When consuming a whole-foods, plant-based diet, there are specific foods that we should try to eat daily to maximize health benefits. Most days a work, I observe people consume a typical lunch of something like a grilled ham and cheese on buttered white bread with a bag of potato chips and a slice of pie or a cookie. With a few exceptions, meals are often lacking in fruits, vegetable, beans, and whole grains that provide vital minerals, vitamins, phytonutrients, fiber, and plant protein. Instead, they are replete with mostly empty calories that are high in processed carbohydrates, saturated fats, and potentially harmful animal protein. Sadly, most of these people are in the healthcare field, the very individuals who should be setting an example of ideal nutrition for everyone else!
Contrary to what I’ve described, I attempt to make almost every calorie I consume have some nutritional value. During weeks where I am working in my office, this is an easy task because I prepare my own lunch. Not only do I save money from not ordering take-out, but I have complete control over what foods I’m putting in my body. On days where I am working in the hospital, I usually eat in the physician’s lounge, where they offer a salad bar and usually some other plant-based prepared dish. A typical lunch for me is a bed of greens topped with chickpeas or black beans, broccoli, and whatever other raw vegetables might be available, including beets, cucumber, tomato, and carrot. I’ll often include a bean soup and a cooked vegetable or grain dish if one is being offered. Finally, I like to finish off with a small bowl of mixed berries or fruit. If I get hungry later in the afternoon, a piece of fruit, a handful of nuts, or a little bit of hummus are typical snacks that I enjoy.
To guide me on which foods I should try to include daily, and those that carry the most nutritional “bang for the buck”, I like to use Dr. Michael Greger’s “Daily Dozen” and Dr. Joel Fuhrman’s “Aggregate Nutrient Density Index” (ANDI).
The Daily Dozen
Dr. Greger’s “Daily Dozen” is based upon the concept that we not only want to consume whole, plant-based foods, but we want to eat a wide variety of them, as each has its own unique health benefits. He has created a list of 10 different food categories, along with beverages and exercise, that we should attempt to include daily.(5)
To simplify the recommendations, there are 16 food boxes to check off. Five of these (~30%) are vegetables, four (25%) are fruits, three each (~20%) are beans and whole grains, and only ~5% are nuts. So rather than memorize the checklist, think of the general concept that ideally 50-60% of what you eat throughout the day should made up of fruits and vegetables, 30-40% of whole grains and beans, only one serving of nuts, and the remainder (hopefully less than 10%) might include unnecessary calories from fats and sugars.
The Aggregate Nutrition Density Index
This is a nutritional index created by Dr. Joel Fuhrman which assigns a score to various foods based on how many nutrients they deliver per calorie. He often refers to the formula H=N/C, or Health is equal to Nutrients per Calorie. Specifically, nutrients refer to the noncaloric micronutrients including vitamins, minerals, and phytochemicals, and the calories refer to those attributed to macronutrients such as carbohydrates, fats, and proteins. An ANDI score for equal-calorie serving of each food was determined by testing levels of numerous vitamins and minerals as well as the antioxidant capacity using the ORAC score. The highest-ranking foods were given a score of 1,000, and all others were categorized relative to these. (4)
Leafy greens rank the highest on the ANDI, and include foods such as kale, spinach, mustard greens, arugula, and romaine lettuce. Not far behind are cruciferous vegetables such as broccoli, cauliflower, and brussels sprouts, as well as other vegetables including onions, mushrooms, peppers, and asparagus. Fruits such as berries, grapes, and melon come next, followed by beans, nuts and seeds, and grains. As expected, processed foods and animal proteins are at the bottom of the list. You can see that many of the foods with the highest ANDI score overlap with Dr. Greger’s “Daily Dozen”.
Are There Studies to Support the Benefits of Eating These Foods?
The “Blue Zones”, a term originally coined by adventure journalist Dan Buettner, are five areas around the world which have the greatest concentration of people living into their 90s and 100s. These include Sardinia, Okinawa, Japan, Ikaria, Greece, the Nicoya Peninsula of Costa Rica, and the Seventh Day Adventists in California. They have a dietary commonality in that all consume more than 90% of their calories from plant food, including some variety of green vegetable and up to a cup of beans daily. People living in the Blue Zone areas also tend to be more active and have strong social relationships, both of which are felt to also contribute to their longevity. Read more about the Blue Zones here or on this site. (6)
Population Studies Which Support Ample Fruit and Vegetable Consumption
A University College of London/Health Survey of England study evaluated the eating habits of 65,226 people from 2001 to 2003 and found that greater consumption of fruit and vegetables was associated with a lower risk of all cause death, specifically from heart disease and cancer as detailed on the chart below. (1)
A Finnish study involving 5,133 men and women also showed a 34% risk reduction in coronary artery disease in those that consumed the most versus least amount of vegetables and a 23% reduction in coronary artery disease in those that consumed the most versus the least amount of fruit. (3)
The Framingham Heart Study showed a 25% reduction in stroke for each daily increment increase of 3 servings of fruits and vegetables.
Analysis of the Nurses’ Health Study and Health Professional’s Follow-Up Study showed a 20% reduction in coronary artery disease alone and a 30% reduction in coronary artery disease and stroke in those that consumed the most versus the least vegetables.
The table below shows the results of 8 studies which all demonstrate a significant reduction in cardiovascular disease in those that consume the greatest amounts of fruits and vegetable.
What Do I tell my patients?
What advice do I give to my patients, many of whom still consume more of a standard American diet? I tell them they don’t have to change their habits completely overnight. I recommend reducing intake of foods we know can have adverse health consequences, and increasing intake of those that are beneficial. Even a small change in diet can lead to a large change in health! I have prepared the handout below which I provide to many of my patients.
