Nutrition Guidelines

See Also

Epidemiology

More than half of U.S. adults have a disorder significantly affected by diet
Normal weight does not ensure that a patient's dietary intake is optimal for health

Evaluation

HIstory
1. Rate your current nutrition health
2. What are your motivation for nutrition change?
3. What barriers do you have for nutrition change?
  1. See Food Insecurity Reources
  2. Do you have access to fresh foods readily available and at a reasonable price?
  3. Do you or your family experience hunger due to lack of money or resources (e.g. transportation, nearby market)
  4. Is your time limited to prepare home meals?
  5. Is it difficult to prepare meals for your family due to different needs or wants?
  6. How are your shopping and cooking skills?
4. What foods do you eat on a regular basis?
  1. Use a questionnaire such as REAP, or food records, diet diary, or smartphone application
  2. Are you following a specific diet plan (e.g. Mediterranean Diet, DASH Diet, low carb diet, intermittent Fasting?
  3. Are you purposely limiting your calorie intake?
  4. Do you frequently eat at fast food restaurants?
  5. Do you frequently eat at sit-down restaurants?
  6. Do you frequently cook home meals from simple or fresh ingredients?
  7. Do you frequently eat with distractions (e.g. television, devices)
  8. Do you typically eat with others such as your family?
5. What other supplements or substances do you use?
  1. How much Caffeine do you ingest per day?
  2. How many drinks of Alcohol do you have per week? per day?
  3. Do you take Vitamins or supplements?
  4. Do you use any Creatine or Protein supplements (athlete ergonomic aids)?
6. Do you perform regular Physical Activity at work or home, or perform regular Exercise?
  1. What activities (aerobic, strength, flexibility or core)?
  2. How much time are you active each day?
  3. How many days per week are you active?
7. What chronic medical conditions do you have that may be affected by diet?
  1. Diabetes Mellitus?
  2. Cardiovascular Disease (e.g. Coronary disease, Hypertension, Hyperlipidemia)?
  3. Celiac Disease?
  4. Eating Disorder?
Dietary history tools
1. 24-Hour Recall
  1. Patient recalls what they ate and drank at each meal over the last day
  2. May be performed verbally or on paper, prior to or during the clinical encounter
2. Rapid Eating Assessment for Participants, Shortened Version 2, released 2022 (REAP-S V2)
  1. Expands on version 1 with 5 additional questions including Mediterranean Diet (beans, fish, nuts, olive oil)
  2. Five groups of questions (food sufficiency, healthy eating, low nutrient foods, Exercise, ready to change) with guidance for counseling
3. Rapid Eating Assessment for Participants, Shortened Version 1 (REAP-S V1)
  1. https://epi.grants.cancer.gov/diet/shortreg/instruments/segal-isaacson_reap-s.pdf
4. Rapid Eating Assessment for Participants, Full Original Version (REAP)
  1. https://www.brown.edu/academics/public-health/chphe/sites/public-health-cher/files/Reap7.pdf
5. Automated Self Administered 24-Hour Dietary Assessment Tool (ASA24)
  1. https://epi.grants.cancer.gov/asa24/
  2. Research tool that may be used by patients to assess their intake
6. USDA Dietary Reference Intakes (DRI) Calculator for Healthcare Professionals
  1. https://www.nal.usda.gov/human-nutrition-and-food-safety/dri-calculator
Nutritional status exam
1. See Subjective Global Assessment of Nutritional Status
2. See Geriatric Nutrition Checklist

Guideline
Choose food predominately from plant sources

Eat 5 or more servings of nutrient-dense vegetables (3) and fruits (2) per day
1. Fresh, non-processed items are preferred
  1. Frozen, dried or canned vegetable and fruits may be used an alternative
  2. When processed foods are used, choose items with minimal or no added sugars
2. Recommendations
  1. One serving Vegetable equivalents
    1. Raw leafy vegetables (1 Cup)
    2. Cooked, chopped or raw vegetables (1/2 Cup)
    3. Vegetable juice (3/4 Cup)
  2. One serving Fruit equivalents
    1. One medium apple, banana, or orange
    2. Chopped, cooked, or canned fruit (1/2 cup)
    3. Fruit juice (3/4 cup)
3. Benefits of Fruits and Vegetables
  1. Decreased risk of Colon Cancer
  2. Decreased risk of Gastric Cancer
Eat other foods from plant sources
1. Recommendations
  1. One serving Whole Grains/Cereal/Pasta
    1. Whole wheat Bread (1 slice)
    2. Ready to eat cereal (1 ounce)
    3. Cooked whole grain cereal, rice or pasta (1/2 cup)
  2. One serving Beans and Nuts
    1. Cooked dry beans or lentils (1/2 cup) preferred over nuts
    2. Peanut butter (2 tablespoons)
    3. Nuts (1/3 cup)
2. Benefits of Dietary Fiber
  1. Decreased risk of Colon Cancer
  2. Water insoluble (wheat bran) fiber may be better

