IDDSI (International Dysphagia Diet Standardisation Initiative) is a global framework for describing food textures and drink thicknesses for people with dysphagia. It defines 8 levels (0–7) with standardised testing methods, adopted in Hong Kong, Australia, the UK, Canada, and 50+ countries.

How many IDDSI levels are there?

IDDSI has 8 levels numbered 0 to 7. Levels 0–4 describe drinks (Thin to Extremely Thick / Puréed), while levels 3–7 describe foods (Liquidised to Regular). Levels 3 and 4 overlap between drinks and foods.

What is the fork pressure test for IDDSI Level 4?

The fork pressure test for IDDSI Level 4 (Puréed) requires applying approximately 140g of pressure with the back of a fork. Food should flatten completely and not spring back, indicating it requires no chewing and can be mashed with the tongue.

What IDDSI level should a care home's soft diet be?

Different institutions define 'soft diet' differently. Always ask care homes and hospitals to specify the IDDSI level clearly — typically Level 5 (Minced and Moist) or Level 6 (Soft and Bite-Sized). Do not assume a 'soft diet' label means a specific IDDSI level.

Which foods are dangerous for people with dysphagia?

High-risk foods for dysphagia patients include hard or dry foods (nuts, biscuits), fibrous foods (celery, pineapple), chewy or sticky foods (mochi, glutinous rice), round foods (whole grapes, peas), mixed-texture foods (bubble tea, watermelon), and konjac products. In Hong Kong, xiao long bao, water spinach, and noodle soups are also high-risk.

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 [Source: IDDSI Framework], 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