What the IDDSI Framework Defines for Level 6
Level 6, also known as 'Soft and Bite-Sized,' is a critical food texture level within the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. It is prescribed for individuals who can safely chew and swallow but have difficulty biting off pieces of food due to weak oral muscles, dental problems, or fatigue. The primary goal is to minimize choking risk by serving food in pre-cut, manageable pieces. A key characteristic is that chewing is still required at this level.
Adult Particle Size Guidelines
For adults, the particle size for a Level 6 diet is strictly defined to prevent choking. Each piece of food must be no larger than 1.5 cm by 1.5 cm. This dimension is roughly equivalent to the width of a standard dinner fork's prongs, providing a practical tool for caregivers to verify correct sizing. The food must also be soft, tender, and moist throughout, requiring no knife for cutting. This ensures it can be easily broken down with the tongue and chewed with minimal effort before swallowing.
Pediatric Particle Size Guidelines
The IDDSI framework specifies a smaller particle size for children under five years old to account for their smaller oral cavities and airways. The target piece size is 0.8 cm by 0.8 cm, which is half the size recommended for adults. Adhering to these smaller dimensions is crucial for pediatric dysphagia management to significantly reduce choking hazards.
The Importance of Texture and Consistency
While size is a vital aspect of a Level 6 diet, texture and consistency are equally important. Food must be soft enough to be easily mashed or broken down with the pressure of a fork. The fork pressure test, where the food squashes and changes shape when pressed with a fork, is a standard method to confirm the correct texture. Food should also be cohesive and moist, without separate thin liquid dripping from it, as mixed consistencies can increase aspiration risk. For instance, rice should be served with a thick, non-pouring sauce to hold it together, rather than as individual, dry grains.
How to Prepare Foods for a Level 6 Diet
Preparing food to the correct Level 6 standard requires specific techniques to ensure both size and texture compliance. The method chosen depends on the starting food item. Below are some preparation strategies:
- For meat and poultry: Cook until exceptionally tender, such as in a stew or casserole. Cut into pieces no larger than 1.5cm x 1.5cm (or 0.8cm x 0.8cm for children). Ensure a thick, smooth sauce or gravy moistens the pieces completely.
- For fish: Choose soft fish and cook by steaming or poaching. Flake into bite-sized pieces, ensuring all bones are removed. Serve with a smooth, thick sauce.
- For vegetables: Boil, steam, or stew until very soft and tender. Cut into the appropriate bite-sized pieces. Avoid fibrous vegetables like celery or tough outer skins.
- For starches: Mash potatoes until smooth or cut boiled potatoes into correct sizes. Serve pasta in a thick sauce. For rice, serve in a thick sauce that holds it together, like a risotto or curry.
- For fruits: Use ripe, soft fruits like banana or avocado. For other fruits, cook and stew them, removing skins and pips, then cut to size. Canned fruits are also suitable if drained and cut.
- For eggs: Prepare as scrambled, poached, or in an omelette, then cut into the correct bite-sized pieces. Hard-boiled eggs can be mashed with mayonnaise.
Foods to Include and Avoid
Achieving a safe and enjoyable Level 6 diet involves a clear understanding of which foods are suitable and which pose a risk. The following table provides a helpful comparison:
| Recommended Level 6 Foods | Foods to Avoid on a Level 6 Diet |
|---|---|
| Tender, braised meat in thick gravy | Hard, tough, or stringy meats (e.g., tough steak) |
| Soft-cooked vegetables (steamed, boiled) | Raw vegetables or stir-fried vegetables |
| Mashed potatoes or sweet potatoes | Crunchy or crumbly textures (e.g., crisps, dry biscuits) |
| Flaked, moist fish (poached, baked) | Batter or crumb-coated fried fish |
| Ripe, soft fruits (banana, avocado) | Fruits with skins, seeds, or pith (e.g., apples, oranges) |
| Soft, moist cakes and puddings | Dry or seeded breads, hard crusts |
| Rice with a thick, cohesive sauce | Rice that separates into individual grains |
| Soft cheeses in small pieces (e.g., melted) | Chewy cheese chunks |
| Eggs (scrambled, poached) | Scotch eggs |
Testing Your Food for Level 6 Compliance
To ensure food safety, you can perform two simple checks at home before serving a meal. These tests are standardized by IDDSI to provide consistent, reliable results:
- Fork Pressure Test: Place a bite-sized piece of food on a flat surface. Using the base of a fork, press down with enough pressure to make your thumbnail blanch white. The food should easily squash and not return to its original shape. If it springs back or is resistant, it is too firm for this diet level.
- Fork Separation Test: Check that the food is moist and cohesive, without any thin liquid that can separate. A good test is to put a forkful of food on a plate and tilt it. The sauce should not drip off easily and leave the solid pieces dry.
Conclusion
Adhering to the correct particle size, moisture, and softness is fundamental for the safe management of a Level 6 soft and bite-sized diet. The IDDSI guidelines provide a clear, evidence-based framework that significantly reduces the risk of choking for individuals with compromised chewing ability. Careful food preparation, along with a simple fork test, ensures that meals are both safe and enjoyable. Always consult with a healthcare professional, such as a Speech-Language Pathologist or dietitian, to confirm the appropriate diet level for individual needs. For more details on the framework, visit the official IDDSI website.