Guideline
Limit intake of high fat foods (especially animal fat, saturated fat and trans fat)

Choose foods lower in fat
1. However, over emphasis on fat-free at the expense of excessive Carbohydrates results in weight gain
  1. Do not trade fat for high Carbohydrate, increased calorie meals
  2. Monounsaturated fats (e.g. olive oil) are a part of a Healthy Diet
2. Recommendations
  1. Replace fatty foods
  2. Eat fruits, vegetables, grains and beans
  3. Eat smaller portions
  4. Select non-fat/low-fat milk and dairy products (and overall limit to 1-2 servings per day)
  5. When eating prepared foods, choose lower saturated fat
Limit consumption of meats (especially high fat meat)
1. Recommendations: 1 serving of meat per day
  1. Lean meat (2-3 ounces)
  2. Poultry (2-3 ounces)
  3. Fish (2-3 ounces)
2. General
  1. Select lean cuts, and smaller portions of meat
  2. Choose beans, seafood and poultry
    1. Instead OF beef, pork and lamb
  3. Select baked and broiled meats
    1. Instead of fried, charcoal-broiled, or smoked
3. Risks of Salt-cured, pickled, or smoked meats
  1. Esophageal Cancer
  2. Gastric Cancer
4. Risks of red meat (RR 1.1 to 1.3)

Guideline
Healthy Eating Plate (Harvard, modified version of ChooseMyPlate.org)

Key Components
1. Vegetables and fruits (50% of the plate)
2. Whole grains (25% of plate)
3. Healthy Protein such as legumes/beans or healthy animal Protein (25% of plate)
Limited items
1. Limit butter, saturated fats and avoid trans fats
  1. Use healthy oils (e.g. olive oil, canola oil)
  2. Small handful of nuts
2. Limit milk/dairy (1-2/day), juice (1/day) and avoid sugar drinks (e.g. soda)
  1. Primary beverage is water
  2. May also use tea, Coffee with little sugar or non-nutritive sweatener (e.g. Sucralose, Aspartame)
3. Limit salt
  1. Limit to 2300 mg/day (1 tsp), and some guidelines recommend 1500 mg/day (2/3 tsp)
References
1. Harvard Nutrition Source
  1. https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/

Guideline
Miscellaneous

Be physically active and maintain a healthy weight
1. Moderate activity for 30 minutes on most days
2. Maintain a body weight within 20% of ideal
Limit Alcoholic beverages
1. Alcohol, when used in moderation may be a part of a healthy lifestyle
  1. However, encouraging Alcohol use in those who use little to no Alcohol, risks Alcohol Abuse
  2. Those who safely use Alcohol in moderation may continue
2. Risks associated with longterm heavy Alcohol use or abuse
  1. Oropharyngeal cancer
  2. Esophageal Cancer
  3. Hepatocellular Carcinoma
  4. Breast Cancer

