Texture Modification Technologies and Their

Opportunities for the Production of Dysphagia

Foods: A Review
Sirada Sungsinchai, Chalida Niamnuy , Pattra Wattanapan, Manop Charoenchaitrakool, and Sakamon Devahastin

Abstract: Dysphagia or swallowing difficulty is a common morbidity experienced by those who have suffered a stroke
or those undergone such treatments as head and neck surgeries. Dysphagic patients require special foods that are easier
to swallow. Various technologies, including high-pressure processing, high-hydrodynamic pressure processing, pulsed
electric field treatment, plasma processing, ultrasound-assisted processing, and irradiation have been applied to modify
food texture to make it more suitable for such patients. This review surveys the applications of these technologies for
food texture modification of products made of meat, rice, starch, and carbohydrates, as well as fruits and vegetables.
The review also attempts to categorize, via the use of such key characteristics as hardness and viscosity, texture-modified
foods into various dysphagia diet levels. Current and future trends of dysphagia food production, including the use of
three-dimensional food printing to reduce the design and fabrication time, to enhance the sensory characteristics, as well
as to create visually attractive foods, are also mentioned.
Keywords: carbohydrates, fruits and vegetables, meat, nonthermal processing, three-dimensional printing, swallowing

Introduction
Dysphagia is a symptom that refers to difficulty or discomfort
during the progression of alimentary bolus from the mouth to the
stomach (Rofes et al., 2011). This condition is commonly experi-
enced by patients who have suffered a stroke or other neurological
disorders. Around 33% of all stroke patients and up to 50% of all
patients with neurological conditions have indeed been reported
to suffer dysphagia (Aslam & Vaezi, 2013; Clavé & Shaker, 2015).
Dysphagia may also be caused by a consequence of treatment in
patients with head and neck cancers (Pedersen, Wilson, McColl,
Carding, & Patterson, 2016; Rofes et al., 2011). In addition,
dysphagia is prevalent among elderly. Such a prevalence is reported
to be around 13% among people who are 65 to 70 years of age,
16% among those who are 70 to 79 years old, and 33% among
those who are ≥80 years old. The symptom affects up to 47% of
frail hospitalized elderly patients and more than 50% of elderly in
CRF3-2019-0101 Submitted 4/22/2019, Accepted 7/28/2019. Authors
Sungsinchai, Niamnuy, and Charoenchaitrakool are with Dept. of Chemical Engineer-
ing, Faculty of Engineering, Kasetsart Univ., Bangkok, 10900, Thailand. Author
Niamnuy is with Research Network of NANOTEC-KU on NanoCatalysts and
NanoMaterials for Sustainable Energy and Environment, Kasetsart Univ., Bangkok,
10900, Thailand. Author Wattanapan is with Dept. of Rehabilitation Medicine, Fac-
ulty of Medicine, and Dysphagia Research Group, Khon Kaen Univ., Khon Kaen,
40002, Thailand. Author Devahastin is with Advanced Food Processing Research
Laboratory, Dept. of Food Engineering, Faculty of Engineering, King Mongkut’s Univ.
of Technology Thonburi, Bangkok, 10140, Thailand. Author Devahastin is with
The Academy of Science, The Royal Society of Thailand, Dusit, Bangkok, 10300,
Thailand. Direct inquiries to author Niamnuy (E-mail: fengcdni@ku.ac.th).
nursing home (Wirth et al., 2016). Dysphagia can also occur in
persons with cerebral palsy due to motor impairment, abnormal
neurological maturation, sensory deficits, impaired esophageal
motility, and gastroesophageal reflux disease (Yi, Oh, Seo, Shin,
& Bang, 2019). Patients experiencing dysphagia have a higher
risk of choking and food aspiration during eating or drinking.
This can lead in turn to a variety of complications, including
lung infection, which result in prolonged hospitalization, frailty,
illness, anxiety, and even decreased rate of survival (Icht et al.,
2018). Dysphagic patients also have a tendency to suffer weight
loss as well as malnutrition and dehydration. Therefore, it is
critically important for these patients to consume foods that are
easy to masticate and safe to swallow (Pedersen et al., 2016;
Tokifuji, Matsushima, Hachisuka, & Yoshioka, 2013). Ingestion of
texture-modified foods and thickened fluids is among alternative
choices for persons with dysphagia (Cichero et al., 2013).
Food texture modification has routinely been conducted to
enhance the quality and safety of foods. Foods containing liquids
can, for example, be thickened by increasing their viscosity to
prevent aspiration; this in turn allows a higher amount of food
intake for dysphagic patients (Kouzani et al., 2017). Recently,
alternative technologies, including those involving the use of
high-pressure, hydrodynamic pressure, pulsed electric field (PEF),
plasma, ultrasound, and irradiation, have been applied to modify
the texture (for example, hardness, adhesiveness, cohesiveness),
sensory characteristics (aroma and flavor), and to maintain the
nutritional value and extend the shelf life of an array of food
materials (Jin, Yu, & Gurtler, 2017; Yoshioka, Yamamoto,
Matsushima, Hachisuka, & Ikeuchi, 2016). It is therefore of


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1898 Comprehensive Reviews in Food Science and Food Safety r Vol. 18, 2019 doi: 10.1111/1541-4337.12495
Texture modification for dysphagia foods . . .
interest to examine the ability of these technologies to modify
foods to suit the need of dysphagic patients.
The objective of this review is to survey the applications of
various alternative technologies for food texture modification and
enhancement of the nutritional functionality of products made
of meat, rice, starch and carbohydrates, as well as fruits and veg-
etables. This review also attempts to categorize, via the use of
such key characteristics as hardness and viscosity, texture-modified
foods into various dysphagia diet levels as defined by the universal
design foods concept (Japan Care Food Conference, 2016). Fi-
nally, current and future trends of dysphagia food production are
mentioned.
Dysphagia
Pathophysiology and etiology of dysphagia
Dysphagia is the condition involving difficulty or even impos-
sibility to swallow liquids, solids (or semisolids) or medication and
can occur during any phase of swallowing, namely, oral, pharyn-
geal, or esophageal phases (Loret, 2015; Stegemann, Gosch, &
Breitkreutz, 2012). Dysphagia can be classified as oropharyngeal
and esophageal dysphagia (Spieker, 2000; Yi et al., 2019). Oropha-
ryngeal dysphagia can cause bolus remaining in the oral cavity or
transport such a bolus toward the larynx, resulting in residue being
trapped in the oropharynx or food aspiration. Therefore, the ma-
jor symptoms of oropharyngeal dysphagia are difficulty initiating
swallowing, coughing, choking, and gagging during swallowing.
In the case of esophageal dysphagia, it can result in the retention
of food and liquid in the esophagus after swallowing. The main
symptoms of esophageal dysphagia are sensation of food sticking
in the chest and symptom of gastroesophageal reflux disease such
as heartburn and belching (Spieker, 2000). Weight loss, malnutri-
tion, and dehydration in dysphagic patients may also occur in the
case where inadequate quantities of food and water can be con-
sumed (Alagiakrishnan, Bhanji, & Kurian, 2013; Stegemann et al.,
2012). Aspiration of small particles or liquids can lead to aspiration
pneumonia, whereas aspirating large pieces of food can lead to
airway obstruction, which may in turn lead to severe hypoxia and
death (Cichero et al., 2013).
Oropharyngeal dysphagia can occur as a consequence in
patients with head and neck cancers (Pedersen et al., 2016),
particularly in patients with oral cavity and oropharyngeal
cancers undergone radiotherapy (RT), chemotherapy (CT),
chemoradiotherapy (CRT), or surgical treatment. RT and CRT,
in particular, are associated with increased risk of nutritional
deterioration. This is because such treatments lead to losses in jaw
mobility, taste sensitivity and perception as well as dry mouth (also
referred to as xerostomia), difficulties in swallowing, and pain
when eating (Epstein, Villines, Singh, & Papas, 2017; Rofes et al.,
2011).
Oropharyngeal dysphagia is also one of the most common mor-
bidities after stroke, with a reported incidence of 29 to 81%; the
symptom is also associated with various systemic or neurological
diseases (Huang et al., 2014; Rofes et al., 2011). Oropharyngeal
dysphagia has been shown to occur in patients suffering differ-
ent types of neuromuscular diseases such as Alzheimer’s dementia,
vascular dementia, dementia with Lewy body, Parkinson’s disease
dementia, frontotemporal dementia, brain stem tumors, and cere-
brovascular accident (Alagiakrishnan et al., 2013; Spieker, 2000).
Although it has been reported that half of patients suffering dys-
phagia may recover after 2 weeks after stroke onset, the other
half might retain a swallowing disorder along with other related
complications, including aspiration pneumonia and malnutrition.

