Philippine Journal of Science 150 (5): 955-968, October 2021 ISSN 0031 - 7683 Date Received: 06 Aug 2020

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

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 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

INTRODUCTION fat. It is made up of food groups, each being called an exchange list that contains food items with approximately The Philippine FEL is a tool used by RNDs in planning the same amounts of energy and macronutrients within meals for individuals who need a calculated intake of the list; thus, a substitute of food with another can be energy and macronutrients – carbohydrates, protein, and made (Caso 1950). The Philippine FEL was initially intended to provide carbohydrate information for use in *Corresponding Author: [email protected] the diet management of persons with diabetes. Today,

955 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning the Philippine FEL is used as a guide in prescribing and METHODS planning meals for healthy and therapeutic diets, as well as an educational tool by nutrition professionals in clinics and The study protocol was approved and project hospitals, fitness centers, and other health care facilities implementation was cleared on 28 March 2017 by (Tanchoco et al. 1994). the Department of Science and Technology–Food and Nutrition Research Institute’s (DOST-FNRI) The first FEL was developed in the 1950s by the American Institutional Ethics and Review Committee (Protocol Diabetes Association, the American Dietetic Association Code FIERC-2017-006). Signed informed consent (ADA), and the United States (US) Public Health Service forms were obtained from the study participants prior for the management of patients with diabetes (Wheeler to data collection. Participants were informed of the et al. 1996). It has undergone several revisions from its confidentiality of all the information obtained from previous title “Exchange Lists for Diabetes” to “Choose them and that their participation in the study is voluntary Your Foods: Exchange Lists for Diabetes” in the sixth and they can withdraw from the study anytime without revision published in 2008 (Wheeler et al. 2008; Geil penalty. Data collection was conducted from April 2017– 2008). The Philippine FEL was adapted from the US March 2018. The authors declared no conflict of interest in 1953 by Corpus et al. and was revised in 1965 by on this project. Madlangsakay that included six food groups [as cited in Flores et al. (1984)]. The 1965 revision was updated The steps undertaken in coming up with the 2019 FEL by Flores et al. in 1984 wherein the sugars and sweets were: 1) collection of data on the needs of FEL users by from the rice group were removed to form the sugar means of survey and FGDs, 2) review and computations exchange as the seventh group. The third revision in 1994 of the macronutrient content of exchange portions of each by Tanchoco et al. had the subgroups of the vegetable food item, and 3) revision/updating of content and design and milk exchanges modified while retaining the seven of handbook. main groups. Some changes in this version included the following: adjustment of portion sizes, use of Filipino Survey language in the food listing, a separate grouping of The survey among FEL users was done using a pre- processed/selected foods, and identified fruits with high tested, semi-structured self-administered questionnaire. vitamin A and vitamin C content. Prior to this study, Survey questions evaluated the technical content, the the 1994 FEL was not updated because the local food physical attributes – comprehensibility, usefulness, layout, composition database was being modified. and design – that were used to improve the 1994 FEL handbook. Tools in nutrition have to be periodically reviewed to keep up with current trends in the management of nutrition- The target population was users of FEL in the Philippines. related conditions. As a guide in dietary planning, the FEL The RNDs were initially targeted as respondents, but the should maintain a list of foods currently available in the addition of student respondents was later on considered market and which are consumed by many people. Novel as users of FEL in school. The inclusion criteria for FEL foods that are now part of family meals have to be evaluated users were any of the following: 1) RND staff in hospitals on how these can fit into the diet plan of individuals with and wellness centers, 2) teachers of major nutrition courses different health concerns. Moreover, the popularity of the using FEL, or 3) students of nutrition in their senior years. FEL as a reference material deems it necessary to always Excluded from the study were non-users of FEL or persons provide timely and adequate information to its users who not belonging to the mentioned criteria. The number of are working in the different fields of nutrition. respondents was calculated based on a 50% proportion of FEL users, with 95% confidence and a 1.0 design effect. The need to innovate the FEL is important because Using the Open Epi software version 3.01, the number of the rising number of Filipino clients with lifestyle- of respondents needed to satisfy the sampling conditions related diseases who will avail of nutrition education and was approximately 400 individuals (Dean et al. 2013). counseling. In improving tools for clients, simplicity, ease of use, user-friendliness, and visual appearance are some A listing of RNDs from government and private hospitals features that have to be considered in addition to its main of the National Capital Region (NCR) and other areas was or technical content. secured from heads of dietary, food service, and nutrition clinics via phone inquiry or internet search. Letters were The FEL was updated for the purpose of reviewing the sent to these institutions to request their participation. calculations and grouping of foods based on current tools The survey questionnaires and consent forms for the and nutritional recommendations, improving the methods RNDs were sent either by courier, personal delivery and of assessing individuals using updated methods, and pick-up, or email. enhancing the design and appearance of the handbook.

