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What are the “Right” Things to Eat?

Erin wants your advice regarding what to eat.

In general, it helps to think of nutrients in terms of two general categories:

• Macronutrients are the energy-providing nutrients we need in large quantities: carbohydrates, fats, and proteins.
• Micronutrients are the compounds we need in smaller quantities: vitamins, minerals, and phytonutrients.

This section reviews some important macro- and micronutrient tips you can incorporate into health plans. After that is a discussion of other topics related to eating patterns, including the use of food pyramids, eating to reduce inflammation, and descriptions of some of the other popular diets that inspire patient questions.

Macronutrients: Some key recommendations you can make

One of the important ways to distinguish between different diets is by the proportions of macronutrients they recommend. For example, the Atkins diet promotes, especially in its first phase, very low carbohydrate intake. The South Beach diet focuses, in part, on “sensible” carbohydrates. You will learn more below about eating with close attention to glycemic index and load, which equates to consuming the “best” carbohydrates. And, of course, for better or worse, an entire branch of the food industry has sprung up since the last few decades because we have placed great value on eating low-fat foods.

The 2015-2020 Dietary Guidelines suggests the following when it comes to macronutrients:¹

• “Choose a variety of nutrient-dense foods across and within all food groups in recommended amounts.”
• Follow an eating pattern that is low in saturated fats, sodium, and added sugars.
• Consume less than 10% of calories daily from added sugar.
• Similarly, consume less than 10% of calories daily from saturated fats.
• Keep sodium intake to less than 2,300 mg.

Mindful Awareness Moment: Your Own Diet

Take a moment to consider the quality of your own diet based on what you have eaten in the past week.

• How many of the “World’s Healthiest Foods” have you eaten? How do you do with eating a Mediterranean diet, or a whole foods, plant-based eating pattern?
• Did you eat vegetables daily?
• How many servings of whole grains did you eat?
• How many different colors of fruits and vegetables have you eaten?

The following sections will provide some specific suggestions about carbohydrates, fats, and proteins for you to incorporate into PHPs.

Carbohydrate tips

Most of the calories in the American diet come from carbohydrates. In plant-based foods, such as fruits, vegetables, grains, cereals, legumes, and beans, 90%-95% of the calories come from carbohydrates. Carbohydrates include the following:

• Simple sugars such as fructose and glucose
• Oligosaccharides including fructo-oligosaccharides (which are “food” for the good bacteria in our intestines)
• Starches (which are energy storage molecules for plants)
• Dietary fiber. Fiber is a carbohydrate, but our bodies cannot digest it. Fiber adds volume—but not calories—to food and it may increase satiety as well.

The United States Department of Agriculture (USDA) recommends that half of all grain intake come from whole grains.² In terms of how they affect satiety, carbohydrates fall between protein and fat, with protein being the most satiating of the three macronutrients.³ Carbohydrates provide 4 kcal/gm in energy. This is roughly equal to the energy of protein, but less than fats, which contain 9 kcal/g. Consumption guidelines include the following recommendations.

Pay attention to fructose

Fructose is a simple sugar found in fruit, honey, and some vegetables. It is the sweetest of the simple sugars, and one form, high-fructose corn syrup (HFCS), is under considerable scrutiny these days. Fructose, on its own and in small quantities, may be a better carbohydrate choice than glucose in patients with prediabetes or diabetes due to its attenuating effects on blood sugar⁴ (think of a serving of fruit, not a serving of juice drink, as the source). This is not true for high-fructose corn syrup, which typically is 50% fructose and 50% glucose, similar to sucrose or table sugar, which is not an ideal combination.⁵

Most Americans consume about 40 gm of fructose daily, mostly in the form of HFCS. Whether HFCS is worse than pure fructose or sucrose remains to be seen; evidence is conflicting. We do know that fructose consumption from processed foods has significant effects on, for example, all the components of metabolic syndrome.⁶ (For more information, refer to the “Endocrine Health” overview, and the “Hypertension” and “Lipids,” tools; these topics are the main components of metabolic syndrome.) It is important to keep in mind that fruit is an important source of fructose (hence the similarity in their names), but the fructose in fruit—even though it may be in higher quantities—is accompanied by fiber, which is known to attenuate rises in blood sugar. In contrast, HFCS is rarely consumed with fiber. In fact, it is often consumed as a carbohydrate in isolation; for instance, it is practically the only ingredient in soda and other sugar-sweetened beverages.

