The Scoop on Oats

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Considerations about oats  

Oats appear to be suitable for most people with celiac disease and gluten-related disorders, but not all.  Medical experts advise waiting until symptoms have resolved before introducing pure, uncontaminated oats (labeled gluten-free).  For some, this could mean delaying the introduction of oats for a year or longer.  The current medical recommendation for adults with celiac disease or gluten-related disorders is to limit consumption of dry oats to no more than 50 grams per day (50/g day is equivalent to about 1/2c dry oats) and 25 grams per day (25g/day is equivalent to about 1/4 cup dry oats) for children.  The CSA Three Step Diet approach to celiac disease and gluten-related disorders can be used as a framework for introducing foods such as pure, uncontaminated oats.

The FDA’s current proposed definition of gluten-free does not include oats as a prohibited grain.  Therefore consumers sensitive to oats or different oat varieties will need to check ingredient labels closely when a final ruling is determined.

CONTAINS: Avenin, in Oats contains similar amino acid sequences as  wheat gluten and can evoke the immune response of celiac disease for some people.  Oats storage protein toxiciity is not the same in all varieties of oats.  Today, there is no way to predict ahead of time, which celiacs will or will not be able to successfully consume oats.

CROSS CONTAMINATION/CONTACT:  Common oats are not appropriate for those with celiac disease, such as store brand.  

CONSIDER: A growing number of oat products are handled to eliminate cross contamination  in the field, transportation and processing. Oat products, grown, processed and packaged to be free of contamination with wheat, barley or rye appear to be suitable for some people with celiac disease, but not ALL people.  Discuss your personal use of oats with your physician.  The CSA Gluten-Free Product Listing includes contact information for the specially grown and processed oats. Since oats are not a risk free choice for all people with celiac disease, products containing oats do not qualify to use the CSA Recognition Seal.

Plan for success, Introduce oats into the diet after the glut Inflammation has diminished or has been eliminated.
Oats appear suitable for some people with celiac disease, but not all. Thus oats are not yet a risk free choice for all people with celiac disease. If choosing to include oats, limit risk by choosing specially handled uncontaminated oats.   Most physicians advise people, newly diagnosed with celiac disease, to wait until their health is restored before ingesting oats. Waiting one year or so to introduce uncontaminated oats in the diet is commonly suggested to increase a successful introduction.  
As always, each individual is responsible for managing the inevitable risks related to living gluten-free. Each person develops a personal criteria for making decisions that will achieve their optimum health and well-being. For some people that means oats and others are oats free.  See Managing the Gluten-Free Diet .

The appropriateness of oats in the gluten-free diet has been pondered for over 20 years.
Studies continue with mixed results on this subject. Further, some study conclusions fail to match the data collected for that study. Until there is clarity in the research, oats is not a risk free choice for those on a medically prescribed gluten-free diet. 50 grams per day is an often quoted upper limit for consuption.

Read the research studies about oats, not just the summaries. Discuss the topic with a helpful physician or dietitian. Confirm that your celiac-health has stabilized. Questions? Call the CSA toll-free number 1-877-CSA-4-CSA (1-877-272-4272).

Please, support additional research through the CSA Peer Review Research Program. Statistically, a sample of 600-1500 people adds validity to a condition affecting 1% of the population.

To begin to understand the diversity of oat studies, compare the following abstracts from research in this area. Want more? Go to http://www.ncbi.nlm.nih.gov/pubmed/ to search for additional studies.

2013
Nutrients.  Novvember 20, 2013
Oats in the diet of children with celiac disease: preliminary results of a double-blind, radnomized, placebo-controlled multicenter. These preliminary results suggest that the addition of non-contaminated oats from selected varieties in the treatment of children with CD does not determine changes in intestinal permeability and gastrointestinal symptoms. 

2009
October 5, 2009 CSA Past President Bill Eyl -- Oats Letter to the Editor of Gluten Free Living magizine.


2008

Measurement of wheat gluten and barley hordeins in contaminated oats from Europe, the United States and Canada by Sandwich R5 ELISA Alberto Hernando, Jorge R. Mujico, Mari´a C. Mena, Manuel Lombardi´a and Enrique Me´ndez*

Objectives
We have investigated the extent of contamination with wheat, barley, rye or a mixture of these cereals in a large number of grains and commercial oats. We have also attempted to identify the type of cereal contaminant.

