Understanding the Level 6 Soft & Bite-Sized Diet
The Level 6 diet, a component of the International Dysphagia Diet Standardisation Initiative (IDDSI) framework, is a texture-modified diet for people with chewing and/or swallowing difficulties, known as dysphagia. It is an important step up from softer pureed or minced diets, allowing for a wider variety of foods while still prioritizing safety. The main goal is to provide foods that require moderate chewing but can be easily broken down, reducing the risk of choking.
Key characteristics of all foods on this diet include being:
- Soft, tender, and moist: Foods must not be dry or crumbly and should be served with a sauce or gravy to prevent separate thin liquids.
- Bite-sized pieces: All solid food must be chopped or minced into a specific size—no larger than 1.5cm x 1.5cm for adults and 8mm for children.
- Easily mashable: A quick and easy test is to press the food with a fork. It should mash easily without returning to its original shape.
- Free from tough or fibrous bits: No hard lumps, skins, seeds, bones, or gristle.
What Foods Are Allowed on the Level 6 Diet?
Protein sources
Protein is vital for maintaining muscle mass and tissue repair. On a Level 6 diet, protein-rich foods must be cooked until very tender and chopped into bite-sized pieces.
- Meat and Poultry: Tender, lean meats like casserole-cooked beef, lamb, or pork. Well-cooked chicken or turkey can be chopped or minced and served in a thick gravy or sauce.
- Fish: Flaked, boneless, and skinless fish served with a thick sauce (e.g., parsley or cheese sauce). Canned tuna or salmon mashed with mayonnaise is also suitable.
- Eggs: Scrambled, poached, or chopped hard-boiled eggs mashed with mayonnaise. Moist, soft omelettes are also acceptable.
- Legumes and Pulses: Well-cooked, skinless beans, lentils, or chickpeas (mashed or in a thick sauce). Smooth hummus is a great option.
- Vegetarian Alternatives: Tofu or Quorn, cooked until soft and cut into appropriate pieces, served in a sauce.
Starchy Foods and Grains
- Potatoes: Mashed potatoes, sweet potatoes, or the soft flesh of a baked potato. Bite-sized, soft boiled or very soft oven chips moistened with gravy are also suitable.
- Pasta and Rice: Well-cooked pasta (like macaroni, ravioli, or noodles) cut into small pieces and served in a thick sauce. Well-cooked rice must be served with plenty of sauce to hold it together and prevent it from becoming dry.
- Cereals: Porridge, Ready Brek™, or other instant hot cereals are ideal. Plain cereals like Weetabix™ or cornflakes can be soaked in milk and any excess liquid drained.
- Bread: Regular dry bread should be avoided. Soaked or pre-gelled plain bread (with crusts removed) may be suitable, but professional advice from a speech and language therapist should be sought.
Fruits and Vegetables
- Fruits: Soft, peeled fruits like ripe bananas, avocado, melon, strawberries, or tinned peaches. All must be chopped into the correct bite-size and any excess liquid drained. Stewed, skinless fruit like apples or rhubarb is also suitable.
- Vegetables: Cooked vegetables like carrots, cauliflower, broccoli, or swede, boiled or steamed until very tender and then cut into bite-sized pieces or mashed. Tinned vegetables like chopped tomatoes or mushy peas are also appropriate.
Dairy and Desserts
- Dairy: Full-fat yogurts, fromage frais, milk puddings (custard, rice pudding), and milk can be used. Grated or melted cheese is acceptable, but hard cheese chunks are not.
- Desserts: Soft sponge cakes (with cream or custard), mousse, trifle, egg custard, and crème caramel.
Foods to Avoid on a Level 6 Diet
To ensure safety, certain food characteristics must be avoided:
- Hard or Tough Textures: Nuts, seeds, corn, hard cheese, raw vegetables (like carrots, celery), and hard candy.
- Chewy or Sticky Textures: Toffees, sweets, chewing gum, marshmallows, and sticky nut butter.
