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The Problem with Oats in the Gluten Sensitive Diet

This article originally appeared in the Winter 2004 edition of Celiac.com's Journal of Gluten-Sensitivity.

Celiac.com 09/19/2014 - Experts have decreed that pure oats are safe for people with celiac disease(1,2,3).  The definition of this disease is based on a very specific type of injury to the intestinal wall that heals following the removal of gluten from the diet.  This intestinal damage, called villous atrophy, is caused by the interaction between the immune system and certain proteins found in wheat, rye, and barley.  Identical proteins are not found in oats (although there is also some variation between the protein groups found in wheat, rye, and barley).  Further, many newly diagnosed celiac patients have been shown to recover from their celiac symptoms while eating significant quantities of oats and their intestinal biopsies do not show signs of villous atrophy1 (Admittedly, the quantity of oats consumed by these study subjects does not rival the grain protein consumption in a regular, gluten-laden diet, but the quantity is significant).  Therefore, this food is considered safe for celiac consumption.

Photo: CC--thebittenword.comGiven these facts, it is not surprising that many gastroenterologists are now recommending that their patients eat oats.  Some claim that patients are more likely to follow a gluten-free diet if that diet allows oats.  Others point to the definition of celiac disease, which clearly requires gluten-induced villous atrophy.  Still others insist that since we now know which proteins cause the villous atrophy, oats must be safe for celiac patients to consume.

There are several problems with these perspectives, beginning with the assumption that patients will be more compliant with the diet if it includes oats.  I have explored the medical literature and have been unable to find a single study that investigates dietary compliance as a function of including oats in the gluten-free diet.  I’d be happy to hear about such a study.  But until the question is investigated, the assumption is just one more opinion afloat in a sea of unfounded beliefs about grains and diet.

Many celiac patients experience an addictive element in gluten.  I have long suspected that is the result of morphine-like, opioid peptides found in the digests of gluten(4-8).  Are some peptides from oats capable of producing these opioids?  Has anyone investigated that issue?  Again, I can find no evidence that this issue has been studied.

Reliance on the biopsy to reveal problems with oat consumption is another relevant problem.  As many of us can attest, and the medical literature reports, gluten challenges that intentionally involve ingestion of relatively large quantities of gluten often fail to reveal villous atrophy for weeks, months, and sometimes, years(9).  Many celiac patients will also agree that despite our best efforts at compliance, gluten sometimes manages to sneak into our diets, particularly in the early months of following the diet.  Yet a second biopsy usually shows dramatic healing of the intestinal wall, despite these dietary errors.  Clearly, the intestinal biopsy is a fairly crude tool for measuring intestinal health.  Its use in exonerating oats thus becomes suspect.  An even more troubling element of this issue is that there are gastroenterologists who are recommending that their patients consume breakfast cereals that contain malt flavoring, because patients consuming such small quantities of malt do not show villous atrophy(10).

Also troubling is the fact that many of the studies that support the safety of oats have not employed the Marsh system for identifying intestinal injury, a refinement that significantly increases the sensitivity of the intestinal biopsy.

The greatest weakness of the pro-oats position is the underlying assumption that we fully understand celiac disease and gluten sensitivity.  This is simply not the case.  The research shows that some celiacs do develop symptoms when consuming oats.  While most newly diagnosed celiacs experience reduced symptoms and improved health, this may simply be the result of consuming less grain-derived protein.  Researchers have long known that even partial compliance with the gluten-free diet produces health improvements in celiac patients(11).

The definition of celiac disease that requires villous atrophy followed the discovery of the beneficial impact of the gluten-free diet by more than 20 years (If in doubt about this point, please refer to the English translation of Dr. Dicke’s Ph.D. thesis at http://www.dangerousgrains.com).  Our current understanding of the disease began with the observed benefits of the gluten-free diet.  Intestinal biopsies were a much later development.

