Updating of the Philippine Food Exchange Lists for Meal ...

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Updating of the Philippine Food Exchange Lists for Meal Planning

Consuelo L. Orense, Marilou L. Madrid*, Noelle Lyn C. Santos, Hazel T. Lat, and David Kenneth C. Mendoza

Department of Science and Technology Food and Nutrition Research Institute (DOST-FNRI)

Bicutan, Taguig City 1631 Philippines

The food exchange list (FEL) is a tool for planning meals using a list of foods grouped with approximately the same amount of energy and macronutrients. The Philippine FEL underwent three revisions from its publication in 1953 until 1994. This most recent revision of the FEL aimed to review calculations of macronutrient and energy content per exchange and by food group, review the methods of dietary calculation, and enhance the design and appearance of the handbook. Revision of the handbook started with needs assessment using a survey as study design among 529 registered nutritionist-dietitians (RNDs) and nutrition students, and focus group discussion (FGD) among 36 selected hospital nutrition supervisors, nutrition faculty, and health workers in three cities of the Philippines – namely, Manila, Cebu, and Davao. The seven food groups in the previous FEL editions were adopted as the main components of foods for substitution. Macronutrient content per exchange was computed from the 2017 Philippine food composition tables (FCTs) and foreign food databases. Results of the survey revealed that most RNDs used the FEL in a clinical or hospital setting (98.1%), while students used the FEL for themselves (93.8%). The FEL was mainly used for meal planning (87.5%), as reference (62.8%), and for counseling (48.4%). Almost all respondents described the FEL as very useful. The addition of more foods available in the market was the most common suggestion of respondents. Based on the suggestions from the survey and FGD the following changes were made: recomputed and reclassified 525 food items within the seven food groups and subgroups; reclassified rice group into low-, medium-, and high-protein subgroups; the alphabetical arrangement of foods with Filipino common names and English names; additional equations for deriving desirable body weight (DBW) and total energy requirement (TER); and included photos of selected foods per exchange. Improvement of the design and appearance of the handbook was accomplished through the use of color-coding, food photos, and a tabulated food listing.

Keywords: food exchange lists, food exchanges, meal planning, nutrition, nutritionist-dietitians

*Corresponding Author: [email protected]

INTRODUCTIONThe Philippine FEL is a tool used by RNDs in planning meals for individuals who need a calculated intake of energy and macronutrients – carbohydrates, protein, and

fat. It is made up of food groups, each being called an exchange list that contains food items with approximately the same amounts of energy and macronutrients within the list; thus, a substitute of food with another can be made (Caso 1950). The Philippine FEL was initially intended to provide carbohydrate information for use in the diet management of persons with diabetes. Today,

Philippine Journal of Science150 (5): 955-968, October 2021ISSN 0031 - 7683Date Received: 06 Aug 2020

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the Philippine FEL is used as a guide in prescribing and planning meals for healthy and therapeutic diets, as well as an educational tool by nutrition professionals in clinics and hospitals, fitness centers, and other health care facilities (Tanchoco et al. 1994).

The first FEL was developed in the 1950s by the American Diabetes Association, the American Dietetic Association (ADA), and the United States (US) Public Health Service for the management of patients with diabetes (Wheeler et al. 1996). It has undergone several revisions from its previous title “Exchange Lists for Diabetes” to “Choose Your Foods: Exchange Lists for Diabetes” in the sixth revision published in 2008 (Wheeler et al. 2008; Geil 2008). The Philippine FEL was adapted from the US in 1953 by Corpus et al. and was revised in 1965 by Madlangsakay that included six food groups [as cited in Flores et al. (1984)]. The 1965 revision was updated by Flores et al. in 1984 wherein the sugars and sweets from the rice group were removed to form the sugar exchange as the seventh group. The third revision in 1994 by Tanchoco et al. had the subgroups of the vegetable and milk exchanges modified while retaining the seven main groups. Some changes in this version included the following: adjustment of portion sizes, use of Filipino language in the food listing, a separate grouping of processed/selected foods, and identified fruits with high vitamin A and vitamin C content. Prior to this study, the 1994 FEL was not updated because the local food composition database was being modified.

Tools in nutrition have to be periodically reviewed to keep up with current trends in the management of nutrition-related conditions. As a guide in dietary planning, the FEL should maintain a list of foods currently available in the market and which are consumed by many people. Novel foods that are now part of family meals have to be evaluated on how these can fit into the diet plan of individuals with different health concerns. Moreover, the popularity of the FEL as a reference material deems it necessary to always provide timely and adequate information to its users who are working in the different fields of nutrition.

The need to innovate the FEL is important because of the rising number of Filipino clients with lifestyle-related diseases who will avail of nutrition education and counseling. In improving tools for clients, simplicity, ease of use, user-friendliness, and visual appearance are some features that have to be considered in addition to its main or technical content.

The FEL was updated for the purpose of reviewing the calculations and grouping of foods based on current tools and nutritional recommendations, improving the methods of assessing individuals using updated methods, and enhancing the design and appearance of the handbook.

METHODSThe study protocol was approved and project implementation was cleared on 28 March 2017 by the Department of Science and Technology–Food and Nutrition Research Institute’s (DOST-FNRI) Institutional Ethics and Review Committee (Protocol Code FIERC-2017-006). Signed informed consent forms were obtained from the study participants prior to data collection. Participants were informed of the confidentiality of all the information obtained from them and that their participation in the study is voluntary and they can withdraw from the study anytime without penalty. Data collection was conducted from April 2017–March 2018. The authors declared no conflict of interest on this project.

The steps undertaken in coming up with the 2019 FEL were: 1) collection of data on the needs of FEL users by means of survey and FGDs, 2) review and computations of the macronutrient content of exchange portions of each food item, and 3) revision/updating of content and design of handbook.

SurveyThe survey among FEL users was done using a pre-tested, semi-structured self-administered questionnaire. Survey questions evaluated the technical content, the physical attributes – comprehensibility, usefulness, layout, and design – that were used to improve the 1994 FEL handbook.

