What is IDDSI?
IDDSI (International Dysphagia Diet Standardisation Initiative) was formally launched in 2019 and has since been adopted by over 50 countries and regions, including Hong Kong, Australia, the UK, Canada, and Singapore.
IDDSI provides standardised, science-based testing methods to ensure that “Level 4” means the same texture regardless of location.
IDDSI 8 Dietary Levels
Level 0 — Thin
Colour code: White
Characteristics: Same flow as water; flows rapidly from a syringe
Suitable for: People with normal swallowing function
Examples: Water, tea, coffee, juice, unthickened soup
Test: Syringe test — 10ml liquid flows completely within 10 seconds
Level 1 — Slightly Thick
Colour code: Grey
Characteristics: Slightly thicker than water; requires more effort to drink through a straw; still flows from a syringe
Examples: Drinks with a small amount of thickener added
Test: Syringe test — 1–4ml remains after 10 seconds
Thickener guidance (xanthan gum per 200ml): 0.6g (approximately half a teaspoon)
Level 2 — Mildly Thick
Colour code: Pink (PANTONE 212 PC)
Characteristics: Can be poured slowly from a cup; flows slower than water; can still be drunk through a regular straw
Examples: Thin yoghurt drinks, thin milkshakes
Test: Fork test — liquid flows through fork tines but noticeably slower than water
Thickener guidance (xanthan gum per 200ml): 1.2g (approximately 1 teaspoon)
Level 3 — Moderately Thick
Colour code: Yellow (PANTONE DS 2-4C)
Characteristics: Can be poured from a spoon but flows slowly; cannot be drunk through a regular straw; wide-bore straw possible
Examples: Thick yoghurt, mango pudding (in liquid state)
Thickener guidance (xanthan gum per 200ml): 2.4g (approximately 2 teaspoons)
Level 4 — Puréed / Extremely Thick
Colour code: Green (PANTONE 368 PC)
Characteristics: Cannot be poured; scooped with a spoon; holds shape off the spoon; smooth and uniform with no lumps; no chewing needed — can be mashed with the tongue
Suitable for: Severe dysphagia, difficulty chewing
Food examples (Hong Kong):
- Smooth steamed egg, silken tofu purée, pumpkin purée, mashed potato
- Smooth congee base (no visible rice grains), homogenised vegetable purée
- Moulded soft meals (mousse-style)
Avoid: Any food with lumps, fibres, or separated liquid
Test: Apply 140g pressure with fork back — food should flatten completely and not spring back
Level 5 — Minced and Moist
Colour code: Orange (PANTONE 172 PC)
Characteristics: Food minced to pieces under 4mm; requires minimal chewing; soft and moist, can be mashed with tongue; does not separate or stick
Food examples (Hong Kong):
- Finely chopped soft steamed fish (boneless), silken tofu, finely cut soft vegetables
- Soft rice grains (individual grains, not clumped)
Avoid: Pieces larger than 4mm, meat with sinew or fibres, crusty bread
Level 6 — Soft and Bite-Sized
Colour code: Blue (PANTONE 2935 PC)
Characteristics: Food cut into pieces under 1.5cm; requires normal chewing but food is soft enough; can be mashed with tongue and palate; not sticky
Food examples (Hong Kong):
- Soft steamed fish fillet (cut into pieces), silken tofu, soft cooked vegetables
- Banana, papaya, soft cooked rice
- Steamed egg, scrambled egg (not overcooked)
Avoid: Any food requiring forceful biting, hard biscuits, nuts
Level 7EC — Easy to Chew
Characteristics: Near-normal texture but specially selected for ease of chewing; requires intact chewing ability but with reduced endurance
Examples:
- Soft white rice, boneless soft-cooked meat, soft-cooked vegetables
- Soft bread (no crusty crust), soft-cooked pasta
Avoid: Hard biscuits, nuts, raw vegetables, hard sweets
Level 7 — Regular
Normal diet with no restrictions.
Dangerous Foods (All Dysphagia Patients)
| Category | Examples |
|---|---|
| Hard/dry foods | Biscuits, nuts, popcorn, crisps |
| Fibrous foods | Celery, pineapple, cabbage |
| Chewy/sticky foods | Glutinous rice balls, tangyuan, mochi |
| Foods with shells/stones | Lychee, longan, whole grapes, plums |
| Round foods | Peas, whole corn kernels, whole grapes, cocktail sausages |
| Long, thin foods | Yard-long beans, long pasta |
| Mixed textures | Bubble tea, watermelon (juicy + fibrous) |
| Konjac products | Konjac jelly, konjac strips |
| Cantonese high-risk foods | Xiao long bao (hot soup), water spinach, noodle soup, congee soup, bamboo pith |
Home IDDSI Testing Methods
Fork Pressure Test
- Place food on a flat surface
- Apply pressure vertically with the back of a fork (approximately 140g — like pressing with one finger)
- Observe how the food responds
Syringe Flow Test
- Use a 10ml syringe (without needle)
- Draw up 10ml of liquid
- Hold vertically, time for 10 seconds, observe how much has flowed out
Frequently Asked Questions
Q: What IDDSI level is a care home’s “soft diet”?
A: Different institutions define this differently. Always ask care homes and hospitals to specify the IDDSI level clearly.
Q: How do I know what IDDSI level homemade food is at?
A: Use the fork pressure test and syringe flow test as described above.
Q: How much thickener is needed?
A: The amount varies by drink type. Milk requires more thickener; acidic drinks (orange juice) require less. Follow product instructions or consult a speech therapist.
Source: IDDSI Framework 2019 (International Dysphagia Diet Standardisation Initiative) Last updated: May 2026