@murphai/murph 1.3.0 → 1.3.1

package/node_modules/@murphai/assistant-engine/skills/nutrition-strategy/references/named-diets/carnivore-animal-based.md

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+# Carnivore and animal-based diets
+
+Evidence reviewed: 2026-08-09.
+
+This is a progressive-disclosure reference, not a registered skill. Use it only after the parent `nutrition-strategy` contract. It adds diet-specific evidence, tradeoffs, harm reduction, and handoffs; it does not replace the parent's routing, universal safety, clinical boundaries, or lowest-tracking-burden rules.
+
+## Define the pattern before evaluating it
+
+These labels are informal and inconsistently used. Ask what the person actually eats rather than inferring one rule set.
+
+| Pattern | Common meaning | Material differences |
+| --- | --- | --- |
+| **Strict carnivore** | All or nearly all food comes from meat, fish, seafood, eggs, animal fats, and sometimes dairy; plant foods are excluded. | Provides essentially no dietary fiber. Carbohydrate is usually very low, but the label does not prove sustained nutritional ketosis. |
+| **Lion or ruminant-only** | One or a few ruminant meats, salt, and water. | The narrowest food variety and concentrated adequacy risk. It should not be treated as nutritionally equivalent to a mixed animal-food pattern. |
+| **Dairy-inclusive carnivore** | Adds milk, yogurt, cheese, cream, or butter while excluding plant foods. | The dairy choices change carbohydrate, calcium, iodine, saturated-fat, and tolerance tradeoffs. Raw dairy is a separate food-safety choice, not a requirement or recommendation. |
+| **Organ-inclusive or "nose-to-tail" carnivore** | Adds liver or other organs to muscle meat. | Organs change micronutrient exposure but do not guarantee adequacy and can create excesses. |
+| **Looser animal-based** | Animal foods predominate while selected plant foods remain--often fruit and honey, and sometimes tubers, rice, vegetables, or other tolerated foods. | There is no standard definition. Fiber, carbohydrate, fat quality, and micronutrient exposure can differ greatly from strict carnivore, so evidence and risks cannot be transferred between them as though they were one diet. Many versions are not ketogenic. |
+
+A carnivore diet is not automatically a therapeutic ketogenic diet. Clinician-managed ketogenic diets for epilepsy or another medical indication are separate, condition-specific care.
+
+## Evidence position
+
+**Bottom line:** direct evidence is too sparse and biased to establish that carnivore eating improves direct health outcomes or is safe long term. A 2026 scoping review found nine human studies in its search window: five case-based studies, two social-media surveys, one exploratory study, and one comparative modeling study. Samples were generally small, follow-up was short, definitions varied, and controlled comparisons were largely absent. Two later 2026 publications reviewed here--a single-patient diabetes case report and a cross-sectional microbiome study of 10 healthy, self-selected long-term adherents--do not change the certainty because neither is a randomized comparison or a long-term clinical-outcome study. No trial has established effects on cardiovascular events, cancer, fractures, kidney failure, mortality, or overall long-term safety.
+
+The largest commonly cited study was an online survey of 2,029 current adherents. It can describe what a self-selected group reported; it cannot show that the diet caused reported improvements or estimate harms among everyone who tried it. People who stopped because it did not help or caused problems were less likely to be represented. Recall, reporting, selection, survivorship, regression-to-the-mean, and community-expectation biases are material.
+
+| Question | What the evidence can support | What it cannot support |
+| --- | --- | --- |
+| **Weight, satiety, glucose, triglycerides, or symptoms** | Some adherents and small reports describe short-term improvement. Lower carbohydrate intake, higher protein, fewer ultra-processed foods, lower energy intake, early glycogen and water loss, or removal of a specific trigger are plausible explanations. | A carnivore-specific advantage, durable benefit, or proof that plant foods caused the original problem. Evidence from ketogenic or low-carbohydrate diets is adjacent and indirect; it does not test whether eliminating all plants adds benefit. |
+| **Nutrient adequacy** | Modeled menus show that animal foods can cover several nutrients, while common versions miss fiber and may fall short in vitamin C, thiamin, folate, calcium, magnesium, iodine, potassium, or other nutrients depending on the food list. | That a theoretical one-day menu predicts an individual's nutrient status, or that ketosis lowers human requirements enough to make identified gaps irrelevant. |
+| **Cardiometabolic safety** | LDL-C and total cholesterol have risen in several direct reports; broader evidence supports concern when a pattern is high in saturated fat and raises atherogenic lipoprotein burden. | That lower triglycerides, higher HDL-C, weight loss, or good subjective energy makes a marked LDL-C or apoB rise harmless. Direct carnivore studies have not tested cardiovascular events. |
+| **Athletic performance** | Very-low-carbohydrate intake can increase fat oxidation. Adjacent ketogenic-diet evidence often finds similar or worse performance than higher-carbohydrate comparators, depending on the task. | A direct carnivore performance advantage. Increased fat oxidation is a metabolic adaptation, not proof of better speed, power, work capacity, or recovery. |
+| **Disease treatment** | A person's symptom report can justify careful follow-up and a search for the least restrictive explanation. | Claims that carnivore cures autoimmune, gastrointestinal, metabolic, psychiatric, or malignant disease. It is not a guideline-supported substitute for diagnosis or treatment. |
+
+Treat the following as unsupported, not as established mechanisms: that plants or "antinutrients" are broadly toxic; fiber is unnecessary for everyone; symptoms during transition are "detox" or "oxalate dumping"; organs prevent every deficiency; an ancestral story proves optimality; high LDL-C or apoB is benign when triglycerides or HDL-C look favorable; or ketosis guarantees health or performance.
+
+## Why a user may choose it
+
+Common aims include simpler decisions, high satiety, preference for animal foods, avoiding ultra-processed foods, weight or glucose goals, a self-directed elimination experiment, hoped-for digestive or inflammatory symptom relief, and belonging or confidence from online testimonials. Validate the underlying aim without validating an unsupported explanation. Simplicity, a protein anchor, fewer ultra-processed foods, or removal of one true trigger can usually be preserved with less restriction.
+
+## Diet-specific tradeoffs
+
+### Fiber and digestive change
+
+Strict carnivore supplies essentially no dietary fiber. Stool volume or frequency may decrease without automatically meaning constipation; ask about hard stool, straining, pain, incomplete evacuation, or a meaningful change from baseline. Abrupt increases in fat, dairy intolerance, or foodborne illness can instead cause loose stool, urgency, or nausea. A 2026 cross-sectional study of 10 selected long-term adherents found a distinct microbiome without a simple reduction in alpha diversity, but its one-time sampling and predicted functions cannot show causation, clinical benefit or harm, or that fiber is unnecessary. Persistent constipation, diarrhea, pain, bleeding, or other digestive symptoms belong with `gut-digestion` and clinical care as appropriate. Do not explain symptoms away as adaptation.
+
+### Micronutrients and food variety
+
+Risk depends on the exact foods. A meat-and-butter pattern, a fish-and-dairy-inclusive pattern, and a fruit-inclusive animal-based pattern are not nutritionally interchangeable.
+
+- Muscle-meat-heavy versions can be low in vitamin C, folate, thiamin, magnesium, calcium, iodine, and potassium; strict versions also remove dietary fiber.
+- Pasteurized dairy can contribute calcium and iodine, and seafood can contribute iodine and long-chain omega-3 fats, but neither makes the whole pattern automatically adequate.
