IDDSI Framework — Complete Guide to All 8 Levels
TL;DR: The IDDSI framework is a global standard that classifies foods and drinks into 8 levels (0 through 7) by texture and thickness. It exists so that a hospital in Hong Kong, a care home in London, and a family kitchen in Tokyo can all describe a “Level 4 puréed” meal and mean exactly the same thing — measurable, testable, and safe for someone with dysphagia.
What IDDSI is, and why it exists
Before 2017, the world had a problem: every country, sometimes every hospital, used different words for “thickened drinks” and “soft foods” for people with swallowing difficulties. “Nectar-thick” in one place meant something different in another. A patient transferred between facilities could get a drink labelled the same way but actually two or three times thicker — sometimes thin enough to choke on, sometimes too thick to swallow safely.
The International Dysphagia Diet Standardisation Initiative (IDDSI) was formed in 2013 by a group of clinicians, researchers, and food scientists to fix this. After three years of research and consultation across more than 50 countries, IDDSI published its framework in 2017. It is now adopted (or being adopted) by health systems in Australia, Canada, the UK, the US, Ireland, New Zealand, Japan, Korea, mainland China, Hong Kong, Singapore, parts of the EU, and more.
The framework has two key features that make it different from older systems:
- It is a continuum. Foods and drinks share the same scale (Levels 0–7), so as a patient’s needs change, you move them up or down without translating between two different vocabularies.
- Every level is testable with kitchen equipment. No lab gear, no specialist training. A fork, a spoon, and a 10 mL syringe are enough to verify any level.
The 8 levels at a glance
| Level |
Name |
Drinks |
Foods |
Who it’s typically for |
| 0 |
Thin |
✅ |
— |
People with no swallowing difficulty |
| 1 |
Slightly Thick |
✅ |
— |
Premature infants; some adults with very mild dysphagia |
| 2 |
Mildly Thick |
✅ |
— |
Adults who need a thicker drink to slow flow |
| 3 |
Liquidised / Moderately Thick |
✅ |
✅ |
People who can drink from a cup but need food smooth enough to drink |
| 4 |
Puréed / Extremely Thick |
✅ |
✅ |
People who need foods that hold their shape on a spoon, no chewing required |
| 5 |
Minced & Moist |
— |
✅ |
People who can manage some movement of the tongue but cannot chew safely |
| 6 |
Soft & Bite-Sized |
— |
✅ |
People who can chew but need help breaking food into small, soft pieces |
| 7 |
Regular / Easy to Chew |
— |
✅ |
People with normal chewing — Level 7 has a “Easy to Chew” sub-category for those who manage soft regular food |
The colour coding (used on hospital signs and meal trays globally) is: Level 0 white, Level 1 grey, Level 2 light pink, Level 3 yellow, Level 4 green, Level 5 orange, Level 6 blue, Level 7 black. These colours are part of the IDDSI brand and help anyone — even staff who don’t read the local language — confirm the level at a glance.
Drinks (Levels 0–4)
Level 0 — Thin
- Flow: Flows like water.
- Examples: Water, juice, tea, coffee, broth (without bits).
- Test: IDDSI Flow Test — using a 10 mL slip-tip syringe with the tip cut off at the 10 mL mark, fill to 10 mL, then let it flow for 10 seconds. Less than 1 mL remaining = Level 0.
Level 1 — Slightly Thick
- Flow: Thicker than water; flows through a straw, syringe, or teat with a little more effort.
- Examples: Some baby formulas; commercially thickened drinks at the lowest setting.
- Test: Flow test result of 1–4 mL remaining after 10 seconds.
Level 2 — Mildly Thick
- Flow: Sippable; flows off a spoon but slowly. Effort needed to drink through a standard straw.
- Examples: Tomato soup at typical commercial consistency; thinly thickened juice.
- Test: Flow test result of 4–8 mL remaining after 10 seconds.
Level 3 — Liquidised / Moderately Thick
- Flow: Can be drunk from a cup; cannot pipe through a standard straw without significant effort. Smooth, no lumps. Holds together on a spoon but pours.
- Examples: Smoothies that have been blended very fine, no seeds or pulp; puréed soups with no lumps.
- Test for drinks: Flow test result of more than 8 mL remaining (almost no flow). For thicker liquidised foods, also passes the Fork Drip Test (see below).
Level 4 — Extremely Thick (also a food level)
- Flow / Texture: Does not flow easily. Holds its shape on a spoon. Cannot be drunk from a cup, cannot be sipped through a straw. No lumps. No separating liquid.
- Examples: Smooth, thick puréed pumpkin; smoothly puréed apple sauce that doesn’t separate.
Foods (Levels 3–7)
Level 3 — Liquidised
Smooth and lump-free, but pourable from a spoon. Suitable for people who can swallow a cohesive liquid but cannot chew. Often delivered via cup or wide-bore straw.
Common mistakes: Adding too much thickener until it becomes Level 4. Not blending long enough — leaving small lumps. Letting starch-based thickeners “drift” thicker over time as they continue to absorb liquid.
Level 4 — Puréed
The texture most people think of as “hospital baby food,” but done properly. Holds its shape on a spoon when scooped, but is smooth, lump-free, and uniform throughout. No separating liquid.
- ✅ Must: Hold a peak when piped from an icing bag. Not stick to the spoon excessively. Be cohesive — falls in a single dollop, not a splatter.
- ❌ Must not: Be runny (that’s Level 3). Have lumps. Have visible bits of skin or fibre. Have liquid separating out at the bottom of the bowl.
- Test: Fork Drip Test — a small amount on a fork should sit on the prongs and only drop through slowly in dollops, not run through.
