Nutrition—An Evidence-Based,

Practical Approach to Chronic

Disease Prevention and
Treatment
Michelle E. Hauser, MD, MS, MPA, FACP, FACLM, DipABLM; Michelle McMacken, MD, FACP, DipABLM;
Anthony Lim, MD, JD, DipABLM; Paulina Shetty, MS, RDN, DipACLM
doi: 10.12788/jfp.0292

CASE STUDY short-term, but no long-term, weight loss and did little to
At an annual visit, Mr. S, a 58-year-old man with a history improve his other medical concerns. How does one counsel
of class III obesity, hypertension, and prediabetes, asks him?
what diet changes he can make to help him lose weight and
improve his other medical conditions. He reports trying many
weight-loss diets over the years, including low-carbohydrate INTRODUCTION
and various calorie-restricted diets. All resulted in modest This patient’s story represents a common clinical scenario
faced by many primary care providers (PCPs)—one that
medical school, residency, and other training have generally
Michelle E. Hauser, MD, MS, MPA, FACP, FACLM, DipABLM1-4
not adequately prepared clinicians to address. The aims of
Michelle McMacken, MD, FACP, DipABLM5,6 this review are to provide an introduction to a whole-food,
plant-predominant eating pattern (a diet consisting pre-
Anthony Lim, MD, JD, DipABLM7
dominantly or exclusively of whole plant foods such as fruits,
Paulina Shetty, MS, RDN, DipACLM8 vegetables, legumes, whole grains, nuts, and seeds) and its
alignment with major medical societies’ dietary recommen-
AUTHOR AFFILIATIONS dations; illustrate a spectrum of dietary change along a con-
1
General Surgery, Department of Surgery, Stanford University tinuum from highly processed foods to less-processed plant
School of Medicine, Stanford, CA
foods; review current research to support a predominantly
2
Primary Care and Population Health, Stanford University School whole-food, plant-based (WFPB) dietary pattern for preven-
of Medicine, Stanford, CA
3
tion and treatment of cardiovascular disease, overweight and
Medical Service–Obesity Medicine, Veterans Affairs Palo Alto
Health Care System, Palo Alto, CA
obesity, and type 2 diabetes, as well as for cancer risk reduc-
4
tion; and provide practical guidance on promoting healthful
Internal Medicine–Primary Care, Fair Oaks Health Center, San
Mateo Medical Center, Redwood City, CA dietary changes in clinical practice.
5
Division of General Internal Medicine, Department of Medicine,
In his 2009 book, In Defense of Food, Michael Pollan
NYU Grossman School of Medicine, New York, NY famously advised to “eat food, not too much, mostly plants.”1
6
Department of Medicine, NYC Health + Hospitals / Bellevue, New This pithy recommendation reflects the overwhelming con-
York, NY sensus in the nutrition science literature: eating patterns that
7
Dr. McDougall Heath & Medical Center, Santa Rosa, CA emphasize whole, plant foods and minimize calorie-dense,
8
American College of Lifestyle Medicine, Chesterfield, MO highly processed foods are associated with significant reduc-
tions in chronic disease risk and mortality.2-6 Conversely,
DISCLOSURES high intake of sodium and low intake of whole grains, fruits,
The authors have no conflicts of interest to disclose. nuts, seeds, and vegetables are among the leading dietary

