Dr. Terry Wahls is an Institute for Functional Medicine Certified Practitioner and conducts clinical research using functional medicine principles in the setting of multiple sclerosis.  In 2018 she was awarded the Institute for Functional Medicine’s Linus Pauling Award for her contributions in research, clinical care, and patient advocacy. Dr. Wahls has secondary progressive multiple sclerosis, which confined her to a tilt-recline wheelchair for four years. Dr. Wahls restored her health using a diet and lifestyle program she designed specifically for her brain and now pedals her bike to work each day. She is the author of The Wahls Protocol: How I Beat Progressive MS Using Paleo Principles and Functional Medicine, The Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles (paperback), and the cookbook The Wahls Protocol Cooking for Life: The Revolutionary Modern Paleo Plan to Treat All Chronic Autoimmune Conditions. Learn more about the current study Efficacy of Diet on Quality of Life in Multiple Sclerosis at terrywahls.com/msstudy. Pick up a one-page handout for the Wahls™ Diet. Follow her on Instagram @drterrywahls, and on Facebook/Twitter at @TerryWahls. Sign up to receive her weekly research updates.

Does your doctor tell you food has no impact on multiple sclerosis (MS)? Do they tell you there is no research showing that diet makes a difference for people with MS? They are wrong!

I have been conducting clinical research testing the effects of diet in people with MS for over a decade. The good news is that the tide is finally turning in favor of using diet to help control MS symptoms. Our research lab has investigated the modified Paleolithic diet, ketogenic diet, and the low saturated fat diet.^1-7 We have consistently observed that improving diet leads to reductions in fatigue,^1,2,6-8 anxiety,⁴ and depression,⁴ and improved quality of life.^1,2,4,6,7 I have conducted 7 clinical trials and have published over 70 peer-reviewed scientific papers, abstracts, and posters. Our MS diet studies have been cited by other researchers hundreds of times.

More people are doing dietary intervention studies in the setting of MS. There have now been 12 published randomized, controlled, dietary intervention studies in people with MS. There was even a recent editorial in Neurology, the highest impact and most widely read journal that publishes MS research, stating there is now evidence that diet can reduce fatigue and improve quality of life for people with MS. This is huge. If your physicians are telling you that diet does not matter, your physician is not keeping up with the latest research!

We are currently inviting people with relapsing-remitting MS to be in our new study, “Efficacy of Diet on Quality of Life in Multiple Sclerosis.” I will tell you how to sign up for this study later in this article.

Diet studies in MS findings

Regardless of what your physician(s) may say, we now have strong scientific evidence that diet matters.

The strongest evidence that an intervention is helpful (or harmful) is when multiple studies are combined and analyzed together. This type of analysis is called a meta-analysis. A network meta-analysis combines and compares all known studies to identify which treatments are the most effective. This is much stronger evidence than looking at a single study. We now have enough published studies on the role of diet on fatigue and quality of life to conduct these important meta-analyses.

The paper, Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systemic Review and Network Meta-analysis of Randomized Trials,was a network meta-analysis. A network meta-analysis allows the investigator to rank the interventions from most effective to least effective. The paper was published in Neurology, the most widely read journal by neuroscientists and practicing neurologists, in January 2023. Dr. Linda Snetselaar examined randomized dietary intervention studies in MS that lasted at least 12 weeks and had either fatigue or quality of life as an outcome. The authors found 12 studies that investigated 8 diets: Mediterranean, Paleolithic, ketogenic, anti-inflammatory, low saturated fat, fasting, calorie restriction, and control diet (the participant’s usual diet). A total of 608 participants were enrolled in these 12 studies. The standardized mean difference (SMD) was calculated for improvements in measures of fatigue, mental health quality of life, and physical health quality of life for the intervention diets and control diet. The 95% confidence interval (CI) was also calculated for the intervention diet and control diet. If both the SMD improvements and the 95% confidence interval are entirely on the side of the intervention, then scientists can safely state the intervention is effective for reducing fatigue or improving quality of life. That was how Dr. Snetselaar determined whether any of the diets were effective at reducing fatigue or improving quality of life. It is also how she ranked the effectiveness of all 8 diets for reducing fatigue or improving quality of life.

When comparing each dietary intervention to the control diet, three diets had confidence intervals that were entirely on the side of reducing fatigue. The other five diets were not significantly better than the control diet. The magnitude of change for reducing fatigue severity in descending order, was Paleolithic (SMD -1.27; 95% CI -1.81, -0.74), low saturated fat diet (Swank diet) (SMD -0.90; 95% CI -1.39, -0.42), and Mediterranean diet (SMD -0.89; 95% CI -1.15, -0.64). When comparing each diet to usual diet for improving quality of life, there were two diets that were associated with significant improvement in quality of life. In descending order, those two diets were the Paleolithic (also known as the Wahls™ diet) (SMD 1.01; 95% CI 0.40, 1.63) and Mediterranean diet (SMD 0.47; 95% CI 0.08, 0.86) diets. All of the Paleolithic diet studies cited in the network meta-analysis and half the low-fat diet (Swank diet) studies were from our lab. Thus the Paleolithic diet that was reported was really the modified Paleolithic diet, also known as the Wahls™ diet.

What diet to follow if you have MS

The three best diets for reducing fatigue and/or improving quality of life are the Mediterranean, modified Paleolithic (Wahls™ diet) and low saturated fat (Swank diet).

The Mediterranean encourages more vegetables and fruits, whole grains, legumes, fish, nuts, and seeds and reduces or eliminates added sugars, processed foods, fast foods, white breads, and white rice. It also reduces dairy and red meat intake.

The low saturated fat (Swank) diet encourages more vegetables, fruits, whole grains, fish, and white poultry, restricts saturated fat to less than 15 grams per day, restricts red meat, dark poultry meat, dairy fat, and saturated fat, and reduces or eliminates added sugar, processed foods, and fast foods.

