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Lifestyle, Clean Macrobiotic

Clean Macrobiotic: A Whole-Food Japanese-Influenced Tradition

A traditional Japanese-influenced way of eating built around whole grains, seasonal local vegetables, beans, sea vegetables, miso soup and fermented foods, balanced according to yin-yang principles. Developed by George Ohsawa from the 1920s1, drawing on the teaching of Sagen Ishizuka, and carried forward by Michio and Aveline Kushi and the wider macrobiotic community.

🍚 Whole Grains as the Base 🥬 Local & Seasonal Vegetables 🌊 Sea Vegetables, in Small Amounts 🍲 Miso Soup Daily 😌 Chew Thoroughly

Last updated:

By the Numbers, United States

How Many Americans Follow This Lifestyle?

Small
share of US adults who follow a strict macrobiotic diet; no major US survey measures it
Niche
practiced mostly in wellness and cancer-support circles2

Sources: No major US survey measures how many people follow a macrobiotic diet, so no figure is given. Use in cancer support: Kushi and colleagues, Journal of Nutrition, 2001 2.

Definition

What Is Macrobiotics?

Macrobiotics ("macro" = large, "bios" = life) is a way of eating and living developed in early-⁠20th-century Japan that uses traditional Asian dietary wisdom and yin-yang philosophy to create a daily plate emphasizing whole grains, seasonal local vegetables, beans, sea vegetables, fermented foods and small amounts of fish1.

The lineage runs from Sagen Ishizuka, to George Ohsawa (1893 to 1966)3, who synthesized the modern macrobiotic philosophy after saying a traditional diet had cured his own tuberculosis (tuberculosis today needs antibiotic treatment4), to Michio and Aveline Kushi (1926 to 2014; 1923 to 2001)5. Michio Kushi settled in New York in 1949, the couple began introducing macrobiotics to North America in the 1950s, and in 1978 they founded the Kushi Institute, which taught the approach across the West56.

At its core, the practice is less a list of forbidden foods than a way of choosing the most appropriate foods for your climate, season, body and current health condition. The plate is intentionally simple: cook clean food well, eat seasonally, chew thoroughly and pay attention to how the body responds.

A macrobiotic plate of kale, broccoli, carrots, mung beans, sea vegetables, seeds, nuts, apple, blueberries and a wedge of lemon, ringed by the words whole, seasonal, local, organic, and yin and yang

Balanced vs. Standard vs. Extreme Macrobiotic

Balanced Macrobiotic

The Kushi Institute's approach, often called the Standard Macrobiotic Diet: whole grains, vegetables, beans, sea vegetables, soups, occasional fish, fermented foods, fruits in season. Flexible, individualized, balanced.

Standard Practice

Used by most home practitioners; emphasizes brown rice, miso, vegetables, beans. Less precise about ratios; usually adjusted to family realities.

Extreme "Diet #7"

Ohsawa's early "Diet #7", the last of ten increasingly restrictive stages, was brown rice and water only3. Very strict versions caused severe malnutrition and some deaths, and it is not recommended1.

The Framework

Six Core Principles

🍚

1. Whole Grains as the Center

Brown rice, millet, barley, oats, buckwheat, making up 50 to 60% of the diet3. Properly soaked and cooked. The Kushi tradition treats grain as a daily anchor.

🥬

2. Local & Seasonal Vegetables

20 to 25% of the diet3. Local, organic, seasonal. Roots in winter, leafy greens in spring, fruiting vegetables in summer, hearty squashes in fall. Avoid out-of-season tropical produce.

🫘

3. Beans & Sea Vegetables Daily

Beans (adzuki, chickpea, black soybean, lentil) cooked with sea vegetables (kombu, wakame, arame, nori, dulse), 5 to 10% of the diet together3. The bean-seaweed pairing is signature. Keep the seaweed to small amounts and kombu occasional: kombu can hold more iodine in one gram than the adult upper limit for a whole day78, and if you have a thyroid condition, ask your clinician before eating seaweed daily8.

🍲

4. Miso Soup Daily

A cup of plain miso soup with wakame, scallion and root vegetables is a daily staple in traditional macrobiotic practice. Miso is very salty, so if you have been told to limit sodium, have it occasionally instead9.