Do not get too bogged down in simple versus complex carbohydrates

Figure 7. Recommended Grain Intake

It is frequently suggested that complex carbohydrates are better than simple ones. Many experts tell patients to eat complex carbohydrates, because they believe they are better for overall health. By definition, simple carbohydrates are composed of mono- or disaccharides (they have just one or two sugar molecule groups in them). Complex carbohydrates are polysaccharides (they have many simple molecules linked up). In short, whether or not carbohydrates are simple or complex is less important than focusing on which foods the carbohydrates come from. It is best to advise patients to eat whole grains and products made from them, as well as fruits, vegetables, and legumes, while minimizing foods with made with sugar or refined white flour. This is especially important because most Americans do not eat enough whole grains (see figure below).

Note: Recommended daily intake of whole grains is to be at least half of total grain consumption, and the limit for refined grain is to be no more than half of the total grain consumption. The blue vertical bars on this graph represent one half of the total grain recommendations for each age-sex group, and therefore indicate recommendations for the minimum amounts to consume of whole grains or maximum amounts of refined grains. To meet recommendations, whole grain intake should be within or above the blue bars and refined grain intake within or below the bars.

For more information on eating whole grains, refer to “Make Half Your Grains Whole” from MyPlate.

Choose carbohydrates based on glycemic index and glycemic load

Rather than focusing on whether a carbohydrate is simple or complex, it may be more helpful to choose which carbohydrates to eat based on how they are metabolized. Glycemic index and glycemic load take into account how much a given food raises blood sugar levels. Glycemic index (GI) compares how much a particular food that contains 50gm of carbohydrates will raise blood glucose levels 2 hours after eating, relative to an equivalent amount of glucose (or white bread). The problem with the GI is that different foods have different amounts of carbohydrate by weight. For example, in order to get 50 gm of carbohydrates from carrots, you would have to eat at least 5 cups of them. To allow for more realistic comparisons, glycemic load (GL) is used instead. Glycemic loads are like GIs, but they account for serving size.⁷ GL is ultimately the GI multiplied by the amount of carbohydrate per serving of a given food. For more information, see the “Glycemic Index” tool.

High glycemic index and load are clearly associated with increased risk of type 2 diabetes. In a 2014 pooled study that included 3.8 million person-years of follow- up, the quintile of patients with the highest food measures of GI and GL had a 33% higher risk of developing the disease.⁸ There is also a correlation between high-GL diet and ischemic (but not hemorrhagic) stroke risk,⁹ obesity,¹⁰ and chronic inflammation.¹¹ A 2008 meta-analysis found that high GI and GL diets correlated with higher risks of certain cancers, including colon and ovarian cancer (but not pancreatic or breast cancers).¹² A low GI/GL diet also reduces gallbladder and coronary artery disease risk.¹³

An interesting area of recent research on glucose tolerance is the “second meal effect.” If you eat a low GI/GL breakfast, your blood sugar will not climb as high after eating lunch. The same thing occurs after you eat a low GI/GL dinner; your blood sugar will not be as high at breakfast the next morning.^14,15 It is in part because of the second meal effect that people with diabetes are encouraged to eat fewer small meals during the day. Carbohydrates are absorbed more slowly and sugars stay lower on average if multiple small meals are eaten, rather than just a few large ones.¹⁶

Avoid refined carbohydrates

Because of their high glycemic load, cutting refined carbohydrates out of your diet can sometimes result in dramatic improvements in health. Common refined carbohydrates include the following:

Corn chips

Potato chips

Pizza crusts

Most flours

Pastries

Cookies

Biscuits

White rice

Pasta

Pies

Bagels

Bread

Buns

Muffins

Sugar

Soda

Breadcrumbs

Cereal bars

Granola

Toffee

For a more comprehensive list, go to the Diagnosis Diet website.

