Nutrition Diet: What is level 6 food dysphagia?

October 19, 2025 •

5 min read

An estimated 1 in 25 adults experiences a swallowing problem, or dysphagia, annually. A key part of managing these conditions is understanding what is level 6 food dysphagia, which involves eating soft, bite-sized foods safely to reduce the risk of choking and aspiration. This diet is based on international guidelines designed to provide clear, standardized instructions for food preparation.

Quick Summary

Level 6 food dysphagia specifies a diet of soft, tender, and moist foods cut into bite-sized pieces for people with chewing and swallowing difficulties. This diet is for individuals who can chew but cannot safely bite off pieces of food.

Key Points

Level 6 Defined: Level 6 food dysphagia, or Soft & Bite-Sized, is part of the IDDSI framework for safe swallowing.
Key Characteristics: Foods are soft, tender, and moist, with no thin liquid separation, and must be easily mashed with a fork.
Bite-Sized Rules: For adults, food pieces must be no larger than 1.5 cm to eliminate the need for biting and reduce choking risk.
Beneficiaries: This diet is suitable for individuals with mild dysphagia, weak oral muscles, or poor dentition who can chew but not safely bite.
Dietary Management: It requires careful meal planning to ensure adequate nutrition and hydration, often involving food fortification and regular small meals.
Foods to Avoid: Hard, chewy, stringy, sticky, or crumbly foods are strictly prohibited, along with mixed consistencies.

Understanding the IDDSI Framework

Dysphagia is a complex condition that requires careful management to ensure a person receives adequate nutrition and hydration without risk. The International Dysphagia Diet Standardisation Initiative (IDDSI) created a global framework to provide standardized terminology for texture-modified foods and thickened liquids. Level 6, known as 'Soft & Bite-Sized,' is a key part of this system, designed for individuals who have enough chewing strength but struggle with biting into larger food items.

Core Characteristics of Level 6 Soft & Bite-Sized Foods

To be classified as Level 6, food must meet specific criteria related to its texture, moisture, and size. The primary goal is to provide a diet that offers more texture and variety than softer diets (like minced and moist) while still minimizing the risk of choking.

Soft and Tender: The food should be soft enough to be easily mashed or broken apart with the side of a fork, spoon, or chopsticks. The fork pressure test, where food is squashed and does not return to its original shape, is a reliable method for confirmation.
Moist: Foods must be tender and moist throughout, with no thin liquid separating from the solid food. Using sauces and gravies is a common strategy to maintain moisture.
Bite-Sized Pieces: For adults, all solid pieces of food must be cut to a size no larger than 1.5 cm by 1.5 cm, approximately the width of a standard dinner fork. This eliminates the need for biting off pieces and reduces the risk of aspiration.
No Sticky or Crumbly Textures: The diet strictly prohibits hard, tough, stringy, fibrous, or chewy foods, as well as those that are sticky or have crumbly textures.

Who Is the Level 6 Diet For?

The Level 6 diet is typically recommended for individuals who have mild oropharyngeal dysphagia but can still chew. These individuals may struggle with certain aspects of eating, and the modified texture helps them manage food more safely. Common scenarios include:

Weak Chewing or Oral Muscles: Those with reduced muscle strength in the mouth or jaw due to neurological conditions or other medical issues.
Poor Dentition: People with missing teeth or ill-fitting dentures who cannot bite or chew tough foods effectively.
Pain or Fatigue with Chewing: Individuals who experience pain or tire quickly while eating, as the soft food requires less effort.
Mild Dysphagia with High Choking Risk: Patients who can chew but are at risk of choking on larger, unmodified pieces of food.

Nutritional Considerations for a Level 6 Diet

Maintaining a nutritionally balanced diet is crucial, and a Level 6 diet offers a wide variety of food groups to achieve this. Dietitians and Speech and Language Therapists often work together to plan meals that are both safe and appealing.

Tips for Ensuring Adequate Nutrition

Fortify Food: To increase calorie and protein intake, foods can be fortified by adding ingredients like extra butter, margarine, cream, cheese, or skim milk powder to mashed potatoes, soups, and cereals.
Use Full-Fat Dairy: Opt for full-fat milk, creamy yogurts, and cheeses to boost energy content.
Include Snacks: Encourage regular small meals and snacks throughout the day, such as custard, soft fruit, or pudding, to prevent unintentional weight loss.
Stay Hydrated: While fluids may need to be thickened, ensuring adequate fluid intake is essential to prevent dehydration, a significant risk with any dysphagia diet.

