Comparison of Oropharyngeal Efficiency Between Two Popular Brands of Marie Biscuits

Abstract

Objective: The main objective of the study was to compare four measures of TOMASS (number of bites, number of masticatory cycles, number of swallowing and total time taken) across brands of Marie biscuits and gender. Methodology: The study employed a cross-sectional design with nonrandomized convenience sampling. A total of 60 participants (30 females and 30 males) were recruited for the study in the age range of 18 to 26 years. Prior to enrolment in the study, the participants were screened for potential speech and swallowing issues. Two commercially available crackers (biscuits) in India, Sunfeast Marie Light and Britannia Marie Gold were used. Video recordings of the participants eating the biscuits were analyzed to document four measures of TOMASS. Results: The mean values obtained on all the measures for males were lesser than mean values for females for both the biscuits. Mann-Whitney U test revealed a statistically significant difference across number of swallows and total time taken across gender. There were no significant differences across biscuits on the four TOMASS measures. Conclusion: It can be concluded that the TOMASS measures were near similar for both brands of Marie biscuits. Thus, any of these two brands of Marie could be used for clinical swallow evaluation. However, gender needs to be kept in mind, while interpreting the results of TOMASS. Future studies need to be conducted with other brands of Marie biscuit and in other age groups.

Introduction

The oral phase of swallowing begins with the ingestion of bolus into the oral cavity. The tongue receives the bolus and places it in the region between the molar teeth, where it can be chewed. Subsequently, the food is masticated through the rotary and lateral movements of the mandible to form a bolus. Mastication is a physiological process whereby food is comminuted, mixed with saliva, and formed into a bolus that can be swallowed safely [1]. During mastication, the food falls medially towards the tongue, which moves the material back onto the teeth as the mandible opens. Thus, mastication involves rapid and regular jaw motion with distinct open and close cycles. The cycle is repeated numerous times before forming a bolus and initiating the swallow [2–4]. For a successful swallow of solid food, an appropriate bite size followed by efficient mastication is essential [5].

For all these processes to occur normally, adequate jaw opening, lip closure, adequate neuromuscular control of the tongue and the masticatory muscles, appropriate functions of the teeth, and right amount of saliva are required [6]. However, in some individuals, this ability can get affected either due to damage to the peripheral swallow mechanism or due to any damage in the nervous system, which can result in oral dysphagia. Oral dysphagia is characterized by difficulty in biting, difficulty in retaining the bolus within the oral cavity, reduction in lateral tongue motion, difficulty maneuvering food in the oral cavity, difficulty chewing, and difficulty in bolus formation. Oral dysphagia can have an impact on the quality of life. Hence, it is highly essential to assess this at the earliest.

One of the methods, gaining popularity to assess and quantify the oral phase efficiency is The Test of Masticating and Swallowing Solids (TOMASS) [7]. The TOMASS was derived from the Timed Water Swallow Test (TWST), which provides quantitative information on swallowing using 100 to 150 ml of water [8]. The TOMASS was considered to be an accompanying tool of TWST, using the same method, but with a solid texture. The TOMASS allows a quantifiable measure that is inclusive of the oral preparatory phase of swallowing, which is not challenged by TWST. The test, in its original formulation, involves ingestion of a single Arnott’s Salada cracker™ with the instruction to eat the cracker “as quickly and as comfortable as possible” and to indicate they have finished by stating their name. Quantitative information such as the number of bites, number of masticatory cycles, and number of swallows, and total time to complete this task is collected. TOMASS is a test of oropharyngeal efficiency for solid bolus ingestion [9].

