The Effectiveness of Intermittent Fasting, Time Restricted Feeding, Caloric Restriction, a Ketogenic Diet and the Mediterranean Diet as Part of the Treatment Plan to Improve Health and Chronic Musculoskeletal Pain: A Systematic Review
Abstract
:1. Introduction
2. Method
2.1. Study Design
2.2. Search Strategy
2.2.1. Eligibility Criteria
2.2.2. Study Selection
2.2.3. Data Extraction
2.3. Deviation from the Protocol
2.4. Assessment of Methodological Quality
2.4.1. Assessment of the Methodological Quality of RCTs
2.4.2. Assessment of the Methodological Quality of Observational Studies
2.4.3. Qualitative Synthesis of the Selected Observational Studies
3. Results
3.1. Study Selection
3.2. Assessment of Methodological Quality
3.3. Study Instruments
3.3.1. Pain
3.3.2. Inflammation
3.3.3. Quality of Life
- -
- Visual Analogue Scale (VAS): a scale used to measure pain. It consists of a horizontal or a vertical line that represents the pain intensity with a score from 0 to 10, where the number 0 is synonymous with “no pain” and 10 is synonymous with “very intense pain/worst pain imaginable” [43].
- -
- SF-36: a tool for the evaluation of Health-Related Quality of Life (HRQoL). Scale applicable to any population. It contains 36 items that lead to the assessment of a positive and a negative quality of life. These questions are divided into eight scales in which physical function, physical role, bodily pain, general health, vitality, social function, emotional role, and mental health are questioned [44].
- -
- Functional Assessment of Cancer Therapy (FACT-G): a quality of life assessment scale. This questionnaire is made up of 27 items that collect, on four scales, the values of physical state, family and social environment, emotional state, and functional capacity. Each item has a value of 0 to 4 points [45].
- -
- Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F): a questionnaire related to health and quality of life associated with chronic pain illnesses. It consists of 27 general questions that encompass physical well-being, family/social well-being, emotional well-being, and functional well-being [46].
- -
- Functional Assessment of Chronic Illness Therapy-Trial Outcome Index (FACIT-TOI): a calculator for any illness, treatment or condition scale. An appraisal criterion that is normally used in clinical trials since it responds to physical and to functional changes [46].
- -
- Fibromyalgia Survey Questionnaire (FSQ): a questionnaire for the evaluation of symptoms in people suffering from fibromyalgia. It incorporates the WPI scale and the modification of the SSS [47].
- -
- Arthritis Impact Measurement Scales 2 (AIMS2-SF): a questionnaire that assesses physical, mental, and social conditions based on nine scales: mobility, physical activity, stroke, dexterity, household activities, pain, social activity, depression, and anxiety. Each scale is made up of four to seven items. The overall score ranges from 0 to 10 points [48].
- -
- Numerical Pain Scale (NPRS): a one-dimensional tool for measuring pain in adults, consisting of 11 items. It is a version of the VAS scale that has scores from 0 to 10, with 0 being synonymous with “no pain” and 10 being “the most intense pain imaginable” [43].
- -
- Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a specific questionnaire for the measurement and the evaluation of pain, stiffness, and functional capacity in knee and hip osteoarthritic disease. It is composed of three scales (pain, stiffness, and functional capacity), which includes 24 items. The items are answered verbally using a scale which has five levels (0–4), ranging from little to a lot [49].
- -
- EuroQoL-5D (EQ-5D):an assessment of the standard of living in Europe. It consists of five questions about mobility, personal care, day-to-day activities, pain/discomfort, and anxiety/depression [50].
- -
- Health Assessment Questionnaire (HAQ): a questionnaire used to calculate the health of people with rheumatoid arthritis. It quantifies gastropathy, risk factors, and the risk of death in rheumatoid arthritis [51].
- -
- Patient Global Assessment (PGA): one of the most used assessments in rheumatoid arthritis. It is based on a question related to general health or disease activity that has a numerical answer from 0 to 10 or 0 to 100 [52].
- -
- Short-Form Health Outcome Survey (SF-12): a survey comprised of 12 questions that evaluates health in relation to quality of life [53].
- -
- Knee Injury and Osteoarthritis Outcome Score (KOOS): this separately evaluates pain (9 items), symptoms (7 items), ADL function (17 items), sport and recreation functioning (5 items), and quality of life (4 items). Each item can be scored on a scale of 0 to 4 [54].
- -
- Disease Activity Score on 28 joints (DAS28): a system to evaluate the activity of the disease and the treatment response in rheumatoid arthritis. The stipulated limit for an increase in treatment is 3.2 [51].
- -
- Simple Disease Activity Index (SDAI): a system to evaluate, at any time or place, the activity of rheumatoid arthritis. Doctors can choose the evaluation tool that best fits the environment they find themselves in [55].
- -
- Rheumatic Arthritis Impact of Disease (RAID): this evaluates pain, functional impairment, fatigue, sleep, and physical and emotional functioning in patients with rheumatoid arthritis. It is a validated tool that is highly trustworthy and sensitive to change [56].
- -
- Healthy Eating Index 2015 (HEI-2015): a measuring tool to evaluate whether certain food groups follow the Dietary Guidelines for Americans (DGA). Each time a new DGA is published, the HEI is updated. In comparison to the 2010 update, the 2015 version included specific recommendations on the limitation of added sugars and saturated fats [57].
