Using Exchange Lists

Exchange lists were developed in the 1950s to standardize meals for people with diabetes. In the original exchange-list system, the diet is divided into six major categories. Foods with similar energy and macronutrient content per single serving were grouped. Each food serving was known as an exchange.⁽¹⁾ Carbohydrate was given priority. Over time, the exchange lists have been developed to suit other medical conditions including chronic kidney disease, overweight/obesity and hypertension. For renal disease, the food groups are similar but the focus is on the nutrients of concern, which is protein, sodium, potassium and phosphorus. In recent years, dietitians have been using the exchange-list system in meal planning for diabetes. The exchange lists have been improved for consistency; now each carbohydrate-containing exchange provides 15 grams of carbohydrate. Exchange groups generally have varying protein and fat profiles. For ease of calculation, "standard" energy and protein values are assigned to each exchange category. Carbohydrate counting is also used for meal planning in diabetes.

Exchange lists provide an efficient means of diet analysis. By mentally converting foods into exchange-list groups, experienced dietitians are able to estimate the energy content of a day's intake in less than three minutes. During a consultation, the dietitian uses exchange lists to plan Nutrition Interventions and patient follow-ups. The practitioner can undertake a more careful analysis at a later stage: for example, for a progress-note entry. 

The major lists are Starch (sometimes called Bread/Cereals), Fruit, Non-Starchy Vegetables, Milk, Meat and Meat Substitutes (sometimes called Protein), Fat (sometimes called Fats/Oil) and Free Foods.  In recent versions, another category called Desserts (sometimes called Alternate Carbohydrates or Sweets) has been added. In addition, in the late 1970's when there was interest in more clearly describing the saturated fat content of the diet the Milk and Meat exchange lists were further subdivided into three levels of fat intake.   Foods in the Free category in the portion sizes described are generally omitted from calculations since they don't include significant amounts of macronutrients and usually have less than 15-20 kcal per serving.  However, clients are cautioned to limit intake to no more than 3 servings spread throughout the day.  They are instructed to be cautious because if they consume more than 3 servings together during a meal or snack it may raise blood sugar.  The Free group includes many fresh, canned or frozen vegetables that are prepared without additional sauces or fat as well as many condiments (e.g. prepared mustard, low calorie salad dressings).  They are not "counted". However, the quantity that is being consumed must be evaluated to determine whether they are consuming sufficient quantity that it should be "counted".

We have created spreadsheets to reduce the time required to undertake dietary analysis using the exchange lists. Note we have selected a standard fat and protein value for each exchange list.    

References:
1. Raymond JL and Morrow, K Krause and Mahan’s Food and the Nutrition Care Process 16th ed St Louis, MO; Elsevier Saunders: 2021.
2. Academy of Nutrition and Dietetics, American Diabetes Association. Choose Your Foods Food Lists for Diabetes. USA: 2014.