Methods
Sandwich R5 ELISA (using either gliadins or hordeins as standards), western blot, matrix-assisted laser desorption/ionization time-of-flight mass spectrometric and quantitative real-time PCR (Q-PCR) techniques have been used to analyze a total of 134 oats, comprising grains and commercial oat products collected from Europe, the United States and Canada.

Results
Twenty-five of the 134 pure, uncontaminated oat varieties were found to have undetectable levels of gluten, whereas most of the 109 grains and commercial oat products were mainly contaminated with mixtures of wheat, barley and rye, barley being the predominant contaminant. The percentages of these cereals in the oat samples have been calculated by specific wheat, barley and rye Q-PCR systems. The oat samples were grouped according to the avenin spectra determined by the mass spectrometric technique. The data confirmed that contaminated oat foods, based on the same variety, could have different levels of wheat, barley and rye contamination.

Conclusions
This study has verified that contamination with wheat gliadins or barley hordeins in oat samples can be measured by the Sandwich R5 ELISA, using either gliadins or hordeins as standards, and also the importance of using confirmatory techniques (such as western blot, Q-PCR and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry) to confirm that most oats are contaminated with mixtures of wheat, barley and rye. Eur J Gastroenterol Hepatol 20:545–554 _c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins.

European Journal of Gastroenterology & Hepatology 2008, 20:545–554
Received 28 June 2007 Accepted 18 September 2007

Should celiac sufferers be allowed their oats?
Heather Julia Ellis and Paul J. Ciclitira

  • Confusion exists over the suitability of oats for coeliac patients.
  • The majority of oats available in Europe are contaminated with other cereals.
  • Barley contamination is a particular problem.
  • One of two commercial gluten test kits is barley-insensitive.
  • A small minority of coeliacs have oat-sensitive small intestinal T cells.
  • Inclusion of oats in the diet should be carefully monitored and backed by robust assay systems.

The suitability of oats as part of a gluten-free diet is controversial. Contamination of many oats products with wheat, rye and particularly barley, together with inadequacy of available gluten-testing systems may account, at least in part, for the confusion. Some clear evidence has, however,emerged in the past few years that a small number of gluten-sensitive patients display a specific small intestinal T cell response to oat peptides that cannot be explained by contamination with other cereals. Oats could form a potentially useful part of a gluten-free diet, but patients require careful advice and monitoring, backed by robust gluten-assay techniques.

 In their conclusion, the authors state: It is our practice to recommend a strict gluten-free dietwith the omission of oats until clinical and histological remission had been achieved. Subsequently, upto 50 g/day of oats, obtained from a dedicated supplier, may be added to the diet with careful follow-up to monitor any adverse effects. Such a regime would best serve gluten-sensitiveindividuals, if appropriate gluten-testing methods are applied to foods labeled as suitable for their needs.

European Journal of Gastroenterology & Hepatology 2008, 20:492–493


2007

No induction of anti-avenin IgA by oats in adult, diet-treated coeliac disease
VIGDIS GUTTORMSEN1, ASTRID LØVIK2, ASTA BYE1, JORUNN BRATLIE3, LARS MØRKRID4 & KNUT E. A. LUNDIN2,5

1Akershus University College, Lillestrøm, Norway, 2Department of Medicine, 3Institute for Medical research, 4Department of Clinical Chemistry, and 5 Institute of Immunology, Rikshospitalet, Oslo, Norway

Objective
Coeliac disease is effectively treated with a gluten-free diet devoid of wheat, rye, barley and related cereals. Oats has until recently also been considered harmful but is now allowed in several countries. We have, however, identified three adult coeliac disease patients who developed a flare of active coeliac disease after ingestion of oats, which suggests that oats might not be entirely innocent in coeliac disease. It is known that patients with untreated coeliac disease have elevated IgA antibodies to oat prolamins. The objective of this study was to investigate whether levels of IgA against oats were increased in treated, adult coeliac disease patients. Material and methods. Serum was collected from 136 adult patients with treated coeliac disease and 139 controls. Eighty-two of the coeliac disease patients had been taking oats as part of their gluten-free diet for 6 months or more. IgA against oats avenin, wheat gliadin and tissue transglutaminase was tested with ELISA.

