@murphai/murph 1.3.0 → 1.3.1

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

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+# Ketogenic diet
+
+Apply the parent `nutrition-strategy` contract first. This progressive-disclosure reference adds ketogenic-diet distinctions, evidence, and failure handling. It does not register a skill, replace the parent's routing or safety rules, authorize medication changes, or turn clinician-managed ketogenic diet therapy into a wellness plan.
+
+## Choose the lane before answering
+
+- **Ordinary weight-loss or wellness use:** use this reference for definition, fit, comparison, low-risk execution, and troubleshooting in a medically uncomplicated adult. If intentional weight or waist change is the main job, `body-composition` owns the strategy and this reference can support food execution.
+- **Marker-, disease-, or medication-led use:** diabetes, glucose-lowering or blood-pressure medication, a large lipid response, kidney or liver disease, pancreatitis, or another clinical constraint changes the risk. Hand off to `cardiometabolic-health`, `chronic-illness-support`, care navigation, and the user's clinician rather than prescribing the diet or medication adjustments.
+- **Therapeutic ketogenic diet therapy:** classic ketogenic, medium-chain-triglyceride, modified Atkins, and low-glycemic-index therapies used for drug-resistant epilepsy or selected rare metabolic conditions are clinician-managed protocols. Their ratios, ketone targets, laboratory monitoring, supplements, and contraindication screening are not ordinary keto advice.
+
+## Definition and meaningful variants
+
+A ketogenic diet restricts carbohydrate enough to produce sustained **nutritional ketosis**, usually while providing adequate protein and deriving most remaining energy from fat. Research definitions vary; common ordinary versions use less than about 50 g carbohydrate per day, often 20–50 g, but the intake that produces ketosis differs by person and context. “Low carbohydrate” does not necessarily mean ketogenic, and a label does not reveal food quality, energy intake, or whether ketosis is present.
+
+**Nutritional ketosis is not diabetic ketoacidosis (DKA).** Nutritional ketosis is a regulated fuel state without metabolic acidosis. DKA is a life-threatening state of substantial ketone accumulation plus acidosis, usually in diabetes; with an SGLT2 inhibitor, glucose can be only modestly elevated. A home glucose or ketone result must not be used to dismiss concerning symptoms.
+
+Variants that materially change the answer:
+
+- An **unsaturated-fat-forward, minimally processed version** can emphasize fish, olive oil, avocado, nuts, seeds, tofu or tempeh, eggs, other suitable protein foods, nonstarchy vegetables, and modest low-carbohydrate fruit.
+- A **saturated-fat- or processed-meat-heavy version** may meet the carbohydrate rule while worsening diet quality and, for some people, LDL cholesterol or apolipoprotein B (apoB).
+- **Targeted or cyclical keto** adds carbohydrate around training or on selected days. Comparative evidence is sparse; use it as an individual fueling adaptation, not a proven superior variant.
+- **Vegetarian keto** is possible but more planning-intensive because protein, fiber, iron, calcium, iodine, and food variety can become harder to cover.
+- **Carnivore-style eating is a separate, more restrictive pattern.** Do not treat its risks or evidence as interchangeable with a produce-containing ketogenic diet.
+
+## What the evidence supports—and does not
+
+Most ordinary keto trials last weeks to months, relatively few extend beyond one to two years, and most measure weight or laboratory surrogates rather than cardiovascular events, mortality, disability, or quality of life. Implementations and comparison diets vary, so a result for “low carbohydrate” is not automatically a result for sustained nutritional ketosis.
+
+- **Weight and appetite:** keto can reduce appetite for some people and can produce short-term weight loss. Early scale loss includes glycogen-associated water and is not all body fat. In a large Cochrane review, low-carbohydrate diets produced little or no clinically important weight-loss advantage over balanced-carbohydrate weight-loss diets through one to two years. Adherence, energy intake, protein, food quality, and support appear more decisive than ketosis itself.
+- **Glycemia in type 2 diabetes:** low- and very-low-carbohydrate patterns can improve A1C and reduce medication needs in some people over roughly the first six months. Comparative advantages usually diminish with longer follow-up. This is a medication-linked clinical lane because insulin, sulfonylureas, and other therapies may need prompt clinician adjustment; very-low-carbohydrate eating should be avoided with SGLT2 inhibitors because of ketoacidosis risk.
+- **Lipids and cardiovascular risk:** triglycerides often fall and HDL cholesterol may rise, but LDL cholesterol and apoB responses are heterogeneous and can rise substantially. An improved triglyceride-to-HDL pattern does not cancel an apoB increase. Trials have not established that ordinary keto prevents cardiovascular events or extends life.
+- **Training:** increased fat oxidation is a mechanism, not proof of better performance. Compared with higher-carbohydrate diets, evidence in healthy exercising adults is mostly neutral or unfavorable for endurance and high-intensity performance; maximal strength is often similar. Most performance studies are short, and elite-athlete studies have been especially limited.
+- **Therapeutic use:** the best-established direct clinical outcome is seizure reduction in some people with drug-resistant epilepsy under specialist care, with stronger randomized evidence in children than adults. Tolerability and dropout remain material.
+- **Other disease claims:** evidence for cancer, dementia, psychiatric conditions, migraine, polycystic ovary syndrome, and broad “metabolic healing” claims remains condition-specific, preliminary, inconsistent, or surrogate-based. Do not present keto as a stand-alone treatment or advise replacing established care.
+
+Across umbrella reviews, many reported keto associations are supported by low or very-low certainty evidence. Popularity, testimonials, ketone production, lower insulin exposure, or increased fat oxidation can explain interest or a plausible mechanism; none proves comparative long-term benefit.
+
+## Why a user may choose it
+
+Likely reasons include a preference for clear food rules, less hunger on a higher-fat pattern, avoiding refined carbohydrate foods, rapid early scale feedback, a short-term glucose goal, fit with familiar foods, or community influence. A therapeutic indication is a different reason and belongs to a clinical team. Identify the actual goal before optimizing ketosis; the useful part may be fewer refined foods, more protein, or simpler meal structure rather than the ketotic state.
+
+## Diet-specific tradeoffs and adequacy concerns
+
+- **Early fluid and electrolyte shifts:** carbohydrate restriction reduces glycogen-associated water and can increase sodium and water loss early. Headache, thirst, fatigue, lightheadedness, cramps, or a rapid scale drop may follow. These symptoms are not proof that the diet is “working,” and universal salt, potassium, fluid, or electrolyte targets are unsafe. Use ordinary fluids and meals; medication, kidney, heart, blood-pressure, and endocrine contexts need individualized guidance.
+- **Constipation and fiber:** removing grains, legumes, and much fruit can sharply reduce fiber and stool volume. Constipation is among the most commonly reported adverse effects. Protect fiber with nonstarchy vegetables, avocado, berries if they fit, nuts, seeds, chia or ground flax, and adequate fluid; increase fiber gradually. Persistent or painful symptoms belong to `gut-digestion` and clinical care when red flags are present.
+- **Food quality and micronutrients:** a fat-first implementation can displace protein, produce, calcium-rich foods, potassium-rich foods, magnesium, folate, thiamin, and food variety. Supplements do not automatically repair a poor pattern and belong to `micronutrients-supplements` when evidence, labels, dose, or safety is the question.
