There is no one-size-fits-all in nutrition, and nutrient requirements vary based on age, sex, physical activity, and even illness. As nutritionists, we need to ensure that our plans meet our client’s unique individuality, as well as their goals.
Case Example Of a Young Female Marathon Runner
In this case, my 25-year-old marathon runner’s goal is to improve performance and feel her best during each race. She needs recommendations for what to consumer before, during, and after her races to ensure performance as well as recovery. A female athlete’s nutritional needs are quite different from those of male athletes: factors that come into play include bone density, as well as differences in caloric consumption and expenditure. While both male and female athlete require more dietary protein than the average couch potato, the maximal increase is about 100% for male athletes and 50-60% for female athletes. Proteins are essential for the marathon runner.
Foods For Faster Recovery
They promote faster recovery after training and race, facilitating muscle growth and repair. Protein also are needed in the synthesis of new structures, red blood cell development, and antibody production. When glycogen stores are low, the protein stores provide about 15% of the needed energy during muscle activity. Those who lack protein are at an increased risk of injury, fatigue, and decreased muscle mass, all factors that hinder performance. My client’s diet plan will include: organic eggs, wild-caught fish, pastured chicken and grass-fed meat, peanut butter and other nuts, if tolerated.
Carbohydrates and Fats For High Performance Runners
Fats should also be a vital inclusion in marathon runners’ nutritional plan. Fats are more calorie-dense, providing 9 calories per gram compared to the 4 calories per gram provided by protein and carbohydrates. Additionally, fats are essential for the transportation of fat-soluble vitamins, for hormone production, brain function, and satiety. A low-fat diet in athletes can limit athletic performance causing earlier onset fatigue during a race. Sources of fats include coconut oil, extra virgin olive oil and olives, butter and ghee, dairy, avocado, and if tolerated dairy.
Carbohydrates are important for providing energy during the races. The runner should be able to consume and maintain optimum carbohydrate intake. This will help prevent hypoglycemia during the races, maintain the intensity of training, strengthen the immune system, and facilitate post-recovery. If this client does not consume enough carbohydrates, she will not be able to endure and perform effectively due to increased glucose depletion. Before a marathon, the total caloric intake should also be increased, including the carbohydrate calories, to achieve an effective carbohydrate-caloric loading effect.
What Is The General Nutritional Advice Given To Marathon Runners?
The general advice given to marathon runners is to consume fruit juice, honey, molasses, whole-grains, cereals, rice and pasta, starchy carbohydrates and legumes, as well as fruit and high-carbohydrate dairy products such as yogurt. About 60 to 70% of the calories should be from carbs. Before the race, only quick sources of energy should be consumed because they are absorbed faster. During the race, she should increase the rate of carbohydrate intake by one gram per minute by consuming carbohydrate-containing drinks. These drinks should be consumed at regular intervals during the race, and oftentimes an alarm can help keep track. Additionally, consumption of carbohydrates with high glycemic index such as honey can help during the marathons. After the races, the goal is to replace the depleted energy stores and fluids. Attention should also be directed to muscle repair and recovery; hence, micronutrients and proteins will be essential. Fast recovery is important so that the body can be ready to get back to training. Carbohydrates will help restore glycogen stores; protein will help with muscle repair and recovery, and electrolytes will help in re-hydrating.
Every Athlete Has Unique Nutritional Requirements
While the general advice has been used in sports nutrition for decades, I like to use a more individual approach with my athletes. In my work, I have found that using a continuous glucose monitor is paramount to study each individual athlete’s response to carbohydrates and glucose. Too much or too little glucose can be detrimental to athletic performance leading up to and during an event. Glucose levels are complex and many factors can influence them. Plus, every athlete has unique fueling requirements. A continuous glucose monitor is my preferred tool when working with athletes. For this reason, I will recommend that this client use this tool to learn how her body responds to different carbohydrates. This will help us find the perfect nutrition for performance. Athletes usually begin glucose loading 3 days before a race. Knowing how her body responds to different foods will allow this client to eat meals that provide a stable and sustainable glucose rise and that will keep her in optimal fuel range.
Hydration is extremely important. Before and during a marathon, my client will make sure to keep well hydrated. I recommend electrolyte supplements, mineral-rich water, and coconut water.
