Food Is Medicine

SPECIAL REPORT
FOOD IS
MEDICINE:
A Healio guide ®
to diets
Contributors: Justin Tondt, MD • Kurt R. Wharton, MD, FACOG
Written by: Melissa Foster

Contents
3 What is the DASH diet?
10 What is the Mediterranean diet?
17 What is the vegan diet?
24 What is the keto diet?
29 What is intermittent fasting?
34 What are the Dietary Guidelines for

Americans, 2020-2025?
Although healthy eating can help prevent some serious chronic

diseases and preserve overall health, it can be difficult to determine
whether a certain diet will be helpful for a specific patient.
This Healio Special Report provides details about several popular

dietary approaches and evidence supporting their potential health
benefits for easy access.
USE THIS TOOL TO LEARN ABOUT:

Q specific diets and what they entail;
Q health benefits of those diets based on current scientific
evidence; and
Q recommendations from the Dietary Guidelines for Americans,
2020-2025
© Healio 2023 / Food is medicine: A Healio guide to diets / Healio Special Report 2
What is the DASH diet?
DASH — or Dietary Approaches to Stop Hypertension — is an
eating plan that focuses on the consumption of vegetables, fruits,
whole grains, low-fat or fat-free dairy products, fish, poultry,
beans, nuts and seeds, and vegetable oils. The plan includes foods
that are rich in potassium, calcium, magnesium, fiber and protein,
and limits foods that are high in saturated and trans fats, sugar-
sweetened beverages and sweets, and sodium.
The standard DASH diet limits daily sodium intake to 2,300 mg,
according to the National Heart, Lung, and Blood Institute (NHLBI)
of the NIH. That’s equivalent to about 1 teaspoon of table salt,
and by limiting intake to 1,500 mg daily, the effect of the diet on
lowering blood pressure may be even greater. When considering
the DASH diet, individuals should discuss the appropriate level of
sodium intake with their physician.
Examples of recommended daily food group servings
based on a 2,000 calorie-a-day DASH diet
Food Group Daily Servings Serving Size
Grains 6–8 1 slice bread

1 oz dry cereal
½ cup cooked rice,
pasta or cereal
Meats, poultry and fish 6 or less 1 oz cooked meats, fish

or poultry
1 egg
Vegetables 4–5 1 cup raw leafy vegetable

½ cup cut-up raw or
cooked vegetable
½ cup vegetable juice
Fruit 4–5 1 medium fruit

¼ cup dried fruit
(unsweetened)
½ cup fresh, frozen or
canned fruit, or fruit juice
Low-fat or fat-free dairy products 2–3 1 cup milk

1 cup yogurt
1½ oz cheese
Fats and oils 2–3 1 tsp soft margarine

1 tsp vegetable oil
1 tbsp mayonnaise
2 tbsp salad dressing
Sodium 2,300 mg*
*1,500 milligrams (mg) sodium lowers blood pressure even further than 2,300 mg sodium daily.
Source: National Heart, Lung, and Blood Institute
Examples of recommended weekly food group
servings based on a 2,000 calorie-a-day DASH diet
Food Group Weekly Servings Serving Size
Nuts, seeds, dry beans, and peas 4–5 1/3 cup or 1 ½ oz nuts
(unsalted)
2 tbsp peanut butter
2 tbsp or ½ oz seeds
½ cup cooked legumes
(dry beans and peas)
Sweets 5 or less 1 tbsp sugar

1 tbsp jelly or jam
½ cup sorbet, gelatin
1 cup lemonade
Source: National Heart, Lung, and Blood Institute
CURRENT EVIDENCE AND HEALTH BENEFITS

Nearly 3 decades ago, researchers funded by the NHLBI conducted
a multicenter, randomized feeding study — the DASH trial — to
determine whether specific dietary changes could affect blood
pressure. The findings were published in The New England Journal
of Medicine in 1997 and showed that, compared with the typical
American diet, a diet rich in fruits, vegetables and low-fat dairy
foods combined with reduced saturated and total fat intake could
significantly reduce both systolic and diastolic BP.
Since then, the DASH diet has been studied in clinical trials for
the treatment and prevention of various diseases in healthy
populations and in those with or at high risk for other conditions,
such as diabetes. The evidence supports the diet’s advantages
in preventing and treating CVD, particularly hypertension and
coronary heart disease, and follow-up studies of the original DASH
trial further suggest the diet also lowers LDL cholesterol. Studies
have also demonstrated that the diet in modified forms or in
combination with additional lifestyle interventions resulted in even
greater improvements in blood pressure and cholesterol levels.
The table below offers a snapshot of several randomized controlled

trials that evaluated the cardiometabolic benefits of the DASH diet.
Study snapshot: Cardiometabolic health benefits of the DASH diet
Trial Design Participants Intervention Results
DASH Multicenter, 459 Adults with high BP followed Among those with hypertension, the
randomized a typical American diet for 3 DASH diet reduced systolic and diastolic
feeding study weeks, and were then randomly BP by 11.4 mm Hg and 5.5 mm Hg more,
assigned to the same diet respectively, than the control diet.
(control), a diet rich in fruits
Among those without hypertension, the
and vegetables or the DASH
DASH diet reduced systolic and diastolic
diet for 8 weeks.
BP by 3.5 mm Hg and 2.1 mm Hg more,
respectively, than the control diet.
DASH- Multicenter, 412 Adults with high BP followed a The DASH diet was associated
Sodium randomized typical American diet or DASH with significantly lower systolic BP
trial diet for 30 days, each with regardless of sodium intake, but in
varying levels of sodium intake. combination with low sodium, the effect
was even greater.
OmniHeart Randomized, 159 Generally healthy adults with Each of the three diets improved BP, LDL
three-period, high BP followed a DASH diet and heart disease risk. The DASH diet
crossover rich in carbohydrates, a DASH that partially replaced carbohydrates
feeding study diet rich in protein or a DASH with protein lowered systolic BP, LDL,
diet rich in unsaturated fats, HDL and triglyceride levels even further.
each for 6 weeks.
PREMIER Multicenter, 810 Generally healthy adults Both behavioral interventions

