DipABLM cheat sheet

Definition: a dietary pattern emphasizing minimally processed plant foods (vegetables, fruits, whole grains, legumes, nuts, seeds) while limiting or excluding animal products and highly processed foods.

Key evidence base: Ornish, Esselstyn, PREDIMED, Adventist Health Study-2, and EPIC-Oxford cohorts link plant-predominant patterns to lower cardiovascular, metabolic, and all-cause mortality risk.

Fiber target: 25-38 g/day for adults; plant-predominant patterns typically deliver this when whole grains and legumes are staples.

Protein adequacy: legumes, soy foods, whole grains, nuts, and seeds supply all essential amino acids; complementary pairing at each meal is not required.

Key micronutrients to monitor: vitamin B12 (supplement required on vegan diets), vitamin D, iron (non-heme, enhance with vitamin C), zinc, iodine, and long-chain omega-3 (algae-based EPA/DHA).

Calcium: aim 1,000-1,200 mg/day from fortified plant milks, tofu set with calcium salts, leafy greens (kale, bok choy, collards), tahini, and almonds.

Sodium: keep under 2,300 mg/day (ideally 1,500 mg for hypertension); processed meats and packaged foods are the largest sources.

Dietary pattern shift rule: replace, don't just restrict - swap red/processed meat for legumes, poultry for soy, and refined grains for whole grains to preserve satiety and nutrient density.

Assessment tool: use a validated screener (e.g., 24-hour recall, food frequency questionnaire, or Mediterranean diet score) to quantify baseline and track change.

Aerobic guideline: 150-300 min/week of moderate-intensity OR 75-150 min/week of vigorous-intensity aerobic activity, or an equivalent combination.

Muscle-strengthening: at least 2 sessions/week involving all major muscle groups for adults.

Moderate intensity = 3.0-5.9 METs; vigorous = ≥6.0 METs. Talk test: moderate allows conversation but not singing; vigorous limits speech to a few words.

MET-minute formula: METs × minutes = MET-minutes; weekly target roughly 500-1,000 MET-minutes for health benefit.

Sedentary rule: replace sitting time with light activity - every additional 30 min of sitting is associated with increased all-cause mortality risk independent of exercise.

Older adults (65+): add balance and flexibility training (e.g., tai chi, single-leg stance) to reduce fall risk.

Dose-response: benefits accrue from the first minute; even 10-minute bouts accumulated across the day count toward weekly totals.

Prescription format (FITT-VP): Frequency, Intensity, Time, Type, Volume, Progression - document each element in the chart.

Screening: use the PAR-Q+ or a similar tool before prescribing vigorous activity; refer to cardiology for concerning symptoms (chest pain, syncope, exertional dyspnea).

Adult sleep duration recommendation: 7-9 hours per night (National Sleep Foundation); <6 hours is associated with cardiometabolic risk.

Sleep architecture: 4-6 cycles of ~90 minutes each; slow-wave (N3) sleep dominates early cycles, REM dominates later cycles.

Sleep hygiene rule: consistent wake time 7 days/week is the strongest single behavioral anchor for circadian alignment.

Caffeine half-life ≈ 5-6 hours; avoid caffeine within 6-8 hours of bedtime to protect sleep onset latency.

Alcohol suppresses REM sleep and fragments the second half of the night despite reducing sleep latency.

Insomnia first-line treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I), not hypnotics; CBT-I has stronger long-term evidence.

Screen for sleep apnea: STOP-BANG score ≥3 warrants further evaluation; untreated OSA worsens hypertension and insulin resistance.

Light exposure: bright morning light (~10,000 lux for 30 min) advances circadian phase; evening blue light delays melatonin onset.

Sleep and weight: short sleep raises ghrelin and lowers leptin, increasing appetite and impairing glucose tolerance.

Physiologic stress response: sympathetic-adrenal-medullary axis (catecholamines, seconds) and HPA axis (cortisol, minutes-hours); chronic activation drives inflammation and insulin resistance.

Allostatic load = cumulative wear from repeated or prolonged stress adaptation; measurable via cortisol, blood pressure, waist circumference, and inflammatory markers.