The target population was users of FEL in the Philippines. The RNDs were initially targeted as respondents, but the addition of student respondents was later on considered as users of FEL in school. The inclusion criteria for FEL users were any of the following: 1) RND staff in hospitals and wellness centers, 2) teachers of major nutrition courses using FEL, or 3) students of nutrition in their senior years. Excluded from the study were non-users of FEL or persons not belonging to the mentioned criteria. The number of respondents was calculated based on a 50% proportion of FEL users, with 95% confidence and a 1.0 design effect. Using the Open Epi software version 3.01, the number of respondents needed to satisfy the sampling conditions was approximately 400 individuals (Dean et al. 2013).

A listing of RNDs from government and private hospitals of the National Capital Region (NCR) and other areas was secured from heads of dietary, food service, and nutrition clinics via phone inquiry or internet search. Letters were sent to these institutions to request their participation. The survey questionnaires and consent forms for the RNDs were sent either by courier, personal delivery and pick-up, or email.

Philippine Journal of Science Vol. 150 No. 5, October 2021

Orense et al.: Updating of the Philippine Food Exchange Lists for Meal Planning

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For respondents in the academe, a listing of schools offering nutrition programs was obtained from the Professional Regulation Commission. Schools with high enrollment in nutrition programs were selected to represent the students who use the FEL. Coordination with the school and the faculty handling major nutrition subjects was made through letters of request or email, which were sent to school heads or the faculty concerned. The distribution and retrieval of the forms from the school to the researchers were also done by the faculty-contact person. Consent forms were also attached to the questionnaire to seek approval to participate in the study.

FGD and Expert Group ConsultationConsultation meetings through FGDs were conducted in Manila, Cebu, and Davao in order to represent the RNDs from the three main islands (Luzon, Visayas, and Mindanao) of the country. RNDs involved in clinical nutrition, with supervisory positions, and among educators/teachers/professors using the FEL in teaching were recruited for the FGD. For each area, participants were identified through inquiries from corresponding institutions to represent the clinical, school, or food service so that varied responses can be gathered from each sector. One FGD group was composed of 12 participants. A member of the research team facilitated the discussion using guide questions that were similar in content with the survey from FEL users. Specifically, the FGD solicited suggestions on the existing food groupings or lists, items to add and/or delete in the 1994 handbook, and items to include for this revision.

The researchers audio-recorded the comments and suggestions of the participants together with hand-written notes taken simultaneously during the FGD session. Data were organized according to similar topics or themes.

Aside from the survey and FGD, an expert group in the field of clinical nutrition consisting of five RNDs and a medical doctor was consulted on the technical contents and various aspects of the development and revision process of FEL. The group also had varied expertise in research, policymaking, and foodservice.

Macronutrient Computation and Grouping of Foods The seven food groups in the 1994 edition (DOST-FNRI 1994) were used as the starting point to classify the exchanges – vegetable, fruit, milk, rice, meat, sugar, and fat – as recommended by the expert group and FGD participants. Additional food items were included in each group based on the suggestions from the survey, FGD, and expert group. Data on the most common foods consumed by Filipinos from the 2013 National Nutrition Survey (DOST-FNRI 2015) also served as an additional data source.

A working database file was kept for each food group that contains information on the food item description, nutrient contents, and a food code that matched an item in the 2017 Philippine FCTs.

The macronutrient and energy contents of foods were calculated from the new FCTs (DOST-FNRI 2017a) and other food databases such as those from Australia, ASEAN, Japan, Korea, and the US. Using Microsoft Excel software, the edible portion (EP) weight of the food was determined to provide one exchange portion. Small adjustments were made on the weight of the food per exchange to avoid difficulty in translating it to household measure, e.g. fractions of a spoon or teaspoon. The cut-off values for macronutrients per exchange that served as a guide for the food groupings were based on previous editions of FEL but were also agreed upon with the expert group.

Mean, standard deviation (SD), and 95% confidence interval (CI) of the macronutrients were computed for each food group and subgroup. Foods that did not meet the value or range of macronutrients per group were classified under “selected foods,” where the number of exchanges of a food group was indicated instead, such as rice, meat, fat, or sugar exchange.

Actual food samples were purchased from different supermarkets, public markets, and other sources. For each food item, weighing was done using an electronic digital scale (Shimadzu UX2200 H), values were recorded to the nearest whole number in gram (g), while a standard ruler with millimeter and centimeter (cm) units was used to measure the food item’s dimension in cm. Thereafter, foods were described in household measures (e.g. cup, tablespoon, or teaspoon) or in terms of its dimension (length, width, and height or diameter in cm) when there is no fixed portion size. Photos of one exchange of food samples were compiled for documentation.

Revision, Updating, and Design of the 4th Edition FEL Handbook The revised or 2019 FEL was formatted with three parts – introduction, food exchange groups, and appendices. The introduction provided basic information on the use of the food exchange groups, i.e. the steps in dietary calculation and the menu plan. The seven major food lists and groups – vegetable, fruit, milk, rice, meat, fat, and sugar – with detailed description and measurement in exchange unit presented in Part 2. The Appendices section contained all other food lists and nutrition assessment tables relevant to meal planning and diet instruction. The final version of the handbook, including the layout, was based on suggestions from the survey, FGD, and the expert group. Another activity in the completion or finalization stage



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was the final review done by the DOST-FNRI technical staff and external peer reviewers.

Data Processing and AnalysisData on the survey part used descriptive statistics to generate frequency distributions on the profile of respondents and evaluation on selected physical attributes of the 1994 FEL handbook – comprehensibility, clarity, and usefulness. For the FGD, transcribed data were organized and similar topics or themes were analyzed and combined for tabulation. The recurring themes were categorized as follows: food subgroups, weights and measures, foods to delete, foods to add, and foods to regroup – including the other relevant remarks presented by the group. All responses obtained from the survey and FGDs were discussed with the technical experts for final resolution.

