Talk:Coeliac disease/Archive - oat controversy

Archive for oat controversy Pdeitiker (talk) 17:16, 11 June 2008 (UTC)

Oats do not induce anti-avenin antibodies on a strict GF diet

Scand J Gastroenterol. 2008 Feb;43(2):161-5. No induction of anti-avenin IgA by oats in adult, diet-treated coeliac disease. Guttormsen V, Løvik A, Bye A, Bratlie J, Mørkrid L, Lundin KE. PMID 18224563

"Results. No significant differences were found in IgA against oats in oats-eating and non-oats-eating coeliac disease patients. Both groups had increased levels of IgA against wheat, oats and tissue transglutaminase compared to healthy controls. A significant positive correlation was found between anti-avenin and antigliadin IgA (p<0.0001), and between anti-avenin and anti-tissue transglutaminase IgA (p=0.0012). Conclusions. Ingestion of oats does not cause increased levels of IgA against oats in adult coeliac disease patients on a gluten-free diet. The findings support the notion that most adult coeliac disease patients can tolerate oats."

The caveat of this argument is that if one cheats on wheat one can become intolerant of oats. Probably another good reason why oats should not be eaten during the first year.Pdeitiker (talk) 14:31, 19 February 2008 (UTC)

With regards to the safety of oats, I think we should wait for a consensus statement from an authoritative body, because this is so immensely controversial, with numerous studies contradicting each other, but if you are extremely sensitive I recommend not consuming it as it can have the same effects as other wheat containing foods one of the effects are diarrhea.

JFW | T@lk 09:39, 24 February 2008 (UTC)

Better source

I've got some misgivings about relying on the following source (#18):

"Grain toxicity" (RTF). The CELIAC list. Retrieved 2006-08-27.

This is essentially from a discussion group and hence has all the problems of an unmoderated non-peer reviewed web source. Any ideas about a good replacement citation? JFW | T@lk 08:16, 7 May 2008 (UTC)

The RTF is old and is basically on the use of the word "Safe" and "Oats". The five year finnish study is complete, oats were found to be safe on >90% of celiac children. There are a number of papers now published . . . .

Can J Gastroenterol. 2007 Oct;21(10):649-51. Consumption of pure oats by individuals with celiac disease: a position statement by the Canadian Celiac Association. Rashid M, Butzner D, Burrows V, Zarkadas M, Case S, Molloy M, Warren R, Pulido O, Switzer C. The treatment of celiac disease is a strict adherence to a gluten-free diet for life. In the past, oats were considered to be toxic to individuals with celiac disease and were not allowed in a gluten-free diet. However, recent evidence suggests that oats that are pure and uncontaminated with other gluten-containing grains, if taken in limited quantities, are safe for most individuals with celiac disease. For adults, up to 70 g (1/2 to 3/4 cup) of oats per day and for children, up to 25 g (1/4 cup) per day are safe to consume. These oats and oat products must fulfill the standards for a gluten-free diet set by the Canadian Food Inspection Agency and Health Canada. The Canadian Celiac Association, in consultation with Health Canada, Agriculture & Agri-Food Canada and the Canadian Food Inspection Agency, has established requirements for growing, processing, and purity testing and labelling of pure oats. These strategies have led to the production of pure, uncontaminated oats for the first time in Canada. Oats and oat products that are safe for consumption by individuals with celiac disease and dermatitis herpetiformis are now commercially available in Canada.

Scand J Gastroenterol. 2007 Nov;42(11):1302-5. Avenins from different cultivars of oats elicit response by coeliac peripheral lymphocytes. Silano M, Di Benedetto R, Maialetti F, De Vincenzi A, Calcaterra R, Cornell HJ, De Vincenzi M. RESULTS: All the varieties of oats tested were immunogenic, with Lampton and Ava avenins inducing lymphocyte activation similar to that activated by wheat gliadin, while Astra and Nave avenins showed less immunogenicity, but still with a measurable effect. CONCLUSIONS: There are still concerns about the suitability of including oats in a gluten-free diet. Coeliac patients consuming oats-containing food should be carefully monitored, until there is more evidence to show the safety of oats and varieties of low-toxicity oats. Another study showed Lampton oats had low reactivity. In each study there was the possibility that strains had introgression of Triticeae species into the feilds where the oats were grown.

Aliment Pharmacol Ther. 2006 May 15;23(10):1463-72.

Scand J Gastroenterol. 2006 Jan;41(1):42-7.

