Weight Loss, Unexpected/ Inability To Gain Weight

What Is Unexpected Weight Loss?

[dropcap]U[/dropcap]nexpected weight loss is unintentional loss of body mass composition or inability to gain weight marked by decreased serum proteins and increased stool fat.¹

What Is Unexpected Weight Loss In Celiac Disease and/or Gluten Sensitivity?

• Relationship between unexpected weight loss and celiac disease. Unexpected weight loss, a classic presentation of celiac disease,² is a symptom of malabsorption characterized by abnormal maintenance or loss of fat, muscle and other tissue.
• Relationship between unexpected weight loss and vitamin B12 deficiency. Vitamin B12 deficiency can cause considerable weight loss.¹
• Relationship between unexpected weight loss and thiamin Deficiency. Thiamin deficiency can cause considerable weight loss.¹
• Relationship between unexpected weight loss and intestinal damage. Vitamin/mineral deficiencies are not, as expected, associated with a higher grade of histological intestinal damage or impaired nutritional status of the body.  Extensive nutritional assessments seem warranted to guide nutritional advices and follow-up in celiac disease treatment.³
• Relationship between unexpected weight loss and lymphoma. Enteropathy-associated T-cell lymphoma (EATL), which is a dire complication of celiac disease, is a cause of weight loss wich should be looked for in patients who do not respond to a gluten free diet.

How Prevalent Is Unexpected Weight Loss In Celiac Disease and/or Gluten Sensitivity?

• Unexpected weight loss is common in untreated patients with celiac disease.⁴
• 34.8% of 109 children at diagnosis were found to be underweight.⁵
• In a Dutch study of 80 adult patients newly diagnosed with celiac disease, 10%  had undesired weight loss and 22% of the women were underweight with Body Mass Index (BMI) less than 18.5.³
• The prevalence of weight loss was 22% in a retrospective study of 60 adults diagnosed with celiac disease in Spain.⁶

What Are The Symptoms Of Unexpected Weight Loss In Celiac Disease and/or Gluten Sensitivity?

Symptoms of unexpected weight loss depend specifically on the cause but generally include:

• Lethargy.
• Weakness.
• Hunger.
• Irritability.
• Loss of vitality.
• Cognitive (thought) impairment that may affect memory, judgment, and reason also called brain fog.
• Apathy.
• Depression.
• Anxiety.

How Does Unexpected Weight Loss In Celiac Disease and/or Gluten Sensitivity Develop?

• Unexpected weight loss or failure to gain weight results from nutritional deficiencies in gluten sensitive enteropathy that may include any of these: carbohydrate, protein, fat, vitamin B12, vitamin K, B-vitamins, zinc, iron, phosphorus, manganese.¹
• Weight loss may result from diarrhea, vomiting, or nausea when present.
• Refractory celiac disease is a cause of chronic weight due to continual inflammation and malabsorption.

Does Unexpected Weight Loss Respond To Gluten-Free Diet?

Yes. Celiac Disease-related weight loss rapidly improves on gluten free diet.

6 Steps To Improve Unexpected Weight Loss 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 lean body mass 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.⁷
• 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.⁸
• 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.⁸
• 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.⁸.
• 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.⁸
• 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.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸[/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 protein, vitamin B12, vitamin K, B-vitamins, zinc, iron, and phosphorus that can cause undesired weight loss.  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 Iron, Vitamin B12, Folic Acid, Zinc.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Iron, Vitamin B12, Zinc.
• Prevacid®, Prilosec® deplete Vitamin B12, Folic Acid.
• Alka Seltzer®, Baking Soda deplete Folic Acid, Proteins.

ANTI-DEPRESSANTS

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

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

• Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins, Vitamin K.
•  Tetracyclines deplete Iron, Zinc.
• Cipro depletes Zinc.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

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

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Carnitine, Vitamin B12, Folic acid,Vitamin B1, Vitamin K, Zinc.

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete Carnitine, Zinc, Vitamin B12.

CARDIOVASCULAR DRUGS

• Antihypertensives (Catapres®, Aldomet) deplete Vitamin B1, Zinc.
• ACE Inhibitors (Capoten®, Vasotec®, Monopril® and others) deplete Zinc.

