The intake–adequacy gap in dysphagia nutrition: texture-modified foods, nutrient delivery and realised intake in older adults

Dysphagia is common among older adults in long-term care and is frequently managed using texture-modified foods (TMFs) aligned with the International Dysphagia Diet Standardisation Initiative (IDDSI). Although texture modification improves swallowing safety and standardisation, nutritional adequacy is often inferred from planned provision rather than verified at the level of actual consumption. This distinction is clinically important because swallowing impairment, fatigue, prolonged mealtimes, reduced appetite, sensory decline and dependence on feeding assistance limit the amount of food consumed. As a result, TMFs may meet prescribed texture requirements and planned nutritional targets while failing to deliver sufficient energy, protein and key micronutrients, including calcium, vitamin D, vitamin B12, iron and zinc, in practice. This review examines this mismatch as an intake–adequacy gap in dysphagia nutrition. We synthesise evidence on reduced intake, plate waste, nutrient-density loss during texture modification, sensory acceptability and limitations in care-home monitoring. We argue that nutritional adequacy in dysphagia care should be evaluated as an intake-realised outcome shaped by food composition, swallowing safety, sensory engagement and mealtime support. Reframing TMFs as structured nutritional interventions may help align texture compliance with nutrient delivery, identify where planned nutrition is lost before consumption, and guide targeted strategies to improve nutritional outcomes among older adults with dysphagia.