Some studies show that most people with celiac disease can tolerate oats, while some studies show sensitivity. Some people with celiac disease seem to be sensitive to oats, whether they are contaminated or not, but recent studies suggest that contamination is the main problem for most people with celiac disease who wish to eat oats. Anecdotal evidence is equally divided, with some folks reporting no problem with oats, while others report adverse reactions.

A recent editorial by doctors Heather Julia Ellis and Paul J. Ciclitira in the European Journal of Gastroenterology and Hepatology notes that oats could be an important component in a gluten-free diet. They point out that a small segment of the population with celiac disease seem to have adverse T cell responses to oats that can not be explained by contamination. The doctors also point out that only one of the two commercially available kits for testing for the presence of gluten in foods is sensitive to barley. Another problem with oat consumption among people with celiac disease is that some may seem to tolerate oats well, and Open Original Shared Link, but still be suffering damage.

Doctors Ellis and Ciclitira note that people with celiac disease who wish to consume oats need sound advice and regular monitoring for telltale antibodies, and reliable, comprehensive assay techniques, which means access to reliably tested, uncontaminated oats. To that, I would add clear labeling. An article by the Irish gastroenterologist William Dickey in the European Journal of Gastroenterology and Hepatology seems to echo that point. According to Dickey, research supports the idea that most people with celiac disease can tolerate pure oats well, and that only in rare cases do pure oats elicit an adverse reaction. Dickey notes that contamination of commercially viable oats is the cause of most adverse reactions in people with celiac disease. He points out that R5 ELISA accurately detects and measures gluten contamination in oat products. Dickey calls for R5 ELISA testing of all oats, and of all “gluten-free” products containing oats. He points out that contamination levels of all such products should be clearly labeled to help people with celiac disease to avoid products with unacceptable contamination levels.

A recent study made by a team of doctors in Spain set out to measure the levels of wheat and barley contamination of oats from Europe, the United States, and Canada. The research team was made up of doctors Alberto Hernando, Jorge R. Mujico, Mara C. Mena, Manuel Lombardía, and Enrique Méndez. The team used 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 to evaluate 134 varieties of “pure,” “uncontaminated” oats from Europe, the United States, and Canada.

Results showed that just 25 of the samples were actually pure, and contained no detectable levels of contamination. The other 109 samples all showed wheat, barley and/or rye contamination. The results also showed that contamination levels vary among oats from the same source.

European Journal of Gastroenterology and Hepatology 20: 492–493; 494–495; 545–554.

Recentevidence from a number of studies has supported the idea that oats aresafe for people with celiac disease. In several countries, oats are nowon the list of safe foods for people with celiac disease. The studieson oats and celiac disease have had various designs, but most have beensmall, and often with high patient drop-out rates. To date, there hasonly been a single randomized and double-blinded study measuring the effects of oats on celiac patients. The studies have been nearly unanimous in concluding that consumption of oats is safe to celiac disease patients.

Mostof these clinical studies have assessed blood histology in reaction tooats, or measured normalization after patients had been diagnosed withceliac disease and were already following gluten-free diets. Threelarge studies from Finland have investigated the effect of dietary oatsand their influence on antibody levels to wheat gluten and to tissuetransglutaminase. Previous studies have shown that people withuntreated celiac disease show elevated IgA antibodies in reaction oatavenins. However, only one study on treated celiac disease patients hasinvestigated IgA antibodies to oats.

Researchers know of justthree confirmed cases of active celiac disease flaring up again inadults after these people ingested oats, which indicates thatintolerance to oats among celiacs may be rare, but also may in facthave some role to play in celiac disease. It also points to the need for clinical monitoring of celiac disease patients who eat oats.

Aresearch team made up of Vigdis Guttormsen, Astrid Løvik, Asta Bye;Jorunn Bratlie, Lars Mørkrid, and Knut E. A. Lundin recently conducteda small study to determine whether treated adult celiac diseasepatients who ate oats showed elevated levels if IgA. The research team compared blood samples of 136 adult patients with treated celiac disease against 139 controls. The team used ELISA to test the blood samples to measure IgA against oats avenin, wheat gliadin and tissue trans-glutaminase.

