foods

Review
Food Processing and Nutrition Strategies for Improving the
Health of Elderly People with Dysphagia: A Review of
Recent Developments
Ting Liu 1 , Jianheng Zheng 2 , Jun Du 2 and Gengsheng He 1, *

1 Key Laboratory of Public Health Safety of the Ministry of Education, School of Public Health,
Fudan University, Shanghai 200032, China; [email protected]
2 Nutrilite Health Institute, Shanghai 200032, China; [email protected] (J.Z.);
[email protected] (J.D.)
* Correspondence: [email protected]; Tel.: +86-21-54237271

Abstract: Dysphagia, or swallowing difficulty, is a common morbidity affecting 10% to 33% of

the elderly population. Individuals with dysphagia can experience appetite, reduction, weight
loss, and malnutrition as well as even aspiration, dehydration, and long-term healthcare issues.
However, current therapies to treat dysphagia can routinely cause discomfort and pain to patients.
To prevent these risks, a non-traumatic and effective treatment of diet modification for safe chewing
and swallowing is urgently needed for the elderly. This review mainly summarizes the chewing and
swallowing changes in the elderly, as well as important risk factors and potential consequences of
dysphagia. In addition, three texture-modified food processing strategies to prepare special foods for
the aged, as well as the current statuses and future trends of such foods, are discussed. Nonthermal
food technologies, gelation, and 3D printing techniques have been developed to prepare soft, moist,
and palatable texture-modified foods for chewing and swallowing safety in elderly individuals. In
addition, flavor enhancement and nutrition enrichment are also considered to compensate for the
loss of sensory experience and nutrients. Given the trend of population aging, multidisciplinary
cooperation for dysphagia management should be a top priority.

Keywords: dysphagia; food texture; swallowing; food processing; thickeners; 3D printing

Citation: Liu, T.; Zheng, J.; Du, J.; He,
G. Food Processing and Nutrition
Strategies for Improving the Health of
Elderly People with Dysphagia: A
Review of Recent Developments.
1. Introduction
Foods 2024, 13, 215. https://doi.org/ Around the world, populations are aging at a fast pace. According to the report
10.3390/foods13020215 from the United Nations (the 2022 revision), the share of people aged 65 years or above is
expected to grow from 10% in 2022 to 16% in 2050 and the number of older persons (65 years
Academic Editor: Youngseung Lee
or over) is projected to be more than twice the number of children under age 5 by 2050,
Received: 28 November 2023 reaching 1.5 billion [1]. Consequently, more elderly-oriented products and services need to
Revised: 29 December 2023 be provided to assist older people. Eating ability is a fundamental factor in improving health
Accepted: 5 January 2024 and wellbeing in old age [2]. However, because of poor oral health, sensory impairment,
Published: 10 January 2024 loss of mobility caused by aging or diseases, and even socio-cultural changes, the elderly
often cannot intake enough food, making them vulnerable to malnutrition and immunity
senescence. Swallowing disorder, also known as dysphagia, is a major health threat to the
elderly and presents with symptoms of aspiration, residual or excessive throat clearing,
Copyright: © 2024 by the authors.
cough, hoarseness, atypical breathing, and repeated swallowing [3]. Dysphagia is classified
Licensee MDPI, Basel, Switzerland.
as either an oropharyngeal (oral) or esophageal (non-oral) condition based on the location
This article is an open access article
distributed under the terms and
of the bolus obstruction [4]. The former has been shown to be more prevalent and serious
conditions of the Creative Commons
than the latter in the elderly. In this review, we mainly focus on oral dysphagia and refer to
Attribution (CC BY) license (https:// it simply as dysphagia.
creativecommons.org/licenses/by/ In general, dysphagia can occur at any age, though the risk is higher in those older
4.0/). than 65. The prevalence is 13% in the 65–70 age group, 16% in the 70–79 age group, and

Foods 2024, 13, 215. https://doi.org/10.3390/foods13020215 https://www.mdpi.com/journal/foods

Foods 2024, 13, 215 2 of 24

around 33% in the ≥80 years group [5,6]. Health status is also a prominent risk factor for
dysphagia. The data indicate that dysphagia affects about 68% of the elderly population
living in nursing homes, 30% of those who have been hospitalized, and 13% to 38% of
those living independently [7]. Up to 64% of stroke patients, 93% of dementia patients, and
82% of Parkinson’s disease patients suffer from difficulty in swallowing [4,8]. Among the
many consequences derived from dysphagia, nutritional deficiencies, reduced physical
fitness and body mass, aspiration pneumonia, and dehydration may occur in these patients.
Clinically, stimulation methods and tube feeding are most often used for dysphagic patients
but these methods can easily cause discomfort and pain to patients, as well as reduce the
quality of life for this population.
Diet modification is a non-traumatic and promising treatment for swallowing dis-
orders. At present, this strategy is mainly accepted by hospitals and nursing homes to
meet the special demands of old people with swallowing difficulties by using thickeners or
crushing solids into purees. However, this process requires careful consideration and con-
sultation with nutritionists, physicians, or pharmacists, thus limiting its wide promotion,
especially among the elderly living at home. Therefore, the food industry must facilitate
the healthy aging of this population by applying appropriate technologies. In this review,
we first describe the chewing and swallowing changes in elderly people and introduce
several important risk factors for, potential consequences of, and suitable management of
dysphagia. Then, the dietary characteristics for dysphagia are briefly described based on
clinical compensatory management. As a bridge, we summarize the mechanisms and appli-
cations of gelation, non-thermal technologies, and 3D printing technologies for developing
special food targeted to elderly dysphagic patients. In addition, the strategies for flavor
and nutrition enrichment and the status of foods for elderly dysphagic patients in different
countries are discussed. Finally, several perspectives for further studies are presented. It is
hoped that this review will shed more light on the understanding of dietary requirements
for the elderly with dysphagia at the multidisciplinary level and encourage more studies
on the topic in order to provide comprehensive solutions regarding aged diets.

2. Dysphagia in the Elderly: Causes, Consequences, Assessment, and Management

2.1. Causes and Health Consequences of Dysphagia
Generally, oral food processing can be divided into the following four stages: trans-
portation, mastication, bolus formation, and swallowing preparation [5]. Figure 1A de-
scribes the whole process with a graphic flowchart. In the initial stage, the food is ingested
into the oral cavity through diet tools. When the presence of food is detected by the sensory
system, the tongue and palate function together to gradually transport them to the gum
ridges. Next, mastication starts with the first bite of solid or semi-solid food and then these
foods begin to be cut by the incisors or the canine teeth and then chewed and sheared by
the molar teeth in order to reduce food piece sizes [9]. During this stage, saliva produced by
the parotid, submandibular, sublingual, and mini glands hydrolyze carbohydrates, dissolve
flavor substances, and enable the brain to produce flavor perception. The food granules are
lubricated by saliva to form a cohesive bolus to make swallowing easy and smooth [10].
While being chewed, the bolus is moved to the back of the buccal cavity through pressure
from the tongue and the oral jaw. Finally, when the bolus possesses appropriate rheological
properties, swallowing is triggered through sensory feedback. This swallowing reflex
lasts approximately one second [11]. During the swallowing process, the soft palate in the
mouth firstly moves upward so that the nasal cavity is covered to avoid food reflux. At
the same time, the epiglottis moves downward in order to close the airway before the food
is transported to this position, which can prevent food residues from entering the airway
and causing diseases such as aspiration pneumonia [10]. While the pharyngeal diaphragm
muscle contracts, the food bolus moves into the proximal esophagus [12] (Figure 1A).
In fact, the respiratory and feeding tracts are two completely different passages but at
the pharynx, both passages are shared and therefore need to be well coordinated during
 pneumonia [10]. While the pharyngeal diaphragm muscle contracts, the food bolus moves
into the proximal esophagus [12] (Figure 1A). In fact, the respiratory and feeding tracts
Foods 2024, 13, 215 3 of 24
are two completely different passages but at the pharynx, both passages are shared and
therefore need to be well coordinated during feeding. Then, the food bolus is gradually
pushed into
feeding. the the
Then, stomach through
food bolus contractile
is gradually movements
pushed of the esophageal
into the stomach wall, which
through contractile
may take 8 to 20 s [11].
movements of the esophageal wall, which may take 8 to 20 s [11].

