IDDSI Texture Levels and Hong Kong Care Food: 8 Levels, Colours and Home Tests

When a family member has difficulty swallowing, how thick should drinks be, and how soft should food be? People describe this in different ways, such as "cook it a bit softer", "thicken it a little" or "chop it up more". These words are vague and easy to misunderstand. For this reason an international standard was created: IDDSI (the International Dysphagia Diet Standardisation Initiative). It uses fixed levels, numbers and colours, so that families, care homes and therapists can describe texture in the same way. This page turns IDDSI into a practical home guide. It explains each level, matches the levels to the Hong Kong Council of Social Service (HKCSS) care food guidelines, and shows how to check the thickness of food and drinks at home with a fork, a spoon and a syringe.

The 8 IDDSI levels, their colours and numbers

IDDSI uses one continuous scale. It describes texture from the thinnest drink, water, to food in its normal form, so that different professionals and care organisations can communicate accurately.

0–7

IDDSI has 8 texture levels

The international standard for dysphagia diets (iddsi.org)

0–4

Drink thickness levels

From thin (0) to extremely thick (4)

3–7

Food texture levels

Levels 3 and 4 overlap with drinks. They are transition textures that can be drunk from a cup or eaten with a spoon

Texture, colour and name of each of the 8 levels

Each level has its own name, number and official colour. The list below describes each level so that carers can check the labels on ready-made care food. The level that suits the patient must be set by a speech therapist after an assessment.

Level 0 \| Thin (white)	Everyday drinks such as water, tea and coffee. No thickener is added, and the drink flows freely.
Level 1 \| Slightly Thick (grey)	A little thicker than water, for example some infant formulas or lightly thickened drinks.
Level 2 \| Mildly Thick (pink)	Can be sipped through a straw, with a little effort. It drips slowly from a spoon and has a thickness similar to nectar.
Level 3 \| Moderately Thick / Liquidised (yellow)	Can be drunk from a cup or eaten with a spoon, but cannot be picked up with a fork. It is smooth with no lumps. This is the level where drinks and foods overlap.
Level 4 \| Extremely Thick / Pureed (green)	Smooth with no lumps and needs no chewing. When scooped with a spoon and tilted, it does not slide off easily. This is the usual pureed diet.
Level 5 \| Minced & Moist (orange)	Food in small, moist, soft pieces that can be mashed with the tongue and gums. It suits people with only mild chewing ability.
Level 6 \| Soft & Bite-Sized (blue)	Food cooked until soft and cut into bite-sized pieces, which can be pressed apart with the side of a fork. The person needs a reasonable level of chewing and tongue control.
Level 7 \| Regular / Easy to Chew (black)	Normal everyday food. Level 7EC (Easy to Chew) means food that keeps its original shape but is cooked until it is soft and easy to chew.

The Hong Kong Council of Social Service care food guidelines

Hong Kong also has a local set of guidelines that fits with IDDSI. It helps carers choose and prepare meals that suit local eating habits.

On 11 May 2023 the Hong Kong Council of Social Service (HKCSS), together with the food research centre of The Chinese University of Hong Kong and the swallowing research institute of The University of Hong Kong, published the care food guidelines (《照護食標準指引》). The guidelines are based on IDDSI and cover Levels 0–7 (including 7EC). They list more than 40 common Hong Kong food examples and a number of recipes. They also show how to do simple tests at home with a fork, a spoon and a syringe, so that care food in Hong Kong follows one standard.

Four tests to check food texture at home

IDDSI has simple tests that need no special equipment and can be done at home. They help carers check that food and drinks match the level set by the therapist.

1
Flow test (10 ml syringe)
Fill a 10 ml syringe with the drink, release the nozzle and let the liquid flow for 10 seconds, then see how much is left in the syringe. This test separates drinks at Levels 0 to 3.
2
Fork drip test
Place the food on a fork and watch how it drips through the prongs. This test separates food textures at Levels 3 to 5.
3
Spoon tilt test
Scoop the food with a spoon and tilt it. The food should slide off in one piece without sticking to the spoon. This test is used to check Level 4 food.
4
Fork pressure test
Press the back of the fork down on the food with the thumb and see how much the food changes shape or breaks apart. This test separates the softness of Levels 4 to 7.

Hong Kong food examples for each level (for reference only)

The examples below help explain the texture of each level. They are not a clinical prescription. The level that suits a family member must be set by a speech therapist after a swallowing assessment.

