Table 1.

Characteristics of included studies in the systematic review.

Source	Method	Setting, Origin	Participant Characteristics	Interventions/ Intervention Period	Control	Outcomes	Quality Assessment *
Bannerman and McDermott (2011) [15]	Observational Cross-sectional	3 LTCs Scotland	Residents >60 y Ex: Nil by mouth, receiving artificial nutritional support, fluid restriction, acutely unwell, palliative Mean age (y) 88.1 ± 5.4	Texture C—Thicker pureed: n = 11 Texture D—Minced/moist: n = 4 [UK national descriptors 2009]	Standard diet n = 15	-Weight comparison -Nutritional status	Neutral
Cassen et al. (1996) [47]	Pre-post Experimental 16 days	LTC US	All residents consumed pureed diet Ex: Discharged or passed away	3D shaped pureed diet n = 18	Unshaped pureed diet n = 18	-Mealtime satisfaction (survey and staff report) -Cost	Neutral
Cassen et al. (1996) [47] Follow-up study	Cross-over cohort 12 m	LTC US	Residents consumed pureed diet for ≥1 m	6 m of 3D shaped pureed diet n = 13	Unshaped pureed diet n = 24	-Weight change	Neutral
Espinosa-Val et al. (2020) [43]	Prospective quasi-experimental	Hospital Spain	Dementia patients >18 y discharged from hospital Mean age (y) 84.1 ± 7.8	18 m follow up with recommendation and advice provided to family/caregivers	On admission n = 219 Standard n = 1 Easy mastication diet n = 117 Blended diet n = 88 Mixed diet n = 13	-Nutritional status	Neutral
Farrer et al. (2016) [48]	Pre-post Experimental 2 weeks	Hospital, Australia	Patients >18 y consuming pureed diet, medically stable and able to communicate	Moulded pureed diet (Texture C) n = 7	Unmoulded pureed diet (Texture C) n = 13	-Mealtime satisfaction (survey)	Neutral
Garon et al. (1997) [49]	RCT 1 year	Hospital stroke rehabilitation UK	Stroke patients with previously identified thin fluid aspiration by videofluoroscopy Mean age (y) 76.8	TFs + free access of water n = 10	TFs only n = 10	-Mealtime satisfaction (survey)	Positive
Gellrich et al. (2015) [50]	Observational Retrospective	38 clinics Germany/Austria/Switzerland	Patients with oral cancer n = 1526	Liquid, mashed	Standard diet	-Weight change	Neutral
Germain et al. (2006) [51]	RCT 12 weeks	LTC Canada	Residents aged 65–90 y admitted ≥3 m and had >7.5% weight loss in the last 3 m or BMI < 24 with dysphagia evaluated by RIC tool (Alzheimer’s n = 8, dementia n = 6, stroke n = 2, Parkinson’s n = 1) Ex. Cancer, chronic intestinal disease, terminally ill patients Mean age (y) 59	Shaped minced, minced/pureed or pureed diet and consistency-controlled TFs using Bostwick consistometer (nectar, honey, pudding) n = 9	Unshaped minced-70, minced-3 or pureed diet and uncontrolled honey-level TF (consistency not systematically controlled) n = 8	-Weight change	Neutral
Higashiguchi (2013) [52]	Experimental Cohort 7 days	17 hospitals/LTCs Japan	Inpatient and residents on TMDs with inadequate consumption (stroke n = 19, cancer n = 9, heart failure n = 7, fracture n = 5, dehydration n = 4, pressure ulcers, n = 3, pneumonia n = 2, anaemia n = 2, COPD n = 2, dementia n = 2, diabetes n = 1, Parkinson’s n = 1, other n = 17, none n = 2) (require total meal assistance n = 17, partial n = 6, none = 34) Mean age (y) 81.6 ± 9.3	3 days of nutrient-dense (enzyme-infused) TMDs nutrients were not diluted, and volume not increased n = 57	4 days of unmodified TMDs	-Mealtime satisfaction (Survey)	Positive