Figure 1. (A) The whole process of oral food processing and swallowing. (B) Several important risk
Figure 1.are
factors (A)associated
The whole process
with dysphagiaof oral food
in the processing
older population.and swallowing.
Notably, (B)decreased
↓ indicates Several function.
important risk
factors are associated with dysphagia in the older population. Notably, ↓ indicates decreased
function.However, physiological dysfunction linked to aging is common in the aged, a group
that is prone to the development of dysphagia. For instance, many older adults have a
greatly reducedphysiological
However, occlusal capacity and with increasing
dysfunction linked toage, the density
aging is common of oral–facial muscles
in the aged, a group
in the elderly significantly decreases, which may lead to a remarkable
that is prone to the development of dysphagia. For instance, many older adults have a reduction in the
contraction
greatly reducedof oral muscles capacity
occlusal during chewingand withand swallowing
increasingand age,an the
inability to coordinate
density of oral–facial
movements well, resulting in dysphagia and related disorders [6,13]. Furthermore, the sali-
muscles in the elderly significantly decreases, which may lead to a remarkable reduction
vary secretion capacity decreases at older ages, affecting the flow-ability of food to form safe
in and
the easy-to-swallow
contraction of boluses oral muscles during chewing and swallowing and an inability to
[14]. Other typical changes include a prolonged oral phase,
coordinate movements
decreased swallow volume,well, resulting
delayed closure inofdysphagia and relatedcervical
the larynx, degenerative disorders
spine,[6,13].
Furthermore, the salivary secretion capacity decreases at older
reduced compensatory capacity of the brain [6], and reduced dental status [15]. Several ages, affecting the flow-
ability of food
important to form
risk factors safe and
associated witheasy-to-swallow
dysphagia in the older boluses [14]. Other
population typical changes
are demonstrated
in Figure 1B. In addition to this, the mixture of aging and related
include a prolonged oral phase, decreased swallow volume, delayed closure of the disorders, including neu- larynx,
degenerative cervical spine, reduced compensatory capacity of the brain [6], and[17]
rological diseases [16], sarcopenia [15], oropharynx lesions [6], and respiratory diseases reduced
is emerging
dental status as a significant
[15]. healthcare concern,
Several important as treatments
risk factors and with
associated medicines targeting
dysphagia insuch
the older
diseases could result in decreased oral ability, taste sensitivity, and xerostomia (mouth
population are demonstrated in Figure 1B. In addition to this, the mixture of aging and
dryness), which in turn triggers swallowing difficulty and pain during feeding [18].
relatedBydisorders, including neurological diseases [16], sarcopenia [15], oropharynx
reason of weakened physiological function and diseases, the elderly cannot intake
lesions [6], and respiratory
foods properly, which in turn diseases
leads to[17] is emerging
malnutrition, as a significant
dehydration, weighthealthcare
loss, and even concern,
as aspiration
treatments and medicines
pneumonia targeting
[16,19,20]. such
Of these, diseases could
malnutrition result in
was found in 17–20%
decreased oral ability,
of elderly
taste sensitivity,
people living alone and xerostomia
with dysphagia,(mouthcompared dryness),
to 37–67% which in turn triggers
of hospitalized swallowing
seniors. Almost
difficulty
50% patientsand with
paindysphagia
during feeding
in nursing[18].
homes were reported to have aspiration pneumonia
within a year of
By reason of weakened
admission [21]. Additionally,
physiological these complications
function and diseases, can the also damage
elderly cannot theintake
mental health of senior citizens by, for example, inducing fear, embarrassment,
foods properly, which in turn leads to malnutrition, dehydration, weight loss, and even depression,
and frustration, which may prolong intensive healthcare, cause adverse prognosis, and
aspiration pneumonia [16,19,20]. Of these, malnutrition was found in 17–20% of elderly
even increase the case fatality rate of patients [6,22]. Dysphagia has multiple impacts on
people living alone with dysphagia, compared to 37–67% of hospitalized seniors. Almost
the health and life quality of older adults and further details are displayed in Figure 2.
50% patients with dysphagia in nursing homes were reported to have aspiration
pneumonia within a year of admission [21]. Additionally, these complications can also
damage the mental health of senior citizens by, for example, inducing fear,
embarrassment, depression, and frustration, which may prolong intensive healthcare,
cause adverse prognosis, and even increase the case fatality rate of patients [6,22].
Dysphagia has multiple impacts on the health and life quality of older adults and further
details are displayed in Figure 2.
Foods 2024, 13, x FOR PEER REVIEW 4 of 24
Foods 2024, 13, 215 4 of 24

Figure
Figure 2. The
2. The impactsofofdysphagia
impacts dysphagia on the
the health
healthand
andlife quality
life of older
quality adults.
of older adults.
2.2. Assessment and Management of Dysphagia
2.2. Assessment and Management of Dysphagia
Coughing and choking are common symptoms of dysphagia [23]. Yet, due to a lack of
Coughingswallowing
awareness, and choking are common
disorder is greatlysymptoms of dysphagia
underrecognized [23].many
and, indeed, Yet, due to a lack
patients
of awareness,
may incorrectlyswallowing
assume itdisorder is greatly
to be normal aging.underrecognized
Consequently, carefuland,questionnaires
indeed, manyand patients
may incorrectly
physical assume may
examinations it toprovide
be normal cluesaging.
for theConsequently, careful questionnaires
assessment of dysphagia. For example, and
the 10-item
physical eating assessment
examinations may provide tool (EAT-10)
clues for[24],
thethe Sydney swallowing
assessment of dysphagia. questionnaire
For example,
the(SSQ)
10-item[8], eating
the water swallowing
assessment tooltest(EAT-10)
(WST) [25], and
[24], theSydney
the volumeswallowing
viscosity swallow test
questionnaire
(V-VST) [26] are commonly used by healthcare personnel for dysphagia evaluation. In
(SSQ) [8], the water swallowing test (WST) [25], and the volume viscosity swallow test (V-
addition, two instrumental analysis methods, flexible endoscopic evaluation of swallowing
VST) [26] are commonly used by healthcare personnel for dysphagia evaluation. In
(FEES, a limited invasive but non-radiation evaluation of dysphagia with pharyngeal
addition,
stage) andtwo instrumental swallow
video-fluoroscopic analysisstudy methods,
(VFSS, a flexible endoscopicof dysphagia
radiation assessment evaluation of
swallowing
with oral, (FEES,
pharyngeal, a limited invasive stages),
and esophageal but non-radiation
are available evaluation of diagnosis
for the clinical dysphagia of with
pharyngeal
swallowing stage) and video-fluoroscopic
dysfunction [16]. swallow study (VFSS, a radiation assessment of
dysphagia Oncewith oral, pharyngeal,
diagnosed, effective dysphagiaand esophageal
managementstages),
can reducearethe
available
morbidity forof the clinical
aspira-
tion andofmalnutrition
diagnosis swallowingasdysfunction
well as its consequences,
[16]. thus recovering swallowing functions
and improving
Once diagnosed,life quality as far dysphagia
effective as possible [27]. Generally, interventions
management can reducefor theswallowing
morbidity of
difficulty are classified into compensatory and rehabilitative types
aspiration and malnutrition as well as its consequences, thus recovering swallowing [7,16]. Rehabilitation is
applied for the acceleration of recovery, including surgical therapy and enteral feeding [27].
functions and improving life quality as far as possible [27]. Generally, interventions for
Yet, 0.4–4.4% of surgeries have been reported to be accompanied by serious complications
swallowing difficulty
requiring further are classified
intervention into compensatory
[3]. Randomized and (RCTs)
controlled trials rehabilitative
have shown typesthat [7,16].
Rehabilitation is applied
the use of enteral feedingfor thenot
does acceleration
reduce the riskof recovery, including
of aspiration and might surgical
lead to therapy
adverse and
enteral
symptoms such as allergy, nausea, vomiting, bloating, and diarrhea [3,28]. In contrast, most by
feeding [27]. Yet, 0.4–4.4% of surgeries have been reported to be accompanied
serious complications
patients requiring further
still rely on compensatory methods intervention
to assist with[3].
safeRandomized
swallowing whether controlled
or nottrials
they have
(RCTs) transfer to rehabilitation.
shown that the use Diet
of modification
enteral feeding (or texture-modified
does not reduce foods,
the riskTMF), ofaaspiration
main
compensation strategy, includes foods that are processed by softening,
and might lead to adverse symptoms such as allergy, nausea, vomiting, bloating, and crushing, and puree-
ing, as[3,28].
diarrhea well asInthickened
contrast,liquids aimed atstill
most patients therely
agedonwith eating dysfunctions
compensatory methods[6,7,29,30].
to assist with
A systematic review involving 26 studies that conducted nutrition intervention through
safe swallowing whether or not they transfer to rehabilitation. Diet modification (or
TMF had a positive impact on weight and mealtime satisfaction [31]. Although more high-
texture-modified
quality follow-up foods,
studies TMF), a main
and clinical compensation
interventions strategy,
are needed includes
to make foods that are
firm conclusions,
processed by softening,
researchers believe thatcrushing, and pureeing,
TMF is a promising as for
strategy well as thickened
improving liquids
nutritional aimed
status [19].at the
aged with eating dysfunctions [6,7,29,30]. A systematic review involving 26 studies that
conducted nutrition intervention through TMF had a positive impact on weight and
mealtime satisfaction [31]. Although more high-quality follow-up studies and clinical
interventions are needed to make firm conclusions, researchers believe that TMF is a
promising strategy for improving nutritional status [19].
Foods 2024, 13, 215 5 of 24

