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The use of texture modified food (TMF) is widely spread in the daily care of patients with oropharyngeal dysphagia (OD). However, TMF have been shown to have a negative impact on the patients' quality of life. Adherence rates are low, increasing the risk of malnutrition and aspiration in an already vulnerable patient population. The aim of this exploratory study was to gain insight in the feasibility of adding particles to pureed food on tongue strength, swallowing safety and efficiency in patients with OD. Ten adult participants with OD swallowed three different boluses. Bolus 1 consisted of no particles (IDDSI level 4), small and bigger particles were added in bolus 2 and 3. Tongue strength during swallowing (Pswal) was measured using the Iowa Oral Performance Instrument (IOPI). Swallow safety (penetration and aspiration) and swallow efficiency (residu) were quantified during fiberoptic endoscopic evaluation of swallowing by means of the PAS scale and Pooling score. RM Anova and Friedman tests were performed for analyzing the impact of bolus on the outcome parameters. No significant effect of bolus type on Pswal was measured. Neither the PAS nor the Pooling score differed significantly between the three different boluses. Aspiration was never observed during swallowing any bolus with particles. This preliminary study shows that the addition of particles to pureed food had no impact on Pswal, swallowing efficiency or safety in patients with OD. This innovative project is the first step in research to explore the characteristics of TMF beyond bolus volume, viscosity and temperature.

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Three-dimensional (3D) food printing is a rapidly emerging technology offering unprecedented potential for customised food design and personalised nutrition. Here, we evaluate the technological advances in extrusion-based 3D food printing and its possibilities to promote healthy and sustainable eating. We consider the challenges in implementing the technology in real-world applications. We propose viable applications for 3D food printing in health care, health promotion and food waste upcycling. Finally, we outline future work on 3D food printing in food safety, acceptability and economics, ethics and regulations.

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The purpose of this study was to analyze mastication and swallowing in the elderly and confirm the association with dysphagia characteristics. A questionnaire was developed to evaluate the masticating and swallowing functions of the elderly. Mastication was analyzed using electromyography, and tongue/lip pressures were measured using Iowa Oral Performance Instrument. The results of the questionnaire showed that statistical difference in the number of teeth between the group without and with, decreased ability to swallow, and there was a correlation with lip pressure. Additionally, the higher number of teeth, the higher muscle activity, and there is a positive correlation between the number of chews and the lip pressure. Consequently, our findings suggested oral health parameters are closely associated with mastication/swallowing ability. Finally, based on the results obtained for different foods tested, we suggested that texture-modified foods are necessary to enhance swallowing ability.

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Rapeseed meal (RSM), a by-product of rapeseed oil extraction, is currently used for low-value purposes. With a biorefinery approach, rapeseed proteins may be extracted and recovered for high-end uses to fully exploit their nutritional and functional properties. This study reports the application of RSM protein isolate, the main output of a biorefining process aimed at recovering high-value molecules from rapeseed meal, as a supplement to texture-modified (TM) food designed for elderly people with mastication and dysphagia problems. The compositional (macronutrients by Official Methods of Analyses, and mineral and trace element profiles using Inductively Coupled Plasma Optical Emission Spectrometry ICP-OES), nutritional and sensory evaluations of TM chicken breast, carrots and bread formulated without and with RSM protein supplementation (5% w/w) are hereby reported. The results show that the texture modification of food combined with rapeseed protein isolate supplementation has a positive impact on the nutritional and sensory profile of food, meeting the special requirements of seniors. TM chicken breast and bread supplemented with RSM protein isolate showed unaltered or even improved sensory properties and a higher nutrient density, with particular regard to proteins (+20-40%) and minerals (+10-16%). Supplemented TM carrots, in spite of the high nutrient density, showed a limited acceptability, due to poor sensory properties that could be overcome with an adjustment to the formulation. This study highlights the potentialities of RSM as a sustainable novel protein source in the food sector. The application of RSM protein proposed here is in line with the major current challenges of food systems such as the responsible management of natural resources, the valorization of agri-food by-products, and healthy nutrition with focus on elderly people.