Other factors to consider are vitamins and minerals. Calcium, for example, is an essential mineral needed for bone growth, density, and prevention of bone loss and fractures. Consumption of calcium-rich foods help maintain strong bones that can endure the intensity of the races. Therefore, this client should consume foods rich in calcium like dairy products, green leafy vegetables, spinach, and broccoli.
B Vitamins And The Health Of Female Athletes
Vitamins are essential nutritional components for the marathon runner. The most important vitamins are vitamin D and B complex vitamins. The body needs vitamin D to metabolize calcium. Vitamin D is necessary for a healthy immune system and hormone production. Therefore, I will advise my client to include fatty fish in her diet and supplement with vitamin D3 if needed. Vitamin B6, B12, and Folate are also important. For example, vitamin B12 and folate are essential for red blood cell development, protein synthesis, and tissue repair. These are important in improving the oxygen-carrying capacity and building endurance during long races.
My client will begin adopting her new dietary plan during training so that she can get used to the changes and, if needed, we can modify the plan according to her needs well before the race.
References
Tarnopolsky MA. Gender differences in metabolism; nutrition and supplements. J Sci Med Sport. 2000 Sep;3(3):287–98.
Burke, L. M., Jeukendrup, A. E., Jones, A. M., & Mooses, M. (2019). Contemporary Nutrition Strategies to Optimize Performance in Distance Runners and Race Walkers. International journal of sport nutrition and exercise metabolism, 29(2), 117–129.
Costa, R., Knechtle, B., Tarnopolsky, M., & Hoffman, M. D. (2019). Nutrition for Ultramarathon Running: Trail, Track, and Road. International journal of sport nutrition and exercise metabolism, 29(2), 130–140.
Smith-Ryan, A. E., Hirsch, K. R., Saylor, H. E., Gould, L. M., & Blue, M. (2020). Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation. Journal of athletic training, 55(9), 918–930.
Thomas, D. T., Erdman, K. A., & Burke, L. M. (2016). American College of Sports Medicine Joint Position Statement. Nutrition and Athletic Performance. Medicine and science in sports and exercise, 48(3), 543–568.
Differences Between Conventional Medicine and Functional Medicine
Fibromyalgia is a syndrome that affects between 2% and 8% of the population (Clauw D. J., 2014). It is more prevalent in women than in men, and it presents with chronic pain that affects the musculoskeletal system, fatigue, sleep problems, mood disorders, memory issues and other symptoms (Bair & Krebs, 2020). Fibromyalgia is not an illness with objective markers, and its diagnosis is usually made by studying a patient’s history and symptoms and then excluding other diseases that cause chronic widespread pain (Häuser, 2016). According to Galvez-Sánchez & Reyes Del Paso (2020) this has historically created problems in the diagnosis, management, treatment, and even social recognition of the disease. Old diagnosing guidelines called for the examination of so-called tender points: these are specific points on the body that are tested for pain and/or tenderness. In order to be diagnosed with fibromyalgia, a patient had to respond positively for tenderness to 11 out of 18 points. This was an inaccurate method, as fibromyalgia symptoms change from day to day. Current diagnostic guidelines now include widespread pain on both sides of the body for a minimum of three months (Fibromyalgia: Understand How It’s Diagnosed, 2020). After diagnosis, the patient is generally referred to a specialist in rheumatology for further treatment.
What Does The Data Reveal?
A study published in 2005 in The Journal of Rheumatology concluded that fibromyalgia can manifest hand in hand with neurotransmitter and neuroendocrine dysfunction, namely, higher than normal levels of excitatory neurotransmitters (catecholamines, serotonin, acetylcholine and histamine), low levels of biogenic amines as well as imbalances of the hypothalamus-pituitary-adrenal axis (HPA) (Mease P., 2005). Despite these findings, conventional medicine does not test for those biomarkers; instead, it manages fibromyalgia with the use of antidepressants (tricyclic and selective serotonin reuptake inhibitors (SSRI)), anti-seizure medications, muscle relaxants, and nonsteroidal anti-inflammatory drugs (NSAIDS). Other drugs prescribed include sedatives, norepinephrine/serotonin reuptake inhibitors, and experimental drugs. Exercise, acupuncture and massage are complementary alternative therapies that are often recommended in conjunction with medication (Chinn et al., 2016).
