Histamine Intolerance and Mast Cell Activity Syndrome symptomatically resemble an allergy, but are not a real allergy, as no antibodies are involved. Histaminosis is the term used for any condition where the histamine level is far from the ideal range in the body, local or systemic. Causing the state of health and bodily or mental functions to be affected. High doses of histamine are toxic for all humans, but individual tolerance determines reactivity to small quantities. It is likely that differences in levels of tolerance are of genetic origin, but tolerance can be reduced by disease, especially allergy and autoimmune diseases, gastro-intestinal issues, stress and some medications.
Causes of Histaminosis
The cause of histamine intolerance (HIT) is thought to be a defect in the enzymatical breakdown of histamine. The breakdown of histamine in the body is done by two enzymes, diamine oxidase (DAO) and histamine methyltransferase (HMT). DAO occurs predominantly in the lining of the intestines whereas HMT has a wider distribution. Both enzymes can be slowed or stopped by a variety of compounds, many of which are used as medications. Stress, intestinal disease or genetic aberration can also cause a reduction in enzyme activity. This deficiency of enzymes activity is referred to as histamine intolerance (HIT).
In people concerned with mast cell activation syndrome (Mastocytosis, MCAS), certain foods, additives, medicines, stress and other environmental factors may lead to mast cell activation and thus release of stored histamine and other chemical compounds stored in the body’s mast cells. Thus flooding the body with histamine from within.
Symptoms of Histaminosis
Symptoms occur when the enzyme system that breaks down histamine cannot keep the histamine in the body at a “normal” level. The symptoms can resemble an allergy, food poisoning, a cold, general discomfort etc. The symptoms especially, but not always, appear associated with food intake. The symptoms can persist chronically or occur in phases or with sudden onset, often without the person having any idea that these symptoms have any connection with each other. Possible symptoms include, but are not limited to: running nose, digestive problems, itching, skin rashes, inflammations, sweating, heart problems, and tachycardia (increased pulse), hypotension (drop in blood pressure), headaches, migraines, dizziness, insomnia, sleep disorders, tiredness, concentration problems, nausea, vomiting, and menstrual cramps.
Not all histaminosis suffers react similarly to the same triggers. Those with HIT react mainly to fermented, aged and perishable foods and less to histamine liberators. Reactions to histamine mostly occur within the first few hours after ingestion. Reactions to liberators are more diverse and may occur quickly or many hours afterwards. Sometimes a single dose of a trigger shows no symptoms but these can build up slowly after repeatedly eating meals with incompatible ingredients over several days. It can then take up to several days for all of the symptoms to go away again. Symptoms are not always reproducible, but depends on how one feels on that particular day. Things like, stress, weather, environmental factors etc. makes a difference.
All in all this means that it can be very difficult to see the correlation between complaints and specific meals or ingredients.
Histamine content of foods
Histamine is a degradation product of the amino acid histidine. Amino acids are the building blocks of proteins, meaning that any food containing proteins can develop levels of histamine. High levels of histamine occurs in spoiling foods, but also in foods produced by deliberate microbial fermentation and ripening processes. Particularly high concentrations of histamine and other biogenic amines (also broken down by DAO in the body) may appear in spoiling fish and shellfish, alcoholic drinks, vinegar’s, matured cheeses, cured meats and sauerkraut. Foods and compounds that trigger the release of histamine from mast cells are referred to as histamine liberators. Foods, and compound that are known to reduce the enzyme activity of DAO (and HMT) are referred to as Inhibitors.
General instructions for Avoiding Histamine Rich Foods
It is important to eat foods that are low in histamine levels in accordance to your threshold. Please always remember that there is no such thing as a “histamine-free diet”! It is impossible to avoid completely, and in the end it is all about finding your personal threshold. Below you can find some general rules of what to avoid and general things to keep in mind.
- Only buy and eat fresh products along with freshly prepared foods (as much as possible)
- Avoid leftovers
- Avoid or reduce eating canned foods and ready meals
- Avoid or reduce eating ripened and fermented foods (older cheeses, alcoholic drinks, vinegar’s, products containing yeast, stale fish)
- Histamine levels in foods vary, depending on how ripe, matured or hygienic the foods are
- Don’t allow foods to linger outside the refrigerator – especially meat and dairy products
- Ensure that your food preparation area (kitchen) is always kept clean – but don’t be manic!
- Everyone has their own threshold; you will need to find yours
please note this list is not complete, but rather a general guide.
Low histamine level foods:
Even though there are a lot of food items to avoid there is still a lot left for you to enjoy, below you can find a general list of items for you to eat.
- Fresh meat (cooled, frozen or fresh)
- Freshly caught fish (gutted and frozen immediately)
- Chicken (skinned and fresh)
- Egg yolk
- Fresh fruits – with the exception of bananas, citrus fruits, pears, plums, pineapple, papaya, and strawberries
- Fresh vegetables – with the exception of tomatoes, eggplant, spinach and avocado
- Grains – rice, rice noodles, yeast free (spelt) bread, oats, puffed rice crackers, millet flour, pasta (spelt and corn based)
- Fresh pasteurized milk, butter, fresh cream cheese
- Milk substitutes – be aware of unwanted additives
- Most cooking oils – check suitability before use
- Most leafy herbs – check suitability before use
- Most non-citric fruit juices
- Herbal teas – check suitability before use
please note this list is not complete, but rather a general guide.
