Lesson 12: An Overview of Various Diets

Table of Contents


Introduction

We have now discussed much of the general information needed to construct a healthy diet from scratch. However, there are also various “named” diets; knowledge from the prior lessons should help us evaluate these to determine if they do or do not have merit for health benefits. In this lesson we will discuss several of these diets. Initially I will present some of the comparative literature that evaluates many of these, and then I will discuss each specific diet briefly and how they fit into the evidence-based knowledge presented in the prior lessons.


Comparative Literature

There have been a handful of recent review articles that have attempt to compare various diets.


Review 1

A review published in 2017 provided an overview of a subset of the diets listed in the 2016 US News & World Report for “Best Weight-Loss Diets”.(Anton, 2017) There were several criteria for inclusion of diets & trials, such as including at least 15 subjects in each trial, at least 3 months duration, no structured exercise component, no specific calorie recommendation, and no commercial products, among others. With these criteria the authors considered 20 of 38 listed diets and found only 16 articles.

There were 10 trials evaluating the Atkins diet, 3 trials for the Zone diet, 2 trials for a low glycemic index/load diet, 2 trials for the Mediterranean diet, 2 trials for the Ornish diet, and 1 trial each for the DASH diet and the paleolithic diet. Ultimately the authors concluded that most trials successfully induced weight loss with the respective diets. However, the main takeaway is that there was relatively little literature evaluating these diets overall. Thus it is difficult to provide an evidence-based opinion of what constitutes the best diet.


Review 2

Moving into 2020 several further reviews have been published. One review evaluated different diets for weight loss, finding no strong evidence that any one dietary scheme is superior to others.(Freire, 2020) This supports the common notion that “the best diet is the one you can stick to”. This review included two nice figures comparing components of various diets; I have reproduced these below.

An image showing foods included in different diets
A figure showing macronutrient ratios in different diets

Review 3

A 2020 systematic review & network meta-analysis of randomized trials compared 14 named dietary programs as well as 3 control diets (low carbohydrate, low fat, and moderate macronutrient) regarding impact on body weight and cardiovascular risk factor reduction.(Ge, 2020) This included 137 articles covering 121 randomized controlled trials. The authors found that the 3 control diets yielded ~4-5kg weight loss at 6 months. However, this decreased to only 3-4kg weight loss at 12 months. Benefits seen in blood pressure & lipids at 6 months were no longer present at 12 months. Comparing all diets, they found only small differences at the 6 month mark and negligible differences at 12 months. The authors conclude there is a lack of direct comparisons in the literature but no strong reason to pick one diet over another. They summarize their findings in the figure I have reproduced below.

A figure showing health outcomes associated with different diets

Review 4

A 2020 umbrella review of meta-analyses of randomized controlled trials evaluating the effects of various diets on anthropometric & cardiometabolic parameters included 80 articles.(Dinu, 2020) The authors acknowledge the overall evidence base for some of the diets is of low quality and/or small samples, but ultimately conclude that the Mediterranean diet has the most consistent evidence supporting a beneficial impact on health. They summarize their findings in the figure I have reproduced below.

A figure showing health outcomes of different diets
This image was taken from Dinu M, Pagliai G, Angelino D, et al. Effects of Popular Diets on Anthropometric and Cardiometabolic Parameters: An Umbrella Review of Meta-Analyses of Randomized Controlled Trials. Adv Nutr. 2020;11(4):815-833 with permission from Oxford University Press; the journal is published by the American Society for Nutrition.

Review 5

One additional 2020 comparative review of various diets for cardiovascular disease prevention notes that benefits are seen with the DASH diet, the Mediterranean diet, and plant-based diets, while the Atkins diet and the ketogenic diet have shown negative impacts in some studies on lipid profiles.(Vargas, 2020)


Summary of comparative literature

Overall, at this point the evidence base does not seem to strongly support any one dietary scheme over another. However, this does not necessarily mean the diets produce the same health outcomes. Many of the dietary trials have high rates of attrition that can make it harder to find meaningful differences. Additionally, the vast majority of dietary trials do not rigorously ensure that the participants are compliant with the diets. This likely explains why results seen on a shorter timescale (up to 6 months) are attenuated when evaluating outcomes at 12 months. Perhaps if diets were followed as written they would produce health differences, but at this point the evidence base does not empirically prove this assertion.

For these reasons I believe it is best to construct a healthy diet based on principles discussed in the prior lessons while tailoring various components to aid compliance for specific individuals.