🥒

5. Fermented & Pickled Foods

Naturally fermented umeboshi, takuan, kimchi, sauerkraut, miso, tamari, nukazuke. A spoonful with each meal is traditional, but salt-preserved and pickled foods are linked to stomach cancer34, so keep them to small amounts rather than at every meal. In a small 17-⁠week trial in healthy adults, a diet high in fermented foods increased gut microbiome diversity10; many pickles are salty, so count them toward your sodium.

😌

6. Chew, Slow Down, Eat in Gratitude

Traditional macrobiotic teaching emphasizes chewing each bite many times, a habit that slows the meal and may help you feel full sooner11.

Food Framework

What to Eat & What to Skip

✅ Daily / Regular:

🍚 Whole Grains (50 to 60%)

Short-grain brown rice (cornerstone), millet, barley, Job's tears (hato mugi), buckwheat (kasha), whole oats, rye, wheat berries. Always soaked or pressure-cooked.

🥬 Vegetables (20 to 25%)

Daikon, burdock, lotus root, carrot, leafy greens (kale, collards, watercress, daikon greens), winter squash, cabbage, cauliflower, turnip, sweet onion. Local and seasonal.

🫘 Beans (5 to 10%, with sea vegetables)

Adzuki, chickpea, lentil, black soybean, mung. Soaked, and occasionally cooked with kombu kelp.

🌊 Sea Vegetables (small daily)

Wakame, kombu, nori, arame, dulse. A tablespoon or so per day for minerals and trace elements. Iodine varies enormously between seaweeds: nori is low12, while kombu averaged 2,276 mcg of iodine per gram in one analysis7, against an adult upper limit of 1,100 mcg a day8. Vary them and keep kombu occasional.

🍲 Soups (1 to 2 cups daily)

Miso soup is foundational. Other broths: shiitake, kombu, vegetable.

🥒 Ferments & Condiments

Umeboshi plums, naturally fermented tamari, miso, kimchi, sauerkraut, takuan, nukazuke pickles, gomashio (sesame & sea salt), kuzu.

🐟 Small Amounts of Fatty Fish (Optional)

Sardines and anchovies, 1 to 2 times per week for those who include animal foods13.

❌ Limit or Avoid:

🥛 Dairy

Macrobiotics considers dairy too "yin" and mucus-forming; traditional practice omits it entirely. Studies have not found that milk increases mucus1415. Without dairy, calcium has to come from other foods, such as kale, bok choy, broccoli and calcium-set tofu, and people who avoid dairy are at higher risk of falling short16.

🍬 Refined Sugar & Strong Sweeteners

Cane sugar, high-fructose corn syrup, honey (mostly), agave, chocolate. Traditional practice allows light sweeteners such as barley malt or mirin, but they are still added sugar, so use small amounts only.

🍅 Nightshades

Tomato, potato, eggplant, peppers, considered too yin in classical macrobiotics. Modern practitioners use moderation rather than strict avoidance.

🍌 Tropical Fruits

Banana, mango, pineapple, citrus (largely): if they are not native to your climate, traditional practice limits them. Eat fruits in season from your region.

🥩 Red Meat & Poultry

Considered too "yang" and rarely included. If used at all: small amounts in winter.

☕ Coffee & Alcohol

Traditionally avoided; green tea (bancha, kukicha) is preferred.

📦 Processed Foods

All ultra-processed packaged foods, refined oils, food colorings, MSG, eliminated entirely.

A Day on the Plate

Sample 1-⁠Day Clean Macrobiotic Pattern

7:00 to 8:00 AM · Breakfast
🍵 Morning Plate

1 cup miso soup with scallion · brown rice porridge (rice cooked with extra water) topped with toasted sesame and a pinch of gomashio · steamed kale with tamari · cup of bancha tea. Chew well.

Macrobiotic morning plate with miso soup, brown rice porridge, steamed kale and bancha tea

🍵 Sample Morning Plate

Miso soup with scallion · brown rice porridge with gomashio · steamed kale with tamari · bancha tea. A warm, gentle start built on miso and whole grain.