randomized with high PB were randomly significantly reduced weight, improved
trial assigned to a behavioral fitness and lowered sodium intake.
intervention, a behavioral
The mean net reduction in systolic
intervention plus the DASH
BP was 3.7 mm Hg in the behavioral
diet, or were given advice only.
intervention group and 4.3 mm Hg in
the behavioral intervention plus DASH
group.
Filippou CD, Meta-analysis 5,545 Researchers searched the The DASH diet reduced both systolic
et al of randomized Medline and Cochrane BP (mean difference, −3.2 mm Hg) and
controlled databases to identify 30 trials diastolic BP (mean difference, −2.5 mm
trials that investigated the effects of Hg). The presence of hypertension did
the DASH diet on BP in adults not change the effect of the DASH diet
with and without hypertension. on BP.
Additional studies suggest that the DASH diet may be beneficial
in the prevention of several other diseases. For instance, the
epidemiologic Insulin Resistance Atherosclerosis Study (IRAS)
and the community-based observational Atherosclerosis Risk in
Communities (ARIC) study have shown that the DASH diet might
lower the risk for type 2 diabetes and kidney disease, respectively.
Some form of the DASH diet has also shown benefits regarding the
following conditions:
Q gestational diabetes; Q heart failure;

Q gout; Q depression; and
Q preeclampsia; Q obesity.
Additionally, a pilot study published in the European Respiratory

Journal in 2016 linked the DASH diet to modest improvements in
asthma control and functional status in patients with uncontrolled
asthma, although researchers noted a larger clinical trial is
warranted.
The NHLBI is also currently assessing the benefits of the diet for
patients with asthma in the Addressing the Quality of Life, Clinical
Outcomes and Mechanisms in Uncontrolled Asthma Following the
DASH Dietary Pattern (ALOHA) trial.
All diets have pros and cons and are not appropriate for every
person. Although the DASH diet has demonstrated beneficial
effects in various studies, physicians should discuss whether a
diet would be appropriate for an individual in the context of their
unique nutritional needs, health status, culture and lifestyle.
REFERENCES:
Addressing Quality of Life, Clinical Outcomes, and Mechanisms in Uncontrolled Asthma Following the DASH
Dietary Pattern (ALOHA). https://clinicaltrials.gov/ct2/show/NCT05251402.
Appel LJ, et al. N Engl J Med. 1997;doi:10.1056/NEJM199704173361601.
Appel LJ, et al. JAMA. 2005;doi:10.1001/jama.294.19.2455.
Blumenthal JA. Arch Intern Med. 2010;170:126-135.
Chiu S, et al. Am J Clin Nutr. 2016;doi:10.3945/ajcn.115.123281.
Filippou CD, et al. Adv Nutr. 2020;doi:10.1093/advances/nmaa041.
Juraschek SP, et al. J Am Coll Cardiol. 2017;doi:10.1016/j.jacc.2017.10.011.
Liese AD, et al. Diabetes Care. 2009;doi:10.2337/dc09-0228.
Ma J, et al. Eur Respir J. 2016;doi:10.1183/13993003.00591-2015.
NHLBI. DASH eating plan. https://www.nhlbi.nih.gov/education/dash-eating-plan.
Obarzanek E, et al. Am J Clin Nutr. 2001;doi:10.1093/ajcn/74.1.80.
PREMIER Collaborative Research Group. JAMA. 2003;doi:10.1001/jama.289.16.2083.
Rebholz CM, et al. Am J Kidney Dis. 2016;doi:10.1053/j.ajkd.2016.05.019.
Sacks FM, et al. N Engl J Med. 2001;doi:10.1056/NEJM200101043440101.
VIEW TABLE OF CONTENTS
What is the Mediterranean diet?
More of a way of eating than a prescriptive diet, a Mediterranean
diet is generally based on traditional eating patterns in countries
situated near the Mediterranean Sea. The diet’s building blocks
include:
Q plant-based foods, such as fruits, vegetables, bread, other

grains, potatoes, beans, nuts and seeds;
Q low to moderate intake of dairy products, eggs, fish and poultry;
Q olive oil as a primary fat source;
Q limited intake of red meat, sweets, sugar-sweetened beverages
and white flour; and
Q optional low to moderate consumption of wine (one serving
per day for women and two servings per day for men), typically
alongside meals.
A Mediterranean diet focuses on minimally processed foods

and building meals around fruits and vegetables. By nature of
its composition, a Mediterranean diet is richer in fats such as
monounsaturated and polyunsaturated fats and omega-3 fatty
acids, and lower in saturated fats, added sugars and sodium.
USDA-recommended serving sizes
based on a 2,000-calorie-per-day Mediterranean diet:
VEGETABLES FRUIT GRAINS

2.5 cup 2.5 cup eq daily 6 oz eq daily
equivalents (eq) daily
DAIRY PROTEIN FOODS OIL

2 cup eq daily 6.5 oz eq daily 27 g daily
Limit calories for other uses to 12% daily