3.4. Intermittent Fasting
3.5. Time Restricted Feeding
3.6. Caloric Restriction
3.7. Ketogenic Diet
3.8. Mediterranean Diet
4. Discussion
4.1. Effects and Benefits of Dietary Strategies on Chronic Musculoskeletal Pain
4.2. Effects and Benefits of Dietary Strategies on Quality of Life in Those Suffering from Chronic Pain
4.3. Strengths and Weaknesses of the Study
4.4. Clinical Application of the Results and Future Research Lines
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Abbreviations
ADL | Activities of Daily Living |
AIMS2-SF | Arthritis Impact Measurement Scales 2 |
ALT | Alanine Transminase |
AST | Asparate Aminotransferase |
BMI | Body mass index |
BUN | Blood Urea Nitrogen |
CG | Control Group |
CINAHL | Cumulative Index to Nursing & Allied Health Literature |
CNS | Central Nervous System |
DHA | Docosahexaenoic Acid |
DNA | Deoxyribonucleic Acid |
EG | Experimental Group |
EPA | Eicosapentaenoic Acid |
FACT-G | Functional Assessment of Cancer Therapy—General |
FSQ | Fibromyalgia Survey Questionnaire |
HDL | High Density Lipoprotein |
HRQL | Generic health-related quality of life |
IVS | Internal Validity Score |
LDL | Low Density Lipoprotein |
MeSH | Medical Subject Headings |
NPRS | Numeric Pain Rating Scale |
PRISMA | Preferred Reporting Items for Systematic Reviews and Meta-Analyses |
RCTs | Randomized Clinical Trials |
RMI | Magnetic Resonance Imaging |
SF-36 | Health Questionnaire |
SIRT3 | Sirtuin 3 |
SSS | Symptom Severity Scale |
TC | Total Cholesterol |
TG | Triglyceride |
VAS | Visual analogue Scale |
VO2 Max | Maximum Oxygen Volume |
WPI | Widespread Pain Index |
WOMAC | Western Ontario and McMaster Universities Osteoarthritis Index |
References
- Nijs, J.; D’Hondt, E.; Clarys, P.; Deliens, T.; Polli, A.; Malfliet, A.; Coppieters, I.; Willaert, W.; Tumkaya Yilmaz, S.; Elma, Ö.; et al. Lifestyle and Chronic Pain across the Lifespan: An Inconvenient Truth? PMR 2020, 12, 410–419. [Google Scholar] [CrossRef]
- Nijs, J.; Leysen, L.; Vanlauwe, J.; Logghe, T.; Ickmans, K.; Polli, A.; Malfliet, A.; Coppieters, I.; Huysmans, E. Treatment of central sensitization in patients with chronic pain: Time for change? Expert Opin. Pharmacother. 2019, 20, 1961–1970. [Google Scholar] [CrossRef] [PubMed]
- Puntillo, F.; Giglio, M.; Paladini, A.; Perchiazzi, G.; Viswanath, O.; Urits, I.; Sabbà, C.; Varrassi, G.; Brienza, N. Pathophysiology of musculoskeletal pain: A narrative review. Ther. Adv. Musculoskelet. Dis. 2021, 13, 1759720X2199506. [Google Scholar] [CrossRef]
- Mills, S.E.E.; Nicolson, K.P.; Smith, B.H. Chronic pain: A review of its epidemiology and associated factors in population-based studies. Br. J. Anaesth. 2019, 123, e273–e283. [Google Scholar] [CrossRef] [PubMed]
- Scholz, J.; Finnerup, N.B.; Attal, N.; Aziz, Q.; Baron, R.; Bennett, M.I.; Benoliel, R.; Cohen, M.; Cruccu, G.; Davis, K.D.; et al. The IASP classification of chronic pain for ICD-11: Chronic neuropathic pain. Pain 2019, 160, 53–59. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Lee, J.Y.; Lee, G.J.; Lee, P.R.; Won, C.H.; Kim, D.; Kang, Y.; Oh, S.B. The analgesic effect of refeeding on acute and chronic inflammatory pain. Sci. Rep. 2019, 9, 16873. [Google Scholar] [CrossRef]
- Bushnell, M.; Čeko, M.; Low, L. Cognitive and emotional control of pain and its disruption in chronic pain. Nat. Rev. Neurosci. 2013, 14, 502–511. [Google Scholar] [CrossRef] [Green Version]
- Sommer, C.; Leinders, M.; Üçeyler, N. Inflammation in the pathophysiology of neuropathic pain. Pain 2018, 159, 595–602. [Google Scholar] [CrossRef]
- Prasad, J.D.; Gunn, K.C.; Davidson, J.O.; Galinsky, R.; Graham, S.E.; Berry, M.J.; Bennet, L.; Gunn, A.J.; Dean, J.M. Anti-Inflammatory Therapies for Treatment of Inflammation-Related Preterm Brain Injury. Int. J. Mol. Sci. 2021, 22, 4008. [Google Scholar] [CrossRef]
- Elma, Ö.; Yilmaz, S.T.; Deliens, T.; Coppieters, I.; Clarys, P.; Nijs, J.; Malfliet, A. Do Nutritional Factors Interact with Chronic Musculoskeletal Pain? A Systematic Review. J. Clin. Med. 2020, 9, 702. [Google Scholar] [CrossRef] [Green Version]
- Sjaarda, L.A.; Radin, R.G.; Swanson, C.; Kuhr, D.L.; Mumford, S.L.; Galai, N.; Silver, R.M.; Wactawski-Wende, J.; Perkins, N.J.; Schisterman, E.F. Prevalence and Contributors to Low-grade Inflammation in Three U.S. Populations of Reproductive Age Women. Paediatr. Perinat. Epidemiol. 2018, 32, 55–67. [Google Scholar] [CrossRef] [Green Version]
- Owen, L.; Corfe, B. The role of diet and nutrition on mental health and wellbeing. Proc. Nutr. Soc. 2017, 76, 425–426. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Totsch, S.K.; Waite, M.E.; Tomkovich, A.; Quinn, T.L.; Gower, B.A.; Sorge, R.E. Total Western Diet Alters Mechanical and Thermal Sensitivity and Prolongs Hypersensitivity Following Complete Freund’s Adjuvant in Mice. J. Pain 2016, 17, 119–125. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Nijs, J.; Elma, Ö.; Yilmaz, S.T.; Mullie, P.; Vanderweeën, L.; Clarys, P.; Deliens, T.; Coppieters, I.; Weltens, N.; Van Oudenhove, L.; et al. Nutritional neurobiology and central nervous system sensitisation: Missing link in a comprehensive treatment for chronic pain? Br. J. Anaesth. 2019, 123, 539–543. [Google Scholar] [CrossRef] [PubMed]