Results
No significant differences were found in IgA against oats in oats-eating and non-oats-eating coeliac disease patients. Both groups had increased levels of IgA against wheat, oats and tissue transglutaminase compared to healthy controls. A significant positive correlation was found between anti-avenin and antigliadin IgA (pB0.0001), and between anti-avenin and anti-tissue transglutaminase IgA (p_0.0012).

Conclusions
Ingestion of oats does not cause increased levels of IgA against oats in adult coeliac disease patients on a gluten-free diet. The findings support the notion that most adult coeliac disease patients can tolerate oats. In their conclusions, the authors further state: In Norway, Sweden, and possibly other countries as well, it is advocated that patients with celiac disease should introduce oats to their diet in agreement with their doctors and that a clinical follow-up should be offered. Such a follow-up would benefit from serological testing for possible oats intolerance. Our study could not support the hope for such a test.

Scandinavian Journal of Gastroenterology, 43:2, 161 - 165
14 December 2007

In vitro tests indicate that certain varieties of oats may be harmful to patients with coeliac disease.
Silano M, Dessi M, De Vincenzi M, Cornell H.

Division of Food Science, Human Nutrition and Health, Higher Institute of Health, Rome, Italy.

Background
The presence of oats in gluten-free diet is controversial. The aim of this work is to evaluate if different varieties of oats exert different toxicity in coeliac disease.

Methods
Three varieties of oats were tested by two in vitro assay based on the known ability of peptic-tryptic digests of coeliac-active proteins to agglutinate K562 cells and to disrupt lysosomes, respectively.

Results
Avenins from the Italian variety Astra and the Australian variety Mortlook were much more active than the Australian variety Lampton. Gliadin, digested in the same way, certainly displayed more activity than all three avenins, but rice (var. Roma) did not have measurable activity.

Conclusions
The results indicate that some varieties of oats may be potentially harmful to individuals with coeliac disease and therefore should be excluded from the gluten-free diet required to maintain good health in coeliac disease. It is important to realize that constant, small amounts of active proteins in the diet, such as certain avenins, may prevent complete recovery of the intestinal mucosa in this disease.

PMID: 17376046


2004

The Molecular Basis for Oat Intolerance in Patients with Celiac Disease.
Arentz-Hansen H, Fleckenstein B, Molberg O, Scott H, Koning F, Jung G, Roepstorff P, Lundin KE, Sollid LM.

Institute of Immunology, Rikshospitalet University Hospital, University of Oslo, Oslo, Norway.

Background
Celiac disease is a small intestinal inflammatory disorder characterized by malabsorption, nutrient deficiency, and a range of clinical manifestations. It is caused by an inappropriate immune response to dietary gluten and is treated with a gluten-free diet. Recent feeding studies have indicated oats to be safe for celiac disease patients, and oats are now often included in the celiac disease diet. This study aimed to investigate whether oat intolerance exists in celiac disease and to characterize the cells and processes underlying this intolerance.

Methods And Findings
We selected for study nine adults with celiac disease who had a history of oats exposure. Four of the patients had clinical symptoms on an oats-containing diet, and three of these four patients had intestinal inflammation typical of celiac disease at the time of oats exposure. We established oats-avenin-specific and -reactive intestinal T-cell lines from these three patients, as well as from two other patients who appeared to tolerate oats. The avenin-reactive T-cell lines recognized avenin peptides in the context of HLA-DQ2. These peptides have sequences rich in proline and glutamine residues closely resembling wheat gluten epitopes. Deamidation (glutamine-->glutamic acid conversion) by tissue transglutaminase was involved in the avenin epitope formation.

Conclusions
We conclude that some celiac disease patients have avenin-reactive mucosal T-cells that can cause mucosal inflammation. Oat intolerance may be a reason for villous atrophy and inflammation in patients with celiac disease who are eating oats but otherwise are adhering to a strict gluten-free diet. Clinical follow-up of celiac disease patients eating oats is advisable.