Named diets

Many people do not wish to create their own dietary plan and would prefer to follow a diet that already exists, or at least base their own diet off a suitable model. It is worth knowing the basic premises of the named diets and how we may expect them to influence health. With this knowledge it is possible to pick a specific dietary plan for one’s own goals. Below I will briefly discuss many of the diets found in the 2020 US News & World Report. I will not discuss diets that require purchases of books, products, or paid membership fees on websites, primarily as I have not spent money on any of those and thus cannot fairly evaluate or critique them.

Click each row to see an overview and health considerations of the various diets:

Also called “the Military Diet”, there is no one standard version of this but the idea is to consume very low calories for 3 days, and then a normal diet for 4 days. Thus, this is intermittent energy restriction (see discussion in Lesson 11 on chrononutrition). Various protocols online specify dietary components during the 3 low energy days. With severe restriction this can contribute to nutrient deficiencies though if one carefully constructs the 4 normal diet days accordingly this can likely be mitigated.

As discussed in the lesson on chrononutrition, intermittent energy restriction can be just as effective as continuous caloric restriction for weight loss; thus this is a viable strategy if it will aid adherence. However, the specific recommended foods with the 3-day diet may make this more restrictive and may increase the risk of nutrient deficiencies. For these reasons, I generally would not recommend the 3-day diet.

The idea is to eat foods that are predominantly “acid reducing” and to mostly avoid foods that are “acid producing”. Thus, this diet relies heavily on fruit, vegetables, seeds, nuts, legumes, and soy products, allows limited whole grains, and typically avoids eggs, meat & animal protein and processed foods. However, for individuals with healthy kidneys the blood pH is maintained in a narrow range regardless of dietary consumption. Thus, this diet may have merit for being mostly plant based, but there are several rules that need to be followed and no research (to my knowledge) indicating superior health benefits relative to a vegetarian diet. Therefore, it does not make sense to me to follow this diet specifically. For people with chronic kidney disease, consider speaking with your provider about the pros and cons of including more alkaline vs acidic foods in your diet.

For those interested, this recent review discusses relevant pathways and speculative positive benefits of an alkaline diet.(Aoi, 2020) At this point there is no strong evidence base suggesting an alkaline diet can be constructed to utilize these pathways to meaningfully influence health outcomes.

Dr. Weil has a website discussing this specific version of the anti-inflammatory diet. A couple of recent reviews have discussed anti-inflammatory diets; they mostly follow the healthy eating patterns discussed throughout this course..(Ricker, 2017; Norde, 2020) Overall this version of the diet will be health promoting, but the version indicated on Dr. Weil’s website advocates for preferentially consuming organic food (see discussion in Lesson 13) and multiple dietary supplements (not covered in this course but generally not necessary). Overall this will be more complicated, costly, and difficult to adhere to than other viable diets that one could choose from.

There is not one “Asian diet”, rather this is a conglomeration of dietary schemes typically seen across Asia. Typically this diet includes daily vegetables/fruits/nuts/seeds/legumes/whole grains, less frequent dairy/eggs/poultry/healthy oils, and infrequent red meat/sugary desserts. The diet recommends six glasses of water or tea daily. Overall this will be a generally healthy diet plan, though the infrequent dairy may make adequate calcium consumption more difficult, and one must be careful not to go overboard on rice/noodles as it can be easy to overeat these and enter an undesirable caloric surplus. For more information, see: https://oldwayspt.org/traditional-diets/asian-heritage-diet

This is essentially a low carbohydrate diet but not necessarily low enough to go into a state of ketosis for the duration of the diet. Phase 1 of the diet will likely yield ketosis but the diet allows progressively more carbohydrates as time goes on. Depending on the choice of non-carb foods, saturated fat intake may be excessive. Additionally, when restricting carbohydrates one will miss out on having several servings of whole grains, and potentially some fruits & vegetables, daily. Multivitamin/mineral supplementation can be useful due to the restrictive nature of the diet. One can expect rapid weight loss in the first few days of following the Atkins Diet, especially if exercising, due to depletion of glycogen stores (as this holds water in the body), and the comparative reviews above do indicate this is effective for weight loss. However, I generally do not recommend restrictive dieting practices, and restricting carbohydrates will limit the intake of many healthy nutrients. Thus, I generally do not recommend following the Atkins diet long term, though it should be safe if constructed optimally over a shorter time period (ie, months).

