Decoding the IDDSI: What are level 6 eating and drinking guidelines?

October 8, 2025 •

5 min read

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), over 590 million people worldwide live with dysphagia, a swallowing disorder. For many, managing this condition safely requires a texture-modified diet, such as the Level 6 Soft and Bite-Sized guidelines, to prevent choking and aspiration.

Quick Summary

Level 6 eating and drinking guidelines from the IDDSI define a soft and bite-sized diet for those unable to safely bite large food pieces but can chew smaller, moist ones. This diet requires moderate chewing and specific particle size limits to mitigate choking risks associated with dysphagia.

Key Points

Level 6 Defined: The Soft and Bite-Sized diet is for individuals who can chew small, moist pieces of food but have difficulty biting off or chewing larger, harder items.
Particle Size is Key: For adults, food pieces must be no larger than 1.5 cm x 1.5 cm, roughly the width of a fork.
Focus on Moisture and Softness: All food should be tender, moist, and easily mashed with a fork, with no separate, thin liquids dripping off.
IDDSI Testing Methods: The fork pressure test, where food is mashed and does not regain its shape, confirms the correct texture for this level.
Avoid High-Risk Foods: Hard, tough, sticky, crunchy, fibrous, or crumbly foods, as well as those with skins, husks, or seeds, are strictly avoided.
Separate Drink Guidelines: Liquid thickness (IDDSI Levels 0-4) is assessed and prescribed independently of food texture by a clinician.
Preventing Complications: Proper adherence to Level 6 helps prevent serious health risks like choking, aspiration pneumonia, malnutrition, and dehydration.

What is the IDDSI Framework?

The International Dysphagia Diet Standardisation Initiative (IDDSI) created a global framework to standardize the terminology and definitions for texture-modified foods and thickened liquids. This was a necessary step to address the previous inconsistencies and confusion in managing dysphagia, or swallowing difficulties, across different healthcare settings and countries. The framework consists of a continuum of eight levels, from Level 0 (thin liquids) to Level 7 (regular foods), each with specific characteristics and testing methods. By standardizing these levels, IDDSI aims to improve patient safety and reduce adverse events like choking and aspiration pneumonia. The guidelines are a language, not a law, and are designed to be person-centered, with clinical judgment guiding the best approach for each individual.

Understanding Level 6: Soft and Bite-Sized

IDDSI Level 6, known as Soft and Bite-Sized, is designed for individuals with limited ability to bite or manage large pieces of food but who can chew and swallow smaller, softer pieces. A person might be prescribed this diet by a speech-language pathologist or clinician if they have: dental issues like missing molars or ill-fitting dentures; reduced bite force; chewing fatigue; or difficulty moving food around in the mouth.

Key Characteristics of Level 6 Foods

Soft, tender, and moist throughout: Foods at this level are not dry, tough, or hard.
Bite-sized pieces: Food is cut or prepared into pieces no larger than 1.5 cm x 1.5 cm for adults. This is approximately the size of a thumbnail or the width of a standard dinner fork.
Easily mashed: Food can be easily mashed or broken down with moderate pressure from a fork or spoon. A good test is to press the food with a fork until your thumbnail blanches white; the food should squash completely and not regain its original shape.
No separate thin liquids: Sauces, gravies, or juices should be thick and smooth, binding the food together rather than leaking from it.
Requires chewing: The individual must have the ability to chew the bite-sized pieces before swallowing.

Foods to Include on a Level 6 Diet

Protein: Well-cooked, tender meats and poultry, chopped into small pieces. Flaked fish (ensure all bones are removed). Eggs (scrambled, poached, or mashed). Cooked pulses, such as well-cooked lentils or beans.
Starches: Soft, well-cooked pasta served with a thick sauce. Fluffy mashed potatoes. Softened cereals like porridge or well-soaked Weetabix. Plain white or wholemeal bread with crusts removed, soaked in soup or sauce.
Fruits and Vegetables: Soft, ripe fruits without skin or seeds (e.g., ripe banana, avocado, cooked apple). Well-cooked, soft vegetables (boiled, steamed) cut to size. Canned fruits and vegetables, ensuring excess liquid is drained.
Dairy and Desserts: Smooth yogurt, custards, milk puddings, and plain sponge cake with cream or custard. Grated cheese added to other soft foods.

Foods to Avoid on a Level 6 Diet

Hard, crunchy, or crispy textures: Including hard biscuits, crackers, nuts, and raw vegetables.
Tough, chewy, or stringy foods: Such as tough meat, pineapple, or celery.
Crumbly foods: Dry cakes, crusts, or pie pastry.
Sticky foods: Including peanut butter, cheese chunks, or marshmallows.
Foods with husks, skins, or seeds: Peas, corn, and grapes.
Mixed consistencies: Foods with separate liquid and solid parts, like cereal in thin milk or watery soups with large pieces.