Mindfulness-Based Stress Reduction (MBSR): 8-week program, ~2.5 hours/week plus a retreat day; evidence for reducing anxiety and depressive symptoms.

Diaphragmatic breathing: slow breathing at ~6 breaths/min increases vagal tone and heart rate variability (HRV); HRV is a practical biomarker of stress resilience.

Relaxation response (Benson): 10-20 min of repetitive focus plus passive disregard of intrusive thoughts, practiced daily.

Cognitive reframing: identify the stressor, appraise controllability, and apply problem-focused coping when controllable versus emotion-focused coping when not.

Screen with validated tools: PSS-10 (Perceived Stress Scale), GAD-7 for anxiety, PHQ-9 for depression; refer when scores indicate moderate-to-severe symptoms.

Burnout triad (Maslach): emotional exhaustion, depersonalization/cynicism, and reduced personal accomplishment - distinct from depression.

Stress and behavior link: chronic stress increases cortisol-driven visceral fat deposition and drives relapse in substance use and unhealthy eating.

Tobacco: no safe level of exposure; quitting before age 40 removes ~90% of the excess mortality risk of continued smoking.

5 A's framework: Ask, Advise, Assess, Assist, Arrange - the standard brief intervention structure for tobacco cessation.

First-line pharmacotherapy: varenicline (most effective monotherapy), bupropion, and nicotine replacement therapy (patch plus short-acting forms); combine counseling for best results.

Alcohol (US guidance): ≤2 drinks/day for men and ≤1 drink/day for women; one standard drink = 14 g ethanol (12 oz beer at 5%, 5 oz wine at 12%, 1.5 oz spirits at 40%).

Alcohol screening: AUDIT-C score ≥4 in men or ≥3 in women suggests hazardous drinking; single-item screen also validated.

Alcohol and cancer: ethanol is a Group 1 carcinogen; risk increases for oral, pharyngeal, esophageal, liver, colorectal, and breast cancers with any consumption.

Cannabis: evidence for harm in adolescent brain development, psychosis risk, and respiratory effects with smoked use; screen with validated tools.

Opioid risk: check prescription drug monitoring programs, co-prescribe naloxone when risk factors present, and apply the CDC opioid prescribing guideline.

Polysubstance rule: combining alcohol with sedatives (benzodiazepines, opioids) multiplies respiratory depression risk - a key counseling point.

Social isolation and loneliness are associated with ~29% increased all-cause mortality risk (Holt-Lunstad meta-analysis), comparable to smoking 15 cigarettes/day.

Loneliness = perceived deficit in social relationships; social isolation = objective lack of contacts - measure both separately.

Screening tools: UCLA 3-item Loneliness Scale and the Lubben Social Network Scale (LSNS-6) are validated brief instruments.

Social prescribing: refer patients to community groups (walking clubs, faith communities, support groups) as an evidence-based adjunct to clinical care.

Marriage/partnership and religious participation are consistently associated with lower mortality in large cohort studies (e.g., Adventist Health Study-2).

Social determinants: transportation, housing, and income constrain social connection - screen for these barriers before recommending interventions.

Caregiver burden: use the Zarit Burden Interview to identify caregivers at risk of depression and isolation.

Group-based interventions (e.g., group medical visits, peer support) improve adherence to lifestyle change more than individual counseling alone.

Lifestyle medicine pillars: whole-food plant-predominant eating, physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connections.

Behavior change model: the transtheoretical (stages of change) model - precontemplation, contemplation, preparation, action, maintenance; match intervention to stage.

Motivational interviewing: use open questions, affirmations, reflections, and summaries (OARS); avoid the righting reflex.

SMART goal rule: Specific, Measurable, Achievable, Relevant, Time-bound - patients set their own goals for autonomy and adherence.

Shared decision-making: present options, discuss risks and benefits, elicit patient values, and document the chosen plan.

Screening: use the AUDIT-C, PHQ-9, GAD-7, PSS-10, and a food/physical activity screener at baseline and follow-up.

Follow-up cadence: 2-4 week intervals early in behavior change improve adherence; longer intervals for maintenance.

Documentation: record the specific pillar addressed, the prescribed dose, and the follow-up plan - the same rigor as a medication prescription.

Self-efficacy (Bandura) predicts initiation and maintenance of lifestyle change; build mastery experiences early.

