Diet Training Manual

A Low-Fat Diet for Fatigue in Multiple Sclerosis Participant Manual

Dietitian: Carly Vong, MPH, RD, LD Tel. 503-494-0174 E-mail: vong@ohsu.edu Study Coordinator: Emma Chase, MS Tel. 503-494-3549 E-mail: chaseem@ohsu.edu Principal Investigator: Vijayshree Yadav, MD Tel. 503-494-5759

OHSU MS WELLNESS RESARCH CENTER

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Table of Contents 1. INTRODUCTION Diet & MS

4

Study diet parameters

5

Carbohydrate, protein, and fat guidelines

6

Foods to avoid

10

Tracking and measuring fat

11

Using a food log Managing cravings

12 13 15

How to get started 2. TOOLS Fat contents of common foods Serving size estimates

17 21

Daily food log template

26

Weekly menu planner template

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3. GROCERY SHOPPING Grocery shopping tips

38

Choosing groceries How to read nutrition labels

39 40

4. COOKING Low-fat cooking tips

43

Suggested cookware Cooking without oil

44 45 46

Meal prep or batch cooking Building a balanced, low-fat meal Staying full and satisfied, countering cravings Adapting recipes

48 51 53

5. DINING OUT Dining out tips

57

Suggested meals (what to order, what to avoid)

59

1

Intoduction 2

Diet and Multiple Sclerosis In spite of growing demand for advice from people living with MS on wellness, lifestyle choices, and daily habits, there is little “hard” evidence about the role that diet might play in MS. Although there are several diets that are popular among people with MS such as the Swank, McDougall, and Wahls diets, not enough research exists to prove that they help MS. Yet common sense tells us that eating a healthy diet that benefits overall health will likely also help MS. Studies show that obesity may be a risk factor for developing MS, and that having high blood pressure, high cholesterol, and diabetes cause MS to progress faster.

Changes in diet can improve obesity, high blood pressure, high cholesterol, and diabetes.

Due to the limited number of scientifically rigorous studies addressing the beneficial effects of diet in MS, most neurologists do not make any dietary recommendations for their patients with MS.

Why study a low-fat diet for MS?

The Swank Studies Dr Roy Swank believed that a very low-fat diet could be used as a treatment for MS. Between 1950 and 2000, He did a series of studies that showed positive outcomes in people with MS following a very low fat diet.

Although the study results were not widely accepted by the scientific community, before the introduction of disease modifying therapies, the “Swank Diet” was widely used

by MS patients and is still followed by many patients today.

1950-2000

A low-fat, plant based diet In 2016, the MS group at OHSU completed a trial investigating a very low-fat, vegan diet. Half of the participants followed the lowfat diet and half of them followed their usual diet for a period of one year.

Early on in the study, participants following the study diet reported feeling less fatigue. Over the course of the study, levels of fatigue decreased significantly.

2016 3

The Diet The main aim of the study is to reduce daily fat intake to less than 20% of daily calories. This can represent a big adjustment, and it should happen gradually. By the time you have completed all four training sessions, no more than 20% of the calories you eat each day should come from fat.

Eating a diet that includes a wide range of natural, unprocessed foods is part of a healthy lifestyle. Although there are many ways to follow a low-fat diet, we encourage you to minimize the number of processed foods in your diet and focus instead on fruits, vegetables, whole grains, and lean protein whether fresh, frozen, or canned.

To follow the diet successfully, DO

DO NOT

 Eat lots of fruits, vegetables, fiber and starches.  Get protein from lean chicken, fish, egg whites, or tofu and soy products.  Use spices and seasonings to add flavor to meals instead of oily sauces and dressings.  Drink caffeine and alcohol in moderation. (12 cups of coffee or tea per day, 1 serving of alcohol per day).  Look for foods that contain few ingredients, are low-fat, unsweetened, and contain no added sugars.

 Eat dairy or red meat (beef, pork, or lamb),  Use protein powders made from animal sources such as whey protein  Take fish oil or flax seed supplements,  Take B12, vitamin D, or other dietary supplements unless recommended by your neurologist or primary care provider.

A note about saturated fats: Saturated fats are primarily found in animal products like meat and dairy. Because you will be eating a diet low in total fat and very little animal fat, your saturated fat intake should easily meet a healthy recommendation of less than 7% of total daily calories.

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NUTRITION 20% of the calories you eat each day should come from fat, 20% should come from protein, and 60% should come from carbohydrates.

Fat 20% Fish, chicken, turkey, nuts, seeds, and oils Carbohydrates 60% fruits, vegetables, grains, and starches like rice, noodles, and potatoes

Protein 20%

Fish, chicken, turkey, egg whites, and tofu or soy

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CARBOHYDRATES Use the general guidelines below when planning your meals.

Try to have at least 4 to 8 servings (2 to 4 cups) daily. Aim to make half of the grains you eat whole instead of refined.

GRAINS

Examples of 1 serving of grains:  1 slice of bread  6-8 inch tortilla or pita bread  1/2 cup of cereal  1/2 cup of cooked rice or pasta  3 cups of air-popped popcorn Try to have 2 to 5 servings (1 to 3 cups) daily. If you’re hungry, you can fill up on these.

STARCHES

Example of 1 serving of starch:  1 small baked potato (or sweet potato)  ½ cup mashed potato  ½ cup of corn or green peas  1 cup of winter squash (acorn, butternut, pumpkin) Try to have 5 to 10 servings (2 ½ to 5 cups) daily. If you’re hungry, fill up on these.

VEGETABLES

FRUIT

Examples of 1 serving of vegetables:  1 cups of raw leafy vegetables  1 cup of salad greens  1 cup of raw vegetables  ½ cup of cooked vegetables  ¾ cup (6 oz.) carrot or tomato juice Try to have 2 to 4 servings (2-4 cups) daily. Eat fruit on its own, or add to salads, yogurt, etc.

For Example:  1 piece of fresh fruit (medium apple, banana, orange, nectarine, peach, or kiwi)  1 cup of fresh berries  ½ cup (4 oz.) unsweetened juice 6

PROTEIN & FAT Many foods which are high in protein also contain fat. As a general rule, half of the fat in your diet should come from the protein sources below. Fill the rest of your fat allowance with whole plant-based fats like avocado, olives, nuts, and seeds. Use oil (even olive oil) last. For a full list of protein sources and their fat content, see the fat content index in section 2 (“Tools”).