For the calculation of food exchanges, the computed energy, carbohydrate, protein, and fat values were presented as mean, SD, and 95% CI. All descriptive statistical analyses were performed using SPSS (version 20, IBM, Armonk, NY, USA).

RESULTS

Profile of Respondents Of the total 529 survey respondents composed of RNDs and students, 54.5% were from NCR and the rest were from other parts of the country. The RNDs comprised about 60% of the total respondents while almost 40% were nutrition students in their senior year in college and had used the FEL. The majority of the respondents were females while only about one in 10 respondents were males. In terms of educational attainment of RNDs, about 14% attained a postgraduate degree. Most of the RND respondents (83.2%) were affiliated with hospitals and more than half were working for five years or less. By location of work, the majority were from NCR (78.2%), while the rest were from Regions 4A, 11, 7, 2, 1, and Cordillera Administrative Region (CAR). The student respondents were highest in the Region 4A area (Table 1).

The FGD participants (n = 36) were mostly affiliated with hospitals (63.9%) and the academe (30.5%). Two participants were medical doctors with nutrition backgrounds and experience in clinical nutrition (no table presented).

Survey on the 1994 FEL HandbookAs shown in Table 2, from the point of view of RNDs, the FEL was intended for use by hospitals or clinical RNDs

(98.1%), instructors/professors of nutrition (86.8%), and students (89.7%). The majority of student-respondents (93.8%) agreed that the FEL was intended for them, followed by the hospital and clinical RNDs (85.2%), faculty (74.2%), and health workers (61.4%). As to its usefulness, the majority (65.7%) of all respondents said it was very useful, while a third of the respondents (33.7%) found the FEL to be a useful tool.

Respondents were asked how they used the FEL in their jobs. According to RNDs, the FEL is used mainly for meal planning (85.6%) and nutrition counseling (82.4%). For student-respondents, the majority (90.5%) also used the FEL for meal planning, then as personal reference in more than half of this group.

In terms of its physical attributes, the majority of the RNDs and students agreed that the title “Food Exchange Lists for Meal Planning” was very clear (51.4%), while 47.4% of said the title was clear/fairly clear and very few (1.2%) found the title not clear. Almost the same proportion of RNDs (87.0%) and students (85.9%) mentioned no confusing words encountered. However, few respondents (13.0% and 14.1%) of RNDs and students, respectively, found some items that confused them.

The comments on the physical attributes of the FEL were covered to improve the visual appearance of the handbook (Table 2). These were expressed in terms of the layout design, use of language, use of pictures or illustrations, and additionally, the features that the respondent found to be attractive. Results showed that while the layout design and language were rated as appropriate by a greater proportion of all respondents (90.0 and 80.9%, respectively), a few found the layout too informal (5.5%) and language (11.0%) too difficult. Also, more than half (54.5%) claimed that the illustrations/pictures were not attractive. A few respondents of the RNDs and students identified the features that attracted them and these include the cover design (17.9%), font size (13.4%), illustrations (8.9%), and layout (15.3%).

The suggested changes in the content of the food listing were combined for RNDs and students (Appendix Table I). Merging of data was done to have a common basis for the changes to be incorporated in the update of the FEL. The addition of more foods was suggested by a large proportion of respondents (40%) for vegetable, fruit, milk, rice, and meat. About three out of 10 respondents suggested including both the “as purchased” (AP) and EP weight of foods especially for vegetables and fruits, while a smaller proportion was recorded for the rest of the food groups. Deletion of food items was suggested by a small proportion of about 3%. The reason for wanting to delete was the unavailability of foods in the market and that the food was no longer consumed in the area. For



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vegetable and fruit, diameter measurement was favored for deletion by 27.1 and 14.1% of respondents, respectively, while a lower proportion was observed for the rest of the food groups. An issue for the change in the carbohydrate content of the rice exchange was posed as a question and about 8% were in favor of the move.

The survey respondents also suggested foods to add or delete and improve in the forthcoming handbook (Appendix Table II). For the vegetable exchange, the

inclusion of more commonly eaten food available in the market, and the addition of different varieties of vegetables like mushroom or cabbage were suggested. The name of group A or B vegetables as a subgroup was found confusing to some respondents. In the fruit exchange, imported fruits and some local/indigenous fruits – including their varieties like banana and melon – were suggested for addition while those not commonly eaten like anonas, datiles, mabolo, and tamarind can be deleted. For easy recognition for fruits, pictures or illustrations help

Table 1. Profile of survey respondents (n = 529).

VariableRNDs Nutrition students All respondents

n % n % n %

Sex

Male 28 8.8 36 17.1 64 12.1

Female 291 91.2 174 82.9 465 87.9

Total 319 60.3 210 39.7 529 100.0

Educational attainment

Undergraduate 0 0 210 100 210 39.7

College graduate 273 85.6 0 0 273 51.6

Master’s degree 43 13.5 0 0 43 8.1

Ph.D. 3 0.9 0 0 3 0.6

Total 319 60.3 210 39.7 529 100.0

Affiliation Hospital Academe Food service/industry Nutrition/fitness center Total

262221714315

83.27.05.44.460.3

020700

207

010000

39.7

.2622291714522

50.243.93.32.7

100.0

Number of years as RND

< 2 yr2–5 yr6–10 yr11–15 yr16– 20 yr> 20 yrTotal

1186632191947301

39.221.910.66.36.315.6100

––––––

–––––––

1186632191947301

39.221.910.66.36.315.6100

Region

NCRRegion 4ARegion 11Region 7Region 12Region 10Region 5Other regions (CAR and Region 1)Total

2482328160002

317

78.27.38.85.0000

0.6

60.4

38811314302552

208

18.338.96.26.7

.14.412.02.41.2

39.6

2861044130302554

525

54.519.87.85.75.74.81.00.8

100.0



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Table 2. Survey on the attributes of the 1994 FEL Handbook among FEL users.

