Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework

Determination of the international dysphagia diet standardization initiative level of commercially available oral nutritional supplements

BACKGROUND/OBJECTIVE

The International Dysphagia Diet Standardization Initiative (IDDSI), a global multi-disciplinary non-profit framework, has created a standardized communication code to describe foods and liquids for individuals with dysphagia. For liquids, four levels have been determined (Level 0: Thin 1; Level 1: Slightly thick; Level 2: Mildly thick; Level 3: Moderately thick; Level 4: Extremely thick). The implementation of the IDDSI terminology is still in progress. Thus, most commercially available oral nutritional supplements lack an IDDSI identification label. The objective of the present work was to characterize oral nutritional supplements in terms of IDDSI, to facilitate its implementation.

METHODS

Several supplements commercially available were tested and categorized according to the IDDSI system for liquids. Supplements in powder form were prepared according to manufacturers' instructions. The IDDSI Flow Test was performed with specified syringes according to standard methodology.

RESULTS

In total, 40 products from seven companies (Abbott, Medella, Nestle Health Science, Nutricia, Nutrisens, and Nutrimedica) were assessed, including different flavors from the same product line. Most products were classified at IDDSI 0 and 1 levels. Compact product forms were classified at the IDDSI 2 level, while soups and creams were classified at the IDDSI 3 or 4 level.

CONCLUSIONS

Patients with dysphagia and malnutrition can choose from various products classified according to the IDDSI classification to meet their nutritional needs.

Validation of the Dynamic Imaging Grade of Swallowing Toxicity for Amyotrophic Lateral Sclerosis

INTRODUCTION

Although dysphagia is prevalent in persons with amyotrophic lateral sclerosis (pALS) and is associated with morbidity and mortality, no validated outcomes currently exist for the gold standard videofluoroscopy (VF) exam. We therefore sought to psychometrically validate the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale in pALS.

METHODS

One hundred pALS attended a research evaluation and underwent a standardized VF and validated clinical outcomes of oral intake (FOIS), perceived swallowing impairment (EAT-10), and ALS disease progression (ALSFRS-Revised). Duplicate, independent, and blinded VF ratings were completed using the DIGEST and MBSImP scales. Weighted kappa, ANOVAs (Tukey's HSD, Welch's correction), and Chi-square analyses were performed to determine intra- and inter-rater reliability, criterion validity, and construct validity of the DIGEST scale for use in pALS.

RESULTS

The mean age was 64.4(SD = 10.4), 50% were male, and the average ALS duration was 28.2 months (SD = 22.2). Excellent intra-rater (kappa = 0.92-1.0) and inter-rater (kappa = 0.94) reliability were noted for DIGEST ratings. DIGEST grades significantly discriminated pharyngeal pathophysiology (MBSImP, F(3,96) = 24.7, p < 0.0001), perceived dysphagia (EAT-10, F(3,40) = 20.8, p < 0.0001), oral intake (FOIS, X2:25.4, df = 3, p < 0.0001), ALS bulbar disease progression (ALSFRS-bulbar, F(3,93) = 20.8, p < 0.0001) with main effects noted for all analyses. Post hoc pairwise comparisons noted differences across all DIGEST grades with the exception of DIGEST 2 versus 3 (moderate vs. severe dysphagia), p > 0.05.

CONCLUSIONS

These data confirm that the DIGEST scale is a reliable and valid VF outcome for use in pALS to distinguish normal versus impaired swallowing and mild versus moderate or severe dysphagia for use in clinical practice and as a clinical trial endpoint marker.

ESSD-ESGAR best practice position statements on the technical performance of videofluoroscopic swallowing studies in adult patients with swallowing disorders

OBJECTIVES

Videofluoroscopic swallowing studies (VFSS) remain the gold standard for the instrumental assessment of oropharyngeal swallowing disorders alongside flexible endoscopic evaluation of swallowing (FEES), requiring a high standard of quality and correct implementation. The current best practice position statements aim to guide the clinical practice of VFSS in individuals experiencing swallowing disorders.

MATERIALS AND METHODS

An international expert consensus panel with expertise in oropharyngeal dysphagia, comprised of radiologists, speech-language therapists, otolaryngologists, and other professionals in the field, convened by the European Society of Swallowing Disorders (ESSD) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), developed best practice position statements. They were established using an online Delphi methodology involving an online panel discussion and item preparation and three consecutive rounds. Consensus was reached when ≥ 80% of the participants agreed on a specific recommendation.

RESULTS

Eighteen best practice position statements were formulated, thereby establishing standard recommendations on the technical performance of VFSS. They cover VFSS planning, correct implementation, documentation, radiation protection, equipment and maintenance, and education and training.

CONCLUSION

These position statements summarise the panel's deliberations and recommendations in performing VFSS, representing the agreed consensus of experts from ESSD and ESGAR. They provide a structured framework for optimising and standardising the performance of VFSS in patients with swallowing disorders.

KEY POINTS

Question Significant regional and national differences in clinical practice when performing VFSS highlight the need for interdisciplinary recommendations to optimise patient care. Findings Eighteen statements were developed by representatives of the ESSD and the ESGAR. Clinical relevance These best practice position statements on the technical performance of VFSS may serve as a basis for standardising the procedure and ensuring high-quality service.

Developing thickened soy protein-based liquid systems: Importance of oil-water interfacial behavior

Rheological properties are critical in the design of dysphagia foods. Interfacial behavior is a critical factor in determining the rheological properties of emulsions. In this study, dysphagia foods were prepared by thickening soy protein-based liquid systems with xanthan gum, guar gum, and pectin. Interfacial behavior in dysphagia foods was focused on using interfacial dilatational rheology and quartz crystal microbalance with dissipation technique. The results showed that xanthan gum/soy protein and pectin/soy protein composite particles exhibited higher dynamic interfacial tension than soy protein particles. The results were opposite for guar gum/soy protein composite particles. Moreover, the thickness and mass of the interfacial layers formed by XG/SP and GG/SP were greater than that of P/SP, with the most stable interfacial microstructure formed by XG/SP. This study reveals the correlation between the physical properties and interfacial behavior of dysphagic foods and provides insights for the development of novel dysphagic foods.

Swallowing Function After Pioneering Partial Face and Whole Eye Transplant: Clinical Insights

PURPOSE

There is limited literature reporting swallowing outcomes in the pre- and postoperative period for patients undergoing facial transplantation. This case report aims to utilize a combination of objective and patient-reported outcome measures to highlight swallowing improvements following the world's first face with whole-eye transplantation.

METHOD

Outcome measures in jaw range of motion, anterior containment, texture progression, airway protection, and pharyngeal swallow function were collected pretransplantation by two speech-language pathologists (SLPs) and at multiple postoperative visits after the procedure was completed. Specific outcome measures included the Gothenburg Trismus Questionnaire, Maximal Incisor Opening, Modified Teachers Drooling Scale, Functional Oral Intake Scale, Eating Assessment Tool-10, The Penetration-Aspiration Scale, and the Modified Barium Swallow Study Impairment Profile. Measures were then compared over a 1-year time period to assess changes in swallow function.

RESULTS

Improvements in jaw range of motion, anterior containment, and airway protection were observed. The patient's stated goal of returning to full PO diet following face transplant was achieved within 1 year.

CONCLUSIONS

Swallowing and trismus outcome measures are an important tool for monitoring progress along a patient's recovery journey, especially following unique procedures such as face transplantation. Based on this single patient case study, facial transplantation can lead to improvements in both objective and patient-reported outcomes. Future goals for research should continue to explore this unique population due to the limited literature available for SLPs, as well as include development of valid and reliable assessment tools specific to the face transplantation population.

State-of-the-art review of blenderized diets-Status and future directions

This state-of-the-art review was produced by a multidisciplinary team composed of pediatric gastroenterology and nutrition healthcare providers to provide a comprehensive overview of the use of blenderized tube feeds (BTFs). The team developed 12 vital questions to address gaps in the current understanding and practice of using BTFs, then performed a comprehensive search of literature published between 2000 and 2023 using PubMed, MEDLINE, Embase databases, and an individual search of references. There was a scarcity of well-designed randomized clinical trials, and most of the studies were prospective or retrospective observational reports from heterogeneous patient demographics, varieties of BTFs, and medical conditions. Use of BTFs was associated with improved outcomes, including higher satisfaction, reduced gastroesophageal reflux, retching, gagging, constipation, frequency of hospitalization for respiratory disease, and greater diversity of the gut microbiome. However, homemade and commercially manufactured BTFs varied in nutrient composition and physical properties, such as viscosity, which posed challenges related to ease of administration and comparison of clinical outcomes. Therefore, whereas the use of BTFs as an alternative to standard commercial formulas has become increasingly popular, further evidence is warranted to provide guidelines on best practices for usage, monitoring, and comparing clinical outcomes. Pediatric dietitians and clinician practitioners must regularly monitor children receiving BTFs to ensure nutritional adequacy, optimize safe and effective delivery, and promote optimal growth. The team proposed future directions regarding best practices for using BTFs, primarily related to clinical application and nutritional outcomes in children and adolescents.

Surface Electromyographic Activities of Submental and Infrahyoid Muscles: Comparisons Based on Residue, Penetration and Aspiration

BACKGROUND

Surface electromyography (sEMG) has been used in a wide range of studies conducted in the field of dysphagia.

OBJECTIVES

The main aim of this case-control study is to obtain how submental and infrahyoid sEMG signals differ based on residue, penetration and aspiration.