Implementation intentions: "If [situation], then I will [behavior]" - a robust planning strategy for habit formation.

Habit loop: cue → routine → reward; change the cue or environment rather than relying on willpower.

Relapse is expected - treat it as data, identify the trigger, and adjust the plan rather than labeling the patient as non-adherent.

Social support and accountability partners improve adherence in exercise and dietary interventions.

Self-monitoring (food logs, step counts, sleep diaries) is one of the strongest predictors of behavior change success.

Ambivalence is normal; use decisional balance (pros/cons) to help patients resolve it.

Health coaching: use reflective listening and open-ended questions; the patient is the expert on their own life.

Anthropometrics: BMI, waist circumference (≥102 cm men, ≥88 cm women indicates central obesity), and body composition when available.

Cardiometabolic labs: fasting glucose, HbA1c, lipid panel, hs-CRP, and liver enzymes (ALT/AST) to assess metabolic dysfunction.

HbA1c reflects ~3 months of glycemia; prediabetes = 5.7-6.4%, diabetes ≥6.5%.

Blood pressure: hypertension ≥130/80 mmHg (ACC/AHA 2017); lifestyle change is first-line for stage 1 without high risk.

Lipid targets: LDL is the primary target; plant-predominant diets reduce LDL by ~10-15% typically.

Inflammation: hs-CRP ≥3 mg/L indicates high cardiovascular risk; plant-predominant patterns lower CRP.

Vitamin B12: check serum B12 (and MMA if borderline) annually on vegan diets; deficiency causes megaloblastic anemia and neuropathy.

Vitamin D: 25-OH vitamin D target 30-50 ng/mL; supplement when deficient, especially in northern latitudes.

Iron: ferritin plus CBC; non-heme iron absorption improves with vitamin C and is inhibited by phytates and tea/coffee at meals.

Social determinants of health (SDOH): economic stability, education, health care access, neighborhood, and social context - screen with tools like the AAFP SDOH screener.

Food insecurity: screen with the Hunger Vital Sign (2-item tool); refer to SNAP, WIC, and food pantries.

Cultural tailoring: dietary recommendations must respect cultural food patterns (e.g., legumes, whole grains, and traditional vegetables across cuisines).

Older adults: increased protein needs (~1.0-1.2 g/kg/day) to prevent sarcopenia; screen for unintentional weight loss.

Pregnancy: plant-predominant diets are safe with attention to B12, iron, folate, DHA, and iodine; monitor weight gain per IOM guidelines.

Children and adolescents: growth monitoring is essential; well-planned plant-based diets meet pediatric needs with B12 and vitamin D supplementation.

Athletes: protein 1.2-2.0 g/kg/day; plant-based athletes should monitor iron, B12, vitamin D, and energy availability.

Access barrier rule: before prescribing, ask about transportation, cooking facilities, budget, and time - the plan must fit the patient's context.

Vitamin K and warfarin: leafy greens are rich in vitamin K; keep intake consistent rather than avoiding greens, and monitor INR.

Grapefruit and statins: grapefruit inhibits CYP3A4, raising simvastatin and atorvastatin levels - counsel avoidance or switch statin.

Potassium and ACE inhibitors/ARBs: high-potassium plant foods may require monitoring in renal impairment or with RAAS blockade.

Metformin and B12: long-term metformin use lowers B12; monitor annually and supplement if deficient.

PPIs and B12/magnesium: long-term PPI use reduces B12 and magnesium absorption; monitor and supplement.

MAOIs and tyramine: aged foods, fermented soy, and some plant foods high in tyramine can trigger hypertensive crisis.

Warfarin and alcohol: acute heavy drinking raises INR; chronic heavy drinking lowers it - counsel consistency.

Deprescribing: when lifestyle change improves biomarkers, reassess medication doses (e.g., antihypertensives, insulin) to avoid hypoglycemia or hypotension.

Motivational interviewing (MI) spirit: partnership, acceptance, compassion, evocation - the patient holds the expertise.

OARS: Open questions, Affirmations, Reflections, Summaries - core MI skills.

Change talk (desire, ability, reasons, need) predicts behavior change; sustain talk predicts status quo - elicit and reinforce change talk.

