This document discusses developing a practical approach to manage micronutrients and other nutrients of concern using food exchange lists for meal planning. It outlines 4 phases: 1) selecting nutrients related to chronic diseases, 2) analyzing nutrient composition in existing food exchange groups, 3) identifying groups with high nutrient variability, and 4) determining mean nutrient values for each group. Nutrients like proteins, sugars, fiber, sodium and potassium were selected based on their roles in diseases. Existing food exchange groups were analyzed and compared to unify secondary nutrients. Groups with high variability in nutrients were identified to control consumption. Mean nutrient values were then determined for each group.

1. PRACTICE APPLICATIONS
Topics of Professional Interest
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
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-
ationintermsofchronicdiseaserisk.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.
Food exchange lists have become a
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
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
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
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.
*
Both authors share equal authorship
of this article. ‡
Certified in Spain.
http://dx.doi.org/10.1016/j.jand.2017.07.020
ª 2017 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1

2. 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
content was considered high when it
provided at least 20% of the energy
value of the food group, and the poly-
unsaturated fatty acids (PUFAs),
monounsaturated fatty acids (MUFAs)
or saturated fatty acids (SFAs) contents,
when they provided more than 20%,
20%, or 10%, respectively. Similarly, a
group was classified as high in fiber
when it contained more than 6% of the
mean net weight in the form of this
component. With regard to micro-
nutrients, a food group could be
considered a source of vitamins and/or
minerals when it provided more than
15% of the European Daily Reference
Intakes (RIs).28
For other nutrients of
concern, traffic light cutoffs were
considered (20% of the daily value).29
A
food group was high in sodium when it
contained more than 480 mg per 100 g
(20% of the European RIs28
), and high
in cholesterol when it contained more
than 60 mg per 100 g (20% of American
Daily Value30
).
Phase 3
CV values outside limits in an irrele-
vant nutrient of a group could be dis-
missed; however, when high
variabilities were associated to a rele-
vant nutrient, it was necessary to
identify which foods caused these var-
iations. In these cases, the z score for
each food was calculated, and foods
with z scores outside limits (between
2) were emphasized as foods with
significantly lower or higher amounts
of a nutrient than the mean, to control
their consumption in menus planning
to avoid deviations from mean data.
Phase 4
The nutrient values of each exchange
group corresponded to the mean
nutrient value subjected to rounding.
Values were rounded down for deci-
mals 0.49 and rounded up for deci-
mals 0.5, as long as the z score of the
exchange value against the mean value
was between 1. If the z score was
outside the limits, a new rounding was
necessary until the established criteria
were met.
FINDINGS
Selection of Nutrients of Interest
Related to Leading Chronic
Diseases
From results of the evidence-based
reviews and from reports about
