AJSLP

Review Article

Dying for a Meal: An Integrative Review of

Characteristics of Choking Incidents and
Recommendations to Prevent Fatal and
Nonfatal Choking Across Populations
Bronwyn Hemsley,a Joanne Steel,a,e Justine Joan Sheppard,b
Georgia A. Malandraki,c Lucy Bryant,a and Susan Balandind

Purpose: The purpose of this study was to conduct an the general public and people at risk of dysphagia. A range
integrative review of original research, across adult of food types were involved, and several actions were
populations relating to fatal or nonfatal choking on food, to reported in response to food choking. Strategies to reduce
understand ways to respond to and prevent choking incidents. the risk of choking were identified in the studies and are
Method: Four scientific databases (CINAHL, Medline, Web presented in 5 main categories.
of Science, and EMBASE) were searched for original peer- Conclusions: Factors leading up to choking incidents
reviewed research relating to fatal or nonfatal choking on extend well beyond the individual to the environment for
foods. Data were extracted on study characteristics; factors mealtimes; the provision of appropriate mealtime assistance
leading up to, events at the time of, and actions taken after and oral care; and regular monitoring of general health, oral
the choking incident; and impacts of choking incidents. An health, and medications. Bystanders’ increased awareness
integrative review of the findings across studies identified and knowledge of how to respond to choking are vital.
several risk factors and recommendations to reduce the The results of this review could be used to inform service
risk of choking. policy and training, for individuals at risk of choking, the
Results: In total, 52 studies met the criteria for inclusion in people who support them, and the general public. Further
this review, of which 31 were quantitative, 17 were qualitative, research is needed to explore choking prevention and
and 4 were of a mixed methods design. Studies reported airway protection in individuals with dysphagia.
the observations and narratives of bystanders or researchers, Supplemental Material: https://doi.org/10.23641/asha.
or else were large-scale autopsy studies, and included both 8121131

F
atal and nonfatal choking on food can occur in & Taylor, 2012; Bours, Speyer, Lemmens, Limburg, &
both younger and older adults, but some groups of de Wit, 2009; Hughes, Enderby, & Hewer, 1994; Kennedy,
adults are at a higher risk of choking on food and Ibrahim, Bugeja, & Ranson, 2014; Morad, Kandel, Ahn,
feature more prominently in reports on choking (Aldridge Fuchs, & Merrick, 2008; Robertson, Chadwick, Baines,
Emerson, & Hatton, 2017; Stewart, 2012). These groups in-
a clude people who are inebriated (Boghossian, Tambuscio, &
Graduate School of Health, The University of Technology, NSW,
Sydney, Australia
Sauvageau, 2010); older people (Kennedy et al., 2014);
b
Department of Biobehavioral Sciences, Teacher’s College, Columbia patients on psychotropic medications (Aldridge & Taylor,
University, New York, NY 2012); adults with neurological conditions such as stroke (Ho,
c
Department of Speech, Language and Hearing Sciences, Purdue Liu, & Huang, 2014), motor neuron disease (Hadjikoutis,
University, West Lafayette, IN Eccles, & Wiles, 2000), Parkinson’s disease (Goh et al.,
d
School of Health & Social Development, Deakin University, 2016), Huntington’s disease (Stewart, 2012), or multiple
Melbourne, Victoria, Australia sclerosis (Hughes et al., 1994); people with intellectual or
e
The University of Newcastle, NSW, Australia developmental disability (Robertson et al., 2017); and
Correspondence to Bronwyn Hemsley: [email protected] people with dysphagia (Sheppard et al., 2017). Therefore,
Editor-in-Chief: Julie Barkmeier-Kraemer focusing on events surrounding choking, regardless of the
Editor: Debra Suiter adult victim’s age or health condition, could (a) inform
Received July 11, 2018
Revision received September 9, 2018
Accepted November 9, 2018 Disclosure: The authors have declared that no competing interests existed at the time
https://doi.org/10.1044/2018_AJSLP-18-0150 of publication.