The modified Paleolithic diet (Wahls™ diet) encourages more vegetables (target is 6 to 9 servings per day), 6 to 12 ounces of meat or fish per day, and some fermented foods, nuts, and seeds each day. It excludes gluten-containing grains, dairy, and eggs and reduces or eliminates added sugars, processed foods, and fast foods.

Sit down and have a family conversation about this research. Which of these diet plans do you want to try? 

Next steps for improving your diet

Processed foods and fast foods are hard to give up. They are everywhere. They are cheap. And they are designed to be incredibly tasty.If you attempt to stop eating processed foods and fast food, you are likely to experience headaches, irritability, and intense cravings. That is because those foods were designed specifically to create food cravings.

I tell my patients that they will be more successful in changing their diet if they implement dietary changes as a family. Talk through which foods you want to eliminate from your diet.  Sugar-sweetened beverages and processed snack foods are a terrific place to start. Once you and your family have agreed which food items you want to emphasize and which food items you wish to reduce or eliminate, you can begin to plan for success.

Design your eating environment to support your agreed upon goals. Make it easier to eat the foods you want to encourage and get the food items you wish to reduce or eliminate out of sight to reduce temptation. 

It is not easy to stop eating sugar, gluten, dairy, and processed foods. Gluten (protein in wheat, rye, barley, and many ancient grains) and casein (protein in dairy) stimulate the endorphin receptors in the brain, which stimulate the pleasure and attention centers in the brain. As people work to reduce or eliminate sugar and/or processed foods, they may experience cravings and irritability. A great first step is to eliminate sugar-sweetened beverages. Next, look to eliminate the foods that spike blood sugar the most rapidly, which are white bread, pasta, cereal, and whipped white potatoes. Third, reduce or eliminate fast foods. Those initial steps are all part of the recommendations for the three most effective diets (Mediterranean, modified Paleolithic, and low saturated fat).

Again, the modified Paleolithic diet (Wahls™ diet) and Mediterranean diets have many common features, including less added sugar, less ultra-processed foods, and more non-starchy vegetables. The low saturated fat diet also reduces added sugar, ultra-processed foods, and fast foods. Taking out the added sugar, ultra-processed snack foods, and fast foods will be an excellent place to start.

We should not be surprised that the largest effect size seen in the meta-analysis by Dr. Snetselaar was with the modified Paleolithic diet (Wahls™ diet). The modified Paleolithic diet that we have investigated in multiple studies removes the three most common food antigens (gluten, casein, and egg albumin) that cause excessive activation of the immune system.

An editorial entitled The Role of Diet in Multiple Sclerosis: Food for Thought appeared in the same issue of Neurology as Dr. Snetselaar’s network meta-analysis. The authors of the editorial recommended that neurologists talk to all their MS patients about the importance of diet. They said that all MS patients should be told that it is vital to have a healthy diet and that diet influences fatigue and quality of life. They also suggested that MS patients be sent to a Registered Dietitian to receive personalized guidance and support for diet improvement, visits that would likely be covered by many health insurance plans. Finally, they stated that patients should be told that adopting a Paleolithic, Mediterranean, or low saturated fat diets can reduce fatigue and improve quality of life.

We have come a long way. In 2010 my ideas about diet were radical. I was banned as a speaker because my ideas were considered dangerous. The modified Paleolithic diet used to be considered dangerous for MS patients. Now well-respected MS researchers are saying all MS patients should be told to adopt a healthy diet such as Mediterranean, Paleolithic, or low saturated fat diet.

Participate in a research study

This is great progress, but larger, longer diet studies are still needed, which means we need participants, people like you who are willing to be in those studies, who want to help make a difference!

We are currently recruiting participants for a two-year study comparing the modified Paleolithic elimination diet and the time-restricted ketogenic diet to usual diet (NCT05007483). We are looking for people with relapsing-remitting MS between ages 18 and 70. People must be willing to be randomly assigned to either the modified Paleolithic, also known as the Wahls™ diet, the time-restricted olive oil ketogenic diet, or usual diet. You can be following a ketogenic or Paleolithic diet now, but you must be willing to switch to the keto diet or modified Paleolithic diet if randomized to that diet.

You must also be willing to come to Iowa at month 0 for the first study visit. You will also need to return to Iowa at month 3 and month 24. At each assessment, you will complete several questionnaires about mood, energy, and your ability to do the tasks of daily life. You will also do some tests of walking function, hand function, memory, and vision. At month 0 and month 24, you will have a brain MRI (without contrast) to help us measure the rate of brain volume change.

One of the most interesting questions we are asking is whether improving diet will lead to healthier brain aging. People with MS have, on average, a rate of brain volume loss that is 3 times as fast as occurs with healthy aging. That is why people with MS have higher rates of memory problems, early dementia, and walking problems than those who do not have MS. Based on my clinical experience with people who have MS, I expect that we can get people back to healthy rates of brain volume loss when they improve their diets. If our study can demonstrate that, it will be huge, because none of the DMTs have been able to get people with MS back to healthy rates of brain volume loss.

If you have relapsing-remitting MS, are between ages 18 and 70, and are willing to come to Iowa for three visits over two years, we want to include you in this study! If you are interested in participating, complete the screening tool here. Even if you do not qualify for this study, we encourage you to become part of our patient registry. If you have optic neuritis, radiologically isolated syndrome, clinically isolated syndrome, or multiple sclerosis (both relapsing-remitting and progressive MS), I encourage you to complete this short survey and become part of our patient registry.

Changing the standard of care takes 30 years. I am 15 years into this journey–halfway there. It is my goal to have diet become the standard of care, so that everyone who has MS is told that diet matters and is encouraged to improve their diet to protect their brains. For that to happen we need more published, peer-reviewed scientific studies. I am doing that research, which requires participants willing to do the study intervention and to be the control. Are you ready to participate? To help me change the standard of care?

Much of my research has been supported by donations from the public. We have received donations from people like you and from grateful patients whose lives we’ve changed. You can learn more about how you contribute to our innovative research program here.

