Should Newly Diagnosed T1Ds Be Taught the Exchange System?

food scale

If you were diagnosed after the year 2000, you are probably saying, “Whooza whatza exchange system? Is that like foreign currency for diabetics?” Ha ha.

Let’s go old school for a minute: does anyone remember this little scale that lived on our kitchen counter-top back in the day? It was usually somewhere between the sweet-and-low packets and the sugar-free Jello boxes (this is well before we learned about the damage artificial sweeteners can do in excessive amounts).

Take any given week-day afternoon in the early ’90s, and I would have my usual routine: Get off the bus from school, check my blood sugar, look at the 8×10 chart on the fridge to remember if I was supposed to get 1 fruit and 1 bread exchange, or was it 1 protein and 1 bread? Ahh, the meal exchange on the fridge—covered with blood stains from finger sticks, and also chocolate from the excitement of sugar-free pudding snacks with cool-whip.

Let me clarify by stating that the exchange system still sort of exists; it’s just called different things depending on the dietitian or diabetes educator that is working with the patient. It may be referred to as the plate method, the glycemic index, or generalized as balanced eating with carbohydrate counting. The specifics of the exchange system back in the day, when anyone who needed insulin was placed on this meal planning system, had its pros and cons. The pros were that, during a time when all we had for long acting insulin was the dreaded peaks and vallies of NPH insulin, the exchange system helped us to avoid drastic spikes and falls of our blood sugars throughout the day. This was crucial to good control, not waking up in the middle of the night with that awful clammy, sweaty low that NPH can really hit you with, and having a close to ideal fasting blood glucose in the morning. The cons were mainly that it was restrictive and made anyone with diabetes feel like they were breaking the law when you “cheated” your meal plan.

It makes me laugh out loud that we now are all so hyper-focused, especially with children who are newly diagnosed, to use the most sensitive and non-judgmental nomenclature, and never tell kids that their blood sugars are bad or good or to test, but instead that they are high or low and to check their blood sugars, so as not to imply a pass or fail. When I was diagnosed in 1990, yes, it plain sucked. I was only 9 and was basically forced into treating food like my enemy. This was an eating disorder waiting to happen. Luckily, I was never affected in that way with food, but I do know others who were diagnosed around the same time as me that really struggled with eating and body image through their teen years. Food is on our minds 24/7. Do I have enough juice or peanut butter crackers in case I’m low? Do I have enough water and low carb items to fill me in case I’m sick and have super high blood sugars? I really want that pasta at dinner but my reservoir is low on my pump…do I have enough to make it and still be able to enjoy myself?

It is literally NEVER ending.

I bring up all of the above points because somewhere over the last decade all of this has been lost. One of the few positive things about the exchange system was that I was always held accountable. While this was difficult at such a young age, for me and my entire family, it taught me that my disease is chronic, serious, and shouldn’t be taken lightly no matter how hungry I was or how good the Halloween candy looks. I am astounded at what is happening with some children and teens today that are newly diagnosed.


When I worked at a diabetes camp almost ten years ago now, I remember starting to see a lot of the staff and campers really struggle with weight. I remember that the food scales, food alternatives or “free foods” (food with little to no calories) were gone from the dining hall. It was a free-for-all. This is when insulin pumps really started to show up on the majority of campers. What happens when a newly diagnosed diabetic is put on an insulin pump right away, or even given a regimen of a long-acting insulin (that is smooth and without peaks and valleys)? Well, they are never taught they should go without. As long as they account for what they are putting in their mouths, through proper math and carb counting, they can eat whatever they want for the most part. How is this holding any of us accountable anymore? Trust me, I am guilty as charged too.

Please know, I am not saying that there is no stress involved in the anxious mom who is hurrying to bolus her son at a birthday party as he wolfs down the pizza and cupcakes. There is a TON of stress, guessing, mistakes, and work involved in eating and managing every second with this disease. But we work so hard at trying to make newly diagnosed kids feel normal that we’ve lost track of the overall goal, which is healthy balanced eating and fully understanding the consequences of not doing that. I am sure there are many dietitians and CDEs out there who attempt to put together a loose meal plan in the form of a glycemic index chart or good portion poster/model but at the end of the day, we know we can just count our carbs and fix what needs to be fixed, if we are not motivated to eat healthy then it’s a recipe for disaster.

Even those of us who have had diabetes for a very long time are still a bit jaded by having been so restricted for so long before we went on a pump, that we still feel guilt when we eat too many cookies, even if we do bolus accordingly. It’s a fine line, but I think the exchange system should be enforced with newly diagnosed diabetics for at least the first couple of months to give them baseline knowledge and a head start toward making eating choices that will help manage both diabetes and weight control through the adolescent years.

*Note: Diabetes camps have worked very hard over the years at finding a balance with the variety of insulin regimens that the campers are on, and making food choices as balanced and healthy as possible while letting the campers be involved in carb counting and taking insulin. The Diabetes Education and Camping Association (DECA) has put together a nutrition manual for all camps (both day and overnight) for kids with diabetes to assist in creating general food and nutrition guidelines. This will be available soon, and I was part of a team of dietitians who created this resource.

Regina Shirley, RD, LDN–ServingUpDiabetes

Read Regina’s blog at

Sign in or Register to view comments.