VariablesRNDs (n = 319) Nutrition students (n = 210) All respondents (n = 529)

n % n % n %

Users of FELa

Hospital/clinical RND

313 98.1 179 85.2 492 93.0

Instructors/professors 277 86.8 156 74.2 433 81.9

Students 286 89.7 197 93.8 483 91.3

Health workers 185 58.0 129 61.4 314 59.4

Othersb 59 18.5 5 2.4 64 12.2

Usefulness of the FEL

Very useful 185 62.9 139 69.8 324 65.7

Useful 108 36.7 58 29.1 166 33.7

Not useful 1 0.3 2 1.0 3 0.6

Total responsec 294 59.6 199 40.4 493 100

Uses of the FELa

Meal planning 273 85.6 190 90.5 463 87.5

Nutrition counseling 263 82.4 93 44.3 356 48.4

Teaching 141 44.2 38 18.1 179 33.8

Personal reference 212 66.5 120 57.1 332 62.8

Othersd 21 6.6 7 3.3 28 5.3

Clarity of the title

Very clear 165 53.0 102 49.0 267 51.4

Clear/fair 143 46.0 103 49.5 246 47.4

Not clear 3 1.0 3 1.4 6 1.2

Total responsec 311 59.9 208 40.1 519 100

With confusing words/phrases

Yes 37 13.0 27 14.1 64 13.5

None 247 87.0 164 85.9 411 86.5

Total responsec 284 59.8 191 40.2 475 100

Lay-out design

Too formal 18 5.8 8 2.5 23 4.5

Appropriate 271 87.7 190 93.6 461 90.0

Too informal 20 6.5 8 3.9 28 5.5

Total responsec 309 60.4 203 39.6 512 100

Language

Simple 25 8.2 16 7.9 41 8.1

Appropriate 239 78.1 172 85.1 411 80.9

Too difficult 42 13.7 14 6.9 56 11.0

Total responsec 306 60.2 202 39.8 508 100

Illustrations/pictures

Very attractive 2 0.7 4 2.0 6 1.2

Attractive 117 38.6 106 52.5 223 41.1

Not attractive 184 60.7 92 45.5 276 54.5



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to recognize less-common foods. In the milk group, all types and variants of milk and products were suggested, including rare and imported ones. Adjustment of the measures per exchange was also suggested for powdered milk and other milk alternatives, non-dairy milk, flavored milk drinks, and commercially prepared milk for use in certain disease conditions.

For the other food groups, respondents suggested more food items in the rice exchange such as native delicacies and varieties of noodles and pasta. There was also a suggestion to make a separate list for starchy and non-starchy foods and that the collective term or name of the group as “rice exchange” may not be appropriate because other non-rice items were also included.

For the meat group, various meat sources (lamb, turkey, rabbit), new types of processed food, fast foods, and plant or soybean-based proteins/products were recommended. Respondents also suggested the use of realistic and practical ways to estimate portion sizes such as the use of palm or a deck of cards as examples. Foods with possible health risks should also be properly described, such as chicken with or without skin, and the cholesterol content of these foods need to be stated. For the fat exchange, new products were again identified to be included in the list, particularly those with health implications, while obsolete brands were to be deleted. In the sugar exchange, more foods that are commercially available in different flavors were suggested, including international brands of sugar/sweet products/items. A review of serving portions was also mentioned because of changes in the sizes of new products.

Information from the FGDComments and suggestions from the FGD group served to validate the data from the survey. The advantage of this data collection method was the face-to-face communication that allowed researchers to see the

expression of respondents and the truth in their words. The comments and suggestions from the FGD were similar to what was obtained from the survey, and these are summarized as follows:

1. Retain the current reference values of macronutrients and energy per exchange for the seven food groups.

2. For all food groups, add more food items and their variants. Include local and international and new foods that are available in the market and are commonly consumed.

3. Reclassify the vegetable subgroups and the milk group, but the meat and fat subgroups were to be retained.

4. Retain measurements in household measures and EP weight in g for all food groups.

5. All the participants agreed to remove the number of calories in the “vegetable A” subgroup. A suggestion was made to validate the macronutrient values and reclassify some items in the vegetable exchange like mung bean and lima beans, young corn, and tomatoes which were said to be confusing.

6. For items under fruits, include local and English names. Check saba banana if this can be considered under the rice exchange instead. Also, banana cue, maruya, and turon may contain more carbohydrates and calories due to the added ingredient in cooking such as sugar and oil; hence, these can be transferred to other groups as well.

7. Update the classification of milk, but retain the skim milk classification. Add more milk products such as soy milk, goat’s milk, different types of yogurt, whey powder, and milk substitutes.

8. For the rice exchange, the majority suggested the retention of the original macronutrient content of 23 g

VariablesRNDs (n = 319) Nutrition students (n = 210) All respondents (n = 529)

n % n % n %

Total responsec 303 60 202 40 505 100

Attractive featuresa

Cover design 57 17.9 60 28.6 117 22.1

Font size 48 15.0 23 11.0 71 13.4

Content 214 67.1 146 69.5 360 68.1

Illustration 20 6.3 27 12.9 47 8.9

Layout 43 13.5 38 18.1 81 15.3aMultiple responses, % computed from total number of RNDs, students, and total respondentsbSpecific response of “others” (medical doctors, fitness workers, meal planners, food industry, nursing students, sports, patients, municipal nutrition action officer)cPercent (%) computed from total response as denominatordOthers (e.g. calorie counting and menu evaluation)



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carbohydrate per exchange, while the ADA exchange of 15 g was also suggested by other participants. It was suggested to include different rice varieties, imported grains, pasta, and noodles.

9. In the meat group, include exotic meat, meat from other animal parts, street foods, and buffet foods. Include footnotes for foods that are rich in omega-3, omega-6, monounsaturated fat, and the type of fat in the meat.

10. Reclassify margarine and mayonnaise to trans-fat, as well as canola oil and peanut butter to monounsaturated fat. Include other types of salad dressing, coconut oil in powder form, virgin coconut oil, shark oil, and all-purpose cream. Include footnotes for foods rich in omega-3 fatty acids.

11. Include sugar substitutes with disclaimer under the sugar exchange group. Add new types of sweeteners such as coco sugar, caramel syrup, muscovado, stevia, powdered sugar, and dark chocolate.