Note: One 4 oz. serving of chicken, fish, or tofu is about the size of a deck of cards.

Lean chicken and turkey are allowed.

For example (fat content in parentheses for one 4 oz. serving): CHICKEN & TURKEY  Deli chicken (1 g)  Extra lean or fat-free ground turkey (1.5 g)  Chicken breast, boneless skinless (fillet) (2 g) Lean fish is allowed.

FISH

For example (fat content in parentheses for one 4 oz. serving):  Cod (1 g)  Canned Tuna (1-2 g)  Halibut (2 g)  Sole (3 g)  Sea bass (3 g)  Tilapia fillet (1-3 g)  Coho Salmon (5-6 g) Caution:  Bluefin Tuna (7 g)  Sockeye Salmon (9 g)  Chinook Salmon (15 g)

EGG WHITES

Egg whites are allowed on the diet without restriction. Use egg whites as a source of fat-free protein. Do not eat egg yolks.

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In general, have soy products as a whole, cooked bean or lowprocessed. For example: edamame, tofu, soy milk. Use soy cheese and soy sauce sparingly.

For example:  Tofu (1-10 g fat per 4 oz. serving, see note below)  Shelled Edamame (4-6 g fat per half-cup)  Soy milk (4g fat per cup) TOFU & SOY PRODUCTS

DO:  Splash a little soy milk on your morning cereal.  Add a few ounces of tofu to a stir-fry.  Season grains with a squirt of soy sauce Caution: Tempeh contains 11g of fat in just 4 oz.

Note: Tofu comes in several forms or consistencies (silken, soft, firm, and super firm). When it comes to fat, not all tofu is created equal.

Choose silken or soft tofu (2-5 g fat per 4 oz) rather than super firm (9 g fat per 4 oz).

Although good sources of protein, nuts and seeds are very high in fat.

Even if you’re just sprinkling some on your hot cereal or in a salad, be sure to measure and count the fat.

NUTS & SEEDS

For example (fat content in parentheses):  Almond milk, 1 cup (8 oz), (3g)  Peanut butter, 2 Tbsp (16 g)  Mixed nuts, ¼ cup (15 g)  Cashews, ¼ cup (13 g)  Almonds, ¼ cup (15 g)  Walnuts, ¼ cup (20 g)  Pecans, ¼ cup (21 g)  Pine nuts, ¼ cup (20 g)  Sesame seeds, 2 Tbsp (18 g)  Flaxseeds, whole, 2 Tbsp (24 g) 8

FOODS TO AVOID RED MEAT

DAIRY

SHELLFISH

    

Pork Beef Lamb Venison Meat broths/stock

   

Milk, yogurt Cheese, Cream Cheese Ice Cream Sour Cream

 Fish sauce  Crab  Shrimp, shrimp paste, and stock When possible, try to avoid these processed foods. These are foods that have low or no nutritional value and may contain undesirable additives:    

PROCESSED FOODS

    

Candies Soft drinks Fried foods Fake meats (also known as meat analogs) which include ingredients like soy protein isolate Breakfast bars Sweetened cereals “Diet products” including: sugar-free, some fat-free, or lowcarbohydrate foods.

Store-bought dips, sauces, marinades, and salad dressings.

Frozen meals

In general, avoid ingredients which include words like modified, textured, autolyzed, and hydrolyzed.

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TRACKING & MEASURING FAT No more than 20% of the calories you eat each day should come from fat. You should precisely keep track of the amount of fat in each meal or food item you consume.

Count all fat, even oil used to coat frying and baking pans. Use our fat tracker (copies available in section 2, “Tools”, or an app like “My Fitness Pal” to keep track of your fat intake. See Cooking Without Oil in section 4 for alternative ways to make your cookware ‘non-stick’.

Measure. Whether it’s oiling a pan or adding nuts to a salad, know how much fat you’re eating. Use standardized measuring cups and spoons.

When in doubt, overestimate. If you can’t measure exactly (for example, if you are out to eat at a restaurant); It is better to overestimate than underestimate the fat content of a meal. Use the “Serving Size Estimates” packet in section 2 (“Tools”) which will help you estimate portion sizes.

When following a recipe, count fat grams for each of the ingredients.  When using fresh ingredients (do this as much as possible!), use an online food database or refer to the Fat Content Index provided in section 2, “tools”, to look up the fat content of various foods.  When using packaged ingredients, find fat information on the nutrition label.

Fat content for each recipe in the study cookbook has been provided. This is a great resource for days you don’t have time to do the math.

Counting Fat When Out to Eat: Some chain restaurants provide nutrition information for menu items. For tips about eating out, see section 5, “Dining Out”.

Use Apps to keep track of fat grams. Smartphone Apps like “My Fitness Pal” can make it easy to keep track of the fat consumption and nutrition information.

However, the nutrition database can be publically edited and is not always reliable. Check the fat content for each entry yourself and save the information so you can easily use it again later. Use the “fat content index” in the tools section to for an easy way to estimate fat content 10 of common foods.

TIP: USE A DAILY FOOD LOG TO TRACK THE FAT YOU EAT Food/Beverage

Serving Size

Calories per serving

Fat per serving

Total Calories*

Total Fat*

Whole wheat pancakes Box mix made with water Maple syrup Mixed berries

3

230

2

230

2

¼ cup 1 cup

210 70

0 0

420 70

0 0

Coffee with soy creamer

1 Tbsp

15

1.5

30

3

2 slices 4 oz 1 Tbsp

195 100 50 10 10 7

2 2 5 0 0 0

195 100 50 10 20 7

2 2 5 0 0 0

Popcorn

3 cups

95

1.5

95

1.5

Orange

1

90

0

90

0

4 oz 1 ½ cups 2 Tbsp 3 pieces 1 Tbsp 3 cups

125 360 25 105 140 25

2 3 0 6 14 0.5

125 360 25 105 140 25

2 3 0 6 14 0.5

2097

41

Turkey sandwich Sliced bread Deli turkey Vegan mayo (reduced fat) lettuce tomato Dill pickle spear

Chicken & pasta dish Chicken breast Whole wheat linguine Chopped garlic Sun-dried tomatoes Olive oil Spinach Total