+- **Training and recovery:** reduced carbohydrate availability can impair repeated sprints, high-volume lifting, team sport, and hard endurance work, particularly during adaptation. Falling output, poor recovery, dizziness, sleep disruption, recurrent injury, menstrual changes, or escalating food preoccupation are reasons to restore fuel or leave the diet—not challenges to out-discipline.
+- **LDL-C and apoB:** the average response hides wide variation. Diets rich in butter, coconut oil, fatty processed meats, and cheese may be especially problematic for some people. A substantial rise deserves reassessment even when weight, glucose, triglycerides, or HDL improve.
+- **Practical burden:** restaurants, travel, family meals, cultural staples, cost, and limited convenience choices can make strict ketosis brittle. A less restrictive lower-carbohydrate or Mediterranean-style pattern may preserve the useful core with less burden.
+
+## Extra caution: do not run an ordinary self-directed trial
+
+Use a clinician-led handoff rather than ordinary keto execution when any of these apply:
+
+- type 1 diabetes, current SGLT2-inhibitor use, or a history of DKA;
+- insulin, sulfonylurea, or another glucose-lowering medicine; clinically important blood-pressure treatment can also require closer observation as intake and fluid balance change;
+- pregnancy or breastfeeding, age under 18, frailty, low intake, substantial unintentional weight loss, or suspected under-fueling;
+- current or prior eating disorder, binge–restrict cycling, purging, compulsive exercise, intense fear around food or weight, or marked number sensitivity;
+- kidney disease, significant liver disease, a history of pancreatitis, severe hypertriglyceridemia, or a known or suspected inherited disorder of fatty-acid transport, oxidation, ketone use, or related metabolism;
+- a proposed therapeutic use for epilepsy, cancer, neurologic or psychiatric disease, or another diagnosed condition.
+
+Known disorders that prevent safe use of fat as a major fuel can make ketogenic therapy dangerous and cannot be screened out in chat. Do not advise starting keto to “test” whether one is present. Never tell a user to stop, reduce, or time medication differently to make keto possible.
+
+## Lowest-risk ordinary execution
+
+For a medically uncomplicated adult who still chooses an ordinary trial:
+
+1. **Define one job and a bounded review point.** Examples are steadier appetite, simpler weekday meals, or tolerability during a specific training block. Ketosis itself is not the outcome, and routine ketone testing is unnecessary for ordinary wellness use.
+2. **Keep a protein anchor at regular meals.** Flexible options include fish, eggs, poultry, tofu, tempeh, plain Greek yogurt or cottage cheese if suitable, and unprocessed meat in amounts that fit the person's preferences.
+3. **Build in produce and fiber rather than adding fat alone.** Options include leafy greens, broccoli or cauliflower, zucchini, peppers, mushrooms, green beans, avocado, a small serving of berries, nuts, seeds, chia, and ground flax.
+4. **Favor unsaturated fats.** Olive oil, avocado, nuts, seeds, and fish are stronger defaults than building the diet around butter, coconut oil, processed meats, cheese, cream, or specialty “fat” snacks.
+5. **Keep one realistic fallback.** Examples: eggs or tofu with frozen vegetables; canned fish with a bagged salad and olive oil; plain Greek yogurt with nuts and berries if it fits; or a prepared protein with microwave vegetables. The fallback should prevent missed meals, not enforce perfection.
+6. **Use normal hydration, not forced electrolyte loading.** Drink to ordinary thirst and conditions, eat regular meals, and do not add a fixed sodium or potassium regimen. Persistent lightheadedness, palpitations, weakness, or inability to hydrate is a stop signal.
+7. **Do not stack restriction.** Avoid combining keto by default with fasting, a large calorie deficit, dehydration practices, or abrupt increases in training. Do not compensate after a higher-carbohydrate meal; return to the next ordinary meal.
+
+Exact carbohydrate counting is optional, not automatic. When precision is genuinely needed, use verified labels and the parent exact-food workflow; do not invent “net carbohydrate” values or turn ketone readings into an adherence score.
+
+## Common failure modes
+
+- Chasing the highest ketone number, buying exogenous ketones, or treating ketosis as the health outcome.
+- Calling early water loss fat loss or using rapid scale change as proof of superior efficacy.
+- Letting added fat displace protein, vegetables, fiber, or total dietary variety.
+- Replacing carbohydrate mainly with butter, coconut oil, processed meat, cheese, and packaged keto products.
+- Ignoring constipation, declining training, poor sleep, low energy, menstrual changes, or food preoccupation as an unavoidable “adaptation.”
+- Starting without a diabetes-medication plan, self-adjusting medication, or using a normal-ish glucose reading to dismiss possible DKA.
+- Treating a higher-carbohydrate meal as failure, then fasting, overexercising, or restricting harder.
+- Continuing despite a large LDL-C or apoB rise because triglycerides, HDL, weight, or glucose moved favorably.
+
+## Monitoring, stop conditions, and off-ramps
+
+### Monitor with the lowest useful burden
+
+During the first days and weeks, watch energy, thirst, dizziness, nausea, bowel function, sleep, mood, food preoccupation, training output, recovery, and whether regular meals remain possible. At the chosen review point, ask whether the actual goal improved enough to justify restriction, cost, social burden, and side effects.
+
+For longer use or when cardiovascular risk is relevant, a clinician can decide whether baseline and follow-up LDL-C, non-HDL cholesterol, apoB, triglycerides, glucose measures, blood pressure, kidney or liver markers, and medication review are appropriate. Do not promise that weight loss protects against an adverse apoB response. Therapeutic ketogenic diets require their own specialist monitoring plan.
+
+### Stop and reassess
+
+Leave the self-directed trial and seek appropriate care for:
+
+- repeated hypoglycemia or concerning glucose changes, medication-related symptoms, or inability to follow an existing diabetes sick-day plan;
+- persistent dizziness, fainting, palpitations, severe weakness, vomiting, inability to keep fluids down, or signs of significant dehydration;
+- persistent constipation, marked abdominal pain or distension, vomiting, or blood in stool;
+- sustained decline in training or daily function, recurrent injury, menstrual change, unexpected weight loss, or other under-fueling clues;
+- escalating restriction, bingeing, compensatory behavior, anxiety, or obsessive ketone, carbohydrate, food, or weight checking;
+- a substantial LDL-C, non-HDL cholesterol, or apoB increase, especially if it persists after replacing saturated fats with unsaturated fats.
+
+**Urgent DKA lane:** nausea or vomiting, abdominal pain, rapid or deep breathing, confusion, unusual drowsiness, severe weakness, or acute deterioration in a person with diabetes—especially with SGLT2-inhibitor use, illness, fasting, or reduced intake—needs urgent medical assessment. DKA can occur without extreme hyperglycemia. Do not use chat, a home glucose value, or a low urine-ketone result to rule it out.
+
+### Practical off-ramps
+
+There is no wellness requirement to remain in ketosis, and no moral or metabolic failure in leaving it.
+
+- Move to a less restrictive lower-carbohydrate or Mediterranean-style pattern while keeping the protein, minimally processed foods, and meal defaults that helped.