- Manchishi, S.M.; Cui, R.J.; Zou, X.H.; Cheng, Z.Q.; Li, B.J. Effect of caloric restriction on depression. J. Cell. Mol. Med. 2018, 22, 2528–2535. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Pace, L.A.; Crowe, S.E. Complex Relationships Between Food, Diet, and the Microbiome. Gastroenterol. Clin. N. Am. 2016, 45, 253–265. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Masino, S.A.; Ruskin, D.N. Ketogenic diets and pain. J. Child Neurol. 2013, 28, 993–1001. [Google Scholar] [CrossRef] [Green Version]
- Elma, Ö.; Yilmaz, S.T.; Deliens, T.; Clarys, P.; Nijs, J.; Coppieters, I.; Polli, A.; Malfliet, A. Chronic Musculoskeletal Pain and Nutrition: Where Are We and Where Are We Heading? PMR 2020, 12, 1268–1278. [Google Scholar] [CrossRef]
- Sibille, K.T.; Bartsch, F.; Reddy, D.; Fillingim, R.B.; Keil, A. Increasing neuroplasticity to bolster chronic pain treatment: A role for intermittent fasting and glucose administration? J. Pain 2016, 17, 275–281. [Google Scholar] [CrossRef] [Green Version]
- Caristia, S.; De Vito, M.; Sarro, A.; Leone, A.; Pecere, A.; Zibetti, A.; Filigheddu, N.; Zeppegno, P.; Prodam, F.; Faggiano, F.; et al. Is Caloric Restriction Associated with Better Healthy Aging Outcomes? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2020, 12, 2290. [Google Scholar] [CrossRef]
- Pureza, I.R.D.O.M.; Macena, M.d.L.; da Silva Junior, A.E.; Praxedes, D.R.S.; Vasconcelos, L.G.L.; Bueno, N.B. Effect of early time-restricted feeding on the metabolic profile of adults with excess weight: A systematic review with meta-analysis. Clin. Nutr. 2021, 40, 1788–1799. [Google Scholar] [CrossRef] [PubMed]
- Adafer, R.; Messaadi, W.; Meddahi, M.; Patey, A.; Haderbache, A.; Bayen, S.; Messaadi, N. Food Timing, Circadian Rhythm and Chrononutrition: A Systematic Review of Time-Restricted Eating’s Effects on Human Health. Nutrients 2020, 12, 3770. [Google Scholar] [CrossRef] [PubMed]
- D’Andrea Meira, I.; Romão, T.T.; Do Prado, H.J.P.; Krüger, L.T.; Pires, M.E.P.; Da Conceição, P.O. Ketogenic diet and epilepsy: What we know so far. Front. Neurosci. 2019, 13, 5. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Alsharairi, N.A. The role of short-chain fatty acids in mediating very low-calorie ketogenic diet-infant gut microbiota relationships and its therapeutic potential in obesity. Nutrients 2021, 13, 3702. [Google Scholar] [CrossRef] [PubMed]
- Welch, V.; Petticrew, M.; Tugwell, P.; Moher, D.; O’Neill, J.; Waters, E.; White, H. Extensión PRISMA-Equidad 2012: Guías para la escritura y la publicación de revisiones sistemáticas enfocadas en la equidad en salud. Rev. Panam. Salud Publica 2013, 34, 60–67. [Google Scholar]
- Maher, C.G.; Sherrington, C.; Herbert, R.D.; Moseley, A.M.; Elkins, M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys. Ther. 2003, 83, 713–721. [Google Scholar] [CrossRef] [Green Version]
- Harrison, R.; Jones, B.; Gardner, P.; Lawton, R. Correction to: Quality assessment with diverse studies (QuADS): An appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multimethod studies. BMC Health Serv. Res. 2021, 21, 231. [Google Scholar] [CrossRef]
- Wegman, M.P.; Guo, M.H.; Bennion, D.M.; Shankar, M.N.; Chrzanowski, S.M.; Goldberg, L.A.; Xu, J.; Williams, T.A.; Lu, X.; Hsu, S.I.; et al. Practicality of Intermittent Fasting in Humans and its Effect on Oxidative Stress and Genes Related to Aging and Metabolism. Rejuvenation Res. 2015, 18, 162–172. [Google Scholar] [CrossRef] [Green Version]
- Harder-Lauridsen, N.M.; Nielsen, S.T.; Mann, S.P.; Lyngbæk, M.P.; Benatti, F.B.; Langkilde, A.R.; Law, I.; Wedell-Neergaard, A.S.; Thomsen, C.; Møller, K.; et al. The effect of alternate-day caloric restriction on the metabolic consequences of 8 days of bed rest in healthy lean men: A randomized trial. J. Appl. Physiol. 2017, 122, 230–241. [Google Scholar] [CrossRef]
- Bauersfeld, S.P.; Kessler, C.S.; Wischnewsky, M.; Jaensch, A.; Steckhan, N.; Stange, R.; Kunz, B.; Brückner, B.; Sehouli, J.; Michalsen, A. The effects of short-term fasting on quality of life and tolerance to chemotherapy in patients with breast and ovarian cancer: A randomized cross-over pilot study. BMC Cancer 2018, 18, 476. [Google Scholar] [CrossRef]
- Liu, B.; Hutchison, A.T.; Thompson, C.H.; Lange, K.; Heilbronn, L.K. Markers of adipose tissue inflammation are transiently elevated during intermittent fasting in women who are overweight or obese. Obes. Res. Clin. Pract. 2019, 13, 408–415. [Google Scholar] [CrossRef] [PubMed]
- Cohen, C.W.; Fontaine, K.R.; Arend, R.C.; Gower, B.A. A Ketogenic Diet Is Acceptable in Women with Ovarian and Endometrial Cancer and Has No Adverse Effects on Blood Lipids: A Randomized, Controlled Trial. Nutr. Cancer 2020, 72, 584–594. [Google Scholar] [CrossRef] [PubMed]
- Stekovic, S.; Hofer, S.J.; Tripolt, N.; Aon, M.A.; Royer, P.; Pein, L.; Stadler, J.T.; Pendl, T.; Prietl, B.; Url, J.; et al. Alternate Day Fasting Improves Physiological and Molecular Markers of Aging in Healthy, Non-obese Humans. Cell Metab. 2019, 30, 462–476.e5. [Google Scholar] [CrossRef]
