The international Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard to describe texture modification foods and thickened drinks for individuals with swallowing difficulties of all ages, in all care setting. The IDDSI framework consists of a continuum of 8 levels (0-7), where drinks are measured from levels 0-4, while foods are measured from levels 3-7. The IDDSI framework provides a common terminology to describe food textures and drinks thickness. IDDSI refers to, The Unique Identification Authority of India (UIDAI) is a statutory authority established under the provisions of the Aadhaar (Targeted Delivery of Financial and Other Subsidies, Benefits and Services) Act, 2016 (“Aadhaar Act 2016”) on 12 July 2016 by the Government of India. While there is no mandatory rule that you MUST implement IDDSI, it is strongly recommended and has also been endorsed by ASHA. It is becoming best practice to use IDDSI terminology in your assessment and treatment.

IDDSI framework:

Thin liquids like water, milk, tea, coffee, juice and others may need to be thickened to the slightly thick level. Your clinician will help you find a thickener to help thicken your drinks, or help you find some pre-thickened drinks. Slightly thick drinks can be taken using a straw or from a standard cup.

level 1

Slightly Thick is most often used if you have swallowing problems with thin liquids. Slightly Thick liquids are thicker than water, but still thin enough to flow through a straw. Some drinks may naturally be slightly thick (like some fruits nectars or milks). It is often used if you have swallowing problems with thin liquids.

What are level 1 foods?

• Pureed Breads (also called “pre-gelled” breads)
• Smooth puddings, custards, yogurts, and pureed desserts.
• Pureed fruits and well-mashed bananas.
• Pureed meats.
• Souffles.
• Well-moistened mashed potatoes.
• Pureed soups.
• Pureed vegetables without lumps, chunks or seeds.

Level 2

Mildly Thick Drinks may be used if thin drinks (water, milk and others) and Level 1 Slightly Thick liquids flow too quickly for you to swallow them safely. Some milk shakes and thick shakes may be this thickness level already, but other drinks may need thickener added to reach the correct thickness level. A level 2 diet is the intermediate level. People on this diet should eat moist and soft-textured foods that are easy to chew. They can also eat pureed, pudding-like foods. They should avoid foods with coarse textures.

What are level 2 foods?

• Grains: Soft breads, pancakes, sweet rolls, French toast, and Danish pastries
• Vegetables and Fruits: Well-cooked, boiled, baked, or mashed potatoes, well-cooked vegetables, and canned, drained, or cooked fruits without seeds or skins.
• Dairy Products: Pudding, custard, cottage cheese, ice cream, sherbet, frozen yogurt, and malts.
• Meat and other protein foods: Moistened ground or tender cooked meat, poultry, and fish with gravy or sauce.
• Fats and oils: Butter, margarines, gravy, cream sauces ,mayonnaise, salad dressing, cream cheese, and sour cream.

You can also try these tips for making foods easier to eat

Cook foods in liquid like broth, water , or juice until soft

Mix foods with butter, gravy, sauce, mayonnaise, or cheese to add moisture and calories

try ready-made foods like frozen dinners or canned foods.

Level 3

Liquidised foods may be used if you have trouble moving your tongue. The thicker consistency gives more time for the tongue to “hold and move” the liquidised food. It is easiest to eat liquidsed food with a spoon. A level 3 diet is the least limited. It is used as a transition to a normal diet. People on this diet can eat bite-sized pieces of moist foods with near-normal textures. They should avoid very hard, sticky, or crunchy foods, such as dried fruits or nuts.

What are level 3 food?

• Wheat biscuit cereal, such as Weetabix, well soaked with milk fully absorbed.
• Soft Fruits (banana, ripe peach, melon)
• Smooth yogurt drinks
• Smooth foods: Smooth porridge, wheat biscuit cereal soaked in milk, Smooth yogurt, fromage frais, and fruit puree.
• Fruits: Peeled and pureed fresh or tinned fruit, such as peaches and pears.
• Dairy: Cream and soft cheese, such as mascarpone, ricotta, and soft goats ‘cheese
• Protein: Ground beef, chicken, turkey, or pork cooked until tender, and baked or steamed fish such as salmon, tuna, tilapia, or cod.
• Sauces: Smooth syrup style sauces such as chocolate or fruit flavor.

Foods at IDDSI level 3 are liquidized and have a smooth texture with no lumps or bits. They can’t be piped, layered, or molded on a plate, and they can only be eaten with a spoon.

Level 4

Extremely thick- level 4 is like the thickness of a pudding or mousse. It is cohesive, has no lumps and holds it’s shape on a spoon. It cannot be consumed from a cup or sucked through a straw as it does not flow easily. It is best to use a spoon to take this fluid. It is pureed foods and extremely thick drinks. Pureed foods don’t require chewing, so you should find them easier to swallow.

What are level 4 food?

