Unlock the Secrets of the Level 6 Diet: Soft & Bite-Sized Foods Perfect for Dysphagia

When dealing with dysphagia, or difficulty swallowing, navigating the world of modified diets can be overwhelming. The International Dysphagia Diet Standardisation Initiative (IDDSI) has stepped in to create a unified system for describing food textures and liquid consistencies, promoting patient safety and reducing confusion. This article delves into the details of the IDDSI Soft & Bite-Sized (Level 6) diet, providing a comprehensive guide for caregivers, individuals with dysphagia, and healthcare professionals.

The Need for Standardized Diets

Without a standard definition for texture-modified foods, ambiguous language like "soft," "chopped," and "nectar-thick" leads to confusion, especially when receiving diet orders from different healthcare facilities. This ambiguity puts individuals with dysphagia at a higher risk for choking. The IDDSI aims to eliminate this confusion by establishing unified principles for all foodservice operations, including:

Consistent diet terminology
Standardized definitions of each diet level
Reliable testing methods

Introducing IDDSI Level 6: Soft & Bite-Sized

IDDSI Soft & Bite-Sized (Level 6) focuses on the size and texture of food particles. It is designed for individuals who:

Have good tongue control and force
Can manage chewing
May have some pain or difficulty chewing
May not choose appropriate bite sizes without help

At Level 6, the size of each bite is predetermined to ensure safety and ease of chewing.

Characteristics of Level 6 Foods

Level 6 foods have specific characteristics to ensure they are easy to manage and safe to swallow:

Read also: Understanding Dysphagia Diets

Bite Size: Food pieces should be no larger than 1.5 centimeters (cm) by 1.5 cm (about .5 by .5 inches) for adults. For children, the maximum size is 8mm square. This size is approximately the size of an adult thumbnail.
Texture: Foods must be soft, moist, and cohesive, with no separate thin liquid.
Fork/Spoon Pressure Test: The pressure from a fork or spoon must easily mash the pieces. The utensil should easily cut through or break apart the food using only the side of the utensil. When mashing the sample to test, only use as much pressure as causes your thumbnail or fingernail to blanch white. After mashing, the food must not return to its original shape.

Testing Foods for Level 6 Compliance

To ensure foods meet the Level 6 criteria, the Fork Pressure Test is essential:

Place your fork or spoon over your food.
Using your thumb, press down on your fork or spoon until your nail turns white.
Your food is soft enough if it is completely squashed and does not return to its original shape.

Level 6 Food Examples

When following a Level 6 Soft & Bite-Sized diet, consider these food options and those to avoid:

Permitted Foods

As long as a food makes chewing and swallowing safer and easier, it can be included in the diet. Examples of permitted foods include:

Fruits and Vegetables: Cooked, peeled, finely chopped, mashed, or blended fruits and vegetables. Avocado may be soft enough to eat as is. Examples include creamed peas, and creamed corn with soft skins.
Grains: Hot cereals (oatmeal, porridge, grits, and Cream of Wheat), soft bread (avoid toasting it), finely cut pasta, cooked rice, refined grains (e.g., white breads), and similar foods.
Meat, Poultry, Fish: Tender meats (e.g., canned tuna, ground beef), thinly shaved meat, and other meats that have been mechanically altered. Always remove the fat and gristle from meat cuts.
Dairy: Milk, powdered milk, cottage cheese, soft cheeses, grated and shredded cheeses, yogurt, ice cream, and other soft dairy products
Eggs: Most cooking methods acceptable - but if eating boiled eggs, ensure they’re chopped finely or mashed, as in egg salad
Plant-Based Proteins: Tofu (silken, regular, firm), cooked beans, pureed beans, soy milk, hummus, peanut butter, and other products
Fats: Butter, margarine, and all plant-based oils (e.g., olive, sesame, coconut)
Desserts: Any soft cake, pastry, cookie, or other dessert (e.g., custard, ice cream, Jell-O) that does not contain nuts, candy, fruit, or other hard pieces of food
Other Foods: Protein powders (whey or plant-based), liquid nutritional supplements (e.g., Ensure, Boost), casseroles, soups without large pieces of meat, jams without seeds, broth, gravy, sauces, condiments, and other products
Beverages: All beverages (including juices with pulp), except for any that contain solid food pieces

Foods to Avoid

Some foods are considered unsafe and unsuitable for a mechanical soft diet. These may include:

Fruits and Vegetables: Raw or stir-fried vegetables, fruit with seeds or pits, unpeeled fruit and vegetables, dried fruit (e.g., raisins, apricots), whole fruits (e.g., grapes, olives), corn on the cob, raw coconut, and fried vegetables (e.g., french fries)
Grains: Hard or crunchy bread (e.g., sourdough, pumpernickel, rye), toast, buckwheat (kasha), egg noodles, garlic bread, granola, muesli, crackers, melba toast, shredded wheat, undercooked pasta, popcorn, hard taco shells, and others
Meats, Poultry, Fish: Hard cuts of meat (e.g., steak, jerky, pork chops), meats or poultry with the bone (e.g., chicken wings), hot dogs, sausage, shellfish, fried meat or fish, and others
Dairy: Hard cheeses (e.g., cheddar, Parmesan, Swiss), soft cheeses with dried fruit or nuts, and more
Plant-Based Proteins: Nuts, seeds, extra-firm tofu, seitan, crunchy peanut butter, and others
Desserts: Chips, pretzels, popcorn, candy, hard cookies, licorice, any sticky dessert (e.g., caramel. taffy), candied nuts, pie crust, and more
Other Foods: Jams with seeds (e.g., raspberry jam), gum, marshmallows, any foods that cannot be mechanically altered, etc.