Conventional Medicine’s Approach To Treatment
Conventional medicine has a reductionist approach to illnesses such as fibromyalgia, while functional medicine uses a holistic approach in the treatment of such conditions. It is frustrating to see such disparities. It is even more frustrating when there are numerous peer-reviewed studies that share important findings demonstrating that addressing the several underlying causes of fibromyalgia can bring this syndrome into remission. These findings have been reviewed, published and shared with the medical community, but conventional medicine is not yet using this knowledge to treat the root causes of the syndrome. The conventional medicine approach uses pharmaceutical drugs to manage symptoms;
this Band-Aid approach is not only unsustainable, it is also faulty.
Functional Medicine’s Approach To Treatment
Functional medicine recognizes fibromyalgia as a painful neuropathic pain syndrome that can have root causes in several systems. HPA imbalances, neurotransmitters dysfunction, endocrine issues, nutrient deficiencies, autoimmunity and stress can all play a role in fibromyalgia (Martínez-Lavín M., 2020). The functional medicine approach to treating fibromyalgia aims at finding the root causes of the disease and correcting them, while continuing to support the patient holistically through the use of targeted therapies as well as with complementary alternative therapies (CAM) like massage therapy, nutrient therapy, acupuncture, etc. (Pfalzgraf et al., 2020).
Among the factors and conditions that are taken into consideration by functional medicine doctors when working with fibromyalgia patients are celiac disease, non-celiac gluten sensitivity, candida overgrowth, hypothyroidism, nutrient deficiencies, leaky gut and small intestine bacterial overgrowth, adrenal fatigue, mercury toxicity, and glutathione deficiency. While the research is still in its early stages, preliminary findings show that people affected by celiac disease and non-celiac gluten intolerance suffer from fatigue, musculoskeletal pain, and brain fog (Isasi et al., 2016). Several studies show that many patients affected by fibromyalgia, myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) also suffer from abdominal discomfort syndrome (ADS) and irritable bowel syndrome (IBS). A study from Maes et al. (2014) shows that the ME/CFS patients also presenting with ADS have higher than normal levels of “IgA and IgM responses to LPS or commensal bacteria” (Maes et al., 2014). Small intestine bacterial overgrowth and leaky gut are also associated with fibromyalgia. Treating the bacterial imbalance has been shown to ameliorate gastrointestinal and fibromyalgia symptoms (Logan & Beaulne, 2002).
Hypothyroidism can cause secondary fibromyalgia (Corsalini et al., 2017); therefore, failure to test and to address thyroid function will perpetuate fibromyalgia symptoms.
A Holistic Overview Of The Treatment OF Fibromyalgia
The functional medicine approach also looks at nutrient status and possible deficiencies: a meta-analysis of 40 observational studies show that fibromyalgia sufferers have lower levels of vitamin D, vitamin B12, magnesium and vitamin E compared to a control group (Joustra et al., 2017) (Pagliai et al., 2020). Studies also show that they have significantly lower levels of glutathione compared to control (Shukla et al., 2020).
The adrenal glands are our stress response system. Fibromyalgia patients are shown to have either hyper-cortisol or hypo-cortisol output, as well as HPA axis imbalances (Eller-Smith et al., 2018).
There are other factors that are assessed by functional medicine doctors who work with fibromyalgia patients. While there I was not able to find peer reviewed studies on them, I was able to find quite a bit of anecdotal evidence online. According to Dr. Amy Myers, MD, factors to consider are exposure to mold, mercury toxicity, and MTHFR gene mutations.
Lastly, functional medicine also focuses on the mind-body connection when treating fibromyalgia: a systematic review of the Cochrane Central Register of Controlled Trials shows that mind-body therapy is effective in improving quality of life, pain management, and mood issues in fibromyalgia sufferers. Mind-body therapy uses techniques such as biofeedback, mindfulness, relaxation and movement therapy (Theadom et al., 2015).
