Dysphagia, or difficulty swallowing, is a life-threatening condition that greatly impacts the daily health and quality of life of affected individuals. It can be the result of many different etiologies consisting of different types of head and neck injuries, neurological disorders, behavioral disorders, or anatomical anomalies. Dysphagia can result from various conditions that impair swallowing mechanisms, such as swallowing of caustic agents (1), and cervical spinal cord injuries (cSCI) (2). Additionally, these injuries can often originate from intraoperative trauma that result in either nerve damage or compression of the bolus pathway. Moreover, neurogenic dysphagia can be present amongst post-stroke patients (3), patients with neurodegenerative disorders, such as Parkinson's disease (4), and patients with neuromuscular disorders (5), such as multiple sclerosis (6), Duchenne muscular dystrophy (7) and Pompe's disease (8). Furthermore, neurodevelopmental conditions including autism Down syndrome (9) can result dysphagia in these patient populations. Other causes of dysphagia result from various anatomical anomalies which include esophageal tumors (10), esophageal strictures, and cervical spine spondyloses (11). In particular, dysphagia can also present in healthy aging adults, due to their increased susceptibility to several of the aforementioned etiologies, in addition to natural age-relate risk factors, such as decreased motor coordination, decreased tongue strength, and decreased salivary secretions (12, 13). Patients with dysphagia are at severe risk of sequelae that present a high risk of mortality. Dysphagia patients have a higher risk of aspirating sterile gastric contents or food remnants that can lead to aspiration pneumonia, a life-threatening pulmonary infection (14). Furthermore, due to dysphagia patients often experiencing impaired deglutition motility, making it difficult for them to consume their necessary daily nutritional requirements obtained through eating and drinking, these patients may be at further risk for malnutrition and dehydration. This difficulty in ingesting food and beverages can have an extended impact on a patients’ overall wellbeing by disrupting vital metabolic processes and immune system responses (15).

In 2013, 2.7 million US adult hospitalized patients (ages 45–90) were reported to have had a dysphagia diagnosis. Notably, this total does not consider the remaining general population who may have only been diagnosed by outpatient facilities, or who refused to seek out clinical care (16). Hong et al. reported that in 2012 9.44 million adults (4.02% of the general US population) reported having dysphagia, with the estimated prevalence increasing to approximately 15.10 million in 2022 (5.91% of the general US population) (17). Hence, a substantial market size exists for the introduction of accommodating technologies and programs that can ease the quality-of-life burdens that accompany dysphagia. Among these, there exists a significant unmet need in providing suitable dietary options for patients with dysphagia during aviation travel. Commercial aviation presents a unique challenge for individuals with dysphagia due to constrained food preparation environments, standardized catering practices, and limited opportunities for individualized meal modification once onboard. Unlike hospitals or long-term care settings, airline food services are not designed around texture-modified diets, creating a potential mismatch between passenger medical needs and available in-flight options.

The ideal approach for accommodating individuals with dysphagia during aviation travel should include a standardized system that allows patients to effortlessly alert a flight attendant of their condition, such as by means of a tag or bracelet specifying their individual food and beverage options. This would ensure that these patients can be arranged to receive a wide range of menu options that meet their specific needs either onboard or through prior notifications during travel booking or check-in. The following work will investigate the current menu options that are presently available within the major three carriers in the United States, American, United, and Delta. The food and beverage options that will be discussed from these airlines will be categorized using the International Dysphagia Diet Standardization Initiative (IDDSI) framework (Figure 1) (18). This framework provides a universal classification of different ingestible consistencies, aiming to minimize the risks of choking and aspiration in individualized patients that each have different levels of dysphagia.

A descriptive review was conducted of publicly available in-flight menu options from the three largest U.S. commercial airlines: American Airlines, United Airlines, and Delta Air Lines. Menu identification and IDDSI classification were performed by a single reviewer due to resource constraints.

Airline menus were sourced directly from the airlines’ official websites to reflect information available to passengers at the time of review. Because menu formats varied by airline and seating class, each airline's publicly available menus were reviewed individually. Menu options across all seating classes were considered, including snack menus and specialty diet menus such as vegetarian, vegan, gluten-free, and Kosher.

