Time to Validate 4Leaf Survey

Enabling it can become an important vital sign in medicine

But let’s start at how 4Leaf started. Everything started with Dr. T. Colin Campbell’s definition of an optimal diet for humans

“The closer we get to eating a diet of whole, plant-based foods, the better off we will be.”

Gorillas (whose DNA is closest to ours) gets over 99% of his calories from those healthiest of foods. The average American gets far less than 10%. Our survey currently does a very good job of identifying the people who need the most help. It’s all of the people whose first 4Leaf score is a negative number. And we have found that, among typical Americans, 90% of them will score in that group. And upon seeing their first 4Leaf score, most people are motivated to get a lot more serious about what they are eating.

We are currently gathering/analyzing data aimed at determining the correlation of the 4Leaf score to changes in blood pressure, A1C, total cholesterol and BMI. Please advise if you have data that you can share with us.

Ideally, we’d like to have something like this:

  • 100 new patients take the survey every three months for a year (a total of five iterations)
  • To the extent possible, their respective blood pressure, A1C, total cholesterol and/or BMI would be measured at the same time.
  • We are confident that a rising 4Leaf score will correlate strongly to improving bio-markers across the board.
  • We don’t believe that we need to validate the survey score’s accuracy in “estimating” percent of calories from whole plants. Rather, the survey provides us a simple and quick pattern of eating that the patient can easily understand and report from memory.

Maybe some of this kind of information is in your database now. If so, we would love to have the opportunity to analyze that data.

4Leaf Credibility

Here’s what we have so far. Four medical doctors (with combined survey use in the thousands) have told us that they already consider the 4Leaf score to be a vital sign (ranging from -44 to +44) and are actually entering it into their respective EMR systems. And they seem to  feel that it is the most important vital sign; in the sense that the patient can easily take steps to improve that vital sign from a very unhealthy diet (below -20) to very healthy diet (over +30) in just a few months.

In the process, many of the traditional vital signs are improved as the patient moves toward the vibrant health that a whole food, plant-based diet can deliver.

Our goal is to someday see the 4Leaf score on the “vital sign” list of  EMR systems everywhere. And the more validation we can produce, the greater the likelihood that will happen. As we gather more validation data for the 4Leaf Survey, we will update this list. Right now, here’s what we have in the way of credibility:

  • Since 2014, the 4Leaf Survey has been the ONLY dietary assessment tool used at eCornell in the  T. Colin Campbell Certificate Course in Plant-Based Nutrition. See Or just click on the eCornell image above.
  • British paper re “Diet vs. Breathing” relationship (January 2019) M. Lingard, Osteopath, who is one of our licensees. Check out how the 4Leaf score clearly correlates with improved health as measured by the Buteyko Method.
  • Michael Lingard, DO, mentions the 4Leaf Survey twice in an April 2018 article on the Center for Nutrition Studies website.
  • Finally, we have an enormous amount of anecdotal data from physicians who are using the 4Leaf Survey in their practice. At least four of those doctors have each purchased between 100 and 1,000 copies of our book.

1. What must we validate?

A. That the survey accurately estimates the percent of food calories from whole plants? OR

B. That the survey score has a positive correlation with more than one bio marker: like BP, total cholesterol, A1C and/or BMI. As the score goes up, the biomarkers get better.

We feel that “B” is far more important even though our survey also does a fairly good job of “A” as well.

2. Can we use existing data that has been gathered by a host of medical doctors  to prove the “B” premise above?

Our thinking is that the positive correlation in biomarkers would be far easier to prove than the actual percent of calories from whole plants. For that, we’d need a lot more than twelve questions, it would be more complex, it would no doubt have many inaccuracies and it would no longer be a two-minute survey.

Many doctors have told us that the best thing about the survey is that it is easy, fast, and does a great job of helping the patient understand that they are eating nowhere near a health promoting diet. They also report that the realization of that fact can be very motivating for the patient.

Relevant Example of a Validation Process. In 2011, a team of researchers headed by Amy E. Paxton, MPH, published a paper in the American Journal of Preventive Medicine. It was entitled Starting the Conversation (STC), Performance of a Brief Dietary Assessment and Intervention Tool for Health Professionals.

Note: This paper is discussed here as an example of the validation process for a dietary assessment tool. It’s interesting to note that throughout this entire paper, not once did they mention the actual reversal of Type 2 Diabetes. This, in spite of the fact that (prior to 2011) Ornish, Barnard, McDougall, Fuhrman and other prominent MDs had published books on the fact that the disease is reversible in over 90% of the time when the patient shifts to a whole food, plant-based diet — eating at the 4Leaf Level.

In contrast, people who take our 4Leaf Survey every few months and see their scores improving, are likely to be seeing corresponding improvements in their A1C, cholesterol levels, blood pressure, BMI and other key health indicators.

Introduction of the 2011 Paper

For chronic disease prevention and management, brief but valid dietary assessment tools are needed to determine risk, guide counseling, and monitor progress in a variety of settings.

They went on to define the dietary assessment tool (STC) that they used as a simplified eight-item, food frequency instrument designed for use in primary care and health-promotion settings. A few specifics:

  • Adults with type 2 diabetes were recruited from primary care medical offıces within Kaiser Colorado (KPCO).
  • Of 2603 recruitment letters sent, 229 decliner postcards and 15 letters were returned. Of 2359 recruitment calls attempted, 544 patients were eligible and agreed to participate; 463 patients were randomized.
  • Data were collected from 2008 to 2010 and they were analyzed for this report in 2010.
  • Pictured below is the eight item assessment tool that they used.

Notice that, even though their mission was to help Type 2 Diabetes patients get better, they included foods like chicken and fish in Question #5 along with pinto and black beans and in so doing, suggesting that the more of all three, the better. The medical doctors mentioned above, with vast experience in reversing type 2 diabetes, do not recommend the consumption of ANY animal protein.

Near the end of the paper, the researchers summed up the results as follows:

Overall, the brief eight-item STC tool identifıed healthful and unhealthful dietary behaviors in a diverse sample,indicating the measure’s feasibility for use in public health and primary care settings. These results are similar to performance of the longer Food Habits Questionnaire and Rate Your Plate. The STC was robust across a variety of participant characteristics, was stable over time in the absence of treatment, was sensitive to treatment, and was a reasonably valid measure of dietary intake compared to the previously validated dietary-fat–focused assessment, but previous studies have employed it as an intervention tool.

The STC offers an attractive option for dietary assessment and intervention by non-dietitians in busy clinical settings. To our knowledge, it is the shortest instrument available, designed specifıcally to help clinic staff identify atherogenic dietary patterns and guide counseling.

As noted above, their STC tool identified healthful and unhealthful dietary behaviors. Of course, the purpose of the 4Leaf Survey is to estimate the percent of calories in one’s diet that are derived from whole, plant-based foods.

Click here to read the entire 2011 five-page paper on the STC.

That’s it for now, refer back to this page to check on our progress.

J. Morris (Jim) Hicks, Founder & CEO, 4Leaf Global, LLC.

PS: One fine day in September of 2015, I received this unsolicited endorsement via email from T. Colin Campbell, PhD, Nutritional Biochemistry, Cornell University. He sent it from an international cancer conference.

“Your 4Leaf model is one-hundredth the complexity but has real value that may exceed any of the very comprehensive survey models developed by some of the world’s top cancer specialists.”–T. Colin Campbell, PhD

Copyright © 2019, 4Leaf Global, LLC

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