A similar debate arose regarding the inclusion of wheat starch.  It was long held to be a safe nutrient in the gluten-free diet in many European countries.  In fact, the studies that showed a reduced risk of cancer and a variety of celiac-associated conditions were often conducted among patient groups living where wheat starch was deemed acceptable(12, 13).  Yet when wheat starch consumption was studied in Canada, against a back-drop of zero tolerance, most of the subjects developed signs and symptoms of celiac disease(14).

Many celiacs and gluten-sensitive individuals know that their symptoms do not fit with the conventional view of celiac disease.  Some of us believe that there is a continuum of severity.  Others believe that there are many sub-types of celiac disease.  Still others believe, me included, that it really doesn’t matter whether a person has intestinal damage.  The important, defining characteristic should be whether a person is mounting an immune response against the proteins in the most common substance in our food supply.  

Whatever our beliefs we turn to the experts when faced with health concerns and crises.  However, those answers often rely on the medical definition of celiac disease, where villous atrophy heals in response to a gluten-free diet.  In cases where the biopsy was improperly taken, or too few samples were taken, or patchy intestinal lesions were missed, or other forms of gluten-induced ailments are causing symptoms, we may not get answers that aid our health.  Many individuals who are gluten sensitive will be, under such circumstances, dismissed with a diagnosis of IBS.

Given the facts, we have several hurdles to overcome before we can, in my opinion, render an informed judgment about the safety of oats.  We need a much better understanding of gluten-induced disease in all of its manifestations.  We also need a definition of celiac disease that is more useful to the patient who is experiencing symptoms of gluten sensitivity/celiac disease.  As part of this, we also need a test that is more accurate, and can identify celiac disease after beginning the diet––a challenge that many of us face.  Until we have overcome these hurdles, any pronouncement regarding the safety of oats is premature.

Further research is, in my opinion, the greatest need of the celiac community.  We need to know more, not just about celiac disease, but about the whole range of nutritional and pathological impacts of eating grains. In my own quest, I have learned from the experiences of other celiac patients.  Each new facet of my own experience has been illuminated by someone else’s story.  I have come to understand ADHD as a frequent companion of celiac disease.  Learning disabilities are also common among celiacs.  Behavioral disturbances are the norm, and speech problems are common.  My understanding continues to grow as I hear from others who struggle with gluten sensitivity.

Despite its usefulness, this patient-to-patient network of information sharing is not enough.  We need well designed, well executed research.  We need a better understanding of our disease and how to protect future generations from the current, inaccurate assumptions about grains.  The oats question is only one facet of a much larger need for more information and better testing methods.

Sources:

  1. Storsrud S, Olsson M, Arvidsson Lenner R, Nilsson LA, Nilsson O, Kilander A.    Adult coeliac patients do tolerate large amounts of oats. Eur J Clin Nutr. 2003 Jan;57(1):163-9.
  2. Kilmartin C, Lynch S, Abuzakouk M, Wieser H, Feighery C.  Avenin fails to induce a Th1 response in coeliac tissue following in vitro culture. Gut. 2003 Jan;52(1):47-52.
  3. Janatuinen EK, Kemppainen TA, Julkunen RJ, Kosma VM, Maki M, Heikkinen M, Uusitupa MI.  No harm from five year ingestion of oats in coeliac disease. Gut. 2002 Mar;50(3):332-5.
  4. Teschemacher H.  Opioid receptor ligands derived from food proteins. Curr Pharm Des. 2003;9(16):1331-44. Review.
  5. Yoshikawa M, Takahashi M, Yang S. Delta opioid peptides derived from plant proteins. Curr Pharm Des. 2003;9(16):1325-30. Review.
  6. Horvath K, Graf L, Walcz E, Bodanszky H, Schuler D. Naloxone antagonises effect of alpha-gliadin on leucocyte migration in patients with coeliac disease. Lancet. 1985 Jul 27;2(8448):184-5.
  7. Zioudrou C, Streaty RA, Klee WA. Opioid peptides derived from food proteins. The exorphins. J Biol Chem. 1979 Apr 10;254(7):2446-9.
  8. Hoggan R.  Considering wheat, rye, and barley proteins as aids to carcinogens. Med Hypotheses. 1997 Sep;49(3):285-8.
  9. Fukudome S, Yoshikawa M.   Opioid peptides derived from wheat gluten: their isolation and characterization. FEBS Lett. 1992 Jan 13;296(1):107-11.
  10. Kuitunen P, Savilahti E, Verkasalo M.  Late mucosal relapse in a boy with coeliac disease and cow's milk allergy. Acta Paediatr Scand. 1986 Mar;75(2):340-2.
  11. Holmes, et. al. "Malignancy in coeliac disease - effect of a gluten free diet" Gut 1989; 30: 333-338
  12. Holmes GK.  Coeliac disease and malignancy.Dig Liver Dis. 2002 Mar;34(3):229-37
  13. Collin P, Pukkala E, Reunala T.  Malignancy and survival in dermatitis herpetiformis: a comparison with coeliac disease. Gut. 1996 Apr;38(4):528-30.
  14. Chartrand LJ, Russo PA, Duhaime AG, Seidman EG.  Wheat starch intolerance in patients with celiac disease. J Am Diet Assoc. 1997 Jun;97(6):612-8.