Decisional balance: list pros and cons of changing versus not changing to resolve ambivalence.

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; set by the patient, not the clinician.

Self-monitoring and feedback loops (step counts, food logs) improve adherence more than education alone.

Follow-up intervals of 2-4 weeks early in change improve retention; taper to 3-6 months for maintenance.

Relapse prevention: identify high-risk situations, plan coping responses, and rehearse them in advance.

Circadian rhythm is entrained by light; the suprachiasmatic nucleus (SCN) is the master clock.

Melatonin onset occurs ~2 hours before habitual bedtime (dim-light melatonin onset, DLMO).

Sleep debt: cumulative short sleep impairs glucose tolerance and increases appetite via ghrelin/leptin shifts.

Shift work is classified as a probable carcinogen (IARC Group 2A) and raises cardiometabolic risk.

OSA screening: STOP-BANG ≥3 warrants a sleep study; untreated OSA worsens hypertension and insulin resistance.

CBT-I components: stimulus control, sleep restriction, cognitive restructuring, relaxation, and sleep hygiene education.

Naps: short naps (≤30 min) before 3 pm do not typically impair nighttime sleep; long late naps do.

Sleep and mood: insomnia doubles the risk of depression; treat sleep to improve mental health outcomes.

HPA axis: hypothalamus → CRH → pituitary → ACTH → adrenal cortex → cortisol; cortisol peaks ~30 min after waking (cortisol awakening response).

Sympathetic nervous system: rapid catecholamine release (epinephrine, norepinephrine) within seconds.

HRV (heart rate variability) is a practical index of autonomic flexibility; higher HRV generally indicates better stress resilience.

Allostatic load: cumulative physiologic wear from chronic stress; measured via cortisol, BP, waist circumference, and inflammatory markers.

Mindfulness-based interventions: MBSR (8 weeks) and MBCT reduce anxiety and depressive symptoms in randomized trials.

Diaphragmatic breathing at ~6 breaths/min increases vagal tone and reduces sympathetic arousal.

Cognitive appraisal (Lazarus): stress = primary appraisal of threat × secondary appraisal of coping resources.

Burnout (Maslach): exhaustion, cynicism, and reduced efficacy - distinct from depression and treated with workload and organizational interventions.

5 A's: Ask, Advise, Assess, Assist, Arrange - brief intervention framework for tobacco and alcohol.

Tobacco pharmacotherapy: varenicline is most effective monotherapy; combine with counseling for best quit rates.

Nicotine replacement: patch for baseline plus short-acting (gum, lozenge) for cravings; combination therapy outperforms monotherapy.

Alcohol: AUDIT-C ≥4 (men) or ≥3 (women) indicates hazardous drinking; brief intervention reduces consumption.

Alcohol withdrawal: benzodiazepines are first-line for significant withdrawal; thiamine before glucose to prevent Wernicke encephalopathy.

Opioid use disorder: buprenorphine and methadone reduce mortality; naloxone reverses overdose.

Cannabis: screen with validated tools; counsel on psychosis risk in adolescents and respiratory harm with smoked use.

Polysubstance risk: alcohol plus sedatives multiplies respiratory depression - a key counseling point.

Loneliness is a perceived deficit; social isolation is an objective lack of contacts - measure both separately.

Holt-Lunstad meta-analysis: social isolation raises all-cause mortality risk by ~29%, comparable to smoking 15 cigarettes/day.

Screening tools: UCLA 3-item Loneliness Scale and LSNS-6 (Lubben Social Network Scale).

Social prescribing: refer to community groups, walking clubs, faith communities, and support groups as adjuncts to clinical care.

Caregiver burden: Zarit Burden Interview identifies caregivers at risk; respite care and support groups help.

Group-based interventions improve adherence to lifestyle change more than individual counseling alone.

SDOH barriers (transportation, housing, income) constrain social connection - screen before recommending interventions.

Digital connection: video calls reduce loneliness in older adults when in-person contact is limited.

Six pillars: whole-food plant-predominant eating, physical activity, restorative sleep, stress management, avoidance of risky substances, positive social connections.

FITT-VP for exercise prescription: Frequency, Intensity, Time, Type, Volume, Progression.

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound - set by the patient.