Food Preparation Tips

To ensure food meets the Level 6 criteria, proper preparation is key. Here are some tips:

Moisture is crucial: Always serve drier foods with a thick sauce, gravy, or custard to increase moisture and help bind the particles together.
Use cooking methods that tenderize: Slow-cooking, steaming, and boiling are effective for making meats and vegetables soft and tender.
Fortification for extra nourishment: To prevent weight loss, consider fortifying meals by adding full-fat dairy products, butter, cream, or extra cheese to soups, potatoes, and puddings.
Check food temperature: Perform the fork pressure test at the temperature the food will be served, as consistency can change upon cooling.

Level 6 vs. Other IDDSI Levels

IDDSI provides a comprehensive continuum of texture-modified diets. Understanding how Level 6 compares to other levels is important for safe and appropriate feeding. This table outlines the key differences in food texture and chewing ability required for some adjacent levels.


Feature	Level 5: Minced & Moist	Level 6: Soft & Bite-Sized	Level 7: Regular Easy to Chew
Chewing Ability	Minimal chewing required.	Moderate chewing required.	Easy to chew, but less effort than regular foods.
Food Texture	Soft, moist lumps (max 4mm adult size) and not sticky.	Soft, tender, moist, and bite-sized (max 1.5cm adult size) pieces.	Normal, everyday soft foods that deform easily with pressure.
Particle Size	Max 4mm (like a grain of rice).	Max 1.5cm (like a thumbnail).	No restriction, but food should be naturally soft.
Consistency	Holds its shape on a spoon but collapses easily.	Can be mashed easily with a fork and requires no knife to cut.	Regular texture but naturally softer than other regular foods.
Associated Condition	Often prescribed for individuals with greater difficulty controlling oral movements.	For those who can chew smaller pieces but cannot safely bite off larger ones.	Suitable for individuals with no choking risk who just need softer options.

Drinks and Hydration

While Level 6 refers to food texture, drinks are classified separately by IDDSI. The required liquid thickness depends on a person's specific swallowing abilities and is assessed by a speech-language therapist. A person on a Level 6 food diet may be prescribed any drink level from 0 (thin liquids) to 4 (extremely thick), depending on their individual needs. Staying properly hydrated is vital, so ensuring an adequate fluid intake from an appropriate thickness is crucial. If an individual requires thickened fluids, it's important to ask a healthcare professional for guidance on whether specific foods can be thickened safely.

Conclusion

For individuals with chewing or swallowing difficulties, adhering to the Level 6 eating and drinking guidelines is a critical step towards safe and enjoyable mealtimes. The IDDSI framework provides clear, evidence-based standards to help caregivers and healthcare professionals ensure food is prepared to the correct texture, significantly lowering the risk of choking and aspiration. By focusing on soft, moist, and bite-sized foods, it is possible to provide a nutritionally complete and varied diet that supports both health and quality of life.

Learn more about IDDSI guidelines and download helpful resources from the official IDDSI website [https://www.iddsi.org/].

Frequently Asked Questions

The primary purpose is to provide a safe diet for individuals with moderate chewing difficulties, such as those with dental problems or conditions like dysphagia, by ensuring food is soft, moist, and cut into small, bite-sized pieces to prevent choking.

You can perform a fork pressure test. Place a small piece of food on a plate and press down on it with a fork until your thumbnail turns white. The food should easily squash and not return to its original shape.

Plain white or wholemeal bread is only suitable if the crusts are removed and it is softened by soaking in a sauce or soup. Dry, untoasted, or seeded bread should be avoided due to the choking risk from crumbs or hard particles.

Use a thick, smooth, non-pouring sauce or gravy that binds the food together, rather than a thin, watery one. This adds moisture and helps prevent the separation of liquid from the solid food.

Yes, avoid fruits that are hard, fibrous, or juicy to the point that liquid separates from the solid part during chewing, such as melons, oranges, or pineapple. Also avoid any fruits with skins or seeds.

To ensure a balanced diet, incorporate soft and bite-sized foods from all major food groups. To prevent weight loss or boost nutrients, enrich meals with full-fat dairy products, butter, or cream.

Level 6 (Soft & Bite-Sized) has soft, moist pieces up to 1.5 cm that require moderate chewing, while Level 5 (Minced & Moist) consists of smaller, moist lumps (max 4mm) that require minimal chewing.