Citations

1.    Bisht B, Darling WG, Grossmann RE, et al. A multimodal intervention for patients with secondary progressive multiple sclerosis: feasibility and effect on fatigue. J Altern Complement Med. May 2014;20(5):347-55. doi:10.1089/acm.2013.0188

2.    Bisht B, Darling WG, Shivapour ET, et al. Multimodal intervention improves fatigue and quality of life in subjects with progressive multiple sclerosis: a pilot study. Degener Neurol Neuromuscul Dis. 2015;5:19-35. doi:10.2147/DNND.S76523

3.    Bisht B, Darling WG, White EC, et al. Effects of a multimodal intervention on gait and balance of subjects with progressive multiple sclerosis: a prospective longitudinal pilot study. Degener Neurol Neuromuscul Dis. 2017;7:79-93. doi:10.2147/DNND.S128872

4.    Lee JE, Bisht B, Hall MJ, et al. A multimodal, nonpharmacologic intervention improves mood and cognitive function in people with multiple sclerosis. J Am Coll Nutr. Mar-Apr 2017;36(3):150-168. doi:10.1080/07315724.2016.1255160

5.    Lee JE, Titcomb TJ, Bisht B, Rubenstein LM, Louison R, Wahls TL. A modified MCT-based ketogenic diet increases plasma beta-hydroxybutyrate but has less effect on fatigue and quality of life in people with multiple sclerosis compared to a modified Paleolithic diet: a waitlist-controlled, randomized pilot study. J Am Coll Nutr. Jan 2021;40(1):13-25. doi:10.1080/07315724.2020.1734988

6.    Wahls TL, Titcomb TJ, Bisht B, et al. Impact of the Swank and Wahls elimination dietary interventions on fatigue and quality of life in relapsing-remitting multiple sclerosis: the WAVES randomized parallel-arm clinical trial. Mult Scler J Exp Transl Clin. Jul-Sep 2021;7(3):20552173211035399. doi:10.1177/20552173211035399

7.    Irish AK, Erickson CM, Wahls TL, Snetselaar LG, Darling WG. Randomized control trial evaluation of a modified Paleolithic dietary intervention in the treatment of relapsing-remitting multiple sclerosis: a pilot study. Degener Neurol Neuromuscul Dis. 2017;7:1-18. doi:10.2147/DNND.S116949

8.    Reese D, Shivapour ET, Wahls TL, Dudley-Javoroski SD, Shields R. Neuromuscular electrical stimulation and dietary interventions to reduce oxidative stress in a secondary progressive multiple sclerosis patient leads to marked gains in function: a case report. Cases J. Aug 10 2009;2:7601. doi:10.4076/1757-1626-2-7601

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Over the last year or so and after Beth sent me some bags of her flour blends to try out, Beth Blends Grain-Free Flour Blend has become my go-to flour to use for everyday cooking. But, it was only recently that I had the chance to try it in this recipe. In my previous iteration of the shortbread base, I had used 6 (yes, SIX) different grain-free flours and starches to try and get the perfect texture for the shortbread bottom layer (not too crunchy, not too crumbly, but strong enough to support the custard layer, two versions were actually squeaky when you bit into it, which was super weird). And, I’m so glad I did, because I now feel confident sharing this recipe with you, just on time for the holidays!

Variations: Because I’ve iterated this recipe so many times, I feel like I’ve tried it all! My favorite is the combination of lime and lemon in this custard, but I’ve tried using just lemon, just lime, Meyer’s lemons (on their own or with lime) and orange (on its own or with lemon). They’re all tasty, so feel free to experiment with other citrus fruits in this recipe. I’ve also used different sugars to sweeten. My preference is unrefined cane sugar because I feel like it doesn’t compete with the citrus flavors, but it’s also tasty with maple sugar if you want to use a more nutrient-dense sugar. You can make this in an 8″x8″ pan for a thicker bar (like in my photo), or a 9″x9″ pan for a thinner bar. It cooks a bit faster if you make it in a 9″x9″ pan. And, if you want to make the shortbread base with a different grain-free flour blend, all I can say is, nothing I tried worked as well as Beth Blends.

Lemon-Lime Bars

Prep time: 20 minutes

Cook time: 20 to 25 minutes

Yield: 16 2-inch squares

Ingredients:

• 1 1/2 cups Beth Blends Grain-Free Flour Blend
• 1/2 cup ghee (or substitute butter or palm shortening)
• 1/4 cup powdered sugar (you can blend maple or cane sugar in a blender for 30 seconds to make this, or use store-bought)
• 3/8 teaspoon salt, divided
• 1/3 cup lime juice (about 3 limes worth)
• 1/4 cup lemon juice (about 2 lemons worth)
• 2 teaspoons lemon zest (about 1 lemons worth)
• 1/2 cup sour cream (I use a coconut-based dairy-free sour cream, you could also substitute whole milk yogurt or coconut cream, but the higher the fat content of this ingredient, the creamier the custard)
• 5 eggs
• 1 cup unrefined cane sugar (like sucanat, or sugar in the raw)

Directions:

1. Preheat oven to 350F. You don’t need to line your pan with parchment, but it does make it a little easier to remove on the other side, so up to you, I usually skip lining my pan.
2. In a bowl, kneed together Beth Blends Grain-Free Flour Blends, ghee, powdered sugar and 1/4 teaspoon salt. This is easiest with your hands as it makes a very stiff dough (similar to pie crust dough in consistency).
3. Press dough into the bottom of an 8″x8″ baking pan to form an even layer. Poke holes all over the top with the tines of a fork.
4. Bake for 20 minutes, until just starting to turn slightly golden. Meanwhile, prepare your custard.
5. Add remaining ingredients to a blender jar and pulse just to combine. Alternatively, you can whisk them together by hand.
6. Remove pan from the oven and pour the contents of your blender over the top. (You can do this while the shortbread layer is still hot, or if you’re not quite ready when the shortbread is, it’s totally okay if it cools down a little. You’ll get slightly more distinct layers if the shortbread is still hot, but it works either way).
7. Return to the oven and bake an additional 20 to 25 minutes, until custard is set. (If you shake your pan slightly, the center shouldn’t wobble.)
8. Cool completely before removing from pan. These are great chilled or at room temperature.
9. Sprinkle the top with additional powdered sugar, if desired. Cut into squares and serve.
10. Store any leftovers in an air-tight container on the counter for up to 3 days, or in the fridge for up to a week. I think these are even better on the second day!