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29 Responses:

 
Beth
Rating: ratingfullratingfullratingfullratingemptyratingempty Unrated
said this on
20 Sep 2014 12:58:56 PM PST
This article makes some good point to consider and while I agree that there are some people who can not tolerate gluten-free oats I'm wondering why the literature used for this article is all 2003 or older. There have been a number of studies since that time which show some different results. Is there a reason for not including those as well?

 
admin
( Author)
said this on
22 Sep 2014 12:40:38 PM PST
As the article states: "This article originally appeared in the Winter 2004 edition of Celiac.com's Journal of Gluten-Sensitivity."

 
Zoe
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said this on
21 Sep 2014 2:29:36 AM PST
Marked down one for no mention of soy and corn, as everyone is so hung up on measuring Anti-Gliadin, should there be an Anti-Soy/Oats/Corn test too? Is this another reason for Neg IgA yet positive gut biopsy?

 
Susie
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said this on
22 Sep 2014 9:30:03 AM PST
I love oats, I CANNOT eat oats! Finally an article that really addresses the reality of living with celiac disease, a disease that has been under-studied and under-diagnosed for years, a disease that doctors and so-called experts like to make you think they really know about and believe in what they say.

 
Donnie
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said this on
22 Sep 2014 11:28:54 AM PST
The best experts are the people who actually have celiac, or food allergies, for that matter. We speak with the voice of experience, which trumps the so-called experts who never had to deal with the real suffering from those illnesses. We know if we can tolerate a food, or not, based on our symptoms and 'experience', in most cases.

 
Marlene
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said this on
23 Sep 2014 2:58:03 AM PST
I agree completely ... we ARE the BEST EXPERTS. As far as I am concerned, they haven't printed enough yet to convince me to eat anything with even a trace of gluten because the price is too painful. Gluten foods do have an addictive element and that explains their wanting to decriminalize some of their favorite oats.

 
Uncle Bruce
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said this on
22 Sep 2014 3:16:18 PM PST
I had one heck of a bad time after eating Bob's Red Mill Gluten Free Oatmeal. Oops. They wouldn't have had cross-contamination with wheat processing, so the oats itself got me.

 
DebW
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said this on
22 Sep 2014 3:57:51 PM PST
Many say oats make you sick from cross-contamination. No mention of "commercial" as opposed to "gluten-free oats" in this article.
I have found I'm better off with no grains, aside from white rice. I never had a positive celiac blood test, just years of symptoms with good relief on a GF diet.

 
Csnewmark
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said this on
22 Sep 2014 5:14:39 PM PST
All impressions based on old literature. There are gluten free oats.

 
admin
( Author)
said this on
23 Sep 2014 9:17:28 AM PST
While there are oats free of gliadin, there are not oats that are free of avenin--which is the gluten that is in oats. If you see the many comments here you will understand that many celiacs still cannot eat oats whether they are of the "gluten-free" variety or not.