Level 6 vs. Level 5: Key Differences

The IDDSI framework provides a clear progression of texture-modified diets. Level 6 (Soft & Bite-Sized) represents a step up in texture and chewing demand from Level 5 (Minced & Moist). The table below summarizes the key distinctions.


Feature	IDDSI Level 6 (Soft & Bite-Sized)	IDDSI Level 5 (Minced & Moist)
Food Texture	Soft, tender, and moist throughout; lumps present.	Minced or finely chopped, with a thick, smooth sauce; small, uniform, visible lumps.
Chewing Requirement	Requires moderate chewing.	Minimal chewing required.
Biting Requirement	Does not require biting off pieces.	No biting required.
Particle Size (Adults)	Pieces no larger than 1.5 cm x 1.5 cm.	Lumps no larger than 4 mm (like the gap between fork tines).
Moisture	Moist; no separate thin liquid.	Moist, with no liquid separation.
Fork Test	Easily mashed with a fork and does not return to its original shape.	Mounds on a fork and holds its shape.

Creating and Managing a Level 6 Diet

Proper food preparation is vital for ensuring safety and enjoyment. Many common foods can be adapted to meet Level 6 standards with some simple modifications.

Foods to Include

Proteins: Well-cooked, tender meats (e.g., roast beef, chicken) cut into 1.5cm pieces and served with gravy or sauce; flaked fish; eggs (scrambled or poached); tender tofu.
Starches: Soft-cooked pasta (e.g., mac and cheese); soft rice in a thick sauce; well-mashed or soft-cooked potatoes.
Fruits: Soft, peeled fruits like ripe bananas, ripe kiwi, or cooked apples, all chopped to size.
Vegetables: Steamed or boiled vegetables (e.g., carrots, broccoli) cooked until soft and chopped to size.
Desserts: Custard, pudding, soft cakes soaked in cream or custard, and gelatin.

Foods to Avoid

Hard or Tough Textures: Nuts, raw vegetables, hard biscuits, hard cheeses, tough meat, and stringy vegetables.
Sticky Foods: Nut butters in their pure form, marshmallows, and sticky rice.
Crumbly Textures: Dry cakes, pastries, crackers, or bread crusts.
Foods with Skins, Seeds, or Gristle: Grapes, seeds, bones, and gristle must be removed.
Mixed Consistency Foods: Soups with large chunks of food and watery broth, or cereal in milk where the liquid separates from the solid.
High Water Content Fruits: Melon and oranges, where juice can separate from the pulp, can be a choking hazard for some individuals.

Conclusion

Understanding what is level 6 food dysphagia is critical for safe and effective nutritional care for individuals with specific swallowing difficulties. By adhering to the standardized guidelines of the IDDSI framework—ensuring food is soft, moist, and cut to the correct bite-sized dimensions—caregivers can significantly reduce the risks of choking and aspiration. A well-managed Level 6 diet, with proper nutritional planning and attention to food texture, not only supports physical health but also improves the quality of life and dignity of those with dysphagia. For more information and resources, consult the official IDDSI website. International Dysphagia Diet Standardisation Initiative

Frequently Asked Questions

The main difference is the size of the food particles and the required chewing. Level 5 (Minced & Moist) features very small, uniform lumps (4mm for adults) that require minimal chewing, while Level 6 (Soft & Bite-Sized) uses larger, soft pieces (1.5cm for adults) that require more moderate chewing.

To perform the test, press down on a food item with a fork until your thumbnail blanches white from the pressure. If the food completely squashes and does not regain its original shape when the fork is lifted, it is soft enough for Level 6.

Plain white or wholemeal bread can sometimes be included, but only if it's finely chopped and thoroughly moistened with soups or sauces. Dry, crusty, or seeded bread should be avoided.

Ignoring the guidelines can lead to serious complications, including choking on large food pieces, aspiration (food or liquid entering the lungs), aspiration pneumonia, and malnutrition due to fear of eating or difficulty consuming enough calories.

To enhance flavor, use herbs, spices, sauces, and gravies, all of which must be tested to ensure they meet the texture standards. You can also fortify foods with ingredients like cheese or cream to boost both flavor and nutrients.

While a pureed texture would be acceptable, Level 6 specifically allows for soft, bite-sized pieces. Pureed food is classified as Level 4. However, you can still include pureed fruits and vegetables in your meals if you prefer.

Level 6 foods are designed to be eaten with a fork, spoon, or chopsticks. A knife is generally not required for cutting, as the food should already be prepared into bite-sized pieces.