10:17 AM

#530 - Erratum, Fruit Intake and Obesity, Best Diets 2024, Fascia

Take 3 – Practical Practice Pointers©

Erratum:  John's Correction from Last Week’s Take 3 Pointer #1:

Alphabet soup and apologies


In last week's pointer about varicella and zoster immunization, there were unfortunately several places where I referred to "ZVL" (the abbreviation for the old, live zoster vaccine) when I should have used "RZV" (the abbreviation for the currently recommended, recombinant vaccine).  We have corrected the online version, and even though the abbreviations are the official CDC way to keep things straight, I think I may revert to using whole words for a complex article like that.  Please do let us know if you notice potential errors like that - it's really helpful.  Here’s a link to the corrected version.

From the Literature

1)  Fruit Intake and Obesity in Children


Obesity in children sometimes feels harder to deal with than adult obesity. The US Preventive Services Task Force advised screening children for obesity but found that the most successful interventions were multi-component interventions delivered in at least 26 sessions over at least six months. The role of fruit intake in obesity has been debated; there is concern from some research studies and popular belief that because fruit has sugar, it may cause weight gain. But avoiding whole fruit intake can reduce dietary fiber and antioxidants that can negatively impact health in other ways. Researchers in China performed a systematic review of diet trials that included interventions to increase fruit consumption in obese children to assess the impact on weight loss.

The review was generally well done. The authors did a comprehensive search of four databases, although they didn’t specify a search for unpublished literature. They had explicit inclusion exclusion criteria for the review and examined each included study for quality. They also explored the data for heterogeneity.

Twenty articles were ultimately included in the review – eight were in non-obese children and 12 included both obese and non-obese children. The studies lasted from 2 months to 30 months. The intervention groups in these studies ate an average of 79 grams more fruit than non-participants (a half-cup of grapes, or a medium orange or apple). The fruit intervention patients did not significantly change their BMI or their standardized BMI (BMI-z) but did improve their waist circumference and they had an overall reduction in the prevalence of obesity (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.60-0.90) compared to the control groups. There was a lot of heterogeneity in the results (I2 = 99.8%).

Multiple subgroup analyses were done to explore this heterogeneity. A sensitivity analysis excluding lower quality studies did not change the results. Interventions to increase fruit intake had a larger effect on BMI-z in those who were already overweight or obese. Interventions that combined education with other strategies (diet planning and recording, physical activity, food preparation, etc.) were more effective at increasing fruit consumption. Larger studies (>300 children) showed more fruit consumption and greater reduction in BMI.

John’s Comments: 

Overall, this study should allay the fears of advising fruit intake as part of dietary counseling for overweight or obese children. However just advising more fruit intake does not solve the whole problem. The 5-2-1-0 program created by Maine Health (emphasizing daily advice of 5 servings of fruit and vegetables, limiting screen time to 2 hours, advising 1 hour of physical activity, and zero sugar sweetened beverages) has been successful as a multi-component intervention and is widely adopted in state health programs and health systems. From this study, we can feel confident about advising fruit intake as part of this counseling.


·         Wang F, Zhang P, Ren Y, et al. The estimated effect of increasing fruit interventions on controlling body weight in children and adolescents: A meta-analysis. Preventive Medicine. 2024;179:107785. Link


From the US News and World Report

2)  “Best Diet” Rankings for 2024


U.S. News recently released its annual assessment of the best diets, ranking 30 based on specific criteria and providing in-depth profiles for 38 popular eating plans.  The rankings were established by a reputable panel of 43 experts in nutrition, obesity, metabolic health, food psychology and chronic disease management, who rated each diet on 11 criteria, including nutritional completeness, healthiness, ease of use, adaptability to various preferences and restrictions, likelihood of promoting weight loss, sustainability, evidence-based effectiveness, and safety.  To ward off possible bias, each panelist had to provide information to ensure financial ties, bias, or affiliation with any of the commercial diet programs reviewed.   

For the 7th consecutive year, the Mediterranean Diet ranks as the No. 1 Best Diet Overall with the DASH Diet rated 2nd and the MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay), rated 3rd.

The Mediterranean diet was rated the best diet in 7 out of the 11 categories, including best diet for diabetes, best heart-healthy diet, easiest diet to follow, best diet for bone and joint health, best family-friendly diet, and best diet for healthy eating.  The DASH diet was rated in the top 3 in 7 out of 11 categories.  The Flexitarian, which might be thought of as a semi-vegetarian or “plant forward” diet was rated the best plant-based diet and was rated in the top 3 in 6 out of 11 categories.     

WeightWatchers was rated the top Weight-Loss Diet with the Mediterranean diet rated 2nd and Volumetrics rated 3rd.  The Keto diet was rated the best Fast Weight Loss diet.  The top Diet Program (formerly called commercial plans) was WeightWatchers followed by the Mayo Clinic diet and Noom.    

