Whole Health Library

• The Standard American Diet (SAD) does not provide us with optimal nutrients. Poor eating habits associated with this diet have a profound negative impact on health.
• Clinicians should individualize care to meet Veterans where they are; even small changes can lead to positive results.
• People often are put off by the word “diet.” This overview focuses on a number of “eating plans” that are popularly followed, noting some pros and cons for several of them.  Remember, a plan’s success is much more likely if the person persists; tying in the benefits of healthy eating to what really matters to a person can be extremely helpful.  Be cautious when it comes to fad diets. 
• Enlist the assistance of dietitians as part of the Whole Health care team. They are a valuable resource.
• When it comes to food safety, pay particular attention to the Dirty Dozen™ and Clean 15™ guidelines on the Environmental Working Group

“The food you eat can be the safest and most powerful form of medicine or the slowest form of poison.” –Ann Wigmore

Erin is a 35-year-old Navy Veteran and mother of two.  Currently, she is overweight, with a body mass index (BMI) of 29.  She often feels tired, struggles with constipation, and has some symptoms of gastritis.  She also notes frequent migraines and chronic sinus infections.  Erin does not have diabetes, but her doctor is concerned because her fasting glucose is elevated, and she has a strong family history of type 2 diabetes.

During a recent visit, Erin completed a Brief Personal Health Inventory (PHI).  Her care team members reviewed it and noted several areas of concern, positivity, and interest. Her PHI vitality signs survey indicated a big difference between how she rates her emotional versus physical well-being:

Rate where you feel you are on the scales below from 1-5, with 1 being miserable and 5 being great.

Erin’s Mission/Aspiration/Purpose (MAP) is centered around her family and her ability to do what she enjoys.

On page 2 of her PHI, Erin reports being where she wants to be in terms of Spirit and Soul, Surroundings, Personal Development, and Family, Friends and Co-workers.  Moving the Body, Food and Drink, and Recharge are where she has the greatest challenges:

Her “0” out of 5 for Food and Drink was particularly striking, and when asked about it, Erin agreed that was the area she wanted to work on.  She has some initial ideas but clearly wants and could use some guidance.

During one of her visits with her care team, Erin described her diet.  Most mornings, she has a bagel or granola bar for breakfast.  For lunch, she has leftovers from dinner the night before.  Her afternoon snack is usually chips or popcorn.  She eats out with her family 3-4 times each week, and for those meals, she usually chooses a fast-food option.  She and her children enjoy vegetables, but they only eat a few servings per week.  When her family eats at home, they usually eat while watching television.  Erin tries to drink mainly water and now avoids beer to cut down on calories.  Her teenage son enjoys fruit drinks, so she always stocks the refrigerator with them.  Sometimes she ends up drinking them herself.

Erin knows she needs to make healthier dietary choices, but she does not know how to go about it without feeling overwhelmed.  She has the following questions and concerns:

• What is the best diet for me to follow? Should I follow a low-fat diet?
• What is fiber, and why is it good for me?
• What are some good options for protein?
• Eating healthy costs too much, and I am not sure I can afford it. Any suggestions?
• Juice is high in calories, but it is healthy, right, since it comes from fruit?
• Water is boring; are there other things to drink that are good for me?
• Sometimes I eat when I am bored or sad, and I know it is not a good way to deal with my feelings, but it makes me feel better. Any ideas? 
• How do I eat well but still feel satisfied? I hate dieting because I always feel like I am starving.
• Should I take a multivitamin?
• What minerals do I really need?

The prevalence of obesity and overweight in Veterans matches and may even be higher than that of the general U.S. population.[96]  Eighty-one percent of male Veterans and 54% of female Veterans are either overweight or obese (BMI>25).  Twenty-five percent of male Veterans and 17% of female Veterans meet the criteria for obesity (BMI>30).[1]  A 2017 Journal of the American Medical Association study concluded that, in 2012, at least 45.4% of all deaths from heart disease, stroke, and diabetes were ultimately caused by poor diet.[2]  The prevalence of overweight and obesity increases every year,[3] and the number of people dying due to poor dietary choices is climbing.[4]  Each year, over 11 million people die worldwide because of obesity, and it its associated with over 255 million disability-adjusted life years (total number of years people live with disabilities due to obesity).[97]

What can be done about the epidemic of unhealthy eating?  Many people look to their physicians or other clinicians for nutritional guidance.  Little do they know that most clinicians receive limited—even negligible—nutrition training.  According to a 20 of 121 medical schools, 71% of schools fail to provide the required 25 hours of nutrition education over 4 years, and 36% of these schools did not provide half that amount.[4]  A 2022 review of the literature on nutrition education found that most of them were optional and the median duration was only 11 hours.[98]  Even more disappointing, courses often lack clinically relevant information that can be applied to patient care.  Rather than reviewing research on how to eat well, much of the nutrition curriculum for health professions focuses on biochemistry. 

Many patients feel that Food and Drink is an important area of focus for a Personal Health Plan.  In fact, many of us tend to fixate on it, even while struggling unsuccessfully with making good dietary choices.  Most people know what they should or should not eat.  However, they also have a difficult time changing their behaviors in accordance with that knowledge.

