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Can J Gastroenterol Vol 21 No 10 October 2007 649
Consumption of pure oats by individuals with celiac
disease: A position statement by the Canadian Celiac
Association
Mohsin Rashid FRCPC1,2, Decker Butzner FRCPC1,3, Vernon Burrows PhD1,4, Marion Zarkadas MSc1,
Shelley Case BSc1,5, Mavis Molloy BSc1,6, Ralph Warren FRCPC1,7, Olga Pulido MD8, Connie Switzer FRCPC1,9
1Professional Advisory Board, Canadian Celiac Association; 2Division of Gastroenterology and Nutrition, Department of Pediatrics, Dalhousie
University, Halifax, Nova Scotia; 3Division of Gastroenterology, Department of Pediatrics, University of Calgary, Calgary, Alberta;
4Department of Agriculture and Agri-Food, Ottawa, Ontario; 5Consulting Dietitian, Regina, Saskatchewan; 6Kelowna General Hospital,
Kelowna, British Columbia; 7Division of Gastroenterology, Department of Medicine, St Michael’s Hospital, University of Toronto, Toronto;
8Bureau of Chemical Safety, Food Directorate, Health Products and Food Branch, Health Canada, Ottawa, Ontario; 9Division of
Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta
Correspondence: Dr Mohsin Rashid, Division of Gastroenterology, Department of Pediatrics, Dalhousie University, IWK Health Centre,
5850 University Avenue, Halifax, Nova Scotia B3K 6R8. Telephone 902-470-8746, fax 902-470-7249,
e-mail mohsin.rashid@iwk.nshealth.ca
Received for publication December 11, 2006. Accepted January 18, 2007
M Rashid, D Butzner, V Burrows, et al. Consumption of pure
oats by individuals with celiac disease: A position statement by
the Canadian Celiac Association. Can J Gastroenterol
2007;21(10):649-651.
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 individu-
als with celiac disease and were not allowed in a gluten-free diet.
However, recent evidence suggests that oats that are pure and uncon-
taminated 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.
Key Words: Celiac disease; Gluten-free diet; Oats; Position
statement
La consommation d’avoine pure par des
personnes atteintes de la maladie cœliaque :
Un document de principes de l’Association
canadienne de la maladie cœliaque
Le traitement de la maladie cœliaque consiste à respecter rigoureusement
un régime sans gluten pendant toute la vie. Par le passé, l’avoine était
considérée comme toxique pour les personnes atteintes de la maladie
cœliaque et n’était pas autorisée dans un régime sans gluten. Cependant,
d’après des données récentes, l’avoine pure non contaminée par d’autres
céréales contenant du gluten, consommée en petite quantité, est sécuri-
taire pour la plupart des personnes atteintes de la maladie cœliaque. Chez
les adultes, il est sécuritaire de consommer jusqu’à 70 g (1/2 à 3/4 de tasse)
d’avoine par jour, tandis que chez les enfants, cette quantité peut attein-
dre 25 g (1/4 de tasse) par jour. L’avoine et les produits de l’avoine doivent
respecter les normes d’un régime sans gluten établies par l’Agence cana-
dienne d’inspection des aliments et Santé Canada. L’Association canadi-
enne de la maladie cœliaque, en consultation avec Santé Canada, le
ministère de l’Agriculture et de l’Agroalimentaire du Canada et l’Agence
canadienne d’inspection des aliments, a établi des exigences pour cultiv-
er, traiter et étiqueter l’avoine pure ainsi que pour en évaluer la pureté.
Pour la première fois au Canada, ces stratégies ont permis la production
d’avoine pure et non contaminée. L’avoine et les produits de l’avoine qui
peuvent être consommés en toute sécurité par les personnes atteintes de
la maladie cœliaque et la dermatite herpétiforme sont désormais en vente
au Canada.
Celiac disease (gluten-sensitive enteropathy) is a perma-
nent intolerance to specific storage proteins in wheat
(gliadin), barley (hordein) and rye (secalin), which are collec-
tively called ‘gluten’ (1). Ingestion of gluten causes damage to
the small intestinal mucosa by an autoimmune mechanism in
genetically susceptible individuals. This can lead to a variety of
symptoms and nutritional deficiencies. The treatment of celiac
disease is a strict, life-long adherence to a gluten-free diet.