References:
Bair, M. J., & Krebs, E. E. (2020). Fibromyalgia. Annals of internal medicine, 172(5), ITC33–ITC48. https://doi.org/10.7326/AITC202003030
Chinn, S., Caldwell, W., & Gritsenko, K. (2016). Fibromyalgia Pathogenesis and Treatment Options Update. Current pain and headache reports, 20(4), 25. https://doi.org/10.1007/s11916-016-0556-x
Corsalini, M., Daniela, D. V., Biagio, R., Gianluca, S., Alessandra, L., & Francesco, P. (2017). Evidence of Signs and Symptoms of Craniomandibular Disorders in Fibromyalgia Patients. The open dentistry journal, 11, 91–98. https://doi.org/10.2174/1874210601711010091
Eller-Smith, O. C., Nicol, A. L., & Christianson, J. A. (2018). Potential Mechanisms Underlying Centralized Pain and Emerging Therapeutic Interventions. Frontiers in cellular neuroscience, 12, 35. https://doi.org/10.3389/fncel.2018.00035
Galvez-Sánchez, C. M., & Reyes Del Paso, G. A. (2020). Diagnostic Criteria for Fibromyalgia: Critical Review and Future Perspectives. Journal of clinical medicine, 9(4), 1219. https://doi.org/10.3390/jcm9041219
Häuser W. (2016). Fibromyalgiesyndrom Basiswissen, Diagnostik und Therapie [Fibromyalgia syndrome: Basic knowledge, diagnosis and treatment]. Medizinische Monatsschrift fur Pharmazeuten, 39(12), 504–511.
Isasi, C., Tejerina, E., & Morán, L. M. (2016). Non-celiac gluten sensitivity and rheumatic diseases. Reumatologia clinica, 12(1), 4–10. https://doi.org/10.1016/j.reuma.2015.03.001
Joustra, M. L., Minovic, I., Janssens, K., Bakker, S., & Rosmalen, J. (2017). Vitamin and mineral status in chronic fatigue syndrome and fibromyalgia syndrome: A systematic review and meta-analysis. PloS one, 12(4), e0176631. https://doi.org/10.1371/journal.pone.0176631
Logan, A. C., & Beaulne, T. M. (2002). The treatment of small intestinal bacterial overgrowth with enteric-coated peppermint oil: a case report. Alternative medicine review : a journal of clinical therapeutic, 7(5), 410–417.
Lord, R.S., & Bralley J. A. (2012) Laboratory evaluations for integrative and functional medicine. 2nd edition. Metametrix.
Maes, M., Leunis, J. C., Geffard, M., & Berk, M. (2014). Evidence for the existence of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) with and without abdominal discomfort (irritable bowel) syndrome. Neuro endocrinology letters, 35(6), 445–453.
Martínez-Lavín M. (2020). Holistic Treatment of Fibromyalgia Based on Physiopathology: An Expert Opinion. Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 26(5), 204–207. https://doi.org/10.1097/RHU.0000000000001455
Mease P. (2005). Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. The Journal of rheumatology. Supplement, 75, 6–21.
Pfalzgraf, A. R., Lobo, C. P., Giannetti, V., & Jones, K. D. (2020). Use of Complementary and Alternative Medicine in Fibromyalgia: Results of an Online Survey. Pain management nursing : official journal of the American Society of Pain Management Nurses, 21(6), 516–522. https://doi.org/10.1016/j.pmn.2020.07.003
Pagliai, G., Giangrandi, I., Dinu, M., Sofi, F., & Colombini, B. (2020). Nutritional Interventions in the Management of Fibromyalgia Syndrome. Nutrients, 12(9), 2525. https://doi.org/10.3390/nu12092525
Shukla, V., Kumar, D. S., Ali, M. A., Agarwal, S., & Khandpur, S. (2020). Nitric oxide, lipid peroxidation products, and antioxidants in primary fibromyalgia and correlation with disease severity. Journal of medical biochemistry, 39(2), 165–170. https://doi.org/10.2478/jomb-2019-0033
Theadom, A., Cropley, M., Smith, H. E., Feigin, V. L., & McPherson, K. (2015). Mind and body therapy for fibromyalgia. The Cochrane database of systematic reviews, 2015(4), CD001980. https://doi.org/10.1002/14651858.CD001980.pub3
The ideal body weight, IBW, is the optimal weight based on gender and height. The ideal weight for a woman my height, 5’ 3”, is 104 to 140 pounds. Unfortunately, ideal body weight is an incomplete measurement and does not necessarily reflect the health of a person. Height and gender are the primary factors determining ideal body weight, and some calculators take age into consideration. However, build, muscular development, and body fat percentage are not taken into account. Because of this, many athletes and fit individuals may be considered overweight based on the ideal body weight, while so-called skinny fat people may be well within their ideal body weight numbers.
