Today’s topic: Histamine.
As much as I love working with my patients….I also, truly love to spend time learning. It’s not unusual for me to print out 3-4 research articles, hop into bed at night with my highlighter and do some light reading. Ha!
When I was writing my Complete Idiot’s Guide to Eating Well with IBS back in 2009, I included a few sentences introducing histamine intolerance to my readers. I find this condition very interesting ….and I am convinced it’s more common than it is diagnosed. I personally am on a mission to learn more and as always…share what I learn.
Disclaimer: I don’t want every person with IBS that follows my blog to feel the need to remove all histamine from their diet! Nor do I want you to feel overwhelmed by this complicated topic I am about to embark on. I do know that some people that follow my blog may very well have histamine intolerance. For this small subset of folks, the goal is to enlighten you to get the help you need.
What is histamine? Histamine is a natural substance, a biogenic (meaning: resulting from the activity of living organisms such as, fermentation) amine that is present in many foods and produced by a small subset of human cells, including mast cells, basophils, platelets, histaminergic neurons and enterochromaffine cells. Wow! That is a mouthful!
Histamine is a neurotransmitter (brain chemicals that communicate information throughout our brain and body) produced in an allergic reaction, often associated with causing itching, redness, swelling, cough or rash. Histamine regulates sleep and also aids in digestion by playing a role in stomach acid secretion.
What is histamine intolerance? Histamine intolerance results from an accumulation of histamine and the inability of the body to completely degrade it. In healthy people, dietary histamine can be rapidly detoxified by enzymes called amine oxidases, particularly, Diamine Oxidase (DAO) enzyme. Some individuals have low levels of these enzymes; therefore, are at greater risk for histamine toxicity. Gastrointestinal diseases can contribute to a decline in these histamine degrading enzymes.
Similar to FODMAPs, histamine can have a cumulative effect on symptoms. Small amounts may be tolerated but multiple sources of histamine in the diet will ‘fill your personal threshold bucket’ and symptoms will ensue. In order to assess if histamine is a problem for you, it is necessary to restrict all of the histamine-associated foods. A food intake and symptom log are essential while undergoing both the elimination and the re-introduction phase of histamine foods. Working with a dietitian knowledgeable in the low histamine diet is key. Food lists for histamine are variable online. It is my understanding that this in part is due to the fact that analysis of histamine in food has not been done for decades. Another area of needed research!
Symptoms of histamine intolerance:
- Rash/Urticaria (hives)/eczema
- Arrhythmia (irregular heart beat)
- Low blood pressure-due to vasodilation caused by the histamine
- Runny nose
- Watery eyes
- Angioedema-swelling of face/hands/lips
- Heartburn-due to increased acid production
- Itching- typically of the skin
- Abdominal Pain
The ingestion of histamine-rich food or of alcohol or drugs that release histamine or block DAO may provoke allergic-like symptoms in patients with histamine intolerance. Symptoms can be reduced by a low histamine diet and/or managed by antihistamine medications.
Do I think all patient’s with IBS have histamine intolerance? NO! But… histamine intolerance can contribute to abdominal pain, diarrhea, and heartburn–certainly common IBS symptoms, for some people. Dr. William Chey, MD, Professor of Medicine, Director of the GI Physiology Laboratory, and Co-Director of the Michigan Bowel Control Program at the University of Michigan weighs in on this discussion, “Anyone who has hay fever already knows that histamine plays an important role in allergic responses caused by things like pollen and animal dander – many popular medications like Benadryl and Claritin block the effects of histamine. The fact that some foods contain histamine has been largely overlooked. It is quite plausible that consuming foods which contain large amounts of histamine or stimulate the release of histamine from cells in the gut could cause GI symptoms in some people.”
Unfortunately, we don’t have a definitive (accurate) test to determine DAO enzyme levels or their functioning capacity or histamine levels, at this time. If you present with 2 or more of the common symptoms of histamine intolerance, improve on a histamine free or low histamine diet and anti-histamine medications, you fit the criteria for having histamine intolerance. A more severe disease state, an occult systemic mastocytosis should be excluded as your diagnosis by measurement of serum tryptase. This is a condition in which a person has abnormally high amounts of mast cells. You don’t need to have mastocytosis to have histamine intolerance.
Histamine and Food: High concentrations of histamine are found in products of fermentation such as aged cheeses, sauerkraut, wine, processed meats and canned fish. Vegetables such as spinach, eggplant have histamine too. In addition to histamine containing foods which I have provided only a partial list, there are foods that have the capacity to release histamine. Foods that have been linked with histamine release include: citrus fruit, papaya, strawberries, pineapple, nuts, peanuts, tomatoes, spinach, chocolate, fish, pork, egg whites and additives and spices.
Alcohol is not only rich in histamine but also inhibits the DAO enzyme to help degrade histamine.
Drugs that release histamine or inhibit diamine oxidase (DAO) can be found in this reference, in TABLE 5 which is also cited below. Some medications included in this list are metoclopramide (reglan), Cimetidine, and Amitriptyline.
Here are some general tips to minimize histamine in diet:
- Avoid or reduce eating canned foods.
- Avoid or reduce eating overly ripened and/or fermented foods (aged cheeses, alcoholic drinks, products containing yeast, stale fish)
- Histamine levels in foods vary, depending on how ripe, matured the foods are–with higher levels the more ripe or aged.
- As much as it is possible, only buy and eat fresh food.
- Don’t allow foods to linger outside the refrigerator – especially meat products or eat left-overs.
- Choose fresh (not aged) meats, fresh white fish or choose those that have been flash frozen.
- Consult a registered dietitian knowledgeable in histamine to help manage your diet modifications and help you balance your diet
If you are a health care professional or pretty savvy with medical jargon, check out this review article about histamine intolerance.
Could alterations in our gut bacteria play a role in histamine intolerance?
Um, yes. Gut bacteria are capable of producing histamine. Little microorganisms in our intestine can produce histidine decarboxylase—converting protein in our gut to histamine. Amy Burkhart, MD, RD, an integrative medicine practitioner in Napa, California notes,”Though its benefits are controversial, I have had patients with dysbiosis/small intestinal bacterial overgrowth experience improvement on a low histamine diet. The low histamine diet is challenging and not necessary for all dysbiosis patients but can be beneficial in selected cases. Once the dysbiosis improves the tolerance to histamine containing foods also tends to improve.”
For further information on histamine containing food lists and research on this condition, here are some articles/resources/references for you to check out:
The Histamine Chef Great site for all sorts of information written by a journalist–with many research articles provided and expert interviews. Check out the interview with expert Dr. Janice Jonega
Dr. Janice Jonega’s site and fact sheet on histamine intolerance.
Amy Burkhart’s site (Amy is an MD and RD) with a great article on histamine here.
Royal Prince Alfred Hospital Allergy Unit has some good resources on food intolerances (Sydney, Australia hospital)
Am J Clin Nutr 2007; 85:1185-96 Histamine and histamine intolerance Excellent review article!
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