+- Liver and other organs are optional, not a universal fix. Frequent large liver servings can create excessive preformed vitamin A and copper exposure; excess preformed vitamin A is especially concerning during pregnancy.
+- Do not improvise supplement doses to "complete" the diet. Route supplement selection, labels, dose, interactions, and lab interpretation to `micronutrients-supplements` or clinical care.
+
+### Saturated fat, LDL-C, and apoB
+
+Versions built around fatty red meat, butter, cream, cheese, and processed meat can be high in saturated fat and may raise LDL-C, non-HDL-C, and apoB. Response is heterogeneous: the direction and size can vary with genetics, baseline risk, weight change, food selection, and other factors, and some people have large increases. Favorable changes in appetite, glucose, triglycerides, or HDL-C do not cancel an adverse rise in atherogenic particle burden.
+
+For harm reduction, emphasize fish and seafood, eggs, leaner or mixed-fat cuts, and lower-fat pasteurized dairy if tolerated rather than using butter, cream, cheese, bacon, or sausage as the main energy sources. A marked lipid change is a cardiometabolic handoff, not a debate to settle from diet identity or ratios alone.
+
+### Kidney stones, uric acid, and gout
+
+Direct carnivore data are insufficient to quantify risk. Adjacent ketogenic-diet evidence--much of it from clinician-managed therapeutic diets--finds kidney stones as a recognized complication, but it cannot provide an ordinary carnivore risk estimate. High animal-protein and purine exposure, high sodium intake, low urinary citrate or pH, and concentrated urine can matter in susceptible people. Organ meats and some seafood can be especially purine-rich.
+
+A history of kidney stones, gout, chronic kidney disease, or abnormal kidney function warrants clinical review before proceeding. Do not promise that extra water, salt, or electrolyte products neutralize the risk, and do not prescribe a universal fluid or sodium target.
+
+### Low carbohydrate and training demand
+
+Strict carnivore is usually very low in carbohydrate. Easy or lower-volume training may feel acceptable for some people, but repeated sprints, high-intensity intervals, high-volume lifting, team sport, and long sessions with hard efforts often depend more on carbohydrate availability. If output, recovery, mood, sleep, or appetite worsens, adding familiar carbohydrate is a lower-risk correction than waiting indefinitely for "fat adaptation." Flexible options include fruit, potatoes, rice, oats, bread, or another tolerated staple; using them means loosening the label, not failing.
+
+### Foodborne risk
+
+Raw or undercooked meat, poultry, seafood, eggs, and organs and unpasteurized milk or dairy can transmit serious infection. Use pasteurized dairy; keep raw and ready-to-eat foods separate; refrigerate promptly; and cook foods to official safe temperatures. Pregnancy, older age, young children, and immune compromise increase the stakes. "High quality," local sourcing, or a healthy animal does not make raw products pathogen-free.
+
+## Lowest-risk execution when a user proceeds
+
+1. **Name the actual pattern and goal.** Record the foods included, foods excluded, whether dairy or organs are used, the intended outcome, and what would count as no benefit. Do not turn the label into an identity test.
+2. **Prefer the least restrictive version that preserves the useful core.** Keep satisfying protein choices such as fish, eggs, poultry, meat, or pasteurized yogurt, and retain tolerated foods such as fruit, cooked vegetables, potatoes, oats, rice, beans, or olive oil when they fit the person's goal. A symptom-led elimination and reintroduction belongs with `gut-digestion`, not an indefinite all-food ban.
+3. **If strict carnivore remains the user's choice, make it bounded and adequacy-aware.** Avoid pairing it with fasting or intentional under-eating; use enough food; vary animal foods within tolerance, access, and budget; minimize processed meats; do not make butter, cream, cheese, or liver the bulk of intake; and use safe cooking and storage. This reduces some risks but does not establish long-term safety.
+4. **Choose one outcome and a few safety signals.** A useful test follows the target plus bowel comfort, energy, training or recovery, unintended weight change, menstrual function when relevant, and food preoccupation or social impairment. A brief food-list snapshot is usually more useful than full daily macro tracking.
+5. **Plan the off-ramp before starting.** Decide which tolerated food returns first and which result would end or loosen the experiment. Use `experiment-onboarding` only after the person has chosen a specific, safe test.
+
+## Common failure modes
+
+- Treating strict carnivore, dairy-heavy carnivore, and fruit-inclusive animal-based eating as the same exposure.
+- Calling early water loss proof of fat loss or long-term efficacy.
+- Building most meals from butter, cream, cheese, bacon, sausage, or very fatty meat while dismissing a lipid rise.
+- Adding fasting because appetite falls, then overlooking low energy, poor recovery, menstrual change, cold intolerance, or unintended rapid loss.
+- Using daily liver, organ concentrates, or multiple supplements as an unmeasured adequacy strategy.
+- Consuming raw milk, raw eggs, raw meat, or undercooked organs because of purity or nutrient claims.
+- Calling constipation, diarrhea, dizziness, palpitations, gout symptoms, or declining performance "detox" or mandatory adaptation.
+- Letting a broad elimination become indefinite because several things changed at once and no reintroduction was planned.
+- Escalating fear of plant foods, social avoidance, compulsive checking, or compensatory exercise.
+
+## Monitoring, stop conditions, and off-ramp
+
+Use the lowest burden that can detect benefit or harm. For someone continuing beyond a brief self-directed test--especially with known dyslipidemia, cardiovascular risk, or a family history of early cardiovascular disease--clinical review of a baseline and follow-up lipid panel is reasonable; apoB can help assess atherogenic particle burden when available. Kidney function, uric acid, or nutrient testing should be selected from history, food exposure, symptoms, and clinician judgment rather than ordered as a universal "carnivore panel." Glucose-lowering or blood-pressure medication may need prompt adjustment when carbohydrate intake, body mass, or fluid balance changes; arrange the medication plan before starting.
+
+Stop, loosen, or seek timely review for a marked or persistent LDL-C, non-HDL-C, or apoB rise; a gout flare or possible stone symptoms; persistent constipation, diarrhea, vomiting, or abdominal pain; weakness, dizziness, palpitations, or inability to train normally; menstrual change, reduced libido, unusual cold, or rapid or unwanted weight loss; or increasing food fear, rigidity, isolation, bingeing, purging, or compensatory exercise. Use the parent's urgent-escalation rules for acute deterioration.
+
+A nonjudgmental off-ramp can keep the parts that helped:
+
+- keep a preferred protein anchor and simple meals;
+- add one familiar, tolerated food at a time, such as fruit or berries, potatoes, oats or rice, cooked vegetables, beans or lentils, or pasteurized yogurt;
+- increase fiber gradually rather than making a large jump when digestive tolerance is uncertain;
+- replace some butter, cream, fatty processed meat, or very fatty cuts with fish, leaner meat, olive oil, nuts, avocado, or other tolerated unsaturated-fat sources; and
+- return to the next ordinary meal without compensation or a "reset."
+
+If symptom recurrence is the main concern, use `gut-digestion` for a structured reintroduction. Moving away from the label is information, not failure.
+
+## Groups needing extra caution
+
+Do not help tighten this pattern without appropriate clinical or dietetic involvement when the person is under 18; pregnant, trying to conceive, or breastfeeding; has current or past eating-disorder risk; is frail, under-fueled, or losing weight unintentionally; uses glucose-lowering medication; has chronic kidney disease, kidney stones, gout, advanced liver disease, significant cardiovascular disease, familial or severe hypercholesterolemia, or a relevant gastrointestinal condition; is post-bariatric surgery; or is using the diet as treatment for a diagnosed condition. Pregnancy adds nutrient-adequacy, foodborne, and liver-derived preformed-vitamin-A concerns and is not an appropriate setting for an unsupervised restrictive experiment.