956 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

For respondents in the academe, a listing of schools A working database file was kept for each food group offering nutrition programs was obtained from the that contains information on the food item description, Professional Regulation Commission. Schools with nutrient contents, and a food code that matched an item high enrollment in nutrition programs were selected to in the 2017 Philippine FCTs. represent the students who use the FEL. Coordination with the school and the faculty handling major nutrition The macronutrient and energy contents of foods were subjects was made through letters of request or email, calculated from the new FCTs (DOST-FNRI 2017a) which were sent to school heads or the faculty concerned. and other food databases such as those from Australia, The distribution and retrieval of the forms from the ASEAN, Japan, Korea, and the US. Using Microsoft school to the researchers were also done by the faculty- Excel software, the edible portion (EP) weight of the contact person. Consent forms were also attached to the food was determined to provide one exchange portion. questionnaire to seek approval to participate in the study. 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. FGD and Expert Group Consultation The cut-off values for macronutrients per exchange that Consultation meetings through FGDs were conducted served as a guide for the food groupings were based on in Manila, Cebu, and Davao in order to represent the previous editions of FEL but were also agreed upon with RNDs from the three main islands (Luzon, , the expert group. and ) of the country. RNDs involved in clinical nutrition, with supervisory positions, and among Mean, standard deviation (SD), and 95% confidence educators/teachers/professors using the FEL in teaching interval (CI) of the macronutrients were computed for were recruited for the FGD. For each area, participants each food group and subgroup. Foods that did not meet the were identified through inquiries from corresponding value or range of macronutrients per group were classified institutions to represent the clinical, school, or food under “selected foods,” where the number of exchanges service so that varied responses can be gathered from each of a food group was indicated instead, such as rice, meat, sector. One FGD group was composed of 12 participants. fat, or sugar exchange. A member of the research team facilitated the discussion Actual food samples were purchased from different using guide questions that were similar in content with the supermarkets, public markets, and other sources. For each survey from FEL users. Specifically, the FGD solicited food item, weighing was done using an electronic digital suggestions on the existing food groupings or lists, items scale (Shimadzu UX2200 H), values were recorded to to add and/or delete in the 1994 handbook, and items to the nearest whole number in gram (g), while a standard include for this revision. ruler with millimeter and centimeter (cm) units was used The researchers audio-recorded the comments and to measure the food item’s dimension in cm. Thereafter, suggestions of the participants together with hand-written foods were described in household measures (e.g. cup, notes taken simultaneously during the FGD session. Data tablespoon, or teaspoon) or in terms of its dimension were organized according to similar topics or themes. (length, width, and height or diameter in cm) when there is no fixed portion size. Photos of one exchange of food Aside from the survey and FGD, an expert group in the samples were compiled for documentation. 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 Revision, Updating, and Design of the 4th Edition process of FEL. The group also had varied expertise in FEL Handbook research, policymaking, and foodservice. 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 Macronutrient Computation and Grouping of Foods food exchange groups, i.e. the steps in dietary calculation The seven food groups in the 1994 edition (DOST- and the menu plan. The seven major food lists and groups FNRI 1994) were used as the starting point to classify – vegetable, fruit, milk, rice, meat, fat, and sugar – with the exchanges – vegetable, fruit, milk, rice, meat, sugar, detailed description and measurement in exchange unit and fat – as recommended by the expert group and FGD presented in Part 2. The Appendices section contained all participants. Additional food items were included in each other food lists and nutrition assessment tables relevant group based on the suggestions from the survey, FGD, and to meal planning and diet instruction. The final version expert group. Data on the most common foods consumed by of the handbook, including the layout, was based on Filipinos from the 2013 National Nutrition Survey (DOST- suggestions from the survey, FGD, and the expert group. FNRI 2015) also served as an additional data source. Another activity in the completion or finalization stage