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risk factors for death and disability-adjusted life years world- diet, emphasizing nutrient-dense, fiber-rich, minimally pro-
wide.7 For these reasons, the American College of Lifestyle cessed plant foods, was linked to a 25% lower risk of coronary
Medicine (ACLM) recommends “an eating plan based pre- heart disease.4 In contrast, an unhealthful plant-based diet
dominantly on a variety of minimally processed vegetables, high in sweets, fried foods, refined grains, and added sugars
fruits, whole grains, legumes, nuts, and seeds.”8 was linked to a 32% increased risk of coronary heart disease.4
Predominantly WFPB eating patterns have grown in
popularity in recent years, while also being rooted in long-
standing cultural traditions from around the world, includ- CASE STUDY (CONT'D)
ing the so-called Blue Zones, populations with greater-than- Mr. S’s PCP is pleased that Mr. S expresses interest in improv-
average longevity.9 In contrast, Western-style diets (aka ing his diet and advises him about the benefits of a predomi-
Standard American Diet, or SAD) typically emphasize ultra- nantly WFPB dietary pattern for addressing his weight, high
processed foods made with added sugars and refined grains, blood pressure, and prediabetes. Mr. S asks about next steps.
as well as animal foods high in saturated fats such as meats
and high-fat dairy products. This Western dietary pattern is
associated with increased risks of mortality from cardiovas- EVIDENCE TO SUPPORT A PREDOMINANTLY
cular disease, cancer, and all causes compared with diets WHOLE-FOOD, PLANT-BASED EATING PATTERN
higher in whole, plant foods.10 Individuals are likely to expe- Cardiovascular Disease
rience health benefits from any progression they make along Healthful plant-based diets appear to confer significant pro-
the spectrum from a typical Western-style diet to one based tection against ischemic heart disease, the leading cause of
on less-processed plant foods (FIGURE 1). Of note, there are disability-adjusted life years globally among adults aged
many approaches to WFPB eating patterns; many diets stud- 50 years and older.17 A 2012 meta-analysis and systematic
ied in the scientific literature represent positive shifts along review of prospective observational cohorts (N=124,706)
a spectrum away from a SAD and toward more WFPB eating found a 29% lower risk of ischemic heart disease mortality
patterns. Evidence cited in this manuscript encompasses a among vegetarians compared with nonvegetarians.18 Simi-
variety of predominantly WFPB dietary patterns, including larly, a 2016 meta-analysis (N=72,298) found a 25% lower risk
entirely WFPB, healthy Mediterranean, Dietary Approaches of ischemic heart disease among vegetarians.19 Among a gen-
to Stop Hypertension (DASH), low-fat vegan, various types of eral population of 12,168 adults, having diets higher in plant
vegetarian, and numerous other plant-predominant recom- foods and lower in animal foods was associated with signifi-
mendations or guidelines. cantly lower risks of cardiovascular disease, cardiovascular
Dietary patterns centered around whole, plant foods disease mortality, and all-cause mortality (16%, 31%-32%,
are also in alignment with dietary recommendations from and 18%-25%, respectively).20
numerous organizations, including the American College of In clinical trials, plant-based diets have been shown to
Cardiology and the American Heart Association,11 the Amer- improve key cardiovascular risk factors, including serum lip-
ican Cancer Society,12 the American Institute for Cancer ids and hypertension. A 2015 meta-analysis of randomized
Research,13 the American Association of Clinical Endocrinol- trials found that vegetarian diets significantly lowered blood
ogists and American College of Endocrinology,14 and Health concentrations of total cholesterol, low-density lipoprotein
Canada.15 Moreover, the Academy of Nutrition and Dietet- (LDL) cholesterol, and non-high-density lipoprotein (non-
ics states that “appropriately planned vegetarian, including HDL) cholesterol (–13.9 mg/dL, –13.1 mg/dL, and –11.6 mg/
vegan, diets are healthful, nutritionally adequate, and may dL, respectively); the effect was even greater for vegan diets.21
provide health benefits for the prevention and treatment of The Portfolio diet, emphasizing plant-based foods, especially
certain diseases. These diets are appropriate for all stages of almonds, soy, plant sterols, and foods high in viscous fiber,
the life cycle, including pregnancy, lactation, infancy, child- reduced LDL cholesterol by 35%—significantly more than a
hood, adolescence, older adulthood, and for athletes.”16 control diet that was equally low in saturated fats but lacked
In considering predominantly plant-based diets, it is emphasis on these specific elements.22
similarly important to emphasize minimally processed foods. A wealth of literature supports the use of diets high in
For example, a number of studies have specifically high- whole and minimally processed plant foods for the preven-
lighted the distinction between healthful and unhealthful tion and treatment of hypertension, perhaps most notably
plant-based diets in chronic disease outcomes. In a large pro- the DASH trials. The DASH diet, which emphasizes whole
spective cohort study with 4.8 million person-years of follow- grains, fruits, and vegetables and limits sweets and red and
up (N=116,969), higher adherence to a healthful plant-based processed meats, was found to lower blood pressure sig-

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The ACLM Dietary Position Statement and the spectrum of dietary patterns from
FIGURE 1.
Standard American Diet to an entirely whole-food, plant-based plate

What We Eat in America (WWEIA) Food Category analyses for the 2015 Dietary Guidelines Advisory
Committee. Estimates based on day 1 dietary recalls from WWEIA, NHANES 2009 2010.
Tuso PJ Ismail MH, Ha BP, Bartolotto C. Nutritional update for physicians: plant-based diets. Perm J.
2013;17(2):61-66.
Food Planet Health. Eatforum.org. Published 2020. Accessed June 4, 2020

