Adapting cultural foods into renal diabetic exchange lists-Cendol

Searching for culture specific patient education may be necessary.   Internet searches are likely to be the quickest and most effective way.

First you may want to search for exchange lists for the culture of interest.  In this case search for Malaysian Diabetic or Renal Exchange Lists or regional exchange lists such as Renal Exchange Lists for Asians.  

Carefully evaluate of the source of the document should be made to determine how confident you are in the information. Usually university based or professional society based resources would be considered reliable. For example Renal Exchange Lists for Asians that include many vegetables and unique cultural foods that are common from that region and is from a university website. For Example,  A Nutrition Education Tool for South Asians with Renal Disease can be found at the San Jose State Uuniversity website.

If you are unable to find an exchange list that includes the foods your patient wants to each, then you may search for recipes, and particularily recipes that include nutrient analysis.  For example in Mei's case Cendol is not included in any of the information that you can find and is not included in the USDA National Nutrient Database.

If you are using information for the initial nutrient analysis it is not necessary to fully translate into the exchanges and can simply use the nutrient values in the analysis.

If you wanted to put the food item into the exchange system to allow the patient to routinely plan that item, then you would start with the macronutrient of most concern, in Mei's case protein followed by carbohydrate.
1)  Calculate the number of protein/ or dairy exchanges by dividing the total protein if the food item included a meat or dairy ingredients.
2) Subtract the fat and carbohydrate content to see what macronutrients remains.  
3)  Then calculate the carbohydrate content into the food category that most closely resembled the source of the carbohydrate (Starch, Fruit, Vegetable).
4)  Decide which column will be used to account for the potassium (usually vegetables or milk) and the phosphorus (will likely be starch, vegetables or other)

See the following example for Cendol where it is not in the USDA National Nutrient Database and not included in the Renal Exchange lists.

Find a source of information about both nutrient content and recipe for ingredients (See below).

http://www.healthguru.sg/learn-about-food/nutrition-information-cendol/ - Starting Nutrient information and recipe

http://aussietaste.recipes/asian-cuisine/south-east-asian-cuisine/thai-cuisine/cendol/ - Additional recipe for comparison

• Cendol Portion: 368 g
• Energy: 386 Calories
• Protein 6 g
• Carbs: 59
• Fat: 15
• Sodium 195 mg

After looking at the recipe and the toppings that are added you take the basic information and record what you know and convert into exchanges. In this case there is no high quality protein (meat, eggs or milk) in the recipe, but there is starch/carbohydrate so you would start with the starch exchanges and see if the protein is accommodated.
1)  In this case 60 g carbohydrate divided by 15 g (for a starch exchange) would be maximum of 4 exchanges, however 4 starch exchanges usually has 3 g of protein per exchange, so that would be 12 g protein which is too much. We can see that we could only have 3 exchanges of regular Cereal/starch before the 6 grams of protein would be accounted for.
2)  Record 2 Starch and 2 Alternate CHO to account for the extra carbohydrate 
3)  Then record the other macronutrients associated with these exchanges.     
      2 Starch = 30 g carbohydrate, 6 g protein, and 2 g fat
      2 Alt Carbohydrate = 30 g carbohydrate
Total accounted for = 60 g carbohydrate, 6 g protein and 2 g fat
 
4)  Subtract these nutrients from total
       Recipe includes 59 g carbohydrate, 6 g protein and 15 g fat
       This means that the recipe still has 13 g fat left
5) Divide by the number of g in a fat exchange
       13 g fat divided by 5 
       The number of fat exchanges would either be 2 or 3.  
       To decide which estimate the number of calories for the total exhanges and compare to recipe total

       2 starch =      80 * 2 =        160
       2 alt starch = 60 *2=          120
       2 fat  =           45*2=            90
Total calories =                         370  compared to recipe total of 386 calories  
 NOTE:  If you used 3 fat exchanges the total calories would be 415 calories, which is too high compared to 386 calories

Then since we also need to evaluate for Potassium and Phosphorus which were not included in the original nutrient information.
Review the recipe ingredients (use links show above) for both the cendol plus the toppings.

There are two food items that appear to be important as potentially high sources of either potassium or phosphorus: Coconut milk and evaporated milk.

You would record those two ingredients and then use the National Nutrient Database to estimate the per serving contribution of those two nutrients. See table below.

In the renal exchange lists the cut off for Phosphorus is over and under 110 mg per serving, so this would be counted as a high phosphorus food item. For potassium the ranges are 1-200 for the low potassium, and from 201-399 for the higher potassium. Portion size will be very important in terms of placement into these two nutrient categories.