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Clinical Guide to
Popular Diets
Clinical Guide to
Popular Diets

Edited by
Caroline Apovian
Elizabeth Brouillard
Lorraine Young
Cover design concept created by Mary-Catherine Stockman, RD, LDN

CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

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Library of Congress Cataloging–in–Publication Data

Names: Apovian, Caroline M., editor. | Brouillard, Elizabeth, editor. |

Young, Lorraine (Physician), editor.
Title: Clinical guide to popular diets / [edited by] Caroline Apovian,
Elizabeth Brouillard & Lorraine Young.
Other titles: Popular diets
Description: Boca Raton : CRC Press, Taylor & Francis Group, 2018.
Identifiers: LCCN 2017048956 | ISBN 9781498774307 (pbk.)
Subjects: LCSH: Reducing diets--Evaluation.
Classification: LCC RM222.2 .C51945 2018 | DDC 613.2/5--dc23
LC record available at https://lccn.loc.gov/2017048956

Visit the Taylor & Francis Web site at

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Contents
Introduction...............................................................................................................vii
Editors........................................................................................................................ix
Contributors...............................................................................................................xi

Chapter 1 The Atkins Diet..................................................................................... 1

Laura E. Matarese and Glenn K. Harvin

Chapter 2 DASH Diet.......................................................................................... 15

Thomas J. Moore, Megan Murphy, and Lin Pao-Hwa

Chapter 3 iDiet..................................................................................................... 35
Susan B. Roberts, Amy Krauss, Madeleine M. Gamache,
and Sai Krupa Das

Chapter 4 The Mediterranean Diet...................................................................... 53

Sally M. Cohen

Chapter 5 The Paleo Diet..................................................................................... 71

Laura Andromalos

Chapter 6 The South Beach Diet......................................................................... 87

Meghan Ariagno

Chapter 7 Vegan Diets.........................................................................................99

Sai Krupa Das, Micaela C. Karlsen, Caroline Blanchard,
and Susan B. Roberts

Chapter 8 The Weight Watchers Diet................................................................ 113

Megan Barnett

Chapter 9 The Zone Diet................................................................................... 127

Catherine Fanning

Index....................................................................................................................... 141

v
Introduction
As most clinicians know obesity rates continue to rise, with the most recent NHANES
data, from 2011–2014, indicating that 36.5% of US adults are considered obese.1 The
health risks of obesity are well researched and documented, including type 2 diabe-
tes, cardiovascular disease, hypertension, stroke, gallbladder disease, osteoarthritis,
sleep apnea, and some types of cancer.2 Modest weight loss of 5%–10% has been
shown to significantly improve obesity-related conditions.3 The physiology behind
obtaining this weight loss is a negative energy balance, however, the diet macronutri-
ent composition for the best results is still debated. The American Heart Association,
American College of Cardiology, and The Obesity Society performed a systemic
review of the literature and found that of the 17 diets with varying macronutrient
composition that have been studied, no diet was superior for weight loss or weight
maintenance. However, the biggest predictor of weight loss was determined to be
adherence to a diet.2 As a clinician, many patients may look to you to recommend
a diet program. Since no one diet has demonstrated superiority, it is important to
understand the available diet plans on the market in order to guide your patients to
the diet right for them; one they will be able to incorporate into their lifestyle for
long-term success.
This book will provide you with a non-biased review of several popular diets that
have been available and marketed for many years. The diets in this review include
The Atkins Diet, The DASH (Dietary Approaches to Stop Hypertension) Diet, the
iDiet, the Mediterranean Diet, Paleo Diets, South Beach Diet, vegetarian diets,
Weight Watchers, and the Zone Diet. Each chapter will give you an overview of the
diet, explain how the diet works, provide current research, illustrate typical results,
list the pros and cons of the diet, and suggest patients that would benefit most from
each diet. Our goal with this book is to assist you in guiding your patients to choose
a diet that is most appropriate for them and one they will be able to follow for long-
term results.

REFERENCES
1. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics
(NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD:
U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention; 2016. https://www.cdc.gov/nchs/data/factsheets/factsheet_nhanes.htm
2. Jensen M, Ryan D. et al. 2013 AHA/ACC/TOS guideline for the management of over-
weight and obesity in adults. A report of the American College of Cardiology/American
Heart Association. J AM Coll Cardiol 2014;63(25):2985–3023.
3. National Institutes of Health, National Heart, Lung, and Blood Institute. Obesity
Education Initiative. Clinical guidelines on the identification, evaluation, and treatment
of overweight and obesity in adults. Obes Res 1998;6(Suppl 2):51S–210S.

vii
Editors
Caroline Apovian, MD, FACP, DABOM, is professor of Medicine and Pediatrics,
in the Section of Endocrinology, Diabetes, and Nutrition at Boston University
School of Medicine, USA. She is also director of the Center for Nutrition and Weight
Management at Boston Medical Center, USA. Dr. Apovian is a nationally and inter-
nationally recognized authority on Nutrition and Obesity Medicine and has been in
the field of Obesity and Nutrition since 1990. Her current research interests are in:
weight loss and its effects on endothelial cell function obesity and cardiovascular
disease, adipose cell metabolism and inflammation, resolution of diabetes and car-
diovascular disease in the bariatric surgery population, disparities in the treatment
of obesity in underserved populations, and novel pharmacotherapeutic anti-obesity
agents. She is also an expert in the technique for subcutaneous adipose tissue biop-
sies, and has been studying the relationship between adipose tissue inflammation and
obesity for over 10 years. Dr. Apovian was a member of the expert panel for updating
the 2013 AHA/ACC/TOS Clinical Guidelines for the Management of Overweight
and Obesity in Adults, published in Circulation and Obesity journals and was the
Chair of the Endocrine Society guidelines for Medical Treatment of Obesity pub-
lished in the Journal of Endocrinology and Metabolism in 2015.
Dr. Apovian was a recipient of the Physician Nutrition Specialist Award given
by the American Society of Clinical Nutrition. This was for her work on developing
and providing nutrition education to medical students and physicians in training at
Boston University School of Medicine. She has published over 200 original peer-
reviewed articles, chapters, and reviews on the topics of: obesity, nutrition, and the
relationship between adipose tissue and risk of developing cardiovascular disease.
Dr. Apovian has given over 150 invited lectures nationally and internationally and
currently serves as President Elect of The Obesity Society (TOS) for 2016-17.

Elizabeth Brouillard, RD, LDN, CDE, is the Nutrition Manager for The Center
of Endocrinology, Diabetes, Nutrition and Weight Management at Boston Medical
Center. She completed her dietetic degree at the University of Maryland and went
to New Presbyterian Hospital for her clinical internship. She has been a registered
dietitian for 10 years and has focused most of her career on weight management and
diabetes. She obtained a certificate in adult weight management from the Academy
for Nutrition and Dietetic and is a Certified Diabetes Educator. Elizabeth works in
outpatient settings and sees patients every day struggle to make diet and lifestyle
changes for weight loss and glycemic control. Many of her patients have tried several
different diets with varying success in the past and Elizabeth has been able to work
with these patients to determine which diet plan will work best for them based on
their current health, lifestyle, and food preferences.

Lorraine Young, RD, MS, CNSC, LDN, is the Clinical Nutrition Manager (CNM)
and Home Nutrition Support Dietitian at Boston Medical Center (BMC). This posi-
tion is part of the Department of Endocrinology, Diabetes and Nutrition. She is also

ix
x Editors

an Instructor of Medicine at Boston University School of Medicine. She is responsible

