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Brito-de la Fuente E, Muñiz-Becerá S, Ascanio G. Lipid emulsions in clinical nutrition: Enteral and parenteral nutrition. ADVANCES IN FOOD AND NUTRITION RESEARCH 2023; 105:301-342. [PMID: 37516466 DOI: 10.1016/bs.afnr.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Clinical nutrition emulsions are important products that can be life-saving for many patients suffering from gastrointestinal tract disorders, swallowing impairment, cancer, liver diseases, and many other clinical conditions. The transfer of lipids to the human body can be either intravenously (Parenteral Nutrition, PN) or through the gastrointestinal tract (Enteral Nutrition, EN). PN emulsions are considered pharmaceuticals and thus regulated accordingly. On the other hand, EN emulsions are classified as Food for Specific Medical Purposes (FSMP) and do not follow pharmaceutical regulations. Regarding product design, PN emulsions must follow theoretical emulsion formulation and production aspects, but special requirements regarding droplet size distribution must be followed to comply with national pharmacopeia monographs. Furthermore, a full clinical program on clinical evidence to prove safety and efficacy must be provided for marketing approval. On the contrary, EN emulsions require limited clinical evidence to substantiate health or clinical benefits. A short introduction to clinical nutrition with a focus on lipid emulsions is presented in this chapter. Furthermore, a general overview of the composition and main ingredients of clinical nutrition lipid emulsions is reviewed. Main clinical aspects are also mentioned here, highlighting the difficulties of clinically proving the efficacy of these products. The manufacturing and control of clinical nutrition emulsions are also reviewed, focusing on PN products and the main regulatory requirements related to the safety of these intravenous emulsions. Finally, stability and physicochemical properties are reviewed, and examples of commercially available products are used to illustrate these properties linked to the stability of these products. Lipids in clinical nutrition is a moving field and we do hope this chapter may remain a valuable source to understand newly emerging research on this topic.
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Affiliation(s)
- Edmundo Brito-de la Fuente
- Instituto de Ciencias Aplicadas y Tecnología, Universidad Nacional Autónoma de México, Circuito Exterior S/N, Ciudad Universitaria, Mexico City, Mexico.
| | - Sahylin Muñiz-Becerá
- Instituto de Ciencias Aplicadas y Tecnología, Universidad Nacional Autónoma de México, Circuito Exterior S/N, Ciudad Universitaria, Mexico City, Mexico
| | - Gabriel Ascanio
- Instituto de Ciencias Aplicadas y Tecnología, Universidad Nacional Autónoma de México, Circuito Exterior S/N, Ciudad Universitaria, Mexico City, Mexico
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2
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Gallegos C, Turcanu M, Assegehegn G, Brito-de la Fuente E. Rheological Issues on Oropharyngeal Dysphagia. Dysphagia 2023; 38:558-585. [PMID: 34216239 DOI: 10.1007/s00455-021-10337-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
There is an increasing proof of the relevance of rheology on the design of fluids for the diagnosis and management of dysphagia. In this sense, different authors have reported clinical evidence that support the conclusion that an increase in bolus viscosity reduces the risks of airway penetration during swallowing. However, this clinical evidence has not been associated yet to the definition of objective viscosity levels that may help to predict a safe swallowing process. In addition, more recent reports highlight the potential contribution of bolus extensional viscosity, as elongational flows also develops during the swallowing process. Based on this background, the aim of this review paper is to introduce the lecturer (experts in Dysphagia) into the relevance of Rheology for the diagnosis and management of oropharyngeal dysphagia (OD). In this sense, this paper starts with the definition of some basic concepts on Rheology, complemented by a more extended vision on the concepts of shear viscosity and elongational viscosity. This is followed by a short overview of shear and elongational rheometrical techniques relevant for the characterization of dysphagia-oriented fluids, and, finally, an in-depth analysis of the current knowledge concerning the role of shear and elongational viscosities in the diagnosis and management of OD (shear and elongational behaviors of different categories of dysphagia-oriented products and contrast fluids for dysphagia assessment, as well as the relevance of saliva influence on bolus rheological behavior during the swallowing process).
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Affiliation(s)
- Crispulo Gallegos
- Product and Process Engineering Center, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352, Bad Homburg, Germany.
| | - Mihaela Turcanu
- Product and Process Engineering Center, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352, Bad Homburg, Germany
| | - Getachew Assegehegn
- Product and Process Engineering Center, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352, Bad Homburg, Germany
| | - Edmundo Brito-de la Fuente
- Product and Process Engineering Center, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352, Bad Homburg, Germany
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3
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Advances in 3D printing of food and nutritional products. ADVANCES IN FOOD AND NUTRITION RESEARCH 2022; 100:173-210. [PMID: 35659352 DOI: 10.1016/bs.afnr.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The main advantage of both 3D printing (3DP) and 3D food printing (3DFP) over other technologies is the enormous capacity of both techniques for customization. Its use makes it possible to obtain products without planning and implementing a complex and costly manufacturing process. This makes 3DFP a technology of choice for the preparation of food products that meet specific needs, such as controlled nutritional or rheological properties. However, further technological developments are still needed before 3DFP can be considered fully useful for innovative and demanding applications. If both preparation and post-processing of materials based on 3D printing are optimized, aiming to reduce production time and/or complication for non-expert users, this would open a whole new range of possibilities. It is in this sense that the development of advanced 3DFP systems becomes a must. This chapter reviews current advances in extrusion-based 3D food printing systems, with in situ gelation and mixing as key aspects to better exploit the potential of 3DFP. On one hand, 3DFP systems based on in situ gelation (G3DFP) provide greater control over the final properties of the printed products, as the selection of adequate printing parameters gives the possibility of influencing the gelation process. On the other hand, mixing is indispensable for true 3DFP automation, so that the formulations do not have to be prepared by the user. Different innovative 3DFP systems based on gelling and/or mixing are presented in this chapter. Finally, the status and future of extrusion-based 3DFP, and its application in the production of customized foods for specific needs, are also overviewed.