Huckabee et al. (2018) established normative data for TOMASS performances using various crackers available in Australia/New Zealand, North America, Ireland/UK, Italy/Portugal, Germany, the Netherlands, and Israel. Seven cracker types and 80–285 participants for each cracker type were studied. Significant differences were identified between two commercially available crackers, nearly identical in shape, size, and ingredients. For example, the Arnott’s Salada™ cracker required on average more bites, more chewing cycles, and more time to ingest than the Nabisco Saltine™ Cracker. The authors suggested that these differences may be related to fat content; the Arnott’s Salada™ cracker and Nabisco Saltine Cracker contain 2.8 g and 0 g fat, respectively. These findings demonstrate that there could be differences across crackers. They recommended that normative data should be established for each variation of cracker. Age and gender differences were found for all raw data measures across all cracker types. Males displayed greater efficiency than age-equivalent females with fewer bites, chews, and swallows as well as a shorter time is taken to complete the TOMASS.

Lamvik-Gozdzikowska et al.(2019) aimed to determine if TOMASS will detect changes in the oral phase of swallowing imposed by topical anesthesia by using the Arnott’s Salada™ biscuit, thus providing validation of its clinical utility. They concluded that TOMASS is a sensitive measure in the evaluation of the oral phase preparation of solid textures. The study by Hagguland et al. (2021) compared the Göteborgskex Gold Marie™ cracker, Guld Marie cracker and a Tuc Original™ cracker using TOMASS. The Guld Marie cracker required descriptively more chewing cycles to ingest the cracker than the Tuc cracker (39.5 vs. 35.6 cycles), but the differences did not reach statistical significance. The ANOVA showed no main effect of crackers on the number of bites used, nor for the numbers of swallows [10]. The Guld Marie cracker took an average longer time to ingest than the Tuc (36.3 vs. 33.4 s), but the differences failed to reach statistical significance. They concluded that when only small differences of crackers’ characteristics are present, the masticatory performances are not significantly affected. There were no significant differences in masticatory performances between the gender as well [11].

In the Indian context, Krishnamurthy et al. (2021) developed normative data for the TOMASS across age and gender groups for a commercially available biscuit (cracker) for the adult Indian population [12]. A total of 300 typical individuals in the age range of 21 to 80 years grouped by age and gender participated in the study. Participants were instructed to eat a Monaco biscuit as quickly and comfortably as possible, and the task was video recorded. The recorded video samples were analyzed to obtain measures of the number of bites, number of masticatory cycles, number of swallows, and total time is taken to complete the ingestion of biscuit. The results of the one-way ANOVA revealed a significant main effect of age and gender, but not an interaction between the two. It was found that males took fewer bites, took less time, chewed less, and swallowed fewer times than females. A definitive age effect was observed for the number of bites, masticatory cycles, and total time. The normative data were also generated.

Henderson (2015), who used TOMASS used for treatment evaluation in persons with Parkinson’s disease, reported that TOMASS is a sensitive tool for identifying a decline in swallowing efficiency [13]. Veld et al. (2020) also reported that this test can be used to provide information on the function and endurance during mastication in children with Down syndrome [14]. Later, Todaro et al. (2021) also concluded from their study that TOMASS was a reliable and valid tool (specifically related to the number of swallows per cracker) to differentiate patients with dysphagia from healthy controls and recommended the application of the same in clinical practice [15].

Need for the Study

Since, TOMASS has been reported as a reliable and valid tool in the assessment of oro-pharyngeal efficiency, this can be used in routine clinical evaluation. A review of the existing studies revealed that there was a difference between cracker types. The type of crackers used also varied across studies. In India, Marie biscuit is popular in the Indian market and is available in over 40 countries (Rafeeque & Saravanan, 2015) [16]. The study by Hägglund et al. (2021) also used a Marie biscuit. Marie biscuit is eaten across all age groups and is eaten with a cup of tea or milk. Marie biscuit is considered a healthy biscuit, and it is recommended by dieticians for calorie-conscious people. Due to the reduced sugar and wheat flour content of Marie biscuits, diabetics are advised to take them in moderation.

However, different companies manufacture these biscuits such as Parle, Britannia, ITC Sunfeast, McVitie’s, Patanjali, etc. Among these, the most popular brands are Sunfeast and Britannia [17]. It is not known whether there could be differences in the masticatory performance on TOMASS across these brands. Previous studies by Huckabee et al. (2018) also reported some differences between cracker types. It would be interesting to study if there were differences seen on TOMASS across these brands. Thus, the need for the current study arose. This study was designed with the aim of investigating the oro-pharyngeal efficiency for two commercially available Marie biscuit brands in the young Indian adult population using TOMASS. The specific objectives were, (i) To compare the performance on TOMASS across the two brands of Marie biscuit, (ii) To compare the performance on TOMASS across gender on both biscuits.