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Vitamin B12, Vitamin K, Iron, Folic acid.

DIABETIC DRUGS 

• Metformin® depletes Vitamin B12, Folic acid.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Zinc.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Vitamin B1, Vitamin B6, Zinc.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete 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, Folic Acid, Zinc.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Vitamin B2, Vitamin B6, Vitamin B12, Folic Acid, Zinc.

MAJOR TRANQUILIZERS  

• Thorazine®, Mellaril®, Prolixin®, Serentil® and others deplete 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.

• 100% 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. Contains all B vitamins.⁹
• B-Vitamin Complex  to supply 100% to 300% or as prescribed.
• Folic acid as prescribed following blood test for status.
• Vitamin B12 as prescribed following blood test for status.
• Chelated zinc as prescribed but do not take at same time as calcium because they compete for absorption.
• Ferrous fumarate or gluconate as prescribed following blood test for iron status.

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 and rids the body of toxins.

• 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.
• 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 Unexpected Weight Loss In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients.” This study aiming to assess the nutritional and vitamin/mineral status of 80 current “early diagnosed” untreated adult celiac disease (CD)-patients in the Netherlands found overall, 17% were malnourished (>10% undesired weight loss), 22% of the women were underweight (Body Mass Index (BMI) less than 18.5).

Vitamin deficiencies were barely seen in healthy controls, with the exception of vitamin B₁₂. Vitamin/mineral deficiencies were counter-intuitively not associated with a (higher) grade of histological intestinal damage or (impaired) nutritional status. Nutritional status and serum concentrations of folic acid, vitamin A, B6, B12, and (25-hydroxy) D, zinc, haemoglobin (Hb) and ferritin were determined (before prescribing gluten free diet). Almost all CD-patients (87%) had at least one value below the lower limit of reference. Specifically, for vitamin A, 7.5% of patients showed deficient levels, for vitamin B6 14.5%, folic acid 20%, and vitamin B12 19%. Likewise, zinc deficiency was observed in 67% of the CD-patients, 46% had decreased iron storage, and 32% had anemia.

The observed findings in this study, sharing deficiencies in water and fat soluble vitamins, zinc and iron, indicate that maldigestion, malabsorption or a structurally moderately inadequate intake might have been present long before the clinical diagnosis of celiac disease was established. It is known that the delay in diagnosing CD can be more than a decade.  Extensive nutritional assessments seem warranted to guide nutritional advices and follow-up in celiac disease treatment.³

“Celiac disease: clinical features in adult populations.” This retrospective study investigating the incidence and clinical manifestations of celiac disease in adults in Spain who were diagnosed with celiac disease between January 1990 and December 2008 found that celiac disease can appear at any age and with a wide manifestation spectrum, which can be atypical in some cases. Specifically, the prevalence of weight loss was (22%).

Sixty eight adult patients were diagnosed of celiac disease in this period. Mean age was 33 (18-65) years and 50 (74%) were women. The clinical manifestations were diarrhea in 38 (55%), abdominal pain in 27 (40%), loss of weight in 15 (22%), dyspepsia in 13 (19%). Analytical results showed a slight increase of transaminases in 26 (38%), ferropenic (low iron) anemia in 33 (48.5%) cases, sub-clinical hypothyroidism in 3 (4.5%) patients, and folic acid deficiency in 16 (23.5%) cases. Population-based incidence of celiac disease in adults had increased from 0.7-2/100,000 per year in the nineties to 3.5-10.3/100,000 in the last years.⁶

“Celiac Disease: Presentation of 109 Children.” In this study, clinical and laboratory features of 109 patients with celiac disease were retrospectively evaluated to determine presentation and manifestations. Of 109 patients with celiac disease, 66 (60.6%) were classical type, 41 (37.6%) were atypical type and 2 (1.8%) were silent type. The mean age was 8.81 ± 4.63 years and the most common symptom was diarrhea (53.2%) followed by failure to thrive, short stature, and abdominal pain. Paleness (40.4%), underweight (34.8%), and short stature (31.2%) were the most common findings.

