What is a number 6 diet? A Comprehensive Guide to the IDDSI Soft & Bite-Sized Framework

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), a global framework used by healthcare professionals, a what is a number 6 diet? refers to the 'Soft and Bite-Sized' food texture level. This specific diet is designed to help individuals with chewing and swallowing difficulties eat safely and comfortably.

Quick Summary

The IDDSI Level 6 diet, or Soft and Bite-Sized diet, consists of moist, tender foods cut into small, safe-to-swallow pieces for people with chewing or swallowing issues. A simple fork test can confirm the correct softness.

Key Points

• IDDSI Framework: The number 6 diet is a specific food texture level within the International Dysphagia Diet Standardisation Initiative (IDDSI).

• Soft & Bite-Sized: It is also known as the Soft & Bite-Sized diet, featuring moist, tender foods that are easy to chew and swallow.

• Specific Dimensions: For adults, all food pieces must be no larger than 1.5cm by 1.5cm to minimize choking risk.

• Fork Pressure Test: A simple test using a fork can verify that a food is soft enough by mashing it with moderate pressure.

• Nutritional Fortification: Special techniques, such as adding extra fats or protein powders, can be used to prevent malnutrition in those with reduced appetite.

• Professional Guidance: This diet should be implemented with guidance from a healthcare professional, such as a dietitian or speech and language therapist.

The International Dysphagia Diet Standardisation Initiative (IDDSI)

The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global framework that standardises terminology for describing food textures and drink thickness. This framework is used by dietitians, speech and language therapists, and other healthcare professionals to ensure patients with dysphagia (swallowing difficulties) receive consistent and safe food preparations. IDDSI features a continuum of 8 levels (0-7), each with specific criteria. The 'number 6 diet' corresponds to the Soft & Bite-Sized level, situated between Level 5 (Minced & Moist) and Level 7 (Regular).

Why the IDDSI framework is important

Before IDDSI, there was no consistent international terminology for dysphagia diets, leading to confusion and potential safety risks for patients. The standardized framework provides clear, universal guidelines, which significantly improves patient safety. This is especially crucial in healthcare settings where patients may move between different facilities or receive care from various professionals. By adhering to IDDSI, clinicians can ensure that all food provided meets the exact specifications for a patient's individual swallowing ability.

What Defines a Level 6 Soft & Bite-Sized Diet?

The characteristics of the IDDSI Level 6 diet are precise and designed to reduce the risk of choking and aspiration. The goal is to provide a texture that requires some chewing but is soft and moist enough to form a cohesive food bolus that is easy to swallow.

Key characteristics of Level 6 foods include:

• Soft and Tender: The food should be soft, tender, and moist throughout.
• Small Pieces: All solid food pieces must be 'bite-sized,' meaning no larger than 1.5cm x 1.5cm for adults. This is roughly the width of a standard dinner fork.
• No Separate Thin Liquid: The food should be moist, but no thin, watery liquid should leak or drip from it.
• Mashable: The food can be easily mashed and broken down with pressure from a fork.
• No Cutting Required: While a fork can be used to help scoop food, a knife is not required to cut it.

How to check food consistency for Level 6

For a home cook or caregiver, IDDSI provides a simple fork pressure test to verify that food meets the Level 6 standard.

1. Press: Press down on a piece of the cooked food with the back of a fork until your thumb starts to turn white from the pressure (blanch).
2. Observe: If the food squishes and does not return to its original shape, it is soft enough for the Level 6 diet.
3. Ensure Proper Size: Make sure all pieces are no larger than 1.5cm x 1.5cm.

Appropriate foods for a Level 6 diet

Following a Level 6 diet doesn't mean sacrificing variety. With careful preparation, a wide range of nutritious and flavorful meals can be enjoyed.

Examples of suitable foods

• Proteins: Soft, tender-cooked meat, poultry, or fish cut into bite-sized pieces and served with thick gravy or sauce. Flaked fish in a sauce, meatballs in a thick tomato sauce, or moistened mince dishes are good examples.
• Starches: Well-cooked pasta (e.g., macaroni cheese), soft potato dishes like mashed potatoes with gravy, and soaked cereals like porridge or Weetabix. Rice must be cooked until soft and moistened with a thick sauce.
• Fruits: Soft, peeled fruits like bananas, ripe avocado, or stewed apples. Tinned fruits are also acceptable, as long as they are drained and cut into the appropriate size.
• Vegetables: Well-cooked vegetables that are steamed or boiled until tender, such as carrots, swede, or cauliflower, and cut into 1.5cm x 1.5cm pieces. Canned, creamed sweetcorn or mushy peas are also suitable.
• Dairy: Yogurt, fromage frais, custard, and milk puddings. Grated cheese can be added to dishes, but hard cheese chunks should be avoided.