As clinicians, the so-called Standard American Diet (SAD) is our nemesis.  Erin’s family’s diet is an example of a SAD; it is not a healthy way to eat.  The SAD is characterized by the following:[5]

• Excessive calorie intake
• Too many refined carbohydrates
• High consumption of fatty meats
• Unhealthy levels of added fats
• Limited intake of nutrient-dense foods such as whole grains, fruits, and vegetables

The purpose of this overview and its related Whole Health tools is to provide practical information about nutrition to guide both your own food choices and the nutrition suggestions you offer to your patients.  Even if you are pressed for time, it can be beneficial to suggest at least one or two of the nutrition tips offered in this overview during a Whole Health visit.  It only takes a few moments, and you can always provide patients with written information that they can review in more detail after their visit.  Additionally, you can refer patients to a registered dietitian who can provide in-depth recommendations.

In 2018, VA Office of Patient Centered Care and Cultural Transformation created skill building courses for each of the eight Whole Health self-care topics.  Figure 1 illustrates the graphic used for Food & Drink.  It offers a series of subtopics that can allow the conversation to go deeper.  Note the “Make One Small Change” circle, which leaves room for creativity in any area the Veteran and clinician prefer. Also note the circle that emphasizes “Work with a Dietitian,” acknowledging that they can be an important resource as patients create Personal Health Plans.

How can weight loss make a difference?

Multiple studies have measured the impact of small reductions in weight.  Make your patients aware of the changes their body undergoes with weight loss.  Below is a chart summarizing some of these changes.[9]

Table 2. Health benefits of a 10kg weight loss for those who are obese

Table 2. Health Benefits of a 10kg Weight Loss For Those Who Are Obese

Note also that research also indicates that 30-40% of cancers can be prevented, and healthy body weight can play an important role.[99]  Similarly, a healthy weight is linked to improved cancer survival.[100]  Loss of weight also leads to some improvements in pain and disability from osteoarthritis and other causes.[101]

During a Whole Health discussion, highlight the number of medical conditions associated with obesity, but make sure to frame the discussion in a positive way.  Tie the effects of being at a healthy weight to a person’s MAP.  Explain that by losing weight, a person can reduce their risk of developing many health problems.  

It is important to make it clear that a “normal” weight does not necessarily equate to having a healthy, nutrient-rich diet, nor does being obese necessarily mean a person lacks nutrients or eats unhealthy foods.  A 2024 study that used data for over 48,000 people noted that using two or more strategies for weight loss (e.g., eating less food, drinking more water, lowering fat intake, and exercising) was linked to a lower risk of death, even among people who gained wait during the study follow up of 9 years.[102]  Most dietitians agree that it is important to look beyond just numbers of calories to the quality of what is consumed.  As with all aspects of Whole Health, explore this in greater depth on an individual basis.

Below is one image that illustrates the risk associated with obesity.

A common mistake that many of us make is to tell ourselves we can work off the calories we consume—that we can out-exercise a poor diet.  While moving the body is an essential component of weight loss, exercise cannot make up for a lack of healthy nutrients in the diet.  The impact of poor dietary choices on our weight is very difficult to overcome through exercise when not also combined with healthier eating A large 2021 review did find that exercise can lead to some weight loss, overall fat loss, visceral fat loss, and helped prevent loss of lean body mass, but it is perhaps best to think of Moving the Body as a complement to Food and Drink when it comes to body weight. [103]  The image below derives from a calculator that determines how much exercise will burn off calories from a common fast-food meal.  For example, ordering an Italian sub sandwich, potato chips, and chocolate chip cookies requires riding a bicycle for 5 hours, dancing for 5 hours, or running for 3 hours to burn the calories from that meal.

Below are some resources to help patients calculate calorie intake:

1. Nutribody
2. Calorie King
3. MyFitnessPal
4. MyPlate
5. Lose It!

Finally, emphasize that a person’s weight is not a permanent state of being but constantly in flux, and the best way to stabilize this process is through achievable healthy habits that one can follow consistently.  Even though recent studies regarding motivational interviewing techniques have not specifically found a clear impact on overweight and obesity, it is still worthwhile to use them as one tool for engaging people in their overall care.[104,105]

Some basic nutrition guidelines

Whether you are discussing food and drinks with patients or thinking about your own dietary practices, the following 10 general guidelines can serve as a good starting point.

• Old Ways Cultural Food Pyramids (Scroll down to select a pyramid.)
• S. Department of Agriculture food pyramids for different ethnic and cultural groups.

2. Small changes in eating habits are typically easier to make than complete diet overhauls.[10] Clinicians should not feel like they are doing all the work; each individual should set goals, working with their clinician.  These goals should feel realistic, and achieving one goal can often lead to the beginning of a positive cycle of setting and achieving other goals as well.  If you are wondering what to change, review the components of the Standard American Diet, as listed above.  Offer examples of possibilities and encourage patients to choose one they would like to try.  For example, if they recognize that their soda consumption may be causing harm to their body, you might encourage them to decrease soda intake by a specified number of ounces per day.  Similarly, if they do not want to completely remove burgers from their diet but are open to eating them less frequently, suggest that they only eat red meat once weekly.  Meet each patient where they are at and help them set SMART goals (Specific, Measurable, Action Oriented, Realistic, and Timed).[11]
   
   Figure 4 shows what percentage of Americans meet various dietary recommendations.

