What is a Level 6 Food Diet? A Guide to Soft and Bite-Sized Foods

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), a global framework, a level 6 food diet is formally known as the Soft and Bite-Sized diet, designed for individuals with specific chewing and swallowing difficulties. This guide clarifies what is a level 6 food diet, outlines its purpose, and explains safe preparation techniques.

Quick Summary

A Level 6 diet consists of moist, tender foods cut into small, bite-sized pieces for safer swallowing. It is prescribed for those who struggle with chewing and biting but retain some oral motor control.

Key Points

• Purpose: A Level 6 diet, or Soft and Bite-Sized, is for individuals who have difficulty biting off food but can safely chew soft, tender pieces.

• Texture Requirements: Foods must be moist, soft, and tender, easily mashed with a fork, and should not contain hard, chewy, or stringy bits.

• Portion Size: All foods must be cut into small, consistent bite-sized pieces, no larger than 1.5cm for adults.

• Safety Test: The fork pressure test, where food is easily squashed and does not spring back, is used to ensure the correct texture.

• Foods to Avoid: High-risk foods include hard nuts, chewy candies, dry crumbly items, fibrous vegetables, and foods with seeds or skins.

• Medical Guidance: This diet should be implemented based on recommendations from a healthcare professional, like a speech-language pathologist.

Understanding the International Dysphagia Diet Standardisation Initiative (IDDSI)

The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global project designed to create a standardized framework for the naming and defining of texture-modified foods and thickened liquids. This initiative ensures consistency and patient safety worldwide, preventing confusion caused by ambiguous terms like “soft” or “chopped,” which can vary between facilities and regions. The IDDSI framework uses a number system (0–7) and color-coding to specify food and drink consistencies. The Level 6 food diet is an important part of this system, identified by the number 6 and the color blue, representing the 'Soft and Bite-Sized' category.

Defining the Level 6 Food Diet

A Level 6 Soft and Bite-Sized food diet is for individuals who can chew but may have difficulty biting into larger food items safely. Foods on this diet are naturally soft or cooked until tender and moist. A key characteristic is that all food is prepared and served in bite-sized pieces, measuring no more than 1.5cm by 1.5cm for adults, or 8mm by 8mm for children. This controlled size minimizes the risk of choking and makes the food easier to manage within the mouth.

Characteristics of Soft and Bite-Sized Foods

To ensure a food is appropriate for a Level 6 diet, it must meet several criteria:

• Soft and tender: The food should be easily mashed or broken apart with a fork or spoon, without much pressure.
• Moist: The food should be moist throughout its texture. Dry, crumbly, or crispy foods are not suitable. Sauces or gravies are often added to maintain moisture.
• Uniform size: Food pieces must be a consistent, bite-sized shape—no larger than 1.5cm for adults and 8mm for children.
• No separate thin liquid: The meal should not contain thin, watery liquids that can separate from the solid food. For example, mince needs a thick gravy, not a watery sauce.

Who is the Level 6 Diet for?

A Level 6 Soft and Bite-Sized diet is typically recommended by a speech-language pathologist, physician, or dietitian for individuals experiencing mild dysphagia or other conditions affecting their ability to safely bite and chew. This can include people who:

• Are unable to bite off larger, harder pieces of food.
• Experience pain or fatigue while chewing.
• Have weak oral muscles or poorly fitting dentures.
• Are at a high risk for choking on regular-sized, solid foods.

The diet may be a short-term solution during recovery or a long-term strategy for managing chronic swallowing difficulties.

Preparing Safe Level 6 Meals

Proper preparation is crucial to ensure the safety and palatability of Level 6 meals. Here are some key tips:

• Cook thoroughly: All food, especially meat, poultry, and vegetables, should be cooked until very tender and soft. Tough or stringy textures must be avoided.
• Ensure consistent moisture: Use gravies, thick sauces, or milk to moisten food. Food should not be dry or crumbly.
• Chop to the correct size: Before serving, cut all food into the appropriate bite-sized pieces. Use the width of a standard fork to visually check the size (approximately 1.5cm).
• Use the fork pressure test: This simple test helps confirm the food's softness. Press on a piece of food with a fork until the pressure on your thumb turns the nail white. The food should squash easily and retain the indentation. If it bounces back or is difficult to mash, it is not suitable.
• Avoid skins and seeds: Remove skins from fruits and vegetables, and avoid seeds or other hard bits.

A Note on Liquids

Individuals on a Level 6 food diet may also require modified liquids, such as thickened drinks, which are part of the IDDSI framework. The correct liquid consistency should be determined by a speech-language pathologist. Mixed consistencies, like soups with thin broth and large lumps, are unsafe and should be avoided.