+
+## Murph handoffs
+
+- Use `food-journal` for a low-pressure snapshot of the actual foods, preparation method, dairy or organ use, labels, and observed links with symptoms or performance.
+- Use `body-composition` when intentional weight, waist, fat-loss, muscle-gain, or recomposition strategy is the main job; return here only for food execution.
+- Use `gut-digestion` for constipation, diarrhea, pain, reflux, symptom-driven elimination, or reintroduction.
+- Use `cardiometabolic-health`, `chronic-illness-support`, care navigation, and the user's clinician for lipids, glucose, blood pressure, kidney function, stones, gout, medication changes, or disease treatment.
+- Use `micronutrients-supplements` for nutrient-gap assessment, supplement labels, dose, interactions, or lab interpretation.
+- Use `experiment-onboarding` after the person chooses one bounded, safe change with an outcome and stop conditions.
+- Use `behavior-followthrough` only when reminders, fallback planning, or ongoing support becomes the main job.
+
+## Source register
+
+Evidence review cutoff: **2026-08-09**. Direct carnivore evidence is labeled separately from adjacent or general evidence so it is not over-transferred.
+
+- **Direct evidence -- [Carnivore Diet: A Scoping Review of the Current Evidence, Potential Benefits and Risks (2026)](https://doi.org/10.3390/nu18020348).** Scoping review of nine human studies in its search window; the central source for the sparse, heterogeneous, short, and mostly uncontrolled evidence base.
+- **Direct evidence -- [Behavioral Characteristics and Self-Reported Health Status among 2029 Adults Consuming a "Carnivore Diet" (2021)](https://doi.org/10.1093/cdn/nzab133).** Large descriptive online survey; useful for reported practices and experiences, but not causal efficacy, incidence of harm, or long-term safety because of self-selection, survivorship, recall, and reporting bias.
+- **Direct observational evidence -- [Long-term adherence to the carnivore diet and its impact on the gut microbiota: a cross-sectional study (2026)](https://doi.org/10.1530/MAH-25-0015).** Ten healthy, self-selected long-term adherents were compared with matched omnivore controls at one time point; useful for hypothesis generation, not causation, clinical outcomes, or long-term safety.
+- **Direct case evidence -- [Reversing 20 years of diabetes using the carnivore diet in India: a case report (2026)](https://doi.org/10.7762/cnr.2025.0026).** One person's uncontrolled outcome; hypothesis-generating only, not evidence of general efficacy, comparative benefit, medication safety, or durable remission.
+- **Direct modeling -- [Assessing the Nutrient Composition of a Carnivore Diet: A Case Study Model (2025)](https://doi.org/10.3390/nu17010140).** Four hypothetical menus; useful for possible nutrient gaps and excesses, not measured nutrient status or health outcomes.
+- **Direct/adjacent sport review -- [Carnivore and Animal-Based Diets in Sport: A Critical Evaluation of Current Evidence and Future Perspectives for Precision Nutrition (2026)](https://doi.org/10.3390/nu18060998).** Clarifies inconsistent definitions and the absence of strong sport-specific trials; much of the performance discussion is extrapolated from low-carbohydrate and ketogenic research.
+- **General guideline -- [Carbohydrate intake for adults and children: WHO guideline (2023)](https://www.who.int/publications/i/item/9789240073593).** Guidance on carbohydrate quality, fiber, fruit, and vegetable intake; not a carnivore trial.
+- **General guideline -- [Saturated fatty acid and trans-fatty acid intake for adults and children: WHO guideline (2023)](https://www.who.int/publications/i/item/9789240073630).** Evidence-informed saturated-fat guidance; relevant to high-butter, high-cream, high-cheese, or fatty-meat implementations.
+- **Causal lipid evidence -- [Low-density lipoproteins cause atherosclerotic cardiovascular disease: evidence from genetic, epidemiologic, and clinical studies (2017)](https://doi.org/10.1093/eurheartj/ehx144).** Establishes the relevance of sustained LDL exposure; not specific to carnivore diets.
+- **Lipid consensus -- [Role of apolipoprotein B in the clinical management of cardiovascular risk in adults (2024)](https://doi.org/10.1016/j.jacl.2024.08.013).** Consensus on apoB as a measure of atherogenic lipoprotein burden; supports not dismissing discordant or marked responses.
+- **Adjacent sport evidence -- [International Society of Sports Nutrition position stand: ketogenic diets (2024)](https://doi.org/10.1080/15502783.2024.2368167).** Critical review in healthy exercising adults; indirect for carnivore and does not test complete plant exclusion.
+- **Adjacent kidney-stone evidence -- [Incidence and Characteristics of Kidney Stones in Patients on Ketogenic Diet: A Systematic Review and Meta-Analysis (2021)](https://doi.org/10.3390/diseases9020039).** Documents stones in ketogenic-diet studies, many in therapeutic settings; does not estimate ordinary carnivore risk.
+- **Stone guidance -- [European Association of Urology: Metabolic Evaluation and Recurrence Prevention](https://uroweb.org/guidelines/urolithiasis/chapter/metabolic-evaluation-and-recurrence-prevention) and [NIDDK: Eating, Diet, & Nutrition for Kidney Stones](https://www.niddk.nih.gov/health-information/urologic-diseases/kidney-stones/eating-diet-nutrition).** Current clinical and official guidance on excessive animal protein, sodium, and stone risk; condition-specific decisions require clinical ownership.
+- **Gout guideline -- [2020 American College of Rheumatology Guideline for the Management of Gout](https://doi.org/10.1002/acr.24180).** Supports a clinical handoff for gout and shows that diet is not a substitute for indicated medical management.
+- **Food safety -- [Safe Minimum Internal Temperatures](https://www.foodsafety.gov/food-safety-charts/safe-minimum-internal-temperatures), [CDC Raw Milk](https://www.cdc.gov/food-safety/foods/raw-milk.html), and [CDC Safer Food Choices for Pregnant Women](https://www.cdc.gov/food-safety/foods/pregnant-women.html).** Primary official sources for cooking, pasteurization, and high-risk groups.
+- **Pregnancy and vitamin A -- [NIH Office of Dietary Supplements: Pregnancy](https://ods.od.nih.gov/factsheets/Pregnancy-HealthProfessional/) and [Vitamin A and Carotenoids](https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/).** Supports concern about restrictive adequacy and excess preformed vitamin A from liver or supplements, especially during pregnancy.

package/node_modules/@murphai/assistant-engine/skills/nutrition-strategy/references/named-diets/dash.md

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+# DASH
+
+Last evidence review: **2026-08-09**
+
+This progressive-disclosure reference supplements the parent `nutrition-strategy` contract. Apply the parent first. This file adds DASH-specific evidence and execution details; it does not own diagnosis, blood-pressure targets, medication changes, or clinician-prescribed sodium, potassium, or fluid limits.
+
+## What DASH is
+
+DASH means Dietary Approaches to Stop Hypertension. It is a flexible, blood-pressure-oriented eating pattern, not a branded food list, cleanse, weight-loss program, or rigid menu.
