Understanding the IDDSI Framework
The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standardisation initiative that provides a framework for describing and managing texture-modified foods and thickened liquids for people with dysphagia, or swallowing difficulties. The framework uses a numbered and colour-coded system to categorise different food and fluid consistencies, helping to reduce confusion and improve safety for patients. IDDSI Level 6, known as 'Soft & Bite-Sized', is a food texture designed for individuals who require food that is easy to chew and swallow but can still manage small, solid pieces.
Defining the Particle Size for Level 6 Soft & Bite-Sized Diet
The specific particle size is a defining characteristic of the Level 6 diet, established to minimise the risk of choking for those with limited chewing capacity.
Particle Size for Adults
For adults, the particle size for Level 6 food must be no larger than 1.5 cm x 1.5 cm. This dimension is roughly the width of a standard dinner fork, which provides a convenient, readily available tool for checking consistency. Food items must be pre-cut to these dimensions, as individuals on this diet may have a limited ability to bite off pieces of food themselves. This standard ensures that pieces are small enough to be easily managed in the mouth before swallowing.
Particle Size for Children
Recognising the smaller airway size of children, the IDDSI framework specifies a significantly smaller particle size for children under five years old. For this age group, the food pieces should be no larger than 0.8 cm x 0.8 cm. This reduced size is critical for enhancing safety and reducing the risk of choking in young children with dysphagia.
Beyond Size: Other Key Characteristics of IDDSI Level 6
While particle size is critical, it is just one of several criteria that food must meet to be classified as Level 6. The overall texture is equally important for safety and ease of swallowing.
Softness
Food at this level must be soft, tender, and moist throughout. It must be easily mashed or broken down with pressure from a fork or spoon, without returning to its original shape once the pressure is released. This is often tested using the IDDSI Fork Pressure Test, where a thumbnail blanching white from the pressure of the fork on the food indicates sufficient softness. A knife is not required to cut food at this level.
Moisture
Level 6 foods must have no separate thin liquid. This means that gravies, sauces, or milk should be thick enough to cling to the food pieces and not run or drip off. The presence of separate thin liquid can increase the risk of aspiration.
Chewing Required
Unlike lower levels that may require minimal to no chewing, Level 6 food requires moderate chewing before it is swallowed. This indicates that the individual has some chewing function but needs assistance with sizing and texture to ensure safety.
How to Test Food for Level 6 Compliance
Testing is a vital step in ensuring food is safe for an individual on a Level 6 diet. There are two primary, simple tests that can be performed in any kitchen.
Fork Pressure Test
This test assesses both the size and softness of the food. To check the size, you can use the tines of a standard dinner fork as a guide, with the length of the tines approximating the 1.5 cm standard for adults. To check the softness, press down on the food with the fork's prongs. If the food squashes easily and does not spring back to its original shape when the pressure is removed, it is soft enough. Pressure should be sufficient to make your thumbnail blanch white.
Spoon Pressure Test
Similar to the fork test, the side of a spoon can be used to cut or break food into smaller pieces. The same principle applies: food should mash down and not regain its shape after the pressure is released.
Level 6 Examples and Foods to Avoid
Proper food selection is key to a successful and safe Level 6 diet. The following lists provide examples of what is generally recommended and what should be avoided.
Recommended Foods
- Tender, slow-cooked meats or fish, cut to size.
- Well-cooked vegetables (steamed or boiled) cut into appropriate sizes.
- Soft, drained fruits without skins or seeds, such as ripe bananas or mashed cooked apples.
- Soft pasta, well-cooked rice (bound with a thick sauce), or moist, fully softened cereals.
- Soft cheeses, hummus, and scrambled eggs.
Foods to Avoid
- Hard, crunchy, or tough foods (e.g., toast, nuts, popcorn).
- Fibrous or stringy foods (e.g., pineapple, celery, bacon).
- Mixed consistency foods (e.g., cereal with thin milk, soups with large chunks).
- Foods with skins, husks, or seeds (e.g., peas, grapes, baked beans).
- Dry, crumbly, or flaky items (e.g., dry cakes, pastry).
- Food with bones, gristle, or tough membranes.
Comparison of IDDSI Level 6 and Level 5
Understanding the subtle differences between IDDSI levels is crucial for patient safety. The following table contrasts Level 6 (Soft & Bite-Sized) with Level 5 (Minced & Moist).
| Feature | IDDSI Level 6 (Soft & Bite-Sized) | IDDSI Level 5 (Minced & Moist) |
|---|---|---|
| Particle Size | Max 1.5cm x 1.5cm for adults; 0.8cm x 0.8cm for children. | Max 0.4cm x 0.4cm for adults (4mm). |
| Chewing Required | Moderate chewing required for small, tender pieces. | Minimal chewing required. |
| Appearance | Recognisable as small, individual food pieces. | Finely minced, moist, and cohesive lumps. |
| Testing Method | Fork/Spoon Pressure Test for softness and size. | Fork Drip Test, Spoon Tilt Test. |
| Characteristics | Tender, moist, not sticky, no separate thin liquids. | Moist and cohesive, but does not separate into liquid. |
Conclusion
The particle size for level 6 soft & bite-sized diet is a cornerstone of the IDDSI framework, providing a clear and measurable standard for patient safety. For adults, the maximum particle size is 1.5 cm x 1.5 cm, while for young children, it is 0.8 cm x 0.8 cm. This guideline, combined with strict adherence to texture and moisture requirements, is essential for reducing the risk of choking and improving mealtime safety for individuals with dysphagia. Consistent testing using the Fork Pressure Test, along with careful food preparation and selection, ensures that a patient receives a diet that is both safe and enjoyable. For more detailed information on the IDDSI framework, consult the official IDDSI website.
Resources and Further Reading
For additional information on food testing methods and a comprehensive overview of the IDDSI framework, visit the International Dysphagia Diet Standardisation Initiative website. This authoritative resource is essential for anyone involved in preparing or serving texture-modified diets.
