Development of a Lebanese food exchange system based on frequently consumed Eastern Mediterranean traditional dishes and Arabic sweets

Background: The important role of Mediterranean diet was elucidated in various clinical and epidemiological studies underlying its impact on reducing the burden of non-communicable diseases in Mediterranean and non-Mediterranean populations. Objective: The aim of this study was to convert the recipes of the Lebanese traditional dishes into meal planning exchange lists whose items are expressed in grams and adjusted to Lebanese household measures (cups and spoons) that could be used by healthcare professionals. Methodology: Thirty traditional Lebanese dishes were collected in which the carbohydrate, fat and protein were analyzed using Association of Official Analytical Chemists procedures then followed by a calculation of exchange lists of foods per serving using Wheeler method. Results: The variations in macronutrients and fiber content were found among the Lebanese dishes. Carbohydrate was lowest (1.1g/100g) and protein was highest (29.7g/100g) in Shawarma Dajaj whereas fat content ranged between 0.5 and 22.4 g/100 g in the dishes. For each dish and according to each serving size, carbohydrate, milk (whole milk, reduced fat or skim), fat and protein (lean meat, medium fat meat and high fat meat) exchanges were calculated. Conclusion: This study provides healthcare professionals, dietitians and consumers the chance to proficiently plan traditional-type dishes, ensuring prominent dietetic and medical nutritional therapy practices and patient's self-control.


Background
The Eastern Mediterranean Region (EMR) is currently facing rapid social and economic changes, urbanization, and advances in technology along with a shift in the prevalence of non-communicable diseases (NCDs) due to the obesogenic environment, nutrition transition and modification of lifestyle patterns characterized by changes in food intake and a reduction in physical activity attitudes and practices 1 . Lebanon is an Arab country with a population of over six million 2 and is considered as part of the EMR. Few data have discussed food attitudes and practices in Lebanon; however, recent evidence published in 2019 from two surveys enrolled previously between 1997 and 2008/2009, showed a shift in the Lebanese diet with regards to an expansion in energy intake from 1728 ± 24 kcal in 1997 to 1877 ± 15 kcal in 2008/2009 and dietary fat from 34.63 ± 0.32% in 1997 to 36.97 ± 0.21% in 2008/2009, coupled with decreases in carbohydrate (CHO) (48.97 ± 0.23% in 2008/2009 compared to 51.32 ± 0.36% in 1997), in fruit consumption (4.72 ± 0.15% vs. 7.36 ± 0.22% in 1997) and a decrease in micronutrient dietary density along with a decrease in the consumption of milk (1.09 ± 0.08% vs. 1.53 ± 0.11% in 2008/2009 and 1997, respectively). No changes were reported with regards to protein and fiber intake 3 . According to the World Health Organization (WHO) statistics, the worldwide probability of premature death due to NCDs accounts for 70% of the 41 million deaths each year. In Lebanon in 2016, 91% (10,334 individuals) of all deaths were due to NCDs 4 . Furthermore, among the 10,334 premature deaths from NCDs, 27.2% of deaths were due to cancer. Around 31% of the population was obese, 13% had diabetes type II, 20% had raised blood pressure and 36% had a sedentary lifestyle 4 .
The implementation of food composition tables and development of exchange lists is drawing attention at a national and international level due to the recommendations and guidelines 5 published by the public and private sectors with the purpose of implementing programs aiming to ameliorate medical nutritional therapeutics for widely distributed NCDs. Food composition tables and exchange lists also have an impact on marketing, on the trade of products and on consumer safety and health 6 . Many factors influence meal planning for a healthy diet, of which food choices, personal preferences, ethnic behaviors and tradition may increase the responsibility and commitment of health care professionals and dietitians in promoting improved nutrition at an individual and community level, through adherence to food composition tables and exchange lists 7 .
At the Middle Eastern level, there is a lack in regional and national exchange lists that incorporate traditional foods. The food exchange list 8 , which helps in translating recipes into food serving sizes and energy intake, was designed to assist individuals in an easily operated and easily understood way in improving their healthy eating habits and in adhering to a healthy diet plan. In the food exchange list, foods available in the same category can be used reciprocally without any change in the quantities of macronutrients and energy yielded by a dish. According to numerous sources, there is a need to add cultural relevance to food exchange lists to improve NCD management 9 , taking into consideration ethnic variations and traditions which may have enormous influence on individual and community health 10 . Thus, the key success factor for improving health care professionals, dietitians and individuals' adherence to healthy food choices is to design and implement culturally accepted exchange lists that add traditional dishes into their meal planning 7 . Currently, Lebanese dietitians are using the American Dietetic Association exchange list to design meal plans. However, this exchange list is limited by a gap in traditional meals consumed in Lebanon. In spite of the availability of a few national food composition tables that involve a limited number of dishes common in Lebanese cuisine 11,12 , ingredients and preparation methods differed substantially across time and these are outdated. The aim of this study is to enable Lebanese healthcare professionals and dietitians to develop, design, and implement practical culture-based meal plans that include traditional cooking.

