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DIGEST was originally validated on a protocol without routine inclusion of thickened liquids. To ensure stability of DIGEST in different settings, we aimed to assess whether DIGEST grades remained stable when derived from a bolus protocol with or without standard inclusion of thickened liquids. MBSSs from 118 unique participants were retrospectively analyzed by 4 reliable raters using a master protocol of thin, thickened, pudding, and solid boluses. DIGEST grades were derived from four bolus protocol conditions: (1) DIGEST core protocol (without thickened liquids); (2) core plus mildly thick liquid; (3) core plus moderately thick; and (4) core plus mildly and moderately thick. Prevalence and Bias-Adjusted Kappa (PABAK) values were calculated to determine agreement of DIGEST grades between the core protocol and variations. PABAK ranged from 0.83 to 1.00 (near-perfect to perfect agreement). In rare instances where thickened liquids affected grades, they invariably worsened by one grade. There was no clear change-driving bolus type for this effect. Safety was more susceptible to change than efficiency. Inclusion of thickened liquids does not appear necessary in a minimum bolus protocol for DIGEST. Clinicians and researchers who wish to routinely include thickened liquids in their protocol should be aware that DIGEST grades may be worsened by one in a minority of cases and that safety grades appear more likely to be affected than efficiency grades.<\/jats:p>","DOI":"10.1007\/s00455-025-10874-8","type":"journal-article","created":{"date-parts":[[2025,10,23]],"date-time":"2025-10-23T14:14:54Z","timestamp":1761228894000},"page":"238-247","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Does Inclusion of Thickened Liquids in a Modified Barium Swallow Study (MBSS) Protocol Affect DIGEST Grades?"],"prefix":"10.1007","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0424-0207","authenticated-orcid":false,"given":"Ryan J.","family":"Burdick","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jenni","family":"Wu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ella","family":"Aldridge","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Claire","family":"Terp","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sara","family":"Gustafson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joanne","family":"Yee","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carla","family":"Warneke","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicole","family":"Rogus-Pulia","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katherine","family":"Hutcheson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2025,10,23]]},"reference":[{"issue":"1","key":"10874_CR1","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1002\/cncr.30283","volume":"123","author":"KA Hutcheson","year":"2017","unstructured":"Hutcheson KA, Barrow MP, Barringer DA, Knott JK, Lin HY, Weber RS, Fuller CD, Lai SY, Alvarez CP, Raut J, Lazarus CL, May A, Patterson J, Roe JW, Starmer HM, Lewin JS. 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