Gut. 2004 May;53(5):649-54.

And more. The bottom line here is that oats can turn on the immune response, but do not appear to cause celiac disease in most cases. Oat avenins are most similar to omega-gliadin. It has been postulated that omega-gliadin could mediate celiac disease, but its pathology is more frequently associated with allergic disease, for example, exercise induced anaphylaxis. There is a risk that co-consumption of oats with wheat contamination or with Aspirin or NSAIDS has a better chance of creating such allergies to oats. In the case of Oat strains, I am still waiting to see if there is some definitively pure strain of oats that can produce a clear response or no evidence of response. No response in a few patients is a good sign, but it should be capable of showing no response in 50 individuals of diverse origin.

Oats are not safe. Gluten free oats are safe for most celiacs and provided they follow the guidelines of abstinence of 1 year after going on a GF diet and get follow-up examinations. Pdeitiker (talk) 13:49, 20 May 2008 (UTC)

Could you replace the reference, Phil? JFW | T@lk 06:09, 23 May 2008 (UTC)

I will try to find the most up to date reference on this. Pdeitiker (talk) 21:52, 23 May 2008 (UTC)

I have added one sentence and two references, reviewing the literature to construct the third, I have replaced the RTF file ref with two reference that detail the comparative immunology of wheat, rye and barley and provide some contrast with oats. We might desire to remove some references to reduce the bandwidth. Pdeitiker (talk) 01:21, 5 June 2008 (UTC)

The references you selected were in vitro studies. Comparative immunology is interesting, but it doesn't answer whether these grains are safe to consume for coeliac patients.

I see absolutely no grounds for removing references at the moment. 82 references is perfectly reasonable for a featured article. Which references are you concerned about? JFW | T@lk 08:29, 6 June 2008 (UTC)

There is a relative hiatus between the paper I mentioned on your talk page and the immunochemistry paper that examines rye and barley compared to wheat. While it is not specifically what you wanted, its not simple either, it does discriminate the concern about oats versus rye and barley. While rye and barley have clearly higher responses, and in some cases identity with pathogenic T-cell epitopes in wheat, oats only show similarity and its epitopes are generally weaker in response. I don't see any papers that have qualitatively purified rye or barley to a level of <10 PPM contamination with wheat that have either been used in clinical so that there is a potential for the issue of contamination as with oats. There is a paper recently published, I have not read but will get to it today, that outlines what I have heard privately that some oat stocks are highly contaminated, this could also apply to stocks of rye and barley previously used in 1978.

To be quite honest, I have my doubts as to whether rye and barley are capable of triggering disease, either acting alone or with environmental agents other than wheat. One of the epitopes of wheat, the innate peptide, is not found in these grains, and neither is the 33mer. While it is possible they have their own innate peptide or own version of the extended T-cell site, I think that these grains can only maintain disease after initiated by wheat. It is doubtful that under any circumstance oats can trigger disease. These comparative immunology _do_ reflect these concerns showing that the number of epitopes in wheat, the presence of innate activation sites, and the intensity of the response do correlate with the ability to initiate disease.

If you can find a publication where they used highly purified rye or barley to challenge celiacs, then that is the article to use. The 1975 paper is as close as I could find. Pdeitiker (talk) 12:55, 6 June 2008 (UTC)

The 2 reverted. One reference is for the safe use of oats by children and the other is for the safe use of oats by adults. The page references for the non-use of oats as per complications, but it does not provide references which suggests the use can be safe. I think that a NPOV requires the addition of the sentence removed.Pdeitiker (talk) 12:55, 6 June 2008 (UTC)

Phil, you are continuously skirting the borders of WP:NOR. We cannot on Wikipedia make statements that have not already appeared elsewhere. If a particular concept (e.g. the inability of barley or rye to "trigger") is not mentioned in recent high-quality secondary reviews, it might as well for all intents and purposes not exist.