Dish/sweet selection
The definition of 'composite dishes' is "dishes consumed at main meals (i.e. lunch or dinner), whose preparation involves culinary skills and contains ingredients from at least three of five main food groups: meat/poultry/fish and eggs; dairy products; fruits and vegetables; starchy foods including legumes; added sweets and fats" 13 . The list of Lebanese composite dishes frequently consumed by Lebanese citizens was retrieved from a study performed in 2005 on a representative sample of 799 Lebanese adults 13 , and in line with a study conducted in 2009 where the objective was to compare the consumption of traditional dishes between Lebanon and France 14 . As for Arabic sweets, a broad selection of almost all types frequently consumed by Lebanese people was compiled. The Lebanese diet includes a range of foods with often complex recipes, and it is rarely possible to analyze all of the types of dishes. In such cases, laboratory analysis of the traditional dishes and a calculation of some nutrients should be achieved. The names of the dishes and Arabic sweets most eaten by Lebanese citizens and chosen for this study are shown in Table 1.

Data collection
A sample of 500 g of each dish or sweet was collected and used for analysis. According to Greenfield et al., this size is a convenient sample to avoid errors during analysis 15 . Our research group collected 500 g of 30 types of traditional dishes from a central kitchen in Beirut and 35 types of Arabic sweets from popular sweet retails in the same area. These popular kitchen and sweet retailers, which serve traditional meals and Arabic sweets were found on the internet and chosen based on the following criteria: 1) their specialty in cooking home-made dishes and serving Arabic sweets; 2) their popularity; and 3) the popular kitchen's involvement in supporting women, as part of social entrepreneurship initiatives that are aimed at empowering women. Regarding traditional meals, five samples for each dish were collected previously from various regions of Lebanon and tested to eliminate any discrepancies 16 . The laboratory analyses of the 150 samples showed, after being tested using Chi-square, no  17 .
To obtain ash, using an Isotemp muffle furnace, an oxidation of all organic matter in a weighed sample was achieved by incineration in a muffle furnace at 550°C overnight; then the weight of the remaining ash was measured. CHO was calculated by subtracting the sum of the percentages of the measured weights of fat, protein, moisture, and ash from the total weight (100g). Energy was expressed in kilocalories (kcal). Using Atwater calorie conversion factors, calorie values were calculated based on the total grams of protein, fat, and CHO, as 4, 4, and 9 kcal/g respectively 18 .

Development of exchange lists
The macronutrient exchanges were determined based on the laboratory values provided from the analysis of 100 g of each dish. Wheeler and collaborators (Wheeler et al. 1996) 19 described a round-off method which was used to yield exchange numbers. The macronutrient exchanges were calculated as follows: CHO exchange. The dish was not considered as one serving if it contained 1-5 g carbohydrate. If the food portion contained 6-10 g CHO, the dish was considered as half a serving and if it contained 11-20 g CHO, it was considered as one serving.
Protein exchange. If the amount of protein ranged between 0-3 g in the meat and meat substitute dishes, it was not counted as a serving. If it contained 4-10 g protein, it was considered as one serving.
Fat exchange. If the amount of fat in food portions ranged between 0-2 g, it was not considered as a serving. However, if the dish contained 3g of fat, it was counted as half a serving and if it contained between 4 and 7 g fat, it was counted as one serving. Moreover, the amount of the meal (in grams) that yielded one CHO, one protein and one fat exchange was obtained by the calculation of CHO grams, protein grams, and fat grams by 15, 7, and 5, respectively.

