IDDSI levels explained: a care kitchen guide to levels 0 to 7

In June 2018, NHS Improvement published a patient safety alert backed by a review of incidents from 1 October 2015 to 30 September 2017. The review found seven reports of significant harm from confusion over the term “soft diet”. Two patients died. The alert told organisations providing NHS-funded care to “eliminate use of imprecise terminology including ‘soft diet’”, with the work “completed by 1 April 2019”.

IDDSI is the framework that replaced local terms such as “custard thickness”. This guide is for care home cooks, kitchen managers, and the care managers who sign off a kitchen’s competence.

Quick answer. IDDSI is “a continuum of 8 levels (0-7)” for describing the texture of food and drink for people who have difficulty swallowing. IDDSI says “drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7”, so Levels 3 and 4 cover both. A clinician decides which level a person needs. The kitchen produces that level and checks it with IDDSI’s published tests. The current documents are Detailed Definitions 2.2 (April 2026) and Testing Methods 2.0 (July 2019).

Chefs Bay Academy is not affiliated with or endorsed by IDDSI. This guide describes the framework in our own words, with short attributed quotes and IDDSI’s exact figures. The official documents at iddsi.org are the reference, and this guide is not a substitute for them or for an individual’s speech and language therapy assessment. We checked the specifications below against IDDSI’s published documents on 2 October 2026.

What are the IDDSI levels?

IDDSI stands for International Dysphagia Diet Standardisation Initiative. Dysphagia means difficulty swallowing. Every level has a number, a name and a colour code.

The names are Level 0 Thin, Level 1 Slightly Thick, Level 2 Mildly Thick, Level 3 (Liquidised for food, Moderately Thick for drink), Level 4 (Pureed for food, Extremely Thick for drink), Level 5 Minced & Moist, Level 6 Soft & Bite-Sized, and Level 7 (Regular, or Easy to Chew). Level 7 has two descriptors that share one number, so it is one level, not two.

Levels 3 and 4 sit on both scales because, in IDDSI’s FAQ (4 November 2024), “at Level 3 liquidised foods and moderately thick drinks share the same flow characteristics and descriptions. The same is also true for Level 4 pureed foods and extremely thick drinks.”

Who chooses the level? Not the kitchen. IDDSI’s definitions put the responsibility for recommending foods or drinks for a particular patient on the clinician, and the Royal College of Speech and Language Therapists (guidance updated March 2025) says: “IDDSI is a communication tool and not an intervention plan.”

Drinks: levels 0 to 4

Levels 0 to 3 are sorted with the flow test, explained below. The pass bands are what is left in a 10 mL slip tip syringe after 10 seconds, quoted from Detailed Definitions 2.2.

Level 0, Thin, leaves “Less than 1 mL remaining in the 10 mL slip tip syringe after 10 seconds of flow” (“Flows like water”). Level 1, Slightly Thick (“Thicker than water”), leaves 1-4 mL, and IDDSI notes it is “Also used in adult populations where thin drinks flow too fast to be controlled safely”. Level 2, Mildly Thick (“Flows off a spoon”), leaves 4 to 8 ml. Level 3, Moderately Thick (“Can be drunk from a cup”), leaves ”> 8 ml”.

Level 4, Extremely Thick, is not flow tested: “please use the Fork Drip Test and Spoon Tilt Test”. IDDSI describes it as “Cannot be drunk from a cup because it does not flow easily”, but the descriptors are only a guide. The tests decide.

Foods: levels 3 to 7

Level 3, Liquidised, has this fork drip description: it “Drips slowly in dollops through the prongs of a fork”. That is one part of IDDSI’s Level 3 criteria, not all of them, and it does not replace the flow characteristics Level 3 foods share with Level 3 drinks (see above). This guide does not summarise IDDSI’s other Level 3 food criteria, so read them in Detailed Definitions 2.2 and Testing Methods 2.0 before you rely on the fork test alone.

Level 4, Pureed, “Does not require chewing” and is “Usually eaten with a spoon (a fork is possible)”. It has “No lumps”, is “Not sticky”, and “Liquid must not separate from solid”. On the fork drip test, “a small amount may flow through and form a short tail below the fork tines/prongs, but it does not flow or drip continuously through the prongs of a fork”. On the spoon tilt test it must be “Cohesive enough to hold its shape on the spoon”, and a full spoonful must fall off in one when the spoon is tilted or turned sideways. IDDSI says it “should not be firm and sticky”. A very gentle flick may be needed to release it, and a thin film left on the spoon is acceptable.