Drinks and liquids (Levels 0–4)

Level 0: water, clear tea
Level 2: milk or juice thickened with thickener to a nectar-like thickness
Level 3: smooth cream soup with no lumps, thick soup or thickened drinks
Level 4: congee or fruit blended to a smooth puree

Food (Levels 5–7)

Level 5: minced meat moistened with gravy, or soft-cooked fish that has been mashed
Level 6: steamed egg custard, soft tofu, melon cooked until very soft
Level 7 / 7EC: normal everyday meals, or dishes with the bones and sinew removed and cooked until soft and easy to chew
Foods to avoid: foods that mix hot and cold, or solid and liquid, such as clear soup with vegetable pieces or thin congee with rice grains

Common mistakes when preparing food at home

Even when the target level is clear, the following situations often come up in daily preparation, and the food ends up at a different level from the one the therapist set.

Points to watch when preparing food

The thickener has not dissolved completely, or has not been mixed well before feeding starts
Not waiting long enough after adding thickener, so the drink is still thickening when the patient drinks it
Believing that thicker is always safer and making the drink or food thicker than the level the therapist set
Not handling solids and liquids separately, for example feeding clear soup with vegetable pieces or thin congee with rice grains
Forgetting that the thickness of food and drinks changes when they are left standing or cool down, and not checking again before feeding
Prepare food at the level the therapist set, and test it with a fork, a spoon or a syringe to make sure the texture is right

Other measures besides changing food texture

Getting the food texture right is only one part of eating safely.

There is currently no convincing medical evidence that thickened drinks and pureed meals alone prevent pneumonia. They are instead linked with dehydration, malnutrition and a lower quality of life (O'Keeffe, 2018). A large randomised controlled trial also found no clear difference in the rate of pneumonia between three groups of patients who used two different drink thicknesses or a chin-down swallowing posture (Robbins et al., 2008). Besides adjusting food texture, swallowing exercises, mouth care and correct feeding methods are also needed. For more on swallowing difficulty and speech therapy, see speech therapy at home.

Key points

IDDSI uses 8 levels (0–7), with matching numbers and colours, to describe drinks (0–4) and food (3–7) clearly, so that healthcare staff and carers can communicate.
The Hong Kong Council of Social Service care food guidelines are based on IDDSI and add dishes and examples common in Hong Kong, so carers can buy and prepare care food that suits local tastes.
At home, carers can check food texture with four simple tests: the syringe flow test, the fork drip test, the spoon tilt test and the fork pressure test. The level that suits the patient must still be set by a speech therapist after an assessment.
Common mistakes when preparing food at home include thickener that has not fully dissolved, not waiting long enough for it to set, making food too thick, feeding foods that mix solids and liquids, and forgetting that thickness changes when food is left standing.
Changing food texture is only part of eating safely. There is no evidence that thickening alone prevents pneumonia, so swallowing exercises, mouth care and correct feeding techniques are needed as well (O'Keeffe, 2018).

Frequently asked questions

Are IDDSI and the Hong Kong Council of Social Service care food guidelines the same standard?

The two fit together. IDDSI is the international standard for diets for people with swallowing difficulty. The Hong Kong Council of Social Service (HKCSS) guidelines on care food (照護食標準指引) are based on it and add food descriptions and examples that suit local eating habits. The levels match one for one, so Hong Kong carers can buy ready-made care food or prepare food at home using the same levels.

Why are food textures graded with colours and numbers?

The aim is to give families, care home staff and therapists the same language for texture. With one set of numbers (0–7) and colours, a hospital discharge or a change of carer does not depend on vague words such as "a bit smoother" or "a bit thicker". This lowers the risk of food or drink going down the wrong way (aspiration).

Can I test at home whether a drink is thick enough?

Yes, as a first check. For drinks, a 10 ml syringe flow test over 10 seconds gives a first idea of which level of thickness the drink is. For food, the fork drip test and the fork pressure test can be used. The level that suits the patient must still be decided by a speech therapist after a swallowing assessment. Home tests are only for day-to-day checking and monitoring.

Is it safer to add more thickener?

No. A drink or food that is too thick can stay behind in the mouth and throat. It can also make the patient drink less, which raises the risk of dehydration and malnutrition. There is also no evidence that thicker textures are better at preventing pneumonia (O'Keeffe, 2018). Carers should prepare food and drinks at the level the therapist has set. The thickener must dissolve completely, and the thickness of a drink can still change after it has been left to stand.

Which IDDSI level matches "soft diet" and "pureed diet"?

In everyday use, a "pureed diet" (糊餐) is close to Level 4 (Extremely Thick / Pureed). "Minced and moist" matches Level 5, and "soft and bite-sized" is Level 6. Names differ from place to place, so the actual level should be based on test results and the therapist's advice, not on the name alone.