• Eggs: Pureed scrambled or poached eggs, or egg salad.
• Meat and Fish: Pureed cooked meat, fish, or poultry, such as casseroles or meat salad. you can use broth or gravy to pure meat.
• Dairy: Smooth yogurt, kefir, cottage cheese, or pureed macaroni and cheese. You can use milk or cream to puree macaroni and cheese.
• Fruits: Pureed fruits, applesauce, or smooth canned pie filling. You can use juice to puree fruit.
• Cereals: Cooked cereals like oatmeal, cream, cream of rice, or wheat.
• Desserts: Milkshakes, pudding, custard, creme brulee, mousse, or frozen yogurt.
• Sauces and condiments: Smooth sweet and savory condiments and sauces.

You can also try these tips for preparing IDDSI level 4 pureed foods: To increase calories, you can try milk or milkshake made with enriched milk and ice cream. To avoid constipation, you can try including more pureed fruits and vegetables in your diet. To soften bread, you can finely chop it and add equal amounts pf water and butter. To thicken drinks, you can follow your speech and language therapist’s advice.

Level 5

Minced and Moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food, but are not able to chew it down into little pieces that are safe to swallow. Foods with skins, husks or outer shells, such as peas, corn, shredded wheat, soya beans, grapes, sweetcorn, chicken skin, fish skin or sausage skin. Finely mash, mince or chop meat, fish, fruit and vegetables to a 4mm lump size and serve in a thick, smooth, non-pouring gravy or sauce.

What are level 5 food?

• Soft, mashed, tinned or fresh fruit (drain away any juice that has separated)
• Stewed fruit with thick custard or cream
• Milk pudding, such as rice pudding, semolina. sago, tapioca
• Egg custard
• Creme caramel
• Smooth, thick yogurt or fromage frais
• Mousse, angel delight, instant whip or blancmange
• Meat and Fish: Finely minced or chopped meat or fish in a thick, smooth sauce or gravy
• Fruit and Vegetables: Finely mashed or chopped fruit and vegetables with excess fluids drained
• Cereal: Thickened cereal with small soft lumps and excess fluids drained
• Bread: Pre-gelled “Soaked” plain bread without seeds or grains
• Dairy: Full-fat milk, cheese, yogurt fromage frais, or dairy alternatives
• Dessert: Thick, smooth yogurt or stewed apple in thick custard.

Other examples include: Small pieces of soft tofu, mashed scrambled eggs, very soft cheese with small lumps, such as cottage cheese and finely grated cheese, Instant pudding, mousse, rice pudding, canned creamed rice, soup with small soft lumps, salsa, sauces and dips with small soft lumps.

Level 6

This diet consists of foods that are nearly regular texture expect for foods that are hard, tough, chewy, sticky, crunchy, or fibrous or stringy. Food may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft and Bite Sized Diet. You may have been recommended a soft and bite sized diet if you are having trouble chewing or swallowing on the advice of your Speech Pathologist. This food texture includes foods that are soft, tender and moist throughout but with no separate thin liquid.

What are level 6 food?

• Meat: Chopped, well-cooked, lean and tender meat, such as chicken, turkey, roast beef, pork, or lamb. You can also serve minced meat in thick gravy.
• Fish: Steamed, poached, or baked fish, such as cod or haddock, served in sauce.
• Vegetables: Steamed or boiled vegetables that are 1.5cmx1.5cm in size. Avoid stir-fried vegetables
• Fruit: Bite-sized pieces of mashed fruit, without stringy parts or excess juice
• Grains: Soft pasta and noodles, porridge, wheat biscuits soaked in milk, or rice bubbles softened with fluid. Rice should be well cooked with plenty of thick sauce, such as rice pudding or risotto.
• Soups and Casseroles: Thick creamy soups, fish pie, or tender meat casseroles with plenty of thick sauce or gravy.

You can also consider serving soaked breads as alternative to sandwiches, To make soaked bread, finely chop bread and add equal amounts of water and butter to create a softened texture. Famous examples like, porridge, wheat biscuits soaked in milk or rice bubbles softened with fluid, soft pasta and noodles, rice quinoa or couscous with a thick, smooth, non-pouring sauce to moisten it and hold it together, rice porridge or congee.

Level 7

REGULAR, It is a diet which; normal everyday foods of various textures that are developmentally and age. Any method may be used to eat the foods. May be hard and crunchy or naturally soft. Sample size not restricted. Includes hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly bits. Meat cooked until tender. Fish cooked until soft enough to break apart easily with the side of a fork or spoon. Fruit soft enough to break apart into smaller pieces with the side of a fork or spoon, such as ripe banana. Regular easy to chew food may be used if you have strong enough chewing ability to break down soft/tender foods into pieces without help, you have no increased risk of choking and do not have swallowing problems.

What are level 7 foods?

Vegetables and fruits skin/husks e.g. peas, grapes, oranges, baked beans, black-eye beans, tomatoes, sweetcorn etc. Mixed consistency foods a mixed consistency is when there is food with a separate runny liquid. Things which include A balanced regular diet.