- Khodabakhshi, A.; Akbari, M.E.; Mirzaei, H.R.; Mehrad-Majd, H.; Kalamian, M.; Davoodi, S.H. Feasibility, Safety, and Beneficial Effects of MCT-Based Ketogenic Diet for Breast Cancer Treatment: A Randomized Controlled Trial Study. Nutr. Cancer 2020, 72, 627–634. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Vadell, A.K.E.; Bärebring, L.; Hulander, E.; Gjertsson, I.; Lindqvist, H.M.; Winkvist, A. Anti-inflammatory Diet in Rheumatoid Arthritis (ADIRA)—A randomized, controlled crossover trial indicating effects on disease activity. Am. J. Clin. Nutr. 2020, 111, 1203–1213. [Google Scholar] [CrossRef] [Green Version]
- Khodabakhshi, A.; Seyfried, T.N.; Kalamian, M.; Beheshti, M.; Davoodi, S.H. Does a ketogenic diet have beneficial effects on quality of life, physical activity or biomarkers in patients with breast cancer: A randomized controlled clinical trial. Nutr. J. 2020, 19, 87. [Google Scholar] [CrossRef]
- Holton, K.F.; Kirkland, A.E.; Baron, M.; Ramachandra, S.S.; Langan, M.T.; Brandley, E.T.; Baraniuk, J.N. The low glutamate diet effectively improves pain and other symptoms of gulf war illness. Nutrients 2020, 12, 2593. [Google Scholar] [CrossRef]
- Che, T.; Yan, C.; Tian, D.; Zhang, X.; Liu, X.; Wu, Z. Time-restricted feeding improves blood glucose and insulin sensitivity in overweight patients with type 2 diabetes: A randomised controlled trial. Nutr. Metab. 2021, 18, 88. [Google Scholar] [CrossRef]
- Veronese, N.; Stubbs, B.; Noale, M.; Solmi, M.; Luchini, C.; Maggi, S. Adherence to the Mediterranean diet is associated with better quality of life: Data from the Osteoarthritis Initiative. Am. J. Clin. Nutr. 2016, 104, 1403–1409. [Google Scholar] [CrossRef]
- Towery, P.; Guffey, J.S.; Doerflein, C.; Stroup, K.; Saucedo, S.; Taylor, J. Chronic musculoskeletal pain and function improve with a plant-based diet. Complement. Ther. Med. 2018, 40, 64–69. [Google Scholar] [CrossRef]
- Ingegnoli, F.; Schioppo, T.; Scotti, I.; Ubiali, T.; De Lucia, O.; Murgo, A.; Marano, G.; Boracchi, P.; Caporali, R. Adherence to Mediterranean diet and patient perception of rheumatoid arthritis. Complement. Ther. Med. 2020, 52, 102519. [Google Scholar] [CrossRef] [PubMed]
- Ortolá, R.; García-Esquinas, E.; Sotos-Prieto, M.; Struijk, E.A.; Caballero, F.F.; Lopez-Garcia, E.; Rodríguez-Artalejo, F. Mediterranean Diet and Changes in Frequency, Severity, and Localization of Pain in Older Adults: The Seniors-ENRICA Cohorts. J. Gerontol. Ser. A 2022, 77, 122–130. [Google Scholar] [CrossRef] [PubMed]
- Cooper, I.; Brukner, P.; Devlin, B.L.; Reddy, A.J.; Fulton, M.; Kemp, J.L.; Culvenor, A.G. An anti-inflammatory diet intervention for knee osteoarthritis: A feasibility study. BMC Musculoskelet. Disord. 2022, 23, 47. [Google Scholar] [CrossRef] [PubMed]
- Hawker, G.A.; Mian, S.; Kendzerska, T.; French, M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 bps), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res. 2011, 63, S240–S252. [Google Scholar] [CrossRef]
- Lins, L.; Carvalho, F.M. SF-36 total score as a single measure of health-related quality of life: Scoping review. SAGE Open Med. 2016, 4, 205031211667172. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Cella, D.; Hernandez, L.; Bonomi, A.E.; Corona, M.; Vaquero, M.; Shiomoto, G.; Baez, L. Spanish Language Translation and Initial Validation of the Functional Assessment of Cancer Therapy Quality-of-Life Instrument. Med. Care 1998, 36, 1407–1418. [Google Scholar] [CrossRef]
- Webster, K.; Cella, D.; Yost, K. The Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System: Properties, applications, and interpretation. Health Qual. Life Outcomes 2003, 1, 79. [Google Scholar] [CrossRef] [Green Version]
- Carrillo-de-la-Peña, M.T.; Triñanes, Y.; González-Villar, A.; Romero-Yuste, S.; Gómez-Perretta, C.; Arias, M.; Wolfe, F. Convergence between the 1990 and 2010 ACR diagnostic criteria and validation of the Spanish version of the Fibromyalgia Survey Questionnaire (FSQ). Rheumatol. Int. 2015, 35, 141–151. [Google Scholar] [CrossRef]
- Guillemin, F.; Coste, J.; Pouchot, J.; Ghézail, M.; Bregeon, C.; Sany, J. The AIMS2-SF: A short form of the arthritis impact measurement scales 2. Arthritis Rheum. 1997, 40, 1267–1274. [Google Scholar] [CrossRef]
- Bellamy, N.; Buchanan, W.W.; Goldsmith, C.H.; Campbell, J.; Stitt, L.W. Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J. Rheumatol. 1988, 15, 1833–1840. [Google Scholar]
- Balestroni, G.; Bertolotti, G. EuroQol-5D (EQ-5D): An instrument for measuring quality of life. Monaldi Arch. Chest Dis. 2012, 78, 2. [Google Scholar] [CrossRef] [PubMed]
- Jensen Hansen, I.M.; Asmussen Andreasen, R.; Van Bui Hansen, M.N.; Emamifar, A. The reliability of disease activity score in 28 joints-c-reactive protein might be overestimated in a subgroup of rheumatoid arthritis patients, when the score is solely based on subjective parameters: A cross-sectional, exploratory study. J. Clin. Rheumatol. 2017, 23, 102–106. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Nikiphorou, E.; Radner, H.; Chatzidionysiou, K.; Desthieux, C.; Zabalan, C.; van Eijk-Hustings, Y.; Dixon, W.G.; Hyrich, K.L.; Askling, J.; Gossec, L. Patient global assessment in measuring disease activity in rheumatoid arthritis: A review of the literature. Arthritis Res. Ther. 2016, 18, 251. [Google Scholar] [CrossRef] [PubMed]
