Advice when you need to follow an IDDSI (International Dysphagia Diet Standardisation Initiative) level 6 soft and bite-sized diet
Information for patients from the Nutrition Team
You have been advised to follow a level 6 soft and bite-sized diet. This leaflet will explain:
what level 6 soft and bite-sized diet is
how to prepare and serve your food
which foods can be included in a soft and bite-sized diet
practical tips and meal ideas
what problems you may have
where to buy ready-prepared meals from; and
how to contact us.
We hope this leaflet will help to answer some of the questions you may have. If you have any further questions or concerns, please speak to a member of your healthcare team.
Introduction
You may be experiencing difficulty with eating, drinking, and swallowing. The medical term for this is “dysphagia”.
Dysphagia can occur for many reasons, for example as a result of:
a stroke
a progressive neurological condition
dementia
a developmental disorder
learning disability
a respiratory complaint
a head trauma (injury); or
head and neck surgery.
This can make having an adequate and nourishing diet difficult. As a result, you may experience:
weight loss
dehydration (not enough fluids)
weakness
depression
malnutrition (a serious condition, when your diet does not contain the right amount of nutrients); and
a reduced ability to fight off infection.
Why have I been referred to the speech and language therapist?
A speech and language therapist will assess you. They will recommend the most appropriate consistencies of food and drink, and any strategies that may help. This will mean that eating and drinking can be as safe, enjoyable, and comfortable as possible.
Follow your speech and language therapist’s guidance. If you have any questions, please ask for advice.
A soft and bite-sized diet is helpful for people who have difficulties:
biting or chewing
handling more challenging food textures with their tongue
swallowing more challenging food textures safely.
Your dietitian will outline a suitable nutritionally adequate diet for you. The dietitian will give you practical advice on how to continue the diet at home.
What is an IDDSI level 6 soft and bite-sized diet?
An IDDSI level 6 diet consists of foods that are very soft, tender and moist, but with no separate thin liquid dripping from the food. Food is in bite-sized pieces for adults, approximately 1.5cm x 1.5cm, which is roughly the size of a thumbnail or width of a standard dinner fork. Eating bite-sized food reduces your risk of choking.
A soft and bite-sized diet
Can be eaten with a fork or spoon.
Can be mashed / broken down, with pressure from a fork or spoon.
Chewing is needed before swallowing.
A knife is not needed to cut this food. Pressure from a fork or spoon held on its side, can be used to cut or break this food into smaller pieces.
Which foods can be included in a soft and bite-sized diet?
It is important to eat as wide a variety of foods as possible. Choose foods from each of the groups below.
Starchy foods
Aim to include at least one starchy food at each meal.
Cereal with pieces no bigger than 1.5cm x 1.5cm, and their texture fully softened. Excess liquid should be drained before serving.
Avoid cereals with added nuts and dried fruit, such as muesli.
Porridge (use fine grain oats) and other instant cereals, such as Ready Brek or Oats-So-Simple.
Ask your speech and language therapist for advice about bread. Do not eat regular dry bread, newly baked bread, and bread containing nuts, seeds, or other bits. It may be easier to eat bread with butter or margarine, and the crusts removed.
Rice needs to have a thick, smooth, non-pouring sauce to moisten it and hold it together. Rice should not be sticky or gluey. When cooked and served, it should not separate into individual grains. Try curry, chilli con carne, casserole, or risotto.
Well-cooked boiled potatoes, mashed or cut into 1.5cm x 1.5cm pieces.
Well-cooked pasta, for example macaroni cheese, ravioli, lasagne, and spaghetti Bolognese. Cut spaghetti to the correct size.
Cake or sponge, such as Eve’s pudding or chocolate Swiss roll.
Avoid pieces of nut and dried fruit.
Soft biscuits, like soft macaroons and Jaffa cakes. These will need to be cut to the correct size.
Fruits and vegetables
Aim to have 5 portions of fruit and vegetables each day. One of these portions could be a glass of pure fruit juice or a smoothie.