nificantly more than comparator diets (–5.5 mm Hg systolic, body weights, lower inflammation,30,31 reduced risk of type 2
–3.0 mm Hg diastolic).23 Modifications on the DASH diet may diabetes, lower blood pressure, and improvements in lipids,
further reduce blood pressure, including a low-sodium DASH endothelial function, and gut bacterial profiles.29 In addition,
diet24 and a plant-based diet rich in soy, nuts, and viscous fiber.25 proportionally high intake of protein from plant vs animal
Diets rich in whole, plant foods are also important for sources has been inversely associated with cardiovascular
secondary prevention of cardiovascular disease. These diets and all-cause mortality.32-35
are an integral component of successful cardiac rehabilita-
tion programs that include diet, exercise, stress reduction, and Overweight and Obesity
group support and aim for comprehensive lifestyle change.26 Plant-based diets are associated with lower body mass
Additionally, the DASH and Mediterranean diets have been indices (BMIs).36 In a cross-sectional analysis of baseline
shown to improve secondary prevention of heart failure.27 data from the Adventist Health Study-236 (N=60,903), par-
Plant-based diets promote heart health by multiple ticipants’ diets were classified as vegan, lacto-ovo vegetar-
potential mechanisms. First, they are higher in beneficial ian, pesco-vegetarian, semi-vegetarian, and nonvegetar-
nutrients such as fiber, unsaturated plant fats, potassium, and ian. These categories were associated in a stepwise fashion
antioxidants, and lower in potentially harmful nutrients such with progressively higher unadjusted mean BMIs, from
as cholesterol,28 heme iron, saturated fats, and nitrite preser- 23.6 kg/m2 for vegan to 28.8 kg/m2 for nonvegetarian diets
vatives.29 Second, plant-based diets are linked to healthier (P<0.0001).

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Interventional studies have similarly shown that plant- type 2 diabetes among those whose diets emphasized health-
based diets of varying types can be used for weight loss— ful plant foods including fruits, vegetables, whole grains,
often more effectively than those higher in non-plant foods. legumes, and nuts, despite adjustments for key diabetes risk
A meta-analysis of interventional studies comparing weight factors including BMI.43
loss between those assigned to vegetarian vs nonvegetarian Plant-based diets have also been shown to be effective
diets showed greater weight reduction in the vegetarian diet for the treatment of type 2 diabetes. A 22-week randomized
arms.37 Subgroup analyses of the vegetarian diets showed trial (N=99) compared a low-fat, plant-based diet with a con-
significantly greater weight loss for those following vegan vs ventional calorie-reduced ADA diet.44 In the plant-based
lacto-ovo vegetarian diets.37 In the BROAD study,38 adults with group, 43% of participants were able to reduce their diabe-
overweight or obesity, and diabetes, ischemic heart disease, tes medications, compared with 25% in the conventional
hypertension, or hyperlipidemia, were randomly assigned to group. Among participants whose medications were stable,
either an intervention arm including group education about a those assigned to a low-fat, plant-based diet experienced sig-
low-fat, non-energy-restricted, WFPB diet or a control arm for nificantly greater improvements in glycemic control (HbA1c
6 months, both of which otherwise received usual care.38 The change, –1.23% vs –0.38%; P=0.01). An additional 52 weeks
plant-based intervention group experienced clinically and of follow-up (total follow-up of 74 weeks) demonstrated sus-
statistically significant improvements in BMI (–4.4 vs –0.4 kg/ tained improvements in glycemic control and lipids for the
m2; P<0.0001) as well as hemoglobin A1c and waist circum- plant-based group compared with the conventional group in
ference, compared to the control group.38 In the 2013 Ameri- analyses controlling for medication changes.45 A 2014 meta-
can College of Cardiology/American Heart Association/The analysis of controlled clinical trials found that vegetarian
Obesity Society Guideline for the Management of Obesity, an diets were associated with a statistically significant reduction
expert panel reviewed available evidence to establish guide- in HbA1c (–0.39 percentage points; 95% confidence inter-
lines for the treatment of obesity and listed a variety of dietary val: –0.62 to –0.15; P=0.001), compared with consumption of
approaches rich in plant foods, including low-fat vegan-style comparator diets.46 A plant-based diet has also been shown
diets without formal prescribed energy restriction and lacto- to reduce symptoms of diabetic neuropathy.47,48
ovo vegetarian and Mediterranean-style diets with prescribed
energy restriction, as having high levels of evidence to support Cancer Risk Reduction
their use as diets effective for weight loss.39 The American Cancer Society publishes diet and physical
activity guidelines to reduce cancer risk on the basis of expert
Type 2 Diabetes Prevention and Treatment review of evidence.12 In addition to controlling weight, achiev-
A predominantly plant-based dietary pattern has been rec- ing adequate physical activity, and eliminating or limiting
ommended by the American Association of Clinical Endocri- alcohol intake, dietary recommendations align with a pre-
nologists as the preferred dietary strategy for individuals with dominantly WFPB dietary pattern, including recommenda-
type 2 diabetes40 and by the American Diabetes Association tions to eat ample whole grains and a rainbow of fruits and
(ADA)41 as a healthful dietary option. Plant-based diets are vegetables and to limit intake of red and processed meat,
associated with markedly lower prevalence and incidence added sugars, highly processed foods, and refined grain prod-
of type 2 diabetes, even after adjustments for BMI and non- ucts. The report also cites evidence reviewed in the Dietary
dietary lifestyle factors. In the Adventist Health Study-2, veg- Guidelines for Americans49 and the American Institute for
ans and vegetarians had approximately half the odds of hav- Cancer Research50 that dietary patterns rich in plant foods
ing type 2 diabetes compared with nonvegetarians.36 In the and low in animal products and refined carbohydrates are
same population, among 41,387 adults followed for 2 years, associated with lower risks of breast and colorectal cancer.
the risk of developing type 2 diabetes was 62% lower for veg- Conversely, even small amounts of processed meat and mod-
ans, and approximately 40% to 50% lower for lacto-ovo and erate amounts of red meat are associated with increased risk
semi-vegetarians, compared with nonvegetarians.42 of colorectal cancer.50 Maintaining a healthy weight is also of
Furthermore, multiple studies have demonstrated a great importance in reducing risk of 13 common types of can-
significantly lower risk of type 2 diabetes among individuals cers51; 40% of all cancers in the United States are associated
who consume diets rich in healthful plant foods and low in with overweight and obesity.52 As noted previously, those eat-
highly processed and animal foods, but who are not neces- ing predominantly plant-based diets are more likely to have a
sarily vegan or vegetarian. A 2019 meta-analysis of 9 stud- healthy body weight than those who are not, and plant-based
ies including more than 300,000 participants from North dietary strategies can be effectively used for weight manage-
America, Europe, and Asia reported a 30% decreased risk of ment in addition to conferring other health benefits.

