How can diet impact back pain. What foods should you eat to reduce inflammation. Why is chronic inflammation harmful to your body. Which dietary changes can lead to less back pain. How does the standard American diet contribute to inflammation. What is the link between inflammatory foods and low back pain.

The Link Between Diet and Back Pain: New Research Insights

Recent research presented at the Association of Academic Physiatrists (AAP) digital conference in February 2021 has shed light on a surprising connection between diet and low back pain. The study suggests that what we eat may play a significant role in managing and even preventing this common ailment.

Valerio Tonelli Enrico, a physical therapist and doctoral student at the University of Pittsburgh, who led the research, stated, “Our findings suggest that diets that are more anti-inflammatory tend to be better for back pain.” This groundbreaking study opens up new possibilities for those suffering from chronic back discomfort.

Key Findings of the Study

• Participants with the most pro-inflammatory diets had a 42% higher chance of experiencing low back pain
• The study controlled for factors such as physical activity, body mass index (BMI), and education
• The research used data from the 2003-2004 National Health and Nutrition Examination (NHANES) survey
• Diet quality was evaluated using the Dietary Inflammatory Index (DII)

Understanding Inflammation: The Good, The Bad, and The Chronic

Inflammation is a complex biological response that plays a crucial role in our body’s defense mechanisms. However, not all inflammation is created equal. To understand its impact on back pain, it’s essential to differentiate between acute and chronic inflammation.

Acute Inflammation: The Body’s First Line of Defense

Acute inflammation is a necessary and beneficial immune response. It helps the body heal injuries and fight off illnesses. This type of inflammation is typically short-lived and localized to the area of injury or infection.

Chronic Inflammation: The Silent Troublemaker

Chronic inflammation, on the other hand, is a persistent, low-grade inflammatory response that can last for months or even years. This type of inflammation can occur in healthy tissues and has been linked to numerous health issues, including:

• Cancer
• Heart disease
• Diabetes
• Alzheimer’s disease
• Depression
• Arthritis
• Back pain

According to the National Institute of Environmental Health Sciences, chronic inflammation can cause significant damage to the body over time. In the context of back pain, it can contribute to ongoing discomfort and reduced mobility.

The Prevalence of Low Back Pain: A Growing Concern

Low back pain is an increasingly common health issue in the United States. The Centers for Disease Control and Prevention (CDC) reports that one out of every four adults experiences low back pain in a three-month period. This high prevalence underscores the importance of finding effective management strategies, including dietary interventions.

Impact on Quality of Life

Chronic low back pain can significantly impact an individual’s quality of life, affecting their ability to work, engage in physical activities, and enjoy daily life. The potential for dietary changes to alleviate this widespread problem offers hope to millions of sufferers.

Pro-Inflammatory Diets: What to Avoid for a Healthier Back

Understanding what constitutes a pro-inflammatory diet is crucial for those looking to manage their back pain through nutritional changes. Ryanne Lachman, RDN, a registered dietitian at the Cleveland Clinic’s Center for Functional Medicine, provides insights into the components of a pro-inflammatory diet.

The Standard American Diet (SAD): A Recipe for Inflammation

The standard American diet, often abbreviated as SAD, is notorious for its pro-inflammatory effects. This dietary pattern is characterized by:

• High consumption of refined grains
• Excessive intake of sodas and fruit juices
• Frequent consumption of trans fats
• Regular intake of meat from grain-fed animals

These dietary choices can lead to blood sugar problems, weight gain, and increased inflammation throughout the body.

Hidden Sources of Inflammation: Refined Vegetable Oils

Lachman highlights an often-overlooked source of inflammation: refined vegetable oils. These include:

• Soybean oil
• Vegetable oil
• Corn oil

These oils undergo extensive processing and contain high levels of omega-6 fats, which are inherently pro-inflammatory. They are commonly used in cooking and are prevalent in many baked goods.

The Anti-Inflammatory Diet: A Path to Reduced Back Pain

While certain foods can promote inflammation, others have the power to combat it. An anti-inflammatory diet may be the key to reducing back pain and improving overall health.

Components of an Anti-Inflammatory Diet

Tonelli Enrico suggests that an anti-inflammatory diet should include:

• Whole grains
• Abundant fruits and vegetables
• Foods similar to those found in the Mediterranean diet

This dietary approach focuses on nutrient-dense, minimally processed foods that have been shown to reduce inflammation in the body.