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@#Introduction: This methodological research study aimed to measure content validity and reliability of a newly developed questionnaire of knowledge, attitudes, and self-reported practices towards pureed diet preparation (KAP DYS Puree) among hospital food handlers for dysphagia management. Methods: The study was conducted through face validation, content validation, content reliability and construct validation. A cross-sectional design with convenience sampling was carried out involving 4 panels for face validation, 10 raters for content validity and 161 food handlers participated for Exploratory Factor Analysis (EFA), while 30 food handlers were involved for test-retest reliability. The questionnaire which consisted of 40 items distributed into 3 domains and was assessed and analyzed using modified kappa (k*) for reliability. Results: Content Validity Index revealed the following I-CVI values: knowledge = 0.915, attitudes = 0.922 and self-reported practices = 0.900 and modified kappa values (k*) knowledge = 0.983, attitudes = 0.9214 and self-reported practices = 0.899. The EFA was employed for two dimensions which were self-reported practices and attitudes based on principal axis of factoring with varimax rotation. The factor analysis yielded two factors with a total of 10 items in the attitudes domain and two factors with a total of 9 items in the self-reported practices domain that had satisfactory factor loading (> 0.3). The Kaiser-Meyer-Olkin (KMO) values for attitudes = 0.816 and self-reported practices = 0.776. Bartlett’s test of sphericity was significant at p < 0.0001 for attitudes and self-reported practices indicating the suitability of this data for factor analysis. Interclass Correlation Index (ICC) values for attitudes = 0.739 and self-reported practices = 0.789. Conclusion: This instrument can be used as a need assessment tool in the development of a comprehensive training module for pureed diet preparations in dysphagia management.

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INTRODUCTION: Dysphagia has received much attention as a factor that affects caregiver burden. However, few studies have examined how its severity can affect caregiver burden. This study aimed to examine the effect of dysphagia severity on caregiver burden. METHODS: A cross-sectional online survey was carried out among family caregivers. We assessed caregiver burden using the Zarit Burden Interview. The dysphagia severity was assessed using the Functional Oral Intake Scale, and the caregivers were divided into three groups based on care receivers' oral intake status (levels 1-3: tube-feeding group; levels 4-6: texture-modified food group; level 7: normal group). To investigate the relationship between caregiver burden and dysphagia severity, univariable and multivariable logistic regression analyses were applied to caregiver burden. RESULTS: The Zarit Burden Interview was significantly higher in the texture-modified food group, and the proportions of high caregiver burden reached 25.2%, 39.5% and 23.4% in the normal group, texture-modified food group and tube-feeding group, respectively. The multivariable analyses applied to caregiver burden (reference, normal group) showed that the texture-modified food group was significantly associated with caregiver burden (OR 1.55, 95% CI 1.04-2.32), whereas the tube-feeding group had no relationship with caregiver burden (OR 0.68, 95% CI 0.31-1.49). CONCLUSIONS: Our study showed that the intake of texture-modified food significantly affected caregiver burden even after adjusting for confounding factors, whereas the use of tube feeding did not increase caregiver burden. These results suggest that it is necessary to consider dysphagia severity to reduce dysphagia-related caregiver burden. Geriatr Gerontol Int 2022; 22: 870-875.

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BACKGROUND/OBJECTIVES: Understanding the mechanism of chewing and swallowing food is important when creating a proper diet for older adults. This study investigated whether texture-modified model foods can reduce the difference in chewing and swallowing parameters between healthy community-living young and older adults. SUBJECTS/METHODS: In total, 35 older and 20 young adults (mean age: 75 and 25 years, respectively), matched for sex and number of teeth, were recruited and their unstimulated salivation and tongue pressure were measured. Simultaneous assessment of chewing and swallowing characteristics was conducted using surface electromyography and a videofluoroscopic swallowing study while the participants ingested 8 g of model food with one to four levels of hardness. RESULTS: The average tongue pressure and salivation among older adults were 61% and 49.7%, respectively, of the corresponding values observed in young adults. The older adult group used significantly (P < 0.05) increased muscle force with more chewing cycles (P < 0.05) than the young adult group, which was maintained even when consuming foods with the lowest hardness, although without chewing. However, the age effect on oral processing time existed only for the hardest foods. Swallowing difficulties among older adults were demonstrated by the significant increase in vallecula aggregation time. The total food intake duration was significantly (P < 0.05) longer in older adults than in young adults, regardless of food hardness. CONCLUSIONS: There were measurable differences in the process of chewing and swallowing food between young and older adults, which can be improved with food hardness control. Adjusting food hardness may help food intake in healthy older adults.