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CASE STUDY (CONT'D) method for ascertaining the patient’s current dietary quality,
Mr. S is presented a range of options for dietary changes potential concerns about diet/weight, and level of interest in
that incorporate more whole, plant foods. These recom- making related changes. An example of a questionnaire that
mendations range from small steps such as adding 1 to 2 can be used is the Starting The Conversation (STC) nutrition
additional servings of produce to his diet each day, to doing assessment, which is an 8-item, simplified food frequency
a 21-day plant-based challenge of eating an entirely WFPB instrument designed for primary care and health-promo-
diet. Mr. S reflects that he has not been successful with tional settings.58
incremental changes in the past and thinks he’ll be more If time allows, it can be helpful to further use the tools
motivated to continue if he sees a larger impact on his health of motivational interviewing, “a collaborative, person-cen-
more quickly, so he decides to make a bigger change and tered form of guiding to elicit and strengthen motivation for
take on the 21-day challenge. The PCP praises him for his change.”59,60 This could include asking the patient to rate on
determination and arranges a follow-up visit with him in 1 a scale of 1 to 10 both the importance of making a change
month. and their confidence level in making said change. One might
further ask a patient what it would take to move from their
selected number to a higher number in order to give insight
PRACTICAL ADVICE FOR ADDRESSING DIETARY into perceived barriers and to make plans to address them, if
BEHAVIOR CHANGE IN CLINICAL PRACTICE possible. Regardless of the amount of time spent on assess-
Effectively counseling on behavioral lifestyle changes can ing, starting with an area a patient has already identified as
be challenging, especially given the time constraints faced an issue and one they’re interested in changing is one of the
by PCPs and the limited training on this topic offered in tra- best ways to make sure the time a clinician spends on behav-
ditional medical training. The 5 A’s (Assess, Advise, Agree, ioral counseling is as high-yield and effective as possible.
Assist, Arrange) behavioral counseling framework, originally A patient may also have other life challenges or priorities a
developed by the National Cancer Institute to assist with PCP might be unaware of that take precedence over mak-
smoking cessation, is increasingly being used by PCPs to ing dietary changes. In that case, it is likely better to focus on
encourage behavior change among patients with overweight what matters most to the patient and save a discussion of diet
and obesity.53 It is the model referenced by the US Preventive for a future office visit.
Services Task Force (USPSTF),54 and is also the model used
by Medicare for intensive behavior therapy for obesity.55 The Advise
model is simple, easy to remember, and can be performed Once it is established that diet and/or weight is a priority for
as a staged process over several visits, making it feasible to a patient, the next step is to advise the patient about their
incorporate in most office visit settings.53 For these reasons, specific health risks related to diet/weight and the potential
we recommend providers use this framework as a starting health benefits of moving toward a predominantly WFPB
place when counseling patients to take steps to move along dietary pattern. Focusing on what is motivating to each indi-
a spectrum toward adopting a predominantly WFPB eating vidual is particularly helpful. For example, younger patients
pattern. may be more interested in performance or benefits to appear-
In addition to counseling on dietary and other healthy ance, whereas middle-aged and older patients may be more
behavior changes, it is important for physicians to also be role interested in disease prevention, treatment, or remission. If
models of good health.56 Patients perceive physicians who a patient has metabolic disease for which they take medica-
practice healthy lifestyles themselves as more credible and tion, such as type 2 diabetes or hypertension, emphasizing
better able to motivate them to make healthy lifestyle choices that a predominantly WFPB dietary pattern can help them
than those who do not.57 Adopting a WFPB eating pattern and lose weight, improve their blood glucose and blood pressure,
leading a healthy lifestyle oneself will increase credibility and and reduce or eliminate medications can be particularly
efficacy with one’s patients when it comes to effecting behav- motivating. Additionally, make sure it is clear that the goal is
ior lifestyle changes. dietary changes that can be maintained long-term, because
short-lived fad, or crash, diets are of limited utility and can
Assess even be harmful.61,62
The first step of the 5 A’s framework as it relates to dietary Physicians typically receive very limited education on
intake and related behavioral lifestyle changes is to assess nutrition and weight management in medical school and
whether diet and/or weight is a priority for the patient. Hav- postgraduate training and, as a result, report inadequate
ing patients fill out a previsit questionnaire is an efficient nutrition knowledge and low self-efficacy when counseling

