, xanthan gum-based thickener
did not increase the prevalence of pharyngeal residue
which gives therapeutic advantage versus starch-based
thickener, as pharyngeal residue puts patients at risk
of post-swallow aspiration.

swallowed and undergo high shear rate, the viscosity of the fluids are
lowered and able to safely flow through the pharynx. A recent review
by Hadde and Chen (2021) showed that the degree of shear-thinning of
xanthan gum-based thickened fluids are within the range of 0.16–0.39,
where 1 means Newtonian fluid and the smaller the value, the more
shear-thinning of the fluid. However, there is still not enough literature
evidence to specify a suitable range of shear-thinning for thickened flu-
ids (Hadde & Chen, 2021).
Extensional properties. A recent review by Hadde and Chen (2021) re-
ported that shear properties of thickened fluids may dominate the de-
formation within the oral cavity, but the bolus deformation within the
pharyngeal region could be dominantly extensional. Capillary Break-up
Extensional Rheometer (CaBER) is a filament thinning device that is
commonly used to measure the apparent extensional viscosity of thick-
ened fluids by measuring the filament diameter of the sample during the
filament thinning (Hadde & Chen, 2019; He et al., 2016). Four studies
reported that xanthan gum-based thickened fluids have higher exten-
sional properties (more cohesive) than starch-based at similar thickness
consistency (Cho et al., 2012; Hadde & Chen, 2019; Mackley et al., 2013;
Waqas et al., 2017). It can be seen in Fig. 3 that the filament break-up
of thickened water with xanthan gum-based thickener in CaBER is sig-
nificantly longer than starch-based thickener at similar thickness con-
sistency (shear viscosity is approximately 255 mPa.s at 50 s−1 ). This
suggests that the xanthan gum-based thickener is more cohesive than
starch-based (Hadde & Chen, 2019). Nishinari et al. (2019) reported that
cohesiveness plays an important role for safe swallowing for individuals
with dysphagia. Hadde et al. (2019) reported that extensional viscos-
ity reduces the elongation of the bolus in the pharyngeal phase during
swallowing, thus potentially reduced the risk of post-swallow residue
due to bolus breakage. Less cohesive fluids will fracture into multiple
droplets if not swallowed efficiently, which may cause aspiration. More-
over, there is also a risk that some of the bolus may get caught in the
pharynx as residue and thus multiple swallows are required in order to
clear it, which may result in muscle fatigue and increase the risk of as-
piration (Cichero & Murdoch, 2006). However, currently there are no
clinical studies which demonstrate the evidence of the effect of yield