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BACKGROUND: Physiological deterioration (aging, poor dental status, and reduced tongue pressure) makes chewing difficult. This study aimed to investigate the chewing patterns of older people with or without dentures, evaluate the textural and masticatory properties of texture-modified radish Kimchi, and investigate the correlation between dental status and tongue pressure. Additionally, differences in the subjective-objective concordance of texture-modified Kimchi were investigated using the preference test. METHODS: This study included 32 Korean women aged between 65 and 85 years. Masticatory behavior was recorded by electromyography, and tongue pressure was measured using the Iowa Oral Performance Instrument. A preference test, with hardness as the relevant textural property, determined the participants' preferences among the test samples (food with a homogeneous structure-radish Kimchi). To assess preference differences, a questionnaire suitable for older people was designed. The preference for cooked radish Kimchi with various blanching times based on overall acceptability and self-reporting of preference was investigated to develop elderly-friendly food. The subjective scores indicated whether the sample (radish Kimchi) was hard or soft based on the chewing ability of the participants. Dental status, muscle activities, and tongue pressure were considered for the food design with optimized texture. The relationship between subject score and mastication properties were examined using multiple regression analysis. RESULTS: The number of chews and chewing time increased with hardness, significantly activating the masseter and temporalis muscles. The evaluation of masseter muscle activity, particularly for level-6 radish Kimchi, showed that older people with complete dentures chewed less actively than those with natural teeth (p < 0.05). The older people with natural teeth (18.94 ± 10.27 kPa) exhibited higher tongue pressure than those with complete dentures (10.81 ± 62.93 kPa), and the difference was statistically significant (p < 0.01). Older people preferred food with familiar tastes and textures. An association was found between the subjective hardness score and the objective hardness level. The perceived hardness intensity was linked to the chewing ability of the participant. Denture wearers exhibited a lower chewing ability, and at level 6, they perceived greater hardness of food than those with natural teeth. CONCLUSIONS: Developing food with a modified texture can bridge the gap between physiological and psychological aspects of food texture; texture-modified radish Kimchi, with limited blanching time, may be favorable for older people.

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The interest to characterize texture-modified foods (TMFs) intended for people with oropharyngeal dysphagia (OD) has grown significantly since 2011. Several instrumental and sensory techniques have been applied in the analysis of these foods. The objective of the present systematic review was to identify the most appropriate techniques, especially for the food industry and clinical setting. The search was carried out in three online databases according to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA). Across the multiple trials reviewed, Texture Profile Analysis and the Uniaxial Compression Test were most used as the instrumental technique for solid foods, and the Back Extrusion Test for fluid and semisolid foods. All trials used descriptive analysis as the sensory technique. However, the experimental conditions of the trials lacked standardization. Consequently, the results of the trials were not comparable. To properly characterize the texture of TMFs intended for OD by each technique, an international consensus is needed to establish standardized experimental conditions. Methods based on these techniques should also be validated by collaborative studies to verify repeatability, replicability, and reproducibility.

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As a result of increasing elderly population, the number of people with dysphagia and difficulty eating is expected to increase as well. It is not always feasible to cook meals to the proper texture for elderly individuals and people with dysphagia living at home. Accordingly, there is high market demand for ready-made texture-modified foods for home consumption. Many methods have been widely used to analyze the structural properties of foods. However, it is difficult to observe the structure of foods in a nondestructive manner with the conventional analysis methods. To observe food as it is without destroying it, we adopted X-ray phase-contrast computed tomography (CT) using a crystal interferometer in this study. The samples were commercially available precooked rice porridge and two texture-modified rice products satisfying the Universal Design Food criteria. A texture profile analysis was also performed to compare the phase-contrast images and the food properties. In the phase-contrast images, both the ingredients and cohesion in the samples were successfully observed. It was also found that the texture-modified rice products were easier to eat and swallow than the rice porridge. These results show that X-ray phase-contrast CT using a crystal interferometer is a promising method for nondestructive observation of food structures and is expected to open up new horizons in food science.

