IDDSI Levels 0–7: A Visual Reference Guide for Hong Kong Carers
When a speech-language pathologist (SLP) tells you that your family member needs “Level 5 food” or “Level 3 drinks,” they are using the IDDSI framework — a set of eight standardised levels that describe how thick, soft, or modified a food or drink must be for a person with swallowing difficulties (dysphagia) to eat and drink safely.
This guide explains each level in plain language, describes what it looks like in a Hong Kong kitchen context, and explains how to test it at home using everyday tools.
Important: This guide is a reference tool. The specific IDDSI level your family member needs should always be determined by a speech-language pathologist following a formal swallowing assessment. Do not change the prescribed level without consulting your SLP.
Understanding the Framework
IDDSI uses two overlapping scales: one for drinks (Levels 0–4), and one for food (Levels 3–7). Levels 3 and 4 appear on both scales — this is because liquidised or puréed food at these levels is thick enough to eat with a spoon but thin enough to flow.
Drink levels (thicker = safer for many dysphagia types):
- Level 0 — Thin
- Level 1 — Slightly Thick
- Level 2 — Mildly Thick
- Level 3 — Moderately Thick
- Level 4 — Extremely Thick
Food levels (softer = safer for many dysphagia types):
- Level 3 — Liquidised
- Level 4 — Puréed
- Level 5 — Minced & Moist
- Level 6 — Soft & Bite-Sized
- Level 7 — Regular / Easy to Chew
Drink Levels
Level 0 — Thin
What it is: Normal water, tea, clear broth, juice, milk — any unmodified liquid.
How it flows: Flows freely like water. If you pour it into a standard 10 ml clinical syringe and release the plunger, all 10 ml exits in under 10 seconds.
Who may need thickening instead: Most people with oropharyngeal dysphagia cannot manage Level 0 safely. Thin liquids move too fast for a delayed swallowing reflex to protect the airway. If your SLP has prescribed any thickened level, Level 0 should not be given without explicit approval.
Hong Kong note: This includes Chinese tea (茶), plain water (白開水), and clear congee water (粥水). All require thickening if Level 0 is not prescribed.
Level 1 — Slightly Thick
What it is: Slightly more resistant than water; still flows easily but slightly slower.
Syringe test: 1–10 ml remains in the syringe after 10 seconds.
What it looks like: Similar to some thinner fruit nectars. Not commonly prescribed in Hong Kong care settings — most clinical pathways move directly from Level 0 to Level 2 or Level 3.
Level 2 — Mildly Thick
What it is: Flows in a thin, slow stream; thicker than juice but thinner than honey.
Syringe test: When tipped from a spoon, it falls in a ribbon rather than dripping.
What it looks like: Approximately the consistency of full-fat evaporated milk or a thin, pourable custard.
Who is commonly prescribed this level: People with mild-to-moderate oropharyngeal dysphagia, often following stroke, early Parkinson’s disease, or mild neurodegenerative conditions.
Hong Kong kitchen note: Thickener added to Chinese soup (湯) at Level 2 should produce a slightly coating effect. Always test with a spoon or syringe — visual estimation is unreliable.
Level 3 — Moderately Thick
What it is: Falls off a spoon in dollops; can be drunk from a cup but requires effort.
Syringe test: Flows very slowly; most remains in the syringe after 10 seconds.
What it looks like: Approximately honey consistency. Pours slowly and holds its shape slightly on a spoon.
Who is commonly prescribed this level: People with moderate dysphagia, particularly those with delayed swallowing reflex or reduced pharyngeal clearance.
Hong Kong note: Level 3 is one of the most commonly prescribed fluid levels in Hong Kong care homes. Correctly prepared commercial thickener (xanthan gum type) at the manufacturer’s specified dose for “moderately thick” should achieve Level 3. Always verify with a syringe test when using a new batch.
Level 4 — Extremely Thick
What it is: Cannot be drunk from a cup. Eaten with a spoon. Does not pour.
Syringe test: Does not flow through a standard 10 ml syringe.
What it looks like: Pudding or thick blancmange. Holds its shape when placed on a plate but is not firm.
Who is commonly prescribed this level: People with severe pharyngeal dysphagia, severely delayed swallowing reflex, or significantly reduced laryngeal elevation. Also used as a transition level for patients recovering from nil-by-mouth status.
Food Levels
Level 3 — Liquidised
What it is: Smooth, pourable, lump-free. Can be drunk from a cup (if thin enough) or eaten with a spoon.
Fork test: Cannot be “mashed” — flows through fork tines without resistance.
What it looks like: Thin congee (稀粥) that has been blended smooth; or blended soup with no solid particles.
Hong Kong kitchen note: Traditional blended rice congee (打爛粥) can approximate Level 3 if blended thoroughly and passed through a fine-mesh sieve. Any visible lumps or grain fragments mean it does not meet Level 3. Commercial thickener may be needed to bring it to Level 3 consistency if it is too thin.