The Mediterranean Diet: A Model for Anti-Inflammatory Eating

The Mediterranean diet, often cited as one of the healthiest eating patterns in the world, serves as an excellent model for an anti-inflammatory diet. It emphasizes:

• Fresh fruits and vegetables
• Whole grains
• Lean proteins, especially fish
• Healthy fats, such as olive oil and nuts
• Limited red meat consumption

By adopting elements of this diet, individuals may be able to reduce their risk of back pain and improve their overall health.

Implementing Dietary Changes: Practical Tips for Back Pain Relief

Making significant changes to one’s diet can be challenging, but the potential benefits for back pain sufferers make it a worthwhile endeavor. Here are some practical tips for implementing an anti-inflammatory diet:

1. Gradually increase your intake of fruits and vegetables
2. Choose whole grains over refined grains
3. Incorporate more fatty fish, such as salmon or mackerel, into your diet
4. Use olive oil as your primary cooking oil
5. Snack on nuts and seeds instead of processed snacks
6. Limit your consumption of red meat and processed foods
7. Reduce your intake of sugary beverages and opt for water or herbal tea

The Importance of Consistency

It’s important to note that dietary changes may take time to show significant effects on back pain. Consistency is key when adopting an anti-inflammatory diet. Patients should commit to these dietary changes for several weeks or months to fully experience the potential benefits.

Beyond Diet: A Holistic Approach to Back Pain Management

While diet plays a crucial role in managing back pain, it’s important to remember that it’s just one piece of the puzzle. A comprehensive approach to back pain management should include:

• Regular exercise and physical activity
• Proper posture and ergonomics
• Stress management techniques
• Adequate sleep
• Professional medical advice and treatment when necessary

Combining these strategies with an anti-inflammatory diet can provide a powerful toolkit for managing and potentially reducing back pain.

The Future of Dietary Interventions for Back Pain

The research linking diet to back pain is still in its early stages, but the initial findings are promising. As more studies are conducted, we may gain a deeper understanding of how specific foods and dietary patterns impact back pain and overall inflammation in the body.

Personalized Nutrition for Back Pain

Future research may lead to more personalized nutritional recommendations for back pain sufferers. Factors such as individual genetic makeup, gut microbiome composition, and specific types of back pain may all play a role in determining the most effective dietary interventions for each person.

Integrating Dietary Advice into Back Pain Treatment

As the evidence for dietary interventions grows stronger, we may see more healthcare providers incorporating nutritional advice into their treatment plans for back pain. This could lead to a more holistic and effective approach to managing this common condition.

In conclusion, the emerging research on the link between diet and back pain offers new hope for those suffering from this widespread condition. By adopting an anti-inflammatory diet and making mindful food choices, individuals may be able to reduce their risk of back pain and improve their overall quality of life. As always, it’s important to consult with healthcare professionals before making significant changes to your diet or treatment plan.

Anti-inflammatory Diet Could Help Reduce Low Back Pain

If you’re one of the millions of Americans with low back pain, chances are you’ve tried a variety of lifestyle adjustments and remedies to improve your symptoms. Although it may help to upgrade to a high-tech mattress or an ergonomic office chair, new research suggests that you may be able to improve your back pain via a less obvious (and less expensive) route: by changing the foods you eat every day.

The research, presented at the February 2021 Association of Academic Physiatrists (AAP) digital conference, found a link between what people ate and their chances of having low back pain.

“Our findings suggest that diets that are more anti-inflammatory tend to be better for back pain,” says Valerio Tonelli Enrico, a physical therapist, research assistant, and doctoral student at the University of Pittsburgh, who presented the findings.

“An anti-inflammatory diet would include whole grains and lots of fruits and vegetables — similar to the Mediterranean diet,” Tonelli Enrico says.

Chronic Inflammation’s Role in Disease and Pain

Inflammation isn’t always a bad thing: Acute inflammation is actually an important immune response that helps heal injuries or fight illness. But chronic inflammation — inflammation that occurs in healthy tissues or that lasts for months or years — can cause damage and contribute to many chronic diseases, including cancer, heart disease, diabetes, Alzheimer’s disease, and depression, according to the National Institute of Environmental Health Sciences. Chronic inflammation can also play a role in conditions such as arthritis or back pain.

