An Intro to Intuitive Eating

 
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Have you heard about Intuitive Eating but aren’t quite sure what it means?

Intuitive Eating (IE) is a flexible, non-diet approach to eating and exercise that considers physical, mental, and emotional health. The IE framework was developed by registered dietitian nutritionists Evelyn Tribole and Elyse Resch after many years of working with nutrition clients and witnessing their struggles with dieting, weight loss (and regain), and body image.

From the cover of the Intuitive Eating book by Tribole and Resch, IE helps people “make peace with food, free yourself from chronic dieting forever, and rediscover the pleasures of eating.” Learning and practicing the principles of IE helps people to tune out external messages about what and how much they should eat and tune into their personal hunger, fullness, and feelings of satisfaction with food.

We are born natural intuitive eaters until we learn and internalize food rules set by our (usually well-meaning) parents and later, diet gurus and weight loss companies, media, advertising, and peers. For many people this causes distrust and distress with their bodies and food. Practicing IE helps people get back into attunement with their bodies so they can stop stressing about food and focus on other things that give them meaning and satisfaction in life.

There are ten principles of Intuitive Eating that guide people to relearn trust in their bodies and the joy of eating.

 
 

I plan to write more about each principle and how you can start applying them in future posts!

Why I adopted this approach

Learning more about IE and a weight-neutral approach to health has changed the way I practice nutrition for the better.

My education and training in dietetics and nutrition didn’t really prepare me for all of the shame and guilt so many people have about food and their bodies. No amount of meal plans, calorie tracking, or education on portion sizes can fix that, even if that’s what people ask for. In fact, it just makes most people feel worse when they can’t follow a plan and reinforces a restrictive mindset about food. People tend to start thinking they’re the problem--they’re just not trying hard enough or something is wrong with them. I became a dietitian to help people reach optimal health--however that looks for them--while enjoying food and this wasn’t the way.

I needed and sought out more knowledge and training in navigating the complex emotions that come up in nutrition counseling. This is when I learned about the concept of Intuitive Eating and immediately bought the book. After reading the book I also delved into courses, podcasts, weight science research, eating psychology, and numerous blog posts from other dietitians and therapists on IE and weight-neutral approaches to health.

I learned that attempts to lose weight tend not to produce long-term results for most people. Intentional weight loss attempts can also lead to biological and psychological stress and disordered eating. Yo-yo dieting (weight loss and regain over and over) has been linked to heart disease, insulin resistance, inflammation, increased blood pressure, and a return to a higher weight than baseline.

On the other hand, studies on intuitive eaters have shown several benefits.

 
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You can learn more about the research on the Intuitive Eating website.

Considering the harm diets and restrictive eating can cause and the benefits that Intuitive Eating has, adopting this approach to helping people in my practice and in my own life was a no-brainer.

Now I have the tools help my clients move away from the mindset that health = losing weight and adopt more sustainable practices to achieving their health goals.

If you’re tired of trying diet after diet and would like one-on-one guidance to a better relationship with food and your body, I’d love to help you get started!

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I'm really excited to start the conversation on Intuitive Eating by sharing this guest post from the talented Taylor Wolfram, MS, RDN, LDN! Taylor is a fellow vegan dietitian who also coaches clients in Intuitive Eating, as well as working a day job in nutrition communications. 

If you've ever wondered how meal planning fits in with Intuitive Eating, Taylor's post is a great introduction!

Interested in intuitive eating?

This non-diet approach to eating was developed by two registered dietitians in the 1990s and continues to gain in popularity. Research shows intuitive eating can improve mental and physical health without stressing about food or focusing on body weight.

The great thing about intuitive eating is there are no rules! The 10 principles of intuitive eating help you reject diet mentality and instill trust back in your body to tell you when, what and how much to eat.

 

While intuitive eating is a journey and there’s really no such thing as “failing” at it, there are a few things you can do to set yourself up for success. In order to honor your hunger, you need to have access to tasty, nourishing food that you enjoy. This is where a little planning and prepping go a long way!

Intimidated by the thought of meal planning and prepping? I get it. Contrary to what you might see on social media, it doesn’t require you to spend all day in the kitchen or plan out every morsel of food you’re going to eat for the week ahead. In fact, just a little extra effort can make a huge difference and help you stress less about food.

