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Food Intolerance

Malabsorption Syndrome Due to Intolerance

Food intolerance is a nonimmune-mediated response to certain foods. It presents with abdominal pain, vomiting, and diarrhea. The mechanism of most forms of food intolerance is largely unknown.


Presentation

Food intolerance presents classically with flatulence, bloating, fatigue, vomiting, abdominal cramps, and diarrhea [9]. Rare symptoms include hives, migraine headache, wheezing, and difficulty in breathing. Symptoms are much severer in food allergy. Also unlike food allergy, symptoms are not immediate and they emerge only after the consumption of large amounts of the food.

In lactose intolerance, lactose sugar, which is found in cow's milk, passes undigested to the colon, raising the luminal osmolarity, causing abdominal bloating, discomfort, flatulence, and diarrhea.

However, in some cases, the trigger factor of the food intolerance is unknown. Symptoms vary in severity and may occur if the food items are ingested in excess. Fatty foods are responsible for intolerance in some individuals.

These symptoms are similar to those of certain GI diseases such an irritable bowel syndrome, which should hence be excluded.

Cough
  • Symptoms of food allergy in children are diverse and include vomiting, poor weight gain, abdominal pain, malabsorption, cough, wheeze, rhinitis, atopic eczema, urticaria and angioedema.[ncbi.nlm.nih.gov]
  • […] with even a trace amount of a food they are allergic to, victims might experience symptoms in the gastrointestinal tract (nausea, vomiting, or diarrhea), skin (itching, swelling, or hives), or respiratory system (stuffy, runny, or itchy nose; sneezing; coughing[consumerreports.org]
  • Word Frequency food intolerance in British ( fuːd ɪnˈtɒlərəns ) noun an intolerance of a specific type of food, causing an adverse reaction Many symptoms of food intolerance can develop, including rhinitis, coughing, asthma, constant sneezing and post-nasal[collinsdictionary.com]
  • Respiratory (lungs and breathing - chronic cough, asthma , sinusitis, bronchitis etc.) Dermatological (skin conditions - eczema or psoriasis etc.)[foodintol.com]
  • The classic symptoms of a life-threatening food allergy include hives, skin swelling, swelling of the lips, tongue or throat, a drop in blood pressure, difficulty breathing, wheezing, coughing, severe crampy abdominal pain and vomiting, Davis said.[bcm.edu]
Nasal Congestion
  • In the respiratory tract as nasal congestion, sneezing, cough, or asthma. In the digestive tract as bloating, cramping, diarrhea, constipation, or mouth ulcers.[bodyecology.com]
  • Alcohol intolerance can cause unpleasant symptoms such as nasal congestion and skin flushing. Once again, intolerance is linked to an enzyme deficiency making it hard for the body to break down alcohol.[bbcgoodfood.com]
  • . • Nasal congestion, lots of secretions. • Noisy breathing. • Wheezing. • Lung problems such as asthma or bronchitis. • Swollen tonsils.[laleche.org.uk]
Dutch
  • The aim of the study was to assess the prevalence of food intolerance (FI) in Dutch 5- and 6-year-old children and its association with chronic ailments with a survey among parents by questionnaire.[ncbi.nlm.nih.gov]
  • Patients from the Dutch Crohn's and Ulcerative Colitis Association were mailed a survey on food intolerance; 105 (31% men) of 137 patients took part. They all reported intolerance to one or more foods.[ncbi.nlm.nih.gov]
  • Partial translations for Dutch, French and Spanish have been added. Many ratings and comments have been updated according to the latest research and several new products have been added.[itunes.apple.com]
Malaise
  • In the case of celiac disease, symptoms of vitamin and iron deficiency, general malaise and oedema may also be evident.[metropolitan-pharmacy.com]
  • It's not so much that I doubt the physiological component in all this tummy rumbling and grumbling, it's more that the social and cultural aspects of the malaise have grown yet still louder in the past half-decade.[bbc.com]
Collapse
  • […] allergen, the person can have potentially life-threatening symptoms, which may include: difficult or noisy breathing swelling of the tongue swelling or tightness in the throat difficulty talking hoarse voice wheeze persistent cough persistent dizziness or collapse[betterhealth.vic.gov.au]
  • Food allergy symptoms low blood pressure, dizziness, faintness or collapse swelling of the lips and throat, nausea and feeling bloated diarrhoea, and vomiting dry, itchy throat and tongue, coughing, wheezing and shortness of breath and a runny or blocked[foodauthority.nsw.gov.au]
Diarrhea