Eat your fiber

The metabolic fate of carbohydrates is determined largely by the company they keep. Fiber, which is composed of carbohydrates the body cannot digest, influences carbohydrate absorption in the gut, decreasing the rise in blood levels of glucose, insulin, and lipids that normally occurs after eating.^17-19 There are two main kinds of fiber. Soluble fiber has beneficial effects on absorption of glucose, insulin, and lipids. Insoluble fiber acts as a laxative and bulking agent. Few Americans consume the recommended daily intake of fiber, which is 14 gm/1,000 kcal, or roughly 25 gm for women and 38 gm for men. Some argue that fiber intake should perhaps be as high as 50 gm a day for those with diabetes.²⁰ Because fiber has important health benefits but is often neglected in the American diet, a discussion about fiber can be another potentially good starting point for the “Food and Drink” section of a PHP. High fiber intake significantly improves health. Fiber intake is associated with reduced all-cause mortality after myocardial infarction.²¹ Intake is inversely associated with esophageal cancer incidence,²² stroke risk,²³ and cardiovascular disease.²⁴ Fiber should be used with caution in people with functional bowel problems, such as irritable bowel syndrome, because it can exacerbate bloating, constipation, and diarrhea.²⁵

When checking nutrition labels, aim for foods with a favorable sugar-to-fiber ratio. This means that there should be no more than five times as much sugar as there is fiber. Avoid foods with higher sugar-to-fiber ratios.

For more information, refer to the two VA Nutrition and Food Services handouts “Types of Fiber” and “Tips to Increase Dietary Fiber”

Dietary Fat Tips

The types of fats you eat make a difference

For quite some time (roughly 1980-2015, in terms of Dietary Guidelines for Americans), the popular belief was that fats are “bad” for us in any form. Fat-free foods have been touted commercially as the solution to all our nutritional ills. However, fat-free eating requires that the calories be replaced with calories in another form. If this “other form” is carbohydrates, eating them may not be as helpful as we assume.²⁶ When large quantities of carbohydrates are eaten, those that are unneeded are stored as fat.

In excess, certain types of fats can contribute to health problems, but they are essential to healthy functioning, providing us the necessary building blocks for cell membranes, myelin sheaths around nerves, and steroid hormones. Fats are also essential for absorption of the fat-soluble vitamins, A, D, E, and K. Many people’s bodies are genetically programmed to hold on to fat; for our ancestors, this could be an advantage during times when food was scarce.

There are a few main categories of fats,²⁷ and knowing more about them can help patients make good food choices:

• Saturated fats (SFAs) are those without any double bonds in their carbon chain. They are solid at room temperature and include animal fat, butterfat, coconut oil, palm oil, and kernel oils. Most experts recommend keeping saturated fat intake to a minimum.
• Monounsaturated fats (MUFAs) are liquid at room temperature and found in avocado, peanut, olive, and canola oils. They have one double bond in their carbon chain.
• Polyunsaturated fatty acids (PUFAs) are also liquid at room temperature. They have more than one double bond and include fish, sesame, sunflower, walnut and corn oils. The PUFAs linoleic acid (LA) and alpha-linolenic acid (ALA) are essential; that is, they are necessary but the body cannot synthesize them and therefore they must be obtained through the diet.
• Essential PUFAs are in vegetables such as dark, leafy greens and purslane. They also come from animals that consumed LA- or ALA-rich algae and plant foods.
• Omega-6 fatty acids have a double bond at position 6 of their carbon chain. They play an important role in inflammation. Inflammation is important to an organism’s survival, but chronic inflammation can be harmful. Omega-6s rev up the chemical reactions that we normally attempt to suppress with medications such as nonsteroidal anti-inflammatories. Linoleic acid is an omega-6 fat, which is plentiful in most diets. It is in many nuts and seeds and in the fat of some animals, like pigs. Red meats and other animal products lead to creation of proportionally more omega-6 fatty acids than other foods.
• Omega-3 fatty acids have a double bond at position 3 in their carbon chain. They contribute to the reduction of inflammation, based on how they influence various chemical pathways in the body. The most important omega-3s to know about are docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Omega-3s are not commonly consumed as part of the standard American diet. They are in fish, as well as walnuts, leafy greens, and many seeds.
• The essential omega-3, ALA, is found in walnuts, flaxseeds, chia seeds, hemp seeds, pumpkin seeds, and canola oil. It can be metabolized to DHA and EPA, but the process by which humans convert ALA to DHA and EPA is inefficient; therefore, it is best to get DHA and EPA directly from the diet, rather than relying on conversion of ALA.
• DHA and EPA are found mainly in fatty, deep-sea fish, krill, and algae. The acronym SMASH can help patients remember fish that are good sources of DHA and EPA: salmon, mackerel, anchovies, sardines, and herring.
• Trans-fats replace the cis-double bonds in MUFAs and PUFAs with trans- bonds. Found in processed food sources,²⁸ trans-fats were created to allow foods to have a longer shelf life. Unfortunately, they may decrease the duration of human life, because they are known to increase cholesterol levels and coronary artery disease.^29,30 It is best to avoid all foods made with trans-fats and partially hydrogenated oils of any kind. The United States now bans use of trans-fats in all foods offered in restaurants and grocery stores.
• Ensure you get enough omega-3s. The essential PUFAs are precursors to prostaglandins, leukotrienes, and other compounds that control levels of inflammation in the body. With the increased consumption of highly processed foods, the ratio of proinflammatory omega-6 fats to anti-inflammatory omega-3 fats in the diet has steadily increased, increasing the number of people whose bodies are in a state of chronic inflammation. Current ratios of omega-6s to omega-3s range from 15:1 to 25:1. The ideal ratio is the subject of some debate, but most sources suggest it should be more in the 2:1 or 4:1³¹ range. Inflammation has an important physiological role, but a system of checks and balances is needed; many of today’s chronic diseases are associated in some way with chronic inflammation.³² It is worth discussing whether or not to recommend omega-3 supplements for many patients.