- Huo, T.; Guo, Y.; Shenkman, E.; Muller, K. Assessing the reliability of the short form 12 (SF-12) health survey in adults with mental health conditions: A report from the wellness incentive and navigation (WIN) study. Health Qual. Life Outcomes 2018, 16, 34. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Roos, E.M.; Roos, H.P.; Lohmander, L.S.; Ekdahl, C.; Beynnon, B.D. Knee Injury and Osteoarthritis Outcome Score (KOOS)—Development of a Self-Administered Outcome Measure. J. Orthop. Sports Phys. Ther. 1998, 28, 88–96. [Google Scholar] [CrossRef]
- Aletaha, D.; Smolen, J.S. The Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI) to monitor patients in standard clinical care. Best Pract. Res. Clin. Rheumatol. 2007, 21, 663–675. [Google Scholar] [CrossRef]
- Mistry, J.; Sharif, M.; Prideaux, A.; Smith, C.; Sumbwanyambe, M.; Sibley, M.; Carpenter, L.; Sweeney, M.; Kiely, P. Use of rheumatoid arthritis impact of disease (RAID) in routine care; identification of DAS28 remission and unmet patient-reported outcomes. Rheumatol. Adv. Pract. 2020, 4, rkaa013. [Google Scholar] [CrossRef]
- Krebs-Smith, S.M.; Pannucci, T.R.E.; Subar, A.F.; Kirkpatrick, S.I.; Lerman, J.L.; Tooze, J.A.; Wilson, M.M.; Reedy, J. Update of the Healthy Eating Index: HEI-2015. J. Acad. Nutr. Diet. 2018, 118, 1591–1602. [Google Scholar] [CrossRef] [Green Version]
- Carter, T.; D’Cunha, N.M.; Georgousopoulou, E.N.; Isbel, S.; Davey, R.; Mellor, D.D.; Kellett, J.; McKune, A.J.; Naumovski, N. Assessing the diet quality of individuals with rheumatic conditions: A cross-sectional study. Rheumatol. Int. 2020, 40, 1439–1448. [Google Scholar] [CrossRef]
- Lowry, E.; Marley, J.; McVeigh, J.G.; McSorley, E.; Allsopp, P.; Kerr, D. Dietary Interventions in the Management of Fibromyalgia: A Systematic Review and Best-Evidence Synthesis. Nutrients 2020, 12, 2664. [Google Scholar] [CrossRef]
- Dragan, S.; Șerban, M.-C.; Damian, G.; Buleu, F.; Valcovici, M.; Christodorescu, R. Dietary Patterns and Interventions to Alleviate Chronic Pain. Nutrients 2020, 12, 2510. [Google Scholar] [CrossRef] [PubMed]
- Field, R.; Pourkazemi, F.; Turton, J.; Rooney, K. Dietary Interventions Are Beneficial for Patients with Chronic Pain: A Systematic Review with Meta-Analysis. Pain Med. 2021, 22, 694–714. [Google Scholar] [CrossRef] [PubMed]
- Brain, K.; Burrows, T.L.; Rollo, M.E.; Chai, L.K.; Clarke, E.D.; Hayes, C.; Hodson, F.J.; Collins, C.E. A systematic review and meta-analysis of nutrition interventions for chronic noncancer pain. J. Hum. Nutr. Diet. 2019, 32, 198–225. [Google Scholar] [CrossRef] [PubMed]
- Paoli, A.; Tinsley, G.; Bianco, A.; Moro, T. The influence of meal frequency and timing on health in humans: The role of fasting. Nutrients 2019, 11, 719. [Google Scholar] [CrossRef] [Green Version]
- Nanri, A.; Kochi, T.; Eguchi, M.; Kabe, I.; Mizoue, T. Demographic and lifestyle correlates of brain-derived neurotrophic factor in a working population: The Furukawa Nutrition and Health Study. Psychiatry Res. 2019, 272, 581–586. [Google Scholar] [CrossRef]
Pubmed |
|
Web of Science |
|
ProQuest |
|
Scopus |
|
CINAHL |
|
Cambridge Core |
|
Oxford Academy |
|
Author, Year | 1 * | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | Total |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Wegman MP. et al., 2015 [27] | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 8/10 Good |
Harder-Lauridsen NM et al., 2016 [28] | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8/10 Good |
Bauersfeld SP et al., 2018 [29] | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 0 | 1 | 1 | 7/10 Good |
Liu B. et al., 2019 [30] | 0 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 6/10 Good |
Cohen CW. et al., 2019 [31] | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 1 | 1 | 5/10 Moderate |
Stekovic S. et al., 2019 [32] | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 6/10 Good |
KhodabakhshiA. et al., 2019 [33] | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 6/10 Good |
Vadell AKE. et al., 2020 [34] | 1 | 1 | 0 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 6/10 Good |
Khodabakhshi A. et al., 2020 [35] | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 5/10 Moderate |
Holton KF et al., 2020 [36] | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 1 | 7/10 Good |
Che T. et al., 2021 [37] | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 9/10 Good |
Author, Year | 2 | 3 | 5 | 6 | 7 | 8 | 9 | PVI |
---|---|---|---|---|---|---|---|---|
Wegman MP. et al., 2015 [27] | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 5/7 Moderate |
Harder-Lauridsen NM. et al., 2016 [28] | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 4/7 Moderate |
Bauersfeld SP et al., 2018 [29] | 1 | 1 | 0 | 0 | 0 | 1 | 0 | 3/7 Limited |
Liu B. et al., 2019 [30] | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 4/7 Moderate |
