A multidisciplinary Delphi consensus on the formulation of an optimized oral diet for dysphagia and malnutrition (FOOD-DM)

BACKGROUND & AIMS: Dysphagia and malnutrition frequently co-occur and are associated with aspiration pneumonia, sarcopenia, increased mortality, reduced quality of life and restricted social participation. Yet foods and drinks for individuals with dysphagia and malnutrition are inconsistently specified and lack objective standards. This study aimed to develop a consensus-based, expert-derived framework for evaluating foods and drinks perceived suitable for individuals with dysphagia and malnutrition (FOOD-DM). METHODS: A two-round online modified Delphi study was conducted (October 2024-May 2025). International experts in medicine, speech-language pathology and nutrition were eligible with ≥5 years of clinical experience and a Hirsch-index ≥5. In round 1, participants rated nine prespecified items relating to texture, nutritional composition and labeling on a 9-point Likert scale. Consensus required ≥70% ratings at 7-9 (critically important) and <15% at 1-3 (not important). Round 2 provided aggregated results, item refinements and a comparison of the International Dysphagia Diet Standardisation Initiative (IDDSI) with quantitative texture measures expressed in the International System of Units (SI). RESULTS: Forty-eight experts participated in round 1. All nine items achieved consensus and were reaffirmed in round 2 (44/48; 92% retention). The final FOOD-DM framework comprises nine criteria across three domains: (1) Texture: availability of consistent textures, accuracy of texture descriptions (IDDSI and/or SI-based rheology), ability to customize texture, and ability to measure texture modifications (IDDSI and/or SI-based rheology); (2) Nutrition: availability of high-calorie options (e.g., 1.5-2.0 kcal/mL), flexibility to adjust calorie content, availability of high-protein options (≥20% energy from protein), and adaptable macronutrient composition; (3) Labeling: clear indications of suitability for dysphagia and malnutrition including detailed explanations of their specifics and composition. Overall, 91% of experts perceived the proposed measures as potentially helpful in improving access to appropriate nutrition; 61% favored a combined IDDSI-plus-SI model for texture description. CONCLUSIONS: Distinct from existing approaches focusing on texture or nutrition alone, FOOD-DM integrates standardized texture specification with nutritional optimization and labeling within a single framework. Implementation of the FOOD-DM framework may support standardized, customizable, and transparent nutrition and foster collaboration between clinical nutrition, dysphagia therapy, and the food industry.