For more information on fats and oils in the diet, patients can see the article “Rethink Fats” Another useful patient education handout is “Common Fats and Oils,” available through the VA Nutrition and Food Services website.

NOTE: Dietary supplements are intended to supplement the diet. They are not medicines and are not intended to treat, diagnose, mitigate, prevent, or cure disease. In some cases, dietary supplements may have unwanted effects, especially if taken before surgery or with other dietary supplements or medicines, or if you have certain health conditions. Also, supplements are not regulated with the same degree of oversight as medications. Products vary greatly in terms of accuracy of labels, presence of contaminants, and the validity of claims on the label

Eat to improve your cholesterol panel

Many people have abnormal lipid panels and struggle to improve them. A few general points to consider include the following:

• Triglyceride levels increase primarily due to eating foods with a high GI; that is, they are closely linked to carbohydrate intake. People with diabetes and/or thyroid disorders often have elevated triglycerides.^33,34
• High-density lipoproteins (HDLs) transport excess triglycerides and cholesterol back to the liver from outlying cells, and low-density lipoproteins do the reverse. For this reason, HDL often is labeled “good cholesterol,” and LDL labeled as “bad.”
• Foods that raise LDL cholesterol levels most are: (1) those high in saturated fats, and (2) those with a high GI. These foods have a much more significant impact than foods that are high in dietary cholesterol, such as eggs, shrimp, shellfish, and caviar.

More information is available in the “Lipids” tool.

Guidance with eating protein

Get enough protein (but not too much) each day, from healthy sources

Adults are encouraged to obtain 10%-35% of their daily calories from protein. That equates to 56 gm for men and 46 gm for women.³⁵ Eating 2-3 servings of protein-rich foods a day seems to cover needs. Examples of protein serving include³⁵ the following:

• A 3-oz piece of meat, which has about 21 gm of protein; a typical 8-oz serving has over 50 gm
• 8 oz of yogurt, which has about 11 gm, or 8 oz of milk with 8 gm
• One cup of cooked beans contains roughly 16 gm of proteins.

Animal protein is a source of significant amounts of protein

However, many meats contain a fair amount of saturated fat and are sources of trimethylamine N-Oxide (especially for red meats and processed meats), which increases risk for cardiovascular events and cancer; they are best eaten with less frequency. Calorie for calorie, protein is the most satiating or filling of the macronutrients.³⁶ The average American consumes roughly 100 gm of protein daily, despite the fact that recommendations encourage a lower quantity.³⁷ A diet high in animal protein can be taxing for the liver and kidneys.^38,39

Eat all of your essential amino acids

There are certain amino acids that must come from the diet; our bodies cannot synthesize them. These amino acids have critical antioxidant and anti-inflammatory properties and are key chemical ingredients for many of the body’s chemical reactions. It helps to vary protein sources in your diet. Bring in meat, fish, legumes (beans, lentils), eggs, nuts, seeds, and whole grains such as quinoa to add variety.

