Gluten Intolerance or Sensitivity

 

 

Introduction

Everybody has heard of gluten intolerance. Many suffer from flatulence, constipation, dysentery, irritable colon, also chronic inflammation of the colon, inflammatory skin diseases, overweight or headaches are rapidly increasing. However, identifying gluten intolerance is anything but easily tangible because, unlike allergies, it can be less drastic, masked and time delayed.

It is believed that as much as 6% of the U.S. population has some form of gluten sensitivity, which translates to nearly 20 million people. In addition, between 0.3% and 1.2% of the population have celiac disease, which has similar symptoms to gluten intolerance but differs in crucial ways. So, you are not alone if you or a loved one has one of these illnesses, and it makes sense to learn more about such a common health issue. [1]

The understanding of gluten intolerance increases daily. Nonetheless, researchers have already developed more than one “gluten intolerance test” using markers in blood, saliva, and stool to help doctors and patients reach a correct diagnosis and a practical treatment approach for gluten intolerance. Also, a cellular food sensitivity test has shown excellent results, see below.

Given the prevalence of gluten in foods and other products understanding this health condition is vital.

This article explains the differences between gluten sensitivity, gluten intolerance, wheat allergy, and celiac disease. It provides an in-depth overview of correlating gut-function disorders and detailed information on tests and treatment strategies, including a gluten-free diet. In addition, you’ll discover research on the surprising relationship between gluten exposure and mental health.

Gut health and Immune System

What are Gluten Intolerance and Non-Celiac Gluten Sensitivity?

It is important to understand that there are differences between gluten sensitivity, gluten intolerance, wheat allergy, and celiac disease.

Gluten is a protein found in many grains. It is present in all forms of whole and refined wheat and processed wheat products like pasta, bread, baked goods, malt, and seitan. Gluten is also present in lesser amounts in rye, barley, triticale (a cross between wheat and rye) and even some vitamins, supplements, and medications as well as cosmetics.

Oats are naturally gluten-free but are often contaminated from processing in the same facilities as gluten-containing grains. Gluten intolerance is also called non-celiac gluten sensitivity, and non-celiac wheat sensitivity and is different from other gluten-related disorders like wheat allergies and the autoimmune disorder celiac disease.

Doctors often use the terms gluten sensitivity, gluten intolerance, and non-celiac gluten sensitivity (NCGS) interchangeably to describe the challenging, but not life-threatening, digestive tract symptoms that characterize this illness. Current research suggests that the small intestine, gut lining, and immune system are all parts of the puzzle in understanding this syndrome and how to heal from it. [2]

Gluten intolerance and the different immune pathways

A person can react adversely to eating gluten due to several underlying conditions. These conditions are all called gluten intolerance. However, the pathogenesis of gluten-related disorders manifests via different immune pathways.

Non-celiac gluten intolerance or sensitivity (NCGS) is distinct from celiac disease and several other gluten-related disorders [3]. A study in 2010 showed celiac disease and non-celiac gluten sensitivity (NCGS) to be separate entities with different mechanisms of pathogenesis. NCGS was proposed to result from an innate immune response to gluten-containing foods, whereas celiac disease was associated with the adaptive immune response. [24,25,26]

The following terms are commonly used for this gluten sensitivity, not caused by celiac disease:

  • Non-celiac gluten sensitivity (NCGS)
  • Gluten intolerance
  • Gluten sensitivity

The most unambiguous term is NCGS. It is most precise when an immune reaction to gluten occurs but no celiac disease is present.

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Figure: Pathogenesis of gluten-related disorders manifesting via different immune pathways. The differentiation between an allergy, intolerance, and sensitivity to a food can be illustrated with the example of wheat.

Non-Celiac Gluten Sensitivity (NCGS)

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NCGS (non-celiac gluten intolerance) affects people of all ages, genders, and ethnicities, although it is slightly more common in women. In some cases, a person is sensitive to gluten from the time they are born; in other cases, this reaction develops later.

It is believed that NCGS (gluten intolerance) is mediated by the innate cellular immune system.

NCGS involves an immune reaction to the protein gluten, resulting in digestive tract symptoms such as gas, bloating, abdominal pain, constipation, and diarrhea and non-digestive symptoms like feeling tired, headaches, skin rashes, and body aches. The symptoms can range from almost unnoticeable to debilitating, although this condition usually causes little to no permanent damage to the gut, small intestine, or other organs.

