There are some concerns about potential adverse effects of dairy intake that DASH-related literature tends to ignore , The Optimal Macronutrient Intake Trial for Heart Health OmniHeart has demonstrated short-term benefits for overall cardiovascular risk of several variations on the DASH diet theme—intake relatively high in carbohydrate, relatively high in protein, and relatively high in unsaturated fat—and suggested advantages to replacing some carbohydrate with either protein or fat 6 , 23 , There are, however, no head-to-head comparisons of a DASH-style diet with other candidate dietary patterns to determine which produces the best long-term health effects.
The DPP , developed and conducted by the National Institute of Diabetes and Digestive and Kidney Diseases, incorporated a fairly similar diet, again emphasizing a mix of foods—especially plant foods and select, mostly lean animal foods—and restrictions of refined starch and added sugar. Subsequent study has indicated the persistence of such benefit, if only partially, over an extended time line , Despite such advantages, widespread adoption at the population level has not occurred. A direct comparison of these or related diets to other leading candidate diets with regard to health outcomes over time is lacking.
The particular focus in Paleolithic diets is on emulating the dietary pattern of our Stone Age ancestors with an emphasis on avoiding processed foods, and the intake of vegetables, fruits, nuts and seeds, eggs, and lean meats. In principle at least, dairy and grains are excluded entirely. Arguments for a Paleolithic diet derived initially, not from modern science, but from the universal relevance of adaptation. We may note, without debate or conflict, that the native diet of any species other than our own is clearly relevant to food selection.
Zoological parks do not feed wild animals in captivity based on randomized trials; they feed them based substantially on the diets of their counterparts in the wild That Homo sapiens should be the one species for which native diet is irrelevant defies reason, and there is thus good reason to examine at least the basis for Paleolithic eating. There is a fairly strong case for the principle of a Paleolithic-style diet in the anthropology literature.
The biomedical literature has limited evidence for this diet compared with the evidence for other dietary patterns reviewed here, but it is generally supportive. One of the lesser challenges in reaching conclusions about the Paleolithic diet is variation in our ancestral dietary pattern and debate regarding its salient features 74 , 99 , , In a modern context, an even greater challenge tends to be the wide variability in how the rubric is interpreted and applied and the impossibility of replicating our Stone Age dietary pattern with any real precision.
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Many of the plant foods and nearly all of the animal foods consumed during the remote Stone Age are now extinct. Whereas the composition of some animals' flesh may mimic that of mammoths, the composition of the flesh of animals most often appearing in the food supply does not 78 , If Paleolithic eating is loosely interpreted to mean a diet based mostly on meat, no meaningful interpretation of health effects is possible. Even more meticulous interpretations of the Paleolithic diet tend to omit details, including but not limited to the very high-caloric throughput of Paleolithic humans, the dramatically different ratio of n-3 to n-6 fatty acids that now prevails, the dramatically different ratio of potassium to sodium that now prevails, the dramatically lower intake of fiber that now prevails, etc.
There is a scientific case for the Paleolithic diet, based in part on anthropological considerations. Intervention studies lend support as well 49 , 74 , suggesting benefits over the prevailing Western diet in measures of both body composition and metabolic health. Among the more interesting controversies informing consideration and adoption of a Paleolithic diet is the relative importance of hunting and gathering to our Stone Age forebears.
The term hunter-gatherer was modified to gatherer-hunter in some contexts over recent years, with a growing appreciation for the salience of plant foods in our native diet. Given the energy density of meat relative to most plants, even this translates to a diet that is, by bulk, mostly plants. Although superficially a departure from the other contending diets, a reasonable approximation of a true Paleolithic diet would in fact be relatively low in fat; low in the objectionable carbohydrate sources—namely, starches and added sugars; high in vegetables, fruits, nuts and seeds, and fiber; and low glycemic.
An emphasis on lean meat remains distinctive, however, and may represent an advantage related particularly to satiety A vegan diet excludes all animal products—notably, dairy, eggs, and meats. As with almost every other dietary approach, vegan eating can be done well or badly. Vegans, in general, tend to be especially mindful eaters and often adhere to the dietary pattern for reasons including, but not limited to, personal health.
Those committed to long-term veganism are typically well versed in the need to combine plant foods to achieve complete protein and in the role of select nutrient supplements Those who adopt veganism for a short term, particularly adolescents seeking rapid weight loss, are not as reliably well informed. In general, vegan diets, when well constructed 33 , are associated with health benefits 1 , 40 , Intervention trials of short to moderate duration suggest benefits related to overall diet quality, inflammation, cardiac risk measures, cancer risk, anthropometry, and insulin sensitivity 10 — 12 , 40 , , Eating only plant foods does not guarantee a healthful, balanced diet.
Sugar, among the more concerning dietary components consumed in excess, is of plant origin. Vegan diets, if ill conceived, can combine the adverse exposures of plant-based junk foods with nutrient deficiencies. Veganism in free-living populations tends to be associated with particular health consciousness. Intervention trials of vegan diets are limited to those willing to be assigned to such a diet for a span of weeks, months, or years.
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Given such constraints, data from intervention trials that are related to direct comparison of vegan diets with various other dietary patterns, that are defended from bias, and that examine long-term health effects are essentially nonexistent. This does not argue against vegan diets, but it does argue against overstating the basis for them in evidence related to human health outcomes.