The Ideal Healthy Body Has Little To Do With The Pounds Displayed On The Scale
When working with clients, I encourage them to ditch the scale and measurements like IBW and to focus instead on body composition, inches lost instead of pounds lost, and, if they really want to explore body composition and have some money to spend, I recommend utilizing tools like Dexa body composition scan and whole body phethysmography.
Excess body weight and body fat have a negative impact on health, and they come with numerous health risks, from type 2 diabetes to sleep apnea. One of the systems that is negatively impacted by obesity and being overweight is the cardiovascular system. Excess body fat is a major contributor to hypertension, which is the number-one cause of stroke. It is also harmful to the kidneys. People who are overweight or obese are also at higher risk for chronic inflammation and diseases of infertility like polycystic ovarian syndrome.
Being overweight or obese is also linked to at least 13 different types of cancers (including breast, thyroid, uterus and ovaries, as well as colon and rectum cancer). While the exact mechanisms aren’t clear, some possible ways in which excess body fat contributes to cancer concern DNA damage resulting from chronic inflammation. The estrogenic effect of fat tissue most likely increases risk of endometrial, breast, ovarian and uterine cancer. Obesity is also linked to high blood levels of insulin and IGF-1, which promote tumor development by inhibiting programmed cell death. Fat cells also produce the hormones adipokines, which have the ability to stimulate or hinder cell growth. It goes without saying that maintaining a healthy body weight is foundational for cancer prevention.
The Mediterranean Diet And Healthy Body Size
The Mediterranean diet is touted as one of the healthiest of the planet. There is not one Mediterranean diet but several variations, depend on the region. While different Mediterranean countries eat different foods, there are staples consumed throughout the Mediterranean, from Italy to Greece to Spain: fresh seasonal vegetables, fish, lamb, nuts, legumes, herbs and spices, some nuts and seeds, and our stars: olives and olive oil. The Mediterranean diets avoid added sugars, highly processed foods, trans-fats, and refined vegetable oils. Water is the beverage of choice; coffee and teas are widely consumed, and wine is also included in moderation.
The Mediterranean diet is rich in fiber and healthy fats, and it is the diet of choice for heart health. Studies show that it improves lipid profiles, decreases lipid oxidation and reduces risk of thrombosis.
The Paleolithic Diet And Reaching Ideal Body Composition
The Paleolithic diet focuses on the foods eaten by our ancestors during the Paleolithic era, when humans were hunter-gatherers. While there are several variants of the diet, the Paleolithic diet (or “paleo”) removes sugar, processed foods, vegetable oils, trans-fats, legumes and grains. It includes meat, poultry, fish, vegetables and fruit, nuts and seeds. Some variations incorporate dairy. Potatoes were initially excluded, but in recent years they have been added to the list of allowed foods. The paleo diet therefore removes many inflammatory foods (processed foods, trans-fats), as well as foods that trigger food sensitivities (gluten and dairy). A 2009 study showed that the Paleolithic diet was superior to the diabetes diet in managing cardiovascular risk factor in patients with type 2 diabetes. Other studies show improvement in serum biomarkers for cardiovascular disease.
Paleolithic Diet Versus Mediterranean Diet
While both diets are beneficial for cardiovascular disease, my preference would be to start a client on the Paleo diet. I like using the paleo diet as an elimination diet. Usually, after an initial phase (lasting 1 to 2 months depending on the client), I carefully and slowly reintroduce foods allowed in the Mediterranean diet. This allows added variety which can help stave off boredom which is extremely important for compliance. Ultimately, the choice will be the client’s. It would be unwise to recommend a Paleo diet to a client who is not likely to comply with such restrictive way of eating. In my practice, clients are active participants in setting goals and how to reach them.
References:
Ortega‐Loubon, C., Fernández‐Molina, M., Singh, G., & Correa, R. (2019). Obesity and its cardiovascular effects. Diabetes/metabolism research and reviews, 35(4), e3135.