12. For the diet computations, the inclusion of body mass index (BMI) as a reference was suggested by the FGD and expert group. However, diverse methods in determining the DBW and TER were reported by participants. A consensus at that time was for the RNDs to be able to choose the method that one is comfortable with to compute DBW and TER in the calculation of the energy and macronutrient contents of foods when planning daily meals.

13. Consider a more appealing layout in landscape style and edit the spacing alignment. Use 12-font size for the text. Some groups favor retaining the old size of the handbook, but others want a bigger size with a new cover photo.

14. Consider a short version of the FEL for use by other allied health professionals like doctors.

Computation of Macronutrient and Energy Values per ExchangeTable 3 shows that the mean macronutrient values per exchange were within the reference values or 95% CI of the means. The mean carbohydrate in the rice and sugar groups were about 1–2 g from the given values but were still within the cut-off range of more or less than 5 g. Mean protein from milk and meat groups were similar per exchange, but it was the fat content that varied from each subgroup as could be noted from its wider SDs. For the rice group, mean values for protein per exchange were varied for the low-, medium-, and high-protein subgroups. The final FELs and reference values for energy and macronutrients of food exchanges used in diet computation is also presented in Appendix Table III.

The 4th Edition FELs for Meal Planning: Composition and Summary of Major ChangesThe updated FEL handbook was completed with three main components – the introductory part, food exchange groups, and the appendices. The main part highlights the food exchange groupings and the list of foods containing the Filipino or common and English names, EP weight, and household measure with selected pictures of foods per exchange (Figure 1). The FEL generated 525 items within the seven exchange groups. Additional tables in the appendices were on selected foods (164 food items), beverages (52 food items), alcoholic beverages (27 food items), and free foods (44 food items). The Appendices also contained references on fatty acid content of fats and oils, methods of pediatric computations, a quick reference for dietary prescription, and a new table on desirable weight according to normal levels of BMI.

The changes made in the 4th edition FEL are summarized as follows:

1. Computation of the macronutrient values using the newly-updated Philippine FCTs (DOST-FNRI 2017b). Use of other food composition databases such as those from the US, Australia, Korea, and Japan were employed in the absence of macronutrient values in the Philippine FCTs. Carbohydrate value represents available carbohydrates.

2. Regrouping of food groups and renamed subgroups based on recomputed macronutrient content.

• Vegetable exchange only included ≥ 3 g of carbohydrate and 1 g of protein.

• Rice exchange was grouped into “rice A” (low-protein), “rice B” (medium-protein), and “rice C” (high-protein).

• Lists of foods were arranged in alphabetical order based on their Filipino names.

3. Additional predictive equations for deriving the DBW and TER were included.

4. Photos of selected food items per exchange were included in the handbook.

5. Additional contents were also included, such as a list of acronyms, abbreviations, and glossary of terms, plus a listing of sample physical activity by level and intensity.

DISCUSSIONNutrition tools like the FEL have to be periodically reviewed and revised to make them more relevant and useful to primary users and intended audience. The



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availability of various foods in the market affecting food habits, updates on nutrition and dietary guidelines, and updates of the local food composition database paved the way to revise the 1994 FEL.

In this revision, the seven food groups in the previous FEL version were adopted as the main components of foods for

Table 3. Reference value, computed energy, and macronutrient contents of one exchange and 95% CI [LL, UL] per food group.

Food groups and sub-groups n Energy(kcal)

Carbohydrate(g)

Protein(g)

Fat(g)

Vegetable 40 (16) 17 ± 6[15.0, 19.0]

(3) 2.6 ± 1.3[2.2, 3.0]

(1) 1.1 ± 0.7[0.93, 1.4]

–0.2 ± 0.1

Fruit 91 (40) 42 ± 3[41.2, 42.5]

(10) 9.3 ± 0.8[9.1, 9.5]

–0.5 ± 0.4 –0.3 ± 0.2

Milk

Whole 8 (170) 181 ± 30[156.0, 205.6]

(12) 12.6 ± 2.7[10.3, 14.9]

(8) 9.4 ± 0.9[8.7, 10.1]

(10) 10.3 ± 3.8[7.1, 13.5]

Low fat 2 (125) 138 ±13

(12) 15.4 ± 3.4 (8) 9.8 ± 0.6 (≤ 5) 4.1 ± 0.5

Non-fat/skim 5 (80) 85 ± 5[78.8, 91.9]

(12) 12.1 ± 0.8[11.1, 13.1]

(8) 8.4 ± 1.4[6.7, 10.2]

(< 1%) –0.4 ± 0.3

Rice

Low protein 26 (92) 94 ± 6[91.3, 96.1]

(23) 22.1 ± 1.9[21.3, 22.8]

–0.5 ± 0.4 (—) 0.4 ± 0.4

Medium protein 46 (100) 99 ± 14[94.8, 111.5]

(23) 21.5 ± 3.8[20.3, 22.6]

(2) 1.8 ± 0.6[1.7, 2.0]

(—) 0.6 ± 0.6

High protein 23 (108) 106 ± 6[94.6, 108.6]

(23) 20.6 ± 1.7[19.9, 21.3]

(4) 3.7+ 0.3[3.6, 3.8]

(—) 1.0 ± 0.6

Meat

Low fat 115 (41) 46 ± 11[44.3, 48.5]

–0.3 ± 0.7 (8) 8.9 ± 2.1[8.5, 9.2]

(1) 1.1 ± 1.0[0.9, 1.3]

Medium fat 32 (86) 82 ± 13[77.7, 86.7]

–0.7 ± 1.1 (8) 8.0 ± 1.6[7.4, 8.5]

(6) 5.3 ± 1.4[4.8, 5.8]

High fat 26 (122) 127 + 10[122.6, 130.7]

–1.1 + 1.1 (8) 7.9 ± 1.6[7.3, 8.6]

(10) 10.1 ± 1.3[9.6, 10.6]

Sugar 51 (20) 21 ± 5[19.5, 22.3]