Thus, a doctor often has difficulty distinguishing between gluten intolerance and Irritable Bowel Syndrome (IBS).

In the past few years, it has become apparent in modern research that celiac disease represents only the tip of the iceberg of an overall disease burden. Scientists discovered different specifications with which neither autoimmune nor allergic mechanisms have been proven – the inflammation causing innate immune cells. Similar symptoms to Celiac disease after gluten-uptake disappear in a little while when gluten-free food is ingested. No antibodies, no heavy inflammation of the mucosa or a significant leaky gut as known from Celiac disease can be found (23).

However, this won’t change the matter that sensitivity against gluten is existent. The potentially involved micro-inflammations can stress the body heavily and trigger other cellular proinflammatory reactions to foods (food intolerances).

Celiac Disease

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Celiac disease (CD), also known as Gluten Sensitive Enteropathy (GSE), is an autoimmune disease stemming from an abnormal gene affecting the autoimmune response to gluten protein.

Common symptoms of celiac disease are chronic diarrhea, abdominal pain, weight fluctuations, weakness, and fatty smelling stool. Celiac disease is a real autoimmune disease triggered by gluten and genetic predisposition (DQ2/DQ8) in CD patients.

Celiac disease is less common than gluten intolerance, affecting about 1%, or 1 in 133 people in the U.S. However, an estimated 80% go misdiagnosed or undiagnosed, potentially leading to osteoporosis from inadequate calcium absorption and anemia from insufficient iron. A “gluten-free diet” is the only effective treatment for celiac disease and other gluten-related conditions. Celiac disease produces antibodies in the blood that a doctor can detect with a test, and ruling out celiac is often one step in reaching a correct gluten intolerance diagnosis. [5]

Untreated celiac disease causes inflammation leading to severe harm to the digestive tract and interference with nutrient absorption. This lack of nutrition deprives bodily systems of the nourishment they need to stay healthy, resulting in untreated celiac disease potentially leading to severe health consequences.

Celiac disease can be verified through proof of antibodies in blood or stool (anti-tTG IgA) and biopsies of the small intestine mucosa. It can only be cured successfully if gluten containing food is strictly avoided consequently and lifelong.

Dermatitis herpetiformis is a skin rash resulting from gluten consumption with symptoms including persistent itchiness and blisters. DH is common in people with celiac disease, but others can also have it. A dermatologist can diagnose DH with a skin biopsy.

Wheat Allergy

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Gluten intolerance is not the same as a wheat allergy; wheat allergies engage a different part of the immune system than other adverse gluten responses. This type 1 food allergy, or “classical” food allergy is triggered by so-called allergen specific IgE antibodies.

Common food allergy symptoms include hives, rashes, and other skin problems, vomiting, difficulty breathing, and the possibility of anaphylaxis. Breathing problems are not typical of gluten sensitivity. Health professionals can diagnose wheat allergies using an immunoglobulin (IgE) blood test. Ruling out a wheat allergy is often another step in a non-celiac gluten sensitivity diagnosis. [6]

While there is a distinct difference between these conditions, they all share the common trait of the body reacting to gluten as a toxin. This reaction then activates an immune cell response, resulting in ongoing inflammation unless the person stops eating gluten.

 

Symptoms of Gluten Intolerance / Sensitivity 

People with gluten intolerance and sensitivity experience a wide range of symptoms of varying severity. Common symptoms include:

  • Abdominal pain and discomfort
  • Weight gain, overweight (“Wheat Belly”)
  • Joint pain
  • Brain fog
  • Constipation alternating with diarrhea
  • Headaches
  • Bloating
  • Fatigue
  • Vomiting and nausea
  • Epigastric pain and other gastro-esophageal symptoms
  • Skin rashes
  • Anxiety, depression, and other mental health problems

Symptoms can vary significantly and come and go, depending on whether the person avoids or consumes gluten, sometimes without realizing it (Cleveland Clinic). [7]

 

Some studies have revealed that people with gluten sensitivity and CD have higher levels of harmful gut microbes than beneficial ones in their small intestine and colon. The imbalance of gut microbes may be linked to many of the symptoms of gluten intolerance. [8] 

Alcat Testprofile

Causes of Gluten Intolerance and Sensitivity

The precise causes of non-celiac gluten sensitivity are not yet clear. However, one possible cause is the malabsorption of specific carbohydrates, resulting in these starches remaining in the gut, where they ferment and disrupt the microbiome population. The gut lining is crucial to bodily defense, keeping dangerous bacteria and other pathogens from getting into the bloodstream and organs. [9]

Overconsumption

With the overconsumption of gluten-containing products in our society, the sensitivity is not a big surprise. Especially in our culture, a lot of bread, pizza, pasta, convenience products with hidden gluten (e.g., soy sauce) and beer are consumed – often daily.