*Multiply by number of servings eaten 11

MANAGING FOOD CRAVINGS Food cravings are strong desires for specific foods (often foods high in sugar, salt, and fat) that can be a challenging part of starting a new way of eating. Although cravings can be a sign that your diet is lacking certain nutrients, often they are related to other factors like mood and can be managed with lifestyle changes. Use the tips below to help avoid or curb cravings.  Set realistic goals and expectations. Decreasing sugar or fat intake in a way that’s realistic and not too restrictive serves as a good recipe for long-term success. Food cravings tend to be stronger in individuals who are dieting or otherwise restricting a particular food. In other words, we’re more likely to crave what we know can’t have. If you love a certain food, find a balanced way to include it in your life, or find a healthful and satisfying substitute.  If you do “splurge” with high sugar or fat foods, limit yourself to a small amount as a treat and then get back on track.  Stay hydrated. An intense craving for any food is often mistaken as hunger when in reality it may mean you’re dehydrated. Sip on liquids throughout the day. Before you reach for something sweet, trying having a full glass of water first. You may realize you weren’t really hungry after all.  De-stress. Food cravings can arise to satisfy emotional needs, such as to calm stress and reduce anxiety. Carbohydrates increase our levels of the hormone serotonin, which has a calming effect, and fat and sugar may have a similar effect. Find relaxing activities to do, such as listening to music, spending time outdoors, or connecting with a good friend.  Get rest and regulate your schedule. We are more vulnerable to cravings if we get overly hungry, tired, or stressed. Eating small, healthy meals throughout the day may reduce cravings.  Be mindful of when you eat and what you are eating. In his book Food Rules: An Eater’s Manual, food author Michael Pollan reminds us to “eat when you are hungry, not when you are bored. If you’re not hungry enough to eat an apple, then you’re not hungry.”

There may be sudden situations or “triggers” that tempt us to eat, such as seeing free donuts and coffee in the break room. Ask yourself some questions: How is this food going to make me feel afterward? When was the last time I had something to eat? Does my body need food right now? Does eating this fit with my nutrition plan for the day?

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 When you decide to eat, take only what you need (don’t just “graze”). Enjoy your food without eating too fast. Eat slowly and enjoy those who are with you and where you are.  Satisfy sugar cravings with whole foods, like fresh fruits, that pack a burst of natural sweetness. These have the benefits of fiber, protein and trace minerals, which enhance your nutrient intake and promote feelings of full and satisfaction.  Dates: For an easy snack, slice open a few, remove the pit and insert a nut — an almond works perfectly — and they’re ready to pack or eat!  Baked Fruit: baking enhances fruits’ natural sweetness. Try grilling fruit or baking fresh fruit on a sheet pan with coconut oil. Apples, pears and peaches are great baked with a pinch of cinnamon or drizzle of honey.  Oatmeal with Maple Syrup: the warmth and sweetness of oats and syrup is an ultimate comforter. If you’re looking for a sweet, warm and nourishing meal, consider this. It can be ready in minutes!  Black Tea with Honey: A craving for sweets might actually signify a craving for energy. For a healthy pick me up with a little sweetness added, try this combo. A cozy, comfort drink with less caffeine than coffee and the added benefit of hydration.

Keep a log of your cravings To hone in on what you’re really craving, make it a point to spot your patterns. A “cravings journal” can help you notice important connections, which may not even be about food!

Instead of a cookie every afternoon, you might just really need a break from your desk. Notice when you may be operating on autopilot, such as grabbing potato chips while watching TV. Finally, avoid letting yourself get too hungry. Hunger makes cravings more difficult to resist.

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HOW TO GET STARTED Know your “baseline”. Do you pay attention to what you eat in a day?

Before you change your habits, keep a diary of everything you eat for at least two full days. (If you can, go a full week). This will help you determine what steps you need to take to adapt to the study diet.

Make plans. Plan meals and snacks and make shopping lists ahead of time to ensure you always have a low-fat food on hand. This will make it easier to stick to this eating plan. You won’t reach for something non-dietcompliant at the last minute.

Use the recipes provided in the cookbook. The fat content per serving is already calculated for each recipe, and all ingredients are diet-compliant.

Prepare your kitchen. Keep the essentials handy: measuring cups and spoons, food storage containers, a crock pot or your cooking gadgets of choice.

Avoid temptation: Start by getting rid of processed foods and snacks in your home or work environments that are high in fat.

Be patient- and realistic. Behavior change doesn’t happen overnight. Give yourself time to adjust to a new way of shopping, cooking, and eating. A small slip-up is not the end of the world.

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Notes

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Tools

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FAT CONTENT INDEX Use this guide to estimate the fat content of the foods you eat. All numbers are approximate. Use nutrition labels for more accurate information whenever you can.

Fish (Per 4 ounce portion, cooked without oil): Fish

Total fat (g) 0.6 0.7 1

Sat fat (g)

Calories

Protein (g)

0.1 0.2 0.3

96 147 131

21 33 29

1 1 1 2 2 3 3 1-3 5

0.2 0 0 0.4 0.4 0.7 1 0.5-2 1.2

119 90-120 100 100-126 145 100 141 90-145 158

26 26 21 21-26 30 17 27 20-30 27

Salmon, Coho, farmed

9.3

2.2

202

28

Salmon, Atlantic, wild

9.2

1.4

206

29

Salmon, Atlantic, farmed Salmon, Chinook

14 15

2.7 3.6

233 262

25 29

Cod, Pacific Tuna, Yellowfin Tuna, Canned (light in water, drained solids), No Salt Cod, Atlantic Mahi fillet Mahi Mahi, Lean fillet, Wild Caught Halibut Snapper Sole (Flatfish, Flounder & Sole species) Sea bass, mixed species Tilapia fillets Salmon, Coho, wild

Chicken & Turkey (Per 4 ounce portion) Chicken Total fat Sat fat Calories (g) (g) Chicken breast, fat-free, deli, 0.5 0.2 90 Sliced Chicken breast, (sliced deli meat, 2 0 120 store-bought) Chicken breast, honey glazed 2 0.5 80 Chicken breast, boneless skinless 3 0.5 120 17

Protein (g) 19 24 22.5 22

Chicken breast fillets Canned Chicken Breast, Chunk breast meat in water Fully Cooked Chicken breast slices (frozen) Chicken Breast fillets w/ Rib Meat Fried Chicken Breast, meat only, skin and breading removed Extra Lean ground turkey breast