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I developed the Nutrivore Score to be the most comprehensive and least biased assessment of the nutrient density of individual foods. Why? When I first started developing the foundational content for Nutrivore.com a little over a year ago, I knew that I needed a method to quantify the nutrient density of foods. This is actually a field of research called nutrient profiling, the science of categorizing foods according to their nutritional composition. My initial plan was to comb through the research and choose one of the dozen or so existing nutrient density scores to use. After reading through nearly every nutrient profiling study ever published (which took me about two months!), I reached a disappointing conclusion: Every nutrient density score that had been developed thus far is flawed.

The goal of a  Nutrivore diet is to fully meet the body’s nutritional needs from the foods we eat, see What Is a Nutrivore?. The most efficient way to achieve this goal is by choosing nutrient-dense superfoods as the foundational foods of our diet. But, how do we even identify which foods those are?  My new Nutrivore Score is a measure of much nutrients, relative to the daily value (DV), a food contains per calorie, using 33 nutrients in its calculation.

But, before we dive into how the Nutrivore Score is calculated, let’s first discuss why it’s necessary.

Defining the Term Nutrient-Dense

Scientists have been working towards a standard method for quantifying the nutrient density of foods for about twenty years, but their efforts have been complicated by fuzzy definitions, incomplete nutrient data, lack of clarity on whether certain nutrients (or food groups) should be more or less heavily weighted in a calculation, disagreement on whether a food should be penalized for containing high levels of problematic compounds (like sodium or added sugars), and a misguided desire to retrofit a nutrient density score to align with the USDA dietary guidelines or its proxy, the Healthy Eating Index, rather than analyzing health outcomes or nutrient status test results.

The concept of a nutrient-dense food was first defined in the 1970s as any food that provided “significant amounts of essential nutrients” per serving. Because of a lack of formal criteria for determining whether or not a food met this definition, inconsistent and subjective standards were applied, largely build around broad food groups, and overly focused on fat and sugar content as problematic, rather than vitamins, minerals, and other important nutrients as beneficial. As a result, some foods were labelled as unhealthy, like nuts, olives, and avocadoes, purely because of their fat content—we now recognize all of these foods contain heart-healthy fats that reduce cardiovascular disease risk and they all have medium to high Nutrivore Scores. In addition, the terms “good source” and “excellent source” were defined as providing 10% or 20% DV, respectively, of a specific nutrient per serving—for example, if a food contained 10% DV of vitamin C, it could include the phrase “A good source of vitamin C” on its label. As a result, some foods were labeled as healthy based on being a good source of a single nutrient; for example, whole grains were promoted based on being a good source of fiber—we now know that whole grains have, on average, the lowest Nutrivore Scores of any whole food while also having high energy density, meaning you consume a whole lot of calories but relatively few essential nutrients per serving.

The Science of Nutrient Profiling

Nutrient profiling, defined as the science of categorizing foods according to their nutritional composition, began in the early 2000s with the development of several similar methods to quantify the nutritional value of foods, including (but not limited to): Nutrient for Calorie (NFC), Calorie for Nutrient (CFN), Nutritious Food Index (NFI), Naturally Nutrient Rich (NNR) Score, Nutrient-Rich Foods Index (NRF), Nutrient Adequacy Score (NAS), and Nutrient Density Score (NDS). These scores/indices differ from each other in small but meaningful ways.

Some scores calculate nutrient density as a function of food weight, which is influenced by nonnutritive compounds like water content, but most represent the nutrient density as a function of energy. Given that our food supply is overabundant in calories while being overall depleted in nutrients, the more important information for the average consumer is how to maximize nutrients for each calorie, rather than for each gram or serving of food.

Some of the scores are normalized (so for example, the range is 0 to 100 or 0 to 1000), whereas others are simply totals. The problem with normalization is communication: while it may seem simpler to represent all foods on a scale from 0 to 100, the immense difference between the nutrient density of vegetables versus, say, fast food, is minimized when the scale is smaller. Some scores also include a weighting by food group, so the most nutrient-dense grain gets allocated the score of 100 in the grains group and the most nutrient-dense vegetable gets allocated the score of 100 in the vegetables group. This food group weighting system completely undermines the entire concept of nutrient profiling. For example, the Nutrivore Score of kale is 4150 whereas the Nutrivore Score of oats is 200, but when you apply a correction for food groups, their nutrient density scores are very similar. Studies show their health benefits are not equivalent, why would be normalize their nutrient-density scores to make them appear to be equally nutritious foods when they clearly aren’t?

The other way these scores differ is in the nutrients used to make the calculations. Most include protein and fiber, but the CFN only includes protein and the NFI only includes fiber. Which vitamins are utilized in the calculations ranges from only vitamin C (in the NDS5) all the way to including all of the vitamins except B7 and K (in the NDS15). And which minerals are utilized ranges from just calcium and iron (in the NQI, NRF6, and NDS5) all the way to calcium, iron, zinc, magnesium, copper, iodine, and selenium (in the NDS23). For the NRF and NDS, multiple variations were created, incorporating anywhere from 5 to 23 nutrients into their calculations (hence the number after the acronym; for example, NDS5 uses 5 nutrients and NRF23 uses 23 nutrients) and either with or without penalizing foods for their sodium, added sugars and saturated fat content (in which case, the acronym has a “.3” added at the end, for example the NRF15.3 includes 15 nutrients in its calculation and penalizes for 3). None of these scores incorporate phytonutrients into their calculations (which is sad given how valuable they are, see The Amazing World of Plant Phytochemicals and Polyphenols: Magic Bullet or Health Hype?).