Method

Study Design

The study employed a cross-sectional design with nonrandomized convenience sampling between March 2021 and September 2021.

Ethical Considerations

All procedures performed in this study were under the current ethical guidelines of bio-behavioral research involving human subjects of the All India Institute of Speech and Hearing, Mysore. All participants received a thorough explanation of the purpose, risks, and procedures, and informed consent was obtained from them.

Participants

A total of 60 participants (30 females and 30 males) were recruited for the study in the age range of 18 years to 26 years. Prior to enrolment in the study, the participants were screened for potential speech and swallowing issues. All the participants are self-reported to be healthy with no history of dysphagia, head and neck, and/or neurological problems. A questionnaire World Health Organization Disability Assessment Schedule-Second Version (WHODAS 2.0), a 12-item short version based on International Classification of Functioning Disability and Health (ICF) which was developed by WHO in 2010 was completed by each participant through interview mode. This questionnaire provides a profile of functioning across six activity domains (i.e., cognition, mobility, self-care, getting along, life activities, and participation). This was to exclude volunteers with any dysfunction in any of the six aforementioned domains. Also, a thorough informal assessment was carried out to preclude cognitive, communicative, sensorimotor, neurological, psychological issues. All the participants obtained a score of < 3 on the Eating Assessment Tool 10 (EAT 10) [18]. Participants with recent dental, temporo-mandibular, gastroenterological, nasopharyngeal issues, and other related health problems were excluded.

Materials

Two commercially available crackers (biscuits) in India, Sunfeast MarieLight and Britannia Marie Gold were used for the present study. Sunfeast Marie Light weighs5 gm per biscuit with a total fat content of 11.7 gm and sugar content of 16.5 gm per 100 gm. Britannia Marie Gold weighs 5.56 gm per biscuit with a fat content of 12 gm and sugar content of 21.5 gm per 100 gm. The constituent ingredients of both the biscuits are the same that includes refined wheat flour (maida), sugar, refined oil, invert sugar syrup, raising agents, milk solids, iodized salt, calcium salt, vitamins, ferrous salt, potassium iodate, and artificial flavor- milk & vanilla. Though both biscuits were similar in size, shape, and appearance, they differed in weight and sugar content.

Procedure

The participants were asked to sit comfortably on the chair during the testing procedure. A rapport with the participants was established before the data collection process. Participants were given two biscuits randomly with a break of five minutes in between the two biscuits. For 50% of the participants, the Britannia Marie Gold (biscuit 1) was given first followed by the Sunfeast Marie Light (Biscuit 2) and vice versa for the remaining 50%. Water was offered before the first biscuit was given and during the break to clear the oral cavity and moisten the mucosa. They were instructed to eat the biscuits “as quickly and comfortably as possible” and say their name aloud to indicate the end of the procedure. The task was recorded using One Plus 8 phone cameras using a mobile tripod stand, placed at 30 centimeters from the participants. At the end of the task, a visual inspection of the oral cavity was done to ensure no pocketing or residual left. After the participants had ingested both biscuits, they were asked to express the differences they felt concerning texture, taste, ease of ingestion, and oral clearance.

Pilot Study

A pilot study was undertaken on five participants randomly. One major challenge which was noted was the drying of the mouth before the test procedure. However, this was sorted out by asking all the participants to take a sip of water before the test to bring homogeneity in the testing procedure.

Measures

The recorded video samples were analysed to obtain the following base measures; the number of bites, number of masticatory cycles, number of swallows per biscuit (cracker), and total time taken to complete the ingestion of biscuit. The number of bites was determined by the number of segments of the biscuits the participants placed in their mouths. The chewing cycles were evaluated using visual inspection of jaw movement. The number of swallows were identified by counting the elevation of the thyroid cartilage. The total time was calculated from the moment the biscuit touched the mouth till the participant expressed the name after finishing the whole biscuit. 10% of the recorded video samples were distributed among two other speech-language pathologists to obtain all the measures mentioned above for testing the inter-rater reliability.

