You may be having difficulty in eating, drinking and swallowing. The medical term for this is “dysphagia”.

Dysphagia can occur for many reasons, for example as a result of stroke, multiple sclerosis (MS), motor neurone disease, Parkinson’s disease, dementia, developmental disorders, head trauma or head and neck surgery.

This can make having an adequate and nourishing diet difficult. As a result, weight loss, dehydration, weakness, depression, nutritional deficiencies and a reduced ability to fight off infection can occur.

The speech and language therapist will assess and diagnose any eating, drinking and swallowing problems you may have. They will then recommend the safest consistencies of food and drink and any strategies that may help. This will ensure 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.

The dietitian will advise on a suitable nutritionally adequate diet for you and give you practical advice on how to continue the diet at home.

Level six soft and bite sized food may be used if you are not able to bite off pieces of food safely but are able to chew bite sized pieces of softer foods down into little pieces that are safe to swallow. Soft and bite sized foods need a moderate amount of chewing, for the tongue to ‘collect’ the food into a ball and bring it to the back of the mouth for swallowing. The pieces are bite sized to reduce choking risk. If you notice the food pieces are not being chewed well though, please contact your speech and language therapist to make sure you are on the correct food texture to reduce choking risk.

In this leaflet we cover:

• what is a level 6 soft and bite sized diet?
• how do I check my food to make sure it is soft and bite sized?
• which foods should not be included in a soft and bite sized diet?
• which foods can be included in a soft and bite sized diet?
• sample meal plan
• ready meals
• getting the right balance
• food fortification.

What is a level six soft and bite sized diet?

A soft and bite sized diet consists of a variety of foods, which are tender and moist, and should be easy to chew.

Level six soft and bite sized foods are:

• soft, tender and moist with no thin liquid leaking or dripping from the food
• able to be eaten without needing to ‘bite off’ a piece
• chewable ‘bite sized’ pieces, so they are safe to swallow
• able to be mashed or broken down with pressure from a fork
• able to be cut without a knife
• able to be eaten with a spoon or a fork.

Foods can be moistened, by adding a thick, smooth sauce, gravy or custard. A soft and bite sized meal will still contain a variety of textures such as flaked fish in a parsley sauce, with tender vegetables, followed by sponge or stewed apple in custard.

How do I test my food to make sure it is soft and bite sized?

Bite sized pieces should be no bigger than 1.5 x 1.5cm. This is about the width of a standard dinner fork.

To make sure the food is soft enough, press down on the food with a fork until your thumbnail blanches to white, then lift the fork to see that the food is completely squashed and does not regain its shape.

Soft and bite sized food must pass both the size and softness tests.

Which foods should not be included in a soft and bite sized diet?

• Foods with skins, husks or outer shells, such as peas, corn, shredded wheat, soya beans, grapes, sweetcorn, chicken skin, fish skin or sausage skin.

• Crunchy, sharp or crispy foods such as toast, dry biscuits, crisps, crackling, crisp bacon, lettuce, cucumber, raw apple, raw carrot, popcorn or cornflakes

• Pips and seeds, including apple seeds, pumpkin seeds or orange pith.

• Hard or dry textures, for example pieces of apple, chunks of cheese, nuts, raw vegetables (such as carrot, cauliflower, broccoli), dry cakes, bread and dry cereal.

• Mixed consistencies, for example soups with lumps or bits, cereal in milk (that does not soak up the milk), mince in thin gravy, juicy fruits with thin liquid, such as watermelon.

• Tough, stringy fibrous textures, such as steak, pineapple, celery, rhubarb, runner beans or celery.

• Crumbly foods, for example dry cake, crumble, bread crusts, pie crusts and dry biscuits.

• Chewy textures, such as toffees, sweets, cheese chunks, chewing gum, marshmallows or dried fruits.

• Sticky foods, including nut butter, overcooked porridge or oatmeal or sticky mashed potato.

• Bones or gristle, such as chicken, fish or other bones or meat with gristle.

• Foods with large or hard lumps – no pieces larger than 1.5 x 1.5cm.

• Any crusts or skins that form on foods during cooking or after heating, such as cheese topping or mashed potato.

