chronic low back pain ( lbp ) has long been one of the most common causes of disability in 
 adults and is a very frequent condition among early retirees in industrialized societies . 

degenerative disc disease ( ddd ) is the most frequent problem in patients with lbp . in 1988 , 
 modic et al .
thereafter , the medical term modic changes ( mc ) has appeared in various studies on spinal 
 degenerative diseases .
the prevalence of mc among patients with ddd of the lumbar spine 
 varies between 19% and 59% .
mc of types 1 and 2 are more common than those of type 3 and 
 mixed changes .
mc are considered a magnetic resonance imaging ( mri ) parameter determining 
 morphological changes in spinal degenerative diseases .
mc are thought 
 to occur because of environmental , genetic , hormonal , mechanical , and degenerative factors , 
 as well as because of the interaction of several unknown factors . among the environmental 
 factors , dietary habits and trends of ddd patients
however , their significance in the monitoring and treatment of the disease remains 
 unclear .
it is the 
 single most common cause of disability in individuals aged over 45  years and the second most 
 common reason for primary care physician visits5,6,7 .
the risk factors associated with ddd include advanced age , socioeconomic status , torsional 
 stress , smoking , obesity , heavy lifting , vibration , trauma , immobilization , psychosocial 
 factors , gender , height , hereditary and genetic factors , and occupations like machine 
 drivers , carpenters , and office workers8,9,10,11,12 .
mc have been described as being strongly associated with lbp13,14,15 . according to modic et al .
, these changes visible on mri scans can 
 be classified into three different types14 , 15 .
type 1 changes are seen on t2-weighted 
 mri as areas of high signal intensity and on t1-weighted mri as areas of low signal 
 intensity extending from the vertebral endplates .
histological examination of material 
 harvested during surgery has shown that mc type 1 manifest as disruption and fissuring of 
 the endplate with regions of degeneration , regeneration , and vascular granulation 
 tissue14 .
type 2 are seen as areas of 
 high signal intensity on both t1- and t2-weighted images , manifesting as disruption of the 
 endplates with increased reactive bone and granulation tissue .
type 3 mc presumably represent bone sclerosis and are visualized 
 on mri as low - signal intensity areas on both t1- and t2-weighted images13,14,15,16 .
the aim of the present study is to investigate the effects of eating habits on the modic 
 classification in patients with ddd .
this randomized , prospective , controlled , single - blinded study was conducted at an 
 outpatient clinic for physical medicine and rehabilitation of lbp patients .
this department 
 is part of the rheumatology outpatient clinic . via face - to - face interviews ,
this form 
 recorded the patients demographics , mc , smoking and alcohol use , concomitant diseases , 
 disease duration , and nutritional status .
the questions related to tobacco and alcohol use , 
 frequency of breakfast consumption , daily water consumption , salt consumption , and frequency 
 of consumption of fast food , eggs , milk , yogurt , cheese , whole wheat bread , white bread , 
 butter , and margarine . for each food choice , the frequency of consumption was rated as every 
 meal , once a day , 3 days a week , 2 days a week , 1 day a week , once every 15 days , once every 
 1 month , and not sure .
in addition to demographic characteristics ( age , gender , weight , 
 height , and body mass index [ bmi ] ) , patients were also questioned about their occupation , 
 main symptoms , and time of diagnosis .
other exclusion criteria included 
 other comorbidities , unavailable mri data , and inability to speak turkish .
all the recruited subjects signed informed consent forms before participating in the study , 
 and the approval of the local ethics committee was obtained .
the erythrocyte sedimentation rate ( esr ;  mm / h ) was measured using the westergren method , 
 and the serum c - reactive protein ( crp ;  mg / dl ) level was determined using nephelometry .
all statistical analyses were performed using statistical package for social sciences for 
 windows software version 16.0 ( spss inc . ,
the kolmogorov - smirnov test was 
 used to confirm that the data were within the ranges of normal distribution in both groups . 