This diet emphasizes fruits, vegetables, whole grains, lean protein, and low-fat dairy. It discourages foods that are high in saturated fat as well as sugar-sweetened beverages and sweets. Sodium intake should not exceed 2300 milligrams. For an overview of the DASH diet, see this 6 page PDF: https://www.nhlbi.nih.gov/files/docs/public/heart/dash_brief.pdf or this longer version: https://www.nhlbi.nih.gov/files/docs/public/heart/new_dash.pdf. As indicated in the comparative reviews above there is ample evidence supporting the merits of this diet. If anybody does want to follow a named diet, the DASH diet is a very reasonable choice.

As far as I can tell there are only a couple studies evaluating this diet, both by the same authors, and this is essentially an Atkins diet that is primarily vegetarian or vegan based but allows a higher percentage of carbohydrates.(Jenkins, 2009; Jenkins, 2014) The macronutrient ratio is fixed at 26/43/31% (carbohydrates/plant fats/plant proteins). I do not recommend this diet due to the macronutrient requirements (making adherence difficult) as well as its restrictive nature.

I discussed gluten and the merits, or lack thereof, of a gluten-free diet in Lesson 10. To summarize, a small percentage of the population (~1%) has Celiac disease and strongly benefits from following a gluten-free diet. A small percentage (<10%) of people may be sensitive to gluten or to compounds commonly found in gluten-containing foods (ie, FODMAPs), and these individuals may also benefit from a gluten-free diet as they will symptomatically improve when following one. Beyond this, there are no expected health benefits from following a gluten-free diet, and it is otherwise needlessly restrictive and expensive.

This diet simply comprises of consuming mostly low GI foods (GI ≤ 55), smaller amounts of moderate GI foods (56 ≤ GI ≤ 69), and infrequent high GI foods (GI ≥ 70). I discussed the GI and the problems with using it as a marker of nutritional status in Lesson 6. In brief, while following this diet will be advantageous for avoiding significant amounts of empty calories (ie, regular cookies), there is no guarantee that one will obtain a fully nutritious diet by sticking to lower GI options. Additionally, high GI foods consumed in moderation with mixed meals do not cause undue harm to one’s blood glucose status. Practically, it is difficult to determine the GI of packaged foods or other foods that are not in online databases (ie, http://www.glycemicindex.com/). For these reasons, I do not recommend the glycemic-index diet.

The ketogenic diet has become extremely popular. One benefit is that it seems to suppress appetite, and for this reason it can be a great dieting tool.(Gibson, 2015) However, as mentioned above, it is also possible for one’s cholesterol and liver function tests to worsen while following a ketogenic diet, and for that reason anybody who chooses to follow this should likely get their labs checked 1-2 months after beginning it to see if they are negatively affected.(Freire, 2020; Vargas, 2020)

Due to the limited carbs there can be a lack of fruits, vegetables, and whole grains, thus limiting the health potential of this diet. This diet is effective for individuals with severe epilepsy, but other health benefits are more speculative in nature.(Ludwig, 2020) Additionally, when in a caloric surplus it seems more difficult to gain skeletal muscle with resistance training when following a ketogenic diet.(Vargas, 2018) Thus, I think it can be a useful tool for some people who are otherwise struggling with hunger in a caloric deficit, but otherwise I do not recommend a ketogenic diet.

For people who decide to use a ketogenic diet, I recommend only using this while actively losing weight, choosing healthy sources of fat (ie, sources with relatively little saturated fat), plugging your proposed diet into cronometer.com, and attempting to make substitutions to optimize the nutritional content for health if possible. Additionally, it is important to ensure there are no safety concerns when starting a ketogenic diet; as always, check with your medical provider prior to starting. Recent guidance(Watanabe, 2020) indicates this diet is either contraindicated or needs to be used very cautiously when:

  • elderly, pregnant, or breastfeeding
  • in people with type 1 diabetes mellitus, severe chronic kidney disease, severe heart failure, or with certain cardiac arrhythmias
  • in people with solid tumors
  • in people with certain rare genetic conditions (if you have a rare genetic condition it is generally advisable to always check with your medical provider prior to starting a new diet)

There are several variations of this diet, which is typically vegetarian or near-vegan and generally emphasizes carbohydrates that are low on the glycemic index. Usually this is a high carbohydrate and low fat diet. This diet emphasizes whole grains and vegetables, limits fruit/seeds/nuts/fish/seafood, and restricts other animal products/processed foods. Despite being high in carbohydrates, there is some evidence this can be helpful for diabetes.(Porrata-Maury, 2014) However, due to the risk of deficiencies of certain nutrients such as vitamin B12 and calcium, as well as the required food restrictions, I generally do not recommend a macrobiotic diet.