Egg Whites (2 large) Egg Whites, 100% Liquid From Carton ( 1/4 cup)

Silken Soft Firm (Regular) Extra Firm Super Firm

1.5 2

0 0

120 120

26 26

3

1

134

23

4 5

1 1.4

120 174

21 32

1.5

0.5

120

26

Calories

Protein (g)

34 33

7 7

Calories

Protein (g)

60 80 95 110 175

5 6.5 11 11 19

Egg Whites Total fat Sat fat (g) (g) 0.1 0 0 0

Tofu (Per 4oz slice) Total fat Sat fat (g) (g) 2.5 0 4 0.5 5.5 1 6 1 10 1.5

Beans (canned, fresh, or cooked) per ½ cup portion Total fat Sat fat Beans (canned, fresh, or cooked) (g) (g) Calories Garbanzo beans 2 0.2 134 All other Beans (Black, red, white, kidney, mung) 1 0.1 104

18

Protein (g) 7 7

Fresh Beans (snap beans, green beans, yellow wax beans, fava, lima, yardlong, dragon tongue, cranberry) Lentils & Split Peas Edamame Edamame (with shell) Soy Beans

1 0.4 4 to 6 2 to 3 8

0 0.1 0.5 0 1

150 110 110-127 65-83 149

Beverages (Per 1 cup/8oz/240ml) Sat fat Total fat (g) (g) Rice milk beverage (unsweetened) 2.4 0 Almond milk (unsweetened) 3 0 Soy milk, Light varieties 2 0 Soy milk, Unsweetened, Original, Plain varieties 4 to 5 0.5

7 9 9 to 11 6-7.5 14

Calories 113 40 70-80

Protein (g) 0.7 2 6

80-100

6 to 7

Dairy Alternatives Total fat (g) 6 6 9 4

Vegan Cheese, sliced (1 oz) Vegan Cheese, grated (1/4 cup) Vegan Cream Cheese (2 Tbsp) Soy yogurt

Sat fat (g) 3 4 4.5 0.5

Calories 80 80 90 150

Protein (g) 40 6

Nuts (per Âź cup) Calories Almonds Brazil Nuts Cashews Hazelnuts Macadamia Nuts

170 190 160 180 200

Protein (g) 6 4 4 4 2 19

Total Fat (g) 14 19 13 17 22

Saturated Fat (g) 1 4 3 1.5 3.5

Peanuts Pecans Pine Nuts Pistachios Walnuts

170 200 190 160 190

7 3 4 5 5

14 20 20 13 18

2 2 1.5 1.5 1.5

Seeds (per 2 tablespoons) Calories

Protein (g)

Total Fat (g)

Saturated Fat (g)

Chia Flax, ground

125 80

6 3

8 6

1 1

Flax, whole

130

4

10

1

Hemp Pumpkin, hulled

120 75

7 4

10 6.5

1 1.5

Sesame Sunflower

103 102

3 4

9 9

1.5 1

Source: USDA National Nutrient Database for Standard Reference Release 28 slightly revised May, 2016.

Condiments, Dressings, Sauces Italian dressing Hummus Miso (paste) Peanut butter Tahini (sesame seed paste)

Amount 2 Tbsp 2 Tbsp 2 Tbsp 2 Tbsp 2 Tbsp

Fat Content 8g 3g 3g 16 g 16 g

Olives, ripe, canned Avocado

4 large 1/2 med

2g 12 g

20

Protein 0g 2g 3g 7g 7g

Calories 85 50 67 190 178

0g 1.5

20 125

Easy Ways to Measure Serving Sizes

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MEAT OR FISH

One serving of cooked meat (about 3 ounces) is equivalent to a deck of cards. Compare this to the palm of your hand so you know the size of the serving when you’re on the go!

22

HAMBURGER PATTY

A hockey puck is about the size of a 3ounce ground hamburger patty.

VEGETABLE OIL

One teaspoon is an approximate serving of a fat or oil.

No measuring spoons around? Use the tip of your thumb as a guide.

23

SOY CHEESE (CHEESE ALTERNATIVE)

One serving (1 ounce) is about four small pieces of “cheese.” When you're slicing up cubes, keep in mind the size and shape of four die, or 2 tablespoons.

PEANUT BUTTER OR OTHER SPREADS

A two-tablespoon serving of peanut butter is about the size of a ping pong ball.

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FRUIT

Whether you're munching on an apple, pear, plum, or peach, in general, one serving of whole fruit is about the size of a tennis ball. 1 serving of fruit is approximately 1 cup.

VEGGIES

A single serving of veggies such as broccoli or carrots should be about the size of a baseball.

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Daily Food Log Food/Beverage

Serving Size

Total *Multiply by number of servings eaten 26

Calories per serving

Fat per serving

Total Calories*

Total Fat*

Daily Food Log Food/Beverage

Serving Size

Total *Multiply by number of servings eaten 27

Calories per serving

Fat per serving

Total Calories*

Total Fat*

Daily Food Log Food/Beverage

Serving Size

Total *Multiply by number of servings eaten 28

Calories per serving

Fat per serving

Total Calories*

Total Fat*

Daily Food Log Food/Beverage

Serving Size

Total *Multiply by number of servings eaten 29

Calories per serving

Fat per serving

Total Calories*

Total Fat*

Daily Food Log Food/Beverage

Serving Size

Total *Multiply by number of servings eaten 30

Calories per serving

Fat per serving

Total Calories*

Total Fat*

Weekly Menu Planner SUNDAY

MONDAY

TUESDAY

WEDNESDAY THURSDAY

Breakfast Breakfast

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Shopping List/Notes:

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Weekly Menu Planner SUNDAY

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Weekly Menu Planner SUNDAY

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Shopping List/Notes:

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Weekly Menu Planner SUNDAY

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Breakfast Breakfast

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Weekly Menu Planner SUNDAY

MONDAY

TUESDAY

WEDNESDAY THURSDAY

Breakfast Breakfast

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FRIDAY

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Shopping List/Notes:

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Notes

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Grocery Shopping

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GROCERY SHOPPING Before you go:  Before you shop, write out a grocery list and stick to it. Keep a running grocery list- it’s much simpler than trying to remember what’s in your pantry! See section 2 (“Tools”) for a grocery list template.  Have a rotating menu or meal plan and a pre-made grocery list for each one.  Shop when you’re not hungry to avoid impulse-buys.  Know the store. Some stores offer maps/floor plans of the store so you can plan your route and avoid wandering the aisles in search of what you need.