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Diañez I, Gallegos C, Brito-de la Fuente E, Martínez I, Valencia C, Sánchez M, Franco J. Implementation of a novel continuous solid/liquid mixing accessory for 3D printing of dysphagia-oriented thickened fluids. Food Hydrocoll 2021. [DOI: 10.1016/j.foodhyd.2021.106900] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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5
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Ruiz-Huerta L, Palacios-Morales C, Caballero-Ruiz A, Vopalensky M, Díaz O, Hernández-Angulo JA, la Fuente EBD, Ascanio G. X-ray technique for visualization of the bolus flow through an esophageal simulator. J Vis (Tokyo) 2021. [DOI: 10.1007/s12650-021-00743-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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6
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Poursani P, Razavi SM, Norouzi A. Numerical investigation of a two-phase system on swallowing behavior in dysphagia: A case study on cress seed gum–xanthan gum thickened liquids. FOOD AND BIOPRODUCTS PROCESSING 2021. [DOI: 10.1016/j.fbp.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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de O S Schmidt H, Komeroski MR, Steemburgo T, de Oliveira VR. Influence of thickening agents on rheological properties and sensory attributes of dysphagic diet. J Texture Stud 2021; 52:587-602. [PMID: 33760237 DOI: 10.1111/jtxs.12596] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 12/11/2022]
Abstract
Dysphagia is the difficulty during the progression of the bolus from the mouth to the stomach. Modifying the texture of the food is a fundamental factor for safe swallowing in patients with dysphagia since inadequate consistency can result in complications. To personalize and develop diets for dysphagia, understanding, and controlling the rheological and sensory properties of thickeners is useful. This review examines the different types of thickeners used to modify the texture of foods, as well as their influence on rheological properties and sensory attributes to efficiently manage the diet in dysphagia. The study discusses characteristics such as: hardness, viscosity, viscoelasticity, as well as sensory attributes related to rheology. The thickeners xanthan gum, methylcellulose, carboxymethylcellulose, guar gum, linseed, and chia, carboxymethylated curdlan, and konjac glucomannan were reviewed in this work. Sensory evaluations of different foods have already been carried out on some products such as: meats, carrots, soups, pates, and timbales with their modified textures. The sensory attributes measured among hydrocolloids are strongly correlated with rheological parameters. Dysphagic diets should have less hardness and adherence, but with adequate cohesiveness to facilitate chewing, swallowing to protect from aspiration and reduction of residues in the oropharynx. The use of a single type of thickener may not be ideal, their mixtures and synergistic effect can improve the viscous and elastic characteristics of foods, to obtain safe food to swallow and to improve the sensory interest of dysphagic patients. Personalized recommendations with follow-up on swallowing approaches, respecting patient's individuality, explaining thickening agents' differences would be pertinent.
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Affiliation(s)
- Helena de O S Schmidt
- Institute of Food Science and Technology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Marina Rocha Komeroski
- Institute of Food Science and Technology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Thaís Steemburgo
- Nutrition Department, Postgraduate Program in Food, Nutrition and Health, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Viviani Ruffo de Oliveira
- Nutrition Department, Postgraduate Program in Food, Nutrition and Health, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
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Herranz B, Criado C, Pozo-Bayón MÁ, Álvarez MD. Effect of addition of human saliva on steady and viscoelastic rheological properties of some commercial dysphagia-oriented products. Food Hydrocoll 2021. [DOI: 10.1016/j.foodhyd.2020.106403] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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9
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Hadde EK, Chen J. Texture and texture assessment of thickened fluids and texture-modified food for dysphagia management. J Texture Stud 2020; 52:4-15. [PMID: 33155674 DOI: 10.1111/jtxs.12567] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/26/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
Abstract
Thickened fluids and texture-modified foods are commonly used in the medical management of individuals who suffer from swallowing difficulty (known as dysphagia). However, how to reliably assess texture properties of such food systems is still a big challenge both to industry and to academic researchers. This article aims to identify key physical parameters that are important for objective assessment of such properties by reviewing the significance of rheological or textural properties of thickened fluids and texture-modified foods for swallowing. Literature reviews have identified that dominating textural properties in relation to swallowing could be very different for thickened fluids and for texture-modified foods. Important parameters of thickened fluids are generally related with the flow of the bolus in the pharyngeal stage, while important parameters of texture-modified foods are generally related with the bolus preparation in the oral stage as well as the bolus flow in the pharyngeal stage. This review helps to identify key textural parameters of thickened fluids and texture-modified foods in relation to eating and swallowing and to develop objective measuring techniques for quality control of thickened fluids and texture-modified foods for dysphagia management.