The Mediterranean diet largely conforms to the Dietary Guidelines for Americans, so much so that Table A3-5 describes how to follow this. As indicated in the comparative reviews above, there is ample evidence suggesting significant benefits from following the Mediterranean diet. One review found the Mediterranean diet to have significant favorable evidence with no evidence of harmful effects, a finding not seen with any of the other examined diets.(Dinu, 2020) If anybody does want to follow a named diet, the Mediterranean diet is a very reasonable choice.

Created as the “Mediterranean-DASH Intervention for Neurodegenerative Delay”, this attempts to combine the best aspects of the Mediterranean & DASH diets for brain health. Daily foods include 3 servings of whole grains, a salad & another vegetable, and if desired a glass of wine. You consume olive oil regularly, nuts on most days, a half cup of beans every other day, poultry & a half cup of berries at least twice weekly, and fish is at least weekly. You mostly avoid red meats, butter, cheeses, sweets, and fried/fast food. Overall, this seems like a sensible diet plan, though the restriction on dairy can prove problematic for calcium intake. This was published for the first time in 2015 with observational data; further research, preferably with trials, is needed to determine if better neurocognitive outcomes continue to be seen.(Morris, 2015)

This involves eating more fruits, vegetables, whole grains, seafood, eating higher quality but less meat overall, seeking out more food from wild landscapes, using organic produce when possible, avoiding food additives, basing more meals on seasonal produce, consuming more home-cooked food, and producing less waste. Meals should aim for a 2:1 ratio of carbohydrates-to-protein. This is a very environmentally-friendly diet plan/philosophy.(Meltzer, 2019) For that same reason, it can be fairly expensive and take a lot of time for food preparation. This diet should yield health benefits(Ramezani-Jolfaie, 2019) but there is no indication this will yield better health outcomes than some of the easier alternatives one can choose from. For people with the time and money on their hands as well as the desire to best support the environment, this diet would be worth looking into more; otherwise there are easier options that are likely just as healthy.

There are various ways to develop an Ornish diet, and there is evidence (initially published in 1990) that a strict version reverses heart disease.(Ornish, 1990) This strict version limits fat to 10% of one’s calories with very little of it being saturated, excludes almost all oils/caffeine, limits refined carbohydrates to 2 servings daily, limits dietary cholesterol (<10 mg daily), and excludes animal products other than egg whites & up to 2 servings of nonfat dairy daily. It emphasizes fiber and complex carbohydrates, and up to 1 serving of alcohol is permitted daily. This dietary plan also emphasizes exercise, stress management, and relationships. Overall, this is a heart-healthy diet but can be very difficult to adhere to due to the significant fat restriction. For more information on the diet, see: https://www.ornish.com/proven-program/nutrition/

This diet is based on the notion that we should eat what we typically consumed throughout our evolutionary history, though one could question how confidently we know what humans consumed thousands of years ago. Nonetheless, this forbids refined sugar, dairy, grains, legumes, and alcohol. Nutrition mostly consist of fruits, vegetables, poultry, fish, meat, eggs, nuts & seeds (but not peanuts or peanut butter as this is a legume). Thus, this diet omits multiple healthy food groups and if care is not taken excess saturated fat can be consumed. Research evaluating this diet does show health benefits, however trials are typically small and a larger body of research is needed.(Ghaedi, 2020; de Menezes, 2019)) If someone wants to follow this there are many recipes available online, and I would suggest being careful to avoid micronutrient deficiencies (always feel free to plug your diet into cronometer.com to see if you are deficient in anything) and excessive saturated fat intake. Nonetheless, I generally do not recommend a Paleolithic diet due to the restrictive nature and lack of healthy whole grains/dairy.

This diet advocates eating foods in the raw form, without cooking at any temperature >115 degrees Fahrenheit, and without processing, microwaving, irradiation, genetic engineering, or exposing to pesticides or herbicides. Common food items will include fresh fruits/vegetables, nuts/seeds, uncooked grains, dried organic legumes, and extra-virgin olive oil. Some people will also consume raw animal products (ie, uncooked eggs, raw milk, raw meat). It can be expensive to obtain appliances to prepare food for this diet and organic ingredients are generally considerably more costly than nonorganic. The risk of food poisoning increases significantly on this diet, and many people consume inadequate calories to meet nutritional needs when following this. One must be careful to ensure sufficient calcium, vitamin B12, and vitamin D intake. Overall, this diet is extremely restrictive, difficult to follow, potentially unsafe due to concerns of food poisoning, and may be nutritionally inadequate depending on what is included. For these reasons I do not recommend the raw food diet.