3. Which diet? You probably have been asked many times about which diet is the best one to follow. In general, research tells us that the diet that works best is whatever one a person is willing and able to stick with long-term.[13]  Be familiar with the eating patterns recommended in popular diets and their pros and cons (some of these are described below and in the “Choosing a Diet” Whole Health tool).[106,107]

4. Meet nutritional needs through foods versus multivitamins or other dietary supplements.[14] Vitamin and mineral supplements have not been found to have significant health effects when it comes to cardiovascular disease, cancer, type 2 diabetes, or other ‘non-communicable’ diseases.[108]  Invest in healthy, nutrient-dense food.  These foods have a high ratio of nutrient content relative to how many calories they contain.  This is in contrast to energy-dense foods, in which the calories in the foods are way out of proportion to how nutritious they are.  Certainly, it can be helpful to focus on a Mediterranean Diet,[15] or a whole foods, plant-based diet.[16]  

The 100 foods on the list of the “World’s Healthiest Foods” were chosen based on being not only nutrient-dense but also because they are familiar, tasty, and affordable.[17]  Many are also part of a Mediterranean diet.  They are also whole foods; that is, they have not been extensively processed or modified from their natural state.  Examples in different categories include (and most of these probably will not surprise you) the following:

• Vegetables: asparagus, avocados, beets, bell peppers, broccoli, Brussels sprouts, cabbage, carrots, cauliflower, celery, corn, cucumbers, eggplant, fennel, garlic, green beans, green peas, greens (mustard and collard), kale, leeks, mushrooms (e.g., cremini and shiitake), olives, onions, potatoes, lettuce, sea vegetables, spinach, squash (summer and winter), sweet potatoes, Swiss chard, tomatoes, and turnip greens
• Fruits: apples, apricots, bananas, blueberries, cantaloupe, cranberries, figs, grapefruit, grapes, kiwi, lemons, limes, oranges, papaya, pears, pineapple, plums, prunes, raspberries, strawberries, watermelon 
• Seafood: anchovies, cod, herring, mackerel, salmon, sardines, scallops, shrimp, tuna
• Nuts and seeds: almonds, cashews, flaxseeds, peanuts, pumpkin seeds, sesame seeds, sunflower seeds, walnuts
• Beans and legumes: black beans, dried peas, garbanzos, kidney beans, lentils, lima beans, miso, navy beans, peanuts, pinto beans, soy sauce, soybeans, tempeh, tofu
• Poultry and meats: grass-fed beef and lamb, pasture-raised chicken and turkey
• Eggs: pasture raised
• Dairy: grass-fed cheese, cow’s milk, and yogurt
• Grains: barley, brown rice, buckwheat, millet, oats, quinoa, rye, whole wheat
• Herbs and spices: basil, black pepper, chili pepper (dried), cilantro, coriander, cinnamon (ground), cloves, cumin, dill, ginger, mustard seeds, oregano, parsley, peppermint, rosemary, sage, thyme, and turmeric

The list is by no means all-inclusive, and selections for lists like this may be a bit subjective, but it gives you some ideas.  A simple Food and Drink suggestion for a Personal Health Plan (PHP) when a clinician is pressed for time could easily be: “How about eating more of [insert one of the top 100 foods here]?”  It is also entirely appropriate to use the elements of the Mediterranean diet - or other whole foods, plant-based diets - to guide such conversations.

5. Dietitians, nutritionists, and health coaches are powerful allies in helping patients with their nutritional needs.  Refer your patients to dietitians for a more in-depth discussion of dietary changes; they do a great deal to improve care related to a variety of conditions.[109-111]  Health coaches can help with goal setting and accountability, supporting people as they institute the goals they set for themselves with the help of clinicians.[112]  Interprofessional collaboration, with all its potential benefits, is a hallmark of successful Whole Health practice.[113]

6. 

1. Avoid oversimplifying. A common weight loss myth is that there are roughly 3,500 calories in a pound of body fat, and if a person decreases caloric intake by 500 calories per day, they can lose one pound weekly.  However, this figure is not accurate, and the weight loss equation is much more complicated than this.[18]  Interestingly, the story of how we obtained “3,500” dates back to the work of a scientist named Bozenrad in 1911.  He once measured 1 pound of human adipose tissue and found that it contained 87% lipid and 13% water.  Another scientist named Wishnofsky expanded on his work in 1958 by using bomb calorimetry to measure 9.5 kcal in each gram of fat.  Since there are 454 grams in 1 pound, and human adipose tissue in Bozenrad’s measurement was 87% lipid content, Wishnofsky determined that there are 395 gm of fat in 1 pound of fat tissue. He then rounded his original value of 9.5 kcal/gram to 9 kcal/gram and multiplied this by 395 gm to obtain 3,555 calories in a pound of fat.

Not surprisingly, the methodology behind this experiment is flawed.  Ignoring rounding errors, Wishnofsky and Bozenrad analyzed only one sample, and subsequent studies have shown that the lipid content in a pound of fat varies significantly between people based on demographics and even within the same person at different phases of weight loss.

