For patients with motor neuron disease, swallowing difficulties will occur sooner or later in the course of the disease, making what should be the enjoyment of good food into a battle at every meal, a battle between the patient and swallowing food, and a battle between the family or caregiver and doing everything possible to increase nutrition for the patient. We can start by understanding what malnutrition is, usually defined as one of two criteria: weight loss of more than 10% or a BMI <18.5 kg/m2. Malnutrition is an independent risk factor for poor prognosis in ALS patients, increasing the risk of death eightfold. Let's go over the three steps of swallowing and what can go wrong at each step in patients with motor neuron disease: Step 1, the tongue moves the food backward to the soft palate - it is likely that in ALS patients the food stays in the mouth or reaches the throat without adequate chewing. In the second step, the muscles of the upper and lower larynx send food down to the stomach (esophagus) while closing the air passages to the nose and lungs (trachea) - and people with ALS tend to send food into the nasal cavity, especially when lying down; or the food sticks in the throat and cannot be swallowed; blocking the trachea creates asphyxia. Step 3: Relaxation of the upper esophageal sphincter to admit food - ALS patients often cannot relax their muscles so that food is obstructed and feels blocked in the throat. In the early stages of difficulty swallowing, the following can be done to help make swallowing easier 1. Take more time and do not rush; 2. Make the patient more relaxed and confident (he/she can control the time); 3. Concentrate (at least one person around), but avoid talking while eating or watching TV while eating; 4. Pay attention to the eating posture (upright, adjust the back of the chair for comfort, close the jaw to close the airway when swallowing, plastic cup); 5. (easy to handle, reduce the possibility of choking); 6, emergency response - patting the back can cause food to get stuck tighter in the throat. Do not use liquid to flush food downward. Choking can be resolved by using a shock to the abdomen and calling the emergency system at the same time. When the patient's ability to eat is further diminished, it is time to consider creating a new access point to address the nutritional problem, i.e., a gastrostomy. There is growing evidence that a proper nutritional status can slow down the progression of the patient's disease, so what are the signs that a patient needs to be considered for gastrostomy surgery? Generally, gastrostomy surgery should be considered when the following symptoms are present 1. clear difficulty in swallowing, eating for more than one hour. 2. There have been many cases of choking and aspiration. 3. Malnutrition and weight loss of more than 10% due to eating disorders. 4.Eating is no longer an enjoyable process at all, instead, patients refuse or actively reduce their diet because of the fear of choking and coughing that may occur during eating.