Do you need to eat fruits and vegetables?

“Eat your fruits and vegetables!” You’ve probably heard that nagging scold more often than any other nutritional advice — not only from your mother but from doctors, health organizations, and governments — over the last four decades.

Eating fruits and veggies is so often recommended as the best way to live longer, healthier lives, that questioning it seems unbelievably controversial. After all, observations show that healthy people who eat fruits and vegetables can consistently live into their 90’s and 100’s.1 While this may show that fruits and veggies can be part of a healthy lifestyle for some, it does not prove that they are required for a healthy lifestyle for everyone.

How many fruits and vegetables do we need to eat? Might some people be better off eating fewer than recommended? More provocatively, do we need any at all? In a world where fruit bowls and green smoothies are seen as virtuous and bacon is viewed as sinful, it may seem difficult to even consider these possibilities.

Yes, there’s been a lot of research on the health benefits of fruits and vegetables, but is it rigorous enough to recommend a standard minimum daily intake? And does the quality of the rest of your diet make a difference in that recommendation? Read on to learn where the scientific evidence currently stands on fruits and vegetables.


1. What are fruits?

Fruits are the seed-containing portion of various flowering plants. They grow exclusively above ground.

Different types of fruit

The broad categories of fruit include pome, citrus, tropical, melons, stone fruits and berries. Most fruits taste sweet, although citrus varieties are often sour or bitter. With the exception of bananas, fruits are juicy due to their high water content.

Nutritional composition of fruits

Nearly all of the calories in fruit come from sugar — not surprising, given their sweet taste. Their net carb counts span a large range: 5 grams to 20 grams of carbs per 100 grams (3.5 ounces) of fruit, depending on the type. A single mid-sized orange would have about 12 grams of carbs and a banana at least 23 grams.

Reviewing the nutrition profiles of different fruits, we see that several are good sources of vitamin C and a few minerals. However, the actual nutrient content can vary depending on the type of fruit, how and where it’s grown and stored, and how long it’s been sitting at a stand or grocery shelf.2 In addition, all fruits fall short in vitamin D and key minerals like calcium, magnesium, iron and zinc.

Low-Carb-Fruits-1-2400x1441

Low-carb fruits and berries – the best and the worst

Guide What are the best and the worst fruits and berries to eat on a low-carb diet? Here’s the short version: most berries are OK low-carb foods in moderate amounts, but fruits can be seen as candy from nature (they contain quite a lot of sugar).


2. What are vegetables?

Speaking from a botanical or gardening point of view, vegetables are the leaves, stems or roots of plants. However, many non-sweet fruits are commonly considered vegetables for eating or cooking purposes.

Different types of vegetables

Vegetables can be broadly classified into four categories:

  1. Above-ground vegetables: greens (spinach, lettuce, chard, et cetera), cruciferous vegetables (broccoli, Brussels sprouts, cabbage, cauliflower, kale, et cetera), bulbs (onions, garlic) and fungi (mushrooms).
  2. Below-ground/root/starchy vegetables: beets, carrots, parsnips, rutabagas, turnips, yams, potatoes, sweet potatoes etc.
  3. Gourds: pumpkins, hard-shelled squashes and other winter squashes.
  4. Technically fruits but treated like vegetables: avocados, olives, bell peppers, eggplant, tomatoes and zucchini. Unlike other fruits, these aren’t sweet and are often prepared and consumed with other vegetables. Avocados and olives are unique among fruits and vegetables because most of their calories come from fat rather than sugar or starch.

Nutritional composition of vegetables

Non-starchy vegetables are keto-friendly foods that provide 5 or fewer grams of net carbs per 100-gram (3.5-ounce) serving. Not so for the root and starchy vegetables, though, which range from 6 to 17 grams of net carbs per serving. Vegetables usually contain moderate to high amounts of fiber, especially avocado — which also happens to be among the lowest in net carbs.

Overall, vegetables are more nutrient-dense than fruits, but their vitamin and mineral content can also be affected by factors like growing and storage conditions. Most veggies are good to excellent sources of potassium, and bell peppers and cruciferous vegetables are also high in vitamin C.

LC-BG-veggies3_good_2400px_3

Low-carb vegetables – the best and the worst

Guide What are the best and the worst vegetables to eat on a low-carb diet? Here’s the short version: Vegetables growing above ground are usually low carb and can be eaten freely.