Results and discussion
The results of the analysis of 100g from each dish and Arabic sweet are presented in Table 2.  (Table 2). On the other hand, although the amount of energy in the dishes was identical, the dissimilarity in protein, CHO or fatty acid content had nutritional implications on health, since a high intake of CHO or fats is associated with a high-risk factor for non-communicable diseases 5 .
The nutrient goal represents the average intake that is compatible with the maintenance of good health in individuals 20 . According to the US Food and Drug Administration (FDA) definition, the daily value (DV) is described as the "reference values for reporting nutrients on the nutrition labels". The percentage (%) of DV assists the consumer in recognizing how the serving of food, and its content in nutrients, fits into their daily diet. As per FDA regulations, the expression "high," "rich in," or "excellent source of" nutrients are used if the food has ≥20% of the daily value per reference amount. The terms "good source," "contains," or "provides" are used if the food yields 5-19% of the recommended dietary intake (RDI) per reference amount of the nutrient. Foods that carry <5% of the RDI from the nutrient per reference amount are considered to have low amounts. In our study, the contribution of each dish (per 100g) to the overall amount of CHO, protein and fat needed per day was calculated. The calculations are presented in Table 2.
Pellet et al., in 1970, showed high total fatty acid content in Lahm bi ajin (39.4%) which was higher than the reported value of 8% in our study 11 . There is limited available research on the composition of Lebanese traditional composite dishes, thus the results provided in this study were compared with data from other countries in the EMR 11,21-26 , mainly the amount of total fatty acid content in these foods. The amount of total fatty acid in the foods consumed in Lebanon, Bahrain, Kuwait, Jordan and Saudi Arabia are extremely important given the elevated prevalence of non-communicable diseases in the countries (Table 3) 26 . Compared to our findings, increased fatty acid content was observed in Falafel that was also reported in many other Arab countries (14.3% in Saudi Arabia to 18.4% in Jordan) 23,24 . The fatty acid content in Baba Ghanouj was double the level described in Jordanian Baba Ghanouj (9.4% and 5.4%, respectively) 23 and triple the level reported previously in 1970 in the Lebanese Baba Ghanouj. Furthermore, the Kuwaiti Baba Ghanouj's fatty acid content was moderately lower than that described in our study (8.7 and 9.4, respectively) 22 . Total fatty acid levels in Batata Mehchi ranged from 5.6% in Lebanon at 1970 to 5.9 % in Saudi Arabia 11,24 . Musiager et al., in 1998 21 , found double the amount of fatty acid levels in Bourgul bi banadoura, Chichbarak and yakhnet Bamia when compared to our study ( Table 3). The high fatty acid content of Fatayer Sabanikh was shown in almost all other studies enrolled in Arab countries; the content found in our findings was higher than all values reported in all countries (Table 3). In our study, Fattoush contained lower fatty acid content compared to the same dish of Kuwait origin (2.94% and 2.17%, respectively) 22 .
In contrast, our results contradicted the values reported previously in Lebanon and in Jordan (6.3% and 8.6% respectively) 11,23 . Since Foul Moudamas is frequently consumed with added olive oil in Lebanon, thus, the availability of total fatty acids is high in this dish. The findings of our study show that the amount of fatty acid in Foul Moudamas was similar to those prepared in all the Arab countries except for Jordan 23 . The values of fat in the remaining dishes are shown in Table 2. Since the protein and CHO content of the meals studied were not explored in all the Arab country-based studies, it is impossible to compare these variables to our findings.
The macronutrient exchanges yielded from the analysis of 100 g of each of the 30 dishes are shown in Table 4. In addition, the serving size of each dish which would provide one exchange of each macronutrient was calculated (Table 4). At least one exchange of starch was found in almost all dishes except Baba Ghanouj, Fattat homos, Fattoush, Hindbe bil zet, Loubia bil zet,  (Table 4). Less than 10 g of protein per portion size was determined in all dishes except for Kafta wa Batata and Shawarma Dajaj (Table 4).