Studies on Mediterranean diets stretch back decades, but one of
the largest trials is the PREDIMED study, which was published in
The New England Journal of Medicine in 2013. The study showed
that the incidence of major cardiovascular events, including
myocardial infarction, stroke or death from any cardiovascular
cause, was lower among participants assigned a Mediterranean
diet supplemented with extra virgin olive oil or nuts than those
assigned a reduced-fat diet. The study, however, was retracted
in 2018 due to “irregularities in the randomization procedures,”
according to the researchers, and was republished in the same
journal in 2018 after they corrected those issues and conducted
further analysis. Results were similar to those originally reported.
Several more studies, including other analyses of PREDIMED,

have also demonstrated the positive effects that a Mediterranean
diet can have on heart health, such as lower stroke and coronary
heart disease risks in both people without CVD and those with
preexisting CVD.
Below is a snapshot of several studies showing the cardiovascular

benefits of a Mediterranean diet.
Study snapshot: Cardiometabolic health benefits of a Mediterranean diet
Lyon Diet Randomized, 605 Survivors of myocardial In patients with prior myocardial
Heart Study single-blinded, infarction followed the infarction, the composite of
multicenter Mediterranean diet or a cardiac death and nonfatal
trial control diet for the secondary myocardial infarction was reduced
prevention of coronary heart with the Mediterranean diet,
disease. compared with the control diet.
PREDIMED Parallel-group, 7,447 Older adults at high The incidence rates of major
(2018 revised) multicenter, cardiovascular risk followed cardiovascular events per 1,000
randomized a Mediterranean diet person-years — the study’s primary
trial supplemented with extra-virgin endpoint — were 8.1 in the group
olive oil, a Mediterranean diet assigned to a Mediterranean diet
supplemented with nuts or a with extra-virgin olive oil, 8 in the
reduced-fat diet. group assigned to a Mediterranean
diet with nuts, and 11.2 in the
control group.
The unadjusted HR associated with

both versions of the Mediterranean
diet was 0.7, compared with the
reduced-fat diet.
CORDIOPREV Randomized 1,002 Adults with coronary The crude rate of major
controlled trial heart disease followed a cardiovascular events was 28.1
Mediterranean diet or low-fat per 1,000 person-years in the
diet for secondary prevention Mediterranean diet group vs. 37.7
of CVD. per 1,000 person-years in the low-
fat group.
In adjusted analyses, the HRs were

approximately 0.75, in favor of the
Mediterranean diet.
Health benefits were more evident

in men than women.
Study snapshot: Cardiometabolic health benefits of a Mediterranean diet (cont.)
Keto-Med Randomized 40 Adults with prediabetes or type The keto group saw a greater
crossover, 2 diabetes followed a keto diet decrease in triglycerides than the
interventional or a Mediterranean diet for 12 Mediterranean group (−16% vs.
trial weeks each, in random order. −5%).
Those following the keto diet had

higher LDL cholesterol (+10% vs.
−5%).
Keto participants experienced

greater weight loss — 8% vs. 7% —
compared with the Mediterranean
group. They also saw a greater
increase in HDL cholesterol (11%
vs. 7%).
Rees K, et al Systematic 12,461 Researchers searched multiple An analysis of the trials showed
review and databases to identify more that the Mediterranean diet
meta-analysis than 30 trials of healthy adults modestly reduced CVD risk factors
of randomized and adults at high risk for CVD for primary prevention, based on
controlled disease (primary prevention) low- to moderate-quality evidence.
trials and those with established
Researchers said there is a
CVD (secondary prevention).
“paucity of evidence for secondary
prevention.”
Other studies have shown that some form of the Mediterranean

diet has cardiometabolic benefits, including weight loss, lower risk
for all-cause mortality in patients with heart disease and lower risk
for type 2 diabetes.
Outside of cardiometabolic health, many studies have evaluated
the diet for its effect on different conditions, and many
studies continue to assess its effects. For example, following a
Mediterranean diet may:
Q reduce risk for frailty;

Q reduce risk for preeclampsia;
Q reduce risk for nonalcoholic fatty liver disease;
Q improve cognition and protect against Alzheimer’s disease;
Q reduce risk of progression in prostate cancer;
Q prevent thyroid autoimmune disorders;
Q increase lifespan;
Q slow psoriasis progression; and
Q protect against depression.
In a Boston cohort of more than 8,000 pregnant

women, the Mediterranean diet was associated with a:
22 %
lower risk for developing
preeclampsia
Source: Minhas AS, et al. J Am Heart Assoc. 2022;doi:10.1161/JAHA.121.022589.
person. Although the Mediterranean diet has demonstrated
beneficial effects in various studies, physicians should discuss
whether a diet would be appropriate for an individual in the
context of their unique nutritional needs, health status, culture and
lifestyle.
REFERENCES:
American Heart Association. What is the Mediterranean diet? https://www.heart.org/en/healthy-living/
healthy-eating/eat-smart/nutrition-basics/mediterranean-diet.
Cochrane Heart Group. Cochrane Database Syst Rev. 2019;doi:10.1002/14651858.CD009825.pub3.
Cleveland Clinic. Mediterranean diet. https://my.clevelandclinic.org/health/articles/16037-mediterranean-
diet.
de Lorgeril M, et al. Circulation. 1999;doi:10.1161/01.CIR.99.6.779.
de Lorgeril M, et al. Lancet. 1994;doi:10.1016/S0140-6736(94)92580-1.
Delgado-Lista J, et al. Lancet. 2022;doi:10.1016/s0140-6736(22)00122-2.
Esposito K, et al. Ann Intern Med. 2009;doi:10.7326/0003-4819-151-5-200909010-00004.
Estruch R, et al. N Engl J Med. 2013;10.1056/NEJMoa1200303.
Estruch R, et al. N Engl J Med. 2018;doi:10.1056/NEJMc1806491.
Estruch R, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1800389.
Fung TT, et al. Circulation. 2009;doi:10.1161/CIRCULATIONAHA.108.816736.
Gardner CD, et al. Am J Clin Nutr. 2022;doi:10.1093/ajcn/nqac154.
Lopez-Garcia E, et al. Am J Clin Nutr. 2014;doi:10.3945/ajcn.113.068106.
Mayo Clinic. Mediterranean diet for heart health. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-
healthy-eating/in-depth/mediterranean-diet/art-20047801.
Salas-Salvadó J, et al. Diabetes Care. 2011;doi:10.2337/dc10-1288.
Salas-Salvadó J, et al. Arch Intern Med. 2008;doi:10.1001/archinte.168.22.2449.
Shai I, et al. N Engl J Med. 2008;doi:10.1056/NEJMoa0708681.
U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for
Americans, 2020-2025. 9th ed. December 2020. Available at: DietaryGuidelines.gov.
What is the vegan diet?
Although there is no official definition, the vegan diet is a stricter
form of a vegetarian eating plan that relies solely on plant-based
foods. Unlike other subsets of vegetarian diets, such as lacto-
vegetarian, ovo-vegetarian or lacto-ovo-vegetarian diets, which
allow consumption of certain animal products, vegan diets exclude
all animal products, including:
Q meat, poultry and fish Q honey; and