  • Tips for Managing Diarrhea Diarrhea can be caused by a range of things from gastroenteritis to food sensitivity. No matter the trigger of diarrhea, it can really disrupt your life.[imodium.com]
  • Prostaglandins appear to have cytoprotective effects in the upper bowel and are released in increased amounts in patients with abnormal peristalsis and diarrhea.[ncbi.nlm.nih.gov]
  • It presents with abdominal pain, vomiting, and diarrhea. The mechanism of most forms of food intolerance is largely unknown. Food intolerance presents classically with flatulence, bloating, fatigue, vomiting, abdominal cramps, and diarrhea.[symptoma.com]
  • The clinical features of food intolerance include vomiting, diarrhea, bloody stool, eczema, failure to thrive, and a protean range of other symptoms.[ncbi.nlm.nih.gov]
  • Common symptoms (scored from 0 absent to 10 severe), included diarrhea (mean score 5.8), fatigue (mean score 5.5), and thirst (mean score 4.6).[ncbi.nlm.nih.gov]
Vomiting
  • Forty-eight (70%) children presented with gastrointestinal symptoms (vomiting, diarrhoea, colic, abdominal pain, failure to thrive), 16 (24%) children with skin manifestations (eczema, urticaria, angioneurotic oedema, other rashes), and 4 (6%) children[ncbi.nlm.nih.gov]
  • The clinical features of food intolerance include vomiting, diarrhea, bloody stool, eczema, failure to thrive, and a protean range of other symptoms.[ncbi.nlm.nih.gov]
  • It presents with abdominal pain, vomiting, and diarrhea. The mechanism of most forms of food intolerance is largely unknown. Food intolerance presents classically with flatulence, bloating, fatigue, vomiting, abdominal cramps, and diarrhea.[symptoma.com]
  • This prospective study included 63 patients presenting with more than four vomiting episodes per week. Therapeutic endoscopy with a 30-mm balloon (Rigiflex ) was performed with radioscopic guidance in the first 16 patients (25.4 %).[ncbi.nlm.nih.gov]
  • Symptoms of food allergy in children are diverse and include vomiting, poor weight gain, abdominal pain, malabsorption, cough, wheeze, rhinitis, atopic eczema, urticaria and angioedema.[ncbi.nlm.nih.gov]
Nausea
  • Food intolerances take place in the digestive system and can cause gastrointestinal complaints such as nausea, bloating, cramps, gas, and diarrhea.[consumerreports.org]
  • These antibodies create the symptoms of a food allergy, such as rash or hives, nausea, stomach pain, diarrhea, itchy skin, shortness of breath, chest pain and anaphylaxis.[ift.org]
  • Common symptoms of a food intolerance: Diarrhea Nausea Bloating Abdominal pain An example of a common food intolerance is to lactose – a sugar found in milk and other dairy products.[imodium.com]
  • Food intolerance is similar in symptomatology to food allergy, presenting with vomiting, diarrhea, flatulence, abdominal cramps, and nausea.[symptoma.com]
Abdominal Pain
  • Gallstones were associated with mid upper abdominal pain in the screening study, and with mid upper abdominal pain, biliary pain, and colic (each independently) in the clinical study.[ncbi.nlm.nih.gov]
  • Forty-eight (70%) children presented with gastrointestinal symptoms (vomiting, diarrhoea, colic, abdominal pain, failure to thrive), 16 (24%) children with skin manifestations (eczema, urticaria, angioneurotic oedema, other rashes), and 4 (6%) children[ncbi.nlm.nih.gov]
  • There was no correlation between either food intolerance or the total mean GSRS score and weight loss, but there was a correlation between weight loss and abdominal pain.[ncbi.nlm.nih.gov]
  • Symptoms of food allergy in children are diverse and include vomiting, poor weight gain, abdominal pain, malabsorption, cough, wheeze, rhinitis, atopic eczema, urticaria and angioedema.[ncbi.nlm.nih.gov]
  • The commonest symptoms among patients were diarrhoea, abdominal pain, and meteorism and among controls, regurgitation.[ncbi.nlm.nih.gov]
Abdominal Cramps
  • Food intolerance is similar in symptomatology to food allergy, presenting with vomiting, diarrhea, flatulence, abdominal cramps, and nausea.[symptoma.com]
  • With a food sensitivity, a person might be able to consume a certain food occasionally without feeling any ill effects, but will sporadically develop symptoms such as acid reflex, nausea, abdominal cramps.[ift.org]
  • Abdominal cramps an loose stools are known side effects. Other IBS symptoms are commonly reported. Preservatives – Maybe making things indigestible by bacteria makes them indigestible by humans.[solvingtheibspuzzle.com]
  • An estimated 30 million to 50 million Americans suffer from gas, bloating, nausea, abdominal cramps, and/or diarrhea when they consume dairy products; because most adults in the world are lactose intolerant, many scientists would prefer that everyone[takepart.com]