Karagiannis et al. (2011) [23]	RCT 8 days	Hospital subacute units Australia	Patients ≥18 y aspirated on thin liquids with prescription of modified or TF diet by SLTs without chronic respiratory conditions or prior tracheostomy Mean age (y) 79.5	TMDs (puree; minced; soft/minced) + TF (honey; pudding; nectar) + free access of water n = 13	TMDs + TF n = 5	-Mealtime satisfaction (survey)	Positive
Keller et al. (2012) [53]	Pre-post Experimental 9 m	Hospital and LTC Canada	All dysphagic residents fully consumed pureed or minced diets (stroke, Parkinson’s, dementia) Ex. Enteral feed Facility mean age 67 and 82 y	6 m of mix of 61% bulk and 39% shaped ready-to-use (reduced nutrients dilution and easier to chew and swallow) commercial TMDs n = 42	3 m of bulk commercial TMDs (unshaped, packaged in bulk)	-Weight change	Positive
Keller and Duizer (2014) [54]	Observational Interview	5 Rehabilitation and LTCs Canada	Consumed pureed diet for ≥1 week (stroke n = 6, delirium n = 2, spinal cord injury n = 1, diabetic coma n = 1, neck cancer n = 1, Parkinson’s n = 1, difficulty chewing/swallowing n = 3 Mean age (y) 77.3	None	Commercial (and in-house made) pureed diet n = 15	-Mealtime satisfaction (interview)	Neutral
Kennewell and Kokkinakos (2007) [55]	Observational Cross-sectional	2 hospitals Australia	Dysphagic patients	Infant-cereal fortified minced/pureed diets n = 17	Unfortified pureed diets	-Mealtime satisfaction (interview) -Cost	Neutral
Konishi and Kakimoto (2020) [56]	Observational Cross-sectional	LTC Japan	Older dementia residents had been admitted to a LTC between 2016–2019 Mean age (y) 87.9	Soft, n = 34 Chopped, n = 28 Blended, n = 9	Standard diet, n = 52	-Weight	Neutral
Maeda et al. (2019) [46]	Retrospective Observational	Hospital Japan	≥65 y admitted to an academic hospital during 2017–2018 with complete nutritional screening Mean age (y) 75.9 ± 7.0	TMDs, n = 110	Standard, n = 3484	-Weight -Nutritional status	Neutral
Massoulard et al. (2011) [17]	Observational Cross-sectional	4 LTCs France	All residents with chewing or swallowing difficulties Mean age (y) 85.8 ± 9.3	Chopped, n = 12 Mixed, n = 26	Standard diet, n = 49	-Weight comparison -Nutritional status	Neutral
Martín et al. (2018) [42]	Quasi-experimental 6 months	Hospital Spain	Acute geriatric unit patients ≥70 y diagnosed with OD during hospitalisation by nurses using volume-viscosity swallow test Mean age (y) 84.6 ± 5.5	14-day menus of TMDs (texture E or C) with TFs (nectar or pudding); ONS for malnourished or patients at risk of malnutrition; oral health recommendations n = 62	Standard hospitalisation recommendations, which were not applied systematically nor in a standardised individualised application n = 124	-Weight change -Nutritional status	Positive
Miles et al. (2019) [44]	Observational Cross-sectional	12 LTCs New Zealand	Residents consuming > 3 servings/day of commercial TMDs (dementia n = 37, cognitive impairment n = 65, brain injury n = 25, progressive neurological disease n = 9) Mean age (y) 85 ± 7.7	None	Commercial fortified TMDs and TFs n = 67	-Weight comparison -Nutritional status -Mealtime satisfaction (interview)	Neutral
Okabe et al. (2016) [57]	Observational Cohort with 1-year follow up	2 mid-sized cities Japan	≥60 y living at home or using in-home nursing care without malnutrition	None	Minced/pureed/mixed n = 339	-Nutritional status	Neutral
