Obesity

What Is Obesity?

[dropcap]O[/dropcap]besity is an inflammatory metabolic disorder that is characterized by body mass index greater than 30% resulting from excessive body fat stored in adipose tissue.

Q: What is body fat?

A: Body fat is part of the body that functions as a reserve of stored energy. It is composed of fat cells, called adipocytes, having thin membranes between these cells. Adipocytes expand to store fat and shrink as fat is released as needed into the bloodstream for other body cells to use for metabolizing energy.

Each adipocyte contains a drop of triglyceride which is a type of lipid (fat). Triglycerides are a normal component in the bloodstream and, as such, are transported wherever needed as a form of energy. Excess triglycerides are the form of fat that is stored.

Initially, fat that is eaten in the diet is changed by digestive enzymes into the triglyceride form which is a molecule composed of three fatty acids and glycerol. Triglycerides are then absorbed through the small intestinal wall to be delivered to the liver. Of note, the liver can make triglycerides from excess protein and carbohydrates eaten in a meal, especially sugar and alcohol. The liver on the other hand makes cholesterol from triglycerides.

Triglyceride levels in the blood generally increase as weight increases. It is thought that an elevated blood triglyceride level hampers the body’s ability to feel full or satisfied with food that is eaten. Elevated triglyceride levels also increase the risk of clot formation because they cause the blood to become thicker. A normal triglyceride blood level is 150 mg/dL.

The causes of obesity are complex and varied. Those related to gluten sensitivity are discussed below.

What Is Obesity In Celiac Disease and/or Gluten Sensitivity?

• Relationship between obesity and celiac disease. Obesity is an atypical symptom of celiac disease and a metabolic disorder complicating celiac disease.¹
• Relationship between obesity and malabsorption. Nutritional deficiencies common in celiac disease that contribute to obesity involve protein, essential fatty acids especially EPA, vitamin C, and calcium.² Vitamin D deficiency has recently been shown to advance obesity.
• Relationship between obesity and appetite. Faulty regulation of body weight and concomitant abnormal appetite are recognized features possibly involving nutritional deficiencies in celiac disease. Unsatisfied need for nutrients results in unsatisfied hunger which stimulates appetite.
• Relationship between obesity and dysbiosis. Dysbiosis is an imbalance of the microbiota. The microbiota is the collection of microbes which reside in the GI tract and represents the largest source of non-self antigens (immune triggers) in the human body. The GI tract functions as a major immunological organ as it must maintain tolerance to commensal and dietary antigens while remaining responsive to pathogenic (disease producing) stimuli. If this balance is disrupted, inappropriate inflammatory processes can result, leading to host (our own) cell damage and/or autoimmunity. Evidence suggests that the composition of the intestinal microbiota can influence susceptibility to chronic disease of the intestinal tract including celiac disease as well as other systemic diseases such as obesity, type 1 diabetes and type 2 diabetes that complicate celiac disease.³
• Relationship between obesity and microbiota. The gastrointestinal (GI) microbiota play a key role in obesity in celiac disease. Microbes in the GI tract are essential for our health. They normally act to break down complex carbohydrates, such as dietary fibers, produce short chain fatty acids from undigested food and make certain vitamins such as vitamin K and biotin. As a result, the composition of the microbiota has the ability to influence our metabolic functions.

However, maldigestion by the small intestine of energy rich nutrients (proteins, fats, carbohydrates) passes excessive amounts to the colon or large intestine. In this case, the microbiota ferment the excessive undigested energy nutrients changing them into excessive short-chain fatty acids. Because short-chain fatty acids are easily absorbed into the body from the colon, their excessive production produces an unexpected source of energy that is not needed. These bonus fatty acids are then absorbed directly into the bloodstream and unfortunately stored as fat.

• Relationship between obesity, calcium and vitamin D deficiency. Vitamin D and calcium deficiencies promote increase in visceral fat which is fat that is deposited around organs that is dangerous to health. Correction of vitamin D deficiency corrects fat accumulation.⁴

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

• Obesity is a newly recognized presentation of celiac disease with varied prevalence.⁵
• At a Celiac Center in New York City, 6% of children at diagnosis of celiac disease were obese.⁶
• In a study of patients with newly diagnosed celiac disease, 13% were found to have a BMI of 30 or above.⁷
• In children at diagnosis in the Midwest, the rate of obesity was 5%.⁸

What Are The Symptoms Of Obesity?