12:30 to 1:30 PM · Lunch
🍚 Midday Plate

1 cup short-grain brown rice · adzuki beans simmered with a sweet vegetable (squash or carrot), and a strip of kombu only once or twice a week · sautéed greens with sesame oil and tamari · daikon-carrot kinpira (julienned and slow-cooked) · 1 tbsp sauerkraut or takuan pickle · half an umeboshi plum · kukicha tea.

Macrobiotic midday plate with brown rice, adzuki beans, sautéed greens, kinpira and umeboshi

🍚 Sample Midday Plate

Brown rice · adzuki beans with sweet vegetable (kombu once or twice a week) · sautéed greens · daikon-carrot kinpira · pickle · umeboshi. The classic grain + bean + sea vegetable + greens + ferment combination, the standard macrobiotic plate.

6:00 to 7:00 PM · Dinner
🍲 Evening Plate

1 cup vegetable miso soup with shiitake and root vegetables · 1 cup millet or quinoa · simmered arame seaweed with carrot and onion · steamed broccoli or bok choy · small piece of grilled wild salmon (optional) · cucumber-wakame pressed salad · ½ baked apple with cinnamon (in-season fruit dessert). The arame and wakame together are the day's seaweed, about a tablespoon in all.

Macrobiotic evening plate with vegetable miso soup, millet, arame seaweed simmered with carrot and onion, steamed broccoli, a pressed cucumber and wakame salad, a small piece of grilled wild salmon and half a baked apple

🍲 Sample Evening Plate

Vegetable miso soup · millet or quinoa · simmered arame with carrot & onion · steamed broccoli · pressed cucumber-wakame salad · baked apple. Lighter than lunch and eaten early, in keeping with macrobiotic tradition.

8:30 PM · Closing
🌙 Pre-Sleep

Cup of bancha tea. Finish eating a few hours before sleep, as the tradition advises. Macrobiotic tradition emphasizes calm, gratitude and reflection, not eating in front of screens.

Practical Guardrails

The Six Most Common Pitfalls

📏 Going Too Rigid

Some practitioners have historically over-restricted, especially around "Diet #7"1. The modern Balanced Macrobiotic approach is flexible: vegetables, beans and occasional fatty fish are healthy and broaden nutrient coverage.

💊 No B12 Plan

Without supplementation, B12 deficiency is documented in long-term strict macrobiotic practice17, and even small amounts of fatty fish may not be enough. Supplement B12.

🦴 Low Fat for Children

Children need more dietary fat than the standard macrobiotic plate provides18. Add more sesame, tahini, nut butters, avocado or fatty fish for growing kids.

🌡️ Climate Mismatch

Traditional macrobiotics is climate-aware: cold climates call for more warming foods and root vegetables; tropical climates call for lighter foods. Follow your local season, not a textbook.

🌾 Brown Rice Monotony

"Just brown rice" is a recipe for boredom and deficiency. Rotate grains, varieties, vegetables and beans.

⚖️ Mineral Excess (Sea Vegetables)

Sea vegetables are mineral-dense; hijiki is high in inorganic arsenic, and UK food safety advice is not to eat it at all19. Vary the seaweed used and keep amounts modest (a tablespoon daily, not bowls), especially with kombu (see the iodine note above).

