PRACTICE APPLICATIONS
Professional Practice
A Practical Approach to the Management of
Micronutrients and Other Nutrients of Concern
in Food Exchange Lists for Meal Planning
C
HRONIC DISEASES ARE THE
major cause of death and
disability worldwide. In recent
years, they have increased,
reaching epidemic levels.1 In Europe, a
great influence from obesity, type 2
diabetes, cardiovascular diseases, and
cancer diseases has been observed,
and it is estimated that they collec-
tively account for 86% of premature
mortality.2 The burden of disease in
Spain follows the worldwide trends
This article was written by Giuseppe
Russolillo-Femenías, PhD, RD*‡,
president, Spanish Academy of
Nutrition and Dietetics, Pamplona,
Spain; Susana Menal-Puey, PhD*,
lecturer of nutrition and dietetics,
Faculty of Health and Sport Sciences,
University of Zaragoza, Huesca, Spain;
J. Alfredo Martínez, MD, PhD, pro-
fessor of food and science nutrition,
Department of Nutrition, Food Science,
and Physiology, Faculty of Pharmacy,
University of Navarra, Pamplona,
Spain; and Iva Marques-Lopes, PhD,
RD‡, lecturer of nutrition and dietetics,
Faculty of Health and Sport Sciences,
University of Zaragoza, Huesca, Spain.
* Food exchange lists have become a
Both authors share equal authorship
of this article. ‡Certified in Spain.
http://dx.doi.org/10.1016/j.jand.2017.07.020
Available online 4 October 2017
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ª 2018 by the Academy of Nutrition and Dietetics.
over the previous years: cardiovascular
and circulatory diseases, diabetes, neo-
plasms, and neurologic disorders are
some of the leading causes of mortality
and disability.3
It is well known that these chronic
diseases could be the result of common
lifestyle habits such as dietary practices
or physical activity.4 Thus, a healthy diet
that includes adequate amounts of
macronutrients and micronutrients has
long been considered essential in treat-
ment and prevention disease.5 The
quality of proteins, fats, carbohydrates,
and sugars is an important consider-
ation in terms of chronic disease risk.4,6-9
In the same way, an inadequate
intake of micronutrients such as
phosphorous, iron, potassium, calcium,
or vitamin D could be determinant in
disease prevention, or, when a chronic
condition has developed, in the reduc-
tion of symptoms.10 Therefore, it is
important to give enough consider-
ation to the development of appro-
priate educational materials for health
care providers and patients to control
the dietary intakes of these nutrients.
useful tool to control the intake of
macronutrients of both healthy in-
dividuals and those patients with
disease.
In 1950, the American Dietetic
Association (now the Academy of
Nutrition and Dietetics), the American
Diabetes Association, and the US Public
Health Service developed the first edi-
tion of food exchange lists unified to
similar carbohydrates value with the
objective of assessing the intake of this
macronutrient for patients with dia-
betes.11 Since that time, they have been
updated periodically,12-15 and many
countries have worked to design their
own food exchange lists to be used in
the development of meal planning for
healthy individuals16 or for those with
chronic disorders such as diabetes,
obesity, cardiovascular disease, and
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
kidney disease.17-23 In the same way,
recently, authors have developed a new
food exchange list arranged according
to the three macronutrients and energy
to be simultaneously assessed, and to
be used both by healthy persons and
patients with diseases.24
These preliminary tools can be useful
to control macronutrients and energy
intakes, but they may result in inade-
quate intake of other nutrients of
concern, both in situations of chronic
diseases and in health and physiologic
states. Although scientific evidence
shows that a diet providing otherwise
adequate energy and macronutrients
amounts could provide sufficient
amounts of all minerals and vitamins,
there are a number of situations where
intake may be inadequate even in a
healthy population.25 Because of the
role of micronutrients in prevention
or treatment of disease, it is important
to develop new nutrition-based tools
for the simultaneous assessment of
energy and other important micro-
nutrient intakes.
The aim of this research was to
design a practical approach to manage
micronutrients and other nutrients of
interest using the same statistical
criteria of the Spanish food exchange
lists.24 It could be used to ensure an
adequate intake of macronutrients and
other nutrients in diet planning for
healthy individuals and patients with
disease, and to control the intake of
those foods groups with certain nutri-
tional richness or deficiency in chronic
disorders such as obesity, diabetes,
cardiovascular disease, and kidney
disease, and in physiologic states with
extra nutritional requirements such as
pregnancy or lactation.
EXCHANGE LIST PHASES
The underpinnings of these food ex-
change lists had four phases: (1) selec-
tion of the nutrients of interest related to
2029
PRACTICE APPLICATIONS
some of the leading chronic diseases in
worldwide and certain physiologic
states, to be considered in the unifica-
tion criterion; (2) study of the compo-
sition in selected nutrients of the food
amounts defined in the Spanish food
exchange lists, to compare data into
each group and match lists; (3) iden-
tification of the food exchange groups
with high variability in a nutrient, and
selection of foods causing variability
according to the established criteria;
and (4) determination of the mean
nutrient values of each exchange group
according to the rounding established
criteria, and identification of food
groups with high content in some nu-
trients, to be taken into account in
health and in certain therapeutic and
physiologic states.
Phase 1
The nutrients to be considered were
selected by reviewing the current sci-
entific knowledge related to the
nutrition-based treatment of different
physiologic and/or pathologic states, in
particular obesity, diabetes, cardiovas-
cular diseae, kidney disease, and preg-
nancy and lactation.
Phase 2
All the amounts of foods defined in the
first edition of food exchange lists
could be exchanged within the same
group, without significant differences
in macronutrients and energy values.24
To match other secondary nutrients of
interest, each of these amounts of
foods were introduced in calibration
software26 and values of each nutrient
were compared, to satisfy the statistical
criteria defined (coefficient of variation
[CV] values <30%).
Due to the large amount of data to be
unified, the nutritional value of the
different food groups was considered,
and each food group was unified to
those nutrients with significant
amounts in each one, and with high
contribution to the diet. According to
the European Regulation about
nutrition-related declarations in
foods,27 the criteria to select significant
nutrients in a food group were as fol-
lows: a food group was considered
high in sugars when it contained more
than 5% of the mean net weight in solid
foods, and more than 2.5% in liquid
foods. In the same way, the protein
2030 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
content was considered high when it were emphasized as foods with
provided at least 20% of the energy significantly lower or higher amounts
value of the food group, and the poly- of a nutrient than the mean, to control
unsaturated fatty acids (PUFAs), their consumption in menus planning
monounsaturated fatty acids (MUFAs) to avoid deviations from mean data.
or saturated fatty acids (SFAs) contents,
when they provided more than 20%,
20%, or 10%, respectively. Similarly, a Phase 4
group was classified as high in fiber The nutrient values of each exchange
when it contained more than 6% of the group corresponded to the mean
mean net weight in the form of this nutrient value subjected to rounding.
component. With regard to micro- Values were rounded down for deci-
nutrients, a food group could be mals <0.49 and rounded up for deci-
considered a source of vitamins and/or mals 0.5, as long as the z score of the
minerals when it provided more than exchange value against the mean value
15% of the European Daily Reference was between
1. If the z score was
Intakes (RIs).28 For other nutrients of outside the limits, a new rounding was
concern, traffic light cutoffs were necessary until the established criteria
considered (20% of the daily value).29 A were met.
food group was high in sodium when it
contained more than 480 mg per 100 g
(20% of the European RIs28), and high FINDINGS
in cholesterol when it contained more
than 60 mg per 100 g (20% of American Selection of Nutrients of Interest
Daily Value30). Related to Leading Chronic
Diseases
From results of the evidence-based
Phase 3 reviews and from reports about
CV values outside limits in an irrele- nutrition-related objectives, the au-
vant nutrient of a group could be thors selected nutrients for which
dismissed; however, when high vari- over- or underconsumption could be
abilities were associated to a relevant directly related to public health issues.
nutrient, it was necessary to identify Figure 1 shows the nutrients of interest
which foods caused these variations. in the dietary treatment of different
In these cases, the z score for each food physiologic and/or pathologic states
was calculated, and foods with z (eg, obesity, diabetes, cardiovascular
scores outside limits (between
2) diseases, kidney diseases, pregnancy,
Nutrient of concern Physiologic and/or pathologic states
a
Proteins Obesity
Sugars Diabetes
Lipidsb Cardiovascular diseases
Fiber Kidney diseases
Sodium
Potassium
Phosphorous Kidney diseases
Physiologic state: Lactation
Iron Physiologic states: Pregnancy
Calcium Physiologic states: Pregnancy and lactation
Vitamin D
a
Animal and vegetable.
b
Fatty acids and cholesterol.
Figure 1. Nutrients of interest in the pathologic and physiologic situations selected
according to the current scientific knowledge.5,31-37
November 2018 Volume 118 Number 11
November 2018 Volume 118 Number 11