Back to grandma’s baking wisdom

A study demonstrates that the resting time of bread dough influences how digestible bread is. The wheat grain contains certain types of sugar called “FODMAPS”. The abbreviation stands for “fermentable oligo-, di- and monosaccharides and polyols”. However, these difficult-to-digest amounts of FODMAPS in bread can be reduced. If the bread dough rests longer, the sugars are broken down:

 

Researchers showed that after one hour of resting, all types of dough contained the most FODMAPS. After four hours, it was only ten percent of the sugars originally contained.

Additives, fertilizers, etc.

The use of fertilizers and so-called fertilizers should not be underestimated in agriculture. Of course, many additives are also used today in bread and all finished products for processing, color, shelf life, texture, and so on.

A person can react directly to chemical additives and fertilizers with an inflammatory reaction. In the long term, they could negatively affect the microbiome.

Infections

Infections in the digestive system, abdominal surgery, and certain medications can also cause gluten intolerance. In addition, some researchers have found similarities between gluten sensitivity and histamine intolerance, suggesting there might be an overlap between these two health issues. [11]

How to Diagnose Gluten Intolerance and Sensitivity 

Diet, Gut Health and Balance

Celiac or NCGS?

It is crucial for a doctor to carefully distinguish between non-celiac gluten sensitivity and celiac disease (CD) because of the potentially dire outcomes of untreated CD.

Another symptom overlap that needs careful differentiation is IBS and gluten intolerance (NCGS); some people are diagnosed with both. Non-celiac gluten sensitivity does not have a known genetic cause. Physicians rely often on a patient’s description of symptoms, past medical history, and sometimes indirect test results involving blood, saliva, stool samples, or a type 1 food allergy test.

A healthcare professional can also use the Gastrointestinal Symptom Rating Scale to gather information for diagnosis. A history of childhood food allergy, specific antibodies in the blood, and microbiological counts in stool samples can all aid in identifying a gluten intolerance. [12]

Thus, a negative test for celiac disease can help point the way toward an accurate diagnosis of gluten intolerance (NCGS). [4]

However, it’s essential to note there is no cure for gluten-sensitivity diseases, and avoiding gluten is the only current treatment for managing symptoms.

Gluten Intolerance Tests (NCGS)

If coeliac disease could be ruled out, a direct approach can further answer the question of whether gluten intolerance (NCGS) is present. Paradoxically, there are very few diagnostic approaches where cellular defenses are used as biomarkers, although neutrophils and eosinophils are direct indicators of inflammation.

It is therefore worth looking at this interesting and promising, but little-known approach.

One study was able to show that NCGS could be identified very reliably with this leukocyte activation test (Alcat Test). This cellular food sensitivity blood test has demonstrated in various very well-controlled studies, e.g., at Yale School of Medicine, that this approach also enables significant improvements in irritable bowel syndrome.

Gluten-Elimination Diet

Another way of testing gluten sensitivity is by doing a gluten-elimination diet. It is best to do an elimination diet with the supervision of a doctor or other health provider. The steps for an elimination diet are as follows:

  • Eat a diet containing gluten products for several weeks.
  • Keep daily records of food intake and digestive symptoms during this time.
  • Next, eliminate all gluten products for several weeks and track the results.
  • Finally, reintroduce gluten and watch for returning digestive symptoms that went away while staying on the elimination diet. [13]

If you suspect you have gluten intolerance, consult a doctor for an accurate diagnosis.

The cellular Alcat Food Sensitivity Test (NCGS)

The Alcat food sensitivity test could more conveniently abbreviate this elimination process.

Cell Science Sytems, the Alcat Test Laboratory offers also the CICA (Celiac, IBS, and Crohn’s Array). The CICA Gut Health Assessment analysis is designed to provide an accurate evaluation of gastrointestinal tract function by gathering information from various pathways considering genetic, Antibody, and cellular biomarkers. 

Alcat Tests contain not only the 5 most prominent grains, gluten, and gliadin, but, dependant on the panel many alternatives and other critical big “allergenes” such as yeast, milk (proteins), egg, soy and many more.