Level 5 — Minced & Moist
Soft, moist, and finely chopped. Particles must be no larger than 4 mm for adults (about the width of a pencil tip) and no larger than 2 mm for children. The food must be moist enough that the particles stick together on the spoon — dry minced food is not Level 5.
- ✅ Soft minced beef in gravy, where the gravy holds the meat together.
- ❌ Dry crumbled cheese — it doesn’t bind, so even small particles are a choking risk.
- Test: Particles must squash easily under the side of a fork pressed flat. If you have to push hard, it isn’t soft enough.
Level 6 — Soft & Bite-Sized
Pieces no larger than 15 mm (about 1.5 cm) for adults and 8 mm for children. Each piece must be soft enough that pressing it with the side of a fork (or thumb) flattens it. The food does not need to be moistened with sauce, but it needs to compress easily.
- ✅ Well-cooked carrot cubes; soft fish flakes; well-cooked pasta cut to 1.5 cm.
- ❌ Skin-on grapes, raw apple cubes, hard bread crusts, sticky rice cakes (mochi).
Level 7 — Regular / Easy to Chew
Normal everyday food, but with two important sub-classifications:
- Level 7 Regular: All textures permitted, including hard, crunchy, dry, or chewy foods.
- Level 7 Easy to Chew (EC): Same nutritional variety as Regular, but the food itself must be soft and tender. No hard, dry, crunchy, sticky, or stringy items. Suitable for older adults and people whose chewing is slower or weaker but who can still manage solids.
The Easy to Chew variant is increasingly used in elderly care globally, including across Hong Kong’s elderly homes, because it allows residents to eat near-normal meals safely without being downgraded to Level 6.
How to test foods to confirm the level
IDDSI deliberately designed all the tests to use kitchen equipment, not laboratory equipment, so any caregiver, nurse, or cook can verify a food at the point of service. The four tests are:
- IDDSI Flow Test (drinks): 10 mL slip-tip syringe with tip cut off at the 10 mL mark, measure remaining volume after 10 seconds of free flow.
- Fork Drip Test (Level 4 foods): puréed food on the prongs of a standard dinner fork, observe how it falls.
- Fork Pressure Test (Levels 4–6 foods): press food with the side (the back) of a fork — does it squash, hold its shape, or resist?
- Spoon Tilt Test (Level 4 foods): scoop a heaped spoon, tilt sideways — should slide off in one dollop, not run, not stick.
For full step-by-step instructions on each test, including photos of pass/fail examples, see How to Test Food Texture for Dysphagia.
Common mistakes when applying IDDSI
- Confusing “smooth” with “Level 4.” A smoothie can be smooth but Level 3 (pourable). Level 4 must hold its shape.
- Letting food “drift” over time. Starch-based thickeners continue to absorb liquid for up to 30 minutes after preparation. A drink that tests as Level 2 fresh may test as Level 3 after sitting on a tray. Gum-based thickeners are more stable.
- Using mesh sizes instead of fork tests. A 4 mm sieve doesn’t tell you if the particles bind together. The fork tests are about cohesion, not just size.
- Skipping the test “because it looks right.” Eye-balling fails. A 30-second test catches most errors.
- Mixing levels on one plate. A Level 4 mash next to a Level 6 vegetable confuses caregivers and patients. If a patient is on Level 4, the whole meal must be Level 4.
How IDDSI relates to other systems
| Older system |
IDDSI equivalent |
| US National Dysphagia Diet “Pudding” |
Level 4 |
| US National Dysphagia Diet “Mechanical Soft” |
Level 5 or 6 |
| UK “Texture C / Thick Purée” (pre-2018) |
Level 4 |
| UK “Texture E / Fork Mashable” |
Level 5 |
| Japan JSDR / 嚥下調整食 Code 0–4 |
Roughly maps to Levels 0–4 (drinks) and Levels 3–6 (foods); Code 4 ≈ Level 5 |
| Hong Kong 護食 (Carewells / 軟餐) |
Aligned to IDDSI Levels 4–7; see Hong Kong 護食標準 guide |
These mappings are approximate. Always verify against the IDDSI test, not the label.
Where IDDSI is going next
IDDSI continues to evolve. Recent updates and active discussions include:
- Transitional Foods: Foods (such as ice cream and certain biscuits) that change consistency in the mouth. IDDSI has guidance on when these can be safely included.
- Drug administration: Crushing and mixing medication into thickened liquids — there is now an IDDSI Drug Adminstration Position Paper covering when this is safe and when it changes the medication’s release profile.
- Implementation in low-resource settings: Adapting the framework for community kitchens and family caregivers, not just hospitals.
For the latest, the official source is IDDSI.org. This guide is unaffiliated with IDDSI itself — we link to and paraphrase their public materials, with attribution.
Citations and sources
- International Dysphagia Diet Standardisation Initiative — iddsi.org (the canonical source for the framework, testing methods, and updates)
- Cichero, J., Lam, P., Steele, C. M., et al. (2017). “Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework.” Dysphagia, 32(2), 293–314.
- Steele, C. M., et al. (2018). “Creation and Initial Validation of the International Dysphagia Diet Standardisation Initiative Functional Diet Scale.” Archives of Physical Medicine and Rehabilitation.
This article paraphrases and summarises the IDDSI framework. For clinical practice, always refer to the current official IDDSI documentation. This page is not medical advice.
Last updated: 2026-04-11 · License: CC BY 4.0 · Maintained by SeniorDeli (Carewells) — Hong Kong’s dysphagia food specialists. Need IDDSI-aligned ready meals delivered in Hong Kong? See our Carewells range →