(5) 4.8 ± 1.2[4.41, 5.11]

–0.1 ± 0.3 (—) 0.1 ± 0.3

Fat 60 (45) 47 ± 6[45.4, 48.9]

–0.8 ± 1.0 –0.7 ± 1.2 (5) 4.6 ± 0.7[4.4, 4.8]

Items in parentheses ( ) are reference and also the final values in diet computation, while those in [ ] symbol are 95% CI.Values expressed as means ± SD represent computed macronutrient contents.Symbol (—) means that the number is not included in diet computation.

substitution. Also, based on general suggestions from the survey, FGD, and expert group, more foods were added and very few items were deleted. The inclusion of more foods that are familiar to more people can help make better food choices and enhance their compliance to follow the recommended diet. To update the food list, corresponding



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Figure 1. Food Exchange Lists for Meal Planning, 4th edition sample content.

nutrient data should be available from local sources and fits the description of the new food.

The development of food exchange groups mainly involved a decision on the foods to include in the list and the amounts in EP weight in g per exchange portion. To attain homogeneity of macronutrient content, each food should conform to the given range of macronutrients of the group so that it can be “exchanged” or substituted with another. A food item that does not meet the criteria is regrouped under “selected foods,” wherein the macronutrient exchanges are given per serving portion instead of the weight or dimension. Subgroups for milk and meat groups were already formed in previous FEL versions to specify the level of fat (Madlangsakay 1965;

Tanchoco et al. 1994).

The vegetable grouping in the previous FEL had relatively more varied opinions and interpretations compared with the other food groupings. To some users, the term “vegetable A and B” was confusing if exclusively meant for leafy or non-leafy vegetables though there was no mention in the 1994 FEL that “vegetable A” consisted mostly of leafy vegetables. This may have been due to the slight difference in defining the groups in previous versions (Madlangsakay 1965; Tanchoco et al. 1994) and the changes in the nutrient value of revised FCTs such as for eggplant, cucumber, and chayote as examples (DOST-FNRI 1994).



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In the updated FEL, the simplified grouping of vegetables into fresh and processed subgroups used in the old version was adopted. However, vegetables with negligible macronutrients were placed in a separate list and intake of more vegetables from this group is encouraged as a healthy option to everyday meals.

A modification of the rice exchange was made due to the wide variation of protein content when treated as a single group. Some locally available rice varieties had much lower protein contents compared to ordinary rice. Thus, the regrouping of rice items into low-, medium-, and high-protein content resulted in more homogenous rice subgroups. The foods in the low protein subgroup have more starch but negligible protein such as root crops, starchy foods, and newly developed low-protein rice. The rice group with moderate protein is the usual rice and rice product, while the high-protein rice subgroup includes most bread and bakery products. Calculation of the rice exchange under this new grouping can improve the planning of meals for patients who need to consider protein intake, such as those with kidney problems or other disorders that need to rest the kidneys.

The unit for rice was 23 g carbohydrate, which is equivalent to about half a cup per exchange. This measure was considered practical and easy to visualize in ordinary circumstances and with limited use of measuring tools. Rice as the staple food is consumed daily in every Filipino household. With more people diagnosed with diabetes, the measurement of rice intake is crucial in the control of blood sugar. The use of one carbohydrate unit varies among countries. In Asia, for instance, South Korea’s rice exchange is similar to that of the Filipinos that utilize the 23-g carbohydrate portion (Ju et al. 2011). Other countries such as Malaysia (MDES 2016) and Taiwan use 15 g, while Hong Kong uses 10 g carbohydrates per exchange (HFHB 2010).

Aside from the main food groupings, some tools and methods of dietary calculation were added in the revised FEL to update nutritionists in dietary planning. Specifically, the formulas for estimating energy requirements in the Philippine Dietary Reference Intakes (DOST-FNRI 2017b) were included among the options for TER calculation. Formulas or short-cuts used in nutrition assessment were either added (e.g. TER, basal metabolic rate equations, and desirable weight range for normal BMI range) or deleted (weight-for-height table for Filipinos) based on literature and recent guidelines. The instruction to guide the calculation of diet prescription was organized systematically using numbered sequences.

Moreover, the unit of measure is still referred to as “exchange” rather than “serving” because in most cases, an exchange portion is different from a serving portion.

A serving portion indicates the amount of food that can be usually consumed by an individual at one time or one meal. For example, a serving of meat or fish may consist of two to three pieces, with each portion approximately the size of one matchbox but would be considered as equivalent to two to three meat exchanges depending on the institution such as hotels, hospitals, and restaurants it is being served.

The enhancement of the design and appearance of the handbook such as color-coded food groups, a background of tables, colored photos of actual food photos, and size of the handbook was done based on the suggestions from the survey, FGD, and expert group.

The unavailability of nutrient analysis of new foods and their variants in the local food database and the challenges in finding the exact match of local foods in foreign FCTs limit the food items that can be included in the food exchanges. In the case of regional or ethnic foods, finding an exact match of the product might be difficult because of a lack of standard recipe and/or regional variations.

While efforts were exerted to compile the foods and nutrient composition data, the local food database can also be expanded to include regional sources so that these can provide more alternative foods to individuals from other regions or areas of the country.

Nonetheless, the updated FEL presented a wider choice of more food sources from all the food exchange groups and in the selected food and beverage lists, as well as guidance in using the FEL and in calculating and planning diets.

CONCLUSIONSThe recomputed food items in each group had mean amounts of macronutrients that were close to the reference value or within the 95% CI. The rice group was reclassified into low-, medium-, and high-protein subgroups due to the large variation in protein levels in the whole group. The fat content of the meat and milk group was more varied than the other macronutrients of these groups, which explains the subgroupings done to maintain homogeneity of the macronutrient content. The total number of foods reviewed or recomputed was 525 items from the seven food groups/lists – vegetable, fruit, milk, rice, meat, fat, and sugar. This excludes other foods outside the food exchanges/lists such as the 164 items from “selected foods,” which were also recomputed to estimate the number of macronutrient exchanges per serving.