6
E.K. Hadde, B. Mossel, J. Chen et al.
Table 2
A summary of the articles included in the review for quality aspect category.
Author Year Title
Alves, Alves & Dantas 2017 Consistency stability of water
thickened with maltodextrin,
xanthan gum and potassium
chloride
Barbon & Steele 2019 Characterizing the Flow of
Thickened Barium and
Non-barium Liquid Recipes
Using the IDDSI Flow Test
Cho & Yoo 2015 Rheological characteristics of
cold thickened beverages
containing xanthan
gum-based food thickeners
used for dysphagia diets
Cho, Yoo & Yoo 2012 Steady and dynamic
rheological properties of
thickened beverages used for
dysphagia diets.
Garcia, Chambers, Matta & 2005 Viscosity Measurements of
Clark Nectar- and Honey-thick
Liquids: Product, Liquid, and
Time Comparisons
Garcia, Chambers, Matta & 2008 Serving Temperature
Clark Viscosity Measurements of
Nectar- and Honey- Thick
Liquids
Hadde & Chen 2019 Shear and extensional
rheological characterization
of thickened fluid for
dysphagia management
Hadde, Nicholson & Cichero 2015 Rheological characterisation
of thickened fluids under
different temperature, pH
and fat contents
Hadde, Nicholson, Cichero & 2015 Rheological characterisation
Deblauwe of thickened milk
components (protein, lactose
and minerals)
Horwarth, Ball & Smith 2005 Taste Preference and Rating
of Commercial and Natural
Thickeners
Kim & Yoo 2018 Rheological characterization
of thickened protein-based
beverages under different
food thickeners and setting
times
Kim, Hwang, Song & Lee 2017 Sensory and rheological
characteristics of thickened
liquids differing
concentrations of a xanthan
gum-based thickener
Kim & Yoo 2015 Viscosity of
dysphagia-orientated
cold-thickened beverages:
effect of setting time at
refrigeration temperature
7
Food Hydrocolloids for Health 1 (2021) 100038
Powder or Liquid Finding
Powder • Thickened water with xanthan gum-based thickener
has good stabilisation during at least 12 h after the
preparation.
Powder • The amount of thickener needed to reach any level of
thickness on the IDDSI continuum is much lower when
using xanthan gum rather than starch-based thickener.
• Xanthan gum-based thickener yielded stable IDDSI
Flow Test results (i.e. stable thickness consistency)
over time, up to 3 h.
Powder • Changes in thickness consistency during storage will
not be an issue because chilling thickened beverages
with xanthan gum-based thickener for several hours
(2 – 4 h) results in stabilization of their rheological
characterisation.
Powder • Xanthan gum-based thickener increase the elastic
properties of thickened fluids
Liquid • The mean viscosity of xanthan gum-based thickened
fluids (water, apple juice, orange juice, milk and
coffee) did not change from their standard preparation
time to 30 min of setting time (i.e. good stability).
• Xanthan gum-based thickened fluids had the smallest
viscosity variation across the different liquids.
Liquid • Most of starch-based and gum-based solutions
decrease in viscosity when temperature is increased,
with the exception of xanthan gum, with only little
change in viscosity.
Powder • Xanthan gum-based thickened water is more cohesive
than starch-based thickened water at particular shear
viscosity at 50 s − 1 .
Powder • Xanthan gum-based thickened water, at a given
thickener concentration, had a consistent viscosity
under different temperature and pH conditions due to
the side chains of the xanthan gum molecular
structure protecting the backbone structure.
• Shear viscosity of xanthan gum-based thickened milk
was found to increase with increased of fat content.
Powder • Protein in the milk increased the shear viscosity of
xanthan gum-based thickened fluid.
• Minerals (e.g. calcium) in the milk slowed down the
thickening rate of xanthan gum-based thickened fluid
due to an ionic interaction between the mineral and
the xanthan gum.
Liquid • Xanthan gum-based thickener was found to be
preferred in taste over starch-based thickener for the
hot chocolate and fruit juice beverages.
Powder • Protein-based beverage thickened with xanthan
gum-based thickener can become thicker over the
initial 15 – 45 min after preparation.
Powder • Xanthan gum-based thickener significantly modified
