Celiac.com 10/07/2020 - It has been two years now since I developed symptoms of celiac disease, and it's been a very difficult thing to go through. My symptoms first developed in August of 2018, and at first I didn't know what was wrong with me. I was losing so much weight – I got down to 87 pounds as opposed to my regular 105. I had no appetite and would have to force every meal down, even though my body kept trying to reject it. I got five cavities in my teeth in the span of six months, when prior to celiac, I had only ever had two. I had to sleep at least 14 hours every night to at least make it out of bed, but the rest of my waking hours were lethargic. I thought getting more exercise would help so I signed up for yoga classes but would have to sit out most of them because of how dizzy I felt. I would easily collapse if the position was slightly strenuous. 

When I discovered that my symptoms could be related to celiac disease, I was relieved at first. It wasn't cancer at least. And I didn't understand how severe the disease really was. I did not get a formal diagnosis, and just stopped eating gluten, and I thought that would be the answer. Sadly, it was not.

The elimination of gluten got rid of the aches and pains and helped me gain my appetite back, but my energy and cognitive functioning had not changed. Once you eliminate gluten after years of being sensitive to it, and especially in those with celiac disease, it can take time for your gut to heal the damage caused by the body's autoimmune reaction to gluten. I had read that it takes most people two years to heal that initial damage, but then of course I read of horror stories from people whose fatigue never went away. 

I was not going to let that be me. I knew there would be a solution.

Just by chance, I watched the documentary "Fantastic Fungi." The film talked about mushrooms having medicinal properties that have not fully been explored in the medical field, and where there are different mushrooms that have cured different illnesses, and some that people use to help treat cancer. After watching, I wanted to research if there were any mushrooms helpful in aiding auto-immune diseases. That is when I happened upon an essay about reishi mushrooms and how they are currently being studied as a potential cure for all auto-immune related disorders. I immediately bought a bag of red reishi powder to try it.

When the mushrooms arrived, I took half a teaspoon of it in my tea. I felt instant results. Suddenly my mind was sharper, in a way it hadn't been in a long time. I feared it may have been the placebo effect, but I kept it up. Half a teaspoon of powder every day in tea or smoothies. After a week, I saw myself sleeping less hours. I was able to focus, and my mood shifted for the better. After a month – I was my old self. I now have my energy mostly back. I've been able to work and concentrate. I can function off of a normal eight hours of sleep. And I am slowly but surely gaining weight. 

I have still had some gluten accidents since then. These mushrooms have in no way prevented my gut from further harm from gluten. But when I previously got glutened, it would be a week or two stuck in bed in pain. Now, it may only be a few days in bed, followed by a week or so of fatigue. So I am still extremely careful, and don't go to restaurants unless they are very strict about cross-contamination and and a fully gluten-free kitchen. Unfortunately the mushrooms aren't a cure and haven't allowed me to deviate from my gluten-free diet, but they have changed how I feel on an average day – which has been a life changer. 

There is no research yet on why reishi mushrooms help some people with auto-immune related fatigue, and I cannot guarantee they will work for everyone, but they have worked so well for me and have given me my life back. So I thought it was only responsible to spread the word about this magical fungus! If you have celiac disease and have had trouble getting your energy going again, I recommend that you try out reishi mushrooms. 

*Article edited on 10/19/2020 to clarify that the author is a self diagnosed celiac.

Celiac.com 09/17/2020 - A recent "Advisory" issued on August 29, 2020 by the Canadian Food Inspection Agency (CFIA), followed by a product recall, has brought up an interesting question: Which food safety system works better, the USA's or Canada's? The alert was issued two weeks ago for President's Choice Brand "Gluten-Free" Chicken Strips, the text of which reads:

• "In response to several reported reactions from consumers, the Canadian Food Inspection Agency (CFIA) is recommending individuals with celiac disease, or others with gluten-related disorders, to not consume the product described below as it may contain undeclared gluten. "

The advisory goes on to list the UPC number (0 60383 20488 4) and product code (2021 AL 20) of the chicken strips to avoid.

What caught our eye about this particular alert was that it was an "Advisory," rather than a recall, and recalls are what we typically see issued by both the CFIA and the FDA. This raised the following question: What is the difference between a CFIA "Advisory" and a "Recall", and is it better to have both?  