Arabic sweets
The amount of moisture ranged between 0.7% in Halawa light to 55.4% in Mohallabiya. The highest amount of protein was observed in Foustoukia (19.2%) and the lowest amount was in Moushabak (2.1%). Barazik, which is a sesame cookie cooked with butter, contains predominantly more than 40% of fat and had the highest energetic content (553 kcal/100 g). on the other hand, the least energy-dense foods were puddings (Riz bi halib and Mohallabiya).
As stated before, there is a gap in the research field on the composition of Lebanese traditional composite dishes and Arabic sweets, thus our findings were compared with data from other countries in the EMR 11,21-26 , mainly the amount of total fatty acid content in these sweets. Compared to our findings, the fatty acid content of Baklava in Lebanon did not differ to that in Jordan; however, it was lowest than the value reported in Bahrain. Lebanese Barazik, Ghourayba, Katayef Kashta, Maakaron and Moushabbak and Maamoul fostok had the highest fatty acid content compared to other EM countries ( Table 3).
The macronutrient exchanges yielded from the analysis of 100 g of each of the 35 types of Arabic sweets are shown in Table 4. In addition, the serving size of each dish which would provide one exchange of each macronutrient was calculated (Table 4). At least one exchange of starch was found in all Arabic sweets. Barazik and Halawa contained the highest amount of fat exchanges (2 exchanges per serving). In addition, less than 5 g of protein per portion size was determined in all Arabic sweets (Table 4). These exchange lists for traditional dishes and Arabic sweets will assist healthcare professionals and dietitians in organizing culturally appropriate planning of healthy food, especially for those with non-communicable diseases. Furthermore, for effective medical nutritional therapy, these exchange lists may assist in monitoring food portions for these traditional dishes. In addition, the chemical composition of traditional foods is highly necessary in order to investigate the dietary consumption of populations 25 and explore the impact of healthy food consumption on disease prevention 26 .
The principal limitation of this study is that the dishes and Arabic sweets analyzed were commercially prepared and the dishes' ingredients were not reported, only recipes. Table 1 provides the ingredient quantities available from Lebanese cookbooks; however, all the relevant findings in our study were analyzed in an accredited laboratory. In addition, there are differences in ingredient proportions and cooking methods among various countries in the Arabian Middle Eastern and Gulf regions 22,27 .
Despite these limitations, this study provides healthcare professionals and consumers with an updated food composition table and a new exchange list of Lebanese traditional dishes and Arabic sweets consumed in Eastern Mediterranean countries by providing the laboratory composition of 30 frequently consumed traditional foods and 35 frequently consumed Arabic sweets. This can help improving diet quality, the achieving weight loss and implementing self-control in obese or overweight individuals and/or individuals with diabetes.

Conclusions
To conclude, the Lebanese food exchange lists for the 30 frequently consumed Middle Eastern traditional dishes and the 35 mostly consumed Arabic sweets are now available 28 . This guide is a good source of information about the macronutrient content of traditional dishes and Arabic sweets cooked in Lebanon. It is important to consumers, dietitians, and researchers and it offers accessible, user-friendly, practical models and uses household measures that allow consumers, dietitians and healthcare professionals to develop meal plans with healthier selections. Jordan, Syria and Palestine also can get the maximum benefit from this work because of the similarity in their traditional dishes. Finally, Lebanese cuisine offers a wide variety of recipes rich in micronutrients which could prevent the rise in NCDs. Thus, data on micronutrients in traditional dishes and Arabic sweets would be of greater importance in halting the rise of diet-related NCDs in the EMR. Efforts like this will provide a solid framework for the implementation of nutrition policies and practices in the region.