Table 1. Nutrient mean content (protein, fatty acids, cholesterol, sugars, and fiber) of food exchanges included in the Spanish food exchange list; standard deviation (SD)
and coefficient of variation (CV) data are includeda

Aproteinb Vproteinc Cholesterol Added

Food groups or (g) CV (g) CV PUFAsd (g) CV MUFAse (g) CV SFAsf (g) CV (mg) CV sugar (g) CV Fiber (g) CV
subgroups N Mean–SD % Mean–SD % Mean–SD % Mean–SD % Mean–SD % Mean–SD % Mean–SD % Mean–SD %

Carbohydrate group
Grains/potatoes 28 0.01
0.04 40 2.20
0.71 34 0.20
0.14 69 0.12
0.12 100 0.09
0.07 78 0.21
1.13 529 0.41
0.32 80 1.57
1.41 90
3.70
1.50g 40
Legumes 3 0
0 — 6.57
0.74 11 0.42
0.37 88 0.22
0.28 130 0.09
0.03 37 0
0 — 0
0 — 4.77
1.03 22
Confectionary 20 0.49
0.43 86 1.53
0.68 45 0.74
0.66 89 2.03
0.88 44 2.83
1.18 42 19.92
20.65 104 4.20
2.88 69 0.94
0.72 77
Protein group
Type I 31 6.68
1.54 23 0
0 — 0.14
0.09 64 0.18
0.17 93 0.21
0.24 112 29.36
20.78 71 0.22
0.67 305 0
0 —
Type II 19 7.27
1.27 17 0
0 — 0.39
0.19 49 0.62
0.28 45 0.64
0.20 32 42.42
52.11 123 0
0 — 0
0 —
Type III 15 7.02
2.16 31 0
0 — 0.82
0.74 90 1.79
0.61 34 2.09
1.14 55 36.02
57.19 159 0.41
0.67 164 0
0 —
Type IV 30 7.05
1.45 21 0
0 — 0.44
0.32 73 2.72
0.69 25 5.47
1.28 23 26.7
6.25 23 0.13
0.35 28 0
0 —
Type V 7 6.85
1.31 19 0
0 — 1.82
0.51 28 6.97
1.07 15 5.62
0.87 16 38.84
12.57 32 0.38
0.58 153 0
0 —
Fat group
Rich in PUFAs 6 0.03
0.06 200 0.38
0.59 155 3.10
0.25 8 1.23
0.29 24 0.59
0.13 21 1.25
3.06 245 0.18
0.29 162 0.19
0.30 159
—
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Rich in MUFAs 12 0
0 0.71
0.70 97 0.78
0.52 66 3.08
1.26 41 0.69
0.38 54 0.42
1.44 34 0.35
0.38 110 0.72
0.70 96
Rich in SFAs 5 0.17
0.23 133 0.20
0.28 137 0.13
0.06 49 0.89
0.54 60 3.34
0.84 25 8.60
7.98 93 0.42
0.37 88 0.56
0.76 137
Other fats 4 0.15
0.24 156 0.01
0.02 120 1.37
1.25 91 1.41
0.41 29 1.61
0.35 22 2.09
2.41 115 0.02
0.03 117 0
0 —
Milk and dairy
Fat dairy 7 7.18
122 17 0
0 — 0.24
0.11 46 1.96
0.27 14 4.52
0.84 19 21.75
8.21 38 0
0 — 0
0 —

