What is the IDDSI Framework in Health and Social Care?

The IDDSI Framework is an international standard that describes textures of food and drink for people who have swallowing difficulties, a condition called dysphagia. Dysphagia can occur in a wide range of situations, such as after a stroke, with certain neurological conditions, or in people with frailty. Swallowing difficulties can put individuals at risk of choking or aspiration (food or drink entering the airway), which can lead to infections like pneumonia. The IDDSI Framework sets out clear levels of texture modification for both solids and liquids so that they can be prepared safely for people at risk.

The framework was developed by the International Dysphagia Diet Standardisation Initiative. It was introduced to address variations in terminology and testing methods between countries and organisations. Before its introduction, different places used different names for similar textures, which could cause confusion between care teams, hospitals, and catering services. By using the IDDSI levels, everyone can follow the same criteria, improving safety and consistency.

Purpose of the IDDSI Framework

The main purpose is to make sure food and drink textures are assessed and described in the same way everywhere. This means when a doctor, speech and language therapist, dietitian, or care worker says a person needs “IDDSI Level 4” food, everyone knows exactly what that means in terms of texture, preparation, and testing.

Dysphagia management depends heavily on correct texture modification. If a person who needs soft food is given something too hard or too sticky, they might not be able to chew or swallow it safely. Similarly, if a drink is too thin for someone who needs a thickened fluid, it can flow too quickly and enter the airway. The framework helps avoid these risks.

The Levels in the IDDSI Framework

The IDDSI Framework consists of eight numbered levels, from 0 to 7. Each level has a clear description and testing method so that staff preparing food or drinks can check if they meet the correct standard. Levels 0 to 4 cover drinks and pureed foods. Levels 5 to 7 cover solid food textures.

The levels are:

• Level 0: Thin – Regular fluids such as water, tea, coffee, juice. No thickening. Suitable for those who have no swallowing difficulty with liquids.
• Level 1: Slightly Thick – Thicker than water but still able to flow through a straw easily. May help control the flow of liquid in people with mild swallowing difficulty.
• Level 2: Mildly Thick – Requires slightly more effort to drink than Level 1. Often used with thickening agents for people needing more control of liquids.
• Level 3: Moderately Thick – Liquids that require sipping from a cup, spoon, or straw but move much more slowly than thinner fluids. Sometimes called ‘thick liquids’ or ‘semi-liquid’.
• Level 4: Puréed – Foods with a completely smooth texture, no lumps, and moist enough to hold together. Cannot be drunk through a straw but can be eaten with a spoon.
• Level 5: Minced & Moist – Small, soft, moist lumps no larger than 4mm across for adults. Food that can be mashed with a fork and easily chewed.
• Level 6: Soft & Bite-Sized – Small pieces no larger than 1.5cm across for adults. Food should be tender enough to chew easily and break apart under gentle pressure.
• Level 7: Regular – No texture modification needed. All foods are safe for those without swallowing difficulties.

Each level is colour-coded and sometimes shown as a diagram to help staff identify them quickly.

Testing Methods

The IDDSI Framework includes practical tests. These are simple checks that help confirm if a food or drink meets its defined level. This is important because preparation can vary depending on ingredients, cooking method, and thickening agents used.

For drinks, a syringe test is often used. This involves drawing liquid into a 10ml syringe and measuring how much remains after 10 seconds when the plunger is released. This test helps classify the fluid into Levels 0–3.

For foods, fork and spoon tests help determine how soft or moist a food is. A fork pressure test checks how food breaks apart when pressed, giving information about its texture and ease of chewing. For puréed foods, spoon tilt or drip tests check if the texture stays together and slides off the spoon smoothly without separating into liquid and solids.

Importance in Care Settings

In care homes, hospitals, and home care, meals are part of health management. For people with dysphagia, the wrong texture can be dangerous. Following the IDDSI guidelines helps carers, nurses, catering staff, and speech and language therapists work as a team to prevent risks.

The framework also helps training. Staff can be shown exactly what each level looks like, feels like, and tests like, making it easier to prepare safe meals and drinks without confusion. It improves communication between health professionals and food service teams in any care environment.

Benefits for People with Dysphagia

The IDDSI Framework offers several benefits:

• Clear texture definitions reduce risk of choking and aspiration.
• Consistent terminology avoids misunderstandings between care professionals.
• Simple testing methods allow safety checks in any kitchen.
• Colour and number coding helps quick identification of correct food or drink.
• Allows meals to be adapted while still being enjoyable and appetising to the person.

By using the framework, meals can be prepared in ways that keep a person safe while still meeting their nutritional and emotional needs. Taste and presentation remain important, even with texture modifications.

Roles of Different Professionals

Speech and language therapists often carry out swallowing assessments and recommend the correct IDDSI level for a person. Dietitians may make sure the modified diet still meets nutritional needs. Catering teams prepare meals according to guidance, and care staff serve the food and supervise eating. Everyone along this chain uses the same IDDSI levels to keep communication clear.

Families can be involved too. If a person is living at home, relatives might be shown how to prepare meals to the right texture. Using IDDSI guidance they can test their cooking to check it meets the recommended level.

Training and Competency

Proper introduction of the framework depends on training. Staff need to learn:

• What each IDDSI level means.
• How to test food and drink textures.
• How to follow recipes to achieve the right texture.
• How to balance safety with appealing meal presentation.

Competency is often tested by asking staff to prepare and test examples, then compare results with guidance. This helps make sure the use of levels stays consistent.

Global Standardisation

Since the framework was adopted internationally, language differences no longer cause serious mistakes. For instance, terms like “thickened fluid”, “soft diet”, or “puréed” mean different things in different places. IDDSI replaces them with numbered levels and precise tests. This way patients moving between hospitals or care providers continue to receive the right food and drink textures without needing lengthy re-assessments.

Adapting Menus

Chefs and kitchen staff in health care kitchens often adapt menus using IDDSI guidance. Meals may need to be altered by blending, mashing, chopping, or thickening, but still aim to keep flavours intact. Where possible, presentation is adjusted so the meal still looks appealing. Puréed meals can be moulded into shapes resembling the original food to help improve mealtime enjoyment.

Menus often have versions for each level. For example, a stew can be served as Level 6 soft bite-sized pieces, Level 5 minced and moist, or Level 4 puréed. Drinks can be served in different thicknesses depending on a person’s needs.

Monitoring Swallowing Safety

Care staff observe how a person eats and drinks to see if changes are needed. Coughing during meals or signs of food remaining in the mouth can mean a texture change is required. These observations go back to the speech and language therapist, who may reassess and adjust the IDDSI level.

Following IDDSI means changes can be made quickly and clearly. If a person moves from soft bite-sized to minced and moist food, staff know exactly how to prepare it without guessing.

Encouraging Independence

Some people with dysphagia can eat independently when food textures match their needs. For example, soft bite-sized meals allow chewing without strain, while thickened liquids may help control swallowing speed. Independence at mealtimes can improve quality of life and self-confidence.

The IDDSI Framework plays an important role here, supporting people to eat without constant assistance when it is safe to do so.

Final Thoughts

The IDDSI Framework brings clarity and safety to the preparation of food and drink for people with swallowing difficulties. By setting numbered levels for textures and providing simple, practical testing methods, it makes sure everyone involved in meal preparation and care can follow the same rules. This means less chance of mistakes, better communication between professionals, and safer mealtimes for those at risk. Above all, it supports dignity and enjoyment at mealtimes by allowing food and drink to be adapted without removing the pleasure of eating.