On August 31, 2020 we sent an email to the the CFIA's media department where we asked several questions, and on September 2, 2020 we received the following responses from Christine:

Q: What is the threshold minimum number of complaints required to trigger this type of public warning?

• Christine's Answer: "There is no set number of complaints required to issue a public warning. The CFIA issues public warnings on a case-by-case basis. In this case, the Agency had credible information from several sources that a particular product was the cause of several illnesses."

Q: Did you test any of this company's products before issuing this warning?  How did you determine that gluten was present in this product before issuing this warning?  

• Christine's Answer: "In this case, the Agency acted on credible information from several sources that a particular product was the cause of several illnesses.  It was affecting individuals with Celiac disease who normally show adverse reactions to the presence of gluten.  Given the potential severity of reactions, the Agency chose to inform individuals with Celiac disease and other gluten related disorders based on a pattern of reactions."

Q: Did you speak with any representatives at this company before issuing this warning?

• Christine's Answer: "Loblaw Companies Limited was contacted before issuing the consumer advisory and the recall warning."

Q: Did any of the people who complained about the product run any tests for gluten?

• Christine's Answer: None of the complainants supplied test results for gluten to the Agency.

After 25 years operating the Celiac.com Web site, including over 15 years of running our site's forum, one thing we've learned is that it can be very inaccurate to try to determine whether or not something has gluten in it just by someone's gut reaction to it. While some celiacs swear they can do this accurately, many celiacs, especially during the 1-2 year period following their diagnosis, can react in a similar way to all sorts of things like casein/milk, corn, eggs, soy, etc., possibly due to the "leaky gut" condition caused by the disease. Some celiacs swear they react to distilled alcohols made using gluten containing grains, even though scientists and the FDA have determined them to be gluten-free.

Given the extremely high expenses that such an advisory could create for a food company, we were hoping to get a more specific answer to our first question, and were very surprised to discover that there is no threshold to trigger such an advisory. Could a single report from a celiac trigger an advisory to be issues? Below are examples of stories that ran in the press just one day following the advisory, which triggered Loblaw to voluntarily recall the product:

Notice that none of these stories leave any doubt that there was gluten in the product, even though the CFIA made it clear in answering our first round of questions that the product never tested positive for gluten. At this point we were scratching our heads and wondering whether this system was working as planned, and whether it was doing a good job of keeping celiacs in Canada safe, or were advisories being issued without any real evidence that the product contained gluten? Since the CFIA indicated that there is no specific threshold for the issuance of such an advisory, we really had no idea if "several" complaints meant two or three, or two or three hundred.

Directly following Christine's September 2, 2020 responses we sent a follow up question to her, but this time Patrick, rather than Christine, responded to it:

Q: How can you be sure that the reactions that have been reported were not caused by a bacterial, chemical, or other issue with the product, rather than by gluten in the product?

• Patrick's Answer: "In this case, multiple individuals consumed the product and only those with celiac disease or allergies to wheat reported reactions.  This points to gluten/wheat being the causative agent.  In addition, some individuals reported anaphylactic shock. Those reactions are not associated with bacterial or chemical contamination in food.

  After the Consumer Advisory was issued, the food safety investigation was able to confirm that one of the ingredients contained gluten and a recall was issued by Loblaw Companies Limited."

Patrick's response certainly makes this sound like an open and closed case of wheat contamination in a product that was labelled gluten-free. If true the CFIA's advisory system was very effective at detecting gluten in a gluten-free product, which is exactly what their advisory system was designed to do—protect its citizens as soon as possible from dangerous foods. 

Even though the CFIA's system appears to have worked well in this case, it also seems like it could easily result in costly errors. By not setting a threshold number of complaints, or verifying the presence of gluten in a product before issuing such an advisory, it's possible that a costly mistake could be made, and if so, such an error could severely damage a small company. In this instance the company was a large one, which means that the product was distributed more widely, and it was therefore more important to react quickly, especially for those with anaphylaxis. 

Many people in the USA have reported complaining to the FDA about the possibility of gluten in products that are labelled "gluten-free," for example certain General Mills cereals, however it appears that the FDA has a much higher threshold for issuing a product recall. At the time of writing this article we could not verify exactly how the warnings sent into the FDA are used to issue a recall, but we assume that they follow up by testing the reported batch and/or lot number of the reported products, and if gluten is found we assume they issue the recall.