If you’re unsure whether a food is safe to eat, speak with a healthcare professional who specializes in mechanical soft diets, such as a registered dietitian.

Tips for Preparing Level 6 Meals

Moist Foods: Try to eat moist foods while on this diet. If you have dry mouth, you may need especially moistened foods to make them slide down better. You may need to get creative with sauces, gravies, and condiments. Applesauce, guacamole, hummus, and olive oils make good additions to add moisture in healthy ways.
Fork Pressure Test: Ensure all foods meet the fork pressure test criteria to guarantee they are soft enough.
Cut to Size: Cut all foods into pieces no larger than 1.5 cm to prevent choking. These pre-cut small pieces can also decrease your effort in having to cut-up the food yourself, especially if you have difficulty using a knife and a fork.
Avoid Mixed Consistencies: Be cautious with mixed consistencies (part solid and part liquid).
Bread Alternatives: Avoid bread, as this is the most commonly choked on food item. Recommendations for bread on this diet will be per your evaluations by an SLP specializing in difficulty swallowing. In other words, it is at the discretion of your clinician, medical team and your own informed decision-making if you should take the risk of eating bread or not. For example, you could ask to have breads tested on your swallow study (e.g., imaging with X-ray or scoping with a thin camera). As noted above: Please see this blog about how bread presents serious choking risks.
Add Calories: Add 2 to 4 tablespoons of canned coconut milk or cream to smoothies, shakes, cereals, and yogurts for extra calories. Make ice cubes from milk or fruit nectar. Use these high-calorie ice cubes in smoothies or to keep your shakes cold. Add sour cream, half and half, heavy cream, or whole milk to your foods. Add pureed tofu to cooked vegetables, soups, or smoothies.

Benefits of a Level 6 Diet

The primary benefit of a Level 6 Soft & Bite-Sized diet is the ability to safely consume food, which can:

Help meet nutritional needs without the risk of choking.
Reduce the effort required for chewing and swallowing, especially for those who are weak or fatigued.
Provide a sense of comfort, safety, and autonomy for those at risk of choking.
Prevent malnutrition, which is highly prevalent in people requiring texture-modified diets.
Support recovery from illness or surgery and act as a transition between liquid and solid food diets.

Tips for a Smooth Transition

If you have been prescribed a mechanical soft diet, here are some helpful tips to help make the transition as smooth as possible.

Use the Right Tools: Having the right kitchen tools can help speed up food preparation. Some tools you may want to use are: sharp kitchen knives (e.g., chef’s knife) a blender or mini blender (e.g., NutriBullet, Magic Bullet) an immersion blender a food processor a mesh strainer (allows you to strain fruits and vegetables) a food grinder (e.g., baby food grinder). Depending on your circumstances, you may wish to use smaller appliances (such as a mini blender or immersion blender) to prepare single-serving dishes. Alternatively, you can prepare large batches to eat throughout the week.
Food Safety: When preparing foods, ensure that you’re practicing food safety. This includes washing your hands, avoiding cross contamination, cooking foods to their proper temperatures, and storing foods in the refrigerator or freezer.
Plan Ahead: If you know you will be eating out at a restaurant or at an event, it’s important to plan ahead. When eating at a restaurant, you can ask the manager or chef to prepare foods for your needs. In many cases, they will happily puree or finely chop food items to ensure they are safe for you. You may also want to request additional sauce or gravy to help moisten food. If you’re going to an event, ask the host ahead of time which foods will be available and if you can use their blender, food processor, or other equipment as needed. If those tools won’t be available to you, ask if you may bring your own. Otherwise, you may want to bring your own meals and heat them in a microwave if you need to.
Work with a Healthcare Professional: If you’re going to be on a mechanical soft diet for longer than a few days, you may want to speak with a healthcare professional who specializes in this diet to ensure you’re meeting your nutritional needs. Most hospitals and healthcare centers will have a registered dietitian or speech language pathologist who can answer your questions and help guide you. In some cases, they may also recommend supplements to ensure you’re getting the right nutrients.
Other tips: Here are some other helpful tips: If you’re unsure whether a food is the right consistency, ask a friend or family member to try it first. Make sure you’re drinking liquids to keep your mouth moist, which helps with chewing and swallowing, and to prevent dehydration. If you’re feeling unwell or too weak to prepare your meal, ask a friend or family member to help. If this isn’t possible, it may be a good idea to have premade, microwavable meals available. For additional nutrition, try adding protein powder, milk, nutritional powders, or other calorie- or protein-rich ingredients to smoothies, yogurts, beverages, soups, or other foods.

IDDSI Resources

IDDSI provides handouts in consultation with clinicians and patients, designed for both adults and children. These handouts offer easy-to-read information about IDDSI levels, testing methods, food examples, and textures to avoid.

The Evolution from Mechanical Soft to IDDSI Level 6

The term "mechanical soft" is outdated and lacks a standardized definition, leading to confusion and inconsistent application. The IDDSI framework offers a more precise and evidence-based approach to dysphagia diet management. The new diet label of “Soft & Bite-Sized” is more descriptive and accurate. The old label of “Dysphagia Advanced” roughly maps over to the new label of “Soft & Bite-Sized, Level 6” per IDDSI. Particle size requirement is now 1.5 cm to prevent choking risk (versus a recommendation of 1/2 inch with Dysphagia Advanced).

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