3. Characteristics, Grades, and Testing Methods of Dysphagia Food

Texture and rheological properties are essential for designing dysphagia foods. Recom-
mendations have indicated that patients with chewing and swallowing difficulties should
intake soft, moist, appropriately viscous, and easy-to-swallow foods [5,32]. For solid foods,
it is suggested to reduce hardness so that dysphagia patients can swallow food with little
or no chewing, as well as consider the water content, food uniformity, and particle size; for
liquid foods, the viscosity should be increased to an appropriate level to avoid accidental
aspiration. Unfortunately, each country has its own national terminology and grades of
liquid and solid food. These guides describe details mostly based on sensory evaluation
such as “ thicker than regular liquids”, “similar to the viscosity of pudding or mousse”,
“difficult to absorb with a thick straw”, “it is better to remove with a spoon”, “sticky and
pudding-like food”, “do not necessarily require chewing”, and “smooth, uniformly viscous,
non-granular, muddy food”, which has been comprehensively reviewed by Yang et al. [33].
In order to reduce clinical confusion and develop standard terminology and definitions
to describe food texture and drink thickness for people suffering from dysphagia, as well
as to facilitate consistent communication in the field, the framework of the International
Dysphagia Diet Standardization Initiative (IDDSI) was announced in 2013 [4] and 6 years
later, the completed and objective framework was published. Based on food texture
and rheological properties such as hardness, adhesiveness, cohesiveness, particle size,
and flow rate, this international system contains a continuum of eight levels (0–7: 0–4
for drinks and 3–7 for foods). Certain solid foods share similar textures with thickened
drinks, thus creating an overlap zone in the middle of the framework (levels 3 and 4) [34].
Figure 3A shows detailed definitions of the complete IDDSI framework [35]. In addition,
the IDDSI developed different testing methods to classify foods. As shown in Figure 3B,
the IDDSI flow test is applied by a 10 mL slip-tip hypodermic syringe to quantify the liquid
categories of levels 0–3 according to the remaining sample volume after 10 s of flow [36].
For moderately/extremely thick drinks (level 3/4), further confirmation is required with
the supplemental IDDSI fork drip test and/or spoon tilt test. In addition, purees and soft,
firm, and solid foods are graded using the IDDSI fork drip test, spoon tilt test, and fork
pressure test (Figure 3C).
To date, the IDDSI framework and testing methods have been accepted in hospi-
tals and industry with the practical advantage of being easy to operate and simple to
understand. Nevertheless, researchers have suggested that instrumental measurements
should be considered in order to perform standardized dysphagia management and qual-
ity control [37], such as using rotational shear rheometers to measure the viscosity and
viscoelasticity of thickened fluids or applying texture analyzers and tribometers to test
the mechanical properties (e.g., harness, adhesiveness, and cohesiveness) and tribology
of soft-fish pastes, beef pastes, and chicken stew [32,38]. Meaningfully, Baixauli et al. [39]
utilized different texture analyzer settings to discriminate four commercial thickeners
through penetration tests, forces, and areas. The results showed that the extrusion tests
provided more rheological parameters beyond shear viscosity, such as a cone probe for
adhesivity, a disc probe for cohesiveness, and a sphere probe for penetration and elasticity,
which suggested that it would make sense to characterize and classify dysphagic food by
means of texture analyzers in order to provide safe and effective clinical effects [39].
 quantify the liquid categories of levels 0–3 according to the remaining sample v
after 10 s of flow [36]. For moderately/extremely thick drinks (level 3/4),
confirmation is required with the supplemental IDDSI fork drip test and/or spoon
In addition, purees and soft, firm, and solid foods are graded using the IDDSI fo
Foods 2024, 13, 215 6 of 24
test, spoon tilt test, and fork pressure test (Figure 3C).

Figure 3. (A) The complete IDDSI framework’s detailed definitions of 2019, used for individuals with
Figure 3. (A) The complete IDDSI framework’s detailed definitions of 2019, used for ind
dysphagia, including texture-modified foods and thickened liquids (https://iddsi.org/Framework
with dysphagia, including texture-modified foods and thickened
(accessed on 18 April 2023)). (B) Flow test for levels 0–4 with the IDDSI framework (https://iddsi.
org/Testing-Methods (accessed on 18 April 2023)). (C) Food test for levels 5–7 with IDDSI framework
(https://iddsi.org/Testing-Methods (accessed on 18 April 2023)).

4. Strategies for Food Texture Modification

The physiological dysfunctions arising from the aging process determine that soft,
moist, appropriately viscous, and easy-to-swallow foods are preferred. Pureed and minced
foods are the simplest technologies to obtain TMF. However, the lack of sensory appeal of
these TMF can cause decreased intake and even food refusal [40]. In this section, we will
overview three categories of technologies for TMF production that maintain appearance,
color, and flavor: (1) gelation to modify the rheology of liquids for safe swallowing [32,38];
(2) conventional nonthermal processes for softening food materials such as enzyme im-
pregnation [40], high-pressure processing (HPP) [5], pulsed electric field (PEF) [41], and
ultrasonic (US) methods [42]; and (3) novel 3D printing technology for structural remodel-
ing [32,43].

4.1. Application of Thickeners

To achieve swallowing safety, thickening agents are effectively used in clinical dys-
phagia management to increase the viscosity, smoothness, and cohesiveness of foods and
beverages [4]. The mechanism involves the interaction of thickeners with water molecules
to form a three-dimensional hydrated network structure and achieve a thickening effect or
an increase in viscosity through the entanglement of molecular chains. Such an application
can assist dysphagia-based patients in controlling the swallowing muscles to quickly close
the respiratory tract and open the food pathway, thereby avoiding aspiration risks. At
present, commercially available thickening agents are classified as modified starch-based
and gum-based thickeners, some of which are summarized in Table 1 along with their
characteristics and applications.
Foods 2024, 13, 215 7 of 24

Table 1. Some modified starch-based and gum-based thickeners applied in dysphagia management.

Type Characteristics Thickeners Application Results References

All thickened fluids with a
nectar-like consistency
Distilled water (300 ± 20 mPa·s) appeared to
Tapioca starch Sport drink be shear-thinning fluids with [44]
Orange juice yield stress closely fitting the
power law and Casson
models.
The milk samples showed the
Low-cost highest viscosities, with the
Environmental sensitivity consistency of “pudding”
Modified Potato starch
Starchy flavor Water (>1750 cPs), and milk with
starch- Grainy texture potato starch achieved good [45]
Juice
based Cloudy appearance acceptability.
Milk
thickeners Increased prevalence of The fluids with corn starch
pharyngeal residue Corn starch showed the consistency of
“honey” (351–1750 cPs).
The powder prepared by
Water maltodextrin and soy protein
Maltodextrin Orange juice increased beverage viscosity [46]
Tea with a nectar-like consistency
(51–350 cPs).
Taro paste was found to have
greater softness, less
Taro starch Paste [47]
stickiness, and better
cohesiveness.
Xanthan gum showed good
Fruits
shear-thinning behaviors,
Vegetables
stable properties, excellent
Xanthan gum Water [48,49]
palatability, and a suitable
Milk
texture for dysphagia-friendly
Pork
formulations.
Agar showed low elastic
Agar Pureed banana behavior and was within the [50]
safe-swallowable range.
Carrageenan had a brittle
Good hydration properties Carrageenan Pureed carrots texture; hence, the food was [51]
Environmental stability difficult to swallow.
Gum-based Clear appearance
thickeners Tasteless and odorless Carboxymethyl
Thickened pea It provided a greater viscous
Low risk of aspiration cellulose component and the bolus was [52]
cream
Tara gum easy to swallow.
KGM showed excellent
thickening capacity in water,
Konjac
Water while a significant viscosity
glucomannan [53]
Model emulsions reduction was observed in
(KGM)
model emulsions containing
maltodextrin.
CMCD in both water and
emulsions showed high
Carboxymethylated Water
viscosity, strong shearing [53]
curdlan (CMCD) Model emulsions
behavior, and appropriate
viscoelasticity.
Foods 2024, 13, 215 8 of 24

Table 1. Cont.

Type Characteristics Thickeners Application Results References

Flaxseed gum reduced the
Water
coefficient of friction in water
Orange-flavored
Flaxseed gum and milk but increased the [54]
soy juice
value in soya juice at higher
Skim milk
concentrations.
A significantly lower
concentration of gellan gum
Gellan gum Pureed carrots [51]
Good hydration properties could present similar
Environmental stability properties with xanthan gum.
Gum-based Clear appearance
thickeners Enhanced viscoelastic
Tasteless and odorless properties were observed
Low risk of aspiration Water
when guar gum was
Guar gum Apple juice [49]
dissolved in milk but a
Low-fat milk
reduced extensional viscosity
was found in apple juice.
The incorporation of alginate
beads achieved the sensory
Alginate Distilled water effect of delaying food [55]
entrance into the pharynx and
increasing oral residence time.
cPs: centipoise; mPa·s: millipascal second; both cPs and mPa·s are units of viscosity, 1 cPs = 1 mPa·s.