American Journal of Speech-Language Pathology • Vol. 28 • 1283–1297 • August 2019 • Copyright © 2019 American Speech-Language-Hearing Association 1283
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development of a guiding framework for increasing Web of Science, and EMBASE) were searched for original
mealtime-related food safety and reduce choking risk peer-reviewed research written in English that related to
across populations and (b) support the development of either fatal or nonfatal choking on edible foods. Search
interventions for those adults who feature more promi- terms were various combinations and permutations of
nently in the choking literature and are known to be at choking or asphyxiation, and food or mealtimes or dysphagia
an increased risk of choking on food (Hemsley, Balandin, decided by authors B. H., J. S., and L. B. We sought re-
Sheppard, Georgiou, & Hill, 2015). ports of original research in English that related to choking
Choking on food is a cause of death defined in the in adults, from any country with no year limits. Studies that
International Classification of Diseases, 10th Revision (ICD-10): did not meet these criteria were excluded from the review.
W79 as “Inhalation and ingestion of food causing obstruc-
tion of respiratory tract” (World Health Organization, 2016).
Choking on food appears in the literature in several ways, Studies Selection
including (a) choking and asphyxiation (incomplete or The first search in 2015 yielded 193 papers. Two raters
complete), choking death (fatal), choking requiring assis- screened the titles and/or abstracts of all papers for a deci-
tance to clear (near-fatal, nonfatal, or near miss), choking sion to exclude, with any differences of opinion being re-
due to compression of the trachea causing blockage of the solved by consensus; in total resulting in 102 proceedings
airway, or “esophageal” choking and (b) dysphagia, with to full-text reading (see process in Figure 1). A decision
aspiration/penetration characterized by coughing on food to exclude a paper at full-text stage was made separately
intake. However, the nonspecific expression conflating by the same two raters, with any differences of opinion
“coughing and choking” also appears in relation to symp- being resolved by a third rater. Of these, 73 studies were
toms of dysphagia (Groher & Crary, 2015). retained for further consideration. The second search in
“Coughing,” described in terms of frequency and severity February 2017 yielded an additional 28 papers, which were
in symptomology (e.g., occasional short coughing, prolonged screened using similar procedures, leaving eight papers for
coughing, or unresolved coughing that needs persistence to further consideration. At this point, it was noted that many
clear), is a rapid expulsion of air from the lungs and is an in- of the studies met the inclusion criteria, but either did not
voluntary or voluntary response to upper airway obstruction define or describe choking in detail, mentioned choking
above the vocal folds (see Sheppard et al., 2017). Choking only in passing, or conflated “coughing and choking” (i.e.,
may reflect transient dysphagia for all people who choke, did not describe choking that involved obstruction of the
because they have not managed to perform a safe swallow airway requiring clearing by coughing or rescue, or se-
when taking in edible food, and thus experience an obstructed vere feeling of asphyxiation, or asphyxiation). Judgments
or partially obstructed airway (Sheppard et al., 2017). on relevance of studies based on this definition were rated
Although choking on food is common across popula- by two raters separately, and differences were resolved
tions and has potentially fatal and devastating consequences, through discussion. Therefore, the 81 studies kept for
to date, there is no scholarly review of studies on choking and further consideration were read closely to exclude those
mealtime safety across populations. Literature relating to that conflated coughing and choking without explicit at-
choking across populations could be used to increase knowl- tention to “choking” (n = 15), mentioned choking but
edge about environmental factors leading to choking, provide did not provide a definition or description of a choking
a broad perspective on the nature of choking incidents to be event (n = 15), or mentioned choking only in passing
alert to, and highlight a wide range of actions taken after a (e.g., noted choking as a risk; n = 3; see Supplemental
choking incident to reduce the risk of future choking and Materials S1 and S2). In July 2018, we searched again for
associated harms. Therefore, the aim of this integrative re- new publications and located no new systematic reviews
view was to locate original peer-reviewed research on fatal and four new studies meeting the inclusion criteria. Over-
or nonfatal choking on food, to identify factors leading all, this entire process resulted in 52 studies for inclusion
up to choking incidents, characteristics of incidents, events in the analysis (see Figure 1).
following incidents, and recommendations for reducing chok-
ing risk. This information could be used to (a) prevent and ad-
equately follow up on choking incidents in residential care Data Analysis Process
settings; (b) reduce the risk of choking death in adults, par- An integrative review method (Whittemore & Knafl,
ticularly those in high risk categories; and (c) inform future 2005) was selected as appropriate to integrate the findings
research investigating choking prevention and airway pro- of both qualitative and quantitative studies in the analysis
tection in individuals with dysphagia (Hemsley et al., 2015). and reporting of results. Data from the included studies
were extracted into an Excel database by two research as-
sistants with each entry checked by a second rater, and
Method qualitative data were coded in NVivo. Data were also ex-
tracted on the characteristics of the studies, including coun-
Eligibility Criteria for Initial Search and Search Items try of origin and design, participants, characteristics of the
In February 2015, and again in February 2017 and choking incidents, and recommendations to reduce the risk
July 2018, four scientific databases (CINAHL, Medline, of choking. The findings of the studies were analyzed for

1284 American Journal of Speech-Language Pathology • Vol. 28 • 1283–1297 • August 2019

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 Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram detailing search
process for literature identification, review, and exclusion.

content themes, which reflected a synthesis of categories Study authors included an anatomically detailed defi-
and subcategories of meaning in relation to events leading nition of choking in only 36 (69.2%) of the 52 studies (e.g.,
up to, during, and following choking incidents. “blockage of the internal airways usually between the
pharynx and the bifurcation of the trachea” [Punia, 2009,
p. 397]). Anatomical terms occurred more in medical or
Results forensic research papers (e.g., Berzlanovich, Muhm, Sim,
& Bauer, 1999; Jacob, Wiedbrauck, Lamprecht, & Bonte,
Characteristics of Included Studies 1992). Four papers used the ICD-10 classification system
The 52 included studies spanned four decades, being to report on choking: ICD-10 codes (W79), and four pa-
published between 1977 and 2017. Reflecting an inter- pers included the ICD-9 code for choking (E911/ICD-933).
national concern with choking, the research originated in The most commonly used terms were food/bolus/foreign
17 countries. There were 31 quantitative, 17 qualitative, body asphyxiation (in 24 studies) and foreign body blocking
and four mixed methods studies. Information on the included or obstructing the airway (in 20 studies). Other authors
studies is presented in Table 1. used less well-defined terms that were descriptive in nature,

Hemsley et al.: An Integrative Review of Choking Incidents 1285

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 Table 1. Information on included studies.

Number of studies (%)

Study details N = 52

Affiliations
Medicine 26
General medicine (n = 16)
Emergency medicine (n = 5)
Public health medicine (n = 3)
Neurology (n = 2)
Speech pathology 4
Forensic science/forensic medicine 9
Psychiatry 8
Nursing 1
Dentistry 2
Epidemiology, radiology 2
Age
Adults 36 (69.2)
Adults and children 16 (30.8)
Health conditiona
General population 28 (53.8)
Lifelong conditions (ASD, CP, DD/LD, DMD, ID, XXY syndrome) 12 (23.1)
Acquired conditions (MS, MSA, stroke, psychiatric conditions, dementias, PD) 12 (22.9)
Older people (aged 65 years or over) 7 (14.6)
Association with dysphagia
Dysphagia was associated with choking 24 (46.2)
No reference to dysphagia or swallowing difficulty 28 (53.8)

Note. ASD = autism spectrum disorder; CP = cerebral palsy; DD/LD = developmental/learning disability; DMD =
Duchenne muscular dystrophy; ID = intellectual disability; MS = multiple sclerosis; MSA = multiple systems
atrophy; PD = Parkinson’s disease.
a
Multiple conditions applied for participants.