In fact, there has been much discussion among scientists over which nutrients to include in nutrient profiling calculations. This concern originates from the fact that certain nutrients are more strongly correlated with health outcomes than others (typically those that we’re most likely to be deficient in rather than the nutrient itself being less important), such as high consumption of omega-3 fats, fiber and vitamin D. To attempt to hone in on the best sampling of nutrients to include in a nutrient-density score, a couple of studies have compared the NRF calculated with 5 to 16 nutrients (with or without limits for sodium, sugars and saturated fats, and with our without weighting for various food groups) to the Healthy Eating Index (HEI). The HEI is a way to quantify compliance with the USDA dietary guidelines, by assigning an energy adjusted score for servings from 9 food groups or nutrients to encourage (total fruits, whole fruits, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant protein, and fatty acids ratio) and subtracting servings from 4 food groups or nutrients to discourage (refined grains, sodium, added sugars, and saturated fat). Interestingly, these studies found that an NRF with fewer nutrients in the calculation better aligned with the HEI, with 9 nutrients (protein, fiber, vitamin A, vitamin C, vitamin E, calcium, iron, magnesium and potassium) being optimal.

But, here’s where this line of reasoning is fundamentally flawed. Why would we retrofit a nutrient density score to align with dietary guidelines that were crafted without nutrient density or nutrient sufficiency in mind? This especially makes no sense when you consider that there is also little understanding of how individual nutrient-dense foods fit into healthful dietary patterns. As discussed in Essential Nutrient Deficiency and Autoimmune Disease, Natural Approaches to Cold & Flu Season (and Covid-19!), The Importance of Nutrient Density and Introduction to Nutritional Sciences, the prevalence of nutrient deficiencies is extremely high, even when people follow the USDA dietary guidelines, and these deficiencies increase risk of chronic and infectious disease. To advance the public’s understanding of what constitutes a nutrient-dense food, nutrient profiling must necessarily be algorithmically independent from the Healthy Eating Index and USDA dietary guidelines. Only then can we use nutrient profiling to improve dietary guidelines. And, the fact that the NRF calculation that best aligns with the HEI is the one that uses only nine nutrients reveals that following the USDA dietary guidelines will not result in nutrient sufficiency.

How Nutrient Profiling Could Inform Dietary Guidelines

It makes vastly more sense to devise a nutrient profiling method that simply reflects the nutritive value of a food, and then to study how eating more nutrient-dense foods impacts disease risk. In fact, there was a 2104 study of people over the age of 55 that showed that the higher the NRF9 of their diet as a whole, the lower their risk of all-cause mortality—the highest NRF9 quartile had a 16% lower chance of dying than the lowest NRF9 quartile. This study helps to prove that potentially huge health benefit of a diet replete with nutrient-dense foods, but more studies like this that incorporate even more nutrients into the calculus are necessary to advance this field of research.

To illustrate how important it is to take a comprehensive approach to nutrient profiling, take a look at how ten whole foods rank, when using 9, 15, 20 or 33 nutrients to quantify their nutrient density (in the NRF9, NRF15, NRF20 and Nutrivore Score, respectively). The more nutrients that are included in a calculation, when following the NRF model which does not cap a nutrient at 100% DV, the higher the score can be—that’s why every food has a higher score when more nutrients are taken into account. However, look not only at the order of the foods, and how including more nutrients provides a more complete picture of how nutrient-dense a food is, but also the spread between the scores. The more nutrients used in the calculus, the easier it is to differentiate between the most nutrient-dense foods and the least. Given what a nutrient powerhouse liver is, it just makes sense that its score would be vastly higher than, say, chicken breast.

The above table also helps to illustrate how a single nutrient can dramatically shift the nutrient profiling score of a specific food. For example, zinc is not included in the NRF9 but is included in the other scores. Oysters are the top food source of zinc, insufficiency of which affects an estimated 73% of Americans in large part because zinc-rich foods are few and far between and those that are, like oysters, are not a common food on the Standard American Diet. In fact, a single serving of oysters contains 174% DV of zinc! As soon as zinc is added to the score, oysters rank much more highly, which makes sense since they’re such a valuable source of vitamins, minerals and healthy fats while being an invaluable source of zinc!

The insight gleaned from nutrient profiling is profound. It emphasizes the value of certain families of plant foods (especially cruciferous vegetables, mushrooms, leafy greens, and fresh herbs) while also elevating the value of fish, shellfish and organ meat. At the same time, it emphasizes the high caloric density and low nutrient density of grains and dairy products.  This information would be super useful were it incorporated into the USDA dietary guidelines, helping people to identify the most nutritious foods to eat!

The Problem with Penalizing, Capping and Emphasizing

Some scores penalize for the presence of nutrients whose excess consumption have been (even loosely) linked to health problems, like sodium, saturated fat, added sugars, and cholesterol.

As I discussed in detail in Eggs: Nutritious Protein or Cholesterol Bomb?, dietary cholesterol does not increase serum lipids for most people and is the backbone of vitamin D and other steroid hormones. Dietary saturated fat is only problematic when intake exceeds about 15% of total calories (although this does depend on genetic predisposition, see Saturated Fat: Healthful, Harmful, or Somewhere In Between? and Genes to Know About: ApoE). Sodium is only problematic when intake exceeds about 7 grams per day, and there are studies showing that even this level is only worrisome when potassium intake is concomitantly low, see Is Salt Paleo?. Added sugars become problematic above about 10% of total calories (and 25% of total carbohydrates), see How Does Sugar Fit into a Healthy Diet? and TWV Podcast Episode 467: Can Eating Sugar Daily Be Healthy?. Most importantly, all of these nutrients are healthy in moderate amounts, and only unhealthy when the whole diet includes excess. And, all of these potentially problematic nutrients are abundant in fast food, junk food and other hyperpalatable manufactured foods that are also low in essential nutrients and very high in calories—this is why scores that penalize for these nutrients give these types of foods scores less than zero!

Penalizing individual foods for the presence of these nutrients does not reflect the diet as a whole, and has the capacity to undervalue otherwise nutrient-dense whole foods which can fit into a health-promoting diet, while not being necessary to show that fast food and junk food are unhealthy (they’re nutritionally void enough to already have low scores!).