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Affiliation(s)
- Enrico K Hadde
- Lab of Food Oral Processing, School of Food Science and Biotechnology, Zhejiang Gongshang University, Zhejiang, Hangzhou, China
| | - Jianshe Chen
- Lab of Food Oral Processing, School of Food Science and Biotechnology, Zhejiang Gongshang University, Zhejiang, Hangzhou, China
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Marconati M, Ramaioli M. The role of extensional rheology in the oral phase of swallowing: an in vitro study. Food Funct 2020; 11:4363-4375. [PMID: 32373829 DOI: 10.1039/c9fo02327e] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Swallowing disorders deteriorate significantly the quality of life and can be life-threatening. Texture modification using shear thinning food thickeners has been proven to be effective in the management of dysphagia. Some studies have recently considered the positive role of cohesiveness, but there is still an insufficient understanding of the effect of the rheological properties of the liquid bolus on the dynamics of bolus transport, particularly when elasticity and extensional properties are combined with a shear thinning behaviour. This study combines steady shear, SAOS and capillary breakage extensional rheometry with an in vitro method to characterize the oral transport of viscoelastic liquids. Bolus velocity and bolus length were measured from exit in vitro experiments using image analysis and related to shear and extensional properties. A theory describing the bolus dynamics shows that the elastic and extensional properties do not influence significantly the oral transit dynamics. Conversely, in vitro results suggest that the extensional properties can affect the transition from the oral to the pharyngeal phase of swallowing, where thin, viscoelastic liquids lead to a fast transit, lower oral post-swallow residues and more compact bolus with a smoother surface, which may suggest a lower risk of fragmentation. This mechanistic explanation suggests that the benefit of the extensional properties of thin viscoelastic liquids in the management of dysphagia should be further evaluated in clinical trials.
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Affiliation(s)
- Marco Marconati
- Department of Chemical and Process Engineering, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, GU2 7XH, UK
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11
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Affiliation(s)
- Vasiliki Evageliou
- Food Science and Human Nutrition Agricultural University of Athens 75 Iera Odos 11855 Athens Greece
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12
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Qazi WM, Ekberg O, Wiklund J, Mansoor R, Stading M. Simultaneous X-ray Video-Fluoroscopy and Pulsed Ultrasound Velocimetry Analyses of the Pharyngeal Phase of Swallowing of Boluses with Different Rheological Properties. Dysphagia 2020; 35:898-906. [PMID: 32048021 PMCID: PMC7669789 DOI: 10.1007/s00455-020-10092-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 01/30/2020] [Indexed: 12/02/2022]
Abstract
The Ultrasound Velocity Profiling (UVP) technique allows real-time, non-invasive flow mapping of a fluid along a 1D-measuring line. This study explores the possibility of using the UVP technique and X-ray video-fluoroscopy (XVF) to elucidate the deglutition process with the focus on bolus rheology. By positioning the UVP probe so that the pulsed ultrasonic beam passes behind the air-filled trachea, the bolus flow in the pharynx can be measured. Healthy subjects in a clinical study swallowed fluids with different rheological properties: Newtonian (constant shear viscosity and non-elastic); Boger (constant shear viscosity and elastic); and shear thinning (shear rate-dependent shear viscosity and elastic). The results from both the UVP and XVF reveal higher velocities for the shear thinning fluid, followed by the Boger and the Newtonian fluids, demonstrating that the UVP method has equivalent sensitivities for detecting the velocities of fluids with different rheological properties. The velocity of the contraction wave that clears the pharynx was measured in the UVP and found to be independent of bolus rheology. The results show that UVP not only assesses accurately the fluid velocity in a bolus flow, but it can also monitor the structural changes that take place in response to a bolus flow, with the added advantage of being a completely non-invasive technique that does not require the introduction of contrast media.
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Affiliation(s)
- Waqas M Qazi
- Agrifood and Bioscience, Product Design and Perception, RISE, Research Institutes of Sweden AB, Göteborg, Sweden. .,Department of Industrial and Material Sciences, Chalmers University of Technology, Göteborg, Sweden.
| | - Olle Ekberg
- Diagnostic Centre of Imaging and Functional Medicine, Skåne University Hospital, Lund, Sweden
| | - Johan Wiklund
- Incipientus Ultrasound Flow Technologies AB, Frans Perssons Väg 6, 412 76, Göteborg, Sweden
| | - Rashid Mansoor
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Mats Stading
- Agrifood and Bioscience, Product Design and Perception, RISE, Research Institutes of Sweden AB, Göteborg, Sweden.,Department of Industrial and Material Sciences, Chalmers University of Technology, Göteborg, Sweden
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Qazi WM, Ekberg O, Wiklund J, Kotze R, Stading M. Assessment of the Food-Swallowing Process Using Bolus Visualisation and Manometry Simultaneously in a Device that Models Human Swallowing. Dysphagia 2019; 34:821-833. [PMID: 30840137 PMCID: PMC6825639 DOI: 10.1007/s00455-019-09995-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 02/26/2019] [Indexed: 11/25/2022]
Abstract
The characteristics of the flows of boluses with different consistencies, i.e. different rheological properties, through the pharynx have not been fully elucidated. The results obtained using a novel in vitro device, the Gothenburg Throat, which allows simultaneous bolus flow visualisation and manometry assessments in the pharynx geometry, are presented, to explain the dependence of bolus flow on bolus consistency. Four different bolus consistencies of a commercial food thickener, 0.5, 1, 1.5 and 2 Pa s (at a shear rate of 50 s-1)-corresponding to a range from low honey-thick to pudding-thick consistencies on the National Dysphagia Diet (NDD) scale-were examined in the in vitro pharynx. The bolus velocities recorded in the simulator pharynx were in the range of 0.046-0.48 m/s, which is within the range reported in clinical studies. The corresponding wall shear rates associated with these velocities ranged from 13 s-1 (pudding consistency) to 209 s-1 (honey-thick consistency). The results of the in vitro manometry tests using different consistencies and bolus volumes were rather similar to those obtained in clinical studies. The in vitro device used in this study appears to be a valuable tool for pre-clinical analyses of thickened fluids. Furthermore, the results show that it is desirable to consider a broad range of shear rates when assessing the suitability of a certain consistency for swallowing.