- Crispy, Crunchy, or Crumbly Textures: Crisps, dry biscuits, crackers, flaky pastry, cornflakes (unless well-soaked), dry toast, and bread crusts.
- Fibrous or Stringy Textures: Pineapple, green beans, runner beans, celery, and rhubarb.
- Skins, Pips, and Gristle: Skins from fruit, vegetables (like peas or grapes), sausages, and chicken, as well as bones and gristle from meat.
- Mixed Consistencies: Foods with a mix of thick and thin liquid, such as soup with lumps or cereal in milk where the milk is thin.
- Excessively Juicy Foods: Fruits like watermelon, where thin juice separates from the solid.
Level 6 Diet vs. Regular Diet: A Comparison
| Feature | Level 6 (Soft & Bite-Sized) | Regular Diet |
|---|---|---|
| Texture | Soft, tender, and moist throughout. Easily mashed with a fork. | Unmodified, can include hard, tough, crunchy textures. |
| Bite Size | Controlled to 1.5cm max for adults. No biting off chunks is required. | Unrestricted; can be any size and require biting and tearing. |
| Moisture | Essential; food must be moist and served with sauces/gravy. No separate thin liquid. | Can be dry, moist, or include mixed liquid/solid consistencies. |
| Chewing Requirement | Moderate chewing is required, but food pieces are small and soft. | Varies from minimal to significant chewing. |
| Preparation | Often requires cooking until very tender, mashing, and chopping. | Little to no special preparation needed for texture. |
Tips for Preparing Level 6 Meals
To ensure meals are both safe and appealing, consider these preparation techniques:
- Use Moistening Agents: Add sauces, gravies, custard, cream, or yoghurt to foods to increase moisture and cohesiveness. This prevents dry or crumbly textures.
- Proper Cooking Methods: Opt for stewing, boiling, braising, or slow-cooking meats and vegetables until they are exceptionally tender.
- Cut Correctly: Always cut food into the required bite-sized pieces after cooking. A fork can be used to gauge the correct size.
- Enrich for Extra Nutrients: If weight gain is a concern, fortify meals by adding butter, margarine, cream, grated cheese, or dried milk powder. Use full-fat dairy products.
- Check Consistency: Perform the fork pressure test on all prepared food before serving to confirm it is soft enough. Also, check that no crusts or dry skin have formed during cooking or standing.
Example Meal Plan for a Level 6 Diet
Breakfast
- Porridge with milk, topped with a spoonful of seedless jam.
- Weetabix soaked in full-fat milk until soft, with excess liquid drained.
- Scrambled eggs with melted cheese.
Lunch
- Soft Spanish potato omelette with mashed tinned tomatoes.
- Cottage pie (using soft minced meat and mashed potato topping).
- Tuna mashed with mayonnaise, served with softened crackers.
Dinner
- Roast chicken pieces (tender, skinless) in thick gravy with mashed potatoes and very soft cooked carrots.
- Fish pie with soft, flaked fish in a cheese sauce and a mashed potato topping.
- Spaghetti bolognese with well-cooked pasta (cut up) and a thick sauce.
Snacks & Desserts
- Full-fat yoghurt with mashed fruit.
- Soft sponge pudding with custard.
- Milky drinks or milkshakes (with no lumps).
- Creamy custard or crème caramel.
For more detailed information and testing methods, consult the International Dysphagia Diet Standardisation Initiative (IDDSI) resources: https://www.iddsi.org/.
Conclusion
Following a Level 6 diet allows individuals with chewing or swallowing difficulties to enjoy a variety of soft, tender, and moist foods safely. By understanding the key requirements—such as cutting food into bite-sized pieces and ensuring it is easily mashable with a fork—you can prepare nutritious and appealing meals. Always focus on adding moisture and avoiding hard, crunchy, or stringy textures to minimize choking risk. Close collaboration with a healthcare professional, such as a speech and language therapist or dietitian, is recommended to ensure the diet meets all nutritional needs.
