IDDSI levels explained: the dysphagia diet framework from 0 to 7

What it means

IDDSI (the International Dysphagia Diet Standardisation Initiative) is a framework, not a single diet. It gives clinicians, kitchens, manufacturers and patients one shared language for texture-modified foods and thickened drinks, which are used for people with dysphagia (difficulty swallowing) to reduce the risk of choking and aspiration.

It was built to end a tangle of local terms. The international survey behind the framework, published in Dysphagia in 2017, found 54 different names in use for food textures and 27 for liquid thickness. The IDDSI Framework, released in November 2015, offers one continuum of 8 levels instead, identified by numbers, text labels, color codes, definitions and measurement methods.

The eight levels

Level	Name	Applies to
0	Thin	Drinks
1	Slightly Thick	Drinks
2	Mildly Thick	Drinks
3	Moderately Thick (drinks) or Liquidised (foods)	Drinks and foods
4	Extremely Thick (drinks) or Pureed (foods)	Drinks and foods
5	Minced & Moist	Foods
6	Soft & Bite-Sized	Foods
7	Easy to Chew or Regular	Foods

Each level also has a short code, such as MM5 for Minced & Moist or SB6 for Soft & Bite-Sized. IDDSI also describes transitional foods, which start as one texture and change when moisture or heat is applied, such as wafers. Clinicians may use them to help re-teach chewing.

How the levels are tested

IDDSI levels are defined by tests, not by dish names:

• Drinks are checked with the IDDSI Flow Test: liquid flows from a 10 ml syringe for 10 seconds, and the amount left decides the level. Level 3 also uses the fork drip test, and Level 4 uses the fork drip and spoon tilt tests.
• Foods are checked with the fork drip, spoon tilt and fork pressure tests. In the fork pressure test, the tester presses the food with a fork until the thumbnail blanches white, and checks that it squashes and does not return to its shape.
• Piece size is limited: up to 4 mm for adults (2 mm for children) at Level 5, and about 15 x 15 mm for adults (8 x 8 mm for children) at Level 6.

IDDSI says its testing methods confirm the flow or texture of a product at the time of testing. A recipe that passed once still needs checking when it is made again.

What it looks like on the tray

The same Indian dish can sit at different levels depending on how it is made. Khichdi blended smooth with no lumps is a Level 4 Pureed candidate. Mashed so the pieces are no bigger than 4 mm, moist, with no separate thin liquid, it is a Level 5 candidate. Cooked soft in pieces of about 1.5 cm that squash under a fork, it is a Level 6 candidate. Only the tests confirm it.

Drinks follow the drink level. For a patient on Level 2 Mildly Thick drinks, tea, buttermilk, juice and soup all need thickening to that level, including the cup that arrives on the ward tea round.

Common mistakes on the ward

• Old and new names mixed. Nectar-thick and honey-thick are not IDDSI terms. Using both systems on one ward invites errors.
• Half an order. The food level is recorded and the drink level is not, or the reverse.
• Easy to Chew treated as choking-safe. Level 7 Easy to Chew has no particle size limit, so it does not reduce choking risk the way Level 6 does.
• Labels without tests. A menu card saying Level 5 is not the same as food that passes the Level 5 tests.
• Lost on transfer. The level stays on the old ward’s board when the patient moves.

How MedMeals handles it

Hospitals can set up IDDSI levels as diet labels in MedMeals, using custom labels and taxonomies, and tag each menu item with the level the kitchen prepares it to. A patient’s menu then offers only matching items, meal cards and KOTs name the diet for the kitchen, and the diet profile moves with the patient on transfer. MedMeals does not test textures or certify levels: the kitchen still runs the IDDSI tests. See diet management or book a demo.