Fruit must be soft and chopped into pieces no larger than 1.5cm x 1.5cm.
Any excess liquid should be drained before serving.
Do not use the fibrous parts of fruit (for example the white part / pith of an orange).
Ideal fruits include ripe avocado, banana, strawberries, raspberries, papaya, and kiwi.
Be extra careful of fruit with a high-water content, where the juice separates from the solid in the mouth during chewing. These include melons, oranges, satsumas, and grapefruits.
Tinned fruit cut to 1.5cm pieces. Do not eat skins, stones, and pips. Drain off excess liquid before serving.
Stewed fruit, such as apples, pears, or rhubarb. Remove the skins before cooking.
Steam or boil vegetables until soft, with a final cooked size no larger than 1.5cm x 1.5cm.
Try swede, broccoli, cauliflower, and carrots.
Tinned vegetables, such as chopped tomatoes, creamed sweetcorn, and mushy peas.
Do not eat stir-fried vegetables, they are too firm.
Meat, poultry, fish, eggs, and pulses
Aim to include 2 portions a day.
Cook meat and poultry until tender. Chop into pieces no bigger than 1.5cm x 1.5cm in size.
If meat or poultry cannot be served like this, finely mince or chop the meat to a 4mm lump size. Serve in a thick, smooth, non-pouring sauce or gravy.
Ideas for meals include:
cottage or Shepherd’s pie
spaghetti Bolognese
meat loaf
chicken supreme
corned beef hash
casserole
curry
tender roast meat with thick gravy or sauce
skinless sausage or soft skinless black pudding.
Cook fish until soft enough to break, and serve in pieces no larger than 1.5cm x 1.5cm. Do not eat fish covered in batter or crumb coatings. You can have tinned fish, but make sure any bones are removed first.
Eggs (poached, scrambled, fried, or omelette) must be cut into 1.5cm x 1.5cm pieces.
Hard-boiled eggs mashed with mayonnaise. Do not eat scotch eggs.
Beans and lentils can be included in thick soups, stews, and casseroles (with or without meat).
Baked beans and smooth hummus.
Tofu, Quorn, and textured vegetable protein. Mince or cut into 1.5cm x 1.5cm pieces.
Milk and milk products
Try to have a pint of milk every day, or include two to three servings of milk products.
Milk can be used in drinks, and as the base for many sauces.
Milk puddings are ideal for a soft and bite-sized diet.
Yoghurt, custard, trifle and Fromage frais make good soft and bite-sized desserts. Do not eat those with nuts, seeds, and grains.
Add grated cheese to mashed potato, puréed soup, white sauce, and cauliflower cheese. Do not eat lumps of cheese bigger than 1.5cm x 1.5cm.
Ice-cream is not suitable for everyone with a swallowing difficulty. Please ask your speech and language therapist for advice.
Homemade, tinned, or packet milk puddings. For example custard, semolina, rice pudding, blancmange, Instant Whip, Angel Delight, and crème caramel.
What foods should not be included in a soft and bite-sized diet?
Foods with skins, husks or outer shells. For example:
peas, corn, shredded wheat, soya beans, grapes, sweetcorn, chicken skin, fish or sausage skin.
Crunchy, sharp or crispy foods. For example:
toast, dry biscuits, crisps, crackling, crisp bacon, lettuce, cucumber, popcorn, cornflakes.
Pips and seeds. For example:
apple seeds, pumpkin seeds, orange pith.
Hard or dry textures. For example:
pieces of apple, chunks of cheese, nuts, raw vegetables (such as carrot, cauliflower, and broccoli), dry cakes, bread, dry cereal.
Mixed consistencies. For example:
soups with lumps or bits, mince in thin gravy, cereal in milk (that does not soak up the milk), juicy fruits with thin liquid (such as watermelon).
Tough, stringy fibrous textures. For example:
steak, pineapple, celery, rhubarb, runner beans.