If you have a reference from a professional guideline that contradicts the Kupper 2005 paper stating that oats are now widely regarded as safe we can quote it. Otherwise, we should let the matter lie. JFW | T@lk 13:03, 6 June 2008 (UTC)

What I am trying to demonstrate to you is that uncertainty about the comparability of rye and barley to wheat exists. When I say trigger, from the sense of autoimmune disease, is the condition that gives rise to the initial growth of T-cells that ultimately results in disease. Not the regrowth seen as a result of restimulation (challenge). That it is unclear whether rye or barley can trigger and their evolutionary relationship, and immunochemisty draw into question what the upper limit of tolerance is for these grains. This is a very germane question regarding the 1970s paper given the fact that there could have been contamination. I am not arguing against the position of barley and rye as maintainers or restimulators of disease, but I am pointing out that the science may not have been careful enough to be decisive. OTOH we have an immunochemistry paper which uses synthetic peptides devoid of wheat contamination that do show the affects of the rye and barley peptides. Pdeitiker (talk) 14:21, 6 June 2008 (UTC)

The point you made on your talk page about wheat varieties is relevant, given the current 'political' situation with oats it is best discussed with a dietitian. We can only provide a NPOV, and that NPOV comes from studies showing association in some, but no restimulation of disease in most. I should point out that the past opinion on oats by some organizations was in error, and that future opinions may also be in error. That error is greatly increased if there is no good literature as a basis of those opinions. Therefore, IMO, in some instances it is better to present the literature that one has instead of opinions and caveot emptor. Let us not apply a double standard here, if an opinion is based on weak scientific literature it is no better or worse than an opinion gathered from that same literature that concludes differently, you will note I do not add my opinions to the main page, but this talk page we should discuss the weak medical opinions provided as references on the main page.Pdeitiker (talk) 14:21, 6 June 2008 (UTC)

I have no access to the dietary guideline at the moment, but if that guideline concedes that the evidence is contradictory, then we can mirror that in the article. JFW | T@lk 15:57, 6 June 2008 (UTC)

I think the guideline concedes the neccesary problems with Oats, and distinqusihes wheat and barley without begging for evidence. The guideline reflects the general state of the literature. It is not dead-on-the-mark but the errors balance the uncertainty in the literature. If I were to make a critique about the abstract, the fact that GF oats can maintain disease in a minority of patients means that it is difficult to distinguish GF refractory disease from oat intolerance if oats are consumed, they concede the problem with contamination, but there are reasons other than contamination to abstain from oats until ATA levels return to baseline.

The removal of the GFO is also warranted since Bob's Red Mill also sells tested gluten free oats, now which are selling in markets. Pdeitiker (talk) 04:11, 7 June 2008 (UTC)

I didn't want you to critique the abstract. I was hoping you were able to reflect the content of the document. JFW | T@lk 11:16, 8 June 2008 (UTC)

Other Grains

A critique: "Wheat varieties or subspecies containing gluten such as barley and rye also induce symptoms of coeliac disease.[18]" This sentence gives the impression that barley and rye are subspecies of wheat. Rye is a member of the species, S. cereale, in the genus Secale, and barley H. vulgare is a member of the genus Hordeum. see Triticeae. Rye and Barley are 'related species'

Alternatives:

"Wheat varieties or subspecies containing gluten and related species such as barley and rye also induce symptoms of coeliac disease.[18]"

"Other than bread wheat, all wheat subspecies, barley and rye can induce symptoms of coeliac disease.[18]"

"Other than [wheat(ref)] gluten, the glutinous proteins in all wheat subspecies, barley and rye can induce symptoms of coeliac disease.[18]"

(ref)since glutens are the glue-like proteins in wheat that instill the ability to kneed and rise dough, wheat gluten is redundant. Having hashed out the debate in the Gluten page, it appears that other seeds that cannot trap gases that allow bread to rise are simply glutinous, or prolamins and glutelins. From those seeds from Triticeae that have been studied all have the ability, in-vitro, to sustain disease.Pdeitiker (talk) 04:11, 7 June 2008 (UTC)

{{Sofixit}} JFW | T@lk 11:16, 8 June 2008 (UTC)

Summary of Oats Issue

Starting from the 2005 guideline

The use of oats may be acceptable, provided

• More studies with more participants are done.
• The source of contaminants is studied and resolved.

Findings since 2005

1. Studies have looked at situation in adults and children and found oats can be used because:

• the majority of celiacs are completely tolerant of uncontaminated oats

but:

• The actual frequency and nature of oat intolerance in CD has not been resolved.
• Oats strains may induce T-cell responses, and other studies contradict these findings (contamination or differences in oat intolerances?), GF-Oats (widely available) have not been tested for celiac or "oat-intolerant" celiacs.

confusing the issue:

• Triticeae contamination(TC) in most 'oat intolerance' studies still an issue.
• Increases in IEL freqeuncy in oat-eating celiacs, but no increased atrophy. TC?.
• In a study that identifies the pathogenic "33mer" the 'triticeae' cultivars are separated (increase sensitivity) from avenins by 2 orders of magnitude. Synthetic peptides of oat homologs to "33mer" failed to show significant binding to mAbs. TC?
• Gluten is what? - Strictly - glaidins and glutenins. From barley and rye, comparisons are rough to wheat and contraditions in quantitation exists (see contamination paper), they seek to define an immunochemical gluten. Are glutinous proteins in oats to be considered gluten? What is the comparison based on, pathogenic epitopes between these species. Not done. Gluten is the glutinous proteins in wheat, but to 95% of coeliacs they are the glutinous proteins within the edible culitvars in Triticeae. What is gluten to an oat intolerant person? Too many different definitions of gluten creates trouble. Trouble is that gluten is a baking definition not a medical definition.

2. TC remains the key problem within the US, Canada and Europe.

• Testing had generally been for wheat only. Studies recommend R5-ELISA (barley sensitive) tests for barley, rye and wheat. Additional, preferred, test resolve the species that contaminate.
• Greater government oversight needed in cereal industries, standards of purity are low.
• Additional testing needs to reflect regional TC threats.
• In US, assuming equal contamination of wheat and barley in oats - seed:seed total TC range from 0 to 11%, estimated, >50% had "unacceptable" contamination by the old Codex standard. Study flaw - No label information provided. Codex standard-current: >200 PPM gluten is "unacceptabl"e.
• One forth oat sources were negative for TC by one assay. No brands or lots given for these sources.
• GF Oats
  • Too many standards - Some dated, many based on obsolete information, and contradictions in standards. The current Codex standard excludes oats and has a maximum of 200 ppm gluten contamination. The proposed Codex standard (proposed) tolerates oats if gluten content of 20 ppm in natural products (includes oats).
  • Testing - Paraphrasing the University of Nebraska FARRP testing discloses.

r-biopharm Inc. Kits "is a sandwich enzyme immunoassay for the quantitative analysis of gliadins from wheat and corresponding prolamines from rye and barley in food". Ridascreen Fast Gliadin (R7002), detection limit is 10 ppm and "Note: In addition to wheat gluten, the Fast Gliadin kit is 100% cross-reactive to rye and barley." This test may give results off by a factor of 2 if species information is not provided. Ridascreen Fast Gliadin (R7002) According to the product literature one can detect down to 2 ppm but quantiation below 10 ppm is questionable. They do use the R5 sandwich assay mentioned in the previous paper. Products that test below 10 PPM can be considered "safe" since Codex recommends contamination less that 20 PPM.

Currently BRM (shelf) and GFO (internet) brands of GF-oats use the R5-ELISA assay, by the proposed Codex standards these products are to be considered gluten-free (based on my internet search). Pdeitiker (talk) 16:38, 11 June 2008 (UTC)

I think my points are bolstered with regards to the importance of guidelines. You have basically shown that many coeliacs will tolerate oats but you can't predict which ones, and how safe the oats are with respect to wheat flour contamination. I really do not think this page should suggest that the guidelines are to be violated.

For the clinician and obviously the patient, these uncertainties are major issues. In the consulting room, a physician cannot - on the basis of the information you provided above - recommend to his patient what to do.

Now, Phil, what changes need to be made in the article? JFW | T@lk 20:34, 11 June 2008 (UTC)

Not at the point of diagnosis, certainly. There is a bit of an ethical issue in terms of physician recommendations. If the physician recommends the patient try oats, again after the 1 year abstinence period, that physician will also have to insist that the patient agree to followup procedures (serology, biopsy) which may incur additional cost for the patient. From the patient side, they should be aware of what refractory disease and the consequences. If the section is to be changed it should be done judiciously, however I think the position of the 2 canadian (NGO and agricultural agency) organization could be added to the page. There is an inevitability where this science is going, oats will need to be handled, at some point, in its own sub-section.

The flip-side of the ethical issue, is the nutrition and fiber brought by oats. Again, using my own personal anecdote, my form of disease requires a large amount of daily fiber. This makes it difficult to pack a lunch, and in my case a dry lunch, oats give me the ability to make dry baked goods comparable to wheat, with 12% fiber, and as the principle binding agent for other materials (such as sunflower seed butter). One can argue that there is an ethical issue if the physician does not provide an alternative that improves the quality of life (This is generally in the first paragraph in most oat studies). Whole oats provide slow carbs (studies indicated celiacs eat too much fast carbs), fiber (studies indicate that celiacs often don't get enough fiber), iron (arthritic celiacs may not be getting enough iron), and vitamins. People have to work and otherwise have an active life, in your medical school or office, what is the availability of GF foods. Here, the contracted provider has said that their food is not gluten free, at most you can eat a green salad and boiled eggs. People who have CD and work need to have options.

