The End of the Exchange Diet

(An old one but interesting figures on percent of people who actually could not/ did not follow this system and fact that it kept on keeping on!!... Ron)

With no fanfare, and with little obvious attention, the dragon is dead! The complicated, poorly understood, and unwieldy exchange diet is fading from vogue in diabetes therapy. It is about time! There have been few treatments that have so poorly served patients than this therapeutic modality. Estimates of compliance to this treatment range from 2-10 percent of all patients given this nutritional program. For those who tried to adhere to this regimen, the experience has ranged from cumbersome to frustrating. And yet health professionals have supported the regimen for decades.

There are few therapies in medicine, which have the (terrible) success rates of the exchange diet that would have persisted, as the exchange diet did. We usually eschew treatments that fail to work in 90-98 percent of patients. The fact that this treatment could work in rigid clinical protocols or inpatient clinical treatment units was viewed as an endorsement of the treatment. The fact that normal people, with reasonable intelligence and psychological make-up, abandoned this therapy with greater frequency than they used it was never understood properly.

Perhaps our constant fidelity to this regimen says more about us as health professionals than it does about the clients we have been serving. The usual reaction to a failure to adhere to the exchange diet has been that the patient was "noncompliant"! This judgment has often been applied both as a clinical observation about the patient as well as an assessment about the patient as a person. Many people, who have been labelled "noncompliant" to the exchange diet, have also been viewed in a negative fashion by the health professionals who have worked with them. The feeling has been that the patient has failed the treatment, and it is the fault of the patient.

In fact, we have been judging patients by standards that have neither scientific basis nor logical foundation. Many of the same health professionals, who have cited patients for being "noncompliant" to this cumbersome regimen, would not follow the exchange diet themselves, if they had diabetes. We have recently learned that many of the treatments we have used in diabetes are specifically responsible for weight gain. Without careful oversight, strict control of blood sugars with insulin therapy is associated with weight gain. Most, but not all oral hypoglycaemic agents for diabetes cause a 6-14 pound weight gain with long-term use. (This is not true with the newer drugs like acarbose or metformin). Thus, the judgment that the failure of dietary treatment is due to the poor performance of the patient may have been incorrect on many occasions.

The exchange diet, as many with diabetes know, is a complex system for structuring eating patterns. Patients use a list of foods, grouped by basic food type - fats, starches, proteins. They are allowed so many selections per meal from each food type. In order to use this sort of program in daily life, one would have to keep a large number of food lists with them. For example, a person would need an exchange list for Chinese food, another for Italian food, and one for each other type of food an individual eats.

Another problem with this treatment is that it is not easily adaptable to new advances in the dietary therapy of diabetes. Today, we are concerned about dietary salt, protein, and fat content. The original exchange diet focused on carbohydrate content of the diet.

It is likely to be a delight to our readers to learn that this diet is now passing out of vogue. When the very same academic centers, which had advocated it for so long, gained the experience of treating large numbers of patients over a long period of time, in studies like the Diabetes Control and Complications Trial, they learned the pitfalls of this diet. Now, alternate dietary approaches, more useful and user-friendly for people in everyday life are being advocated. We suggest that people discuss these new approaches with their diabetes health professionals, if they are on exchange diets, and find them difficult or unpleasant to use.

by S.B. Leichter, M.D.

(Dr. Leichter is a physician specializing in metabolic disorders and is associated with The West Georgia Center for Metabolic Disorders and Columbia Doctors Hospital in Columbus, Georgia)

Copyright © 1997
Columbia/HCA Healthcare Corporation