3. How many fruits and vegetables should people eat per day?

Looking at official recommendations for fruit and vegetable intake in different countries, it’s clear that they’re basically all variations on “5 a day.” The US dietary guidelines, the UK National Health Service, and the World Health Organization all set minimums that are generally equivalent to two cups of fruit and two and a half cups of vegetables each day.

According to the Centers for Disease Control, only 1 in 10 adults consistently meet the US Dietary Guidelines recommendations for fruit and vegetable intake.3 But is this really a problem?

Some low-carb and ketogenic diet experts would say no; that if someone is following a diet that meets their needs for essential nutrients, eating several servings of fruits and vegetables every day isn’t necessary. For instance, Dr. Eric Westman initially recommends two cups of leafy greens and one cup of above-ground vegetables per day — and no sweet fruit of any kind — as part of a very-low-carb diet.4

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Other doctors have gone on record as saying that consuming plants is entirely optional — and in some cases may be problematic — including the Paleomedicina Group and Dr. Georgia Ede.5

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Health organizations state that their recommendations for fruit and vegetable intake are evidence-based. But as we’ve discussed previously in other guides, there are different levels of scientific evidence. And almost all these fruit and vegetable recommendations are designed for someone who is eating a standard Western diet or a low-fat, high-carb diet.6

Let’s explore the high-quality evidence available to see whether eating more fruits and vegetables has actually been proven to improve health.


4. Research on the benefits of eating fruits and vegetables

Obesity

With few exceptions, eating more fruits and vegetables is standard weight loss advice. But if we look at the results of experimental trials in which people actually ate more — or at least were encouraged to eat more — of these foods, that advice just doesn’t seem to work for everyone.

A 2014 systematic review of eight randomized controlled trials (RCTs) lasting between 4 and 52 weeks found that people assigned to increase their fruit and vegetable intake lost an average of only 1.5 pounds more than those assigned to eat smaller amounts of these foods.7

The same year, researchers who published a systematic review of seven different RCTs failed to find any measurable differences in weight change between people who consumed high vs. low amounts of fresh produce.8

However, the interventions differed among the RCTs included in both of these analyses. In some cases, people were provided with fresh fruits and vegetables or vouchers to purchase them; in others, they only received advice to consume more of a specific fruit or vegetable. Furthermore, in most of these studies, researchers relied on reported produce intake from the groups rather than closely monitoring their intake. Often it just wasn’t clear whether people actually ended up eating their assigned amounts of fruits and vegetables or not.

In some cases, people who eat more fruits and vegetables may actually gain weight because they don’t compensate by cutting back on other foods — and juice seems to be especially problematic.

For instance, in one RCT, when overweight and obese people were provided with fresh fruits and vegetables to add to their diets for eight weeks, they gained twice as much weight as lean participants, who responded to increased produce intake by eating less of other foods. However, people from all three groups gained weight after consuming the same amount of produce in juice form during a second eight-week period. Still, obese participants gained the most.9

On the other hand, replacing highly processed refined food with fruits and vegetables is not only a smart choice nutritionally; it might also lead to weight loss. In a three-month study, overweight women who were given vouchers to purchase fresh produce lost 6 pounds, whereas those who were given vouchers to purchase any type of groceries gained 4 pounds by the study’s end.10

Overall, though, eating more fruit and vegetables hasn’t been shown to produce meaningful weight loss in most experimental studies.

Yet we often hear that doing so is the key to achieving and maintaining a healthy weight. What is the basis for this advice?

For decades, it’s been predominantly larger yet lower-quality observational (also called epidemiological) research. For instance, a 2015 systematic review analyzing 17 epidemiological studies found statistically weak associations between eating a lot of produce and lower body weight and waist size.11

In observational nutrition studies, a hazard ratio (HR), odds ratio (OR) or relative risk (RR) that is close to 1 means there is almost no observable difference. That means any OR less than 2 or greater than 0.50 strongly suggests that any association between a behavior (e.g., eating produce) and an outcome (e.g., weight loss) is possibly random and false. What were the ORs in this study? They were 0.83 for high intake of fruits or vegetables separately, and 0.91 for high intake of fruits and vegetables combined. Indeed, even the study authors acknowledged that “The present meta-analysis seems to be limited by low study quality.”