sensory descriptive attributes (appearance, texture,
and major flavour attributes)
Powder • Increase in viscosity of xanthan gum-based
cold-thickened beverages (orange juice and milk) over
setting time was observed up to 60 min after
preparation.
• Water thickened with xanthan-gum based thickener
was thickened almost instantaneously.
(continued on next page)
E.K. Hadde, B. Mossel, J. Chen et al.
Table 2 (continued)
Author
Lee & Yoo
Mackley, Tock, Anthony,
Butler, Chapman & Vadillo
Martinez, Vicente, Vega &
Salmeron
Matta, Chambers, Garcia &
Helverson
Ong, Steele & Duizer
Ortega, Bolivar-Prados,
Arreola, Nascimento,
Tomsen, Gallegos, Brito-de
La Fuente & Clave
Park, Kim, Oh, Lee, Hwang,
Lee & Han
Steele, James, Hori, Polacco
& Yee
Turcanu, Siegert, Secouard,
Fuente, Balan & Gallegos
Vallons, Helmens & Oudhuis
Vickers, Damodhar,
Grummer, Mendenhall,
Banaszynski, Hartel, Hind,
Joyce, Kaufman & Robbins
Waqas, Wiklund, Altskar,
Ekberg & Stading
Year Title
2020 Agglomerated xanthan gum
powder used as a food
thickener: Effect of sugar
binders on physical,
microstructural, and
rheological properties.
2013 The rheology and processing
behaviour of starch and
gum-based dysphagia
thickeners
2019 Sensory perception and flow
properties of dysphagia
thickening formulas with
different composition
2006 Sensory Characteristics of
Beverages Prepared with
Commercial Thickeners Used
for Dysphagia Diets
2018 Sensory characteristics of
liquids thickened with
commercial thickeners to
levels specified in the
International Dysphagia Diet
Standardization Initiative
(IDDSI) framework
2020 Therapeutic Effect,
Rheological Properties and
alpha-Amylase Resistance of
a New Mixed Starch and
Xanthan Gum Thickener on
Four Different Phenotypes of
Patients with Oropharyngeal
Dysphagia
2014 Comparison of different
gum-based thickeners using a
viscometer and line spread
test: a preliminary study
2014 Oral Perceptual
Discrimination of Viscosity
Differences for
Non-Newtonian Liquids in
the Nectar- and Honey-Thick
Ranges
2018 An alternative elongational
method to study the effect of
saliva on thickened fluids for
dysphagia nutritional support
2015 Effect of human saliva on the
consistency of thickened
drinks for individuals with
dysphagia
2015 Relationships amongst
Rheological, Sensory
Texture, and Swallowing
Pressure Measurements of
Hydrocolloid-Thickened
Fluids
2017 Shear and extensional
rheology of commercial
thickeners used for
dysphagia management
8
Food Hydrocolloids for Health 1 (2021) 100038
Powder or Liquid Finding
Powder • Agglomeration of xanthan gum powders with sugar
binder lowered the elastic properties of xanthan gum.
Powder • Xanthan gum thickener has higher extensional
properties than starch-based thickener
Powder It is possible to discriminate significantly amongst
concentrations for xanthan gum-based products.
The thickness consistency of xanthan gum-based fluids is
increased more gradually with an increase of thickener
concentration than starch-based fluids.
Liquid • Starch-based thickeners imparted a starchy flavour
and grainy texture, whereas xanthan gum-based
thickeners gave added slickness to the beverages.
Powder Graininess and chalkiness were seen predominantly in
starch-based thickened fluids, while slipperiness was
characteristic of xanthan gum-based thickened fluids.
The perceived viscosity of xanthan gum-based samples was
lower than that of starch-based samples, even though they
are in the same IDDSI level consistency.
Powder • Xanthan gum-based thickener is resistant to salivary
𝛼-amylase.
Powder Xanthan gum-based thickener is more shear-thinning than
guar gum-based thickener.
The viscosity of xanthan gum-based thickener was easy to
maintain as it is not dependant on time, unlike
starch-based thickener, which was difficult to maintain due
to time dependant alteration.
Powder • An increase in apparent viscosity of 0.67-fold xanthan
gum-based thickened liquids is detectable in the
nectar- to honey-thick range.
Powder • The elongational properties of starch-based thickened
fluids were significantly decreased in the presence of
saliva, while xanthan gum-based thickened fluids
remain unaffected.
