IDDSI Level 6: Soft and Bite-sized diet

Please note, this page is printable by selecting the normal print options on your computer.

If you’re having problems eating, chewing or swallowing food, you may find it helpful to change the texture of your food. Your Speech and Language Therapist (a person with specialist knowledge of swallowing problems) or Dietitian has advised you to eat soft and bite-sized food. This leaflet contains ideas and practical advice on how to make soft and bite-sized food correctly and to make sure your diet remains varied and enjoyable. If you have a small appetite or you have recently lost weight, you will also find some advice on how to enrich your meals to make them as nourishing as possible. If you need a special type of diet, for example, gluten-free, lactose-free, dairy-free, low sodium or low potassium, speak to your Dietitian about which foods are suitable for you.

What is soft and bite-sized food?
Soft and bite-sized food is soft, tender and moist throughout with no separate thin liquid. Food can have “bite-sized” pieces up to a maximum of 15mm. These foods need chewing before swallowing. A knife should not be required to cut this food but may be required to load onto a fork or spoon. These foods can be mashed/ broken down with pressure from a fork, spoon or chopsticks. If you enjoy a diet associated with a cultural background or religious belief (ethnic food), and after reading this leaflet you’re not sure whether certain foods are suitable for a soft and bite-sized diet, ask your Speech and Language Therapist for more advice.

Why do I need soft and bite-sized food?
As you get older, the swallowing muscles in the mouth and throat often become weaker, slower or less efficient. This can be made worse when you’re ill. Certain medical conditions can also affect your swallowing. These changes might make it more difficult to eat certain types of foods so that there is a risk the food could go down the wrong way. If it gets into the windpipe and even the lungs it can cause you to cough or choke when eating. This is called ‘aspiration’. ‘Aspiration’ can cause serious chest infections, or even pneumonia. Eating soft and bite-sized food may
help prevent this from happening.

What are the signs of aspiration?
● Coughing, choking or throat clearing before, during or after swallowing
● Shortness of breath before, during or after swallowing
● Wet, gurgly voice quality
● Changes in skin colour; e.g. face turning red and sweaty, or very pale
● Unplanned weight loss
● Recurrent chest infections: if you are worried that you have a chest infection, please speak to your GP.

If you are concerned that you have any new symptoms/ changes in your swallowing, please tell your Speech and Language Therapist and/or GP. Soft and bite-sized food is also safer and easier to eat when the mouth and throat muscles are too weak to chew and swallow normal food. It may also be helpful if you’re finding it hard to bite and chew well because you don’t have teeth or dentures.

A note about drinks

Most people need to drink 6-8 glasses or mugs of fluid (around 2 litres) every day to keep hydrated. You may need more on a hot day. Drinks may include water, squash, tea, coffee, hot chocolate, milk and milky drinks, fruit juice or smoothies, enriched drinks or nutritional supplements. If you’re having problems swallowing drinks, your Speech and Language Therapist will tell you how to
make sure you’re drinking safely. There is a separate booklet available for people who also have problems swallowing drinks – ask your Speech and Language Therapist for details.

How do I make soft and bite-sized food?
Most of your everyday foods can be made into a soft and bite-sized consistency. There are many foods are that already naturally the correct consistency, whilst other foods may need
adapting slightly to ensure they meet the requirements for a soft and bite-sized diet. You may need:

– A fork or potato masher
– A sharp knife and chopping board

If food requires cooking it is recommended you cook it before you modify it. Food does not need to be blended smooth, unless you are unable to adapt it be soft and bite-sized.