957 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning was the final review done by the DOST-FNRI technical (98.1%), instructors/professors of nutrition (86.8%), and staff and external peer reviewers. 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%), Data Processing and Analysis faculty (74.2%), and health workers (61.4%). As to its Data on the survey part used descriptive statistics usefulness, the majority (65.7%) of all respondents said it to generate frequency distributions on the profile of was very useful, while a third of the respondents (33.7%) respondents and evaluation on selected physical attributes found the FEL to be a useful tool. of the 1994 FEL handbook – comprehensibility, clarity, and usefulness. For the FGD, transcribed data were Respondents were asked how they used the FEL in their organized and similar topics or themes were analyzed jobs. According to RNDs, the FEL is used mainly for meal and combined for tabulation. The recurring themes were planning (85.6%) and nutrition counseling (82.4%). For categorized as follows: food subgroups, weights and student-respondents, the majority (90.5%) also used the measures, foods to delete, foods to add, and foods to FEL for meal planning, then as personal reference in more regroup – including the other relevant remarks presented than half of this group. by the group. All responses obtained from the survey and FGDs were discussed with the technical experts for final In terms of its physical attributes, the majority of the RNDs resolution. and students agreed that the title “Food Exchange Lists for Meal Planning” was very clear (51.4%), while 47.4% For the calculation of food exchanges, the computed of said the title was clear/fairly clear and very few (1.2%) energy, carbohydrate, protein, and fat values were found the title not clear. Almost the same proportion presented as mean, SD, and 95% CI. All descriptive of RNDs (87.0%) and students (85.9%) mentioned no statistical analyses were performed using SPSS (version confusing words encountered. However, few respondents 20, IBM, Armonk, NY, USA). (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 RESULTS 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, Profile of Respondents and additionally, the features that the respondent found Of the total 529 survey respondents composed of RNDs to be attractive. Results showed that while the layout and students, 54.5% were from NCR and the rest were design and language were rated as appropriate by a from other parts of the country. The RNDs comprised greater proportion of all respondents (90.0 and 80.9%, about 60% of the total respondents while almost 40% respectively), a few found the layout too informal (5.5%) were nutrition students in their senior year in college and and language (11.0%) too difficult. Also, more than half had used the FEL. The majority of the respondents were (54.5%) claimed that the illustrations/pictures were not females while only about one in 10 respondents were attractive. A few respondents of the RNDs and students males. In terms of educational attainment of RNDs, about identified the features that attracted them and these include 14% attained a postgraduate degree. Most of the RND the cover design (17.9%), font size (13.4%), illustrations respondents (83.2%) were affiliated with hospitals and (8.9%), and layout (15.3%). more than half were working for five years or less. By location of work, the majority were from NCR (78.2%), The suggested changes in the content of the food listing while the rest were from Regions 4A, 11, 7, 2, 1, and were combined for RNDs and students (Appendix Table Cordillera Administrative Region (CAR). The student I). Merging of data was done to have a common basis for respondents were highest in the Region 4A area (Table 1). the changes to be incorporated in the update of the FEL. The addition of more foods was suggested by a large The FGD participants (n = 36) were mostly affiliated proportion of respondents (40%) for vegetable, fruit, with hospitals (63.9%) and the academe (30.5%). milk, rice, and meat. About three out of 10 respondents Two participants were medical doctors with nutrition suggested including both the “as purchased” (AP) and backgrounds and experience in clinical nutrition (no table EP weight of foods especially for vegetables and fruits, presented). while a smaller proportion was recorded for the rest of the food groups. Deletion of food items was suggested by a Survey on the 1994 FEL Handbook small proportion of about 3%. The reason for wanting to As shown in Table 2, from the point of view of RNDs, the delete was the unavailability of foods in the market and FEL was intended for use by hospitals or clinical RNDs that the food was no longer consumed in the area. For

