Dysphagia Diet Levels

What are the dysphagia diet levels? And more importantly, is there a PDF for quick reference?

In this post, you’ll find descriptions of the diet levels with example foods and drinks—and yes, a free downloadable cheat sheet!

For more dysphagia patient handouts and treatment guides, check out the bestselling Dysphagia Pack!

More Dysphagia Articles

• Swallowing Exercises and Strategies
• Oral Mechanism Examination
• How To Treat Dysphagia

About Dysphagia Diet Levels

The following diet levels, descriptions, and examples are from the International Dysphagia Diet Standardisation Initiative (IDDSI) framework.

The IDDSI has been adopted worldwide, including official support by the American Speech-Language-Hearing Association since 2013.

These dysphagia diet levels categorize food textures and drink thickness into eight levels.

To determine where any particular food or drink fits, use the tests for each level.

Keep scrolling for more details. Or, download your free cheat sheet and move on!

Free! Dysphagia Diet Levels PDF

0 – Thin Liquids

Description/Characteristics

• Flows like water
• Fast flow
• Can drink through any type of teat/nipple, cup, or straw as appropriate for age and skills

Examples

Most liquids, including water, coffee, and milk.

1 – Slightly Thick

Description/Characteristics

• Thicker than water
• Requires a little more effort to drink than thin liquids
• Flows through a straw, syringe, teat/nipple
• Similar to the thickness of most commercially available ‘Anti-regurgitation’ (AR) infant formulas

2 – Mildly Thick

Description/Characteristics

• Flows off a spoon
• Sippable, pours quickly from a spoon, but slower than thin drinks
• Mild effort is required to drink this thickness through standard bore straw (standard bore straw = 0.209 inch or 5.3 mm diameter)

3 – Moderately Thick

Description/Characteristics:

• Can be drunk from a cup
• Moderate effort is required to suck through a standard bore or wide bore straw (wide bore straw = 0.275 inch or 6.9 mm)
• Cannot be piped, layered, or molded on a plate because it will not retain its shape
• Cannot be eaten with a fork because it drips slowly in dollops through the prongs
• Can be eaten with a spoon
• No oral processing or chewing is required. Can be swallowed directly
• Smooth texture with no ‘bits’ (lumps, fibers, bits of shell or skin, husk, particles of gristle or bone)

Examples

Some sauces, gravies, and syrups.

4 – Extremely Thick (Pureed)

Description/Characteristics

• Usually eaten with a spoon (a fork is possible)
• Cannot be drunk from a cup because it does not flow easily
• Cannot be sucked through a straw
• Does not require chewing
• Can be piped, layered or molded because it retains its shape, but should not require chewing if presented in this form
• Shows some very slow movement under gravity but cannot be poured
• Falls off spoon in a single spoonful when tilted and continues to hold shape on a plate
• No lumps
• Not sticky
• Liquid must not separate from solid

Examples

Pureed meat, thick cereal.

5 – Minced & Moist

Description/Characteristics

• Can be eaten with a fork or spoon
• Could be eaten with chopsticks in some cases, if the individual has very good hand control
• Can be scooped and shaped (e.g. into a ball shape) on a plate
• Soft and moist with no separate thin liquid
• Small lumps visible within the food
  • Adult, equal to or less than 4mm width and no longer than 15mm in length
• Lumps are easy to squash with tongue

Examples

• Meat
  • Finely minced or chopped (for adults, equal to or less than 4mm width and no more than 15mm in length)
  • Serve in mildly, moderately, or extremely thick, smooth, sauce or gravy, draining excess
  • If texture cannot be finely minced it should be pureed
• Fish
  • Finely mashed in mildly, moderately, or extremely thick smooth, sauce or gravy, draining excess (for adults equal to or less than 4mm width and no more than 15mm in length)
• Fruit
  • Serve finely minced or chopped or mashed
  • Drain excess juice
  • If needed, serve in mildly, moderately, or extremely thick smooth sauce or gravy AND drain excess liquid.
  • No thin liquid should separate from food
  • For adults, equal to or less than 4mm width and no more than 15mm in length
• Vegetables
  • Serve finely minced or chopped or mashed
  • Drain any liquid
  • If needed, serve in mildly, moderately, or extremely thick smooth sauce or gravy AND drain excess liquid. No thin liquid should separate from food.
  • For adults, equal to or less than 4mm width and no more than 15mm in length
• Cereal
  • Thick and smooth with small soft lumps
  • Texture fully softened
  • Any milk/fluid must not separate away from cereal. Drain any excess fluid before serving.
  • For adults, equal to or less than 4mm width and no more than 15mm in length.
• Bread
  • No regular, dry bread, sandwiches, or toast of any kind
  • Pre-gelled ‘soaked’ breads that are very moist and gelled through the entire thickness
• Rice, couscous, quinoa (and similar food textures)
  • Not sticky or glutinous
  • Should not be particulate or separate into individual grains when cooked and served
  • Serve with smooth mildly, moderately, or extremely thick sauce AND Sauce must not separate away from rice, couscous, quinoa (and similar food textures). Drain excess fluid before serving.