+- Add flexible carbohydrate foods according to preference and tolerance: beans or lentils, fruit, oats or another whole grain, potatoes or squash, milk or yogurt, or culturally familiar staples. A gradual return can be easier on appetite and bowel comfort, but a special “reverse diet” is not required.
+- For hard or repeated training, restore carbohydrate before, during, or after the relevant sessions rather than protecting ketosis at the expense of performance and recovery.
+- For an adverse lipid response, reduce butter, coconut oil, fatty processed meats, cream, and excess cheese; favor olive oil, nuts, seeds, avocado, fish, and soluble-fiber foods. A large or persistent apoB/LDL-C rise still needs clinical review and may be a reason to stop keto entirely.
+- Anyone using glucose-lowering medication should coordinate carbohydrate changes with the prescribing team rather than tapering the diet or medication alone.
+
+## Murph handoffs
+
+These are internal ownership cues; do not expose route labels in a user-facing answer.
+
+- `body-composition`: intentional fat loss, muscle gain, recomposition, weight, waist, plateau, or calorie strategy.
+- `cardiometabolic-health`, `chronic-illness-support`, care navigation, and the user's clinician: diabetes, medications, blood pressure, LDL-C or apoB response, kidney or liver disease, pancreatitis, severe hypertriglyceridemia, or any therapeutic indication.
+- `gut-digestion`: persistent constipation, diarrhea, reflux, abdominal symptoms, or a fiber-change strategy.
+- `food-journal`: a brief, low-pressure record to learn what was eaten and how energy, bowel function, appetite, or training responded.
+- `micronutrients-supplements`: electrolyte powders, ketone products, MCT products, fiber supplements, multivitamins, labels, doses, and interactions.
+- `experiment-onboarding`: only after the user chooses one safe, bounded change with an outcome and stop conditions.
+- `behavior-followthrough`: recurring support after the plan is judged safe and worthwhile.
+- Eating-disorder-informed clinical and dietetic care: any material restriction, compensation, binge–restrict, or relapse risk.
+
+## Source register
+
+Evidence checked **2026-08-09**. Links are stable DOI records; source summaries state what each source can and cannot establish.
+
+- **American Diabetes Association Professional Practice Committee for Diabetes (2026), “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes.”** [DOI 10.2337/dc26-S005](https://doi.org/10.2337/dc26-S005). Current diabetes guidance on short-term low-carbohydrate effects, medication supervision, SGLT2-inhibitor ketoacidosis risk, and groups for whom very-low-carbohydrate plans are not recommended.
+- **Multi-society consensus report (2024), “Hyperglycemic Crises in Adults With Diabetes.”** [DOI 10.2337/dci24-0032](https://doi.org/10.2337/dci24-0032). Defines DKA by ketonemia plus metabolic acidosis and covers euglycemic presentations; it does not evaluate wellness keto efficacy.
+- **Cochrane systematic review (2022), “Low-carbohydrate versus balanced-carbohydrate diets for reducing weight and cardiovascular risk.”** [DOI 10.1002/14651858.CD013334.pub2](https://doi.org/10.1002/14651858.CD013334.pub2). Large randomized evidence synthesis finding little or no clinically important comparative weight or risk-factor advantage through one to two years; low-carbohydrate definitions and interventions were heterogeneous.
+- **Umbrella review of randomized-trial meta-analyses (2023), “Effects of ketogenic diet on health outcomes.”** [DOI 10.1186/s12916-023-02874-y](https://doi.org/10.1186/s12916-023-02874-y). Calibrates certainty across conditions, identifies an LDL-C signal, and emphasizes the lack of long-term direct-outcome trials.
+- **Meta-analysis of randomized clinical trials (2024), “Impact of the ketogenic diet as a dietary approach on cardiovascular disease risk factors.”** [DOI 10.1016/j.ajcnut.2024.04.021](https://doi.org/10.1016/j.ajcnut.2024.04.021). Across short heterogeneous trials, keto lowered several risk factors but increased mean total and LDL cholesterol; it provides surrogate, not cardiovascular-event, evidence.
+- **Randomized trial in healthy adults (2024), “Ketogenic diet but not free-sugar restriction alters glucose tolerance, lipid metabolism, peripheral tissue phenotype, and gut microbiome.”** [DOI 10.1016/j.xcrm.2024.101667](https://doi.org/10.1016/j.xcrm.2024.101667). Shows that fasting glucose, glucose tolerance, apoB, and microbiome signals can move in different directions and change over 4–12 weeks; the small, short trial cannot establish long-term outcomes.
+- **National Lipid Association scientific statement (2019), “Review of current evidence and clinical recommendations on the effects of low-carbohydrate and very-low-carbohydrate (including ketogenic) diets.”** [DOI 10.1016/j.jacl.2019.08.003](https://doi.org/10.1016/j.jacl.2019.08.003). Cardiometabolic tradeoffs, variable LDL response, food-quality priorities, contraindication screening, and monitoring; predates newer trials but remains a major clinical consensus source.
+- **American Heart Association scientific statement (2023), “Popular Dietary Patterns: Alignment With American Heart Association 2021 Dietary Guidance.”** [DOI 10.1161/CIR.0000000000001146](https://doi.org/10.1161/CIR.0000000000001146). Evaluates diet-pattern quality and sustainability rather than proving clinical events; very-low-carbohydrate patterns align poorly when they restrict protective plant foods or favor saturated fat.
+- **Randomized crossover trial (2022), “Effect of a ketogenic diet versus Mediterranean diet on glycated hemoglobin in individuals with prediabetes and type 2 diabetes mellitus.”** [DOI 10.1093/ajcn/nqac154](https://doi.org/10.1093/ajcn/nqac154). Twelve-week-per-phase comparison finding no significant A1C advantage for keto, with higher LDL-C and lower intake of several nutrients; single-site and short-duration limits apply.
+- **International Society of Sports Nutrition position stand (2024), “Ketogenic diets.”** [DOI 10.1080/15502783.2024.2368167](https://doi.org/10.1080/15502783.2024.2368167). Reviews healthy exercising adults; performance is largely neutral or unfavorable versus higher-carbohydrate diets, maximal strength is often similar, and most trials are short.
+- **International adult ketogenic-therapy recommendations (2021), “International Recommendations for the Management of Adults Treated With Ketogenic Diet Therapies.”** [DOI 10.1212/CPJ.0000000000001007](https://doi.org/10.1212/CPJ.0000000000001007). Specialist consensus for therapeutic variants, contraindications, baseline assessment, adverse-effect management, and monitoring; not a wellness-diet protocol.
+- **Cochrane systematic review (2020), “Ketogenic diets for drug-resistant epilepsy.”** [DOI 10.1002/14651858.CD001903.pub5](https://doi.org/10.1002/14651858.CD001903.pub5). Supports seizure reduction in selected patients while showing limited adult evidence and meaningful tolerability/dropout concerns.
+- **Systematic adverse-event analysis (2026), “Adverse events and tolerability of ketogenic diets.”** [DOI 10.1186/s40795-026-01277-5](https://doi.org/10.1186/s40795-026-01277-5). Finds gastrointestinal events, especially constipation, commonly reported across heterogeneous ketogenic interventions; pooled frequencies should not be treated as a precise risk estimate for one ordinary adult implementation.