METHODS

A total of 100 participants (50 patients with suspected dysphagia and 50 healthy controls) were enrolled in the present study. Participants with suspected dysphagia underwent a detailed fibreoptic endoscopic evaluation of swallowing (FEES) to observe the efficiency and safety of swallowing using the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS) and the Penetration-Aspiration Scale (PAS), respectively. Afterward, sEMG parameters, including submental muscle activity duration (SMM-AD), infrahyoid muscle activity duration (IM-AD), amplitude of submental muscles (A-SMM) and amplitude of infrahyoid muscles (A-IM) were obtained during three consecutive dry swallows from all study cohorts.

RESULTS

There were significantly higher SMM-AD values in patients with a YPRSRS score of 1-2 and a YPRSRS score of 3-5 for residue in vallecula compared to the controls (p < 0.001 and p = 0.001, respectively). Both subgroups of patients with a YPRSRS score of 1-2 and a YPRSRS score of 3-5 for residue in piriforms showed significantly higher SMM-AD values compared to the controls (p < 0.001 and p = 0.048, respectively). The same prolongation of SMM-AD was also evident for the patients with airway invasion (penetration or aspiration) compared to the controls (p = 0.042 and p < 0.001, respectively). The other measured sEMG parameters (IM-AD, A-SMM and A-IM) did not differ significantly based on FEES outcomes (p > 0.05).

CONCLUSION

Since the availability of instrumental swallowing assessment methods in clinical practice is quite challenging, specific sEMG parameters may be useful to predict possible residue, penetration, or aspiration events in patients with dysphagia. SMM-AD can be considered as a first-line assessment parameter for possible residue, penetration, and aspiration events before referring patients for further instrumental methods.

Development of soft food gels from high-methyl pectin-protein conjugates via acid- and heat-induced crosslinking for dysphagia-friendly applications

This study developed pea protein isolate (PPI)-high-methyl (HM) pectin conjugates via the Maillard reaction to enhance PPI's functionality as a texture modifier for dysphagia-friendly soft food gels. Conjugation at 1:1, 2:1, and 4:1 protein-to-pectin ratios significantly improved structural flexibility, physicochemical characteristics, and functional properties. Fourier Transform Infrared Spectroscopy (FT-IR) confirmed successful conjugation through shifts in amide I and II bands, while SDS-PAGE revealed higher molecular weight aggregates, indicating effective crosslinking. Circular Dichroism (CD) spectroscopy showed a reduction in β-sheet content (from 47.41 % to 16.15 %) and an increase in α-helices (from 0 % to 12.70 %), enhancing solubility (from 1.79 % to 100 %) and reducing surface hydrophobicity (from 74.52 % to 18.16 %). These structural changes facilitated improved protein dispersion and stable gel network formation, enhancing gel cohesiveness and softness, key attributes for dysphagia-friendly textures. Conjugate-incorporated gels exhibited softer textures than firmer control gels. Acid-induced gels formed soft, easily deformable matrices, while heat-induced gels produced firmer structures, accommodating different dysphagia severity levels. International Dysphagia Diet Standardization Initiative (IDDSI) assessments classified these gels as Level 6, ensuring safe swallowing. Rheological analyses revealed non-Newtonian shear-thinning behavior, while SAXS confirmed uniform nano-aggregation. Overall, PPI-HM pectin conjugates demonstrate potential as safe, functional solutions for texture-modified foods targeting dysphagia management.

Identifying dysphagia in the intensive care unit: Validation of the Swedish version of the Gugging swallowing screen-Intensive care unit

BACKGROUND

Dysphagia is independently associated with adverse outcomes in intensive care units (ICU). Early identification through dysphagia screening does not occur routinely, negatively impacting optimal patient management. This study aimed to validate the Swedish version of the Gugging Swallowing Screen-Intensive Care Unit (GUSS-IVA).

METHODS

This is a prospective multicentre study of 56 adult ICU patients with endotracheal intubation exceeding 48 h at three hospitals in Sweden. The GUSS-ICU was translated into Swedish (GUSS-IVA) and used to screen all prolonged intubated patients (>48 h) once extubated. The GUSS-IVA screen was conducted by ICU nursing staff and then compared with a gold standard Flexible Endoscopic Evaluation of Swallowing (FEES) within 2 h of the GUSS-IVA screen. Fifty-one of 56 patients underwent FEES (where assessors were blinded to the GUSS-IVA screen results). Sensitivity and specificity were calculated, as was the area under the receiver operating characteristic curves (AUC) with 95% confidence intervals (CI). For inter-rater reliability, within 2 h of the initial screen, 29/56 patients were GUSS-IVA screened a second time by a nursing staff blinded to the first GUSS-IVA results.

RESULTS

Among the 56 patients, 38 (67.9%) were identified as dysphagic using the GUSS-IVA screen. With FEES, 42 of 51 patients (82.4%) were diagnosed with dysphagia; of these, 16 (31.4%) were classified as aspirating. Compared to FEES, GUSS-IVA showed high sensitivity and specificity values (81% and 89%, respectively) with an AUC of 0.85 (95% CI: 0.71-0.95) and a positive predictive value of 97%. High convergent validity was obtained for GUSS-IVA compared with the Dysphagia Outcome Severity Scale (ɸ = 0.57, p < .001) and the Functional Oral Intake Scale (ɸ = 0.52, p < .001) and moderate validity with the Penetration-Aspiration Scale (ɸ = 0.30, p = .033). The inter-rater reliability showed moderate agreement (Cohen's kappa κ = 0.501, p = .006).

CONCLUSIONS

This study indicates that the Swedish GUSS-IVA is a valid and reliable screen to identify dysphagic ICU patients. Given the negative impact of dysphagia on short and long-term patient outcomes, the Swedish GUSS-IVA is recommended as an essential first step by nursing staff for early identification of dysphagia for further diagnostics and subsequent patient management.

Carrageenan-xanthan gum composite gel achieves the elimination of bitterness and easy swallowability of Coptis chinensis based on electrostatic induction and interpenetrating network interaction

Natural polysaccharides possess the potential function of masking bitterness due to their three-dimensional network structures. However, they also have relatively high mechanical strength, which is not conducive to swallowing. Taking Coptis chinensis as an example, this study developed a composite gel composed of 0.17 % iota-carrageenan, 0.13 % lambda-carrageenan and 0.17 % xanthan gum. This composite gel can eliminate the bitterness and achieve good swallowability. Compared with the Coptis chinensis decoction, the bitterness of this gel is reduced by 60 %. Its hardness and crispness are only 1 % and 0.7 % of those of iota-carrageenan used alone. In addition, 60 % of the berberine in the composite gel can be released in artificial gastric juice within 10 min, and it has no significant impact on the hypoglycemic effects of Coptis chinensis. Further mechanism studies revealed that the sulfate group of iota-carrageenan disperses the electron cloud density of the bitter group of alkaloids through electrostatic induction, thus realizing the masking of bitterness. Meanwhile, the formation of an interpenetrating network structure between xanthan gum and carrageenan improves the swallowability. This study has developed a Coptis chinensis composite gel with excellent taste and easy swallowability, providing evidence for expanding the new applications of polysaccharides in masking taste.

Validation of the Deglutition Handicap Index-Informal Caregiver questionnaire

BACKGROUND

The Deglutition Handicap Index-Informal Caregiver (DHI-IC) questionnaire is a dysphagia assessment tool derived from the psychometrically validated Deglutition Handicap Index (DHI) self-reported dysphagia questionnaire in French. Like the DHI, the DHI-IC comprises 30 items, in 3 equal domains: Physical, Functional and Emotional.

MATERIALS AND METHODS

A prospective study included 61 patients and 61 caregivers recruited from an ENT clinic dedicated to dysphagia.

OBJECTIVES

To validate the DHI-IC as an assessment tool and to compare results with the DHI and swallowing endoscopy.

CONCLUSIONS

The DHI-IC, like the DHI, showed good internal consistency. The results indicate that it is an appropriate tool for assessing functional status, health and quality of life related to dysphagia in patients via caregiver reporting.

The Impact of Bolus Rheology on Physiological Swallowing Parameters Derived by Pharyngeal High-Resolution Manometry Impedance

BACKGROUND

The shear rheology of ingested fluids influences their pharyngo-esophageal transit during deglutition. Thus, swallowed fluids elicit differing physiological responses due to their shear-thinning profile.

METHODS

Two hydrocolloid fluids, xanthan gum (XG) and sodium carboxymethylcellulose gum (CMC), were compared in 10 healthy adults (mean age 39 years). Manometry swallowing assessments were performed using an 8-French catheter. Swallows were analyzed using the Swallow Gateway web application (www.swallowgateway.com). Grouped data were analyzed by a mixed statistical model. The coefficient of determination (r2) assessed the relationship between measures and bolus viscosity (SI units, mPa.s) at shear rates of 1-1000 s-1.

KEY RESULTS

Rheology confirmed that the thickened fluids had similar viscosities at 50 s-1 shear rate (XG IDDSI Level-1, 2, and 3 respectively, 74.3, 161.2, and 399.6 mPa.s vs. CMC Level-1, 2, and 3 respectively 78.0, 176.5, and 429.2 mPa.s). However, at 300 s-1 shear, CMC-thickened fluids exhibited approximately double the viscosity (XG Level-1, 2, and 3 respectively 19.5, 34.4, and 84.8 mPa.s vs. CMC Level-1, 2, and 3 respectively, 41.3, 80.8, and 160.2 mPa.s). In vivo swallows of CMC, when compared to XG, showed evidence of greater flow resistance, such as increased intrabolus pressure (p < 0.01) and UES Integrated Relaxation Pressure (UESIRP, p < 0.01) and shorter UES Relaxation Time (p < 0.05) and Bolus Presence Time (p < 0.001). The apparent fluid viscosity (mPa.s) correlated most significantly with increasing UESIRP (r2 0.69 at 50 s-1 and r2 0.97 at 300 s-1, p < 0.05).