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Affiliation(s)
- Waqas M Qazi
- Agrifood and Bioscience, Product Design and Perception, RISE, Research Institutes of Sweden AB, Göteborg, Sweden.
- Department of Industrial and Material Sciences, Chalmers University of Technology, Göteborg, Sweden.
| | - Olle Ekberg
- Diagnostic Centre of Imaging and Functional Medicine, Skåne University Hospital, Lund, Sweden
| | - Johan Wiklund
- Incipientus Ultrasound Flow Technologies AB, Frans Perssons Väg 6, 412 76, Göteborg, Sweden
| | - Reinhardt Kotze
- Incipientus Ultrasound Flow Technologies AB, Frans Perssons Väg 6, 412 76, Göteborg, Sweden
| | - Mats Stading
- Agrifood and Bioscience, Product Design and Perception, RISE, Research Institutes of Sweden AB, Göteborg, Sweden
- Department of Industrial and Material Sciences, Chalmers University of Technology, Göteborg, Sweden
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14
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Hadde EK, Cichero JAY, Zhao S, Chen W, Chen J. The Importance of Extensional Rheology in Bolus Control during Swallowing. Sci Rep 2019; 9:16106. [PMID: 31695062 PMCID: PMC6834566 DOI: 10.1038/s41598-019-52269-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/10/2019] [Indexed: 11/16/2022] Open
Abstract
Thickened fluids are commonly used in the medical management of individuals who suffer swallowing difficulty (known as dysphagia). Previous studies have shown that the rheological properties of a liquid affect the flow behavior of the bolus in swallowing, such as pharyngeal transit time. While there is no doubt that shear rheology is a highly important factor for bolus flow, it is suspected that extensional properties of a liquid bolus also plays an important role in swallowing, due to elongation of the bolus as it flows through the oropharynx. Our aim in this work was to observe the effect of extensional viscosity on pharyngeal transit time and elongation of the bolus during swallowing. Eight samples of thickened liquid barium that were shear-controlled, but varied in extensional viscosity and two samples that were extensional-controlled, but varied in shear viscosity were swallowed by eight healthy individuals. Data were collected under lateral view of videofluoroscopy swallow study (VFSS); measures of pharyngeal transit time and the ratio of the length to the width of the bolus on the frame of Upper Esophageal Sphincter (UES) opening were taken from the VFSS recordings. It was observed that the pharyngeal transit time generally increases when the fluids are thickened to higher IDDSI consistency. Additionally, higher extensional viscosity fluids reduced the elongation of the bolus during swallowing, thus potentially reducing the risk of post-swallow residue due to bolus breakage. This study confirmed the relevance of the extensional viscosity of the bolus in swallowing.
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Affiliation(s)
- Enrico Karsten Hadde
- School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China.
| | | | - Shaofeng Zhao
- The 1st Affiliated Hospital of Soochow University, Suzhou, China.,The Eight Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Wei Chen
- School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
| | - Jianshe Chen
- School of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China
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15
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de Villiers M, Hanson B, Moodley L, Pillay M. The impact of modification techniques on the rheological properties of dysphagia foods and liquids. J Texture Stud 2019; 51:154-168. [PMID: 31397895 DOI: 10.1111/jtxs.12476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 08/01/2019] [Accepted: 08/03/2019] [Indexed: 01/25/2023]
Abstract
Modifying food and the textures of food has been done for decades within the food science and technology field. More recently, modifying the texture of foods has been used to manage swallowing disabilities (dysphagia). Swallowing disabilities are often associated with dehydration and malnutrition, thus nutritional intervention has formed part of serving texture-modified diets. The question remains whether these modification techniques are viable for individuals with swallowing disabilities living in majority world countries. This study used two modification methods on a widely used specialized nutritious food (SNF) to determine whether it may be modified and used in dysphagia management. The techniques had to be ergonomic and economically appropriate for individuals with swallowing disabilities living in majority world countries. The International Dysphagia Diet Standardization Initiative's (IDDSI) standards were used to determine whether the texturally modified SNF is safe for swallowing. Rheological measurements were performed to determine apparent viscosity and structure recovery of each sample. The effects of two modification techniques, aeration and particle separation, on the rheological properties of the SNF were also measured and analyzed. It was determined that both milk and water could be used with this SNF to create a dysphagia diet, but only under certain conditions. The overall results indicated that heating the samples increased the apparent viscosity and exacerbated lumping. Room temperature samples had less lumps and could be classified to the desired levels of the IDDSI (Level 2 and Level 4). Using a whisk to aerate the samples reduced lumps significantly and using a sieve to separate particles of liquid samples eliminated lumps. This study provides new data on how texture modification techniques and the IDDSI framework could be adapted to individuals living in majority world countries. By using modification techniques that are ergonomic and economically viable and an SNF with longevity, this study could be useful in guiding future training of nursing staff and caregivers of individuals living in poverty or resource-constrained communities. This study also adds to the data on the rheological properties of dysphagia foods, although this study did not make use of commercial thickeners generally used in the modification of diets.