for the management of all in-patient Clinical Nutrition Services and dietitians for both
adult and pediatric patients as well as two pediatric outpatient dietitians. Clinically,
she manages all home parenteral and complex enteral patients discharged from the
hospital or referred to the Endocrinology, Diabetes and Nutrition Department, which
includes many short bowel patients and patients with Inflammatory Bowel Disease.
She has over 35 years of experience in the field of Nutrition Support as well as
in conducting clinical research with one of the original developers of parenteral
nutrition in the United States. These research projects included work with intrave-
nous and enteral glutamine and growth hormone in critically ill patients. She also
manages complex bariatric surgery patients who may have developed complications
and may require specialized nutrition therapies. She is a co-investigator on an NIH
funded R21 to study the Effects of Metabolic Support immediately post-trauma with
Dr. Peter Burke, Director of BMC’s Trauma Center. She has been involved as a con-
sultant in an International Research Program with AFINS project (Abbott Fund in
Nutritional Sciences) whose goal is to improve inpatient Clinical Nutrition Services
in Vietnam. She has published extensively with over 50 publications in the clini-
cal nutrition field. She was the first recipient of the Dietitian’s in Nutrition Support
Research Award and was also a recipient of the Massachusetts Young Dietitian
Award in the 1980s. As the CNM at the hospital, she also serves as a teacher, lec-
turer, and mentor to the hospital nutrition and medical staff.
Contributors
Laura Andromalos
Clinical Nutrition
Virginia Mason Medical Center
Seattle, Washington
Meghan Ariagno
General and GI Surgery
Brigham and Women’s Hospital
Boston, Massachusetts
Megan Barnett
Department of Endocrinology, Weight
Management, and Nutrition
Boston Medical Center
Boston, Massachusetts
Caroline Blanchard
Energy Metabolism Laboratory
Jean Mayer USDA Human Nutrition
Center on Aging
Tufts University
Boston, Massachusetts
Sai Krupa Das
Energy Metabolism Laboratory
Jean Mayer USDA Human Nutrition
Center on Aging
Tufts University
Boston, Massachusetts
Catherine Fanning
Nutrition Boston Medical Center
Boston, Massachusetts
Madeleine M. Gamache
Energy Metabolism Laboratory
Jean Mayer USDA Human Nutrition
Center on Aging
Tufts University
Boston, Massachusetts
Glenn K. Harvin
Division of Gastroenterology,
Hepatology and Nutrition
Brody School of Medicine
East Carolina University
Greenville, North Carolina
Micaela C. Karlsen
Nutritional Epidemiology
Laboratory
Jean Mayer USDA Human Nutrition
Center on Aging
Tufts University
Boston, Massachusetts
Amy Krauss
Energy Metabolism Laboratory
Jean Mayer USDA Human Nutrition
Center on Aging
Tufts University
Boston, Massachusetts
Laura E. Matarese
Division of Gastroenterology,
Hepatology and Nutrition
Brody School of Medicine
East Carolina University
Greenville, North Carolina
Thomas J. Moore
Boston University School of
Medicine
University in Boston
Boston, Massachusetts
Megan Murphy
e-Havior Change, LLC
Waban, Massachusetts
xi
xii Contributors

Lin Pao-Hwa Susan B. Roberts

Department of Medicine Energy Metabolism Laboratory
Nephrology Division Jean Mayer USDA Human Nutrition
Duke University Medical Center on Aging
Center Tufts University
Durham, North Carolina Boston, Massachusetts
 1 The Atkins Diet

Laura E. Matarese and Glenn K. Harvin

CONTENTS
Overview..................................................................................................................... 1
How the Diet Works.................................................................................................... 1
The Atkins Plan........................................................................................................... 2
Current Research......................................................................................................... 6
Effects of Carbohydrate Restriction for Individuals with Type 2 Diabetes
and Metabolic Syndrome.................................................................................... 6
Effects of Carbohydrate Restriction on Cardiovascular Disease........................... 8
Weight Loss, Compliance, and Recidivism........................................................... 9
Typical Results.......................................................................................................... 10
Pros and Cons....................................................................................................... 10
Is This Diet Right for You?....................................................................................... 11
Conclusion................................................................................................................ 11
References................................................................................................................. 11

OVERVIEW
Despite the fact that there are well over 1000 published weight-loss diets in the lay lit-
erature, few have attracted as much attention as the Atkins Diet. The late Dr. Robert
C. Atkins developed this low-carbohydrate, high-protein weight-loss plan which was
publicized in his best-selling book, The Atkins Diet Revolution.1 Dr. Atkins promoted
the plan as not only a quick weight-loss diet but as a change in eating for a lifetime.
The diet was extremely popular allowing individuals to consume large quantities of
meat and high-fat foods without considering caloric restrictions. Critics referred to
the diet as a high-protein, high-fat, low-carbohydrate ketogenic diet which could be
potentially harmful. Early claims on both sides were often fueled by perception and
personal biases without scientific evidence. Eventually, the emergence of numerous
clinical trials appeared in the scientific literature demonstrating the efficacy and
safety of the Atkins Diet.

HOW THE DIET WORKS

Historically, obesity has been considered to be a result of an imbalance in caloric
intake versus expenditure. The idea was simple: when individuals take in more calo-
ries than they expend, the result will be weight gain. Given the growing incidence of

1
2 Clinical Guide to Popular Diets

obesity worldwide, however, it has become clear that this represents an over-simpli-
fication of a complex disease whose cure is more complicated than simply creating
a caloric deficit. Physiologically, carbohydrate restriction, as opposed to a negative
energy balance, is responsible for initiating the metabolic response to fasting.2 The
Atkins hypothesis is that dietary carbohydrate, particularly from simple sugars,
causes hyperinsulinemia, leading to insulin resistance, obesity, and the metabolic
syndrome. Excess carbohydrate prevents effective lipolysis with resulting lipogene-
sis. Low carbohydrate diets reduce the dietary contribution to serum glucose thereby
lowering insulin levels. Insulin is a potent stimulator of lipogenesis and inhibitor of
lipolysis. Lowering insulin levels allows the utilization of stored body fat for energy.
Severe carbohydrate restriction leads to a progressive depletion of glycogen stores
eventually switching metabolism to lipolysis. With a reduction in dietary carbohy-
drate, there is a corresponding increase in dietary protein and fat. This leads to the
production of ketones which act as an appetite suppressant and contribute to an over-
all voluntary caloric reduction.3,4 It has been proposed that inefficient protein and fat
oxidation leads to additional energy loss since more adenosine triphosphate (ATP)
is required to oxidize these macronutrients.5 Lipolysis is maintained despite excess
calories because glycerol from fat is needed as a gluconeogenic precursor.2 The car-
bohydrate level required to produce the metabolic shift from lipogenesis to lipolysis
has been debated, but it is thought to be between 20 and 50 g of carbohydrate per day
in the initial phases of the diet. This contrasts sharply with the typical carbohydrate
content of the Western diet which often exceeds 300 g per day comprising large
quantities of simple, rapidly hydrolyzed carbohydrates.

THE ATKINS PLAN

The foundation of the Atkins Plan is a reduction of carbohydrates. The diet has
evolved over the years to currently offer two options (Table 1.1). With Atkins 20™,
the starting point (Phase 1, Induction) is 20 g of “Net Carbs” (carbohydrate minus
grams of fiber) per day. The Atkins 40™ allows a starting point of 40 g of Net Carbs
per day. Both plans allow for an increase in carbohydrates. One plan adds foods one
at a time and the other raises the carbohydrate portion-size allowance as individuals
approach their weight loss goals (Table 1.1).
The Atkins 20TM (the original plan) includes a four-step process beginning with
a two-week induction phase with carbohydrates restricted to 20 g Net Carbs per day
(Table 1.2). The carbohydrates are derived primarily from low-glycemic, nutrient-
dense, fiber-rich carbohydrates such as leafy green salads and other non-starchy
vegetables. The client is instructed to consume 4–6 oz. of protein at each meal and
enough natural fat to feel satiated. Trans fats are eliminated. The protein is derived
from a variety of sources to include meat, fish, poultry, eggs, and vegetable-based
proteins such as tofu. Adequate fluid (water preferred) intake along with exercise
and a complete multivitamin/mineral supplement is recommended in order to obtain
optimal nutrition. Dairy intake is limited because of its carbohydrate content, there-
fore, calcium supplementation is recommended.
The second phase of the program is referred to as the ongoing weight loss
phase. During this phase, carbohydrates are added into the diet in the form of
The Atkins Diet 3

TABLE 1.1
Comparison of the Atkins Diet Plans
Atkins 20TM Atkins 40TM

Initial Phase of Weight Loss

Net carbs (grams) 20 40
Protein 3 servings of 4–6 oz per serving 3 servings of 4–6 oz per serving
Healthy fats 3 servings of added healthy fats per 3 servings of added healthy fats
day, e.g., butter, salad dressings, olive per day, e.g., butter, salad
oil, etc. dressings, olive oil, etc.
Carbohydrates Limited—Most carbs are derived from All Food Groups—About 1/3
vegetables during first 2 weeks, e.g., carbs from vegetables, remaining
leafy greens and other low-carb carbs from fruit, nuts, and/or
vegetables whole grains
Dairy foods high in fat and low in
carbs: cream, sour cream, and most
hard cheeses are allowed
Phase 2 of weight Add in 5 g net carb increments starting Add 10 g of net carbs when
loss increasing with lower carb foods and gradually individual is within 10 pounds of
carbohydrates progressing to higher carb foods goal weight by increasing serving
size or adding more variety
• Nuts and seeds (but not chestnuts)
10 g of net carbs may be added
• Berries, cherries, and melon (but
each week as long as weight loss
not watermelon)
continues. Continue to use the
• Whole milk yogurt and fresh
same acceptable foods list
cheeses, such as cottage cheese
and ricotta
• Legumes, including chickpeas,
lentils, and the like
• Tomato and vegetable juice
“cocktail”
• Other fruits (but not fruit juices or
dried fruits)
• Higher-carb vegetables, such as
winter squash, carrots, and peas

