When a person with dysphagia travels internationally, moves into a new care facility, or is transferred between hospitals, the stakes of miscommunication are high. A meal that is “safe” under one country’s labelling system may be dangerously different from a meal carrying the same label in another. This article maps the world’s major dysphagia diet classification systems side by side — explaining what each standard covers, why IDDSI was created to replace many of them, and what the differences mean in practice.
Before 2017, dysphagia diet terminology was a patchwork. Clinicians in the United States used the National Dysphagia Diet (NDD). Australian speech pathologists used their own texture descriptors. British dietitians used the British Dietetic Association / Royal College of Speech and Language Therapists descriptors. Japanese facilities used the Japan Society of Dysphagia Rehabilitation (JSDR) classification, alongside the consumer-facing Universal Design Food (UDF) labels. And within each country, individual hospitals often layered their own house systems on top.
The consequences were predictable. A patient transferred from a US hospital (on “NDD Level 2 — Mechanically Altered”) to a UK nursing home was met with blank stares: the UK had no equivalent label. Terms like “minced,” “pureed,” and “soft” meant subtly different textures to different teams. Studies showed that even within a single hospital, the same label was prepared differently by different kitchen staff.
In 2013, a group of international researchers and clinicians launched the International Dysphagia Diet Standardisation Initiative (IDDSI). After four years of development, testing, and consultation across 33 countries, the IDDSI Framework was published in 2017 and formally launched for global adoption in 2019.
Scope: Foods and drinks. Levels: 0–7 (8 levels total). Governance: IDDSI Foundation (not-for-profit; framework is freely available).
The IDDSI framework uses a single continuous scale — a bold design choice. Drinks occupy Levels 0–4; foods occupy Levels 3–7. Levels 3 and 4 overlap intentionally, representing the transition zone where thick drinks and soft foods converge.
| Level | Name | Key descriptor |
|---|---|---|
| 0 | Thin | Water; flows through a 10 mL syringe in ≤10 sec |
| 1 | Slightly Thick | Slower than water; still pours in a continuous stream |
| 2 | Mildly Thick | Pours in a ribbon; requires some effort to drink through a straw |
| 3 | Moderately Thick / Liquidised | Can be drunk from a cup; loses shape on a spoon |
| 4 | Extremely Thick / Pureed | Smooth, no lumps; holds shape briefly on a spoon; cannot be drunk |
| 5 | Minced & Moist | Soft moist lumps ≤4 mm; fork-pressable |
| 6 | Soft & Bite-Sized | Tender, moist pieces ≤15 mm; fork- or spoon-pressable |
| 7 | Regular / Easy to Chew | Normal everyday food; sub-level 7 “Easy to Chew” for those who need softer-than-normal regular food |
Testing methods are a core IDDSI contribution: the Fork Drip Test, Fork Pressure Test, Spoon Tilt Test, and Syringe Flow Test give any clinician or kitchen worker an objective, equipment-free way to verify a texture.
Current adoption: IDDSI is now mandatory or recommended in the United States (transitioned 2020), Canada, Australia/New Zealand (2017–2020 transition), United Kingdom (2019), Ireland, South Africa, and several European countries. Over 50 countries have formal IDDSI working groups.
Scope: Foods and drinks. Codes: 0j, 0t, 1j, 2-1, 2-2, 3, 4 (7 subcategories across 5 main tiers). Governance: Japan Society of Dysphagia Rehabilitation (JSDR).
Japan’s JSDR classification has been refined multiple times; the 2021 version is the current standard. It is codified using numeric-alphabetic codes rather than English descriptors, reflecting the linguistic and culinary context of Japanese care settings.
