Understanding IDDSI Level 6: Soft and Bite-Sized
The International Dysphagia Diet Standardisation Initiative (IDDSI) created a framework to standardize food textures and drink thickness globally for individuals with dysphagia (swallowing difficulties). The Level 6 diet, known as Soft and Bite-Sized, is suitable for people who can chew but have difficulty biting off large pieces of food. Key characteristics of this diet include:
- Moist and Tender: All food must be soft, tender, and moist throughout, without any separate thin liquid leaking from it.
- Bite-Sized Pieces: Pieces should be no larger than 1.5 cm x 1.5 cm for adults. This is approximately the width of a standard fork tines.
- Easily Mashable: The food must be soft enough to be mashed or broken down easily with pressure from a fork or spoon.
- Chewing Required: This level requires some chewing before swallowing.
- No Knife Needed: You should not need a knife to cut and eat the food.
Protein-Rich Foods for a Level 6 Diet
Protein is vital for tissue repair and muscle maintenance. For a Level 6 diet, protein sources must be prepared to be exceptionally tender, moist, and bite-sized.
Suitable Proteins:
- Slow-Cooked Meats: Cuts of beef, pork, or lamb that have been slow-cooked until very tender can be chopped into the correct size and served with a thick, smooth gravy or sauce.
- Poultry: Chicken or turkey cooked until tender and shredded or chopped into 1.5 cm pieces. Always serve with a thick sauce or gravy.
- Fish: Flaked, moist fish such as salmon, cod, or haddock, served in a sauce like parsley or hollandaise. Ensure all bones are removed.
- Eggs: Scrambled eggs, poached eggs, or omelettes with soft fillings are excellent choices. Mashed hard-boiled eggs with mayonnaise or butter are also suitable.
- Legumes: Well-cooked, skinless beans and lentils, such as kidney beans or red/yellow lentils, served mashed or in a thick sauce. Hummus is also a good option.
- Tofu: Small, soft pieces of tofu can be included.
Safe Carbohydrates for Texture-Modified Meals
Starchy foods provide energy and are a cornerstone of a balanced diet. For a Level 6 diet, they must be soft and easy to manage.
Suitable Carbohydrates:
- Potatoes: Mashed potatoes (with added cream, butter, or gravy), baked potato flesh (without the skin), or well-cooked, chopped soft chips moistened with gravy.
- Pasta: Well-cooked pasta, such as macaroni or ravioli, served in a thick sauce and cut into small pieces.
- Rice: White rice cooked until very soft and served with plenty of thick, smooth, non-pouring sauce to bind it together.
- Cereals: Porridge, Ready Brek, or Weetabix soaked in milk until very soft, with excess liquid drained.
- Bread: Speak to a healthcare professional before including bread, as it can pose a choking risk. Soft white bread with crusts removed, well-soaked in soup or sauce, may be acceptable for some.
Fruits and Vegetables for a Dysphagia Diet
These are important for vitamins, minerals, and fiber but require careful preparation for a Level 6 diet.
Suitable Fruits and Vegetables:
- Soft Fruits: Ripe banana, avocado, strawberries, papaya, and kiwi, all peeled and chopped into 1.5 cm pieces.
- Stewed or Tinned Fruit: Softened fruits like apples, pears, or rhubarb (with skins removed), or chopped tinned fruit drained of excess liquid.
- Cooked Vegetables: Steamed or boiled vegetables, like carrots, cauliflower, or sweet potato, cooked until tender and cut into 1.5 cm pieces. Tinned options like chopped tomatoes are also suitable.
- Mushy Peas: Cooked until soft and mashed.
Dairy and Desserts
Dairy products offer important calcium and protein. Soft desserts can be a safe and enjoyable part of the diet.
Suitable Dairy and Desserts:
- Yogurt and Custard: Thick and creamy yogurts, custards, and milk puddings like rice pudding or semolina.
- Soft Cheese: Grated cheese or small chunks of soft cheese like cream cheese.
- Mousse and Cream: Smooth mousse, trifles, or soft sponge cake soaked in cream or custard.
Comparison of Food Textures: IDDSI Level 6
| Feature | Safe (IDDSI Level 6) | Unsafe (Foods to Avoid) |
|---|---|---|
| Texture | Soft, tender, moist throughout | Hard, tough, chewy, stringy, crunchy, crumbly |
| Particle Size | Bite-sized pieces ≤ 1.5 cm for adults | Large chunks or mixed sizes |
| Moisture | Moist, with no separate thin liquid | Dry food or mixed consistency (e.g., thin gravy with chunks) |
| Preparation | Cooked until tender; mashable with a fork | Fried, breaded, or tough meats |
| Specific Exclusions | No hard seeds, pips, husks, bones, or gristle | Nuts, uncooked vegetables, fruit skins, and seeds |
Practical Tips for Preparing and Enjoying Meals
- Fortification: For individuals with a poor appetite, fortify meals with nutritious, calorie-dense additions like butter, cream, mayonnaise, or grated cheese. Add skim milk powder to milk for extra protein.
- Presentation: Presenting food attractively can stimulate appetite. Instead of mixing everything together, serve different food components separately on the plate.
- Flavoring: Use herbs, spices, and sauces to enhance flavor. Avoid seasonings that cause mouth soreness.
- Meal Timing: Eating smaller, more frequent meals can be easier to manage than three large ones, especially if fatigue is a factor.
- Hydration: Always ensure adequate fluid intake. For people who need thickened liquids, this is especially important.
Conclusion
Navigating a dysphagia Level 6 diet can be challenging, but focusing on soft, moist, and bite-sized foods ensures safe and enjoyable eating. By understanding the IDDSI guidelines and applying the preparation techniques mentioned, caregivers and individuals can create a balanced, nutritious, and appealing diet. Consulting with a speech and language therapist or dietitian is essential to tailor the diet to individual needs and to ensure continued safety and well-being. For further guidance and resources, you can visit the official IDDSI website to learn more about the framework (https://iddsi.org/framework/).