Menu item descriptions were classified using the International Dysphagia Diet Standardization Initiative (IDDSI) framework, which provides standardized definitions for food textures and liquid consistencies used in dysphagia management. Drink items were classified using IDDSI Levels 0–4, while food items were classified using IDDSI Levels 3–7, consistent with IDDSI guidance. Classification was based solely on publicly available menu descriptions, without direct testing or preparation of food items.

When menu descriptions lacked sufficient detail to clearly determine texture or consistency, items were classified conservatively based on the most typical form in which the item is served or were noted as uncertain when classification could not be reasonably inferred. The reviewer recorded the total number of menu items assigned to each IDDSI level for each airline. Descriptive statistics, including counts and proportions of items per IDDSI level, were used to summarize menu distributions across airlines. No inferential statistical testing was performed due to the descriptive nature of the study.

When identifying the criteria for how accommodating a given menu is for dysphagic patients, a few factors are important to consider. First, there is no clinical evidence to suggest that menu items at one level are objectively best for dysphagic patients. Often dysphagic diets need to be specifically tailored to patients by speech-language pathologists and dieticians. Generally, however, these food and beverage items will typically range from Levels 2–7 in order to avoid highly viscous liquids that may present severe risk for aspiration. For the purposes of this study, the three major American airlines will be evaluated on whether they offer a well-distributed variety of menu options across each of the IDDSI Levels 2–7, ensuring an equal accessibility and choice for all individuals with different dietary needs.

It is important to note that the menu options for each of the following American airlines are subject to frequent changes. Furthermore, these airlines frequently offer specialized meal options that are exclusive to premium membership holders. The following menu listings focus on food and beverage items that are publicly available on the airlines’ official websites and can be reasonably accessed by economy passengers booking a flight with one of the respective airlines.

The three major U.S. airlines evaluated in this study offer diverse menu options intended to enhance passenger comfort and experience during air travel. Across all carriers, a wide range of beverages, including water, coffee, juice, soda, beer, and wine, are consistently available and are categorized as IDDSI Level 0 (thin liquids) (18). In addition, each airline provides special meal accommodations such as vegetarian, vegan, gluten-free, and Kosher options, with some carriers also offering diabetic, low-fat, or lactose-free meals. While these accommodations address certain dietary preferences and restrictions, they do not specifically account for texture and consistency modifications required by many individuals with dysphagia (18).

When evaluating menu items across IDDSI Levels 2–7, results from publicly available airline menus reveal a substantial lack of options suitable for a broad range of dysphagia severities. The full listing of identified menu items and their IDDSI classifications is presented in Table 1, while the prevalence of items across IDDSI levels is summarized in Figures 2, 3. Figure 2 depicts the overall distribution of all identified menu options by IDDSI level, whereas Figure 3 excludes items restricted to snack boxes, specific times of day, or flight distance and destination requirements. This distinction was included to assess how temporal and logistical constraints further limit accessibility for passengers with dysphagia. Such restrictions may exacerbate feelings of exclusion among dysphagic travelers, particularly during long-duration flights where alternative food options are limited or unavailable (14, 15).

Across all airlines, menu offerings were heavily concentrated at IDDSI Level 0 (thin liquids) and Level 7 (regular foods). While certain individuals with mild dysphagia may safely tolerate Level 7 foods, this does not adequately address the needs of patients who require texture-modified or thickened consistencies. Individuals with dysphagia vary widely in their swallowing capabilities and nutritional requirements (18), and many may require lower-level options (e.g., Levels 2–6) to eat safely. The limited availability of such options highlights a significant accessibility gap in current airline food service practices and raises concerns regarding passenger safety, nutritional adequacy, and overall inclusivity (14, 15).

No inferential statistical testing was performed, as this study was designed as a descriptive review of publicly available menu information. The intent was to characterize existing menu offerings and identify gaps relative to a standardized dysphagia diet framework, rather than to draw statistical inferences about differences between airlines. Nevertheless, the observed absence or scarcity of menu items at several IDDSI levels across all three carriers consistently points to a systemic lack of dysphagia-appropriate accommodations in commercial aviation.