Some of these scores (like the NDS) cap a nutrient’s contribution at 100% DV, whereas others recognize that a food having more than a 100% DV of a specific nutrient per serving makes that food a very valuable source of that nutrient! There’s no such thing as a nutritionally complete food, so the goal is nutrient sufficiency of the entire diet, not of any one particular food. Thus, it’s important to understand how to combine foods that are good sources of different nutrients in order to achieve dietary nutrient sufficiency. Capping a nutrient’s contribution to the nutrient density score at 100% hinders our ability to understand the importance of food combining for nutrient sufficiency. For example, Brazil nuts are the most nutrient-dense nut attributable to their very high selenium content—a 1-ounce serving delivers nearly 1000% DV of selenium! But, if you capped the contribution of selenium to the calculation of Brazil nut nutrient density, they would erroneously appear to be one of the lowest nutrient-density nuts. It just makes sense to fully value the awesome selenium content of Brazil nuts and have that reflected in its nutrient density score!

Another topic for discussion is whether to weight certain nutrients more in nutrient profiling.

It makes sense on the surface to count those nutrients for which a larger proportion of the population are deficient more than those nutrients for which very few people are deficient. But, here’s the challenge with that logic: the potential for overcorrection and simply shifting towards different common nutrient deficiencies. If those foods that are particularly good sources of the nutrients that, for example, an estimated 70% or more of Americans routinely don’t consume enough of (vitamin B9, vitamin D, vitamin E, choline, calcium, potassium, zinc, omega-3 fats, and polyphenols) had inflated scores as a result of weighting these nutrients more heavily in nutrient profiling, food sources of other nutrients end up being undervalued. This approach has the capacity to shift food choices in a way that could help address some population level nutrient deficiencies over the short term, but that’s not the same thing as moving towards nutrient sufficiency, especially over the long term.

When we look at nutrient profiling methods described in the scientific literature, it becomes abundantly clear that a nutrient-density score best describes a food when it includes as many nutrients as possible, when the contribution of nutrients are not capped at 100% DV, when they are presented relative to calories, when they are not weighted by food groups, and when they are not normalized to a fixed scale.

Consumer-Focused Nutrient Profiling

Several other nutrient profiling methods have been devised by non-researchers with the goal of educating consumers, such as the ANDI Score, NuVal (based on ONQI), Guiding Stars, and Nutrition IQ.

The ANDI score may be one of the most comprehensive nutrient profiling systems, but the score overemphasizes nutrients inherent to plant foods while deemphasizing nutrients inherent to animal foods, creating a biased result. For example, the ANDI score incorporates separately into its calculation: beta carotene, alpha carotene, lycopene, lutein and zeaxanthin (all carotenoids); fiber and resistant starch (both fiber); glucosinolates and organosulfides (both organosulfur compounds); phytosterols, angiogenesis inhibitors, aromatase inhibitors, resveratrol and ORAC score (most plant phytonutrients are antioxidants as are vitamin C and E). On the other hand, the score omits protein, functional amino acids and peptides (like anserine, creatine, carnosine, carnitine, and taurine) and all types of health-promoting fats (like omega-3s, monounsaturated fats, CLA and MCTs).

The ONQI is calculated based on 16 nutrients, with penalties for 5 nutrients and corrections for fat and protein quality and for glycemic load. Most notably, only 5 minerals are included, only three of the B vitamins are included, and only two types of phytonutrients (flavonoids and carotenoids) are included, while vitamin K and choline are excluded. In addition, because both cholesterol and saturated fat are penalized (despite the fact that whether these are problematic is entirely context-dependent), animal foods are penalized unnecessarily.

The Guiding Stars system rewards whole grains (despite their low nutrient-density compared to vegetables, fruits, legumes, nuts and seeds), and penalizes for total fat, sodium, sugar and cholesterol  And, the Nutrition IQ system also rewards whole grains, uses only a few nutrients in its determination, and also penalizes for saturated fat and sodium. The net result for both of these scores is to overemphasize grains, which are not nutrient-dense by any objective measure, and deemphasize animal foods.

The Problem of Incomplete Data

There’s one final challenge to nutrient profiling: incomplete data.

The United States Department of Agriculture maintains arguably the most comprehensive nutrient database in the world, called Food Central, with expanded nutrient data compiled for over 7,000 basic foods and partial nutrient data (at least what is required on food label) for nearly 360,000 different branded foods. But, even this amazing database is missing some key information. Many of the main entries are missing measurements for some nutrients (commonly vitamin D, vitamin B5, manganese, vitamin K2, and phytosterols) and certain nutrients aren’t included in the database at all (including vitamin B7, iodine, polyphenols, CoQ10, and other functional compounds, including most phytonutrients). Fiber is not differentiated between soluble and insoluble, and the method used to measure fiber is known to undercount resistant starch and oligosaccharides.

In addition, the entries generally provide average measurements for common quality food products, so it’s not possible to differentiate the nutrient content of higher quality options. And, while many of these gaps can be filled in from measurements presented in scientific studies, it’s surprising to discover how incomplete human knowledge is about the nutrient content of common foods.

There’s really no good solution, other than to scour the scientific literature and other databases for as many nutrients as possible missing from the USDA Food Central database (which my team and I are doing), label when a nutrient-density score is calculated based on incomplete data, and advocate for continued measurements of the nutrient content of foods.

How the Nutrivore Score Is Calculated

The Nutrivore Score is currently the most comprehensive, and least bias, method for representing the inherent nutrient content of foods, borne out of a confusing array of similar, yet all flawed, nutrient density scores, while recognizing the current limitations posed by incomplete data.

The Nutrivore Score is calculated based on 32+1 nutrients. The 32 primary nutrients that go into the score are:

The score is calculated as the sum of each nutrient relative to its RDA or AI present in 100 grams of the food, divided by the amount of calories per 100 grams. Data that’s not included in the Food Central Database are obtained from scientific papers and other databases like Phenol Explorer whenever possible. When multiple papers report the amount of a nutrient for a particular food, the highest value is utilized, unless there’s a clear methodological advantage to one specific measurement, and provided it is no more than one standard deviation from the mean of all available data (in which case, the second highest value is utilized following the same statistical test). Also, periodically two entries from the Food Data Central database are amalgamated to calculate the Nutrivore Score when two highly-related foods (for example, sockeye salmon and Coho salmon) have incomplete data. This is noted wherever it’s the case.