  • cramps breathing difficulties, including wheezing and asthma vomiting, nausea.[betterhealth.vic.gov.au]
Eczema
  • There was no significant difference in infant eczema (eight studies, 2558 infants, typical RR 0.84, 95% CI 0.68, 1.04), childhood eczema incidence (two studies, 950 infants, typical RR 0.83, 95% CI 0.63, 1.10), childhood eczema prevalence (one study,[ncbi.nlm.nih.gov]
  • Parents frequently associate FI with eczema, hives, chronic diarrhoea and hyperactivity.[ncbi.nlm.nih.gov]
  • No significant difference was reported in one study in infant asthma (RR 1.10, 95% CI 0.86, 1.40), infant eczema (RR 1.20, 95% CI 0.95, 1.52), childhood eczema prevalence (RR 1.10, 95% CI 0.73, 1.68), infant rhinitis (RR 0.94, 95% CI 0.76, 1.16) or childhood[ncbi.nlm.nih.gov]
  • Forty-eight (70%) children presented with gastrointestinal symptoms (vomiting, diarrhoea, colic, abdominal pain, failure to thrive), 16 (24%) children with skin manifestations (eczema, urticaria, angioneurotic oedema, other rashes), and 4 (6%) children[ncbi.nlm.nih.gov]
  • The clinical features of food intolerance include vomiting, diarrhea, bloody stool, eczema, failure to thrive, and a protean range of other symptoms.[ncbi.nlm.nih.gov]
Dermatitis
  • Recently, we identified a subgroup of patients with atopic dermatitis (AD) with a clinical relevant food intolerance proven by double blind placebo controlled challenge.[ncbi.nlm.nih.gov]
  • Tartrazine (E102), a yellow dye widely used in soft drinks, sweets, and sauces, can cause nettle rash (urticaria), dermatitis, asthma, or rhinitis. * Gluten.[rd.com]
  • […] allergies that trigger immune-system response generally create the more serious reactions like tongue swelling, respiratory difficulty, tingling sensations, anaphylactic shock, acute/severe gastrointestinal upset, chronic/acute joint pain, chronic painful dermatitis[deliciousliving.com]
  • Environmental triggers Eczema, other dermatitis and dry skin rashes can also be reactions to products such as bubble bath, baby wipes, skin cream, fabric conditioner or washing detergent.[laleche.org.uk]
  • The pictures show a patient with atopic dermatitis who was treated with an elimination and rotation diet after identifying incompatible foods (Alcat Test ). Figure 4 Skin condition before treatment and 14 weeks later.[cellsciencesystems.com]
Flushing
  • Another example of an intolerance would be if a person eats fish that has not been refrigerated appropriately, causing buildup of histidine, which is metabolized by bacteria to histamine, causing flushing and a fast heart rate.[bcm.edu]
  • Some people have reported symptoms such as flushing, temperature increase and headache after eating the flavour enhancer MSG.[safefood.eu]
  • A rash and/or itching of the skin - the rash may be raised, blotchy and red or the skin may be flushed. Wheezing or feeling breathless. Feeling sick or being sick (vomiting). Tummy pain. Diarrhoea. Sneezing or a runny nose.[patient.info]
  • Alcohol intolerance can cause unpleasant symptoms such as nasal congestion and skin flushing. Once again, intolerance is linked to an enzyme deficiency making it hard for the body to break down alcohol.[bbcgoodfood.com]
  • IgE-mediated reactions are the ones we worry about when we hear about a “food allergy”: flushing, itchy skin, wheezing, vomiting, throat swelling, and even anaphylaxis.[sciencebasedmedicine.org]
Headache
  • Lactose and food intolerance cause a wide range of gut and systemic symptoms, including gas, gut pain, diarrhoea or constipation, severe headaches, severe fatigue, loss of cognitive functions such as concentration, memory and reasoning, muscle and joint[ncbi.nlm.nih.gov]
  • The most common symptoms were bowel symptoms, tiredness, stomach symptoms, and headaches. Of those who completed the programme (n 150), the majority were discharged after the HE plan as their symptoms had improved (n 106, 70.6%).[ncbi.nlm.nih.gov]
  • FOOD intolerances can often be identified by symptoms such as bloating and headaches. However, your face could also indicate whether you should ditch gluten, sugar or dairy.[express.co.uk]
  • More often, the cause is food intolerance, a result of some dysfunctioning metabolic process that then triggers other reactions into a cascade that ends in bloating, weight gain, headache, tiredness, etc.[deliciousliving.com]
  • Sometimes, substances within foods can increase the frequency and severity of migraine headaches, rashes (such as hives) or the stomach upset of irritable bowel. Professional diagnosis and confirmation of allergens is important.[betterhealth.vic.gov.au]