PMID: 15526039 [PubMed - as supplied by publisher]     Read the full text.

Oats to children with newly diagnosed coeliac disease: a randomized double blind study.
Hogberg L, Laurin P, Falth-Magnusson K, Grant C, Grodzinsky E, Jansson G, Ascher H, Browaldh L, Hammersjo JA, Lindberg E, Myrdal U, Stenhammar L.

Department of Pediatrics, Norrkoping Hospital, Sweden

Background
Treatment of coeliac disease (CD) requires lifelong adherence to a strict gluten free diet (GFD) which hitherto has consisted of a diet free of wheat, rye, barley, and oats. Recent studies, mainly in adults, have shown that oats are non-toxic to CD patients. In children, only open studies comprising a small number of patients have been performed. Aim: To determine if children with CD tolerate oats in their GFD.

Patient And Methods
In this double blind multicentre study involving eight pediatric clinics, 116 children with newly diagnosed CD were randomized to one of two groups: one group was given a standard GFD (GFD-std) and one group was given a GFD with additional wheat free oat products (GFD-oats). The study period was one year. Small bowel biopsy was performed at the beginning and end of the study. Serum IgA antigliadin, antiendomysium, and antitissue transglutaminase antibodies were monitored at 0, 3, 6, and 12 months.

Results
Ninety three patients completed the study. Median (range) daily oat intake in the GFD-oats group (n = 42) was 15 (5-40) g at the six month control and 15 (0-43) g at the end of the study. All patients were in clinical remission after the study period. The GFD-oats and GFD-std groups did not differ significantly at the end of the study regarding coeliac serology markers or small bowel mucosal architecture, including numbers of intraepithelial lymphocytes. Significantly more children in the youngest age group withdrew.

Conclusions
This is the first randomised double blind study showing that the addition of moderate amounts of oats to a GFD does not prevent clinical or small bowel mucosal healing, or humoral immunological downregulation in coeliac children. This is in accordance with the findings of studies in adult coeliacs and indicates that oats, added to the otherwise GFD, can be accepted and tolerated by the majority of children with CD.

Publication Types:

  • Clinical Trial
  • Multicenter Study
  • Randomized Controlled Trial

Gut. 2004 May;53(5):649-54.

PMID: 15082581

Effect of an oats-containing gluten-free diet on symptoms and quality of life in coeliac disease. A randomized study.
Peraaho M, Kaukinen K, Mustalahti K, Vuolteenaho N, Maki M, Laippala P, Collin P.

Dept. of Medicine, Jyvaskyla Central Hospital, Finland

Background
Evidence suggests the acceptability of oats in a gluten-free diet in coeliac disease. We investigated the impact of an oats-containing diet on quality of life and gastrointestinal symptoms.
METHODS Thirty-nine coeliac disease patients on a gluten-free diet were randomized to take either 50 g of oats-containing gluten-free products daily or to continue without oats for 1 year. Quality of life was assessed using the Psychological General Well-Being questionnaire and gastrointestinal symptoms using the Gastrointestinal Symptom Rating Scale. Small-bowel mucosal villous architecture, CD3+, alphabeta+, gammadelta+ intraepithelial lymphocytes, serum endomysial and tissue transglutaminase antibodies were investigated.

Results
wenty-three subjects were randomized to the oats-containing diet and 16 to the traditional gluten-free diet. All adhered strictly to their respective diet. Quality of life did not differ between the groups. In general, there were more gastrointestinal symptoms in the oats-consuming group. Patients taking oats suffered significantly more often from diarrhoea, but there was a simultaneous trend towards a more severe average constipation symptom score. The villous structure did not differ between the groups, but the density of intraepithelial lymphocytes was slightly but significantly higher in the oats group. The severity of symptoms was not dependent on the degree of inflammation. Antibody levels did not increase during the study period.

Conclusions
The oats-containing gluten-free diet caused more intestinal symptoms than the traditional diet. Mucosal integrity was not disturbed, but more inflammation was evident in the oats group. Oats provide an alternative in the gluten-free diet, but celiac patients should be aware of the possible increase in intestinal symptoms.