Foundational Supplements

Supplements Often Helpful on Clean Macrobiotic

SupplementWhyTypical DoseNotes
Vitamin B12Even with small amounts of fatty fish, intake can run low20.500 to 1,000 mcg, 2 to 3x/week21Ask your clinician to check serum B12, and MMA if B12 is borderline, from time to time21.
Vitamin D3Some people run low on vitamin D, especially with little sun22. Fatty fish provides some; sun provides more.Set the dose with your clinician; most adults need no blood test firstSome people add vitamin K2 (MK-⁠7), 100 to 200 mcg; trials have been inconclusive on whether it adds benefit alongside vitamin D23. If you take warfarin, clear any vitamin K supplement with the clinician managing your anticoagulation before starting or stopping it: vitamin K antagonizes warfarin, and changing your intake destabilizes the INR24. Consistency matters more than avoidance. This does not apply in the same way to direct oral anticoagulants such as apixaban or rivaroxaban, but tell your prescriber about any supplement you take25.
Algae EPA/DHA (or fatty fish)Fish and seafood are the main food sources of EPA and DHA, so intake is low if you eat little fatty fish; algal oil is a plant-based alternative13.500 to 1,000 mg EPA+DHA from algae OR sardines/​anchovies 1 to 2x/week13Whole-food coverage preferred when possible. In heart trials, fish oil supplements raised the risk of atrial fibrillation, an irregular heartbeat, more so above 1 g a day26, so check this dose with your clinician first.
Iron (if ferritin low)Non-heme plant iron absorbs less efficiently27.25 to 50 mg bisglycinate + vitamin C on empty stomach if neededTest ferritin periodically, especially in menstruating women27. Too much iron causes stomach upset and, in people with hemochromatosis, iron overload27. The top of this range sits above the 45 mg/day tolerable upper intake level for adults27. That is appropriate only when correcting a confirmed deficiency under clinical supervision, not as general supplementation. Test ferritin first, and retest rather than staying on it indefinitely. Take it at a different time of day from zinc, since 25 mg of iron or more can reduce zinc absorption27. Keep iron out of children's reach; accidental overdose can kill a small child27.
ZincGrains and legumes are zinc-modest28.15 to 25 mg zinc bisglycinate28Pumpkin seeds (kabocha squash seeds) are a strong food source28.
IodineSeaweed iodine varies too widely to rely on, from very little in nori to a gram of kombu that can pass a day's upper limit. If you have no other reliable source, a 150 mcg supplement is steadier.150 mcg if dietary intake is low8Don't double up with daily kelp + supplement. If you have a thyroid condition, check with your clinician before taking iodine or eating seaweed daily8.
Vitamin A (retinol)Plant beta-carotene converts inefficiently in some people29.Small servings of cod liver oil (1 tsp) several times per week if fish-eating2930Skip if strict plant-based.
Magnesium GlycinateWhole grains, beans and greens are good sources of magnesium31, so many people on this plate do not need a supplement; glycinate is a form some people find gentler on the gut300 to 500 mg elemental, at bedtime (or split AM/PM)The top of this range is above the 350 mg/day upper intake level for supplemental magnesium; above that, diarrhea is common. With kidney disease, take it only on your clinician's advice.
Zinc CarnosineThe grain- and bean-heavy macrobiotic plate is zinc-modest and bound by phytates; this is an optional alternative to the plain zinc above, not an addition to it75 to 150 mg/day (delivers about 17 to 34 mg elemental zinc)Take with food. After 8 to 12 weeks, drop to the lower dose to avoid copper depletion. Pair with 2 mg copper if used long term.
Suitability

Who Benefits Most, and Who Should Be Careful

💪 Often Benefits

Chronic digestive issues

Some people find simple, well-cooked whole foods easier on digestion; trials of macrobiotic eating in digestive disease are lacking, so if you have an inflammatory bowel condition, plan fiber changes with your care team.

Inflammatory conditions

Cutting sugar and refined foods is a reasonable step; removing dairy and nightshades has little trial evidence behind it for inflammatory conditions in general.

Cardiometabolic risk

People following macrobiotic diets tend to have lower cholesterol and blood pressure than the general population32, and a short trial of a macrobiotic diet in type 2 diabetes improved blood sugar and HbA1c33, though longer trials are needed.

Cancer adjunct (carefully)

Some people with cancer use macrobiotics as a supportive practice. There is no scientific evidence that it can prevent or cure cancer, and strict versions can leave people short of the calories they need during treatment1, so it is never a replacement for oncologic care and needs your oncology team's knowledge.

Spiritual and aesthetic appeal

For people drawn to simplicity, ceremony and intentional eating.

⚠️ Use Caution or Avoid

Children

Strict macrobiotic plates can underprovide calories, fat and B12 for growing kids18. Adapt portions and add fatty fish, eggs or supplements with expert input.

Pregnancy & breastfeeding

Needs careful planning for protein, calories, omega-⁠3, B12, iron, vitamin D, choline. Cancer center guidance advises against following a macrobiotic diet while pregnant or breastfeeding3; if you want to eat this way, plan it with a clinician or dietitian.

High-volume athletes

May need more dense fat and protein than the standard plate provides.

Eating disorder history

Macrobiotic rules can rationalize restrictive patterns. Work with a clinician.