958 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

Table 1. Profile of survey respondents (n = 529). RNDs Nutrition students All respondents Variable 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 262 83.2 0 0 262 50.2 Academe 22 7.0 207 100 229 43.9 Food service/industry 17 5.4 0 0 17 3.3 Nutrition/fitness center 14 4.4 0 0 14 2.7 Total 315 60.3 207 39.7 522 100.0 Number of years as RND < 2 yr 118 39.2 – – 118 39.2 2–5 yr 66 21.9 – – 66 21.9 6–10 yr 32 10.6 – – 32 10.6 11–15 yr 19 6.3 – – 19 6.3 16– 20 yr 19 6.3 – – 19 6.3 > 20 yr 47 15.6 – – 47 15.6 Total 301 100 – 301 100 Region NCR 248 78.2 38 18.3 286 54.5 Region 4A 23 7.3 81 38.9 104 19.8 Region 11 28 8.8 13 6.2 41 7.8 Region 7 16 5.0 14 6.7 30 5.7 Region 12 0 0 30 .14.4 30 5.7 Region 10 0 0 25 12.0 25 4.8 Region 5 0 0 5 2.4 5 1.0 Other regions (CAR and Region 1) 2 0.6 2 1.2 4 0.8 Total 317 60.4 208 39.6 525 100.0

vegetable and fruit, diameter measurement was favored for inclusion of more commonly eaten food available in deletion by 27.1 and 14.1% of respondents, respectively, the market, and the addition of different varieties of while a lower proportion was observed for the rest of the vegetables like mushroom or cabbage were suggested. food groups. An issue for the change in the carbohydrate The name of group A or B vegetables as a subgroup content of the rice exchange was posed as a question and was found confusing to some respondents. In the fruit about 8% were in favor of the move. exchange, imported fruits and some local/indigenous fruits – including their varieties like and melon – were The survey respondents also suggested foods to add suggested for addition while those not commonly eaten or delete and improve in the forthcoming handbook like anonas, datiles, mabolo, and tamarind can be deleted. (Appendix Table II). For the vegetable exchange, the For easy recognition for fruits, pictures or illustrations help

959 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

Table 2. Survey on the attributes of the 1994 FEL Handbook among FEL users. RNDs (n = 319) Nutrition students (n = 210) All respondents (n = 529) Variables n % n % n % Users of FELa Hospital/clinical 313 98.1 179 85.2 492 93.0 RND 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

960 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

RNDs (n = 319) Nutrition students (n = 210) All respondents (n = 529) Variables 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 15.3 aMultiple responses, % computed from total number of RNDs, students, and total respondents bSpecific 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 denominator dOthers (e.g. calorie counting and menu evaluation)

to recognize less-common foods. In the milk group, all expression of respondents and the truth in their words. types and variants of milk and products were suggested, The comments and suggestions from the FGD were including rare and imported ones. Adjustment of the similar to what was obtained from the survey, and these measures per exchange was also suggested for powdered are summarized as follows: milk and other milk alternatives, non-dairy milk, flavored milk drinks, and commercially prepared milk for use in 1. Retain the current reference values of macronutrients certain disease conditions. and energy per exchange for the seven food groups. For the other food groups, respondents suggested more 2. For all food groups, add more food items and their food items in the rice exchange such as native delicacies variants. Include local and international and new foods and varieties of noodles and pasta. There was also a that are available in the market and are commonly suggestion to make a separate list for starchy and non- consumed. starchy foods and that the collective term or name of the 3. Reclassify the vegetable subgroups and the milk group, group as “rice exchange” may not be appropriate because but the meat and fat subgroups were to be retained. other non-rice items were also included. 4. Retain measurements in household measures and EP For the meat group, various meat sources (lamb, turkey, weight in g for all food groups. rabbit), new types of processed food, fast foods, and plant or soybean-based proteins/products were recommended. 5. All the participants agreed to remove the number of Respondents also suggested the use of realistic and practical calories in the “vegetable A” subgroup. A suggestion ways to estimate portion sizes such as the use of palm or was made to validate the macronutrient values and a deck of cards as examples. Foods with possible health reclassify some items in the vegetable exchange like risks should also be properly described, such as chicken mung bean and lima beans, young corn, and tomatoes with or without skin, and the cholesterol content of these which were said to be confusing. foods need to be stated. For the fat exchange, new products 6. For items under fruits, include local and English were again identified to be included in the list, particularly names. Check if this can be considered those with health implications, while obsolete brands were under the rice exchange instead. Also, , to be deleted. In the sugar exchange, more foods that are , and may contain more carbohydrates commercially available in different flavors were suggested, and calories due to the added ingredient in cooking including international brands of sugar/sweet products/ such as sugar and oil; hence, these can be transferred items. A review of serving portions was also mentioned to other groups as well. because of changes in the sizes of new products. 7. Update the classification of milk, but retain the skim milk classification. Add more milk products such as Information from the FGD soy milk, goat’s milk, different types of yogurt, whey Comments and suggestions from the FGD group served powder, and milk substitutes. to validate the data from the survey. The advantage of this data collection method was the face-to-face 8. For the rice exchange, the majority suggested the communication that allowed researchers to see the retention of the original macronutrient content of 23 g