Meats and fish: Remove all skins, bones and gristle first. Meats and fish should be tenderised and chopped so that particles are no bigger than 15mm. If served with a sauce, this should be very thick, smooth and non-pouring.
Vegetables and pulses: Remove skins and steam/ boil until soft. Stir-fried vegetables will often be too firm. Chop any larger vegetables so that pieces are no bigger than 15mm, and drain excess fluids. Some vegetables are easy to cook to a soft consistency eg. broccoli, cauliflower, carrots, swede. Vegetables with a shell or husk ie. peas, sweetcorn and beans would require pureeing and sieving.
Fruit: Soft fresh fruits can be eaten with skins removed and chopped so that pieces are no bigger than 15mm. Cooked fruit may be easier to prepare safely – all skins should be removed before cooking and excess fluids should be drained. Fruit with a high water or juice content, such as oranges and watermelon, may need to be avoided; this is because the juice separates from the solid in the mouth whilst chewing. Please ask your Speech and Language Therapist if you unsure about whether you should be eating this type of fruit.
Breakfast cereals: These should be fully softened in milk, and may contain pieces which are no bigger than 15mm. The fluids cannot separate from the cereal. Excess fluids should be drained.
Breads: Plain white or wholemeal bread can only be eaten if finely chopped into pieces no larger than 15mm and must be softened/pre-soaked in soups or sauces. Seeded breads are not suitable.
Rice: Rice can only be eaten if cooked until very soft, and served in a thick sauce that binds the rice together. It should not be sticky, glutinous and should not separate into individual grains on serving. Other types of rice would be too difficult to manage and should be avoided.
Pasta: Tinned or very well cooked pasta, chopped so that pieces are no bigger than 15mm and served in a thick sauce to bind them together.

Are there any foods I should avoid?
Most foods can be made soft and bite-sized, but there are exceptions. The following do not modify well and may not make the correct consistency foods:

• Crisps, nuts and crackers
• Muesli or hard cereals
• Raw or salad vegetables
• Sticky or chewy foods such as marshmallows, soft jelly sweets and dried fruit
• Foods with skins or pith will be difficult to modify
• Fibrous foods
• Boiled sweets, toffees and chunks of chocolate
• Crunchy or crispy toppings, eg. breaded chicken or battered fish

Whilst your Speech and Language Therapist is advising you to have a soft and bite-sized diet, these foods should be avoided. This may not be a permanent change – please discuss this further with your Speech and Language Therapist.

How can I check my food is the right consistency?

Fork and Spoon Pressure Test:
When pressed with a fork or spoon on its side, the food particles can be cut and broken into smaller pieces. When a 15mm sample is pressed with a fork or spoon, the sample should squash or change shape and should not return to its original shape when the fork/spoon is removed.

Finger Test:
It is possible to hold a 15mm sample of this texture using your fingers. The sample can be squashed between the thumb and index finger. The sample will not return to its initial shape.

Sample Menu
All foods below should be cut so that pieces are no bigger than 15mm.

• Soft chopped fruits eg. banana, peaches (skins removed)
• Cereals well soaked with no separate milk e.g Ready Brek, Weetabix
• Scrambled egg
• Chopped poached haddock
• Yoghurt/ Fromage frais

Lunch and Dinners:
• Cottage Pie with chopped veg
• Fish – not breaded or battered, in a creamy white sauce
• Soft tender chopped meats served with potatoes and vegetables
• Dahl
• Curry (providing meat/veg is cooked soft and chopped)
• Stews and casseroles
• Pasta (well cooked) with a thick sauce such as Macaroni Cheese
• Tinned pasta ie. ravioli
• Baked potato with a soft chopped filling – do not eat the skin
• Soft omelette (cheese can be added)

Puddings and Snacks:
• Semolina, sago or rice pudding
• Thick custard
• Soft chopped or stewed fruits – could be served with cream/ yoghurt
• Yoghurt and fromage frais
• Chopped sponge cake with custard/cream
• Trifle
• Ice cream and jelly (If you have been recommended to be on a thickened fluid, these items may not be suitable as they melt to a thinner fluid)

Practical Tips
Appearance: Don’t mix a whole meal together, unless it is a complete meal such as a stew. Prepare each individual element separately and serve them so you can see each portion of food on the plate. This retains the individual flavours of each food.
Variety in meals: It is important to keep variety in your meals to keep you interested in food and eating. You will need a healthy balanced diet to ensure you get all the nutrients you need.
Flavour: Season foods to taste. You could consider adding herbs, spices, or other sauces.
Environment: Eat in a quiet and relaxed atmosphere where there are no distractions and no rush to finish quickly. This will help you concentrate on eating safety.

