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Absence of oats toxicity in adult coeliac disease

^a Department of Immunology, St James's Hospital, Dublin 8, Republic of Ireland, ^b Department of Histopathology, St James's Hospital, Dublin, ^c US Department of Agriculture, Albany CA 94710, USA, ^d Department of Gastroenterology, St James's Hospital and Trinity College, Dublin, ^e Education and Research Centre, St Vincent's Hospital, Elm Park, Dublin

Correspondence to: Professor Feighery.

Coeliac disease is a gluten-sensitive disorder characterised by malabsorption and a typical histological lesion. Treatment with a strict gluten-free diet results in complete clinical and histological recovery. The conventional gluten-free diet used to treat coeliac disease proscribes oats cereal as well as wheat, barley, and rye.¹ However, the issue of oats toxicity has not been conclusively resolved, and the prohibition of this important cereal deprives patients of a valuable source of fibre and nutrients. The aim of this study was to examine the clinical, histological, and immunological responses of adult patients with coeliac disease to challenge with oats.

Patients, methods, and results

Ten adult patients with coeliac disease in clinical and histological remission were recruited from the coeliac outpatient clinic in St James's Hospital, Dublin. Each patient consumed 50 g of oats (as porridge) daily for 12 weeks while maintaining a strict gluten-free diet. Patient compliance was recorded daily using diaries, and all patients complied fully with the study protocol. The oats cereal (Peter Kolln, Germany) used in the study was tested for evidence of gluten contamination using reverse phase high performance liquid chromatography, enzyme linked immunoassay, and polymerase chain reaction techniques and was shown to be entirely gluten free.

The patients were assessed clinically at 0, 1, 4, and 12 weeks. Laboratory investigations were performed at each of these visits and included full haematological and biochemical profiles and serological tests for antibodies to gliadin and endomysium. Duodenal biopsies were obtained endoscopically before the start of oats challenge and after 12 weeks. The biopsy specimens underwent standard evaluation for evidence of morphological damage. Furthermore, two independent observers performed intraepithelial lymphocyte counts, and enterocyte height (in µm) was measured by computerised image analysis.

Throughout the oats challenge all patients remained asymptomatic with normal haematological and biochemical indices. Endomysial and gliadin antibody values were unaltered by the oats supplement. No morphological damage was evident on standard histological evaluation. Quantitative histological examination showed no significant change in intraepithelial lymphocyte count or enterocyte height (table 1). Two patients were subsequently given a gluten "micro-challenge" consisting of 500 mg of gluten daily for six weeks: both developed histological evidence of relapse, and in one patient the antibody tests became positive.

Table 1--Serological and quantitative histological analysis of 10 patients with coeliac disease before and after oats
challenge for 12 weeks
----------------------------------------------------------------------------------------------------------------------
                                                                             Intraepithelial
                  Gliadin           Endomysial                             lymphocyte count      Enterocyte height
              antibody titre*      antibody titre         Histology              (%)                   (µm)
----------------------------------------------------------------------------------------------------------------------
             Before    After      Before    After      Before    After      Before    After      Before    After
Patient    challenge challenge  challenge challenge  challenge challenge  challenge challenge  challenge challenge
----------------------------------------------------------------------------------------------------------------------
1            <1.0      <1.0      Negative  Negative   Normal    Normal        16        14       36.3      35.3
2            <1.0      <1.0      Negative  Negative   Normal    Normal        26        15       36.0      38.3
3            <1.0      <1.0      Negative  Negative   Normal    Normal        19        13       40.8      37.9
4            <1.0      <1.0      Negative  Negative   Normal    Normal         6        13       44.9      37.6
5            <1.0      <1.0      Negative  Negative   Normal    Normal        22        32       32.8      28.8
6            <1.0      <1.0      Negative  Negative   Normal    Normal        17        18       28.8      27.1
7             7.0       8.0      Negative  Negative   Normal    Normal        36        20       38.4      42.6
8            <1.0      <1.0      Negative  Negative   Normal    Normal        15        13       31.1      34.7
9            <1.0      <1.0      Negative  Negative   Normal    Normal        23        13       29.8      30.6
10           <1.0      <1.0      Negative  Negative   Normal    Normal        13        13       30.2      36.8
Mean (SE)                                                                  19 (2.5)  16 (1.9)  35 (1.7)  35 (1.5)
----------------------------------------------------------------------------------------------------------------------
*Reference range for adult gliadin antibody titres is 0-3.0.

Comment

This study shows the safety of adding oats to the gluten-free diet of 10 patients with coeliac disease. Seven of the patients have continued to take the same quantity of oats for more than 12 months without adverse effect. These findings are in agreement with a recently published study.² In that study, however, the authors stated that they excluded coeliac patients with "severe" disease. No such policy was adopted in our study, and two of our patients were subsequently shown to be exquisitely sensitive when given a gluten micro-challenge. A third patient was also shown to be very sensitive to trace quantities of gluten taken inadvertently.

Activation of the immune system by cereal protein is likely to be centrally involved in the pathogenesis of coeliac disease,³ and evidence of immunological stimulation is a sensitive marker of disease activation. Such evidence includes lymphocyte infiltration of the surface epithelium⁴ and the production of antibodies to endomysium and gliadin. Oats challenge caused no change in these parameters whereas in the patients given a gluten microchallenge, abnormalities were observed.

Our results suggest that oats cereal is neither toxic nor immunogenic in coeliac disease. This has important implications for the coeliac population since the inclusion of oats would substantially improve the fibre and nutrient content of their gluten-free diet.⁵ The knowledge that oats are not toxic may help to define the toxic moiety in other cereals.

Funding: None. Conflict of interest: None.

1. Meeuwisse GW. Diagnostic criteria in coeliac disease. Acta Paediatr Scand 1970;59:461-3.
2. Janatuinen EK, Pikkarainen PH, Kemppainen TA, Kosma VM, Jarvinen RMK, Uusitupa MIJ, et al. A comparison of diets with and without oats in adults with celiac disease. N Engl J Med 1995;333:1033-7. [Abstract/Free Full Text]
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4. Leigh RJ, Marsh MN, Crowe PJ, Garner V, Gordon D. Studies of intestinal lymphoid tissue IX. Dose dependent gluten-induced lymphoid infiltration of coeliac jejunal epithelium. Scand J Gastroenterol 1985;20:715-9. [Medline]
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