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Because dysphagic patients have difficulty ingesting oral nutrients,
it is essential to provide food that does not induce aspiration in
order to maintain favorable nutritional and health conditions of
the patients.
Esophageal dysphagia can occur in patients with various types of
neuromuscular disorders such as achalasia, spastic motor disorders,
scleroderma, and esophageal tumor. In addition, an often over-
looked cause of esophageal dysphagia is the patient’s treatments
such as radiation-, chemical-, and medication-induced dysphagia
(Spieker, 2000).
Desired characteristics of dysphagia foods
Dysphagic patients often have inadequate caloric intake and are
at a higher risk of nutritional deficiency. One possible means to
alleviate this inadequacy is through the consumption of texture-
modified foods, which are easier to chew and swallow; such foods
must also exhibit desirable nutritional value and are ready to eat in
much the same way as regular food. Information provided by the
Juravinski Cancer Centre (2016), for example, indicated that foods
for head and neck cancer patients after RT and/or CT should be
soft and moist; these may include such foods as soups, puddings,
yogurts, jellies, apple sauces, custards, gelatins, smoothies, and soft
cookies or baked goods in milk. Such foods should preferentially
exhibit safe eating characteristics (for example, ability to avoid
choking) and give sensory enjoyment (for example, having
good taste) (Aguilera & Park, 2016). The European Society
of Parenteral and Enteral Nutrition and American Society for
Parenteral and Enteral Nutrition also recommended that ambulant
and bedridden patients with cancer should have daily energy
intakes of 30 to 35 and 20 to 25 kcal/kg body weight, respectively;
minimum daily protein need of 1 g/kg body weight and target
need of 1.2 to 2 g/kg body weight should be observed (Arends
et al., 2006; Giles, Kubrak, Baracos, Olson, & Mazurak, 2016).
Costa, Carrion, Puig-Pey, Juarez, and Clave (2019) suggested
the energy requirements of 25 kcal/kg/day for elderly with
dysphagia but otherwise having normal nutritional status or early
risk of malnutrition and 35 kcal/kg/day for malnourished elderly
with dysphagia. Iwamoto, Higashibeppu, Aroika, and Nakaya
(2014) indeed illustrated that patients who consumed less than
22 kcal/kg/day during the acute dysphagic period experienced
significantly poorer recovery from the symptom when compared
with those who consumed more than 22 kcal/kg/day.
Texture-modified foods is a term that refer to foods with soft
texture; the softening may be due either to physical or chemical
modification to reduce the risk associated with choking (Aguilera
& Park, 2016; Cichero et al., 2013). Food texture recommended
for dysphagia diets should be soft, moist, elastic, smooth, and
easy to swallow (Tokifuji et al., 2013; Yoshioka et al., 2016).
Sticky and adhesive textures as well as thin liquids should be
avoided since these textures can cause food residue to accumu-
late in the oropharynx and may lead to aspiration after swallowing
(Park, Kim, Lee, & Park, 2017). According to the International
Dysphagia Diet Standardization Initiative (IDDSI) framework, a
global initiative recommending the implementation of standard-
ized textures terminology throughout the world, dysphagia diets
can be classified into eight levels (0 to 7). The syringe flow test
classifies IDDSI levels 0 to 3 based on the rate of flow. A fork
pressure test, on the other hand, is best used to assess foods of
levels 4 to 7 (Cichero et al., 2017; IDDSI, 2016). Note that the
pressure exerted by human tongue during swallowing is around
17 kPa (Steele, Molfenter, Péladeau-Pigeon, Polacco, & Yee,
2014), which is equivalent to the pressure exerted by foods of
Texture modification for dysphagia foods . . .
Figure 1–Texture-modified foods (diet levels 4 to 7) for dysphagic
patients (modified from IDDSI, 2016).
levels 4 to 7. Foods classified as levels 4 to 7 are therefore noted
in this review as texture-modified foods for dysphagic patients
(Figure 1). Level 4 (pureed) does not require chewing, but is co-
hesive enough to hold its shape on a spoon; level 4 foods include
such products as potato purée, carrot purée, and avocado purée.
Level 5 (minced and moist) represents soft and moist foods with
no separate thin liquid; small lumps (of 2 to 4 mm in size) may be
visible within the foods and minimal chewing is required. Level 5
foods include such items as minced meat and fish, mashed fruits,
fully softened cereal, and rice (not sticky or glutinous). Level 6 (soft
and bite-sized) foods can be mashed/broken down with pressure
from fork, spoon, or chopsticks and are soft, tender, and moist
throughout but with no separate thin liquid; chewing is required
for this class of foods, which include cooked tender meat, cooked
fish, and steamed or boiled vegetables. Level 7 is regular foods with
various textures (for example, hard, crunchy, and naturally soft).
Any food can be defined by its textural characteristics, with
approximately two dozen separate characteristics being identified.
However, only eight of these characteristics are considered as the
most significant in relation to dysphagia. Descriptions that are used
for food texture are similar to those used for chewing and swal-
lowing; hardness, adhesiveness, cohesiveness, firmness, fractura-
bility (biteability), springiness, viscosity (applied only to liquids),
and yield stress are used for such a purpose (National Dysphagia
Diet Task Force, 2002). For dysphagia diets, such parameters that
mimic human textural perception as hardness, adhesiveness, and
cohesiveness can be used. Hardness is defined as the force necessary
to attain a given deformation of food at the first bite (Nishinari,
Fang, & Rosenthal, in press). Adhesiveness is defined as the force
required to remove the material that adheres to a mouth during
normal eating (Park & Han, 2016), whereas cohesiveness is defined
as the ability of the food to form a united whole and withstand
compression (Inamoto et al., 2018).
When taking food into the mouth, mastication starts with the
first bite of solid or semisolid food and is conducted by the
forcible occlusion of the opposing edges of the upper and lower
incisors (stage i) (Laguna, Sarkar, & Chen, 2017) as shown in Fig-
ure 2. The food is reduced to particulate form during chewing
(stage ii), and saliva is secreted from the oral cavity to help lubricate
and prevent irritation in the mouth. This stage is related to tribo-
logical behavior of food when mixed with saliva at the oral surface,
which refers to as granulation (stage iii) (Stokes, Boehm, & Baier,
2013). Although hardness of food decreases with an increasing
1900 Comprehensive Reviews in Food Science and Food Safety r Vol. 18, 2019
number of chewing cycles (Nakagawa et al., 2014), hard semisolid
food, which is unlikely to disintegrate, may present an aspiration
risk for dysphagic patients (Momosaki, Abo, & Kobayashi, 2013).
Formation of bolus (stage iv) involves molding of food particles and
saliva (Chen & Lolivret, 2011). Since saliva is continually secreted
into the oral cavity, the bolus rheology alters with time (Stokes
et al., 2013). During the swallowing process (stage v), the bolus is
held on the dorsal surface of a tongue and then propelled into the
esophagus through the pharynx (Nakagawa et al., 2014). After the
swallowing process (stage vi), higher adhesiveness of food bolus
can increase the risk of pharyngeal residue due to its stickiness
nature (Nakagawa et al., 2014). Momosaki et al. (2013) indeed
observed that residual semisolid foods having significantly higher
cohesiveness were more likely to accumulate in the pharynx. Nev-
ertheless, excessively lower cohesiveness of food bolus raises the
risk of oral residue and aspiration (Nakagawa et al., 2014).
Since texture-modified foods or semisolid foods (for example,
jellies, puddings, and purees) that can be easily compressed be-
tween tongue and hard palate or can easily swallowed without
chewing can facilitate dietary intake of dysphagic patients, dys-
phagia diets should have lower hardness and adhesiveness, but
appropriate cohesiveness for easy chewing, swallowing for aspira-
tion protection and residue reduction in the oropharynx (Inamoto
et al., 2018). No clear correlation between hardness and cohesive-
ness of food has been reported in the literature, however. This is
because these textural properties are associated with the different
steps of food intake. Hardness is a key characteristic when con-
sidering the initial or first bite, whereas cohesiveness is considered
during mastication. Considering the values of hardness and co-
hesiveness of food as listed in Table 1, it is seen that when food
has higher hardness, cohesiveness should also be high to lower the
fracturability of food and prevent choking from food fragments
(Cichero, 2015).
When considering cross-modality of textural properties to aid
the process of texture modification for dysphagia food production,
another technical term, namely, gumminess is suggested to be used
along with other textural properties. Gumminess is defined as the
product of hardness and cohesiveness and is the energy required
to disintegrate food until it can be swallowed (Nishinari & Fang,
2018; Szczesniak, 1986). Gumminess is a characteristic of semisolid
foods with a lower degree of hardness and higher degree of cohe-
siveness, the characteristics that are suitable for dysphagia foods.
Dysphagia diet classification that carefully takes food texture into
account is necessary for providing dysphagic patients with the most
appropriate foods, thereby contributing to their safety and health
(Momosaki et al., 2013); some of the results are shown in Table 1.
Hardness, adhesiveness, and cohesiveness can be used to classify
foods into three classes (I, II, and III) according to the “Food
for Special Dietary Uses for Dysphagic Patients” provided by the
Ministry of Health, Labour and Welfare (2009) of Japan (Tokifuji
et al., 2013; Yoshioka et al., 2016. The Japan Care Food Con-
ference (2016) has established the universal design foods concept,
in which foods are classified into four levels based on their hard-
ness and viscosity. The first hardness level (under 5 × 105 N/m2 )
refers to softened food that is easy to chew but nevertheless unsuit-
able for persons with impaired dental functions such as weakened
muscles, loss of natural teeth, and declined movement coordina-
tion. The second hardness level (under 5 × 104 N/m2 ) refers to
foods that can be broken up by gums and are suitable for patients
without natural teeth. The third hardness level (under 2 × 104
N/m2 and viscosity over 1500 mPa·s) refers to foods that can be
broken up by tongue. Finally, the fourth hardness level (under 5 ×