PRACTICE APPLICATIONS
Low-fat dairy 2 6.60
0.28 4 0
0 — 0.05
0.07 141 0.95
0.01 1 1.99
0.13 6 12
2.83 24 0
0 — 0
0 —
Nonfat dairy 6 9.08
1.68 19 0.17
0.41 25 0
0 — 0.13
0.16 120 0.15
0.17 115 2.92
1.80 62 2.25
0.68 30 0.5
1.22 245
Sweetened dairy 8 3.85
0.57 15 0.05
0.13 283 0.03
0.05 138 0.70
0.21 31 1.55
0.43 28 5.34
5.28 99 5.50
1.57 28 0.12
0.26 223
Dairy desserts 4 4.45
0.76 17 0.11
0.21 200 0.28
0.21 74 1.55
0.44 28 2.49
0.55 22 60.98
70.13 115 12.79
5.45 43 0.10
0.13 125
Fruits 45 0
0 — 0.96
0.53 55 0.07
0.15 205 0.04
0.09 221 0.02
0.04 210 0
0 — 14.66
3.60 h
24 2.87
3.55 124
Vegetables 40 0
0 — 2.25
1.21 54 0.19
0.15 83 0.04
0.10 239 0.08
0.10 123 0.02
0.07 398 0
0 — 3.21
2.21 69
Sugars 7 0.18
0.48 265 0.10
0.21 203 0.01
0.01 204 0.06
0.14 211 0.15
0.34 225 0.64
1.70 265 9.53
1.45 15 0.03
0.06 182
a
Gray-shaded cells mark a relevant nutritional contribution in groups or subgroups according to European regulation and other criteria.
b
Aprot¼animal protein.
c
Vprot¼vegetal protein.
d
PUFAs¼polyunsaturated fatty acids.
e
MUFAs¼monounsaturated fatty acids.
f
SFAs¼saturated fatty acids.
g
Data for breakfast cereals and other commercial products with added sugars.
2031

h
Natural sugars.
 PRACTICE APPLICATIONS
2032

Table 2. Micronutrient mean content (sodium, potassium, phosphorous, calcium, iron, and vitamin D) of foods exchanges included in the Spanish food exchange list;
standard deviation (SD) and coefficient of variation (CV) data are includeda
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Food groups or Sodium (mg) Potassium (mg) Phosphorous, mg Calcium (mg) Iron (mg) Vitamin D (mg)
subgroups Mean–SD CV % Mean–SD CV % Mean–SD CV % Mean–SD CV % Mean–SD CV % Mean–SD CV %

Carbohydrate group
Grains/potatoes 29.26
92.16 116 86.79
109.80 127 45.45
37.25 82 7.30
5.09 70 0.67
0.68 103 0.07
0.19 291
Legumes 17.80
17.47 98 330
172.37 52 105.80
30.86 29 33.90
14.56 43 1.88
0.28 15 0
0 —
Confectionary 121.67
80.69 66 58.28
65.76 113 36.64
18.41 50 12.79
7.19 56 0.46
0.25 54 0.12
0.12 100
Protein group
Type I 81.65
68.10 83 116.53
44.96 39 78.35
29.07 37 22.18
25.27 114 1.02
0.50 50 0.11
0.37 356
6.40
4.50b 70
Type II 63.13
151.13 230 112.91
31.33 28 82.22
24.28 30 5.99
7.22 120 0.80
0.31 38 1.07
1.57 147
3.60
0.45c 13
Type III 283.89
481.86 170 87.32
35.17 40 107.41
72.93 68 77.48
123.28 159 0.56
0.39 70 1.01
1.59 158
Type IV 253.01
124.12 49 39.07
24.27 62 152.08
60.53 40 173.88
100.51 58 0.22
0.14 64 0.06
0.03 50
Type V 436.30
266.20 61 80.31
24.04 30 63.71
20.44 32 10.10
7.49 74 2.27
3.87 170 0.07
0.13 171
Fat group
Rich in PUFAsd 18.86
45.88 243 17.05
26.93 158 14.70
21.39 145 1.64
2.91 178 0.12
0.18 156 0
0 —
Rich in MUFAse 10.51
17.11f 162 53.65
86.46 161 16.48
15.83 96 8.59
8.19 95 0.25
0.22 88 0
0 —
Rich in SFAsg 4.09
3.01 73 29.25
23.05 79 10.80
5.97 55 6.40
7.38 115 0.14
0.16 113 0.06
0.06 100
Other fats 5.50
5.25 95 1.75
1.90 108 1.36
1.47 108 0.75
0.71 94 0.01
0.03 200 0.23
0.28 122
Milk and dairy
Fat dairy 110.43
48.93 44 330.18
73.78 22 195.89
27.43 14 261.29
45.35 17 0.18
0.06 30 0.14
0.15 106
Low-fat dairy 92
0 0 332
0 0 170
0 0 234
8.49 4 0.14
0.08 61 0.01
0.01 100
Nonfat dairy 122.25
34.21 28 387.42
40.16 10 237.83
51.24 22 291.08
51.55 18 0.25
0.06 23 0
0 —
Sweetened dairy 79.75
37.54 47 212.56
70.41 33 104.84
9.02 9 132.81
15.67 12 0.38
0.35 92 0.09
0.15 161
Dairy desserts 65.60
16.26 25 179.15
33.60 19 121.83
11.59 10 141.68
29.13 21 0.42
0.29 68 0.28
0.24 87
—
November 2018 Volume 118 Number 11