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carbohydrate per exchange, while the ADA exchange The 4th Edition FELs for Meal Planning: of 15 g was also suggested by other participants. It was Composition and Summary of Major Changes suggested to include different rice varieties, imported The updated FEL handbook was completed with three grains, pasta, and noodles. main components – the introductory part, food exchange groups, and the appendices. The main part highlights the 9. In the meat group, include exotic meat, meat from other food exchange groupings and the list of foods containing animal parts, street foods, and buffet foods. Include the Filipino or common and English names, EP weight, footnotes for foods that are rich in omega-3, omega-6, and household measure with selected pictures of foods monounsaturated fat, and the type of fat in the meat. per exchange (Figure 1). The FEL generated 525 items 10. Reclassify margarine and mayonnaise to trans-fat, as within the seven exchange groups. Additional tables in well as canola oil and peanut butter to monounsaturated the appendices were on selected foods (164 food items), fat. Include other types of salad dressing, coconut oil beverages (52 food items), alcoholic beverages (27 food in powder form, virgin coconut oil, shark oil, and items), and free foods (44 food items). The Appendices all-purpose cream. Include footnotes for foods rich in also contained references on fatty acid content of fats and omega-3 fatty acids. oils, methods of pediatric computations, a quick reference for dietary ­prescription, and a new table on desirable 11. Include sugar substitutes with disclaimer under the weight according to normal levels of BMI. sugar exchange group. Add new types of sweeteners th such as coco sugar, caramel syrup, , stevia, The changes made in the 4 edition FEL are summarized powdered sugar, and dark chocolate. as follows: 12. For the diet computations, the inclusion of body mass 1. Computation of the macronutrient values using the index (BMI) as a reference was suggested by the newly-updated Philippine FCTs (DOST-FNRI 2017b). FGD and expert group. However, diverse methods Use of other food composition databases such as in determining the DBW and TER were reported by those from the US, Australia, Korea, and Japan were participants. A consensus at that time was for the RNDs employed in the absence of macronutrient values in to be able to choose the method that one is comfortable the Philippine FCTs. Carbohydrate value represents with to compute DBW and TER in the calculation of available carbohydrates. the energy and macronutrient contents of foods when 2. Regrouping of food groups and renamed subgroups planning daily meals. based on recomputed macronutrient content. 13. Consider a more appealing layout in landscape style • Vegetable exchange only included ≥ 3 g of and edit the spacing alignment. Use 12-font size for carbohydrate and 1 g of protein. the text. Some groups favor retaining the old size of the handbook, but others want a bigger size with a • Rice exchange was grouped into “rice A” (low- new cover photo. protein), “rice B” (medium-protein), and “rice C” (high-protein). 14. Consider a short version of the FEL for use by other allied health professionals like doctors. • Lists of foods were arranged in alphabetical order based on their Filipino names. Computation of Macronutrient and Energy Values 3. Additional predictive equations for deriving the DBW per Exchange and TER were included. Table 3 shows that the mean macronutrient values per exchange were within the reference values or 95% CI of 4. Photos of selected food items per exchange were the means. The mean carbohydrate in the rice and sugar included in the handbook. groups were about 1–2 g from the given values but were 5. Additional contents were also included, such as a list of still within the cut-off range of more or less than 5 g. acronyms, abbreviations, and glossary of terms, plus a Mean protein from milk and meat groups were similar listing of sample physical activity by level and intensity. 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 DISCUSSION subgroups. The final FELs and reference values for energy and macronutrients of food exchanges used in Nutrition tools like the FEL have to be periodically diet computation is also presented in Appendix Table III. reviewed and revised to make them more relevant and useful to primary users and intended audience. The

962 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

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 Carbohydrate Protein Fat (kcal) (g) (g) (g) Vegetable 40 (16) 17 ± 6 (3) 2.6 ± 1.3 (1) 1.1 ± 0.7 –0.2 ± 0.1 [15.0, 19.0] [2.2, 3.0] [0.93, 1.4]