Examining documents

Guide to observational vs. experimental studies

Guide In this guide, we discuss the differences between observational and experimental studies, the advantages and disadvantages of each, and why in nearly all cases observational research shouldn’t be used when making decisions about your diet.

Diabetes and metabolic syndrome

Fruits and vegetables are generally considered diabetes-friendly foods. In fact, nearly all types of produce make the “low GI foods” list on the American Diabetes Association website, with the exception of melons and pineapple. But how does adhering to “5 a day” or similar dietary advice affect blood sugar control and insulin resistance? The evidence from clinical trials is mixed.

One systematic review and meta-analysis of eight RCTs examining the effects of fruit and vegetable intake in people with metabolic syndrome found that although diastolic blood pressure slightly improved in those who ate more produce, fasting blood sugar levels were no different among the groups.12 The same held true for waist circumference, triglycerides and HDL cholesterol levels — all of which are considered markers of insulin resistance when outside the normal range.13

In 2017, Scottish researchers analyzed results from four RCTs with fruit and vegetable interventions in people with type 2 diabetes or other health conditions. The groups assigned to eat more fruits and vegetables improved their vitamin C and beta-carotene intake but consumed significantly more carbs and calories.14 That doesn’t sound very diabetes-friendly, does it?

In one randomized controlled trial published in Diabetes Care — a journal of the American Diabetes Association — researchers assigned overweight adults to consume two, four, or seven portions of fruits and vegetables per day for 12 weeks. Ultimately, none of the groups experienced any improvement in insulin resistance.15

However, results from another RCT suggest that including low-carb vegetables like broccoli and broccoli sprouts may help lower insulin levels and improve insulin sensitivity in adults with type 2 diabetes.16 Of course, neither the experimental nor control group were consuming low-carb or keto diets. It’s unknown whether adding broccoli or other green vegetables to low-carb or keto diets would provide any further benefit on insulin resistance. Since low-carb diets by definition eliminate two likely offenders behind insulin resistance — sugar and other high-carb foods — there may already be a maximal benefit which may not increase by adding more vegetables. Controlled trials exploring this would need to be done.

What about lower-quality observational studies that suggest eating plenty of fruits and vegetables can help protect against diabetes? Large meta-analyses of these studies have shown very weak associations between fruit and vegetable intake and diabetes risk.17

Finally, although results from observational nutrition studies often have such weak correlations that they’re likely due to chance, occasionally there are exceptions. For example, a 2017 prospective cohort study in pregnant women found that those who reported consuming the highest amount of fruit during their second trimester had a 480% greater risk (OR of 4.82) of developing gestational diabetes than women with the lowest reported fruit intakes.18

Controlled studies exploring this relationship are needed. However, it certainly seems possible that eating large amounts of fruit (“nature’s candy”) during pregnancy — a time of dramatic hormonal fluctuations and insulin resistance — could increase a woman’s likelihood of developing gestational diabetes.

Videos about diabetes

Heart disease

Are fruits and vegetables heart-healthy? Although some experimental research suggests that eating more produce might reduce some cardiovascular disease (CVD) risk factors, the bulk of evidence to date is inconclusive in regards to clinical outcomes.

For instance, in 2013 researchers conducted a systematic review of 10 RCTs investigating whether increased fruit and vegetable consumption led to improvements in heart health markers. They reported that the trial designs differed significantly and often included other nutrition and lifestyle interventions that may have contributed to observed beneficial effects on CVD risk. Their conclusion? Further trials investigating higher fruit and vegetable intake as the sole intervention are needed.19

Another systematic review of RCTs found that high potassium intake seemed to be beneficial for arterial health, while the effects of high fruit and vegetable intake on arterial function weren’t clear.20

Some RCTs conducted after the 2013 systematic review discussed above suggest that eating more fruits and vegetables may increase blood levels of antioxidants that could improve HDL function and might also reduce inflammation in those at high risk for CVD, such as those with diabetes.21

Yet others found no reduction in CVD risk factors in overweight people who consumed seven servings of produce per day compared to those who consumed two servings per day for 12 weeks.22 In these studies, blood levels of lutein (an antioxidant found in vegetables) were measured to confirm compliance among the different groups.

The evidence from observational studies in this area is very weak. For instance, a large 2017 meta-analysis of 95 studies reported only an 8 percent reduction (RR of 0.92) in CVD risk for every 200 grams of fruits and vegetables people reported consuming per day, up to a maximum of 800 grams per day (roughly 10 servings).23 Yet despite the very weak association and low quality of evidence, major medical organizations cite this paper as conclusive support that fruits and vegetable reduce heart disease event.