Fruits 6.62
10.31 156 280.71
143.32 51 26.25
15.36 59 24.28
18.73 77 0.67
0.49 74 0
0

Vegetables 91.43
154.22 169 343.67
164.74 48 48.88
23.30 48 41.90
25.35 61 0.90
0.49 54 0
0 —
123.5
21.90h 18 3.75
0.42i 11
Sugars 5.32
6.56 124 27.56
30.89 112 9.55
14.23 149 10.49
15.77 150 0.13
0.18 137 0
0 —
a
Gray-shaded cells mark group or subgroup source of a micronutrient (15% of European Daily Reference Intakes28).
b
Data for edible bivalve mollusks.
c
Data for entrails.
d
PUFAs¼polyunsaturated fatty acids.
e
MUFAs¼monounsaturated fatty acids.
f
Data without olives.
g
SFAs¼saturated fatty acids.
h
Data for cruciferous vegetables.
i
Data for leafy vegetables.
 PRACTICE APPLICATIONS

Food exchange group Nutrients with high Foods with z score >2 Foods with z score <2
variability in the group
Carbohydrate group
Grains and potatoes Fiber Cereals high in fiber —
a
Confectionary SFAs Chocolate cake Muesli
Cholesterol Cupcake Muesli
Added sugar Chocolate cake —
Sodium Crackers —
Light chips
Protein group
Type I Cholesterol Squid Monkfish
Crab Egg white
Prawn Skim white cheese
Iron (mollusk subgroup) Cockle —
Clam
Type II Cholesterol Entrails —
Vitamin D Tuna Different meals
Sardine Entrails
Swordfish
Trout
Type III MUFAsb Cured jam with fat —
SFAs Different types of cheese —
Cholesterol Egg —
Sodium Canned anchovies in oil Different meals
Different fishes
Egg
Cottage cheese
Phosphorous Low-fat cheese in portion —
Cottage cheese
Vitamin D Canned anchovies in oil —
Type IV Sodium Chorizo —
Sliced cheese to melt
Roquefort cheese
Phosphorous Sliced cheese to melt —
Calcium Parmesan cheese Different meals
Type V Cholesterol Black pudding —
Sodium — Pancetta
Iron Black pudding —

(continued on next page)

Figure 2. List of foods with z scores outside limits for relevant nutrients into each group.

November 2018 Volume 118 Number 11 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2033
PRACTICE APPLICATIONS

Food exchange group Nutrients with high Foods with z score >2 Foods with z score <2
variability in the group
Fat group
Rich in MUFAsa MUFAs Avocado —
SFAs Avocado —
Sodium Olives —
Rich in SFAs b
Cholesterol — Coconut
Milk and dairy
Fat dairy Cholesterol — Fermented milk (Lactobacillus casei)
Other fats PUFAs c
Margarine —
Dairy desserts Cholesterol Egg flan —
Fruits Potassium Apricot —
Melon
Quince
Blackberries
Raspberries
Vegetables Protein Artichoke —
Brussels sprouts
Broccoli
Spinach
Potassium Brussels sprouts Canned or frozen peas
Spinach Canned palmetto
Thistle Canned sprouted soybean
a
SFAs¼saturated fatty acids.
b
MUFAs¼monounsaturated fatty acids.
c
PUFAs¼polyunsaturated fatty acids.
Figure 2. (continued) List of foods with z scores outside limits for relevant nutrients into each group.

and lactation) that have been consid-
ered in these exchange lists.
Analysis of Composition in
Select Nutrients of the Spanish
Food Exchanges List and
Comparison of Data into
Each Group
From calibration of the food portions
indicated in each group of the previous
edition, the secondary nutrient con-
tents were obtained. These data, with
the statistical parameters studied, are
shown in Table 1 and Table 2. The food
groups or subgroups that contribute
significant amounts of nutrients to diet
are marked, to be considered in the
unification.
Identification of Food Exchange
Groups with High Variability in an
Important Nutrient and the
Causes of Variability, According
to Statistical Criteria
If the amounts of foods defined satis-
fied the statistical criterion for nutri-
ents, they were incorporated in the
exchange lists. If groups showed high
variability for some of the relevant
nutrients (ie, CV outside limits), the
causes of variation were studied
(foods with z scores >2 or <2).
Although the z score for each one of
the foods was not shown, the list of
foods with z scores outside limits in
groups with high CV value is pre-
sented in Figure 2. These foods should
be taken into account in menus plan-
ning to avoid high deviations from
mean values. If none of the food listed
in a group with high CV showed z
scores outside limits, variability of the
group was dismissed.
Determination of the Mean
Nutrient Values of each Exchange
List and Highlighting of those
Groups with High Nutritional Value
The nutrient values assigned to each
food list after subjecting them to the
rounding criterion are shown in
Table 3. Also, the food groups with high
contribution in some nutrient are
marked, to avoid or include them in
meal planning.

2034 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS November 2018 Volume 118 Number 11
November 2018 Volume 118 Number 11

Table 3. Mean nutrient values (by rounding mean values) of the food groups proposed in the Spanish food exchange lista

Food group or Aprotb Vprotc PUFAsd MUFAse SFAsf Cholesterol Added Fiber Sodium Potassium Phosphorous Calcium Iron Vitamin D
subgroup (g) (g) (g) (g) (g) (mg) sugar (g) (g) (mg) (mg) (mg) (mg) (mg) (mg)

Carbohydrate group
Grains/potatoes 0 2 0 0 0 0 0 2 29 87 45 7 1 0
4g
Legumes 0 7 0 0 0 0 0 5 18 330 106 34 2 0
Confectionary 0 2 1 2 3 20 4 1 122 58 37 13 0 0
Protein group
Type I 7 0 0 0 0 29 0 0 82 117 78 22 1 0
6h
Type II 7 0 0 1 1 42 0 0 63 113 82 6 1 1
4i
Type III 7 0 1 2 2 36 0 0 284 87 107 78 1 1
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Type IV 7 0 0 3 5 27 0 0 253 39 152 174 0 0

