Solid foods may be modified to accommodate perceived limitations in elderly patients with dysphagia. Solid food modification has been suggested to promote safe swallowing and adequate nutrition. However, no strong and universal clinical guidelines are available to describe the most appropriate modification of foods.14 At least one study indicated that among nursing home residents, 91% of patients placed on modified diets were placed on overly restrictive diets.76 Only 5% of these patients were identified to be on an appropriate diet level matching their swallow ability and 4% of patients were placed on diets above their clinically measured swallow ability. More recently, in an attempt to standardize the application of modified diets in patients with dysphagia, the National Dysphagia Diet was proposed.77 The National Dysphagia Diet is comprised of four levels of food modification with specific food items recommended at each level (Table 4). While this approach is commendable, unfortunately, to date no studies have compared the benefit of using this standardized approach to institution specific diet modification strategies.