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This study was undertaken to determine the correlation between instrumental and sensory evaluation on texture-modified carrot puree. Texture-modified foods (TMFs) are prescribed to dysphagia individuals to aid in the oral manipulation and facilitate swallowing of food. There is a lack of correlation between instrumental measurements and sensory attributes on TMF. Understanding this correlation will aid in the formulation of safe foods with desired sensory properties for dysphagia patients. Instrumental measurements of carrot purees were performed by back extrusion method using a texture analyzer and the attributes obtained were firmness, consistency, cohesiveness, and adhesiveness. Quantitative descriptive analysis with eight trained panelists was employed to characterize the texture of the carrot puree based on seven sensory attributes: firmness, viscous, adhesive (mouth), smoothness, adhesive (throat), rate of breakdown, and difficulty to swallow. Five thickeners, namely gellan gum, xanthan gum, Suberakaze, UNI-PURE® Dys-sperse instant thickener, and ULTRA-SPERSE® M Starch, were evaluated against carrot puree without any thickener as control. The correlation results obtained from texture analysis and sensory evaluation were statistically significant (p < .05). The firmness attributes from instrumental and sensory results were positively correlated. The consistency parameter was positively correlated to sensory attribute viscous and negatively correlated to smoothness. The sensory attribute rate of breakdown was negatively correlated to instrumental parameter of cohesiveness. Lastly, instrumental adhesiveness was positively correlated to sensory attributes adhesive to mouth and throat, and difficulty to swallow. The correlation results showed a well-designed instrumental technique can be used to understand the impact of thickeners on TMF for dysphagia subjects.

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OBJECTIVE: This study aimed to clarify the association between texture-modified diets and poor appetite in older adults, as it is not fully understood. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: We included 208 inpatients who were aged ≥65 years (mean age 78.9 ± 7.6 years, 57.7% female) and admitted to a rehabilitation unit with stroke, musculoskeletal disease, or hospital-associated deconditioning covered by the Japanese insurance system, between January 2019 and January 2020. METHODS: Participants were divided into 2 groups according to their food texture level: International Dysphagia Diet Standardization Initiative (IDDSI) levels 3 to 5 for the texture-modified diet group and levels 6 and 7 for the normal diet group. Appetite was assessed using the Simplified Nutritional Appetite Questionnaire for the Japanese elderly, and a score ≤14 was defined as poor appetite. The relationship between IDDSI levels and poor appetite was analyzed using the Cochrane-Armitage trend test. Logistic regression analysis was used to investigate the relationship between the consumption of texture-modified diets and poor appetite. Statistical significance was set at P < .05. RESULTS: The numbers of participants on modified diets according to the IDDSI framework were as follows: 4, 11, 41, 76, and 76 in levels 3, 4, 5, 6, and 7, respectively. In total, 152 and 56 patients were classified into the regular diet group and texture-modified diet group, respectively. A significantly higher prevalence of poor appetite was observed with the consumption of texture-modified diets (P < .001 for trend). Logistic regression analysis showed that poor appetite was independently associated with the consumption of texture-modified diets (odds ratio 3.443, P = .011). CONCLUSIONS AND IMPLICATIONS: These findings indicate that the consumption of texture-modified diets is associated with poor appetite. Further studies are required to verify whether a multimodal approach involving improvement in the appearance, taste, flavor, and nutrients of the food can improve poor appetite.

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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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One in every twelve people worldwide suffers from dysphagia that affects the swallowing mechanism and some patients require a special texture-modified food for their sustenance. Fish is a great source of nutrients and proteins, however the commercially dysphagia diet made from fish is limited. This study investigated the textural characteristics of a soft fish paste produced from steamed grass carp fillet with different the water addition, grinding cycles and ratio of starch with the mixture of steamed fillet and water, following International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines and other instruments. The water addition and particle size affected the physical properties, and the starch had a certain masking effect on fishy odor. The mixture of steamed fish fillets and water (91:9 wt/wt) was ground in a colloid mill for 3 cycles. The fish paste was then sterilized by adding sugar, salt, and starch in the mixture (ratios of 0.5:100, 0.5:100, and 0.6:100, wt/wt, respectively) and mixing well. The paste conformed to Level 4-pureed and extremely thick of IDDSI framework. The fish paste product had a light fishy odor that was acceptable to sensory specialists.