Peterson, C. M., Thomas, D. M., Blackburn, G. L., & Heymsfield, S. B. (2016). The universal equation for estimating ideal body weight and body weight at any BMI. The American journal of clinical nutrition, 103(5), 1197-1203.
Obesity and Cancer Fact Sheet – National Cancer Institute [Internet]. 2017 [cited 2020 Nov 2]. Available from: https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet
Dağ ZÖ, Dilbaz B. Impact of obesity on infertility in women. J Turk Ger Gynecol Assoc. 2015;16(2):111–7.
Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., … & Djousse, L. (2020). Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation, E139-E596.
Mediterranean diet for heart health [Internet]. Mayo Clinic. [cited 2020 Nov 2]. Available from: https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet/art-20047801
Jönsson T, Granfeldt Y, Ahrén B, Branell U-C, Pålsson G, Hansson A, et al. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 2009 Jul 16;8:35.
Sharman MJ, Kraemer WJ, Love DM, Avery NG, Gómez AL, Scheett TP, et al. A ketogenic diet favorably affects serum biomarkers for cardiovascular disease in normal-weight men. J Nutr. 2002 Jul;132(7):1879–85.
Cystic Fibrosis (CF) is a genetic disorder that affects a protein that regulates membrane transport and creates the main epithelial cell chloride channel. In CF sufferers, disorders of the epithelial cell chloride channel cause mucus and other secretions to become excessively vicious. The viscosity of mucus flattens the cilia and causes excessive phlegm, chronic respiratory infections, exocrine pancreatic insufficiency, frequent bowel movements, poor weight gain, nutritional deficiencies, and multiple organ dysfunctions. About a third of CF sufferers develops CF-related diabetes.1
In the pancreas, excessive mucus viscosity clogs the pancreatic ducts and impairs transport of pancreatic enzymes and pancreatic juice to the small intestine. The secretions backflow into the pancreas, causing chronic inflammation.
In the duodenum, the lack of pancreatic enzymes leads to fat and protein maldigestion, as well as vitamin malabsorption. Lack of bicarbonate secretions cause the pH of the chyme to remain too acidic, further exacerbating maldigestion.
The gallbladder is also affected as the viscosity of the mucus can block the bile duct, preventing bile flow and causing the bile to become thick and viscous. This further exacerbates fat maldigestion and malabsorption of fat-soluble vitamins.
If You Suffer From CF Make Sure You Eat Nutrient Rich Food To Give You The Energy You Need
CF sufferers have considerably higher energy requirements, caused by the chronic inflammation. For this reason, a high-calorie, high-fat, nutrient dense diet is recommended. There should be an emphasis should also be placed on healthy proteins and nutrient-rich foods. Foods high in omega-6 fatty acids are best avoided. High intake of omega-6s is linked to increased oxidative stress and has a pro-inflammatory effect, especially on lung tissue2 while omega-3 fatty acids have proven beneficial in reducing sputum volume and improving lung function3.
Nutritional therapy for Cystic Fibrosis must also focus on supplementation. Pancreatic enzyme supplements need to be taken with every meal to improve nutrient absorption. Supplementation of fat-soluble vitamins, zinc, selenium, vitamin B12, EFAs, iron, calcium, and vitamin B6 is also indicated.
Glutathione is also recommended as it shows to improve pulmonary function and increase the resistance of the lungs against Pseudomonas infections.4
References:
1C. Mansbach, P. Tso, A. Kuksis (Eds.), Intestinal lipid metabolism, Kluwer Academic/Plenum Publishers (2001).
2 Woestenenk JW, Castelijns SJ, van der Ent CK, et al. Dietary intake in children and adolescents with cystic fibrosis. Clin Nutr. 2014;33(3):528-32. [PMID:23920501]
3 Oliver C, Watson H. Omega-3 fatty acids for cystic fibrosis. Cochrane Database Syst Rev . 2016; CD002201-CD002229. Back to Citation
4 Bishop C, Hudson VM, Hilton SC, Wilde C. A Pilot Study of the Effect of Inhaled Buffered Reduced Glutathione on the Clinical Status of Patients With Cystic Fibrosis. CHEST. 2005 Jan 1;127(1):308–17.
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