3 Food Strategies for Intuitive Eating Success

Buy Your Favorites

This is the planning piece. Keeping a variety of food in the house is key to moving past restrictive eating and fulfilling your hunger and cravings. Think through the building blocks for satisfying meals and snacks, including grains, veggies, fruits, protein foods, calcium-rich foods and fun foods. When you’re writing your grocery list, jot down items in each category or food group that you know you enjoy and that can be mixed and matched in different meals and snacks.

Batch Cook

This is where the prepping comes in. If you know you enjoy rice and quinoa as the base to meals, cook batches of these grains and refrigerate or freeze so you can quickly create meals without having to wait for them to cook. The same goes for your favorite beans, veggies, etc. If it seems like you’re always short on time, this can really help prevent time from being an excuse as to why you aren’t able to feed your body what it wants.

Keep a Snack Stash

Whether it’s at the office, in your car or wherever else you spend your time, it’s important to ensure you’re able to eat when hunger strikes. Non-perishable snacks such as nuts, dried fruit and snack bars are great to toss in your bag and carry around with you. If you have access to a fridge or can keep perishable food cold with a cold pack in an insulated bag, dips and veggies and cut fruit are tasty choices. Whatever your favorite snacks, make sure you’ve got a reliable stock at all times!

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Taylor Wolfram, MS, RDN, LDN

Taylor uses a non-diet approach to health and wellness and provides virtual lifestyle coaching to help clients prioritize self-care, ditch dieting and make peace with food and their bodies.

Learn more about Taylor and follow her here:
www.wholegreenwellness.
www.twitter.com/taylorwolframrd
www.instagram.com/taylorwolframrd
www.facebook.com/wholegreenwellness

Fibromyalgia Awareness Day

Last Saturday, May 12th, was the 20th annual Fibromyalgia Awareness Day. In true me fashion, I’m a couple of days late but wanted to acknowledge the day with a short post.

The main thing that I personally would like people to be aware of, and I think many people with fibromyalgia syndrome (FMS) would agree, is that FMS is a REAL medical condition, not a “wastebasket” diagnosis or all in your head as some people (doctors included) suggest.

Yes, FMS is an invisible illness without a specific lab marker to confirm it (yet), so I understand that people without personal experience of chronic illness may have a difficult time wrapping their head around its existence. However, FMS does have diagnostic criteria and physicians use this in conjunction with ruling out other diseases with overlapping symptoms to make a diagnosis.

There have also been multiple observed differences in biological function is people with FMS, although they are not currently being used as diagnostics for the condition. Using fMRI, researchers have found differences in brain activity in response to pain. Higher levels of substance P, a peptide involved in increased pain sensation, has also been detected in the cerebrospinal fluid of people with FMS.

You don’t have to fully understand something in order to practice compassion toward a loved one or coworker dealing with this diagnosis. Sometimes just asking what their experience with FMS is like and what helps them feel better can go a long way in showing someone that you support them. For the person with FMS, not having to struggle to convince the people in their lives that it’s a real and chronic condition makes life a bit easier. Dealing with a chronic illness is tough enough on its own. 

What's one thing you'd like people to know about living with fibromyalgia?

If you’d like to learn more about fibromyalgia I’d suggest checking out these links:

Fibromyalgia-- Harvard Medical School

Common misconceptions about fibromyalgia

Chronic Pain - Is it All in Their Head? - Daniel J. Clauw M.D

The Hidden Reality of a Fibro Warrior

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It’s not news that eating more fruits, vegetables, and other plant foods is good for our health, but many of us are still not eating close to the recommended daily servings (5-9 servings a day of fruit and vegetables). Besides personal health, a plant-based dietary pattern can save you money on groceries and help protect the planet and animals used for food. Getting started doesn’t have to be complicated and you don’t have to overwhelm yourself and change everything overnight (unless that’s how you do things. In that case, go for it!). Here are some of my best tips for getting more plant-based meals into your weekly rotation.

Make a Plan

I’m sure you’ve probably heard the saying “if you fail to plan, you plan to fail.” It definitely applies to changing your eating habits! Planning ahead will ensure that when meal time comes around and you’re getting hungry, you’ll know what you're making and have your ingredients at the ready. Planning your meals at least a couple of days ahead of time will prevent you from grabbing take-out or eating chips and salsa for dinner because that’s what’s in your kitchen (guilty).