Low back pain is the most common type of pain reported in the United States; one out of every four adults report having low back pain in the previous three months, according to the Centers for Disease Control and Prevention (CDC).

RELATED: Best Home Remedies for Low Back Pain: Advice From a Physical Therapist

Low Back Pain Is More Likely in People With a Pro-inflammatory Diet

The study used data from the 2003–2004 National Health and Nutrition Examination (NHANES) survey database and included 3,966 subjects. The incidence of back pain was assessed by whether or not a participant had experienced low back pain at any time in the three months before the survey.

Diet was evaluated through a survey in which participants were asked to recall all the foods they ate in a 24-hour period. Researchers used the Dietary Inflammatory Index (DII), a measure based on nearly 2,000 studies on different foods and their effect on different inflammatory markers, according to a paper published in 2019 in Advances in Nutrition.

A DII score was assigned to each participant in the trial on the basis of the foods they reported eating; the higher the score, the more likely the diet was considered “pro-inflammatory,” or likely to cause inflammation.

Researchers ranked the participants and placed them into quartiles according to their DII score. People in the top quartile, who had the most inflammatory diet, had a 42 percent higher chance of having low back pain compared with the group with the least pro-inflammatory diet.

“From my clinical experience, these findings make sense,” says Ryanne Lachman, RDN, a registered dietitian with the Center for Functional Medicine at Cleveland Clinic in Ohio. “We do commonly see pain associated with inflammation,” she says.

“A 42 percent higher chance of having low back pain with a pro-inflammatory diet is absolutely significant and worth paying attention to,” says Lachman. The DII measurement tool and the inflammatory biomarkers the researchers used are both reliable sources of information, she says.

“The researchers controlled for physical activity, body mass index (BMI), and education, which adds some weight to their findings,” says Lachman. Low back pain can be associated with a higher BMI, and so it’s meaningful that the improvements weren’t just because some people on a low-inflammatory diet weighed less, she adds.

RELATED: U.S. News & World Report’s Best and Worst Diets of 2021

What Is a Pro-Inflammatory Diet?

Many of the foods that increase inflammation, or are “pro-inflammatory,” can be found in the standard American diet, also known as the SAD diet, says Lachman. “This is a diet where we consume mainly refined grains that are too easily absorbed and create lingering blood sugar problems and weight gain,” she says. Sodas, fruit juices, trans fats, and meat from grain-fed animals can be pro-inflammatory as well, says Lachman.

“One source of inflammation that I think a lot of people don’t realize are refined vegetable oils such as soybean oil, vegetable oil, and corn oil. They’ve all gone through a high level of processing, and they contain omega-6 fats which are inherently pro-inflammatory,” she says. These oils are not only used in cooking, but often used in baked goods such as cookies or cupcakes.

“Some of these things aren’t outright harmful in small doses, but when we have them embedded in every product, every processed food, and every restaurant uses them, that’s when chronic inflammation can ensue — from chronic exposure,” says Lachman.

RELATED: Good Fats vs. Bad Fats: Everything You Should Know About Fats and Heart Health

Anti-Inflammatory Diet More Likely to Improve Back Pain Related to Inflammation

For this study, everyone who had experienced lower back pain within a three-month period was included in the study, no matter what the cause.

“Low back pain is a complex syndrome that be caused by many different issues, and not all these individuals who experienced low back pain had inflammation as a main driving cause. Some people might have back pain because of an injury or mechanical issue,” says Tonelli Enrico.

Inflammatory back pain is typically caused by a form of inflammatory arthritis, such as ankylosing spondylitis or psoriatic arthritis, according to the National Institute of Neurological Disorders and Stroke.

Mechanical causes of back pain can result from such things as sleeping on a bad mattress, straining your back during a workout, or being injured in a fall or a car accident.

“If we can zero in on the subset of people with back pain where inflammation is the most important factor, I think that an anti-inflammatory diet might even make a bigger difference in reducing the likelihood of lower back pain,” he says.

Expert Tips on Reducing Inflammation in Your Diet

Although diet may help improve pain, people shouldn’t think that food has the immediate effect that pain medications may provide, says Lachman. “If you change your diet and don’t feel different in the short-term, don’t get discouraged,” she says.