conveying only observable aspects of choking (e.g., the (d) older people (aged 65 years or over). Boghossian et al.
person started coughing and was unable to breathe on reported that one of the contributors to choking death was
swallowing food, had food stuck in the throat, or changed a history of alcoholism or the use of alcohol (in three cases;
color while eating). Such descriptions of choking appeared in Boghossian et al., 2010, p. 648). Overall, difficulty with
studies that did not involve examination of medical records. swallowing or a diagnostic description of dysphagia was
The wide range of terms used in relation to choking included associated with choking in less than half of the studies,
acute respiratory failure, airway occlusion, airway obstruc- with the majority of studies not commenting on dysphagia or
tion (by food), bolus death, café coronary (or obstructive as- swallowing difficulty.
phyxia during a meal), food causing obstruction (in the
pharynx, larynx, or trachea), foreign body in the larynx/
pharynx, mechanical asphyxia due to a food bolus occlusion, Characteristics of Choking Incidents
gagging, obstructive, subglottic obstruction, suffocation, Descriptions of choking incidents in the studies
and tracheal obstruction. yielded context and detail on the food types (see Table 2),
people involved, environments, responses, and narratives
of those who had choked or bystanders (see Table 3).
Disciplines and Populations Represented in the Studies These characteristics are summarized below.
The primary disciplines represented in the studies,
judging from author affiliations, were medicine and forensic Food Types and Textures in the Choking Incident
science, with the disciplines of speech-language pathology, A range of foods were identified in relation to the
psychology, psychiatry, nursing, otolaryngology, dentistry, choking incidents, and these are presented in Table 2. The
radiology, epidemiology, and public health also reflected most common foods associated with choking included various
in the affiliations listed (see Table 1). The majority of stud- types of meat, bread or sandwiches, and fruit and vegetables.
ies related to adults only (n = 36), and 16 related to both Food size, consistency, texture, and temperature of food
adults and children, describing (a) people with or without any were rarely reported in the studies but, when mentioned,
health conditions; (i.e., the general population, who could included descriptions of soft mashed foods (n = 5), solid
have no or multiple health conditions), (b) people with life- food (n = 4), small chopped food items (n = 2), pureed food
long conditions, (c) people with acquired conditions, and (n = 1), crumbly foods (n = 1), hot foods (n = 1), and large

1286 American Journal of Speech-Language Pathology • Vol. 28 • 1283–1297 • August 2019

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Table 2. Food group and type of food in choking event.

Food group Food type (as specified by author) Authors (year, number of cases/% if specified)

Meat Meat (lamb, chicken or pork, sirloin steak, poultry) Balandin et al. (2009), Berzlanovich et al. (1999, 48%),
Berzlanovich et al. (2005, meat/fish: 50%), Blaas et al. (2016),
Dolkas et al. (2007, 17%), Ekberg & Feinberg (1992, n = 24),
Guthrie et al. (2015), Grubbs et al. (1997), Hwang et al. (2010),
Kikutani et al. (2012), Kinoshita et al. (2015, n = 6), Mittleman
& Wetli (1982, 74%), Sridiharan et al. (2016), Tashtoush et al.
(2015), Wick et al. (2006, 29%)
Ground meat Ekberg & Feinberg(1992, n = 2)
Sausages Berzlanovich et al. (1999,19%), Berzlanovich et al. (2005, 20%),
Blaas et al. (2016), Jacob et al. (1992)
Fish Carter et al. (1984), Kikutani et al. (2012, n = 4)
Breads and Bread, garlic bread Aquila et al. (2018), Berzlanovich et al. (1999), Ekberg & Feinberg
grains (1992, n = 8), Gravestock et al. (2007), Irwin et al. (1977),
Kikutani et al. (2012, n = 1), Kinoshita et al. (2015, n = 27),
Mittleman & Wetli (1982), Nagamine (2011, all cases), Wick
et al. (2006)
Mixed bread product with meats (hamburger, Ekberg & Feinberg (1992, n = 14), Grubbs et al. (1997)
hotdog, sandwich, pizza, meat and potato/
spaghetti and meatballs)
Pastries (croissant, cake, pastry meat balls, Berzlanovich et al. (1999), Berzlanovich et al. (2005, 12%),
breadstick, crackers, donuts) Blain et al. (2010), Carter et al. (1984), Guthrie et al. (2015),
Hwang et al. (2010), Ekberg & Feinberg (1992)
Pasta, spaghetti, macaroni, rice, noodles Ekberg & Feinberg (1992), Hwang et al. (2010), Kikutani et al.
(2012, n = 3), Pollak (1985), Wick et al. (2006)
Cooked cereal Ekberg & Feinberg (1992)
Peanut butter and jelly sandwich Dolkas et al. (2007, 4%), Pollak (1985), Wick et al. (2006)
Fruits and Fruit (orange pieces, bananas, small fruit pieces) Berzlanovich et al. (2005, 7%), Blaas et al. (2016), Carter et al.
vegetables (1984), Ekberg & Feinberg (1992, n = 5 fruit/vegetables),
Irwin et al. (1977), Jacob et al. (1992), Kikutani et al. (2012,
n = 7), Mittleman & Wetli (1982), Wick et al. (2006)
Vegetables (beet, brussel sprout, sweet potato/ Blain et al. (2010), Irwin et al. (1977), Kikutani et al. (2012, n = 4),
potato, lima beans, peas) Kinoshita et al. (2015, n = 9), Pollak (1985)
Other Unspecified solid food, semisolid food, creamy Berzlanovich et al. (2005, semisolids: 61%), Chen et al. (2015),
semisolid cereal, soft food Corcoran & Walsh (2003, n = 6/9 cases), Dolkas et al. (2007, 20%),
Ekberg & Feinberg (1992, semisolid: n = 11), Inamasu et al.
(2010, solid: n = 14, semisolid: n = 18), Irwin et al. (1977),
Kikutani et al. (2012, n = 6), Tan et al. (2012)
Small bolus (peanuts, popcorn, and hard candies) Ekberg & Feinberg (1992, n = 5)
Large cheese ball (bocconcini), cheese Finestone et al. (1998), Irwin et al. (1977), Mittleman & Wetli (1982)
Dry crumbly food Hughes et al. (1994), Hwang et al. (2010)
Videofluoroscopy trial foods (jelly, pancake) Hanayama et al. (2008)
Steamed bun Hwang et al. (2010)
Rice cakes/mochi (Japanese glutinous rice cakes) Kiyohara et al. (2018), Kinoshita et al. (2015, n = 21), Usui et al. (2016)
Sushi/sashimi Kinoshita et al. (2015, n = 11)
General snacks Kinoshita et al. (2015, n = 10), Wick et al. (2006)
French fries Mittleman & Wetli (1982)
Peanut butter Mittleman & Wetli (1982)
Vomit Dolkas et al. (2007, n = 3), Sherrard et al. (2001), Wu et al. (2015)
Mixture/multiple foods Wick et al. (2006, 48%)

portion sizes (n = 1). In studies on choking in older people, with disability (e.g., direct support staff [n = 5], nursing staff
modified textured food (e.g., puree, ground meat) was in- [n = 1], mental health staff [n = 1], paramedics [n = 2]), paid
volved in 61% of choking incidents for nonhospitalized staff in non–health-related fields (e.g., restaurant personnel
people (Berzlanovich, Fazeny-Dorner, Waldhoer, Fasching, [n = 1]), and other people who were bystanders (n = 10),
& Keil, 2005). including service users, family members, and the general
public, or the person was alone (n = 4).
People Present During the Incident
Although in some reports the person had been alone Timing of the Incident
at the time of choking, across the studies, there were a wide Reflecting the sudden onset of choking and reli-
variety of people present. When documented, people re- ance on retrospective reports of bystanders, medical
ported as present at the time of choking included disability staff, or autopsy studies, little detailed information on
or health care staff or volunteers working with people the timing of the choking incident was extracted from