C 2019 Institute of Food Technologists®
Texture modification for dysphagia foods . . .

Figure 2–Oral processing of solid or semisolid food (modified from Foster et al., 2011; Stokes et al., 2013; Witt & Stokes, 2015).

Table 1–Textural properties of dysphagia diets of various levels (modified from Yoshioka et al., 2016 and Park et al., 2017).

Textural property
Criterion/ Level Hardness (N/m2 ) Adhesiveness (J/m3 ) Cohesiveness Viscosity (mPa·s) Reference
I 2.5 × 103 to 1.0 × 104 4.0 × 102 or less 2.0 to 0.6 – Yoshioka et al. (2016)
II 1.0 × 103 to 1.5 × 104 1.0 × 103 or less 2.0 to 0.9 –
III 3.0 × 102 to 2.0 × 104 1.5 × 103 or less – –
1 Under 5 × 105 – – – Park et al. (2017)
2 Under 5 × 104 – – –
3 Under 2 × 104 – – >1500
4 Under 5 × 103 – – >1500

103 N/m2 and viscosity over 1500 mPas) refers to foods that do
not require chewing (Eom, Lee, Chun, Kim, & Park, 2015; Park
et al., 2017). These levels are used here to evaluate the texture of
foods treated with selected processing technologies.
Although cohesiveness is also a key characteristic of texture-
modified foods, there are very few reports on the consideration
of cohesiveness in relation to the criteria listed in Table 1. Only
some conditions of the production of meat-based dysphagia diets
as reported by Yoshioka et al. (2016) could be cited for using
cohesiveness as a criterion.
Food Texture Modification Technologies
Several studies have reported that dysphagic patients consum-
ing texture-modified foods tend to have 17 to 37% lower en-
ergy intakes, leading therefore to increased risk of malnutrition
(Miles et al., in press; Sura, Madhavan, Carnaby, & Crary, 2012;
Wright, Cotter, & Hickson, 2008; Wright, Cotter, Hickson, &
Frost, 2005). One of the reasons for such an observation is that
conventional food texture modification involves a step of dilution
with water or other fluids in the blending and/or size reduction
processes (Costa et al., 2019). This naturally leads to the required
larger portion or volume of dysphagia diets, when compared with
regular diets, to achieve the same level of nutrients and energy.
For this reason, selection of an appropriate texture modification
method must be made with extreme care. Nonthermal technolo-
gies are of special interest for their ability to preserve color, texture,
taste, nutrients, and nutritional density of foods. Selected nonther-
mal processing technologies that can be employed for food texture
modification for the purpose of dysphagia diets production are
therefore of our focus here.
Textural modification of meat and meat products
Meat and meat products are rich sources of protein. However,
constriction of collagen and coagulation of myofibrillar protein
(MP), which occur during heating, generally result in the hard
texture of meat and meat products, causing subsequently the dif-
ficulty in consuming such products by dysphagic patients. Non-
thermal technologies can therefore serve as an alternative to the
modification of the texture of meat and meat products. It is impor-
tant to note that such technologies not only improve the textural
properties of meat and meat products but are also able to preserve
nutritional characteristics of the modified products. This is because
nonthermal technologies are generally known to exhibit less ef-
fects on small molecules such as amino acids, vitamins, and flavor
compounds; proteins, enzymes, and nucleic acids, which are of
larger molecules may be altered, however (Rastogi, Raghavarao,
Balasubramaniam, Niranjan, & Knorr, 2007). Use of nonthermal
treatment to modify the texture of meat and meat products should
therefore result in no disruptive effect on protein primary structure
(a sequence of amino acids in polypeptide chains) as well as free
amino acids and covalent bonds (Chen et al., 2019; Zhang, Yang,
Zhou, Zhang, & Wang, 2017). In addition, in the case where
it is not necessary to add water to modify the texture (as in the
case of high-pressure processing (HPP) or γ -irradiation, as will be
discussed below) soluble proteins and free amino acids would not
be lost from the products. Based on one serving to a dysphagia
patient, the concentration of protein in nonthermally processed
meat products is expected to be higher than that in thermally
processed meat products. This is because the texture of the latter
needs to be softened by conventional moist heat with the use of a
large amount of water.