or shellfish; Q all foods containing these
Q eggs; products, such as mayonnaise
Q dairy products, such as milk or meat-based or cream-
and yogurt; based broths, sauces or

gravies.
Products sold as “milks,” such as almond, rice, coconut, oat and

hemp milks, may be consumed as a source of calcium; they are not
deemed part of the dairy group.

Vegan diets can be nutritionally adequate and offer significant
health benefits when planned appropriately, but there remains the
potential for nutrient deficiencies, according to a 2016 position
paper published in the Journal of the Academy of Nutrition and
Dietetics. Those following a vegan or vegetarian diet may have lower
blood levels of the following:
Q long-chain n-3 fatty acids, Q zinc;

such as eicosapentaenoic acid, Q iodine;
docosahexaenoic acid and Q calcium;
omega-3 fatty acids; Q vitamin D; and
Q iron; Q vitamin B12.
To avoid these deficiencies and associated health problems, the

position paper emphasizes the importance of a balanced vegetarian
or vegan diet. Physicians should ensure that people following a
vegan diet are consuming enough calories from a variety of healthy
foods, discuss the potential need for supplementation when
appropriate and educate people about sources of specific nutrients,
according to the position paper. MyPlate.gov provides information
on alternative protein or dairy sources.
Below is a snapshot of several studies showing the cardiometabolic

health benefits of a vegan diet.
Study snapshot: Cardiometabolic health benefits of a vegan diet
Barnard ND, Randomized 99 Patients with type 2 Both diets resulted in significant
et al controlled trial diabetes followed a low-fat weight loss, without much
vegan diet or an American difference between groups, and
Diabetes Association (ADA)- both saw changes in HbA1c (−0.34
recommended diet for 74 with the vegan diet and −0.14 for
weeks. the ADA diet).
LDL cholesterol decreased by 13.5

mg/dL in the vegan group and 3.4
mg/dL in the ADA group.
GEICO Multicenter 291 Corporate employees at 10 U.S. Those in the vegan group who
randomized sites with a BMI of at least 25 completed the study saw mean
controlled trial kg/m and/or type 2 diabetes
2
changes in body weight of −4.3 kg
followed a low-fat vegan diet compared with −0.08 kg in the
with weekly group support or control group.
made no changes to their diet
LDL cholesterol fell 13 mg/dL in
for 18 weeks.
the vegan group and 1.7 mg/dL in
the control group, and HbA1c levels
decreased 0.7 vs. 0.1 percentage
points, respectively.
BROAD Randomized 65 Patients with overweight or The whole food plant-based diet
controlled trial obesity and at least one of resulted in a greater mean BMI
type 2 diabetes, ischemic heart reduction compared with normal
disease, or the cardiovascular care — 4.4 vs. 0.4 kg/m2.
risk factors of hypertension or
The difference in mean cholesterol
hypercholesterolemia followed
reduction between the groups was
a whole food plant-based diet
not statistically significant.
or standard medical care for 6
months.
Study snapshot: Cardiometabolic health benefits of a vegan diet (continued)
Barnard ND, Randomized, 62 Patients with overweight After 36 weeks, the vegan diet
et al crossover trial were assigned to follow a led to greater reductions in body
Mediterranean or vegan diet weight (by 6 kg), fat mass (by 3.4
for 16 weeks, returned to their kg), visceral fat (315 cm3) and
baseline diet for 4 weeks, and plasma lipid concentrations vs. the
then began the opposite diet Mediterranean diet.
for another 16 weeks.
However, the Mediterranean diet
led to greater reductions in systolic
and diastolic BP (by 6 mmHg and
3.2 mmHg, respectively).
Termannsen Meta-analysis 796 Researchers searched multiple Compared with control diets,
AD, et al of randomized databases and identified vegan diets reduced body weight
controlled 11 trials that investigated (−4.1 kg), BMI (−1.38 kg/m2),
trials the effect of vegan diets on HbA1c (−0.18% points), total
cardiometabolic risk factors in cholesterol (−0.30 mmol/L) and
people with overweight or type LDL cholesterol (−0.24 mmol/L).
2 diabetes.
However, the diet had no effect
on BP, HDL cholesterol and
triglycerides.
In terms of health benefits, a vegan diet, especially when compared
with a non-vegetarian diet, has been linked to:
Q weight loss;
Q reduced risk for CVD, including hyperlipidemia, ischemic heart
disease and hypertension;
Q reduced risk for and improved control of type 2 diabetes;
Q lower risk for cancer;
Q reduction in hot flashes in menopausal women; and
Q reduced joint pain and swelling in rheumatoid arthritis.
The Adventist Health Study-2 offers insight into the relationship

between a vegan diet and different diseases. Adventists following
a vegan diet had a mean BMI that was 5 points lower, a 75% lower
risk for hypertension and a 47% to 78% lower risk for diabetes
than their non-vegetarian counterparts. Moreover, their risk for
all cardiometabolic-related outcomes was lower than that for
those following a lacto-ovo-vegetarian diet compared with a
non-vegetarian diet. It should be noted that the Adventist Health
Study-2 relied on observational data, and results could be affected
by healthy user bias.
Additionally, the Adventist Health Study-2 found a “modest”