What if I have a small appetite?
As you get older, it’s natural to start eating less because you tend to become less physically active. This means your body might need less food.

• If you can’t manage to eat three large meals per day, have smaller amounts more frequently with nutritious snacks between mealtimes.
• If you find it difficult to eat a full meal, have a milkshake, hot milky drink or cup-a-soup made with enriched milk after eating (see Page 7). Alternatively, enjoy a thick soup and a pudding instead.
• It’s important to eat regularly, at least three times a day. You might not always feel like cooking so you could choose to eat more tinned, chilled and frozen ready-prepared meals. It’s a good idea to make some fork mashable foods in bulk and store them in the freezer. Divide them into portions using small storage containers or freezer bags. Always make sure you heat chilled and frozen food until it’s piping hot all the way through.
• Use enriched drinks such as Build up drinks or Complan as a nutritious snack between your meals to give you the extra calories and nutrients your body needs. You can buy these from your chemist or supermarket.
• Because drinks can make you feel full, you might not feel as hungry after drinking. Instead of drinking before you eat, drink after meals, or in between meals, so that you feel hungrier and can eat more at mealtimes.

How can I add extra nourishment to my drinks?
Use the following ideas to help you increase the calories in your drinks:
• Use full fat milk instead of semi-skimmed or skimmed milk.
• Enrich your milk by adding 4 tablespoons of milk powder to 1 pint of full fat milk. Mix the milk powder into a smooth paste with a little of the milk. Then whisk in the rest of the pint with a fork or whisk.
• Try to use at least 1 pint of enriched full fat milk in your food and drink every day.
• Use enriched full fat milk instead of water to make hot and cold drinks, such as those below:

o Milky coffee made with enriched warm milk
o Hot chocolate or malted drink such as Horlicks or Ovaltine made with enriched milk
o Cup-a-soup made with enriched warm milk
o Yoghurt or banana blended with enriched milk to make a thick drink – add honey, syrup, treacle,
o Milk or milkshake made with enriched milk and ice cream

How can I add extra nourishment to my food?

Use the following ideas to help you increase the calories in your food:

• Use enriched milk, cream or double cream, evaporated or condensed milk when making drinks, porridge, puddings (e.g. custard, rice pudding, Angel Delight), soups, mashed potatoes, white and
cheese sauces.
• Add 1-2 handfuls of grated cheese (pieces no bigger than 15mm), or extra cream cheese, cream, butter, margarine, or mayonnaise to warm vegetables, potatoes, stews, soups and sauces.
• Add extra sugar, cream, syrup, jam, honey, treacle or chocolate spread into puddings, drinks and cereals. If you have diabetes, speak to your Doctor, Dietitian or Diabetic Nurse for more advice. You may need to check your blood sugar levels more often, or you may need to change your medication.
• Use full fat dairy food instead of low fat options, e.g. whole milk, thick and creamy yoghurts, full fat cream, cheese and mayonnaise.

How can I tell if I’m losing weight?
A modified diet should not result in any weight loss. If you have concerns that you are not meeting your nutritional needs or are losing weight, please contact your GP or dietitian for further advice.
Weigh yourself weekly to check if you’re losing weight. If you can’t weigh yourself, you may notice you’re losing weight if your clothes or jewellery feel looser. If you have followed this advice but you’re still losing weight, ask your Dietitian, Doctor or Practice Nurse for more help.

Contact details
If you have any questions or concerns, please contact your Speech and Language Therapist:
Speech and Language Therapy Service
Milton Keynes University Hospital
Standing Way
Milton Keynes
Tel: 01908 725292