Following an anti-inflammatory diet isn’t just about eliminating foods that cause inflammation, says Lachman. “We also need to eat enough of the kinds of foods that will reduce the triggers for inflammation.”

• Eat lots of colorful fruits and vegetables. “If pain reduction is the primary goal, eating 4 to 6 cups of colorful vegetables and fruits without any added sugars will essentially guarantee a supply of anti-inflammatory nutrients, along with many other benefits,” says Lachman. “This should mostly be veggies, especially things in the cruciferous family such as watercress, broccoli, and arugula; they have really strong anti-inflammatory benefits,” she adds.
• Consuming more omega-3s can help offset omega-6s. “I suggest steering clear of refined oils altogether, but increasing omega-3s can help provide a more anti-inflammatory balance of those oils,” says Lachman. Research, including a paper published in November 2018 in the BMJ, shows that increasing omega-3 consumption while reducing omega-6 consumption reduces the inflammatory response of a high-fat meal. “My suggestions for upping omega-3 intake would include cold-water fish like salmon, sardines, and cod. Plant-based options can include hemp, flax, or chia seeds,” says Lachman.
• Prepare foods with anti-inflammatory spices. Spices such as ginger, cinnamon, and cayenne can be used to decrease inflammation, as well. Turmeric is another good example of this; you can use it in savory foods or add it to a smoothie, says Lachman.

The way you cook certain foods can also worsen inflammation. A 2017 meta-analysis published in Scientific Reports found that frying, roasting, microwaving, searing, or grilling meats, fish, and eggs produces compounds called advanced glycation end products (AGEs).

Although your body produces AGEs naturally and they are found in raw animal products, cooking, especially at high temperatures, forms new AGEs. High levels of the compounds in tissues and blood can trigger an inflammatory response and are suspected to increase inflammation in the body.

To limit this effect, try preparing meat dishes that call for steaming, simmering, or braising, and cut down on processed foods, which have often been exposed to a high cooking temperature to increase their shelf life, according to the Arthritis Foundation.

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Relieving back pain with what you eat

Back pain is one of the most common ailments and it almost always comes with inflammation. It can occur as a result of an injury, poor posture, a too-soft mattress, or improper sleeping position. Luckily, there are ways that inflammation can be remedied. Lifestyle and diet modifications, like adopting a Mediterranean Diet, or eating a plant-based diet, often helps to reduce inflammation in the spine and joints by decreasing pro-inflammatory foods and adding anti-inflammatory foods to your diet.

Inflammation can be triggered by what we eat. Some examples of food that may increase or trigger inflammation, also known as pro-inflammatory foods, are:

• Saturated fats – red meat (especially grain fed animals) and whole fat dairy
• Trans fats – hydrogenated oils seen in baked goods/crackers
• Omega 6 – corn oil, safflower oil, soybean oil, sunflower oil
• Sugar – table sugar and other simple carbohydrates such as cake, white rice and bread

Eating a well-balanced diet comprised of a variety of whole, colorful foods can help reduce inflammatory markers. Some examples of anti-inflammatory foods are:

• Omega 3 – canola oil, walnuts, fish
• Monounsaturated fats – olive oil, peanut oil, nuts, avocado
• Fruits and vegetables
• Whole grains
• Herbs, spices and teas – ginger, turmeric, oregano, sage, cinnamon, cloves, rosemary and green tea

When selecting food to eat, think about including all the colors of the “rainbow” in your shopping cart. Not only will eating these foods provide anti-inflammatory benefits, but they’ll also increase your intake of vital antioxidants. Here’s our starter guide to anti-inflammatory foods to try and how you can incorporate them into meals:

1. Avocados
   Avocados are high in monounsaturated fat. They can help to decrease inflammation of the joints and are good for brain health including neurogenerative diseases.
   Meal idea: Eggs with avocado over whole grain toast