CONCLUSION

Fluids with divergent shear viscosities demonstrated differences in pharyngeal function. These physiological responses were linked to the shear viscosity and not the IDDSI level.

Pharyngeal Residues Following Swallowing of Pureed Diets Thickened with a Gelling Agent or a Xanthan Gum-Based Thickener in Elderly Patients with Dysphagia

The ideal texture of pureed diets to prevent aspiration pneumonia remains unclear. The aim of this study was to evaluate the effectiveness of a pureed diet with either a gelling agent or a xanthan gum-based thickener to prevent pharyngeal residues in patients with dysphagia. We retrospectively analyzed a randomized, crossover trial of pureed rice with either a gelling agent or a xanthan gum-based thickener in patients with dysphagia. The enrolled patients were classified into mild and moderate-to-severe dysphagia groups. The primary outcome measure was degree of need for cyclic ingestion using test jelly for pharyngeal residuals (cyclic ingestion score). The secondary outcome was the patient's sense of material remaining in the throat following swallowing. Sixty-two patients (58% men; mean age 83 ± 9 years) with dysphagia were included. They were classified into mild dysphagia (n = 26) and moderate-to-severe dysphagia (n = 36) groups. In the moderate-to-severe dysphagia group, pharyngeal residuals were significantly less likely with pureed diets using a gelling agent than with those using a xanthan gum-based thickener, with respective median cyclic ingestion scores (range) of 1 (0-4) vs. 2.5 (0-4) (p = 0.001). There was no significant difference in pharyngeal residuals between the pureed diets in the mild dysphagia group. The multivariate analysis identified gelling agent as an important factor significantly associated with less pharyngeal residual after swallowing of pureed diet in patients with moderate-to-severe dysphagia. Pureed diets thickened by a gelling agent decrease pharyngeal residues in patients with moderate-to-severe dysphagia and may reduce risk of aspiration pneumonia.

Effectiveness of diet modification on dietary nutrient intake, aspiration, and fluid intake for adults with dysphagia: a meta-analysis of randomized controlled trials

OBJECTIVES

To determine and explore the effectiveness of diet modification on dietary nutrient intake, aspiration, and fluid intake in adults with dysphagia.

PARTICIPANTS

Adults with dysphagia.

DESIGN

A meta-analysis of randomized controlled trials (RCTs).

METHODS

We conducted a comprehensive literature search in EMBASE, Cochrane Library, Ovid-Medline, CINAHL, Web of Science, PubMed, and reference lists until November 2023. Quality of the included studies was assessed by the Cochrane Risk of Bias Assessment tool 2.0. Data analysis was performed using Comprehensive Meta-analysis 3.0 for pooled Hedges' g and odds ratios (ORs) with corresponding confidence interval (CI) adopting a random-effects model. A X2- based test using Cochran's Q (P < 0.10) and I2 statistics evaluated heterogeneity.

RESULTS

In total, 16 RCTs from among 3,854 studies retrieved from the literature search with 1812 adults with dysphagia were included in this meta-analysis. Texture-modified diets revealed a significant small effect on increasing energy intake (g: 0.37, 95% CI = 0.05-0.68) and a medium effect on increasing protein intake (g: 0.56, 95% CI = 0.13-0.99). Thickened fluids revealed a significantly reduced risk of aspiration (OR: 0.59, 95% CI = 0.44-0.79), and thickened fluids combined with water protocol revealed a significant large effect on increasing fluid intake (g: 3.96, 95% C = 0.75-7.16).

CONCLUSIONS

The findings of this meta-analysis demonstrated that texture-modified diets increase dietary intake of energy and protein for adults with dysphagia. In addition, thickened fluids reduced the risk of aspiration while thickened fluids combined with water protocol increased fluid intake in adults with dysphagia.

Thickened feeds for infants with critical CHD: a survey of current practices

INTRODUCTION

Dysphagia is common in infants born with critical CHD. Thickened liquids are often used to treat dysphagia, but associated risks limit widespread use among feeding specialists. This survey aims to assess dysphagia treatment patterns and thickened liquid use across paediatric cardiac surgical centres.

METHODS

A 24-question, cross-sectional survey. Convenience and snowball sampling methods were used to engage 52 paediatric cardiac surgical centres affiliated with the Cardiac Newborn Neuroprotective Network. Descriptive statistics were used to analyse and compare responses.

RESULTS

Twenty-six individual respondents represented 21 unique paediatric cardiac surgical centres. Most responses were from experienced, speech-language pathologists (78%) at medium size centres (88%). Ninety-three percent of responding centres used thickened liquids to treat dysphagia and 81% only after formal instrumental assessment of swallowing. Thickened oral feeding was used for single-ventricle patients by 85% versus 69% for two-ventricle patients. Barriers to recommending thickened oral feedings included the cost of thickening agents, parental non-adherence, and gastrointestinal concerns.

CONCLUSIONS

This is the first survey to report multi-institutional dysphagia treatment practice variation at United States congenital cardiac surgical centres. Thickened oral feedings are frequently used across centres in high-risk critical CHD patients but treatment benefit remains unclear. This survey highlights a broad scientific community poised to direct dysphagia research in critical CHD to address practice variation, short- and long-term impact of thickened oral feeding on feeding outcomes, and barriers to use and access of thickening agents.

Analysis of Patients' Dietary Status/Restrictions Following Instrumental Swallow Evaluations in Skilled Nursing Facilities

Many residents in Skilled Nursing Facilities (SNFs) present with dysphagia and receive altered diets or liquids to minimize the risk of complications. Limited access to timely instrumental evaluations of swallow may impede the best management of these dysphagic residents. De-identified FEES reports completed by a mobile FEES company during a single month, January 2019, were reviewed. Descriptive statistics were used to summarize the pre-study diet/liquid levels and the post-study diet/liquid recommendations. FEES reports (n = 952) were reviewed. Before the FEES evaluation, 209 residents were receiving only non-oral nutrition. After the FEES evaluation, 76% of these residents were recommended to receive oral nutrition. Before the FEES evaluation, 442 (46%) residents were receiving thickened liquids, after the FEES evaluation, 244 (26%) were recommended to have a less restrictive liquid level. Before the FEES evaluation, 576 (60%) residents were receiving altered food texture, after the FEES evaluation, 413 (43%) were recommended to have a less restrictive food texture. The percentage of residents recommended to receive thin liquids increased from 32 to 68% and those recommended to receive a regular diet increased from 18 to 34%. These data indicate that access to instrumental swallow evaluations in the SNF setting generally resulted in lifting liquid and diet restrictions for many residents in the cohort reviewed and potentially improved their quality of life.

Effect of Thickened Fluids on Swallowing Function in Oropharyngeal Dysphagia: Impact of Shear Rheology and Disorder Subtype

INTRODUCTION

Fluid thickeners used in the management of oropharyngeal dysphagia exhibit non-Newtonian shear-thinning rheology, impacting their viscosity during deglutition. This study investigated how the rheological properties of thickened fluids affect pharyngeal swallowing parameters in patients with oropharyngeal motor disorders diagnosed by pharyngeal high-resolution manometry impedance (P-HRM-I).

METHODS

Seventy-two patients (18-89 years) referred for P-HRM-I were diagnostically assessed with a 10 mL thin bolus. In 57 of the patients, 10 mL swallows of two moderately thick formulations-xanthan gum (XG) and sodium carboxymethylcellulose gum (CMC)-were also tested. The XG and CMC fluids had equivalent empirical thickness but different viscosity at pharyngeal phase shear rates: XG 87 mPa.s (83-91) versus CMC mean 157 mPa.s (148-164) at 300 s-1. Standard metrics of pharyngeal and upper esophageal sphincter (UES) function were derived from P-HRM-I recordings and analyzed to characterize patients into one of four disorder subtypes: (i) No Disorder, (ii) UES Disorder, (iii) Pharyngeal Disorder, and (iv) Combination UES/Pharyngeal Disorder. Impedance recordings also assessed pharyngeal bolus transit.

RESULTS

Patients with a Combination UES/Pharyngeal Disorder were most likely to have abnormal bolus transit (82%, p < 0.001). Increasing bolus viscosity significantly influenced UES residual pressure, UES opening area, and post-swallow residue. Patients with UES Disorder exhibited pronounced increases in UES residual pressure with CMC compared to XG. Pharyngeal contractility was unaffected by viscosity changes. Post-swallow residue increased with CMC, particularly in patients with a Combination Disorder. Case-by-case analysis revealed individual variability in response to the different viscosities.

CONCLUSION

The rheological properties of thickened fluids significantly affect swallowing function, with these effects dependent upon the disorder subtype.

A prospective study of diagnostic testing and hospital charges after brief resolved unexplained event

OBJECTIVES

To evaluate diagnostic testing frequency/yield and determine drivers of hospital charges in a prospective cohort of infants with brief resolved unexplained event (BRUE) to test the hypothesis that length of stay (LOS), low-yield diagnostic testing, and repeat hospital visits increase costs.

