Diet & Lifestyle Questionnaire
Created by: William Harris, M.D.

If you are unable to download the spreadsheet version, you may
print a copy of this and make calculations by hand.

Kaiser-Permanente Vegan Lifestyle Clinic (VLC)

Food and Exercise Questionnaire

This questionnaire is about your usual food intake. There are also some questions about exercise.  Foods are scored in such a way as to reflect both an adequate nutritional intake and the degree to which your lifestyle follows the exercise and vegan food recommendations of the Kaiser-Permanente Vegan Lifestyle Clinic (VLC). A larger and self-calculating spreadsheet version is available via free download.

Name : Last ___________ First______________
MRNR
Date of birth:
mm/dd/yy
Male __ Female__

Wt (lbs)______Ht (in)_______

BMI=
Body Mass Index (BMI) = 705x(lbs) (in) sqd
Ex: 705X175 lbs (62"x62")=32.1 (Obesity II)
See chart at bottom to interpret your BMI number.

Instructions: 
Listed below are food items divided into sections according to food type. Please put a whole or decimal number (or leave blank when appropriate) in the times/week column to indicate how many times you have eaten each food during the last week.

Estimate whether the serving was Small - (1 2 3 4 5) - Large.  Try to estimate the amounts of a given food that may be in recipes made mostly of some other food.

Example:

Times/wk

x Sm-(1 2 3 4 5)-Lar

x VF

= Score

Half a head of Romaine lettuce 3 times/week

3

x 4

x 4.9

=58.8

(Times/wk = 3)

Sm-(1 2 3 4 5)-Lar = ~ 4

(approximate)

ANIMAL SOURCE FOOD
Animal food Value Factors (VF) are based on cholesterol and saturated fat content.  In the context of the VLC it is judged that whatever nutritional values may be found in these foods are offset by their disadvantages so that value of animal food is negative. 

While animal foods are good sources of second-hand amino acids and other nutrients, they all contain first-hand saturated fat and cholesterol, which are risk factors for obesity, cardiovascular disease, six types of cancer, and diabetes.  The excessive protein and sulfur amino acid content are risk factors for kidney disease ans osteoporosis.  Animal source food has no fiber and is deficient in vitamin C, and magnesium.  At least 28 separate food-borne illnesses are transmitted to humans from animal source food and, because of modern agricultural practices, these foods are also contaminated by pesticides, herbicides, and hormones at a much higher concentration than plant foods.  Animal source food is adaptive when there's not enough food (the condition of our ancestors), but only harmful and obselete when there are diverse and plentiful plant foods to choose from (our present condition).

MEAT (VF from -5 to -4)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

Spam, luncheon meats, Vienna sausage, etc.

   

-5.0

 

ham, bacon, pork roast, pork chops

   

-4.9

 

beefsteak, hamburger, sirloin steak, beef ribs

   

-4.8

 

lamb chops, lamb roast

   

-4.5

 

POULTRY (VF from -4 to -3)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

chicken, turkey, duck, pheasant, goose

   

-3.5

 

EGGS (VF from -3 to -2)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

whole eggs

   

-3.0

 

egg white (no cholesterol but #3 on food allergy list)

   

-2.0

 

FISH (VF from -2 to -1)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

shellfish

   

-1.7

 

fish

   

-1.4

 

DAIRY (VF from -1 to 0) A good source of calcium but also of saturated fat and cholesterol.

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

whipped cream, dairy desserts, ice cream.

   

-1.0

 

butter (almost 100% fat)

   

-1.0

 

cheese

   

-0.9

 

milk

   

-0.8

 

"low fat" cottage cheese

   

-0.1

 

NO MAN'S LAND Mostly packaged foods (VF from -1 to +1).

DRESSINGS AND SPREADS

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

mayonnaise

   

-1.0

 

stick margarine (usually contains hydrogenated fat)

   

-0.7

 

canola oil and olive oil

   

0.5

 

flaxseed oil

   

0.7

 

oil-free dressing

   

0.8

 

Dijon sauce (p. 9 VLC "Getting Started")

   

0.9

 

Vinaigrette Dressing (p. 9 VLC "Getting Started")

   

0.9

 

"Healthy gravy" (p 9 "Getting Started")

   

1.0

 

SWEETS (empty Calories)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

candy, chocolates

  &fbsp;

-0.6

 

honey

   

-0.3

 

sugar added to tea, coffee, cereal

   

-0.2

 

maple syrup

   

0.7

 

blackstrap molasses

   

1.0

 

DRINKS. Empty Calories

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

hard liquor

   

-1.0

 

beer / wine

   

-0.4

 

soft drinks, e.g. Coca Cola, Pepsi, 7-Up

   

-0.3

  

coffee, tea, decaffeinated

   

0.0

 

herbal tea

   

0.6

 

non-alcoholic beer / wine

   

0.9

 

CONDIMENTS

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

salt

   

0

 

vinegar

   

0.0

 

pepper

   

0.3

 

soy sauce

   

0.3

 

mustard

   

0.4

 

pickles (avoid "alum" on label)

   

0.9

 

tomato paste

   

1.0

 

NUTS AND SEEDS: natural, but high fat plant foods (VF from 0 to 1)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

raw hulled sunflower seeds

   

0.7

 

natural peanuts and peanut butter

   

0.8

 

raw unhulled sesame seeds (high in calcium)

   

0.8

 

raw almonds, walnuts

   

1.0

 

BREAD (VF from 1 to 2)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

white bread and rolls

   

1.0

 

brown bread and rolls

   

1.5

 

wholewheat bread, Pita bread

   

2.0

 

GRAINS (VF from 2 to 3)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

refined grains: white rice, white flour

   

0.5

 

brown rice

   

3.0

 

MEAT SUBSTITUTES: OK, but not required.