• Obesity is marked by abnormally large accumulations of body fat.
• The most common presenting symptoms of celiac disease among obese children were abdominal pain, diabetes, and diarrhea.

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

• Obesity results from unclear etiology in celiac disease. Nutritional deficiencies that contribute to obesity involve protein, essential fatty acids, vitamin C, and calcium.² Dietary calcium, a non-energy-supplying nutrient, has been identified as playing a pivotal role in the regulation of energy and lipid metabolism. Observational studies have demonstrated calcium intake is inversely associated with body weight.⁴
• Vitamin D deficiency has recently been shown to advance obesity.⁴
• Many of the  effects of nutritional deficiencies, such as low energy, apathy, depression, weakness, pain, impaired metablism and endocrine factors, affect energy expenditure (burning calories) by making it hard for the individual to exercise or want to exercise.

Does Obesity Respond To Gluten-Free Diet?

Yes. Celiac disease-related obesity responds to nutritious, balanced gluten free diet.⁶

In a retrospective study of obese children at diagnosis, the gluten free diet resulted in weight loss in half of patients while 25% were found to gain weight 1 year after starting on gluten free diet.⁹ Weight gain is mainly due to unhealthy food choices. Weight loss varies and involves weight management strategies involving diet to make nutritious food choices and exercise education.

Calcium and/or vitamin D supplementation is helpful. Research shows that calcium and/or vitamin D supplementation contributes to a beneficial reduction of visceral abdominal fat (VAT).¹⁰,¹¹

Additionally, certain natural plant substances called polyphenols can be added to the diet. Polyphenols have been shown to help obesity by changing lipid and energy metabolism and may facilitate weight loss and prevent weight gain. Examples of polyphenols include catechins present in tea (green, black, oolong and white teas), resveratrol present in raspberries, cocoa, red grapes, red wine, peanuts, and ground nuts, anthocyanins present in blueberries, and curcumin present in the spice turmeric.¹²

6 Steps To Improve Obesity 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 obesity 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.¹³
• 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.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) because these increase triglyceride levels. Also limit EXCESSIVE omega-6 fatty acid oils like corn oil. Avoid 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[/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 green leafy vegetables such as lettuce and kale, also 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 one or more nutrients that promote obesity including protein, essential fatty acids, vitamin C, vitamin D, and calcium. 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, Vitamin D.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete  Calcium, Vitamin D.
• Alka Seltzer®, Baking Soda deplete Proteins.

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

• Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete Vitamin C.
•  Tetracyclines deplete Calcium.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Calcium, Vitamin D, Vitamin C.
• Aspirin and Salicylates deplete Calcium, Vitamin C.

ANTICONVULSANTS

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

ANTIVIRAL AGENTS

• Foscanet depletes Calcium. 

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Vitamin D.

DIURETICS

• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Calcium,Vitamin C.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Calcium.

FEMALE HORMONES disrupt intestinal permeability which complicate celiac disease.

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

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

• Zenicol (Orlistat®) depletes Vitamin D.

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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.
• Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.
• Vitamin D3 as prescribed following blood test for status.
• Vitamin C 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 improves circulation, rids the body of toxins, and improves triglyceride levels in the blood.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness. and is especially helpful to reduce triglyceride levels aftet eating.
• Stretching improves 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 Obesity In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Patients with coeliac disease are increasingly overweight or obese on presentation.” This study aimed to establish the frequency of obesity in newly diagnosed celiac disease found that a significant proportion of celiac disease patients (close to half of patients) were diagnosed with a body mass index (BMI) of 25 or over. Compared to males, females have a wider range of BMI and more likely to be obese (BMI of 30 or more). Dietetic records of celiac disease patients were reviewed and patient demographics, initial assessment date, and BMI recorded and statistically analyzed. Out of 187 celiac disease patients diagnosed between 1999 and 2009, 127 patients were female (68%) and 60 male (32%) (ratio 2:1). Overall 83 patients (44%) had a BMI of 25 or above. 25 patients (13 %) had a BMI of 30 or above. Twenty were female with a median age of 56 years (range 18 – 71). The proportion of females with a BMI of 30 or more was 11% compared with only 3% males (ratio 5:1). Only 5 patients (3%) had a BMI less than 18.5 (underweight).¹⁵

“Calcium and vitamin D supplementation is associated with decreased abdominal visceral adipose tissue in overweight and obese adults.” This study  investigating the effect of  calcium and vitamin D on obesity showed findings that suggest calcium and/or vitamin D supplementation contributes to a beneficial reduction of visceral abdominal fat (VAT).