Type V 7 0 2 7 6 39 0 0 436 80 64 10 2 0
Fat group
Rich in PUFAs 0 0 3 1 1 1 0 0 19 17 15 2 0 0

PRACTICE APPLICATIONS
j
Rich in MUFAs 0 0 1 3 1 0 0 1 11 54 16 9 0 0
Rich in SFAs 0 0 0 1 3 9 0 1 4 29 11 6 0 0
Other fats 0 0 1 1 2 2 0 0 6 2 1 1 0 0
Milk and dairy
Fat dairy 7 0 0 2 5 22 0 0 110 330 196 261 0 0
Low-fat dairy 7 0 0 1 2 12 0 0 92 332 170 234 0 0
Nonfat dairy 9 0 0 0 0 3 2 1 122 387 238 291 0 0
Sweetened dairy 4 0 0 1 2 5 6 0 80 213 105 133 0 0
(continued on next page)
2035
PRACTICE APPLICATIONS

Vitamin D PRACTICAL GUIDELINES TO

USING THIS TOOL
The Spanish food exchange lists were
(mg)

0 unified to the three macronutrients

0
0

0
and energy, but other secondary nu-
(mg)

trients were not controlled. This

Iron

4m
practical approach was planned to
0
1
1

0
consider the unification of other nu-
Calcium

trients of interest (MUFAs, PUFAs,

(mg)

SFAs, cholesterol, added sugars, fiber,

124l
24
42

10
142

sodium, potassium, phosphorous, cal-

cium, iron, and vitamin D) in those
Phosphorous
Table 3. Mean nutrient values (by rounding mean values) of the food groups proposed in the Spanish food exchange lista (continued)

food groups with relevant amounts of

them. This could be a useful tool for
professionals in that they could esti-
(mg)

122
26
49

10

mate the number of exchanges to

meet energy and macronutrients pro-
portions of a patient, and at the same
Potassium

time, the requirements of other sec-

ondary nutrients, both in health and
(mg)

28
179
281
344

diseases.
This tool offers a wide variety of
Sodium

foods in each group to be included in

(mg)

meal planning, and a list of foods

7

5
66

91

marked as exceptions in the contribu-

tion of any of the nutrients (upward
Fiber

and downward).
(g)

0
3
3

Nutrition and dietetics practitioners

could make food choices according to
sugar (g)
Added

particular preferences without signifi-

cant variations in nutrient intakes, but
k

0
13
15

10

they should control the intake of

marked foods, which could influence
Cholesterol

expected outcomes in health and clin-

ical situations.
(mg)

Also, this tool includes nutrient

61
0
0

content claims of the food exchanges

groups defined. These claims describe
SFAsf

the high level of a nutrient in a food

(g)

2
0
0

exchange group, and aid in choosing

the exchange groups. For example, food
MUFAse

Data for breakfast cereals and other commercial products with added sugars.

groups with high content in a nutrient

(g)

with positive effects on health (eg,

2
0
0

protein, fiber, potassium, phosphorous,

PUFAsd

calcium, iron, or vitamin D) and certain

physiologic states (eg, iron, calcium,
(g)

and vitamin D) should be present in

0
0
0

0
Gray-shaded cells mark a relevant nutritional content.

the right measure in a diet, and those

Vprotc

with restrictions (eg, SFAs, cholesterol,

(g)

added sugar, and sodium), should be

0
1
2

controlled. In treatment of diseases, the

MUFAs¼monounsaturated fatty acids.
Aprotb

food groups with richness in nutrients

PUFAs¼polyunsaturated fatty acids.

Data for edible bivalve mollusks.

implicated as potential contributing

(g)

Data for cruciferous vegetables.

4
0
0

factors (eg, sugars, SFAs, and sodium in

SFAs¼saturated fatty acids.

Data for leafy vegetables.

Vprot¼vegetable protein.

metabolic chronic diseases, and potas-

Aprot¼animal protein.
Food group or

sium and phosphorous in kidney dis-

Dairy desserts

Data without olives.

eases) could be avoided.

Data for entrails.
Vegetables

Natural sugars.
subgroup

With an understanding of the

Sugars
Fruits

nutrient composition of the exchange

lists proposed, several recommen-
m
b

g
h
e
a

k
f

l
i

dations are described for the diets

2036 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS November 2018 Volume 118 Number 11
November 2018 Volume 118 Number 11

Table 4. Practical application of the management of micronutrients and other nutrients of interest in exchange lists for meal planning: A short case (pregnant woman,
aged 32 years); the number of exchanges, the distribution in the day with examples of frequent food choices (between others), and the Dietary Reference Intake (DRI)38
values covered were included

Food exchange Exchange Distribution of the Exchanges in the Day with Examples of Different Food Choices Expressed in Net Weight (grams or home measures)
group no. Breakfast Midmorning snack Lunch Afternoon snack Dinner Others

Carbohydrate group
Grains and 13 2 1 6 4
potatoes Whole bread (60 g, 2 Whole bread (30 g, 1 Brown rice (80 g, 4 Whole-grain pasta
slices) or slice) Tbsp) or whole- (40 g, 4 Tbsp) or
unsweetened dry grain pasta (80 g, 8 potato (200 g, 1
cereals (40 g, 1/2 Tbsp) or potato medium size) or
bowl) (400 g, 2 medium brown rice (40 g, 2
size) with whole Tbsp) with whole
bread (60 g, 2 bread (60 g, 2
slices) slices)
Protein group
Type I 3 1 2
Cooked jam (30 g, 1 Cooked ham (60 g, 2
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

regular slice) or regular slices) or

nonfat fresh cod (80 g, 2
cheese (75 g, 1 portions) or hake
small container) (80 g, 2 portions)
or cockles (100 g,
24 units) or prawns