Be aware of the location of restrooms and of a place to sit and rest, if necessary.

At the store:  Buy in bulk. Save money by buying bulk foods. Make a meal plan with recipes that use the same ingredients in different ways to make shopping simpler without sacrificing variety  Consider buying frozen fruits and vegetables. Frozen produce often lasts longer, is less expensive, and is often already washed and chopped.  At checkout, ask the bagger not to fill your bags too full. Spread out the items into more bags that will weigh less. Ask that all frozen or perishable foods be put into one bag. This keeps things organized and ergonomic!

Where to shop:  If you can, shop at off-peak times to avoid crowds and long wait times.  For convenience, shop online and have groceries delivered.

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CHOOSING GROCERIES PAY ATTENTION TO “HIGH-FAT” WORDS Often, foods which are considered “health foods” can be high in fat. Look out for added nuts, seeds, or coconut, which can be clues that a certain food is higher in fat. Bread, crackers, or chips with flax seed, pumpkin seed, or are “multi-grain” for example are often high in fat.

Watch out for foods advertised as “lean” or “low-fat”, which may contain more fat than you expect, and lots of additives or sodium. Example- lean turkey which has 9 grams of fat in 4 ounces.

Watch out for vegan or vegetarian alternatives. Often, dairy is replaced with nut milk, nut paste and other high fat nut, seed, or coconut products.

There are 15 g of fat in 2 tablespoons of this vegan ranch dressing!

LOOK OUT FOR “HIDDEN” DAIRY Packaged foods may contain unexpected dairy. Be aware that chocolate-flavored products, such as energy bars, cereals, spreads and desserts often contain milk. Look out for yogurt such as yogurt chips in cereals, or yogurt coatings on sweets or energy bars.

Products such as buttermilk pancake mix or ranch dressing seasoning packets also contain milk (opt for whole wheat pancakes and Italian dressing instead!)

READ LABELS: Just because a product looks the same does not mean the nutrition is the same. And just because something is advertised as “skinny” doesn’t mean it is low in fat.

7g fat in 3 cups

10g fat in 3 cups 39

1.5 g fat in 3 cups

HOW TO READ NUTRITION LABELS Note the serving size

Check fat Aim for less than 2 grams of fat per serving

Sodium Diets high in sodium are linked to high blood pressure. Aim for less than 140 mg of sodium per serving and 2300 mg daily.

Be mindful of fiber, sodium, and sugars

Fiber Look for foods with 5 or more grams of fiber per serving. Try to eat 21-38g daily. Fiber promotes fullness and is good for digestive health.

Sugars Minimize added sugars

INGREDIENTS Nutrition labels are accompanied by ingredients lists. In general, the fewer ingredients a food has, the better it is for you. Choose foods with familiar ingredients: If the ingredients list is full of words you don’t know or can’t pronounce, look for a more natural food. The ingredients are organized by how much volume is in the product. (If sugar is the first ingredient, there is more sugar than anything else in the package).

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Notes

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Cooking 42

TIPS: LOW-FAT COOKING Preparing your kitchen  Before you start cooking, gather all the ingredients and equipment you need  Read the recipe all the way through at least twice before you start cooking. Be sure you are aware of baking times, or if things need to marinate or sit overnight.

 Find ways to replace oil in recipes. See “alternatives and substitutions” for some ideas  Use parchment paper or foil instead of oiling bakeware. Or, use non-stick bakeware 

Adapt your favorite recipes to make them low-fat and dairy-free. It will be easier to stick to this eating plan if you can continue to eat the foods you love. Look through the cookbook or online for low-fat and dairy free versions of your favorite dishes, or “alternatives and substitutions” for ideas to eliminate egg, butter, milk, and oil from your cooking.

 Keep meals simple. Grilled chicken or tofu with a side of steamed or roasted vegetables is a great staple. (Especially if vegetables are prepared in advance!)  Use frozen ingredients. Frozen fruits and veggies can save time and effort without sacrificing nutrition. No washing/chopping required!  Cut down on dish-washing: Perfect the art of a “one-pot meal” or use a slow-cooker to make large batches of food and use fewer dishes.  Cook in batches and use the same base for several meals. Grain bowls or salads with different toppings are convenient ways to cook many meals at once without sacrificing variety. Keep your favorite sauces and seasonings on hand to add flavor quickly.  Make the most of “good days”. On days you have more energy than usual, make soups, put together casseroles, and assemble meals you can freeze and defrost on days you don’t have the time or the energy to cook.

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SUGGESTED COOKWARE Non-stick cookware can help reduce oil use. Aluminum cookware should be avoided because of the association between aluminum ingestion and Alzheimer’s disease.

The following equipment may come in handy. Consider adding a few items to your kitchen, including: Bakeware:  Baking pans (coated) – Stainless steel, iron, with non-stick (e.g., Silverstone® or Teflon®)  Baking pans – Silicone-solid or coated  Pans coated w/ non-stick surface (e.g., Griddle, Frying pan)  Loaf pan – Silicone coated  Muffin tin – Silicone coated

Cookware:  Slow cooker Crockpot  Electric wok w/ non-stick coating  Pressure Cooker (such as Instant Pot brand)

 Glass cookware coated w/ silicone (such as Arcuisine)  Porcelain Bakeware & Cookware

 Saucepan – Stainless steel non-stick  Stockpot – Stainless steel non-stick  Steamer/Pasta cooker – Stainless steel

Equipment  Blender, Food Processor, or Hand-held blender  Silicon or basting brush  Spatulas

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COOKING WITHOUT OIL Oil used to coat frying pans, roasting dishes and bakeware does count toward fat allowance.

Use the methods below to minimize use of oil when cooking.

Instead of coating meat or vegetables in olive oil, pour some vegetable broth in the bottom of the pan or roasting dish. It will help soften the vegetables and enhance flavor.

Add ¼ cup of vegetable broth or water to the pan instead of oil. Add ingredients and cover.

If you do use oil, minimize oil use by blotting pots and pans very lightly with a small piece of paper towel sopped with a minimal amount of oil. Or, use a baking brush to spread a thin layer of oil onto the pan. Use non-stick cookware to avoid cooked-on food.