Follow-up cadence: 2-4 weeks early in change, tapering to 3-6 months for maintenance.

Documentation: record the pillar addressed, the prescribed dose, and the follow-up plan - same rigor as a medication prescription.

Screening battery: AUDIT-C, PHQ-9, GAD-7, PSS-10, food/physical activity screener, and sleep screener at baseline.

Deprescribing: reassess antihypertensives and insulin when lifestyle change improves biomarkers to avoid hypoglycemia or hypotension.

Shared decision-making: present options, discuss risks/benefits, elicit values, document the chosen plan.

Metabolic syndrome: ≥3 of - waist circumference (≥102 cm men, ≥88 cm women), triglycerides ≥150 mg/dL, HDL <40 (men)/<50 (women), BP ≥130/85, fasting glucose ≥100 mg/dL.

Prediabetes: HbA1c 5.7-6.4%, fasting glucose 100-125 mg/dL, or 2-hour OGTT 140-199 mg/dL.

Diabetes: HbA1c ≥6.5%, fasting glucose ≥126 mg/dL, or 2-hour OGTT ≥200 mg/dL.

Hypertension: ≥130/80 mmHg (ACC/AHA 2017); lifestyle change is first-line for stage 1 without high risk.

LDL is the primary lipid target; plant-predominant diets typically lower LDL by ~10-15%.

hs-CRP ≥3 mg/L indicates high cardiovascular risk; plant-predominant patterns lower CRP.

Plant-predominant diets reduce HbA1c by ~0.3-0.5% in type 2 diabetes in randomized trials.

Weight loss of 5-10% of body weight improves glycemia, BP, and lipids meaningfully.

Vitamin B12: supplement required on vegan diets (e.g., 2,000-2,500 mcg weekly or 250 mcg daily); deficiency causes megaloblastic anemia and neuropathy.

Vitamin D: target 25-OH vitamin D 30-50 ng/mL; supplement when deficient, especially in northern latitudes.

Iron: non-heme iron absorption improves with vitamin C and is inhibited by phytates, tannins, and calcium at meals.

Zinc: phytates reduce absorption; soaking, sprouting, and leavening improve bioavailability.

Iodine: seaweed and iodized salt are sources; excess seaweed can cause thyroid dysfunction.

Calcium: aim 1,000-1,200 mg/day from fortified plant milks, calcium-set tofu, leafy greens, tahini, and almonds.

Omega-3: algae-based EPA/DHA supplements are the direct plant source; flax and chia supply ALA only.

Fiber: target 25-38 g/day; increase gradually with fluids to avoid bloating.

Aerobic: 150-300 min/week moderate OR 75-150 min/week vigorous, or an equivalent combination.

Muscle-strengthening: ≥2 sessions/week covering all major muscle groups.

Moderate intensity = 3.0-5.9 METs; vigorous = ≥6.0 METs; use the talk test for practical assessment.

MET-minutes = METs × minutes; aim for ~500-1,000 MET-minutes/week.

Older adults: add balance and flexibility training (tai chi, single-leg stance) to reduce fall risk.

Sedentary behavior: replace sitting with light activity - prolonged sitting raises mortality risk independent of exercise.

PAR-Q+ screens for exercise readiness before vigorous activity; refer concerning symptoms to cardiology.

Progression: increase volume by ~10% per week to reduce injury risk.

Adult sleep duration: 7-9 hours per night; <6 hours is associated with cardiometabolic risk.

Sleep architecture: 4-6 cycles of ~90 minutes; slow-wave sleep dominates early, REM dominates later cycles.

CBT-I is first-line for chronic insomnia; it outperforms hypnotics long-term.

Caffeine half-life ≈ 5-6 hours; avoid within 6-8 hours of bedtime.

Alcohol suppresses REM sleep and fragments the second half of the night.

STOP-BANG ≥3 warrants a sleep study for suspected OSA.

Bright morning light (~10,000 lux for 30 min) advances circadian phase; evening blue light delays melatonin onset.

Short sleep raises ghrelin and lowers leptin, increasing appetite and impairing glucose tolerance.

PSS-10 measures perceived stress over the past month; higher scores indicate greater stress.