Workup

Diagnosis of food intolerance is essentially clinical and laboratory investigations are rarely needed. However, in some cases where doubts arise, a food allergy needs to be excluded through skin allergy tests and serum IgE levels.

The diagnosis of lactase deficiency or lactose intolerance may require certain special tests, such as hydrogen breath tests and milk intolerance tests.

It is essential to note that self-diagnosis and uninformed avoidance of supposed food triggers are not recommended, as it may lead to nutritional deficiencies and masking of a more severe underlying gastrointestinal disease.

Diagnosis of food intolerance should be confirmed by a healthcare professional. Food intolerance can be diagnosed from the history. Also, when the suspected food is eliminated from the diet symptoms tends to disappear, while its re-institution induces the re-initiation of these symptoms.

Pneumoperitoneum
  • Complications rate was 9.5 %, including three cases of bleeding, two intragastric ring erosions, and one pneumoperitoneum; all treated clinically with no need for reintervention.[ncbi.nlm.nih.gov]

Treatment

Specific treatment plans are currently unavailable because of the limited knowledge on the mechanism behind food intolerance. However, the mainstay of treatment of food intolerance is dietary restriction. Patients are required to identify and avoid or reduce the intake of the dietary triggers for a period of about 4 weeks to achieve symptomatic relief.

Lactase-free products may be considered in cases of patients with lactose intolerance. However, in lactose intolerance, whole milk may be well tolerated. Additionally, lactase enzyme preparations are available for use as an adjunct treatment for symptomatic relief in lactose intolerance. Lactose can be found in a lot of medications and several other foods besides the well-known lactose-containing foods. These foods with hidden lactose include curd and non-fat dry milk powder, hence patients are advised to check labels of drugs and food items before purchasing or consuming them. Calcium supplementation is necessary for all patients who are treated for lactose deficiency by eliminating dairy products from their diet.

Patient education would consist of providing information about alternative diets to ensure adequate nutrition. The food is gradually reintroduced to prevent nutritional deficiencies and because prolonged avoidance or elimination of the diet restores tolerance to the food. Probiotics may also be employed as a useful adjunct treatment for most GI symptoms [10].

Prognosis

Food intolerance is often self-limited. Symptoms fail to recur in children if they are re-exposed to the offending food after a couple of years of avoiding them. Food intolerance is generally not fatal, unlike food allergies which may be life-threatening.

Etiology

Food intolerance typically results from certain constituents of foods which have properties that trigger gastrointestinal symptoms. These constituents include salicylates, glutamates, caffeine, and vasoactive amines such as histamines.

Short-chain fermentable carbohydrates are particularly implicated in the induction of GI-related symptoms. These carbohydrates are generally termed fermentable oligo-, di-, monosaccharides and polyols (FODMAPs). These substances have been associated with increased GI symptoms in individuals with predisposing diseases such as inflammatory bowel syndrome. Avoiding all foods under the group causes significant improvement in symptoms [5] [6] [7].

A very common form of food intolerance is lactose intolerance which occurs due to the inability of the small intestinal cells to produce lactase. This results in an inability of lactose hydrolyzation or breakdown into its simpler constituent: glucose and galactose. These monosaccharides are the only absorbable forms of lactose. Lactose is contained in milk and processed dairy products. Lactase deficiency may be a genetic disorder or an acquired problem secondary to GI pathologies which cause the destruction of the intestinal mucosa. Diseases which cause acquired lactase deficiency include gastroenteritis, Whipple's disease, inflammatory bowel diseases, and celiac disease.

