CD: Inclusion of Gluten-Free Oats 2009
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
CD: Inclusion of Gluten-Free Oats as Tolerated
The registered dietitian (RD) should advise individuals with celiac disease who enjoy and can tolerate gluten-free oats to gradually include them in their gluten-free dietary pattern. Research on individuals with celiac disease reports that incorporating oats uncontaminated with wheat, barley or rye at intake levels of approximately 50g dry oats per day is generally safe and improves compliance with the gluten-free dietary pattern.
Risks/Harms of Implementing This Recommendation
In a small number of persons with celiac disease, research reports that oats may cause villous atrophy, an increase in intraepithelial lymphocytes or exacerbate dermatitis herpetiformis.
Conditions of Application
- This recommendation applies to individuals with celiac disease who enjoy and can tolerate gluten-free oats
- Inclusion of oats requires medical supervision
- Gluten-free oats must meet the proposed FDA definition Oats may be labeled gluten free only if they contain less than 20 parts per million of gluten.
- The introduction of oats may result in gastrointestinal symptoms such as diarrhea and abdominal discomfort. These symptoms may be due to an increase in fiber intake and not be a sign of intolerance to oats.
Refer to the recommendation on Education on Food Cross-Contamination available at ada.portalxm.com/eal/template.cfm.
Potential Costs Associated with Application
- Specially-manufactured gluten-free oats may be costly
- Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT sessions are essential for improved outcomes.
- Studies have shown that incorporating oats uncontaminated with wheat, barley or rye into a gluten-free dietary pattern for people with celiac disease at intake levels of approximately 50g dry oats per day is generally safe and improves compliance (Janatuinen et al, 1995; Srinivasan et al, 1996; Hardman et al, 1997; Reunala et al, 1998; Hoffenberg et al, 2000; Janatuinen et al, 2000; Thompson, 2000; Picarelli et al, 2001; Janatuinen et al, 2002; Lundin et al, 2003; Storsrud et al, 2003; Hogberg et al, 2004; Peraaho, Collin et al, 2004; Peraaho, Kaukinen et al, 2004; Srinivasan et al, 2006)
- However, many studies report that the introduction of oats may result in gastrointestinal symptoms such as diarrhea and abdominal discomfort. These symptoms tend to be the primary reason for study subject withdrawal.
- Additional adverse effects that have been reported include dermatitis herpetiformis, villous atrophy and an increased density of intraepithelial lymphocytes, indicating that some persons with celiac disease may be unable to tolerate oats.
- Since limited research has been conducted on the similarities among those with adverse reactions to oats, further research is needed in this area.
Recommendation Strength Rationale
Conclusion statement received Grade II.
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
Hardman CM, Garioch JJ, Leonard JN, Thomas HJW, Walker MM, Lortan JE, Lister A, Fry L. Absence of toxicity of oats in patients with dermatitis herpetiformis. N Engl J Med 1997; 337: 1884-7.
Hoffenberg EJ, Haas J, Drescher A, Barnhurst R, Osberg I, Bao F, Eisenbarth G. A trial of oats in children with newly diagnosed celiac disease. J Pediatr 2000; 137: 361-6.
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. Oats to children with newly diagnosed celiac disease: a randomized double blind study. Gut 2004; 53:649-654.
Janatuinen EK, Kemppainen TA, Julkunen RJK, Kosma VM, Maki M, Heikkinen M, Uusitupa MIJ. No harm from five year ingestion of oats in celiac disease. Gut 2002; 50: 332-335.
Janatuinen EK, Kemppainen TA, Pikkarainen PH, Holm KH, Kosma VM, Uusitupa MIJ, Maki M, Julkunen RJK. Lack of cellular and humoral immunological responses to oats in adults with celiac disease. Gut 2000; 46: 327-331.
Janatuinen EK, Pikkarainen PH, Kemppainen TA, Kosma VM, Jarvinen RMK, Uusitupa MIJ, Julkunen RJK. A comparison of diets with and without oats in adults with celiac disease. N Engl J Med 1995; 333: 1033-7.
Lundin KEA, Nilsen EM, Scott HG, Loberg EM, Gjoen A, Bratlie J, Skar V, Mendez E, Lovik A, Kett K. Oats induced villous atrophy in celiac disease. Gut 2003; 52: 1649-1652.
Peraaho M, Kaukinen K, Mustalahti K, Vuolteenaho N, Maki M, Laippala P, Collin P. Effect of an oats-containing gluten-free diet on symptoms and quality of life in celiac disease. A randomized study. Scand J Gastroenterol 2004; 39:27-31.
Peraaho M, Collin P, Kaukinen L, Miettinen S, Maki M. Oats can diversify a gluten-free diet in celiac disease and dermatitis herpetiformis. J Am Diet Assoc 2004; 104: 1148-1150.
Picarelli A, Di Tola M, Sabbatella L, Gabrielli F, Di Cello T, Anania MC, Mastracchio A, Silano M, De Vincenzi M. Immunologic evidence of no harmful effect of oats in celiac disease. Am J Clin Nutr 2001; 74: 137-140.
Reunala T, Collin P, Holm K, Pikkarainen P, Miettinen A, Vuolteenaho N, Maki M. Tolerance to oats in dermatitis herpetiformis. Gut 1998; 43: 490-493.
Srinivasan U, Jones E, Carolan J, Feighery C. Immunohistochemical analysis of coeliac mucosa following ingestion of oats. Clin Exp Immunol 2006;144(2):197-203.
Srinivasan U, Leonard N, Jones E, Kasarda DD, Weir DG, O'Farrelly C, Feighery C. Absence of oats toxicity in adult celiac disease. BMJ 1996; 313: 1300-1301.
Storsrud S, Hulthen LR, Lenner RA. Beneficial effects of oats in the gluten-free diet of adults with special reference to nutrient status, symptoms and subjective experiences. Br J Nutrition 2003; 90: 101-107.
Thompson T. Questionable foods and the gluten-free diet: Survey of current recommendations. J Am Diet Assoc 2000; 100(4):463-465.
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process