Fiber foods.

- Oats-Rolled 12% - Can be served as a hot cereal or baked into cookies, or made into flour.

- Buckwheat 12%, a frequent allergen, almost as bad as wheat in Asia.

- Brown rice 8 - 12%, must be cooked until soft to be edible.

- Polenta 8% (Corn grits) - Generally limited to a breakfast dish.

- Whole stone ground tortillas, 8% - Diminishing market, can be used for lunch.

- Hominy w/germ - 8% For soups, etc.

- Quinoa 8% - flour-bitter contains soponins, seeds washed, generally for soups. Pdeitiker (talk) 19:49, 12 June 2008 (UTC)

I wanted to know your ideas for the article, not your personal experiences. Will you please focus on the issues? JFW | T@lk 21:47, 12 June 2008 (UTC)

I think the conversation has devolved into rhetoric. I have created a section in gluten sensitivity on "the oat controversy"Pdeitiker (talk) 03:44, 13 June 2008 (UTC). It does not make a recommendation but it addressed the issues from all sides. Should you desire you can link to it within the article.

Fine. We are already linking to the GS article, so I don't think any further link is necessary. JFW | T@lk 14:40, 13 June 2008 (UTC)

Also there is a section on the controversy under Gluten-Free diet, although it is not current. FYI - Cynthia Kupper (of Kupper. Gastroenterology 2005: 128, S121-S127.) does the certifications for gluten-free oats. [1]. I don't mean to be rhetorical, but in science one sees trends of inevitability, and the evolving situation with the oat controversy is such. Pdeitiker (talk) 16:58, 13 June 2008 (UTC)

You're not making much sense re inevitability. Also, certification is a local issue not well suited for discussion in articles intended to have a global scope. JFW | T@lk 09:14, 15 June 2008 (UTC)

Reviews of Oat sensitivity in CD

PMID 17068278 and PMID 17327936 review oats in a gluten-free diet. Tim Vickers (talk) 20:50, 16 June 2008 (UTC)

I looked at the first review, I would pass on that one. The second review, I have a problem with bias in that one, they claim 1 in 165, but another study, which drew from those studies 'drop-outs' found 3 patients with avenin-sensitive enteropathy, and 1 patient with oat-allergy induced anaphylaxis avenin-sensitive enteropathy. I am fearful of giving the wrong impression that is a 3 fold increase in the rate of sensitivity, that does not include drop-outs who did not appear in the ASE study, either. It has been disclosed in some critiques that the exact nature of study drop-outs is not fully disclosed. If this were a science paper the rate would be 0.6% < ASE in GSE < ~5.0% and that as a backdrop what is a good compromise? Give me some time to read the second carefully, with WP:SYNTH how does one reconcile the difference. (Thanks for the pointer to the second reference) Pdeitiker (talk) 13:25, 18 June 2008 (UTC)

I have read this review. First. I agree the early studies, in which the Codex alimentarius 1983 was based, are deeply flawed and should not be considered (Purity issues, uncontrolled, indirect methods). The author mentions 1 patient in the 165 the but discounts the other 2 other patients in PMID 15526039. I have examined 15526039 and reviewed the evidence they present, a solid case for T-cell reactivity to an immunodominant region of oat-avenin which cannot be discounted in 3, but were excluded because the 3 were 'walkins'. Another from the 165 in 'review' study grouping one would classify as Marsh 1 grade avenin-sensitive after 12 weeks and had T-cell reactivity to the immunodominant region of avenin and may have progressed to ASE if the study were allowed to continue.

Several people had symptoms to oats in the studies, in total 8 in 35 (symptoms include diarrhoea from fiber and non-dextrose sugars in oat bran, avenin allergies, and avenin-sensitive enteropathy). Each study differed on how symptoms were qualified. If this review is to be presented, for example as: "only 0.6% of celiacs in controlled studies developed CD in response to avenin, however many had symptoms to oats and low-level disease cannot be excluded in some"(reference 17327936, 15526039, PMID 12548312, and PMID 15082581). I have a number of lingering concerns that are inappropriate here.Pdeitiker (talk) 16:53, 18 June 2008 (UTC)