Is it possible that you can greatly decrease your risk of heart disease solely by eating 10 servings of fruits and vegetables every day? The relative risk findings suggest that this association has a high chance of being random and false. Plus, given that food-frequency questionnaires and food recalls in observational studies are notoriously inaccurate, it makes sense that we should not rely on this low-quality evidence to make individual health decisions.24

In all likelihood, anyone who actually eats 10 servings of produce on a daily basis likely also engages in other habits known to protect heart health, such as working out regularly and avoiding junk food, excessive alcohol consumption and smoking.

Videos about heart disease

Cancer

Eating lots of fruits and vegetables can help reduce your cancer risk.” This message is taken verbatim from the website of the American Cancer Society. But is there strong scientific evidence that eating large amounts of fruits and vegetables will help protect you from cancer?

Although fruits and vegetables are whole foods that contain beneficial nutrients, it’s too early to make that claim for them. In fact, it’s too early to make that claim for any foods with certainty, because very little high-quality experimental research has examined how specific foods affect cancer risk and progression.

It’s known that damage to cellular DNA may raise the risk of developing cancer in the future. One randomized cross-over study in healthy people found that consuming kiwifruit for three weeks led to increased antioxidant activity that helped repair DNA, regardless of whether small or large amounts were consumed.25 Similar results were seen in young male smokers who consumed three servings of broccoli per day for 10 days.26

However, other studies haven’t shown any improvement in DNA repair in people who increased their fruit and vegetable intake.27 And one even suggested that cruciferous vegetables may temporarily damage DNA, although this effect seems to disappear within several hours.28

Can healthy people reduce their chance of developing cancer by consuming antioxidants found in plants? At this point, we don’t know. After all, our bodies have their own built-in antioxidant systems in place that, when functioning normally, can help repair cell damage.29 Additional trials exploring the effects of fruits and vegetables on DNA repair would give us more information about this.

Cruciferous vegetables contain compounds that might help reduce cancer risk in several ways, such as decreasing inflammation and improving cell signaling.30 Yet it appears there’s probably a threshold of these protective compounds that can be absorbed, so that very high intakes offer no further benefit than consuming more modest amounts.31

Many fruits and vegetables have other phytochemicals (literally “plant chemicals”) with potential anti-cancer activity, such as resveratrol and sulforaphane.32 However, their effects have been studied mainly in test tubes and animals. High-quality human research is needed before any conclusions can be made about their use in cancer prevention or treatment.

In contrast to the limited amount of experimental research, plenty of observational studies have explored the relationship between fruit and vegetable intake and cancer risk. Researchers who conduct systematic reviews and meta-analyses of these studies often conclude that people who eat the most fruits and vegetables decrease their risk of developing cancer. Yet these analyses reveal weak associations (RRs of 0.78 to 0.92) between eating a lot of produce and being diagnosed with any type of cancer, including breast, lung, colon, bladder, and non-Hodgkin’s lymphoma.33

In summary, eating fruits and vegetables — especially cruciferous types — may very well decrease your risk of cancer, but much more rigorous research is needed before we can say this for sure.

Rendering of blood cells with one infected cell

Diet and cancer: What we know and what we don’t

Guide In this guide, we’ll look at what we know — and what we don’t know — about food and cancer.

Other conditions

Nearly all research on the benefits of fruit and vegetables for other conditions is observational, but a couple of experimental studies suggest potential benefits:

  • Bone health: Results from one RCT found that increasing intake of certain fruits, vegetables and herbs may improve bone health. Postmenopausal women assigned to consume the “Scarborough Fare” diet — which included several daily servings of leafy greens, cabbage, onions, mushrooms, prunes and, of course, parsley, sage, rosemary and thyme (remember the old Simon and Garfunkel song?) — experienced less bone breakdown and calcium loss than women who consumed their usual diets or added other types of plants to their diets.34 By contrast, a meta-analysis of both observational studies and RCTs found no association between bone health and intake of fruits and vegetables.35
  • Psychological health: Only a single two-week study has investigated the potential psychological benefits of increasing fruit and vegetable intake in young adults who typically consume very little of these foods. The study participants reported improvements in well-being and motivation but no changes in depressive symptoms or overall mood.36