Instead of oiling bakeware, line trays with parchment paper or foil or use silicone bakeware.

For tips to minimize oil use in recipes, see “Alternatives & Substitutions”

Steaming is naturally oil-free and can be used to prepare chicken, fish, and vegetables.

Fresh herbs and spices go a long way in any steamed dish. Generously garnish a piece of chicken breast in the steamer with seasonings and fresh basil leaves.

Example: Prepare fish wrapped in parchment paper (“en Papillote”) with thinly sliced vegetables, thyme, lemon, and white wine. Steam for about 12 minutes.

To achieve a barbecue-like flavor, grill food on a sheet of baking paper or silicone baking sheet on a tray in a hot oven on the “grill” or “broil” setting. Toss vegetables in vegetable broth prior to putting them in the oven.

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“MEAL PREP” OR COOKING IN BATCHES Save time cooking and cleaning – and make sure you always have something to eat in the fridge- by cooking in batches. “Batch cooking” means preparing most or all of your meals and snacks for entire week on one day of the week.

There are several “batch-cooking” strategies to make your meal prep more efficient.

PREPARE INGREDIENTS AHEAD OF TIME: Get as much prep-work as possible out of the way at once. Chop vegetables, broil chicken, cook noodles or grains for multiple recipes so that when you’re ready to eat all that’s left to do is assemble.

For example: Cook noodles and chop veggies ahead of time for a vegetarian lasagna.

Add variety: Choose meals with a common base (like rice bowls, stir-frys & salads), and prepare the ingredients all at once. Advantage: these meals don’t need a recipe! Use our “build a balanced meal” tool for a simple formula.

For example: Cook a big pot of rice and eat it with different toppings each day. Keep a “salad bar” in your fridge: a big bag of lettuce and many containers of chopped veggies.

VOLUME: Double recipe sizes and cook a double or triple portion of the same dish. Portion into usable/individual sizes and store.

For example: Cook a crock-pot full of Mayan black bean soup (serves 8-10, recipe available in the Low-Fat Cookbook), and store in individual portions.

What you’ll need

Batch Cooking Staples

 Our guide to building a balanced meal, or your favorite recipes  Containers (Tupperware or glass) in a variety of sizes  Ziploc bags and snack-size bags  High-speed blender  Mixing bowls  Meal ingredients

   

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Soups Salads Rice/Grain Bowls Smoothies

HOW TO START BATCH-COOKING

Start small. What time of day is most difficult for you to cook or to find something healthful to eat? Perhaps you are pressed for time in the mornings, and don’t have time to prepare a nutritious breakfast, or you would like to start bringing your lunch to work.

TIPS:  If you have the time and energy, prepare ingredients (chop, measure) as soon as you come home from the grocery store and store until you are ready to cook.  When cooking, make a plan to optimize time (for example, chop vegetables for a stir fry while you wait for rice to cook). Set a schedule to make it easier to keep track of recipe steps. Start with the ingredients with the longest cook time.  To prevent things getting soggy and make things easy to reheat, keep ingredients “naked”: Don’t add dressings, sauces, and seasonings or garnish until you are ready to eat.  Store cooked food in individual portions. When you are ready to eat, reheat if necessary and add toppings.

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BUILD A BALANCED, LOW-FAT MEAL No time to follow a recipe? Use this simple formula to build a balanced meal that meets your nutrition requirements. Use this when you are “batch cooking” to add variety to your meals while minimizing cooking time.

1. START WITH STARCH (1 serving = 1/2 cup of cooked grains)     

1 cup Rice (brown or white) 1 cup Couscous, Quinoa, or other grain (barley, bulgur) 1 cup oatmeal Tortilla (white, wheat, spinach, corn….)

Bread, roll, or bun (whole, white, wheat…)

2. ADD SOME PROTEIN 

4 oz Chicken breast  4 oz Tofu  3 Egg whites  4 oz White Fish fillet or canned tuna



1 cup of Beans or edamame  ¼ cup Nuts (almonds, cashews, hazelnuts, walnuts)

3. THROW IN SOME FRUIT OR VEGGIES (1 serving = ½ cup of cooked vegetables)  Other grain (amaranth, Leafy greens (spinach, bok choy)



bulgur, farrow,  barley, Bell peppers



 millet) Peas  Potatoes









Beets  Squash



Purple cabbage Green beans Corn Cucumber Berries Dried fruit

4. SEASON, SPICE, ADD SAUCE     

Barbecue sauce Horseradish Bragg Amino Acid Spray Hot sauce 48 Ketchup

    

Miso paste Worcestershire Teriyaki sauce Vegetable broth Maple syrup

EXAMPLE: BUILD A GRAIN BOWL (OR STIR FRY) Choose a common base and add different toppings each day. Great for batchcooking.

TERRIYAKI BOWL: Rice + Tofu + Broccoli + Carrots + Teriyaki Sauce SOUTHWEST BOWL: Rice + Black Beans + Corn + Bell Peppers + Onions + Salsa

EXAMPLE: BUILD A WRAP OR BURRITO CAESAR WRAP: Tortilla + Chicken Breast + Romaine Lettuce + Vegan Dressing CHICKEN BURRITO: Tortilla + Grilled Chicken + Lettuce + Olives + Salsa Look for more examples in the recipe book.

Low-fat meal to-go: Make an Oatmeal Jar Assemble your favorite ingredients in a mason jar for an easy meal on-the-go. When you’re ready to eat, shake it up and pour into a bowl, or enjoy straight from the jar.

The recipes below can be prepped in advance and stored in the pantry. Alternatively, use fresh fruit and store in the refrigerator!

In a pint-sized canning jar, combine: ½ cup dry rolled oats + dried or freeze-dried fruit, nuts, vegan chocolate, or the toppings of your choice. When ready to eat, stir in 1 cup of boiling hot water or non-dairy milk. Let sit for 10-20 minutes (depending on desired consistency).

Apple Cinnamon Oats

Banana Coconut Oats

   

 ½ cup oats  Banana chips  Dried coconut flakes

½ cup oats Freeze-dried apples walnuts cinnamon

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Low-fat meal to-go: Make a Smoothie Pack Simplify breakfast prep with these individual portion smoothie packs. Fill plastic sandwich bags with fruit and greens and keep in the freezer. When ready to use, combine 1 cup of liquid (water, juice, soy or almond milk) and one smoothie pack in a blender and blend until smooth. The basic formula is as follows: 2 cups fruit + 1 sliced banana + 1 cup greens. Get inspired with the low-fat recipes below.