Fruit 91 (40) 42 ± 3 (10) 9.3 ± 0.8 –0.5 ± 0.4 –0.3 ± 0.2 [41.2, 42.5] [9.1, 9.5] Milk Whole 8 (170) 181 ± 30 (12) 12.6 ± 2.7 (8) 9.4 ± 0.9 (10) 10.3 ± 3.8 [156.0, 205.6] [10.3, 14.9] [8.7, 10.1] [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 (12) 12.1 ± 0.8 (8) 8.4 ± 1.4 (< 1%) –0.4 ± 0.3 [78.8, 91.9] [11.1, 13.1] [6.7, 10.2] Rice Low protein 26 (92) 94 ± 6 (23) 22.1 ± 1.9 –0.5 ± 0.4 (—) 0.4 ± 0.4 [91.3, 96.1] [21.3, 22.8]

Medium protein 46 (100) 99 ± 14 (23) 21.5 ± 3.8 (2) 1.8 ± 0.6 (—) 0.6 ± 0.6 [94.8, 111.5] [20.3, 22.6] [1.7, 2.0]

High protein 23 (108) 106 ± 6 (23) 20.6 ± 1.7 (4) 3.7+ 0.3 (—) 1.0 ± 0.6 [94.6, 108.6] [19.9, 21.3] [3.6, 3.8] Meat Low fat 115 (41) 46 ± 11 –0.3 ± 0.7 (8) 8.9 ± 2.1 (1) 1.1 ± 1.0 [44.3, 48.5] [8.5, 9.2] [0.9, 1.3]

Medium fat 32 (86) 82 ± 13 –0.7 ± 1.1 (8) 8.0 ± 1.6 (6) 5.3 ± 1.4 [77.7, 86.7] [7.4, 8.5] [4.8, 5.8]

High fat 26 (122) 127 + 10 –1.1 + 1.1 (8) 7.9 ± 1.6 (10) 10.1 ± 1.3 [122.6, 130.7] [7.3, 8.6] [9.6, 10.6]

Sugar 51 (20) 21 ± 5 (5) 4.8 ± 1.2 –0.1 ± 0.3 (—) 0.1 ± 0.3 [19.5, 22.3] [4.41, 5.11]

Fat 60 (45) 47 ± 6 –0.8 ± 1.0 –0.7 ± 1.2 (5) 4.6 ± 0.7 [45.4, 48.9] [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.

availability of various foods in the market affecting food substitution. Also, based on general suggestions from the habits, updates on nutrition and dietary guidelines, and survey, FGD, and expert group, more foods were added updates of the local food composition database paved the and very few items were deleted. The inclusion of more way to revise the 1994 FEL. foods that are familiar to more people can help make better food choices and enhance their compliance to follow the In this revision, the seven food groups in the previous FEL recommended diet. To update the food list, corresponding version were adopted as the main components of foods for

963 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

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

nutrient data should be available from local sources and Tanchoco et al. 1994). fits the description of the new food. The vegetable grouping in the previous FEL had relatively The development of food exchange groups mainly more varied opinions and interpretations compared involved a decision on the foods to include in the list and with the other food groupings. To some users, the term the amounts in EP weight in g per exchange portion. To “vegetable A and B” was confusing if exclusively meant attain homogeneity of macronutrient content, each food for leafy or non-leafy vegetables though there was no should conform to the given range of macronutrients of mention in the 1994 FEL that “vegetable A” consisted the group so that it can be “exchanged” or substituted mostly of leafy vegetables. This may have been due to with another. A food item that does not meet the criteria the slight difference in defining the groups in previous is regrouped under “selected foods,” wherein the versions (Madlangsakay 1965; Tanchoco et al. 1994) macronutrient exchanges are given per serving portion and the changes in the nutrient value of revised FCTs instead of the weight or dimension. Subgroups for milk such as for eggplant, cucumber, and chayote as examples and meat groups were already formed in previous FEL (DOST-FNRI 1994). versions to specify the level of fat (Madlangsakay 1965;