Two studies, entitled CALERIE 1 and CALERIE 2, found that we typically undergo two phases of metabolism during weight loss, and this affects how many calories we burn.[19,20]  The first phase of weight loss lasts days to weeks and involves exhaustion of glycogen stores, small fat content, and water content.  During this phase, lower calorie deficits are needed to achieve weight loss; participants 4 weeks into the study only needed to lose, on average, 2,208 calories per pound.  Over time, as our glycogen pool is exhausted, our body begins breaking down protein and more fat content, and this leads to a slower second phase of metabolism.  At this time, the body reduces thermogenesis.  Study participants at 24 weeks, for example, needed to burn an average of 2,986 calories per pound.

While it may not be beneficial to explain the details of the CALERIE studies to patients, it is important to avoid oversimplifying weight loss as a basic equation.  Weight gain and loss are affected by many other factors, such as hormones, the microbiome, toxins, food sensitivities, stress, sleep, and many other factors.  Moreover, it can be helpful to know that early gains from diet and exercise do slow down over time based on shifts in our metabolism, and patients should not be surprised or discouraged by this.

7.Choose beverages wisely.  Around 21% of our daily caloric intake comes in liquid form. [21]  Moreover, 47% of our dietary sugar intake comes from beverages (see Figure 5 below).

If you are looking for one piece of advice to give patients who want to improve their nutrition, this may be it: changing what you drink has a powerful effect.  Cut out or minimize intake of soda, sweetened tea or coffee, juice, alcohol, energy drinks, smoothies, soda or milk, and replace them with water.  If patients miss the carbonated aspect of soda, consider carbonated water or kombucha.  If patients miss the flavor of sweetened beverages, recommend naturally flavoring water with herbs and fruits (e.g., pineapple and mint-infused water).  Total calorie intake (and proportion of healthy calories) will likely decrease substantially, and overall health will improve.  A 2024 systematic review and meta-analysis found that artificially sweetened beverages, like sugar-sweetened beverages, increase cardiovascular and all-cause mortality.[114]

Alternatively, if patients are unwilling or unable to eliminate beverages other than water, consider creating a beverage plan for them with specific guidelines.  See the sample beverage plan created by the Harvard School of Public Health, below.

For more information on beverages, please refer to the “What We Drink” Whole Health tool.

8. Pay attention to portion sizes. How much of a food people actually eat may be much more than the serving size listed on the package.  For example, many nutrition experts recommend getting 7-9 servings of fruits and vegetables daily, but a serving is not as big as many people assume.  For green leafy vegetables, such as spinach, kale, or lettuce, it is generally 1 cup.  For other vegetables, a typical serving is ½ cup.  A serving of fruit is ½ cup, which would equal a small banana, a slice of melon, or ¼ cup of dried fruit.  Fresh fruits and vegetables are best, but if these are not available or affordable, frozen is generally a better option than canned.  Look for frozen or canned fruits without added sugars, and those packed in water or their own juice, instead of in syrup.

Keep in mind that it may be easier for people to meet serving recommendations than they might think.  They can search online for photos of various serving sizes, go to ChooseMyPlate for a visual, and or review the Dietary Guidelines for Americans and more information.

9. Share advice from people who have successfully made healthy behavior changes related to nutrition. For example, the National Weight Control Registry (NWCR) recorded the habits of over 10,000 individuals who lost an average of 66 pounds and kept it off for 5.5 years.[115]  Here are four common themes from their experiences:

• 78% ate breakfast daily
• 75% weighed themselves at least once a week
• 62% watched less than 10 hours of TV per week
• 90% exercised, on average, about 1 hour per day

A 2014 study concluded, based on NCWR data, that “Long-term weight loss maintenance is possible and requires sustained behavior change.”[116]

Visit the National Weight Control Registry for updates on research findings.  While weight loss is just one aspect of a healthy approach to Food and Drink (and quality of food is a focus, not just quantity), this does speak to some overall recommendations for a healthy lifestyle.

10. Encourage mindful eating.[117] It is easy to eat without even noticing what we are eating.  Most of us have had an experience where the entire bag of chips or bowl of popcorn seems to vanish, and we have no recollection of having eaten it.  We may not eat because of physical hunger; it helps to notice how much of our eating is influenced by habit, emotion, social surroundings, and so on.  We know that stress exposure alters the brain’s response to food in ways that predispose us to poor eating habits.[23]

Mindful eating involves recognizing when we are stressed and finding ways to counter these effects.  As with all mindful awareness activities, it is not about judging so much as simply paying attention.  Mindful eating has been found to reduce binge eating and help with obesity, and it leads to as much weight reduction as conventional diet programs.[118,119]

Some suggestions that are widely used by instructors in mindful eating include the following:[24-26]