METHODS

We conducted a prospective cohort study of infants admitted after BRUE to determine how clinical practice impacts the cost of care. Charge data from our institution's billing records database included room and board, diagnostics, medications, and professional fees for index hospitalizations and 6-month follow-ups. Charts were reviewed for clinical data, testing results, and repeat hospitalizations. Parent-reported symptoms and management changes were obtained by questionnaires. Multivariable analyses with linear regression were conducted to determine risk factors for hospitalization charges and total charges including hospitalization and 6-month follow-up.

RESULTS

The cohort included 155 subjects with median index hospitalization charges of $11,256 and total charges of $15,675. Overall, 76% had persistent BRUE symptoms and 15% repeat hospitalization; 34% were treated with acid suppression. Only 9.7% of the tests performed provided a potential diagnosis, but the videofluoroscopic swallow study (VFSS) had the highest yield with 70% abnormal. On multivariable analysis, LOS, VFSS, flexible laryngoscopy, electroencephalogram, and repeat hospital visits were all associated with increased charges (fold change: 142%-354%).

CONCLUSIONS

Hospitalization and follow-up care are costly after BRUE. Potentially modifiable drivers of charges include test number, LOS, and repeat hospital visits. Most testing is low-yield, but timely performance of VFSS may allow for cost-effective and appropriate treatment of oropharyngeal dysphagia and prevention of persistent symptoms. Gastroenterologists are frequently involved in caring for these children and are uniquely positioned to help guide testing and treatment related to gastroesophageal reflux disease and oropharyngeal dysphagia.

The Efficacy of Outpatient Swallowing Therapy: A Retrospective Longitudinal Cohort Study

Oropharyngeal dysphagia is an independent predictor of poor outcomes in many health conditions and can be targeted directly through swallowing therapy. This study aims to explore the outcomes of outpatient swallowing therapy in clinical practice across a diverse cohort of patients. This was a retrospective, single-site longitudinal cohort study. Patients 18 years or older with dysphagia who completed 7-8 weeks of outpatient swallowing therapy with a pre- and post-treatment videofluoroscopy were included. Therapy employed a progressive swallowing exercise regimen based on the Systematic Exercise for Treatment of Swallowing (SETS) protocol. Outcome measures included the pharyngeal components of the Modified Barium Swallow Impairment Profile, penetration-aspiration scale scores, and diet recommendations using the International Dysphagia Diet Standardization Initiative. 152 patients were included. Swallowing therapy improved all MBSImP component scores except 1, 7, and 13. Therapy improved total pharyngeal impairment scores by 2.66 points (p < .001) and total oral impairment score by 1.41 points (p < .001). Odds of elevated aspiration risk were reduced by 49% (p < .001). Patients were more likely to be on an unmodified food consistency after completion of therapy (OR 26, p = .004), but liquid consistency was not altered (OR 2.0, p = .57). Overall, 44% of patients in the cohort with an efficiency issue improved, and 50% of patients at risk for aspiration pre-therapy improved. Completing a 7-8 week course of exercise-based outpatient swallowing therapy is effective at improving multiple measures of swallowing physiology, safety and efficiency. It can also enable relaxation of diet consistency restrictions based on the IDDSI framework.

Feasibility of Cerebellar Stimulation for the Treatment of Post-Stroke Dysphagia

Post-stroke dysphagia (PSD) is common and associated with poor outcomes. We aimed to explore the feasibility, safety, and proof of concept of cerebellar rTMS in patients with sub-acute PSD. We intended to recruit 48 participants with PSD. Randomised to: (i) sham treatment twice-daily for five days, (ii) cerebellar rTMS daily for three days, and (iii) cerebellar rTMS twice-daily for five days (1:1:1). Participants were blinded to treatment group. Primary outcomes were feasibility, safety, and functional outcome intake scale (FOIS), dysphagia severity rating scale (DSRS), and feeding status scale (FSS) at two weeks. However, due to lower-than-expected enrolment, the active rTMS groups were combined. We recruited 14 participants in total, (mean 68 years, 57% female). Due to the time-limited funding period, recruitment was adversely affected by the COVID-19 pandemic. DSRS and FSS trended lower in the combined active rTMS groups at two weeks, i.e. less swallowing impairment. However, at death/discharge FOIS was higher/better (mean, (standard deviation)), 4.0 (2.1) vs. 1.8 (1.0) (p = 0.032) with active TMS, with trends to lower/better DSRS and FSS. There was no difference in the acceptability of treatment between groups. High-intensity (n = 5) vs. low-intensity (n = 5) cerebellar rTMS was associated with lower DSRS 3.0 (1.4) vs. 9.4 (2.7) and FSS 0.6 (0.5) vs. 1.6 (0.5) at 2 weeks, and DSRS 3.0 (1.4) vs. 9.0 (3.7) at hospital discharge or death. Cerebellar rTMS is a feasible ward-based treatment for reducing swallowing impairment. Although enrolment was lower than desired, there was evidence for proof of concept, particularly for high-intensity cerebellar rTMS. Larger studies are warranted.

Characterization of Beverage Viscosity Based on the International Dysphagia Diet Standardisation Initiative and Its Correspondence to the Japanese Dysphagia Diet 2021

Background/Objective: The International Dysphagia Diet Standardisation Initiative (IDDSI) and the Japanese Dysphagia Diet 2021 (JDD2021) are prominent systems that classify thickened beverages for dysphagia management. We herein aim to establish a correspondence between these systems through systematic viscosity measurements. Methods: We analyzed 49 thickened beverage samples using an E-type viscometer, IDDSI flow test, and JDD syringe test. Results: Receiver operating characteristic analysis revealed the following viscosity cutoffs for IDDSI levels: 0-1 at 72.0 mPa·s (area under the curve [AUC] 0.94), 1-2 at 112.0 mPa·s (AUC 0.95), and 2-3 at 303.0 mPa·s (AUC 0.97). Multiple regression analysis revealed that beverage characteristics, including fat, sodium content, and settling time, significantly influenced viscosity (R2 = 0.803). The findings established that IDDSI Level 0 corresponds to a thinner viscosity than JDD Stage 1 and Stage 1 (0-72 mPa·s), Level 1 to Stage 1 (72-112 mPa·s), Level 2 to Stages 1-2 (112-303 mPa·s), and Level 3 to Stage 3 (>303 mPa·s). Moreover, the measurement methods had high correlations (r = 0.83-0.93, p < 0.001). Conclusions: The comprehensive map between IDDSI and JDD2021 classifications developed from the results of this study enables healthcare providers to translate between the classification systems, improving dysphagia management internationally while supporting evidence-based care and global research.

Predictors of Pneumonia in Patients With Penetration-Aspirations Detected on Fiberoptic Endoscopic Evaluation of Swallowing

Aspiration pneumonia is a serious condition resulting from swallowing dysfunction. However, predicting high risk patients remains challenging. This study aimed to assess the incidence and risk factors for pneumonia in oropharyngeal dysphagia patients exhibiting episodes of penetration or aspiration during fiberoptic endoscopic swallowing evaluation (FEES). A retrospective analysis was performed on patients who visited a dysphagia clinic between 2016 and 2022, and demonstrated at least one episode of penetration or aspiration during the FEES (Penetration Aspiration Scale [PAS] score ≥ 3). Data collected included demographics, comorbidities and FEES findings. Outcomes included mortality, hospital admissions to treat pneumonia events, and incidents of pneumonia managed by primary care providers or outpatient medical facilities. Statistical analyses included descriptive statistics, chi-squared tests, t-tests, logistic regression and Kaplan-Meier survival analysis. Among 73 patients (mean follow-up: 3.87 ± 1.5 years), 33 (45.2%) exhibited penetration, and 40 (54.8%) aspiration. Pneumonia developed in 41 patients (56%), with 33 (45%) hospitalized. A total of 28 patients (38.4%) died during follow-up. A history of prior pneumonia (OR: 1.374, p = 0.02) and Murray Secretion Scale score (OR: 1.121, p = 0.022) were associated with subsequent pneumonia events. Reduced laryngeal sensation showed a near-significant trend toward association with pneumonia-related hospitalizations in the penetration group (58.3% vs. 19%, P = 0.052). No significant association was found between PAS and pneumonia or mortality. Prior pneumonia and secretions accumulation during FEES significantly predict pneumonia in patients presenting with penetration-aspiration during FEES. Reduced laryngeal sensation showed a nearly-significant trend toward pneumonia-related hospitalizations.

High-pressure homogenization transformed salmon protein filament into micelle structure: Improvement on the stability and swallowing rheology of dysphagia-oriented salmon emulsion gels

The aging population is stimulating increased demand for dysphagia-oriented foods, yet most current options are made of ultra-processed macronutrients and lack high-quality protein and ω-3 fatty acids. This study explores the use of whole salmon fillets as a myofibrillar protein source to stabilize salmon backbone oil, creating ω-3-rich emulsion gels (50-60 vol%) for dysphasia individuals. Two-step high-pressure homogenization (HPH; 50 MPa) improved emulsion texture, storage stability, and swallowability (IDDSI level 4) by reducing oil droplet size (from 20 to 2 μm) and increasing elastic modulus by 6-8 times and viscosity by more than 10 times. These emulsion gels, rich in PUFAs, support cardiovascular health. HPH altered the structure of salmon myofibrillar proteins, transforming from micro-sized filament (2.5 μm) to assembled nano-sized micelle aggregate (400 nm) through reducing α-helix structure, crystallization, particle size, and aggregation. The protein interfacial stiffness and stability were improved, thus exhibiting greater oil droplet stabilization. The study offers a compelling reference for applying HPH in producing dysphagia-oriented products.