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

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+# Low-carbohydrate eating
+
+Evidence checked: **2026-08-09**
+
+Use this reference only after the parent `nutrition-strategy` skill routes a low-carbohydrate question here. This file adds diet-specific evidence and execution detail; the parent still controls universal safety, routing, data reuse, tracking burden, clinical boundaries, and answer shape.
+
+## What the label means
+
+Low-carbohydrate eating is an umbrella for patterns that reduce carbohydrate relative to a person's usual intake or a comparison diet. It is broader than ketogenic eating: carbohydrate reduction alone does not establish nutritional ketosis. The label does **not** identify one food list, macronutrient split, protein intake, fat quality, calorie level, or clinical purpose.
+
+Published thresholds conflict. Examples include:
+
+- about 26-45% of energy from carbohydrate in one diabetes-education scheme;
+- less than 130 g/day or less than 26% of energy in many trial reviews; and
+- roughly 20-50 g/day or less than 10% of energy for some very-low-carbohydrate or ketogenic protocols.
+
+Treat those as study conventions, not universal cutoffs. When precision matters, state the actual foods, approximate grams or percentage, and whether fiber is included instead of relying on the label. [2][7][12]
+
+Meaningful variants include:
+
+- **Flexible lower-carbohydrate:** fewer sugary drinks, sweets, refined-grain snacks, or oversized starch portions while retaining fruit, legumes, dairy, whole grains, or starchy vegetables as useful.
+- **Plant-forward lower-carbohydrate:** more nonstarchy vegetables, soy foods, legumes in workable portions, nuts, seeds, avocado, and unsaturated oils.
+- **Higher-protein lower-carbohydrate:** more protein replaces some carbohydrate; satiety and adequacy depend on total intake and food choices.
+- **Higher-fat lower-carbohydrate:** more fat replaces carbohydrate; the balance of unsaturated and saturated fats can materially change lipid response.
+- **Very-low-carbohydrate:** a stricter range that may produce ketosis, but the label alone does not prove sustained nutritional ketosis.
+- **Ketogenic:** deliberately formulated to induce and maintain nutritional ketosis. It is a narrower pattern with different implementation and safety issues and should not be inferred from a general low-carbohydrate request.
+
+## Evidence bottom line
+
+### Glycemia
+
+In randomized trials enrolling adults with type 2 diabetes, low- and very-low-carbohydrate diets can produce modest short-term improvements in A1C, triglycerides, weight, and medication use over about six months. A 2021 systematic review rated much of this evidence moderate to low certainty, and many comparative advantages were smaller or absent by 12 months. These findings are condition-specific and do not establish a cure, a universal best diet, or a reason to change medication without clinical supervision. [1][2]
+
+Eating less carbohydrate at a meal can reduce the immediate glucose load. That plausible mechanism and a lower post-meal reading are surrogate observations, not proof of better long-term health for every person.
+
+### Triglycerides and other lipids
+
+Triglycerides often fall and HDL cholesterol may rise, especially over shorter periods. LDL cholesterol, non-HDL cholesterol, and apoB responses are heterogeneous: they may fall, remain similar, or rise, occasionally substantially. A scientific statement found mixed LDL effects, and a 2024 meta-analysis found larger average LDL increases in lower-BMI trial groups than in higher-BMI groups. Neither body size nor food choice predicts an individual's response with certainty. [3][4]
+
+Do not treat lower triglycerides or higher HDL as canceling a meaningful rise in LDL-related markers. What replaces carbohydrate matters: olive or canola oil, nuts, seeds, avocado, fish, tofu, and legumes create a different pattern from one dominated by butter, coconut oil, fatty or processed meats, and large amounts of cheese.
+
+### Weight and satiety
+
+Some people find lower-carbohydrate meals more filling or simpler and may spontaneously eat less. This is not universal. Effects can reflect more protein, less refined or highly palatable food, fewer choices, or—in variants that actually achieve nutritional ketosis—ketosis. Appetite suppression is not proof of adequate intake or a unique fat-loss mechanism. [3]
+
+Initial scale change may include glycogen and water. Across randomized weight-reduction trials, low-carbohydrate and balanced-carbohydrate diets probably produce little to no meaningful difference in weight loss or common cardiovascular risk factors by one to two years. The sustainable energy and food pattern matters more than the label. [5]
+
+### Cardiovascular outcomes
+
+Comparative trials mostly measure weight and risk factors rather than heart attacks, strokes, or cardiovascular death. A category-wide causal cardiovascular benefit from low-carbohydrate eating has not been established.
+
+A 2026 analysis of three long-running cohorts linked higher-quality low-carbohydrate patterns—emphasizing plant foods, whole grains, and unsaturated fats—with lower coronary heart disease incidence, while lower-quality versions emphasizing refined carbohydrates and animal fats and proteins were linked with higher incidence. This is direct health-outcome evidence but remains observational, based on dietary reports and pattern scores; it cannot prove that prescribing a low-carbohydrate diet prevents events. [6]
+
+### Guideline and consensus position
+
+Diabetes guidance treats carbohydrate reduction as one individualized eating-pattern option, especially for short-term glycemic goals, while emphasizing food quality, nutritional adequacy, and medication safety. Lipid and cardiovascular statements do not endorse carbohydrate restriction as a universal goal; they prioritize sustainable pattern quality, unsaturated fats in place of saturated fats, fiber-rich foods, and response monitoring. [1][3][7][8]
+
+### What the evidence does not support
+
+- Carbohydrate is not inherently harmful, and carbohydrate avoidance is not a purity test.
+- Insulin or ketosis explanations alone do not prove superior long-term fat loss or disease prevention.
+- Short-term changes in weight, A1C, triglycerides, hunger, or glucose do not establish long-term cardiovascular benefit.
+- Evidence from adults with type 2 diabetes, overweight, or obesity does not automatically generalize to children, pregnancy, frailty, eating-disorder recovery, high-performance athletes, or people with complex disease.
+- Evidence for very-low-carbohydrate or ketogenic diets should not be presented as evidence for every flexible lower-carbohydrate pattern, or vice versa.
+
+## Why users may choose it
+
+Common jobs include reducing sugary drinks or refined snacks, simplifying meals, seeking steadier perceived energy or appetite, supporting a clinician-managed glycemic goal, lowering triglycerides, losing weight, or matching a food preference. Ask which job matters when it changes the recommendation; do not assume weight loss or diabetes from the label. Popularity is also reinforced by simple rules, visible early scale changes, testimonials, and commercial branding; that shows demand, not comparative efficacy.
+
+A useful core may be much smaller than the branded rule package. For many users, the lowest-risk version is simply fewer low-fiber discretionary carbohydrates, better meal structure, and carbohydrate portions matched to activity—not a fixed gram ceiling.
+
+## Diet-specific tradeoffs and adequacy
+
+Restriction is not automatically harmful, but risk rises as more food groups disappear without replacement.
+
+- **Fiber:** Removing whole grains, legumes, fruit, and starchy vegetables can lower fiber and worsen constipation. Preserve workable sources such as nonstarchy vegetables, berries or other whole fruit, avocado, nuts, seeds, soy foods, legumes, and any whole grains that fit the chosen version.