Weight Maintenance Phase

Adding foods back Progressive—Carbohydrates are slowly
into the diet added back into the diet
Protein 3 servings of 4–6 oz per serving
Healthy fats 3 servings of added healthy fats per
day, e.g., butter, salad dressings, olive
oil, etc.
Increasing Carbohydrates are added back in 5 g
carbohydrates net carb increments until weight
stabilizes. That carb intake is
continued to maintain weight
All Food Groups—The acceptable
foods list remains the same until
goal weight is achieved
3 servings of 4–6 oz per serving
3 servings of added healthy fats
per day, e.g., butter, salad
dressings, olive oil, etc.
Carbohydrates are added back in
10 g net carb increments until
weight stabilizes. That carb intake
is continued to maintain weight
4 Clinical Guide to Popular Diets

TABLE 1.2
Example Menu for Atkins 20TM
Net
Breakfast Carbs (g)

Phase 1—Induction
Net carbs = 20 g/day 2 scrambled eggs (with milk) 2.0
1/2 medium tomato 2.0
1/2 Haas avocado 1.5
Coffee/tea 0
Snack
String Cheese, 1 oz. 1.0
Cucumber, 1/2 cup 1.6
Lunch
1 cup mixed greens 1.5
Grilled chicken 0
Caesar Dressing 1.0
Coffee/tea/water/diet soda 0
Snack
2 celery stalks 2.0
Creamy Italian dressing 2.0
Coffee/tea/water/diet soda 0
Dinner
Grilled salmon 0
Steamed broccoli (1/2 cup) 2.2
Arugula salad (1 cup) 0.4
Coffee/tea/water/diet soda 0
Total net carbs 17.2

Phase 2—Ongoing Weight Loss

Net carbs start at 25 g/day gradually increasing Yellow squash and Gruyere frittata 2.5
intake in 5 g increments each week or every
several weeks until weight loss ceases or
begins to slow. Net carb prescription is then
reduced by 5 g.
Coffee/tea 0
Snack
2 tablespoons oil roasted mixed nuts 2.0
Coffee/tea/water/diet soda 0
Lunch
Canned tuna 0
1/4 cup red bell pepper 1.5
1/2 medium tomato 2.0
Coffee/tea/water/diet soda 0
Snack
4 oz. whole milk Greek yogurt 6.1
1/2 cup fresh blackberries 3.3
(Continued)
The Atkins Diet 5

TABLE 1.2 (Continued)

Example Menu for Atkins 20TM
Net
Breakfast Carbs (g)
Dinner
Flank steak 0
Grilled asparagus (6) 2.0
1 cup Romaine hearts 1.0
2 tablespoons Green Goddess dressing 1.0
1/2 cup fresh raspberries 3.4
Total net carbs 24.8

Phase 3—Pre-Maintenance
Carbohydrate intake increased by 10-gram Total net carbs Variable
increments every week to maintain very
gradual weight loss, generally half a pound a
week. Once the goal weight is achieved, the
individual remains at that carbohydrate
intake level until body weight stabilizes for
one month.

Phase 4—Lifetime Maintenance

Emphasis on sustainable changes to lifestyle in Total net carbs Variable
order to maintain the weight loss. Individuals
continue to eat the same variety of foods as in
the last month of Pre-Maintenance, while
controlling carbohydrate intake to ensure
weight maintenance. Since body fat is no
longer the primary source of energy, a slightly
greater intake of natural fats is necessary to
maintain weight.

nutrient-dense, fiber-rich foods increasing to 25 g of Net Carbs per day during

the first week. The carbohydrate content is further increased each week or every
several weeks in 5-gram increments until weight loss ceases or begins to slow. At
this point, the Net Carb prescription is reduced by 5 g. The individual remains at
this level for a sustained, moderate weight loss, generally averaging one to two
pounds per week.
Phase three is “Pre-Maintenance,” which transitions the individual from weight
loss to weight maintenance by increasing daily carbohydrate intake in 10-gram
increments every week for several weeks to maintain very gradual weight loss, gen-
erally half a pound a week. Once the goal weight is achieved, the individual remains
at that carbohydrate intake level until body weight stabilizes for one month.
The final phase is referred to as “Lifetime Maintenance.” Emphasis is placed on
sustainable lifestyle changes in order to maintain the lower weight. Individuals con-
tinue to eat the same variety of foods as in the last month of Pre-Maintenance while
6 Clinical Guide to Popular Diets

controlling carbohydrate intake to ensure weight maintenance. A slight increased

intake of natural fats is necessary to maintain the lower weight since body fat is no
longer the primary source of energy.
Over the years, the diet has evolved to emphasize healthy protein and fat choices
from a variety of foods. Vegetables are included in every phase of the Atkins pro-
gram including the most restrictive induction phase. As an individual progresses
through the diet phases, ingestion of more vegetables along with low-glycemic fruits,
nuts, seeds, whole grains, and legumes is encouraged. Later versions of the original
Atkins Diet acknowledged that exercise is important for weight loss and mainte-
nance as well as for achieving overall health benefits.

CURRENT RESEARCH
Designing controlled trials to evaluate the safety and efficacy of dietary interven-
tions is challenging. Randomization of interventions is possible, but blinding is
difficult. Results may vary depending on whether the study was conducted as an
outpatient in a “free-living” environment versus a controlled metabolic inpatient
setting. The study population may not always be homogenous in terms of the dis-
ease process, comorbidities, age, gender, body mass index (BMI), and medications.
Adherence to a dietary intervention is not always optimal, making interpretation of
the results difficult. Outcome parameters vary considerably and many are poorly
defined. For example, it may be debated whether weight loss alone is an adequate
outcome parameter or whether it is more important to look at changes in risk factors
for disease and medication requirements. Many studies were underpowered, short in
duration, or had high dropout rates, leading investigators to perform meta-analyses.
There is a significant body of literature despite these challenges that has evaluated
the low-carbohydrate Atkins Plan. Many of the studies evaluated the “low carbohy-
drate” concept, but the actual study design may or may not necessarily follow the
“Atkins Diet.” For the purpose of this review, all studies evaluating low carbohydrate
diets are considered to be indicative of the Atkins Diet.

Effects of Carbohydrate Restriction for Individuals

with Type 2 Diabetes and Metabolic Syndrome

Diabetes is a disease of altered carbohydrate metabolism. There are a number of

factors which increase the risk of type 2 diabetes. Individuals who are overweight
or obese, especially central obesity, can have insulin resistance. Obesity, in addi-
tion to high blood pressure, high cholesterol, and triglycerides, results in metabolic
syndrome. It is logical to assume that reduction of dietary carbohydrate content may
result in better glucose management and weight loss.
Feinman and colleagues’ systematic review concluded that dietary carbohydrate
restriction should be the first approach in diabetes management.5 Restriction of dietary
carbohydrate consistently reduces elevated blood glucose independent of weight loss,
and reduces the requirement of medications to control blood sugar such as insulin.
There is also evidence that improved glucose concentrations, weight loss, and lipid
profiles reduce the cardiovascular risk seen in individuals with type 2 diabetes.
The Atkins Diet 7