Nutrition Prescription — General Guidelines for Beginners
Eat ½ to 1 cup of raw or cooked leafy greens daily. If just starting, can try aiming for 3-5 days each week. Leafy greens include spinach, arugula, kale, romaine lettuce, swiss chard, collard greens, and mustard greens. These are rich in potassium, calcium, and magnesium.
Eat ½-1 cup of raw or cooked cruciferous vegetables daily. If just starting, can try aiming for 3-5 days each week. Cruciferous vegetables include broccoli, cauliflower, cabbage, brussels sprouts, bok choy, etc. They contain a unique compound called sulforaphane which has been found to have powerful anticancer properties.
Try to include up to ¼ cup daily of onions, garlic, or leeks. These belong to the Allium family and contain organosulfur compounds which have been found to be beneficial in fighting various forms of cancer as well as heart disease.
Eat ½-1 cup of dark berries daily. These include blueberries, blackberries, strawberries, cranberries, pomegranate seeds, etc. The pigments in brightly-colored berries, including the polyphenol ellagic acid, tend to harbor some of the highest concentration of cancer-fighting antioxidants.
Eat 1 serving of fruits or vegetables that are high in carotenoids (these usually will be orange or red). Choices include carrots, yams, red and orange peppers, tomatoes, yellow squash, cantaloupe, and papaya. These foods help to promote natural killer cells which fight cancer.
Eat ½-1 cup of legumes daily. If just starting, can try aiming for 3-5 days each week. These are a good source of protein and fiber and are good substitutes for traditional meat-based protein sources. Legumes include black beans, kidney beans, garbanzo beans (chickpeas), lentils, cannellini beans, lima beans, and split peas. Dried lentils cook quickly, however it is easier to buy most legumes precooked in cans. Look for low sodium varieties in BPA-free cans if possible, and be sure to rinse and drain before eating. Beans are not only high in protein and fiber, but are also loaded with vitamins and minerals such as iron, potassium, zinc, and folate.
Eat ½-1 cup of cooked whole grains daily. Choices include brown rice, barley, bulgur, amaranth, farro, sorghum, quinoa, and oatmeal.
Eat 1 ounce of nuts daily. Preferentially eat raw nuts such as almonds, walnuts, cashews, etc. Can also include 1-2 tablespoons of chia seeds, hemp hearts, and flax seeds which provide fiber, essential nutrients, and protein. These are also a great source of essential omega-3 fatty acids.
Incorporate an unlimited rainbow of other vegetables into your daily diet as desired.
Inclusion of the above foods will help meet the goal of consuming 30-35 grams of fiber daily as well as plant sterols, both of which have been shown to significantly reduce cholesterol. Additionally, these foods contain potassium, magnesium, and calcium and have been shown to significantly reduce blood pressure. Eating a variety of these foods increases consumption of a number of antioxidants (lycopenes, beta-carotene, resveratrol, selenium, vitamin c, and vitamin e) which have been shown to reduce the development of various cancers and heart disease.
Limit processed grains (breads, most cereals, waffles, baked goods, etc) to no more than 1-2 servings daily. For example, try to consume no more than 2 slices of bread, one serving of cereal, etc.
Limit oil to no more than 1 tablespoon daily, and avoid dressings and sauces. Canola oil and olive oil have a much more favorable ratio of omega-3 (anti-inflammatory) to omega-6 (pro-inflammatory) fatty acids. Coconut oil is higher in saturated fat and should generally be avoided. Because it is primarily composed of lauric acid, it does tend to have a neutral effect on cardiovascular disease.
Limit cheese to no more than 3 servings each week. One serving is 2 ounces or ⅓ cup.
Limit animal protein consumption (red meat, chicken, pork, turkey, fish, etc.) to 4-6 ounce portions, and try to eat no more than once daily. Aim to cut animal protein out of the diet completely a few days each week.
Limit eggs to no more than 3-4 each week.
Limit consumption of dairy products (milk, cream, yogurt, cottage cheese, etc) to no more than one serving daily. Try to substitute nut milks (soy, almond, cashew, coconut). Some grocery stores sell soy and coconut milk based yogurts.
Limit sodium consumption to less than 1.5 grams daily. This can help to significantly reduce blood pressure along with a plant-based diet. Avoid processed foods, sauces, dressing, processed meats, etc.
All animal proteins contain saturated fat, and can contribute to the development and progression of cardiovascular disease. Cheese is the greatest source of saturated fat in our country. Processed foods (especially commercially baked crackers and cookies) and fried foods often contain trans-fats (look for “partially hydrogenated oil” in the ingredient listing). These are high in omega-6 fatty acids, are highly pro-inflammatory, and can also contribute to cardiovascular disease and other systemic illness.
1. Walker, Alice, Mindell, Jennifer, et al. “Fruit and Vegetable Consumption and All Cause, Cancer, and CVD Mortality: analysis of Health Survey for England Data”. J Epidemiol Community Health; 31 March 2014
2. Hu, Frank B. “Plant-based Foods and Prevention of Cardiovascular Disease: an overview”. Am J Clin Nutr. 2003;78:544S-51S. Chart
3. Knekt, P et al. Antioxidant vitamin intake and coronary mortality in a longitudinal population study. Am J Epidemiol 1994; 139:1180-9.
4. Fuhrman, Joel, M.D. Eat For Health. Flemington, NJ. Gift of Health Press. 2012.
5. Greger, Michael, M.D. How Not to Die. New York. Flatiron Books. 2015.
6. Mackey, John, Pulde, Alona, M.D., and Lederman, Matthew, M.D. The Whole Foods Diet: The Lifesaving Plan for Health and Longevity. New York. Grand Central Life and Style. 2017.