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Affiliation(s)
- Marilize de Villiers
- School of Health Sciences, Discipline of Speech-Language Pathology, University of KwaZulu-Natal, Durban, South Africa
| | - Ben Hanson
- UCL Mechanical Engineering, University College London, London, UK
| | - Legini Moodley
- School of Health Sciences, Discipline of Speech-Language Pathology, University of KwaZulu-Natal, Durban, South Africa
| | - Mershen Pillay
- School of Health Sciences, Discipline of Speech-Language Pathology, University of KwaZulu-Natal, Durban, South Africa
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Hadde EK, Nicholson TM, Cichero JAY. Evaluation of Thickened Fluids Used in Dysphagia Management Using Extensional Rheology. Dysphagia 2019; 35:242-252. [PMID: 31115661 DOI: 10.1007/s00455-019-10012-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
Abstract
Recent studies show that understanding the rheological properties of thickened fluids, such as viscosity and yield stress, is advantageous in designing optimal thickened fluids for the treatment of dysphagia. To date, these studies have focused on the rheological behavior of thickened fluids in shear deformation, while limited information is available on the surface tension of thickened fluids or their rheological behavior in extensional deformation. Knowledge of the extensional properties of thickened fluids (extensional viscosity and cohesiveness) is important to fully understand the behavior of such fluids while swallowing. Our aim in this work, therefore, was to characterize water and skim milk thickened with a commercial thickener (xanthan gum based) to determine extensional deformation and surface tension properties. It was observed that the surface tension decreases as the thickener concentration increases due to the accumulation of the biopolymer at the surface of the fluid when it dissolves in water. In addition, the extensional viscosity of the fluid increased over time as the filament thinned (i.e., as the Hencky strain increased) until it reached a plateau. It was observed that the maximum extensional viscosity, which is related to the cohesiveness of the fluid, increases with the higher concentrations of thickener. However, the cohesiveness of thickened skim milk was lower than that of the thickened water at a given thickener concentration due to lower surface tension. This study confirms that by increasing the concentration of thickener, it will not only increase the shear viscosity (i.e., bolus thickness) of the fluid, but also the extensional viscosity (i.e., bolus cohesiveness).
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Affiliation(s)
- E K Hadde
- School of Chemical Engineering, The University of Queensland, St Lucia, QLD, 4072, Australia.,School of Food Science and Engineering, Zhejiang Gongshang University, Hangzhou, 310018, Zhejiang, China
| | - T M Nicholson
- School of Chemical Engineering, The University of Queensland, St Lucia, QLD, 4072, Australia.
| | - J A Y Cichero
- School of Pharmacy, The University of Queensland, St Lucia, QLD, 4072, Australia
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Nishinari K, Turcanu M, Nakauma M, Fang Y. Role of fluid cohesiveness in safe swallowing. NPJ Sci Food 2019; 3:5. [PMID: 31304277 PMCID: PMC6550271 DOI: 10.1038/s41538-019-0038-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 02/28/2019] [Indexed: 01/18/2023] Open
Abstract
In patients with dysphagia, it has been a practice to thicken fluid food to prevent aspiration—the transport of a bolus into the trachea instead of the oesophagus. In these patients, aspiration is a risk behaviour and is closely related to pneumonia (caused by the aspiration of oral bacteria into the lungs). Since excessive thickening of fluids can cause adverse effects, such as lowering the palatability of food, subsequent reduction of liquid intake, dehydration and malnutrition, identifying the optimum thickening level is vital. Thickening might not only increase fluid viscosity, but could also modify its cohesiveness, which is another key factor affecting aspiration. Even though cohesiveness is more of a concept than a well-defined measurable parameter, this property describes the degree of coherency provided by the internal structure of a material against its fractional breakup. In fluids, this concept is less explored than in solids, powders and granules, and during the last decade few scientists have tackled this topic. Although the role of cohesiveness in the swallowing of heterogeneous solid foods is briefly overviewed, the aim of the present paper is to introduce the concept of cohesiveness for a relatively homogeneous fluid bolus and its effect on swallowing. Cohesiveness is highly correlated with the extensibility and yield stress of the fluid, suggesting that a high cohesiveness could have an important role in preventing aspiration.