Iron deficiency anemia (81.6%), zinc deficiency (64.1%), prolonged prothrombin time (35.8%), and elevated transaminase levels (24.7%) were the most common laboratory findings. Eight percent of patients had at least 1 autoantibody, and 28 of 52 patients had low BMD. Abdominal distention, iron deficiency, prolonged prothrombine time, hypoalbuminemia, and elevated transaminase levels were more significantly frequent in the classical type than atypical type.¹⁰

“Clinical features of children with screening-identified evidence of celiac disease.” This case-control study investigated Denver area healthy infants and young children at risk for celiac disease to evaluate growth and clinical features of children who later test positive for an autoantibody associated with celiac disease. Researchers found that screening-identified TG antibody-positive children demonstrate mild alterations in growth and nutrition and report more symptoms than control subjects.

A group of children with HLA genetic susceptibility for celiac disease were followed prospectively since birth for the development of immunoglobulin A antitissue transglutaminase autoantibodies (TG). Clinical evaluation, questionnaire, blood draw, and small bowel biopsy were performed. Growth and nutrition and frequency of positive responses were measured.

Compared with 100 age- and gender-matched TG-negative controls, 18 TG-positive children 5 to 6 years of age, had a greater number of symptoms and lower z scores for weight-for-height and for body mass index. Responses that were independently associated with TG-positive status were irritability/lethargy, abdominal distention/gas, and difficulty with weight gain.¹¹

“Restoration of body composition in celiac children after one year of gluten-free diet.” This study investigating anthropometric, biochemical, and bone densitometric assessment performed in 23 celiac children aged 1 to 12 years at diagnosis and one year after gluten free diet demonstrated that a year of gluten free diet allows virtually complete return in body mass composition. At diagnosis, the patients had height, arm muscle triceps, skin folds, subscapular skin folds, fat area index, and bone mineral content significantly lower than controls.

After one year on gluten free diet, no significant difference was found between patients and controls in all parameters studied except in height and arm muscle area, which, however, were very near to the normal expected. Serum hemoglobin, iron, and zinc values were below the normal range in more than half of patients at diagnosis and within the normal range in almost all of them after 1 year of gluten free diet. Serum hemoglobin, iron, zinc, triglycerides, proteins, albumin, and calcium values rose significantly during the year of gluten free diet.¹²

“Low plasma cholesterol: a correlate of nondiagnosed celiac disease in adults with hypochromic anemia.” Study defining the correlates of celiac disease in 100 anemic adults without overt malabsorption demonstrated that compared to anemic patients without celiac disease, anemic patients with celiac disease had significant or borderline significant differences for plasma cholesterol, albumin, and body mass index but not for blood hemoglobin, mean corpuscular volume, plasma iron, and ferritin.¹³

CASE REPORT SUMMARIES

“A rare but potentially fatal cause of diarrhea and weight loss: enteropathy-associated T-cell lymphoma.“ This case report describes finding celiac disease and enteropathy-associated T-cell lymphoma (EATL) in a patient who presented to the physician with diarrhea and weight loss.  EATL commonly presents with abdominal pain, diarrhea and weight loss, but can also present with complications such as bowel obstruction and perforation. It is the most common neoplastic complication of celiac disease, but can occur with no prior diagnosis of celiac disease.

This case demonstrates the difficulties that can be faced in diagnosing this disorder, particularly when there is no preceding history of celiac disease. Early diagnosis is of utmost importance in order to start treatment before the effects of malnutrition increase the risk of complications from chemotherapy. Hence awareness of the condition among general medical physicians, to whom it will often present first, is essential. However, even with prompt diagnosis, outcomes for this condition remain poor.¹⁴

“Macroamylasemia as the first manifestation of celiac disease.” This case report describes diagnosis of celiac disease in a 52-year-old woman who was referred to an outpatient clinic with a 6-month history of weakness, weight loss of 6 kg, maculopapular rash on her legs and persistent hyperamylasemia for 3 months (amylase >1,400 U [normal 35–120 U] and very low 24-hour urine amylase and amylase clearance/creatinine clearance ratio (1.9% [normal 3.0 ± 1.1%]), consistent with macroamylasemia.