14% reduction in the risk for all cancer among vegans vs. non-
vegetarians, but data on specific cancers were mixed.
Reduced mortality risk associated with the
vegan diet in the Adventist Health Study-2:
14 %
lower risk for all-
42
lower risk for
%
55
lower risk for
%
cause mortality cardiovascular ischemic heart
disease-related disease-related
mortality mortality
Source: Le LT, et al. Nutrients. 2014;doi:10.3390/nu6062131.
person. Although vegan diets have demonstrated beneficial effects
in various studies, physicians should discuss whether a diet would
be appropriate for an individual in the context of their unique
nutritional needs, health status, culture and lifestyle.
REFERENCES:
Barnard ND, et al. J Am Nutr Assoc. 2022;doi:10.1080/07315724.2020.1869625.
Barnard ND, et al. Am J Clin Nutr. 2009;doi:10.3945/ajcn.2009.26736H.
Barnard ND, et al. J Am Nutr Assoc. 2020;doi:10.1080/07315724.2020.1869625.
Cleveland Clinic. Going vegan 101. https://health.clevelandclinic.org/going-vegan-101/.
Kaiser Permanente. Vegan diet. https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/
he.vegan-diet.abq2485.
Le LT, et al. Nutrients. 2014;doi:10.3390/nu6062131.
Mayo Clinic. Vegetarian diet: How to get the best nutrition. https://www.mayoclinic.org/healthy-lifestyle/
nutrition-and-healthy-eating/in-depth/vegetarian-diet/art-20046446.
Melina V, et al. J Acad Nutr Diet. 2016;doi:10.1016/j.jand.2016.09.025.
Mishra S, et al. Eur J Clin Nutr. 2013;doi:10.1038/ejcn.2013.92.
NHS. The vegan diet. https://www.nhs.uk/live-well/eat-well/how-to-eat-a-balanced-diet/the-vegan-diet.
Termannsen AD, et al. Obes Rev. 2022;doi:10.1111/obr.13462.
Tonstad S, et al. Diabetes Care. 2009;doi:10.2337/dc08-1886.
U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for
Americans, 2020-2025. 9th ed. December 2020. Available at: DietaryGuidelines.gov.
Wright N, et al. Nutr Diabetes. 2017;doi:10.1038/nutd.2017.3.
What is the keto diet?
Although definitions vary, the ketogenic diet, or the “keto” diet,
focuses on foods that are high in fat, low in carbohydrates and
moderate in protein. The driving concept is to force the body into
a physiological state called ketosis, in which the body’s primary
energy source comes from fat instead of carbohydrates.
The diet’s actual composition is considered less important

than being in the state of ketosis itself. Some sources suggest
monitoring of ketone bodies using blood, urine or breath tests
to determine whether they have entered ketosis, but this is not
a requirement. Unlike some other diets, there is generally less
discrimination between which types of foods are best, such as
opting for fish or poultry instead of red meat for protein, and
consumption of fruits, vegetables, grains and legumes is limited.

The first written record of a low-carbohydrate diet dates back to
the 19th century, by William Banting. It has been popularized since
then under various names, including Atkins. The keto diet was even
established as a treatment for drug-resistant epilepsy in children
in the 1920s and continues to be used and studied for this purpose.
Here is a sampling of randomized clinical trials of keto diets.
Study snapshot: Cardiometabolic health benefits of a keto diet
Yancy WS, et al Randomized 120 Adults with overweight The keto diet resulted in greater
controlled trial and hyperlipidemia were weight loss than the low-fat diet,
randomly assigned to follow with mean changes of −12.9% and
a keto diet plus nutritional −6.7%, respectively.
supplementation or a low-
The keto diet also led to greater
fat diet for 24 weeks. Group
decreases in triglyceride levels
meetings and exercise
(−0.84 mmol/L vs. −0.31 mmol/L)
recommendations were offered
and greater increases in HDL
in both study arms.
cholesterol (0.14 mmol/L vs. −0.04
mmol/L).
Changes in LDL cholesterol did not

differ significantly between the two
groups.
Bazzano LA, Randomized, 148 Men and women with CVD Those assigned the keto diet
et al parallel-group and diabetes were randomly experienced greater weight loss
trial assigned to follow a keto diet vs. those in the low-fat diet group,
or low-fat diet with dietary with a mean difference in change
counseling for up to 12 of −3.5 kg. They also had greater
months. decreases in fat mass (mean
difference in change, −1.5%), the
ratio of total to HDL cholesterol
(mean difference in change,
−0.44) and triglyceride levels
(mean difference in change, −0.16
mmol/L).
Keto participants had greater