Further, the Nutrivore Score adds the highest value of available data for one bonus nutrient (that’s the +1), relative to a threshold set using epidemiological studies for that nutrient, similar to a %DV. The bonus nutrient currently can be any of: glucosinolates (the precursor for isothiocyanates and indoles), thiosulfinates, CoQ10, CLA, betaine, betalains, myo-inositol, ergothioneine, taurine and medium-chain triglycerides. The reason why only one bonus nutrient is included in the Nutrivore Score is because incomplete data would mean less common or understudied foods are unnecessarily penalized. Where the level of multiple nutrients in a food remain unknown, the Nutrivore Score is marked with an asterisk to denote that the score is likely underestimated for that food and should be thought of as a minimum.

The Nutrivore Score is not corrected for nutrient bioavailability, nutrient absorption capacity, or metabolic conversion inefficiencies. It’s true that specific isoforms of nutrients are more easily absorbed and/or used by the body. For example, while vitamin K1 accounts for approximate 90% of the total vitamin K in the diet, only 10 to 15% of it is absorbed in the digestive tract, the net effect being that vitamin K1 accounts for about half of the total absorbed vitamin K, whereas vitamin K2 is highly absorbable and represents the remaining 50% (see TWV Podcast Episode 417: Vitamin K2, Hype, or Essential?).  While vitamin K isoform data is available for some foods in the USDA Food Central database, as a general rule, nutrient isoform data is rarely available, making correcting for absorption or utilization efficiency of different nutrient forms impossible. It’s also true that certain combinations of nutrients can either enhance or hinder absorption. For example, vitamin C can increase iron absorption, fats can increase carotenoid and vitamin K absorption, but zinc and copper compete for absorption as do calcium and magnesium. However, this can’t be accounted for in a nutrient density score for an individual food because all nutrients present in an entire meal interact. And sometimes, absorption is influenced by factors independent of food. For example, vitamin D status influences calcium absorption; a functioning gallbladder is necessary for efficient fat and fat-soluble vitamin absorption; and while folic acid is much more readily absorbed in the digestive tract than the active form of vitamin B9, L-methylfolate, those with MTHFR gene variants can’t covert folic acid efficiently (see Paleo for Pregnancy and Lactation and Genes to Know About: MTHFR). So, because nutrient absorption competition or facilitation goes beyond an individual food and is instead related to all of the foods consumed at a meal as well as other factors such as genetics, it makes no sense to correct for these in a nutrient profiling method. The Nutrivore Score also does not incorporate a satiety index, again because satiety is related to macronutrient and water combinations from an entire meal rather than an individual food.

Rather than penalizing for the presence of nutrients whose excess is associated with health problems (like saturated fats, sodium and sugars), these nutrients are simply not included in the Nutrivore Score calculation. It is helpful to note that foods high in fats and sugars have a higher energy density, meaning more calories per gram or per serving of food, which does lower the Nutrivore Score. In addition, the presence of antinutrients such as phytates or oxalates are not taken into account. This is because the impact of antinutrients on nutrient absorption is also extremely context dependent. For example, our gut bacteria can liberate a substantial amount of the calcium, magnesium, iron, potassium and zinc bound to phytates for us, thereby releasing the bound minerals as well as phosphorus and thereby enhancing their bioavailability. A healthy, diverse gut microbiome can typically degrade about half (about 500 to 600 mg daily) of the phytate consumed in the average American diet. Other factors influencing bioavailability include health of the gastrointestinal tracts, nutrient status, competitive binding with other nutrients, meal composition, various drugs and supplements, time of day and biorhythms, age and gender. It doesn’t make sense to try to reflect nutrient digestibility and absorption in the Nutrivore Score when the system is so complex and varies from individual to individual.

You can think of the Nutrivore Score as a simple yet comprehensive representation of the inherent nutrients within a food, and acknowledge that a variety of factors will determine whether or not your body absorbs and uses all of those nutrients.

Because nutrients can be lost, formed and transformed by cooking, the Nutrivore Score is calculated based on the nutrients within the raw whole food, unless noted otherwise. Also, it is unusual for there to be nutrient data for different quality levels of a food. For example, the Food Central database contains only one entry for olive oil, but research has shown that the polyphenol content of virgin olive oil can range from anywhere between 50 to 5000 mg/kg, and the vitamin E content can range from 100 to over 1000 mg/kg. Another example: even though locally-grown, in-season organic vegetables and fruit and known to have higher nutrient density (due to being grown in higher quality soil, picked ripe, and eaten much sooner after harvest), there are no separate entries in the Food Central database for organic versus conventionally-grown produce. For this reason, we can think of Nutrivore Scores as a minimum or average value and feel confident that the effort to seek out higher quality options (grass-fed meat, wild-caught fish, fresh cold-pressed extra-virgin olive oil, and local in-season vegetables and fruit) is still nutritionally valuable if currently not quantifiable.

As more nutrient data become available, the Nutrivore Score will be updated to reflect more complete nutritional information. This obviously applies to missing nutrition information from the Food Central database, but there’s also the likelihood of adding nutrients to the Nutrivore Score calculation in the future. For example, a protein digestibility score, soluble versus insoluble fiber, trace minerals, functional nonproteinogenic amino acids and peptides, functional fatty acids, and vitamin-like compounds that aren’t currently utilized to calculate the Nutrivore Score could all be added once there is sufficient data to rationalize their inclusion. For now, extremely sparse data makes this prohibitive, and similarly would reward foods simply for being better studied, not necessarily for inherently higher nutritional value, relative to less common foods.