 
Janice Dalton
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said this on
22 Sep 2014 6:20:05 PM PST
I am so glad to have clear and concise, annotated information in a celiac.com article. Thank you. Thank you. I had all but quit reading these articles.

 
Tatjana
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said this on
22 Sep 2014 8:06:07 PM PST
Solid citations. I like the attitude~ 'Listen, I don't care if you have intestinal damage or not....' I'm definitely a believer in the spectrum/subtype celiac. I can't eat oats to save my life. My brother doesn't tolerate grains well in general. I'm good with a few.
I docked a point for the European digs. The Germans diagnosed me. To be sure, I'd already started to feel much better after moving there. I didn't eat a lot of bread (East German bread is not great) but I drank beer! They do use different wheats, but that seemed beyond the scope of the article.

 
Deb
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said this on
23 Sep 2014 12:26:15 AM PST
The article is plenty relevant today. I cannot eat oats. I cannot eat corn. If I do, I get horrible, glutened-type pain and a resultant long stay in the thrown room. There is absolutely not enough research into this disease, which I believe goes way deeper than just gluten. I have problems with many kinds of proteins, and I can't eat the same foods daily. I have biopsied celiac. I have other autoimmune diseases, as well, but I really think celiac has more to do with an inability to digest proteins, and especially grain proteins, due to a lack of many enzymes needed to do so. I am very tired of the "experts" claiming to know the facts about this disease when, in my opinion, they have barely scratched the surface.

 
Terry Lynch
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said this on
23 Sep 2014 12:29:21 AM PST
There are many interesting recent developments.
There are a number of cofactors mediating gluten sensitivity but I have concluded it is possibly related in many cases to low stomach acid and thus pepsin production. You simply end up with undigested gliaden proteins that over time may initiate either an antibiody response or bacterial growth endotoxicity which inflames the villi.
It is interesting that B vitamin mal absorption also occurs with celiac patients. It is no wonder that ADHD increased occurrence exists with Avitaminosis since Vitamin B-3 is the precursor to ATP and the brain depends solely on mitochondrial ATP for energy. Low ATP exists with ADD autism and other brain function disorders. It is interesting also that high fructose corn syrup greatly exacerbates the problem by preventing the absorption of tryptophan also needed for Niacin and Seratonin.

If you are on a diet that excludes enriched flour product you should definitely consider a natural daily Balanced B-Complex vitamin and be aware that villous atrophy is not always fully corrected by dietary compliance

 
Eddie
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said this on
23 Sep 2014 2:31:11 AM PST
No mention of oats being genetically engineered (crossed with wheat).

 
admin
( Author)
said this on
23 Sep 2014 9:11:28 AM PST
Celiac.com has never heard of this, and don't believe it exists. If you have references, feel free to post them, otherwise please don't spread fear.

 
NGE
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said this on
24 Sep 2014 7:11:27 AM PST
I agree. There's an article in Modern Farmer explaining why there are NOT and probably never will be GMO oats. I can't link to it, but search for Dan Mitchell, January 10 2014.

 
Dwight
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said this on
23 Sep 2014 6:22:45 AM PST
I'm another GF/no oats celiac. 25 years GF and the last time I tried GF oats, it was slowly a bad result. After 3 days the typical symptoms appear. I have given up on the oats.

 
celiacMom
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said this on
23 Sep 2014 7:25:50 AM PST
While this is a very good article, and as others have mentioned concerns on how old it is and how much research has changed in 10 years, would be good to ask Dr. Hoggan to do an update on the same topic.

 
admin
( Author)
said this on
23 Sep 2014 9:08:06 AM PST
Celiac.com ran the article as is because the basic premise of the article is still valid, and there hasn't been any breakthrough research in the past 10 years that would invalidate the premise of this article.

 
avwalters
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said this on
23 Sep 2014 7:31:30 AM PST
The problem is what I call TDMV (Too Damn Many Variables.) By the time an adult receives a diagnosis of celiac (regardless of the diagnostic method), he/she likely has a number of food related reactions. Thus is an intolerance to, say, oats, the result of celiac or some other acquired food sensitivity. I can tolerate oats without noticeable symptoms, so long, of course, as I don't eat them with milk products, shellfish, peanuts or citrus. I don't consider myself fragile--indeed--over ten years gluten free has taken a generally unhealthy me and transitioned to a robust me. Still, I listen when someone has food issues that extend beyond just gluten. We all need to listen to our own bodies for the guidelines to stay healthy.