Created by the National Institute of Health’s National Cholesterol Education Program, this includes 6+ servings of grains daily, 3-5 servings of vegetables/dry beans/peas, 2-4 servings of fruits, 2-3 servings of fat free or low-fat dairy, up to 2 egg yolks weekly, up to 5 ounces of meat daily (preferentially fish and skin-off poultry), and canola/olive oil. This diet sets calorie goals based on gender and desire for weight loss, caps saturated fat at 7% of daily calories, and caps dietary cholesterol at 200 milligrams daily. After 6 weeks if LDL cholesterol has not dropped by 8% one should add 2 grams of plant stanols or sterols & 10-25 grams of soluble fiber daily. For a full overview, see: https://www.nhlbi.nih.gov/files/docs/public/heart/chol_tlc.pdf. Theoretically this is a healthy diet plan, and it can decrease cholesterol.(Lichtenstein, 2002) However, there have been few large/prolonged trials, if any, evaluating the TLC diet. Overall this is a reasonable dietary plan though it will require care to ensure you do not exceed the saturated fat or cholesterol limits.

Due to the exclusion of many different foods and food products, planning a fully nutritious vegan diet takes care. It can be easy to consume inadequate amounts of calcium, vitamin D, vitamin B12, zinc, omega-3 fatty acids, iron, and protein. Due to the very restrictive nature and the likelihood of nutritional deficiencies without careful planning, as well as little evidence of significant benefit compared to other diets listed here, I do not recommend a vegan diet for health purposes. However, for people who wish to follow a vegan diet for ethical, environmental, or personal reasons, it will be important to do so as healthily as possible. Plugging your diet into cronometer.com, taking supplements when needed, and discussing this with your medical provider are steps you can take to help ensure this is done healthily. Many evidence-based tips are available online at websites such as https://www.veganhealth.org, and the Academy of Nutrition and Dietetics put out a position statement in 2016 advising how to consume both vegetarian and vegan diets in a healthy manner.(Melina, 2016)

If done appropriately this is a healthy option, as indicated in Tables A3-3 and A3-4 in the Dietary Guidelines for Americans. A MyPlate equivalent with guidelines has even been created for children.(Baroni, 2019) However, depending on food choices this may not yield great health benefits, for example if one chooses mainly to consume refined grains & sugary/fatty products. When done in such a way as to meet the dietary guidelines this should overall be a very healthy diet and should be environmentally friendly as well.(Fresán, 2019) Thus, for individuals willing to give up meat, a well-designed vegetarian diet is a great option to consider.

The idea of this diet is to eat meals with 40% carbohydrates, 30% protein, and 30% fat, to keep your insulin and inflammation-promoting hormones in a healthy zone (of note, I am not aware of any evidence suggesting this is a valid concept). The diet limits calories to 1200 &1500 for women & men, respectively. There are 3 meals & 2 snacks daily. One should consume breakfast within 1 hour of waking & should not go more than 5 hours without eating (except overnight). This diet encourages low glycemic index carbohydrates, protein from skinless chicken/turkey/fish/egg whites/low-fat dairy/tofu/soy meat substitutes, and plant-based fat options such as nuts/olive oil. Due to the very regimented approach it takes a lot of planning and effort to stick to the Zone diet, and as indicated in the comparative literature above there is no evidence suggesting this will generate health benefits superior to other dietary approaches. Thus, I do not recommend following the Zone diet.


Conclusion

There are many different available diets that anyone can follow if desired. While some logically seem to be more conducive to adherence and/or health benefits, the overall literature base comparing these various diets is thin. Considering diets with no complete food restrictions, the Mediterranean Diet and the DASH Diet seem to have the most evidence supporting their health benefits. However, several of the diets are reasonable options for individuals with different food and/or environmental preferences. If using these, choosing one that will suit your individual goals and allow adherence is critical. Alternatively, one can use the knowledge gained in the prior lessons to tailor any of the above diets to suit their individual needs in a healthy manner.

With a firm understanding at this point of what constitutes healthy eating, in the next lesson we will consider practical aspects of doing so in a cost-effective & time-efficient manner.

Click here to proceed to Lesson 13


References

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