+- **Micronutrients:** Common pressure points can include folate, thiamin, magnesium, potassium, and vitamin C; calcium and vitamin D may also become harder to cover if dairy or fortified alternatives disappear. Risk depends on the foods removed, not the carbohydrate number alone, and a carefully constructed pattern can still be adequate. [7][11]
+- **Fat quality:** A low-carbohydrate label can hide a large rise in saturated fat. Prefer unsaturated fats and varied protein sources rather than making butter, coconut oil, processed meat, or cheese the default energy replacement. [3][8]
+- **Protein and total energy:** More protein can help meal structure, but protein alone does not correct under-fueling. Higher-fat foods are energy dense, while appetite suppression can also produce unintentionally low intake.
+- **Training fuel:** Easy or low-volume training may be compatible with a lower-carbohydrate pattern, but repeated high-intensity work, long endurance sessions, tournaments, and high weekly volume rely more on carbohydrate availability. Preserve or reintroduce carbohydrate around key sessions rather than treating the label as a ban. [9]
+- **Ordinary life:** Strict rules can increase cost, preparation burden, social friction, or food preoccupation. A pattern that only works in controlled weeks is not yet a durable plan.
+
+Do not recommend supplements automatically. Route supplement evidence, dose, label, and safety questions to `micronutrients-supplements`.
+
+## Lowest-risk practical execution
+
+Use the least restrictive version that serves the user's actual goal.
+
+1. **Name the change, not just the diet.** Start with one high-leverage source: sugary drinks, frequent sweets, low-fiber snack foods, or a starch portion that is routinely larger than wanted. Do not automatically remove whole fruit, legumes, milk or yogurt, whole grains, or starchy vegetables.
+2. **Keep a flexible meal scaffold.** Combine a protein option, nonstarchy vegetables or another fiber-rich food, enough fat or sauce for satisfaction, and a deliberate carbohydrate portion matched to preference and demand.
+3. **Choose replacement quality deliberately.** Options include fish, eggs, tofu or tempeh, plain yogurt or a fortified alternative, poultry, lean meat, beans or lentils in workable portions, olive or canola oil, nuts, seeds, and avocado.
+4. **Keep useful carbohydrate available.** Fruit, oats, beans, lentils, potatoes, rice, whole-grain bread or tortillas, and milk or yogurt can remain flexible options—especially before, during, or after demanding training.
+5. **Use an ordinary-life fallback.** At a restaurant, family meal, or travel stop, choose a satisfying protein and produce when available, take the carbohydrate portion that fits the situation, and resume the usual pattern at the next meal. Do not compensate.
+
+A minimally restrictive example is “replace the daily sweet drink, add vegetables and protein at lunch, and keep rice or potatoes around hard training,” not “ban all starch and fruit.” Concrete foods are options, not requirements.
+
+## Common failure modes and repairs
+
+- **The label is doing all the work.** Repair by naming the actual foods reduced, retained, and added. Two people at the same carbohydrate percentage can have very different diets.
+- **Unplanned drift into ketogenic intake.** Repair by checking whether fruit, legumes, dairy, grains, and training fuel have disappeared. Treat very-low-carbohydrate intent as a separate decision with added safety review.
+- **Carbohydrate is replaced mostly with saturated fat.** Repair by shifting toward olive or canola oil, nuts, seeds, avocado, fish, tofu, legumes, and leaner protein options.
+- **Fiber falls sharply.** Add tolerated fiber-rich foods gradually. Persistent constipation, pain, or other digestive symptoms belong with `gut-digestion`.
+- **Training output or recovery declines.** Add carbohydrate before, during, or after the demanding sessions first; do not explain persistent decline away as required “adaptation.”
+- **Appetite suppression becomes under-fueling.** Restore regular meals and accessible carbohydrate or energy. Falling performance, persistent fatigue, cold intolerance, menstrual changes, recurrent injury or illness, food preoccupation, or unintended weight loss outrank the diet goal.
+- **Early water loss is treated as proof of superior fat loss.** Route intentional body-change strategy and interpretation to `body-composition`.
+- **One higher-carbohydrate meal becomes a lapse.** Return to the next normal meal. Do not fast, overexercise, or tighten rules in response.
+- **The plan requires full-time tracking.** Step down to meal structure or one decision-changing target. Do not require ketone testing, continuous glucose monitoring, daily weighing, or full macro logging for ordinary execution.
+
+## Monitoring, stop conditions, and off-ramps
+
+For a low-risk fit test, define one goal and one or two signals before adding tracking. Useful signals include hunger and satisfaction, daytime energy, training output and recovery, bowel pattern, food preoccupation, social fit, and whether the meals remain practical.
+
+When a clinical marker, disease, or medication is central, hand off rather than inventing a lab schedule or treatment target. If lipids are already being monitored in usual care, a material rise in LDL cholesterol, non-HDL cholesterol, or apoB warrants clinical review rather than assuming the triglyceride response makes it harmless.
+
+Pause the restriction, restore adequate food or carbohydrate as appropriate, and escalate when any of these appear:
+
+- symptomatic or recurrent low glucose, especially in a person using insulin or an insulin-releasing medicine;
+- persistent dizziness, weakness, fatigue, poor concentration, low mood, or impaired training and recovery;
+- substantial unintended weight loss, very low appetite, recurrent illness or injury, menstrual disruption, or increasing cold intolerance;
+- escalating food fear, rigid rules, binge-restrict cycles, compensatory behavior, or social withdrawal;
+- persistent constipation, vomiting, abdominal pain, or other meaningful digestive change; or
+- a marked adverse lipid response or conflict with a clinician-directed eating plan.
+
+Use the parent's urgent-care rules for acute deterioration. Very-low-carbohydrate or ketogenic intake combined with an SGLT2 inhibitor adds ketoacidosis risk; nausea or vomiting, abdominal pain, rapid breathing, unusual drowsiness, or confusion needs urgent assessment even when glucose is not dramatically elevated. Do not advise medication changes. [1][10]
+
+An off-ramp is not failure. Reintroduce one or more tolerated carbohydrate sources at the meal or training window where energy, performance, fiber, or flexibility is most constrained. A moderate-carbohydrate, quality-first pattern may preserve the useful core with less burden.
+
+## Groups needing extra caution
+
+Apply the parent `Clinical Boundaries` section. Diet-specific caution is especially important for:
+
+- anyone using insulin, sulfonylureas, meglitinides, or an SGLT2 inhibitor;
+- type 1 diabetes or any diabetes plan where medication and carbohydrate are tightly linked;
+- known markedly elevated LDL-related markers, a prior large lipid response to carbohydrate restriction, or a clinician-managed lipid disorder;
+- pregnancy or breastfeeding, people under 18, frailty, low intake, or recent substantial weight loss;
+- kidney disease, advanced liver disease, significant heart disease, relevant endocrine disease, or post-bariatric surgery;
+- current or past eating-disorder symptoms, compulsive exercise, or strong number sensitivity; and
+- high-volume or high-intensity training, multiple daily sessions, or competition periods.
+
+General education and flexible food ideas may still help, but condition-specific targets and therapeutic versions belong with a clinician or registered dietitian.