 
Carol
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said this on
23 Sep 2014 7:53:38 AM PST
I'm glad to know that there are doubts about oats...I have been hesitant to add them to my diet, even before I read this. I was diagnosed 25 years ago with dermatitis herpetiformis ( SP? ), and was told to avoid gluten. That's all...avoid gluten. It was only 8 years ago that I actually learned how to be gluten free! Much more is known today, fortunately. I've never been tested for celiac, but I do know what will ensure a breakout of blisters and malted barley heads the top of that list. My sister has suggested that perhaps I am simply allergic to malted barley, and maybe I could eat regular bread, etc. as long as the product doesn't contain malted barley. I'm amazed that even my sister does not take my condition seriously!

 
miguel
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said this on
23 Sep 2014 8:44:30 AM PST
I develop canker sores eight hours after I eat oats, and over the next few days get pimples in my testicles and butt. Experimented with GF oats and did the same. Been GF for five years.

 
Ruth
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said this on
23 Sep 2014 8:53:05 AM PST
I'd love to read an updated article (this one is ten year's old) on this topic. I, too, feel that even current research doesn't seem to answer a lot of questions about celiac disease. The more I read the more I've reluctantly realized that the research is muddy and that double-blind studies are few and far between. Now that gluten free diets are a money making industry it may be harder to find unbiased research not funded by gluten free food manufacturers. Regardless, many thanks for this article.

 
Kris
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said this on
23 Sep 2014 10:40:49 AM PST
I have been diagnosed with celiac for 6 years and strictly GF for 6 years. I have had NO problems with GF oats that I am aware of. I actually have come to really like having them in my diet, as they are so healthy and high in protein. Unfortunately everyone is different, I guess I lucked out on oats. Everything else gluten wise I am extremely sensitive to (wheat, rye and barley). I agree it would be nice to have more studies on oats and the relationship to enzymes and proteins and how people digest them.

 
norm
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said this on
23 Sep 2014 12:56:27 PM PST
I was diagnosed 3 years ago, biopsy and bold test. I get blood tests every 6 months or so so I can confirm that I am gluten-free. I have been eating GF oatmeal all this time with no issues. I just went through a scope test and every thing was clear. I was in a GF study for UCSD last year where they are trying to ID stages of celiacs. I did not have the bowel issues they were looking for but I had severe joint issues. These went away when the study was over. The 2 times I cheated I also had these severe joint issues. Just from those I will not eat gluten food.

 
Ktb
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said this on
24 Sep 2014 6:34:49 AM PST
Great article---finally a voice of reason in the celiac world!! Oats were out for us the first year of diagnosis in 2005, but it took about 2 weeks for symptoms to develop. Celiac is certainly understudied and at this point, unless an MD lives with it or someone in their house does, their word is worthless as to what a celiac can or cannot eat safely. I agree there are varying degrees of the disease, of sensitivity and the testing protocol is HORRENDOUSLY inaccurate, leaving too many with the All Clear when in fact gluten or all grains are their enemy.

 
Monica Peeke
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said this on
24 Sep 2014 1:02:06 PM PST
Deb,
I completely agree with what you have said!!! I LOVE oats too, but I can not eat them. Makes me so sad!! I wish there was more research, because I feel so alone when I can't eat oats and want to so bad. Need more research!! I too struggle with other issues.

 
David Lapham
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said this on
25 Sep 2014 8:29:09 PM PST
I found it very informative and interesting. I love oats, but find they cause a partial return of the problems. I agree that there is a woeful lack of founded information about this disease, even an accurate "test" to see if one has it or not. I have found the best test is to go gluten free for a few weeks to a few months a see what the effect is.




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