Powder Drinks thickened with xanthan gum-based thickener were
significantly less sensitive to thinning by human saliva
compared with drinks thickened with starch-based
thickener.
Xanthan gum-based thickeners maintain their consistency
better in contact with human saliva than starch-based
thickeners.
Powder • Xanthan gum-based thickener is generally perceived as
less thick, with less adhesive properties (stickiness,
adhesiveness, mouthcoating and number of swallows)
and greater slipperiness.
Powder • Xanthan gum-based thickeners used for dysphagia
management are slightly more shear-thinning and
have higher extensional viscosities than starch-based
thickeners.
E.K. Hadde, B. Mossel, J. Chen et al.
Fig. 3. Photographic sequence of the filament break-up captured with CaBER
for thickened water with (a) xanthan gum-based thickener, (b) mixture of xan-
than gum and starch-based thickener, (c) starch-based thickener at similar shear
viscosity (shear viscosity is approximately 255 mPa.s at 50 s−1 ). Adapted from
Hadde and Chen (2019).
stress or extensional viscosity on the therapeutic effect of thickening
products.
Stability of xanthan gum-based thickener
Regardless of the thickening format (liquid or powder), the thicken-
ing time or setting time for xanthan gum-based thickener were observed
in six studies. It was observed that thickened water reached equilib-
rium viscosity almost instantaneously (Garcia et al., 2005; Hadde et al.,
2015a; Kim & Yoo, 2015). Park et al. (2014) stated that the viscosity of
xanthan gum-based thickener was not dependant on time due to excep-
tionally fast setting time, unlike starch-based which was dependant on
time. However, three of these studies reported that milk-based bever-
ages thickened with xanthan gum-based thickener can become thicker
over the initial 15 to 45 min after preparation (Hadde et al., 2015b; Kim
& Yoo, 2015; Kim et al., 2018). This is believed to be due to an ionic
interaction between the positively charged calcium ions binds together
with the negatively charged xanthan gum, and then release it slowly
resulting in slowing down the thickening rate (Hadde et al., 2015b).
Stabilisation of xanthan gum-based thickened fluids after preparation
was discussed in four studies. Two of these studies observed good sta-
bilisation of xanthan gum-based thickened fluids during storage for sev-
eral hours after preparation (Alves et al., 2017), while one other study
observed good viscosity stability of xanthan gum-based thickened fluids
from preparation to mealtime (30 min) (Garcia et al., 2005). The remain-
ing study observed good viscosity stability of xanthan gum-based thick-
ened fluids for 3 h post-preparation using the IDDSI Flow Test (Barbon &
Steele, 2019). Changes in thickness consistency during storage is of par-
ticular interest to the dysphagia therapist and patients in clinical prac-
tice because it is common to store thickened beverages for several hours
(2 to 4 h) before consumption.
One of the main advantages of xanthan gum-based thickener over
other types of thickener (e.g. starch-based) is the ability to retain its vis-
cosity under extreme of temperature and pH. Two studies observed the
effect of temperature on the viscosity of thickened fluids and showed
that xanthan gum-based thickened fluids had a consistent viscosity un-
der different temperature condition, unlike starch-based thickened flu-
ids which showed a decrease in viscosity when temperature is increased
(Garcia et al., 2008; Hadde et al., 2015a). It was also reported that the
viscosity of xanthan gum-based thickened fluids is unaffected at differ-
ent pH conditions (Hadde et al., 2015a). An additional three studies
reported that xanthan gum-based thickener is resistant to salivary 𝛼-
amylase, suggesting that the thickness/consistency of the fluid remains
constant when it is swallowed (Ortega et al., 2020; Turcanu et al., 2018;
9
Food Hydrocolloids for Health 1 (2021) 100038
Vallons et al., 2015), unlike starch-based, whose breakdown by amylase
would result in decreasing viscosity and cohesiveness, thus increasing
bolus velocity. Vallons et al. (2015) stated that drinks thickened with
xanthan gum-based thickener were significantly less sensitive to thin-