Salicylate intolerance is another form of food intolerance in certain people. Salicylates are naturally found in plants as a protective substance. Foods rich in salicylates include vegetables and fruits.

Food additives have also been implicated in a few cases of food intolerance. Common offending food additives include MSG, nitrates, and sulfites. Sulfites are additives in alcoholic beverages and are responsible for some cases of intolerance to alcohol and wine.

Non-celiac gluten sensitivity is a novel diagnosis which is nonimmune-mediated, as opposed to celiac disease.

Epidemiology

Food intolerance occurs in up to 20% of the population. However, it may be more predominant in certain ethnic groups.

Whereas lactose intolerance is least commonly found in northern Europeans, it is most commonly found among Asian-Americans and African-Americans with an incidence rate of 90% and 75% respectively. Nonetheless, lactase deficiency affects persons of all races and has no gender predilections.

Sex distribution
Age distribution

Pathophysiology

Food intolerance may result from defects in digestive enzymes, GI effects of certain substances such as vasoactive amines found in foods, metabolic and other GI abnormalities [8].

In lactose intolerance, undigested lactose moves into the colon where it induces an osmotic gradient which causes transfer of fluids and electrolytes into the intestinal lumen. This colonic distension results in increased intestinal peristalsis which, coupled with the high colonic osmolarity, accounts for all the GI symptoms.

FODMAPs are particularly implicated in the pathogenesis of food intolerance. Fructose, for example, is a monosaccharide found naturally in fruits and honey. It is found in high amounts in corn syrups. GI absorption of fructose is restricted, determined exclusively by the facilitated transports present. The most common routes of carbohydrate transports are the glucose transporters (GLUT) 2 and 5. Glucose and fructose are transported in equal proportions via the GLUT-2 in the luminal surface of the intestinal mucosa. Other transporters have not been so extensively studied. Diets containing excess fructose trigger GI symptoms by interfering with the absorption of glucose, this results in an increased osmolarity, causing GI distress.

Fructans are short-chain sugars with low GI absorptive properties, due to the absence of the enzymes to break them down. Polyols, also called sugar alcohols, include sorbitol, xylitol, and mannitol. Polyols are found as natural components of certain fruits including apricots, apples, cherries, peaches, pears and vegetables such as cauliflower and mushrooms. They are also used industrially as artificial food sweeteners and in pharmaceutical industries for making sugar-free cough syrup. They are absorbed passively in the small intestine at varying rates, depending on the size of the molecular mass of the polyol, the size of the intestinal pore, the intestinal transit time, and a preexisting gastrointestinal pathology. Absorption of mannitol is better than that of sorbitol. This may be attributed to a higher water solubility and its hydroxyl group.

Prevention

Food intolerance can be prevented by keeping a list of the offending foods and avoiding their intake.

Summary

Food intolerance is a non-IgE-mediated hypersensitivity to food. Food intolerance is similar in symptomatology to food allergy, presenting with vomiting, diarrhea, flatulence, abdominal cramps, and nausea.

The pathophysiologic mechanism behind food intolerance is largely unknown, however, it could be caused by genetic or acquired enzyme deficiencies, osmotic food components such as sugars, and additives including sulfites, histamines, and monosodium glutamate (MSG). Lactose intolerance is a very common cause of food intolerance and it results from lactase deficiency, the enzyme necessary to digest lactose. These symptoms of lactose intolerance typically occur within 2 hours of ingesting lactose-containing foods, such as cheese and ice cream. The symptoms reflect the amount of lactose ingested [1] [2] [3] [4].

Certain sugars induce osmotic diarrhea if poorly absorbed and foods containing fructose and sorbitol are the commonest cause of food intolerance. The sugars are poorly absorbed in the small intestine; often due to the impaired breakdown into their absorbable forms, they present in the colon where they are fermented by colonic bacteria. These products of bacterial breakdown cause flatulence and other symptoms of intolerance. Foods containing monosodium glutamate (MSG) and histamines are also implicated in a few cases of food intolerance.

Food additives are considered as triggers of certain food intolerances such as wine intolerance.

Diagnosis of food intolerance is largely from the history and by elimination or diagnostic diet, where elimination of the offending food classically causes relief of symptoms and vice versa. Although the history can distinguish food allergy from food intolerance, a skin allergy test may be done in some cases to exclude allergy.