Level 4 — Puréed
What it is: Smooth, uniform, with no lumps, skin pieces, or fibrous particles. Holds its shape on a plate but falls off a spoon under gravity within 3 seconds.
Fork test: Falls through fork tines leaving no solid pieces behind.
What it looks like: Smooth mashed potato (no lumps or skin), blended steamed fish, smooth pumpkin purée. With food moulds, Level 4 meals can be shaped to resemble the original food — improving dignity and appetite.
Who is commonly prescribed this level: People with moderate-to-severe oropharyngeal dysphagia, people who have lost adequate lingual control, and many residents with advanced dementia.
Hong Kong kitchen note: Many traditional Chinese foods can be prepared to Level 4 with a blender and sieve: steamed egg (蒸水蛋 — naturally Level 4 if soft), smooth lotus root paste (蓮蓉), or blended rice congee thickened with appropriate starch.
Level 5 — Minced & Moist
What it is: Soft, moist, with particles no larger than 4 mm in any dimension. No tough fibres, hard pieces, or gristly portions.
Fork test: Can be mashed with a fork using light pressure (approximately 150g force).
What it looks like: Finely minced chicken in gravy, well-softened fish in sauce, minced tofu with sauce. Every piece must be coated or bound in moisture — dry, crumbly minced food does not meet Level 5.
Who is commonly prescribed this level: People with mild-to-moderate dysphagia who can manage some oral processing but cannot bite or chew safely.
Hong Kong kitchen note: Traditional Hong Kong soft foods that often naturally meet Level 5 include: silken tofu (嫩豆腐), very well-cooked minced pork with sauce (肉碎), and soft steamed egg with minced additions. Critical check: no particle should exceed 4 mm.
Level 6 — Soft & Bite-Sized
What it is: Soft, tender food that can be broken with tongue and palate without chewing. Pieces no larger than 15 mm × 15 mm.
Fork test: Can be mashed with moderate tongue pressure (no need for fork force).
What it looks like: Soft-cooked vegetables (well-cooked broccoli florets, soft-boiled carrot), tender fish (steamed white fish), soft bread without crust, ripe banana.
Who is commonly prescribed this level: People with mild dysphagia or reduced dentition who can still manage some oral processing and tongue movement.
Hong Kong kitchen note: Many Cantonese dishes naturally approach Level 6 when well-cooked: braised daikon (蘿蔔), steamed fish fillet (清蒸魚), soft-cooked winter melon (冬瓜). Portion sizing to ≤15 mm is the main adjustment needed.
Level 7 — Regular / Easy to Chew
What it is: Normal food, but may exclude foods that are particularly hard, sticky, or that separate into fibrous strands.
Who is prescribed this level: People with mild oral-phase difficulties or reduced dentition who can still manage regular food with some modifications. Also used for people who have recovered from dysphagia to near-normal function.
Hong Kong note: Even at Level 7, certain foods are typically excluded: whole nuts, raw vegetables, chewy meats, and sticky rice products (such as glutinous rice balls — 湯圓 — which carry aspiration risk even for people without diagnosed dysphagia).
How to Test at Home
You do not need clinical equipment to perform basic IDDSI tests:
| Test | Equipment needed | What you test |
|---|---|---|
| Fork pressure test | An ordinary dinner fork | Levels 4–6 food: press gently; food should yield easily |
| Spoon tilt test | An ordinary teaspoon | Level 4 purée: tilt spoon; food should slide off within 3 seconds |
| Syringe flow test | A 10 ml clinical syringe (available at pharmacies) | Drink levels 0–4: fill, hold vertical 10 sec, measure how much flows out |
IDDSI publishes free testing cards in multiple languages at iddsi.net/resources. Download and keep one in your kitchen.
Quick Reference Summary
| Level | Category | Name | Simple description |
|---|---|---|---|
| 0 | Drink | Thin | Normal water/tea |
| 1 | Drink | Slightly Thick | Slightly slower than water |
| 2 | Drink | Mildly Thick | Nectar-like |
| 3 | Drink/Food | Moderately Thick / Liquidised | Honey-like; or smooth pourable food |
| 4 | Drink/Food | Extremely Thick / Puréed | Pudding-like; or smooth moulded food |
| 5 | Food | Minced & Moist | Soft, particles ≤ 4 mm |
| 6 | Food | Soft & Bite-Sized | Tongue-mashing texture, pieces ≤ 15 mm |
| 7 | Food | Regular | Normal texture, some exclusions |
References
- IDDSI Complete Framework — iddsi.net (free download; available in Traditional Chinese, Simplified Chinese, Japanese, and English)
- HKCSS Care Food Endorsement Scheme — hkcss.org.hk
- HKU Swallowing Research Laboratory — swallowhku.hku.hk
This guide is for educational reference only and does not replace assessment by a speech-language pathologist. For enquiries, contact [email protected].