Severe gluten / grain intolerance

Possible to adapt (drop wheat/​barley/rye, lean on rice, millet, buckwheat), but it stops being traditional.

Anyone going "Diet #7" long-term

Brown-rice-only protocols are not the modern recommendation and have caused documented harm1. Don't.

Next Steps

Less a Diet, More a Way of Eating

Macrobiotics done cleanly is a whole-food way of eating with many decades of practice behind it. The clean version honors the macrobiotic tradition while respecting today's nutritional science: chew well, eat seasonally, supplement what the diet cannot provide and don't go to extremes.

← Back to Lifestyle Library Compare to Clean Mediterranean →

References & Evidence Notes

Each numbered entry below is either a source you can follow or a note setting out what the evidence does and does not support. Both are numbered together so the markers in the text line up.

Last reviewed October 20, 2026. This page is nutrition education, not medical advice, and it does not replace your doctor. Strict macrobiotic eating can leave growing children short of calories, fat and B12, cancer center guidance advises against it in pregnancy and breastfeeding, and it is never a replacement for cancer treatment. Keep kombu occasional because of its iodine, and if you take warfarin or have a thyroid condition, check with your clinician before starting vitamin K, iodine or daily seaweed.

  1. Cancer Research UK. Macrobiotic diet and cancer. Last reviewed September 23, 2022. cancerresearchuk.org. A cancer charity's information page for patients. It supports the Greek roots of the word, George Ohsawa developing the diet in the 1920s, the severe malnutrition and sometimes death caused by very strict early versions that allowed nothing but whole grains, that the diet has not been shown to prevent or treat cancer, and that people in cancer treatment often need more calories than usual. ↩
  2. Kushi LH, et al. The macrobiotic diet in cancer. J Nutr. 2001. PubMed 11694648. A review of the macrobiotic diet and cancer, which describes macrobiotics as one of the most popular alternative or complementary approaches used by people with cancer. We read the abstract only. ↩
  3. OncoLink, Trustees of the University of Pennsylvania. Macrobiotic Diet. oncolink.org. A cancer center's information page for patients. It gives George Ohsawa's dates (1893 to 1966), describes his diet of ten increasingly restrictive stages ending in rice and water only, gives today's diet as generally 50 to 60% whole grains, 20 to 25% vegetables, 5 to 10% beans and sea vegetables, and 5% soups, and says pregnant or nursing women should not use the macrobiotic diet. ↩
  4. Centers for Disease Control and Prevention. Treating Tuberculosis. April 17, 2025. cdc.gov. Active tuberculosis disease is treated with medicine. ↩
  5. Rafu Shimpo. Natural foods pioneer Michio Kushi dies at 88. January 2015. rafu.com. A newspaper obituary, biographical rather than scholarly. It gives Michio Kushi's birth in 1926, his settling in New York in 1949 and his death in Boston on December 28, 2014. It also gives Aveline Kushi's dates (1923 to 2001). ↩
  6. Congressional Record (Bound Edition), Vol. 145 (1999), Part 8, p. 11812. In Recognition of Michio Kushi. govinfo.gov. A tribute entered in the Congressional Record, biographical rather than scholarly. It states that the Kushis introduced macrobiotics to North America in the 1950s and founded the Kushi Institute in 1978. ↩
  7. Aakre I, et al. Commercially available kelp and seaweed products: valuable iodine source or risk of excess intake? Food Nutr Res. 2021. PubMed 33889064. An analysis of seaweed products on sale, in which the species with the most iodine were oarweed, sugar kelp and kombu, with kombu averaging 2,276 mcg per gram. ↩
  8. Office of Dietary Supplements, National Institutes of Health. Iodine: Fact Sheet for Health Professionals. ods.od.nih.gov. The source for the adult upper limit of 1,100 mcg a day, the adult recommended amount of 150 mcg and the caution that people with autoimmune thyroid disease may have adverse effects at intakes considered safe for others. ↩