| Code | Name (Japanese / English equivalent) | Characteristics |
|---|---|---|
| 0j | 嚥下訓練食品 0j — Jelly type | Homogeneous jelly; for training swallows only; no nutritional meal |
| 0t | 嚥下訓練食品 0t — Thickened liquid | Thickened drink for swallowing training; mildly to moderately thick |
| 1j | 嚥下調整食 1j | Smooth pureed jelly; uniform texture; cohesive; melts in mouth |
| 2-1 | 嚥下調整食 2-1 | Puree/paste consistency; homogeneous; no lumps; requires no chewing |
| 2-2 | 嚥下調整食 2-2 | Soft moist mass; slight texture; easier to aggregate than 3 |
| 3 | 嚥下調整食 3 | Minced & moist equivalent; easily broken apart; soft pieces |
| 4 | 嚥下調整食 4 | Soft & bite-sized equivalent; fork-pressable; suitable for mild dysphagia |
JSDR 2021 explicitly cross-references IDDSI levels in its appendix, acknowledging that codes 0t, 2-1, 2-2, 3, and 4 roughly parallel IDDSI Levels 2, 4, 4–5, 5, and 6 respectively. However, the mapping is approximate: Japanese cuisine context (e.g., cohesive rice-based foods, tofu, fish paste) means that a JSDR 4 meal may have different shear properties than a Western IDDSI Level 6 meal even if both pass the fork-pressure test.
Key difference from IDDSI: JSDR retains jelly-training foods (0j) as a separate medical category — something IDDSI folds into its thin/mildly thick liquid range without a dedicated training-food tier. JSDR 2021 also distinguishes between 2-1 and 2-2 at the puree level, which IDDSI collapses into a single Level 4.
Scope: Commercially packaged foods. Categories: 1–4. Governance: Japan Care Food Conference (日本介護食品協議会).
UDF is not a clinical standard — it is a consumer-facing labelling scheme for supermarket and convenience store products marketed to elderly and dysphagic consumers. The four UDF categories are defined by simple physical tests (chewability and spoon-pressability) and are printed prominently on product packaging.
| UDF Category | Icon colour | Description | Target user |
|---|---|---|---|
| 1 — Easily Chewable | Yellow | Bite-through with gums; moderate chewing required | Mild chewing difficulty |
| 2 — Gum-Chewable | Orange | No teeth needed; gums alone sufficient | Cannot use back teeth |
| 3 — Tongue-Pressable | Red | Can be mashed between tongue and palate | Cannot use gums |
| 4 — No Chewing Required | Purple | Swallowed without any oral processing | Severe dysphagia |
UDF Category 4 approximately maps to JSDR 2-1/2-2 and IDDSI Level 4; UDF Category 1 roughly maps to IDDSI Level 6–7. UDF is primarily a purchasing and procurement tool rather than a clinical prescription tool. A dietitian in Japan will prescribe using JSDR codes; a carer shopping in a supermarket will look for UDF icons.
Scope: Foods and thin/thickened liquids. Levels: NDD 1–3 (foods) + Thin; NDD liquid levels: Thin, Nectar-Like, Honey-Like, Spoon-Thick. Governance: American Dietetic Association (now Academy of Nutrition and Dietetics). Status: REPLACED by IDDSI in most US facilities from 2020.
The NDD was the dominant US standard for 18 years. It divided foods into three main texture tiers and liquids into four viscosity tiers.
NDD Food Levels:
| NDD Level | Name | Description |
|---|---|---|
| NDD 1 | Dysphagia Pureed | Pudding-like; no lumps; cohesive; no chewing required |
| NDD 2 | Dysphagia Mechanically Altered | Moist, soft, semi-solid; some chewing required; excludes fibrous, crunchy, or sticky foods |
| NDD 3 | Dysphagia Advanced | Bite-sized, moist, soft foods; near-normal texture |
| Regular | Regular | No restrictions |
NDD Liquid Levels:
| Liquid Level | Approximate viscosity | Flow test |
|---|---|---|
| Thin | <50 cP | Free-flowing |
| Nectar-Like | 51–350 cP | Coats a spoon; streams in a thin thread |
| Honey-Like | 351–1,750 cP | Drips slowly; thick coating |
| Spoon-Thick | >1,750 cP | Spoon-able; does not pour |
Why NDD was replaced: The NDD had no standardised testing methods. “Mechanically Altered” was interpreted inconsistently. Liquid viscosity ranges were defined in centipoise (cP) — a laboratory measurement not feasible at the bedside. Multiple studies documented inter-facility variation. IDDSI addressed these gaps directly with objective bedside tests.
Governance (legacy): Speech Pathology Australia (SPA); Dietitians Association of Australia.