It is important to find out what the root of your problems is, and keep in mind that there is often more than one thing causing your symptoms. It is currently not possible (at least to my knowledge) to reliably diagnose either histamine intolerance or MCAS by laboratory tests. Only an exclusion diagnosis or presumptive diagnosis is possible. In order to determine whether histamine is the most likely culprit of your symptoms, a minimum of the following things should be done:
- A detailed anamnesis (medical history)
- Differential diagnosis/detection of other accompanying gastrointestinal conditions and allergies/intolerance’s
- A laboratory test indicating abnormally high levels of histamine in the body
- Test to determine the activity of DAO in blood serum
- Diagnostic elimination diet followed by a provocation test
General procedure for the elimination diet
In order to discover whether an individual responds to a histamine elimination diet and how strictly the diet needs to be, the following five steps needs to be taken.
- Differential diagnosis for food allergies/intolerance’s
- Diagnostic elimination diet (4 weeks)
- Provocation test
- Reintroduction of a more diverse diet (“permanent diet”)
- Supportive medication (if necessary)
1) Differential diagnosis
Histaminosis most often presents in combination with other food intolerance’s or food allergies. If these remain undetected, the histamine elimination diet will not be effective. A significant improvement can only be achieved if any other diseases are detected and properly treated. Thus, before starting the elimination diet, we first of all need to determine whether any other intolerance’s, allergies or diseases exist.
2) Diagnostic elimination diet (4 weeks)
A diagnostic elimination diet (followed by a provocation test) is currently the only meaningful way to determine if a person shows any reaction to histamine or histamine liberators. However this regime is challenging and requires some real commitment for a long period of time. This diet is very demanding, and cannot be as easily understood or easily implemented as other diets. It is often a good idea to take a week or so to practice the diet before beginning for real, in order to learn the culprits of the diet.
As long as somebody suffers continuously from symptoms, it is often not possible to determine which foods or ingredients trigger these symptoms. Toleration of foods can only be assessed in a symptom-free state. It is therefore important to stick to the list of allowed food items for the first four weeks, until the symptoms have either subsided or reached a low stable level. Note that not everyone is able to reach complete symptom relief by following the diet, in that case the diet can be even further restricted or it might be caused by an undiscovered food allergy/intolerance or another underlying issue.
It is very advisable to keep a food and symptoms diary.
3) Provocation tests
This phase is still part of the diagnosis, and the goal is not to identify any tolerated foods, but rather to see as clearly as possible whether there is a reaction or not when the histamine free diet is not being followed. Consume a variation of restricted foods (red wine, prepared meats, cheeses, vegetables, fruit, additives etc.) if you react to them, it confirms the diagnosis. If you have any other food intolerance’s or food allergies it is important to NOT include these during this phase, as they may obscure the effects the histamine rich foods have on your body. Once the results are clear to you, you can move on to the next phase.
4) Reintroduction of a varied diet/therapeutic elimination diet (finding your limit)
To prevent malnutrition, a wide and balanced variety of foods is required. Therefore it is important that you identify as many foods as possible that you can tolerate and in which quantities. Try to reintroduce more and more foods one by one, ideally consumed three times over the course of one day. If no symptoms appear within 48 hours, you can be relatively certain that the food you have eaten is probably tolerated, so you can try out another food. If you do have a reaction to a food, continue to avoid this food and test it again at a later stage.
As toleration is dose-dependent, not all the badly tolerated ingredients have to be left out completely. They are quite often tolerated if consumed in small quantities and combined with safe ingredients.
An optimal supply of nutrients is likely to improve toleration, unlike an unbalanced diet. Aim to represent each of the following three macro nutrients in every meal:
- Protein (meat, fish, dairy products, egg yolk, nuts and seeds…)
- Vegetables/fruit (aim to eat a minimum of ½ kg/ 18 oz of vegetable per day)
- Healthy fats (omega-3 fatty acids, olive oil and saturated plant fats like coconut oil)
5) Medical drug support
Depending on the severity, the elimination diet alone is sometimes not sufficient to get rid of all the symptoms completely. Several drugs are available that can improve your quality of life. However, it is important to remember that food tolerability can better be assessed if you do not take these kinds of medication. The medication may suppress symptoms and skew tolerance levels. Nevertheless, drugs cannot replace the diet. The diet itself should definitely be maintained as the main part of the therapy.
The following websites and books provide additional important information, which can be helpful towards a successful therapy. Extra information like recommended medication, up-to-date list of incompatible medications, foodstuffs, ingredients, additives, cooking tips etc.
- Mast-Cell-Friendly and Low-Histamine Cooking, by Heinz Lamprecht
- What HIT me? Living with Histamine Intolerance, by Genny Masterman
- The Beginner’s Guide to Histamine Intolerance, by Dr. Janice Joneja
- Is Food Making You Sick?: The Strictly Low Histamine Diet, by James L Gibb
- Never Bet Against Occam: Mast Cell Activation Disease and the Modern Epidemics of Chronic Illness and Medical Complexity, by Lawrence B. Afrin M.D.
- Histamine beperkt diet basisboek, Marloes Collins, Erica Herder en Marjolein van Kleef (In Dutch)
- http://www.allergieplatform.nl/allergieen/voeding/voedselovergevoeligheid/histamine-intolerantie/ (In Dutch)
- http://www.histamineintolerantie.nl/ (In Dutch)
- http://www.histamine-intolerance.info/nl/ (In Dutch)
- https://www.dietcetera.nl/intoleranties-en-aversies/histamine-intolerantie (In Dutch)
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