What are the food texture requirements for IDDSI?

Approximately 8% of the global population experiences swallowing difficulties, known as dysphagia. The International Dysphagia Diet Standardisation Initiative (IDDSI) was developed to create a single, international terminology for describing food textures to improve safety and patient care. Understanding what are the food texture requirements for IDDSI is vital for caregivers and healthcare professionals to ensure individuals receive appropriate and safe nutrition.

Quick Summary

The International Dysphagia Diet Standardisation Initiative (IDDSI) offers a standardized framework for food textures and liquid thicknesses to enhance safety for individuals with swallowing disorders. Food levels range from 3 (Liquidised) to 7 (Regular), with specific requirements for particle size, moisture, and cohesiveness. Simple, practical tests using common utensils ensure foods meet the criteria for each level.

Key Points

• Level 3 (Liquidised): Food is completely smooth with no lumps and drips slowly through a fork; it cannot be molded or hold its shape.

• Level 4 (Pureed): Food has a smooth, pudding-like consistency, holds its shape, and leaves a clear fork mark without dripping through the tines.

• Level 5 (Minced & Moist): Features soft, moist lumps no larger than 4mm for adults, which are easily mashed with the tongue.

• Level 6 (Soft & Bite-Sized): Foods are soft and tender, cut into specific bite-sized pieces (1.5cm for adults), and require chewing.

• Level 7 (Easy to Chew): A sub-level for soft, tender everyday foods that can be easily chewed, excluding hard or tough textures.

• Fork Pressure Test: Used to check the firmness and softness of food by observing how it deforms under fork pressure.

• Spoon Tilt Test: Assesses food cohesiveness and stickiness by tilting a spoon and observing if the food slides off in a single lump.

• Moisture is Key: Adding appropriate liquids like gravy or stock is crucial for achieving the correct texture, especially for minced and moist foods.

The Importance of the IDDSI Framework

The IDDSI framework provides a universal language for describing modified food textures and drinks. This standardisation is critical for preventing adverse events like choking or aspiration pneumonia, which can result from serving incorrectly prepared food to someone with dysphagia. Each level within the framework has specific, measurable requirements to ensure consistency and safety, helping healthcare professionals and caregivers accurately prepare meals. By adhering to these standards, patients can receive nutrition safely, and their quality of life can improve.

Food Levels 3 to 7 Explained

The IDDSI food framework covers levels 3 to 7, transitioning from pureed to regular foods. Here is a breakdown of the specific requirements for each level:

• Level 3 - Liquidised: This food is a completely smooth, lump-free texture that requires no chewing. It is usually eaten with a spoon but cannot be molded or hold its shape. Food at this level should drip slowly in dollops through the prongs of a fork.
• Level 4 - Pureed: The consistency is smooth and lump-free, similar to a thick pudding. It holds its shape on a plate, is not sticky, and does not require chewing. A fork should leave a clear pattern on the surface.
• Level 5 - Minced and Moist: This level features soft, moist food with no separate thin liquid. It contains small, soft lumps (4mm for adults) that are easily mashed with the tongue. A scooped sample should hold its shape on a spoon but fall off easily when tilted.
• Level 6 - Soft and Bite-Sized: Foods are soft, tender, and moist, cut into specific bite sizes (1.5cm for adults). It requires chewing and can be mashed or broken down easily with a fork. No knife is needed to cut the food.
• Level 7 - Regular (Easy to Chew): A sub-level for softer, everyday foods that can be easily chewed and swallowed. It excludes hard, tough, chewy, or fibrous textures.
• Level 7 - Regular: This includes normal, everyday foods of various textures with no restrictions.

Essential IDDSI Testing Methods

IDDSI provides simple, objective testing methods to verify that a food's texture meets the required level. These tests use common utensils and are essential for ensuring patient safety.

• Fork Drip Test: Used for levels 3 to 5. A sample is placed on a fork and checked for how it flows or holds its shape through the prongs. For Level 3, it should drip slowly in dollops, while for Level 4 and 5, it should mound and not completely flow through.
• Spoon Tilt Test: Used for pureed and minced and moist foods (levels 4 and 5). Checks for stickiness and cohesiveness. The food should hold its shape on the spoon and slide off easily when tilted, without leaving significant residue.
• Fork/Spoon Pressure Test: For levels 4 through 7 Easy to Chew. Tests the firmness and hardness of the food. For minced and moist (Level 5), food particles should easily separate through the fork prongs with minimal pressure. For soft and bite-sized (Level 6), firmer pressure should mash the food, which should then not return to its original shape.