ning by human saliva compared with drinks thickened with starch-based
thickener. However, changes in thickness consistency of xanthan gum-
based thickened fluids in the presence of nutrients composition (e.g.
protein, sugar, minerals, etc.) were observed in four studies. Two of
these studies reported that proteins in the milk increased the viscos-
ity of xanthan gum-based thickened fluids (Hadde et al., 2015b; Kim &
Yoo, 2018). As protein is a long-chain polymer, it is suspected the pro-
tein molecules entangles the water molecules interacting with the xan-
than gum and increasing the viscosity of the fluid (Hadde et al., 2015b).
One other study showed that the viscosity of xanthan gum-based thick-
ened milk was found to increase with increased fat content (Hadde et al.,
2015a). An explanation of this is as a result of the increased fat phase
that leads to enhanced intermolecular interactions which lead to an in-
crease in viscosity (Bayarri et al., 2009).
The requirement for thickening agents in patients diagnosed with dysphagia
Traditionally, thickening agents used in the management of OD have
been composed of modified starch granules where the carbohydrates
absorb water and swell, causing an acute increase in liquid viscos-
ity (Newman et al., 2016). However, research has shown that starch-
based thickeners have numerous disadvantages in clinical application
due to limitations, such as a decrease in viscosity due to starch set-
tling (Payne et al., 2012) or continued thickening beyond the desired
clinical consistency upon holding (Garcia et al., 2005). Additionally,
starch-based thickeners are often associated with a starchy taste and
a grainy texture (Matta et al., 2006) making them unpalatable, which
negatively impacts on compliance. Xanthan gum-based thickeners have
been extensively reported in the literature as better options than starch-
based (Garcia et al., 2005; Hadde & Chen, 2019; Matta et al., 2006;
Payne et al., 2012). Xanthan gum causes liquids to increase their vis-
cosity through the development of a colloidal network, based on inter-
molecular hydrogen bonding amongst the xanthan gum molecules, in
addition to limited polymer entanglement (Sharpe et al., 2007). This
physical chemistry, which is distinct from starch-based thickeners, has
numerous advantages in OD management, such as increased cohesive-
ness and viscoelasticity.
Collectively, the studies included in this synthesis clearly show the
advantages of xanthan gum-based thickener over other types of thick-
ener used in the management of OD. From this literature review, it can
be concluded that fluids thickened with xanthan gum-based thicken-
ers are more effective in improving the safety of swallow (i.e. signifi-
cant reduction in PAS as compared to thin fluids) (Leonard et al., 2014;
Ortega et al., 2020). Moreover, they reduce aspiration without increas-
ing the prevalence of pharyngeal residue (Bolivar-prados et al., 2019;
Rofes et al., 2014; Vilardell et al., 2016), more cohesive bolus, reduce
the risk of choking and aspirational pneumonia in individuals with OD.
In addition, fluids thickened with xanthan gum-based thickeners have
better oral texture perceptions (i.e. they are not perceived as thick and
grainy but rather slippery and smooth) making them more palatable,
leading to increased compliance and greater hydration (Matta et al.,
2006). Fluids thickened with xanthan gum are also more stable under
different conditions (e.g. temperature, pH, salt, saliva) than other types
of thickeners (e.g. starch-based) typically used in the management of OD
(Garcia et al., 2008; Hadde et al., 2015a; Lee et al., 2016; Ortega et al.,
2020). These findings are consistent with those of another systematic
review of the literature, The European Society for Swallowing Disor-
ders (ESSD) as published in their white paper (Newman et al., 2016).
However, Steele et al. (2015) in their comprehensive review of the lit-
erature reported a lack of conclusive evidence regarding the important
possibility that properties of a liquid bolus other than apparent viscos-
E.K. Hadde, B. Mossel, J. Chen et al. Food Hydrocolloids for Health 1 (2021) 100038