Statistical Analysis

The data obtained from the participants were averaged and subjected to statistical analysis using SPSS software version 25. Cronbach’s alpha was used to assess the test-retest reliability. Descriptive statistics were computed to assess mean, standard deviation, and median values. The results of Shapiro-Wilk test revealed that the data for gender and the type of biscuits were not normally distributed (p < 0.05). Therefore, the Mann-Whitney U test was carried out to check the level of significance across gender and brands of biscuits for TOMASS measures under study.

Results

Reliability Measures

For all TOMASS measures, Cronbach’s alpha revealed a moderate to good (0.85 to 0.95) test-retest reliability. Cronbach’s alpha also suggested a high level of inter-rater reliability (> 0.85) for all TOMASS measures.

Comparison Across Gender

The mean values of males on all the TOMASS measures were lesser than that obtained in the females for both the brands of biscuits. Mann-Whitney U test revealed a statistically significant difference across two measures of the TOMASS, namely number of swallows (Biscuit 1; /z/= 3.25; p = 0.001; Biscuit 2; /z/= 2.54; p = 0.011) and total time taken (Biscuit 1; /z/= 3.71; p = 0.000; Biscuit 2; /z/= 2.32; p = 0.021) across genders. Table 1 shows the mean and standard deviation on all the measures for males and females.

Table 1.

Mean and standard deviation (SD) on all the measures for males and females for both the brands of biscuits

Gender	Biscuits	No. of Bites		No. of swallows			No. of masticatory cycle		Time Taken(secs)
		Mean	SD	Mean	SD		Mean	SD	Mean	SD
Males	Biscuit 1	3.14	0.63	2.94		0.78	57.27	19.91	48.14	15.68
	Biscuit 2	3.17	0.53	3.00		0.74	55.07	19.47	47.80	15.63
Females	Biscuit 1	3.34	1.15	4.06		1.50	62.34	13.74	61.40	13.88
	Biscuit 2	3.20	1.24	3.97		1.95	57.80	13.30	55.27	14.41

Comparison Across Brands of Biscuits

The mean values for both brands of biscuits on all the measures were compared in males and females separately. Mann Whitney test revealed no significant difference on all the four TOMASS measures across the biscuits; Number of bites (males /z/=0.404; p = 0.686; females /z/= 0.716; p = 0.474), Number of masticatory cycles (males, /z/=0.644; p = 0.520; females /z/=1.250; p = 0.211), Number of swallows (males /z/= 0.348; p = 0.728; females /z/= 0.661; p = 0.508) and Total time (males /z/=0.000 p = 1.000; females/z/=1.886; p = 0.059).

Discussion

TOMASS is a newly developed and widely used quantitative measure to assess oro-pharyngeal efficiency for solid food swallow [9]. Since Marie is a popular biscuit, is widely available in over 40 countries including India, and has been used in some of the previous studies, the current study employed this biscuit. The study aimed to compare the measures of TOMASS between two commonly available and popular brands of Marie biscuits in the young Indian adult population. A comparison was made also across gender. It was noted that the TOMASS assessment was easy to perform and participants were able to finish the tests within five minutes similar to as reported in the study by Krishnamurthy et al. (2021).

