Nutrition Diet: What are examples of level 6 food?

Affecting up to 8% of the global population, dysphagia, or swallowing difficulty, requires careful dietary management to ensure safety and adequate nutrition. The International Dysphagia Diet Standardisation Initiative (IDDSI) framework provides clear guidelines for this, making understanding what are examples of level 6 food essential for those who need a modified diet. This soft and bite-sized level ensures food is easy to chew and swallow, reducing the risk of choking and aspiration.

Quick Summary

This article details the International Dysphagia Diet Standardisation Initiative's Level 6 framework, outlining the criteria for Soft and Bite-Sized foods. It provides specific examples from various food groups, offers preparation and testing methods, and compares Level 6 with other dysphagia diet levels.

Key Points

• Level 6 Defined: A Soft and Bite-Sized diet for individuals with dysphagia who can chew, but need help with biting and managing tough textures.

• Specific Size Requirements: For adults, Level 6 foods must be cut into pieces no larger than 1.5cm x 1.5cm to minimize choking risk.

• Fork-Test Verification: A simple fork pressure test confirms if a food is soft enough; it should mash easily and hold its squashed shape.

• Variety is Possible: A wide array of protein, fruit, vegetable, and starch options are available, provided they are prepared to the correct softness and moisture.

• Moisture is Key: Foods must be moist, often requiring thick sauces or gravy, with no separate thin liquid that could increase aspiration risk.

• Certain Foods to Avoid: Hard, chewy, stringy, or crumbly foods, as well as those with skins, husks, or seeds, are not appropriate for a Level 6 diet.

What Is a Level 6 Soft and Bite-Sized Diet?

Level 6, or the Soft and Bite-Sized diet, is a texture-modified food category defined by the International Dysphagia Diet Standardisation Initiative (IDDSI). It is intended for individuals with dysphagia who can chew but may have difficulty biting off pieces of food or managing tough, hard, or fibrous textures. The defining characteristics are that the food is soft, tender, and cut into pieces no larger than 1.5 cm by 1.5 cm for adults. The food must also be moist, with no separate thin liquid, and should be easily mashed with the pressure of a fork. This approach prioritizes safety while still offering variety and flavor.

Characteristics of Level 6 Foods

To qualify as Level 6, food must meet specific criteria related to its texture, size, and moisture content. The goal is to provide a satisfying eating experience that requires minimal biting but moderate chewing. Key characteristics include:

• Size: For adults, all solid food pieces must be no larger than 1.5cm x 1.5cm. This can be checked by ensuring the food fits between the prongs of a standard fork.
• Softness: The food must be tender and easily broken down. A fork pressure test can be used to check this: the food should squash and not return to its original shape when pressed.
• Moisture: Food must be moist, with no separate thin liquid. This often requires the addition of thick sauces or gravies.
• Lack of Texture: Foods that are hard, tough, stringy, fibrous, crispy, or crumbly must be avoided.

Examples of Level 6 Soft and Bite-Sized Food by Group

Successfully following a Level 6 diet involves selecting appropriate foods and preparing them to the correct texture. Here are examples organized by food group:

Proteins

• Tender, slow-cooked meats: Stewed beef, pork, or lamb, with all gristle and fat removed, chopped into the correct size and served with a thick sauce.
• Poultry: Moist, tender, and finely diced chicken or turkey, often from casseroles or pot pies.
• Fish: Flaked, moist fish (like cod or salmon) baked, poached, or steamed. Ensure all bones are removed.
• Eggs: Scrambled, soft-poached, or boiled and mashed with butter or mayonnaise.
• Meat Alternatives: Soft tofu cut into small pieces, or well-cooked beans and lentils without skins.

Fruits and Vegetables

• Soft, cooked vegetables: Boiled, steamed, or roasted vegetables like carrots, butternut squash, or green beans, cut to size. Avoid stir-fried vegetables.
• Potatoes: Mashed potatoes (moistened with milk or butter) or soft, baked potato flesh without the skin.
• Soft fruits: Peeled, seeded, and chopped fresh fruits like bananas, ripe peaches, and kiwi. Canned or stewed fruits are also suitable.

Starches and Grains

• Pasta and Rice: Well-cooked pasta or rice served with plenty of thick sauce to prevent stickiness or separation.
• Cereals: Porridge, well-soaked wheat biscuits, or other plain cereal softened with milk (and excess liquid drained).
• Bread: Speak to a clinician regarding bread. If allowed, it should be plain white bread with crusts removed, well-moistened with a filling or soaked in soup.