• Focus on what sort of hunger you are experiencing. There is the actual physical state of hunger, but we may also eat because something has visual appeal, or because we like how it smells.  We may eat because of the emotions we feel, because of a craving of some kind, out of habit, or for many other reasons. 
• Do not get too caught up in the “right” or “wrong” way you should eat, but simply note your level of awareness around experiencing food.
• Recognize that each individual has unique experiences when it comes to eating. Get to know yours through paying attention, and then you will be more empowered to make choices about what and how you eat.
• When you eat, do not do anything else. Do not watch TV or try to work.  Focus on your meal (and perhaps the people with whom you are eating).
• Periodically take time to note how hungry you are. Note how hungry you are before eating and then check in on your hunger as you eat.  The goal is to stop eating if you are not experiencing hunger.  Ideally, you can stop just before you are sated, since it takes at least 20 minutes for your stomach to signal your brain that it is full.
• Set your utensils down between bites.
• Taste every bite. It can help to have a set number of times to chew for each bite you take.  Start with 10-15 chews per bite.
• Never eat while standing. Relax.
• Note if there are other reasons why you are eating. Are you eating to satisfy hunger, or to fulfill an emotional need?
• Consider taking a moment for gratitude or a pause after a meal (for satiation). Take time to focus on all the resources and people who made it possible for you to have what you are eating and drinking.
• Use all your senses to guide your food choices.

More information on mindful eating is available in the “Mindful Eating” Whole Health tool and the “Mindful Awareness” Whole Health overview.  Another excellent resource is the VHA National Center for Health Promotion & Disease Prevention’s "Mindful Eating Handout.

Dietary Guidelines for Americans, 2020-2025 suggests the following:

1. Follow a healthy dietary pattern in every life stage.
2. Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations.
3. Focus on meeting food groupneeds with nutrient-dense foods and beverages and stay within calorie limits.
4. Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages.

This section reviews some important macro- and micronutrient tips you can incorporate into a health plan.  After that is a discussion of other topics related to eating patterns, including the use of food pyramids, eating to reduce inflammation, and descriptions of some of the other popular diets that inspire patient questions.

Macronutrients: Some key recommendations you can make

One of the important ways to distinguish between different diets is by the proportions of macronutrients they recommend.  For example, the Atkins diet promotes, especially in its first phase, very low carbohydrate intake.  The South Beach diet focuses, in part, on “sensible” carbohydrates.  One section of this overview discusses eating with close attention to glycemic index and load, which equates to consuming the “best” carbohydrates.  And, of course, for better or worse, an entire branch of the food industry has sprung up since the last few decades because we have placed great value on eating low-fat foods.

The following sections will provide some specific suggestions about carbohydrates, fats, and proteins that can guide clinicians in setting Whole Health shared goals with patients.

Carbohydrate tips

Most of the calories in the American diet come from carbohydrates.  In plant-based foods, such as fruits, vegetables, grains, cereals, legumes, and beans, 90%-95% of the calories come from carbohydrates.  Carbohydrates include the following:

• Simple sugars such as fructose and glucose
• Oligosaccharides including fructo-oligosaccharides (which are “food” for the good bacteria in our intestines)
• Starches (which are energy storage molecules for plants)
• Dietary fiber. Fiber is a carbohydrate, but our bodies cannot digest it.  Fiber adds volume—but not calories—to food and it may increase satiety as well.

The United States Department of Agriculture (USDA) recommends that half of all grain intake come from whole grains.[121]  In terms of how they affect satiety, carbohydrates fall between protein and fat, with protein being the most satiating of the three macronutrients. [27]  Carbohydrates provide 4 kcal/gram in energy.  This is roughly equal to the energy of protein, but less than fats, which contain 9 kcal/gram.  

Carbohydrate consumption guidelines include the following recommendations:

Pay attention to fructose.  Fructose is a simple sugar found in fruit, honey, and some vegetables.  It is the sweetest of the simple sugars, and one form, high-fructose corn syrup (HFCS), is under considerable scrutiny these days.  A 2023 review and meta-analysis concluded that increased intake of total sugars and fructose is linked to higher all-cause and cardiovascular mortality, but not cancer mortality, based on the available research.[122]  Fructose, on its own and in small quantities, may be a better carbohydrate choice than glucose in patients with prediabetes or diabetes due to its attenuating effects on blood sugar[28] (think of a serving of fruit, not a serving of juice drink, as the source).  However, this is not true for high-fructose corn syrup, which typically is 50% fructose and 50% glucose, similar to sucrose or table sugar, which is not an ideal combination.[29]    

Most Americans consume about 40 grams of fructose daily, mostly in the form of HFCS.  Whether HFCS is worse than pure fructose or sucrose remains to be seen; evidence is conflicting.[123]  We do know that fructose consumption from processed foods has significant effects on, for example, all the components of metabolic syndrome.[30]  (More information can be found in Endocrine Health Whole Health overview, and the Hypertension and Lipids Whole Health tools; these topics are the main components of metabolic syndrome.)  The 2024 CARDIA study found that HFCA beverage consumption in black young adults is linked to higher risk of cardiovascular disease.[124]  Increased addition of HFCS to foods is linked to digestive problems, including disruption of the microbiome in the gut.[125]

It is important to keep in mind that fruit is an important source of fructose (hence the similarity in their names), but the fructose in fruit—even though it may be in higher quantities—is accompanied by fiber, which is known to attenuate rises in blood sugar.  In contrast, HFCS is rarely consumed with fiber.  In fact, it is often consumed as a carbohydrate in isolation; for instance, it is practically the only ingredient in soda and other sugar-sweetened beverages.  