Suitable Foods for a Level 6 Diet

This diet includes many items that, with proper preparation, can be both nutritious and enjoyable. Suitable foods include:

• Meats and proteins: Tender, shredded meats like pot roast or soft casseroles, flaked fish (with bones removed), eggs (scrambled, poached), and soft tofu.
• Fruits: Soft, peeled, and chopped fruits such as bananas, ripe kiwi, peaches, or stewed apples.
• Vegetables: Well-cooked, peeled, and diced vegetables like carrots, sweet potatoes, cauliflower, or mushy peas.
• Starches: Mashed potatoes, soft-cooked pasta (like macaroni and cheese), and soft, moist rice with a thick sauce.
• Cereals: Well-softened cereals such as porridge or soaked Weetabix (drain excess liquid).
• Desserts: Yogurts, custards, rice pudding, and soft, moist cakes.

Foods to Avoid on a Level 6 Diet

To prevent choking hazards, certain textures are strictly prohibited:

• Hard or dry items: Nuts, seeds, hard candies, raw vegetables (e.g., raw carrots).
• Chewy or sticky foods: Tough meat, cheese chunks, marshmallows, peanut butter.
• Fibrous or stringy foods: Pineapple, celery, runner beans.
• Crumbly textures: Dry cake, bread crusts, pie crusts, and dry biscuits.
• Skins and seeds: Skins from fruits and vegetables, seeds from berries.
• Mixed consistencies: Cereal that doesn't fully soak up milk, mince in thin gravy.

Level 6 Diet vs. Other IDDSI Food Levels

The IDDSI framework standardizes texture, and understanding the differences is key for patient safety.

Feature	Level 5 (Minced & Moist)	Level 6 (Soft & Bite-Sized)	Level 7 (Easy to Chew)
Particle Size (Adult)	4mm (minced)	1.5cm (bite-sized)	Regular size, but easy to chew
Chewing Required?	Very minimal chewing required	Moderate chewing required	Chewing required
Texture	Soft, moist, and easily mashed with tongue	Soft, tender, moist, and easily mashed with a fork	Soft, moist, and tender. No hard or stringy textures
Liquid Content	Moist throughout, no thin liquid separates	Moist, no thin liquid separates	Moist, but can be a single food item without added sauce
Fork Test	Falls easily through fork prongs	Mashes easily, retains shape slightly	Can be cut or mashed with minimal effort
Biting Required?	Not required	Not required to bite off pieces	Not required to bite off pieces

Conclusion

A Level 6 food diet, or Soft and Bite-Sized diet, is a critical part of the IDDSI framework, designed to help people with mild dysphagia or chewing difficulties eat safely and comfortably. By focusing on soft, tender, and moist foods that are cut into precise, bite-sized pieces, this diet minimizes the risk of choking and improves mealtime quality of life. Successful implementation relies on careful food preparation, adherence to specific texture guidelines (which can be checked with a simple fork test), and the exclusion of high-risk foods. Consultation with a healthcare professional, such as a speech-language pathologist or dietitian, is essential to ensure the diet is appropriate and nutritionally adequate for the individual's needs.

For more information on IDDSI standards and resources, you can visit the official IDDSI website.

Frequently Asked Questions

What is the difference between Level 6 and Level 5 diets?

A Level 6 diet (Soft and Bite-Sized) requires moderate chewing for small, tender pieces (1.5cm for adults), while a Level 5 diet (Minced and Moist) consists of soft, moist minced particles (4mm) that can be swallowed with minimal chewing.

Who should be on a Level 6 soft and bite-sized diet?

Individuals with mild dysphagia, weakness in mouth muscles, pain or fatigue during chewing, or issues with poorly fitting dentures are candidates for a Level 6 diet.

Can a person on a Level 6 diet have regular bread?

Regular dry bread is not recommended due to its crumbly and dry texture, which presents a choking risk. Soft sandwiches with crusts removed or toast with moist toppings may be suitable if approved by a speech-language therapist.

How do I make sure meat is suitable for a Level 6 diet?

Meat must be cooked until very tender and then chopped into pieces no larger than 1.5cm x 1.5cm for adults. It should also be served with a thick, smooth, non-pouring sauce or gravy to prevent dryness.

What kind of fruits can be eaten on a Level 6 diet?

Soft fruits that are peeled and chopped are suitable. Examples include bananas, ripe avocado, soft pears, and stewed fruits with skins removed. Fruits that release a lot of juice when chewed, like watermelon, should be approached with caution.

Is the Level 6 diet a permanent dietary change?

The duration of a Level 6 diet varies depending on the individual's needs. It may be temporary, with a speech-language pathologist monitoring progress and advancing the diet when appropriate, or it may be a long-term safety measure.

How can I check if food is soft enough for a Level 6 diet?

Perform the fork pressure test: press down on the food with the side of a fork until your nail turns white. The food should easily squash and change shape without returning to its original form.