Publication Types: 

  • Clinical Trial
  • Randomized Controlled Trial

Scand J Gastroenterol. 2004 Jan;39(1):27-31.

PMID: 14992558


2003

Oats induced villous atrophy in coeliac disease
Lundin KE, Nilsen EM, Scott HG, Loberg EM, Gjoen A, Bratlie J, Skar V, Mendez E, Lovik A, Kett K.

Department of Medicine, Rikshospitalet, Oslo, Norway

The current trend is to allow coeliac disease (CD) patients to introduce oats to their gluten free diet. We sought further data from the clinical setting with regards to oats consumption by coeliac patients. Several oat products were tested for wheat contamination using a commercial enzyme linked immunoassay (ELISA) kit, and six samples were examined by an ELISA using a cocktail of monoclonal antibodies, mass spectrometry, and western blot analysis. Nineteen adult CD patients on a gluten free diet were challenged with 50 g of oats per day for 12 weeks. Serological testing and gastroduodenoscopy was performed before and after the challenge. Biopsies were scored histologically and levels of mRNA specific for interferon gamma were determined by reverse transcription-polymerase chain reaction analysis. Oats were well tolerated by most patients but several reported initial abdominal discomfort and bloating. One of the patients developed partial villous atrophy and a rash during the first oats challenge. She subsequently improved on an oats free diet but developed subtotal villous atrophy and dramatic dermatitis during a second challenge. Five of the patients showed positive levels of interferon gamma mRNA after challenge. Some concerns therefore remain with respect to the safety of oats for coeliacs.

Gut. 2003 Nov;52(11):1649-52

PMID: 14570737

Dietary treatment of coeliac disease and dermatitis herpetiformis
Lovik A, Lundin KE.

Enhet for klinisk ernaering, Madisinsk avdeling, Rikshospitalet, Oslo, Norway

Life-long gluten-free diet is the established therapy for coeliac disease and dermatitis herpetiformis. Diet therapy allows the intestinal mucosa to recover, improves nutrient malabsorption, osteoporosis and a weakened general condition. A gluten-free diet is without wheat, rye and barley and related products. Oats tested free of contamination by other cereals has recently been allowed for adult coeliac patients, but concern still remains regarding its general safety. Gluten-free flour mixes contain more starch and less proteins, vitamins, minerals and fibre compared to regular flour. Recently some questions have been raised as to the nutritional quality of the gluten-free diet. Successful therapy with gluten-free diet requires motivation and dietary counselling, including knowledge of the nutritional value of foods, labelling of prepackaged foods and practical training in cooking. The local chapters of the Norwegian Coeliac Society are active partners, as are the clinical nutritionists that work in most major hospitals. The physician making the diagnosis has a duty to see to it that all coeliac patients get adequate dietary counselling and management.

Tidsskr Nor Laegeforen. 2003 Nov 20;123(22):3237-40. [Article in Norwegian]

PMID: 14714019


2002

CSA notes: This is the five year follow-up study to the 1995 Finnish study on oats consumption by celiacs. It is interesting to note that of the 39 persons contacted from the original oats-eating group, 4 dropped out of the followup, and 12 were no longer eating oats, citing uncertainty of the safety of oats, flatulence and rash.

No harm from five year ingestion of oats in coeliac disease
E K Janatuinen, T A Kemppainen, RJK Julkunen, V-M Kosma, M Maki, M Heikkinen and M I J Uusitupa

Background
Six to 12 months of ingestion of moderate amounts of oats does not have a harmful effect in adult patients with coeliac disease. As the safety of long term intake of oats in coeliac patients is not known, we continued our previous 6–12 month study for five years. Aim: To assess the safety of long term ingestion of oats in the diet of coeliac patients.

Patients
In our previous study, the effects of a gluten free diet and a gluten free diet including oats were compared in a randomised trial involving 92 adult patients with coeliac disease (45 in the oats group, 47 in the control group). After the initial phase of 6–12 months, patients in the oats group were allowed to eat oats freely in conjunction with an otherwise gluten free diet. After five years, 35 patients in the original oats group (23 still on an oats diet) and 28 in the control group on a conventional gluten free diet were examined.