If dietary carbohydrate restriction is beneficial for individuals with type 2 dia-

betes, what is the optimal level of restriction to achieve these beneficial effects?
Westman and colleagues randomized 84 subjects with obesity and type 2 diabetes to
receive either a low-carbohydrate, ketogenic diet or a low-glycemic index diet over
a 24-week trial.6 The low-carbohydrate group lost more weight (11.1 kg) compared
to the low-glycemic group (6.9 kg). The hemoglobin A1c was reduced by 1.5% in
the low-carbohydrate group compared to 0.5% in the low-glycemic group. Diabetes
medications were either reduced or eliminated in 95.2% of the low-carbohydrate
group compared to 62% in the low-glycemic group, and only the low-carbohydrate
group achieved an increase in high-density lipoprotein (HDL) cholesterol.
Since individuals with diabetes often have significant cardiovascular risk pro-
files, Tay and colleagues compared the effects of a very-low-carbohydrate, high-
unsaturated fat, low-saturated fat (LC) diet with a high-carbohydrate, low-fat (HC)
diet on glycemic control and cardiovascular disease risk factors in 115 obese patients
with type 2 diabetes over a 52-week trial.7 Both diets were hypocaloric. The LC diet
provided 14% of energy as carbohydrate (50 g/d), 28% of energy as protein, and 58%
of energy as fat (10% saturated fat). The energy-matched, HC diet provided 53% of
energy as carbohydrate, 17% of energy as protein, and 30% of energy as fat (10%
saturated fat). Both groups received supervised aerobic and resistance exercise for 60
minutes, three days per week. Study completion rates were similar in both groups as
were weight loss, blood pressure, HbA1c, and reduction in fasting glucose. The LC
diet, however, which was high in unsaturated fat and low in saturated fat, achieved
greater improvements in the lipid profile, blood glucose variability, and reductions in
diabetes medication requirements.
Samaha and colleagues randomized 132 severely obese subjects (mean BMI,
43 kg/m2), many of whom had metabolic syndrome or type 2 diabetes, to either an
ad libitum low-carbohydrate, ketogenic diet (LCKD) or a calorie-restricted, low-fat
diet (LFD).8 The study was conducted in an ambulatory setting and subjects received
weekly group counseling sessions for four weeks followed by monthly sessions. At
six months, there was significantly greater weight loss (5.8 kg vs 1.9 kg; P = 0.002)
and triglyceride reduction (20% vs 4%; P = 0.001) in the LCKD group compared
with the LFD group. Diabetic subjects in the LCKD group demonstrated improved
serum glucose (decrease of 25 mg/dL versus a decrease of 5 mg/dL; P = 0.01) com-
pared with their LFD group, whereas the nondiabetic subjects in the LCKD had
improved insulin sensitivity (6% vs −3%; P = 0.01) compared with their LFD group.
Seven LCKD subjects had a reduction of diabetic medication dosage compared with
only one from the LFD group. Overall, the low-carbohydrate diet resulted in signifi-
cantly more beneficial effects on body weight and metabolic parameters.
There have been a number of these individual trials in subjects with type 2 diabetes.
A systematic review and meta-analysis of the dietary approaches to the management
of type 2 diabetes was conducted by Ajala and colleagues.9 A total of 20 randomized
controlled trials (RCTs) with 3073 patients were included in final qualitative analyses
and 16 studies were included in the quantitative analysis. The low carbohydrate, low-
glycemic index, Mediterranean, and high-protein diets all led to a greater improvement
in glycemic control with HbA1c reductions compared with their respective control
diets. The largest effect was seen in the Mediterranean Diet. The low-carbohydrate
8 Clinical Guide to Popular Diets

and Mediterranean Diets led to greater weight loss of more than 20 kg and an increase
in HDL seen in all diets except the high-protein diet. Overall, the data suggests that
controlling carbohydrate intake, particularly of simple sugars, results in better blood
sugar control, weight loss, and even reduction in diabetic medications.

Effects of Carbohydrate Restriction on Cardiovascular Disease

Obesity and dyslipidemia are modifiable factors associated with cardiovascular dis-
ease. There has been a concern that the high-protein/low-carbohydrate diets which are
high in fat may lead to an increase in blood cholesterol, triglycerides, and low-density
lipoproteins. To evaluate the effects of diet on weight loss and lipid profiles, Aude
and colleagues randomized 60 overweight subjects to receive the low-fat National
Cholesterol Education Program (NCEP) diet or a diet that was low in carbohydrate
and high in monosaturated fat over a 3-month period.10 Both groups received a caloric
restriction. Weight loss was significantly greater in the low-carbohydrate group
(6.2 kg) compared to the NCEP group (3.4 kg), (P = 0.02). There were no significant
differences between the groups for total, low density, or high density lipoprotein cho-
lesterol, triglycerides, or the proportion of small, dense, low-density lipoprotein par-
ticles. The low-carbohydrate group did show a significant reduction in triglycerides.
Waist-to-hip ratio was not significantly reduced between the groups (P = 0.27), but it
significantly decreased within the low carbohydrate group (P = 0.009).
Volek and colleagues conducted a detailed analysis of the effects of dietary inter-
vention on weight loss and metabolic and lipoprotein markers.11 Forty overweight
subjects with dyslipidemia were randomized to a low-carbohydrate diet or a low-fat
diet over a 12-week period. Both diets were energy-restricted and overall caloric
intake was similar for both groups. Each of the dietary interventions resulted in
improvements in metabolic parameters. The low-carbohydrate group had reduced
glucose (−12%) and insulin (−50%) concentrations, insulin sensitivity (−55%),
weight loss (−10%), and decreased adiposity (−14%). The low-carbohydrate group
also demonstrated a more favorable lipid profile including a reduction of triacylg-
lycerol (−51%) and increase in HDL cholesterol (13%) and total cholesterol/HDL-
cholesterol ratio (−14%) response. The low-carbohydrate diet also demonstrated
positive effects on other cardiovascular risk factors including postprandial lipemia
(−47%), Apolipoprotein B/Apolipoprotein A-1 ratio (−16%), and low-density lipo-
protein (LDL) particle distribution. The saturated fatty acids in the triacylglycerols
and cholesteryl esters and palmitoleic acid were significantly decreased in the low-
carbohydrate group compared to subjects consuming the low-fat diet.
Foster and colleagues studied the effects of targeted diet interventions on weight
loss and lipid profiles over the course of one year.12 Sixty-three subjects were ran-
domized to receive a low-fat, calorie-restricted diet or a low-carbohydrate diet with-
out a caloric restriction. The low-carbohydrate group experienced greater weight loss
(7.3% vs 4.5%) and improvements in triglycerides and HDL compared to the low-fat
group. This study demonstrated that it was the composition of the macronutrients as
opposed to energy that influenced weight loss and changes in lipid profiles.
Yancy and colleagues conducted a number of studies to evaluate the effects of
LCKD in overweight and obese individuals with dyslipidemia. In one study, the ad
The Atkins Diet 9

libitum LCKD along with vitamin supplementation was compared to a low-fat, low
cholesterol, reduced-calorie diet. LCKD participants followed the traditional Atkins
Diet using an unrestricted energy intake with initial carbohydrate restriction to less
than 20 g per day.13 Carbohydrates were gradually increased as goal body weight was
approached. Completion of the trial was greater in the subjects on the LCKD com-
pared to the reduced-calorie subjects (75% versus 53%; P = 0.03). Weight loss was
greater in the LCKD subjects compared to the low-fat subjects (14% reduction versus
9% reduction; P < 0.001). The LCKD group also demonstrated beneficial changes in
serum lipids with a decrease in triglycerides of 42% and increase in HDL cholesterol
by 13%. There was not a significant change in total cholesterol and LDL cholesterol.
Their data were corroborated in another trial in which ambulatory overweight sub-
jects with hyperlipidemia were randomly assigned to LCKD (<20 g), (N = 59) or a
low-fat (<30%), low-cholesterol, reduced-calorie diet (n = 60) for 24 weeks.14 Both
groups received exercise and participated in group meetings. The low-carbohydrate
group lost more weight, had higher HDL-C levels, and had a greater reduction in
triglyceride levels.
There have been numerous trials which have looked at the effects of low-carbo-
hydrate diets on weight loss and lipid profiles. A systematic review of randomized
controlled trials of the LC diets versus low fat from 2000 to 2007 showed that the
low-carbohydrate, high-protein diet was more effective at six months and was as
effective if not more so as the low-fat diet in reducing body weight and cardiovas-
cular risk parameters up to 1 year.15 Several other systematic reviews with meta-
analyses have been conducted on the low-carbohydrate, ketogenic diet versus the
low-fat diet. In each of these analyses, the low-carbohydrate diet produced greater
weight loss and improved cardiovascular risk parameters.16–19