GAD-7 screens for generalized anxiety; scores ≥10 suggest moderate anxiety warranting further evaluation.

PHQ-9 screens for depression; scores ≥10 suggest moderate depression warranting treatment.

Burnout triad: emotional exhaustion, depersonalization/cynicism, reduced personal accomplishment.

MBSR: 8-week program with evidence for reducing anxiety and depressive symptoms.

HRV is a practical biomarker of autonomic flexibility and stress resilience.

Cognitive appraisal: stress = primary appraisal of threat × secondary appraisal of coping resources.

Refer to mental health services when screening scores indicate moderate-to-severe symptoms or safety concerns.

5 A's: Ask, Advise, Assess, Assist, Arrange.

Varenicline is the most effective single-agent pharmacotherapy for tobacco cessation.

Combination NRT (patch plus short-acting) outperforms monotherapy.

Quitting before age 40 removes ~90% of the excess mortality risk of continued smoking.

Alcohol standard drink = 14 g ethanol (12 oz beer at 5%, 5 oz wine at 12%, 1.5 oz spirits at 40%).

AUDIT-C ≥4 (men) or ≥3 (women) indicates hazardous drinking.

Ethanol is a Group 1 carcinogen; any consumption raises risk for several cancers.

Thiamine before glucose in alcohol withdrawal to prevent Wernicke encephalopathy.

Loneliness = perceived deficit; isolation = objective lack of contacts - screen both.

UCLA 3-item Loneliness Scale and LSNS-6 are validated brief screeners.

Social prescribing refers patients to community groups as an evidence-based adjunct.

Group-based interventions improve adherence to lifestyle change more than individual counseling alone.

Caregiver burden: Zarit Burden Interview identifies at-risk caregivers; respite care helps.

SDOH barriers (transportation, housing, income) constrain social connection - screen first.

Religious participation and partnership are associated with lower mortality in large cohorts.

Video calls reduce loneliness in older adults when in-person contact is limited.

Transtheoretical model: precontemplation, contemplation, preparation, action, maintenance - match intervention to stage.

Self-efficacy (Bandura) predicts initiation and maintenance; build mastery experiences early.

Implementation intentions: "If [situation], then I will [behavior]" - a robust planning strategy.

Habit loop: cue → routine → reward; change the cue or environment rather than relying on willpower.

Decisional balance (pros/cons) resolves ambivalence.

Self-monitoring (food logs, step counts, sleep diaries) strongly predicts success.

Relapse is expected - treat it as data and adjust the plan.

Change talk predicts behavior change; sustain talk predicts status quo.

MI spirit: partnership, acceptance, compassion, evocation.

OARS: Open questions, Affirmations, Reflections, Summaries.

Avoid the righting reflex - resist arguing for change.

Reflections should outnumber questions in a good MI conversation.

Elicit change talk (desire, ability, reasons, need) and reinforce it.

Decisional balance helps resolve ambivalence without pushing.

SMART goals are set by the patient to preserve autonomy.

Follow-up intervals of 2-4 weeks early in change improve retention.

24-hour recall: quick, low burden, but relies on memory and may not reflect usual intake.

Food frequency questionnaire (FFQ): captures usual intake over weeks-months; used in large cohorts.

Food records (3-7 days): detailed but high burden; record at the time of eating to reduce recall bias.

Mediterranean diet score (e.g., PREDIMED 14-item) quantifies adherence to a plant-predominant pattern.

Hunger Vital Sign (2 items) screens for food insecurity.

Biomarkers (HbA1c, lipids, B12, ferritin) complement self-report and reduce misreporting bias.

Assess the whole pattern, not single nutrients - patterns predict outcomes better than isolated foods.

Cultural tailoring: ask about traditional foods and adapt recommendations accordingly.

Ornish program: intensive lifestyle change regressed coronary atherosclerosis in randomized trials.

Esselstyn: plant-based diet plus statins arrested/reversed coronary disease in a small case series.

PREDIMED: Mediterranean diet plus olive oil or nuts reduced major cardiovascular events by ~30%.

Diabetes Prevention Program: intensive lifestyle change reduced progression to diabetes by 58%.

Adventist Health Study-2: plant-predominant patterns associated with lower all-cause mortality.