Level 5, Minced & Moist, is “Soft and moist with no separate thin liquid”, with “Small lumps visible within the food”. For adults the lumps are “equal to or less than 4mm width and no longer than 15mm in length”. For children the lumps are “equal to or less than 2 mm width and no longer than 8mm in length”. For width, the fork is the ruler: “4mm is about the gap between the prongs of a standard dinner fork”. The 15 mm length is a separate limit. The food can be “easily mashed with little pressure from a fork”, and IDDSI adds that the pressure should not make the thumbnail blanch to white. IDDSI sets further criteria for Level 5 beyond these; this guide does not summarise them, so read them in Detailed Definitions 2.2.

Level 6, Soft & Bite-Sized, is “Soft, tender and moist throughout but with no separate thin liquid”. Adult pieces are no larger than 15 mm (1.5 cm), and children’s no larger than 8 mm. Food has to pass both the size test and the softness test. For softness, press a thumbnail-sized sample (1.5 x 1.5 cm) with fork tines until your thumbnail blanches to white. The sample should squash, break apart, change shape and not return to its original shape.

Level 7 Regular has “NO texture restrictions”, and no test. Level 7 Easy to Chew is “Normal, everyday foods of soft/tender textures that are developmentally and age appropriate”, with no size limit. It “Requires the ability to chew and orally process soft/tender foods without tiring easily”, and IDDSI warns: “This level could present a choking risk for people with clinically identified increased risk of choking, because food pieces can be of any size.” This guide does not summarise IDDSI’s testing criteria for Easy to Chew, so use the IDDSI documents for those.

Across the scale, IDDSI says: “Mixed thin-thick textures are a choking risk because they require an ability to hold the solid piece in the mouth while the thin liquid portion is swallowed.”

Bread and sandwiches: what changed in April 2026

Bread is where IDDSI’s documents moved this year. The IDDSI FAQ (posted 4 November 2024) says: “As a general rule, bread products are considered a regular food texture (Level 7) and are not permitted at levels 6 (Soft & Bite-Sized) or 5 (Minced & Moist).” It allows adult pre-cut pieces below 15x15x15 mm at Level 6 only “on a case-by-case basis”, which is the clinician’s decision.

Separately, the change log for version 2.2, dated 28 April 2026, removed the wording “Pre-gelled ‘soaked’ breads that are very moist and gelled through the entire thickness” from the Level 5 and Level 6 examples, along with the Minced & Moist sandwich image. The wording was removed. The change log does not say bread is now banned or now allowed. Version 2.2 still says “No regular dry bread, sandwiches or toast of any kind” at Level 6, and it still refers to IDDSI’s Level 5 Minced & Moist sandwich recipe video. The FAQ, the version 2.2 text and the April alert are not worded the same way, so bread at Levels 5 and 6 is a decision for the speech and language therapist, not for a recipe card.

On 20 April 2026 IDDSI published a bread choking alert saying it is “reviewing the IDDSI Detailed Definitions Document, considering and acting upon Coronial findings and new evidence”. The case behind it is Australian. IDDSI has also announced document updates for autumn 2026.

How to test: the flow test, fork and spoon

For the flow test, remove the plunger, cover the nozzle and fill the syringe to 10 mL. Release the nozzle and start timing, stop at 10 seconds, and read what is left.

The syringe matters. IDDSI gives the length of the 10 mL scale as 61.5 mm, measured between the zero and 10 mL marks, and says “You must check your syringe length because there are differences in syringe lengths.” Testing Methods 2.0 adds that “Using a syringe of different dimensions to that described here or a 12 mL syringe will give results that cannot reliably be used with the IDDSI Framework.” Measure yours.

A reading of exactly 8 mL is, in IDDSI’s FAQ wording, “neither Level 2 nor Level 3”, and exactly 4 mL falls between Levels 1 and 2 in the same way. Adjust the recipe and test again. For thickened drinks, Testing Methods 2.0 says to “follow the manufacturer’s instructions and mix thoroughly, watching closely that there are no lumps or air bubbles present” and to “Test twice or more to ensure more reliable results.”

Test under real conditions. IDDSI says: “Testing should be done on foods and drinks under the intended serving conditions (especially temperature).” Our IDDSI dysphagia training course for cooks covers the levels and the flow, fork drip, spoon tilt and fork pressure tests.