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TABLE 1. Making goals into SMART goals

Example of non-SMART goal Example of SMART goal
I will eat more fruits and vegetables. By the end of next week, I will increase my daily fruit and
vegetable intake from 0 servings per day to 3 servings per
day.
I will decrease the amount of soda that I drink. Over the next 2 weeks, I will decrease my soda intake from
two 12-oz cans per day to one 12-oz can per week.
I will learn how to make home-cooked plant-based meals. During the next 4 weeks, I will use a specific cooking blog to
learn and prepare 1 plant-based recipe per week at home.
SMART, Specific, Measurable, Achievable, Relevant, Time-Bound.

TABLE 2. Foods to emphasize

Category Examples
Vegetables Leafy vegetables (eg, kale, spinach, romaine, Swiss chard, collard greens, cabbage), garlic, onions,
peppers, leeks, parsnips, potatoes, radishes, turnips, squashes, green beans, tomatoes, carrots, corn,
peas, cauliflower, broccoli, cucumbers, eggplant, mushrooms
Fruits Apples, bananas, kiwi, oranges, blackberries, strawberries, raspberries, blueberries, mango, cantaloupe,
watermelon, honeydew, plums, pineapple
Legumes Black beans, kidney beans, pinto beans, garbanzo beans, cannellini beans, lentils, lima beans, fava beans,
soybeans
Whole grains Quinoa, brown rice, oats, barley, wild rice, black rice, whole-grain tortillas/pasta/breads, whole-grain
couscous, millet, teff
Nuts Almonds, peanuts, pistachios, cashews, Brazil nuts, soy nuts, hazelnuts, walnuts
Seeds Chia seeds, flax seeds, hemp seeds, pumpkin seeds, sunflower seeds

patients about diet and weight management.63,64 Thus, the be helpful to, again, use the 1 to 10 scale for confidence in
more that a PCP learns about the benefits of predominantly achieving the next component of a goal. If a patient rates their
WFPB dietary patterns for chronic, noncommunicable dis- confidence as lower than a 7 out of 10, ask what it would take
eases, such as obesity, cardiovascular disease, diabetes, to increase confidence to a 7 or greater. If this is a barrier that
hypertension, and many cancers, the better equipped they can be addressed, help them make a plan to address it; if not,
will be to advise patients on how to improve their dietary a more feasible action plan should be selected.64
behaviors.
Assist
Agree After agreeing upon a SMART goal or specific action plan for
This step involves helping a patient identify and agree to spe- a larger goal, clinicians should assist patients in achieving
cific steps they plan to take toward achieving their specific their objectives whenever possible. This can be done simply
dietary change goal(s). Asking a patient how they feel about via a variety of formats and methods in typical clinical set-
where they are now and where they’d like to be at discrete tings. Below are a few examples of ways to provide assistance
times in the future can help a provider to better understand a to patients:
patient’s short- and long-term goals. One way to assist patients • Handouts: Provide handouts regarding the benefits
in making changes is by using SMART goals (TABLE 1).65 With of predominantly WFPB dietary patterns and how-
SMART goals, patients can practice making goals that are to articles (eg, sample meal plans, grocery lists, tips
specific, measurable, achievable, relevant, and time-bound.66 on eating out or batch cooking, etc) that show simple
When striving for larger, long-term, or more difficult goals, steps patients can take to improve their diets. These
make sure to build in smaller, easier-to-achieve, short-term can help increase interest and confidence in making
components of the goal (ie, an action plan) so the patient can dietary changes while patients are waiting to be seen
frequently experience a sense of achievement during the pro- and are easy to take home when they leave. TABLE 2
cess. This helps to foster confidence and maintain momen- lists categories of foods to emphasize along with exam-
tum and motivation toward achieving the larger goal. It can ples; FIGURE 2 illustrates relative proportions of these