We wonder if the FDA's current system would have been able to detect gluten in these chicken strips and issue a recall as quickly as the CFIA's advisory system did? On one hand it makes perfect sense to verify complaints with positive testing for gluten before issuing any recall, if only to avoid costly errors that could harm companies, on the other hand it's possible that such delays could cause serious injury, or even deaths. 

Ultimately it's possible that both countries' systems could learn something from one another, and each could be improved.

Tell us in the comments below which food safety system you like better,  the FDA's possibly more conservative approach, or the CFIA's seemingly more aggressive approach?

Read the original consumer alert at: healthycanadians.gc.ca

Celiac.com 07/09/2020 - Celiac disease is an autoimmune disease that occurs in genetically predisposed individuals. It is estimated to affect 1 in 100 people worldwide, and is treated by a gluten-free diet. However, there’s also dermatitis herpetiformis (DH) to consider, which is basically celiac disease of the skin instead of the intestines. 

It’s a skin condition characterized by groups of itchy blisters that commonly occur on pressure points such as the elbows, the front of the knees, the buttocks, back, shoulders, face, and scalp. However, they can occur anywhere on the body. Dermatitis herpetiformis is eruptions can be very painful, and the itchy rashes may progress to red, raised patches of skin that can develop into small, watery blisters.  

To get a DH diagnosis you need to make an appointment with a gastrointestinal (GI) doctor and a dermatologist. Note that you need to continue to consume gluten until all tests for celiac disease and DH are concluded, and for DH a doctor will take a skin biopsy. (It should heal relatively quickly, with very little scarring.) Then, a lab will use dye to see if you have IgA in a particular type of pattern. This tells your doctor whether you have dermatitis herpetiformis or not. They can help you to get the inflamed reaction under control with cortisone (a steroid), while you simultaneously begin your lifestyle adjustment of not eating wheat, rye, barley, oats, and even dairy (specifically casein because the protein is very similar to that in gluten.) 

After diagnosis you will need to maintain a 100% gluten-free diet, and you’ll need to use topical products that are gluten-free as well. Be sure to double check your makeup (lipstick, mascara, eyeshadow, eyeliner, blush, etc.), hand lotions, facial wipes, detergents, soaps, sanitizers, perfumes, bug spray, sunblock, and much more.

Basically, what it comes down to is reading all ingredients, checking FAQ sections on websites, and calling the manufacturer directly to question cross contamination procedures. Taking these extra precautions will help to keep your skin clear, smooth, and free from continuing outbreaks.  

However, even with doing all of the above the healing time can be different for everyone. Some individuals heal in a few months, while some take a couple of years. Even if you’re clear for years but accidentally get gluten from cross contamination, you could suffer another outbreak. This is why it’s very important to be extra focused on your nutrition and beauty products after a positive DH diagnosis. 

A picture of DH from one of our forum members "amine33".

References: 

• gluten.org
• celiac.org
• Forum discussions about dermatitis herpetiformis.

Celiac.com 07/03/2020 - My daughter's birthday is today and she is awesome!

Normally, we go out to dinner to the restaurant of her choice. However, her favorite restaurant is one that has ZERO gluten free options. It is an Italian restaurant and we all know that I avoid Italian restaurants and pizza joints like the plague. This causes me a great deal of concern because she is young and without any food restrictions. Is it fair of me to deny her favorite restaurant because I cannot eat there? Should I make her think of others when she is trying to have her family birthday party? Is it ever okay to be selfish? These are all the big questions that I think about when dealing with this disease and my family.

This issue only comes up with my children. My husband can go to all of the gluten filled restaurants he wants to when he is at work. When we go out as a family, I restrict where we can go so that I can ensure that I can enjoy a meal out safely while still enjoying everyone's company. It shows empathy and caring for the family unit.

Now there are times when I'm not home or have other commitments and their father takes over parenting duties. These are the times they go to the places I cannot. There are 4-5 restaurants around us that I just refuse to go into because I cannot eat there and it makes me sad. So, I avoid it. They enjoy those nights and I try to make sure they can have them at least once a month.

