Successfully Preparing Meals for Soft & Bite-sized Diets

With the new guidelines from the International Dysphagia Diet Standardization Initiative (IDDSI), we now have very clear definitions for diet consistency and texture, and guidance on how to test the foods to be sure they are correct. This is vital, since choking is a leading cause of death for individuals with intellectual and developmental disabilities.

A dysphagia advanced diet is now known as a Level 6 Soft and Bite Sized Diet. You can see how it fits within the framework below. While many aspects of the Soft and Bite Sized diet are similar to the advanced diet, there are some important differences, and there is more structure to help you identify the correct consistency.

Source: The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/

Identifying and Testing Level 6 Soft and Bite Sized Foods

Soft and bite sized foods should be soft, tender, and moist, with no thin liquid dripping or leaking from it. The ability to bite off pieces of food is not required, but the individual needs to be able to chew the food so it can be safely swallowed. The size of the food particles should be no more than 1.5 centimeters by 1.5 centimeters, which is about the width of a standard dinner fork.

The food should not need to be cut with a knife, and can be mashed, or broken down, using the pressure from a fork. However, the food can be eaten with a fork, spoon, or chopsticks.

Soft and bite sized foods may be tested for proper consistency using the fork pressure test. Please note: Foods do not need to be mashed before serving, unless otherwise specified. The fork pressure test is used only to test a food sample for proper softness.

Fork Pressure Test – With the food sample on a plate, apply pressure to the fook with your thumb to mash the food. Enough pressure should be applied so the tip of your thumb blanches to white. This is similar to the tongue force used during swallowing. When the fork is lifted, the food sample should be completely squashed, and should not regain its shape. See the image below demonstrating correct thumb placement and pressure, and correct consistency of food.

Source: The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/

How To Get the Right Texture and Consistency

To prepare foods to level 6 soft and bite sized, you will need a sharp knife and cutting board. Chop all food items to the correct size, 1.5 cm by 1.5 cm or smaller. This can be done either before or after the food is cooked. Note that some foods will shrink when they are cooked. 

It can be helpful to cook foods, especially meat, in a marinade, gravy, or other liquid to keep them moist. Remember to drain the liquid before serving the food. Vegetables should be cooked until they are very soft; never al dente.

If the food cannot be made soft enough, it should be served minced and moist, as per the Level 5 Minced and Moist Diet instructions.

What to Serve on a Level 6 Soft and Bite Sized Diet

Here are some examples of foods in appropriate textures that can be served on a Level 6 diet:

• Meat or fish, without bones, that is cooked tender, and cut small, no bigger than 1.5cm.
• Casseroles with thick liquid portion, and without hard lumps. All pieces of the casserole must be mashable soft, and with size no more than 1.5cm.
• Fruit served mashed, with any excess liquid drained away. No piece larger than 1.5cm.
• Vegetables that are steamed or boiled until very soft, with final cooked size 1.5cm or less.
• Cereal that is smooth, or with soft, tender lumps no bigger than 1.5cm. Any excess milk or other fluids should be drained away.
• Rice that is not particulate or grainy, or sticky or glutinous.
• Bread that is pre-gelled or soaked. It should be very moist and gelled throughout. Regular bread is not allowed, unless assessed as suitable by a dysphagia specialist.

Foods to Avoid on the Level 6 Soft and Bite Sized Diet

These are some foods that should not be given to someone on a level 6 soft and bite sized diet (please note that this list may not be exhaustive, and caretakers will need to use professional judgement):

• Peanut butter and other nut butters
• Foods with mixed textures, like soup with chunks of food in it, or cereal and milk
• Chewy foods like marshmallows, chewy candy, chewing gum, and cheese chunks
• Dried fruit
• Regular bread (see above instructions for making bread meet the guidelines)
• Crispy food like bacon or corn flakes
• Crunchy foods like raw vegetables and popcorn
• Hard raw fruit, like apples, fruits with skin, like grapes
• Fibrous or stringy foods, like pineapple, rhubarb, or green beans
• Nuts and seeds
• Chips, pretzels
• Dry, crumbly foods like cake and biscuits
• Foods with skins or outer shells, like corn and peas
• “Skins” like on sausage, or skins of chicken, salmon, etc.
• Meat with bones or gristle in it (chicken leg, some steak, etc.)
• Round or long shaped foods, like grapes or hot dogs
• Any crust or skin that forms on food after heating, like on cheese
• Sticky or gummy food, like over-cooked oatmeal or porridge, or sticky rice cakes
• “Floppy” foods, like lettuce, cucumbers, and uncooked spinach
• Juicy foods where liquid separates from the food in the mouth, like watermelon
• Any food bigger than 1.5cm in diameter

Tips For Feeding

Since individuals requiring a level 6 soft and bite sized diet are at an increased risk of choking, there are some tips and strategies you can use to help lower that risk. Unless otherwise ordered by a physician or speech therapist, follow these tips:

• Have the person sit upright at all times, and wear/use any adaptive equipment needed, including during administration of medication, and while drinking beverages.
• If the individual is able to eat unassisted, do not feed them. If assistance is needed, provide the minimal assistance necessary. This helps preserve the individual’s dignity.
• Use a small spoon, or a “baby” spoon, if a spoon is needed. Put a similarly small amount of food onto a fork. Having too much food in the mouth at a time is a choking hazard.
• Allow the person adequate time to chew the food and swallow before offering more. Do not rush.
• Offer a sip of a drink after each bite to help clear the mouth.
• Check the person’s mouth after each bite to make sure s/he is not holding food in the cheeks, and that it is not sticking to the teeth or the roof of the mouth.
• Do not comment negatively on the look, smell, or texture of the food. This can influence the person to not eat or eat less. Find something to comment positively on.
• Make efforts to make the foods look nice on the plate. Everyone eats with their eyes first. Use different shapes, sizes, and colors. Example:

Remember that some individuals on the Level 6 Soft and Bite Sized Diet will also require thickened liquids. Always follow the individual’s diet and liquid order. Consult your supervisor, the speech therapist, or dietitian with any questions you might have about how to prepare certain foods or if it may or may not be given.

With the right strategies, you can prevent a majority of choking episodes!