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Affiliation(s)
- Katsuyoshi Nishinari
- 1Glyn O. Phillips Hydrocolloids Research Centre, School of Food and Biological Engineering, Hubei University of Technology, Wuhan, 430068 China
| | - Mihaela Turcanu
- 2Product & Process Engineering Center- Germany, Pharmaceuticals Division, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352 Bad Homburg, Germany
| | - Makoto Nakauma
- San-Ei Gen F.F.I., Inc., 1-1-11, Sanwa-cho, Toyonaka, Osaka 561-8588 Japan
| | - Yapeng Fang
- 4Department of Food Science and Engineering, School of Agriculture and Biology, Shanghai Jiao Tong University, Shanghai, 200240 China
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18
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A review of the approaches to predict the ease of swallowing and post-swallow residues. Trends Food Sci Technol 2019. [DOI: 10.1016/j.tifs.2019.02.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Stading M, Waqas MQ, Holmberg F, Wiklund J, Kotze R, Ekberg O. A Device that Models Human Swallowing. Dysphagia 2019; 34:615-626. [PMID: 30673839 PMCID: PMC6717600 DOI: 10.1007/s00455-018-09969-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 12/31/2018] [Indexed: 11/02/2022]
Abstract
The pharynx is critical for correct swallowing, facilitating the transport of both air and food transport in a highly coordinated manner, and aberrant co-ordination causes swallowing disorders (dysphagia). In this work, an in vitro model of swallowing was designed to investigate the role of rheology in swallowing and for use as a pre-clinical tool for simulation of different routes to dysphagia. The model is based on the geometry of the human pharynx. Manometry is used for pressure measurements and ultrasonic analysis is performed to analyze the flow profiles and determine shear rate in the bolus, the latter being vital information largely missing in literature. In the fully automated model, bolus injection, epiglottis/nasopharynx movement, and ultrasound transducer positioning can be controlled. Simulation of closing of the airways and nasal cavity is modulated by the software, as is a clamping valve that simulates the upper esophageal sphincter. The actions can be timed and valves opened to different degrees, resembling pathologic swallowing conditions. To validate measurements of the velocity profile and manometry, continuous and bolus flow was performed. The respective velocity profiles demonstrated the accuracy and validity of the flow characterization necessary for determining bolus flow. A maximum bolus shear rate of 80 s-1 was noted for syrup-consistency fluids. Similarly, the manometry data acquired compared very well with clinical studies.
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Affiliation(s)
- M Stading
- Agrifood and Bioscience Product Design and Perception, RISE Research Institutes of Sweden AB, Göteborg, Sweden. .,Department of Industrial and Material Sciences, Chalmers University of Technology, Göteborg, Sweden.
| | - M Q Waqas
- Agrifood and Bioscience Product Design and Perception, RISE Research Institutes of Sweden AB, Göteborg, Sweden.,Department of Industrial and Material Sciences, Chalmers University of Technology, Göteborg, Sweden
| | - F Holmberg
- Animato Konstruktions AB, Domsjö, Sweden
| | - J Wiklund
- Agrifood and Bioscience Product Design and Perception, RISE Research Institutes of Sweden AB, Göteborg, Sweden
| | - R Kotze
- Agrifood and Bioscience Product Design and Perception, RISE Research Institutes of Sweden AB, Göteborg, Sweden
| | - O Ekberg
- Diagnostic Centre of Imaging and Functional Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
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Turcanu M, Siegert N, Secouard S, Brito-de la Fuente E, Balan C, Gallegos C. An alternative elongational method to study the effect of saliva on thickened fluids for dysphagia nutritional support. J FOOD ENG 2018. [DOI: 10.1016/j.jfoodeng.2018.02.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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22
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Martín-Alfonso JE, Cuadri AA, Berta M, Stading M. Relation between concentration and shear-extensional rheology properties of xanthan and guar gum solutions. Carbohydr Polym 2017; 181:63-70. [PMID: 29254016 DOI: 10.1016/j.carbpol.2017.10.057] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/10/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
Abstract
The influence of concentration on the shear and extensional rheology properties of aqueous solutions of xanthan and guar gums was studied in this work. Shear rheology involved small amplitude oscillatory shear (SAOS), flow curves and transient flow, while the extensional rheology was analyzed using hyperbolic contraction flow. In addition, the mechanical properties during solutions manufacture were monitored in situ through the evolution of torque with processing time by mixing rheometry. The results showed that the hydrocolloids exert a great influence on the process rheokinetics and on the resulting rheological response. SAOS tests showed that the xanthan gum solutions behaved as weak gels, whereas guar gum solutions suggest the presence of entanglement and the formation of a viscoelastic, gel-like structure. All the systems exhibited shear-thinning behaviour. Guar gum solutions obeyed the Cox-Merz rule, with some divergence at high rates for the more concentrated solutions, while the Cox-Merz rule was not followed for xanthan gum in the range of concentration studied. The extensional viscosity exhibited an extensional-thinning behaviour within the strain range used and all solutions were characterized by a high Trouton ratio.