Postextubation Dysphagia Among Patients With COVID-19: Results of Instrumental Swallow Studies and Clinical Swallow Evaluations

PURPOSE

Research has shown that prolonged endotracheal intubation can increase risk of aspiration following extubation. This study examined the relationship between swallowing and intubation among patients with COVID-19. We investigated the association between the duration of intubation and time until an oral diet was safely initiated and the correlation between the length of intubation and reduced sensation with aspiration as seen on flexible endoscopic evaluation of swallowing (FEES)/videofluoroscopic swallowing study (VFSS).

METHOD

This study is a retrospective analysis of all intubated patients admitted with the primary diagnosis of COVID-19 between April 2020 and March 2021 who received an inpatient speech-language pathology consultation. We utilized univariate linear regressions to investigate the dose-response relationship between duration of intubation and time until cleared for oral diet post-extubation. Dysphagia outcomes were analyzed, including results from 39 instrumental evaluations (VFSS and FEES).

RESULTS

During this 1-year period, 94 extubated patients were examined by a speech-language pathologist (SLP). We observed a near-exponential increase in the days until cleared for oral diet from 3% versus 69% when intubated for 10-16 days versus 17-34 days, respectively. Second, 39 patients received a VFSS/FEES evaluation. Of those who aspirated on an instrumental swallow study, there was a 78% rate of silent aspiration.

CONCLUSIONS

Prolonged intubation has a near exponential dose-response on the time until a patient becomes cleared for an oral diet after extubation. Prolonged intubation also increases the rate of aspiration observed on VFSS/FEES evaluations. Thus, SLP evaluation of oropharyngeal swallow physiology is important to minimize complications and improve patient outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28165631.

Development and Characterization of Cannabidiol Gummy Using 3D Printing

Oropharyngeal dysphagia and pain are prevalent concerns in the geriatric population. Therefore, this study investigates advances in the development of cannabidiol (CBD) gummies using 3D printing technology and compares them to commercially available molded gummies for pain management. A gelatin-based CBD formulation was prepared and printed using a syringe-based extrusion 3D printer. The formulation's rheological properties were assessed, and the printed gummies were characterized using a texture analyzer. Drug content was analyzed using HPLC, and in vitro dissolution studies were conducted in phosphate buffer (pH 1.2 and 6.8). Our results demonstrated that the gelatin-based formulation had shear-thinning rheological properties for 3D printing at a temperature of 38.00 °C, filament diameter of 26 mm and flow of 110%. The optimized printing parameters produced gummies with higher elasticity compared to marketed gummies and comparable toughness. Drug content analysis showed 98.14 ± 1.56 and 97.97 ± 2.14% of CBD in 3D-printed and marketed gummies, respectively. Dissolution studies revealed that both gummy types released 100% of the drug within 30 min in both pH 1.2 and 6.8 buffers. Overall, 3D printing enables customizable CBD gummies with optimized release and offer a personalized and patient-friendly alternative to traditional oral forms for geriatric care.

Dysphagia Rehabilitation Using Digital Technology: A Scoping Review

AIM

Digital health technology in swallowing rehabilitation offers personalized exercises, remote monitoring, and real-time feedback, enhancing accessibility and effectiveness of therapy. This scoping review was conducted to summarize what types and features of digital technology-based dysphagia rehabilitation interventions exist, how they are applied in patients with dysphagia, and what the effectiveness and facilitators and barriers to intervention application are.

METHODS

We searched Medline Complete, Embase, CINAHL, Scopus, and gray literature for articles published between January 2000 and June 2023. We used subheadings and terms related to digital health, dysphagia, and rehabilitation to search for articles. The included studies were mapped according to the types and features, effectiveness, enablers, barriers, and future improvements of swallowing rehabilitation using digital technologies.

RESULTS

Twenty-five studies met the inclusion criteria. Three types of digital swallowing rehabilitation interventions were identified: home-based rehabilitation using the mHealth app, synchronous telepractice and monitoring, as well as game-based biofeedback and tracking. The included studies reported positive results regarding physiological changes in swallowing function, swallowing performance, and quality of life. Digital unfamiliarity, resources for digital access, and technical issues related to the failure of the mobile device operating system were identified as barriers to the use of digital swallowing rehabilitation technology and future improvements.

CONCLUSIONS

Digital technology has potential value in dysphagia rehabilitation. In the future, developing various interventions utilizing the advantages of digital technology and conducting additional research to validate their effectiveness is necessary. Additionally, improved digital familiarity, better accessibility, better technology, and management practices will be needed.

Thickening liquids for pediatric dysphagia: a perspective from clinical practice

BACKGROUND

Dysphagia is a common condition in infants and young children, particularly among those with neurodevelopmental disabilities. The management of pediatric dysphagia requires customized approaches based on individual clinical features. This report describes our experience in managing pediatric dysphagia using a locust bean- and xanthan gum-based thickener (ThickenUp® Junior), which offers stable consistency and preserves the original taste of liquids.

CASE REPORT

Four cases were discussed to highlight the use of the new thickener. Each case illustrates different aspects of dysphagia management, such as improving swallowing safety, enhancing oral control, and maintaining nutritional intake through tailored thickening strategies. Our experience demonstrates the importance of using specialized thickening agents to prevent aspiration pneumonia and, ultimately, improve the well-being of affected children. We also highlighted the importance of individualized treatment plans, which consider each child's unique needs. A comprehensive evaluation by a multidisciplinary team led to an effective treatment strategy tailored to the child's specific condition and challenges.

CONCLUSIONS

The new locust bean- and xanthan gum-based thickener is effective in managing dysphagia and preventing complications in infants and young children. Such agents can improve swallowing safety, enhance oral control, and maintain nutritional intake, ultimately improving the well-being of the affected children.

Dysphagia

Dysphagia, or difficulty swallowing, has significant impacts on patients' quality of life. A thorough history and physical examination can provide important information to determine if dysphagia is originating from oropharyngeal or esophageal causes. Identifying the underlying pathology contributing to dysphagia allows for optimal treatment and improved quality of life.

Long-Term Outcomes of Dysphagia Rehabilitation With an Adjustable Resistance Training Device in Laryngectomized Individuals

BACKGROUND

This study investigated long-term outcomes of dysphagia rehabilitation with an adjustable resistance training device (Swallowing Exercise Aid, SEA2.0) in laryngectomized individuals.

METHODS

Seventeen laryngectomized participants who participated in a Clinical Phase II Trial were reevaluated at T3 (approximately 6 months after T2), including an interview, PROMS, oral intake, and swallowing capacity. Results of T3 were compared with the earlier time points T0 (baseline), T1 (after 6 weeks of training), and T2 (after 8 weeks of rest).

RESULTS

All outcomes at T3 remained improved compared to T0. Compared to findings at T2, participants reported some deterioration in swallowing at T3. Swallowing capacity and oral intake slightly decreased. Swallowing-related quality of life slightly improved.

CONCLUSIONS

Benefits of swallowing rehabilitation with the SEA2.0 in laryngectomized individuals are still noticeable long term. The need for continued exercising to fully maintain improved function is likely, but the required intensity and extent should be determined in further research.

Voluntary Swallowing Initiation Difficulty After Dorsomedial Prefrontal Cortex Damage: A Case Report

The dorsomedial prefrontal cortex plays a critical role in movement initiation, and damage to this area can impair this function. Here we present the case of an individual who had difficulty with voluntary initiation of liquid swallowing after surgical removal of a glioblastoma from the right dorsomedial prefrontal cortex. This individual had no difficulty swallowing solids, perhaps because of the additional external movement triggers (eg, chewing) involved. Liquid swallowing involves fewer movement triggers and requires a quicker application of force during the oral propulsive phase when liquids are transferred from the oral cavity to the oropharynx. This individual did not have buccofacial apraxia or apraxia of speech, which are often associated with swallowing apraxia linked to damage in the precentral, premotor, and inferior frontal gyri. To our knowledge, few studies have focused on movement initiation impairments affecting the upper extremities and speech, and cases involving swallowing are notably rare.

What is the evidence for dietary modification in the management and prevention of malignant bowel obstruction? A scoping review

PURPOSE

Dietary modification is one tool in the multidisciplinary and multi-faceted management of malignant bowel obstruction (MBO). However, the evidence for this has not been systematically explored and no guidelines currently exist. The purpose of this review was to identify the type and breadth of published evidence available to support the use of dietary modification in MBO, and to identify key characteristics of dietary interventions and outcome measures used in evaluating these interventions.

METHODS

Systematic searches of three databases were conducted, last in September 2024. Title and abstract screening and full-text review were conducted before data were extracted using a data extraction tool.

RESULTS

Only seven records met the criteria for inclusion. Quality of interventions was low, with four abstracts, one retrospective review and two feasibility studies identified. Most interventions focused on gynaecological cancers, where MBO is most prevalent. Key characteristics of dietary modification included a low-fibre diet and modification of the texture of the diet. These approaches were often used in conjunction and in a stepwise manner (progressing from liquid to soft to low-fibre diet). All records reported benefit of dietary modification, but with limited justification. The number, type and quality of records retrieved might reflect that this is a novel area of research, with local practice and clinical experience being published as abstracts. We found no methodologically robust, large-scale interventions.

CONCLUSION

This review demonstrates a lack of evidence to support the use of dietary modification in MBO. High-quality studies assessing the efficacy and impact of dietary modification are needed to support the advice commonly being provided in clinical settings. However, this research is ethically and logistically challenging to conduct. Nutritional management guidelines based on expert consensus might be a useful resource for clinicians managing MBO given the lack of research evidence currently available to inform practice.

Effect of Elevation Training Mask on Swallowing Function in Individuals with Parkinson's Disease

To evaluate the impact of the elevation training mask (ETM) on swallowing safety and swallowing efficiency in patients with Parkinson's disease (PWP) when used as a respiratory muscle strengthening tool. Study Design. Prospective cohort study. Setting. Tertiary university-affiliated medical center. Thirteen PWP underwent Fiberoptic Endoscopic Evaluation of Swallowing and spirometry assessments both before and after a 4-week ETM use, which included incrementally increasing resistance each week. Measurements taken included EAT-10, swallowing disturbances questionnaire (SDQ), Penetration Aspiration Score (PAS), Yale Pharyngeal Residue Severity Rating Scale, and Peak Expiratory Flow (PEF). Disease severity was assessed using the Unified Parkinson's Disease Rating Scale (UPDRS). Eleven out of 13 male participants (median age 70 years, UPDRS 33, disease duration 8.5 years) completed the 4-week protocol (84.6% completion rate). Vallecular residue significantly decreased for solids (median from 3.0 [IQR: 2.0-3.0] to 2.0 [IQR: 1.0-2.0], p = 0.028) and semi-solids (from 3.0 [IQR: 2.0-4.0] to 2.0 [IQR: 1.0-3.0], p = 0.025), with a non-significant improvement for liquids (from 2.0 [IQR: 2.0-2.0] to 2.0 [IQR: 1.0-2.0], p = 0.19). Patient-reported outcomes (EAT-10, SDQ, VHI-10, RSI) and PEF showed non-significant trends toward improvement. A 4-week use of ETM, serving as a form of respiratory muscle strengthening, demonstrated specific improvements in vallecular residue for semi-solid and solid consistencies in PWP with dysphagia. While other swallowing and respiratory measures showed positive trends, these changes did not reach statistical significance. Further research with a larger cohort is needed to evaluate ETM's role in swallowing rehabilitation.

Viscosity study of maternal and formula milks according to the assessment proposed by the International Dysphagia Diet Standardisation Initiative Model: a comparison with Rheological Assessment

PURPOSE

The present study aimed to investigate the behavior and the viscosity classification of liquids recommended for infants, up to six months, in Brazil, and their formulations used in Videofluoroscopy Swallowing Studies.

METHODS

Breast milk from different gestational and breastfeeding time, two regular infant formulas, and one anti-reflux formula were evaluated in five different formulations: pure, mixed with liquid barium sulfate, in two proportions (20 and 33%), thickened with a specific thickener for neonates and thickened and mixed with 20% liquid barium sulfate, using the International Dysphagia Diet Standardisation Initiative model. The results were compared with data obtained from a previous rheological study.

RESULTS

The breast milk samples and the infant formulas, in pure presentation, exhibited similar behavior except for the anti-reflux formula. The thickened samples with the addition of barium and the pure liquid barium sulfate exhibited the highest viscosity among the formulations. The increase in viscosity with the addition of barium occurred for all samples and for the thickened formulations, but not in linear behavior. The results showed minor differences of IDDSI classification compared to the findings obtained in the rheological study.

CONCLUSION

The present study revealed the variability of liquid viscosity across different formulations, supporting the idea of the importance of this knowledge in videofluoroscopic assessment. It has also highlighted the risk associated with using a subjective method in preparing the stimuli offered, allowing for greater reliability in diagnosing swallowing dynamics in neonates and infants. This approach may help prevent inaccurate diagnoses and harmful interventions.

Early application value of flexible laryngoscope swallowing function assessment in patients after partial laryngectomy

To investigate the influence of early dysphagia on quality of life in patients with partial laryngectomy, and to investigate the application value of Flexible Endoscopic Evaluation of Swallowing (FEES). This study included 30 inpatients who underwent partial laryngectomy due to laryngeal cancer. In the early postoperative period, a comprehensive assessment was conducted on each patient, encompassing Videofluoroscopic Swallowing Study (VFSS), Flexible Endoscopic Evaluation of Swallowing (FEES), and MD Anderson Dysphagia Inventory (MDADI). Each patient underwent two evaluations at different time points following the surgical procedure, all conducted on the same day. The patients' first MDADI assement score after surgery was 45.4 ± 3.6 points, and the second score was 54.7 ± 13.4 points. VFSS as the gold standard, FEES showed good sensitivity (84%) and specificity (94%) for detecting aspiration, as well as good sensitivity (78%) and moderate specificity (86%) for detecting penetration. The Kappa consistency test results showed high consistency between FEES and VFSS swallowing function evaluations (Kappa value = 0.669); evaluations of thin liquid, thick liquid, and solid bolus had high consistency (Kappa value = 0.631, 0.675, and 0.678, respectively), while evaluations of semi-liquid bolus had poor consistency (Kappa value = 0.598); evaluations of four bolus sizes all had high consistency (Kappa value = 0.658, 0.647, 0.705, 0.670). The Kappa values for evaluating patients undergoing horizontal partial laryngectomy, vertical partial laryngectomy, and supraglottic laryngectomy were 0.572, 0.604, and 0.680, respectively. This study shows that dysphagia is an important problem affecting the early quality of life of patients after partial laryngectomy, and early instrumental evaluation is also extremely important. This study also emphasizes the reliability problems in the identification of false invasion and aspiration. FEES can be used to evaluate the early swallowing function of patients after partial laryngectomy, thus guiding the timing and type of eating, and evaluating the rehabilitation effect. In addition, compared with VFSS, FEES have more advantages for the identification of penetration.

Study on Drug-Food Thickening Agents' Interactions between Warfarin and Prebiotics Used for Viscosity Adjustment

INTRODUCTION

Prebiotics are widely used in nutritional supplements, with water-soluble dietary fibers used as thickeners for patients with swallowing difficulties. Interactions between thickeners and medications have been reported; however, the effects of thickeners on warfarin remain unclear. Here, we examined the interaction between warfarin and thickeners through clinical and basic research studies.

METHODS

The clinical research study evaluated the effects of combining warfarin and thickeners on blood coagulation, while the basic research study measured the impact of different prebiotics and mixing with gastric and intestinal fluids on warfarin concentration.

RESULTS

The clinical research study showed no significant differences in the patients' prothrombin time-international normalized ratio and Warfarin Sensitivity Index (WSI) before and after the combination. However, the WSI decreased postcombination in half of the patients. Meanwhile, in the basic research study, a concentration-dependent decrease in the residual rate of warfarin was observed with xanthan gum, guar gum, and pectin. When mixed with artificial gastric and intestinal fluids, the residual rate decreased with xanthan and guar gum in gastric fluid and with pectin in intestinal fluid.

CONCLUSION

Thickeners primarily composed of xanthan gum, guar gum, and pectin may reduce the effectiveness of warfarin due to drug-food interactions.

Toward the Optimal Choice of Gelled Vehicles for Oral Drug Administration in Dysphagic Patients

Background/Objectives: Thickened waters are commonly used for dysphagic patients to ensure hydration, facilitate safer swallowing, and administer oral therapies, yet their impact on drug dissolution remains unclear. This study aims to investigate how thickening agents, viscosity, and solid oral dosage form (SODF) formulations influence drug release in gelled vehicles. Methods: Twelve commercially available thickened waters, including both ready-to-use products and powders for extemporaneous preparation, were used to disperse crushed sodium pravastatin tablets. The resulting preparations were evaluated for their rheological properties and dissolution performance. Results: Thickened water products vary in consistency, with starch-based thickeners providing more consistent results than gum-based ones. Pravastatin release profiles closely matched the original tablets with starch thickeners, while gum-based thickeners showed greater variability, primarily influenced by viscosity. Conclusions: These findings emphasize the importance of selecting the appropriate thickening agent for controlling drug release in thickened water products, highlighting the need to balance patient compliance with the potential impact on drug release during product development.

Performance of swallowing function between older people with and without clinical complaints

PURPOSE

To compare the findings of speech-language-hearing evaluations, signs in fiberoptic endoscopic evaluation of swallowing, and nutritional risk between healthy older adults with and without self-reported swallowing difficulties and correlate the level of oral intake with the severity of pharyngeal residues and nutritional risk.

METHODS

This cross-sectional retrospective study included 71 older people and divided them into two groups based on the presence of swallowing complaints. Data were collected from speech-language-hearing evaluations, oral health status, and videoendoscopy signs with four food consistencies classified by the International Dysphagia Diet Standardisation Initiative (IDDSI) to compare the groups. Pharyngeal residues were analyzed and classified using the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS), the level of oral intake was assessed using the Functional Oral Intake Scale (FOIS), and nutritional risk was evaluated using the Malnutrition Screening Tool (MST).

RESULTS

Differences were found in speech-language-hearing evaluations, as well as signs of posterior oral spillage and pharyngeal residues with levels 0, 2, and 4 consistencies and laryngeal penetration with level 0 consistency. The level of oral intake was moderately negatively correlated with the severity of pharyngeal residues and nutritional risk.