Ott et al. (2019) [58]	Pre-post Experimental 12 weeks	2 LTCs, Germany	Residents diagnosed with chewing or swallowing receiving TMDs regularly (all participants had cognition impairment) Mean age (y) 86.5 ± 7.4	6 weeks of usual TMDs (completely pureed or partial soft food) n = 16	6 weeks of one level of reshaped TMDs and enriched with 600 kcal energy and 30 g protein n = 16	-Weight change -Mealtime satisfaction (interview)	Neutral
Reyes-Torres et al. (2019) [37]	RCT 12 weeks	National Institute, Brazil	≥65 y with a caregiver and a confirmed diagnosis of oropharyngeal dysphagia, and consumed TMDs and TFs (evaluated by V-VST and EAT by dietitians) Mean age (y) 76	Consistency-modified and standardised TMDs and nectar or pudding level TFs (measured with Brookfield viscometer) n = 20	Unmodified pureed diet with one viscosity of TFs (consistency not systematically controlled) n = 20	-Weight change -Handgrip -Nutritional status	Positive
Shimizu et al. (2018) [59]	Retrospective Cross-sectional	Hospital rehabilitation ward, Japan	≥65 y patients Ex. Tube feeding, parenteral nutrition, history of stroke, neurodegenerative disease Mean age (y) 80.6 ± 7.5	TMDs, n = 22	Standard diet, n = 123	-Weight -Nutritional status
Shimizu et al. (2020) [39]	Retrospective Cohort	7 rehabilitation facilities, Japan	≥65 y with pneumonia enrolled in rehabilitation facilities with record of malnutrition screening at admission and discharge Mean age (y) 82.9 ± 9.8	Providing multiple TMD stage ≥ 6 n = 109	Providing TMD stage < 6 n = 109	-Weight -Nutritional status change	Neutral
Vucea et al. (2019) [45]	Observational Cross-sectional	32 LTCs, Canada	Randomly recruited residents > 65 y admitted for ≥1 m Mean age (y) 86.8 ± 7.8	TMDs Bite-sized, n = 91 Minced, n = 139 Pureed, n = 68	Standard diet, n = 338	-Nutritional status	Positive
Welch et al. (1991) [60]	Pre-post Experimental 6 m	LTC US	Residents consumed pureed diet and weighed below average or serum albumin/transferrin levels below normal values (identified from medical records) Mean age (y) 81	Pureed diets with fortified high-fibre cereals and commercial supplements n = 15	Pureed diets with unfortified cereals	-Weight change	Neutral
Wright et al. (2005) [36]	Observational Cross-sectional	Hospital elderly and neurology wards UK	All medically stable patients consumed TMDs or standard diet (reasons for TMDs: 80% dysphagia, 20% poor dental state; stroke n = 19, fall n = 8, other n = 3) Mean age (y) 81.5	Texture B—Smooth pureed, n = 10 Texture D—Minced/mashed, n = 9 Texture E—Soft, n = 11 (UK national descriptors, 2002)	Standard diet, n = 25	-Weight comparison	Neutral
Zanini et al. (2017) [41]	Pre-post experimental 6 m	20 LTCs Italy	Dysphagic residents >65 y with low comorbidity levels (diagnosed by a physician or reported in medical records) Mean age (y) 79.72 ± 12.31	6 m of personal-modified levels of density, viscosity, texture and particle size TMDs n = 401	6 m of unmodified TMDs	-Weight change -Nutritional status -Mealtime satisfaction (EdFED)	Positive

Note. RCT—randomized control trial; Ex.—exclusions; BMI—body mass index; LTC—long-term care; y—years old; TMD—texture-modified diet; TF—thickened fluids; RIC tool—Rehabilitation Institute of Chicago Clinical Evaluation Dysphagia; SLT—speech-language therapist; ONS—oral nutrition supplement. m—months. * Quality of the study was assessed using Quality Criteria Checklist (QCC). Positive studies were identified as clearly addressed issues of criteria, bias, generalisability, data collection and analysis. Neutral studies were indicated as neither exceptionally strong nor exceptionally week.