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FIGURE 2. ACLM whole-food, plant-based plate

The WFPB plate shows relative proportions of whole and minimally processed plant foods within their respective food categories. Following
this plate method helps to ensure adequate intake of nutrients and a balanced diet. Refer to TABLE 2 for examples of foods, and TABLE 3 for
more details about nutrient intake.

foods to recommend; and TABLE 367-70 reviews nutrients and Resources webpage to explore evidence-based tools
to consider in a WFPB eating pattern. and resources for physicians, health professionals, and
• Multimedia: Learning is enhanced with multiple modal- patients.71 TABLE 4 indicates additional resources (some
ities, and learners sometimes prefer formats other than available publicly, others to ACLM members only).
reading. Therefore, consider providing or recommend- • Referral for additional support: Refer patients to
ing videos, podcasts, audiobooks, documentaries, appropriate clinician or allied health professional sup-
books, or other multimedia resources that patients can port (eg, a Certified Diabetes Care and Education Spe-
use to explore adopting dietary behavior changes. cialist [CDCES], registered dietitian, behavioral medi-
• ACLM Tools and Resources: Go to the ACLM Tools cine psychologist, or weight management specialist).

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TABLE 3. Plant-based sources of selected nutrients67

Nutrient Food sources
Protein Beans, lentils, peas, nuts, seeds, tofu, tempeh
Carbohydrate Fruits, starchy vegetables, whole grains, legumes
Fat Nuts, seeds, avocado, olives
Fiber Fruits, vegetables, whole grains, legumes, nuts and seeds
Omega-3 fatty acids Chia seed, ground flaxseed, walnuts, soybeans, tofu, tempeh, algae-based omega-3 supplement
Fortified plant milks, low-oxalate leafy greens (such as broccoli, bok choy, cabbage, collard
Calcium
greens, kale, watercress), calcium-fortified tofu, almonds, sesame seeds, figs, and molasses
Iron Beans, lentils, peas, nuts, leafy greens, soybeans, quinoa, dried fruit
Vitamin B12 Fortified plant milks, nutritional yeast, cyanocobalamin supplement68-70*
*Vitamin B12 supplement is recommended for individuals who consume no animal-based foods.

TABLE 4.Suggested tools and resources for predominantly whole-food,

plant-based dietary patterns
Resource type Name of resource
Foundations of Lifestyle Medicine Board Review Course (lifestylemedicine.
org/boardreview)
CME/CE online courses Lifestyle Medicine Core Competencies (lifestylemedicine.org/lmcc)
Food as Medicine for Medical Professionals (lifestylemedicine.org/food-
as-medicine)
LM 101 Curriculum (lifestylemedicine.org/lm101)
Academic and patient-facing curriculum
Culinary Medicine Curriculum (lifestylemedicine.org/culinary-medicine)
Benefits of Plant-Based Nutrition White ACLM Public-Facing (or Open-Source) Tools and Resources
Paper Series (lifestylemedicine.org/plant-based-nutrition)
ACLM Public-Facing (or Open-Source) Tools and Resources
Patient-facing tools and resources
(lifestylemedicine.org/tools)
Clinical validated assessment tools and ACLM Members-Only Portal
resources
Lifestyle Medicine Shared Medical ACLM Members-Only Portal
Appointment Toolkit

For example, if a patient has a history of diabetes, it nutrition, cooking, and food purchasing and acquisi-
could be very helpful for the patient to meet with a tion skills emphasizing predominantly WFPB dietary
registered dietitian/CDCES to better understand how patterns. This can be a useful way to share WFPB eat-
shifting to a more plant-based, less processed diet ing in ways specific to different cultural food practices.
can affect blood glucose and medication use. For a Additional potential benefits of group-based classes
patient who identifies emotional eating as a barrier are community building, developing peer support net-
to making dietary changes, a behavioral medicine works, and increasing accountability. Interactive cook-
psychologist can aid them in distinguishing physi- ing classes wherein patients learn to cook and sample
ological from psychological hunger and help them various plant-based dishes are especially useful for
develop strategies and techniques for minimizing building skills and confidence in the kitchen.
the latter.72
• Recommend classes and educational opportuni- Arrange
ties: Provide patients with a list of classes available The next step is to arrange follow-up. Patients making dietary
within your health system or community that teach and other lifestyle changes initially require frequent check-