Claims for the specific advantages of diverse dietary practices abound. Many such practices, such as juicing or intermittent fasting, do not constitute a complete dietary pattern. Others, such as raw-food eating or calorie restriction, may be a complete dietary pattern but have limited population-level application, even if they do enjoy considerable attention in the media and popular culture. Space does not allow for full treatment of such practices here, but they are considered in the conclusions below.
Can we say what diet is best for health? If diet denotes a very specific set of rigid principles, then even this necessarily limited representation of a vast literature is more than sufficient to answer with a decisive no. If, however, by diet we mean a more general dietary pattern, a less rigid set of guiding principles, the answer reverts to an equally decisive yes. The aggregation of evidence in support of a diets comprising preferentially minimally processed foods direct from nature and food made up of such ingredients, b diets comprising mostly plants, and c diets in which animal foods are themselves the products, directly or ultimately, of pure plant foods—the composition of animal flesh and milk is as much influenced by diet as we are 31 —is noteworthy for its breadth, depth, diversity of methods, and consistency of findings.
The case that we should, indeed, eat true food, mostly plants, is all but incontrovertible. Perhaps fortuitously, this same dietary theme offers considerable advantages to other species, the environment around us, and even the ecology within us An important aspect of this message is that the same basic dietary pattern exerts favorable influences across a wide spectrum of health conditions.
The notions that some combination of foods or nutrients is most important to the prevention and management of diabetes whereas another is most important to cardiovascular disease never made much sense and was very impractical: Given that people with diabetes are at heightened risk of cardiovascular disease, which should they choose?
The literature strongly supports a common set of dietary principles for health promotion and the prevention, or management, of virtually all prevalent conditions in modern societies.
In this context, guidance that places an exaggerated emphasis on any one nutrient or food is ill advised 86 , The message that there is a clearly established theme of healthful eating, relevant across generations, geography, and health concerns could, theoretically, exert a considerable and advantageous influence on public nutrition. This message, however, is at present a relatively feeble signal lost in a chorus of noise. In pursuit of marketing advantage, notoriety, or some other bias, the defenders of competing diets tend inevitably to emphasize their mutual exclusivities.
This pattern conforms well with prevailing media practices 82 , 92 , and the result is perpetual confusion and doubt.
Both the scientific literature and consideration of indelible links between native diet and adaptation for all species including our own lead to the conclusion that a diet of foods mostly direct from nature and predominantly plants is supportive of health across the life span. If as a society we were genuinely interested in consensus about the best dietary pattern, rather than a never-ending parade of beauty pageant contestants, the compatibilities and complementarities of all reasonable candidates for best diet would be fairly evident Figure 1.
Even if the dietary destination were clearly and uniformly espoused, however, there would still be the challenges involved in getting there from here. The average supermarket in the United States offers in excess of 40, products, the majority of which are processed foods in bags, boxes, bottles, jars, and cans—virtually all of which sport marketing messages, many pertaining to health. Additional marketing messages populate pages, airwaves, and cyberspace 22 , 26 , 57 , For better or worse, there may be a need for nutritional analogs to GPS to traverse the foodscape and arrive at good health Ultimately, diets are made up of foods.
Unlike a whole dietary pattern, which needs to be constructed over time, a food selection is a discrete choice that can be made at a given time.
There is thus a potential practical advantage in dietary guidance directed at the level of either-or food selections. Among the better known of such tools is the Weight Watchers point system, originally pertaining only to calories but revised to incorporate salient considerations of nutritional quality Another, developed by a team including the author, was specifically designed to stratify foods on the basis of overall nutritional quality for purposes of health promotion 27 , 93 , 94 and has proven in some cases to be a potent contributor to weight loss Other such systems exist in the United States and around the world The potential utility of validated tools to guide food choice, combined with consistent messages about the theme of healthful eating, could represent a powerful combination in the service of public nutrition.
The clutter of competing claims likely obscures the established body of knowledge and forestalls progress, much like the proverbial trees and forest 76 , This problem is particularly acute in the United States, where life expectancy lags behind that of other developed countries, and health expectancy that much more so Public health objectives related to nutrition could almost certainly be facilitated by widespread endorsement of the basic theme of what we truly do know to be healthful eating, a candid acknowledgment of the many details we simply do not know, and a concerted effort to do all that is needed to help people get there from here.
The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review.
A study in the United States showed that the substitution of dietary carbohydrate for dietary protein increased the risk of hypertension, lipid disorders, and year coronary heart disease risk 6. Willett 1,3 and Meir J.
Substituting protein or monounsaturated fat for carbohydrate reduces blood pressure and improves blood lipids Wilmot, 1,2 Nima Ghasemzadeh, 1,2 Daniel L. Gongora, 1,2 Arshed A. Quyyumi, 1,2 and Laurence S.
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A plant-based diet is associated with higher fasting plasma ascorbic acid concentrations and antioxidant status in addition to lower cholesterol, improved glycemic control, and lower blood pressure in adults 6, 68, Chan, 2 and Christos S. Bastian et al. Hjorth , 1 Yishai Zohar , 2 James O. Higgins, 2 Ashley G. Jacobs, 1 Breanna M. McArthur, 2 Benjamin W. Redan, 1 Rebecca L. Rivera, 1 Leigh R. Schmidt, 2 and Richard D. Schork 1,2,3 and Laura H. Some of the more obvious measures include body weight and body composition e.
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