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

soya meats, textured vegetable protein-TVP

   

2.8

 

Vegeburger, Boca Burger, Garden Burger Vegan. etc.

   

2.9

 

PASTA : A good pasta label reads "Durum semolina".

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

refined pasta (spaghetti, macaroni, noodles)

   

2.3

 

whole grain, spinach, or artichoke pasta

   

2.8

 

CEREALS

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

commercial dry cereal (Kellogg's, Post, etc.)

   

2.0

 

oatmeal

   

2.5

 

muesli

   

2.8

 

FRUIT : Because of the high sugar content, diabetics should use fruit with restraint. (VF from 3 to 4)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

avocado

   

3.0

 

apples, bananas, grapes

   

3.2

 

pure fruit juice e.g. orange, apple, grapefruit

   

3.2

 

raisins (good iron source)

   

3.3

 

melons, watermelon

   

3.4

 

mango, papaya

   

3.8

 

strawberries, other berries

   

3.9

 

apricots, nectarines, peaches, pears, plums

   

3.9

 

VEGETABLES: The healthiest foods of all on average, only deficient in vitamin B12. (VF from 4 to 5)

STARCHY AND ROOT VEGETABLES

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

commercial potato chips or fries

   

0.2

 

boiled, mashed, baked, roasted potatoes (plain)

   

4.0

 

taro root, poi

   

4.1

 

mushrooms (high in zinc)

   

4.1

 

leeks, onions, garlic

   

4.1

 

yams , sweet potato

   

4.2

 

parsnips, turnips, beetroot

   

4.2

 

carrots (highest source of beta-carotene)

   

4.4

 

BEANS (A good protein source but deficient in vitamins A, and B2.)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

beans, lentils, peas

   

4.0

 

tofu ( high in fat, but a good substitute for dairy)

   

4.1

 

soybeans

   

4.8

 

GREEN VEGETABLES (THE best foods of all and the biochemical source of most organic nutrients.)

Times/wk

x Sm (1 2 3 4 5) Lar

x VF

= Score

green or red peppers

   

4.1

 

vegetable soup (no hydrogenated fat or meat stock)

   

4.2

 

celery

   

4.2

 

green beans, wax beans

   

4.4

 

peas, lima beans

   

4.5

 

broccoli, cabbage, cauliflower*

   

4.5

 

spinach and taro leaf **

   

4.5

 

Bok choy, won bok

   

4.6

 

sprouts: alfalfa, mung bean, soybean, etc.

   

4.6

 

Chinese pea pods

   

4.6

 

tomatoes ***

   

4.7

 

watercress, parsley

   

4.8

 

cucumber

   

4.8

 

collard greens, kale, Brussels sprouts,

   

4.9

 

Romaine, other green lettuce****

   

4.9

 

low sodium V-8 juice or V-4 juice (VLC p.9)

   

5.0

 

* (cruciferous vegetables protect aginst cancer)
**(high in nutrients, but their oxalic acid content interferes with calcium absorption)
***(saponins and lycopenes in tomatoes protective against prostate cancer)
****(chlorophyl, carotenoids, and luteins in leaf vegetables also protective against cancer)

EXERCISE (VF 1-5)

In a typical week during the last 12 months, how often did you do any of the following: (zero, decimal fraction, whole numbers).

Times/wk

x Minutes per day

x VF

= Score

walking

   

2.0

 

swimming

   

3.0

 

stair climbing

    

3.5

 

stationary or real bike

   

3.5

 

jogging

   

4.0

 

weight training

   

4.5

 

running

   

5.0

 

other vigorous sport _________
(assign your own VF from 0 to 5)

   

?

 
VLC total score (from all pages)=  

This diet spreadsheet is named "Dietque4.wb1". It was done using Quattro Pro for Windows v5.0.   You could print this out and calculate your score by hand, but a simpler alternative is to download a larger version of this diet spreadsheet, with all the self-calculating cells intact.  It can then be loaded into Quattro, Excel, or Lotus 1-2-3, (although the BMI and VF graphs may not come through).  Nonetheless, the numbers are easily plugged in and a running score is calculated automatically. The basic form can be used repeatedly by not saving the data each time, or by renaming the file each time it is used. (e.g. "Jane.WB1", "Dick.XLS", "Sam.WKS", etc., the file extension as assigned by your spreadsheet). 

if you would like to download the larger version of this diet spreadsheet, with all the self-calculating cells intact, click here.

Copyright William Harris, M.D.
Former Medical Director
Kaiser-Permanente Vegan Lifestyle Clinic (VLC)
1010 Pensacola Street
Honolulu, HI 96814
(808) 597-2118 (W)
e-mail: HARRISMDW001@hawaii.rr.com

Value Factors Graph Series:

value.gif (33862 bytes)

-5

Meat

-4

Poultry

-3

Eggs

-2

Fish

-1

Dairy

1

Nuts

2

Bread

3

Grains

4

Fruit

5

Vegetables

 

BMI Table bmi.gif (38424 bytes)

40

70

30

Obesity III

30

40

10

Obesity II

25

30

5

Obesity I

18.5

25

6.5

Normal(18.5-25)

17

18.4

1.4

Malnutrition I

16

17

1

Malnutrition II

0

16

16

Malnutrition III