Vegetarians can get the full spectrum of amino acids in the diet if they eat a variety of the foods listed above. Bacteria that live in our digestive tract also serve as a protein source. Epidemiologic studies show that those who eat a nutritious, primarily vegetarian diet derive health benefits from doing so.⁴⁰ Of course, “vegetarian” is not synonymous with “healthy.” A diet of sports drinks and corn chips may even be vegan, but it is not nutritious.

Micronutrients: vitamins and minerals

Micronutrients are essential for life. They serve many vital roles in our health and development including production of adenosine triphosphate (ATP), hormones, enzymes, and neurotransmitters. The multitude of biochemical reactions that happen throughout the body require micronutrients as cofactors. They include vitamins and minerals, as well as phytonutrients. One can become deficient in micronutrients in the absence of a well-balanced diet. Specific clinical findings related to various deficiencies, while beyond the scope of this overview, are available at the Public Health Reviews website.⁴¹

Eat your vitamins

Vitamins were discovered in the early 1900s and were originally called “vital amines” because it was initially thought that they all contained amino (nitrogen) compounds.⁴² The name was changed to “vitamins” after it was discovered this wasn’t true. Vitamins are classified as water-soluble (B vitamins, vitamin C) and fat-soluble (vitamins A, D, E, and K). Many people follow the recommended dietary allowance (RDA) created by the Institute of Medicine to ensure they are consuming the necessary amounts of vitamins each day. However, the RDA is the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97-98%) of healthy people. The RDA of a given micronutrient depends on many things such as sex, age, overall health status, and, for women, whether or not they are pregnant or lactating. The Dietary Reference Intakes (DRI) are a set of recommendation levels for specific nutrients that consists of a number of different types of recommendations. The DRIs are not a minimum or maximum nutritional requirement and are not intended to fit everybody. They are intended to be used as guidelines for the majority of the healthy population.

Most people can get all of the vitamins they need through a balanced diet (this is difficult with vitamin D, however). Vitamin B12 is the only vitamin that is available solely through animal sources, putting vegans at risk for deficiency; for this reason, vegans should always be asked about B12 supplementation. If people have a very poor diet (e.g., they live in an urban “food desert”) or they absolutely insist on taking a multivitamin supplement, it is important to be able to offer good advice on how to select an appropriate one.

Eat your minerals, too

There are approximately 18 minerals necessary for our physiologic functioning. Table 1 briefly summarizes information about several of the minerals that are most likely to be discussed in a clinic visit—iron, calcium, zinc, selenium, and magnesium.

Table 1. Micronutrients: Functions, Sources, and Clinical Tips43-45
Micronutrient	Main functions	Comments
Iron	Part of hemoglobin and myoglobin Necessary for red blood cell development Aids with immune function	Found in meat, and is more absorbable in this form, called heme iron Plant sources (non-heme iron) include beans, spinach and other leafy greens, brewer’s yeast, pumpkin seeds, blackstrap molasses, sunflower seeds, almonds, and raisins Bioavailability of non-heme iron is increased when consumed with vitamin C Can increase daily intake by cooking with non-coated iron pans If taking an iron sulfate supplement and constipation is a problem, try using a chelated iron (e.g., iron bisglycinate)

Table 1. Micronutrients: Functions, Sources, and Clinical Tips43-45
Micronutrient	Main functions	Comments
Calcium	99% of body calcium is in bones and teeth The rest is used for muscle contractions, nervous system function, and blood clotting Mean intake ranges from 870-1,270 mg daily for men and 750 -970 mg daily for women.46,47 If not, taking a supplement with added vitamin D can be helpful to bring levels up to the DRI.*	Dairy is a major food source Nondairy sources include dark leafy greens (collards, mustard greens, turnip greens, bok choy), sesame seeds, tahini, almonds, soybeans, tofu, and garbanzo beans. Sardines and mackerel (canned with bones), salmon with bones, and raw oysters also have it as do fortified fruit juices and soy milk Ethanol, caffeine, and fiber can increase fecal excretion48 Aspartame, glucose, excess sodium, and excess protein increase urinary excretion Recent trials indicate that calcium levels may modestly negatively influence cardiovascular risk and must be considered in advising patients.49 Note that a 2014 prospective cohort study of data from the Nurses’ Health Study (n=74,245) did not find a link between calcium supplement intake and cardiovascular risk in women.50
Zinc	Critical to immune function, wound healing, and prostate health Consider if symptoms of poor wound healing, frequent infections, inflammatory bowel disease (IBD), acne, or psoriasis exist Most experts recommend 8 mg daily for females and 11 mg daily for males	Sources include oysters, beef, pork, chicken, and egg yolk. Also found in legumes, nuts, seeds, and whole grains If taking more than 30 mg daily, it is suggested to take zinc with a supplement that contains copper as well, as zinc and copper compete for absorption in the small intestine