Hemsley et al.: An Integrative Review of Choking Incidents 1287

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Table 3. Evaluating the impact of the choking episode: views of staff or victims.

Impact Person who choked Direct support worker/family member

Shock/trauma “Staff described service-user shock as an initial

reaction” (Guthrie et al., 2017, p. 5).
“No physical injuries are described on any of
the near miss choking reports studied but a small
number of cases reported psychological trauma,
stress or pain” (Guthrie et al., 2015, p. 125).
Embarrassed/dread/humiliation “They used terms such as shocked, worried, scared “Staff accounts showed they were also
and panic, while one said ‘I think she were [sic] conscious of the service-user’s
just embarrassed’.” (Guthrie et al., 2017, p. 125). emotional reaction at the time of the
Richard (age 65 years) said that he was “dreading” incident” (Guthrie et al., 2017, p. 5).
eating in public at work events due to his poor
saliva control, recurrent coughing, and choking
episodes that he found “humiliating” and
“embarrassing” (Balandin et al., 2009, p. 201).
“Case 1 was embarrassed by his problem”
(Hughes et al., 1994, p. 19).
Fear “It was frightening; thank heavens it went down without “The emotional stress from being involved
me having to go to hospital. I felt awful because in the incident was clearly related in words
everyone was staring at me” (Balandin et al., 2009, such as ‘scariest’ and ‘most frightening’”
p. 200). (Guthrie et al., 2017, p. 8).
“It’s a very frightening experience” (Balandin et al.,
2009, p. 202).
“I eventually won, but it was a real fright” (Balandin
et al., 2009, p. 200).
Anxiety/worry “Triggered more marked eating and swallowing anxieties” “His wife’s concern was considerable”
(Gravestock et al., 2007, p. 45). (Hughes et al., 1994, p. 19).
“Case 5 repeated this worry, adding that she thought
sometimes she might die from choking” (Hughes et al.,
1994, p. 21).
“Frightened to swallow solid foods in case he choked
again” (Gravestock et al., 2007, p. 45).
Other “A generic description of ‘distress’ at the time of the “I didn’t know, I know we should do, I know
incident was included for reports 19% (n = 11)” (Guthrie the procedure for when to go in for the
et al., 2015, p. 125). abdominal thrust but I was a bit wary of
“5% ( n = 3) recorded…service user’s reaction of ‘panic’” doing it (Alan, line 19)” (Guthrie et al.,
(Guthrie et al., 2015, p. 125). 2017, p. 54).
“Only one report described ‘pain’” (Guthrie et al., 2015,
p. 125).
“All cases of the ‘sudden collapse’ category were
associated with a short-term agony. The remaining
heterogeneous group of cases had a long-term agony”
(Blaas et al., 2016, p. 83).

the studies. Across studies, the choking incidents occurred Events During the Choking Incident
at various times and mainly around mealtimes (n = 5). Two of the studies included personal narrative ac-
However, often, there was no “timing” information counts from the perspective of the person who had choked
mentioned in relation to the choking incidents, or else (Hughes et al., 1994; Sridharan, Amin, & Branski, 2016).
the actual timing of the choking incident could not be One woman with multiple sclerosis described the onset
determined. being marked by “an uncomfortable sensation at the
front of her mouth around her tongue” (Hughes et al.,
1994, p. 19). Her choking at night—when her husband
Setting of the Incident was out—frightened her children (Hughes et al., 1994).
The studies reflected great diversity in the location of In another study (Sridharan et al., 2016), a 57-year-old
the choking incidents reported. Settings where the choking woman reported on voice hoarseness beginning a month
occurred included locations for eating out (n = 10), pri- after choking on meat. In a description of self-rescue,
vate homes (n = 8), and residential care settings (n = 8) “during the choking episode she put her finger into her
and in the course of hospitalization to a variety of hospi- airway and manually removed the bolus” (Sridharan
tal settings (n = 8) and psychiatric hospitals (n = 5). Across et al., 2016, p. 33).
the studies, other locations included schools, in the street In total, 23 papers included the reports of bystanders,
or public vehicle, in hotels, at a picnic, or in unknown witnesses, or researchers on the signs or symptoms at the
locations. moment of choking. These signs and symptoms included

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(a) sudden loss of respiration and/or voice during a meal Discussion
or while taking medications (e.g., Guthrie, Lecko, &
Roddam, 2015), which could be accompanied by a bodily Reducing the Risk of Choking
movement (e.g., clutching neck, moving arms) closely Using a systematic search procedure and integrative
followed by collapse, and (b) behavioral or other environ- review method, we identified the main characteristics of a
mental elements. This is illustrated in the following quota- choking incident and the more frequently reported recom-
tion: “Eyewitnesses uniformly reported that the choking mendations for preventing choking. The wide range of
victim suddenly stopped eating and talking during a meal, contributing factors, and events leading up to choking inci-
could not breathe, became pale, then deeply cyanotic, and dents, reflects a need for services to implement multiple
collapsed” (Berzlanovich et al., 1999, p. 352). In qualitative strategies to reduce choking risk and incidence, particu-
studies, there was some detail on events occurring imme- larly with individuals who are known to be at risk of
diately before the choking incident (e.g., “Eating a hot choking (e.g., people with high support needs in residential
dog at a picnic when he started choking.” ; Grubbs, Kort, care settings). In this section, the five major categories of
Murray, & Ingham, 1997, p. 288]) or the person’s activity recommendations to reduce the risk of adults choking on
(e.g., “had grabbed two hot cross buns and rammed them food are discussed and directions for future research are
into his mouth” [Guthrie et al., 2015, p. 127]) that pro- proposed.
vided information about the event.
1. Modify mealtimes to reduce the risk of choking. The
most frequent strategy reported or suggested to re-
Actions Taken to Clear the Airway duce risk of choking in almost half of the studies
During a choking event, or in immediate response to related to modifying mealtimes in various ways as
it, people acted by giving verbal prompts to cough (Guthrie reflected in the following seven subcategories.
et al., 2015; Samuels & Chadwick, 2006), putting the per-
son in the “recovery position” (Guthrie et al., 2015), and 1.1. Modify food textures. Food texture modifi-
calling emergency services (Dolkas, Stanley, Smith, & Vilke, cations were mentioned in nine studies
2007). People responded to the choking incidents using a (Balandin et al., 2009; Corcoran & Walsh,
wide range of actions: the finger sweep (Dolkas et al., 2007; 2003; Hu, Yi, & Ryu, 2014; Hughes et al.,
Inamasu et al., 2010; Kinoshita, Azuhata, Kawano, & 1994; Hwang et al., 2010; Inamasu et al.,
Kawahara, 2015; Sridharan et al., 2016), backslaps/back-blows 2010; Kiyohara et al., 2018; Samuels &
(Guthrie et al., 2015; Inamasu et al., 2010; Kinoshita et al., Chadwick, 2006; van Bruggen et al., 2014).
2015), the Heimlich maneuver (Blain, Bonnafous, Grovalet, National guidelines for food consistencies
Jonquet, & David, 2010; Corcoran & Walsh, 2003; Fioritti, should be used to guide the implementa-
Giaccotto, & Melega, 1997; Grubbs et al., 1997; Kinoshita tion of texture modifications (Samuels &
et al., 2015; Tan, Chou, & Ko, 2012; Tashtoush et al., Chadwick, 2006), and adaptations to food
2015), the “table maneuver” (Blain et al., 2010), abdomi- texture need to be based on sufficiency of the
nal thrusts (Guthrie et al., 2015), mechanical suctioning airway defense mechanism, cough strength,
combined with the finger sweep (Kinoshita et al., 2015), and calorie intake (van Bruggen et al., 2014).
and cardiopulmonary resuscitation (Grubbs et al., 1997; Only two of the included studies referred to
Inamasu et al., 2010). Other actions taken in response in- enteral tube options (Corcoran & Walsh,
cluded “more sophisticated techniques” when a paramedic 2003; Hu et al., 2014).
arrived (Dolkas et al., 2007, p. 177), “reanimation” (Fioritti 1.2. Avoid problem foods. The wide range of
et al., 1997, p. 517), ambulance transport to a hospital emer- foods described in choking incidents indi-
gency department, or tracheal intubation. cates the importance of chewing and masti-
cation in the oral phase. Avoidance of
Evaluating the Impact of the Choking Episode problematic foods or situations was also
Six studies provided personal insights into what it suggested, along with limiting access to high-
was like to choke or to witness a choking incident (Balandin, risk, inappropriate, or problematic foods (e.g.,
Hemsley, Hanley, & Sheppard, 2009; Blaas, Manhart, Port, chewy, dry, or sticky foods; Balandin et al.,
Keil, & Buttner, 2016; Gravestock, Vekaria, & Hurault, 2009; Hwang et al., 2010; Kiyohara et al.,
2007; Guthrie et al., 2015; Guthrie & Stansfield, 2017; 2018; Morad, Kandel, & Merrick, 2009; van
Hughes et al., 1994). Stories of experience provided insight Bruggen et al., 2014). There was also the sug-
into the impact of choking, particularly the shock or gestion that direct support workers ensure
trauma of choking; embarrassment and humiliation; and that food products associated with choking
feelings of dread, fear, and anxiety or worry about choking are kept away from residents at risk of choking
in the future. Studies reflected an emotional impact of chok- (Morad et al., 2009). As being outside and
ing on both the surviving victim and bystanders including consuming celebratory foods can increase
family members and direct support workers. Quotes from risk of choking, such events should be
studies reflecting these impacts are presented in Table 3. planned and monitored carefully for this

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 risk (Kiyohara et al., 2018; Matsubayashi & positioning the client to reduce the risk of
Ueda, 2016). aspiration (Hu et al., 2014). Blaas et al. (2016)
Despite a strong focus on the responsibility also noted that it was important to look
of individuals to reduce their own risk of beyond “training in swallowing or a change
choking by avoiding problematic foods, there in diet” (p. 86) to also consider the impor-
is little information in the literature reflect- tance of extended mealtimes and a person’s
ing the views on food texture restriction of posture contributing to bolus deaths.
individuals who are at risk of choking or
1.5. Document mealtime management. Good
have choked. Lack of person-centered
documentation and communication about
planning and shared decision making may
mealtimes were also important in strategies
threaten the effectiveness of strategies to
to prevent choking (Blisard et al., 1988; Guthrie
reduce choking risk (Balandin et al., 2009).
& Stansfield, 2017; Samuels & Chadwick,
Recommendations might not be valid or
feasible for individuals and could be 2006). As well as mealtime plans, people
viewed as restrictive practices if the person’s with communication difficulties might need
views and preferences are not taken into communication supports in place to plan,
account. talk about, and evaluate their meals (Guthrie
& Stansfield, 2017). Furthermore, appropri-
1.3. Address problematic mealtime behaviors. ate documentation of mealtime support
Mealtime eating behaviors, eating style, needs should be provided to the person with
and participation in the meal can all be dysphagia (Blisard et al., 1988), and the
modified to reduce choking risk (Cvetkovic, documentation should outline both safe and
Zivkovic, Lukic, & Nikolic, 2017; Guthrie high-risk foods using food examples that the
& Stansfield, 2017; Hughes et al., 1994; Morad person is familiar with or likes (Samuels &
et al., 2009; Samuels & Chadwick, 2006). Chadwick, 2006).
Maladaptive feeding behaviors need to be
considered (Samuels & Chadwick, 2006), 1.6. Modify the mealtime environment. Sugges-
and staff need to be familiar with the person’s tions for changes to the mealtime environment
behavior so that changes over time can be to reduce choking risk appeared in several
managed (Guthrie & Stansfield, 2017). When studies (Balandin et al., 2009; Finestone
assisting people during mealtimes, it is also et al., 1998; Guthrie & Stansfield, 2017;
important to increase their participation in the Hughes et al., 1994; Usui et al., 2016). Envi-
mealtime activity (Guthrie & Stansfield, 2017). ronmental variables can be manipulated
Researchers recommended using smaller particularly in relation to creating a quiet
utensils or cups to reduce the bolus size mealtime environment (Hughes et al., 1994),
(Finestone, Fisher, Greene-Finestone, Teasell, with provision to increase the amount of
& Craig, 1998; Hwang et al., 2010; Irwin, time taken to eat (Balandin et al., 2009;
Ashba, Braman, Lee, & Corrao, 1977; Usui Usui et al., 2016) and to have flexible timing
et al., 2016) or reducing the number of items of meals to account for changes in behaviors
on the person’s plate to decrease impulsive (Guthrie & Stansfield, 2017). This may in-
eating behaviors (Finestone et al., 1998). clude having the person with dysphagia eat
Setting utensils down between bites (Finestone with other people who are effective role
et al., 1998) and pacing the meal (Kikutani, models for appropriate mealtime behaviors
Tamura, Tohara, Takahashi, & Yaegaki, to reduce choking risk (Finestone et al.,
2012) were examples of teaching new meal- 1998). Observers could provide just enough
time routines to prevent choking. These mealtime assistance, ensuring that the per-
strategies are proposed to benefit the person’s son remains alert (Ball et al., 2012), and
safety and also to reduce their dependence on provide encouragement to the person to
others during meals. Providing smaller maintain self-feeding (Smith, Teo, & Simpson,
more frequent meals is also recommended to 2014).
avoid fatigue during meals (Hughes et al., 1.7. Improve mealtime assistance, supports, or
1994). supervision. The importance of improving
1.4. Improve posture during meals. Improving the quality of supervision over a meal was
posture during mealtimes was highlighted in noted in several studies (Balandin et al.,
three studies (Blaas et al., 2016; Hu et al., 2009; Blaas et al., 2016; Corcoran & Walsh,
2014; Hughes et al., 1994), specifically being 2003; Fioritti et al., 1997; Irwin et al., 1977;
seated in an upright position with neck flex- Kikutani et al., 2012; Wu, Sung, Cheng, &
ion (Hughes et al., 1994). Hu et al. included Lu, 2015; Zhang et al., 2018). A person

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 being available to supervise and specifically medications and their side effects (Hsieh, Bhatia,
observe the person eating (Corcoran & Andersen, & Cheng, 1986; Hwang et al., 2010),
Walsh, 2003; Wu et al., 2015) and provide particularly in patients with psychiatric conditions
assistance in the event of choking was (Aquila et al., 2018). There was an increased risk
important (Balandin et al., 2009). The recom- of choking for some patients medicated with sed-
mendation to “monitor” the person’s meal- atives (Chen, Chen, Chan, Lan, & Loh, 2015;
times included monitoring and, if necessary, Dolkas et al., 2007; Irwin et al., 1977), antidepres-
assisting the person to maintain the prescribed sants (Boghossian et al., 2010), extrapyramidal medi-
food modifications at the table (e.g., check- cations (Hwang et al., 2010; Nikolić, Živković,
ing the consistency of foods presented and Dragan, & Juković, 2011), antipsychotics (Hwang
cutting up food; Fioritti et al., 1997; Irwin et al., 2010), drugs with anticholinergic effects
et al., 1977; Wu et al., 2015) and monitoring (Corcoran & Walsh, 2003; Fioritti et al., 1997),
the person in order to recognize the symp- neuroleptic medication (Corcoran & Walsh, 2003),
toms of dysphagia, including extended and hypnotics (Hwang et al., 2010). Side effects of
food intake, coughing at mealtimes, and in- medication affected swallowing by impacting on
creased difficulty managing some consisten- movement of the muscles for swallowing (see Nikolić
cies, and to recognize the potential influence et al., 2011, p. 130) and on saliva production (Aquila
of posture on eating or choking (Blaas et al., et al., 2018). The need to attend to and avoid poly-
2016). pharmacy (Fioritti et al., 1997) and to monitor the
Implementing multiple strategies to reduce level of consciousness of patients at breakfast was
choking risk might pose a challenge in busy also noted (Hwang et al., 2010), along with the
residential care settings, and implementing need to monitor any deterioration in the swallow,
one strategy at a time might reduce the inci- any worsening of reflux symptoms (Ruschena
dence of choking, leading to premature et al., 2003), and the effects of medication-related
abandonment of a useful strategy. Through xerostomia (Aquila et al., 2018). Although medica-
repeated episodes of nonfatal choking, tions of a solid or liquid consistency may be diffi-
people may begin to view the coughing and cult for people with dysphagia to swallow, the risk
choking symptoms as typical and become of choking on solid or liquid medication was rarely
complacent to risk—preferring not to impose mentioned in studies. When people with develop-
restrictions on texture or avoid desirable mental disability or mental health conditions are
but risky foods (Hemsley, Balandin, & prescribed medications with psychotropic or anti-
Sheppard, 2014). For example, promoting cholinergic effects, particularly sedatives, it is vital
a calm environment might be difficult to that their choking risk is monitored and that other
treatments are considered.
maintain if food modifications or restric-
tions are met with resistant behaviors. People 4. Provide multidisciplinary or interdisciplinary services
at risk of choking and their supporters might to manage dysphagia. Fourteen studies contributed
need advice on ways to manage the multiple to this category across the studies.
strategies recommended in the residential
4.1. Adopt a multidisciplinary/interdisciplinary
care setting.
service model. Several studies outlined the
2. Promote rigorous dental and oral hygiene and main- need (a) for a multidisciplinary team and as-
tain dentition. Six studies highlighted the preventive sessment or interventions (Gravestock et al.,
aspect of adequate dentition (Aquila et al., 2018), 2007; Hsieh et al., 1986; Morad et al., 2009;
dental care, and reconstruction starting as early as Samuels & Chadwick, 2006), (b) to use
adolescence (Berzlanovich et al., 2005). Good dental interprofessional assessment, and (c) for
care included good or “aggressive” oral hygiene re- collaboration in relation to clinical diagno-
gimes due to the potential for high levels of oral sis formulation, coordinated care planning,
residue after meals in people with dysphagia (Hu and multiagency service supports (Gravestock
et al., 2014; Inamasu, 2010) and to prevent cavities et al., 2007). Samuels and Chadwick (2006)
and periodontal problems (Kikutani et al., 2012). noted that speech pathologists
Maintaining good dentition with the continuous
must be clear exactly what they have
support of dentists was important particularly in
to offer in the management of
older people to prevent loss of occlusal support
asphyxiation risk. If, as has been
(Kikutani et al., 2012) and unintentional swallowing
found here, the trigger factors include
of loosened dentures (Chung, Lai, Chien, Lin, &
maladaptive eating styles, one
Cheng, 2013).
implication of this finding is that
3. Monitor medication effects and polypharmacy. assessment and management should
Eleven studies highlighted the need to monitor be a joint process carried out with

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 psychologists, behavioural support language pathologists and dietitians, and
workers or occupational therapists. indeed disability and health service pro-
(Samuels & Chadwick, 2006, p. 368) viders, should consider how they will im-
plement the International Dysphagia Diet
4.2. Implement regular screening for choking
Standardization Initiative (Cichero et al.,
or dysphagia. On the basis of the studies
2013; Steele et al., 2015).
reviewed, factors affecting choking, and
the impacts and outcomes of choking, af- 4.3. Assess swallowing and general health. As
fect a diverse range of individuals, with and there is a high rate of second episodes of
without dysphagia. Indeed, less than half choking (Hwang et al., 2010), it is important
of the studies about choking referred to either to assess swallowing skills especially for
the presence or absence of dysphagia in re- those with a history of choking. Video-
lation to the choking incidents outlined. fluoroscopy of the person’s swallow
Early detection, identification, and inter- (Hanayama et al., 2008) improved imag-
vention for dysphagia and mealtime diffi- ing methods (Hughes et al., 1994), and a
culties were recommended to prevent choking comprehensive assessment of their neuro-
on food (Blaas et al., 2016). The multidisci- logical and medical conditions (Fioritti
plinary team need to set up dysphagia et al., 1997) was recommended. It is also
screening protocols (Jacob et al., 1992), in- important to address the person’s overall
cluding screening by nurses, occupational mental and physical health and social needs
therapists, and otolaryngologists (Jacob (Gravestock et al., 2007). Repeated, peri-
et al., 1992). This could involve regularly odic assessment of mealtimes and nutrition
asking people about their eating (Fioritti was also highlighted specifically to take
et al., 1997), using specific questions about account of any changes associated with ad-
swallowing, severity of difficulties, any vancing age (Morad et al., 2009). In partic-
medications, and eating habits (Fioritti ular, family members working with support
et al., 1997). Identifying risk factors for workers and health professionals of people
choking and the precaution measures was with intellectual disability need to be pro-
also emphasized (Berzlanovich et al., 2005; active in monitoring the person’s general
Chen et al., 2015; Guthrie et al., 2015), health needs (Perez et al., 2015), particu-
particularly as people get older and as larly if the person has a history of dysphagia
aging also increases the risk of developing or choking. Assessment should not over-
dysphagia (Blaas et al., 2016). look nutritional status, injury during meal-
There is an urgent need to look beyond times, and dehydration (Chadwick, Jolliffe,
identification of aspiration (i.e., to avoid & Goldbart, 2002) and should lead to
the risk of aspiration-related pneumonia), strategies addressing any visual, dental,
to also consider the risk of choking-related or behavioral issues (Ball et al., 2012).
death in individuals with dysphagia. The
risk factors for choking identified in this re- 5. Implement training and risk management programs.
view (e.g., multiple medications, dentition, There were four categories in study recommenda-
oral hygiene) support use of the Choking tions to reduce choking risk.
Risk Assessment and the Pneumonia Risk 5.1. Implement population-wide, awareness-raising
Assessment scales (Sheppard et al., 2017) strategies. The general public, health pro-
in screening for choking risk. Service man- fessionals, family members, and people
agers need to consider ways to implement with dysphagia or at risk of choking need
regular screening and assessment of indi- to be made aware of (a) symptoms of aspi-
viduals identified as having choking risk ration (Hu et al., 2014) and food/foreign
and seek appropriate health professional body asphyxia risk (Berzlanovich et al., 2005;
advice for further assessment (Sheppard, Kiyohara et al., 2018); (b) signs of choking
Hochman, & Baer, 2014; Tong, Lee, Yuen, as distinct from cardiac events, as emer-
& Lo, 2011). Indeed, choking and swal- gency medical staff do not always recognize
lowing risk assessment should be a routine fatal choking as asphyxiation (Berzlanovich
practice conducted with adults with intel- et al., 2005, 1999; Kiyohara et al., 2018;
lectual or developmental disability (Thacker, Mittleman & Wetli, 1982; see “café coronary”
Abdelnoor, Anderson, White, & Hollins, [Mittleman & Wetli, 1982, p. 1285]); and (c)
2008). With the recommendation to follow the relationship between food choking and
national guidelines (Samuels & Chadwick, associated chronic diseases (e.g., heart dis-
2006), service providers and national pro- ease; Kramarow, Warner, & Chen, 2014).
fessional associations supporting speech- Further education on responding to choking