6 – Soft & Bite-Sized

Description/Characteristics

• Can be eaten with a fork, spoon, or chopsticks
• Can be mashed/broken down with pressure from fork, spoon, or chopsticks
• A knife is not required to cut this food, but may be used to help load a fork or spoon
• Soft, tender, and moist throughout but with no separate thin liquid
• Chewing is required before swallowing
• ‘Bite-sized’ pieces as appropriate for size and oral processing skills
  • Adults, 15 mm = 1.5 cm pieces (no larger than)

Examples

• Meat
  • Cooked, tender meat no bigger than (for adults, 15 mm = 1.5 x 1.5 cm pieces)
  • If texture cannot be served soft and tender at 1.5 cm x 1.5 cm (as confirmed with fork/ spoon pressure test), serve minced and moist
• Fish
  • Soft enough cooked fish to break into small pieces with fork, spoon or chopsticks no larger than 15 mm = 1.5 x 1.5 cm pieces (for adults)
  • No bones or tough skins
• Casserole/Stew/Curry
  • Liquid portion (e.g. sauce) must be thick (as per clinician recommendations)
  • Can contain meat, fish, or vegetables if final cooked pieces are soft and tender and no larger than 15 mm = 1.5 x 1.5 cm pieces for adults
  • No hard lumps
• Fruit
  • Serve minced or mashed if cannot be cut to soft & bite-sized pieces. 15 mm = 1.5 x 1.5 cm pieces (for adults)
  • Fibrous parts of fruit are not suitable
  • Drain excess juice
  • Assess individual ability to manage fruit with high water content (e.g. watermelon) where juice separates from solid in the mouth during chewing
• Vegetables
  • Steamed or boiled vegetables with final cooked size of 15 mm = 1.5 x 1.5 cm pieces (for adults)
  • Stir-fried vegetables may be too firm and are not soft or tender. Check softness with fork/spoon pressure test
• Cereal
  • Smooth with soft tender lumps no bigger than 15 mm = 1.5 x 1.5 cm pieces (for adults)
  • Texture fully softened
  • Any excess milk or liquid must be drained and/or thickened to thickness level recommended by clinician
• Bread
  • No regular dry bread, sandwiches, or toast of any kind
  • Pre-gelled ‘soaked’ breads that are very moist and gelled through the entire thickness
• Rice, couscous, quinoa (and similar food textures)
  • Not particulate/grainy, sticky or glutinous

7 – Easy to Chew

Description/Characteristics

• Normal, everyday foods of soft/tender textures that are developmentally and age-appropriate
• Any method may be used to eat these foods
• Sample size is not restricted at Level 7, therefore, foods may be of a range of sizes
  • Smaller or greater than 15 mm = 1.5 cm pieces (Adults)
• Does not include: hard, tough, chewy, fibrous, stringy, crunchy, or crumbly bits, pips, seeds, fibrous parts of fruit, husks or bones.
• May include ‘dual consistency’ or ‘mixed consistency’ foods and liquids if also safe for Level 0, and at clinician discretion. If unsafe for Level 0 Thin, liquid portion can be thickened to clinician’s recommended thickness level.

Examples:

• Meat
  • Cooked until tender.
  • If texture cannot be served soft and tender, serve minced and moist
• Fish
  • Soft enough cooked fish to break into small pieces with the side fork, spoon or chopsticks
• Casserole/Stew/Curry
  • Can contain meat, fish, vegetables, or combinations of these if the final cooked pieces are soft and tender
  • Serve in mildly, moderately, or extremely thick sauce AND drain excess liquid
  • No hard lumps
• Fruit
  • Soft enough to be cut and broken apart into smaller pieces with the side of a fork or spoon. Do not use the fibrous parts of fruit (e.g. the white part of an orange).
• Vegetables
  • Steam or boil vegetables until tender. Stir-fried vegetables may be too firm for this level. Check softness with fork/spoon pressure test
• Cereal
  • Served with texture softened
  • Drain excess milk or liquid and/or thicken to thickness level recommended by clinician
• Bread
  • Bread, sandwiches, and toast that can be cut or broken apart into smaller pieces with the side of a fork or spoon can be provided at clinician discretion
• Rice, couscous, quinoa (and similar food textures)
  • No special instructions

7 – Regular

Description/Characteristics

• Normal, everyday foods of various textures that are developmentally and age-appropriate
• Any method may be used to eat these foods
• Foods may be hard and crunchy or naturally soft
• Sample size is not restricted at Level 7, therefore, foods may be of a range of sizes
  • Smaller or greater than 15 mm = 1.5 cm pieces (Adults)
• Includes hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy, or crumbly bits
• Includes food that contains pips, seeds, pith inside skin, husks or bones
• Includes ‘dual consistency’ or ‘mixed consistency’ foods and liquids

Examples

All foods!

Transitional Foods

Description/Characteristics:

Food that starts as one texture (e.g. firm solid) and changes into another texture specifically when moisture (e.g. water or saliva) is applied, or when a change in temperature occurs (e.g. heating).

IDDSI Transitional Foods may include and are not limited to

• Ice chips
• Ice cream/Sherbet if assessed as suitable by a Dysphagia specialist
• Japanese Dysphagia Training Jelly sliced 1 mm x 15 mm
• Wafers (also includes Religious Communion wafer)
• Waffle cones used to hold ice cream
• Some biscuits/ cookies/ crackers
• Some potato crisps – only ones made or formed from mashed potato (e.g. Pringles)
• Shortbread
• Prawn crisps

More Dysphagia Resources