However, birthdays are special. They only come once a year. They should be enjoyed and treasured as a special time. These are family times, for now. I know one day they will be up and grown, but for now they are medium-sized. They are both tweens. I want my kids to have what they want on their day because they don't always get to eat out at their special places.

This year for my younger child, we've done it differently. This year, I cooked her other favorite food - Mexican food. We had steak fajitas; shrimp tacos; a black bean, corn, and avocado salsa with chips; and refried beans. I made it all and she loved it. I did relent and give her a gluten cake - made in a throw away pan. I bought myself one of the Whole Foods gluten free Salted Caramel Mousse cakes that cost about 10x the gluten box mix and frosting for her cake, but who cares? My Salted Caramel Mousse cake was AMAZINGLY good - if you can, you should buy one!

She was very happy with the option of cooking at home and having extended family over for her "family" birthday. The kids played outside. The adults played board games and drank margaritas. It was a great day.

Today is her actual day of birth. I will be making her favorite meal - fettucini alfredo with peas and chicken. She will love it! Yes, it will have gluten. No, I don't live in a gluten-free house. Yes, I know how to manage the situation to avoid getting sick. The dishwasher and stainless steel pots, pans, and colanders solve a lot of problems. While I still wonder if the family tradition of taking a person out for their birthday should be their choice or if I should make them go someplace everyone can eat - this year, I've gotten around it. I've made her happy and kept myself safe. I think I've come to a good compromise here.

PS - I'll make her dad and brother take her to her favorite place this week sometime.

NOTE - This article was written before the COVID-19 Lockdown. While we may not have to make these decisions right now, we will have to make them again in the future. This issue doesn't go away and I fight it each time a child of mine has a birthday!

Celiac.com 06/19/2020 (Revised 06/24/2020) - It is not uncommon to have received blood testing from your doctor to see if you have celiac disease, and it comes back negative, when in fact your body is actually having a problem and you are on the celiac spectrum. The tests most doctors use to determine whether or not someone has celiac disease are very accurate for end stage celiac disease-after you have total villous atrophy, but not earlier stages of the disease (1). In those earlier situations, these tests often come back negative, even though you truly have a problem and are reacting to wheat moving towards total villous atrophy (1, 2, 3, 4, 5). It’s the wrong test.

If you have an earlier stage in terms of the amount of damage incurred, the standard blood tests can be wrong over 70% of the time giving false negatives

Standard blood tests for celiac disease have been extremely accurate and dependable if a person has total villous atrophy celiac disease. However, the accuracy of the blood test results for the two accepted blood markers (Endomysium and Tissue Transglutaminase) with anything less than total villous atrophy drops tremendously (to as low as being wrong 7 out of 10 times) (8,9). The reason these tests are often wrong in some people is that the research to validate the test used subjects who all had been diagnosed with celiac disease which by definition was total villous atrophy (Marsh IIIa,b,c). The earlier stages, Marsh 1 and 2 by most are considered ‘potential celiac disease’. So, when researchers were looking to validate if their blood tests were accurate in diagnosing celiac disease, they tested the blood of people diagnosed with celiac disease (total villous atrophy). And in that scenario, endomysium and tissue transglutaminase are highly accurate.

from Lerner A, Jeremias P, Neidhöfer S, Matthias T (2017) Comparison of the Reliability of 17 Celiac Disease Associated Bio-Markers to Reflect Intestinal Damage. J Clin Cell Immunol 8: 486.

from Lerner A, Jeremias P, Neidhöfer S, Matthias T (2017) Comparison of the Reliability of 17 Celiac Disease Associated Bio-Markers to Reflect Intestinal Damage. J Clin Cell Immunol 8: 486.

Why? Celiac disease is defined as total villous atrophy. However, you don’t just magically go to sleep one night fine and wake up the next morning with total villous atrophy celiac disease. This disease, like all diseases, needs to be looked at more as a spectrum. That’s why Prof. Michael Marsh identified the spectrum of celiac disease development (Marsh I, II, III a, b, c). Bottom line? The test for total villous atrophy celiac disease (Marsh III a, b, c) are not the tests to rely on for earlier phases of the spectrum (Marsh I, II). 