+
+The common pattern emphasizes:
+
+- vegetables and fruit;
+- whole grains and other minimally processed starches;
+- beans, lentils, nuts, and seeds;
+- fat-free or low-fat dairy in the classic version;
+- fish, poultry, eggs, tofu, or lean unprocessed meat as desired; and
+- unsaturated oils and other satisfying fats in practical amounts.
+
+It generally reduces sodium, sugar-sweetened drinks and frequent sweets, fatty or processed meats, and foods high in saturated fat. These are pattern-level priorities, not purity rules or absolute bans.
+
+Meaningful variants include:
+
+- **Standard-sodium DASH:** official materials commonly use a ceiling near 2,300 mg sodium per day.
+- **Lower-sodium DASH:** commonly uses about 1,500 mg per day and lowered blood pressure further in short controlled feeding research, but is more restrictive and not an automatic target for every user.
+- **Lactose-free or lactose-reduced DASH:** keeps the classic dairy structure with tolerated products.
+- **Dairy-free DASH-style:** replaces dairy with nutrient-aware plant foods. It can preserve the broad pattern, but it is not the exact version tested in the landmark trials.
+- **DASH-like higher-protein or higher-unsaturated-fat variants:** short feeding studies found that replacing some carbohydrate with protein or unsaturated fat could improve selected blood-pressure and lipid outcomes. This does not require a high-protein or low-carbohydrate diet.
+
+Clinician-set sodium, potassium, or fluid instructions override these variants. Do not convert a DASH reference number into a personalized prescription from chat.
+
+## What the evidence supports
+
+- **Blood pressure versus usual or control diets:** DASH has unusually strong named-diet evidence for this specific surrogate outcome. The landmark trials were randomized controlled feeding studies, and a 2020 meta-analysis of 30 randomized trials found average between-group reductions of about 3.2 mm Hg systolic and 2.5 mm Hg diastolic, with moderate certainty. Effects varied across populations and implementations.
+- **DASH plus sodium reduction:** sodium reduction lowered blood pressure independently, and the combination produced the largest reductions in the short DASH-Sodium feeding trial. The standard and lower-sodium variants therefore have a real evidence basis rather than being marketing categories.
+- **Guideline support:** the 2025 United States blood-pressure guideline strongly supports a heart-healthy pattern such as DASH, lower sodium, and higher dietary potassium for adults, while placing medication and target decisions in clinical care.
+- **Plausible mechanisms:** lower sodium and saturated fat, more potassium-, calcium-, magnesium-, and fiber-rich foods, and displacement of highly processed foods are plausible contributors. No single nutrient proves the effect of the whole pattern.
+
+## What the evidence does not establish
+
+- **Not a medication replacement:** a useful dietary pattern does not justify delaying evaluation, stopping medication, changing a dose, or ignoring a clinician's action plan.
+- **No guaranteed individual effect:** average trial results do not predict one person's response. Baseline blood pressure, sodium exposure, medication, kidney function, energy intake, food access, and adherence can all matter.
+- **Limited duration and real-world certainty:** the landmark feeding trials lasted weeks and provided participants' food. Free-living execution over months or years is less controlled and usually more difficult.
+- **Direct health outcomes remain uncertain:** lower rates of cardiovascular events and diabetes have been associated with greater DASH adherence in prospective cohorts, but those findings are observational and vulnerable to confounding. Long-term DASH-specific randomized trials of heart attack, stroke, or mortality are lacking.
+- **No universal superiority over every healthy pattern:** a 2026 systematic review in adults with elevated blood pressure or hypertension found no statistically significant blood-pressure advantage over other dietary interventions in head-to-head randomized comparisons; heterogeneity was substantial and certainty ranged from moderate to very low. DASH is better supported than most fad diets for blood pressure, but that does not make it uniquely best for every person or goal.
+- **Not inherently a weight-loss diet:** weight can change when total intake changes, but DASH's defining evidence does not require intentional weight loss. Route intentional body change to its owner.
+
+## Why a user may choose it
+
+Common reasons include wanting a guideline-supported food pattern for blood-pressure-oriented eating, preferring ordinary grocery foods over specialty products, seeking a less restrictive alternative to elimination diets, or wanting a structure that can work for omnivorous, vegetarian, family, and culturally specific meals. Name recognition, rankings, and testimonials may increase demand, but they do not strengthen the trial evidence.
+
+Clarify whether the real job is a definition, a practical food-system change, blood-pressure interpretation, medication-linked care, or intentional weight change. The DASH label alone does not settle that routing decision.
+
+## Tradeoffs and adequacy checks
+
+### Sodium burden
+
+The lower-sodium version can require substantial label reading, cooking, and restaurant negotiation. Do not default to exact milligram tracking. Start with the one or two foods that contribute the most sodium in the user's actual routine: often breads, sauces and condiments, soups, cured or deli foods, cheese, packaged meals, or restaurant food. Compare like-for-like labels or use a smaller amount before adding a full tracking system.
+
+Do not focus only on the salt shaker. Also do not remove so much flavor or convenience that the plan becomes unsustainable or intake falls. Acids, herbs, spices, aromatics, toasted seeds, and small amounts of strongly flavored condiments can preserve enjoyment.
+
+### Potassium and kidney or medication risk
+
+DASH naturally raises potassium through foods such as beans, lentils, potatoes, leafy greens, tomatoes, squash, fruit, yogurt, and some fish. That is useful for many adults, but more potassium is not universally safer.
+
+Do not encourage a potassium supplement or potassium-chloride salt substitute without a clinician or pharmacist check when the user has kidney disease, impaired potassium handling, a history of high potassium, significant heart disease, or medicines that affect potassium. Relevant medicines can include renin-angiotensin system drugs, mineralocorticoid receptor antagonists, potassium-sparing diuretics, and prescribed potassium; this list is not exhaustive.
+
+### Dairy and non-dairy adaptations
+
+The classic evidence base used fat-free or low-fat dairy. Lactose-free or lactose-reduced milk and yogurt can preserve that structure. Lactose-free dairy is still dairy and is not suitable for a milk allergy.
+
+For a dairy-free version, flexible options include unsweetened fortified soy milk or yogurt, calcium-set tofu, beans, leafy greens, nuts, seeds, and tahini. Check that the replacement pattern supplies meaningful protein, calcium, and vitamin D rather than assuming every plant beverage is nutritionally equivalent. If the pattern also removes all animal foods, use the narrower vegan reference when available and hand supplement or adequacy questions to `micronutrients-supplements`.
+
+### Fiber, energy, and protein
+
+A rapid increase in beans, whole grains, vegetables, fruit, nuts, and seeds can cause bloating, gas, or stool changes. Add one repeatable food or swap at a time over days to weeks, and keep ordinary fluid intake appropriate to thirst and any clinical plan.
+
+Avoid turning "low fat" into low energy, low satiety, or a diet built from sweetened low-fat products. Preserve enough food, protein, carbohydrate for demand, and satisfying unsaturated fat. Frailty, low appetite, under-fueling, or high training demand outranks tighter sodium or serving targets.
+
+## Lowest-risk practical execution
+
+Use the smallest version that solves the user's problem. A useful starting sequence is:
+
+1. **Add one DASH anchor to a routine meal:** a fruit or vegetable, beans or lentils, a whole grain or potato, or a tolerated dairy or fortified alternative.
+2. **Change one frequent sodium source:** compare two breads or sauces, choose no-salt-added when practical, drain and rinse canned beans, use half the seasoning packet, or put a salty condiment on the side.
