AI-Enabled Mobile App for Safe Eating in Older Adults With Dysphagia

Dysphagia (swallowing impairment) is a highly prevalent condition in older adults and is associated with increased risks of aspiration, malnutrition, dehydration, and reduced quality of life. While the International Dysphagia Diet Standardization Initiative (IDDSI) framework provides standardized terminology and practical methods for modifying food and liquid textures, ensuring accurate and consistent adherence to prescribed texture levels remains challenging in community settings. In particular, adherence is often limited by the lack of real-time feedback, variable caregiver skills, and difficulties in verifying food texture during routine meal preparation.

This study evaluates a novel, implementation-oriented digital health intervention designed to address these barriers. The intervention is an AI-enabled mobile application that supports real-time classification of food and liquid textures using smartphone-based image capture. The application incorporates a safety-first decision logic, providing conservative classification outputs alongside prompts encouraging users to verify textures using established IDDSI field tests (e.g., flow test, fork pressure test) when classification uncertainty is detected. The system is designed to function within everyday meal preparation workflows, thereby targeting behavioral adherence at the point of consumption rather than relying solely on retrospective education.

The trial adopts a pragmatic, community-based randomized controlled design to assess real-world effectiveness under typical home-use conditions. The intervention is delivered over a defined period of active use, during which participants and/or caregivers may engage with the application during meal preparation, food purchase, or consumption. The application records usage metrics (e.g., frequency of image captures, classification outputs, and uncertainty prompts), enabling evaluation of engagement and fidelity. The intervention is supported by structured onboarding and ongoing technical support to ensure usability among older adults and their caregivers.

The comparator reflects current standard practice in community dysphagia management and allows evaluation of the incremental benefit of digital decision support beyond education alone. The study is designed under a superiority framework to determine whether access to the AI-enabled tool results in meaningful improvements in behavioral adherence, which is considered the proximal mechanism linking dietary modification to downstream clinical outcomes. By focusing on adherence as the primary target, the study aligns with an implementation science perspective, recognizing that efficacy of dietary recommendations depends on their consistent and correct application in daily life.

In addition to assessing behavioral outcomes, the trial incorporates a multidimensional evaluation framework spanning symptom burden, functional oral intake, health-related quality of life, and safety events. These domains provide a comprehensive understanding of both intended benefits and potential unintended consequences, including risks related to misclassification, over-reliance on automated guidance, or increased user burden. A subsample will undergo instrumental swallowing assessments to explore potential changes in swallowing physiology associated with improved adherence, thereby linking behavioral and mechanistic outcomes.

The study also integrates human-technology interaction considerations, including usability and perceived workload, to evaluate implementation feasibility and scalability. These measures are important for determining whether the intervention can be sustainably adopted in routine practice, particularly among older populations with varying levels of digital literacy.

From an analytical perspective, the trial is designed to estimate real-world effectiveness using an intention-to-treat framework, capturing the impact of offering the intervention under typical conditions rather than ideal adherence scenarios. Exploratory analyses will examine associations between engagement metrics and clinical outcomes, as well as potential effect modifiers such as baseline functional status, cognitive factors, and living arrangements.

This research addresses a critical gap in dysphagia care by evaluating a scalable, technology-assisted approach that operationalizes standardized dietary guidelines in real-world settings. It also contributes to the emerging field of AI in healthcare by providing rigorous evidence from a randomized controlled trial conducted outside of highly controlled clinical environments. The findings are expected to inform both clinical practice and public health strategies aimed at improving safe eating behaviors among community-dwelling older adults with dysphagia.

Inclusion criteria

• Adults aged 60 years or above
• Community-dwelling (living in a home or community setting)
• Suspected or clinically identified oropharyngeal dysphagia
• Currently consuming food or liquids orally at texture-modified levels
• Able to provide informed consent, or with caregiver support if mild cognitive impairment is present
• Access to a smartphone or tablet, either independently or with caregiver assistance
• Willing and able to participate in study procedures and follow-up assessments

Exclusion criteria

• Exclusive dependence on non-oral feeding (e.g., tube feeding)
• Severe cognitive impairment or severe visual impairment that prevents meaningful participation
• Medical conditions or circumstances that make participation unsafe
• Life expectancy less than 6 months
• Current participation in another dysphagia-related interventional study
• Use of other digital tools specifically designed for food texture classification during the study period