PRACTICE APPLICATIONS
(80 g, 8 units)
Type II 3 3
Pork loin (90 g, 3
medium fillets) or
beef (90 g, 1
medium fillet) or
chicken leg (90 g, 3
units) or sardine
(120 g, 6 units) or
trout (120 g, 1 unit)
(continued on next page)
2037
 PRACTICE APPLICATIONS
2038

Table 4. Practical application of the management of micronutrients and other nutrients of interest in exchange lists for meal planning: A short case (pregnant woman,
aged 32 years); the number of exchanges, the distribution in the day with examples of frequent food choices (between others), and the Dietary Reference Intake (DRI)38
values covered were included (continued)
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Food exchange Exchange Distribution of the Exchanges in the Day with Examples of Different Food Choices Expressed in Net Weight (grams or home measures)
group no. Breakfast Midmorning snack Lunch Afternoon snack Dinner Others

Fat group
Rich in PUFAsa and 13 2 4 3 4
MUFAsb Olive oil (10 g, 1 Olive/sunflower/ Hazelnuts (24 g, 24 Similar to lunch
Tbsp) or hazelnuts soybean oil (20 g, units) or almonds
(16 g, 16 units) or 2 Tbsp) or (24 g, 18 units) or
almonds (16 g, 12 mayonnaise (20 g, walnuts (24 g, 6
units) or walnuts 2 Tbsp) units) or pine nuts
(16 g, 4 units) (24 g, 3 heaping
tsp)
Milk and dairy
Nonfat dairy 3 1 0.5 0.5 1
Nonfat milk (200 g, Nonfat yogurt (125 g, Similar to Similar to breakfast
1 c) or yogurt (250 g, 1 commercial midmorning snack
2 commercial container) or milk
containers) (100 g, 1/2 c)
Fruits 3 1 1 1
Apple (120 g, 1 small Similar to breakfast Similar to breakfast
unit) or banana
(100 g, 1 small
unit) or kiwifruit
(120 g, 1 medium
unit) or orange
(200 g, 1 big unit)
November 2018 Volume 118 Number 11

Vegetables 2 1 1
Green bean (150 g, Similar to lunch
1 small flash dish)
or lettuce (150 g,
1 big flash dish) or
zucchini (150 g,
a half unit) or
tomato (150 g,
1 unit) or onion
(100 g, 1 unit)
(continued on next page)
November 2018 Volume 118 Number 11

Table 4. Practical application of the management of micronutrients and other nutrients of interest in exchange lists for meal planning: A short case (pregnant woman,
aged 32 years); the number of exchanges, the distribution in the day with examples of frequent food choices (between others), and the Dietary Reference Intake (DRI)38
values covered were included (continued)

Food exchange Exchange Distribution of the Exchanges in the Day with Examples of Different Food Choices Expressed in Net Weight (grams or home measures)
group no. Breakfast Midmorning snack Lunch Afternoon snack Dinner Others

Sugars (optional) 0-1 1

Soluble cocoa or
sugar (10 g, 2 tsp)
or honey (16 g,
2 tsp) or jam (15 g,
1 Tbsp)
DRI38 covered (%) and recommendations in the food selection
Energy 99%
Protein 99% (Data without legumes: Due to their protein richness, if they are chosen, they count as 1 exchange of cereals/potatoes plus a half exchange of
the protein group.)
Carbohydrates 98%
Sugars 55% (Data providing of added sugars and cereals low in sugar. Cereals high in sugars or sweetened fruits beverages should be chosen occasionally.)
Fiber 180%
Fats 100%
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

PUFAs: 7% TCVc; SFAsd: 6% TCV (Data including, at least 3 fat exchanges rich in PUFAS, nuts, and/or oils.)
Cholesterol 76% (Data avoiding confectionary. Occasionally these products could be chosen, and they should count as 1 exchange of cereals plus 1 exchange of
fat group.)
Sodium 104% (Data avoiding canned fishes, cheeses with salt, and olives. They could be chosen occasionally.)
Potassium 108%
Phosphorous 200%