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Texture modification for dysphagia foods . . .
Figure 3–Structural changes of proteins and expected change in softness upon HPP (modified from Bolumar et al., 2016; Zhang et al., 2017).
HPP can be used to modify the texture of meat and meat
products. HPP has been noted to be capable of improving the
gelation behavior of protein by changing its conformational
structure; such a change nevertheless depends on the applied
pressure level. A scheme of changes in the protein structure as well
as the expected evolution of the softness of the treated protein
is presented in Figure 3. Without the application of pressure,
protein is in the form of closely packed arrangement of two or
more folded polypeptide chains, or subunits, and is referred to as
the quaternary structure (Bolumar, Middendorf, Toepfl, & Heinz,
2016). This structure is mainly held by hydrophobic interactions.
Exposure of hydrophobic groups to moderate pressures (100 to
200 MPa) results in unfolding and dissociation of the quaternary
structure into the tertiary structure (Bolumar et al., 2016; Zhang
et al., 2017). At a pressure higher than 200 MPa, the tertiary struc-
ture would suffer major change due to disruption of noncovalent
interactions in such a structure (Chen et al., 2019), unfolding then
to the secondary structure. The secondary structure is indeed the
result of the formation of polypeptide chains into alpha helices or
beta sheets with intra- or intermolecular hydrogen bonds (Huang,
Hsu, Yang, & Wang, 2014; Zhang et al., 2017). Higher pressures
(300 to 700 MPa) cause the secondary structural change involving
protein denaturation and formation of aggregates (Bolumar et al.,
2016; Chen et al., 2019; Zhang et al., 2017). A pressure higher
than 700 MPa eventually produces irreversible denaturation of
protein due to disruption of the secondary structure into the
primary structure (Goyal, Sharma, Upadhyay, Sihag, & Kaushik,
2013). HPP has no disruptive effect on the protein primary
structure since no loss of amino acids and rupture of covalent
bonds generally take place (Zhang et al., 2017).
Physical properties of proteins are highly dependent on their
microstructure. Microstructure evolution of MP upon HPP is, for
example, shown in Figure 3 (Zhang et al., 2017). Nonpressurized
MP sample (0.1 MPa) contains many filaments and irregular cavi-
ties. Compared with the sample treated at 100 MPa, MP pressur-
1902 Comprehensive Reviews in Food Science and Food Safety r Vol. 18, 2019
ized at 200 MPa has denser and more homogeneous network. This
is probably because MP has the smallest particle size at 200 MPa;
this in turn contributes to the more regular space arrangement of
proteins during microstructure formation. Applying HPP at mod-
erate pressures (≤200 MPa) could help increase the solubility of
MP due to dissociation of the quaternary structure. HPP at these
conditions leads to protein unfolding speed that is higher than the
rate of protein aggregation; this phenomenon promotes forma-
tion of homogeneous and stronger gel during gelation. Stronger
gel may, however, adversely affect patients who cannot chew, so
treatment at 100 to 200 MPa may not be suitable for the produc-
tion of meat-based dysphagia foods.
On the other hand, treatment at higher pressures (≥300 MPa)
causes MP gel cavities to become larger and less homogeneous.
The treatment induces reduction of hardness and protein solubility,
although HPP at these conditions results in significant denatura-
tion and destabilization of the protein. Such an observation is due
to the formation of insoluble aggregates; the unfolding speed in
this case is lower than the rate of aggregation. It could be con-
cluded that MP gels with higher hardness have smaller, denser,
and homogeneous gel microstructure, whereas gels with lower
hardness have larger cavities and coarse microstructure. Therefore,
HPP at ≥300 MPa could be an alternative to produce meat-based
dysphagia foods.
Another important property that can be used to describe protein
functionality is the rheological property, which can be evaluated
through the storage modulus (G ) and loss modulus (G ). G and
G are noted to decrease with an increase in the applied pressure
level as a result of denaturation of myosin and actin. The ratio of
the loss modulus to storage modulus (G /G ) can also be described
in terms of the loss tangent (tan δ). Since typically treated MP ex-
hibit higher G than G , tan δ becomes less than 1. Based on the
results in Table 1, all HPP-treated MP could be categorized as per
their hardness values into level 3. Foods with the hardness values of
lower than 2 × 104 N/m2 may be suitable for dysphagic patients

C 2019 Institute of Food Technologists®
Texture modification for dysphagia foods . . .
who have the ability to break up meat by their tongue. However,
such foods are not suitable for patients who have weakened mus-
cles and loss of movement coordination, which require hardness
value of lower than 5 × 103 N/m2 or viscosity of higher than
1500 mPa·s.
According to Ishihara, Nakauma, Funami, Odake, and
Nishinari (2011), tan δ in the range of 0.1 to 1 is suggested as a
rheological criterion for good bolus in terms of swallowing ease
for dysphagic patients. Sikes, Tobin, and Tume (2009) indicated
that HPP at 200 MPa for 2 min could increase the hardness of beef
sausage batter; however, increasing the pressure further to between
200 and 400 MPa led to a decrease in the hardness. According to
the criteria in Table 1, batters treated at 200 and 400 MPa can be
classified by their hardness as close to level 1. This hardness level
is suitable for patients who have the ability to chew soft meat, but
fatigue quickly if longer chewing is needed. Tokifuji et al. (2013)
later reported that pork meat gel with a meat-to-water ratio of 1:1
and pressurized at 400 MPa for 20 min exhibited lower hardness
and adhesiveness and scored higher in terms of smoothness and
ease of swallowing compared with a pressurized sample with a
meat-to-water ratio of 1:0.5. The gel prepared at a meat-to-water
ratio of 1:1 was able to retain water in its matrix and hence allowed
for better solubilization of its proteins, resulting subsequently in
the softer texture than gels made at other conditions. This meat
gel could be categorized into level 3 and is suitable as a dysphagia
diet because it requires less extensive mastication and shorter
transition time through the oropharynx; it also leaves no residues
in the oropharynx. These results indicate that increasing the
applied pressure level and time as well as addition of water affect
the structural change of proteins, resulting in turn in reduced
hardness of a final product. Note that to promote safe swallowing,
foods should exhibit the highest softness and smoothness, but the
lowest mastication need and residues in the oropharynx.
Lipids are also an important component of all types of meat
and significantly contribute to the flavor, texture, mouth feel, and
overall sensory characteristics (for example, tenderness and juici-
ness) of meat and meat products (Amaral, Silva, & Lannes, 2018;
Bolumar, Toepfl, & Heinz, 2015). Use of appropriate nonthermal
technologies can, however, help reduce the amount of lipids (or
fat) of meat and meat products without sacrificing the desirable
texture; otherwise, the technologies can be used to modify the
texture of meat and meat products without the need for fat, espe-
cially animal fat, in the formulation. Briones-Labarca, Perez-Won,
Zamarca, Aguilera-Radic, and Tabilo-Munizaga (2012), for ex-
ample, reported that HPP-treated abalone exhibited a significant
decrease in the fat content at all tested pressure/time combina-
tions (500 MPa for 8 min or 550 MPa for 3 and 5 min). Kruk
et al. (2014) indicated that chicken breast meat with added olive
oil treated by HPP at 300 MPa exhibited significantly reduced
hardness.
High hydrodynamic pressure (HDP) processing is a novel tech-
nology that allows high-pressure shockwave to pass through water
to tenderize vacuum-packaged meat. Besides causing instanta-
neous tenderization, HDP treatment has been shown to enhance
aging tenderization in whole fresh muscle products. Bowker, Liu,
Callahan, and Solomon (2010a), for example, reported that HDP
treatment could help improve brine retention, water holding ca-
pacity, and textural properties of pork loins. Bowker, Callahan, and
Solomon (2010b) also demonstrated that HDP treatment could
increase brine uptake, processing yield, and tenderness of cooked
turkey breast products. According to the criteria listed in Table 1,
HDP-treated pork loins could be categorized into level 4, which

