Soft & Bite-Sized, Level 6 Replaced Dysphagia Advanced

By: Karen Sheffler

May 12, 2014

“Soft & Bite-Sized, IDDSI Level 6″ Replaces

“Dysphagia Advanced Diet”

by Karen Sheffler, MS, CCC-SLP, BCS-S of

Being discharged to home from a hospital or rehab facility can be an overwhelming process, especially if your Speech-Language Pathologist (SLP) and medical team have prescribed a modified diet due to difficulty swallowing (dysphagia). Diet modifications are made to attempt to prevent choking and to avoid getting food stuck in the mouth, throat and/or esophagus (food tube to the stomach). Food that gets stuck in the mouth or throat can fall into the airway after the swallow, causing aspiration of food particles or actual choking (airway blockage or asphyxiation).

You may be having difficulty with regular foods like meats, breads, dry-hard textures, ad crumbly-dry foods. You may be having difficulty biting off an appropriate size piece of food. You may also be having difficulty chewing hard foods in order to break them down enough so that they are safe to swallow. Make sure you have had your swallow fully evaluated to know where the problem is, as we treat issues differently depending on whether the problem is in your mouth, throat, and/or esophagus. 

Examples of challenging foods:

  • Peas, corn, and dry rice may roll to the back of your throat before you are ready to swallow them.
  • Meat that is not cooked appropriately may be too hard to chew, cause significant fatigue, or get stuck in your throat or esophagus. Cutting meat up into small bite-sizes of 1.5cm will reduce your risks of choking on them. The idea is that 1.5cm is the size of a food piece that will fall through your airway (larynx and trachea) and NOT completely block the airway causing choking. 
  • Sticky rice may get balled up and stuck in your throat and fall into your airway, especially if not enough moisture content.
  • Mixed consistencies are part solid and part liquid. While you are chewing the solid, the liquid may accidentally fall into your throat and airway, causing aspiration. Cold cereal and even very juicy fruits like watermelon are examples of mixed consistencies.
  • Bread can cause an especially high risk for choking. Breads may feel soft, but they require a lot of chewing and oral processing. People tend to swallow bread before it is really processed in the mouth or “swallow-ready.” Bread can stay in a sticky ball in the throat and actually completely block your airway. Please see this blog about how bread is a challenging regular food item that is one of the most frequently choked on foods. See this FAQ from the United States IDDSI Reference Group on bread and mixed consistencies


You may do best with foods that are accurately tested as “soft” with the IDDSI Fork Pressure Test and cut-up into bite-sized pieces (no bigger than 1.5cm/15mm cubed). Food should be cooked soft so that pressure from a fork will smash or deform them. Foods also must be moist and cohesive and NOT sticky or crumbly. You want foods to stay together in the mouth while you are chewing and forming a cohesive ball of food (bolus). That bolus is combined with your saliva to make it slippery to slide down easily. 

If you get food stuck in your throat, a cohesive food may stay in a pocket in your throat until you are able to swallow again or use liquid to wash it down. Alternating liquids and solids can be helpful. 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. You can also swish and swallow with an artificial saliva substitute (gel or spray) before meals to literally lubricate your pipes!

What is a Standardized Soft & Bite-Sized Diet?

What is “soft?” Unfortunately, healthcare professionals have been labeling a vaguely “soft” diet with so many different terms, causing great confusion around the nation and world. Consider that the following diets may be referring to roughly the same texture:

Dysphagia Mechanically Altered (per the National Dysphagia Diet/NDD of 2002),

Dysphagia Advanced (per the National Dysphagia Diet/NDD of 2002),

or the worst and most ambiguous term of “Mechanical Soft.”

The term “mechanical soft” is very old, as it came before any attempt in 2002 to standardize dysphagia diets into the NDD format. “Mechanical soft” has no approved or agreed upon definition, and each facility has their own “homegrown” descriptions. Some facilities lack of definitions and protocols all together! “Mechanical soft” has never been an official diet for people with dysphagia, and there is no evidence to support its use. Most of my choking cases within my dysphagia expert witness work have been choking deaths partially due to the facility’s use of this out-dated label of “mechanical soft.” This lack of standardization that has plagued the nation and world for decades has lead to many preventable choking deaths, aspiration pneumonias, and other negative sequela. 

Fortunately, now the International Dysphagia Diet Standardisation Initiative or has standardized diet labels, descriptions, rationales for the level, and testing methods to place foods into individual levels. The new diet label of “Soft & Bite-Sized” tells it all. The labels are very descriptive and easily translatable into all languages.

Please note:  “Dysphagia Advanced” is the old term from the old National Dysphagia Diet, which was a first attempt at dysphagia diet standardization in America in 2002. The standardization of diet frameworks has been updated globally by the International Dysphagia Diet Standardisation Initiative or (framework first published in 2016). The old label of “Dysphagia Advanced” roughly maps over to the new label of “Soft & Bite-Sized,” per IDDSI. There are important differences to note between “Dysphagia Advanced” and “Soft & Bite-Sized, Level 6”:

  • Particle size requirement is now 1.5 cm to prevent choking risk. This is about the size of an adult thumbnail and ideally smaller than the adult trachea. You would want the pieces to fall through the trachea and not block the trachea (opening to the airway).
  • Foods need to pass the Fork Pressure Test, showing that the food is soft, moist and easily squashed with pressure by your thumb on a dinner fork, pressing into the food.
  • 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. See this FAQ from the United States IDDSI Reference Group on bread and mixed consistencies

Soft & Bite-Sized Diet Characteristics:

Overall, this category of food textures can be challenging, as it is close to a regular diet. Do not advance to this diet unless under the guidance of your SLP and medical team.

This diet has some basic diet modifications or restrictions to make foods easier and safer for you:

  • Avoid very hard, sticky, crumbly or crunchy foods. Foods like nuts, rice, corn, some beans and peas may roll into your throat or get stuck in your mouth, throat, and/or esophagus (food tube). These challenging textures should be reviewed with your SLP.
  • Foods should be fork pressure test “soft” and easy to chew. In order for meats to pass the Fork Pressure Test, try cutting them thin, carefully choosing the cut of meat, and using certain cooking techniques that allow the meat to remain soft (e.g., marinating, using meat tenderizers, slow cooking in a pan, roasting/braising, etc.). 
  • Easily cut/broken/mashed with a fork, using the Fork Pressure Test noted above and per You should not need a knife to cut this food.
  • Helpful for people with poor dentition, but with a relatively intact chewing and swallowing function.
  • Small and bite-sized pieces to avoid the risk of choking. Small pieces (1.5 cm per IDDSI) are safer and easier to chew. No biting is required.
  • 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. Ask your Occupational Therapist for a rocker knife if you only have the use of one hand.

Overall, this diet may be good to reduce fatigue that may occur in trying to eat a full regular meal.

More Resources for Soft & Bite-Sized, Level 6 and other IDDSI Information:

See all IDDSI Framework Testing Methods here.

Read more about NDD changing to IDDSI here.

See a list of IDDSI resources here. 

Time for IDDSI Updates

Creating a Dysphagia Cookbook IDDSI-Style