Modified starches prepared through a gelatinization process are developed to pro-

duce thickened liquids, mainly including modified corn starch, potato starch [45], tapioca
starch [44], taro starch [47], and maltodextrin [46]. For instance, Yang and Lin [44] evaluated
the stability of three fluids (distilled water, sport drink, and orange juice) thickened with
modified tapioca starch and the results suggested that the employed thickener presented
good physical and chemical properties to be potentially utilized for dysphagia-friendly
formulations. In addition to these, non-traditional sources of starch such as quinoa starch
have been highlighted due to their high freeze–thaw stability and additional nutritional
value [56]. Unfortunately, modified starch-based thickeners are not well accepted by
patients on account of the limitations of starchy flavor, grainy texture, and cloudy appear-
ance [38]. Furthermore, their viscosity increases with time, easily causing increased residue
after swallowing. And they may be hydrolyzed by contact with amylase in saliva, leading
to a potential risk of post-swallowing aspiration.
To address these shortcomings, gum-based thickeners with better palatability and
viscosity stability are being explored as new alternatives. In particular, xanthan gum is the
most commercially used microbial polysaccharide secreted by the bacterium Xanthomonas
campestris and its main structure is composed of a β-1,4-D-glucopyranose backbone substi-
tuted on alternate glucose residues with a trisaccharide side chain [57]. As a new generation
of thickening agents, xanthan gum has desirable properties, including high viscosity with a
slippery mouth feel, good hydration properties, time stability, and insensitivity to amylase,
temperature, and pH. It is normally used in dysphagia management to prevent complica-
tions [49]. Cao et al. [48] investigated the effect of a xanthan-gum-based thickening agent on
the incidence of pneumonia and life quality in dysphagia patients aged over 65 years. The
results showed that, compared to the control group, the incidence of aspiration pneumonia
in the experimental group was significantly lower (p < 0.05), while the life quality score
was better (p < 0.001). Similarly, the finding of Chang et al. [58]’s clinical intervention also
indicated that the application of thickening agents could improve swallowing safety. Other
hydrocolloids include agar, carrageenan [50], guar gum [4], gellan gum, carboxymethyl
cellulose [38], and carboxymethylated curdlan (CMCD). Wei et al. [53] investigated plant-
and meat-based diets to provide a good viscous component and a bolus that is easier to
Foods 2024, 13, 215 9 of 24

swallow, as shown in Table 1. More recently, several new natural thickeners are attracting
considerable interest for their additional benefits. Flaxseed gum is a soluble and stable
polysaccharide extracted from flaxseed hulls which contains a valuable natural source of
phenolic compounds that exhibit pharmacological properties such as anti-diabetic, anti-
hypertensive, immunomodulatory, and anti-inflammatory effects and the intake of flaxseed
fiber can improve intestinal transport and promote weight control [59]. Wei et al. [53] found
that konjac glucomannan (KGM) presented an excellent thickening ability in water and a
significant viscosity reduction in model emulsions containing maltodextrin. Given the ben-
eficial characteristics of KGM as dietary fiber, the authors suggested that the antagonistic
effect of maltodextrin on its viscosity could provide an opportunity to use more dietary
fiber in dietary formulations for dysphagia. Similarly, alginate is an anionic polysaccharide,
naturally derived from brown algae, which can undergo ionic cross-linking with calcium
ions in an aqueous solution to form an “egg-box model” gel structure [55,60]. Laguna’s [55]
research has shown that using such alginate microbeads could delay the entry of food into
the pharynx and increase the oral residence time, which would be helpful in designing
special foods for people with swallowing disorders. In addition, alginate has been med-
ically found to form a foamy gel on the surface of gastric contents. This barrier-like gel
can replace the acid pocket at the esophagogastric junction and protect the esophageal and
upper respiratory tract mucosa from acid and non-acid reflux [60]. For this reason, alginate
is also frequently applied in gastric reflux therapy and delivery systems for patients with
dysphagia [61].
Compared to gum-based thickeners, starch-based thickening agents usually present
different rheological properties, such as yield stress and extensional viscosity [57]. Recent
studies have shown that starch-based thickeners require greater mass to achieve viscosity
similar to that of gum-based thickeners [33]. Moreover, sensory perception is important
for the acceptability of thickeners. Some patients do not like the sensory characteristics
of starchy thickeners but age and physiological status have been reported to influence
the perception of liquid viscosity in the oropharynx [33,62]. Studies have demonstrated
that stroke patients with swallowing difficulties expressed a greater taste preference for
modified starch-based thickeners [63]. Yang et al. [33] speculated that such thickeners are
partially digested by salivary amylase in the mouth, creating a sweet taste and reducing
dryness, which in turn makes starch-based thickeners more preferred by older people
with dysphagia. Baert et al. [64] also found that broccoli soup prepared with starch-based
thickeners exhibited superior taste and aroma intensity. On the other hand, two types of
thickeners have different influences on aspiration in dysphagia patients. Xie et al. [65]
found that, compared to starch thickeners, xanthan gum thickeners exhibited better effects
on decreasing the incidence rates of aspiration and pulmonary injury in dysphagia patients,
which was consistent with previous works [33,38]. Nonetheless, partial meta-analyses
have demonstrated that there is no convincing evidence that thickened fluids prevent
pneumonia caused by dysphagia or that they improve life quality [66]. Accordingly, high-
quality clinical trials and long-term observations will be required in future studies. At the
same time, the composition, the optimal dose, application temperature, and therapeutic
range of each thickener, as well as personalized recommendations, should be considered in
clinical treatments.

4.2. Nonthermal Processing Technologies

4.2.1. Enzyme Treatment
Enzyme treatment is the impregnation of foodstuff with enzymes which break down
cell wall components and/or structures leading to softened textures [29]. Papain and
bromelain are commonly used plant proteases for meat tenderization, which is based
on the degradation activity on meat connective tissue proteins and myofibrillar proteins
of meat [67]. For instance, Ribeiro et al. [68] found that the combination of papain and
microbial transglutaminase could be used to develop much softer burgers made from
chicken and beef, contributing to oral comfort during the consumption of these products.
Foods 2024, 13, 215 10 of 24

Similarly, Eom et al. [69] utilized a 1.0% concentration of bromelain and collupulin to
soften the chicken breast and eye of round beef, providing food alternatives for elderly
individuals who have problems with mastication. It is also interesting to note that texture-
modified pumpkin [70] and softened kombu [71] have been developed by using enzyme
impregnation. These products retained their original appearances while being soft enough
to be completely mashed with the tongue and upper jaw, making them ideal for elderly
people. Furthermore, in order to improve this softening effect and its efficiency, enzyme
impregnation is often used with other techniques. Botinestean et al. [72] optimized an
innovative beef product formulation method to achieve reduced chewiness through 120 min
sous-vide cooking and adding papain (0.01 mg/100 g). Based on freeze–thaw enzyme
infusion, senior individuals with poor masticating function can easily enjoy hard and
fiber-rich vegetables such as lotus rhizome and carrot [73].

4.2.2. High-Pressure Processing

High-pressure processing (HPP) is a non-thermal technique by which food is treated
at a pressure of more than 100 MPa through a compressing fluid [74,75]. Due to the abil-
ity to improve the gelation behavior of protein by changing its conformational structure,
HPP has been noted for creating innovative foods, especially meat and meat products.
Figure 4A displays a scheme of changes in the protein structure. Without the application
of high pressure, two or more folded peptide chains or subunits are tightly arranged to
form a quaternary structure, which is maintained by hydrophobic interactions [5]. Fur-
thermore, HPP treatment with 100 MPa–200 MPa disrupts the non-covalent hydrophobic
and electrostatic interactions and hydrogen bonding between protein molecules, which
results in the stretching and unfolding of the quaternary structure of the protein [76]. At a
pressure higher than 200 MPa, the tertiary structure would suffer conformational modifi-
cations: hydrophobic groups previously buried in the internal regions of the protein and
surrounded by a non-polar environment would be exposed to an aqueous environment,
leading to the dissociation into an unstable secondary structure that is present as alpha
helices or beta sheets [5,76]. Such changes also offer the opportunity to lead to protein
denaturation, cohesion, aggregation, and gelation [74,77]. Furthermore, a pressure over
700 MPa irreversibly disrupts the secondary structure into the primary structure, which
is not damaged by HPP, as the amino acid chains are connected by covalent bonds that
hardly rupture [5,78]. Zhang et al. [76] manifested a lower hardness of chicken gels with
increasingly high pressure from 100 to 500 MPa and also suggested that HPP treatment at
≥ 300 MPa could be more suitable for the production of meat-based dysphagia foods. As
reported by Tokifuji et al. [79], pork meat gel prepared at a meat/water (w/w) ratio of 1:1
and treated with 400 MPa for 20 min at 17 ± 2 ◦ C showed good smoothness, softness, and
elasticity. In addition, a VFSS test also revealed that this gel left little residue in the orophar-
ynx, indicating that HPP treatment could be used to create dishes for a dysphagia diet.
Three years later, the same technology and processing parameters were used to prepare fish
meat gels with a meat/water (w/w) ratios of 1:1 and 1:1.5 that conformed to the Japanese
Dysphagia Diet 2013 criteria [80]. Additionally, several researchers have applied HPP
technology to the production of starch-based and fruit-based products with low hardness,
springiness, and chewiness, such as buckwheat starch [81] and apple purée [82], which
could be considered adequate TMFs for people with chewing and swallowing difficulties.
 parameters were used to prepare fish meat gels with a meat/water (w/w) ratios of 1:1 and
1:1.5 that conformed to the Japanese Dysphagia Diet 2013 criteria [80]. Additionally,
several researchers have applied HPP technology to the production of starch-based and
fruit-based products with low hardness, springiness, and chewiness, such as buckwheat
Foods 2024, 13,starch
215 [81] and apple purée [82], which could be considered adequate TMFs for people 11 of 24
with chewing and swallowing difficulties.