ity, such as density, yield stress, cohesiveness, or slipperiness (to list a

few) influence swallowing physiology and function.

The importance of the form of the thickening agent for oropharyngeal

dysphagia management

Thickened fluids used in the management of OD can be thickened

with a thickening agent that is in either powdered or a liquid form
(sometimes referred to as gels) (Cichero et al., 2013). The efficacy of
altering bolus rheology using powdered xanthan gum-based thickeners
as a basic therapeutic strategy for patients with OD is well established in
the clinical literature (Bolivar-prados et al., 2019; Newman et al., 2016;
Rofes et al., 2014; Vilardell et al., 2016). However, there is an emerg-
ing body of evidence for the role of xanthan gum-based thickeners in a
liquid format in the management of OD (Tables 1 and 2). Xanthan gum-
based thickeners in a liquid format has been pre-hydrated, therefore
the thickener is more readily dissolved directly into the fluid than pow-
dered thickeners. Four of the 43 studies included in this review describe
a dysphagia intervention where the xanthan gum was in a liquid form Fig. 4. (a) Pump provided from the manufacturer for dosing. (b) Press down
(Garcia et al., 2005, 2008; Horwarth et al., 2005; Matta et al., 2006). the pump for an unbroken stream flows from the nozzle. (c) Look for the BLACK
From these studies, it can be concluded that liquid xanthan gum thicken- LINE indicating the pump as fully returned to the top to ensure an accurate
ers have a long (> 10 years) history of use in the management of OD and dosage. (d) full scoop of thickener powder.
have the same clinical efficacy as powdered xanthan gum-based thick-
eners. Garcia et al. (2008) reported that the apparent viscosity of fluids
quires less effort and muscle involvement to safely swallow the fluid
thickened with a liquid xanthan gum-based thickener was unaffected
(Stokes et al., 2013) and as the yield stress parameter is closely as-
when temperature was increased from 4 °C to 25 °C. This is consistent
sociated with the elastic behaviour of the fluid (Seo & Yoo, 2013),
with the finding of Hadde et al. (2015a) who used a powdered xanthan
greater tongue force may be required to initiate fluid flow in thicker
gum-based thickener form and reported that the apparent viscosity of
fluids (Reimers-neils et al., 1994). Furthermore, the apparent viscosity
xanthan gum-based thickened fluids remained constant over tempera-
reported for the liquid xanthan gum-based thickened water is in agree-
ture ranges tested (8 °C to 40 °C). Additionally, the oral perception of
ment with those reported by Bolivar-prados et al. (2019) for water thick-
the texture of beverages thickened with a liquid xanthan gum-based
ened with powdered xanthan gum (150 – 800 mPa.s at 50 s−1 ) that
thickener was described by Matta et al. (2006) as ‘slickness’ or ‘slipper-
demonstrated improved swallow safety. Thus, quantifying the effects of
iness’. This is equivalent to the oral perception of the texture beverages
bolus flow through the pharynx clearly demonstrated that the formula-
thickened with powdered xanthan gum-based thickener described by
tion found in liquid xanthan gum does not differ appreciably from the
Ong et al. (2018). This suggests that the form of xanthan gum (liquid or
powdered xanthan gum and food modifiers for altering the viscosity of
powder) does not influence sensory perception of thickened fluids.
fluids as part of a therapeutic strategy for management of OD. How-
Only 10% studies included in this review used liquid xanthan gum-
ever, there were no literature about the extensional properties of fluids
based thickeners. This shows that liquid xanthan gum-based thickeners
thickened with xanthan gum-based thickener. Therefore, the extensional
are not as popular choice as powdered xanthan gum-based thickeners.
properties of xanthan gum-based thickener in liquid and powdered form
Limited studies can be found that used xanthan gum-based thickener
cannot be compared.
in liquid form. Therefore, additional sources other than peer-reviewed
articles, such as other published materials (e.g. PhD thesis, poster pre-
sentation, technical reports) were also reviewed to determine the safety Advantages of liquid thickening agents for the management of
and efficacy of xanthan gum-based thickener in liquid format. oropharyngeal dysphagia
Recent review paper by Omari and Schar (2018) provided some in-
sight into the information on swallowing physiology that can be gath- Table 3 summarises the advantages and disadvantages of liquid xan-
ered using high-resolution pharyngeal manometry (HRPM). Omari and than gum-based thickeners compared to powdered xanthan gum-based
Schar (2018) reported many cases that show improved safety of swal- thickeners in the management of OD. In clinical practice, powdered
low when viscosity is increased using the liquid xanthan gum thickening thickeners are measured volumetrically using scoops provided by the
agent as part of the Standardized Bolus Medium (SBM) kit in HRPM mea- manufacturer. Due to the inherent nature of the powders, their deliv-
surement (unthickened fluid vs. extremely thick fluid) (Fig. 5). Addi- ered volumes may be significantly inaccurate as the bulk density of the
tionally, a PhD thesis from the University of Queensland (Hadde, 2017) powder is affected by the degree of packing and the degree of com-
quantified the flow profile, yield stress, and viscoelastic properties of pression in scooping. A PhD thesis from The University of Queensland
water thickened with liquid xanthan gum-based thickener to the Aus- reported that the scoop measures provided by the manufacturer is li-
tralian National Standards for thickened fluids: Level 150 (mildly thick); able from 3% up to 10% extra error (Hadde, 2017). In contrast, liquid
Level 400 (moderately thick); and Level 900 (extremely thick). The ap- xanthan gum-based thickener is measured using a manual pump system
parent viscosity decreased with an increase in shear rate demonstrating which provide a dosage rate with precision of ± 3.5% (Fig. 4).
that water thickened with liquid xanthan gum exhibits shear-thinning In 2015, a case study conducted at the Geriatric Assessment & Reha-
behaviour. Further, the dynamic moduli (i.e. G’ and G”) increased with bilitation (GARU), in Princess Alexandria hospital (Brisbane, Australia)
increasing fluid thickness, which is indicative of an increase in viscoelas- (Du Plessis et al., 2016). The study involved an assessment of the effect
tic properties with thickener concentration. These findings are consis- of liquid xanthan gum-based thickener in improving hydration and com-
tent with past research for fluids thickened with powdered xanthan gum pliance with taking thickened fluids, in patients diagnosed with OD, was
(Hadde et al., 2015a; Park et al., 2014; Sopade et al., 2007) and there- conducted with 35 nurses across three rehabilitation wards. The major-
fore it can be surmised that liquid and powdered xanthan gum have ity of nursing staff (95%) reported being satisfied with liquid xanthan
similar implications for the management of OD. For example, a lower gum-based thickener as a product and reported liquid xanthan gum-
friction coefficient value would indicate a ‘smoother’ material that re- based thickener as beneficial to patient care. Specifically, an increase