Weight Loss, Compliance, and Recidivism

In both short to medium term studies, low-carbohydrate, high-protein diets have
resulted in greater weight loss compared to high-carbohydrate, low-fat diets. The
degree of weight loss may have varied, but overall, the low-carbohydrate diets pro-
duce greater weight loss compared to the low-fat diets. In most of the studies, calo-
ries were restricted in the low-fat groups, while subjects in the low-carbohydrate
group enjoyed an unrestricted caloric intake with an overall emphasis on macro-
nutrient content. In those studies which had caloric restriction for both groups, the
low-carbohydrate diets resulted in greater weight loss,11,20 although this was not the
case in some of the studies.21–23 In one study of subjects with type 2 diabetes, the low-
fat group lost more weight (0.5 kg) than the low-carbohydrate group, but the results
were not statistically significant.24 In those studies which evaluated the change in
visceral fat, the low-carbohydrate diets demonstrated greater reduction.10,11 Brehm
and colleagues demonstrated a reduction in body fat as measured by DXA in healthy
women with a very low-carbohydrate diet compared with a low-fat group at three
and six months.25
Compliance with any dietary intervention or plan is always a concern with adher-
ence often decreasing over time. In those studies reporting this data, non-compliance
occurred with both the low-carbohydrate and the low-fat diets. There was a slight
10 Clinical Guide to Popular Diets

compliance advantage overall with the low-carbohydrate diet. The reason may be
that the low-carbohydrate diet was associated with reduced appetite.26,27
The ability to maintain the weight loss declines in both groups, but there appears
to be a slight advantage with the low-carbohydrate plan. The Atkins Plan is a life-
style plan designed to help individuals lose weight and maintain that weight loss.
Individuals that abandon the overall plan after achieving their desired weight loss
and return to their previous eating habits will regain their weight.

TYPICAL RESULTS
As with any weight-loss diet, individual results may vary. In general, healthy weight
loss is considered to be two pounds per week. The initial weight loss on the Atkins
Diet is dramatic and averages 8–15 pounds in the first two weeks. However, this ini-
tial weight loss is most likely due to a reduction in total body water and glycogen and
not necessarily adipose tissue. Eventually, metabolism shifts to lipolysis and lean
muscle is preserved. Some individuals with type 2 diabetes will experience a dra-
matic improvement and resolution of their diabetes when there is sufficient weight
loss. Other comorbidities such as hypertension are generally improved as well. As a
result, medications to control these conditions will have to be adjusted.

Pros and Cons

The benefit of the Atkins Diet is that it results in dramatic reduction in body weight
and often with reversal of comorbidities, improvement of lipid profiles, and reduction
or elimination of associated medications. The Atkins Diet has a very good safety
profile with extremely low reported complications. There are some potential com-
plications that should be considered, nonetheless. The effects of low-carbohydrate,
high-protein diets on urinary stone formation have not been extensively studied, and
there are conflicting results.28 There are some data to suggest that high-carbohydrate
diets, especially from simple carbohydrates such as glucose or xylitol, result in an
increase in calciuria.29,30 Xylitol consumption has been associated with a rise in uri-
nary excretion of phosphate and oxalate, which can promote the formation of cal-
culi.30 A high sucrose intake was associated with an increased risk for kidney stones
in individuals with no history of kidney stones in the Nurses’ Health Study.31 Sucrose
has been shown to result in increases in serum insulin and urine calcium excretion.32
Although the data is limited, studies such as these would suggest that high-protein,
low-carbohydrate diets are protective against renal stones.
One short-term study specifically addressed the effects of consumption of a
high-protein, low-carbohydrate diet on kidney stone formation. This study showed
a marked increase in the acid load to the kidney with an increased risk for stone
formation and a decreased estimated calcium balance.33 Thus, the exact effects of
high-protein, low-carbohydrate diets on nephrolithiasis remain unclear.
Overall, reported complications are low, not serious, and generally from a few
select case reports. Nevertheless, there are certain groups of individuals who may
require additional monitoring or slight modifications to the Atkins Diet plan. For
example, individuals with compromised renal function should be closely monitored
The Atkins Diet 11

or placed on a modified regimen that would not adversely affect renal function.
Individuals with gout who become symptomatic should be placed on the maintenance
phase of the program. Pregnant women and nursing mothers are advised to follow
the maintenance phase of carbohydrate restriction, avoiding ketosis as a precaution.
There is one reported case of ketoacidosis associated with a low-­carbohydrate diet
in a non-diabetic lactating woman.34 However, her estimated carbohydrate intake
was less than 20 g per day for 10 days prior to admission to the hospital, an amount
that is even less than what is typically prescribed in the induction phase. The low-
carbohydrate, high-fat diet in combination with the high substrate demand of lacta-
tion appears to be the etiology of this rare case of ketoacidosis.

IS THIS DIET RIGHT FOR YOU?

The diet has a very good safety profile. However, there are certain considerations
that may influence the decision to embark on this dietary regimen. First, can you
drastically reduce the carbohydrate and sugar in your diet including grains, fruit,
and dairy products? The diet works by restricting grams of carbohydrates so the
individual must be willing to calculate and keep track of the carbohydrate intake.
Next, can you consume a high percentage of protein from meat, poultry, fish, eggs,
and fats? If you are vegetarian, can you consume nuts, tofu and soy products, eggs,
and cheese? Can you consume at least eight cups of water daily? Whether you are
vegetarian or consume animal products, all individuals should take a multivitamin
to ensure adequate intake of all micronutrients.

CONCLUSION
In each of these well-controlled clinical trials and meta-analyses, the low-carbohy-
drate ketogenic diet demonstrated superior weight loss when compared to more tra-
ditional approaches. There are some potential adverse effects, although they have not
been observed in any of the clinical trials to date. These include the development of
kidney stones, hypokalemia and hypomagnesaemia, elevated fatty acids, and gout in
susceptible individuals. When this diet technique is employed in individuals taking
medications for diabetes mellitus or hypertension, meticulous monitoring is required
in order to prevent hypoglycemia and hypotension as body weight is rapidly reduced.
Ultimately, the best weight-reduction diet is the one an individual will follow to
achieve and maintain a healthy body weight.

REFERENCES
1. Atkins RC. Dr. Atkins Diet Revolution. New York: Bantam Books; 1972.
2. Kirk E, Reeds DN, Finck BN. et al. Dietary fat and carbohydrates differentially alter
insulin sensitivity during caloric restriction. Gastroenterology 2009;136:1552–1560.
3. Boden G, Sargrad K, Homko C. et al. Effect of a low-carbohydrate diet on appetite,
blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. Ann
Intern Med 2005;142:403–411.
4. Gibson AA, Seimon RV, Lee CMY. et al. Do ketogenic diets really suppress appetite?
A systematic review and meta-analysis. Obes Rev 2015;16:64–76.
12 Clinical Guide to Popular Diets

5. Feinman RD, Pogozelski WK, Astrup A. et al. Dietary carbohydrate restriction as the
first approach in diabetes management: Critical review and evidence base. Nutrition
2015;31:1–13.
6. Westman EC, Yancy WS, Mavropoulos JC. et al. The effect of a low-carbohydrate,
ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes
mellitus. Nutr Metab 2008;5(36):1–9.
7. Tay J, Luscombe-Marsh ND, Thompson CH. et al. Comparison of low- and high-­
carbohydrate diets for type 2 diabetes management: A randomized trial. Am J Clin
Nutr 2015;102:780–790.
8. Samaha FF, Iqbal N, Seshardi P. et al. A low-carbohydrate as compared with a low-fat
diet in severe obesity. N Engl J Med 2003;348:2074–2081.
9. Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary
approaches to the management of type 2 diabetes. Am J Clin Nutr 2013;97:505–516.
10. Aude YW, Agatston AS, Lopez-Jimenez F. et al. The national cholesterol education
program diet vs a diet lower in carbohydrates and higher in protein and monounsatu-
rated fat. Arch Intern Med. 2004;164:2141–2146.
11. Volek JS, Phinney SD, Forsythe CE. et al. Carbohydrate restriction has a more favor-
able impact on the metabolic syndrome than a low fat diet. Lipids 2009;44:297–309.
12. Foster GD, Wyatt HR, Hill JO. et al. A randomized trial of a low-carbohydrate diet for
obesity. N Engl J Med 2003;348:2082–2090.
13. Hickey JT, Hickey L, Yancy WS. et al. Clinical use of a carbohydrate-restricted
diet to treat the dyslipidemia of the metabolic syndrome. Metab Syndr Relat Disord
2004;1(3):227–232.
14. Yancy WS, Olsen MK, Guyton JR. et al. A low-carbohydrate, ketogenic diet versus a
low-fat diet to treat obesity and hyperlipidemia: A randomized, controlled trial. Ann
Intern Med. 2004;140(10):769–777.
15. Hession M, Rolland C, Kulkarni U. et al. Systematic review of randomized controlled
trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity
and its comorbidities. Obes Rev 2009;10:36–50.
16. Bezerra Bueno N, Vieira de Melo IS, Lima de Oliveira S. et al. Systematic review with
meta-analysis very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight
loss: A meta-analysis of randomised controlled trials. Br J Nutr 2013;110:1178–1187.
17. Santos FL, Esteves SS, da Costa Pereira A. et al. Systematic review and meta-analysis
of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors.
Obes Rev 2012;13:1048–1066.
18. Hu T, Mills KT, Yao L. et al. Effects of low-carbohydrate diets versus low-fat diets on
metabolic risk factors: A meta-analysis of randomized controlled clinical trials. Am J
Epidemiol. 2012;176(Suppl):S44–S54.
19. Clifton PM, Condo D, Keogh JB. Long term weight maintenance after advice to con-
sume low carbohydrate, higher protein diets—A systematic review and meta-analysis.
Nutr Metab Cardiovasc Dis 2014;24:224–235.
20. Halyburton AK, Brinkworth GD, Wilson CJ. et al. Low- and high-carbohydrate weight-
loss diets have similar effects on mood but not cognitive performance. Am J Clin Nutr
2007;86(3):580–587.
21. Meckling KA, O’Sullivan C, Saari D. Comparison of a low-fat diet to a low-­
carbohydrate diet on weight loss, body composition, and risk factors for diabetes and
cardiovascular disease in free-living, overweight men and women. J Clin Endocrinol
Metab 2004;89:2717–2723.
22. Tay J, Brinkworth GD, Noakes M. et al. Metabolic effects of weight loss on a very-low-
carbohydrate diet compared with an isocaloric high-carbohydrate diet in abdominally
obese subjects. Am Coll Cardiol 2008;51:59–67.
The Atkins Diet 13