Figure 4. (A) Structural changes in proteins under high-pressure processing treatment. The bidirec-
tional arrow indicates that the protein structure is reversibly changed during the process, while the
unidirectional arrow indicates that the structural change is irreversible. (B) Schematic representation
of the pulsed electric field mechanism. The arrow indicates reversible or irreversible perforation of
the cell membrane. (C) Diagrammatic sketch of the impact of ultrasound on meat and ultrasonic
cavitation effect. The red wavy line indicates a series of non-linear changes of acoustic pressure
with time.

4.2.3. Pulsed Electric Field

A pulsed electric field (PEF), a non-thermal technique, is performed by the applica-
tion of short and intense electric field pulses to a food material located between two or
more electrodes [41,83]. In the presence of such short-duration external pulses, the cell
membranes of food ingredients are electroporated, which in turn leads to local structural
changes. Figure 4B illustrates the mechanism of PEF treatment. Depending on electric
field parameters such as intensity, frequency, treatment time, pulse length and shape, and
food material properties, PEF can lead to reversible or irreversible electroporation of the
cell membrane. Specifically, reversible electroporation means that the formation of small
pores is transient and that the cell membrane is resealed after the external field’s impact
has ceased, which can be used to incorporate different bioactive substances into biological
cells [84,85]. However, when irreversible electroporation occurs, permanent membrane
disruption leads to cell breakdown and the leakage of intercellular contents; this is mainly
used for freezing, drying, osmotic dehydration, extraction, or microbial inactivation [41].
Such nonthermal technology has a positive effect on food color and even taste, so it has
been successfully used for meat and plant processing. Huo et al. [86] explored the effects of
different pulse electric field intensities (1.00, 2.25, and 3.50 kV/cm) on the palatable quality
of beef. The results showed that, at 3.50 kV/cm, the hardness, cohesiveness, chewiness,
and elasticity of beef were significantly reduced compared to the control group. This is
similar to the results of Jeong et al. [87], which suggested that the shear force, chewiness,
and hardness of beef decreased as the electric field intensity increased. Such a phenomenon
may rely on the fact that PEF treatment could increase the degradation of troponin and
pro-myosin in beef, resulting in improved tenderness. Moreover, because PEF technology
not only retains heat-sensitive components such as vitamins, carotenoids, and phenols
but also increases the extractability of bioactive compounds, it has been applied to soften
apple, potatoes, carrots [88], and sweet potato tubers [89]. Jin et al. [90] revealed that PEF
treatment caused a softer texture of blueberries but hardly changed the color or appearance.
And after PEF treatment, the anthocyanins and phenolic contents increased by 10% and
25%, respectively.
Foods 2024, 13, 215 12 of 24

4.2.4. Ultrasonic
Ultrasonic (US) is a type of sound wave with a frequency higher than can be heard by
humans (≥20 kHz) [41]. It is considered as another effective technology that can be applied
to improve food texture and quality due to its ability to penetrate various substances.
Depending on the frequency, the US employed in the food industry can be divided into
low-frequency US (20–100 kHz) and high-frequency US (1–10 MHz) [91,92]. Among these,
high-frequency US is commonly used for non-destructive testing, process control, and
quality evaluation as well as for monitoring food packaging materials, as it does not modify
the physical or chemical properties of the material [41,92], while low-frequency US is
useful for generating cavitation through high power levels and, thus, is applied in the
food processing processes of drying, freezing, extraction, emulsification, homogenization,
enzyme inactivation, and sterilization [41,91]. Dong et al. [42] and Alarcon-Rojo et al. [91]
reviewed various studies elucidating the effects of different meat and meat products in
detail, which might lay a foundation for the production of dysphagia-based foods. For
example, Wang et al. [93] found that beef semitendinosus showed an increased myofibrillar
fragmentation index (MFI) value and the proteolysis of desmin and troponin-T after US
treatment with 20 kHz frequency for 20 or 40 min at 3 and 7 days of post-mortem aging,
indicating an improvement in beef tenderness. The mechanism of US for tenderizing meat
relies on the cavitation effect, which can be interpreted as a series of non-linear processes
including the formation, expansion, compression, and collapse of tiny bubbles or cavities
over a short period of time, caused by the propagation of sound waves between positive and
negative pressures [42], which is shown in Figure 4C. At the time of collapse, the bubbles
release high amounts of energy, triggering extreme pressure (50–100 MPa) and temperature
(5500 ◦ C) conditions as well as generating some physical effects such as microstreaming,
jetting, free radicals, and high shear stress, which could cause cell membrane damage
and changes in protein properties. Such effects may contribute to the depolymerization
of actin filaments or the breakdown of myogenic fibrin, which in turn increases the meat
tenderness [41,94]. For starch-based foods and vegetables, US treatment modifies chewiness
mainly by affecting the viscosity of the materials. Sit et al. [95] demonstrated that US
treatment with a 30 kHz frequency for 5 min resulted in the highest solubility, swelling, and
viscosity of taro starch. Anese et al. [96]’s work revealed that the viscosity and lycopene
release of tomato pulp increased with US treatment of 24 kHz frequency for 30 min.

4.2.5. Overview of Mentioned Technologies

It can be seen that the applications of enzyme, HPP, PEF, and US have effects on the
textural and physicochemical characteristics of meat, fish, carbohydrate-based products,
and fruit and vegetables, which provides the possibility to produce dysphagia-oriented
foods (as summarized in Table 2). The advantages of such technologies include negligible
loss of vitamins, nutrients, volatile compounds, and flavor, as well as high convenience
and non-destructiveness [91]. Nevertheless, it is too early to judge which technology
would produce the best results in terms of texture modification. The textures of softened
diets depend not only on the parameters of these techniques but also on the type and
size of raw materials [5]. It has been reported that free radical chain reactions triggered
by the US cavitation effect could promote the oxidation of fat and protein, contributing
to unpleasant flavors [42]. HPP tends to change the color of meat, which is one of the
most important quality features to consider when consuming. Furthermore, different
patients with swallowing disorders may present distinct symptoms and taste preferences,
creating different texture requirements. Consequently, more considerations are necessary
for selecting suitable technology and imaging techniques (such as VFSS) and should
be implemented to assess the suitability and swallowability of foods prepared by these
techniques.
Foods 2024, 13, 215 13 of 24

Table 2. Traditional processing technologies used in texture-modified foods for the elderly.

Technology Applications Processing Conditions Results References

0.2% papain and/or 1% Papain resulted in a pronounced
Beef and chicken
microbial transglutaminase increase in the softness of beef [68]
burgers
for 4 h at 5 ◦ C and chicken.
The hardness of
bromelain-treated chicken breast
Chicken breast and 1.0% bromelain for 24 h at and eye of round beef reached
[69]
eye of round beef 4 ◦C 1.4 × 104 N/m2 and
3.2 × 104 N/m2 , respectively,
while the shapes did not change.
1 g/100 g protease with
Phosphate buffer resulted in a
0.3 mol/L sodium phosphate
Seaweed kombu softened texture and proteolysis [71]
Enzyme treatment buffer (pH 8.0) for 15 h at
resulted in reduced stickiness.
4 ◦C
The pumpkins were softened
Vacuum enzyme
Pumpkins and the treatment had positive [70]
impregnation for 1 h at 36 ◦ C
effects on antioxidant capacity.
Good parameters, such as shear
0.01 mg/100 g papain with force values, chewiness, TPA
Beef meat [72]
120 min sous-vide cooking hardness, cooking loss, and color,
were received.
0.25% cellulase solution with
different vacuum pressures This freeze–thaw treatment can
Lotus rhizome and
(0–0.05 MPa), vacuum times soften foodstuffs but retain their [73]
carrot
(5–30 min), and restoration original shapes.
times (0–120 min)
Meat/water (w/w) ratio of Good smoothness, softness, and
Pork meat gel 1:1 with 400 MPa for 20 min elasticity, and little residue was [79]
at 17 ± 2 ◦ C observed.
Meat/water (w/w) ratio of The food conformed to the
Fish meat gel 1:1 and 1:1.5 with 400 MPa Japanese Dysphagia Diet 2013 [80]
for 20 min at 17 ± 2 ◦ C criteria.
With pressure, the hardness,
HPP Buckwheat
120 to 600 MPa for 20 min swelling, and viscosity [81]
starch
decreased.
At 400 MPa, the active
0 to 600 MPa at 20 ◦ C for
Apple purée compounds were unaffected but [82]
5 min
the viscosity increased.
The condition of 3.50 kV/cm
Beef 1.00, 2.25, 3.50 kV/cm resulted in a reduced hardness [86]
of beef meat.
0.3 to 1.2 kV/cm, 540 pulses
PEF treatment reduced the
Sweet potato tubers of 20 µs pulse width, and [89]
energy required for cutting.
50 Hz
PEF 2 kV/cm electric field
PEF treatment caused a softer
strength, 1µs pulse width,
Blueberries texture and an increased level of [90]
and 100 pulses per second
anthocyanins and phenolics.
for 2, 4, and 6 min
Foods 2024, 13, 215 14 of 24

Table 2. Cont.