Meal planning can be as simple as writing out what you’ll have on your calendar or notepad and then making a grocery list of the ingredients you need from there. Or you could print out meal planning sheets or use an app to keep track of everything.

If you're just starting out with plant-based meals, pick one meal a day or one day a week to eat plant-based and increase from there once you've accomplished that goal. Meatless Mondays are a popular way of helping people eat plant-based at least one day a week. 

There are also several plant-based meal planning services, some paid and some free. Lighter, Forks Over Knives, EatLove, and Plant-based on a Budget are just a few. Explore them and find what works best for you.

Make Plant-based Versions of Your Favorites

Plant-based food often has the stigma of being unsubstantial “rabbit food” or entirely different to what most people are eating but that isn’t the case. Anything omnivores eat, plant-based eaters can eat, too, with some simple substitutions. Are tacos your favorite? Swap lentils, veggie crumbles, seasoned tofu, or beans for the usual meat and top with cashew sour cream or guacamole.  Love Indian food, burgers, mac and cheese, or BBQ? Check out my links for delicious, plant-based versions of all of these. Think about your current favorite meals and how you can make satisfying meat- and dairy-free versions. Get creative on your own or use cookbooks or recipe sites for inspiration. Minimalist Baker, The Full Helping, Vegan Richa, and Hot for Food are some of my favorite recipe blogs.

Stock Your Fridge & Pantry

As you use up your current stock, buy plant-based versions of your usual staples, like plant-based milks, cheese, ice cream, mayo and other condiments, etc. Know that plant-based versions usually won't taste 100% the same as animal products (many taste even better) and give your taste buds time to adjust. Try different brands and flavors. For example, if you didn't like the provolone-style dairy-free cheese, you may love the pepper jack; if one type of veggie burger is too mushy, try another brand next time.  

Keeping convenient foods stocked will help you throw together quick meals. Convenient doesn't have to mean ultra-processed, either. Having pre-washed salad greens, canned beans, nuts, seeds, tortillas/wraps, your favorite condiments and dressings, and fresh and frozen vegetables and fruit can make whipping up plant-based meals fast and simple. 

Join a Meal Delivery Service

Meal delivery services seem to be springing up all over lately. If you can afford this option, it can be a great way to try new plant-based meals without the hassle of digging up recipes and grocery shopping yourself. Some services deliver premade meals that you just have to heat up when ready to eat and others deliver recipes and ingredients for you to cook. Two companies that offer plant-based meals are Purple Carrot and Hungry Root.

Find Recipe Sharing Communities

If you’re on Facebook, there are several groups and pages that share plant-based recipes. I searched “vegan recipes,” “plant-based recipes,” and “whole food plant-based recipes” and came up with dozens of groups! This can be helpful for finding tried and true recipes before you spend your hard earned cash on ingredients for a new recipe that may turn out to be not-so-great. 

Take a Vegan Cooking Course

In person or online, there’s no better way to learn than by hands on cooking. Check your local Whole Foods, culinary school, Sur la Table, and community ed classes for vegan cooking classes. Online options include Forks Over Knives, JL Fields, and if you’re really serious about mastering your culinary skills, you can get a professional certification in plant-based cooking through Rouxbe! (feel free to ask me questions—I completed this training in 2015). You can also find free cooking demos on YouTube.  

Find Restaurants That Have Plant-Based options

If cooking isn’t really your thing, or you just want to treat yourself, check out Happy Cow to see what restaurants in your area have vegetarian and vegan options. So many restaurants these days have at least one or two things on the menu plant-based eaters can choose from. Even better is to try fully vegan restaurants and be amazed (and sometimes overwhelmed) at all the choices!

Host a Plant-Based Potluck or Dinner Party

Having the support of friends and family can make healthy eating easier and so much more fun and open others to new foods, too. You could try having a theme like vegan BBQ, holiday foods, dishes inspired by a favorite movie or show, a regional cuisine, etc. There is no limit to your creativity with this!   

Whether you intend to eat 100% plant-based or simply up your plant food intake, I hope you found some helpful information to get started. Please post your questions and tips below or contact me. I'd love to help guide your way to satisfying, healthful plant-based eating! 

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On this last day of National Nutrition Month, I thought I’d write about what a Registered Dietitian/Registered Dietitian Nutritionist (RD or RDN) is and what we do (and maybe a little about what we don’t do).