EPIC-Oxford: vegetarians had lower ischemic heart disease mortality than meat-eaters.

Holt-Lunstad: social isolation raises mortality risk by ~29%.

Look AHEAD: intensive lifestyle intervention improved fitness and glycemia but did not reduce cardiovascular events in type 2 diabetes.

Pregnancy: plant-predominant diets are safe with attention to B12, iron, folate, DHA, and iodine.

Children: growth monitoring is essential; well-planned plant-based diets meet needs with B12 and vitamin D supplementation.

Older adults: protein ~1.0-1.2 g/kg/day to prevent sarcopenia; screen for unintentional weight loss.

Athletes: protein 1.2-2.0 g/kg/day; monitor iron, B12, vitamin D, and energy availability.

Renal disease: monitor potassium and phosphorus; plant proteins may be preferable but require individualized planning.

Type 2 diabetes: plant-predominant diets reduce HbA1c by ~0.3-0.5% in randomized trials.

Cardiovascular disease: plant-predominant diets lower LDL by ~10-15% and reduce events.

Access barriers: ask about transportation, cooking facilities, budget, and time before prescribing.

Warfarin and vitamin K: keep leafy green intake consistent; monitor INR rather than avoiding greens.

Grapefruit and statins: CYP3A4 inhibition raises simvastatin and atorvastatin levels - counsel avoidance or switch statin.

Potassium and ACE inhibitors/ARBs: high-potassium plant foods may require monitoring in renal impairment.

Metformin lowers B12 with long-term use; monitor annually and supplement if deficient.

PPIs reduce B12 and magnesium absorption with long-term use; monitor and supplement.

MAOIs and tyramine: aged and fermented foods can trigger hypertensive crisis.

Deprescribing: reassess antihypertensive and insulin doses when lifestyle change improves biomarkers.

Alcohol and warfarin: acute heavy drinking raises INR; chronic heavy drinking lowers it - counsel consistency.

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound - set by the patient.

Start with a goal the patient is confident about (≥7/10 confidence) to build self-efficacy.

Self-monitoring and feedback loops improve adherence more than education alone.

Follow-up cadence: 2-4 weeks early, tapering to 3-6 months for maintenance.

Relapse prevention: identify high-risk situations and rehearse coping responses in advance.

Accountability partners and social support improve adherence in exercise and dietary interventions.

Health coaching uses reflective listening and open-ended questions - the patient is the expert.

Document the pillar, dose, and follow-up plan with the same rigor as a medication prescription.

AUDIT-C screens for hazardous alcohol use; ≥4 (men) or ≥3 (women) is positive.

PHQ-9 and GAD-7 screen for depression and anxiety; scores ≥10 warrant further evaluation.

PSS-10 measures perceived stress; higher scores indicate greater stress burden.

STOP-BANG ≥3 warrants a sleep study for suspected OSA.

Hunger Vital Sign (2 items) screens for food insecurity.

PAR-Q+ screens for exercise readiness before vigorous activity.

UCLA 3-item Loneliness Scale and LSNS-6 screen for social isolation.

Annual labs on plant-based diets: B12, 25-OH vitamin D, ferritin, CBC, and metabolic panel.

Six pillars: whole-food plant-predominant eating, physical activity, restorative sleep, stress management, avoidance of risky substances, positive social connections.

Assess all six pillars at baseline to identify the highest-yield target for change.

Match intervention to stage of change - precontemplators need information, not action plans.

Use shared decision-making: present options, discuss risks/benefits, elicit values, document the plan.

Set SMART goals the patient chooses to preserve autonomy and adherence.

Follow up in 2-4 weeks early in change to reinforce and adjust.

Deprescribe when biomarkers improve to avoid hypoglycemia or hypotension.

Document the pillar, dose, and follow-up plan - same rigor as a medication prescription.

Emphasize vegetables, fruits, whole grains, legumes, nuts, and seeds; limit animal products and highly processed foods.

Fiber target: 25-38 g/day from whole grains and legumes.

Protein: legumes, soy, whole grains, nuts, and seeds supply all essential amino acids; no need to pair at each meal.

Fat quality: prioritize unsaturated fats (olive oil, nuts, avocado, seeds) over saturated fat.