Two parallel double-blind, placebo-controlled trials were conducted in which 171 people were given either orange juice fortified with 350mg of calcium and 100 IU of vitamin D (CaD) or non-fortified orange calcium and vitamin D juice. After four months, the average weight loss in both groups was the same – about 5.5 pounds. Scans revealed that in the group supplemented with calcium and vitamin D, the loss of visceral (abdominal) fat was significantly greater than the loss of subcutaneous fat, which is fat under the skin.

After 16 wk, the average weight loss (about 2.45 kg) did not differ significantly between groups. In the regular orange juice trial, the reduction of VAT was significantly greater in the CaD group (-12.7 ± 25.0 cm(2)) than in the control group (-1.3 ± 13.6 cm(2)). In the lite orange juice trial, the reduction of VAT was significantly greater in the CaD group (-13.1 ± 18.4 cm(2)) than in the control group (-6.4 ± 17.5 cm(2)) after control for baseline VAT. The effect of calcium and vitamin D on VAT remained highly significant when the results of the 2 trials were combined.¹⁶

“Calcium plus vitamin D3 supplementation facilitated fat loss in overweight and obese college students with very-low calcium consumption: a randomized controlled trial.” This study investigating  the effect of calcium plus vitamin D3 (calcium+D) supplementation on anthropometric and metabolic profiles during energy restriction in healthy, overweight and obese adults with very-low calcium consumption found that calcium plus vitamin D3 supplementation for 12 weeks augmented body fat and visceral fat loss in very-low calcium consumers during energy restriction.

Fifty-three subjects were randomly assigned in an open-label, randomized controlled trial to receive either an energy-restricted diet (about 500 kcal/d) supplemented with 600 mg elemental calcium and 125 IU vitamin D3 or energy restriction alone for 12 weeks. Repeated measurements of variance were performed to evaluate the differences between groups for changes in body weight, BMI, body composition, waist circumference, and blood pressures, as well as in plasma TG, TC, HDL, LDL, glucose and insulin concentrations.

Eighty-one percent of participants completed the trial (85% from the calcium + D group; 78% from the control group). A significantly greater decrease in fat mass loss was observed in the calcium + D group (-2.8±1.3 vs.-1.8±1.3 kg; P=0.02) than in the control group, although there was no significant difference in body weight change between groups. The calcium + D group also exhibited greater decrease in visceral fat mass and visceral fat area. No significant difference was detected for changes in metabolic variables.¹¹

“Celiac disease in normal-weight and overweight children: clinical features and growth outcomes following a gluten-free diet.” This study investigated the presentation of celiac disease among children with a normal and an elevated body mass index (BMI) for age, and their BMI changes following a gluten-free diet. Results show that both normal weight and overweight frequently occur in North American children presenting with celiac disease. A Gluten Free Diet may have a beneficial effect upon the BMI of overweight and obese children with celiac disease.

One hundred forty-two children (age 13 months-19 years) with biopsy-proven celiac disease, contained in a registry of patients studied at our center from 2000 to 2008, had follow-up growth data available. Patients’ height, weight, and BMI were converted to z scores for age and grouped by BMI as underweight, normal, and overweight. Compliance was confirmed using results of serological assays, and data of noncompliant patients were analyzed separately. Data were analyzed during the observation period and were expressed as change in height, weight, and BMI z score per month of dietary treatment.