Choose complex carbohydrates, but remember that context matters.  Simple carbohydrates are composed of mono- or disaccharides (they have just one or two sugar molecule groups in them).  Complex carbohydrates are polysaccharides (they have many simple molecules linked up to each other).  The American Heart Association notes that complex carbohydrates take longer to digest, so they leave a person feeling full for a longer period of time, and they are more likely to be found in foods that also contain a variety of healthy nutrients.[126]  

Whether or not carbohydrates are simple or complex may be less important than focusing on which foods the carbohydrates come from.  It is best to advise patients to eat whole grains and products made from them, as well as fruits, vegetables, and legumes, while minimizing foods with made with sugar or refined white flour.  This is especially important because most Americans do not eat enough whole grains (see figure below). Keep in mind that “multi-grain” foods include combinations of different types of grains, but they may not have all of the healthy parts of the grain in them like “whole grain” foods.  Choose “whole grain” foods over “multigrain” ones. 

For more information on eating whole grains, refer to USDA Whole Grain Tips.

Choose carbohydrates based on glycemic index and glycemic load.  It can be helpful  to choose which sources of carbohydrates to eat based on how they are metabolized.  Glycemic index and glycemic load take into account how much a given food raises blood sugar levels.  Glycemic index (GI) compares how much a particular food that contains 50 grams of carbohydrates will raise blood glucose levels 2 hours after eating it, relative to an equivalent amount of glucose (or white bread).  The problem with the GI is that different foods have different amounts of carbohydrate by weight.  For example, in order to get 50 grams of carbohydrates from carrots, you would have to eat at least 5 cups of them.  To allow for more realistic comparisons, glycemic load (GL) is used instead.  Glycemic loads are like GIs, but they account for serving size.[31]  GL is ultimately the GI multiplied by the amount of carbohydrate per serving of a given food.  More information, is available in the “Glycemic Index” Whole Health tool.

A 2019 study found a strong causal relationship between GI and GL and  type 2 diabetes.[127]  A 2021 New England Journal study concluded that high GI diets are linked to “...higher risk of cardiovascular disease and death.”[128]  Hi GI diets are linked to higher metabolic syndrome risk.[129]  There is also a correlation between high-GL diet and ischemic (but not hemorrhagic) stroke risk,[32] obesity,[33] insomnia,[130] and chronic inflammation.[34]  A 2022 meta-analysis found that high GI diets increased overall cancer risk, but certainty evidence was rated as low.[131]  Level of risk is higher for certain types of cancers, including  breast, ovarian (GL but not GI),  bladder, colorectal, prostate, and kidney; there may be less of a link to stomach and lung cancers.[132-135]  A low GI/GL diet also reduces gallbladder disease risk[35] and is one of the diets that can help to improve mood states.[136]

An interesting area of recent research on glucose tolerance is the “second meal effect.”  If you eat a low GI/GL breakfast, your blood sugar will not climb as high after eating lunch.  The same thing occurs after you eat a low GI/GL dinner; your blood sugar will not be as high at breakfast the next morning.[36,37]  It is in part because of the second meal effect that people with diabetes are encouraged to eat fewer small meals during the day.  Carbohydrates are absorbed more slowly and sugars stay lower on average if multiple small meals are eaten, rather than just a few large ones.[38]

Avoid refined carbohydrates. Because of their high glycemic load, cutting refined carbohydrates out of your diet can sometimes result in dramatic improvements in health. Common sources of refined carbohydrates include the following:

For a more comprehensive list, go to the Diagnosis Diet website.

Eat your fiber. The metabolic fate of carbohydrates is determined largely by the company they keep.  Fiber, which is composed of carbohydrates the body cannot digest, influences carbohydrate absorption in the gut, decreasing the rise in blood levels of glucose, insulin, and lipids that normally occurs after eating.[39-41]  There are two main kinds of fiber.  Soluble fiber has beneficial effects on absorption of glucose, insulin, and lipids.  Insoluble fiber acts as a laxative and bulking agent.  Few Americans consume the recommended daily intake of fiber, which is 14 grams/1,000 kcal, or roughly 25 grams daily for women and 38 grams for men.  Some argue that fiber intake should perhaps be as high as 50 gm a day for those with diabetes.[42]  Because fiber has important health benefits but is often neglected in the American diet, a discussion about fiber can be another potentially good starting point for the “Food and Drink” section of a Whole Health plan.  

High fiber intake significantly improves health.  Fiber intake is associated with reduced all-cause mortality, cancer-related mortality, and cardiovascular disease mortality (hazard ratios of 0.77, 0.71, and 0.74, respectively).[137]  It also reduces overall mortality in people with type 2 diabetes.[138]  Fiber intake is inversely associated with esophageal cancer incidence,[43] stroke risk,[44], and management of hypertension and cardiovascular disease.[139]  It helps with management of type 2 diabetes as well.[140]  Fiber should be used with caution in people with functional bowel problems, such as irritable bowel syndrome, because it can exacerbate bloating, constipation, and diarrhea.[45]

When checking nutrition labels, aim for foods with a favorable sugar-to-fiber.[141]  This means that there should be no more than five times as much sugar as there is fiber.  Avoid foods with higher sugar-to-fiber ratios.