C 2019 Institute of Food Technologists® Vol. 18, 2019 r Comprehensive Reviews in Food Science and Food Safety 1903
represents softened food with no need to chew. However, HDP-
treated turkey breasts could only be categorized as close to level 2;
the breasts could be broken up using human gum. Nevertheless, al-
though HDP treatment could help improve the textural properties
of meat, brine is still needed to increase the meat tenderness. This
treatment method is therefore an unsuitable technique to produce
dysphagia diets when compared with HPP. High salt intake as a
result of brine addition may not be welcome as it can increase the
risk of high blood pressure or kidney disease and kidney failure of
dysphagic patients.
PEF treatment is another interesting technology that can be
used to modify the texture of meat. McDonnell, Allen, Chardon-
nereau, Arimi, and Lyng (2014) demonstrated that PEF at higher
frequencies and lower pulse numbers could lead to a decrease in
the water loss, but to an increase in the water-holding capacity
of pork upon cooking. PEF treatment of 150 pulses at an electric
field strength of 1.2 kV/cm and a frequency of 200 Hz resulted
in the lowest hardness of pork. From Table 1, PEF-treated meat
could only be categorized as close to level 1. The hardness of the
treated pork was higher than 5 × 104 N/m2 , implying that it is a
food that is hard to swallow without mastication. PEF has not yet
found its application for the preparation of high-protein foods for
dysphagic patients.
Ultrasound (US) is another efficient technology that can be used
to improve the texture of protein gel. Limited works are available
reporting that US treatment could decrease meat hardness and may
thus play a role in dysphagia food production. Among such limited
works, Yeung and Huang (2017) noted that the hardness of pork
loins significantly decreased upon US treatment at 300 W for more
than 30 min or at 2200 W for 2 min. According to the criteria in
Table 1, the hardness of US-treated pork loins at these conditions
could be categorized into level 3. The loins are thus suitable for
patients who have ability to break up food by their teeth, gums,
and tongues. However, the loins are unsuitable for patients who
cannot chew or have lost their movement coordination. There
are still no reports on the optimal conditions of US treatment for
dysphagia diets production.
Gamma irradiation is another promising technique for meat
tenderization. Previous studies suggested that γ -irradiation signif-
icantly affects heat-induced gel, water holding capacity, apparent
viscosity, and textural properties of meat products. Such property
changes might be due to the free radicals produced by irradiation
(Zhao et al., 2017). Choi et al. (2015), for example, studied the
effect of γ -irradiation level (0 to 10 kGy) on selected properties
of chicken salt-soluble proteins. Based on the criteria listed in
Table 1, the hardness of the γ -irradiation–treated chicken could
be categorized into level 4. The results demonstrated that protein
solubility as well as hardness, springiness, cohesiveness, gummi-
ness, and chewiness of the sample decreased with an increase in
the γ -irradiation level. Nevertheless, no study on the application
of irradiation to produce dysphagia foods so far exists.
It can be seen from the aforementioned reviews that nonthermal
technologies have potential to modify the texture (and other rele-
vant properties) of meat and meat products. However, the hardness
level of meat and meat products not only depends on the operating
parameters of these nonthermal technologies but also depends on
the type of proteins and other preparation of raw materials. Com-
bination of nonthermal technologies with other appropriate pre-
treatment methods such as pretreatment using enzymes like papain,
bromelain, and actinidin (Takei, Hayashi, Umene, Kobayashi, &
Masunaga, 2016; Zhu, Kaur, Staincliffe, & Boland, 2018), organic
acids like lactic and citric acids (Aktaş, Aksu, & Kaya, 2003), soy
Texture modification for dysphagia foods . . .
sauce (Kim et al., 2013), vinegar (Tänavots et al., 2018), and fruit
and vegetable juices (Gök & Bor, 2016) has proved to help reduce
the hardness of meat and meat products from level 1 or 2 to level
3 or 4. Therefore, it is still too early to conclude which technique
would yield the best results. Investigation on the effect of texture
modification on the swallowability via the use of such evaluation
techniques as videofluoroscopy should also be conducted.
Some recent investigations on texture modification of meat and
meat products, which can be applied for dysphagia diets produc-
tion, are summarized in Table 2.
Texture modification of rice, starch, and
carbohydrate-based products
Rice (Oryza sativa L.) is mainly produced and consumed in
Asia, whose production accounts for over 90% of the world’s total
production (Xia et al., 2017). Nonthermal processing technologies
have been noted to be the most effective method to shorten the
cooking time and soften the texture of rice, in particular brown
rice. Nonthermal treatment has also been noted for its ability to
maintain higher nutritional density of brown rice (for example,
protein, dietary fiber, lipids, vitamin B, and minerals), starch, and
carbohydrate-based products (Chen, Chen, & Chang, 2012; Park
& Han, 2016). This is again due to the fact that such micronutrient
remains unaffected by nonthermal technologies.
HPP has widely been used for texture improvement and physic-
ochemical properties enhancement of rice in much the same way as
its use for meat and meat products. Yu, Ge, Zhu, Zhan, and Zhang
(2015), for instance, studied the effect of HPP treatment (200 to
600 MPa for 0 to 20 min) after soaking on selected properties of
cooked brown rice. HPP was noted to be capable of reducing the
hardness and significantly shortening the cooking time; gummi-
ness and springiness of brown rice significantly decreased when
pressures above 500 MPa were used. It is also interesting to note
that the untreated brown rice structure had a combination of bran
layer (pericarp, aleurone layer, and germ) and starchy endosperm.
Pericarp and aleurone layer became thinner, whereas the starch
granules in endosperm became fuzzy and smooth when treated at
200 MPa. Upon treatment at 400 MPa, aleurone layer and ker-
nels cracked; the cracks were produced and propagated along the
edges of the kernels. Small cavities and gaps occurred in the starch
granules when the pressure increased to 500 MPa. Increasing the
holding time resulted in the destruction of the pericarp and aleu-
rone layer in all cases. The cracks along the pericarp, aleurone
layer, and starch granules as well as damage of the bran layer upon
HPP treatment were believed to facilitate water absorption during
the cooking process, which resulted in the reduced hardness of the
rice. Based on the criteria in Table 1, the hardness of HPP-treated
brown rice can be classified into level 1. Diets of this level may
be unsuitable for patients who do not have ability to chew be-
cause of the loss of their natural teeth. Therefore, combination of
appropriate pretreatment (such as germination, pregelatinization,
and enzymatic process) and HPP may be needed to further reduce
the hardness of rice (especially brown rice).
For other starchy products than rice, Liu, Wang, Cao, Fan,
and Wang (2016) demonstrated that use of HPP to treat com-
mon buckwheat starch (CBS) led to the reduction of its swelling
power, hardness, and viscosity. In particular, treatment at 600 MPa
did result in crystalline conversion from A-type to B-type. This
is because the amylopectin structure was destroyed, hence allow-
ing the rearrangement of double helices that resulted in changes
in the crystalline structure. Such a rearrangement limited amylose
leaching and amylopectin dispersion, resulting in an increase in the
1904 Comprehensive Reviews in Food Science and Food Safety r Vol. 18, 2019
amylose content but a decrease in the hydration, swelling power,
and viscosity of CBS. During gelatinization, the HPP-modified
CBS with higher amylose content swelled less than the native
starch as a result of incompletely disintegrated starch granules, re-
sulting thereby in a weaker gel. The scheme of starch gelatinization
is shown in Figure 4. The hardness of HPP-treated CBS was noted
to fall into either level 2 or 3 as per the criteria listed in Table 1,
so it can be claimed as suitable for dysphagic patients. However,
no study is so far available on the relationships between the pa-
rameters (pressure and time) of HPP and the desired properties of
carbohydrate-based dysphagia diets.
US treatment after soaking can help modify textural and nu-
tritional properties of brown rice. Park and Han (2016) indicated
that US treatment (185 W, 400 kHz, 50 °C for 60 min) after
8 hr of soaking resulted in a lower pasting temperature and higher
breakdown viscosity of brown rice. Although brown rice kernels
still consisted of hard bran layer, US treatment posed a signifi-
cant impact on the texture of cooked brown rice. Soaking time
prior to US treatment as well as treatment condition itself are the
important parameters affecting the final product properties.
In the case of other starchy products, US treatment has noted
to help increase the yield, swelling, solubility, and pasting prop-
erties (peak, hold, final, breakdown, and setback viscosities). Sit,
Misra, and Deka (2014), for example, reported that solubility and
swelling of taro starch increased upon US treatment at a higher
amplitude. Such results are attributed to the breakdown of starch
structure, which allowed more water to be absorbed. Viscosities
of the starch with treatment at half cycle and 100% amplitude
for 5 min were found to be the highest. This is due to increased
swelling when the treatment time was shorter; loss of soluble por-
tions of starch at half cycle was also slightly less than in the case
where full cycle was applied. The treated sample was more resistant
to shearing and formed a more rigid gel after cooling. The firmness
of the US-treated starch paste was also significantly higher than
that of the untreated sample, probably due to the higher swelling
and viscosities of the starch granules. As per the criteria listed in
Table 1, the viscosity of the treated taro starch was close to that of
level 3 or 4, implying that the product can be broken up by the
tongue or does not need to be chewed. However, detailed effects
of US parameters should be further investigated for dysphagia diets
production.
Plasma processing (PP) has noted to be effective in improving
the cooking properties of brown rice. Chen, Chen, and Chang
(2012) studied the effect of PP (1 to 3 kV) on the cooking and
textural properties of brown rice. All PP-treated samples exhibited
reduced cooking time, elongation, and cooking loss. Hardness of
the rice was also significantly lower than that of the untreated
rice, especially when PP was conducted at 1 kV. The hardness
of PP-treated brown rice can be classified into diet level 1 as
per the criteria listed in Table 1. This is due to the wide and
shallow destruction of brown rice surface. Fissure of the bran
layer improved water absorption and reduced the cooking time.
Swelling of starch granules due to the uptake of water not only
reduced the cooking time but also softened the texture of the
cooked rice and made it easier to chew. The advantage of PP,
which is different from those of HPP and US, in the case of
rice texture modification is that the presoaking step prior to the
treatment is not required. It is still necessary to study the effects of
treatment parameters (such as power, time, and pressure) on the
key properties of a treated sample, however.
Irradiation can result in modification of physicochemical, tex-
tural, or rheological property of starch. This may include an

C 2019 Institute of Food Technologists®
Texture modification for dysphagia foods . . .