Approach
Cohort-Based Guidance

Approach
Pearls

Avoid products that raise the risk of excess calories, weight gain, Diabetes Mellitus
1. Avoid sugar-containing soft drinks
Cereal grains (wheat, rye, barley, corn, rice, oats, millet) and pseudo-grains (quinoa, amaranth)
1. Whole grains are preferred
  1. Whole grains mill all three grain components (bran, germ, endosperm) together
  2. Refined grains contain only the milled endosperm (germ and bran are removed)
2. Wet grains are preferred over dried grains (from a nutritional, excess calorie standpoint)
  1. Cooked oatmeal is more filling initially than dried cereals
Dietary Fat
1. Use healthier oils high in monounsaturated fat (olive oil, saflower oil, canola oil, peanut oil)
  1. Avoid unhealthy, tropical oils (coconut oil, palm oil) that are 86-92% saturated fat
2. Decrease in saturated fat and trans fat lowers coronary risk
3. Unsaturated fats in moderation are considered a part of a Healthy Diet
  1. Over emphasis on fat-free at the expense of excessive Carbohydrates results in weight gain
  2. Replacing unsaturated Dietary Fat with refined starch and sugar results in worse outcomes
Dairy
1. Vitamin D is more likely than Calcium to be deficient
  1. Most people in the U.S. (esp. northern climates) could benefit from 1000 IU/day Vitamin D
2. Calcium intake is sufficient with 3 servings per day
  1. High Calcium intake increases Prostate Cancer risk
Plant-based food focus (plant forward)
1. See Plant Based Diet
2. Encourage superfoods
  1. https://thecurbsiders.com/wp-content/uploads/2022/10/Superfoods-5-9-2022.pdf
Eat less meat (esp. less red meat)
1. Replace red meat with nuts, legumes, fish and poultry
2. Avoid highly processed meats such as deli slices (increased cancer risk)
3. High Temperature cooking (e.g. barbeque, open flame) of meat or poultry is associated with Diabetes risk
  1. Liu (2017) Diabetes Care 40(8):1041-9 +PMID: 28611054 [PubMed]
Logistics and social factors
1. For those who have too little time to practice a healthy lifestyle (but avoid preaching)
  1. If you do not have time to be sick, you must take time to be well
  2. Healthier dietary change is superior to medications in its effect on morbidity and mortality
    1. Consider this as disease modifying nutrition
2. Implement dietary changes in steps (e.g. one per clinic visit)
  1. At each step, replace one less Healthy Dietary item with a more healthy item of the patient's choice
  2. Have patients choose one healthy item from a superfoods list
  3. In the longterm, diet improves by "crowding out" the less healthy choices
3. Make media-free, family dinners a habit
  1. Set out a plate of cut vegetables for snacking while preparing dinner
4. Have lunch containers open to prepare at same time while making dinner
  1. Many of the dinner items can be placed directly into lunch containers
5. Make time to eat breakfast (high quality with fiber and nutrients)
  1. Breakfast skipping increases the risk of Type 2 Diabetes Mellitus, Obesity, Coronary Disease
  2. Bi (2015) Public Health Nutr 18(16):3013-9 +PMID:25686619 [PubMed]
Produce shopping and storage
1. Buy max of only 2 weeks of perishables, wash, trim and store in humidified refrigerator door
2. Choose recipes in advance of shopping and stick to a shopping list
  1. Choose recipes that share core ingredients, may be prepped in advance, and good as left-overs
3. Keep salad greens and herbs wrapped in damp towel or in a container with water at bottom
4. Roast left over vegetables at the end of each week

Approach
Public Health and Prevention

Healthy Lifestyle is the keystone to reversing a U.S. trend of worsening overall health despite medical advances
1. Maximal medical management for cardiovascular disease has reached a mortality plateau (2010)
  1. Further advances in lowering cardiovascular mortality will need to maximize healthy lifestyle
2. "Greatest advances... offset by the burden... caused by too many people eating too much... moving too little"
  1. (2005) Institute of Medicine +PMID:22379642
Children are not compelled to relive their parent's medical history ("genes are not destiny")
1. High genetic risk patients with healthy lifestyle lowered their coronary event risk by 46%
  1. Khera (2016) N Engl J Med 375:2349-58 [PubMed]
Since 1994, Obesity (BMI>30 kg/m2) has dramatically increased throughout the U.S
1. As of 2015, most U.S. states have more than 26% Obesity rates (contrast with <14-18% in 1994)
2. As of 2014, Type II Diabetes Mellitus Prevalence in the U.S. has increased to 22% (contrast with 5% in 1980)
3. Up to 60% of U.S, toddlers in 2017 are projected to be obese by age 35 years old
  1. Ward (2017) N Engl J Med 377:2145-53 [PubMed]
Food insecurity and hunger
1. Associated with increased hospitalizations and worse comorbidity management
2. Most plant-based meals can be prepared for $1-3 per serving
Protein importance in the diet is over-stated at the expense of health, cost and the environment
1. In the U.S., even those on plant based diets far exceed Protein requirements (0.8 g/kg or 40-60 g/day)
  1. Most in U.S. consume >70 g/day, and on average >90 g/day
  2. Even for other countries with high Protein intake (Europe), plant-based Protein is more prevalent
2. Agriculture (esp. live stock) is the world's second largest emitter of greenhouse gases (behind energy)
3. LIvestock are heavy resource utilizers (food, water); the same resources could support far more people directly