nutrition-related objectives, the au-
thors selected nutrients for which
over- or underconsumption could be
directly related to public health issues.
Figure 1 shows the nutrients of interest
in the dietary treatment of different
physiologic and/or pathologic states
(eg, obesity, diabetes, cardiovascular
diseases, kidney diseases, pregnancy,
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
Nutrient of concern Physiologic and/or pathologic states
Proteinsa
Sugars
Lipidsb
Fiber
Sodium
Potassium
Obesity
Diabetes
Cardiovascular diseases
Kidney diseases
Phosphorous Kidney diseases
Physiologic state: Lactation
Iron Physiologic states: Pregnancy
Calcium
Vitamin D
Physiologic states: Pregnancy and lactation
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
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3. 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
Food groups or
subgroups N
Aproteinb
(g)
Mean–SD
CV
%
Vproteinc
(g)
Mean–SD
CV
%
PUFAsd
(g)
Mean–SD
CV
%
MUFAse
(g)
Mean–SD
CV
%
SFAsf
(g)
Mean–SD
CV
%
Cholesterol
(mg)
Mean–SD
CV
%
Added
sugar (g)
Mean–SD
CV
%
Fiber (g)
Mean–SD
CV
%
Carbohydrate group
Grains/potatoes 28 0.010.04 40 2.200.71 34 0.200.14 69 0.120.12 100 0.090.07 78 0.211.13 529 0.410.32 80 1.571.41 90
3.701.50g
40
Legumes 3 00 — 6.570.74 11 0.420.37 88 0.220.28 130 0.090.03 37 00 — 00 — 4.771.03 22
Confectionary 20 0.490.43 86 1.530.68 45 0.740.66 89 2.030.88 44 2.831.18 42 19.9220.65 104 4.202.88 69 0.940.72 77
Protein group
Type I 31 6.681.54 23 00 — 0.140.09 64 0.180.17 93 0.210.24 112 29.3620.78 71 0.220.67 305 00 —
Type II 19 7.271.27 17 00 — 0.390.19 49 0.620.28 45 0.640.20 32 42.4252.11 123 00 — 00 —
Type III 15 7.022.16 31 00 — 0.820.74 90 1.790.61 34 2.091.14 55 36.0257.19 159 0.410.67 164 00 —
Type IV 30 7.051.45 21 00 — 0.440.32 73 2.720.69 25 5.471.28 23 26.76.25 23 0.130.35 28 00 —
Type V 7 6.851.31 19 00 — 1.820.51 28 6.971.07 15 5.620.87 16 38.8412.57 32 0.380.58 153 00 —
Fat group
Rich in PUFAs 6 0.030.06 200 0.380.59 155 3.100.25 8 1.230.29 24 0.590.13 21 1.253.06 245 0.180.29 162 0.190.30 159
Rich in MUFAs 12 00 — 0.710.70 97 0.780.52 66 3.081.26 41 0.690.38 54 0.421.44 34 0.350.38 110 0.720.70 96
Rich in SFAs 5 0.170.23 133 0.200.28 137 0.130.06 49 0.890.54 60 3.340.84 25 8.607.98 93 0.420.37 88 0.560.76 137
Other fats 4 0.150.24 156 0.010.02 120 1.371.25 91 1.410.41 29 1.610.35 22 2.092.41 115 0.020.03 117 00 —
Milk and dairy
Fat dairy 7 7.18122 17 00 — 0.240.11 46 1.960.27 14 4.520.84 19 21.758.21 38 00 — 00 —
Low-fat dairy 2 6.600.28 4 00 — 0.050.07 141 0.950.01 1 1.990.13 6 122.83 24 00 — 00 —
Nonfat dairy 6 9.081.68 19 0.170.41 25 00 — 0.130.16 120 0.150.17 115 2.921.80 62 2.250.68 30 0.51.22 245
Sweetened dairy 8 3.850.57 15 0.050.13 283 0.030.05 138 0.700.21 31 1.550.43 28 5.345.28 99 5.501.57 28 0.120.26 223
Dairy desserts 4 4.450.76 17 0.110.21 200 0.280.21 74 1.550.44 28 2.490.55 22 60.9870.13 115 12.795.45 43 0.100.13 125
Fruits 45 00 — 0.960.53 55 0.070.15 205 0.040.09 221 0.020.04 210 00 — 14.663.60h
24 2.873.55 124
Vegetables 40 00 — 2.251.21 54 0.190.15 83 0.040.10 239 0.080.10 123 0.020.07 398 00 — 3.212.21 69
Sugars 7 0.180.48 265 0.100.21 203 0.010.01 204 0.060.14 211 0.150.34 225 0.641.70 265 9.531.45 15 0.030.06 182
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
PUFA¼polyunsaturated fatty acid.
e
MUFA¼monounsaturated fatty acid.
f
SFA¼saturated fatty acid.
g
Data for breakfast cereals and other commercial products with added sugars.
h
Natural sugars.