Nearly 19% of patients had an elevated BMI at diagnosis (12.6% overweight, 6% obese) and 74.5% presented with a normal BMI. The mean duration of follow-up was 35.6 months. Seventy-five percent of patients with an elevated BMI at diagnosis decreased their BMI z scores significantly after adherence to a Gluten Free Diet, normalizing it in 44% of cases. Of patients with a normal BMI at diagnosis, weight z scores increased significantly after treatment, and 13% became overweight.¹⁷

“Obesity in pediatric celiac disease.” This retrospective study of 143 patients with Celiac Disease diagnosed between 1986 and 2003 at Children’s Hospital of Wisconsin was designed to estimate the prevalence of obesity at diagnosis in children with Celiac Disease and to describe the clinical characteristics of this group found obesity to be more common in children with Celiac Disease than previously recognized.

Data collected included patient’s age, sex, ethnicity, presenting signs and symptoms, BMI, celiac antibody titers, small-intestinal biopsy results, and follow-up weight 1 year after initiating a gluten-free diet. Seven of the 143 (5%) patients had BMI greater than the 95th percentile. The most common presenting symptoms among obese patients were abdominal pain, diabetes, and diarrhea. Symptoms improved in all of the patients on a gluten free diet. BMI decreased in 4 (50%), increased in 2 (25%), and was not available in 1 patient at 1 year after starting on gluten free diet.⁹

Sources:

1. Murray JA, The widening spectrum of celiac disease. American Journal of Clinical Nutrition. Mar 1999;69 (3):354-365. [↩]
2. Kathleen Mahan and Sylvia Escott-Stump, ed. Krause’s Food, Nutrition & Diet Therapy, 10th Edition. Philadelphia, PA. USA: W.B. Saunders Company, 2000. [↩] [↩]
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4. Zhu W, Cai D, Wang Y, Lin N, Hu Q, Qi Y, Ma S, Amarasekara S. Calcium plus vitamin D3 supplementation facilitated fat loss in overweight and obese college students with very-low calcium consumption: a randomized controlled trial. Nutr J. 2013 Jan 8;12:8. doi: 10.1186/1475-2891-12-8. [↩] [↩] [↩]
5. National Institutes of Health, “National Institutes of Health Consensus Development Conference Statement, Celiac Disease,” August 9, 2004; 1-14. [↩]
6. Reilly NR, Aguilar K, Hassid BG, Cheng J, Defelice AR, Kazlow P, Bhagat G, Green PH. Celiac disease in normal-weight and overweight children: clinical features and growth outcomes following a gluten-free diet. J Pediatr Gastroenterol Nutr. 2011 Nov;53(5):528-31. doi: 10.1097/MPG.0b013e3182276d5e. [↩] [↩]
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10. Rosenblum JL, Castro VM, Moore CE, Kaplan LM. Calcium and vitamin D supplementation is associated with decreased abdominal visceral adipose tissue in overweight and obese adults. Am J Clin Nutr. 2012 Jan;95(1):101-8. doi: 10.3945/ajcn.111.019489. [↩]
11. Zhu W, Cai D, Wang Y, Lin N, Hu Q, Qi Y, Ma S, Amarasekara S. Calcium plus vitamin D3 supplementation facilitated fat loss in overweight and obese college students with very-low calcium consumption: a randomized controlled trial. Nutr J. 2013 Jan 8;12:8. doi: 10.1186/1475-2891-12-8. [↩] [↩]
12. Meydani M, Hasan ST. Dietary polyphenols and obesity. Nutrients. 2010 Jul;2(7):737-51. doi: 10.3390/nu2070737. [↩]
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. Tucker E, Rostami K, Prabhakaran S, Al Dulaimi D. Patients with coeliac disease are increasingly overweight or obese on presentation. J Gastrointestin Liver Dis. 2012 Mar;21(1):11-5. [↩]
16. Rosenblum JL, Castro VM, Moore CE, Kaplan LM. Calcium and vitamin D supplementation is associated with decreased abdominal visceral adipose tissue in overweight and obese adults.Am J Clin Nutr. 2012 Jan;95(1):101-8. doi: 10.3945/ajcn.111.019489. [↩]
17. Reilly NR, Aguilar K, Hassid BG, Cheng J, Defelice AR, Kazlow P, Bhagat G, Green PH. Celiac disease in normal-weight and overweight children: clinical features and growth outcomes following a gluten-free diet. J Pediatr Gastroenterol Nutr. 2011 Nov;53(5):528-31. doi: 10.1097/MPG.0b013e3182276d5e. [↩]