Update of procedures in planning and calculating diets was done by adding predictive equations to compute for TER based on the PDRI.



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The design and appearance of the handbook were enhanced with color-coded food groups and the background of tables plus colored food photos for ease in visualizing an exchange portion.

ACKNOWLEDGMENTSThe authors wished to thank the survey and FGD participants and expert groups; research assistants Merlyn G. Tajan, Joan Pauline F. Forcadilla, and Dianna Rose F. Aytona; and members of the DOST-FNRI Technical Committee – namely, Ms. Mildred A. Udarbe and Ms. Julieta B. Dorado – for their invaluable insights/input.

NOTES ON APPENDICESThe complete appendices section of the study is accessible at http://philjournsci.dost.gov.ph

REFERENCES CASO EK. 1950. Calculation of diabetic diets. J Am Diet

Assoc 26: 575–583.

CORPUS VA. 1953 (October–December). The calculation of dietetic diets. Nutr News 6: 4–9.

DEAN AG, SULLIVAN KM, SOE MM. 2013. Open Epi: Open Source Epidemiologic Statistics for Public Health, Version [Updated 06 Apr 2013]. Retrieved from www. OpenEpi.com

[DOST-FNRI] Department of Science and Technology–Food and Nutrition Research Institute. 2017a. Philippine Food Composition Tables (PhilFCT) Online Database. iFNRI Website. Retrieved in January 2017 from http://i.fnri.dost.gov.ph/fct/library

[DOST-FNRI] Department of Science and Technology–Food and Nutrition Research Institute. 2017b. Philippine Dietary Reference Intakes (PDRI) 2015: Summary of Recommendations. Taguig City, Philippines.

[DOST-FNRI] Department of Science and Technology–Food and Nutrition Research Institute. 2015. Philippine Nutrition Facts and Figures 2013: Food Consumption Survey. Taguig City, Metro Manila, Philippines.

[DOST-FNRI] Department of Science and Technology–Food and Nutrition Research Institute. 1994. Food Exchange Lists for Meal Planning, 3rd Revision. Taguig City, Philippines.

FLORES EG, VILLADOLID MP, BASIG CC, TANCHOCO CC, VELANDRIA FV. 1984. Revised Food Exchange Lists for Meal Planning. Philippine Journal of Nutrition, October–December. p. 201–207.

GEIL PB. 2008. Choose Your Foods: Exchange Lists for Diabetes: The 2008 Revision of Exchange Lists for Meal Planning. Diabetes Spectrum 21(4).

[HFHB] Hong Kong Food and Health Bureau. 2010. Hong Kong Reference Framework for Diabetes Care for Adults in Primary Care Settings. Retrieved in December 2018 from https://www.fhb.gov.hk/pho/rfs/src/pdfviewer/web/pdf/diabetescare/en/15_en_RF _DM_full.pdf

JU DL, JANG HC, CHO YY, CHO JW, YOO HS, CHOI KS, WOO MH, SOHN CM, PARK, YK, CHOUE RQ. 2011. Korean Food Exchange Lists for Diabetes: Revised 2010. J Korean Diabetes 12(4): 228–244. https://doi.org/10.4093/jkd.2011.12.4.228

MADLANGSAKAY R. 1965. Food Exchange Lists in the Estimation of Selected Nutrients in Mixed Diets. Philippine Journal of Nutrition. July–September. p. 167–183.

[MDES] The Malaysian Diabetes Educators Society. 2016. Diabetes Education Manual 2016. Retrieved in January 2017 from https://mdes.org.my/wp- content/uploads/2017/04/Final_Diabetes_Edu_Manual_hires_facing_pg.compres sed.pdf

TANCHOCO CC, VILLADOLID MF, CRUZ AJ. 1994. Evaluation and Revision of the Food Exchange List for Meal Planning. J NDAP 8(2): 52–58.

WHEELER ML, FRANZ M, BARRIER P, HOLLER H, CRONMILLER N, DELAHANTY LM. 1996. Macronutrient and Energy Database for the 1995 Exchange Lists for Meal Planning: A Rationale for Clinical Practice Decisions. J Am Diet Assoc 96(11): 1167–1171.

WHEELER ML, DALY A, EVERT A, FRANZ MJ, GEIL P, HOLZMEISTER LA, KULKAMI K, LOGHHMANI E, ROSS TA, WOOLF PZ. 2008. Choose Your Foods: Exchange Lists for Diabetes 2008: Description and Guidelines for Use. J Am Diet Assoc 108(5): 883–888.



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APPENDICES

Table I. Percentage distribution of responses of survey participants on the suggested changes in the food listing.

SuggestionFood exchange group

Vegetable Fruit Milk Rice Meat Fat Sugar

Add more foods 46.1 45.3 36.4 39.0 37.9 25.0 29.0

Delete food items 3.0 1.9 0.8 2.9 1.3 0.6 1.5

Include AP and EP weight 36.0 31.2 15.2 19.4 20.8 13.9 14.1

Use household measures 19.0 17.5 10.5 12.6 13.1 9.9 11.0

Delete “diameter” in household measure

27.1 14.1 5.1 9.3 9.9 5.5 7.2

Change reference portion None None None 7.7 None None None

Food group Comments and suggestions

Vegetable exchange

Add Commonly consumed vegetables from National Nutrition Survey (NNS): more vegetables like alfalfa, artichoke, arugula, broccoli, kale, sugar, beets, zucchini; ethnic and local foods – gising gising, lubi lubi; imported vegetables; canned and processed vegetables; varieties of cabbage, lettuce, mushroom, pechay; young corn

Delete Vegetables not commonly consumed: alagaw; bataw, canned chestnuts, golden sweet corn, himbabao, talinum

Other comments

Review accuracy of Group A and B vegetables; define group A and group B vegetables; do not classify “vegetable A” as leafy; include serving portion in household measure; list exact measure of mixed vegetables; generalize sizes; indicate local and English names for uncommon vegetables; list starchy and non-starchy vegetables separately; include colored photos or illustrations; cultural, ethnic, and religious considerations

