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Chronic Fatigue / Lassitude / Tiredness

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Chronic FatigueWhat Is Chronic Fatigue?

Chronic fatigue or lassitude is a state of weariness not relieved by rest and the inability to do normal physical or mental work.

Q: What are causes of chronic fatigue?

A: Chronic fatigue can be a feature of many disorders including nutritional problems like poor diet or malabsorption, sleep problems, systemic conditions like anemia or heart disease, respiratory disorders like COPD or asthma, infectious disease like tuberculosis, endocrine disorders like diabetes, autoimmune disease like thyroid disease, and cancer.

Fatigue greatly reduces quality of life in all aspects including the desire and ability to socialize and find fullfillment in new and interesting ways.

What Is Chronic Fatigue In Celiac Disease and/or Gluten Sensitivity?

  • Relationship between chronic fatigue and celiac disease. Chronic fatigue that is unexplained is a classic symptom of celiac disease and a frequent presentation in visiting the doctor.
  • Relationship between chronic fatigue and diet.  In a study of 5912 celiac support group members with a biopsy-confirmed diagnosis of celiac disease or dermatitis herpetiformis, the length of time on a gluten free diet was positively associated with symptom recovery. In persons adhering to a gluten free diet, 44% reported fatigue as a reaction to gluten exposure.1
  • Relationship between chronic fatigue and diet in children. There is a statistically significant decrease in the incidence of chronic fatigue in children compliant with a gluten free diet compared to children at diagnosis and children who were not compliant.2
  • Relationship between chronic fatigue and gut symptoms. The presence or absence of gastrointestinal symptoms does not correlate with fatigue score.3 This means that the severity of fatigue should not be considered in terms of gut symptoms but rather that fatigue develops from nutritional deficiencies.
  • Relationship between chronic fatigue and depression. In adult patients with celiac disease, fatigue is a common finding and is strictly correlated with depression.4
  • Relationship between chronic fatigue and body mass index. Adult celiac disease patients with chronic fatigue showed a significantly lower body mass index than controls, meaning they were thinner, and lower serum iron.3
  • Relationship between fatigue and stress. Psychological stress is produced in celiac disease both by the effects of gluten and by insufficiency of many nutrients. Such stress activates multiple physiological processes aimed at maintaining balance within the body. However, these physiological processes also have the capacity to influence the composition of microbial communities in the digestive tract, and research now indicates that exposure to stressful stimuli leads to gut dysbiosis.5 Importantly, dysbiosis in turn worsens fatigue.
  • Relationship between chronic fatigue and quality of life. A study investigating fatigue and quality-of-life in 51 patients showed that the greater the fatigue the worse the quality of life scores (inversely correlated). Fatigue severity was also greater in patients with worse quality of life (13 vs. 2). Multiple regression analysis showed fatigue to be an independent determinant of quality of life.6

How Prevalent Is Chronic Fatigue In Celiac Disease and/or Gluten Sensitivity?

Study results vary:

  • In a Canadian questionnaire involving 5912 adults with a biopsy-confirmed diagnosis of celiac disease or dermatitis herpetiformis nationwide, extreme tiredness before diagnosis was reported by 74.2% of respondents. In less than a year, 42% recovered from fatigue. Within 5 years, 72.4% recovered from fatigue.1
  • Chronic fatigue is a common complaint at diagnosis in 75% of patients.7
  • In a study of 106 consecutive Irish patients with adult celiac disease, the prevalence of fatigue  was 8%.8
  • Fatigue was found in 33% of the children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in these children with gluten sensitivity.9
  • In the reverse, the prevalence of celiac disease was found to be 3.3% in research participants with chronic fatigue.10

What Are The Symptoms Of Chronic Fatigue?

  • Chronic fatigue is marked by a sense of exhaustion, and
  • Decreased capacity to do normal physical or mental work.

How Does Chronic Fatigue Develop In Celiac Disease and/or Gluten Sensitivity?

  • Chronic fatigue results from inflammation in the body due to gluten, and/or
  • Nutritional deficiencies from malabsorption in celiac disease that most commonly involve carbohydrates, proteins, vitamin B1 (thiamin), vitamin C, vitamin D, iron, calcium, zinc, and magnesium. Please visit each of these nutrient posts to see which ones are causing your fatigue. For example, while vitamin D deficiency itself is a cause of fatigue, it will lead to calcium deficiency as an additional cause of fatigue plus all the other problems that come with these deficiencies.

Does Chronic Fatigue Respond To Gluten-Free Diet?

Yes. Celiac disease-related fatigue responds to a strict gluten free diet in most, but not all, patients.11 Supplementation may be required at diagnosis and thereafter for nutritional deficiencies that persist.

It has been established that many persons do not regain absorption of all nutrients even when the small intestinal mucosa heals with elimination of gluten. On the other hand mucosal recovery was reported in only 66% of adults with celiac disease after five years of treatment with a gluten free diet.12 As a cause, gluten ingestion perpetuates intestinal damage and malabsorption causing nutritional deficiencies.

Follow-up with a physician and a dietitian is essential for all patients with celiac disease, especially for patients who experience difficulty maintaining a gluten free diet.11

6 Steps To Improve Chronic Fatigue In Celiac Disease and/or Gluten Sensitivity:

Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both fatigue and gut health.

  • Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
  • A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
  • Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

  • Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
  • Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.13
  • The intestinal lining may take up to a year to heal.
  • 2 Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

Here Are Major Inflammatory Food Types That Reduce Healing:

  • Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.14
  • Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
  • Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.14
  • Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.14.
  • Excessive Refined White Flours (bran layer removed)Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.14
  • Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
  • Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.14
  • Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.14
Here Are Important Anti-Inflammatory Food Types to Promote Health:

  • Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
  • Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
  • High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
  • Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
  • Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
  • Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
  • Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
  • Protective Herbs and Spices.  See below #6 below for examples.
  • 3 Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

 

  • 4 Manage Your Medications Safely:

Certain prescription drugs cause deficiencies of these nutrients that cause fatigue: vitamin B1 (thiamin), vitamin C, vitamin D, iron, calcium, magnesium, and protein. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

ANTIBIOTICS disrupt intestinal permeability.

  • Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins, Vitamin C.
  •  Tetracyclines deplete Calcium, Magnesium, Iron.

ANTI-INFLAMMATORIES disrupt intestinal permeability.

ANTICONVULSANTS

  • Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Calcium, Vitamin B1.

ANTIVIRAL AGENTS

BRONCHODILATORS

  • Inhaled corticosteroid inhalers (Flovent, Pulmicort and others) that are breathed in on a daily basis as a long term therapy to reduce inflammation in airways deplete Calcium, Vitamin D, and B vitamins.
  • Albuterol inhalers that are breathed in on a daily basis as a long term therapy and also for quick relief as rescue inhalers to open airways depletes Magnesium, Calcium.

CARDIOVASCULAR DRUGS

  • Antihypertensives (Catapres®, Aldomet) deplete Vitamin B1.

CHOLESTEROL DRUGS

DIURETICS

  • Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Magnesium.
  • Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Calcium, Magnesium, Vitamin B1, Vitamin C.
  • Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Calcium.

FEMALE HORMONES disrupt intestinal permeability.

  • Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Vitamin C, Magnesium.
  • Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Vitamin C, Magnesium.

LAXATIVES

  • Metamucil, FiberCon, Citrucel, Colace, Glycolax, Milk of magnesia, Dulcolax deplete: Vitamin D, Calcium.

WEIGHT LOSS DRUGS THAT BIND FAT also interfere with absorption of some nutrients.

  • 5Nutritional Supplements To Help Correct Deficiencies:

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

  • Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
  • Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
  • Ferrous fumarate or gluconate as prescribed for low iron following blood test for status.
  • Chelated magnesium  as prescribed but do not take at same time as calcium because they compete for absorption.
  • Natural vitamin C such as Ester-C as prescribed.

Storage NoteStore container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.

  • 6Manage Natural Remedies: 
Hydration is very important in managing fatigue:

Research in young men showed that mild dehydration induces adverse changes in vigilance and working memory, and increased tension/anxiety and fatigue.15

Research investigating how mental performance is affected by slowly progressive moderate dehydration induced by water deprivation shows that subjective ratings by subjects of mental performance changed significantly toward increased tiredness and reduced alertness, and higher levels of perceived effort and concentration necessary for test accomplishment during dehydration.16

  • Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
  • If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
  • Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
  • What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.

Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

  • Raspberry.
  • Carrot is also a cleansing digestive tonic.
  • Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
  • Redbeets also stimulate and improve digestion and are easily digested.
  • Cabbage also stimulates and improves digestion and is also a liver decongestant.
  • Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
  • Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

  • Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
  • Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
  • Parsley also relieves indigestion.
  • Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
  • Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

  • Cloves are also antispasmodic.
  • Nutmeg is also useful for indigestion.
  • Ginger.
Exercise Helps:

Exercise improves circulation and rids the body of toxins.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal.

What Do Medical Research Studies Tell About Chronic Fatigue In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Clinical, serologic, and histologic features of gluten sensitivity in children.”  This study seeking to describe the clinical, serologic, and histologic characteristics of children with gluten sensitivity demonstrated findings that support the existence of gluten sensitivity in children across all ages with clinical, serologic, genetic, and histologic features similar to those of adults. Fatigue was found in 33% of the children with gluten sensitivity.

 Subjects were 15 children (10 males and 5 females; mean age, 9.6 ± 3.9 years) with gluten sensitivity who were diagnosed based on a clear-cut relationship between wheat consumption and development of symptoms, after excluding celiac disease and wheat allergy, along with 15 children with active celiac disease (5 males and 10 females; mean age, 9.1 ± 3.1 years) and 15 controls with a functional gastrointestinal disorder (6 males and 9 females; mean age, 8.6 ± 2.7 years). All children underwent celiac disease panel testing (native antigliadin antibodies IgG and IgA, anti-tissue transglutaminase antibody IgA and IgG, and anti-endomysial antibody IgA), hematologic assessment (hemoglobin, iron, ferritin, aspartate aminotransferase, erythrocyte sedimentation rate), HLA typing, and small intestinal biopsy (on a voluntary basis in the children with gluten sensitivity).

Abdominal pain was the most prevalent symptom in the children with gluten sensitivity (80%), followed by chronic diarrhea in (73%), tiredness (33%), bloating (26%), limb pain, vomiting, constipation, headache (20%), and failure to thrive (13%). Native antigliadin antibodies IgG was positive in 66% of the children with gluten sensitivity. No differences in nutritional, biochemical, or inflammatory markers were found between the children with gluten sensitivity and controls. HLA-DQ2 was found in 7 children with gluten sensitivity. Histology revealed normal to mildly inflamed mucosa (Marsh stage 0-1) in the children with gluten sensitivity.9

The Pediatric Symptom Checklist as screening tool for neurological and psychosocial problems in a paediatric cohort of patients with coeliac disease.” This study investigating neurological and behavioral disorders in a pediatric cohort of patients with newly diagnosed celiac disease compared with treated patients in order to detect possible differences related to compliance with gluten-free diet found that gluten-free diet had a positive impact on chronic fatigue.

A cohort of 139 patients was divided into three groups: A (40 patients with newly diagnosed CD), B (54 patients with CD in remission after gluten-free diet) and C (45 patients with potential CD). Patients first underwent a screening neurological visit, detecting signs associated with CD, and then were evaluated with Pediatric Symptom Checklist (PSC), a psychosocial screen for cognitive, emotional and behavioural problems.

RESULTS: In the group B as compared to group A, there was a statistically significant decrease (p < 0.05) in the incidence of chronic fatigue, headache and inattention. The same applied to patients compliant to gluten-free diet vs. non-compliant. Potential celiacs turning into overt CD had a higher incidence of headache and inattention compared with potential celiacs showing normal mucosa. The PSC mean score in group A was statistically higher than in group B.17

“Clinical features and symptom recovery on a gluten-free diet in Canadian adults with celiac disease.” This study investigating the clinical features and symptom recovery on a gluten-free diet in a Canadian adult celiac population found that many patients report continuing symptoms despite adhering to a gluten-free diet for more than 5 years, with women experiencing more symptoms and a lower recovery rate than men. 74.2% reported extreme tiredness at diagnosis; 72.4% reported recovery from fatigue after 5 years on a gluten free diet.

All adult members (n=10,693) of the two national celiac support organizations, the Canadian Celiac Association and Fondation québécoise de la maladie coeliaque, were surveyed using a questionnaire.

A total of 5912 individuals (18 years of age or older) with biopsy-confirmed celiac disease and⁄or dermatitis herpetiformis completed the survey. The female to male ratio was 3:1. Mean time to diagnosis after onset of symptoms was 12.0 ± 14.4 years. In addition to tiredness, symptoms of abdominal pain and bloating (84.9%), diarrhea (71.7%) and anemia (67.8%) were the most commonly reported at the time of diagnosis. Sex differences were reported in clinical features before diagnosis, recovery after being on gluten-free diet and perceived quality of life, with women experiencing more difficulties than men.

Delays in diagnosis of celiac disease in Canada remain unacceptably long despite wider availability of serological screening tests. Awareness of celiac disease needs improvement, and follow-up with a physician and a dietitian is essential for all patients with celiac disease.11

“Adult celiac disease in Ireland: a case series.” The aim of this Irish study was to analyse the presenting symptoms, associated conditions and complications in a consecutive series of patients with adult celiac disease. Data were obtained from database on patients with celiac disease between 1988 and 2004.

One hundred and six patients (69 females to 37 males, mean age: 46, range: 23-95 years) were included. The modes of presentation were diarrhoea in 44 patients (45%), weight loss in 41 (42%), anaemia in 37 (38%), abdominal pain in 15 (15%), fatigue in 8 (8%), hypocalcaemia in 4 (4%) and steatorrhoea in 4 (4%). Associated conditions included thyroid disorders in 7 patients (7%), bipolar affective disorder in 4 (4%), major depression in 3 (3%), rheumatoid disease in 3 (3%), inflammatory bowel disease in 4 (4%) and type I diabetes mellitus in 2 (2%). Malignancy emerged as a major complication in 15 patients (15%).8

Fatigue as a determinant of health in patients with celiac disease.” This prospective, cross-sectional study investigating the influence of fatigue on perception of health in celiac disease patients determined as their quality of life found that fatigue is a major concern in untreated celiac disease patients, which impacts their quality of life.

Instruments used were the D-FIS to measure fatigue and the generic EuroQol5D to measure quality of life. An additional question on the frequency of problems due to fatigue, scored on a 7-point Likert scale, was used to evaluate the importance of fatigue.

51 patients were included (13 untreated and 38 treated with a gluten-free diet). D-FIS score was significantly worse in untreated celiacs (16 vs. 3). Scores on the frequency scale of fatigue-related problems were also worse in untreated celiacs (2 vs. 6). Fatigue and quality-of-life scores were inversely correlated. Fatigue severity was also greater in patients with worse quality of life (13 vs. 2). Multiple regression analysis showed fatigue to be an independent determinant of quality of life.6

Fatigue in adult celiac disease.” This study evaluating the prevalence, characteristics and associations of fatigue in adult celiac disease patients found that fatigue is a common finding, which ameliorates with the gluten-free diet and is strictly correlated to depression.

A total of 130 coeliac disease patients were consecutively recruited in both treated (59 on gluten-free diet) and untreated conditions (71 on normal diet). The control group was made up of 80 healthy controls. Celiac disease patients and healthy controls underwent laboratory tests, a set of questionnaires for studying fatigue: visual analogue scale for fatigue,chronic fatigue syndrome questionnaire, fatigue severity scale and a modified version of the Zung self-rating depression scale.

Celiac disease patients showed a significantly lower body mass index than controls and lower serum iron. The entire cohort of celiac disease patients reported greater modified version of the Zung self-rating depression scale score, greater visual analogue scale for fatigue score and greater chronic fatigue syndrome questionnaire score compared with healthy controls.

Celiac disease patients on a gluten-free diet had a significantly higher modified version of the Zung self-rating depression scale score than celiacs on a normal diet. The prevalence of pathological modified version of the Zung self-rating depression scale score was 17% in all celiac disease patients and 0% in healthy controls. A significant correlation was found between modified version of the Zung self-rating depression scale score and fatigue scale scores in celiacs on a normal diet. Presence/absence of gastrointestinal symptoms did not show any significant correlation with modified version of the Zung self-rating depression scale score and fatigue scale scores.18

“Antigliadin antibodies in the absence of celiac disease.” This study measuring IgG and IgA isotypes and IgG subclasses demonstrated significantly higher proportion of patients with positive IgA gliadin antibodies reported chronic fatigue.19

  1. Pulido O, Zarkadas M, Dubois S, Macisaac K, Cantin I, La Vieille S, Godefroy S, Rashid M. Clinical features and symptom recovery on a gluten-free diet in Canadian adults with celiac disease. Can J Gastroenterol. 2013 Aug;27(8):449-53. [] []
  2. Terrone G, Parente I, Romano A, Auricchio R, Greco L, Del Giudice E. The Pediatric Symptom Checklist as screening tool for neurological and psychosocial problems in a paediatric cohort of patients with coeliac disease. Acta Paediatr. 2013 Jul;102(7):e325-8. doi: 10.1111/apa.12239. []
  3. Siniscalchi M1, Iovino P, Tortora R, Forestiero S, Somma A, Capuano L, Franzese MD, Sabbatini F, Ciacci C. Fatigue in adult coeliac disease. Aliment Pharmacol Ther. 2005 Sep 1;22(5):489-94. [] []
  4. Siniscalchi M1, Iovino P, Tortora R, Forestiero S, Somma A, Capuano L, Franzese MD, Sabbatini F, Ciacci C. Fatigue in adult coeliac disease. Aliment Pharmacol Ther. 2005 Sep 1;22(5):489-94. []
  5. Galley JD, Bailey MT. Impact of stressor exposure on the interplay between commensal microbiota and host inflammation. Gut Microbes. 2014 May 1;5(3):390-396. Epub 2014 Apr 1. []
  6. Jordá FC, López Vivancos J. Fatigue as a determinant of health in patients with celiac disease. J Clin Gastroenterol. 2010 Jul;44(6):423-7. doi: 10.1097/MCG.0b013e3181c41d12. [] []
  7. Gregory C, Ashworth M, Eade OE, Holdstock G, Smith CL, Wright R. Delay in diagnosis of adult coeliac disease. Digestion. 1983;28(3):201-4. []
  8. Saleem A, Connor HJ, Regan PO. Adult coeliac disease in Ireland: a case series. Ir J Med Sci. 2012 Jun;181(2):225-9. doi: 10.1007/s11845-011-0788-z. [] []
  9. Francavilla R, Cristofori F, Castellaneta S, Polloni C, Albano V, Dellatte S, Indrio F, Cavallo L, Catassi C. Clinical, serologic, and histologic features of gluten sensitivity in children. J Pediatr. 2014 Mar;164(3):463-7.e1. doi: 10.1016/j.jpeds.2013.10.007. [] []
  10. Sanders DS, Patel D, Stephenson TJ, et al. A primary care cross-sectional study of undiagnosed adult coeliac disease. European Journal of Gastroenterology and Hepatology. Apr 2003;15(4)407-13. []
  11. Pulido O, Zarkadas M, Dubois S, Macisaac K, Cantin I, La Vieille S, Godefroy S, Rashid M. Clinical features and symptom recovery on a gluten-free diet in Canadian adults with celiac disease. Can J Gastroenterol. 2013 Aug;27(8):449-53. [] [] []
  12. Rubio-Tapia A, Rahim MW, See JA, Lahr BD, Wu TT, Murray JA. Mucosal recovery and mortality in adults with celiac disease after treatment with a gluten-free diet. Am J Gastroenterol. 2010;105:1412–20. []
  13. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. []
  14. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [] [] [] [] [] []
  15. Ganio MS, Armstrong LE, Casa DJ, McDermott BP, Lee EC, Yamamoto LM, Marzano S, Lopez RM, Jimenez L, Le Bellego L, Chevillotte E, Lieberman HR. Mild dehydration impairs cognitive performance and mood of men. Br J Nutr. 2011 Nov;106(10):1535-43. doi: 10.1017/S0007114511002005. []
  16. Szinnai G, Schachinger H, Arnaud MJ, Linder L, Keller U. Effect of water deprivation on cognitive-motor performance in healthy men and women. Am J Physiol Regul Integr Comp Physiol. 2005 Jul;289(1):R275-80. []
  17. Terrone G, Parente I, Romano A, Auricchio R, Greco L, Del Giudice E. The Pediatric Symptom Checklist as screening tool for neurological and psychosocial problems in a paediatric cohort of patients with coeliac disease. Acta Paediatr. 2013 Jul;102(7):e325-8. doi: 10.1111/apa.12239. []
  18. Siniscalchi M1, Iovino P, Tortora R, Forestiero S, Somma A, Capuano L, Franzese MD, Sabbatini F, Ciacci C. Fatigue in adult coeliac disease. Aliment Pharmacol Ther. 2005 Sep 1;22(5):489-94. []
  19. Kamaeva OI, Reznikov IuP, Pimenova NS, Dobritsyna LV. Antigliadin antibodies in the absence of celiac disease. Klinicheskaia Meditsina. 1998;76(2):33-5. []

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