+3. **Build one repeatable meal scaffold:** a protein or legume, a produce item, a grain or starchy food, and enough fat or sauce for satisfaction.
+
+Concrete flexible options include:
+
+- oats with fruit, plain yogurt or fortified soy yogurt, and nuts or seeds;
+- beans or lentils with rice or corn tortillas, vegetables, and avocado or an unsaturated oil;
+- fish, tofu, chicken, or eggs with potatoes or a whole grain and vegetables;
+- a bean-based soup or stew with extra vegetables and bread, using lower-sodium stock when feasible; or
+- an emergency meal of drained beans, frozen vegetables, and a microwave grain, followed by fruit or yogurt if wanted.
+
+These are examples, not a menu or compliance test.
+
+### Affordability
+
+Use dried or rinsed canned beans, lentils, oats, rice, potatoes, frozen vegetables, store-brand dairy or fortified alternatives, eggs, peanut butter, and seasonal or canned fruit. "No salt added" is useful when available, but comparing brands or draining and rinsing can be a more realistic fallback. Spend effort on foods eaten often rather than expensive specialty products.
+
+### Cultural and family fit
+
+Keep the user's staple foods and meal identity. Adjust proportions, cooking method, or the dominant sodium source rather than replacing the cuisine. Examples could include dal with rice and vegetables, beans with corn tortillas and cabbage, a tofu-and-vegetable stir-fry with sauce used to taste, or a familiar stew with more legumes and a lower-sodium stock. Serve sauces, cheese, cured meat, or salty garnishes separately when family members need different amounts.
+
+### Restaurants and travel
+
+Restaurant sodium is difficult to estimate, so do not pretend precision. Choose a meal with a vegetable, fruit, bean, fish, poultry, tofu, or whole-grain component; ask for sauce or dressing on the side or less added salt when feasible; and use the next ordinary meal rather than compensation after a salty meal. A convenience meal that preserves adequate intake is better than skipping food to stay "perfect."
+
+## Common failure modes
+
+- treating 1,500 mg as a moral pass/fail rule or a universally safer target;
+- tracking every milligram before identifying the few major sodium sources;
+- focusing on table salt while ignoring packaged foods, sauces, and restaurant meals;
+- replacing dairy with a sweetened, low-protein, unfortified beverage and assuming adequacy is unchanged;
+- increasing fiber abruptly and interpreting predictable discomfort as proof the pattern is unsuitable;
+- cutting sodium or fat so aggressively that meals become unsatisfying or energy and protein intake fall;
+- using potassium supplements or salt substitutes without checking kidney and medication context;
+- changing or skipping blood-pressure medicine because of a few readings;
+- turning DASH into a short cleanse, rigid serving-count challenge, separate family menu, or weight-loss promise; and
+- escalating restriction when blood pressure remains a clinical concern instead of handing off.
+
+## Monitoring, stop conditions, and off-ramps
+
+Use low-burden feedback first:
+
+- Is the meal structure repeatable within the user's budget, culture, schedule, and household?
+- Are hunger, energy, training, and intake still adequate?
+- Are fiber and dairy or non-dairy substitutions tolerated?
+- Did the user change one meaningful sodium source rather than merely add tracking work?
+
+When blood pressure is the actual outcome and the user already has a home-monitoring plan, use a validated upper-arm cuff, the clinician's measurement schedule and action thresholds, and averages or trends rather than one isolated reading. Do not use cuffless wearable estimates for diagnosis or medication decisions.
+
+Pause the new sodium or potassium change and seek prompt clinical guidance for recurrent lightheadedness, fainting, unusual weakness, palpitations, confusion, or vomiting, especially when blood-pressure or potassium-affecting medicine is involved. Follow the parent's urgent-care gate for severe symptoms or acute deterioration.
+
+Useful off-ramps include:
+
+- keep the produce, legume, whole-grain, and meal-structure gains while dropping a burdensome numeric sodium target;
+- use standard-sodium rather than lower-sodium DASH when the stricter version is not safe, adequate, or sustainable;
+- choose another evidence-based heart-healthy pattern when it fits the user's culture, household, access, or preferences better; or
+- stop tightening food rules and hand off when blood pressure remains concerning, symptoms appear, or medication or kidney decisions become central.
+
+Changing course is adaptation, not failure.
+
+## Groups needing extra caution
+
+Do not personalize sodium, potassium, fluid, or blood-pressure treatment from this reference alone for users with:
+
+- kidney disease, impaired potassium handling, prior high potassium, or dialysis;
+- significant heart disease, fluid limits, or clinician-prescribed sodium or potassium limits;
+- blood-pressure, diuretic, potassium, or other medication that can change blood pressure or electrolyte safety;
+- pregnancy or breastfeeding;
+- age under 18;
+- frailty, sarcopenia, low appetite, substantial unintentional weight loss, or probable under-fueling;
+- a history or signs of an eating disorder or harmful restriction;
+- post-bariatric anatomy, a severe food allergy, or another therapeutic diet; or
+- high-volume heat training, unusually high sweat losses, or an individualized electrolyte plan.
+
+General meal ideas may still help, but the relevant clinician or registered dietitian should own condition-specific targets and medication-linked changes.
+
+## Murph handoffs
+
+- Use `cardiometabolic-health` when blood-pressure readings, diagnosis, risk, targets, or marker interpretation are the main job.
+- Use `chronic-illness-support`, care navigation, and the user's clinician or pharmacist when kidney disease, heart disease, medication, prescribed sodium or potassium limits, or therapeutic blood-pressure management is central.
+- Use `food-journal` for low-pressure observation of actual meals, restaurant context, or the few recurring sodium sources; do not create a DASH adherence score.
+- Use `gut-digestion` for persistent bloating, constipation, diarrhea, or a symptom-driven fiber strategy.
+- Use `body-composition` when intentional weight or waist change is the real goal, then return here for meal execution.
+- Use `micronutrients-supplements` for potassium supplements, salt-substitute labels, or calcium, vitamin D, vitamin B12, or other adequacy questions that cannot be answered from food structure alone.
+- Use the parent `nutrition-strategy` hydration and performance lane when training, heat, sweat, or fueling demand makes a generic lower-sodium target unsafe or impractical.
+- Use `experiment-onboarding` only after the user chooses one specific, safe change with a bounded window and stop conditions.
+
+## Source register
+
+Reviewed **2026-08-09**. Stable DOI, PubMed, and official-source links are provided without relying on popularity rankings or testimonial evidence.