Eighty-two of the celiac disease patients had been eating oats as part of their gluten-free diet for 6 months or more.  Both the oats-eating and non-oats-eating celiac disease patients showed no significant differences in IgA against oats. However, both groups did show elevated levels of IgA against wheat, oats and tissue tTG compared to healthy controls. Thegroups also showed a significant positive correlation betweenanti-avenin and antigliadin IgA (pB0.0001), and between anti-avenin andanti-tissue transglutaminase IgA (p 0.0012).

The researchersconcluded that eating oats does not cause increased levels of IgA inadult celiac disease patients on a gluten-free diet. The findings support the notion that most adult celiac disease patients can tolerate oats.

Scandinavian Journal of Gastroenterology, 43:2, 161 - 165.

A team of Italian and Australian doctors conduced in vitro tests on three different kinds of oats. They wanted to see if certain kinds of oats showed any kind of toxicity in people with celiac disease. These tests showed that the Avenins of the Italian variety Astra and the Australian variety Mortlook showed a much higher activity than those of the Australian Lampton variety, while Rice of the Roma variety showed no activity. Gliadin which is found in wheat and rye showed the expectedly high levels of activity.

Of the oat types tested in this study, the Lampton variety seems to be safer than either the Astra or the Mortlock. However, even oats that are “safer” must still be processed in a dedicated facility that is free of contamination and routinely tested to make sure they meet the minimum levels to be gluten-free. For oat products to be considered gluten-free, they must show less than 20ppm of gliadin.

A study published in the New England Journal of Medicine by Trisha Thompson, M.S., R.D.,* showed that no commercial brand of oats were reliably gluten-free. In fact, nine of the twelve samples from three major brands of oats showed gluten levels ranging from 1,807 to 23 ppm.

There are several companies who now sell "certified gluten-free oats," which are oats that are farmed, harvested, processed and packed using special methods to avoid cross-contamination with gluten during every step of the way. Gluten-free oats currently sell for around $4 to $5 a pound. These type of oats are typically tested for gliadin to less than 3ppm, and are thus considered safe for celiacs who are not sensitive to Avenins.

As far as certain types of oats being better than others, it’s worth some checking, but I’m unsure of the availability of, say, the Lampton strain in America. Also, given the results of commercially available oat brands, the question of the conditions under which the oats were processed becomes very important. Previous studies have shown children with celiac produce significantly greater numbers on antibodies to oat protein than non-celiac children (Scand J Gastroenterol. 2003 Jul; 38(7):742-6).

Many folks with celiac disease are looking to avoid contamination, as no one wants to suffer the unpleasant symptoms of a gluten reaction. Basically, people just want to know what’s safe and to be able to enjoy those items without worrying about getting sick. Since cross-contamination is such a problem of particular importance to celiacs, and since oats grown and processed commercially are likely not gluten-free, it would seem wise to start with gluten-free oats just to be on the safe side.

But anyone looking for a definitive answer will just have to wait. And remember, as with so much with the gluten-free diet, you are the best judge of your own body.

*Thompson T. Gluten Contamination of Commercial Oat Products in the United States. N Engl J Med 2004; 351:2021-2022

Main article:
Journal of Gastroenterology and Hepatology 22 (4), 528–531, 2007.
Marco Silano, Mariarita Dessì, Massimo De Vincenzi, Hugh Cornell (2007).

An international research team made up of doctors Tarja Kemppainen (1); Esko Janatuinen (2); Kati Holm (3); Veli-Matti Kosma (4); Markku Heikkinen (5); Markku Mäki (3); Kaija Laurila (3); Matti Uusitupa (1); Risto Julkunen (5), set out to evaluate local cellular immune response after 5 years of oat consumption by adult celiac patients.

The doctors looked at a group of 42 celiac patients who had previously participated in a 6-12 month oats intervention study.