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Treating Gluten Sensitivity and Intolerance 

Gluten intolerance does not have a cure that allows a person to continue consuming gluten. However, following a gluten-free diet often stops symptoms and restores health and happiness to daily life for many people. Working with an experienced doctor or nutritionist to develop a diet can be a significant benefit in finding the right foods and preparation methods for your preferences.

Gluten sensitivity often goes hand in hand with leaky gut or irritable bowel syndrome. These articles address these topics: https://alcat.com/en/leaky-gut-syndrome/ and https://alcat.com/en/irritable-bowel-syndrome/

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Hidden Gluten Sources

Gluten is present in many products that you might not think of, including:

  • Farina cereals
  • Graham
  • Einkorn wheat
  • Triticale
  • Barley
  • Rye
  • Seitan and other gluten protein products
  • Modified food starch
  • Some brands of soy sauce

According to U.S. Food and Drug Administration (FDA) standards, more prepared foods are labeled’ gluten-free.’ In addition, many whole foods do not contain gluten but don’t have such labels. For example, the following grains are naturally gluten-free, and you can find many recipes for creatively using them to substitute for wheat products like bread and pasta.

  • Quinoa
  • Brown and white rice
  • Millet
  • Buckwheat
  • Amaranth
  • Oats from a gluten-free processing facility
  • Corn
  • Sorghum

Food Sources that May Help

Adding probiotics to the diet can also help with gluten sensitivity. Probiotics are healthy gut bacteria performing numerous tasks in the small intestine, digesting food, producing vitamins, and assisting in the immune response. Probiotic bacteria are found in:

  • Live culture yogurt, kefir, and sour cream
  • Naturally fermented sauerkraut, kimchi, and pickles
  • Miso, natto, and tempeh
  • Some cheeses

Including some of these foods in your daily diet – unless, of course, you have a food allergy or sensitivity – can help boost and balance the populations of beneficial microorganisms in the gut, which can help heal the digestive system after eliminating gluten from the diet. [14]

For people who are not sensitive to gluten, this protein is an excellent source of prebiotics – the preferred diet of probiotic microorganisms. However, if you go on a gluten-free diet, eating other prebiotic foods to replace gluten and keep the gut microorganisms nourished and thriving is essential.

In addition, when switching to a gluten-free diet, it’s wise to avoid processed gluten-free products made from potato flour, tapioca, rice flour, corn meal, sugar, artificial sweeteners, unhealthy fats, and other additives. [16]

The most successful treatment strategy for wheat protein intolerance is tailored by a doctor to the individual and their unique food sensitivities and intolerance profile (Havard University School of Public Health). [15]

 

Gluten Sensitivity and Mental Health

Essential Role of Gut Health vs Inflammation

The connection between gluten and mental health is complex and under investigation. However, research suggests several ways gluten can affect emotions, cognition, and behaviors, including through ongoing inflammation of the brain and malabsorption of nutrients in the small intestine. [17]

In one study, researchers looked at the neurology of people with celiac disease, finding that neurological symptoms were common. For example, 67% of participants had frequent headaches, and most had abnormalities in gait and balance. Later studies used brain imaging to confirm abnormalities in brain structures in participants with a positive test for gluten antibodies. Those who stayed completely gluten-free did not have the same brain changes. [18]

Now let’s look at other research results into gluten sensitivity and specific mental health conditions.

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Gluten and Anxiety

A long-term study from Scandinavia found that a gluten-free diet reduced anxiety in people with celiac disease. Other research into nutritional remedies for anxiety reveals the benefits of strictly avoiding gluten and artificial sweeteners and increasing consumption of omega-3 fatty acids, vitamin D, and turmeric. [19, 20]

 

Gluten, Depression, and Other Mood Disorders

There have been mixed results in research on gluten’s effect on depression. Still, several studies show a significant improvement in depression symptoms and other mood disorders when gluten-sensitive individuals remove it from their diets. [21]

Gluten and ADHD

One study of 67 people with ADHD found that 10 had undiagnosed celiac disease, a larger proportion than expected in a random sample. For these patients, removing gluten from their diet significantly improved ADHD symptoms. [22]

Gluten and Schizophrenia 

Research into a connection between gluten and schizophrenia goes back many decades, and researchers have noted shared immunologic features in those with schizophrenia and those with celiac disease. Some studies find a gluten-free diet improves daily life for people diagnosed with schizophrenia, while a minority of studies have found no significant benefit. [23]

 

Science Behind the Role of Food Reactions & Inflammation

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Do Food Intolerances Affect Gut Health?