2. Fatty fish
   Fish such as sardines, salmon, anchovies and mackerel are high in omega 3 fatty acids. Since we don’t make omega 3 in our bodies, we must get it from food sources. Nutrients found in these fish can help with autoimmune disorders, diabetes and brain health.
   Meal ideas: Salmon burgers, smoked salmon, sardines over salad
3. Cruciferous vegetables
   Veggies like broccoli, cauliflower and Brussel sprouts are high in phytochemicals, antioxidants, vitamin K, vitamin C, magnesium, and fiber. Broccoli in particular helps to protect against cancer and decrease inflammation.
   Meal ideas: Broccoli salad, steamed broccoli, cauliflower rice
4. Garlic
   Garlic helps combat damage caused by free radicals. Free radicals are unstable atoms that can damage cells, causing illness and aging. Garlic also contains quercetin which may help protect against heart disease and cancer as well as stimulate the immune system to fight diseases.
   Meal ideas: Shrimp in garlic sauce, sautéed garlic with swiss chard
5. Ginger
   Ginger helps to decrease pain and inflammation by “turning off” pain receptors. Ginger also improves gut immunity.
   Meal ideas: Scallops with ginger, ginger soup, ginger tea
6. Flax and chia seeds
   These seeds are high in fiber and omega 3’s and can help balance blood sugar levels, improve gut health and fight free radicals.
   Meal ideas: Add to shakes, yogurt, and salads
7. Berries
   Berries contain anthocyanins which act as antioxidants to help fight free radicals and may offer anti-inflammatory, anti-viral and cancer-fighting benefits.
   Meal ideas: Add to shakes, yogurt, and salads, or have on their own as a snack

David J. BenEliyahu, DC, DAAPM, DABCSP is the Administrative Director of the Back & Neck Pain Center at Mather Hospital. 

Nicole Drepaniotis, MBA, MS, RDN, CSOWM, CDN, is a Registered Dietitian Nutritionist and Nutrition Education Coordinator in Mather Hospital’s Center of Excellence in Metabolic & Bariatric Surgery.

Diet, nutrition in diseases of the back and joints

Many diseases of the musculoskeletal system are often caused by metabolic disorders in the human body, which are often the result of malnutrition. Consider how food can affect the functioning of the musculoskeletal system.

1. The intra-articular fluid has the most alkaline pH-7.74.

   When it changes to the acidic side, cartilage is malnourished, accumulation of under-oxidized products and uric acid salts, which leads to premature wear of cartilage tissue. Therefore, in the diet, it is necessary to limit the consumption of products that lead to acidification of the internal environment of the body, namely: meat, flour, sweet and canned foods. Alkalinization and restoration of the pH of the joints contribute to: dairy products, vegetables and fruits (especially fresh).

2. Formation of uric acid salts.

   When eating protein foods, uric acid salts are formed in the body, which is then excreted through the organs of the excretory system (liver, kidneys). With excessive intake of protein or in violation of the function of internal organs, additional ways of its excretion open: skin, mucous membranes, including the synovial membranes of the joints. This contributes to the accumulation of uric acid salts in the joint cavity, in periarticular tissues, as well as the formation of stones in the internal organs, in the oral cavity (tartar).

   Prevention consists in observing the norm of daily protein intake – no more than 80-100 g per day, limiting meat products. It should be borne in mind that a lot of protein is found in dairy products, cereals, cereals, nuts, and legumes.

3. The use of essential macro- and microelements, vitamins.

   Sulfur is an important element in the construction of collagen and elastin fibers. Its sufficient intake contributes to the timely restoration and renewal of cartilage tissue. A lot of sulfur is found in legumes.

   Calcium is an important building block of bone tissue. Found in dairy products, cheese, spinach, beans, nuts.

   Vitamin D3 improves the absorption of calcium by bone tissue. It is formed in the skin during sunburn, and is also found in fish products.

4. Ensuring normal blood circulation in the muscular-articular apparatus. The main causes of blood flow disorders associated with food intake:

• Blood with cholesterol impedes the movement of blood through the vessels, contributes to the formation of cholesterol plaques, which narrow the lumen of the vessels, limit the flow of nutrients to the tissues. Prevention consists in the need to limit the intake of food rich in cholesterol – meat, fatty foods.
• Blood clotting. To eliminate blood clotting, it is necessary to take a sufficient amount of water up to 1.5-2 liters. per day. This amount also includes water contained in food, in first courses.
• Viscous blood containing a large amount of protein that sticks red blood cells together.
• High level of adrenaline, appears if a person is nervous all the time or is at a high level of adrenaline professionally (eg driver, leader, artist, etc.). Adrenaline always constricts blood vessels, contributing to the difficulty of blood flow.
• The presence of toxins in the blood. To remove them, it is necessary to periodically carry out cleansing procedures, observe the correct diet.