Table 1. Micronutrients: Functions, Sources, and Clinical Tips43-45
Micronutrient	Main functions	Comments
Selenium	Antioxidant that works with vitamin E Important for thyroid and immune	Found in seafood, meats, legumes, and whole grains, but also specifically in Brazil nuts. Eating two nuts daily is sufficient to maintain healthy selenium levels. The levels of selenium in nuts and grains depends on the levels of selenium found in the soil. A Cochrane review of selenium and cancer prevention showed that those in the highest quartile of selenium intake compared to those in the lowest quartile of selenium intake had 31% lower cancer risk and 45% lower cancer mortality risk as well as a 33% lower risk of bladder cancer and, in men, 22% lower risk of prostate cancer.51
Magnesium	Cofactor for over 300 different enzymatic reactions Necessary for muscles and blood vessels, protein and fat synthesis, energy production, and the synthesis of urea Inadequate magnesium intake is common in the United States	Found in large amounts in green vegetables, but can also be found in whole grains, nuts, legumes, meat, fish, and dairy In supplement form, magnesium citrate and magnesium glycinate are the most absorbable forms. Toxicity may develop in patients taking high doses of magnesium-containing antacids and laxatives. The first sign of magnesium toxicity is diarrhea. The maximum recommended amount of magnesium is 1,000 mg per day before patients develop symptoms of toxicity. Can be taken to help patients with constipation, muscle cramps, headaches, anxiety, depression, kidney stones, and diabetes. It may also be helpful for patients with hypertension52

* DRI = dietary reference intakes

Keep sodium (salt) and potassium balanced

In terms of electrolytes, potassium is mostly intracellular, and sodium and chloride (the electrolytes in table salt) are mostly extracellular. Sodium deficiency is rarely a problem in the United States, given that so much of our food is processed, pre-seasoned, and over-salted, but it can occur with starvation, diarrhea, or vomiting. Most Americans exceed the tolerable upper intake level for sodium, with an average intake of 5-6 gm/day.⁵³ For more information on how to eat less sodium, see “The DASH Diet” tool in the “Heart Health” module. For more information on salt, refer to “Sodium in Your Diet” from the US Food and Drug Administration, and several VA Nutrition and Food Services handouts on lowering sodium intake. Consider having people replace table salt with health-promoting spices, such as turmeric.

Potassium, in contrast to sodium, often is depleted. Depletion may be due to medications or for other reasons. Potassium is important for nerve transmission, muscle contraction, glycogen and glucose metabolism, and cellular integrity. Potassium is found in potatoes with skin, tomatoes, bananas, dairy, legumes, seafood, broccoli, almonds, raisins, and peanuts. Potassium deficiency can occur with diarrhea, vomiting, starvation, taking certain diuretics, and magnesium deficiency. Of course, it is important to remember that that for certain medical conditions (e.g., chronic kidney disease) there may be dietary restrictions for potassium. “Dietary Guidelines For Americans” offers more information on the potassium content of foods.

What we know about integrative health care has come to us thanks to the efforts, experiences, and collective wisdom of people from many cultures and backgrounds. We wish to acknowledge all the healers, researchers, patients, and peoples who have informed the content of this tool.

Author(s)

This overview was adapted for the Osher Center for Integrative Health at the University of Wisconsin-Madison from the original written by Samantha Sharp, MD, and updated by Sagar Shah, MD, with additional updates from Shari Pollack, MD, and Adam Rindfleisch, MD.

Originally Created: 2014, Updated: 2020

Modified for UW Integrative Health: 2020

References

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