The SWOT analysis included in this study was intended as a qualitative, industry-oriented framework to contextualize potential implementation pathways for dysphagia accommodations. While SWOT analysis is useful for identifying operational strengths, limitations, opportunities, and threats, it inherently involves subjective interpretation and does not provide quantitative decision-making rigor. Future research could build upon the present findings by incorporating more structured analytical frameworks, such as gap analyses of IDDSI-aligned menu availability, benchmarking against healthcare or other transportation catering systems, multi-criteria decision analysis to evaluate intervention feasibility, or cost-effectiveness and policy gap analyses to assess regulatory and economic considerations.

The discussion of wearable neuromuscular electrical stimulation (NMES) technology is included as a forward-looking perspective rather than as a component of the present menu analysis. Wearable NMES devices have demonstrated potential in dysphagia rehabilitation (22) and may, in the future, serve as adjunctive tools to support safer swallowing in non-clinical environments. However, such technologies should be viewed as complementary rather than replacements for appropriate dietary accommodations. Ensuring access to safe and suitable food and beverage options remains a foundational requirement for inclusive travel experiences among individuals with dysphagia.

This study relied on publicly available online menu descriptions, which may not fully capture variations in food preparation, texture, or moisture content that occur during in-flight service. Menu offerings may also vary by route, aircraft type, and catering provider. Additionally, menu classification was conducted by a single reviewer, which may introduce subjective bias despite the use of a standardized framework (18). Resource constraints prevented the use of multiple reviewers or inter-rater reliability assessment. Finally, the study focused exclusively on U.S. airlines, which may limit generalizability to international carriers with different regulatory environments and catering practices.

Despite these limitations, this work highlights a clear and underexplored accessibility gap in commercial aviation. As air travel continues to serve an increasingly diverse and aging population, addressing the needs of passengers with dysphagia will be essential to promoting safety, dignity, and inclusion. The findings underscore the need for airlines to consider texture-modified dietary accommodations as part of broader accessibility initiatives and provide a foundation for future research and policy development in this area.

To support safe swallowing for individuals with dysphagia, airlines should consider expanding the availability of food and beverage options spanning IDDSI Levels 2–7. Many individuals with dysphagia are unable to safely consume thin liquids classified as IDDSI Levels 0–1 due to increased aspiration risk (19) and instead require thickened liquids or texture-modified foods tailored to their swallowing needs.

Although passengers may bring their own thickening agents for in-flight use, this option can present practical challenges, particularly in the context of aviation security procedures governing liquids. While medical exceptions exist, reliance on personal accommodations places additional responsibility on passengers and may limit equitable access to safe nutrition during air travel. Providing onboard alternatives could therefore reduce this burden and improve inclusivity.

From an implementation perspective, several potential interventions can be considered across different time horizons. Short-term, lower-barrier strategies include offering commercially available thickening agents upon request or ensuring that at least one thickened beverage or puréed food option is available during meal service. Longer-term strategies may involve modifying existing menu items through puréeing or partnering with commercial suppliers of pre-prepared texture-modified meals designed for dysphagia management. These approaches would require greater coordination with catering services but may offer more comprehensive and consistent accommodations.

The range of feasible options and their respective strengths, limitations, opportunities, and challenges are summarized through a qualitative SWOT analysis (Table 2). Together, these findings underscore the need for airlines to consider dysphagia-related dietary accessibility as part of broader inclusive service initiatives and provide a foundation for future research and policy development in this area.

Furthermore, given that wearable electrode technology is permitted by the TSA for passenger carry-on, patient swallowing during long flights can be significantly improved beyond dietary measures through the use of smart technologies that permit electroceutical therapy while concurrently monitoring swallowing capabilities. For appropriate patients, neuromuscular electrostimulation (NMES) has shown to be more effective than traditional exercise-based swallowing alone (20) while providing similar anatomical advantages, such as neurogenesis and improved skeletal muscle hypertrophy and repair (21). Carnaby-Mann et al. found that in a synthesis of acceptable studies (n = 7) analyzing the application of NMES for swallowing therapy, that a mean score improvement of 20% in swallowing performance was detected following NMES treatment (22). Moreover, combining this with a real-time risk stratification model that assesses therapeutic efficacy via wireless telemetry that is compatible in airplane mode and with FAA-compliant battery technology would give the patient a much clearer insight into their current condition and progress. Alongside the implementation of dysphagia-accommodating meals, which is an immediate call-to-action that needs to be addressed, the following serves as a future step in catering to passengers during air travel that requires comprehensive support for swallowing difficulties.