Resume . For normal operation and prevention of diseases of the musculoskeletal system, it is necessary to adhere to a dairy-vegetarian diet, while limiting meat and sweet foods. It is also necessary to limit the total amount of food, do not overeat. Do physical education. Purify the body and normalize the functioning of internal organs with the help of diet and herbal medicine.

Back pain and diet

Lose weight

In case of back pain, the attending physician will definitely recommend a diet to a patient with overweight in order to reduce excess weight and reduce the load on the musculoskeletal system (spine and joints).

In practice, body mass index (BMI) is used to determine overweight. If the BMI is from 25 to 29.9, then this indicates excess weight, if the BMI is above 30, it indicates obesity. To get your BMI, you need to divide your weight (in kilograms) by your height (in meters) squared.

To lose weight, you need to follow two golden rules: reduce your calorie intake and introduce moderate exercise into your life. It is very important to understand that you need to seriously change your lifestyle: short-term diets and physical activity allow you to lose weight, but when you return to old habits, the weight will be restored.

The best way is to make small changes in your lifestyle and stick to them. Then you can gradually add new changes, which also need to be adhered to.

Currently, there are drugs and surgical interventions that help to reduce body weight, but they are indicated only for people with a high BMI and those who have not been able to lose weight through diet and exercise. But even after surgery, patients must adhere to diet and exercise.

Balance your diet

Many studies have examined the effects of various foods and supplements on back pain. A minor analgesic effect was found in black pepper, turmeric, soybeans, avocado, fish oil, and vitamin D. A review of several studies found positive effects of nutritional supplements such as L-carnitine, curcumin, passion fruit skin extract, collagen hydrolyzate, glucosamine and chondroitin, cytidine and uridine.

Strengthen bones

Several independent studies have shown better results in the treatment of patients with back pain who took fish oil (omega 3 fatty acids) for 2 years. This is most likely due to the anti-inflammatory effects of the acids found in fish oil.

If a patient with back pain has osteoporosis or is at increased risk of developing it, two dietary supplements, calcium supplements and vitamin D, should be added to the diet. The main sources of calcium in the diet are milk and other dairy products such as hard cheese , cottage cheese or yogurt, as well as green vegetables (cabbage and broccoli). Some grains, soy products, and fruit juices are fortified with calcium.

“Give food” to nerve fibers

If the spinal roots are damaged, a persistent pain neuropathic syndrome develops. It is manifested by shooting pain, a crawling sensation in the area for which the damaged nerve is responsible, a burning sensation. Pain syndrome significantly reduces the quality of life: it is difficult to sit and stand, bend over, lead an active lifestyle, do your favorite things.

Neuropathic pain develops against the background of damage to the membrane of the spinal root, which consists of myelin. Against the background of the prescribed treatment, the damaged shell can be restored. Studies have shown that nucleotides, B vitamins, and folic acid play an important role in the restoration of this shell. In the complex therapy of pain in the back, the patient may be recommended to take Keltikan® complex, which contains the nucleotide uridine monophosphate, vitamins B6 and B12, folic acid, which contribute to the restoration and regeneration of the nerve fiber. The drug is prescribed 1 capsule in the morning for at least 20 days.

Thus, the patient with back pain is advised to reduce excess body weight by reducing the caloric intake and introducing moderate physical activity. The diet should be balanced and complete. It is recommended to include foods rich in calcium and B vitamins: soybeans, avocados, milk and other dairy products, hard cheese, cottage cheese, yogurt, green vegetables, cabbage, broccoli, fish, liver, chicken meat, eggs, nuts, legumes , bananas. Use black pepper and turmeric in cooking. Recommended intake of fish oil and vitamin D, L-carnitine, passion fruit skin extract, collagen hydrolyzate, glucosamine and chondroitin, cytidine and uridine.

References

• Torlak MS., Bagcaci S., Akpinar E., Okutan O., Nazli MS., Kuccukturk S. The effect of intermittent diet and/or physical therapy in patients with chronic low back pain: A single-blinded randomized controlled trial. // Explore (NY) – 2020 – Vol – NNULL – p.; PMID:32859542
• Bowman M.A., Neale A.V., Seehusen D.A. New Research on Back Pain, Diet and Diabetes, Advanced Care Planning, and Other Issues Frequently Seen in Family Medicine. // J Am Board Fam Med – 2020 – Vol32 – N6 – p.