CONCLUSION

The group of older adults with complaints had differences in speech-language-hearing evaluations, posterior oral spillage, and pharyngeal residues with levels 0, 2, and 4 consistencies, and laryngeal penetration with level 0 consistency. The correlation indicated that the lower the level of oral intake, the greater the severity of pharyngeal residues and nutritional risk in the sample.

Validity and Reliability of the Swedish Version of the Gugging Swallowing Screen for use in Acute Stroke Care

The purpose of this study was to cross-culturally validate the Swedish version of the Gugging Swallowing Screen (GUSS-S) for use in the acute phase of stroke. Further, to evaluate the inter-rater reliability between different healthcare professionals. GUSS was translated into Swedish using a forward-backward method followed by expert rating to obtain content validity. For criterion validity, the GUSS-S score was compared with Flexible Endoscopic Evaluation of Swallowing (FEES) assessed with the Penetration-Aspiration Scale (PAS) in acute stroke patients (≤ 96 h after stroke onset). Convergent validity was calculated by comparison with the Functional Oral Intake Scale (FOIS) as per the comprehensive FEES assessment, the Standardized Swallowing Assessment (SSA), and the National Institutes of Health Stroke Scale (NIHSS). To evaluate inter-rater reliability, a nurse and a speech-language pathologist (SLP) independently assessed 30 patients. In total, 80 patients (32 women, median age 77 years (range 29-93) were included, mean 1.7 ± 0.9 days after admission. With a cut-off value of 14 points, the GUSS-S identified aspiration with a sensitivity of 100% and a specificity of 73% (area under the curve: 0.87, 95% CI 0.78-0.95). Spearman rank correlation showed very strong correlation between the GUSS-S and PAS (rs=-0.718, P = < 0.001) and FOIS (rs=0.720, P = 0.001) and strong correlation between the GUSS-S and SSA (rs=0.545, P = < 0.001) and NIHSS (rs=-0.447, P = 0.001). The inter-rater agreement for GUSS-S was substantial (Kw=0.67, P = < 0.001). The results indicate that the GUSS-S is a valid and reliable tool for the assessment of dysphagia in acute stroke patients by different healthcare professionals.

An accelerometry and gyroscopy-based system for detecting swallowing and coughing events

Measuring spontaneous swallowing frequencies (SSF), coughing frequencies (CF), and the temporal relationships between swallowing and coughing in patients could provide valuable clinical insights into swallowing function, dysphagia, and the risk of pneumonia development. Medical technology with these capabilities has potential applications in hospital settings. In the management of intensive care unit (ICU) patients, monitoring SSF and CF could contribute to predictive models for successful weaning from ventilatory support, extubation, or tracheal decannulation. Furthermore, the early prediction of pneumonia in hospitalized patients or home care residents could offer additional diagnostic value over current practices. However, existing technologies for measuring SSF and CF, such as electromyography and acoustic sensors, are often complex and challenging to implement in real-world settings. Therefore, there is a need for a simple, flexible, and robust method for these measurements. The primary objective of this study was to develop a system that is both low in complexity and sufficiently flexible to allow for wide clinical applicability. To construct this model, we recruited forty healthy volunteers. Each participant was equipped with two medical-grade sensors (Movesense MD), one attached to the cricoid cartilage and the other positioned in the epigastric region. Both sensors recorded tri-axial accelerometry and gyroscopic movements. Participants were instructed to perform various conscious actions on cue, including swallowing, talking, throat clearing, and coughing. The recorded signals were then processed to create a model capable of accurately identifying conscious swallowing and coughing, while effectively discriminating against other confounding actions. Training of the algorithm resulted in a model with a sensitivity of 70% (14/20), a specificity of 71% (20/28), and a precision of 66.7% (14/21) for the detection of swallowing and, a sensitivity of 100% (20/20), a specificity of 83.3% (25/30), and a precision of 80% (20/25) for the detection of coughing. SSF, CF and the temporal relationship between swallowing and coughing are parameters that could have value as predictive tools for diagnosis and therapeutic guidance. Based on 2 tri-axial accelerometry and gyroscopic sensors, a model was developed with an acceptable sensitivity and precision for the detection of swallowing and coughing movements. Also due to simplicity and robustness of the set-up, the model is promising for further scientific research in a wide range of clinical indications.

The development of thickened fermented rice milk formulation for people with dysphagia: A view of multiple in vitro simulation methods

Based on the huge blank of thickened fluid staple food for people with dysphagia, multiple in vitro simulations were utilized to develop the thickened fermented rice milk. Here, the effect of amylase content, hydrolysis time and thickener content were considered. The rheological study and Cambridge throat evaluation revealed that hydrolysis could significantly reduce the viscosity and yield stress of fermented rice milk, accompanied by the decreased swallowing residue. The addition of thickeners increased the viscosity and cohesion of the fermented rice milk due to the entanglement network formation, which facilitated the formation of lubricating film, decreased the coefficient of friction, and improved the sensory score. Increasing thickener content from 0 % to 0.5 % induced the longer oral transition time (0.26 s to 0.45 s), more residue (0.85 g to 2.07 g) and shorter stretching length (850.42 mm to 313.62 mm) shown in the Cambridge throat simulation. Among them, the fermented rice milk with 0.40 % thickener showed the best sensory properties, and its swallowing properties evaluated by computer simulation also suggested concentrated frequency distribution of velocity, shear rate and viscosity without splashing or choking compared with the normal fermented rice milk, showing excellent swallowing safety.

Gelation properties and swallowing characteristics of heat-induced whey protein isolate/chia seed gum composite gels as dysphagia food

Soft gels based on protein-polysaccharide composite systems play a crucial role in the dietary management of people with dysphagia. The effect of chia seed gum (CSG) on the gelling and swallowing properties of heat-induced whey protein isolate (WPI) gels (3.125-75 mg/mL) was investigated. The results showed that adding CSG reduced the gelation concentration of WPI and weak gels could form at 12.5 mg/mL WPI concentration. In addition, the viscoelasticity and water-binding capacity of the WPI/CSG composite gels were gradually enhanced with increasing WPI concentrations. The WPI/CSG composite systems can be classified as level 2-5 dysphagia-oriented foods according to the International Dysphagia Diet Standardization Initiative (IDDSI) framework. The incorporation of CSG promoted the cross-linking of protein aggregates and the formation of compact and continuous network structures, resulting in improved gelling properties of composite systems. This study contributes to the development of novel soft gel-type dysphagia foods with better textural characteristics.

Preparation and texture assessment of purple red rice bran anthocyanins-rice starch based dysphagia food masses

The decline in physiological functions caused by aging increases the prevalence of dysphagia. Anthocyanins play a dual role in enhancing the nutrition of the food and influencing its swallowing properties. The objective of this study was to investigate the impact of anthocyanins from purple red rice bran on the viscosity, rheological and textural properties, and IDDSI classification of rice starch-based dysphagia food masses.The results showed that anthocyanins increased the peak viscosity (PV) and contributed to amylose leaching from the food masses. In contrast, the addition of 1% and 2% anthocyanins inhibited the retrogradation and recrystallization of starch, which resulted in a reduction in the final viscosity (FV) of the food masses. The presence of anthocyanins (0.5%) also could increase the storage/loss modulus of the food masses, while the addition of 1.0% and 2.0% anthocyanins showed the opposite trend. In addition, purple red rice bran anthocyanins reduced textural parameters such as hardness and chewiness of the food masses. All four prepared food masses were classified as level 4 (Pureed) in the IDDSI framework, and the food masses with 2% anthocyanins appeared to be more suitable for ingestion by dysphagia populations, with lower viscosity and less sticky retention on the spoon. These results offer a theoretical foundation for designing innovative and functional dysphagia foods.

Swallowing Kinematics in Male Patients with Total Laryngectomy

OBJECTIVE

The present study aimed to investigate the symptomatic swallowing complaints in individuals with total laryngectomy (TL) and reveal how swallowing kinematics differs between those with and without symptomatic dysphagia complaints.

METHODS

A total of 34 subjects with TL were included in the study. Swallowing kinematics of those with symptomatic swallowing complaints (Group 1) were compared to those without (Group 2). Kinematic parameters including pharyngeal transit duration (PTD), maximum pharyngeal constriction ratio (MPCR), upper esophageal sphincter opening ratio (UESOR), upper esophageal sphincter opening duration (UESOD), and bolus clearance ratio (BCR) were investigated from Videofluoroscopic Swallowing Study (VFSS) records via ImageJ software.

RESULTS

Symptomatic swallowing complaints were determined in 47.1% of the subjects (n = 16). Difficulty while swallowing solid foods and pills, diminished pleasure of eating, food getting stuck in the throat, and increased level of stress during swallowing were among the major swallowing complaints in the present cohort. PTD, MPCR, and BCR parameters were significantly higher in subjects with symptomatic swallowing complaints than those without.

CONCLUSION

These preliminary findings indicate that almost half of individuals with TL may have symptomatic swallowing complaints. The underlying pathophysiology of this phenomenon may be the devianced kinematic parameters including PTD, MPCR, and BCR in this population. Therefore, it is recommended to include the kinematic measurements in the dysphagia evaluation protocol in individuals with TL, most notably in those with symptomatic swallowing complaints.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:809-817, 2025.