4. Modern-day fruits: larger, sweeter and widely available

Looking back at the diets of our hunter-gatherer ancestors, it’s clear that humans have been consuming plants (along with animals) for over a million years.37 Roots, leaves, berries and other fruits were readily eaten, but always based on seasonal availability. Today, a simple trip to the grocery store can present us with hundreds of produce options 365 days a year — many of them larger and more visually appealing than ever as a result of advanced farming methods and hybridization.38

Fruits in particular have become much bigger and sweeter than anything paleolithic humans could have imagined:

Diet Doctor: What fruits looked like before we domesticated them

Colossal apples, oranges and other fruits deliver more sugar with each bite — delighting our taste buds but ushering more glucose and fructose into the bloodstream than our bodies may be able to handle effectively.

Should we really be consuming much of these modern-day fruits if we’re concerned about our weight, blood sugar and general health?

Indeed, following a very-low-carb diet containing no fruit at all (other than perhaps minimal amounts of berries on occasion) has been repeatedly shown to help people lose body fat and get their diabetes or pre-diabetes under optimal control.39


5. Can eating fruits and vegetables cause health problems in some people?

Most of us can eat a moderate portion of vegetables without any difficulty. Because they’re higher in sugar, fruits are generally best enjoyed in smaller quantities. However, for some people, both fruits and vegetables may cause issues.

Although there isn’t much published research about sensitivities to specific compounds found in fruits and vegetables, plenty of personal stories can be found online about some of the more common ones, including:40

  • Salicylates: Although harmless for most of us, salicylates are chemicals found naturally in certain foods and also synthetically produced for use in medications like aspirin and other products. Ingesting them can lead to asthma, nasal discharge, and digestive issues in susceptible people.41 Fruits and vegetables high in salicylates include berries, oranges, pineapples, apricots, broccoli, cucumbers and zucchini.
  • Oxalate: People who suffer from kidney stones may find that their symptoms worsen after consuming fruits and vegetables high in oxalate.42 Spinach contains much more oxalate than any other vegetable, but rhubarb, beet greens, kale and other leafy greens also contain large amounts.
  • Histamines: Your body releases histamine on its own as part of an immune response, but in people with excessive levels or an inability to break it down, histamine can cause symptoms like hives, abdominal pain, asthma and headaches, among other symptoms.43 High-histamine foods include eggplant, spinach, tomatoes, sauerkraut, and avocados.
  • FODMAPS: This is an acronym for fermentable oligosaccarides, disaccarides, monosaccarides and polyols. Essentially these are all fermentable sugar molecules, found most often in fruits, vegetables and grains, that can cause digestive upset in people with Irritable Bowel Syndrome (IBS). People with IBS often find reducing or eliminating FODMAP foods greatly improves their symptoms.44

If you suspect you may have one of these sensitivities, keep in mind that processed, canned and fermented foods also contain some of these compounds. Moreover, your symptoms might be due to another health problem. Make sure to see a doctor for a full work-up to rule out other causes.

Vegetables and fruits large overhead mix group on colorful background


6. Will a diet devoid of fruits and vegetables lead to nutrient deficiencies?

Many people feel that fruits and vegetables are indispensable for health because they provide important vitamins and minerals. While it’s true that they provide a range of micronutrients, other minimally processed foods can help meet your needs. Meat, fish, and dairy provide as many (or more) essential vitamins and minerals as fruits and vegetables do, and organ meats like chicken liver and beef kidney are excellent sources of vitamin C.

In fact, there is evidence that we may need less vitamin C on a low-carb diet because glucose competes with vitamin C receptors; the more sugar or carbs you eat, the more vitamin C you might need in your diet.45 That said, it may be difficult to consistently meet your nutrient needs for vitamin C, potassium, folate and other key nutrients on an entirely produce-free diet.

What about fiber? Although fiber isn’t an essential nutrient, many health organizations recommend a daily minimum of 25 grams per day for adults. Of course, fruits and vegetables aren’t the only source of dietary fiber; nuts and seeds also provide some. However, the amount of fiber we actually need has been a hotly debated topic within the low-carb and keto community for some time. And to date, studies demonstrating fiber’s health benefits have been in people eating higher-carb diets.46

Recently, ketogenic experts Dr. Steve Phinney and Jeff Volek PhD wrote a post on their Virta Health blog explaining that although high fiber intake may be important for people who don’t follow a ketogenic diet, fiber needs may be greatly reduced for those of us in nutritional ketosis. 47 They point out that  the ketone body beta hydroxy butyrate (BHOB) can help nourish the cells lining your large intestine because it’s very similar to the chemical butyrate  produced by the gut microbiome when it digests fiber.48

Virta Health blog: Fiber and colon health on a well-formulated ketogenic diet.