Technology Applications Processing Conditions Results References

20 kHz frequency for 20 or An improvement in beef
Beef [93]
40 min tenderness was observed.
The highest solubility, swelling,
US Taro starch 30 kHz frequency for 5 min and viscosity of taro starch were [95]
observed.
An increased viscosity and
Tomato pulp 24 kHz frequency for 30 min lycopene release of tomato pulp [96]
was tested.

4.3. Designing Food Texture with 3D Printing

Three-dimensional printing, known as additive manufacturing, is a layer-by-layer
construction technology in three-dimensional spaces [97,98]. Specifically, it refers to the
process by which material layers are joined or solidified to shape 3D objects in geometrically
complex shapes under the control of computer software. Due to its advantages of high
precision, fast speed, and low cost, 3D printing technology has been considered to have
potential for industrial revolution and has been greatly applied in the areas of biological
organs, healthcare, manufacturing, and construction [99]. In 2007, this technology was
used for the first time by researchers at Cornell University in the food sector to allow
individuals to print out chocolate at home [100,101]. Since then, the application of 3D
printing technology for food fabrication has stimulated the interest of manufacturers
and academia for its potential to customize food products according to necessities and
preferences.
Currently, 3D printing techniques available in food production mainly include
extrusion-based printing (or fused deposition modelling), selective sintering printing,
binder jetting, and inkjet printing [102–105]. Among them, extrusion-based printing is the
most widely used in the food sector due to the multiple choices of printed materials and
simple operation of the printing system [106]. With this technology, a semi-solid or fluid ma-
terial is extruded from the nozzle by power from a syringe, the air, or a screw, then solidified
and deposited layer by layer onto the printer bed [107]. Figure 5 displays the pictorial flow
of the 3D food printing process based on extrusion technology. Indeed, food printing starts
with the pretreatment of food materials and the design of formulations, as the printing
properties of ingredients need to be taken into account [101]. The next stage consists of cre-
ating 3D models through computer-aided design (CAD) (https://www.autodesk.com.cn/
(accessed on 4 January 2024)) or scanning an existing object. Then, the model is transferred
to slicing software, where the model layers are created and parameters such as the layer
height, nozzle speed, extrusion rate, and temperature are set [105]. After that, a G-code is
sent to the printer, which then fabricates the pre-defined structure. Finally, the product is
treated through freezing, baking, or frying to make it edible [43,101,107,108].
As mentioned above, the characteristic of food materials required for extrusion-based
printing is viscous but not too thin, which creates great possibilities for the creation of
3D-printed soft foods to meet the requirements of the elderly and patients with poor
swallowing abilities [106]. For instance, dysphagia-friendly pork and beef products have
been successfully printed using different hydrocolloid additions. For pork paste, samples
containing xanthan gum and guar gum, either independently (0.36%) or combined (0.36%
in proportion 0.5:0.5, 0.7:0.3, and 0.3:0.7), presented excellent rheology and extrusion-
based printability and thus were categorized as potential transitional foods in the IDDSI
framework (levels 5–7) [109]. During the process of printing beef paste, the individual or
mixed addition of cold-swelling (xanthan and guar gum) and heat-soluble (κ-carrageenan
and locust bean gum) hydrocolloids were analyzed and suitable products with different
formulations were classified within IDDSI levels 5–7 through texture profile analysis (TPA)
and IDDSI testing methods [110]. Similarly, other 3D-printed meat products for people
Foods 2024, 13, x FOR PEER REVIEW 14 of 24

manufacturers and academia for its potential to customize food products according to
Foods 2024, 13, 215 15 of 24
necessities and preferences.
Currently, 3D printing techniques available in food production mainly include
extrusion-based printing (or
with swallowing difficulties alsofused
include deposition modelling),
pureed chicken and tuna selective sintering
[111]. When it comes printing,
binder
to vegetable/fruit-based foods, Pant et al. [112] selected three distinct fresh vegetables is the
jetting, and inkjet printing [102–105]. Among them, extrusion-based printing
most widely
(garden peas, used inand
carrots, thebok
food sector
choy), alongdue to the
with multiple (xanthan
hydrocolloids choices of gumprinted
or/andmaterials
locust and
simple operation
bean gum), to printofnutritious
the printingand system [106].
tasty foods. With
Also, this technology,
printed products were a semi-solid
assessed foror fluid
their suitability
material for dysphagia
is extruded from thepatients
nozzle by by the IDDSI
power spoon
from tilt and fork
a syringe, pressure
the air, tests. then
or a screw,
Qiu et al. [113] used apple and edible rose as raw materials, with the addition
solidified and deposited layer by layer onto the printer bed [107]. Figure 5 displays the of xanthan
and basilflow
pictorial seedofgum,
the to
3Dproduce level 5 minced
food printing processand moist
based ondysphagia
extrusionfoods. Black fungus
technology. Indeed, food
had health benefits but required certain chewing efforts [114] and Hypsizygus marmoreus
printing starts with the pretreatment of food materials and the design of formulations, as
by-products with medicinal values [115] were also developed for attractive 3D-printed
the printing
dysphagia properties
diets of ingredients
with the incorporation of need
xanthanto gum.
be taken
Lee et into account
al. [116] used[101]. The and
egg white next stage
consists
alternative food ingredients to study the foods’ foaming properties, rheological properties, (CAD)
of creating 3D models through computer-aided design
(https://www.autodesk.com.cn/
and printability for special diets through(accessed on food
printing 4 January
foams, 2024))
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improve Then, theproperties
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parameters suchtwoas traditional
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freezing, baking, or
as IDDSI levels 4 and 6, respectively. Table 3 lists detailed examples of the production of
frying to make it edible [43,101,107,108].
dysphagia foods using 3D printing technology.

Figure 5. General stages of 3D food printing process based on extrusion technology.

Figure 5. General stages of 3D food printing process based on extrusion technology.
In summary, the 3D printing technique has attracted a significant amount of attention
As mentioned
in food production forabove, the characteristic
its advantage of freedom of to
food materials
design novel required
structuresfor andextrusion-based
textures
printing is viscous
and to develop but not too
personalized thin, which
nutrition creates[119,120].
and flavors great possibilities for the creation
Also, mechanized produc- of 3D-
printed soft foods to meet the requirements of the elderly and patients food
tion simplifies and speeds up the manufacturing process, in addition to reducing with poor
waste [101,105].
swallowing In spite
abilities of this,
[106]. For 3D food printing
instance, for dysphagia has
dysphagia-friendly porktheandfollowing disad- have
beef products
vantages:
been high cost,
successfully limitedusing
printed compatible
different materials, slow mass
hydrocolloid printing,For
additions. andporkunattractive
paste, samples
appearances. Furthermore, a considerable number of consumers have shown concern
containing xanthan gum and guar gum, either independently (0.36%) or combined (0.36%
or even negative attitudes towards the food safety and nutritional values of 3D-printed
inproducts
proportion 0.5:0.5, 0.7:0.3, and 0.3:0.7), presented excellent rheology and extrusion-
[119,121]. Consequently, it is hoped that more alternative ingredients with envi-
based printability andand
ronmental, nutritional, thus were categorized
economic values, such asas potential transitional
surpluses and by-products foods
frominfood
the IDDSI
framework
production or(levels
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sources fromthe process
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algae, can bebeef paste, to
developed thefacilitate
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products with different
sector should be
formulations considered
were classified to meet
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IDDSI levels 5–7for healthiertexture
through foods [122]. Andanalysis
profile
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 attractive
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study through
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Foods 2024, 13, 215 Recently,
foams, Zhang’s research
suggesting the team employed
potential to a similar
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properties using two traditional
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24
properties,
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theincluding intelligence
best formulations methods forand
were thethe
Chinese foodsTable
respectively. for the
3 elderly
lists withexamples
detailed dysphagia, of the mooncake
production of [117]chosen
dysphagia and Qingtuan
foods using
purposes of searching
final mooncake and forQingtuan
potential products
materials, optimizing the printing formulation, and
[118].
3D Through
printing the texture
technology. and IDDSI tests,were categorized
the best as IDDSI
formulations were levels
chosen4 andandthe 6,
predicting the printing
respectively. Table 3 fidelity
lists by means
detailed of machine
examples of the learning
productionandofgenetic algorithms
dysphagia foods or
using
final mooncake and Qingtuan products were categorized as IDDSI levels 4 and 6,
artificial neuraltechnology.
3D printing networks [43]. However, there is a long way to go in terms of raising
respectively. Table 3 lists printing
Table 3. Three-dimensional detailedtechnologies
examples of usedtheinproduction
dysphagia of dysphagia foods using
management.
consumers’ perception, for which safety assessments and extensive advertisements are
3D printing technology.
Food necessary.
Table 3. Three-dimensional printing technologies used in dysphagia management.
Classification by
Products Physical Properties References
Applications
Food Table 3. Three-dimensional printing technologies used in dysphagia IDDSI Testsby
management.
Classification
Table 3. Three-dimensional printingPhysical
Products technologies used in dysphagia management.
Properties References
Applications
Food IDDSI Testsby
Classification
Products Physical Properties Classification by References
Applications
Food Applications Products Physical Properties IDDSI TestsReferences
IDDSI Tests
Samples with hydrocolloids
Pork and beef
presented
Samples lower
with hardness,
hydrocolloids Level 5–7 [109,110]
Porkpastes
and beef cohesiveness, and chewiness
presented
Samples lower
with hardness,
hydrocolloids Level 5–7 [109,110]
Porkpastes
and beef Samples with hydrocolloids
Pork and beef pastes cohesiveness,
presented
presented and chewiness
lower hardness, Level 5–7Level 5–7 [109,110]
lower hardness, [109,110]
pastes cohesiveness, and chewiness
cohesiveness, and chewiness