Table 2–Effects of various processing technologies on textural properties of meat and meat products.

Diet
Product Treatment Processing condition Result level Reference
Abalone (Haliotis HPP 0.1 to 550 MPa, 3 to Hardness decreased with 2 Briones-Labarca et al.
rufescens) 8 min (at 20 °C) increasing pressure and (2012)
time
Alaska pollock surimi HPP 0 to 300 MPa, 0.3 to 300 MPa was the best 1 Cando, Herranz,
gel 3% (w/w) NaCl (at condition to reduce NaCl Borderı́as, and
10 °C and improve mechanical Moreno (2015)
for 10 min) and sensory properties
Beef sausage batter HPP 0.1 to 400 MPa 200 MPa was the most 1 Sikes et al. (2009)
(at 10 °C for 2 min) effective condition to
soften the texture
Chicken γ -irradiation 0 to 10 kGy (cobalt-60 Hardness, springiness, 4 Choi et al. (2015)
as source irradiator) cohesiveness, gumminess
and chewiness of samples
decreased with increased
γ -irradiation level
Chicken meat HPP 0 to 300 MPa 300 MPa for 120 or 180 s was 1 Ros-Polski, Koutchma,
(60 to 180 s) the best condition to Xue, Defelice, and
decrease hardness Balamurugan
(2015)
Minced fish meat gel HPP 400 MPa (at 17 °C Meat to water ratios of 1:1 3 Yoshioka et al. (2016)
for 20 min) and 1:1.5 (w/w) resulted in
gels suitable for dysphagia
individuals
Myofibrillar protein HPP 0.1 to 500 MPa Treatment at 200 MPa 3 Zhang et al. (2017)
gel (10 min) increased solubility and
hardness of myofibrillar
protein
Nemipterus virgatus HPP 0.1 to 600 MPa Pressure at 400 MPa 4 Ma, Yi, Yu, Li, and
surimi gel (at 25 °C for increased gel properties Chen (2015)
15 min) and WHC, while decreased
cooking loss and solubility
Palm ruff (Seriolella HPP 450 to 550 MPa Decrease in hardness in 3 Roco et al. (2018)
violacea) for 3 and 4 min post-rigor samples was
observed when treated at
550 MPa for 3 min
Parexocoetus HPP 0 to 200 MPa Mechanical properties 4 Moreno et al. (2015)
brachyterus surimi (at 15 °C for increased with increase in
gel 10 min) pressure level; at 200 MPa
product was more elastic
Pork PEF 1.2 to 2.3 kV/cm, 1.2 kV/cm with 200 Hz for 1 McDonnell et al.
20 to 100 Hz, 150 pulses resulted in the (2014)
25 kV, lowest hardness of samples
4 to 32 µs and 150
to 300 pulse
number
Pork loin HDP 4 rpm (10 min on-off) Brine retention, processing 4 Bowker et al. (2010a)
cycle yield, and texture were
for 3 hr (at 4 °C) improved by HDP
treatment
Pork loin US 300 W (0 to 60 min) Treatment at 2000 W for 3 Yeung and Huang
and 2000 W (0 to 2 min gave the lowest (2017)
6 min) at 15 kHz hardness and chewiness
Pork meat gel HPP 400 MPa (at Meat to water ratio of 1:1 3 Tokifuji et al. (2013)
17 °C for 20 min) resulted in the highest
softness, elasticity and
smoothness and lowest
residue in oropharynx
Spicy beef Chop γ -irradiation 0 to 8 kGy (cobalt-60 Irradiation dose of 8 kGy 2 Zhao et al. (2017)
as source irradiator) resulted in the lowest
hardness of sample
Turkey breast HDP 4 rpm (at 2 °C for 30% brine resulted in the 2 Bowker et al. (2010b)
30 min) highest brine uptake,
and 0 to 30% brine processing yield, moisture
loss, hardness and
cohesiveness
Turkey breast meat HPP 0 to 200 MPa (at 50 and 100 MPa were the 3 Chan, Omana, and
gel 4 °C for 5 min) best treatment condition to Betti (2011)
increase WHC and lower
meat pH
Abbreviations: HDP, high hydrodynamic pressure; HPP, high-pressure processing; PEF, pulsed electric field; US, ultrasound.Diet levels are referred to those defined by the Universal Design Food (Park et al., 2017).

increase in the gelatinization temperature, water solubility, wa-
ter absorption capacity, and oil absorption capacity, but a decrease
in the peak, trough, final, breakdown, and setback viscosities.
Such modifications, however, seem to vary with the cultivar of
the plant that is the source of starch (Singh, Singh, Ezekiel, &
Kaur, 2011). Bashir and Aggarwal (2016) studied γ -irradiation
(0.5 to 10 kGy) with cobalt-60 as an irradiator source and found
that peak, trough, final and setback viscosities as well as hard-
ness, adhesiveness, cohesiveness, gumminess, and springiness of
chickpea flour decreased with an increase in the irradiation dose.


C 2019 Institute of Food Technologists® Vol. 18, 2019 r Comprehensive Reviews in Food Science and Food Safety 1905
Texture modification for dysphagia foods . . .
Figure 4–A scheme of starch gelatinization and relevant microstructural changes (modified from Knorr, Heinz, & Buckow, 2006).
Irradiation induced depolymerization and destruction of the
crystalline structure of chickpea flour, resulting in the gamma-
irradiated flour being cooked more easily with lower retrograda-
tion. The cooked flour was therefore softer. Based on the criteria
listed in Table 1, the hardness of irradiation-treated chickpea flour
could be categorized as close to diet level 3 or 4. However, other
important properties of the irradiation-treated starch, including
sensory and dysphagia-related functional properties (such as con-
sistency), have not so far been investigated.
Since dysphagic patients require soft food that is safe for
swallowing, characteristics and gel properties of starch play an
important role in the desired final product quality. According to
the criteria in Table 1, hardness higher than over 5 × 105 N/m2
could become a challenge and deem unsafe for dysphagic patients.
Based on the above-mentioned reviewed studies, HPP and US
have been used to improve the quality of cooked rice, starch, and
carbohydrate-based products, whereas PP has been used to modify
the texture of brown rice. Irradiation, on the other hand, is often
used for native starch modification. It is still nevertheless too early
to conclude which technology would be best for the production
of texture-modified rice, starch, and carbohydrate-based products
for dysphagic patients. Comparative studies on the effects of
different nonthermal treatment technologies for the production
of rice, starch, and carbohydrate-based products for dysphagic
patients have not yet been completed.
Some recent investigations on the textural properties of rice,
starch, and carbohydrate-based products undergone various tech-
nologies, which can possibly be applied for dysphagia diets pro-
duction, are summarized in Table 3.
Texture modification of fruits and vegetables
Fruits and vegetables are good sources of vitamins, minerals, di-
etary fiber, and antioxidants (Bevilacqua et al., 2018; Chakraborty,
Kaushik, Rao, & Mishra, 2014), which are important for maintain-
ing good health. Due to their highly perishable nature, these types
of foods have short shelf life and can even be contaminated with
1906 Comprehensive Reviews in Food Science and Food Safety r Vol. 18, 2019
microorganisms causing human diseases (Kim, Kim, Kim, & Yook,
2010). Thermal processing (TP) such as hot-water blanching has
widely been used to preserve fruit and vegetable products through
the inactivation of microorganisms and deleterious enzymes (Barba
et al., 2017; Chakraborty et al., 2014; De Roeck, Sila, Du-
vetter, Van Loey, & Hendrickx, 2008; Landl, Abadias, Sárraga,
Viñas, & Picouet, 2010). In addition, thermal processing generally
causes significant degradation of pectic polysaccharides, resulting
in the reduction of intercellular adhesion and consequently soft-
ening of the final products (De Roeck et al., 2008; Ranganathan,
Subramanian, & Shanmugam, 2016). Such a processing may, how-
ever, adversely affect fruits and vegetables as these produce is
heat sensitive in nature. During heating of fruits and vegetables,
thermally induced solubilization of intercellular cementing pectin
may take place, leading to cell wall loosening and hence degra-
dation of bioactive compounds, especially vitamins (De Roeck
et al., 2008; Keenan, Rößle, Gormley, Butler, & Brunton, 2012).
This in turn results in losses of nutritional density of fruits and
vegetables treated by thermal processing. Alternative nonther-
mal treatment technologies have therefore been proposed and
tested.
Kingsly, Balasubramaniam, and Rastogi (2009) reported that the
hardness of HPP-treated pineapple slices was lower than that of
the fresh sample. The hardness of HPP-treated samples decreased
with an increase in the applied pressure level up to 100 MPa,
but did not significantly change in the pressure range of 100 to
500 MPa. As shown in Table 1, the hardness of pineapple slices
could more or less be classified into diet level 2, implying that
the slices can be chewed using gums. Landl et al. (2010) later
studied the effects of HPP at 0 to 600 MPa and compared with a
mild conventional pasteurization treatment at 75 °C on the quality
of apple purée products. The results suggested that only HPP at
400 MPa significantly increased the viscosity of the purée. The
increase in the viscosity is due to an increase in the linearity of
cell walls and volumes of particles caused by HPP. The viscosity
of apple purée was close to that listed in diet level 3 or 4 (Table 1),

C 2019 Institute of Food Technologists®
Texture modification for dysphagia foods . . .