23. Brinkworth GD, Noakes M, Buckley JD. et al. Long-term effects of a very-low-­
carbohydrate weight loss diet compared with an isocaloric low-fat diet after 12 mo. Am
J Clin Nutr 2009;90:23–32.
24. Guldbrand H, Dizdar B, Bunjaku B. et al. In type 2 diabetes, randomisation to advice
to follow a low-carbohydrate diet transiently improves glycaemic control compared
with advice to follow a low-fat diet producing a similar weight loss. Diabetologia
2012;55:2118–2127.
25. Brehm BJ, Seeley RJ, Daniels SR, D’Alessio DA. A randomized trial comparing a very
low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardio-
vascular risk factors in healthy women. J Clin Endocrinol Metab 2003;88:1617–1623.
26. Nickols-Richardson SM, Coleman MM, Volpe JM, Hosig KW. Perceived hunger is
lower and weight loss is greater in overweight premenopausal women consuming a
low-carbohydrate/high-protein vs high-carbohydrate/low-fat diet. J Am Diet Assoc
2005;105:1433–1437.
27. McClernon FJ, Yancy WS Jr, Eberstein JA. et al. The effects of a low-carbohydrate
ketogenic diet and a low-fat diet on mood, hunger, and other self-reported symptoms.
Obesity. 2007 Jan;15(1):182–187.
28. Nouvenne A, Ticinesi A, Morellli I. et al. Fad diets and their effect on urinary stone
formation. Transl Androl Urol 2014;3(3):303–312.
29. Iguchi M, Umekawa T, Takamura C. et al. Glucose metabolism in renal stone patients.
Urol Int. 1993;51(4):185–90.
30. Nguyen NU, Dumoulin G, Henriet MT. et al. Carbohydrate metabolism and urinary
excretion of calcium and oxalate after ingestion of polyol sweeteners. J Clin Endocrinol
Metab. 1993;77(2):388–392.
31. Curhan GC, Willett WC, Speizer FE. et al. Comparison of dietary calcium with supple-
mental calcium and other nutrients as factors affecting the risk for kidney stones in
women. An Int Med 1997;126(7):497–504.
32. Holl MG, Allen LH. Sucrose ingestion, insulin response and mineral metabolism in
humans. J Nutr 1987;117:1229–1233.
33. Reddy ST, Wang CY, Sakhaee K. et al. Effect of low-carbohydrate high-protein diets
on acid-base balance, stone-forming propensity, and calcium metabolism. Am J Kidney
Dis. 2002 Aug;40(2):265–274.
34. Von Geijer L, Ekelund M. Ketoacidosis associated with low-carbohydrate diet in a non-
diabetic lactating woman: A case report. J Med Case Rep 2015;9:224.
 2 DASH Diet

Thomas J. Moore, Megan Murphy,

and Lin Pao-Hwa

CONTENTS
Overview................................................................................................................... 15
What is the DASH Diet?........................................................................................... 16
How to Follow the DASH Diet................................................................................. 16
How the Diet Works.................................................................................................. 18
What Component(s) of the DASH Diet Lower Blood Pressure (BP)?............ 18
What Is the Mechanism of the DASH Diet’s Blood Pressure Effect?............. 22
Current Research....................................................................................................... 23
DASH Diet and Blood Pressure................................................................................ 23
DASH Diet Plus Sodium Reduction................................................................ 23
DASH Diet Plus Antihypertensive Medications.............................................. 23
DASH Diet in Free-Choice Setting.................................................................24
Modifying the DASH Diet...............................................................................24
Other Health Effects of the DASH Diet....................................................................25
Cardiovascular Disease....................................................................................25
Cancer������������������������������������������������������������������������������������������������������������� 25
Cognition.........................................................................................................26
Diabetes........................................................................................................... 27
Weight Loss..................................................................................................... 27
Typical Results.......................................................................................................... 27
Pros and Cons of Following the DASH Diet............................................................ 29
The Pros: Well-Balanced, Customizable, Proven, and Safe..................................... 29
The Cons: Preference and Planning.......................................................................... 30
Is the DASH Diet Right for Your Patient?................................................................ 30
References................................................................................................................. 31

OVERVIEW
The DASH (Dietary Approaches to Stop Hypertension) diet was developed and tested
to help slow the rising incidence of hypertension in the United States. The original trial
was a controlled feeding study, funded by the National Heart, Lung, and Blood Institute,
and was conducted from 1993 to 1996 in five centers across the United States located in
Boston, Massachusetts, Durham, North Carolina, Baltimore, Maryland, Baton Rouge,
Louisiana, and Portland, Oregon.
This was a randomized control trial that included 459 study participants (aver-
age age 44 years; 49% women) with either prehypertension or stage 1 hypertension

15
16 Clinical Guide to Popular Diets

(overall eligible blood pressure range was 80–95 mm Hg diastolic and <160 mm Hg
systolic). After eating a typical American (control) diet for three weeks, participants
were randomly assigned to one of three diets for an eight-week period; the typical
American diet (control diet), the typical American diet with added fruits and veg-
etables, or the DASH Diet. All three diets contained the same amount of sodium.
Each participant visited the study location once per day (Monday through Friday) to
consume the main meal for the day and took the rest of his or her food to eat at home.
Adherence was monitored by directly observing the participants eating their main
meal of the day and verified via periodic analysis of urinary electrolytes. Caloric
intake was adjusted throughout the study to ensure baseline weights were maintained.
After two weeks, study participants eating the DASH Diet lowered their blood
pressure by an average of 5.5/3 mm Hg and this reduction remained through the
eight-week intervention. For those with a blood pressure greater than or equal to
140/90 mm Hg at baseline and who were also assigned to the DASH Diet group, blood
pressure was lowered by an average of 11.4/5.5 mm Hg. In addition to blood pressure
reduction, the DASH Diet also lowered total cholesterol an average of 14 mg/dL.1
Subsequent studies have shown that the DASH Diet also promotes weight loss and
has beneficial effects on several other health outcomes (see Current Research section).

WHAT IS THE DASH DIET?

The DASH Diet emphasizes fruits, vegetables, whole grains, and low-fat dairy,
and is reduced in meats, saturated fats, and sweets. The DASH Diet was originally
designed with the goal of reaching a certain intake level of selected nutrients that
were hypothesized to benefit blood pressure control. These nutrients include protein,
fiber, potassium, magnesium, and calcium. After the DASH Diet was proven to be
very effective in blood pressure reduction, it was translated and introduced to the
public as a dietary pattern characterized by eight food groups: Fruits, Vegetables,
Grains, Dairy, Meats, Nuts/Seeds/Legumes, Added Fats, and Sweets.