+
+1. **2025 guideline for prevention, detection, evaluation, and management of high blood pressure in adults.** Guideline and official summary; supports DASH as one heart-healthy pattern while keeping targets and medication care clinical. [DOI](https://doi.org/10.1161/CIR.0000000000001356) | [Official summary](https://professional.heart.org/en/science-news/2025-high-blood-pressure-guideline/top-things-to-know)
+2. **NHLBI DASH Eating Plan, Following DASH, and Health Benefits of DASH.** Official pattern definition, 2,300 mg and 1,500 mg sodium variants, lactose-free options, and summaries of the controlled feeding trials; pages updated 2026-02-25. [Eating plan](https://www.nhlbi.nih.gov/health/dash-eating-plan) | [Following DASH](https://www.nhlbi.nih.gov/health/dash/following-dash) | [Health benefits](https://www.nhlbi.nih.gov/health/dash/health-benefits)
+3. **A clinical trial of the effects of dietary patterns on blood pressure.** Randomized controlled feeding trial; 459 adults, eight-week intervention, short-term blood-pressure surrogate. [DOI](https://doi.org/10.1056/NEJM199704173361601) | [PMID 9099655](https://pubmed.ncbi.nlm.nih.gov/9099655/)
+4. **Effects on blood pressure of reduced dietary sodium and the DASH diet.** Randomized controlled feeding trial; 412 adults, three sodium levels, strongest short-term effect from lower sodium plus DASH. [DOI](https://doi.org/10.1056/NEJM200101043440101) | [PMID 11136953](https://pubmed.ncbi.nlm.nih.gov/11136953/)
+5. **Dietary Approaches to Stop Hypertension diet and blood pressure reduction in adults with and without hypertension: a systematic review and meta-analysis of randomized controlled trials.** Thirty randomized trials, 5,545 participants; moderate-certainty evidence for blood-pressure reduction versus control. [DOI](https://doi.org/10.1093/advances/nmaa041) | [PMID 32330233](https://pubmed.ncbi.nlm.nih.gov/32330233/)
+6. **Effectiveness of the DASH diet versus alternative dietary interventions for hypertension management: a systematic review and meta-analysis.** Published online 2026-07-23; no statistically significant blood-pressure superiority over comparator diets, substantial heterogeneity, and moderate-to-very-low certainty. [DOI](https://doi.org/10.1016/j.cpcardiol.2026.103397) | [PMID 42492868](https://pubmed.ncbi.nlm.nih.gov/42492868/)
+7. **DASH dietary pattern and cardiometabolic outcomes: an umbrella review of systematic reviews and meta-analyses.** Separates controlled-trial biomarker evidence from prospective-cohort event associations; direct outcome certainty was lower. [DOI](https://doi.org/10.3390/nu11020338) | [PMID 30764511](https://pubmed.ncbi.nlm.nih.gov/30764511/)
+8. **How potassium can help prevent or treat high blood pressure.** Official safety source for kidney disease, medication, supplements, and potassium-based salt substitutes; reviewed 2025-08-14. [Official page](https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/how-potassium-can-help-control-high-blood-pressure)

package/node_modules/@murphai/assistant-engine/skills/nutrition-strategy/references/named-diets/intermittent-fasting.md

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+# Intermittent fasting
+
+Use this progressive-disclosure reference only after the parent `nutrition-strategy` contract selects the named-diet lane. The parent remains authoritative for routing, safety, tracking burden, clinical boundaries, and answer shape. This file distinguishes intermittent-fasting variants and adds diet-specific execution guidance; it is not a registered skill or a therapeutic fasting protocol.
+
+## Decision summary
+
+- Intermittent fasting is a family of timing and intermittent-energy-restriction patterns, not one diet. Time-restricted eating, 16:8, 14:10, 5:2, alternate-day fasting, and one meal a day are not interchangeable.
+- In adults studied for overweight, obesity, or cardiometabolic risk, fasting patterns can produce modest short-term changes in weight and surrogate markers, but they are generally not superior to a sustainable non-fasting energy-restriction pattern. Evidence for adverse effects, long-term durability, and direct health outcomes is limited.
+- Earlier time-restricted eating has a modest average advantage over late time-restricted eating for some surrogate outcomes, but eating-window duration has not shown a consistent dose-response. A shorter window is not automatically better.
+- For an adult without caution flags who wants a simple timing boundary, prefer the least restrictive viable version: first remove unwanted late eating or use a roughly 12-hour overnight gap; if a named fasting pattern is still desired, start with 14:10. Do not jump to 5:2, alternate-day fasting, or OMAD.
+- Adequate food, medication safety, eating-disorder recovery, sleep, social life, and training fuel outrank keeping a fasting streak.
+
+## What the label can mean
+
+| Pattern | Common meaning | Material distinction |
+|---|---|---|
+| **Time-restricted eating (TRE)** | Food and energy-containing drinks are kept within a recurring daily window; total energy is not necessarily prescribed. | The window may be early, middle, late, or self-selected. TRE does not tell Murph whether the person eats for 6, 8, 10, or 12 hours, or whether intake falls. |
+| **14:10** | A 14-hour fast and 10-hour eating window each day. | Usually leaves room for three eating occasions and is the least restrictive common named version. It is not a biological threshold. |
+| **16:8** | A 16-hour fast and 8-hour eating window each day. | Often compresses intake to two or three occasions. A noon-to-8 p.m. version differs from an 8 a.m.-to-4 p.m. version in sleep, training, family, and circadian fit. |
+| **5:2** | Five usual-intake days and two days each week with little or no energy; research often uses modified, not zero-energy, fast days. | It is a weekly intermittent-energy-restriction pattern, not daily TRE. Consecutive and nonconsecutive fast days create different practical burdens. |
+| **Alternate-day fasting (ADF)** | Alternating usual-intake days with zero- or very-low-energy days. | Restriction occurs about every other day, so fueling, social, and rebound-eating pressure is usually greater than with 5:2 or moderate TRE. |
+| **One meal a day (OMAD)** | One meal in a short daily window, often implying about 22-23 hours without food. | This is a highly compressed daily pattern with direct evidence much thinner than for broader TRE. It makes adequate total intake and distributed protein or training fuel harder. |
+
+A label also may not specify water, energy-free drinks, milk, supplements, or medication timing. Do not turn "clean fasting" rules into a purity test. Prescribed medication, hydration needs, and safe fueling take precedence over preserving a technical fast.
+
+## What the evidence supports
+
+### Comparative efficacy
+
+- The 2026 Cochrane review found that intermittent fasting made little to no difference in weight loss or quality of life compared with regular dietary advice in adults with overweight or obesity. Included trials lasted no longer than 12 months, and adverse-event evidence was uncertain.
+- A 2025 network meta-analysis of 99 randomized trials found broadly similar weight and cardiometabolic effects for intermittent fasting and continuous energy restriction. ADF had the only average advantage over continuous restriction for body weight, about 1.3 kg, which was below that review's prespecified threshold for a clinically important difference. Most trials were short, and most participants had an existing health condition.
+- A 10-hour TRE trial published in 2026 found short-term reductions in weight and fat in selected adults with obesity. That result shows that a feasible TRE protocol can work for some people; it does not establish superiority, long-term durability, or direct disease prevention.
+- A one-year 5:2 trial found similar modest weight outcomes to standard brief dietary advice. Participants initially liked the simple rule, but reported adherence fell substantially over time. Preference can make a pattern useful without making it more efficacious.
+
+### Meal timing versus energy intake
+
+- TRE often reduces eating opportunities and therefore energy intake. Trials that prescribe similar energy intake in both groups generally find little or no added weight-loss advantage from the time window itself.
+- Timing may still have independent circadian effects. A 2026 network meta-analysis found early TRE modestly better than late TRE for body weight and fasting insulin, while rankings by eating-window length were inconsistent. These are surrogate outcomes, not proof that an early window prevents disease or extends life.
+- A short, intended-isocaloric crossover trial found that early and late 8-hour windows shifted circadian timing but did not produce clinically meaningful cardiometabolic differences. This supports a plausible clock effect while limiting claims about its health importance.
+- Do not promise that 16 hours, 20 hours, or any other duration activates a clinically validated "autophagy stage." Cellular mechanisms and ketone production are plausible research pathways, not a consumer clock for guaranteed outcomes.