Table 3–Effects of various processing technologies on textural properties of rice, starch and carbohydrate-based products.

Processing Diet
Product Pretreatment/preparation Treatment condition Result level Reference
Bread All ingredients were HPP 350 MPa (at 42% of wheat replacement 2, 3 Collar and Angioloni
mixed with water at 20 °C for with 3% CMC but no (2017)
ratio of 1:1 10 min) gluten resulted in high
sensory ratings and soft
initial texture
Buckwheat Starch was isolated by HPP 120 to 600 MPa Amylose content, pasting 2, 3 Liu et al. (2016)
starch 0.3% NaOH, (20 min) temperature and thermal
ground and dried at stability increased, while
40 °C (12 hr) hardness, swelling and
viscosity decreased with
increased in pressure level
Chickpea flour – γ -irradiation 0.5 to 10 kGy Peak, breakdown and setback 3, 4 Bashir and Aggarwal
(cobalt-60 as viscosities as well as (2016)
source hardness decreased,
irradiator) whereas swelling,
solubility, oil and water
absorption capacities
increased with increased
irradiation dose
Cooked brown – PP 1 to 3 kV, 1 kV plasma treatment 1 Chen et al. (2012)
rice 1.2 mA (at decreased cooking time,
800 Pa for water absorption and
30 min) hardness of cooked brown
rice
Cooked brown Soaked in water at HPP 200 to 600 MPa, Increasing pressure and time 1 Yu et al. (2015)
rice 25 °C for 60 min 0 to 20 min resulted in decreased
hardness, gumminess,
springiness and shorter
cooking time
Cooked milled Soaked in water at US 185 W, 400 kHz, Ultrasound at 50 °C (60 min) 1 Park and Han (2016)
and brown room temperature 30 to 60 min resulted in lower hardness,
rice for 2 to 8 hr at 25 to 50 °C adhesiveness and
chewiness, while having
higher water absorption
than sample treated at
25 °C (30 min)
Oat starch Suspensions were US 350 W and Probe sonication at 350 W 4 Falsafi et al. (2019)
prepared by 5% 5 W/cm2 of with density of 63 W/cm2
(w/v) bath and 150 for 20 min resulted in
to 350 W, 39 sample with the lowest gel
to 63 W/cm2 hardness, the highest water
of probe for and oil absorption
10 and capacities
20 min
Potato starch Starch was isolated by γ -irradiation 0.01 to 0.5 kGy 0.5 kGy irradiation resulted in 3 Singh et al. (2011)
0.5% K2 S2 O5 and (cobalt-60 as the lowest hardness,
dried at 40 °C source gumminess, and
irradiator) springiness
Pregerminated Soaked in water at 22 HPP 100 to 500 MPa Treatment at 300 MPa 2 Xia et al. (2017)
brown rice to 25 °C for 12 hr (10 min) resulted in the highest
(pregermination) mineral bioaccessibility;
500 MPa resulted in the
lowest hardness,
cohesiveness, gumminess,
chewiness and resilience
Taro starch Slurry was mixed with US 100 W, 30 kHz, Treatment for 5 min with 0.5 3, 4 Sit et al. (2014)
100 mL water 125 µm, 5 to cycle and 100% amplitude
20 min, 0.5 to resulted in the highest
1 cycle solubility, swelling and
viscosity
Wheat bread Wheat flour was HPP 50 to 250 MPa, Hardness increased with 3 Bárcenas,
mixed with salt to 1 to 4 min increased pressure level; Altamirano-
prepare dough holding time 200 MPa (2 min) resulted Fortoul, and Rosell
in the highest hardness (2010)
Abbreviations: HPP, high-pressure processing; PP, plasma processing; US, ultrasound.Diet levels are referred to those defined by the Universal Design Food (Park et al., 2017).

implying that such a product does not need to be chewed. This
in turn implies that the efficacy and safety for oral and pharyngeal
phases of swallowing could be increased. The effect of HPP on
texture modification varies with the raw material as well as the
applied pressure level.
Anese, Bot, Panozzo, Mirolo, and Lippe (2015) demonstrated
that US treatment at power, frequency, and amplitude of 71 W,
24 kHz, and 100 µm, respectively, increased the viscosity of tomato
pulp when compared with the values of the untreated sample.
This is because US causes partial de-esterification of pectin, which
subsequently establishes hydrogen bonds and hydrophobic interac-
tions, resulting in a new network with increased gel-like properties
and hence the increased viscosity. As per the criteria listed in
Table 1, the viscosity of US-treated tomato pulp could be
classified into diet level 3 or 4. This indicates that US treatment
can not only be used for the production of texture-modified meat
products, rice, starch, and carbohydrate-based products but can
also be applied to enhance the dysphagia quality of tomato pulp.