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To delay impacts of aging, optimal nutritional status is essential. Several factors can reduce food intake, such as isolation, income, and cognitive/physical decline. Additionally, chewing and swallowing difficulties, or dysphagia, often disrupt the ability to consume life-long favorite dishes. Food and liquids could require modification of texture or consistency to ensure a comfortable or safe swallow. The food industry, foodservices facilities, and caregivers need quality control benchmarks to provide adequate nourishment and meet these new feeding challenges. The International Dysphagia Diet Standardisation Initiative (IDDSI) is proposing the IDDSI framework and testing methods to describe food used in nutritional care plans to circumvent dysphagia and improve communication among caregivers. This systematic review assesses the validity and reliability of the IDDSI testing methods using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). Two publications presented content validity whereas 19 publications looked at construct validity or reliability for the IDDSI testing methods. One study was conducted in older adults presenting dysphagia. This review concludes that there is insufficient evidence to recommend the IDDSI testing methods. Further research, conducted with robust methodological design and reporting, is needed to develop and assess nutritious adapted food for frail older populations.

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In 2020, the older adult population ( ≥ 65 years old) reached 703 million worldwide and 3.6 million in Taiwan. By 2026, Taiwan will become a super-aged society with at least 20 percent of the population in this category and 180,000 new older adults joining this population annually. The consequences of oropharyngeal physiological degradation include dysphagia, malnutrition, and a negative impact on quality of life. The provision of texture-modified foods and thickened liquids assist users with chewing or swallowing disorders, making foods easier to ingest and improving diet safety. The classification of texture modified foods allows for consistent communication among health professionals, care providers, and industry partners to improve quality of care for users. This article reviews the four texture-modified food classification systems currently in use internationally. 1. International Standardization Committee for Dysphagia: 22 countries implemented this framework, which was developed by a wide range of professions, including nutrition & dietetics, medicine, speech pathology, occupational therapy, nursing, food science & technology. This framework provides internationally standardized terminology and definitions for texture-modified foods and thickened liquids for persons with dysphagia. 2. Japanese Universal Design Foods: This voluntary standard established by the food industry addresses the physical properties related to the texture of food. The four categories in this standard are distinguished based on the hardness and viscosity of food. The category-based terms and the universal design foods logo are displayed on foods to facilitate consumer selection. 3. The smile care food-The Japanese Ministry of Agriculture, Forestry and Fisheries reclassified nursing care food into the following three categories: (i) Food for people without eating problems but with nutrition supplement needs; (ii) Food for people with problems with swallowing functions; and (iii) Food for people with problems with chewing functions. 4. Eatender, Taiwan senior friendly food. This standard designates four texture specifications: Easy to chew, gum mashable, tongue mashable, no chewing needed. This standard is used to grade the texture of packaged foods that use agricultural food ingredients sourced in Taiwan.