It is important to note that there isn't "a" Mediterranean diet.  The cultural lifestyle of people in countries bordering the Mediterranean Sea shares common principles, including an active lifestyle, weight control, and a diet high in produce, nuts and healthy oils and low in red meat, sugar, and saturated fat.   A Mediterranean diet pyramid has been developed to help guide those desiring to follow this nutritional approach (see References). 

The DASH Diet (Dietary Approaches to Stop Hypertension) is promoted by the NHLBI to stop or prevent HTN.  It emphasizes vegetables, fruits, whole grains, lean protein and low-fat dairy.  DASH also discourages foods that are high in saturated fat, such as fatty meats, full-fat dairy foods and tropical oils, as well as sugar-sweetened beverages, sweets, and sodium.  The NHLBI publishes free guides on the plan (See references). 

Mark’s Comments (With Guest Commentary):

The word “diet” is a misnomer.  The most highly rated “diets” are really about healthy, structured, intentional approaches to eating over a lifetime.  To that end, I reached out to faculty colleague and “Lifestyle Medicine guru” Beth Polk, MD, for her insights.  In addition to regularly speaking nationally on this topic, Beth served as one of 4 national faculty on an AAFP Advisory Committee for Lifestyle Medicine and is one of 3 co-chairs for the  AAFP Lifestyle Medicine conference.  Two years ago she started a clinic focusing on Lifestyle Medicine as part of her clinical practice. 

Beth replied:  "The best advice we are able to give our patients is still ‘eat food (unprocessed), mostly plants, and not too much.'  Rather than focusing on a "diet", if we think about the way we eat in terms of the general principles of increasing fiber: fruits, vegetables, beans, whole grains, nuts and seeds, and eliminating processed foods, sugar sweetened beverages and decreasing meat intake, the top 5 diets listed meet these criteria, and they can be easily adapted to regional and cultural differences. There are many alternative pyramids available to help promote creative thinking about using local produce, farmer’s markets and staples such as beans and rice to make this approach both more accessible and affordable.  

One such free resource that I recommend to all my patients to help them learn how to do this in a very simple, accessible way is called Full Plate Living.  Remember as well that the healthiest eating plans focus not only on attaining healthy body weight, but more importantly, to provide the best nutrition for optimal body functioning and disease prevention. As such, the new weight loss agents do not supplant the importance of healthy nutrition, but necessitate it even more, including the importance of healthy proteins to maintain lean body mass.”


  • U.S. News Best Diets Rankings for 2024.  January 2, 2024. Link
  • Oldways Mediterranean Diet (Link) and Diet Pyramid (Link)
  • DASH Eating Plan: Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Thanks Fascia ….


“I’m less interested in skin than in fascia – connective tissue.”  Matthew Barney, contemporary artist and film maker

Fascia is having a moment.  Well, at least it is for me, and apparently for many of our musculo-skeletally oriented colleagues as well.  Recently as I sat mesmerized by a fascinating talk titled “The Fascia” being given by one of those colleagues, I realized it was time for my understanding of the facia to enter the 21st century. 

Fortunately, I’m not as “behind the times” as I first feared.  Apparently, the understanding of fascia as a living, dynamic tissue has evolved gradually rather than being a single moment of discovery.  It wasn't until the 1990s and early 2000s that a significant shift occurred as advanced imaging techniques provided a more in-depth exploration of fascia's properties.  This led to an appreciation of its optimal functioning as being crucial for our body’s overall health.

Indeed, as I listened and viewed numerous amazing ultrasound images, it became quite obvious that the fascia I was taught about in medical school as a passive covering and mechanical support structure was instead a vital connective tissue network, helping to create a harmonious symphony of movement and support.  As I looked around the conference room, it became quite apparent that this interconnected biological network mirrors the equally complex and essential web of connections in our lives as physicians – the relationships and communities that support, sustain, and empower us in our professional journey.

I could not help but be struck by the parallels between these recent “discoveries” regarding the importance of fascia for our bodies and those of the “loneliness epidemic” and the importance of relationships for our well-being.  It seems crucial for us to understand that our professional relationships are not simply static structures of support but rather are vital, interconnected networks that allow for our own adaptability and resilience.  Our professional networks, when actively engaged, encourage us to stretch beyond our individual capabilities, protect us from injury, and allow us to move through our days with greater strength and grace.  Embracing this interconnectedness not only enhances our well-being but also enriches the quality of care we provide to our patients.

As healers, we thrive on connection – with our patients, peers, and the broader medical community.  Let us challenge ourselves to actively nurture these connections, particularly with each other – to seek out mentorship, offer support, and collaborate with our peers.  In doing so, we strengthen not just ourselves but the entire fabric of the healthcare community.  Thanks for the reminder, fascia ….


Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org