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Recommendations Summary

CD: Oats (2021)

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.


  • Recommendation(s)

    CD: Inclusion of Gluten-free Oats: Adult

    In adults with celiac disease, the registered dietitian nutritionist or an international equivalent may suggest incorporating gluten-free oats as part of a nutritionally adequate gluten-free diet.

    Rating: Level 2(D)
    Conditional

    CD: Inclusion of Gluten-free Oats: Children

    In children with celiac disease, gluten-free oats are an appropriate option as part of a nutritionally adequate gluten-free diet.

    Rating: Consensus
    Conditional

    • 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. 

      The outcome of including or excluding oats as part of the gluten-free diet intervention would hold important uncertainty at both the patient and population level as including oats in the diet appears to have greater benefits compared to risks, but the role in gastrointestinal function is largely unknown. Therefore, for patients that do not have issues with gluten free oats, they can add healthy benefits to the diet. However, for patients that cannot consume oats due to GI symptoms, oats do not need to be included in the diet.

    • Conditions of Application

      Implementation Considerations

      • Since this recommendation has changed since the previous review, the RDN should be prepared to discuss the literature in this area with their client as there may be resistance. Focusing on the nutrients delivered in oats as part of a well-balanced meal should be the focus.
      • Including gluten-free oats in the diet can be accomplished in a variety of ways. Gluten-free oatmeal as cereal in the morning, used as the base for a pancake recipe, incorporated into a smoothie, or sprinkled on fruit as a replacement for granola can all be ways to deliver the fiber and protein in oats as part of a well-balanced meal. 
      • This recommendation applies to individuals with celiac disease who enjoy and can tolerate gluten-free oats. 
      • 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.

    • 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.
      • Oats are permitted to be bought as a part of Supplemental Nutrition Assistance Program.

    • Recommendation Narrative

      A total of eight studies and nine articles were examined that explored the effects of oats, compared to a control, on nutrition-related outcomes in patients with celiac disease. All included studies were conducted in Europe (Norway, Finland, Italy and Sweden). Five studies included adults with celiac disease and four studies included children with celiac disease as their target population. Sample sizes of participants analyzed ranged from 10-715 per group (some studies included additional participant groups not considered for this review). All intervention groups investigated the effect of oats, in addition to a gluten-free diet, compared to a control, on nutrition-related outcomes among patients with celiac disease. While two studies specified that the oats investigated were gluten-free (Gatti et al, 2013/Lionetti et al, 2018; Koskinen et al, 2009), the remaining studies indicated that oats were consumed as a part of a gluten-free diet, but the sources of oats were not described. The comparison group varied across studies, but all groups also received a gluten-free diet that did not include oats, except for Koskinen et al, 2009, in which the control group underwent a gluten challenge followed by an oat challenge.

      Of the studies that examined the effects of oats, compared to a control, on nutrition-related outcomes in patients with celiac disease, seven reported on celiac disease-related antibodies, inflammatory & immunlogocial indicators, including TTG and AGA IgA and intraepithelial lymphocytes (Aaltonen et al, 2019; Guttormsen et al, 2008; Kaukinen et al, 2009; Kemppainen et al, 2007; Koskinen et al, 2009; Lionetti et al, 2018; Sj?berg et al, 2014). Two studies (Kaukinen et al, 2009; Løvik et al, 2009) reported on nutrient intake (fiber). Two studies (Kaukinen et al, 2009; Lionetti et al, 2018) reported on anthropometrics (body mass index). One study (Løvik et al, 2009) reported on nutrition-related laboratory measures. One study (Aaltonen et al, 2019) reported on indicators of quality of life. Two studies (Aaltonen et al, 2019; Løvik et al, 2009) reported on gluten-free diet adherence. Five studies (Aaltonen et al, 2019; Gatti et al, 2013; Kaukinen et al, 2009; Koskinen et al, 2009; Lionetti et al, 2018) reported on indicators of gastrointestinal health and gastrointestinal symptoms, including the gastrointestinal symptom rating scale and villous height to crypt depth ratio. 

      Results Overview
      All studies that reported on celiac disease-related antibodies, inflammatory & immunological indicators (Aaltonen et al, 2019; Guttormsen et al, 2008; Kaukinen et al, 2009; Kemppainen et al, 2007; Koskinen et al, 2009; Lionetti et al, 2018; Sj?berg et al, 2014) reported that, in comparison to a control group, participants in a group that consumed oats as a part of a gluten-free diet did not experience any significant differences in indicators such as IgA (anti-avenin, anti-gliadin, anti-TG2, TTG, or AGA), AGA IgG, or intraepithelial lymphocytes (αβ+, γδ+ and CD3+). 

      One study (Løvik et al, 2009) reported that, after a 12-week oat challenge, participants experienced significant difference in nutrition-related laboratory measures, including P-total proteins, P-albumin, P-total cholesterol, S-folate, P-ALAT, P-phosphorus, P-bilirubin and P-ASAT, in comparison to their pre-oat challenge values. This same study noted that, in a cross-sectional analysis, there was a tendency for higher bilirubin values for celiac patients who consumed oats in comparison to those who do not consume oats.

      Two studies (Kaukinen et al, 2009; Løvik et al, 2009) concluded that consumption of oats, in comparison to a gluten-free diet without oats, results in significantly higher daily intake of fiber. 

      Two studies (Kaukinen et al, 2009; Lionetti et al, 2018) concluded that groups of celiac disease patients who consume oats do not have a higher BMI when compared to similar groups of celiac patients who do not consume oats. 

      One study (Aaltonen et al, 2019) used multiple assessment methods to evaluate the impact of oat consumption on indicators of quality of life. While there was no difference in general psychological well-being between oat consumers and non-oat consumers, participants who consumed oats scored significantly better on assessments of physical role limitations (limitations due to physical health problems, pain or general health) and general health in comparison to non-oat consumers.

      The effect of oats on gluten-free diet adherence among patients with celiac disease is unclear. While Aaltonen et al, 2019 concluded that there was no significant difference between oat consumers and non-oat consumers in self-reported dietary adherence, Løvik et al, 2009 found that introduction of oats in an oats challenge resulted in a significant reduction of gluten intake. 

      The effect of oats, in comparison to a control group, on indicators of gastrointestinal health and gastrointestinal symptoms, is unclear. Three studies (Aaltonen et al, 2019; Gatti et al, 2013; Lionetti) concluded that there was no difference in the Gastrointestinal Symptom Rating Scale scores between oat consumers and non-oat consumers. Koskinen et al, 2009 also concluded that there was no difference in villous height to crypt ratio between celiac disease patients who underwent an open oat challenge in comparison to celiac disease patients who underwent a gluten challenge followed by an oat challenge. However, Kaukinen et al, 2009 concluded that GSRS scores were negatively correlated with daily oat intake and that mucosal villous crypt depth ratios positively correlated with daily oat intake, indicating that gluten-free oat consumption may be protective against gastrointestinal symptoms among patients with celiac disease.

    • Recommendation Strength Rationale

      The evidence supporting the recommendation is based on Grade III /Grade C or D evidence. 

    • Minority Opinions

      Consensus reached.