Very Berry Smoothie

Tropical Bliss Smoothie

Strawberry Banana Smoothie

    

    

   

1 cup blueberries 1 cup strawberries 1 banana, sliced 1 cup spinach 1 cup apple juice

1 cup pineapple 1 cup mango 1 banana, sliced 1 cup orange juice 1 cup spinach (optional)

2 cups strawberry 1 banana, sliced 1 cup almond milk 1 cup spinach (optional)

Tip: For a Low-fat meal to-go, make a Jar Salad Assemble your favorite ingredients in a mason jar for an easy lunch on-the-go. When you’re ready to eat, shake it up and pour into a bowl, or enjoy straight from the jar.

1. Greens (on top) 2. Protein (chicken, tofu, chickpeas, beans, nuts, hard-boiled egg whites)

3. Veggies & Grains (cucumber, bell pepper, quinoa, broccoli, sprouts, radishes, tomato, red onion, corn, peas, mushrooms, carrots, green beans)

4. Dressing (on the bottom) 50

STAYING FULL & SATISFIED 1. BULK UP YOUR MEALS As you cut out fat from your diet, you may notice you have a harder time feeling full after a meal. Use the ingredients below to bulk up your meals. fruit & Vegetables- which are mostly water- will fill your stomach and help you vegetables feel full without adding fat starches & Keep a variety on hand: oatmeal or steel cut oats, brown rice, quinoa, grains yams, winter squashes, plantains.

Steam, boil, or roast them ahead of time so they can simply be tossed in a variety of dishes or heated to have with a quick meal! beans

Beans can be added to salads, soups, wraps, tacos, tossed with grains, or simply eaten as a side garnished with simple herbs or spices.

egg whites Need some extra protein? Add egg whites as a “topper”, or have “egg drop soup” by adding egg whites to vegetable soup. vegetable soups

Blended vegetable soups and purees (cauliflower, butternut squash, tomato…) may help you feel full longer with lunch or dinner.

protein powder

Plant-based, dairy-free protein powders such as rice, pea, and hemp proteins can add bulk to smoothies, pancakes, and other meals.

2. ADD FLAVOR, NOT FAT “Low-fat” doesn’t have to mean “bland”! Use these meal-enhancers on veggies, starches, and protein to add flavor without adding fat.

Vegetable broth Artichoke hearts Barbecue sauce Canned tomato products (diced, whole, purée, paste) Chili paste Chutney Cilantro Cocoa powder Curry paste or powder Dried chilies Dried fruits (raisins, cranberries, apricots, dates) 51

Fresh tomato Hoisin sauce Jerk sauce Lime or Lemon Lime juice & pepper Minced ginger Miso paste Nondairy milk (almond, rice, soy, oat) Parsley Soy sauce Teriyaki sauce Tomato salsa

3. COUNTER YOUR CRAVINGS Instead of a “one-to-one” substitution for an ingredient, condiment, or snack, (such as swapping dairy-free ice creams for regular ice cream), replace with similar things. Consider swapping the high fat option for foods similar in texture (crunchy, creamy, smooth), temperature (cool, warm), flavor (sweet, savory, tart), or type (fresh, dried, raw).

Instead of…

Avocado

Have: Cucumber slices Banana (mashed or sliced) Dried fruit (apricots, mango, raisins) 1-2 Tablespoons shredded almond cheese

Peanut butter

Mashed beans

or Cream cheese

Jelly or Jam 1 teaspoon Vegan Mayonnaise Make your own herb dressing using garlic, onion, shallots, minced chives, basil, or mint with 1 teaspoon olive oil (count within your fat allowance).

Cheese

Crumbled tofu

Chopped nuts

Crackers, crumbled

or Seeds

Croutons Rice crackers Dried fruit bits – cranberry or dates

Ice Cream

Creamed or whipped banana or other soft fruit Pure fruit sorbet Frozen juice bars

Creamy Salad

Squirt of fresh lemon or lime juice, or a low-fat dressing

dressing

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ADAPTING RECIPES ALTERNATIVES & SUBSTITUTIONS IN COOKING OR BAKING Although it is ok to substitute, it is best to find recipes that are naturally low-fat, dairy free, and oil free. Try these suggestions for alternatives to foods that are high in fat.

To avoid fat, dairy, or processed soy: If the recipe calls for:

Use:

Vegetable Oil

Applesauce Babyfood Prunes Replace the oil called for in a recipe with half the amount of another moist food, such as applesauce, mashed bananas/pumpkin/potatoes, tomato sauce, soy yogurt….

Milk (baking)

Soy, almond, or oat milk

Coconut Milk

Soy, almond or oat milk with a teaspoon of coconut extract

Chocolate Chips or Nuts

Dried fruit Vegan chocolate chips *note: cocoa powder, cocoa nibs, and chocolate liquor are acceptable ingredients. Dairy-free unsweetened chocolate is available but contains fat.

Cheese

Almond or cashew cheese Crumbled tofu Nutritional yeast

Mayonnaise

Vegan mayonnaise Soy yogurt Use soy yogurt or vegan mayo in egg, chicken, or tuna salad

Peanut butter

Dried peanut butter

Creams, dairy, oil

Replace creams, dairy, or oil called for in a soup or puree with almond or soy milk.

• Replace soy burgers with low-fat bean or grain burgers • Use rice to bulk up bean chili instead of soy sausage • Top your pizza with tomato sauce and vegetables instead of soy cheese • Choose fruit or sorbet instead of soy ice cream

Processed Soy

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Use these healthful, low-fat substitutions to keep your baking low-fat and dairy-free

1 CUP SUGAR =

 ¾ cup applesauce  ¾ cup honey or maple syrup – reduce liquid by 2 Tbsp & reduce baking temperature by 25  Reduce sugar to ½ cup & add 1 tsp vanilla extract  Puree 1 cup of pitted dates with ½-1 cup hot water to make a paste  1 cup coconut sugar

1 CUP FLOUR =

 1 cup pureed black beans  1 cup nut flour + ½ tsp rising agent  1/3 cup coconut flour + 4 egg whites + 1/3 cup of liquid  1 cup gluten-free flour blend

1 CUP BUTTER =

 ¾ cup prunes plus ¼ cup boiling water blended – works well in dark baked goods  1 cup applesauce or apple butter  1 cup mashed banana  1 cup fruit puree  ¾ cup pumpkin or squash puree

1 EGG (AS A BINDER) =

 ½ banana  1 Tbsp flax meal or ground chia seeds mixed with 3 Tbsp water – allow to sit for 5 minutes  1 tsp gelatin dissolved in 3 Tbsp boiling water.