+
+## Murph handoffs
+
+- `food-journal`: exact labels, capture, or retrospective links among food, glucose, symptoms, energy, or performance.
+- `body-composition`: intentional fat loss, muscle gain, weight or waist trends, plateaus, and calorie tradeoffs.
+- `gut-digestion`: constipation, diarrhea, reflux, bloating, elimination, or reintroduction.
+- `cardiometabolic-health`, `chronic-illness-support`, and care navigation: glucose, lipids, blood pressure, disease, medication, therapeutic diets, and lab interpretation.
+- `micronutrients-supplements`: supplement need, product evidence, dose, label, and safety.
+- `experiment-onboarding`: a bounded test after the user chooses one specific safe change.
+- `behavior-followthrough`: recurring support after the plan itself is sound.
+
+## Source register
+
+Checked **2026-08-09**. Sources support the evidence distinctions above; none makes one low-carbohydrate threshold or implementation universally correct.
+
+1. **Standards of Care in Diabetes—2026, Section 5: Facilitating Positive Health Behaviors and Well-being.** Individualized eating patterns, short-term low-carbohydrate evidence, nutritional adequacy, and SGLT2 caution. DOI: [10.2337/dc26-S005](https://doi.org/10.2337/dc26-S005).
+2. **BMJ systematic review and meta-analysis (2021), “Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission.”** Twenty-three randomized trials; moderate-to-low-certainty short-term benefits with attenuation by 12 months and population limits. DOI: [10.1136/bmj.m4743](https://doi.org/10.1136/bmj.m4743).
+3. **National Lipid Association scientific statement (2019), “Review of current evidence and clinical recommendations on the effects of low-carbohydrate and very-low-carbohydrate diets.”** Appetite, triglycerides, mixed LDL response, adherence, food quality, and long-term evidence gaps. DOI: [10.1016/j.jacl.2019.08.003](https://doi.org/10.1016/j.jacl.2019.08.003).
+4. **American Journal of Clinical Nutrition meta-analysis (2024), “Increased low-density lipoprotein cholesterol on a low-carbohydrate diet in adults with normal but not high body weight.”** Short-duration randomized trials showing heterogeneous LDL response and effect modification by trial-group BMI; not a cardiovascular-outcomes study. DOI: [10.1016/j.ajcnut.2024.01.009](https://doi.org/10.1016/j.ajcnut.2024.01.009).
+5. **Cochrane Review CD013334 (2022), “Low-carbohydrate versus balanced-carbohydrate diets for reducing weight and cardiovascular risk.”** Little to no comparative difference in weight loss or common risk factors through one to two years in adults with overweight or obesity, with and without type 2 diabetes. DOI: [10.1002/14651858.CD013334.pub2](https://doi.org/10.1002/14651858.CD013334.pub2).
+6. **JACC cohort analysis (2026), “Effect of Low-Carbohydrate and Low-Fat Diets on Metabolomic Indices and Coronary Heart Disease in U.S. Individuals.”** Direct coronary outcomes showing strong food-quality dependence; observational and not proof of causal benefit. DOI: [10.1016/j.jacc.2025.12.038](https://doi.org/10.1016/j.jacc.2025.12.038).
+7. **Scientific Advisory Committee on Nutrition report (2021), “Lower carbohydrate diets for adults with type 2 diabetes.”** No agreed universal definition; short-term, population-specific findings; fiber, micronutrient, saturated-fat, and medication considerations. Stable report page: [GOV.UK](https://www.gov.uk/government/publications/sacn-report-lower-carbohydrate-diets-for-type-2-diabetes).
+8. **American Heart Association scientific statement (2026), “Dietary Guidance to Improve Cardiovascular Health.”** Pattern quality, vegetables and fruit, whole grains, protein sources, unsaturated-fat substitution, and minimally processed foods. DOI: [10.1161/CIR.0000000000001435](https://doi.org/10.1161/CIR.0000000000001435).
+9. **Joint position statement (2016), “Nutrition and Athletic Performance.”** Carbohydrate availability matched to training and competition demand rather than a universal daily intake. DOI: [10.1249/MSS.0000000000000852](https://doi.org/10.1249/MSS.0000000000000852).
+10. **Standards of Care in Diabetes—2026, Section 6: Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises.** Hypoglycemia risk with insulin, sulfonylureas, and meglitinides, and the need to review treatment when lows recur. DOI: [10.2337/dc26-S006](https://doi.org/10.2337/dc26-S006).
+11. **Obesity Reviews systematic review (2019), “Impacts of carbohydrate-restricted diets on micronutrient intakes and status.”** Variable definitions and limited reporting, but recurring risks when carbohydrate-rich food groups are removed without adequate replacement. DOI: [10.1111/obr.12857](https://doi.org/10.1111/obr.12857).
+12. **American Diabetes Association professional nutrition overview, “Nutrition & Wellness” (accessed 2026-08-09).** Examples of one education scheme using 26-45% of energy for low-carbohydrate and 20-50 g non-fiber carbohydrate or less than 26% of energy for very-low-carbohydrate patterns; these are not universal cutoffs. Stable page: [professional.diabetes.org](https://professional.diabetes.org/clinical-support/nutrition-wellness).

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+# Mediterranean-style eating
+
+Use this reference only for a narrow Mediterranean-style eating question routed by the parent `nutrition-strategy` skill. The parent remains authoritative for routing, tracking burden, clinical boundaries, and answer shape. This is ordinary food-pattern guidance, not a therapeutic-diet protocol.
+
+## Working definition
+
+Mediterranean-style eating is a flexible pattern, not one menu, macro split, national cuisine, or list of imported foods. Common versions emphasize:
+
+- a variety of vegetables and fruit;
+- beans, lentils, peas, whole grains, nuts, and seeds when tolerated and safe;
+- unsaturated fats used mainly in place of saturated fats;
+- fish or seafood in many, but not all, versions;
+- optional poultry, eggs, yogurt, and cheese in amounts that fit the person; and
+- less processed meat, red meat, refined grain, sweets, and sugar-sweetened drinks than in the person's starting pattern.
+
+Extra-virgin olive oil and nuts were supplied in landmark trials, so those trials most directly support the tested packages rather than every possible substitution. For ordinary implementation, another acceptable unsaturated oil, seed, seed butter, or other tolerated local source of unsaturated fat can preserve the broader substitution principle when olive oil or nuts do not fit cost, taste, access, culture, or allergy constraints. Do not imply that the substitute has identical direct trial evidence.
+
+Meaningful variants include ad-libitum patterns rich in unsaturated fat; energy-reduced versions bundled with activity and behavior support; pescatarian, vegetarian, and omnivorous versions; and locally adapted versions. "Green Mediterranean," MIND, branded score-based plans, and other hybrids are distinct interventions; do not automatically transfer all Mediterranean-diet findings to them.
+
+Wine is optional, not a defining nutrient or treatment. Do not advise a non-drinker to start alcohol for this pattern or for heart health. For someone who drinks, answer the food question without presenting alcohol as beneficial and route risk-specific alcohol guidance appropriately.
+
+"Mediterranean" is research shorthand derived from selected food patterns in parts of a large, diverse region. Do not imply that communities around the Mediterranean share one timeless cuisine, grade a user's food as culturally authentic, or require Greek- or Italian-coded dishes. Preserve the useful pattern with the user's own staples, flavors, cooking methods, household meals, and access.