Effect of Biscuits on TOMASS Measures

This study was carried out to compare two popular brands of biscuits. However, the results revealed no significant differences on all the four measures of TOMASS across biscuits. This could be attributed to the near similar characteristics (similar shape, size, and ingredients) of both biscuits. Though they differed in weight and sugar content, this did not affect the measures on TOMASS differentially. This indicates that for a swallow assessment either of these two brands could be utilized. Similar findings were obtained by Hagguland et al., (2021). Though they compared Göteborgskex Guld Marie™ cracker (n = 234), Guld Marie cracker, and a Tuc Original™ cracker, which were slightly different in fat content, sugar, and weight, no significant differences were found. The Guld Marie cracker required more chewing cycles and an average longer time to ingest than the Tuc cracker. In the present study as well Britania Marie required more bites, masticatory cycles, the number of swallows, and time than Sunfeast Marie, however, there was no statistically significant difference between these two brands. These findings are in contrast to the finding by Huckabee et al. (2018) who found significant differences between crackers, nearly identical in shape, size, and ingredients. For example, the Arnott’s Salada™ cracker required on average more bites, more chewing cycles, and more time to ingest than the Nabisco Saltine™ Cracker. They attributed this difference to the difference in fat content of the crackers. In the two brands considered in their study, the fat content was nearly similar and hence no statistically significant differences were found.

The subjects also provided feedback regarding both the biscuits after the completion of the task in our study. They reported differences between the two biscuits for texture, taste, ease of ingestion, and oral clearance. Participants in our study favored Sunfeast over Britania. This might be due to the lesser at and sugar content of Sunfeast as compared to Britannia.

Effect of Gender on TOMASS Measures

There was a significant difference across gender in two measures (number of swallows and total time taken) of TOMASS. Males took significantly fewer bites, fewer masticatory cycles, lesser number of swallows, and lesser time to finish a biscuit. The decreased total measures for males compared to females align with some previous reports concerning both mastications [19, 20] and swallowing function [8, 21]. Huckabee et al. (2018) and Krishnamurthy et al. (2021) also reported that males displayed significantly greater efficiency than age-equivalent females with fewer bites, chews, and swallows as well as a shorter time is taken to complete the TOMASS.

A study by Milford et al. (2020) also revealed a higher number of mastication cycles and longer total mastication durations for females [22]. This might be due to the anatomical and physiological variations between males and females in the swallowing musculature, that is larger oral and pharyngeal structures used for mastication and swallowing. Male participants were observed to have increased masticatory muscle electrical activity and chewing power (µV) in the temporal and masseter musculature as reported in the studies by Nagasawa et al. (1997) and Park and Shin (2015), respectively. Gender role differences in dining etiquette (e.g., consuming small bites and chewing food thoroughly), may also explain these differences observed in mastication performance [23]. Also, females might have been more conscious during the testing procedure because of the male tester. This variable must be controlled in future studies. On the contrary, the number of bites was not significantly different across the gender. It should be noted that the number of bites and other swallowing functions has not been consistently reported in the literature. Some studies report differences across the gender [10, 24]. While this is in contrast to the finding by Hagglund et al. (2021) who reported significant differences in masticatory performances between genders. Significant effects of gender on masticatory performance were only observed for the number of bites for Guld Marie cracker. Other studies have not reported differences in gender across different parameters [25–29].

Conclusions

It can be concluded that the TOMASS measures were near similar for both brands of Marie biscuits. Thus, during assessments, clinicians can use either of these and need not be concerned about the brand (particularly Britannia or Sunfeast), while instructing patients to bring biscuits for offline and /or online swallow assessments. However, gender needs to be kept in mind, while interpreting the results of TOMASS as we found gender differences on three measures of TOMASS in the present study. Future studies need to be conducted with other brands of Marie and compare Marie with the Monaco biscuit, which was used in a previous study carried out in India. . This study was done only on young adults. Future research could include the other age groups.

Author Contribution

Biraj Bhattarai and Syamkrishna Vijayan were involved concept development, study design, data collection, analysis of the data, interpretation and writing the manuscript; Swapna N was involved in concept development and writing the manuscript.

Funding

This is a non-funded research.

Declarations

Conflict of Interest

There is no conflict of interest to disclose.

Ethical Standards

The manuscript adheres to the ethical standards according to the Declaration of Helsinki. .

Ethical Approval

All procedures performed in this study were in accordance with the ethical guidelines of bio-behavioral research involving human subjects of the All India Institute of Speech and Hearing, Mysore.

Informed Consent

Informed consent was obtained from the participants to participate in the study.