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    Oats Intolerance in Celiac Disease


    Scott Adams

    Celiac.com 10/28/2004 – The obvious problem with this study is that it is so small—only nine people. It does, however, bring up valid concerns about the safety of oats for all celiacs. There may exist a sub-set of celiacs who also have avenin-reactive mucosal T-cells, avenin being the oat counterpart to wheats gliadin. It is important to conduct future studies that are designed to determine just how many celiacs also have avenin intolerance.


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    Most patients with celiac disease can eliminate their symptoms--at a price: life-long adherence to a gluten-free diet. This means no wheat, rye, barley, and, until recently, no oats. Then some recent studies suggested that oats did not cause the intestinal inflammation characteristic of the disease, and thus oats are now often included in the celiac disease diet. This is good news for patients coping with severe restrictions on what they can and must not eat, but a study by Ludvig Sollid and colleagues in this issue of PLoS Medicine suggests that oats are not safe in all cases.

    Like other chronic inflammatory diseases, celiac disease is caused by a complex interplay between genetic and environmental factors, but it is better understood than most. Long believed to be a relatively rare disorder, it is now thought to affect about one in 250 people worldwide. Clinical symptoms are present in less than half of patients and vary considerably. Genetically, almost all patients have one of two predisposing HLA molecules, which determine the context in which their immune system encounters foreign antigens, including gluten proteins found in wheat and other cereals. In individuals with celiac disease, the immune system mounts an abnormal response to gluten, which is characterized by gluten-reactive intestinal T cells and by inflammation and compromised function of the small intestine.

    Ludvig Sollid and colleagues applied the current understanding of celiac disease and a range of molecular pathology tools to studying the response to oats of nine patients with celiac disease. The nine patients were not a random sample: all of them had been eating oats, and four of them had shown clinical symptoms after oats ingestion. The goal of the study was to characterize the intestinal T cell response to oats in these patients, and to relate it to clinical symptoms and intestinal biopsy results. All patients were on a gluten-free diet and ate oats that were free of contamination by other cereals.

    Three of the four patients who had reported problems after eating oats showed intestinal inflammation typical of celiac disease, and Sollid and colleagues studied intestinal T cells from these three patients. Two of the five patients who seemed to tolerate oats also had oats-reactive intestinal T cells. Functional study of these T cells showed that they were restricted to celiac-disease-associated HLA molecules and that they recognized two peptides derived from oat avenin that are very similar to peptides of gluten.

    Taken together, the findings show that intolerance to oats exists at least in some patients with celiac disease, and that those patients have the same molecular reaction to oats that other patients have to wheat, barley, or rye. However, identical reactions were also seen in two of the patients who were clinically tolerant to oats. The authors suggest that these reactions could develop into symptomatic disease after some time delay, but there is no proof that the presence of oats-reactive T cells is an indicator of future symptoms or even of enhanced susceptibility to clinical oats intolerance.

    Oats are not safe for all patients with celiac disease, but future studies are needed to determine the frequency of oats intolerance.

    Abstract of Study:

    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.

    Copyright: © 2004 Public Library of Science.

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    Guest sian thorne

    Posted

    my son has been on a strict diet at home with me , for the last 15 months...gluten, dairy, soy, corn, free...but after returning from his every other weekend dad..he has been ill....even though I know his dad is not as strict as me, with organic, no preservatives etc...yesterday he only had one meal there..ie breakfast...oats....within 2 hrs returning, he was complaining about a headache...fell asleep on the floor...seen this so many times, when he returned...after another 2 hrs sleeping, he awoke complaining about a painful stomach...the meal was gluten free oats....finally...I get the answer!...

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    Guest asttesa

    Posted

    Yes, I too have a bad allergic reaction to oats, much worse than wheat or rye. Also eat breads without additives and without baking powder and be sure to make sure there is no soy.

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    Good article. I have been gluten free for some time now, but after having an "episode" after breakfast (oatmeal) one day on a recent trip, I was once again trying to figure out why I felt so bad. Then, my wife happen to remember something she read recently about Oats and I did some additional research. Oats are now out of my diet and it appears to be working out - and of course this adds additional food restrictions. There is not a lot of research on this, and as it was suggested in the article, more is needed. Thanks for the info.

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    Guest OKIISAN

    Posted

    I ate TRADER JOE'S gluten free oats and broke out with dermatitis herpetiformis type lesions that have persisted for a year after I stopped eating OATS. SO beware of oats. I have had CELIAC disease for over 34 years, people still do not understand the dietary restrictions and make fun of it.

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    Guest OKIISAN

    Posted

    Good article. I have been gluten free for some time now, but after having an "episode" after breakfast (oatmeal) one day on a recent trip, I was once again trying to figure out why I felt so bad. Then, my wife happen to remember something she read recently about Oats and I did some additional research. Oats are now out of my diet and it appears to be working out - and of course this adds additional food restrictions. There is not a lot of research on this, and as it was suggested in the article, more is needed. Thanks for the info.

