What Is IDDSI Level 6 — Soft & Bite-Sized?
IDDSI Level 6 — Soft & Bite-Sized is prescribed for people with mild-to-moderate dysphagia who retain adequate chewing ability but cannot safely manage regular-texture foods. It sits between:
- Level 5 (Minced & Moist) — requires no chewing; food is finely minced ≤4 mm
- Level 7 (Regular) — normal everyday food with no texture modification
At Level 6, food must be soft, moist, and tender — cut into pieces no larger than 1.5 cm × 1.5 cm — with no mixed textures, hard centres, or items requiring extensive chewing. The key distinction from Level 5 is that Level 6 food can have visible, recognisable pieces and does require some chewing, but the chewing effort must be manageable without back teeth or full dentition.
Important: Level 6 must always be prescribed by a speech-language pathologist (言語治療師) following a clinical swallowing assessment. Do not upgrade or downgrade texture levels without SLT guidance.
IDDSI Level 6 Formal Definition
According to the IDDSI Framework:
| Property | Requirement |
|---|---|
| Piece size | ≤ 1.5 cm in any dimension |
| Texture | Soft, tender, moist — yields easily to tongue or gum pressure |
| Cohesion | Holds together; does not crumble or fall apart |
| Mixed textures | Not permitted — no foods with hard centres and soft outer layers |
| Chewing | Required, but only gentle; manageable without back molars |
| No | Hard, crunchy, fibrous, chewy, sticky, or very dry components |
The Fork-Pressure Test for Level 6
The fork-pressure test is the standard IDDSI bedside test for Level 6 foods:
- Place a representative piece of the food on a fork
- Press the pad of your thumb onto the food — use only the pressure you would use to press a thumbnail without causing discomfort
- Pass: The food flattens or squashes easily, showing the impression of your thumb without springing back
- Fail: The food resists, springs back, or does not deform under gentle thumb pressure
This simulates the tongue pressure available to someone with mild dysphagia. If the food fails the fork-pressure test, it is too firm for Level 6 and requires further texture modification.
Spoon tilt test (for sauce and binding): A Level 6 plate should have adequate moisture or sauce that prevents dry crumbling — but the sauce should not pool freely like a liquid.
Foods That Qualify as IDDSI Level 6
Proteins
- Poached or steamed fish (bones fully removed) — cod, tilapia, sole qualify naturally
- Soft braised chicken thigh (skin removed, cut ≤1.5 cm)
- Steamed silken tofu cut into cubes — qualifies without modification
- Soft-scrambled eggs (moist, not rubbery)
- Well-cooked, tender minced pork patty
- Soft canned tuna in water or sauce (not oil-packed/dry)
Grains & Staples
- Soft congee (稠粥) with visible rice — naturally Level 6 if thick enough
- Steamed white rice cooked until very soft and sticky (without separate hard grains)
- Soft bread without crust, with spread incorporated
- Soft noodles (細麵, vermicelli cooked beyond al dente) cut ≤1.5 cm
Vegetables
- Well-cooked carrot, zucchini, pumpkin (南瓜), aubergine
- Steamed spinach or choy sum leaves (no tough stems)
- Mashed or very well cooked potato, taro, sweet potato
- Avoid: raw vegetables, fibrous greens, skins, seeds
Desserts
- Soft tofu pudding (豆腐花) — qualifies naturally
- Ripe banana (mashed or sliced)
- Steamed egg custard (燉蛋)
- Soft canned fruit (peaches, pears in syrup) — drain excess liquid
Foods That Do NOT Qualify as IDDSI Level 6
These common Hong Kong foods frequently fail Level 6 and cause aspiration risk:
| Food | Why it fails |
|---|---|
| Siu mai / har gow (dim sum) | Chewy wrapper; mixed textures |
| Rice cake (年糕) | Sticky, cohesion risk, hard to clear |
| Whole nuts, seeds | Hard, require strong chewing |
| Leafy greens with tough stems | Fibrous; uneven texture |
| Unripe or firm fruit | Too firm; fails fork test |
| Crispy-skinned roast meat | Hard, crunchy outer layer; mixed texture |
| Bread with crust | Crust is firm; creates mixed texture |
| Raw tomato | Slippery skin separates from soft flesh — mixed texture |
| Whole grapes | Slippery; skin does not yield under tongue pressure |
Care Home Implementation Tips
Staff Training
Ensure all kitchen and care staff can perform the fork-pressure test reliably. Periodic spot-checks (once per shift) reduce texture drift — food that starts the day at Level 6 may firm up as it cools or dries out.
Plating and Moisture Control
- Sauce or gravy should be incorporated into the cut food, not pooled separately
- Never send a Level 6 plate that has dried out under a heat lamp — rehydrate with a small amount of stock or sauce before serving
- Use divided trays to prevent cross-contamination of textures if residents on different levels share a dining area
Documentation
Record the IDDSI level on the resident’s daily diet card and meal record. Any refusal, coughing episode, or voiced concern during meals should be documented and reported to the senior care staff for SLT follow-up.
Labelling in Chinese
For bilingual care homes, use the standardised Chinese term: 軟質及小塊（Level 6） on diet cards and kitchen prep sheets. Avoid informal terms like “軟飯” which is ambiguous between levels.
References
- IDDSI Framework (2019). Complete IDDSI Framework — Detailed Definitions. Available at iddsi.org.
- Cichero JAY, et al. (2017). Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids. Dysphagia, 32(2), 293–314.
- Hospital Authority HAHO (2021). Dietetic and Speech Therapy IDDSI Implementation Guide for HA Care Settings.