A Level 6 diet, part of the globally recognized IDDSI framework, is medically prescribed for people with specific chewing or swallowing challenges, known as dysphagia. The 'Soft & Bite-Sized' designation means foods must be soft enough to be mashed with a fork and prepared in small, controlled pieces. The goal is to provide a diet that is satisfying and varied while mitigating the risk of choking or aspiration.
Understanding the Level 6 Soft & Bite-Sized Standard
The IDDSI framework uses a continuum of eight levels to describe food textures and liquid thickness, with Level 6 focusing on texture, not liquid thickness. A key feature is the requirement that all food be cut into bite-sized pieces no larger than 1.5cm for adults. This size restriction, along with the required softness, ensures the food is easy to manage orally before swallowing. The food should be moist throughout, with no separate, thin liquid present, which helps to hold the bolus together.
The Fork-Pressure Test
To ensure food meets the Level 6 standard, you can perform a simple check. Using the side of a fork, you should be able to mash the food with light pressure. When you remove the pressure, the food should not spring back to its original shape. The pieces should be no larger than the width of a standard dinner fork.
Approved Foods for Your Level 6 Diet
Protein Sources
- Meat and poultry: Cooked until very tender and chopped into 1.5cm pieces. Serve with thick gravy or sauce. Suitable options include casseroles, stews, shepherd's pie, and shredded chicken.
- Fish: Skinless, boneless fish cooked until soft and flaky, served in a thick sauce.
- Eggs: Scrambled eggs, moist omelettes, or hard-boiled eggs mashed with mayonnaise.
- Legumes: Well-cooked, skinless beans and lentils, mashed or served in a thick, non-pouring sauce.
- Meat alternatives: Soft tofu or Quorn, cut into small pieces and served in a thick sauce.
Starches and Grains
- Pasta: Well-cooked pasta such as macaroni or lasagna, with a thick sauce.
- Rice: White rice served with plenty of sauce to moisten and hold it together, avoiding sticky, individual grains.
- Potatoes: Mashed or soft-cooked potatoes. Only the insides of baked potatoes should be used.
- Cereal: Porridge or instant oats. Other cereals like Weetabix or cornflakes must be softened thoroughly with milk, and any excess liquid drained off.
- Bread: Must be assessed by a healthcare professional. Soaked or pre-gelled bread is sometimes recommended. Crusts should be removed.
Fruits and Vegetables
- Fruits: Ripe bananas, avocados, and soft, drained tinned fruit (peaches, pears). Remove all skins, seeds, and fibrous parts.
- Cooked Vegetables: Steamed or boiled vegetables (carrots, sweet potato, cauliflower, beetroot) cooked until soft and cut into 1.5cm pieces.
- Other: Mushy peas, mashed pumpkin, or cooked tomatoes (drained).
Dairy and Desserts
- Yogurt and dairy: Smooth, thick yogurt, cottage cheese, and grated cheese.
- Puddings: Smooth milk puddings like custard, rice pudding, and tapioca.
- Desserts: Mousse, trifle, crème caramel, or soft sponge cake softened with cream or custard.
Foods to Strictly Avoid
- Hard, tough, or chewy foods: Steak, bacon, tough meat, hard lumps of cheese.
- Crunchy or crispy foods: Dry toast, crisps, crackers, nuts, seeds, pie crusts.
- Fibrous or stringy foods: Celery, pineapple, peas with skins.
- Mixed consistencies: Soups with lumps and a thin liquid base, cereal with excess milk.
- Small, hard, or round foods: Grapes, nuts, popcorn, corn with husks.
- Sticky foods: Peanut butter.
Comparison: Level 5 (Minced & Moist) vs. Level 6 (Soft & Bite-Sized)
| Feature | Level 5 (Minced & Moist) | Level 6 (Soft & Bite-Sized) |
|---|---|---|
| Particle Size | Adult: 4mm lumps, mashed with a fork. | Adult: 1.5cm pieces, mashed with a fork. |
| Texture | Lumps are soft and easy to squash with the tongue. The food holds its shape on a spoon but does not separate into individual grains or pieces. | Food is soft, tender, and moist throughout. Moderate chewing is required. |
| Moisture | Extremely thick, smooth, non-pouring sauce or gravy is essential to bind the food together. | Food is moist throughout, but no separate thin liquid. Sauce or gravy is often used to ensure moisture. |
| Chewing Required | Minimal to none, as lumps are easily squashed. | A moderate amount of chewing is needed. |
Sample Level 6 Diet Meal Plan
- Breakfast: Porridge or instant oats with full cream milk (ensure excess is drained) and mashed banana.
- Lunch: Flaked tinned salmon mixed with mayonnaise, served with the insides of a soft jacket potato and a side of soft, well-cooked diced carrots.
- Dinner: Tender chicken casserole with thick gravy, served with mashed sweet potato and softly cooked green beans, all cut to size.
- Snacks: Soft fruit (e.g., avocado or ripe mango), smooth yogurt, or soft sponge cake with custard.
Tips for Safe and Enjoyable Level 6 Meals
To make your Level 6 diet as enjoyable and safe as possible, focus on proper preparation and nutritional value. All foods must be cooked until soft enough to pass the fork test and cut to the correct 1.5cm size. Use thick sauces, gravy, or creams to add moisture and flavor, which can also help with swallowing. If appetite is poor, consider adding high-calorie ingredients like butter, cream, or cheese to fortify meals and prevent weight loss. Always serve food at a consistent temperature. If your healthcare provider has recommended thickened fluids, ensure all beverages are also prepared to the correct level. For more detailed guidance, the IDDSI Framework provides comprehensive descriptors and testing methods.
Conclusion
A Level 6 diet is a carefully designed modification to support safe eating for individuals with dysphagia, allowing for a good variety of foods. By adhering to the Soft & Bite-Sized standards—ensuring food is moist, tender, and cut to the specified size—you can enjoy a satisfying diet while reducing the risks of choking and aspiration. Always consult your speech-language therapist or dietitian for personalized recommendations to ensure you meet your nutritional needs safely.
