Objective differences and pathway differentiation between twin subtypes within the same IDDSI level: A...

This study adopts a "pathway-priority" perspective to systematically quantify the texture-moisture-nutrition continuum of elderly-preferred food ingredients commonly consumed in China under the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. It focuses on intra-level differentiation between "twin-type/pathway pairs" (MO3 vs. LQ3, EX4 vs. PU4, EC7 vs. RG7), aiming to reveal objective distinctions in texture and nutritional orientation across pathways and to provide quantitative evidence for dietary level classification and prescription substitution in dysphagia management.

Twenty-six representative food ingredients were collected from seven major Chinese dietary regions through Python-based web crawling. According to IDDSI classification, samples were grouped into the liquid pathway (Levels 0-2, MO3, EX4) and food pathway (LQ3, PU4, Levels 5-7 including EC7/RG7). A TA.New Plus texture analyzer was used to measure hardness, adhesiveness, and cohesiveness. Nutritional components per 100 g-including energy, protein, fat, carbohydrate, and dietary fiber-were calculated using Huaxi Hospital Nutrition software. Statistical analyses included Mann-Whitney U tests with Cliff's δ for twin-type comparisons, Spearman correlation and Theil-Sen slope analysis for monotonic trends within pathways, and Kruskal-Wallis followed by Dunn-Bonferroni tests for intra-level differences among food categories. False discovery rate (FDR-BH) correction was applied, with significance set at q ≤ 0.05.

(1) In twin-type comparisons, MO3, EX4, and EC7 exhibited significantly lower hardness and energy density but higher moisture content (q ≤ 0.05), whereas LQ3, PU4, and RG7 contained higher energy and protein levels, reflecting hydration-safety orientation in liquid pathways versus structural-nutritional orientation in food pathways. (2) Within-pathway analyses showed that the liquid pathway (Levels 0 → 4) followed a "thickening-hardening-dehydrating" monotonic trend, with increasing hardness and energy but decreasing adhesiveness and moisture. The food pathway (Levels 3 → 7) displayed a "structuring-hardening-dehydrating-energizing" trajectory, indicating enhanced granularity and nutritional concentration. (3) Significant texture differences among food categories within the same level were observed (ε² = 0.37-0.67, q ≤ 0.05), suggesting that "same level ≠ interchangeable.". (4) The established "safety-nutrition balance window" identified key control zones: moisture 88.9-96.8 g/100 g and hardness 100-160 N/m² for MO3/EX4, and energy 70-324 kcal/100 g for PU4/RG7, providing practical references for clinical and process optimization.

Twin subtypes within the same IDDSI level exhibit systematic differences in texture and nutrition, confirming the hypothesis that "same level ≠ interchangeable." The liquid pathway emphasizes safety and hydration, while the food pathway prioritizes structure and nutrient density. By constructing an intra-pathway "texture-nutrition continuum" and safety-nutrition balance window, this study offers quantitative evidence for pathway selection, diet prescription, and quality control in dysphagia management. Future work should integrate VFSS/FEES imaging and clinical outcomes to map laboratory metrics to swallowing safety, facilitating translation from experimental assessment to clinical application.