+
+## Evidence calibration
+
+Mediterranean-style eating has a relatively mature cardiometabolic evidence base compared with many named diets, especially for cardiovascular prevention in adults at increased risk. That does not make every version equivalent or establish it as uniquely best.
+
+| Question | Current evidence read |
+| --- | --- |
+| **Guideline and consensus support** | Strong. Current cardiovascular guidance favors the same pattern-level priorities: varied plant foods, whole grains, healthy protein sources, unsaturated fats replacing saturated fats, and fewer highly processed foods, added sugars, and excess sodium. Mediterranean-style and DASH-like patterns are examples, not the only valid routes. |
+| **Direct cardiovascular outcomes** | Randomized trials and a 2023 network meta-analysis support fewer major cardiovascular events, and probably lower mortality for some increased-risk populations, versus minimal intervention. The clearest trials followed older or higher-risk adults for roughly five to seven years and included repeated counseling and, sometimes, supplied foods. |
+| **Comparison with other high-quality patterns** | Less certain. The 2023 network meta-analysis found no convincing mortality or nonfatal-heart-attack advantage over well-implemented low-fat programs. Comparator quality, support intensity, and the exact rule package matter; do not call Mediterranean eating universally superior. |
+| **Weight, glycemia, lipids, and blood pressure** | Average changes are often favorable but usually modest and heterogeneous. The pattern is not inherently calorie restricted and does not guarantee weight loss. A 2025 trial found lower diabetes incidence with an energy-reduced Mediterranean pattern plus physical activity and intensive behavior support, but that bundle does not isolate the diet label. |
+| **Cancer, cognition, mood, longevity, or other broad claims** | Much of the support is observational, surrogate-based, or secondary. Associations can be useful context but do not justify prevention, treatment, reversal, or lifespan promises. |
+
+Important limits:
+
+- The direct-outcome randomized evidence is concentrated in Spanish, older, and increased-risk populations; generalization to younger, lower-risk, and culturally different populations is plausible but not equally direct.
+- The republished PREDIMED analysis addressed departures from individual randomization. Its direction was similar after reanalysis, but the design history and intensive intervention warrant explicit caution.
+- CORDIOPREV was a single-center secondary-prevention trial whose participants were mostly men with established coronary disease. It supports a clinician-managed population, not condition-specific instructions from Murph.
+- Trials tested packages of foods, substitutions, counseling, and social support. They do not prove that olive oil, nuts, fish, wine, polyphenols, or any supplement reproduces the whole pattern's effect in isolation.
+- Plausible mechanisms include higher fiber and micronutrient density, unsaturated-for-saturated-fat substitution, lower intake of some highly processed foods, and easier long-term food variety. Mechanistic plausibility helps explain coherence; it is not comparative-outcome proof.
+
+## Why users may choose it
+
+Common reasons include wanting a flexible heart-health-aligned pattern, more plant foods without excluding all animal foods, fewer calculations, meals that can work for a household, or an evidence-supported alternative to a highly restrictive plan. Clarify the user's actual job before expanding the pattern: definition, comparison, one meal change, grocery defaults, cultural adaptation, or troubleshooting.
+
+## Tradeoffs and adequacy
+
+A Mediterranean label does not guarantee diet quality or adequacy.
+
+- **Under-fueling:** A "salad and fish" interpretation can provide too little energy, carbohydrate, or protein, especially with high training demand, low appetite, frailty, or recovery needs. Keep useful grains, potatoes, bread, rice, corn, legumes, fruit, and other tolerated carbohydrate sources.
+- **Fiber tolerance:** A rapid increase in legumes, whole grains, vegetables, nuts, or seeds can cause discomfort. Increase gradually and use `gut-digestion` when persistent symptoms, elimination, or reintroduction is the actual problem.
+- **Energy-dense additions:** Oils, nuts, seeds, cheese, and spreads can be useful foods, but simply adding them to an unchanged pattern may not serve an intentional body-change goal. Do not frame them as free foods; hand that goal to `body-composition`.
+- **Food-pattern quality:** Pastries, refined grains, processed meats, salty convenience foods, and alcohol do not become protective because they are marketed as Mediterranean. Judge the whole pattern and the substitution, not the label.
+- **Allergens and exclusions:** Nuts, sesame, fish, shellfish, dairy, and gluten-containing grains can be central in some versions but are never mandatory. Use exact-label and cross-contact checks when material.
+- **Vegetarian or vegan adequacy:** Legumes, soy foods, peas, nuts or seeds when safe, and whole grains can anchor protein. Depending on exclusions and total intake, iron, vitamin B12, calcium, iodine, vitamin D, and omega-3 adequacy may need focused review; do not invent supplement doses here.
+- **Cost and access:** Fresh fish, imported oil, specialty cheese, or branded products can make an otherwise flexible pattern expensive. Frozen or canned produce, dry or canned legumes, oats, rice, corn, potatoes, local whole-grain foods, eggs, tofu, peanut or seed butter, canned fish when wanted, and an affordable unsaturated oil can carry the pattern.
+
+## Lowest-risk practical execution
+
+Start with one recurring meal or shopping default rather than an adherence score.
+
+1. **Add a plant anchor.** Use a vegetable or fruit plus beans, lentils, peas, or a whole-grain or other high-fiber staple that already fits the household.
+2. **Make one replacement, not a purity rule.** At some meals, replace processed meat or a saturated-fat-heavy default with beans, soy foods, fish, poultry, eggs, yogurt, nuts, seeds, or an unsaturated oil that fits the user.
+3. **Protect satisfaction and adequacy.** Keep enough familiar starch, protein, fat, sauce, seasoning, and total food for appetite, training, recovery, and ordinary life.
+
+Flexible meal structures include:
+
+- beans, lentils, tofu, fish, chicken, eggs, or yogurt with rice, barley, potatoes, bread, or corn tortillas plus vegetables and a flavorful unsaturated-fat-based sauce;
+- oats or whole-grain toast with fruit and yogurt, soy yogurt, nuts, seeds, or seed butter;
+- a familiar soup, stew, curry, grain bowl, pasta dish, sandwich, or family meal shifted toward more legumes or vegetables and less processed meat; or
+- a fallback such as canned beans with frozen vegetables and a microwave grain, lentil soup with bread and fruit, hummus or a seed spread sandwich, or canned fish with potatoes or crackers when those foods fit.
+
+Cultural adaptation is expected, not a compromise. Keep local legumes, grains, vegetables, fruits, spices, sauces, and shared dishes. Organic produce, fresh seafood, imported olive oil, wine, and specialty products are not entry requirements.
+
+For common constraints:
+
+- **Vegetarian or vegan:** Use legumes, tofu, tempeh, textured vegetable protein, peas, nuts or seeds when safe, and fortified alternatives as needed; fish is not required.
+- **Nut allergy:** Use seeds or seed butter when safe, legumes, soy foods, eggs, dairy, fish, poultry, or other tolerated proteins and fats.
+- **Fish or shellfish allergy, dislike, or avoidance:** Use legumes, soy foods, eggs, dairy, poultry, nuts, or seeds as appropriate; do not treat fish as mandatory.