Ensuring that the foods and beverages are free of gluten
remains a challenge for patients on such a diet. In a recent sur-
vey of a large number of Canadian individuals with celiac dis-
ease, 85% of respondents reported difficulty in finding gluten-free
foods, especially gluten-free foods of good quality (2,3).
Oats are a good source of vitamins and minerals, and con-
tain approximately twice the protein content of rice. The
starch in oats (composed of amylose and amylopectin) is easily
digested. Oat oil (6% to 8% by weight) is largely polyunsatu-
rated. Oats are rich in soluble dietary fibre, which may help
reduce low-density lipoprotein cholesterol in hypercholes-
terolemic individuals. Oat groats also contain unique antioxi-
dants (avenanthramides). The bran in oats can have a
beneficial laxation effect. In the past, oats (avenin) were
believed to be toxic to individuals with celiac disease and were
not allowed in the gluten-free diet. However, recent evidence
has shown that oats are safe for consumption by most individ-
uals with celiac disease. Availability of oats will not only
REVIEW
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improve the nutritional value of a gluten-free diet but will also
increase palatability, expand food choices and may improve
the quality of life for those with celiac disease (4,5).
Commercially available oats in North America are variably
contaminated with gluten-containing grains (6,7). Contamination
can occur on the farm, during the growing cycle or during stor-
age, cleaning, transportation or processing (8). There was a
need to develop strategies that would provide oats that are
pure and uncontaminated, making them safe for consumption
by individuals with celiac disease and dermatitis herpetiformis.
The Professional Advisory Board of the Canadian Celiac
Association, in collaboration with Health Canada, reviewed
the literature on the safety of oats in celiac disease (9-27) and
developed the following position statement on oats (28):
“The safety of oats in individuals with celiac disease
has been extensively investigated. Clinical evidence
confirms that consumption of pure, uncontaminated
oats is safe in the amount of 50 to 70 grams per day (1/2-
3/4 cup dry rolled oats) by adults and 20 to 25 grams per
day (1/4 cup dry rolled oats) by children with celiac dis-
ease. Studies looking at the consumption of oats over
five years have confirmed their safety. However, the
studies looking at safety of oats in celiac disease have
involved a small number of subjects, the oats used were
pure, free of gluten contamination and the amount
allowed per day was also limited.
In Canada, pure and uncontaminated* oats are now
being produced. Individuals with celiac disease who
wish to add oats or oat products to their diet must ensure
that the oats they are eating are free from gluten con-
tamination.
A small number of individuals with celiac disease
may not tolerate even pure, uncontaminated oats. To
ensure that persons with celiac disease are not intolerant
to pure and uncontaminated oats, proper clinical follow
up with the physician is advised when introducing oats
to a gluten-free diet.
The Canadian Celiac Association will continue to
monitor the scientific developments in the area of oats
in celiac disease and will keep its members updated.
*These oats will meet or exceed the purity standards of
Foundation #1 as defined by the Canada Seeds Act” (29).
The following guidelines are recommended when starting
oats in the diet of a patient with celiac disease:
1. The patient’s celiac disease should be well controlled on
a gluten-free diet and the patient should have no
gastrointestinal complaints.
2. It is recommended that adults receive no more than
50 g to 70 g (1/2 to 3/4 cup) of dry rolled oats daily and
children receive no more than 20 g to 25 g (1/4 cup) of
pure, uncontaminated oats daily.
3. The fibre content of an oat-containing diet is often
higher than the typical gluten-free diet. When adding
oats to the diet, individuals may experience a change in
stool pattern or mild gastrointestinal symptoms,
including abdominal bloating and flatulence. These
symptoms should resolve within a few days.
4. There are case reports of individuals with celiac disease
relapsing with the consumption of pure
uncontaminated oats. Patients should be warned of this
possibility. They should discontinue the oats and
contact their physician if symptoms persist.