Approach
Restaurants - Menus of Change (Harvard, Culinary Institute of America)

Regionally sourced foods
Intact whole grains (minimal processing), nuts and legumes
Healthier oils (olive oil, saflower oil, canola oil, peanut oil)
Decrease the sugar and salt
Prepare more home meals (less eating-out at restaurants)
Plant-based food focus (plant forward)
1. "Delicious, unapologetic, cravable" recipes making use of mediterranean, asian and latin flavors
2. Maximize the use of local produce
Meat in smaller amounts (2 ounce), less frequently overall (Protein-flip: meat becomes the side-dish)
1. More seafood (diverse selection) than poultry/eggs than red meat
  1. Replace red meat with nuts, legumes, fish and poultry
2. Blended burgers (meat mixed with mushrooms, grains, vegetables, legumes)
3. Meat becomes the dish condiment or seasoning
Resources
1. Menus of Change
  1. http://www.menusofchange.org/
2. Plant Forward 50 (chefs and restaurants)
  1. https://www.plantforward50.com/

Approach
Teaching Kitchens

Many health care organizations, teaching institutions and communities have built teaching kitchens
Offers hands-on education for delicious, healthy meal preparation for sustained habits
Minimal home kitchen kit
1. Chef knife, pairing knife, cutting board, vegetable peeler, can opener
2. Measuring spoons and cups, whisk, slotted spoon, colander/strainer, mixing bowls
3. Stock pot with lid (5 qt)
4. Saute pan (11")
5. Sheet pan and cooling rack
Minimal home pantry
1. Flour (whole wheat, unbleached all-purpose), Brown rice, rolled oats, grains (e.g. quinoa), whole wheat pasta
2. Nuts (e.g. almonds), dried fruit (e.g. raisins), dried beans (e.g. lentils, black beans, split peas)
3. Oils (olive, canola), Vinegar (wine, rice or apple), mustard, honey
4. Kosher salt, black pepper
Flavor foods by cuisine
1. Asian
  1. Light soy sauce, fish sauce, rice vinegar, sesame oil, chili Garlic sauce
  2. Garlic, Ginger, lemon grass, lime, chilles, cilantro, Tofu, scallions
  3. Cumin, coriander, cinnamon
2. Mediterranean
  1. Olive oil, balsamic, red wine vinegar
  2. Garlic, tomato, olives, onions
  3. Parmesan, feta, capers, basil, thyme, oregano, parsley
3. Latin America
  1. Tortillas, lime, chiles (serano, jalapeno, chipolte), cilantro, Garlic
  2. Rice, beans, corn, avocado, tomatillo, onions, cheese
Workspace organization ("Mise en Place")
1. Back row
  1. Tray for ingredients and prep bowls
  2. Large scrap bowl (and consider bags for freezing stock)
2. Front row
  1. Cutting board, knives, spices/oils

Resources
Education

See Food Insecurity Resources
Disease Modifying Nutrition (Curbsiders Podcast, Dr. Michelle McMacken)
1. https://thecurbsiders.com/internal-medicine-podcast/360-disease-modifying-nutrition-with-dr-michelle-mcmacken
Superfoods Patient Education (Curbsiders Podcast, Dr. Michelle McMacken)
1. https://thecurbsiders.com/wp-content/uploads/2022/10/Superfoods-5-9-2022.pdf
Healthy Eating Plate (Harvard)
1. https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/
Choose My Plate
1. http://www.choosemyplate.gov/
Healthy Kitchens, Healthy Lives Conference, Harvard and CIA, St. Helena, CA
1. http://www.healthykitchens.org
U.S. Dietary Guidelines
1. https://www.dietaryguidelines.gov/

Reference

Eisenberg, Willet, Clark, Hu (2018) Healthy Kitchens, Healthy Lives Conference, Harvard and CIA, St. Helena, CA
(1996) CA Cancer J Clin 46:325-341 [PubMed]
Pierre (2022) Am Fam Physician 106(4): 427-38 [PubMed]
Elsayed (2026) Am Fam Physician 114(1): 98-100 [PubMed]