You can test for food intolerances using an elimination diet. If you are using a food sensitivity/intolerance blood test, make sure you are using a cellular test as the immune cells are a direct indicator of inflammation (e.g. the Alcat Test).

Immune cell mediated inflammation causing food sensitivity/intolerance can lead to various symptoms such as:

  • Gut (celiac, IBS, Crohn’s disease,diarrhea, gas, constipation, bloating,gastritis, acid reflux, naucea)
  • Metabolic (overweight, diabetes,thyroid, inability to lose weight)
  • Skin (acne, eczema, psoriasis, rashes, urticaria)
  • Musculoskeletal (stiff/sore joints, arthritis,tendonitis, fibromyalgia)
  • Respiratory (chronic cough, asthma, post nasal drip, wheezing, sinusitis)
  • Neurological (chronic fatigue, headache, migraine, depression, cognitive impairment, ADD, ADHD)

Personalized Diet Based on Laboratory Data

The Alcat food intolerance test is an important tool for prevention and identification of foods that can trigger inflammation in the gut. In a simple blood test, immune cells are exposed to foods, additives, medications, substances in dietary supplements, and more.

Food intolerances are mediated by cellular defenses. The inflammatory processes that occur are often hidden – hence the term silent inflammation -, and are more difficult to detect than an immediate-type food allergy.

Cells on fire

See figure / right side: In the resting state, neutrophil granulocytes (innate immune cell type) have a round shape. As they ingest danger-molecules or pathogens, they swell – the cell activation process begins.

During a strong reaction, granulocytes can burst. Consequently, the highly toxic proinflammatory mediators – the cell’s own “arsenal of weapons”, free radicals and even DNA are released. Chronic activation of the immune system caused by food components can be associated with a wide variety of diseases (image right).

Cell mediated Food Intolerance

The Alcat Test includes a precise interpretation of the test results and makes a clear distinction between allergy, enzyme mediated intolerance and food intolerance, also adressed as sensitivity. It also includes the creation of a personalized profile with dietary recommendations and integrates lifestyle questions (eating out, vacations, celebrations, consumption of stimulants, stress reduction).

 

This personalized diet concept allows you to address effectively underlying inflammatory processes and prevent the development of chronic diseases.

Information about the Alcat Food Inflammation Test and Cellular Micronutrient Tests

FAQ’s

1) What are the first signs of being gluten intolerant?

Digestive problems are usually the first sign, including frequent diarrhea, constipation, or altering bouts. Nausea, abdominal bloating and discomfort, and headaches after eating gluten are common symptoms of gluten intolerance. However, gluten can also effect mental health and cognition, producing symptoms like brain fog, anxiety, and mood swings.

2) Can you suddenly become gluten intolerant?

Yes, and it’s also possible to have undiagnosed celiac disease without symptoms for many years and then suddenly develop symptoms later in life. It is also possible to suddenly become gluten intolerant without celiac disease.

3) How do I know if I’m gluten intolerant or celiac?

Celiac disease can be reliably diagnosed with blood tests. Testing for celiac disease and wheat allergy is often the first step in reaching a diagnosis of gluten intolerance. While there are no direct tests for non-celiac gluten sensitivity, after ruling out celiac and allergies, you can use indirect blood tests for food allergies, sensitivities, and intolerances and a gluten elimination diet challenge to verify a gluten intolerance diagnosis.

Conclusion

Gluten intolerance, especially with existing gut dysbiosis or increased gut permeability, may result in subsequent intolerances irritating the gut and contribute to leaky gut. Therefore, a broad food sensitivity test (including additives, colorings, environmental chemicals) such as the Alcat Test is a simple solution to a complex problem so that critical foods can be avoided for a while.

Many people struggle with non-celiac gluten sensitivity, and most know someone with this condition. The more we know about this health problem, the better we can help those around us and ourselves to enjoy and participate in daily life. If you suspect you might be gluten intolerant or have celiac disease, it’s crucial to seek a diagnosis from a doctor or other qualified healthcare professional. If you are diagnosed with a gluten intolerance disease, switching to a gluten-free diet is the most crucial action you can take to heal.