Sodium: keep under 2,300 mg/day (ideally 1,500 mg with hypertension).

Added sugar: limit to <10% of calories per dietary guidelines.

Calcium: 1,000-1,200 mg/day from fortified milks, calcium-set tofu, leafy greens, tahini, and almonds.

Replace, don't just restrict - swap red meat for legumes and refined grains for whole grains to preserve satiety.

PAR-Q+ screens for exercise readiness before vigorous activity.

Refer to cardiology for chest pain, syncope, or exertional dyspnea before prescribing vigorous exercise.

Moderate intensity allows conversation but not singing; vigorous limits speech to a few words.

Progression: increase volume by ~10% per week to reduce injury risk.

Older adults: add balance training (tai chi, single-leg stance) to reduce fall risk.

Hydration and heat: adjust intensity in hot weather and monitor for heat illness.

Diabetes: monitor glucose before and after exercise; carry fast-acting carbohydrate.

Sedentary behavior: replace sitting with light activity throughout the day.

Consistent wake time 7 days/week is the strongest circadian anchor.

Caffeine half-life ≈ 5-6 hours; avoid within 6-8 hours of bedtime.

Alcohol suppresses REM sleep and fragments the second half of the night.

CBT-I components: stimulus control, sleep restriction, cognitive restructuring, relaxation, and sleep hygiene education.

Stimulus control: use the bed only for sleep and intimacy; leave the bed if awake >20 min.

Sleep restriction: limit time in bed to actual sleep time to consolidate sleep.

Bright morning light advances circadian phase; evening blue light delays melatonin onset.

Naps ≤30 min before 3 pm do not typically impair nighttime sleep.

Diaphragmatic breathing at ~6 breaths/min increases vagal tone and HRV.

MBSR: 8-week program with evidence for reducing anxiety and depressive symptoms.

Relaxation response (Benson): 10-20 min of repetitive focus plus passive disregard of intrusive thoughts, daily.

Progressive muscle relaxation reduces physiologic arousal.

Cognitive reframing: appraise controllability and use problem-focused coping when controllable.

HRV is a practical biomarker of stress resilience.

Chronic stress increases cortisol-driven visceral fat and drives relapse in substance use and unhealthy eating.

Refer to mental health services when screening scores indicate moderate-to-severe symptoms.

AUDIT-C: 3 items; ≥4 (men) or ≥3 (women) indicates hazardous drinking.

Single-item alcohol screen: "How many times in the past year have you had 5+ (men) or 4+ (women) drinks in a day?"

5 A's: Ask, Advise, Assess, Assist, Arrange.

Tobacco: varenicline is the most effective single agent; combination NRT outperforms monotherapy.

Opioid risk: check prescription drug monitoring programs and co-prescribe naloxone when risk factors present.

Cannabis: screen with validated tools; counsel on psychosis risk in adolescents.

Polysubstance risk: alcohol plus sedatives multiplies respiratory depression.

Thiamine before glucose in alcohol withdrawal to prevent Wernicke encephalopathy.

Social isolation raises all-cause mortality risk by ~29% (Holt-Lunstad meta-analysis).

Loneliness is a perceived deficit; isolation is an objective lack of contacts.

UCLA 3-item Loneliness Scale and LSNS-6 are validated brief screeners.

Social prescribing refers patients to community groups as an evidence-based adjunct.

Group-based interventions improve adherence to lifestyle change more than individual counseling alone.

Caregiver burden: Zarit Burden Interview identifies at-risk caregivers.

SDOH barriers (transportation, housing, income) constrain social connection.

Religious participation and partnership are associated with lower mortality in large cohorts.

Record the pillar addressed, the prescribed dose, and the follow-up plan.

FITT-VP for exercise: Frequency, Intensity, Time, Type, Volume, Progression.

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound.

Baseline screening battery: AUDIT-C, PHQ-9, GAD-7, PSS-10, food/physical activity screener, sleep screener.

Follow-up cadence: 2-4 weeks early, tapering to 3-6 months for maintenance.

Deprescribing: reassess antihypertensives and insulin when biomarkers improve.

Shared decision-making: present options, discuss risks/benefits, elicit values, document the plan.

Relapse is expected - document the trigger and the adjusted plan.