  9. US Department of Agriculture, FoodData Central. Miso (SR Legacy, FDC ID 172442). fdc.nal.usda.gov. The national food composition database lists 3,730 mg of sodium in 100 g of miso. ↩
  10. Wastyk HC, et al. Gut-microbiota-targeted diets modulate human immune status. Cell. 2021. PubMed 34256014. A 17-⁠week trial in healthy adults, with 18 people in each diet group, in which a diet high in fermented foods steadily increased gut microbiome diversity and lowered inflammatory markers. The amounts eaten were much larger than a spoonful with each meal. ↩
  11. Miquel-Kergoat S, et al. Effects of chewing on appetite, food intake and gut hormones: a systematic review and meta-analysis. Physiol Behav. 2015. PubMed 26188140. A review of chewing studies, which concludes that chewing may decrease self-reported hunger and food intake. The first author works for a chewing-gum company. ↩
  12. Teas J, et al. Variability of iodine content in common commercially available edible seaweeds. Thyroid. 2004. PubMed 15588380. Iodine measured in seaweeds sold in shops ranged from 16 mcg per gram in nori to over 8,000 mcg per gram. ↩
  13. Office of Dietary Supplements, National Institutes of Health. Omega-⁠3 Fatty Acids: Fact Sheet for Health Professionals. ods.od.nih.gov. The source for dietary advice of one to two servings of seafood a week, for fish and seafood as the food sources of EPA and DHA, and for algal oil as a vegetarian supplement form. ↩
  14. Pinnock CB, et al. Relationship between milk intake and mucus production in adult volunteers challenged with rhinovirus-⁠2. Am Rev Respir Dis. 1990. PubMed 2154152. Healthy adult volunteers given a common cold virus; no significant overall link was found between milk and dairy intake and mucus symptoms. ↩
  15. Wüthrich B, et al. Milk consumption does not lead to mucus production or occurrence of asthma. J Am Coll Nutr. 2005. PubMed 16373954. A review of the evidence, which concludes that drinking milk does not lead to mucus production. ↩
  16. Office of Dietary Supplements, National Institutes of Health. Calcium: Fact Sheet for Health Professionals. ods.od.nih.gov. People who avoid dairy, including vegans, are at higher risk of inadequate calcium intake; the sheet names kale, broccoli and Chinese cabbage, such as bok choy, among calcium sources and lists tofu made with calcium sulfate. ↩
  17. Miller DR, et al. Vitamin B-⁠12 status in a macrobiotic community. Am J Clin Nutr. 1991. PubMed 1989421. In 110 adults in a New England macrobiotic community, 51% had low blood B12, and the longer people had followed the diet, the lower their levels. ↩
  18. Dagnelie PC, van Staveren WA. Macrobiotic nutrition and child health: results of a population-based, mixed-longitudinal cohort study in The Netherlands. Am J Clin Nutr. 1994. PubMed 8172122. Dutch infants and young children on macrobiotic diets were short of energy, protein, vitamin B12, vitamin D, calcium and riboflavin, and the authors recommended adding fat, fatty fish and dairy products to their diet. ↩
  19. Rose M, et al. Arsenic in seaweed: forms, concentration and dietary exposure. Food Chem Toxicol. 2007. PubMed 17336439. A UK survey of arsenic in seaweed, which records that the UK Food Standards Agency advised consumers to avoid eating hijiki. ↩
  20. van Dusseldorp M, et al. Risk of persistent cobalamin deficiency in adolescents fed a macrobiotic diet in early life. Am J Clin Nutr. 1999. PubMed 10197567. Adolescents who were macrobiotic until age 6 and later ate fish, meat or chicken 2 to 3 times a week; moderate amounts of animal foods did not restore normal B12 status. The study was in adolescents, not adults. ↩
  21. Office of Dietary Supplements, National Institutes of Health. Vitamin B12: Fact Sheet for Health Professionals. ods.od.nih.gov. Single-ingredient B12 supplements typically contain 500 to 1,000 mcg, no upper limit was set because of B12's low potential for toxicity, and methylmalonic acid (MMA) is the most sensitive marker of B12 status. ↩
  22. Harmon BE, et al. Nutrient composition and anti-inflammatory potential of a prescribed macrobiotic diet. Nutr Cancer. 2015. PubMed 26212923. An analysis of a prescribed macrobiotic diet, which often met or exceeded recommended amounts except for vitamin D, vitamin B12 and calcium. ↩