data were compared 
 between groups using the independent - samples t - test . statistical 
 significance was set at p < 0.05 with a 95% confidence interval .
most were female ( 85% ) , and the mean age of the entire cohort was 43.65  
 11.36  years .
the mean disease duration was 4.16  1.59  years , and mean bmi was 27.52  5.32 . 
 in terms of smoking and alcohol use , 15 patients ( 37.5% )
the mean daily tea consumption was 1.65  1.27 cups , while the mean water 
 consumption was 1.12  0.92 l. thirty percent of the patients did know exactly how much milk 
 they consumed ; 20% said they consumed it on 2 days a week , while 20% stated that they never 
 consumed it .
the frequency of yogurt consumption was 3 days a week for 47.5% patients , 
 frequency of cheese consumption was 3 days a week for 92.5% patients , and frequency of white 
 bread consumption was 3 days a week for 62.5% patients .
half the patients did not know how 
 frequently they consumed whole wheat bread , while 30% reported eating it 3 days a week .
the 
 frequency of margarine consumption was unknown by 72.5% patients ; 30% did not know how often 
 they ate butter , while 27.5% reported that they ate it once every 15 days .
the frequency of egg consumption was 
 1 day per week for 30% patients and once every 15 days for 27.5% .
then , 60% did not know how 
 often they consumed fast food , and 20% reported that they did not consume fast food .
the 
 frequency of red meat consumption was 2 days a week for 35% patients and once every 15 days 
 for 35% patients .
the frequency of white meat consumption was once every 15 days for 35% and 
 1 day a week for 30% patients ( table 
 1table 1.frequency of consumption of various foods in terms of number of daysdo not knowneverone day a monthonce every 15 daysonce a weektwice a week3 days a weekevery daymilk12 ( 30%)8 ( 20%)4 ( 10%)3 ( 7.5%)3 ( 7.5%)8 ( 20%)2 ( 5%)0 ( 0%)yogurt2 ( 5%)1 ( 2.5%)0 ( 0%)2 ( 5%)7 ( 17.5%)9 ( 22.5%)19 ( 47.5%)0 ( 0%)white bread5 ( 12.5%)3 ( 7.5%)1 ( 2.5%)0 ( 0%)1 ( 2.5%)0 ( 0%)25 ( 62.5%)5 ( 12.5%)whole wheat bread20 ( 50%)1 ( 2.5%)1 ( 2.5%)0 ( 0%)1 ( 2.5%)0 ( 0%)12 ( 30%)5 ( 12.5%)margarine29 ( 72.5%)4 ( 10%)2 ( 5%)2 ( 5%)3 ( 7.5%)0 ( 0%)0 ( 0%)0 ( 0%)butter12 ( 30%)1 ( 2.5%)0 ( 0%)11 ( 27.5%)9 ( 22.5%)7 ( 17.5%)0 ( 0%)0 ( 0%)fish1 ( 2.5%)9 ( 22.5%)15 ( 37.5%)10 ( 25%)4 ( 10%)1 ( 2.5%)0 ( 0%)0 ( 0%)eggs2 ( 5%)0 ( 0%)0 ( 0%)5 ( 12.5%)12 ( 30%)10 ( 25%)11 ( 22.5%)0 ( 0%)fast food24 ( 60%)8 ( 20%)3 ( 7.5%)2 ( 5%)2 ( 5%)1 ( 2.5%)0 ( 0%)0 ( 0%)cheese0 ( 0%)1 ( 2.5%)0 ( 0%)0 ( 0%)1 ( 2.5%)1 ( 2.5%)37 ( 92.5%)0 ( 0%)red meat0 ( 0%)1 ( 2.5%)2 ( 5%)14 ( 35%)9 ( 22.5%)14 ( 35%)0 ( 0%)0 ( 0%)white meat0 ( 0%)2 ( 5%)5 ( 12.5%)14 ( 35%)12 ( 30%)7 ( 17.5%)0 ( 0%)0 ( 0% ) ) .
the mean body fat percentage of the patients was 31.22%  9.58% and fat amount was 23.37  
 10.22  kg .
the average esr was 24  8  mm / h , and mean crp level was 1.42  1.2  mg / dl .
the 
 cervical disc was affected in 11 patients , the lumbar disc in 18 , and both lumbar cervical 
 discs in 11 patients .
the modic classifications according to the type of disc degeneration 
 are given in table 2table 2.modic classification according to degenerated disc typeregioncervicallumbarboth cervical and lumbartotal modic type 18 ( 2.5%)8 ( 20%)4 ( 10%)20 ( 50%)modic type 22 ( 5%)8 ( 20%)5 ( 12.5%)15 ( 37.5%)modic type 31 ( 2.5%)2 ( 5%)2 ( 5%)5 ( 12.5%)total ( n , % ) 11 ( 27.5%)18 ( 45%)11 ( 27.5%)40 ( 100% ) . a weak negative correlation was noted between fish and egg consumption and 
 the modic types ( r = 0.361 , p = 0.42 ; r = 0.428 , p = 0.14 , respectively ) .