+
+### What is not established
+
+- No fasting variant has high-certainty randomized evidence for lower all-cause mortality, cardiovascular events, cancer, dementia, or longer human lifespan.
+- Evidence is dominated by short- to medium-term trials in adults with overweight, obesity, or metabolic risk. It transfers poorly to pregnancy, breastfeeding, adolescence, frail older adults, people with low intake, eating-disorder recovery, lean athletes, or high-volume training.
+- Short-term weight or biomarker changes do not establish long-term adherence, diet quality, psychological safety, or net benefit for a specific person.
+
+## Why users may choose it
+
+Common reasons include fewer food decisions, a clear boundary around late-night eating, dislike of calorie tracking, a schedule that naturally favors later or earlier meals, appetite preference, weight or biomarker goals, religious or cultural familiarity with fasting, and claims about metabolism, longevity, or "discipline." Clarify the actual job before recommending a protocol.
+
+Treat a preference for simple rules as useful fit information. Do not treat hunger tolerance, longer fasts, or a tighter window as virtue. Religious fasting may have distinct food, fluid, timing, and community rules; do not silently replace it with a research TRE protocol.
+
+## Lowest-risk practical execution
+
+1. **Confirm the goal and owner.** A definition or ordinary meal-timing question can stay here. Intentional fat loss, muscle gain, calorie targets, or a plateau belongs with `body-composition`; marker, condition, or medication goals belong with clinical owners.
+2. **Start wider than the user's maximum tolerance.** First try a consistent overnight gap near 12 hours or a 14:10 pattern. Tighten only when the person is eating enough, feels well, and can name a benefit that the tighter window adds.
+3. **Fit the window around real life.** Protect sleep opportunity, work, family meals, culture, and the most demanding training. If early and late windows fit equally well, an earlier finish is a reasonable preference; do not force an early window that causes missed recovery food, very early waking, or social isolation.
+4. **Protect meal quality and distribution.** Keep roughly three meaningful protein-containing eating occasions when feasible. Build meals from flexible options: eggs, yogurt, milk, tofu, beans, fish, poultry, meat, or fortified alternatives; oats, bread, rice, potatoes, pasta, tortillas, fruit, or other demand-matched carbohydrate; vegetables or another fiber-rich food; and nuts, seeds, avocado, olive oil, cheese, sauce, or another satisfying fat or flavor.
+5. **Keep an easy fallback.** Examples include yogurt with fruit and cereal; a bean-and-rice bowl; eggs or tofu with toast and fruit; a sandwich with milk or a fortified alternative; or a frozen meal plus produce. Convenience food is compatible with a useful eating window.
+6. **Return to the next normal meal after a deviation.** Do not compensate for a late meal, social event, or large meal by extending the next fast.
+
+### Variant-specific guidance
+
+- **14:10:** Preferred first named version. It often preserves breakfast, lunch, and dinner or three shifted eating occasions without requiring a separate diet.
+- **16:8:** Use only when an 8-hour window still permits adequate meals and training fuel. If intake becomes rushed, the last meal becomes very large, or protein is compressed into one or two weak occasions, widen to 14:10.
+- **5:2:** Not a default first step. Do not invent a fast-day calorie target or rigid menu in this reference. If an appropriate user has already chosen it, favor nonconsecutive lower-demand days, ordinary balanced eating on the other days, and no "earning" or repayment cycle.
+- **ADF:** Do not present its small average short-term weight advantage as a reason to accept greater burden. Frequent low-intake days commonly collide with training, social meals, and adequate intake; 14:10 or a regular daily pattern is the preferred off-ramp.
+- **OMAD:** Do not recommend as a routine starting pattern. One meal makes total energy, protein distribution, carbohydrate around exercise, fiber, micronutrients, and medication-with-food needs harder to meet and can promote an overly large meal or rebound eating. Offer two or three eating occasions within a wider window instead.
+
+## Exercise, protein, and under-fueling
+
+- Fasted exercise is optional, not a marker of fitness and not clearly superior for performance or fat loss. A short easy session may be fine when the person feels normal; this does not justify applying the same approach to long, hard, high-volume, or repeated sessions.
+- Place the eating window so a demanding session can receive familiar carbohydrate beforehand and carbohydrate plus protein afterward. A banana with yogurt, toast with eggs, cereal with milk, a sandwich, or rice with tofu or poultry are options. Breaking the fast is the correct repair when fuel is needed.
+- Daily adequacy and distributed protein matter more than defending a narrow window. If a strength, muscle, or recovery goal cannot fit the parent's protein distribution guidance, widen the window rather than cramming everything into one meal.
+- Watch for persistent fatigue, falling performance, slow recovery, recurrent illness or injury, dizziness, feeling unusually cold, irritability, sleep disruption, menstrual change, reduced libido, food preoccupation, or unexpected weight loss. These are reasons to stop tightening the window and assess under-fueling, not proof of low motivation.
+
+## Common failure modes and repairs
+
+| Failure mode | Lowest-burden repair |
+|---|---|
+| Skipping food all day, then eating rapidly or beyond comfort at night | Move food earlier, widen to 14:10 or regular meals, and add a planned protein-plus-carbohydrate meal or snack before extreme hunger. |
+| Recurrent rebound or loss-of-control eating after fasting | Stop the fasting protocol and restore regular nourishment; route eating-disorder risk rather than adding more rules. |
+| A late window worsens sleep, reflux, or family fit | End earlier if feasible, widen the window, or use regular meals. Route persistent digestive symptoms to `gut-digestion`. |
+| A strict early window removes post-training food | Move or widen the window, or eat the recovery meal and end the fast. Training recovery outranks timing theory. |
+| Protein, produce, or total food is crowded out | Add another eating occasion and use easy foods; do not solve low total intake with protein alone. |
+| Excess caffeine is used to suppress hunger | Reduce the fasting demand and eat. Do not use stimulants as a substitute for adequate food or sleep. |
+| Weekday rigidity produces weekend compensation | Use a flexible 12-hour or 14:10 baseline instead of all-or-none rules. |
+| A missed window is treated as failure | Resume at the next ordinary meal. No punishment, extra fasting, or compensatory exercise. |
+| The person tracks every minute without a decision benefit | Drop timer precision. A repeatable meal boundary and a few feedback signals are enough. |
+
+## Monitoring, stop conditions, and off-ramps
+
+Use the lowest useful monitoring burden. A short fit check can ask whether the pattern preserves stable daytime energy, ordinary hunger rather than extremes, sleep, training quality and recovery, social flexibility, and enough food. Do not require calorie logging or daily weighing. Glucose monitoring belongs to an existing clinician-directed plan, not this reference.
+
+**End the fast and follow the person's existing medical plan** for shakiness, sweating, confusion, faintness, or other suspected low-glucose symptoms. Seek urgent help for confusion, fainting, chest pain, severe weakness, inability to keep fluids down, severe dehydration, or symptoms that do not improve.
+
+**Stop the protocol and return to regular nourishment** for recurrent dizziness, headaches or nausea; sleep worsening; persistent fatigue; training decline; menstrual change; food preoccupation; recurrent rebound or loss-of-control eating; substantial unintentional weight loss; or any sign that the window is displacing needed food or medication.
+
+Use the least restrictive off-ramp that resolves the problem:
+
+- 16:8 to 14:10, then to a simple overnight gap or regular meals;
+- 5:2 or ADF to a consistent daily pattern;
+- OMAD to two meals plus a snack, then to three ordinary eating occasions when useful.
+
+If a tighter pattern offers no clear valued benefit, keeping it is unnecessary. Do not wait for harm or treat a wider window as failure.
+
+## Groups needing extra caution
+
+Do not provide a self-directed fasting protocol when any of these are present:
+
+- pregnancy or breastfeeding;
+- adolescence or anyone under 18;
+- frailty, sarcopenia, low appetite, low intake, substantial unintentional weight loss, or recovery from prolonged very low intake;
+- a known or suspected eating disorder, severe restriction, recurrent loss-of-control eating, purging, compulsive exercise, intense food or weight fear, or number sensitivity;
+- current under-fueling or a training load that already exceeds available recovery;
+- post-bariatric surgery or another clinician-managed nutrition plan.
+
+Require clinician or registered-dietitian involvement before fasting when diabetes, recurrent hypoglycemia, kidney disease, advanced liver disease, significant heart disease, a relevant endocrine disorder, or a fluid restriction is material. The same applies to insulin or another medicine that can cause hypoglycemia, any medicine that must be taken with food, or a medicine whose safety changes with dehydration or major meal-timing changes. Do not recommend medication adjustments.
+
+Acute illness, surgery or injury recovery, heat exposure, endurance events, and other periods with increased food or fluid needs are reasons to suspend the fasting goal or obtain individualized guidance.
+
+## Murph handoffs
+
+- `body-composition`: intentional weight, fat, muscle, recomposition, calorie, or plateau strategy; return here for meal execution only.
+- `cardiometabolic-health`, `chronic-illness-support`, and care navigation: glucose, lipids, blood pressure, disease-specific goals, hypoglycemia, medication timing, or therapeutic fasting.
+- `food-journal`: low-pressure observation of timing, hunger, rebound eating, sleep, symptoms, or training response when retrospective data would change a decision.
+- `gut-digestion`: persistent reflux, constipation, nausea, diarrhea, bloating, or symptom-driven elimination work.
+- `micronutrients-supplements`: supplement evidence, label review, dosing, or a specific adequacy concern that food structure cannot answer.
+- `experiment-onboarding`: only after the user chooses one bounded, safe version with feedback and stop conditions.
+- `behavior-followthrough`: reminders or repeated implementation repair after the plan is accepted.
+
+## Source register
+
+Reviewed **2026-08-09**. Prefer the synthesis-level sources for overall claims; use individual trials to understand a specific protocol, not to override the full evidence base.
+
+| Source | Evidence type and population | Decision use and limits |
+|---|---|---|
+| [Intermittent fasting for adults with overweight or obesity (Cochrane, 2026)](https://doi.org/10.1002/14651858.CD015610.pub2) | Systematic review of 22 randomized trials, 1,995 adults; interventions up to 12 months. | Best current anchor for little-to-no comparative difference in weight or quality of life and for uncertain adverse-event evidence. Limited to adults with overweight or obesity and short follow-up. |
+| [Intermittent fasting strategies and cardiometabolic risk factors (BMJ, 2025)](https://doi.org/10.1136/bmj-2024-082007) | Network meta-analysis of 99 randomized trials, 6,582 adults; TRE, ADF, whole-day fasting, continuous restriction, and usual intake. | Distinguishes variants. Supports broadly similar effects to continuous restriction and only a small ADF weight advantage that did not reach the review's clinical-importance threshold. Outcomes were mainly weight and risk markers. |
+| [Timing and eating duration of TRE (BMJ Medicine, 2026)](https://doi.org/10.1136/bmjmed-2024-001071) | Systematic review and network meta-analysis of 41 randomized trials, 2,287 participants. | Supports a modest early-versus-late TRE advantage for some surrogate outcomes and inconsistent rankings by window length. No direct disease-event evidence. |
+| [Calorie restriction with or without TRE (2022)](https://doi.org/10.1056/NEJMoa2114833) | Twelve-month randomized trial in 139 adults with obesity; both groups received calorie restriction. | Supports no clear added weight or metabolic benefit from an 8-hour early window when energy restriction was shared. Population and prescribed intervention limit generalization. |
+| [Intended-isocaloric early versus late TRE (2025)](https://doi.org/10.1126/scitranslmed.adv6787) | Two-period crossover trial in 31 women with overweight or obesity; two weeks per 8-hour window. | Shows meal timing can shift circadian phase without clinically meaningful short-term cardiometabolic differences. Small, short, and single-population. |
+| [TREAD 10-hour TRE trial (2026)](https://doi.org/10.1002/oby.70228) | Twelve-week randomized trial in adults with obesity. | Recent evidence that a moderate 10-hour window can reduce weight and fat in a selected group. Does not establish superiority, durability, or direct health outcomes. |
+| [TREAT 16:8 trial (2020)](https://doi.org/10.1001/jamainternmed.2020.4153) | Twelve-week randomized trial of noon-to-8 p.m. TRE in 116 adults with overweight or obesity. | Shows that a common late 16:8 schedule is not reliably superior to structured meals for weight or cardiometabolic markers. |
+| [Randomized trial of the 5:2 diet (2021)](https://doi.org/10.1371/journal.pone.0258853) | One-year pragmatic trial in 300 adults with obesity. | Supports similar modest outcomes to standard advice, higher initial preference, and substantial adherence decline. Does not justify treating 5:2 as superior. |
+| [TRE and sleep systematic review (2024)](https://doi.org/10.3389/fnut.2024.1419811) | Systematic review of randomized trials lasting at least eight weeks. | Short- to medium-term TRE did not usually worsen sleep, but findings were limited and population-dependent. Personal sleep fit still needs monitoring. |
+| [Standards of Care in Diabetes - 2026: nutrition and fasting](https://doi.org/10.2337/dc26-S005) and [hypoglycemia](https://doi.org/10.2337/dc26-S006) | Current major clinical guideline. | Supports medication review, glucose-safety planning, and hypoglycemia precautions rather than self-directed fasting in medication-linked diabetes. Not a general endorsement of fasting. |
+| [Consensus statement on Relative Energy Deficiency in Sport (2023)](https://doi.org/10.1136/bjsports-2023-106994) | Multidisciplinary sport-health consensus. | Supports prioritizing adequate energy availability and taking performance, recovery, reproductive, bone, and psychological warning signs seriously. It does not diagnose under-fueling from chat data. |
+| [Practical guideline on nutrition and hydration in geriatrics (2022)](https://doi.org/10.1016/j.clnu.2022.01.024) | Major clinical nutrition guideline for older adults. | Supports protecting energy, protein, hydration, muscle, and function in frailty or malnutrition risk rather than adding restriction. |
+| [Pediatric guidance on preventing obesity and eating disorders (2016)](https://doi.org/10.1542/peds.2016-1649) | Clinical report focused on adolescents. | Supports avoiding dieting and meal skipping as self-directed weight-control tools in youth and favoring sustainable health behaviors. |
+| [Eating-disorders recognition and treatment guideline NG69](https://www.nice.org.uk/guidance/ng69) | Current official guideline, updated with surveillance. | Supports prompt recognition and specialist care when restriction, loss-of-control eating, purging, compulsive exercise, or medical instability is present. It is not evidence that fasting causes every eating disorder. |
+| [Official research summary on intermittent fasting and aging](https://www.nia.nih.gov/news/research-intermittent-fasting-shows-health-benefits) | Public research summary from a national aging institute. | Separates plausible mechanisms and animal findings from the lack of long-term human lifespan evidence; supports rejecting transformation and longevity promises. |