The end result is many people have been told they do not have celiac disease and wheat is not a problem continue eating this food that is leading them further down the path of autoimmune disease. And of course, the tests for celiac disease are NOT the tests for the spectrum of Wheat Related Disorders (9).

Predictive autoimmunity can tell you what areas of your body are under attack. Identifying an autoimmune mechanism early in the spectrum of development gives an opportunity to address it before there is so much tissue damage, now you have an autoimmune disease. Autoimmunity is the number 3 cause of death and highly preventable. If you could peek inside and determine what is going on before it does irreparable damage, it gives you a window of opportunity to address the problem early on and change the course of your health. This is called Predictive Autoimmunity (30). Identifying that you are on the celiac spectrum at Marsh I, gives you the opportunity to take action (gluten-free diet) and prevent progressing to Marsh III total villous atrophy. So the tests that are highly accurate for Marsh III are the wrong tests for Marsh I and II. They may be helpful and they may be misleading

Gluten, Autoimmunity, and Your Gut

Dr. Alessio Fasano is the chair of pediatric gastroenterology at Mass. General Hospital, Harvard, and director of Mucosal Immunology and Biology Research Center at Mass General Hospital for Children. He has done extensive research in the area of mucosal lining of the gut. He discovered, in the early 2000’s, a trilogy present in the development of autoimmunity: genetics, triggers, and intestinal permeability. (10) With celiac, we all know this – DQ2/DQ8, gluten, leaky gut = vulnerability to developing celiac disease.

In the last 15 years, research has continued to expand to include two more features - thus a total of 5 components in the development of autoimmune diseases. In addition to genetics, environmental triggers and intestinal permeability, we now know that a dysbiotic microbiome and a systemic inflammatory immune response are involved. (11)

This is important in our understanding of treatment. You can arrest the development of autoimmunity by healing the gut and addressing intestinal permeability. The majority of people with leaky gut do not show symptoms in the gut. A leaky gut spews out macromolecules into the blood stream that travel throughout your body that are considered foreign objects that your immune system will protect you from. And the resulting systemic inflammation from a leaky gut can affect any area of your body. And what are the most common triggers that will trigger a leaky gut? Gluten and small intestinalal bacteria overload. (11)

Dangers of a Gluten-Free Diet

Now this is a ‘Big Picture’ concept, but when you read the science it is clear that no one can fully digest the proteins in wheat (11, 12, 13, 14). It is indigestible to all humans, and in every single person causes a transient state of intestinal permeability (12, 13). Having said that, not everything about wheat is bad. Wheat (78%) and barley (3%) account for 78 - 81% of total prebiotics in the Western diet (14, 15, 16). When you remove wheat from your diet, a large percentage of the good bacteria will likely starve. This may be a contributing factor to the jaw-dropping statistic from the largest study ever done on mortality and celiac disease, that being diagnosed with celiac disease is associated with an 86% increased risk of mortality from a cardiovascular incident within 1 year (18). Just by being diagnosed. As far as I know, no one has pursued further research on this fact. What is different after diagnosis? People go on a gluten-free diet. What else? For most people, nothing else-they just stat eating gluten-free foods. You MUST be conscious of replacing the loss of prebiotics in your diet. Replacing wheat-based products with gluten-free products is a landmine. The vast majority of gluten-free products do not have prebiotic fibre, are not enriched, and are just tasty white paste. There’s nothing wrong with a gluten-free blueberry muffin once in a while, or gluten-free pasta on occasion. But these products are not healthy for you and can NOT be the cornerstone of your new diet. Be mindful of this at the onset of starting your gluten-free diet, so that you replenish your body with the necessary prebiotic nutrients your microbiome needs to increase diversity and balance. (14) 

So many people make the same newbie mistakes of just shopping in the gluten-free aisle and walk away with gluten-free cookies and snacks. I’m sorry to say that those are pretty much just as unhealthy, or worse, than the gluten versions. They just lack the antigen gluten.

You need to look towards the produce aisle, vary your food choices from day to day, eat a wide variety in colour and types of organic fruits and vegetables, eat fermented foods rich in probiotics, and feed that good bacteria in your gut with foods that are prebiotics (root vegetables daily).  