  23. Linus Pauling Institute, Oregon State University. Micronutrient Information Center: Vitamin K. lpi.oregonstate.edu. Intervention trials have been inconclusive on whether supplemental vitamin K1 or K2 further reduces bone loss. It also notes that MK-⁠7 at doses as low as 10 to 20 mcg may unsettle warfarin control. ↩
  24. Office of Dietary Supplements, National Institutes of Health. Vitamin K: Fact Sheet for Health Professionals. ods.od.nih.gov. People taking warfarin and similar anticoagulants need to keep their vitamin K intake from food and supplements consistent, because sudden changes can raise or lower the drug's effect. ↩
  25. Kampouraki E, Kamali F. Dietary implications for patients receiving long-term oral anticoagulation therapy for treatment and prevention of thromboembolic disease. Expert Rev Clin Pharmacol. 2017. PubMed 28635328. A review of diet and long-term blood thinners. Whether vitamin K in the diet affects the response to direct oral anticoagulants in people remained to be investigated. ↩
  26. Gencer B, Djousse L, Al-Ramady OT, Cook NR, Manson JE, Albert CM. Effect of long-term marine omega-⁠3 fatty acids supplementation on the risk of atrial fibrillation in randomized controlled trials of cardiovascular outcomes: a systematic review and meta-analysis. Circulation. 2021;144(25):1981-⁠1990. PubMed 34612056. Seven trials with 81,210 people followed for about 5 years: omega-⁠3 supplements were linked to a higher risk of atrial fibrillation (hazard ratio 1.25), more so in trials of more than 1 g a day (1.49), and the risk rose with each additional gram. ↩
  27. Office of Dietary Supplements, National Institutes of Health. Iron: Fact Sheet for Health Professionals. ods.od.nih.gov. The source for the adult upper limit of 45 mg, for heme iron from meat being better absorbed than nonheme iron from plant foods, for ferritin as a test of iron stores and for the higher risk of low iron in women who menstruate. ↩
  28. Office of Dietary Supplements, National Institutes of Health. Zinc: Fact Sheet for Health Professionals. ods.od.nih.gov. Zinc from beans, nuts and whole grains is less available than from animal foods because of phytates; the adult upper limit is 40 mg, above the dose in the table; and roasted pumpkin seeds give 2.2 mg in an ounce. ↩
  29. Office of Dietary Supplements, National Institutes of Health. Vitamin A and Carotenoids: Fact Sheet for Health Professionals. ods.od.nih.gov. Conversion of beta-carotene to vitamin A may vary genetically, and the adult upper limit for preformed vitamin A is 3,000 mcg RAE a day. ↩
  30. US Department of Agriculture, FoodData Central. Fish oil, cod liver (SR Legacy, FDC ID 173577). fdc.nal.usda.gov. The database lists 30,000 mcg of vitamin A (RAE) in 100 g of cod liver oil and a teaspoon as 4.5 g, so a teaspoon is well under the adult upper limit. ↩
  31. Office of Dietary Supplements, National Institutes of Health. Magnesium: Fact Sheet for Health Professionals. ods.od.nih.gov. Green leafy vegetables, legumes, nuts, seeds and whole grains are good sources of magnesium. ↩
  32. Lerman RH. The macrobiotic diet in chronic disease. Nutr Clin Pract. 2010. PubMed 21139126. A review describing studies in which people following a macrobiotic diet had lower blood lipids and blood pressure than the general population. These are comparisons between groups, not trials. ↩
  33. Soare A, et al. The effect of the macrobiotic Ma-Pi 2 diet vs. the recommended diet in the management of type 2 diabetes: the randomized controlled MADIAB trial. Nutr Metab (Lond). 2014. PubMed 25302069. Adults with type 2 diabetes ate a specific macrobiotic diet (Ma-Pi 2) or a recommended diet for 21 days, and metabolic control improved more on the macrobiotic diet. ↩
  34. Ren JS, et al. Pickled food and risk of gastric cancer: a systematic review and meta-analysis of English and Chinese literature. Cancer Epidemiol Biomarkers Prev. 2012. PubMed 22499775. A meta-analysis of 60 observational studies, in which people who ate pickled vegetables or foods had about 50% higher odds of stomach cancer than those who did not, with the strongest links in Korea and China. ↩