Foods to avoid on a Level 6 diet

Certain foods are high-risk for individuals with dysphagia and must be avoided.

High-risk foods include:

• Hard, crunchy, or crumbly foods: Hard biscuits, crusts, crispbreads, or raw vegetables.
• Chewy or sticky foods: Tough meat, toffees, dried fruits, or marshmallows.
• Stringy or fibrous textures: Pineapple, celery, rhubarb, or runner beans.
• Mixed consistencies: Foods with both thin liquid and solid chunks, such as a thin soup with lumps or mince in thin gravy.
• Foods with seeds, pips, or skins: Grapes, peas, or tomatoes with skin.

Comparison of IDDSI Levels 5, 6, and 7

Feature	Level 5 (Minced & Moist)	Level 6 (Soft & Bite-Sized)	Level 7 (Regular)
Particle Size	Max 4mm for adults (fork prong width)	Max 1.5cm (thumbnail width)	Standard size
Chewing	Not required (mashable with tongue)	Required (some chewing ability)	Normal chewing
Moisture	Moist throughout, no separate thin liquid	Moist throughout, no separate thin liquid	Moist and soft versions may be advised
Consistency	Minced with thick sauce/gravy, holds shape on spoon	Soft, tender, and moist; holds shape on fork	Normal consistency
Fork Test	Falls easily through fork prongs	Easily squashed and broken down with fork pressure	Holds shape with fork pressure

Maximizing nutrition on a Level 6 diet

To prevent weight loss or malnutrition, especially if a patient has a reduced appetite, food fortification can be used. This involves adding extra calories and protein to meals without significantly increasing volume.

Tips for nutritional fortification:

• Dairy: Add extra butter, margarine, or sour cream to mashed potatoes. Use full-fat milk, cream, or evaporated milk in soups and sauces.
• Protein: Add pureed tofu, cooked eggs, or plain protein powder to smoothies and liquids. Stir grated cheese into mashed potatoes or vegetables.
• Snacks: Offer nourishing drinks like milkshakes made with ice cream or yogurt, or fortified soups.
• Meal Timing: Encourage smaller, more frequent meals and snacks throughout the day to boost calorie intake.

Conclusion

The number 6 diet, or IDDSI Soft & Bite-Sized diet, is a critical tool for managing dysphagia and ensuring patient safety during mealtimes. By providing soft, moist, and appropriately sized foods, it allows individuals with impaired chewing or swallowing abilities to consume adequate nutrition with a reduced risk of choking. Successful implementation requires a clear understanding of the IDDSI framework and the specific characteristics of Level 6 foods, along with practical skills in food preparation and nutritional fortification. Close collaboration with healthcare professionals, such as speech and language therapists and dietitians, is essential for determining the correct diet level and maintaining a patient’s overall health and well-being.

For more information on the IDDSI framework, you can visit the official website: iddsi.org.

Frequently Asked Questions

What is the primary purpose of the Level 6 diet?

The primary purpose of the IDDSI Level 6 diet is to provide a safe eating texture for individuals who have mild-to-moderate swallowing difficulties (dysphagia) or limited chewing ability, thereby reducing the risk of choking and aspiration.

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

To check if food is soft enough, perform the IDDSI fork pressure test. Press down on the food with the back of a fork; if it squashes easily and does not return to its original shape, it is likely suitable.

What kind of meat is safe for a Level 6 diet?

Safe meat includes tender cuts of meat, poultry, or fish that are well-cooked and cut into small pieces (under 1.5cm). These should be served with a thick, smooth sauce or gravy to keep them moist.

Which fruits should be avoided on a Soft & Bite-Sized diet?

Avoid fibrous, tough, or dry fruits like pineapple, dried fruits, or fruits with skins, seeds, and pips. Also be cautious with juicy fruits like melon, where thin liquid can separate from the solid, creating a mixed consistency.

What are some breakfast ideas for a Level 6 diet?

Suitable breakfast ideas include fully soaked cereal like porridge or Weetabix, creamy scrambled eggs, mashed banana, and smooth yogurt or fromage frais.

How can I prevent malnutrition on a Level 6 diet?

To prevent malnutrition, use food fortification techniques such as adding extra butter, cream, or powdered milk to meals. Include high-calorie snacks like milkshakes between meals and ensure all products used are full-fat.

Can children follow a Level 6 diet?

Yes, children can follow an IDDSI Level 6 diet if advised by a speech and language therapist, but the recommended bite-size is smaller at 8mm. Always consult with a healthcare professional to determine the appropriate diet level for a child.