Using the Nutrivore Score

It is time for a positive approach to dietary guidance using nutrient density as a basic principle.  The Nutrivore Score is a necessary foundational step towards achieving this goal! By understanding the nutrients per calorie offered by individual foods via the Nutrivore Score, in addition to recognition that certain nutrients are exclusive to specific food groups, we can achieve nutrient sufficiency by choose a variety of nutrient-dense superfoods as well as the highest Nutrivore Score options from the various foundational food groups.

As I build Nutrivore.com, the Nutrivore Score is one of several tools that I am using to communicate which foods have the most to offer us. As you can see with the sample nutrient card above, I’m also highlighting the nutrients per serving (rather than only considering nutrients per calorie), including which are excellent sources (more than 20%DV) and which are good sources (10-20%DV). I’m combining this nutritional information with a review of the scientific literature on the specific health impacts of eating a food, and detailed information on what nutrients do in the body and how much of them we need. And, I’m creating educational resources on how to select various foods with complementary nutrition to achieve nutrient sufficiency!

I’m building this website outside of any dietary dogma. Being a Nutrivore is about the overall quality of the whole diet, and not about a list of yes-foods and no-foods. Even though eliminating empty calorie foods helps to achieve nutrient sufficiency without overeating, no food is strictly off-limits. In this way, being a Nutrivore is a diet modifier rather than a diet itself—a Nutrivore approach can be layered atop of other dietary structures and priorities in order to meet an individual’s specific health needs and goals.

I see Nutrivore as the natural extension of my science-grounded approach, and one that will allow me to both level up the depth of my resources for my long-time readers who love my science deep dives, but also meet people where they are and embrace the idea that even a small first step is worth celebrating. (See also What Is a Nutrivore?, Ditching Diet Dogma, My Personal Journey with the Autoimmune Protocol and My Personal Journey as a Blogger).

My vision for Nutrivore.com is extremely ambitious: A detailed educational resource devoid of dietary dogma and instead purely based on scientific studies and nutrient profiling to quantify nutrient density, all with the goal of helping people achieve dietary nutrient sufficiency (a.k.a. Nutrivore) through informed day-to-day choices.

The Nutrivore Score is a measure of much nutrients, relative to the daily value (DV), a food contains per calorie. A nutrient-dense powerhouse superfood is any food with a Nutrivore Score higher than 800. High nutrient-density foods have a Nutrivore Score between 400 and 800. Medium nutrient-density foods have a Nutrivore Score between 150 and 400. And, low nutrient-density empty-calorie foods have a nutrivore score less than 150. Remember, there are no yes-foods and no-foods on a Nutrivore approach, but instead what matters is whether the diet as a whole meets the body’s nutritional needs. Overall dietary nutrient sufficiency is easy to achieve by selecting a variety of the highest Nutrivore Score foods within each food category.

So far, I have calculated the Nutrivore Score of about over 7,500 different foods, and boy there have been some surprises!  Did you know that golden kiwis are a little more nutrient-dense than green kiwis? Or that dark meat turkey is more nutrient-dense than light meat turkey? Or that maple syrup and molasses have a medium nutrient-density score and that molasses is more nutrient-dense than cheese or pears?! Or that Asian pears are the most nutrient-dense Rosaceae family fruit (the apple and stone fruit family). Or that blackberries, strawberries and raspberries are all more nutrient-dense than blueberries? You’ll be able to find all of this information in my new e-book, Guide to Nutrivore!

Introducing the Guide to Nutrivore E-Book!

Guide to Nutrivore lays the foundation for Nutrivore as a general health approach, a base dietary philosophy devoid of dogma, on top of which you can layer additional food focus or eliminations to meet individual needs. In this sense, being a Nutrivore is a diet modifier rather than a diet itself.

With this beautifully-designed e-book, you’ll:

• learn how a Nutrivore approach can improve health
• appreciate what essential and nonessential nutrients do in the body
• get practical tips on how to increase nutrient-density
• examine how to use the Nutrivore Score to choose healthier foods
• find detailed nutrition information on the Top 100 Nutrivore Score Foods
• compare the nutrient-density versus energy-density of food groups
• easily implement Nutrivore with handy-dandy visual guides and reference tables!

The Guide to Nutrivore explains how to eat a Nutrivore diet and introduces the Nutrivore Score, the most comprehensive and least-biased method to assess the nutritive value of individual foods.  Detailed nutrition information for the Top 100 Nutrivore Score Foods is summarized with beautiful graphics for each food. And, the Guide to Nutrivore includes analysis of food groups, considerations when preparing Nutrivore meals, practical tips to increase the nutrient density of your diet, and a look-up table for the Nutrivore Score of approximately 300 foods.

Nutrivore Scores of Common Foods

And, while you wait for Guide to Nutrivore and Nutrivore.com, here’s the Nutrivore Scores of some common foods!

And, don’t forget to grab my free Nutrivore Score Guide to Food Groups!

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The post The Nutrivore Score appeared first on The Paleo Mom.

Even though this is my last episode as a weekly co-host, I am leaving the podcast in the more than capable hands of Stacy, who gives a sneak peak into some of the outstanding guests and topics that she has planned on the podcast for the upcoming months. Not only that, but I am also already scheduled to guest-co-host and discuss the topic of salt in five weeks time! For our Patreon subscribers, we recorded a full final Q&A episode complete with a BUNCH of questions sent in by patrons. At the end of this podcast, we give a short teaser of a few good questions, including: how to battle someone who drinks a ton of soda, concerns (or not) about grain and soy-fed meat products, and is sparkling water a good or bad way to include hydration in your day.

If you enjoy the show, please review it on iTunes

Recommended Reading and Listening

• TWV Podcast Episode 437: Intro To Nutrivore
• What Is a Nutrivore?
• The Nutrivore Score
• Ditching Diet Dogma
• Reflecting on a Decade of Health Education
• TWV Podcast Episode 400: Modern Science and a Real Life Approach to Health
• TWV Podcast Episode 411: Do we still follow the Paleo diet?
• TWV Podcast Episode 436: What Is Health, and How Do You Measure It?

The post TWV Podcast Episode 500: A Look Back and What’s Next appeared first on The Paleo Mom.