    Just because it is gluten free other proteins mimic gluten i.e. AVENIN IN OATS. BEWARE.

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    In 1994 I was diagnosed with celiac disease, which led me to create Celiac.com in 1995. I created this site for a single purpose: To help as many people as possible with celiac disease get diagnosed so they can begin to live happy, healthy gluten-free lives. Celiac.com was the first site on the Internet dedicated solely to celiac disease. In 1998 I founded The Gluten-Free Mall, Your Special Diet Superstore!, and I am the co-author of the book Cereal Killers, and founder and publisher of Journal of Gluten Sensitivity.

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  • Related Articles

    Scott Adams
    GUT 2002;50:332-5
    Celiac.com 03/19/2002 - According to a long term study conducted by Dr Matti Uusitupa and colleagues from the University of Kuopio, Kuopio, Finland, long-term ingestion of a moderate amount of oats in an otherwise gluten-free diet is safe for adult patients with celiac disease. In a previous study Dr. Uusitupa found no harmful effects from oats after patients ate them for 12 months, which was reflected by the patents symptoms, nutritional status, duodenal villous architecture, and mucosal mononuclear cell infiltrate, as seen in celiac patients who are in remission. The earlier study also showed that ingestion of oats did not delay recovery of mucosal damage in newly diagnosed celiacs.
    Dr. Uusitupas first study compared the effects of a gluten-free diet and a gluten-free diet that included oats with a randomized trial involving 92 adult celiac patients: 45 in the oats group whose intake averaged approximately 34 grams per day, and 47 patients in the control group. 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 of whom were still eating oats at least twice a week, and 28 in the control group that was on a conventional gluten free diet were examined. The results confirmed that eating oats did not cause ANY duodenal mucosal damage to the adult celiac patients in the study. Further, the patients were also examined using histological, histomorphometric, and immunological methods, and AGA, ARA, and EMA serological test results of those in the oat group showed no negative effects that could be linked to eating oats.
    According to Dr. Uusitupa, the high antibody levels that appeared in some of the patients that were in both groups are most likely explained by poor compliance to a gluten free diet, and the reason why celiac patients can tolerate oats must be based on structural differences between the proteins of oats, wheat, barley, and rye. The toxic portion of the harmful gluten protein lies in the ethanol soluble fraction called gliadins, whose toxicity remains after digestion. With oats, however, it is possible that the absence of specific amino acid sequences that are found in wheat gliadin but are not found in oat avenin allow oats to be tolerated by celiacs. Last, the researchers note that taking oats off of the list of forbidden cereals might improve patient compliance to the gluten-free diet by giving them more food choices.

    Scott Adams
    Celiac.com 3/14/2003 - After conducting an extensive review of the medical literature concerning the safety of oats for people with celiac disease, the American Dietetic Association recently concluded that even though oats are not yet endorsed as safe for people with celiac disease by doctors and support groups in the USA, they should, however, be safe for celiacs who choose to consume them if they limit their consumption to amounts found to be safe in several studies (approximately one-half cup of dry whole-grain rolled oats per day). Ideally, they also should be advised to consume only those products tested and found to be free of contamination. If this is not possible, patients should be counseled on steps they can take to help reduce their chances of consuming contaminated oat products (e.g., avoiding oats sold in bulk from bins, determining from manufacturers whether a dedicated line or facility is used for processing). In addition, patients should be advised to discuss any dietary changes with their physicians.
    The American Dietetic Associations conditional acceptance of oats as safe for people with celiac disease is another big step forward for celiacs in the USA.
    For more information see:
    Oats and the gluten-free diet
    Journal of the American Dietetic Association
    March 2003 - Volume 103 - Number 3


    Dr. Ron Hoggan, Ed.D.
    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.
    Given 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:
    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. 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. 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. Teschemacher H.  Opioid receptor ligands derived from food proteins. Curr Pharm Des. 2003;9(16):1331-44. Review. Yoshikawa M, Takahashi M, Yang S. Delta opioid peptides derived from plant proteins. Curr Pharm Des. 2003;9(16):1325-30. Review. 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. Zioudrou C, Streaty RA, Klee WA. Opioid peptides derived from food proteins. The exorphins. J Biol Chem. 1979 Apr 10;254(7):2446-9. Hoggan R.  Considering wheat, rye, and barley proteins as aids to carcinogens. Med Hypotheses. 1997 Sep;49(3):285-8. Fukudome S, Yoshikawa M.   Opioid peptides derived from wheat gluten: their isolation and characterization. FEBS Lett. 1992 Jan 13;296(1):107-11. 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. Holmes, et. al. "Malignancy in coeliac disease - effect of a gluten free diet" Gut 1989; 30: 333-338 Holmes GK.  Coeliac disease and malignancy.Dig Liver Dis. 2002 Mar;34(3):229-37 Collin P, Pukkala E, Reunala T.  Malignancy and survival in dermatitis herpetiformis: a comparison with coeliac disease. Gut. 1996 Apr;38(4):528-30. 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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