10
E.K. Hadde, B. Mossel, J. Chen et al. Food Hydrocolloids for Health 1 (2021) 100038

Table 3
Advantages and disadvantages in clinical application of Liquid Xanthan Gum thickeners compared to powdered Xanthan Gum thickeners.

Powdered Xanthan Thickener Liquid Xanthan Thickener

Advantages Disadvantages Advantages Disadvantages

• Clinically efficacious (improves the
safety of swallow).
• Most common form of commercial
thickening agent for Dysphagia
treatment in EU
• Less expensive than liquids
• Good pH, salt and temperature
stability
• Able to freeze thaw
More waste
Less accurate volumetric dosing
Can’t adjust thickness once mixed
Requires ABSOLUTELY dry cup
Can’t add directly to beverage
Short shelf life after opening
More cross contamination
Scoop reused
Many people and hands
Poorer Quality of Life
Effective in fewer beverages (e.g.
carbonated beverages)
Can’t add directly to beverages
Difficult to use outside of home
More dirty dishes
Poor appearing and poorly carbonated
beverages
Clinically efficacious (improves the safety of swallow). Heavy (water)
Liquid thickeners are “pre hydrated” and can completely More expensive than powders
hydrate in more beverages (e.g. carbonated beverages).
Good pH, salt and temperature stability
Able to freeze thaw
Less waste
More accurate volumetric dosing
Can readily adjust thickness once mixed
Does not require ABSOLUTELY dry cup
Can add directly to beverage
Long shelf life (inclusive of 12 months primary) after
opening
Less cross contamination
No cross contact with product due to pump hermetically
sealed to unit
No people and hands
Improved Quality of Life
Easy to use outside of home
No increase in dirty dishes
Less whipped, no lumps
Quicker and simpler to use

Fig. 5. Impedance detection of pre-swallow

bolus presence. (a) Pressure topography plots
for a postextubation ICU patient being evalu-
ated prior to introduction of oral feeding. Bo-
lus presence time is defined by hypopharyngeal
impedance signal. Note with a 10 ml thin liquid
bolus (unthickened) (left) impedance detects
pre-swallow bolus presence consistent with
premature spillage. When the bolus consistency
is increased to extremely thick (3 pumps of
SBM Kit per 100 mL of a 0.9% saline solution)
(right), the pre-swallow bolus in no longer ap-
parent. (b) Graph of mean bolus presence time
for 5 and 10 ml thin liquid boluses and 10 ml
extremely thick bolus (14 women, age 19 – 79
years, using Standardized Bolus Medium Kit,
Trisco Pty Ltd, Brisbane, Australia). (adapted
from Omari & Schar, 2018).