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 or cardiopulmonary resuscitation should be is discharged home (Corcoran & Walsh,
provided to lay people to improve choking 2003). Additional prompt questions could
outcomes (Inamasu et al., 2010; Kinoshita be added to reporting systems (Guthrie
et al., 2015). In 74% of fatal cases of choking et al., 2015). First aid protocols for choking
reported in Berzlanovich et al. (2005), the should be available in all psychiatric wards
food item was within the glottis and there- (Punia, 2009), and injury prevention pro-
fore likely within reach for removal. Educa- grams should be implemented (Sherrard,
tion on the relationship between high blood Tonge, & Ozanne-Smith, 2001).
alcohol content and risk of choking death is The majority of studies in this review focused
also recommended (Cvetkovic et al., 2017). on the cause of choking based on reports
5.2. Educate health professionals and other of witnesses, bystanders, or autopsy re-
health care staff. Staff working with adults ports. Responding to choking is problem-
at a high risk of choking need improved atic for many bystanders, who need to
awareness of choking risk factors, charac- know how to recognize the signs of chok-
teristics (Chen et al., 2015), response tech- ing, make a differential diagnosis of choking
niques (e.g., use of suction units and long and cardiac arrest, and respond appropri-
handled forceps; Corcoran & Walsh, 2003), ately using recommended strategies. Mem-
and provision of first aid (Fioritti et al., bers of bystander groups (e.g., peers with
1997; Irwin et al., 1977). Staff should be disability, support workers, family members,
trained to reduce future choking risk for in- and older people) may need specifically
dividuals by implementing improved reporting targeted support for recognizing and respond-
systems for choking incidents (Guthrie et al., ing to choking. Studies reviewed reflect the
2015) and by recognizing the subtle risks emotional impact of choking both on the
particular to individuals known to staff person who choked and on bystanders (e.g.,
(Guthrie & Stansfield, 2017). results presented in Table 3). Experiencing or
5.3. Educate support workers, family members, observing choking is often anxiety-provoking
and people with choking risk. Education and distressing (e.g., Balandin et al., 2009;
aimed at the person at risk of choking was Palmer, Herrington, Rad, & Cohen, 2007),
recommended, including education on safe and witnessing a choking event can provoke
eating habits, the importance of exercise to fear and anxiety of choking in other adults
avoid obesity as a risk factor, and compen- with disability and dysphagia (Balandin
satory swallowing techniques (Corcoran & et al., 2009). Hadjikoutis et al. noted that
Walsh, 2003). Older people in particular anxiety around choking was not related to
are in need of education on the impact of the number, duration, or severity of cough-
dysphagia on their quality of life and health, ing and choking episodes in patients with
with individual responsibility emphasized motor neuron disease (Hadjikoutis et al.,
(Berzlanovich et al., 2005), along with facil- 2000), and it is not known whether fear
itating behavior change in the individual of choking, or witnessing choking, in-
and encouragement of healthy eating habits creases or decreases choking risk across
(Berzlanovich et al., 2005; Fioritti et al., 1997). populations. There was little in the re-
Recommendations also suggest education search indicating the types of supports
for family members and support workers that are needed to help support workers
to minimize environmental risk factors for or people with disability and dysphagia
choking. This includes ensuring that food who witness choking, or choking death,
products linked to choking are kept away recover from or manage their feelings af-
from people at risk of choking (Morad et al., ter the incidents.
2009) and that people present at mealtimes
have the knowledge to respond appropriately Limitations and Directions for Future Research
to a choking event (Carter & Jancar, 1984).
This review was limited by its focus on (a) choking,
5.4. Implement risk management and choking and not on the broader field of aspiration pneumonia,
prevention programs. Asphyxia prevention which might have provided additional strategies for reduc-
and dysphagia prevention programs for in- ing the risk of choking in people with dysphagia; (b) articles
patients should be implemented in hospitals from the English literature, when choking is a worldwide
(Corcoran & Walsh, 2003), as not all pa- problem and research published in other languages might
tients follow recommendations; consequently, provide relevant insights on the influence of cultural prac-
a risk/benefit analysis of eating should tices on choking; and (c) peer-reviewed literature, when
be done before a person at risk of choking gray literature, including practice guidelines and disability

Hemsley et al.: An Integrative Review of Choking Incidents 1293

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death review reports, may detail circumstances leading individual’s safe seating and positioning during meals. Vig-
up to choking events and recommendations for reducing ilance in detecting and monitoring choking risk must ex-
choking risk. tend beyond assessment of the individual’s swallowing and
The focus of this review was only on adults, and it recommendations for oral intake, to include consideration
would also be important to similarly review the literature of their mealtime environment, their active involvement
for reports of children choking on food. Observational in decisions about meals, access to excellent oral health
studies of mealtime and between–meal-eating situations care, good medication management, and the provision of
would provide further insights on whether recommended excellent mealtime assistance (e.g., by reducing competing
strategies are being implemented and any barriers and demands for staff in residential care settings). Training in
facilitators to combining the multiple strategies are suggested. managing choking risk to prevent choking, and ways to
Longitudinal studies are required to determine whether respond immediately should choking occur, must extend
identifying choking risk by screening and services imple- beyond disability support staff and health professionals, to
menting the recommended strategies, including better doc- include people with disability and their family members.
umentation or reporting of choking incidents, significantly Incident reporting might also help those involved in a chok-
reduces risk of choking in high-risk groups. ing incident to “make sense” of what happened before,
Further research is needed on the cultural aspects of during, and after the choking incident and serve to inform
choking, including an examination of the views of people the development of service-level strategies and policies to
with choking risk on incidents and their impacts, and the reduce choking risk and the negative impacts of choking
potential of stigmatization or exclusion from group meal- and improve outcomes for all concerned.
time situations when others find eating with someone with
dysphagia or at risk of choking confronting. When consid-
ering the impact of mealtime changes on quality of life,
Acknowledgments
including mental health (e.g., depression, which is common
in patients with dysphagia; Holland et al., 2011), it is vital This research was supported by a grant from the National
Health and Medical Research Council of Australia. Justine Joan
that there is a greater focus on the views and inclusion of
Sheppard’s contribution to this review article was substantial.
people with dysphagia on how to manage and reduce their Prior to her death on March 31, 2018, she collaborated on the
choking risk. This information could provide additional in- study design and analysis and met with the authors on several oc-
sights on risk reduction strategies that are person centered casions in preparing this review article for submission. The authors
and respect the rights of individuals to encounter and man- dedicate this review article to Sheppard and to the people with
age the risk of choking, with appropriate supports in place. developmental disability and their families who benefited from
Considering its potential negative impact on individuals, her life’s work. The authors would also like to acknowledge
families, service providers, and society and its common Rebecca Smith for her research assistance during the first search
physical features across populations, the problem of chok- of the review and The University of Newcastle, Australia, with
whom the first, second, and fifth authors were affiliated during
ing is of central importance to both disability and health
the early stages of this research and who, during this time, admin-
service providers. The participation of the person with dis- istered the grant.
ability and dysphagia in menu planning, food selections,
food preparation, and timing and location of meals is of
vital importance not only in relation to health but also in re-
lation to their mealtime safety and enjoyment. Research on References
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