Food intolerance is treated by avoidance of the offending food in the diet.

Patient Information

Food intolerance is quite different from a food allergy, although both conditions present similarly. Notable differences are the lack of involvement of the immune system, absence of allergic reactions, and the negative allergy testing in food intolerance. Therefore, food intolerance refers to a non-allergic sensitivity to certain foods.

Food intolerance may be caused by deficiencies of the necessary digestive enzymes or the properties of a food responsible for causing GI upset. Some individuals are born with this enzyme deficiency, while others acquire it as they age. Lactose intolerance and alcohol intolerance are examples of food intolerance caused by the unavailability of digestive enzymes. However, the mechanism of most forms of food intolerance is largely unknown.

Lactose intolerance may result from a genetic absence of lactase or from intestinal diseases, which destroy the intestinal cells which produce lactase. These diseases include gastroenteritis and inflammatory bowel diseases.

Unlike celiac disease, which is a response to gluten in foods mediated by the immune system, non-celiac gluten intolerance is a non-allergic response to gluten in the diet and has been shown to exist. This novel diagnosis is a common cause of food intolerance. Examples of gluten-containing foods include wheat and cereals.

A few individuals display intolerance to wine and preserved foods, this is due to the sensitivity of these individuals to the additives in these foods. Alcoholic beverages contain an additive called sulfite, which is responsible for most cases of wine intolerance experienced by some persons.

Food intolerance typically presents with nausea, vomiting, abdominal cramps, diarrhea, flatulence, and weight loss. These symptoms of food intolerance occur after the ingestion of large quantities of the offending food and do not occur immediately. These are contrary to the case of a food allergy, where the symptoms occur upon the ingestion of a little amount of the food and occur immediately after ingestion

Food intolerance is generally self-limited and resolves when the offending food is avoided; food allergy, on the other hand, may be life-threatening due to the significant breathing difficulties associated with it. A diagnosis of food intolerance is made from the history and the characteristic absence of symptoms once the foods are eliminated. Skin allergy tests and blood tests may be done to exclude food allergy.

The treatment of food intolerance basically involves the elimination of the offending food, while taking alternatives of similar nutritional value. However, tolerance can be achieved again when the food is reintroduced after a long time, however, reintroduction has to be done in smaller quantities.

Patients who have lactose intolerance should check the labels of foods and drugs well before consuming them because some of these items may have lactose hidden in them. Because patients with lactose intolerance may avoid diary products as a way of testing the condition, calcium supplements are necessary to provide an alternative source of calcium for the body.

References

Article

  1. Lomer MC. Review article: the aetiology, diagnosis, mechanisms and clinical evidence for food intolerance. Aliment Pharmacol Ther. 2015;41(3):262-75
  2. Leiß O. Fiber, food intolerances, FODMAPs, gluten and functional gastrointestinal disorders--update 2014]. Z Gastroenterol. 2014;52(11):1277-98.
  3. Skypala I, Vlieg-Boerstra B. Food intolerance and allergy: increased incidence or contemporary inadequate diets? Curr Opin Clin Nutr Metab Care. 2014;17(5):442-7
  4. Savaiano DA. Lactose digestion from yogurt: mechanism and relevance. Am J Clin Nutr. 2014;99(5 Suppl):1251S-5S.
  5. Tomar BS. Lactose intolerance and other disaccharidase deficiency. Indian J Pediatr. 2014;81(9):876-80.
  6. Fedewa A, Rao SS. Dietary fructose intolerance, fructan intolerance and FODMAPs. Curr Gastroenterol Rep. 2014;16(1):370.
  7. Zigich S, Heuberger R. The relationship of food intolerance and irritable bowel syndrome in adults. Gastroenterol Nurs. 2013;36(4):275-82
  8. Boettcher E, Crowe SE. Dietary proteins and functional gastrointestinal disorders. Am J Gastroenterol. 2013;108(5):728-36
  9. Finsterer J, Mahjoub SZ. Fatigue in healthy and diseased individuals. Am J Hosp Palliat Care. 2014;31(5):562-75
  10. Singh VP, Sharma J, Babu S, Rizwanulla, Singla A. Role of probiotics in health and disease: a review. J Pak Med Assoc. 2013;63(2):253-7.

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Last updated: 2018-06-22 08:46