in fluid intake resulting from liquid xanthan gum-based thickener us-
age was reported by 76.5% of nurses. Furthermore, 93.8% of nurses
reported that the liquid xanthan gum-based thickener assisted with pa-
tient compliance and satisfaction with thickened fluids (i.e. it increased
fluid intake and improved patient compliance as a direct result of pa-
tients having significantly greater fluid choice options) (Du Plessis et al.,
2016). Hadde (2017) reported that liquid format thickener was more
suitable for thickening carbonated beverages including beer than pow-
dered xanthan gum-based thickeners because it more readily dissolves
directly into the fluid. Mixing xanthan gum-based powdered thickener
with carbonated beverages is difficult as a significant amount of foam is
produced due to nucleation as the thickener powder is added and stirred
(necessarily) vigorously. Small powder particles provide surfaces where
the carbon dioxide molecules collect and form large bubbles of gas that
rise to the top of the liquid (Gardner et al., 2010). As a result, the thick-
ener dissolves in the foam, thus thickening the foam instead of the liquid
(Hadde, 2017), making it a beverage of mixed thickness consistency un-
suitable for individuals with OD.
Summary
This review of the literature explored the safety and efficacy of xan-
than gum as a thickening moity and its effect in modifying bolus rhe-
ology in the therapeutic medical management of oropharyngeal dys-
phagia. Synthesis of the included literature found that xanthan gum-
based thickened fluids are effective in improving the safety of swallow

11
E.K. Hadde, B. Mossel, J. Chen et al.
and reduce aspiration without negatively increasing the prevalence of
pharyngeal residue in individuals with OD. Furthermore, this review
has demonstrated that xanthan gum-based thickeners have numerous
clinical advantages over starch-based thickeners for the management of
OD. Specifically, they offer preferred oral perceptions of texture, form
a more cohesive bolus (i.e. less fragmented and thus reduce the risk of
small fragmented liquid particles being aspirated into the lungs) and
have better stability to wider conditions common to food and beverage
vehicles, such as temperature, pH and are resistance to amylase present
in saliva.
One important thing to note that the advantages and the disadvan-
tages of powdered and liquid xanthan thickeners described in this re-
view were not derived from peer-reviewed articles, but from other pub-
lished materials, such as PhD thesis, poster presentations or technical
reports. It was observed that both forms of xanthan gum thickener (liq-
uid and powder) are effective on clinical efficacy (i.e. improved swal-
low safety) through altered bolus rheology and reduced aspiration in
individuals with OD. Both thickeners demonstrate a lower friction co-
efficient value indicating a ‘smoother’ material that requires less effort
and muscle involvement to safely swallow the fluid and similar yield
stress which is associated with the elastic behaviour of the fluid and
has been extrapolated to greater tongue force being required to initiate
fluid flow in thicker fluids. Regardless of delivery format, the apparent
viscosity of water thickened with xanthan gum-based thickener were
within the therapeutic range (150 – 800 mPa.s at 50 s-1 ) reported by
Bolivar-Prados et al. (2019) that was shown to improve swallow safety.
Thus, the authors conclude that both formats are substantially equiv-
alent. However, in some situations liquid xanthan gum-based thicken-
ers are more advantageous in the management of OD than powdered
xanthan gum thickener. Liquid xanthan gum-based thickener is more
suitable to thicken carbonated beverages than powdered xanthan gum-
based thickener as it is pre-hydrated and more readily dissolves directly
into the fluid. In addition, liquid thickeners are more accurate and hy-
gienic than powdered thickeners as the scoop used to measure the pow-
dered thickener has a greater error margin and needs to be washed or
stored properly to prevent potential infection. In contrast liquid xan-
than gum-based thickeners are measured using a displacement pump,
thus eliminating hygiene issues as there is no human or instrumental
contact with the thickening medium during dosing. Though, it should
be noted that the cost associated with liquid xanthan gum-based thick-
eners is higher than powdered xanthan gum-based thickeners.
This review looked for peer-reviewed articles in the literature de-
scribing the safety and efficacy of xanthan gum-based thickeners in the
therapeutic medical management of oropharyngeal dysphagia and the
importance of the thickener delivery mode, whether it is in liquid or
powdered form, on the impact on quality of life and oral nutrition and
hydration compliance factors. While most of the studies included in this
review used conventional powdered xanthan gum-based thickeners, ap-
proximately 10% studies included in this review used liquid xanthan
gum-based thickeners. Future studies may be required to validate the
importance of the thickener delivery mode on the impact on quality of
life and oral nutrition and hydration compliance factors.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
The authors would like to acknowledge the financial support from
Trisco Foods Pty Ltd. The authors also gratefully acknowledge San-
tage Keighley for her insightful comments offered during review of this
manuscript.
12
Food Hydrocolloids for Health 1 (2021) 100038
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