increases in HDL cholesterol
(mean difference in change, 0.18
mmol/L).
Tay J, et al Randomized 115 Adults with obesity and type Patients on both diets achieved
controlled trial 2 diabetes were randomly substantial weight loss and
assigned to a low-carbohydrate comparable reductions in HbA1c
diet or a high-carbohydrate diet and fasting glucose.
for up to a year.
Notably, the low-carbohydrate diet
led to greater reductions in the use
diabetes medications, suggesting
better glycemic control in that
group.
Study snapshot: Cardiometabolic health benefits of a keto diet (continued)
DIRECT Randomized 322 Adults with moderate obesity, The Atkins and Mediterranean diets
controlled trial some with diabetes, were led to greater mean weight loss
randomly assigned to a low- (−4.7 kg and −4.4 kg, respectively)
fat, restricted-calorie diet, a compared with the low-fat diet
Mediterranean diet, or a low- (−2.9 kg).
carbohydrate, nonrestricted-
The Atkins diet had a more
calorie diet (Atkins) for up to
favorable effect on lipids, and the
2 years.
Mediterranean diet had a more
favorable effect on glycemic
control in participants with
diabetes. The different beneficial
metabolic effects of both diets
suggest that they can be tailored to
patients' specific needs, according
to the researchers.
Sackner- Meta-analysis 1,797 Researchers searched the Both diets were associated with
Bernstein J, of randomized PubMed database to identify significant weight loss and a
et al controlled 17 trials that compared low- reduced risk for atherosclerotic
trials carbohydrate diets with low-fat cardiovascular disease (ASCVD).
diets with at least 8 weeks of
However, the low-carbohydrate diet
follow-up data. The analysis
was associated with a significantly
only included participants who
greater reduction in weight
strictly adhered to their diets.
(pooled mean net change, −2 kg)
and significantly lower predicted
ASCVD risk in trials that lasted
from 8 to 24 weeks.
The keto diet has grown in popularity as a weight loss mechanism,
and studies indicate that the diet does lead to weight loss in people
with obesity, particularly in the short term and when compared
with low-fat diets, although more research is underway. The diet is
further linked to:
Q significant improvements in blood glucose and HbA1c in patients

with diabetes;
Q weight loss and resuming menstruation in women with
polycystic ovary syndrome;
Q reductions in BP;
Q potential benefits for women with ovarian and endometrial
cancers;
Q improvements in nonalcoholic fatty liver disease;
Q improved cardiometabolic health in patients with heart failure;
Q increased testosterone in men with obesity; and
Q potentially decreased risk for Alzheimer’s disease.
Keto is being investigated in randomized controlled studies for

its effect on brain health. In addition to Alzheimer’s disease,
researchers are looking at its benefits in the setting of multiple
sclerosis and Parkinson’s disease.
There is also limited evidence suggesting that the keto diet may
improve patients' response to cancer treatment, although more
research is needed.
Despite its benefits, the keto diet is not without drawbacks. The
most immediately noticeable side effect is the “keto flu,” which
includes headache, “brain fog” and gastrointestinal discomfort.
Researchers have reported that the symptoms peak about 1 week
after starting the diet and usually resolve within 4 weeks.
person. Although the keto diet has demonstrated beneficial effects
in various studies, physicians should discuss whether a diet would
be appropriate for an individual in the context of their unique
nutritional needs, health status, culture and lifestyle.
REFERENCES:
Associated Press. 150 years of dieting fads: An American story. https://www.cbsnews.com/news/150-years-
of-dieting-fads-an-american-story. Published Jan. 24, 2023.
Bazzano LA, et al. Ann Intern Med. 2014;doi:10.7326/M14-0180.
Brehm BJ, et al. J Clin Endocrinol Metab. 2003;doi:10.1210/jc.2002-021480.
Bueno NB, et al. Br J Nutr. 2013;doi:10.1017/S0007114513000548.
Cleveland Clinic. Ketogenic diet (keto diet) for epilepsy. https://my.clevelandclinic.org/health/
treatments/7156-ketogenic-diet-keto-diet-for-epilepsy.
Harvard Health Publishing. Should you try the keto diet? https://www.health.harvard.edu/staying-healthy/
should-you-try-the-keto-diet. Published Aug. 30, 2020.
Harvard T.H. Chan School of Public Health. Diet review: Ketogenic diet for weight loss. https://www.hsph.
harvard.edu/nutritionsource/healthy-weight/diet-reviews/ketogenic-diet.
Ludwig DS. J Nutr. 2019;doi:10.1093/jn/nxz308.
Martin-McGill KJ, et al. Cochrane Database Syst Rev. 2020;doi:10.1002/14651858.CD001903.pub5.
Neal EG, et al. Lancet Neurol. 2008;doi: 10.1016/S1474-4422(08)70092-9.
Sackner-Bernstein J, et al. PLoS One. 2015;doi:10.1371/journal.pone.0139817.
Shai I, et al. N Engl J Med. 2008;doi:10.1056/NEJMoa0708681.
Tan-Shalaby J. Fed Pract. 2017;34(Suppl 1):37s-42s.
Tay J, et al. Am J Clin Nutr. 2015;doi:10.3945/ajcn.115.112581.
Wheless JW. Epilepsia. 2008;doi:10.1111/j.1528-1167.2008.01821.x.
Yancy WS, et al. Ann Intern Med. 2004;doi:10.7326/0003-4819-140-10-200405180-00006.
What is intermittent fasting?
Less of a diet and more of an eating regimen, intermittent fasting
focuses on when a person eats rather than what a person eats.
Specifically, it is an eating pattern that cycles between periods of
fasting and eating.
There are multiple approaches to intermittent fasting. The most

popular of these include:
Q Alternate-day or whole-day fasting: Fast or eat one small

meal — typically fewer than 500 calories — for 1 or more days
per week and eat a normal diet during the remaining days of
the week. An example is the popular 5:2 approach in which a
person fasts or eats one small meal for 2 days per week and eats
normally the other 5 days.
Q Time-restricted eating: There are set fasting and eating
windows. For example, a person can eat meals within an 8-hour
window each day while the other 16 hours are designated for
fasting.
Generally, there are no restrictions on food intake or types of food

consumed during the eating periods. During fasting, water, coffee,
tea and other non-caloric beverages are allowed.
Although intermittent fasting has gained popularity, the number of
high-quality studies on its effects in humans is limited, according
to two systematic reviews.
Here are examples of randomized trials that investigated the

cardiometabolic benefits of intermittent fasting in its various
forms.
Study snapshot: Cardiometabolic health benefits of intermittent fasting
Chair YS, et al Randomized 101 Prediabetic adults with Both intervention groups
controlled trial overweight or obesity were experienced significantly more
assigned to alternate-day weight loss than the control
fasting, eating restricted to group, and they also experienced
an 8-hour window, or a control significant reductions in blood
group for 3 weeks. glucose and triglycerides.
Changes in weight and BMI were

more pronounced in those who
followed an alternate-day plan vs.
those who restricted eating to 8
hours, but there were no significant
changes between the two groups
in terms of blood glucose, waist
circumference and LDL cholesterol.
Xie Z, et al Randomized 90 Healthy volunteers without Results showed that early time-
controlled trial obesity were randomly restricted eating was more
assigned to two different time- effective than restricting eating to
restricted eating approaches: the middle of the day at improving
restricting eating to the early insulin sensitivity, which was the
part of the day and restricting primary endpoint. Early time-
it to midday. Both regimens restricted eating also improved
lasted 5 weeks. fasting glucose, reduced total
BMI and adiposity, improved
inflammation and increased
gut microbial diversity, whereas
restricting eating to midday did not
achieve these outcomes.
Study snapshot: Cardiometabolic health benefits of intermittent fasting (cont.)
Cienfuegos S, Randomized 58 Adults with obesity were Restricting eating to 4 hours and 6
et al controlled trial randomly assigned to three hours each day led to comparable
groups: those who only ate reductions in body weight —
between 3 p.m. and 7 p.m. approximately 3% — as well as
each day, those who ate insulin resistance and oxidative
between 1 p.m. and 7 p.m. stress compared with a control
each day, and a control group diet.
to determine which approach
Time-restricted eating, whether
led to more weight loss over an
limited to 4 or 6 hours, reduced
8-week period.
energy intake by about 550 kcal/
day.
Sundfør TM, Randomized 112 Participants were randomly According to the researchers,
et al controlled trial assigned to intermittent fasting both groups lost similar
(consuming 400-600 kcal on amounts of weight, and both
two nonconsecutive days) or saw improvements in waist
continuous energy restriction circumference, BP, triglycerides and
for up to 12 months. HDL cholesterol. However, there
were no significant differences
between the two groups.
Those in the intermittent fasting

group reported greater feelings of
hunger.
Patikorn C, et al Umbrella Median Researchers evaluated results Overall, intermittent fasting

review of sample size from 11 meta-analyses, improves anthropometric and
meta-analyses per RCT = 38 including a total of 130 RCTs cardiometabolic outcomes,
of randomized that described obesity-related particularly for adults with
controlled health outcomes associated overweight or obesity.
trials with intermittent fasting —
The review found a significant
including alternate-day fasting,
association supported by high-
the 5:2 diet and time-restricted
quality evidence between alternate-
eating.
day fasting for 1 to 2 months and
a moderate reduction in BMI in
healthy adults and adults with
overweight, obesity or nonalcoholic
fatty liver disease vs. a regular
diet.
Most research has primarily focused on weight loss, for which
intermittent fasting has shown promise, but the approach has also
demonstrated potential cardiometabolic benefits in patients with:
Q overweight, obesity or insulin resistance;

Q type 2 diabetes;
Q metabolic syndrome; and
Q nonalcoholic fatty liver disease.
Regarding CVD, research has linked alternate-day fasting and

time-restricted eating to reductions in BP and routine fasting to a
reduced risk for coronary artery disease, but the data on its effect
on lipids remain unclear.
In a review published in The New England Journal of Medicine,

researchers also noted that preclinical or early clinical evidence
suggests that intermittent fasting may warrant further study for:
Q cancer;
Q neurodegenerative disorders;
Q asthma;
Q multiple sclerosis; and
Q arthritis.
However, studies in these areas are currently lacking.
All diets and eating patterns have pros and cons and are not
appropriate for every person. Although intermittent fasting has
demonstrated beneficial effects in various studies, physicians
should discuss whether a diet would be appropriate for an
individual in the context of their unique nutritional needs, health
status, culture and lifestyle.
REFERENCES:
Chair YS, et al. J Nurs Res. 2022;doi:10.1097/jnr.0000000000000469.
Cienfuegos S, et al. Cell Metab. 2020;doi:10.1016/j.cmet.2020.06.018.
de Cabo R, et al. N Engl J Med. 2019;doi:10.1056/NEJMra1905136.
Evert AB, et al. Diabetes Care. 2019;doi:10.2337/dci19-0014.
Harvard T.H. Chan School of Public Health. Diet review: Intermittent fasting for weight loss. https://www.
hsph.harvard.edu/nutritionsource/healthy-weight/diet-reviews/intermittent-fasting.
Headland M, et al. Nutrients. 2016;doi:10.3390/nu8060354.
Horne BD, et al. Am J Clin Nutr. 2015;doi:10.3945/ajcn.115.109553.
Johns Hopkins Medicine. Intermittent fasting: What is it, and how does it work? https://www.hopkinsmedi-
cine.org/health/wellness-and-prevention/intermittent-fasting-what-is-it-and-how-does-it-work.
Liu D, et al. N Engl J Med. 2022;doi:10.1056/NEJMoa2114833.
Mayo Clinic. What is intermittent fasting? Does it have health benefits? https://www.mayoclinic.org/healthy-
lifestyle/nutrition-and-healthy-eating/expert-answers/intermittent-fasting/faq-20441303.
Patikorn C, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.39558.
National Institute of Aging. Calorie restriction and fasting diets: What do we know? https://www.nia.nih.gov/
news/calorie-restriction-and-fasting-diets-what-do-we-know. Published Aug.14, 2018.
Sundfør TM, et al. Nutr Metab Cardiosasc Dis. 2018;doi:10.1016/j.numecd.2018.03.009.
Trepanowski JF, et al. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2017.0936.
Xie Z, et al. Nat Commun. 2022;doi:10.1038/s41467-022-28662-5.
What are the Dietary Guidelines for
Americans, 2020-2025?
Under the 1990 National Nutrition Monitoring and Related
Research Act, the U.S. Department of Agriculture and HHS must
jointly publish a report — the Dietary Guidelines for Americans —
containing nutritional and dietary information and guidelines for
the general public at least every 5 years.
The 2020-2025 Dietary Guidelines include four principal