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ins. As these changes become more ingrained in a patient’s OTHER CONSIDERATIONS RELATED
routine, check-ins can gradually be spaced further apart TO DIETARY CHANGES
over time. These check-ins can be done in person and/or as There are numerous factors beyond nutrition knowledge
synchronous telehealth visits by video or phone with vari- and food choices that affect dietary intake. Many of these are
ous members of the healthcare team. Some practices and mentioned in the sidebar (“Factors Beyond Nutrition Knowl-
systems also have means of asynchronously checking in edge That Affect Dietary Choices”). Others, related to social
such as texting or secure email messaging. Using different determinants of health, food insecurity, and cultural prac-
team members and different modalities is important for a tices and cooking in families, are briefly addressed below.
variety of reasons, including but not limited to time con-
straints of the busiest team members, adding different per- Social Determinants of Health
spectives and expertise that may be useful to patients, and For many, cost and access can be barriers to healthy eat-
more flexible scheduling to meet patient scheduling needs. ing. Although the relatively low-calorie density of a healthful
Using telehealth, texting, or emailing also reduces travel, plant-based diet can be beneficial in maintaining a healthy
time, and financial burdens for patients who might not oth- weight while feeling satiated, it can make it difficult for some
erwise be able to attend frequent appointments. with very limited food budgets to achieve adequate caloric
Many practices leverage shared medical appointments, intake. This is because foods higher in nutrient density, such
otherwise known as group visits, for check-ins as well. Group as fruits and vegetables, are associated with higher per-cal-
visits have additional benefits such as providing peer support orie costs than refined grains and sweets.75 In addition, the
and giving patients and providers time to address knowledge, investment in equipment necessary for cooking, as well as
attitudes, and behaviors around making lifestyle changes. access to a kitchen, may be obstacles for some individuals.
They also allow time to check in on medical conditions, order However, those with even a modest food budget can eat a
laboratory tests/studies, and ensure appropriate preventive predominantly WFPB diet—if they know how to cook, meal
health services are provided in a timely manner. For more plan, and have access to a kitchen.76 For example, among
information on starting shared medical appointments in your the 3 Healthy Food Patterns recommended in the 2015-2020
practice, ACLM offers a Lifestyle Medicine Shared Medical Dietary Guidelines for Americans,49 the Healthy Vegetarian
Appointment Toolkit, which includes a helpful guide; infor- dietary pattern was found to be $2.37 and $2.87/day/person
mation on coding, billing, and virtual group visits; webinars less expensive than the Healthy US Style and Healthy Medi-
on shared medical appointments; sample consent forms; a terranean Style dietary patterns, respectively.77 Additionally,
marketing flyer template; and more.73,74 within this analysis, legumes, whole grains, nuts, seeds, and
soy were found to be far more economical per kilocalorie
than dairy, meat, poultry, eggs, and seafood.77
CASE STUDY (CONT'D)
One month later, Mr. S presents for a follow-up visit. He Food Insecurity
reports that the 21-day challenge of eating only plant-based To this end, it is important to identify patients with food
foods went very well and he feels more energetic and health- insecurity, defined by the US Department of Agriculture as
ier than he has in years. When choosing less-processed and the lack of consistent access to enough food to live a healthy
higher-fiber foods, he notices that he feels more satiated and active life.78 This is quick and easy to do using the vali-
and is relieved he no longer needs to spend time trying to dated 2-question Food Insecurity Screener.79 In many com-
count calories. Instead, he now works on choosing appro- munities, there are a variety of resources and services that
priate portion sizes, paying more attention to hunger cues, can be used to increase access to free, healthy food for those
and trying to use non-food rewards for his successes. in need. In the United States, these include federal govern-
Vital signs are reviewed with Mr. S; he has lost 10 ment programs (such as the Supplemental Nutrition Assis-
pounds and his blood pressure is now low enough to stop tance Program [SNAP] and the Special Supplemental Nutri-
1 of his 2 antihypertensive medications. Mr. S feels a 9 out tion Program for Women, Infants, and Children [WIC]), food
of 10 level of confidence that he can continue the lifestyle bank programs associated with Feeding America (search
changes he has made, so follow-up appointments are https://www.feedingamerica.org/ for the location nearest
extended in 3-month intervals for the next year to help pro- you), market match programs associated with farmers mar-
vide support and encouragement and to monitor his health kets in selected locations that give participants double their
conditions, especially any need for further reduction in SNAP dollars in vouchers for fresh produce, and many others.
medications. Additionally, there has been an increase in the availability of