• Floppy foods such as lettuce, cucumber or raw spinach leaves.

• Round foods, including grapes and whole cherry tomatoes.

• Make sure long foods, for example sausages are cut up.

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, and to choose foods from each of the groups below.

Starchy foods

Aim to include at least one starchy food at each meal.                 

• Cereal should be served with pieces no bigger than 1.5 x 1.5cm, with its texture fully softened. Excess liquid should be drained before serving. Try porridge (use fine grain oats) and other instant cereals such as Ready Brek or Oats-So-Simple. Cereals such as Weetabix or cornflakes can be soaked in milk and excess liquid drained before serving. Avoid cereals with added nuts and dried fruit such as muesli.
• Ask your speech and language therapist for advice about bread. Regular dry bread, newly baked bread and bread containing nuts, seeds or other bits are not recommended. Bread with butter or margarine with crusts removed may be easier to eat.
• Rice needs a thick, smooth, non-pouring sauce to moisten it and hold it together. Rice should not be sticky or gluey and should not separate into individual grains when cooked and served. Try curry, chilli con carne, casserole or risotto.
• Well-cooked boiled potatoes mashed or cut into 1.5 x 1.5cm pieces.
• Well cooked pasta for example macaroni cheese, ravioli, lasagne, or spaghetti bolognese.
• Cake or sponge such as Eve’s pudding or chocolate Swiss roll. Avoid pieces of nut and dried fruit.
• Soft biscuits like wafers, soft macaroons and Jaffa cakes.

Fruits and vegetables

Aim to have five portions each day, one of which could be a glass of pure fruit juice or a smoothie.

• Fruit should be soft and chopped into pieces no larger than 1.5 x 1.5cm. Any excess liquid should be drained before serving. Do not use the fibrous parts of fruit (the white part and pith of an orange). Ideas 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, such as melon, oranges, satsumas and grapefruit. Tinned fruit cut to 1.5cm pieces is suitable but avoid skins, stones and pips and drain off excess liquid before serving. You could also try stewed fruit, including apples, pears or rhubarb but remove the skins before cooking.
• Vegetables should be steamed or boiled until soft with a final cooked size of no larger than 1.5 x 1.5cm. You could try swede, broccoli, cauliflower and carrots. Tinned vegetables such as chopped tomatoes, creamed sweetcorn and mushy peas would be suitable. Stir fried vegetables are not suitable as they are too firm.

Meat, poultry, fish, eggs and pulses

Aim to include two portions a day.

• Meat and poultry should be cooked until tender and chopped so that pieces are no bigger than 1.5 x 1.5cm in size. If meat or poultry cannot be served like this it should be finely minced or chopped to a 4mm lump size and served in a thick, smooth, non-pouring sauce or gravy. Ideas for meals include cottage pie, shepherd’s pie, pasta 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.
• Fish should be cooked until soft enough to break and serve in pieces no larger than 1.5 x 1.5cm. Batter and crumb coatings should be avoided. Tinned fish is suitable but ensure any bones are removed.
• Eggs, such as poached, scrambled, fried or omelette, all cut into 1.5 x 1.5cm pieces. Hard boiled eggs mashed with mayonnaise are suitable but avoid scotch eggs.
• Beans and lentils can be included in thick soups, stews and casseroles (with or without meat). Baked beans and smooth houmous are suitable. Tofu, Quorn and textured vegetable protein should be minced or cut into 1.5 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 (avoid those with nuts, seeds and grains).
• Grated cheese can be added to mashed potato, pureed soup, white sauce and cauliflower cheese. Do not have lumps of cheese bigger than 1.5 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.

Sample menu plan

Breakfast

Fruit or juice

Weetabix and milk

Tea

Mid-morning         

Milky coffee/drink

Sponge cake

Lunch

Soup

Pasta with bolognese sauce

Mashed jacket potato (skin removed) with tuna and grated cheese

Stewed apples with custard

Mid-afternoon

Milkshake

Wafer biscuits

Evening meal        

Glass of fruit juice

Lamb or meat casserole with gravy and soft, cooked vegetables

Bedtime     

Malted milk drink

Ready 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 (make sure no pieces larger than 1.5cm)

Sauces can be made from granules or bought ready prepared.