Her medical history was remarkable only for several years of chronic normocytic normochromic anemia (hemoglobin 9.9 g%) and osteoporosis. She was not receiving any medications. Other than a sallow pallor and the maculopapular rash on both legs, the physical examination was completely negative. Laboratory results: thrombocytosis (510,000 platelets/ml), albumin 3.1 g, AST 60 U (normal 15–30), rheumatoid factor 81 (normal 0–15), anti-mitochondrial antibody (AMA) 1:80. The rest of the laboratory results were normal. An abdominal computerized tomogram with contrast yielded no pathological findings. Biopsy from the skin lesions on her legs revealed leukocytoclastic vasculitis (erythema elevatum diutinum).

The patient had macroamylasemia and anemia, which can present as an autoimmune disease, such as celiac disease. Her serology for celiac disease was strongly positive, and she underwent esophagogastroduodenoscopy which revealed scalloping of folds in the second part of the duodenum. A histological evaluation confirmed the diagnosis of celiac disease. The patient was started on a gluten-free diet which led to a significant clinical improvement two months later: she felt generally stronger, had gained weight, the rash had disappeared, the serum amylase values were normal, hemoglobin had increased to 11.7 g%, and there was a return of serum albumin to normal values.¹⁵

Sources:

1. Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Kathleen Mahan, Sylvia Escott-Stump. 2000. W.B. Saunders Company. [↩] [↩] [↩] [↩]
2. Murray JA, The widening spectrum of celiac disease. American Journal of Clinical Nutrition. Mar 1999;69 (3):354-365. [↩]
3. Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA. Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients. 2013 Sep 30;5(10):3975-92. doi: 10.3390/nu5103975. [↩] [↩] [↩]
4. Delco F, El-Serag HB, Sonnenberg A. Celiac sprue among US military veterans: associated disorders and clinical manifestations. Digestive Diseases and Sciences. May 1999;44(5):966-72. [↩]
5. Zarife et al. Celiac Disease: Presentation of 109 Children. Yonsei Med J. 2009 October 31; 50(5): 617–623. [↩]
6. Fernández A, González L, de-la-Fuente J. Celiac disease: clinical features in adult populations. Rev Esp Enferm Dig. 2010 Jul;102(8):466-71. [↩] [↩]
7. 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. [↩]
8. 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. [↩] [↩] [↩] [↩] [↩] [↩]
9. Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA. Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients. 2013 Sep 30;5(10):3975-92. doi: 10.3390/nu5103975. [↩]
10. Zarife K,et al. Celiac Disease: Presentation of 109 Children. Yonsei Med J. 2009 October 31; 50(5): 617–623. [↩]
11. Hoffenberg EJ, Emery LM, Barriga KJ, Bao F, Taylor J, Eisenbarth GS, Haas JE, Sokol RJ, Taki I, Norris JM, Rewers M. Clinical features of children with screening-identified evidence of celiac disease. Pediatrics. 2004 May;113(5):1254-9. [↩]
12. Rea F, Polito C, Marotta A, et al. Restoration of body composition in celiac children after one year of gluten-free diet. Journal of Pediatric Gastroenterology and Nutrition. Nov 1996;23(4):408-12. [↩]
13. Ciacci C, Cirillo M, Giorgetti G, et al. Low plasma cholesterol: a correlate of nondiagnosed celiac disease in adults with hypochromic anemia. American Journal of Gastroenterology. Jul 1999;94(7):1888-91. [↩]
14. Wali GN, Tyrrell HE, Collins GP, Eagleton HJ. A rare but potentially fatal cause of diarrhoea and weight loss: enteropathy-associated T-cell lymphoma. BMJ Case Rep. 2015 Jan 7;2015. pii: bcr2014204125. doi: 10.1136/bcr-2014-204125. [↩]
15. Depsames R, Fireman Z, Niv E, Kopelman Y. Macroamylasemia as the first manifestation of celiac disease. Case Rep Gastroenterol. 2008 Jun 6;2(2):196-8. doi: 10.1159/000132771. [↩]