7. Summary – fruits and vegetables: Optional, optimal, or essential?

In summary, fruits and vegetables are whole foods that provide vitamins, minerals and fiber, along with other potentially beneficial compounds like phytochemicals. In addition, many people — although certainly not all — genuinely enjoy the taste and texture of keto-friendly fruit and veggies, especially when combined with a fat or a tasty sauce. Think creamed spinach, zucchini noodles with alfredo sauce, or berries with high fat cream.

Moreover, there’s no question that replacing processed foods high in added sugar and refined carbohydrates with fresh fruits and vegetables is a healthy move.

It’s possible that fruits and vegetables may play an independent role in reducing disease risk. In the case of cruciferous and leafy green vegetables, it seems likely. However, there’s a limited amount of high-quality evidence on this, and much of it is conflicting. The observational research is much larger in volume but can’t be relied upon due to extremely weak correlations and a likely “healthy user” bias.

Aside from phytochemicals (and vitamin C, if organ meats aren’t consumed), fruits and vegetables don’t contain any nutrients that can’t be found in other minimally processed low-carb foods. And since there’s a lack of high-quality evidence on the role that phytochemicals play in human health, at this time we can’t say with certainty that eating fruits and vegetables is absolutely necessary for everyone.

On the other hand, including vegetables — and in some cases low sugar fruit like berries — probably makes sense for most people. Yet the optimal amounts to consume are unknown, and they likely vary from person to person. Some of us thrive on a diet that includes several servings of produce a day, while others seem to do best with minimal amounts.

On a keto or low-carbohydrate diet, low-sugar fruit and vegetables should be consumed based on personal preference, metabolic goals, and individual tolerance. Across-the-board recommendations to include five or more servings of produce every day, especially when the types aren’t specified, isn’t based on strong evidence.

/ Franziska Spritzler, RD


  1. These observations were made in the so-called “Blue Zones,” areas where people live into their 90’s and 100’s much more often than the world-wide population. However, this was from observations, not a scientific study. Plus, these individuals at baseline are thin, are routinely physically active, they eat fewer calories than the general population, they eat mostly home-prepared local ingredients, and have other healthy lifestyle habits not enjoyed by most people.

  2. American Journal of Alternative Agriculture 1992: Factors affecting the nutritional quality of crops [overview article; ungraded]

  3. Morbidity and Mortality Weekly Report 2017: Disparities in state-specific adult fruit and vegetable consumption — United States, 2015 [overview article; ungraded]

  4. This is based on clinical experience of low-carb practitioners. [weak evidence]

  5. This is based on opinion of individual practitioners and is not assigned a level of evidence.

  6. We are not aware of any studies examining the RDA of fruits and vegetables in the setting of a low-carb of keto diet.

  7. BMC Public Health 2014: Systematic review and meta-analysis of the effect of increased vegetable and fruit consumption on body weight and energy intake [strong evidence]

  8. American Journal of Clinical Nutrition 2014: Increased fruit and vegetable intake has no discernible effect on weight loss: a systematic review and meta-analysis [strong evidence]

  9. Obesity (Silver Spring) 2012: Beverage vs. solid fruits and vegetables: effects on energy intake and body weight [randomized trial; moderate evidence]

  10. Health Promotion Practice 2011: Pass the fruits and vegetables! A community-university-industry partnership promotes weight loss in African American women [randomized trial; moderate evidence]

  11. PloS One 2015: Fruit and vegetable consumption and changes in anthropometric variables in adult populations: a systematic review and meta-analysis of prospective cohort studies [observational cohort study with ORs < 2; very weak evidence]

  12. International Journal of Food Sciences and Nutrition 2015: Effect of fruits and vegetables on metabolic syndrome: a systematic review and meta-analysis of randomized controlled trials [strong evidence]