Crumbly foods. For example:
dry cake, crumble, bread crusts, pie crusts, dry biscuits.
Chewy textures. For example:
toffees, sweets, cheese chunks, chewing gum, marshmallows, dried fruits.
Sticky foods. For example:
nut butter, overcooked porridge or oatmeal, sticky mashed potato.
Bones or gristle. For example
chicken, fish or other bones or meat with gristle.
Foods with large or hard lumps. No pieces larger than 1.5cm x 1.5cm.
Any crusts or skins that form on foods during cooking or after heating. For example:
cheese topping, mashed potato.
Floppy foods. For example:
lettuce, cucumber, raw spinach leaves.
Round or long-shaped foods. For example:
grapes, whole cherry tomatoes, sausages.
Make sure all food it cut to the correct size.
Practical tips
We all must eat. For most of us it is an enjoyable time, often involving family and friends. Eating a soft and bite-sized diet will mean a change from your normal routine. However, by following these ideas, you can hopefully still enjoy your food.
Add sauces to drier foods, to make them easier to chew and swallow. For example, add thick gravy, parsley sauce, custard, or double cream.
Include a variety of foods to avoid boredom. Make sure you get lots of different nutrients to keep you healthy.
Make the food look appetizing, choose food of different colours.
To bring out the flavour, serve foods at the correct temperature.
Eat slowly and serve a small amount at a time, so your food does not get cold before you finish it. If you feel that you can manage more, you could heat up another small portion later.
Warm your plate before serving. This may help to keep your food hot for longer.
Eat in a quiet, relaxed place, and take your time. Sit upright during your meal.
Finish each mouthful before taking the next. If you feel any food remains in your mouth or at the back of your throat, swallow again until the food is cleared.
If you are unable to manage three meals a day, try eating ‘little and often’. Eat more during the times or days when your appetite is good.
Have nourishing snacks or drinks handy for when you feel hungry, for example, mousses, milkshakes, yogurts, and custard.
Drinks such as water, tea, and coffee give very little nourishment and can fill you up. Try milky drinks instead.
Do not drink just before a meal, as you may not be able to eat as much.
A small amount of alcohol helps to stimulate your appetite, for example a small glass of sherry or brandy. Check with your doctor first.
If you are struggling to cook or shop on a regular basis, make use of convenience foods or order in pre-prepared food from delivery companies. See links for these and store cupboard ideas below.
If possible, weigh yourself once a week. If you are losing weight or your appetite is poor, please make sure you are following the ideas in the What should I do if I am losing weight? section below.
Your dietitian or speech and language therapist will be happy to help you. Please contact them if you are worried or have any questions about your diet or swallowing.
Soft and bite sized meal ideas
All meals / snacks must be cut up into 1.5cm x 1.5cm pieces.
If you are diabetic, it is important to regularly monitor your blood sugar levels when you make changes in your diet. Please speak to your diabetic nurse if you need advice.
Breakfast
Cereals soaked or cooked in milk, for example Ready Brek, Weetabix, porridge. Make sure any milk is absorbed fully into the cereal.
Yoghurt.
Boiled, poached, or scrambled eggs.
Between meals drinks and snacks
Milky drinks, such as Cocoa, Horlicks, or drinking chocolate. Add extra sugar, but be careful if you have diabetes.
Coffee made with milk. Add extra sugar, but be careful if you have diabetes.
Milk, milkshakes, and smoothies.
Complan Shake / Aymes Shake.
Fruit juice, for example orange or cranberry.
Full fat yogurt or soft pudding. See Puddings below.
Drinks may need to be thickened. Your dietitian or speech and language therapist will be happy to help you.
Snack ideas
Smooth homemade, packet, or tinned soup. Do not eat soups like minestrone, as they have a lot of chunks of different sizes. To thicken the soup, add dried potato flakes (such as Smash or breadcrumbs). Add grated cheese.
Condensed cream of soups (such as Campbell’s) can be made up with milk.