C 2019 Institute of Food Technologists® Vol. 18, 2019 r Comprehensive Reviews in Food Science and Food Safety 1907
Texture modification for dysphagia foods . . .
Nevertheless, although several studies exist on the use of US
to modify the texture of fruits and vegetables, no detailed
study is so far available on the relationships between treatment
parameters such as power, frequency, time, and textural properties
of dysphagia diets.
In the case of PEF, Jin et al. (2017) demonstrated that com-
bined use of PEF at 2 kV/cm field strength, 1 µs pulse width and
100 pulses per second, and a sanitizer solution led to a softer tex-
ture of whole blueberry fruits than that of the untreated sample.
The softening of PEF-treated blueberries may be due to cell mem-
brane breakdown. Longer treatment time (4 min) resulted in the
more obvious effect than the shorter (2 min) treatment time. The
hardness of blueberries was close to that listed in level 1 (Table 1),
which is soft and easy to chew by teeth. Similar to HPP and US
treatment, it is still necessary to study the effects of PEF treatment
parameters (electric field strength, frequency, number of pulse, and
time) on the key properties of dysphagia diets.
Previous studies demonstrated that gamma irradiation leads
to breaking up of cell walls, resulting then in tissue softening
of fruits and vegetables. Nayak, Suguna, Narasimhamurthy, and
Rastogi (2007), for example, demonstrated that irradiated carrot
and beetroot exhibited lower hardness than the untreated samples.
In particular, irradiation doses up to 12 kGy resulted in the lowest
hardness, which was close to that of diet level 1 as per the criteria
listed in Table 1. Kim et al. (2010) later studied the effect of irra-
diation dose level (0 to 2 kGy) on the hardness of peach. Results
demonstrated that irradiated peach exhibited lower hardness than
the untreated sample; increasing the irradiation dose resulted in a
lower hardness. The hardness of the irradiated peach was also close
to that of diet level 1.
Based on the above-mentioned reviewed studies, HPP and US
have been used to modify the texture of fruits and vegetables into
a pulp or purée form. These techniques could reduce the hardness
of the products to close to diet level of 3 or 4 based on criteria listed
in Table 1. On the other hand, PEF and irradiation have been used
to modify the texture of vegetable pieces or whole fruits, which
resulted in the hardness of PEF- and irradiated-treated samples be
only close to that of diet level 1. Even though there are reports on
the potential of HPP, PEF, US, and irradiation to improve the tex-
tural properties of fruits and vegetables, investigation on the food
production for dysphagic patients has not been reported. Since
different people with dysphagia may have different symptoms, re-
quirements on textural property of food may also be different.
Therefore, pretreatment technology should be carefully selected
to match the required texture modification need.
Some recent investigations on the textural properties of fruits
and vegetables upon treatments by various technologies, which
can be applied for dysphagia diets production, are summarized in
Table 4.
Current and Future Trends
In order to create the shape of food that is attractive, traditional
manual approach such as the use of silicone molds is commonly
employed. However, such an approach is time consuming and
suffers an inability to create a variety of foods with realistic
shapes to satisfy the consumers. Recently, three-dimensional (3D)
printing technology has been used to produce foods with a variety
of texture from various raw material sources; demands in terms of
visual appearance can also be better met. 3D printing has been ap-
plied to the production of cereal-based food (Severini, Derossi, &
Azzollini, 2016), chocolate (Mantihal, Prakash, Godoi, &
Bhandari, 2017), orange-concentrate based snack (Azam, Zhang,
1908 Comprehensive Reviews in Food Science and Food Safety r Vol. 18, 2019
Mujumdar, & Yang, 2018), fruit-based snack (Derossi, Caporizzi,
Azzollini, & Severini, 2018), fish surimi gel (Wang, Zhang, Bhan-
dari, & Yang, 2018), combination of mashed potato and strawberry
juice gel (Liu, Zhang, & Yang, 2018), protein and fiber-rich food
(Lille, Nurmela, Nordlund, Metsä-Kortelainen, & Sozer, 2018),
and gel system (Liu, Bhandari, Prakash, Mantihal, & Zhang,
2019). However, very few studies have been made to utilize 3D
food printing to produce special foods for people with dysphagia.
Among the few available works, Kouzani et al. (2017) reported that
3D printing reduced the design and fabrication time, improved the
consistency and repeatability of 3D printed tuna fish (consisting
of tuna, pureed pumpkin and pureed beetroot), and enhanced the
sensory characteristics of such a purée food for dysphagic patients.
In order to apply 3D printing to food, a starting material should
possess suitable rheological characteristics to allow for its extru-
sion and be cohesive enough to hold its shape (Hamilton & Alici,
2018; Yang, Zhang, & Bhandari, 2017). Currently, most starting
food materials for 3D printing are in the form of purée. However,
there is so far no report on the use of nonthermal technologies to
prepare food materials for 3D printing. Therefore, it is worthwhile
to investigate the application of selected nonthermal technologies
as a means to modify food texture for subsequent 3D printing.
The use of nonthermal technologies may not only help maintain
bioactive compounds (especially heat-labile compounds) in food
but also manipulate the rheological properties of a starting mate-
rial in a desirable fashion. Future investigation should also cover
the study of relationships among nonthermal technologies (type of
technology and conditions), printing variables (print speed, flow
rate, chemical composition), and rheological properties of print-
ing materials in order to improve the quality of 3D printed foods
for dysphagic patients. Moreover, the effect of postprinting op-
eration, for example, drying and baking, should be investigated.
Combination of 3D printing and drying can indeed be used to
design foods for daily consumption of dysphagic patients or might
become an opportunity to develop new products into the market.
Materials that are soft, stable, and having smaller particle sizes
such as gels, microgels, and emulsion gels can be used as thickening
agents for texture-modified foods (Aguilera & Park, 2016; Li &
Nie, 2016; Zou, Thijssen, Yang, & Scholten, 2019). Addition of
nutrients into gels, resulting, for example, in microgels contain-
ing fiber (Leon, Aguilera, & Park, 2019), whey protein emulsion
gels containing bioactive compounds (Liu et al., 2019a; Luo, Ye,
Wolber, & Singh, 2019), milk protein composite gels (Liu et al.,
2019b), and soft gel beads containing fish oil (Rathod & Kairam,
2018) can also result in attractive healthy products for dysphagic
patients. These products would not only provide soft texture and
desirable sensory characteristics, but would also help increase nu-
trients and health benefits of the products. However, combination
of such food and 3D printing technology is limited.
Concluding Remarks
Possibility of applying various nonthermal processing technolo-
gies to produce foods for dysphagic patients is reviewed. HPP has
widely been used for meat tenderization and softening of fruits
and vegetables. HPP is indeed capable of reducing the hardness
of such foods to close to level 4 as per the universal design food
concept for texture-modified foods for dysphagic patients. US,
on the other hand, has been noted to be capable of reducing the
hardness of starch-based foods to the lowest level (level 4) and
is therefore a recommended technique to improve the texture of
carbohydrate-based foods for dysphagic patients. It is important to
note, however, that hardness (or texture in general) of dysphagia

C 2019 Institute of Food Technologists®
Texture modification for dysphagia foods . . .

Table 4–Effects of various processing technologies on textural properties of fruits and vegetables.

Product Treatment Processing condition Result Diet level Reference

Apple purée HPP 0 to 600 MPa (at 20 °C Total vitamin C and ascorbic 3, 4 Landl et al. (2010)
TP for 5 min) acid contents were
75 °C for 10 min unaffected by treatment at
400 MPa, while viscosity
increased
Blueberry PEF 2 kV/cm, 1 µs pulse Combined use of sanitizing 1 Jin et al. (2017)
Sanitizer solution width, 100 solution and PEF for 4 min
pulses/sand 0 to reduced hardness and
6 min (22 °C) increased anthocyanins
0 to 0.5% peracetic and phenolics contents
acid for 0 to 4 min
Carrot and γ -irradiation 3 to 12 kGy (12000 Ci Irradiation doses up to 12 kGy 1 Nayak et al. (2007)
beetroot power source) resulted in the lowest
hardness, cohesiveness,
springiness, gumminess
and chewiness
Peach γ -irradiation 0 to 2 kGy (100 kCi Total polyphenols content 1 Kim et al. (2010)
source strength) at and antioxidant activity
13 °C increased, while hardness
decreased with increased
irradiation dose
Pineapple HPP 50 to 700 MPa (at Hardness, springiness and 2 Kingsly et al. (2009)
25 °C for 10 min) chewiness decreased with
increased pressure level
Tomato pulp US 71 W, 24 kHz, 100 µm Viscosity and lycopene 3, 4 Anese et al. (2015)
(30 min) release increased with US
treatment
Abbreviations: HPP, high-pressure processing; PEF, pulsed electric field; TP, thermal processing; US, ultrasound.Diet levels are referred to those defined by the Universal Design Food (Park et al., 2017).

foods does not depend only on parameters belonging to an ap-
plied nonthermal technology, but is also dependent on the type of
food, size, and preparation of raw materials. In addition, suitabil-
ity of foods for dysphagic patients does not depend only on the
texture but also on nutritional value and palatability. Although 3D
printing has emerged as a potential alternative for the production
of geometrically complex structure, which can help improve the
various sensory characteristics of foods, this printing technology
has still found limited use for the production of dysphagia foods.
Future trends related to the production of dysphagia foods may
involve the use of nonthermal technologies in combination with
3D printing. This should allow the production of foods that are
safe and easy to consume and at the same time are nutritional,
visually appealing, and exhibit higher palatability for dysphagic
patients.
Acknowledgements
Author Sungsinchai expresses her sincere appreciation to the
Thailand Research Fund (TRF) through the Royal Golden Ju-
bilee Ph.D. Program (Grant No. PHD/0121/2559) for supporting
her doctoral study. Author Niamnuy expresses her sincere appre-
ciation to the National Nanotechnology Center (NANOTEC),
NSTDA, Ministry of Science and Technology, Thailand, through
its program of Research Network NANOTEC (RNN). All au-
thors express their sincere appreciation to the TRF for the financial
support through the Senior Research Scholar Grant (Grant No.
RTA6180008) to author Devahastin.
Conflict of Interest
The authors declare that there is no conflict of interest.
Author Contributions
Authors Niamnuy and Sungsinchai designed the structure of
the article, compiled and analyzed the literature, and drafted the
article. Authors Charoenchaitrakool, Wattanapan, and Devahastin
reviewed and provided inputs on the structure and contents of the
article. All authors revised, edited, and approved the final form of
the article.
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