  13. World Journal of Diabetes 2010: Surrogate markers of insulin resistance: A review [overview article; ungraded]

  14. British Journal of Nutrition 2017: The effect of increased fruit and vegetable consumption on selected macronutrient and micronutrient intakes in four randomised-controlled trials [moderate evidence]

  15. Diabetes Care 2013: Dose-response effect of fruit and vegetables on insulin resistance in people at high risk of cardiovascular disease: a randomized controlled trial [moderate evidence]

  16. International Journal of Food Sciences and Nutrition 2012: Effect of broccoli sprouts on insulin resistance in type 2 diabetic patients: a randomized double-blind clinical trial [moderate evidence]

  17. In This meta analysis, they found green leafy veggies, yellow veggies, cruciferous veggies and blueberries all had weak associations with reduced diabetes risk between 0.72 and 0.93

    Journal of Diabetes Investigation 2016: Higher intake of fruits, vegetables or their fiber reduces the risk of type 2 diabetes: a meta-analysis [observational study; very weak evidence]

    In this meta analysis, fruit and vegetable intake combined had a very low association with reduced diabetes (odds ratio 0.93) but when taken individually, vegetable intake was statistically significant while fruit intake was not.

    BMJ Open 2014: Fruit and vegetable intake and risk of type 2 diabetes mellitus: meta-analysis of prospective cohort studies [observational study; very weak evidence]

    Finally, this meta analysis showed no overall association between fruit and vegetable intake and risk of DM, but when separated, the data did start to show weak associations.

    European Journal of Clinical Nutrition 2017: Fruit and vegetable intake and risk of incident of type 2 diabetes: results from the consortium on health and ageing network of cohorts in Europe and the United States (CHANCES) [observational study; very weak evidence]

  18. Scientific Reports 2017: Excessive fruit consumption during the second trimester is associated with increased likelihood of gestational diabetes mellitus: a prospective study [observational study; weak evidence]

  19. Cochrane Database of Systematic Reviews 2013: Increased consumption of fruit and vegetables for the primary prevention of cardiovascular diseases [systematic review of randomized trials; strong evidence]

  20. Nutrition, Metabolism and Cardiovascular Diseases 2015: A systematic review of vascular and endothelial function: effects of fruit, vegetable and potassium intake [strong evidence]

  21. Cardiovascular Diabetology 2014: A randomised controlled trial of increasing fruit and vegetable intake and how this influences the carotenoid concentration and activities of PON-1 and LCAT in HDL from subjects with type 2 diabetes [moderate evidence]

    American Journal of Clinical Nutrition 2014: Flavonoid-rich fruit and vegetables improve microvascular reactivity and inflammatory status in men at risk of cardiovascular disease–FLAVURS: a randomized controlled trial [moderate evidence]

  22. Journal of Nutrition 2015: Increasing fruit and vegetable intake has no dose-response effect on conventional cardiovascular risk factors in overweight adults at high risk of developing cardiovascular disease [randomized trial; moderate evidence]

    Nutrition, Metabolism and Cardiovascular Diseases 2016: Increasing fruit and vegetable intake has no effect on retinal vessel caliber in adults at high risk of developing cardiovascular disease [randomized trial; moderate evidence]

  23. International Journal of Epidemiology 2017: Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies [observational study; very weak evidence]

  24. Cancer, Epidemiology, Biomarkers & Prevention 2005: Is it time to abandon the food frequency questionnaire? [overview article; ungraded]

  25. Carcinogenesis 2003: Nutritional modulation of DNA repair in a human intervention study [randomized trial; moderate evidence]

  26. Mutagenesis 2010: DNA damage and repair activity after broccoli intake in young healthy smokers [randomized trial; moderate evidence]

  27. European Journal of Nutrition 2018: Effect of increasing fruit and vegetable intake by dietary intervention on nutritional biomarkers and attitudes to dietary change: a randomised trial [moderate evidence]

    Cancer, Epidemiology, Biomarkers and Prevention 2003: No effect of 600 grams fruit and vegetables per day on oxidative DNA damage and repair in healthy nonsmokers [randomized trial; moderate evidence]

  28. Journal of Nutritional Biochemistry: Assessment of DNA damage and repair in adults consuming allyl isothiocyanate or Brassica vegetables [randomized trial; moderate evidence]

  29. Cellular Physiology and Biochemistry 2017: Antioxidants maintain cellular redox homeostasis by elimination of reactive oxygen species [overview article; ungraded]