Where care kitchens go wrong

Old paperwork is one failure. IDDSI’s 2019 Level 3 handout says “no less than 8 mL remaining”, where the current definitions say more than 8 mL, and its 2019 adult handout says “Lumps of 4mm in size” for Level 5, where version 2.2 adds the 15 mm length limit. Check the poster on the wall against the current document.

Thickeners are another. The NHS Specialist Pharmacy Service (article updated 17 December 2024) warns: “Scoop size differs between products. Always use the right scoop for the product.” It also advises that jugs of thickened fluid kept in a shared fridge should “Clearly note the IDDSI level, thickener used, and date and time they were made up.” The BDA care home digest (June 2024) says prescribed thickeners should not be used to thicken food.

Then there are failures between the care plan and the plate. A coroner’s prevention of future deaths report (reference 2025-0390, dated 29 July 2025) concerns a woman assessed as “Normal Diet IDDSI L7 easy chew and to avoid difficult textures”. It records that “a chef in evidence at the inquest was not aware that breaded fish was not a suitable food stuff in the diet identified”. In March 2026 the Health and Safety Executive reported a prosecution after a resident of a Scottish care home choked to death on a meal, saying its investigation “found a failure in the system of work for preparing and serving modified meals”.

These are single cases, and we found no UK figure for how common such failures are.

What the regulations say in England

This section covers England. Wales, Scotland and Northern Ireland have their own regulations and guidance.

Regulation 14(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 says: “The nutritional and hydration needs of service users must be met.” The text of Regulation 14 does not mention IDDSI or dysphagia. CQC’s guidance on the regulation (last updated 16 May 2025) says: “Where a person is assessed as needing a specific diet, this must be provided in line with that assessment.” CQC’s page on caring for people at risk of choking (updated 15 April 2026) says of the IDDSI descriptors: “You should have been using these since April 2018.”

IDDSI is not itself mandatory. The BDA’s Nutrition and Hydration Digest (June 2023) says so in as many words: “The IDDSI Framework is not mandatory.” No regulation names a specific IDDSI or dysphagia certificate for care staff in England. Regulation 18(2)(a) requires staff to “receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform”, and the RCSLT’s care home guidance (undated) puts the decision on the organisation, “including carers and catering staff”. Our guide to mandatory training for care workers explains why no statutory course list exists.

Free training exists too: NHS England’s e-learning for healthcare platform has a Dysphagia Guide with an “Essentials for Cooks” session and an e-assessment. The same kitchen also needs food hygiene (our level 2 guide), and our dementia awareness training guide covers residents living with dementia.

Check the source

Read the current versions on the IDDSI framework documents page before you rely on any figure here.

Attribution required by IDDSI’s guidelines for use: © The International Dysphagia Diet Standardisation Initiative 2019 @ https://iddsi.org/standards//framework. Licensed under the CreativeCommons Attribution Sharealike 4.0 License https://creativecommons.org/licenses/by-sa/4.0/legalcode.

Frequently asked questions

Can IDDSI level 4 have scrambled eggs?

IDDSI has no ruling on scrambled egg. One NHS trust’s Level 4 leaflet (CUH, approved 14 August 2026) lists “Pureed scrambled egg with cheese and butter and pureed avocado”. Treat that as one trust’s example and test what you make against Level 4.

Can level 6 have sandwiches?

Generally not: see the bread section above. Pre-cut pieces at Level 6 are a case-by-case decision for the clinician.

What foods are allowed at level 6 or level 4, and which should be avoided?

IDDSI says: “Due the overwhelming number of foods globally and variation in preparation methods, it is not possible to outline lists of foods under each Level.” So there is no exhaustive list to copy. That is different from having no restrictions. Detailed Definitions 2.2 still says “No regular dry bread, sandwiches or toast of any kind” at Level 6, and IDDSI’s FAQ says bread is generally not permitted at Levels 5 or 6. A food has to meet the published restrictions for its level and pass that level’s tests, which describe a sample at the moment it is tested, under the intended serving conditions. Even then the clinician, not the kitchen, decides what a particular person may have.

Is IDDSI a legal requirement for care homes?

The BDA says “The IDDSI Framework is not mandatory”, and Regulation 14 does not name it. CQC does say providers should have been using it since April 2018: see the regulations section above.

How often should a care kitchen test texture?

The BDA’s June 2024 care home digest says to test at each meal, snack and drink time. We found no frequency rule in IDDSI’s documents, so that is BDA advice, not an IDDSI requirement.