Comparison of IDDSI Food Texture Levels

Feature	Level 3: Liquidised	Level 4: Pureed	Level 5: Minced & Moist	Level 6: Soft & Bite-Sized
Chewing Required	No	No	Minimal	Yes
Consistency	Smooth, lump-free, flows in dollops	Smooth, lump-free, holds shape, not sticky	Soft, moist, small soft lumps (4mm adult)	Soft, tender, moist, specific bite-sized pieces
Preparation Method	Blended to smooth, liquid consistency	Processed to a smooth, thick consistency	Finely minced or chopped, mixed with sauce/gravy	Cut to size, or easily mashed with a fork
Key Test	Fork Drip Test (drips in dollops)	Fork Drip Test (mounds) & Spoon Tilt Test	Fork Pressure Test (separates easily)	Fork Pressure Test (mashes with pressure)

Conclusion

Adhering to IDDSI food texture requirements is a critical aspect of providing safe and appropriate nutrition for individuals with dysphagia. The framework's standardized language and objective testing methods empower caregivers and professionals to prepare meals with the correct level of texture, minimizing risks like choking and aspiration. By following these guidelines, the dining experience can remain safe, dignified, and enjoyable for those with swallowing difficulties. Education, attention to detail, and regular review of patient needs are paramount for successful implementation of IDDSI standards.

Additional Considerations for IDDSI Diets

• Visual Appeal: Modified diets can be unappealing, but using food molds or piping different elements can improve a meal's look and appeal.
• Nutritional Density: Since portion sizes may be smaller or less dense, enriching food with extra protein and calories can help maintain nutritional intake.
• Temperature: Testing foods at their serving temperature is important, as temperature can change a food's consistency and flow characteristics.
• Hydration: Ensuring adequate hydration is vital, as dysphagia can often lead to reduced fluid intake. Thickened liquids may also be required, following the IDDSI drink levels.

References

• NISCC. (2025). IDDSI: International Dysphagia Diet Standardisation Initiative. Retrieved from https://niscc.info/app/uploads/2025/06/Swallow-Awareness-Session-Presentation.pdf
• Enjoy Safe Meals. (2021). A Cook’s Companion for People With Swallowing Difficulty. Retrieved from https://enjoysafemeals.com/wp-content/uploads/2021/10/Cooks_Companion_V01.pdf

Frequently Asked Questions

What is the purpose of the IDDSI framework?

The IDDSI framework provides a global, standardized terminology for describing food textures and drink thickness. Its purpose is to improve the safety and care for individuals with swallowing difficulties (dysphagia) by ensuring foods and drinks are prepared to a safe, consistent texture.

How do I test if food meets the IDDSI Level 6 requirements?

To test for Level 6, use the Fork Pressure Test. A standard metal fork should be able to break down the food easily. When pressure is applied, the food should mash and not return to its original shape. Additionally, ensure all pieces are no larger than 1.5 cm x 1.5 cm for adults.

What kind of food is considered IDDSI Level 4 Pureed?

IDDSI Level 4 Pureed food is smooth and lump-free, with a thick, pudding-like consistency. It should hold its shape on a plate and not be sticky. When tested with a fork, it should retain the mark of the fork tines.

Are bread and toast suitable for IDDSI level 6 Soft & Bite-Sized?

Regular dry bread and toast are generally not suitable for Level 6 due to their high choking risk. While bread can be modified, it must be pre-gelled or soaked thoroughly to become a moist, cohesive gel, and individual patient assessment is crucial.

What is a 'transitional food' in IDDSI?

Transitional foods are solid foods that start as one texture and change into another when moisture or temperature is applied. They require minimal chewing and can be broken down by tongue pressure once moistened.

Why is it important to test food at serving temperature?

Testing food at its intended serving temperature is important because both hot and cold temperatures can change the food's consistency. A food that is the correct texture when warm might become too hard or sticky when cooled, and vice-versa.

Can a person be prescribed different IDDSI levels for food and drinks?

Yes, an individual's ability to manage food and drinks should be assessed independently. For instance, a person might need moderately thick drinks (Level 3) due to poor oral control but can safely manage minced and moist foods (Level 5).