Garden
Foods peas,
2024, 13, x FOR PEER REVIEW Adding very low amounts of 16 of 25
carrots,
Gardenand peas,bok hydrocolloids
Adding very low
Adding very led amounts
amounts
low toofgreat 3D
of Level 4 [112]
Foods 2024,
Garden 13,carrots,
peas, x FOR PEER REVIEW hydrocolloids led to great 3D 16 of 25
carrots,choy
and bok printability and
hydrocolloids food palatability.
led to great 3D Level 4 Level 4 [112] [112]
Garden
and bok13,peas,
choy Adding very
printability and low
foodamounts of
Foods 2024,
choy x FOR PEER REVIEW printability and food 16 of 25
carrots, and bok hydrocolloids
palatability. led topalatability.
great 3D Level 4 [112]
Foods 2024,
choy13, x FOR PEER REVIEW The addition of xanthan gum
printability
Combining andgum
xanthan foodgumpalatability.
and basil 16 of 25
Combining xanthan and
displayed
basilseed gum good
seedaddition
gum self-supporting
displayed
displayed higher
Blackand
Apple
Apple fungus
and rose
rose Combining
The xanthan gum and
of xanthan gumbasil Level 55
Level 5 Level [114]
[113][113]
capability
higher gumminess,
gumminess, and smoothand
stiffness,
stiffness, surface
self-
seed
displayed
Combining
The gum displayed
good
xanthan
addition higher
self-supporting
gum and
ofability.
xanthan gumbasil
Apple
Blackand rose
fungus and self-supporting
texture.
supporting ability. Level
Level55 [113]
[114]
gumminess,
capability
seed gum
displayed andstiffness,
smooth
displayed
good and self-
surface
higher
self-supporting
Apple
Black and rose
fungus The addition
The addition supporting of xanthan
texture.
of xanthan ability.
gumand
gum Level 5 [113]
[114]
gumminess,
capability and stiffness,
smooth self-
surface
displayed
displayed good self-supporting
good ability.
Black fungus
Black fungus supporting
texture. Level 5 Level 5 [114] [114]
Incorporating andxanthan
capabilitycapability
self-supporting smooth andgum surface and
Hypsizygus smoothbean surface texture.
locust gum showed better 3D
texture.
marmoreus by- Incorporating xanthan gum and Level 5 [115]
Hypsizygus printability, mouth feel, and
products locust bean
Incorporating gum showed
xanthan better 3D
marmoreus
Hypsizygus by- Incorporating swallowing
xanthan gum gum and
easiness. Level 5 [115]
Hypsizygus locust printability,
bean gum mouth
showed feel, and3D
better
productsby- and locust bean
Incorporating gum showed
xanthan gum andLevel 5 Level 5
marmoreus
marmoreus swallowing easiness. [115] [115]
Hypsizygus betterprintability,
3D printability, mouthmouth feel, and
by-products
products locust bean gum showed better 3D
marmoreus by- feel, and swallowing
swallowing easiness.
easiness. Level 5 [115]
Adding printability,
soybean mouthoil andfeel, Arabic andgum
products
swallowing
reduced easiness.
the hardness and
Adding soybean oil and Arabic gum Level 4
Addingadhesiveness
soybean oil andofArabic mooncake.
Mooncake and gumAdding reduced
reduced soybean theoil
the soluble
hardnesshardness
and andArabicandgum (mooncake)
Using soybean Level 4 [117,118]
Qingtuan adhesiveness
adhesiveness
reduced of of
mooncake.
the mooncake.
hardness and Level 6
Mooncake and
Mooncake and Adding polysaccharide
soybean oil decreased
and Arabic thegum
Level (mooncake)
4 (mooncake)
Level 4 [117,118]
Using Usingsolublesoluble
soybeansoybean (Qingtuan). [117,118]
Qingtuan
Qingtuan adhesiveness
hardness and of mooncake.
adhesiveness Levelof 6 (Qingtuan).
Level 6
Mooncake and reduced
polysaccharide
polysaccharide the hardness
decreased the and (mooncake)
hardness Using solubledecreased
Qingtuan.
and adhesiveness soybean
of
the Level 4
(Qingtuan). [117,118]
Qingtuan adhesiveness
hardness and of mooncake.
adhesiveness of Level 6
Mooncake and polysaccharide
Qingtuan. decreased the (mooncake)
Using soluble
Qingtuan. soybean (Qingtuan). [117,118]
Qingtuan hardness and adhesiveness of Level 6
polysaccharide decreased the
Qingtuan. (Qingtuan).
hardness and
Utilizing adhesiveness of
Utilizingegg eggwhite
white andand xanthan
Egg white food xanthan gum led Qingtuan.
to minimal
Egg white food foam gum led to minimal water seepage Level 4–6Level 4–6 [116] [116]
foam water Utilizing
seepageegg andwhite
excellent and xanthan
Egg white food and
foam excellent
stability. foam stability.
gum
Utilizingled to minimal
egg white and water seepage
xanthan Level 4–6 [116]
foamfood
Egg white and excellent foam
gum led to minimal water seepage stability. Level 4–6 [116]
foam Utilizing egg white and xanthan
Egg white food 5. Nutrition and Sensorygum and excellentinfoam
Improvement TMFstability.
In summary, the 3D printing led to minimal
techniquewater seepage a significant
has attracted Level 4–6amount of[116]attention
foam
Owing to physiological dysfunctions
and excellent or/and
foam aging-related
stability.
in food production for its advantage of freedom to design novel structures diseases, impairments in
and textures
eating In summary,
ability and the 3D
sensory printing are
perception technique
common hasinattracted
the older,a significant
which causesamount
reducedof attention
food
and to develop personalized nutrition and flavors [119,120]. Also, mechanized production
in food production
In summary, thefor
3D its advantage of freedom to design novel structures
amountand textures
simplifies and speeds upprinting technique
the manufacturing has attracted
process, a significant
in addition to reducing of attention
food waste
inand to
food develop
production personalized
for its nutrition
advantage ofand flavors
freedom to[119,120].
design Also,
novel mechanized
structures andproduction
textures
[101,105]. In spite of
In summary, thethis,
3D 3D food printing forhasdysphagia has the following disadvantages:
simplifies
and to developand personalized
speeds upprinting technique
thenutrition
manufacturing
and flavors
attracted
process, a significant
in addition
[119,120].
amount
to reducing
Also,unattractive
mechanized
of attention
food waste
production
high
in cost, limited
food production compatible
for its3D materials,
advantage slow
of freedom mass printing,
to design and
novel structures appearances.
and textures
[101,105].
simplifies In spite
andaspeedsof this,
up the numberfood printing
manufacturing for dysphagia
process, has the
in addition following
to reducing disadvantages:
food waste
Furthermore,
and considerable of consumers have shown concern or even negative
hightocost,
[101,105].
develop
limited
In
personalized
compatible
spite of this,
nutrition
3Dsafetymaterials,
food printing
andslow flavors [119,120].
for mass
dysphagiaprinting,
has
Also,
and mechanized
unattractive
the following
production
appearances.
disadvantages:
attitudes
simplifies towards the
and aspeeds food
up the number and nutritional
manufacturing values
process, of 3D-printed
in addition products
to reducing [119,121].
food waste
Furthermore, considerable of consumers have shown concern or even negative
Foods 2024, 13, 215 17 of 24