Back to the Bottle: Comparison of Palatoplasty Outcomes Before and After Systematic Changes to Postoperative Precaution Protocols

Main ObjectiveTo analyze postoperative palatoplasty outcomes before and after systemic protocol changes to preferred bottle and arm immobilizer use after surgery.DesignRetrospective, cohort study.SettingUrban, academic, tertiary medical center in New York City, NY.ParticipantsEighty-four patients who underwent primary palatoplasty and met inclusion criteria during 1 of 2 treatment periods, 2016 to 2017 (group A, n = 45) and 2019 to 2020 (group B, n = 39).InterventionsProtocols were amended over the 2018 calendar year to allow for utilization of the baby's preferred bottle (vs alternative feeding methods) and hand socks (vs arm immobilizers) in the immediate postoperative period. Data was extrapolated from electronic medical records to compare surgical outcomes.Main Outcome MeasuresPostoperative wound complications (fistula and dehiscence) that did not resolve within 1 month, length of stay (hours), and 30-day re-admission. Nonparametric Mann-Whitney U tests and Fisher's Exact test were utilized for statistical analysis.ResultsThere were no statistically significant differences between sex, age at surgery, Veau classification, or hard and soft palate surgical repair technique. Group A had a wound complication rate of 8.7% (n = 4) versus a 2.6% rate (n = 1) for group B. No patients were re-admitted to the hospital from either group. There were no statistically significant differences between groups regarding length of stay (P = .528) or wound complication (P = .366).ConclusionsThe findings from this study suggest relaxing postoperative protocols following palatoplasty to allow immediate bottle feedings and unrestricted arm use may be safe without compromise to surgical outcomes.

Development and characterization of soy protein-based custard-like soft foods for elderly individuals with swallowing difficulties

There is growing interest in developing protein-rich foods for the elderly using plant proteins. The application of soy protein isolate (SPI) as a model protein to create protein-rich, custard-like soft foods presents a unique opportunity for innovative formulations tailored to those within the aging population suffering from swallowing difficulties. This study investigated the physicochemical and textural properties of custard-type soft food formulations developed using SPI for dysphagic elderly individuals, with the goal of achieving characteristics similar to those of optimal milk protein-based counterparts. The protein content in the SPI-based custards varied from 8.9 % to 13.9 % and the milk-protein based custards had 8.9 % protein content. There was a substantial difference in textural, rheological and creep resistance and other properties between SPI and milk protein-based formulations. The SPI-based custards also had lower water-holding capacity, looser structure, and higher level of insoluble protein aggregates. The SPI-based custards imparted a more spreadable mouthfeel suitable for the aging population. The custards containing 13.9 % SPI had higher gel strength, viscosity, texture, and product stability. All of these custards were classified as Level 6 - Soft & Bite-sized dysphagia diet, based on International Dysphagia Diet Standardisation Initiative (IDDSI) tests. Instrumental IDDSI tests for Level 6 foods corroborated these observations, yielding reliable and consistent data. This research provides insights for developing protein-rich plant-based soft foods intended for the elderly population that have characteristics close to milk protein-based custards and comply with IDSSI criteria.

The Oropharyngeal Dysphagia Screening Test for Patients and Professionals: Validation in Cognitive Impairment and in Severe Mental Illness

Dysphagia is a symptom that appears with high prevalence in persons diagnosed with dementia, intellectual disability, or severe mental illness. Risk of aspiration pneumonia or even death is very high in these populations. However, screening for dysphagia risk in these patients is complicated by the fact that most of them suffer from cognitive impairments and behavioral manifestations that hinder the assessment process using the existing screening tests. The aim of this study was to validate the Oropharyngeal Dysphagia Screening Test for Patients and Professionals, in patients with cognitive impairment (dementia/intellectual disability) or with severe mental illness (schizophrenia and other psychotic disorders, bipolar disorder, or major depressive disorder). For this purpose, 148 institutionalized patients were evaluated by professionals responsible for their food intake. The Oropharyngeal Dysphagia Screening Test for Patients and Professionals was used to assess its validity in screening for oropharyngeal dysphagia in patients with cognitive impairments and in patients with severe mental illness. Also, the Eating Assessment Tool-10 and the Swallowing Disturbance Questionnaire were used for convergent reliability procedures. Four comparison groups were established: patients with cognitive impairment with and without oropharyngeal dysphagia, and patients with severe mental illness with and without oropharyngeal dysphagia. Results from the Oropharyngeal Dysphagia Screening Test for Patients and Professionals adequately distinguished between groups with and without dysphagia, in addition to presenting adequate levels of convergent validity and reliability. These results were obtained from other-reports (professionals responsible for patients' food intake), using a simple, quickly applied test that does not require the use of food in patients with an altered cognitive state or with severe mental illness. With this study we expand the validity of the Oropharyngeal Dysphagia Screening Test for Patients and Professionals in populations with severe cognitive deficits and mental illness in which there is a great deficiency of oropharyngeal dysphagia screening instruments.

Association Between Cognitive Impairment and Dysphagia: A Two-Sample Mendelian Randomization Study

INTRODUCTION

Previous observational studies have implied a correlation between cognitive impairment and dysphagia, but some have indicated no correlation between the two. Such contradictory findings may have been influenced by small sample sizes and potential confounders. In this Mendelian randomization (MR) analysis, we genetically estimated a causal relationship between cognitive impairment and dysphagia.

METHODS

The study included a large meta-analysis of genome-wide association studies (GWAS) of cognitive impairment in 269,867 individuals of European ancestry and pooled data from a GWAS of dysphagia in 165,765 individuals of European ancestry (cases 3497, controls 161,968). We then used five different complementary MR methods, including IVW, MR-Egger, MR-RAPS, weighted median, and weighted mean, to estimate causality between cognitive impairment and dysphagia and finally also assessed heterogeneity and horizontal pleiotropy by extensive sensitivity tests.

RESULTS

No evidence of heterogeneity in the effect of instrumental variables was found in Cochran's Q test; therefore, a fixed effects model was used. IVW analysis (OR: 1.206, 95% CI: [1.041, 1.371], p = 0.00508) found that cognitive impairment was associated with an increased risk of dysphagia and that there was a causal association between the two. Also, the weighted median (OR: 1.248, 95% CI: [1.012, 1.484], p = 0.0253), weighted mode (OR: 1.216, 95% CI: [1.043, 1.389], p = 0.0412), and MR-RAPS (OR: 1.225, 95% CI: [1.069, 1.381], p = 0.00627) validated the conclusions. Furthermore, extensive sensitivity analyses found no evidence of heterogeneity or horizontal pleiotropy, confirming the reliability of this MR result.

CONCLUSION

Our MR study demonstrated a causal effect of cognitive impairment on dysphagia from a genetic perspective, suggesting that individuals with a history of cognitive impairment require specific clinical attention to prevent the development of dysphagia.

Critical Review of Ketogenic Diet Throughout the Cancer Continuum for Neuroglioma: Insights from a Medical Nutrition Therapy (MNT) Perspective

PURPOSE OF REVIEW: A Ketogenic diet (KD; a diet comprised of 75% fat, 20% protein and 5% carbohydrates) has gained much popularity in recent years, especially regarding neurogliomas (or "gliomas"). This review critically assesses literature on the application of KD throughout the cancer continuum from a Medical Nutrition Therapy (MNT) perspective. RECENT FINDINGS: 2021 revised classification standards for Central Nervous System (CNS) tumors are available. Despite research on KD and CNS tumors increasing, the role and benefits of MNT to augment side effects of traditional treatment and KD throughout the cancer continuum remain unclear. Glioma cancer survivors may benefit from a KD. It is a challenging, yet feasible non-pharmacological adjuvant approach. More research is needed regarding KD for prevention and post-treatment of glioma. Standard guidelines regarding macronutrient composition of KD for glioma are warranted. The need and benefits of nutritional guidance provided by a Registered Dietitian Nutritionist (RD or RDNs) during adherence to KD are understated.

Exploring the textural characteristics of foods preferred by Chinese elderly individuals based on IDDSI levels

OBJECTIVE

This study aimed to investigate the textural characteristics of foods preferred by elderly Chinese individuals and their suitability based on the International Dysphagia Diet Standardization Initiative (IDDSI) framework. The goal was to provide objective data to support the development of safe and nutritious diets tailored to the swallowing abilities of the elderly.

METHODS

A cross-sectional observational study was conducted, using web-scraping technology to identify 26 commonly preferred food ingredients among elderly individuals across seven regions of China. These foods were prepared and evaluated according to IDDSI levels 0-7. Texture analysis was performed to measure hardness, cohesiveness, and adhesiveness, with statistical tests including chi-square analysis and multiple linear regression used to explore the relationships between these textural properties and IDDSI levels.

RESULTS

As IDDSI levels increased, the hardness of various food categories generally showed an upward trend, with significant increases observed in fruits, vegetables, grains, and tubers at IDDSI levels 6-7 (p≤0.05). Cohesiveness varied without a clear linear trend, showing significant changes at specific IDDSI levels for meats, grains, and tubers (p≤0.05). Adhesiveness initially increased and then decreased across the IDDSI spectrum, with the most significant fluctuations occurring in mixed beans, fruits, and grains at levels 5-7 (p≤0.05). Regression analysis revealed that cohesiveness had the most substantial impact on IDDSI levels (coefficient = -5.224, p≤0.05), followed by adhesiveness (coefficient = -0.021, p≤0.05), and hardness (coefficient = 0.002, p≤0.05).

CONCLUSION

The findings underscore the importance of considering the textural properties of foods when designing diets for elderly individuals with dysphagia. The study provides empirical evidence supporting the IDDSI framework and offers a predictive model that can assist in the development of customized diets, ensuring both safety and nutritional adequacy. Future research should focus on refining food preparation methods to better meet the specific needs of this population.