For more information, refer to the two VA Nutrition and Food Services Patient Education Handouts “Types of Fiber” and “Tips to Increase Fiber Intake”

DIETARY FAT tips

The types of fats you eat make a difference.  For quite some time (roughly 1980-2015, in terms of Dietary Guidelines for Americans), the popular belief was that fats are “bad” for us in any form.  Fat-free foods have been touted commercially as the solution to all our nutritional ills.  However, fat-free eating requires that the calories be replaced with calories in another form.  If this “other form” is carbohydrates, eating them may not be as helpful as we once assumed.[46]  When large quantities of carbohydrates are eaten, those that are unneeded are stored as fat.

In excess, certain types of fats can contribute to health problems, but they are essential to healthy functioning, providing us the necessary building blocks for cell membranes, myelin sheaths around nerves, and steroid hormones.  Fats are also essential for absorption of the fat-soluble vitamins, A, D, E, and K.  Many people’s bodies are genetically programmed to hold on to fat; for our ancestors, this could be an advantage during times when food was scarce.

There are a few main categories of fats,[47] and knowing more about them can help patients make good food choices:

• Saturated fats (SFAs) are those without any double bonds in their carbon chain. They are solid at room temperature and include animal fat, butterfat, coconut oil, palm oil, and kernel oils.  Most experts recommend keeping saturated fat intake to a minimum.
• Monounsaturated fats (MUFAs) are liquid at room temperature and found in avocado, peanut, olive, and canola oils. They have one double bond in their carbon chain.

Polyunsaturated fatty acids (PUFAs) are also liquid at room temperature.  They have more than one double bond and include fish, sesame, sunflower, walnut and corn oils.  The PUFAs linoleic acid (LA) and alpha-linolenic acid (ALA) are essential; that is, they are necessary but the body cannot synthesize them and therefore they must be obtained through the diet.  Essential PUFAs are in vegetables such as dark, leafy greens and purslane.  They also come from animals that consumed LA- or ALA-rich algae and plant foods.  These fats have some of the most favorable effects on health.[142]

• Omega-6 fatty acids have a double bond at position 6 of their carbon chain. They play an important role in inflammation.  Inflammation is important to an organism’s survival, but chronic inflammation can be harmful.  Omega-6s rev up the chemical reactions that we normally attempt to suppress with medications such as nonsteroidal anti-inflammatories.  Linoleic acid is an omega-6 fat, which is plentiful in most diets.  It is in many nuts and seeds and in the fat of some animals, like pigs.  Red meats and other animal products lead to creation of proportionally more omega-6 fatty acids than other foods.   
• Omega-3 fatty acids have a double bond at position 3 in their carbon chain. They contribute to the reduction of inflammation, based on how they influence various chemical pathways in the body.[143]  The most important omega-3s to know about are docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA).  Omega-3s are not commonly consumed as part of the standard American diet.  They are in fish, as well as walnuts, leafy greens, and many seeds.  Omega-3’s seem to have beneficial effects on cardiovascular disease, depression, dementia, and an array of other disorders.[144-147] DHA and EPA are found mainly in fatty, deep-sea fish, krill, and algae. The acronym SMASH can help patients remember fish that are good sources of DHA and EPA: salmon, mackerel, anchovies, sardines, and h 
• The essential omega-3, ALA, is found in walnuts, flaxseeds, chia seeds, hemp seeds, pumpkin seeds, and canola oil. It can be metabolized to DHA and EPA, but the process by which humans convert ALA to DHA and EPA is inefficient; therefore, it is best to get DHA and EPA directly from the diet, rather than relying on conversion of ALA.
• Trans-fats replace the cis-double bonds in MUFAs and PUFAs with trans- bonds. Found in processed food sources,[48] trans-fats were created to allow foods to have a longer shelf life. Unfortunately, they may decrease the duration of human life, because they are known to increase cholesterol levels and coronary artery disease.[49,50] It is best to avoid all foods made with trans-fats and partially hydrogenated oils of any kind.  The United States now bans use of trans-fats in all foods offered in restaurants and grocery stores. 

Ensure you get enough omega-3s.  The essential PUFAs are precursors to prostaglandins, leukotrienes, and other compounds that control levels of inflammation in the body.  With the increased consumption of highly processed foods, the ratio of proinflammatory omega-6 fats to anti-inflammatory omega-3 fats in the diet has steadily increased, increasing the number of people whose bodies are in a state of chronic inflammation.  Current ratios of omega-6s to omega-3s range from 15:1 to 25:1.  The ideal ratio is the subject of some debate, but most sources suggest it should be more in the 2:1 or 4:1range.[51]   Inflammation has an important physiological role, but a system of checks and balances is needed; many of today’s chronic diseases are associated in some way with chronic inflammation.[52]  It is worth discussing whether or not to recommend omega-3 supplements for many patients. 

For more information on fats and oils in the diet, patients can see the article “Why is it Important to Consume Oils?”  Another useful patient education handout is “Common Oils and Fats” available through the VA Nutrition and Food Services website.