Before IDDSI, Australia used a five-tier food texture scale and a four-tier liquid scale under the Texture Modified Foods and Thickened Fluids Framework (2007):
Australian legacy food textures:
| Code | Name |
|---|---|
| A | Texture A — Soft |
| B | Texture B — Minced & Moist |
| C | Texture C — Smooth Pureed |
| D | Texture D — Liquidised |
Australian legacy fluid levels: Mildly Thick, Moderately Thick, Extremely Thick (plus Regular/Thin).
Australia and New Zealand transitioned to IDDSI during 2017–2020. Speech Pathology Australia published transition guides mapping old texture codes to IDDSI levels (e.g., Texture B → IDDSI Level 5; Texture C → IDDSI Level 4). This transition is now complete; new care plans should not reference the legacy A–D codes.
Governance (legacy): British Dietetic Association (BDA) / Royal College of Speech and Language Therapists (RCSLT) — the “BDA/RCSLT Texture Descriptors” (2011).
The UK used six food texture descriptors and three liquid descriptors:
UK legacy food textures:
| Code | Name |
|---|---|
| B | Thin Puree |
| C | Thick Puree |
| D | Pre-Mashed |
| E | Mashed |
| F | Fork Mashable / Soft Diet |
| Regular | Regular |
UK legacy thickened fluids: Stage 1 (Syrup), Stage 2 (Custard), Stage 3 (Pudding).
The UK formally adopted IDDSI in April 2019 (with a 12-month transition period). The RCSLT/BDA published crosswalk documents: e.g., UK Texture B → IDDSI 4 (Pureed); UK Texture E → IDDSI 5 (Minced & Moist); UK Stage 1 → IDDSI 2 (Mildly Thick).
Scope: Foods and thickened liquids. Status: New — published 2025. Governance: Shanghai Association for Standardization of Assistive Technology for the Aged (上海市老年辅助技术标准化协会); Greater Bay Area (GBA) scope.
China has historically lacked a unified national dysphagia diet standard. Hospital and care home practice varied widely, often borrowing from JSDR or informal translations of NDD. The T/SATA 084-2025 and T/SATA 085-2025 standards represent the first formally published GBA-level (Greater Bay Area) group standards addressing texture-modified foods for dysphagia.
Both standards explicitly reference IDDSI as the primary international basis. They are group/association standards (团体标准, T/ prefix), not mandatory national standards (GB), but are expected to be adopted across Guangdong, Hong Kong, and Macau care sectors as GBA integration progresses. Full national GB standard development is anticipated.
The table below provides approximate equivalences. No mapping is exact — local culinary context, test methods, and clinical intent differ. Use this table as a starting point for care team communication, not as a clinical prescription substitute.
| IDDSI Level | IDDSI Name | NDD (US, legacy) | UK legacy | Australia legacy | JSDR 2021 (Japan) | UDF (Japan) | GBA T/SATA 084/085 |
|---|---|---|---|---|---|---|---|
| 0 | Thin | Thin liquid | Regular fluid | Regular fluid | — | — | Grade 0 liquid |
| 1 | Slightly Thick | — | Stage 1 (partial) | Mildly Thick | — | — | Grade 1 liquid |
| 2 | Mildly Thick | Nectar-Like | Stage 1 | Mildly Thick | 0t (partial) | — | Grade 2 liquid |
| 3 | Moderately Thick / Liquidised | Honey-Like | Stage 2 | Moderately Thick | — | — | Grade 3 liquid |
| 4 | Extremely Thick / Pureed | Spoon-Thick / NDD 1 | Stage 3 / Texture B–C | Extremely Thick / Texture C–D | 2-1, 2-2 | UDF 4 | Grade 5 food |
| 5 | Minced & Moist | NDD 2 (partial) | Texture D–E | Texture B | 3 | UDF 3 (partial) | Grade 4 food |
| 6 | Soft & Bite-Sized | NDD 2–3 | Texture E–F | Texture A–B | 4 | UDF 2 | Grade 3 food |
| 7 | Regular / Easy to Chew | NDD 3 / Regular | Texture F / Regular | Texture A / Regular | 4 (upper) | UDF 1 | Grade 2–1 food |
| Country / Region | Current standard | Legacy standard | Transition status |
|---|---|---|---|
| United States | IDDSI (2019–2020) | NDD 2002 | Largely complete; some facilities lag |
| Canada | IDDSI | Provincial variations | Largely complete |
| United Kingdom | IDDSI (2019) | BDA/RCSLT Descriptors | Complete |