HOW TO FOLLOW THE DASH DIET

Getting started requires three steps:

1. Calculate daily calorie needs. There are many online sites and apps that offer
calorie calculators (e.g., MyFitnessPal, 360HealthWatch, dashforhealth.com,
and the DASH Food Tracker app). These sites will calculate how many calo-
ries one needs to maintain current weight. If weight loss is desired, subtract
500 calories from the calories needed for weight maintenance.
2. Determine the number of daily servings of each DASH food group (Table 2.1)
based on the calorie need calculated in Step 1 above.
3. Learn what is a DASH “serving” in each food group:

Fruits
• One medium piece of fruit (about the size of a tennis ball)
• 1/2 of a large piece of fruit (grapefruit, 7-inch banana)
Another random document with
no related content on Scribd:
 THE FALCON.
Scene.—An Italian Cottage. Castle and Mountains seen through
Window.

Elisabetta discovered seated on stool in window darning. The

Count with Falcon on his hand comes down through the door at
back. A withered wreath on the wall.

Elisabetta.

So, my lord, the Lady Giovanna, who hath been away so

long, came back last night with her son to the castle.

Count.

Hear that, my bird! Art thou not jealous of her?

My princess of the cloud, my plumed purveyor,
My far-eyed queen of the winds—thou that canst soar
Beyond the morning lark, and howsoe’er
Thy quarry wind and wheel, swoop down upon him
Eagle-like, lightning-like—strike, make his feathers
Glance in mid heaven.

[Crosses to chair.

I would thou hadst a mate!

Thy breed will die with thee, and mine with me:
I am as lone and loveless as thyself.

[Sits in chair.

Giovanna here! Ay, ruffle thyself—be jealous!

Thou should’st be jealous of her. Tho’ I bred thee
The full-train’d marvel of all falconry,
And love thee and thou me, yet if Giovanna
Be here again—No, no! Buss me, my bird!
The stately widow has no heart for me.
Thou art the last friend left me upon earth—
No, no again to that.

[Rises and turns.

My good old nurse,

I had forgotten thou wast sitting there.

Elisabetta.

Ay, and forgotten thy foster-brother too.

Count.

Bird-babble for my falcon! Let it pass.

What art thou doing there?

Elisabetta.

Darning, your lordship.

We cannot flaunt it in new feathers now:
Nay, if we will buy diamond necklaces
To please our lady, we must darn, my lord.
This old thing here (points to necklace round her neck),
they are but blue beads—my Piero,
God rest his honest soul, he bought ’em for me,
Ay, but he knew I meant to marry him.
How couldst thou do it, my son? How couldst thou do it?

Count.

She saw it at a dance, upon a neck

Less lovely than her own, and long’d for it.

Elisabetta.

She told thee as much?

 Count.

No, no—a friend of hers.

Elisabetta.

Shame on her that she took it at thy hands,

She rich enough to have bought it for herself!

Count.

She would have robb’d me then of a great pleasure.

Elisabetta.

But hath she yet return’d thy love?

Count.

Not yet!

Elisabetta.

She should return thy necklace then.

Count.

Ay, if
She knew the giver; but I bound the seller
To silence, and I left it privily
At Florence, in her palace.

Elisabetta.

And sold thine own

To buy it for her. She not know? She knows
There’s none such other——

Count.
 Madman anywhere.
Speak freely, tho’ to call a madman mad
Will hardly help to make him sane again.

Enter Filippo.

Filippo.

Ah, the women, the women! Ah, Monna Giovanna, you here
again! you that have the face of an angel and the heart of a—
that’s too positive! You that have a score of lovers and have not
a heart for any of them—that’s positive-negative: you that have
not the head of a toad, and not a heart like the jewel in it—that’s
too negative; you that have a cheek like a peach and a heart
like the stone in it—that’s positive again—that’s better!

Elisabetta.

Sh—sh—Filippo!

Filippo (turns half round).

Here has our master been a-glorifying and a-velveting and a-

silking himself, and a-peacocking and a-spreading to catch her
eye for a dozen year, till he hasn’t an eye left in his own tail to
flourish among the peahens, and all along o’ you, Monna
Giovanna, all along o’ you!

Elisabetta.

Sh—sh—Filippo! Can’t you hear that you are saying behind

his back what you see you are saying afore his face?

Count.

Let him—he never spares me to my face!

Filippo.
 No, my lord, I never spare your lordship to your lordship’s
face, nor behind your lordship’s back, nor to right, nor to left, nor
to round about and back to your lordship’s face again, for I’m
honest, your lordship.

Count.

Come, come, Filippo, what is there in the larder?

[Elisabetta crosses to fireplace and

puts on wood.

Filippo.

Shelves and hooks, shelves and hooks, and when I see the
shelves I am like to hang myself on the hooks.

Count.

No bread?

Filippo.

Half a breakfast for a rat!

Count.

Milk?

Filippo.

Three laps for a cat!

Count.

Cheese?

Filippo.
 A supper for twelve mites.

Count.

Eggs?

Filippo.

One, but addled.

Count.

No bird?

Filippo.

Half a tit and a hern’s bill.

Count.

Let be thy jokes and thy jerks, man! Anything or nothing?

Filippo.

Well, my lord, if all-but-nothing be anything, and one plate of

dried prunes be all-but-nothing, then there is anything in your
lordship’s larder at your lordship’s service, if your lordship care
to call for it.

Count.

Good mother, happy was the prodigal son,

For he return’d to the rich father; I
But add my poverty to thine. And all
Thro’ following of my fancy. Pray thee make
Thy slender meal out of those scraps and shreds
Filippo spoke of. As for him and me,
There sprouts a salad in the garden still.
(To the Falcon.) Why didst thou miss thy quarry yester-even?
To-day, my beauty, thou must dash us down
Our dinner from the skies. Away, Filippo!

[Exit, followed by Filippo.

Elisabetta.

I knew it would come to this. She has beggared him. I always

knew it would come to this! (Goes up to table as if to resume
darning, and looks out of window.) Why, as I live, there is Monna
Giovanna coming down the hill from the castle. Stops and
stares at our cottage. Ay, ay! stare at it: it’s all you have left us.
Shame upon you! She beautiful! sleek as a miller’s mouse! Meal
enough, meat enough, well fed; but beautiful—bah! Nay, see,
why she turns down the path through our little vineyard, and I
sneezed three times this morning. Coming to visit my lord, for
the first time in her life too! Why, bless the saints! I’ll be bound to
confess her love to him at last. I forgive her, I forgive her! I knew
it would come to this—I always knew it must come to this!
(Going up to door during latter part of speech and opens it.)
Come in, Madonna, come in. (Retires to front of table and
curtseys as the Lady Giovanna enters, then moves chair
towards the hearth.) Nay, let me place this chair for your
ladyship.

[Lady Giovanna moves slowly down

stage, then crosses to chair,
looking about her, bows as she
sees the Madonna over fireplace,
then sits in chair.

Lady Giovanna.

Can I speak with the Count?

Elisabetta.
 Ay, my lady, but won’t you speak with the old woman first, and
tell her all about it and make her happy? for I’ve been on my
knees every day for these half-dozen years in hope that the
saints would send us this blessed morning; and he always took
you so kindly, he always took the world so kindly. When he was
a little one, and I put the bitters on my breast to wean him, he
made a wry mouth at it, but he took it so kindly, and your
ladyship has given him bitters enough in this world, and he
never made a wry mouth at you, he always took you so kindly—
which is more than I did, my lady, more than I did—and he so
handsome—and bless your sweet face, you look as beautiful
this morning as the very Madonna her own self—and better late
than never—but come when they will—then or now—it’s all for
the best, come when they will—they are made by the blessed
saints—these marriages.

[Raises her hands.

Lady Giovanna.

Marriages? I shall never marry again!

Elisabetta (rises and turns).

Shame on her then!

Lady Giovanna.

Where is the Count?

Elisabetta.

Just gone
To fly his falcon.

Lady Giovanna.

Call him back and say

I come to breakfast with him.
 Elisabetta.

Holy mother!
To breakfast! Oh sweet saints! one plate of prunes!
Well, Madam, I will give your message to him.

[Exit.

Lady Giovanna.

His falcon, and I come to ask for his falcon,

The pleasure of his eyes—boast of his hand—
Pride of his heart—the solace of his hours—
His one companion here—nay, I have heard
That, thro’ his late magnificence of living
And this last costly gift to mine own self,

[Shows diamond necklace.

He hath become so beggar’d, that his falcon

Ev’n wins his dinner for him in the field.
That must be talk, not truth, but truth or talk,
How can I ask for his falcon?

[Rises and moves as she speaks.