From some of the questions and responses I’ve gotten when asked what I do, I have a feeling many people are confused about our role if they even knew we existed in the first place! People have asked me to make them a meal plan (for free, of course), what trendy diet I think is best, to not look at what they’re eating because they think I’ll judge them, if eating x food is bad, and if they should buy x supplement or shake for weight loss. This tells me RDs have an image problem of being the food police or diet pushers and I want to help destroy those stereotypes!

This post doesn't encompass all possible areas of nutrition careers, but hopefully it gives you a better idea of what RDs who see people one-on-one do (and that it's so much more than telling people what to or what not to eat). 

Our Training

RDs have at least a bachelor’s degree in dietetics and nutrition from an accredited university (a master’s degree will be required for entry-level RDs in a few years) + 1200 or more hours of supervised practice in clinical, community, and food service nutrition, and have to pass the national registration exam before being eligible to practice. We learn behavior change skills, biochemistry, anatomy and physiology, nutrient metabolism, therapeutic nutrition for many conditions, traditional foods of various cultures, drug and nutrient interactions, food safety, nutrition policy, and SO MUCH more. This is what distinguishes our training from a “nutritionist” or "health/nutrition coach" which aren't regulated titles.

That means pretty much anyone, regardless if they have any training or a degree in nutrition science, can call themselves those things and start giving nutrition advice and selling supplements. Which is scary when you think about the harm it can cause giving someone with a health condition bad information (disclaimer: not saying every nutritionist or coach gives bad advice or every RD is perfect, so please don't be offended). Would you want someone who wasn't qualified advising your grandma with chronic kidney disease on nutrition and her ending up in the hospital from dangerous levels of potassium and phosphorus in her body? Likely not. Some RDs (including me) are now using the credential Registered Dietitian Nutritionist (RDN), which is equal to the RD credential, but sort of a reclaiming of the title “nutritionist.”

What RDs Do

Similar to doctors, we can be general practitioners, seeing people for a variety of nutrition concerns, or specialize in areas like pediatric, renal, oncology, cardiac rehab, digestive health, or diabetes. Some of us branch out from hospital or clinic jobs into private practice and create our own unique specialties, seeing clients in an office or virtually through secure video conferencing. Some of my RD colleagues in private practice specialize in skin care, food sensitivities, Intuitive Eating, eating disorder recovery, blenderized food for tube feedings, lactation consulting, and plant-based nutrition. Our jobs are as varied as there are nutrition needs!

During an appointment, we’ll look at your health history, labs, medication and supplements, what you typically eat, your food likes and dislikes, and other important info, ask you questions to clarify information and determine your goals, work with you to come up with a plan, provide resources and handouts if necessary, and support you through follow-up appointments. Most of all, a good RD will really listen to you. We have the benefit of longer appointment times so you're not rushed like it can feel at a doctor appointment. 

 Behind the scenes, we’re working on education materials, keeping up with the latest research, taking courses or attending seminars for continuing education, communicating with your doctor or other members of your healthcare team, and typing up notes.

With the word “diet” being a part of our title, I know it can be confusing, but our focus is less “dieting” to lose weight and more your diet as in overall pattern of what you eat and how that can affect your health and nutrition status. Some RDs absolutely work with people who want to lose weight, but that’s just a small part of our skill set. Many RDs don’t offer weight loss as a service at all and are pushing back against diet culture, weight stigma, and helping people recover from damage long-term dieting can cause. Food is only one piece of the health puzzle and focusing too much on weight and calories aren’t healthful behaviors. I’ve had many people be surprised that I actually helped them expand the amount and types of foods to eat instead of restricting all their favorite things like they were expecting.

Seeing an RD legitimately changes people's lives for the better! I might be biased, but from my own experiences and hearing about others, it's true. RDs have helped so many people deal with difficult and painful digestive issues, reduce or eliminate medications (under a physician's supervision), lower their cholesterol or blood pressure, find foods they could eat when they have food allergies or intolerances, feed picky kids, recover from an eating disorder, stay nourished through cancer treatment, and so many other scenarios. It's always my goal and I feel so fortunate to be in this field when someone tells me I helped them solve a problem.  

Should You See an RD?