964 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

In the updated FEL, the simplified grouping of vegetables A serving portion indicates the amount of food that can into fresh and processed subgroups used in the old version be usually consumed by an individual at one time or one was adopted. However, vegetables with negligible meal. For example, a serving of meat or fish may consist macronutrients were placed in a separate list and intake of two to three pieces, with each portion approximately of more vegetables from this group is encouraged as a the size of one matchbox but would be considered as healthy option to everyday meals. equivalent to two to three meat exchanges depending on the institution such as hotels, hospitals, and restaurants it A modification of the rice exchange was made due to is being served. the wide variation of protein content when treated as a single group. Some locally available rice varieties had The enhancement of the design and appearance of the much lower protein contents compared to ordinary rice. handbook such as color-coded food groups, a background Thus, the regrouping of rice items into low-, medium-, of tables, colored photos of actual food photos, and size and high-protein content resulted in more homogenous of the handbook was done based on the suggestions from rice subgroups. The foods in the low protein subgroup the survey, FGD, and expert group. have more starch but negligible protein such as root crops, starchy foods, and newly developed low-protein rice. The unavailability of nutrient analysis of new foods and The rice group with moderate protein is the usual rice their variants in the local food database and the challenges and rice product, while the high-protein rice subgroup in finding the exact match of local foods in foreign FCTs includes most bread and bakery products. Calculation of limit the food items that can be included in the food the rice exchange under this new grouping can improve exchanges. In the case of regional or ethnic foods, finding the planning of meals for patients who need to consider an exact match of the product might be difficult because protein intake, such as those with kidney problems or other of a lack of standard recipe and/or regional variations. disorders that need to rest the kidneys. While efforts were exerted to compile the foods and The unit for rice was 23 g carbohydrate, which is nutrient composition data, the local food database can also equivalent to about half a cup per exchange. This measure be expanded to include regional sources so that these can was considered practical and easy to visualize in ordinary provide more alternative foods to individuals from other circumstances and with limited use of measuring tools. regions or areas of the country. Rice as the staple food is consumed daily in every Filipino Nonetheless, the updated FEL presented a wider choice of household. With more people diagnosed with diabetes, more food sources from all the food exchange groups and the measurement of rice intake is crucial in the control in the selected food and beverage lists, as well as guidance of blood sugar. The use of one carbohydrate unit varies in using the FEL and in calculating and planning diets. 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, CONCLUSIONS while Hong Kong uses 10 g carbohydrates per exchange (HFHB 2010). The recomputed food items in each group had mean amounts of macronutrients that were close to the Aside from the main food groupings, some tools reference value or within the 95% CI. The rice group and methods of dietary calculation were added in was reclassified into low-, medium-, and high-protein the revised FEL to update nutritionists in dietary subgroups due to the large variation in protein levels in planning. Specifically, the formulas for estimating energy the whole group. The fat content of the meat and milk requirements in the Philippine Dietary Reference Intakes group was more varied than the other macronutrients of (DOST-FNRI 2017b) were included among the options for these groups, which explains the subgroupings done to TER calculation. Formulas or short-cuts used in nutrition maintain homogeneity of the macronutrient content. The assessment were either added (e.g. TER, basal metabolic total number of foods reviewed or recomputed was 525 rate equations, and desirable weight range for normal BMI items from the seven food groups/lists – vegetable, fruit, range) or deleted (weight-for-height table for Filipinos) milk, rice, meat, fat, and sugar. This excludes other foods based on literature and recent guidelines. The instruction outside the food exchanges/lists such as the 164 items from to guide the calculation of diet prescription was organized “selected foods,” which were also recomputed to estimate systematically using numbered sequences. the number of macronutrient exchanges per serving. Moreover, the unit of measure is still referred to as Update of procedures in planning and calculating diets “exchange” rather than “serving” because in most cases, was done by adding predictive equations to compute for an exchange portion is different from a serving portion. TER based on the PDRI.