22 of these patients already incorporated oats as part of their gluten-free diet. During the 5-year follow-up study, 10 patients who were concerned about the safety of long-term oat consumption stopped eating oats. The 12 remaining patients consumed oats for the whole 5-year period. The remaining 20 celiac patients formed the control group, and followed a strict, conventional, gluten-free diet that excluded oats.

The team conducted biopsies and counted Intraepithelial CD3, TCR (IEL) and TCR (IEL) T cells to determine corresponding densities.

No Adverse Effects for Celiac Disease Patients Who Eat Oats

The results showed no differences in the densities of CD3, IEL and IEL T cells between the oat and the control groups. The researchers concluded that the mucosa of the small intestine show no immunological response in celiac patients who consume oats over a long period of time.

Scandinavian Journal of Gastroenterology, Volume 42, Issue 1 2007 , pages 54 - 59

Participating Institutions:

Thompson T. NEJM. 2004;351:2021-2022 (Nov. 4, 2004, Number 19)

Celiac.com 11/09/2004 - While oats do not appear to naturally contain gluten, like other grains they can become contaminated during harvesting, transporting, milling and processing. Open Original Shared Link have shown that moderate amounts of uncontaminated oats are safe for most adults with celiac disease. There may, however, also exist a sub-set of celiacs who also have Open Original Shared Link, avenin being the oat counterpart to wheats gliadin.

To summarize the study—12 containers of oats representing 4 different lots of 3 brands (Quaker, Country Choice, and McCanns) were tested for gluten contamination using the R5 ELISA developed by Mendez. Contamination levels ranged from below the limit of detection (3 ppm gluten) to 1807 ppm gluten. Three of the 12 oat samples contained gluten levels of less than 20 ppm, and the other nine had levels that ranged from 23 to 1,807 ppm. All brands of oats tested had at least 1 container of oats that tested above 200 ppm gluten. It is interesting to note that Country Choice oats ranged from below the limit of detection to 210 ppm—an amount that is nearly at the level allowed by the Open Original Shared Link for products that normally contain gluten but have had their gluten removed—and of the three brands had the least amount of cross-contamination. We must caution, however, that the sampling done in the study was much to small to make any firm conclusions about the average level of gluten-contamination of each of these brands.

This study shows that cross-contamination is indeed a concern for celiacs who want to try oats. Celiac patients should contact oat millers directly and talk to them about their clean-out procedures, and whether they have done any testing of their own for gluten cross-contamination.

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.

Celiac.com 11/05/2003 - A study conducted by Norwegian researchers has found that some patients with celiac disease may not be able to tolerate oats, especially those who also have Open Original Shared Link. The researchers looked at 19 adult celiac disease patients who were given 50g of uncontaminated oats per day for 12 weeks. The patients were given biopsies before and after the challenge and were scored histologically, and "levels of mRNA specific for interferon were determined by reverse transcription-polymerase chain reaction analysis." The researchers determined that oats were well tolerated by most celiac patients, with the exception of several who reported initial abdominal discomfort and boating, and one patient who eventually developed total villous atrophy and "dramatic dermatitis during a second challenge." Further, five of the patients showed positive levels of interferon mRNA after challenge, which leads to some concern by the researchers regarding the safety of oats for those with celiac disease. Several larger studies have demonstrated that oats are well tolerated by most celiacs.

Celiac.com 08/25/2003 – A recent study published in the July edition of the Scandinavian Journal of Gastroenterology demonstrates that avenin oat prolamines can be detected at higher levels in children with celiac disease compared to those without celiac disease. The researchers prepared a crude avenin extract using an ethanol and salt solution, and used it as an antigen in a three step ELISA test. The blood of 81 children, including 34 with celiac disease, were analyzed for both IgA and IgG antibodies to avenin and gliadin. The researchers found that: Children with coeliac disease on a normal diet had significantly higher levels of antibodies to avenin, both IgG and IgA, than reference children (P

The researchers conclude: Children with coeliac disease have antibodies to oat proteins at significantly higher levels than reference children. The absorption test did not indicate a cross-reactivity between the prolamines of wheat and oats. The method will be employed for repeated sampling of anti-avenin antibodies during a prospective interventional study with a gluten-free diet supplemented with oats. An emphasis should be added to the last sentence, as it appears that they will now perform a study on celiac children who actually eat oats, and most other major studies of this type have shown no intestinal damage caused by the avenin oat prolamines in people with celiac disease. It is interesting that this study shows a different response to oats in those with celiac disease, but it remains to be seen if this response is actually harmful to celiacs.