Cohen CW. et al., 2019 [31] | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 2/7 Limited |
Stekovic S. et al., 2019 [32] | 1 | 0 | 0 | 0 | 1 | 1 | 0 | 3/7 Limited |
Khodabakhshi A. et al., 2019 [33] | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 3/7 Limited |
Vadell AKE. et al., 2020 [34] | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 4/7 Moderate |
Khodabakhshi A. et al., 2020 [35] | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 3/7 Limited |
Holton KF et al., 2020 [36] | 1 | 0 | 1 | 0 | 1 | 1 | 0 | 4/7 Moderate |
Che T. et al., 2021 [37] | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 6/7 Good |
Author, Year | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | Total |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Veronese N. et al., 2016 [38] | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 11/14 Good |
Towery P. et al., 2018 [39] | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 1 | 0 | 1 | 1 | 11/14 Good |
Ingegnoli F. et al., 2020 [40] | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 9/14 Good |
Ortolá R. et al., 2021 [41] | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 0 | 11/14 Good |
Cooper I. et al., 2022 [42] | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 0 | 1 | 0 | 10/14 Good |
Author, Year | Type of Study | Experimental Group Control Group Samples | Interventions | Variables | Results |
---|---|---|---|---|---|
Wegman MP. et al., 2015 [27] | Randomized clinical trial | EG: 12 people Age range men: 22.1–30.05 Average age of men: 22.82 Age range women: 20.05–30.08 Average age women: 24.05 Average BMI for men: 25.32 Average BMI women: 22.77 CG: 12 people Age range of men: 22.1–30.05 Average age of men: 22.82 Age range of women: 20.05–30.08 Average age of women: 24.05 Average BMI for men: 25.32 Average BMI for women: 22.77 | EG: progressed to intermittent fasting for 3 weeks CG: for 3 weeks, progressed to intermittent fasting and intake of antioxidant supplements | Satisfaction with diet Genetic expression Oxidative stress level Plasma insulin level | Patients had good adherence and tolerance to fasting. There were no major weight changes. Decrease in the level of oxidative stress and no significant change in gene expression, but SIRT3 trended towards significance (p = 0.0772). Metabolic changes emerged. Intermittent Fasting decreased plasma insulin (p = 0.0023). |
Veronese N. et al., 2016 [38] | Cohorts study | N = 4470 (2605 women & 1865 men) | All participants had their adherence to the Mediterranean diet (MD) and their quality of life measured by SF-12. Disability, pain, and stiffness were measured by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D). | Adherence to Mediterranean diet Disease impact Depressive symptoms Quality of life | A higher MD was significantly associated with a higher SF-12 scale value (b: 0.10; 95% CI: 0.05, 0.15; p = 0.0001), lower WOMAC scores, except for stiffness, and lower CES-D scores (b: 20.05; 95% CI: 20.09, 20.01; p = 0.01). |
Harder-Lauridsen NM. et al., 2016 [28] | Randomized clinical trial | EG: 10 healthy people CG: 10 healthy people | EG: during alternate days they were served 175% (4 meals) or 25% (1 meal). The fasting days were 16–19 h CG: they received 100% (3 meals) | VO2 max Glycemic control MRI Cholesterol Glucose levels | There were no significant differences between groups in the energy obtained from food, in the glycemic control, in the MRI (0.047). Systolic pressure increased in the experimental group (p = 0.04), as well as their plasma glucose level decreased in the mornings after fasting (p = 0.34) |
Bauersfeld et al., 2018 [29] | Randomized clinical trial | EG: 18 women diagnosed withgynecological cancer Age range: 28–63 years old Mean age of diagnosis: 49.8 ± 9.1 years CG: 16 women diagnosed with gynecological cancer Age range: 44–69 years old. Mean age of diagnosis: 53.6 ± 7.3 years | EG: fasted while receiving the first three chemotherapy sessions. During the last three they received normocaloric nutrition. CG: they followed normocaloric nutrition during the first three chemotherapy sessions. During the last three they fasted. | Pain intensity (FACT-G). Fatigue intensity (FACIT-F) Fatigue intensity (FACIT-TOI) | There were no significant differences between the two groups in the FACT-G results, only in social/family well-being (p = 0.042). In group A there were significant changes during fasting with respect to chemotherapy received with normocaloric nutrition (mean 12.8). Group B did not have any significant change between both cycles of chemotherapy. They found changes of QQL (mean difference 4.6). |
Towery P. et al., 2018 [39] | Observational study | 20 people with chronic musculoskeletal pain. | For 8weeks they went on a plant-based diet. | Limitation on ACV Pain (SF-36) Quality of life | The level of pain decreased by 3.14 points out of 10 on the scale (p = 0.0001). The SF-36 scores improved from 57.5 to 82.5 (p = 0.0001). Weight decreased on average by 1.207 kg (p = 0.895). |
