Whatever happened to the diabetes exchange Lists?...

When I was working on my dietetics degree in the mid 90s, the Diabetes Exchange List was the recommended meal planning program for people with diabetes.  I remember sitting through a day long class on how to use and teach the Diabetes Exchange Lists for Meal Planning and thinking “no wonder diabetes nutrition is such a thorn in everyone’s side”.  
 
If you’re not familiar with it, the American Diabetes Association's Exchange Lists for Meal Planning groups together foods according to their common nutritional content based on calories, carbohydrate, protein, and fat (food groups).  Patients are given a certain number of exchanges from each of the groups for each meal or snack based on their needs.  Sounds good right?  In a perfect world yes.  But in a world of busy schedules, food preferences, food availability issues, and grocery budgets it is very difficult to implement.  I’ve come across a few people in my career who have used it well- but very few.  The “why” of the Exchange Lists is good- proper nutrition spread out throughout the day.  But the idea that you must include something from each food group in EVERY meal is unrealistic, and I think unnecessarily burdensome.  Who has time for that?
 
While I was still in school, I shadowed a hospital dietitian to get experience in the field.  One day there was a patient in the hospital with diabetes and the provider ordered education.  My mentoring dietitian handed me a copy of the Exchange Lists and sent me in to do the education.  I’m not sure how the patient felt about the experience, but it felt like a disaster to me. Number one- inpatient hospital settings are THE WORST place to do education.  Patients are sick- that’s why they’re there- not a good state to be in for learning.  I think in-depth education is best saved for the outpatient setting and education in the hospital should cover only the basics. The patient I attempted to educate that day was a middle-aged male with lots of health issues.  And using the Exchange Lists required brain power neither of us had at the time.  I’m pretty sure my visit was a waste of this man's time.  But it was very valuable to me!  I came away thinking “there has to be a better way- I will never educate that way again”.
 
I did find a better way and 25 years later my approach includes “proper nutrition spread out throughout the day”- the “why” of the Diabetes Exchange Lists- in a simplified “how”.  The people with diabetes I’ve worked with over the years have taught me the best eating plan is one that makes sense, includes foods they like, and is easy to implement. And the goal of a diabetes nutrition plan is threefold it (1) Contributes to good blood sugar control (2) Provides adequate nutrients for energy, disease prevention, and healing and (3) Is appropriate in quantity to maintain a healthy weight.  These are lofty goals! 
 
 
Carbohydrate foods have the biggest impact on blood sugars after meals.  That doesn’t mean carbohydrates are bad as some popular diets would have us believe.  Carbohydrates are our bodies’ most efficient fuel source, some of our most nutritious foods are carbohydrate foods, and some of our most loved foods are carbohydrate foods. Energy, nutrients, and love are all very good!  For this reason, I like the recommendation that ½ of a person’s calories should come from carbohydrates but those carbohydrates should be of the highest quality possible (most of the time) and spread out throughout the day.  So, I recommend a budget for carbohydrates at meals and snacks based on the person’s needs.
 
Adequate nutrients come from eating a variety of foods.  Our bodies use hundreds of nutrients to get us through a typical day.  Not to mention the nutrients needed to ward off heart disease and heal wounds- very important for people with diabetes!  These nutrients are provided by a variety of foods- foods from all the food groups- and are stored in our bodies.  Typical dieting restricts too many foods that help fill our nutrient stores.  For this reason, I teach eating a variety of foods from all the food groups but realize that it won’t come perfectly from all the food groups every meal as the Exchange Lists recommend.  Our bodies are amazing at adapting- storing, and using nutrients according to supply. Often if we’re craving a particular food it’s because our stores are running low of the nutrients that food provides. So, if we lack a few servings from one group at one meal, hopefully we’ll make up for it in the next meal or next day.  The average nutrient intake over a few weeks is really the best indicator of healthy nutrient stores.  If we’re focusing on most of our intake coming from healthy food choices, there’s no need to stress over each meal being a perfect representation of each group.
 
Appropriate quantity is the tricky part because that is different for everyone every day. Larger, more active people generally need a higher quantity of food than smaller, less active people- but that varies too.  The good news is, our bodies are made to know exactly how much we need if we’ll listen. So many are caught up in using a list of arbitrary rules (diets) and have drowned out their body’s hunger cues to what and how much it needs.  I teach eat before you get too hungry because it’s hard to watch your portions if you’re too hungry and being too hungry all the time is almost guaranteed to cause you to binge.  But also stop eating before you get too full because that uncomfortable feeling means you’ve gone past the amount needed to maintain a healthy weight.  In other words, listen and trust your body not some piece of paper telling you what and how much you should eat today!
 
The ADA no longer lists the Exchange Lists under nutrition recommendations and instead now recommends an individualized approach to meal planning for patients with diabetes under the care of a Registered Dietitian 2019 ADA Consensus Report on Nutrition.   We don’t want to throw the baby out with the bath water so the approach I take implements the good parts of the Diabetes Exchange Lists for Meal Planning in a simpler way.
 
I think back to that patient I tried to educate in the hospital some 25 years ago and wish I could have a do-over.  I wonder how things turned out for him and hope and pray that he found someone who could explain it better for him than I did.  I thank him for the lesson he taught me that day.  I think it’s helped many people over the years!
 
​#stonesoupblog

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