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The design and appearance of the handbook were enhanced FLORES EG, VILLADOLID MP, BASIG CC, with color-coded food groups and the background of TANCHOCO CC, VELANDRIA FV. 1984. Revised tables plus colored food photos for ease in visualizing an Food Exchange Lists for Meal Planning. Philippine exchange portion. 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). ACKNOWLEDGMENTS [HFHB] Hong Kong Food and Health Bureau. 2010. The authors wished to thank the survey and FGD Hong Kong Reference Framework for Diabetes Care participants and expert groups; research assistants Merlyn for Adults in Primary Care Settings. Retrieved in G. Tajan, Joan Pauline F. Forcadilla, and Dianna Rose December 2018 from https://www.fhb.gov.hk/pho/ F. Aytona; and members of the DOST-FNRI Technical rfs/src/pdfviewer/web/pdf/diabetescare/en/15_en_RF Committee – namely, Ms. Mildred A. Udarbe and Ms. _DM_full.pdf Julieta B. Dorado – for their invaluable insights/input. 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: NOTES ON APPENDICES Revised 2010. J Korean Diabetes 12(4): 228–244. https://doi.org/10.4093/jkd.2011.12.4.228 The complete appendices section of the study is accessible at http://philjournsci.dost.gov.ph MADLANGSAKAY R. 1965. Food Exchange Lists in the Estimation of Selected Nutrients in Mixed Diets. Philippine Journal of Nutrition. July–September. p. 167–183. REFERENCES [MDES] The Malaysian Diabetes Educators Society. CASO EK. 1950. Calculation of diabetic diets. J Am Diet 2016. Diabetes Education Manual 2016. Retrieved in Assoc 26: 575–583. January 2017 from https://mdes.org.my/wp- content/ uploads/2017/04/Final_Diabetes_Edu_Manual_hires_ CORPUS VA. 1953 (October–December). The calculation facing_pg.compres sed.pdf of dietetic diets. Nutr News 6: 4–9. TANCHOCO CC, VILLADOLID MF, CRUZ AJ. 1994. DEAN AG, SULLIVAN KM, SOE MM. 2013. Open Evaluation and Revision of the Food Exchange List Epi: Open Source Epidemiologic Statistics for Public for Meal Planning. J NDAP 8(2): 52–58. Health, Version [Updated 06 Apr 2013]. Retrieved from www. OpenEpi.com WHEELER ML, FRANZ M, BARRIER P, HOLLER H, CRONMILLER N, DELAHANTY LM. 1996. [DOST-FNRI] Department of Science and Technology– Macronutrient and Energy Database for the 1995 Food and Nutrition Research Institute. 2017a. Exchange Lists for Meal Planning: A Rationale for Philippine Food Composition Tables (PhilFCT) Online Clinical Practice Decisions. J Am Diet Assoc 96(11): Database. iFNRI Website. Retrieved in January 2017 1167–1171. from http://i.fnri.dost.gov.ph/fct/library WHEELER ML, DALY A, EVERT A, FRANZ MJ, GEIL [DOST-FNRI] Department of Science and Technology– P, HOLZMEISTER LA, KULKAMI K, LOGHHMANI Food and Nutrition Research Institute. 2017b. Philippine E, ROSS TA, WOOLF PZ. 2008. Choose Your Foods: Dietary Reference Intakes (PDRI) 2015: Summary of Exchange Lists for Diabetes 2008: Description and Recommendations. Taguig City, Philippines. Guidelines for Use. J Am Diet Assoc 108(5): 883–888. [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.

966 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

APPENDICES

Table I. Percentage distribution of responses of survey participants on the suggested changes in the food listing. Food exchange group Suggestion 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 27.1 14.1 5.1 9.3 9.9 5.5 7.2 household measure Change reference portion None None None 7.7 None None None

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

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 Review accuracy of Group A and B vegetables; define group A and group B vegetables; do not classify “vegetable A” as comments 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, , 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 Use realistic measurements; use pictures; include Tagalog name of food items comments 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 Include milk from different sources; milk replacement formulas; lactose-free milk. use of household measure for one serving comments 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, , breakfast cereals; sugar-coated cereals; varieties of noodles and pasta – couscous; imported items; variety of doughnut flavors; taco shells Delete Cornstarch, flour, masapudrida, , tupig, pan de limon, , marwekos, , non- Other Use starch instead of rice in terminology; this group should not be called “rice”; separate list of foods under starch and comments 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

967 Philippine Journal of Science Orense et al.: Updating of the Philippine Food Vol. 150 No. 5, October 2021 Exchange Lists for Meal Planning

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 More realistic measurement sizes (bigger portions); measurement is confusing; adjust serving portion; reword some comments 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 Include serving portion in household measure; change existing serving; separate fat from oils and nuts; update fatty acid comments 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 ; new icing and creams Delete Champoy; pakaskas; tira-tira, panutsa, sugar substitutes; obsolete brands Other Update food items; change existing serving; more specific description of product and ingredients; specify dimension of comments 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. Carbohydrate Protein Fat Energy List Food exchange group (g) (g) (g) (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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