Freeze until thickened. Beat until frothy.  ¼ cup fruit puree  ½ banana  1 Tbsp tapioca flour for every cup of whatever is being thickened  1 Tbsp of arrowroot for every cup of whatever is being thickened  1 tsp baking powder + 1 tsp vinegar

(AS A THICKENER) =

(AS A LEAVENING AGENT)

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Notes

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Dining Out

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DINING OUT There are three main scenarios in which you may find yourself dining out. For the study, we are considering “eating out” any time you are not eating food you have prepared yourself.

This could be at a restaurant, at a holiday party or work event, or when grabbing a quick meal or snack when you are on the road or running errands.

Try not to eat out more than twice per week.

On the road or running errands • Build a meal out of filling, low-fat snacks such as hard-boiled eggs, hummus and crackers, applesauce, bagged salads, fruits and vegetables, small cereal boxes, and juice boxes.

• Focus on foods that will be filling. Look for foods with lots of protein.

Parties, work functions and special occasions 

Bring Your Own. Heading to a party, event or work celebration where there may not be diet-compliant food available? Bring your own! This goes for restaurants, too: ask if you can bring your own dressing or side.



Bringing your own food to a party? Stick to the theme! Bringing your own food doesn’t have to mean feeling left out from a social event. Bring foods that will allow you to feel included. Heading to a BBQ or cookout? Bring veggie kebabs or bean burgers to throw on the grill.



If you feel comfortable, make your dietary needs known to your co-workers (or party hosts) and ask for help. Suggest recipes that are festive and diet-compliant (we have some such recipes in our cookbook) Eat regular meals during the day so you aren’t famished when you arrive to the party.

Make substitutions to make your holiday favorites diet study compliant.

Substitute steamed vegetables or fruit, instead of fried potatoes.

Use salsa or marinara to moisten your baked potato, pasta, or rice, instead of butter or cream.

Have coffee, tea, or an espresso drink after dinner instead of a dessert.

    

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At a restaurant  Plan ahead. If possible, review menus ahead of time.  Always ask for ingredient information when deciding what to order. Look at nutrition label information if it’s available.

 Be wary of sauces, soups, marinades, and dressings. Ask for sauces on the side, or leave them off altogether. Season with salt and pepper instead!  Substitute. Ask to swap high-fat items (fries, coleslaw, creamy soups) for a side salad.  Choosing a restaurant: Ethnic Restaurants like Mexican, Chinese, or Thai tend to offer the best options. Eat mostly starches (rice, beans, potatoes) with vegetables and chicken or tofu. Steer clear of dishes with coconut milk or cream, such as Indian or Thai curries.  Use apps to locate vegetarian and vegan restaurants. These restaurants are often more likely to offer low-fat options which are diet-compliant.

Note: Just because a restaurant or menu item is called “vegan” or “vegetarian” does not mean it will fit the requirements of this diet. Ask about ingredients.  Nothing diet-friendly on the menu? Build your own meal from sides and small plates.

Breakfast: Oatmeal (be sure it’s prepared without milk or butter), cereals with soy or almond milk, fruit, toast with jam, egg white omelet, hash browns cooked “dry” (without oil).

Lunch: Ask for whole-grain bread, veggies, and hummus or mustard to make your own sandwich.

Dinner: Have a soup, salad, and whole grain bread, or potatoes/pasta/rice with steamed vegetables.

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When ordering at a restaurant, ask your server:     

May I have this without dressing?

Could you cook this without oil?

What is in the sauce that comes with this fish/chicken?

Can I substitute ____ for _____? (a side salad for a soup?)

Could you please leave the sauce off my meal and season only with salt and pepper?

Don’t be bashful about sending your meal back if it doesn’t match the low-fat meal you requested! (blame it on the research study  )

DINING OUT: WHAT TO ORDER & WHAT TO AVOID Mexican Food: Instead of….

Have a…

Burrito

Burrito bowl (no tortilla)

Taco shells or tostadas

Plain corn or flour tortilla

Refried beans

Whole black beans

Veggies grilled in oil

Raw veggies or veggies grilled over an open flame

Cheese or sour cream

Pico de gallo, cilantro & onions, tomatillo sauce, pepperoncinis, escabeche (Mexican spicy pickled vegetables), radishes, or salsa

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Chinese Food: Instead of….

Have a…

Chicken or tofu stir-fried in oil

Ask for option to be sautéed in soy sauce or vegetable both (no oil).

Low fat a la carte or steamed options.

Fried tofu

Ask for braised, boiled, or raw.

Fried rice or noodles

Congee (rice porridge), noodles in soup.

Fried potstickers

Steamed potstickers.

Veggies stir-fried in oil

Side of steamed vegetables.

Thai Food Instead of….

Suggest…

Peanut sauce

Sweet chili sauce, Sweet & sour sauce

Coconut curry

Clear soups (Tom Yum)

Fried rice

Brown rice

Noodles stir-fried in oil

Salad entrees, Salad rolls

Oil dressings

Lemon, balsamic, or other vinegar dressing available.

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Italian Food: Instead of….

Suggest…

High fat dressings

“Dry” salad and soup

Pizza

Pizza with no cheese

Butter or Cream Sauce

Marinara Sauce

Cheese

No cheese (extra marinara)

Stuffed pasta (ravioli, manicotti)

Angel hair pasta, no cheese

Garlic bread with butter and cheese

Bruschetta

Fast Food (Burger Joint): Instead of….

Suggest…

Burger and French fries

Veggie sandwich and Salad with light vinaigrette (leave out cheese or fried strips) or Side salad

Milkshake

Fruit smoothie

Crispy chicken sandwich

Grilled chicken or fish sandwich or bowl (no bacon, cheese, mayo or tartar sauces)

Cookie

Fruit

Caffè Latte

Plain coffee or with soy

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Notes

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