Scrambled, poached, or soft-boiled egg. Serve with chopped tinned tomatoes and creamed potato or tinned spaghetti.
Corned beef, tinned tuna, or salmon. Serve with tinned spaghetti or creamed potato.
Jacket potato (without the skin) with soft filling. For example cream cream, cottage cheese, pate, tuna or egg mayonnaise.
Main meal ideas
Minced / tender beef, lamb, pork, chicken, or turkey. Chop pieces of meat, so no bigger than 1.5cm.
Shepherd's / cottage pie.
Corned beef hash.
Omelette (plain or with cheese).
Flaked fish in a thick, smooth sauce (for example cheese, parsley, or white sauce).
Cauliflower or broccoli cheese, making sure the vegetables are cooked until soft.
Cheese soufflé.
Vegetable or lentil stew / curries, well-cooked dhal.
Quorn mince / lentil Bolognese.
Tofu in a thick, smooth sauce.
Pasta dishes such as spaghetti Bolognese. Baked pasta dishes (such as lasagne) may have a hard / chewy texture, especially on the top layer. If so, they may not be suitable for a soft and bite-sized diet.
Risotto.
Except for the pasta and risotto, serve the above with:
creamed, instant mashed, or soft-boiled potatoes, or soft chips in gravy
well-cooked pasta
soft / mashed vegetables, for example carrots, swede, cauliflower, parsnip, broccoli
butter, gravy, or sauce (for example white sauce or mushy peas, tinned plum tomatoes (no juice)).
Puddings
Where possible, make all desserts with full fat milk.
Ice-cream is not suitable for everyone with a swallowing difficulty. Please ask your speech and language therapist for advice.
Milk puddings, for example rice, tapioca, sago, semolina or custard. Serve with jam, honey, smooth marmalade, cream, sugar, puréed fruit.
Stewed fruit / soft tinned fruit (pieces no bigger than 1.5cm) in syrup. Serve with custard, or evaporated or condensed milk.
Sponge pudding, with custard and stewed fruit.
Egg custard, with no pastry.
Full fat Fromage frais.
Crème caramel.
Trifle, with raspberry, strawberry, or other soft fruit.
Yogurt, such as thick and creamy or Muller fruit corner yogurts.
Mousse, for example chocolate.
Blancmange.
Milk jelly.
Instant Whip or Angel Delight.
Banana (pieces no bigger than 1.5cm) and ice-cream / custard.
Try adding the following to your puddings:
cream
natural / Greek yogurt (not low fat)
Complan powder (neutral flavour)
Condensed / evaporated milk. Make sure it is well absorbed / thicken before adding, if necessary.
What should I do if I am losing weight?
If you are losing weight, add extra nourishment to the food that you are managing to eat. By doing this you will receive more energy and protein, which will help to maintain your weight or prevent further weight loss.
Always use full fat milk.
To make fortified milk, add 4 tablespoons of milk powder (for example Marvel) to 1 pint of full fat milk. Use this milk whenever you use milk in drinks, puddings, mashed potato, and sauces. One tablespoon of milk powder can also be added to porridge or soup.
Add grated cheese to cooked vegetables, mashed potato, soups, and sauces.
Make packet soups with fortified milk, or add 2 tablespoons of milk powder to smooth tinned or packet soup. Try savoury Complan or Aymes soups. These are available from your chemist and some supermarkets.
Butter / margarine / oil - use plenty on pasta, potatoes, and vegetables.
Add double cream to soup, potato, cereals, milk puddings, and milky drinks.
Use the following on puddings - ice-cream, evaporated or condensed milk, full cream yogurt, or custard. Ice-cream is not suitable for everyone with a swallowing difficulty. Please ask your speech and language therapist for advice.
Add sugar, syrup or honey to drinks, desserts, and cereals. Be careful if your are diabetic.
Remember to thicken all drinks and foods, if told to by your speech and language therapist.