| Australia / NZ | IDDSI (2017–2020) | SPA Texture A–D | Complete |
| Ireland | IDDSI | Irish national descriptors | Complete |
| Japan | JSDR 2021 + UDF | JSDR 2013 | Ongoing; IDDSI not formally adopted |
| China (GBA) | T/SATA 084/085-2025 | Informal JSDR / NDD | Emerging; no national GB standard yet |
| China (national) | No unified standard | Varied hospital protocols | In development |
| South Africa | IDDSI | — | Largely complete |
| Germany / DACH | IDDSI (DGEM endorsed) | Varied | Transitioning |
| Scandinavia | IDDSI | National descriptors | Largely complete |
| Hong Kong | Transitioning to IDDSI / aware of T/SATA | UK / JSDR influence | In transition |
Patient transfers across borders are the highest-risk scenario. A Japanese resident admitted to a Hong Kong hospital on “JSDR 3” may receive a meal calibrated to IDDSI Level 5 — close, but differences in cohesiveness and lump size matter for patients with pharyngeal dysphagia. Communication between the sending and receiving speech-language pathology teams is essential; the crosswalk table above should be shared but never treated as a prescription-to-prescription translation.
Families purchasing commercial foods abroad face the UDF-vs-IDDSI gap. A product labelled UDF Category 3 (tongue-pressable) bought in Japan is not guaranteed to meet IDDSI Level 4 test criteria because UDF uses simplified consumer tests, not IDDSI’s validated methods. When in doubt, perform the IDDSI Fork Pressure Test or Spoon Tilt Test at home.
Care homes with mixed-nationality residents — increasingly common across the GBA (Hong Kong, Shenzhen, Macau), Singapore, and major cities globally — should standardise on IDDSI internally, then provide crosswalk reference cards for family members who may be more familiar with JSDR or UDF terminology.
Electronic health records (EHR) and diet ordering systems in transitional countries may still display legacy NDD or Australian A–D codes. Clinicians should verify that IT systems have been updated and that kitchen staff have been retrained. Ambiguity in the EHR has been identified as a root cause in multiple reported adverse events.
GBA-specific note: As Hong Kong, Macau, and Guangdong increasingly share care infrastructure under GBA integration, the emergence of T/SATA 084/085-2025 is a significant development. Facilities operating across the border will need staff familiar with both IDDSI (dominant in Hong Kong’s hospital sector) and the new GBA standards. A bilingual crosswalk (English IDDSI ↔ Chinese T/SATA) should be part of every cross-border care team’s orientation materials.
| Framework | Origin | Year | Levels | Primary users |
|---|---|---|---|---|
| IDDSI | International | 2017 | 8 (0–7) | Clinicians worldwide |
| JSDR 2021 | Japan | 2021 | 7 subcodes | Japanese clinicians, dietitians |
| UDF | Japan | 1994 (updated) | 4 | Consumers, carers, retail |
| NDD | USA | 2002 | 4+4 | Legacy; mostly replaced |
| BDA/RCSLT | UK | 2011 | 6+3 | Legacy; replaced 2019 |
| SPA Texture A–D | Australia/NZ | 2007 | 4+3 | Legacy; replaced 2017–2020 |
| T/SATA 084/085 | China (GBA) | 2025 | 5+4 | GBA care sector |
The global direction is clear: IDDSI is becoming the dominant international standard, with national systems either formally adopting it or explicitly cross-referencing it. Japan’s JSDR and China’s emerging GBA standards remain important regional frameworks, but are increasingly aligned with IDDSI methodology. Clinicians, dietitians, and care facilities working across borders should maintain fluency in at least IDDSI and the regional standard of their patient population — and should never assume a food descriptor translates safely without verification.
This article is published under CC BY 4.0. You may share and adapt it with attribution to Editorial Team editorial team / softmeal.org.
For clinical decisions, always consult a qualified speech-language pathologist or dietitian. Texture classifications are medical prescriptions and must not be changed without professional assessment.