If you want expert, individualized advice sorting out a health issue or just want to learn how to eat better, then absolutely! Many RDs offer a free consultation call so you can see if you're a good fit to work together. Seeing an RD one-on-one is usually so much more effective than reading a popular diet book or following a general plan that will probably not meet your individual needs. RDs can help you cut through the misinformation that is so common in the media and popular wellness culture, come up with an action plan to help you meet your health goals, and support and encourage you through it. 

So, Will I Make You a Meal Plan?

Possibly, if it fits your needs and you want help getting started with a new way of eating! I'd rather help you learn how to create healthy meals on your own, so you don't have to rely on a plan, though. And...you have to pay me. :) 

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Welcome to my blog! I'm so happy you're here. I want to start with a topic that's near and dear to my heart: fibromyalgia. Diagnosed in my 20s, this is a complex chronic pain syndrome that has deeply affected my life, along with an estimated 5 million Americans (75-90% are women). 

Symptoms include fatigue, widespread muscle/soft tissue pain, stiffness, sleep disturbance, chemical and environmental sensitivities, migraine, and memory and concentration issues (aka fibro fog). There are also overlapping conditions that some fibro sufferers experience, such as lupus, rheumatoid arthritis, anxiety and depression, TMJ disorder, and irritable bowel syndrome (IBS).

Although there is not yet a cure for fibromyalgia, and this can feel hopeless, there are treatments and lifestyle modifications that can be made to ease symptoms. The severity of symptoms can wax and wane, as well, sometimes flaring or going into remission for a period of time. 

There is no one diet that works for all people with fibromyalgia, but there are a number of things that can help address symptoms and support overall health. When you already feel like you've been trampled by a herd of elephants, the last thing you want is to feel even worse because of what you eat. 

Address Nutrient Deficiencies

Studies have shown a correlation with chronic pain and low vitamin D. One small randomized controlled study showed promise of pain reduction in women with fibro who supplemented with vitamin D. Other studies have shown that low vitamin D is associated with anxiety and depression in people with fibro. Have your levels checked (25-hydroxy vitamin D blood test) by your doctor to determine if supplementation is appropriate for you.  

Magnesium, selenium, and other antioxidants were found to be low in people with fibromyalgia. Whether this contributes to the symptoms of fibro or is a result of the disorder is unclear. Improving antioxidant status through including plenty of colorful fruits, vegetables, and legumes (beans, peas, lentils) is typically more beneficial than supplementing because you're getting all the nutrients of the whole food and studies on antioxidant supplements have not shown to be helpful in disease prevention (and supplementation is sometimes harmful). 

Foods high in magnesium include beans, sunflower, pumpkin, sesame, and chia seeds, dark leafy greens like kale, and whole grains. The RDA for magnesium is 320mg for women and 420mg for men. 

Selenium is found in high amounts in Brazil nuts. Just one large Brazil nut can contain over 2x the RDA for selenium, if grown is selenium-rich soil. Beans, whole grains, nuts, and seeds are also good sources. The adult RDA is 55 micrograms per day. 

Eat a Balanced Diet

The first line of defense to prevent nutrient deficiencies is to make sure we're getting the vitamins and minerals we need from our food when possible. Some nutrients, like vitamin D, can be difficult to get from food only.  In general, I only consider supplementing if someone is already eating a nutrient-dense diet but has a deficiency confirmed by a blood test. 

Decreasing refined, processed foods that are typically low in micronutrients and high in sodium and/or sugar (such as white bread, pastries, and frozen meals) is the best place to start. Simple, homemade meals with fresh ingredients as often as you can will provide your body with the nutrients it needs. A good rule of thumb to is to make half your plate non-starchy vegetables of all colors, including dark leafy greens that contain magnesium, vitamin k, calcium, and iron. To make things easy, I keep frozen kale, spinach, and broccoli on hand so I can add them to whatever I'm cooking. 

Eating regularly and not skipping meals is important for stabilizing blood sugar and energy levels. If you're going more than 4-5 hours between meals, try to have a snack that includes complex carbohydrates, a healthy fat, and protein, such as an apple with peanut butter (or small handful of almonds), or whole grain crackers with hummus and veggies. 

Investigate Possible Food Sensitivities

Along with environmental sensitivities, some people with fibromyalgia have food or food additive (such as MSG or aspartame) sensitivities, especially if IBS or migraines are an issue. It's important to note that food sensitivities differ from food allergies. Registered Dietitian Erica Julson has a great post here about the differences between an allergy, intolerance, and sensitivity to food. 

