How It's Used to Manage Carbohydrates in the Diet
Dr. Danielle Weiss is double board-certified in internal medicine and endocrinology. She is the founder of the Center for Hormonal Health and Well-Being in San Diego, California.
A key part of managing type 2 diabetes—or preventing prediabetes from getting worse—is sticking to a diet that makes it easy to limit carbohydrates so you can control blood glucose levels. For many years, the most recommended dietary approach for controlling diabetes was the exchange diet.
In the exchange diet, foods are grouped together based on the amount of carbohydrates they contain. The diet allows you to swap one food for another that had a similar “carb count.” This type of diabetes diet is no longer the standard for all people with diabetes. Instead, nutritionists and healthcare providers work to provide nutritional information to help people create personalized meal plans. Even with these new options, though, the exchange diet, or a version of it, is preferred by many people with diabetes.
This article explains how the exchange diet and exchange lists work, current recommendations from the American Diabetes Association, and what you should know before you decide to follow the exchange diet.
The exchange diet was first introduced in 1950 by the American Dietetic Association (now known as the Academy of Nutrition and Dietetics). The list of foods was updated several times.
In 2008, the dietary approach was revised again and renamed “Choose Your Foods.” The new approach focuses on helping people choose from a greater variety of foods. It provides information on portions and includes food exchanges for fats, protein, fruits, and other types of foods.
For decades, healthcare professionals recommended the exchange diet as the best way for people with diabetes to manage blood sugar. Today, rather than supporting one specific dietary plan, the American Diabetes Association now recommends that healthcare providers work with you to figure out a "patient-centered" approach. In other words, the best diet is one that fits your particular health and lifestyle needs. There's no one-size-fits-all diet.
The ADA does provide general guidelines, though, that a dietitian or other healthcare provider can use to help you determine an effective meal plan. These recommendations include:
The updated exchange diet can help you follow the American Diabetes Association's recommendations. The primary purpose of the "Choose Your Foods" approach is to help you regulate your blood sugar by tracking carbohydrates. But it also helps people with diabetes meet other goals.
For people with type 1 diabetes, the information on exchange lists can help you plan when and how much food to eat. Eating regulated amounts of food at regulated times makes it easier to keep blood sugar stable.
If you have type 2 diabetes, the exchange lists are an excellent way to help you maintain a healthy weight or to lose weight. It makes it easy to control how many calories and the amount of fat you consume.
While the exchange lists have been shown to be very helpful to people with diabetes, some find them too restrictive. Also, the counting of carbs and other nutrients can be overwhelming.
The American Diabetes Association recommends a simpler approach for those who find the exchange diet challenging. Called the Diabetes Plate Method, this approach recommends that you physically set up a plate to contain the following:
While healthcare providers now embrace a number of diets or meal plans for people with diabetes, the exchange diet continues to be preferred by many people.
The American Diabetes Association makes using the exchange diet easy by publishing the booklet "Choose Your Foods: Food Lists for Diabetes." The guide focuses on helping you track the carbohydrates in specific foods. It divides foods into six categories:
Choose Your Foods provides a series of lists. Each list has foods that share a specific amount of carbohydrates. This allows you to switch, or exchange, one food for another without affecting how many carbs you take in. The purpose is to allow people with diabetes to easily plan meals.
Beyond just being a tool to count carbs, though, the diet also aims to help you choose healthier carbohydrates. For instance, it shows how legumes, whole grain or multi-grain foods, and whole fruits are more nutritious than highly processed foods, fruit juices, and sweetened beverages.
In carb counting plans such as the exchange diet, each serving is estimated to contain approximately 15 grams of carbohydrates.
Women typically need about 45 to 60 grams of carbohydrates per day, which equals three to four choices on the exchange lists. Men usually need 60 to 75 grams, which equals about four to five choices.
However, exactly how many carbohydrates are right for you may vary. You should speak to a nutritionist and your healthcare provider for personalized advice.
To help people with diabetes manage their overall health, the guide includes more than a summary of carbohydrates, Choose Your Foods includes additional nutritional information, including:
It also contains a glossary with definitions of technical terms so you can better understand all the data.
Not all foods can be easily compared, though. To help you manage more complicated types of food, the exchange diet also breaks out two special types of foods: free foods and combination foods.
The items listed as "free" foods and beverages contain little to no carbohydrates and fewer than 20 calories per serving. Many are listed without a specified serving size, meaning they can be eaten in any quantity. The foods that do have a specific serving size should be limited to two or three servings, ideally spread out throughout the day to prevent a rise in blood sugar.
Examples of free foods are:
Combination foods are those that do not fit into a single exchange list because they contain more than one food group. For example:
The lists on the exchange diet show how much of one food is equal to another. These lists cover carbohydrates as well as other important nutrients.
Each of these items represents a single serving of about 15 grams of carbohydrate. Each serving counts as one carbohydrate portion.
All of these selections have 7 grams of protein. The differences between them will be in the amounts of fat and calories each contains.
Each item listed here contains about 5 grams of carbs, 2 grams of protein, and 25 calories. Unless otherwise noted, the serving size for cooked vegetables or vegetable juice is 1/2 cup and the serving size for raw veggies is 1 cup. These and similar vegetables are generally regarded as non-starchy vegetables.
Unless otherwise noted, the serving size for one fruit is 1/2 cup fresh fruit or fruit juice and 1/4 cup dried fruit.
Regardless of whether whole, low-fat, or skim, the milk and dairy products listed here have 12 grams of carbohydrates each.
Although the foods on this list do not contain carbs, they are high in fat and calories and should be measured carefully.
You can mix, match, and double up on foods however you'd like, as long as you stick to the prescribed number of exchanges and the ideal amount of carb, protein, fat, and calories you should eat each day.
For example, 1/3 cup of rice equals one carb exchange. If you would like to enjoy an entire cup of rice, you would count the cup of rice as three carb exchanges. With this kind of flexibility, using the exchange method can be simple, straightforward, and effective.
The exchange diet has been used for decades to help people with diabetes choose foods that will help them keep their carb intake within a specific range. Using the exchange lists, you can swap one food for another. It requires you to keep portions within a set limit, though, and some people find the diet is too restrictive or difficult to track.
Today, the exchange diet is only one of a number of meal planning methods that healthcare providers say could help people with diabetes. The goal now is to help people put together a personalized diet.
Lim SS. Choose your foods, food lists for diabetes. Journal of Nutrition Education and Behavior. 2015;47(1):117.e7. doi:10.1016/j.jneb.2014.10.004
Kloss KA, Funnell MM, Piatt GA, Nwankwo R. One size does not fit all: Nutrition strategies for people with diabetes. Nursing. 2020;50(8):32-38. doi:10.1097/01.nurse.0000684176.14404.ff
American Diabetes Association. Key Takeaways from ADA’s Nutrition Consensus Report.
Gray A, Threlkeld RJ. Nutritional recommendations for individuals with diabetes. Endotext. MDText.com, Inc.; 2019
American Diabetes Association. What is the Diabetes Plate Method?
UCSF Medical Center. Simply Counting Carbohydrates.
University of California, San Francisco. Diabetes Education Online. Carbohydrate exchanges.
Gary Gilles is a licensed clinical professional counselor (LCPC) who has written about type 1 diabetes and served as a diabetes counselor. He began writing about diabetes after his son's diagnosis as an infant.
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