If you are diabetic, it is important to regularly monitor your blood sugar levels when you make changes in your diet. Please speak to your diabetic nurse if you need advice.
Buying ready prepared soft and bite-sized meals
Supermarkets now sell a wide variety of ready meals, some of which may be suitable for a soft and bite-sized diet. For example:
cottage or Shepherd’s pie.
fisherman’s pie (check for bones and pieces larger than 1.5cm).
corned beef hash.
cheddar cheese and onion mash.
pasta dishes, such as lasagne, spaghetti Bolognese, and macaroni cheese.
cauliflower cheese.
casserole or hot pots (check for pieces larger than 1.5cm).
Sauces can be made from granules or bought ready prepared.
Buying ready prepared soft and bite-sized meals
The following companies provide meals delivered to your door:
Wiltshire Farm Foods
Softer food range, includes soft and bite-sized meals and puddings.
Telephone: 0800 077 3100
Simply Food Solutions
A range of texture modified meals and puddings.
Telephone: 0191 4560456
Oakhouse Foods
A selection of soft and bite-sized meals, as part of softer foods range.
Telephone: 0333 370 6700
The above products / services are listed solely to advise our NHS patients. It does not imply endorsement by East Kent Hospitals University NHS Foundation Trust, nor discrimination against similar brands, products, or services not mentioned. We are not responsible for the contents or reliability of any other websites to which we provide a link and do not necessarily endorse the views expressed within them.
Store cupboard ideas
The following are examples of convenience foods to keep in your store cupboard.
Breakfast cereal, such as porridge oats and Ready Brek.
Smooth tinned and packet soups, for example cream of chicken, tomato, mushroom and lentil.
Tinned meats, for example corned and minced beef.
Tinned fish, for example tuna mayonnaise, salmon and sardines.
Tinned pasta, for example macaroni cheese, spaghetti Bolognese.
Dried potato flakes, for example Smash.
Tinned milk puddings, such as custard, semolina, and creamed rice.
Packet mousses, instant whip, and jelly.
Long-life products, such as UHT milk, fruit juice, yogurts, and ready-made custard pots.
Powdered hot drinks, for example Horlicks, Ovaltine, Cocoa, and drinking chocolate.
Tinned cream, or evaporated and condensed milk.
If you are trying to gain weight, do not have low fat or diet products.
Getting the right balance
If you choose a variety of foods from each of the five food groups, you should be having a balanced diet. However, it is sometimes more difficult to achieve this on a soft and bite-sized diet, so here are a few tips.
Constipation (not pooing as often or finding it hard to poo)
Constipation may be a problem because you are lacking fibre in your diet. Slowly introduce more fibre into your diet. Good sources of fibre include:
Breakfast cereals, such as porridge, instant hot oat cereals, or Weetabix.
Fruits and vegetables. Try to have the recommended five portions a day. Pureed prunes and prune juice may help.
Pulses, for example beans. All pulses are high in fibre.
Over-the-counter fibre supplements are available if recommended. Your GP can prescribe other fibre supplements.
Fluids are essential to:
help the fibre to work
prevent dehydration
make sure your skin keeps its elasticity; and
your kidneys work properly.
Aim for at least 6 to 8 drinks a day. Include a variety of tea, coffee, squash, juice, water, milk, milkshakes, and malted bedtime drinks.
Vitamin C
Having five portions of fruit and vegetables a day will help. Try to include a rich source of vitamin C, such as:
Ribena
C-Vit
supermarkets’ own fortified blackcurrant squash
rose-hip syrup; and
pureed fruit, such as strawberries or kiwis.
Iron
Meat is a good source of iron. If you are still finding meat especially difficult to swallow, please ask your dietitian for ideas.
Other good sources include egg yolk, breakfast cereals, pulses, and dark green leafy vegetables.
Drink a glass of fruit juice with a meal. This will help your body to absorb the iron.
What if I have any questions or concerns about my diet?
If you have any questions or concerns, please speak to your dietitian or GP.