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NUTRITION

FACTORS BEYOND NUTRITION KNOWLEDGE THAT AFFECT DIETARY CHOICES

Behavioral Health and Behaviors
• Trauma or abuse history, post-traumatic stress disorder (PTSD), depression, anxiety, substance use, chronic stress
• Binge eating disorder, anorexia, bulimia, other disordered eating, emotional eating/psychological hunger
• High intake of ultra-processed foods, especially refined grains and added sugars
Sleep and Pulmonary
• Untreated/undertreated obstructive sleep apnea, obesity hypoventilation syndrome, insomnia, poor sleep hygiene
Genetics
Neurologic
• Restless leg syndrome, dementias, traumatic brain injuries, neuromuscular disorders, seizure disorders, migraines,
idiopathic intracranial hypertension
Digestive-Gastrointestinal
• Gastroesophageal reflux disease, irritable bowel syndrome, gastroparesis, history of bariatric surgery, inflammatory
bowel disease, nausea, other gastrointestinal causes
• Microbiome
Endocrine
• Hypo-/hyperthyroidism, diabetes, elevated cortisol states/conditions, hypogonadism, other hormone derangements
Severe Medical Disease and Related Treatments
• Poor appetite associated with severe medical conditions such as heart failure, cirrhosis, and end-stage renal
disease
• Cancer and side effects of cancer treatments
Pregnancy and Lactation
Aging and Related Changes in Sense of Taste and Appetite
Medication Side Effects
• Some medications in the following classes affect dietary intake and can contribute to weight gain: tricyclic
antidepressants, selective serotonin reuptake inhibitors (SSRIs), antipsychotics, antiepileptics, beta blockers,
insulin, sulfonylureas, thiazolidinediones, corticosteroids, steroids, antihistamines
• Some medications affect dietary intake and can contribute to weight loss: bupropion, topiramate, zonisamide,
venlafaxine, desvenlafaxine, stimulant medications or drugs, naltrexone, glucagon-like peptide-1 (GLP-1) agonists,
sodium-glucose cotransporter-2 (SGLT2) inhibitors
Socioeconomic Status, Food Insecurity, and Food Access
Food and Family Traditions and Foodways, Cultural Traditions, and Religious Beliefs/Practices
Culinary Skills/Literacy, Kitchen Access, and Physical Limitations to Cooking
Built Environment and Food Environment

food pharmacies—dispensaries that give or sell healthy food behavior changes. We are all influenced by our cultures
upon receipt of a prescription from a healthcare professional of origin and the people who surround us. Taking time to
for the treatment or prevention of food-related disease. Some learn about the cultural food traditions of your patients can
of these services and organizations also offer cooking classes, assist in tailoring recommendations, such as by recom-
tips, and recipes. For patients with limited food preparation mending familiar plant foods, healthy cooking techniques,
experience, providing support for improving these skills is an or local groceries and food establishments. Most cuisines
important step in making healthy dietary changes.80 can be tailored to focus on healthier aspects without exclud-
ing traditional foods entirely, and many traditional cuisines
Cultural Factors and Families are healthier than modern, ultra-processed, and fast-food
Considering cultural factors and influences is another essen- options.76 Additionally, given that plant-based diets are
tial element in partnering with patients in making dietary healthful, adequate, and appropriate for all stages of life,16

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 NUTRITION

encourage patients to engage their households in making ACLM offers lifestyle medicine and nutrition-related continu-
healthy dietary changes; when changes are a family affair, ing medical education opportunities through online educa-
they are more likely to be maintained. ACLM offers many tional courses including the Foundations of Lifestyle Medicine
pediatric-focused resources,71 and more tips on assisting oth- Board Review, Lifestyle Medicine Core Competencies, Food
ers in making dietary behavior changes can be found in the as Medicine courses, and events such as the ACLM annual
Culinary Medicine Curriculum.76 conference and more that can be accessed at lifestylemedi-
cine.org/education.81 In becoming familiar with the evidence
supporting predominantly WFPB eating patterns and adopt-
CASE STUDY ing effective techniques to support dietary behavior changes,
Mr. S follows up 1 year after first being advised on dietary healthcare providers have the potential to significantly reduce
behavior changes—specifically, the recommendation to the burden of chronic disease in their patient populations. l
move toward a predominantly WFPB dietary pattern. During
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