Liu B. et al., 2019 [30] | Randomized clinical trial | EG 1: 25 women diagnosed with obesity. Age range: 35–70 years old. EG 2: 25 women diagnosed with obesity. Age Range: 35–70 Years EG 3: 26 women diagnosed with obesity. Age Range: 35–70 Years CG: 12 women diagnosed withobesity. Age range: 35–70 years old. | For 8 weeks: CG: maintained the same diet. EG 1: carried out 70% caloric restriction. EG 2: performed 70% intermittent fasting. EG 3: performed 100% intermittent fasting. | Metabolic glucose Tissue inflammation. Fat tissue and muscle. | There was no largely significant difference in metabolism between groups (p = 0.05). The size of adipocytes decreased in all groups (p = 0.01). Insulin sensitivity appeared to be altered in group 3 (p = 0.06). The levels of inflammation in the tissues and muscles increased after the meal sessions (p = 0.02). |
Cohen CW. et al., 2019 [31] | Randomized clinical trial | EG: 23 women with ovarian or endometrial cancer. CG: 20 women with ovarian or endometrial cancer. | EG: for 12 weeks they followed a Ketogenic diet: 70% fat, 25% protein and 5% carbohydrate. CG: for 12 weeks they followed the dietary requirements established by the ACS and the Academy of Nutrition and Dietetics for cancer patients and survivors. | Cholesterol Β-hydroxybutyrate Colorimetric assay | There were no significant differences in total cholesterol, HDL-C, LDL-C, TC:HDL-C ratio or TG:HDL-C ratio between groups. The ACS group decreased fasting triglycerides (p < 0.05) and TG:HDL-C levels (p < 0.05). The KD group had higher Β-hydroxybutyrate concentrations (p < 0.001). Significant difference between groups in total energy expenditure (p < 0.01). Between-group differences in total carbohydrates, total protein, saturated fat, cholesterol, dietary fiber, and total sugar were observed (p < 0.0001). |
Stekovic S. et al., 2019 [32] | Randomized clinical trial | EG: 30 people CG: 30 people | EG: for 4 weeks alternate days of intermittent fasting and days of standardized nutrition. CG: performs standardized nutrition for 4 weeks. | Levels of inflammation Blood in plasma Cholesterol Oxidative stress | Experimental group reduced body weight, as well as the risk of cardiovascular disease (p < 0.0001). There were no differences in energy activity levels between both groups (p = 0.258). The levels of inflammation were significantly lower over a long period of time (p = 0.04). |
Khodabakshi A. et al., 2019 [33] | Randomized clinical trial | EG: N = 40; Mean age = 44.8 ± 8.4 CG: N = 40; Mean age = 45.2 ± 15.0 Both groups have patients with a malignant biopsy and undergoing chemotherapy for at least 3 months. | EG: they follow a Ketogenic diet (6% carbohydrate, 19% protein, 20% medium chain triglycerides, and 55% fat) for 90 days. CG: they follow a regular diet (55% carbohydrate, 15% protein and 30% fat) for 90 days. | Body weight BMI Body fat Fasting blood sugar Ketone bodies TG ALT AST BUN Cr Level HDL-LDL Cholesterol | The levels of fasting blood sugar increased in the EG (p <0.001). The EG reduced body-weight (p < 0.001). There were significant differences between groups in weight, BMI, and body fat (p < 0.001, p <0.001, p = 0.03). TG, AST, Cr Level, and BUN were different between groups (p = 0.04, p = 0.04, p = 0.01, p = 0.04). |
Vadell AKE. et al., 2020 [34] | Randomized clinical trial | EG: 26 people with a diagnosis of Rheumatoid Arthritis for ≥2 years. Age range: 18–75 years old. Residence: Sweden. CG: 24 people with a diagnosis of Rheumatoid Arthritis for ≥2 years. Age range: 18–75 years old. Residence: Sweden. | There were two periods of 10 weeks (the groups exchanged intervention). EG: performed an anti-inflammatory nutrition. CG: performs standardized nutrition. | Levels of inflammation Quality of life | There was no difference between energy intake and weight levels (p = 0.082) during the separate diets (median: −0.4 kg; IQR: −1.4, 0.6 kg during the intervention period; p = 0.082 and median: 0.3 kg; IQR: −0.7, 1.6 kg during the control period; p = 0.122). The experimental group presented a reduction in the concentration of anti-inflammatory indicators. |
Ingegnoli F. et al., 2020 [40] | Observational, cross-sectional, single-center study | N = 205 (165 women & 40 men) | All participants had their adherence to a Mediterranean diet and their score of various scales related to their quality of life and the impact of their disease recorded. | Adherence to Mediterranean diet Impact of their disease Quality of life | An association between the Mediterranean Diet score and the Health Assessment Questionnaire (p-value = 0.033) and patient global assessment and general health (p-value = 0.023 in both) was observed. Rheumatoid Arthritis Impact of Disease total score had a statistically significant negative relationship with the Mediterranean Diet score (p-value = 0.016). A statistically significant negative association was found for pain (p-value = 0.025), functional disability (p-value < 0.001), sleep (p-value = 0.041), physical well-being (p-value = 0.027), and coping (p-value = 0.008). |