consumption, thereby leading to deficiencies in energy and nutrients and even malnutrition.
As a result, nutritional fortification and flavor enhancement are highlighted as ways to
accommodate specific needs and alleviate malnutrition in the aged population.
On the one hand, the elderly have an increased demand for nutrients such as protein;
amino acids; many micronutrients, especially vitamins B, D, C, and E; calcium; and dietary
fiber that are linked to body weight, muscle mass, and gut health [15,123]. Garcia et al. [124]
designed a functional food on the basis of the protein hydrolysate from sea cucumber to
specifically meet the nutritional needs of the western elderly. Giura et al. [125] provided
nutritional vegetable purees with significant amounts of proteins (6.1–6.7%) and antioxi-
dant bioactive compounds (43–53 mg phenolic compounds/100 g) for dysphagic people.
Kersiene et al. [126] prepared a stable double emulsion with several bioactive substances
(adding vitamins B6, B12, and C and anthocyanins in the aqueous phase and vitamins A
and D3 in the oil phase) for formulations tailored to the elderly, which showed that the
encapsulated compounds were stable and such active substances could be released during
digestion. Xie et al. [120] considered that 3D food printing is crucial to meet requirements
for the elderly regarding energy supplementation (protein enrichment and fat reduction),
flavor regulation, and nutrition balance. Their review demonstrated that the addition of
whole eggs, whey protein, oats, and peanuts in 3D-printed food increased the nutritional
profiles. And 3D-printed emulsion gels or oleogels could include bioactive substances in
order to promote the health of elderly people. Furthermore, Costa et al. [127]’s dietary study
suggested that dysphagia patients without nutritional risks should consume 1750 kcal
of energy (25 kcal/kg/day), 70 g protein, and 1750 mL water/day, while 2037 kcal of
energy (35 kcal/kg/day), 90 g protein, and 2000 mL water/day need to be provided for
malnourished patients. In the market, IFF Nourish® has launched a thickening agent
compounded by xanthan gum and guar gum. The solution also considers the addition of
protein, fiber, and probiotics to improve nutritional deficiencies in elderly patients with
swallowing difficulties. Maruha Nichiro Corporation (https://www.maruha-nichiro.com/
(accessed on 2 May 2023)) in Japan developed a series of products called “Protein 21”,
which contain more than 21 g of protein per 100 g of ingredients, specifically for the elderly,
meeting the requirements for a low portion but high nutrition.
On the other hand, it has been reported that the elderly present a greater preference
for taste-fortified foods [14,15]. Natural ingredients with intense flavors, such as soy sauce,
garlic, onions, ginger, basil, and leeks, increased the average energy intake among el-
derly hospitalized patients by 13–26% [128]. A recent study formulated different protein
beverages with the same viscosity for elderly people with dysphagia, showing that the
beverages flavored with meat broth received higher comfort and ease scores compared
to the beverages flavored with mushroom [129]. Other methods, such as microencapsula-
tion of effervescent powders and tiny high-pressure bubbles of carbon dioxide, were also
applied to change the flavor of pureed food by promoting the activation of the trigemi-
nal pathways [14,130]. It is worth noting that there is significant heterogeneity in taste
and smell impairment, which prevents flavor enhancement from being widely applied.
Ribes et al. [131] suggested that packet sauces might be an alternative way, since the elderly
could choose according their preferences and add them as needed.

6. Current Aged Food Status Based on Dysphagia

In general, meals for older adults can be divided into regular and soft foods. Elderly
people with normal chewing abilities can obtain regular meals through home cooking
or institutional supply, while soft foods are more preferred for people with chewing and
swallowing dysfunction or for the oldest of the elderly. Japan has been an aging society since
the 1970s, which has ignited the idea of developing “care food”. In 2002, the Japan Care
Food Association was established and issued the universal design food (UDF) standard,
which involves adjusting the shape, texture, and other aspects of processed foods according
to the eating ability of the consumer. Since then, several initiatives to guide diets for the
elderly were issued in Japan, including the Dysphagia Diet in 2013 and the “Smile Care”
Foods 2024, 13, 215 18 of 24

food in 2015. “Smile Care” food is categorized using different color labels, with blue
for normal individuals without chewing or swallowing problems, yellow for those with
chewing disorders, and red for those with swallowing disorders. To date, approximately
70 companies in Japan have developed aged-care foods, such as Maruha Nichiro, Kewpie,
Meiji, Morinaga, etc. (https://www.udf.jp/outline/members.html (accessed on 2 May
2023)), driving the market’s rapid growth for 10 consecutive years. The total domestic
market of nursing, elderly and therapeutic foods reached at JPY 173.6 billion in the fiscal
year of 2019 in terms of the manufacturer’s shipments [14]. Furthermore, certain food
companies in South Korea have exploited various soft foods through enzyme technology,
such as rice cakes, soft fish, grilled meat, and even burger steak with insect powder, which
are especially suitable for elderly people to intake and digest [14]. Hormel Health Labs,
established in America, provides a full range of safe, affordable, and tasty aged foods for the
population with dysphagia, including Thick & Easy® pureed foods, dessert purees, and tea
sticks (https://www.hormelhealthlabs.com/products/condition/dysphagia-swallowing
difficulties/ (accessed on 2 May 2023)). Nutricia (Fulda, Germany) and Nestlé Portugal
S.A. (Linda-a-Velha, Portugal) also commercially developed starch and gum thickeners for
dysphagia-oriented clear liquids such as Nutilis® and Boost® Nutritional Pudding [40].
However, compared with the sound aged food industry in foreign countries, this
market in China is relatively lacking. At present, there are few varieties of food specially
exploited for the elderly, most of which are cakes, biscuits, paste-type foods (oatmeal paste
and sesame paste), and prepared milk powder with good palatability for swallowing.
However, such foods cannot meet the daily nutritional supplement needs of senior citi-
zens and the changes in sensory level among the aged is less considered in food design.
Kang et al. [132] used a cross-sectional survey to collect and analyze the nutritional claims
of 220 prepackaged aged foods in China. The results showed that the types and contents of
nutrients added to the powdered dairy products varied and that certain products claiming
to be “nutritional formulas” could not meet the physiological requirements of the elderly.
In addition, although pastry products can be chewed and digested easily, the contents of
fat, sugar, and salt are commonly high, which is not suitable for long-term consumption by
the elderly. Consequently, it is necessary to strengthen the research on geriatric food and
nutrition in order to meet the diversified health needs of Chinese elderly people at different
levels.

7. Conclusions and Future Prospective

Dysphagia is a common problem with a higher prevalence in the elderly. People with
swallowing dysfunction are more susceptible to suffering from malnutrition, dehydration,
aspiration pneumonia, or even death. Therefore, developing soft, moist, and palatable
texture-modified diets is pressingly needed. This review clarifies changes in the physiology
of oral processing and swallowing in the elderly. According to the characteristics of
dysphagia foods, traditional non-thermal technologies (enzyme treatment, HPP, PEF, and
US), gelation, and 3D printing for chewing and swallowing safety in older individuals
are summarized herein. Meanwhile, flavor enhancement and nutrition enrichment are
considered to compensate for the loss of sensory and nutrients.
It should be pointed out that there are still multiple challenges in exploring special
foods for the elderly with dysphagia. Firstly, the IDDSI framework has provided feasible
testing methods and grading criteria for dysphagia-oriented food texture but it is easily
affected by subjective factors. Additional rheological parameters, such as the viscosity,
viscoelasticity, hardness, cohesiveness, adhesiveness, and tribology of food boluses during
swallowing, remain to be investigated, which will constitute evidence for quality criteria
and clinical guidelines. Next, it is noticeable that there are limited and disjointed com-
prehensive research studies on the long-term impacts of thickened fluids and TMF on
mastication and digestion in the elderly to some extent. Bolus formation and disintegration
determine the rate of nutrient absorption and release into the body. In this regard, an
in vitro dynamic simulation system particularly targeting elderly individuals will become
Foods 2024, 13, 215 19 of 24

meaningful and valuable and it may shed more light on the design of aged foods. Thirdly,
we should attach importance to elderly individuals with co-morbid conditions such as
hypertension, diabetes, and sarcopenia, who have special dietary demands such as low salt,
low sugar, or high protein. Designing such foods requires an integrated consideration of nu-
trition, taste, texture, and medical effect. Undoubtedly, the advance of aged foods requires
strengthened multidisciplinary cooperation with nutrition, food technology, geriatrics, and
healthcare and is essential to tackling complex challenges associated with designing and
developing suitable diets for the elderly with swallowing disorders. Addressing the above
limitations will provide a more complete understanding of the dietary requirements of
older adults with dysphagia and will contribute to improved solutions for healthy aging.

Author Contributions: T.L.: conceptualization, software, and writing—original draft and manuscript
revision; J.Z.: framework designing, formal analysis, and review and editing; J.D.: formal analysis
and visualization; G.H.: conceptualization, supervision, and review and editing. All authors have
read and agreed to the published version of the manuscript.
Funding: This review received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: Author Jianheng Zheng and Jun Du are employed by the company Nutrilite
Health Institute. The conclusions and interpretations provided, based on the scientific data reviewed,
are those of the authors and not of the employer or funding agencies of the study. They participated
in the concept, formal analysis and framework in the review. The role of the company was to provide
information related to aged foods. The remaining authors declare that the research was conducted
in the absence of any commercial or financial relationships that could be construed as a potential
conflict of interest.

Nomenclature
CAD Computer-aided design
CMCD Carboxymethylated curdlan
EAT-10 10-item eating assessment tool
FEES Flexible endoscopic evaluation of swallowing
HPP High-pressure processing
IDDSI International Dysphagia Diet Standardization Initiative
KGM Konjac glucomannan
MFI Myofibrillar fragmentation index
PEF Pulsed electric field
RCTs Randomized controlled trials
SSQ Sydney swallowing questionnaire
TMF Texture-modified foods
TPA Texture profile analysis
UDF Universal design food
US Ultrasonic
VFSS Video-fluoroscopic swallow study
V-VST Volume viscosity swallow test
WST Water swallowing test

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