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OBJECTIVES: Due to the water-rich cooking process required to soften texture modified diets (TMDs), TMDs may have poorer nutrition. The aim of this study was to investigate the associations between daily premorbid TMD consumption and nutritional status at the time of hospitalization, and its burden on hospitalization outcomes. DESIGN: Retrospective observational study. SETTING: An academic hospital. PARTICIPANTS: The cohort comprised 3,594 older adult patients aged ≥65 years admitted to the hospital. MEASUREMENTS: Patients were interviewed on admission using a premorbid daily consumption meal form to determine whether the patient ate a TMD. Nutritional status was examined using nutritional screening tools (Mini-Nutritional Assessment Short Form [MNA-SF], Malnutrition Universal Screening Tool [MUST], Geriatric Nutritional Risk Index [GNRI]) and the European Society of Clinical Nutrition and Metabolism (ESPEN)-defined criteria of malnutrition at admission. Length of hospital stay (LOS) and in-hospital mortality were considered outcomes of hospitalization. Multivariate analyses were performed to detect associations between premorbid TMD consumption and nutritional status and outcomes. RESULTS: The mean age of the subjects was 75.9±7.0 years, including 58% males. Overall, 110 (3.1%) patients consuming a premorbid TMD were identified. They were older (p<0.001), had poor nutritional status (lower MNA-SF score [p<0.001] and GNRI value [p<0.001], higher MUST score [p<0.001], and more prevalent ESPEN-defined malnutrition [61.8% vs. 14.0%, p<0.001] than did patients without a TMD. The mortality rate and LOS of patients with TMD was higher (7.3% vs. 2.9%, p=0.017) and longer (19 days vs. 8 days, p<0.001) than those without TMD. Multivariate analyses showed that TMD consumption was independently associated with poor nutritional status and prolonged LOS after adjusting confounders. CONCLUSION: Daily consumption of a TMD during the premorbid period affects nutritional status at the time of hospitalization and outcomes. Further studies are necessary to investigate whether nutritional intervention can improve outcomes for people on a TMD.

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BACKGROUND: The energy and protein provided by texture-modified diets decreases dramatically as the stage increases. To prevent malnutrition in individuals on texture-modified diets, nutrition management detailing the amount of energy and protein required and consumed is needed; however, this has not yet progressed. AIM: To consider the factors responsible for the lack of progress in nutrition management. METHODS: We reviewed the work content of the registered dietitian in Japan. RESULTS: It takes over an hour a day to make calculations for the amount of energy and protein consumed for all of these patients, but it turned out that this time cannot be extracted considering the daily work of the registered dietitian. CONCLUSION: To prevent malnutrition, it is necessary to increase the number of registered dietitians.

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Texture-modified food has become an important strategy in managing dysphagia. Pureed food is proven to be the safest texture due to its high viscosity which can slow down the rate of the food bolus during swallowing. In this study, texture-modified chicken rendang was developed according to Texture C (smooth puree) as described by the Australian standard for texture-modified food. Samples were added with five different thickeners (sago starch, tapioca starch, modified corn starch, xanthan gum and carboxymethyl cellulose gum) at three different concentrations (10, 20 and 30% w/w). Their rheological effects were analyzed through dynamic and steady shear test. Results obtained reveals that samples contained xanthan gum have higher structure rigidity and shear thinning behaviour, while carboxymethyl cellulose gum provides the highest viscosity as well as yield stress than other samples. In terms of concentration, a strong dependence of structural rigidity and viscosity of all prepared samples with amount of thickeners added was observed. Overall, based on its rheological properties, the addition of carboxymethyl cellulose gum at 30% concentration was found to be the most suitable thickener, to be incorporated in the texture-modified chicken rendang. Selecting a suitable food thickener in developing food for individual with dysphagia plays an important role to ensure the right texture and consistency for their safe consumption.

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Reductions in muscle mass and strength are well known complications of advancing age. All muscles of the body are affected, including those critical to chewing and swallowing. A diagnosis of frailty and its features of weakness and unintentional weight loss are particularly relevant to the aging swallowing system. Age related changes to eating and swallowing function means that there is a natural tendency for elders to self-select 'soft' foods due to loss of dentition and fatigue on chewing. However, it is not well known that tooth loss and poor dental status is associated with increased choking risk, especially as people age. In fact, people over 65 years of age have seven times higher risk for choking on food than children aged 1-4 years of age. Texture modified foods are provided clinically to reduce choking risk and manage dysphagia. Although certain food textures offer greater swallowing safety, they significantly restrict food choice. This commentary paper will highlight age-related changes to the eating and swallowing system, noting especially those that are relevant for frail elders. Swallowing impairments also affect the ability to manage liquids, and aspiration risk in healthy and frail elders is also discussed. Modified food textures that are most often recommended by clinicians to maintain sufficient oral intake and reduce choking risk will be described, while also highlighting the nutritional challenges associated with these foods and offering some solutions. The ethical challenges associated with balancing the autonomy of choice of food textures with swallowing safety will be addressed.