Delivered meals

Meals on wheels can provide a level six soft and bite sized meal on request.

Specialist companies who deliver frozen meals to clients, for example Wiltshire Farm Foods, Oakhouse Foods, Simply Puree and Mrs Gills cater for people with swallowing problems. Level six soft and bite sized meals are available.

Getting the right balance

If you choose a variety of foods from each of the five food groups, as shown, you should be having a balanced diet. However, it is sometimes more difficult to achieve this on a soft and bite sized diet. Here are a few tips.

Energy (calories)

If you are having difficulty maintaining your weight, please read the section on food fortification to boost the energy and nutrient content of your diet.

Constipation

Constipation may be a problem because you are lacking fibre in your diet. Introduce more fibre slowly into your diet to let your body adapt. Good sources of fibre are:

• breakfast cereals such as porridge and instant hot oat cereals or Weetabix
• fruits and vegetables – try to have the recommended five portions a day. Pureed prunes and prune juice may be helpful
• pulses, for example beans – all pulses are high in fibre

Over-the-counter fibre supplements are available and your GP can prescribe other fibre supplements.

Fluid is essential to help the fibre to work, and to prevent dehydration ensuring your skin retains its elasticity and your kidneys function properly. You should aim for at least six to eight drinks a day, include a variety of tea, coffee, squash, juice, water, milk, milkshakes, 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 or rose-hip syrup
• 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 the dietitian for ideas. Other good sources include egg yolk, breakfast cereals, pulses and dark green leafy vegetables. A glass of fruit juice with a meal will help your body to absorb the iron.

Food fortification

Food fortification is a way of boosting the amount of nutrients in your food.

Having a good nutritional intake will help you:

• regain lost weight or maintain your current weight
• maintain your muscles and keep your skin healthy
• feel healthier and have more energy.

How to fortify your food

Skimmed milk powder

• Add two to four tablespoons to a pint of full fat milk and use whenever you take milk. Add one tablespoon to porridge, soups or mashed potato etc.

Cheese

• Add grated cheese to cooked vegetables, potatoes, soup, pasta and sauces.

Yoghurt and fromage frais

• Choose thick and creamy, full fat varieties or Greek yoghurt.

Butter, margarine and oil

• Use full fat spreads added generously on all foods.
• Fry foods such as onions, vegetables and meat.
• Use oil-based dressings generously, you could add to hot potatoes or pasta.
• Mayonnaise and salad cream can be added to food.

Cream

• Add to soups, sauces, custard, porridge and milk puddings.
• Serve whipped or clotted cream with mousse or fruit.
• Add to milky drinks and coffee.

Sugar and sugary foods

• Check with your healthcare professional first if you have diabetes.
• Add sugar to drinks, cereals and desserts.
• Use ordinary fizzy drinks and squashes, rather than low calorie or sugar free.
• Add seedless jam, honey or syrup to fruit or puddings.

General tips to improve intake

• Make sure that all your food is served at the correct texture and consistency suited to your swallowing and chewing ability.
• Remember that tiredness may affect your food intake and your swallowing ability.
• Try to eat little and often, aim for three small meals and two to three snacks.
• Have nourishing drinks between meals, including milk, Horlicks, hot chocolate or Ovaltine.
• Try to have a portion of meat/fish (or alternative) at each main meal.
• Use full fat products, such as full fat milk, thick and creamy yoghurts and full fat cheese.
• It is a good idea, if you are able, to check and record your weight regularly (every two to four weeks).
• Speak to your dietitian or speech and language therapist if you are unsure of anything.

Alcohol

In small amounts alcohol can stimulate your appetite, such as sherry or an aperitif. Please check that alcohol will not react with any medications you are taking.

Oral nutritional supplements

If you are not managing to eat and drink enough to meet your protein and calorie requirements your healthcare professional may recommend an oral nutritional supplement. These are specialist products, usually drinks or puddings that contain increased levels of nutrition. They should be taken in addition to your normal meals and snacks.

Get in touch

Contact the Nutrition and Dietetics Service or Adult Speech and Language Therapy Service, using the details below.