Dairy and Desserts

• Yogurt and Custard: Smooth yogurt, fromage frais, milk puddings, and plain custard.
• Soft Cake: Plain sponge cake with cream or custard, softened to the correct consistency.
• Crème Caramel or Mousse: Soft, smooth desserts are excellent choices.

Comparison of IDDSI Diet Levels: 5, 6, and 7

The IDDSI framework features a continuum of food textures, and understanding the differences between adjacent levels is critical for patient safety. Levels 5, 6, and 7 represent different stages of dietary modification for solids.

Feature	Level 5 (Minced & Moist)	Level 6 (Soft & Bite-Sized)	Level 7 (Easy to Chew)
Particle Size (Adults)	4mm pieces, fits between fork prongs.	1.5cm pieces, easily mashes with fork.	No particle size restriction.
Biting Required?	No.	Minimal, only moderate chewing.	Biting is required.
Chewing Required?	No, food is easily squashed with tongue.	Yes, moderate chewing is necessary.	Yes.
Moisture	Moist and cohesive, no separate thin liquid.	Moist and tender throughout, thick sauce/gravy.	Can be dry, but softer than regular food.
Food Texture	Soft, with minimal lumps.	Soft, tender, and easily broken down.	Normal food, but softer, no specific rules.

How to Prepare and Test Level 6 Foods

For caregivers and individuals on a Level 6 diet, ensuring food meets the required consistency is paramount. The IDDSI framework provides simple, practical tests for this.

Preparation Tips

• Moisten with Sauces: Use thick sauces, gravies, or creamy dressings to ensure food is sufficiently moist and cohesive. Avoid thin or watery liquids that can separate from solids.
• Slow Cooking: Techniques like slow cooking or stewing are ideal for making meats tender enough to be easily broken down.
• Cut to Size: Use a fork or spoon to measure and cut food into the required 1.5 cm pieces. Always cut stringy meats and vegetables against the grain.
• Avoid Problem Foods: Stay away from foods that are hard, tough, dry, sticky, crumbly, or have skins, husks, or seeds, such as nuts, seeds, raw apples, sausages, or peas.

The Fork Pressure Test

The fork pressure test is a quick and reliable way to check if a food is Level 6 compliant.

1. Place a sample of food (about 1.5cm) on a flat plate.
2. Press down with the side of a fork until your thumbnail blanches white from the pressure.
3. Observe: The food should squash and change shape. If it springs back to its original shape, it is not soft enough.

Conclusion

Understanding what are examples of level 6 food is a vital step in providing safe and nutritious meals for individuals with dysphagia. The IDDSI framework offers a clear, international standard that helps caregivers, dietitians, and individuals ensure food texture is appropriate, reducing the risk of aspiration and choking while promoting enjoyment of mealtimes. By focusing on soft, moist, and appropriately sized foods, and using simple tests, it's possible to maintain a varied and appealing diet for those with chewing and swallowing challenges.

For more detailed information and testing protocols, the official IDDSI website provides comprehensive resources [iddsi.org].

Frequently Asked Questions

What is the primary difference between Level 5 and Level 6 foods?

The main difference is particle size and the chewing required. Level 5 (Minced & Moist) consists of smaller 4mm pieces that do not require chewing, while Level 6 (Soft & Bite-Sized) uses larger 1.5cm pieces that require moderate chewing.

Can people on a Level 6 diet eat bread?

Bread can be a high choking risk due to its dry, crumbly texture. If allowed by a healthcare professional, plain white bread with crusts removed should be well-moistened with a filling or soaked in soup to be safe.

What kind of fish is safe for a Level 6 diet?

Flaked, moist fish that is baked, poached, or steamed, such as cod or salmon, is safe. All bones must be removed, and it can be served with a sauce.

Are all cooked vegetables acceptable for a Level 6 diet?

No. Cooked vegetables must be tender and cut into 1.5cm pieces. Stringy or tough vegetables, like stir-fried versions or celery, are not suitable.

How can I ensure meat is tender enough for a Level 6 diet?

Slow cooking meat in a casserole or stew until it is very tender is an effective method. Removing all gristle and fat and serving it with a thick sauce also ensures the correct texture.

What should I do if a food on the menu is too hard for my Level 6 diet?

If a food, like roast chicken, is not tender enough, it can be prepared as minced and moist (Level 5) with a thick gravy or sauce. Alternatively, a different, naturally softer option can be chosen.

Why are foods with mixed consistencies, like soups with chunks, often avoided in a Level 6 diet?

Mixed consistency foods, where thin liquid and solid pieces are present together, are dangerous because the thin liquid is easily aspirated (inhaled into the lungs) before the solid can be chewed or swallowed. For Level 6, any sauces or gravies must be thick.