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Affiliation(s)
- J E Martín-Alfonso
- Department of Chemical Engineering and Material Science, Campus de El Carmen, University of Huelva, Chemical Product and Process Technology Research Center (Pro2TecS), 21071 Huelva, Spain.
| | - A A Cuadri
- Department of Chemical Engineering and Material Science, Campus de El Carmen, University of Huelva, Chemical Product and Process Technology Research Center (Pro2TecS), 21071 Huelva, Spain
| | - M Berta
- Research Institutes of Sweden, Bioscience and Materials, Product Design and Perception, 402 29 Gothenburg, Sweden
| | - M Stading
- Research Institutes of Sweden, Bioscience and Materials, Product Design and Perception, 402 29 Gothenburg, Sweden; Chalmers University of Technology, Department of Industrial and Materials Science, 412 96 Gothenburg, Sweden
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Waqas MQ, Wiklund J, Altskär A, Ekberg O, Stading M. Shear and extensional rheology of commercial thickeners used for dysphagia management. J Texture Stud 2017; 48:507-517. [PMID: 28464563 DOI: 10.1111/jtxs.12264] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/24/2017] [Accepted: 02/23/2017] [Indexed: 11/28/2022]
Abstract
People who suffer from swallowing disorders, commonly referred to as dysphagia, are often restricted to a texture-modified diet. In such a diet, the texture of the fluid is modified mainly by the addition of gum or starch-based thickeners. For optimal modification of the texture, tunable rheological parameters are shear viscosity, yield stress, and elasticity. In this work, the flow properties of commercial thickeners obtained from major commercial suppliers were measured both in shear and extensional flow using a laboratory viscometer and a newly developed tube viscometry technique, termed Pulsed Ultrasound Velocimetry plus Pressure Drop (PUV + PD). The two methods gave similar results, demonstrating that the PUV + PD technique can be applied to study flow during the swallowing process in geometry similar to that of the swallowing tract. The thickeners were characterized in relation to extensional viscosity using the Hyperbolic Contraction Flow method, with microscopy used as a complementary method for visualization of the fluid structure. The gum-based thickeners had significantly higher extensional viscosities than the starch-based thickeners. The rheological behavior was manifested in the microstructure as a hydrocolloid network with dimensions in the nanometer range for the gum-based thickeners. The starch-based thickeners displayed a granular structure in the micrometer range. In addition, the commercial thickeners were compared to model fluids (Boger, Newtonian, and Shear-thinning) set to equal shear viscosity at 50/s and it was demonstrated that their rheological behavior could be tuned between highly elastic, extension-thickening to Newtonian. PRACTICAL APPLICATIONS Thickeners available for dysphagia management were characterized for extensional viscosity to improve the understanding of these thickeners in large scale deformation. Extensional deformation behavior was further explained by using microcopy as corresponding technique for better understanding of structure/rheology relationship. Moreover, the major challenge in capturing human swallowing process is the short transit times of the bolus flow (<1 s). Therefore, the ultrasound-based rheometry method; PUV+PD which measures the real-time flow curve in ∼50 ms was used in addition to classical shear rheometry. The two methods complimented each other indicating that the PUV+PD method can be applied to study the transient swallowing process which is part of our future research, where we are studying the flow properties of fluids in an in vitro swallowing tract.
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Affiliation(s)
- Muhammad Qazi Waqas
- SP - Food and Biosciences, Soft Materials Science, Gothenburg, Sweden.,Department of Materials and Manufacturing Technology, Chalmers University of Technology, Gothenburg, Sweden
| | - Johan Wiklund
- SP - Food and Biosciences, Soft Materials Science, Gothenburg, Sweden.,Department of Materials and Manufacturing Technology, Chalmers University of Technology, Gothenburg, Sweden
| | - Annika Altskär
- SP - Food and Biosciences, Soft Materials Science, Gothenburg, Sweden
| | - Olle Ekberg
- Diagnostic Centre of Imaging and Functional Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Mats Stading
- SP - Food and Biosciences, Soft Materials Science, Gothenburg, Sweden.,Department of Materials and Manufacturing Technology, Chalmers University of Technology, Gothenburg, Sweden
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Gallegos C, Brito-de la Fuente E, Clavé P, Costa A, Assegehegn G. Nutritional Aspects of Dysphagia Management. ADVANCES IN FOOD AND NUTRITION RESEARCH 2016; 81:271-318. [PMID: 28317607 DOI: 10.1016/bs.afnr.2016.11.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
This chapter describes the nutritional aspects of dysphagia management by starting with the definition of these two conditions (dysphagia and malnutrition) that share three main clinical characteristics: (a) their prevalence is very high, (b) they can lead to severe complications, and (c) they are frequently underrecognized and neglected conditions. From an anatomical standpoint, dysphagia can result from oropharyngeal and/or esophageal causes; from a pathophysiological perspective, dysphagia can be caused by organic or structural diseases (either benign or malignant) or diseases causing impaired physiology (mainly motility and/or perception disorders). This chapter gathers up-to-date information on the screening and diagnosis of oropharyngeal dysphagia, the consequences of dysphagia (aspiration pneumonia, malnutrition, and dehydration), and on the nutritional management of dysphagic patients. Concerning this last topic, this chapter reviews the rheological aspects of swallowing and dysphagia (including shear and elongational flows) and its influence on the characteristics of the enteral nutrition for dysphagia management (solid/semisolid foods and thickened liquids; ready-to-use oral nutritional supplements and thickening powders), with special focus on the real characteristics of the bolus after mixing with human saliva.