recommendations:
1. Follow a healthy dietary pattern at every life stage: infancy,

toddlerhood, childhood, adolescence, adulthood, pregnancy,
lactation and older adulthood.
2. Customize nutrient-dense food and beverage choices to

reflect personal preferences, cultural traditions and budgetary
considerations.
3. Select nutrient-dense foods and beverages that focus on

meeting food group needs within calorie limits.
4. Limit foods and beverages that are higher in added sugars,

saturated fat and sodium. Also limit alcoholic beverages.
Overall, the guidelines aim to promote health and prevent disease
while focusing on healthy dietary patterns throughout a person’s
lifespan rather than focusing on individual foods. The USDA
provides specific guidance about food groups, daily nutrition needs
and serving sizes at MyPlate.gov.
The USDA has created MyPlate to easily show what and

how much to eat based on a specific calorie allowance.
Patients can personalize food plans at https://www.
myplate.gov/myplate-plan.
EVALUATING THE PROCESS

When updating the guidelines, the USDA and HHS convene a
Dietary Guidelines Advisory Committee (DGAC) to review the
relevant scientific evidence. Upon completion, they submit the
DGAC Scientific Report, which summarizes the current evidence and
offers recommendations to the federal government. The public
then has the opportunity to comment on the guidance.
After a previous edition of the scientific report was published

in 2015, questions arose about how the DGAC arrives at its
recommendations, which are generated every 5 years. In 2016,
Congress asked the National Academies of Sciences, Engineering,
and Medicine to review the entire process. Subsequently, in
2017, the National Academies made several recommendations
— including developing a better process for prioritizing topics,
improving the methods by which current evidence is reviewed and
interpreted and offering greater transparency to the public about
what information is ultimately accepted into the report and why.
In 2022, the National Academies published a midcourse report,

indicating that several of their suggestions had been implemented
but there remains significant room for improvement.
The full midcourse report can be found at the National Academies

website.
REFERENCES:
National Academies of Sciences, Engineering, and Medicine. Evaluating the process to develop the dietary
guidelines for Americans: 2020-2025: A midcourse report. 2022;doi:10.17226/26406.
U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Ameri-
cans, 2020-2025. 9th ed. December 2020. Available at: DietaryGuidelines.gov.
CONTRIBUTORS:
Justin Tondt, MD Kurt R. Wharton, MD, FACOG
Assistant professor of family and Professor of OB/GYN, Oakland University
community medicine William Beaumont School of Medicine
Penn State College of Medicine OB/GYN Service Line Chief, Corewell Health East
Disclosure: Tondt reports no relevant financial Disclosure: Wharton reports no relevant financial
disclosures. disclosures.
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CHECK OUT OUR FOOD IS MEDICINE RESOURCE CENTER:
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SPECIAL REPORT

Written by: Melissa Foster

10 What is the Mediterranean diet?

17 What is the vegan diet?

24 What is the keto diet?

29 What is intermittent fasting?

34 What are the Dietary Guidelines for

Although healthy eating can help prevent some serious chronic

This Healio Special Report provides details about several popular

USE THIS TOOL TO LEARN ABOUT:

Food Group Daily Servings Serving Size

Grains 6–8 1 slice bread

Meats, poultry and fish 6 or less 1 oz cooked meats, fish

Vegetables 4–5 1 cup raw leafy vegetable

Fruit 4–5 1 medium fruit

Low-fat or fat-free dairy products 2–3 1 cup milk

Fats and oils 2–3 1 tsp soft margarine

Sodium 2,300 mg*

Food Group Weekly Servings Serving Size

Sweets 5 or less 1 tbsp sugar

Source: National Heart, Lung, and Blood Institute

CURRENT EVIDENCE AND HEALTH BENEFITS

The table below offers a snapshot of several randomized controlled

Trial Design Participants Intervention Results

PREMIER Multicenter, 810 Generally healthy adults Both behavioral interventions

Q gestational diabetes; Q heart failure;

Additionally, a pilot study published in the European Respiratory

VIEW TABLE OF CONTENTS

Q plant-based foods, such as fruits, vegetables, bread, other

A Mediterranean diet focuses on minimally processed foods

VEGETABLES FRUIT GRAINS

DAIRY PROTEIN FOODS OIL

Limit calories for other uses to 12% daily

CURRENT EVIDENCE AND HEALTH BENEFITS

Several more studies, including other analyses of PREDIMED,

Below is a snapshot of several studies showing the cardiovascular

Trial Design Participants Intervention Results

The unadjusted HR associated with

In adjusted analyses, the HRs were

Health benefits were more evident

Trial Design Participants Intervention Results

Those following the keto diet had

Keto participants experienced

Other studies have shown that some form of the Mediterranean

Q reduce risk for frailty;

In a Boston cohort of more than 8,000 pregnant

Source: Minhas AS, et al. J Am Heart Assoc. 2022;doi:10.1161/JAHA.121.022589.

VIEW TABLE OF CONTENTS

Q meat, poultry and fish Q honey; and

and yogurt; based broths, sauces or

Products sold as “milks,” such as almond, rice, coconut, oat and

CURRENT EVIDENCE AND HEALTH BENEFITS

Q long-chain n-3 fatty acids, Q zinc;

To avoid these deficiencies and associated health problems, the

Below is a snapshot of several studies showing the cardiometabolic

Trial Design Participants Intervention Results

LDL cholesterol decreased by 13.5

Trial Design Participants Intervention Results

The Adventist Health Study-2 offers insight into the relationship