Khodabakhshi A. et al., 2020 [35] | Randomized clinical trial | EG: N = 40 CG: N = 40 Both groups comprised of patients between 18 and 70 years of age who had breast cancer with locally advanced or metastatic disease, and who were receiving chemotherapy for at least 12 weeks. | EG: they followed a Ketogenic diet (6% carbohydrates, 19% protein, 20% medium-chain triglyceride and 55% fat) for 12 weeks. CG: they followed a standard diet (55% carbohydrates, 15% protein and 30% fat) for 12 weeks. | Biomarkers (Na+, K+, Ca++, P+, Lactate, Mg++, LDH, Albumin, Ammonia, ALP) Quality of life (EORTCQLQ-C30, IORTCQLQ-BR23) | The EG had a better global Quality of Life (p = 0.02). Diarrhea increased in CG (p = 0.02). There was an increase in physical performance measures in the EG (p = 0.04). The CG had a significant decrease in role functioning and social functioning (p = 0.02, p = 0.02). |
Holton et al., 2020 [36] | Randomized clinical trial | EG: 20 people with Gulf War Syndrome. Average age: 54.35 ± 6.02 years. BMI: 32.10 ± 5.34 kg/m2 CG: 20 people with Gulf War Syndrome. Average age: 54.35 ± 6.02 years. BMI: 32.10 ± 5.34 kg/m2 | EG: followed a low glutamate diet for a month. CG: they did not make any changes in their type of diet. | Intensity and frequency of pain. | There were severe changes in the intensity and frequency of symptoms. The mean evaluation of symptoms in the experimental group was 11.7 ± 5.3, and in the control group it was 18.1 ± 5.7. |
Ortolá R. et al., 2021 [41] | Cohorts study | N = 1726 (1091 women & 635 men) | Adherence to the Mediterranean diet was measured with the Mediterranean Diet Adherence Score (MEDAS) at baseline. Frequency, severity, and location of pain from baseline and follow-up were used to compute a pain scale. | Adherence to the Mediterranean diet Pain characteristics | Participants with the lowest adherence to the Mediterranean diet showed a lower frequency of pain improvement (relative risk ratio [95% confidence interval]: 1.43 [1.03, 1.99]). This was also evidenced by an improvement in pain severity (1.43 [1.01, 2.04]) and a reduction in pain location (1.54 [1.08, 2.20]). A tendency to pain frequency improvement (1.34 [0.92, 1.93]) was also observed. |
Che T. et al., 2021 [37] | Randomized clinical trial | EG: N = 60; Mean age = 48.21 ± 9.32; Female = 29; Male = 31 CG: N = 60; Mean age = 48,78 ± 9.56; Female = 26; Male = 34 Both groups were comprised of people with type 2 diabetes. | EG: they followed Time-restricted feeding (ate freely from 8:00 to 18:00 and fasted from 18:00 to 8:00) for 14 weeks. CG: they followed a regular diet for 14 weeks. | Biomarkers: (Hemoglobin, Fasting plasma glucose (FPG), Β-cell function (HOMA-β), Insulin resistance (HOMA-IR), Cholesterol). Body weight and BMI Adherence Physical activity (step count) | The difference in average eating was not notable (p = 0.62). The eating window reduced significantly (p ≤ 0.001). The EG had a significant reduction in Hemoglobin (p < 0.001), FPG (p < 0.001), body weight (p < 0.001), BMI (p < 0.001), HOMA-IR (p = 0.02) and HOMA-β (p = 0.005). The total step count was similar in both at 12 weeks (p = 0.62) |
Cooper I. et al., 2022 [42] | Single-arm feasibility trial | N = 28 (23 women & 5 men) Intervention: 22 Losses: 6 | All participants followed a 9-week anti-inflammatory diet, which consisted of minimal processed foods and higher amounts of “good” fats and whole foods. They were encouraged to consume a normocaloric diet to satiety. | Knee symptoms Health-related quality of life Body mass | The Knee Injury and Osteoarthritis Outcome Score reported an improvement in the results supported by the minimal detectable change (MDC) in 8–10. EuroQoL-5D reported a non-significant variation in the quality of life of the participants. Participants lost an average of 3 kg, but it was not a significant difference. |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Cuevas-Cervera, M.; Perez-Montilla, J.J.; Gonzalez-Muñoz, A.; Garcia-Rios, M.C.; Navarro-Ledesma, S. The Effectiveness of Intermittent Fasting, Time Restricted Feeding, Caloric Restriction, a Ketogenic Diet and the Mediterranean Diet as Part of the Treatment Plan to Improve Health and Chronic Musculoskeletal Pain: A Systematic Review. Int. J. Environ. Res. Public Health 2022, 19, 6698. https://doi.org/10.3390/ijerph19116698
Cuevas-Cervera M, Perez-Montilla JJ, Gonzalez-Muñoz A, Garcia-Rios MC, Navarro-Ledesma S. The Effectiveness of Intermittent Fasting, Time Restricted Feeding, Caloric Restriction, a Ketogenic Diet and the Mediterranean Diet as Part of the Treatment Plan to Improve Health and Chronic Musculoskeletal Pain: A Systematic Review. International Journal of Environmental Research and Public Health. 2022; 19(11):6698. https://doi.org/10.3390/ijerph19116698
Chicago/Turabian StyleCuevas-Cervera, Maria, Jose Javier Perez-Montilla, Ana Gonzalez-Muñoz, Maria Carmen Garcia-Rios, and Santiago Navarro-Ledesma. 2022. "The Effectiveness of Intermittent Fasting, Time Restricted Feeding, Caloric Restriction, a Ketogenic Diet and the Mediterranean Diet as Part of the Treatment Plan to Improve Health and Chronic Musculoskeletal Pain: A Systematic Review" International Journal of Environmental Research and Public Health 19, no. 11: 6698. https://doi.org/10.3390/ijerph19116698