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Affiliation(s)
- C Gallegos
- I&D Centre Complex Formulations and Processing Technologies, Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany.
| | - E Brito-de la Fuente
- I&D Centre Complex Formulations and Processing Technologies, Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany
| | - P Clavé
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Barcelona, Spain
| | - A Costa
- Dysphagia Unit, Universitat de Barcelona, Hospital de Mataró, Mataró, Barcelona, Spain
| | - G Assegehegn
- I&D Centre Complex Formulations and Processing Technologies, Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany
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Wada S, Goto T, Fujimoto K, Watanabe M, Nagao K, Nakamichi A, Ichikawa T. Changes in food bolus texture during mastication. J Texture Stud 2016; 48:171-177. [DOI: 10.1111/jtxs.12228] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 07/24/2016] [Accepted: 08/15/2016] [Indexed: 01/09/2023]
Affiliation(s)
- Sachie Wada
- Department of Oral & Maxillofacial Prosthodontics; Institute of Biomedical Sciences, Tokushima University Graduate School; 3-18-15 Kuramoto Tokushima Japan
| | - Takaharu Goto
- Department of Oral & Maxillofacial Prosthodontics; Institute of Biomedical Sciences, Tokushima University Graduate School; 3-18-15 Kuramoto Tokushima Japan
| | - Keiko Fujimoto
- Department of Oral & Maxillofacial Prosthodontics; Institute of Biomedical Sciences, Tokushima University Graduate School; 3-18-15 Kuramoto Tokushima Japan
| | - Megumi Watanabe
- Department of Oral & Maxillofacial Prosthodontics; Institute of Biomedical Sciences, Tokushima University Graduate School; 3-18-15 Kuramoto Tokushima Japan
| | - Kan Nagao
- Department of Oral & Maxillofacial Prosthodontics; Institute of Biomedical Sciences, Tokushima University Graduate School; 3-18-15 Kuramoto Tokushima Japan
| | - Atsuko Nakamichi
- Department of Oral Functional Management, School of Oral Health Sciences, Faculty of Dentistry; Kyushu Dental University; 2-6-1 Manazuru Kokurakita-ku, Kitakyusyu Fukuoka Japan
| | - Tetsuo Ichikawa
- Department of Oral & Maxillofacial Prosthodontics; Institute of Biomedical Sciences, Tokushima University Graduate School; 3-18-15 Kuramoto Tokushima Japan
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Nishinari K, Takemasa M, Brenner T, Su L, Fang Y, Hirashima M, Yoshimura M, Nitta Y, Moritaka H, Tomczynska-Mleko M, Mleko S, Michiwaki Y. The Food Colloid Principle in the Design of Elderly Food. J Texture Stud 2016. [DOI: 10.1111/jtxs.12201] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Katsuyoshi Nishinari
- Department of Food and Pharmaceutical Engineering, Glyn O Phillips Hydrocolloids Research Centre; Hubei University of Technology; Wuhan 430068 China
- Hubei Collaborative Innovation Centre for Industrial Fermentation; Hubei University of Technology; Wuhan 430068 China
| | - Makoto Takemasa
- School of Creative Science and Engineering; Waseda University; Tokyo 169-8555 Japan
| | - Tom Brenner
- Department of Materials and Life Sciences; Sophia University; Chiyoda-ku, Kioimachi 7-1 Tokyo 102-8554 Japan
| | - Lei Su
- Institute of Chemistry, Chinese Academy of Sciences; Zhongguancun North First Street 2 100190 Beijing China
| | - Yapeng Fang
- Department of Food and Pharmaceutical Engineering, Glyn O Phillips Hydrocolloids Research Centre; Hubei University of Technology; Wuhan 430068 China
- Hubei Collaborative Innovation Centre for Industrial Fermentation; Hubei University of Technology; Wuhan 430068 China
| | - Madoka Hirashima
- Faculty of Education; Mie University; 1577 Kurima-machiya-cho Tsu Mie 514-8507 Japan
| | - Miki Yoshimura
- School of Human Science and Environment; University of Hyogo; 1-1-12 Shinzaike-Honcho Himeji, Hyogo 670-0092 Hyogo Japan
| | - Yoko Nitta
- Graduate School of Health and Welfare Science; Okayama Prefectural University; 111 Kuboki Soja-shi Okayama 719-1197 Japan
| | - Hatsue Moritaka
- Graduate School of Human Life Science; Showa Women's University; 1-7 Taishido Setagaya-ku Tokyo 154-8533 Japan
| | - Marta Tomczynska-Mleko
- Institute of Plant Genetics, Breeding and Biotechnology; University of Life Sciences in Lublin; 15 Akademicka Street 20-950 Lublin Poland
| | - Stanisław Mleko
- Department of Milk Technology and Hydrocolloids; University of Life Sciences in Lublin; 8 Skromna Street 20-704 Lublin Poland
| | - Yukihiro Michiwaki
- Oral Surgery Division, Japanese Red Cross Musashino Hospital; Musashino-shi, Kyonancho, 1-26-1 Tokyo 180-8610 Japan
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Gastelum A, Mata L, Brito-de-la-Fuente E, Delmas P, Vicente W, Salinas-Vázquez M, Ascanio G, Marquez J. Building a three-dimensional model of the upper gastrointestinal tract for computer simulations of swallowing. Med Biol Eng Comput 2015; 54:525-34. [DOI: 10.1007/s11517-015-1338-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 06/19/2015] [Indexed: 11/29/2022]
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