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4. 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
Food groups or
subgroups
Sodium (mg)
Mean–SD CV %
Potassium (mg)
Mean–SD CV %
Phosphorous, mg
Mean–SD CV %
Calcium (mg)
Mean–SD CV %
Iron (mg)
Mean–SD CV %
Vitamin D (mg)
Mean–SD CV %
Carbohydrate group
Grains/potatoes 29.2692.16 116 86.79109.80 127 45.4537.25 82 7.305.09 70 0.670.68 103 0.070.19 291
Legumes 17.8017.47 98 330172.37 52 105.8030.86 29 33.9014.56 43 1.880.28 15 00 —
Confectionary 121.6780.69 66 58.2865.76 113 36.6418.41 50 12.797.19 56 0.460.25 54 0.120.12 100
Protein group
Type I 81.6568.10 83 116.5344.96 39 78.3529.07 37 22.1825.27 114 1.020.50 50 0.110.37 356
6.404.50b
70
Type II 63.13151.13 230 112.9131.33 28 82.2224.28 30 5.997.22 120 0.800.31 38 1.071.57 147
3.600.45c
13
Type III 283.89481.86 170 87.3235.17 40 107.4172.93 68 77.48123.28 159 0.560.39 70 1.011.59 158
Type IV 253.01124.12 49 39.0724.27 62 152.0860.53 40 173.88100.51 58 0.220.14 64 0.060.03 50
Type V 436.30266.20 61 80.3124.04 30 63.7120.44 32 10.107.49 74 2.273.87 170 0.070.13 171
Fat group
Rich in PUFAsd
18.8645.88 243 17.0526.93 158 14.7021.39 145 1.642.91 178 0.120.18 156 00 —
Rich in MUFAse
10.5117.11f
162 53.6586.46 161 16.4815.83 96 8.598.19 95 0.250.22 88 00 —
Rich in SFAsg
4.093.01 73 29.2523.05 79 10.805.97 55 6.407.38 115 0.140.16 113 0.060.06 100
Other fats 5.505.25 95 1.751.90 108 1.361.47 108 0.750.71 94 0.010.03 200 0.230.28 122
Milk and dairy
Fat dairy 110.4348.93 44 330.1873.78 22 195.8927.43 14 261.2945.35 17 0.180.06 30 0.140.15 106
Low-fat dairy 920 0 3320 0 1700 0 2348.49 4 0.140.08 61 0.010.01 100
Nonfat dairy 122.2534.21 28 387.4240.16 10 237.8351.24 22 291.0851.55 18 0.250.06 23 00 —
Sweetened dairy 79.7537.54 47 212.5670.41 33 104.849.02 9 132.8115.67 12 0.380.35 92 0.090.15 161
Dairy desserts 65.6016.26 25 179.1533.60 19 121.8311.59 10 141.6829.13 21 0.420.29 68 0.280.24 87
Fruits 6.6210.31 156 280.71143.32 51 26.2515.36 59 24.2818.73 77 0.670.49 74 00 —
Vegetables 91.43154.22 169 343.67164.74 48 48.8823.30 48 41.9025.35 61 0.900.49 54 00 —
123.521.90h
18 3.750.42i
11
Sugars 5.326.56 124 27.5630.89 112 9.5514.23 149 10.4915.77 150 0.130.18 137 00 —
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 acid.
e
MUFAs¼monounsaturated fatty acid.
f
Data without olives.
g
SFAs¼saturated fatty acid.
h
Data for cruciferous vegetables.
i
Data for leafy vegetables.
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5. Food exchange group Nutrients with high
variability in the group
Foods with z score 2 Foods with z score 2
Carbohydrate group
Grains and potatoes Fiber Cereals high in fiber —
Confectionary SFAsa
Chocolate cake Muesli
Cholesterol Cupcake Muesli
Added sugar Chocolate cake —
Sodium Crackers
Light chips
—
Protein group
Type I Cholesterol Squid
Crab
Prawn
Monkfish
Egg white
Skim white cheese
Iron (mollusk subgroup) Cockle
Clam
—
Type II Cholesterol Entrails —
Vitamin D Tuna
Sardine
Swordfish
Trout
Different meals
Entrails
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.
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6. 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.