5. The physician or a dietitian should review the diet to
ensure that the patient is not consuming foods that
contain gluten.
6. Screening with an immunoglobulin A-tissue
transglutaminase or immunoglubulin A-endomysial
antibody may not identify the rare patient who reacts to
oats. These tests are not sufficiently sensitive for detecting
‘mild’ dietary indiscretions, especially over a short period
of challenge; ie, less than 100 mg to 1000 mg of gluten
per day. A positive endomysial antibody or tissue
transglutaminase will help confirm oats sensitivity but a
negative one will not exclude oats sensitivity.
7. It is worthwhile to rechallenge patients if they wish to
try oats again. Development of symptoms at the time of
the second challenge would strongly suggest intolerance
to oats. Extensive patient research suggests intolerance
to oats occurs but is rare. The mechanism for this is
unknown.
In consultation with Health Canada, Agriculture & Agri-
Food Canada and the Canadian Food Inspection Agency
(CFIA), requirements for growing, processing, and purity test-
ing and labelling have been established. The Canadian Celiac
Association has adopted the grade of Foundation #1 (grown by
Select Seed Growers) as the standard for seed to be used for
patients with celiac disease, because this grade only permits
0 to 1 wheat, barley, rye or triticale seed/kg of oat groats
(approximately 30,000 to 40,000 oat groats/kg) to be present.
The actual number of groats/kg depends on the kernel weight
of the seeds, which is a reflection of both genetic and environ-
mental factors. Pedigreed Foundation seed is a very good meas-
ure of oat purity because CFIA inspectors carefully examine
thousands of plants in the field (large sample size) and official
seed testing laboratories monitor the purity of the harvested
grain before deciding if it meets Foundation #1 classification.
Seeds produced in this dedicated system can be delivered to a
dedicated Hazard Analysis Critical Control Points certified oat
processing facility and made into product. The rolled oats or
the oat flour made into products from these oats are then eval-
uated for gluten content using an R5-ELISA test (30,31). This
test will detect gluten contamination with as little as 3 ppm.
One wheat seed per kilogram of oats will contribute approxi-
mately 1 ppm to 2 ppm of gluten/kg in a thoroughly mixed
(essential) oat flour. This degree of contamination will not be
detected even with the R5-ELISA test and is well below the
20 ppm maximum allowed in gluten-free foods by the CFIA
and Health Canada.
To produce pure, uncontaminated oats, the manufacturer
must have a dedicated system, including fields, harvesting, pro-
duction, storage, transportation, manufacturing equipment and
a production plant. Growers and processors able to meet these
requirements were contacted. The CFIA and Health Canada
were consulted to establish their support and labelling require-
ments. The oat food manufacturers will ensure that the pure
oats they use and sell are grown and processed in the prescribed
dedicated manner and the oats and products pass ‘track and
trace procedures’. The pure oats that are sold as rolled oats, oat
groats or whole oat flour, or the products that are made from
these oats must have passed a CFIA field inspection (visual and
Rashid et al
Can J Gastroenterol Vol 21 No 10 October 2007650
10089_Rashid.qxd 28/09/2007 3:17 PM Page 650
chemical), a registered seed analysis to qualify for the
Foundation #1 rating and an R5-ELISA test in a Hazard
Analysis Critical Control Points certified food processing facil-
ity. The Canadian Celiac Association is working on the
development of a special trademark that would identify these
pure and uncontaminated oats, thereby making it easier for
the consumer to identify products that meet the strict guide-
lines.
In Canada, pure and uncontaminated oats are now com-
mercially available. Since 2005, one company, based in the
province of Quebec, has produced and marketed oats that
meet the required purity standards. These oats are now avail-
able to consumers as rolled oats, oat flour and whole oat ker-
nels (groats). It is expected that other Canadian companies
will also start producing pure oats in the coming year.
In conclusion, oats that are pure and uncontaminated by
gluten-containing grains are safe for consumption by most
individuals with celiac disease, when taken in limited quanti-
ties. The availability of oats would improve food choices for
those on a gluten-free diet.
Safety of oats in celiac disease
Can J Gastroenterol Vol 21 No 10 October 2007 651
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