+- **Dairy-free:** Use tolerated fortified alternatives and other calcium-containing foods; exact needs belong with the focused adequacy owner.
+- **Gluten-free:** Use rice, corn, potatoes, quinoa, buckwheat, and certified gluten-free oats as appropriate, with exact-label and cross-contact checks when needed.
+- **Olive oil does not fit:** Use another affordable unsaturated oil or tolerated whole-food fat while being clear that this is a practical adaptation, not the exact landmark-trial intervention.
+
+## Common failure modes
+
+- Reducing the pattern to olive oil, wine, cheese, or one "superfood."
+- Adding oil and nuts without replacing anything when the user's actual goal depends on overall energy intake.
+- Turning a flexible pattern into unnecessary bans on bread, pasta, potatoes, dairy, or all red meat.
+- Buying costly imported foods or preparing separate "Mediterranean" meals instead of adapting familiar dishes.
+- Using an authenticity score or moral language that makes ordinary variation feel like failure.
+- Increasing fiber so quickly that the plan becomes uncomfortable or unsustainable.
+- Building meals around produce alone and missing energy, protein, or carbohydrate needs.
+- Treating observational associations, supplements, or a biomarker change as proof of disease prevention or treatment.
+
+## Monitoring, stop conditions, and off-ramps
+
+Use the lowest-burden signals that can change the next decision: meal satisfaction, hunger, energy, training and recovery, digestive tolerance, time, cost, access, and social fit. Clinician-ordered markers may inform a clinical plan, but this reference does not set condition-specific targets or medication changes.
+
+Adjust, pause, or hand off when the pattern is followed by persistent inadequate intake, unintended weight loss, fatigue, dizziness, declining performance or recovery, ongoing digestive symptoms, a suspected allergic reaction, increasing food fear or rigidity, compensatory behavior, or a concerning change in a clinician-monitored marker or medication response. Apply the parent's urgent and clinical-boundary rules rather than creating a Mediterranean-specific emergency protocol.
+
+A useful off-ramp is to drop the label while keeping one or two workable elements: a bean-based meal, more produce, an unsaturated-fat substitution, or a reliable emergency meal. Slow the fiber increase, restore tolerated foods, or move to another evidence-aligned pattern when cost, symptoms, culture, access, or preference makes this one a poor fit. Do not compensate after an off-pattern meal; return to the next ordinary meal.
+
+## Extra caution
+
+The parent's clinical boundaries control. Mediterranean-specific implementation needs additional care when:
+
+- a condition, medication, therapeutic diet, pregnancy, growth, frailty, post-bariatric status, or low intake makes changes in carbohydrate, protein, potassium-rich foods, sodium, alcohol, or total intake clinically material;
+- severe allergy or celiac disease makes ingredient identity or cross-contact decisive;
+- eating-disorder risk, recent major restriction, or unintentional weight loss makes a named-diet score or further restriction unsafe; or
+- the user plans to replace prescribed care, alter medication, or use the pattern to treat a disease.
+
+Keep general meal ideas low risk while routing the condition-specific decision to the appropriate clinician or registered dietitian.
+
+## Murph handoffs
+
+- Keep ordinary definition, comparison, cultural adaptation, grocery defaults, meal structure, and adequacy-preserving execution in `nutrition-strategy`.
+- Use `food-journal` for capture, retrospective pattern finding, or exact ingredient, allergen, and label provenance.
+- Use `body-composition` when intentional weight, waist, fat loss, muscle gain, or calorie strategy is the primary job; return here only for meal execution.
+- Use `gut-digestion` for persistent symptoms or elimination and reintroduction work.
+- Use `cardiometabolic-health`, `chronic-illness-support`, care navigation, and the user's clinician for marker-first, disease-specific, medication-linked, or therapeutic-diet decisions.
+- Use `micronutrients-supplements` when supplement evidence, dose, safety, or focused adequacy is the actual question.
+- Use `experiment-onboarding` only after the user chooses one specific safe change, and `behavior-followthrough` when reminders or repeated support becomes the main job.
+
+Do not expose these internal route labels in the user-facing answer.
+
+## Source register
+
+Evidence reviewed through **2026-08-09**. Prefer the pattern-level conclusions and stated population limits over isolated component claims.
+
+| Source | Evidence type and use |
+| --- | --- |
+| American Heart Association, ["2026 Dietary Guidance to Improve Cardiovascular Health"](https://doi.org/10.1161/CIR.0000000000001435), *Circulation* (2026) | Current scientific statement supporting food-pattern focus, plant variety, whole grains, healthy protein, unsaturated-for-saturated-fat substitution, and not initiating alcohol. |
+| American Heart Association, ["Popular Dietary Patterns: Alignment With American Heart Association 2021 Dietary Guidance"](https://doi.org/10.1161/CIR.0000000000001146), *Circulation* (2023) | Consensus comparison placing Mediterranean-style patterns among the closest alignments while preserving multiple valid heart-healthy patterns. |
+| ["Comparison of seven popular structured dietary programmes and risk of mortality and major cardiovascular events in patients at increased cardiovascular risk"](https://doi.org/10.1136/bmj-2022-072003), *BMJ* (2023) | Systematic review and network meta-analysis supporting direct cardiovascular outcomes versus minimal intervention in increased-risk adults; head-to-head superiority over low-fat programs remained unconvincing. |
+| ["Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts"](https://doi.org/10.1056/NEJMoa1800389), *New England Journal of Medicine* (2018) | Republished PREDIMED randomized analysis; direct outcomes over a median 4.8 years in older Spanish adults at high cardiovascular risk, with randomization departures and intensive support limiting transfer. |
+| ["Long-term secondary prevention of cardiovascular disease with a Mediterranean diet and a low-fat diet (CORDIOPREV)"](https://doi.org/10.1016/S0140-6736(22)00122-2), *The Lancet* (2022) | Randomized direct-outcome comparison over about seven years in people with established coronary disease; single-center, mostly male, clinician-managed population. |
+| ["Mediterranean-style diet for the primary and secondary prevention of cardiovascular disease"](https://doi.org/10.1002/14651858.CD009825.pub3), *Cochrane Database of Systematic Reviews* (2019) | Systematic review documenting heterogeneity and earlier uncertainty in intervention definitions and clinical endpoints; predates CORDIOPREV and the 2023 network meta-analysis. |
+| ["Comparison of an Energy-Reduced Mediterranean Diet and Physical Activity Versus an Ad Libitum Mediterranean Diet in the Prevention of Type 2 Diabetes: A Secondary Analysis of a Randomized Controlled Trial"](https://doi.org/10.7326/ANNALS-25-00388), *Annals of Internal Medicine* (2025) | Long-term randomized evidence for a bundled energy-reduction, activity, and behavior-support intervention; does not isolate a Mediterranean label or justify condition-specific treatment advice. |
+| ["Culturally adapting the Mediterranean Diet pattern - a way of promoting more sustainable dietary change?"](https://doi.org/10.1017/S0007114522001945), *British Journal of Nutrition* (2022) | Review supporting adaptation around local foods, preferences, access, and barriers while preserving core pattern characteristics; not a direct-outcome trial. |