O my sick boy!
My daily fading Florio, it is thou
Hath set me this hard task, for when I say
What can I do—what can I get for thee?
He answers, “Get the Count to give me his falcon,
And that will make me well.” Yet if I ask,
He loves me, and he knows I know he loves me!
Will he not pray me to return his love—
To marry him?—(pause)—I can never marry him.
His grandsire struck my grandsire in a brawl
At Florence, and my grandsire stabb’d him there.
The feud between our houses is the bar
I cannot cross; I dare not brave my brother,
Break with my kin. My brother hates him, scorns
The noblest-natured man alive, and I—
Who have that reverence for him that I scarce
Dare beg him to receive his diamonds back—
How can I, dare I, ask him for his falcon?

[Puts diamonds in her casket.

Re-enter Count and Filippo. Count turns to Filippo.

Count.

Do what I said; I cannot do it myself.

Filippo.

Why then, my lord, we are pauper’d out and out.

Count.

Do what I said!

[Advances and bows low.

Welcome to this poor cottage, my dear lady.

Lady Giovanna.

And welcome turns a cottage to a palace.

Count.

’Tis long since we have met!

Lady Giovanna.

To make amends
I come this day to break my fast with you.
 Count.

I am much honour’d—yes—

[Turns to Filippo.

Do what I told thee. Must I do it myself?

Filippo.

I will, I will. (Sighs.) Poor fellow!

[Exit.

Count.

Lady, you bring your light into my cottage

Who never deign’d to shine into my palace.
My palace wanting you was but a cottage;
My cottage, while you grace it, is a palace.

Lady Giovanna.

In cottage or in palace, being still

Beyond your fortunes, you are still the king
Of courtesy and liberality.

Count.

I trust I still maintain my courtesy;

My liberality perforce is dead
Thro’ lack of means of giving.

Lady Giovanna.

Yet I come
To ask a gift.

[Moves toward him a little.

 Count.

It will be hard, I fear,

To find one shock upon the field when all
The harvest has been carried.

Lady Giovanna.

But my boy—
(Aside.) No, no! not yet—I cannot!

Count.

Ay, how is he,

That bright inheritor of your eyes—your boy?

Lady Giovanna.

Alas, my Lord Federigo, he hath fallen

Into a sickness, and it troubles me.

Count.

Sick! is it so? why, when he came last year

To see me hawking, he was well enough:
And then I taught him all our hawking-phrases.

Lady Giovanna.

Oh yes, and once you let him fly your falcon.

Count.

How charm’d he was! what wonder?—A gallant boy,

A noble bird, each perfect of the breed.

Lady Giovanna (sinks in chair).

What do you rate her at?

 Count.

My bird? a hundred
Gold pieces once were offer’d by the Duke.
I had no heart to part with her for money.

Lady Giovanna.

No, not for money.

[Count turns away and sighs.

Wherefore do you sigh?

Count.

I have lost a friend of late.

Lady Giovanna.

I could sigh with you

For fear of losing more than friend, a son;
And if he leave me—all the rest of life—
That wither’d wreath were of more worth to me.

[Looking at wreath on wall.

Count.

That wither’d wreath is of more worth to me

Than all the blossom, all the leaf of this
New-wakening year.

[Goes and takes down wreath.

Lady Giovanna.

And yet I never saw

The land so rich in blossom as this year.
 Count (holding wreath toward her).
Was not the year when this was gather’d richer?

Lady Giovanna.

How long ago was that?

Count.

Alas, ten summers!

A lady that was beautiful as day
Sat by me at a rustic festival
With other beauties on a mountain meadow,
And she was the most beautiful of all;
Then but fifteen, and still as beautiful.
The mountain flowers grew thickly round about.
I made a wreath with some of these; I ask’d
A ribbon from her hair to bind it with;
I whisper’d, Let me crown you Queen of Beauty,
And softly placed the chaplet on her head.
A colour, which has colour’d all my life,
Flush’d in her face; then I was call’d away;
And presently all rose, and so departed.
Ah! she had thrown my chaplet on the grass,
And there I found it.

[Lets his hands fall, holding wreath

despondingly.

Lady Giovanna (after pause).

How long since do you say?

Count.

That was the very year before you married.

Lady Giovanna.
When I was married you were at the wars.

Count.

Had she not thrown my chaplet on the grass,

It may be I had never seen the wars.

[Replaces wreath whence he had

taken it.

Lady Giovanna.

Ah, but, my lord, there ran a rumour then

That you were kill’d in battle. I can tell you
True tears that year were shed for you in Florence.

Count.

It might have been as well for me. Unhappily

I was but wounded by the enemy there
And then imprison’d.

Lady Giovanna.

Happily, however,
I see you quite recover’d of your wound.

Count.

No, no, not quite, Madonna, not yet, not yet.

Re-enter Filippo.

Filippo.

My lord, a word with you.

Count.
 Pray, pardon me!

[Lady Giovanna crosses, and passes

behind chair and takes down
wreath; then goes to chair by
table.

Count (to Filippo).

What is it, Filippo?

Filippo.

Spoons, your lordship.

Count.

Spoons!

Filippo.

Yes, my lord, for wasn’t my lady born with a golden spoon in

her ladyship’s mouth, and we haven’t never so much as a silver
one for the golden lips of her ladyship.

Count.

Have we not half a score of silver spoons?

Filippo.

Half o’ one, my lord!

Count.

How half of one?

Filippo.
 I trod upon him even now, my lord, in my hurry, and broke
him.

Count.

And the other nine?

Filippo.

Sold! but shall I not mount with your lordship’s leave to her
ladyship’s castle, in your lordship’s and her ladyship’s name,
and confer with her ladyship’s seneschal, and so descend again
with some of her ladyship’s own appurtenances?

Count.

Why—no, man. Only see your cloth be clean.

[Exit Filippo.

Lady Giovanna.

Ay, ay, this faded ribbon was the mode

In Florence ten years back. What’s here? a scroll
Pinn’d to the wreath.
My lord, you have said so much
Of this poor wreath that I was bold enough
To take it down, if but to guess what flowers
Had made it; and I find a written scroll
That seems to run in rhymings. Might I read?

Count.

Ay, if you will.

Lady Giovanna.

It should be if you can.

(Reads.) “Dead mountain.” Nay, for who could trace a hand
So wild and staggering?

Count.

This was penn’d, Madonna,

Close to the grating on a winter morn
In the perpetual twilight of a prison,
When he that made it, having his right hand
Lamed in the battle, wrote it with his left.

Lady Giovanna.

Oh heavens! the very letters seem to shake

With cold, with pain perhaps, poor prisoner! Well,
Tell me the words—or better—for I see
There goes a musical score along with them,
Repeat them to their music.

Count.

You can touch

No chord in me that would not answer you
In music.

Lady Giovanna.

That is musically said.

[Count takes guitar. Lady Giovanna

sits listening with wreath in her
hand, and quietly removes scroll
and places it on table at the end
of the song.

Count (sings, playing guitar).

“Dead mountain flowers, dead mountain-meadow flowers,

Dearer than when you made your mountain gay,
Sweeter than any violet of to-day,
Richer than all the wide world-wealth of May,
To me, tho’ all your bloom has died away,
You bloom again, dead mountain-meadow flowers.”

Enter Elisabetta with cloth.

Elisabetta.

A word with you, my lord!

Count (singing).

“O mountain flowers!”

Elisabetta.

A word, my lord! (Louder).

Count (sings).

“Dead flowers!”

Elisabetta.

A word, my lord! (Louder).

Count.

I pray you pardon me again!

[Lady Giovanna, looking at wreath.

Count (to Elisabetta.)

What is it?

Elisabetta.
 My lord, we have but one piece of earthenware to serve the
salad in to my lady, and that cracked!

Count.

Why then, that flower’d bowl my ancestor

Fetch’d from the farthest east—we never use it
For fear of breakage—but this day has brought
A great occasion. You can take it, nurse!

Elisabetta.

I did take it, my lord, but what with my lady’s coming that had
so flurried me, and what with the fear of breaking it, I did break
it, my lord: it is broken!

Count.

My one thing left of value in the world!

No matter! see your cloth be white as snow!

Elisabetta (pointing thro’ window).

White? I warrant thee, my son, as the snow yonder on the

very tip-top o’ the mountain.

Count.

And yet to speak white truth, my good old mother, I have seen
it like the snow on the moraine.

Elisabetta.

How can your lordship say so? There, my lord!

[Lays cloth.

O my dear son, be not unkind to me.

And one word more.