the main aim of this study was to investigate the relationship between the diet of ddd 
 patients and the degree of disease as assessed from the modic classification .
the most 
 important feature of our study is that the extent or frequency of water , salt , fast food , 
 eggs , milk , yogurt , cheese , whole wheat bread , white bread , butter , and margarine 
 consumption was recorded .
the consumption of cheese , yogurt , and white bread is 
 significantly more than that of other food .
although cheese and yogurt are rich in calcium , 
 they are also abundant in fats .
, a weak 
 negative correlation was found between fish and egg consumption and the modic 
 classification .
these food products contain essential amino acids along with omega-3 and 
 omega-6 fatty acids . in most cases in the present study
, disc degeneration was observed in 4th and 5th decades 
 of life , a finding similar to those of other studies17 , 18 .
the prevalence of modic type 1 changes in this study was 50% , which is comparable what is 
 reported in some previous studies19 , 20 , and some studies have reported a 
 prevalence ranging from 43 to 59% .
mc 
 did not seem to influence the clinical course of pain and function and were not prognostic 
 factors for recovery .
clinicians need to be reminded to treat patients with chronic lbp by using a biopsychosocial 
 model of recovery21 .
the pathogenetic mechanisms underlying mc are not completely understood . a suggested cause 
 is disc degeneration , which increases the shear force on the lumbar vertebral endplates , 
 leading to microfractures .
mc could be either edema - initialized via endplate microfractures 
 or an inflammatory response caused by proinflammatory chemicals seeping from the nucleus 
 pulposus through such microfractures22 .
the current study is based on the assumption that mc could be the singular cause of lbp in 
 some patients .
however , these changes are often detected along with other mri findings 
 ( i.e. , degeneration , bulges , and herniation ) , which could also cause lbp . in the present 
 study , patients were excluded if they had a competing somatic disease such as disc 
 herniation with symptomatic root compression ; nevertheless , it is still very likely that the 
 pain in some cases could have another pathological cause or a combination of causes .
a study 
 conducted in the general population showed that the clinical profile of individuals with 
 both disc degeneration and mc was more pronounced than that of individuals with only disc 
 degeneration , suggesting that mc are the crucial element connecting lbp and clinical 
 findings . to our knowledge
johansen et al . studied the relationship between vitamin d and mc and surprisingly found 
 that mc were more common in individuals with normal levels of vitamin d than in those with 
 low levels .
findings suggest that the link between vitamin d and mc is perhaps related to 
 inflammation , though further confirmatory studies are needed23 . according to our theoretical framework
, individuals with mc are 
 expected to have low levels of vitamin d because of an increased susceptibility to 
 inflammation and/or because microfractures occur in the vertebrae because of increased 
 levels of parathyroid hormone24 , 25 . in conclusion , although the results of our study are promising , further studies with 
 comparison groups and larger samples are needed before a cause - and - effect relationship can 
 be proposed .
 [ purpose ] this study was conducted to examine the association between modic 
 classification and the eating habits in patients with degenerative disc disease ( ddd ) and 
 to determine the influence of nutrition on disease severity . 
 [ subjects and methods ] sixty 
 patients with ddd visiting a low back pain outpatient clinic were enrolled . through 
 face - to - face interviews 
 , they completed questionnaires regarding their demographics , 
 disease activity , smoking and alcohol use , concomitant diseases , disease duration , and 
 nutritional status.exclusion criteria were age < 20  years or > 65  years , other 
 comorbidities , missing mri data , and inability to speak turkish . 
 [ results ] forty patients 
 were finally included in the study . 
 the frequency with which they consumed water , salt , 
 fast food , eggs , milk , yogurt , cheese , whole wheat bread , white bread , butter , and 
 margarine was recorded . 
 a weak negative correlation was observed between the modic types 
 and fish and egg consumption . 
 [ conclusion ] modic changes , which indicate the severity of 
 ddd , seem to be correlated to patients dietary habits . 
 however , studies with comparison 
 groups and larger samples are needed to confirm our promising results before any 
 cause - and - effect relationship can be proposed . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION