Muscle Weakness 

What Is Muscle Weakness?

[dropcap]M[/dropcap]uscle weakness is the impaired status of muscle function characterized by decreased or low muscle strength and inability to perform normal work such as lifting a pot off the stove.

Q: How do muscles work?

A: Muscles do their work by contracting or shortening. For example, to move the foot up and down at the ankle, muscles attached to the foot by tendons must contract to shorten or relax to return to their resting length. Calf muscles contract to point the foot down (flexion) while the shin muscles relax (extension).  For the foot to point up, calf muscles relax while the opposing shin muscles contract.

Each muscle is made up of individual muscle fibers. A muscle fiber is a long cylindrical cell that contains many nuclei, mitochondria, and sarcomeres. Each muscle fiber is surrounded by a thin layer of connective tissue called the endomysium.

Approximately 20–80 of these muscle fibers are grouped together in a parallel arrangement called a muscle fascicle or fiber bundle that is encapsulated by a perimysium. A distinct muscle is formed by enveloping a large number of muscle fascicles in a thick collagenous external sheath extending from the tendons called the epimysium.¹

Muscles fall into three types:

• Voluntary muscles.  These muscles, also called skeletal, we can control by will. Voluntary muscles function by contracting their fibers to draw one part of the body toward another in flexion while opposing muscles that extend or pull a body part away from another. They move our bones to perform activities such as walking to get somewhere, chewing to eat food, lifting to do work, and moving the eyeball to look at something.
• Involuntary muscles. These muscles work independently of our conscious control. They are needed for internal organs, sphincters, and other parts to do their work, such as peristalsis in the gut that must function at all times to digest and move food, the squirting of bile juice into the duodenum by the Sphincter of Odi in the presence of fat eaten, and action of the pupil to see.
• Cardiac muscles. These muscles are specialized to keep the heart functioning at all times.

  Muscle weakness can involve all types of muscles.

What Is Muscle Weakness In Celiac Disease and/or Gluten Sensitivity?

Relationship between muscle weakness and celiac disease. Muscle weakness is a well-recognized feature of multiple nutritional deficiencies due to malabsorption in celiac disease. These include:

• Carbohydrate, protein, fat, vitamins B1 (thiamin), B2 (riboflavin), B3 (niacin),  B6 (pyridoxine), vitamin C, zinc, and phosphorus deficiencies which result in generalized weakness or low strength due to their essential activities in energy metabolism.
• Calcium deficiency causes generalized weakness due to poor muscle contraction.
• Potassium deficiency causes generalized weakness due to poor muscle conduction.
• Magnesium deficiency limits the ability of muscles to relax normally thereby causing weakness.
• Vitamin D deficiency leads to proximal muscle weakness involving upper arms and thighs.  Regarding newborn infants, an epigenetic study showed conclusively that deficient vitamin D status of the mother changes the way muscle cells develop in her offspring. The vitamin D deficiency directly altered genes that controlled muscle development which resulted in smaller muscles.²
• Vitamin B12 deficiency causes generalized weakness in the legs.
• Selenium deficiency causes generalized weakness by a metabolic effect involving thyroid hormone.
• Co-Q 10 enzyme which is used by cardiac muscle for fuel.

How Prevalent Is Muscle Weakness In Celiac Disease and/or Gluten Sensitivity?

Muscle weakness is common in untreated celiac disease.

What Are The Symptoms Of Muscle Weakness?

Muscle weakness symptoms are specific to nutritional deficits that have developed.

• Magnesium deficiency is a cause of constipation due to inability of gut muscles to fully relax before the next contraction thus causing spasms that do not move the food mass along in a timely manner. At the same time, magnesium deficiency can result in tight shoulder muscles and spasms in other such voluntary muscles that limit the strength of muscles because they cannot properly relax before contracting.
• Calcium and potassium deficiencies cause generalized weakness due to impaired muscle conduction making it difficult to initiate or perform simple work such as standing.
• Carbohydrate, protein, fat, vitamins B1 (thiamin), B2 (riboflavin), B3 (niacin),  B6 (pyridoxine), folic acid, vitamin C, zinc,  and phosphorus deficiencies impair energy production needed for muscle function.

How Does Muscle Weakness In Celiac Disease and/or Gluten Sensitivity Develop?

• Muscle weakness results from nutritional deficiencies due to malabsorption in celiac disease.³
• Nutritional deficiencies that cause muscle weakness include any or all of the following which explains why muscle weakness is a major symptom of celiac disease:

• The macronutrients needed to supply energy to muscles. These nutrients include carbohydrate, protein, and fat that contain energy.
• The micronutrients needed to use energy. These nutrients include vitamins B1 (thiamin), B2 (riboflavin), B3 (niacin),  B6 (pyridoxine), vitamin C, zinc, and phosphorus.
• The micronutrients needed to produce thyroxine which controls metabolism of energy. These nutrients include selenium and magnesium.
• The micronutrients needed for muscles to function properly. These nutrients include calcium, magnesium, vitamin D,  and potassium.
• The micronutrients needed to form healthy red blood cells that carry oxygen to muscles. These nutrients include folic acid, vitamin B12, riboflavin, vitamin C, copper and iron.

Does Muscle Weakness Respond To Gluten-Free Diet?

Yes. Adherence to a strict gluten-free diet was associated with a significant reduction of weakness.⁴

6 Steps To Improve Muscle Weakness In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both muscle 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.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

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.⁵
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] 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).

[box type=”shadow” ]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.⁶
• 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.⁶
• 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.⁶.
• 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.⁶
• 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.⁶
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁶[/box]

[box type=”shadow” ]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.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

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Certain medications deplete these nutrients: vitamins B1 (thiamin), B2 (riboflavin), B3 (niacin),  B6 (pyridoxine), folic acid, vitamin B12, vitamin C, zinc, calcium, magnesium, selenium, phosphorus, potassium, protein, and coenzyme Q10 deficiencies that cause muscle weakness either directly or indirectly.

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

• Pepcid®, Tagamet®, Zantac® deplete Calcium, Folic Acid, Iron, Vitamin B12, Vitamin D, Zinc, Magnesium, Copper, Potassium.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Calcium, Folic Acid, Iron, Vitamin B12, Vitamin D, Zinc, Magnesium, Copper, Potassium.
• Prevacid®, Prilosec® deplete Vitamin B12.
• Alka Seltzer®, Baking Soda deplete Folic Acid, Magnesium, Potassium, and protein.

ANTI-DEPRESSANTS

• Adapin®, Aventyl®, Elavil®, Pamelor®, and others deplete Coenzyme Q10,Vitamin B12, Riboflavin.

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

• Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins, Vitamin C.
•  Tetracyclines deplete Calcium, Magnesium, Iron, Vitamin B6, Zinc, Riboflavin.
• Cipro depletes Zinc.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium, Vitamin D, Magnesium, Zinc, Vitamin C, Vitamin B6, Vitamin B12, Folic Acid, Selenium.
• NSAIDS (Motrin®, Aleve®, Advil®, Anaprox®, Dolobid®, Feldene®, Naprosyn® and others) deplete Folic acid.
• Aspirin and Salicylates deplete Calcium, Folic acid, Vitamin C, Iron.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Calcium, Vitamin D, Folic Acid, Vitamin B12, Vitamin B1, Copper, Selenium, Zinc, and Carnitine (amino acid).

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete Copper, Zinc, Vitamin B12, and Carnitine (amino acid).
• Foscanet depletes Calcium, Magnesium, Potassium. 

CARDIOVASCULAR DRUGS

• Antihypertensives (Catapres®, Aldomet) deplete Vitamin B6, Vitamin B1, Zinc.
• ACE Inhibitors (Capoten®, Vasotec®, Monopril® and others) deplete Zinc.
• Beta blockers (Inderol®, Lopressor®, Corgard®, Atenolol®) deplete Coenzyme Q10.

CHOLESTEROL DRUGS

• Lipitor®, Crestor®, Zoco®r, and others deplete Coenzyme Q10.
• Colestid® and Questran® deplete Vitamin B12, Vitamin D, Folic Acid, Iron.

DIABETIC DRUGS 

• Metformin® depletes Folic acid, Vitamin B12.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Potassium, Magnesium, Zinc.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Calcium, Magnesium, Vitamin B1, Vitamin B6, Vitamin C, Coenzyme Q10, Potassium, Zinc.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Calcium, Folic Acid, Zinc.

FEMALE HORMONES disrupt intestinal permeability which complicate celiac disease.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Vitamin B2, Vitamin B3, Vitamin B6, Vitamin B12, Vitamin C, Folic Acid, Magnesium, Selenium, Zinc.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Vitamin B2, Vitamin B6, Vitamin B12, Vitamin C, Folic Acid, Magnesium, Zinc.

MAJOR TRANQUILIZERS  

• Thorazine®, Mellaril®, Prolixin®, Serentil® and others deplete Coenzyme Q10, Vitamin B12.

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

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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.
• B-Vitamin Complex to supply Vitamins B1, B2, B3, B6, B12, and folic acid as prescribed.
• Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
• Vitamin D3 as prescribed following blood test for status.
• Chelated magnesium  as prescribed but do not take at same time as calcium because they compete for absorption.
• Chelated zinc as prescribed but do not take at same time as calcium because they compete for absorption.
• Vitamin B12 sublingually if unable to absorb tablets as prescribed following blood test for status.
• Coenzyme Q10 as prescribed.

Storage Note: Store 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.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• 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.[/box]

[box type=”shadow” ]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.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise should be aimed at improving flexibility so you can, for example, bend over to pick up a box, and improving strength so you can properly lift the box, according to advice from the American Physical Therapy Association. Overall, everyday exercise is important to improve circulation and rid the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Other aerobic exercises include running, jumping rope, swimming, hiking and bicycling. Read more about Exercise and Fitness.
• Weight training builds muscle and strength. Read more about Exercise and Fitness.
• Stretching improves muscle flexibilty. Read more about Exercise and Fitness.

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

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

RESEARCH STUDY SUMMARIES

“Relationships between 25-hydroxyvitamin D and nocturnal enuresis in five- to seven-year-old children.” This study investigating whether there is a relationship between serum 25-hydroxyvitamin D [25(OH)D] concentrations in five- to seven-year-old children  with nocturnal enuresis (NE) found that low 25(OH)D was associated with an increased risk of NE (bedwetting) in children aged five to seven years.

Two hundred forty-seven five- to seven-year-old children were recruited from Taizhou, Zhejiang Province, China. Serum 25(OH)D concentrations were measured, and the structured questionnaire was administered to the parents of all children. Low 25(OH)D was defined as serum 25(OH)D concentrations below 20 ng/ml.

The prevalence of NE was 7.3% in the group of children with 25(OH)D concentrations that exceeded 20 ng/ml; this prevalence was much lower than the 17.5% observed in the group of children with 25(OH)D concentrations below 20 ng/ml. After adjusting for potential confounders, serum 25(OH)D (≥20 ng/ml) was significantly associated with NE and represented a protective factor against NE. A nonlinear relationship between 25(OH)D and NE was observed. The prevalence of NE decreased with increasing 25(OH)D concentrations above 19 ng/ml. Additionally, children exhibiting higher frequencies of bedwetting had lower 25(OH)D concentrations [5-7 times/week: 18.3 ng/ml plus or minus 4.8; 2-4 times/week: 20.9 ng/ml plus or minus 4.1; 0-1 times/week: 23.6 ng/ml plus or minus 6.4].⁷

“Clinical and neurological abnormalities in adult celiac disease.” This study investigating the occurrence of neurological signs and symptoms in adult patients with celiac disease and the correlation between neurological features and diet found that muscle weakness is associated with celiac disease and can be ameliorated by a gluten-free diet.

A total of 176 patients and 52 age-matched controls underwent a semistructural interview and a neurologic examination. The effect of gluten-free diet was evaluated by comparing the prevalence of signs and symptoms among patients adhering to a gluten-free diet and patients on an unrestricted diet. The occurrence of headache, dysthymia (depression) and signs of peripheral neuropathy was significantly higher in patients with celiac disease than in control subjects. Adherence to a strict gluten-free diet was associated with a significant reduction of headache, dysthymia, cramps and weakness, but did not modify the occurrence of paresthesia or hyporeflexia. Neurological signs and symptoms are associated with celiac disease and can be ameliorated by a gluten-free diet.⁸

CASE REPORT SUMMARIES

“Quadriplegia due to celiac crisis with hypokalemia as initial presentation of celiac disease: a case report.”   This case report describes diagnosing celiac disease in an 8-year-old girl with previously undiagnosed celiac disease who presented with flaccid quadriparesis secondary to severe hypokalemia associated with celiac crisis. Celiac crisis is a rare, life-threatening complication of celiac disease characterized by worsening of clinical symptoms, multiple metabolic derangements and shock.

Diagnosis was expedited by an elevated anti-tissue transglutaminase antibody titer. The patient improved with correction of hypokalemia, corticosteroids and gluten-free diet. In tropical countries such as India, where both acute flaccidparesis and diarrhea are usually of infective etiologies, this rare clinical condition should also be considered in the differential diagnosis of both.⁹

“Celiac disease causing symptomatic hypocalcaemia, osteomalacia and coagulapathy.” This case report describes diagnosing celiac disease in a 36-year-old gentleman who presented with 6 months of poor energy, tingling in fingers and weight loss with a change in bowel habit. He appeared cachectic and had clubbing, demineralisation of teeth, pectus carinatus, kyphosis, spinal tenderness, proximal muscle weakness and generalised muscle atrophy.

Chvostek’s and Trosseau’s signs were positive. His hemoglobin (Hb) was 8.7 g/dl, MCV 64.7 fl with low iron. Calcium corrected was 1.30 nmol/l, parathyroid hormone 440.4 ng/l, vitamin D <12.5 nmol/l; INR was 2.7 with coagulation inhibitor studies negative. Radiographs of spine and pelvis commented on osteopenia with thoracic kyphosis and mild anterior wedging of thoracic vertebrae. Antitissue transglutaminase was 145 U/ml, and antiendomysial antibodies were positive. An esophagogastroduodenoscopy was consistent with celiac disease. A diagnosis of osteomalacia and coagulopathy secondary to celiac disease was made.

The hypocalcaemia was treated with calcium gluconate infusions with symptomatic relief. Coagulopathy was treated with vitamin K intravenously with normalization of INR (international normalised ratio), a lab measurement to determine coagulation.¹⁰

Sources:

1. http://www.ncbi.nlm.nih.gov/books/NBK57140/ [↩]
2. Max D, Brandsch C, Schumann S, Kühne H, Frommhagen M, Schutkowski A, Hirche F, Staege MS, Stangl GI. Maternal vitamin D deficiency causes smaller muscle fibers and altered transcript levels of genes involved in protein degradation, myogenesis, and cytoskeleton organization in the newborn rat. Mol Nutr Food Res. 2014 Feb;58(2):343-52. doi: 10.1002/mnfr.201300360. [↩]
3. Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Kathleen Mahan, Sylvia Escott-Stump. 2000. W.B. Saunders Company. [↩]
4. Cicarelli G, Della Rocca G, Amboni M, Ciacci C, Mazzacca G, Filla A, Barone P. Clinical and neurological abnormalities in adult celiac disease. Neurol Sci. 2003 Dec;24(5):311-7. [↩]
5. 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. [↩]
6. 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. [↩] [↩] [↩] [↩] [↩] [↩]
7. Li L, Zhou H, Yang X, Zhao L, Yu X. Relationships between 25-hydroxyvitamin D and nocturnal enuresis in five- to seven-year-old children. PLoS One. 2014 Jun 9;9(6):e99316. doi: 10.1371/journal.pone.0099316. eCollection 2014. [↩]
8. Cicarelli G, Della Rocca G, Amboni M, Ciacci C, Mazzacca G, Filla A, Barone P. Clinical and neurological abnormalities in adult celiac disease. Neurol Sci. 2003 Dec;24(5):311-7. [↩]
9. Bhattacharya M, Kapoor S. Quadriplegia due to celiac crisis with hypokalemia as initial presentation of celiac disease: a case report. J Trop Pediatr. 2012 Feb;58(1):74-6. doi: 10.1093/tropej/fmr034. Epub 2011 Apr 27. [↩]
10. McNicholas BA, Bell M. Coeliac disease causing symptomatic hypocalcaemia, osteomalacia and coagulapathy. BMJ Case Rep. 2010 Dec 1;2010. pii: bcr0920092262. doi: 10.1136/bcr.09.2009.2262. [↩]