Understanding the IDDSI Framework
The International Dysphagia Diet Standardisation Initiative (IDDSI) created a global framework to provide standardized terminology and testing methods for modified foods and liquids. This framework consists of eight levels, with foods ranging from Level 3 to Level 7 and liquids from Level 0 to Level 4. The consistent guidelines help healthcare professionals and caregivers prepare meals safely, reducing the risk of adverse events like choking. Level 6 is a key part of this system, bridging the gap between minced and regular diets.
What are the characteristics of a Level 6 diet?
A Level 6 Soft and Bite-Sized diet requires food that meets several specific criteria to ensure patient safety and nutritional adequacy. The key characteristics include:
- Soft, tender, and moist: Food must be cooked until very soft and kept moist with gravy, sauces, or custard to prevent it from becoming dry and crumbly.
- Bite-sized pieces: For adults, all pieces of food must be cut into a maximum size of 1.5cm x 1.5cm, which is roughly the width of a standard dinner fork. This eliminates the need for the individual to bite off a piece of food themselves.
- Easily mashable: The food should be soft enough to be broken down with a fork or spoon, without much resistance.
- No separate thin liquids: Any sauces, gravy, or other liquids served with the food must be thick and smooth, not separating from the solid food.
- Minimal chewing required: While some chewing is needed, the softness of the food makes it less effort to manage.
Foods included on a Level 6 Soft and Bite-Sized diet
To meet the requirements of a Level 6 diet, meals can be prepared using a variety of ingredients, focusing on proper preparation and texture. Below is a list of suitable foods:
- Protein: Tender, moist meats such as slow-cooked stews, casseroles, and minced meat dishes with thick gravy. Soft poultry and flaked fish are also suitable. Eggs, prepared as scrambled, poached, or omelettes, are also excellent choices.
- Starches: Soft, well-cooked cereals like porridge or soaked wheat biscuits. Mashed potatoes or well-cooked pasta with thick, smooth sauce are also appropriate.
- Fruits: Soft, fresh fruits like ripe banana, kiwi, or berries can be chopped to the correct size. Tinned or stewed fruits, with skins and seeds removed and chopped, are also excellent options.
- Vegetables: Steamed or boiled vegetables, like carrots, sweet potato, cauliflower, or broccoli, must be tender and chopped to the appropriate size.
- Dairy: Thick and creamy yogurts, custards, cottage cheese, and soft cheeses are all suitable additions.
Foods to avoid on a Level 6 Soft and Bite-Sized diet
Certain food items are considered high-risk due to their texture and should be strictly avoided by individuals on a Level 6 diet. These include:
- Hard, tough, and chewy foods like tough meat, raw vegetables, and hard fruits.
- Fibrous or stringy textures such as pineapple, celery, or runner beans.
- Crumbly and dry foods like bread crusts, dry cakes, or crackers.
- Sticky foods such as marshmallows, peanut butter, or chewy sweets.
- Foods with skins, pips, seeds, or bones.
- Mixed textures, like thin soup with solid lumps or cereal in thin milk.
- Food that produces a lot of thin liquid when chewed, like watermelon.
Comparison of IDDSI Level 6 and Other Levels
| Feature | Level 5 (Minced and Moist) | Level 6 (Soft and Bite-Sized) | Level 7 (Regular / Easy to Chew) |
|---|---|---|---|
| Texture | Soft and moist minced or finely chopped food with minimal lumps. | Tender and moist, bite-sized pieces requiring some chewing. | Regular food that is soft enough to be easily chewed. |
| Particle Size | Lumps no bigger than 4mm. | Lumps no bigger than 15mm x 15mm for adults. | No specific particle size restriction, but easy to chew. |
| Chewing | Very little chewing required. | Moderate amount of chewing required. | Chewing is required but with minimal effort. |
| Appearance | Minced and moist texture, typically served with gravy or sauce. | Recognizable food shapes cut to a specific size, with added moisture. | Normal food appearance, but with softer texture. |
| Swallowing | Safe for those with limited chewing ability. | Safe for those who can chew but not safely bite off pieces. | For those with mild chewing difficulties or needing softer food choices. |
Nutritional considerations and food fortification
Patients on modified texture diets may be at risk for malnutrition or weight loss because they consume less food or find modified meals less palatable. Therefore, food fortification is often recommended to increase caloric and nutritional intake without increasing volume. This can involve adding sources of extra calories and protein to meals, such as:
- Using full-fat dairy products instead of low-fat versions.
- Mixing powdered milk into milk, soups, and sauces.
- Stirring butter, margarine, or oil into mashed potatoes, vegetables, or sauces.
- Adding cream, cheese, or sauces to foods.
- Using syrups, honey, or sugar to boost the energy content of desserts and cereals.
- Serving nourishing drinks like milkshakes or commercial supplements between meals.
Conclusion
A Level 6 Special Diet, or the Soft and Bite-Sized diet, is an important safety measure for individuals experiencing swallowing difficulties. By adhering to the precise texture and size requirements outlined by the IDDSI, caregivers and patients can significantly reduce the risk of choking and aspiration. This diet ensures that individuals with moderate chewing challenges can still enjoy a wide variety of foods, promoting adequate nutrition and a better quality of life. Consulting with a healthcare professional, such as a Speech and Language Therapist or a Dietitian, is essential for implementing this diet correctly and safely.
A note on preparation and meal ideas
For those preparing Level 6 meals at home or in a care setting, a focus on proper cooking methods is crucial. Cooking foods until tender, using moist cooking methods like braising or stewing, and ensuring food is chopped to the correct size are all vital steps. Combining tender protein, soft vegetables, and a suitable carbohydrate with a smooth, thick sauce can create a well-balanced and safe meal. For example, a shepherd's pie with a soft, mashed potato topping and minced meat in a thick gravy is an excellent Level 6 meal.
For further guidance and resources, the International Dysphagia Diet Standardisation Initiative (IDDSI) offers comprehensive information on their website, including testing methods and detailed food guides.