PRACTICAL GUIDELINES TO
USING THIS TOOL
The Spanish food exchange lists were
unified to the three macronutrients
and energy, but other secondary nu-
trients were not controlled. This prac-
tical approach was planned to consider
the unification of other nutrients of
interest (MUFAs, PUFAs, SFAs, choles-
terol, added sugars, fiber, sodium, po-
tassium, phosphorous, calcium, iron,
and vitamin D) in those food groups
with relevant amounts of them. This
could be a useful tool for professionals
in that they could estimate the number
of exchanges to meet energy and
macronutrients proportions of a
Food exchange group Nutrients with high
variability in the group
Foods with z score 2 Foods with z score 2
Fat group
Rich in MUFAsa
MUFAs Avocado —
SFAs Avocado —
Sodium Olives —
Rich in SFAsb
Cholesterol — Coconut
Milk and dairy
Fat dairy Cholesterol — Fermented milk (Lactobacillus casei)
Other fats PUFAsc
Margarine —
Dairy desserts Cholesterol Egg flan —
Fruits Potassium Apricot
Melon
Quince
Blackberries
Raspberries
—
Vegetables Protein Artichoke
Brussels sprouts
Broccoli
Spinach
—
Potassium Brussels sprouts
Spinach
Thistle
Canned or frozen peas
Canned palmetto
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.
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7. Table 3. Mean nutrient values (by rounding mean values) of the food groups proposed in the Spanish food exchange lista
Food group or
subgroup
Aprotb
(g)
Vprotc
(g)
PUFAd
(g)
MUFAe
(g)
SFAf
(g)
Cholesterol
(mg)
Added
sugar (g)
Fiber
(g)
Sodium
(mg)
Potassium
(mg)
Phosphorous
(mg)
Calcium
(mg)
Iron
(mg)
Vitamin D
(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
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
Rich in MUFAs 0 0 1 3 1 0 0 1 11j
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)
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8. patient, and at the same time, the re-
quirements of other secondary nutri-
ents, both in health and diseases.
This tool offers a wide variety of
foods in each group to be included in
meal planning, and a list of foods
marked as exceptions in the contribu-
tion of any of the nutrients (upward
and downward).
Nutrition and dietetics practitioners
could make food choices according to
particular preferences without signifi-
cant variations in nutrient intakes, but
they should control the intake of
marked foods, which could influence
expected outcomes in health and clin-
ical situations.
Also, this tool includes nutrient
content claims of the food exchanges
groups defined. These claims describe
the high level of a nutrient in a food
exchange group, and aid in choosing
the exchange groups. For example, food
groups with high content in a nutrient
with positive effects on health (eg,
protein, fiber, potassium, phosphorous,
calcium, iron, or vitamin D) and certain
physiologic states (eg, iron, calcium,
and vitamin D) should be present in
the right measure in a diet, and those
with restrictions (eg, SFAs, cholesterol,
added sugar, and sodium), should be
controlled. In treatment of diseases, the
food groups with richness in nutrients
implicated as potential contributing
factors (eg, sugars, SFAs, and sodium in
metabolic chronic diseases, and potas-
sium and phosphorous in kidney dis-
eases) could be avoided.
With an understanding of the
nutrient composition of the exchange
lists proposed, several recommenda-
tions are described for the diets plan-
ning 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
Table
3.
Mean
nutrient
values
(by
rounding
mean
values)
of
the
food
groups
proposed
in
the
Spanish
food
exchange
list
a
(continued)
Food
group
or
subgroup
Aprot
b
(g)
Vprot
c
(g)
PUFA
d
(g)
MUFA
e
(g)
SFA
f
(g)
Cholesterol
(mg)
Added
sugar
(g)
Fiber
(g)
Sodium
(mg)
Potassium
(mg)
Phosphorous
(mg)
Calcium
(mg)
Iron
(mg)
Vitamin
D
(
m
g)
Dairy
desserts
4
0
0
2
2
61
13
0
66
179
122
142
0
0
Fruits
0
1
0
0
0
0
15
k
3
7
281
26
24
1
0
Vegetables
0
2
0
0
0
0
0
3
91
344
49
42
1
0
124
l
4
m
Sugars
0
0
0
0
0
1
10
0
5
28
10
10
0
0
a
Gray-shaded
cells
mark
a
relevant
nutritional
content.
b
Aprot¼animal
protein.
c
Vprot¼vegetable
protein.
d
PUFA¼polyunsaturated
fatty
acid.
e
MUFA¼monounsaturated
fatty
acid.
f
SFA¼saturated
fatty
acid.
g
Data
for
breakfast
cereals
and
other
commercial
products
with
added
sugars.
h
Data
for
edible
bivalve
mollusks.
i
Data
for
entrails.
j
Data
without
olives.
k
Natural
sugars.
l
Data
for
cruciferous
vegetables.
m
Data
for
leafy
vegetables.
PRACTICE APPLICATIONS
8 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2017 Volume - Number -

9. 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
group
Exchange
no.
Distribution of the Exchanges in the Day with Examples of Different Food Choices Expressed in Net Weight (grams or home measures)
Breakfast Midmorning snack Lunch Afternoon snack Dinner Others
Carbohydrate group
Grains and
potatoes
13 2
Whole bread (60 g, 2
slices) or
unsweetened dry
cereals (40 g, 1/2
bowl)
1
Whole bread (30 g, 1
slice)
6
Brown rice (80 g, 4
Tbsp) or whole-
grain pasta (80 g, 8
Tbsp) or potato
(400 g, 2 medium
size) with whole
bread (60 g, 2
slices)
4
Whole-grain pasta
(40 g, 4 Tbsp) or
potato (200 g, 1
medium size) or
brown rice (40 g, 2
Tbsp) with whole
bread (60 g, 2
slices)
Protein group
Type I 3 1
Cooked jam (30 g, 1
regular slice) or
nonfat fresh
cheese (75 g, 1
small container)
2
Cooked ham (60 g, 2
regular slices) or
cod (80 g, 2
portions) or hake
(80 g, 2 portions)
or cockles (100 g,
24 units) or prawns
(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)
Fat group
(continued on next page)
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10. 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
group
Exchange
no.
Distribution of the Exchanges in the Day with Examples of Different Food Choices Expressed in Net Weight (grams or home measures)
Breakfast Midmorning snack Lunch Afternoon snack Dinner Others
Rich in PUFAsa
and
MUFAsb
13 2
Olive oil (10 g, 1
Tbsp) or hazelnuts
(16 g, 16 units) or
almonds (16 g, 12
units) or walnuts
(16 g, 4 units)
4
Olive/sunflower/
soybean oil (20 g,
2 Tbsp) or
mayonnaise (20 g,
2 Tbsp)
3
Hazelnuts (24 g, 24
units) or almonds
(24 g, 18 units) or
walnuts (24 g, 6
units) or pine nuts
(24 g, 3 heaping
tsp)
4
Similar to lunch
Milk and dairy
Nonfat dairy 3 1
Nonfat milk (200 g,
1 c) or yogurt (250 g,
2 commercial
containers)
0.5
Nonfat yogurt (125 g,
1 commercial
container) or milk
(100 g, 1/2 c)
0.5
Similar to
midmorning snack
1
Similar to breakfast
Fruits 3 1
Apple (120 g, 1 small
unit) or banana
(100 g, 1 small
unit) or kiwifruit
(120 g, 1 medium
unit) or orange
(200 g, 1 big unit)
1
Similar to breakfast
1
Similar to breakfast
Vegetables 2 1
Green bean (150 g,
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)
1
Similar to lunch
(continued on next page)
PRACTICE
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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
group
Exchange
no.
Distribution of the Exchanges in the Day with Examples of Different Food Choices Expressed in Net Weight (grams or home measures)
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
Protein
Carbohydrates
Sugars
Fiber
Fats
Cholesterol
Sodium
Potassium
Phosphorous
Calcium
Iron
Vitamin D
99%
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.)
98%
55% (Data providing of added sugars and cereals low in sugar. Cereals high in sugars or sweetened fruits beverages should be chosen occasionally.)
180%
100%
PUFAs: 7% TCVc
; SFAsd
: 6% TCV (Data including, at least 3 fat exchanges rich in PUFAS, nuts, and/or oils.)
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.)
104% (Data avoiding canned fishes, cheeses with salt, and olives. They could be chosen occasionally.)
108%
200%
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.)
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.)
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 acid.
c
TCV¼total caloric value.
d
SFAs¼saturated fatty acids.
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12. requirements of potassium and phos-
phorous (more than 15% of European
RI) in health situations, but it could be
a necessary restriction in certain dis-
eases such as kidney dysfunction.
Legume exchanges could be a success-
ful 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 sodium
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
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 cardio-
vascular diseases and hypertension;
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 pregnancy and
lactation. For its part, frequent con-
sumption of dairy desserts 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.
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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.
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