Eat to improve your cholesterol panel. Many people have abnormal lipid panels and struggle to improve them.  A few general points to consider include the following:

• Triglyceride levels increase primarily due to eating foods with a high GI; that is, they are closely linked to carbohydrate intake. People with diabetes and/or thyroid disorders often have elevated triglycerides.[53,54] 
• High-density lipoproteins (HDLs) transport excess triglycerides and cholesterol back to the liver from outlying cells, and low-density lipoproteins do the reverse. For this reason, HDL often is labeled “good cholesterol,” and LDL labeled as “bad.” 
• Foods that raise LDL cholesterol levels most are: (1) those high in saturated fats, and (2) those with a high GI. These foods have a much more significant impact than foods that are high in dietary cholesterol, such as eggs, shrimp, shellfish, and caviar.

For more information, check out to the “Lipids” Whole Health tool.

Guidance with eating protein

Get enough protein (but not too much) each day, from healthy sources.  Adults are encouraged to obtain 10%-35% of their daily calories from protein.  That equates to 56 grams for men and 46 grams for women.[148]  Eating 2-3 servings of protein-rich foods a day seems to cover needs.  Examples of protein servings include the following:[149]

• A 3-ounce piece of meat, which has about 21 grams of protein; a typical 8-ounce serving has over 50 grams
• 8 ounces of yogurt, which has about 11 grams, or 8 ounces of milk with 8 grams
• One cup of cooked beans contains roughly 16 grams of proteins.

Animal protein is a source of significant amounts of protein.  However, many meats contain a fair amount of saturated fat and are sources of trimethylamine N-Oxide (especially for red meats and processed meats), which increases risk for cardiovascular events and cancer; they are best eaten with less frequency.[150]  Calorie for calorie, protein is the most satiating or filling of the macronutrients.[55]  The average American consumes roughly 100 gm of protein daily, despite the fact that recommendations encourage a lower quantity.[56]  A diet high in animal protein can be taxing for the liver and kidneys.

Eat all of your essential amino acids.  There are certain amino acids that must come from the diet; our bodies cannot synthesize them.  These amino acids have critical antioxidant and anti-inflammatory properties and are key chemical ingredients for many of the body’s chemical reactions.  It helps to vary protein sources in your diet.  Bring in meat, fish, legumes (beans, lentils), eggs, nuts, seeds, and whole grains such as quinoa to add variety.

Vegetarians can get the full spectrum of amino acids in the diet if they eat a variety of the foods listed above.  Bacteria that live in the digestive tract also serve as a protein source.  Epidemiologic studies show that those who eat a nutritious, primarily vegetarian diet derive health benefits from doing so.[151-153]  Of course, “vegetarian” is not synonymous with “healthy.”  A diet of sports drinks and corn chips may even be vegan, but it is not nutritious.

Micronutrients: vitamins and minerals

Micronutrients are essential for life.  They serve many vital roles in our health and development including production of adenosine triphosphate (ATP), hormones, enzymes, and neurotransmitters.  The multitude of biochemical reactions that happen throughout the body require micronutrients as cofactors.  They include vitamins and minerals, as well as phytonutrients.  One can become deficient in micronutrients in the absence of a well-balanced diet.  Specific clinical findings related to various deficiencies, while beyond the scope of this overview, are available at the Public Health Reviews.[154]

Eat your vitamins.  Vitamins were discovered in the early 1900s and were originally called “vital amines” because it was initially thought that they all contained amino (nitrogen) compounds.[57]  The name was changed to “vitamins” after it was discovered this wasn’t true.  Vitamins are classified as water-soluble (B vitamins, vitamin C) and fat-soluble (vitamins A, D, E, and K).  Many people follow the recommended dietary allowance (RDA) created by the Institute of Medicine to ensure they are consuming the necessary amounts of vitamins each day.  However, the RDA focuses on the minimum amounts of vitamins required to prevent deficiency.  Dietary Reference Intake (DRI) is probably a more reliable number to follow, if possible.  The DRI of a given micronutrient depends on many things such as sex, age, overall health status, and, for women, whether or not they are pregnant or lactating.  The National Institutes of Health has an indexed guide to Vitamin and Mineral Supplement Fact Sheets that is worth recommending.  Users can select from provider and consumer-friendly versions.

Most people can get most of the vitamins they need through a balanced diet (this is difficult with vitamin D, however).  Deficiencies are not uncommon, however.[155]  Vitamin B12 is the only vitamin that is available solely through animal sources, putting vegans at risk for deficiency; for this reason, vegans should always be asked about B12 supplementation.  If people have a very poor diet (e.g., they live in an urban “food desert”) or they absolutely insist on taking a multivitamin supplement, it is important to be able to offer good advice on how to select an appropriate one.

Eat your minerals, too.  There are approximately 18 minerals necessary for our physiologic functioning. Table 1 briefly summarizes information about several of the minerals that are most likely to be discussed in a clinic visit—iron, calcium, zinc, selenium, and magnesium.  In general, these are available on the VA formulary.

Table 3. Micronutrients: Functions, Sources, and Clinical Tips[66-68]