  30. Nutrition and Cancer 2009: Effect of broccoli intake on markers related to oxidative stress and cancer risk in healthy smokers and nonsmokers [randomized trial; moderate evidence]

    PloS One 2008: Broccoli consumption interacts with GSTM1 to perturb oncogenic signaling pathways in the prostate [randomized trial; moderate evidence]

  31. Cancer Prevention Research 2016: Harnessing the power of cruciferous vegetables: Developing a biomarker for brassica vegetable consumption using urinary 3,3′-diindolylmethane [randomized trial; moderate evidence]

  32. Anticancer Agents in Medicinal Chemistry 2012: Plants vs. cancer: a review on natural phytochemicals in preventing and treating cancers and their druggability [overview article; ungraded]

  33. Breast Cancer Research and Treatment 2012: Fruits, vegetables and breast cancer risk: a systematic review and meta-analysis of prospective studies [observational study; very weak evidence]

    Annals of Oncology 2016: Fruits, vegetables and lung cancer risk: a systematic review and meta-analysis [observational study; very weak evidence]

    Journal of the National Cancer Institute 2007: Fruits, vegetables, and colon cancer risk in a pooled analysis of 14 cohort studies [observational study; very weak evidence]

    Cancer Medicine 2015: Fruits, vegetables, and bladder cancer risk: a systematic review and meta-analysis [observational study; very weak evidence]

    International Journal of Cancer 2013: Fruits and vegetables consumption and risk of non-Hodgkin’s lymphoma: a meta-analysis of observational studies [observational study; very weak evidence]

  34. Nutrients 2015: Increased intake of selected vegetables, herbs and fruit may reduce bone turnover in post-menopausal women [randomized trial; moderate evidence]

  35. PLoS One 2019: Fruit and vegetable intake and bones: A systematic review and meta-analysis [Systemic review of RCTs and Cohort studies combined; moderate evidence]

  36. PloS One 2017: Let them eat fruit! The effect of fruit and vegetable consumption on psychological well-being in young adults: A randomized controlled trial [moderate evidence]

  37. American Journal of Clinical Nutrition 2000: Plant-animal subsistence ratios and macronutrient energy estimations in worldwide hunter-gatherer diets [overview article; ungraded]

  38. Journal of Experimental Botany 2014: The fruit, the whole fruit, and everything about the fruit [overview article; ungraded]

  39. Diabetes and Metabolic Syndrome 2017: Induced and controlled dietary ketosis as a regulator of obesity and metabolic syndrome pathologies [randomized trial; moderate evidence]

    The Journal of Clinical Endocrinology and Metabolism 2017: Body composition changes after very-low-calorie ketogenic diet in obesity evaluated by 3 standardized methods [randomized trial; moderate evidence]

    Nutrition & Metabolism 2008: The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus [randomized trial; moderate evidence]

    Nutrition & Diabetes 2017: Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes [moderate evidence]

    Journal of Medical Internet Research 2017: An online intervention comparing a very low-carbohydrate ketogenic diet and lifestyle recommendations versus a plate method diet in overweight individuals with type 2 diabetes: A randomized controlled trial [moderate evidence]

  40. This is based mostly on anecdotal reports

  41. Deutsches Ärzteblatt International 2008: Salicylate intolerance: pathophysiology, clinical spectrum, diagnosis and treatment [overview article, ungraded]

  42. Korean Journal of Urology 2014: Medical and dietary therapy for kidney stone prevention [overview article; ungraded]

  43. Foods 2018: Biogenic amines in plant-origin foods: Are they frequently underestimated in low-histamine diets? [overview article; ungraded]

  44. Nutrition 2018: Low fermentable, oligo-, di-, mono-saccharides and polyol diet in the treatment of irritable bowel syndrome: A systematic review and meta-analysis [strong evidence]

  45. Journal of Physiology 2008: Vitamin C transporters [overview article; ungraded]

  46. We are unaware of any studies examining an RDA for fiber in the setting of a low-carb or keto diet

  47. This is based on clinical experience of low-carb practitioners and was unanimously agreed upon by our Low-Carb Expert Review Panel. You can learn more about our panel here [weak evidence].

  48. Journal of Nutrition and Metabolism 2018: Potential Synergies of β-Hydroxybutyrate and Butyrate on the Modulation of Metabolism, Inflammation, Cognition, and General Health [overview article; ungraded]