Methods
Clinical and nutritional assessment, duodenal biopsies for conventional histopathology and histomorphometry, and measurement of antiendomysial, antireticulin, and antigliadin antibodies.

Results
There were no significant differences between controls and those patients consuming oats with respect to duodenal villous architecture, inflammatory cell infiltration of the duodenal mucosa, or antibody titres after five years of follow up. In both groups histological and histomorphometric indexes improved equally with time.

Conclusions
This study provides the first evidence of the long term safety of oats as part of a coeliac diet in adult patients with coeliac disease. It also appears that the majority of coeliac patients prefer oats in their diet.

Gut 2002;50:332–335


1999

Dietary treatment of celiac disease
Lovik A, Fluge G, Dybdahl JH, Holsdal ER, Ek J, Rohme R, Dahl R.

Medisinsk avdeling A, Rikshospitalet, Oslo, Norway

Life-long gluten-free diet is the established therapy of coeliac disease. Patients suffering from dermatitis herpetiformis benefit from the same treatment. In Norway the gluten-free diet has excluded oats as well as wheat, rye and barley. The basis for this recommendation was a 1972 report indicating that ten out of 23 children consuming oats as part of their gluten-free diet for at least 18 months developed signs of damage to the intestinal mucosa. During the last decades, the clinical picture of coeliac disease has changed as a result of better diagnostic tools. Controlled clinical trials during the last few years indicate that some patients may tolerate small amounts of oats in their gluten-free diet. As a consequence, patients may be confused with regard to what dietary regime is recommended in coeliac disease. Compliance with gluten-free diet is important to secure growth and development, the all-round condition, fertility, bone density and a reduced risk of nutrient deficiency and malignancy. Consensus on dietary treatment is essential. A number of controlled trials are under way and the outcome of these studies will in a few years determine whether oats might be included in the standard gluten-free diet. So far oats are not recommended. The physician who makes the diagnosis is responsible for all patients getting adequate dietary counseling and management. Dietary advice given by health personnel must be consistent.

Tidsskr Nor Laegeforen. 1999 May 20:119 (13):1888-91 [Article in Norwegian]

PMID: 10382335 [PubMed - indexed for MEDLINE]


1995

CSA notes: The following study was conducted in Finland in 1995 and reflects the first large scale study of oats consumption by celiacs. It is also the only study with long-term follow-up. (See 2002 studies). Eleven of the original 92 subjects withdrew from the study and were not followed up. The sample also did not include subjects with severe celiac disease or other complicating conditions.

A Comparison of diets with and without oats in adults with celiac disease.
Esko K. Janatuinen, Pekka H. Pikkarainen, Tarja A. Kemppainen, Veli-Matti Kosma, Ritva M.K. Jarvinen, Matti I.J. Uusitupa and Risto J.K. Julkunen.

Background
Wheat, rye, and barley damage the small-intestinal mucosa of patients with celiac disease; maize and rice are harmless. The effects of a diet containing oats are uncertain. Methods. In a randomized trial, we compared the effects of gluten-free diets without oats and with oats (with a goal of 50 to 70 g per day from three sources: two types of wheat-starch flour mixed with an equal amount of oats, muesli containing 60 percent oats, and rolled-oat breakfast cereal). Fifty-two adults with celiac disease in remission were followed for 6 months and 40 with newly diagnosed disease for 12 months. Endoscopy with duodenalbiopsy was performed at the beginning and end of the study.

Results
The mean (+ or - SD) oat intake in the oat group was 49.9 + or - 14.7 g per day at 6 months for patients in remission and 46.6 + or - 13.3 g per day at 12 months for patients with newly diagnosed disease. The oat and control groups did not differ significantly in nutritional status, symptoms, or laboratory measures. Patients in remission, regardless of diet, did not have worsening architecture of the duodenal villi or increased mononuclear-cell infiltration. All the patients with new diagnoses were in remission at one year, except for one in the control group. Six patients in the oat group and five in the control group withdrew from the study.

Conclusions
Moderate amounts of oats can be included in a gluten-free diet for most adult patients with celiac disease without adverse effects.

N Engl J Med 1995;333:1033-7.