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50 PHYTO basic

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20 MYK (moulds)

Alternaria alternate, Aspergillus fumigatus, Aureobasidium pullulans, Botrytis cinerea, Candida albicans, Cephalosporium, Cladosporium herbarum,  Curvularia spicifera, Epicoccum nigrum, Fusarium oxysporum, Geotrichum candidum, Helminthosporium, Hormodendrum, Monila sitophila, Mucor racemosus, Penicillium, Phoma herbarum, Rhizopus nigricans, Rhodotorula rubra, Spondylocladium, Trichoderma

Popular COMBI Test Packs for Gluten & Food Intolerance & Micronutrients

Support gut health: What to eat and what not to eat – targeted nutrient recommendations and supplementation

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Cellular Nutrition Assays CNA (100 micro/macro nutrients)

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100 Alcat Food Intolerance Test + 100 Micro/Macro Nutrients

Combi Food Intolerance Test and Cellular Nutrition Assays

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245 Alcat Food Reaction Test + Additives / 100 Micro/Macro Nutrients

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Sources

[1] https://link.springer.com/article/10.1007/s12016-010-8223-1

[2] https://my.clevelandclinic.org/health/diseases/21622-gluten-intolerance#:~:text=Gluten%20intolerance%20is%20when%20you,called%20non%2Dceliac%20gluten%20sensitivity.

[3] https://www.tandfonline.com/doi/abs/10.1080/07315724.2014.869996

[4] https://www.academia.edu/27746095/Non_celiac_gluten_sensitivity_an_emerging_syndrome_with_many_unsettled_issues

[5] https://nationalceliac.org/resources/what-is-celiac-disease-2/

[6] https://www.chop.edu/conditions-diseases/wheat-allergy

[7] https://my.clevelandclinic.org/health/diseases/21622-gluten-intolerance#:~:text=Gluten%20intolerance%20is%20when%20you,called%20non%2Dceliac%20gluten%20sensitivity.

[8] https://www.mdpi.com/2072-6643/12/6/1832

[9] https://pubmed.ncbi.nlm.nih.gov/24667093/

[10] https://keep.lib.asu.edu/items/165450

[11] https://link.springer.com/article/10.1007/s00011-017-1117-4

[12] https://nyulangone.org/conditions/celiac-disease-gluten-sensitivity/diagnosis#:~:text=Currently%2C%20there%20is%20no%20test,celiac%20disease%20or%20gluten%20sensitivity.

[13] https://www.mdpi.com/2072-6643/7/6/4966

[14] https://www.mdpi.com/2072-6643/12/6/1832

[15] https://www.hsph.harvard.edu/nutritionsource/gluten/

[16] https://link.springer.com/article/10.1007/s00011-017-1117-4

[17] Neurologic and Psychiatric Manifestations of Celiac Disease and Gluten Sensitivity | SpringerLink

[18] Neurological Evaluation of Patients with Newly Diagnosed Coeliac Disease Presenting to Gastroenterologists: A 7-Year Follow-Up Study – PubMed (nih.gov)

[19] Anxiety But Not Depression Decreases in Coeliac Patients After One-Year Gluten-free Diet: A Longitudinal Study: Scandinavian Journal of Gastroenterology: Vol 36, No 5 (tandfonline.com)

[20] Frontiers | Nutrition as Metabolic Treatment for Anxiety (frontiersin.org)

[21] Mood Disorders and Gluten: It’s Not All in Your Mind! A Systematic Review with Meta-Analysis – PMC (nih.gov)

[22] Association of Attention-Deficit/Hyperactivity Disorder and Celiac Disease: A Brief Report – PMC (nih.gov)

[23] Use of a Gluten-Free Diet in Schizophrenia: A Systematic Review – PMC (nih.gov)

(24) Sapone et al: Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: celiac disease and gluten sensitivity. BMC Medicine 2011;9:23

(25) Lammers et al: Gliadin Induces an Increase in Intestinal Permeability and Zonulin Release by Binding to the Chemokine Receptor CXCR3. Gastroenterol 2008;135:194-204

(26) Sollid, L.M. and Jabri, B. “Triggers and drivers of autoimmunity: lessons from coeliac disease,” Nat Rev Immunol, vol. 13, no. 4, pp.294-302, 04 2013.

(27) Sollid et al: Coeliac disease: dissecting a complex inflammatory disorder. Nat Rev Immunol 2002;2:647-655

(28) Silano et al: Effect of the timing of gluten introduction on the development of celiac disease.  World J Gastroenterol  2010;16:1939-42