PRACTICE APPLICATIONS
Calcium 132% (Nutrient of interest in pregnancy. Important to include 3 nonfat dairy exchanges or to choice skim cheese in the protein group or cruciferous
in the vegetable group.)
Iron 89% (Nutrient of interest in pregnancy. Important to include food exchanges mark as source of iron, but low in fat: legumes, edible bivalve mollusks,
and leafy vegetables.)
Vitamin D 60% (Important to include food exchanges mark as source of vitamin D, but low in fat: protein type II group, particularly tuna, sardine, swordfish, and
trout.)
a
PUFAs¼polyunsaturated fatty acids.
b
MUFAs¼monounsaturated fatty acids.
c
TCV¼total caloric value.
d
SFAs¼saturated fatty acids.
2039
PRACTICE APPLICATIONS
planning in healthy or physiologic/
pathologic situations.
In the carbohydrate group, nutrition
and dietetics practitioners should opt
for foods exchanges with low added
sugar such as legumes (also, high in
protein) and whole grains, avoiding
sugary breakfast cereals. Also, the
confectionary subgroup should be
controlled due to the simultaneous
high content in added sugars, SFAs, and
cholesterol, with the exception of
muesli, and the contribution in sodium,
a nutrient with harmful effects on
health. These recommendations could
be applicable to promote health and
even to treat chronic diseases. With
regard to micronutrients, legume ex-
changes contribute to reaching the re-
quirements of potassium and
phosphorous (more than 15% of Euro-
pean RI) in health situations, but it
could be a necessary restriction in
certain diseases such as kidney
dysfunction. Legume exchanges could
be a successful option in pregnancy
diets for the relevant contribution in
iron.
Within the protein exchanges group,
those foods rich in MUFAs and PUFAs
vs SFAs (type I and II) are advisable, but
taking into account the cholesterol
contribution of all of them, especially
liver of lamb and chicken or kidney of
beef, and squid, crabs, or prawns. Also,
some edible bivalve mollusks are a
source of iron, an important nutrient in
pregnancy and lactation.
All the varieties of fish classified as
type II and III could be a good option to
reach the vitamin D intake in usual
diets and in pregnancy and lactation.
Attention should be paid to the so-
dium contribution of some type III,
IV, and V food exchanges (canned
anchovies, chorizo, and some cheeses)
and to the phosphorous contribution
of cheeses in kidney disease and
others.
Because saturated fats should be
replaced by mono- and poly-
unsaturated fats, foods in the rich in
PUFAs and MUFAs are recommended.
Careful choices should be made for ol-
ives in menu planning to control so-
dium intake, especially in diets for
individuals with hypertension.
The exchanges of the milk and dairy
group are high in protein. If they are
low in fat, they could meet the protein
requirements, incorporating fewer
2040 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
amounts of SFAs and cholesterol
than protein food groups. Also, they
contribute potassium, phosphorous,
calcium, and low sodium. They could
be a good option, especially in car-
diovascular diseases and hyperten-
sion; nevertheless, these exchanges
should be limited in cases of kidney
disease due to the phosphorous and
potassium content. At the same time,
these low-in-fat exchanges would be a
healthy source of calcium in preg-
nancy and lactation. For its part,
frequent consumption of dairy des-
serts exchanges could contribute
high added sugars and cholesterol to a
diet.
Some vegetable exchanges could be
high in protein with low calories,
particularly artichoke, brussels sprouts,
broccoli, and spinach. In addition, they
are a good source of potassium, a
micronutrient of public health concern,
principally brussels sprouts, spinach,
and thistle, and the subgroup of leafy
vegetables could be a source of iron,
important in pregnancy and lactation.
On the other hand, the cruciferous
group is remarkable for its calcium
content, and these foods could be a
good selection to increase the calcium
intake in a diet. In disease states with
restriction of potassium intake, nutri-
tion and dietetics practitioners should
avoid the highest potassium vegetables
and opt for the lowest, either canned-
cooked vegetables or frozen vegeta-
bles (eg, peas, palmetto, or sprouted
soybean).
Fruits exchanges are another good
source of potassium in the diet;
nevertheless, this group presents a
high content of natural sugars, which
increases when adding sugars (some
commercial fruit nectar and other
fruit beverages). The beverages with
the highest content of sugar (some
commercial nectars) should be avoi-
ded in diets with sugar control
consumption.
Finally, it is necessary to note that
the processed foods incorporated in
this database should be considered
generic, and it is possible that there are
other brands with different nutritional
profiles. Therefore, the authors recom-
mend the use of Nutrition Facts from
food labels when more specific infor-
mation is needed and to check for a
possible deviation from mean data of
the group.
PRACTICAL APPLICATION OF
THE MANAGEMENT OF
MICRONUTRIENTS AND OTHER
NUTRIENTS IN EXCHANGE LISTS
FOR MEAL PLANNING: ONE
CASE
To benefit from the use of this meth-
odology, a short clinical case (a woman
in the second trimester of pregnancy,
aged 32 years), has been provided
(Table 4). The number of exchanges
was defined to reach the energy needs
(2,300 kcal) and the total caloric value
percentages from fat, protein, and car-
bohydrates close to 32:18:50, respec-
tively. Less than 10% and more than 7%
of total caloric value from SFAs and
PUFAs and a minimum intakes of 90%
of the Dietary Reference Intakes38 were
taken into account. If this intake was
not reached, recommendations in the
food selection were considered.
References
1. McGrail K, Lavergne R, Lewis S. The
chronic disease explosion: Artificial bang
or empirical whimper? BMJ. 2016;15.
352-i1312.
2. European Food and Nutrition Action Plan
2015-2020. Copenhagen, Denmark: World
Health Organization; 2014. EUR/RC64/14:
1-19.
3. Haro JM, Tyrovolas S, Garin N, et al. The
burden of disease in Spain: Results from
the global burden of disease study 2010.
BMC Med. 2014;12(236):1:25.
4. WHO/FAO. Diet, Nutrition and Prevention
of Chronic Diseases. Report of a Joint FAO/
WHO Expert Consultation. Geneva,
Switzerland: WHO Technical Report Ser-
vice. 2003;916:1-150.
5. American Diabetes Association. Nutrition
recommendations and interventions for
diabetes: A position statement of the
American Diabetes Association. Diabetes
Care. 2008;31(1 suppl):S61-S78.
6. WHO/FAO. Carbohydrates in Human
Nutrition. Report of a Joint FAO/WHO
Expert Consultation. Rome, Italy: FAO Food
Nutrition Paper. 1998;66:1-140.
7. WHO/FAO. Fats and Fatty Acids in Human
Nutrition. Report of a Joint FAO/WHO
Expert Consultation. Geneva, Switzerland:
FAO Food Nutrition Paper. 2010;91:
1-166.
8. WHO/FAO. Protein and Amino Acid Re-
quirements in Human Nutrition. Report of a
Joint FAO/WHO Expert Consultation.
Geneva, Switzerland: WHO Technical
Report Service. 2007;935:1-265.
9. Hu FB. Resolved: There is sufficient sci-
entific evidence that decreasing sugar-
sweetened beverage consumption will
reduce the prevalence of obesity and
obesity-related diseases. Obes Rev.
2013;14(8):606-619.
10. Aranceta J, Serra Majem L, Arija V, et al.
Nutritional objectives for the Spanish
November 2018 Volume 118 Number 11