I highly recommend finding a Certified Gluten-free Practitioner (CGP) who has received extensive training in celiac disease, gluten sensitivities, wheat-related disorders and autoimmunity. That is the most comprehensive training out there in this area. Find a CGP in your area-they’re all over the world, and most do on-line private consults.

Addressing the intestinal permeability that has been developing with every exposure to wheat (12), within 5 minutes of wheat coming out of the stomach into the small intestine (20), is a game-changer in your overall health. There are over 300 autoimmune conditions. With the ‘Gateway’ in the development of autoimmune diseases being intestinal permeability, addressing this, and focusing on healing the gut can bring big rewards. 

Heal the Gut

• Identify and eliminate your triggers.
• Reduce inflammation.
• Reduce stress.

The following supplements all have many studies showing their value in addressing intestinal permeability: Glutamine (21), Fish oils (22), Vitamin D (23), Colostrum (24), Turmeric (25), Pre (26) and Probiotics (27). Each of these basic nutrients modulates (has their hands on the steering wheel) of genes to reduce inflammation achieving a similar end goal, but they each work in different ways. Using a pleiotropic approach ensures success (great scrabble word-pleiotropic-means ‘all roads lead to Rome’.

When you have a gluten-related disorder, the treatment is a strict gluten-free diet - without exception. Don’t let the treatment be the trigger for more problems. I’m known for the saying “You can’t be a little pregnant, you can’t have a little gluten” (if your immune system is activated fighting any of the peptides of wheat). Cheating once-per-month increases your risk of early death 6-fold! (19)

Take measures to protect yourself against nutritional and vitamin deficiencies associated with a gluten-free diet. The benefits of a ‘Coach’ to learn the correct basics through this transition cannot be overemphasized (28, 29). A CGP, Nutritionist, trained Registered Dietician, Health Coach, … are invaluable in you learning the basics of this transition into a new way of eating. Eat different colors of the rainbow at every meal, every day. It will help restore balance to your gut health and rebalance your immune system.

If you’re going to do this alone, avoid wheat (gluten), dairy, and added sugar for a month. Eat nutrient dense organic foods, such as quinoa, amaranth, vegetables, and quality meats. Gauge how you feel. Is your weight better managed? Do your hands and feet no longer feel cold? Are you able to think more clearly? If so, continue to eliminate those offending foods and eat a varied diet rich in nutrients. If you reintroduce and notice a problem, now you know those were foods that are inflammatory to you. And be careful of your tricky mind. Humans are the only species on the planet that finds something that works, and they stop doing it! 

References:

1. Lerner A, Jeremias P, Neidhöfer S, Matthias T (2017) Comparison of the Reliability of 17 Celiac Disease Associated Bio-Markers to Reflect Intestinal Damage. J Clin Cell Immunol 8: 486
2. Immunoglobulin A autoantibodies against transglutaminase 2 in the small intestinal mucosa predict forthcoming coeliac disease.
3. Salmi TT, Collin P, Järvinen O, Haimila K, Partanen J, Laurila K, Korponay-Szabo IR, Huhtala H, Reunala T, Mäki M, Kaukinen K.Aliment Pharmacol Ther. 2006 Aug 1;24(3):541-52
4. Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease. Brar P, Kwon GY, Egbuna II, Holleran S, Ramakrishnan R, Bhagat G, Green PH.Dig Liver Dis. 2007 Jan;39(1):26-9
5. Seronegative celiac disease: increased prevalence with lesser degrees of villous atrophy. Abrams JA, Diamond B, Rotterdam H, Green PH.Dig Dis Sci. 2004 Apr;49(4):546-50
6. Utility in clinical practice of immunoglobulin a anti-tissue transglutaminase antibody for the diagnosis of celiac disease. Abrams JA, Brar P, Diamond B, Rotterdam H, Green PH.Clin Gastroenterol Hepatol. 2006 Jun;4(6):726-30
7. Tests for Serum Transglutaminase and Endomysial Antibodies Do Not Detect Most Patients With Celiac Disease and Persistent Villous Atrophy on Gluten-free Diets: a Meta-analysis. Silvester JA, Kurada S, Szwajcer A, Kelly CP, Leffler DA, Duerksen DR.Gastroenterology. 2017 Sep;153(3):689-701
8. Screening for celiac disease.Lebwohl B, Green PH.N Engl J Med. 2003 Oct 23;349 (17):1673-4
9. Joint BAPEN and British Society of Gastroenterology Symposium on 'Coeliac disease: basics and controversies'. Coeliac disease in the twenty-first century. Dickey W. Proc Nutr Soc. 2009 Aug;68(3):234-41.
10. Mechanisms of disease: the role of intestinal barrier function in the pathogenesis of gastrointestinal autoimmune diseases. Fasano A, Shea-Donohue T. Nat Clin Pract Gastroenterol Hepatol. 2005 Sep;2(9):416-22.
11. Fasano A. All disease begins in the (leaky) gut: role of zonulin-mediated gut permeability in the pathogenesis of some chronic inflammatory diseases. F1000Res. 2020;9:F1000 Faculty Rev-69. Published 2020 Jan 31. doi:10.12688/f1000research.20510.1.
12. Celiac Disease and Nonceliac Gluten Sensitivity: A Review. Leonard MM, Sapone A, Catassi C, Fasano A. JAMA. 2017 Aug 15;318(7):647-656.
13. Effect of gliadin on permeability of intestinal biopsy explants from celiac disease patients and patients with non-celiac gluten sensitivity. Hollon J, Puppa EL, Greenwald B, Goldberg E, Guerrerio A, Fasano A.Nutrients. 2015 Feb 27;7(3):1565-76.
14. Lerner A, O'Bryan T, Matthias T. Navigating the Gluten-Free Boom: The Dark Side of Gluten Free Diet. Front Pediatr. 2019;7:414. Published 2019 Oct 15. 
15. Effects of a gluten-free diet on gut microbiota and immune function in healthy adult Human subjects - comment by Jackson. Jackson FW. Br J Nutr. 2010 Sep;104(5):773.
16. On the presence of Inulin and Oligofructose as natural ingredients in the western diet Jan Van Loo , Paul Coussement , Leen De Leenheer , Hubert Hoebregs & Georges Smits Critical Reviews in Food Science and Nutrition, Volume 35, 1995 - Issue 6.
17. Prebiotic effects of wheat arabinoxylan related to the increase in bifidobacteria, Roseburia and Bacteroides/Prevotella in diet-induced obese mice. Neyrinck AM, Possemiers S, Druart C, Van de Wiele T, De Backer F, Cani PD, Larondelle Y, Delzenne NM. PLoS One. 2011;6(6):e20944.
18. Small-intestinal histopathology and mortality risk in celiac disease. Ludvigsson JF, Montgomery SM, Ekbom A, Brandt L, Granath F., JAMA. 2009 Sep 16;302(11):1171-8.
19. Mortality in patients with coeliac disease and their relatives: a cohort study. Corrao G, Corazza GR, Bagnardi V, Brusco G, Ciacci C, Cottone M, Sategna Guidetti C, Usai P, Cesari P, Pelli MA, Loperfido S, Volta U, Calabró A, Certo M; Club del Tenue Study Group.Lancet. 2001 Aug 4;358(9279):356-61.
20. Confocal endomicroscopy shows food-associated changes in the intestinal mucosa of patients with irritable bowel syndrome. Fritscher-Ravens A, Schuppan D, Ellrichmann M, Schoch S, Röcken C, Brasch J, Bethge J, Böttner M, Klose J, Milla.  PJ.Gastroenterology. 2014 Nov;147(5):1012-20.
21. Glutamine and the regulation of intestinal permeability: from bench to bedside. Achamrah N, Déchelotte P, Coëffier M.Curr Opin Clin Nutr Metab Care. 2017. Jan;20(1):86-91
22. Potential of Omega-3 Polyunsaturated Fatty Acids in Managing Chemotherapy- or Radiotherapy-Related Intestinal Microbial Dysbiosis. Zhang Y, Zhang B, Dong L, Chang P.Adv Nutr. 2019 Jan 1;10(1):133-147.
23. Novel role of the vitamin D receptor in maintaining the integrity of the intestinal mucosal barrier. Kong J, Zhang Z, Musch MW, Ning G, Sun J, Hart J, Bissonnette M, Li YC.Am J Physiol Gastrointest Liver Physiol. 2008 Jan;294(1):G208-16.
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