S Størsrud1,a,b, M Olsson2,b, R Arvidsson Lenner1,b, L Å Nilsson3,b, O Nilsson4,b and A Kilander2,b
1) Department of Clinical Nutrition, Sahlgrenska University Hospital, Gothenburg, Sweden
2) Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
3) Department of Medical Microbiology and Immunology, Sahlgrenska University Hospital, Gothenburg, Sweden
4) Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden

Abstract:

Celiac.com 3/14/2003 - Objective: The aim of the present study was to investigate whether adult patients with coeliac disease in remission could include large amounts of oats in their daily gluten-free diet for an extended period of time without adverse effects.

Design, subjects and methods: Twenty adult coeliac patients in remission included large amounts of uncontaminated rolled oats in their daily diet for a prolonged period. The examinations, performed four times during the study period, included small bowel endoscopy with biopsies, blood samples (nutritional status, serological analysis), height and body weight, gastrointestinal symptoms and dietary records. Gastrointestinal symptoms and diet were also investigated through unannounced telephone interviews once a month during the study period.

Results: No adverse effects of a large intake of oats were seen in small bowel histology, serology nor in nutritional status in the 15 subjects who completed the whole study period. Two of the subjects dropped out because of gastrointestinal symptoms and three for non-medical reasons. The median intake of oats was 93 g/day and the compliance to the oat diet was found to be good. Examinations of the patients after drop-out did not show any deterioration in small bowel histology or nutritional status nor raised levels of antibodies.

Conclusion: Results from this study indicate that adult patients with coeliac disease in remission can include large amounts of controlled wheat-free rolled oats for an extended period of time without adverse effects.

Sponsorship: This study was supported by Vårdalstiftelsen, Kommunalförbundet Västra Götaland, Stiftelsen Cerealia FoU, and the Swedish Nutrition Foundation. Kungsörnen AB supported the study with rolled oats.

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

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.

Celiac.com 10/10/2000 - Dr. Hoffenberg and colleagues from the University of Colorado School of Medicine, Denver report that the short-term consumption of commercially available oat cereal is safe for children with celiac disease new to a gluten-free diet. To determine this they studied 10 children with celiac disease who consumed 24 g of oat cereal per day, and examined small bowel histomorphology and antitissue transglutaminase IgA antibody titer at baseline and at 6 months. According to Dr. Hoffenberg: Compared with start of study, at completion there was a significant decrease in biopsy score, intraepithelial count, antitissue transglutaminase IgA antibody titer and number of symptoms.

They reported the gluten content of several substances:

Study oatmeal (%, range) average of 4 samples 0.009 (0.003-0.014)
Irish Oatmeal 0.006 %
Quaker oatmeal 0.006 %
Safeway oatmeal 0.005 %
Jane Lee oatmeal 0.026 %
Soy flour 0.001 %
Brown rice flour 0.000 %
Pancake mix 0.000 %
Cornmeal 0.000 %
Rice flour 0.000 %

Test was done with RIDASCREEN ELISA test for omega-gliadins. It detects wheat/barley/rye high molecular weight proteins but not oat avenin. The grain scientists tell us that even though oat proteins are different, they do have similar amino acid sequences to the toxic gliadin sequences. Similarly, in vitro (test tube) studies do show that oat proteins trigger the immune response of cells taken from celiac patients.

The team emphasized, however, that the long-term effects of oat cereal added to a gluten-free diet in children with celiac disease still need to be determined.