Keeping a food and symptom journal for at least a couple of weeks may help you notice patterns. If you suspect food sensitivities, it's best to get the support of an experienced health practitioner (physician or dietitian) before trying an elimination diet. The goal of an elimination diet is to determine the culprit(s) that may be causing digestive upset or other symptoms and to then include the widest variety of foods that do not cause symptoms.

Elimination diets can sometimes trigger disordered eating behaviors in some people, so if you have a history of an eating disorder, please get the advice of a healthcare professional before attempting one. 

It's also important to note that digestive symptoms can also be caused by stress, so sometimes it may seem like food is the issue when it's not. People with fibromyalgia are prone to digestive issues due to our hyperactive nervous systems. If digestive disturbances (bloat, nausea, constipation, diarrhea) are affecting your quality of life, a consult with a gastroenterologist (GI doctor) is best before making any diet or supplement changes on your own. 

Eat More Plants

There are a few studies that show switching to a vegan diet reduced fibromyalgia pain and other symptoms in some participants. These were small, preliminary studies, though, and more research is needed.  Regardless if you remove all animal products, greatly increasing your plant food intake can provide health benefits, including reduced inflammation from increased antioxidant intake and better digestion from more fiber. Healthful plant-based diets have also been shown to be preventive in certain diseases like type 2 diabetes, heart disease, and some cancers. 

Hydrate 

This is important for everyone, but people with fibromyalgia will want to especially make sure to drink plenty of water. Dehydration can lead to headaches, fatigue, irritability, and constipation--all things that can make you feel worse. I definitely notice a drop in energy if I haven't been getting enough fluids! 

Watching your intake of alcohol and caffeinated drinks is helpful as well. If you have anxiety or panic disorder, I would consider reducing or eliminating alcohol and caffeine as both can exacerbate it. I know it's tempting to reach for caffeine when you have low energy, but it can be counterproductive and affect sleep, which is already disrupted in most people with fibromyalgia . 

Switch to herbal teas, sparkling water infused with fruit or herbs, and mocktails (non-alcoholic cocktails) if you want something other than plain water. There are some amazing sounding infused water recipes here and one of my favorite herbal teas is here to give you a couple of ideas. 

In Summary

  • Have your doctor test for any nutrient deficiencies and supplement if needed.

  • Eat a well-balanced, whole foods, plant based-diet.

  • If you suspect food sensitivities play a role in your symptoms, ask your doctor for a referral to a GI specialist and keep a food and symptom journal to bring to your appointment.

  • Drink plenty of fluids, reduce caffeine and alcohol consumption.

If cooking meals from scratch or changing your diet seems daunting to you, start with one small change at a time and go from there. A registered dietitian can provide individualized advice and support. Also, stay tuned for future posts on how to make meal prep easier and other simple changes you can make to feel better. 

I'd love to hear what has worked for you or one change you'd like to try--please share in the comments! 


References

Florian Wepner, Raphael Scheuer, Birgit Schuetz-Wieser, Peter Machacek, Elisabeth Pieler-Bruha, Heide S. Cross, Julia Hahne, Martin Friedrich. Effects of vitamin D on patients with fibromyalgia syndrome: A randomized placebo-controlled trial. PAIN®, 2014; 155 (2): 261 DOI: 10.1016/j.pain.2013.10.002

https://nccih.nih.gov/health/antioxidants/introduction.htm

K. Kaartinen, K. Lammi, M. Hypen, M. Nenonen, O. Hänninen, A.-L. Rauma (2009)Vegan diet alleviates fibromyalgia symptoms, Scandinavian Journal of Rheumatology, 29:5, 308-313, DOI: 10.1080/030097400447697

Arranz LI, Canela MA, Rafecas M. Fibromyalgia and nutrition, what do we know? Rheumatol Int 2010;30:1417-1427.

Hänninen O, Kaartinen K, Rauma AL et al (2000) Antioxidants in vegan diet and rheumatic disorders. Toxicology 155:45–53 24. Donaldson MS, Speight

N, Loomis S (2001) Fibromyalgia syndrome improved using a mostly raw vegetarian diet: an observational study. BMC Complement Altern Med 1:7