Fruit exchange

Add Local and common varieties of fruits – atis, aratiles, bignay, cacao fruit, dragon fruit, guyabano, kamias, jackfruit, mangosteen, marang, passion fruit, santol, wild fruits; imported fruits – apricot, blueberry, cranberry, kiwi, lemon, longan, lychee, peaches, pears, persimmon, plum; varieties of citrus fruits – kiat-kiat, dalandan, ponkan, pomelo; varieties of banana – senorita; melon – cantaloupe, honeydew; varieties of fruit juices, all-natural or otherwise, açai berry, fruit shake; canned fruits

Delete Fruits not commonly eaten – tamarind; anonas, makopa, marang, datiles, mabolo, balimbing, camachile

Other comments

Use realistic measurements; use pictures; include Tagalog name of food items

Milk exchange

Add Add common milk brands; specific milk brand; non-dairy milk – rice, soy, almond milk; goat’s milk; cultured milk; fermented milk – kefir; chocolate-flavored non-fat milk; fortified milk; flavored milk and yogurt; yogurt milk; brands of yogurt; milk formulas; enteral formulas; commercial supplemental milk – diabetes and others; breastmilk; industrial cheese; different types of milk tea; coffee-flavored milk drink; milkshake

Delete Buttermilk and brand of skim milk no longer available

Other comments

Include milk from different sources; milk replacement formulas; lactose-free milk. use of household measure for one serving portion; change one serving powdered milk of 4 level tbsp; adjust exchange measures; classify items; add international brands; include enteral formulas and nutrition composition

Rice exchange

Add Commonly eaten foods listed in NNS and those available in the market; more rice and rice products; varieties of colored rice; malagkit flour; rice substitutes; variety of grains – adlai, buckwheat, barley, quinoa, granola; variety of biscuits, cakes, cookies; cakes with and without frosting; varieties of breads and pastries – bagel, bun, cornbread, dinner rolls, Spanish bread; fast food items – chao fan; native delicacies/kakanin – bilo bilo, binignit, maha, rice cake, breakfast cereals; sugar-coated cereals; varieties of noodles and pasta – couscous; imported items; variety of doughnut flavors; taco shells

Delete Cornstarch, flour, masapudrida, ice cream, tupig, pan de limon, bibingka,suman marwekos, apas, non-Filipino cuisine

Other comments

Use starch instead of rice in terminology; this group should not be called “rice”; separate list of foods under starch and non-starchy category; use common names; use simpler measures of rice products; specify cake with or without icing; more processed products; update weights and measures of products; relocate beans and nuts, ice cream; add picture of foods

Table II. Comments and suggestions of survey participants on items to add or delete in the revision of FEL.



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Food group Comments and suggestions

Meat exchange

Add Common foods from NNS data; meat from goat, lamb, rabbit, turkey; cured, canned, and processed meat – hotdog of different sizes and varieties; more cold cuts, burger patties; sweet ham; more species of fish, shellfish, and seashells – cream dory, eel, salmon, sea urchin, yellowfin tuna; canned and processed products – sardines; street foods - kikiam, siomai, chicken skin; plant proteins – textured vegetable protein, vegemeat, gluten, soy products; fast food items; more/all types of cheese and products; egg white and egg substitutes

Delete None

Other comments

More realistic measurement sizes (bigger portions); measurement is confusing; adjust serving portion; reword some confusing measurements; use modern terms for estimating size such as palm/deck of card for size instead of matchbox; include pictures; update weights and measures; use appropriate measuring tools; place English name for uncommon fish/shellfish; include serving portions of fish parts; indicate amount fat for chicken, indicate if with or without skin; indicate cholesterol content in each food item; describe medium and small size chicken wings; include tilapia under medium or a large variety of fish; refer to ADA meat exchange list; take note 1 serving is 1/3 palm size

Fat exchange

Add New products in this group; international items; kinds of salad dressings and sandwich spread flavors; lite mayonnaise; lard; fortified oils; different margarine types; oils with MUFA; chicken and fish skin; ghee butter; instant coconut cream; varieties of nuts and seeds – cashew, walnuts, pistachio, macadamia, hazelnut, pecans, flaxseed, pumpkin/ watermelon/jackfruit/rimas seeds; sugar-coated pili nuts; all types of fat for frying; chicken oil

Delete Chicharon; pili nut; rapeseed

Other comments

Include serving portion in household measure; change existing serving; separate fat from oils and nuts; update fatty acid composition

Sugar exchange

Add Commonly eaten foods from NNS data; more choices; all sugar and sugar products; cake muffin/cupcakes; sugar icing; choco and maple syrup; candied fruits; candies and chocolate all forms; jellies including fruit-flavored individually packed; commercially flavored drink like coconut; different ice cream flavors; agave; muscovado; bottled iced tea; powdered juices, milk drinks/shakes; sugary drinks from cafes; coffee blends; artificial sweetener; international brand of candies and chocolates; cotton candy; coco sugar; sweet desserts; new icing and creams

Delete Champoy; pakaskas; tira-tira, panutsa, sugar substitutes; obsolete brands

Other comments

Update food items; change existing serving; more specific description of product and ingredients; specify dimension of tira-tira and chewing gum

Note: foods listed in the 1994 FEL were excluded in this table.

Table III. Energy and macronutrient composition of exchanges.

List Food exchange groupCarbohydrate

(g)Protein

(g)Fat(g)

Energy(kcal)

I Vegetable 3 1 – 16

II Fruit 10 – – 40

III Milk Whole-fat 12 8 10 170

Low-fat 12 8 5 125

Non-fat/skim/fat-free 12 8 – 80

IV Rice A Low-protein 23 – – 92

Rice B Medium-protein 23 2 – 100

Rice C High-protein 23 4 – 108

V Meat Low-fat – 8 1 41

Medium-fat – 8 6 86

High-fat – 8 10 122

VI Fat – – 5 45

VII Sugar 5 – – 20



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