population. Spanish J Community Nutr.
2011;17(4):178-199.
11. Caso EK. Calculation of diabetic diets. J Am
Diet Assoc. 1950;26:575-583.
12. Wyse BW. Nutrient analysis of exchange
lists for meal planning. Variation in
nutrient levels. J Am Diet Assoc.
1979;75(3):238-242.
13. Franz MJ, Barr P, Holler H, Powers MA,
Wheeler ML, Wylie-Rosett J. Exchange
lists: Revised 1986. J Am Diet Assoc.
1987;87(1):28-34.
14. Wheeler ML, Franz M, Barrier P,
Holler H, Cronmiller N, Delahanty LM.
Macronutrient and energy database for
the 1995 exchange lists for meal plan-
ning: A rationale for clinical practice
decisions. J Am Diet Assoc. 1996;96(11):
1167-1171.
15. Wheeler ML. Nutrient database for the
2003 exchange lists for meal planning.
J Am Diet Assoc. 2003;103(7):894-920.
16. Moore C, Gitau R, Goff L. Successful
manipulation of the quality and quantity
of fat and carbohydrate consumed by
free-living individuals using a food
exchange model. J Nutr. 2009;139(8):
1534-1540.
17. Ahn HJ, Han KA. Small rice bowl-based
meal plan versus food exchange-based
meal plan for weight, glucose and
lipid control in obese type 2 diabetic
patients. Korean Diabetes J. 2010;34(2):
86-94.
18. Cho JW, Kweon MR, Park YM. A survey
of diabetic educators and patients for
the revision of Korean food exchange
lists. Diabetes Metab J. 2011;35(2):
173-181.
19. Shaw DI, Tierney AC, McCarthy S. LIP-
GENE food-exchange model for alteration
of dietary fat quantity and quality in
free-living participants from eight Euro-
pean countries. Br J Nutr. 2009;101(5):
750-759.
20. Weech M, Vafeiadou K, Hasaj M.
Development of a food-exchange model
to replace saturated fat with MUFAs and
n-6 PUFAs in adults at moderate
AUTHOR INFORMATION
Address correspondence to: Susana Menal-Puey, PhD, Faculty of Health and Sport Sciences. University of Zaragoza, Plaza Universidad, 3, 22002
Huesca, Spain. E-mail: smenal@unizar.es
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
There is no funding to disclose.
November 2018 Volume 118 Number 11
PRACTICE APPLICATIONS
cardiovascular risk. J Nutr. 2014;144(6):
846-855.
21. Benezra LM, Nieman DC. Intakes of most
nutrients remain at acceptable levels
during a weight management program
using the food exchange system. J Am Diet
Assoc. 2001;101(5):554-561.
22. Mokubo A. Food exchange lists for meal
planning in the patients with diabetic
nephropathy. Nihon Rinsho. 2002;60
(10 suppl):752S-757S.
23. Herselman MG, Esau N. Development of
the South African renal exchange lists.
S Afr Med J. 2005;18(2):51-57.
24. Marques-Lopes I, Menal-Puey S,
Martínez JA, Russolillo G. Development of
a Spanish food exchange list: Application
of statistical criteria to a rationale pro-
cedure. J Acad Nutr Diet. 2017;2(suppl):
2212-2672.
25. Shenkin A. Micronutrients in health and
disease. Postgrad Med J. 2006;82(971):
559-567.
26. Palma I, Farrán A, Cantos D. Food
Composition Tables of Habitual Spanish
Household Measures. Aravaca, Madrid,
Spain: McGraw-Hill Interamericana; 2008.
27. Commission Regulation (EC) no. 1924/
2006 of the European Parliament and of
the Council of the European Union of 20
December 2006 on nutrition and health
claims made on foods. Brussels, Belgium:
Off J Eur Union L. 404/30:3-18.
28. Commission Regulation (EC) no. 1169/
2011 of the European Parliament and of
the Council of the European Union of 25
October 2011 on the provision of food
information to consumers. Brussels,
Belgium: Off J Eur Union L. 304/18:18-63.
29. Babio N, Vicent P, López L, Benito A,
Basulto J, Salas-Salvadó J. Adolescents’
ability to select healthy food using two
different front-of-pack food labels: A
cross-over study. Public Health Nutr.
2014;17(6):1403-1409.
30. Food and Drug Administration. Guidance
for industry: A food labeling guide (14.
Appendix F: Calculate the percent daily
value for the appropriate nutrients).
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
2013. https://www.fda.gov/food/guidance
regulation/guidancedocumentsregulatory
information/labelingnutrition/ucm064928.
htm. Accessed August 8, 2017.
31. Cuervo M, Baladia E, Goñi L, et al. Pro-
posed Dietary Reference Intakes (DRI) to the
Spanish Population. Pamplona, Spain:
University of Navarra Editions; 2010.
32. Aaron KJ, Sanders PW. Role of dietary salt
and potassium in cardiovascular health
and disease: A review of the evidence.
Mayo Clin Proc. 2013;88(9):987-995.
33. Stone NJ, Robinson J, Lichtenstein AH,
et al. 2013 ACC/AHA guideline on the
treatment of blood cholesterol to reduce
atherosclerotic cardiovascular risk in
adults: A report of the American College
of Cardiology/American Heart Associa-
tion Task Force on Practice Guidelines.
J Am Coll Cardiol. 2014;63(25):2889-
2934.
34. Jensen MD, Ryan DH, Apovian CM, et al.
2013 AHA/ACC/TOS guideline for the
management of overweight and obesity
in adults: A report of the American Col-
lege of Cardiology/American Heart Asso-
ciation Task Force on Practice Guidelines
and The Obesity Society. American Col-
lege of Cardiology/American Heart Asso-
ciation Task Force on Practice Guidelines;
Obesity Society. J Am Coll Cardiol.
2014;63(25):2985-3023.
35. National Kidney Foundation. KDOQI clin-
ical practice guideline for diabetes and
CKD: 2012 update. Am J Kidney Dis.
2012;60(5):850-886.
36. National Kidney Foundation. KDOQI clin-
ical practice guideline for hemodialysis
adequacy: 2015 update. Am J Kidney Dis.
2015;66(5):884-930.
37. Ekmekcioglu C, Elmadfa I, Meyer AL,
Moeslinger T. The role of dietary potas-
sium in hypertension and diabetes.
J Physiol Biochem. 2016;72(1):93-106.
38. Institute of Medicine, Food and Nutrition
Board. Dietary Reference Intakes: Guiding
Principles for Nutrition Labeling and Forti-
fication. Washington, DC: The National
Academies Press; 2003.
2041